The modern stage of social development is characterized by the expansion of the scale, the growing importance of the tertiary sector of the state economy – the service sector. The complication of economic relations, aggravation of competition in most markets, an increase in the pace of life, an increase in the quality of life have led to an increase in the importance of issues of building effective management of the social sphere of the state.

The problem of the distribution of limited resources with unlimited needs made it necessary to coordinate the actions of producers and consumers of goods. Historically, two “polar” types of economic relations have been formed:

market economy, characterized by the freedom of economic entities in making managerial decisions;

command-administrative or planned economy, built on the centralization of decision processes about the volume and structure of production.

However, the development of the economy, politics, the struggle between these two systems objectively led to the development of a mixed economy.

Currently, a mixed economy is “a type of economic mechanism that combines market and planning principles, private and public ownership of factors of production, capitalized and socialized sectors of the national economic complex” [1]. The main principle of a mixed economy is, therefore, the optimal combination of economic efficiency and social justice, realized through the function of socially fair distribution and redistribution of the national income of the state.

When highlighting the social sphere of the state, a number of scientists include education, culture and art, health care, physical culture and sports, social security, housing and communal services, etc. The definition of the composition of the social sphere is traditionally based on the theory of public goods, according to which these include goods that are not competitive and are not excluded from the consumption of a citizen, which distinguishes them from private goods. Indeed, for example, health care services have these characteristics: they cannot be excluded from the life of any member of modern society, and competition between the benefits of health care and any other benefits is practically impossible.

In turn, the social complex “belongs to the tertiary sector of the national economy – the service sector, which is an integral part of the national economic complex, and therefore is part of the general system of economic relations, obeys the general economic laws prevailing in this society”.

A special place in the social complex of the state is occupied by the healthcare sector, which directly affects the quality of life of the population, the quality of the state’s labor resources. The need for health care reforms, the accumulated problems of its development in Russia, increase the relevance of issues of healthcare management.

The choice of methods and forms of management of any object is determined, first of all, by the characteristics, structure of this object and the external environment of its functioning. The structure of the health care system will be presented in section 1.2. of this dissertation research. In this section, we will consider the specifics of the healthcare sector as a special type of activity, its place in the national economy, as well as special requirements from the external environment for the formation of methods and forms of management.

In accordance with the Constitution of the Russian Federation, every citizen “has the right to health protection and medical assistance” [4]. Thus, the state, in accordance with international legal provisions, the principles of the World Health Organization (WHO) gives a social character to health care, recognizing the non-exclusion of medical care and other health care measures from the consumption of citizens.

At the same time, the protection of the health of a citizen and society is interpreted as a complex set of measures united by a single goal. Thus, the legislation recognizes that “the protection of the health of citizens is a set of measures of a political, economic, legal, social, cultural, scientific, medical, sanitary-hygienic and anti-epidemic nature, aimed at preserving and strengthening the physical and mental health of each person, maintaining his long-term active life, providing him with medical assistance in case of loss of health. The state guarantees the protection of the health of every person in accordance with the Constitution of the Russian Federation and other legislative acts of the Russian Federation, the Constitutions and other legislative acts of the republics within the Russian Federation,

Thus, it is generally accepted to refer health care to the social sphere or the social complex of the state.

Recognizing the social nature of health care means a number of management requirements.

First of all, we note that according to the theory of public good, the public sector replaces the market where market mechanisms do not work [6]. This factor explains the significant participation of the state in the formation and development of the social sphere in general and its individual sectors in particular, ensuring the achievement of a complete market of social services. For example, in the United States, over 17 million people did not have access to medical care during the period of the functioning of a pure private health care system [7]. Of particular importance is the constant monitoring and forecasting of the needs for health services.

Second, the non-competitiveness of healthcare services increases the importance of such factors as the advantage of large-scale activities of organizations, differentiation of services in organizations, non-price competition, and self-regulation. Taken together, these factors make it impossible to organize this sphere on the principles of pure competition, and lead to the organization of a monopolistic or oligopolistic market. In turn, such restriction of competition requires special government regulation on the availability of healthcare services (both price and non-price accessibility).

Third, externalities in the social sphere in general, and in health care in particular, have a significant impact on the functioning of the system itself for the provision of specific services. For example, health care, by restoring working capacity, extending the life span, improving the quality of life, in turn creates new needs for medical and other services, and also contributes to economic growth. This circumstance requires a special approach to the planning and organization of the healthcare system on the part of the state.

