Will there be enough Zemstvo doctors? The main problems of medicine in the village

For someone aid stations — a relic of the past, and for many — the only way to survive.

All autumn in the country has launched a campaign “Welcome to the village”, in which volunteers and doctors from major medical centers visited in rural feldsher-midwife stations: volunteers helped to repair, the doctors (usually specialists) were receiving. What problems were decided with this project and who will help of rural medicine to deal with them?

The money can be found. And the frames?

Hard to find in the Russian region, which would once and for all solved the problem of rendering medical aid to inhabitants of villages and small towns.

How to entice young people?

For example, in Bashkiria, according to the regional Ministry of health, the number of doctors 8% below the Russian level. Although in the last 5 years the shortage of specialists has decreased by almost 600 people, a shortage still is 1680. But in the rural healthcare provision of the population with doctors in 2,5 times lower than in the cities. Outside the zone of accessibility to primary health care 5,300 people living in 108 towns. To help them is to go mobile first aid stations. Here in the Republic there are only 2064, of which 72% are in emergency condition.

“In 2064 152 of FAPs Bashkiria are only nurses. 105 points generally empty due to the lack of specialists” — such gloomy figures led by acting Minister of health of the Republic Rafael Yapparov. But in 2018 the Bashkir medical University has released 800 specialists of medical Affairs, of which about half are public sector employees. But in September-October 2018 to serve in the institutions of the Republic received a total of 417 physicians. Arrived to the place of work every fourth (!) 270 tselevikov.

To put up with the situation here is not want with 2012, when in Bashkiria has begun the implementation of the program “Zemsky doctor” in the village and towns managed to attract 1321 specialist. Entice the youth in the village the opportunity to improve their living conditions. And medical students from CIS countries are invited to work five years in a rural area in exchange for Russian citizenship. Will it be possible to solve the personnel problem?

“Be a generalist”. Rural doctor about his work

“People who have lived for years and studied in the city, accustomed to the facilities, infrastructure, cultural and leisure activities, — says a doctor from Ufa Gulshat N. — The most that he signs up to work 5 years a country doctor, to build on due to him 1 million rubles home or buy a car, and then… back to the city. Undoubtedly, the work on the village gives the physician an invaluable experience: having to deal with different diagnoses, including beyond its core competencies. But in a rural hospital, even CDH, it’s hard to count on career and professional growth. In addition, a physician of the city there is a possibility well to earn money in the commercial clinics, which deprived rural doctor.”

Hospital stalled

In the Lipetsk region residents Volovsky district (13 thousand people), which for a long time fought for the return of the hospital, was able to succeed. Volovsky district hospital in the notorious process optimization combined with Terbunskiy, making it the main. Once in volovskiy hospital 5 departments — surgical, therapeutic, children’s, infectious disease and maternity. And after the reorganization were only surgery and therapy, and then only in truncated form. But added a hospice. “Come to die! bitterly ironically, then, the resident of the village of Volovo Tatiana Dushkin. — What can we do? Before seriously ill patients with heart attacks, strokes treated on the spot. And now driven in Yelets and Lipetsk in traffic, on rough roads”.

Volochanin in recent years, often had to travel for medical care in neighboring Terbuny. But the car is not at all, and the taxi ride costs 1500 RUB this pension many just RUB 8620

How to pay for health? Best country doctor country about rural medicine

“It is urgent to save valovcin, which the authorities cornered — said the Deputy of the Lipetsk regional Council Sergey Tokarev. — Officials save money, but they forget that there also live people. And these people were normal without medicine. The worst thing is that optimization Volovskiy hospital occurred on the background adopted in 2011 the Federal law “About bases of health protection of citizens in Russia”, one of the articles which tells about the availability and quality of health care.” And now the good news: volochine got back the hospital. As reported “AIF” the press-service of the regional administration, within a month, they will begin to work pediatric ward, and then in full will function an adult hospital.

“Optimization of the health care system was designed to rid the region from inefficient, often outdated and not corresponding to modern requirements of the Fund, — says the doctor of medical Sciences, Professor Michael Ball. — But we have under this brand began to close the whole district hospital. Naturally, went the popular indignation, and the authorities decided to give back. Now proudly report on how many FAPs opened. But this is not an achievement, but an attempt to correct errors. Yes, it is possible to rebuild buildings, buy new equipment, but to return to the hospital personnel is extremely difficult. But the footage — the most important thing, and some of them we just lost.”

Babi revolt

The government of the Irkutsk region in the beginning of the year reported that in the villages of the region for 2017 have built a record number of FAPs — 21. However, after the ceremonial cutting of red ribbons almost all the new posts… closed on the lock. Some could not accept patients due to building violations, the other was not equipment or furniture in the third — paramedic. Most of the health facilities during the year are still running. But there were also those where still not said an official housewarming party. So, in the village Buzykanov tayshetskiy district, where the old infirmary huddled in the post office building, in a small not adapted for the reception of patients the office, to the designated contract date, the builders have just built a box for the future of the Station with no Windows, fixtures and fittings. The case went to the Prosecutor’s investigation, which revealed numerous violations.

“Check last may, but the builders still have not corrected all violations, — said the “AIF V Vostochnoy Sibiri” the head of the municipal formation Buzanowski Pavel Kulakov. Doctors are tired of waiting for the careless of the contractor and in September moved into the new building. Let it not built very well, but at least spacious, with a separate reception, treatment, Laundry and even shower”.

