Health­care de­fense

What Ukrainian health­care should do in 2020

The Ukrainian Week - - CONTENTS - Dr. Ulana Suprun, Act­ing Min­is­ter of Health­care in Ukraine (2016–2019)

What Ukrainian health­care should do in 2020

Think of the front­line. Your en­emy is half a kilo­me­ter away. There may be a Rus­sian sniper wait­ing for two days to take his shot. The mil­i­tary in the war zone should there­fore al­ways be com­posed and alert. But the main thing for them is to be healthy. Now, think of an out­break of measles or diph­the­ria on the front­line. The sol­diers with com­pli­ca­tions ly­ing in trenches and wait­ing to be trans­ported to a hos­pi­tal and put on me­chan­i­cal ven­ti­la­tion.

Most peo­ple in Ukraine im­ply de­fense ca­pac­ity — bor­ders, army and fleet — when they speak about na­tional se­cu­rity. Hardly any­one looks at na­tional se­cu­rity from the health­care per­spec­tive. Yet, no coun­try can de­velop with­out healthy cit­i­zens who are able to work. The world of fi­nance mostly looks at health­care from the per­spec­tive of spend­ing, although fund­ing of this sec­tor should rather be viewed as an in­vest­ment in hu­man cap­i­tal.

When the num­ber of peo­ple un­able to work grows in a coun­try, its bur­den on the work­ing pop­u­la­tion in­creases while eco­nomic growth slows down. As la­bor po­ten­tial shrinks, it pushes

GDP down. Pro­tect­ing na­tional se­cu­rity is pro­tect­ing vi­tal in­ter­ests of both in­di­vid­ual cit­i­zens and the state for con­stant devel­op­ment of so­ci­ety. There­fore, de­fense of health­care is un­de­ni­ably a mat­ter of na­tional se­cu­rity. How­ever, this is not yet an ax­iom and needs to be proven con­stantly. Our team man­aged to get changes off the ground. Health­care be­came a pri­or­ity of Volodymyr Hro­is­man’s Cab­i­net and of the state agenda. Mil­lions of Ukraini­ans have al­ready ex­pe­ri­enced the first re­sults of the trans­for­ma­tion via pri­mary health­care. Next are changes in spe­cial­ized and highly spe­cial­ized med­i­cal fa­cil­i­ties to be launched in April 2020. The state will stop fund­ing hos­pi­tals for the mere fact of their ex­is­tence. In­stead, the money will fol­low spe­cific med­i­cal ser­vices pro­vided to pa­tients. Au­ton­o­miza­tion, con­tracts with the Na­tional Health­care Ser­vice of Ukraine and reg­is­tra­tion with the e-health­care sys­tem will be manda­tory con­di­tions for the work in the new sys­tem. New rules will help to bet­ter or­ga­nize the work of hos­pi­tals and in­crease wages for their staff while pa­tients will re­ceive a guar­an­teed pack­age of med­i­cal ser­vices which they do not have to pay for. The shift from the old sys­tem will not be easy. It will take a lot of ef­fort and po­lit­i­cal will. All op­po­nents of change will try to pres­sure the gov­ern­ment into de­lay­ing the trans­for­ma­tion “for a while”, ar­gu­ing that hos­pi­tals are not ready for it. We saw at­tempts to use th­ese ma­nip­u­la­tions while trans­form­ing pri­mary health­care, but they did not work. The next stage should be launched on time and im­ple­mented in close co­or­di­na­tion with the re­gions and the med­i­cal com­mu­nity.

To­tal bud­get for health­care will be UAH 113.3bn in 2020, 13% up from last year. Health­care has an im­por­tant place in the bud­get and its fund­ing is in­creas­ing grad­u­ally. But will that be enough to fully cover the needs of Ukraini­ans? Given Ukraine’s slow GDP growth, it can­not quickly and se­ri­ously in­crease in­vest­ment in build­ing ca­pa­ble health­care. It is there­fore very im­por­tant for all fund­ing to be used as ef­fec­tively as pos­si­ble.

Ukraine lags be­hind EU coun­tries both by the share of GDP spent on health­care, and by spend­ing on health­care per capita. Swe­den’s spend­ing is 40 times higher at US $5,710 than Ukraine’s US $141. Com­pared to Poland, an EU mem­ber-state with some of the low­est spend­ing on health­care per capita at US $809, Ukraine is still far be­hind. Still, pub­lic fund­ing cov­ers just 50-60% of the to­tal amount of ser­vices Ukraini­ans need. Pa­tients pay for the rest on their own. Grad­ual in­crease of pub­lic spend­ing on health­care is a great chal­lenge for Ukraine and a manda­tory el­e­ment of the 2021 bud­get plan­ning.

