V. Dufynets 1, T. Gruzieva 2
1 Uzhgorod National University, Uzhgorod, Ukraine,
2 Bogomoets National Medical University, Kyiv, Ukraine
ABSTRACT. Introduction. In today's conditions of the epidemic of non-infectious diseases, the significant increase in the incidence of diseases of the eye and its adnexa, disability due to eye diseases, including blindness, providing the population with affordable and quality medical care is a priority of any country. This requires the introduction of modern organizational models for providing ophthalmic care in terms of multiform health system.
The Aim of the Study. the rationale for a modern regional system of provision of ophthalmic care to the population in conditions of multiform health system.
Material and Methods. In the course of the study bibliographic, epidemiological, medical-statistical, sociological methods were used.
Results. The study identified shortcomings in the organization and provision of ophthalmic services to the population of the region, lack of resources to ensure the real needs of the population in ophthalmic care, low level of cooperation between communal and private health care institutions.
A high need for ophthalmic services was identified in view of the increase in incidence (by 41.7 %) and prevalence (47.1 %) of eye diseases among the population of the region during 2000–2015 and overload in the work of the ophthalmic service, as evidenced by the significant occupancy of profile beds throughout the year (360.7 days), short treatment terms (6.8 days) and high rates of bed turnover (53.1), with lower than the average in the country of provision population by specialists of the ophthalmologic profile (by 19.6 %).
This, along with other factors, negatively affected the availability and quality of medical services, which is confirmed by the results of a sociological survey. In contrast, from 69.7 to 92.2 per 100 respondents highly estimated the quality of service in private institutions, with their full availability for 54.3 per 100 respondents.
Based on the results of the research and taking into account the strategic directions of the development of the domestic health care system, recommendations of international organizations, the author justified the modern regional system of providing ophthalmic care to the population in the conditions of multiform health care and its administrative, normative-legal, information-analytical, educational-methodological, research, communicative functions.
Conclusions. The modern regional system of provision of ophthalmic care to the population in the conditions of multiform health system will increase the accessibility and quality of ophthalmic services to the population of the region, optimize the formation and distribution of resources for health care, create a competitive environment, increase the level of cooperation between health care institutions of various forms of ownership with positions of the patient-oriented approach, to introduce modern medical-organizational and medical-preventive technologies into the work of medical institutions.
Key Words: incidence and prevalence of of diseases of the eye and its adnexa, ophthalmic care system, financial and personnel resources, functions, healthcare institutions, forms of ownership.
Relevance
The priority task of the healthcare system is to prevent eye diseases and to improve the provision of medical care to patients. The importance of these problems is determined by the role of the eye in ensuring the life activities of each person, in addition, significant medical and social losses and economic losses for individuals, families, society as a whole owing to eye diseases and their appendages, which commonly leads to disability, in particular blindness.
World statistics data confirm the significant scale of visual impairment among the population. Despite considerable efforts to overcome these negative events. Even now, this condition is threatening and global. Under conditions of ageing of the planet’s population, it is predicted that the social significance and scale of this condition will increase [1-5].
A number of research studies are devoted to solving problems of prevention of visual impairment, timely detection and efficient treatment of eye diseases. They became the basis for many programs aimed at improving ophthalmologic health.
The defining document for control of ophthalmologic conditions is the Action Plan to Provide General Access to Eye Health for 2014–2019. It specifies the following: a fundamental shift towards improving ophthalmologic health can be achieved by incorporating prevention and rehabilitation issues into inter-sectoral healthcare programs and strategies. Its implementation is possible only with the provision of general access to comprehensive eye care [6].
However, implementation of the indicated directions faces significant problems. The low effectiveness of medical programs to control ophthalmologic conditions is associated with insufficient human, financial, material and technical resources, imperfect medical and organizational technologies, population poverty, and a low level of its sanitary culture.
Given the situation, under conditions of limited material resources, the priority task is to develop strategies for the provision of eye care with the maximum involvement of all available resources of the country, including state, municipal, private sectors in the implementation.
That particular position is set out in “Health 2020” European policy framework. The document outlines the need for a multi-level, nation-wide approach involving the whole society [7].
The innovative organizational approach involves the participation of civil society, the private sector, the media, etc. in addition to the state in solving the priority problems of public health. In addition to the state partnerships, it is expedient to use many other forms of cooperation between the state and private sectors, including the provision of the part of services by private organizations; allocation of state funding for private non-profit organizations working with a population at the local level [8].
