INTRODUCTION
Throughout the history of the development of public healthcare, civil society has been organized into various forms of public associations to solve urgent problems and needs of vulnerable groups of the population, overcome crisis situations in the healthcare industry, while improving approaches in its organization and management [1,2].
In recent years, the participation of civil society institutions in making managerial decisions in the field of public health protection and promotion has become an important part of state social policy in most countries worldwide. By taking part in social movements, the population becomes involved in the processes of forming priorities for the development of the health system and the development of national projects and programs in public health and healthcare. This is due to the fact that civil society is the target consumer of medical services, and its participation in healthcare policy makes the healthcare industry more patient-oriented and democratic, which is reflected in improving the quality and accessibility of medical care. As a result, this increases the level of public satisfaction with medical services [3,4,5,6,7].
The situation with the spread of the new coronavirus infection COVID-19 around the world has demonstrated the need to unite the state and society; thus, representatives of public and volunteer associations, healthcare professionals, students of medical educational organizations and public authorities have united to help those in need and overcome the consequences of the pandemic.
The experience of public participation during the pandemic determined the importance of supporting civil society institutions and its consolidation with state structures to confront potential future emergencies, paying special attention to the formation of common goals and objectives [8,9,10].
The World Health Organization has repeatedly emphasized in all public health promotion programs the need for cooperation between health authorities, non-governmental organizations and private sector entities, charity foundations, medical organizations, and other non-governmental structures, stressing the need to encourage public participation in the formation and implementation of public health policy. Participation and empowerment of citizens in the field of public health and healthcare have become key words in strategic documents aimed at the development of health systems in most countries. Due to this fact, the social policy of many countries is based on enhancing the responsibility and transparency of new forms of health system management through the involvement and participation of civil society [11].
At the same time, it is impossible to overestimate the importance of public participation in the processes of determining and forming priority areas for the development of public health and healthcare. In the absence of public control and the participation of civil society in the formation of state social policy, any transformation of the healthcare sector will likely not bring the desired effect, and significant improvements in the protection and promotion of public health will not be achieved.
Intersectoral cooperation in healthcare can identify vulnerable groups of population and ensure their inclusion in government decision-making processes, taking into account their needs. The implementation of a coordinated intersectoral policy on public healthcare promotes a better understanding and helps meet individual needs of various groups of the population for quality medical services [12].
Currently, the preservation and improvement of public health, improvement of public well-being, provision of affordable and high-quality medical services, as well as overcoming threats to public health are the main priorities of health policy and the goals of sustainable development of the modern state, the achievement of which requires close attention from both all levels of government and civil society [13,14].
Adhering to the principles of democracy, public authorities actively interact with civil society institutions on the solution of socially important problems, including in the field of healthcare, while widely applying the experience gained in the processes of their activities, which involve the participation of leading experts from among medical specialists. Thus, by taking part in public associations, active citizens and experts are involved in the processes of developing and implementing global health policy, identifying gaps in the healthcare system and contradictions in the legislation, being actively engaged in solving urgent problems of public health and healthcare industry and forming proposals for its improvement [15,16].
It is important to note that the Russian Federation has formed the necessary legislative framework for the activities of various forms of public associations in the field of healthcare, which allows them to involve active citizens in their activities, accumulate public opinion and convey it to the state, raise topical and systemic problems in the field of public health and healthcare, protect the rights of patients and doctors and influence the process of law-making, etc. [17].
Currently, in order to improve public health and healthcare, there are in Russia public councils under state health management bodies, professional medical associations, public organizations for the protection of patients' rights, volunteer movements and other non-profit organizations that collaborate closely with the state. This allows them to exercise public control over the activities of authorities aimed at implementing the constitutional right of citizens to health protection and medical care, which is the sign of an organized legal state [18].
Meanwhile, the development of public associations, including in the field of public healthcare protection and promotion, depends on the level of public trust and support for such associations as well as on the public and political activity of the population [19].
