The healthcare reform that began in 2016 has already made a number of positive changes in the healthcare system. How did it all begin and at what stage is the "revolution" in the field where nothing has changed much for 25 years?
Expensive "free" medical care
In 2016, the reform of the healthcare system began in Ukraine under the leadership of a team that was assembled and led by Ulana Suprun, the Acting Minister of Health of Ukraine.
Prior to that, from 1991 to 2016, citizens of Ukraine and its guests could receive medical care in state medical institutions where it was free, but there was not sufficient material support. For examinations, medicines and medical procedures, citizens had to pay out of their own pocket.
Polyclinics and hospitals were financed centrally, from the state budget—on a leftover principle and with a colossal deficit. Or one could go to private clinics where sometimes exactly the same specialists worked as in state clinics and hospitals, but the examination was made on the better apparatus, and the service was of many times higher quality.
Since 2008, the possibility of health insurance has appeared: a potential patient or employer for an employee themselves bought a medical policy. In the case of illness or injury, the insurance company covered all or part of the medical care, drugs, or procedures.
The goal of the Suprun reform was to change the financing of medical institutions and make the provision of medical care not formally free, but truly as affordable and high-quality as possible.
Public procurement and contracts with NHSU
A huge step was the change in the principle of the drugs procurement at the state level.
This step led to many scandals and outright black PR directed at Ulana Suprun personally, including from the then Verkhovna Rada Committee on Public Health and the Heart Institute under the Ministry of Health headed by Boris Todurov. The point is that the new procurement principle destroyed some of the old schemes that made it possible to earn money on public procurement. And at the same time, when solving the issue of such hidden earnings, slow down the supply of drugs for months. Crucial, for example, for people with cardiovascular diseases, diabetes, viral hepatitis C, tuberculosis, and HIV.
And for the first time, procurement began to be carried out openly and on a competitive basis. This saved the budget about a third of the amount spent annually and improved the quality of the treatment received by chronic patients.
In 2017, the National Health Service of Ukraine or NHSU was established. It is the NSZU that signs contracts with medical institutions and pays them directly for the provision of medical care.
That is, each consultation with a doctor, examination, and vaccination is paid for by the NHSU.
Another challenge was the change in the operating principle of municipal polyclinics. Previously, people were "assigned" to polyclinics at the place of registration. It was very difficult to change a medical institution and even a medical worker with whom you have no mutual understanding. It took time, a lot of documents and sometimes "charitable contributions".
Doctors provided medical care to a certain number of people living in a fixed territory—a city street, a village or several villages. A general practitioner had about 1,500 people (permissible fluctuations in 100 people or so either way), a pediatrician—700 people (permissible fluctuations in 50 people or so either way). Of these, a certain number of people had to have chronic diseases and be registered with dispensaries.
The fact that the age scale can vary from locality to locality—somewhere there are more retirees and two-thirds of them are chronically ill, and somewhere there are several university dormitories and the majority of the locality's population are healthy young people—was not taken into account.
The physician had to create documents on patients in order to reach the "required" number of patients.
Declaration by choice and new doctor in 20 minutes
It is now possible to sign a declaration with a personally chosen physician—a general practitioner, pediatrician, or family doctor—at a public or private clinic, regardless of place of registration or residence. This takes 10 to 20 minutes. If a person moves to another city or another area, or just wants to change a doctor for various reasons, then he or she can do it in the same 10-20 minutes.
Medical information systems (MIS) were put into operation for fast, high-quality and, most importantly, transparent document flow. It is in the MISs that information is recorded about the declared people, their medical cards with information about diseases, examinations, vaccinations, treatment in hospitals and rehabilitation centers, etc.
It is by the number of declarations that the NHSU finances polyclinics. Hospitals were to receive payment for each patient examined and treated. According to the same principle, they will have to pay for the work of the specialized doctors and medical workers of laboratory and instrumental departments of polyclinics.
Nearly 20 million patients and new salaries for doctors
Almost 20 million Ukrainians have signed declarations in three years. Thanks to this, several hundred outpatient clinics were opened throughout Ukraine, computers were purchased for almost every doctor's consulting room, laboratory and diagnostic equipment was updated.
Thanks to the work of the NHSU, many family doctors were paid official salaries higher than indicated in the tariff scale. The more declarations a family doctor has, the higher their salary is.
European studies have shown that after permanent working with more than 2,000 people, the family doctor's work efficiency drops. Considering that the essence of this work is people's health, the NHSU imposed a restrictive mechanism: after 2,000 declarations, for each next patient, a decreasing coefficient is introduced for the financial payment. It was simply not profitable to be "greedy".
What can you get for free?
Now healthcare has become accessible to patients and partly free of charge—because now the NHSU pays for a part of medical services to medical institutions.
The list of services that a declared person can receive in a medical institution that has entered into a contract with the NHSU:
- monitoring the health of patients with the help of various examinations, diagnostics, and treatment of the most common diseases, injuries, poisoning, pathological, and physiological (during pregnancy) conditions;
- supporting patients with chronic diseases;
- provision of emergency assistance;
- referring the patient for the provision with secondary (specialized) or tertiary (highly specialized) medical care;
- prevention: vaccinations, examinations, and studies of at-risk patients;
- consulting on a number of medical and paramedical issues with a family doctor;
- a number of tests will be free of charge:
- a general blood test with a leukocyte formula,
- blood glucose,
- total cholesterol,
- urine tests,
- common urine test,
- resting electrocardiogram (ECG)
- sputum microscopy,
- rapid HIV tests,
- viral hepatitis,
- free consultations will be provided by specialized doctors, ophthalmologists, cardiologists, urologists, etc., subject to a referral from a family doctor.
If the sick person does not have a declaration or is not a citizen of Ukraine, they will still receive medical assistance, but for some of the services they will have to pay to the medical institution.
COVID-19 and reform
Unfortunately, during implementing the second stage of medical reform concerning hospitals and specialized doctors, an epidemic of the SARS-CoV-2 virus began.
Some of the money and human resources was transferred to the treatment of COVID patients, the re-equipment of hospitals to work in an epidemic, the purchase of aseptics and antiseptics for the work of medical personnel, including disposable masks, gowns, payment for expensive tests—PCR and determination of antibodies to the SARS-CoV-2 virus, etc.
Another part of the finance was spent on organizing mass vaccinations, training medical personnel, purchasing syringes for vaccinations, etc.
Healthcare reform, even partially implemented, has shown its effectiveness in helping people. Further implementation requires the same as for other reforms—time, sufficient funding, and a lot of work.