In much of the world, the ability to choose your own doctor is a given. But in Ukraine, citizens have long been forced to seek treatment only at clinics near their legally registered address – even if they in fact live elsewhere.
Not anymore. On April 2, the Ukrainian Ministry of Health launched a reform campaign aimed at breaking free of this Soviet tradition and drastically restructuring Ukraine’s stodgy healthcare system. Titled “A Doctor for Every Family,” the campaign is to alter how Ukrainians seek primary medical care and the way the state funds healthcare.
For Ukraine’s medical reformers, its launch is a major victory. They have long stressed that, with presidential elections coming up, it is critical to implement change before electioneering populism or post-election horse-trading can derail the reform.
The reformers appear to have had a point: Just a day after the Health Ministry’s campaign went live, the Verkhovna Rada’s healthcare committee called for the ouster of acting Health Minister Ulana Suprun, who spearheaded the country’s medical reform.
Breaking bad healthcare
Passed by the Verkhovna Rada in Oct. 2017, Ukraine’s medical reform aims to revive a healthcare system that is on life support. Currently, medical services are officially free in state clinics, but patients often have to pay unofficially to receive care. Corruption and bribery are common, and doctors make paltry official salaries.
Functionally, the system often works backwards, with the majority of Ukrainians initially seeing a specialist rather than a primary care doctor. The results of this collapsing system are stark: the average life expectancy in Ukraine is five years lower than the world average, and most citizens live with the fear that one serious illness could bankrupt them.
Under the new program, patients will sign an individual declaration with a general practitioner or pediatrician. That declaration will then be included in the “Electronic Health” database. Should the patient later decide to switch primary care doctors, he or she will simply sign a declaration with another doctor. That new agreement will then cancel out the previous one.
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. Family doctors will be able to take on 1,800 patients, general practitioners can sign declarations with up to 2,000, and pediatricians can treat up to 900 children. Reformers believe that this will both incentivize doctors to take on more patients and to provide better medical care.
The reform will also allow hospitals to use their funding as they see fit, whether that means hiring new specialist doctors or repairing decaying facilities.
“It will be a market model of relations,” says Inna Boiko, executive director of the Patients of Ukraine organization. “If (doctors and medical institutions) misuse this freedom, patients can stop coming and they will lose this money.”
Ministry versus committee
But medical reform has faced serious pushback from the Rada’s healthcare committee, chaired by Olga Bogomolets, a prominent doctor and lawmaker.
Under the reform bill passed in October 2017, some medical services will be covered by the state, while the patient will be responsible for paying for others. By 2020, the authorities are also supposed to have fully introduced a framework for patients to choose their own doctors and hospitals, and an insurance system financed by the government.
At the time of the law’s passage, acting Health Minister Suprun characterized it as a move “to regain the dignity of doctors and patients in our healthcare system” and a “decisive step in a large systemic transformation.”
Bogomolets took a different view. “Genocide has begun: Ukrainians will be destroyed by this law,” she said on Oct. 19 after the bill was passed. She alleged that the reform would deprive the country’s most vulnerable of medical care.
“‘A Doctor for Every Family’ is a great goal, which for now will be difficult to realize without losing the quality, accessibility, and safety of medical assistance for people in today’s reality: economic and social crisis,” Bogomolets told the Kyiv Post in a written statement.
She particularly fears that the reform will decrease access to medical assistance in rural areas.
Others have lodged similar criticism. “That main component of medical reform, which will launch in April, will lead to a decrease in financing for medical facilities and a decrease in doctors,” Oleg Panasenko, the head of the Free Professional Union of Medical Workers, told the Golos.ua website. “It’s consequences will be a large-scale lack of access to medical help.”
Reformers disagree. They argue that there is already a shortage of doctors in rural areas, and the new approach will actually make working in villages and small towns an extremely profitable proposition for general practitioners and pediatricians.
Other opponents of the reform are personally dependent on the current medical system, they suggest.
“When we talk about freer and more transparent relations between doctors and patients, we’re getting into a discussion of budgetary money,” says Svitlana Bubenchikova of the Reanimation Package of Reforms coalition. She believes that some of the medical reform’s opponents are people who work in medicine based upon bribery and kickbacks.
But she also admits there is resistance to change that introduces greater competition into the field.
“This can cause discomfort for people who are not focused on working for results, but on going with the flow,” Bubenchikova says.
Taking aim
One day after the “Doctor for Every Family” campaign began, the Rada’s healthcare committee recommended that the parliament call on the Cabinet of Ministers to sack acting Health Minister Suprun. In the draft decree, committee chair Bogomolets accused Suprun of “official negligence” in administering a program for publicly procuring medicines in 2016, which caused “acute public tension.”
Now it will be up to the Rada to vote on the decree. For her part, Suprun says she plans to remain at her post.
“Our team thinks this is the best advertisement for our reform – that it’s moving in the right direction,” Suprun told journalists on April 4. She also said she had received a call of support from Prime Minister Volodymyr Groysman.
Meanwhile, reformers also believe the “Doctor for Every Family” campaign is off to a good start. A thousand hospitals and 12,000 doctors have already joined the program, according to Boiko from Patients of Ukraine. More will join as time goes on, she said.
“Although the campaign only started yesterday, 151,000 declarations have already been signed,” she said. “And I think they’re growing as we speak.”
