Health Systems in Transition
Vol. 12 No. 8 2010
Ukraine
Health system review
Valery Lekhan • Volodymyr Rudiy
Erica Richardson
Erica Richardson (Editor) and Martin McKee (Series editor) were responsible for this
HiT profile
Editorial Board
Editor in chief
Elias Mossialos, London School of Economics and Political Science, United Kingdom
Series editors
Reinhard Busse, Berlin University of Technology, Germany
Josep Figueras, European Observatory on Health Systems and Policies
Martin McKee, London School of Hygiene & Tropical Medicine, United Kingdom
Richard Saltman, Emory University, United States
Editorial team
Sara Allin, University of Toronto, Canada
Matthew Gaskins, Berlin University of Technology, Germany
Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies
Anna Maresso, European Observatory on Health Systems and Policies
David McDaid, European Observatory on Health Systems and Policies
Sherry Merkur, European Observatory on Health Systems and Policies
Philipa Mladovsky, European Observatory on Health Systems and Policies
Bernd Rechel, European Observatory on Health Systems and Policies
Erica Richardson, European Observatory on Health Systems and Policies
Sarah Thomson, European Observatory on Health Systems and Policies
Ewout van Ginneken, Berlin University of Technology, Germany
International advisory board
Tit Albreht, Institute of Public Health, Slovenia
Carlos Alvarez-Dardet Díaz, University of Alicante, Spain
Rifat Atun, Global Fund, Switzerland
Johan Calltorp, Nordic School of Public Health, Sweden
Armin Fidler, The World Bank
Colleen Flood, University of Toronto, Canada
Péter Gaál, Semmelweis University, Hungary
Unto Häkkinen, Centre for Health Economics at Stakes, Finland
William Hsiao, Harvard University, United States
Alan Krasnik, University of Copenhagen, Denmark
Joseph Kutzin, World Health Organization Regional Office for Europe
Soonman Kwon, Seoul National University, Republic of Korea
John Lavis, McMaster University, Canada
Vivien Lin, La Trobe University, Australia
Greg Marchildon, University of Regina, Canada
Alan Maynard, University of York, United Kingdom
Nata Menabde, World Health Organization Regional Office for Europe
Ellen Nolte, Rand Corporation, United Kingdom
Charles Normand, University of Dublin, Ireland
Robin Osborn, The Commonwealth Fund, United States
Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France
Sophia Schlette, Health Policy Monitor, Germany
Igor Sheiman, Higher School of Economics, Russian Federation
Peter C. Smith, Imperial College, United Kingdom
Wynand P.M.M. van de Ven, Erasmus University, The Netherlands
Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland
Health Systems
in Transition
Valery Lekhan, Dnipropetrovsk State Medical Academy
Volodymyr Rudiy, Committee on Health of the Verkhovna Rada of Ukraine
Erica Richardson, European Observatory on Health Systems and Policies
Ukraine:
Health System Review
2010
The European Observatory on Health Systems and Policies is a partnership
between the WHO Regional Office for Europe, the Governments of Belgium,
Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the
Veneto Region of Italy, the European Commission, the European Investment
Bank, the World Bank, UNCAM (French National Union of Health Insurance
Funds), the London School of Economics and Political Science, and the
London School of Hygiene & Tropical Medicine.
Keywords:
DELIVERY OF HEALTH CARE
EVALUATION STUDIES
FINANCING, HEALTH
HEALTH CARE REFORM
HEALTH SYSTEM PLANS – organization and administration
UKRAINE
© World Health Organization 2010, on behalf of the
European Observatory on Health Systems and Policies
All rights reserved. The European Observatory on
Health Systems and Policies welcomes requests for
permission to reproduce or translate its publications,
in part or in full.
Please address requests about the publication to:
Publications,
WHO Regional Office for Europe,
Scherfigsvej 8,
DK-2100 Copenhagen Ø, Denmark
Alternatively, complete an online request form for
documentation, health information, or for permission
to quote or translate, on the Regional Office web site
(http://www.euro.who.int/en/what-we-publish/publicationrequest-forms).
The views expressed by authors or editors do not
necessarily represent the decisions or the stated policies of
the European Observatory on Health Systems and Policies
or any of its partners.
The designations employed and the presentation of the
material in this publication do not imply the expression
of any opinion whatsoever on the part of the European
Observatory on Health Systems and Policies or any of
its partners concerning the legal status of any country,
territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. Where the
designation “country or area” appears in the headings of
tables, it covers countries, territories, cities, or areas.
Dotted lines on maps represent approximate border lines
for which there may not yet be full agreement.
The mention of specific companies or of certain
manufacturers’ products does not imply that they are
endorsed or recommended by the European Observatory
on Health Systems and Policies in preference to others
of a similar nature that are not mentioned. Errors and
omissions excepted, the names of proprietary products
are distinguished by initial capital letters.
The European Observatory on Health Systems and Policies
does not warrant that the information contained in this
publication is complete and correct and shall not be liable
for any damages incurred as a result of its use.
Printed and bound in the United Kingdom.
Suggested citation:
Lekhan V, Rudiy V, Richardson E. Ukraine: Health system review.
Health Systems in Transition, 2010; 12(8):1–183.
ISSN 1817-6127 Vol. 12 No. 8
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
List of tables and figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Geography and sociodemography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Economic context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Political context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Health status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2. Organizational structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1 Overview of the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2 Historical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.3 Organizational overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4 Decentralization and centralization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.5 Patient empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3. Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1 Health expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.2 Population coverage and basis for entitlement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.3 Revenue collection/sources of funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.4 Pooling of funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.5 Purchasing and purchaser–provider relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.6 Payment mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4. Regulation and planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.1 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.2 Planning and health information management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Contents
Contents
iv
Health systems in transition
Ukraine
5. Physical and human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.1 Physical resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.2 Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
6. Provision of services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.1 Public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.2 Patient pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
6.3 Primary/ambulatory care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
6.4 Secondary care (specialized ambulatory care/inpatient care) . . . . . . . . . . . . . . . . . . . . 126
6.5 Emergency care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
6.6 Pharmaceutical care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
6.7 Rehabilitation/intermediate care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
6.8 Long-term care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
6.9 Services for informal carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
6.10 Palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
6.11 Mental health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
6.12 Dental care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
6.13 Complementary and alternative medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
6.14 Health care for specific populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7. Principal health care reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
7.1 Analysis of recent reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
7.2 Future developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
8. Assessment of the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
8.1 The stated objectives of the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
8.2 The distribution of the health system’s costs and benefits across
the population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8.3 Efficiency of resource allocation in health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8.4 Technical efficiency in the production of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.5 Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.6 The contribution of the health system to health improvement . . . . . . . . . . . . . . . . . . . 170
9. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
10. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
10.1 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
10.2 HiT methodology and production process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
10.3 The review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
10.4 About the authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
T
he Health Systems in Transition (HiT) profiles are country-based reports
that provide a detailed description of a health system and of reform
and policy initiatives in progress or under development in a specific
country. Each profile is produced by country experts in collaboration with the
Observatory’s staff. In order to facilitate comparisons between countries, the
profiles are based on a template, which is revised periodically. The template
provides detailed guidelines and specific questions, definitions and examples
needed to compile a profile.
HiT profiles seek to provide relevant information to support policy-makers
and analysts in the development of health systems in Europe. They are building
blocks that can be used:
•
to learn in detail about different approaches to the organization,
financing and delivery of health services and the role of the main
actors in health systems;
•
to describe the institutional framework, the process, content and
implementation of health care reform programmes;
•
to highlight challenges and areas that require more in-depth analysis;
•
to provide a tool for the dissemination of information on health systems
and the exchange of experiences of reform strategies between policymakers and analysts in different countries; and
•
to assist other researchers in more in-depth comparative health
policy analysis.
Compiling the profiles poses a number of methodological problems. In
many countries, there is relatively little information available on the health
system and the impact of reforms. Due to the lack of a uniform data source,
quantitative data on health services are based on a number of different
Preface
Preface
vi
Health systems in transition
Ukraine
sources, including the World Health Organization (WHO) Regional Office for
Europe’s European Health for All database, national statistical offices, Eurostat,
the Organisation for Economic Co-operation and Development (OECD) Health
Data, the International Monetary Fund (IMF), the World Bank, and any other
relevant sources considered useful by the authors. Data collection methods
and definitions sometimes vary, but typically are consistent within each
separate series.
A standardized profile has certain disadvantages because the financing
and delivery of health care differ across countries. However, it also offers
advantages, because it raises similar issues and questions. The HiT profiles
can be used to inform policy-makers about experiences in other countries that
may be relevant to their own national situation. They can also be used to inform
comparative analysis of health systems. This series is an ongoing initiative and
material is updated at regular intervals.
Comments and suggestions for the further development and improvement
of the HiT series are most welcome and can be sent to info@obs.euro.who.int.
HiT profiles and HiT summaries are available on the Observatory’s web
site at http://www.healthobservatory.eu.
T
he HiT profile on Ukraine was written by Valery Lekhan (Dnipropetrovsk
State Medical Academy), Volodymyr Rudiy (Committee on Health of
the Verkhovna Rada (Parliament) of Ukraine) and Erica Richardson
(European Observatory on Health Systems and Policies). It was edited by
Erica Richardson and the Research Director was Martin McKee. The European
Observatory on Health Systems and Policies is especially grateful to Paolo Belli
(World Bank), Andriy Huk (Public Health Board of the Ministry of Health
of Ukraine) and Mariia Telishevska (Danylo Halytsky Lviv National Medical
University) for reviewing the report and for their important contributions.
The authors would like to thank the many individuals who have helped in
the preparation of this report. The authors greatly benefited from the support,
detailed comments, suggestions and information provided by Nina Sautenkova
(WHO Regional Office for Europe) and the WHO Country Office team in
Kyiv, Ukraine. None of these individuals or organizations is responsible for the
authors’ interpretation or any remaining errors.
The current series of HiT profiles has been prepared by the research directors
and staff of the European Observatory on Health Systems and Policies. The
European Observatory on Health Systems and Policies is a partnership between
the WHO Regional Office for Europe, the Governments of Belgium, Finland,
Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto
Region of Italy, the European Commission, the European Investment Bank, the
World Bank, UNCAM (French National Union of Health Insurance Funds), the
London School of Economics and Political Science, and the London School of
Hygiene & Tropical Medicine.
The Observatory team is led by Josep Figueras, Director, and Elias Mossialos,
Co-director, and by Martin McKee, Richard Saltman and Reinhard Busse, heads
of the research hubs. Jonathan North managed the production and copy-editing,
Acknowledgements
Acknowledgements
viii
Health systems in transition
Ukraine
with the support of Sophie Richmond (copy-editing) and Pat Hinsley (layout).
Administrative support for preparing the HiT profile on Ukraine was undertaken
by Caroline White. Special thanks are extended to the WHO Regional Office
for Europe for their European Health for All database, from which data on
health services were extracted, to the OECD for the data on health services
in western Europe, and to the World Bank for the data on health expenditure
in central and eastern European countries. Thanks are also due to national
statistical offices which have provided national data.
The HiT reflects data available in May 2010.
AR
Autonomous Republic
ATC
Anatomic-therapeutic-chemical
CECs
Clinical Expert Commissions
CIS
Commonwealth of Independent States
CPI
Corruption Perception Index
DOTS
Directly observed treatment, short course
DMFT
Decayed, missing or filled teeth
DTP
Diphtheria-tetanus-pertussis vaccine
EU
European Union
FAP
Feldsher and midwife post
GDP
Gross domestic product
GLP
Good laboratory practice
GMP
Good manufacturing practice
GP
General practitioner
HALE
Health-adjusted life expectancy
ILO
International Labour Organization
IMF
International Monetary Fund
MHI
Mandatory social health insurance
NATO
North Atlantic Treaty Organization
NGO
Nongovernmental organization
NHA
National Health Accounts
OECD
Organisation for Economic Co-operation and Development
OSCE
Organization for Security and Co-operation in Europe
PPP
Purchasing power parity
SPH
School of Public Health
STI
Sexually transmitted infection
TB
Tuberculosis
TRIPS
Trade-Related Aspects of Intellectual Property Rights
UNICEF
United Nations Children’s Fund
List of abbreviations
List of abbreviations
x
Health systems in transition
VHI
Voluntary health insurance
WHO
World Health Organization
WTO
World Trade Organization
Ukraine
List of tables and figures
List of tables and figures
Tables
page
Table 1.1
Population/demographic indicators, 1990–2009 (selected years)
3
Table 1.2
Macroeconomic indicators, 1999–2008
4
Table 1.3
Mortality and health indicators, 1990–2006 (selected years)
Table 1.4
Main causes of death (all ages per 100 000), 1990–2006 (selected years)
Table 1.5
Maternal, child and reproductive health indicators, 1990–2008 (selected years)
11
Table 3.1
Health care expenditure trends, 1999–2008
30
Table 3.2
Government health expenditure by service programme (% total public health
expenditure (THE)), 2003, 2004 and 2008
36
Table 3.3
Sources of revenue as a percentage of total expenditure on health in Ukraine, 2003–2008
41
Table 3.4
Volume and structure of out-of-pocket payments for various services, 2004
44
Table 3.5
Sickness funds’ activity in 1999–2006 and in 2009
49
Table 3.6
Sickness funds’ activity in different regions of Ukraine, 2009
50
Table 3.7
State budget resources allocation, 2008
53
Table 3.8
Distribution of national health expenditure based on budget system level, 2004
57
Table 5.1
Inpatient hospital capacity, 1990–2008 (selected years)
79
Table 5.2
Transformation of the network of outpatient clinics and polyclinics, 1991–2008
(selected years)
82
9
10
Table 5.3
Transformation of the network of inpatient medical facilities, 1991–2008 (selected years)
83
Table 5.4
Trends in health care human resources per 1 000 population, 1990–2008 (selected years)
94
Table 5.5
Basic training of specialists, 2006/2007
Table 6.1
Inpatient hospital utilization, 1990–2008 (selected years)
128
Table 6.2
Development of day hospitals, 1991–2008 (selected years)
129
Table 8.1
Frequency of delaying seeking, utilizing and being refused health services, 2006
164
Table 8.2
Avoidable mortality indicators for the population aged 25–64 years in Ukraine, 1989,
1995 and 2006 (per 100 000 population)
170
103
xii
Health systems in transition
Figures
Ukraine
page
Fig. 1.1
Map of Ukraine
Fig. 1.2
Level of immunization for measles in the WHO European Region, 2008 or latest
available year
2
13
Fig. 2.1
Overview of the health system
16
Fig. 3.1
Health care financing flowchart
28
Fig. 3.2
Health expenditure as a share (%) of GDP in the WHO European Region, 2005
31
Fig. 3.3
Health expenditure in US$ PPP per capita in the WHO European Region, 2005
32
Fig. 3.4
Trends in health expenditure as a share (%) of GDP in Ukraine and selected other countries
and averages, 1998 to latest available year
33
Fig. 3.5
Health expenditure from public sources as a percentage of total health expenditure in the
WHO European Region, 2005
35
Fig. 3.6
Percentage of total expenditure on health according to source of revenue, 2008
40
Fig. 5.1
Beds in acute hospitals per 1 000 population in Ukraine and selected other countries,
1990 to latest available year
80
Fig. 5.2
Average retail prices of the “pharmacy market basket” including components influencing
the price increase, 2006–2008
91
Fig. 5.3
Number of physicians per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
95
Fig. 5.4
Trends in the supply of family doctors/GPs, 1997–2008
96
Fig. 5.5
Number of nurses per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
98
Fig. 5.6
Number of dentists per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
100
Fig. 5.7
Number of pharmacists per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
101
Fig. 6.1
Outpatient contacts per person in Ukraine and selected countries in the WHO European
Region, 2008 or latest available year
125
T
he HiT profiles are country-based reports that provide a detailed
description of a health system and of policy initiatives in progress or under
development. HiTs examine different approaches to the organization,
financing and delivery of health services and the role of the main actors in
health systems; describe the institutional framework, process, content and
implementation of health and health care policies; and highlight challenges
and areas that require more in-depth analysis.
The Ukrainian health system has preserved the fundamental features of
the Soviet Semashko system against a background of other changes, which
are developed on market economic principles. The transition from centralized
financing to its extreme decentralization is the main difference in the health
system in comparison with the classic Soviet model. Health facilities are
now functionally subordinate to the Ministry of Health, but managerially
and financially answerable to the regional and local self-government, which
has constrained the implementation of health policy and fragmented health
financing. Health care expenditure in Ukraine is low by regional standards and
has not increased significantly as a proportion of gross domestic product (GDP)
since the mid 1990s; expenditure cannot match the constitutional guarantees
of access to unlimited care. Although prepaid schemes such as sickness funds
are growing in importance, out-of-pocket payments account for 37.4% of total
health expenditure.
The core challenges for Ukrainian health care therefore remain the
ineffective protection of the population from the risk of catastrophic health care
costs and the structural inefficiency of the health system, which is caused by
the inefficient system of health care financing. Health system weaknesses are
highlighted by increasing rates of avoidable mortality. Recent political impasse
Abstract
Abstract
xiv
Health systems in transition
Ukraine
has complicated health system reforms and policy-makers face significant
challenges in overcoming popular distrust and “fatigue” in the face of necessary
but as yet unimplemented reforms.
Introduction
U
kraine is the second largest country in Europe and had a population
of 46 million in 2009, which is 12% smaller than it was in 1991 when
the country gained independence from the USSR. Heavy industry and
manufacturing is concentrated in the east and south of the country, whereas the
west is more agricultural. There is a political split along similar geographical
lines. Populations in the western regions show stronger support for candidates
advocating European Union (EU) and North Atlantic Treaty Organization
(NATO) accession, while populations in the eastern and southern regions
(where more Russian-speakers live) support candidates looking to maintain
closer contacts with the Russian Federation.
Rapid marketization and hyperinflation following independence caused
severe socioeconomic hardship in Ukraine and, while there was some
stabilization in the economy from 2000 and even growth from 2003–2004
and 2006–2007, the global economic downturn has hit the Ukrainian
economy hard and the country has sought assistance from the IMF and
World Bank. The “Orange Revolution” in 2004 occurred, in part, as a response
to dissatisfaction with the economic situation as well as political institutions.
However, the government brought to power after the “Orange Revolution”
was not able to overcome internal divisions in order to bring about lasting
economic improvements.
While the overall health status of the Ukrainian population fell after
independence, there has been a steady improvement since the mid 1990s.
Maternal and infant mortality rates have been falling steadily, but so too have
birth rates. The main contribution to the still elevated mortality rate is from
cardiovascular diseases, which account for more than 60% of total mortality.
However, infectious diseases are also key public health issues as it is estimated
that 1.6% of the population is living with HIV/AIDS and 1.4% of the population
are currently tuberculosis (TB) patients.
Executive summary
Executive summary
xvi
Health systems in transition
Ukraine
Organizational overview
In 1991, Ukraine inherited an extensive and highly centralized Semashko
system, which it was not possible to maintain through the economic downturn
that followed independence. There has been considerable decentralization
in the system; however, in most other respects the system remains largely
unreformed. Decentralization has meant deconcentration of functional and
managerial powers at the regional and subregional level. Regional and local
health directorates are responsible for health facilities in their territory and
are functionally subordinate to the Ministry of Health, but managerially and
financially answerable to the regional and local self-government. Only the
State Sanitary-Epidemiological Service and the State Pharmaceuticals Quality
Control Inspectorate, each with relevant facilities at the different levels of
administration, remain fully centralized and vertically subordinated to the
Ministry of Health. Consequently, while the Ministry of Health formally takes
the lead in developing health policy, implementation is constrained.
Financing
Health care expenditure in Ukraine is low by regional standards and has
not increased significantly as a proportion of GDP since the mid 1990s.
The proportion of general government expenditure on health as a proportion
of total health expenditure was 55.7% in 2007 (WHO, 2009). The bulk of
government expenditure pays for inpatient medical services, with only
a relatively small proportion (13%) going to outpatient services. Private
expenditure primarily consists of out-of-pocket payments, which are high on
account of the high cost of pharmaceuticals; patients generally purchase them
at full cost price.
Officially, Ukraine has a comprehensive guaranteed package of health
care services provided free of charge at the point of use as a constitutional
right; nevertheless “charitable donations” are widely levied in the Ukrainian
health system. Government attempts to define a more limited benefits
package have left it to the individual facilities to determine which services are
covered by the budget and which are subject to user charges. This has led to
a lack of transparency in the system, which has contributed to an increase in
informal payments.
Health systems in transition
Ukraine
Most health financing comes from general government revenues raised
through taxation (value added taxes, business income taxes, international trade
and excise taxes). Personal income tax is not a significant contribution to total
revenues. Out-of-pocket payments also account for a significant proportion of
total health expenditure, and there are some limited voluntary health insurance
(VHI) schemes. Funds are pooled at the national and the local level, as local
self-governments retain a proportion of the taxes raised in their territory. There
are also inter-budgetary transfers to boost the coffers of poorer local authorities
which cannot raise as much revenue. With the exception of a couple of pilot
projects in small rural districts, allocations and payments are made according
to strict line-item budgeting procedures as under the Semashko system. This
means payments are related to the capacity and staffing levels of individual
facilities rather than the volume or quality of services provided.
Regulation, planning and management
The Ministry of Health plays the key regulatory role in the Ukrainian health
system at the national, regional and district levels. The Ministry is responsible
for the accreditation of all health facilities regardless of ownership, but this is
more of a formality than a tool for improving quality of services. Similarly,
standardization efforts through the development of clinical guidelines and
protocols have been ongoing, but they are not generally evidence-based and
their efficacy has not been monitored. Since 2007, improving the quality of
health care has become a more systematic activity and there is a department in
charge of assessing the quality of health care services.
As health facilities are owned by local authorities rather than the Ministry
of Health, management of the system is decentralized, which impedes the
implementation of plans developed at the national level, and there is no central
health planning agency. Approaches to capacity planning have remained almost
unchanged since Soviet times. The mechanisms currently in place neither reflect
the health care needs of the population nor account for regional characteristics
of health service provision. There is also little incentive for rational use of
resources or cost control over health facilities, which are predominantly funded
from the national budget and out-of-pocket payments.
xvii
xviii
Health systems in transition
Ukraine
Physical and human resources
Ukraine has an extensive health care infrastructure despite a rapid reduction in
the number of beds in 1997–1998 in response to severe economic crisis. Ukraine
does not have a regular system for monitoring the upkeep of medical facilities
and the conditions in which services are provided, but regular inspections by the
State Sanitary-Epidemiological Service have found that, in 2007, only 29.6% of
health facilities are on mains water supply and only 21.1% have mains sewerage.
Unsatisfactory sanitary conditions are found most often in rural areas. The lack
of systematic updates on the condition of medical facilities and the minimal
financing of capital costs in the state health system are the two main reasons
for the lack of planning in prospective development (construction, renovation)
of medical facilities. The Ukrainian health system has also consistently
encountered severe difficulties with the supply and maintenance of existing
technological equipment.
The number of medical human resources per capita has increased gradually
since 1990, but this does not ref lect a growth in the number of medical
personnel so much as a decline in the total population, as the absolute number
of doctors has been falling. At the same time the medical workforce is ageing
rapidly as new graduates choose to work outside the state health system or
seek opportunities abroad. The key staff shortages are in rural areas and in
primary care, which has a high turnover. The number of nurses has fallen much
more rapidly due to the low wages and low status of nursing, and the limited
possibilities for professional development. This is a trend witnessed throughout
the Commonwealth of Independent States (CIS) and one which runs counter to
developments in EU countries.
Provision of services
Traditionally, primary care in Ukraine has been provided within an integrated
system by district internists and paediatricians employed by state polyclinics.
In 2000 the transition to a new model of primary care based on the principles
of family medicine began. Family doctors/general practitioners (GPs) make up
a third (32.9%) of all primary care physicians. They work at family medicine
polyclinics or in appropriate polyclinic departments, and the overwhelming
majority of family doctor/GP facilities and departments are located in rural
areas (70%).
Health systems in transition
Ukraine
The inpatient system is a hierarchical system organized into three levels. The
first (lower) level is that of rural hospitals providing basic inpatient facilities. The
second (middle) level is the true foundation of the system. Secondary inpatient
care is provided in central district and municipal multi-profile hospitals, also in
children’s hospitals, specialized clinics (dispensarii), and specialized hospitals
which are located and governed at this organizational level. The third (higher)
level is that of regional and supra-regional specialization provided by regional
hospitals, diagnostic centres and specialized clinics, and specialized clinical
and diagnostic centres at the national research institutes of the Ministry of
Health and the National Academy of Medical Sciences. These were originally
designed to provide highly specialized medical care to patients with the most
severe and complicated conditions, but there has been some blurring of the lines
between secondary and tertiary care levels.
Health care reforms
The Ukrainian health system has preserved the fundamental features of
the Soviet Semashko model against a background of other changes, which
developed on market economic principles. The transition from centralized
financing to its extreme decentralization is the main difference in the health
system in comparison with the classic Soviet Semashko model.
Although no fundamental reform has taken place, many changes in the health
sector have been initiated and often realized since independence, although most
of them were oriented not towards meeting the health needs of the population but
towards solving problems in the health sector. User fees have been introduced
to mobilize additional resources, and sickness funds and VHI have begun to
develop. To reduce government expenditure in circumstances where there was
an acute shortage of funds, the stock of hospital beds was cut by a third. The
legal basis was also laid and measures realized which were directed towards
institutional reform of the health sector (for example, to reorient the system
towards primary care and introducing family medicine); and specific quality
guarantees for health services were also introduced (the licensing of medical
practice, accreditation of health facilities, standardization of clinical practice).
xix
xx
Health systems in transition
Ukraine
Assessment of the health system
Despite changes since independence, the core challenges for Ukrainian
health care are still the ineffective protection of the population from the risk
of catastrophic health care costs and the structural inefficiency of the health
system, which is caused by the inefficient system of health care financing.
Health system weaknesses are highlighted by increasing rates of avoidable
mortality. The recent political impasse has complicated health system reforms
and policy-makers face significant challenges in overcoming popular distrust
and “fatigue” in the face of necessary but as yet unimplemented reforms.
1.1 Geography and sociodemography
U
kraine is the second largest country in Europe, situated strategically
at the crossroads of Europe and Asia. The country is bordered by
Belarus in the north-west, the Russian Federation in the north-east,
the Republic of Moldova, Romania and Hungary in the south-west, and
Slovakia and Poland in the west (see Fig. 1.1). It is washed by the Black Sea
and the Sea of Azov in the south. The climate is predominantly moderatecontinental; however, subtropical conditions are found in the southern shores
of the Crimean peninsula.
Ukraine is divided administratively into 27 regions: the Crimean Autonomous
Republic (Crimea AR), 24 oblasts (regions) and two city authorities (Kyiv and
Sevastopol); 67% of the population live in urban areas. The eastern regions are
the most urbanized. Heavy industry and manufacturing are concentrated east
and south of the country, whereas the west is more agricultural.
The 2001 census recorded more than 130 nationalities and ethnic groups
in Ukraine. The main ethnic groups are Ukrainians (78%) and Russians
(17%). Since the census, the number of Ukrainians has increased by 0.3%
and their proportion among all the groups in Ukraine has increased by 5.1%.
Many different religions are also present in Ukraine. Freedom of religion and
relative tolerance allow for the coexistence of various religions and atheism.
Christianity predominates: Ukrainian Orthodox in the north, east and central
parts (Moscow and Kyiv Patriarchates, Autocephalous Church) and Ukrainian
Catholic in the west (Greek Catholic and Uniate). Ukrainian is the official state
language; Russian, Romanian, Polish and Hungarian are also spoken.
The current demographic situation in Ukraine is very complicated (see
Table 1.1). The population stands at 46 million, but has been falling since
the mid 1990s. It fell drastically between 1995 and 2000 (-0.9% annually).
Recently, the annual decrease has been 0.6%. Since independence, Ukraine’s
1. Introduction
1. Introduction
2
Health systems in transition
Ukraine
Fig. 1.1
Map of Ukraine
Source: United Nations, 2008.
population has fallen by 5.8 million or 11%. Population density has decreased
by 12% since 1990 and now is 76 people per km 2. The population is also
ageing dramatically.
The birth rate is low and in 2008 was 11 per 1000 population. The rate
dropped by 38% between 1990 and 1999, and reached its nadir in 2000 (7.8 per
1000 population). Between 2000 and 2008, it increased slightly, thus increasing
the fertility rate from 1.1 to 1.5 births per woman, but this does not offset the
high mortality rate (see below). Demographers explain this birth rate increase
by the fact that the last numerous group of women born in the 1980s have
reached active reproductive age.
Health systems in transition
Ukraine
Table 1.1
Population/demographic indicators, 1990–2009 (selected years)
1990
1995
2000
2005
2006
2007
2008
Total population (millions)
51.8
51.7
49.4
47.3
46.9
46.6
46.2
46.0
Population, female (% of total)
53.8
53.6
53.5
53.8
53.8
53.9
53.9
53.9
Population aged 0–14 (% of total)
21.5
20.5
17.9
14.8
14.5
14.2
14.1
14.1
Population aged 65+ (% of total)
12.0
13.6
13.9
15.9
16.2
16.4
16.2
15.9
–
0.0
-0.9
-0.9
-0.6
-0.6
-0.9
-0.4
86.0
86.0
82.0
78.0
77.0
77.0
77.0
76.0
1.8
1.4
1.1
1.2
1.3
1.3
1.3
1.5
Birth rate, crude (per 1 000 people)
12.6
9.6
7.8
9.0
9.8
10.2
11.0
–
Death rate, crude (per 1 000 people)
12.1
15.4
15.4
16.6
16.2
16.4
16.3
–
Age dependency ratio (population
0–14 and 65+ population 15–64 years)
0.50
0.52
0.47
0.44
0.44
0.44
0.44
0.43
Distribution of population (urban
population %)
67.3
67.9
67.5
67.7
67.9
68.3
68.2
68.5
–
–
20.9
22.2
24.6
24.0
23.7
–
99.4
99.5
99.6
–
99.4
99.7
–
–
Population growth (average annual
growth rate %)
Population density (people per km2)
Fertility rate, total (births per woman)
Proportion of single-person
households (%)
Education level (literacy rate %) a
2009
Sources: State Statistics Committee of Ukraine, 2010b; a WHO Regional Office for Europe, 2010a.
1.2 Economic context
Ukraine is considered a lower middle income country. Following independence
and the transition to a market economy, Ukraine was challenged by a deep
economic crisis. Industrial output fell by 54% between 1989 and 1999 and GDP
fell by 59.2% (Åslund, 2005). In the early 2000s, the country implemented some
economic reforms and GDP growth jumped to 12.1% in 2004 (see Table 1.2).
Nevertheless, the average salary in 2004 was US$ 111 per month. Dissatisfaction
with the economic situation and political institutions helped to trigger the
“Orange Revolution” at the end of 2004. This event amplified social expectations
among population and increased the government’s expenditure on social needs,
which was further stimulated by non-stop parliamentary elections in March
2006 and November 2007. Populist socioeconomic policies, combined with
attempts to reverse the results of privatization, drastically lowered economic
growth from 12.1% in 2004 to 2.7% in 2005. GDP stabilized somewhat in 2006
and 2007, but this did not reflect an improvement in industrial output; it was
primarily due to price increases for energy and bank loans which caused the
price of goods and services to spike.
3
38.5
14.3
47.2
22.9
11.6
4.1
Industry, value added (% of GDP)
Agriculture, value added (% of GDP)
Services etc., value added (% of GDP)
Labour force, total (millions)
Unemployment, total (% of total labour force)
Official exchange rate (hryvnya per US$, period average)
Source: World Bank, 2009.
Poverty headcount ratio at national poverty line
(% of population)
–
21.6
29.0
GINI index
Real interest rate (%)
-0.2
2 992
GDP per capita, PPP (current international $)
GDP growth (annual %)
4 044
148 637
GDP per capita (constant hryvnya)
GDP, PPP (current international $, millions)
1999
130 442
GDP (current hryvnya, millions)
Table 1.2
Macroeconomic indicators, 1999–2008
2000
31.5
15.0
5.4
11.6
23.0
46.6
17.1
36.3
–
5.9
3 271
4 326
160 838
170 070
2001
–
20.3
5.4
10.9
23.1
48.9
16.4
34.7
–
9.2
3 695
4 772
179 866
204 190
2002
–
19.2
5.3
9.6
23.1
50.8
14.6
34.5
28.3
5.2
3 994
5 070
192 531
225 810
2003
19.5
8.9
5.3
9.1
23.0
53.3
12.1
34.6
–
9.4
4 499
5 592
215 117
267 344
2004
–
2.0
5.3
8.6
23.0
52.2
11.9
35.9
–
12.1
5 228
6 316
248 073
345 113
2005
–
-6.7
5.1
7.2
23.2
57.3
10.4
32.3
28.2
2.7
5 583
6 534
263 007
441 452
2006
–
0.3
5.0
6.8
23.1
55.2
8.7
36.1
–
7.3
6 222
7 059
291 100
544 153
2007
–
-7.2
5.0
–
23.3
55.8
7.5
36.7
–
7.9
6 933
7 662
322 441
720 731
2008
–
-9.0
5.3
–
–
54.8
8.3
36.9
–
2.1
7 271
7 865
336 355
949 964
4
Health systems in transition
Ukraine
Health systems in transition
Ukraine
In 2008, the rate of growth of the Ukrainian economy slowed down to 2.3%.
Consequently, despite the favourable growth in GDP in the 2000s, in 2008 it
was 74.1% of the GDP level in 1990. The falling rate of GDP growth has been
accompanied by a high rate of inflation, 10.3% in 2005, 11.6% in 2006, 16.6% in
2007, 22.3% in 2008, and in 2009 it fell a little, to 15.0% (currency.in.ua, 2010).
These economic problems and the impact of the global financial crisis led the
Ukrainian government to approach the IMF and World Bank for assistance
in late 2008. The global economic crisis has hit Ukraine especially hard and
official figures for the first quarter of 2009 show that GDP fell by 20.3% when
compared with the first quarter of 2008, 17.8% for the second and 15.9% for
the third compared to the figures for 2008. In 2008, calculations based on the
International Labour Organization (ILO) methods show that the unemployment
rate among the working age population was 6.5%, and registered unemployment
was 2.8%, but this has grown with the deepening economic crisis; in 2009,
9.4% of the working age population was unemployed (3.7% were registered).
Although it would seem that employers in Ukraine have preferred not to lay off
employees but have put them on unpaid leave or cut working hours instead, it
has been estimated that the true unemployment rate in 2009 was between 9%
and 12% (Blinov, 2008).
According to the State Statistics Committee of Ukraine, the average monthly
income per household in 2007 was 715 hryvnya (US$ 141.60): 764 hryvnya
(US$ 151.30) in urban areas and 613 hryvnya (US$ 121.40) in rural areas;
in 2008 it was 1031 hryvnya (US$ 133.90): 1116 hryvnya (US$ 144.90) in
urban areas and 852 hryvnya (US$ 110.60) in rural areas; and in 2009, it was
1098 hryvnya (US$ 137.3): 1172 hryvnya (US$ 146.5) in urban areas and
941 hryvnya (US$ 117.6) in rural areas. In 2008, in comparison with 2007,
the average monthly income per household nominally grew by 38%, but in
real terms it grew by just 9.6%, and in 2009, it nominally grew by 6.5%, but
in real terms shrank by 8.5%. In the annual household budget survey, 86%
of respondents considered themselves poor, while only 13.4% said they were
middle class. Consequently, almost no one in Ukraine perceived themselves to
be wealthy. In 2008, 17.7% of the population earned less than the subsistence
minimum of 607 hryvnya (27.2% of the rural population and 13% of the
urban population). In 2009, 16.1% of the population did not earn a living wage
(22.4% of the rural and 13% of the urban population).
As per the joint resolution of the Ministry of Labour and Social Policy,
Ministry of Finance, Ministry of Economy, State Statistics Committee of
Ukraine and National Academy of Science Methods of integrated poverty
assessment (Resolution No. 171/238/100/149/2 issued 5 April 2002), the poverty
5
6
Health systems in transition
Ukraine
line in Ukraine is calculated based on a relative measure and is set at 75% of
median equivalent expenditures, whereas the threshold of extreme poverty is
set at 60%. According to one study, in 2005, 14.4% of the population in Ukraine
lived below the extreme poverty line, meaning that they did not earn 45% of
the officially established living wage (Cherenko, 2006). Using this method,
extreme poverty began rising in 2003–2005. In 2005, the extreme poverty ratio
returned to the 1999 level, despite the general improvement in the population’s
living conditions during this period. Considering improvements in the material
well-being of the majority of the population, the increased level of extreme
poverty indicates a significant gap between various socioeconomic groups
(Cherenko, 2006).
However, this relative measure could be a poor tool for determining the
poverty threshold assessment since the poverty line depends on income
distribution in society. Another frequently used poverty criterion is the ratio
of income (expenditures) and living wage, which already includes the costs
of certain food, manufactured products and services. According to the State
Statistics Committee of Ukraine, the number of people with average per capita
monthly income below the living wage fell by 2.7 times from 80.2% to 29.3%
between 2000 and 2007. However, this approach to calculating the poverty
line receives much criticism as well, due to its imperfect method of defining a
standard living wage. The World Bank, the Institute for Demography and the
National Academy of Science now use a combined solution, based on a standard
method of determining the absolute poverty threshold based on a daily food ration.
According to this method, the national poverty rate in Ukraine fell steeply from
a peak of nearly 32% in 2001 to less than 8% in 2005; largely as a result of the
growth in real wages and real social transfers (mainly increased pensions) (World
Bank, 2007). However, it was also noted that these increases were not fiscally
sustainable, particularly in the face of rising fuel costs (World Bank, 2007).
1.3 Political context
Ukraine is a unitary parliamentary–presidential republic. The Constitution
divides power between political institutions. The unicameral Parliament
(Verkhovna Rada) holds legislative power, while the government (Cabinet of
Ministers) holds the executive power. The judicial system of Ukraine consists
of a system of courts of general jurisdiction with the Supreme Court of
Ukraine being the highest judicial body in the system. The President, who is
the head of state, is elected on the basis of universal, equal and direct suffrage
Health systems in transition
Ukraine
by secret ballot to a five-year term for not more than two consecutive terms.
The President guarantees observance of the Constitution, state sovereignty,
territorial integrity, and the rights and freedom of all people and citizens. The
Parliament is formed on the basis of proportional representation. Currently,
five parties and blocs are represented in the Verkhovna Rada: Party of the
Regions (39%), Yulia Tymoshenko Bloc (35%), Our Ukraine–People’s Defence
Bloc (16%), Communist Party (6%) and Lytvyn Bloc (4%). It should be noted
that the majority of parties in Ukraine do not have a clear ideological basis and
instead reflect the interests of separate corporate groups. In the first month
after its election, the Parliament forms a coalition of factions, which includes
the majority of deputies. The coalition forms the government and suggests
candidates for the prime minister and ministerial posts which the President
officially submits for consideration to the Parliament.
Executive power in the regions and districts, and in the cities of Kyiv and
Sevastopol, is executed by local state administrations whose heads are appointed
and dismissed by the President on appeal from the Cabinet of Ministers. Local
self-government officials in Ukraine are elected directly by representatives
of village, rural, municipal and district councils. Executive bodies of village,
rural and city councils are represented by their executive committees. They
are administered by the village, rural or city Holova (head), who is elected
by the respective local community by direct vote for a period of five years.
The Crimea AR has its own Constitution, which was adopted by the highest
representative body of the Crimea AR, the Verkhovna Rada of the Crimea AR,
and approved by the Parliament of Ukraine. Its government is the Council of
Ministers of the Crimea AR.
The main health care laws in Ukraine are enacted by the Parliament. The
country is working hard to bring national legislation in line with international
health standards. In recent years, however, due to unstable parliamentary
functions, the legislative promotion of the health system has slowed significantly
(see Chapter 7).
Following independence from the USSR in 1991, Ukraine became a
presidential–parliamentary republic, with the President wielding significant
power. Citizens were unhappy with the socioeconomic distribution of wealth,
the concentration of power in one person’s hands, the power of the pluralist elites,
and bureaucratic administrative control. This dissatisfaction contributed to the
“Orange Revolution” during the presidential elections in November–December
2004, when the flawed elections returning incumbent Viktor Yanukovych to
power for a second term were challenged in street protests which prompted
7
8
Health systems in transition
Ukraine
new elections. These elections brought the leaders of the “Orange Revolution”
(Viktor Yushchenko and Yulia Tymoshenko) to power. The clashing parties
in the “Orange Revolution” reached a compromise and several amendments
were added to the Constitution regarding the political system. Thus Ukraine
changed the balance of power, becoming a parliamentary–presidential republic.
The electoral system underwent changes as well. Since 2006, the Parliament
has been formed on the basis of proportional representation. The second step of
political reforms has not yet been implemented. It entails the democratization
and decentralization of local self-government.
The new political system of 2004 has proved unstable. A series of political
conflicts was caused by unfinished political reforms and the unclear boundaries
between presidential and parliamentary powers. In 2007, the President
disbanded the Parliament elected in 2006. After the pre-term parliamentary
elections, the Yulia Tymoshenko Bloc and the Our Ukraine–People’s Defence
Bloc (the parties at the root of the “Orange Revolution”) created a fragile
majority of 227 deputies in a 450-seat Parliament. Yulia Tymoshenko became
Prime Minister in December 2007. However, tensions between President Viktor
Yushchenko and the Prime Minister worsened significantly. They held different
views on controlling inflation, the sale of state assets and budget distribution. On
the international stage, the President sought closer ties with the EU and NATO,
whereas Tymoshenko advocated a well-balanced relationship with the Russian
Federation. In 2008, the Parliament, supported by the Yulia Tymoshenko Bloc
and the oppositional Party of the Regions led by Viktor Yanukovych, reduced
the powers of the President. The Our Ukraine–People’s Defence Bloc left the
coalition soon after. Presidential elections were called for early in 2010 and the
results signalled the end of the “Orange Revolution”. Viktor Yushchenko was
knocked out in the first round of presidential elections and Yulia Tymoshenko
lost by a narrow margin to Viktor Yanukovych in the second round. Political
stability in Ukraine remains elusive, however, and the country is quite divided.
Support for Yanukovych is very much concentrated in the eastern and southern
regions of the country (where more Russian-speakers live) while support for the
Orange incumbents is predominantly in the western regions of Ukraine.
Under Viktor Yushchenko’s presidency Ukraine aspired to join both the EU
and NATO. Ukraine has established much closer ties with the EU, although no
formal application for membership has been made. NATO decided not to offer
Ukraine membership at its summit meeting in April 2008. Ukraine is a full
member of the United Nations, the World Trade Organization (WTO) since
July 2008, the CIS, the Council of Europe since 1995 and the Organization
for Security and Co-operation in Europe (OSCE). The country has ratified
Health systems in transition
Ukraine
most major international treaties which have an impact on health, including the
Convention on the Rights of the Child and the WHO Framework Convention
on Tobacco Control (as of June 2006). The Millennium Development Goals
have been adapted to the Ukrainian context and are being pursued in relation
to poverty reduction, control of HIV/AIDS, improving child and maternal
mortality and other areas.
Ukraine scored 2.2 on the 2009 Corruption Perception Index (CPI) where
10 would be a country with no corruption; this was the same score as the
Russian Federation, Sierra Leone and Zimbabwe in 2009 (Transparency
International, 2010). The CPI score for Ukraine in 2008 was 2.5 (Transparency
International, 2009), indicating that corruption levels have been increasing,
which is disappointing given that tackling corruption was one of the core
policies of the Orange government.
1.4 Health status
Social transformations, caused by new economic and socio-political
developments, have had a negative impact on population health in Ukraine,
which peaked in 1995–1996, although in recent years, the situation seems to be
stabilizing and even improving (see Table 1.3). Average life expectancy at birth
Table 1.3
Mortality and health indicators, 1990–2006 (selected years)
1990
1995
2000
2003
2004
2005
Life expectancy at birth, female (years)
75.0
72.6
73.6
73.6
73.6
73.4
2006
73.8
Life expectancy at birth, male (years)
65.7
61.3
62.3
62.3
62.0
61.5
62.3
Life expectancy at birth, total (years)
70.5
66.9
67.9
67.8
67.7
67.3
68.0
Mortality rate, female (per 1 000 female
population)
8.8
10.4
9.8
10.0
9.8
9.9
9.6
Under 65 mortality rate, female (per 1 000 female
under age 65)
2.8
3.7
3.3
3.4
3.5
3.6
3.4
Mortality rate, male (per 1 000 male population)
15.6
19.8
18.7
19.1
19.2
19.7
18.8
7.2
10.3
9.7
9.8
10.1
10.5
9.8
Infant deaths (per 1 000 live births)
13.0
14.8
12.0
9.5
9.4
10.0
9.6
Probability of dying before 5 years of age
(per 1 000 live births)
16.7
19.0
15.5
12.8
12.3
13.0
12.3
Under 65 mortality rate, male (per 1 000 male
under age 65)
Source: WHO Regional Office for Europe, 2010a.
9
10
Health systems in transition
Ukraine
fell by over three years between 1990 and 1995; it has since recovered, but has
still not reached pre-independence levels. It then began improving slowly and
in 2007 it was just one year lower than in 1990.
Most mortality is related to cardiovascular diseases (60%), followed by cancer
(12%), and external causes including accidents and poisoning (9.7%); these
three causes account for 81.8% of all deaths in Ukraine (see Table 1.4). Healthadjusted life expectancy (HALE) is not routinely calculated; international
research conducted in 2003 found that in 2002 HALE was 54.9 years for men
and 63.6 years for women in Ukraine.
Table 1.4
Main causes of death (all ages per 100 000), 1990–2006 (selected years)
1990
1995
2000
2003
2004
2005
2006
11.8
20.2
25.9
25.1
25.9
35.9
33.9
8.8
15.1
22.3
21.5
22.6
24.3
21.3
– Circulatory diseases (I00–I99)
589.0
780.2
774.6
819.7
808.0
827.2
801.6
– Malignant neoplasms (C00–C97)
184.4
182.7
173.2
164.3
162.7
164.2
161.7
– Trachea/bronchus/lung cancer
(C33–C34)
40.8
37.8
33.4
29.5
29.0
28.1
27.8
– Respiratory diseases (J00–J99)
66.5
82.5
67.4
53.7
50.7
50.1
44.0
– Digestive diseases (K00–K93)
29.7
42.6
42.1
48.2
54.6
62.1
59.0
Main causes of death (ICD-10 Classification)
I. Communicable diseases
– Infectious and parasitic diseases
(A00–B99)
– TB (A17–A19)
II. Noncommunicable conditions
III. External causes (V01–Y89)
– Transport accidents (V01–V99)
– All external causes, injury and poisoning
IV. Symptoms, signs and ill-defined conditions
26.1
19.1
14.1
18.5
18.9
19.8
19.9
107.4
162.1
146.0
146.0
143.9
141.4
130.3
104.2
88.1
50.3
61.7
61.9
63.8
57.5
Source: WHO Regional Office for Europe, 2010a.
In 2002–2005, 62% of the adult male population and 17% of the adult female
population smoked in Ukraine (WHO Regional Office for Europe, 2010b).
Alcohol consumption levels are also high and there is a growing tendency
towards alcohol abuse among children and young people. According to a
2007 survey of 15–16-year-old students, 83% had drunk alcohol in the past
12 months and 32% had been drunk; 72% of boys and 56% of girls had smoked
at least once in their lives and 13% had tried cannabis (Hibell et al., 2009).
Despite the difficulties of the transitional period, maternal and child health
has received a large amount of attention in Ukraine and significant progress
has been made on this issue. Infant mortality rose between 1991 and 1995, but
then fell by a third between 1995 and 2006. WHO and UNICEF indicators were
Health systems in transition
Ukraine
higher by 40%, but follow the same trend. The Soviet definition of a live birth is
still being used (requiring the infant to weigh a minimum of 1000 g, rather than
500 g at birth, for example), which helps account for this difference. Formally,
Ukraine adopted international reporting criteria in 2007, but as the registered
level of infant mortality did not increase that year, it is likely that it is not yet
being fully implemented. Research conducted by the Ministry of Health and
National Institute for Strategic Studies also revealed that the number of neonates
weighing between 500 g and 999 g decreased by half in the 2006–2007 period.
