The Constitution specifically demands that public health care be provided free of charge and that the existing network of medical establishments shall not be reduced. Under constitutional law, the state must favor and promote the development of health centers regardless of their ownership.
However, high state officials close to President Viktor Yanukovych interpret these constitutional provisions in their own way. Irina Akimova, first deputy head of the Presidential Administration, disagrees with the current healthcare budgetary policy and believes that the reallocation of funds would help to improve medical service in Ukraine.
In her view, the Constitution does not directly prohibit paid medical services and the provisions on free health care restrict ability to reform.
The authorities seem unwilling to adhere to the constitutional framework and directly violate fundamental civil rights. A number of districts within the Cherkaska, Vinnytsa and other regions of Ukraine will see the closure of district hospitals in accordance with official policy. As a result a vast amount of Ukrainian citizens living in small towns will be left without emergency medical service within reachable distance.
Medical staff and equipment will be lost for good making the future recovery of the hospitals virtually impossible. Another controversial decision will see a significant reduction in the patient capacity of the
Ukrainian Children’s Specialized Clinic for Maternity and Child Protection (“UDSB OHMATDET”) situated in the centre of Kyiv.
Opposition figures attempt to rally public concern over the continued deterioration of the medical sector. Mykola Tomenko, Deputy Chairman of the Verkhovna Rada, recently exposed a covert reduction of medical establishments that has already started in Ukraine. According to Tomenko, the governing authorities attribute this to the reduction of budget available for health care in Ukraine for 2011.
The 2011 budget sees finance for disease control reduced by 58 million UAH (10.05%) to 577 million UAH, despite the fact that Ukraine maintains the highest infection rate in Europe for tuberculosis, AIDS and cancer. Adding to the perspective, the medical bills for the annual treatment, diagnostics and health resorts of the average Rada Deputy are the equivalent to one year’s health care expenses for 5,130 citizens. The new budget also increases the provision for air travel for high state officials to 189 million UAH – 30 times the total costs for treatment of the nations cancer patients and the victims of the Chernobyl accident combined. Ukraine currently allocates only 4% of its GDP to health care, compared with a 7% average in Europe.
Not surprisingly the population of Ukraine is decreasing. According to the Ministry of Economic Development and Trade the population totaled 45,778,000 people as of the 1st of January 2011 – 184.4 thousand people less than the same date in 2010.
Between 1989 and 2010, the population decreased by between10 and 30% in the majority of regions with the greatest loss in the northernmost regions. The districts surrounding large cities have seen slower population decrease, due to migration gain.
Ravil Safiulin, former minister of family, youth and sport, commented that by 2050 the population of Ukraine would drop to between 25 and 30 million people. Since gaining independence Ukraine has lost 6 million citizens (1989 – the population was 52 million people) with one of the major factors being the deterioration of the public health care.
The Ukrainian people themselves view the state medical service as unsatisfactory and corrupt. Research conducted by the Gorshenin Institute in February 2011 shows that 74.6% of respondents believe strongly that corruption has penetrated the state health care system. 43.4% of participants stated that they had personally witnessed medical workers operating at public medical centres who extorted money for their services. 44.6% of Ukrainians believe that an insurance-based healthcare system may be a possible solution to the problem.
Professional comment: The Constitution is the place to guarantee rights, not the place for defending an existing network of health care facilities and their often expired equipment. The Ukrainian network emerged from the Soviet era Semashko model which was aimed at communicable disease and episodic care for acute illnesses. This model is no longer relevant to the present burden of disease and is increasingly ineffective and costly to maintain. The burden of disease has shifted to non-communicable disease, conditions associated with behavioral risk factors and chronic conditions.
Using the Constitution to maintain the old network is inappropriate, the system needs reform.
Buildings and equipment do not treat or care for the sick. People do. Some are health professionals. Others are not. The venue for treatment and care need not be a hospital – it can be the home, or at a primary care ambulatory centre. Ensuring timely and equal access to quality care at the right venue is more important than protecting existing buildings. Developing a sound ambulance program to reach into rural areas and building better roads whilst improving medical training and the quality of practice, and ensuring adequate numbers of appropriately trained Family Medicine physicians is a much better investment.
