Ru­ral Ukraine wary about pro­posed med­i­cal re­forms


BOHUSLAV, Ukraine — It takes just two hours to drive south of Kyiv to Bohuslav, a re­laxed city of 16,000 peo­ple strad­dling the Ros River. But, in terms of health­care, one might as well be trav­el­ing sev­eral decades back in time.

At the city’s cen­tral district hos­pi­tal, chief of surgery Ser­hiy Un­gurian com­mu­ni­cates with other doc­tors and nurses us­ing two of­fice ro­tary phones, one red and one white. He does surgery on sturdy, but worn op­er­at­ing ta­bles. Nurse’s aides ster­il­ize his in­stru­ments by hand. Lit­tle of the equip­ment his depart­ment uses is mod­ern.

“Ru­ral medicine is trapped in the USSR,” Un­gurian says. “That sys­tem no longer func­tions, but re­gional hos­pi­tals in places like this have not reached a new sys­tem.”

That would seem­ingly make him a nat­u­ral sup­porter of Ukraine’s cur­rent med­i­cal re­form, spear­headed by act­ing Health Min­is­ter Ulana Suprun.

But Un­gurian — who is also a mem­ber of Bohuslav’s town coun­cil from the Samopomich party — is afraid the re­form will leave his pa­tients and neigh­bors with­out ac­cess to med­i­cal care. And he’s far from unique.

Vir­tu­ally ev­ery­one in Ukraine agrees that the coun­try’s med­i­cal sys­tem needs help. But as the Health Min­istry takes rad­i­cal steps to save Ukrainian medicine, its big­gest crit­ics fre­quently al­lege that small towns stand to lose what lit­tle health­care they have.

Hon­est con­cerns about med­i­cal re­form mix with pop­ulist pol­i­tick­ing. And of­ten ru­ral doc­tors and their pa­tients find them­selves caught in the in­for­ma­tion cross­fire.

Post-Soviet de­cay

With the col­lapse of the Soviet Union, Ukraine in­her­ited a highly cen­tral­ized Soviet-style state health­care sys­tem. Lit­tle has been re­formed since 1991.

Like its com­mu­nist pre­de­ces­sor, Ukrainian health­care “still pri­or­i­tizes cu­ra­tive ser­vices over preven­tion, hos­pi­tals over am­bu­la­tory ser­vices, and spe­cial­ists over pri­mary care,” po­lit­i­cal sci­en­tist Judyth Twigg wrote in a 2017 ar­ti­cle for the Cen­ter for Strate­gic and In­ter­na­tional Stud­ies.

The Ukrainian con­sti­tu­tion guar­an­tees ci­ti­zens free med­i­cal care. In prac­tice, how­ever, they are of­ten forced to pro­vide un­der-the-ta­ble mon­e­tary “gifts” to doc­tors in or­der to re­ceive care.

The is­sue is not sim­ply un­scrupu­lous physi­cians. Doc­tors and nurses re­ceive abysmally low salaries and state fund­ing for med­i­cal in­sti­tu­tions is poor at best. Of­ten, cor­rup­tion keeps crit­i­cal fa­cil­i­ties run­ning.

The sit­u­a­tion is worse in many small towns and vil­lages, which lack fi­nan­cial re­sources, spe­cial­ized medicine, med­i­cal de­vices, and some­times even doc­tors. Of­ten, pa­tients must travel to Ukraine’s re­gional cap­i­tals to re­ceive any­thing beyond ba­sic care.

Ukraine’s med­i­cal re­form aims to change that. In April 2018, the Health Min­istry launched a pro­gram al­low­ing ci­ti­zens to se­lect their pri­mary care physi­cians and reg­is­ter their doctor-pa­tient re­la­tion­ship in the coun­try’s new eHealth data­base.

Un­der this new sys­tem, doc­tors will re­ceive a set pay­ment for each pa­tient, ir­re­spec­tive of whether that pa­tient re­quires med­i­cal care. By mak­ing the money fol­low the pa­tient, the Amer­i­can-born Suprun hopes to in­cen­tivize good care.

In July, Ukraine’s newly formed Na­tional Health Ser­vice be­gan fund­ing pri­mary care in­sti­tu­tions that had joined the new sys­tem. Most of the rest will join by the end of next year. And, in the next two years, the Health Min­istry will ex­tend the

re­form to spe­cial­ized medicine.

Although the changes have not yet reached his hos­pi­tal, Un­gurian is worried. Part of the re­form re­quires cre­at­ing hos­pi­tal dis­tricts aimed at en­sur­ing the even distri­bu­tion of med­i­cal ser­vices across the coun­try. Bohuslav falls in the district cen­tered on the city of Bila Tserkva.

Un­der the cur­rent plan, there will only be two hos­pi­tals like Un­gurian’s in the district, and the neigh­bor­ing city of My­ronivka was cho­sen over Bohuslav to host one of them — de­spite car­ry­ing out fewer op­er­a­tions an­nu­ally, he says.