The analysis also showed a significant increase in the survival rate of these
infants (from 36.4 to 50.3 per 1000 live births), despite continued problems with
access to neonatal intensive care equipment (Ministry of Health of Ukraine
and Ukrainian Institute of Public Health, 2008). The early neonatal death rate
and maternal mortality have both halved since independence (see Table 1.5).
However, WHO and UNICEF consider the maternal mortality rate to be
underestimated, undercounting being due to the punitive nature of the control
system, which encourages health workers to disguise poor health outcomes.
Table 1.5
Maternal, child and reproductive health indicators, 1990–2008 (selected years)
Adolescent birth rate (per 1 000 women aged 15–19 years) a
Births to mothers aged 15–19 years (% total live births) a
Abortion rate (per 1 000 live births)
1990
2000
2005
2006
2007
59.1
32.1
28.6
29.5
30.3
2008
–
–
–
–
10.8
10.3
–
281.0
1550.6
897.9
445.6
382.2
332.3
Neonatal deaths per 1 000 live births
–
6.7
5.7
5.6
–
–
Postneonatal deaths per 1 000 live births
–
5.3
4.3
4.1
–
–
Perinatal deaths per 1 000 births
14.3
9.6
8.9
8.8
8.6
8.5
Maternal mortality rate (all causes) per 100 000 live births
32.4
24.7
17.6
15.2
19.9
15.5
Maternal deaths per 100 000 live births (WHO estimates)
50.0
35.0
–
–
–
–
Sexually transmitted infections (STIs)
Syphilis incidence per 100 000 population
Gonococcal infection incidence per 100 000 population
STI prevalence (newly registered cases of syphilis and
gonorrhoea) per 100 000 populationb
6.0
91.9
42.2
34.5
29.9
27.5
73.2
52.9
38.7
33.1
29.8
27.1
–
–
–
67.4
59.7
–
Sources: WHO Regional Office for Europe, 2010a; a State Statistics Committee of Ukraine, 2010b; b Ministry of Health of Ukraine and
Ukrainian Institute of Public Health, 2008.
After a serious rise in the prevalence of sexually transmitted infections
(STIs) in the 1990s, the rates of syphilis and gonorrhoea are now decreasing.
The abortion rate dropped by 71% between 1990 and 2007, and the number of
births to 15–19-year-old mothers dropped by 36%. Although the rate is still high
by European standards, the reduction is closely linked to the development of
family planning services since independence (see section 6.1).
11
12
Health systems in transition
Ukraine
Childhood immunization levels for vaccine-preventable diseases are
relatively high, but have been falling since 2002, which is cause for concern.
Polio, DTP (diphtheria-tetanus-pertussis) and measles vaccination coverage
fell to 90.6%, 90.5% and 94.6% in 2008, respectively (see Fig. 1.2 for data on
measles). The falling rates are unlikely to be the result of improved data quality
and are more likely the result of problems with the immunization programme
and the reporting of vaccination scares in the mass media.
The TB and HIV/AIDS situation in Ukraine is very serious. According to
the data from the Medical Statistics Centre (2008c), since 1995, TB has been
classified as an epidemic in Ukraine and TB rates increased for 10 years before
showing some signs of stabilization in 2006. The TB rate is 47 times higher
in the prison system than in the rest of the country and 1.4% of the population
are TB patients. About 10 000 people die from TB every year. Especially
worrisome is the lack of stabilization for multi-drug resistant forms of the
disease. HIV-related TB is also spreading rapidly. HIV/AIDS prevalence in
Ukraine is among the highest in the WHO European region. The first cases of
HIV in Ukraine were registered in 1987. The infection spread slowly for the
next seven years at a rate of 6–40 new cases per year, but an outbreak among
injecting drug users in 1995 aggravated the situation tremendously. The number
of HIV-positive patients is growing every year and the actual spread of HIV is
much higher than the number of registered cases. According to the Ministry
of Health HIV/AIDS Committee, 1.6% of the population are HIV-positive.
Injecting drug use remains the main mode of transmission for HIV (54.4% of
new cases), but the rate of heterosexually transmitted HIV is growing as well.
More and more children are also being born to HIV-positive mothers.
There are very limited data on health inequalities among different population
groups in Ukraine. The 2001 health study linked to the general census in
Ukraine launched a large-scale social research project aimed at establishing
measures to reduce health inequality, and protect and promote public health
(Gruzeva, 2006). The research revealed significant health differences between
various income groups. Few individuals in low-income groups evaluated their
health as excellent or good (1.2% and 11.4%, respectively); 67.8% of people in
low-income groups estimated their health as poor; and 2.3% responded with
very poor. These numbers are much higher than in the total population (12.3% to
23.2%, according to other studies). Medical facilities provide data showing
that disease rates are 45.7% higher among low-income groups than among
the wealthy. According to prophylactic screening data, disease prevalence
varies dramatically between groups according to income. General disease
prevalence was twice as high in low-income groups than in high-income groups.
Health systems in transition
Ukraine
Fig. 1.2
Level of immunization for measles in the WHO European Region, 2008 or latest
available year
100.0
99.9
Kazakhstan
Hungary
Kyrgyzstan
Belarus
Monaco (2004)
Slovakia
Turkmenistan
Greece
Russian Federation
Poland (2007)
Uzbekistan
Andorra
Albania
Spain
The former Yugoslav Republic of Macedonia
CIS
Azerbaijan
Romania (2007)
Lithuania
Finland
Turkey
Czech Republic (2004)
Portugal
Latvia
Georgia
Sweden
Luxembourg
Netherlands
Slovenia
Iceland
Bulgaria
Croatia
Germany
Republic of Moldova
Estonia
WHO European Region
Ukraine
Israel
Armenia
EU
Norway
Belgium (2007)
Serbia
Montenegro
Ireland
Denmark (2007)
Cyprus
Italy (2006)
France
Switzerland
Tajikistan
United Kingdom
Bosnia and Herzegovina
Austria
Malta
San Marino
99.1
99.0
99.0
99.0
99.0
98.7
98.9
98.7
98.6
98.6
98.3
98.3
98.3
98.3
98.0
98.0
98
98
97.8
97.8
97.7
97.8
97.3
97.1
97.0
97
97.0
97
97.0
97
96.9
96.6
96.6
96.5
96.2
96.2
96.2
96.0
96.0
95.9
95.5
95.4
95.0
95.0
94.7
94.3
94.0
94.0
93.1
93.0
91.9
91.8
89.0
89.0
89.0
87.0
87.0
87.0
87.0
85.5
85.5
83.5
83.0
78.0
73.0
0
Source: WHO Regional Office for Europe, 2010a.
20
40
60
80
100
13
14
Health systems in transition
Ukraine
Hypertension morbidity was 1.9 times higher in low-income groups, and
chronic bronchitis morbidity was 2.7 times higher. Prevalence of gastric ulcers
was 2.4 times higher in low-income groups than in wealthy groups, and chronic
gastritis was 3.3 times higher. Children from low-income households were
3 times more prone to chronic diseases than their wealthy counterparts.
According to epidemiological research conducted by the Ukraine Dental
Association, there is a high prevalence of dental caries in the country (Ministry
of Health, 2008): 87.9% of 6-year-old children with 4.6 decayed, missing and
filled teeth (DMFT) had temporary occlusion caries; 72.3% of 12-year-old
children with 2.75 DMFT had permanent occlusion caries; 70–80% of
15-year-olds surveyed had periodontal problems. Caries prevalence is much
higher in areas with low fluoride content in the drinking water (78.6% of the
population with 3.62 DMF), whereas in areas with standard fluoride content,
caries affects 61.7% of the population with 2.05 DMFT. Over 60% of children
and teenagers between the ages of 7 and 18 have teeth and jaw defects. The
congenital malformation rate remains high. Dental problems among children
in heavily polluted areas are 1.5 to 3 times higher than among children in
ecologically clean areas.
In Ukraine 72.3% of water supply systems do not comply with sanitary
norms due to a lack of sanitary protection zones; 17.4% of water supply systems
lack necessary treatment facilities and 18.2% do not have disinfecting facilities.
The water supply pipeline network is in poor condition; in some regions 30–70%
of pipes are worn out. Routine and major repairs, as well as emergency repairs,
do not occur in a timely manner. Some regions, especially in the south of the
country, suffer from insufficient water supplies on top of poor water quality.
Timed water supply and long interruptions lead to the bacterial contamination
of drinking water. Sometimes water supply facilities are denied power services,
which aggravates the situation. Agricultural water supply is of particular
concern. Transferring rural water supply networks to the jurisdiction of local
self-governments had a negative impact on water quality. Often, citizens have to
repair the infrastructure themselves. Many rural water systems lack treatment
and disinfecting facilities. Only a quarter of rural areas have a centralized water
supply. The rest of the population use decentralized water sources such as wells.
These water sources often suffer from unsatisfactory sanitary and technical
conditions (Ministry of Health, 2006). In 2006, 12.6% of drinking water samples
from the centralized system did not comply with sanitary requirements due to
sanitary and chemical indicators; 4.1% of samples were unsatisfactory due to
bacteriological indicators. For decentralized water samples, these percentages
were 31.9% and 20.6%, respectively.
2.1 Overview of the health system
T
he Ukrainian health care system is still based on the integrated Semashko
model. Officially the system is financed by general taxation and formally
provides universal access to unlimited care free at the point of use in
public medical facilities. The different levels of public medical facilities are
funded directly by the respective budgets. But all levels of local budgets (regional,
municipal, district and village budgets) are financed through the allocation of
funds from the central budget according to special formula approved by the
Cabinet of Ministers of Ukraine. Formally, the health system in Ukraine is
completely controlled by the state. In theory, management of the system and the
coordination of its activities are provided by the Ministry of Health of Ukraine.
In practice, however, the Ministry’s influence is significantly limited.
The national Ministry of Health coordinates and governs the core health
system through regional health authorities, which are structural subdivisions of
local administrations but are functionally under the jurisdiction of the Ministry
of Health (see Fig. 2.1). At the regional level the Ministry of Health of the
Crimea AR, oblast (regions), and Kyiv and Sevastopol health administrations
are accountable to the national Ministry of Health for national health policies
within their territory. They are also responsible for regional health care facilities
which primarily provide specialized and highly specialized services. At the
local level, primary and secondary care facilities and hospitals are owned by
the various tiers of local self-government – district administrations, municipal,
city district, village and rural councils. Most medical services are provided to
the population in facilities which are under local self-government at the regional,
district, municipal or village level and which are generally financed from the
budgetary resources of the relevant tier of the government which are allocated
transfers to the local self-government level. However, due to poor government
financing of the health system, the population is required to pay for outpatient
and inpatient pharmaceuticals as well as provide unofficial remuneration to
medical personnel.
2. Organizational structure
2. Organizational structure
16
Health systems in transition
Ukraine
Fig. 2.1
Overview of the health system
STATE BUDGET
CENTRAL GOVERNMENT
State SanitaryEpidemiological Service
(SES)
Ministry of Health
Medical higher education
establishments
National-level
medical facilities
Central
SES
State Pharmaceuticals
Quality Control
Inspectorate
Other ministries
National Academy
of Medical Sciences
Regional administration
Parallel medical facilities
Specialized centres,
scientific research
institutes
Regional-level
medical facilities
Regional
budget
Regional
SES
Municipal
budget
Municipal
SES
District
budget
District
SES
Regional health
authorities
Town councils
Municipal health
authorities
Municipal hospitals
Municipal polyclinics
FAPs
District administration
District health
authorities
Village councils
Central district hospital
Rural hospitals
Rural outpatient clinics
Community budget
FAPs
Administrative relations
Financial flows
Private clinics
Private hospitals
PRIVATE SECTOR
Patients
Pharmacies
The private sector of the health system is rather small in Ukraine and
consists mostly of pharmacies, medico-prophylactic facilities (inpatient and
outpatient), and privately practising physicians (see section 5.1.2 Capital
stock and investments). They receive their financing mostly through direct
payments from the population for medical services and devices. Apart from
Health systems in transition
Ukraine
the development of a formal private sector, the basic organizational structure
of the Ukrainian health system has essentially remained unaltered since the
Soviet period.
2.2 Historical background
After the First World War, the October Revolution and the Civil War, the USSR
suffered massive epidemics and famine. The country faced serious health
problems with much of the health care infrastructure destroyed and inadequate
resources to control communicable and other diseases. In 1918, N.A. Semashko,
the first Peoples’ Commissioner of Health, formulated the concept of Soviet
health care. The officially stated principles were state responsibility for health
care; universal access to free health care; the provision of high-quality services
aimed at maintaining health, treatment and rehabilitation and the prevention
of social diseases; and sustaining close links between medical science and
practice. The state assumed responsibility for universal health care by creating
a theoretically uniform state system to control communicable and occupational
diseases and protect mother and child health. Epidemiological control measures
for the prevention of epidemics were put into place, especially with regard to TB,
louse-borne typhus, enteric fever, malaria and cholera. Public health measures
involved interventions such as quarantine, improving urban sanitation and
hygiene and drainage of malaria marshes. There were extensive programmes
of periodic examinations of particular population groups deemed to be at risk
(Lekhan, Rudiy & Nolte, 2004).
The health system in Ukraine, under strict control of the central government
in Moscow, was formally under the control of the Commissariat (subsequently
the Ministry) of Health of the USSR, although in reality many decisions
were taken by the parallel Communist Party apparatus. Control was exerted
through five-year plans, with their centrally determined norms for equipment
and personnel that took no account of local needs. These norms were revised
periodically at party congresses, which emphasized expansion of staff and
facilities, although with little regard for quality. The government was also
responsible for developing the state hospital network and for training health
professionals. The state was the direct employer of health care workers; it also
paid staff salaries and was responsible for equipping health care facilities,
research institutes and educational institutions. Planning of resources and
personnel was strictly centralized so that what passed for management of local
health facilities involved merely low-level administrative functions. For some
17
18
Health systems in transition
Ukraine
time, a social health insurance model of health care that had been introduced in
1912 coexisted with the Soviet Semashko model. However, in 1927, health funds
were abolished by governmental decree; hospitals and other health care facilities
were nationalized and subordinated to local and regional health administrations.
Health care workers became civil servants. At the same time, separate parallel
health services, usually providing higher-quality services, were introduced for
certain population groups, such as government officials, military and security
service, or miners and other industrial workers. The territory that is now West
Ukraine retained the Hungarian and Polish systems of health insurance until its
annexation by the USSR in 1939 (Lekhan, Rudiy & Nolte, 2004).
During the Second World War Ukraine suffered greatly. Once again, many
health facilities were destroyed and many health professionals were killed or
deported. The post-war period saw a rebuilding of the health system, with
wide-ranging, if basic, interventions bringing rapid reductions in many
communicable diseases. The health system was rebuilt, based on a hierarchy
of facilities at rayon (district), oblast (region) and republic levels. It included
sanitary and epidemiological stations, hospitals, polyclinics and specialized
health care facilities, each staffed and equipped according to norms based on the
local population size rather than health needs. The polyclinic in each district was
linked to the district hospital and health staff rotated between these facilities in
an attempt to ensure continuity of services and to enhance the professional level
of health care workers; these measures, however, were increasingly unsuccessful
as demand outstripped resources. Sanitary and epidemiological stations
monitored the status of water supplies, sewerage, air and soil, investigated
outbreaks of communicable diseases, and monitored the health and nutrition
of children. Medical and sanitary aid posts delivered health care at industrial
sites and monitored occupational safety; specialized clinics provided various
services in the field of medical rehabilitation and recuperation.
The rapid expansion of the health system, providing universal access to
professional health services, along with some improvement in living standards,
was, initially, very successful in improving population health, with substantial
reductions in infant mortality and the incidence of many communicable
diseases. Health progress was steady, with life expectancy increasing up to
70 years by the early 1970s. However, the epidemiological shift in the 1960s
towards noncommunicable diseases stimulated an increasing specialization
of health care. The 1970s and 1980s saw considerable growth in the network
of specialized health care facilities, the introduction of specialized consulting
rooms in polyclinics and the conversion of general-medicine units in hospital
into specialized units. The intense and in many ways uncontrolled process
Health systems in transition
Ukraine
of specialization had shifted the priorities in health care at the expense of
primary health care, with local physicians – the leading figures in the Soviet
Semashko model – increasingly reduced to mere dispatchers of patients to
specialists. However, these developments failed to halt the increasing impact
of noncommunicable diseases, with several indicators of population health in
the USSR beginning to deteriorate from the mid 1960s onwards. These trends
had several explanations. One was the consequence of failure to invest in the
social sector as the economy of the USSR faltered. However, the USSR was also
lagging increasingly far behind the West in its ability to deliver new, complex
interventions, such as modern pharmaceuticals and surgical techniques, and
health care management continued to be based on indicators of quantity rather
than quality. Notably, the USSR missed out on the development of evidencebased medicine, which had begun to advance especially in the West from the
1970s onwards, with prikaz (official guidance) based on so-called “expert”
opinions rather than empirical evidence, a weakness whose repercussions are
still apparent. Many treatment regimes were either ineffective or, in many
cases, harmful.
Despite the limited resources available for the health system, planning
continued to be oriented towards the goal of ever-increasing capacity, measured
by the number of hospital beds and of health personnel. As a result, Ukraine,
like many other republics of the former USSR, had one of the world’s highest
numbers of hospital beds and physicians per capita. By the late 1980s, most
health expenditure was directed to inpatient care (up to 80%) with around 15%
spent on specialist outpatient services and just 5% on primary care. Inevitably,
increased quantity was at the expense of quality, and in many cases encouraged
harmful practices such as lengthy hospitalizations for minor disorders.
However, in the late 1980s, following liberalization of political and economic
relations by the policies of perestroika (restructuring) and glasnost (openness),
some regions in the USSR saw the introduction of new forms of health care
planning, financing and management called the “new economic mechanism”.
It aimed at transforming the old financing system based on capacity to one
based on the performance of public health care facilities, thus replacing the
previous administrative approach to management by contractual relationships.
The polyclinic was to become the key player in the system, holding financial
resources that would purchase services from hospitals and other health care
providers. However, these initiatives received no support from the Ministry
of Health of the then Ukrainian Soviet Socialist Republic and soon ceased
to function.
19
20
Health systems in transition
Ukraine
After 1991, Ukraine underwent a painful process of economic restructuring
that was accompanied by social instability and drastically reduced living
standards for large parts of the population, especially pensioners, disabled
people and other vulnerable groups, leading to further worsening of population
health (see section 1.4). This increased need for health care took place against
the background of reduced ability of the health system to respond adequately.
The general economic downturn also had an impact on the resources available
for health care at a time when the costs of running the system have increased
substantially. In Soviet times, costs of material and medical supplies, and basic
services such as electricity, heating and others were fixed, thus allowing the
state to maintain the extensive network of facilities. Also, the running costs
of hospitals were comparatively low. The costs of pharmaceuticals were also
relatively low, as the limited range available from production in the USSR or
in other socialist countries was subsidized. The transition to a market economy
has resulted in soaring prices of pharmaceuticals as well as basic services such
as energy, thereby further complicating the already difficult economic situation
in the health care sector. Against this background, maintaining the complex,
inefficient public health system with its unbalanced structure of services in
Ukraine has resulted in a highly unequal health system of low quality.
2.3 Organizational overview
The Verkhovna Rada (Parliament) sets the goals, major objectives, priorities,
budget guidelines and regulatory framework for the health sector, and approves
the targeted national health programmes. State health policy is then implemented
by the Ministry of Health. The President is responsible for ensuring that health
policy is implemented in accordance with health care legislation and the
Constitution through the system of executive bodies. The Cabinet of Ministers
coordinates the development and implementation of comprehensive and targeted
national programmes, and creates legal, economic and managerial mechanisms
to promote the efficient operation of the health system.
The Ministry of Finance prepares the draft state budget, which is then
submitted to the Parliament for approval. This defines the public resources to
be allocated to the health sector in any given year. The Ministry of Finance is
also the body which establishes the requirements for state institutions (including
health care facilities) in formulating and implementing budgets.
Health systems in transition
Ukraine
The Ministry of Health is the leading body within the executive power branch
responsible for implementing health policy and administering state-owned
health facilities. The health system is managed by the Ministry of Health through
the regional health authorities in the 24 regional administrations and two city
states of Sevastopol and Kyiv, where the departments are part of the city state
administrations. There is also a separate Ministry of Health of the Crimea AR,
which is part of the Crimean government (see section 2.4). At the national level,
the Ministry of Health is responsible for setting national health policies, and
directly managing and funding certain specialized health care institutions which
are in state ownership, higher medical educational establishments, research
institutes, and state-owned medico-prophylactic facilities (see Fig. 2.1, p. 16).
The Ministry of Health provides vertical management with basic command-andcontrol institutions which provide regulatory functions in the sphere of social
health protection (for example, the State Sanitary-Epidemiological Service and
the State Pharmaceuticals Quality Control Inspectorate).
The Ministry of Health is also responsible for the organizational and
methodological management of activities in the state medical catastrophe
service. The latter, in essence, is a functional interagency body. It consists
of medical forces, equipment and facilities at the central and regional levels,
which are independent of local self-government and are instead under the
Ministry of Health in cooperation with the Ministry of Emergencies, the
Ministry of Defence, the Ministry of Internal Affairs, the Ministry of Transport
and Communications, the Council of Ministers for the Crimea AR, and state
administrations for the oblast, Sevastopol and Kyiv cities. Besides this, the
Ministry of Health also manages the undergraduate and postgraduate medical
education programme, the medical research system and controls a significant
proportion of the centralized state purchase of pharmaceuticals, medical devices
and equipment for the relevant state programmes.
The Ministry of Defence, Ministry of Internal Affairs, Security Service
and Ministry of Transport and Communications all have their own health
care facilities for their employees and their relatives, which operate in parallel
to the main statutory system under the Ministry of Health. The State Penal
Jurisdiction Department is responsible for the organization of health services
within the prison system.
The Ministry of Labour and Social Policy is responsible, among other
things, for providing long-term residential care for elderly people and people
with disabilities.
21
22
Health systems in transition
Ukraine
The National Academy of Medical Sciences of Ukraine controls the research
institutes which provide highly specialized medical services. These facilities
are financed directly from the state budget through a separate funding stream.
Local authorities include district, city district, town and village councils
and state administrations. These local authorities are important actors in the
system as they own and co-finance primary care services provided to their
local populations.
Many nongovernment organizations (NGOs) – professional medical
associations and patient groups – are planned or in operation, but they are
not very influential actors in the health system. There is no self-governing of
the medical profession in Ukraine, although this is something that has proved
important in ensuring quality and transparency in other countries of Europe.
There are many international organizations working in the Ukrainian health
sector, but their activities are focused quite narrowly on specific areas such as
sexual health, HIV/AIDS and TB.
2.4 Decentralization and centralization
In Ukraine, a highly centralized model of decision-making in the health system
inherited from the Soviet era has gradually been replaced by a system in which
authority has been delegated to local administrations and self-governing bodies.
As a consequence, many recent innovative activities in the health care sector
were initiated at the regional and local levels rather than the national level. Today,
the health system is a complex multi-layered system where responsibilities in the
health care sector are fragmented among central government (the Ministry of
Health and many other ministries and public authorities), as well as 27 regional
administrations and numerous administrative bodies at municipal, district and
village levels.
Decentralization has meant deconcentration of functional and managerial
powers at the regional and subregional levels. Functional deconcentration
means that the system is managed through the Ministry of Health of Crimea AR
and the health authorities of regional administrations, which are financially
and managerially independent, while functionally subordinate to the national
Ministry of Health. Only the State Sanitary-Epidemiological Service and
the State Pharmaceuticals Quality Control Inspectorate, each with relevant
facilities at the different levels of administration, remain fully centralized and
vertically subordinated to the Ministry of Health. Deconcentration of general
Health systems in transition
Ukraine
managerial powers at the regional and subregional levels means that executive
functions in the regions and districts are exercised by the relevant local (regional
or district) administrations, the heads of which are appointed by the President.
The head of the government in Crimea AR is appointed by its Crimea AR
Parliament. As outlined earlier, the government of Crimea AR and the other
regional administrations have to ensure that decisions by local self-governments,
including those relating to the health of the population, conform to current
legislation. They also coordinate the activities of state services. The heads of local
administrations, in turn, with the approval of the Ministry of Health, appoint
the heads of local health administrations and their deputies who participate in
decision-making. The Minister of Health in Crimea AR is appointed to office
by the Parliament, and approves the appointment of the heads of the health
facilities as do the heads of the other regional health authorities.
With the enactment of the Law on local self-government in Ukraine (1997),
significant budgetary authority was delegated to regional and district councils,
which pass on management functions in health care to relevant local executive
authorities. Somewhat similar relations are seen in Crimea AR between the
Council of Ministers, the republic’s Ministry of Health and the representative
bodies. At the community level these responsibilities are delegated to councils
and their executive bodies, which are by law also responsible for managing
the local health facilities and have certain additional powers, including the
assurance of accessible health services that are free of charge, development
of a network of health services, human resource planning, contracting for the
training of specialists, provision of pharmaceuticals and medical devices to
certain disadvantaged population groups, accreditation of health facilities, and
proposals for licensing individual entrepreneurial activities in the health care
sector. Once again, local self-governments face a division of accountability, to
the Ministry of Health for compliance with norms and standards, and to the
local administrations for funding and management. They are responsible for:
•
implementing national health policies at the local level;
•
drafting local budgets and proposals on health care financing and
reporting to the councils on expenditure against budget;
•
funding and running public health care facilities;
•
pooling budgetary and other resources to invest into health care facilities;
and
•
undertaking appropriate action to prevent and eliminate communicable
diseases.
23
24
Health systems in transition
Ukraine
In contrast, decentralization through privatization has been largely inhibited
by provisions of the Constitution prohibiting the reduction of the existing network
of public health facilities. Instead the private sector is developing mainly through
the establishment of new private health facilities and medical practices.
Local authorities are given responsibility for organizing their health services
subject to strict central regulation. Decentralization of financing, along with
increasing recognition of the health care needs of the population, has, however,
led to increasing inequalities between wealthier and poorer areas. Deprived
regions have been affected by the lack of sustainable sources of income
and health care has become a heavy burden on local budgets. A number of
communities have found it increasingly difficult to maintain health services
in the public sector. However, with the passing of the Budget Code (2001),
strict rules were established, allowing for inter-budget transfers as of 2002. The
volume of transfers is based on a specific formula that takes account of financial
norms of adjusted budget allocations, the number of residents in the territory
and an index of relative fiscal solvency. This mechanism has, to a certain
degree, levelled differences in budget capacities among regions and territories.
In addition, the Budget Code explicitly defines the types of health facilities that
can be funded by budgets at various administrative levels. However, public
health care facilities may not be financed from more than one budget.
The most notable changes have taken place in specialized health facilities.
The law has provided for centralized financing and management of specialized
health facilities at regional level. These provide a range of mental health, TB,
dermato-venereological and other services, generally involving low technology
but used by a substantial number of patients. The decision to concentrate these
services at the regional level has raised concerns among health professionals
and decision-makers, specifically in cities where these specialized services
exist in independent structural units, as the changes may impede integration
of municipal health services. The transfer of these facilities to the regional
level has also created problems for regional budgets. A number of municipal
administrations have therefore decided to formally convert, that is, to
re-designate specialized facilities as multi-specialty facilities. For example, one
specialist psychoneurology clinic in Dnipropetrovsk oblast was joined with
the pulmonological department of a general municipal hospital. The newly
created organization officially became a municipal hospital. The move to strict
legislative regulation of public finding of health care facilities led to some
streamlining of resource use but created problems in integrating different levels
of service provision.
Health systems in transition
Ukraine
2.5 Patient empowerment
2.5.1 Patient information, rights and choice
By law all citizens have the right to access information about their health and
services available to them, but the mechanisms for accessing such information
are not transparent. Patients also have the right to access care of adequate quality,
and this is recognized as part of the accreditation process for health facilities,
but this has not thus far acted as a clear mechanism for quality improvement
(see section 4.1.2 Regulation and governance of providers). Patients officially
have a choice of doctor and facility, but this is difficult to realize due to the
way in which the system is financed (see Chapter 3 and section 6.2). Overall,
the health system in Ukraine is not oriented towards the real health needs
of patients.
2.5.2 Complaints procedures (mediation, claims)
There is no specific legal mechanism for patient complaints procedures within
the health system. It is dealt with in general legislation regarding complaints
(Law on citizens’ appeals 1996) and thereafter to the Law on human rights
ombudsman under the Parliament of Ukraine.
2.5.3 Patient participation/involvement
Although there are a number of legal provisions for public participation in the
health sector and various patient groups, they have not yet played an active role
in policy-making.
The necessity of protecting patient rights is noted in many normative acts, for
example in basic legislation about health care and criteria for the accreditation
of health facilities. However, patient rights in the Ukrainian health system
are not protected systematically. In Parliament in 2007 there was a legislative
project for protecting patient rights, which set up the legal basis for government
policy and regulated relations in the provision and protection of patient rights.
However, full consideration of the legislative project has not yet taken place. In
Ukraine in recent years, a movement for creating community advisory boards
in health care has begun. They are created under the local health authorities,
medical facilities and independent social organizations, but their influence on
the activities of the health sector is not yet significant (Angelov, 2007).
25
26
Health systems in transition
Ukraine
The population of Ukraine is very critical of the condition of health care
in their country. In an international social survey conducted in 24 countries
of Europe in 2005, Ukrainians gave their health system the lowest marks of
any country – just 2–3 on a scale of 1–10 (Golovakha, Gorbachik & Panina,
2006). Another piece of social research, conducted in Mykolayiv oblast in 2006,
found that most respondents felt the health service had poor accessibility and
that services were of poor quality (Glukhovskii, 2007). The main source of
dissatisfaction in patient complaints is the quality of medical care. The Ministry
of Health alone receives around 5000 letters of complaint every year. This is
only a small fraction of the total volume of complaints, as the majority of them
are sent to and dealt with at a lower level of the health system.
H
ealth care expenditure in Ukraine is low by regional standards and
has not increased significantly as a proportion of GDP since the mid
1990s. The proportion of general government expenditure on health
as a proportion of total health expenditure was 57.2% in 2008 (WHO, 2009).
The bulk of government expenditure pays for inpatient medical services, with
only a relatively small proportion (22.7%) going to outpatient services. Private
expenditure primarily consists of out-of-pocket payments, which are high on
account of the high cost of pharmaceuticals. These are generally purchased at full
cost price by patients; significant informal payments are also levied in the system.
Officially, Ukraine has a comprehensive guaranteed package of health care
services provided free of charge at the point of use as a constitutional right,
nevertheless user charges are widely levied in the Ukrainian health system.
Government attempts to define a more limited benefits package have left it to
the individual facilities to determine which services are covered by the budget
and which are subject to user charges. This has led to a lack of transparency in
the system which has contributed to an increase in informal payments.
Most health financing comes from general government revenues raised
through taxation (value added taxes, business income taxes, international
trade and excise taxes). Personal income tax is not a significant contribution to
total revenues (see Fig. 3.1). Out-of-pocket payments account for a significant
proportion of total health expenditure and there are some limited VHI schemes.
Funds are pooled at the national and the local level, as local self-governments
retain a proportion of the taxes raised in their territory. There are also interbudgetary transfers to boost the coffers of poorer local authorities which cannot
raise as much revenue. With the exception of a couple of pilot regions, allocations
and payments are made according to strict line-item budgeting procedures
as under the Semashko system. This means that payments are related to the
capacity and staffing levels of individual facilities rather than the volume or
quality of services provided.
3. Financing
3. Financing
Health systems in transition
Ukraine
Fig. 3.1.
Health care financing flowchart
Social
insurance
fund
Compulsory contributions
Donor aid
State budget
General
taxation
State health
programmes
State SanitaryEpidemiological
Service (SES)
Medical universities
and training
Ministry
of Health
Interbudgetary
transfers
Republican
sanatorium
National-level
health facilities
Parallel health
services
Other
ministries
Local
budgets
Regional
health
budgets
Local taxes
28
Regional
health
authorities
Municipal/
district
health
budgets
Municipal/
district
health
authorities
Population
Primary,
secondary,
tertiary care
services
Academy of
medical sciences
Research and
tertiary care
Local sanatoria
Rehabilitation
care
Regional-level
health facilities
Inpatient care
Municipal and
district health
facilities
Health centres
Rural health
facilities
Community
budgets
Sanatoria
care
Primary care
Emergency care
Health
promotion
Primary care
Private
medical
practitioners
Salaries
Patients
Informal
payments
Private
medical
facilities
Health
workers
Enterprises
Pharmacies
Direct payments
VHI,
sickness funds
State
facilities
Services
provided
Private health
facilities
Health systems in transition
Ukraine
3.1 Health expenditure
The State Statistics Committee of Ukraine is the main source of health
expenditure data, but the official data underestimate total health expenditure, as
they do not fully reflect unofficial payments for health services. National Health
Accounts (NHA) have only recently been introduced to better summarize,
describe and monitor health care financing. Based on the approach to the creation
of NHA developed by the OECD in 2000, an investigation was completed on
total health expenditure from 2003–2004, with particular regard to the funding
of services for people living with HIV/AIDS (Gotsadze et al., 2006). In this
report, official data from the State Statistics Committee of Ukraine were used
to investigate the expenditures of state and private companies. To estimate
donor activity in financing, data were collected through interviews with donors
and the analysis of various reports from national and international organizations.
The investigation of out-of-pocket payments used data from a special household
survey undertaken in 2003–2004. The survey included 10 238 households and
26 675 respondents. It covered the entire population except for servicemen,
convicts, permanent residents of boarding schools and nursing homes, and the
marginal population (homeless people etc.). Nevertheless, it was felt that the
data on out-of-pocket expenditure were underestimated in this study (Gotsadze
et al., 2006). Consequently, the State Statistics Committee of Ukraine was
advised to revise its methods when conducting household surveys for future
estimates in NHA.
The NHA project materials formed the basis for the Methodological
recommendations on compiling National Health Accounts, which was approved
by Order No. 137 of the State Statistics Committee of Ukraine on 10 May 2007.
As a result, the State Statistics Committee of Ukraine compiled a generalized
table of NHA for the first time in 2005. This chapter uses primarily the official
data of the State Statistics Committee of Ukraine. Data from before 1996 are
impossible to compare with the subsequent period.
Health care expenditure increased rapidly in 2000 after the prolonged
economic crises of the 1990s. Between 1999 and 2006, official health care
expenditure per capita calculated by the State Statistics Committee of Ukraine
increased 5.1 times. NHA data showed that total health expenditure grew
3.4 times. However, trends in real expenditure levels, which take inflation into
account, are lower (only 1.3 times higher for the period 2003–2008). In 1999,
the annual increase in total health expenditure was about 9% less than the
previous year as a result of the 1998 financial crisis, which affected nearly all
CIS countries. From 2000 to 2003, health care expenditure increased annually
29
30
Health systems in transition
Ukraine
(by 9.3% in 2000 up to 24.9% in 2003), which reflected the rapid growth of
the Ukrainian economy. Political crisis in 2004 slowed economic growth and
brought negative growth of health care spending in 2005 (by 2.6%). In 2006, the
level of expenditure increased by 8.1% (and by 7.7% in 2007 and 4.3% in 2008)
compared with the previous years (see Table 3.1). Total health expenditure as
a percentage of GDP remains comparatively low for a country in the WHO
European Region (see Fig. 3.2).
Table 3.1
Health care expenditure trends, 1999–2008
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Total health expenditure
(hryvnya per capita)
119.5
160.5
201.9
251.6
339.0/
390.4 a
412.3/
485.2 a
499.8/
603.0 a
748.7
990.0
1 328.2
Total health expenditure
corrected for inflation
(hryvnya per capita)
70.9
77.5
88.6
104.8
130.9/
150.7a
138.3/
162.8 a
134.7/
162.5 a
175.8
189.4
197.6
Total health expenditure
per capita (US$)
29.0
29.1
38.1
46.8
63.6/
73.2 a
77.8/
91.2 a
99.0/
119.4 a
148.3
196.0
259.8
Total health expenditure
per capita PPP (US$) b
187.0
195.0
209.0
250.0
387.0
427.0
475.0
498.0
Total health expenditure
per capita (% GDP)
4.5
4.6
4.9
5.4
6.1/
7.0 a
5.7/
6.6 a
5.3/
6.4 a
6.4
6.4
6.6
Share of state health
expenditure in total
health expenditure (%)
65.5
62.0
62.3
62.1
66.6/
58.0 a
68.3/
58.1a
66.0/
59.3 a
60.4
61.5
57.2
Share of expenditure from
all other sources in total
health expenditure (%)
34.5
38.0
37.7
37.9
33.4/
42.0 a
31.7/
41.9 a
33.9/
40.7a
39.6
38.5
42.8
Formal out-of-pocket
expenditure (%)
34.5
38.0
37.7
37.9
33.0 a
30.8 a
32.1a
–
–
–
Informal out-of-pocket
expenditure (%)
–
–
–
–
8.5 a
10.4 a
8.3 a
–
–
–
External sources (%)
–
–
–
–
0.5 a
0.7a
0.3 a
-8.6
+9.3
+14.3
+18.3
Annual growth in total
real health expenditure
from 1996 baseline (%)
314.0
+24.9
348.0
+5.6
- 2.6
0.3
0.3
0.3
+8.1
+7.7
+4.3
Sources: State Statistics Committee of Ukraine, 2001–2007, 2010a; Medical Statistics Centre, 2001–2008, 2007; a Gotsadze et al., 2006;
b
WHO, 2010.
The expenditure in US$ PPP (purchasing power parity) per capita reveals
trends similar to the real level of expenditures for health in national currency
with the decline at the end of the 1990s and the following growth in the first
decade of the 21st century. According to WHO estimates (WHO, 2010), the
full scale of changes from 1996 to 2008 is slightly greater, with expenditures
increasing from $176 PPP in 2006 to $488 PPP in 2008 (see Fig. 3.3).
Health systems in transition
31
Ukraine
Fig. 3.2
Health expenditure as a share (%) of GDP in the WHO European Region, 2005
Switzerland
France
Germany
Portugal
Austria
Greece
Belgium
Denmark
Iceland
Sweden
Netherlands
Norway
EU
Italy
Bosnia and Herzegovina
Georgia
Slovenia
Malta
Spain
United Kingdom
Ireland
Montenegro
Serbia
The former Yugoslav Republic of Macedonia
Israel
Hungary
WHO European Region
Bulgaria
Luxembourg
Republic of Moldova
Finland
Croatia
San Marino
Czech Republic
Slovakia
Ukraine
Belarus
Albania
Latvia
Andorra
Poland
Cyprus
Kyrgyzstan
Lithuania
Turkey
CIS
Romania
Armenia
Russian Federation
Estonia
Tajikistan
Uzbekistan
Turkmenistan
Monaco
Kazakhstan
Azerbaijan
11.4
11.2
10.7
10.2
10.2
10.1
9.6
9.4
9.4
9.2
9.2
9.1
8.9
8.9
8.8
8.6
8.5
8.4
8.2
8.2
8.2
8.0
8.0
7.8
7.8
7.8
7.74
7.7
7.7
7.7
7.5
7.5
7.5
7.4
7.4
7.3
7.1
7.1
7.0
6.6
6.5
6.4
6.3
6.2
6.1
6.0
5.9
5.7
5.5
5.51
5.5
5.4
5.2
5.0
5.0
5.0
4.8
4.6
3.9
3.9
0
Source: WHO Regional Office for Europe, 2010a.
2
4
6
8
10
12
32
Health systems in transition
Ukraine
Fig. 3.3
Health expenditure in US$ PPP per capita in the WHO European Region, 2005
5 521
Luxembourg
Monaco
Norway
Switzerland
Austria
France
Iceland
Germany
San Marino
Netherlands
Denmark
Ireland
Belgium
Sweden
Greece
Andorra
United Kingdom
Italy
EU
Finland
Spain
Israel
Portugal
Slovenia
WHO European Region
Malta
Cyprus
Czech Republic
Hungary
Slovakia
Croatia
Lithuania
Latvia
Estonia
Poland
Bosnia and Herzegovina
Bulgaria
Turkey
The former Yugoslav Republic of Macedonia
Russian Federation
Belarus
Romania
Ukraine
CIS
Serbia
Albania
Georgia
Turkmenistan
Kazakhstan
Armenia
Azerbaijan
Uzbekistan
Republic of Moldova
Kyrgyzstan
Montenegro
Tajikistan
5 447
4 331
4 088
3 485
3 406
3 354
3 250
3 191
3 187
3 169
3 125
3 071
3 012
2 949
2697
2 697
2 598
2 494
2 468
2 299
2 242
2 143
2 034
1 959
1 748
1748
1 733
1733
1 550
1 447
1 329
1 130
1 001
862
860
846
844
779
734
592
569
561
515
507
488
448
395
353
318
308
306
270
193
171
170
113
106
67
0
Source: WHO Regional Office for Europe, 2010a.
1000
2000
3000
4000
5000
6000
Health systems in transition
Ukraine
The exact level of total health expenditure in Ukraine is difficult to determine,
mainly because of problems in obtaining data on health care spending in the
informal sector. From 1998 to 2005, total health expenditure fluctuated between
5.0% and 6.5% of GDP, and was close to the average of the CIS countries (see
Fig. 3.4). NHA data in Ukraine show that total spending on health in 2003 and
2004 was 7.0% of GDP, and 6.4% of GDP in 2008. However, NHA data include
under-the-table payments in total health care expenditure, whereas the rate of
GDP is calculated based only on official data without including the informal
sector, which is substantial, so this may overestimate the level of total health
expenditure as a proportion of GDP. For example, in the first quarter of 2007,
the integrated informal sector accounted for 26% of official GDP (Ministry of
Economy, 2007).
Official health expenditure data show that expenditure fluctuated between
4.5% and 6.0% of GDP between 1996 and 2006, reaching its nadir in 1999–2000
(4.5–4.6% of GDP). Health expenditure increased from 2001 to 2003, but in
2004–2005 it fell again from 7.0% to 6.4% (see Table 3.1). Overall, growth in
total health expenditure as a percentage of GDP did not match the speed of
economic growth in Ukraine.
Fig. 3.4
Trends in health expenditure as a share (%) of GDP in Ukraine and selected other
countries and averages, 1998 to latest available year
9
EU
8
Republic of Moldova
7
Ukraine
Poland
6
CIS
Russian Federation
5
1998
1999
2000
2001
Source: WHO Regional Office for Europe, 2010a.
2002
2003
2004
2005
33
34
Health systems in transition
Ukraine
Total health expenditure as a proportion of GDP fell in most countries of the
CIS following independence from the USSR, and in some countries, including
Ukraine, overall expenditure levels have remained low (see Fig. 3.4). In terms of
PPP, health expenditure per capita in Ukraine is one of the lowest in the WHO
European Region (see Fig. 3.3), which shows the low priority that health care
has been afforded in the country.
Based on official statistics, the share of public revenues in total health
expenditure was over 80% in 1996, but fell to 62% from 2000 to 2002. Only
between 2003 and 2006 was there some increase in the share of government
health expenditure in total health expenditure (66–68%). NHA, which include
informal payments, show that government expenditure in 2003–2008 fluctuated
around 60% of total health expenditure. This is low for countries of the WHO
European Region (see Fig. 3.5).
Table 3.2 shows data on the main categories of health care spending in
Ukraine as a proportion of total health expenditure in 2003, 2004 and 2008.
More than half of total health care expenditure goes towards providing medical
services. About a quarter of expenditure on health care goes to inpatient care;
about 13–14% to outpatient care (including primary care and specialized
outpatient consultations). Both types of services are financed primarily from
public sources. Ukraine spends a relatively small proportion of current health
expenditure on outpatient care in comparison with other countries in the WHO
European Region. It has been argued that this reflects an inefficient use of
resources as patients who could have been treated as outpatients are instead
hospitalized (Gotsadze et al., 2006). Significant sums (about 7%) are spent on
rehabilitation care provided primarily in sanatoria – a remnant of the Soviet
era – where patients spend their vacations and receive restorative treatments.
Ancillary services receive about 4.5% of total health care expenditure.
Government sources cover about half of spending on rehabilitation and a quarter
of spending on ancillary services: laboratory tests, X-rays and other diagnostic
procedures. This shows that three-quarters of ancillary services are covered
by out-of-pocket payments. A relatively small proportion of spending goes to
treatment in psychiatric facilities, addictions clinics and day-care hospitals, as
well as long-term medical care, where almost all the expenses are covered by
public financing.
Health systems in transition
Ukraine
Fig. 3.5
Health expenditure from public sources as a percentage of total health expenditure in
the WHO European Region, 2005
90.7
Luxembourg
Czech Republic
United Kingdom
San Marino
Denmark
Norway
Iceland
Sweden
Croatia
France
Ireland
Finland
Malta
Estonia
Germany
Italy
Belarus
Austria
EU
Montenegro
Monaco
Slovakia
Slovenia
Portugal
Serbia
Turkey
Spain
Belgium
Hungary
Andorra
The former Yugoslav Republic of Macedonia
Romania
Poland
Lithuania
Turkmenistan
Israel
Netherlands
Kazakhstan
Russian Federation
Bulgaria
Latvia
Switzerland
Bosnia and Herzegovina
CIS
Republic of Moldova
Ukraine
Uzbekistan
Cyprus
Greece
Albania
Kyrgyzstan
Armenia
Azerbaijan
Tajikistan
Georgia
88.6
87.1
85.7
83.6
83.5
82.5
81.7
81.3
79.9
79.5
77.8
77.4
76.9
76.9
76.6
75.8
75.7
75.54
75.5
75.54
75.5
74.9
74.4
72.4
72.3
71.9
71.4
71.4
71.4
70.8
70.5
70.4
70.3
69.3
67.3
66.7
66.5
64.9
64.2
62.0
60.6
60.5
59.3
58.7
56.2
56.18
55.5
52.8
47.7
43.2
42.8
40.3
39.5
32.9
24.8
22.8
19.5
0
Source: WHO Regional Office for Europe, 2010a.
20
40
60
80
100
35
36
Health systems in transition
Ukraine
Table 3.2
Government health expenditure by service programme (% total public health
expenditure (THE)), 2003, 2004 and 2008
Type of expenditure
Total expenditure (% THE)
Public expenditure (% THE)
2003
2004
2008b
2003
2004
2008b
Health system administration
3.3
3.2
2.8
3.3
3.2
2.7
Education and training
2.1
2.1
–
2.1
1.9
–
Research and development in health
0.4
0.4
–
0.4
0.4
–
Investment in medical facilities
3.1
4.7
5.5
3.1
4.7
5.1
Public health and preventiona
3.7
3.7
3.4
3.5
3.3
3.2
32.7
32.7
32.7
1.0
1.2
0.5
–
–
–
–
–
–
Medical services
53.6
52.1
52.6
43.9
42.4
44.2
– inpatient care
24.5
23.6
27.1
24.2
23.2
22.2
0.4
0.3
0.4
0.4
0.3
0.4
12.7
12.7
14.3
10.8
10.8
13.0
Medicines
Medical devices
– day care
– outpatient care (excluding dental care)
– outpatient dental care
1.4
1.4
1.4
0.9
0.8
0.8
– ancillary services
4.5
4.5
4.6
1.1
1.1
1.2
–
–
–
–
–
–
– treatment in psychiatric and addiction
hospitals and clinics
2.5
2.5
–
2.3
2.3
–
– long-term care
0.2
0.2
0.1
0.2
0.2
0.1
– rehabilitation
7.4
6.9
4.8
4.0
3.8
–
– other unclassified services
1.1
1.1
2.8
0.6
1.1
–
– home care
a
This includes international aid for communicable disease prevention and family planning services.
Sources: Gotsadze et al., 2006; b State Statistics Committee of Ukraine, 2010a.
The share of spending on drugs and medical supplies accounts for a rather
large proportion of total health care expenditure (33%). State resources cover
only a small part of that expenditure (about 0.5–1%). The population carries the
main burden here, as both inpatients and outpatients have to pay for most drugs
and medical supplies out-of-pocket. Public health and prevention activities
receive only 3.5–4% of total health expenditure. This is very low, especially
considering the scale of current public health problems: population decrease,
HIV/AIDS and TB epidemics, high mortality from cardiovascular diseases and
so on (see section 1.4).
Health systems in transition
Ukraine
3.2 Population coverage and basis for entitlement
Officially, Ukraine has a comprehensive guaranteed package of health care
services provided free of charge at the point of use as a constitutional right.