Fourth, the principles of a mixed economy raise the issue of combining economic efficiency and social equity in the operation of the health care system. Consequently, the decisions taken in the field of health care must be economically justified and contribute to the implementation of the social function of health care.

In general, the role of the state in the socio-economic development of society in a mixed economy is determined by three main functions:

stabilization function – is to regulate the proper indicators of macroeconomic parameters;

resource allocation function (allocative) means the allocation of resources between the private and public sectors;

the distribution function of income (distributive) assumes the distribution of income based on the accepted principles [8].

During the formation of the mixed economy, a number of approaches to the management of the social sphere in general and health care in particular have been formed, differing in the peculiarities of performing the above-mentioned functions of the state.

M. Fotaki [9] examines modern health care systems, classifying them according to the criteria of the level of social development and methods of managing the social sphere:

universalist (Beveridge model),

social insurance (Bismarck model),

“southern model” (Spain, Portugal, Greece and partly Italy),

institutional or social – democratic “Scandinavian model”,

liberal (residual social security),

conservative corporate (Japan),

Latin American,

healthcare systems of industrialized states of East Asia,

health systems in countries with economies in transition.

In our opinion, many of these approaches at the present stage of development can be summarized as follows:

The state (socialist) approach, which consists in the centralized management of the social sphere and health care in particular. According to this approach, all management decisions are determined centrally by the health authorities, and the health budget is financed from tax deductions. With this approach, the independence of the subjects of the health care system is minimal, their actions must comply with government decisions. Health care management at the regional and local levels is becoming a detail and concretization of management decisions in the field of health care at the federal level. In this case, administrative forms of managerial influence are mainly implemented.

Private (market) approach, according to which the state practically does not interfere in healthcare management, with the exception of general administrative functions (consumer protection, regulation of contractual relations, etc.). Here, all management decisions are made independently by the subjects of the health care system. This approach leads to the formation of an incomplete market, lack of access to health care for a number of population categories, which contradicts the social nature of health care. Governance is a generally decentralized process. Management decisions at the regional and local levels are made according to the principles of a market economy, according to the laws of supply and demand. The prevailing importance in the private approach to health care management is taken by economic management methods,

A social approach based on the recognition of the importance of the social sphere and the need for its special regulation in a mixed economy. It combines the principles of economic feasibility of management decisions and social justice in the distribution of social benefits (in particular, health benefits). Management is based on the use of mixed management methods, including administrative, economic, socio-psychological, etc. In the social approach, a number of methods (forms) of health care management should be distinguished, which are, in fact, different methods of income distribution:

– management based on compulsory health insurance (MHI), which involves the active development of MHI funds by levels of management (federal, regional, local) and the provision of medical care to citizens in the structure and volumes provided for by MHI policies and per capita financing standards. This system is the most targeted and personalized of all the existing approaches. However, its functioning requires special systemic management decisions, especially in the field of financial management and the formation of the information environment;

– management based on state minimum social standards (GMSS), which provides for the development of a certain standard for the provision of services, which is, in fact, a specific state guarantee to a citizen. GMSS takes the form of a specific funding standard in value terms. At the same time, the standard itself is formed on the basis of industry (or professional) standards that impose special requirements on the volume and quality of the provision of a basic set of public services. in turn, such standards will be natural norms of provision with infrastructure facilities, material and labor resources used in the process of providing specific services [10]. The main feature of this approach is the development of an average list of medical services,

– the marketing approach, unlike those listed above, is not a common or common practice. The specificity of the marketing approach to health care management is to monitor the dynamics of population needs and make management decisions on finance, personnel and other health care resources in the future development of identified needs,

– a mixed approach, involving a combination of the above approaches.

Currently, a social approach to health care management is being implemented in the Russian Federation, within the framework of which the compulsory medical insurance system has been formed and the foundations for the development of GMSS are laid, marketing approaches, as practice shows, are occasionally used in the private health sector.



1.    Health care management system of the Russian Federation.

2.    Ways of reforming the healthcare system in Russia (decentralization, demonopolization, democratization).

3.    Factors affecting the management of nursing personnel in medical institutions at the present stage

4.    Features of health care facilities that affect personnel management.

Healthcare management system

The goal of the health care system is to prevent and eliminate diseases, reduce mortality and disability, improve physical development, increase working capacity and increase the life expectancy of people.