For Un­gurian, who ini­tially ran for elec­tion to the town coun­cil in 2010 to pro­tect his hos­pi­tal from re­or­ga­ni­za­tion, this is un­ac­cept­able.

“I don’t think it’s right to leave peo­ple (here) with­out emer­gency sur­gi­cal and trau­ma­to­log­i­cal care,” he says.

He isn’t the only doctor with con­cerns. Ivan Pa­sich­nyk, a young sur­geon work­ing in Novo­volynsk on Ukraine’s bor­der with Poland, has seen the dearth of med­i­cal care in vil­lages.

The sit­u­a­tion is bet­ter in Novo­volynsk, a pro­vin­cial city with over 52,000 peo­ple, but not enor­mously, Pa­sich­nyk says. Peo­ple are pay­ing for medicines out of pocket, state fi­nanc­ing is lim­ited, and the hos­pi­tal lacks im­por­tant equip­ment like a CT scan­ner. Doc­tors’ salaries are small, forc­ing them to think more about money than pro­vid­ing good care. Many seek work abroad.

So far, med­i­cal re­form has not reached Pa­sich­nyk’s spe­cial­iza­tion. But where it has launched, ques­tions re­main.

“In my par­ents’ vil­lage, ev­ery­body signed agree­ments (with their pri­mary care doc­tors, as re­quired within the re­form), but peo­ple don’t know what will hap­pen,” he says. “Peo­ple in the vil­lage aren’t in­formed.”

Even re­form sup­port­ers see prac­ti­cal chal­lenges. Iryna, a fam­ily doctor who asked not to be iden­ti­fied out of fear it could neg­a­tively af­fect her em­ploy­ment, be­lieves medicine “sim­ply can­not ex­ist” in its pre-re­form state.

But im­ple­ment­ing the re­form has been a chal­lenge for her clinic in a small city in Ch­er­nivtsi Oblast, where many of her col­leagues are of pen­sion-age. The lo­cal author­i­ties gave the clinic only one com­puter for 14 doc­tors to reg­is­ter doctor-pa­tient con­tracts and bring med­i­cal records into the 21st cen­tury.

“They car­ried out some train­ing on how to use (the com­puter sys­tem), but it was rather su­per­fi­cial,” Iryna says.

In­for­ma­tion war

Beyond prac­ti­cal chal­lenges, the Health Min­istry ap­pears to have a com­mu­ni­ca­tion prob­lem, sev­eral doc­tors told the Kyiv Post. Both pa­tients and doc­tors are con­fused about the re­form, and some pa­tients fear putting their per­sonal data in the new eHealth sys­tem.

When the Kyiv Post car­ried out a small “Vox Pop­uli” sur­vey in Kyiv’s Taras Shevchenko Park in May, it found peo­ple es­pous­ing nu­mer­ous in­cor­rect be­liefs about med­i­cal re­form.

But Health Min­is­ter Suprun be­lieves the prob­lem is big­ger than con­fu­sion. Her min­istry ac­tively pub­lishes in­for­ma­tion ex­plain­ing med­i­cal re­form. It also trav­els to the re­gions to meet physi­cians and holds video con­fer­ences with re­gional health de­part­ments. But lit­tle of that in­for­ma­tion reaches the pub­lic.

“The ex­pected chan­nels of in­for­ma­tion don’t work,” Suprun told the Kyiv Post. “The peo­ple who should be most in­ter­ested in what’s hap­pen­ing don’t seek info.”

In­stead, the pub­lic turns to provoca­tive pun­dits and bi­ased re­port­ing on Ukraine’s oli­garch-con­trolled tele­vi­sion chan­nels.

“Doubt is be­ing sown by those who don’t want to see med­i­cal re­form hap­pen,” Suprun says.

It’s a difficult charge to ar­gue with. Op­po­nents of the Health Min­istry’s plans have of­ten given into ex­treme hy­per­bole in their crit­i­cism of the re­form.

One prom­i­nent critic, Olga Bo­go­mo­lets, chair of the Verkhovna Rada’s health­care com­mit­tee, has called the re­form a “geno­cide” of Ukraini­ans and said the “par­lia­ment was raped” in pass­ing the le­gal foun­da­tion for the re­form.

Be­hind this rhetoric are some more con­crete cri­tiques of re­form. Bo­go­mo­lets be­lieves the new sys­tem is ori­ented to wealthy Ukraini­ans and will force pa­tients to pay for life­sav­ing medicine.

In con­trast, the Health Min­istry says the state will pay for a packet of pri­mary care, pre­ven­ta­tive, emer­gency, and pal­lia­tive ser­vices ac­count­ing for 80 per­cent of all doctor and hos­pi­tal vis­its.

Bo­go­mo­lets of­fers a dif­fer­ent vi­sion of re­form.