At the same time, the trust of the population, the desire to participate in the activities of public institutions and the assessment of their work are largely determined by the awareness of citizens about such associations. However, currently there is insufficient information openness of civil society institutions, poor study and coverage of their activities in the public space, weak involvement of citizens and a low level of public confidence in the public institutions themselves. In Russia, the level of trust in the non-profit sector is about 18%, which is significantly lower than in Denmark - 67%, Norway - 62%, Finland - 58% and Sweden - 56%, the Netherlands - 48%, Switzerland - 42%, Estonia -36%, Great Britain - 35%, Israel - 32% and others countries. The church enjoys the greatest trust of all civil society institutions in Russia – 51% of Russians are committed to it, 49% trust charity organizations, 31% of citizens trust trade unions [20,21].
It should be noted that at present, there has been insufficient study of public associations in the field of public health protection and promotion, their role and place in civil society as well as their impact on the improvement of health care system. Very little research has been conducted to study public opinion about the activities of such movements. Based on the above, it seems necessary to study the opinion of the population on the activities of public movements in the field of public health and healthcare, priority areas of work and mechanisms for their implementation, development problems, as well as the formation of proposals for improving the activities of public associations in public health and healthcare and strengthening interaction with government agencies.
The relevance of the research topic is due to the importance of the participation of public associations in the formation of state policy in the field of healthcare as the most important area in public life.
The purpose of the study is to examine public opinion about the activities of social movements in the field of public health protection and promotion in Russia, identify priority areas of work and create recommendations for improving their activities in the development of public health and healthcare.
MATERIALS AND METHODS
The sociological study was conducted on the basis of a mass public association established on the initiative of Russian citizens – the All-Russian public movement «NATIONAL FRONT «FOR RUSSIA» (Movement). One of the activities of this movement is the development of public health and healthcare.
The Movement's branches have been established in all regions of the Russian Federation, involving over 2,000 experts in the field of public health and healthcare and more than 10,000 active citizens, which allows the Movement to ensure a constant and stable dialogue between civil society and public authorities. The large number of activists among Russian citizens involved in the activities of the Movement allows for large-scale research on public opinion about public health and healthcare issues, as well as about the organization of the work of the Movement itself in order to improve its activities in public health protection and promotion.
Participating in the activities of the Movement, experts and activists organize and carry out public control and civil monitoring of the implementation of laws, priority state decisions and state projects and programs in public health protection and promotion. The results of the implemented work and the identified problems are raised for public discussion on the platform of the Movement with the participation of representatives of health management bodies, as a result of which expert proposals are formed to eliminate the identified violations and improve the health system for referral to the responsible authorities.
This questionnaire was created by researcher Romanova A.V. based on the study of research and publications in this area by foreign and domestic authors. The questionnaire included questions that allowed the researcher to study in detail the attitude of the population towards social movements and existing problems. The present study protocol was approved by the Local Ethics Committee of the Sechenov First Moscow State Medical University. The study was conducted in May–June 2022 through a sociological survey of adult citizens in the form of a questionnaire, which was posted in a single form in the Movement’s mobile application «People's control». Users of the application can participate in surveys and monitoring of the movement, have access to information about the main directions of its activities in the field of healthcare. The study involved 8,499 citizens from 85 regions of Russia. Analysis of respondents' responses contributed to the creation of proposals for solving the main problems in the field of providing medical care to the population. Collection of information was carried out by combining the data obtained, data processing was carried out using Microsoft Excel program.
RESULTS
The distribution of respondents by gender was 80.40% women (n=6,830) and 19.60% men (n=1,669). Citizens aged 35–44 prevailed among the respondents - 31.50% (n=2,679). The share of respondents aged 45–54 was 25.90% (n=2,198) and those aged 24–35 – 17.0% (n=1,447). Citizens with higher education prevailed among the respondents – 57.60% (n=4,894) while those with secondary specialized education constituted for 26.70% (n=2,268). The majority of respondents resided in cities - 78.50% (n=6,670).
Analysis of the conducted research demonstrated that a third of the survey participants (34.2%) approve of public movements carrying out activities in the field of public health protection and promotion. At the same time, it is important to note that another third of respondents (33%) do not know anything about such social movements (Table 1).
