Analysis of legal acts regulating activity of general practitioners and nurses

AnnotAtion

The availability and quality of medical care largely depend on efficiently organized activities of physicians and nurses. Regulations play a key role in organizing activities of general practitioners and nurses. Therefore, purpose of the study was review of regulatory acts regarding general practitioners and nurse's activity in order to determine changes or tendency on regulatory acts. As well as analyzed changes in workload of general practitioners and nurses.

This study was conducted through reviewing changes and additions in legal acts regulating activities of general practitioners and nurses. Overall, 25 regulatory documentations and scientific publications were analyzed. Sources of legal acts and scientific publications were website www.zakon.kz, Republican Center for Healthcare Development. The results of the study showed that there are many legal acts that govern activities of general practitioners and nurses. During content analysis of legal acts were identified inequality of physicians and nurses. For example, general practitioners belong to highly qualified specialists, while nurses to specialists of secondary qualification, although in recent years in the national health care system have been trained nurses with higher education.

In addition, nurses belong to B3 unit, while general practitioners are categorized as B2. These facts reduce the status of nurses.

Healthcare development programs giving priority on development of primary care, increasing number of general practitioners, improving status of general practitioners and nurses.

As well as there is a downsizing of general practitioners' district, and a gradual reduction in workload of general practitioners. For example, in 2018 according to legislatives 1700 population comes to 1 general practitioner.

Changes in order on preventive medical examination and target groups shows that workload of general practitioners and nurses still remain higher comparing with 2011. This is because target groups for cervical and breast cancer in 2017, were expanded compared with 2011.

The results of research shows, those functional duties of nurses are expanding. For instance nowadays nurses can individually accept patients on medical organization and may delegate home visits.

According to results, general practitioners acquire skills in following areas: obstetriciangynecology, internal diseases, pediatrics, therapy, nephrology, etc. Nurses acquire skills in following areas: propaedeutic of internal diseases, nursing in pediatrics, nursing in surgery, nursing in obstetrics and gynecology, nursing in epidemiology, clinical pharmacology, nursing in neurology and general practice nurse. The analysis shows that domestic nurses acquire skills for admitting and consultation of patients with chronic diseases.

General practitioners are driving depend on efficiently organized activities force of primary health care. The of physicians and nurses. It is worth to note, availability and quality of medical care largely there is a huge shortage of human resources for health. According to the State Health Development Program «Densaulyk» for 20162019, on average 1 general practitioner serves 2,200 attached population, while in countries of Organization for Economic Cooperation and Development, 1 general practitioner serves 1500 populations. As well as there is a shortage of nurses (1.1 nurses comes to 1 general practitioners) [1]. These challenges bring to workload of general practitioners and nurses, which reduces availability and quality of primary health care.

Legislative documents are basics for organizing physicians and nurse's activity. Sufficient and proper quality legislatives help to effectively organize provisions of primary care services to population. For instance according to research conducted by Avril Kaplan, if healthcare workers know their responsibility, it is contributing them to fulfill their duties [2]. In this regard it is worth noting that the duties of general practitioners and nurses are many-sided and consist of many following areas: patient admission, home visits, medical examination, hospitalization, preventive examinations, promotion of a healthy lifestyle, etc. Therefore it is necessary to conduct analysis of legislative acts regarding activity of general practitioners and nurses, to find out tendencies.

Although there is enough research regarding workload of general practitioners, their working time [3,4], it is worth to note that there is not research that's related to workload and its correlation with legislations regulating general practitioners and nurse's activity.

Materials and methods of research. A review of the legal acts and scientific publications regulating activities of general practitioners and nurses was conducted. The main inclusion criteria were legal acts that regulate activities of general practitioners and nurses. Overall, 25 regulatory documentations and scientific publications were analyzed. Sources of legal acts and scientific publications were website www.zakon.kz, Republican Center for Healthcare Development.

