On 19 October, Ukraine’s Verkhovna Rada approved the draft law No. 6327 “On state financial guarantees for the provision of medical services and medicines,” in the second reading. Even though Ulyana Suprun, Ukraine’s healthcare minister, emphasized there are quite a few pieces of legislation to adopt, the healthcare reform will be finalized soon. Our partners at The Reforms Guide analyzed what is to expect when the reform will be implemented
During the years of independence, Ukraine hasn’t been able to create a healthcare system that can effectively provide the population with quality and affordable medical services, respond to the current challenges related to increasing mortality rates and the spread of AIDS, tuberculosis or hepatitis C, and to carry out effective preventive measures. Today, despite high levels of state expenditure on the medical sector, citizens are forced to pay for expensive treatment on their own. For the disadvantaged section of the population, the payment of medical services is often excessive.
Here is what you need to know about the reform:
- Medical facilities do not have enough equipment for the examination and treatment of patients, drugs, or qualified personnel. In addition, very low salaries provided by the state for medical workers—4000-8000 UAH (130-255 EUR) depending on qualification—has led to corruption in this area. The results of a survey conducted by TNS-Ukraine in 2016 indicate that the medical sector is the most corrupted sector. This was stated by 61% of respondents. Also, according to a study by the anti-corruption organization Transparency International, in 2016, 33% of respondents made informal payments in a medical institution.
- The reform foresees shift from financing a medical institution to financing the services provided to the patient. In the past the state allocated money for the maintenance of hospitals and a certain number of beds; now these funds will be used for services provided to patients. A number of bills should change the existing system of healthcare financing, including the Draft Law On State Financial Guarantees for the Provision of Medical Services and Medicines (No. 6327), which was adopted by the Verkhovna Rada in the first reading on June 8, 2017.
- Hospitals will receive financial and managerial autonomy. It is planned that they will turn into non-profit enterprises that will be able to receive financing from different sources. Article 18 of medical reform law № 2309a-d, which was adopted in April 2017, introduced the principle of “money follows the patient,” according to which hospitals and private doctors will receive direct payments for the treatment of a patient and his/her medical case. The reform will double down on this principle.
- Personal insurances will play a big role. Nowadays the market of health-related insurances in Ukraine is almost non-existent in comparison to western countries. According to the reform, all medical services and medicines provided to patients should be entirely or partially paid for by the state through the state insurance system, which will cover all persons living in Ukraine. The issue here is not about insurance as such, but about another model of budget financing, because the issue is not about a certain contribution, but reallocation of budgets. Its specificity lies in the fact that the population will not have to pay any additional insurance contributions, as the financial provision of obtained medical services will be received from taxes. Thus, everyone who lives in Ukraine is automatically insured as they pay taxes.
- Flexible salary of doctors will be introduced. It will depend directly on the number of patients who visit this doctor. On average, the state plans to allocate 210 UAH (7 EUR) per year for one patient. The doctor’s norm will be 2,000 patients. For pediatricians, the number will be 800-900 patients. They will receive more per patient—about 270 UAH (9 EUR) per patient, taking into consideration the greater amount of work and workload. The same applies to doctors who will treat elderly people. Payment will be received monthly. The patient can still choose a doctor, but now the specialist who has more patients must be paid primarily. However, the corresponding mechanisms are not yet sufficiently spelled out. It could happen that an institution that provides services to more patients will receive more funding. Instead, a doctor who works in this institution and has many patients will not receive bigger pay.
- A new authority called the National Health Service of Ukraine will administer budgetary funds allocated for financing the services. This structure will procure medical services for the population, sign contracts with primary healthcare providers. Such services are available in almost every country in the world.
- Hospital districts will be created in order to regulate the existing network of hospitals. The need for the establishment of hospital districts is the lack of the possibility to obtain high-quality specialized assistance on the ground, but only in regional centers and some cities. The reform should contribute to the creation of one hospital of the second level of intensive care in each hospital district. According to Ulyana Suprun, Ukraine’s healthcare minister, the ministry does not plan to close hospitals, but on the contrary, is interested in increasing the number of multi-field hospitals. However, the population fears that, because of this process, hospitals in small towns and paramedic-obstetric stations in villages will be closed, and in order to receive medical care it will be necessary to turn to medical establishments located many kilometers away. At the same time, there is always the problem of Ukrainian roads. Many regions refused to provide information on hospital districts. And there is already a great deal of nonsense in the submitted documents. For example, in a newly-created district for an ultrasound examination, it is suggested that the patient go to Kyiv for 8 hours.
- The establishment of hospital districts and the distribution of functions between hospitals takes place at local level. Local authorities have better knowledge of the needs of their population. For these purposes, the members of the hospital district set up an advisory body called the Hospital Council, which develops the district development plan for five years, reorganizes and re-profiles medical facilities, appoints and dismisses heads of medical institutions. The Hospital Council has no authority as a body. It does not have any leverage that would exceed the influence of district authorities. We can deal with the fact that nobody will negotiate on any issue. Hospital districts envisaged enlargement of the regions. However, each district remains the owner of these hospitals and the recipient of funds.
- The hospital district should include at least one multi-specialty intensive care hospital of the first and/or second level and other healthcare facilities. The intensive care polyclinic of the first level will admit at least 120,000 people, and of the second level at least 200,000 people. Thus, the intensive care hospital will be the most powerful in the region, and the other hospitals will be restructured.
- The boundaries of the hospital districts will be formed in such a way as to ensure the access of all residents of the district to the secondary (specialized) medical care. The administrative center of the district is a city with a population of more than 40,000 people with an intensive care polyclinic of the second level. Consolidation of areas is very important for medicine. But territorial areas should be created at the level of the particular region. Such a system proved to be good both in financial management and in technical equipment.
Prepared by Zoriana Chernenko for The Reforms Guide, adapted for UkraineWorld group (ukraineworld.org) by Vitalii Rybak
Zoriana Chernenko is chair of the board of the Ukrainian Medical-Law Association, a leading expert on health reform of “The Reanimation Package of Reforms,” director of NGO “Health Forum”, member of the World Association for Medical Law.