Article 49 of the Constitution of Ukraine of 1996 states as follows (Verkhovna
Rada of Ukraine, 1996).
•
Everyone has the right to health protection, medical care and medical
insurance.
•
Health protection is ensured through state funding of the relevant
socioeconomic, medical and sanitary, health improvement and
prophylactic programmes.
•
The state creates conditions for effective medical service accessible to
all citizens. State and communal health protection institutions provide
medical care free of charge; the existing network of such institutions
shall not be reduced. The state promotes the development of medical
institutions of all forms of ownership.
•
The state provides for the development of physical culture and sports,
and ensures sanitary-epidemiological welfare.
In accordance with the 1992 Principles of legislation on health care in
Ukraine, foreign citizens and people without citizenship who permanently
reside in the territory of Ukraine enjoy the same rights and have the same
responsibilities in the health care sector as Ukrainian citizens. The rights and
responsibilities in the health care sector of foreign citizens and people without
citizenship who temporarily reside in the territory of Ukraine are determined
by law and respective to international agreements. There are no legal barriers
to receiving medical care for different population groups. Article 38 of the
Principles of legislation on health care in Ukraine states that “every patient,
according to his/her condition, has the right to be treated in any governmentrun health care and prophylactic facility, given that the facility is able to provide
the required type of care”.
The volume of government health care financing dropped significantly due
to the economic downturn in the 1990s. This resulted in the state not providing
real financial support for its commitments to providing free universal health
care for all citizens. In an attempt to rectify this situation, the government
undertook several attempts to introduce standards and restrictions into the
guaranteed package of free health care, and to balance it with the country’s real
economic and financial capacities. Cabinet of Ministers’ Resolution No. 1138,
37
38
Health systems in transition
Ukraine
issued on 17 September 1996, introduced official user fees for a number of
services provided by state and community health facilities. It was declared that
the official list was to include only services considered non-essential. In reality,
the range of health services that could be provided for some sort of payment was
essentially unlimited. Health care and prevention facilities were permitted to
charge for services outside their principal professional work. These procedures
include examining and treating patients referred by private practitioners, organ
and tissue transplantation, reconstructive surgery, almost all types of dental
care and many other services. In addition, health facilities were allowed to ask
patients for voluntary compensation for services rendered, which in essence is
a hidden form of payment. Only health services for children were to remain
absolutely free of charge.
The lack of an explicit boundary between paid and unpaid services created
an increase in service charges and a substantial reduction in access to health
care. This gave rise to widespread resentment and complaints. Twice – in
1998 and 2002 – the Constitutional Court of Ukraine examined the issue of
whether user charges for health services were unconstitutional. In May 2002,
the Constitutional Court stated that health care offered in state and community
facilities should be provided to all citizens without preliminary, current or
subsequent charges. At the same time it stipulated that state and community
health facilities could charge for services beyond the limits of the health system.
It was also deemed possible to mobilize additional resources using voluntary
insurance mechanisms and various other forms of financial participation by the
population, such as sickness funds and credit unions.
The size of a guaranteed health care package was the subject of intense
debate over a period of two years, but only after the strict ruling by the
Constitutional Court did the government finally approve the Programme for
Providing the Citizens of Ukraine with Free Health Care Guaranteed by the
State (2002). It gives a defined list of health care services to be provided by
state and community health care facilities for free, as well as standards on the
extent of services provided. The Programme includes:
•
accident and emergency care
•
outpatient polyclinic care
•
inpatient care for acute disease and emergencies requiring intensive
treatment; 24-hour medical surveillance and hospitalization
•
emergency dental care (complete for children, disabled people, students,
pregnant women and women with children under 3 years of age)
Health systems in transition
Ukraine
•
pre-physician aid to the rural population
•
specialized sanatoria and health resorts for disabled people and children
•
medical care for children in orphanages.
The standard for providing outpatient polyclinic care was established on the
number of visits per 1000 people. The standard for inpatient care was based
on the number of hospitalizations per 1000 people, the number of beds per
1000 people, and average length of hospital stay. The standard for emergency
care was based on the number of calls per 1000 people. In this way, the
Programme introduced a principle of accountability by tying state commitments
to the expected health budget. Despite this, the standards of health care and the
financing that should compensate the costs involved in providing care free of
charge still have not been determined.
In 2002, the government also drew up a list of paid services that should
be available in state and community health facilities (Cabinet of Ministers
Resolution No. 989, issued 11 July 2002) if the patient or a third party pays
for them in full. The government decided to charge user fees for the following
services: infertility treatment; cosmetic services; anonymous examinations and
treatment of substance abuse and STIs; surgical interventions for termination
of pregnancy (unless medically indicated); dental, hearing, ophthalmic and
other appliances; vision correction with spectacles or contact lenses; dental care
provided in state practices; physiotherapy for adults; medical examinations for
job applications, driver’s licence acquisition, the right to carry weapons and
the relevant periodic medical exams; speech therapy; treatment of stuttering
in adults; home care and treatments when feasible in an outpatient setting;
diagnostic examinations and patient appointments without referral from a
physician; parental stay at a hospital with children over 6 years (unless required
by the child’s condition); medical services for sports competitions and public
and cultural events; medical services to foreigners; and others. There were no
explicit criteria to define the services provided for a charge; however, it appears
from the list it produced that the government decided to charge for non-critical
health services.
In Ukraine, therefore, the list of guaranteed free health care services is
quite large, but in fact it is left up to the health care providers themselves to
decide which services will be provided free of charge and which ones for a
fee. Certain population groups are entitled to discounts for outpatient drugs.
For instance, benefits are provided to war veterans and so-called “socially
vulnerable” population groups: patients with socially significant and severe
39
40
Health systems in transition
Ukraine
diseases; disabled workers; physically disabled people (grouped into three
discrete categories); people disabled from birth; disabled children under the
age of 16; retired people receiving the minimum pension; children under
age 6; teenage girls and women with contraindications to pregnancy (provided
with free contraceptives); victims of the Chernobyl disaster; those under 18
suffering alopecia due to chemical intoxication in the city of Chernivtsi in 1988;
retired and disabled victims of political repression; and honourable donors.
3.3 Revenue collection/sources of funds
There are many different sources of financing for the health system in Ukraine
(see Fig. 3.6). Since the lack of an appropriate accounting system makes it
impossible to analyse the structure of health expenditure from different
sources over time, this chapter will deal primarily with data received after
the introduction of NHA, that is, from 2003 to 2008 (see Table 3.3). However,
even the NHA underestimate the population’s participation in direct health
care financing (Gotsadze et al., 2006). Data from separate regional surveys
indicate that the population’s share of health system financing is higher by about
10% (Kryachkov, Bechke & Boyko, 2000; Litvak, Pogoreliy & Tishuk, 2001;
Lekhan, Kryachkova & Maximenko, 2007).
Fig. 3.6
Percentage of total expenditure on health according to source of revenue, 2008
Donors
0.3%
VHI, sickness
funds, other
0.8%
State budget
16.0%
Local budgets
42.4%
Out-of-pocket
payments
40.2%
Social health
insurance fund 0.3%
Source: State Statistics Committee of Ukraine, 2010a.
Health systems in transition
Ukraine
Table 3.3
Sources of revenue as a percentage of total expenditure on health in Ukraine,
2003–2008
2003
2004
2005
2006
2007
2008
58.0
58.1
59.3
60.6
61.7
57.2
– Central budget
18.2
20.2
17.5
16.3
18.6
15.6
– Local budgets
39.5
37.7
41.6
44.1
42.8
41.4
– Social insurance funds
0.3
0.2
0.2
0.2
0.3
0.3
Private sources, including:
41.5
41.2
40.4
39.4
38.3
42.5
State sources, including:
– Direct payments from households
38.5
38.2
37.4
36.2
34.6
39.3
– Expenditures from private enterprises
2.2
2.2
2.2
2.3
2.8
2.3
– VHI
0.8
0.7
0.7
0.8
0.8
0.8
– Sickness funds
0.1
0.1
0.1
0.1
0.1
0.1
0.5
0.7
0.3
0.3
0.3
0.3
100.0
100.0
100.0
100.0
100.0
100.0
External sources
Totala
Sources: Gotsadze et al., 2006; State Statistics Committee of Ukraine, 2010a.
Note : a Totals subject to rounding errors.
3.3.1 Compulsory sources of finance
Central and local self-government budgets represent the major official source
of financing for health care (see Table 3.3). The total budget in Ukraine is
derived chiefly from taxation revenues (more than 70% from all kinds of
income), non-fiscal income, revenues from trade with capital and other
sources. The majority of all fiscal revenues (value added taxes, business income
taxes, international trade and excise taxes) goes to the national budget. Local
budgets are derived mainly from the part of taxation that is raised in different
administrative and territorial units. This represents about 85% of their fiscal
revenues. Local budgets are derived from small business taxes, land taxes,
licence fees on certain entrepreneurial activities, vehicle taxes, environmental
pollution payments and local taxes, dues and duties. National tax rates are set in
accordance with taxation laws as determined by Parliament (Verkhovna Rada).
Local administrations set the rates for local taxes and dues. There are no taxes
specifically earmarked for health financing and there is no system of tax relief
for the purchase of health cover.
The tax administration system, comprised of the State Tax Administration of
Ukraine and regional and municipal tax authorities, is responsible for enforcing
the tax laws, ensuring correct amounts and the timeliness of charges. The Tax
Administration coordinates its activities with fiscal authorities and the State
Treasury. It reports all taxes received, as well as other charges and fees.
41
42
Health systems in transition
Ukraine
Health care funding is considered a state responsibility. In accordance with
Ukrainian law, the execution of state duties can be delegated to subnational
levels. In this case, the national budget must assign budget resources in the form
of assigned national taxes, fees, mandatory payments or shares thereof to the
relevant budgets, or perform transfers from the national budget. To determine
the volume of inter-budgetary transfers, Ukraine uses the so-called Financial
Standard of Budget Sufficiency – that is, the guaranteed amount of resources
transferred for the implementation of assignments delegated by the state within
the limits of budget resources. In reality, the government underfunds allocations,
forcing local authorities to use their own resources. In 2005, the revenue basket
of local authority budgets was used to support social programmes, including
health (Ganushchak, 2006). As financial resources are collected through a
system of general taxation this should mean health care funding is progressive.
However, the Ukrainian system has a number of specific regressive traits. For
example, the existence of two taxation subsystems – a standard and a simplified
system – undermines the integrity of the taxation system. Further, widespread
tax evasion and the existence of tax benefits cause significant irregularities
in the distribution of the tax burden; there is a single flat income tax rate for
people with different incomes. As a result, the Ukrainian taxation system is not
as progressive as it could be and a number of loopholes challenge the stability,
administrative simplicity and efficiency of the system.
On 13 June 2007, Ukraine passed the National plan for health care
development by 2010 (Cabinet of Ministers Decree No. 815) to reform the
health system. One chapter deals with strengthening the financial base of the
sector through a transition to social health insurance. However, the problem
of complementary sources of finance has not yet been resolved. There are
multiple economic obstacles confronting the decision to introduce social health
insurance. First of all, it is a heavy tax burden on employers (social insurance
tax already accounts for 39% of the salary fund). Second, the price increase of
utilities, particularly gas, has undermined the Ukrainian economy’s competitive
ability and has thus reduced the chances of reaching a consensus regarding the
introduction of, what is in essence, a new income tax.
3.3.2 Out-of-pocket payments
According to NHA, the share of out-of-pocket payments in total health
expenditure in 2003–2008 was almost 40% (minimum 34.6% in 2007,
maximum 42.5% in 2008). Out-of-pocket payments are consistently increasing
in all main forms of spending: official service charges, drug and medical
product purchases, and informal payments. During the 1990s, the proportion
Health systems in transition
Ukraine
of formal out-of-pocket payments in total health care expenditure increased
significantly (from 19% in 1996 to 38% in 2000). It stabilized at 38% from
2000 to 2002 and then decreased slightly to 32–34% from 2003 to 2006. User
charges make up a relatively small proportion (7.3–8.6%) of total spending
or 19.7–22.5% of out-of-pocket payments for health care. Fees-for-service
in public and private health facilities account for only 2.9–3.1% of total
spending. It is possible to estimate the share of informal payments in total
health expenditure only from 2003, when NHA started being used; from 2003
to 2005 informal payments accounted for 8–10% of total health expenditure.
Out-of-pocket payments are mainly for the purchase of drugs and medical
supplies for outpatient as well as inpatient care (19.7–21.8% of total health care
expenditure and 55.4–58.4% of the total volume of out-of-pocket payments
between 2003 and 2005) (Gotsadze et al., 2006). Retail pharmacies distribute
79% of all pharmaceuticals directly to the population, while 21% go through
hospitals. NHA data show that out-of-pocket payments on pharmaceuticals
and medical supplies at pharmacies accounted for 1.3–1.4% of GDP in 2006,
but 2.1–2.2% in 2008, a significant increase from 0.8% of GDP in 1996 (State
Statistics Committee of Ukraine, 2010a). According to household surveys
performed by the State Statistics Committee of Ukraine in 2008–2009,
89.0–90.4% of inpatients had to pay for their pharmaceuticals themselves. NHA
surveys found that, as well as pharmaceutical expenditure, the share of direct
private expenditure on dental care is quite large (32.9%), as is rehabilitation
care (19.3% of total expenditure on these types of services) (see Table 3.4).
This survey found a rather small percentage of out-of-pocket payments in
outpatient and particularly inpatient care due to discrepancies in the way data
were collected. Other statistical publications have provided data on informal
payments to medical professionals. Some cities even have unofficial price-lists
for different types of services.
In order to protect themselves from pharmaceutical costs, some patients
use VHI and sickness funds as a complementary source of funding (see
section 3.3.3 VHI). They do not, however, have a significant influence overall.
The only mechanism used to ease the public burden of payments for
pharmaceuticals is the exemption of sales of pharmaceuticals and medical
supplies from value added taxes. To protect socially vulnerable population
groups and patients with socially significant and serious diseases, there are
certain benefits available for outpatient health services and pharmaceuticals.
These groups can receive pharmaceuticals from the approved government list
43
110.2
Outpatient dental treatment
Source: Gotsadze et al., 2006.
Rehabilitation including sanatoria
307.2
7 202.5
115.9
Retail pharmaceuticals
297.5
Outpatient treatment
Hryvnya
(millions)
Inpatient treatment
Type of service
58.0
1 359.0
20.8
21.9
56.1
US$
(millions)
19.3
95.8
32.9
2.0
10.0
% total
expenditure
on this type
of service
Direct payments
from the population
415.1
–
31.2
–
100.1
78.3
–
5.9
–
18.9
US$
(millions)
26.1
–
9.3
–
3.4
% total
expenditure
on this type
of service
Payments to private providers
and enterprises
Hryvnya
(millions)
Table 3.4
Volume and structure of out-of-pocket payments for various services, 2004
–
33.2
–
–
–
Hryvnya
(millions)
–
6.3
–
–
–
US$
(millions)
Sickness funds
–
0.4
–
–
–
% total
expenditure
on this type
of service
44
Health systems in transition
Ukraine
Health systems in transition
Ukraine
for free or for a discount with a prescription. However, expenditure through
this programme does not exceed 2.7% of the total spending on pharmaceuticals
(Gordienko, 2003). Expenditure on medical benefit is covered by general
allocations to health care provided by the budgets. In reality, however, even
socially vulnerable groups have to pay out-of-pocket for guaranteed services.
Some patients from vulnerable groups pressure doctors into giving them more
pharmaceuticals than required. This has caused the government to attempt to
adjust the list of groups covered and introduce subsidies instead of benefits.
The government has attempted to regulate payments for health care services.
The Cabinet of Ministers Resolution of 1996 introduced official user charges
for health services and allowed local and regional governments to establish
their own fees for health services provided at state and community facilities.
The Resolution applies to those paid services that medical facilities provide in
accordance with the approved services list and does not apply to these services
that are required to be provided to the population for free. In reality, however,
there is no clear line between free and paid medical services. As a result, the
government does not regulate prices for those services which are provided for a
fee in real life, but which are not yet included in the official list of paid services
approved by the Cabinet of Ministers. Additionally, there is no official method
of determining the full costs of medical services.
According to NHA, the volume of informal payments is currently almost
equal to the volume of formal payments, that is, 8–10% of total health expenditure
and 22% of household expenditure. But it is likely that the amount of informal
payments is underestimated (Gotsadze et al., 2006). Informal payments
existed in Soviet times, but their presence then was on a very small scale. Most
informal payments were in the form of gratuities for a service received (such
as produce in rural areas, for example, or chocolate elsewhere). As a result of
the economic downturn in the 1990s coupled with wage arrears, personnel
in health facilities have introduced informal payments in order to provide an
acceptable wage for themselves. These payments are mostly monetary and are
made before the service is provided. Often, the necessity of such payments is
indirectly initiated by medical staff: patients tell each other about the necessity
and the amounts required. For additional payment, doctors offer different drugs
and services which they claim are more modern and efficient (or faster access
to both). Payments in kind (gifts, produce) are still present in rural areas. It
is extremely difficult to gauge the true extent of informal payments in the
total income of medical staff. According to the limited NHA data, informal
payments account for roughly 20% of the total salary funds. Their distribution
is highly uneven as well, depending on location (rates are higher in the city
45
46
Health systems in transition
Ukraine
than in the country), type of care (inpatient care is much more expensive than
outpatient), the doctor’s qualifications (specialists receive higher payments than
family doctors/GPs), case complexity and so on.
Informal payments persist due to several factors, including low pay for
medical staff and the weak regulation of service providers, especially doctors
and professionals involved in decision-making. Further, the government is
not ready to admit its incapacity to provide free health care in full, which
breeds tolerance towards informal payments, despite regular loud campaigns
against corruption.
3.3.3 VHI
VHI still plays a very minor role in health care financing in Ukraine. Despite
the relative growth in the number of insured people and insurance premiums,
only 2.5% of the population use VHI, and its contribution to total health care
expenditure is 0.8%. About 1.6% of the population participates in sickness funds
and contributes nearly 0.1% of total resources to the system. The introduction
and development of VHI was only made legally possible in 1996 when the
Law on Insurance was passed.
VHI in Ukraine is offered exclusively by private insurance companies that
are often not specialized in health. According to the State Statistics Committee
of Ukraine, there are currently nearly 100 private companies in the VHI market,
offering various health care packages (Kiselyev et al., 2004). Corporate (group)
insurance, purchased by an employer, is the main form of VHI. Individual
cover insurance makes up only a small portion of VHI – individual clients
make up only 10% of the total number of VHI contracts. Many companies
purchasing VHI prefer to substitute insurance without actuarial settlements,
thereby replacing paid services by various financial schemes. The majority
of VHI customers receive health services in the same state and community
facilities as uninsured patients. Moreover, the same medical equipment is used
in treating both groups and often they receive the same level of care. The main
difference is that VHI offers partial coverage of pharmaceutical costs.
The framework within which VHI operates in Ukraine is not clearly defined.
On the one hand it can be classified as a substitute, since it is used to cover
expenses for drugs, laboratory work and other services that are not covered
by the state health system in reality. However, these services are not officially
excluded from the list of services guaranteed by the government. In fact a VHI
customer is often paying for what is supposed to be provided for free. VHI is
intruding into the state health care domain by duplicating state commitments
Health systems in transition
Ukraine
to a considerable degree, since the boundary between paid and free services is
very unclear. On the other hand VHI can be classified as complementary since
its customers receive the right to be treated in the best facilities.
There are several serious obstacles to VHI development in Ukraine. First,
VHI premiums purchased by employers for employees do not carry any tax
benefits, which means employers do not have any incentive to include health
insurance in a benefits package. The structure of financing public medical
facilities is based on an expenditure estimate which forbids using VHI resources
to create incentives for medical personnel. Doctors (and particularly surgeons)
in public medical facilities resent treating insured patients, since they refuse
to pay informally. However, medical facilities sign contracts with insurance
companies since it is now a legal way of selling medical services to the public.
A significant proportion of VHI contracts are technically quasi-insurance, a
disguise for patients paying for health services themselves. Patients pay official
premiums into VHI, but the insurance company often acts merely as an agent,
transmitting resources between the patient and the facility in purchasing health
services. Also there is a noticeably low level of compensation from VHI, which
fluctuates between 40% and 60% (Kapshuk, Sitnik & Pashchenko, 2007).
Health insurance for railway workers
There is a special part of the VHI system for insuring railway workers. It started
as an experiment initiated by the railway management in 2001. Now the entire
sector is covered by health insurance. At first, this insurance covered the rolling
stock workers and the operations department. It is gradually spreading to cover
other categories of railway workers (Kiselyev et al., 2004). In 2001–2006, the
programme insured retired workers as well; until 1 January 2001, health
insurance for retirees was substituted by fixed payments during inpatient
care at a rate of 20 hryvnya per day for no more than two hospitalizations per
calendar year.
The railway system and its workers pay premiums on an equal footing. The
total amount of monthly premiums in 2001–2006 was 4 hryvnya (a little more
than US$ 9). In 2007, it was raised to 16 hryvnya per month (US$ 38) (Yavorskiy,
2007). More than 600 000 people are covered, that is, 38% of railway workers.
In 2009, more than 40 million hryvnya in premiums was collected, making
up 7% of additional revenues for the health care budget of the Ministry of
Transport and Communications.
A private insurance company provides insurance for the railway workers.
This insurance covers inpatient care primarily in the parallel network of medical
facilities. The resources allocated to the medical facilities are designed to cover
47
48
Health systems in transition
Ukraine
spending on pharmaceuticals, food and laundry stocks for each individual
patient to cover the portion underfunded by the government budget, but only to
a fixed maximum amount. In 2007, additional compensations for inpatient and
outpatient pharmaceuticals were introduced. Further, the insurance company
makes payments to the medical facility for case administration. Medical
facilities keep a personalized record of expenditures on each insured patient.
Sickness funds
As an alternative means to mobilize additional resources for the health system,
a number of sickness funds and credit unions are being established in Ukraine,
alongside various charitable institutions and funds. Sickness funds represent
quite a well-developed network of non government organizations established on
a voluntary basis for complementary financing of the health system. Sickness
funds function as VHI on a non-profit-making basis. While, legally, VHI
companies are profit-making private organizations, sickness funds function in
accordance with the Law on charity and charitable institutions, as charitable
non-profit-making organizations guided by a common interest to improve
health care for their members.
Membership in a sickness fund is voluntary. It may comprise individuals
as well as working collectives, enterprises, agencies and institutions paying
premiums for their members. The performance of sickness funds depends
directly on the number and nature of its members. For this reason, preference
is given to corporate membership, where working collectives, enterprises, or
institutions cover fees for their employees. However, the individual premiums
remain the main source of revenue. In 2009, individual premiums accounted
for 95.7% of funds, while enterprises and institutions made up the remainder
at 4.3%. Workers make up the majority of members in sickness funds at 64%,
while 20.6% are pensioners and 15.4% are other categories of non-working
citizens. The major function of sickness funds is to provide pharmaceuticals
to their members in case of insufficient coverage from the government – in
2009, 79.8% of sickness funds’ expenditure was on purchasing pharmaceuticals
and other medical devices. A number of sickness funds have also committed
themselves to contributing modern medical equipment to health facilities,
developing targeted programmes, training and retraining personnel, advocating
for healthy lifestyles, protecting mother and child health, and many other
activities. About 17% of collected funds are spent on administration. The
income of sickness funds is derived from a number of sources: founders’ and
members’ premiums, charitable contributions, and donations and profit from
Health systems in transition
Ukraine
charity transactions. The premiums are determined by the sickness funds’
administration as a percentage of salary (usually no more than 5%) or fixed
payment (7–9 hryvnya per month or US$ 10–14 per year).
According to Ministry of Health data, the number of sickness funds increased
by 22 times between 1999 and 2006, but in 2009 they shrank as a result of the
economic crisis. In 2009, more than 750 000 people, or 1.6% of the population
of Ukraine, were covered by sickness funds (see Table 3.5). The popularity of
sickness funds differs greatly among various regions (see Table 3.6). In Ukraine,
17 out of 27 regions have a very small percentage of the population covered by
sickness funds (1%), but in 7 regions, 1–4% is covered; in 2 regions, 6–10% is
covered; and in Zhytomyr oblast, the number of members exceeds 16% of the
population. Since 1999, sickness funds’ revenues have increased by more than
50 times, and in 2009 totalled 80 million hryvnya.
Table 3.5
Sickness funds’ activity in 1999–2006 and in 2009
Number of sickness
fund members (in thousands)
Resources collected
by sickness funds
(hryvnya, millions)
Average expenditure
per member (hryvnya)
1999
2000
2001
2002
2003
2004
2005
2006
2009
39.4
76.7
232.2
403.3
652.2
826.1
844.2
858.4
751.2
1.6
3.6
13.0
17.2
28.7
37.5
39.7
50.6
80.1
40.4
47.1
56.0
42.5
44.0
45.3
47.0
58.9
103.5
Source: Ministry of Health, unpublished data, 2010.
Sickness funds reduce the overall cost of drugs and medical devices to
members and facilitate better monitoring of prescription practices. However,
considering that sickness funds cover only a small proportion of the population,
their impact on overall health care spending is rather limited: 0.13% of total
health care expenditure. In some regions, however, where municipal sickness
funds have been established with the active support of local authorities,
opinions are generally very positive about their performance, citing improved
accessibility and quality of health care (Bondarenko et al., 2003; Popov et al.,
2003). Some of these regions include Zhytomyr oblast, and small cities such as
Komsomolsk in Poltava oblast, Priluki in Chernihiv oblast and Voznesensk in
Mykolayiv oblast, among others.
49
50
Health systems in transition
Ukraine
Table 3.6
Sickness funds’ activity in different regions of Ukraine, 2009
Region
Number of
sickness fund
members
% of
population
Volume of
revenues collected
(in 1 000 hryvnya)
Hryvnya
per member
Zhytomyr oblast
213 514
16.50
24 483.0
114.7
Chernihiv oblast
85 905
10.00
7 279.0
84.7
Mykolayiv oblast
70 978
6.00
6 720.5
94.7
Poltava oblast
56 999
3.80
7 359.4
129.1
Donetsk oblast
43 932
1.00
1 910.9
49.4
Sumy oblast
41 371
3.50
4 176.1
101.0
Kharkiv oblast
34 530
1.30
1 277.9
37.0
Rivne oblast
29 789
2.60
1 071.3
36.0
86.0
Volynska oblast
29 085
2.80
2 499.9
Odesa oblast
29 050
1.20
2 405.7
82.8
Kirovohrad oblast
27 878
2.70
5 311.5
190.7
Luhansk oblast
18 071
0.80
3 918.6
216.8
Vinnytsia oblast
10 958
0.70
1 809.2
165.1
Dnipropetrovsk oblast
10 860
0.30
685.5
61.1
Kyiv city
10 790
0.40
1 709.3
158.4
Kyiv oblast
9 626
0.60
1 956.2
203.2
Chernivitsi oblast
6 841
0.80
500.2
73.1
Kherson oblast
6 093
0.60
497.7
81.7
Zakarpatska oblast
5 924
0.50
1 069.2
180.5
Cherkasy oblast
3 965
0.30
749.8
189.1
Khmelnytskyi oblast
3 809
0.30
254.5
66.8
Ivano-Frankivsk oblast
1 133
0.10
101.1
89.3
174
0.01
19.7
113.2
Zaporizhzhia oblast
Sevastopol city
0
0
0
0
Crimea AR
0
0
0
0
Lviv oblast
0
0
0
0
Ternopil oblast
0
0
0
0
751 255
1.60
80 088.5
103.5
Ukraine
Source: Ministry of Health, unpublished data, 2010.
Further expansion of the VHI sector will depend on a number of conditions,
primarily:
•
a clear boundary between state obligations and additional health services
and drugs not paid for within state guarantees;
•
an extension of tax incentives for individuals and legal entities aiming to
purchase VHI; and
•
the creation of incentives for medical personnel involved in VHI.
Health systems in transition
Ukraine
However, even if these conditions are met, an immediate expansion of VHI
is unlikely simply because it is not affordable for the general public.
3.3.4 Parallel health systems
Many ministries and other government bodies have separate “parallel” health
systems for their workers. The largest are in the Ministry of Transport and
Communications (see section 3.3.3), Ministry of Internal Affairs, Ministry of
Defence, Ministry of Labour and Social Policy, and the National Academy
of Medical Sciences, among others. These parallel systems are funded from
the national budget and almost 42% of health expenditure from the national
budget is spent on parallel medical facilities and more than 11% of total public
health expenditure.
According to data from 2008, the parallel health care network had
255 hospitals (10% of the total number of hospitals in the country), and
435 outpatient polyclinics (5.9% of the total in the country). The number of
inpatients in the parallel networks made up 7.7% of the total number of inpatients,
and visits to polyclinics made up 6.9%. The Ministry of Transport possesses
the largest parallel network: 80 hospitals and 175 outpatient polyclinics. Data
on the number of people served by the parallel health system is unavailable, but
1.7 million people work for the railway system, which is the largest industry
within the jurisdiction of the Ministry of Transport and Communications (see
also section 3.4.1 Pooling agencies and allocation).
3.3.5 External sources of funds
It is difficult to estimate the impact of external sources of financing in Ukraine.
Overall donor activity contributes very little to financing of the health sector;
according to NHA, their contribution accounts for less than 1% of total health
expenditure (0.3–0.7% in 2003–2008). Donors to the health sector include
international organizations (United Nations agencies, the EU, World Bank, the
Global Fund) as well as governments of individual countries (Japan, Sweden,
the United Kingdom, United States and others). Donations are used mostly to
provide technical assistance. For instance, the EU carried out several projects
in Ukraine, including Primary Health Care Support (€2 million; 2002–2005),
Health Financing and Management (€4 million; 2003–2006), Support for the
Development of a System of Medical Standards (€4 million; 2004–2006) and
Support for Secondary Health Care Reform (€4 million; 2007–2009).
51
52
Health systems in transition
Ukraine
There are also major initiatives involved in fighting infectious diseases
such as TB and AIDS, and supporting maternal and infant health programmes.
In 2006, the Global Fund approved a US$ 151 million grant to Ukraine to
fund the programme HIV-AIDS Prevention, Treatment, and Care for the Most
Vulnerable Populations in Ukraine, 2007–2011. In 2007, however, the Global
Fund denied Ukraine’s request for a US$ 94.6 million grant to fight TB, due
to an unclear spending plan. The Global Fund had already denied a grant for
fighting TB in 2004. In 2006, however, the country managed to secure a grant
to fight HIV/AIDS. The resources were granted directly to the Ukrainian
government, but this was followed by a scandal over an increase in the price
of medication. As a result, the Global Fund had to suspend financing, citing
concerns over slow progress and management problems. A statement issued
by the Global Fund said it had taken the decision because of implementation
bottlenecks, and management and governance issues. Financing resumed after
International HIV/AIDS Alliance, an NGO, was put in charge of the project.
Following this, in 2009, the Global Fund approved a US$ 105 million grant
requested by Ukraine to combat TB.
3.3.6 Other sources of financing
The Ukrainian government mandates that it is the responsibility of the owners
and administrators of enterprises, agencies and institutions to protect the health
of their workers. Employers, therefore, must provide their own resources to fund
compliance with safety techniques, sanitation in the workplace, recruitment and
periodic medical exams for certain categories of workers in labour-intensive,
unhealthy or dangerous jobs. They are likewise responsible for providing
thorough medical examinations and rehabilitation for workers with potential
professional or occupational diseases, and prophylactic medical examinations
for groups of workers at risk of developing occupational diseases. The State
Sanitary-Epidemiological Service administers compliance with sanitary
requirements, within the limits of budget financing.
In accordance with the Law on mandatory social insurance covering
temporary disability, occupational accidents and occupational diseases, the
Social Insurance Fund against Occupational Accidents and Occupational
Diseases uses its own resources to take measures against occupational accidents,
to remove work-related threats to workers’ health and so on. The only available
data show that the Social Insurance Fund spent 15.5 million hryvnya in 2003
(US$ 2.9 million or 0.08% of total health expenditure) and 10 million hryvnya
in 2004 (US$ 1.9 million or 0.4% of total health expenditure).
Health systems in transition
Ukraine
3.4 Pooling of funds
3.4.1 Pooling agencies and allocation
Pooling of funds for health care occurs within the budgetary process outlined by
the Budget Code of Ukraine (Law of Ukraine No. 2542-III) issued 21 June 2001.
The budget system is divided into 4 levels: (1) state/national budget, (2) regional
budgets, (3) district and municipal budgets, (4) small town and village budgets,
but it is still a “single payer” system. The Budget Code authorizes the financing
of the health system assigned to different levels of the budget system. The
historic approach remains the primary strategy for determining health care
budgets for different levels. A targeted programme approach is used to solve
acute problems in the health care sector. The national government and local
self-governments at all levels are responsible for pooling funds: the Ministry
of Health and other ministries, regional and municipal health authorities, and
rural self-governments.
State budget resources allocated to health care in accordance with the Law
on the state budget approved by Parliament are distributed among numerous
agencies controlling the budget. The most important of these are the Ministry
of Health and the National Academy of Medical Sciences of Ukraine, as well
as a number of other ministries and departments in charge of medical facilities
(see Table 3.7). Each of these agencies is responsible for financing the medical
facilities and programmes allocated to them. As a result, the Ministry of Health
is responsible for slightly more than half of the resources allocated from the
state budget (see Table 3.7).
Table 3.7
State budget resources allocation, 2008
Volume of resources
Ministries and departments
Hryvnya
(millions)
%
Ministry of Health
5 706.8
58.0
Other ministries and departments:
4 132.5
42.0
– Ministry of Transport and Communications
629.7
6.4
– Ministry of Defence
669.1
6.8
– Ministry of Labour and Social Policy
– Other ministries
– Academy of Medical Sciences of Ukraine
Total
Source: State Statistics Committee of Ukraine, 2010a.
649.4
6.6
1 102.0
11.2
1 082.3
11.0
9 839.3
100.0
53
54
Health systems in transition
Ukraine
The process of calculating the level of inter-budgetary transfers and the
estimated local budget health care expenditures depend directly on the local
population size, with the exception of those who receive care through a parallel
network (see section 3.3.4 Parallel health systems). However the majority of
parallel networks do not provide a full health care package to their workers.
Workers in these ministries and other bodies have the right to seek care in their
local community medical facilities, and they exercise this right – especially
those workers with acute conditions. Therefore the pool of funds designed to
finance parallel networks partially intersects with the regional financial pool.
Citizens benefiting from access to parallel networks as well as regular medical
facilities use a portion of the finances allocated to provide care to other people
in the same region. The interaction between parallel and regional health systems
faces a number of bureaucratic obstacles. This leads to the irrational use of
combined resources in the health system in general. The government’s National
plan for health care development by 2010 (Cabinet of Ministers Decree No. 815,
issued 13 June 2007) outlines the steps towards the formation of a unified
medical system under the Ministry of Health. This means that parallel health
facilities would come under the community’s jurisdiction and be integrated into
regional health systems. However, no practical steps have been taken in this
direction to make this happen.
Final approval of local health budgets by local representative authorities
together with general budgets takes place not later than two weeks after the
publication of the Law on the state budget. Regional health budgets include the
budgets of the Crimea AR, the 24 oblasts and 2 cities (Kyiv and Sevastopol)
which have the same status as an oblast. Regional health administrations
finance their health facilities from their own budgets. Local health authorities
or local administrations (if they have no separate health authorities in their
structure) finance health care facilities under their jurisdiction from the
relevant municipal health budgets. At the rural level, local self-governments
finance medical facilities under their jurisdiction: small rural hospitals, rural
outpatient clinics, feldsher or feldsher and midwife posts (FAPs). Splitting off
the rural level in the budgetary system led to a catastrophic fragmentation of
local health budget resources. On average there are fewer than 5000 people
per local self-government in Ukraine. Not more than 10 800 territorial and
administrative entities and settlements out of 30 000 can be considered viable
self-governing units.
The Budget Code of Ukraine presents some possibilities to improve the
effectiveness of pooling the local health system’s financial resources. It allows
municipal and local communities (settlements, villages and towns) to pool
Health systems in transition
Ukraine
their funds on a contractual basis in order to fulfil their commitments, transfer
resources for these commitments to the upper budgets, and transfer subventions
from one budget to another for the maintenance of shared facilities. In reality,
however, these options are not used. In 2005, efforts were made to centralize
expenditures on primary care in rural areas at the district level without specifying
them in the budget of the actual communities. The appropriate amendments to
the Budget Code of Ukraine (Law of Ukraine No. 2350-IV, issued 13 January
2005) were made, but the Cabinet of Ministers of Ukraine put the fulfilment of
those amendments on hold. The political opposition to this decision claimed that
depriving small communities of the possibility of financing their own primary
medical care needs by transferring these functions to the district budgets is in
effect an attack on the rights of local self-governments. In 2008, the amendments
to the Budget Code of Ukraine mentioned above were annulled.
3.4.2 Mechanisms for allocating funds among pooling/
purchasing agencies
The financing of social needs including health care is a state duty, but often
the execution of these duties is delegated to the subnational level. Delegated
assignments are financed through the system of inter-budgetary transfers. The
size of transfers is calculated with the goal that they would completely finance
the regional and local levels. The regional budget gives part of the received
transfers to the district and municipal budgets, which in turn direct part of
these resources to the small community budgets. The volume of health care
expenditures in the regional, district and municipal budgets is determined by
special formulas approved by the Cabinet of Ministers (Decree No. 1195 issued
5 October 2001, amended 14 October 2005, On approving the distribution of
inter-budgetary transfers between state and local budgets and Decree No. 1782
issued 31 December 2004, amended 29 December 2005, On regulation of interbudgetary relations), which take into account the gender and age specifics of
the population.
Inter-budgetary transfers are designed to finance all duties of the state,
including public administration and social needs. Within the total volume
of transfers, there are no specifications for resource allocation for separate
state commitments such as health care. Regional administrations and local
self-governments have the right to determine the structure of their expenditure
and therefore decide independently where to use the transferred resources.
The rights of local authorities are limited, however, by decisions passed at
the national level, for example, to raise the salaries of budget system workers,
as well as obligations imposed by the Budget Code to pass down part of the
55
56
Health systems in transition
Ukraine
transfer. It is also forbidden to decrease the volume of spending on state
programmes targeting diabetes mellitus and diabetes insipidus. Expenditure
on these programmes is included in the sums transferred.
The structure of health care expenditure distribution between the levels of
the budget system within the amounts of transfers that are passed down from
the state budget is as follows:
•
at the regional level, 35.4% of the total expenditure should be kept for
health care;
•
at the municipal and district level, not more than 55.1% of total
expenditure within the inter-budgetary transfer must be kept for health
care; and
•
community budgets must receive not less than 23% of the total health
budget included in the transfers passed by the state down to the municipal
and district budgets mentioned above (or not less than 9.5% of the total
health care budget included in the transfers passed by the state down to
the regional budgets), but this money is not ring-fenced.
In practice, however, the planned expenditure does not always match the
calculated figures during the passing of subnational budgets. A certain authority,
for example, might decide to allocate more resources to the education system
and cut the financing of the health system. For instance, during the drafting
and passing of the budget in 2005, 17 out of 25 regions in Ukraine planned a
smaller volume of health care expenditure in their budgets than was foreseen
in the figures calculated by the Ministry of Finance. No nationwide data are
available, but a study of six regions found that the community budget resources
allocated to health care make up only 13–16% of the estimated health care
expenditure within the transfer passed down from the state budget to regional
budgets, which is only half to two-thirds of the estimated 23%.
State budget expenditure includes subventions to the subnational budgets
for supplying medical equipment to rural outpatient clinics, feldsher posts and
FAPs, and for the purchase of ambulances for rural medical facilities. In earlier
years the Ministry of Health itself and other central agencies used resources
from the national budget. Instead of transferring money down to the regional
level, they purchased and sent equipment, drugs and so on. The majority of
resources come from local budgets, however, and their share has increased in
recent years, due to the decrease in centralized purchasing from the state budget.
Health systems in transition
Ukraine
Municipal budgets play the main role in the consolidated health care budget
structure, which is not surprising considering that 68.1% of the population in
Ukraine is urban. Community budgets play the smallest role (see Table 3.8).
Table 3.8
Distribution of national health expenditure based on budget system level, 2004
Budgets
Public health
expenditure
(million hryvnya)
Proportion of
public health
expenditure, %
National budget
4 628.6
34.8
Territorial budgets, including: a
8 687.5
65.2
– Regional budgets
2 318.3
17.4
– Municipal budgets
3 464.3
26.0
– District budgets
2 064.0
15.5
– Community budgets
Total public health expenditure
517.1
3.9
13 316.1
100.0
Source: Gotsadze et al., 2006.
Note : a Data are missing on the allocation of about 323.8 million hryvnya of territorial budget resources to the lower budget levels.
The growing importance of local self-government in health spending has
been matched by the growing importance of input norms which determine the
demand for funds as opposed to the supply of funds (see section 3.6.1 Paying
for health services).
State targeted programmes
There are a large number of state targeted health care programmes that address
a wide spectrum of health care problems such as immunization, fighting TB
and HIV/AIDS epidemics, reproductive health, prevention and treatment of
cardiovascular and cerebrovascular diseases, prevention and cancer treatment,
and so on. The programmes are approved either by executive order or by law.
The Ministry of Health orders, manages and coordinates these programmes. As
the government passes these programmes, it orders the Ministry of Finance and
the Ministry of Economy to make provisions for these programmes in drafting
the state budget and forming a state policy of economic and social development
for a given period. At the same time, the regional executive authorities receive
recommendations for drafting and approving the corresponding regional
programmes that must contain directions and measures outlined by the
appropriate state programmes. They also receive recommendations for using local
budget funds and other legal resources for the execution of these programmes.
However, these recommendations almost always remain unfulfilled, and even
if the regional programmes take place they receive a very small portion of
57
58
Health systems in transition
Ukraine
resources from local funds. For example, data from the Ministry of Finance
show that in 2004 the government allocated 580.1 million hryvnya from the
state budget to finance state targeted programmes, but all the regional and
local budgets together allocated only 31.04 million hryvnya to run programmes
fighting TB and HIV, providing insulin to people with diabetes, immunization
programmes and centralized measures for treating cancer. Within the limits of
these state programmes, the Ministry of Health purchases drugs for cancer, TB,
HIV/AIDS and other illnesses, and delivers them to the regions.
There are no special budgets for the development of human resources and
mental health protection. The proper expenditure is calculated in drafting first
a state budget and then local, primarily regional, budgets.
3.5 Purchasing and purchaser–provider relations
The organizational relationship between purchasers and providers is based on
an integrated model. State and community medical facilities (the providers
of medical services) are under the administrative jurisdiction of their owners,
that is, the corresponding state and local authorities (purchasers). Therefore in
Ukraine the model is based on the principles of appropriate budgetary payments
for medical services but not on the purchasing of medical services, which would
be based on strategic public procurement contracting.
In financing health care from the budget, payments are made by state
authorities, which are also established in the Budget Code as the chief
administrators of budgetary resources. The chief health administrators of
budgetary resources are the Ministry of Health and the National Academy
of Medical Sciences of Ukraine, as well as a number of other ministries
and departments. Each of these authorities finances the medical facilities
and programmes in its jurisdiction – the list is approved by the Cabinet of
Ministers (Decree No. 342, issued 15 April 2002, On approving the list of
medical facilities and health programmes financed from the state budget). The
medical agencies of ministries and departments receive their funding from the
state budget. In calculating inter-budgetary transfers, the estimates of health
expenditure from local budgets depend on the size of the local population,
excluding those who receive care through the parallel network. However the
majority of parallel networks do not provide a full health care package to their
workers. Workers in these departments have the right to seek care in their local
community medical facilities, and they exercise this right – especially those
workers with acute conditions.
Health systems in transition
Ukraine
The Ministry of Health finances the State Sanitary-Epidemiological
Service, higher medical education institutions, the State Pharmaceuticals
Quality Control Inspectorate and related local inspections, and approximately
50 national-level medical agencies under its control that provide everything
from primary to tertiary care. Additionally, the Ministry of Health funds state,
interagency, and integrated programmes and measures related to health that are
financed from the state budget. There are also certain centralized procedures
through which the Ministry of Health purchases pharmaceuticals, medical
devices, immunobiological medicines, expensive medical equipment and
hospital vehicles.
The regional chief administrators of budgetary resources for health are the
Ministry of Health of Crimea AR, along with health authorities in the regions, and
the municipal administrations of Kyiv and Sevastopol, which finance medical
facilities under their control. At the municipal level, the chief administrators of
budgetary resources are the health authorities within the executive municipal
powers. At the district level, there are no requirements regarding the existence
of health authorities. On 11 May 2005, the Cabinet of Ministers added a health
authority to the list of departments in the administration at the district level
(Decree No. 328, On the structure of local state authorities, Appendix 3).
However, its goals, functions and authorities were defined by the Cabinet of
Ministers only on 28 November 2007 (Decree No. 1364, On approving basic
regulations for the health sector of district state authorities). Therefore, health
authorities in district administrations are currently exceptions, not the rule. The
district director fulfils the role of the chief administrator of budgetary resources.
At the community level, local self-governments distribute budget resources to
rural outpatient clinics, FAPs and feldsher posts. The activity of purchasers is
controlled through this hierarchical management structure.
3.6 Payment mechanisms
3.6.1 Paying for health services
Payment mechanisms in the Ukrainian health system are prospective. The
overwhelming majority of state and community health care facilities are
officially financed by the government. According to the Budget Code of
Ukraine, they must be supported by the national or the relevant local budget.
There is strict allocation of resources between the budgets, and any given
facility can receive financing from one budget only. The real level of resource
59
60
Health systems in transition
Ukraine
allocations to government-financed facilities is based on historical budgeting
adjusted for inflation and any budgetary increases. The Ministry of Finance
and local fiscal authorities give the Ministry of Health, local health authorities
and local self-governments the maximum health expenditure from the draft
budget for the following year. The Ministry of Health, local health authorities
and local self-governments then determine the maximum expenditure for the
health facilities funded by them, and the facilities produce cost estimates for
the next fiscal year. The Ministry of Health, local health authorities and local
self-governments then examine these estimates to ensure they include accurate
projected income and expenses figures, justification for planned expenditure,
and that they comply with established wages, norms, prices, limits and other
indicators in accordance with the law. They then create the draft budgets. Based
on the draft estimates, the Ministry of Health, local health authorities and
local self-governments draft budget requests and submit them to the financial
authorities to be included into the appropriate draft budget. Once the draft
budgets are drawn up, the Ministry of Health, local health authorities and local
self-governments make any necessary corrections to the volume of budget
funding to the facilities, before approving the drafts.
The primary and mandatory responsibility of government-financed facilities
is to provide budget resources for salaries, pharmaceuticals, food and the
maintenance of facilities. Thus the purchase of equipment, renovations and
other expenditure not considered priorities can receive financing only if the
primary requirements are covered and there are no other debts. In reality, salary
expenditure accounts for more than two-thirds (70.8% in 2008) of territorial
health care expenditure, followed by pharmaceutical expenditure and catering
(19.8%), utilities (8.3%) and other expenditure (1.1.%) (Gotsadze et al., 2006).
The allocation of budgetary funds is thus based on a list of permitted line
items, which in turn is based on norms set by the Ministry of Health defining
inputs such as staff, salaries, pharmaceuticals, catering and so on. The majority
of these norms depend on the capacity of a health facility (number of beds
in hospitals or number of visits in polyclinics). Many of these norms do not
reflect real expenditure, for example on pharmaceuticals or hospital food.
Facilities must spend resources exactly as allocated. They are not permitted to
reallocate resources from one line item to another. Any changes in the facility’s
income and expense estimates must be approved by the chief administrators
of budgetary resources and by the appropriate fiscal authorities, if the changes
involve adjustments to the consolidated level of budgetary expenditure. If there
are any unspent funds at the end of the year, the fiscal authorities will cut the
facility’s budget estimates for the next year by the same amount.
Health systems in transition
Ukraine
Line-item budgeting is very straightforward for the fiscal authorities in
planning expenditures and controlling the targeted usage of allocated resources.