Results and discussions: The main Legal acts' governing activities of medical and a pharmaceutical worker is «Code of People's Health and the Healthcare System», and Labor Code of the Republic of Kazakhstan. Code - a set of laws in any industry. Therefore «Code of People's Health and the Healthcare System» - is a set of laws in healthcare system. This code defines the rights and obligations of medical and pharmaceutical workers, labor relations, in articles 182,183,184 [5].

According to 183 articles of «Code of People's Health and the Healthcare System», labor relations and salaries of medical workers are regulated on the basis of Labor Code of the Republic of Kazakhstan.

The Labor Code of the Republic of Kazakhstan is a set of laws in the labor sphere. The action of the labor code applies to many activities and areas, including health care. The Labor Code of the Republic of Kazakhstan from 23 November, 2015, No. 414-V, regulates working time standards, types of recreation and types of remuneration of health workers. For example, below demonstrated several norms and rules that should be followed by all health care workers:

1.Weekly workload for workers of all qualifications should not exceed 40 hours

2.Overtime work must be done with the consent of health workers and should not exceed 2 hours per day.

1. Payment for overtime work and work on holidays shall be made according to the contract, but not less than 1.5 times based on salary per day [6].

The next legal documents according to hierarchy are decrees of the President of the Republic of Kazakhstan. The current State health care development program «Densaulyk» for 2016-2019, was approved by the decree of the President of the Republic of Kazakhstan No. 176, dated January 15, 2016. This program contains an analysis of situations in the field of health care, goals and objectives for improving public health. According to the objectives of this program, it is planned to get this goals till 2019:

1. To increase salaries of physicians.

2. To achieve the share of primary health care physicians up to 26.6% in the total number of physicians

One of the directions in this programis the priority development of primary health care. According to this direction, it is planned to introduce family principle of care, ensure the continuity of medical care by developing an integrated health care system and transferring coordination of medical care to primary care specialists [7].

Similarly, in State Healthcare Development program for 2011-2015 “Salamatty Kazakhstan”, were set following tasks:

1. Clarity of duties and delegation of general practitioners tasks to nurses

2.Improving labor remuneration and employee motivation mechanisms

3.Increasing number of general practitioners

1. Training specialists in accordance with international standards [8].

State Healthcare Development program for 2005-2010, also puts emphasis to primary health care, and training of primary health care professionals.

Analysis of Healthcare development programs shows that there is a tendency to developing primary care, increasing number of general practitioners, improving status of general practitioners and nurses [9].

After the decrees of the President of the Republic of Kazakhstan according to legal force goes Decrees of the Government of Kazakhstan. The Decree of the Government of the Republic of Kazakhstan from 31 December, 2015, No. 1193, regulates salaries of medical workers. It should be noted that register of civil servants has been developed, which is the basis for determining the salary of health workers. This register is divided into 4 blocks and 11 units and takes into account the qualifications and category of medical workers. Physician in this registry refer to 2 block and unit B2, while nurses refer to unit B3. Every unit are given by certain coefficients, which are multiplied to base salary (base salary is 17,697), in order to determine total salary. It should be noted that these coefficients would increase with the growth of the experience of a medical worker. It should be noted that qualification, category, work experience of medical workers are taken into account in calculating salary [10]. The coefficients for health workers are listed in the table - 1.

Table 1. Determining salary of physicians and nurses according to category and working experience

Source: The Decree of the Government zan.kz/rus/docs/P1500001193). of the Republic of Kazakhstan from 31 The next in hierarchies of legal acts December 2015, No. 1193, (URL: http://adilet. is orders from Ministry of Healthcare of the

Republic of Kazakhstan. The basis organizing primary health care, objectives, principles and types of organization for the provision of primary health care are identified in the order of the Ministry of Healthcare and Social Development of the Republic of Kazakhstan from 28 April, 2015, No. 281 “On approval of Rules for the provision of primary health care and the Rules for the attachment of citizens to organizations of primary health care” [11].

This order has undergone some changes and additions since the order was accepted. For example, according to edition from 5 December, 2017 the number of attached population is determined on the basis of staff standard.

