Министерство здравоохранения Республики Беларусь

УЧРЕЖДЕНИЕ ОБРАЗОВАНИЯ
«ГРОДНЕНСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ
УНИВЕРСИТЕТ»

Кафедра общественного здоровья и здравоохранения

М. Ю. Сурмач

ЗДРАВООХРАНЕНИЕ И УПРАВЛЕНИЕ
В ОХРАНЕ ЗДОРОВЬЯ

M. Yu. Surmach

HEALTH SERVICES AND MANAGEMENT

IN HEALTH SPHERE

Рекомендовано учебно-методическим объединением

по высшему медицинскому, фармацевтическому образованию
в качестве учебно-методического пособия
для студентов учреждений высшего образования,
обучающихся на английском языке
по специальности 1-79 01 01 «Лечебное дело»

Гродно
ГрГМУ
2017
УДК 614.2(07)=111
ББК 51.1я73
С94

Автор: зав. каф. общественного здоровья и здравоохранения

УО «Гродненский государственный медицинский университет»,
д-р мед. наук, доц. М. Ю. Сурмач.

Рецензенты: зав. каф. общественного здоровья и здравоохранения

Белорусского государственного медицинского университета,
канд. мед. наук, доц. Т. П. Павлович;
зав. каф. общественного здоровья и здравоохранения
с курсом ФПК и ПК УО «Витебский государственный
ордена Дружбы народов медицинский университет»,
д-р мед. наук, проф. В. С. Глушанко.

Сурмач, М. Ю.
С94 Здравоохранение и управление в охране здоровья : учебно-
методическое пособие для студентов учреждений высшего образования,
обучающихся на английском языке по специальности 1-79 01 01
«Лечебное дело» = Health Services and Management in Health Sphere :
Educational-methodical manual for students of higher education institutions,
the specialty 1-79 01 01 «General Medicine», English language of studying
/ М. Ю. Сурмач. – Гродно : ГрГМУ, 2017. – 240 с.
ISBN 978-985-558-903-8.

Учебное пособие подготовлено в соответствии с образовательным стандартом

высшего образования специальности 1-79 01 01 «Лечебное дело», утвержденным и
введенным в действие постановлением Министерства образования Республики Беларусь
от 30.08.2013 № 88, типовым учебным планом специальности 1-79 01 01 «Лечебное
дело» (регистрационный № L 79-1-001/тип.), утвержденным первым заместителем
Министра образования Республики Беларусь 30.05.2013, типовой программой «Типовая
учебная программа по учебной дисциплине «Общественное здоровье и здраво-
охранение» для специальностей 1-79 01 01 «Лечебное дело», 1-79 01 02 «Педиатрия».
Содержит материал для подготовки к практическим занятиям по предмету
«Общественное здоровье и здравоохранение», примеры решения типовых задач, мате-
риалы к тестовому контролю знаний для изучении второй части предмета (9 семестр).

УДК 614.2(07)=111
ББК 51.1я73

ISBN 978-985-558-903-8

© Сурмач М. Ю., 2017

© ГрГМУ, 2017

2
 CONTENTS

LESSON № 1
MEDICAL СARE IN OUT-PATIENT
AND IN-PATIENT CONDITIONS ........................................................ 5
1.1. Рolyclinic ............................................................................................. 5
1.2. Hospital ............................................................................................... 9
Typical tasks: HEALTH CARE ................................................................. 16
LESSON № 2
ORGANIZATION OF MEDICAL CARE
TO CHILDREN AND WOMAN .......................................................... 18
2.1 Maternal health as the global medical-social problem ...................... 18
2.2 Basic parameters of maternal health welfare ..................................... 23
2.3 Health sector interventions
for sexual and reproductive health care ............................................ 27
2.4 MCHC services in Belarus ................................................................. 33
2.5 Basic parameters of children’s health well-being .............................. 41
2.6 Health of the adolescent ..................................................................... 46
2.7 Management and prevention of health problems: children and
adolescents......................................................................................... 52
2.8 Public health services for children in Belarus.................................... 57
Typical tasks: ORGANIZATION OF MEDICAL CARE
TO CHILDREN AND WOMAN ......................................................... 69
LESSON № 3
SANITARY AND EPIDEMIOLOGICAL WELL-BEING ............... 76
3.1 Sanitary and epidemiological well-being.
State sanitary inspection services in Belarus ..................................... 76
3.2 Medical-Hygienic training. Self-saving behavior and
Healthy mode of life ........................................................................... 86
LESSON № 4
MEDICAL CARE FOR RURAL POPULATION,
FOR WORKING PEOPLE. CONCEPT OF REHABILITATION.
SOCIAL PROTECTION OF POPULATION .................................... 98
4.1 Medical care for rural population....................................................... 98
4.2 Medical care for working people ..................................................... 103

3
4.3 Concept of rehabilitation. Medical rehabilitation
as the main basis .............................................................................. 118
4.4 Social protection of population ........................................................ 123
Typical tasks: MEDICAL CARE FOR RURAL POPULATION,
FOR WORKING PEOPLE. CONCEPT OF REHABILITATION ....... 131
LESSON № 5
HEALTH CARE MANAGEMENT,
PLANNING AND FINANCING ......................................................... 134
5.1 Health care: quality........................................................................... 134
5.2 Bases of standartization .................................................................... 145
5.3 Health care: Management ................................................................. 148
5.4 Health care: Planning ....................................................................... 155
5.5 Health care: Economy, Financing .................................................... 169
5.6 Health care Informatization. Bases of marketing ............................. 179
LESSON № 6
TESTS .................................................................................................... 186
ANSWERS FOR TESTS ………………………………………….…...237

4
 LESSON № 1
THEME:
MEDICAL СARE IN OUT-PATIENT AND IN-PATIENT
CONDITIONS

Questions:
1. Medical care of the population on an out-patient basis.
2. Primary Health Center, Clinic of the General Practitioner,
polyclinic: structure, objectives, activities.
3. Medical care of the population on in-patient basis.
1.1. Рolyclinic
A polyclinic is the medical-preventive organization intended for
the medical care to the out-patiens. A polyclinic renders preventive,
medical-diagnostic and rehabilitation help for population of the
attended area.
The word «polyclinic» includes two words of the greek origin:
«polis», which means a city, and «klinice», which means treatment.
Approximately 80% of all patients start and finish their treatment in
a polyclinic, and only 20% of patients have to be hospitalized. Due
to this fact, there is a huge need for the out-patient polyclinic care.
A city polyclinic is the typical out-patient organization, aimed
to carry out its activity in the given area:
 carrying out of wide preventive actions, aimed to prevent
and decrease sickness (morbidity rate),
 early detection of patients with any illnesses;
 performing of the qualified specialized medical aid to the
population;
 propagation of a healthy way of life, and health forming.
The city polyclinic is organized in according to the established
procedure in towns, in settlements of city type for out-patient care
carrying out to the population, living in the areas of its activity.
The city polyclinic works according to divisional-territorial
principle. It also provides medical aid to the attached workers of the
industrial enterprises, construction organizations and the enterprises

5
of transport according to the section-production principle. City
polyclinic can be the independed organization or the part of a hospital.
Functions of a city polyclinic are follows:
1) performing the qualified specialized medical aid to the
population of the served area directly in a polyclinic and at home;
2) organization and performing the set of the preventive actions
directed to the decrease of morbidity, time sickness absence from
work, stable disability (handicap) and death rate;
3) the organization and carrying out of the medical-hygienic
training of the population, propagation of a healthy way of life,
including a balanced diet, increasing of movement activity,
prevention measures for smoking and other harmful habits.
Principles of polyclinic functioning are as follows:
1. Divisional-territorial principle: all territory of the served
area is divided into districts; 1700 of people older than 15 years old
are secured for one of these therapeutic district.
2. Work of the polyclinic is organized according to the sliding
schedule: within a week the district doctor works during various
period of time, for example: «Monday – from 8.00 till 11.00,
Tuesday – from 11.00 till 14.00, etc.; Saturday – the doctor on duty».
3. Principle of alternation (cyclic system). The doctor from a
polyclinic once in 2 years from 4 till 6 month works in a hospital. He
advances his qualification there.
4. Two-section system: every day doctor works both in a
polyclinic, inspecting his patients and visits a patient at home.
5. The method of preventive medical examination service
(dyspensarization).
6. The connection between polyclinic and hospital in medical
aid providing.
A capacity of polyclinic is determined by number of visitings
during one shift.
The structure of a city polyclinic consisits of:
 Management of a polyclinic (administration).
 Reception desk.
 Department of prevention.
 Medical-preventive departments.
 Auxilliary-diagnostic departments.

6
  The office of medical statistics.
 Economic part.
The office of medical statistics is the coordination center. An
account, according to the established forms, is performed here and
medical staff load, sickness rate and other indicators are studied here.
The office of medical statistics also carries out the control over
reliability of information, especially of doctors diaries filling in; it
makes annual reports, it participates in the parameters calculation,
which make up the model of ultimate results (see below).
Patients visiting a polyclinic first of all go to the reception
desk. The reception desk is one of the basic divisions of a polyclinic,
the correct organization of its work determines greatly the efficiency
of all arganization of public health services activity.
The reception desk organizes of preliminary and urgent record
of patients to see the doctor ether by their direct applying in a
polyclinic or by phone. Reception desk provides of precise
regulation of intensity of the population stream with the purpose of
creation of uniform load of doctors and its distribution according to
the kinds of services, which are given. Reception desk also
maintenances of duty selection and delivery of the medical
documentation in doctors offices, correct conducting and storage of
a card file of a polyclinic.
At the reception desk patients are distributed into the following
streams:
1) extraordinary patients (the patients which demand
immediate receiving and providing medical aid),
2) urgent patients (such patients should be examined in the day
of the their apply for help),
3) practically healthy (inspecting this patient can be
transferred for another day if it necessary because the population
stream is more intensive).
The network of the out-patient polyclinic help in Belarus is
organized on territorial-district principle. All the population living
in the areas of a polyclinic service is distributed according to the
districts with the fixed district doctor for each district. The district
doctor is the central figure, providing this help.

7
 District doctors’s duties are following: the timly qualified
therapeutic help to the population of the district in a polyclinic and at
home; emergency medical care to the patient irrespective of their
residence, in case of their direct applying at occurrence of sharp
conditions, traumas, poisonings; timely hospitalization of therapeutic
patients, with obligatory preliminary examination in case of
scheduled hospitalization; consultation of patients in necessary cases
performed by head of the therapeutic department, by doctors of other
specialities in a polyclinic; use of other specialities in a polyclinic;
the use of modern methods of prevention, diagnostics and treatment
in the work, including complex therapy and regenerative treatment;
examination of temporary sickness absence from work (temporary
disability) according to valid state regulations; organization and
carrying out of the complex of actions on preventive medical
examination of adult population of the district; giving the
conclusions to the inhabitants of the district, who undergo medical
check-ups or who go abroad; the organization and carrying out of
preventive inoculations; early detection, diagnostics and treatment of
infectious diseases; sending of the emergency notice in the Center of
Hygiene, Epidemiology and Public Health; regular advance of the
qualification and a level of medical knowledge of the district medical
nurse; active and regular carrying out of medical-hygienic work
among the population of the district.
However in past years several changes in dispensary-polyclinic
system section as the growing of the specific gravity of particular
specialists have happened that lead to a considerable substituting the
work of district doctors. The prestige of the last oneshas started to
fall down.
The payment for GP (doctor of the primary health care, district
doctor) activity must depend on health of the maintained population;
reduction of the level and gravity of the chronic diseases
exacerbation; reduction of the number of the indications for
hospitalization; reduction of emergency calls; optimal use of the
financial resources.
But, as a rule, the district doctor in Belarus in the majority of
cases provides dispatching functions, directing patients to particular
specialists or on hospitalization. Practically district physician does

8
not carry responsibility for health picture of the population, living in
his area, he is not interested in the final result of treatment and his
own work. For this reason every second patient from primary
addressed comes to a particular specialist’s consultation that in 10
times exceeds the similar index in the developed countries and,
accordingly, leads to significant material expenses. In considerable
degree this is conditioned by the existing disproportion in medical
correlation of different professions. When in the developed European
countries the particular specialists form 25,0% from all doctors, in
the Republic of Belarus on the contrary: only every fourth doctor
works in primary health care.
Thereby, the experience of the majority of foreign countries
and present problems in qualitative and efficient medical help
provision set the purpose for reforming implementation in the state
public health system in Belarus on type of general practitioner.
1.2. Hospital
Hospital is the medical-preventive organization which renders
the in-patient care.
All hospitals in Belarus are divided according to the number of
signs:
 according to organizational sign (into united with polyclinic
and not united, independent);
 according to the territorial sign (into city and rural hospitals);
 according to the contingents (into the common, i.e. for
service of both the adult and children population, and serving only
adult population or only the children population);
 according to the type (into common-typed and specialized).
For more full satisfaction of the population need in stationary
medical care, for improvement of a polyclinic work in conditions of
economic methods, for introduction of public health services
management and for rational use of bed’s fund the day-time hospitals
are intended for.
The day-time hospitals may be opened both in polyclinic, and in
hospital. Structure of the day-time hospital is the following: cabinets
of doctors, a procedure study, chambers for patients day stay.
A capacity of hospital is determined by the number of
mid-annual beds (hospital bed fund).
9
 Hospital bed fund and indicators of its use
Basic indicators of hospital bed fund are the following.
1. The number of discharges of hospital in-patients during
the year.
2. The number of hospital days per 100 000 inhabitants.
3. Capacity of hospital bed fund is defined as the quantity of
hospital beds available in hospital (the number of hospital beds).
4. Security of the population by hospital beds (beds/population
ratio) is defined as a parity of quantity of the hospital beds which are
available in given territory within a year, to a mid-year population of
the given territory:
Hospital Beds х 1000
Mid-year population
5. The structure of bed fund is a distribution of total of hospital
beds on separate nosologies (therapeutic, surgical, obstetric-
gynecologic, etc.) and on directions of use (for intensive treatment;
for rehabilitation and regenerative treatment; for day-time hospital
treatment of patients with chronic diseases in an aggravation stage;
medical-social beds).
The indicators of bed fund using:
1. Number of days of bed employment during a year
(or occupancy of the bed) =
The general number of hospital days spent by patients in a hospital
Mid-year number of hospital beds
The highest occupation level of hospital beds during a year in
Belarus has been registered in hospitals of Minsk and the Minsk
area – 325 and 323 days during or withing a year accordingly.
The lowest – in Gomel and the Gomel area – 306 days.
For city hospitals the given indicator above, than for rural
(330 and 300 days accordingly), is more low in infectious and delivery
depar-tments, than in the others (300 days withing a year are occupied
cots in infectious and delivery rooms in hospitals in city and 280 days –
in rural).
The given indicator is planned in advance, certain
specifications are developed for it.

10
 2. Percent of bed’s fund using (in %) =
Actual number of days of bed employment days during a year х 100
The mid-year specification (norm) of bed employment
Value of the given indicator should be close to 100%.
If the planned number of bed employment days during a year
exceeds the actual value, it testifies about not sufficient effective
using of the fund.
If the planned number of days of bed employment days during
a year appears less, than actual, it speaks about presence of «added»
beds (in corridors, additional beds in chambers). These «added» beds
are not included in number for calculation of the specification (norm).
3. Average length of the patients stay on the hospital bed
(the average in-patient length of stay)=
The general number of hospital days spent by patients
Number of discharges within a year
In the beginning of 1990 the given indicator was maximal in
Belarus and made about 15 days. Now it consists of 12 days, and in
a city the indicator is more low, than in a village.
4. The bed turn-over ratio =
Number of discharges
Mid-year number of hospital beds
Rational use of bed fund is provided with timeliness of hos-
pitalization, creation of continuity in health services between a poly-
clinic and a hospital (with the purpose to reduce time of stay in a
hospital, to increase the number of hospitalized patients, not to
overload laboratory with additional analyses, etc.); timely started
rehabilitations-preventive actions, keeping of regulations and
stationary regimen. То the factors, influencing the duration of the
patient's stay in a hospital and rational use of bed's fund one can also
refer the following: timeliness of diagnostic researches; performance
of the quality standards of diagnostics and treatment; adequacy of the
examination of temporary sickness absence from work; timeliness of
consultations; presence of examinations by the head of the
department; carrying out of clinical monitoring; introduction of new

11
effective methods of treatment; regular analysis of the department
work; proper control of the paramedical personnel work.
The main organization of public health services which provides
medical aid to the population, is a city hospital.
The basic registration forms of the medical documentation in
hospital are as follows:
 The medical inpatient`s card (case history).
 Journal of patients reception and refusals in hospitalization.
 Journal for operative interventions record.
 The form of the daily account of patients and beds' fund in
the department.
 The patient`s card, discharged from the hospital.
 The book of pathoanatomical dissections.
 The medical death certificate.
 The paper of administrations.
 The temperature paper.
 The portion demand.
The structure of city hospital includes: a reception, medical -
diagnostic units, unit of functional diagnostics, physiotherapeutic
unit, unit of rehabilitation, laboratories and studies (procedural, for
injections, a X-ray study, etc.); pathoanatomical unit and other
structural subdivisions (such as the drugstore, food stuffs unit, a
medical statistics, medical archive, library, depot study, etc.).
The structure of the reception ward includes the following
rooms: a lobby, a room of the medical staff, a study for patients
examinations, a dressing room, a study for a cleansing, the room for
discharge.
In the reception the following functions are performed: the
account of patients movement in a hospital, transfering of patients
from one unit to another, reception of patients, diagnosing of the
patient when admitted, filling of the medical documentation,
distribution of patients in units, a cleansing of admitting palients,
registration and account of admitted and discharged palients,
reception of things and their giving back, reception of parcels for
patients and the organization of their meetings with relatives,
creating an easement of the patient's condition and, if necessary,
providing of emergent aid.

12
 The structure of pathoanatomical department includes: a study
of the head of the department, other administrative studies, a sectional
hall, laboratories, a mourning hall, the room for storage of corpses.
In the pathoanatomical unit the dissection of corpses, anatomical-
histological (tissue research, pathoanatomieal diagnosing are carried
out as well as establishment of death cause, carrying out of clinical-
anatomic conferences, the analysis of the clinical and sectional data.
The city hospital is headed by the Head physician and his
assistants (concerning medical work, medical rehabilitation and
examination, organizational-methodical work).
The Head physician is responsible for correct personnel
placement. He controls exercise of the interchange principle.
He provides timely improvement of professional skills of stuff. He is
responsible for carrying out of diagnostics, for introduction in
practice of the newest methods, for work of drugstores, for supplying
with soft and firm stock. The head physician analyses morbidity rate
and parameters of medical care providing to the population.
He works out action on medical care improvement.
Functions of the head of the department are numerous, they are
the following. He carries out a management of the department and
doctors; makes the schedule of work; follows the correct diagnostics
and treatment; solves problems on the discharge, performing of
operations, examinations of a working capacity; consults doctors;
arranges consultations; examines the patients again accepted on
hospitalization in the day of their entering; regularly examines
seriously ill patients; carries out «five-minutes»; introduces in work
the major achievements of medical science and practice. He also
presents at pathoanatomical research of died patients; carries out
medical clinical and pathoanatomical conferences; improves quality
of medical care in the department. Head of the department makes
daily rounds of the department together with clinical interns and
senior sister of the department. During them performance of medical
assignments, a sanitary condition of the department, the organization
of patients' relatives visiting, a medical – protective regimen, duties,
care of patients, performance of regulations, storage of medicines,
the schedule of work and improvement of professional skill of the
medical personnel are checked.

13
 Resident conducts fixed number of patients during their
observation and treatment in the organization of public health
services; applies necessary diagnostic researches and treatment of
patients on time and professionally; conducts medical
documentation; monitors correctness of performance by the average
medical personnel of medical assignments; represents patients on
consultation (meetings between doctors); participates in rounds of
patients by the head of the department; performs duty on hospital.
The senior medical sister carries out a management of work of
the paramedical and junior medical personnel; controls the
organization of care over patients and a sanitary-and-hygienic
condition of the department, maintenance by the personnel, patients
and visitors of regulations; prescribes and delivers the medicines
from a drugstore; does sister controls over storage of medicines and
schedule of work of the paramedical and junior medical personnel.
The ward nurse carries out the performance of medical
assignments; patients' сare; maintenance of hygienic regimen;
feeding of seriously ill patients; organization of communication with
patients' relatives; carrying out of sanitary – educational work with
patients; monitoring of work of the junior medical personnel;
measuring the temperature (in the morning and in the evening),
observation over pulse and respiration of seriously ill patients,
measuring of a daily urine, if it is indicated by the doctor, collecting
of urine, feces for laboratory researches; maintenance of a medical –
protecttive regimen of the department; acquaintance of newly
admitted patients with the rules of the department regulations.
The schedule of medical sisters work in a hospital is based on the
principle of three or two-shifts work.
Daily ward nurses inform the senior nurse of the department
about presence of patients with the indicating of the diets appointed
to them (number of tables of dietetic therapy) according to the state
at the definite hour. After that senior nurse of each department fills
portions demand of a meal for patients being treated in the
department for the next day. It is signed by the head of the
department and senior nurse and it is given to the dietary nurse of the
medical establishment. On the basis of the received portions
demands dietary nurse makes the portions` list for all patients.

14
For each dish, a card – allocateion should be previously written, in
which the list of products, norms of their use, chemical contents,
caloric contents, weight (output) of a prepared dish as well as
preparation technology and ready dish characteristics are indicated.
On the basis of portions demands and cards – allocations dietary
nurse together with the chief – cook, the worker of accounts
department makes the menu – allocation under the supervision of
dietary doctor. Ready food try-out is performed by the responsible
doctor on duty. In the presence of the doctor, adding of oil, sour
cream, acidum ascorbinicum, etc. is performed. These products are
weighed. The weight of the portions, the prepared dishes (not less
than 10 dishes) are also checked. The data are written down in the
menu – allocation and certification journal and then the food is given
to the department. Delivery of dishes in the department is carried out
on special – carriages in thermoses and buckets. Distribution of the
prepared food from easting foodstuffs unit is made according to
distributing sheet.
The medical – protective regimen includes:
 actions on elimination of negatively acting irritants, negative
psychological experiences connected with the ways of treatment,
carrying out of operations, painful sensations caused by medical
manipulations;
 a combination of rest and physical activity;
 prolongation of physiological dream;
 a raising of the general psychological tone of patients;
 consumption of tasty prepared and timely served food;
 keeping the medical ethics and deontology.
Sanitary-and-epidemiologic regimen means:
 wet cleaning of a room;
 general cleaning with the help of disinfecting means;
 maintenance with overalls and linen;
 keeping the personal hygiene rules;
 the medical control over a state of the personnel health;
 care of the patients;
 the control over keeping the regulations.
Components of intrahospital infections prevention are the
following: the allocation of diagnostic chamber in the reception for
patients with high temperature (for specification of the diagnosis);
15
the tap of isolators or isolation wards in nurseries and infectious
diseases hospitals; the carrying out of a sanitary cleansing; the
maintenance of the special order of things storage and distribution of
hospital clothes; the organization of the system of patients care and
the systems of syringes and medical toolkit processing.

Typical tasks
HEALTH CARE
A. 1680 patients were treated at surgical branch of city hospital
within a year. 1200 from them were hospitalised in a planned order.
1500 patients, including 1050 – in a planned order were
operated within a year.
Please, define surgical activity of the branch, proportion of
emergency hospitalisation and proportion of emergency surgical care.
B. 705 operations were spent at surgical branch within a year,
including 70 at children.
4 patients, including 1 child have died in the postoperative period.
Please, define postoperative lethality and proportion of
operated children.
C. 890 patients left therapeutic branch of city hospital. 440 of
them have left with recover, 400 – with improvement, 40 – without
changes of a state, 8 – with change for the worse and 2 have died.
Please, define distribution of patients by results of treatment
(the structure), hospital lethality.
D. There are 700 hospital beds in area. 180 hospital beds are
therapeutic, 60 – pediatric, 35 – infectious hospital beds.
Please, calculate the bed fund structure.
E. There are 1300 hospital beds in the area within a year.
390 hospital beds are therapeutic, 210 – surgical, 55 – gynecologic,
110 – pediatric.
Please, calculate the bed fund structure.
F. 940 patients were treated at infectious branch for adults on
30 hospital beds within a year; 8920 hospital days (bed-days) were
spend by them.
Please, define the bed fund indicators.
G. 1650 patients were treated at the local hospital on
16
50 hospital beds within a year; 16700 hospital days (bed-days) were
spend by them.
Please, define the bed fund indicators.
H. 700 patients were treated at oncological branch on 30
hospital beds within a year; 10900 hospital days (bed-days) were
spend by them.
Standard mid-annual employment of hospital bed (the speci-
fication) is equal to 340 days. Please, define the bed fund indicators
(all the indicators including percent of the bed fund use).
I. 1718 patients with intestinal obstruction, 26878 with acute
appendicitis, 2476 with strangulated hernia, 3186 with extra-uterine
pregnancy were operated in surgical branches in the region within a year.
In general, 44365 patients were operated at the diseases
demanding the emergency surgical care. 287 persons have died,
including 31 – with intestinal obstruction, 10 – with acute
appendicitis, 23 – with strangulated hernia.
Please, define postoperative lethality as a whole and from
separate reasons, proportion of separate diseases among operated
and among died.
J. Please, define peculiarities of hospitalization structure
(on months; days of week) in Grodno Regional Hospital, if it is
known that:
- the number of hospitalized people is 7542;
- from them in January were hospitalized 660, in February –
657, in March – 663, in April -642, in May – 658, in June – 520,
in July – 530, in August – 550, in September – 671, in October –
648, in November – 693, in December – 650 patients;
- average number of hospitalized persons in Monday – 5,
Tuesday – 3, Wednesday – 3, Thursday – 5, Friday – 3, Saturday – 2,
Sunday – 1.
K. Please, find the mid-annual loading of the out-patient doctor
on policlinic reception if: the number of visitings to doctors, including
preventive, has made 181595 for a year, the mid-annual number of
the occupied medical posts in the given polyclinic has made 27.
L. Please, find the loading of general practitioner on the out-
patient reception (person/hour) if it is known, that:it has been
executed 18 visitings per working day, the number of actual working
hours on out-patient reception has made 4.

17
 LESSON № 2
THEME:
ORGANIZATION OF MEDICAL CARE TO CHILDREN
AND WOMAN

Questions:
1. Maternal health as the global medical-social problem.
2. Basic parameters of maternal health welfare.
3. Health sector interventions for sexual and reproductive
health care.
4. Principles and organizational structure of medical-preventive
care to women, to children. MCHC services in Belarus.
5. Basic parameters of children’s health well-being.
6. Health of the adolescent.
7. Management and prevention of children`s health problems.
8. Public health services for children in Belarus.
2.1 Maternal health as the global medical-social problem
In any community, mothers and children constitute a priority
group and they are also a «vulnerable» or special-risk group. The
risk is connected with child-bearing in the case of women and
growth, development and survival in the case of infants and children.
The knowledge of obstetrics and gynaecology aid bases is
necessary for all physicians. The medical professional of any
specialty has neither legal, nor moral right to refuse rendering
medical aid during delivery or help to a gynecologic patient, when
there isn’t an obstetrician-gynaecologist near her.
Most maternal deaths are preventable (figure 1).
The low status of women in the society in developing countries
coupled with their low literacy levels prevent women from taking the
antenatal care even if services are available. Most deliveries in
developing countries take place at home without the services of the
trained midwifery personnel. There is an inverse relationship between
the life-time risk of maternal death and the availability of the trained
health worker during pregnancy and at the time of delivery.

18
The life-time chances of maternal death in the world as a whole varies
from region to region and from country to country (Tab. 1).

Figure 1. – Causes of maternal deaths in the world

Table 1. – Estimates of Maternal mortality ratio (MMR, mathernal deaths per
100 000 live births), number of maternal deaths, and lifetime risk by United
Nations Millenium Development Goal Region, 2013 (source: Trends in
Maternal Mortality: 1990 to 2013, Executive Summary; www.who.int)

19
 Every day in 2015, about 830 women died due to complications
of pregnancy and child birth. Almost all of these deaths occurred in
low-resource settings, and most could have been prevented. The
primary causes of death are haemorrhage, hypertension, infections,
and indirect causes, mostly due to interaction between pre-existing
medical conditions and pregnancy. The risk of a woman in a
developing country dying from a maternal-related cause during her
lifetime is about 33 times higher compared to a woman living in a
developed country. Maternal mortality is a health indicator that
shows very wide gaps between rich and poor, urban and rural areas,
both between countries and within them.
It is a tragic situation as these deaths are not caused by disease
but occurred during or after a natural process. It is one of the leading
cause of death for women of reproductive age in many parts of the
world. Most maternal deaths and pregnancy complications can be
prevented if pregnant women have access to good-quality antenatal,
natal and postnatal care, and if certain harmful birth practices are
avoided.
The term «obstetrics» comes from the French word «accoucher» –
to give birth to a child. The word «gynecology» is of the greek origin
«gyne», what means a woman, and «lolgs», what means a doctrine.
Many centuries ago a woman gave birth without any help, she
was assisted by the senior woman of the family. The formation of
professional treating began at the slaveowing system. The сhapters
on obstetrics and female illnesses were first available from well-
known «Canon of a medical science» of the Tadjic physician
Avitcenna. The first certain doctors who assisted at complicated
deliveries appeared in the XIIth century. The first maternity hospital
was opened in Strasburg in 1728.
At the end of the XVIIIth century obstetrics or midwifery has
been allocated into an independent, obligatory discipline of the
higher medical education, with a special faculty, program and post of
the professor. The introduction of gynecology into a special medical
discipline took place only in the middle of the XIXth century.
Vladimir Pavlovich Snegirev (1847-1916) is considered to be the
founder of Russian gynecology. Nestor Maximovich Maksimovich-
Ambodic (1774-1812) is the founder of Russian obstetrics.

20
 The present strategy is to provide mother and child health
services as an integrated package of «essential health care», also
known as primary health care, which is based on the principles of
equity, intersectoral coordination and community participation. The
primary health care approach combines all elements in the local
community necessary to make a positive impact on the health status
of the population, including the health of mothers and children.
The relationship between skilled attendance and maternal
mortality is obvious (Figure 2).

Figure 2. – Relationship between skilled attendance

and maternal mortality ratio for all countries
The evidence concerning the effect of skilled attendants at
delivery is some what muddied by different definitions that have
been used and by the variation across countries in the training of
midwives and in the regulations governing the specific procedures
they are permitted to perform. There is also wide variation in the
extent to which skilled attendants are supported and supervised in the
broader health system. UN agencies have developed a definition of
skilled attendant that focuses on midwifery skills, and that is the one
we use here (Figure 3).
21
 Figure 3. – Definition of Skilled Attendant
The current trend in many countries is to provide the
integrated maternity and children’s health care (MCHC) and family
planning services as the compact family welfare service. This
implies a close relationship of maternity health to child health, of
maternal and child health to the health of the family, and of the
family health to the general health of the community. In providing
these services, specialists in obstetrics and child health (paediatrics)
have joined hands, and now they are looking beyond the four walls
of hospitals into the community to meet the health needs of mothers
and children aimed at positive health. In the process, they have
linked themselves to preventive and social medicine, and as a result,
the terms such as «social paediatrics», «preventive paediatrics»,
«social obstetrics» have come into vogue.
The maternity and childhood protection as well as the
demographyc safety providing are the major direction of public
health services development in the Republic of Belarus nowadays.
22
The maternity and newborn health care services compose the whole
system that represents the interconnected complexes of medical-
social actions and services directed at strengthening women`s and
children’s health.
Theactions are realized stage by stage:
1. The medical-social preparation of women for a maternity
since childhood (health of girls).
2. The medical-preventive help for women before and outside
of pregnancy: woman should be in a good health prior to conception,
for her own save and for the save of her infant. Chronic illness
should be well controlled, and all medications should be reviewed
for teratogenic potential. The preconceptional care measures include
also the decreasing of risk to ova and sperm. It is important to
address any potential risk of germ cell mutation or expiration due to
the exposure to environmental or occupational hazards (e. g.,
pollutants, additives, pesticides, radiation etc.). Testing and
counseling may minimize the risks of an adverse outcome due to
underlying genetic abnormalities, HIV infection or other conditions.
3. Antenatal protection of fetus and routine well-woman care
during pregnancy.
4. Intranatal protection of fetus, female’s health preservation in
labor stage.
5. Newborn’s and mother’s health protection during the
puerperal period.
6. Child health protection before arrival to school (during
preschool period).
7. Health protection of schoolchildren; including health
protection of adolescent and his transmission to «adult» teriitorial
out-patient clinic (polyclinic).
2.2 Basic parameters of maternal health welfare
Basic indexes characterizing maternal health well-being are
follows:
1. Maternal mortality ratio, that calculated as:
MMR = (the death of woman during the pregnancy or within
42 days of the termination of pregnancy, irrespective of the duration
and the site of the pregnancy, from any cause related to or
23
aggravated by the pregnancy or its management, but not from
accidental or incidental causes / the number of live births reported
during the same interval) x 1000000 live births.
2. The number of abortions and abortion/women ratio.
3. Indexes of health care delivery for women and children:
Doctor-population ratio (providing of female and children
population with out-patient services);
population-bed ratio (providing of female and children
population with hospital beds).
4. Fertility rates:
 Age-specific fertility rate – is the number of live-births
a year to 1000 married and unmarried women in any specified age-
group.
ASFR = (the number of live-births in a particular age group /
the midyear female population of the same age group) x 1000.
ASFR for under-age women should be minimal.
 Total fertility rate represents the average number of children
a woman would have if she were to pass through her reproductive
years bearing children at the same rates as the woman now in each
age group. It is computed by summing the age-specific fertility rates
for all ages, if 5-year age groups are used, the sum of the rates is
multiplied by 5. This measure gives the approximate magnitude of
“completed family size”.
 Gross reproduction rate is the average number of girls that
would be born by woman if she experiences the current fertility
pattern throughout her reproductive period (15-44 or 15-49 years),
assuming no mortality.
GRR represents a number of girls, which, on the average, will
be born by each woman during the reproductive period. In
calculating GRR it is accepted, that death rate of women up to the
end of reproductive age is absent.
 Net reproduction rate is defined as the number of
daughters a newborn girl will bear during her lifetime assuming
fixed age-specific fertility and mortality rates.
5. Special children’s death indexes (mortality in and
around infancy) (Figure 4):

24
 Infant mortality

Neonatal mortality:
Postneonatal mortality
early, late

Perinatal mortality

Fetal
mortality

1 YEAR
22 weeks of 28 days
gestation 7 days
BIRTH

Figure 4. – Mortality in and around infancy (scheme)

 Infant mortality rate (IMR) is the number of deaths among

infants less than one year old per 1000 live births in a given time
period:
IMR = (number of deaths among infants less than 1 year old/
4/5 live births at the same year + 1/5 live births at the last year) x 1000.
 Neonatal mortality rate (NMR) is the number of deaths
among infants less than 28 days old per 1000 live births; including:
early neonatal mortality rate, it is mortality during the
1st week of life or during 168 hours of life for 1000 being born alive;
late neonaral mortality rate, it is the mortality during
2-4 weeks of life (the children, being born alive – the children,
deceased at the first 4 weeks of life).
 Postneonatal mortality rate (PNMR) is the number of deaths
among infants aged from 29 days to 1 year (11 months 30 days) per
1000 live births (difference between the number of being born alive
and the deceased during the first 4 weeks of life).
 Perinatal mortality rate is the number of fetuses deaths of
gestational age greater than 22 weeks plus the number of deaths of
infants less than 7 days (or 168 hours) old per 1000 total births
25
(all births in a given time period, usually one year), including fetuses
of gestational age greater than 22 weeks. This parameter includes
three sub-parameters: antenatal (since 22 weeks of pregnancy),
intranatal, and early neonatal mortality.
PMR is usually expressed per 1000 total, not only live, births.
 Fetal mortality (or Mortinatality, or Stillbirth) rate is
(The number of stillbirths of gestational age older than 22 weeks / all
births in a given year, including fetuses of gestational age greater
than 22 weeks) × 100 (in %).
This parameter refers to fetal loss in the third trimester of
pregnancy, which results in stillbirth, and loss of child during delivery.
The 20-week cutoff sometimes is used in its calculation (USA).
6. Women’s health indexes:
Morbidity rates (obstetric and extragenuital pathology); sterility
prevalence; gynecological incidence and prevalence rates.
The estimation of potential readiness for the motherhood
(paternity), bound to health, is carried out by means of the estimation
of reproductive potential.
Reproductive potential (not health) is a level of physical and
menthal condition, which allows reproducing healthy posterity when
social maturity is achieved. If a child is brought up in optimum terms
there is the balance of his reproductive health i. e. the balance
between reproductive potential and factors that influence it.
The organism of every child possesses certain reproductive resources
i.e. possibility to change reproductive potential.
Estimation of reproductive potential includes the analysis of:
1. Prevalence of general somatic diseases, influencing the
reproductive function.
2. Child’s physical and sexual development condition.
3. Prevalence of reproductive system diseases.
4. Estimation of the complex physician-social factors,
influencing the reproductive system condition.
5. Analysis of the age and sexual education and girls’
psychological readiness to motherhood.

26
 2.3 Health sector interventions
for sexual and reproductive health care
There are three categories of conditions that can be first of all
addressed by health sector interventions:
(1) unwanted and mistimed pregnancies;
(2) sexually transmitted infections;
(3) maternal mortality and morbidity.
Unwanted and mistimed pregnancies
Pregnancy itself is obviously not a disease, but an unwanted or
mistimed pregnancy can lead to serious health consequences for
women and children alike. These include complications of the
pregnancy itself, which we address in the section below on maternal
mortality and morbidity. But the very number and spacing of
pregnancies has also potential health consequences. Birth spacing
has well-documented effect on child health. Studies have shown that
children who are born before or after a short birth interval and
children who are born as a result of an unwanted pregnancy have a
greater risk of negative health outcomes.
Undesired fertility also contributes directly to the level of mater-
nal mortality. Put simply, if a woman is not pregnant, she will not die
in pregnancy or childbirth. The refore access to the methods to control
fertility can have a significant impact on the number of maternal
deaths, simply by reducing the number of times when a pregnant
woman runs the risk that a complication will occur and that she will
die from it. It has been estimated that if the unmet need for contra-
ception were filled and women had the number of pregnancies only at
the interval they wanted, maternal mortality would drop by 20-35%.
A substantial proportion of unwanted pregnancies, ended by
induced abortion, whether or not it is legal. Of the estimated
45 million abortions that take place in the world each year, some
19 million occur in the countries where the procedure remains unsafe
(WHO 2004). Approximately 95% of unsafe abortions are
characterized by the lack or inadequacy of the provider`s skills, the
hazardous techniques and unsanitary facilities occur in developing
countries, despite the fact that, of countries with populations over
one million, all but two legally permit abortion for one or more
27
indications. Yet unsafe abortions are estimated to account each year
for more than 68,000 deaths (WHO 2004), approximately 13% of all
maternal mortality. Indeed, complications of unsafe abortion are one
category of fatal obstetric complications that could be almost totally
prevented through the provision of appropriate services. Hence, the
world community has repeatedly agreed that where abortion is legal,
it should be provided safely and, in all cases, complications of unsafe
abortion should be treated through high quality health services.
As abortion is legal in almost every country for at least one reason,
and in three-fifths of all countries to preserve the physical and mental
health of the woman, the international community agreed in 1999
that «health systems should train and equip health-service providers
and should take other measures to ensure that such abortion is safe
and acceptable».
Global problem is teenage pregnancy (Figure 5).

Figure 5. – Adolescent motherhood

The primary health intervention for preventing unwanted or
mistimed pregnancies is the contraceptive services. Although
contraceptive prevalence rates have steadily risen since the 1960s,
28
according to UNFPA, 350 million women still do not have access to
safe and affordable contraception (2002).
In the Republic of Belarus, concept of family planning includes
pregnancy control using contraception, abortion prevention, and
infertility control.
Sexually Transmitted Infections
The inability of women to protect themselves from HIV
infection is a function of lack of access to safe and appropriate
contraception and meaningful sexuality information, as well as the
power imbalances in sexual relationships that leave many women
vulnerable. Separate from HIV, there are about 340 million of new
cases of curable STIs each year (WHO 2003) – and a person with an
STI other than HIV is more likely to contract HIV, thus significantly
magnifying the impact of STIs (UNFPA 2002).
One of dangerous indexes for maternal and child well-being is
prevalence of antenatal syphilis (Figures 6, 7, 8).

Figure 6. – Percentage of antenatal care attendees positive

for syphilis

29
 Figure 7. - Percentage of antenatal care attendees test
for syphilis at first visit

Figure 8. - Percentage of antenatal care attendees positive

for syphilis who received treatment, as reported by countries in 2014 (by WHO)

30
 Additional necessary and effective reproductive and sexual
health interventions fall in the whole or in part outside of the health
sector. Sexuality education that stresses partner communication,
redress of power imbalances, and promotion of gender equality, as
well as programs that address women's educational and economic
advancement, have substantial impact on reproductive and sexual
health outcomes including STIs among others.
Both the number of maternal deaths and the maternal mortality
ratio (MMR) are extremely difficult to calculate accurately. Even in
a country such as the United States with a strong vital registration
system, it is estimated that maternal deaths are underreported by
approximately 50%. Using several different statistical techniques,
WHO, UNICEF and UNFPA have estimated MMRs for most
countries in the world. However, as the authors of the
WHO/UNICEF/UNFPA publication have carefully explained, MMR
should be used only to give a sense of the scope of the problem, not
to measure short-term trends, and cross-country comparisons should
be undertaken only with great caution.
Keeping these caveats in mind, the geographic distribution of
the approximately 530,000 maternal deaths that occur each year is
telling. Sub-Saharan Africa has dramatically higher maternal
mortality ratios than any other part of the world. It also accounts for
47% of all maternal deaths. Although Asia on the whole has lower
MMR than Sub-Saharan Africa, it has a much larger population, so
this region (including both some very high and some very low
mortality countries) still accounts for 48% of maternal deaths. Data
on the proportion of births attended by skilled health personnel
similarly indicate huge disparities in access to this aspect of
pregnancy care.
In the early years of the Safe Motherhood Initiative, launched
in 1987, most program recommendations rested on the hypothesis
that obstetric complications could be prevented or predicted by good
care during pregnancy and delivery. Antenatal care programs were
expanded and improved in hopes that routine monitoring and
improved health practices during pregnancy (such as good nutrition)
would prevent or enable early recognition of complications.
Recognizing that most women in high mortality countries deliver

31
at home, early programs also focused on training traditional birth
attendants (TBAs) in safe and hygienic practices. Although antenatal
care and TBA training programs may improve the overall health of
mothers very well, it turned out that these interventions were
ineffective in reducing maternal deaths. Neither antenatal care nor
trained TBAs prevented the vast majority of complications, and once
the complication occurred, there was almost nothing TBAs, by
themselves, could do to alter the chance that death would ensue.
Thus neither of these interventions proved to have substantial impact
on maternal mortality levels.
Another set of early recommendations was based on the
hypothesis that obstetric complications could be predicted by
screening to know the risk factors and that high-risk women could
then be carefully monitored and treated. Indeed, women with certain
attributes – e. g. young age, high parity – have a higher risk of dying
than other women and, in some settings where a functioning health
system already exists, attention to high-risk pregnancies can bring
already low MMRs even lower. But high-risk women account for
only a small percentage of all maternal deaths; the vast majority of
deaths occur among the women who don`t know risk factors. Thus,
risk-screening programs had little impact on overall maternal
mortality levels.
Instead, maternal mortality reduction programs are based on the
principle that every pregnant woman is at risk for life-threatening
complications. For MMR to be reduced dramatically (certainly, for it
to drop by 75%, as the MDGs demand), all women must have access
to high-quality delivery care. That care has three key elements:
1. Skilled attendant at delivery;
2. Access to emergency obstetric care (EmOC) in case of a
complication;
3. A referral system to ensure that those women, who
experience complications can reach life-saving EmOC in time.