However, this approach has a number of drawbacks: (1) input-based financing
encourages health facilities to maintain excess capacity; (2) allocating resources
for the maintenance of medical facilities, rather than the volume of work, does
not provide incentives to improve productivity; instead the incentive is given
to increase the infrastructure; (3) line-item budgeting limits the authority and
responsibility of the management in medical facilities and does not provide
incentives to look for more efficient ways to use resources. Therefore, resource
allocations based on expenditure estimates are not linked to the workload of
those who receive the resources. There are no incentives for health facilities
to use their resources more rationally, and this creates a cost-based type of
management. Consequently, even a significant increase of resource allocations
to health facilities does not guarantee better fulfilment of the government’s
social commitments (see section 8.3).
Individuals and legal entities that are not financed by the government may
receive funds from the budget to contribute to state programmes. They must use
these funds in accordance with the budget resources usage plan, that is, they must
distribute budget allocations in accordance with line-item budgeting. The budget
resources usage plans are approved by officials in accordance with the chief
administrators of budgetary resources, through which they receive the funds.
Centralized purchasing is done by the chief administrators of budgetary
funds for facilities under their jurisdiction. Centralized purchasing includes
items such as vaccines, pharmaceuticals to fight TB, for the prevention and
treatment of HIV/AIDS, and for treating cancer, pacemakers, implants and
other medical devices, expensive medical equipment, ambulances for rural
medical facilities, and other items for fulfilling the measures outlined in state
programmes. Centralized purchasing is conducted through tendering procedures
by enterprises under the jurisdiction of the Ministry of Health (Ukrvaccine,
Politechmed, Ukrmedsnab). The purchased pharmaceuticals and equipment
are then distributed to the regions. The quantity, quality and assortment of
purchased pharmaceuticals and medical devices often fail to satisfy the needs
of medical facilities.
Budget allocations do not cover all health care expenditure in public medical
facilities, despite the constitutional guarantees regarding free health care in
state and community medical facilities (see section 3.2). In reality, there are
many methods of payments, both formal and informal (see section 3.3.2 Out-ofpocket payments).
61
62
Health systems in transition
Ukraine
The Budget Code stipulates that outpatient care (primary and specialized)
can receive financing from different budget levels. There are therefore
allocations for these types of services in budgets at different levels; however
most comes from municipal district health care budgets and community budgets.
Private payments (user fees) are funnelled into special accounts (so-called
commission accounts) and can be used at the discretion of the facility’s
management as they supplement allocations according to line-item budgets;
informal payments go directly to the medical staff involved (see section 3.3.2
Out-of-pocket payments).
Inpatient care and dental care are purchased in a similar manner via local
budgets. Formal private payments for dental services in public facilities go
to special budget fund accounts, when declared. In private facilities, private
resources come either in the form of fees-for-service from the patients or as
contracts from private firms and corporations that cover a package of services.
The majority of drug purchasing from budgetary sources is carried out by local
or regional health authorities based on requests from medical facilities. The
pharmaceuticals are then distributed among facilities. Pharmaceuticals are
partially purchased with resources from a special budget fund in accordance
with health insurance company contracts and sickness funds. The amount of
these purchases is very small, however. Most pharmaceuticals are purchased
directly by patients themselves, on the recommendation of their physician, and
they pay out of pocket in full.
Psychiatric care is covered by local budgets through the line-item budget
system. The prospective budget estimates do not take into account the cost of
pharmaceuticals which patients purchase out of pocket in full. Only a small
proportion (0.6%) is officially covered from public resources, usually for
alcohol and substance abuse treatment in private clinics. Long-term medical
care is usually financed from local budgets in accordance with line-item budget
estimates drafted by social protection agencies. Rehabilitation services are
normally provided by resorts and sanatoria. About half of this treatment is
financed from budget resources. The remainder comes from employers or is
paid out of pocket by patients.
Experiments with new methods of financing
There have been several experiments in Ukraine involving the introduction of
new financing mechanisms, such as a global budgeting and payments on a per
capita basis. These experiments are typically the result of local initiatives, and
they are supported by technical assistance projects run by international donor
organizations. For example, in Komsomolsk (Poltava oblast, population 60 000)
Health systems in transition
Ukraine
in 1997, the municipal authorities and medical community launched an
experimental model of primary care organization. Trained family doctors
signed contracts with municipal authorities for the provision of primary care
services financed on a per capita basis. Since there were no legal precedents
for a project in which services provided by community medical facilities
were purchased on a contracting basis, the city established family practices.
Currently there are 11 private family doctors who sign contracts with the
municipal health authority and provide primary care to about 40% of the city’s
population. Funds are allocated from the budget on a per capita basis according
to the number of citizens assigned to a particular physician. The rest of the
population received primary care at a polyclinic that is government-financed
according to line-item budgets. In 2003/2004, doctors in independent practices
were brought together into group practices, and the polyclinics were turned into
primary care centres.
In the early stages of this experiment there was an attempt to introduce a
scheme of partial fund-holding in purchasing services from family doctors,
but this mechanism was not supported by the local authorities. According to
the results of a public opinion poll in Komsomolsk, the delivery of primary
care services by family doctors is more financially efficient than the current
system (Nadutaya, Nadutiy & Zhalilo, 2003; Nadutaya, 2004). The quality
and accessibility of health care also improves. After the transition to the
new model, the number of visits to medical specialists decreased by 36%,
the number of adult hospitalizations decreased by 16%, and the number of
emergency calls per 10 000 population decreased by 46.4%. Further, public
satisfaction increased from 70–80% (within the traditional model of care by
district internists and paediatricians in polyclinics) to 88% with health care
provided by family doctors.
In 2005, the EU-funded project Health Financing and Management in
Ukraine, conducted experiments aimed at changing the mechanisms of
financing health care facilities. Two pilot rural regions were chosen in Kharkiv
and Zhytomyr oblast with a population of about 35 000 in each. In these pilot
medical facilities, line-item budgeting was replaced by global budgeting,
meaning that the facility was financed based on the volume of care it provided,
but, in contrast with the existing approach, resource allocation was not itemized
and the amount did not depend on the capacity of the facility. Facilities were
financed within the limits of an agreement, which took the form of a simple
block-contract for the government’s purchase of services. District-level health
authorities acted as health services purchasers, according to the provisions of
the Civil, Economy and Budget Codes of Ukraine and the Law on the public
63
64
Health systems in transition
Ukraine
procurement of goods, works and services (No. 1490-III of 22 February 2000).
The purchaser negotiated with health care providers (that is, the district central
hospital) on the volume of allocated resources and inpatient and outpatient
care that the latter was obliged to provide to the population over the course
of one year. Once the resources were received, the hospital itself determined
where to direct them, taking into account its current needs and priorities. The
hospital’s autonomy was secured by its transformation into a form of non-profitmaking communal enterprise as recognized by the Economy Code of Ukraine
(Rudiy, 2005).
Local fiscal authorities resisted experimenting with new methods of paying
medical care providers. In 2005, in a pilot district in Kharkiv oblast, the local
authorities divided the financing of primary and secondary care to create two
independent health care providers. The plan was to sign separate contracts to
purchase medical services from the newly created district primary care centre
(an independent non-profit-making community enterprise), and the central
district hospital. In the contract for purchasing inpatient care and specialized
outpatient care from the central district hospital, global budgets were the chosen
method of payment. In the contract regarding the purchase of primary care,
payment was to be on a per capita basis based on the list of patients from every
family doctor/GP. In May–June 2006, however, when the project was scheduled
for launch, authorities from the central district hospital, together with medical
specialists from the inpatient care ward and the polyclinic, began strongly
interfering with the launch. They used different methods to put pressure on
the district parliament, including street protests by the medical workers. Their
main argument was the inevitable breakdown of inpatient care and specialized
outpatient care, claiming that the hospital would lose part of its funding. They
also pointed out the difficulties of undertaking reforms during the period of
state financial deficit. The true cause of the hospital’s resistance lay in its
unwillingness to lose resources and property earmarked for transfer to the
primary care centre. Inpatient doctors and the polyclinic’s medical specialists
worried that the reform would decrease demand for their services, leading to
staff reductions for specialists and reducing both formal and informal income.
As a result of their protests, the project launch was postponed.
However, a different component of the same project had more success,
where centralized financing of the district health system was achieved. All
rural medical facilities (rural outpatient clinics, FAPs, etc.) became district
community property. A united community non-profit-making enterprise was
created on the basis of the central district hospital. All rural facilities became
subdivisions and lost their status as independent legal entities. Unifying financial
Health systems in transition
Ukraine
resources and rural medical facilities at the district level created conditions
for the more efficient utilization of budgetary resources allocated by local
self-governments to health care. It also stabilized financing and protected the
health care budget from rural community leaders redistributing the resources to
other community needs. In March 2006, after securing an agreement with the
relevant regional authorities, the Ministry of Health issued an order assigning
additional districts in Zhytomyr and Kharkiv oblast to join the project. These
new forms of financing are not widespread, however. The Ministry of Finance
is the main opponent to reforming purchasing mechanisms for medical services.
The Ministry expressed concerns about new purchasing mechanisms potentially
upsetting the balance between existing and required resources (Lekhan, Rudiy
& Shishkin, 2007).
3.6.2 Paying health care personnel
Workers in government-financed agencies and institutions (including health
care facilities) are paid according to the laws and regulations of Ukraine, and
according to general, departmental and regional agreements, and collective
contracts between proprietors and work unions, within the limits of budget
allocations and non-budgetary income. The health workers union has not had
much success recently in their fight to increase salary levels. Ukraine has also
largely retained the Soviet practice of remunerating public sector health care
professionals using fixed salary scales. The advantage of this method lies in the
simplicity of calculating the cost of salaries and the lack of financial risks for
health care professionals. The main disadvantage is that there is no correlation
between salary level and quality of work. Medical professionals do not have
much incentive to increase their work volume, efficiency or quality.
One goal in the Concept of the development of health care in Ukraine (2000)
was to differentiate medical and pharmaceutical workers’ salaries based on their
level of qualification, and the quantity, quality, complexity and efficiency of
their work, while also taking into account their working conditions. Since then
several attempts have been made to make payments to health workers more
flexible. These attempts retained the basic principle of salaried employment
but took into account a system of stimuli to improve clinical quality, enhance
the prestige of medical specializations in short supply, increase the volume of
work and so on. A Cabinet of Ministers Decree (No. 1298, issued 30 August
2002) adopted the Unified Tariff System of categories and quotients for the
remuneration of workers in institutions and organizations of some governmentsupported sectors. Official rates are calculated by multiplying the salary of
a worker of the first tariff category (in essence the minimum wage) by the
65
66
Health systems in transition
Ukraine
appropriate tariff quotient. The specific conditions of remuneration for health
workers are set by a joint order from the Ministry of Health and the Ministry of
Labour and Social Policy (No. 308/519 issued 5 October 2005, amended 2007,
On regulating remuneration of medical and social protection facilities workers).
Professional salaries for the majority of medical personnel (medical
doctors, mid-level health staff, pharmacists) are set in accordance with their
qualifications which reflects a worker’s professional level (no category, first
category, second category and highest category). Professional salaries (tariff
rates) are the government’s guaranteed minimum wage to certain groups
of workers with professional qualifications in public and private health care
facilities. Managers at government-financed health care facilities have the
right to raise salaries within the salary fund provided by the line-item budgets.
Salaries can be increased for certain workers with hazardous or heavy working
conditions, or for surgeons, depending on the quantity, complexity and type
of work they carry out. For example, in outpatient and polyclinic facilities
salaries can be increased up to 15%; in a day hospital specializing in surgery,
they can be increased up to 25%; and in a hospital, the increase can be up to
40% of a professional salary. The list of facilities and jobs with higher wages
due to hazardous or heavy work conditions is determined by a special addition
to the joint order of the Ministry of Health and the Ministry of Labour and
Social Policy. The list of actual workers who have the right to receive higher
wages is determined by the enterprise’s authorities in accordance with the
union’s committee and depends on the tasks and the volume of work. Additional
remuneration is granted for specializing in more than one area, substituting for a
missing worker, increasing the amount of work or the area served, and working
nights at an hourly rate of 35–50% extra. For certain staff, bonuses are given
for working long uninterrupted hours, performing complex duties, excellent
achievements or for the execution of particularly important tasks. Bonuses are
also given for being on-call at home, nursing duty, holding an honorary title
and more. However, these bonuses can be decreased or removed if problems
with clinical quality or discipline are identified.
In public facilities, the salaries of different categories of medical workers
(medical doctors and mid-level medical staff) are virtually undifferentiated
according to qualifications or the type of work. There are only two groups
of specialists among medical doctors. The first group includes professionals
whose qualifications are in demand and who have priority in the recruitment
process: surgeons of all kinds, anaesthetists, any medical doctors for rural areas,
and primary care physicians such as district internists, district paediatricians
and family doctors/GPs. The salary for these specialists is one category higher
Health systems in transition
Ukraine
than for others. Public health care specialists (hygienists, epidemiologists, etc.),
for example, are included in the second category: medical doctors of other
specialties. The salaries of their support staff are equal to those of mid-level
medical staff. The salaries of mid-level medical staff are 3–4 categories lower
than that of medical doctors and there is no specialty gradation.
In an attempt to reduce turnover in emergency care and outpatient care,
doctors and mid-level medical personnel in these sectors are paid bonuses for
continuity of service. The largest bonuses for continuity of service are provided
for emergency care doctors (up to 60%) and doctors practising in rural areas (up
to 40%). Primary care physicians in cities can receive up to 30% of base salary.
Moreover, like other specialists, these specialists can receive an additional
bonus of up to 50% base salary for increasing the area served, substituting for
a missing worker (which is important in understaffed facilities) and for a larger
workload. There are no significant differences between inpatient sector medical
personnel and other personnel, except for surgeons and anaesthetists, whose
salaries can be increased by up to 40% for performing specific surgeries.
In all medical facilities with hazardous or difficult work conditions (inpatient
and outpatient care), all types of personnel are paid higher salaries, including
doctors as well as mid- and low-level medical staff. Salaries in psychiatric
and addictions clinics can be up to 25% higher, while primary care physicians
in polyclinics can be paid up to 15% more; 15% more in infectious diseases
clinics; and up to 60% more in HIV/AIDS treatment facilities. Salaries in
auxiliary facilities such as physiotherapy and radiological facilities can be paid
up to 15% more of the professional base salary. The remuneration of dental
specialists does not differ from other specialists. Mid-level dental workers and
dental assistants have the same level of remuneration as other mid-level medical
personnel. The base salary of medical facility managers and their deputies is
the highest in comparison with other medical personnel. Their salaries depend
on the capacity of the facility. Additional payments (24–25%) are provided for
specific qualifications in health care organization and management.
In Ukraine, social workers work primarily in institutions for vulnerable
groups, including special homes for retired and disabled people, territorial social
care centres for senior citizens and single people, centres for home care, charity
services, homeless centres, homeless shelters, centres for reintegration of the
homeless people and so on. The base salaries of social workers are 1–2 times
lower than the salaries of non-priority specialty doctors. As with doctors, their
salaries are differentiated between categories of qualification. Social workers
67
68
Health systems in transition
Ukraine
employed at long-term facilities for children with developmental disorders can
receive an additional bonus up to 25%, as can social workers at long-term care
facilities for elderly or disabled people.
There is a relatively small number of private medical facilities in Ukraine,
but the proportion of full-time workers in private health facilities usually does
not exceed 50%, with the exception of dental practices and dental centres,
which are mostly staffed by full-time workers. Other personnel are hired as
contractors, since their primary work is at public health care facilities. They are
paid primarily on a contractual basis. A contract between the administration
and an individual medical worker provides either an hourly rate or a fixed sum
for the total volume of work. Different forms of remuneration can be used for
different employees at the same facility. The fixed rate differs significantly
from facility to facility, which causes a high turnover. The hourly rate is usually
based on the categories of medical personnel rates approved by the Ministry of
Labour and Social Policy and the Ministry of Health, although remuneration is
between 10% and 15% higher for working at a private facility.
The methods of remuneration give some flexibility in salaries for medical
personnel at public medical facilities. However, this has not proved a significant
incentive to increase the volume or quality of services provided. In the majority
of cases, the remuneration of labour in health facilities is related only to the
hours of work, without real consideration of the volume, quality or efficiency
of work. Bonuses and additional payments (except for mandatory payments for
substituting a missing worker, length of service or a qualification category) are
extremely rare due to the chronic lack of funding. In cases where additional
payments are awarded, the criteria are not transparent. Bonuses are given not
necessarily to the best workers from a professional perspective, but to those
who, for whatever reason, are more pleasing to the facility’s administration.
The lack of transparent bonus criteria removes any incentive to increase the
efficiency or quality of work. Moreover, salaries are still very low. For example,
a medical doctor with the highest qualifications, whose specialty is among the
best paid, usually does not earn more than US$ 300 a month, including bonuses
and additional payments. The average monthly salary for doctors in 2006 was
901.6 hryvnya (US$ 178.5), 610.6 hryvnya (US$ 120.9) for mid-level medical
staff, and 507.5 hryvnya (US$ 100.5) for low-level medical staff. On average,
salaries in the health sector are lower than those in other sectors of the economy.
Salaries are 1.79 times lower than in industry and 1.22 times lower than in
education. Such salaries do not attract personnel (particularly the young) to
the health system and certainly cannot retain them. To a certain extent, these
Health systems in transition
Ukraine
low salaries provoked the appearance and spread of informal payments, which
have negatively affected the general equity and accessibility of medical care.
The poor have suffered especially.
Another obstacle to the implementation of more effective forms of
labour remuneration is the lack of a legal basis for contracting at medical
facilities. This tool would stimulate the development of clear criteria for
work evaluation. It would create more transparent regulation of mutual
commitments between the administration and staff, including the organization
of labour remuneration.
69
4.1 Regulation
4.1.1 Regulation and governance of third-party payers
T
he overwhelming majority of health care and preventive services are
provided through government-owned health facilities and the relationship
between purchasers and providers is still integrated, as it was in the
Semashko system (see section 3.5). Different levels of government act as
agents that ensure the maintenance of health facilities within the limits of strict
line-item budgets (see section 3.6). Health facilities therefore do not have any
autonomy in managerial and financial decision-making. Although the Law on
public procurement of goods, works and services was passed in February 2000
to regulate the purchase of health services with public funds on a contractual
basis from both public and private actors, in practice this law has not been fully
implemented (Lekhan & Rudiy, 2007). In its place, the Temporary regulations
on public procurement of goods, works and services, approved by the Cabinet
of Ministers in 2008, are being used, but the formal frameworks for contracts
have not yet been developed by the Ministry of Health.
Therefore, in spite of the main legal means for the introduction of contractbased purchasing of medical services from different forms of health service
provider appearing a few years ago, the transition to an active purchasing model
for these services on the basis of public procurement contracts has not taken
place (see sections 3.5, 3.6). The principal legal means for giving providers
autonomy, which appeared recently, are also not being used (see sections 3.5, 3.6
and Chapter 7). As a result, the Ukrainian health system continues to function
on the basis of hierarchical relations between the state (as third-party payer)
and directly subordinated local authorities (as state property) and the public
providers of medical services.
4. Regulation and planning
4. Regulation and planning
72
Health systems in transition
Ukraine
The public providers, which supply the population with the overwhelming
majority of medical services, are financed on the basis of itemized estimates of
expenditure agreed by the higher authorities at the required level and have the
status of so-called budgetary institutions. These two factors, combined with
the compulsory use of strict Ministry of Health normative planning structures
and the staff of public medical facilities, condition the extremely limited rights
of public providers to make independent managerial and economic decisions.
4.1.2 Regulation and governance of providers
State regulation of health care providers is concentrated at the national level;
there are few regulatory activities under the authority of local self-government.
The Ministry of Health develops and approves state quality standards and
clinical protocols for health care, and is responsible for the organization and
implementation of mandatory state medical accreditation of health facilities
and issuing licences to legal entities and individuals that are engaged in the
delivery of medical services or the production and sales of pharmaceuticals and
medical equipment (Lekhan & Rudiy, 2007). Accreditation was introduced on
15 July 1997 by Cabinet of Ministers Decree (Decree No. 765, On approving
the procedure of state accreditation of a health facility), and is mandatory for
all facilities regardless of their form of ownership. Assessment of the first stage
of accreditation indicated that it has led to some improvement in material and
technical resources, the qualification of medical staff and the quality of care. At
present there are 27 accreditation commissions in Ukraine at the health boards
of regional, Crimea AR, Kyiv and Sevastopol administrations (Lekhan & Rudiy,
2007). The accreditation process initiated the creation of preconditions for the
realization of patients’ rights to medical care of adequate quality. However,
due to a lack of working mechanisms for accreditation, the process gradually
became a formality. Currently it has no real impact on the quality of care (see
section 4.1.4 Regulating quality of care).
The Ministry of Health establishes the requirements for professional staff,
training and development of health and pharmaceutical workers, uniform
qualification standards for people pursuing medical or pharmaceutical activities,
the list of medical specializations and the classification of types of health care
facilities. Practising doctors are subject to certification every five years, but
there is no system of registration for doctors (see section 5.2.4 Registration/
licensing). Public and private medical health care providers (individuals and
legal entities) are licensed under the Law on licensing of specific types of
economic activities No. 1775-14 (2000) and joint order of the State Committee of
Ukraine for Regulatory Policy and Entrepreneurship and the Ministry of Health
Health systems in transition
Ukraine
as of 16 February 2001, No. 38/63 Licensing conditions for economic activity
relating to medical practice (Lekhan & Rudiy, 2007). The legislation is designed
to ensure that professional staff or provider organizations achieve minimum
standards of competence and meet function-specific requirements regarding
sanitation and safety and technical standards of equipment. Unfortunately, the
licensing of medical practices has not assured the quality of health care. Many
medical facilities, especially in rural areas, face severe structural problems.
Many buildings have become dilapidated, with equipment that is outmoded
and in poor condition (see section 5.1.3 Medical equipment, devices and aids).
Some of the reasons behind this are the lack of modern standards for material
and technical support as well as a very liberal form of licensing for state and
community medical facilities, which usually manage to keep their historically
established range of services.
4.1.3 Regulation and governance of the purchasing process
Since 2005, an EU project Health Financing and Management in Ukraine
has identified the key regulatory barriers to providers being granted more
autonomy so that health care financing could move away from the line-item
model (see section 3.6). In the pilot project, hospitals were funded using global
budgets with line-item accounting. The total amount of funds for a year was
transferred to the service provider according to a simple block-contract for
an agreed volume of outpatient and inpatient care rather than the level being
dependent on the hospital’s capacity and without strict allocations to specific
expenditures. The project met with strong resistance from regional and local
authorities, and tax collection agencies, which focus on detailed expenditure
and revenues of budgetary institutions rather than their efficiency (Lekhan,
Rudiy & Shishkin, 2007).
As a part of this project, which effectively introduced a purchaser–provider
split, budgetary health facilities were transformed into communal non-profitmaking enterprises so that they could avoid the line-item financing of services
and conclude contracts for service provision and make spending decisions
independently. However, due to conflict between the Commercial Code and tax
legislation, the tax authorities refused to register non-profit-making enterprises
as profit-tax exempt non-commercial organizations. Budgetary institutions are
exempt from land tax, but non-profit-making enterprises are not; there was also
a risk that the health facilities would have to pay the standard rate for utilities,
rather than the reduced budget institution rate. Financial authorities opposed
any change to the status of budget institutions for fear of losing control over
their financing (Lekhan, Rudiy & Shishkin, 2007).
73
74
Health systems in transition
Ukraine
4.1.4 Regulating quality of care
As part of the reform programme, the government and the Ministry of Health
have taken certain steps over the years to improve the quality of health care. The
main efforts have been aimed at standardizing medical services and licensing
and accrediting health facilities (see above). The standardization of medical
practice in Ukraine began in 1998 with an order from the Ministry of Health
which set standards for inpatient care (Order No. 226, issued 27 July 1998,
On approving temporary uniform standards for inpatient medical diagnostics
and treatment for adults at medico-prophylactic facilities in Ukraine, and
temporary standards for the vo lume of chi ldren’s diag nostic research,
treatment, and service quality). Medical standards or clinical protocols have
now been developed for most common diseases and compliance is mandatory.
In 2002–2007, clinical protocols were developed and approved for 66 different
types of medical services, however, the quality of these protocols is not very
high. The majority of these protocols were created based on an expert consensus,
without using evidence-based data. There was no clinical testing of their quality,
no patients were involved and there was no monitoring of the effectiveness of
their use.
4.2 Planning and health information management
In Ukraine, the health system is “integrated” in that health care providers
are directly owned or employed by the third-party purchaser. Providers are
therefore managerially responsible to a series of governing bodies depending
on the level of care. This decentralized management of the system impedes
the implementation of plans developed at the national level and there is no
central health planning agency. The intersectoral comprehensive programme
“Health of the Nation” for 2002–2011 was the first unified state plan for health
since independence (see section 8.1). Regional administrations were tasked with
developing regional programmes in consultation with the national programme
and to set annual goals for implementation using local funds (Lekhan &
Rudiy, 2007).
Approaches to capacity planning in the Ukrainian health care sector have
remained almost unchanged since Soviet times. The mechanisms currently
in place neither reflect the health care needs of the population nor take into
account regional characteristics of health service provision. There is also little
incentive for rational use of resources or cost control over health facilities.
Health systems in transition
Ukraine
For example, regional health authorities are responsible for establishing the
total number of hospital beds, taking into account area-specific norms for
inpatient care. The norm for Ukraine as a whole was set at 8 hospital beds
per 1000 population. However, these are global standards; norms for hospital
bed numbers according to specialty have not been specified. The defined bed
capacity also determines staffing of hospitals, which is according to numbers
of hospital beds by specialty.
Staffing levels for independent outpatient clinics and polyclinic facilities and
outpatient units are determined according to norms approved by the Ministry
of Health. These norms are differentiated for two population groups (children
and adults) and administrative type (community, district, municipal, regional).
The number of primary care providers – district internists and paediatricians
– is calculated from the population in the catchment area. It is also possible to
introduce positions for occupational health physicians in outpatient settings,
as well as paediatricians providing services to children in preschool facilities
and schools. Levels of nursing staff required to provide outpatient care are
determined according to norms tied to a specified number of appropriately
specialized physicians. Also, there are individual norms for the number of
mid-level staff at the FAPs providing basic health care in rural areas. Clearly,
these rigid standards provide few opportunities for effective management at
facility level. In summary, current practices of human resource planning and
management of the state-run health system do not follow a coherent model or
else correspond to organizational goals. Overall, the current system also lacks
any coherent approach to ensuring appropriate levels of health care workers
(Lekhan, Rudiy & Nolte, 2004).
4.2.1 Health technology assessment
Health technology assessment may be defined as “the structured analysis
of a health care technology, a set of related technologies, or a technologyrelated issue that is performed for the purpose of providing input to a policy
decision” (Mossialos, Allin & Figueras, 2007). On this basis, health technology
assessment is not yet a feature of the system in Ukraine.
4.2.2 Information systems
There is a unified electronic health information system for reporting from the
regional level upwards, but at the municipal and community level reporting is
done on paper using standardized forms. There are other localized information
75
76
Health systems in transition
Ukraine
systems, but these are not necessarily compatible and they are for the
management of individual facilities rather than national-level planning and
coordination. The reliability of data generated by and the efficacy of health
information systems are discussed in section 1.4.
4.2.3 Research and development
Health research is conducted in the medical universities and academies of
Ukraine and in the Ukrainian Institute for Strategic Research under the Ministry
of Health, which publishes annual reports on the health system. The Institute
started coordinating health research work in 2008, focusing on the development
of primary and secondary care, continuous quality improvement in health care
and health care financing. Previously priority areas for research to underpin
health system development were set more spontaneously.
In 2009, the Ministry of Health approved priority directions for research and
development of the health system.
•
Identifying a model and development path for primary care based on the
principles of family medicine.
•
Identifying a route for the optimization of both the organization and the
size of secondary and tertiary care.
•
Identifying ways of overcoming the impact of the global economic crisis
on the Ukrainian health system.
•
Identifying the optimal model of health care financing for the current
stage of development.
•
Developing a strategy for increasing overall life expectancy in
the country.
•
Identifying a model for the provision of diagnostic services at the
regional level.
•
Refining the system of continuous quality improvement in medical care.
•
Identifying appropriate information systems in health care and the
introduction of telemedicine.
•
Refining the organization of medical services for rural communities.
•
Forecasting population health and the demographic situation in Ukraine.
•
Forecasting the demand for human resources for the health system for
the current stage of development.
•
Optimizing the system of health care management at all levels.
Health systems in transition
Ukraine
•
Developing the state-owned sanatoria and health spas.
•
Reforming the medical rehabilitation system.
•
Identifying ways of increasing the efficiency of resource distribution.
Research in these directions will be conducted by medical universities
and coordinated by the Ukrainian Institute for Strategic Research under
the Ministry of Health. Specific financing for conducting research has not
been provided.
77
5. Physical and human resources
5. Physical and human resources
5.1 Physical resources
5.1.1 Infrastructure
T
he Ministry of Health is responsible for accrediting health care facilities
and individuals practising medicine (see section 4.1.2). In 2008, there were
440 000 hospital beds in total in Ukraine, 92.3% of which were located in
inpatient health facilities under the normative scope of the Ministry of Health.
Between 1990 and 2008, the total number of beds fell by almost a third (37.2%),
or 30% in terms of beds per capita (from 13.6 to 9.5 per 1000 population) (see
Table 5.1). However, the decrease in bed numbers was only in facilities under
the Ministry of Health; elsewhere the number of beds has actually increased.
Table 5.1
Inpatient hospital capacity, 1990–2008 (selected years)
1990
1995
2000
2005
2006
2007
Hospital beds per 1 000 population, total
13.6
12.5
9.5
9.5
9.6
9.5
2008
9.5
Hospital beds per 1 000 population in facilities
under the Ministry of Health
13.0
11.9
8.9
8.7
8.8
8.8
8.8
Beds per 1 000 population in acute care hospitals a
10.6
9.8
7.2
7.1
7.1
–
–
Psychiatric hospital beds per 1 000 populationa
1.4
1.2
1.0
0.9
0.9
0.9
0.9
Nursing and elderly home beds per
1 000 population
1.2
1.1
1.0
1.0
1.0
–
–
Sources: Ministry of Health and Ukrainian Institute for Strategic Research, 2009; WHO Regional Office for Europe, 2010a;
Medical Statistics Centre database, unpublished date, 2009.
Note : a Beds in Ministry of Health facilities.
The main reduction in the number of hospital beds took place in 1997–1998
and was caused by the severe financial and economic crisis (see Fig. 5.1). It
became impossible to maintain the massive overcapacity of the inpatient sector.
The Cabinet of Ministers Decree On introducing area-specific maximum
norms for inpatient care (No. 640, 28 June 1997) set a rate of 8 beds per
80
Health systems in transition
Ukraine
1000 population as the norm, thus requiring regions to adjust their bed numbers
accordingly. As a result, more than 150 000 beds in facilities under the Ministry
of Health were cut between 1996 and 1998. Further contraction in the hospital
bed stock has progressed at a slower rate. The downsizing mainly affected rural
hospitals, which were converted into rural outpatient clinics, and municipal
hospitals, most of which were reorganized into polyclinics (see section 5.1.2
and section 6.4).
Although relatively low in comparison with other countries of the CIS,
the number of acute care hospital beds in Ukraine is still high by European
standards (see Fig. 5.1), even acknowledging the differences in the way the
number of acute care beds is calculated. The European Health for All data
show the sum of all hospital beds minus beds in TB and psychiatric hospitals.
In Ukraine, there is no strict differentiation of beds according to the intensity
of treatment and care. Thus the majority of inpatient facilities treat both acute
patients and chronic patients who require long-term care, as well as “sociomedical patients” in need of long-term care for social rather than clinical
reasons (such as vulnerable older people during winter months). There are
very few so-called emergency care facilities providing care to acute patients
only (12 facilities located in 10 out of 24 regions).
Fig. 5.1
Beds in acute hospitals per 1 000 population in Ukraine and selected other countries,
1990 to latest available year
1 100
1 000
Russian Federation
900
800
CIS
700
Ukraine
600
500
Republic of Moldova
Poland
EU
400
300
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: WHO Regional Office for Europe, 2010a.
Health systems in transition
Ukraine
The number of beds in psychiatric hospitals has fallen rapidly as well. Their
number has dropped by 37% since 1990, reflecting a fall of 1.4 to 0.9 beds per
1000 population. Although the financial crisis has been a major factor, changes
in the way mental health problems are treated in law have also had an impact
(see section 6.11).
The Ministry of Labour and Social Policy is responsible for the number
of beds in long-term care facilities and these beds are not included in bed
number calculations made by the State Statistics Committee of Ukraine or
the Ministry of Health. Their number has fallen by 20% since 1990, while the
demand for these beds is growing, due to the rapid ageing of the population
(see section 6.8).
5.1.2 Capital stock and investments
Ukraine has an extensive health care infrastructure. The health sector is
monopolized by state and community health care facilities, most of which were
inherited from Soviet times. Private facilities account for not more than 1% of
the total volume of medical care. The total value of fixed assets of medical and
social care facilities (including buildings and equipment) was 42 billion hryvnya
(US$ 8.4 billion) in 2006. This has almost doubled since 2000. However, the
infrastructure is being eroded gradually as current financing mechanisms
exclusively finance current health care costs and only partially finance capital
costs (and only since 2000).
In 2008, outpatient care in Ukraine was provided by 8000 state and
community outpatient clinics and polyclinics of different levels, 94.1% of which
were under the normative scope of the Ministry of Health. More than half (61.3%)
of the outpatient facilities under the Ministry of Health provide only primary
care (rural and municipal outpatient clinics, and outpatient departments of rural
primary care clinics); 25.2% provide primary and secondary outpatient care
(free-standing polyclinics, the polyclinic departments of municipal hospitals
for adults and children, central district and district hospitals). The remainder
provide secondary and tertiary outpatient care. Also, more than 15 000 FAPs
provide first aid in more remote rural areas. Since independence in 1991, the
total number of outpatient care facilities increased by 16.5% and the number
of facilities under the scope of the Ministry of Health increased by 7.2% (see
Table 5.2). A more detailed analysis, however, reveals a more multi-directional
trend: the number of free-standing outpatient clinics and polyclinics is growing
rapidly, whereas the number of FAPs and polyclinic departments in hospitals is
decreasing. The rapid growth of outpatient clinics and polyclinics began with
81
82
Health systems in transition
Ukraine
the introduction of family medicine/general practice in 2000 (see section 6.3),
when more than half of the rural clinics and FAPs that provided services for
1000 or more people were converted into primary care physician-led outpatient
clinics. There are very few newly opened facilities. The falling number of
polyclinic departments in hospitals is also connected with the reorganization
of hospitals into free-standing polyclinics.
Table 5.2
Transformation of the network of outpatient clinics and polyclinics, 1991–2008
(selected years)
Type of facility
1991
1995
2000
2005
2007
2008
±2008
since 1991
Outpatient and polyclinic facilities, total
Outpatient and polyclinic facilities under
the Ministry of Health, including:
6 869
7 220
6 423
6 544
7 430
7 776
8 000
8 000
+1 131
6 456
6 692
6 842
6 888
+465
– free-standing polyclinics and outpatient
clinics, of which
2 015
2 033
2 850
3 605
3 841
3 944
+1 929
• primary care physician-led outpatient
clinics
1 618
1 636
2 408
3 076
3 294
3 628
+2 010
– polyclinic departments in hospitals
3 071
2 983
2 624
2 281
2 213
2 114
-957
– polyclinic departments in specialist
outpatient clinics
545
527
491
372
369
367
-178
– dental polyclinics
FAPs
316
324
320
309
300
–
–
16 402
16 282
16 113
15 459
15 229
15 100
-1 302
Sources: State Statistics Committee of Ukraine, 2010b; Medical Statistics Centre, 2009; Ministry of Health and Ukrainian Institute for
Strategic Research, 2009.
In 2008, there were 2800 inpatient care facilities in Ukraine, 90.9% of which
operated under the scope of the Ministry of Health. The rest belong to other
ministries and departments as well as to the Academy of Medical Sciences of
Ukraine, which also runs 36 research institutes and centres. Since 1991, the total
number of inpatient care facilities has fallen by 27.8% (see Table 5.3). As noted
above, this is chiefly due to the reorganization of rural hospitals into primary
care physician-led outpatient clinics. The decrease in the number of specialized
clinics was caused by their fusion with multi-profile hospitals as departments.
Of the total number of beds under the scope of the Ministry of Health,
7.9% are in tertiary care facilities (regional hospitals for adults and children),
55.3% are in multi-profile secondary care hospitals, 31.2% are in specialized
secondary and tertiary care facilities (specialized clinics, psychiatric and
addiction clinics, etc.) and 5.5% are in rural hospitals (Medical Statistics
Centre, 2006).
Health systems in transition
Ukraine
Table 5.3
Transformation of the network of inpatient medical facilities, 1991–2008
(selected years)
Type of facility
1991
1995
Hospital facilities, total
3 882
3 855
Hospital facilities under the Ministry
of Health, total, including:
3 776
3 762
2000
2005
2007
2008
±2008
since 1991
3 258
2 905
2 800
2 800
-1 082
3 049
2 636
2 574
2 537
-1 239
– regional hospitals
30
28
25
25
25
25
-5
– regional paediatric hospitals
25
28
28
28
29
29
+4
– municipal hospitals
683
673
592
551
547
539
-144
– specialized hospitals
125
130
125
–
119
–
–
– municipal paediatric hospitals
124
120
104
99
97
96
-28
– district central hospitals
481
487
486
480
474
472
–
–
–
125
134
142
–
–
1 481
1 423
948
668
609
580
-901
92
90
93
92
92
92
0
– district hospitals
– rural hospitals
– psychiatric hospitals and
addiction clinics
– maternity hospitals
83
87
93
89
89
89
+6
– specialized clinics
411
398
367
283
281
281
-130
Sources: State Statistics Committee of Ukraine, 2010b; Medical Statistics Centre, 2009; Ministry of Health and Ukrainian Institute for
Strategic Research, 2009.
The number of private medical facilities is growing steadily. The first survey
of all health facilities irrespective of their form of ownership was undertaken
in 2008. It was found that in the private health sector in Ukraine there are
82 inpatient facilities, 577 medical centres, 1938 individual practices, and
6917 individual doctors active in private provision (Knyazevich et al., 2009).
The majority of all private facilities and individual practices (about 75%) are
engaged in dental care, while about 15% are diagnostic centres and laboratories.
Medico-prophylactic institutions account for 5–10% of private medical
enterprises and usually comprise small offices leased from large state facilities.
Of the many fully private clinics in Ukraine, only 10 have a large capacity.
Ukraine does not have a regular monitoring system to oversee the upkeep of
medical facilities and the conditions in which they provide their services. The
condition of medical facilities can be assessed indirectly using data from the
State Sanitary-Epidemiological Service, evaluating the sanitary conditions of
medical facilities in the course of routine inspections. According to the data
from 1 January 2008, of the total number of state and community medicoprophylactic facilities (including FAPs), 6.8% did not fulfil sanitary and
hygienic requirements; 1.8% of these facilities required major repairs and
0.2% were situated in dilapidated and/or dangerous structures that could not
be repaired. Moreover, only 29.6% of medico-prophylactic facilities have mains
83
84
Health systems in transition
Ukraine
water; 59.5% have hot water (31.4% of which are on a centralized hot water
system); and 21.1% have mains sewerage. Unsatisfactory sanitary conditions
are found most often in rural medical facilities. Based on the survey of primary
care facilities and units conducted by the Ministry of Health in 2007 (Order
No. 237, issued 11 May 2007), major repairs are required by 19.5% of rural
outpatient clinics and local primary care physician-led outpatient clinics, and
16.4% of FAPs; 1% and 2% respectively are in a critical condition. More than
two-thirds of the structures have been used for over 25 years, and 20% have
been used for over 50 years. The majority of private medical facilities appeared
in the last 15 years and comply with sanitary and hygienic requirements.
The lack of systematic updates on the condition of medical facilities and
the minimal financing of capital costs in the state health system are the two
main reasons for the lack of planning in prospective development (construction,
renovation) of state and community medical facilities.
Strategic development planning and investment in the private medical sector
depend on several factors. The main factor is the profitability of potential
investments as well as identifying problem areas in the state health system.
Consequently, most investments are made in the capital city and several other
large cities. Diagnostic services, dentistry, gynaecology and a few other fields
attract the most investment. Another important factor in investment planning
is the focus of high public officials on certain areas of the health system. For
example, consistent presidential attention to cancer problems has created a
lucrative field for investment.
Ukraine does not have a system of amortized deductions for providing
services (even paid services) at state and community medical facilities. The
total volume of investments in the health system has increased slightly in
recent years but is still small. According to the unpublished data from the
State Statistics Committee of Ukraine, in 2004–2007 the volume of investments
in fixed assets (including capital construction, updating of equipment and
purchase of new equipment) in both health and social care sectors gradually
increased from 1.5 billion hryvnya (US$ 290 million) to 2.5 billion hryvnya
(US$ 500 million). This did not exceed 6% of total expenditure on health from
all sources. Investments in the public sector account for half of all investments
and are primarily used to purchase equipment (see section 5.1.3 Medical
equipment, devices and aids). The remainder goes into the private sector for
construction and equipment. No separate data exist for each sector, nor for the
volume of investments for construction and equipment in each sector.
Health systems in transition
Ukraine
Until recently, investments in the private sector were sufficient only to open
offices and small medical facilities that provided consulting and diagnostic
services. However, with economic growth in Ukraine, despite the general
difficulties facing foreign investors (political instability, lack of transparency
in the legal system and taxation, bureaucracy and corruption), there has been
significant growth in foreign investment in the health sector (Makarenkov,
2007). Quite large private hospitals and highly equipped medical centres have
started to open. From 2006 to 2008, Israeli, American, Russian and other foreign
companies invested in the construction of a private hospital (US$ 30 million), an
endoscopic surgery clinic (US$ 10 million), an oncology clinic (US$ 30 million),
and an oncology and cardiology scientific production centre (US$ 60 million)
(Ksenz, 2007). Potentially, therefore, discussions about the transformation of
the private medical sector should focus more on its qualitative rather than its
quantitative growth.
5.1.3 Medical equipment, devices and aids
The Ukrainian health system has continuously encountered severe difficulties
with the technological supply and maintenance of existing equipment. The
deterioration of fixed assets at state and community medical facilities is very
serious and continues to worsen: in 2000, 50% of equipment was worn out
and obsolete; in 2007, this proportion had grown to 60–70%. The majority of
equipment has been in use for 20 to 25 years, exceeding its technological lifespan
by 2–3 times. For instance, in 2005, 80% of X-ray equipment had completed
its depreciation period 10 years previously. The replacement of worn-out and
obsolete equipment takes place at a very slow rate despite these findings being
reported in the State programme concept for medical technology production
development for 2008–2012 (Cabinet of Ministers Decree No. 102, issued
21 March 2007). According to the Ministry of Health data, the estimated costs
of equipment replacement in health facilities in 2008 was 12 billion hryvnya
(US$ 2.5 billion), whereas the annual volume of equipment purchasing did not
reach even 10% of that amount.
Purchasing medical equipment for state and community health care facilities
is performed on a competitive basis by the administrators of budgetary resources
(officials from health care agencies and facilities). About 20% of purchases
are completed through centralized procedures under the Ministry of Health
within the framework of targeted state programmes. Many officials disapprove
of both the content of centralized purchases (the makes, modification and
integration of the purchased equipment) and the price, which is often higher
than if the equipment were bought independently. They also disapprove of the
85
86
Health systems in transition
Ukraine
way purchased equipment is distributed to the regions. In 2008, the National
Health Council under the President of Ukraine examined problems with the
purchase of expensive equipment (“big ticket technologies”) and concluded
that planning was unsatisfactory and there was no transparency in the purchase
process. There is no registry of expensive equipment or its utilization in the
Ministry of Health, thus there are no data on the distribution of such equipment
nationally. Nevertheless, there are data which demonstrate the inefficient usage
of such equipment. For instance, some facilities operate such equipment for only
one shift. Such equipment is used to its full capacity only in specialized centres,
while the usage is 3–4 times lower in multi-specialty facilities.
Domestically manufactured equipment accounts for 30–35% of purchases.
Currently, more than 250 enterprises of various forms of ownership develop
and produce medical equipment. Of these, 15% are government-operated
and the remainder are fully private enterprises, of which 19% are joint-stock
companies, 0.2% are joint ventures, 44.8% are limited liability companies
and 20% are various small-scale enterprises. Before independence, Ukraine
received medical equipment from 350 supplier plants in the USSR, only 19%
of which were in Ukraine. Consequently, at independence, domestic Ukrainian
industry could provide only 13–15% of the range and about 20% of the volume
of medical equipment needed. The government has put significant effort
into establishing and developing the domestic medical industry. Two state
programmes on medical technology development were implemented between
1992 and 2003. This resulted in a tripling of the range of medical equipment
production: from 740 to 2200 items. Currently, domestic manufacturers provide
artificial pulmonary ventilation and respiratory anaesthetic equipment, hearing
aids, radiology, electrocardiography and ultrasound machinery, refrigeration
and cryogenic equipment, specialized medical furniture, equipment for trauma,
orthopaedics and patients with restricted mobility, surgery and dentistry tools,
colposcopes, sterilizing equipment (dry-air, steam and bactericidal sterilizers),
electrodiagnostic equipment and electrical stimulators. Nevertheless, the range
of domestically manufactured medical equipment remains limited, thus the
purchase of more expensive imported equipment is still necessary.
The significant reliance on imported equipment and limited financing has
made full replacement of equipment in medical facilities costly and very slow.
The government considered several options, including purchasing expensive
imported equipment, and purchasing medical equipment technologies and
manufacturing licences abroad for domestic production before deciding to
develop competitive domestic medical equipment, which is significantly
cheaper and, overall, equal in quality. The third state programme is currently
Health systems in transition
Ukraine
under way concerning the development of domestic manufacturing of medical
equipment for 2008–2012. The programme aims to broaden significantly the
range of manufactured items (1.5 times), while assuring that the equipment
is of a comparable quality to replace the imported equipment. Equipment
for early diagnosis of diseases will be manufactured first, that is, radiology,
electrocardiography and ultrasound machinery. Some modern scientific
technology such as magnetocardiography, digital technology, biotelemetry,
endoprosthesis replacement, oxygenators and implants will also be produced.
The estimated cost of the programme is 170 million hryvnya (US$ 36 million),
30% of which is financed by the government. The impact of this programme on
the availability of essential medical equipment in hospitals is not yet clear.
There is no licensing system for medical equipment in Ukraine, but according
to the Cabinet of Ministers Decree (No. 1497, issued 9 November 2004) On
approving the order of state registration of medical equipment and devices, all
domestic and imported medical equipment and devices are subject to mandatory
state registration by the State Department on the Control of Quality, Safety and
Production of Medicines and Medical Devices. Registration is based on a review
of the appropriate set of documents presented by an applicant – an individual or
a legal entity responsible for the production, safety and effectiveness of medical
devices. The applicant takes part in choosing the appropriate agencies to review
the documents. Based on the outcome of this review, the State Department
on the Control of Quality, Safety and Production of Medicines and Medical
Devices may require the medical equipment to be tested before registration.
5.1.4 Information technology
Internet access is still limited in Ukraine, but it is spreading rapidly. There
were 15.3 million Internet users in 2009, which accounts for 33.7% of the total
population (ITU, 2010). All the regional hospitals, about 80% of municipal
hospitals and polyclinics and 90% of central district hospitals have Internet
access. There are very few rural outpatient clinics and rural hospitals that
are connected to the Internet. However, most facilities use the Internet only
for e-mail and access to the central authorities’ resources (official sites of the
Ministry of Health, the Parliament and government). Few facilities use the
Internet to access medical databases.
Primary care facilities by and large are not equipped with computers.
Even among family medicine/GP facilities, which are provided with all their
necessary equipment, only 12.3% have computers. In a few regions that were
chosen as pilot regions for the implementation of EU projects Prevention and
87
88
Health systems in transition
Ukraine
Primary Health Care, and Health Financing and Management, and which
received technical support, 50–70% of family medicine/GP centres are fully
equipped. In other regions, only 5–7% of outpatient clinics are equipped with
computers (Krivenko, Likhotop & Leshchuk, 2008). The primary care sector
uses computers mostly for developing patient databases. A number of NGOs
are working on creating software for primary care facilities. For example, the
CIET “MediFAM” company is providing software for tasks such as maintaining
patient registers, registering new patients, acquiring clinical information about
patients from other facilities, the work schedule of primary care physicians
and nurses, monitoring and analysis of nurse performance, analysis of nurse
workload, monitoring nurse reports, creation of report forms and so on. This
system is very successful in certain primary care facilities. However, there
is no drive to implement this or some similar system on a large scale. A new
national programme in the planning phase aims to develop the primary health
system and provide computers and software to all primary care facilities. In
the overwhelming majority of other medical facilities, computers are used
mainly for producing statistics reports, payroll, financial monitoring and human
resources records. Several facilities have created their own automatic control
systems. However, these systems are neither unified nor certified, and their
implementation in other medical facilities has proven to be difficult.
