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1618 государственная служба 2017 том 19 № 4
теория и практика управления
doi: 10.22394/2070-8378-2017-19-4-18-24
вопросы модернизации управления здравоохранением в регионах
МАРИНА АлЕКСАНДРОвНА ЯАКтАЕвА, кандидат юридических наук, доцент кафедры государственно-правовых дисциплин Российской академии народного хозяйства и государственной службы при Президенте Российской Федерации, почётный адвокат России.
ЕКАТЕРИНА АЛЕКСАНДРОВНА ЯАКТАЕВА, кандидат медицинских наук, врач-психиатр, заведующая отделением медицинской и социальной реабилитации № 35, Клинического филиала № 2, ГБуЗ МнПЦ наркологии департамента здравоохранения г. Москвы.
ВАДИМ ГЕННАДИЕВИЧ ИВАНОВ, старший преподаватель кафедры государственного и муниципального управления Российской академии народного хозяйства и государственной службы при Президенте Российской Федерации.
Аннотация: в статье рассматриваются проблемы модернизации российского здравоохранения на уровне регионов, исследуются вопросы, возникающие в ходе реализации Концепции развития здравоохранения в российской Федерации, обозначаются подходы к их решению. Авторы указывают, что в стратегии национальной безопасности россии определены основные приоритеты развития системы здравоохранения нашей страны, в частности, установлено, что развитие системы здравоохранения, а равно и укрепление здоровья населения страны является одним из важнейших направлений обеспечения национальной безопасности, обеспечение которого требует выработки и последовательной реализации долгосрочной государственной политики в сфере охраны здоровья граждан. вместе с тем, существует и понимание основных проблем на пути реализации государственных гарантий оказания гражданам россии бесплатной медицинской помощи, к каковым относятся: традиционно недостаточное финансовое обеспечение указанных гарантий, выраженная дифференциация субъектов российской Федерации по уровню реализации программ в указанной сфере, а также известная раздробленность источников финансирования медицинской помощи, препятствующая развитию и внедрению в полном объеме системы обязательного медицинского страхования населения. сейчас система финансирования здравоохранения фрагментирована и децентрализована в гораздо большей степени, чем, например, в большинстве стран Европы.
Ключевые слова: реформа здравоохранения, управление здравоохранением, государственные стратегии, коррупция в здравоохранении
issues of modernization of health care management in the regions
MARiNA A. LAKTAEVA, Candidate of Law, Associate Professor at the Department of State and Legal Disciplines of the Russian Presidential Academy of National Economy and Public Administration, Honorary Lawyer of Russia. EKATERiNA A. LAKTAEVA, Candidate of Medicine, Psychiatrist, Head of the Medical and Social Rehabilitation Department No. 35, Clinical Branch No. 2, GBUZ MNPT Narcology of the Moscow City Health Department. VADiM G. iVANOV, Senior Lecturer of the Department of State and Municipal Administration of the Russian Presidential Academy of National Economy and Public Administration.
Abstract: The article examines the problems of modernizing Russian health care at the regional level, investigates the issues arising in the course of implementing the Concept of Health Development in the Russian Federation, and identifies approaches to their solution. The authors point out that the Russian National Security Strategy defines the main priorities for the development of the health care system in our country, in particular, it has been established that development the healthcare system, as well as strengthening the health of the country's population, is one of the most important directions to ensure national security, which requires the development and consistent implementation of the long-term state policy in the sphere of health protection of citizens At the same time, there is an understanding of the main problems in the way of implementing state guarantees for the provision of free medical care to Russian citizens, which include: traditionally insufficient financial support for these guarantees, differentiation of the subjects of the Russian Federation in terms of implementing programs in this area, as well as well-known fragmentation of the sources of financing medical care, preventing the development and full implementation of the mandatory system of compulsory medical insurance for the population. Now the health financing system is fragmented and decentralized to a much greater extent than, for example, in most European countries.
Keywords: health care reform, health care management, state strategies, corruption in health care
The health care system overview
The health care system at the present stage is designed to solve the main problems of the service providers' activities and build a new model for ensuring the rights of citizens of the Russian Federation for free and equable medical care.
The health care system of the Russian Federation performs functions in a difficult economic and geopolitical situation, which is reflected in the statistical indicators of public health.
