“Pay or Treat Yourself”: How Millions of Ukrainians Were Left Without Medical Care

Ukrainians who did not choose a family doctor before April 1st of this year go “off the books”. The Ministry of Healthcare made the decision ahead of schedule to stop financing the so-called “red list”, i.e., the patients who did not sign a declaration with doctors. As a reminder: last year 240 hryvnia was spent from the budget per “undecided” person (for patients with declarations – from 370 to 1,500 hryvnia, depending on the age coefficient). Since the beginning of this year financing was cut in half – to 120 hryvnia. It was planned to continue to make payments until July, but the Ministry of Healthcare suddenly made the decision to “shut up shop” earlier.

And although the ministry says that nothing terrible will happen, and Ukrainians without declarations will be able to receive further medical aid, the policlinics disagree.

As the Ukrainian “Strana” news agency managed to find out, in the last two weeks the Kiev residents who don’t have declarations and who saw doctors were frankly blackmailed in many capital clinics: it was as if they had to urgently sign a declaration or from April 1st go to private companies – nobody will serve you free of charge.

There is a similar spirit in regions too. “In principle, there is no state of emergency – people will still be able to come to policlinics and calmly sign a declaration. But those who will not sign one will not be served. It is, after all, reform,” said the mayor of the regional center of Gayvoron in the Kirovograd region Roman Voluyko.

Experts predict that a third of the country risks being left without medicine – citizens have to either go to private companies or pay state doctors from their own pocket. Plus – the financing of policlinics will sharply be reduced, and this calls into question the record salaries of doctors, who the authorities very much like to refer to as one of the examples of the success of medical reform.

What will happen to ill Ukrainians who don’t have declarations and who will treat them from April 1st?

With a cold and an inquiry – do not go

The draft of the scandalous resolution of the Cabinet of Ministers on the termination of financing for the “red list” from April 1st has not yet been approved. Formally it is being publicly discussed until April 7th. I.e., in fact, the timeframe specified in the document – April 1st – will obviously expire even before its acceptance by the Cabinet of Ministers.

But in fact this order is already in effect. And, as “Strana” found out from sources, all payments of the National Health Service for patients without declarations have been frozen. Doctors were also warned about the termination of financing for the “red list”.

And the Ministry of Healthcare comments on this decision as if it’s already a fact. Thus, most likely, the draft law will be approved at one of the next meetings of the Government.

In the explanatory note to the draft law it is specified that this year a sharp increase in the dynamics of signing declarations has been observed. Thus, in March almost on 816,000 more declarations were signed than in February, and in February 1.2 million more were signed than in January. Therefore, for the “purpose of the rational use of funds”, it was decided to cancel in general the payments for those Ukrainians who did not sign a declaration yet.

I.e., apparently the National Health Service is simply not able to simultaneously pay bills both the growing “green” (patients with declarations) list and the “red” list – there is a banal lack of money.

If in December of last year the National Health Service gave 14.4 million hryvnia to clinics, then in January it was 23.5 million, in February – 24.7 million, and in March – 25.5 million.

The refusal to finance the “red list”, according to the estimates of the Ministry of Healthcare, will allow to save more than 360 million hryvnia. In addition, “it will force healthcare institutions to sign contracts with the National Health Service or to look for other sources of financing,” it is said in the forecast of the impact of this document on the market.

As was explained by the Ministry of Healthcare, today a family doctor was chosen by 26 million Ukrainians – this is two thirds of potential patients. What is offered by the department of Ulana Suprun for the other third, and this is 13 million people?

“Firstly, nobody will remain unaided,” assured the Ministry of Healthcare. It also added: everyone will be able to visit a doctor. “From April 2019, a therapist or paediatrician will provide medical aid in a medical emergency to patients who did not select a family doctor. At the same time, the family doctor can suggest to the patient to sign with them a declaration. In order to use the guaranteed package of services at the primary level, the patient has to sign a declaration. Now your doctor is your point of entry in the system of medical care. For example, from April 2019 it will be impossible to get a prescription for ‘affordable medicines’ without a signed declaration,” noted the Ministry of Healthcare.

In fact, the ministry recognises – citizens who don’t have a declaration will be helped only in extreme cases, say, if there is a real threat to their life and health. For banal sniffling or complaints about indigestion it is even possible not to make contact, as well as for a medical examination, certificate, and so on.

But even with the promised help in an “medical emergency” there can be nuances. It is unclear who should provide it if, for example, therapists already have 2,000 patients, and there aren’t any “extra” doctors in the policlinic. It turns out that for many doctors such “non-payment” patients become a burden, with all that it implies – rudeness, negligent attitude, outright extortion of “gratitude”, and so on.

Therefore, it is possible that in practice doctors will refuse to give people assistance at all or will start to give it only for money. “In fact, the traditional situation is preserved – 100 people were received by the doctor, and they received service. Many citizens got used to it, therefore they are not especially indignant,” said the Vice Chairman of the Board of the Ukrainian Medical Society Konstantin Naduty.

However, it is a direct violation of the Constitution. “Article 49 of the Constitution is, after all, higher than any declaration. By the way, it, according to this article, is illegal in general. I, for example, live in Bucha and did not sign any declaration, and if I am denied assistance, then this is a violation of the Constitution. Let them prepare for legal claims,” explained the doctor, head of the Pharmaceutical Association “Lege Artis”, and business coach Alena Romanovskaya.

