Analysis of health care systems in different countries reveals urgent problems in general in medicine at the national and global levels. The modern development of this area depends mainly on the progress of biomedical sciences and the use of innovative educational technologies in the training of medical personnel.

Each country has its own health care system, the characteristics of which are determined by different circumstances. There are several classifications of "states" and institutions depending on the country's health care system. Let's dwell on them in more detail.

• 1. According to the polarization of the socio-political structure of society, it is conventionally accepted to distinguish the following types of health care systems:
  • a) classical (disordered);
  • b) pluralistic;
  • c) insurance;
  • d) national;
  • e) socialist.
• 2.From the point of view of Russian scientists (OP Shchepina, VB Filatov, Ya.D. Pogorelov, etc.), it is customary to single out the following health care systems:
  • a) utilitarian;
  • b) communal;
  • c) liberal.
• 3. Domestic practice, headed by G. Zharkovich and co-authors, I propose to put the theory of a "prosperous society" as the basis for the typology of health care systems. I.A. Torgunov et al. Note that the basis should be the relationship between the doctor and the patient from the point of view of the legal foundations of the individual.
• 4. Foreign practice (WHO experts: S. Hakansson, B. Majnoni, D'Intignano, GH Mooney, JL Roberts, GL Stoddart, KS Johansen, H. Zollner) offers three health systems:
  • a) state or Beveridge system;
  • b) the Bismarck system - a system based on comprehensive health insurance;
  • c) non-state, market or private health care system.

• 5. Another group of authors distinguishes the following types of systems:
• 1) universalist (Beveridge model);
• 2) social insurance (Bismarck model);
• 3) "southern model" (Spain, Portugal, Greece and partly Italy);
• 4) institutional or social democratic "Scandinavian model";
• 5) liberal (residual social security);
• 6) conservative corporate (Japan);
• 7) Latin American;
• 8) health care systems of the industrialized states of East Asia;
• 9) health systems of countries with "transitional economies". [1]

As you can see, based on the name of the "pure" models at present

At the same time, the healthcare system in Russia tends more towards an insurance medical model, which is designed to provide social protection to the population in the field of health protection and act as a guarantor of receiving and financing medical care on the basis of insurance principles. At the same time, the receipt of medical services is assumed both in cases of treatment of actual diseases, and in the implementation of preventive measures. This model is essentially designed, on the one hand, to reduce the share of private funding, as in the case of a predominantly private health care system, and on the other hand, to improve the quality of services provided, which, as we see, is often a pressing problem in countries with health systems, the most close to the Beveridge model.

Thus, each of the presented models has both advantages and disadvantages.

Germany is the most prominent example of a health financing insurance system. The first national health care system, created by Chancellor O. Bismarck in 1881, was a program of insurance for workers and their families and was based on the laws already in force at that time on compensation for railway workers (1838) and on miners' societies (1854). ).

The most important feature of German health care is a clear boundary between public health (sanitary and epidemiological surveillance, health education, clinical examination, etc.), primary and specialized outpatient care and inpatient care. Primary and specialized outpatient care in the country is mainly private and commercial. Short-term and long-term care is provided on a commercial and non-commercial basis with the involvement of nurses and nurses, elderly care workers, and social workers.

Structurally, in Germany, about half of the doctors working in primary health care are specialist doctors; 5% of all physicians in private practice have the right to treat patients in a hospital; the rest send their patients for inpatient treatment to hospitals, and after discharge they take them for follow-up care and rehabilitation.

In recent years, special departments in hospitals have also begun to provide primary health care in Germany. A contract has been developed that permits the provision of primary health care in hospitals for 400 types of interventions, and for 150 diseases, outpatient (one-day) surgery has become mandatory. It is believed that about a third of operations can gradually move to outpatient practice.

In France, a health care system of a mixed type has developed, combining the principles of the Beveridge and Bismarck systems, i.e. financing is carried out at the expense of health insurance premiums and at the same time is under the strict control of the state.

In France, primary and specialized outpatient health care, which does not require hospitalization, is provided by private practitioners, dentists, other health professionals, and doctors employed by hospitals and clinics. Hospitals account for approximately 15% of all outpatient consultations. Outpatient care, albeit on a smaller scale, is also provided by about 1000 polyclinics (state, mutual insurance societies, charitable foundations, etc.). Typically, patients pay directly for MU and then receive a set amount of reimbursement from their insurance fund.

Outpatient care in France is provided mainly by private practitioners (GPs and specialists), most of whom work alone. Only 38% of doctors are united in groups (more often it is a GP), thus striving to optimize the time of admission to patients, as well as to share expensive equipment in their work.

There are public, private non-profit and private for-profit hospitals in France. They can provide both specialized and non-specialized MT. Public hospitals make up a quarter of all hospitals (1000 out of a total of 4000), and their bed capacity is 320 and 490 thousand, respectively.

