The second stage of Ukraine's medical reform started on April 1. A month later, President Volodymyr Zelenskyy said that it was necessary to "preserve all the positive aspects of this reform" and "urgently correct the mistakes."
The Ministry of Health, on behalf of Zelenskyy, decided to "modify" it, because "in the form in which we received it, it does not provide anything good for either patients or doctors." Ulana Suprun, the former health minister who started the reform, has already called that decision a "cowardly step into the past."
So why is the reform we have now not good enough, and how does the government want to improve it?
What is the essence of medical reform?
Allow us a brief digression: the reform in Ukraine consists of several stages, according to the number of settings of the medical system. The primary setting is the doctors Ukrainians turn to when it is not clear what they are ill with: a therapist, a family doctor, a paediatrician.
Ukrainians had to sign declarations with family doctors. What are the benefits for patients? The ability to make appointments online, order medication, and what’s more a family doctor should know everything about their patient and understand the history of their illness.
What are the benefits for the doctor? Their salary will depend on the number of signed declarations (i.e. on the doctor's reputation). At the end of January 2019, out of the expected 4-5 million by the Ministry of Health, a whopping 25 million Ukrainians have concluded agreements with a family doctor.
The secondary setting is specialized doctors: surgeon, gynecologist, rehabilitation specialist. It was the reform of this link that started on April 1. The idea is "money follows the patient": you will choose your own hospital, and the medical institution will receive as much money as it has patients. This should have stimulated hospitals to buy modern equipment and hire good specialists.
The National Health Service of Ukraine will pay for the services at special rates. These services will also be provided in packages. Which of them will be free and which will not, depends on how much will be allocated for medicine in the state budget.
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The reform does not stipulate closure of hospitals or the reduction of a number of doctors. However, if the institution is uncompetitive, doctors are unprofessional (this does happen), no one will turn to them and such hospitals will not get money. As of April 1, 2020, the National Health Service has signed contracts with 1,524 hospitals, which is 90% of all facilities that have submitted their proposals.
The tertiary setting is high-tech assistance and special single-discipline services. For example, outpatient and inpatient treatment that requires complex procedures. After the implementation of this reform, patients will be hospitalized not at the place of residence, but where the family doctor will refer. It should be completed in 2020-2021.
MPs at a meeting of the parliamentary committee on health on March 13 decided that the reform was successful. At the time, they were considering a bill from the Opposition Platform – For Life party calling for the end of medical reform. The chairman of the committee, Mykhailo Radutsky, reported on the analysis of the reform, "which showed that the reform of the primary setting of medical care was successful, as well as the actual readiness for the reform of the secondary phase," according to the Verkhovna Rada's website. As a result, deputies voted against the initiative to abolish medical reform with 9 votes out of 10.
What are the complaints about the reforms?
"The medical reform in its current form means the dismissal of about 50,000 medical workers and the closure of 332 hospitals," said Health Minister Maksym Stepanov. Both he and his followers stress the need to mitigate the impact of the reforms on doctors, as they are hurt by the changes and quit.
"If nothing is changed, the mass quitting will lead to a catastrophic increase in mortality, the rapid spread of diseases such as tuberculosis," says Stepanov. It is worth clarifying that Ukraine is still among the leaders in Europe in the number of TB patients.
Health Minister Maksym Stepanov said the government had decided to "modify" health care reform and "mitigate the impact of the reform on doctors." The photo shows President of Ukraine Volodymyr Zelenskyy (left) and Minister Maksym Stepanov in the Parliament Hall on the day of his appointment, Kyiv, capital of Ukraine, March 30, 2020. Photo: UNIAN
What is Stepanov's plan?
He sums it up as"save everything valuable, but correct mistakes":
- From June 1, the State program of medical guarantees will additionally fund new packages (primary care; emergency care; acute myocardial infarction; acute stroke in hospital; as well as four packages for the treatment of COVID-19).
