Features of the organization Honey assistance to the rural population. Features of the organization of medical care in rural areas

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General provisions

Based on the organization medical care Residents of the village lie the same principles as the city's population. However, the special way of life of the village, the settlement system, low (compared to the city) population density, poor quality, and sometimes the lack of roads, the specificity of agricultural labor impose a print on the organization of medical care to rural residents.

This applies to the type, power, dislocation of health care institutions, the provisions of their qualified medical personnel, the possibility of obtaining specialized medical care. These features also dictate the need to develop and introduce differentiated standards for separate species resources.

For example, for rural areas located in large areas with low population density (extreme north, Siberia, Far East), the population value for the organization of the Feldsher-obstetric item or the center of the general medical (family) practice should be significantly lower in the south of the country, where the population density is higher, settlements are located close to each other and there is a good transport connection.

Comprehensive therapeutic plot

Fig. 12.1. Stages of medical care to rural population

The first medical institution, in which, as a rule, turns a rural resident is a paramedic-obstetric item (FAP). It functions as a structural unit of the precinct or Central District Hospital. The FAP is advisable to organize in settlements with the number of residents from 700 or more at the distance to the nearest medical institution over 2 km, and if the distance exceeds 7 km, then in settlements with the number of residents up to 700 people.

The Feldsher-obstetric item rests on the solution of a large complex of health care facilities:
. carrying out measures aimed at preventing and reducing the incidence, injury and poisoning among the rural population;

Reducing mortality, primarily infant, maternal, in working age;
. providing advantageous medical care;
. participation in the current sanitary supervision for children's pre-school and school educational institutions, utilities, food, industrial and other objects, water supply and cleaning of settlements;
. Conducting household details for epidemiological indications in order to identify infectious patients, contact with them and persons with suspected infectious diseases;
. Improving the sanitary and hygienic culture of the population.

Thus, the FAP is a health care institution to a greater degree of prophylactic orientation. The functions of the pharmacy point for the sale of the population of finished dosage forms and other pharmacy goods may be imposed on it.

Fapa's work is directly heading the head. In addition to him, the midwife and the patronage nurse work.

Despite the important role of the FAPs, the leading medical institution at the first stage of the provision of medical care residents of the village serves a local hospital, which in its composition may have a hospital and a medical ambulatory. Types and amount of medical care in the precinct hospital, its capacity, equipment, staffing with medical personnel depends largely on the profile and power of others medical institutionsincluded in the health care system of the municipal district (rural settlement). The main task of the precinct hospital is to provide the population of primary health care.

Ambulatory and polyclinic assistance to the population represents the most important section of the work of the precinct hospital. It can be provided with an ambulatory as part of the hospital structure and independent. The main task of the ambulance is to carry out preventive measures to prevent and reduce morbidity, disability, mortality among the population, early detection of diseases, dispensarization of patients.

The doctors of the ambulance are taking adults and children, challenges home and emergency care. Feldscher can take part in the reception of patients, however, medical assistance in the ambulance should mainly have doctors. In the district hospital, an examination of temporary disability is carried out, and if necessary, patients are sent to ITU.

In order to approach specialized medical care to residents of the village, doctors of the Central District Hospital on a certain schedule are leaving to an ambulatory for receiving patients and selection of them if it is necessary to hospitalize in specialized institutions. Recently, many subjects of the Russian Federation occurs the process of reorganization of district hospitals and an ambulatory into centers of a common medical (family) practice.

O.P. Schepin, V.A. Medic

Main feature of medical care rural population lies in its stratia. Conditionally allocate three stages to the organization of medical care to the rural population.

Tab. 3. Stages of medical care to rural population

The first stage - the health care institutions of the rural settlement, which are part of the complex therapeutic area. At this stage, rural residents receive prefigure, as well as the main types of medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental).

The first medical institution, in which, as a rule, turns a rural resident is a paramedic-obstetric item (FAP). It functions as a structural unit of the precinct or Central District Hospital. The FAP is advisable to organize in settlements with the number of residents from 700 or more at the distance to the nearest medical institution over 2 km, and if the distance exceeds 7 km, then in settlements with the number of residents up to 700 people.

The Feldsher-obstetric item rests on the solution of a large complex of health care facilities:

Conducting measures aimed at preventing and reducing morbidity, injury and poisoning among rural populations

Reducing mortality, primarily infant, maternal, in working age;

Providing advantageous medical care;

Participation in the current sanitary supervision for children's pre-school and school educational institutions, utilities, food, industrial and other objects, water supply and cleaning of settlements;

Conducting household details for epidemiological indications in order to identify infectious patients, contact with them and persons with suspected infectious diseases;

Improving the sanitary and hygienic culture of the population.

Thus, the FAP is a health care institution to a greater degree of prophylactic orientation. The functions of the pharmacy point for the sale of the population of finished dosage forms and other pharmacy goods may be imposed on it.
Fapa's work is directly heading the head. In addition to him, the midwife and the patronage nurse work.

Despite the important role of the FAPs, the leading medical institution at the first stage of the provision of medical care residents of the village serves a local hospital, which in its composition may have a hospital and a medical ambulatory. Types and amount of medical care in the district hospital, its capacity, equipment, staffing with medical personnel in many ways depend on the profile and capacity of other medical institutions that are included in the health care system of the municipal district (rural settlement). The main task of the precinct hospital is to provide the population of primary health care.

Ambulatory and polyclinic assistance to the population represents the most important section of the work of the precinct hospital. It can be provided with an ambulatory as part of the hospital structure and independent. The main task of the ambulance is to carry out preventive measures to prevent and reduce morbidity, disability, mortality among the population, early detection of diseases, dispensarization of patients.

The doctors of the ambulance are taking adults and children, challenges home and emergency care. Feldscher can take part in the reception of patients, however, medical assistance in the ambulance should mainly have doctors. In the district hospital, an examination of temporary disability is carried out, and if necessary, patients are sent to ITU.

In order to approach specialized medical care to residents of the village, doctors of the Central District Hospital on a certain schedule are leaving to an ambulatory for receiving patients and selection of them if it is necessary to hospitalize in specialized institutions. Recently, many subjects of the Russian Federation occurs the process of reorganization of district hospitals and an ambulatory into centers of a common medical (family) practice.

Unity Principles for the Provision of Medical and Preventive Assistance urban and rural population: 1) prophylactic nature; 2) dilution; 3) Massiness; 4) Medical Specialization 5) Accessibility.