32
 2.4. MCHC services in Belarus
Approximately 435 children’s polyclinics and 17 children’s
hospitals, 27 children’s sanatoria are functioning, medical care to
female population is given by more than 330 female consultations
and obstetrics-gynaecology departments, 10 consultations «marriage
and family». The center of medical care network for women and
children is the Republican Scientific and Practical Center (RSPC)
«Mother and Child».
Types of MCHC and family planning services in Belarus are
the following:
1. The out-patient public health services:
 female consultations;
 consultation «marriage and family»;
 children’s polyclinic;
 department (the cabinet) of medical geneticist.
2. The in-patient public health services (stationary or hospital
medical care):
 children’s hospital or children’s departments of hospital;
 specialized children’s hospitals (infectious, tuberculosis,
psychiatric, rehabilitative);
 maternity hospitals (perinatal centers) and maternity
departments of hospitals;
 gynecologic departments of hospital or gynecologic hospitals
(in Minsk).
3. Other public health services for women and children:
 orphanage (general, specialized – with mental disorders, with
speech disturbances, visual impairment, support-motor apparatus
disturbances and etc.);
 infant feeding centers,
 children’s sanatorium, maternal and child’s sanatoria and
others;
 The Republican Scientific-Practical Center (RSPC) «Mother
and Child» (Minsk);
 the network of private medical cabinets for women health care.
Basic medical-preventive organisation (public health service)
of mother and child health protection system in the Republic of
33
Belarus is the female consultation. It is the public health care
organization that provides modern medical technologies, family
planning facilities and reproductive health protection at the out-
patient obstetric and gynecological help.
Objectives of female consultation are as follows:
1. To render obstetric help during pregnancy, postpartum
period, preparation for pregnancy and delivery;
2. To render outpatient help for women with gynecological
diseases;
3. To provide consultations and services on family planning
(including prevention of abortion and sexually transmitted diseases);
4. To render specialized obstetric-gynecological help;
5. To render separate types of stationary help (in terms of the
day permanent establishment – «day-hospital»);
6. To render social-legal help for woman and family;
7. To provide hygienic education and education on the problem
of reproductive health;
8. To provide sanitary-antiepidemic actions;
9. To adopt new medical technologies.
The structure of female consultation in Belarus includes:
 consulting-rooms (cabinets) of district obstetrician-
gynecologist;
 consulting-rooms (cabinets) of specialized intendance:
family planning cabinet, cabinet of prenatal diagnostic, cabinets of
gynecological endocrinology, of habitual interruption of pregnancy;
 consulting-rooms (cabinets) of other specialists: internist,
stomatologist, psychotherapist, lawyer, social worker,
psychoprophylactic training for delivery.
Female consultation is working according to territorial-local
(district) principle. The norms of loading are as follows:
 one obstetrician-gynecologist per 3300 women older than
15 years (or 6000 adult population);
 1 internist (terapeutist) per 60 thousand of adult population;
 1 stomatologist per 80 thousand of adult population;
 1 laboratory doctor per 20 medical posts;
 the number of midwives posts is equal to the list of
obstetrician-gynecologists’ posts;

34
  work time: up to 6 hours on call, 0,5 hour home calls; load
on call 5 in 1 hour, on home call 1,25 in 1 hour, preventive (regular)
examinations – 8 in 1 hour.
All women observed in female consultation are divided into the
following groups: pregnant, gynecological sick, women suffering
from sterility, healthy and practically healthy women. Since 1998
delivery potential groups formation (only women in fertile age) has
been started. Such groups have been formed: 1 group – healthy,
2 group – almost healthy, 3 group – gynecological sick, 4 group –
suffering from extragenital diseases, 5 group – suffering from
extragenital and gynecological diseases.
The documentation of female consultation include: an
individual card of a pregnant and puerperant woman (form number
111/ acc.); an exchange card of the maternity hospital (form
number113/ acc.).
The basic figure in female consultation is district obstetrician-
gynecologist. Functions of the district obstetrician-gynecologist are
as follows:
1. He is carrying out periodical medical examination of women
of the district with the purpose of revealing chronic inflammatory
diseases, tumours and pre-cancer conditions, STIs, etc., taking into
account women, suffering from gynecologic diseases and working
out complex plans of improvement of women health including timely
hospitalisation and direction for sanatorim rehabilitation.
2. The district obstetrician-gynecologist is carrying out timely
diagnostics and registering women in early stages of pregnancy
(before 12 weeks of gestation) and organizing preventive measures
on medical-hygienic training of future mothers and fathers; the
district obstetrician-gynecologist is hospitalizing all women with the
complications of pregnancy or complicated obstetrician anamnesis.
3. He is studying the pregnant women`s working conditions
and fills in certificates about the need of the translation to easy and
harmless work (form number 081/ acc.), or medical comment about
translation to different work (084 / acc.).
4. The district obstetrician-gynecologist provides the
continuity with other organizations of public health services (and,
first of all, with children’s polyclinic).

35
 5. The district obstetrician-gynecologist conducts the work on
the healthy way of life formation.
Gynecological help in the female consultation is rendered in
full size: active detection of gynecological sick (every woman should
be routine examined once a year by obstetrician-gynecologist using
cytological and colposcopic methods); treatment and hospitalization
on indications; disability examination.
The main objective of female consultation is rendering of
antenatal care. Antenatal care is the care of the woman during
pregnancy. The primary aim of antenatal care is get at the end of a
pregnancy a healthy mother and a healthy baby. Ideally this care
should begin soon after conception and continue throughout
pregnancy. In some countries, notification of pregnancy is required
to bring the mother in the prevention care cycle as early as possible.
The objectives of antenatal care are:
 to promote, protect and maintain the health of the
mother during pregnancy;
 to detect «high risk» cases and give them special
attention;
 to foresee complications and prevent them;
 to remove anxiety and dread associated with delivery;
 to reduce maternal and infant mortality and morbidity;
 to teach the mother elements of child care, nutrition, personal
hygiene, and environmental sanitation;
 to sensitize the mother to the need for family planning,
including advice to cases seeking medical termination of pregnancy;
 to attend to the under-fives accompanying the mother.
The significant place among the purposes of female
consultation is taken by the prevention of premature fetuses birth.
Underdevelopment of pulmonary tissue and surfactant system by the
moment of childbirth, massive aspiration, disrupted expansion of
pulmonary tissue and disrupted formation of pulmonary blood flow
during the first hours and days of the child's life may cause the
development of respiratory distress syndrome. Respiratory distress
syndrome (RDS) is one of the main reasons causing death of
premature children in Belarus.

36
 Mature fetus corresponds to the pregnancy terms from 37 to
42 full weeks (259-293 days). Overmature fetus corresponds to
pregnancy terms of 42 full weeks (294 days and more).
Antenatal care in female consultations of Belarus is carryed out
by strictly medical observation of pregnant women.
Every pregnant women should go through regular medical
check-up, with the schedule.
1. Well-timed taking into medical account before 12 weeks
(2006–94% of pregnant women in Belarus were taken into medical
account before 12 weeks of pregnancy);
2. Systematic observations: the first one – before 12 weeks (on
the taking into medical account). The first checkup includes total and
special anamnesis gavering, general examination, height, weight,
circumference of the belly measurement, the pelvic dimensions,
examination of blood pressure on two hands, obstetric examination,
the most important organs examinations.
The second check-up carries out in time of 12-th week; in the
first half of pregnancy once a month; after 20 weeks – 2 times
a month; after 32 weeks – 3-4 times a month (i.e. up to 15 time).
Internist carries out checkup of the pregnant women on the first
visit and in time of 32th weeks of pregnancy. The stomatologist and
otolaryngologist carry out checkup of the pregnant women on the
first visit and on indications, should undergo oral cavity sanation.
In time of 32 weeks of pregnancy an exchange card of the
maternity hospital is filled in (form number 113/acc.), this form has
three cells: destined to patronage, puerperant, hospitalized;
this information is kept in the cabinet of the physician till the date of
the following visit of the pregnant women.
3. The all-round examination of pregnant and somatic diseases
treatment. Analyses: clinical blood test 2–3 times, clinical urine
analysis on every visit; blood grouping, Rh-factor (if negative –
examination of the partner), Wassermann test – 2 times, bacteriological
study of vaginal discharge.
Since 1991 prenatal diagnostic has been obligatory for all
pregnant women, ultrasound screening is carrying out two times up
to 22 weeks.

37
 Others examination tests are carried on strict indications and
include biochemical and invasive methods, such as fetoprotein
examination, chorion biopsy, amniocentesis.
4. Selection of the risk group for pregnant women. Five groups
of the risk-factors are distinguished: social-biological, obstetric-
gynecological anamnesis, mother’s extragenital diseases, complications
of pregnancy, fetus’s state value.
5. Prenatal nursing (those who didn’t come in the specified period).
6. Determination of the delivery date and granting of
antepartum leave.
7. The well-timed qualified treatment (more than 1/3 of
pregnant in the Republic of Belarus need antepartum hospitalization;
before 20 weeks and in case of extragenital diseases – to profile
departments, in other periods and cases – to the pathologic
pregnancy department of the maternity hospital).
8. Physical and psychoprophylactic training of the pregnant to
delivery: since the first visit to the antenatal clinic, the group method
(8-10 people) is used since 32-34 weeks of pregnancy. Organization
and giving lessons in «mother’s school», «mother’s and father’s
schools» since 15-16 weeks (regimen for a pregnant, feeding for a
pregnant, child care and etc.).
After the period of pregnancy by delivery women should visits
the female consultation (or must be organised the patronage, or
home-visit) for 2 times: through 10-12 days after discharge, and
through 5-6 weeks after delivery. The following recommendations
should be done: observance of personal hygiene, care after mammary
glands, physical exercises, observance of mode of the rest, labour,
feeding, vitaminization, wearing of the abdominal support.
Breastfeeding is an important factor determining health status of
children under one year. Over the last eight years the number of
breastfeded children until three months increased in Belarus from
46,6% in 1993 to approximately 80,0% in 2008.
Organization of obstetric-gynecological help for girls in
Belarus consists of three stages.
First stage - primary health care (the pediatricians, adolescent
internist).
2nd stage – child’s and adolescent gynecologist (1 job title per
50 thous. of children, reception at child’s polyclinic).
38
 3rd stage – centers of reproductive health (the youth centers,
physician-pedagogical centers). The staff: obstetricians-gynecologists,
venerologist, psychologist, social worker, teacher. Directions of
activity: (a) rendering medical-social and psychological help for
adolescent: general questions of the family planning, individual
selection of contraception, diagnostics, treatment and prophylaxis of
STD, HIV, psychosexual relations, in-family conflicts and
psychology of communication; (b) legal questions of reproductive
health; (c) free provision with contraceptives and literature about
family planning, (d) rendering consulting-diagnostic and medical
help on reproductive health problems; (e) medical-pedagogical
direction: education for teachers, psychologists, doctors; increasing
of population competence, work in children’s group, help for families.
4 stage – specialized hospital departments,
5 stage – sanatoria.
The basic service of stationary (hospital) obstetric-gynecological
help in Belarus is the perinatal centre or maternity hospital.
It is rendering stationary (hospital) qualified help for women at
the period of pregnancy, delivery, puerperal period, qualified
medical help and care for a newborn, rendering help in case of
gynecological diseases.
Maternity hospital includes some departments:
1. The admitting office: a waiting room, information bureau, a
room for the personnel, the filter (in which midwifes examine
integuments, fauces, measure temperature), two rooms for patient’s
examination: for the healthy and for the sick, two sanitary inspection
rooms, two rooms for discharging of patients (for the healthy and for
the sick).
2. Physiological (first) obstetric unit (50-55% from all
obstetric hospital beds, includes reception, prenatal, puerperal,
postnatal departments).
3. Unit (or chambers) for the pregnant with a pathology of
pregnancy (25-30% of the general number of obstetric beds, for
women with extragenital diseases, complications of pregnancy,
wrong fetal position, compromised obstetric anamnesis).
4. Observative (second) obstetric unit (20-25% beds). With a
view of prevention of purulent-septic diseases, the sanitary-and-
hygienic regimen is carried out. It is providing strict isolation of sick
39
patients from healthy at the admission and during stay in the
maternity hospital.
5. Unit (or chambers) for newborn children in the structure of
the first and the second obstetric units. Modern particularities:
hospital of good-natured relations to child (early child’s breast
application, mother and child joint stay).
6. Gynecological departments (for operative treatment, for
conservative treatment, for fetus wastage). It occupies approximately
25-30% of beds in maternity hospital. Usually the gynecological
department has three types of beds: for operative methods of treatment,
for conservative methods of treatment, and for the conduct of artificial
(induced) abortions. The conservative department is organized as the
therapeutic one. The operation department is organized as the surgical
and is subdivided into pure and purulent ones.
Induced abortions are allowed in Belarus up to 12 weeks of
pregnancy (rendering in female consultations or day-hospitals).
Abortions on social indications are allowed up to 22 weeks.
Abortions on medical indications are allowed regardless of duration
of gestation. The medical card of the induced abortion is filled in.
Alternative birth centres and home births are not wide
spreading in Belarus. Aspects of contemporary hospital-based care,
such as the use of electronic fetal monitoring, ultrasound and the
certified medical personnel are the reason that absolutely most births
in Belarus currently occur in hospitals attended by physicians.
During the last twenty five years intrauterine hypoxia and
asphyxia during delivery were the main causes of infant morbidity in
Belarus. Every year the condition of about 7000 newborns requires
urgent care. The strategic task of primary intensive care in the
peurperal unit is to get by the 5th minute the maximum possible
grade by Apgar scale as its value correlates with the neurological
prognosis by the end of the first year of life of the child. That is why
a health professional attending delivery has 1-2 minutes to make a
decision on the scope of the required medical aid.
Therefore, the focus should be made on the organization of
intensive care in maternal clinics, the development and introduction
of unified algorithms for diagnosing and schemes of primary
intensive care as well as the relevant training of the staff.

40
 2.5 Basic parameters of children’s health well-being
Basic indexes characterizing children’s health well-being are
follows:
1. Infant mortality rate, that calculated as:
IMR = (number of deaths among infants under 1 year/ 4/5 live
births at the same year + 1/5 live births at the last year) x 1000”.
The IMR traditionally is divided into:
the neonatal mortality rate, NMR = (total deaths of children
during the first 4 weeks or 28 days of life / all been born alive) x 1000;
and the postneonatal mortality rate, PNMR = (total deaths
during 28 days – 1 year of life / (the children, been born alive –
the children, deceased at the first 4 weeks of life)) x 1000.
2. Perinatal mortality rate, that calculated as:
PMR = [(deaths of fetuses of gestational age older than
22 weeks + deaths of infants under 7 days or 168 hours old) / all
births in a given time period (usually one year), including fetuses of
gestational age older than 22 weeks] x 1000.
Perinatal mortality is divided into:
a) antenatal (since 22 weeks of pregnancy to birth) or fetal
mortality,
b) intranatal mortality (in time of birth or labour process),
c) early neonatal mortality (first 7 days or 168 hous of life).
3. Fetal mortality or Mortinatality, that calculated as:
FMR= (The number of stillbirths of gestational age older than
22 weeks / all births in a given year, including fetuses of gestational
age older than 22 weeks) × 100.
4. Other indicators of child death, such as:
under-five mortality rate or the UNICEF index; or the Child
mortality rate; that is calculated as follows:
Child mortality rate = (Number of children`s deaths under 5 years
in a given year / Number of live births in the same year) x 1000;
and Death-rate of the children from the 1 to 15 years (to the
annual average number of the children from the 1 to 15 years).
5. Morbidity rates among children.
6. Physical development parameters.

41
 Whereas 50 per cent of all deaths in the developing world
occur among people over 65, the same proportion of deaths occur
among children during the first five years of life in the developing
world.
Under-five mortality is an important indicator reflecting health
status of the children's population.
UNICEF defines Under – 5 Mortality rate (or Child mortality
rate) as the "annual number of children`s deaths under 5 years of life,
expressed as a rate per 1000 live births." More specifically, it
measures the probability of dying between birth and exactly 5 years
of age. UNICEF considers this as the best single indicator of social
development and well-being rather than GNP per capita, as the former
reflects income, nutrition, health care and basic education, etc.
The number of under-five deaths worldwide has declined from
12.7 (12.6, 13.0) million in 1990 to 5.9 (5.7, 6.4) million in 2015.
Global under-five mortality rate dropped 53% since 1990.
This translates into 19 000 fewer children dying every day in 2015
than in 1990. The remarkable decline in under-five mortality since
2000 has saved the lives of 48 million children under age five –
children who would not have survived to see their fifth birthday
if the under-five mortality rate from 2000 onward remained at the
same level as in 2000. Yet, despite these substantial gains, progress
is insufficient (Figure 9).
5.9 million children under age five died in 2015, nearly 16 000
every day. Most of these deaths occur in low-income and middle
income countries. Most deaths among under-fives are still
attributable to just a handful of conditions and are avoidable through
existing interventions (Figure 10). About 83% of deaths in children
under age five are caused by infectious, neonatal or nutritional
conditions.
UNICEF regards Child mortality rate as one of the main
indicators of social well-being as it reflects not only the presence of
biological factors of the risk of mortality in children but also the
level of their social well-being (quality of nutrition, availability of
medical care, immunization coverage, etc.).

42
 Figure 9. – Under-five mortality trends, 1990–2015

Figure 10. – Major causes of death among children under five

(global, 2015)
43
 Poor or delayed care-seeking contributes to 60-70 per cent of
child deaths. Summarizing data across regions and countries masks
substantial differences in the distribution of causes of death.
Approximately 90% of all malaria and HIV/AIDS deaths of children,
more than 50% of measles deaths and about 40% of pneumonia and
diarrhoeal deaths are in the African region (Figure 11).

Figure 11. – Structure of Global Under-five death (by region)

The risk of a child dying before completing five years of age is

still highest in the WHO African Region (81 per 1000 live births),
about 7 times higher than that in the WHO European Region (11 per
1000 live births). Many countries still have very high under-five
mortality – particularly those in WHO African Region, home to 6 of
the 7 countries with an under-five mortality rate above 100 deaths
per 1000 live births. In addition, inequities in child mortality
between high-income and low-income countries remain large.
44
In 2015, the under-five mortality rate in low-income countries was
76 deaths per 1000 live births – about 11 times the average rate in
high-income countries (7 deaths per 1000 live births). Reducing
these inequities across countries and saving more children’s lives by
ending preventable child deaths are important priorities.
11,648 children under one year of life died in the Republic of
Belarus in 1950. Infant mortality rate (IMR) made up 57,4‰ which
was within the average rate for Europe at the beginning of the 1950s.
The pronounced reduction recorded in 1950-1969 allowed to place
Belarus among the countries of the European region with the mid-
level rate of infant mortality.
The data allowing to get ratios for describing IMR age structure
have been available since 1970. The increase of infant mortality in
the first half of the 1970s was related to its neonatal component.
Among the most evident reasons worth mentioning is the
implementation of measures aimed at ensuring registration of ail
death instances of children including the syndrome of «delayed
infant death».
Slow down in the rates of infant mortality from 1977 till the
end of the 1980s was the result of lack of progressive changes in the
dynamics of neonatal component being, in their turn, the result of
lack of positive changes in the dynamics of early neonatal death rate
and, starting from the 1980s, the increased number of death instances
of children aged 7-27 days. The increase of IMR in 1990-1996 was
caused by the increased number of death instances of infants
survived during the first month of life.
Paradoxical situation was observed in Belarus in 1986-1996
when the decline of the birth rate was accompanied by the rise of
infant mortality. The decrease in infant mortality since 1996 to great
extent was stipulated by health-organizational measures such as
reorganization of perinatal care on the three-level base.
The reorganization of perinatal care based on the principle of
multi-level perinatal centres has been implemented in the country
since 1996. The efficiency of the organizational measures on
enhancing services to women and children has been higher in urban
areas where the reduction of infant mortality began in 1996 and
during the next 5 years the rate went down from 12,2‰ to 8,3‰

45
(795 infants below one year of age died in 1996 and 563 infants died
in 2000). In rural areas the increase of infant mortality continued till
1999 and the reduction to 12,0‰ was reported only in 2000. Efforts
of physicians in realization of the National program of demographic
safety of Belarus for 2007–2010 promoted that infant and maternal
mortality death rates in Belarus have reached the lowest level
recently: 4,5 per 1000 live births, that corresponds to middle level for
the European Union countries. Today (2016) Belarussian data are
about 3 cases of infant death per 1000 live births.
The data allowing to characterize the infant mortality structure
by reasons have been available since 1965. According to the data,
flu, acute respiratory syndrome and pneumonia were in general the
main reasons of mortality in infants during the first year in the
country up to 1980, in urban areas with much better opportunities for
treatment (mainly intensive care) were available up to 1971 and up to
1983 in rural areas.
The structure of mortality in children under one year of age has
remained fairly stable during the last 20 years. The main reasons are
congenital malformations and certain perinatal conditions which in
total account for 70% of IMR. The third in ranking are flu, acute
respiratory disease and pneumonia (0,8‰) followed by accidents,
trauma and poisoning (0,8‰), infectious and parasitic diseases
(0,5‰) and other reasons (0,5‰).
2.6 Health of the adolescent
According to the Report of the WHO research group on youth
problems «Health of youth is a care of society» (Geneva 1989),
teenage age (adolescences) is the period from 10 till 19 years, the
term «youth» is used in reference to people of 15-25 years, «young
men» – persons aged 10-24 years.
This period is characterized by rapid growth and change in
anatomy and physiology as well as shifting values and allegiances.
Around 1 in 6 persons in the world is an adolescent: that is
1.2 billion people aged 10 to 19.
Most are healthy, but there is still significant death, illness and
diseases among adolescents. Illnesses can hinder their ability to grow
and develop to their full potential. Alcohol or tobacco use, lack of
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physical activity, unprotected sex and/or exposure to violence can
jeopardize not only their current health, but often their health for
years to come, and even the health of their future children.
Promoting healthy practices during adolescence, and taking
steps to better protect young people from health risks are critical for
the prevention of health problems in adulthood, and for countries’
future health and social infrastructure.
Main health issues of this period include:
Early pregnancy and childbirth: Complications linked to
pregnancy and childbirth are the second cause of death for 15-19-
year-old girls globally. Some 11% of all births worldwide are to girls
aged 15 to 19 years, and the vast majority are in low- and middle-
income countries. The 2014 World Health Statistics put the global
adolescent birth rate at 49 per 1000 girls this age – country rates
range from 1 to 229 births per 1000 girls. This indicates a marked
decrease since 1990. This decrease is reflected in a similar decline in
maternal mortality rates among 15-19 year olds.
One of the specific targets of the health Sustainable Development
Goal is that by 2030, the world should ensure universal access to
sexual and reproductive health-care services, including for family plan-
ning, information and education, and the integration of reproductive
health into national strategies and programmes. To support this,
a proposed indicator for the «Global Strategy for Women’s, Children’s
and Adolescents’ Health» is the adolescent birth rate.
Better access to contraceptive information and services can
reduce the number of girls becoming pregnant and giving birth at too
young an age. Laws that specify a minimum age of marriage at 18
and which are enforced can help.
Girls who do become pregnant need access to quality antenatal
care. Where permitted by law, adolescents who opt to terminate their
pregnancies should have access to safe abortion.
HIV: More than 2 million adolescents are living with HIV.
Although the overall number of HIV-related deaths is down 30%
since the peak in 2006 estimates suggest that HIV deaths among
adolescents are rising. This increase, which has been predominantly
in the WHO Africa Region, may reflect the fact that although more
children with HIV survive into adolescence, they do not all then get

47
the care and support they need to remain in good health and prevent
transmission. In sub-Saharan Africa only 10% of young men and
15% of young women aged 15 to 24 are aware of their HIV status.
Young people need to know how to protect themselves and
have the means to do so. This includes being able to obtain condoms
to prevent sexual transmission of the virus and clean needles and
syringes for those who inject drugs. Better access to HIV testing and
counselling, and stronger subsequent links to HIV treatment services
for those who test HIV positive, are also needed.
Other infectious diseases: thanks to improved childhood
vaccination, adolescent deaths and disability from measles have
fallen markedly – for example, by 90% in the African Region
between 2000 and 2012. But diarrhoea, lower respiratory tract
infections and meningitis are among the top 10 causes of death for
10 to 19 year olds.
Mental health: depression is the top cause of illness and
disability among adolescents and suicide is the third cause of death.
Violence, poverty, humiliation and feeling devalued can increase the
risk of developing mental health problems.
Building life skills in children and adolescents and providing
them with psychosocial support in schools and other community
settings can help promote good mental health. Programmes to help
strengthen ties between adolescents and their families are also
important. If problems arise, they should be detected and managed
by competent and caring health workers.
Violence: is a leading cause of death. An estimated 180
adolescents die every day as a result of interpersonal violence.
Around 1 of every 3 deaths among adolescent males of the low- and
middle-income countries in the WHO Americas Region is due to
violence. Globally, some 30% of girls aged 15 to 19 experience
violence by a partner.
Promoting nurturing relationships between parents and children
early in life, providing training in life skills, and reducing access to
alcohol and firearms can help to prevent violence. Effective and
empathetic care for adolescent survivors of violence and ongoing
support can help deal with the physical and the psychological
consequences.

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 Alcohol and drugs: harmful drinking among adolescents is a
major concern in many countries. It reduces self-control and increases
risky behaviours, such as unsafe sex or risky driving. It is a primary
cause of injuries (including those due to road traffic accidents),
violence (especially by a partner) and premature deaths. It also can
lead to health problems in later life and affect life expectancy.
Setting a minimum age for buying and consuming alcohol and
regulating how alcoholic drinks are targeted at the younger market
are among the strategies for reducing harmful drinking. Drug use
among 15 to 19 year olds is also a concern.
Injuries: unintentional injuries are a leading cause of death and
disability among adolescents. In 2012, some 120 000 adolescents
died as a result of road traffic accidents. Young drivers need advice
on driving safely, while laws that prohibit driving under the
influence of alcohol and drugs need to be strictly enforced. Blood
alcohol levels need to be set lower for teenage drivers. Graduated
licences for novice drivers with zero-tolerance for drink-driving are
recommended. Drowning is also a major cause of death among
adolescents – 60 000, two-thirds of them boys, drowned in 2012,
and teaching children and adolescents to swim is a useful
intervention to prevent this.
Malnutrition and obesity: many boys and girls in developing
countries enter adolescence undernourished, making them more
vulnerable to disease and early death. The number of adolescents
who are overweight or obese is increasing in both low – and high-
income countries.
Exercise and nutrition: available survey data indicate that
fewer than 1 in every 4 adolescents meets the recommended
guidelines for physical activity – 60 minutes of moderate to vigorous
physical activity daily.
Anaemia resulting from a lack of iron affects girls and boys,
and is the third cause of years lost to death and disability. Iron and
folic acid supplements help to promote health before adolescents
become parents, and regular deworming in areas where intestinal
helminths such as hookworm are common is recommended.
Developing healthy eating and exercise habits at this age are
foundations for good health in adulthood. Reducing the marketing of
foods high in saturated fats, trans-fatty acids, free sugars, or salt
49
and providing access to healthy foods and opportunities to engage in
physical activity are important for all but especially children and
adolescents.
Tobacco use: the vast majority of people using tobacco today
began doing so when they were adolescents. Prohibiting the sale of
tobacco products to minors and increasing the price of tobacco
products through higher taxes, banning tobacco advertising and
ensuring smoke-free environments are crucial. Globally, at least 1 in
10 younger adolescents (aged 13 to 15) uses tobacco, although there
are areas where this figure is much higher. Cigarette smoking seems
to be decreasing among younger adolescents in some high-income
countries.
Rights of adolescents: the rights of children (people aged
between 0-17 years) to survive, grow and develop are enshrined in
international legal documents. The Committee on the Rights of the
Child (CRC), which oversees the child rights convention, in 2013
published guidelines on the right of children and adolescents to the
enjoyment of the highest attainable standard of health, and a General
Comment on realizing the rights of children during adolescence is
under development, building on existing CRC guidelines on states’
obligations to recognise the special health and development needs
and rights of adolescents and young people.
As the Committee on the Rights of Children expressed it in a
General Comment reinforcing the status of adolescents as rights
holders and elaborating the obligations of Member States to promote
their health and development: «The dynamic transition period to
adulthood is also generally a period of positive changes, prompted
by the significant capacity of adolescents to learn rapidly, to
experience new and diverse situations, to develop and use critical
thinking, to familiarize themselves with freedom, to be creative and
to socialize» (Committee on the Rights of Children 2003). Yet,
adolescents' reproductive and sexual health needs have long been
ignored and their views silenced by decision makers influencing
health and education policy and programs.
Key facts (by WHO):
 An estimated 1.3 million adolescents died in 2015, mostly
from preventable or treatable causes.

50
  Road traffic injuries were the leading cause of death in 2012,
with some 330 adolescents dying every day.
 Other main causes of adolescent deaths include HIV, suicide,
lower respiratory infections and interpersonal violence.
 Globally, there are 49 births per 1000 girls aged 15 to 19 per
year.
 Half of all mental health disorders in adulthood start by age
14, but most cases are undetected and untreated.
The leading causes of death among adolescents in 2012 were:
 road injury
 HIV
 suicide
 lower respiratory infections, and
 interpersonal violence.
For both biological and social reasons, adolescents, and
particularly adolescent girls, are a vulnerable group. In many areas of
the world, especially in West Africa and South Asia, East and
Central Africa a large percentage of girls are already married by their
mid – to late- teenage years and have given birth at least once by the
age of 18. Early marriage reduces girls' educational opportunities,
starts them on a path toward early childbearing with its resultant
health risks (including mortality) and often locks them into highly
unequal relationships with much older men. Adolescents, particularly
those living in highly-dependent, precarious circumstances – e.g.,
in intense poverty, in refugee settings, or as orphans – are subject
to high rates of abuse, including sexual abuse.
Indeed, in many countries in Africa, to be young and female
means substantially higher risk of HIV/AIDS: women aged 15 to 24
are 2,5 times as likely as their male counterparts to be infected with HIV.
Key facts (by WHO):
 About 16 million girls aged 15 to 19 and some 1 million
girls under 15 give birth every year – most in low and middle-
income countries.
 Complications during pregnancy and childbirth are the
second cause of death for 15-19 year-old girls globally.
 Every year, some 3 million girls aged 15 to 19 undergo
unsafe abortions.

51
  Babies born to adolescent mothers face a substantially
higher risk of dying than those born to women aged 20 to 24.
As for all other members of society, health services for
adolescents must be tailored effectively to address their unique needs
and circumstances.
2.7 Management and prevention of health problems:
children and adolescents
The risk of death is highest in the first month of life. Preterm
birth, birth asphyxia and infections cause most newborn deaths.
Health risks to newborns are minimized by:
 quality care during pregnancy;
 safe delivery by a skilled birth attendant; and
 strong neonatal care: immediate attention to breathing and
warmth, hygienic cord and skin care, and early initiation of exclusive
breastfeeding.
From one month to five years of age, the main causes of death
are pneumonia, diarrhoea, malaria and measles. Malnutrition is
estimated to contribute to more than one third of all child deaths.
 Pneumonia is the prime cause of death in children under five
years of age. Addressing the major risk factors – including
malnutrition and indoor air pollution – is essential to preventing
pneumonia, as are vaccination and breastfeeding. Antibiotics and
oxygen are vital tools for effectively managing the illness.
 Diarrhoeal diseases are a leading cause of sickness and death
among children in developing countries. Breastfeeding helps prevent
diarrhoea among young children. Treatment for sick children with
Oral Rehydration Salts (ORS) combined with zinc supplements is
safe, cost-effective, and saves lives.
 One child dies every minute from malaria. Insecticide-
treated nets prevent transmission and increase child survival.
 Over 90% of children with HIV are infected through mother-
to-child transmission; this can be prevented with antiretrovirals, as
well as safer delivery and feeding practices.
 Worldwide, about 20% of deaths among children under-five
could be avoided if feeding guidelines are followed. WHO
recommends exclusive breastfeeding for six months, introducing
52
age-appropriate and safe complementary foods at six months, and
continuing breastfeeding for up to two years or beyond.
About two-thirds of child deaths are preventable through
practical, low-cost interventions. WHO is improving child health by
helping countries to deliver integrated, effective care in a
continuum – starting with a healthy pregnancy for the mother,
through birth and care up to five years of age. Investing in strong
health systems is key to prevention and delivery of quality care.
Medical-organizational measures for management and
prevention of infant health problems can be classified as follows:
1. Identification of high-risk parents:
a. Maternal age: mothers younger than 18 have an increased
risk of delivering a low-birth-weight infant. Mothers older than 34 in
the past presented an increased risk of delivering low-birth-weight
infants but currently account for an insignificant percentage of such
births.
b. Intrauterine infections. Several organisms can produce
congenital anomalies as well as increase the risk of low-birth-weight
infants. Rubella and syphilis are preventable. Other infections (e. g.,
toxoplasmosis, herpes (HSV), cytomegalovirus (CMV) and others)
can be detected by routine antibody screening of pregnant women.
c. Preexisting maternal illnesses. Such conditions includeheart,
kidney, and thyroid disease; diabetes mellitus; hypertension; and
substance abuse. Early detection and aggressive man agement of
maternal illnesses can reduce the toll of infant loss.
d. Maternal history of reproductive problems. Women who
have experienced adverse conditions during prior pregnancies (e. g.,
premature labor, vaginal bleeding, hypertension, miscarriage,
delivery of a low-birth-weight or stillborn infant) have an increased
risk of adverse outcomes in subsequent pregnancies.
e. Family history of disease. The presence of such a disease
may suggest the need for screening and special management.
2. Prevention of unwanted pregnancies among high-risk parents
may involve genetic counseling, sex education, and family planning.
3. Management of high-risk pregnancies includes:
a. Early start of prenatal care, including preconceptional care
and prenatal care.
53
 b. Identification of obstetric risk and referral to the appropriate
level of obstetric care until resolution of the risk or delivery in a
hospital equipped to manage potential problems related to
complications of pregnancy.
c. A regionalized system of obstetric and neonatal services to
coordinate and assure movement of patients and information among
providers at various levels of care.
d. Monitoring and treatment of the newborn for problems
related to obstetric and neonatal risk factors
4. Management of high-risk newborns includes:
a. Immediate access to intensive care.
b. Continued medical, social, and nutritional monitoring.
Medical-organizational measures for management and
prevention of childhood mortality and morbidity:
1. Immunization. Routine immunization of children has been
shown repeatedly to be one of the most cost-effective means of
preventing mortality and morbidity. Recommended immunization
schedules vary in different countries.
2. Screening for occult treatable conditions. Suitable
screening tests and accepted treatment for the condition must exist,
and diagnostic and treatment facilities must be available.
 Conditions for which screening has proven cost-effective
follow, with the appropriate timing of the screening noted in parentheses:
 Phenylketonuria (PKU), in the neonatal period.
 Congenital hypothyroidism, in the neonatal period.
 Iron deficiency anemia, at 6 or 9 months.
 Tuberculosis (regularly during childhood).
 Vision impairment (regularly during childhood).
 Additional screening procedures that should be considered
include:
 Assessment of physical growth and developmental status.
 Measurement of blood pressure (in children 3 years of age
and older).
 Hearing assessment and other somatic impairmaents
indicators.
4. Prevention of specific health problems:

54
 a. Injuries are the major cause of death of preschoolers and
school-age children. Two major approaches to prevention have been
identified.
(1) Modification of hazards to reduce their potential to cause
injury, such as: use of products with child-proof caps, lowering the
temperature of hot water heaters, installation of window guards, etc.
(2) Modification of behavior to reduce exposure to hazards,
including the use of: motorcycle and bicycle helmets, infant car
seats etc.
b. Psychosocial problems are more prevalent among children
from socioeconomically dis-advantaged families. Early intervention
may prevent these problems in target groups of children.
(1) High-risk groups include: children with increased risk of
morbidity and mortality by virtue of the circumstances of their birth
(e.g., low birth weight, congenital malformations); disadvantaged
children whose development is hampered by lack of environmental
stimulation; children with established problems known to result in
severe developmental delay, such as Down syndrome.
(2) Preventive strategies: screening and monitoring to detect
the emergence of problems can be conducted as part of well-child
care. Formal instruments have been developed for office use to
screen developmental delay, behavioral problems, school readiness,
learning disabilities, and physical training. Problems discovered in
such screening efforts require further diagnostic evaluation before
recommendations can be made. Increasingly, more extensive
preventive efforts are successful in high-risk groups.
4. Strategies to prevent adult diseases: increasing attention is
paid to encouraging health behaviors in childhood to prevent adult
chronic illnesses. Caution should be exercised, however, when
recommendations being made, as the long-term consequences of a
lifetime commitment to special diets and other habits in a developing
child are often unknown. Current recommendations include: (1)
Routine medical examinations according to shedule; a prudent,
balanced diet appropriate to the growth needs of the child; an active
exercise program appropriate to the child's age and coordination.

55
 Management and prevention of adolescent health
problems:
1. Sex-related problems:
a. Sex education is intended to increase the use of
contraceptives by adolescents and thereby reduce the risk of
unwanted pregnancy. The same is true for provision of free
contraceptive services.
b. Intensive management of adolescent pregnancies may
reduce the risk of low-birth-weight infants and, with follow-up, the
risk of postneonatal death.
c. Routine adolescent care should also include Pap smears and
vaginal cultures for sexually active adolescent girls to screen for
STDs and early cervical changes indicative of cancer.
d. Reproductive health services for adolescents should be
incorporated into routine well-person care in a setting that provides
continuity of care sensitive to the needs of adolescents. School-based
clinics have proven successful models of such care.
2. Smoking and substance abuse:
a. Educational campaigns meet limited success, but intensive
school-based efforts may limit cigarette smoking among adolescents.
b. Potential methods for prevention of substance abuse
include: enforcement of drinking-age laws; parental monitoring.
3. Injuries:
a. Regulatory activities have proven more effective than
educational campaigns. Such activities include the establishment of:
drinking-age laws; motorcycle and bicycle helmet laws;
requirements for protective gear in athletic programs; regulations
concerning access to firearms, etc.
b. Management of injuries is an essential component of
adolescent health program, which should also include prompt access to
emergency services and careful assessment of psychological status.
Management of injuries and drug ingestion in adolescents also may
require referral to mental health services if suicidal intent is indicated.