- From July 1, the salaries of doctors will be increased (this requires an additional 11 billion hryvnias ($409 million)).
- From May 11, a detailed examination of the entire medical infrastructure will begin to determine the capacity and efficiency of the hospital network.
- From May 11, the Ministry of Health will develop new state standards for medical care with the involvement of scientists and leading experts in the field.
- From 2021, new medical tariffs will operate, which will be based on market wages for industry workers and quality standards for medical services.
In almost every point, Stepanov proposes to increase the salaries of doctors and set more expensive tariffs for services provided by hospitals. This will be paid for by the National Health Service of Ukraine. MP Radutsky also decided to support Stepanov (despite considering the current reform a success just two weeks ago): “We call on the government and parliament to reconsider the amount of funding for medicine. We understand very well how difficult it is to find additional funding in a crisis. But today medicine is our second front."
Radutsky also says that it is necessary to introduce a system of professional liability insurance. He notes that most medical errors are not due to unprofessionalism, but due to poor supply and old hospital equipment, so it is necessary to insure doctors, otherwise they start resigning.
Mykhailo Radutsky, the chairman of the Health Committee of the Verkhovna Rada, supported the current Minister Stepanov in changing the course of reforming the healthcare system, even though two weeks ago he considered the reform a success. The photo shows Radutsky on the sidelines of the parliament, Kyiv, Ukraine, March 3, 2020. Photo: Oleksandr Kuzmin / UNIAN
Why are these changes labelled the "murder of reform"?
Because the idea of reform, when "money follows the patient" and the most funding is received by those hospitals where there will be more of those who have recovered and the best treatment of patients, is being thrown into disarray. Because the state will finance the hospital anyway. As a result of such distribution of funds, the highest quality hospitals will potentially lose the incentive to become even better:
"The reason (for such changes – ed.) is the negativity in the media because some hospitals began to receive less funding when the money started "following the patient." It will be a new system in form. But the content remains the same… Of course, this will not solve the problems of hospitals, nor realistically the problems of patients. But it will solve the problems of the minister," said Pavlo Kovtonyuk, former Deputy Minister of Health (2016-2019), about the announced changes in health care reform.
Golos MP Oleksandra Ustinova, a member of the nation's health committee and former employee of the Anti-Corruption Action Center, wrote that the changes proposed by Stepanov will lead to hospitals continuing to receive money per square meter and the number of staff:
"The resolution to return to the old methods of financing has already been prepared, and empty beds in huge hospitals will be paid for again, where chief doctors will travel not just in 4x4s, but on yachts. I once broke down the budget of Kyiv’s Feofania hospital, where the chief doctor has 5 (!) deputies and 52 cooks."
Ulana Suprun, a former health minister, commenting on the current ministry's decision to stop the health reform wrote that it is done in order to "be liked": "You can't transform the level of medical care in hospitals and clinics when you look at doctors as an electorate / potential risk for local elections in the fall."
Experts say that the new reform will not solve the problems of hospitals or patients, patients will receive funding for large hospitals in terms of staff, on the other hand those who really need money won’t receive it. The photo shows the ward in the infectious department of Brovary Hospital, Kyiv region, February 27, 2020. Photo: Viktor Kovalchuk / UNIAN
What do doctors say?
It is physicians who are experiencing the most painful changes as a result of the healthcare reform. Especially during the coronavirus pandemic and when the changes are in full swing. Some institutions have already completed the reform, some have not yet started, but "primary" and "secondary" settings have to communicate with each other. For now, because the reform is ongoing.
