CC BY
42
ARCHITECTURE
UDC 725.51
Bulakh Irina Valerievna
PhD of Architecture, Associate Professor Department of Design of the Architectural Environment,
Kiev National University of Construction and Architecture ResearcherID:V-4802-2018; Spin-код: 9274-0113 ORCID: 0000-0002-3264-2505 DOI: 10.24411/2520-6990-2019-10181 HOSPITAL SYSTEMS IN EASTERN EUROPE
Булах Ирина Валерьевна
Кандидат архитектурных наук, доцент кафедры дизайна архитектурной среды, Киевский национальный университет строительства и архитектуры ResearcherID: V-4802-2018; Спин-код: 9274-0113 ORCID: 0000-0002-3264-2505
ГОСПИТАЛЬНЫЕ СИСТЕМЫ В ВОСТОЧНОЙ ЕВРОПЕ
The countries of Central, Eastern Europe and the former USSR should be considered together, since despite certain differences they all have the same foundation of the Soviet health care model. To fully understand the essence of the changes that occurred after 1990, it is necessary to clarify the preceding historical context. Post-Soviet countries inherited a health care system in which hospitals played a dominant role. The latter were grouped by administrative principle, by the nature of specialization, by the level of assistance provided and by occupation and the social status of the patients served.
Today, in the post-Soviet space, healthcare is being reformed, but the extent of the changes carried out in different countries varies. The main features of the Soviet hospital system, to some extent also characteristic of the countries of Central and Eastern Europe, are as follows. First, the number of hospitals and the density of accommodation is very high. A large number of hospitals were thought to be the main indicator of a good health care system. All-Union Institute of Social Hygiene. N. Semashko set standards (number of places per 10,000 population, etc.), which are mandatory for use throughout the USSR. Due to increased attention to hospitals, the remaining components of the health care system were financed at a low level. Thus, the established priorities of financing and organization of health care contributed to the fact that hospitalization was the most common form of medical care and the number of needs in hospital hospitals remained high.
Secondly, the presence of hospital specialization was considered a sign of good and efficient performance of the health care system. Eastern Europe, in contrast to Western Europe, has an extensive network of specialized (children's, psychiatric, tuberculosis, oncological, dermatological, venereal, ophthalmic, etc.) hospitals at state, regional, and district levels. The third sign is the presence of hierarchy according to the level of administrative subordination. Hospitals are divided into district, city, regional and republican (national). In practice, the functional difference between inpatient treatment at the city and national levels is poorly expressed (patients using the services of national hospitals mostly live in capitals). Specialized hospitals and
dispensaries, including for patients with tuberculosis, operate at the district, regional and national levels. The fourth sign is the existence of parallel systems of medical services. Special hospitals were envisaged for the party-state leadership, for the main divisions of the government (ministries of the interior, foreign affairs, communications, defence, etc.), as well as for large industries.
The fifth sign is a strongly pronounced flow of patients directed upward in the hospital hierarchy. The presence of this stream is due to several factors. Central hospitals have at their disposal relatively large budgets, the best doctors, medicines and equipment. On the other hand, primary care is underdeveloped; due to inadequate training, doctors cannot cope even with relatively simple diseases. Compared with their colleagues in Western Europe, general practitioners are much less involved in diagnosis and treatment. Therefore, the doctors of the local health network (ambulance workers, clinics, etc.) performed only a minimal function, often resorting to hospitalization. Finally, as was shown above, the average length of hospital stay was significantly higher than in Western Europe. Treatment was largely determined by centralized clinical protocols providing for a long hospital stay. Adequate substitution for hospital treatment was generally not available.
Summarizing, we can say that in most countries of Eastern Europe the number of hospitals and their capacity is too large (at least in comparison with Western European standards), hospitals perform slightly different functions - they serve as the main providers of medical services, as well as official social assistance. Longer periods of stay in hospitals are caused not only by financial incentives, but also by the disparity between the quality of equipment and the level of training of personnel with the requirements of modern medicine.