Table 1.
Public attitude to social movements carrying out activities in the field of protection and promotion of public health
| Variables | Total N=8,499 (100%) | |
|---|---|---|
| n | % | |
| Cautious | 801 | 9.4 |
| Indifferent | 618 | 7.3 |
| Approving | 2,907 | 34.2 |
| I do not know anything about such public movements | 2,807 | 33 |
| It is hard to say | 1,193 | 14.1 |
| Other | 173 | 2 |
Of the respondents who are aware of the existence of public movements in the field of public health (n=5,692), almost half (47.2%) believe that such movements are beneficial for the development of public health and healthcare, while about 40% found it difficult to answer, which may also indicate a lack of awareness of the population about the activities of such movements (Table 2).
Table 2.
Public opinion about the benefits of public movements in the development of public health and healthcare
| Variables | Total N=5,692 (100%) | |
|---|---|---|
| n | % | |
| The activity of public movements is beneficial | 964 | 16.9 |
| The activity of public movements is likely to be beneficial | 1,725 | 30.3 |
| The activity of public movements is not beneficial | 352 | 6.2 |
| The activity of public movements is not likely to be beneficial | 442 | 7.8 |
| It is hard to say | 2,209 | 38.8 |
About one third of the surveyed citizens (28.9%) believe that the activity of public movements increases the level of trust between the population and state authorities, about 11% answered that they do not think so, slightly less than a third of respondents (23.2%) reported that the activity of movements does not affect the level of trust, however, about 40% of respondents found it difficult to give an answer to the question raised, which can also be attributed to a lack of information among the population about the activities of public movements in health protection and promotion.
About half of the respondents (47%) believe that the biggest contribution to the field of public health protection and promotion is made by the state, at the same time about 40% of the survey participants believe that the greatest contribution to the development of public health and healthcare should be made by the state together with public movements engaged in the protection and promotion of public health (Table 3).
Table 3.
Public opinion regarding who should make the biggest contribution to the development of public health and healthcare
| Variables | Total N=8,499 (100%) | |
|---|---|---|
| n | % | |
| State | 3,993 | 47 |
| Public movements carrying out activities on public health protection and improvement | 105 | 1.2 |
| Both, the state and public movements, carrying out activities on public health protection and improvement | 3,313 | 39 |
| It is hard to say | 1,055 | 12.4 |
| Other | 33 | 0.4 |
At the same time, according to half of the respondents, it is necessary to strengthen the control of citizens and their associations over the fulfillment by public authorities of their duties and obligations in healthcare (52.1%) (Table 4).
Table 4.
Public opinion on the need to enhance control by citizens and public associations over the performance of their duties by the authorities in the field of public health and healthcare
| Variables | Total N=8,499 (100%) | |
|---|---|---|
| n | % | |
| Control should be enhanced | 4,426 | 52.1 |
| Control should not be enhanced | 752 | 8.8 |
| It is hard to say | 3,321 | 39.1 |
Among priority areas of the activities of public movements in the development of public health and healthcare industry, respondents noted the following:
– protection of citizens' rights in the field of health protection (50.1%),
– formation of proposals for solving acute problems of the healthcare system, development of public health and healthcare (38.3%),
– implementation of public control over the activities of government bodies, implementation of state projects and programs in the field of protection and promotion of public health (38%),
– protection of the rights of medical workers (33.1%),
– sanitary and hygienic education of the population, preventive work (25.9%),
– increasing the transparency of decision-making by government representatives (21.9%),
– engaging the public in direct implementation of government decisions in the field of healthcare (16.7%),
– development of the institute of volunteerism (10.8%).
At the same time, citizens noted that public movements in the field of public health protection and promotion should work with citizens' appeals (38.5%), place publications in the media that attract the attention of authorities and society to the problems of the health system and contain expert proposals for their solution (31.4%), conduct an independent analysis of the problems of the health system and present the results to the public and authorities (33.6%), organize public monitoring of the implementation of state projects and programs in the field of public health protection and promotion, identify the facts of violation of their implementation (30.8%).