Need for medical personnel in outpatient organizations are determined on the basis of staff standard. Staff standards in domestic health care system are regulated by order No. 238, which sets the following standards:

1.1 general practitioner should to serve 1700 population

1. Average general practitioners must spend 15 minutes for admitting one patient, and 30 minute on home visiting.

3.3 nurses must come to 1 general practitioner

Analysis of this order shows that, according to edition from April 7, 2010, there were no standards for outpatient organizations. Then in 2011 there was stated that 2000 mixed population must serve 1 general practitioner. However in 2018 there was set a new standard 1700 mixed population for 1 general practitioner.

The time standards for patient admission and home visits were established in the edition of the order from August 17, 2013 [12].

The analysis shows that there is a downsizing of general practitioners' district, and a gradual reduction in workload of general practitioners.

But, it is worth noting that it is planned to abandon staffing standards and introduce flexible system for forecasting human resources for health.

The main tasks of primary health care are providing population with preventive examinations and screenings. The rules for conducting prenatal, neonatal and psychophysiological screenings are set out in order No. 704 of the Ministry of Healthcare of the Republic of Kazakhstan dated September 9, 2010 “On Approving the Rules for Organizing Screening” [13].

This order was amended twice. In edition from September 9, 2010, there was indicated only two types of screenings: prenatal and neonatal. In edition from August 31, 2017, the following screenings were added: audiological screening of newborns, screening for the psychophysical development of young children and ophthalmic screening of premature babies.

Preventive medical examinations on target groups of population are carried out on the basis of the order No. 685 “On approval of the rules for conducting preventive medical examinations, for target population groups”. This order lists the target groups and the procedure for screening on circulatory diseases, diabetes, glaucoma, and malignant neoplasms [14].

The analysis of this order was carried out on changes in target groups for various screening programs. The target groups for circulatory system disease was patients aged 18, 25, 30, 35, and from 40 to 64 every two years, in 2011. Then, screening began to be carried out every two years from 40 to 60, starting from 2014. It is worth to note that the target groups were expanded till 70 years in 2017. Target groups for glaucoma and colorectal cancer remained unchanged. The target groups for cervical and breast cancer was expanded in 2017 compared with 2011. The highest workload from screening was during 2014-2017. However, due to the expanding of target groups in some categories, it can be assumed that, the workload of general practitioners and nurses will be high in 2017 compared with 2011. The target groups are provided in table 2.

Table 2. Target groups

The functional responsibilities of nurses and general practitioners are specified in the order No. 7 «on approval of the Regulations on activities of healthcare organizations that provide outpatient care». According to this order, general practitioners carry out the diagnosis and treatment of the most common diseases by profile: cardiology, rheumatology, pulmonology, endocrinology, gastroenterology, etc. This shows that general practitioners take some functional responsibilities of narrow specialists. Also, nurses have a right to independently admit patients within their competencies, prescribe medications to patients with chronic diseases that was prescribed by physicians [15]. This order entitles nurses to delegate some responsibilities of physicians and independently accept patients. As noted earlier, this practice is carried out in Scandinavian countries, where nurses carry out the initial admission of patients and refer them to general practitioners only when it is needed. It is worth noting that this order states that nurses should conduct home visits within their competence, if there are no indications for physician's assistance. This practice saves the time of general practitioners. According to the order of the Ministry of Healthcare No. 519 “On realization of the pilot introduction of payment for outpatient care on comprehensive per-capita normative” envisaged extension of nurses responsibilities [16]

It is important to develop clinical protocols on main chronic non-communicable diseases, in order to properly delegate responsibilities of general practitioners to nurses and ensure protection of nurses' rights. Clinical protocols in various areas are developed by efforts of research institutes, medical organizations and associations of healthcare workers, in recent years (Сlinical protocols: [Site of Republican center for healthcare development]. URL: http://www. rcrz.kz/index.php/ru/2017-03-12-10-51-13/ klinicheskie-protokoly).

