Implementation of the state policy in the field of healthcare as a factor of improving the quality of life of the population (regional aspect)

Bizin Sergei Viktorovich ORCID: 0000-0003-3462-5327 PhD in Economics Associate professor, Department of Public Administration and Management, Lipetsk State Technical University 398055, Russia, Lipetsk region, Lipetsk, Moskovskaya str., 30 april88@yandex.ru

Introduction

The relevance of the study is due to the fact that the priority strategic goal of public policy in our country is to improve the quality of life of citizens, while the health care system acts as a key social sphere, on the development and effective functioning of which the level of quality of life of each citizen and the nation as a whole depends.

The quality of life is a complex generalizing concept that includes as an integral part the "standard of living" and the indicators characterizing it, on the other hand, it evaluates the level of development in a particular territory of social sectors (health, education, social services. provision, culture, physical culture and sports, etc.) ^{[4, p.312]}.

Many methods are used to assess the quality of life, but in each of them the indicators of the healthcare industry occupy a significant place.

Thus, one of the most common ways to assess the quality of life is the method of calculating the quality of life index, which has been used since 2005 by the British research center and includes 9 indicators, the first of which is the indicator of public health – life expectancy ^[22].

In domestic practice, the methodology of calculating and rating the subjects of the Russian Federation on the quality of life, conducted annually by the Agency for Strategic Initiatives, which has a more practical orientation, is of the greatest interest. In the rating of the assessment of the efforts of regional executive authorities to create a high-quality environment for the lives of citizens, one of the key areas affecting the improvement of the quality of life of Russian citizens is medical care. The rating includes 16 indicators comprehensively assessing the effectiveness of healthcare in the subjects of the Russian Federation: satisfaction of citizens, average waiting time, indicators of accessibility of medical institutions, life expectancy at birth, etc. ^[21]

In addition, many researchers have noted the direct connection between the development of the healthcare system and the level of quality of life in their writings, emphasizing the crucial role of the state and the policy in the functioning of this industry ^[12].

Thus, Dyatlov S.P. ^[8] notes the fundamental role of health in ensuring the well-being of the population, and Samuilova I.A. and Minakova P.S. ^[24] on the basis of an empirical study (the survey "Assessment of quality of life" and analysis of the results) confirmed the hypothesis of the existence of a relationship between the quality of life, the level of trust and the assessment of the Russian healthcare system.

According to sociologists of the Financial University under the Government of the Russian Federation, a high quality of human life implies, including a sufficient duration of a healthy (active) life, supported by good medical care and safety (absence of significant threats to life and health) ^[18].

From a medical point of view, improving the quality of life is either the main or additional goal of treatment. An additional goal of improving the quality of life is if the disease can lead to a shortening of life, and the main one is if it cannot lead to a shortening of life or, conversely, if the disease is incurable and will certainly lead to the death of the patient. In the latter case, improving the quality of life remains the only goal of treatment ^[11].

It is worth noting that the study of the quality of life, the allocation of the concepts of "health" and "well–being of people" is a highly informative tool that determines the effectiveness of the medical care system and allows an objective assessment of the quality of medical care at the level of its main consumer - the patient, which is key in Russian state policy ^{[12, p.88]}.

The State health policy, being an integral part of the state social policy, is the activity of public authorities aimed at ensuring the effective functioning and development of the health system in order to protect the health of citizens, through the implementation of a set of legislative, executive and supervisory measures.

Currently, the problems of saving people, increasing life expectancy, protecting the health of citizens and the effectiveness of public policy measures in the Russian Federation are of key importance, since health is the main economic resource of an individual, and nationwide characterizes the quality of labor resources for the economy.

The information basis of the study was the key regulatory legal acts regulating this area, primarily Decree of the President of the Russian Federation dated 06.06.2019 No. 254 "On the Strategy for the development of healthcare in the Russian Federation for the period up to 2025", Federal Law No. 326-FZ dated 29.11.2010 "On Compulsory Medical Insurance in the Russian Federation", Federal Law of On 11/21/2011, No. 323-FZ "On the Basics of Public Health protection in the Russian Federation", and other regulatory legal acts at the federal and regional levels, as well as statistical data on the field under study, periodic, methodological and scientific literature.

The problems of the healthcare industry and its regional component add additional relevance. According to many researchers ^{[16, 17]}, the most acute problem of the healthcare system is the provision of medical personnel (both doctors and secondary medical personnel) and the effectiveness of personnel policy (the level of personnel planning, the shortage of employees of narrow specializations, etc.).

Another problem is the insufficiency of the work carried out by healthcare institutions in the education and popularization of a healthy lifestyle, including among young people, as evidenced by the high proportion of the population with drug and alcohol addictions ^{[8, p.648]}.

