Ukraine’s medical system: Nocebo effect

Author : Yulia Samaieva

Source : 112 Ukraine

Allegedly, free medical care, on which the state spends about 3% of GDP annually, lies on the shoulders of the patients who pay for everything - from bandages and iodine to costly operations
20:10, 21 October 2016

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medical system in Ukraine
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Under-funding is daunting. Only pediatric oncology and rare diseases will be fully financed by the government programs (in the coming year), the other spheres will be lucky if they get at least some little funding. Medical state subvention traditionally covers only utility services and staff salaries. At the same time, doctor is one of the most low-paid jobs in the country. The budget of the next year shifts utilities and energy to local budgets - about 13% of medical subvention (46.8 billion UAH). The same local budgets are transmitted to the content of nearly 30 institutions under the Ministry of Health in the field of management, including a sanatorium for tuberculosis patients. The released funds will be used for 25-per cent increase in the salaries of medical staff, so that they reach the national average level in five thousand hryvnia. But the money, unfortunately, is not a major deficiency in the health system

A bottomless pit

Expert community actively discussed the issue of increasing funding of medicine due to the excise tax on tobacco and alcohol. Indeed, in many countries the tax for the "sin" finance health, because at some point, fans of this "sin" require more medical involvement than other residents. In the end, the state also creates the Road Fund, which will be funded by the fuel surcharge, so why not create a Medical Foundation, funded by excise taxes on tobacco and alcohol? Especially since these revenues are stable and from one year to grow - at the end of 2015 they exceeded 24 billion UAH, for eight months of 2016 amounted to nearly 35 billion, and next year from increased excise taxes are expected to increase by another 5.2 billion UAH. That is, in terms they may catch up with medical subventions. But the Ministry of Finance in no hurry to tie the article to income on health care costs. And in some ways he's right. The scope of medicine is not reformed for years, there is a huge underfunding, the system no doubt, would "utilize" 50, and 100 and 150 billion UAH, but the quality of services for the population will not increase. Pour any amounts in the current system of medicine - to put out the fire with gasoline.

Related: Ukraine to start introduction of medical insurance in 2017

"Health care is traditionally underfunded. This is a "historical problem," even in Soviet times, the need to allow no more than 3% of GDP. However, the majority of post-Soviet countries performed reform, and the figure they reached the European average level of the 6- 8% of GDP.  Ukraine in a quarter century has remained at the same level in terms of financing of medicine, that is, all the same 3%," says Deputy Minister of health Paul Kovtonyuk.

The state paid 3% of GDP on health care through taxes are collected from the same people who give another 3% of GDP to pharmacies and hospitals. And paying for medicine twice, Ukrainians live less, suffer more, and "free" medical care gets worse.

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Three-quarters of the money spent on health care, "from the purse", according to the deputy minister, is exclusively for drugs and often is not on medication essentials. No wonder that the largest share (about 70%) of the total cost drugmakers marketing programs falls on "the promotion of drugs to doctors." Physicians who receive in this country are among the lowest wages, is forced to go "on the second salary" from the distributors of pharmaceutical companies by "advise" the concrete manufacturer.

Ideally, the government would have to declare a guaranteed package of health services and purchase it from those who provide them. The citizen, in turn, should determine those who have these services need to buy, according to the principle "money follow the patient. This scheme operates around the world, and this principle should be declared at the ministry level and at the governmental one.

 The key to start?

Reforms in the Ministry of Health are announced, but not initiated. However it promises global changes. What is significant, the reform does not begin with a deep analysis of the situation and forecast of its consequences, and once with practical proposals.

Related: Ukraine stops life-saving medication supply to Russia

For example, from next year the healthcare system would become the insurance model. Already in 2020, the first medical insurance should work everywhere. Starting with the launch of the reform of family medicine "European model" based on the primary level of the system - health centers, clinics, and health care centers. According to the reformers, Ukrainians will be able to freely choose the family doctor and pediatrician for their children and sign them with direct agreements with a clear range of services, guaranteed and paid by the state. If the patient does not meet the family doctor, it can change him, as binding to a residence canceled. Family doctors will provide the primary diagnosis, if necessary, they might sent to further research to specialists, and among other things, to issue certificates to the kindergarten, school, swimming pools. Primary care physicians will be able to choose any form of organization of work. If a family physician decides to start in private practice, the payment will arrive to his account directly, without intermediaries. Technical operator budget will allocate money to a special insurance agency. Medical licensing procedure will be accelerated, building codes and health rules for opening a medical practice will be simplified and harmonized with the European legislation. Paper statements for primary care physicians will be abolished. Their work will be charged according to the norm (see figure below) depending on the number of agreements and compliance with medical protocols.