Healthcare management is a complex multi-level and multi-component system of activities.

The system ensures the rational functioning of the industry and its resources (personnel, healthcare organizations, material and technical base, financing).

The functioning of the industry is carried out through legal regulation, medical technology, knowledge and skills of medical workers.

The healthcare management process includes:

  • sources and channels of information on health resources;
  • regulatory and technical base of health care, database of medical, including managerial, technologies;
  • a structure for analyzing the information received and developing optimal management    decisions.

Ways of reforming the healthcare system

Socio-economic and political changes in the country have affected the health care system.

The introduction of market relations in health care required changes in the industry management system.

The economic model (in terms of funding sources) of health care has changed from “budgetary” to “budgetary and insurance”.

According to the form of ownership, health care institutions were divided into state, municipal, and private.

Reforming the healthcare system followed the path:

·         Decentralization;

·         Demonopolization;

·         Democratization.


Decentralization is one of the elements of system reform

health care in many European countries.

A centralized health care system and strict methods of managing it were necessary and effective in the past, especially in the pre-war and wartime conditions, the need to solve very difficult health problems with the most severe shortage of resources and personnel.

The principle of decentralization is based on the idea that small organizations with effective structure and management have more organizational flexibility and accountability than large organizations.

In Russia, health care reform has also followed the path of decentralizing management.

The administrative vertical of health care management was destroyed, the health care system split into federal, regional (oblast) and municipal systems.

On the one hand, two ministries merged into the Ministry of Health and Social Development of the Russian Federation, on the other hand, the Ministry of Health and Social Support appeared in the constituent entities of the Federation as in the Saratov region. the division of ministries took place again.

Decentralization has led to a redistribution of the functions of economic and social responsibility, both between different levels of government and between individual links in the provision of health care. This division made it possible to form a regional approach in the development of national programs, to create conditions for the formation of intersectoral approaches in the management of public health protection.

The state level of government was left with such important functions as:

·         Monitoring of the main indicators of public health;

·         Legislative policy;

·         Definition of medical and medico-economic standards;

·         Determination of uniform requirements for the training of specialists;

·         Approval of sanitary and hygienic norms, standards and rules;

·         Development of standards of professional activity and medical ethics;

·         Coordination of scientific activities;

·         Scientific and methodological support for the implementation of national policy and strategic planning;

·         Development of a system for financing health care institutions;

·         Optimization of the health care structure.

The competence of the state also includes non-medical measures, including improving the state of the environment, the material well-being of people, the quality of food, water, a comfortable psychological environment, safety, etc.

Decentralization has brought both positive and negative consequences.

The positive side is that decentralization allows the constituent entities of the Russian Federation to take into account regional characteristics and thereby in the most effective way to improve medical care and optimally allocate resources.   Management becomes more flexible and faster can be responding to changing circumstances.

The negative sides that make effective management difficult are:

firstly, the functions of health care management were not supported by appropriate information support. In particular, this concerns the issues of rational use of resources of territorial health care systems;

 secondly, organizational decentralization, due to the lack of a unified methodological approach, narrows the capabilities of the health authorities of the constituent entities of the Russian Federation to pursue a targeted policy in the field of health protection.

For example, due to the independence of budgets of different levels, it is very difficult to calculate a single per capita funding standard for individual territories. Hence the unevenness and duplication of functions in the network of health care facilities (municipal, departmental, specialized, etc.) in certain cities and regions;

third, the separation of functions   leads to a weakening of the central apparatus and the public sector.

An extreme form of decentralization is the privatization of health care institutions.

fourthly, decentralization is one of the reasons for the duplication of activities of various structures of the system.

The second reason for duplication is the development of departmental health care systems, each of which uses its own hospitals and clinics.

The development of the private health sector also creates duplication.

Patients, at present, themselves have the opportunity to choose between different systems (state, departmental, private) and thereby stimulate the activities of certain medical institutions.

Duplication is overcome through the formation of regional markets for medical services and through regional planning.

In the UK, private healthcare organizations participate in the State Guarantee Program and are funded by the state for an agreed amount of state guarantees, in Russia private healthcare provides exclusively paid medical services.