Among the main challenges of the healthcare system in the Russian Federation, accessibility of medical care is also highlighted, when residents of remote territories do not always have access to the necessary services of the healthcare industry (including due to lack of financial opportunities for movement) ^{[8, p.647]}, primarily for the population living in rural areas ^[20].

Also, the key problems of the healthcare industry are the low provision of preferential medicines to citizens in need. ^{[7, p.56]}.

Many scientists see one of the main reasons for the current situation in the industry as insufficient funding for the medical sector. For example, I. P. Katkova points to "...low levels of public spending on healthcare in Russia" ^[10], and Yu. Yu. Sadovnikova, L. N. Timeychuk and G. G. Uvarova argue that "a negative trend is a reduction in the number of medical institutions, which indicates an underfunding of the industry and leads to an increase in the sector of private medical services and reducing the availability of medical care" ^[23].

The consequence of these trends is the lack of free places and the possibility of making an appointment with a doctor in public institutions, giving rise to long queues for medical services by the population, especially for high-tech medical care.

Research methods and results

The reliability of this study is provided by extensive empirical material and a system of its study. The research methods include content analysis, statistical data analysis, comparison, description, generalization.

Theoretical and normative approaches to public health policy

In recent years, there have been fundamental changes in the socio-economic situation in the country, which have affected all spheres of society ^{[5, p. 16]}.

The pandemic caused by the new coronavirus infection, structural changes in the economy, and the subsequent decline in the standard of living of the population led to the emergence of negative trends in the dynamics of public health. On the other hand, the ongoing special military operation and unprecedented sanctions imposed on the Russian Federation have led both to the emergence of new problems in the healthcare industry and exacerbated systemic problems.

To date, there are a number of studies devoted to aspects of the essence and content, as well as practical issues of applying various tools and implementing public policy in the healthcare system both in Russia and at the regional level. These directions are reflected in the works of famous Russian scientists, Ulumbekov G. E. ^[25], Sadovnikov Yu. Y. ^[23], Kuzmin A.V. ^[14], Kozlikov S. P. ^[13], Lobyntsev I. I. ^[15], Arslanbekov A. Z. ^[1] and other scientists ^[30]. Much attention is also paid to the research of certain key issues of state policy in the field of health protection: strategic planning ^{[2, 28, 31]} staffing ^[17] and digitalization of healthcare ^{[9, 26, 27, 29]}.

Public health protection is the most important function of the state, enshrined in Article 41 of the Constitution of the Russian Federation. Public health protection is defined as a system of measures of a political, economic, legal, social, scientific, medical, including sanitary and anti-epidemic (preventive) nature, carried out by state authorities of the Russian Federation, authorities of subjects of the Russian Federation, local governments, organizations, their officials and other persons, citizens in order to prevent diseases, preserving and strengthening the physical and mental health of each person, maintaining his long-term active life, providing him with medical care (Federal Law No. 323-FZ of 11/21/2011 "On the Basics of protecting the health of Citizens in the Russian Federation").

In accordance with the Decree of the President of the Russian Federation dated 06.06.2019 No. 254 "On the strategy for the development of healthcare in the Russian Federation for the period up to 2025", the state policy in the field of public health protection is a key factor in the quality of life of the population and is implemented through adoption and execution:

- programs of state guarantees of free medical care to citizens (territorial programs in the Lipetsk region),

- the state program of the Russian Federation "Development of healthcare" and state programs of the subjects of the Russian Federation (the state program "Development of healthcare in the Lipetsk region"),

- national projects "Healthcare" and "Demography", as well as federal projects (regional projects of the Lipetsk region) that are part of them,

- departmental targeted programs (regional programs "Modernization of primary health care in the Lipetsk region", "Development of the palliative care system" in the Lipetsk region, etc.).

According to Kuzmin A.V., "state policy in the field of healthcare, it seems, should be understood as the activity of the state in this area, aimed at ensuring its effective functioning and development" ^{[14, p. 158]}.

Public policy includes targeted actions implemented in practice by government agencies with the active participation of civil society institutions. ^{[1, p. 68]}.

Management of the development of the healthcare sector is a set of measures aimed at creating and optimizing the socio-economic, legal and organizational conditions for the functioning of the industry. When managing healthcare, it is necessary to take into account its specific features. In this context, state regulation of the healthcare system plays a major role as an integral factor of human life.

The political activity of the State is carried out through the mechanism of state social security programs and the system of providing social services. The state forms and creates a general concept and main directions for the development of the healthcare system, as well as provides legislative and legal support for the industry ^{[15, p.29]}.

The main goal of improving the development of healthcare is to improve the quality and accessibility of medical care to the population ^{[6, p. 6]}. 