There are plans to increase and systematize computer usage in the state
health system. The Concept of the electronic registry system and medical
information exchange between medical facilities has been developed and put
up for public discussion. It provides for the creation of a nationwide system
of electronic registry, storage and analysis of data, the introduction of a
personalized electronic patient’s card with an eye to the future creation of
electronic document circulation on all health care levels, and the introduction
of distance education and telemedicine technologies. However, technological
remodelling of the entire system requires significant resources. According to
experts, about 25 000 new computers need to be purchased. Moreover, quality
software development will also incur considerable expense.
5.1.5 Pharmaceuticals
A series of interventions have now been implemented to regulate the
pharmaceutical sector. With the 1996 Law on pharmaceuticals, foundations
were laid for state policies on the development, registration, production and
quality control of drugs manufactured in Ukraine. The main regulatory
functions in pharmaceuticals are currently split between two entities: the
State Pharmacological Centre and the State Pharmaceuticals Quality Control
Health systems in transition
Ukraine
Inspectorate. The State Pharmacological Centre has the main regulatory function
of market authorization (that is, the registration and licensing of medicines) and
pre-marketing quality control as well as responsibilities for clinical research,
monitoring adverse drug reactions (although adverse drug reaction reporting by
physicians is very low) and rational use of medicines (including development of
the National Drug Formulary). The State Pharmacological Centre is completely
funded through fees and charges for services with no contribution from the state
budget. The State Pharmaceuticals Quality Control Inspectorate is responsible
for quality control once drugs are on the market and it has a network of
laboratories across the country to facilitate this. Good manufacturing practice
(GMP) inspection, as well as the inspection of pharmacies and distributors, is
also the responsibility of the State Inspectorate and, as of 2009, the licensing of
production, distribution and retail sales fell under the remit of the Inspectorate,
having previously been under the State Service on the Control of Quality, Safety
and Production of Medicines and Medical Devices.
All pharmaceuticals that are manufactured, released on the market and
used in medical practice are required to undergo state registration/marketing
authorization according to the Cabinet of Ministers Decree (No. 379, issued
26 May 2005) On state registration and re-registration of medicines. The
registration process consists of the examination of all the necessary files by
the Pharmacological Expert Centre and then, based on its decision, the Ministry
of Health approves the registration. In 2007, Ukraine had 11 500 registered
pharmaceuticals, a third of which were manufactured domestically. The
largest proportions of imported pharmaceuticals come from India (13.6%) and
Germany (8.3%). Ukrainian law provides for intellectual property protection
for the developers of medicines. A state registration applicant must provide a
patent copy or a licence and a letter which indicates that the patentee’s rights are
not violated by registration. Moreover, the Law on pharmaceuticals, which was
passed when Ukraine joined the WTO (with several amendments in 2006–2007),
forbids the registration of pharmaceuticals (that is, generics) using registration
data from another pharmaceutical for a period of five years, regardless of the
lifetime of the patent. In linking the registration of generics to the expiration
of a patent’s lifetime and a five-year exclusive right to the original brand name,
Ukraine undertook commitments that are rather steep in comparison with
the WTO and Trade-Related Aspects of Intellectual Property Rights (TRIPS)
requirements, and contradictory to “Bolar Provision”, which allows generics
manufacturers to submit their products for regulatory approval before the expiry
of a patented intervention. Implementation of these commitments may make
89
90
Health systems in transition
Ukraine
pharmaceuticals less accessible to the population and create problems for the
pharmaceutical industry of Ukraine, and therefore for the country (Polyakova,
2006; Sur, 2006).
To ensure the quality and safety of pharmaceuticals, the registration process
requires the presentation of pre-clinical examinations and clinical trial results.
From 2008 the registration process for generics also requires proof of their
bioequivalence to their brand-name counterpart (see section 6.6).
Complementary medications (primarily biologically active supplements) are
not subject to state registration and must only undergo a sanitary and hygienic
examination. Advertising for prescription-only drugs is banned in Ukraine.
This ban is frequently violated, however. People purchase pharmaceuticals over
the Internet, which is also illegal; it is not widespread, however, because of the
wider population’s limited access to the Internet.
Price regulation for pharmaceuticals in Ukraine is based on the Law
on prices and price regulation. The main direct mechanism of state price
regulation was delegated to regional authorities by government decree in 1996
and consists of establishing maximum retail surcharges for pharmaceuticals
and medical devices. Decentralized regulation has, however, resulted in
substantial regional differences in retail surcharges as well as in wholesale and
retail prices for pharmaceuticals. Sometimes the prices differ by 2–3 times even
in the same region. State price regulation is implemented through the setting of
maximum retail surcharges for pharmaceuticals on a special list that includes
149 unpatented international pharmaceuticals of different pharmacological
groups, accounting for 21% of the national list of essential pharmaceuticals
and medical devices. The Cabinet of Ministers Decree (No. 1499, issued
16 November 2001) On amendments to certain decrees of the Cabine t of
Ministers has established a maximum limit of retail surcharges at the national
level for these pharmaceuticals: 35% of the manufacturer’s wholesale price
(customs cost) distributed through the pharmacy network, and 10% for products
that are purchased by public health facilities with funds allocated from the
budget. Research conducted by the Ministry of Health revealed that the average
level of retail surcharges on domestic and imported pharmaceuticals, the prices
of which are subject to state regulation, decreased to 13.7% in comparison
with 23.2% for pharmaceuticals not subjected to price regulation. However,
these measures did not cap retail prices, since they depend not only on retail
surcharges but also on the cost of imported materials for drug manufacturing
(for domestic pharmaceuticals), the dollar and euro exchange rates (for imported
Health systems in transition
Ukraine
pharmaceuticals), and the relative economic wealth of different regions. There
is currently no mechanism for monitoring prices, which hampers evidencebased policy-making in the area.
A more indirect method of price regulation has been the introduction of
certain tax privileges. For example, sales of pharmaceuticals and medical
devices registered in Ukraine are exempt from value added tax. Fig. 5.2 shows
the price of retail sales on various pharmaceutical products in 2006–2008. Over
three years the average price of pharmaceuticals increased by 28%, 10% of
which is related to inflation and 2% to the introduction of expensive new drugs
on the market. Moreover, 14% of this price increase is related to the substitution
of cheaper medications with more expensive pharmaceuticals by a doctor at
various stages of medical treatment.
Fig. 5.2
Average retail prices of the “pharmacy market basket” including components
influencing the price increase, 2006–2008
16
14
Price in hryvnya
12
10
8
2006
2007
6
2008
4
2
0
Pharmaceuticals
Prescription drugs
Cosmetics
Biologically active
supplements
Source: State Service on the Control of Quality, Safety and Production of Medicines and Medical Devices, under the Ministry of Health,
unpublished data, 2008.
About 800 pharmaceutical manufacturers operate in Ukraine, and it has the
largest pharmaceutical production capacity among the countries of the former
USSR. There are 143 private pharmaceutical manufacturers, five of which
produce 60–70% of domestic pharmaceuticals. Ukrainian pharmaceutical
manufacturers strive primarily to produce generics. In order to compete with
91
92
Health systems in transition
Ukraine
imported drugs, large domestic manufacturers have initiated a transition
to manufacturing pharmaceuticals in compliance with GMP. So far, about
15 enterprises have a GMP certificate. Larger pharmaceutical manufacturers
have found it easier to pass certification, which could reduce the number of
manufacturers and concentrate pharmaceutical production. The GMP Inspection
in Ukraine has applied to become a member of the Pharmaceutical Inspection
Cooperation Scheme. Legislation and implementing guidelines for drug
manufacturing follow closely the EU Pharmaceutical “acquis communautaire”
process, and are designed to echo developments in the EU (Stará, 2008).
In 2007, 21 945 companies were involved in retail distribution, including
10 342 pharmacies, as well as 6075 pharmacy kiosks and 5528 pharmacy units,
which are separate pharmacy subdivisions designed to provide ready-made
pharmaceuticals. Kiosks are permitted to sell only non-prescription drugs,
whereas pharmacy units can sell both. State and community-based pharmacies
comprise 24.6% of all pharmacies; the rest are private or collectively owned.
Rural areas have only 15% of pharmacies, although 33% of the population lives in
rural areas. All pharmacies are served by 320 wholesale units – pharmaceutical
warehouses. Only 4.7% of these belong to the state or community. The number
of wholesale distributors is decreasing rapidly. It must be noted that only five
companies deliver 80% of goods to the pharmacies. Moreover, the profitability of
retail distribution motivates wholesale distributors to create their own pharmacy
chains. Pharmacists offer their consumers substitutes for indicated medication
without consulting the doctor in charge. A number of pharmacies contract with
clinical doctors to advise their patients to choose a particular treatment.
The administrators of budgetary resources are responsible for purchasing
medications for state and community facilities (see section 3.6) in accordance
with the approved list of domestic and imported pharmaceuticals that can be
purchased with budgetary resources through tendering. The Ministry of Health
is responsible for arranging procurement through tendering for centralized
state purchases to support targeted state programmes. The existing system of
centralized purchasing of pharmaceuticals is disliked by health care facilities
and agencies, as well as by the monitoring institutions, because the Ministry
of Health purchases and distributes drugs without taking into account regional
demand regarding the type and volume of drugs needed. Moreover, the prices
of purchased pharmaceuticals are often too high, despite the use of tendering
in procurement (Main Auditing Agency, 2006).
Health systems in transition
Ukraine
There is no state reimbursement system in Ukraine. In 2008, the first
reimbursement mechanism was developed and put up for public discussion.
It reimburses pharmacies for the cost of prescription drugs for treatments
approved by the Ministry of Health (insulin and its analogues). It recommended
reimbursement from the state and local health budgets based on prices
established by the Ministry of Health with the pharmacy sale price limit taken
into account.
5.2 Human resources
5.2.1 Trends in health care personnel
This chapter uses figures from the State Statistics Committee of Ukraine, which
until recently did not include specialists employed by private medical facilities.
From 2008, in compliance with an order of the Ministry of Health (No. 378,
issued 10 July 2007, On approving health care report forms and instructions for
their completion), identical statistical reporting forms are sent out to all medical
facilities regardless of which agency they report to or the form of ownership.
However, the incomplete statistical data have little influence on workforce per
capita ratios because the private health care sector is small and only half of
its staff are full-time employees. Others have a second job in state facilities.
Dentists and pharmacists are the exceptions, as the majority are employed full
time by private facilities. Detailed information on various categories of health
care workers can be obtained only from the Medical Statistics Centre which,
until the issuing of the order mentioned above, collected data only on health
care agencies and facilities under the jurisdiction of the Ministry of Health.
These data cover 88.2% of health care workers with higher education and 88.4%
of those with mid-level education. There are currently no data on the number
of full-time equivalents, only the number of individual workers. However, in
accordance with a Ministry of Health order (No. 456, issued 7 September 2005,
On the introduction of a unified state registry of specialists in the health system),
an individual registry of doctors should soon be completed, which will allow
such data to be collated.
In compliance with the current qualification requirements in Ukraine,
those who must have a medical degree include not only personnel involved
in treating patients, but also health care managers, public health specialists
(in the State Sanitary-Epidemiological Service), workers in laboratories and
diagnostic centres, and so on (Ministry of Health and Ministry of Labour and
93
94
Health systems in transition
Ukraine
Social Policy, 2004). All these specialists are counted as doctors and mid-level
medical personnel by the State Statistics Committee of Ukraine and the Medical
Statistics Centre. Only from 1996 has the Medical Statistics Centre categorized
all medical specialists employed by the Ministry of Health as so-called active
physicians. They defined active physicians as those who are directly involved
in treating patients, and therefore do not include administrators, statisticians,
methodologists and sanitary specialists; dentists are also not included.
According to the State Statistics Committee of Ukraine, in 2008 the health
system employed more than 220 000 doctors or 4.8 doctors per 1000 population,
with 4.3 per 1000 population working under the Ministry of Health. The number
of medical human resources per capita has increased gradually since 1990 (see
Table 5.4), but this does not reflect a growth in the number of medical personnel
so much as a decline in the total population. The absolute number of doctors
has also been falling: in 1990 by 0.9% (2000 doctors) and in the facilities of
the Ministry of Health by 1.3% (2600 doctors). In 1995 and 1996 (when the per
capita rate was at its highest), it decreased by 2.2% and 4.8% respectively, or
by 5000 and 10 000 doctors. At the same time, the medical workforce is ageing
Table 5.4
Trends in health care human resources per 1 000 population, 1990–2008
(selected years)
1990
1995
2000
2005
2006
2007
Doctors, total
4.3
4.4
4.5
4.7
4.7
4.8
4.8
Doctors working in Ministry of Health structures
3.8
4.0
4.0
4.2
4.2
4.2
4.3
Public health specialists (in sanitaryepidemiological services)
0.2
0.2
0.2
0.2
0.2
0.2
0.2
–
3.0
3.0
3.0
3.0
3.0
3.0
Practising doctors, clinical medicine, total
of which: a
2008
– doctors working in outpatient care a
–
1.6
1.7
1.7
1.7
–
–
– doctors working in inpatient care a
–
1.4
1.3
1.3
1.3
–
–
– primary care physicians a
–
–
0.5
0.5
0.6
–
–
– medical scientists a
–
–
–
–
3.0
3.1
–
Mid-level health personnel
117.5
116.5
110.3
106.2
106.1
105.5
101.0
Mid-level health personnel working in Ministry
of Health structures a
102.1
105.7
99.1
98.7
93.8
92.9
93.6
Nurses (including midwives and feldshers) a
8.4
8.4
7.9
7.9
7.9
7.9
7.8
Dentists
0.4
0.5
0.5
0.5
0.5
0.5
0.5
–
Dental technicians
0.1
0.1
0.1
0.1
0.1
–
Pharmaceutical chemistsb
0.4
0.4
0.3
0.4
0.4
–
–
Pharmacists
0.5
0.4
0.4
0.5
0.5
–
–
Management staff
0.2
0.2
0.3
0.3
0.3
–
–
Sources: State Statistics Committee of Ukraine, 2001–2007; Medical Statistics Centre, 2001–2008, 2007; Gruzeva & Galienko, 2009.
Notes: a Specialists working in facilities under the Ministry of Health; b Pharmacists with a higher education degree.
Health systems in transition
Ukraine
rapidly. In 2007, 22.5% of active physicians were of retirement age (16.1% in
1994; 19.5% in 2002) and 20% were approaching retirement age. The supply
of public health workers, primarily in the sanitary-epidemiological services,
has been stable since 1995, but the number of specialists decreased by 9.3%
(more than 900 specialists). Although the number of active physicians under the
Ministry of Health has remained stable at 3.0 per 1000 population since 1995
(see Table 5.4), their total number has fallen by almost 9.5% (15 000 physicians)
between 1995 and 2008.
The supply of medical specialists in Ukraine (especially if counting all
doctors, not only those working under the scope of the Ministry of Health)
is close to the average number in the WHO European region and the EU, but
lower than in CIS countries (see Fig. 5.3), although many countries in the CIS
count all health system workers with a medical degree and not only active
physicians. The sharp drop in the number of physicians per 100 000 in Ukraine
in 1995/1996 shown in Fig. 5.3 reflects this transition to calculating only the
number of physicians actively treating patients in the statistics.
Fig. 5.3
Number of physicians per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
500
Russian Federation
400
CIS
300
EU
Republic of Moldova
Ukraine
200
Poland
100
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: WHO Regional Office for Europe, 2010a.
The outpatient sector employs 55% of all active physicians. Despite a
decrease in the total number of doctors by almost 4.9% (4000 doctors), the
supply of active physicians working in an outpatient setting slowly grew from
95
96
Health systems in transition
Ukraine
1.6 per 1000 population in 1995 to 1.7 in 2006 as a direct result of government
policies on strengthening the primary care sector and the development of
family medicine (see section 6.3). The total number of primary care physicians
increased by 0.6% between 2000 and 2006, and the supply increased from 0.5 to
0.6. The total number and supply of family medicine/GP physicians is growing
rapidly (see Fig. 5.4), whereas the number and supply of district internists
and district paediatricians are decreasing. Thus, according to regional health
authorities, the situation is getting worse with regard to primary care staff
supply in large cities where family medicine has not yet been well developed.
The primary care staff turnover rate is also rather high. A survey of primary
care structures conducted by the Ministry of Health in 2007 showed that almost
a third of all doctors (29.5%) had left their posts in the previous five years.
Moreover, more than a quarter (25.6%) of the total number of primary care
physicians are of retirement age and another 17% will reach retirement age
within five years.
Fig. 5.4
Trends in the supply of family doctors/GPs, 1997–2008
9 000
1.70
1.8
X
1.6
1.50
X
7 000
1.4
1.25
X
6 000
1.2
1.06
X
5 000
1.0
0.80
X
4 000
0.56
3 000
0.38
2 000
0.22
1 000
0
0.8
0.10
0.06
0.03
0.03
X
X
X
1997
1998
1999
0.6
X
0.4
X
X
0.2
X
0.0
2000
X
2001
2002
2003
2004
2005
2006
absolute number of family doctors/GPs
rate of family doctors/GPs per 1 000 population
Source: Medical Statistics Centre, Ministry of Health, unpublished data, 2009.
2007
2008
Rate of family doctors/GPs per 1 000 population
8 000
Health systems in transition
Ukraine
The total number of inpatient sector doctors has fallen by 12.4%
(9000 doctors) since 1995, or from 1.4 to 1.3 per 1000 population. This is due
mostly to the conversion of low-capacity rural hospitals into outpatient clinics
(see section 5.1). This can be interpreted as a positive trend which is intended
to optimize the use of inpatient sector resources (see section 6.4).
The Ministry of Health and higher medical educational institutions employ
about 3.0 medical scientists per 1000 population. This figure is incomplete
since there is no information available on the number of medical scientists
employed by the 36 research institutes of the Academy of Medical Sciences
of Ukraine. Also, a small number of medical specialists in alternative and folk
medicine work at facilities under the control of the Ministry of Health: 20 folk
medicine doctors and 123 reflexologists (about 0.003 per 1000 population). The
majority of these specialists have private practices and it is impossible to obtain
accurate data on their numbers.
As with physicians, the State Statistics Committee of Ukraine includes in
the category of mid-level medical personnel everyone with appropriate medical
training, including dental assistants, public health specialist assistants and so
on. The total number of mid-level medical workers has decreased by 18.9%
since 1990, and the number of these workers at facilities under the Ministry of
Health has decreased by 17.8%. There has been a rapid decline in the supply
of mid-level medical workers since independence (see Table 5.4). In 2007, over
14% of mid-level medical workers were of retirement age. As with the number
of doctors, the dramatic fall in the number of nurses between 1995/1996 and
1997 reflects a change in the way statistics were calculated to include only those
actively working with patients in the health system.
Nurses, feldshers and midwives provide both preventive and medical services.
Feldshers represent a special category of mid-level health workers between
nurses and physicians. Unlike nurses, who in Ukraine work as assistants to
physicians, feldshers are sufficiently independent in their work, performing a
broad range of preventive, diagnostic and therapeutic tasks, prescribing some
drugs, performing administrative functions and, in certain circumstances,
conducting expert examinations to establish a patient’s ability to work. The
total number of nurses, feldshers and midwives decreased by 15.1%, or from
8.4 to 7.8 per 1000 population. The falling number of nurses has been caused by
the falling status of mid-level health personnel. Medical nurses leave the health
care field for other sectors of the economy, primarily due to the low wages and
97
98
Health systems in transition
Ukraine
the lack of possibilities for professional development. This is a trend witnessed
throughout the CIS and one which runs counter to developments in countries
of the EU (see Fig. 5.5).
Fig. 5.5
Number of nurses per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
1 200
1 100
1 000
900
Russian Federation
CIS
Ukraine
EU
Republic of Moldova
800
700
600
500
Poland
400
300
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: WHO Regional Office for Europe, 2010a.
The Ministry of Health is alarmed by the human resources situation in the
health sector. In June 2008, a special board of the Ministry of Health identified
the main reasons for such developments as the natural loss of human resources
through ageing and migration (Bernik, 2008). Due to natural causes alone, the
number of doctors decreases annually by 3% (6000 doctors). There has been
an alarming increase in the number of rural primary care health facilities in
which every post is vacant; in 2006, this was the case in 273 rural outpatient
clinics and for 386 FAPs. Graduates from university-level medical institutions
often prefer positions in pharmaceutical companies to medical practice or
leave the health sector all together. Moreover, in recent years, Ukraine has
become a donor country of medical human resources. As a result, many health
facilities are understaffed. The available data on medical human resources
do not allow the volume of emigration to be measured, but data from border
regions show that a significant number of doctors are seeking work abroad. The
main “push” factors are low wages, poor social conditions, poor infrastructure
in rural areas and the low status of the medical profession. The government is
Health systems in transition
Ukraine
planning to develop comprehensive measures aimed at lowering the turnover of
medical staff. This is particularly important since Ukraine signed the Bologna
Declaration, which provides for the free movement of medical personnel within
the European continent (see section 5.2.4 Registration/licensing). Parliament
decided that from 1 January 2009, three more days should be added to paid
annual leave for primary and emergency care medical workers who have served
continuously for three years (Law of Ukraine No. 21-VI, issued 12 February
2008, On amendments to Article 77 of the Principles of legislation on health
care in Ukraine). Parliament is also working to improve the social protection
of health care workers.
According to the State Statistics Committee of Ukraine, the supply of dentists
employed by state and community medical facilities, and medical facilities in
parallel systems is increasing gradually and in 2008 there were 0.5 dentists
per 1000 population. However, this figure does not include dentists in private
facilities, which predominate. Including these, the supply of dentists is higher
by 40% at 0.8 per 1000 population. Dental assistants and dental graduates
(analogous to a feldsher in general medicine) are considered mid-level dental
staff. Dental assistants are not differentiated from other mid-level medical
personnel. According to the State Statistics Committee of Ukraine data on
dental personnel, the number of these specialists decreased drastically since
independence due to the growing delimitation between the functions of doctors
and mid-level staff in dentistry. There are no available data on the number of
dentistry graduates working in the private sector. Officially, levels are similar
to those in Central Europe, and high relative to other countries of the CIS
(see Fig. 5.6).
Since 1990 the number of pharmaceutical chemists (pharmacists with a
higher education degree) working under the Ministry of Health and other
departments has decreased by 20%. There are no exact data regarding the
number of pharmaceutical chemists, including those working for private
companies. However, according to the Ministry of Health, the real number of
these specialists is double that given by the State Statistics Committee of Ukraine.
Practically all pharmaceutical chemists work in pharmacies. Large hospitals
with a capacity of 300 or more beds should have a clinical pharmaceutical
chemist on staff, who is responsible for advising patients and doctors on the
most effective pharmaceuticals available. In reality, there are only ten employed
by a few hospitals. Officially, the supply of mid-level pharmacists has not
changed much since independence, but there are no data regarding the number
of pharmacists in the private sector. Excluding private sector specialists, the
99
100
Health systems in transition
Ukraine
Fig. 5.6
Number of dentists per 100 000 population in Ukraine and selected other countries,
1990 to latest available year
60
EU
50
Republic of Moldova
40
Ukraine
30
CIS
Russian Federation
Poland
20
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: WHO Regional Office for Europe, 2010a.
supply of pharmacists with a higher education degree is lower in Ukraine than
in the EU, but is higher than in other CIS countries (see Fig. 5.7). However,
including specialists from the private sector, the supply of pharmacists with
a higher education degree in Ukraine is actually closer to the average for the
EU countries.
5.2.2 Planning of health care personnel
The number of admissions to institutions of higher medical education is
established by government order and supervised by the Ministry of Health,
based on the estimated needs of the population for different medical specialists
and the state’s economic potential. Institutions of higher medical education
also admit students on a contractual basis, where the student is self-funded or
sponsored by a legal entity. Internships are based on requests from regional
health authorities, taking into account the real and estimated staffing levels in
health facilities, in compliance with staffing standards.
Health systems in transition
Ukraine
Fig. 5.7
Number of pharmacists per 100 000 population in Ukraine and selected other
countries, 1990 to latest available year
90
Republic of Moldova
80
EU
70
60
Poland
50
Ukraine
40
30
20
CIS
10
Russian Federation
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: WHO Regional Office for Europe, 2010a.
5.2.3 Training of health care personnel
State policies stipulate that higher medical and pharmaceutical education shall
remain in the state health system. According to Article 30 of the state Law
on higher education (Law of Ukraine No. 2984-III, issued 17 January 2002),
medical education is organized into several stages, comprising generalist
medical education (complete mid-level medical education), specialist training
(basic higher medical and pharmaceutical education) and postgraduate training
at the Master of Science level (completed higher medical and pharmaceutical
education). It must be noted that the Master of Science level provides teaching
staff for institutions of higher education.
The system of higher medical education consists of two stages: undergraduate
and postgraduate training. At present, training is provided by 18 state
university-level medical schools and faculties, including three postgraduate
medical schools. The institutions are funded by the Ministry of Health and are
supervised by both the Ministry of Health and the Ministry of Education. In
addition, there are four medical faculties within multi-specialty universities
supervised and funded by the Ministry of Education. During the 1990s, there
were also six nongovernmental institutes offering higher medical education.
101
102
Health systems in transition
Ukraine
However, five of these institutes have now lost their licence and were closed
due to the poor quality of training provided. Therefore, only one private higher
medical educational institution remains: the Medical Institute of the Ukrainian
Association of Folk Medicine. Higher medical educational establishments are
evenly distributed around the country. They are located in 16 regional centres
and in the capital of the Crimea AR. Each institution has an education licence
and accreditation levels III–IV, which allows them to provide specialist and
Master-level training.
Undergraduate medical education provides training in two main directions:
medicine (general medicine, paediatrics, disease prevention and dentistry) and
pharmacy. All medical specialties are taught courses; correspondence education
is permitted only for pharmacy students. Training usually lasts for six years,
but general dentistry and pharmacy courses are five years long or five and a
half years by correspondence.
In 2006–2007, 60 000 people attended higher medical educational
institutions under the Ministry of Health, of whom 10 000 (18.0%) were
international students. Of the 12 000 admitted, 10 000 graduated, 45.1% of
whom received training in general medicine and paediatrics, 3.4% in disease
prevention, 17% in dentistry and 28.5% in pharmacy. Of the graduates,
39% were supported by government funding. Most students funded by the
government trained in disease prevention and paediatrics (93.4% and 71.3%
respectively), and the smallest proportion was in dentistry and pharmacy
(32.0% and 34.6% respectively) (see Table 5.5).
The number of medical graduates fluctuated between 7600 and 8400 in
1995–2005, but it increased by 20% in the two years to 2007. Admittance to
higher educational medical institutions fluctuated over the years, but overall
it is also growing. A financial deficit in 1996 prompted the Ministry of Health
to reduce the number of university places for training specialists allocated
by the state. Thus the number of students trained at the expense of the state
budget fell by 40% between 1995 and 2007. At the same time, in an attempt
to mobilize additional sources of funding, higher medical education institutes
were permitted to introduce tuition fees. Correspondingly, the number of
fee-paying students entering higher medical education increased by 6.7 times,
which allowed for the retention of staff and the strengthening and upgrading
of material and equipment in the institutions. However, these policies created
many problems for the health system as well. On the one hand, a large
proportion of fee-paying students tend to choose particular specializations,
which aggravates existing imbalances in the supply of human resources in the
Health systems in transition
Ukraine
Table 5.5
Basic training of specialists, 2006/2007
Admissions
Total
Students
studying
Statefunded
Total
Graduates
Total
Statefunded
Higher Education Institution III–IV level accreditation
Total
Medicine
12 082
4 246
59 468
10 236
3 978
3 795
2 309
23 194
3 761
2 020
Paediatrics
919
708
4 478
863
615
Public health
534
499
2 296
347
324
Dentistry
2 113
388
9 930
1 740
558
Pharmacy
3 797
271
16 237
2 612
303
Clinical pharmacy
249
17
1 221
305
57
Other specializations
625
54
2 112
618
101
Higher Education Institution I–II level accreditation
Total
24 662
13 741
66 166
24 186
–
Nursing, midwifery, medicine
19 297
11 405
52 664
19 211
–
558
414
1 613
531
–
1 390
489
3 026
1 303
–
Public health
Dentistry, orthopaedic dentistry
Laboratory work
Pharmacy
Other specializations
755
652
1 690
697
–
2 612
787
6 593
2 290
–
120
6
580
154
–
Source: Medical Statistics Centre, 2008b.
health system as there are no caps on the number of students allowed to follow
different specializations. On the other hand, some legislative issues remained
unresolved, which allowed the Ministry of Health unofficially to limit the
employability of contractual graduates at state and community health facilities.
Moreover, low wages prompt fee-paying students to seek employment outside
the health care sector.
The government has already offered 500 fee-paying students the possibility
of switching to government-financed education in 2008/2009, on condition
that they will fill posts in the most wanted specialties, primarily in rural areas.
There are plans to increase the number of specialists allocated by the state, as
well as to start a gradual transition to the residency model, which will promote
the concentration of specialist training with competitive selection at the higher
education level.
Postgraduate medical training is based on the principle of continuous
professional education and involves a main specialization, further specialization
and the advanced professional training of physicians. Main specialization is
achieved through an internship, which combines intra- and extramural forms of
103
104
Health systems in transition
Ukraine
training. Medical schools usually do not have their own clinical centre, thus the
full-time part of the internship takes place within medical schools, while only
the extracurricular part is undertaken within health facilities. The internship
can be completed in 34 specialties, 24 of which are clinical. The remainder are
disease prevention, dentistry, pharmacy and so on. The length of internship
training currently varies between one and two years, depending on specialty.
In order to improve the quality of training, the range of specialties and length
of internship were revised in 2005 as part of a Ministry of Health order (No. 81,
issued 23 February 2005, On approving the list of specialties and the length
of internship for medical and pharmaceutical graduates from institutions of
higher education). The number of specialties was reduced from 54 to 34. The
number of clinical specialties was reduced from 35 to 24, but the length of
training was extended from 1–2 years to 2–3 years. The number of internship
places available for each specialty is determined according to the requirements
for specialists as identified by regional health authorities. Fee-paying interns
choose their future specialty themselves. Training in specialties not covered
by the internship programme, or the retraining of specialists, is offered at
postgraduate medical faculties after completing an internship in the main
specialty. The length of training is usually similar to the length of the full-time
part of an internship, which is too short to provide sufficient training in the
chosen specialty. Moreover, before training begins, the graduate must work as
an apprentice.
Completing an internship and specialist medical training generally leads to
doctors being given a certificate and awarded the title of “specialist doctor” in
a particular field. Physicians who have completed formal medical training are
required to continue professional development in order to maintain knowledge
and skills, with the necessary programmes being provided at postgraduate
medical faculties. In compliance with the concept of developing medical
education, the Ministry of Health aims in the next few years to implement a
system of continuing professional development for doctors and pharmaceutical
chemists. The system is based on the principles of democratization of education,
integration of traditional and new formal and informal structures, flexibility
of curricula and syllabuses, and alternative approaches to the organization
of the educational process. The system was developed while considering the
professional medical traditions of the Ukrainian school of advanced training.
Doctors are expected to improve their knowledge and skills through different
forms of training. Along with traditional postgraduate faculty programmes,
the system encourages correspondence courses and a credit system from all
professional activity in order to be admitted for certification (which began
Health systems in transition
Ukraine
to be introduced in 2010). Currently, the Ministry of Health is developing
the theoretical and organizational grounds for a system of continuous
professional medical education (Order of the Ministry of Health No. 484 of
7 June 2009, On the ratification of changes to the conduct of pre-certification
cycle examinations).
All practising physicians are subject to regular re-accreditation at least every
five years. Eligible physicians are required to have completed a pre-accreditation
cycle within one year before the official accreditation, performed by committees
at the Ministry of Health or regional health bodies. The main criterion for
appraisal is length of professional record. There are no clear appraisal criteria for
the quality of a doctor’s performance, however, and decision-making has thus
been rather subjective. One major drawback of the existing accreditation system
is that it largely aims at increasing the specialist’s salary. Thus, a specialist who
failed to verify his or her qualification level will only lose out on salary while
their right to practise will not be affected.
The training of medical staff is based on educational standards. The
development of standards for higher medical and pharmaceutical education is
the responsibility of the Ministry of Health and the Ministry of Education. The
Ministry of Health supervises the content, level and number of state educational
standards, develops and approves syllabuses and qualification requirements
for specialist training, and monitors the quality of basic medico-biological and
professional training at undergraduate and postgraduate levels. The ministries
develop and approve syllabuses and model curricula. To safeguard compliance
with state educational standards and the achievement of a minimum level of
professional competence within the higher medical education system, Ukraine
has introduced state integrated licensing examinations. These examinations are
performed in all higher medical educational establishments by the Centre for
Testing Professional Skills of Health Workers, an independent unit established
under the Ministry of Health. Medical students must complete two state
licensing examinations during their undergraduate training, after studying
basic disciplines (“Step 1”) and after completing the full training course
(“Step 2”). In 2004 the state licensing examinations for internship training
were introduced, which is equivalent to “Step 3” in the current system of higher
medical education. Medicine, paediatrics and public health graduates have
an examination in general medicine, while dentistry graduates must pass an
examination in dentistry.
105
106
Health systems in transition
Ukraine
Educational standards are mandatory for all medical and pharmaceutical
educational establishments. However, the model curricula and syllabuses can
be changed for not more than 15% of the total number of hours. Thus, within
the allowed limits of standards modifications, the single private university-level
medical school – the Folk Medicine Institute – offers a number of courses on
folk and non-traditional medicine, including phytotherapy, homeopathy, manual
therapy, bio-energy therapy and iridology, among others.
Public health specialists with a higher education degree can be divided
into two groups: sanitation and disease prevention workers and public health
education workers. The training for the first group of specialists (the majority of
public health workers) consists of a six-year undergraduate programme in disease
prevention followed by a one-year internship in one of the three specialties:
general hygiene, epidemiology or virology, plus a four-month training in a
narrow specialization. Public health education workers are required to follow
the six-year programme for a medical degree in therapeutics, paediatrics or
medico-prophylactics. They must then complete an internship in one of the
clinical or disease prevention specialties.
Practising physicians go through a basic undergraduate six-year training
process in medicine (therapeutics) or paediatrics, followed by two years of
therapeutics internship or a surgery internship of three years, then voluntary
training in one of 61 narrow specializations.
Primary care physicians receive the basic six-year undergraduate training
in general medicine or paediatrics followed by a two-year internship in general
medicine (for district internists), or paediatrics (for district paediatricians).
Family doctors/GPs have a two-year internship or a six-month retraining course
for active physicians.
Folk and non-traditional medicine specialists receive basic undergraduate
training in therapeutics or paediatrics, followed by an internship in one of the
clinical specialties and then specialize in folk and non-traditional medicine.
Dentists are trained through the basic five-year undergraduate programme
in dentistry, followed by a two-year internship in dentistry. They then specialize
in one of the following: therapeutics, surgery, maxillofacial orthopaedics,
children’s dentistry, orthodontics and so on.
Pharmaceutical specialists receive the basic five-year undergraduate
training in pharmacy, followed by a one-year internship in general or
clinical pharmacy.
Health systems in transition
Ukraine
Health care managers must have a higher education degree in medicine and a
specialization in “health care organization and management” in compliance with
qualification requirements. Specialization training is conducted at postgraduate
medical schools and covers six modules, including social medicine, basics of
health care management, the economic and legal foundation of management,
management culture. However, neither the duration (two months) nor the content
of the training ensure high quality.
Insufficient training often compels medical students and especially young
managers to take a second higher education degree in economics or law. In
order to supply the ever-growing demand for modern managerial skills, some
higher education establishments have started training health care managers.
The first department of health care management was established at the Kharkiv
Medical Academy of Postgraduate Education in 2001, offering a one-year
training programme to professionals with higher medical education (one year
full time, or two years for intra- or extramural training). Graduates receive
a specialist diploma in health care management, qualifying them to work in
related fields. In 2004, the first Ukrainian School of Public Health (SPH) was
established within the Kyiv-Mohyla Academy, which offers a two-year Master’s
degree programme in health care management. In 2009, a joint project was
accomplished in two universities (the Dnipropetrovsk Medical Academy and
the Dnipropetrovsk Economics and Law University) to provide a postgraduate
health care management course. Teaching is both in-house and distance learning
for two years and two months. Courses in both schools are for fee-paying
students only. There are plans to launch more management programmes in other
higher education establishments, but the supply is still insufficient. “Health
care manager” has also not been officially recognized as a medical specialty
and there are no corresponding positions at medical facilities, thus limiting
students’ prospects of adequate employment after graduation. The majority
of trainees at the Kharkiv Medical Academy of Postgraduate Education and
the Dnipropetrovsk Medical Academy are active managers who return to their
posts after training, without having gained any advantage over their untrained
colleagues. Graduates of the Kyiv-Mohyla Academy seek employment mostly
with international programmes related to health care.
The government and the Ministry of Health understand that the lack of
well-trained managerial staff is a serious obstacle to the implementation of
health care reforms. There are constant debates about the creation of a modern
system of health care management. Following an order from the Ministry
of Health, the experts of the EU project Support to Secondary Health Care
Reform in Ukraine, together with specialists from the National Academy for
107
108
Health systems in transition
Ukraine
Postgraduate Education (Kyiv), have developed the qualification requirements
and the postgraduate programme to prepare health facility managers for the
specialization of “health care management”. Ministers of Health have planned
to conduct the retraining of health care managers and the managers of large
health facilities over the course of five years, and in ten years to have retrained
all managers working in the health system. However, as yet no real decisions
have been made to improve the training of managerial staff.
Mid-level junior staff are trained at more than 100 medical vocational
schools which are evenly distributed among the regions, and only two of which
are private. These schools have medical education certification and hold the
status of higher educational establishments at accreditation levels I–II, allowing
them to train mid-level specialists (nurses, feldshers, etc.) and undergraduates.
Some of these schools and several higher medical educational establishments
at accreditation levels III–IV train nurses to degree level. Mid-level specialists
are trained in such specialties as general medical nurse, midwifery nurse,
disease prevention nurse, dental nursing, orthopaedic dental nursing, pharmacy,
laboratory work and so on. Mid-level specialists at the undergraduate level
study nursing, pharmacy, laboratory diagnostics and so on. Training is offered
in full-time/intramural, part-time/evening and distance/extramural forms;
the duration of courses is up to three years for students who have a general
secondary education, up to four years for students who have just a basic
secondary education and undergraduate courses last four years.
In 2006–2007, more than 66 000 people attended medical vocational schools
and colleges (higher educational establishments at accreditation levels I–II).
Fewer than 25 000 were admitted and more than 24 000 graduated. Of these,
79.4% studied nursing, therapeutics and midwifery, 9.5% studied pharmacy,
5.4% studied dentistry and orthopaedics and 2.2% studied disease prevention
(see Table 5.5, p.103). More than 95% of students took full-time/intramural
training; 3.4% took part-time training in nursing, laboratory work and pharmacy;
and 1.6% used the distance/extramural form of training in pharmacy. Over half
(55.7%) of enrolled students were state-funded. The majority of state-funded
mid-level specialist places are in laboratory work and public health (86.3% and
74.2% respectively). The lowest proportion of state-funded mid-level specialist
places are in dentistry and pharmacy (35.2% and 30.1%).
Mid-level medical graduates are required to continue their education and
attend advanced training courses at medical vocational schools, colleges and
specialized advanced training vocational schools. Like practising physicians,
all mid-level medical workers are subject to regular process of accreditation at
Health systems in transition
Ukraine
least every five years. Accreditation is conducted by accreditation committees
in medical facilities and by regional accreditation committees in regional
health administration facilities. There are three categories of mid-level medical
specialists. The main criterion for improvement of one’s grade is the length of
professional record.
Nurses occupy a special place among mid-level medical personnel. In the
past 10 years, their training has gone through some transformations. Nurses are
trained in one of three areas: nursing, therapeutics or midwifery, with further
narrow specialization. The training involves a two-year basic course, which
now also includes disciplines such as the theoretical foundations of nursing,
interpersonal communication, evaluation of patient’s health, clinical nursing
and public health. Graduates may then enter advanced training at degree level,
which lasts for two years full-time (three years part-time). Advanced training
offers a deeper education in family medicine nursing, surgery, midwifery,
management and so on. While, in theory, nurses trained to degree level qualify
for positions as chief or senior nurses, or as deputy chief physician for managing
nursing staff, this is rarely the case as there still is no appropriate regulatory
framework. Qualified professional nurses continue to work in positions similar
to junior nurses and their degree does not affect their salary. The Ministry
of Health is planning to continue restructuring the nurse training system
to establish nursing as a separate profession, with nurses working in health
promotion, disease prevention, and patient care – all activities traditionally
performed by doctors in Ukraine.
5.2.4 Registration/licensing
Ukraine does not have a system of doctor registration. Medical facility
administrators and agencies in charge of medical business licensing are
responsible for monitoring compliance with educational requirements. The
licensing conditions are established in a Joint Resolution of the State Committee
of Ukraine for Regulatory Policy and Entrepreneurship and the Ministry of
Health (No. 38/63, issued 16 February 2001, Licensing conditions for conducting
a medical business) and require a number of documents to establish compliance
with education and qualification requirements such as:
•
state model medical diploma
•
medical specialist certificate issued by a higher education medical school
upon completion of internship or specialization
•
proof of qualification
109
110
Health systems in transition
Ukraine
•
proof of advanced training accomplishment and retraining of mid-level
medical and pharmaceutical workers
•
professional record.
Specialists trained in other countries are permitted to practise in Ukraine after
verification of their qualifications in compliance with the Ministry of Health
Order No. 118-с, issued 19 August 1994, On the rules of admittance to medical
and pharmaceutical practice in Ukraine for medical and pharmaceutical
specialists trained in other countries.
In recent years, Ukraine has made an effort to bring medical training in line
with European standards. In 2005, the country officially joined the Bologna
Convention. In order to bring higher medical education up to these standards, the
Ministry of Health has taken comprehensive measures: new curricula have been
developed and the gradual introduction of a system of credit-units is taking place.
This is also a uniform system of knowledge evaluation, and state accreditation is
performed in compliance with the principles of quality provision. The material
and technical base of educational facilities is also being renovated, and new
educational technology is being introduced – including distance learning. The
new medical training system was planned to be implemented by 2010. The full
implementation of the Bologna Declaration principles is expected to improve
cooperation with European universities, give more educational choices to the
students, and facilitate the international mobility of students, teachers and
specialists. However, these measures have left unresolved a number of problems
with the higher educational system, particularly:
•
insufficient compliance of medical education with EU standards
•
poor quality of training due to the low motivation of students and teachers
for self-improvement
•
outdated educational technology
•
the low level of computerization in education
•
a lack of clinical centres in medical schools
•
the low level of remuneration of pedagogical staff, which aggravates
this situation.
The creation of clinical centres in medical schools has been debated for
several years now. Even existing clinical centres lack legislative protection. In
2008, there were amendments made to the Law on higher education, providing
for the creation of so-called “university clinics” – medical and research centres
Health systems in transition
Ukraine
within medico-prophylactic facilities, based on reciprocal agreements. University
clinics are expected to become an integrated subdivision of higher medical
education at accreditation level IV. They would provide highly specialized
medico-prophylactic services and consulting to other medico-prophylactic
facilities. They would also provide training, retraining and advanced training
to medical specialists in compliance with higher educational standards, as
well as conducting medical research, and testing and implementing new
medical technologies.
111
6.1 Public health
P
ublic health agencies and medical facilities are responsible for
improving the population’s health in the country. Health education is
the responsibility of doctors of any level of qualification, particularly
physicians of the lowest rank. Special medical facilities known as health centres
exist on paper to coordinate activities to promote a healthy lifestyle, involving
nonmedical institutions and facilities interested in this process as well, but they
have yet to be fully implemented. However, current activities do not have a
significant impact on public and individual attitudes towards their own health.
Unfavourable health tendencies aggravated by widespread risk behaviours (see
section 1.4) have increased the understanding that the traditional health care
model (focusing primarily on treatment) does not improve health in Ukraine.
There is a lack of human resources capacity to improve health communication
in Ukraine, as well as organizational and financial barriers.
The Cabinet of Ministers Resolution On approving the inte rsectoral
programme “Health of the Nation for 2002–2010” (No. 14, issued 10 January
2002) was, among other topics, dedicated to the promotion of a healthy
lifestyle. The programme it introduced aimed for a number of measures to
be taken in different branches of the economy, including education, creating
an infrastructure of healthy recreational activities and incentives to support
a healthy lifestyle. Unfortunately, the implementation of this part of the
programme proved to be ineffective. The media actively advertises products
harmful for health, particularly alcohol and tobacco. Furthermore, the Social
Advertisement Institute is practically inactive, and health education for young
people is lacking (Ministry of Health of Ukraine and Ukrainian Institute
for Strategic Research, 2006). Nevertheless, there have been a number of
indications of a breakthrough in the government’s attitude towards healthy
lifestyle issues. In 2005, a law was passed On measures of prevention and
reduction of tobacco products use and their harmful impact on the population
health (Law of Ukraine No. 2899-VI, effective 25 October 2005). In 2006, the
6. Provision of services
6. Provision of services
114
Health systems in transition
Ukraine
Parliament ratified the WHO Framework Convention on Tobacco Control. In
2008, amendments to the Law on advertising were issued, banning tobacco
and alcohol advertising (Law of Ukraine No. 145-VI, effective 23 March
2008). Thus, from January 2009, there has been a ban on tobacco, alcohol and
low-alcoholic beverages in “external advertisements” inside and outside of city
limits. Further, the advertising or promotion of alcoholic beverages is banned
from television programmes. From 1 January 2010, it is forbidden to advertise
alcohol and tobacco in all printed media except for specialist titles.
Currently, the Government-approved Concept of the state target programme
“Healthy Nation 2009–2013” (Special Resolution of the Cabinet of Ministers
No. 731-p, issued 21 May 2008) provides for the implementation of a series
of coordinated intersectoral measures to create favourable conditions for a
healthy lifestyle in Ukraine (including more physical activity, rationalized
nutrition, hygiene, cessation of tobacco smoking, and alcohol and drug usage)
and the prevention of accidents. Financing for this programme comes from
the pooling of funds from the state, local communities, public institutions and
private organizations.
The State Sanitary-Epidemiological Service is the main structure in
Ukraine that is legally responsible for public health protection. Its two main
functions are the control of communicable diseases and environmental
protection (monitoring the quality of water, air, soil and food). The State
Sanitary-Epidemiological Service is organized hierarchically. It is financed
exclusively from the state budget, which gives it relative independence from
local authorities. The infrastructure comprises 816 sanitary-epidemiological
stations including stations in rural areas, municipal and district stations,
regional, central and one republican station, as well as disinfecting stations
and one anti-plague station. The facilities have laboratory capacity for physicalchemical and microbiological analyses to identify the sources of infectious
diseases. State Sanitary-Epidemiological Service facilities primarily employ
medical professionals and mid-level medical staff. Specialists in the State
Sanitary-Epidemiological Service are responsible for maintaining preventive
and routine sanitary and epidemiological surveillance to ensure safe working
conditions in public and private enterprises, facilities and institutions, including
community buildings, water-pumping and sewerage facilities, residential
and public buildings, residential institutions for children and teenagers, and
medico-prophylactic institutions, among others. Anti-epidemic work is
performed by the epidemiological sector of the State Sanitary-Epidemiological
Service in concert with medico-prophylactic institutions. The Service is also
responsible for monitoring the quality of drinking water: it is in charge of
Health systems in transition
Ukraine
19 290 centralized water supply sources. It also controls 101 252 decentralized
water supply sources, including 96 813 wells, 1142 water catchment systems
and 3304 artesian wells.