Public health, primary care and specialized care in the Netherlands refer to different types of health care. The country has a well-developed primary health care system, which mainly employs family doctors, as well as district nurses, home care professionals, midwives, physiotherapists, social workers, dentists and pharmacists. Each patient must be registered with a GP who, if necessary, will refer the patient to a specialist or hospital. This “dispatching” principle of the Dutch family medicine system means that patients do not have free access to specialized and inpatient MP, except in urgent cases.

The Dutch health care system is considered efficient and cost-effective because, when needed, primary health care is provided by the doctor who is best suited for qualifications rather than geography. Family doctors primarily deal with common and minor diseases, treat chronic patients, and help resolve issues of a psychological and social nature. Family doctors cannot admit patients to the hospital and treat them there, but they can use the diagnostic services of the hospital. Specialists are responsible for a narrow spectrum of overall morbidity. This is due to the fact that, as in many countries of the world, money follows the patient, and not vice versa.

It is worth re-emphasizing that it is necessary and important to maintain a reasonable mix of public funding and the private insurance system. Thus, the use of only one VHI system is not able to ensure full compliance with the basic principles of the health care system in the country, which promotes social protection of the population. One example is the refusal of voluntary health insurance to citizens due to diseases in the past or present, as well as the presence of chronic diseases. The aforementioned options for reforming the health care system can contribute to the "shift" of the Russian health care system towards the medical insurance model, not only in name, but also in content. This model, in our opinion, should be based on a reasonable combination of compulsory medical insurance and voluntary medical insurance systems,

A polyclinic (clinic, outpatient clinic or outpatient clinic) is a medical institution that primarily deals with the outpatient treatment of patients. Polyclinics can be privately or publicly run and funded and are generally dedicated to providing first aid to the local population, as opposed to larger hospitals that offer specialized care and allow for inpatient care. Some clinics are organized in large specialized institutions, such as large hospitals or medical schools, are often associated with these institutions, but at the same time retain separate names for "polyclinics".

Health care in India, China, Russia and Africa is supported by a large number of rural district mobile health clinics or roadside outpatient clinics, some of which use traditional medical methods for treatment. In India, these traditional clinics use herbal herbal medicine and Ayurvedic medicine methods. In each of these countries, traditional medicine has deep roots and a tendency to remain a hereditary medical practice.

Consider the foreign experience of organizing and managing a medical institution using the example of the United States.

Steps are being taken across the United States to move towards a managed health care mechanism based on per capita funding.

The causes of diseases and the very process of the course of diseases are undergoing changes. Infectious diseases thought to be under control in the United States are suddenly re-emerging in forms such as AIDS; some childhood illnesses that were thought to have been defeated by immunization are returning. [2]

Today, in most medical institutions in the United States, this problem is solved by creating and managing work teams. Technical skills require an understanding of the methods and processes by which work is done. In a medical context, this means an understanding of the treatment process, as well as knowledge of clerical jobs such as keeping patient records, budgeting, patient lists, planning appointments or procedures, and other similar activities.

Forming work teams changes the roles and relationships between managers, doctors, and other healthcare professionals. Many years ago, US hospitals were headed by doctors. But as the management of hospitals became more complex organizationally and financially, they were replaced by professionally trained managers. Doctors, on the other hand, took over the leadership of the medical staff, representing their colleagues when making decisions about the hospital as a whole. The medical staff could select a physician from among their own members as a leader, a manager, often holding the title of medical director, reporting to or working with the chief administrator of the hospital, but not directly reporting to that administrator. The medical director in this case was only concerned with the actual medical problems of the hospital, medical work, not supervising the work of other doctors, but serving as a liaison between the medical staff and the main administrator. These relationships were often quite complicated.

Recently, there has been a resurgence in the US health care system of holding physicians in formal administrative positions. This began to happen when the national health system began to give preference to managed care and per capita financing. Under a fee-based health care system, physicians were able to practice independently. With the trend towards integrated health systems and a shift towards per capita payments instead of service fees, many doctors are becoming employees in the health system. This change deprives many doctors of their autonomy, and they feel frustrated. Previously, a doctor who was not satisfied with the job could simply move from one hospital to another.

Today it is much more difficult. Many doctors, dissatisfied with their situation, try to change it and regain control over their practice by taking part in management.

Another factor that motivates physicians to enter the realm of management is the importance attached to measuring the quality of health services and the relationship of treatment outcomes to the financial performance of a hospital or health care system. The role of physicians is unique in that, as medical specialists, they can advocate for the interests of patients. In addition, their professional training provides them with an understanding of the scientific foundations of management in this area.