Thus, the state health policy, being an integral part of the state social policy, is the activity of public authorities aimed at ensuring the effective functioning and development of the health system in order to protect the health of citizens, through the implementation of a set of legislative, executive and supervisory measures expressed in the implementation of targets and measures (control points) government programs and national projects.

Implementation of the state policy in the field of healthcare (on the example of the Lipetsk region)

The Lipetsk region is a typical region of the Central Chernozem region in terms of the territorial organization of the population and the main medical and demographic trends. The compact size of the region, the average population density, and the developed transport infrastructure ensure the availability of medical care (Fig. 1). There are no settlements outside the medical care area in the region ^[19].

Figure 1 – The structure of the Lipetsk region health care network

The medical network of the Lipetsk region includes 89 polyclinics and polyclinic departments (33.7 thousand visits per shift): 35 for children, 54 for adults, as well as 38 round–the–clock hospitals with a capacity of 8884 beds (79.8 per 10 thousand people) – 6415 MHI beds and 2454 beds funded from the regional budget.

The capacities of the regional medical network generally correspond to the level and structure of morbidity of the population, taking into account the age structure of the population (Fig. 2), and the established standards for the volume of medical care

Figure 2 – Age structure of the Lipetsk region population, %

An important advantage of the organization of medical care in the Lipetsk region is the preserved infrastructure of rural healthcare. In rural healthcare, there are 18 district and central district hospitals, 68 general practice departments, 22 outpatient clinics, 376 paramedic and obstetric stations.

As part of the implementation of the model for achieving the national goal of increasing life expectancy, the Lipetsk region, on the one hand, focused efforts on reducing premature mortality of the population, on the other hand, within existing capabilities, we ensure an increase in the birth rate.

In terms of reducing premature mortality, the region has achieved significant improvements in public health over the past year. Among the subjects of the Russian Federation that are part of the Central Federal District, the Lipetsk Region ranked fifth in terms of total mortality (Fig. 3).

Figure 3 – A model for achieving the national goal of increasing life expectancy in the Lipetsk region

An effective tool for improving the state of public health is medical prevention, implemented in the form of medical examinations and preventive examinations, as well as mass preventive actions of various directions. By the end of 2022, the region was ranked 20th in terms of carrying out preventive examinations and medical examinations of the population (59.8% in the region, 35.3% in the Russian Federation) and 16th in terms of carrying out in-depth medical examinations of the population (100% in the region, 77.7% in the Russian Federation)

More than 12 thousand people applied to public health centers, more than 160 thousand residents of the region were trained in the basics of a healthy lifestyle. More than 26 thousand people have been trained in the "Health Schools" operating in medical organizations in the region. In general, in 2022, more than 6.8 thousand preventive measures and actions were carried out, covering about 270 thousand people.

Despite the achieved results, a number of territories did not cope with the planned volumes of preventive work. The reasons for this are explained both by organizational miscalculations when planning a preventive campaign at the level of specific medical organizations, and due to insufficient motivation of citizens, primarily working people, to undergo an examination. In this regard, the regional Government, since last year, has introduced the practice of weekly listening to the heads of local governments in order to create favorable conditions for medical examinations and occupational examinations on the ground, including through direct interaction with employers and organized labor collectives.

The total mortality rate in the reporting period decreased by 27% compared to 2021 and reached 15.3 per 1,000 people. The value of life expectancy was 72 years, exceeding the corresponding level in 2021 by 3.4 years. A more or less pronounced decrease in mortality affected all territories of the region without exception. At the same time, the mortality rate of the entire population turned out to be 7% higher than the corresponding level in 2019, which indicates the available reserves for further improvement of the medical and demographic situation (Fig. 4).

Figure 4 – Mortality rates in the Lipetsk region

Taking into account the importance of diseases of the circulatory system in the formation of public health in the region, a vertically integrated system of medical care for patients with a cardiological profile has been formed, represented by four primary vascular departments and two regional vascular centers.

Since 2020, the Lipetsk Regional Clinical Center has been operating a Center for the Diagnosis and Treatment of Chronic Heart Failure with load testing and expert ultrasound diagnostics rooms, a cardiology department and an intensive care unit.

A cardiological dispensary has been operating in the Lipetsk Regional Clinical Hospital since 2021, which ensures the organizational and methodological unity of the process of providing affordable, high-quality and timely medical care to patients with cardiovascular diseases.