Over the past two decades, the sickness rate among the country's population has been steadily increasing, which, in addition to the factors mentioned, is also due to the growing proportion of the elderly population, the low effectiveness of the disease prevention system, and the more effective detection of diseases in connection with introduction of new diagnostic methods and techniques.
Thus, the number of registered cases of lethal diseases, such as, for example, diseases of the blood circulation system, increased by 2.3 times, neoplasm's - by 2 times, etc. Attention is drawn to the high sickness rate among children aged 0 to 14 years and adolescents 1517 y.o., which has increased significantly since 1992. Among persons recognized as disabled for the first time, the share of working age persons remains stably high. Industrial injuries are constantly decreasing, but the number of casualties with a fatal outcome remains high. The indicators of infant and child mortality, as well as the health status of preschool and school children, demonstrate that the priority in the health policy of the Russian Federation should be given to protecting the health of children and women of reproductive age.
The National Security Strategy1 of Russia identifies the main priorities for the development of the health care system of the Russian Federation, in particular, it determines that developing the health care system, as well as strengthening the health of country's population, is one of the most important directions to ensure national security, which requires development and consistent implementation of long-term state policy in the Sphere of citizens' health protection.
Accordingly, the strategic objectives of state regulation and management in this area are to reduce disability and mortality rates, increase the life expectancy of the population, improve the prevention of morbidity, ensure the provision of timely and qualified medical care, develop a system of standards for medical care, as well as quality control, safety and efficiency of medicine.
The issues of health care system in the Russian Federation
In the long-term perspective, addressing topical is-
1 Decree of the President of the Russian Federation of December 31,
2015 No. 683 «On the Strategy of National Security of the Russian
Federation» // Official Internet Portal of Legal Information http://
www.pravo.gov.ru, 12/31/2015
sues of national security in the health sector implies:
developing national projects for prevention and treatment of diseases classified as socially significant (oncological, cardiovascular, endocrine, and narcological), including the development of unified methodological approaches to diagnosis, treatment and rehabilitation of patients and standards of medical care;
developing the state system of accessibility and quality management of medical care, training and certification of health professionals;
ensuring quantitative and qualitative changes in the structure of morbidity and reducing the probability of epidemic outbreaks, including those caused by pathogens of particularly dangerous infectious diseases through the development and subsequent implementation of national programs of state support for disease prevention, based on the introduction of promising technological solutions2.
At the same time, there is an understanding of the main problems in the way of implementing state guarantees for providing free medical care to citizens of the Russian Federation, which include: traditionally insufficient financial support for these guarantees; differentiation of subjects of the Russian Federation in terms of the level of programs implementation in this area; and notorious fragmentation of funding sources for medical aid, impeding the development and full implementation of compulsory medical insurance system for the citizens 3.
The main problematic issues in the sphere of health care in the Russian Federation are [Rodionov, 2009]:
• an increase in the sickness rate of cancer, cardiovascular and endocrine diseases, the spread of HIV infection and tuberculosis, consistently high prevalence of narcological diseases;
• progressive downgrade in the demographic situation and health status of the population (for example, infant mortality in Russia is almost 3 times higher than the average one in the civilized world);
• steady growth of the population's need for medical care (in particular, due to the increase in the proportion of elderly people and the complications of several traditional diseases);
• high level of corruption among medical workers;
• the existence of organizational problems of a fundamental nature that require strategic measures for their resolution (here are, for example, the issues of the lack of technical equipment in medical institutions and insufficient training of senior medical personnel);
2 Decree of the President of the Russian Federation of December 31, 2015 No. 683 «On the Strategy of National Security of the Russian Federation» // Official Internet Portal of Legal Information http:// www.pravo.gov.ru, 12/31/2015
3 The concept for development of the health care system in the Russian Federation until 2020. // The official website of the Ministry of Health and Social Development of the Russian Federation // http:// www.minzdravsoc.ru/
20 государственная служба 2017 том 19 № 4 теория и практика управления
• decrease in the availability of medical care due to a decrease in the level of state regulation of health financing;
• insecurity of state guarantees for providing free medical care with appropriate financing;
• insufficient efficiency of monitoring the health of country's population, especially women of reproductive age, particularly pregnant women, children, etc.;
• negative impact of the media on the health of population (especially children and youth);
• lack of required information for the majority of population on the ecology of habitats (including the technosphere), the quality of food products sold, medicines, etc.;
• insufficient provision of confidentiality for patients' personal information on health status (especially in the context of health information systematization);
• unreasonable dissemination in the media of information on medical phenomena that are dangerous from a medical point of view (epidemics, etc.), hiding information about health-threatening phenomena;
• medical Internet sites, TV shows and other media can be the sources of poor-quality, inaccurate, outdated and even dangerous information;
• «dilution» of a single country from the point of view of rendering medical assistance, etc.