56
 2.8 Public health services for children in Belarus
Public health services children's organizations in Belarus is a
network of medical establishments, where medical care to the
children's population is given.
This network includes:
 children's hospitals (city, interdistrict, regional territorial –
medical associations, which structure includes the central regional
hospital with children's department);
 independent children's polyclinics, including the specialized
polyclinics;
 children's sanatoria, or health resorts (antitubercular,
osteotuberculous, orthopedic, cardiological, etc.);
 summer health – improving and recreation camps;
 kindergardens and day nursery-schools, schools and boarding
schools;
 mother and child care offices, items of children's feed and
dairy kitchens;
 orphanages, etc.
The basic types of medical preventive aid for children are:
a) out-patient (polyclinic);
b) in-patient (hospital);
c) health resort (center).
Since 2003 in Belarus once in three years certification of
educational institutions for correspondence to sanitary rules and
codes has been conducted.
Orphanages are organized for children under 3 years (as
general and specialized) and for older children (as preschool, school,
mixed, special).
One orphanage for children under 3 years may be up to 100
places with one pediatrician per 40 children. When child is arriving
from the family or hospitals there organized quarantine for 21 days.
Basic documentation of orphanage is the following: the journal
of children’s arrival to the orphanage; if a child has fallen ill at home
registration in the dispensary journal (074/acc.), history of children’s
development (registration of diseases), a control card of dispensary
observation can be also set up (030/acc.).
57
 The basic link of pediatric service is a children's polyclinic
(out-patient department). A children’s polyclinic is a public health
organization, providing children with out-patient help. In its activity
policlinic provides medical preventive aid to children till they are
14 (14 years, 11 months, 29 days).
The polyclinic includes a waiting room and two rooms: for
admitting sick children and for examination of healthy children.
The room for sick children reception consists of a filter with
isolation wards and with an isolator. It should have a separate
entrance and exit.
The room for reception of healthy children consists of the filter;
a waiting room, a wardrobe, a room for recording of calling a doctor
at home, a registry (for recording of medical specialists).
То the tasks of the children's policlinic registry (reception) one
refers preliminary and urgent record of children concerns to the
doctor and for service domiciliary, well-timed delivery of medical
documentation in doctors’ consulting rooms, inquiry maintenance.
Local pediatricians frequently use the decentralized principle of
registry at which card files arе gathered according to the districts.
In a children's polyclinic there are series of studies (consulting
rooms): a study of the manager; studies of local (district)
pediatricians; a study for inoculations; a room of a young mother;
subsidiary-diagnostic studies. Rendering of a help specialized, which
is carried out in the studies of certain specialists, is of great value:
cardiorheumatological, surgical, orthopedic, traumatological,
otorhinolaryngological, ophthalmological, psychoneurological,
logopedic, surdological, phthisiological, physiotherapeutic, X-ray, a
study of medical exercise, etc., clinical-diagnostic laboratories.
There is usually the inquiry office in the lobby of children's
polyclinics: business hours of polyclinic and separate doctors, rules
of children's reception in a polyclinic, the order of polyclinic doctors
and the ambulance calls, disposition of medical districts, addresses of
polyclinics on duty, drugstores, a list of the necessary documentation
for registration of a child in preschool establishments and in school.
Capacity of children's polyclinic is defined by the number of
visits during one shift. Five categories are singled out:
 the I category – 800 visits;
 the II category – 700 visits;
58
  the III category – 500 visits;
 the IV category – 300 visits;
 the V category – 150 visits.
Principles and features of children's polyclinic functioning:
1. The district-territorial principle of medical care providing is
put in the basis. It is recommended to have 800 children on the
pediatric district. On 8-10 pediatric districts one singles out 1 head of
the department. On 10 schools and preschools – 1 head of the healthy
childhood. Loading norms: 12,5 district pediatricians per 10 000
children; 4,64 posts of subspecialists per 10 000 children,
1 pediatrician per 180-200 infants, per 600 pre-school children and
per 2000 school children; 1,5 nurses per 1 district pediatrician; 1 nurse
for the preventive work with healthy children per 10 000 children.
2. The work of polyclinic is planned under the slipping
schedule.
3. The doctor works according to the principle of two-links
systems of medical services: 2,5 hours are given on reception, the
rest time is occupied by medical aid at home. Load on reception
makes up 5 persons per hour. At home – 1,5 visitings per hour.
The principle of alternating is observed.
4. Dispensary method of service.
5. The system of the uniform pediatrician.
6. Continuity in observation over a healthy child since the first
days of his life.
7. Stages of treatment: polyclinic, hospital, sanatorium.
8. The bilateral continuity in work of doctors between
children's polyclinic and female consultation is kept, children's
polyclinic and maternity hospital, between children's polyclinic and
polyclinic on service of adult population, teenagers servings.
Basic documentation:
The history of the child’s development – form number 112/acc.
Control card of child’s regular examination – form number
030/acc.
Card of the prophylactic immunization account – form number
063/acc.
Child’s medical card (attending kindergarden, school) – form
number 026/ acc.
Hospital chart (the hospital record) – form number 003/ acc.

59
 The basic directions of a children's polyclinic activity:
 Carrying out of the complex of preventive actions among
the children's population.
 The medical – advisory help to children at home and in
a polyclinic.
 The medical – preventive help in preschool establishments
and schools.
 Antiepidemic actions.
 Legal protection of children.
 Improvement of professional skills of medical staff.
Under the exercise of preventive actions it is understood:
maintenance of dynamic medical observation over healthy children,
prophylactic medical examination of children, carrying out of
preventive inoculations, the organization of the work of dairy
kitchens and the dairy-distributing items which are included in its
structure, reading popular scientific lectures, carrying out of
conversations, conferences for parents, classes at schools etc.
Duties of the district pediatrician include the organization of
connection with female consultation, creation of continuity in
observation over pregnant women (especially for «risk» groups), home
nursing of newborns in the first 3 days after discharge from maternity
hospital, the control of visitings by the district nurse at home.
During reception of children in a polyclinic they are
administered the regime, a balanced diet; specific and nonspecific
prophylaxis of rachitis is carried out, physical and psychological
development of children is estimated.
Preventive observation over children is exercised through a
referring for consultation to doctors – experts and for necessary
laboratory researches, planning (together with the district nurse)
preventive inoculations, dynamic observation over children, taken on
the dispensary account, their health improvement together with
doctors – experts, the analysis of efficiency of prophylactic medical
examination, inspection and improvement of children before their
entering in children's preschool establishments and schools, the
account and selection of children for sanatorium treatment.
The medical care of sick children at home is carried out on the
day of the call. Thus physiotherapcutic methods of treatment,
medical exercises are appointed.
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 Duties also include: informing of CHE about infectious disease,
carrying out of antiepidemic actions, improvement of professional
skills, introduction of the newest methods of diagnostics and
treatment in practice of pediatry, sanitary – educational work on
questions of development and education of a healthy child and
prophylaxis of diseases, keeping of the medical documentation,
control over work of the district medical nurse, organization of the
sanitary active.
The duties of the district medical nurse of a children's city
polyclinic are as follows:
 home nursing of pregnant women;
 visiting newborns in the first three days after the discharge
from the maternity hospital;
 studying material - household, cultural - hygienic and social
-psychological conditions of newborn’s and child’s family;
 performing administrated procedures at home;
 monthly control of inoculation of children who don't attend
school;
 maintenance of regular observation over healthy and sick
children;
 invitation of children to an inoculation;
 the well-timed organization of medical examinations of
children consisting on dispensary account, according to the plan of
prophylactic medical examination.
The district nurse is obliged to assist in carrying out medical
surveys (she carries out anthropometry inquiries, makes letters of
referrals, extracts), to carry out conversations with parents on
problems of development and education of a healthy child and
prevention of diseases, to participate in the organization of sanitary -
educational exhibitions in polyclinic, to improve qualification.
At providing medical care at home, condition of the child,
character and current stage of disease, age of the child and domestic
conditions are taken into account.
During the first visit the treatment is appointed, the character of
nutrition, regimen are determined.
The medical care at home is provided to children with acute
diseases; with infectious diseases or with suspicious on presence of

61
infection, and also to children who contacted with infectious
patients; in case of serious health condition of the child.
The calls till 14 p.m. are served by district doctors, from
14 p.m. till 16 p.m. – by pediatrician on duty, from 16 p. m. till
8 a. m. by emergency at stations of urgent medical care.
То the main task of healthy child serving one refers the
following:
1. Promotion of a healthy way of life.
2. Training of parents for the rules of care for children at
early age.
3. Children psychological development control over.
4. Estimation of physical development level.
Complex estimation of child’s health state assumes carrying out
of preventive reviewes, the account of the certain features,
distribution of children into groups of health according to health state
and dynamic estimation of physical development, somatic and
psychological condition during the dispensary observation of healthy
and sick children.
Complex estimation of child's health state is carried out by
pediatricians of children's city polyclinics during routine inspections
which can be carried out according to residence or in children's
establishment. Besides the named ones, profound routine inspections,
complex and target preventive examinations are singled out.
At the profound routine inspections medical examination is
preceded by carrying out of functional – diagnostic researches.
Complex preventive examinations are carried out annually by
pediatrician, ophthalmologist, otolaryngologist, surgeon –
orthopedist, neuropathologist, stomatologist.
The example of the target preventive examination can be
examination by logopedist at the age of 3, 5, and 7. We shall notice,
that in case of children speech defects it is necessary to correct them
before entering school.
During routine inspections of children it is necessary to take
into account their features:
 dependence of surveys periodicity on age: the younger a
child is, the more often they are carried out;

62
  necessity of the deviations revelation from the degree of
development adequate for the given age and acceptance of measures
to their well-timed correction;
 orientation on achievement of the basic purpose of
preventive examination – not only to keep, but also to improve the
health of healthy children;
 correspondence of volume and the contents of preventive
examinations to age, physical, functional and psychological
development.
During complex estimation, the functional condition of bodies
and systems, resistance and reactivity of organism, physical and
psychological development level, presence of chronic (including
congenital) pathologies are taken into account.
As the result after the preventive examination, all children are
divided into 5 health groups.
The first group – the healthy children who don`t have
deviations according to all parameters of health: who are not sick for
the period of observations, and also those having insignificant
individual deviations which are not influencing the health state, not
demanding corrections.
The second group – «children at risk» – weakened children,
with risk of occurrence of chronic pathology and inclined to the
increased sickness rate; children with the functional deviations
caused by the degree of morphological maturity of bodies and
systems are in this group; children of the first year of life with
burdened obstetrical and genealogical anamnesis; children –
frequently sick or who have had one serious disease with
unsuccessful current of the rehabilitational period, etc.
The dispensary observation of children till they are three is
conducted at the increased medical-social risk: at premature and
postmature; twins; children with the body mass of 4000 grammes
and more; patients with oligotrophy and rachitis; frequently ill with
respiratory diseases; with log in psychological development; being
on artificial feeding up to 3 months; children of seriously sick
parents, etc.
The third, fourth and fifth groups – sick children with chronic
pathology in a condition of indemnification, subindemnification
and decompensations.
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 The following groups of children should be under dispensary
observation: children with illnesses in the early age, of the
cardiovascular system illnesses, of the bodies of respiration, liver and
bile duct, stomach and duodenum, genitourinary system, blood,
endocrine system, psychological diseases, illnesses of the skeletal
system, ear, throats, nose, with illnesses and defects of eyes, definite
infectious diseases.
Up to 150-200 children are under dispensary observation of
medical specialists.
Preventive medical examination of children with tuberculosis,
malignant neoplasms, alienations, etc. is carried out in specialized
clinics. In case of their absence - in a children's polyclinic.
Dynamic observation over health state of children assumes the
use of dispensary method.
Preventive medical examination of the children's population
consists of:
 periodic preventive examinations in groups of the healthy
children, united by general age-physiological features;
 active regular dynamic observation over patients;
 well-timed and complex carrying out of all necessary
medical – improving actions.
Prophylactic medical examination of healthy children includes
antenatal protection of a fetus, prophylactic medical examination of
children of preschool age, prophylactic medical examination of
healthy pupils.
То the functions, which are carried out by a children's
polyclinic on antenatal protection of a fetus one refers: home nursing
of pregnant women; participation in carrying out of classes in school
of mother; advancing knowledge of pediatrician in the area of
perinatal pathologies.
At preventive medical examination of preschool aged children,
the special attention is given to transferring children from the
newborns department to children's polyclinics; to active preventive
observation over children at the age of 1, 2, 3; to dynamic observation
over the health state of children going to the first grade at school.
Observation over the health state of children at early and
preschool age assumes presence of many features.

64
 Prenatal nursing (the district pediatrician and nurse) is carrying
two times – after pregnancy registration in female consultation and
in time of 31-33 week of pregnancy.
During first year of life the special attention is given to
prophylaxis of rachitis and oligotrophy. During the first year of life
there should be 14-16 observations by the doctor: the first month of
life – weekly, the first year – monthly, the second year – quarterly,
the third year – 2 times per annum, further – annually.
Prevention of rachitis is carried out by vitamin D2. Every visit
doctor defines child weigh and its changes. Once in 3 months
anthropometric measuring with an estimation of physical and
psychological development (average, high and low) are made.
By the first year a child is examined on a congenital dislocation of
hip joint by orthopedist twice, haemoglobin in blood is defined at
matures in 5 months, at prematures in 3 months, urine on
phenylketonurius is examined, vision is examined by the
ophthalmologist. A child is examined by the surgeon, the
neurologist, the otorhinololaryngologist, the stomatologist. Walking,
speech, presence of teeth are estimated. In the first year of life stage
epicrisis is written (labors proceeding, feeding, diseases,
inoculations, estimation of general health state are pointed).
The special attention needs to be given to the preventive work
with children of the first 2 years of life. At the age from 1 till 2 the
child is examined by the doctor ones quarterly (movement, speech,
tempering, vision, hearing).
At the age from 2 till 3, once in 6 months (with all
anthropometric measurings).
At the age from 3 – preventive medical examination.
At the age from 3 till 7 the children are examined once a year.
At the age of 6-7, preventive medical examination (before
beginning of school education) is carried out. Special attention is
given tо children, entering preliminary school. At the age of 6, the
rate of physical development of a child accelerates, loads on the
cardiovascular system increase, there are various infringements of
bearing; hypertrophy of the lymphatic device of a nasopharynx is
frequently marked. For survey of this group it is necessary to allocate
one day in a week.

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 The conclusion of each expert is written down both in the form
№ 026/acc. and form № 112/acc. It is also necessary to specify
contraindications to inoculations if there are any. «Control card of a
dispensary observation» is filled in (form № 030/acc.) as well as its
duplicate. The plan of medical improving actions is made. Then form
№ 026/acc. and the duplicate of form № 030/acc. are transfered to a
school. After that, the nurse makes out the Diary of the health of
the class for the class teacher.
Children attending preschool establishments are examined
with the following frequency: till 1 year – once a week, from 1 till
2 years – 1 time in 10 days, from 2 till 7 years – once a month. And
at the obligatory scheduled profound surveys: till 1 year once a
month, from I till 3 years – once a quarter, from 3 up to 7 years –
2 times per year.
All data are filled in a card of the child development form
№ 112/acc.
The special attention is paid to physical and psychomotor
development of a child. Weighing, measuring of body height, circle
of head and breast are performed. Thus sensory acuity and visions
are defined, detailed research of organs and systems is carried out.
Health services at schools
Preventive medical examination of healthy children includes
the scheduled profound medical surveys. The special attention is
given to the day regimen, nutrition, well-timed carrying out of
preventive inoculations, the medical control over physical training,
hygienic education of schoolchildren, transferrence of 15-years old
teenagers to a polyclinic for adults, carrying out of improving actions.
At the age of 7, observation by school doctors is established.
Pupils of the senior classes, graduating school, are also examined.
Rendering the out-patient – polyclinic aid to adolescents
Rendering the out-patient – polyclinic aid to adolescents at
the age of 15-17 is carried out by the children's organizations of
public health services on the residence, in the place of time residing,
and also in the place of study (work).
In staffs of the children's organizations of the public health
services rendering the out-patient – polyclinic aid, the posts of
teenagers (adolescents) doctors – therapists are introduced and

66
teenage studies (consulting-rooms) are created. Teenagers-therapist
carries out treatment and medical prevention of diseases among
teenagers, renders the methodical help to other medical specialists.
The basic medical document of teenager is the medical card
of an ambulatory patient (the form 025/acc.) which is opened at the
age of 15.
All adolescents are subject to the dispensary observation.
A basic element of preventive medical examination of adolescents
is medical surveys which are carried out once a year.
Medical surveys of young men at the age of 16 years are
combined with physical examination at registration to the call-up
(ambulance) station.
According to the results of medical examination by adolescent
therapist the state of health is determined as well as the group of
health for the physical training classes.
Results of medical examination are written down in the list of
the adolescents subject to medical examination.
The information on the results of medical examination is sent
to adolescent`s place of study (work).
In the children's organizations of public health services
rendering the out-patient – polyclinic aid, medical professional
consultating of the teenagers having deviations in the health state is
carried out.
The medical information is provided (the form 086/acc.) to
those who are going to study in the establishments providing
reception professional, average special and higher education,
preliminary medical surveys of the adolescents who are employed
are carried out.
The order of transfering adolescents from pediatrician to
adolescent's therapeutist: at the age of 18 a transitional epicrisis is
made in the children's organization of public health services
(branch), rendering the out-patient – polyclinic aid, and the teenager
is transferred under observation of the organization of public health
services for adult population.
For reception of aolescents from the children's organization of
public health services (branch) the commission is formed. The
structure of commission is approved by the head physician order of
the public health services for adult population organization.
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 Each month the following medical documentation is presented
to the commission for consideration:
Adolescent`s epicrisis at the age of 18;
medical card of an ambulatory patient (the form 025/ acc.);
medical card of an army recruit (the form 053/acc.) – on young
men of army enrollment.
Transfering of the adolescents medical documentation in the
organization of public health services (branch) for adult population is
made out by the act of transferring.
То the act of transferring the list of adolescents who are
accepted and (or) not accepted under observation of the organization
of public health services for adult population is enclosed.
Modern tendencies are as follows:
Firstly – the general practitioner practice: the Group of a
general medical practice is created, when not less than two
physicians (GP) secure the state of population health, 1 post per
1200 inhabitants, including children. Meanwhile children under
3 years can be observed by a pediatrician.
Secondly, the transfer of adolescent services to children’s
polyclinics.
Hospital services for children
The basic children's medical establishment for stationary
(in-patient, hospital) treatment is the united children's hospital.
It includes a hospital and polyclinic, is headed by the chief physician
and his assistants on medical-preventive issues, on polyclinic services.
Children’s hospitals differ on capacity (they`re divided into
7 types – from 50 up to 400 beds accordingly). Besides, they are
divided into the profile (multiprofile, specialized) ones and on the
administrative and territorial ground (departments of the district
hospital, town (city) hospital, regional, republic.
Тhe main departments include the united children's hospital
consisting of a hospital, a polyclinic, subsidiary-diagnostic
subdepartments and administration and economic department.
Children’s hospitals have such particularities as listed above:
a. For hospitalization it is necessary to show such documents,
as an appointment card, record from the history of the child’s
development, certificate about infectious contacts absence (validity
for 24 hours), certificate about immunization.
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 b. Children hospital has chambers-boxes.
c. Hospital wards are formed according to the disease nature,
sex, age (for born prematurely, for newborns, for children before one
year, for younger children, for senior children).
d. Parents (mother, father or any adult) can stay with their
children under three years free of charge and under 5 years
(handicapped children under 18 years) for money.
e. The studies are organized for the pupils in the hospital.
f. Strict sanitary and epidemiological regimen should be
observed.
Specialized out- and in-patient aid for children
Existing standards do not allow to have doctors of all
specialties in each polyclinic (hospital). In connection with that,
town or inter-district principle is used (concentration in one or
several polyclinics). The association of specialized help on the basis
of consulting-diagnostic centers and subspecialized centers
(for instance, the centre of reproductive health), including the
permanent establishment, are conducting.
Beside this, children’s departments in specialized dispensaries
(for instance, psychoneurological, narcological, antituberculous,
dermatovenereological etc.), children’s departments of specialized
multiprofile hospitals (traumatological, cardiosurgical) exist.

Typical tasks
ORGANIZATION OF MEDICAL CARE
TO CHILDREN AND WOMAN
№1
Some absolute indicators characterizing death rate of children
in a city X:
Value
Indicator
(аbs.)
1 Children has died till 18 years old 208
2 Children has died from 0 till 5 years 126
3 Children has died till 1 year old 108
From them was born in the given year 90

69
 Value
Indicator
(аbs.)
4 From children who have died aged till 1 year, has died from:
Illnesses of bodies of breath 15
Some reasons of perinatal diseases and death rates 51
Infectious diseases 7
Congenital anomalies 30
other reasons 5
5 Children has died during the period since 28 weeks of 39
pregnancy before birth
6 Children has died during birth process 9
7 Children has died during the first 168 o'clock of a life 59
8 Children has died during 2, 3, 4 weeks of a life 18
9 Children has died during the period from 1 month of a life 31
till 1 year

Calculate and analyze:

a) infant mortality rate;
b) etiological structure of infant mortality rate;
c) early and late neonatal death rates,
d) postneonatal death rate,
e) neonatal death rate and its part (proportion) in the structure
of infant mortality rate;
f) indicators of perinatal, antenatal, intranatal and postnatal
death rates.
№2
Define the under-five mortality rate (the UNICEF index) and
maternal mortality rate in Belarus if it is known, that 1 080 500
children were born alive in 2011, 5834 children till 5 years have
died, 8 women have died during pregnancy, delivery and the
postnatal period.
№3
12800 children were born alive and 40 were born dead in the
area in 2010; 31 children have died on the first week of life.
Please, define: Fetal mortality (or Mortinatality) rate (FMR),
Early neonatal mortality rate (ENMR) and Perinatal mortality
rate (PMR).

70
 №4
12150 children were born alive and 47 were born dead in
the area; 30 children have died on the first week of life.

Please, define: Fetal mortality (or Mortinatality) rate (FMR),

Early neonatal mortality rate (ENMR) and Perinatal mortality
rate (PMR).
№5
5210 deliveries, including 738 from rural inhabitants have been
taken in maternity hospital within a year. From the whole number of
deliveries, 28 cases were with twins-births, 1615 were absolutely
normal.
Number of deliveries at women with nephropathia was 276,
with anomalies of delivery activity – 630, with illnesses of urogenital
system – 338, with anemia – 724, with bleeding in postpartum and
postnatal period – 114.
Please, define:
 the proportion of deliveries at inhabitants of village;
 proportion of deliveries with twins;
 of normal deliveries;
 and deliveries of women with concrete pathology.

№6
38000 women are serviced by female consultation. The
diagnosis of breast cancer was established for the first time in a life
for 11 women, including 3cases of cancer in the late stages.
Please, define cancer incidence, proportion of diagnosis in the
late stages of cancer.
№7
5970 women are covered by contraception within a year in female
consultation, including 5700 – with Lippes loop (intrauterine spiral),
which in 1210 cases are entered after abortions, in 82 – after labors.
19000 women of fertile age are covered by female consultation
activity. There were 1100 labors, 3800 abortions.
Please, define frequency of contraception using (in general and
intrauterine), proportion of women with contraception after
abortions, after labors.
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 №8
3250 labors, including 142 premature, have taken place in
maternity hospital within a year.
30850 hospital days have been spent by women in general, on
125 mid-annual hospital beds.
554 deliveries have been conducted by caesarian sections.
3198 children were born alive, 152 children were born dead.
Please, define indicators of hospital bed fund, percent of
premature births, fetal mortality rate (mortinatality), frequency of
caesarian sections.
№9
284 patients have been treated in a day-time hospital of female
consultation on 8 hospital beds within a year, including 126 women
with inflammatory diseases of female genitals, 81 with complications
of second half of pregnancy, 46 with complications of pregnancy in
early terms of gestation, 21 with fibroma. 2415 hospital days were
spent by them.
Results of treatment were as follows: improvement – for
101 patients, recovering – for 85, 41 were hospitalized on higher
level for more specialized treatment, condition has not changed
for 57 patients.
Please, define indicators of hospital bed fund, distribution of
patients by results of treatment and structure of hospitalized in a day-
time hospital women by nosology.
№ 10
8621 woman were surveyed within a year by ultrasonic
diagnostics in term till 15 weeks of pregnancy, 10220 women –
in term of 15-22 weeks (including 9326 women were surveyed
twice), 9714 women – in term after 22 weeks of pregnancy. It was
revealed 6 developmental anomalies of fetus till 15 weeks of
pregnancy, 73 – from 15 till 22 weeks, after 22 weeks – 14.
91 pregnancies were interrupted.
Please, define developmental anomalies rate in various terms of
pregnancy,
Proportion of artificial abortions among pregnancies with
developmental anomalies of fetus.

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 № 11
54360 abortions, including 10664 which begun out of a
medical institution, were made within a year in Belarus.
47040 vacuum-regulations were made the same year. 91720 children
were born alive, 532 children were born dead.
Number of women in fertile age is 2651700 persons. From all
women making abortions and vacuum regulations, 51 woman was
aged till 14 years, 9064 at the age of 15-19 years, 20532 at the age of
35 years and is more senior.
13 women have died in total during pregnancy, labor and in the
postnatal period, including 1 woman from artificial abortion, 2 –
from out-hospital abortions, 1 – from bleeding during pregnancy and
labor, 4 – from hestoses of pregnancy.
Please, define:
1. Abortions rate, vacuum-regulation rate.
2. Proportion of out-hospital abortions.
3. Maternal mortality rate in general and from separate reasons.
4. Structure of maternal mortality rate by separate reasons.
5. Age structure of women making abortions.
6. Number of abortions per 100 born alive.
№ 12
350 children were born in the area of children's polyclinic
activity within a year. 307 children were on breast feeding till
3 months of age, 164 – till 6 months, 77 – till 12 months.
Please, define indicators of breast feeding of children of 1st
year of life.
№ 13
106 children aged till 1 year have died in the area N within
a year, including 51 in maternity hospital, 32 – in other hospitals,
23 – at home.
11 children have died during first days after childbirth, 9 from
them – in maternity hospitals, 2 – in other hospitals. 5 children have
died at the first 24 o'clock after hospitalization.
Please, define a before-day lethality and structure of infant
mortality rate by the place of death.

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 № 14
46700 children and teenagers are served by children's
polyclinic.
84 persons aged till 18 years for the first time are recognized
as invalids within the year, including 7 – because cancer, 9 – because
mental retardation, 21 – because nervous system and sense organs
diseases, 1 child – because cardiovascular diseases, 22 – because
congenital anomalies of development, 4 – after traumas.
Please, define indicators of the first handicapped (primary
invalidity) rate for children and teenagers, and also structure of
its reasons.
№ 15
46 doctors-pediatrists are working in the area. 6 from them
have the higher, 26 – the first and 4 – the second qualifying category.
115 midwifes, from which 42 have the higher, 27 – the first and
10 – the second category are working in the area.
Please, define proportions of doctors and midwifes with
different qualifying categories.
№ 16
7000 children aged till 1 year consist on the dispensary account
in a children's polyclinic №5. 4750 children have received the
finished vaccination against a diphtheria. The population of Belarus
this year was 9 950 900 persons, including 1 751 360 children.
25 cases of diphtheria, including 7 – among children, – are registered.
Please, define diphtheria incidence for all population,
separately for adults and for children. Define an indicator of finished
immunization against a diphtheria for children till 1 year.

№ 17
87317 full-term infant and 4403 premature infants were born
alive within a year in Belarus. 13621 full-term and 4218 premature
children were born sick, including 2490 full-term and 62 premature
infants – with labour traumas, 18 and 14 accordingly –
with pneumonia, 9 and 3 – with a sepsis, with congenital anomalies
1875 full-term and 393 premature infants.

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 272 children, including 112 full-term and 160 premature
infants, have died within the first 6 days of a life. Among full-term
infants 3 have died from labor traumas, 2 – from a sepsis, 45 – from
congenital anomalies. Among premature infants 2 children have died
from labor traumas, 3 – from a pneumonia, 33 – from congenital
anomalies.
To calculate:
1) proportion of premature births;
2) indicators of morbidity of newborns (full-term and
premature) in general and for separate diseases;
3) lethality of full-term infants and of premature infants
(separately);
4) early neonatal death rate for full-term infants and for
premature infants (separately);
5) the structure of lethality (in general) by causes;
6) the structure of reasons of early neonatal death rates for
full-term and premature infants.

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 LESSON № 3
THEME:
SANITARY AND EPIDEMIOLOGICAL WELL-BEING

Questions:
1. Sanitary and epidemiological well-being.
2. State sanitary inspection services in Belarus.
3. Medical-hygienic training of population.
4. Health education models.
5. Healthy mode of life formation.
3.1 Sanitary and epidemiological well-being.
State sanitary inspection services in Belarus
Sanitary and epidemiological well-being is the absence of
conditions for the occurrence and distributions of the infectious
diseases, the absence of harmful influence of environmental factors
and the optimal epidemiologic conditions of the population.
The sanitary-and-epidemiological well-being in the country is
provided by the system of the state stimulus directed at the
maintenance of authorized sanitary norms, by the statement of the
uniform sanitary-and-hygienic requirements to supervising objects,
by the system of the state and departmental sanitary inspection.
Concept «Sanitary-and-epidemiological business» includes the
sanitary legislation, the practical activities of bodies and organization
of sanitary-and-epidemiological service, and the state sanitary-
improving actions. The basic state sanitary-improving action
contains the state sanitary inspection. The basic tasks of the
inspection are the following: the supervision of the sanitary
legislation observance; the carrying out of sanitary-and-hygienic
examination of dangerous factors; the supervision of the organization
and carrying out the sanitary and antiepidemic actions; the
supervision of state policy realization concerning the preventive
maintenance of diseases among the population.
The state sanitary control is the activity of specialized organs
and institutions, directed at the prevention of diseases, by warning,

76
discovery and cessation of the sanitary legislation and sanitary rules
breaches.
The sanitary standards, rules and hygienic standards are the
statutory acts that install the human safety or harmlessness criteria of
environmental factors as well as the sanitary-hygienic and
antiepidemic requirements for provision of the favorable vital
activity conditions.
The legal foundations of the sanitary-epidemic service organs
and the institutions activity are defined also by the group of sanitary-
hygienic and sanitary-antiepidemic standards and rules of the
separate government regulations. The specialists of the given
services work according to the state and branch standards (the State
Standard), the technical specifications (TS), building norms and
rules, sanitary codes and others documents.
Types of responsibility for the sanitary-hygienic and
antiepidemic standards and rules breaches are: disciplinary,
administrative and criminal liability.
In the Republic of Belarus the state sanitary control of the
sanitary legislation and sanitary rules execution is realized by the
sanitary-epidemiological organs and the institutions of the Health
Ministry.
Sanitary-and-epidemic services of Belarus began its
development in the 1920-1930 years. The main organizational
department was the Sanitary-Epidemic Station. The main task of the
services was the creation of the sanitary-epidemic welfare by the
implementation of preventive and the current sanitary-hygienic
control, the compliance with the sanitary legislation and the sanitary-
epidemic guard of the state borders.
The Sanitary-Epidemic Stations were reorganized in the 1990th
years in the Centers of Hygiene and Epidemiology, and in 2002 –
in the Centers of Hygiene and Epidemiology and Public Health.
Nowadays the structure of the state sanitary-epidemiologic
service in Belarus is as follows:
The Sanitary service is headed by the Main State Sanitary
Physician of the Republic of Belarus, the Deputy Minister of the
Public Health.
The Main State Sanitary Physician controls the Main Sanitary
Physicians of Regional Centers of Hygiene and Epidemiology and
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Public Health, the City (areal) and the District Centers of Hygiene
and Epidemiology, that simultaneously are the deputies of the
leaders of the local medical administration.
The sanitary physicians in Belarus have rights to discharge
from work those persons who are bacteria carriers (the food industry
workers, the working people in preschool institutions, the communal
services); to require the obligatory hospitalization of the sick with
infection which are dangerous for people around; to require the
undertaking of the obligatory disinfection of the subjects, residing in
use of a sick person (which can be a source of spreading); to visit the
objects which are under control presenting or showing the service
certificate; to require from the executives and separate people the
information and documents about the sanitary and epidemiological
conditions of the object; to suspend the construction and the usage of
the enterprise, the usage of a storehouse, to shut down bad or
dangerous for health products for some period or with no fixed term;
to seize the food-stuffs, products, substances and materials for the
laboratory tests and hygienic expert examinations, as well as the
samples of the food-stuffs.
Workers of the sanitary-epidemiological service obtain their
rights and duties with the administrative and legal documents –
acts: state, order, bilateral agreement, permissive, administrative
enforcement, jurisdictional.
More often the facts of the sanitary-hygienic standards and
sanitary-antiepidemic rules breaches are registered in the act of the
examination and in the protocol of a sanitary breach. The protocol of
a sanitary breach is formed in a five-day period in two copies. One of
them is delivered to the person guilty in the sanitary breach.
The other one remains in the Center of Hygiene and Epidemiology.
The resolution about the penalty is formed in three copies. One of
them is delivered to the leader of the enterprise or a higher organ,
where the guilty person works. If the fine is not repaid in the stated
15-day period since the day of the resolution, it is enforced from the
salary of the forfeit.
The basic organizations of state sanitary inspection services
in Belarus are The Regional Center of Hygiene and Epidemiology
and the Public Health, and The City (areal) Center of Hygiene and
Epidemiology.
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 The basic functions of the Regional Center of Hygiene and
Epidemiology and the Public Health are the following:
1. To study the main questions of the economic building and
sanitary state of the region; the study and monitoring of public health.
2. The preventive sanitary control over the objects of local
importance construction.
3. The current sanitary control (the systematic sanitary-hygienic
checking of water, air, soil and mass-consumption products).
4. To conduct the set of antiepidemic actions.
5. Radiation safety securing.
6. Prevention of AIDS and HIV.
7. Medical-hygienic education and bringing-up of the
population.
The basic directions of the activity of the Center of Hygiene
and Epidemiology and the analysis of the information about the
sanitary-and-epidemiologic, ecologic and demographic situation are
gathering; the revealing of factors of environment and the reasons
influencing the health of the population; the account and analysis of
infectious and occupational diseases; the development of measures
for maintenance of sanitary-and-epidemiologic well-being.
The preventive sanitary control is realized in relation to the
NEW objects of industrial, housing, communal and cultural
construction, while the reconstruction, changing the profile and
technologies of the production process.
The preventive sanitary control provides:
1) the expert examination of the design documentation at
construction; the extension, reconstruction, reequipment of the active
enterprises, buildings, utilities, the expert examination of the general
plan of cities, villages and other populated items;
2) the control of the construction (the sanitary supervision of
construction in accordance with the confirmed project);
3) the sanitary physician participates in the state commission
when commissioning the dwelling houses, the buildings of industrial,
cultural and housing purpose (the object usage is prohibited without
the consent of the representative sanitary-epidemic service);
4) the expert examination of the normative-technical
documentation (the standards, technical specifications, formulation
and etc.) of raw materials, products, technological processes,
79
equipment, materials, substances, articles, including items of food
and medical biological preparations;
5) the preventive control provides the control of the
atmospheric air, water, soil and includes the account of all industrial
and home sources of the contamination; the laboratory supervision of
their sanitary condition.
The current sanitary control is a systematic observation of
the existing objects to provide the affirmed sanitary-hygienic
standards and rules. The current sanitary control supposes:
1. The study of sanitary-hygienic labour conditions. The
hygienic estimation of the working environment.
2. Laboratory supervision. The observation of object’s
condition.
3. Sanitary hazards finding and ascertainment.
4. The study of disease incidence and traumatism.
5. Preventive examinations organization.
6. Supervision of sanitary legislation observance concerning
women and teenagers labour.
7. Supervision of physical development of children and
teenagers.
8. Supervision of the hygienic codes of the education, the day
regime of the pupils and children in other institutions.
9. Supervision of the air ambience, the state of water
reservoirs, soil.
10. The observation of the population health.
11. The organization of the sanitary-educational work and the
sanitary-technical education.
12. Impose sanctions (disciplinary penalty, fines, product
confiscation, the stoppage of the shop work, discharge).
13. Sanitary-hygienic observance of the concerning standards
production, transportation, keeping and realization of the food-stuffs.
14. Organization of the rational feeding of the population.
15. Supervision of sanitary actions, provided by the complex
plan.
16. Organization recovery actions.
When the sanitary physician reveals the breaches, the act of the
sanitary object examination (form number 315/acc.) is composed and
the corresponding mark is made in the sanitary journal, which is used
80
for every object under observation. If the measures on defect removal
were not accepted, the Protocol about the sanitary breach is
composed. These documents are the detailed report about the sanitary
breach. The protocol is formed in a 5-day period since the day of the
breach revealing in duplicate: one is delivered to the person guilty in
the sanitary breach, the other remains in the documents of the
corresponding department of the Center of Hygiene and Epidemiology.
The penalty sanctions can also be undertaken. The regulations
of fine impose can not be made later than one month since the day of
the sanitary breach. The regulations are formed in three copies: one
remains in the documents of corresponding institutions (the division)
of the Center of Hygiene and Epidemiology, the other is for the
forfeited man or by the registered letter to the working place.
The period of the voluntary contributing of the fine is no more
than 15 days since the day when the fine resolution is invested. If the
fine is not paid the specified period it is collected without recourse to
the court from the salary (the resolution moves in book-keeping of
the working place). If the forfeited person does not work, the fine is
recovered by the officers of the court by executors by referencing the
claim to property. Nowadays the system of the fines isn`t used and it
is worse when a concrete person is taken off the job or is sent on the
reexamination of the sanitary minimum.
The structure of the Regional Center of Hygiene and
Epidemiology and Public Health (RCHEPH) includes such
departments as:
1. Disinfection department.
2. Epidemiological department.
3. Radiological department,
4. Sanitary-and-hygienic (or Organizational-methodical)
department.
5. Department of especially danger infections.
6. Department of public health.
The structure of the City (areal) Center of Hygiene and
Epidemiology (CCHE) includes such departments as follows:
1. Sanitary-and-hygienic.
2. Disinfection.
3. Epidemiological department.

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 District CHE includes the Sanitary-hygienic Department with
the laboratory and the Epidemic Department with the bacteriological
laboratory.
The disinfection department includes the sub-department of
evacuation and focal disinfection; the sub-department of chamber
disinfection and sanization. The sub-departments of preventive
disinsection, disinfection and disinfectation, viral laboratory,
ecological division can be also included.
The sanitary-and-hygienic department carries out the
inspection of construction (housing, and constructing sanitation), of
food (food sanitation), of enterprises (enterprises sanitation), of
schools and kinder-gardens (school sanitation).
Tasks of housing and constructing (communal) sanitation are
used for planning and building of settlements, for the regulation of
chemicals in the environment (checking the concentration standards
of pollutants and chemicals in air, water, land). The planning and the
construction of the populated places; city, village, settlement sanitary
improvement (i.e. water supply and sewerage, purification, greenery
planting); the sanitary guard of the air, the water-supply, the soil, the
living places, the public buildings; the domestic and social wastes are
drained by neutralization; noise control; the supervision of the health
picture of working population.
Tasks of food sanitation include the control of food (for
example, of food additives, carcinogens, toxic chemicals, radioactive
materials, etc. in consumer food products; the control for sanitary
norms observing in public nourishment (restaurants)) and of the
health condition of public nourishment’s organization for workers.
Food sanitation realizes the supervision of food industry and
public feeding, including transportation, keeping and selling the
foodstuffs; pesticide use in agricultures; the health picture of food
workers. It makes assessment of gastrointestinal diseases, bacterial
food poisoning, food toxicoinfection.
Enterprises (industrial) sanitation controls the enterprises
building, the hygienic norms observance at the industry enterprises.
The enterprises sanitary activity is directed at decreasing of the
streading occupational hazards and the workplace traumas.

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 The sanitation realizes the supervision of the industrial
construction, the industrial equipment and the technological process;
the hygienic standards and the sanitary legislation observance of
active enterprises. It makes the assessment of morbidity with
temporal and constant disability at industrial enterprises, the
development of preventive measures; holds the fight with
professional hazards and occupational traumatism.
School sanitary controls the building and equipment of schools
and kinder-gardens, the hygienic norms being observed and checks
the hygiene of the pedagogic process. It realizes the supervision of
the construction and equipping of the preschool institutions and
schools; the hygienic standards observance in active schools, the
day-care centers; the hygiene of the pedagogical process, the
psychiatric and physical upbringing; the improvement of the
children's health and organization of the necessary preventive
measures; organizes the mass improvement of the children's health in
day-care centers and school.
The sanitary-hygienic department is composed of the groups in
accordance with the sanitary activity spheres:
1) communal (municipal) hygiene;
2) hygiene of labour and industrial sanitation;
3) nutrition hygiene;
4) hygiene of children and adolescents;
5) corresponding laboratories.
The contents of the work of the epidemiological department
of the Center are as follows:
 carrying out of epidemiological inspection of the infectious
diseases centers;
 a methodological management of the antiepidemic work of
the medical-preventive organizations;
 the development of the complex of antiepidemic actions;
 the estimation of the inoculations efficiency.
The structure of the epidemiological department is the
following:
1) an antiepidemic group;
2) a parasitological group;
3) a cabinet of rabies vaccinations;
4) a bacteriological laboratory.
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 Also can be included:
5) an enteric infections control department;
6) an AIDS prevention department;
7) a hospital hygiene department;
8) a social-hygienic monitoring department.
The epidemiological department is carrying out the
precautionary (preventive) and the current sanitary inspection on the
content of the sanitary-and-epidemiologic well-being of the territory.
The precautionary (preventive) sanitary inspection includes such
actions, as the supervision of constructions, the lay-out and
buildings, the examination of the design documentation, the
participation in the state commissions at input of the built objects in
the operation.
The department concerns with the sanitary control of the
territory about the delivery and spreading quarantine and other
infectious diseases; the study of the epidemic background in a certain
area; the warning of the origin and spreading of infectious diseases;
the organization of the antiepidemic work in a certain area and the
supervision of the attending medical doctors’ antiepidemic activity;
the spreading of the epidemic information and hygienic knowledge
among the population.
Qualitative indices of the Center of Hygiene and
Epidemiology activity are the following: the incidence of the
infectious diseases, its structure and levels; the incidence of the
poisoning and professional diseases; the proportion of the sick with
infectious diseases in relation TO the total number of sick in the area
(city, district); the specific gravity of the nixed construction projects;
the completeness of the observation coverage of the objects under
construction; the completeness of the preventive and final
disinfection and disinsection coverage; the completeness of
vaccination, revaccination coverage; the efficiency of vaccination,
the revaccination; the completeness of the objects coverage by the
current sanitary control, its multiplicity and number of the revealed
events of the sanitary codes breaches; etc.
The Center of Hygiene and Epidemiology interacts in their
work with other organizations and institutions, such as follows:
The committees of public health and social security;

84
The extraordinary antiepidemic commission in executive committee;
The state committees on the construction and architecture;
The interdepartmental committees, the sanitary-technological
councils; The Red Cross Society; The nature protection society;
The trade inspections of quality; The veterinary inspections; The trade-
union organizations; The technical inspections on labour protection;
The organs of the public prosecutor's office and police; etc.
Beside these, the Center of Hygiene and Epidemiology controls
the sanitary condition, THE antiepidemic regime provision in all
medical-preventive organizations in Belarus.
Special part of the Center of Hygiene and Epidemiology
activities is the control and prevention of infectious morbidity.
It should be noted, that an important problem of the activity of
any doctor, especially of the district doctor or GP, is the organization
and carrying out of a set of the preventive actions which are directed
on the sanitary-and-epidemiologic well-being maintenance. The
special attention in this work is paid to the infectious diseases
prevention because GP and the district doctor is usually the first one
who examines these patients.
The set of anti-epidemic actions of district doctor or GP
activity includes:
1. The maintenance of the early diagnostics of infectious
diseases.
2. The acceptance of the necessary measures for timely
hospitalization of infectious patients, and in case of leaving the
patient with easy form of disease - at home: his treatment, receiving
the material for out-patient inspection, the control over observance of
anti-epidemic regimen, the organization of supervision over the
person, being in contact with the sick with infectious disease.
3. The submission «The emergency notice of the infectious
disease, food, acute professional poisoning, and unusual reaction to
the inoculation» in the corresponding Center of Hygiene,
Epidemiology and Public Health on everyone revealed infectious or
suspected in infectious disease patient (the form number 060/ acc.).
4. The registration of all revealed or suspected in infectious
disease patients in a special journal (the registrational form number
060/ acc.).