Feature of the presence of medical and preventive assistance to the rural population:

1) the stratification of assistance

2) Mobile types of medical care (exit medical brigades).

Features of the organization of rural medical care:

1) Low population density is the number of rural population in 2004 2.803.600, 2005 2.744.200, 2006. 2.691.500. Compared to 2002, the population of the rural population decreased by 118 thousand. In 2005, 90.307 people were born, from them in the village 24.205 (26.8%). Birth rate in 2005 9.2 in the Republic of Belarus, on the village - 8.9. Mortality on the village is 2.2 times more than in the city. Infant mortality in general 6.4, on the village - 9.3. Life expectancy in the village of 64.52, in the city of 70.53

Ludith is the number of people in the village. The average number of rural population is 200 people.

2) the dispersion of settlements in the large area - rural settlements 24 thousand. The average population density in the Republic of Belarus is 48 people at km 2, in the village - 10 people at km 2. The proximity is the distance between settlements, the service radius is the distance from the settlement, where there are medical facilities to the very remote settlement, the inhabitants of which are attached to this institution for medical care. This value is controlled and varies depending on the population.

3) bad quality of roads

4) Agricultural Labor Specificity: Seasonality, Weather Dependency

5) Conditions, Lifestyle, Tradition

6) low security specialists

Stages of the provision of medical and preventive assistance to the rural population and main organizations:

Stage I - Earlier - Rural Medical Point (SVA), including a complex of medical institutions:

a) A rural district hospital (sub, has both outpatient and inpatient assistance) or a rural medical ambulatory (su, only outpatient assistance is provided)

b) Feldsher-obstetric item (FAP)

c) healthy health (if available industrial enterprise on the service area).

Currently There is no, SPE and district hospitals - branches of the CRH, FAP-s - Branches of SPE.

The main function of the stage: Providing first prefigure assistance, first qualified medical care with possible elements of specialized medical care.

Fighu- 400 people are created for medical care and more than 2 km and more from a medical institution. When servicing more than 400 people. In the states of FAPA, they laid: 1 position of the paramedic or midwife or medical sister and 0.5 positions of sanitary. Fairs costs - 1.5-2.0% of the budget of the area of \u200b\u200bthe district.

FAP functions:

Provision of successful medical care and timely execution of the prescribing of a doctor;

Conducting preventive work and anti-epidemic work;

Organization of patronage of pregnant women, children,

Carrying out measures to reduce infant and maternal mortality;

Hygienic learning and education of the population.

Rural Medical Point (SVA) - serviced 7-9 thousand population within a radius of 7-9 km.

Section Hospital - This is the main institution in the UKU, consists of a hospital and an ambulance. Depending on the number of beds, the I categories can be - by 75-100 beds, II - 50-75 beds, III - 35-50, IV - 25-35 beds. In the district hospital it turns out all types of qualified medical and preventive care. Of great importance is the medical care to the population during the field of field work. Significant work is carried out on the protection of women and children, the introduction of modern methods of prevention, diagnosis, treatment.

All types of medical and preventive assistance to pregnant women, mothers and children has doctor of the district hospital. If several doctors are, one of them is responsible for the state of the health of children and women in this area.

For unprofitable activity of precinct hospitalsthey closes or replicate in the department rehabilitation of district hospitals, and for medical care people open independent rural medical ambulatory (SPE), in the state of which should be: therapist, dentist, obstetrician gynecologist, pediatrician. Medical assistance in patients with dental diseases in the district hospital or in a rural medical ambulance is provided by the dentist (dentist).

From regular regulations of the medical personnel of district hospitals:

1. The posts for the provision of outpatient polyclinic assistance to the population are established at the rate of 10,000 people:

2. Positions of the hospital departments are established at the rate of 1 Position:

Therapist is 25 beds;

Pediatrician - on 20 beds;

Surgeon - on 25 beds;

Dentist - on 20 beds.

Floor capacity of the rural district hospital - 27-29 beds.

Organization of the work sub:

The provision of medical and preventive assistance to the population

Introduction into the practice of modern methods of prevention, diagnosis and treatment of patients

Development and improvement organizational forms and methods of medical care of the population, improving the quality and effectiveness of therapeutic and preventive care

Organization and holding of a complex of preventive measures among the population population

Conducting medical and preventive measures to protect the health of mother and child

Studying the causes of general morbidity and morbidity with temporary disability and development of measures to reduce it

Organization and implementation of the disposal of the population, primarily children, adolescents

Implementation of anti-epidemic measures (vaccinations, identification of infectious patients, dynamic observation of persons who are in contact with them, etc.)

The implementation of the current sanitary supervision over the state of industrial and utility rooms, sources of water supply, children's institutions, catering institutions;

Conducting medical and preventive measures to combat tuberculosis, skin-venereal diseases, malignant neoplasms

Organization and conduct of measures for sanitary and hygienic education, promotion of a healthy lifestyle, including rational nutrition, enhancing motor activity; Fighting alcohol, smoking and other harmful habits

Widely attracting the public to the development and conduct of public health measures

Stage II - Territorial Medical Association (TMO).

Guilty TMO tMO chief physician (He is the chief physician of the CRH) and his deputies:

Deputy Medical Services of the Population (He is the head of the organizational and methodological office);

Deputy for medical part (with the number of beds 100 or more);

Deputy for medical and social expertise and rehabilitation (with the number of at least 30,000 people serviced by the population);

Deputy for objects and childhood (with the number of at least 70,000 people served by the population);

Deputy Economic Issues;

Deputy administrative and economic part.

The medical council includes: Chief Physician, his deputies, chief physician of the Center for Hygiene and Epidemiology, Head of the Central District Pharmacy, leading specialists from the district, Chairman of the Trade Union medical workers, Chairman of the Red Cross and Red Crescent Society.

The decision to create a TMO is accepted hasional organ Health management. In small cities and rural areas The TMO unites usually all therapeutic and preventive institutions and replaces the Mozdravotel and CRH. In major cities with a population of more than 100,000 people, there may be several TMOs, one of them is the head.

TMO - This is a complex of LPU, functionally and organizationally interconnected. The TMO may include:

Polyclinics (adults, children's, dental);

Women's consultations, dispensary, hospitals, maternity hospitals;

ambulance stations;

Children's sanatoriums and other institutions.