6.1.1 Immunization
Immunization is the main part of the preventive work. There are 10 mandatory
vaccines in Ukraine: TB, polio, diphtheria, pertussis, tetanus, measles, mumps,
rubella, hepatitis B and Haemophilus influenzae type b (Hib, since 2006).
Depending on the specifics of their job or industry, certain categories of workers
are required to receive certain other vaccines. The actual planning of activities
and registration of children eligible for immunizations is the responsibility of
local paediatric services or family doctors/GPs. The immunization of children is
organized and performed by special units in children’s polyclinics (vaccination
surgeries) or family doctors/GPs, the polyclinic departments of hospitals,
rural health facilities, as well as nurseries and schools. The State SanitaryEpidemiological Service monitors the organization and regular administration
of vaccines.
Two national immunization programmes have been implemented in Ukraine
(1993–2000, 2002–2006) to reduce the rate of communicable diseases. In
2007 the percentage of the population immunized against the main vaccinepreventable diseases reached 95%, including measles – 98.8%; diphtheria –
98.7%; and pertussis, polio and TB (among infants) – 97.8%. Implementing
these programmes allowed Ukraine to overcome the negative epidemiological
situation that appeared in the 1990s and reduce the number of infectious
diseases, primarily diphtheria, rubella and mumps. However, measles and
pertussis levels remain undesirably high (there was an outbreak of measles
in 2001/2002 and another in 2005/2006). The Ministry of Health regards
this problem as a consequence of the vaccine shortages between 1992 and
1994. Moreover, vaccines received via humanitarian aid were never officially
registered in Ukraine, and had a low immunogenic factor. This led to raised
levels of these diseases among adults (Ministry of Health, 2007). An audit by the
Accounting Chamber revealed a number of problems with the vaccination period,
particularly irregular and sometimes insufficient supplies of vaccines (which
caused a decline in immunization coverage from 2001 to 2003), insufficient
compliance with the immunization schedule, disregard of contraindications
in certain cases in order to reach coverage goals and insufficient monitoring
of post-immunization complications. Low levels of health education among
the general population aggravated the situation, leading to the mass refusal of
vaccination (Flisak & unpublished document, Shakh, 2008).
115
116
Health systems in transition
Ukraine
The state immunization programme was developed for the period 2007–2015
and was ratified by Law No. 1658-VI of 21 October 2009. The programme aims
to raise the levels of vaccination and revaccination for children in order to create
a post-vaccination immunity that can contain an epidemic spread.
6.1.2 Family planning
The family planning system is one of the youngest subsystems in the Ukrainian
health system. It was created as a result of the consecutive implementation
of two national programmes, Family Planning (1995–2000) and Reproductive
Health (2001–2005). Refining the family planning system remains one
of the main goals of the current national programme, entitled the National
Reproductive Health Programme to 2015. A network of family planning centres
and offices has been created in the country. The service is headed by the
Ukrainian State Family Planning Centre established at the Ukrainian Research
Institute of Paediatrics, Obstetrics and Gynaecology. Regional family planning
centres and contraception clinics have been established within obstetrical and
gynaecological services. These new measures have thus far been relatively
successful, with abortion rates falling by almost 4.5 times. However, abortions
continue to be the main method of birth control in Ukraine. Government
statistics suggest that modern contraceptive methods are utilized by only about
29% of women of reproductive age. More frequent use of modern contraception
is hampered not only by high costs but also by low public awareness and the
unsatisfactory family planning system. According to a sociological survey, only
61% of women who had undergone an abortion received further advice regarding
contraception; only 15.6% received a prescription or actual contraceptives.
6.1.3 Routine examinations and screening
Ukraine regulates mandatory preliminary and routine medical examinations
for certain categories of workers, including workers involved in public
services which could lead to the spread of communicable diseases or cause
food poisoning (food workers in community or children’s facilities and school
teachers) and employees who do heavy labour or work in hazardous conditions.
The responsibility for arranging and conducting the routine mandatory medical
examinations of employees lies with the owners of enterprises, facilities and
institutions. Monitoring adherence is the responsibility of the State SanitaryEpidemiological Service.
Since the mid 1980s, during the Soviet era, there have also been universal
health examinations to provide dynamic monitoring of public health. Preventive
screenings took place in accordance with certain programmes, the contents
Health systems in transition
Ukraine
of which differed according to the age of target population groups. These
examinations revealed certain factors which had an impact on public health, and
preventive work was based on these factors. Decreased health care financing
had a pernicious effect on the preventive work of medical facilities, particularly
concerning screenings of the adult population, which were reduced and took on
a mostly declaratory form. At the turn of the century, the Ministry of Health
passed a number of resolutions proclaiming the resumption of mass health
screenings and the monitoring of public health (for example, the Ministry of
Health Order No. 327, issued 8 December 2000, On the resumption of mass
health screening and monitoring of p ublic health). This work was to be
accomplished in two stages: the mass health screening of vulnerable groups
during 2001–2002, and prophylactic examinations to cover the remainder of the
population during 2003–2005. However, due to a lack of resources (primarily
financial), only the first stage was accomplished. Currently, only certain groups
undergo compulsory medical screenings: children (monthly during the first
year, quarterly during the second, twice a year during the third and annually
from age 5 to 14), pregnant women, teenagers, students, emergency services
workers and victims of the Chernobyl disaster. The local authority area is
traditionally in charge of community health monitoring. Screenings involve
other medical specialists (otorhinolaryngologist, ophthalmologist, surgeon,
neurologist, dentist and others depending on indications), laboratory work and
equipment tests. Unfortunately, the clumsy and expensive model of compulsory
mass health screenings by a group of professionals without any proof that these
screenings are effective is still present. There is still excessive attention paid to
preventive screenings, alongside a formal attitude to health improvement and
preventive treatments.
Along with mass health screenings in Ukraine, there are also targeted
preventive screenings aimed at the early detection of certain conditions and
diseases. For example, the state oncology programme (Cabinet of Ministers
Decree No. 392, issued 29 March 2002) provides for a number of screening
programmes: detection of cervical cancer (yearly cytological screenings of
women aged 18–60 and colposcopy for women in risk groups), breast cancer
(mammogram screenings for women aged 40–65 and early palpation exams for
women starting age 15), and colon and prostate cancer (annual examinations
for people over 50). In order to improve the timeliness and effectiveness of
cervical cancer detection, the Ministry of Health launched another programme
for cervical pathology screening (Ministry of Health Order No. 766, issued
31 December 2004). There is no special financing provided for screening
programmes; they are financed primarily from local budgets from general
resources allocated to health care. The lack of earmarked financing prevents
117
118
Health systems in transition
Ukraine
these programmes from acquiring sufficient equipment, and there is a
catastrophic shortage of mammographs in the country. The cytological service
is rather small, which has a negative impact on screenings for cervical cancer.
There are organizational problems as well, with no coordinated system of
preventive screenings for women, which interferes with planning and evaluating
the true scale of screening coverage. As a result, screening programmes are
not overly effective. The mortality rate for cervical and breast cancer did not
change significantly from 2002 to 2006. The frequency of advanced breast
cancer detection in 2007 was 27% (Medical Statistics Centre, 2008a). In 2006,
the National Reproductive Health Programme (Cabinet of Ministers Decree
No. 1849, issued 27 December 2006) made plans for lowering cervical and
breast cancer rates by 2015 and made provision for the special financing for
these goals.
Ukraine pays special attention to screening women during antenatal
and postnatal periods. Screening is performed by family doctors/GPs and
obstetricians/gynaecologists at specialized outpatient clinics called women’s
consultation clinics. These clinics provide dynamic monitoring of women’s
health during the antenatal period from 12 weeks of pregnancy, and provide
health education and maternal care during the postnatal period. There are a
number of screening programmes for pregnant women, including early detection
of congenital defects (two ultrasound tests before 22 weeks and a test for
alpha-fetoprotein), and tests for syphilis and HIV. Ultrasound tests cover about
94.6% of pregnant women, while the alpha-fetoprotein test covers 29.6%, the
syphilis test covers 96–98%, and the double test for HIV covers 94.5%. Despite
extensive screening, the morbidity and mortality rates for congenital defects are
still very high: in 2007, 22.3 and 2.8 per 1000 live births respectively (Ministry
of Health and Ukrainian Institute for Strategic Research, 2008). The rate of
HIV-infected pregnant women in Ukraine is one of the highest in Europe, at
0.31% in 2006. The number of children born to HIV-infected mothers continues
to grow and reached a record high of 2736 in 2006. However, Ukraine has had
significant success in lowering the rate of mother-to-child transmission. In 2006,
93.4% of all HIV-infected pregnant women received antiretroviral treatment to
prevent transmission. As a result, the rate of mother-to-child transmission has
fallen by 4 times since 2001, from 28% to 7%. However, approximately 10%
of HIV-infected pregnant women are not registered with women’s consulting
clinics and are not tested for HIV. Therefore they do not receive timely treatment.
The optimal vertical transmission level (up to 1%) is possible only through
universal HIV testing during pregnancy, and treating all women with positive
results with three-component antiretroviral therapy (Ministry of Health and
Ukrainian Institute for Strategic Research, 2007a).
Health systems in transition
Ukraine
The HIV/AIDS and TB epidemics have become major public health problems
in Ukraine (see section 1.4). A number of legislative and other acts have been
passed to fight the TB epidemic (for example, Law of Ukraine No. 2586-III,
issued 5 July 2001, On fighting TB; Presidential Decree No. 643/2001, issued
20 August 2001, On a national programme of f ighting TB for 2002–2005;
Cabinet of Ministers Resolution No. 143, issued 15 February 2006, Ordering
mandatory prophylactic TB screening for certain population groups; Law of
Ukraine No. 3537-IV, issued 15 March 2006, On amendments to some laws
to strengthen the fight against TB). Mandatory fluorographic screening was
introduced in 2002 for the entire population, but especially for at-risk groups.
In 2003, Parliament approved the use of the directly observed treatment, short
course (DOTS) strategy (Resolution of Verkhovna Rada No. 989-IV, issued
19 June 2003, On Parliament hearing of TB epidemics in Ukraine and their
prevention). In 2005, the Ministry of Health officially adopted a new strategy
for fighting TB in accordance with international DOTS standards (Order of
the Ministry of Health No. 610, issued 15 November 2005, On adopting the
DOTS strategy in Ukraine), and signed a protocol regarding the treatment of
TB patients (Order of the Ministry of Health No. 45, issued 28 January 2005,
On approving the regulations of medical services for TB patients). In 2006,
a new legislative decision required all patients with active TB to undergo
mandatory treatment.
All measures for fighting TB received designated funds from the state
budget. Furthermore, external technical and financial aid arrived from various
sources. For example, in 2003 the World Bank issued a loan to strengthen the
anti-TB and AIDS programmes. In 2007, a special agency was created within
the Ministry of Health, the National Council to Counteract Tuberculosis and
HIV/AIDS, which serves as the national coordination body for health facilities
regardless of their affiliations. However, all these measures have not produced
desired results. The TB epidemic has not been halted and there is a rapid spread
of HIV-associated TB. The ineffectiveness of previous measures has been
linked to insufficient systematic and coordinated organizational measures, the
weak laboratory basis for TB diagnostics, the lack of a clear system of planning,
purchasing, distribution and monitoring of anti-TB medications, creating
problems with the regularity of their supply, the lack of a quality-control system
for purchased medications, the insufficient qualifications of medical personnel
at clinics for TB screening, consulting and treatment, the widespread use of
mass fluorography screenings, palliative care in inpatient settings and so on – as
these are all ineffective medical practices, from clinical and economic points of
view (Barbova et al., 2006). To deal with these issues, in 2007 a state programme
119
120
Health systems in transition
Ukraine
for fighting TB in 2007–2011 was developed and made law (Law of Ukraine
No. 648-V, issued 8 February 2007, On approving the all-national programme
of struggle against TB for 2007–2011). The programme aims to reduce TB
incidence and TB-related deaths through improving laboratory TB diagnostics,
raising the efficacy of treatment, preventing the development of resistant TB
strains, and improving the system of personnel training and retraining.
For the authorities, the problem of HIV/AIDS prevention has been at the
centre of attention since the first Ukrainian cases, registered in 1987. In 1991,
Parliament passed the Law on the prevention of AIDS and on social protection
of the population. In 1992, the first national programme on AIDS prevention
was launched in Ukraine. The fifth national programme on HIV prevention,
care and treatment of HIV-infected and AIDS patients ran from 2004 to 2008.
However, this is only the second programme with earmarked financing and
the first programme that provided 90% of the necessary financial coverage for
HIV/AIDS prevention and treatment. This programme received funding from
state and local budgets, a loan from the World Bank, and a grant from the Global
Fund to Fight AIDS, Tuberculosis and Malaria. A network of special facilities –
AIDS centres – has been created throughout the country. They are responsible
for epidemiological monitoring and control, clinical and laboratory diagnosis
of HIV/AIDS and opportunistic infections, organization and provision of
necessary types of medical, psychological and social help for people living with
HIV/AIDS, as well as educating medical facilities about HIV/AIDS. However,
the interaction between these centres and general health care facilities is rather
weak. Public and HIV-service institutions play a major role in solving the
social, psychological and logistical problems encountered by people living with
HIV/AIDS. However, they are not able to fully accomplish this work due to
financial and organizational problems.
The worsening situation with HIV/AIDS led to the approval of the Sixth
National Programme on Prevention, Treatment, and Support for HIV/AIDS
Patients for 2009–2013 (Law of Ukraine No. 1026-VI, issued 19 February
2009). The programme puts forward a complex approach to fighting the
epidemics, including the evaluation and monitoring of the epidemic situation,
mass education on HIV/AIDS, primary prevention and steps on fighting
HIV/AIDS among high-risk groups. The programme also creates effective
working conditions for public organizations responsible for HIV prevention,
respects and defends the rights of HIV/AIDS patients, and provides universal
access to high-quality care, support and treatment for these patients. Also, in
order to draw injecting drug users to antiretroviral therapy, a heroin-substitution
programme has been launched. An important step in overcoming the HIV/AIDS
Health systems in transition
Ukraine
and TB epidemics is detection, prevention and treatment of HIV-associated TB.
Currently, access to HIV screening at TB treatment facilities is offered free of
charge; combined TB and HIV/AIDS treatment is provided if necessary.
6.2 Patient pathways
Patient pathways in Ukraine can be characterized as chaotic and uncontrolled,
and often they do not correspond with the gravity and course of the disease. A
patient can see a doctor of any specialty at a polyclinic. Where patients self-refer
to the wrong specialist, they are redirected to another specialist as necessary.
Some patients self-refer to inpatient facilities and some of them are hospitalized
unnecessarily if there are empty beds that need to be filled.
According to research on patients with arterial hypertension and related
diseases, 41.2% of patients first sought help from their primary care physician,
29.5% from medical specialists, 9.2% from the inpatient department of a
hospital, 3.2% from emergency care and 16.9% from hospitals of different
specializations (Kryachkova, 2003). There were also several different ways
patients reached primary care: 44.2% seek district internists directly, 21% are
referred to by medical specialists, 23.2% come from hospitals, 4.6% from day
and home care hospitals, and 7% come from other facilities. Only a third of
such patients are referred to primary care by specialized and highly specialized
care in order to complete their treatment, while the remainder are referred to
primary care due to the incompatibility of the patient’s health condition with the
type of care that was initially sought. The majority of patients circumvent their
primary care physicians to see medical specialists and self-refer to hospitals
directly: 34.1% of patients who seek specialized help self-refer and 31.3% of
patients who come to general hospitals do so directly. Every third patient who
seeks secondary care directly makes a mistake in their choice of a specialist
and is redirected to a different narrow specialist. Nearly half of all patients who
self-refer to specialist care at hospitals do not have a condition compatible with
the hospital’s level or profile and are transferred to a different health facility.
District internists only partially coordinate the movements of their patients
in the health system: only 8% of patients received specialized outpatient care
based on a referral from their district internist, while 33.7% were admitted
to multi-specialty hospitals, and 61.5% went to day hospitals and home care
hospitals (as a share of total visits to an appropriate level). On average, only a
quarter of patients (26.5%) receive medical care at only one level and are not
transferred to other specialists or to different medical facilities. The location
121
122
Health systems in transition
Ukraine
(level) of provided health care has been found to be compatible with the patients’
health condition only in a third of cases; in 43.2% of cases patients received care
far beyond the level that was really necessary, and in 22.7% of cases patients
needed a higher level of medical care than they received.
Problems in the organization of patient pathways sometimes lead to
unjustified complications. Some pathways have “loops” in them, whereby
patients return several times to the same specialist or to the same facility at
the different stages of their treatment. For example, it is typical for an arterial
hypertension patient who goes to see a cardiologist at a specialized clinic to be
redirected to his district internist who refers him back to the cardiologist. The
main reason behind such chaotic patient movement is the lack of coordination
of patient pathways from primary care physicians. Moreover, there is no
distribution mechanism of patients to different levels of medical care, and there
is an insufficient material and technical base for primary health care as well.
The convoluted system of patient pathways leads to the irrational usage of
limited resources, compromises the quality of medical health and has a negative
impact on population health. Adequate referral mechanisms could prevent
a significant portion of patients from developing more serious conditions
or complications.
6.3 Primary/ambulatory care
Traditionally, primary care in Ukraine has been provided within an integrated
system by district specialists – district internists and paediatricians employed
by state or community polyclinics. From 2000, family medicine/GP models
have also been a feature of the system (see section 7.1). Currently, family
doctors/GPs make up a third (32.9%) of all primary care specialists. They
work at family medicine/GP clinics or in appropriate polyclinic departments.
The overwhelming majority of family doctor/GP facilities are located in
rural areas (70%). The number of privately practising family doctors/GPs is
relatively small (0.8% of the total number of doctors in this specialization). The
majority of privately practising physicians work under contracts either with the
local authorities (for example, the city of Komsomolsk, in Poltava oblast; see
section 3.6.1 Paying for health services) or with insurance companies.
District internists provide general medical care to the assigned adult
population living in their catchment area (dilnytsia) in outpatient clinics or during
home visits they are responsible for preventive work among the population,
Health systems in transition
Ukraine
perform dynamic monitoring of patients with chronic diseases, provide health
education and immunization, and make referrals to medical specialists and
hospitals. Primary care nurses perform mostly auxiliary functions: under
doctors’ supervision they prepare and fill out medical forms (except for the
primary document, an outpatient patient’s medical record), perform certain
tests during a visit (take temperature, blood pressure, etc.) and explain the
preparatory steps for diagnostic examination to the patients.
Depending on their qualifications, family doctors/GPs are responsible
for providing general medical care to an assigned population (children and
adults) in outpatient settings and during home visits, including prevention,
diagnosis, treatment and after-care/rehabilitation for common diseases. As
with other primary care physicians, family doctors/GPs organize referrals to
specialists and hospitalizations for their patients, provide immunization services
according to the vaccination calendar, conduct examinations for temporary
work incapacity, issuing documents and verifying results, and promote healthy
lifestyles and health education for patients. However, they can also perform
basic surgical treatment of wounds, the immobilization of fractures and the
dynamic monitoring of pregnant women with a normal course of pregnancy
during the antenatal and postnatal periods. Family doctors/GPs work together
with family medicine/general practice nurses. However, especially in urban
areas, people are reluctant to bring very young children to family doctors/GPs
who are retrained adult district internists rather than retrained primary care
paediatricians. Sometimes children are already 7 or even 12 years old before
their first visit. The retraining programme of six months is viewed as inadequate
and, unlike in rural areas where district internists and district paediatricians
had been de facto working as family doctors/GPs prior to retraining, a former
district internist may have had very little contact with children. Consequently,
in some areas, family doctors/GPs only work with children older than 3 or
7 years of age.
The optimum number of patients is set at 1700 adults per internist
and 800 children per paediatrician. For family doctors/GPs it is set at
1110–1200 adults and children in rural areas and 1500–1600 in urban areas.
However, in practice, on average there are about 2500 patients per internist
in an urban area. The number of children per paediatrician is slightly lower
than the set norm and there are about 1500 per family doctor/GP. However,
these averages hide significant fluctuations in workloads for different types of
primary care physicians. Nationwide, 13% of doctors working in primary care
serve fewer than 1000 people (adults and children) and about one-fifth (20.4%)
provide care for more than 2500 assigned patients. In rural areas the number
123
124
Health systems in transition
Ukraine
of doctors serving more than 2500 patients comes close to a third (29.1%).
Although FAPs provide primary care services as well, the shortage of doctors
in rural areas causes a number of problems with the accessibility and quality of
medical care. In some areas this is further aggravated by low population density
of 30–70 people per 1 km2. About 11.4% of rural communities have outpatient
clinics and hospitals with outpatient departments with a catchment area of
between 2.5 and 9.5 km; 56% of rural communities have FAPs. About a third
of rural communities have no medical facilities on their territory. Moreover, in
some medical facilities located in rural areas not a single position is filled by
a medical worker. The number of such facilities is growing (see section 5.2.1
Trends in health care personnel).
The organization of primary care delivery is based on the territorial-district
principle by which the area served by a particular primary care unit is divided
into catchment areas with a certain number of residents. Ukrainians have
been granted free choice of primary care physician; however, this has not yet
been implemented widely because, while a patient has the option to change
their primary care provider, this is usually blocked by the receiving physician
since it would stretch the territorial boundaries of their catchment area and
complicate home visits. Developing primary care is considered the leading
strategic direction and one of the main goals of health system development.
There are plans for implementing comprehensive primary care reforms in the
upcoming years (see section 7.2).
The total number of outpatient contacts per citizen per year is rather high in
Ukraine and significantly higher than in the countries of Central and Eastern
Europe and in EU countries (see Fig. 6.1). The high rate of visits per capita
is a result of the Ukrainian method of paying for services based on capacity
measures (see section 3.6.1 Paying for health services). Out of the total number
of outpatient contacts, visits to medical specialists account for 75%, while
home visits account for about 9%. More than a third of visits (36.7%) to an
outpatient clinic or a polyclinic are for preventive checks. The number of
preventive visits is influenced by two factors. First, there are strict requirements
for target screening coverage for certain population groups (cervical cancer,
breast cancer and TB screenings) and second, medical examinations are
performed by a team of six or seven different specialists, using some tests the
effectiveness of which have not been scientifically established. The number
of outpatient visits in rural areas remains significantly lower than in urban
areas and the majority of them (61%) are visits to mid-level medical specialists.
Health systems in transition
Ukraine
Fig. 6.1
Outpatient contacts per person in Ukraine and selected countries in the WHO
European Region, 2008 or latest available year
Slovakia
13.5
Czech Republic
13.3
Belarus
13.1
Hungary
11.3
Ukraine
10.8
Spain (2003)
9.5
Russian Federation (2006)
9.0
9.0
Uzbekistan
CIS
8.6
Serbia
8.3
Germany (2007)
7.5
Estonia
7.4
7.0
Lithuania
Belgium
6.9
EU (2007)
6.9
Slovenia
6.7
Poland (2007)
6.6
Kazakhstan
6.6
Republic of Moldova
6.3
Turkey
6.3
The former Yugoslav Republic of Macedonia (2006)
6.0
Latvia
6.0
Croatia
6.0
Netherlands
5.9
Romania
5.4
Azerbaijan
4.6
4.4
Iceland (2005)
Finland
4.2
4.2
Denmark (2007)
Portugal (2007)
4.1
Tajikistan (2006)
4.0
Turkmenistan
3.6
Kyrgyzstan
3.5
3.3
Bosnia and Herzegovina (2007)
Armenia
3.2
Montenegro (2000)
3.1
Sweden (2006)
2.8
Georgia
2.1
Albania
1.8
0
5
10
15
Source: WHO Regional Office for Europe, 2010a.
Access to secondary care is not regulated since there is no strict distinction
between primary and secondary care in Ukraine. In essence, the concept of
primary care is applied to the entire polyclinic – including the specialists
working there – and not only its primary care unit. Patients may seek care from
a specialist directly without a formal referral from their primary care physician
and this option is used widely (see section 6.2).
125
126
Health systems in transition
Ukraine
6.4 Secondary care (specialized ambulatory care/
inpatient care)
Secondary outpatient care is provided within the integrated model primarily by
specialized offices (departments) of territorially based polyclinics and polyclinic
departments of city hospitals, children’s hospitals, central district hospitals and
the polyclinic departments of specialized clinics (dispensarii). The average urban
multi-specialty polyclinic serving a catchment area of 25 000 residents will
have six or seven specialists, such as surgeons, orthopaedists, traumatologists,
neurologists, ophthalmologists and otolaryngologists, whereas larger polyclinics
may also have cardiologists, rheumatologists, gastroenterologists, urologists and
others. As noted above, since there is no strict distinction between primary and
secondary care in Ukraine, specialists in municipal polyclinics provide services
to patients referred to by primary care physicians and those who seek care
directly. The organization of secondary outpatient care is based on a territorial
principle, with each polyclinic being assigned a defined area. Residents of that
catchment area are entitled to full diagnostic examinations and appropriate
treatment, and may be referred to the tertiary level when necessary.
The volume of secondary outpatient care provided by private facilities is
not very significant, although private dental practices are developing rapidly.
Private practices such as clinics providing gynaecological care (reproductive
health clinics and centres offering family planning and infertility treatment)
and alcohol, tobacco and drug dependency treatment centres or services are
also quite widespread. These units are usually separate from the main health
system. Some of them have a contractual relationship with institutions or private
insurance companies, but the majority provide services to patients based on
an established price list. There are also very well-equipped private facilities
specializing in outpatient diagnostic services. Often, patients are referred to
these facilities by medical specialists in state and community medical facilities
that do not possess the appropriate diagnostic infrastructure. However, the
relationship between these state and private facilities is not formalized, thus
patients pay out of pocket.
The inpatient system is a hierarchical system organized into three levels.
The first (lower) level is that of rural hospitals. These are very basic inpatient
facilities with an average of 16 beds, providing general care for adults and
children, chronic disease care, treatment of some infectious diseases,
rehabilitation, completion of treatments, simple obstetric care, and more. The
number of these facilities is decreasing (see section 5.1.2 Capital stock and
investments). In 2008, they accounted for only 2.1% of beds. The second, middle
Health systems in transition
Ukraine
level is the true foundation of the system. Secondary inpatient care is provided
in cities by inpatient wards in multi-profile hospitals, children’s hospitals,
specialized clinics and hospitals (for communicable diseases, maternity care
and so on). In rural areas, it is provided by the inpatient departments of district
and central district hospitals, and by hospitals in parallel health systems. These
facilities have 75% of the total number of beds, and most are in multi-profile
hospitals. Due to a general reduction in hospital beds, their capacity is gradually
decreasing. Thus, in 2008, the average capacity of municipal hospitals was
about 195 beds, while central district hospitals had about 210 beds. Hospitals
offer several specialties usually in 7 to 12 units (general medicine, surgical,
infectious diseases, maternity services, etc.), although the range of specialties
covered is not regulated. In large cities there are also specialized clinics (most
often for communicable diseases), maternity hospitals and highly specialized
centres (for example, a burns centre or a neonatal centre) based at multi-profile
hospitals. In addition, municipal specialized clinics provide inpatient health
care for some socially significant diseases such as TB, STIs, psychiatric illness,
endocrine conditions and others.
The third level is that of regional and supra-regional specialization provided
by regional hospitals and specialized clinics, and specialized clinical and
diagnostic centres at the national research institutes of the Ministry of Health
and the Academy of Medical Sciences. These facilities hold over 20% of the
total number of hospital beds. They were originally designed to provide highly
specialized medical care to patients with the most severe and complicated
conditions. Recently, however, the boundaries between secondary and tertiary
inpatient care have become blurred. It has been reported that about one-third
of patients admitted to regional hospitals should, in fact, have been treated
in secondary-level hospitals. There are very few private inpatient facilities
and most of them are specialized, highly equipped centres for oncology and
cardiology patients, among others.
Despite the reduction in the number of beds, there is significant underutilization of secondary care beds. The total hospitalization rate and, in
particular, hospitalization of patients with non-chronic diseases decreased by
21% between 1990 and 2000. However, both figures started to increase slightly
in 2001. The average length of hospital stay and stays in hospitals for patients
with non-chronic conditions show a steady decreasing trend (see Table 6.1). Total
inpatient care utilization and acute inpatient care utilization fell considerably
between 1990 and 2000, and have stabilized at these levels (see Table 6.1). A
high rate of hospital bed utilization combined with significant financial barriers
to accessing inpatient care highlights the inefficiency of hospital financing
127
128
Health systems in transition
Ukraine
based on the number of beds. This stimulates facilities to keep these beds
and hospitalize patients irrespective of their medical needs. Based on regional
research from 2006–2007, almost a third of all hospitalizations (32.9%) were
without specific indications which would require hospitalization. This number
fluctuates widely depending on the unit’s profile: cardiology departments
for heart attack patients have 11–14% of unnecessary hospitalizations, while
pulmonology and gastroenterology departments have 55–73% (Lekhan &
Volchek, 2007).
Table 6.1
Inpatient hospital utilization, 1990–2008 (selected years)
1990
1995
2000
2005
2006
2007
2008
Inpatient care admissions per 100 people a
24.4
21.9
19.4
21.6
21.9
22.5
22.5
Acute care hospital admissions per 100 people a
23.2
20.8
18.4
20.5
20.8
21.3
21.4
Average length of stay, all hospitals (days)
16.4
16.8
14.9
13.5
13.3
12.9
12.8
Average length of stay, acute care hospitals
(days) a
14.0
14.6
12.7
11.6
11.3
11.1
10.9
Inpatient care utilization (days per capita), total a
4.0
3.7
2.9
2.9
2.9
2.9
2.9
Inpatient care utilization, acute hospitals
(days per capita) a
3.3
3.0
2.3
2.4
2.4
2.4
2.3
Sources: Ministry of Health and Ukrainian Institute for Strategic Research, 2009; WHO Regional Office for Europe, 2010a;
Medical Statistics Centre, unpublished database, 2009.
Note : a Utilization in Ministry of Health facilities.
Inpatient facilities are not differentiated by the complexity of interventions
carried out. The same beds are used for patients with very different needs in
terms of both services and equipment. Based on the same research, 74.6% of
hospitalized patients required emergency care in the acute disease department,
14.9% required scheduled care in the chronic disease department, 8.2% required
medical and social aid, and 2.3% required medical rehabilitation (Lekhan &
Volchek, 2007).
6.4.1 Day care
In Ukraine, day-care inpatient facilities are expected to provide quality medical
care services (complex diagnosis, intensive therapy using innovative medical
technologies) to patients through their hospitalization as a day case where there
are no actual indications for full-time medical observation. The Ministry of
Health has regulated that day hospitals can function only as a part of outpatient
clinics and polyclinics. Primary care day hospitals have gained the most
popularity, followed by multi-profile day hospitals, which provide treatment
mostly for cardiovascular, respiratory and digestive diseases. Some facilities
Health systems in transition
Ukraine
have day hospitals specializing in cardiology, neurology, gastroenterology,
surgery, urology, ophthalmology, trauma, gynaecology and paediatrics,
among others.
Day hospitals, like outpatient clinics and polyclinics, are financed according
to the number of visits. However, day hospital financing is even less adequate
in terms of real expenditure than the financing of polyclinics. For example,
the estimated average spending on pharmaceuticals is 0.35–0.5 hryvnya or
US$ 0.07–0.1 per case at a day hospital. This is not very different from the
allocation for one admission at a polyclinic (0.3–0.5 hryvnya or US$ 0.05–0.06).
However, the volume of services provided at a day hospital is much larger.
Therefore, patients have to pay out of pocket for various pharmaceuticals and
medical devices. Since independence, the number of day hospital beds has
increased ninefold and the number of patients treated at day hospitals grew to
match the increase in bed capacity (see Table 6.2). In 2008, 25.1% of the total
number of hospitalizations received care at day hospitals, and day hospitals
comprised 16.4% of the total number of beds in the facilities under the Ministry
of Health. Patients prefer this form of care and often favour it over a 24-hour
hospital stay. However, the growth of alternative inpatient care has so far had
only a small impact on the utilization of inpatient facilities, and inpatient
facilities lack the possibility of substituting their 24-hour services with day
care, because of the way these services are financed.
Table 6.2
Development of day hospitals, 1991–2008 (selected years)
1991
1995
2000
2005
2007
Number of beds (per 1 000 population)
0.2
0.3
0.9
1.5
1.5
2008
1.4
Number of patients treated (per 1 000 population)
6.6
9.2
25.6
51.0
58.9
56.3
Sources: Ministry of Health, 2001; Ministry of Health and Ukrainian Institute for Strategic Research, 2007b, 2008.
The national programme for health care development outlines significant
reforms of the inpatient sector (see Chapter 7), including a reduction in the
number of hospitalizations by:
•
developing clear indications for the involvement of inpatient care;
•
lifting restrictions on the development of inpatient care substitutes and
on outpatient care in inpatient facilities;
•
transferring facilities of the parallel systems to the Ministry of Health;
•
reorganizing beds based on their functional differences;
129
130
Health systems in transition
Ukraine
•
enlarging general hospitals to provide emergency inpatient care and
creating service coverage for 100 000 to 200 000 people;
•
reorganizing some hospital departments into chronic disease facilities to
provide medical and social support, as well as palliative services; and
•
reorganizing materials and equipment in health facilities based on their
future use.
Furthermore, it has been proposed that, in order to provide the population
with highly specialized and well-equipped medical care, university-based clinics
must be established in the form of a holding union of medical universities and
regional hospitals.
6.5 Emergency care
Formally, emergency care is defined in Ukraine as a type of medical care
in health- or life-threatening conditions at the scene of an accident, en route
to or at a hospital. All medical workers and facilities are required to provide
emergency care. In urgent cases, when medical help is unavailable, emergency
care must be provided by civil defence forces, militia, the fire department,
rescue services, public transport drivers and others. In such cases, enterprises,
agencies, institutions and citizens are obliged to provide vehicles to transport
victims to the appropriate medical facility. In case of a life-threatening
emergency, medical workers have the right to use any vehicle to reach victims
or to get to hospital. In reality, the primary component in emergency care
is the emergency care service of physicians and feldshers. The emergency
care service is responsible for providing pre-admission care to patients and
victims of accidents on-site and en route to the appropriate medical facilities.
Due to the lack of differentiation based on the intensity of medical care (see
section 6.4), emergency care is provided at medical facilities along with other
medical services.
In 2007, the government approved a national programme on emergency
care development by 2010 (Cabinet of Ministers Decree No. 1290, issued
5 November 2007). The programme provided for the development of a unified
emergency care system, strengthening material, technical and human resources
in medical facilities, and training and retraining medical staff, rescuers and
other workers who use a vehicle to provide high-quality emergency care.
Health systems in transition
Ukraine
In 2007, the state’s emergency care system comprised 96 independent and
891 hospital-based ambulance stations. The ambulance stations are supplied
with appropriate equipment and special vehicles (primarily cars). Mobile
emergency care is provided by 3114 mobile teams (0.71 per 1000 population).
Since 1990, the number of teams has decreased by 14.5%, and the provision
of care by 13.4%. Out of the total number of teams, 35% are general physician
teams, 54% are feldsher teams and 11% are specialized (cardiology, intensive
care, neurology, psychiatry, etc.). Specialized teams appeared during the period
of increasing specialization of health care in the 1970s and 1980s, in order to
raise the quality of pre-admission emergency care. These goals were not reached,
however. Intensifying and narrowing the specialization of teams created
some positive results alongside negative consequences. Using the specialized
teams for their direct purpose significantly decreased their workload, which
is now almost three times smaller than the professional workload of teams
comprised of general physicians and feldshers. There have been attempts to
increase the workload of specialized teams, which means that these teams
have to make so-called “non-profile” trips and be used as general emergency
teams. Using specialized teams in such a manner has a negative impact on the
quality of emergency care, however, due to each team’s narrow specialization.
A well-organized emergency care system would mean about 15–16 trips per
24 hours for one team. In fact, the teams are making 1.5–2 times fewer trips:
physicians and feldsher teams make about 10–11 trips, and specialized teams
make 8.5 trips per 24 hours. This leads to the wasteful use of limited resources.
The low workload of the teams is caused by general discrepancies in emergency
care organization and administration, as well as by problems beyond the health
sector, primarily the unsatisfactory management of road traffic. There are no
special lanes for public transport and vehicles performing important social
functions. Ambulances are often stuck in traffic, which significantly prolongs
each trip.
In 2007, mobile emergency teams responded to 13.8 million calls, or 297 per
1000 population. The main reasons for calls were sudden acute illnesses, accidents
and traumas (77.2%). Among other reasons were births (6.8%), transportation
of patients and women in labour to hospitals (7.0%), and calls for diseases that
did not require emergency care (7.0%). Since 1990, the frequency of calls has
decreased by 13%. The reasons for calls have changed more drastically: the
proportion of calls related to births and pregnancy complications has dropped
significantly, due to a general fall in the birth rate. There were fewer calls for
common diseases, while calls for acute diseases increased. At first glance, the
calls structure for 2007 seems to correspond better with the main functions
131
132
Health systems in transition
Ukraine
of emergency care. However, there was an increase not only in the number of
calls related to acute diseases, but in the frequency of these calls as well. The
frequency increased by 1.3 times between 1990 and 2007, from 153.8 to 206.9
per 1000 population. This is caused not by organizational issues but by reduced
access to emergency care, particularly for financial reasons (see section 8.2).
Officially, state and community facilities must be free for all patients regardless
of their origins (Ukrainian citizens, foreigners or people without citizenship). At
the same time, standard budget allocations on pharmaceuticals per emergency
call fluctuate from region to region, between 1.5 and 2.7 hryvnya (US$ 0.3–0.5).
This funding cannot cover even the minimum costs of pharmaceuticals and
equipment needed for emergency services. Thus, patients themselves, or their
relatives, are forced to search for life-saving medicine at any given time of the
day or night.
There are a number of private emergency care services in Ukraine. These
services are usually established in larger cities and are well equipped for
providing medical care and patient transportation. However, high costs
(300–400 hryvnya or US$ 60–80 per call) mean that only a small proportion
of population can use them. Data about their quality or capacity are unavailable.
One of the main qualities of emergency care is its timeliness. Emergency
service timeliness in Ukraine is measured as the percentage of all calls where
the team is in attendance within 15 minutes after the call has been received.
According to the data from the Medical Statistics Centre, overall in 2007, mobile
teams arrived on the scene in a timely fashion 88% of the time in general, and
90% of the time for accidents, traumas and acute conditions. However, the
veracity of these data is questionable since the majority of emergency stations
do not have the necessary equipment to automatically register the time when a
call is received and when the team arrive on the scene. There are data showing
that the number of late arrivals by emergency teams is very high and that
sometimes patients have to wait for hours.
In case of emergencies caused by natural, man-made or social catastrophes,
initial emergency care at the scene is provided by special rescue units.
Subsequent care outside of the rescue zone is provided by the State Service
of Catastrophic Medicine. The service was created in 1997 and comprises the
Republican Scientific and Practical Centre, as well as 27 territorial centres
of emergency care and catastrophic medicine, a mobile hospital, specialized
mobile teams and brigades, and more than 780 teams of the regular emergency
care service. The catastrophic medicine service also includes 12 emergency
care hospitals and 77 other medical facilities, which can expand, if needed,
Health systems in transition
Ukraine
to hold up to 15 000 beds. State and local budgets reserve funds to reimburse
expenses that may arise from the provision of medical care to the victims of
emergency situations.
6.6 Pharmaceutical care
The organization of activity in the pharmaceutical sector is described in detail
in section 5.1.5 Pharmaceuticals. According to the state law, drug provision
is considered a part of the health service, and pharmaceuticals at state and
community medical facilities must be paid for from the government budget.
However, even under the Soviet Semashko system, outpatients were obliged
to pay for drugs out of pocket (with the exception of certain groups entitled to
benefits). Since independence, severe shortages in health care financing have
forced patients to pay out of pocket even for inpatient drugs (see section 3.3.2
Out-of-pocket payments). Currently, only 13.3% of all pharmaceuticals
consumed are provided through hospitals; 86.7% are purchased by the
population at pharmacies. Certain population groups are entitled to some
benefits in receiving medical services and pharmaceuticals. So-called
vulnerable population groups and patients with socially significant and very
serious diseases such as TB, cancer and so on, receive medical services either
free of charge or with significant discounts. These benefits mostly include
outpatient drugs. Drugs prescribed in the home which are on the governmentapproved list must be provided for free or with discounts. Benefits-related
pharmaceutical costs are meant to be covered by state budget allocations to
health care. However, poor health care financing limits their availability. In
reality, even vulnerable population groups have to pay for their medications
out of pocket most of the time.
In order to improve pharmaceutical access for the population, the
government approved a national list of essential pharmaceuticals and medical
devices in 2009 (Cabinet of Ministers Decree No. 333 of 25 March 2009, A few
issues with the state reg ulation of prices for pharmaceuticals and medical
devices). The list was developed according to anatomic-therapeutic-chemical
(ATC) classification based on international non-proprietary names and
includes 215 efficient, affordable and safe pharmaceutical drugs that are used
in Ukraine in the prevention, diagnosis and treatment of the most common
diseases. The list represents the foundation of a basic medical entitlement
package and, by an order of the Ministry of Health, is to be used for arranging
tender procurement for state purchases to support targeted programmes, state
133
134
Health systems in transition
Ukraine
support of the domestic pharmaceutical industry, plans for benefits costs
recovery, the creation of clinical protocols and forms, and the monitoring of
pharmaceutical supplies and price formation. However, in 2007, pharmaceutical
usage by the population was uncontrolled (Cabinet of Ministers assignment
No. 29029/1/1-07, issued 3 July 2007).
As most pharmaceuticals are purchased both by outpatients and inpatients,
the scope for influencing prescribing patterns is rather limited, and is further
hampered by the liberalization of pharmacy dispensing procedures. A list of
prescription-only drugs has been developed by the Ministry of Health, but
most of them can nonetheless be bought over the counter. In 2005, the Ministry
of Health attempted to regulate procedures for dispensing prescription drugs
(Ministry of Health Order No. 360, issued 19 July 2005). However, low levels of
public education and poor preparation of the health system limited the attempt
to move towards greater regulation of prescription-only drugs. At the same time,
pharmacies do maintain strict controls on the supply of psychotropic drugs
and hormonal preparations, even though many others, such as antibiotics, can
usually be bought without a prescription.
Clinical protocols can have a certain influence on prescribing patterns as
long as they contain a very clear definition of the medical indications for the
use of a specific drug. There is no national programme promoting efficient
generic drugs that are less expensive, as opposed to the more expensive brand
names. Pharmaceutical companies have a significant influence on prescribing
patterns. They have a very aggressive marketing policy, actively advertise
pharmaceuticals in the mass media (advertising for prescription-only drugs
is banned in Ukraine), hold free seminars for medical specialists and reward
doctors who prescribe their products. As a result, there is a high level of
over-prescription among physicians, who often prescribe expensive brandname pharmaceuticals instead of less expensive generics and, in certain cases,
disregard rational drug therapy. Doctors only prescribe generic drugs from the
National Essential Drugs List to patients who are exempted from co-payments
or who pay reduced prices for pharmaceuticals, which the patient then obtains
from their local community pharmacy.
A combination of financial and educational measures could influence
prescription patterns positively. For instance, the use of global funds that would
at least partially cover the government’s pharmaceutical expenditure has been
suggested (Rudiy, 2005), as has the introduction of a system of reimbursements
for pharmaceutical expenses (Lekhan, Slabkii & Shevchenko, 2009). However,
there has been no real implementation of these initiatives.
Health systems in transition
Ukraine
In order to improve pharmaceutical provision, a national programme has
been developed for 2004–2010 which outlined the selection of safe and efficient
pharmaceuticals using pharmaco-economic analysis (Cabinet of Ministers
Decree No. 1162, issued 25 July 2003). The programme also introduces a
formulary-based drug procurement system, improves tender procedures for
state purchases of medications and identifies state priorities for medication
purchases. Finally, the programme introduces the state registration of wholesale
prices, as well as the introduction of appropriate laboratory, clinical, industrial
and distribution practices based on such standards as GMP, good laboratory
practice (GLP) and so on. A list of essential pharmaceuticals and medical
devices was approved in accordance with the programme, and necessary
preparations have been completed to launch a formulary-based drug use system
by the State Pharmacological Centre under the Ministry of Health (Ministry
of Health Order No. 173, issued 17 March 2009 and Ministry of Health Order
No. 59, issued 28 January 2010). The formulary-based system should improve
the quality of treatment and should provide clinicians with access to its unified
teams of clinicians and other health care specialists with information on the
use of pharmaceuticals registered in Ukraine (their pharmacological properties,
contraindications and distribution methods). The first National Drug Formulary
of Ukraine for the supply of pharmaceuticals in health facilities was published
in 2009.
6.7 Rehabilitation/intermediate care
In 2006, the government approved a model state programme on the rehabilitation
of disabled people which provides a list of rehabilitation services and medical
devices that the government should provide free of charge regardless of age,
gender or type of disability (Cabinet of Ministers Resolution No. 1686, issued
8 December 2006). The model state programme serves as the framework for an
individual rehabilitation programme which defines the types, forms, quantity
and timeliness of rehabilitation, aimed at the restoration of or compensation
for disabilities or lost bodily functions and capabilities as well as determining
when and where rehabilitation should take place. The government has assumed
responsibility for developing a rehabilitation policy, which is delegated to central
authorities (the Ministry of Labour and Social Policy, the Ministry of Health, the
Ministry of Education and Science, the Ministry for Family, Youth and Sport)
as well as local authorities. Local authorities should work in partnership with
public organizations for disabled people to develop and implement programmes
for the prevention of disability and provide for the alleviation or treatment of
135
136
Health systems in transition
Ukraine
disabling conditions. Disabled adults and children are treated through medical,
psycho-pedagogical, psychological and professional means, as well as with
physical therapies, sporting activities and social rehabilitation.
Medico-social expert commissions are responsible for diagnosing
disabilities and establishing the level of health loss, as well as determining
a disabled adult’s occupational capacity. They also develop individualized
rehabilitation programmes. These committees act as independent centres
within the regional health authorities. There are more than 400 medico-social
expert committees in the country. Treatment-and-consultation committees in
medico-prophylactic institutions are responsible for establishing the degree of
disability in disabled children.
By law, the rehabilitation sector in Ukraine is comprised of executive
authorities, local self-governments and various institutions such as rehabilitation
facilities for disabled people, special and sanatorium-type preschools and
schools for children requiring long-term treatment for physical and/or mental
development problems, prosthetic and orthopaedic enterprises, sanatoria and
health resorts for labour unions, social protection agencies, cultural activities
agencies and public organizations for disabled people. Rehabilitation facilities
are composed primarily of social rehabilitation centres for disabled children
to correct developmental disorders and prepare them for education (services
range from preschool to middle school, to technical, professional and higher
education), professional rehabilitation centres to restore a person’s capabilities
and prepare them for work, medico-social rehabilitation subdivisions in social
care centres for elderly people and single disabled people.
These rehabilitation centres function as national and local specialized facilities,
receiving financing from national or local budgets, or as nongovernmental,
non-profit-making organizations that receive financing from extra budgetary
resources. Each centre’s structure is determined by its specialization and
can contain rooms for occupational and social rehabilitation, laboratories,
workshops, classrooms and so on. These centres are staffed by both medical
and psychological assistants. Currently, there are more than 270 rehabilitation
centres for children in the network, 72 professional rehabilitation centres, and
more than 270 medico-social rehabilitation departments within territorial social
care centres for elderly people. The Ministry of Labour and Social Policies
is responsible for the majority of rehabilitation facilities, and the Ministry
of Education and the Ministry for Family and Youth are responsible for
the remainder.
Health systems in transition
Ukraine
Despite the fact that the model rehabilitation programme outlines the basic
medical rehabilitation services to be provided to disabled individuals, there are
no medical facilities attached to organizations engaged in rehabilitation. To
provide these services, the programme refers patients to appropriate specialized
departments of health facilities, the clinics of research institutes, and sanatoria
and spas. For instance, people with locomotor and central nervous system
problems can be provided with medical rehabilitation, reconstructive surgery,
prophylactic measures, and sanatorium and spa treatments. People with
psychological disabilities can receive restorative treatments, psychiatric help,
prophylactic measures, and sanatorium and spa treatments. Patients with serious
vision or hearing impairment are eligible for restorative therapy, prophylactic
measures, and sanatorium and spa treatments (hearing-impaired patients are
provided with hearing aids, reconstructive surgery and cochlear implants).
