By Olena Levenets, Tallinn University of Technology
Photo Credit RawPixel
Ukraine is undergoing the first major attempt to reform the system since gaining independence 27 years ago. International experience on the implementation of similar reforms, as well as Ukraine’s historical background and country’s specifics, point to several potential bottlenecks. The major ones are: an excess of hospital facilities, unclear reform indicators, lack of accountability for newly established processes and clear communication with the public, underutilization of primary health care, , insufficient number of specialists, low wages and lack of political stability and support.
Ukraine constitutes an interesting case for international policy-makers and comparative health policy analysis since it is one of the last Post-Soviet countries that eradicated shared common Soviet legacy and transformed healthcare service delivery. This brief will be useful for policy-makers around the world, as Ukraine’s healthcare reform is a special case when major implementation is done in a difficult environment. Ukraine’s policy-makers should keep in mind possible bottlenecks even when the reform is already designed and is in the implementation phase.
In this policy brief, I am taking a broad perspective to present a non-systematic review of potential major bottlenecks that Ukraine might face in the course of the implementation of five reform pillars.
Long awaited transformations in the health care sector in Ukraine started in 2014-2015 with the creation of its legislative base. Active implementation phase began in 2018, and national roll-out will be reached in 2020.
The rise of political commitments to reforms after the revolution led to a discussion about the chosen reform strategy. In addition to existing confrontation in government, reform actors, interest groups and international organisations share a different vision of Ukraine’s health sector which mitigated the practical implementation of reforms. As a result, similarly to many other countries that reformed their health care, policy-makers in Ukraine deal with potential bottlenecks to the reform: from resistance to the reform by the part of medical personnel to influential opposition in the government, as well as the need to optimise and redistribute scarce resources and overcome rooted corruption.
Reform Pillars and Bottlenecks
The recent health care reform package is based on five pillars: health care financing, family medicine model, guaranteed benefits package (GBP), co-payment system and international standards.
First, the system of health care financing was reorganised in 2017 when Parliament and Cabinet of Ministers approved decrees that increased financial and managerial freedom of regions and hospitals. As such, the split of purchaser and provider was introduced by establishing a new central agency of health care system – National Health Service of Ukraine (NHSU), which acts as state health insurance fund with the main role of single purchaser of health care services from service providers. Consecutively, healthcare market became competitive since both private and public hospitals were enabled to sign a contract with NHSU.
According to evaluations, large-scale budgetary decentralisation resulted in improved services and more efficient resource spending. Still, experts stress the risk of unclear indicators and accountability for newly established processes under the condition of disintegration and funding inequities among regions. While national health purchasers in many Post-Soviet countries are obliged to contract with public health care facilities, it may impede efficient usage of hospital care, since countries still possess excess hospital capacity. In the case of Ukraine, this effect might be to some extent mitigated since, on the initial stages of the reform, Ukraine’s healthcare infrastructure was reorganised, and hospitals’ districts were established with the aim to optimise the resource usage.
The second pillar, the transition to the gatekeeper family medicine model, took place in 2018. The main goal was placing primary health care in the centre of health service provision. As a result of the gradual transformation of primary health care services and orientation toward the incentive-driven approach of family medicine, the family doctor is now the first point of patients’ contact with the health care system. People have the freedom to choose primary health physician without limitation to the place of registration. In order to consult a specialist, or to undergo the basic diagnostic test, the referral from the primary health care physician is obligatory. In turn, physicians are paid per capita via single NHSU.
Historically, primary health physicians in USSR were perceived by the public as not highly qualified, neither it was prestigious to be a therapeut. This opinion is still prevalent in modern Ukraine since approximately 30% of respondents of nationally representative survey Health Index are not satisfied with doctors of primary health care level. This can be seen as a risk toward underutilization of primary health care and, as a result, unequal access to health services and overall worsening of the population’s health are expected. This is crucially important for policymakers, because underutilised primary health care undermined the efficacy of the health care reform that can be expected unless successful public informatization campaigns are developed and managed to improve patients’ attitude toward primary health care.