The association of institutions should be appropriate, not necessarily. Institutions that are not included in the TMO act independently. As a rule, these are health centers and hygiene and epidemiology centers, a bureau of forensic medical examination, blood transfusion station.

Principles of formation of the TMO:

1. A certain population is the optimal SMO size - 100-150 thousand people.

2. Organizational and financial separation of outpatient and stationary institutions.

3. Coincidence of the borders of the TMO service area with the administrative boundaries of the district (city).

4. Rational Association of Institutions - Association of institutions that provide medical care to the adult and the children's population.

TMO Tasks - ensuring accessible and qualified medical and preventive care to the population.

TMO functions:

1. Organization of medical and preventive assistance to the attached population, as well as any citizen who appeals for medical care.

2. Carrying out preventive measures.

3. Ambulance Patients.

4. Timely provision of medical care at the reception, at home.

5. Timely hospitalization.

6. Dispensarization of the population.

7. Conducting medical and social expertise.

8. Conducting hygienic learning and education.

9. Analysis of the activities of the LPU.

The main medical and preventive institutionsStage II are the Central District Hospital (CRH) and other facilities of the district (see Question 102).

For the organization therapeutic and preventive assistance to women and children At this stage, the district pediatrician and the district obstetrician gynecologist are responsible. In the number of people's population, more than 70,000 people are appointed by the post of deputy chief physician for childhood and objects - an experienced pediatrician or an obstetrician gynecologist.

Ambulatory dental care At stage in stage, it may be provided in dental clinics and dental departments of the Polyclinics of the CRH. Stationary dental assistance in the dental separation of the CRH hospital or on special beds for dental patients in the surgical department.

III Stage - Regional Hospital and Medical Institutions of the region.

Regional Hospital - This is a major multidisciplinary medical and prophylactic institution, providing highly qualified highly specialized assistance to residents of the region. This is the center of organizational and methodological management with medical institutions posted on the territory of the region, the database of specialization and advanced training of doctors and medium medical personnel.

Structure of the regional hospital:

1. hospital.

2. Consultative polyclinic.

3. Other divisions (kitchen, pharmacy, morgue).

4. Organizational and methodological department with the department of medical statistics.

5. Department of emergency and planning and advisory assistance, etc. (see Question 104).

Floral capacity of the regional hospital adult - 1000-1100 beds, children's - 400 beds.

Consultative Polyclinic It has highly qualified, highly specialized medical care, exit consultations, by telephone - correspondence consultations, analyzes the activities of therapeutic and preventive institutions, the discrepancy between the diagnoses of expressive institutions and clinics, diagnoses of polyclinics and hospital, error analysis. Does not have the right to issue a hospital.

The children's and female population of the region receives all kinds of qualified specialized medical care in the advisory clinic. Inpatient assistance to women finds in regional maternity hospitals, regional dispensaries and other medical facilities.

Outpatient qualified specialized dental care Patients turn out to be in regional dental polyclinics, stationary - in the dental departments of regional hospitals.

The number of hospital organizations in the village in 2005 - 274, of which district hospitals 184, hospitals of nursing departments - 90. The number of ambulatory-polyclinic organizations 3326. Independent medical ambulatory on 2005 - 253, an ambulatory practice of general practitioner for 2005 - 336. FAP-s in 2005 - 2524.

IV Stage: Republican level (RNPC, Republican hospitals).

31. Dispensarization of the population. Definition, tasks. Organization and content of dispensary in medical and preventive organizations. Indicators for evaluating dispensary work - see question 67.

Medical and social expertise (ITU), definition, content, basic concepts. Management of the Medical and Social Examination and Rehabilitation Service in the Republic of Belarus.

Medical and Social Expertise (ITU) - This is an independent area of \u200b\u200bscientific knowledge and the scope of practical activity, which studies the state of human life and its working capacity, which detects the degree of their violation and the pursuing goal of their recovery by carrying out a complex of medical and rehabilitation activities. The subject of the medical and social expertise is to define in the prescribed manner of the needs of an examined person in social protection measures, including rehabilitation.

Medical and social expertise (ITU) a relatively new concept, which came to replace the "medical and employment examination" after adoption in 1991 social Protection Disabled in the Republic of Belarus. " According to this law, it is determined next structure ITU:

1) VTEK transferred to the health care system with subsequent reorganization of them into medical rehabilitation expert commissions (IARK)

2) The scientific and practical system of medical and social expertise has been operating under the management of the Ministry of CSC, including

a) Republican Scientific and Practical Center in the form of a research institute of medical and social expertise and rehabilitation (ISEIR Research Institute)

b) regional, urban, interdistrict medical rehabilitation expert commissions (IRK)

c) Separate services and specialists involved in ITU and rehabilitation in stationary and outpatient organizations of the republic.

The main tasks of ITU.:

1. Scientific soundability assessment

2. Establishing the causes of disability

4. Systematic observation and control over the state of disabilities

5. Promoting the prevention and treatment of diseases, disability prevention

6. Expert control over long-suffering

7. Definition and study of economic and social causes of disability

8. Establishment of the degree of working capacity of workers and employees who received injury or other health damage associated with their work

The main concepts of ITU:

1) ability - This state of the body, in which the set of physical and spiritual possibilities allows a person to fulfill its professional duties (work of a certain amount and quality). When evaluating the working capacity, criteria are taken into account:

but) medical - the influence of biological, medical factors (painful condition of the body); When evaluating the state of ability to be diagnosed, the stage and course of the disease, the presence and nature of complications, the degree of functional violations, the clinical forecast. Many diseases, especially in the initial period, do not lead to the need to terminate work; In this case, if the patient's work is not contraindicated, and the disease does not harm others, disability is not determined.

b) social - include the characteristic of the profession, position, degree of prevalence of physical or neuropsychic stress, the duration of the working day, the displacement nature of labor, working conditions, labor forecast, social status of man, marital status, etc. Disability can be determined by social indications, i.e. In cases where there is no disease, but the legislation establishes the possibility of temporary liberation from work in connection with various circumstances (for example, care for a sick family member, due to quarantine, etc.).

2) Disability divided by:

but) temporary - The functional state of the body caused by the disease, injury or another reason in which the violation of functions that prevents the continuation of professional work is temporary, reversible and possibly the return of the patient to fulfill its work. The main criterion of temporary disability is the reversibility of functional violations, a favorable clinical and labor forecast. This means a complete recovery or a significant improvement in the disturbed organism functions with disability in a relatively short time.

b) resistant - It arises if the violation of functions that prevents the performance of professional labor, despite the treatment, has acquired a steady and long-term nature, and therefore performing professional work becomes impossible or a significant change is required.

