Ukraine's health care system is sick. It is immune to change and kept on life support by bribes that patients pay to doctors. It is indeed on the brink of breakdown.
Despite free health care being enshrined in the Ukrainian Constitution, the reality is starkly different. Patients are at the mercy of indifferent and underpaid doctors, and have no guarantee of getting decent care even when they pay bribes.
According to an anecdotal poll conducted by the Kyiv Post involving 15 women who have recently had children in Kyiv, giving birth can cost anything from Hr 900 – just for hospital medicine bills – to around Hr 25,000 for hospital suite accommodation or for the services of a particular obstetrician.
Several women paying in the high end of this spectrum told the Kyiv Post they never even saw the doctor they had paid to perform the delivery, while one said she was left sitting on a couch even after her water had broken.
“There’s chaos and uncertainty for the patient,” pediatrician Oleksandr Yabchanka told the Kyiv Post. He heads the health care reform group of the Reanimation Package of Reforms, a civic sector initiative lobbying for health sector modernization.
“Even when a patient agrees to pay a doctor under the table, it’s unclear what she can expect,” he said.
According to Yabchanka, doctors mask payments and avoid talking about the specifics of treatment so they can’t be linked to the actual care and don’t provide grounds for criminal charges.
Ukraine’s new government has been trying to cure the sector’s ills. A former Georgian reformist minister of health, Alexander Kvitashvili, was brought in by the post-EuroMaidan Revolution leadership to deal with the mess.
After his appointment December, Kvitashvili launched initiatives such as medical insurance, legalizing payments, electronic documentation and greater autonomy for medical institutions. But his drive for change quickly stalled, and on July 2 he tendered his resignation amid political pressure.
Not one bill he submitted to parliament to improve health care was passed.
Yabchanka accuses Kvitashvili’s critics of misdiagnosing the problems. It wasn’t up to the ministry to singlehandedly decide on the country’s healthcare policy. Rather it was up to the prime minister’s office and parliament to act, and approve Kvitashvili’s proposals, Yabchanka said.
“Kvitashvili was overwhelmed by the resistance he met here,” Yabchanka said.
The daunting task faced by the former health minister cannot be overestimated. Health care in Ukraine is still a strictly top-down governed system that dates back to the times of micromanaged Soviet planning.
“The problem is not so much the misuse of public funds, as seen in other sectors, but an inefficient system with faulty incentives built in,” Yabchanka said.
For instance, hospital managers aren’t allowed to prioritize resources according to actual needs. Even laying off a cleaning lady to hire a nurse is impossible. Moreover a measure of success for hospitals is for all the beds to be occupied at all times, making the system focus on prolonging patient stays instead of promoting recovery.
“To fulfill the bed occupancy plan they force patients to hospitalize or stay longer than needed,” Yabchanka said. “They even falsify patient notes, thinking up a continuation of the illness long after the patient has left.”
Yabchanka describes a situation where 80 percent of health care costs are consumed by salaries, building maintenance and utilities. The World Bank has estimated that Ukraine has 40 percent more hospital beds relative to the population than in the European Union.
“The focus has to change from the bed to the patient,” Yabchanka added.
With salaries below living costs, state clinics and hospitals are undergoing unofficial privatization. The state only provides medics with facilities and equipment, which doctors then use to provide what is in effect private treatment.
But the state healthcare system could achieve more even with the existing low level of financing, Yabchanka believes.
“Basic medical services should be provided free of charge. Prevention and screening should move to the forefront. The price and rules of other services should be transparent,” he said.
Moreover, Yabchanka sees competition as a way out. If state hospitals and clinics had control over their own budgets, they could compete for state medical contracts. This is a different approach from privatizing healthcare, where hospitals make money from treating sick patients.
Instead, the state health care system should have an interest in keeping the population healthy. In 2013 life expectancy in Ukraine was 71 years, 10 years less than in the United Kingdom, where the NHS state healthcare system has gone through years of reforms similar to those proposed for Ukraine.
“As it is now, patients will only go to a clinic when they’ve already been ill for a long time,” said Yabchanka. “At that point they might not have the funds for full treatment.”
Ukraine’s doctors would also benefit from progressive reform, Yabchanka said.
“The underpaid doctor has to choose whether to beg for, or extort money from the patient. Either way he is made a criminal. No wonder doctors take it out on the patients – it’s all nonsense,” he said.
Staff writer Johannes Wamberg Andersen can be reached at [email protected].
