Translated by Ollie Richardson & Angelina Siard
In the upcoming weeks the parliament is going to adopt medical reforms. It is pushed forward actively by the Acting Minister of Health, the volunteer of Maidan Ulana Suprun, calling for a “Revolution of Dignity” in health care. Formally the medical bills were supported also by the government (they are submitted to parliament on behalf of the Prime Minister).
But even among the Deputies of the Bloc of Petro Poroshenko there is no unity concerning these documents. Not to mention other factions. This isn’t surprising – the project of transformation involves a fundamental change of approach to health care. And part of the proposed measures are very controversial and painful for society.
“Strana” tried to understand what the essence of the offered reform is, and what the arguments are of its supporters and opponents.
The 4 pillars of reform
4 bills – No. 6327, 6328, 6329, 6347 – are the cornerstone of the alleged reform of health care.
The main bill of reform – No. 6327 “About State financial guarantees of providing medical services” – is submitted on behalf of the Prime Minister Vladimir Groisman, and the main committee for it is not the committee on health care questions, but the committee on questions of social policy, where the chances of it being passed in the hall are much higher than in the former.
The three other bills only supplement the main one – they give guarantees to participants of the anti-terrorist operation, and make changes to the budgetary code concerning expenses on primary medicine and changes in the law on public purchases. But also with close examination it is possible to find many nuances in these bills, for example, in the bills where guarantees are given to ATO members the legalization of international protocols in Ukraine is recorded.
On May 18th the parliament was unable to introduce these bills on the agenda of plenary sessions.
According to “Strana”, the day before Deputies had a meeting with the Acting Minister of Health Ulana Suprun, but she couldn’t convince Deputies to vote for these four pillars of reform. The deputy head of the Bloc of Petro Poroshenko faction Aleksey Goncharenko, in particular, in comment to “Strana” reported that at this meeting Suprun couldn’t answer all the questions of parliamentarians, from which many drew the conclusion that the bills are raw. As a result only 164 Deputies voted for their inclusion in the agenda (it is indicative that the Bloc of Petro Poroshenko gave only 65 votes, and the People’s Front – 56). Then the Ministry of Health burst into an angry tirade.
“Today the parliament didn’t vote for the inclusion in the agenda of bills No. 6327, 6328, 6329, 6347, which must become a Revolution of Dignity for the healthcare system of Ukraine. Now the postponed changes affect our children, parents, the Ukrainian military servicemen who sacrifice their health in the east to defend the country… Changing the healthcare system? It is a question of dignity. It is a maturity test for society and the responsibility of the political elite for the lives and health of the citizens. Ukraine must escape at last from the vicious circle and to leave it on a positive: in life expectancy, in birth rate, in state of health,” said the official statement of the Ministry of Health.
The haste of the Ministry of Health was explained by the acting minister. “That is why we are hurrying everyone with a vote for reform? If it was accepted now, then we could begin reform ‘quickly’ already on July 1st. In a year – by July 1st, 2018 – we will have enough data to calculate the State guaranteed package until September 15th, 2018 and to impose the real budget for 2019,” stated Ulana Suprun.
“And if it is not accepted soon, we will begin the political process – the auction for a new government will begin, preparation for parliamentary elections, then for presidential ones, and it will never be accepted,” predicted the acting minister.
So what does this “Revolution of Dignity” in medicine bring to the people and the country? We tried to briefly formulate its essence in 5 points.
1. Cancellation of the guaranteed free healthcare service
This is the main innovation of the reform, which is hidden under the beautiful definition “creation of a package of medical services guaranteed by the State”.
What does it mean?
Proceeding from the concept of reform, from the State budget only primary medical care, and also emergency and preventive care – directed towards the prevention of a disease – will be paid.
Specialized and highly specialized medical care, i.e. the most expensive, will appear on the terms of additional payment by patients as a part of its cost.
Thus, the boundaries of this sum are in no way stated in the bills. Neither the volume of the guaranteed medical care, nor the tariffs for which the State will pay services of hospitals is known. Even within the framework of diagnostics it remains unclear – who will finance expensive diagnosis that can reveal a disease at its early stages.
I.e., roughly speaking, from the bills it is absolutely unclear – where the “guaranteed package” comes to an end and “specialized medical care” begins. To cut out appendicitis enters into the free package (as emergency help) or already at additional expense (as a specialized operation)? And carrying out ultrasonography? And how big will this payment be?
It is assumed that all of this will be specified in separate regulations of the government. But the sense is in general clear. A considerable part of medical services will officially require payment (an exception – veterans of the anti-terrorist operation).
In principle, if the State refuses general free healthcare, certain compensatory mechanisms must be provided. For example, the introduction of medical insurance (at least for the working people). However, in the bills this isn’t mentioned in general.
But the acting minister Ulana Suprun stated that the current reform is the first step towards the creation of health insurance.