Where disability is the result of problems with internal organs, patients can
receive restorative therapy, prophylactic measures, and sanatorium and spa
treatments. Cancer patients are eligible for restorative treatment, prophylactic
measures, medical supervision, reconstructive surgery, and sanatorium and
spa treatments.
Medical facilities are not differentiated according to the intensity of care
or treatment provided (see section 6.4). Restorative treatments and medical
rehabilitation are therefore performed at practically all levels of health facility.
The health system does include several facilities whose main priority is
rehabilitation, however. Among inpatient facilities, these include a hospital
for medical rehabilitation, a physical therapy clinic and a centre for children
with impaired nervous systems. Among sanatoria and spas, these include a
balneotherapeutic health resort and a mud cure clinic. The number of such
facilities is very small, rehabilitation services are limited and not many patients
are served. For example, the rehabilitation hospital of the Ministry of Health
has 600 beds, provided primarily for patients exposed to ionizing radiation
(Chernobyl survivors) as well as for other therapeutic and neurological patients.
Natural remedies are used in conjunction with pharmaceuticals for rehabilitation,
as well as physiotherapy, dietary treatments and so on. The Vinnytsia oblast
rehabilitation hospital for children with organic locomotor system disorders
uses a complex of physiotherapy and natural remedies (heat therapy, water
therapy, mud therapy, etc).
The basic elements of a modern rehabilitation system do exist in Ukraine.
However, this system does not address the full spectrum of problems in
rehabilitating and reintegrating people with limited physical abilities or
psychological and mental problems. Only 10% of disabled children are in fact
137
138
Health systems in transition
Ukraine
undergoing rehabilitation (Interfaks-Ukraina, 2007). The majority of disabled
children do not attend preschools. Individuals with limitations in physical
and mental development account for only 1% of the students in vocational
schools (Interfaks-Ukraina, 2007). According to the Ministry of Education,
in the 2007/2008 school year, special classes were created for only 14% of
disabled children attending comprehensive secondary schools, and the rights of
disabled children with technical or other rehabilitation devices are not respected.
Disabled people make up only 0.4% of students in higher education. The reason
for such low coverage of rehabilitation care is the inconsistent interactions
between medical facilities, and labour and social protection agencies.
In 2007, the government approved a state programme to develop the
rehabilitation system by 2011 (Cabinet of Ministers Resolution No. 716, issued
12 July 2007). The programme provides for:
•
improvement of the delivery system of rehabilitation services;
•
an increase of the production and supply of high-quality modern
rehabilitation devices;
•
easier access to education, including correspondence, integrated and
inclusive education for people with physical and mental disabilities;
•
training, retraining and professional development of disabled people
according to current market demands; and
•
creating easy access to social infrastructure and public transport.
The programme also provides for a personal database of disabled individuals
as well as a list of required equipment and literature for rehabilitation facilities.
The reorganization of medico-social expert commissions into medico-social
expertise and rehabilitation facilities appears to be a promising solution for
rapid development of the rehabilitation facilities network. Within five years,
the programme should return 170 000 disabled people to work and social
life, and fully satisfy the demand for medical, technical and other means of
rehabilitation. This will save more than 100 million hryvnya, since there will
be a reduced need to pay disability pensions, social benefits or compensation
to the rehabilitated individuals.
So far, a social protection programme has been adopted to provide easy
access to public and private facilities for disabled people, and new state
construction standards have been approved to secure a convenient environment
for people with limited mobility. This includes the production of accessible
public transport vehicles. However, the programme lacks incentives to improve
Health systems in transition
Ukraine
the medical rehabilitation system, despite the fact that the Ministry of Health
acts as a co-executor on a number of tasks. At the same time, the National Plan
of Health Care Development provides for the establishment of rehabilitation
hospitals by 2010 in compliance with the functional differentiation of secondary
inpatient care facilities (Cabinet of Ministers Degree No. 815, issued 13 June
2007). The Ministry of Health developed and publicly displayed on its web
site the project for this Plan, which takes into account international experience
of running this kind of medical facility. It is intended that the hospitals will
incorporate all modern approaches in the treatment of patients with trauma
and various diseases that require rehabilitative measures for the prevention of
disabilities and the rapid restoration of working capacity.
6.8 Long-term care
Long-term care in Ukraine is provided by facilities in the social care system
(under the Ministry of Labour and Social Policy) that provide medico-social
care to certain population groups. These facilities include homes for disabled
children and nursing homes for elderly people and disabled people, as well
as mental institutions and the inpatient departments of territorial centres for
elderly people and single disabled people.
Homes for children are medico-social facilities designed to provide assisted
living, education, upbringing and medical services for children aged between
4 and 18 with psychologically and physiologically impaired development. They
are divided into four groups: (1) children of preschool and school age with
normal intellectual development, whose physical impairment severely limits
their movement; (2) children with severe mental disabilities who can move
freely and attend to their own needs; (3) children with severe mental disabilities
who can move freely but cannot attend to their own needs; (4) children with
various levels of mental disabilities and complex physical problems who cannot
move freely or attend to their own needs. Currently, there are 58 homes with
more than 6000 children. The capacity of these schools fully covers demand,
but their material and technical resources do not meet modern requirements
(Yaskal, 2000). The deinstitutionalization of these children and the prevention
of their institutionalization have not as yet received any serious attention from
policy-makers.
Mental institutions are inpatient medico-social facilities that provide assisted
living for patients with psychoneurological disorders who need medical services
and assistance with daily living. These institutions accept patients of retirement
139
140
Health systems in transition
Ukraine
age and disabled people over the age of 18 with psychoneurological disorders,
regardless of whether they have relatives (who are generally required by law
to care for them).
Nursing homes for elderly people and disabled people are inpatient facilities
with long-term stay for elderly people, war veterans, and disabled adults who
need medical services and assistance with daily living. These facilities accept
individuals without relatives. If there are vacancies, however, they can accept
patients with able-bodied relatives when all financial costs are paid in full.
Nursing homes provide 24-hour medical services and advisory assistance. The
inpatient departments of territorial centres for long-term or temporary assisted
living are designed for people who are unable to work and have lost mobility,
cannot attend to their own needs, and need medical services and daily life
assistance. According to the Ministry of Labour and Social Policy, currently
there are 316 nursing homes with 55 000 beds, assisting 50 000 elderly and
disabled people. There are also 270 inpatient departments of territorial centres
for long-term and temporary assisted living.
Nursing homes and mental institutions receive their funding from local
budgets, primarily through inter-budgetary transfers from the state budget, social
insurance funds and through patients’ pensions. However, with little funding
available, these facilities are unable to provide proper sanitary conditions and
enough food. Many of these facilities are situated in old buildings, poorly
equipped and in poor condition. The quality of care is low. Moreover, these
facilities do not have enough beds so there are waiting lists.
The types of medical staff employed at these facilities are determined by
their areas of expertise. Thus, in nursing homes for elderly people, care is
provided by geriatric and psychiatric specialists, while psychiatrists provide the
care in mental institutions, and so on. Social workers provide social support and
every facility is required to have a dentist. Since rehabilitation services in these
facilities are rather unsatisfactory, the state rehabilitation programme provides
for the introduction of medical and physical rehabilitation specialists as well as
medical psychologists.
6.9 Services for informal carers
In Ukraine, many people use and participate in providing informal care
services. There is no political or financial support from the government for
this type of care, and there are no data available on the number of people
involved in providing it. There are different NGOs which are usually set up
Health systems in transition
Ukraine
by people required to provide care for relatives with certain conditions (for
example, children with cerebral palsy etc.). Sometimes, these organizations
receive grants from various funds.
6.10 Palliative care
There is great demand for palliative care in Ukraine, due to the high mortality
rate and an ageing population (see section 1.4). There are approximately
1.5 million people in Ukraine each year who need support from palliative care
services; that is, approximately 480 000 patients and family members who care
for terminally ill patients. However, there is no developed palliative care system
in the country.
Medical services for terminally ill patients are usually provided by medical
facilities of various specializations and levels, and they are treated alongside
other patients without specific consideration for the type of services needed
during the terminal phase of a disease. Primary care physicians and nurses bear
the main burden of palliative care, including care for cancer patients, who make
up the most prevalent group in need of palliative services. Hospitalization for
these patients occurs in the acute phases only for a short period of time.
The first hospices were initiated by local self-governments and NGOs. The
first hospice was opened in 1994 in Lviv. Currently, there are about 20 hospices
and palliative care departments in multi-specialty hospitals with 650 beds for
palliative care (Barmina, 2008). Services are located in urban areas such as
Donetsk, Zaporizhzhia, Luhansk, Lviv, Lutsk, Ivano-Frankivsk, Kherson,
Kharkiv and Kyiv. Current capacity can satisfy only 10% of the demand for
palliative care. Most of these facilities are community-based and receive their
small amount of funding from local budgets. They cannot provide the social side
of palliative care as hospice staff do not include social workers, psychologists
or attorneys. There is no developed networking between hospices and other
medical facilities, social care agencies, public organizations and so on to assist
continuity of care.
There is still an acute problem in providing pain relief to patients in the
terminal phase of a disease. Because of strict narcotics control, doctors are
significantly limited in their freedom to prescribe the correct type and dosage
of opiate analgesics, especially to non-cancer patients, and for their use in home
settings or social protection facilities. Another significant problem in palliative
care is that medical staff and social workers lack the necessary knowledge and
141
142
Health systems in transition
Ukraine
skills in the methods and principles of pain relief and in relieving physiological
and other somatic problems. The limited access to effective pain relief and
essential medicines, the limited access to palliative care facilities, insufficient
training of specialists and the limited capacity of NGOs all mean that the
majority of patients do not receive adequate palliative care.
There is still no government policy regarding the development of palliative
care. Even though the Ministry of Health legalized hospices in 1995 by including
them in the list of medical facilities (Ministry of Health Order No. 114, issued
22 June 1995), and approved staffing standards for these facilities in 2000
(Ministry of Health Order No. 33, issued 23 February 2000), there is still no
legislation regarding the activities of such facilities, with the exception of AIDS
hospices (Ministry of Health Order No. 866, issued 27 December 2007, On
approving temporary regulations for hospice and palliative care departments
for HIV/AIDS patients). The lack of government policies regarding palliative care
slows its development. There are insufficient institutional and human resources
to create a palliative care facilities network; there are no methodological
grounds or delivery standards; and there is no training system for medical and
social workers engaged in palliative care. Many issues hamper the development
of palliative care in Ukraine, such as insufficient government knowledge
regarding the scale of the problem and a lack of state policies regarding the
development of palliative care for various groups of patients with incurable
illness. There are also insufficient integration and coordination between the
Ministry of Health, the Ministry of Labour and Social Policy, NGOs, private
providers, public associations for socio-medical protection and palliative care.
This is compounded by a lack of resources and the use of outdated, inefficient
technologies and models of palliative care (Ministry of Health of Ukraine and
Ukrainian Institute of Public Health, 2008).
Nevertheless, there have been some positive changes in the government’s
attitude towards palliative care. In 2006, the All-Ukrainian Association of
Palliative Care was created, along with the Inter-Departmental Work Group for
Improvement of the Legal Basis of Palliative Care. In April 2008, in accordance
with an order from the Ministry of Health on the national programme of
palliative care development in Ukraine for 2010–2014, the Coordination
Council on Palliative and Hospice Care was created. The Council is comprised
of government members and public organizations. Currently, a programme has
been drafted that provides for the development and improvement of the legal
basis for using opiates in pain relief, the development of a hospice network, the
creation of palliative care delivery standards, and the formation of a national
system of medical and social staff training in palliative care.
Health systems in transition
Ukraine
6.11 Mental health care
The 2000 Law on mental care (Law of Ukraine No. 1489-III, issued 22 February
2000) set out the legal and institutional basis for providing mental care based
on principles of human and civil rights for the first time in the Ukrainian
context. It determines the responsibilities of executive authorities and local
self-governments as well as the legal and social rights of individuals suffering
from mental illness, and regulates the rights and responsibilities of physicians
and other workers involved in providing psychiatric care. For instance, the
law provides for mandatory consent from the patient and his relatives or legal
guardians for receiving medical care, and the use of compulsory treatment can
only be based on a court decision using measures approved by law. The law
also establishes a patient’s right to receive limited psychiatric care according
to the patient’s condition, preferably in home settings. Ukraine has also signed
the Mental Health Declaration for Europe (2005) in Helsinki, and the Mental
Health Action Plan. The openness of mental care to national and international
NGOs has caused a shift in public attitudes towards both the providers and
receivers of mental health care services.
The mental health protection system consists of psychiatric hospitals and
outpatient clinics, and the psychiatric departments of multi-profile hospitals that
operate under the Ministry of Health. There are also low-capacity psychiatric
agencies that work under the jurisdiction of the security services, the Ministry
of Internal Affairs, the Ministry of Transport and Communications, and the
Ministry of Defence, providing services directly to the employees of these
departments and their families. There are a small number of private medical
facilities providing psychiatric, psychotherapeutic and drug treatment
services. In 2007, the network of psychiatric facilities under the Ministry
of Health consisted of 88 psychiatric hospitals with an average capacity of
500 beds, 29 specialized mental health clinics, as well as 656 psychiatric and
162 psychotherapeutic units in polyclinics within the main health system.
Mental health receives about 2.5% of total health care expenditure. It has been
estimated that 89% of all resources are used on inpatient psychiatric care,
while outpatient services receive only 11%. It must be noted that psychiatric
patients have to purchase their own medications, and less than 1% of patients
receive the necessary psychotropic medication with up to 80% cost coverage.
Neuroleptic medication would cost up to 10% of the daily minimum wage, and
antidepressants would cost 3%. Therefore, the lack of a national system for
supplying medication to psychiatric patients creates a heavy burden for the
patients’ families, reduces access to treatment and decreases its efficacy.
143
144
Health systems in transition
Ukraine
In 2007, facilities under the Ministry of Health employed 3362 psychiatrists
(7.2 per 100 000 population), and 422 paediatric psychiatrists (4.7 per
100 000 children). Depending on the region, the supply of psychiatrists varies
significantly: some regions have twice as many psychiatrists as others; most are
concentrated in the eastern part of the country, with very few working in the
west. According to staffing standards, every psychiatric hospital department
and every mental health clinic is required to have at least one psychologist.
In reality the numbers are much lower, which slows the humanization of
psychiatric care and limits the implementation of psychotherapeutic measures.
Staffing standards do not provide for social workers in medical facilities, and
social care nurses are responsible for providing services to psychiatric patients
(1 nurse per 150 beds). Each department for compulsory psychiatric treatment
is required to have a social care nurse on staff as well.
There are 9.4 psychiatric beds per 10 000 population, 10.4 per 10 000 for
adults and teenagers, and 2.95 per 10 000 for children. Psychiatric beds
account for 10.7% of the total number of beds under the Ministry of Health
(see section 5.1.1). The ratio of beds in inpatient facilities for non-chronic and
psychiatric conditions is 1:7.5, while the ratio for psychiatric beds and long-term
stay beds is 1:1. The overwhelming majority of psychiatric beds (96%) are
in 106 specialized psychiatric facilities (88 hospitals, 18 specialized clinics
(dispensarii)), including 96% of beds for adults and teenagers, and 96.2% for
children. The remaining beds are distributed among several multi-profile
hospitals of different levels: 3 regional hospitals, 20 municipal hospitals, 15 central
district and district hospitals, 1 rural catchment area facility and 1 municipal
children’s hospital. The conditions provided by the majority of specialized
psychiatric facilities are far below modern standards. The rooms contain 10 or
more patients, and up to 24–30 patients in certain regions (Pinchuk, 2007).
The number of beds for patients in psychiatric hospitals has dropped by
37% since Ukraine gained its independence. However, the related optimization
capacity has not yet been exhausted, as between 10% and 30% of beds in mental
hospitals are still being used as socio-medical or long-term care beds. In some
cases, beds are “re-allocated” rather than being closed. For example, in 2004,
one psychiatric hospital became the property of Social Services and was then
transformed into a psychiatric nursing home. This has not become a common
practice, although the shortage of beds in mental health facilities is still an acute
problem. The psychiatric health protection system has 105 day hospitals with
5137 beds – there are only 0.44 beds per 100 registered psychiatric patients. In
a number of regions, the number of day hospitals ranges from 1 to 4. In general,
the reduction in inpatient capacity has not been coordinated with development
Health systems in transition
Ukraine
on the community level of psychiatric health protection services. Moreover,
the network of outpatient care facilities is shrinking, from 33 in 2002 to 29 in
2006. This deinstitutionalization of psychiatric care is also not supported by the
population. Since there is no parallel creation of adequate alternative services
to meet local needs, these bed closures serve to deprive a significant proportion
of psychiatric patients of access to professional medical care (Strannikov, 2008).
A state target programme is being drafted to further develop the mental
health protection system. Its main goals will be:
•
a structural and functional reorganization of psychiatric care to increase
the quality and accessibility of services;
•
the integration of psychiatric care into the system of primary and
secondary care;
•
the development of prevention programmes among children and adults; and
•
the implementation of measures to prevent the stigmatization of
psychiatric patients.
This programme was developed in 2006, but still has not been approved.
6.12 Dental care
Currently, most dental health services are commercial. Patients must pay out
of pocket for diagnostic tests, filling materials and so on, not only in private
dental facilities – the number of which is growing rapidly in Ukraine – but also
in state-owned facilities. State regulation of dental care prices is insignificant;
the market plays the primary role in setting prices. Dental care for children
and dental prosthetics for certain population groups remain free. There is
limited quality control of dental services. According to data collected by
the Medical Statistics Centre under the Ministry of Health, in 2007, in stateowned facilities, the only aspects of care which are regulated are those related
to routine screening, the population examined during screening, the percentage
of those examined who need check-ups, and the percentage of those who need
check-ups and who actually receive them. There is no systematic quality control
in the majority of private facilities.
In the 1990s, the drop in the accessibility and quality of dental services led
to an increase in dental health problems, particularly among children. These
factors prompted the approval of the State Programme for the Prevention and
Treatment of Dental Diseases, 2002–2007 (Presidential Decree No. 475/2002,
145
146
Health systems in transition
Ukraine
issued 21 May 2002). The main goals of the Programme were to improve dental
services, reinforce the primary and secondary prevention of dental diseases,
ensure that the resources and organization of dental care comply with local
needs and coordinate the activities among dental facilities. Some positive
changes have occurred since the Programme’s implementation. Each oblast
created a registry of dental diseases (particularly targeting areas with endemic
fluorosis), and dental facilities began providing preventive and dental hygiene
services. However, the Programme’s overall goals were not achieved due to
a lack of specific financing, and poor coordination between the departments
involved in the programme’s implementation. The population’s dental health
continues to worsen.
According to the Dental Association, there are numerous factors responsible
for these negative tendencies. Dental equipment is in fairly poor condition in
state-owned facilities, especially in children’s dental polyclinics, departments
and practices. Also, techniques in use are incompatible with modern dental
prevention and treatment standards. The disintegration of the national system
of primary and secondary prevention has played a role, as has the downsizing
of the network of dental practices in preschools and schools. Moreover, there
is a lack of coordination between state and private dental sectors, and a lack of
proper quality control for dental hygiene devices on the national market.
Dental care reforms are currently under public discussion. The reforms
suggest transforming state-owned dental facilities into lease-holding, local
or national companies, reorganizing the service model by providing equal
conditions for facilities of different forms of ownership. Moreover, the
government must present the public with a standard package of guaranteed
dental services, primarily for children and population groups who are subject
to mandatory medical check-ups. Further, the reforms would include the
introduction of an intersectoral system of health education, with further
development of effective methods of primary and secondary prophylactic care,
primarily for children and pregnant women.
6.13 Complementary and alternative medicine
Since the 1990s, Ukraine has been going through a social crisis, accompanied
by a decline in the prestige of science and education. Combined with the
compromised quality and accessibility of mainstream medical care, there
was an explosion in alternative healing. A large number of fraudulent healers
appeared and, during the 1990s, these “healers” managed to obtain licences
Health systems in transition
Ukraine
or similar documents from the Ministry of Health, alongside legitimate
specialists who use holistic approaches. As the massive uncontrolled spread
of these healing practices began negatively to affect the population’s health,
the government began to react. In 1998, the President issued a special decree
to bring this activity under public control (Presidential Decree No. 823/98,
issued 31 July 1998, On the regulation of folk and alternative medicine). The
decree commissioned the Ministry of Health to strengthen the licensing law
for alternative medicine, and tasked the Ministry of Internal Affairs and the
Ministry of Finance jointly to find and punish illegal “healers”. It commissioned
the Ministry of Information and the State Committee on Nationalities and
Religion to control the mass media, filtering out advertisements for “medical”
services that could harm public health. In fulfilling this decree, the Ministry of
Health created a special Folk and Alternative Medicine Committee (reorganized
in 2006 as a state enterprise) responsible for proposing state policies regarding
the development of the field, creating a database of alternative practitioners,
controlling their activity, and issuing special permits to practise folk and
alternative medicine to people without a degree in medicine. A permit can be
issued on the basis of the Ukrainian Association of Folk Medicine’s expertise
and a positive decision by the special committee that includes specialists
from the Ministry of Health and other health authorities. Folk and alternative
medicine practitioners are forbidden to treat cancer, infectious diseases
including STIs, AIDS and contagious skin diseases, drug addiction and
mental disorders that require immediate hospitalization. They are forbidden
to assess psychological health, monitor and treat pregnancy complications, or
perform surgical interventions including abortion. They are also not permitted
to perform mass healing sessions with the use of hypnosis or other methods of
psychic or bioenergetic influence.
To a certain extent, the committee has organized the field of alternative
medicine, but a number of goals still have not been met. For instance, there is
still no registry of alternative practitioners, which makes it difficult to control
their activities. Many individuals continue to practise and advertise services
unrelated to medicine (removal of curses, fortune telling, etc.) under cover of
a licence from the Ministry of Health, further discrediting legitimate folk and
alternative medicine practitioners. This caused the Ministry of Health to issue
another order in 2003, which mandated an analysis of the implementation of
legislation for folk and alternative medicine (Ministry of Health Order No. 267,
issued 19 June 2003, On controlling illegal medical practice in the field of folk
and alternative medicine). Further, this Order mandated the recertification of
practitioners with a new licence from the Ministry. However, the necessary
147
148
Health systems in transition
Ukraine
legitimization of the field has still not been implemented, a situation aggravated
by massive, uncontrolled advertisements of pseudo-healing practices in the
mass media.
According to the Ukrainian Federation of Health Care Promotion, there
are about 4000 alternative medicine practitioners in the country, but medical
circles suggest a number at least 10 times higher. A small proportion of these
practitioners are medical professionals specializing in folk and alternative
medicine (see section 5.2.1 Trends in health care personnel). The remainder
do not possess any medical training. Moreover, according to the Ukrainian
Federation of Health Promotion, up to 70% of these so-called healers are neither
professionally nor morally affiliated with healing. About 5.5 million people
receive services from these “healers”, and this number does not show any
signs of decreasing. There are several reasons people seek care from healers,
among which two are mentioned most often: the lack of positive outcomes
from a doctor’s treatment and an unsatisfactory relationship with a doctor. The
majority of patients seeking alternative treatment from healers are elderly or
have a low level of education, but there are significant numbers of patients with
specialized secondary education and higher education.
As noted in section 5.2.1 Trends in health care personnel, there are no
exact data about the number of professional specialists in the field of folk and
alternative medicine. A small proportion of them are employed at state-owned
facilities as reflexologists or specialists in folk medicine. The rest practise
privately. They have minimal connection with mainstream health care.
6.14 Health care for specific populations
Ukrainian law guarantees equal access to health care to all Ukrainian citizens,
foreign citizens and people without citizenship who permanently reside in
Ukraine. However the rights of foreign citizens and people without citizenship
temporarily residing in Ukraine are determined ultimately by special laws
and international treaties (for example, Law of Ukraine No. 2801-XII, issued
19 November 1992, Principles of legislation on health care in Ukraine).
Medical health care for prisoners is provided in accordance with the health
care law as with the population at large. Care is normally provided directly in
a prisoner’s cell. In emergencies, prisoners can be transported to a medical
facility in the Department of Justice or to the medical facilities of the Ministry
of Health with the appropriate security measures in place.
7.1 Analysis of recent reforms
U
nlike many post-Soviet countries, large-scale health system reform
has not been undertaken in Ukraine. However, the wider political and
socioeconomic transformation in Ukraine has had an impact on the
health system. The decentralization of management in the health sector was
a part of the general government policy of administrative decentralization.
Reform in this area consisted of the transfer of a series of administrative
functions in the health system to the regional and local level – local state
administrations and local authorities. On the one hand this allowed for an
increase in the accountability of local authorities for the condition of medical
services available to the local population, but on the other it brought extreme
fragmentation of financial pooling and a growth in inequalities between
territories. The reform of budgetary systems since 2000 also affected the
resource allocation mechanisms in health financing (see section 3.4). The
reform of territorial equalization mechanisms became a constituent part of the
development of a system of inter-budgetary transfers for the financing of health
service provision. The mechanisms introduced allowed some smoothing of
territorial differences. However, the scale of inequalities remained significant,
primarily because of flaws in the very method of equalization (see section 8.2).
Within the framework of a general strategy of state divestiture of industry,
the privatization of pharmaceutical and medical facilities was also undertaken.
Under the influence of market relations, a private sector began to develop in
the health system and most pharmacies were privatized.
Moreover, in the Ukrainian health system, different reforms heading in
different directions were frequently initiated. Some of these were reactive in
nature – in answer to new developments arising during the transition period.
In the context of the sustained economic crisis in the country through the early
1990s, the main efforts were directed towards preventing the collapse of the
existing health system and preserving a minimal level of social guarantees
7. Principal health care reforms
7. Principal health care reforms
150
Health systems in transition
Ukraine
for the provision of medical assistance to the population. At that time, with
the aim of mobilizing resources for supplementary funding for health care,
some health services were excluded from the state benefit package and became
available for a fee. VHI was provided a legal basis. The necessity of attracting
more resources for health led to the appearance and development of different
types of organizations with charitable status which accumulate resources from
enterprises, groups and individual citizens who make voluntary payments to
prepay for medical services. Sickness funds are the most widespread, the
activities of which are based on the simplest solidarity cover schemes for
expenses. However, the share of expenditure on private services, voluntary
donations and VHI in the overall volume of health care financing is very small.
Most private payments for medical services are informal in nature, such as
out-of-pocket payments to cover most of the cost of pharmaceuticals, medical
materials, food, gratuities for staff and so on (see section 3.3.2).
To control expenditure in the face of an acute shortage of government
resources for financing the health system, the hospital bed stock in the statutory
system was swiftly reduced by almost a third (see section 5.1.1 Infrastructure).
However, the chosen approach to rationalization – by reducing the gross number
of beds while preserving the existing network of inpatient facilities, particularly
in urban areas – did not have the desired effect of creating efficiency gains (see
section 8.3).
The sharp fall in the health of the population in the 1990s and the critical
demographic situation brought the necessity of systemic reform in the health
sector to the top of the agenda. Economic stabilization and the beginning of
economic growth were favourable factors for carrying out reform in this area.
At the end of the 1990s, a series of reforms commenced, which were directed
at improving the structural efficiency of the health system and improving the
quality of care.
After long discussions regarding the development and provision of primary
care, in 2000, the Cabinet of Ministers passed a new Resolution (No. 989,
issued 20 June 2000, On comprehensive measures directed at introducing
family medicine within the system of health care), which began a transition to a
new model of primary care based on the principles of family medicine/general
practice. The aim was to improve the quality of primary care services available,
but it was also a cost-containment strategy as the family doctors/GPs would act
as strong gatekeepers to hospital care and hopefully broaden access to services,
thereby reducing pressure on emergency care services (see section 6.3). As
part of implementation, the Ministry of Health developed and passed norms
Health systems in transition
Ukraine
to ensure the development of this aspect of health reform. In the regions, the
primary care infrastructure started to take shape, based on the principles of
family medicine: family medicine/GP clinics were founded (mainly in rural
areas on the premises of existing rural outpatient clinics, rural hospitals and
large FAPs). However, the speed of primary care reforms was almost entirely
dependent on the position of local and especially regional authorities. In regions
where the authorities were conservative, family medicine/GP services are
rudimentary. In regions where the authorities actively led the changes, financial
and administrative support for reforms existed and the process of establishing
family medicine/GP clinics was swift.
At the beginning of 2009, according to monitoring data for the development of
family medicine, in Ukraine there were 4228 primary care facilities functioning
according to the principles of family medicine (of these more than 86% are
rural) and the proportion of family doctors/GPs among the overall number of
doctors working in primary care was around 30%. Also, 35.7% of the general
population were covered by family doctors/GPs (78% of the rural population
and 17% of the urban population). At the same time, regional differences in
coverage ranged from 77.8% in Zakarpatska oblast to 6% in Kyiv. Moreover,
in a number of cases the reform of primary care is of a formal character
and consisted merely of renaming existing facilities without changing their
character or activities. This limited the potential positive influence of reforms
for allocative efficiency and population health. The primary care reform process
was held back by the lack of a distinct general government policy and economic
stimuli for the development of this sector.
Although extremely inequitable between different regions, the development
of forms of care to substitute inpatient care (such as day care and home care,
outpatient surgical centres) in Ukraine is ongoing. Since independence in
1991, the number of hospital beds for day care has risen from 0.2 to 1.5 per
1000 population by 2007 (see section 6.4.1 Day care). However, the growing
volume of inpatient-substituting forms of care has not been of practical influence
on the volume and structure of secondary care due to the prevailing ineffective
administrative methods of coordination and integration in the health system.
Reforms directed at improving the quality of medical care have been
undertaken more systematically (see section 8.5). Since 1999, according
to a government resolution, all health facilities, irrespective of their form
of ownership, have to undergo compulsory accreditation once every three
years, and since 2001, in accordance with the Law on licensing, the licensing
of clinical practice in all types of medical establishment has also become
151
152
Health systems in transition
Ukraine
compulsory. However, a system of incentives utilizing the results of licensing
and accreditation (for example, excluding certain medical procedures from
licensing or selecting medical service providers as recipients of state funding
according to the quality of services provided) was absent. Also, licensing and
accreditation commissions were conducted exclusively by health authorities,
and this was not conducive to the transformation of these mechanisms into
adequately formal instruments for internal assessment.
At the end of 1990s, the process of elaborating clinical standards started.
The first elaboration was begun in 1998 with the “Temporary branch unified
standards of medical technology of the therapeutic-diagnostic process of
inpatient care for the population”, which was presented in the form of a list of
diagnostic and therapeutic procedures with an indication as to the length of
treatment and anticipated results. The development stimulated standardization
in Ukraine and the adoption in 2000 of the Law on state social standards and
state social guarantees. Until recently, improvement of health care quality was
not a systematic activity. This started to change in 2007, when the Ministry
of Health created a special department in charge of assessing the quality of
health care services and pharmaceuticals. The National Research Institute of
the Ministry of Health also opened a Department of Scientific Support for
Standardization and Health Care Quality Control. The Concept of health care
quality control in Ukraine was approved (Ministry of Health Order No. 166,
31 March 2008) and was being implemented. It provided for the creation of one
unified multi-level system of quality control, with the introduction of evidencebased medicine and systematic monitoring for health care quality. It called for
unified methods and the development of clinical recommendations, medical
standards and clinical protocols based on more reliable, modern scientific data.
It establishes controls for licensing, accreditation, certification and expertise,
and improves the measurements of the population’s satisfaction with health care.
The proposed quality-control model was a vertically organized structuralfunctional system which included all levels of leadership – from the Ministry
to individual facilities. The coordinating, consultative and advisory functions
were the responsibility of Coordinating Councils for Quality Management
and Control in Medical Services, which were to be set up at every level of
leadership to bring together administrators, leading specialists, academics and
representatives from NGOs. The responsibility for quality management and
control was to lie with Clinical Expert Commissions (CECs) which were to work
continuously and be made up of freelance specialists from the appropriate health
care organ, highly qualified personnel in health facilities, higher education
Health systems in transition
Ukraine
institutions, scientific research facilities and community representatives.
CECs were to present general quality-control materials to meetings of the
coordinating councils. CECs also tabled proposals to the attestation and
accreditation commissions about the implementation of sanctions against the
relevant medical worker or health facility where systematic and/or gross defects,
clinical mistakes or other factors which could negatively impact quality of care
are brought to light. However, this order was superseded by another ministerial
order (No. 163) on 24 February 2010, before the impact of the proposed qualitycontrol model could be assessed.
A significant achievement for the health system, which is still not fully valued
or adopted by policy-makers, was introduced in 2006 (with methodological
support from a range of international organizations) – the NHA – a recognized
international instrument, which makes it possible to obtain full information
about financial flows in the health system (from both public and private sectors)
(Gotsadze et al., 2006). Detailed data about national expenditure create a more
reliable base for the development of strategies and policies in the area of health
care financing (see section 3.3).
Significant changes have also taken place in the system of medical education.
Since 2004, in accordance with the Bologna Convention, which Ukraine joined
in 2005, the transition to European standards for the training of physicians has
been implemented in higher medical education (see section 5.2.3). It is planned
that the new system will be fully introduced in 2010.
However, on the whole, health care reforms in Ukraine have been notable for
their slow speed of implementation, inconsistency and, in a number of instances,
the contradictory nature of processes which, in reality, have not influenced the
health of the population. The political instability in the country, the frequent
changes of government and, accordingly, the leadership of the Ministry of Health
have provoked permanent revisions to the course of reforms which, in the final
analysis, led to delays in decision-making with regard to institutional changes
in health care. Decisions affecting medical education may serve as examples:
between 1994 and 2006, the decision to move from streamed undergraduate
training (in general medicine, disease prevention, paediatric departments) to
the training of all undergraduate physicians in general medicine was twice
made and twice revoked. Each time, the adoption of a new decision starts a
new 7–8 year cycle of physician training – and its repeal is accompanied by
the corresponding costs.
153
154
Health systems in transition
Ukraine
The most prominent obstacles to the health care development in Ukraine
may be summarized as:
•
the focus on meeting the demands of the health system rather than
meeting the health needs of the population;
•
insufficient funding from public sources;
•
violation of the principles of equity and solidarity;
•
the ineffective use of available health care resources;
•
the structural imbalance of medical services; and
•
the inefficient use of health care potential to influence public health.
7.2 Future developments
After the Orange Revolution in February 2005, the government approved a
programme with an ambitious title Towards the People. It included declared
aims to provide all citizens with a guaranteed package of free medical services,
to introduce social health insurance, to strengthen primary medical care and
to facilitate the establishment of an institute for family medicine. However, the
series of parliamentary elections in 2006 and 2007, with the accompanying
changes in the format of parliamentary coalitions and the make-up of Parliament
did not, at least formally, bring about any changes of note. A reform document
proposing a set of institutional and structural changes in health care was passed
for the first time only in 2007, albeit with an unrealistic time scale – the National
Plan for the Development of the Health System for the Period to 2010. The
results of work done as part of the joint project of the Ministry of Economics
and the Ministry of Health, the World Bank, the European Commission and the
Swedish Agency for International Development (Key Strategies for the Further
Development of the Health Care Sector in Ukraine) were used as a scientific
basis for the development of this document (Lekhan & Rudiy, 2007). For the
National Plan, the eight key strategies for development were as follows.
1. Strengthening the financial basis and providing a stable financial
structure for the health system through the introduction of social health
insurance and the elimination of fragmentation of financial flows.
2. Increasing the efficiency of financial resources distribution and utilization
in the health system through the introduction of a government order on
the provision of medical services and the establishment of contracting
between purchasers and autonomous health service providers, and
Health systems in transition
Ukraine
changes to the principles of provider payment (moving from line-item
financing of medical organizations to paying for services depending on
the volume and structure of services provided).
3. The linking of the scale of government commitments with the financial
resources available to health care through the development of a realistic
programme of state guarantees with regard to free health care.
4. Structural reorganization of the system of medical service provision,
on the basis of which the development of primary care on the family
medicine model can take place: the organization of effective linking
between primary and secondary care levels; the optimization of the
network of secondary care facilities, arising from the needs of the
population; and the gradual transfer of parallel service providers to
the statutory system under the Ministry of Health.
5. The formation of an effective quality management and control system,
and the establishment of a system-wide programme of standardization
and quality monitoring for medical services.
6. The material and technical renovation of health facilities.
7. The implementation of rational pharmaceutical policies through the
introduction of a purchasing system for essential medicines, state price
controls for pharmaceuticals and medical devices, and quality control
for pharmaceuticals.
8. The improvement of personnel management, through improved planning
for required medical personnel, ensuring training for specialists in family
medicine/general practice and specialists in health care management in
line with priorities.
Currently, several aspects of the National Plan are actively being implemented.
The state programme for the development of primary care has been passed
(Law No. 1841-VI of 22 January 2010, On approving the “State Programme
for the Development of Primary Health Care on the Basis of Family Medicine
by 2011”), which envisages a series of tasks: the development of primary care
infrastructure in both rural and urban areas with the aim of moving it closer
to where people live; legal and financial demarcation of primary care from
other levels of medical care; the division of service purchasing and provider
functions in primary care; the transition to organizing primary care in line with
the family medicine/general practice model; the introduction of mechanisms
to allow patients free choice of their primary care physicians and organizing
patient access to secondary and tertiary care by referral from primary care
155
156
Health systems in transition
Ukraine
level doctors (gatekeeping); transition to per capita payments for primary care
service providers and the reimbursement of staff in relation to the volume and
results of their work; assistance for the development of private family doctors/
GPs and their participation in fulfilling state contracts for primary care; and the
participation of citizens in the process of developing, taking and monitoring of
decisions affecting the functioning of primary care (see section 6.3).
A unified method of developing/adapting clinical recommendations has
been prepared and passed (based on AGREE, the international tool for clinical
recommendations quality evaluation – Appraisal of Guidelines, Research and
Evaluation), as have clinical standards and unified clinical protocols (Joint
Order of the Ministry of Health and the National Academy of Medical Science
No. 102; No. 18 of 19 February 2009, On accepting the unified method for
developing clinical guidelines, medical standards, unified clinical protocols for
medical care, local protocols for medical care (clinical patient pathways) on
the basis of evidence-based medicine (parts one and two)). For the organization
and methodological coordination of standardization processes, a state centre
for the development, monitoring and maintenance of medical standards was
opened at the Ukrainian Institute for Strategic Research under the Ministry
of Health. Working groups there are being put together and trained to develop
or adapt clinical recommendations and, as necessary, rework the clinical
protocols in place. The next challenge is to ensure the implementation of these
clinical recommendations, protocols and standards at the provider level. Over
10 years (1999–2008) standards were created in the form of clinical protocols
for virtually all clinical specialties. However, most of them were developed on
the basis of expert opinion without the use of evidence and implementation was
not supported by adequate incentives.
In the framework of the EU project Financing and Management of Health
Care in Ukraine, several experiments have been conducted: encouraging
financial and administrative autonomy of medical facilities, purchasing medical
services on a contractual basis and using new payment mechanisms (generally
substituting line-item financing with global budgets) (Rudiy, 2005). The results
of these experiments were used in draft laws to provide the legislative basis for
the planned reforms, including the new version of the Principles of legislation
on health care as well as the draft Law on medical services and facilities.
The global economic crisis brought definite amendments to the plans for
health care reform. The growth in pharmaceutical costs, food and energy
prices caused a general increase in expenditures for maintaining the network
of health facilities and an increase in the cost of health services. Rising
Health systems in transition
Ukraine
costs intensified the problem of improving the efficiency of using available
resources to preserve access for the population to medical care of adequate
quality. Ukrainian experts working with World Bank consultants developed
a new strategy for the development of the national health system in the new
economic conditions (Lekhan, Slabkii & Shevchenko, 2009). Based on this,
the Ukrainian government developed wide-ranging anti-crisis measures
(Cabinet of Ministers Decree No. 208 of 17 February 2010, Some issues for the
improvement of the health care system). A specific package of measures was put
together by the Ministry of Health, in which, along with short-term measures,
there were plans for long-term measures of a more strategic nature, which were
directed towards rationalization of the network of health care facilities and
structural reorganization of the health system. At the same time, strengthening
and developing an effective system of primary care remained the main priority.
Along with primary care reform, a reorganization of secondary care was also
proposed. The main idea was to introduce new territorial-functional units –
hospital districts profiled to suit the health needs of the local population and
refitted accordingly. These hospitals would be inpatient facilities in a multiprofile hospital with intensive care facilities and an outpatient clinic (one per
district), a hospital for chronic conditions, one for rehabilitation, a hospice and
a medical-social care department.
It is proposed that such reorganization would allow the rational regrouping
of available resources and provide medical services of appropriate quality
for patients with different needs. At the same time, the mechanisms for
implementing these reforms are not yet certain. Two differing perspectives
are being discussed: (1) creating a single financial pool at the regional level
for secondary and tertiary care with the aim of creating the conditions for the
optimization of planning for the medical facility network; (2) on a contracting
basis creating inter-territorial unified hospitals under the administration of a few
local self-government authorities. There are also plans for medical universities
to have training clinics in the regional hospitals, with the aim of improving
highly specialized care for the population and the quality of clinical training,
and increasing the efficiency of medical research (see section 6.4). With their
Decree (No. 208) the government launched two pilot projects in regions to trial
these reforms in order to assess the potential risks and to develop measures to
neutralize such risks before the implementation of reform at the national level.
After the presidential elections in January 2010, and the formation of a new
parliamentary coalition and a new government, the basic course towards the
introduction of the announced reforms in the health system has been preserved
and supported, with the additional aim of introducing a system of mandatory
157
158
Health systems in transition
Ukraine
social health insurance (MHI) by the end of 2014 (Economic Reform Committee,
2010). MHI plays an important role in the proposed reforms. Some view the
introduction of MHI as a source of additional financing; others view it as a
powerful economic catalyst for the general transformation of the sector – an
indispensable condition for the transition from an administrative command
system (based on the Semashko model) to a system answerable to the health
needs of the population. Deepening economic crisis in Ukraine (see section 1.2)
did not prevent many politicians from calling for a rapid transition to a health
insurance model, indeed, such calls multiplied. For example, in May 2009,
during a parliamentary session, it was recommended that the relevant draft
law be looked at again as a priority (Verkhovna Rada Decree No. 1461-VI of
4 June 2009). However, recent Ukrainian history shows that the final decision
on the introduction of social health insurance will not be easy to make. Since
independence, Parliament has returned to this issue many times – in 2003 a
bill on the issue reached a third reading, but the law was not passed. Moreover,
representatives of the political elite have completely different opinions about
which model of MHI would be the most suitable in Ukraine.
The Ministry of Health considers the availability of trained administrative
personnel to be an important condition for the successful implementation of
reforms (see section 5.2.3). A draft 18-month Master’s degree in Health Care
Management programme for professional training has been prepared, as have
the relevant teaching materials, which meet the requirements of the International
Federation of Medical Education and the WHO Regional Office for Europe for
postgraduate education programmes for health system managers. A five-year
transition period is envisaged, after which, on appointment, the directors and
deputy directors of health care facilities will only be able to start work if they
are in possession of a relevant Master’s degree. However, this decision has not
yet been put into law. There are also plans for the introduction of a system of
continuous professional development for doctors and pharmacists.
Overall, despite the fact that the goals and objectives of executive authorities
have become much clearer recently, health reforms are still facing serious,
even institutional, barriers, including the presence of constitutional norms
guaranteeing free health services in state medical facilities. There is a lack of
internal economic incentives for radical change within the health system, a lack
of skills in solving health care issues among decision-makers at different levels
and a lack of understanding of the national context while adopting international
experience. Moreover, health care policies are often inconsistent, in line with
the associated weak methodological and political leadership from the centre.
Health systems in transition
Ukraine
Managerial staff in health care lack many necessary skills as well. However,
the main obstacles for the implementation of reform are political instability in
the country, a low level of public trust in the government, and a multitude of
lobbying groups seeking either to preserve the existing system or to pursue
their own reform agenda in line with their corporate interests. Consequently, a
number of private insurance companies openly resist socially oriented reforms
as they would like to gain access to public financial resources for the health
system and to block the development, or at least restrict activities, of a non-profitmaking state fund for social health insurance that operates on a tripartite basis.
Pharmaceutical companies that are displeased with the prospects of greater
control over the use of pharmaceuticals resort to covert lobbying as well.
There is also covert resistance in the medical field. The majority of health
managers who verbally promote independence are afraid of the responsibility
of meeting their obligations, especially since many of them lack the appropriate
training. Health authorities are reluctant to relinquish traditional levers of
power. The medical community in general is interested in restoring their
professional status and establishing fair remuneration for their work from the
state. However, there is no single opinion in the community on the reforms of
the health system. Many doctors would prefer to preserve the existing social
contract, which provides them with informal remunerations, ensuring a high
income. A smaller but very active percentage of doctors, disenchanted with the
possibility of real change in the near future, decide to leave the health sector,
or the country, altogether.
Political parties and other civil society groups play a significant role in
prolonging the reform process. In election campaigns, all political parties have
improving health care as a declared key aim. However, their views on the
goals, and particularly the methods, for improving health care are significantly
different, from the preservation of full free medical care (for parties on the left
of the political spectrum) to the transition to VHI as the main source of health
care financing and the privatization of health facilities (for right-wing parties).
Centrists propose social health insurance together with comprehensive reforms
of the health sector. Since no party has a parliamentary majority and the parties
only form situational coalitions, it is difficult to make balanced legislative
decisions to address pressing problems in the health system. Since regional and
local authorities are elected from party lists, their political affiliation influences
their attitudes towards health care reform. Thus, it is impossible to form a
consolidated demand for the needed health reforms from the bottom up.
159
160
Health systems in transition
Ukraine
It is well known that implementing reform requires public trust alongside
political forces united around the goals and principles of reform. Unfortunately,
however, there is currently a very low level of public trust and support for
political forces in the Parliament and trust in central and local executive
authorities is even lower. Thus, it is doubtful that the public will support health
care reforms, despite dissatisfaction with the current situation. Successful
health reform implementation requires the establishment of certain conditions
in order to overcome the distrust and so-called “fatigue” of promised but
unfulfilled reforms.
•
Health must be proclaimed a basic fundamental social and economic
priority by all branches and levels of government; this must be supported
by appropriate economic policy.
•
There must be a political will to implement reforms.
•
There must be clear, consistent and transparent health care policies, the
development and control over which must involve all interested parties,
primarily the public and the medical community.
8.1 The stated objectives of the health system
T
he stated aims of the health system reform programme in independent
Ukraine were first formulated in the Concept for the development of health
care, which was introduced by the Presidential Decree on 7 December
2000. The main aims were:
•
to maintain and promote the health of the population and to extend active
longevity;
•
to create legal, economic and administrative mechanisms to empower
the citizens of Ukraine to exercise their constitutional rights to health
protection, care and medical insurance;
•
to ensure a guaranteed level of high-quality health care free of charge
in accordance with legislation;
•
to establish a regulated market for health services, facilitating the
performance of health facilities of any type of ownership and creating
conditions to meet the health care needs of the population;
•
to ensure efficient use of available personnel, financial and material
resources; and
•
to establish joint participation of the state, employers, communities,
enterprises and individuals in the financing of health services.
In 2002, Parliament ratified the long-term comprehensive programme
Health of the Nation for 2001–2011, the aims of which were given as improving
the demographic situation, improving and strengthening the health of the
nation, improving the quality and efficiency of health care, and ensuring social
equity and the right of citizens to health protection. Moreover, every government
on coming to power has announced its aims in the sphere of health protection.
8. Assessment of the health system
8. Assessment of the health system
162
Health systems in transition
Ukraine
As part of their programme of activities in the Ukrainian Breakthrough: for
the People, not Politicians, the “Orange” government declared in the Cabinet
of Ministers Decree No. 14 of 16 January 2008) that:
the provision of high-quality and accessible medical care,
the orientation of the health system towards disease prevention,
and the creation of safe and healthy environments (working conditions,
living conditions, study, relaxation, nutrition, healthy lifestyles and
improving the demographic situation) should become the priority
activities of all those in power.