85
 5. Carrying out of the preventive inoculations and the
registration in the journal (form number 064/ acc.).
6. Carrying out of the necessary actions on dehelmentization.
7. The organization and carrying out of the actions on hygienic
training and education of the population, the propaganda of the
healthy way of life, the attraction of the public to the solution of
these problems.
The further task of sanitary-epidemiological service organs in
the Republic of Belarus is connected with the automation and
informatization of their work, commissioning to different
departments of the administration that gives possibility to keep a
complete online control of the sanitary situation and the health
picture of the population on the territory of the Center of Hygiene
and Epidemiology.
3.2 Medical-Hygienic training. Self-saving behavior
and Healthy mode of life
The dynamic definition of health education, accepted by
Alma-Ata Declaration (1978) is as follows: «A process aimed at
encouraging people to want be healthy, to know how to stay healthy,
to do what they can do individually and collectively to maintain
health, and to seek help when needed».
The concentrated expression of the intercoupling and mutual
influence of lifestyle and health of the population is a notion of
healthy life style, or healthy life mode.
The healthy life mode (WHO) is the optimum quality of life,
reflected in a motivated behaviour of a person, directed at the
conservation and fortification of health, in terms of the
environmental and social factors influence.
Components of the healthy life mode are as follows:
1. Rational feeding.
2. Correct motor and physical activity.
3. Conscious refusal of bad habit.
4. Psychological health.
5. Healthy sexuality.
The healthy life mode expects a positive attitude to health both
of the separate person and society in general and provides active
86
longevity with a high level of health and working capacity. The
healthy life mode formation is a complex of national actions,
directed, on the one hand, at the shaping positive and responsible
health behaviour, and on the other hand, at making the conditions,
that present equal chances to its realization to all people in all
spheres of activity.
The propaganda of the healthy way of life is a duty of any
doctor and any nurse, from hospitals and from polyclinics. The
carrying out of the actions on propaganda of the healthy way of life
is included into the tasks of any medical-preventive organization –
both polyclinic and hospital. For example, any district pediatrician
visits a newborn in the first three days after discharge from a
maternity hospital, organizes the dispensary observation of the
children of serving district, renders medical-preventive help to
children and carries out sanitary-educational work. Any school
doctor and school medical nurse have to conduct the sanitary-
educational work among the pupils at schools. The preventive work
of the shop doctor includes the formation of the healthy way of life
among workers. The duties of any obstetrician-gynecologists of a
female consultation include the minimizing of risk factors which
influence pregnant women`s conduct by felling from about the
healthy way of future parent’s life. So, Health Education and Health
Communication the foundations of a preventive health care system.
The basic tasks of the medical-hygienic training of the
population are as follows:
 the popularization of medical science achievements;
 the propaganda of a healthy way of life.
The purposes of the medical-hygienic training and education of
population are the improvement of population health, the increase of
sanitary-and-epidemiologic well-being of a region, the correction of
risk factors of diseases (mostly social factors).
The basic criteria of the activity of any doctor on hygienic
training of population are the following:
1) the decreasing of the morbidity rate parameters;
2) the popularization of the healthy way of life among the
educated population;

87
 3) the increasing of the medical activity of the population:
early (in time) addressing to a doctor, carrying out of all
recommendations.
The modern concept of health education emphasizes the health
behaviour and related actions of people. Any health professional
should be able to spread the information, to gain the trust of people, to
listen to people sympathetically and to understand other person’s
feelings, to help people reduce or resolve their problems.
The role of health care providers in the Health Education is to
provide opportunities for people to learn how to identify and analyze
health and health related problems, how to set their own targets and
priorities; to make health and health-related information easily
accessible to the community; to indicate to the people the alternative
solutions for solving health and health-related problems.
In general, all methods of the medical-hygienic training and
education of the population are representing the communication for
Health Education.
Communication can be regarded as a two-way process of
exchanging or shaping ideas, feelings and information. It is a process
necessary to pave the way to desired changes in human behavior, and
informed individual and community participation to achieve the
predetermined goals. Communication and education are closely
connected.
The ultimate goal of all communication is to bring the change of
the person who receives the communication in the desired direction.
This may be in terms to increase knowledge; it may be affective
in terms of the changing existing patterns of behavior and attitudes;
and it may be psychomotor in terms of the acquiring new skills.
So, any doctor requires communication skills and must know
the peculiarities of communication process.
Any communication is a complex process; it has the following
main components:
1) sender (source);
2) receiver (audience);
3) message (contents);
4) channel (or channels) (medium);
5) feedback (effect).

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 The sender in the Health Education is the Health Care System
and its professionals (medical stuff).
The receiver may be a single person (methods of individual
influence), a group of people (methods of influence on the group of
persons), and a large group (methods of mass communication).
The audience may be of two types: the controlled and the
uncontrolled. The controlled audience is the one of held together by
a common interest. It is a homogenous group. The uncontrolled or
«free» audience is the one which has gathered together because of
curiosity. It is a nonhomogeneous group. The more homogeneous the
audience is, the greater the chances of effective communication are.
The message is the information which the communicator
transmits to his audience to receive, understand, accept and act upon.
A good message must be: in line with the objective(s), meaningful,
based on the felt needs, clear and understandable, specific and
accurate, timely and adequate, fitting the audience, interesting,
culturally and socially appropriate.
The main principles of information for theHealth Education are
the following: general availability, mass character, scientific and
educational maintenance, preventive orientation, and aiming for
education, motivation, persuasion, counseling, raising morals, health
development needs.
People seek such information rarely although they have the
right to know the facts about health and diseases. The education and
access to the proven preventive measures – are the crucial factors in
achieving optimum health.
The channel of communication is dependent from the receiver
and the method of health education. All methods are divided into the
methods of individual influence, the methods of influence on a group
of persons and the methods of mass communication. The methods of
individual influence are based on the interpersonal communication
(or “face-to-face”).
It is more persuasive to be personal and direct and effective
than any other form of communication. The interpersonal
communication may be represented by oral or combined methods.
Group communications may be realized by oral, printed, visual
or combined methods.

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 Basic means of oral method are: «Chalk and talk» (lecture),
individual consultation (personal interview, conversation), group
discussion, symposium, workshop, role playing.
Means of the printed method include graphic (figure and
poster), and/ or text (brochures, books).
Means of the combined method include exhibitions,
demonstrations, health-museums, folk media means, and the channel
is one or more of the following «mass media», viz. TV, radio,
printed media, etc.
The example of mass media means is the United Days of Health,
which were introduced by the Order of Health Ministry of the
Republic of Belarus from 26.12.2001 № 729-A «About information
work with population of the Republic of Belarus». The order explains
the undertaking of the United Days of Health as follows:
The 1st of March – the International Day of struggle against
drug abuse.
The 24th of March – the World Day of of struggle against
tuberculosis.
The 7th of April – the World Day of health.
The 15th of May – the Family Day.
The 31st of May – the World Day without tobacco.
The 1st of June – The children’s protection Day.
The 1st of October – the World Day of elderly people.
The 10th of October – the World Day of menthal health.
The 14th of October – the Mother’s Day.
The 14th of November – the World Day of struggle against
diabetes.
The 1st of December – the World Day of AIDS prevention.
Mass media have the advantage of reaching relatively larger
population in a shorter period of time than it is possible with other
means. But the superiority of interpersonal communication over
mass media for creation of motivational effect has been well
documented. Why?
When the relayed via mass media message gets diffused in the
community, it is picked up by the interpersonal and informal
networks. Then the message is the subject of discussion of
interpersonal communications. Mass media carry messages only

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from the centre to the periphery, and feedback mechanisms are
poorly organized. So, if message is not clear or otherwise is not
acceptable, the audience may reject it outright, or the message may
be hurt by interpersonal discussing.
Many communities have its own network of traditional or folk
media. These are the important channels of communication which
are close to the cultural values of the population, especially rural.
So, every channel of communication has its advantages and
limitations. The proper selection and the use of channels results in
successful communication. The effective communication is seldom
achieved through the use of one method alone, but the attempt to
combine a variety of methods to accomplish the educational purpose
should be made.
The basic component of Health education communication
process is the feedback. The feedback is the flow of information
from the audience to the sender; it is the reaction of the audience to
the message. The feedback provides an opportunity to the sender to
modify his message and render it. It can rectify transmission errors
(the errors may arise because there barriers may be between the
educator and the community).
The barriers may be physiological (difficulties in hearing,
expression), psychological (emotional disturbances, neurosis, levels
of intelligence, etc.), environmental (noise, invisibility, congestion),
cultural and social (levels of knowledge and understanding, religion,
attitudes, etc.).
The main part in Health Education belongs to counseling.
Counseling is a process that can help people understand each other
better and deal with their problems and communicate better with
those who they are emotionally involved with. It can improve and
reinforce the motivation to change the behaviour. It can provide
support at the time of crisis, it helps to reduce or solve problems.
Counseling implies choice. It is different from advising. Advising
means to direct people and to caution them against some we do’s and
don’ts – it implies force.
Counseling is an important part of treatment, disease
prevention and health promotion that is why it is an integral part of
all health care programmes.

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 Feedback is the basic component, that distinguishes health
education and especially counseling from propaganda.
There are three main health education models:
1. Medical;
2. Motivational;
3. Social intervention.
The medical model is the most widespread one. This model is
primarily interested in the recognition and treatment of disease
(curing) and technological advances to facilitate the process, in the
dissemination of health information based on scientific facts. The
assumption of this model is that people thanks to the on the
information supplied by health professionals would act to improve
their health. This model did not bridge the gap between knowledge
and behavior – so, this model is insufficiently effective.
The motivation model. This model is directed to emphasize the
motivation as the main force to translate the health information into
the desired health action (Figure 12).

Awareness Interest

Motivation
Evaluation

Decision-making

Action Adoption or
acceptance

Figure 12. – Motivation model of health education

There are 3 stages in the process aimed to change the behavior.

If the individual evinces the interest in the subject, he/ she may
seek more detailed information about the usefulness, limitations or
applicability of the new idea or practice. Than he/ she evaluates
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various aspects (social, psychological, economic) of the received
information, if necessary by consulting others.
Such an evaluation is a mental exercise and the results in
decision-making. He/ she finally decides whether to accept or reject
the new idea, programme or proposal. At this stage, the interpersonal
communication (friends, kinship groups, etc.) is vital to lend support
to his/ her decision.
The conviction leads to action, the adoption or acceptance of
the new idea. The new idea or acquired behavoiur becomes the part
of his own existing values. This is called internalization.
The adoptions are very slow at first and increase when people accept
the practice.
Social intervention model
The motivation model ignored the fact that in a number of
situations, it is not the individual who needs to be changed but the
social environment which shapes the behaviour of individual and the
community. It is often found out that people will not readily accept
and try something new until it has been «legitimated» (or approved)
by the group to which they belong.
Social intervention model is based on precise knowledge of
human ecology and socilolgy and understanding of the interaction
between cultural, biological, physical and social environmental
factors.
An effective health education is based on the involvement all of
the ways to change behaviour and to recognize that the approach will
differ from the behaviour one wants to change.
Contents of Health Education covers every aspect of family and
community health and includes all medical-social problems, such as
rational nutrition, family health, disease prevention and control,
prevention of accidents, etc.
Process of Health Education planning follows the main step,
which are:
1. Collecting the information on the specific problems of
community.
2. Identification of the problem.
3. Deciding of priorities.
4. Setting goals and measurable objectives.

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 5. Assessment of resources.
6. Consideration of possible solutions.
7. Preparation of the plan of action (what will be done, when,
by whom).
8. Implementing the plan.
9. Monitoring and evaluating the degree at which the stated
objectives have been achieved.
10. Reassessment of the process of planning.
A new division of Health Education and Health Promotion has
been established by the WHO. The division will support regional
offices of WHO in strengthening the national capabilities in health
education and promotion, and will develop and test new ideas and
tools. Health Education is a complex activity in which different
individuals and organizations take part, and where very social
institution has own role.
The medical-hygienic education (Health Education and Health
Promotion) in the Republic of Belarus is a part of the state system
of the public health, including medical and hygienic knowledge
irradiation, healthy life mode formation and impart hygienic skills to
the population to preserve and build health, increase the working
capacity and active longevity.
The main purpose of themedical-hygienic education of the
population is to give knowledge and skills about making conclusion
on the questions of health preservation and fortifying on one’s own.
The principles on the basis of the hygienic education and
healthy life mode formation in Belarus are the following:
1. State character: the state finances the activity of the
institutions of the hygienic education and upbringing the population,
provides the development of the material and technical basis,
preparing the personnel, legal foundation for institutions’ activity.
2. Scientific character: the correspondence of medical and
hygienic knowledge with the present scientific situation.
3. Generality: the participation of all medical workmen, the
involvement of the specialists of other departments and public bodies.
4. Accessibility: during the presentation of medical material it
is necessary to avoid the incomprehensible medical terms, the speech
must be understandable.

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 5. Purposefulness: the work must be made according to the
chosen direction differentially with a glance to different groups of
the population.
6. Optimistic approach in order to achieve the needed effect it
is important to put the accent on the possibility of the successful
fight with diseases.
7. Topicality: the choice of the working direction must be
actual at the moment.
The healthy life mode formation service institutions in
Belarus
Historically the services were as follows:
 Sanitary education houses.
 Health centers.
 Centers of Hygiene, Epidemiology and Public health.
The necessity of healthy life mode formation as a complex
problem including collective and individual prevention of infectious
and non-infectious diseases and hygienic upbringing of the
population was revealed in Belarus in the second half of XX century.
In 1989 the sanitary education service was reorganized in the
service of the healthy life mode formation, and the Sanitary education
houses – into the Health Centers, in order to co-ordinate the whole
activity of different organs, institutions and public bodies on hygienic
education and upbringing of the population. 18 health centers
(republic, regional, town) functioned in the Republic of Belarus.
The Order of Health Ministry of the Republic of Belarus from
the 7th of July 1992 № 129 «About the increasing role of the
hygienic education and upbringing healthy life mode formation of
the population of the Republic of Belarus» was approved. The
Positions of the order obliged to include the questions of the healthy
life mode propaganda into the program of all refresher courses for
medical personnel of different specialties; to introduce the course of
healthy life mode formation into the school and student’s educational
programme; to comprise into the nomenclature of the medical
professions and job titles the speciality of physician – valeologist and
medical assistant-valeologist; to include into the job description of
each medical profession four hours every month for healthy life
mode propaganda.

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 The Order of Health Ministry of the Republic of Belarus from
the 29th of March, 2002 № 181-A «About improvement of the work
on healthy life mode formation» obliged to comprise the section of
the hygienic knowledge propaganda among the population into the
working plans of all medical-preventive organizations of Belarus as
obligatory; to comprise into the functional duties 4 hours on
propaganda of healthy life mode; to take measures on machine-
technical fortification of healthy life mode cabinets in medical-
preventive organizations; etc.
The Division of The Public Health of Regional Center of
Hygiene and Epidemiology and Public Health is the basic
organizational, coordinating, methodical institution on problems of
healthy life mode formation among the population in Belarus.
The division of Public Health of Regional Center of Hygiene,
Epidemiology and Public Health is an organizer of the healthy life
mode education both among medical profession and among other
specialists. The Division trains the cultural workers, social
organizations, analyses the work on healthy life mode formation,
organizes and holds seminars, conferences, counsels, spreads the
leading experience on healthy life mode propaganda among the
population. The publishing activity is the development and
publishing the methodical handbooks, information materials, popular
science literature, propagandizing the healthy life mode.
The functions of the Division are as follows:
1. Development together with the medical-preventive
organizations, as well as with other departments, programs on
population health fortification and preservation, participates in their
realization.
2. Participation in organization and undertaking the mass
actions among the population directed on HLS propaganda, health
fortification, increasing the working capacity, achievements of active
longevity.
3. Introduction of new forms and methods of work: holidays of
health, Days of health, actions of health, marathons of health and
others.
4. Broad use of the optional forms of the population education
(the schools of health).

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 5. Organization of the actions on public opinion formation,
raising the prestige of health with the help of mass media (TV, radio,
press, cinema).
6. Conducts the sociological studies and executes the functions
of the medical-preventive organizations press centre.
The problems of the health preservation and fortification of the
population can be solved only under systemic, complex approach
realized in the state program (program-target method of the work).
It is impossible to solve the problem of healthy life mode
formation only with the help of external transformations (social-
economic, hygienic, technical, legislative). The problem of healthy
life mode formation is also the ethical problem. The internal factor is
a morality of the person, his attitude to own health and the health of
people surrounding him.

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 LESSON № 4
THEME:
MEDICAL CARE FOR RURAL POPULATION,
FOR WORKING PEOPLE. CONCEPT OF REHABILITATION.
SOCIAL PROTECTION OF POPULATION

Questions:
1. Rural population: organization of medical care.
2. Medical care for working people.
3. Concept of rehabilitation.
4. Social protection of population
4.1 Medical care for rural population
The rural polulation has the same right to medical aid, as well
as the city dwellers. The quality of medical care in a village should
not differ from quality of the medical aid available to cities dwellers
through the volume of the medical services given in a countryside,
can be influenced by economic and other not medical factors.
So, the cardinal principles of the public health services
organization in general should be typical for rural polulation. However
in rural conditions the notion of medical help availability is not
identical to territorial approach because its’ realization sometimes is
impossible. In connection with that fact the question is about such
system that makes possible the rendering or the rendering organization
of the well-timed, adequate and full-fledged medical help.
The basic factors influencing the organization of the medical
aid for rural population in developed countries are the following:
a) the territorial dislocation (the small density of the rural
population);
b) the increase in the specific gravity of elderly and old people
(for some countries, for example, for the Republic of Belarus);
c) the specificity of agricultural work;
d) the seasonal schedule of work;
e) the insufficient development of the transport communications
(for some countries, for example, for the Republic of Belarus);
f) the versatility of doctor’s work.
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 The Goverments of developing countries is supporting such
measures and efforts in solving the rural health problems solving:
a) the water supply for rural population;
b) rural electrification;
c) the elementary education and adult education for rural
population;
d) the nutrition for rural population, etc.
For example, information, education and communication are
the integral part of rural sanitation programme in India.
The constant efforts directed on the conformity achievement of
the best national standard of skilled level of all suppliers of medical
services, working in a countryside, are necessary.
Rural communities and regions should collect and analyse the
facts necessary for the estimation of the requirements of the given
district inhabitants in medical aid, for the planning and development
of local medical services.
The educational level, the social and economic development in
a rural community are interconnected. The popularizations of
medical knowledge in the society are promoted by the co-operative
efforts of the organizations of local self-management, public
organizations and medical workers, directed on the achievement and
maintenance of the high level of practical public health services.
In a countryside, the relation «doctor-patient» should be
completely preserved. The auxiliary medical staff should be only
temporarily involved in performance of medical duties. The state
system of public health services is obliged to provide the rural
medical services development at the same degree, as in a city.
In a village there should be enough doctors, who received the
modern preparation, srecially adapted to medical needs of rural
population. At the same time, there should be enough auxiliary
junior and senior medical staff of nurses, prepared according to the
cultural and educational level, in the countryside.
Both in the cities and villages, integration of programs of the
preventive and medical help development, hygiene and sanitary-and-
hygienic education and means of its realization should be provided.
At present, the level of the stationary medical help for the
country people in Belarus practically has reached the level for the
city dwellers. But the problem is that the level of dispensary-
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polyclinic medical help for the rural and city population differs
greatly.
In this connection in the Republic of Belarus we have the
medical help system 4 stages for the rural population that provides
the higher level of specialized help on the following stage in contrast
with the previous one.
Basic tasks of management of medical-preventive
organizations for rural citizens in Belarus are the following:
 strenghtening of material base of the rural organizations of
public health services,
 equipment of rural establishments of public health services
with sanitary motor transport,
 creation of hospitals of the nursery care for medical-social help.
Medical-economic model of Public Health services for rural
population in Belarus assumes the observance of the following major
principles:
a) maintenance of social justice, the availability of medical aid
without dependence on the social status of citizens, the level of their
incomes and a residence;
b) preventive orientation;
c) economic, social and medical efficiency;
d) unity of medical science and practice.
There are 4 basic territorial technological levels of medical aid
providing to rural population:
1) level of rural doctor’s district;
2) level of rural area or interareas level;
3) level of the region;
4) republican level.
The basic level of the medical aid organization for rural
population is the level of rural doctor’s district. The main
organization of this level is the ambulatory of general practitioners
(including medical attendant-obstetric posts in their structure).
From 6 to 15 thousand of the population on average live in the
rural health care area. The fortification of medical ambulatories at
the expense of their reorganization into GP ambulatories,
reequipment, transport, telephone connection gives them the status
of «emergency medical help». The service radius of one district can
vary from 5 to 20 km depending on local conditions.
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 According to the existing standard the district of medical
attendant-obstetric post service includes 700 rural inhabitants and as
exception, with a glance to settling particularities – 500 people.
There are some infrequent events, when medical attendant-obstetric
post works with the smaller number of the population.
Local rural hospital including medical attendant-obstetric posts
in their structure may be also organized at the level of rural doctor’s
district. It renders the stationary and out-patient medical help to adult
population and to children (including pediatric and obstetric ones).
Level of rural area or interareas level
Functions of management in the rural area are assigned by the
head physician of the Central area hospital (CAH).
The important role in medical help rendering for the rural
population belongs to the district link, which has in its composition
the following organizations:
 CAH;
 the Centers of Hygiene and Epidemiology;
 district dispensaries.
Activity of these institutions covers the territory with radius of
the service approximately 40 km with such payment that transport
accessibility is one hour to any populated item.
The leader of CAH is the Head Doctor who simultaneously has
the responsibility for activity of all public health organizations on the
territory of the district. CAH carries out medical-preventive and
organizing-methodical work, control and activity assessment of all
subdivisions available on rural health care area, provides the
population of the district with emergency medical help.
Area hospitals are subdivided in 4 categories according to the
number of hospital beds ranging from 25 to 100. The developed
network of the small district hospitals that had played positive role
for a long-lasting period, nowadays can not fulfill all present modern
requirements. The majority of these hospitals do not play its way in
economic position and quality of medical help.
CAH includes 4 basic medical branches (departments): surgical,
therapeutic, pediatric, obstetric-gynecologic. Other branches can be
organized at the population rate of more than 30000, they are the
following: infectious, neurologic, ophthalmologic, traumatologic, etc.

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 The practice of the interareal departments of CAHs creation is
widespread in Belarus. This practice is organized for specialized
medical help rendering for rural population from nearby located areas.
Level of the region
This level is presented by regional hospital with consulting
polyclinic; regional dispensaries; regional Centers of Hygiene,
Epidemiology and Public health, and other organizations.
Functions of the hospital are rendering of emergency and
sheduled medical care; highly specialized in-patient medical help.
The regional hospital renders the organizational-methodical work in
the medical-preventive establishments of the region. The basic
function of the hospital is the improvement of the doctors` and
nurses` professional skills.
The regional hospital includes an advisory (consultative)
polyclinic, a hospital with auxilliary-diagnostic departments,
cardiological, neurologic, traumatologic, otorhinolaryngologic,
pulmonologic and other specialized departments.
The bed fund of the regional hospital is 1000 beds
approximately. The hospital services the region of radius 100 km
approximately (within 3-hours transport accessibility).
The major modern problem and direction of the improvement
of medical help rendered for rural population in Belarus is the
restructuring of the medical service.
It includes such measures, as:
a) reduction of inefficiently used hospital beds and the
reduction of disproportions in their distribution on the territories of
the Republic;
b) introduction of the technologies which can replace in-patient
departments (hospital-replacing technologies, such as day-time hospital);
c) restructuring of medical aid according to the level of
intensity of the medical-diagnostic process and according to the
territorial technological level of its rendering;
d) wide introduction of GP-practice.
The reduction of the number of beds is carried out without
decrease of the financing volume guaranteed by specifications of
budjetary security of charges on public health services counting upon
one inhabitant, with planning (at the territorial level) of regular
number of the personnel of the public health services organizations
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proceeding from the number of the served population. At reduction
of beds number, the space for one bed comes to sanitary norms or
reaches them; opportunities to use these areas to povide in-patient
medical help, medical-social help, to finish the treatment of patients
after the exact period of a disease is determined.
The introduction of technologies which can replace in-patient
departments (hospital-replacing technologies, such as day-time
hospital) is one of the major reserves in public health services of
the Republic because it costly reduces «hotel-hospital service».
Restructuring of medical aid according to the level of intensity
of medical-diagnostic process includes the partial structural
reorganization of medical help service with the creation of in-patient
departments of intensive therapy, the chambers (departments) for
medical-social help, the departments of medical rehabilitation, and
wards for the final treatment after acute conditions or for the
treatment of the sick with chronical pathology in the acute stages.

4.2 Medical care for working people

Occupational health is an essentially preventive medicine.
Occupational health should be aimed at the promotion and
maintenance of the highest degree of physical, mental, and social
well-being of workers in all occupations; of the prevention of the
workers of departures from health caused by their working
conditions; at the protection of workers in their employment from
risks resulting from factors adverse to health; at the placing and
maintenance of the worker in the occupational environment adapted
to his physiological and psychological equipment, to summarize, of
the adaptation of work to man and of every man to his job.
Preventive medicine and occupational health have the same
aim – the prevention of disease and maintenance of the highest
degree of physical, mental and social well-being of workers in all
occupations; the levels of application of preventive measures are the
same – health promotion, specific protection, early diagnosis and
treatment, disability limitation and rehabilitation; the tools are the
same – epidemiologic approach, statistics, health screening, health
education, etc.

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 Occupational health, therefore, is the application of preventive
medicine in all places of employment.
The outstanding scientist of the Renaissance period, the Swiss
doctor and chemist Paracelsus (Philip Aureol Teofrast Bombast von
Gogenheim, 1493-1541) had firstly analyzed the connection of the
miners and founders` illnesses with the professional poisonings with
lead, mercury and antimony.
The German doctor George Agricola (Bauer, 1494-1555)
offered the following measures of the illnesses prevention: protective
footwear and clothes, intensified feeding, the installing of ventilating
«mashines of airing» and mine ladders, the strengthening of mines
vaults with special support, the removal of subsoil waters, etc.
The founder of professional pathology and labour hygiene as
the branches of medicine was Italian doctor Ramazzini Bernardino
(1633-1714).
The knowledge of the occupational help to the workers has
foresee the knowledge of occupational medicine. It includes
knowledge from toxicology (the study of external substances and their
effects on humans), epidemiology (the study of disease in populations)
and environmental epidemiology (the study of environmental toxins
and their effects on populations), ergonomics (the study of the
mechanical interaction between people and their living on work
environment for the purpose of tailoring tools, tasks and workplace
design for better overall efficiency and individual well-being).
Occupational disease is any disease caused (in whole or partly)
by exposure of the work environment (usually excluding workplace
trauma).
The key question of occupational medicine is to recognize the
occupational disease. Occupational diseases frequently present as
common medical conditions, such as asthma, lung cancer, atopic
dermatitis, peripheral neuropathy, and psychiatric disorders. To help
to recognize the occupational disease, any doctor serving working
people, should know the list of jobs, focusing on work processesed
encountered, a description of any temporal relationships between a
work exposure and presenting illness, hazards in the workplace.
Additional information may be required to establish the degree of
exposure when an occupational disease is suspected. In addition
to seeking occupational inforation from the patient, it may be useful
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to obtain information from the employer. This information should
include general conditions of the workplace, the specifics of the
patient’s exposure (such as the distance from the toxin and the route
of absorbtion), personal protective devices (such as the types of
respirators, the availability of replacement filters, etc.), the presence
of disease in cowokers, the chemical composition of the toxin and
the levels of exposure.
Medical staff (Health care workers) have special of occupational
hazards. Due to the complexity of health care and the risks inherent in
caring for sick patients, there are many health hazards to which health
care workers are exposured, including the following:
 Safety hazards, such as filting heave patients, which can
cause back injury; electric shocks; needle stiks; which can lead to
transmission of blood borne infections agents, such as human
immunodeficiency virus (HIV) and hepatitis B virus (HBV), etc.
 Ethylene oxide. This commonly used sterilant is mutagenic
and a suspected human carcinogen and teratogen.
 Wastle anesthetic gases. This gases in trace concentrations
are associated with spontaneous abortion, teratogenesis, mutagenesis,
carcinogenesis, liver disease.
 Infectious agents, such as viruses of hepatitis,
mycobacterium of tuberculosis, herpes simplex virus, HIV, etc.
 Cytotoxic agents. Chemotherapeutic agents are potentially
dangerous. Although undocumented as yet, chronic effects in
workers who administer these agents may include reproductive
abnormalities, cancer, irritation to mucous membranes, and skin.
Preventive measures
The various measures for the prevention of occupational
diseases may be grouped under three heads: medical, engineering
and statutory legislative.
Medical measures are as follows:
1) medical examinations;
2) organization of medical and health care services for
workers;
3) supervision of working environment;
4) maintenance and analysis of records, account of temporary
sickness absence from work;
5) health education and counseling; etc.
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 Engineering measures are as follows:
1) design of building;
2) good housekeeping;
3) general ventilation;
4) mechanization;
5) substitution (the replacement of harmful material by a
harmless one, or by one of less toxicity);
6) protective devices (respirators, gas masks, etc.);
7) environmental monitoring; etc.
Legislation includes such aspects, as employment of young
factors, hours of work, occupational diseases, employment in
hazardous processes, etc. Society has an obligation to protect the
worker`s health engaged in diverse occupations.
Obligatory medical check-ups (medical examinations) of
working people are the basic part of medical measures for prevention
of occupational diseases in Belarus.
Among the parameters describing the health of workers,
occupational sickness rate takes a special place as it has medical,
social, economic and legal aspects. Obligatory physical examinations
of workers are performed to decrease occupational sickness rate.
They are divided in groups (on the Belarussian example):
Preliminary medical surveys, that are carried out when one
starts to work; their purpose is to determine the conformity
(suitability) of workers and employees to perform his work, the
prevention of occupational and common diseases, work safety and
prevention of spreading infectious and parasitic diseases. The results
of preliminary check ups written down as the social-clinical
conclusion. On the basis of the conclusion the worker receives
the document, where it is written whether a person is suitable or not
for this work.
Periodic medical check ups. They have the following tasks:
 revealing the persons with occupational diseases or with
suspicion on occupational disease;
 recognition of the common (nonprofessional) diseases at
which the further work together with occupational hazards can
worsen the workers` state;

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  assignment of individual medical-improving actions to
persons with the revealed diseases or with suspicion on occupational
disease (clinical supervision, inspection in clinic, out-patient
treatment, treatment in a hospital, improvement in dispensaries, rest
house, rational employment, etc.);
 estimation of working conditions and development of the
sanitary-and-hygienic actions directed on liquidation of the reasons,
causing an occupational disease.
On the first list of the individual card of a dispensary patient a
professional route is indicated i.e. it is indicated for years, the
profession of the patient and with what productive hazards he was in
contact, as well as the duration of this contact. A doctor, receiving
the patient, looks through the occupational history, immediately sees
notices, what pathology to look for.
The main purpose of periodic preventive examinations is to
catch initial symptoms of professional diseases and to assume the
measures for prevention on the base of it. During these examinations
the contingent is constant so it is possible to consider them as the
mass health examination of healthy people. Different specialists can
participate in professional examinations depending on concrete terms.
Depending on the revealed diseases preventive medical
examination is carried out by the shop internist 3-4 times per annum,
including the examination of particular specialists up to 2-3 times.
From contingent of observed the special group is selected.
This group is only under observation of the shop internist. These are
the working people who are being frequently illed.
The most wide-spread is the following criterion. Long and
often being ill is a person that has 4 and more etiologically similar
diseases during the year, 40 and more days of disability; or 6 and
more etiologically heterogeneous diseases, 60 and more days of
disability for different. Reasons to reveal long and often being ill the
shop physician looks through the cards of personal account of
disability time of the workers in his shop area and chalks up the
people with recurrent diseases.
All data of periodic medical check-up are written down in a
medical card of the out-patient (the form number 025/ acc). Thus
each doctor participates in a medical check up, draws the conclusion

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about professional suitability. Three versions of the conclusions are
possible:
1. A person is practically healthy, he or she can continue
the work with the given professional hazards (to specify a trade);
2. The general (nonprofessional) disease (to specify the
diagnosis) is revealed:
 the worker may continue the work, he or she is subject to
treatment and clinical supervision; or
 the further work in contact with professional hazards is
contra-indicated (transferring to another work and another post is
carried out according to the Medical Rehabilitation Experts
Committee (MREC) conclusion).
3. Suspicion on occupational disease. The worker is subject to
additional inspection, dynamic supervision by the shop or the local
doctor.
Work on periodic check up finishes after drawing up in a
month's time the certificate by the final commission, which includes
head of the commission on the periodic medical check up, doctor
hygienist and other doctors of profile specialties. The sertificate of
the final comission reflects the medical-improving and sanitary-and-
hygienic actions and includes three sections: ascertaining, the data of
dynamic supervision, and recommendations.
Organization of medical care for workers
Organization of the medical help for workers may include
different forms, various for different countries. For example, in USA
these services are the following.
A. Independent university or hospital services include:
 Clinical evaluations of patients who are suffering from
occupational disease (patients may be self-referred, or referred from
physicians, lawyers, labor unions, companies by whom they are
employed, or governmental agencies).
 Epidemiologic and laboratory evaluations (supported by grants
from the government or private industry) of newly suspected toxins.
 Epidemiologic studies on worker cohorts with various
оccupational exposures.
 Preventive advice to unions or industries on occupational
health.

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  Communicating and understanding of the workplace
environment to practicing physicians, other health care professionals,
and community groups.
 Expert testimony in toxic injury litigation or workers'
compensation cases.
B. Government services include:
 Laboratory, clinical, and epidemiologic research to expand
the knowledge of occupational medicine and toxins.
 Advice to local, state, and federal government policymakers
concerning safety standards to protect the health of workers.
 Epidemiologic and laboratory evaluation of new chemicals.
 Consultation to health professionals concerning
occupational health problems.
 Publication of scientific reports on occupational toxins.
 Reviewing university research for the purposes of funding
and training in all disciplines of occupational health.
C. Labor union services include:
 Advice concerning design and content of health and safety
educational programs for the membership.
 Hazard evaluation and literature review concerning local
union plant health and safety problems.
 Health and safety policy development, both for collective
bargaining and legislation.
 Aiding the membership in epidemiologic or toxicologic
study of problems.
D. Corporate services either in plants or on a contractual basis
with community hospitals or out patient facilities include:
 Pre-employment physical examinations to assess the ability
of employees to perform required tasks.
 Periodic medical examinations and biologic testing to
monitor the adverse effects of toxins to which workers are exposed
(e.g., pulmonary function testing for workers exposed to silica dust).
 Recommendations concerning preventive programs to
control toxins in the plant environment.
 Acute medical therapy for injuries and illnesses and in some
programs, case management.

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  Advice to personnel departments regarding work
restrictions for partially incapacitated employees and an employee's
ability to return to work following an illness.
 Disability evaluations.
 Identification of, and communication with, medical
consultants concerning workers suffering illness or injury on the job.
 Policy development for collective bargaining and
legislation.
E. Hospital, group practice, or primary care services provide
many of the services on a contract basis.
The workers in Belarus may be served by the organizations of
public health services of the industrial enterprises, i.e. in the place of
work, and by the territorial public health organizations (out-patient
and in-patient).
So, working people in Belarus can get the medical help in such
organizations, as:
1. In special medical institutions, organized directly on
enterprise (medical-sanitary parts – MSP, factory (shop) polyclinics,
medical and medical attendant posts);
2. In «shop therapeutic districts» of territorial polyclinics;
3. In the general medical territorial network according to the
living place (polyclinics, hospitals, dispensaries and etc);
4. In medical institutions according to the place of the
worker’s location (for business-trips).
The medical help organization is a powerful factor of the
labour productivity ascent, the reduction of the working hours is
connected with disability.
Differentiated service for the working people is that medical
help organizing forms which depends on the power and specificity of
the industrial enterprises. So, MSU (medical-sanitary unit) and shop
polyclinics are intended for big enterprises of the key industries, they
have special economic importance. It provide the highest level of the
service for working people.
The shop principle is put in a basis of out-patient health
services of workers at the industrial enterprises, construction
organizations and transport.
The shop therapeutic district in polyclinics of the general
network serves the enterprises of average and small output.
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The organization which is situated directly on the industrial
enterprises of any medical institution depends on the number of
working, industrial sectors and financial-economic possibilities of
the enterprise.
Basic role in the organization of medical help for workers in
Belarus belongs to medical-sanitary parts (MSP).
MSP have been actually founded since 1939 at the large
industrial enterprises. But wide spread it had in 1944, when a new
type of complex medical-preventive establishments at the
enterprises, as MSP, was officially founded.
The primary goal of MSP is maintenance of workers with the
qualified help, availability of this help for workers.
MSP (medical-sanitary part) consists in general of six parts:
polyclinic, permanent establishment (hospital), health units (the
doctor’s and medical assistant’s), dietary canteen, preventorium,
baby milk feeding. Besides, MSP can have other subdivisions, for
instance athletic-sanitary complexes, sanitarium, kindergartens,
physiotherapeutic and balneological clinics and others.
Basic parts of MSP are the out-patient department (polyclinic)
and the in-patient department (hospital).
MSP can be of two types: the close (servicing only the workers
of its enterprise) and the open (servicing not only their own working
people and their families, but also the close living population).
Close MSP create more comfortable conditions for the
maximal reinforcement of the preventive measures, the medical
examination of labour conditions and specificity of the production
process, joint work with administration and public organizations.
However they don’t often render all types of specialized medical
help, their power is not completely always used, and therefore the
large MSP are non-economic.
As one of the organizing forms the factory (shop) polyclinics
are recommended, combining in itself advantages of the close MSP
but without its defects. Being included in large multifield hospitals,
they give possibility to shop doctors to use the consulting help
broadly, including particular specialists, upgrade their own
qualification on the basis of these institutions.

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 Nowadays the organization of polyclinics becomes very
popular. They are built and kept on the expenditures of the
enterprise. The industrial enterprises build also the in-patient medical
establishments on own account, routinely promoting hospitalization
of their own workmen, for a preventive purpose.
On the expenditures of the enterprise the medical-diagnostic
complexes are fit out, the equipment and technique for
physiotherapeutic rooms, the inhalatorium, hydropathic
establishment and others, servicing working people
Today, in the absence of thereof own medical establishment,
industrial enterprises conclude the contract with a territorial
polyclinic to organize shop therapeutic areas, servicing the working
people of one or several related on profile enterprises directly in the
polyclinic. The small enterprises without economic possibilities to
have own shop physician, conclude the contract with the nearest
territorial polyclinic for the prophylactic examinations organization.
The medical personnel, servicing only working people at the
enterprise, are included in the staff of this enterprise. Depending on
the specificity of the industrial enterprise particular specialists are
taken in the staff of the enterprise, paramedical personnel.
The major tasks of the medical institutions at the enterprises
are: the maximum approximation to the working place of competent
and specialized medical aid, the development and implementation of
the actions directed on recovery of working conditions and the mode
of life, the prophylaxis and reduction of the general and professional
incidence, the traumatism, the morbidity with temporal disability and
invalidity.
The central figure in the medical service of working people is a
shop therapeutist. According to the regulations about a shop
therapeutist is stated that a shop physician is a therapeutist who
knows the particularities of production, the working conditions and
the professional pathology of workers and serving in the maintained
shop area.
A shop therapeutic area is a main and initial link in the system
of the rendering medical-preventive help for working people.
Therefore its formation is under the serious attention. Herewith the
principle of shops’ homogeneity on production technologies and
the principle of their territorial planning are in the basis.
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 Successful work of the shop internist is impossible without the
systematic and detailed study of technologies production, the
sanitary-hygienic terms and the organizations of working conditions
on enterprise in general and in separate professional working groups
determining the job hazards with a glance. Without the sufficient
knowledge in this sphere it is impossible to assess incidence
correctly, reveal the reasons of professional pathology promptly, to
assess the degree of working ability of a workman.
Basic functions of the shop doctor are following:
1. Preventive work on the factory. To reveal the reasons of
high incidence and traumatism the joint actions of shop therapeutist
and other specialists are very important. For this purpose the shop
physician must work right in the shop: from the budget of the
working hours he has no more than 9 hours a week for preventive
measures.
For these purposes the shop therapeutist must form a job
description of his shop. The job description is a table, in which all
available in the shop job hazards are given in the vertical position
and the similar working placesin the horizontal position (or shops if
the job description is made for the whole enterprise). In intersection
of the vertical and horizontal columns the number of working
dealing with the named hazard is written. In the table it is also
necessary to mention what specialists and with what frequency the
working people with the named hazard have to be examined, what
analyses should be made and with what frequency.
The job description gives the possibility to orientate in the
present doctor’s and laboratory load on undertaking the periodic
physical examination of the working people with harmful working
conditions.
2. Early revealing of diseases, timely diagnostics and the
qualified treatment of patients of served district in a polyclinic and in
the hospital of his speciality. The referring of patients for special
kinds of stationary and out-patient treatment in the corresponding
medical-preventive establishment. For these purposes the
organization of preliminary, periodic and target physical
examinations are used.