At the same time, the low efficiency of using the available financial resources of the health care system is caused both by the disorder of the system of state financing from the funds of compulsory heath insurance (CHI) and budgets of all levels, and by inadequate coordination of the health authorities and other CHI subjects; the primacy of the principle of financing medical institutions from the budget funds in terms of indicators that do not reflect their real performance; the lack of incentives for participants in the insurance process to participate in the restructuring of the health care system; the current legislation in the sphere of health protection, which does not contribute to formation of the unity of the health care system and ensuring the effective use of the resources of health care sector [Alekseev, 2016].
challenges of health care management
The most important social and economic challenge in Russia is the discontent of the population with the quality and availability of free medical care4. The low availability of medical care, the increased demand for it, and the increasing inequality in the ability to pay for medical services out of personal funds can lead to increased tensions in society.
According to various estimates, today in Russia up to 50% of the population has a monthly average per
4 Data from the All-Russian Public Opinion Research Center // http:// rusnovosti.ru/news/295345
capita income not exceeding 19 thousand rubles while maintaining stable growth in spending on priority items of household budget expenditures: food, utility services, transportation, education of children, etc. From the health care system, in these conditions, the availability and quality of free medical care is expected to increase, primarily in outpatient settings [Ulumbekova, 2015].
Today, the standardized death rate of the working-age population in Russia remains 2-3 times higher than in the EU countries [Shalnova, Deev, 2011]. The share of cardiovascular diseases in the mortality rate of the working-age population is about 30% and does not decrease, and the economic losses exceed a trillion rubles per year [Shalnova, Deev, 2011]. This determines the high relevance of the development and implementation of effective strategies to fight against the CNID.
The lack of effect from the activities carried out in the field of public health is largely due to the fact that the emphasis is on detection and treatment of diseases, while comprehensive preventive measures are not envisaged at all. At the same time, attention is not paid to the final result and health promotion. In our opinion, the problem lies in the fact that in health care all stages of medical care (diagnosis, treatment, rehabilitation), including prevention of diseases, are treated as separate independent elements. Accordingly, they are separately funded, often in proportion to their importance, with prevention suffering the most. It is possible to reverse the situation only by putting prevention at the heart of the matter.
A high mortality rate (above the national average) is observed in 18 subjects (21.7%); this figure is above 790 in the Komi Republic (797.1), Sakha Republic (Yakutia) (794.8), Sverdlovsk (795.5), Omsk (794.1) and Novosibirsk (790) regions.
The most favorable situation with mortality among men is noted only in three subjects: Moscow (444.1), the Republics of Dagestan (417) and Ingushetia (411.9), where the death rate is lower than the average Russian one [Starodubov et al., 2015].
A different picture is observed with respect to mortality rates of the female population in the subjects of the Russian Federation, although extremely high ratios persist in the Far Eastern Federal District (88.9% of the subject), NFO (41.7% of the subject), NWFD (54.5% of the subject). An extremely high mortality rate is registered among women in the Chechen Republic (540.7), and in 50% of the subjects of the SFD and UFO. The number of subjects of the Russian Federation with low mortality rates among women compared to men: Moscow (294.3), Tambov and Ivanovo (317.7) regions, the Republic of Dagestan (313.3), Ingushetia, the Chuvash Republic (316.9) [Son, Soboleva, Savchenko, 2015].
preventive measures as an essential part of health care system
The extremely negative demographic situation in the country is due to many reasons, the main of which
is the low willingness of citizens to take care of their own health. On the one hand, the population, primarily young people, is not psychologically ready to maintain one's health; on the other hand, the preventive measures that are carried out do not provide positive result due to contradictory policies in the field of prevention, in particular, healthy lifestyles (HLS) in a whole country. With high awareness of the population about the causes of diseases and measures for their prevention, which is confirmed by the results of opinion polls (more than 80% of respondents), less than 30% of respondents maintain a healthy lifestyle. The main reason can only be the insufficient preventive work carried out among the population [Son, Soboleva, Savchenko, 2015].
