Organization of rehabilitation and habilitation programs for persons with disabilities due to musculoskeletal disorders in the Russian Federation

Because of extensive changes in social protection laws in the Russian Federation (RF), as well as ratification of the Convention on the Rights of Persons with Disabilities, the organization of rehabilitation for disabled persons with musculoskeletal disorders has especially become relevant. Aim To improve the organizational and legal mechanisms for implementing individual programs of rehabilitation or habilitation of disabled persons with musculoskeletal system diseases in RF. Materials and Methods The authors analyzed existing international and Russian literature. The study used analytical, legal, organizational, and methodological techniques aimed at perfecting the system for rehabilitation of disabled adults and children. Results In RF, the “disabled child” category was established for the first time for more than 70,000 children (70,600 in 2013 and 72,800 in 2014) according to governmental statistics of the Institutions of Medical and Social Examination, and more than 340,000 individual rehabilitation programs for disabled children were established, including for those recognized as disabled children for the first time and for those who were re-recognized as disabled children. The disability due to diseases of the musculoskeletal system and connective tissue was established for the first time in 3,500 children and is the fifth highest ranking primary disability in RF. Conclusion The introduction of fundamentally new federal schemes of implementing individual programs of rehabilitation or habilitation requires the authorities of RF to be experienced in the field of health promotion to create the organizational and legal mechanisms for implementing such programs. Thus, the features of regional rehabilitation infrastructure, medical care and monitoring should be considered.


INTRODUCTION
Since 2012, the system of rehabilitation for adults and children with disabilities has been undergoing reform in our country.The overall aim of the reform is optimization of expert and rehabilitation care for the general public.Reform became urgent due to emerging uncoordinated actions within the structures of different departments in the implementation of individual rehabilitation or habilitation programs (IRHP) [11].
In the Russian Federation, medical and social assessment (MSA) agencies develop approximately 3,000,000 individual rehabilitation programs (IRP) every year.In 2014, there were 2,420,000 IRPs for adults with disabilities and 342,000 IRPs for children with disabilities.
The Russian Federation's state program "Health Development" expects the coverage of medical rehabilitation for children with disabilities who are in need to grow from 72 % in 2013 to 85 % in 2020 [1].The state program "Accessibility" for 2011-2020 makes provision for raising the level of rehabilitation and habilitation services for people with disabilities [2].
A key challenge is adopting and testing interdepartmental interactions among specialists and organizations involved in the multifaceted process of rehabilitation.The new control schemes for the rehabilitation system for adults and children with disabilities, discussed in the present paper, are relevant and timely from practical and scientific perspectives.These schemes are based on new federal normative legal documents.
Study objective Improvement of organizational and legal mechanisms for the implementation of IRHP for persons with disabilities due to diseases of the musculoskeletal system in the Russian Federation.

MATERIALS AND METHODS
The present study involved analysis of: current Russian normative legal documents; provisions of the Convention on the Rights of Persons with Disabilities [3]; the biopsychosocial concept of disability as defined by the International Classification of Functioning, Disability and Health [4]; methodological and information materials; and the experiences of Russian regions.

RESULTS
According to Russian government statistics for MSA agencies, more than 70,000 children were included in the newly established "disabled child" category (2013 = 70,600, 2014 = 72,800).More than 340,000 IRPs Every year approximately 80,000 adults in the Russian Federation are recognized for the first time as having a disability due to diseases of the musculoskeletal system and connective tissue.This represents 8.4 %-9.9 % of the number of persons recognized as having a disability for the first time from 18 years of age.This class of diseases is ranked 3rd among the adult primary disabilities (Table 1).
In the Russian Federation in 2008-2014, the number of adults recognized as having a disability for the first time due to diseases of the musculoskeletal system and the connective tissue ranged from 72,000-82,000 people per year (7.2-6.2 per 10,000 population).
The rehabilitation needs in technical terms for people with disabilities is high.In 2014, 282,000 recommendations were made for adults with disabilities for prosthetics and orthotics, of which 81,000 were for those recognized for the first time as having a disability; 71,000 recommendations were for orthopedic shoes, of these 13,000 were primary recommendations.
-A new form of the IRHP document, "the IRHP for a child with a disability" [5]; -A new system of management of rehabilitation for adults and children with disabilities; and, -New legal organizational forms for interdepartmental interactions in the implementation system for IRHPs for children with disabilities [3][4][5][6].
The execution of a large number of measures is scheduled, with the aim of improving the system of comprehensive rehabilitation and habilitation for adults and children with disabilities at the federal level [2].The budgetary appropriations from the federal budget and the budgets of state non-budgetary funds for this purpose is planned to amount to 281 billion rubles [2].
An IPRH for a child with a disability is a set of optimal rehabilitation measures that covers the types, kinds, amounts, timing, and implementation of medical, professional, and other rehabilitation measures [5].
A fundamental change that occurred in the system of rehabilitation and habilitation for people with disabilities from January 1, 2016 was the participation in these activities of executive authorities of a constituent entity of the Russian Federation in various spheres of life, including the sphere of public health.A new participation scheme was created: a) "IPRH developer", defined as federal state institutions of medical and social expertise; b) "IPRH performer", defined as state executive authorities of a constituent entity of the Russian Federation in the field of public health (in the context of medical rehabilitation); and, c) "Performer of IPRH activities", defined as organizations that carry out rehabilitation or habilitation activities for persons with disabilities in the relevant field of activity of the executive authority.
Federal law regulates the fundamental issues of organization of the rehabilitation system for persons with disabilities [5,6] and specific mechanisms of interdepartmental interaction between IPRH implementation participants (orders of the Ministry of Labor of Russia No. 528n dated 31.07.2015 and No. 723n dated 15.10.2015)[7,8].Specific schemes for the flow of personal data for persons with disabilities [1,10] are formed between participants through the "IPRH epicrisis" and "Information on the performance of IPRH activities" (Fig. 1).
Table 1 Dynamics of the number and weight of adults recognized as having a disability for the first time due to diseases of the musculoskeletal system and the connective tissue in the Russian  For the execution of medical rehabilitation measures, the federal normative legal documents determined:

Original Article
-The term of sending the IPRH epicrisis to the executive authority of the constituent entity of the Russian Federation in the field of health at a primary care facility of the person with a disability (not later than 3 working days from the date of IPRH issuance); -The mechanisms of transfer of the IPRH epicrisis (it should be conducted using a unified system of interdepartmental electronic interaction with connected regional interdepartmental electronic interaction systems; in cases of lack of access to this system, on paper in compliance with the requirements of legislation of the Russian Federation regarding personal data); -Work of the executive authority of the Russian Federation constituent entity in the field of health (development of a list of activities indicating the performers and scheduled time of specific activities within 3 days from the date of receipt of the IPRH epicrisis); and, -Sending information on IPRH implementation from the executive authority of the Russian Federation constituent entity in the field of health to the MSA agencies (no later than 1 month before the expiry of IPRH or 5 days after the measures implementation).

DISCUSSION
Compared with the previous IPRH implementation model for an adult or child with a disability (2004-2015), the new IPRH implementation model has three significant differences.a) Human rights, including the state executive authorities in different spheres of life in the mechanism of execution of IPRH rehabilitation measures that do not discriminate against persons with disabilities on the grounds of disability.This means the state executive authorities in the field of health, not social protection, manage health aspects of persons with disabilities.b) Legal changes, as implementing a new model required appropriate changes to the whole "legislative pyramid," that is, federal laws, decrees of the Russian Government, and orders of ministries and departments.c) Organizational and methodological changes related to changes in the organizational units of the rehabilitation system and their interactions.
However, in our opinion, there are key issues that need to be addressed in interactions between IPRH developers and IPRH performers: Adoption of a legal instrument (e.g., agreement, contract) that regulates the procedures and mechanisms of interactions between MSA agencies and the executive authority in the field of healthcare in a particular constituent entity of the Russian Federation, based on specific features (e.g., geographical position, territory, development of the state, municipal, and private systems of health care, rehabilitation infrastructure).

Original Article
Organization of how the executive authority of the constituent entity of the Russian Federation is joined to the unified system of interdepartmental electronic interactions and the regional systems; Creation of an order for personal data exchange in hard copy in cases of lack of access to the above system; Assignment of an employee of an executive authority of the Russian Federation constituent entity, who is responsible for the exchange of information between institutions (with additional professional training if necessary); Monitoring by the executive authority of terms of IPRH implementation for an adult or child with a disability, and the terms for sending a summary on the execution of IPRH activities to MSA agencies; Settlement of questions on interactions of an executive authority on health of the Russian Federation constituent entity with other executive authorities of the Russian Federation constituent entity, as well as with the regional offices of the Social Insurance Fund and the Pension Fund; Monitoring by the executive authority in the field of health of the Russian Federation constituent entity of all institutions (state, private systems) providing medical rehabilitation services for persons with disabilities (e.g., creation of a "data bank on institutions," or a register of rehabilitation institutions); and, Development (by the executive authority in the field of health of the Russian Federation constituent entity) of regional rehabilitation infrastructure (as necessary) to meet the medical rehabilitation needs of persons with disabilities, recommended by that person's IPRH.
In the interactions between IPRH performers and performers of IPRH activities, the key issues that need to be addressed are: Organization of rational activity by an executive authority in the field of health of the Russian Federation constituent entity on developing a specific list of activities, with an indication of performers and timing of specific activities.This may only be performed after diagnostic work with a person with a disability to identify specific medical rehabilitation needs, which cannot be implemented in the government authority itself, and therefore requires involvement of other institutions and organizations (e.g., medical institutions, rehabilitation centers, and others).This includes determination of the procedure and techniques for this work; Unification of forms of information transfer from the performers of IPRH activities to the performers of IPRH; Organization of persons with disabilities at the level of medical institutions and rehabilitation institutions, that is, performer of IPRH activities; and; Feedback on the implementation of IPRH from persons with disabilities to healthcare institutions.

CONCLUSION
Introduction of a fundamentally new federal management system for the implementation IPRH for persons with disabilities requires the state authorities of the Russian Federation constituent entity in the field of health to create organizational and legal mechanisms of interaction with the implementing institutions.This needs to consider the regional peculiarities of the rehabilitation infrastructure and a new approach to organization of rehabilitation professionals, including accounting and monitoring.
To ensure timely and high-quality execution of IPRH for prosthetics and orthotics, and provision of prostheses, orthoses, and orthopedic footwear, improvement is needed in the financial and organizational systems of interaction among prosthetic and orthopedic enterprises, orthopedic footwear factories with the competent authority involved in financing of technical means of rehabilitation, and the state authority of the Russian Federation constituent entity in the field of health.Introducing a rehabilitation certificate and the possibility of co-financing technical means of rehabilitation by the person with a disability are further areas for exploration.

Fig. 1
Fig. 1 Information logistics for medical rehabilitation in the implementation of the individual program of rehabilitation and habilitation for a person with a disability in the Russian Federation constituent entity