Temporary and persistent disability can:

1. full - the impossibility of continuing professional work, in connection with which the patient is exempt from the obligations to work and society takes care of his material support.

2. partial (disability limit) - the impossibility of fulfilling its professional work, while the patient without prejudice to health is able to perform another, easier work.

Aspects of disability examination:

1) medical - study of the nature of the disease;

2) social - the possibility of performing professional work, change it or stop;

3) legal - expertise is governed by documents, the doctor is responsible;

4) statistical - on state level It is carried out statistical accounting of disability, disability;

5) Economic - according to documents, the state pays benefits or pensions.

33. Rehabilitation: Medical, Professional, Social. Defining concepts. Organization of the system of rehabilitation of patients and disabled in the Republic of Belarus. Law of the Republic of Belarus "On the prevention of disability and rehabilitation of persons with disabilities."

Rehabilitation - This is a set of measures of various nature aimed at reducing the impact of disabled factors and conditions leading to physical and other defects, as well as to ensure the possibility of disabled social integration. This is an interdepartmental concept (not only doctors should participate in rehabilitation).

Main types of rehabilitation:

a) medical rehabilitation - process aimed at restoring and compensation for medical and other methods functionality The human body disturbed due to a congenital defect transferred to diseases or injuries

b) Medical and Professional Rehabilitation - the process of restoring disability, combining medical rehabilitation with the definition and training of professionally significant functions, selection of profession and adaptation to it;

c) professional rehabilitation - a system of measures that disabled the opportunity to get a suitable job or maintain the previous and promotion (work), thereby contributing to its social integration or reintegration;

d) labor rehabilitation - the process of employment and adaptation of a disabled person at a particular workplace;

e) social rehabilitation - system of measures to improve the standard of living of persons with disabilities, the creation of equal opportunities for them to fully participate in society

Rehabilitation directions:

1) Rehabilitation of patients - aimed at preventing a defect, disability prevention

2) Rehabilitation of persons with disabilities - decrease in the severity of disability, adaptation of the disabled person to the household and labor environment.

Levels of disability warning

a) Primary disability prevention - Reducing the frequency of the occurrence of disturbed functions, impede life and restricting disability.

b) secondary disability prevention - restriction of the degree of violation of functions or reverse development in existing diseases of congenital or acquired defects.

c) tertiary disability prevention - Preventing the transition of the emergence or congenital functional disorders at the level of disability into sustainable defects, resulting in weightlessness of disability and disability.

In 1994, adopted law "On the prevention of disability and rehabilitation of persons with disabilities". It is based on a state program to prevent disability and rehabilitation of persons with disabilities.

Article 4. Objectives of the legislation of the RB in the field of disability disabilities and rehabilitation:

Creation of legal guarantees for the organization and development of the disability prevention and rehabilitation system;

Ensuring and protecting the rights of citizens of the Republic of Belarus to medical, professional and social rehabilitation;

Participation of public organizations of persons with disabilities in state programs for the rehabilitation of persons with disabilities.

Article 5. The State Program for Disabilities Prevention includes:

Study of the causes of disability;

Development of measures to prevent or limit the loss of health, including immunization programs;

Development of measures to prevent congenital defects, chronic and professional diseases, accidents, injuries, as well as restructuring of human psyche with

external impact;

Creating a system for early detection and prevention of disability;

Creature special programs to reduce injuries

Development of certification programs and rationalization of jobs and working conditions as measures for the prevention of professional and other diseases

Conducting medical examination and recovery of children;

Analysis of all cases of injuries caused by emergency and environmental circumstances or risk of such circumstances;

Control over the unlimited use of medicines, drugs, alcohol, tobacco and other stimulants;

Creation of special programs to reduce the frequency and severity of hereditary pathology, endocrine, mental diseases leading to disability, as well as diseases of alcoholism;

Education measures, explanatory work on the dangers of smoking and alcoholism, excess body weight, insufficient physical activity as risk factors oncological, cardiovascular and

other chronic diseases;

Scientific support for programs developed, training, educational, educational and other measures.

34. Sanitary and epidemiological service in the Republic of Belarus, structure, functions, management. Sanitary activities. Law of the Republic of Belarus "On the Sanitary and Epidemic Welfare of the Population."

Sanitary and epidemic service - System public institutionsexercising public health supervision, development and conduct of sanitary and preventive and anti-epidemic activities.

Tasks of SanEpidservable:

1) Ensuring the timely hygienic assessment of the whole new, which is being implemented in national economy

2) Development and implementation, normalization of maximum permissible concentrations of harmful substances and methods for controlling them

3) organization and control over the implementation of activities and recommendations for the improvement of working conditions, life, rest of the population

The basis of the organization SanEpidservable lies:

1. State Sanitary and Epidemic Activities

2. Scientific planned basis for sanitary and anti-epidemic events

3. The Unity of Management of Sanitary and Preventive and Anti-Epidemic Activities, which is that this work is focused in a single complex institution - CGIE.

4. Participation of all medical organizations in sanitary and preventive and anti-epidemic work in the organizing role of the SanEpide service

5. Participation of the population in sanitation and propaganda of hygienic knowledge

The main task is state sanitary supervision; Control over sanitary and anti-epidemic activities.

1) Warning and environmental pollution

2) Recovery of working conditions on agricultural and industrial production to reduce general and professional morbidity

3) the creation of the most favorable conditions for the normal development and training of children and adolescents

4) Population rehabilitation of the population - rational food, prevention of poisoning of food products

The state sanitary supervision is carried out by the Sansepid services (SES) bodies in the form of warning and current supervision of sanitary and anti-epidemic activities, for compliance with ministries, departments, enterprises, institutions, organizations, officials, individual citizens of sanitary and hygienic and anti-epidemic norms and rules.

Organizational structure of the SES RB:

a) Republican Level: The Deputy Minister of the CA is the chief state sanitary doctor of the Republic of Belarus, he has 4 deputy, heads the sanitary and epidemic department. There are republican CGIE, which is engaged in scientific and practical activities.

b) Regional level: Regional TsGIE, its chief physician is the main state sanitary doctor of the region, he is also the deputy head of the department of the region

c) district level: District CGIE - Chief Doctor - Chief State Sanitary Doctor of the district, Deputy Chief Doctor of the district

SES Research Organizations: Scientific Practical Center for Hygiene (Earlier Hygiene Research Institute), Scientific Research Institute of Microbiology and Epidemiology.