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 3. Clinical supervision over the revealed contingents.
The recommendations on rational employment. The control over the
rational employment of workers together with the trade-union
organization. The participation in the complaining and performance
of the collective agreement on health improving actions at the shop
site and at the enterprise. The participation in the work of medical-
engineering team.
The purpose of the medical-engineering team creation is the
study of working conditions, incidence and traumatism; the
development and supervision of sanitary-health and medical-
preventive actions realizations on the enterprise. The main role in
medical-engineering team formation belongs to the head doctor of
the medical-sanitary part and to the head doctor of the Centre of
Hygiene and Epidemiology.
The manager of the enterprise gives the special order about
medical-engineering team. Its composition is firmly established by
the head doctor of the medical-sanitary part and by the head doctor
of the Centre of Hygiene and Epidemiology and may include the
chief plant engineer or its deputies; the heads of the departments of
the shop polyclinic; the sanitary physician of industrial sanitation of
the Center of Hygiene and Epidemiology; the main members of the
trade-union committee; the safety engineer; the main specialists of
the enterprise (on energy market, industrial design, on mechanization
and intensification of work, constructors, technologists and others);
the shop internists; the machine-shop manager.
Medical-engineering team has the following functions: the
complex studies of working conditions, ther researches of the new
technological processes; the detailed study of traumatism and
morbidity in the shop in connection with the working conditions; the
development of sanitary actions; the rational job placement of sick;
the professional rehabilitation of people with limited working ability;
the development of the technical recommendations of the productive
processes; etc.
4. Analysis of the parameters of dispensarization (efficiency
and organization).
5. Selection of the patients required the sanatorium treatment,
the stay in dispensaries, a dietary feeding and other kinds of the
medical-preventive help.
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 6. Control over sanitary-and-hygienic conditions in the shop.
The carrying out of necessary antiepidemic actions. The creation of
the sanitary active members. The sanitary-educational work.
7. Participation in the investigation of the industrial traumas
and poisonings reasons. The account and analysis of the total and
professional incidence and traumatism. It is obligatory to study the
reasons of each event of traumatism on the enterprise. In this case the
accident certificate is filled up.
8. Regular analysis of the morbidity rates in the shop, the
proof analysis of the health condition of those, who are frequently
and continuously ill. The development of the measures how to
decrease their number. The examination of temporary disability of
workers.
The report about incidence reasons of the population with
temporal disability (form number 16-TD) is formed by the shop
therapeutist one in a quarter, in half a year, in 9 months and in a year
according to medical certificates, which are kept in a book-keeping
of the enterprise during three years. 16-TD form is a list of the
diseases and conditions, most often leading to TD. For each group of
the reasons the own number of the line is assigned, in which it is
written. For instance, line 1 – pulmonary tuberculosis, 4 - malignant
neoplasms. To determine what line to refer that or other disease there
is a code of the disease according to ICD-10.
All MC are put in alphabetical order to select them on one
person and define the number of the events of TD. The event of TD
is a persistent TD on one or different diseases regardless to the place
of giving the TD; the event is considered finished if the working man
has proceed to his work and has worked at least one full working
day. On each event of TD the main disease is defined, on which it is
written in the determined line. In each table line the number of the
events (in absolute value) and the number of the calendar days of TD
is written. Then, with a glance to average number of working days
for corresponding time period, the event-type indicators of time
disability (temporary sickness absence from work) are calculated in
percentage ratio and include such parameters, as the following:
 Number of events (cases of diseases with temporary
disability on 100 of working people), it is calculated in the following

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way: (the number of cases / number of working people) x 100. This
parameter depends from the incidence rate.
 Number of days with temporary sickness absence from work
on 100 of working people), it is calculated as follows: (the number of
days with sickness absence / the number of working people) x 100.
This parameter characterizes severity of morbidity and depends from
the prevalence rate.
 Average length of one case in days (total, on each reason),
it is calculated as arithmetic mean (the sum of every case durations
divided by the number of cases).
 Structure of diseases with sickness absence from work
(in days and causes). It is calculated as a proportion to express the
relationship of one part to the whole, in percentage ratio.
 The integrated index: the percent of disability, it is a
proportion of the workers which had temporary sickness absence
from work during the year of studying, per 100 of working people.
The advanced study of the incidence reasons, the determination
of the extent of social and industrial-professional factors on its rate
and structure is recommended to be made on the contingent, that
have worked at the given enterprise for a full year.
It is known that among ther newly called-in employees the
indicators of time disability are usually lower. The reasons are the
following: the smaller persistent record of service, the low
appealability, the psychological factor. On the contrary, the
incidence among the people who are discharged is in two times
above, than for the preceding year. In this situation there is no the
duration in growth of disability but only frequency of the events.
Each Medical sertificate of temporary disability (the Note of
disability) must be registered in the card of personal account by
medical personnel (otherwise named a personal card) before its
compensation by the book-keeping of the enterprise. The card of
personal account is created for every worker who has got at least one
Medical sertificate of temporary disability (the Note of disability)
during hours of service i.e. practically for all working personnel. In
the personal card except detailed passport data and working place the
information about each Medical sertificate of temporary disability is
written down: the period of time the Medical sertificate of temporary

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disability is given on, its duration at calendar days, the diagnosis of
the disease (or its code on ICD-10), who gave it (the surname of the
physician if he services the working people of the given enterprises
or institution, where the Medical sertificate was given).
9. Making up quarterly and annual work plans confirmed by
the head physician and strictly checked execution of the plans.
The work plan of the shop therapeutist is made for one year
and quarterly. It contains the following sections:
a) organizational work (the analysis of sickness rate, the report
at shop working meeting, the participation in the commissions on
employment, etc.);
b) medical-preventive work (the planning and carrying out of
receptions, the dispensaryzation, employment, the examination of
work capacity, the preventive measures against infectious diseases,
traumatism, etc.);
c) actions on improvement of working conditions and the life
of workers and employees (the preventive work in the shop on
revealing defects of the organization and working conditions, the
rest, the feeding of workers; the round ups of rest rooms, the
recommendations observance check, etc.);
d) improvement of professional skills (the realization of
various forms and methods of professional skill improvement of
doctors and average medical personnel);
e) propagation of medical and hygienic knowledge, the work
with a sanitary active members (lecturing and carrying out of
conversations, organization of sanitary rooms, bulletins, etc.;
the instructing of sanitary representatives, sanitary posts, etc.).
The comprehensive plan of health improving actions at the
industrial enterprise (the united complex plan of sanitary actions) is
composed by the shop doctor and is confirmed by the manager of the
enterprise and by the head of the trade-union organization. Every
year between the administration of the enterprise and working people
presented by trade-union organization the collective agreement is
concluded, in which the medical service and social insurance have an
entire section. The comprehensive plan is the component part of this
agreement.

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 The comprehensive plan includes such measures, as:
a) sanitary-technical measures – the measures on the
rationalization of work and work place, the improvement of
technological processes, on the safety devites and the prevention of
occupational diseases, etc.;
b) sanitary-hygienic measures – the measures on the general
sanitary accomplishment of shops, rest rooms (water supply, feeding,
clearing, heating of rest rooms, etc.); on the struggle with the most
frequently meeting diseases (separately on each kind of disease);
c) medical-preventive actions – measures that are directed on
the improving of the organization and quality of the first medical aid
and the specialized treatments; the dispensarization of revealed
contingents under industrial and medical indications, the temporary
improvement of them; the actions directed on the labour safety of
women and teenagers, etc;
d) organizational-mass actions – the measures that are directed
on the propagation of medical and hygienic knowledge, the
organization of sanitary teams, the sanitary amateur performance.

4.3 Concept of rehabilitation.

Medical rehabilitation as the main basis
By WHO, primary tasks of medicine are following:
fortification of health; prophylaxis of the diseases; treatment;
rehabilitation.
Rehabilitation has been defined as «a system of state, social-
economic, medical, professional, pedagogical, psychological actions
directed to the diseases prevention, leading to temporary or
permanent loss of the working ability and possibility to sick and
invalid’ return in the society and to social useful work» (Prague,
1967); as «a process directed to disability prevention at period of the
disease treatment and support the patient in achievement of
maximum physical, psychic, professional, social and economic
adequacy in the network of the existing disease» (WHO, 1963);
as «all measures, directed to reduction incapacitating factors and
conditions leading to physical and other defects, as well as ensuring
the possibility for invalid to reach the social integration» (WHO, 1981).

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 In French-speaking countries the term «readaptation» is used
(the adjustment to labor activity). «Readaptation» is a tertiary
prevention.
So, rehabilitation is the combined and coordinated use of
medical, social, educational and vocational measures for training
and retraining the individual to the highest possible level of
functional ability.
It includes all measures aimed at reducing the impact of
disabling and handicapping conditions and at enabling the disabled
and handicapped to achieve social integration. Social integration has
been defined as the active participation of disabled and handicapped
people in the mainstream of community life.
The following areas of concern in rehabilitation have been
identified:
1) medical rehabilitation – restoration of function;
2) vocational rehabilitation – restoration of the capacity to earn
a livelihood;
3) social rehabilitation – restoration of family and social
relationships;
4) psychological rehabilitation – restoration of personal dignity
and confidence.
Rehabilitation is no longer upon as an extracurricular activity
of the physician. The current view is that the responsibility of the
doctors does not end when the temperature is normal and stitches are
removed. The patient must be restored and retrained to live and work
within the limits of his disability but to the hilt of his capacity.
As such medical rehabilitation should start very early in the process
of medical treatment.
Among being in need of rehabilitation there are two main
contingents:
1. Sick, long and often being ill, including: completely
rehabilitated, partly and become heavy disabled;
2. Invalids (handicapped), including: rehabilitated completely
and partly, transferred to the heavier group; person without group
exchange.
For the handicapped persons The individual program of
rehabilitation (IPR) is arranged in primary and specialized MREC in
Belarus. It has a number, corresponding to the number of the
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protocol and act of expert examination and date of issue. The
signature of the chairman of MREC is certified by a seal.
The program is given on invalid’s arms in MREC. If there is
doubt after invalid’s possibility to bring the IPR to attending medical
doctor the IPR moves directly to MCC for copying the
recommendations (on medical rehabilitation and, selective,
professional and social rehabilitation) with later giving it on invalid’s
arms. At impossibility of the IPR use by invalid himself (with mental
diseases and others), IPR moves to MCC or a relative (the guardian)
of the invalid.
The need for undertaking the rehabilitation computes with a
glance of rehabilitative potential of the invalid (sick), reflecting his
reserves and real possibilities for return to a labor activity of any
form – without restriction, with partial restrictions or with the use of
remained working capacity in special or individual created
conditions. Rehabilitative potential is defined on the base of complex
medical and social factors, as well as the results of obtained
rehabilitation procedures.
The individual program of rehabilitation of the invalid includes
three sections, reflecting measures of medical, social-home and
professional rehabilitation, each of which moves in the medical-
preventive institution accordingly, labour and social protection
administration (department), social security administration
(department), the placement service or in the organization. MREC
gives to invalid’s arms a short variant of the program
(a commemorative booklet) with instruction of the main measures of
rehabilitation, place and periods of its carrying out, the address and
working hours of the institution, where a person has to arrive.
Medical rehabilitation is a process directed to restoration and
compensation of the functional capabilities of the organism, broken
as a result of innate defects, diseases and traumas using medical or
other methods (the Law of the Republic of Belarus «About disability
prevention and rehabilitation of the disabled»).
The Purpose: recovery of the functional capabilities of the
organism. Tasks: medical: – broken functions restoration, – restoration
of selfgenetic mechanism of the organism and its personal qualities;
non-medical: – social-domestic adaptation, professional restoration.

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 Periods and stages of medical rehabilitation are clearly
defined – in-patient, out-patient, sanatorium.
The tasks of medical rehabilitation are restoration and
compensation of the functional possibilities of the organism:
 at high rehabilitation potential – increase of the working
capacity according to the demands of the main or new profession;
 at average (limited) rehabilitation potential – reduction of
pathomorphological changes, stabilization of the clinical course of
the chronic diseases, increase of the working capacity, as well as
optimization of the treatment methods (including constantly
supporting therapy);
 at low rehabilitation potential – reception in people with
positive labor aim, the clinical effect with stabilization of the course of
the chronic diseases, increase or conservation of the working capacity.
So, there are three levels of medical rehabilitation application:
the first – restoration of functions, the second – recovering the
criterion of vital activity, the third – social restoration of the sick.
Principles of medical rehabilitation are following:
1. Early beginning of rehabilitative actions: rehabilitation
should be a part of treatment under the threat of disability.
2. Continuity of rehabilitation.
3. Complex character of rehabilitative actions.
4. Individuality of rehabilitative actions.
5. Rehabilitation realization in mass groups.
Directions of rehabilitation medical services can be divided
into two ways: the 1-st – integration of medical rehabilitation to
medical-diagnostic process at all stages of medical help organization
as its integral component; the 2-nd – medical rehabilitation service
organization (actually) can be nonspecialized (rehabilitative help for
sick with different nosologies) and specialized, depending on the
type of disabling consequences (the speech, hearing, vision, mental
disorders) and the etionosological factor (diabetes mellitus, arterial
hypertension).
Organizing forms in Belarus are classified as following:
 centers of medical rehabilitation: monoprofile and
multiprofile; Republican hospital of spa-treatment;

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  departments (the cabinets) of medical rehabilitation in
polyclinics, hospitals, sanatorium;
 rehabilitation at home.
There are approximately 200 departments of medical
rehabilitation of the dispensary-polyclinic stage in Belarus.
The structure of the medical rehabilitation department is united.
The cabinets: physiotherapy, work therapy, exercise therapy,
mechanotherapy, reflexology, psychotherapy.
The methods of medical rehabilitation are following:
 physiotherapy,
 exercise therapy,
 work therapy,
 drug treatment,
 operative treatment,
 psychotherapy,
 social rehabilitation.
Hospital beds fund in Belarus include more than 35% of beds
for medical rehabilitation, 30% – for intensive treatment, 20% – for
continuous treatment of sick with chronic diseases, 15% – for
medical-social help.
Social rehabilitation includes the list of procedures directed to
granting the social help and services for adaptation in social sphere
and social rehabilitation.
Professional rehabilitation includes vocational guidance,
professional training or re-education, rational job placement,
granting the backup facilities for labor activity.
A medical expert of MREC makes the expert examination of
vocational attitude according to the professional functions condition
and with a glance to working conditions.
Professional education or re-education is carried at the working
place – at the enterprise, at re-educational courses – in the
employment centre, as well as in educational institutions.
The rational job placement is carried by enterprises and
institutions, as well as the employment centre. In the Individual
Program of rehabiliotation the broadened recommendations are
included into corresponding directions for realization.
The results of the IPR realization are used in the MCC and
MREC reports about rehabilitation of invalids and sick.
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 It is now recognized that rehabilitation is a difficult and
demanding task that seldom gives totally satisfactory results; but
needs enthusiastic cooperation from different segments of society as
well as expertise, equipment and funds not readily available for this
purpose even in affluent societies. It is further recognized that
interventions at earlier stages are more feasible, will yield results and
are less demanding of scarce resources.
4.4 Social protection of population
Social protection schemes in the EU, but also in other
countries, can be classified within three pillars and five fields of
social security plus social allowances and services (see the Figure 13).

3rd pillar: OTHER (private)

2nd pillar: SUPPLEMENTARY/

occupational

1st pillar: STATUTORY (sickness,

mathernity, pensions, employment
accident insurance, unemployment, child
benefit)

Figure 13. – Social security in the EU (scheme)

Social security can be found only in the first pillar, which

refers to statutory and obligatory schemes. In this pillar statutory is
the main criteria, because it refers to schemes which are in force
through a law, and the requirements for the right to such benefits
are stipulated in the law itself. They are completely always a part of
public administration, mostly obligatory and financed by taxation,
by special social taxes or contributions from employers and
employees.

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 The first main branch of social security is the social protection
for disabled. The ultimate goal of this social assistance system is to
help disabled people to become more self-sufficient, actively involve
them in social life and create equal opportunities in everyday
activities.
The second basic branch of social protection is the support
for the elderly.
In some European countries, as in the Republic of Belarus,
pensioners and single disabled people, who do not want or can not
move to nursing homes (nursing hospitals) can take care from social
workers of territorial centres. These elderly people, who are clients
of nursing homes, contribute part of their pensions to the bank
account of the nursing home in which they reside.
Strictly speaking, the second pillar schemes are not social
security, but they supplement them – especially in the field of
sickness benefits, medical care and pensions. They can be obligatory
and can also be legislated, but in this case the legislation benefits are
not mentioned. The legislation only lays out requirements concerning
the institutions that run the schemes. The schemes are collective
arrangements, usually functioning in a special branch of activities or
they can be arranged by employers for their employees. That is why
they are usually called the «occupational schemes».
Third pillar schemes refer to private insurances. They also
can supplement the first and the second pillar schemes, especially in
the field of sickness benefits and medical care and pensions.
Sometimes, as in group of life insurances, they can be classified
in second pillar, too.
First pillar of social sequrity schemes form the basic security
for the people in most of the countries. If the security is not good
enough, there is a need to supplement it from other pillars schemes.
The variety among countries connected with pillars in different
fields of social protection is wide.
There are countries like the USA, where the first pillar schemes
are small, covering only pensions and medical care for pensioners.
Mostly of the security comes from the second and the third pillar:
collective or private arrangements or insurances.
In most of European countries the first pillar of social security
provides the main secutiry, but second pillar schemes are rather large
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in countries like Great Britain or the Netherlands. In Germany the
second pillar schemes are not as common in pensions as in sickness
funds because of a special salary ceiling of 3,875 euros per month.
Supplementary arrangements are more common, because employees
with salaries above this ceiling limit are not allowed to join the first
pillar social of security sickness scheme. Supplementary benefits can
also be taken by those whose salary is below the ceiling and who are
members of the funds.
There is a close connection between social and health services.
At least three types of social services can be provided by health
workers. Such services include:
 Socio-medical services e.g. counseling on the prevention of
possible organic disorders, preservation, support and protection of
the person’s health, provision of preventive measures, therapeutic-
rehabilitational activities and work therapy.
 Psychological services, e.g. counseling on issues of menthal
health and improving relations with social environment, using of
psycho-diagnostics aimed at studying socio-psychological
characteristics of the personality for the purposes of its psychological
support or rehabilitation and provision of methodological
recommendations.
 Services in professional rehabilitation of physically-
handicapped persons, e.g. a package of medical, psychological,
information activities aimed at creating favourable conditions for the
realization of the right to professional orientation and training,
education and employment.
The necessity of reforms of public health services are
determined by the following problems: shortage of financing,
increase in expenditure, problrms of national economy, public health
system problems, dissatisfaction, lack of professionalism and
competence of management. Their purposes are to achieve basic
goals and principles of public health services activity, such as equity,
high quality, cost-effectiveness of medical aid.
Reformation is interrelated with structure and state of the
economy, policy in public health, condition of the independent
system of public health. Basic factors are as follows:
1) technical base: the current conditions and repairs – 10% of
public health institutions are in critical state and without repair their
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maintenance costs would exceeds their construction costs; rational use
of the available premises; the progressive tax on medical equipment
(since the 5th year of use – it is more, than the price of the equipment);
2) human labour resources – surplus of medical personnel
(excessive specialization, duplication of personnel);
3) the programme of average time estimation, social diseases;
4) the programme of medicamental storage;
5) medical-social priorities.
One should distinguish such reformation levels as global,
national and regional; and such categories of the participants, as
citizens, civil population united by one social interest, political elite,
workmen of the public health.
Some factors are crucial for reforming process, for example the
form of public health services financing (centralization,
decentralization, privatization); liberty of choice and participation of
citizens; the role of the state in health protection system.
All reforms can be divided into for groups.
Reforms of the first group is directed at the insufficient
resources solution. These reforms can be conducted by means of
public health system:
 by expenses deterrence, for example, by standardization of
the access to medical help, reduction of hospital beds, medical-
preventive organizations reduction and modification, reduction of the
medical personnel, development of medical workmen
encouragement, etc.;
 by changing of the personal payment mechanism (by
development of the pay services, additional state payment for
physicians, etc.);
 by statement and change of the priorities through state
programs realization.
Reforms of the second group are the reforms aimed at
improvement of financial stability. These reforms are implemented
on the level of government and political elite. For example, by
legislative determination of the financial and other resources
allocation, by attraction of the additional facilities in public health
(through tax legislation and governmental documents).
Reforms of the III-rd group are the reforms aimed at efficient
resource usage, such as determination of medical standards, efficient
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distribution of resources, economically effective provision of
population with medicines (actions in the field of taxes on medicines,
compensation of the payments on medicines).
Reforms of the IV-th group are the reforms that provides
availability and quality of medical help: improvement of treatment’s
results and its quality, licensing, accreditation, structural
reorganization, improvement of the medical personnel qualifications
(certification, qualifying evaluation, category), etc.
To solve the issues of social-service financing it is necessary to
calculate the populations` need for medical and social services. It is
impossible unless a unified list of social services, their content and
quality is not introduced. In the Republic of Belarus such list in
accordance with the above law is included in the state classifier of
social standarts and norms, which is approved by the Cabinet of
Ministers of the Republic of Belarus and is published in the mass
medias by central executive authorities.
The central body of Belorusian social services are the Ministry of
Labor and The Social Security and The Ministry of Health. These
Ministries are in charge of the development of social security and
social and healthcare services. They are also in charge of implementing
policy in the field under the national guidelines for social and
healthcare legislation defined by the government and the Parliament.
The Ministry manages and supervises social and health services and
formulates policy and strategy for social and healthcare in Belarus.
Social protection schemes in Belarus, as in EU countries, include
the system of mandatory state social insurance against unemployment,
time sickness absence from work, protection in case of an industrial
accident or occupational disease; and also the system of state social
payments (childbirth or funeral benefits). This scheme ensures a certain
level of protection for the workers participating in the scheme.
So, insurance benefits are increasing gradually in the Republic
of Belarus (for example, the size of the benefit for the birth of the
child, benefits for taking care of the child under 3, etc.).
Belorusian budgets are socially oriented at all levels.
National insurance in Belarus is the system of pensions,
allowance and other payments for people of the Republic of Belarus
at the expense of means of the state insurance funds.

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 Citizens of the republic have right to set up a contract for the
voluntary social insurance. Employers have a right to make the
additional social insurance for their workers on own account.
The means of the state social insurance consist of mandatory
contributions of the employers and working people to the state
insurance funds as well as from voluntary donation and other arrivals.
The Fund of social protection of the population of the Ministry
of Labour and The Social Security of the Republic of Belarus (the
Fund) pertains to the state off-budget insurance funds. It is the part of
the public management of the means of the national insurance.
The cash means of the Fund are the property of the republic. They are
not included in the budget of the Republic of Belarus, are not
subjected to withdrawal, and are kept on bank accounts of the Fund.
The central management staff of the Fund, as well as local
administration – regional, Minsk municipal government, municipal,
district and district divisions in the cities are formed to provide the
Fund activity.
The central management of the Fund is its board. The
composition of the Fund board is as follows: the Minister of Labour
and Social Protection (the president), the deputy secretary – the
business manager of the Fund, his deputies, as well as
representatives of the Ministry of Finance, the Ministry of Economy,
the State Revenue Committee, the National Bank, Associations of
the employers and trade unions.
Quantitative and personal composition of the Fund board
becomes firmly established by the Council of Ministers of the
Republics of Belarus. The central management of the Fund is
convened not less than once in quarter. The Fund board is competent
to come to a conclusion at presence no less than two third of the
number of the board members. The decisions are made by the
majority vote of the present board members.
Types of payments on state social insurance in the Republic of
Belarus are as follows:
The insured people are all population of the Republic of
Belarus. Population is provided with:
1) pensions on age, disability, survivor’s pension, long service
pension;

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 2) allowance and compensation connected with industrial
accidents and occupational diseases;
3) allowance, connected with child birth, parental benefit till
the age of three;
4) illness and temporary disability allowance, compensation
for sanatorium-and-spa treatment and health improvement;
5) unemployment benefit;
6) funeral expenses.
The underlying principles of the state social insurance in
Belarus are as follows:
 participation of the working people and the employers in the
state insurance fund formation;
 disposition of funds from the able-bodied people to
disabled, from the working to the unemployed;
 guaranteed pension, allowance and other payments under
legislation;
 equity of the people of the Republic of Belarus regardless of
a social position, race and nationality, sex, language, sort of
occupation, living place in right of the national insurance;
 differentiation of conditions and amounts of pensions,
allowance and other payments of the state social insurance;
 participation of the legal and physical persons`
representatives who pay insurance contributions, in the state social
insurance control.
Annually to the Fund of the social security of the population
required benefit is paid in the determined amounts from the size of
the remuneration of labour fund.
Incomes of the Fund include: contributions from organizations,
enterprises, businessmen; mandatory contributions of the people;
contributions from state budget.
Expenses of the Fund are pensions and allowances for the
retirees; sick pay; allowances for families which bring more than two
children and child benefits; maternity benefit; funeral expenses;
military service pension; etc.
The good model of social protection of motherhood and
children is the model adopted in Finland.
Two of the medical examinations scheduled for pregnant
mothers are linked to social benefits. The examination before the end
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of the fourth month of pregnancy is neded to quality for the
maternity allowance. Mothers can choose to take either a «maternity
package» containing child care items or a cash benefit.
The package is unique for Finland and worths considerably
more than the cash allowance. It contains infant care supplies and baby
clothes. A post-natal check-up is required for the parental allowance.
The benefit is provided for each newly-born. For example, in
the case of a twin birth, mothers can choose either two maternity
packages or two cash benefits or one of each. About 85% of mothers
choose the package.
The amount of the cash benefit is determined by legislation.
The contents of the package varies slightly from year to year
regarding the material and colour of the clothers.
The parental leave system in Finland includes maternity,
paternity and parental allowances. Parents are entitled to maternity
and parental allowances when the pregnancy has lasted 154 days.
These allowances are paid for a period of 263 weekdays.
Mothers have to be resident in Finland for a period of 180 days
before the date of delivery. An application for a maternity allowance
should be made no later than two months before the expected date of
delivery.
The maternity allowance is replaced by a parental allowance
after 105 weekdays. Mother has to take the first 105 days of the
parental leave and the remainder can be used either by mother or
father. If father wishes to use the remaining amount, the consent of
both parents is required.
The size of the maternity, paternity and parental allowances is
calculated on the basis of taxable income, the minimum sum being
approximately 12 euros per day.
In addition, after the birth of a child, father can take up to
18 weekdays off in up to four segments during the maternity
allowance period or the mother’s parental allowance period.
The paternity leave can be extended from 1 to 12 weekdays if
father takes the last 12 weekdays of the parental leave. The extension
is possible a period immediately following the parental leave.
If both parents are employed, one of them is entitled to shorter
working days till the end of the child’s second school year in

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elementary school. An employer can reject this entitlement only if it
may have a significant adverse effect on quality of work.
Parents can also receive a home care allowance for children
under school age. Alternatively, the parents are entitled to municipal
day care, for which there is a charge based on the total gross monthly
income of the parents.
Mother or father is also legally entitled to three years of unpaid
child care leave without losing her or his job. Child allowances are paid
for the maintenance of children under the age of 17 years. These allo-
wances are graded according to the number of children in the family.
In Finland child allowances are paid until a child reaches the
age of 17. The maternity care package is given to every mother who
wants it and has attended a maternity health unit or isited a GP
before the end of the fourth month of pregnancy provided that the
pregnancy has lasted for at least 154 days.
A maternity grant is given to every child in the form of goods or
money. The majority of mothers take this assistance in the form of the
maternity pack, a choice which has an international meaning as the
pack contains requisites the baby needs during its first year of life.
It has been estimated that 15% of mothers take the maternity
benefit in cash. The original purpose of the maternity benefit was to
encourage all pregnant women to visit maternity clinics for guidance
and advice made in good time.

Typical tasks
MEDICAL CARE FOR RURAL POPULATION,
FOR WORKING PEOPLE.
CONCEPT OF REHABILITATION
№1
Please, calculate indicators of morbidity with time sickness
absence from work at factory in 2011, if it is known, that
224 persons were working at factory at 01.01.2011, and 242 persons –
at 01.01.2012;
185 cases of time sickness absence from work have been
registered in 2011, which consisted 1922 days of absence from work.
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 №2
The mid-annual number of factory workers has made
620 persons, including 442 women.
Within a year 112 cases of time sickness absence from work
concerning inflammatory diseases of the female genital sphere,
which consisted 916 days of absence from work, and 41 case
(319 days) concerning complications of pregnancy, delivery and
postnatal period were registered.
Please, define indicators of morbidity with time sickness
absence from work among women as a whole and same indicators
for concrete nosological forms.

№3
Mid-annual number of workers of the enterprise has made
720 persons.
810 cases of time sickness absence from work which consisted
10050 days of absence from work were registered. This number
includes 390 cases (2450 days) diseases of bodies of breath,
195 cases (2105 days) cases of cardiovascular diseases, 52 cases
(711 days) of traumas and poisonings.
Please, define the structure of morbidity with time sickness
absence from work and indicators morbidity with time sickness
absence from work for separate classes of illnesses.
№4
In the area of activities of clinics in a city that supports 60270
adult persons (including 43890 of working age), 410 cases of
primary disability, including 198 cases – of persons of working age,
were registered.
Рlease, identify the indicators of primary disability, including
the indicator for population of working age, and the proportion of
disabled people of working age among all persons with disabilities.
compare the frequency of primary disability in the able-bodied and
disabled age: are significant differences exist?

№5
60,000 population inhabits in the area of activity of clinic,
including 42000 persons at able-bodied age. 410 cases of primary
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disability were registered during the year, including 200 in the
working age group of population.
Please, determine the rate of primary disability for total
population and for working age group.

№6
11800 live children were born alive in the N th area within
a year.
4 women have died during pregnancy and deliveries, including
1 woman have died from abortions which have been made not
in clinic (home or criminal, il-legal abortions). Please, calculate
the indicator of maternal mortality ratio (MMR) and proportions of
maternal deaths from home or criminal abortions.

№7
175 hospital beds for pregnant women and women in
postpartum period and 120 hospital beds for pregnant women with
pathologies of pregnancy are developed in maternity hospital.
5039 pregnant women and women in postpartum period, 2633
women with pathologies of pregnancy were hospitalized in
accounting year, including accordingly 827 and 189 from village.
1 woman has died from bleeding in the postpartum period.
5061 hospital days were spent in total in the branch for
pregnant women and women in postpartum period, and 40262
hospital days were spent in the branch of pathology of pregnancy,
including accordingly 6038 and 3524 hospital days were spent
by women from village.
Please, define
 the maternity hospital bed fund indicators,
 lethality,
 volume (proportion) of work of maternity hospital on the
service of rural inhabitants.

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 LESSON № 5
THEME:
HEALTH CARE MANAGEMENT,
PLANNING AND FINANCING

Questions:
1. Health care: quality, bases of standartization.
2. Health care: Management
3. Health care: Planning
4. Health care: Economy, financing
5. Informatization of health services
5.1 Health care: quality
Quality is a set of characteristics of the object distinguishing it
from other objects. Quality is also the degree of the superiority of the
object consumer properties in comparison with other objects.
High quality of medical aid is one of the main tasks for public
health services. Principal causes of the task superiority have
economical and organizational-legal origin.
Quality of medical aid is a set of the characteristics
confirming the conformity of rendered medical aid to available
requirements of the patients (population), to their expectations, and
to the modern level of the medical science and technology.
WHO, 1988: quality of medical aid is due, according to
standards, carrying out of all actions which are safe, comprehensible
in sense of spent financial means in the given society, actions which
influence death rate, morbidity and disability rates and change other
indicators of the population health.
Medical aid is qualitative (WHO, 1990) when each patient
receives such complex of the diagnostic and medical help which
leads to the optimal results for health of the patient according to the
main diagnosis (basic disease) and the accompanying diagnosis, to
the level of the medical science and such biological characteristics of
the patient as age, heredity, sex etc.

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 The WHO recommends to define the term «medical aid
quality» as the sum of several parameters, such as efficiency,
profitability, and adequacy.
According to WHO recommendations, each patient should
receive such medical aid which would lead to optimal results for his/
her health according to the level of the medical science, age of the
patient, the diagnosis, reaction to treatment provided – so, each
patient has the right to qualitative medical aid. Besides, amount of
the money spent and other resources should be rational, risk of
additional injuries and disability risk should be minimal, and the
result and satisfaction from the process of rendered medical aid
should be maximal.
Characteristics of medical aid quality include the following:
1. The professional competence:
a) presence of knowledge and skills of medical workers and
support personnel;
b) how medical workers use knowledge and skills in their
work, how they are following clinical management principles,
reports and standards.
2. Availability of medical aid should not depend on
geographical, economic, social, cultural, organizational or language
barriers. Parameters of geographical availability: transport presence,
road time, distance and other. Parameters of economical availability:
the guaranteed volume and level of qualities irrespective of patient`s
financial position. Parameters of social or cultural availability:
perception of medical aid in the light of cultural values and creed of
the patient. Organizational availability: optimisation of separate
medical services.
3. Productivity: it is a search of answers to such questions as
following: will the appointed treatment result desirable? Whether the
appointed treatment will lead to the best results in the given
conditions?
4. Efficiency: efficiency in general is the relation of spent
resources to the received results (resources are limited – efficiency is
relative).
5. Continuity: it is getting of medical aid without delay,
unjustified breaks, unreasonable repetitions.

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 6. Safety it is minimising the risks of by-effects of diagnostics
and treatment and of other undesirable consequences of medical aid
rendering (in the relation as for patients, and for medical workers
egually).
7. Convenience - comfort, cleanliness, confidentiality.
8. Optimality.
9. Satisfaction: for patients – it is defined by such factors as
how much medical aid meets patient`s requirements and expectations
and how much it is timely; for medical workers - it is defined by
necessary conditions in the medical aid organization, by size and
form of the payment.
Components of medical aid quality are the following:
1 – Structural quality, or quality of structure, is a component of
quality of the medical aid, describing conditions of its rendering.
Levels of its estimation are the following: the medical
organisation as a whole; the medical worker separately.
Estimation of the medical aid quality at the first level (the
medical organisation as a whole) includes: conditions of buildings,
premises, conditions and rationality of the medical equipment use,
level of medical products and products of medical appointment
security, service, personnel maintenance and other.
At the second level (the medical worker separately) the quality
of structure is presented by professional qualities of the medical
worker, namely the sum of theoretical knowledge, abilities, skills of
performance of concrete medical-diagnostic manipulations.
2 – Quality of technology, or quality of process, is a component
of the medical aid quality, which reflects the process of its rendering.
Level of estimation is connected to the concrete patient with
the account of the clinical diagnosis, kinds of accompanying
pathologies, age and other factors.
Quality of technology includes:
 observance of medical aid standards;
 a choice of tactics from the moment of the diagnosis
statement untill the treatment termination;
 conformity of a complex of medical-diagnostic actions to the
concrete patient, standards of medical technologies (process should
be optimal);

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  conformity of expenses to medical-economic standards
(if expenses are excessive - the help is a poor-quality one);
 presence or absence of medical errors.
3 – Quality of result is a component of the medical aid quality,
which describes the result of its rendering. Levels of estimation are
distinguished in relation to the concrete patient; in relation to all
patients of the medical organization; in relation to the population as a
whole.
At the first level (in relation to the concrete patient) the quality
of technology is estimated by the following results: how much
results of treatment reached are close to the expected with the
account of the clinical diagnosis, age and other factors influencing
outcomes of the disease (results of treatment: recover, without
changes, with deterioration, with improvement, with stable disability,
lethality, or transfer in other medical establishment).
At the second level (the quality of medical aid in the relation to
all patients of the medical organization) it is estimated based on
quality indicators of establishment activity during a year, or on
models of ultimate results.
At the third level (the quality of medical aid in relation to the
population as a whole) it is estimated on the indicators of the
population health.
Medical aid quality management is the organization and the
control of activity of public health services system for maintenance
of available and prospective requirements of the population in
medical aid and for satisfactions of consumers (Russia).
Quality management is a system approach to transformation of
medical organization management according to occurring changes,
current working situation and the pressure caused by changes.
The control system of medical aid quality is a set of
organizational-administrative structures and the actions which are
analyzing, estimating and correcting conditions, process of rendering
and result of medical aid for maintenance to the patient of qualitative
medical aid in the volumes provided by territorial programmes of the
state guarantees.
Principles are the following:
 the continuity;

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  use of evidence–based medicine achievements;
 carrying out of medical aid quality examination on the basis
of medical standards (reports);
 use of economic and legal methods for quality management
of medical aid;
 unity;
 monitoring;
 the analysis of economic efficiency on achievement of an
optimum level of medical aid quality;
 studying of public opinion.
Kinds of activities on medical aid quality management are the
following:
1. Continuous improvement of quality. It is a complex of
actions carried out by the medical organizations with the purpose to
increase their activity efficiency and productivity, to perfect all
indicators of public health services activities (at the medical
organization level, level of separate divisions and separate
employees).
2. Quality provision. These are the kinds of activity, planned
and regularly carried in the medical care quality management system
limits with condition of their acknowledgement and in the presence
of confidence that the object will carry out planned requirements to
quality (such as the standard-legal base, according to it - structures
and resources, technological standards and the control of their
performance).
3. The design of quality is an activity on creation the system of
qualitative medical aid. It includes the following points:
a. Who is the consumer of medical services.
b. An establishment of consumers` needs.
c. The description of the result answering to consumers needs.
d. Structure of system for the result achievement.
e. Transformation of the plan into action.
4. Quality assurance (quality control) are methods and kinds of
activity of the operative character, used for an estimation of
requirements to quality performance, its measurement and monitoring.
The monitoring system of medical aid quality consists of the
following components:

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  Participants of the control (those who carry out the control).
 Control devices (by means of what the control is carried out).
 Control mechanisms (how the control is carried out).
Participants of the control can be divided in the three groups:
 participants from manufacturers of medical services;
 participants from consumers of medical services,
 participants of the control from the independent
organizations of consumers and manufacturers of medical services.
According to the second classification, there are following
kinds of control:
1. State control.
2. Professional control: internal (departmental), external (non-
departmental), independent (auditor).
3. Public control.
4. Control of the patient.
Control devices are more than ten. The core among them are:
 Medical standards.
 Indicators of activity of the public health services
organizations.
 Expert estimation of quality.
Medical standards have a number of advantages. So, they are
more objective (in comparison with an expert estimation). They are
characterized by higher «throughput» (cover simultaneously more
number of objects). Lacks of medical standards are the following:
considerable financial and labour expenses for working them out; not
always it is possible to work out standards which could consider all
the variety of factors.
The expert estimation has the following advantages: research
demands less means, the expert can consider variety of factors.
Lacks of the expert estimation are: the big greater degree of
subjectivity, low «throughput».
Activity indicators as a control device of medical aid quality
possess two basic advantages: their working out and estimation of
quality by means of indicators not demand expenses, they are
objective. The small scope of indicators limits possibilities of their
use in estimation of medical aid quality.

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 Control mechanisms:
1. Licensing of kinds of activity.
2. Accreditation of medical-preventive organizations.
3. Certification of medical products, iatrotechnics.
4. Certification of organizations for medical workers education.
5. The control of professional qualities of medical workers.
Examination of medical aid quality can be planned, off-
schedule, complex.
The algorithm of examination of medical aid quality includes
an estimation of sufficiency and timeliness of appointment and
carrying out of diagnostic actions, correctness and timeliness of
statement of the diagnosis, adequacy of the medical actions,
corresponding registration of the medical documentation at three
basic levels: the head physician, the assistant to the head physician,
the manager of department.
According to Position about a control system of medical aid
quality to the population in medical-preventive organizations of the
Republic of Belarus (confirmed by the Ministry of Health of the
Republic of Belarus on December, 26th, 2001), the object of
management is the medical aid representing a complex of preventive,
medical-diagnostic, rehabilitation actions, spent according to the
certain medical technology providing achievement of concrete result
by the most rational way. The control system of medical aid quality
includes:
1) standard documents;
2) licensing;
3) organization of control;
4) techniques of quality and efficiency estimation;
5) analysis of quality.
Principles:
 integrated approach,
 objectivity,
 reliability,
 productivity,
 organizing role of a control.
Medical aid quality assurance includes:
 the Estimation of the conditions and using of the personnel
and material resources in the medical-preventive organization;
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  Examination of the process of medical aid rendering to
concrete patients;
 Studying of patients` satisfaction by medical aid rendered to
them;
 Revealing of the reasons promoting occurrence of defects of
medical aid rendering and negatively influencing its quality;
 Calculation and analysis of the indicators characterizing the
quality of medical aid.
Dimensions of quality assessment, according WHO
recommendations, are following:
 Structure – refers to the characteristics of medical personnel,
the organizational setting, and physical resources.
 Process of care is the manner in which health care
professionals diagnose disease and implement treatments.
 Outcome assessment is an essential and expanding area of
health care research because it assesses the ultimate result of medical
care. The complex factors that affect outcome make difficult the
evaluation of outcomes. Socioeconomic status, level of education,
compliance and health beliefs all have an impact on the outcome of a
treatment course.
The concept of availability of medical aid, according to the
WHO, is characterized by the following parameters:
1) security of the population with medical personnel (doctor/
population ratio, nurse/ population ratio);
2) security of the population with hospital beds (beds/
population ratio, or number of hospital beds per 10000 of
population).
For practical purposes cost-effectiveness is an essential
component of effective and quality care.
Cost-effectiveness attempts to relate the quantity of resources
expended in the pursuit of a given outcome with the desirability of
the outcome. Cost-effective medical care implies that the outcome of
a medical intervention (e.g., immunization) is less costly than
treating the complications of the disease.
All the factors determining achievable improvement of the
health state of the population, time expenses and economic
efficiency of all kinds of the used resources, are taken into account at

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the complex approach to medical aid quality. The quality management
system can be considered as the activity aimed at creation the
conditions of medical aid provide to the population, allowing to carry
out the guarantees declared by the state according to the established
criteria and parameters of quality in the view of satisfaction of the
population in the received medical aid. Final quality is created while
using qualitative processes, materials and tools.
The quality estimation of medical aid should have complex
character and provide:
 Comparison of the applied medical technology with the
disease severity and features of its current;
 Conformity definition of the applied medical technology to
the commonly applied one (or to the standard);
 Estimation of the applied medical technology in indissoluble
connection with the ultimate result of its application.
The technique of carrying out the quality assurance
examination in public health services in Belarus is well organized.
Quality assurance of medical aid rendering is carried out by means of
expert method by the officials of medical-and-preventive
organizations (heads of organizations, heads of departments); staff
and non-staff experts of public health services state control organs.
The first step of control is the estimation of medical aid quality,
which carried out by the heads of the structural divisions. Within a
month, heads of the structural divisions of hospitals carry out
examination of not less than 40% of the finished cases. Heads of the
structural divisions of the out-patient-polyclinic organizations carry
out quality examination of medical aid rendering both in the finished
cases of treatment, and in its process. Not less than 10% of all
finished cases of treatment in the given department of the medical-
preventive organization are subject to the monthly control.
Examination of medical aid quality is carried out by heads of
deputy of the organization at the second step. Experts of the second
step carry out a selective expert appraisal of medical cards of both
out-patients and inpatients of the department, subordinated to them
in volume of not less than 30-40 cases within a month.
To the expert control in the second and third stages the
following subjects are necessary:
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 In a hospital – cases of lethal outcomes, cases of intrahospital
infectioning and complications, cases of diseases with unreasonably
lengthened or shortened term of treatment, cases of hospitalization in
the not profile department, cases of repeated hospitalization
concerning the same disease within a month, cases of complaints
(of patients or their relatives).
In the out-patient polyclinic departments – cases of lethal
outcome at home, neglected cases of oncological diseases and
tuberculosis, cases of physical inability of children and persons of
able-bodied age, cases accompanying with complaints of patients or
their relatives.
Members of clinical-expert commissions are carrying out
examination of medical aid quality at the third step of the control.
The main staff and non-staff experts of the Ministry of Health,
regional managements of public health services carry out an expert
estimation of medical aid quality at complex target and control
checks of the treatment-and-preventive organizations, and also by
preparation of materials on medical-supervisory commissions
(the fourth step of the control) of the corresponding level.
During examination of medical-diagnostic process expert
estimates the quality of completeness and timeliness of diagnostic
actions, correctness and accuracy of diagnosing, adequacy of choice
and duly assignment of medical and rehabilitation actions according
to the diagnosis and an objective state of the patient’s health, reveals
defects and establishes their reasons.
As the criteria of estimation of the public health services
organizations activity in general and its separate parts, the estimation
technique of the medical-preventive activity is applied on the basis
of models of ultimate results (MUR).
Model of ultimate results is the sum of the parameters for
estimation of medical-preventive organizations activity.
MUR includes two types of parameters, describing the result
of activity:
1) The parameters of productivity:
a) reflecting the population health;
b) describing polyclinic or hospital activity.
2) The parameters of defects.