In order to support the decision to conduct thrombolytic therapy at the pre-hospital stage, as well as for the round-the-clock processing of ECGs remotely transmitted by emergency medical teams and the prompt issuance of expert opinions, a Single Advisory Center (ECC) has been operating in the region since 2021. ECC specialists provide round-the-clock advisory assistance for acute coronary syndrome and other acute forms of circulatory system diseases in patients at home, when calling an ambulance, take using the tele-ECG method and decode electrocardiograms with recommendations on patient management tactics, including addressing the need for thrombolytic therapy in acute coronary syndrome.

In order to reduce the time of delivery of emergency patients from the districts of the region to Lipetsk, as well as to the federal centers of Russia, air ambulance flights are carried out. In 2022, known flight restrictions were established, but in agreement with the Russian Ministry of Defense, in difficult cases, permission to transport patients can be negotiated.

Intensive development of high-tech methods of diagnosis and treatment of vascular diseases is provided in the health care of the Lipetsk region. According to the results of last year, more than 10,000 angiographs were performed, about 3,000 angioplasty, including 2,570 with stenting (Fig. 5).

Figure 5 – Indicators of diseases of the circulatory system

This year it is planned to overcome the milestone of 3,000 stenting, all the necessary forces and means are available for this.

Since last year, the region has begun to solve the problem of further replication of high-tech vascular operations. To this end, on the basis of Yelets City Hospital No. 1 named after N.A. Semashko, an X-ray surgical operating room equipped with a modern angiographic installation was created at the expense of the regional budget, and the volume of high-tech care was determined.

In order to improve the quality and accessibility of medical care for cancer patients, 5 outpatient cancer care centers with 28 beds for chemotherapy have been established in the region under the organizational and methodological guidance of the regional oncological dispensary. This year, work has begun on the creation of the sixth CAOP as part of the Lebedyanskaya CRH. Thanks to the coordinated work of oncologists, the early detection of malignant neoplasms increases, timely initiation of treatment is ensured and mortality from neoplasms is reduced (Fig. 6).

Figure 6 – Indicators of medical care for cancer patients

Systematic work is being carried out in the health care of the Lipetsk region to increase the birth rate. Due to the continuous improvement of the activities of the maternity and childhood service in close cooperation with the relevant federal NMIC, a reduction in infant mortality and a reduction in the number of abortions is ensured (Fig. 7), including through an active awareness campaign among pregnant women and the provision of medical and psychological assistance to women in a situation of reproductive choice: monitoring the main reasons that prompted a woman to apply on abortion; interaction with NGOs; programs: "Youth for healthy lifestyle", "I know, I act, I live", "Small homeland - family"; placement of social advertising in publicly accessible places; "scripts" with social support measures.

Figure 7 – The proportion of women who have decided to carry a pregnancy out of the number of women who have applied to medical organizations for termination of pregnancy

The years of testing by the coronavirus epidemic have demonstrated the special importance of human resources. In 2022, it was not possible to reduce the shortage of doctors and paramedical personnel (staffing and provision of medical personnel are in the range of 88.4% to 96%). In fact, the regional project "Providing medical organizations of the healthcare system with qualified personnel" turned out to be the only unfulfilled among all other program-targeted activities of the national project "Healthcare", for which performance targets were achieved.

At the end of the year, the number of doctors and average health workers decreased by 279 and 842 people, respectively. Such a marked decrease in the number of health workers in 2022 is mainly due to the amendment of the current legislation in the field of pension provision, according to which the annual indexation of pension payments to working pensioners was canceled. Due to the significant increase in pension provision in 2022, retired medical workers who continue to work are forced to terminate their employment relationships in order to be eligible for pension provision indexation (Fig. 8).

Figure 8 – Analysis of health care staffing indicators in the Lipetsk region

The decrease in the number of medical workers could have been even more significant if it had not been for the comprehensive measures implemented at the regional level to reduce the shortage of public health personnel:

1. Development of the Lipetsk region pre-university in cooperation with medical universities (31 medical classes).

2. An increase in the number of students in medical universities and colleges (a fivefold increase in scholarships for students of medical universities studying according to the target set from the Lipetsk region).

3. Implementation of comprehensive social support measures for health workers in the most scarce specialties:

- one-time social payments "Governor's one and a half million",

- social payments for the construction and purchase of housing,

- compensation for rental expenses.

4. 100% participation of health workers in the system of continuing education.

5. Organization of the activities of 4 clinical bases for postgraduate training of doctors.

6. Creation of an online version of the Center for attracting medical personnel of the Lipetsk region.

There is a three-stage system of medical personnel training in the Lipetsk region.

The first stage is career guidance. To ensure the active career guidance of applicants for medical specialties, the scientific and educational medical cluster "Preuniversary of the Lipetsk Region" operates in the region in the form of 31 medical classes created under the auspices of the Voronezh and Ryazan State Medical Universities.

