The April 1 deadline for the implementation of the second phase for medical reform has passed. The result is that the citizens of Ukraine still do not have the assurance that after years of consultations amongst all of Ukraine’s major medical stakeholders that a new medical system will be implemented that would replace the inefficient, bureaucratic and unaccountable communist system that they have suffered under for so long.
The philosophical inspiration for the first credible medical reform in Ukraine’s modern history was inspired by the EuroMaidan Revolution, which ended Viktor Yanukovych’s presidency in 2014, and its focus on human dignity.
The revolutionary effects of this movement and the ensuing renaissance that focused on the need to affirm human dignity in terms of institution-building would soon be translated within the health ministry under the leadership of Dr. Ulana Suprun.
The results of the first phase, based on the belief that individuals would have the “right” to choose their own doctor, was lauded as a transformative breakthrough in the formation of government policy in post-Maidan Ukraine.
The health ministry established a program whereby Ukrainians would have the right to choose their own doctor for which they would have to sign up. Initial estimates from international organizations prognosticated that Ukraine’s primary health-care transformation phase would be a success if they got 2 million signed up within a year. At this moment, almost 28 million have signed up.
Exercising this right, Ukrainians not only affirmed their autonomy and desire in exercising their right to choose their own doctor, but affirmed the philosophical basis and direction of medical reform.
The governments’ new funding formula would affirm this choice by introducing a payment scheme whereby doctors would be paid on the basis of the individuals for whom they provided medical services.
This approach created a mindset within the system and a new form of expectation, that being, that by having the right to choose their doctor, the ordinary citizen could pass judgment on the state of the system by voting, or rewarding quality care provision with their feet, by being allowed the freedom to not only choose their doctor but decide which hospital or clinic they would wish to seek medical care.
The purpose of the second phase of medical reform was to begin to incorporate specialists into the established system of medical financing already established in the first phase with general practitioners, whereby the money would follow the patient. Thus, not only would general practitioners, the frontline of the medical system, but specialists such as cardiologists and rheumatologists, would now be included in the funding model established in Phase I.
By so doing, medical reform would now be extended into areas of specialized medicine that would focus on the need for highly skilled and trained medical service providers to respond to changing behaviors and expectations of their patient/clients.
The implementation of the second phase of reform would create a sense of “competition” amongst the country’s specialists while also asserting the need to invest in leading equipment and technology that would directly benefit patients.
It would not only affirm the need for specialists to provide for the efficient delivery of medical services, but would also reiterate that the primary focus would be on direct, efficient and quality service provision at the level of specialized medicine.
The pursuit of such a strategic goal would not be targeted on “bricks and mortar”, physical institutions, like hospitals or clinics, but rather on service delivery and quality care.
Most importantly, the focus of Phase II of reform would be to apply “patient choice” that began with general practitioners in Phase I and institutionally consolidate these success factors in relation to specialists.
That said, the financing model of Phase II would be informed by:
The provision of medical costs to those hospitals, clinics, etc. who would provide the best “quality” medical services in the specialists’ field;
Those facilities and medical providers who would provide the best quality services as determined by patients. As funding would “follow the patient,” it would create a competitive incentive within the medical system;
The continued “justification” of government financing would be determined by the quality of medical provision by individual practitioners.
With this intention and proscribed financial model, doctors, hospitals and clinics, would have to “compete” for patients on the basis of the quality of care they provide.
This “built-in” competitive mechanism would inherently raise the standard of medical service delivery in the field of specialized medicine because it would be based on the assumption that quality of care, determined by a patients ability to choose their doctor, as the most important factor that determines who would be financed and at what facility this care would be provided.
Thus, after years of consultation of all major medical stakeholders, it was agreed to that the fundamental purpose of medical reform was first to determine, and then implement a fair and equitable financial model that focused on efficient service delivery to patients.
This approach would create a sustainable model for patient-based service delivery with the objective of creating system-wide efficiencies that would demand financial discipline and justification within a transformed medical system that would not only affirm the principle of dignity and individual-based medical care but which would respect taxpayers in the delivery of medical care and attempt to eliminate corruption.