As studies show, it is not exclusively medical measures that ensure an improvement in the health status of the population. The implementation of broad preventive measures, general steps to promote health, hygienic training of the population in a complex can turn the tide. Part of the problem can be solved by systematically motivating the population to lead a healthy lifestyle and regular (planned) participation in preventive activities, which is one of the key areas of prevention in the state program «Development of Health» [Mirzoyan, 2014].
The formation of healthy lifestyle is carried out by a set of measures of primary prevention, which is a combination of medical and non-medical activities aimed at strengthening and maintaining health. The main role in the implementation of this direction is assigned to the medical prevention service, which includes centers, departments and offices. Regional centers of medical prevention (CMP) coordinate the service.
currently, the medical prevention service in the country is low-powered, it is represented by 78 regional health centers, of which only 30 are independent (35.3%), 24 (28.2%) are legal entities (united with a health center or medical and sports dispensary), 24 (28.2%) are offices that perform the function of a regional CMP [Son, Soboleva, Savchenko, 2015].
The analysis of the preventive service activities revealed the following shortcomings: the lack of autonomy of the regional CMPs due to their association with medical and sports dispensaries and health centers in most regions or their complete absence; their low power due to inadequate structure and inadequate staffing. Availability of CMP cadres' personnel is extremely low: practically in all subjects of the Russian Federation the number of doctors (individuals) is 2 times less than the stipulated standard medical rates.
The effectiveness of prevention depends to a large extent on the financing of preventive work and prevention programs. Out of 85 subjects of the Russian Federation in 49 of them (56.7%) this direction is not funded by health authorities [Son, Soboleva, Savchenko, 2015].
It should also be noted that the existing low quality of primary prevention is largely provided only quantitatively - an increase in the number of mass events held,
lectures delivered, seminars held, etc., while the problem of individual prevention is almost not solved. The CMP lays its priority on working in direction of prevention for children and adolescents, while the working-age population is left out.
To change the situation, we need to:
• really strengthen preventive activities of the medical prevention service, ensure the training of health workers in matters of health promotion and healthy lifestyles;
• provide human resources and funding;
• develop and implement educational programs for various groups of the population, as well as for teachers, doctors of preschool institutions, etc.;
• expand the coordination activities of various state bodies and institutions aimed at creating healthy lifestyle (inter-agency approach);
• construct an information block of methods and forms for the promotion of healthy lifestyle and thematic blocks for the promotion of disease prevention, taking into account population contingents and the profile of a specialist;
• develop an optimal model to organize primary prevention, the principles of phasing it out with the definition of preventive measures volume at each stage;
• orient the activities ofthe CMP towards strengthening the work with the working-age population.
All of the above is impossible, obviously, outside of the framework of conceptualized program for health care modernization, focused mainly on the regional level.
The health care reform
In 2008, the Concept of Health Care Development in the Russian Federation until 2020 was presented, which, as it follows from its general provisions, includes the main goals, objectives and methods for improving public health in the Russian Federation on the basis of systematic approach to analyzing the condition of this sector in the country.
The implementation of the goals and objectives defined by the said Concept implies deep modernization of health care and does not seem feasible outside the legal field, bypassing the formation of legal mechanisms and regimes for the provision of various types of medical assistance, as well as organizational and legal mechanisms in the said sphere as a whole.
Modernization is feasible only within the framework that exists objectively, due to the external environment. The process of modernization of health care is influenced by political, economic, demographic and social situation in the country; social stratification of society; sociocultural characteristics of society, including national and ethnic, and many others.
Under the modernization of public health services, it is proposed to understand the coordinated activity of the authorities at different levels, bodies of govern-
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ment in the sphere of public health and medical community that is scientifically supported by society, based on taking into account available industry resources and significant factors of external environment and aimed at transferring health care to a level that meets modern requirements and world standards [Pidde, 2011].
Let us consider the issues, solving which, according to the Concept, requires activities aimed to adopt or modernize existing norms of law.
First, such activities should include the measures associated with modernization of medical care financial security.