Not going to give up and the residents of the Yaroslavl region in the region, according to regional Department of public health and pharmacy, 315 work of feldsher-midwife stations (including 3 mobile), 60 outpatient clinics, and 75 offices of medical practices. It’s a lot, considering that 6 years ago, the region has thundered all over the country the closure of health facilities in the village and the ensuing rebellion of village women. Then, in December 2012, future moms in the last months of pregnancy came to the defense of Boris and Gleb hospital redundancy. Six days they held the building “under siege”, but was unable to defend. Then it was closed 6 rural hospitals are recognized as ineffective. No one is confused nor the vast distances that now have to overcome maternal or broken-down rural roads. Subsequently, officials were not embarrassed or the deaths of newborns or pregnant women, if the birth started suddenly or came with complications nor sharply increased the number of births at home with midwives.

“You need a repair — you do”. How is medicine in the village

One of the recent high-profile closures in the Yaroslavl region hospital Borok Nekouz district. Over 3 years the medical staff of the hospital and residents tried to defend her, but well equipped hospital for 70 beds still optimized at the beginning of this year. Instead, people got the clinic where he works and where the therapist 2 times a week, come pediatrician and dentist. Everything else is in Nekouz CRB, 30 km from Borok.

This year the authorities of the region are purchased for the rural hinterland 7 mobile first-aid stations. A new modular medical and obstetric items will appear in the villages of Bogorodskoye (wooden building of the local Station built in 1908 is 100% worn out) and zaozer’e. “From the reserve Fund of the government of the Russian Federation for this purpose we allocated more than 60 million rubles”, — said the Director of the regional Department of health and pharmacy Ruslan Saidgareev.

Who will heal the villagers?

In March 2018, the Russian Government has allocated 45 regions of 1.23 billion rubles for the purchase of modular constructions, outpatient clinics and feldsher-midwife stations. According to the popular front, to the middle of autumn it was established only 10 of them in 4 regions. The money is only 3% of the allocated funds.

“When we or our friends have to seek medical help, we want milorganite was located near the house was clean, comfortably equipped, so we could quickly make an appointment and not wait in line to be thought of as competent professionals,” says a member of the Central headquarters of the popular front, the Director of the Foundation “Health” Eduard Gavrilov. However, residents of rural areas and small towns the opportunity is often missing. And the prospects for change in the situation yet. “The pace, what is the expansion of the network of medical organizations in small settlements, raise serious questions. Unfortunately, there are all prerequisites in order to work in the regions this year was broken”, — said Gavrilov.

Moreover, according to the popular front, the “age” of 6.2 million (22%) buildings — 50 years has a lifetime of 37 years. It is projected that by 2024 there will be 9.5 thousand (33%). Not in need of overhaul only 16%. It is not surprising that physicians are often forced to accept patients in rooms where chunks of plaster is about to fall down on his head. This means that many settlements with population from 100 to 2,000 people and will continue to be without primary medical care.


Some experts doubt whether, in principle, to expand the network of FAPs. “FAPs — a relic, they are not anywhere else in the world, — said Chairman of the Moscow city scientific society of physicians Professor Pavel Vorobiev. — More than half of rural settlements — villages where live less than 400 people. The paramedic is there to do practically nothing, come to him 1-2 people a day to take the blood pressure or sugar levels. So does it make sense to include specialist education in buildings worth 10 million rubles? In addition, the average age of paramedics is well over 60 years, they are, to put it mildly, inconsistent with modern knowledge and skills. To be honest, half of the paramedics is nurses, who have not been taught to handle patients and make diagnoses. And half the country’s existing feldsher-midwife stations there are no staff (recently publicized case where in one of villages of Transbaikalia people treated the janitor of the Station while the assistant was on vacation. — Ed.). It turns out that the paramedic is such pseudomedicine that exists for the sake of calming authority, who is accountable, what makes medical care available.”

“The contents of the Station costs 5 million rubles per year — confirms the Director of the Institute of health Economics HSE Larisa Popovich. But if a person has a serious problem, in FAP it still will not go, because there will not be specialist who can help him. So the attempt to build Centres in every yard seems to me a completely unjustified waste of money”.

Drones instead of paramedics

But how to ensure timely medical assistance in remote regions?

“Worldwide, the primary support may be provided by the paramedics — trained salespeople, firemen, postmen, policemen, etc., not having a medical education and living in the area, he said Vorobyov. — And given the level of development of telemedicine technologies in today paramedic can replace a smartphone, tablet, computer. No need to keep the paramedic and drug delivery to the beneficiaries. This may be done by “Mail of Russia”.

The share of truth in it — anyone would prefer to be treated in a large multidisciplinary clinics, and not in a rundown hospital and especially in FAP. So, it is necessary to build roads, to promote aviation, to ensure the availability of modern care to all. The positive experience of such organization we have is the creation of a network of vascular centers and intelligent routing of patients. “The man with the heart attack quickly brought to the hospital, where you can spend the stenting of coronary vessels or other life-saving manipulations. This has drastically reduced mortality, improved the efficiency of medicine. On the same principle, must build and everything else,” says Pavel Vorobiev.

How this issue is resolved in the world? “Very common pattern — the work of the doctor of the day, when the doctors on a rolling basis go to the villages and give free consultations — says Larisa Popovich. In Canada it is a prerequisite for professional growth of doctors. In Australia for delivery of medications widely used drones. In the US develop telemedicine, the main focus there is to create a network of ambulance stations and ensure their maximum throughput. People do come back. But in the States well developed roads. In the Nordic countries and India are actively developing the volunteer movement of paramedics who can provide first aid and to deliver to the medical center. And in the case of chronic conditions not requiring emergency treatment, used communication type is telephony, Skype video consultations.

In Russia, assistance can also come centralized consultation with the possibility of communication with remote villages. Communication can be kept through the homes of villagers, not necessarily to have FAP. You only need to provide residents with modern means of communication.”

So, perhaps we need to reconsider its attitude to the decision to build clinics in every village. The more that it is implemented with such difficulty.