With the recent appointment of new Health Minister Maksym Stepanov, there has been a change in this approach, and even a direct contradiction of the philosophy of medical reform as it has been practiced the last few years.
When questioned at a recent parliamentary committee on health, the minister, the third since Dr. Suprun was replaced, did not affirm the fundamental philosophical direction of medical reform.
Rather than affirming patient-centric reform, he largely focused on issues of “bricks and mortar” and was reluctant to affirm the need for “competitive” measures within the system. He stated that it was his intention to “save” the medical system by refusing to close any hospital and to ensure that no medical workers would be laid off.
Under questioning, he argued that if the proposed model for reform would go ahead, 332 hospitals would close and that some 50,000 medical practitioners would lose their jobs.
But when challenged by parliamentarians as to the figures upon which he based his prognostications, he did not provide any factual justification for his statements to the committee. This shocked the parliamentarians who were well aware of the many years of country-wide consultations and negotiations that went into preparing Phase II of medical reform and the establishment of an enormous information base. Stepanov abandoned the principle of “facts-based” policy development.
They were further discomfited when he next added that it was his intention to increase the salaries of medical workers up to 50% or by a 1 billion hryvnias. But when asked how he would do this, he simply answered, “We’re looking, we’ll have to look at the budget.” Incredulity only expanded when he also proclaimed, rather belligerently to their incessant demands that he justify his statements, by saying, “we are going to reform, but we won’t ruin medicine.”
After his performance, anxious concerns grew as to whether the minister was prepared to carry through on the promises and spirit of medical reform that had taken years to devise. It has become readily apparent that Stepanov is not going to follow the established direction of medical reform.
But after further study of his statements, it became clear that the minister was echoing the talking points of the “Opposition Platform” party, a parliamentary faction that has historically opposed any type of democratic based government reform and which has historically argued for maintaining the status quo and oppose any type of democratically inspired change.
The ministers’ statements caused even further alarm when he suggested that medical reform as proposed would lead to the governments’ inability to fight tuberculosis. With this, it became clear that the minister was prepared to use fear tactics to discredit any previously prepared reform efforts.
Thus, in the initial months of his ascension to the leadership of the health ministry, reformers began to conclude that it was the intention of the minister to derail, and even dismantle proscribed medical reform.
The failure to implement the second phase of medical reform according to a long-established deadline reveals a major fault line in Ukraine’s form and practice of government.
More specifically, it shows the failure of successive Ukrainian governments to build on the efforts of previous governments to transform its major institutions into democratic ones that are inspired to develop and implement government policy based on human dignity and to provide government services that would respond to the needs of individual citizens. Ukraine’s governments have shown the inability to govern based on democratic values and practice.
In President Volodymyr Zelensky’s government, It is evident that government policy and actions are once again catering to established bureaucratic considerations and to entrenched interests who are now practicing a form of “revanchism. Government policy is made to meet immediate political considerations, while using misinformation and fear tactics.
So, what is the state of medical reform at the present moment?
Fundamental reform has stalled. The COVID-19 pandemic, however, is not an excuse.
The present government has not affirmed the patient based philosophical underpinnings of medical reform that has been pursued for the last 3 years and which were inspired by the Maidan and on the need to focus on the establishment of individual and dignity based institutions.
It has backslid in affirming the principle that democratic transformation or change, which can only be attained when there is an uncompromising commitment by a democratically elected government to the establishment of democratic institutions based on individual choice and the freedom of its citizens to choose how, and by which standards, their government is to provide basic services.
The present government has failed to implement a “facts-based” course of action. By so doing, they illustrate those years of work, resulting in the development of a comprehensive reform plan, the development of a fair and equitable funding formula, the establishment of medical standards that would meet European standards, can be cast aside due to alleged “populist” pressure resulting from political fear-mongering. Ukrainians deserve better.
Yuri Polakiwsky is a writer who resides both in Toronto and Kyiv. He is the author of the book, “Ukraine – A Lament of a Promise” and a member of the Association of Ukrainian Writers and Poets in Kyiv.
