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The Impact of Health Care Reforms on Improving the Quality of Medical Services: International Experience

The study of foreign experience in the field of reforming the medical industry is relevant at the present stage. Therefore, the purpose of the article is to summarize the experience of countries that have successfully implemented the reform of the health system, to identify mechanisms and tools for improving the quality of medical services. The article examines the concept of "quality of medical services". Based on the expert survey, the directions of improving the quality of medical services in the process of implementing health care reforms have been identified. Following these directions, the international experience of reforming the health care system to improve the efficiency of the use of budget funds for the provision of medical services, ensuring equal access to medical services for urban and rural populations, and the development of primary health care has been considered. The study concludes that improving the quality of medical services in the process of health care reforms is possible with the implementation of specific activities based on the use of international experience in health care reform.


Introduction
Public health governance is defined by the state's public health policy, which is focused on ensuring equal access to health care for each person and individual communities. The state health policy is formed and implemented following the strategic directions defined by the World Health Organization. Twelve principles of health organization for any national system were defined at the 17th interaction), the main goal of which is to strengthen, restore and maintain the health of the country's population 3 .

Literature Review
The formation of an effective health care model is one of the most relevant areas of scientific research in modern conditions. When analyzing the quality of medical services, researchers focus on the management mechanisms for the implementation of state health policy in the aspect of quality management 4-6 , focus on monitoring the problems that the authorized authorities should solve in this area, as well as on the formation of tasks and innovative approaches 7,8 .
Therewith, the definition of the quality of medical services is a subjective value category, which is understood variously by different researchers (Table 1). Quality of medical services/Source the result (the so-called technical quality) of the way of using funds (cost-effectiveness), the organization of the provision of services, and the satisfaction of patients 9 the most favorable result with minimal negatives 10 technical cost (knowledge, clinical skills, technology), the cost of relationships between people (patient, doctor, nurse, medical staff), and mandatory services (comfort and aesthetics) 11 it is considered from the point of view of the structure (covers the characteristics of the available resources for providing care, in particular, material resources, qualified medical and managerial personnel, as well as organizational aspects (methods of cost compensation, quality management of medical care), the process (characteristics of the medical care provided, i.e. its validity, adequacy in scope, the competence of staff in choosing methods, consistency of actions) and the results of treatment (survival, functional state, disability in patients with certain initial diseases or conditions, as well as the degree of patient satisfaction with the Research hypothesis: improving the quality of medical services in the process of health care reforms is possible with the implementation of specific activities based on the use of international experience in health care reform.

Research Problem
• To identify areas for improving the quality of medical services in the process of implementing health care reforms based on international experience.
• To reveal the features of improving the quality of medical services in the implementation of specific areas of activity based on the use of international experience in healthcare reform.
The article consists of an introduction, a literature review, methods, results, discussion, and conclusion.

Methods
A literature search has been conducted, relevant literature sources have been selected and their information has been summarized, which allowed achieving the research goal. The method of system analysis was used (aspects of the quality of medical services were studied and analyzed), as well as the bibliosemantic method (the world experience of healthcare system reform was studied).
The study also used the method of the expert survey in the field of research under consideration.
The experts were asked voluntarily to answer a question concerning the main, in their opinion, directions for improving the quality of medical services in the process of implementing health care reforms and to justify these directions, which determined the direction of further research.
The survey was attended by experts in the field of healthcare (20 people). The experts include representatives of the medical profession, whose professional activity is related to management issues in the field of healthcare for more than 8 years.
All participants were warned about the purpose of the survey and the planning of the organizers of the study to publish the results of the study in a generalized form.

Results
The results of the expert survey showed that the main directions of improving the quality of medical services in the process of implementing health care reforms are the following (  Note: compiled based on an expert survey; *percentage of expert mentions Following certain directions, we will try to reveal the features of their implementation in the reform of the health care system in different countries.