The second stage is the stage of professional education. By the forces and means of regional medical colleges, this year it is planned to open medical classes in 11 more municipal districts that previously did not have such a form of organization of the educational process.

The number of medical students studying under "targeted" contracts has increased by 10%. Currently, more than 800 students are being trained for regional healthcare.

In accordance with the instructions of the President of the Russian Federation, admission to Lipetsk and Yelets medical colleges has been increased by 30%.

The third stage is the stage of postgraduate education. 100% participation of health workers in the system of continuing education has been achieved, including through the use of distance learning technologies that form the necessary professional competencies and qualifications.

Intensive development of clinical bases has been ensured, providing for the introduction of practice-oriented technologies into the educational process and the expansion of cooperation between medical universities and healthcare institutions in the region. To date, the region has four clinical bases operating at the sites of the Lipetsk Regional Clinical Hospital, the Regional Children's Hospital, the Lipetsk Regional Oncological Dispensary and the Lipetsk Regional Clinical Center.

In order to reduce the shortage of medical personnel in rural areas, the implementation of the federal programs "Zemsky Doctor" and "Zemsky Paramedic" continued, which made it possible to attract 440 doctors and 78 paramedics to regional and central district hospitals in the region since 2012 (Fig. 9).

Figure 9 – Implementation of the Zemsky Doctor and Zemsky Paramedic programs in the Lipetsk region

At the same time, these programs are becoming less attractive to their potential participants due to a decrease in the purchasing power of the proposed social benefits.

At the beginning of the implementation of the Zemsky Doktor program in 2012, a social payment of 1 million rubles allowed the participating doctor to purchase a 1-2-room apartment or house in the Lipetsk region. The current payment amount of 1-1.5 million rubles, even if there are regional social support measures of comparable value, does not allow this to be done. Similarly, the established payment amounts of 500 and 750 thousand rubles are not attractive enough. for paramedics.

In the context of the continuing personnel shortage in the region, emphasis is being placed on improving the efficiency of existing personnel, including by reducing inappropriate workload.

The introduction of new organizational processes for the provision of medical care developed by the NMIC of Therapy and Preventive Medicine of the Ministry of Health of the Russian Federation continued (Fig. 10).

Figure 10 – Introduction of new organizational processes in healthcare in the Lipetsk region

These processes are designed to reduce the unreasonable burden on doctors and nurses, primarily those employed in the district service. Among them, an important place is occupied by improving the work of emergency medical care. The result of this work is the release of district doctors and secondary health workers from servicing calls at home. The district doctor and the nursing staff employed with him should devote all their time to receiving patients within the walls of the polyclinic.

To date, emergency departments (offices) have been established in all adult and children's polyclinics and polyclinic departments of the region. Their number has increased from 32 in 2021 to 56 in 2022: 36 offices (departments) for adults and 20 for children.

The staffing of emergency departments and offices is mainly carried out by personnel with secondary medical education. The experience of attracting paramedics, midwives, and nurses during the epidemic spread of a new coronavirus infection to perform functions previously classified as medical has shown that medical workers with secondary education can solve most routine medical and diagnostic tasks. And only in rare cases they are forced to seek medical help.

In 2022, the practice of assigning certain functions of the attending physician to paramedics and midwives with insufficient staffing of the medical organization providing primary medical care, internists, district doctors and general practitioners continued. Thus, 59 paramedics were involved in the work at the sites.

Of course, involving paramedics to work at the sites is a forced decision, but in the context of the dilemma between accessibility or quality of medical care, it is advisable to make a choice in favor of accessibility, as demonstrated by the coronavirus epidemic.

Another practice designed to alleviate the severity of the shortage of medical personnel last year was the project "Taking care of you". For the first time, a mechanism was tested for transferring a number of functions previously performed by district nurses and paramedics to junior nursing staff.

For this purpose, about fifty people who had never worked in the healthcare sector before were recruited to 11 polyclinics, who were trained at a medical college and brought to the site in 4 months. To date, it can be argued that the project turned out to be quite successful and can be recommended for replication on a regional scale. Junior nurses not only fully cope with the implementation of a number of procedures related to the maintenance of pre-medical primary health care, but also successfully solve tasks in the positions of duty administrators, medical registrars, etc.

It is worth noting that in areas excluding the mandatory availability of medical workers, persons without medical education are employed: most of the routine document management is assigned to such employees (623 people are employed in state medical organizations).

Digitalization of regional healthcare is an important area of activity of the Lipetsk Region healthcare system, which ensures an increase in the efficiency of the industry, as well as reducing the burden on medical personnel by automating a number of processes.