 But, according to experts, it would be difficult to implement this scheme in practice, because in order to calculate the guaranteed package of health services, we need to understand how the system annually spends on them now, and what services are provided. But we have no real statistics on the number of services provided by the health system. The current data is artificially inflated and distorted. Clinics, of the same "financial" reasons, tried to "fulfill the plan for consultations."

Related: Ukrainian diaspora sent the medical equipment to Kyiv hospital

Indeed, no matter how much money is poured into a medicine, these expenses are not effective without prevention programs. Beginning with primary health care reform, responsible for prevention and early detection is the right step. It is no secret that prevention of a disease is cheaper than the cure. For example, the cost of a course of treatment of the patient with a mild form of tuberculosis is 870 UAH, and the cost of the course of treatment a patient with MDR is almost 40 thousand UAH.

 But at the primary level, the reform will require a minimum of material to support the costs, as we are talking about structural changes in the field, where often basic necessities are in lack.

Bloodthirsty "pharma"

The Ministry of Health also plans to launch a reimbursement from January 1, 2017. This will create a list of essential drugs (in accordance with WHO recommendations), which will contain drugs having a reasonable evidence base to its efficiency and international protocols included in the treatment of patients. These drugs will be introduced reference prices and their cost will be reimbursirovana that is recoverable. The main priority of the introduction of reimbursement in 2017 will be the treatment of diseases, which primarily affect the basic indicators of population health and effectively treated at the outpatient stage: cardiovascular diseases, diabetes Type II diabetes, bronchial asthma - a total of 22 drug.

In order to reduce the cost and increase the availability of medicines, it is proposed to simplify the access to foreign currency purchase of medicines importers and stabilize the possible currency risk (nod imported pharmaceutical business). In addition, the VAT on medicines and medical devices is reduced to 2-5% (a nod to the domestic pharmaceutical business). Wholesale and retail margins be limited in the form of regressive margins: the higher the price, the less is the margin.

Related: Japan granted Ukraine $335,000 on educational and medical projects

Reimbursement operates as follows. For example, the proscribed drug in the pharmacy costs 100 UAH, its reference price in this case is 85 UAH. The patient, giving the pharmacist a prescription, pays only 15 UAH difference in cost, and the pharmacist for a prescription reimburse the remaining 85 UAH from the state budget. Naturally, distributors oppose reimbursement least because they need to pay now, and get the money would come sometime later.

On the one hand, manufacturers can push the list of "his own" products, on the other hand - pharmacies can put sticks in the wheels of reimbursement as they are interested in how to get the money now, not later. Considering that the pharmaceutical business is a network, and cartels in it as often as in the pharmaceutical industry, to manipulate the market and put on the cross reimbursement is simple. Analyzing the results of the pilot project on reimbursement of drugs for hypertension in 2013, you can see a whole bunch of corrupt system diseases.

Here is collusion of producers and abnormal increase in the number of prescriptions by 2.3 times (15-20 "hypertonic" prescriptions per day per doctor), of which only 40% fell into the pharmacy, and defies logic coverage of patients, and blocking project-level distributors to whom growing budget debt. All this led to that of the 1.2 million "official" hypertensive 700 thousand. The privilege of the state as a result and has not taken advantage of it. Yes, it indicated in the outcome of the project, that the consumption of antihypertensive drugs in daily doses increased by 54%. But the increase is only on paper.

Related: Poland grant 230 thousand EUR for medicines for Ukrainian IDPs

 After all of the 24 million prescription by doctors state partially offset recipes only 11 million. At the same time all the selected state for reimbursement funds have not been spent, and total savings for patients in Kyiv region, for example, accounted for as much as 20 UAH per year.

But the main challenge faced by physicians during the "pilot" reimbursement is the lack of reliable statistics on patients to provide them those or other medical services, the needs for services and medicines. In this same problem will rest sooner or later, and the rest of the medical reform in the country.

The Ministry of Health reform initiatives are most confusing in terms of the lack of understanding of these problems and the desire to start with them. Without an objective analysis of the current situation, agency officials say everywhere that they have begun the reforms would not require any legislative changes or additional funds, they say, the main thing to start, and there and collect data and define the needs. That is why the Ministry proposes to start reform in three months, but does not mention a specific list of services that will be available to patients at the primary level, their cost and the number. Why the Ministry of Health does not explain the essence of the future changes neither to the doctor nor to the patients? And is it possible to believe in the success of these initiatives, with the sad years of experience of similar reforms in medicine? This is a nocebo effect when negative expectations ultimately dictate the outcome of the experiment.

Related: The Military Medical Clinical Centre of Western Region hosted 150 specialists from Ukraine, Canada, and the United States.


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