Medical reform has been ongoing in Ukraine since last year. But this month, for the first time, Ukraine’s public was allowed to take part in it, with the start of a campaign allowing citizens to choose their primary physicians.
Over two million Ukrainians have registered their doctor-patient relationship in the country’s eHealth database since its launch on April 2.
The campaign, called “A Doctor for Every Family,” is a significant break from Ukraine’s Soviet-style old system, in which patients were assigned to doctors at public clinics near their legal address.
This older system proved problematic for a number of reasons, among them that it left Ukraine’s wartime displaced people unsure how to access medical services, and ordinary citizens with little say in how they’d get care.
Now, with visible public eagerness to take part in the new system, some are already hailing the campaign as a success. Inna Boiko, executive director of the Patients of Ukraine organization, says that experts initially predicted that 10 percent of the population would register by the end of the year, she says. Already, though, it around 5 percent have signed up in the first month.
“That demonstrates that the public trusts the reform and the medical institutions are getting ready for it,” Boiko says.
But a small survey of Kyivans suggests the situation is more complicated, opinions are mixed, and misinformation abounds.
Reform in three stages
Ukraine’s medical reform, spearheaded by Health Minister Ulana Suprun, is undeniably ambitious. In the course of roughly four years, it aims to modernize the country’s ossified and often corrupt public healthcare system — making it affordable, more transparent and information-driven.
The bulk of Suprun’s legislative package passed the Verkhovna Rada in October 2017, but reforms began earlier, with the April 2017 launch of a drug reimbursement program called “Dostupni Liky” (Accessible Medicines).
This program allows patients to receive medications for a number of common conditions — cardiovascular disease, type 2 diabetes and bronchial asthma — for free or a for small payment at participating pharmacies.
With an estimated 1.38 million Ukrainians living with diabetes, the program was a solid first step. Two months later, the Health Ministry launched eHealth, an electronic database for Ukraine’s medical records. It also serves as a unified registry of all things medical: institutions, patients, doctors, and medications.
These initial reforms received attention. But, supporters believe the launch of the declaration-signing campaign last month will be transformative for Ukraine’s medical system.
According to Boiko, patients registering with their doctors does more than simply attach a medical professional to each Ukrainian citizen and his or her family. As patients fill in the eHealth system, they will also give the government more information about Ukraine’s health issues, and what medications the country needs.
As it stands, says Boiko, the government doesn’t know how many patients with each kind of illness are living in Ukraine, with the exception of HIV.
“Statistics here are limping along,” Boiko says. “It’s very difficult for the medical system to understand how much medical attention is needed and what kinds.”
Health Minister Ulana Suprun speaks at a rally in support of medical reform on July 10, 2017. Suprun has been one of the reform’s staunchest advocates. (Volodymyr Petrov)
New state insurance
Officially, the Ukrainian Constitution guarantees free medical care. In practice, however, the system has been severely underfunded and patients often have to pay unofficially for medical service. Medical reform aims to change that.
In July, Ukraine’s new National Health Service will begin payments to the first doctors and hospitals who have signed an agreement with the organization.
The service will, in effect, be a state insurance company paying for the medical care provided to the public. Over Hr 8 billion ($305 million) have been allocated from the state budget to finance the NHS in 2018.
Medical reform’s slogan-like guiding principle is that “the money follows the patient.” Each doctor will receive Hr 370 ($14) per patient annually (and more for children and elderly patients), regardless of whether that patient seeks medical treatment. By connecting state money to the patient, reformers believe they will both incentivize doctors to take on more patients and to provide better medical care.
The new system of financing will also give hospitals more freedom to utilize state money as they see fit. That means the funds can be used to hire needed personnel or repair facilities depending on their individual needs, reformers say.
The reform aims for all medical institutions to transition to the new system of financing by 2020. Until then, every medical institution and private practice doctor who does not sign up with the NHS will be financed by the old system.
All this falls under medical reform’s first stage, which addresses primary medical care. But, reformers also envisions two more stages.
The second stage, set to begin in 2019, will reform specialized medicine that treats more complex health issues — fields like gastroenterology and gynecology. The Cabinet of Ministers will confirm a list of medical procedures and services that will be covered by the state budget.
The third stage, scheduled for 2020, will address highly specialized medicine, which treats serious and complex medical issues. For example, many surgical interventions and organ transplantation will be a stage 3 issue.
However, according to Svitlana Bubenchikova of the Reanimation Package of Reforms coalition, both these stages are still in the works.
Mortality rates for infants, woman, and men
Success?
At the present moment, the “Doctor for Every Family” registration campaign continues and medical reform is moving forward. But the process has faced significant criticism both from doctors and prominent politicians — notably, doctor and lawmaker Olga Bogomolets, who chairs the Rada’s healthcare committee and has called for Health Minister Suprun’s sacking.
In an April 2018 comment to the Kyiv Post, Bogomolets argued that the reform would undermine the quality, accessibility and safety of medicine in Ukraine.
Specifically, she suggested there were not enough family doctors in Ukraine to service all its citizens. Moreover, sending all patients first to primary care physicians is risky in a country with low levels of vaccination, facing epidemics of illnesses like HIV and tuberculosis.
But perhaps her most salient criticism is that medical reform will leave Ukrainians living in rural communities underserved by the medical system without access to free medical care. Without enough local general practitioners, these people will “not only not receive access to primary medical care, but also won’t be able to count on secondary and tertiary care without a referral from a family doctor,” Bogomolets wrote. “What will happen to these people?”
Supporters of medical reform believe that the new system will actually make working as a rural doctor a financially viable profession and, thereby, encourage doctors to service these areas. But other doctors have echoed Bogomolets’ concern, and members of the public are also worried.
“Where should [rural people] go, 300 or 150 km away? When they close down rural medical clinics, when they remove medical workers, is that normal?” said Nadezhda Stepushenko, one of several people questioned by Kyiv Post in Shevchenko Park. “[Villages] have been left at the verge of extinction.”
Others expressed concerns about having to pay for medicine, losing access to specialists, and dysfunctional bureaucracy sidelining the reform. (For more public reactions, see the Kyiv Post’s Vox Populi online about the subject.)
For their part, reformers remain committed to medical reform. But they admit that measuring the program’s success can be a challenge.
“We’ve never done this before. We’ve never had an electronic system of healthcare,” says Bubenchikova.
So far, however, she believes the results show “public awareness, citizens’ desire to sign declarations with their family doctors, and that people have figured out how to do it.”
Where to get care for minor medical emergencies and routine care in Kyiv