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 The parameters of productivity characterize the level of
achievement of the purposes by this or that service, department, and
organization of public health service.
The parameters of productivity which are reflecting the
population health are following:
 crude death rate;
 hospital lethality parameters;
 morbidity rate;
 morbidity with time sickness absence from work;
 primary invalidity (first handicapped) rate (on 10 000 of the
population);
 primary invalidity (first handicapped) structure: on groups, age;
 proportion of change of the long-time or proof disability
group while reexamination; etc.
The parameters of productivity which are describing the
polyclinic activity are as follows:
 coverage (proportion of really captured from total of the
persons who are subject to some intervention) of immunization of
adult population;
 coverage of the population by preventive examination;
 coverage of the disabled persons by rehabilitation;
 doctor/ population ratio; etc.
The parameters of productivity which are describing the
hospital activity are as follows:
 Number of days of bed's employment during a year
(or occupancy of the bed).
 Percent of bed’s fund using (in %).
 Average length of patient`s stay on the hospital bed
(the average in-patient length of stay).
 The bed turn-over ratio.
The parameters of defects are as follows:
 Proportion of the patients which are revealed in neglected
stages of disease (especially for tuberculosis, cancer, cardiovascular
diseases etc.).
 Divergence (in %) of clinical and pathological-anatomical
diagnoses.
 Frequency of justified complaints.

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 Parameters of defects take into account the most rough
infringements in activity of the public health services organizations
and (as the parameters of productivity) are individual for each type
of the medical organization.
Besides that, MUR includes:
1) predicted level (that is the level with which we should
compare the parameters);
2) the scale of parameters of a numerical estimation of the
activity results.
The estimation of medical aid quality in general is the
estimation of difference between quality of medical aid to the patient
(or to the patients) rendering by the concrete doctor, department or
medical-preventive organization, and a level of defects during work.
Quality parameters of medical aid of structural departments are
calculated as average arithmethic-values of quality degrees of
doctors work corrected in view of experts opinion.
Quality of medical aid can be defined from the point of patient.
Medical aid quality from the point of patients is defined by two basic
parameters: quality of treatment and quality of service. Studying of
public opinions on the quality and the organization rendered by a
polyclinics and hospitals medical aid is carried out in the medical
organizations and on the residence. Sociological researches can be
carried out with use of single-moment or current gathering the
information by a continuous or selective way depending on the
capacity of the medical-and-preventive organization and the
purposes of research. The factor of social satisfactions (number of
patients, satisfied with the given kind of aid, is taken as the
numerator, and the general number of surveyed patients is taken as
the denominator) is calculated for each of studying points.
5.2 Bases of standartization
Standardization in public health services is the activity
directed on achievement of optimum degree of streamlining in the
system of public health services by working out and an establishment
of requirements, norms, rules, characteristics, conditions,
technologies at the process of manufacture and realization of medical
goods and services.

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 Functions of standardization are the following:
1. Economic:
 granting of the information about production and its quality;
 assistance to competition by means of test methods
standardization and unification of production parameters that allow
to spend its objective comparison;
 maintenance of compatibility and interchangeability of goods
or services of different kinds;
 management of technological processes rationalization.
2. Social:
Provides definition of such level of services which would
correspond to the requirements of public health and to its protection.
3. Communicative:
Provides creation of base for objectivization of various kinds of
human perception of the information, and also unification of terms.
The standard is the standard document regulating a set of rules,
norms and requirements to the object of standardization and
confirmed by a competent official body.
There are two types of standards in public health services:
medical (clinical) and social.
Clinical (medical) standards are worked out to diagnostic,
treatment and rehabilitation procedures for patients, who suffer from
certain disease (clinical-statistical groups). Medical standards can be
defined as quality standards, too. The quality standards are
developed for each disease treated in a polyclinic and in a hospital,
for healthy, sick with acute and sick with chronic diseases.
The quality standards include the standard of treatment, the standard
of health state of the patient finished treatment, the standard of
inspection and diagnostics.
As the minimal social standards in the field of public health
services, the state establishes the following:
 Specifications of budgetary financing of charges on public
health services on one inhabitant;
 Norms and specifications of material, drugs, personnel
maintenance, feeding, regimentals, soft stock in the state
organizations of public health services of various types and kinds;
 Norms and specifications of privileged providing with

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medical products, artificial limbs, dressing means and subjects of
medical purpose;
 Formation of the services list on rendering the stationary,
out-patient (polyclinic) and fast (urgent) aid.
Kinds of medical standards are the following:
1. On dependence from administrative-territorial division:
 international;
 national;
 territorial;
 local.
2. On departmental belonging:
 state;
 branch.
3. On objects:
 Structurally-organizational standards – standards which
establish obligatory requirements to the conditions of medical aid
rendering.
 Professional standards – standards which establish obligatory
requirements to professional qualities of the medical worker.
 Technological standards – standards which establish the list
of necessary medical-diagnostic manipulations on supervision of
patients with concrete diagnoses with the account of sex, age and of
some other factors.
4. On the mechanism of using:
 simple – one standard;
 group – a complex of hierarchically connected standards.
5. On the maintenance:
 standards of patients conducting,
 standards regulating actions of the medical personnel in
definite situations (rendering of emergency medical aid, performance
of manipulations);
 standards regulating conditions of various kinds of medical aid
rendering (material equipment, sanitary norms and rules and others);
 standards of technology requirements to manufacturing,
application of medical products and iatrotechnics;
 the standards regulating the requirements to the level of
vocational training and professional medical education.
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 Standardization principles:
1. Consensuality: all the subjects – participants of
standardization processes should aspire to uniformity of form and
maintenance of standard documents.
2. Uniformity.
3. Expediency.
4. Integrated approach and checking.
Objects of standardization:
1. Medical services.
2. Manufacture, conditions of realization, quality, safety of
medical products and iatrotechnics.
3. Requirements to the personnel.
4. The registration and accounting documentation.
5. Information technologies.
The basic standard documents regulating activity on
standardization of public health services in the Republic of Belarus
are: Law of the Republic of Belarus «About the state minimum
social standards» (1999), Law of the Republic of Belarus «About
technical rationing and standardization» (2004).
5.3 Health care: Management
The term management means to manage, to achieve the given
purposes by using work, motives of behaviour and intelligence of
other people.
This term is used in many senses: it is sometimes confused with
such terms, as «administration» or «organization», sometimes – with
leaderships. The widely prevalent view is that administration broadly
means «getting things done», and management «the purposeful and
effective use of resources – manpower, materials, finances – for
fulfilling a pre-determined objective». Administration is more
common term than management that reflects depersonalized control
system. A manager works in point of a particular person.
«Governance» is a way that helps the organization to set the
direction of activity, decide about people, priorities, programs and
services. The leader sets up the idea, the manager provides its
realization.

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 «Business» is an activity, directed to gain profit with the help
of formation and realization of the definite production or services.
Businessman is a person who makes money.
Occurrence of management is dated by IX century B.C.
The first period of management development was the ancient
period (from IX-VII centuries B.C. till XVIII century A.D.).
Management was considered only as the practical skill in this period.
Monuments of effective management of the Ancient period are the
Egyptian pyramids and ancient temples. Experience of skill to
manage have been described by Plato and Socrates.
The second historical period of management development is
connected with manufacture occurrence. It is the industrial period.
The third period is connected with appearance of schools of
management. Development of management as the science was
started during this period. It is the period of systematization.
The next one – the information period – is connected with
application of mathematics and computers in management.
Occurrence of schools of management is dated XIX century
A.D. Main schools of management are as follows:
1) School of scientific management (was founded by
F. Taylor, the main service of the school is that the management was
proved as the science).
2) Classical, or administrative school (was founded by
A. Fajol, the main service of the school – principles and functions of
management were based).
3) School of «Human relations» (or «Behavioral school»).
Psychological and sociological principles and methods are put in the
basis of the school. The school was founded by E. Mejo.
4) School of social systems. Was connected with appearance
of system analysis and theory of systems.
5) Quantitative school. It connected with application of
mathematics and computers in management and was founded at the
information age.
Particularities of management as a science are as follows:
a) scientific method;
b) systemic orientation;
c) using of the models.

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 Modern trends of management as science and practice are as
follows: globalization; general spreading of the strategic
management (the long-term plans, competitive ambience).
Consciousness of importance of material, technological base;
increasing the role of productivity, quality (reengineering). Terms
“familiar to everybody” – missionn (the main task defining its
purpose itself), vision (an image of the enterprise in future),
benchmarking (the target landmarks of activity not behind of the
leading companies).
According to Peter Druker, management is a process of the
planning, formation, motivation and control that are necessary to
state and reach the goal of the organization. It is a special kind of
activity that turns the disorganized crowd into the effective,
purposeful and productive group.
Management consists of four basic functions (activities):
 planning (determining what has to be done);
 organizing (setting up the framework or apparatus and
making it possible for groups to do the work);
 communicating or motivating people to work;
 monitoring and controlling – checking to make sure that the
work is satisfactorily progressing.
Management functions, principles and laws are familiar in
industry, business, defense and other fields, including health care.
The current emphasis by WHO is on improving the efficiency of the
health care delivery systems through the application of modern
management methods and techniques.
The basic historical instruments of management are the following:
 hierarchy: the main source of influence is the pressure on a
person by means of enforcements;
 market: a network of the equal horizontal relations based on
products and buying and selling services; on relations of the
property, on balance of interests, on equal position of the seller as
well as the customer;
 culture: this instrument is produced and acknowledged by
the society, organization, group of same interest, social rates,
installation that force a person to behave so, rather than otherwise.
One usually singles out objects and subjects of management.

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 The subject of management is a body or a person who is
carrying out managing action.
The subject of management has a power – an ability to
influence separate personalities and groups, turn their efforts to
achievement of goals of the organization. Influence is a behaviour of
one individual which introduces changes into behaviour, relations,
feelings etc. of the other individual.
Types of power are as follows: official (the official job titles);
unofficial (without official authorities).
The power is defined by the job title. The personality can
enlarge and reduce the manifestation of power and the degree of
liability. «Coincidence of the position and personality» creates the
normal work environment.
Management style is an individual way of the management
activity realization. One can distinguish such styles as:
1) the authoritarian style (administrative-command forms of
leadership, authority centralization, individual management decision-
making);
2) the liberal style (formal, anarchistic, with connivance) is the
style when the leader is aside from the working group, minimum
interference, low level of the requirements; initiative is not
suppressed and is not encouraged;
3) democratic style is the style of decentralization of control,
collective taking of decisions, high tactfulness of contact,
amicability, endurance, support.
The optimal style is dynamic, that is characterized by clear
position, creative approach, scientific validity, flexibility, efficiency,
irreconcilability to defects, advertency to people, handhold on
masses, absence of subjectivism and formalism.
The subject of management in public health in Belarus are
specialists on public health and public health services, with specialty
in public health management and qualification; and institutions of
public health (double subordination: the Health Ministry and
Regional Executive Committees).
Levels of control are as follows:
1. Strategic (institutional). Control of the highest level is a
chief doctor.

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 2. Tactical (managerial). Control of the middle level is a
deputy of the chief doctor
3. Operative (technical). Control of the lower level are heads of
subdivisions (departments) without subordination with other leaders
(a head of department, chief nurse).
To wide extent an «ordinary doctor and a nurse» are also
leaders because they exercise control of patients.
The object of management is the organization or its part on
which managing action is directed (for example, organization of
Public Health services is the object of management).
The organization is a group of people, whose activity is directed
at some general purpose. The obligate requirements to organization
are as follows: presence of two people, who consider themselves
being a part of a group; presence of one purpose, which takes as
general intent by all members of the given groups; presence of the
members of the group, which suppose to reach significant purpose.
Any organization as the object of management passes through
five phases of development:
1) birth, when the main purpose is to survive, the main tasks
are to advance on the market and to achieve the profit, and crisis of
the management style (management by one person) are typically;
2) childhood and youth, when the purposes are to grow and to
achieve maximal profit and to capture the part of the market;
3) maturity, when image of organization is formed and
delegation of powers is typically;
4) ageing, when the main problem is to keep results and
positions;
5) death or revival (rejuvenation).
Any organization as the object of management has several
generalized characteristics.
The main features of the organization are as follows:
1. Facilities (resources): people, finance, technologies,
information, material and others.
2. Dependency a external ambience: terms, legislation, value
system, traditions, trade unions and others.
3. Horizontal division of labor: division of labor (the
production process) on the forming components (the diagnostics,

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treatment, etc.; admission to hospital; drugs; diagnostics, etc.).
Horizontal division of labor creates the subdivisions that performe
their own functions.
4. Vertical division of labor is necessary for co-ordination of
actions.
Success of the organization is the achievement of the tasks,
goals, purposes.
Any organization as the subject of management depends on the
environment. All factors of the environment are interconnected and
can be divided into external and internal.
External environment of medical organization include
authorities (politics, technology, society), population as the medical
services clients, competitors (conjuncture of the market), trade
unions, etc. Transformation of medical and pharmaceutical service
into the goods, having the cost and the price, was the main feature of
market relations development in public health services. The relations
are connected with commencing of health protection, increasing the
volume of paid medical services in public health services, formatting
of competitive environment in health care.
Internal environment factors of medical organization are as
follows:
1) Purposes and tasks.
2) Resources: people (stuff or personnel), materials and
finances, technologies and information, economic mechanism of the
organization.
3) Organizational culture.
Administrative (or manager) work has several generalized
properties, such as brain-work- character, work with information,
administrative decisions as the result of the work.
Administrative work is realized from specific methods, such as
follows: economical, social-psychological, organizational-
instructional, self-government as the method of management.
Organizational-instructional, or organizational-administrative
methods refers on regulation, normalization and instructing, they
include such means, as instructions, sanctionations (orders) and
recommendations.

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 The special responsibility of taken decisions, complexity of
prognosing the remote consequences of administrative decisions,
impossibility or difficulty of correction of uncorrected administrative
decisions are characteristic for management in health care.
Management functions on three levels:
1) technical – local or the lowest level of management;
2) administrative – average level;
3) institutional – supreme or the highest level of management.
Managers of all levels work for final desirable result
achievement – for implementing organizational purposes.
One can single out several generalized features or
administrative roles at the work of managers on any level.
Cardinal models of administrative education are as follows:
1. Traditional (German) model is based on the idea of training
the qualified leaders. It includes: higher professional education,
upgrading the qualification (widespread in Russia).
2. American model is based on professional manager training.
It supposes getting higher professional education in the field of
management on the basis of the diploma of general higher education
(Master of Business Administration).
3. Mixed model (Italy, France and others).
Management in public health is a science of administration,
regulation and supervision of the financial, material and labor
resources of medicine. The purpose of management is improvement
of public health. The task of management is the most efficient
achievement of purposes by increasing the quality of medical-
preventive actions and rational use of public health resources.
Management process in public health services (or in any field
of activity) includes such parts as: definition of the purpose,
gathering of information, development of administrative decision
and control.
Administrative decisions in public health services may be
social, medical, administrative-organizational, administrative-economic.
The requirements for the effective administrative decision are as
follows: competence, practicality, timeliness, concreteness, flexibility.
Control is the compulsory component of any effective decision.
It is the process of maintenance of the purposes achievement by the
organization (or by the employee).
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 Particularities of management in public health are social
significance of the results, difficulty of the quantitative indices for
assessment using, particularities of financing, particularities of the
personnel (different professional groups, specialization), particularities
of control objects, particularities of external factors. Main object of
control in public health services is the medical aid quality.
5.4 Health care: Planning
Health care planning is the scheduled working out of the
system of actions on health services of the population. The general
purpose of health care planning is the coordinated and
comprehensive provision of medical treatment, prevention of
disease, and promotion of health. Planning activity is directed on
improvement of quality and efficiency of the medical and preventive
help to the population, and achievement an optimum ratio between
the need of the population in medical aid and the opportunity of it
satisfaction.
The purpose of planning is to match the limited resources with
many problems, to eliminate wasterful expenditure or duplication of
expenditure, to develop the best course of action to accoumplish a
defined objective. Planning and management are considered essential
if higher standards of health and health care are to be achieved.
The resources (the manpower, money, materials, skills, knowledge,
techniques and time are needed or available for the performance of
planning action, can be readily wasted if there is no proper planning
and management.
The main purpose of health care planning is to meet the health
needs and demands of the people. Health needs are the deficiencies
in health that call for preventive, curative, control or education
measures. The health needs as seen by the people are not exactly the
same as seen by experts.
Forecasting is a prediction advancing display of the validity.
It is based on the knowledge of laws of nature, society, human
thinking. Scientific forecasting leans against knowledge of objective
laws, expert estimations, logic, a trustworthy information,
mathematical methods (modelling), however does not deny also
intuition, supersensual perception.

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 The futurology is a science about the future – is engaged in
forecasting bases.
Depending on the degree of concrete definition and the
character of influence on a course of investigated processes one can
distinguish the hypothesis, the forecast, the plan.
Hypothesis – is a scientific prediction at a level of the theory,
revealing of the general laws.
The forecast – is more defined and is authentic, but
nevertheless is probabilitable and multiversiable because of
uncertainty. Scenarios of possible development are made out in the
presence of alternatives of the plan realization. The scenario is the
description of the future made with the account of plausible
positions, it is developed for a certain set of conditions of the future
development. As the forecast is under construction on likelihood
succession of events, it can presuppose optimistic, pessimistic, or
optimum-realistic scenarios.
The scenario establishes a logic sequence of events. It is
developed by functional-logic method, is of system character and
reveals the factors, allowing to reach objects in view.
The forecast is a complex of proved assumptions (which are
expressed in qualitative and quantitative forms) concerning the
future parametres of the system.
The aim of the forecast is to give objective, authentic
representation of events that will be with the system under those or
other conditions. From here comes the origin of a search forecast.
Such kind of the forecast shows what can be with the system of
public health services development under the set conditions in
advance. It is a passive role of the forecast. The active role of the
forecast is illustrated by target forecasts. Target forecasts define the
purposes put by the state, a society before public health services, and
also ways of their achievement.
Forms of forecasts are the following:
1. On forecasting time:
 operative (flowing);
 short-term (annual);
 perspective (intermediate term – five years, long-term – ten
years and more).

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 2. On the character of their influence on object of forecasting:
passive, active.
 global, international;
 national;
 regional (regional, areal, local, city-level, etc.);
 for separate groups of the population and individuals.
3. On complexity of objects for forecasting:
 supersimple (when predict separate indicators without the
account of their interaction);
 simple (when only pair relations are considered at forecasting);
 complex (when the diversified interrelations of indicators
and factors influencing the system are considered at forecasting).
4. Depending on the purpose:
 research (search);
 standard (program, target).
5. On ways of the results representation:
 dot or momental (when event during certain time is
predicted);
 interval (when events are in some time interval).
Forecasting methods total more than 150. All of the methods
can be united in four groups:
1. Expert estimations,
2. Modelling,
3. Extrapolation,
4. The combined methods.
Beside these, the system analysis and synthesis apply at an
initial development cycle of forecasts. Its stages are:
 statement of a problem,
 definition of the purposes and criteria of estimations,
 the structural analysis of factors and tendencies (allocate the
factors connected with general economical situation, with public
health services activity, the factors formed under the influence of
market relations and state regulation),
 working out of the conception.
The plan is an administrative decision which if properly issued
includes the precisely defined purpose, the prediction of end results,
ways and means of the purpose achievement.

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 Planning in public health services is the purposeful activity of
the state control organs and public health services organizations on
working out of public health services system perspectives of
development.
Designing is the creation of concrete samples of the medical
goods and services in the future.
The project is a decision concerning any action or
corresponding aspect of the program.
Distinctions between forecasting and planning:
Forecasting has a likelihood, probabilitable character,
planning – a determined one.
Forecasting does not contain obligatory indicators, planning
has directive (obligatory) value.
Forecasting is of information character, and planning is
functional.
5.4.1 Planning in public health services: classifications,
principles, methods
Public health services planning is rational and effective using
of material, labour and financial resources in branch, for the purpose
of the fullest satisfaction of the population in medical aid according
to economic possibilities.
The primary goals of planning are:
 Proportional provision for the population of medical aid
volumes and kinds, and consequent formation of the network,
personnel, financial streams.
 Proportional development of public health services.
 Perfection of public health services forms and management
methods.
Principles of planning are the following:
1. Instructionity (directiveness),
2. Integrated approach,
3. Allocation of priorities,
4. Observance of the state and society interests,
5. Scientific and technical validity,
6. Economical efficiency,
7. Combinations of perspective and routine planning,
8. Combination of branch and territorial planning.
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 Kinds of public health services planning:
1. On terms:
 strategic. It defines the purposes, problems, priorities, an
order and conditions of activity of public health services for 10 years
and more. An example of a long-term plan is the Conception of
public health services development in the Republic of Belarus;
 perspective - for 3-5 years;
 flowing - it is carried out for a year, annually.
2. On how the plan is made:
 Directive - it is carried out by means of address tasks and
distribution of resources necessary for their performance. The basic
levels of directive planning: budgetary financing, limits of capital
investments, funds of material resources, the state orders.
Instructionity (directiveness) means compulsion of the plan
performance. Executors cannot solve independently a problem about
the maintenance, dates of performance.
 Indicative planning is one of the forms of involving the
organizations of public health services in working out the plans and
development programs on an equal bases with the state control
institution of public health services. It is based on a system of special
indicators and economic mechanisms of influence on the public
health services organization valid for working out and realization of
the plans.
 Contractual planning regulates commercial relations
between the organizations of public health services and other
organizations on a voluntary and mutually advantageous basis.
 Enterprise planning - one of the management functions
directed on substantiation and choice of ways of effective
development within the limits of enterprise activity.
3. On a planning orientation (on what it is directed):
 Program-target planning provides the system approach,
allows to direct each action on definite purpose performance.
 Functional-branch planning can be carried out by the
supreme bodies of management of public health services.
Basic methods of planning are following:
1. Analytical.
2. Normative.

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 3. Balance.
4. Economical-mathematical.
5. Experimental.
Analytical method – planning on the basis of studying of
public health indicators and results of medical institutions work. This
method provides the analysis of initial positions, the analysis of plan
tasks and problems, of rates and proportions in the public health
services development, the analysis of prospective results of the plan
performance.
Normative standard method is planning of public health
services on the basis of specifications. It is applied to calculation of
forecasted and planned targets. Normative method is based on the
normatives – specifications, that provide comparability and uniform
estimation of various levels and rates of public health services
development.
Norm is the established and documentary confirmed size
defining a maximum level for the expenditure of resources, receiving
of incomes and profits, output of production.
The specification is a settled size of expenses of the material,
labour, time, financial and other resources applied at rationing of
work and planning of industrial and economic activities.
The basic specifications for a medical-preventive organization
activities are the specifications of requirements for the out-patient
(polyclinic) and in-patient (hospital) help, regular specifications,
specifications of medical staff work, specifications of material
maintenance, financing specifications.
Requirements to specifications: scientific validity, stability,
long term.
Classification of specifications and norms:
1. On the character of their establishment:
 Directive (obligatory) – developed by higher bodies.
 Facultative – establishhed by medical organizations.
2. On their content:
 Material – establishing the level of expenses in material
(natural) expression (the expense of the energy carrier on 1 m3,
quantity of sets of linen per one hospital bed, the expenses for a food
per 1 hospital day, etc.).

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  Financial – establishing level of expenses in money terms
(financing for one inhabitant).
 Time – the specification of time of rendering of the out-
patient-polyclinic help and others.
3. On the degree of integrity:
 Private – norms and specifications on separate articles of
expenses or elements of expenses,
 Summary (integrated) – full expenses for one post, for one
hospital bed.
4. On methods of working out:
 Calculated (tariffs for medical services, specifications of
formation of a salary payment fund, etc.);
 Averaged (norms for the expense of fuel, major repairs and
other).
5. On the form of expression:
 Absolute (financing specifications on one inhabitant),
 Relative (doctor-population ratio and others).
As a basis for plan formation following data can be used:
estimated figures – are brought to notice of medical-preventive
organization as reference points for the purpose of definition of
planning role and place. Should provide achievement of social
guarantee to the population in health preservation and improvement.
Estimated figures include:
 Population number and structure,
 Volume of medical services carried out by medical-
preventive organization,
 Indicators of technical equipment,
 Indicators of social development of the population.
Besides estimated figures, the state order, long-term economical
specifications, limits can be used also as a basis for plan formation.
The state order is issued for input, reconstruction, technical
updating according to the established sanitary norms at the expense
of public funds and capital investments.
Long-term economical specifications should provide
interrelation of public interests with interests of medical-preventive
organization (specifications of budgetary financing, specifications of
a wage (salary) fund formation and others).

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 Limits establish the limiting size of the state centralized capital
investments.
The balance method. This method is applied to a substantiation
of proper correlations between plans for development of public
health services in various economic-administrative areas of the
country. The balance method of planning allows to co-ordinate
requirements of the population for those or other kinds of medical
aid to their resource maintenance. The system of balances includes
their following kinds: natural (material), cost (monetary), labour
(personnel), interbranch.
One distinguishes the certain kinds of balances:
 balance of the plan of construction and introduction in the
network of new medical organizations;
 balance of population need in medical staff and of their
preparation plan;
 balance of newest technical equipment, manufacture of
newest medicines and medical toolkit development and of the plan of
public health care material support.
The economical-mathematical method of planning is widely
applied at regulation of expenses for medicines, foodstuffs, soft stock
and includes:
 the establishment of specifications of expenses based on
actual expenses of the previous period with application of the
correction factor reflecting a rate of inflation;
 the establishment of the specifications reflecting the share of
expenses for separate kinds in a total sum of financing;
 the updating of cost specifications operating before with the
inflation account;
 the working out of cost specifications on the basis of norms
of resources expense in natural expression.
Planning in its broadest sence includes three steps: plan
formulation, execution, and evaluation. Effective planning demands
of other fields specialists (such as economics, statistics, sociology,
management, etc.) participations.
Any plan consists of five major elements: objectives, policies,
programmes, schedules and budget.
An objective is precise – it is either achieved or not achieved.
It is a planned end-point of all activities.
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 A programme is a sequence of activities designed to implement
policies and accomplish objectives. A programme gives a step-by-
step approach to guide the action necessary to reach a predetermined
goal.
A schedule is a time sequence for the work to be done.
Policies are the guiding principles stated as an expectation, not
as a commandment. Policies are interconnected with procedures – a
set of rules for carrying out work which, when observed by all, help
to ensure the maximum use of the resources and efforts.
Plan formulation is a process of analyzing a system, or defining
a problem, formulating goals and objectives, examining and
choosing from among alternative intervention strategies; so, planning
involves a succession of steps:
The analysis of the health situation – the collection, assessment
and interpretation of information in such a way as to provide a clear
picture of the health situation.
It is necessary:
 to know the population, its statics and dynamics (age and
sex structure, statistics of morbidity and mortality);
 to study the basic parameters of the population health (the
epidemiology and geographical distribution of different diseases);
 to know hospital bed and out-patient (polyclinic) network:
medical care facilities, such as hospitals, health centres, private and
public health agencies);
 to study the last year plan, its performance, and use of the
current year plan.
Establishment of objectives and goals – this process involves
all levels. At upper level objectives are general, at lower levels
objectives become more specified and detailed. The objectives of
upper level are long-term, of lower levels – are short-term.
Assessment of resources – it is necessary to define financing of
public health services organizations, to know a wage fund, number
of workers, the budget of public health services.
The next steps are following:
 Fixing priorities: attention is paid to financial constraints,
mortality and morbidity data, diseases which can be prevented at low
cost, and also community interests.

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  Write-up of formulated plan.
 Programming and implementation.
Any plan of health care must contain a built-in system of
evaluation and must be approved by the policy making authorities.
The implementation stage includes definition of roles and tasks;
selection, training, motivation and supervision of the involved
manpower; organization and communication.
Monitoring is the day-to-day follow-up of activities during
their implementation to ensure that they are proceeding as are
planned and are on schedule, keeping track of the course of activities
and identifying deviations and taking corrective action if excessive
deviations occur.
Evaluation is mostly concerned with the final outcome and
with factors associated with it. Evaluation measures the fulfill and
quality of the results, the productivity of resources in achieving
objectives.
The Territorial Program of the State guarantees of medical aid
(Republic of Belarus) represents a package of the official documents
defining the list of diseases, kinds, volumes, conditions of granting
and financing of the medical aid rendered to the population for the
means of the budget account.
The purpose of Territorial Programs of the State guarantees of
medical aid consists in maintenance of the guaranteed volume and
quality of medical aid according to the Constitution of the Republic
of Belarus.
Basic problems of Territorial Programs of the State guarantees
of medical aid:
1. Consolidation of the state tools of financing.
2. Increase of efficiency of public health services resources use.
3. Maintenance of equation of the state obligations on medical
aid granting.
Structure of Territorial Programs of the State guarantees of
medical aid:
1. The list of kinds of medical aid given to the citizens at the
expense of the budget of an administrative or territorial unit;
2. Conditions and order of free medical aid rendering;
3. Medical aid volumes;

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 4. The rights and duties of local executive and administrative
bodies and public health services bodies.
The instruction on working out and realization of Territorial
Programs of the State guarantees on securing the citizens with health
services (confirmed by the Decision of Ministry of Health of the
Republic of Belarus on May, 27th, 2002 № 28) allocates the
following basic indicators to the used while working out and
realizing the Territorial Programs:
 the specification of hospital-days;
 the level of hospitalization;
 the average duration of treatment;
 the number of calls for the first aid;
 the specification of out-patient-polyclinic vizitings;
 the specification of security of population by doctors of the
general practice (GP) and local doctors (doctor-population ratio);
 the provision with hospital beds (bed-population ratio);
 the provision with drugstores (drugstore-population ratio);
 the provision with brigades of the first (emergency) medical
help;
 the economical (money) specification per one inhabitant of
the territory in a year.
Modern peculiarities of public health services planning in the
Republic of Belarus consist in the following. Planning is carried out
based on financial possibilities of the state. The attention is accented
on the important medical-social problems of the population health.
The volumes of medical aid necessary for the population are planned
first of all, based on them are indicators of network and staff. There
is a certain independence in hospital bed fund development and in
introducing of staff in each medical-preventive organization.
Reduction (80 hospital beds on 10 thousand of population),
re-structuring (35% of hospital beds are beds of intensive treatment,
30% – of rehabilitations, 20% – of long treatment, 15% – medical-
social beds) are characteristic for hospital bed fund planning.
Hospital-replacing technologies are introduced (to 25% of volume of
the in-patient help to the population). Decrease in level of
hospitalization (to 10%), reduction of average duration of patient`s
stay in a hospital, increase of diagnostics and treatment intensity are

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characteristic. Standardization is widely introduced. Rendering of
paid medical service and services develops.
Reduction of general medical staff, increase in a share of
doctors in a primary link (PHC), development of institute of the
doctor of the general practice (GP), change of doctor – nurse ratio
towards increase in a share of medical sisters is observed in planning
of medical posts in Belarus nowadays. Academic education of
medical sisters develops. Working out of scientific rationing of work
is introduced. The new Nomenclature of medical specialities and
posts forms base for planning.
Peculiarities of planning in the Republic of Belarus are
integrated approach and program-target direction. Complex program-
target planning presupposes working out of medical-social programs
on the basis of the chosen priorities in public health care.

5.4.2 Technique of the stationary aid planning

This technique is based on the population need in beds
definition. To calculate correctly need of the population for the
stationary help, it is necessary to have the below-mentioned
information:
1) A level of addressing the population for medical aid in the
out-patient polyclinic organizations of public health services, in
connection with diseases on 1000 population.
This parameter reflects the level of morbidity rate, and is
connected with population size.
2) A level of hospitalization. Having the data about addressing,
it is possible to determine the needs of patients in hospitalization
which according to some of research data change in limits from 17%
up to 29% to number of polyclinic references.
3) Annual number of occupied beds (employment of the bed).
According to the established norms, hospital bed in one year should
function roughly: in city – 340 days, and in a countryside – 310 days.
4) An average number of in-hospital days (for one patient).
This number is approximately 18 days (in case of well advanced
hospital network and presence of sufficient number of beds on all
specialities). However, actually, this number may be different and
duration has significant fluctuations.
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 Modern tendency is the reduction of averge number of in-hospital
days. Reduction of the average of days a patient’s stay in bed descends
on timeliness of hospitalization and diagnostic researches, application
of effective methods of diagnostic and treatment, etc.
It is possible to define need for the stationary (hospital,
in-patient) care having the given initial data. This need is defined
as the «need in beds».
Calculation of need in beds is as follows:
Beds = (PxHxA)/ (DX100),
where are P – population;
H – percentage of hospitalization;
A – average in-patient days for one patient;
D – employyment of one hospital bed in one year (or scheduled
number of bed use days in one year). Beds is the required number of
annual beds, or population need in hospital (in-patient) beds.
Function of a hospital bed (or bed turnover) is estimated as
follows:
F=D/A,
where are F – function of a hospital bed (bed turnover);
D – employment of the bed (how many days in one year the
hospital bed should be employed);
A – average duration of patient in-bed stay.
Calculation of population needs in hospital staff is as follows:
Number of doctors = number of beds in a hospital / number of beds
on one doctor.
Number of beds on one doctor is determined by specifications
of medical staff loading.

5.4.3 Technique of the out-patient polyclinic network

planning
Population need in the out-patient aid is established by follows:
 By calculation of the scheduled number of visits;
 By calculation of medical posts number.
Calculation of the scheduled number of visits is as follows:
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 V= (NxP)/1000,
where V is the number of visits of polyclinic on 1000 of
population;
N is the number of visits on one inhabitant in a year;
P is the number of population.
The second way of calculation is as follows:
V=(MxF)+Cl+Pr,
where: V is the number of visits of polyclinic on 1000 of
population;
M is the morbidity, on 1000 of population;
F is the factor of frequency of visits with the medical purpose
on one disease on the given speciality;
Cl is the number of clinic visitings in connection with disease;
Pr is the number of visits on preventive health service.
Calculation of medical posts number is as follows:
MPN= (NxP) / (L x WH x WD),
where are MPN is the medical posts number;
N is the number of visits on one inhabitant in a year;
P is the population size;
L is the loading of the doctor of the given speciality per one
working hour; WH is the number of working hours (on the reception
and at home);
WD is the number of working days per a year.
(L x WH x WD) is the function of one of the medical posts of
the given specialtity (or number of visits served by one medical post
within a year).
Number of polyclinics of the certain category can be defined on
the basis of planned number of visits; because the category is a
parameter of polyclinic capacity. Scheduled throughput ability of all
polyclinics should be divided into the number of visits during one
shift of a polyclinic of the given category. Number of visits during
one shift is a parameter of capacity (for example, capacity of the first
category polyclinic makes 1200 visitings in change).
It should be noted, that the parameter of the hospital capacity is
the number of beds.
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 5.5 Health care: Economy, Financing
Many countries have no overall, coordinated programmes to
provide or pay for health care services. Because health care costs are
rising, at such an alarming rate without a corresponding increase in
objective measures of health status and health outcomes, many
people suggest reforming the current health care system.
Health care costs accounted for about 5% of the gross national
ptoduct (GNP) in Belarus and about 12-15% of GNP in the USA.
This percentage in USA is far higher than that of any other
industrialized nation. From 1965 to 1987 the amount of employer
contributions to health care in the USA was expressed as a
percentage of corporate profits increased from 14% to 74%.
Employers in the USA have spent 25-30% more on health care in
2007 than they did in 1987. Hospital care accounts for the largest
percentage of personal health care expenditures (44%) in the USA.
The economy of public health services is the science about
the place and interrelations of public health services in the general
system of development, planning of the national economy, about
methods of finding and correct using of public health services
resources and reserves, about methods of the estimation of efficiency
on public health care, and their influence on changes of the public
product manufacturing that are conduct by improvement of the
people’s health state.
The purpose of public health services economy is the maximal
meeting of the population needs in the sphere of medical aid at the
economically justified material and financial expences. So,
profitability of public health services is the struggle for saving of
means and also for full meeting of the population needs in public
health services activity at the same and smaller expences.
The problems and tasks of public health services economy are
as follows:
1) Correct the definition of volumes and rational use of
economic resources;
2) Reveal the tendency of the further changeof the structure of
public health services charges;
3) Scientific substantiation of technical progress tendencies
and material development of the branch dynamics;
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 4) Determination of the most favourable conditions between
the number of various workers (physicians, nursing staff, junior
medical and support staff, managerial staff etc.) in public health
services;
5) Studying the social and economic problems connected with
change of payment, material stimulation of workers.
The public health services activity influences the manpower
increasing by means of major factors among which the growth of the
gross national ptoduct (GNP) and expense of the state are depend.
There are the factors:
 the number of the goods produced by workers of
manufacturing sphere increase (by means of the death rate decrease);
 the health of workers strengthening (a healthy person creates
more product and of better quality, than physically weak or ill
person);
 population average life expectancy increase (due to physical
inability rate decrease);
 the expences for treatment and social insurance payments
decrease (due to decrease of morbidity rate, traumatism and,
especially, sickness rate with absence from work and stay disability).
The main concepts in economy of public health services are the
efficiency and profitability.

5.5.1 Efficiency of public health services

Efficiency, in general, is the degree of achievements of the
planned effect in accordance with expenditures.
Efficiency = result (effect) / expences.
Definition of public health services economic efficiency is
based on indirect economic benefit estimation. Indirect benefit is
determinated by the size of the prevented economic damage. This
prevented damage develops due to reduction of:
 Expences on health services;
 Payments on social insurance;
 Cases of premature death.
Definition of public health services economic expences
depends on the price of medical service. The price is the parameter

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of quantity and quality of the work spent for rendering of the service
by medical workers, expressed in money.
The basic standard units of the technique of the medical aid
cost definition are the one visit of the local therapeutist in out-patient
polyclinic organization (for out-patient medical aid) and the one bed
maintenance middle cost (for in-patirent hospital aid). The cost of
one visit of the local therapeutist is the cost of the medical post main-
tenance divided into the number of visits on reception and at home.
The price of medical service includes profit, cost price and
value-added tax.
The profit and the cost price are to be known also for calculation
of profitability. Profit is a part of the clear profit which is included
in the price proportionally to any kind of expences or all expences as
a whole. Cost price is a money equivalent of quantity and quality, put
in the medical service of work, both direct and indirect.
The price for the medical services, carried out under contracts
with the enterprise on a self-supporting basis, is defined by means of
calculation. Components of the cost price of medical service are as
follows:
 Depreciation charges,
 Expences for medicines,
 Wages of medical staff,
 Charge on wages.
Definition of the cost price is the basis of medical services
pricing.
The effect in public health services is the concrete ultimate
result describing social, medical and economic aspect.
Social efficiency is a degree of planned purposes achievement
in the field of demographic parameters improvement. Social effect
can be measured by such parameters, as average life expectancy,
birth rate, death rate, a natural increase of the population, etc. Social
efficiency is the influence upon medical-demographic processes and
is expressed in increase of the life quality, improvement of the
environment, working conditions and etc.
Social effect of public health services is measured in relation
with national (public) level. This effect depends on change of all
social and economic conditions in the country.

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 Medical efficiency is a degree of tasks achievement in the field
of preventive activity, diagnostics and treatment. Medical effect can
be measured in relation with concrete patient or with all population
level. The medical effect on population level can be expressed by the
various parameters: a level of morbidity (incidence, prevalence)
rates, its tendencyes, number of fallen ill, etc. Medical efficiency is
degree of improvement in the picture of health, reduction of
treatment periods, reduction of the number of the morbid events and
mortality.
Economical efficiency is a degree of positive economic results,
that can be measured by money equivalent. Economical efficiency is
calculated as the achieved economic result divided by the expences
(or the effect divided by expences). Economic efficiency is valued
resort and price criteria.
Economic benefit can be measured also as follows:
 Losses in the national product in connection with the level of
premature death rate;
 Numbers of the saved lives at able-bodied age;
 Level of physical inability and its dynamics;
 Cost of liquidation or decrease of some diseases, etc.

5.5.2 Forms of health care financing

One can distinguish five basic health care financing forms:
1) State financing;
2) Medical insurance;
3) Private medicine;
4) Public medicine (charitable);
5) Mixed form.
State financing of health care system is based on budgetary
credits. State financing is the main form of health care system
financing in Belarus.
The budget is annually performed balanced list of incomes and
charges. The state budget is the fund of money resources for
financing the national economy, culture and defence. Incomes of the
state budget show sources of money resources; charges – are using of
these means for nation-wide needs.