Total CGIE in RB - 146, besides them there are disinsection and deratization centers, disinfection stations, sanitary control points.

The organizational structure of CGIE (for example):

1. The Organizing Department - coordinates all the work of the SES on the scale of the service area, consists of offices: computerization, information support, metrology and standardization, epidemic analysis and forecasting

2. Sanitary and hygienic separation of municipal hygiene, occupational health, food hygiene, children's hygiene and adolescents, toxicological.

4. Radiation hygiene.

5. Hospital hygiene and disinfection department

6. Department of Especially Dangerous Infections

7. The AIDS Prevention Department.

The legal frameworks of CGIE activities are determined by:

a) Constitution of RB

b) the law on zo

c) Law "On Sanitary and Epidemic Welfare"

d) a set of sanitary and hygienic and sanitary and prophylactic standards, norms, rules, individual government decisions, council decisions people's Deputies on sanitary-anti-epidemic issues.

State sanitary supervision by bodies and institutions SES carried out in 2 forms:

a) preventive - for construction, layout, building settlements, industrial planning planning

b) current - sanitary examination of objects municipal economy, industrial events, food facilities, children's pre-school and school institutions, sources of infection and other.

CGIE officials in the implementation of state sanitary supervision perform control and organizational functions. Among the health workers, only a sanitary doctor has the right of coercion.

Law of the Republic of Belarus "On Sanitary and Epidemic Welfare of the Population" (1993) regulates public relations in ensuring the sanitary and epidemic well-being of the Republic of Belarus, the preservation and promotion of health, physical, spiritual development and the long-life active life of people; The law defines the competence of republican and local government and management bodies in the field of providing sanitary and epidemic well-being of the population; the obligations of enterprises, institutions, organizations and other business entities, public associations, officials and citizens to comply with sanitary standards, rules, hygienic standards and conducting sanitary and hygienic, preventive, anti-epidemic and antiragonal measures; system of state control and supervision; types of responsibility for violations of sanitary legislation.

The main sections of the law:

General provisions

Rights and obligations of citizens, enterprises, institutions and organizations to ensure the sanitary and epidemic well-being

The powers of the highest bodies of state and management in the field of providing sanitary and epidemic well-being

General requirements to ensure the sanitary and epidemic well-being of the population

State control and supervision of compliance with the sanitary legislation of the Republic of Belarus

Departmental Sanitary Supervision, Production and Public Sanitary Control

Responsibility for violation of sanitary legislation. Reliability, which is that this work is focused

The basic principles of the organization of medical care in rural areas:

· Stage

· Free

· Accessibility

· Premiestness of medical care

However, the features of living in rural areas impose a print on the entire organization of medical care.

Features of rural health care:

Plot service of the rural population (with the organization on the site of one or two paramedics and pharmacies, and in the center of each site - hospitals with an ambulatory);

Low security specialists;

The absence of the right to choose a medical institution, since in small settlements, medical assistance is, as a rule, by one doctor (Feldsher);

Low level (compared to urban) consumption of medical communications infrastructure significantly reduces the availability of medical care to rural residents;

Low (compared to the city) population density, which is located on the larger territory, the dispersion of settlements and their remoteness;

Outless, pensioners are dominated among the serviced population.

Poor quality, and sometimes the lack of roads;

Specificity of agricultural labor (seasonality of field work, dependence on weather conditions, etc.);

Features of the conditions, lifestyle, national traditions and customs of the rural population

Structure of rural health

The initial provision of health care in the village is presented:

Network of Feldsher-obstetric items (FAP)

Medical (Feldshers) ambulatory

Central district polyclinics (as part of the CRH).

The stationary network includes:

· Plot hospitals

· Central District Hospitals (CRH)

· Edge (regional) hospitals.

Organization of medical and social assistance in the village, its volume and quality depend on:

Remoteness of medical institutions from the residence of patients;

Staffing by qualified personnel, equipment;

Opportunities to obtain specialized medical care;

The possibility of implementing medical and social security standards.

The main feature of the organization of medical care to the rural population is the stratitude of its provision. Conditionally allocate three stages of the treatment and preventive care to the population.

The first stage is a rural medical plot (STU) or, taking into account the new organizational structures - Territorial Medical Association (TMO). The territorial rural medical plot includes: a district rural hospital or an independent medical ambulatory, Feldsher-obstetric checkpoints (FAP), health-friendly healthcare facilities (they can be organized under large state farms), medical educational institutions, the maternity hospitals.

The main institution is a rural area hospital (sub) or a medical ambulance, where rural residents receive qualified medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental).

The second stage is district medical facilities.

The main institution is the Central District Hospital (CRH), providing specialized medical equipment for its main species.

Third stage - regional (edge, district, republican) institutions. The main institution in the regional healthcare is the regional (edge, district, republican) hospital - a major multidisciplinary medical and prophylactic institution, designed to provide highly qualified specialized assistance in full, not only rural, but also to all residents of the subject of the Russian Federation for all major specialties.

At these stages of the institution can be divided into two groups:

Institutions that are necessarily present in each area, regions (Fpa, CRH, CGSAN, etc.)

Institutions, which, depending on local conditions, can be, and may not be available (district maternity hospitals, license hospitals, etc.) in separate regions.

FIRST STAGE

Rural medical plot (STU). Organization of primary health care on the site.

Tasks of the SCA:

Providing the population of publicly available qualified medical care

Sanitary-anti-epidemic events

Formation of the residents of the installations and skills of a healthy lifestyle.

The composition of St.:

Rural area hospital (sub) or medical ambulatory

Maternity

Medpunky children. Educational institutions

Feldsher Sweatpeople with enterprises and state farms

SOVOGO PLABS

The structure of the BCU is formed depending on the number of serviced population (5 - 9 thousand people), service radius (7 - 10 km), distance to CRH and road states. However, depending on the natural and economic and geographical factors affecting the availability of medical assistance, the size of medical sites, the population in the area may be different.

All medical facilities that are part of the BCU are organizationally combined and operate unified Plan Under the guidance of the chief doctor of the district hospital (ambulance).