The efficiency of involvement of the private structures to the provision of eye care is confirmed by sociological surveys, according to which the vast majority of patients in private ophthalmologic clinics are satisfied with the quality of medical services [9-11].
Considering the scale of the problem and the epidemiological trends, the problem of ophthalmologic health provision, prevention of its violations, including disability of the population as a result of blindness, is relevant to Ukraine [12-14].
Its solution lies in the wide range of organizational, managerial, informational, economic and other aspects at all levels of healthcare that have been studied by many researchers. For example, the main problems, their causes and the negative consequences that were the basis for the development of new models of eye care organization were determined [15-17].
However, such studies are extremely rare and relate mainly to solving the problems of the control of individual eye diseases, organization of care to not all categories of the population. They do not take into account new trends in social development, in particular formation of multiform healthcare. However, the need for such an approach is due to socio-economic changes in the country, including the development of the market for medical services for patients with eye conditions [18-21].
Taking into account the strategic guidelines of the social policy of Ukraine, its focus on ensuring the diverse needs of citizens and creating conditions for a healthy lifestyle, the issues of effective cooperation of the state, municipal and private sectors of healthcare, including eye care provision to the population, are of great importance. The Concept for the reform of the financing of the healthcare system of Ukraine, which implements a new financing model with clear guarantees of the provision of care by the state, financial protection in case of disease, effective distribution of finances and combating informal payments, is aimed at this. [22-23].
Thus, despite the high need for modern medical-organizational forms of eye care provision to the population, the issue of effective cooperation between the state, municipal and private sectors in terms of organization of ophthalmologic medical services remains unresolved. Therefore, the need for the search and implementation of new organizational models of cooperation in the context of multiform healthcare is an urgent requirement of time.
Objective of the study is a substantiation of the modern regional system of eye care provision to the population under the conditions of multiform healthcare.
Materials and methods. The study used bibliographic, epidemiological, medical and statistical, sociological methods. The statistical reporting forms No. 12, No. 17, No. 20, No. 47, data of the Centre for Health Statistics of the Ministry of Health of Ukraine, Department of Health of Zakarpattia Regional State Administration, Department of Medical and Social Expert Evaluation of the Ministry of Health of Ukraine and State Institution “Ukrainian State Scientific and Research Institute of Medical and Social Problems of Disability of the Ministry of Health Ukraine” for 2000–2015 were analysed; 796 patients were surveyed to study the accessibility and quality of eye care to the population of the region and Ukraine in healthcare facilities of various forms of ownership; the opinion of 24 healthcare organizers and leading scientists for expert evaluation of the proposed system has been obtained.
Discussion. A number of problems have been identified during the study of ophthalmologic health of the population of the region and the organization of the activities of the regional eye service. High demand for eye services in view of the growth of morbidity (by 41.7 %) and prevalence (47.1 %) of eye conditions among the population of the region during 2000–2015 has been established. The overload in the work of the eye service was revealed, as evidenced by the significant occupancy of profile beds throughout the year (360.7 days), short treatment terms (6.8 days) and high rates of bed turnover (53.1), with lower provision of the population with ophthalmologic profile professionals than average in the country (by 19.6 %).
This, along with other factors, negatively affected the accessibility and quality of health services, which is confirmed by the results of a sociological survey. For example, in municipal healthcare facilities, 72.4 ± 1.9 patients per 100 respondents expressed dissatisfaction with the work of medical staff. The main reasons were lack of attention from the staff (61.6 ± 2.2 per 100 respondents), significant waiting times for the doctor in the clinic (69.7 ± 1.6), scheduled hospitalization (61.6 ± 2.2), roughness and ill-nature of medical staff (34.1 ± 2.9), low level of staff qualification (48.7 ± 2.5), inadequate equipment of the facility (66.8 ± 2.0), manifestation of mercenary interests by medical staff (34.8 ± 2.9).
Instead, 69.7 ± 1.6 to 92.2 ± 1.0 per 100 respondents highly assessed the quality of services in private institutions by the wide range of characteristics, with full accessibility for 54.3 ± 1.8 per 100 respondents.
It was revealed that the main problems include shortcomings in the organization and provision of eye medical services to the population of the region, lack of resources to ensure the real needs of the population in eye care, low level of co-operation between municipal and private healthcare facilities.
