Abstract
Economic and social losses due to epidemics of non-communicable diseases have put prevention and control of them on the first line in the field of sustainable development of the United Nations. The tasks of combating NCDs and risk factors within the framework of the Sustainable Development Goals require targeted actions on the part of States in the field of policy and legislation and provision of health systems with appropriate resources. In the Russian Federation, such work is being implemented within the framework of the national project "Healthcare", federal programs to combat oncological and cardiovascular diseases. Each subject takes into account the peculiarities of economic development, staffing, implementation of informatization processes, etc. The rapid pace of transformation of Moscow healthcare, its unique institutional structure allowed to form the basis for the effective development of a system of proactive dispensary monitoring of patients suffering from chronic diseases. The authors describe the process of formation of preventive work and organization of dynamic dispensary observation in Moscow. The paper presents in detail the organizational, administrative and technological resources used to create a unique system of dynamic dispensary observation. In addition, the article illustrates the personalized subsystem of dynamic dispensary observation in EMIAS and the institute of "physician assistant". The introduction of a proactive dispensary monitoring system will reduce premature mortality and disability among residents of the city. Moscow through an individual monitoring program and motivation for the responsible attitude of metropolitan patients to their health.
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