Requirements to medical workers qualifications are governed by the order of the Ministry of Healthcare No. 791 “on approval of qualification characteristics of health workers positions”. This order is the basis for certification of employees, selection and placement of medical personnel. According to this order in order to become a general practitioner it is necessary to have a higher medical education and a certificate of specialist in specialty “General practice”. Besides diagnosis and treatment of the most common diseases, general practitioner should know the statistics of diseases, labor laws and regulations in the field of health [17].

According to the order No. 791 in order to become a nurse it is necessary to have secondary special education, higher education in specialty «Nursing».

An analysis of order shows that duties of nurses have undergone some changes. For example, general practice nurse should monitor patient condition and provide data to an advanced practice nurse. As well as, nurses should carry out clinical examination and simplest physiotherapeutic procedures. It is worth of note that new position of “advanced practice nurse” was added to the qualification characteristics of health workers in 2018. Advanced practice nurses should supervise general practice nurses, conduct patronage of pregnant women, sick and elderly patients. And it is required to have at least applied baccalaureate level to work as advanced practice nurse. Duties of nurses indicated on table 3.

Table 3. Duties of nurses.

The analysis shows, that nursing duties are increasing, and functions of general practitioners are delegated to nurses.

Analyzing a similar order of the Ministry of Health and Social Development of the Russian Federation from 23 July, 2010, No. 541n “on approval of unified qualification catalog of managers, specialists and employees”, it can be noted that the general practitioner in the Russian Federation refers to specialists with higher medical and pharmaceutical education and nurses refer to specialists with secondary medical and pharmaceutical education. But, in requirements for qualifications required only secondary special education in order to be a nurse. It is worth noting that in Kazakhstan, general practitioner refers to highly qualified specialists, while nurses to secondary qualified specialists, despite of the fact that a nurses may have a higher education [18].

In the order of the Ministry of Healthcare of the Republic of Kazakhstan No. 774 “on approval of the nomenclature of medical and pharmaceutical specialties”, general practice nurse treats to specialists with technical and professional medical and pharmaceutical education [19].

Taking some powers of general practitioners, nurses expand their responsibilities. There are advanced-practicenurses who manage chronic diseases and take part on developing protocols in United States of America. The qualification requirements for such specialists are master education. In light of the expanding responsibilities, qualification requirements should be reviewed taking into account international practice [20].

According to the order of the Ministry of Health and Social Development No. 647, were approved model curricula for specialty “6R110200 - General Medical Practice” and “6B110300-Nursing”. The standard curriculum for specialty «6R110200 - General Medical Practice» includes such disciplines as internal diseases (childhood diseases), obstetrics and gynecology, ophthalmology, oncology, neurology, emergency aid, which forms competencies of general practitioners in relevant areas [21].

Nowadays, training of general practice nurses is carried out in medical colleges according to State Educational Standard from 2010, on qualification 0302033 -«general practice nurse». During training process, general practice nurses acquire skills in following areas: internal diseases propaedeutic, pediatrics, surgery, obstetrics and gynecology, epidemiology, clinical pharmacology, neurology and general practice nurse. These disciplines are aimed to build following competencies: assessment of child's condition, knowledge on anatomical and physiological characteristics of children, using medicines for treating patients, managing pregnancy, features of the most common diseases [22].

It should be noted that “Model programs for advanced training and retraining of medical and pharmaceutical personnel” were approved by order No. 165. This order identifies priority topics for advanced training cycles in specialty “General Medical Practice”. According to this order, priority topics for advanced training are:

1.«Questions of evidence-based medicine in general medical practice»;

1. «Actual issues of pediatrics in general medical practice»;
2. «Actual issues of therapy in general medical practice»
3. «Surgical diseases in general medical practice»;
4. «Actual issues of phthisiatry in general medical practice»;
5. «Prevention of diseases and formation of healthy lifestyle in general medical practice»;
6. «Actual issues of obstetrics and gynecology in general medical practice»
7. «Questions of neurology, psychiatry and narcology in general medical practice»;

The abovementioned topics show that general practitioner must have skills not only in therapy and pediatrics, but also have to know surgery, obstetrics and gynecology, neurology, psychiatry and narcology [23].