Feldsherko-Obstetric Item (FAP)

The first institution in which the patient is usually drawn in rural areas is the Feldsher-Obstetric Item (FAP). The FAP is organized in settlements with the number of residents from 700 or more than 2 km from the nearest medical institution, and if the distance to the nearest medical institution exceeds 7 km, the FAP can be organized in the settlement with the number of residents to 700 people.

In the chapter, depending on the number of serviced population, can work:

Feldsher;

Feldsher and midwife;

Feldsher, midwife and sister sister.

FAP functions:

Providing the population of first prefigible medical care;

Ensuring the population by drugs (according to the approved health authorities by the nomenclature);

Timely and in full implementation of the appointments of the doctor;

Organization of patronage of children and pregnant women, dynamic observation of the state of health of individual categories of citizens;

Systematic observation of the state of health of disabled wars and leading experts agriculture (mechanisters, livestock breeders);

Carrying out measures to reduce children's and maternal mortality;

Sanitary and hygiene learning and population education

Rendering urgent dental care (for example, removal of acute pain)

Rural Section Hospital (Sub)

The rural area hospital (sub) is a leading institution in the Security Council. In its composition may have a hospital and a medical ambulatory.

The nature and amount of medical care in the district hospital is determined by the capacity, equipping, the presence of specialist doctors. However, regardless of capacity, it is obliged, first of all, to provide outpatient care for therapeutic and infectious diseases, assistance in childbirth, medical and preventive care for children, emergency surgical and traumatural assistance.

In the state sub must be doctors in the main specialties: therapy, pediatrics, dentistry, obstetrics and gynecology, surgery.

Tasks sub:

Ensuring the population of the attic territory by qualified medical assistance (outpatient and stationary);

Planning and conducting measures to prevent and reduce morbidity and injuries among various groups of the rural population;

Conducting medical and preventive measures to protect the health of mother and child;

Introduction into the practice of modern methods of prevention, diagnosis and treatment, advanced forms and methods for organizing medical care;

Organizational and methodological management and control over the activities of FAPs and other health care facilities that are part of the medical site.

The organization of outpatient polyclinic assistance to the population can be provided with an ambulatory (polyclinic), which is part of the sub-structure, or an independent rural medical ambulatory (clinic). The main tasks of this institution: carrying out broad preventive measures to prevent and reduce morbidity, early detection of patients, dispensarization, providing qualified medical care to the population. Doctors are receiving adults and children, challenges home and emergency care. In the reception of patients they can take part and paramedic, however, outpatient assistance in a rural medical ambulance should be provided by doctors.

Sub function:

Carrying out measures for the approach of community-friendly assistance to workers in agriculture during the period of mass field work;

A set of sanitary-anti-epidemic activities (preventive vaccinations, current sanitary supervision of institutions and objects, water supply and purification of settlements, etc.);

Planned departures of doctors in subordinate Fairs and children's educational institutions to provide practical assistance and control over their work;

Conducting temporary disability examination and, if necessary, the direction of IEC.

SECOND PHASE

Central District Hospital (CRH)

CRH - the main institution of the second phase of rural health care is the central district hospital, which carries out the main types of specialized qualified medical care and at the same time performs the functions of the management body. The CRH serves as the center of operational management by all health care facilities in the district, is responsible for organizing, the production and quality of medical care to the population is carried out by organizational and methodological work.

In different regions of the country there are CRH of different power, which depends on the population, the provision of hospital institutions and other factors. The optimal power of the CRH is at least 250 beds.

The composition of the CRH:

· Hospital with branches for the main specialties;

· Polyclinic with medical and diagnostic cabinets and laboratory;

· Department of ambulance and emergency medical care;

· Pathoanatomy separation;

· Organizational and methodical office;

· Structural auxiliary units (pharmacy, kitchen, medical archive, etc.).

The profile and number of specialized branches in the CRH depend on its capacity, but their optimal number should be at least five:

1) therapeutic;

2) surgical with traumatology;

3) pediatric;

4) infectious;

5) obstetric-gynecological (if there is no maternity hospital in the area).

Tasks of the CRH:

Ensuring the population of the district and the district center qualified specialized stationary and polyclinic medical care;

Organization of emergency medical care;

Operational and organizational and methodological management of all health care facilities, control over their activities;

Planning, financing and organization of material and technical support of health care institutions;

Development and implementation of activities aimed at improving the quality of medical care of the population, reducing the incidence, infant and overall mortality, health promotion;

Development and implementation of measures for alignment, rational use, advanced training and education of medical personnel of health care facilities.

The management of the district is carried out by the head physician of the CRH, which has deputies for the main activities:

By medical part;

On polyclinic work;

On organizational and methodological work (head of the organizational and methodological department);

According to administrative work

According to childhood and objectiveness (in areas with a population of 70 thousand and more).

The sanitary and preventive service is headed by the Chief State Sanitary Doctor of the district, which is the chief physician of the CGSAN.

The doctors of rural medical sites for the provision of Methodical, organizational and advisory assistance, the CRH allocates regional specialists who, as part of their specialty, carry out the organizational and methodological management of all medical institutions of the district. This is essentially the heads of the CRH offices, the most experienced doctors.

Functions of the head of the department of the CRH:

Heads therapeutic work in the area in its specialty;

Leaving for consultation;

Conducts indicative operations;

Examination and treatment of patients;

Directors teams of medical professionals in medical facilities of rural medical sites;

Hears reports of the doctors of district hospitals, headsets;

Analyzes work plans, statistical reports;

Conducts scientific conferences, seminars;

Exercises advanced training in the workplace, etc.

Polyclinic CRB

Polyclinic (ambulance) CRH provides qualified medical assistance to the rural population of 8 - 10 medical specialties.

Tasks Polyclinic:

· Providing qualified outpatiently polyclinic help of the attached population of the district and the district center;

· Organizational and methodological management of ambulatory-polyclinic divisions of the district, control over their activities;

· Planning and conducting measures aimed at preventing and reducing morbidity and disability;

· Timely and widespread introduction into the practice of the work of all outpatient facilities of the area of \u200b\u200bmodern methods and facilities for the prevention and treatment of diseases, excellence in the provision of outpatient polyclinic care.

Rural residents in the areas of medical facilities of rural medical sites are treated in the district clinic for specialized medical care, a functional examination, consultations from specialist doctors.

In order to approach specialized medical care to the place of residence on the basis of CRH from among full-time doctors and a nurse, exit brigades of medical and outpatient care can be created.