To achieve these aims, the government took on a series of ambitious
obligations, including:
•
appropriate financing of the sector with a fixed social protection
mechanism for health workers;
•
developing the legal basis for the introduction of mandatory state health
insurance with the provision of state-guaranteed free health services;
•
developing measures to encourage citizens to purchase VHI;
•
undertaking structural reorganization of the health system with the
development of primary care according to a family medicine/general
practice model and providing every family with access to a family
doctor/GP in the course of five years;
•
developing rural health care through the Village Doctor Programme,
making provisions for the building/renovation of rural outpatient clinics
and FAPs and updating of their medical equipment;
•
improving the efficiency of health care spending by moving to resource
allocation by services provided rather than capacity criteria, and the
introduction of contracting between the state purchaser and health
service providers with different forms of ownership;
•
creating a state control mechanism for pharmaceuticals and medical
devices, in accordance with the Programme to Combat the Sale of
Counterfeit Pharmaceuticals, 2009–2012; and
•
writing a Concept on regulating the quality of health services,
2008–2012.
Health systems in transition
Ukraine
8.2 The distribution of the health system’s costs and
benefits across the population
One of the main problems faced by the health system in Ukraine is the
mobilization of adequate resources in such a way as to guarantee equity in
access to core health services. In accordance with the current requirements,
health care financing should be both vertically and horizontally equitable;
overall, however, the system of health care financing in Ukraine may be
considered regressive. The main funding source, general taxation revenues,
combines revenues from direct and indirect taxes so the financing system can
be considered generally progressive (Mossialos & Dixon, 2002). However,
the progressiveness of financing from budgetary resources is reduced by a
considerable volume of activities in the shadow economy (up to 26% of GDP;
see section 3.3.1), especially as wealthier citizens conceal their income from
taxation. Moreover, the allocation structure according to the type of health
service provider reinforces the inequality of state expenditure in vertical equity.
Research conducted by the World Bank found that 70% of general government
expenditure on health goes to hospitals, specialist facilities and sanatoria,
although the poorest sections of the population use the services of these facilities
considerably less frequently than wealthy citizens (World Bank, 2008).
To a greater extent, direct payments undermine vertical equity in financing.
Although estimates of private health expenditure from different sources and
using different methods vary greatly, even the most conservative suggest that
they account for more than 40% of total health expenditure (see section 3.1), or
up to 3% of GDP (World Bank, 2008). Patients pay for a considerable volume of
services out of pocket. Most of the population pay out of pocket in full for their
pharmaceuticals in both outpatient and inpatient care. Both rich and poor pay
for drugs and treatment. The growth in payments is taking place in a chaotic
and uncontrolled fashion, without any attempts by the government to mitigate
the negative consequences of this process for the population (see section 3.2).
Overall, in the World Bank’s assessment, population payments for medical
services in Ukraine are more regressive than in other countries of the WHO
European region and OECD countries, and, potentially, health care costs could
push many people into poverty (World Bank, 2008).
All of this results in significant inequalities in access to care. Irrespective
of the economic growth witnessed in the country prior to the global financial
crisis, in 2009 almost 20.5% of households could not access necessary medical
care (see section 3.3.2). The diffusion of informal payments deters the poorest
groups and rural populations (most of which are low-income) from using
163
164
Health systems in transition
Ukraine
medical services most of all. Due to their inability to pay for medical services,
both urban and rural poor more often do not seek medical care or postpone it
and, moreover, low-income patients are more often refused treatment because
they cannot pay for services or pharmaceuticals (see Table 8.1). Vulnerable
groups include many elderly people who rely on their state pensions as their
main source of income and people with low educational attainment as they
find it hard to find well-paid employment. Inequality in access to health care
is also demonstrated by access for people living in regions with different
levels of economic development. Research shows that in the poorer regions
in western Ukraine financial access to health services is lower than in the
wealthier regions in eastern and central Ukraine (Lekhan & Shishkin, 2007).
High out-of-pocket payments also lead to considerable differences in the quality
of services offered.
Table 8.1
Frequency of delaying seeking, utilizing and being refused health services, 2006
Monthly household
income level
Place of
residence
Low
High
Rural
Urban
Frequency of delaying seeking health care due to
the inability to pay for services, %
16.8
6.7
17.3
8.9
Frequency of utilizing health care, %
68.2
84.7
70.3
81.4
Frequency of being refused health care, %
19.6
10.0
–
–
Sources: Kyiv International Institute for Sociological Research, unpublished data, 2006; State Statistics Committee
of Ukraine, 2007.
There are grounds for thinking that the scale of social inequalities is reaching
crisis proportions. Data from the State Statistics Committee of Ukraine show
that in the first quarter of 2009, prices for imported pharmaceuticals rose by
43% compared with the same period in 2008, due the devaluation of the hryvnya.
The inescapable consequence of this was a reduction in the acquisition of
pharmaceuticals by state-owned health facilities. The increase in pharmaceutical
prices against a background of falling real incomes led to a reduction in the
ability of people to purchase essential medicines and make formal or informal
payments, as a result of which access to health care was reduced, particularly
for the poor and vulnerable (Sheiman & Shishkin, 2009).
Inequalities caused by out-of-pocket payments can also have a horizontal
regional character, as people with the same income level living in richer
regions pay more out of pocket than those living in poorer regions. Similarly,
in villages and small towns, gratuities are smaller than in big cities. Horizontal
Health systems in transition
Ukraine
equity in budgetary payments also infringes upon the functioning of parallel
health systems. Often, especially in emergencies, patients who use services in
parallel health facilities access services in the local statutory facilities, thereby
taking a portion of the resources allocated to the financing of medical services
for other patients in that territory who cannot access the parallel system (see
section 3.4).
The system of budget financing in place allows for a certain amount
of redistribution of financial resources. Following decentralization after
independence (see section 2.4), the available approaches for inter-budgetary
transfers did not equalize financial provisions for health expenditure because
the prime concern was historical precedent in allocations to facilities, and
differences in the age and sex structures and morbidity levels of populations
living in different territories were not taken into account. The difference between
maximum and minimum funding levels for health from territorial budgets was
2.1 times. Budgetary reforms undertaken in 2001 changed these budgetary
transfers so they were calculated according to a single norm – per capita funding
corrected by coefficients for the budgets of different levels and territories (see
section 3.4). The system led to a definite reduction (of up to 1.6 times) in the
inequalities between residents in different regions of Ukraine. However, the
formula, which gives the requirements for disbursements and associated level
of transfer equalization, not only included the age and sex structure of the
population but also was burdened with multiple correcting coefficients taking
into account the resources involved. For example, a few coefficients linked
financing to the characteristics and number of health personnel working in the
health facility network, so the shortcomings of budgeting based on historical
precedent were not overcome (World Bank, 2008). It also became a defining
factor for the preservation of significant territorial inequalities in health care
financing in connection with the presence of existing differences in regional
resource provision.
One of the more pressing problems being addressed by the Ministry of
Health is how to reduce the scale of inequalities, particularly during a global
financial crisis which has led to a reduction in the amount of finances available
for distribution. For this the Ministry of Health is looking at the possibility
of unifying the health protection budgets resources of villages, districts and
towns by creating a single unified pool for the provision of all local primary
care services. More radical suggestions include the unification of resources
for the financing of inpatient care at the regional (oblast) level that would open
up opportunities to not only rationalize the inpatient facility network, with
165
166
Health systems in transition
Ukraine
an emphasis on reducing excess hospital capacity and creating inter-district
specialist care centres, but also overcome duplication of activities at secondary
and tertiary level state facilities (Sheiman & Shishkin, 2009).
8.3 Efficiency of resource allocation in health care
Under the Soviet Semashko system, resource allocation was conducted
according to the number of beds and staff in health facilities and not on
population health care needs. The volume and quality of work conducted
were not a factor. This approach created inappropriate incentives for extensive
development and the preservation of excessive and inefficient infrastructure,
resulting in the unjustified growth in outpatient appointments, unnecessary
hospitalizations, longer hospital stays and so on. The biggest health facilities
were also concentrated in the cities, towards which most health care resources
were directed. This Soviet approach to allocating resources to health facilities
based on their size was preserved in Ukraine (see section 4.2 and section 3.6.1).
Formally, budgets at the health facility level are based on Ministry of Health
norms, which define the staffing levels and other essential resources (such as
the number of doctors) arising from the number of beds and visits to health
facilities and not from the demand for medical services. The imperative nature
of these normative acts (if they are not fulfilled, there may be harsh sanctions)
is a contributory factor to the inflexibility of resource allocation in health care.
This leads to high routine expenditure (particularly wages, utility bills and the
like) and limits investments to improve the quality and efficiency of services
for patients. Exacerbating this problem is the legislation which prohibits the
closure of health facilities and the difficulties local authorities encounter when
trying to reduce staff numbers.
At the same time, under the pressure of economic crises in Ukraine through
the 1990s, there were a number of specific structural changes in the health
system. The acute shortage of state funding for health care became the main
reason for changes in the most expensive sector – inpatient care. The Parliament
instituted an empirically grounded norm for the maximum number of beds
(8 beds per 1000 population) (Cabinet of Ministers Decree No. 640, issued
28 June 1997). The accompanying indicators for the number of beds distributed
between community and state facilities in a given territory should have been
brought below this maximum level by the regional health authorities. This
norm did not include the bed stock of parallel health providers. The number
of beds was reduced rapidly (by 150 000 beds between 1996 and 1998) by
Health systems in transition
Ukraine
administrative means without any change in the approach to resource allocation
(for beds) or to defining the number of medical staff (according to norms based
on the number of beds). This provoked strong resistance from both the health
care leadership and the many medical personnel. For the former it would mean
a cut in funding and for the latter they could lose their jobs. Cutting the number
of beds was achieved mainly by cutting hospital capacity (see section 5.1). As
a result, the main saving from reducing bed numbers was insignificant in the
face of dominant expenditure structures financing care irrespective of the
volume provided.
More radical ways of reducing the number of hospital beds by closing
facilities generally only affected the smallest rural hospitals, which, as a rule,
were turned into outpatient clinics. In a number of cases, the closure of these
facilities was dictated not so much by expediency as by the limited resistance
to their closure. Besides economic factors, the reduction in the size of the
population served was also influential for reducing the number of hospital beds.
In total, from 1991, the number of hospital beds fell by almost a third (30.4%),
the number of inpatient facilities fell by 27.8%. At the same time, the network
of small rural hospitals shrank by 60%, while the number of secondary care
hospitals in towns decreased less (down by 20%), and the number of tertiary
care level facilities remained virtually unchanged. Hence the overall number of
hospital beds has remained high (see section 5.1.1 Infrastructure).
A reasonably high level of utilization against the background of poor access
to inpatient care, which is extremely expensive for a significant proportion of the
population, is strong evidence of the inefficiency of financing inpatient care by
the number of bed-days. This pushes hospitals to keep beds open and fill them
with patients irrespective of whether they really need inpatient treatment. As a
result, the dominance of funding for inpatient care in total health expenditure
has been preserved, and spending on outpatient and particularly primary care
remains far too low.
Human resources are extremely unevenly distributed. The biggest staff
shortages are in rural areas and in primary care. Measures taken by the
Ministry of Health in the form of sending new graduates to work in underserved
areas and specialties, and the introduction of some benefits for health workers
working in rural areas have not brought the desired results (see section 5.2).
To improve the efficiency of resource distribution, Ukraine needs to address
a series of tasks listed in the National Plan for the Development of Health
Care by 2010, including the financial and organizational demarcation between
primary and secondary care, conducting structural reorganization of health care,
167
168
Health systems in transition
Ukraine
first and foremost the development of primary care along the lines of family
medicine/general practice, the apportionment and strengthening of hospitals for
acute care, the transition from the current way of distributing resources to one
based on contracting between purchasers and providers of health services, and
the introduction of new modern forms of paying service providers.
8.4 Technical efficiency in the production of health care
Assessing the economic efficiency of the health system is not feasible as this
kind of research has not been conducted in Ukraine. However, there are indirect
indicators showing economic inefficiencies in the system. The reduction of bed
numbers pushed the task of raising the efficiency of resource utilization into
second place. Hospitals, trying to preserve their bed capacity and to receive
additional informal funds from the population, increase the volume of services,
weakening demand for hospitalization to be necessary on medical grounds. The
expansion of day and home care from polyclinics has not been accepted as a
substitute for inpatient care.
As noted in section 6.4, unnecessary hospitalizations account for a third of
all hospitalized patients. It was found that nearly 13% of patients were receiving
specialist outpatient care and 20% were receiving treatment using technologies
which did not require hospitalization. The average cost of medical services for
one patient based on total expenditure (not only those which are really covered
by the budget) in an outpatient setting would be approximately four times lower,
and for day cases two times lower than the cost of inpatient treatment. These
figures demonstrate the economic inefficiency of the current health system
and lead us to conclude that the optimization of just one constituent medical
service – the choice of an adequate place to provide health care – demonstrates
the opportunity to increase the real funding possibilities of the sector.
8.5 Quality of care
The quality of health services is not regulated by a specific piece of legislation in
Ukraine. However, since independence, the normative base has been formed and
different efforts have been directed at improving the quality of health care (see
section 4.1.4). In the mid 1990s, a system of quality guarantees for health care
was created: in addition to the Soviet Semashko system’s accreditation of health
personnel, the licensing of medical practice was introduced (initially in private
Health systems in transition
Ukraine
structures, but from 2001 licensing was rolled out to all health care facilities
irrespective of ownership) as well as the accreditation of health facilities (since
1997). However, in relation to the remaining obvious incentives, particularly
for state and community health facilities, these mechanisms are more of a
formality and do not much influence the safety or quality of health services. In
2008, on the basis of verifying the observance of licensed conditions in private
facilities, 48 licences, representing 15% of private providers, were annulled.
Not one state or community facility underwent such verification and none was
deprived of its licence (Ministry of Health of Ukraine and Ukrainian Institute
for Strategic Research, 2009). Conditions in health facilities are run down –
both physically and morally; and their renovation is progressing extremely
slowly (see section 5.1).
From the late 1990s, the standardization of health care has developed rapidly
in Ukraine. Thousands of clinical protocols have been developed for different
medical specialties. However, the level of the standards has remained low, and
their implementation is only checked periodically, usually in connection with
a patient complaint about the quality of care or a court case or other conflict
situation. Health personnel lack adequate motivation to improve the quality of
their work, and, in the case of adopting clinical standards, most often this is
linked to the low and inflexible remuneration of staff (see section 3.6.2).
A system of quality control for pharmaceuticals has been introduced, which
includes assessments of their manufacture, regulation of their entry to the market,
the monitoring of adverse reactions and so on (see section 5.1.5). The system for
monitoring adverse reactions, the implementation of which is the responsibility
of the State Pharmacological Centre under the Ministry of Health, analyses
spontaneous communications about adverse reactions and conducts pharmacoepidemiological research. The number of notifications about adverse reactions
between 1996 and 1999 grew 25 times, which shows that the system has come
into being. On the basis of notifications received, the State Pharmacological
Centre has banned or limited the use of 18 pharmaceutical preparations and
groups of pharmaceuticals.
In 2009, the Ministry of Health introduced a new system of quality control
and management in health care and began its implementation. However, there
are few incentives to improve the quality of health services and increase patient
satisfaction (see Chapter 7). Overall, irrespective of the many activities aimed
at improving quality, the health system is hardly oriented towards population
needs and is not answerable to its users for the results of its actions. Patients as
end users have almost no participation in managing the system.
169
170
Health systems in transition
Ukraine
8.6 The contribution of the health system to health
improvement
Thus far, there has been no official assessment of the contribution made by the
health system to improving population health. However, available data shows
that despite increased spending on health in 2000–2008 (see section 3.1), with
the exception of maternal and infant mortality, the main health indicators have
changed little (see section 1.4).
Research on avoidable mortality in Ukraine from 1989 to 2006 found that
it reached a peak in 1995, growing by 52.6% among men and 29.6% among
women from 1989, and that avoidable mortality rates fell towards 2006, but are
still 36% higher for men and 20% higher for women than rates for the base-level
year of 1986. The reduction in the level of avoidable mortality between 1995
and 2006 was mainly the result of broad prevention measures outside the health
sector (Group I). Indicators for deaths which are amenable to health systemwide activities (detection and treatment of disease in the early stages – Group II)
and effective medical intervention (Group III) were virtually unchanged for
men or women (see Table 8.2) (Libanova et al., 2008).
Table 8.2
Avoidable mortality indicators for the population aged 25–64 years in Ukraine,
1989, 1995 and 2006 (per 100 000 population)
Cause of death
Group I
Men
Women
1989
1995
2006
1989
1995
2006
479.0
720.4
624.0
134.6
188.2
167.4
Group II
3.0
3.5
3.4
46.2
51.6
51.7
Group III
118.9
192.9
192.5
42.0
48.9
49.1
Total
600.8
916.9
819.8
222.8
288.7
268.2
Source: Libanova et al., 2008.
Irrespective of the increase in funding for the health sector, the lack of any
improvement in avoidable mortality, that is, deaths which could be prevented
by timely access to health services of reasonable quality, is evidence that the
health system has had little impact on population health. It can be assumed
that improving access to effective health care, but above all more rational and
equitable distribution of resources and effective policy in the area of health
protection, could ensure that real progress is achieved in the health status of
the population of Ukraine.
T
he Ukrainian health system has preserved the fundamental features of
the Soviet Semashko model of health care, such as general taxation being
the main source of funding, the allocation of resources depending on the
size of the medical facility, and budgetary financing of health facilities. Today
the Ukrainian health system is close to a centrally planned system against a
background of other changes which are developed on market economic principles.
The transition from centralized financing to its extreme decentralization is the
main difference in the health system in comparison with the classic Soviet
model in Ukraine.
Apart from the reform of inter-budgetary relations which took place in
2001, the decentralization of the four-level budget system is characterized by
the fragmentation and duplication of pooling in health care. The existence of
parallel systems of financing has further reinforced this tendency. The system
of financing in place not only contributes to the preservation of inefficient
methods of resource distribution and patient pathways, but also fails to
facilitate adequate access to essential medical services. The financing of
health facilities on the basis of line-item budgeting and the preservation of
the legal status of facilities as state-owned reproduce the existing pattern of
expenditure and increases the need for a large volume of budgetary financing,
which does not lead to improved efficiency. As a result, health care financing
in Ukraine does not provide successful protection of the population from the
risk of catastrophic health care costs by equalizing the burden of health care
expenditure between different social and territorial groups. The situation is
intensified by the practically unlimited and weakly regulated out-of-pocket
payments for medical services, which are demanded by state health facilities,
and that create inequalities in access to health care for population groups. The
state guarantees of free medical care for citizens are declarative and have
inadequate state funding.
9. Conclusions
9. Conclusions
172
Health systems in transition
Ukraine
Health facilities and workers do not have the motivation to improve the
quality of medical services, increase the efficient use of resources, or take
responsibility for the health status of the population. Health workers receiving
hourly-rate salaries which disregard the real results of their work have no
incentive to use resources rationally, to strive for the best population health
outcomes possible per unit of resources spent, to build their professional
activity on the basis of evidence-based medicine, or to find the optimum
balance between cost and quality. Similarly, health care managers have no
incentive to initiate structural internal changes in their organizations as such
changes (for example reducing the number of inpatient beds or staff) within
the existing framework of management and financing would also mean a
reduction in budgetary allocations to the facility. In view of the virtual absence
of competition between health service providers, the managers also have no
motivation to organize effective quality control or to find ways of reducing the
cost price of medical services. The results of the health system’s activities are
not as good as they could be given the resources at its disposal. The population
in Ukraine is fundamentally unsatisfied with the health service and the necessity
of reform in the health system is generally recognized.
Many changes in the health sector have been initiated and often realized since
independence. Most of them were oriented not towards meeting the health needs
of the population but towards solving problems in the health sector. Often a part
of the medical services was made chargeable in order to mobilize additional
resources; charitable payments and donations were allowed; and sickness funds
and VHI began to develop. To reduce government expenditure in circumstances
where there was an acute shortage of funds, the decision was taken to reduce
the stock of hospital beds, as a result of which its volume was cut by over a
third. Together with this, the legal basis was laid and measures realized which
were directed towards institutional reform of the health sector (starting with
the conversion of primary care to family medicine/general practice from the
established inpatient-focused forms of medical service). A series of decisions
were also made directed at setting up specific quality guarantees for health
services (the licensing of medical practice, accreditation of health facilities,
standardization of clinical practice).
However, it is hard to call the changes undertaken in Ukrainian health care
“reforms” in so far as they were notable for their slow speed, inconsistency and,
on a number of occasions, the contradictoriness of different processes. The
main reasons for this are:
Health systems in transition
Ukraine
•
the lack of clearly designated aims for the reforms (in both qualitative
and quantitative respects);
•
the lack of a clear strategy for changes, constant revisions and slow
implementation of reforms;
•
the lack of a clear policy provided to fulfil decisions taken and the
disregarding of scientifically demonstrable or assessed experience
of approaches, forms and methods of reforms; and
•
the influence of different lobby groups on decision-making.
The government, when analysing the reasons for the lack of success in health
care reform, came to the conclusion that, in order to ensure equitable access to
medical services, achieve greater efficiency in the health system and improve
its impact on population health, it would be necessary to reform the institutions
which fulfilled all functions of the financing system – that is, to replace the
entire Soviet Semashko model with one that is appropriate to the new social
conditions. In 2007, with the National Plan for the Development of Health
Care, the government started the attempt to introduce systemic reform and
to move towards a health care model which was orientated towards satisfying
the population’s demand for accessible health services of reasonable quality.
However, political instability in the country due to the changes of government
and permanent parliamentary crisis hindered the passing of the legislative acts
necessary to implement the proposed health care reform. Attempts to revise
the apparently fixed course of the sector’s development were resumed with
new vigour. Reasonably consistently, albeit very slowly, the strategic direction
of the National Plan is being implemented – that is, those parts which are
linked to forming a system of quality control and management for medical
services. A standardized method for the development of clinical management,
medical and clinical protocols on the principles of evidence-based medicine
and a programme of standardization of medical services, as well as processes
for quality control and management of medical services, have been developed
and approved, and await implementation.
The global financial crisis and associated reduction in financing for health
care have once again brought the issue of Ukrainian health care reform to
the fore. The Ministry of Health prepared an order on improving the system
of health services for the population of Ukraine in a time of crisis which was
approved by the Parliament. The aim was to minimize reduced access to health
services at a time of crisis, primarily for the poorest sections of the population,
and to create conditions for increasing the efficiency of the health system in
the face of tighter budget limits. The leading role in this order is taken by
173
174
Health systems in transition
Ukraine
measures for increasing the structural efficiency of health care, in particular
the intensification of reforms of primary and secondary care. However, serious
institutional barriers remain on the path of reform: more parties have an interest
in preserving the status quo than in reform. Reform requires a considered choice
of expedient innovations and strong political will to actually implement changes.
Consequently, there are high hopes for the economic reform programme for
2010–2014 announced in June 2010, which promises concrete health financing
reforms, but whether or not they can be implemented this time remains to be
seen (Economic Reform Committee, 2010).
10.1 References
Angelov AV (2007). Community advisory boards in Ukrainian health care – Legal aspects
and early experience. In: Glukhovskii VV, ed. Community participation in decisionmaking which influences the health system: Conditions, positions and ideas. Kyiv,
Dizain v poligrafii:74–81.
Åslund A (2005). The economic policy of Ukraine after the Orange Revolution. Eurasian
Geography and Economics, 46(5):327–353.
Barbova A et al. (2006). Analysis of the National Programme for fighting TB in 2001–2005.
Kyiv, Rayevskogo Publishing.
Barmina H (2008). Problems with the development of palliative care in Ukraine.
“Apteka” Weekly 11(632) (http://www.apteka.ua/article/6348, accessed 14 April 2010).
Bernik N (2008). Human resources of the health system. Vashe zdorov’e 23(950).
Blinov A (2008). Possible prognoses for developments in the Ukrainian economy in 2009.
Business Guide (Kyiv) (http://biznesgid.com.ua/articles/19.11.08/145.html, accessed
25 January 2011).
Bondarenko GM et al. (2003). Kirovohrad Sickness Funds. Chief Doctor, 7:40–42.
Cherenko LM, ed. (2006). Living standards in Ukraine. Kyiv, Konsultant Publishing.
currency.in.ua (2010). Inflation index (Ukraine) 29 April (http://currency.in.ua/index/infl/,
accessed 29 April 2010).
Economic Reform Committee (2010). Zamozhne susil’stvo, konkurentospromozhna
ekonomika, efektivna derzhava [Rich society, competitive economy, effective state],
2 June. Kyiv, Economic Reform Committee under the President of Ukraine.
Flisak YA, Shakh GA (2008). On audit results for using state budget resources allocated
to the Ministry of Health for national immunization procedures. Kyiv (Accounting
Chamber Bulletin series, unpublished).
Ganushchak U (2006). Local taxes – Payment for the right to vote. Zerkalo nedeli (Kyiv),
18(597) (http://www.zn.ua/2000/2040/53336, accessed 12 April 2010).
Glukhovskii VV (2007). The preparedness of Ukrainian society to participate in decisionmaking and management of health care: Sociological research materials. Research
undertaken by the Centre for the Study of Public Opinion “Noval’ ekspert” and the
Medical-technological centre of the Association of Physicians (Mykolayiv). In:
Glukhovskii VV, ed. Community participation in decision-making which influences
the health system: Conditions, positions and ideas. Kyiv, Dizain v poligrafii:8–46.
10. Appendices
10. Appendices
176
Health systems in transition
Ukraine
Golovakha E, Gorbachik A, Panina N (2006). Ukraine and Europe: Results of international
comparative sociological research. Kyiv, Institute of Sociology, National Academy of
Sciences Ukraine.
Gordienko S (2003). Pharmaceutical revenge. Ezhenedel’nik 2000 (Kyiv), 52(202)
(http://2000.net.ua/2000/derzhava/3220, accessed 12 April 2010).
Gotsadze G et al. (2006). Ukraine National Health Accounts 2003–2004 (Vol. 1 and Vol. 2).
Bethesda, MD, The Partners for Health Reformplus Project, Abt Associates Inc.
Gruzeva TS (2006). Detecting and overcoming inequalities in health promotion.
Head Doctor, 12:28–35.
Gruzeva TS, Galienko LI (2009). Social health in Ukraine: Main indicators for 2008.
Kyiv, Kniga-plyus.
Hibell B et al. (2009). The 2007 ESPAD report – Substance use among students in
35 European countries. Stockholm, Swedish Council for Information on Alcohol
and Other Drugs (CAN).
Interfaks-Ukraina (2007). In Ukraine the rights of disabled children are infringed.
Likar Info (Kyiv) (http://www.likar.info/news/13721.html, accessed 14 April 2010).
ITU (2010). World telecommunication/ICT indicators database 2010, 14th edn. Geneva,
International Telecommunication Union.
Kapshuk OG, Sitnik AP, Pashchenko VM (2007). The current condition and prospects for
the development of voluntary health insurance in Ukraine. Transport Medicine, 2:87–91.
Kiselyev EM et al. (2004). Urgent problems of health insurance development in Ukraine.
Railway Transport Medicine in Ukraine, 1:74–78.
Knyazevich VM et al. (2009). Health care in Ukraine: Conditions, problems and
perspectives. Kyiv, Polimed.
Krivenko EM, Likhotop RI, Leshchuk NM (2008). The state of computerization of the
health care sector. In: Ministry of Health, Ukrainian Institute for Strategic Research
and Knyazevich VM, eds. Annual report on the health system activity in Ukraine, 2007.
Kyiv, Polimed:130–135.
Kryachkov LB, Bechke IP, Boyko OO (2000). Household budget surveys as a means of
assessing the demand for medical services. Journal of Social Hygiene and Health Care
Organization in Ukraine, 1:90–92.
Kryachkova LV (2003). Analysis of cardiology patient pathways. Journal of Social Hygiene
and Health Care Organization in Ukraine, 3:61–64.
Ksenz L (2007). Capitalizing doctors: Private medics and insurance companies cannot
yet find the optimal method of ‘treating’ the sector. Companies and Markets, 310(16)
(http://www.dsnews.ua/companies-markets/art30606.html, accessed 18 April 2010).
Lekhan V, Rudiy V, Nolte E (2004). Health care systems in transition: Ukraine. Copenhagen,
WHO Regional Office for Europe on behalf of the European Observatory on Health
Systems and Policies.
Lekhan V, Rudiy V, eds. (2007). Key strategies for further development of the health care
sector in Ukraine: Joint report. Kyiv, Rayevsky Scientific Publishers.
Lekhan V, Shishkin S (2007). Inequity in access to health care for the population of Ukraine.
Report prepared in fulfilment of the two-year agreement on cooperation between the
Ministry of Health of Ukraine and the WHO Regional Office for Europe 2006/2007
(unpublished).
Health systems in transition
Ukraine
Lekhan V, Volchek VV (2007). Comparative analysis of approaches to increasing the
structural efficiency of inpatient departments of a therapeutic profile in multi-profile
hospitals in major cities. Meditsinskie perspektivy, 12(3):104–109.
Lekhan V, Kryachkova LV, Maximenko OP (2007). Regulation of health care expenditure
– Guaranteed success of reforms aiming for health improvement. Health Protection in
Ukraine, 1:14–15.
Lekhan V, Rudiy V, Shishkin S (2007). The Ukrainian health financing system and options
for reform. Copenhagen, WHO Regional Office for Europe (Health Financing Policy
Paper 2007/1).
Lekhan V, Slabkii GA, Shevchenko MV (2009). Strategy for the development of the health
system: The Ukrainian dimension. Kyiv, Tsifra Print.
Libanova E et al. (2008). Almost half of all deaths at working age are preventable.
Demoskop Weekly, 327–328 (http://demoscope.ru/weekly/2008/0327/tema05.php,
accessed 14 April 2010).
Litvak A, Pogoreliy V, Tishuk M (2001). The shadow economy and the future of medicine
in Ukraine. Odesa, Odesa region devision of All-Ukrainian Medical Association with
support from Budapest Open Society Institute.
Main Auditing Agency (2006). Audit results on the use of budgetary resources for centralized
purchasing of pharmaceuticals and medical devices. Finansovyi kontrol’, 4.
Makarenkov A (2007). The warming investment climate in health care. “Apteka” Weekly,
2(573) (http://www.apteka.ua/article/4248, accessed 18 April 2010).
Medical Statistics Centre (2001–2008). Medical personnel and the network of medical
facilities in Ukraine. Kyiv, Ministry of Health.
Medical Statistics Centre (2006). Health of the population and health sector activities in
2001–2005. Kyiv, Ministry of Health.
Medical Statistics Centre (2007). Population health indicators and utilization of resources
in the health system in Ukraine. Kyiv, Ministry of Health.
Medical Statistics Centre (2008a). Malignant tumours in Ukraine 1998–2007. In: Statistical
Reference Book. Kyiv, Ministry of Health.
Medical Statistics Centre (2008b). Medical personnel and the network of facilities in the
health system under the Ministry of Health of Ukraine 2006–2007. Kyiv, Ministry
of Health.
Medical Statistics Centre (2008c). Population health indicators and utilization of resources
in the health system in Ukraine. Kyiv, Ministry of Health.
Medical Statistics Centre (2009). Population health indicators and utilization of resources
in the health system in Ukraine. Kyiv, Ministry of Health.
Ministry of Economy (2007). Shadow economic trends in Ukraine (1st quarter of 2007).
Kyiv, Ministry of Economy, Department of Economic Strategy, Division of Economic
Security and the Elimination of the Shadow Economy.
Ministry of Health (2001). The health of the population and results of the activities
of health care facilities: Annual report 2000. Kyiv, Ministry of Health.
Ministry of Health (2006). Annual report on public health and sanitary and epidemiological
situation in Ukraine. Kyiv, Ukrainian Institute of Public Health.
Ministry of Health (2007). Final report on the implementation of the Cabinet of Ministers
Decree No. 1566, issued 24 October 2002, on approving the Programme of National
Immunization in 2002–2006. Kyiv, Ministry of Health.
177
178
Health systems in transition
Ukraine
Ministry of Health (2008). Dental service reforms in Ukraine. Draft. Public discussion
on the official web site of the Ministry of Health, 9 June. Kyiv, Ministry of Health
(http://moz.gov.ua/ua/main/docs/?docID=10235, accessed 29 April 2010).
Ministry of Health and Ministry of Labour and Social Policy (2004). Handbook of required
qualifications for workers in the health system. Kyiv, Ministry of Health and Ministry
of Labour and Social Policy.
Ministry of Health and Ukrainian Institute for Strategic Research (2006). Implementation
experience of the intersectoral programme “Health of the Nation” for 2002–2011. Kyiv,
Ministry of Health.
Ministry of Health and Ukrainian Institute for Strategic Research (2007a). Annual report
on public health and sanitary and epidemiological situation in Ukraine: 2006. Kyiv,
Ministry of Health.
Ministry of Health and Ukrainian Institute for Strategic Research (2007b). Population health
indicators and the use of health care resources in Ukraine for 2005–2006. Kyiv, Ministry
of Health.
Ministry of Health and Ukrainian Institute for Strategic Research (2008). Annual report on
the results of activities in the health system in Ukraine, 2007. Kyiv, Ministry of Health.
Ministry of Health and Ukrainian Institute for Strategic Research (2009). Annual report on
the health of the population in Ukraine and the Sanitary-epidemiological situation: 2008.
Kyiv, Ministry of Health.
Ministry of Health and Ukrainian Institute for Strategic Research (2009). Annual report on
the results of activities in the health care system of Ukraine. Kyiv, Ministry of Health.
Ministry of Health of Ukraine and Ukrainian Institute of Public Health (2008). Annual report
on the health system in Ukraine, 2007. Kyiv, Ukrainian Institute for Strategic Research.
Mossialos E, Dixon A (2002). Funding health care in Europe: Weighing up the options. In:
Mossialos E et al., eds, Funding Health Care: Options for Europe. Buckingham, Open
University Press:272–300.
Mossialos E, Allin S, Figueras J (2007). Health Systems in Transition: Template for analysis.
Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory
on Health Systems and Policies.
Nadutaya GM (2004). Role of public organizations in municipal health care reform. Extended
field seminar of the Ministry of Health of Ukraine: Experience of health care reform on
municipal level, city of Komsomolsk, Poltava oblast. Kyiv, Poltava, Komsomolsk,
26–27 May 2004.
Nadutaya GM, Nadutiy KA, Zhalilo LI (2003). Comparative study of the cost-efficiency
of two primary care organization models based on family medicine principles.
All-Ukrainian Scientific and Applied Conference: Increasing the efficiency of public
health care administration on the regional level and on the level of local self-government
based on civil society principles. Komsomolsk, Poltava, 6–7 November 2003.
Pinchuk I (2007). Protection of mental health – One of the main directions in the modern
development of international community. Vestnik Assotsiatsii Psikhiatrov Ukrainy,
1:57–72.
Polyakova Dy (2006). TRIPS contract and the protection of registration data. “Apteka”
Weekly, 47(568) (http://www.apteka.ua/article/34615, accessed 14 April 2010).
Popov AP et al. (2003). Municipal sickness funds as a tool of power in the health system.
Chief Doctor, 7:42–44.
Health systems in transition
Ukraine
Rudiy VM (2005). Legislative support for health system reforms in Ukraine. Kyiv, Sfera.
Sheiman I, Shishkin S (2009). Health system assessment in Ukraine and recommendations
for actions in the frame of the financial crisis and the Tallinn Charter for Health and
Wealth. Report prepared in the framework of the project of the WHO Regional Office
for Europe. Copenhagen, WHO Regional Office for Europe (unpublished).
Stará D (2008). Review of the medicines regulatory system with focus on HIV/AIDS and
TB medicines and related commodities in Ukraine. Kyiv, WHO Regional Office for
Europe, Delegation of EU Commission in Ukraine, and USAID.
State Statistics Committee of Ukraine (2001–2007). Health care in Ukraine. Kyiv, State
Statistics Committee of Ukraine.
State Statistics Committee of Ukraine (2007). Household expenditure and resources:
Self-reported population health and accessibility of different kinds of health care.
Kyiv, State Statistics Committee of Ukraine.
State Statistics Committee of Ukraine (2010a). National Health Accounts, Ukraine 2008.
Statistical Bulletin series. Kyiv, State Statistics Committee of Ukraine.
State Statistics Committee of Ukraine (2010b) [web site]. Kyiv, State Statistics Committee
of Ukraine (http://www.ukrstat.gov.ua/, accessed 23 December 2010).
Strannikov V (2008). Psychiatrists on strike in Donetsk. Ezhenedel’nik 2000 (Kyiv),
41(433) (http://2000.net.ua/2000/derzhava/ekspertiza/43943, accessed 14 April 2010).
Sur S (2006). Ukraine: Misdeveloping country? “Apteka” Weekly, 42(536)
(http://www.apteka.ua/article/3841, accessed 14 April 2010).
Transparency International (2009). Global corruption report 2009: Corruption and the
private sector. Cambridge, Cambridge University Press.
Transparency International (2010). Corruption Perception Index 2009. Berlin, Transparency
International (http://www.transparency.org/policy_research/surveys_indices/cpi/2009/
cpi_2009_table, accessed 26 February 2010).
United Nations (2008). Map No. 3773, Revision 5. New York, NY, United Nations
(http://www.un.org/Depts/Cartographic/map/profile/ukraine.pdf, accessed 9 March 2011).
Verkhovna Rada of Ukraine (1996). Constitution of Ukraine. Kyiv, Verkhovna Rada of
Ukraine (http://www.rada.gov.ua/const/conengl.htm, accessed 10 March 2010).
World Bank (2007). Ukraine: poverty update. Washington, DC, World Bank.
World Bank (2008). Ukraine – improving intergovernmental fiscal relations and public
health and education expenditure policy: selected issues. Washington, DC, Poverty
Reduction and Economic Management Unit (ECSPE) Europe and Central Asia Region,
World Bank.
World Bank (2009). World Development Indicators [online database]. Washington, DC,
World Bank (http://go.worldbank.org/IW6ZUUHUZ0, accessed 15 February 2010).
WHO (2009). Ukraine. National health accounts. Geneva, World Health Organization
(http://www.who.int/nha/country/ukr.pdf, accessed 4 March, 2010).
WHO (2010). Ukraine. National health accounts. Geneva, World Health Organization
(http://www.who.int/nha/country/ukr.pdf, accessed 30 April 2010).
WHO Regional Office for Europe (2010a). European Health for All database
(HFA-DB) [offline database]. Copenhagen, WHO Regional Office for Europe
(http://www.euro.who.int/hfadb, accessed 8 March 2011).
179
180
Health systems in transition
Ukraine
WHO Regional Office for Europe (2010b). Tobacco control database [online database].
Copenhagen, WHO Regional Office for Europe (http://data.euro.who.int/tobacco,
accessed 8 April 2010).
Yaskal LM (2000). The development of care for children with special needs in Ukraine.
Research Notes: Sociological Studies, 18:56–61.
Yavorskiy M (2007). The future of railway health care lies in the continuous improvement
of voluntary health insurance. Lviv Railway Worker, 2.
10.2 HiT methodology and production process
The HiT profiles are produced by country experts in collaboration with the
Observatory’s research directors and staff. The profiles are based on a template
that, revised periodically, provides detailed guidelines and specific questions,
definitions, suggestions for data sources and examples needed to compile HiTs.
While the template offers a comprehensive set of questions, it is intended to be
used in a flexible way to allow authors and editors to adapt it to their particular
national context. The most recent template is available online at: http://www.
euro.who.int/en/home/projects/observatory/publications/health-system-profileshits/hit-template-2010.
Authors draw on multiple data sources for the compilation of HiT profiles,
ranging from national statistics, national and regional policy documents
to published literature. Furthermore, international data sources may be
incorporated, such as those of the OECD and the World Bank. The OECD
Health Data contain over 1200 indicators for the 33 OECD countries. Data are
drawn from information collected by national statistical bureaux and health
ministries. The World Bank provides World Development Indicators, which
also rely on official sources.
In addition to the information and data provided by the country experts,
the Observatory supplies quantitative data in the form of a set of standard
comparative figures for each country, drawing on the European Health for All
database. The Health for All database contains more than 600 indicators defined
by the WHO Regional Office for Europe for the purpose of monitoring Health
in All Policies in Europe. It is updated for distribution twice a year from various
sources, relying largely upon official figures provided by governments, as well
as health statistics collected by the technical units of the WHO Regional Office
for Europe. The standard Health for All data have been officially approved
by national governments. With its summer 2007 edition, the Health for All
database started to take account of the enlarged EU of 27 Member States.
Health systems in transition
Ukraine
HiT authors are encouraged to discuss the data in the text in detail,
including the standard figures prepared by the Observatory staff, especially
if there are concerns about discrepancies between the data available from
different sources.
A typical HiT profile consists of 10 chapters.
1 Introduction: outlines the broader context of the health system, including
geography and sociodemography, economic and political context, and
population health.
2 Organizational structure: provides an overview of how the health system
in the country is organized and outlines the main actors and their decisionmaking powers; discusses the historical background for the system; and
describes the level of patient empowerment in the areas of information,
rights, choice, complaints procedures, safety and involvement.
3 Financing: provides information on the level of expenditure, who is
covered, what benefits are covered, the sources of health care finance,
how resources are pooled and allocated, the main areas of expenditure,
and how providers are paid.
4 Regulation and planning: addresses the process of policy development,
establishing goals and priorities; deals with questions about relationships
between institutional actors, with specific emphasis on their role in
regulation and what aspects are subject to regulation; and describes the
process of health technology assessment, and research and development.
5 Physical and human resources: deals with the planning and distribution of
infrastructure and capital stock; the context in which IT systems operate;
and human resource input into the health system, including information
on registration, training, trends and career paths.
6 Provision of services: concentrates on patient flows, organization and
delivery of services, addressing public health, primary and secondary
health care, emergency and day care, rehabilitation, pharmaceutical care,
long-term care, services for informal carers, palliative care, mental health
care, dental care, complementary and alternative medicine, and health
care for specific populations.
7 Principal health care reforms: reviews reforms, policies and organizational
changes that have had a substantial impact on health care.
181
182
Health systems in transition
Ukraine
8 Assessment of the health system: provides an assessment based on
the stated objectives of the health system, the distribution of costs and
benefits across the population, efficiency of resource allocation, technical
efficiency in health care production, quality of care, and contribution of
health care to health improvement.
9 Conclusions: highlights the lessons learned from health system changes;
summarizes remaining challenges and future prospects.
10 Appendices: includes references, useful web sites and legislation.
The quality of HiTs is of real importance since they inform policy-making
and meta-analysis. HiTs are the subject of wide consultation throughout the
writing and editing process, which involves multiple iterations. They are then
subject to the following:
•
A rigorous review process (see the following section).
•
There are further efforts to ensure quality while the profile is finalized
that focus on copy-editing and proofreading.
•
HiTs are disseminated (hard copies, electronic publication, translations
and launches). The editor supports the authors throughout the production
process and in close consultation with the authors ensures that all stages
of the process are taken forward as effectively as possible.
One of the authors is also a member of the Observatory staff team and they
are responsible for supporting the other authors throughout the writing and
production process. They consult closely to ensure that all stages of the process
are as effective as possible and that the HiTs meet the series standard and can
support both national decision-making and comparisons across countries.
10.3 The review process
This consists of three stages. Initially the text of the HiT is checked, reviewed
and approved by the series editors of the European Observatory. The HiT is
then sent for review to two independent academic experts and their comments
and amendments are incorporated into the text, and modifications are made
accordingly. The text is then submitted to the relevant ministry of health, or
appropriate authority, and policy-makers within those bodies are restricted to
checking for factual errors within the HiT.
Health systems in transition
Ukraine
10.4 About the authors
Valery Lekhan is Chief of the Department of Social Medicine and Health Care
Management of Dnipropetrovsk State Medical Academy, Ukraine. She is also
a Professor, PhD/MD and the author of more than 400 scientific works. She
specializes in health care management and health care effectiveness analyses,
and collaborates with WHO and the World Bank on questions of Ukrainian
health care system assessment and its further development. She is the expert of
the “Health Care Reform” directorate of the Committee on Economic Reforms
under the President of Ukraine.
Volodymyr Rudiy is Head of the Secretariat of the Committee on Health
of the Verkhovna Rada (Parliament) of Ukraine. He is also a MD, Lawyer,
PhD in Public Administration (specialty in Health Care Administration). He
is the author and co-author of more than 60 scientific publications on health
legislation, health care management and health system analysis. He has strong
practical experience in developing national laws to regulate the health sector
in Ukraine, and many years of experience as the lead policy and legal expert
with a variety of health care reform projects in Ukraine, supported by WHO,
the EU, World Bank, USAID and others.
Erica Richardson is a Research Fellow at the European Observatory on Health
Systems and Policies, specializing in health system monitoring for countries
of the CIS. She is an Honorary Research Fellow at both the London School of
Hygiene & Tropical Medicine and the Centre for Russian and East European
Studies at the University of Birmingham, United Kingdom.
183
The Health Systems in Transition profiles
A series of the European Observatory on Health Systems
and Policies
T
he Health Systems in Transition (HiT) country profiles provide an
analytical description of each health care system and of reform initiatives in
progress or under development. They aim to provide relevant comparative
information to support policy-makers and analysts in the development of health
systems and reforms in the countries of the WHO European Region and beyond.
The HiT profiles are building blocks that can be used:
•
to learn in detail about different approaches to the financing, organization
and delivery of health services;
•
to describe accurately the process, content and implementation of health
reform programmes;
•
to highlight common challenges and areas that require more in-depth
analysis; and
•
to provide a tool for the dissemination of information on health systems
and the exchange of experiences of reform strategies between policymakers and analysts in countries of the WHO European Region.
How to obtain a HiT
All HiT country profiles are available as PDF files at www.healthobservatory.eu,
where you can also join our listserve for monthly updates of the activities of
the European Observatory on Health Systems and Policies, including new HiTs,
books in our co-published series with Open University Press, Policy briefs,
Policy summaries, the EuroObserver newsletter
and the Eurohealth journal.
If you would like to order a paper copy
of a HiT, please write to:
info@obs.euro.who.int
The
publications of the
European Observatory on
Health Systems and Policies
are available at
www.healthobservatory.eu
HiT country profiles published to date:
Albania (1999, 2002ag)
Poland (1999, 2005k)
Andorra (2004)
Portugal (1999, 2004, 2007)
Armenia
(2001g,
2006)
Republic of Korea (2009)
Republic of Moldova (2002g, 2008g)
Australia (2002, 2006)
Austria
(2001e,
2006e)
Romania (2000f, 2008)
Azerbaijan (2004g, 2010g)
Belarus
(2008g)
Russian Federation (2003g)
Slovakia (2000, 2004)
Belgium (2000, 2007, 2010)
Bosnia and Herzegovina
(2002g)
Slovenia (2002, 2009)
Spain (2000h, 2006, 2010)
Bulgaria (1999, 2003b, 2007g)
Sweden (2001, 2005)
Canada (2005)
Switzerland (2000)
Croatia (1999, 2007)
Tajikistan (2000, 2010gl)
Cyprus (2004)
Czech Republic (2000, 2005g, 2009)
The former Yugoslav Republic of
Macedonia (2000, 2006)
Denmark (2001, 2007g)
Turkey (2002gi)
Estonia (2000, 2004gj, 2008)
Turkmenistan (2000)
Finland (2002, 2008)
Ukraine (2004g, 2010)
France (2004cg, 2010)
United Kingdom of Great Britain and
Northern Ireland (1999g)
Georgia
(2002dg,
2009)
Germany (2000e, 2004eg)
Uzbekistan (2001g, 2007g)
Greece (2010)
Hungary (1999, 2004)
Iceland (2003)
Key
Ireland (2009)
All HiTs are available in English.
When noted, they are also available in other languages:
Israel (2003, 2009)
a
Italy (2001, 2009)
Albanian
b
Japan (2009)
Bulgarian
c
Kazakhstan (1999g, 2007g)
French
d
Kyrgyzstan (2000g, 2005g)
Georgian
e
German
Latvia (2001, 2008)
f
Romanian
Lithuania (2000)
g
Russian
Luxembourg (1999)
h
Spanish
Malta (1999)
i
Turkish
Mongolia (2007)
j
Estonian
Netherlands (2004g, 2010)
k
Polish
New Zealand (2001)
l
Tajik
Norway (2000, 2006)
View publication stats
ISSN 1817-6127
HiTs are in-depth profiles of health systems and policies, produced using a standardized approach that allows comparison across countries. They provide facts, figures and analysis and
highlight reform initiatives in progress.
The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands,
Norway, Slovenia, Spain, Sweden and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health
Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.