Oleksandr Linchevskiy: “The best-off Ukrainians are demonstrating against the Health Ministry”
Deputy Minister of Health on the reform of the medical system
Deputy Minister of Health Oleksandr Linchevskiy talked to The Ukrainian Week about the reform of Ukraine’s medical system.
One of the main accusations being made by your opponents is that the state is not allocating enough money for healthcare while people are getting poorer, meaning that healthcare spending needs to grow and reforms should come later.
The Verkhovna Rada establishes the percent of GDP that is allocated for healthcare. How cynical can people be, to complain that little is being spent on medicine, and then to vote for 2-3%? There is never enough money for healthcare. Not in any country. However good medical treatment is, it can always be better, even when healthcare is fully taken care of: the doctors are smart, the equipment is available, the treatment facility gleams... you still want to sow some pretty flowers so that patients will have a nice view from their windows. There is no limit to improvement. As soon as everything is fine at the hospital, some new technology appears that also needs to be bought. This is a constant process. No system of medical education has ever said, “That’s it! Enough’s enough. Let’s stop here because everything’s perfect.” In fact, all this nonsense about allocating and not allocating comes down to one thing: the state isn’t allocating anything right now.
Your opponents also claim that, after reforms, 80% of healthcare will remain without funds.
Right now, it’s 100%. Try to take even one step in a hospital today for free. The only thing the hospital won’t take money from you for is heating and electricity. That’s it. The money that is available now is being used by our opponents. After reform, that money will go to serve ordinary Ukrainians. There’s only one reason for all these contrary statements. How to fool people, to manipulate them, to cry on camera is all just a matter of technique. Only functionaries and crooks don’t want to see the system changed. Period.
How do these crooks get their hands on the money?
There are a lot of ways. Right now, UAH 50 billion is available for medicine and this money has to be split among 25 oblasts. These subventions that go to the oblast are then allocated to the counties, which further distribute them among medical facilities. The question is, which facility and how much? For example, depending on personal relations. What do we propose? Say that one hospital has 10 patients and the one next door has 20. We will set up a National Healthcare Service that will directly transfer funds to the hospital. Oblast and county officials, and bad hospitals, don’t like this idea.
What will stop the National Healthcare Service from also engaging in corruption?
The center will have a computer that registers everything. A patient comes in a hospital and money is transferred. That’s all. The available funds can be distributed fairly but on the basis that those who work get paid. Those who don’t really work have already started to protest. When did you ever see the directors of clinics, head physicians and academics standing outside the Ministry’s offices? When did VR deputies ever lead rallies? Today, the wealthiest people are demonstrating against the Ministry of Health. Where were they before? Where were they when Raisa Bohatyriova was minister or when Viktor Yanukovych was president? That system suited them just fine.
Let’s look at the details. Right now, wherever a patient goes, they have to pay for everything. They have no control over things and they don’t know anything. So you come to the hospital and the staff say, “Oh, we don’t have anything.” But they charge everyone, in one way or another. We see situations
WE WILL SET UP A NATIONAL HEALTHCARE SERVICE THAT WILL DIRECTLY TRANSFER FUNDS TO THE HOSPITAL. OBLAST AND COUNTY OFFICIALS, AND BAD HOSPITALS, DON'T LIKE THIS IDEA
today where even people coming in in a state of emergency are told to pick up this and that because the hospital doesn’t have it and the government isn’t handing anything out. That’s simply not true. The state is giving money out, but the patient has been brought to one place while the state gave it somewhere else altogether. But nobody knows that. Formally, the UAH 50bn has been allocated, but in fact nothing gets to the hospitals themselves. We have no medications, no blankets, all the elementary things that should be in a hospital, while in the meantime something extraordinary shows up elsewhere. The most powerful tomographic apparatus in the country, for instance, stood in Kalush (a town in Western Ukraine – Ed.) for a long time. Why was it there? What was such a powerful machine, intended for heart surgery, doing in Kalush? Because someone in Kalush got their hands on the money and spent it that way.
Ordinary Ukrainians don't always understand this. For instance, I heard a lot of grumbling that a recently renovated village maternity ward was being
shut down. To these people, the reformers make no sense.
