Medical Branch Diagnosis
According to the IFAK poll conducted in 2013 year, 87% of the population of Ukraine was not satisfied with the quality of medical care. Results of another poll show that the health care reform is the most expected one. 43.6% of the respondents prioritized it without realizing what exactly they were waiting for. The reform will most certainly not provide full implementation of the constitutional right to free and universal health care. The infantile Ukrainian society that still lives with the faith in the immediate life improvement has to fully realize this fact. In order to understand what to expect from the new reform, it is necessary to analyze the present state of health care, as well as the experience of previous attempts at reform.
Ukrainian Medicine Today. Structural Defects
De jure, Ukraine still has a system of free and universal health care, unchanged since the Soviet times and characterized by command and control management. State and municipal health care institutions have the status of “budgetary institutions”, and, according to the Budget Code of Ukraine, the only possible approach to their financing is the itemized one. Primary health care is financed from budgets of cities and districts, secondary and tertiary – from regional budgets. The lion’s share of public hospital funding, 80-90%, is spent on staff salaries and utilities. The share of official health spending is about 3-3.5% of the GDP.
For medical institutions the status of “a budget organization” means an object-target distribution of costs and inability to transfer funds between articles. For calculating the estimate of a medical facility the following indicators are used: a number of beds, a number of medical personnel, etc…. Thus, there are no conditions for an efficient resourse use and costs control, as a result, it is more profitable to keep additional and unnecessary technical and material base. It is also important to point out that because of the itemized approach the estimated budget planning horizon is limited to one year, which means that there is no possibility for strategic planning and long-term investments.
The structural division into primary and secondary care is not functioning properly in Ukraine. Primary care is the main and closest to people link of the medical care, providing illness prevention, diagnosis and treatment. Developed primary care enables better results at lower costs and higher levels of patient satisfaction. Costs saving is achieved by reducing the need for hospitalization, providing specialized assistance, ambulance calls and so on. In Ukraine, the primary link has little effect on patient’s “medical route”, about a third of patients self-refer themselves to medical specialists. As a result, in almost 50% of cases medical care is provided on higher levels than necessary. At the same time, the cost of medical services on the primary level is 4-9 times lower than on the secondary and about 20 times lower than on the tertiary. In developed countries, around 90% of all care is provided on the primary level. Illness prevention and early diagnosis is a win-win situation for everyone, both patients and the budget. Unfortunately, in Ukraine the opposite is true, patients suffer, and the budget is under big pressure. The following figures prove that we treat diseases instead of caring about health, only 5-10% of total expenditure on health care goes to funding primary care, in European countries it is 25-30%.
Another essential problem is a parallel system of hospital services with various subordination, state, municipal and departmental. More than 40% of total expenditures on health care is spent on financing a number of parallel health services of ministries and departments. In most cases departmental health care establishments duplicate each other’s functionality, which ultimately leads to unreasonable state budget costs.
In general, the health care management system is highly inefficient. Shortcomings of the system cause appearance of gray market, as “a compensatory mechanism”. In fact, an informal payment becomes a tool for care quality management and an increase of doctors’ earnings. Official doctors’ salary is miserably low, is determined within budget appropriations and is not influenced by market forces. “Informal” and “voluntary” patients’ contributions are an element of the market, although informal, designed to financially motivate doctors to provide better medical help.
One of the priorities of the President Yanukovych’s economic reform program Prosperous Society, Competitive Economy, Effective State was reforming the healthcare industry. On July 7, 2011, the Parliament of Ukraine approved two laws that launched the reform, №8602 On Amendments to the Basic Legislation of Ukraine on Health Care for the Improvement of Medical Care and №8603 – On Reforming the Health Care System in Vinnytsya, Dnipropetrovsk, Donetsk regions and Kyiv. The second law covered testing of the main approaches to health care reform in the pilot regions, their monitoring and evaluating for further implementation in other parts of the country. Practical fulfillment of the pilot projects began with restructuring primary and emergency medical care. Separation of primary care into a detached structure, followed by creating centers of primary health care, was an important innovation. Further stages of the reform envisaged reforming the network of secondary and tertiary care and gradual transition to health insurance.
In practice, all errors in theoretical models quickly became obvious. Many experts warned that simple reformatting of the structure of medical institutions and widespread introduction of family doctors without changing fundamental mechanisms on which the system is based were doomed. New rules for future physicians meant training and retraining without adequate financial incentives, since wages basically did not change. As for patients, the new system meant changing established routes without offering a higher quality of medical services or lower costs. Thus, neither doctors nor patients were to benefit from such changes. Besides, not a single massive educational campaign was carried out to inform the society about the benefits of the reform and its necessity.
Particularly weak was the human dimension of the pilot project. According to the concept, a family physician had to have comprehensive training in not only therapy and pediatrics, but also neurology, surgery, psychiatry, ophthalmology and other sections of medicine. He/she had to have some knowledge about clinical psychology, legislation on health care and social protection of families, and so on. The reorientation of health care into family medicine had high requirements for doctors of this specialty. According to statistics, before the reform the shortage of specialists of family medicine amounted to 30 000. Semi-annual retraining courses were introduced, although training of a highly qualified family doctor requires at least 7 years (for instance, an Australian family doctor after graduation still has 2 years of internship and a three-year course afterwards). As a result, the quality of care on the primary level not only did not experience the expected improvement, but decreased significantly. In Vinnytsya region adult health indicators worsened considerably compared to 2010, in 2014 the number of deaths from pneumonia increased by 2.8 times; the number of strokes amounted to 186 cases in 2010 and 224 in 2014. Also, increase was witnessed in the rates of disability, child and maternal mortality. The situation with professionals’ training can be illustrated by the following data: in the last 4 years only 4 out of 65 patients were diagnosed correctly by family doctors in cases of myocardial infarction.
In addition to training issues, the pilot project revealed a number of significant problems, from logistics and equipping primary health care centers to the lack of proper explanatory work among doctors and patients. It is important that this, though negative, experience is thoroughly investigated and taken into account by specialists before they make another attempt at reforming this sphere. After all, one way or another, we have to return to the starting point, to the reorganization of primary care.