October 19 was the day Ukrainian Parliament adopted the new 2018 healthcare reform. Although it is still not completely clear how the nation’s health will be managed, some of the announced changes have already aroused debates and criticism among pundits and medical workers. Absence of certainty urges many to seek answers to questions uncomfortable for Ukraine’s current ‘innovative’ government and Minister of Health Ulana Suprun.
Ukraine has one of the highest mortality rates in the world with population decrease of about 6 mln people over the last 16 years. Cardiovascular diseases are called the main death cause amounting to 68% of the total statistics, while cancer holds the 2nd place with 18%. Even losses in the military conflict in the east of Ukraine did not change the overall numbers, yielding first positions in the rating to diseases, as well as deaths caused by alcohol. According to UN, Ukrainian population is facing a danger of losing another 10 mln people by 2050 in case the situation does not change. However, the new reform hardly offers an optimistic perspective, promising instead a set of neo-liberal novelties designed to create an image of system’s transformation by application of market strategy to healthcare.
Ukrainian State budget of 2017 allocated 3,7% of GDP for medical purposes, while international researchers believe the system needs at least 5% to provide necessary care. EU countries allocate about 10%, US have currently settled on 18%. Mandatory health insurance is typical for most western countries, which has inspired Ukrainian government to speak about introducing the same requirement. Today about 60% of people in the country live in poverty, the minimum wage is 3200 UAH (about 100 EUR)*. At the same time, basic annual health insurance package (including private medical consultation, examination, testing and emergency services) nowadays costs about 7 000 UAH (230 EUR). Corporate insurance will cost up to 20 000 UAH (660 EUR), whereas full service (including visual therapy, private nutritionist, massage, all types of surgery etc.) will surpass this amount. Ministry of Health predicts annual Social Insurance Fund incomes of 11 bn UAH (350 mln EUR) if obligatory health insurance fees will be set at 7-10% of salaries, granting medical services to officially employed workers and leaving all others (unemployed or self-employed) face-to-face with hardships of paid medicine.
Current Ukrainian Minister of Health Ulana Suprun
Former Ukrainian Minister of Health Oleh Musiy says reform implementation will cost Ukraine around 70 bn UAH (3,5 bn EUR), which is hardly feasible for country’s struggling economy. He also notes the shortage of family doctors, who according to the new reform will become the main link in the reassembled healthcare system. Today Ukraine has only 10 000 of them, while there should be at least 30 000, and this number can be achieved only in 8 – 9 years, even if all family doctors will be required to remain in the profession (decision made by only 30% out of 12 thsd annual undergraduates). Each family doctor will have to cover about 1,5 – 2 thsd patients (against current 1,2 – 1,5 thsd), receiving yearly 210 UAH (7 EUR) for each (420 thsd/year), which makes a gross salary of 35 000 UAH (1100 EUR) per month. If all associated costs (utility bill payments, salaries of other personnel) will be deducted from this amount, it only means that doctors will be paid even less than now, when most of them receive around 5000 UAH (160 EUR) working in public hospitals (and twice as much in the private ones).
Doctors will also face the risk of losing their jobs in the absence of patients. Meanwhile, cancellation of treatment ‘by the place of residence registration’ means too many people will be attracted to big cities with better qualified healthcare, leaving minor local hospitals with small or no hope to survive. Another problem is that regional medical institutions will be divided into ‘hospital districts’, each one consisting of one multipurpose institution plus polyclinics, resorts etc. E. g., if there are two neighboring large hospitals, one of them will be downgraded and turned into one of the mentioned institutions. The main hospital has to remain within the ‘golden hour’s’ reach, but many towns and villages do not have direct connection, which can create obstacles for patients traveling alone. No compromise for people without means of transportation.
Patients will be allowed to make voluntary donations through every hospital’s cashier’s desk, which is believed to eliminate corruption typical for Ukraine’s healthcare system. In reality, nothing will prevent people seeking more privileges from bribing doctors just like before. Incoming donations will be controlled by a new institution – the National Health Service responsible for funds and preparing the lists of free and paid medicine. The latter will be divided into 3 groups: 1) the green list containing free medication, 2) the blue list containing medicine co-funded by the state and the patient, 3) the red list containing medication fully paid by the patient. Surgical operations will be divided likewise, but with some exceptions for soldiers partaking in the ‘anti-terrorist operation’ on the east of Ukraine. Overall, paid manipulations will comprise only 20% of the total services. Such innovations are aimed at fighting corruption and replacing the ‘outdated’ free healthcare, which is said to be corrupted due to low funding resulting in low quality. From now on, everyone is required to contribute, but nobody in the government says about better state funding. Moreover, the ‘lists’ will be reassessed and edited every year.
Another target of the reform are the emergency crews. If now a typical crew counts 3 – 4 people (a doctor, a driver, a medical assistant and sometimes a nurse), it is planned to reduce it to only 2 members (a doctor and a driver, which has already become typical for some areas). This will change the purpose of emergency: instead of providing first aid locally, the patient will be taken to the hospital. What is left out of notice here is the quality of Ukrainian roads, especially in the province. Cues in the waiting rooms will only worsen the situation. Despite plans to equip the emergency vehicles with GPS trackers and improve the registration system, this does not solve the described issues.
The reform has to start working before 2022. Although all citizens were required to find a family doctor in advance, the online service launched by the government still has only 4 cities to choose from.
VECTOR:media previously published a healthcare reform-related article containing a set of theses by a law expert. Available to read here.
* current exchange rate is 31,5 UAH per 1 EUR