An important role in the organization of medical and preventive care in the area is played by the organizational and methodological office of the CRH. It should be staffed by the most experienced doctors, and have data on the economy and sanitary condition of the district, about the network and staffing of medical institutions by personnel, on the security of the population by various types of medical and social security, etc. Heads the organizational and methodological office of the head, which is at the same time is Deputy Chief Doctor CRH.

Interdistrict specialized branches (MSO)

In order to approach specialized medical care to the rural population in district centers, inter-district specialized branches (centers) equipped with modern equipment can be created.

The functions of inter-district centers are performed by the LPU capable of providing the population of specialized highly qualified stationary or outpatient polyclinic medical care, in cases where the CRH of the surrounding areas does not have the ability to provide specialized assistance in this specialty.

Along with the fulfillment of the function of the structural division of the LPU, inter-district specialized centers (separations) are carried out:

MSO functions:

Advisory techniques in the polyclinic of patients in the direction of the doctors of the LPU attached areas;

Hospitalization of patients from attached areas;

Organizational and methodological and advisory assistance (including the examination of working capacity) by the doctors of the LPU attached areas, including by planned departures;

Introduction into the practice of work of health institutions of modern means and methods for the prevention, diagnosis and treatment of patients according to the appropriate specialty;

Analyzing the results of the provision of medical assistance to residents of attached areas, submission of information on the work of the Interdistrict Medical Center;

Conducting joint control and expert commissions, thematic conferences, seminars.

The health care organizations of the attached areas provide transportation of patients and pregnant women to the Interdistrict Center (by agreement), the direction of patients for consultation only under the condition full examination In accordance with the medical and economic standards, they inform the population about the work of the Center's specialists. Interdistrict medical councils are created to coordinate the work of inter-district medical centers and assigned areas.

Ambulance service

The ambulance service on the village remains today and the most popular and most problematic.

Tasks:

Providing patients and affected prefigure medical care aimed at preserving and maintaining vital important functions organism;

Downting them as soon as possible to the hospital for the provision of qualifier-bath and specialized medical care.

Currently, the main trends are clearly marked by the influence on the emergence of the country's ambulance.

They are associated primarily with the following factors:

An increase in injuries and other accidents related to man-made human activities;

Deterioration of economic conditions of the population, social
instability, increasing stressful situations;

An increase in rope and deterioration of the operational situation;

Weighing and chronization of pathologies;

Deterioration in the material and technical equipment of exit team of emergency medical care, developed by the resource of equipment, etc.;

Lack of a system of organizing the provision of first aid at the scene of the accident (injury) before the arrival of the ambulance brigade;

Socio-psychological problems of the personnel of emergency medical care and caused by them conflicts, fluidity of personnel, an increase in incidence among service workers;

The provision of medical assistance to residents of a large number of small populations at their remoteness from the main medical and prophylactic institutions, the absence of communications and communications.

At the same time, the current system of emergency care for the population, oriented to the Patients of the Mac-Similar Assistance at the Dogo Point, does not provide the necessary effectiveness, being also highly cost.

For the emergency service in the village, both all the above problems are characterized in the village, as well as characteristic only to it - the provision of medical care to residents of a large number of small settlements during their remoteness from the main medical and preventivecies, the absence of communications and communications.

One of the consequences of the socio-economic crisis in Russia was the deterioration of the health of the population. Over the past decade, there has been a persistent tendency to increase mortality due to increasing injury, poisoning, diseases of the cardiovascular system of medical prevention and the limited availability of drugs led to the chronization of pathologies and the population needs increase in emergency medical care.

Emergency medical care is socially significant species medical care, which in new conditions economic Development can not be completely translated on market conditions Management. First medical care is in the first place in the "Program of State Guarantees to Provide Citizens of the Russian Federation free medical help", which implies the priority of its financing.

The ambulance stations in rural areas, as well as urban, are divided into categories depending on the number of catchers per year. In rural areas, this is mainly the stations of the third and four-time category, respectively, from 25 thousand to 50 thousand and from 10 thousand to 25 thousand challenges per year.

The main structural and functional unit of the ambulance station is Fel-Drsher's Brigade:

Two paramedics;

Sanitary;

Driver.

The brigade provides the necessary medical assistance within the compecting defined by industry standards, rules and standards for Feldsher staff. The composition and structure of the brigade applies to the head of the station (separation) of ambulance.

A specialist with secondary medical education specialist, who has a diploma and a corresponding certificate, is appointed to the post of Medium Medical Education, a specialty "Medical Business", which has a diploma and a compliant certificate, for the post and transfer of call challenges (separation) ambulance with an average medical education for specialism "therapeutic matter" or "nursing case".

Responsibilities and rights of the Feldscher Departure Brigade of Emergency Medical Aid and Feldscher (Medical Sitter) on the reception and transfer of the challenges of the station (separation) of emergency medical care, as well as their responsibility are governed by the Order of the Ministry of Health of Russia of March 26, 1999 No. 100 "On improving the emergency medical care to the population Russian Federation".

Departments (branches) of emergency medical care are created on the basis of precinct hospitals and rural medical ambulances with round-the-clock consolidation of sanitary transport. Such organizational models allow for an ambulance and medical care guaranteed, around the clock and for free in accordance with the standards and protocols of patients.

It is impossible to realize the tasks without adopting effective measures at the regional level, without constant and painstaking work on training, certification and certification of emergency medical staff, especially the paramedic composition as the main personnel service. As well as logistics of exit brigades.

In the decisions of the Collegium of the Ministry of Health of Russia of May 22, 2001, "On the state of medical assistance to the rural population", health authorities of the constituent entities of the Russian Federation, it is recommended to develop and approve territorial plans for agricultural health development, incl. and in terms of developing territorial development programs for emergency medical care.

When creating such programs, it is necessary to take into account priority areas in the development of emergency medical care:

Creating an emergency medical management scheme in the subject of the Russian Federation as a whole and in each settlement in particular;

Modernization of equipment. The introduction of information technologies of the dispatch service of emergency medical care and receiving departments of hospitals with a clear formation of hospitalization fluxes;

Expanding the amount of medical and diagnostic assistance based on uniform medical and economic standards for emergency medical care and developed patient management protocols;

Improving the wage and tariff policy for institutions that provide emergency medical care in rural areas.

