By Olana Levenets, PhD candidate at Tallinn University of Technology
The common message from Ukraine’s politicians for last 15 years has been that more money is needed for its health care system to function properly and cover all needs. Only in the middle of the second decade of Ukraine’s independence, its government finally officially questioned the idea of the efficiency of health care system – e.g. how to increase output with existing sources? And even became open to the idea that current infrastructure is overbalancing the needs on some levels.
An efficient use of existent resources is crucial for every meant-to-be rational processes. This is applicable to all systems and health care system is not an exception. Resources are always limited and directly affect the final cost of services. In health care, inefficient use of sources multiplied by the scale of the system can aggregate substantial amounts of funds, which are wasted. Crucially these could be used otherwise to save lives and improve the quality of treatment and life.
Depending on the design of the health care system and the goals of certain programs, indicators for a rational usage of the system’s resources may differ. These range from detectability of diseases at the early stage and life expectancy in the relatively modern countries to the number of hospital beds of physicians per 100 000 inhabitants in the Post-Soviet countries with unreformed health care systems.
At a first look, there is nothing wrong with such variable as a number of days when the bed was in use when we look at it as the input into health care system. Yet, when we are talking about Semashko’s health care system, which perfectly reflects the soviet economy of centralized administrative planning, a number of bed/days are not simply a resource, inputted into the system. Rather, this is the main criterion while planning supply of resources available to inpatient treatment departments. According to Semashko’s system, all other resources for inpatient departments were brought into system on the basis of hospital beds’ numbers. In other words, money followed beds. This approach has lasted for decades and made hospitals’s autonomy impossible, since all norms and resources were provided centrally based on the number of hospital beds.
Under such conditions, hospitals have an incentive to overestimate their real needs in order to receive more money. This conclusion is based on logic and anecdotal evidence. For instance during my field trip in rural areas of Western Ukraine, I saw that hospital stays crowded until 1 pm, maximum. In the second part of the day doctors do some paperwork, but mostly chat with their colleagues.
On the other hand, hospitals have little intention to show high-death rates in their departments. It means that soon to die patients, who could really benefit from daily in-patient care, are discharged from hospitals. As a result, hospital managers face a conflict. They want as little number of deaths as possible, but they also have to present high rates of usage of beds, in order to get extra funding for departments. Most hospital managers find themselves in a “between Scylla and Charybdis” situation which, in turn, results into considerable waste and in irrational usage of resources for whole health care system of Ukraine.
On 2nd of September 2016, a new team in Ukrainian Ministry of health canceled Decree #33 which made hospital bed the main criteria determining financial planning. The picture I saw at the hospitals a month after withdrawal of the law did not substantially differ from previous periods: hospitals were half empty and personnel had lots of time to perform their personal tasks at work. Yet, we should remember that changes in the planning, funding and optimization of resources need time to show effect in practice. The Ministry of Health has started modernizing systems and approaches to healthcare in Ukraine, but there is still a long road ahead. Resistance to new is part of our basic life-saving instinct and in the case of Ukraine’s reforms, the healthcare system’s tendency to resist changes might make this path long and rocky. At least, we are in front of the first step into the right direction.