If the maternity ward sees less than 400 births a year, it is bad for both the mother and the child. If there isn’t at least one birth a day, the medical staff begins to lose its skills. This is the kind of maternity ward where more problems arise, more children end up damaged, and more newborns and mothers die. The WHO recommends shutting down such maternity wards because they are harmful.
Getting back to reform, what's its main component?
We propose covering for the most vital services with 100% funding, because everything depends on them: emergency treatment, primary care, and palliative care. This is the guaranteed basic package. There was nothing like this before and today, the state guarantees patients nothing. The ambulance drives up to the patient’s home and says, we don’t have this medication. The patient has no control over anything and cannot demand anything from the state system. Any complaint gets the same answer: the share of GDP is too small.
What's this guaranteed basic package? Let's say I came to an outpatient clinic with a complaint about something. How can I find out what rights I have?
The guaranteed basic package is a list of specific services that must be provided. The clinic is basically guaranteed. Everything that’s in the clinic can be provided to the patient absolutely free. We transfer the funds to that clinic because this is the basic package of service guaranteed by the government. Primary care is guaranteed. You can’t show up at a clinic only to be told that there’s no doctor that day. The doctor is paid to be there, the budget is there, the cash is available, and so on. Nor can you show up at a clinic only to be told that they can’t do the necessary tests. The tests are all available. We have guaranteed and funded that. And we’re saying that the basic services—outpatient clinics, emergency treatment, palliative care—are covered 100%. Special therapy and urgent surgery are guaranteed 100%. We are telling people truthfully that the country has enough money for this much.
The guaranteed package can, of course, change, depending on the budget allocated. If we get more funding, the package will expand. Later on we may be able to cover routine treatment (treatment of chronic illnesses, non-urgent treatment – Ed.). Right now we can only cover that partly because we don’t have enough money. Our options are cofinancing based on private insurance plans, employer insurance benefits, local budgets, charitable funds, patients themselves. But the hospital will know that it will always get money for these listed services that is guaranteed and established by the Ministry of Health.
Can you give us some examples of routine or non-urgent treatment? For instance, if someone has been diagnosed with cancer, is that primary care?
This is included in primary care. In this, some medications are covered, some are not by the state funding. Right now we’re covering even fewer of those because money is being spent on everything but the patient: we’re buying things nobody needs, while the things that are really needed aren’t being bought. What’s important for us is that both the hospital and the patient know about the guaranteed basic package and that the state is providing it. There shouldn’t be a situation where the patient is referred to a specialist but the means of treatment are not provided. At the secondary level, you know exactly what’s state-funded, and what you have to pay for. Patients support the idea of co-pay. Right now, relations between the hospital and the patient are unclear. The state might be allocating something to the hospital but no one knows exactly how it’s being used. Elective items, such as cosmetic dental work, will not be covered at all. And this is what our opponents are fighting against. MPs are against co-paying. They don’t like it. They want primary care to be 100% covered and secondary care 0%. Because the concept of copaying is political poison. Everybody’s having fits because everything was supposedly free and now patients have to pay for something.
Does that mean that reforms have already been taken down?
Well, MPs have agreed to a guaranteed package and a different distribution of funds. OK, so at least we’ll have that. At least we’re guaranteeing something. The rest remains as it was at this stage. This is the maximum compromise for us.
As to state insurance, that’s just a lot of talk. We are talking about the British NHS model, where your and my tax money are distributed in this way. We already pay these taxes. But our opponents have their views, their own interests in the insurance business.
How interested is the insurance market in your copayment proposal? How possible is it to have normal insurance coverage now?
Frankly, it’s impossible. It’s like we’re in the Middle Ages. The patient will be conned by either one side or the other. For us at the Ministry what’s important is the guaranteed package, so that everyone can feel reassured. We’re telling people openly: this is available and that’s not, because there’s no money for it.
What will you be doing right now for secondary care? Theoretically, if you manage to break the Rada and MPs agree to medical reform with these changes, does that mean that secondary care will remain completely unchanged?
Let’s wait and see. The system for allocating funds is being changed to one where hospitals that treat 100 patients get funding for 100 patients and certain services are covered while others are not.
So, after reforms, will Ukrainians have a British model of healthcare or will it merely be a soviet one with frills?