“I’m for the preser­va­tion of hu­man life and ac­ces­si­ble medicine for ci­ti­zens of Ukraine on the ba­sis of oblig­a­tory state med­i­cal in­sur­ance,” she told the Kyiv Post in a state­ment in April.

Bo­go­mo­lets also ar­gues that the first stage of med­i­cal re­form will leave four mil­lion Ukraini­ans, many of them ru­ral res­i­dents, with­out med­i­cal care be­cause there are sim­ply not enough fam­ily doc­tors to ser­vice these ar­eas. And with­out a re­fer­ral from a fam­ily doctor, these peo­ple will be un­able to ac­cess more spe­cial­ized care un­der the new sys­tem.

Claims that med­i­cal re­form will harm ru­ral res­i­dents are com­mon among the re­form’s op­po­nents, and they have pa­tients and some doc­tors worried. But Suprun says they are sim­ply not true.

She ar­gues that the new sys­tem makes work­ing as a ru­ral fam­ily doctor ex­tremely lu­cra­tive be­cause the money doc­tors re­ceive per pa­tient goes much farther in Ukraine’s small towns and vil­lages.

More­over, the sys­tem of hos­pi­tal dis­tricts is aimed at bring­ing spe­cial­ized care closer to ru­ral pa­tients.

Un­der the new sys­tem, each hos­pi­tal district of 250,000 peo­ple will have at least one hos­pi­tal that pro­vides the high­est level of sur­gi­cal care 24 hours a day. Ad­di­tion­ally, all pa­tients should be able to reach the hos­pi­tal within one hour. There must also be at least one planned surgery hos­pi­tal, which of­fers less spe­cial­ized care, and a va­ri­ety of other med­i­cal in­sti­tu­tions.

Beyond the ba­sic re­quire­ments, the re­gions them­selves de­cide how to di­vide up ser­vices among other med­i­cal in­sti­tu­tions. And the wide­spread idea that hos­pi­tals will be closed down and doc­tors fired en masse is not true, ac­cord­ing to Suprun.

“If there’s a need for doc­tors, then ob­vi­ously no one’s go­ing to get fired,” she says. “They will have jobs in other hos­pi­tals.”

Po­lit­i­cal show­down

De­spite push­back against med­i­cal re­form, Suprun is op­ti­mistic about its progress.

Ac­cord­ing to her min­istry, over 17.5 mil­lion Ukraini­ans — ap­proach­ing 40 per­cent of the coun­try — have signed agree­ments with their pri­mary care doc­tors. By the end of the year, the min­istry be­lieves 60 per­cent of the pop­u­la­tion will have signed up. Fur­ther­more, over 50 per­cent of pri­mary care clin­ics have signed agree­ments with the Na­tional Health Ser­vice.

But there are chal­lenges ahead. In 2019, Ukraine will hold both pres­i­den­tial and par­lia­men­tary elec­tions, which cast an omi­nous shadow over many re­form projects.

More­over, med­i­cal re­form has op­po­nents among the pres­i­den­tial can­di­dates. In late Au­gust, for­mer Prime Min­is­ter Yu­lia Ty­moshenko — the cur­rent fron­trun­ner — harshly crit­i­cized Suprun dur­ing a speech in Myko­laiv.

She al­leged that med­i­cal re­form would force pa­tients to pay for all care, promised to re­in­state the old sys­tem in ru­ral ar­eas, and spoke in fa­vor of in­sur­ance-based medicine.

“I just pray ev­ery day that they don’t have time to im­ple­ment this re­form be­fore the pres­i­den­tial elec­tion,” she said, ac­cord­ing to the Novosti-N site.

Suprun says that the Health Min­istry is tak­ing steps to pro­tect its work. It is re­form­ing the min­istry’s struc­ture to in­clude more civil ser­vants cho­sen through a se­lec­tion process and fewer ap­pointees. That way, if a new gov­ern­ment selects a new min­is­ter, the broader staff will re­main con­stant.

“You can’t bring a new min­is­ter in and then nix ev­ery­thing and start from scratch,” Suprun says. “That is why very few re­forms have stuck.”

But as cam­paign sea­son kicks off, Un­gurian in Bohuslav ex­pects med­i­cal re­form won’t reach his hos­pi­tal any­time soon. Un­til the elec­tions are over, he be­lieves no one will want to fur­ther im­ple­ment the re­form, which ap­pears to many peo­ple as an ef­fort to cut down on hos­pi­tals and doc­tors.

“This re­ally wor­ries peo­ple,” Un­gurian says. “The com­mu­nity doesn’t ac­cept this re­form.”

Act­ing Health Min­is­ter of Ukraine Ulana Suprun speaks with the Kyiv Post at her of­fice on Aug. 30. Suprun has spear­headed Ukraine's med­i­cal re­form drive, de­spite crit­i­cism from the re­form's po­lit­i­cal op­po­nents. (Oleg Pe­tra­siuk)

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