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 Incomes of the state budget are carried out due to taxes and
profits of a national economy (industry, agriculture, external and
domestic trade), due to taxes from the population and not state
organizations (enterprises, companies, cooperative societies, etc.).
The budgetary system is organized according to the state
system. According to the constitution of Belarus, each body of the
government establishes the budget providing performance of the
problems, assigned to it. The state budget is made for 1 year: from
01/01 till 31/12. This period is called budgetary one. The state
budget includes republic and local budgets.
The budget plays an important role in state financing of public
health-care service.
Cash circulation of the financing is assigned to the National
Bank of Belarus. To each establishment of public health services the
National Bank department opens current accounts. Head (Chief)
physicians of public health services are managers of credits (means
for health service charges, arrived on the current account for
storage). A chief physician is responsible for a correct expenditure of
the state money resources under financial clauses.
The planned budget of public health services is calculated
according to changes and conditions and rise in prices on the
developed rates of growth of charges on public health services for
the last year.
Medical insurance – is the system providing preservation of
health by creation of economically responsibile citizens, enterprises
for public health care. It is a system of economical relationship
providing the creation of special funds and their use for
indemnifying the damage of medical-social risk factors (such as
follows: disease; accident; loss of working ability; maternity; death).
The insurance medicine is the model of financing of public
health services, when health-care service charges arrive from several
sources, based on personal means of citizens.
Some terms are used in the OMI system. As follows:
 the Programme of the obligatory medical insurance is a vo-
lume of medical aid determined for the territory or working conditions;
 the insurance accident is a realization of one or all
conditions of the insurance contract;

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  the insurance risk is an economic expression of possible
insured accident occurrence;
 the medical insurance tariff is a cost of medical and other
services, defining the possible activity of the institutions that render
them;
 the contract of medical insurance is an agreement between
the assured parties and the insurance medical company;
 the insurance medical policy is a legal document reflecting
the relations between the assured and the insurance medical
company;
 a medical organization (in the system of medical insurance)
is a legal entity that has the right for medical activity in the volume
and terms determined with accreditation. A medical organization is
the subject of management.
The economic understanding of the term «insurance medicine»
is a market model of public health services financing. «Insurance
medicine» – is the system of obligatory medical insurance (OMI).
Economic relations in health care system whith the OMI conditions
are regulated by the state law. OMI gives equal opportunities on
medical aid to the insured, irrespective of the labour contribution and
the sizes of an individual payment. OMI provides reception of
medical aid volume, which is socially-guaranteed by the state.
The basic sources of financing in conditions of insurance
medicine are the deductions of the enterprises, personal means of
citizens and the state budget. The additional sources are means of the
enterprises for direct payment of medical services, charitable
payments, credits of banks, incomes of securities.
Obligatory insurance does not study the initial health picture.
The state defines the insurance premium. In this situation the
insurance company studies the initial health and as a result the sum
of the insurance premium is defined (up to failure that is not
encouraged by state).
OMI has principal differences from voluntary medical (health)
insurance (VMI). VMI provides reception of additional services
over guaranteed by obligatory medical insurance or over guaranteed
by state financing system. VMI can be both private and state, but it is
always commersial. The role of voluntary medical insurance in EU

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can be classified as substitute, supplementary or complementary.
VMI enables access to services that are not available under OMI, or
cover user charges. Where VMI substitutes for OMI, as in Germany
or Netherlands, individuals with high incomes are covered. As
income is related to the risk of ill health, separating public (OMI)
and private (VMI) insurance according to income concentrates
people at a higher risk of ill health within the public system.
The insurance companies accumulate resources for medical
service payment (means from obligatory insurance, means from the
voluntary insurance, means for health damage): pay for rendering of
medical services; coordinate of the medical service price; supervise
for observance the normative quality level; supervise for volume of
the rendered services; supervise for funds for inflicted damage
attraction; render financial, consulting, expert help. Insurance
company pays for bad days (in the system of obligatory insurance) or
for a set of the medical services (if voluntary insurance);
compensates expenditures according to the estimated references or
pays for the treatment.
Shortly, the basic differences between voluntary and obligatory
medical insurance are as follows:
1) voluntary insurance is always commercial, obligatory one is
always state;
2) voluntary MI is individual, obligatory MI is a group
(public);
3) voluntary MI prices are defined by the document between
the insured patient and insurance company, obligatory MI prices are
defined by the state.
The governments of many countries, such as Austria, Ireland,
Portugal subsidise health insurance through tax credits or tax relief.
Problems of medical insurance system are as follows: seriously
ill citizens (does not manage with any system); comparison of the
activity results of the different health services (who and how much
contribute); the problem of dependence between the results of
treatment and help quality and the type of the payment.
Medical insurance demands some conditions for its
implementation, as follows: legal (presence of legislation which
adjusts the relations of insurance subjects); economical (the stable

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economy); organizational (preparing the package of documents that
adjust the relations); social-psychological (mentality of medical
personnel and the population formation).
There are three systems of medical insurance in the world:
centralized, decentralized, mixed.
Centralized system of medical insurance works in Germany.
Russia uses the German model also. All citizens are insurable.
Money concentrates in regional insurance funds (national,
professional). The amount of the insurance fund consists of 13% of
the salary fund (50% enters from enterprises, 50% from workers).
Working people provide the non-working. The cost of the medical
services is defined by item. The price of the item is checked by state.
Advantages: equality and accessibility.
Defects: absence of motivation for health preservation; absence
of the direct relations between patient and medical institution.
Regulators of the relations «patient – insurance company» are
executed by insurance office association, doctors’ association; the state.
Decentralized system of medical insurance works in France.
Approximately 80% of people are involved, 20% are not involved or
are deprived. About 75% of expenses for medical facilities come
from insurance fund, 25% – from citizens directly or from voluntary
insurance. There is the motivation for health preservation. There is
direct mutual settlement of accounts between a patient and a doctor.
The item is revised two times per annum and checked by the state.
If means (funds) are not enough, the insurance company can take
the credit from the state, that’s why the item changes depending on
the situations. The regulators: the same, as in Germany.
Mixed system of medical insurance works in Japan. This system
is based on territorial-production sign. The insurance system is open,
what means that there is a control from territory, non-working, small
businessman. Insurance premium from hardship allowance is raised
by autonomic authorities, 90% of expenses at the expense of the
insurance premium, 10% from the patient (but can be 25% from the
patient or voluntary insurance).
Belarus. The law was drawn up (1992), but has not passed yet.
The Order of Health Ministry of the Republic of Belarus № 192 from
the 29th of July, 1997 «About voluntary medical insurance» is

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accepted. The Order of the President of the Republic of Belarus
№ 354 from the 26th of July, 2000 «About obligatory medical
insurance for the foreign citizens and stateless people, sojourners in
the Republic of Belarus» is passed.
The insurance method of financing has lead to some positive
shifts, such as follows: growth of medical personnel qualifications;
modern medical technologies development; the system of the quality
control become opened; appearance of motivation for health
preservation; promotes the system public associations establishment.
Negative shifts of the medical insurance are as follows: growth
of number of examinations; growth of number of consultations;
growth of the expenses.
Therefore it is necessary to regulate the legal relations. The
main legal protectors: associations, declaration of the doctor’s free
choice.
Private medicine is the model of free market in public health
services and health care system. The market of medical services
includes set of existing and potential consumers (population) and
sellers (health care organizations) of medical services. Any medical
service has its own cost-price. The price realizes communication
between supply and demand on medical services.
The basic sources of financing in condition of private medicine
are the direct consumer payments, VMI, and government pays.
The dramatic growth health care expenditures has resulted from
the increased governmental funding (for example – in the USA –
programs such as Medicare and Medicaid), growth in private insurance
coverage, and increased governmental regulation of free market model.
The USA is the example of free market in health care
financing. The cost-benefit analysis of the U.S. health care system
showed, that this model has poor results, such as following: the
infant mortality rate (IMR) is higher in the USA than in many other
industrialized countries; the average life expectancy is not
significantly higher in the USA than in other industrialized nations;
a high percentage of U.S. children are not immunized thoroughly.
And approximately 15% of the USA population is not covered by
health insurance. They may delay seeking care until their condition is
critical, and many hospitals are less willing to provide non-

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emergency care for those who cannot pay. So, the government of the
USA pays for approximately 40-50% of all personal health care
expenditures. Medicare and Medicaid are the principal governmental
supporting health programs. Beside this, such direction as “Managed
health care” takes place in the USA and Europe. To manage health
benefit costs better, arrangements that relate the beneficiary’s
coverage to the use of selected health care provides have emerged.
Managed care refers to a wide range of techniques employed
by payers to control health benefit expenditures, including
management of health care (emphasizing low-cost alternatives to
inpatient care, such as outpatient services; implementing risk-sharing
arrangements with providers; negotiating volume discounts with
tertiary hospitals and other suppliers, such as medical equipment
companies, laboratories, pharmacies; etc).

5.5.3 The estimate as the basic financial document

The basic financial document of public health service
organization is the estimate.
The estimate is a financial plan of charges of the public health
services organization. It includes all charges in determined period.
The estimate is affirmed according to the definite order. The estimate
is the basic scheduled document determining total amount, purpose
and quarterly distribution of the means accrued for its maintenance.
The estimate includes charges, which necessity is determined by the
type of activity of given organization.
The estimarion charges determined by corresponding financial
clauses includes is performed in the following way. The chief doctor
conducts the book of orders for particular section. This book should
be numbered, filed and sealed by wax. Before the beginning of a new
year the chief doctor approves the schedule for holidays, forms a
selection of orders of the directive instances regulating activity of
establishment (official salaries, volume of the help, duties, etc.). The
head physician should make tarif list of all employees of the given
establishment (first name; date of birth; last job; education – when
and from which Department graduated; number of the diploma; the
date of entering the work; duration of service). After that he makes
the list of staff of the establishment.
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 The estimate includes such clauses, as follows:
 Wages;
 Charge on wages;
 Business trips;
 Research work and purchase of literature;
 Charges on feeding;
 Purchase of medicines and uniform;
 Purchase of the equipment and stock, purchase of soft stock,
overhaul, other cost, etc.
Charges on public helth services increase annually. But, at the
same time, public health services influence on the growth of
economic efficiency of the social production increases as well. It is
expressed in the gain of the national income as a result of
achievements in health protection of working people.

5.6 Health care Informatization. Bases of marketing

Medical informatics is a developing scientific branch which
deals with accumulation, searching for and optimum usage of bio-
medical information, database and knowledge for different medical
tasks solution.
The main sources of data that are necessary for public health
analysis are collected from operating health care system. Data are
transformed into information by reducing them, summarizing them
and adjusting them for variations, such as the age and sex
composition of the population so that comparisons over time and
place are possible.
A mechanism for collection, processing, analysis and
transmission of information required for organizing and operating
health services, and also for research and training is defined as
health information.
The WHO Expert Committee identified the following
requirements to be satisfied by health information systems:
1. The system should be population-based.
2. The system should avoid unnecessary agglomeration data.
3. The system should be problem-oriented.
4. The system should employ functional and operational terms
(e. g., episodes of illness, treatment regimens, laboratory tests).
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 5. The system should express information briefly and
imaginatively (e. g. tables, charts, percentages).
6. The system should make provision for the feedback of data.
The components of health information system are the following:
1. Demography and vital events.
2. Environmental health statistics.
3. Health status: morbidity, mortality, disability, quality of life.
4. Health resources: facilities, beds, manpower.
5. Utilization and non-utilization of health services:
attendance, admissions, waiting lists.
6. Indices of outcome of medical care.
7. Financial statistic (cost, expenditure) related to the particular
objective.
The important uses where health information may be applied are:
 To measure the health status of the people and to qualify
their health problems.
 For local, national, and international comparisons of health
status of community (communities). The data need to be subjected to
rigorous standardization and quality control.
 For planning, administration and effective management of
health services and program.
 For research into particular problems of health and disease.
The health information system should be population-based. The
routine statistics collected from medical records linkage,
epidemiological surveillance, environmental health data, do not
provide all the information about health and disease in the
community. The term «health surveys» is used for surveys related to
any aspect of health – morbidity, mortality, etc. When the main
variable to be studied is a disease suffered by the people, the survey
is reffered to as «morbidity survey».
Health surveys on a permanent basis are used in only a few
countries.
According for G. Mintsberg, any manager implements a set of
several behavioral norms:
 Interpersonal roles;
 Information roles;
 Roles connected with decision-making.

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 Information is the basic subject of any manager’s work
In general, information is the new data perceived and
appreciated for the solution of organizational tasks. Medical
information is a system of documents for data recording about health
state of the population and quality of the medical aid rendered to
them. The following kinds of information are necessary for
management in the system of public health services: accounting and
registration (or statistic), economic, legal, special medical information.
One can single out four main groups of information in public
health services:
 The medical administrative and legal information;
 The medical technological information;
 The medical statistical information;
 The medical economic information.
Suitability of the information for management in health care is
determined by its reliability, adequacy, timeliness and completion.
The main purpose of public health informatization is to ensure
the branch functioning with the help of information-computer
support of medical technologies at all levels to increase the quality of
medical-preventive help and efficiency of public health control.
Modern peculiarity of informational work is connected with
automated control systems development and exploitation.
ACS (automatically controlled system) of public health is
a system, providing automated collection and information handling
for control optimization.
One can single such automated control system (ACS) as ACS
of hospital and ACS of polyclinic. Each type of the organization of
public health corresponds to its type of ACS.
ACS of hospital includes such components, as the operative
account of movement of patients; management of bed fund;
management of medical-diagnostic process; management of a drug
store, the stuff, the finance; system of analysis of work.
ACS of polyclinic includes such components as organization of
the served population account; automation of doctors workplaces;
organization of preventive examination; account of resources and
analysis of work.
ACS helps to optimizate the resource policy of hospital or
polyclinic, to intensificate of new medical technologies development,
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to increase the efficiency of preventive and medical-diagnostic
actions and qualities of medical-diagnostic process.
For the best satisfaction of population medical needs, in the
commercing of health care and market relations conditions, manager in
public health services must know principles and methods of marketing.
Marketing is a kind of human activity directed to satisfaction
of needs by means of exchange. It is a complex process of planning,
economical basis and administration of health care services and its
cost, of health care services promotion and realization. Tasks of
marketing are following:
 To study the market and to reveal the consumers
(population) needs and inquiries;
 To influence the demand and realization of medical,
diagnostic, rehabilitation and preventive services in the direction of
intensification;
 Marketing is a kind of manager’s work, where information
plays the main role.
Marketing is a process of management and satisfaction of needs
for goods, facilities and ideas by means of exchange. It is a process
of planning and management of products and services development,
price policy, promotion of services and goods to consumers and sales
to make wide variety of benefits the source of satisfaction of needs
both separates personalities and organizations.
Main principles of marketing are following:
1. An attentive count of needs, conditions and dynamics of the
demand and market conjuncture.
2. Making the conditions for maximum adjustment of
production to the market conditions.
3. The influence on the market and consumer by means of
advertisement and enlightenment.
Marketing in public health services is possible only in the
following conditions:
- presence of market and competition of medical services (each
medical-preventive organization has to be accredited and be licensed
on the determined type to activity),
- presence of market relations between medical-preventive
organization and patient.

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 It depends on forms of the public health financing, forms of
medical services payments, and patterns of ownership.
One can distinguish such types of marketing, as following:
1. Marketing of the medical services. It is influenced by the
level of public health, structure of the demographic indices (for
instance, age-sexual structure), level of education, culture, living
place (the city has higher level), level of income.
It includes study of needs of the population (in medical
service); formation and regulation of the medical services market and
informing the population about possibility of the medical services
granting.
2. Marketing of the medical preparations.
Particularities of this form of the marketing are as follows: a
product is produced in strictly necessary amount, a product is not
delivered directly consumer, pricing is directly or indirectly defined
by government, presence of competitors.
3. Marketing of medical equipment.
4. Marketing of medical technologies.
Medical technologies are collection of the standardized
processes that logically finish the determined medical interference,
specified with directive documents or traditions. For example, such
technologies, as follows: blood transfusion, transplantation of the
marrow, ways of the diagnostics, treatment, rehabilitation,
technology of the reception of medicinal production (standardization
is important).
Marketing in this area includes: collection of the information,
standardization (by protocols of treatment), advertisement, actions
for medical market advancement.
5. Marketing of scientific ideas includes: patent-information
studies, an expert examination, legal protection.
By the early 1990s, health systems were already in serious
disarray. Now, in some quarters of the international health policy
world, PHC conjured up not images of self-reliant communities
engaged with committed health workers and professionals in locally
relevant health structures; rather it evoked images of empty clinics,
lacking staff, drugs and equipment, and a public system riddled with
corruption, abuse and waste (Filmer, Hammer et al., 2000).

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 By the 1990s, the World Bank had become the leading funder
of health sectors, and its view of the problems and prescriptions for
solutions dominated the field. The highly influential World
Development Report 1993, entitled Investing in Health, introduced
new priority-setting techniques for public spending and ushered in a
new orthodoxy in health policy. Drawing on the neoliberal ideology
that framed policies of the international financial institutions in other
sectors as well, the core of the new orthodoxy was the view that the
private sector could most efficiently meet most health care needs
and should be allowed – indeed, actively encouraged – to do so. The
public sector would be assigned the task of «gap-filling»: it would
provide a set of cost-effective services determined on the basis of
burden of disease measures, which would become an «essential
service package» offered to the poorest through public sector facilities.
The consequence of this approach was the marketization of
health care: in every part of the health system (whether nominally
public or nominally private), health care – professional services,
drugs, transport, basic access and decent, humane treatment – came to
be bought and sold. «The marketization of public services has become
so ubiquitous in some countries that parts of the health system are
more appropriately understood as government subsidized private
services than as a publicly-funded service with minor problems with
corruption» (Bloom and Standing, 2001). Health policy, still
grounded in an idealized model of public-private sectors, was
becoming dangerously disconnected from the reality on the ground.
Bloom and Standing have argued persuasively that instead of
premising policy discussions (or prescriptions) on the increasingly
insupportable view of discrete public and private health sectors, the
situation in many – perhaps most – poor countries can be more
accurately described as pluralistic, and more appropriately divided
into «organized» and «unorganized» categories. The choice that
people confront is not between a private health system that charges for
a maximum choice of high quality services, and a public health
system offering essential services for free or at low cost. Instead, all
users, rich and poor alike, are confronted with a bewildering array of
sources for health care: from drug peddlers, to traditional healers, to
highly trained specialist physicians, to civil servants setting up private

184
practices of wildly uneven quality. Indeed, the CHWs who had been
given minimal training with the expectation that they would be the
backbone of a public health service working under careful supportive
supervision of health professionals – these CHWs are, in some places,
a substantial portion of the private sector providers. As Bloom and
Standing point out, the weakening of government supervision systems
is «an important factor contributing to the de facto marketisation of
health services» (Bloom and Standing 2001).
Yet, for CHWs and other health providers, faced with woefully
inadequate salaries, the selling of services is sometimes the only way
to survive (Van Lerberghe, Conceicao et al., 2002). Studies
examining workers' survival strategies in the face of health sector
reforms help make the link between structural policies and the
individual behavior that is often addressed simply as widespread
corruption. Coping mechanisms and their implications are addressed
in later sections of the report on human resources.
The marketization of health care and mushrooming of
unorganized markets alongside collapsing organized ones have
profound ramifications for health equity. Far from the scenario of the
poor seeking essential health services in public clinics, «unorganized
markets are not only used by the poor but do their greatest harm to
the poor. They suffer the greatest information asymmetries and are
much more likely to be at the purchasing end of shoddy or dangerous
goods and services» (Standing and Bloom, 2002).
In societies where inequality is deeply entrenched, the
marketization of health care implicitly, but powerfully, legitimizes
exclusion. Any approach to rebuilding health systems must confront
this fact.
This disintegration of the public health system – or, indeed, the
failure ever to reach a functioning point from which it could
disintegrate – is a core factor in the grim failure of many countries to
address maternal mortality. The obstetric complications that kill
women in pregnancy and childbirth cannot be managed outside of a
functioning health system. Even when families are willing to pay –
willing to incur truly catastrophic costs – women with life-threatening
complications will need professional, skilled health care, and the
drugs and equipment on which it depends, in order to survive.

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 LESSON № 6
TESTS
Social protection of population.
Medical care in out-patient and in-patient conditions

1. Indices of long-time and proof disability are as follows:

1. The first handicapped rate
2. The first handicapped accommodation
3. The first handicapped structure
2. The commonly used disability rates are supplemented with
such parameters, as:
1. Sullivan’s index
2. Bullivan’s index
3. HALE (Health-Adjusted Life Expectancy)
4. DALY (Disability – Adjusted Life Expectancy).
5. GULE parameter
3. The key legal grounds of disability (stable disability,
handicap):
1. Stable disability since childhood
2. Trauma
3. General disease
4. Occupational injury
5. Occupational disease
4. The key medical grounds of disability:
1. Blood circulation system diseases
2. Neoplasm
3. Traumas, poisonings and other consequences of external
factors’ influence
4. Respiratory organs diseases
5. The most often registered group of physical disability
(invalidity, stable disability, handicap) is:
1. The second group
2. The first group
3. The third group
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 6. The main indicators of disability are as follows:
1. Proportion of childhood disability
2. Total disability rate
3. Primary disability (first handicapped) rate
4. Secondary disability rate
7. The functional class I is the criterion failure of life ability:
1. Up to 5%
2. Up to 10%
3. Up to 20%
4. Up to 25%
8. Physical disability groups correspond to functional classes:
1. 1st group – FC (functional class)-4
2. 2nd group – FC-3
3. 3rd group – FC-2
4. 4th group – FC-1
9. Criteria of life ability – the ability of:
1. Self-service
2. Moving
3. Driving a vehicle
4. Controlling behavior
5. Communicating
10. The grounds for the estimation of I disability group are:
1. Severe disturbance of communicating ability
2. Considerable restriction of moving
3. Moderate restriction of self-service
4. Full loss of the ability to work
11. The grounds for the estimation of II disability group are:
1. Full loss of the moving ability
2. Considerable restriction of orientation
3. Impossibility of professional training
4. Moderate infringement of the behavior control
5. Limitation of the extent of professional work
12. The Individual Program of Rehabilitation for Disabled
Persons in the Republic of Belarus includes the following sections:
1. Medical
2. Pedagogical
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 3. Social
4. Professional
13. The Individual Program of Medical Rehabilitation
determines:
1. The scale of rehabilitation actions
2. The methods of rehabilitation actions
3. The terms of rehabilitation actions
4. The groups of rehabilitation actions
14. The professional section of the Individual Program
includes:
1. Professional orientation
2. Professional training
3. The perfect possession of a subject and situation
4. Employment
5. Adaptation at a certain working place
15. In the Republic of Belarus the state guarantees to disabled
persons the following:
1. Protection of rights, freedom and legal interests
2. Free qualified medical aid
3. Free medicinal provision
4. Conditions for education and professional training
16. In the Republic of Belarus the following laws are
executed:
1. «About the social protection of disabled persons»
2. «About the medical rehabilitation of disabled persons»
3. «About the prevention of disability and rehabilitation of
disabled persons»
17. According to the Law of the Republic of Belarus «About
the prevention of disability and rehabilitation of disabled persons»
the invalidity prevention is achieved with the help of the following
measures:
1. Medical
2. Hygienic
3. Pedagogical
4. Regional
5. Professional

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 18. The Law of the Republic of Belarus «About the
prevention of disability and rehabilitation of disabled persons»
defines the following types of rehabilitation:
1. Medical
2. Professional
3. Labour
4. Social
5. Sectoral
19. The types of social care to disabled persons granted by the
state in the Republic of Belarus are as follows:
1. Payments
2. Provision with a mobile phone persons living in countryside
with 50% discount of payment
3. Provision with technical means
4. Assistance in domestic services
20. Coordination of the policy concerning the problems of
disability is performed by:
1. Ministry of Labor and Social Protection
2. Ministry of Public Health
3. The Republican Interdepartmental Council on Disability
Problems
21. According to the Law of the Republic of Belarus «About
the prevention of disability and rehabilitation of disabled persons»
the social rehabilitation is a system of the actions providing:
1. Improvement of a living standard of disabled persons
2. Treatment
3. Creation of equal possibilities for disabled persons to
participate in a society life
22. The main organizational forms of medical rehabilitation:
1. Centers
2. Departments
3. Polyclinics
23. Synonyms of the term «rehabilitation» are as follows:
1. Readaptation
2. Prevention
3. Tertiary prevention

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 24. The main stages of medical rehabilitation are as follows:
1. Sanatorium stage
2. Hospital stage
3. Consulting stage
4. Polyclinic stage
25. Technological stages of medical rehabilitation according
to WHO are as follows:
1. Restoration of the functional ability
2. Preventive medical examination
3. Involvement into a working process
4. Treatment
5. Restoration for a daily life
26. Nowadays the medical rehabilitation makes an emphasis on:
1. Work with physically and mentally defective persons
2. Work with patients
3. Work with disabled persons
27. The main tasks of the Fund of social protection of the
population of Belarus are:
1. Collection of obligatory social insurance payments
2. Financing of the expenses for pensions, allowances,
sanatorium treatment
3. Organization and introduction of the individual record of
data about insured persons
4. Carrying out of explanatory work among payers
5. Granting of preferential credits for insured persons
28. Where do the means of the Fund of social protection of
the population of Belarus go?
1. Payment of pensions by age, disability
2. Payment of allowances according to the state social
insurance
3. Payments for sanatorium treatment and health improvement
4. Rendering of financial aid to needy elderly and disabled
citizens
5. The aid for earthquakes and floods survivors

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 29. In cases of diseases and traumas the following regimen is
recommended:
1. In-home
2. Out-patient
3. Bed rest
4. Stationary
5. Unrestricted
30. In-home regimen can be prescribed by a doctor in the
following cases:
1. Nursing care after an adult patient at hospital
2. Nursing care after a child under 3 years old and disabled
child under 18 years old in case of a mother’s sickness
3. Disease (trauma)
4. Quarantine
31. Health care has many characteristics. They include:
1. Appropriateness (relevance)
2. Adequacy
3. Kindness
4. Complexity
5. Availability
6. Accessibility
32. Levels of health care are as follows:
1. Primary care level
2. Simplex care level
3. Secondary care level
4. Tertiary care level
5. Intermediate care level
33. What types of medical posts and specialities exist:
1. Physicians (primary-care physicians and hospital specialists)
2. Nursing staff (nurses and midwives)
3. Senior medical staff
4. Additional staff
5. Internal practitioners
34. When and where a new approach to health care (is known
as «primary health care») came into existence:
1. 1978, New-York

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 2. 1960, Moscow
3. 1978, Alma-Ata
4. 1960, Deli
35. What principles of PHC exist:
1. Equitable distribution
2. Medical stuff participation
3. Intersectoral coordination
4. Difficult technology
36. The main sections of medical-preventive help to
population are as follows:
1. Prevention, coordination, treatment
2. Prevention, diagnostics, treatment, rehabilitation
3. Diagnostics and treatment
37. What types of medical organisations are considered as
specialized organisations:
1. Oncological clinic
2. Blood transfusion station
3. Regional consultative polyclinic
4. The Regional Centre of Hygiene, Epidemiology and Public
Health
5. Antituberculous dispensary
38. The advantages of the primary health care are as follows:
1. Available to all population
2. Economical factor
3. Reduces the average term of staying in hospital
4. Includes prevention, treatment and rehabilitation
5. Provides constant supervision of the population health
39. The primary health care is:
1. Rendering of first aid in case of sudden diseases and traumas
immediately and during transportation
2. The first level of contact of population with the public health
system
3. Rendering of consultative medical help at the pre-hospital stage
40. The main principles of the activity of a doctor of general
practice (general practitioner) are as follows:
1. Generality
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 2. Continuity
3. Availability
4. Specialization
5. Confidentiality
41. A general practitioner deals with patients:
1. With any nosological forms of diseases
2. With most often met and accessible to diagnostics diseases
3. With acute infectious diseases
42. For the organization of work of the medical personnel
with a family the following aspect is taken into consideration:
1. Family structure
2. Staffing of a medical establishment
3. The indicator of fertility
4. Total birth rate
43. The patients of a general practitioner are:
1. All adults
2. Adults, except for pregnant women
3. All age-sexual groups of population
4. Adults and teenagers
44. The primary medical statistical documentation is
necessary for:
1. The registration of a studied phenomenon (for example,
morbidity with a first diagnosed disease)
2. Efficient management
3. Working out of certain, reasonable decisions
4. Studying of features and regularities of the population health
state
5. Decrease of the quantity of patients’ groundless complaints
45. In organizing social-medical care for a family the
following should be considered:
1. Socio-demographic indicators of a family
2. Biomedical characteristics of a family
3. The indicator of the preventive work at children's polyclinics
46. What is the proportion of Belarussian patients receiving
medical aid in out-patient (polyclinic) conditions?
1. 50%
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 2. 40%
3. 60%
4. 90%
5. 80%
47. The tasks of a city polyclinic in the Republic of Belarus
are as follows:
1. Carrying out of a dispensary supervision over various
contingents
2. Carrying out of a sociomedical examination (assessment of
temporary disability)
3. Rendering of specialized qualified medical aid
4. Improvement of environment of a servicing area
5. Medical-hygienic education of population
48. Out-patient-polyclinic service of population is based on
the following principle:
1. Divisional principle
2. Divisional-territorial (district-territorial) principle
3. Territorial principle
4. Manufactory principle
49. The main part of work of a district therapist takes place:
1. At the hospital
2. At the polyclinic and at home
3. At the department of preventive work of a polyclinic
4. In diagnostic rooms of a polyclinic
5. In a polyclinic laboratory
50. The structure of a city polyclinic includes the following
structural subdivisions:
1. The management of a polyclinic
2. Registration office
3. The department of prevention
4. The department of dispensary supervision
5. The department of psychoprophylaxis
51. The indicator of medical aid appealability in a polyclinic
(attendance rate) is:
1. The number of visits to a polyclinic during one shift

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 2. The number of primary visits to a polyclinic for a year
per 1 person
3. The number of primary and repeated visits to a polyclinic
4. Population morbidity rate
52. The district covered by a therapist (territorial therapeutic
district) in the Republic of Belarus includes:
1. 600 persons
2. 1500 persons
3. 1700 persons
4. 2300 persons
5. 4000 persons
53. The structure of the department of prevention of a city
polyclinic includes:
1. The room of a preliminary examination
2. Women’s examination room
3. Procedure room
4. The room for rendering assistance to teenagers
5. Anamnestic room
54. The primary tasks of the department of prevention are as
follows:
1. Early revealing of patients with a high risk of a disease
2. Organization and carrying out of preliminary preventive
medical examinations
3. Organization and control over carrying out of preventive
medical examinations
4. Organization and carrying out of medical expert
examinations
5. Assigning patients to MCC (Medical Consultative
Commission)
55. The department of prevention includes the following
subdivisions:
1. Anamnestic room
2. The room of functional-tool methods of research
3. Day-time in-patient department
4. Women’s examination room
5. The room of promoting a healthy way of life

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 56. The main tasks of the preliminary examination room are
as follows:
1. Sanitary preparation of patients
2. Carrying out of anthropometry, measuring of blood pressure,
body temperature
3. Reception of patients for making the decision about the
urgency of their referral to a doctor
4. Participation in organization and carrying out of preventive
medical examinations
5. Working up of individual rehabilitation programs for patients
57. The measures taken for reduction of queues to the
registration office in polyclinics:
1. The presence of helpful information
2. Introduction of the method of self-making an appointment
with a doctor
3. Calling a doctor by the phone
4. Regulation of a stream of visitors at a polyclinic
5. The increase of the number of in-home medical visits
58. The polyclinic registration office does not perform the
following functions:
1. To make an appointment with a doctor
2. Mass referral of visitors for the examination
3. To receive calls for a doctor’s visit at home
4. To ensure the optimal stream of visitors
59. The department of medical rehabilitation of polyclinics
includes following parts:
1. The room of exercise therapy
2. Physiotherapeutic rooms
3. Acupuncture rooms
4. Day-time in-patient department
5. The room of medical-hygienic knowledge propaganda
60. The functions of the doctor of the infectious diseases
room in polyclinics:
1. Consultation of the patient with an infectious disease suspected
2. Treatment of patients with present infectious diseases
3. Registration and analysis of the infectious morbidity

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 4. Carrying out of disinfection
5. The primary reception of infectious patients
61. During in-home consultation of a patient the district
doctor should not do the following:
1. To ensure the early revealing of a disease
2. To render the assistance to needy persons timely
3. To visit patients without indications at home every day
4. To visit patients at home on the day of calling a doctor
62. The medical record of the ambulatory patient contains the
following:
1. The forms of long-term information
2. The forms of monthly information
3. The forms of operative information
63. The head of the polyclinic department does not fulfill
the following functional duties:
1. To improve the qualification of district physicians
2. To analyze and control the work of district physicians
3. Organizational-methodical and consultative work
4. To execute orders within a department
64. The regimen and forms of functioning of a polyclinic and
personnel load should be estimated at the following level:
1. Republican level
2. Regional level
3. The head of the establishment
65. The term «the case of polyclinic service» does not include:
1. Every visit of a patient to the polyclinic
2. The total number of patients’ visits to the polyclinic with
a certain purpose until its realization
3. Reception of one patient by the doctor
4. A visit concerning a record for returning to work
66. The main directions of the work of a medical specialist are:
1. Medical-diagnostic work at the polyclinic and at home
2. Consultative work at the polyclinic and at home
3. Carrying out of preventive measures in the sphere of
personal specialization
4. Control of the work of a district therapist
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 67. The work of a polyclinic is characterized by the following
indicators:
1. Birth rate and average duration of life
2. The coverage of preventive medical examinations and the
load of doctors
3. Diseases with a temporary and stable disability (invalidity)
4. The prevalence of illnesses and fertility rate
68. The organization of the work of a polyclinic is
characterized by the following data:
1. The structure of visits according to a speciality
2. The distribution of visits according to the type of medical
aid rendered
3. The structure of in-home visits
4. The ratio of primary and repeated in-home visits
5. A percentage of refusals to hospitalization
69. The volume of medical aid at polyclinics is affected by
the following factors:
1. Provision of population with hospital beds (population-bed ratio)
2. The function of a doctor’s position
3. Population morbidity
4. Staffing level of a polyclinic
70. In the analysis of the work of a polyclinic the following
data is taken into consideration:
1. The number of pathologicoanatomic autopsies of the persons
died at home
2. Carrying out of preventive work and its results
3. Organization of the work of a polyclinic
4. A percentage of the coincidence of clinical and
pathologicoanatomic diagnoses
5. The continuity of the work of a polyclinic and hospital
71. In the analysis of the doctors’ load of a polyclinic the
following data is taken into consideration:
1. The load of doctors according to a speciality during the
working hours of a polyclinic
2. The load of doctors with in-home visits
3. A proportion of visits of patients living within the area of
a polyclinic
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 4. The load of doctors by the days of a week
5. The number of patients referred to hospitalization
72. The qualitative indicator of a polyclinic is:
1. The total morbidity of population
2. Infectious morbidity
3. The number of persons removed from the dispensary
registration due to the change of the place of residence
4. Primary disability (first handicapped) rate
5. Death rate
73. The dispensary method includes the following principles:
1. Early active revealing
2. Active regular dynamic medical supervision
3. Self-examination
4. Public prevention
74. Specify the statistical document which contains the
information about endured diseases and results of conducted
medical examinations:
1. A list of exacted diagnoses of an ambulatory patient
2. A medical record of an ambulatory patient
3. A record of a patient, who is referred to preventive medical
examinations
4. A control record of dispensary supervision
75. Specify the main registration document in studying the
morbidity rate of a dispensary group:
1. A control record of dispensary supervision
2. Ambulatory record
3. Medical patient’s history
4. A list of temporary disability
76. The quality of the organization of preventive medical
examinations is characterized by the following indicators:
1. A full coverage with dispensary registration
2. The duration of dispensary supervision
3. Prevention of diseases and complications
4. A timely dispensary registration
5. A timely revealing of a disease

199
 77. Indicators of the organization of dispensary supervision are:
1. A full coverage with dispensary registration
2. Death rate of patients who had the dispensary examination
3. The dynamics of a temporary disability rate of patients who
passed a dispensary examination
4. A timely dispensary registration
5. The timely carrying out of medical and health-improving
measures
78. The efficiency of dispensary supervision is estimated by a
number of persons removed from the dispensary registration due to
the following reasons:
1. Retirement
2. Disability
3. Recovery
4. The change of the residence place
5. The patient’s refusal to dispensary supervision
79. For estimating the efficiency of dispensary supervision the
following indicators are used:
1. A shift from one dispensary group to another
2. Morbidity with a temporary disability
3. Birth rate dynamics
4. The frequency of relapses and stable remission
5. The change of a disability group
80. The indicators of the efficiency of dispensary supervision
are as follows:
1. The frequency of relapses
2. The dynamics of a temporary disability rate of patients who
passed a dispensary examination
3. A shift from one health group to another
4. Primary disability rate (first handicapped)
5. A timely dispensary registration
81. The indicators of efficiency and quality of the carrying
out of dispensary supervision can be as follows:
1. The frequency of exacerbations, the regularity of examinations
2. The frequency indicator of the carrying out of medical-
preventive measures

200
 3. An average number of days of hospitalization
4. A number of persons removed from the dispensary
registration due to recovery
82. The functions of the admission room in hospital are as
follows:
1. To render urgent medical aid to a patient
2. To write down the medical history of a patient
3. To carry out sanitary prophylaxis of patients
4. To organize a patient’s referral to the in-patient department
5. To write the list of a temporary disability
83. The doctor on duty does not perform the following
functions:
1. To issue a death certificate
2. To receive and render medical aid to patients
3. To observe of seriously ill patients
4. To consult patients at the admission room
84. The admission room does not perform the following:
1. Twenty-four-hour hospitalization of patients according to
profiles of diseases
2. Rendering of first medical aid
3. Analysis of a discrepancy between the diagnoses of
emergency aid and the admission room
4. Analysis of the causes of the refusal to hospitalization
5. The issue of documents certifying a temporary disability
85. The preparation and quality of food intended for patients
in hospitals of the Republic of Belarus is to be controlled by:
1. Head doctors
2. Assistants to the head doctor for medical work
3. Chief accountant
4. Head nurse
5. The responsible doctor on duty
86. Discharge from the hospital is permitted in the following
cases:
1. In case of a patient’s violation of the internal order of a
public health organization
2. In case of a patient’s recovery

201
 3. By the written request of a patient before recovery takes
place if the patient is dangerous for another patients
4. If there is a necessity of a patient’s transfer to another public
health organization
5. In case of the stable health improvement in order to continue
treatment in out-patient conditions
87. The following actions are not subjected to mechanization:
1. Cleaning of hospital wards
2. Bedpans cleansing
3. Collection of dirty bedclothes
4. Serving out of food
88. The main forms of medical documentation in hospital are:
1. A medical record of a hospital patient
2. A development history of a child
3. An individual record of a pregnant woman and woman in the
postnatal period
4. A registry journal of deliveries and in-home obstetrics
5. A statistical coupon for the registration of final (exacted)
diagnoses
89. Specify the period of storing medical records of hospital
patients (form № 003/acc.):
1. 10 years
2. 25 years
3. 50 years
4. Constantly
90. Specify the period of storing statistical records of the
patients discharged from the hospital (form № 066/acc.):
1. 10 years
2. 25 years
3. 50 years
4. Constantly
91. In studying refusals to hospitalization the following
medical documentation is not used:
1. A statistical coupon for a doctor’s consultation
2. A record of a discharged patient
3. A registration list of patients and bed fund

202
 4. A registry journal of receiving patients and refusals to
hospitalization
92. The general indications to the treatment of a patient in the
day-time hospital are as follows:
1. The necessity of introduction of medicinal substances by an
intravenous drop method
2. The necessity to follow a strict bed regimen due to the
patient’s state of health
3. The limited ability of independent moving
4. The necessity of twenty-four-hour parenteral introduction of
medicinal preparations
5. The necessity of carrying out of some medical procedures (a
puncture of the pleural cavity, puncture of the abdominal cavity, etc.)
93. Medical indications to a patient’s referral to the day-time
hospital are determined by:
1. The nosological form of a disease
2. Willingness of a patient
3. The possibility of self-service
4. The stage of a pathological process
94. The general contra-indications to a patient’s referral to
the day-time hospital are as follows:
1. The necessity of preparing patients to complex diagnostic
examinations and a subsequent medical supervision
2. The necessity of carrying out balneal procedures (bathing,
mud applications, etc.) along with a basic treatment
3. Considerable aggravation of a patient’s state of health during
night time
4. Acute diseases
5. The presence of infectious skin diseases in a patient
95. Social indications to the referral to the day-time hospital
are determined by:
1. The absence of severe accompanying diseases in a patient
2. Domestic living conditions of a patient
3. The absence of complications caused by the main pathology
in a patient
4. The possibility to organize the in-home patient’s care

203
 96. The ways of improving the quality of inpatient treatment
do not include the following:
1. The control over the quality of inpatient aid
2. Total hospitalization of patients
3. Strict following the stages of a medical-diagnostic process
4. The presence of reasonable grounds for a patient‘s referral to
the hospital
5. The referral of a patient to the specialized department of a
hospital
97. The department of intensive therapy and resuscitation
does not perform the following:
1. Rendering of medical aid to the most seriously ill contingent
of patients
2. Intensive supervision over postoperative patients
3. Rendering of medical aid to ambulatory patients
4. Intensive supervision over patients with myocardium heart
attack in the acute stage
98. The corpses of the dead persons should be subjected to the
obligatory pathologicoanatomic examination in the following cases:
1. Infectious diseases or suspicion of their presence
2. In the cases of the obscure diagnosis of a disease
3. In the cases of a fetal death, death of newborns and children
under 1 year old
4. After the artificial abortion conducted outside a medical
establishment
5. Poisonings
99. In the analysis of the work of a hospital the following
aspects are taken into consideration:
1. The continuity of work of a hospital and polyclinic
2. The quantity of refusals to hospitalization
3. Organization of the work of a hospital
4. The quality of medical diagnostics
5. The quality of patients’ treatment
100. The qualitative indicators of a hospital are as follows:
1. The distribution of patients discharged from the hospital by
the results of treatment