That’s a pointless question because no one here knows exactly how the NHS works. No one is aware that it’s the best working system today. Based on all the problems and advantages of different systems, the British one is the best and it suits Ukraine. With our way of doing things and the way people coexist here, this is the best option. The American model wouldn’t work here, so no point in even going there. What’s important for us is a guaranteed basic package. As to co-paying, we wanted what was best, but we lost that one. The populists keep saying let’s go for what’s worst.
What we want is for the medical facility to be autonomous, to get its money and use it the way it needs for its patient. Not for departments and ministries to decide things: this much for utilities, this much for medicine, and this much for payroll. Because that means that payroll is covered 100%, utilities 90% and nothing goes for medication. The hospital should manage its money on its own. Right now there are such distortions that hospitals are funded “based on their needs.” But if the hospital “needs” UAH 18 million for utilities, do we really need that hospital? Is it actually serving patients? Should half of it be shut down? Or should it be expanded? Are there any other options? The main principle should be autonomy: the opportunity to manage funding independently.
How are we doing with experienced specialists and doctors who want to work under a different system?
Build a church and the people will come. Even at the current level of GDP, Ukraine could easily raise wages. If we optimize doctors’ salaries, they will feel motivated. If we optimize overheads, money will appear to buy medications. It’s a winwin for patients. The only losers are those who oppose medical reform.
But those people are in power. You'll never achieve anything without them. What kind of compromise is possible is this a clash of world views that can't be reconciled?
Would you like this kind of compromise, as a patient? For us, what’s important is not how MPs vote for a bill but how patients will vote for those MPs.
Patients always vote the same way.
That depends on the press, on how well you will be able to explain what’s happening.
What about the Ministry's educational initiatives?
Money has no meaning if the doctor is untrained, unmotivated and in the wrong place. He won’t be able to treat you properly because he won’t know what to do. This is a serious problem and it’s part of what needs to change. What can be done so that medicine is high quality? The would-be physician has to apply to university, spend six years studying, go through an internship, and find a job. What happens at the entrance stage? Who are our students? Will these people make good doctors and be able to operate on our children? Our position is that those with C’s and D’s should not be studying at university. It’s already clear that they are not studying properly.
Others are not motivated for the right reasons. If they don’t dream of being the best, they shouldn’t be in medical school. They studied any old way and went to university either to marry or because their parents are doctors. These aren’t the people who should be working in healthcare, yet from the very start, we let anyone who wants to go to university. Then they study on a paid basis, manage to somehow pass their exams, finish their internships, and pay every step of the way. Then they get a job and the hospital is stuck with a bad doctor.
One of our propositions was for applicants to have a minimum of 150 points on their external independent testing (ZNO, a school graduation test). Afterwards, six corrupted rectors approach two MPs: the chair of the VR Healthcare Committee and the chair of the VR Education and Science Committee. The Rada begins to exert unprecedented pressure on the Government, and the Government drops the proposal. The 150-point initiative has been around since March. Where are the voters? Where are the future patients? Where’s the press?
In 2015, we saw 40,000 heart attacks in Ukraine. Of that number, 20,000 needed stents immediately. At that time, 7,000 stents were procured for X million UAH. In 2017, we are buying 10,500 better-quality stents for half the money. Now, if we can buy another 10,500 with the money saved, we'll completely cover this need
Then we move to the open competition. This is a situation where places are left for applicants with high ZNO grades. They can gain admission to any post-secondary institution they choose. Obviously, the stronger, better institutions get the stronger applicants, additional spots and more funding. Weaker institutions lose out. Where will those rectors go? To their protectors in the legislature. We’ll see what happens this year with the open competition, because last year there wasn’t any in medicine. Right now, if you’re a poor university, you will get zero applicants.
We lost the first round in the battle for the 150-point requirement. The open competition is currently under attack. The third is the Krok [Step] exam. During the sixth year and the internship we have Krok-2 and Krok-3, which is the examination for licensing. Whoever fails it doesn’t get to be a doctor. These examinations are organized by the Independent Testing Center at the Ministry of Health, which was established along the lines of the National Board of Medical Examiners in the US and has been acknowledged by NBME. The testing procedure is the same as in the US.
