International and Russian Experience in Primary Health Care Organization

In this study, they presented the analysis of current views on the important link in medical care provision to the population, namely, primary health care. According to the Alma-Ata Declaration on the organization of primary health care this type of medical assistance has made it possible to carry out reforms within this area in many countries, which has led to effective results (the reduction of infant mortality, the increase of life expectancy and a number of other indicators). In this paper, they performed the analysis of Russian and foreign sources of literature on the topic under study between 1978 and 2018. It has been established that primary health care is regarded as the most effective instrument of health protection than specialized medical care according to the experience of Russian Federation, a number of countries in Europe, Asia and the African continent, Australia and the United States. The performed analysis clearly shows that the experience of some countries demonstrates the correlation between the general coverage of primary health care and the achievement of public health indicative indicators. At the same time, the question is raised about the expediency of certain aspect replacement concerning the provision of specialized medical care by the doctors of general practice, i.e. primary health care. The obtained results can be interpreted as an evidence base for the necessity and an undeniable effectiveness of primary health care as a central link in the health care system.


Introduction
Various models of health care are used, which are applied and implemented depending on the historical, political, economic, cultural and social factors of state development in order to organize the health care in various countries. However, a special role is given to primary health care, this type of medical care is the basic element in the organization of public health protection (Federal Law, 2011;Karmanbaeva, 2017).
The World Health Organization (WHO) defines health care as an important component of national health care systems, and the WHO Regional Office for Europe contributes to the reform of primary health care in Member State health systems through its policies, clearly shows the significant role of medical care type in health care (World Health Organization, 2015).
In some countries, the health protection system exists apart from the health care system, although a number of authors indicate that only when these two segments of national health systems work together one can one achieve very positive results according to certain indicators. Thus, during the treatment of diseases, various preventive measures can be introduced, and the health protection system can facilitate the correct organization of medical care, which can lead to the expected effective results. Primary health care combines these two segments, the boundaries between individual health of a particular person and population health (for example, family, society) are lost (Meshcheryakov, 2017).
The authors of this study set the goal -to review the effectiveness of primary health care organization in different countries.

Methods
In this analysis of foreign and Russian sources of literature, they used the publications of medical data text database PubMed (http://www.ncbi.nlm.nih.gov/pubmed), the materials from the scientific electronic library (http://elibrary.ru) and the library fund of the Kazan federal (Privolzhsky) university and Kazan state medical university for the period from 1978 to 2018.