In order to promptly present and visualize analytical information in 2022, the Lipetsk Region implemented the dashboard "Regional Information and Analytical Medical System of the Lipetsk Region (RIAMS)", intended for use by the chief physicians of the region. The dashboard forms an operational monitoring of the availability of an appointment with a doctor, and also helps to control the formation of electronic medical documents at the level of a medical organization (Fig. 11).

Figure 11 – Dashboard "Regional information and analytical medical system of the Lipetsk region (RIAMS)"

In cooperation with the Ministry of Health of the Russian Federation, in order to improve the quality of the therapeutic and diagnostic process through its information support, vertically integrated medical information systems (VIMIS) in the profiles "Cardiovascular diseases", "Oncology", "Obstetrics, gynecology and neonatology" are being actively introduced into practice.

In September 2022, the Lipetsk region launched VIMIS "Preventive Medicine", which allows real-time monitoring of all stages of dispensary supervision, medical examination, preventive and medical examinations and vaccination.

At the initiative of the Government of the Lipetsk Region, the implementation of an Intelligent Management System (IAS) continues in the region. The PSU is based on the principle of improving the efficiency of employees.

This principle is implemented using automatic analysis of the actions of medical personnel in information systems when performing production activities; search for growth points in the work of each individual employee based on computer algorithms; automatic task generation for employees and managers with recommendations of specific steps to improve work efficiency, as well as automatic control of the performance of these tasks.

In 2022, in cooperation with the Central Research Institute of the Lipetsk Region, the Lipetsk region implemented the project "Making an appointment with a doctor" (Fig. 12). In public medical organizations providing primary health care," a list of specialties of doctors has been defined, the schedule of which should be available for self-registration on the Unified Portal of Public Services and functions, through information desks located in medical organizations, call centers and registries.

Thanks to the proven processes, a reduction in patient waiting time at the registry is ensured; an increase in the productivity of medical registrars and the quality of service to citizens, as well as standardization of the personnel management process.

Figure 12 – Implementation of the pilot project "Making an appointment with a doctor"

The Government of the Lipetsk Region, in close cooperation with the federal center, ensures the financial stability of the regional healthcare system.

30.5 billion rubles were allocated for financial support of the Lipetsk Region's State Program "Development of Healthcare in the Lipetsk Region" in 2022, and 31.2 billion rubles were provided in 2023. (fig. 13).

Figure 13 – Financial stability of the region's healthcare system

Accounts payable of state medical organizations are monitored on an ongoing basis and the reasons for the formation of overdue accounts payable are analyzed. It should be noted that the presence of overdue accounts payable is typical for medical organizations providing medical services in the compulsory health insurance system.

Figure 14 – Accounts payable of state medical organizations of the Lipetsk region

As of February 1, 2023, the amount of overdue accounts payable for MHI funds with a term of three months or more amounted to 66.37 million rubles.

The main reasons for the formation of overdue accounts payable is the redistribution of funds to ensure the growth of salaries of medical workers at a rate faster than the growth in the volume of subventions from the budget of the federal compulsory medical insurance fund.

In the health care of the Lipetsk region, measures are being implemented aimed at reducing unjustified and inappropriate expenses for the maintenance of the medical network of the region, optimizing the number of other personnel.

In order to maintain financial stability, funds from the regional budget are allocated to repay overdue accounts payable on compulsory medical insurance. So, in 2021, about 800 million rubles were spent for these purposes, in 2022 - more than 700 million rubles.

Last year, the Lipetsk region ensured the implementation of the entire range of measures related to the construction and repair of healthcare facilities, the purchase of medical equipment, vehicles and equipment within the framework of the implementation of the national project "Healthcare" and the state program "Development of Healthcare in the Lipetsk region":

1. Built and put into operation:

- an operating unit with the department of anesthesiology and intensive care of the regional oncological dispensary,

- polyclinic building of the Lipetsk City Children's Hospital (including the creation of a rehabilitation center),

- children's polyclinic and women's consultation GUZ "Chaplyginsky district Hospital",

- 2 departments of general medical practice,

- 4 paramedic and obstetric stations.

2. 58 major repairs and 4 reconstructions were carried out in 34 medical organizations.

3. Purchased:

- 48 vehicles (including 12 ambulances),

- 1165 units of medical equipment and medical products.

According to the estimates of the Ministry of Health of the Russian Federation, the Lipetsk region is among the regions that have fulfilled the targets for strengthening the material and technical base by 100%.

One of the key results of evaluating the effectiveness of the implemented state policy in the field of healthcare in the Lipetsk region is public opinion on the satisfaction of the population with medical care (Fig. 15).

Figure 15 – Assessment of public opinion on the satisfaction of the population of the Lipetsk region with medical care

By the end of 2022, according to the information of the Ministry of Health of the Russian Federation, the average Russian indicator of public satisfaction with medical care turned out to be 42.7%. In the Lipetsk region, this indicator, measured according to the federal methodology, amounted to 45.7%.