The Constitutional prohibition against reducing the existing network of medical establishments freezes the health system in the past and bars efficient use of limited resources. Countries like Georgia and Azerbaijan have progressed far with their health reform programs. They first optimized their health care network models, then proceeded to renew and modernise the remaining buildings and equipment. No locality likes to see its health facility closed. But no one wants access to a health facility whose sole benefit is proximity, if it cannot provide quality care. People will usually give up their demand for a facility in their area if they can be guaranteed access to quality care within a reasonable travel time.
The redistribution of funds can improve health care. Strengthening priority for primary care has the potential of meeting up to 80% of medical needs in a cost effective way. Ukrainians face much higher rates of death and disease than their European neighbours. Adult male mortality rates are on par with Benin, Togo, Guinea, Haiti and Ghana and are directly linked to alcoholism and infectious diseases, like HIV/AIDS and tuberculosis. About half of all deaths before age 75 are avoidable – approximately one third are preventable, one third are treatable and the rest avoidable through a combination of treatment and prevention. About 80% of the deaths of working age males and 30% of working age females could be avoided by providing effective primary health care. 98% of premature mortality due to tobacco smoking, alcohol and road accidents could be avoided with adequate education and with these avoidable problems removed less hospital beds would be required.
The provision of “free” health care need not restrict reforms. Most European countries have undergone major health system reform and offer useful lessons from their experience. Primary amongst which is accessibility. Their health care financing is overwhelmingly from government, leaving the patient to pay relatively small amounts that can be privately insured, resulting in notionally “free” care. Studies show however that the poor often do not seek necessary care because these relatively small charges plus time lost and travel are prohibitive.
On a Purchasing Power Parity basis (PPP) Ukraine health care expenditure per capita is almost one seventh of the average of OECD countries. Ukrainian health care is underfunded. It has had low priority amongst all governments. Ukrainian lack of confidence and trust in the health care system is telling. That nearly half of the people think “insurance medicine” is a possible solution is evidence of grasping at straws, not evidence of informed public opinion on the costs, benefits and beneficiaries of “insurance medicine”.
A systemic view and approach to reform is necessary. No single approach will solve all problems but western experience over the past six decades offers enough knowledge to suggest which approach leads to better or worse results. Attempting to use market forces to ensure that people get the health care they need, at the time they need it, at the price they are willing to pay, has limited prospects – as is demonstrated in the USA. The five “control knobs” of the health system: financing, payment, organisation, regulation and behaviour are well recognized. These knobs are interdependent. Their setting determines the efficiency, quality and accessibility of the system. This in turn affects how well population-based performance goals of health status, customer satisfaction and risk protection are realised.
Unless there is informed and sustained political will for health system reform in the face of vested interests, it will flounder and fail. The President, Parliament and Government need to advocate for and protect the interests of the people. This role has not been realised by any authorities in power since independence and the results are strikingly obvious.
Myroslaw Kohut
Visiting Professor, MBA Programme in Health Care Management, International Management Institute (MIM-Kyiv). International Health Sector Expert on planning and reform in 17 countries for the World Bank, national Ministries of Health and others.
People First Comment: ‘Health care and access to it is one of the primary political issues in all democratic nations. If politicians cannot be trusted to look after the sick and infirm how can they be trusted to look after the rest of the nation. Care of the sick is also one of the primary factors that define civilised society so one has to ask why in Ukraine it has such a low priority. The reason is very simple. It is not a political priority because politicians are not accountable to their local electorates.
If politicians were required by law to hold regular town meetings as in most other democracies and to listen personally to the woes of their constituents they would either force the government to act or risk losing the next election. Whilst they remain immune to their electorate Healthcare will remain as a budget item and not an issue of public morality.
Viktor Tkachuk is chief executive officer of the People First Foundation, which seeks to strengthen Ukrainian democracy. The organization’s website is: www.peoplefirst.org.ua and the e-mail address is: [email protected]