Demonopolization is the second direction in the reform of the health care system.

The division of health care institutions according to the form of ownership into state, municipal and private, creates conditions for competition, which stimulates the search for more effective forms of work.

Demonopolization of the healthcare network will make it possible to abandon outdated types of institutions, instructions and dogmas, which have accumulated a lot. This also made it possible to accelerate the reconstruction and strengthening of the material and technical base of health care.

Demonopolization solves the problem of the patient’s right to choose the attending physician and medical institution in which he would like to receive qualified diagnostic, medical and rehabilitation assistance at any time.

However, demonopolization should not turn medical institutions into sources of profit, at the expense of the population that has been put in a hopeless position.


The main idea of ​​building health care was the democratization of management and financing of the system

The democratization of the healthcare management system is aimed at weakening administrative methods and strengthening the economic independence of medical organizations:

Ø  finding sources of financing not prohibited by law (sponsors, introduction of a volume of paid services at the discretion of the head of a health care facility, but not more than those established by the regulation, renting out premises, bank loans, securities);

Ø a  new incentive system of remuneration for medical workers, taking into account the coefficient of participation in the labor process of an employee;

Ø  independence of health care facilities in choosing an insurance organization (or refusing to choose) when fulfilling a state order under the compulsory medical insurance or contracts for the provision of medical care in excess of the state order.

Ø  Involvement in extra-departmental control:

·         Consumer advocacy organizations;

·         Associations of citizens created in order to protect and implement the rights of certain categories of citizens to quality medical care and a healthy lifestyle;

·         Board of Trustees (from citizens representing the local government).

Factors affecting the management of nursing staff in medical institutions at the present stage

The management activities in medical institutions are influenced by many factors, the number of which has significantly increased in connection with the reform of the health care system and which complicate the management process, including for nursing personnel.

Problems in the management of a medical and prophylactic institution arise as a result of factors:

1.    complication of the structure of the health care system;

2.deficiency    of a scientific management approach to solving

problems in medicine;

3.the    emergence of market relations between business entities

military activity in the health care system;

4. the    emergence of a market for paid medical services;

5.the    emergence of competition between treatment-and-prophylactic

institutions of various forms of ownership (municipal, state, private);

6.    soaring quality requirements of medical

services from consumers, MHIF and insurance companies;

7.increasing    the requirements and forms of reporting by the authorities

health management and other regulatory organizations;

8.    personnel imbalance   (lack of junior medical

staff, nursing staff shortage);

9.the    growth of self-awareness and the need for nursing staff for

increasing the level of knowledge;

10.the          emergence of the state reform program

nursing and the need for their implementation;

11.          development and implementation of innovative nursing technologies;

12. The          trend towards the differentiation of professional sestrin-

business and its separation into an independent sphere of medical activity;

13.          implementation of the national project “Health” and other federal and regional target programs;

14.          introduction of a new system of remuneration.

All of these changes increase the burden on healthcare workers, increase the stressful situation, provoke resistance among a number of employees and make it difficult to manage personnel.

The complexity of the management of   medical personnel is also associated with the peculiarity of the medical and preventive institution as a specific organization.

Features of health care facilities affecting personnel management

1.     The complexity of the social structure of medical institutions .

No other company has such a diversity in its employees as a healthcare facility, in terms of professionalism.

This is the difference in education, work experience, experience, qualifications, responsibility for their actions, professional independence, a variety of characters.

2.     High level of conflict.

High conflicts are associated with:

Ø  with a complex social structure of personnel;

Ø  with high intensity of medical work;

Ø  interdependence of labor and other organizational reasons.

3.    The consequences of erroneous decisions are difficult or even impossible to correct.

The activity of a medical worker, constantly related to the health and life of the patient, does not give the right to make a mistake that can lead to deterioration of health or loss of life.

In a   market economy, due to changes in   the health care system, the role of the leader in this reformed system is significantly changing.

On the one hand, he is given independence in dealing with the functioning and distribution of financial resources, on the other hand, the responsibility of the management for achieving the set goals increases.

In modern conditions, managers are required to:

1.    knowledge of the laws of economics, marketing,   psychology and sociology, conflict management;

2.    knowledge of the theory of health care management;

3. the    ability to react intelligently to a rapid change in the situation;

4.    special responsibility for decision-making;

5.    entrepreneurial spirit, etc.