Second, intense law-making work will require the formation and implementation of new models of medical care organization. In this case, significant changes are needed in the organizational and legal forms of health care management, as well as defining market and non-market sectors.
Third, the legislative support is needed in reforming the existing system of medical insurance, the need for which has matured for a long time. In this case, it is necessary to create a new number of insurance mechanisms and significantly change the legal status of their participants.
Fourth, the concept considers, in essence, the creation of a new system for medicinal provision of population and the introduction of compulsory and voluntary insurance of medical assistance, which also needs legislative support.
Fifth, the activities envisaged by the concept need legislative clarification for the legal status of main participants in the legal relationship of the health care sphere (doctor, patient, nurse, pharmacist, etc.), and besides, the general amendments to the legal status of such participants, as well as special norms, also need to be revised.
sixth, adapting to the new demands of the training and retraining system for medical personnel is necessary.
Also it is necessary to mention the necessity for normative and legal provision of informatization in public health services [Chukhraev, 2014].
In order to realize the goals and objectives of the said Concept, within a short period of time a number of federal laws that were most important for the healthcare sphere were adopted:
• On 8.05.2010, No. 83-FZ "On Amendments to Certain Legislative Acts of the Russian Federation in Connection with the Improvement of the Legal Status of State (Municipal) Institutions" (hereinafter -Federal Law No. 83-Fz) 5;
• On 29.11.2010, No. 326-FZ "On Compulsory Medical
5 Federal Law No. 83-FZ of 08.05.2010 (as amended on November 30, 2011) // «On Amending Certain Legislative Acts of the Russian Federation in Connection with the Improvement of the Legal Status of State (Municipal) Institutions // Collection of Legislation of the Russian Federation. - No. 19, art. 2291
Insurance in the Russian Federation" (hereinafter -the Federal Act on CMI)6;
• On 21.11.2011, No. 323-FZ "On the fundamentals of protecting the health of citizens in the Russian Federation"7.
The key provisions of the new legislation were [Chukhraev, 2014]:
• the state withdrawing itself from of a number of unconditional obligations for the maintenance of medical and preventive institutions and rigid binding of these obligations to the volumes of services rendered to health facilities and a number of other indicators of their activities;
• elimination of subsidiary liability of owners for obligations of budgetary and autonomous institutions;
• toughening of responsibility for the management of budgetary institutions, including personal financial responsibility of managers.
Among the structural reasons for the inefficiency of the domestic health care system, the redundancy of inpatient capacities of state and municipal medical and preventive institutions is of great importance. Overcoming this problem requires deep restructuring of the system of health facilities in Russian regions, based on strategic plans for the creation of a rational network to provide medical care. Such plans include measures to increase the role of primary health care and ambulatory care in the health care system, create a multi-tiered system of inpatient medical care, with the differentiation of the hospital bed capacity according to the intensity of its use, and concentrate medical care in the interdistrict centers of its provision.
At the same time, despite the known budget constraints caused by current economic downturn, it is unreasonable to postpone measures for increasing accessibility and rationalizing the use of medicines, fully or partially provided from the budget, as in the medium term these measures will improve the state of citizens' health, reduce the risk of lowering the living standards for socially vulnerable groups of population and increase social welfare in the country as a whole. In this connection, the issue of expanding financial and organizational involvement of the state in provisioning medicines for citizens in outpatient care also remains urgent.
A necessary element for creating an efficient health care system in Russia is the formation of a single-channel financing system.
Now the system of financing health care in the Russian Federation is largely fragmented and decentralized
6 Federal Law No. 326-FZ of 29.11.2010 «On Compulsory Medical Insurance in the Russian Federation» // Collection of Legislation of the Russian Federation «, 06.12.2010, N 49, art. 6422
7 Federal Law No. 323-FZ of 21.11.2011 (as amended on 25.06.2012) «On the fundamentals of protecting the health of citizens in the Russian Federation» // Collection of Legislation of the Russian Federa-
tion «, 28.11.2011, No. 48, art. 6724
to a much greater extent than, for example, in most European countries. The single channel for financing health care will have a positive impact on accelerating the restructuring of regional health care delivery programs, reduce intra-industry barriers, and create a system of material incentives for medical institutions.
Corruption in health care
Finally, the fight against corruption is of paramount importance for modernization of the health care system in the Russian Federation.