The third and fourth pillars are the introduction of the GBP and co-payments for services not included in it (expected to start in 2019). According to the statements of the Ministry of Health (MOH), patients will have fully covered costs for emergency treatment, primary healthcare, childbirth, palliative care and pharmaceutical treatment of cardiovascular diseases, diabetes type 2 and bronchial asthma. Yet, the full list of the services is not announced officially, but services other than those listed in the guaranteed benefits package are projected to require either co-payments or full coverage by the patient.
Still, not only well-balanced GBP that reflects the need of the population and its health care status is a crucial element of the reform, but also establishing a dialog between policymakers and community to raise awareness of the reform and GBP in particular. In the initial stage of the healthcare reform in Georgia, despite the introduction of GBP large share of patients was not aware of it. The common problem in Tajikistan is that patients find the lists of services in GBP too long and complicated to understand. Lack of single price list for GBP across all healthcare facilities is named to be another barrier to successful implementation of secondary healthcare reform in Tajikistan and should be considered by Ukrainian policymakers as one of the possible barriers.
The fourth pillar is the introduction of a co-payment system that protects equal access to health care services. Lessons from other Post-Soviet countries show that an insufficient number of specialists create a risk of long waiting time for specialist consultations, like in the case of Estonia and Lithuania. In addition to that, a limited number of health care services in GBP and high co-payments might increase patients’ expenditures, as in the case of Moldova. In Moldova and Kyrgyzstan, due to the limited number of specialist’s services in benefit packages and incomplete insurance, direct self-referrals to specialists do not cost more to patients as GP referral. Moreover, a guaranteed benefits package that is about to be introduced in Ukraine should reflect the population’s need for so-called “catastrophic illnesses” that are chronic and rare diseases, when treatment cost is impoverishing, and no alternative is found. State’s protection is crucial in this case, in addition to systematic screening and prophylactic.
The last element of the reform strategy is the incorporation of current international standards and treatment protocols into physicians’ practice. It is envisaged that physicians should refer to international standards when making decisions regarding treatments, in opposite to outdated national standards.
Even countries that managed to introduce health care reforms much earlier than Ukraine are still struggling with the shift to evidence-based medicine and implementation of modern standards. This results into extended stays, not needed hospitalisations, and ineffective treatment.
Research shows that up to one-third of hospitalisations in Ukraine are unnecessary and efficiency is reduced, and a waste of resources is increased. So impeded incorporation of international standards by other countries and a present waste of resources stresses the importance of international treatment protocols in Ukraine.
Finally, there is a problem of low salaries that potentially undermine most pillars and, thus, the overall success of the reform. First of all, well-balanced salaries and benefits for healthcare professionals aimed at minimisation of personnel outflow from rural areas is another challenge that many countries didn’t pass. Disproportionally low salaries, especially in rural areas, result in understaffed health care facilities and persistent informal practices in Kazakstan, Kyrgyzstan, and Russia and this constitutes a major challenge for those countries. In case of Ukraine, where official salaries to specialists remain low and “brain drain” is flowing not only from rural areas but also abroad, this situation might be seen in near future unless salaries will reach market level.
Secondly, Ukraine has taken a course of the gradual reforms in opposite to shock reforms, that are stretched in time, and, thus turbulent political situation may impede overall success. Health care reform in Ukraine will not be complete before upсoming presidential elections in 2019. Consecutively, there is a possibility that ruling power will change after the election with the following shift of priorities of the new government. So in this worst-case scenario, where new ruling party will be averse to the current reform strategy in addition to weak public and political support, reform collapse and rollbacks are possible. Logically, the current MOH should develop strong key legislative allies and public support that will be crucially needed for continuity of the reform under the new government. Lack of reform communication with the public might increase disapproval in society. Politicians who are eager to exploit this for their benefit might decide to postpone the reform. However, if the public is well-informed, there are more chances for support in society and smaller chances for reform cancellation.
As such, all stages of healthcare services delivery are intertwined, and overall success of improving populations’ access to health care depends on coherent and coordinated effort in prophylactic, diagnosis and treatment.
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