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In Shargorod, Vinnytsa region, the protests against health reform in terms of the creation of hospital districts do not stop for several weeks. Protesters blocked one of the roads and threaten to block the railroad. Mass protests were held in other cities of the region - in Kazatin, Ilintsi. January 26 regional council of deputies, heads of regional councils and Health Department representatives set up a working group to study the issue of hospital districts. At the first meeting the group decided to prepare an appeal to the Cabinet of Ministers with the requirement to suspend the reform.
Why people are scared in Vinnutsia, why they go for protest? Firstly, the fear of closing the existing hospitals. In addition, people do not agree with the boundaries of hospital districts. Sharhorod, for example, is attached to a district center in Mohyliv-Podilsky. It is a city on the border with Moldova. And people need more than an hour to get there.
We tried to figure out what does it mean and how this reform is running. And most importantly, do the fears of protesters have enough ground.
Hospital district: what’s that?
The reform was launched November 30, 2016 at a meeting of the Cabinet. Then, few people (except for doctors, of course) drew attention to Facebook post of associated Health Minister Ulyana Suprun.
"This is a day of victory, - wrote Deputy Minister Pavlo Kovtonyuk. The government officially defined the vector of medical reform and confirmed its priority..."
The package of documents also included a resolution on the formation of hospital districts - № 932. This document envisages the creation of inhabited locality as a rule, a city with a population of more than 40 thousand man. The center should have an intensive treatment multi-hospital of the second level. It means the healthcare institution, which allows the provision of specialized medical care in hospitals, day hospital or outpatient conditions for adults and children in a state of acute illness or chronic disease. With the mandatory emergency assistance.
District is formed in such a manner that it would take an hour to get to the hospital from the nearby towns.
The hospital must ensure the provision of medical care is not less than 200 thousand persons. At the same time, a temporary gap in the document is not updated. Well, 200 thousand people per year or per month is not the same thing.
Why do we need hospital districts
For optimization. The authorities try to explain every problem connected with the hospital districts with this word. Even the text of the order states that the decision (creation of hospital districts) would "optimize the resources of health institutions and create conditions for more efficient use of budgetary funds, which are directed at ensuring financing secondary health care."
Myroslav Pyttsyk, executive director of the Association of Ukrainian Cities, have described the essence of the reform. "This year budget this year provided 55.7 billion UAH for the medical sphere. If you divide them between all the institutions, we would get what we used to have, that we have, we will have what we had. It means our hospitals in their current form - with outdated equipment, walls, techniques, apparatus, where patients have to provide self-medication, even buy saline syringe and film for X-ray. But if we will concentrate resources on districts…"
"The problem of Ukraine is that hospital beds in hospitals are distributed nominally. In the Sumy region there is a maternity ward in the district hospital. I asked them how much services they provide? It turned out that 11 per six months. This means that the doctor sees some childbirth every two weeks and there is a question – is it a doctor?” noted Health Deputy Minister Kovtoniuk.
Thus, according to Ministry of Health, after the district with the central hospitals for them, as well as long-term plans for their local development will be approved, it will be the time for "phase of attracting investment, including government, the implementation of these plans." "The following year, it is necessary to develop a master plan for hospital districts, to develop the network, because the main thing is not the definition of administrative boundaries. It is necessary to draw up a list of priority hospitals, roads, into which the state will invest in the next 5 years," he says.
The state would not have more money for medicine in the near future, but it should distribute the current budget more efficiently.
The ultimate goal of this whole project sounds, by the way, very reasonable. The implementation of further parts of medical reform, carried by Ministry of Health (it implies a change in financing of medical institutions, and payment of the implementation of the work of medical workers to transfer to the health insurance system) should ultimately lead to the fact that "the money will be used for the service - that is, hospital beds serve the demand."
But this will be in the distant and bright future.
Today, there would be hospitals, which have priority and those which do not have it. And what will happen to latter and to the staff who work in these hospitals now?
Judging from the responses of officials, they have no clear idea of what should happen with the agencies, which fell into the category of non-priority.
The only thing they say is that none of the institutions will not be closed. In particular, it was stated by Deputy Prime Minister Gennady Zubko.
According to article 49 of the Constitution, the existing network of health care institutions cannot be reduced, officials emphasize. No one will close them, but they be redeveloped.
The issue to be decided by the local authorities, communities.
"In small towns, we do not have a great need for surgery, but there is a need for rehabilitation services," says Zubko. Because, according to him, for example, a man with heart attack, stroke, should be operated in a large regional hospital. But when he returns to his small town, he needs rehabilitation services.
It turns out that the surgeon must retrain as a nurse? Or is it better to leave him out of town, where his services are not in demand?
It should be noted that Zubko and Ministry of Health officials have put forward more original ideas and retraining just such non-priority hospitals. For example, the creation of a hospice, even the center of social services, nursing homes, diagnostic centers.