Konstantin Naduty also predicts claims from dissatisfied patients. “One high-profile judicial case is enough for the whole system will fall down. At the moment ‘reform’ is saved only by the patience of people, but it already is like a compressed spring,” considers the expert.

Forced to sign declarations urgently and blackmailed with medical aid

The unexpected changes in the system of financing, to put it mildly, did not please doctors. In principle, the fact that without a declaration patients will not receive reimbursement was known long ago, but medical institutions prepared for D-Day on July 1st. And the fact that it was moved to April 1st took many unawares.

According to the estimates of the head of the Council of the Kiev City Labor Union of Healthcare Workers Sergey Kubansky, in Kiev the centers of primary medical aid will receive less than 200,000-800,000 per month.

Now policlinics will receive less than 360 million hryvnia, and in order to patch this hole they need to urgently gather additional “paying” patients with declarations. And doctors already went on the offensive.

“I went to a district clinic with a complaint about a prolonged cough. I have no declaration. I stayed for two hours in a queue for the therapist until she had received all her ‘own’. The doctor offered to immediately draw up a contract with me, and when I refused, she began to shout that I will not be received free of charge, and she was told to not send people without declarations for an X-ray. The issue managed to be settled for 150 hryvnia, and for 100 more I was sent for an X-ray,” said the Kiev resident Zhanna.

Other residents of the capital also say that in the last two weeks doctors openly blackmail those who had the imprudence to come into a policlinic. They demand to urgently sign a declaration, threatening that they will not be accepted “free of charge”

The mayor of the regional center of Gayvoron (Kirovograd region) Roman Voluyko told “Strana” that they are also glad to help locals at the expense of the budget, but simply cannot do it now. “We allocated funds when there was a lack of insulin. But, firstly, this involves huge money, which is simply unaffordable for the local budget, and secondly, no one planned for such costs in the scheme of the budget”. He also confirmed to “Strana” that people will be able to come to a policlinic only on the condition of being ready to sign a declaration. Without it receiving the subsequent service is questionable. At the same time, according to Voluyko, 71% of the population signed a declaration.

There are about 13 million more people across all of Ukraine who don’t have a declaration. “On average, 20% of people in villages did not sign a declaration, and in the cities it is 30-40%. Most of all – in Kiev. Here about 5 million live, although 2.7 million are registered. Declarations were signed by 60% of registered Kiev residents, and less than 2% of non-residents signed one,” said Konstantin Naduty. Across the Kiev region about 60% of people signed declarations, the process is slowed down by an acute shortage of doctors – about 170 people.

Among those who refuse to sign a declaration there are many citizens who are not going to sign anything. “This concerns, firstly, believers who are frightened by any numerology with codes; secondly, those who do not want to expose their personal data to open access without any guarantees of confidentiality; and thirdly, different ‘problematic’ categories of the population. We will leave them as now, without medical aid? This is more dangerous than it seems at first sight. How, for example, to diagnose tuberculosis. It is known that this disease is in many respects social. Many patients will not come to policlinics, there aren’t any local or general practitioners, and such patients aren’t needed by anybody. We will see them when they are already in trouble, in the country there is already an epidemiological situation with tuberculosis,” notes the expert.

Ukrainians who are sharply against declarations, but can pay fir treatment, will simply go to private clinics or will bribe doctors of utility clinics. It is necessary to pay also those who will drop into a policlinic “for a minute” in order to “get permission to go to a swimming pool”, or “show one’s throat to the otolaryngologist”.

Salary or ultrasound machine?

If doctors do not succeed to “pressure” 13 million patients who don’t have a declaration, they will receive less than 360 million hryvnia. According to Konstantin Naduty, this means that clinics will have less money for updating their material and technical resources. “In fact, the ‘red list’ was perceived by many as some kind of investment. In this category patients are not really active and do not go to the doctor every day, i.e., the costs of serving them is minimal. Meanwhile, for this money it is possible to buy, for example, equipment. After all, when signing contracts with the National Health Service, many clinics lie – they do not have the foundations that the National Service insists on. In the institutions where the experiment of 2012-2014 took place, the situation is better, up to 70% of the foundations were updated. But in the others considerable investment is necessary,” said the expert.

Also, the record salaries of doctors that the authorities like to talk so much about can also be questioned. As a reminder: after the medical reform started, and family doctors gained 2,000 patients, many receive up to 20,000 hryvnia per month instead of the former 6,000-7,000.

But experts already warned that chief doctors can only pay such salaries by blowing all the money on salaries, and investing nothing in policlinics. With a reduction in financing the problem will become even more aggravated, so it is possible that the management of medical institutions will have to take unpopular measures and cut doctor salaries. Especially since the National Service announced checks and threatened to remove financing in general in case defects are identified.

“If financing for the ‘red list’ is removed, the salaries of doctors of state and utility clinics may decrease. At the same time, they will need to service ‘free’ patients. Thus, the essence of medical reform is negated – to equalise the rights of state, municipal, and private clinics,” notes Kubansky.

The main intrigue is what will happen if doctors nevertheless manage to pressure Ukrainians, who in turn in large quantities will start to sign declarations. If there is not enough money for financing according to the “green list” already now, then in the future the monetary deficit will only become worse. According to the “red list” patients pay at least three times less than those on the “green” one. For 13 million citizens, having decided to sign those declarations, the state will be forced to pay more than 4.8 billion hryvnia.

In this case, experts do not exclude that the National Health Service will simply cease to pay in time and debts will accumulate.

Lyudmila Ksenz

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