Discussion
The effectiveness of the use of budget funds for the provision of medical services can be considered in the example of the financial support system for healthcare in the UK, which is an example of a budget model for the formation of industry resources. The National Health Service (NHS) plays a leading role in providing health care to the population, accounting for 85% of the corresponding public expenditure. The remaining medical expenses are covered by other sources (direct payment for medical services and health insurance). Therewith, there is a replacement of direct payment for services with insurance, which is becoming more widespread 13 .
Financial resources of the NHS are formed at the expense of budgets of all levels (84%), social insurance contributions (12%), co-payments of the population in fixed amounts, regardless of the type of medical service (4% In 2010, the government announced the largest reform of the NHS in the country's history, which was supposed to ensure its decentralization. Only part of the NHS system in England was subject to the reforms, as its units in Wales and Scotland are subordinate to local authorities. The essence of the reform was to transfer control over the budget financing of the health care system (107 billion British pounds sterling annually) directly to doctors. According to the reform plan set out in The Health and Social Care Act 2012, since 2013, up to 80% of the health system budget in England has been transferred to 42 thousand general practitioners (GPs), united in 212 clinical expert groups (CCGs) to make decisions on the use of funds. The system of primary care trusts and strategic health departments was eliminated, but an authorized board with an independent status (NHS Commissioning Board) was established. Therewith, general practitioners were granted the right to order specialized medical services for patients in secondary care trusts on a tender basis 15 .
The key objective of the NHS reform was to reduce the administrative costs An important aspect of the medical reform was also the improvement of the mechanism for financing care for the elderly, which is relevant in the context of the growing share of the disabled in the structure of the country's population. Following the norms of The Health and Social Care Act 2012, it was provided for the introduction of a personal health budget mechanism for persons in need of longterm treatment. Therewith, patients were given the opportunity to independently maintain the budget of their treatment (budget-holding), determining the volume and structure of medical services.
However, such an initiative causes discussions among specialists, since a significant part of people who need long-term care do not have the appropriate knowledge and experience to independently manage funds to ensure the effectiveness of the treatment process 16 .
Despite the possible positive consequences of the NHS reform implementation, it was negatively perceived by a part of British society and politics. According to its opponents, the reform will destroy a fairly effective health care system in the country, which, according to expert estimates, functions better than in the United States, Canada, and Germany. Liberalizing the process of ordering medical services by general practitioners and allowing private medical institutions to participate in tenders will lead to a rapid collapse of the network of public hospitals, which do not have sufficient funds and will not be able to withstand competition. Given this, some experts call the reform the first In Western countries, the main focus in the field of health care in rural areas is on family doctors, general practitioners who are guided in various diseases from therapeutic to gynecological.
Development of primary health care (PHC). WHO documents state that the development of PHC will ensure the implementation of the basic principle of health protection, namely, the inclusion in the health care system not only of treatment, the purpose of which is to restore health, prevent the development of disease, and alleviate the suffering of a sick person, but also prevention, the purpose of which is to protect and promote health 23 .
An important point in the priority development of PHC in the health care system is the proximity of the doctor to the patient, which is a sign of the rational organization of medical care 24 . The results of studies 25,26 showed a positive statistically significant correlation between the degree of PHC development and such indicators as mortality from all causes, premature mortality from major diseases of the cardiovascular system. At the macro level, there is a correlation between PHC and GDP per capita, the total number of doctors per 1,000 people, the percentage of the elderly and senile population; at the micro-level, the average number of outpatient visits, the per capita consumption index, alcohol and tobacco consumption.
In the Netherlands, where there is a social health insurance system, since the mid-90s, new organizational forms of integrated health care, or the "bottom-up" approach, have been widely developedmedical care, as much as possible focused on the needs of the patient, is provided based on close cooperation (interaction and coordination) between primary and specialized health care In general, it can be concluded that preferences in European countries are given to the development of PHC and family medicine, where PHC dominates in health systems as a cheaper and more affordable link, which satisfies about 80% of patients.

Conclusion
The reform of the health care system will have a positive result if national preferences and traditions are supplemented by the effective use of the best international practices. In the course of the study of foreign approaches to the reform of the health system, it was found out that in the process of reforming the health system, it is important to take into account the following components of state policy in this area: the development of tools for the formation of state policy in the field of health; the definition of tasks and goals for state authorities responsible for making appropriate decisions; the optimal allocation of health resources.
International experience in health care reform points to the importance of effective reallocation of public spending over time in the interests of health; demonstrates that almost all states are trying to solve the problem of equal access to health services for rural populations by developing primary preventive care in rural areas and directing efforts to find new forms of health care for rural residents; develop PHC.
In general, summarizing the above, we can conclude that the study concludes that improving the quality of medical services in the process of health care reforms is possible with the implementation of specific activities based on the use of international experience in health care reform.