Olena Levenets, Tallin University
This blog reviews the findings outlined in a book chapter titled “Coping mechanisms of Ukrainian patients: bribes, gifts, donations, and connections” that I wrote for the forthcoming book The illegal, the immoral and the criminal: transnational perspectives on informality (Polese, et al. 2019). The chapter explores how patients cope with barriers to access to treatment in Ukraine. Our study explores coping strategies from the angle of health care users, providing empirical illustrations of the complexity of personal strategies that include paying informally, giving gifts and using social relationships.
With the collapse of the Soviet Union, Ukraine inherited an inefficient and resource intensive health care system. Under the conditions of economic decline during the post-Soviet transitional period, the burden of keeping the system functional shifted to the patients’ side. This, in turn, lead to the flourishing of patients’ coping strategies as a means to access health care services. Limited access, inequality, and inequity to health care, resulted in Ukraine having one of the lowest health care satisfaction rates among Post-Soviet countries. The patients themselves best illustrate the general approach to the state health services in Ukraine: “Over the time, we have developed our own schemes of how to refer to physicians for the treatment. Usually, we try to cope on our own, avoiding the state system; sometimes with the use of private hospitals and acquaintances from the state hospitals” (Levenets, et al. 2019). This citation also gives us a glimpse on one of the diverse coping strategies that Ukrainian patients apply to navigate health care system and to ensure access to health care services. Our study revealed that other strategies include personal connections (through family, professionals and extended networks), cash payments (informal or quasi-formal), gifts, exchange of favors, and triangulation of health care advice (second opinion, mass/social media information, and advice of family members).
Since informal practices are an integral part of Ukrainian health care system in general and patients’ coping strategies in particular, this book chapter also analyses informal payments and informal practices applied by health care consumers. Informality studies have an increasing interest among scientists for the past two decades. In literature, informal practices are mostly viewed negatively, as barriers to health care access. Interestingly, the nature of informal practices appears to be ambivalent in the Ukrainian context, since informal payments are perceived as a barrier to health care services and, at the same time, they are a coping instrument too. For example, in most cases, patients are required to pay unofficially for medicines, surgery etc., which is seen as a barrier to treatment due to the high cost and probable consecutive impoverishment of patients. At the same time, by the means of unofficial payments directly to doctors, patients are able to shorten waiting time and/or receive treatment that are not available otherwise. Within this frame of duality, findings outlined in book chapter add to exploration of informal practices as coping strategies.
Another interesting finding of our study is the suggested new approach to understanding the health system’s structure and patient’s coping along all levels of health service provision. De jure Ukraine has a hierarchical system of primary, secondary and highly specialized tertiary level of health care service provision. However, according to the approach suggested by the patients, in reality (de facto) health system structure consists of five levels: The first level of health care is self- and community-help, which includes resorting to coping strategies such as alternative medicine and pharmaceuticals available at the patients’ home. At the second level, a relative of the sick person refers to the pharmacy where health care goods are bought. The assortment of the goods is assessed either by a web-search or previous experience of coping with the symptoms or by the consultation provided by the pharmacy employees, relatives etc. Third and fourth levels apply when the symptoms are still present and the “sick one” visits the family doctor or district therapist in a public and/or private health care facility. At the fifth level, in-patient facility specialist (in city or rayon) is visited by the patient and at the sixth level, oblast (region) level hospital specialists are reached for getting an advice on the treatment” (Levenets et al. 2019).
The above mentioned key findings on coping strategies in Ukrainian health care are confirmed by quantitative data. Interestingly, coping strategies substantially vary between regions, and this requires future scientific exploration. Although coping strategies help patients on individual level to access health care services, this cannot be used as a long-term solution for closing gaps in the health care system. Future health care reforms should aim at the optimization of resource usage and improved access to health care. Recent reforms seem to be a substantial step in the right direction.
Levenets et. al (2019) ‘Coping mechanisms of Ukrainian patients: bribes, gifts, donations, and connections’ IN Abel Polese, Alessandra Russo and Francesco Strazzari, (Ed.) The illegal, the immoral and the criminal: transnational perspectives on informality (Palgrave: Macmillan forthcoming in 2019)
Balabanova, D. and McKee, M., 2002. Understanding informal payments for health care: the example of Bulgaria. Health Policy, 62(3), pp.243-273.
Footman K, Roberts B, Mills A, Richardson E, Mckee M. Public satisfaction as a measure of health system performance: A study of nine countries in the former Soviet Union. Health Policy. 2013;112(1-2):62-69. doi:10.1016/j.healthpol.2013.03.004
Stepurko, T., Pavlova, M., Gryga, I., Gaál, P. and Groot, W., 2017. Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years and type of services. Health policy and planning, 32(4), pp.453-466.
The views and opinions expressed by the author(s) on this blog do not necessarily reflect the opinions and views of CASPIAN or the universities affiliated to the project.