Transformation experience. The countries of Eastern Europe today differ in the scale of reform and the changes that have been made, but here, unlike in Western Europe, the changes are more often caused by external circumstances. In some countries, such as Albania, Bosnia and Herzegovina, Georgia, Tajikistan, wars
or riots played an important role, leading to a significant reduction in hospital capacity (partly due to hostilities, partly due to lack of funds to support ). Thus, between 1990 and 1998, the number of capacity of hospitals in Albania and Tajikistan decreased more than by 20%.
However, the main reason for the very significant drop in the capacity of hospitals in the countries of the former USSR was the economic crisis that led to the closure of many small hospitals in rural areas. These hospitals were generally very poorly equipped; they could not even have running water. Some of them were abandoned due to the complete lack of funding. In Kazakhstan between 1990 and 1997, the number of hospital capacity decreased by 40%, and the number of hospitals approximately doubled; while in 1994, 684 village hospitals functioned in the country, then in 1997 there were only 208 left. In some countries, the closure of hospitals is provided for by national health plans and supported by presidential decrees, for example, in Kyr-gyzstan.
The financing problems that accompanied the liberalization of the Czech health system also led to the closure of many hospitals. The adoption of a system of remuneration of doctors on the basis of the fee for the service and the inability to set maximums for hospital fees led to an increase in the cost of inpatient treatment and the bankruptcy of insurance funds. By 1998, out of 27 medical funds, only nine were left; the number of places for the treatment of acute cases has decreased by 23%. In other post-Soviet countries, serious changes actually began with the fact that hospitals were granted independence from the central government (usually by reassigning hospitals to local governments). Such hospitals continued to jealously guard their independence, which complicated the creation of regional bodies (as in France) or the merging of hospitals with each other (as in the UK). Thus, all attempts of the Hungarian government to reduce the capacity of hospitals invariably face tough opposition. The situation was not affected by such measures as the creation of district committees (with limited powers) and the introduction of payments based on the distribution of groups according to diagnosis. Between 1990 and 1997, the number of places for the treatment of acute cases decreased by only 7%, while government spending on hospitals grew.
It was expected that a change in the official payment mechanism would lead to the closure of many hospitals and cost containment, but in this region of Europe these expectations were not met. In a number of countries of the former USSR official payments make up only a small part of the total financial flow. Thus, in Georgia, the state health insurance agency introduced a system of payments for inpatient treatment based on the characteristics of each individual case; however, hospitals recently transformed into joint-stock companies are 80% funded by direct (official and unofficial) payments to patients.
A historical overview shows that hospitals must continue to adapt to changes in the internal and external environment. This study outlined the dynamics of the historical evolution of hospitals, and pointed out differences in the speed of evolutionary processes in different countries in different regional contexts. Traditional hospital performance indicators, such as capacity and length of stay, indicate that the importance of a hospital
in the health care system is gradually and naturally decreasing; on the other hand, such an indicator as the frequency of admission of patients indicates a higher than before intensity of the work of hospitals. As hospital functions change, more detailed information is needed about outpatient services and outpatient operations, which are now widely implemented in hospitals. Comparative data for different countries do not provide a simple answer to the question of what capacity hospitals are needed for each individual country.
Many countries have sufficient capacity to reduce the capacity of hospitals by transferring patients requiring long-term care to more suitable facilities for this purpose. This, of course, does not mean that all countries should follow the example of those states where the level of hospital capacity is low; it is believed that over-optimization may not correspond to real needs. An ideal model does not exist, the same way of organizing a hospital system cannot be used in a "pure form" - adaptation to regional particularities, social, economic and political opportunities of each specific state is necessary, as well as taking into account demographic indicators and the dynamics of progressive diseases.
In the presence of an excess of hospitals, their inflated capacity, it is wiser to undertake a planned reorganization than to start the process of influence of market factors. In particular, independent hospitals are particularly active in countering closure; Meanwhile, change may require the creation of new organizational units and even new institutions. Thus, instead of "reducing" it is better to talk about "modernization or optimization." It should not be thought that the problem of overcapacity can be solved by simply closing some institutions; for the remaining institutions are usually not better equipped and, accordingly, are not prepared to solve problems that may arise in the future. Finally, a significant reduction in the capacity of hospitals in Eastern Europe was not planned in advance, but was the result of a recession or military upheaval. In other words, the systems were forced to respond to unforeseen external circumstances.
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