Ukrainian healthcare

As the presidential elections unwind there will be stark realities to face for the new politicians, one of these will be the state of Ukrainian healthcare, which in a recent study was ranked the fourth top issue for voters and was seen as being important for creating political stability.

The public is of course quite right and we hope they will be listened to. Whilst in the boom years of Ukraine’s economy the private sector rapidly expanded and developed a new ethos the Health Services struggled to recover from the collapse of the Soviet Union which left many preventative programmes in shreds and hospitals recovering from decay, not surprisingly life expectancy dropped by nearly 5 years and is still recovering.

The Soviet health care system was designed to respond to a military need and the system was highly centralised and controlled, medical education was geared to deliver this model within an equally inflexible business environment which had fixed budget lines controlled by the Ministry of Finance leaving the Ministry of Health with no fiscal responsibility or control. Whilst a new state was finding its way in the world and private business was flourishing in comparative freedom the health services were struggling to stay alive under an administrative system that was ripe for reform but had neither the will, the experience nor the capacity to change.

The constitution decrees that Ukrainian health care is free to all citizens but also states that charges can be levied. As a result many still pay into health care’s own black economy - it is estimated that personal contributions match the state’s contribution in a funding nightmare and all still have to pay for medications. In this lottery big losers have been the elderly, those with mental health problems, those with learning difficulties and the disabled. Not only the poor suffer as it is estimated that within Kiev perhaps over 50% of the population is over treated. The resultant trust in both the system and doctors as a whole is incredibly low.

The business of healthcare runs in parallel to oblast and rayon administration with the rayon hospital being one of the main providers of secondary healthcare, whilst in large  cities it will be a city hospital. Such hospitals suffered huge decay in the last years of the Soviet Union and large percentages of budgets are required to maintain their fabric and service old equipment. Budgetary income is in part related to bed numbers and activity a formula often encouraging unecessary or prolonged use of beds and staffing levels are difficult to change. Ukraine has many more doctors per 1000 population than most European countries and one of the largest numbers of specialities.

Primary healthcare is provided by polyclinics in rayon towns and cities but health care for many rural Ukrainians still means a village clinic run by an isolated doctor or health care assistant and administered by the village council. In general primary care fails to impact on the major health care needs of the population - stroke, heart disease, maternal and child health, sexual health and cancers - although in some areas incentive schemes have been cost effective.

There is no business sense of a purchaser provider split between primary and secondary care although such is possible within rayon administration and they have been created in project work. There is very little training in healthcare administration and little opportunity to relate to western european and american experience.

Medical education is strictly regulated by a small number of postgraduate academies in Ukraine and has not changed to embrace western standards and indeed the immediate healthcare needs of the population. Ukraine is probably one of the most isolated of post soviet countries in this respect and consequently the impact of evidence based medicine, medical audit, and patient-centered medicine upon the practice of medicine has been very limited. Many young doctors have found this professional climate frustrating and few doctors over the age of 40 have any european experience or speak and european language, many have left their jobs and work for pharmaceuticals

Outside agencies and big players like the EU have been active in healthcare reform but must face critiscism that they have cherry-picked specific areas and whilst recognising the need for sectoral reform more than 5 years ago have failed to launch such projects.

Whilst much of this may sound necessarily negative it is important to recognise some inherent strengths upon which to build. The first is the huge amount of care that comes from doctors and nurses working in extremely difficult circumstances and their continuing enthusiasm to improve the countries health, secondly is the well known fact from both the business world and from project work that given opportunity, training and encouragement healthcare administrators also have the Ukrainian qualities that create success. These human resources need to be recognised and invested in.

So with a new government what can be done? First is the acceptance of the reality of the problem and of the public’s concern and the creation of a medium to long term plan with realistic goals which may include a defined minimum standard of care. Such a road map of healthcare reform has been effectively used in Georgia. Ukraine needs to both increase the percent of GDP spent on healthcare (one of the lowest in Eastern Europe) and capture the money that goes into the black health care economy so it can be more effectively used. Most analyst accept this is both extremely difficult and essential as is the need to clearly define a method of financing healthcare. Some Eastern European countries have established insurance based funding for healthcare but it has been criticised as an expensive way to levy what is essentially a tax and even in Estonia which was held to be the most advanced in terms of reform it failed to cover some 15% of the population and has now been abandoned. Studies have shown that the people of Ukraine are resistant to it and would prefer a state financed service.

Legislation will need to be enacted to underpin such reform and enabling legislation will need to be created to allow both administrative and fiscal flexibility at oblast and rayon level as well as educational reform. Consideration will need to be given to creating a Ministry of Health that has fiscal control and executive power. Primary care should through incentive schemes be made to impact directly on healthcare needs whilst decreasing the demand on secondary care and consideration should be given to creating a purchaser provider split between primary and secondary care. It should be administered at rayon level not village level. In secondary care reforms will include the decrease in the number of doctors and increasing activity and throughput creating an economic environment that allows for capital investment and investment in human resource.

Outside agencies such as the World Bank and the EU can support healthcare reform by adopting a sectoral approach and helping to fund pilots and by creating imaginative and longitudinal schemes to support young doctors and administrators in both foreign exchange and language programmes to enable the development of human resource and capacity building.

Within reform there will always be huge business opportunities for insurance based healthcare and a developed private sector which will inevitably be the choice of many wishing to choose the sophistication of care they require over and above a minimum package as the reality is that Ukraine will neither have the resources nor human capacity to produce a Swiss or Austrian healthcare service for several decades. It can however with political will, strong leadership and popular support create an effective service that will start to effectively impact on the health of all and ensure that in coming years we will see more old people and fewer widows on the streets of Ukraine.

Thursday, 01 January 1970

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