Corruption practices in the health sector form the so-called everyday corruption. Economists refer to the market of everyday corruption the sphere of routine interactions between citizens and authorities in the field of health care, education, legal proceedings, military conscription, various kinds of registrations, personal safety, etc. [Levin, Satarov, 2012].
The phenomena of domestic corruption are primarily recorded by sociologists, according to the studies of which free medical care ranks first in the structure of domestic corruption market by the share of corruption bribes and is leading among other special markets of domestic corruption in terms of the annual volume on the corruption market. It should be noted that such indicators are primarily due to the extremely high level of citizens' contacts with the health care system in the total number of cases of their appeals to state institutions: 37% of such appeals fall precisely on medical institutions 8. The social consequences of domestic corruption in this area lead to the degradation of "human capital", as a result of which the life expectancy and the level of people's health decrease, and the intellectual capital is degraded [Andrichenko, Belyaeva, Vasiliev etc., 2014].
In the legal science there is a different approach to defining domestic corruption: the legal specific of this phenomenon lies in one of the subjects of the corruption relationship. Lawyers encompass these concept cases where one of the parties to the corruption relationship is a natural person without the status of a state and municipal employee, or state and municipal unitary enterprises and institutions.
In connection with the legal underdevelopment of the category "domestic corruption", its use in the anticorruption activities of the subjects of the Russian Federation is poorly developed. At the same time, the unity of the phenomena covered by this concept and their differentiation from corruption in general with the necessary obviousness require the adaptation of general legal measures to fight corruption to the specifics of corruption manifestations in the spheres of health care,
8 Report of the Ministry of Economic Development of the Russian Federation and the All-Russian Public Foundation «Public Opinion» «The state of domestic corruption in the Russian Federation (based on a sociological survey conducted in the second half of 2010)» // http:// www.economy.gov.ru/minec/activity/sections/anticorruptpolicy/ doc20 110614_027
education, etc. and specialization of anti-corruption legal mechanisms.
In some regions of the Russian Federation, health care is allocated as an area with an increased risk of corruption 9, which allows concentrating the regulatory efforts of regional and local authorities on the anti-corruption struggle in the field of protecting the health of citizens. Such special legal status of corruption in health care obliges to approve departmental anti-corruption programs in the sphere of public health by the supreme executive body or obliges the executive bodies of state power of the subject of the Russian Federation to adopt departmental plans of measures to counter corrup-tion.10
At the same time, the health authorities are assigned special powers in the field of combating corruption (implementing within the scope of their competence activities to execute anti-corruption policies, ensuring the implementation of measures to counter corruption in public health authorities, subordinate state unitary enterprises and state institutions, including autonomous institutions, etc.).
An anti-corruption correction of the legal status of persons who replaced civil service positions in public health authorities is being implemented, measures are being taken to prevent corruption offenses, such as: regulating the way of notifying about the facts of appealing in order to induce officials into committing corrupt practices, the way to register such notifications, the list of information contained in the notifications, the organization to audit the information [Andrichenko, Belyaeva, Vasilyev, 2014].
Typical shortcomings of the legal and regulatory framework for countering corruption in the subjects of the Russian Federation in the health sector include:
• the lack of structures and mechanisms to resolve conflicts of interest arising in the implementation of medical and pharmaceutical activities;
• the lack of involvement of public organizations, including patient associations, doctors, parents,
9 See, for example: Resolution of the Government of the Republic of Buryatia dated January 14, 2009 No. 2 «On the Republican target Program «Anti-Corruption in the Republic of Buryatia for 20092011», Decree of the Government of the Republic of Ingushetia dated September 8, 2012 No. 210 «On the Republican target program «On Counteracting Corruption in the Republic of Ingushetia for 2012-2014»; Resolution of the Government of the Karachay-Cherkess Republic of September 21, 2012 No. 385 «On the Republican target Program «Counteraction to Corruption in the Kara-chaevo-Cherkess Republic for 2012-2014, «Decision of the Makhachkala City Assembly of March 18, 2010 No. 24-3k «On approval of the city program «On combating corruption in Makhachkala for 2009-2011.»
10 See, for example, Law of the Voronezh Region of March 12, 2009 No. 43-OZ «On the Prevention of Corruption in the Voronezh Region»; Law of the Lipetsk Region dated October 7, 2008 No. 193-OZ «On Prevention of Corruption in the Lipetsk Region».