The team is usually led by a general manager, doctor or nurse. The team decides what kind of data and other information it needs to fully understand the process of providing health services in a particular area. When it comes to heart disease, the team will study all aspects of service to patients suffering from these diseases. She will investigate patient management policies, prescribed procedures, and any available data on treatment quality and costs. In addition, the team will decide if it needs additional assistance, such as, for example, special training in the QCC methodology. As they gather and analyze information, the team will need to periodically assess their progress and possibly share information with colleagues in the hospital to better understand how their research results are affecting the work of others. This can lead to changes in treatments and procedures and related retraining of staff. The team will also determine the criteria by which the results of the introduced changes will be evaluated. After the implementation of the innovations, the team will continue to come together to evaluate them continuously and make amendments, if necessary.

Managing the provision of health care services to the general population or a large group of people requires strategies that are different from those that are appropriate for serving individuals, one patient after another. With per capita funding, a hospital or health care system contracts to provide health care to a group of people in the insurance area. A certain amount is paid by the insurer to the hospital or the whole system for each insured person as a patient. These payments are made in advance in order to cover possible future treatment costs, if it turns out to be necessary within a certain period of time. With this prepayment method, healthcare administrators need to be able to assess in advance the likelihood of patients needing certain medical services and costs, which these services will require. Without this, it is impossible to negotiate prices and payments for each patient. If the estimates are erroneous, the actual costs may be greater than what the hospital will receive. At the same time, if prices are too high, the medical institution will lose in competition with others.

In a fee-for-service system, the administrator must be confident that adequate resources are available to serve the patients for whom the physician is responsible. He should make sure that the fees are high enough to cover the costs of these services.

When services are funded on a per capita basis, the administrator must strategize to reduce the cost of the proposed treatment and avoid providing unnecessary services. To be able to do this, the administrator must understand the treatment process, and the doctor, in turn, must understand the value of the cost of treatment. More importantly, they must collaborate to develop high quality treatments at an affordable cost.

Using methods of mass management, teams of doctors and managers together assess the health of the part of society that includes their patients. Working with epidemiologists, teams use their data to analyze and evaluate indicators of public health such as demographics, observation of pregnant women, births, accidents and injuries, and more. This data can be used to determine which patient groups will appear in the future and what they need. For example, with a large number of women of childbearing age, society will need services related to the protection of pregnancy and motherhood. The elderly will need long-term services. We also need information about who and where will provide such services.

National bodies such as the National Committee for Quality Assurance (NCQA) are already developing criteria for evaluating treatment outcomes, and these criteria are used in the accreditation process. Obtaining approval from a given national organization through accreditation will determine whether a hospital or health care system will be able to receive payments (reimbursements) from both the government and private insurers. In preparation for this, hospitals are increasingly trying to quantify the results of their activities.

Health care management becomes more complex as the health service delivery system itself evolves. To succeed in their positions, administrators must become creative leaders and be well trained in management practices. Moreover, they must be effective “players” in the team. The survival of hospitals and clinics in a changing environment will depend largely on the ability of administrators to understand the future direction of health care and to respond to the challenges facing them today.

Thus, summing up the above, we can draw a conclusion. That Russia and many foreign countries have the same problems. But at the same time, their solutions are different, since the reforms being carried out are not the same.

The dissimilarity of the reforms lies, first of all, in the fact that there are currently three models in the world (state with elements of private, insurance and mixed), which require a certain level of funding.

Based on the analysis carried out in this chapter, it can be concluded that today there are three main models of health care, as well as a number of combined ones, which contain elements of all three main systems in different interpretations. These basic models are:

• 1) State health care system (Semashko system);
• 2) Health care based on a private insurance system;
• 3) Public (insurance) medicine.

At present, the healthcare system in Russia tends more towards an insurance medical model, which is designed to provide social protection to the population in the field of health protection and act as a guarantor of receiving and financing medical care on the basis of insurance principles. At the same time, the receipt of medical services is assumed both in cases of treatment of actual diseases, and in the implementation of preventive measures. This model is essentially designed, on the one hand, to reduce the share of private funding, as in the case of a predominantly private health care system, and on the other hand, to improve the quality of services provided, which, as we can see, is often a pressing problem in countries with health systems, the most close to the Beveridge model.

• [1] Order of the Ministry of Health and Social Development of the Russian Federation dated 05/10/2007 No. 323 "On approval of the procedure for organizing work (services) performed in the implementation of pre-medical, outpatient and polyclinic (including primary health care, medical care for women during pregnancy , during and after childbirth, specialized medical care), inpatient (including primary health care, medical care for women during pregnancy, during and after childbirth, specialized medical care), emergency and emergency specialized (air ambulance), high-tech , sanatorium-resort medical care "[Electronic resource]. - http://www.consultant.ru.
• [2] Lindenbraten A.L. Health and healthcare. Thoughts are serious and not so much. M .: GO-ETAR-Media, 2017.S. 162.