The system of human resources planning and forecasting is gradually developing. It is well-known that the basis of effective planning and forecasting is high-quality evidence based information on human resources for health. In order to improve the quality of information, in 2013, was adopted order No. 598 “On improving the system of accounting and analysis of data in the field of human resources for health”. The forms of registration cards for specialists with higher medical and pharmaceutical education, specialists with secondary medical education was approved by this order. According to approved form, collects data on health care specialists [24].

As well as, Observatory of Human Resources for Health was established under Republican Center for Health Development by order of the Vice-Minister of Healthcare No. 173. The Health Human Resources Observatory is a center for data collection, processing, planning and forecasting of human resources for health [25]

Conclusions and recommendations. There are many legal acts that regulate activities of general practitioners and nurses. Analysis shows that in nomenclature of positions, nurses are classified as professionals with technical and medical education, although in recent years in the national health care system have been trained nurses with higher education. In Government order № 1193, physician refers to 2 block and unit B2, while nurses refer to unit B3. These facts reduce the status of nurses. It is necessary to improve the status of nurses, and divide nurses according to the level of education.

One of the pros of legislative reforms is introducing new position “advanced practice nurse', who can delegate more responsibilities of general practitioners. However it is needed to introduce new curriculum for this specialists, according to international standard.

Training of general practitioners and nurses is carried out on the basis of approved State Educational Standard. General practitioners acquire skills in following areas: obstetrician-gynecology, internal diseases, pediatrics, therapy, nephrology, etc. Nurses acquire skills in following areas: propaedeutic of internal diseases, nursing in pediatrics, nursing in surgery, nursing in obstetrics and gynecology, nursing in epidemiology, clinical pharmacology, nursing in neurology and general practice nurse. The analysis shows that domestic nurses acquire skills for admitting and consultation of patients with chronic diseases.

It is also necessary to separate nurses in various areas and determine functional responsibilities of the relevant specialties. For example, nurses who work with general practitioners should not have the same competencies and education as nurses that work with narrow specializations or in inpatient organizations.

According legislative documentations 3 nurses comes to 1 general practitioner. But in practice it is about 2.4 nurses per 1 general practitioner. Taking into account nurses responsibility, including increasing responsibility on screenings, it is necessary to increase the number of nurses.

Legislative documentations and healthcare development programs are seeking to downsize attached population to 1 general practitioner till 1700.

Therefore, it is become important to increase number of general practitioners and improve mechanisms for keeping specialists in primary care.

ReFeRenceS

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19. Приказ Министра здравоохранения Республики Казахстан от 24 ноября 2009 года № 774 «Об утверждении номенклатуры медицинских и фармацевтических специальностей».
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21. Приказ и.о. Министра здравоохранения и социального развития Республики Казахстан от 31 июля 2015 года №647 «Об утверждении государственных общеобязательных стандартов и типовых профессиональных учебных программ по медицинским и фармацевтическим специальностям».
22. Приказ Министерство здравоохранения Республики Казахстан от 2010 года № 378, ГОСО РК 4.05.146-2010.
23. Приказ министра здравоохранения РК от 14 апреля 2017 года № 165 был утвержден «Типовые программы повышения квалификации и переподготовки медицинских и фармацевтических кадров».
24. Приказ и.о. Министра здравоохранения Республики Казахстан от 16 октября 2013 года № 598 «О совершенствовании системы учета и анализа данных в области кадровых ресурсов здравоохранения».
25. Приказ вице-министра здравоохранения от 7 апреля 2014 году № 173 О создании системы планирования и прогнозирования кадровых ресурсов здравоохранения «Обсерватория кадровых ресурсов здравоохранения».