But, we will repeat, no concrete steps in this direction so far in the bills put forward for voting are provided.
2. How hospitals will change
Medical institutions will be divided into three components. Instead of the usual policlinics there will be family out-patient clinics (they already, by the way, were created in the last years five in a number of regions as an experiment). This is the first component. The second component is dedicated medical care. This includes ultrasound, MRI, various laboratory tests and hospitals. The third component is highly specialized hospitals.
However, in the present “reformatory package” only the first component is registered in detail.
As was explained by the ministry, Ukrainians will have the opportunity to choose for themselves the family doctor. Furthermore, an electronic e-health system, which will allow to collect data on all doctors and their activity – experience, education, qualification, average time of consultation, etc. will be introduced. On the basis of these parameters the rating of doctors who citizens will be able to register with will be created. After choosing a doctor the patient must sign with them a declaration and examine the procedure of providing primary medical care developed by the Ministry of Health (in this document it will be actually describe what guaranteed free medical care the patient will be able to receive).
The ministry promises that within the framework of reform the salary of physicians of the “first component” will increase. The Ministry of Health even made a table of future incomes.
Proceeding from this table, for example, a family out-patient clinic serving 2000 patients will gain an average income of 35,000 hryvnias a month. From this sum 9,081 hryvnias will go for diagnostic tests, expendables, and the depreciation of equipment. As a result, there will be 25,919 UAH a month for salaries and other operating costs of medical practice.
It isn’t clear, however, how many people have to work in such an out-patient clinic and between who this money will be shared.
3. “The money will follow the patient”
Concerning the financing of the healthcare system, ideologists of reform give simple examples. For example, a person is registered in Vinnytsia, but lives in Kiev. This means that the money will go not to Vinnytsia, but to Kiev, to that out-patient clinic where the specific patient goes.
In the first component the principle will be introduced that money goes towards the number of patients who address the specific doctor, and not for the number of visits of patients.
Within this direction it is provided to create a National Health Service of Ukraine, which will organize the process of distribution of this money. This body will be under the direct supervision of the Ministry of Health. Also, it will carry out both functions of the single customer of medical services and the function of control of observance of conditions of contracts on medical care of the population.
The service will sign agreements with all medical institutions working in the primary sector. What is characteristic is that it can be not only State out-patient clinics, but also doctors who conduct private practice or are registered as individual entrepreneurs. I.e., they too will be able to receive State financing to render the “guaranteed package” of medical services.
In addition, the means of medical subvention (in 2017 this sum was 55 billion hryvnias), which currently go to local governments, will be transferred to these new bodies of authority. Supporters of reform say that it will allow to win against corruption.
Critics of the reform say that the regional withdrawal of medical subvention will lead to a reduction of financing of medical institutions with their subsequent closure, and the privatization of rooms and land plots. Apparently, all means will be redirected for “kickbacks” in “their” clinics.
4. Medicinal revolution
One more innovation concerns medicine. For a reduction in the cost of medicines, the launching of reimbursement is planned – the cost of medicine for three categories of patients will be compensated: diabetics, people with cardiovascular diseases, and bronchial asthma.
The State already tried to compensate the cost of medicine for hypertensive persons. The project involved municipal pharmacies and private networks. The program managed to cover 80% of patients, who had the opportunity to buy medicines with essential discounts. However, the project failed because the State ran out of money for it. The debt to pharmacies reached 4 million hryvnias.
Since April 1st of this year the government started the project on the reimbursement of medicines for the treatment of cardiovascular diseases, diabetes of the II type, and bronchial asthma. As was planned, the right to apply for partial/full compensation of the cost of medicines in pharmacies was received by 13 million people. However, in practice the implementation of the project was difficult. For example, 157 medicines were entered in the register of trade names of medicines, and for compensation in pharmacies no more than a third received it. Not all pharmacies agreed to participate in the program.
The biggest problem with receiving reimbursement for medicine arose in rural areas. Financing of the program of reimbursement was also negligible. In the budget for this year 38 hryvnias are planned for one patient. Thus, the need for medicine, for example, for hypertensive persons is about 500 UAH a year on one person.
Now the Ministry of Health threatened to aim for not only partial, but also full reimbursement. Whether there will be money for this great idea – is another question.
5. The introduction of clinical protocols
Clinical protocols are standards of treatment of diseases on the basis of clinical supervision created on the international sample. Unlike the current standards in Ukraine that tacitly assumed that doctors have to do everything possible to help patients, in the international practice there is no requirement for physicians to try their best.
For example, a doctor can independently make the decision to visit a patient, proceeding from the complaints of the patient. Nobody can force the doctor to go to the house of the patient, he can suggest to the patient to attend an appointment independently.
Or another example: in the European practice, after waters broke or contractions began, the woman, who in most cases is giving birth, will be told to reach the maternity hospital by herself. In Ukraine the ambulance can still quickly bring the woman in labor to the maternity hospital.