On the basis of the obtained data, an optimized system of provision of eye care to the population was substantiated at the regional level in the context of multiform healthcare. This was supported by the priorities of the state health policy, modern health development strategies supported by WHO and other international institutions.
Taking into account the need for partnerships between state and private sector in healthcare, the provisions of the European policy “Health 2020” on the flexible regulatory and institutional framework, provision of strategic management, and coordinated activities of all stakeholders on the part of private and state sectors, a well-considered scheme of state management and accountability have been used.
Focusing on Sustainable development strategy “Ukraine-2020”, National healthcare reform strategy, the involvement of institutions of various forms of ownership for eye services provision is provided in Ukraine for 2015–2020. According to the Concept of healthcare funding reform, the need for involvement of service providers of all forms of ownership to the provision of a state-guaranteed healthcare package has been identified. Such an approach creates the opportunity to purchase services by the state through a single national customer with maximum economic efficiency. At the same time, the legislative basis ensures the implementation of the provisions of the Law of Ukraine “On State-Private Partnership” with solving uncoordinated issues and discrepancies.
On the basis of the epidemiological characteristics of the morbidity, problem situations in the organization of eye care to the population, existing needs, directions for improving the activities of the regional eye service under conditions of multiform healthcare have been outlined.
An optimized system will provide the population of the region with accessible and high-quality eye medical care, using the resources and potential of healthcare facilities of different forms of ownership. The strategic directions of the activity of the system will include maximal use of resources and potential of healthcare facilities of different forms of ownership, implementation of scheduled, control, monitoring, analytical, and communicative functions. Planning, formation and implementation of orders for eye medical services, control over their accessibility for the population and quality, monitoring of the efficiency of activities of healthcare facilities of different forms of ownership are among the priorities.
Provision of medical care to patients of ophthalmologic profile due to the measures outlined will be implemented from the standpoint of modern approaches to provision of medical care and medical care of the population harmonized with the European requirements under the conditions of multiform healthcare with the formation of appropriate administrative, organizational, informational and analytical, educational and methodological, as well as scientific and research structures, and differentiation of their powers at different levels of management.
For example, the organizational and managerial components of the functioning of system of medical care provision for patients of ophthalmologic profile include the planning of service development, creation of an order for their provision in accordance with the existing needs, taking into account the possibilities, on the basis of monitoring of the activities of participants in the market of medical services by a set of parameters. Department of Health of the Regional State Administration and the relevant local government units form a regional policy and strategy for the development of the eye service and monitor its implementation in the region. An independent institution, acting through the National Health Service, will procure such services on the basis of uniform tariffs and quality requirements. The functions of the agency, its central and regional departments will include contracting service providers of all levels and forms of ownership, concluding contracts with institutions that will provide eye medical care to the population of the region.
The organizational and managerial function of the system of medical care provision to ophthalmologic patients is to assess the participants in the market of medical services in terms of accessibility, quality, safety and efficiency, as well as in planning the needs and executing orders for the procurement of eye services in healthcare facilities.
Regarding regulatory and legal functions at the regional level, its implementation is reliant on the Department of Health of the Regional State Administration and the relevant local government units. Its tasks are the development of draft documents on statutory regulation of the service activities. The key players of regulatory aspects of the provision of eye services are the management of the eye service at the regional level, professional associations whose representatives will participate in the drafting of documents on the normative regulation of the service actions at the regional level, its powers, tasks, measures, resources provision, etc.
According to the model, information and analytical function of the system of medical care provision for ophthalmologic patients includes monitoring of ophthalmologic morbidity, analysis of the activity of medical institutions of the ophthalmologic profile, assessment of their resource base and capacity, planning and prediction of resource requirements, assessment of the quality of resources. The implementation of this function will be provided by the information and analytical units of the Department of Health of the Regional State Administration and the relevant local government units, information and analytical services of healthcare facilities of various forms of ownership, professional associations, public health services.
The important tasks of an optimized eye care system are based on the educational function that will be implemented by institutions of higher education, practical healthcare facilities of the municipal and private form of ownership, postgraduate education institutions, training centres, etc. It envisages the implementation of continuous education of ophthalmologists with different forms of training, the formation of competencies, exchange of specialists for the purpose of their internship in healthcare facilities of the municipal and private form of ownership, etc.
The management and staff of healthcare facilities, territorial units of healthcare administration have the function of managing labour processes and supply in the system of eye medical care provision. For its successful implementation, it is necessary to create favourable conditions for the work of specialists and healthcare facilities of the ophthalmologic profile, to provide the financial basis for remuneration in accordance with the extension and quality of the work on the provision of medical services, to promote involvement and development of human resources.