This is the only barrier that saves patients from unqualified physicians. The universities don’t do this because they’re happy to teach the D students. Just watch how they start attacking that exam. This year, we added 30 questions from the American exam to Krok-3 and only 3% passed (see A major deficit on p. 24). Which means that only 3% are doctors in the American sense of the word. That’s the price for a medical education. The average mark across the country was 37% and only 3% reached the passing grade of over 70%. The Ukrainian questions for Krok exams are written by Ukrainian instructors. Then they are shuffled in a barrel and issued. As a result, the Ukrainian test is passed, but not the American one. Why is this important? In fact, our students get normal results in those things that they have studied: 95% passed Krok-2. Only this test, like all our medical education, does not reflect modern conditions. Our students aren’t being taught what they need to know and not that which is being taught all over the world.
How capable are these instructors of teaching something different?
Where might they get that from? It’s these same students who eventually begin to teach. It’s a closed circle. So now, imagine what will be happening with reforms if we say that this year the American sub-test is optional, whereas starting next year it will be mandatory? Imagine what will happen when a portion of international tests is added to Krok-2? I mean, there’s still the International Foundations of Medicine (IFOM), a test that was developed (by the NBME. Ed.) not for the US but for other countries. We have taken this IFOM as part of our own test and have made it mandatory. Who at the universities will be happy to see this happen? Who will teach paying students for six years, at the risk that they will complain later that they failed the exam? There will be enormous resistance.
Still, we have to start somewhere. We say that there are qualification requirements of a doctor, which is to pass the IFOM test. If you pass IFOM, you can call yourself a doctor.
But now, the university has to review its curriculum and its staff qualifications. Do the instructors know even a modicum of English? Are they publishing? Are they reading? If you want your university to survive, hire those who can teach properly. Find them and hire them. Teach less, but teach better. Give us doctors with a European education. Right now, our country is missing the boat. People are indifferent, the Rada is indifferent, the universities couldn’t care less, and the media is not keeping an eye on any of it. As a society, we allowed them to accept D students, so shame on us. After that, the entire system of funding universities suits everyone so it’s not convenient to expel them.
If Ukrainians as a society want to have highlyqualified doctors, then we should support Krok. We should defend the Center for Testing and this exam, and make it as demanding as it is in the West. Once we decide we want high-quality doctors, a lot of people are going to feel the pain, most of them C- and D-grade. So why do we feel sorry for them?
We have interns and they continue to learn. We give them an instrument such as Decree #1422, which allows them to treat following western procedures. We say, you weren’t taught this, but we’re giving you a chance. Look: this is how this particular disease is treated around the world. From now on, you can choose what you want: a German course of treatment, a French one, a British one, or an American one. Go and treat your patients. Before, this was not allowed, but now we’re giving people the opportunity. Surprisingly, it turns out that everyone’s against this, too.
One of the arguments opponents bring up is that the procedures need to be translated into Ukrainian. Has this been done?
The decree states that they are supposed to be translated into Ukrainian. But first of all, there are thousands of these procedures and obviously you can’t just sit down and translate all of them at the same time. Secondly, they are constantly being updated. They’re not set in stone so you can translate them once and that’s that. Medicine is always on the move. The decree also provides an addendum with sources that are constantly being updated and the international academic societies are constantly updating the procedures. This year, it’s like this. Later a new table or treatment method appears and everything changes. We actually allow doctors to take those procedures and translate them, so yes, they are all being translated, but not by the Ministry but by the hospitals that need them.
I can tell you that these procedures are at a way higher level than Ukrainian ones. We are meeting with resistance, regardless, from those who draw up procedures in Ukraine, from those who are doing dirty business, and from those who included their own or others’ medications and made their
use mandatory. Right now, the top 10 medications in Europe and the top 10 in Ukraine don’t have a single medication in common. This is the result of our education, our post-graduate education, and our procedures. Our clinical procedures and our medical education mean that Ukrainians are not treated with the same medications as other Europeans and then we wonder why the results are so bad.
What about the practice to hand over the purchase of medicine to international organizations? Dr. Suprun promised to sign a respective contract by March. Has last year's budget been spent and are we now spending 2017 allocations?
Not exactly. In 2015, we saw 40,000 heart attacks in Ukraine. Of that number, 20,000 needed stents immediately. At that time, 7,000 stents were procured for X million UAH. In 2017, we are buying 10,500 better-quality stents for half the money. Now, if we can buy another 10,500 with the money saved, we’ll completely cover this need. Every patient with a heart attack in Ukraine will receive the most up-to-date, hitech treatment absolutely free.