Emergency medical care is one of the factors national Security. Its level of its organization directly affects the decline in the losses of society from acute diseases, injuries, poisoning and other states threatening the life and health of the population. The priority of the development of emergency medical care in the village should be united ambulance stations with a developed network of service units, as close as possible to a rural resident.

Third stage

Regional (edge, district, republican) institutions

The regional (regional, district, republican) hospital is a major multidisciplinary medical and prophylactic institution, designed to provide highly qualified specialized assistance not only to rural residents, but also to all residents of the subject of the Russian Federation. Heads health state body Health Management Administration (Government) of the Directory of the Russian Federation in accordance with the law and within the authority provided to him.

The regional hospital is the center of organizational and methodological management by medical institutions posted on the territory of the region (edges, district, republic), the basis of specialization and advanced training of doctors and medium medical personnel.

The capacity of the hospital is determined by the number of the population of the administrative territory (including the administrative center), and the states, in turn depend on the power. The optimal is considered the power of the regional (regional, district, republican) hospital at 700 - 1000 beds.

Terms of Regional (Regional) Hospital:

The provision of highly qualified specialized advisory and diagnostic and medical assistance to the population of the administrative territory in outpatient and inpatient conditions using highly efficient medical technologies;

Provision of advisory and organizational and methodological assistance to specialists of other LPU administrative territories;

Organization and provision of qualified emergency and planning-consultation medical care using sanitary aviation and ground transport;

Implementation of the examination of the quality of the medical and diagnostic process in medical institutions of the administrative territory;

The implementation of other expert functions on a contractual basis with health authorities and medical institutions of the administrative territory, licensed accreditation commissions, funds medical insuranceInsurance medical organizations and etc.;

Development and implementation of contracts with health authorities to implement targeted medical care programs;

Introduction into the practice of LPU administrative territory of modern medical technologies, economic methods management and principles of health insurance;

Participation in the preparation, retraining and advanced training of medical workers.

Structure of the Regional (Regional) Hospital:

Organizational and methodological department;

Advisory clinic;

Diagnostic department

Hospital with a reception unit;

Department of clinical expert and organizational and economic work;

Department of Expert and Planning Advisory Assistance;

Pathoanomatic department (bureau - in the absence of independent republican (regional, district) bureau);

Others structural unitsnecessary for the normal functioning of the hospital (sophistication, accounting, medical archive, library, garage, etc.);

Pension for patients;

Hostel for medical workers.

Regional (edge) Consultative Polyclinic (OKP)

The activities of the regional hospital has its own characteristics. One of these features is the presence of the hospital of the regional advisory clinic (OKP), where the residents of all cities and areas of the region come for help, which causes the need to organize their placement. For these purposes, a pension or a hotel for patients is created.

OKP tasks:

Ensuring a partitioned from medical institutions of a precinct or district level to a specialized qualified advisory assistance to establish or clarifying the diagnosis;

Prescription and methods of treatment, if necessary, inpatient care in the offices of the regional hospital;

Evaluates the quality of the work of rural doctors, district urban and district hospitals;

Together with the Department of Emergency and Planning and Advisory Assistance, organizes and conducts on-site consultations of specialist doctors.

In the regional counseling polyclinic, patients are directed, as a rule, after prior consultation and surveys from district professionals. For a uniform distribution of the flow of patients, the OKP regularly reports the availability of free places in the boarding house, in the hospital departments, coordinates the timing of the receipt of patients from rural facilities. On each patient gives medical conclusionwhich indicates a diagnosis of the disease conducted by treatment and further recommendations. The clinic systematically analyzes cases of discrepancies in diagnoses, errors made by the doctors of LPU areas during examination and treatment of patients in the field.

Department of emergency and planned advisory assistance.

A feature of the regional hospital is the presence of an emergency and planning-consultative office in its composition, which, using sanitary aviation or other transport, provides emergency and advisory assistance with departure to distant locality or location of the dislocation (work) of rural residents.

Functions of the department:

Transportation of patients in medical institutions;

The direction of challenges from districts and support communication with brigades aimed at providing medicinal assistance;

In urgent cases, the organization of the delivery of patients accompanied by medical personnel in specialized institutions outside the region;

Urgent delivery of various medical preparations and means necessary to save the life of patients;

This department, as a rule, has a car park (part - with high patency) for trips to the countryside. Aviance are performed on the basis of contracts with local airlines, which requires significant financial costs. The staff work, in addition to the head, doctors for the provision of emergency medical help, Feldscher, nurses. All experts from the regional hospital and other institutions-Deni may be involved in the work of the department. Department of emergency and planning-consultative in power, as a rule, is a basic medical unit of the Regional Center for Medicine Catastrophe. In this case, practical work on the implementation of sanitary assignments is carried out by brigades of a specialized medical care for constant readiness - BSMPP.

Organizational and methodical department

Unlike the city, in the regional hospital, the function of the organizational and methodological department is significantly wider. In fact, it serves as a scientific and methodological basis of the state-based health authority for the introduction of advanced organizational forms and methods of the population of the population.

Functions of the organizational and methodological department:

Analysis of the activities of the area of \u200b\u200bthe region;

Organizational and methodological and advisory in-power authorities and healthcare facilities;

Study of the health-population indicators of the region;

Organization of enhancing codification of personnel;

Planning work.

In the organizational and methodological work of medical institutions of the region take part:

Main full-time (chief surgeon, therapist, pediatrician, obstetrician-gynecologist) Specialists of the State Health Management Authority.

Freelance (most often managed by specialized and highly specialized branches) Specialists of the Human Health Management Authority.

Exit forms of work

In order to approximate specialized medical care to the rural population important Brigades of exit medical and outpatient care, which are created on the basis of CRH and regional hospitals. The exit brigade is formed by the chief physician of the hospital from among the full-time doctors and medium honey. workers. It may include honey. Employees of other hospitals and preventive institutions (urban hospitals, born. houses, dispensaries, etc.).

Planned exit consultations of specialist doctors at the regional (regional) hospital organizes and conducts a consultative polyclinic together with the Department of Emergency and Planning and Advisory Assistance.

Types of departure forms of medical care:

Mobile medical ambulances,

Clinical diagnostic laboratories,

Fluorographic installations

Dental cabinets.

The main tasks of the departure forms of medical care of the population:

Performing a large amount of preventive and therapeutic work.

Apply the provision of medical care to rural residents, make it more affordable and timely.

Implementation of advisory assistance.