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Healthcare reform: What new authorities should pay attention to?

Author : Oleh Titamir

Now Ukrainians are interested in how exactly the new government will restart state medicine, which until recently was in a terrible post-Soviet decline
11:31, 13 August 2019

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After the snap parliamentary elections, it became possible to completely reboot the authorities at all levels. Already today it is obvious that the political team of President Zelensky will be fully responsible for the economy and social sphere. At the same time, many people are interested in how exactly the new government will restart state medicine, which until recently was in a terrible post-Soviet decline. And most importantly, will Ze-team take into account the mistakes of their predecessors and will it ensure real, not nominal, access to medical services?

New power - new uncertainty

From the signals that come from the political force of Zelensky - the Servant of the People party, it is known that the government will continue medical reform. However, the format is not clear. Will the changes be implemented, as before, on three levels, which are primary medical care, secondary specialized medical services, and free diagnostics and highly specialized medicine? Or the power will choose a different format? Or maybe they will introduce some other model of state insurance medicine, in addition to the current one?

From the side of the new team, rather abstract positions were voiced regarding the reform of the medical sphere. So, leader of the party Dmytro Razumkov, not expressing any specific vision, emphasized the need for a comprehensive audit of medical reform and introducing changes. Like, on the basis of this, one must either leave the status quo or adjust the reform. Most likely, they will choose the latter, since Zelensky still admits that in this form, as now, medical reform does not suit a significant part of Ukrainians. Attention is also focused on its halfness and lack of effectiveness because the access of citizens to effective medical care is still extremely unsatisfactory.

And here we can agree with this position: to be frank, most of the "free" services under the Constitution are still paid out of the pocket of citizens. And the vast majority of Ukrainians are sorely lacking funds to get help in the field of highly specialized medicine. And there is no need to talk about the quality of state medical care for patients from rural areas: a significant part of the elderly are simply not able to get to medical facilities for several tens of kilometers. Hence, one of the highest mortality rates in Europe.

The position of the new power regarding the model of state insurance medicine is also far from certain specificity. As a presidential candidate, Volodymyr Zelensky noted that the transition to insurance medicine is an essential component in healthcare. At the same time, “the patient must determine the insurance program himself,” and for the poor, the basic level of insurance will be paid from the state budget.

In the election program of the "Servant of the People" political party, the intention to introduce a system of "compulsory medical insurance" is extremely succinctly expressed. However, which model will be taken as a basis - the British (which was chosen by the ideologists of the current medical reform), American, German, Israeli or some other – there is no information about this. It is also unknown which structures the insurer will be entrusted with - the National Health Service of Ukraine, a separate state insurance fund (such as a pension fund) or the private insurance sector. In addition, the vision regarding the sources of financing of health insurance is in no way disclosed.

In addition, Razumkov recently said that insurance medicine can only concern officially hired workers, to whom enterprises will pay for insurance. But as for the risk group - children, disabled people, and elderly citizens, their insurance will be paid by the state. The rest will be provided with a guaranteed package of medical services, Ukrainians will pay for other highly specialized treatment from their pocket. Regarding the sources of financing, there is currently no comprehensive vision, as well as regarding the specific model of insurance medicine.

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Of course, it cannot be ruled out that certain expert groups from the Servant of the People are already working on a detailed strategy and plan for medical reform (although it is not yet clear when, by whom and how the audit mentioned by Mr. Razumkov will be carried out). In any case, it will be useful now to identify the most sensitive and weakest places in the changes implemented by the predecessors, so that the current reform team would not repeat their mistakes.

Medical reform: benchmarks

It’s already clear today that the president’s team is facing an extremely complex task - to make the medical reform successful, namely, that Ukrainians have free access not only to the services of a family doctor but also to quality diagnostics on the best equipment, and if necessary, so that they can undergo highly complex and diverse surgical operations. And all this for the cost of the insurance funds, which in one way or another will be formed either from taxes or from contributions paid by Ukrainians.

However, all these changes encountered a number of obstacles, which mainly stem from the low level of state top management, significant miscalculations in the planning of all stages of medical reform, and especially from the lack of a realistic and balanced estimate of the reform (at the level of understanding from sources to take financing not only for each stage of the reform, but also for each component and step). Moreover, this applies not only to the national levels but also to the local ones: primarily because medical changes are not correlated with the decentralization reform.