 Results and conclusions

Improving the quality of life of the population is one of the most priority strategic goals for the development of the country and regions ^{[3, p. 1226]}, and state policy in the field of health protection is its most important component.

The main task of the healthcare system is to preserve and restore human health, increase life expectancy by reducing morbidity and mortality, which, in turn, should help stimulate the growth of human capital, lead to an increase in the well-being of citizens and the national income of the country.

The study analyzed the main aspects of the health care system of the Lipetsk region that determine the quality of life: life expectancy of the population, which amounted to 72 years by the end of 2022; satisfaction of the population with medical care (45.7% under the plan – 43.5%); mortality rates, including for key diseases – neoplasms and diseases of the circulatory system (significantly decreased in 2022). The positive dynamics of these indicators and the availability of potential for growth gives an objective positive assessment of the quality of medical care in the region and, as a result, indicates an improvement in the quality of life of the population.

It is worth noting that the positive dynamics of indicators in 2022 is due to objective factors, primarily the "effect of a high base" of mortality in 2020-2021. Given the current trends, it is possible to predict a further increase in public health indicators in 2023, taking into account the increased mortality of the population in the 1st quarter of 2022 (due to the incidence of COVID-19 and its consequences), and the achievement of the values of the "pre-epidemic" level in 2019.

At the same time, it is not correct to downplay the positive contribution to the state of public health of effectively implemented measures of state policy in the field of health protection in the Lipetsk region, considered in this study: improvement of current and introduction of new organizational processes of medical care; large-scale re-equipment of medical facilities in the region; continuous improvement of the activities of the maternity and childhood service; creation of new facilities and departments (CAOP, cardiological dispensary, center for diagnosis and treatment of chronic heart failure, etc.); digitalization of regional healthcare (including the implementation of the pilot project "Doctor's appointment").

Currently, strategic planning documents are being developed and implemented at the federal and regional levels (strategies, state programs, projects) in the field of state regulation and management of the healthcare system aimed at achieving citizens' satisfaction with high-quality and affordable medical care at all its stages, while the effectiveness of their implementation and public policy in general varies in each subject of the Russian Federation.

In the Lipetsk region, despite a number of problems (personnel shortage, high incidence of certain diseases, accounts payable of healthcare institutions, etc.), the state policy in the field of healthcare is being implemented quite successfully. The correctness of the chosen strategy for comprehensively improving the quality and accessibility of medical care is confirmed by data from federal and regional statistics, as well as the results of the analysis conducted in this study.

It is worth noting that the problems of the healthcare system of the Lipetsk region correlate with the problems of the healthcare industry of the Russian Federation described in scientific research ^{[16, 17, 7, 10]}.

The only significant difference is the problem of territorial accessibility ^{[8, 20]}, which is not relevant for the region due to administrative and geographical features - the Lipetsk region is compact and an extensive medical network ensures that the need for most types of medical care for the population is met. In addition, the region has almost complete Internet coverage, which contributes to a high level of digitalization of healthcare (primarily telemedicine services).

On the other hand, a reduction in the number of medical institutions ^[7] in the Lipetsk region also occurs, but, as a rule, not due to the closure of facilities, but due to the transformation of their organizational structure: for example, the unification of all children's polyclinics in Lipetsk under the leadership of the Lipetsk City Children's Hospital or the unification of emergency medical stations into a system GUZ "Center for Emergency Medical Care and Disaster Medicine of the Lipetsk region". Another reason may be the transformation in accordance with the order of the Ministry of Health of the Russian Federation dated 02/27/2016 No. 132n "On the requirements for the placement of medical organizations of the state health system and the municipal health system based on the needs of the population": during the construction of an object to replace the existing one, its type is determined based on the number of the attached population (for example, in the case of a decrease in the number below 2000 people. in the locality, a FAP will be built instead of an OOP).

To solve the existing problems of the health care system of the Lipetsk region and improve the effectiveness of public policy, it is advisable to consider the possibility of implementing a set of practical recommendations in the following areas:

1. Analysis and development of organizational management solutions:

1) conducting a regular analysis of the medical and demographic indicators of the Lipetsk region, indicators of the state and activity of the healthcare system with the identification of the most unfavorable trends (up to the level of municipalities of the Lipetsk region and medical organizations) with the adoption of organizational and managerial decisions;

2) conducting on an ongoing basis an analysis of the causes of mortality from diseases of the circulatory system and neoplasms in individual medical organizations, an analysis of preventable mortality;

3) based on the analysis of public health indicators, promptly redistribute material and organizational resources for timely risk management;                                                                                                             