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teachers, in the implementation of anti-corruption activities;
• the underdevelopment of specialized anticorruption mechanisms.
Unlike the conflict of interests of federal civil servants from public health authorities, the situation of conflict of interests in the implementation of medical and pharmaceutical activities was not sufficiently resolved. A rare example of the legal development of anticorruption activities in this area is the Order of the Ministry of Health of the Republic of Tatarstan of March 11, 2012, No. 313 "On the Prevention of Corruption and the Elimination of Conflicts of Interest in Health Care Institutions of the Republic of Tatarstan," which provides the establishment in labor contracts of the responsibility of health workers for violations of standards of art. 75 of the Federal Law of November 21, 2011 No. 323-FZ "On the fundamentals of protecting the health of citizens in the Russian Federation."
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Pidde A., Novyy pravovoy status meditsinskikh uchrezhdeniy i programmy modernizatsii zdravookhraneniya v Rossii: voz-mozhnosti, problemy, riski [New legal status of medical institutions and health care modernization programs in Russia: opportunities, problems, risks] // Sotsialnaya politika i sotsi-alnoye partnerstvo [Social policy and social partnership] 2011. No. 4. Pp. 21-28.
Rodionov M. A. Sotsialno-politicheskaya bezopasnost Rossii [Socio-political security of Russia] / RAGS pri Prezidente RF. - M.: Izd-vo RAGS, 2009. Pp. 75-83.
The underdevelopment of specialized anti-corruption mechanisms in the healthcare sector is a characteristic defect not only of regional but also of federal normative legal acts. Thus, the legal regulation of anticorruption does not reflect the specifics of corruption offenses in the health care sector, which is that often its subjects are employees of health care institutions that are not state employees. The reasons for this state of modern anti-corruption legislation in the health care sector include the noted inadequacy of theoretical research in this area in both domestic and foreign literature [Vian, 2008; Balebanova, 2013].
The need for sectoral solutions requires that the constituent entities of the Russian Federation adapt existing general legal anti-corruption mechanisms and specialize in anti-corruption measures, taking into account the specifics of the health care sector
Son I. M., Soboleva N. P., Savchenko Y. D., Profilaktika neinfektsi-onnykh zabolevaniy, problemy i puti resheniya [Prevention of non-infectious diseases, problems and ways of solving] // Analiticheskiy vestnik Soveta Federatsii RF [Analytical Herald of the Federation Council of the Russian Federation] 2015. No. 44. Pp. 49-56.
Starodubov V. I., Rudnev S. G., Nikolayev D. V., Korostylev K. A., O kachestve dannykh profilakticheskogo skrininga v tsentrakh zdorov'ya i sposobe povysheniya effektivnosti byudzhetnykh raskhodov [About the quality of data on preventive screening in health centers and the method of increasing the efficiency of budgetary expenses] // Analiticheskiy vestnik Soveta Federatsii RF [Analytical Herald of the Federation Council of the Russian Federation] 2015. No. 44. Pp. 43-46.
Ulumbekova G. E., Zdravookhraneniye Rossii. Chto nado delat: nauchnoye obosnovaniye [Health care of Russia. What should be done: the scientific substantiation] / Strategii razvitiya zdravookhraneniya RF do 2020 goda, 2-e izd. [Strategy for the Development of Health Care in the Russian Federation until 2020, 2nd ed.] M.: GEOTAR-Media, 2015. 599 p.
Chukhrayev A. M., Upravleniye razvitiyem meditsinskikh kom-pleksov klyuchevoy kompetentsii v Rossiyskom zdra-vookhranenii [Management of development of medical complexes of key competence in Russian public health] Sankt-Peterburg: Chelovek, 2014. 263 p.
Shalnova S. A., Deyev A. D. Tendentsii smertnosti v Rossii v nachale XXI veka (po dannym ofitsialnoy statistiki) [Mortality trends in Russia at the beginning of the XXI century (according to official statistics)] // Kardiovaskulyarnaya terapiya i profilaktika [Cardiovascular therapy and prevention] 2011. No. 10 (6) Pp. 5-10.
Vian T., Review of corruption in the health sector: theory, methods and interventions // Health Policy and Planning. 2008. No. 23 Pp. 83-94.