In my opinion, the benchmarks of medical reform, which should first of all be mentioned by potential managers of the state medical industry, are as follows:

- Firstly, the biggest problem of medical reform today is the disruption of the introduction of the second level - the organization of the secondary (specialized) link on the principle of "Money goes after the patient." We are talking primarily about such an important component as "Free Diagnostics", as well as the introduction of electronic medical books, directions, and sick leave. These changes should be introduced from July 1 of this year, including payment by the state of 50 diagnostic procedures (a number of tests, X-ray, ultrasound, mammography, echocardiography, biopsy, etc.). 2 billion UAH (79 million USD) was provided for this from the state budget. But! Cabinet failed "Free Diagnostics", taking 1 billion UAH for the needs of primary care. By the way, here everything is not all right. More than a third of Ukrainians have not signed declarations with family doctors. Shouldn't I say hello here to the Ministry of Health and local authorities, which did not pay due attention to the informational and explanatory component? What can I say about the fact that the primary link did not have enough funds allocated earlier. In addition, the failure of the “Free Diagnostics” is directly related to the infrastructural and technical unwillingness of medical institutions to connect to the e-Health National Electronic Health System. In other words, there is a huge problem with hardware and software (and what kind of electronic medical books and sick-lists can we talk about here?). Worst of all, it is not yet known when the secondary level of medicine and the "Free Diagnostics" will finally work. Actually, here we are talking about the inaction and irresponsibility of the still existing "Groysman government." Ukrainians will continue to pay for tests from their own pockets. Consequently, the new power team needs to ensure the implementation of the law "On State Financial Guarantees of Public Health Services" as soon as possible. As a matter of fact, it is necessary to legislatively secure the budget items regarding the financing of all stages of medical reform. And on the other hand, to draw up a comprehensive financial estimate to provide all medical institutions of the country with high-quality information and technical infrastructure that works according to the most modern algorithms. At the same time, specifically identify diversified funding sources;

- secondly, this is an unsatisfactory tariff policy that creates obstacles to the full involvement of private medical institutions in providing guaranteed medical services to Ukrainians. Here are the prices the Ministry of Health has previously proposed for private clinics: the cost of 12 tests is from 29 to 120 UAH (from 1 to 5 USD), x-rays are 82-134 UAH (3 – 5.5 USD), the cost of endoscopic procedures and interventions (including punctures and biopsies) is 195-1975 UAH (8 – 79 USD). According to some heads of private medical institutions, such prices are too low, and some tariffs are almost 6 (!) times lower than the cost. According to some state prices, even municipal medical facilities cannot work profitably! Or someone will work with such prices? In the end, in order to fail medical reform, the best “budget” approaches cannot be found. Therefore, first of all, the Ministry of Health should set realistic tariffs, based not on the data of the municipal institution, but on the average market estimates of private clinics. To do this, at least it is worth going to the "Doc.ru" medical portal;

- thirdly, this is the lack of motivation to attract graduates of medical universities to work in state and municipal clinics, not to mention highly qualified doctors. This problem is especially noticeable in the regions - at the level of district medical institutions and even in some regional centers. For example, in Cherkasy out of 48 necessary pediatricians, there are only 35. According to preliminary estimates by the Department of Health, about 10 000 children remain in the regional center without a contract with a doctor. Therefore, the state needs to create a motivation package for graduates of medical universities in order to attract them to work where there is a shortage of personnel. This is especially true in remote areas. The local government should provide young professionals with temporary housing and official vehicles, equip their offices with modern equipment, possibly pay extra funds for salaries from the local budget. For these doctors, it is also worthwhile to establish a special work experience. Otherwise, the quality of personnel in regional clinics of the “depressed” regions will remain at the level of the Soviet period;

- fourthly, this is the inconsistency of local medical reform in the context of decentralization processes, especially the low ability of local budgets to build new clinics and hospitals or to overhaul existing ones. For example, during a recent visit of President Zelensky to Boryspil, it turned out that the city hospital is in a state of neglect because the city and district authorities cannot determine who of them should finance the repair. Hence, the lack of adequate access to quality medical services for a significant number of citizens from the Ukrainian outback. Sometimes villagers (especially the elderly) need to travel more than 50 km to get to the nearest polyclinic or hospital in the nearest center of the territorial community. Of course, local budgets, as a rule, do not have the financial ability to create modern medical infrastructure there;

- and, finally, fifthly, this is the long-term uncertainty of the model of insurance medicine, from which medical services of the second and third levels would be covered. Today, Ukraine has a British quasi-insurance model, according to which every citizen is considered "insured" (domestic medicine is financed from general taxes (VAT and excise taxes)). The state allegedly guarantees for all a certain set of medical services that it can cover as part of its economic viability. The practice has shown that the latter value is very low, and these "abilities" cannot fully finance even the primary link in medicine, let alone specialized, and especially highly specialized medicine. That is why it is necessary to create a system of differentiated (multichannel) financing of medicine. For example, to cover the cost of specialized medical services and third-level extra-complicated operations, it is worth introducing mandatory (joint) state insurance, the operator of which may be the National Health Service of Ukraine. The insurance fund (according to the German or French model) must be filled in part by the employer and employee. Together, this can be 10% (with a simultaneous slight decrease in the unified social contribution and personal income tax). At the same time, it is necessary to increase the share of allocations of GDP to the health budget from 3 to 5%. Today it is already obvious: without a good model of insurance medicine and a solution to the problems listed above, there can be no talk of any guaranteed package of medical services and their quality for the Ukrainian consumer.

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