Are you talking about this year?
Yes. We will be talking about this separately and we invite people to join us because it’s important that patients, doctors, and all healthcare professionals know about this. The Ministry’s position is changing and we will be keeping track of this, but the public also needs to be on top of things. This is the price of international procurements. It represents the actual saving of someone’s life. Can you imagine the scale? We’re talking about something like UAH 150mn. Of course, not everyone’s happy about international procurements. Now they can come up with a new excuse: “It took them a month to put it in, so let’s drop it all.”
What's going on with palliative care?
We’d like palliative care to be part of the guaranteed package. People have the right to a dignified death. Ukraine was still lacking humane forms of reducing pain in the 21st century. Now, these have been registered. We’re organizing a mobile palliative care service in Decree #41, which lists all the palliative states. This means access to a chaplain, qualification requirements for physicians who work there, and changes in the rules for the circulation of narcotics to make it easier for pharmacies to issue them. Right now this is very complicated and not convenient for the pharmacies, so patients often have to go abroad and buy them. We’re also working with the Interior Ministry and the process is all in motion. Last year, some of this was provided through humanitarian aid, moreover for a great low price: about 40¢ a flacon. This medicine has already been registered and we have it in plasters and syrup.
The main value of reform and its philosophical significance is in raising the quality of life of the ordinary person. Our motto is that health is the most important thing. We have no respect for those who voted in favor of the tax on the export of scrap metal but ignored medical reform. This is completely unacceptable. We’re talking about real values and real people. Health and life are the most important. This reform is not about money and not even about education but about new relations within our society.
In the end, this is about two great quotes: “There’s no stopping an idea whose time has come” and “Freedom for nations, freedom for individuals.” In our case, the two echo each other. The human being is important to us. Not the nation, the state, the society, or the masses, but a specific patient. We must do all in our power to ensure that the individual is born healthy, lives healthy, and dies in dignity. The person is becoming a value in this country. Not achievements, not glory, not the flag, not television, not even Olympic gold matters as much as the individual. That’s why this is so important.
How much of an impact did anti-vaccine propaganda have and how accurate are the statistics that people use? What's the coverage of vaccines in Ukraine today?
Our coverage is the lowest in Europe and the press is entirely to blame for this. Ignorance, ignorance and more ignorance. Fairy tales about non-existent “black transplantologists” are killing normal transplantology. Spreading myths, yellow press, unconfirmed “facts.” One headline chases another and all about how bad vaccines are. I could talk for a long tie about the incident in Kramatorsk (where a 17-year old died after being vaccinated -- Ed.), but when journalists are sloppy with their terms and don’t understand the difference between a vaccine and a serum, a critical distinction, between an expired license and an expired vaccine, when they confuse “importing without a certificate of compliance” with “importing something unregistered and of poorquality,” we end up with headlines that the Ministry of Health once imported uncertified and outdated vaccines and a child died. In fact, that child didn’t die after being vaccinated and what was imported was a quality vaccine that was in compliance with all the rules and laws about humanitarian aid, and what was expired was not the vaccine but the certificate for it. Yet the journalists took up that headlines. The people read them and stop vaccinating their kids. That’s how we’ve managed to take a civilizational step backwards.
Has this process stopped at least?
We really want everyone to learn. We’re learning every day ourselves. The press needs to understand how important the choice of words is in this situation.
RIGHT NOW, WHEREVER A PATIENT GOES, THEY HAVE TO PAY FOR EVERYTHING. THEY HAVE NO CONTROL OVER THINGS AND THEY DON'T KNOW ANYTHING
Oleksandr Linchevskiy was born in Kyiv in 1975. He graduated from the Bohomolets National Medical University in Kyiv. Dr. Linchevskiy took a series of internships and professional courses in various European countries. He holds the Candidate of Sciences title. Dr. Linchevskiy worked as a surgeon at the polytrauma department of Kyiv Clinical Hospital No17. After the war in the East began, he headed the medical unit of Mykola Pyrohov First Volunteer Mobile Hospital. In 2016,
Dr. Linchevskiy was appointed Deputy Minister of Healthcare.