Supporters of the reforms speak about the end of corruption
“Reforms will have a wide range of opponents to face: bribe takers in hospitals and medical universities, pharmaceutical lobbyists and unfair distributors, functionaries, who retain rooms and beds, Deputies who don’t want to take unpopular steps and hide behind rhetoric about the inadequacy of the laws, or the imperfection of accounting,” wrote Ulana Suprun on Facebook.
The department even published colourful pictures about those who oppose the reforms.
Olga Stefanishina, the executive director of charitable foundation “Patients of Ukraine”, urging parliamentarians to vote for reform, said: “Now Deputies have a historical chance to change it and to vote for the reform of healthcare, which will clean the black cache in hospitals and will provide patients with the guaranteed free treatment that currently isn’t present. For this reason we urge each People’s Deputy to fulfil the duty and to vote for the health care reforms”. The Ambassadors of the “G7” countries (the US, Japan, Germany, Great Britain, France, Italy, and Canada) also supported the reform of health care in Ukraine.
Why criticize the reforms
Many Deputies oppose the reforms in their current form.
“The adoption of these bills will lead to a reduction in the availability of medical care to most of the population, which in Ukraine is below the poverty line,” said the member of the parliamentary committee on health care questions, the Deputy from the “Opposition Bloc” Tatyana Bakhteeva in comment to “Strana”. “In the government bills there are no guarantees of receiving medical care by needy citizens, pensioners, veterans, Chernobyl veterans, disabled people, orphan children, internally displaced persons, and many other categories of the population who need frequent or long-term treatment, and also have no financial possibility to pay by themselves. Such guarantees are clearly written out only concerning participants of the anti-terrorist operation. All of this will lead to an increase in morbidity, disability, and mortality among the population of Ukraine”.
Oleg Musiy, the Minister of Health in Arseniy Yatsenyuk’s government, and nowadays – a Deputy from the Bloc of Petro Poroshenko – also agrees with his colleague.
“The Ministry of Health feeds society with myths that are discredited before our eyes – the number of doctors is reduced, ‘money follows the patient’ can’t be possible, because there isn’t any available, medicines became unavailable, I don’t know how anyone can call the new bills of the Ministry of Health social,” he said.
The parliamentarian on Facebook even gave answers to 23 popular questions about the four bills within the framework of medical reform.
Here are only some of them:
- “Is it in the Constitution?” No. In the Constitution there is no mention of a “guaranteed package of medical services”.
- “How are the purposes and purposes of medical care outlined?” They aren’t specified. Reference points for the development of the system are absent. Responsibility for the results of reforms is offset.
- “Who is the subject of the guarantees, who is the object? Where do patient stand?” The subject of guarantees is the National Agency of Health. The object of guarantees are healthcare institutions (?!). It is unknown who the citizen/patient is in this system – only the means to receive the money.
- “How will tariffs for medical services be formed?” On the basis of the “detailed description of the service”. What this is, isn’t known, the science and practice concerning this are absent.
- “The rights and responsibility of institutions are specified?” Concerning this, nothing was specified at all.
- “The rights and responsibility of patients are specified?” It is specified. The patient is absent in the system of legal relations proposed by the bill, and isn’t responsible for anything.
The president of the All-Ukrainian Council for Patients’ Rights and Safety Viktor Serdyuk considers that the Verkhovna Rada is on track to collapse the healthcare system in Ukraine, and not to its reforming. “Imagine that a patient with intestinal bleeding needs to travel 200 km for a colonoscope, which at this time can be repaired. The patient will unambiguously die in rural areas, in a district hospital. The initiatives of the Ministry of Health concerning the conclusion of contracts with doctors of the primary component will be negatively reflected in the quality of the provided services. Doctors who independently choose for themselves patients and sign contracts with them will choose for themselves the young and healthy, and children, pregnant women, and old men will remain without medical care,” notes the expert.
Also the Ministry of Health’s announced reform of the ambulance service underwent criticism. The aim is to reduce the time of arrival of the ambulance from 15-20 minutes to 4-8. For this purpose there is a plan to expand the network of substations, and also to employ paramedics – especially trained hospital nurses-volunteers who will give pre-medical help until the patient is taken to hospital.
The interlocutor of “Strana” working 20 years in the “ambulance service” made a helpless gesture concerning the question about this part of the reforms.
“Take for example a patient with stomach pain. Where will they be taken by a paramedic without medical education or who hasn’t completed a course? To the surgeon? To the gastroenterologist? To the gynecologist? To the nephrologist? Or, maybe, straight to the mortuary? Or other example – a patient complains of dizziness and a headache. Paramedics will anaesthetise them and leave. On whose conscience will this remain? Those who will want to live, will be compelled to call an ambulance from private clinics. These cost at least 1000 hryvnias. Such is the reform”.
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