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.
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.
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.”
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)