In addition, respondents noted the need to involve representatives of public movements in commissions, councils and working groups under the authorities on solving problems of the healthcare system (27.8%) and the importance of providing volunteer assistance to citizens in need and medical workers (19.3%), arranging meetings with representatives of the medical community and authorities on problems of the healthcare system (19%). Also, according to citizens, public movements should be engaged in the development and submission of proposals on the improvement of the regulatory framework as part of the people's law-making initiative in the field of protection and promotion of public health (18.2%).
In addition, this research examines the problems of the development of the activities of movements in the field of public health and healthcare. Thus, according to the respondents, the main problems faced by public movements in the field of public health protection and promotion are: low activity of the population and insufficient awareness of the activities of public organizations in the protection and promotion of health, insufficient state support for public organizations, limited powers of public movements and weak legislative framework regulating their activities, low motivation of activists and experts. At the same time, a third of all respondents found it difficult to answer the question about possible problems in the development of these social movements.
DISCUSSION
The development of public movements and the effectiveness of their activities largely depends on state and public support, civic engagement, and improvement of legislation [1, 16, 24,25,26].
It is important to note that Russian and foreign literature mainly presents separate perspectives on the activities of social movements in the field of healthcare, and there are no comprehensive descriptions of their activities in the field of public health and healthcare. Development problems have not been sufficiently studied and recommendations for solving them have been considered [1, 16, 27].
The present study has revealed problems in the development of public associations engaged in activities in the field of protection and promotion of public health. First of all, the limiting factor in their development is the lack of awareness among the population about the activities of such movements, which can form citizens' distrust of social movements in meeting social needs and solving socially important tasks, as well as reduce citizens' participation in their work, hindering the development of the entire civil society as an integral element of a modern democratic state.
The works of other researchers examine similar barriers to the provision of services by non-profit organizations in the field of public health and healthcare: the closed nature of medical organizations, excessive demands of social and medical institutions on the non-profit sector, insufficient trust in the activities of public organizations in the field of healthcare, etc. The reasons for these problems are the low level of awareness of the population about the activities of non-profit organizations, insufficient work with the population to increase literacy in matters of civil society development, as well as the lack of a professional approach of the public associations themselves [3, 20, 22, 23].
Taking into account poor awareness of the population–about the movements in the field of health protection and promotion, it is wrong to talk about the existence of a stable attitude to the public associations in question, rather, it can be concluded that public opinion is based on vague ideas and intuitive assessments, and citizens do not fully understand the need to create and operate public organizations, as well as–their place and role in civil society.
At the same time, the surveyed population connects the activities of public associations primarily with the protection of citizens' rights to health care and solving problems of the–healthcare system, and it also believes that the state makes the greatest contribution to the development of public health and healthcare in cooperation with public movements, which indicates the potential of citizens' trust in the activities of public associations in the field of healthcare.
Despite the lack of awareness of the population about the work of public movements in the field of public health and healthcare at present, in our opinion, their activities receive a serious support base (34.2% of respondents approve of such public movements), therefore, in order to develop their potential, it is required to have a broader information policy on the activities of the non-profit sector in the field of protection and promotion of public health, directions and results of their work both on the part of the associations themselves and on the part of state authorities. In connection with the above-mentioned, it becomes obvious that in order to achieve this goal, it is necessary to create special structures under the health management bodies acting in the interests of public associations.
Analysis of the results of this study made it possible to form recommendations for improving the activities of public associations and enhancing their engagement with government agencies in the development of public health and healthcare:
– increase public awareness about the activities of public associations in the field of health protection and promotion, their rights, tasks, powers, areas, and results of work, including through placing information in media and social networks,
– legislatively approve the role of public associations engaged in activities in the field of public health and healthcare, fixing their rights, duties, responsibilities, powers, procedures, and mechanisms of interaction with public authorities and medical organizations in the relevant regulatory legal documents,
– enhance control over the execution by the authorities of expert proposals of public associations aimed at the development of the healthcare sector, and increase state support for such associations (provision of preferential loans, expansion of tax incentives, exemption from taxes and fees, advance payments on taxes, other property, financial, information support),
– develop a set of measures aimed at heightening responsibility of citizens for maintaining and improving their health, formation of a healthy lifestyle, prevention, and control of diseases,
– develop additional measures for the promotion of voluntary (volunteer) activities in the field of public health and healthcare, including among young people, providing a mechanism for motivating and encouraging volunteers and members of public associations to protect and improve public health,
– create a register of public associations in the field of public health protection and promotion in the subjects of the Russian Federation by placing it on the official websites of health management bodies indicating the directions of their activities and contact information, create an industry-specific communication and educational platform for heads of healthcare institutions on issues of interaction with public associations engaged in activities in the field of healthcare, and interested socially oriented non-profit and volunteer organizations, etc.
