APPROACHES TO FORMATION OF A HEALTHCARE MANAGEMENT SYSTEM
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.