The optimized model provides for the provision of scientific and research function, in particular, scientific substantiation and development of new methods of prevention, diagnostics and treatment of eye conditions, their implementation.
Equally important is the communicative function of the regional system of eye care, which involves cooperation between the governing bodies, the regional unit of the National Health Service, the professional environment, including healthcare facilities of various forms of ownership, public health service, patient organizations, the media, international, foreign and public organizations, etc. The communicative function will be implemented by the territorial units of the department of health, healthcare facilities, the regional unit of the National Health Service, public health services, professional associations, public organizations, patient organizations, and the media.
The formation of a new modern regional system for medical care provision for ophthalmologic patients will create conditions for a comprehensive solution to the problem of providing the population of the region with accessible and high-quality ophthalmologic care under the conditions of multiform healthcare, development of public-private partnership, preventive orientation of eye care, continuity in work of various healthcare facilities, patient-oriented approach, development of modern medical technologies, increase of the accessibility of private services and the level of patient care, creation of the competitive environment that will improve the quality of eye medical services.
The principal difference between the new modern regional system of medical care provision for ophthalmologic profile and the existing one is a new approach to the planning and funding of medical services, the distinction between the functions of the customer and provider of medical services, implementation of contractual principles between them, monitoring of service quality. Qualitatively new elements of the proposed model are an independent customer of medical services, which takes part in planning and carries out the procurement of services; a new sound provider of medical services in accordance with the order - private healthcare facilities; regional department of the National Health Service, which will monitor compliance with standards, protocols, agreements, etc.; public health service, which will implement preventive programs in cooperation with the primary healthcare sector, professional associations and patient organizations involved in the planning and monitoring of the quality of eye services.
Implementation of innovation elements into healthcare practice and fulfilment of proper functions will create the basis for the formation of a real market of eye medical services, free competition of facilities, contractual relations between customers and service providers, formation of a unified medical space, will contribute to the provision of the population of the region with accessible eye medical care of high the level of quality and satisfaction of the population with medical care.
Conclusion. Therefore, based on the study results, the high need for eye services for the population of the region was revealed in view of the growth of morbidity (by 41.7 %) during 2000–2015 and the prevalence (47.1 %) of eye-related conditions among the population; overload in the work of the eye service, which is suggested by significant occupancy of profile beds throughout the year (360.7 days), short treatment terms (6.8 days) and high rates of bed turnover (53.1), with lower than average provision of the population with specialists of the ophthalmologic profile (by 19.6 %) at the national level. This, along with other factors, negatively affected the accessibility and quality of health services, which is confirmed by the results of a sociological survey. Instead, 69.7 to 92.2 per 100 respondents highly assessed the quality of services in private institutions, with full accessibility for 54.3 per 100 respondents.
Taking into account the strategic directions of the state healthcare policy outlined in the National strategy for reforming the healthcare system of Ukraine for 2015–2020, Concept of the reform of funding healthcare system of Ukraine, taking into account the WHO recommendation, the optimized regional system of eye medical care provision to the population has been substantiated. The directions provided by the system include managerial and organizational, regulatory, information and analytical, educational and methodological, scientific and research, communicative aspects.
The principal differences between an optimized regional system for eye medical care provision to the population in the context of multiform healthcare in relation to the existing system are the differentiation of the functions of the customer and the provider of medical services, implementation of contractual relations between them and creation of a real market for medical services and competition between providers of services of the state, municipal and private forms of ownership. The proposed system provides a systemic and integrated solution to the problem of ensuring the accessibility and quality of eye medical care to the population of the region under the conditions of multiform healthcare.
The advantages of the model are the rational use of human, material and technical, as well as financial resources of healthcare at the regional level under the conditions of their deficiency, preventive direction of medical care, patient-oriented approach, medical and technological improvement of medical services, high level of patient care, competitive environment for improving the quality of medical care.
Implementation of the proposed optimized regional system of eye medical care under the conditions of multiform healthcare in the practice of healthcare will create prerequisites for expanding the list of key players, providing them with new functions, ensuring the independence of customer of eye medical services, differentiation of the customer and supplier, forming a unified medical space and a real competitive environment for providing eye care to the population of the region.
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Надійшла до редакції 28.02.2019 р.