Moreover, in our opinion, an effective tool for ensuring transparency in government decision-making can be implementation by the state, together with public movements, monitoring, and research on the implementation of state programs in the field of public health protection. Such research will reflect the real situation with the execution of state events and identify gaps in their organization, which will contribute to the increase in confidence of civil society in state policy.
In addition to interaction with state authorities, it is important to establish interaction between public associations and medical organizations, for which it is proposed to develop methodological recommendations for organizing joint collaboration, providing for the possibility of creating public councils at medical organizations with the participation of representatives of public associations in the field of public health protection and promotion, as well as providing information at the request of one of the parties, etc.
The key solution in strengthening the role of public associations in the field of public health protection and promotion is to provide them with additional legislative powers, including: protection of citizens' rights to health protection and medical workers, the right of legislative initiative in the field of public health and healthcare, participation in the formation, coordination, approval of state programs aimed at improving the health system and improving public health, as well as monitoring the progress of their implementation, conducting independent public control of the quality of medical services provided to the population, the material and technical condition of medical organizations, staffing of medical organizations, conducting public control over the organization of public procurement by government authorities and the expenditure of public funds allocated for the development of healthcare, participation of representatives of public associations in the composition of commissions and councils under state authorities to make public decisions in the field of health care, in the commissions for independent verification and evaluation of the healthcare system with the development of proposals and their subsequent implementation.
CONCLUSION
In the context of reforming global health systems against the background of a complex political and economic situation in the world, related among other things to global health challenges, the need for the participation of public associations in the processes of formation and implementation of state social policy is increasing.
In recent years, the role of public associations has increased significantly, and their activities have played a crucial part in public and political life. Currently, social movements participate in the development of civil society and in the formation of civic responsibility, they successfully solve topical and systemic problems in the field of public health and healthcare, engage in charitable and educational activities, lend a shoulder to the state in supporting the needy population at critical moments. In this connection, the problems and issues of the development of public associations are becoming an important part of the state agenda and require the attention of public authorities to further improve the activities of civil society institutions.
Thus, the sociological study allows us to draw the following conclusions:
– insufficient awareness of the population about the existence of public movements in the field of protection and promotion of public health, their activities, areas, and results of work has been revealed,
– almost half of the citizens who are aware of movements in the field of protection and promotion of public health believe that such movements are beneficial for the development of public health and healthcare,
– a significant part of the population notes that the greatest contribution to the development of public health and healthcare should be made by the state along with public movements engaged in the protection and promotion of health, while it is also necessary to strengthen the control of citizens and their associations over the fulfillment by public authorities of their duties and obligations in healthcare. In order to achieve the most effective operation of public associations in health protection and promotion as well as to guarantee active involvement of the population in public and political life, it is necessary to increase the role of such associations by legislative expansion of their powers in the processes of formation of public health policy. For this purpose, it is necessary to make appropriate changes to regulatory legal documents, approving the rights, duties, responsibilities and powers of public associations, which will contribute to increasing the level of trust of citizens not only in the activities of such movements, but also in the activities of state bodies.
Summing up the results of the study, it can be noted that the effectiveness of efforts to develop public associations in the field of public health protection and promotion will increase significantly if they are based on complete and objective information, on constructive interaction between public authorities and socially oriented non-profit organizations and the provision by the state of guarantees of their independence in solving socially significant problems in the field of public health and healthcare.