204
 2. Lethality
3. Morbidity
101. The qualitative estimation of the work of a surgical
department can be characterized by the following indicators:
1. The structure of conducted surgical operations
2. The frequency indicator of complications during operations
3. The frequency indicator of the application of various types of
narcosis
4. Postoperative lethality rate
5. A percentage of the patients who refused surgical operation
102. The indicators characterizing the usage of the hospital’s
bed fund are as follows:
1. Bed turn-over ratio
2. Lethality
3. A number of hospital beds in a department
4. The average number of days per year when a bed is occupied
5. The average duration of a patient’s stay in a hospital
103. The average bed turn-overratio in city hospitals:
1. 13-15
2. 20-25
3. 16-19
4. 30-35
104. Surgical activity is:
1. The ratio of the number of operated patients by urgent
indications to the number of all operated patients
2. The ratio of the number of operated in a planned order
patients to the number of hospitalized patients
3. The ratio of the number of operated patients to the number of
hospitalized patients
4. The ratio of the number of surgical operations to the number
of registered surgical patients
105. Surgical activity in a hospital is characterized by:
1. The number of operations per 100 operated patients
2. The number of operations per 100 hospitalized patients
3. The number of operations per 1 doctor of a surgical profile
for the reporting period

205
 106. The indicators of lethality are subdivided into the
following classes:
1. Out-hospital lethality
2. Daily lethality
3. Postoperative lethality
4. Lethality at night
5. Total lethality in a hospital
107. The information required for the estimation of a lethality
indicator in a hospital:
1. The number of patients at the beginning of the year
2. The number of patients in the end of the year
3. The number of discharged from the hospital patients
4. The number of patients died in a hospital
108. In calculating the lethality parameter it is necessary to
know:
1. Population number
2. The number of patients
3. The number of died persons
109. The indicator of daily lethality is estimated by the
following:
1. The ratio of the number of died persons during first 24 hours
to the number of hospitalized persons
2. The ratio of the number of hospitalized persons to the
number of died persons during first 24 hours
3. The ratio of the number of discharged from the hospital
patients to the number of persons died during first 24 hours
4. The ratio of the number of persons died during first 24 hours
to the number of discharged from the hospital patients
110. Postoperative lethality is:
1. The ratio of the number of patients died after operation to the
number of hospitalized patients
2. The ratio of the number of died patients to the number of
patients discharged from the hospital
3. The ratio of the number of died patients after operation to all
the operated patients
4. The ratio of the number of died patients after operation to
the number of hospitalized patients
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 111. For the calculation of the lethality rate due to
cardiovascular diseases the following data is required:
1. The number of patients died from cardiovascular diseases
during a year
2. The number of patients with cardiovascular diseases
within a year
3. Population number
4. Total number of cardiovascular diseases within a year
112. The persons working at industrial enterprises in the
Republic of Belarus can receive medical aid:
1. In special medical establishments situated at the territory of
enterprises
2. At the public office of medical forensic examinations
3. In the centers of hygiene, epidemiology and public health
4. At «factory therapeutic sectors» of polyclinics of a general
network
5. At the general medical network according to the place of
residence (polyclinics, hospitals, dispensaries)

Medical care for rural population, for working people

113. Under what three heads the various measures for the
prevention of occupational diseases may be grouped:
1. Medical
2. Scientifical
3. Engineering
4. Preventive
114. Medical measures for the prevention of occupational
diseases may be as follows:
1. Medical examinations
2. Organization of medical and health care services for workers
3. Supervision of working environment
4. Change in the education level
5. Growth of salary
115. Engineering measures for the prevention of
occupational diseases may be as follows:
1. Medical examinations
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 2. General ventilation
3. Organization of medical and health care services for workers
4. Substitution (the replacement of harmful material by a
harmless one, or by one of less toxicity)
5. Protective devices (respirators, gas masks, etc.)
116. Legislation for the prevention of occupational diseases
includes such aspects, as:
1. Employment of young
2. Length of working day
3. General ventilation
4. Medical examinations
5. Employment in hazardous processes
117. Indicators of time disability (temporary sickness absence
from work) are as follows:
1. Number of events on 100 workers
2. Number of days with temporary sickness absence from work
on 100 workers
3. Structure of one case in percent
4. Average length of one case in days
5. Complexity of cases
118. What are the basic territorial technological levels of
medical aid providing to rural population:
1. Level of village
2. Level of rural doctor’s district
3. Level of rural area or interareas level
4. Level of city
5. Level of the region
6. Republican level
119. A factory’s therapeutic sector is established by the
following principle:
1. Service radius
2. Gender structure of workers
3. Age structure of workers
4. The number of workers
5. Similarity of technological processes

208
 120. The main duties of a factory's sectorial doctor are as
follows:
1. To render primary health care to workers
2. Additional examination and treatment of persons requiring
regular medical check-up
3. To render specialized medical care
4. Studying of working conditions
5. Sanitary-preventive work
121. The types of medical preventive examinations are as
follows:
1. Periodic
2. Gender-specificl
3. Out-patient
4. Preliminary
122. The following types of obligatory medical preventive
examinations of workers are distinguished:
1. Preventive medical examinations
2. Preliminary medical examinations
3. Periodic medical examinations
4. Consultative medical examinations
5. Final medical examinations
123. The sanitary-hygienic characteristic of working
conditions of personnel is prepared by:
1. The administration of the enterprise
2. The Territorial Centre of Hygiene, Epidemiology and Public
Health
3. A factory’s sectorial doctor
4. A qualified pathologist
5. Professional unions
124. The purpose of preliminary medical examination is:
1. To reveal contra-indications to the work in a certain
profession or to the training in the given specialty
2. To estimate if the state of health corresponds with the
requirements of a profession or training
3. To reveal the diseases which can exacerbate and progress in the
course of studying or in conditions of working with professional
hazards
4. To estimate the indications for sanatorium treatment
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 125. The sanitary-hygienic characteristic of working place
should contain the following data:
1. The list of harmful factors of the industrial environment and
working process
2. The reasons and number of days of a temporary disability for
the last year
3. The characteristic of working process factors
4. The characteristic of living conditions
5. Personal protection equipment and its usage
126. The medical-engineering team consists of:
1. A chief engineer or his assistants
2. A director of an enterprise
3. Cooks or a manager of a canteen
4. A doctor for industrial hygiene
5. Safety engineer
127. The sections of a complex plan for health-improving
measures at industrial enterprises are as follows:
1. Sanitary-technical measures
2. Sanitary-hygienic measures
3. Medical-preventive work
4. Organizational work
5. Calculation of the expenses for technical measures
128. The uniform complex plan for health-improving
measures consists of the following sections:
1. Measures for the prevention of occupational diseases and
traumas
2. Measures for promoting a healthy way of life
3. Sanitary-technical measures
4. Medical-preventive measures
5. Mass health-improving measures
129. The quality of preventive medical examinations is
estimated by the following:
1. The number of the examined obligatory contingents
2. The quality of anamnestic data collecting
3. The presence of qualified medical personnel
4. Availability and usage of modern equipment

210
 130. The difference in health service between urban and rural
population is determined by:
1. The peculiarity of rural population’s settling
2. Seasonality of agricultural work
3. The lower salary of a doctor in the rural area
4. The prevalence of persons occupied mainly with a physical
work
5. Social-economic and living difficulties
131. The peculiarities of the organization of medical aid to
rural population are not determined by the following factors:
1. Scattered settlements
2. The small number of population in these settlements
3. A specific character of agricultural production
4. Religious beliefs
132. The factors determining the peculiarities of the
organization of medical care to rural population are as follows:
1. Geographic
2. Medical
3. Extreme
4. Social
5. Natural-climatic
133. The improvement of the quality and availability of
medical service for rural inhabitants is determined by the following:
1. The development of mobile devices of medical-diagnostic
care
2. Addition of paid services
3. The reception of patients by a doctor with a nurse assisting
4. The establishment of inter-district specialized departments
5. Financial and technical support of central district hospitals
134. The extent and quality of medical-social care to
population is influenced by the following factors:
1. The remoteness of medical establishments from the
residence place of patients
2. The population ratio according to sex
3. Provision of medical establishments with equipment
4. A possibility of receiving specialized medical care
5. Staffing with qualified personnel
211
 135. The functions of a rural medical sector do not include
the following:
1. Rendering of medical-preventive care to population
2. Carrying out of sanitary measures
3. Obstetrics
4. Health protection of children and teenagers
5. Rendering of the consultative help to patients
136. The main purpose and functions of a rural district
hospital are as follows:
1. To render medical-preventive care to rural population
2. To arrange medical-preventive measures in health protection
of a mother and child
3. To organize the dispensary supervision of rural inhabitants
4. To fulfill the examination of a stable working ability
137. The main structural subdivisions of central district
hospital are as follows:
1. A consultative polyclinic
2. A children's department
3. A specialized department
4. First and urgent medical care department
5. The Centre of Public Health
138. The structure of regional hospital does not include the
following departments:
1. A hospital with specialized departments
2. A consultative polyclinic
3. The regional department of medical labour examination
4. Organizational-methodical department
139.Functions of chief specialists at the organs of public
health service control are as follows:
1. Administrative function
2. The control of specialized medical care
3. Consultative function
4. Professional training of medical personnel

212
 Organization of medical care to children and woman

140. What are the basic indexes characterizing maternal

health well-being?
1. Maternal mortality ratio
2. Child mortality rates
3. Indexes of health care delivery for women and children
4. The number of diseases per one woman
5. The number of abortions and abortions / women ratio
141. What are the basic indexes characterizing health care
delivery for women and children:
1. Doctor-population ratio
2. Woman/ children ratio
3. Child mortality ratio
4. Hospital beds-population ratio
5. Maternal mortality ratio
142. What is «pure coefficient of reproduction»?
1. Age-specific fertility rate
2. Total fertility rate
3. Gross reproduction rate
4. Net reproduction rate
143. What indexes are using as special children’s death
indexes?
1. Indexes of mortality in and around infancy
2. Indexes of mortality from specific diseases
3. Indexes of mortality of children under 3 years of old
144. What are basic indexes characterizing children’s health
well-being?
1. Infant mortality rate
2. Perinatal mortality rate
3. Gross reproduction rate
4. Age-specific fertility rate
5. Fetal mortality or Mortinatality
6. Under-five mortality rate

213
 145. What is «the UNICEF index»?
1. Infant mortality rate
2. Under-five mortality rate
3. Perinatal mortality rate
4. Maternal mortality ratio
146. Motherhood and childhood protection is a system of
state, public and medical-social measures providing conditions for:
1. Birth of healthy children
2. The all-around development of rising generation
3. Prevention and treatment of illnesses in men
4. Prevention and treatment of illnesses in children
5. Prevention and treatment of illnesses in women
147. The following state allowances are granted in the
Republic of Belarus:
1. Maternity allowance
2. The allowance granted with childbirth
3. The allowance granted to a mother who was registered
before the 12th week of the pregnancy term
4. The allowance granted for taking care of a child under
3 years old
5. The allowance granted to unemployed persons registered at
the Social Protection Fund during 10 years and more
148. The main principles of the preventive medical examina-
tion of children (children dispensary supervision) are as follows:
1. Age-dependent
2. Nosological
3. Mixed
4. Gender-dependent
149. The types of medical-preventive care to children are as
follows:
1. Polyclinic
2. Stationary (hospital)
3. Sanitary-preventive
4. Sanatorium
150. The main principles of the work of a children's polyclinic:
1. A district principle

214
 2. A regular dynamic examination
3. The continuity of work of the doctors rendering medical-
preventive aid
4. Conclusion of contracts with insurance companies
151. The complex of preventive measures among children
population is realized in the following way:
1. The dynamic examination of healthy children
2. Referring for the hospital treatment
3. Carrying out of preventive vaccinations
4. Sanitary-educational work
152. The working schedule of a district pediatrician should be:
1. Rotating
2. Free
3. Mixed
153. The cases of obligatory health service for children at
home performed by a district pediatrician are as follows:
1. All sick children under the age of 1 year
2. All children with the temperature 38ºC and more
3. Children who had contacts with infectious persons
4. All children under the age of 3 years
5. Healthy children during first month of life
154. The frequency of examinations of a healthy child during
first year of life by a district pediatrician in Belarus is:
1. Once during 3 months
2. Once per month
3. Once during 6 months
4. Twice per month
155. The organizational peculiarities of a children's hospital
are as follows:
1. The presence of boxes
2. The age-dependent principle in the filling of wards
3. The presence of teachers in the hospital staff
4. Creation of conditions for rooming-in (joint stay of a mother
and her child)
5. The presence of a room of woman’s hygiene

215
 156. The criteria of a complex assessment of children and
teenagers’ state of health are:
1. The presence of chronic illnesses at the moment of
examination
2. The presence of chronic illnesses for the previous year
3. The functional state of basic systems of an organism
4. The system of organism’s resistance to unfavorable factors
157. The main tasks of maintaining and improving the
reproductive health of women and children are:
1. Protection of pre-pregnancy state of health
2. Family planning
3. Antenatal protection of fetus
4. Children health protection
5. The transfer of pregnant women starting from the 12 th week
to the sectors with less intensive work
158. What measures are intended for maintaining and
improving the health of women and children?
1. Family planning
2. Antenatal protection of fetus
3. Breast feeding support
4. Prevention and early diagnostics of the reproductive system
cancer in women
5. Investigation of complications after vaccination
159. Family planning is:
1. Freedom in decisions making about the number of children
in family, terms of their birth
2. A possibility to control child-bearing in a certain situation
3. Birth of the desired children only
4. A guarantee of giving to birth only healthy children
5. The level of sexual education
160. Public health organizations of the 2nd level of the
perinatal aid system in the Republic of Belarus are as follows:
1. Maternity clinic
2. Obstetric hospital with the quantity of deliveries less than
400 per year
3. Inter-district perinatal centre

216
 4. Public health organizations which perform the special care of
newborns
5. Regional maternity hospital
161. Public health organizations of the 3rd level of the
perinatal aid system in the Republic of Belarus are as follows
1. Maternity clinic
2. Obstetric hospital with the quantity of deliveries less than
400 per year
3. Inter-district perinatal centre
4. Regional maternity hospital
5. Regional children's hospital
162. Inter-district perinatal centre is:
1. A public health organization referred to the 1st level of the
perinatal aid system
2. A public health organization referred to the 2nd level of the
perinatal aid system
3. A public health organization referred to the 3rd level of the
perinatal aid system
163. Public health organizations of the 1st level of the
perinatal care system are as follows:
1. Maternity clinic
2. Obstetric hospital with the quantity of deliveries less than
400 per year
3. Inter-district perinatal centre
4. Obstetric department with the number of deliveries 400-2000
per year
5. Regional maternity hospital
164. The estimation of the reproductive potential of women is
performed on the basis of the following:
1. The prevalence of general somatic diseases
2. The state of physical and sexual development
3. The decrease in the quantity of purulent-septic complications
and intrahospital infections in a hospital
4. Estimation of the influence of sociomedical factors on the
state of the reproductive system
5. The prevalence of the reproductive system diseases

217
 165. The indicators of reproductive loss cases are as follows:
1. Infant mortality rate
2. Children morbidity rate
3. Children disability rate
4. Physical development of children
5. Maternal mortality ratio
166. Female contingents of a childbirth reserve group in the
Republic of Belarus are as follows:
1. 0-14 years old
2. 15-17 years old
3. 18-24 years old
4. 25-34 years old
5. 35-40 years old
167. Pre-pregnancy medicinal preparation is conducted for:
1. Women of a childbirth reserve group, planning pregnancy
2. Both spouses 2-3 months prior to conception
3. Pregnant women and their husbands
168. The purpose of dynamic supervision over the women of
a childbirth reserve group in the Republic of Belarus is as follows:
1. Improvement of the reproductive health
2. Integration of therapeutic and gynecologic aid
3. The decrease of extragenital pathologies among pregnant
women
4. The decrease of infant death rate
5. The decrease of maternal death rate
169. The main functions of the maternity clinic are as
follows:
1. To render the obstetric care during pregnancy and in the
postnatal period
2. Preparation to delivery and pre-pregnancy preparation
3. Diagnostics and treatment of infertility
4. Treatment of habitual noncarrying of pregnancy
5. To render the out-patient care to women with gynecologic
diseases
170. The consultation «Marriage and a family» is:
1. A specialized public health organization of the regional level

218
 2. Public health organizations rendering help to the married
couples with infertility
3. Public health organizations rendering aid concerning the
treatment of a gynecologic pathology to women only, and are the
specialized maternity clinics
171. The term «safe motherhood» means the following:
1. Provision of pregnant women with antianemic preparations,
polyvitamins
2. Prevention of the birth of children with congenital
development abnormalities
3. Qualitative medical examinations of female teenagers
4. Prevention of the unplanned pregnancy in female teenagers
172. The antenatal protection of fetus consists in the
following:
1. Improvement of the quality of the pregnant women’s
examination
2. The timely antenatal hospitalization of pregnant women with
pathologies
3. Prevention of the unplanned pregnancy
4. Prevention of birth of children with congenital development
abnormalities
5. Improvement of a multilevel system of perinatal care
173. The measures of antenatal fetal protection are as follows:
1. Rendering of resuscitation aid to newborns
2. Maintenance of a temperature regimen in maternity
(delivery) wards
3. Improvement of a multilevel system of perinatal care
4. Revealing of a pathology in women of a fertile age and its
treatment
5. Sanation of chronic infections, extragenital diseases in
pregnant women
174. The most often met extragenital diseases during
pregnancy in the Republic of Belarus are as follows (select two
groups):
1. Anemia
2. Infectious and parasitic diseases

219
 3. Thyroid gland dysfunctions
4. Fat exchange disturbance (endocrinous pathology)
5. Illnesses of the blood circulation system
175. The main directions of the work of a maternity clinic for
preventing abortions are as follows:
1. Organization of the rooms of preventing abortions
2. Improvement of women’s health
3. Improvement of women’s medical literacy
4. Training in the methods of using contraceptives
176. Sociomedical consequences of abortion are as follows:
1. Obstetric-gynecologic bleedings
2. Infertility
3. Gynecologic diseases
4. The increase of infant death rate
177. The indicator of frequency of contraception usage is:
1. The number of women using contraceptives to 1000 women
living in the area of service
2. The number of women using contraceptives to 1000 women
of a fertile age
3. The number of women using contraceptives to 1000 abortions
178. The qualitative indicators of the work of maternity
clinics are as follows:
1. The number of abortions conducted by the vacuum-
aspiration method
2. Population’s complaints
3. The number of received women
4. The frequency of using contraceptives by women
5. Premature birth rate
179. The peculiarities of gynecologic diseases are as follows:
1. Latent course
2. Revealing in the course of preventive medical examinations
3. Progressive course
180. Premature birth proportion is:
1. The number of pregnancies ended with a birth of fetus at any
term of the pregnancy, multiplied by 100 and divided by the number
of all registered pregnant women
220
 2. The number of pregnancies at the term of more than
22 weeks which have ended with a birth of fetus having more than
500 g in weight, multiplied by 100 and divided by the number of all
childbirths
181. The leading position in the structure of malignant
neoplasm morbidity of female population in the Republic of
Belarus belongs to:
1. Cervical carcinoma
2. Ovarian carcinoma
3. Breast cancer
182. How often should women pass the preventive
gynecologic examination with a cytologic inspection?
1. 1 time during 6 months
2. Once per year
3. 1 time during 2 years
4. 1 time during 5 years
183. The structural characteristics of a maternity hospital are
as follows:
1. Physiological and observation obstetrical departments
2. A department of pathologic pregnancy
3. Newborns department
4. Admission room
5. Gynecological department
184. The presence of the department of neonatal resuscitation
and intensive therapy is characteristic for:
1. I level of the system of perinatal medical care
2. II level of the system of perinatal medical care
3. III level of the system of perinatal medical care
4. Regional maternity hospital, regional children's hospital
185. The following cases are estimated by experts in the
Republic of Belarus:
1. Every complaint of population
2. Every case of an intrahospital infection of newborns
3. Every case of the late revealing of malignant neoplasms of
the women’s reproductive organs and mammary glands

221
 186. The registration documents of the obstetric hospital
(maternity hospital, delivery room) include the following:
1. Birth history
2. The history of the newborn’s development
3. Exchange record
4. An instruction booklet for pregnant women and women after
childbirth
5. An individual record of pregnant women and women after
childbirth
187. The qualitative indicators of the work of a maternity
hospital are as follows:
1. Newborns morbidity
2. Early neonatal death rate
3. Maternal death ratio
4. Health index
Sanitary and epidemiological well-being.
Transplantation
188. A donor of blood and its components is:
1. A person requiring the transfusion of blood and its
components due to a disease or trauma
2. A person who is a voluntary donor of blood and its
components for medical purposes
3. All persons older than 18 years old who are potential blood
donors in case of a necessity
189. A donor is:
1. A person who is a potential blood donor of organs or tissues
for the transplantation to ill persons
2. A person who grants voluntarily his anatomic formations for
the transplantation to ill persons
3. A person to whom the organs or tissues of another person are
transferred with a medical purpose
190. A donor of blood and its components can be:
1. Every capable of functioning person who reached the age of
18 years old, passed a medical examination and not suffering from
the diseases in which donorship is contraindicated

222
 2. A person who has not reached the age of 18 years old with
the consent of his parents
3. All persons older than 18 years old
191. Transplantation means a transfer of:
1. Any organ
2. A twin organ
3. A part of an organ or tissue if its absence does not cause
irreversible processes in the organism
192. Transplantation of organs and tissues of a person is
conducted:
1. At any public health organizations
2. At the private public health organizations
3. At the state public health organizations only
193. In case if a donor is under the age of 18 years old it is
allowed to carry out the following transplantation:
1. Transplantation of the bone marrow only with a written
consent of his parents (adoptive parents) and the organ of care and
trusteeship, and with a person’s consent
2. Transplantation of twin organs with a consent of parents
(adoptive parents)
3. Transplantation of any organs and tissues
194. A medical certificate of the necessity of organs and
tissues’ transplantation is issued to a recipient by the commission
of the following doctors:
1. Doctor in charge
2. Surgeon
3. Doctors of other specialties if necessary
4. The head doctor of a public health organization
5. Anesthesiologist
195. What are the main state measures to provide the
sanitary-and-epidemiological well-being?
1. The system of the state stimulus directed at the maintenance
of authorized sanitary norms
2. The uniform sanitary-and-hygienic requirements to
supervising objects

223
 3. The uniform requirements to diagnostics, prevention and
rehabilitation
4. The system of the state and departmental sanitary inspection
196. The state sanitary inspection is:
1. The activity of state organs and organizations, directed at the
prevention of diseases by the means of detecting and suppressing the
sanitary-epidemic violations of legislation
2. Control of the work of medical organizations
3. Control of the work of industrial enterprises
197. Sanitary-epidemiologic situation is:
1. The condition of sanitary-epidemic well-being at the certain
territory
2. The condition of sanitary-epidemic well-being during the
certain period of time
3. The measures taken by the public health organs to improve
the population’s life
198. The current sanitary inspection includes:
1. Realization of the regular control over the functioning
objects
2. Organization and control over the carrying out of medical
preventive examinations
3. Carrying out of the regular sanitary control over the course
of objects’ construction
4. Registration of all reconstructed objects and objects which
are under construction
5. Control over the complying with sanitary rules during
transportation, storage and realization of food
199. The precautionary sanitary inspection includes the
following basic elements:
1. Hygienic studying and control over the state of air
environment, reservoirs, soil
2. Ensuring of the complying with sanitary-hygienic norms in
the food production
3. Coordination of the land allotment for building projects
4. Approval of a construction (reconstruction) project of the
object
5. Putting into operation of a reconstructed object
224
 200. The establishments of sanitary-epidemiologic service of
the Republic of Belarus are subdivided according to performed
functions into the following levels of management:
1. The first level – regional, city and zonal centers of hygiene
and epidemiology
2. The second level –regional centers of hygiene, epidemiology
and public health
3. The third level – the Republican Centre of Hygiene,
Epidemiology and Public Health
4. The fourth level – the territorial centre of hygiene and
epidemiology
5. The fifth level – the regional centre of hygiene and
epidemiology
201. The Centre of Hygiene and Epidemiology of the first
level with the number of serviced population amounting to
30 thousands includes the following departments:
1. Sanitary-epidemiologic department
2. Epidemiologic department
3. Disinfection department
4. Microbiological laboratory
5. Sanitary-hygienic department
202. The fields of the sanitary-hygienic activity are as follows:
1. The department of extremely dangerous infections
2. The department of nutrition hygiene
3. The department of occupational hygiene
4. The department of children and teenagers hygiene
5. The department of municipal hygiene
203. According to the number of persons involved in the work
concerning a medical-hygienic training, the following methods of
this training are distinguished:
1. The methods of individual influence
2. The methods of group influence
3. Mass communication methods
4. Globalization methods
204. The means of hygienic training and educating
population are subdivided into:
1. Verbal propaganda
225
 2. Printed propaganda
3. The means of visual propaganda
4. A combined method
5. The means of virtual propaganda
205. Euthanasia is:
1. Killing of healthy persons
2. A voluntary, coordinated with a doctor, death of an incurable
patient with the help of special anesthetics
3. A voluntary, coordinated with a doctor, death of patients
with the help of special anesthetics

Health care management, planning, financing

206. Basic methods of planning are following:
1. Analytical
2. Descriptive
3. Balance
4. Historical
5. Experimental
207. Objects of standardization in public health services are
as follows:
1. Medical services
2. Population health
3. Population morbidity
4. The registration and accounting documentation
5. Information technologies
208. What components are included in the minimal social
standards in the field of public health services in the Republic of
Belarus:
1. Specifications of budgetary financing on one inhabitant
2. Norms of population health
3. Norms and specifications of privileged providing of citizens
with medical products
4. List of medical services free of charge for citizens
209. The main principles of public health service planning
are as follows:
1. Scientific and technical validity
226
 2. Selection of priority directions
3. Combining of prospective and current planning
4. Improvement of forms of public health service management
5. Proportional development of public health services
210. The following complex programs are realized in the
Republic of Belarus:
1. «Population Health and Demographic Safety»
2. «Specializes medical care»
3. «Palliative Care Programm»
211. The problems of countries which reform the public
health service, are connected with:
1. Population aging
2. The increase of chronic pathologies
3. A higher level of male morbidity rate in comparison to
female morbidity rate
4. Development and introduction of new medical technologies
5. The increase of expenses for public health service
212. At the present time the most effective form of planning
in public health services is:
1. Individual planning
2. State order
3. Target programs
4. Economic norms and limits
5. A business plan of public health establishments
213. A need of population in out-patient care is estimated
by the following:
1. A number of visits per one medical position during a year
2. A number of visits per one inhabitant during a year
3. A number of consultations per one inhabitant during a year
4. A number of medical positions per certain number of
population
214. A need of population in hospitalization is understood as:
1. A number of beds per certain number of population
2. A percentage of population requiring hospitalization
3. A number of patients hospitalized within a year
4. A number of medical positions of a hospital per certain
number of population
227
 215. The indicator of the extent of population’s need in
polyclinic help is:
1. The load norm of doctors working in a polyclinic
2. A proportion of elderly and old people in the servicing area
of a polyclinic
3. An average number of visits to a polyclinic per one
inhabitant during a year
4. A function of the medical position
216. Capacity of a hospital is:
1. A number of available beds
2. A number of available beds and currently unavailable beds
(«repair» works)
3. A number of hospitalized patients within a year
4. A number of bed profiles in a hospital
217. The indicator of the extent of work in a hospital is:
1. A number of beds in a hospital
2. A number of bed-days spent by patient during a year
3. A number of hospitalized patients per 1000 inhabitants
4. A number of patients hospitalized within a year
218. The indicator of the extent of work in a polyclinic is:
1. A number of visits during one shift
2. A number of doctors per 10000 inhabitants
3. A number of medical visits per 1 inhabitant
4. A number of visits per day
219. The function of a hospital’s bed is:
1. A number of days when a bed was occupied during a year
2. A number of patients assigned to 1 bed during a year
3. A period of time during which beds were occupied by
patients
4. A bed’s capacity per year in days
220. The norm of a medical personnel’s load is:
1. Expenditure of working time for certain work
2. The regulated extent of work, which should be performed by
a worker during a unit of working time
3. A fixed number of workers to perform the certain volume of
work

228
 221. For the estimation of population’s need in hospital
medical aid the following data is required:
1. The level of appealability to public health establishments due
to diseases per 1000 persons
2. The level of hospitalization
3. A number of dispensary patients
4. An average annual rate of bed’s occupancy
5. An average duration of a patient’s stay in a hospital
222. In order to estimate a function of the medical position
the following basic data is required:
1. A number of visits to a doctor during a working day
2. A sum of receptions and routine inspections for 1 hour
3. A doctor’s load for 1 hour at different types of work
4. A number of working days per year
5. A number of working hours spent for reception of patients,
preventive medical examinations, and in-home visits
223. The sources of financial receipts for health care in
Belarus are as follows:
1. Penalties for violating sanitary norms and rules
2. State budget
3. Paid medical services
4. Voluntary payments of enterprises, establishments and
individuals
5. Allowance for childbirth and bringing up of children till the
age of 3 years
224. At the present time the sources of public health service
financing in the Republic of Belarus are as follows:
1. State budget
2. Donations
3. Incomes from paid services of population
4. Obligatory insurance payments for a disease case
225. The most effective forms of economic stimulation of
medical personnel’s work in the Republic of Belarus are as
follows:
1. Payment for work over the rate
2. Payment for expansion of a servicing zone

229
 3. Payment for complexity and intensity
4. Payment according to a labor participation coefficient for the
volume and quality of performed work
5. Payment for combination of professions
226. The capacity of a hospital department (a number of beds)
is calculated with consideration of the following load:
1. The load of the head of a department
2. The load of a hospital doctor
3. The load of a nurse of the procedure room
4. The load of a nurse on duty
5. The load of a hospital cleaner
227. «Direct» expenses defining the cost price of a certain
medical service do not include:
1. Payment for the work of medical personnel who render
services
2. Charge of wages
3. Expenses for food
4. Amortization of buildings, constructions
228. The computer program of the work with personnel
includes:
1. Individual registration of specialists
2. Personnel rotating
3. The data on certification and recertification, professional
trainings
4. Marital status and its changes
5. Individual registration of rewards and penalties
229. Medical insurance is a system of economic relations
ensuring the establishment of a fund for compensating damages:
1. In case of a disease
2. In case of disability
3. In case of a doctor change
230. According to the WHO the main principles of public
health service are:
1. Availability
2. Preventive measures
3. Confidentiality

230
 4. Qualification
5. Population participation
231. In the Republic of Belarus the following financial
mechanisms take place:
1. Obligatory medical insurance of foreigners
2. Voluntary medical insurance of citizens
3. Voluntary state social insurance
4. Paid medical services at private and state public health
organizations
232. Voluntary medical insurance has the following
character:
1. State character
2. Commercial character
3. Individual character
4. Tariffs are controlled by the state
5. Incomes are used for any activity
233. Conditions of the introduction of medical insurance are
as follows:
1. Legal
2. Organizational
3. Economic
4. Medical
5. Socio-psychological
234. The main forms of medical insurance:
1. Centralized
2. Decentralized
3. Complex
4. Mixed
235. Medical insurance answers the following questions:
1. How to fulfil payments?
2. How to attract financial means?
3. How to ensure quality?
4. How to maintain health?
236. What are the components of medical care quality?
1. Quality of structure
2. Quality of technology
231
 3. Quality of diagnostics
4. Quality of prevention
5. Quality of result
237. Levels of estimation of quality of structure are as
follows:
1. Medical organization as a whole
2. Concrete patient
3. Medical worker separately
4. Population as a whole
238. Levels of estimation of quality of result are as follows:
1. Concrete patient
2. All patients of the medical organization
3. All patients of the doctor
4. The population as a whole
239. The general principles of management are as follows:
1. A principle of the optimal combination of centralization and
decentralization
2. A principle of objectivity (scientific validity)
3. A principle of the market system
4. A principle of systematization
5. A system-defined principle (the management of an
organization as a complete phenomenon)
240. «Management» is:
1. A synonym of the term «control»
2. A complex mechanism of the interaction between a
consumer and producer
3. A system of prices, markets and connections between
organizations
4. A group of professionally trained individuals occupied with
administrative work
5. A branch of science studying the organizational-technical
and socio-economic aspects of management
241. General management in public health service consists
in the following:
1. Management of an organization of public health service
2. Improvement of the quality of medical measures

232
 242. Functional (special) management is:
1. Management of certain fields of the activity of public health
organizations and their branches
2. Management of innovative, financial, professional and
marketing activity
3. The state policy concerning public health care
243. The general laws of management include the following:
1. The law of management specialization
2. The law of management integration
3. The law of moral and financial stimulation
4. The law of time saving
244. The objective of management in public health service is
as follows:
1. To decrease the losses of a society caused by morbidity, stable
disability and mortality of population on the base of existing resources
2. To increase the salaries of medical workers
3. To work up new methods of diagnostics and treatment
245. Economic methods of management are as follows:
1. Financial stimulation
2. Application of economic norms and specifications
3. Working out of planned-economic indicators and means of
their achievement
4. Regulations and instructions of managers
246. Socio-psychological methods of management are:
1. Financial compensation
2. Participation of the personnel in management
3. Creation of a normal psychological climate within a collective
4. Moral encouragement
5. Development of initiative and responsibility
247. A group of people can be considered as an organization, if:
1. There are not less than two persons united into a group
2. There are joint aims in a group
3. A group of people have the joint property
4. The activity of a group is coordinated for the achievement of
certain purposes

233
 248. The resources of an organization are as follows:
1. People (labor resources)
2. Information
3. Basic and circulating assets
4. Objectives and mission of an organization
5. Independence from the external environment
249. The factors of the internal environment of an
organization are as follows:
1. Purposes and tasks
2. Clients
3. Competitors
4. Technology
5. Labor resources
250. The authority in the management of an organization is:
1. A possibility of the manager to influence his subordinates
2. A possibility of subordinated to influence their manager
3. Responsibility of a person for the results of work
4. An instrument to realize the mission of an organization
251. The methods of management are as follows:
1. Organizational-administrative
2. Economic
3. Mathematical
4. Socio-psychological
252. The following styles of management are distinguished:
1. Autocratic (authoritarian)
2. Convincing
3. Adaptive (flexible)
4. Democratic (partner)
5. Imperious
253. The main principles of scientific management of labor
are as follows:
1. Organization of a working place
2. The unity of information base
3. Regulation of labor operations
4. Cooperation and specialization of labor
5. Rational use of working time

234
 254. The main functions of automated control systems are as
follows:
1. Management of medical-preventive care
2. Analysis of the dynamics of health state
3. Working up of recommendations for decision making
4. System-defined approach
5. Continuous development of a system
255. Marketing is a form of the activity directed at:
1. Planning
2. Satisfaction of needs and requirements by the means of
exchange
3. Development of motivations
256. The types of marketing in public health service are as
follows:
1. Marketing of medical services
2. Marketing of public health organizations
3. Marketing of separate persons
4. Marketing of operations
5. Marketing of ideas
257. The market of medical services is segmented by the
following signs:
1. Geographical
2. Psychographic
3. Biologic
4. Demographic
258. Working out of a marketing complex includes:
1. Working out of a service
2. Selling of a service
3. Advertising
4. Advancement to the market
5. Fixing of a price
259. The factors influencing the demand for medical services
are as follows:
1. Advertising
2. Population structure
3. Biological factors

235
 4. Actions and recommendations of the medical personnel
5. The level of population’s income
260. The control system over the quality of medical care in
the Republic of Belarus requires the working up of the following:
1. Normative values of indicators
2. Scales for estimating the results of activity
3. Models of ultimate results
4. Quality standards
261. Efficiency of medical care is:
1. Improvement of functioning of a patient’s organism after
conducting of medical actions
2. A degree of the achievement of concrete results during the
rendering of medical-diagnostic and preventive help with
consideration of financial and labor expenses
3. A degree of financial and labor resources’ savings during
medical aid rendering
262. The quality standards include:
1. Treatment cost
2. Examination standard
3. A number of visits to a polyclinic per one finished case
4. Treatment standard
5. A standard of health condition of a patient who has finished
the treatment
263. The main groups of the reforms of public health service
are aimed at the following problems solving:
1. Insufficiency of resources
2. Efficient use of resources
3. Financial stability
4. Ensuring of free of charge services
5. Ensuring of availability and quality
264. The categories of participants in public health service
reforming are as follows:
1. Citizens
2. The groups of population united according to social interests
3. Workers of public health service
4. Workers of the educational sphere
5. Political elite
236
 ANSWERS FOR TESTS

1. 1,3 26. 2 51. 2 76. 1,4,5

2. 1,3,4 27. 1,2,3,4 52. 3 77. 1.4.5
3. 1,3,4,5 28. 1,2,3,4 53. 1,2,5 78. 3
4. 1,2,3 29. 1,2,3,4 54. 1,2,3 79. 1,2,4,5
5. 1 30. 2,3,4 55. 1,2,4,5 80. 1,2,3,4
6. 1,2,3 31. 1,2,5,6 56. 2,3,4 81. 1,4
7. 4 32. 1,3,4 57. 1,2,3,4 82. 1,2,3,4
8. 1,2,3 33. 1,2 58. 2 83. 1
9. 1,2,4,5 34. 4 59. 1,2,3,4 84. 5
10. 1 35. 1,3 60. 1,2,3,5 85. 1,2,5
11. 2,3 36. 2 61. 3 86. 2,4,5
12. 1,3,4 37. 1,2,5 62. 1,3 87. 4
13. 1,2,3 38. 1,2,4,5 63. 4 88. 1
14. 1,2,4,5 39. 2 64. 3 89. 2
15. 1,2,4 40. 1,2,3,5 65. 1,3,4 90. 1
16. 1,3 41. 2 66. 1,2,3 91. 1,2,3
17. 1,2,3,5 42. 1 67. 2,3 92. 1,5
18. 1,2,3,4 43. 3 68. 1,2,3,4 93. 1,4
19. 1,3,4 44. 1,2,3,4 69. 1,3,4 94. 3,4,5
20. 3 45. 1,2 70. 1,2,3 95. 2,4
21. 1,3 46. 5 71. 1,2,4 96. 2
22. 1,2 47. 1,2,3,5 72. 1,2,4,5 97. 3
23. 1,3 48. 2 73. 1,2,4 98. 1,2,3
24. 1,2,4 49. 2 74. 2 99. 1,3,4,5
25. 1,2,3,5 50. 1,2,3 75. 1 100. 1,2
101. 1,2,3,4 127. 1,2,3,4 153. 1,2,3,5 179. 1,2
102. 1,4,5 128. 3,4,5 154. 2 180. 2
103. 2 129. 2,3,4 155. 1,2,3,4 181. 3
104. 3 130. 1,2,5 156. 1,3,4 182. 3
105. 2 131. 4 157. 1,2,3,4 183. 1,2,3,5
106. 1,2,3,5 132. 1,2,3 158. 1,2,3,4 184. 3
107. 3,4 133. 1,4,5 159. 1,2,3 185. 2,3
237
108. 2,3 134. 1,3,4,5 160. 3,4,5 186. 1,2
109. 1 135. 5 161. 4,5 187. 1,2,3
110. 3 136. 1,2,3 162. 2 188. 2
111. 1,2 137. 1,2,3,4 163. 1,2 189. 2
112. 1,4,5 138. 3 164. 1,2,4,5 190. 1
113. 1,3 139. 1,3,4 165. 1,3,4,5 191. 2,3
114. 1,2,3 140. 1,3,5 166. 3,4,5 192. 3
115. 2,4,5 141. 1,4 167. 1,2 193. 1
116. 1,4,5 142. 4 168. 1,3,4,5 194. 1,2,3,5
117. 1,2,4 143. 1 169. 1,2,5 195. 1,2,4
118. 2,3,5,6 144. 1,2,5,6 170. 1,2 196. 1
119. 4,5 145. 2 171. 1,2 197. 1,2
120. 1,2,4,5 146. 1,2,4,5 172. 1,2,4,5 198. 1,2,5
121. 1,4 147. 1,2,3,4 173. 3,4,5 199. 3,4,5
122. 2,3 148. 1,2 174. 1,3 200. 1,2,3
123. 2 149. 1,2,4 175. 1,3,4 201. 1,3,4
124. 1,2 150. 1,2,3 176. 1,2,3 202. 1,3,4,5
125. 1,3,5 151. 1,3,4 177. 2 203. 1,2,3
126. 1,4,5 152. 1 178. 1,2,4,5 204. 1,2,3,4
205. 2 231. 1,2,4 257. 1,2,4
206. 1,3,5 232. 2,3,5 258. 1,3,4,5
207. 1,4,5 233. 1,2,3,5 259. 1,2,4,5
208. 1,3,4 234. 1,2,4 260. 3,4
209. 1,2,3 235. 2,3,4 261. 2
210. 1 236. 1,2,5 262. 2,4.5
211. 1,2,4,5 237. 1,3 263. 1,2,3,5
212. 2,3,5 238. 1,2,4 264. 1,2,3,5
213. 2 239. 1,2,5
214. 2 240. 1,4,5
215. 1,3,4 241. 1
216. 2 242. 1,2
217. 4 243. 1,2,4
218. 4 244. 1
219. 2 245. 1,2,3
238
220. 2 246. 2,3,4,5
221. 1,2,4,5 247. 1,2,4
222. 3,5 248. 1,2,3
223. 1,2,3,4 249. 1,4,5
224. 1,2,3 250. 1,2,4
225. 4 251. 1,2,4
226. 4 252. 1,3,4
227. 4 253. 1,3,4,5
228. 1,2,3,5 254. 1,2,3
229. 1,2 255. 2
230. 1,2,4,5 256. 1,2,3,5

239
 Учебное издание

Сурмач Марина Юрьевна

ЗДРАВООХРАНЕНИЕ И УПРАВЛЕНИЕ
В ОХРАНЕ ЗДОРОВЬЯ
Учебно-методическое пособие
для студентов учреждений высшего образования,
обучающихся на английском языке
по специальности 1-79 01 01 «Лечебное дело»

HEALTH SERVICES AND MANAGEMENT

IN HEALTH SPHERE
Educational-methodical manual
for students of higher education institutions,
the specialty 1-79 01 01 «General Medicine»,
English language of studying

Ответственный за выпуск В. В. Воробьев

Компьютерная верстка М. Я. Милевской

Корректура М. Ю. Сурмач

Подписано в печать 29.11.2017.

Формат 60х84/8. Бумага офсетная.
Гарнитура Times New Roman. Ризография.
Усл. печ. л. 13,95. Уч.-изд. л. 10,75. Тираж 99 экз. Заказ 171.

Издатель и полиграфическое исполнение

учреждение образования
«Гродненский государственный медицинский университет».
ЛП № 02330/445 от 18.12.2013.
Ул. Горького, 80, 230009, Гродно.

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