4) conducting an analysis of existing legal acts and developing algorithms to ensure the availability of primary health care and specialized medical care to patients, including the timing of medical care in accordance with the Program of state guarantees of free medical care to citizens;

5) formation of a plan for preventive medical examination, medical examination (including in-depth medical examination) and medical supervision (monthly, weekly) with decomposition to the level of the therapeutic site;

6) organization of preventive medical examinations by citizens, medical examinations (including in-depth medical examinations), including in the evening and on Saturdays, as well as providing citizens with the opportunity to make remote appointments with medical professionals;

7) conducting an information and communication campaign for the population on a regular basis (in the media and social networks) regarding the need and timeliness of preventive measures in order to identify the initial manifestations of chronic pathology, as well as in terms of increasing early access to medical care when symptoms of diseases manifest, increasing adherence to medical recommendations for the prevention of diseases and complications;

8) an increase in the volume of mobile teams' field work to increase the availability of medical examinations and examinations within the framework of dispensary supervision in rural areas, in remote and hard-to-reach areas of the Lipetsk region;

9) improving the activities of Health Schools for patients, including using field forms of work in labor collectives, as a mandatory method of dispensary observation and treatment of patients;

10) the introduction of a proactive invitation for patients under dispensary supervision to see a doctor, ensuring a planned referral for specialized care for cardiovascular diseases and malignant neoplasms.

2. Promoting a healthy lifestyle:

1) carrying out a set of measures aimed at the prevention of diseases, hygienic education and formation of a healthy lifestyle among the population, including information and explanatory work through the media, social networks and social advertising, distribution of printed products and preventive measures;

2) implementation of corporate programs containing the best practices for improving the health of employees;

3) implementation of municipal public health programs;

4) regular monitoring of the incidence of alcoholism in the context of municipalities;

5) updating and correcting interdepartmental plans/programs for the prevention of drunkenness and alcoholism, the use of narcotic and psychoactive substances, providing for strengthening the work of psychiatric and narcological services.

3. Measures to attract medical personnel to the region and reduce the personnel deficit:

1) increasing the attractiveness of the Zemsky Doctor and Zemsky Paramedic programs using additional regional social support measures;

2) improving the efficiency of existing staff, including by reducing the unreasonable burden on medical personnel – introducing the practice of attracting staff without medical education and optimizing the process of working with the patient queue;

3) improvement of career guidance: opening of additional medical classes in schools located in municipal areas; field events with the participation of medical personnel, etc.;

4) additional recruitment in the target area at the expense of the regional budget and municipalities.

4. Strengthening the material and technical base: accelerated implementation of program and project activities in 2024 and 2025 for the construction, reconstruction and overhaul of healthcare facilities, as well as advanced purchase of vehicles and medical equipment with the involvement of budget loans.

Moreover, taking into account the high incidence of neoplasms and in order to increase the availability of oncological care, it is necessary to consider the possibility of opening and equipping an outpatient oncological care center in the village of Terbuny in the Terbunsky district of the Lipetsk region (covering Volovsky and Dolgorukovsky districts), since this territory does not have a full-fledged oncological service.

5. Improving the financial stability of the healthcare system.

The problem of accounts payable of medical organizations in the compulsory medical insurance system is inevitable, since the annual growth rate of subventions from the FFOMS budget is below the inflation rate (8.7% for 2023, with inflation in 2022 in the Lipetsk region – 13%), which exacerbates the underfunding of the industry and the above problems.

Repayment of accounts payable is carried out at the expense of the regional budget, in this regard, it is advisable to conduct weekly monitoring of its condition, dynamics and structure in order to allocate funds in a timely manner, preventing the growth of overdue debts.

In addition, it is necessary to reduce inefficient expenses of medical organizations: transfer illiquid assets and facilities to the regional treasury, create a single centralized accounting department in healthcare, strengthen control and supervisory measures for financial activities, etc.

On the other hand, it is necessary to increase the volume of state funding for the health care system of the Lipetsk region.

6. To ensure the timeliness and full availability of preferential medicines to the population by improving the process of turnover and public procurement of medicines and medicines, reducing bureaucratic delays, expanding the network of state pharmacies, and primarily in rural areas.

7. Continue to actively implement digitalization tools in the region's healthcare system: develop a regional information and analytical medical system (including electronic document management, creation of digital patient profiles, etc.), develop and implement chatbots for pregnant women, patients with diabetes, hypertension, with the possibility of emergency doctor calls, etc.

Thus, the implementation of a set of state policy measures to improve the organizational processes of medical care, optimize personnel functions, digitalize and strengthen the material and technical base allows to reduce the negative impact of problematic aspects on the health sector of the region and, as a result, improve the quality of life of the region's population.