Results and Discussions
In 2011 they adopted the Federal Law N 323-FL "On the fundamentals of citizen health protection in Russian Federation" (21.11.2011), which regulates the entire field of health care activities, from diagnosis to hygienic education of the population. Chapter 5 of the aforementioned Federal Law identifies the key aspects of public health protection organization, including the classification of medical care types: 1. primary health care; 2. specialized health care, including high-tech medical care; 3. first-aid, including an emergency medical care; 4. palliative medical care. This Federal Law defines the first type of medical care classification as the basis of medical care system in Russia and "includes various measures for the prevention, the diagnosis and the treatment of diseases and conditions, medical rehabilitation, the monitoring of pregnancy course, the formation of a healthy lifestyle and sanitary-hygienic education of population". This definition of primary health care refers to the large scale of activity field for medical organizations which provide this type of health care.
A number of Russian researchers note that an excessive specialization of medical personnel at the level of the territorial polyclinics has turned the district doctor into a "dispatcher", who, in view of the lack of continuity in medical care provision at his work, can provide medical assistance only for a certain limited list of diseases, and he is not able to provide a constant monitoring at a qualitative level of patient health status, which leads to the issuance of a large number of referrals to patients for expert consultations depending on preliminary diagnoses and patient complaints. Also, some studies show a negative trend, which manifests itself in the dissatisfaction of about 40% of Russia population by territorial polyclinic operation. The above-mentioned facts were the prerequisites for the establishment of general practitioner institute (Antonov, 2007;Khalfin, 2003).
Some authors point out that during the improvement of the general practitioner institute model in the organization of primary health care at regional program adjustment for the development of general medical practice in cities, it is necessary to take into account the features of population settlement and density, the public transport system, taking into account the prospects for a further development of this type transport, which is one of the key moments during the establishment of general practitioner offices (Russev and Borisov, 2002).
The role of non-state medical organizations deserves a special attention in the organization of primary health care to the public. At present, there is the tendency of application number increase to the private healthcare sector for this type of medical care. According to the data of various studies, the able-bodied population of Russia prefers this variant of health protection more and more. There are many reasons for this situation. Such factors can be the system of able-bodied population values, in which career and work occupy a higher priority as compared with health. Also, the territorial state polyclinics are less competitive in the modern market of medical services in comparison with non-state clinics despite high technical opportunities. More client-oriented healthcare organizations of the private health sector are able to provide the medical service that meets the needs of the able-bodied population. Such requirements may be a more convenient work schedule of a non-state clinic, the attitude of medical personnel, the regulated record to experts, and the lack of queues. On the territory of modern Russia, private medical organizations first appeared in Moscow in the late 1980-ies. Dentistry has become the pioneer in the medical field in the private health sector. In 1999, the branches of large foreign networks of medical clinics began to appear in Russian market. At present, the main trend of non-state medicine development is the expansion of private clinic profile and the development of medical organization networks (Gerasimenko et al., 2002;Muzalevsky, 2002).
It is noted that in economically developed countries, where the public health system is characterized as a highly organized one, the sector of non-state medicine is an integral part of the medical and social complex (Bolton, 2013).
In foreign countries, primary health care is also seen as the central link in health care, which was noted during the international conference on primary health care in 1978, held in Almaty and the main postulates were reflected in the Declaration of Alma-Ata WHO. This declaration determined the strategy for health care system development within the framework of primary health care, i.e. at the stage of primary health care provision.
The ratio between general practitioners and medical specialists deserves a special attention. Thus, according to WHO official data, in 2005, in some countries, like Egypt and the Kingdom of Bahrain, they noted the predominance (more than 75%) of medical specialists from the total number of medical personnel. In other countries, such as Sudan, Sri Lanka, Rwanda, Cameroon, Australia, general practitioners predominated. And in such countries as Indonesia, Burkina Faso and Algeria, there was an approximately equal ratio of general practitioners and medical specialists. This situation demonstrates the state of the health care system to a greater or lesser extent within the framework of primary health care provision to the population of these states (Rohde, 2008).
In certain countries, the Alma-Ata Declaration contributed to the significant development and the expansion of opportunities and access to medical care for the population. The example of such contribution is the healthcare system of Pakistan. In this country, after the introduction of the main provisions of the Alma-Ata Declaration, primary health care has become available for the population in the deepest corners of the state.
In the People's Republic of Bangladesh, a large-scale program for primary health care organization was tested. 340,000 poor families were involved under this program. The result of the primary health care program introduction for this cohort was the reduction of infant mortality by 52% and the reduction of under-five year old children mortality by 48%. These indicators were achieved during the sixth year of the program on primary health care organization for the population.
The achievement of such results contributes to the emergence of positive effects for the demographic and socioeconomic situation in the People's Republic of Bangladesh, which once again emphasizes the importance of primary health care in the health care system.
There is the tendency of more complex and qualitative manipulation increase in primary health care. Taking into account the focus on primary health care in Europe permanently reformed countries, it is necessary to conduct more research on the organization of studied medical care type provision to determine the effectiveness of the performed transformations.
There are data that about 30 countries with low and medium incomes of population were able to reform effectively the organization of primary health care for the population after the adoption of the Alma-Ata Declaration. An example of such a country is Thailand, which was able to achieve high rates of mortality reduction among children under the age of 5, a high immunization coverage and the access to a qualified obstetric service.
The experience of the United States of America identified primary health care as more promising, cost-effective, which correlates with low overall mortality, increased life expectancy, infant mortality reduction, the probability of low birth weight reduction, and several other indicators. This fact clearly demonstrated the necessity and the possibility of medical specialist reorientation to general practitioners due to more effective primary health care as opposed to specialized medical care.

Conclusions
The performed analysis of literature sources on the topic under study clearly demonstrates that the Alma-Ata Declaration served as an important basis to reform the existing health systems in many countries. So, a central role was assigned to primary health care in the system of medical care. It is worth noting that the type of medical care under study, in addition to medical and diagnostic measures, includes the element of hygienic education for population, which allows to carry out preventive work at the primary stage. Given that the Federal Law N 323-FL "On the fundamentals of citizen health protection in Russian Federation" (21.11.2011) fixes the priority of prevention in health protection. A great responsibility is put on the organization of primary health care. During the organization of the medical care type to be examined, population density and distribution and existing transport schemes at the municipal level should be taken into account in order to locate the offices of general practitioners properly. In the People's Republic of Bangladesh, a large-scale program for the organization of primary health care provision made it possible to reduce infant death by 52% and the mortality rate under the age of 5 years by 49% during the sixth year of its implementation. Thailand, implementing the Alma-Ata Declaration, achieved significant success and demonstrated the mortality rate among children under the age of 5, high immunization coverage and the access to a qualified obstetric service.
Primary health care should be considered as a promising tool that is used for public health protection and allows to achieve positive medical and demographic indicators. However, given that this type of medical care is more profitable than specialized medical care, taking into account the preventive work, the component of which is entrusted to primary health care, it can be concluded that this type of medical care will have the priority as compared to other medical care types.