Daryna Dmytrievska, a family doctor from Kyiv, says it was difficult at the beginning, but now everything has fallen into place and the "primary" doctors are just waiting for the "secondary" reform to be completed so that the full cycle of treatment can be renewed:
"There were technical problems, the system was constantly freezing, there were no computers at all. Six months into the reform, our salaries did not change, but when I began to look into it, it turned out that it was not a matter of reform, but of my management, which received money from the National Health Service, but did not tell us about it. Doctors do not know their rights. Now there is the same skepticism from secondary doctors. The only difference is that we had nothing to lose, we had no cash flows, no kickbacks, except perhaps among the top management. The primary setting works well now. If there are any complaints, then we look into them and it turns out that in this particular case, either managers are hiding something, or the doctor is unqualified. Secondary doctors have it in for primary care doctors, because our salaries have increased (but they have increased, because if I don't get enough, I take more patients or negotiate with the manager and we review the contract). But without reform, they will not increase. Secondary doctors are panicking, as they do not believe that things can get better."
Dmytrievska says that some hospitals spent years building a system of "charitable" contributions or paying doctors for services "in envelopes", even though their services should be free. It is difficult to do away with this. Not all hospital managers, inspired by the changes, will be able to start introducing other approaches to patients, to treat them differently: “Nobody says that everything is perfect. Initially, it is impossible to plan the whole system down to the smallest detail on paper, it is necessary for doctors to be able to give feedback to the management and the ministry and then correct what is not working properly together."
Some institutions have already completed the reform, some have not yet begun. The photo shows the admission department of the Kyiv City Clinical Ambulance Hospital, November 8, 2019. Photo: Andriy Skakodub / UNIAN
Vadym Shukhtin, the chief physician of the Odesa Regional Clinical Medical Center, which was directly affected by the secondary reform, says that now is not the time for change – the coronavirus caught the hospital by surprise:
"The reform was planned for another time, the ‘turbo regime’ hasn’t done any good. We retrained to accept patients with COVID-19, but we do not have 200 or 300 of them. We had a maximum of 32 patients. We do not work according to the packages we received, because we do not accept other patients now."
Shukhtin says that in comparison with other hospitals, his institution received a "significant amount", but now the hospital does not earn anything, the money is guzzled away:
"I now have enough funds for the minimum wage for all employees, a little for food, a little for medicine. In two months I will be able to pay only a salary, and in four – I will be in the red. The electronic system keeps freezing, it does not work, there are many problems. We are offered 4,000 hryvnias ($149) per operation, have you ever heard of a surgery that costs that much? The amounts allocated for services are incorrect. We will not be able to maintain hospitals with the money they offer us. To sign a contract with the National Health Service, we bought used equipment, we are not competitors for private clinics. I understand that the reform is badly needed, but currently there is nothing better than the Semashko system (previous Soviet medical system – ed.). The reform is a bit ill-considered and untimely."
Meanwhile, Mykola Maslenchuk, the chief physician of the Ilyinets Central District Hospital in the Vinnytsia region in central Ukraine, called on Zelenskyy not to cancel the second stage of medical reform. He says that thanks to the reform that his hospital has been preparing for since 2017, they received 3 million hryvnias ($112,000) more than usual: “I understand your fears and doubts, I feel that in your understanding these risks outweigh the benefits, but perhaps the time has come for you to hear the voices of other hospitals – those who for the first time in 30 years have a chance not to survive, but to live and function effectively without looking at the patient's pocket at every opportunity… Change is always a painful process that requires strength and endurance. And we are ready for that."
The Cabinet of Ministers of Ukraine held a regular meeting on May 6, but changes in medical reform were not discussed. The issues of the second stage of medical reform were postponed to May 8.
On the eve of May 5, at a meeting of the Parliamentary Committee on Health of the Nation, it was agreed that no changes will take place until they are considered and discussed by the relevant committee, which is expected to take place on May 8.
At a briefing on May 7, Health Minister Stepanov once again assured that his department will make adjustments to the implementation of medical reform "taking into account the interests of both patients and medical workers."
He called the reform of the anti-tuberculosis service in the Odesa region during 2017-2019 an example of such an approach. At that time, the current minister was the head of the Odesa Regional State Administration.
/By Anna Tokhmakhchi
/Translated by Hromadske International