Perhaps one of the most realistic ideas is the creation of an office for the family doctor (the therapist) on the basis of the current establishment. The only problem is that all this is pronounced by the officials "from television", but the Ministry of Health does not create the basic documents that would regulate the issue of conversion, the further fate of the hospitals, defined as non-priority.
Perhaps one of the most seemingly realistic ideas is the creation on the basis of the establishment of an office for the family doctor - the therapist.
Indeed, these documents that would regulate the procedures, conditions, terms of conversion of non-priority recognized hospitals, does not exist, agrees to the head of outpatient department in Hluhiv specialized psychiatric hospital Evgeny Skrypnyk. According to him, despite all the efforts of the local community, Hluhiv Central Regional Hospital was denied to become interdistrict department of hemodialysis. The Ministry of Health has approved the district center in Shostka. "And what to do with the equipment of the maternity ward, hemodialysis? Transfer it to Shostka? There are no regulations governing this?" says Skrypnyk.
And the staff? Doctors say that even if they take someone for a job, it might be a person who lives very far from the hospital, and this person would spend all the wages to get to a working place.
Problematic hospital districts
Not only Vinnytsa region has faced the problems with the hospitals. There are cases where people create “gerrymandering” conditions, trying to bring the medical center to their administrative district. There is a confrontation with the heads of district councils, who do not fully understand the essence of the reform.
Sometimes officials do for compromises. As an example, like in Odesa region.
"Odesa region had two strong territorial districts Balta vs Podolsk (two cities, each of which had a hospital, one of them should become central one, while the second, of course, non-priority). Podolsk has a historically strong base, Balta is dynamically developing. It was decided to leave these two hospitals, which will compete for the patient," says Kovtonyuk.
"Here, in the case of Balta, the Ministry of Health made an exception, and in our case (with Hluhiv district hospital) - no way," complains Eugene Skrypnyk.
According to him, the center Shostka was chosen because its population amounts to 76 thousand, and in Hluhiv, there are 35 thousand people.
MP Serhiy Rudyk, who defends the creation of a hospital district center in Smila, Cherkasy region, also came to a press conference with Zubko.
"Ministry of Health have voiced regional authorities the precise number of hospital districts. Four. Cherkasy regional state administration, in turn, expressed its "vision," on the basis of which towns district hospitals should be created. Proposal which, in fact, has already been discussed, remains without attention. I mean to create one of the hospital centers on the basis of Smila," wrote Rudyk on his Facebook.
After this, MP had a personal meeting with Prime Minister. It seems that medical reform uses a variety of methods in its dialogue - from blocking the roads to writing letters to the prime minister. According to the latest data of the Ministry of Health, 18 regions have already submitted the projects of hospital districts. In the near future, they will be approved by the Cabinet.
The Ministry of Health plans to form the district in all areas until the end of 2017. Also before the end of the year, it plans to form hospital councils in the districts and to prepare a 5-year development plans.
Overall, the proposed reform of the Ministry of Health appears to be quite reasonable and attractive. The devil, as we know, is in the details.
Will we see the queues in hospital corridors? Will be there enough hospital beds or in case of epidemics the patients will be put on mattresses in the lobby? Will corruption and bribery of doctors disappear?
Answer to these questions is no.
Ministry of Health officials tell about the need to break the Soviet trend, when 8 out of 10 people who applied with the complaints were sent to the hospital, while the other in the European countries everything goes the way around. Only two go to the hospital, and eight get effective treatment at home.
Will the villages and small towns have proper conditions for working professionals to determine whether the person does not exactly need a hospital? Would the mortality increase? Will there be more obscure diagnoses and neglected diseases?
Kovtonyuk himself says that good professionals might be in Ukrainian villages if they get the salary of 10-12 thousand UAH, an equipped workplace, comfortable housing, car, and so on…
"You pay money for services, which follow the protocol. And you will see that even the existing financing medical things can be different," says the deputy, noting that the treatment of, for example, pneumonia, on the principle of "reinsurance" costs in 4375 UAH, and implementation of recommendations of the "evidence" will cost only 160 UAH.
Doctors have many questions concerning that the ambulance should reach the patient for less than an hour. They excitedly called diagnoses for which the expectation within an hour can cost a person her life: acute peritonitis, heavy knife or gunshot wound, serious injuries in an accident, complicated by the rapid delivery.
Explanation of the Ministry of Health that 1 hour is the "gold standard for heart attack, stroke" did not convince. Person with this diagnosis should receive intensive therapy no later than in 60 minutes, says Kovtonyuk.
And if the hospital is 50 minutes away from the patient's home, from the moment of "oh, my heart", plus 2 minutes to call an ambulance, plus the time to register the call, plus 50 minutes of "emergency" in the way from the hospital to the patient... This is not the "gold standard". We should also take into consideration that the roads are in very bad condition.
By the way, Kovtonuk highlights that improving the quality of Ukrainian roads as part of the reform is predicted. But how exactly the road to the district hospitals will be improved, is not clear, and is not registered in any basic documents, setting out the obligations and guarantees of the state.