2018 re­search by the Amer­i­can Jour­nal of Pub­lic Health re­vealed that Rus­sian trolls ar­ti­fi­cially fu­eled ar­gu­ments on vac­ci­na­tion and spread dis­in­for­ma­tion, pre­sent­ing it as their per­sonal opin­ions, at least through­out 2014-2017. In 2019, the World Health Or­ga­ni­za­tion (WHO) pre­sented its five-year strate­gic plan with top threats for global health. Th­ese in­clude vac­cine hes­i­tancy fu­eled by mil­i­tant com­mu­ni­ca­tion about health.

From 2016 to 2018, the level of vac­ci­na­tion against measles in one-year olds grew from 44.5% to 91% in Ukraine. Pro­cure­ment of safe and ef­fec­tive vac­cines, free vac­ci­na­tion fol­low­ing the na­tion­wide cal­en­dar and aware­ness rais­ing cam­paigns have de­liv­ered pos­i­tive re­sults. Still, Ukraine saw a measles out­break with 115,000 cases and 41 deaths reg­is­tered in 2017 as a re­sult of low vac­ci­na­tion in the 10 years be­fore that and in­ef­fec­tive Rus­sian vac­cines. Apart from that, Ukraine still has low lev­els of vac­ci­na­tion against diph­the­ria and hepati­tis B. There­fore, it should keep up the pace and do more work in 2020 to pro­tect its cit­i­zens from in­fec­tious dis­eases which have no place in the mod­ern world. In ad­di­tion to ac­cess to med­i­cal ser­vices, Ukraine should work fur­ther on im­prov­ing their qual­ity. Re­quire­ments for med­i­cal ed­u­ca­tion grad­u­ally in­crease in Ukraine. In the past, med­i­cal de­grees were ac­ces­si­ble to all who could af­ford to pay for the course, and to keep pay­ing for ex­ams in an en­vi­ron­ment of high tol­er­ance of cor­rup­tion. From 2018, school grad­u­ates need at least 150 grades on ev­ery ma­jor sub­ject in Ex­ter­nal Na­tional Test­ing to en­roll in med­i­cal train­ing and 130 grades for phar­ma­col­ogy.

In 2019, the Uni­fied State Qual­i­fi­ca­tion Exam was launched. Its first re­sults re­vealed that med­i­cal ed­u­ca­tion in Ukraine re­quires se­ri­ous changes. Rather than pre­pare for the in­ter­na­tional exam on med­i­cal fun­da­men­tals, some stu­dents took it to the streets in the runup to it. Later, they tried to sab­o­tage the test by spread­ing it on­line. They were sup­ported by ad­min­is­tra­tions of some uni­ver­si­ties that, while hav­ing cur­ricu­lum au­ton­omy, failed to pre­pare stu­dents for the exam. Even­tu­ally, the test showed that the rank­ing of ev­ery univer­sity cor­re­sponds to at­ten­dance of the test: stu­dents from uni­ver­si­ties with high at­ten­dance rank high in terms of per­for­mance. The stu­dents who sab­o­taged the test had the low­est re­sults. In 2020, the sys­tem of as­sign­ing in­tern­ships should be au­to­mated to ex­clude cor­rup­tion. For the first time, grad­u­ates from med­i­cal uni­ver­si­ties will be able to choose their post-grad­u­ate train­ing. This, too, has trig­gered some stu­dent protests, but only those who planned to solve this via bribes can re­ally be frus­trated about fair as­sign­ment.

Pa­tients will not ex­pe­ri­ence the re­sults of th­ese changes for the next ten years, un­til cur­rent first-year stu­dents or high-school



grad­u­ates be­come doc­tors. Yet, even th­ese changes are the first steps in over­com­ing the stag­na­tion of med­i­cal ed­u­ca­tion that has barely changed since the soviet time. Would you trust a doc­tor who has not up­graded his or her knowl­edge and skills ever since grad­u­at­ing from univer­sity in the 1970s and who does not know that MRI ex­ists? Your an­swer to this ex­plains why ed­u­ca­tion should never stop even af­ter grad­u­a­tion. Con­stant pro­fes­sional devel­op­ment for medics is a must for im­proved qual­ity of med­i­cal ser­vices in Ukraine.

In 2020, the prin­ci­ple of fund­ing re­search will change. The money should be spent on spe­cific R&D, not just on salaries for “re­searchers” im­i­tat­ing ac­tiv­ity. The grant sys­tem works in many ad­vanced coun­tries, en­cour­ag­ing re­searchers to work on ap­plied so­lu­tions and projects. It is ex­tremely im­por­tant that th­ese changes start work­ing and are mon­i­tored in Ukraine: if a project lacks qual­ity, the fund­ing should be with­drawn. This would re­quire fo­cus and a prin­ci­pled po­si­tion from the Health­care Min­istry, among other things.

We spend mil­lions of hryv­nia on the Treat­ment of Ukrainian Cit­i­zens Abroad pro­gram ev­ery year. Yet, it is still not enough to pro­vide care to all pa­tients in need of it. De­vel­op­ing trans­plan­ta­tion in Ukraine will help strengthen this. The launch of the Uni­fied State Trans­plan­ta­tion In­for­ma­tion Sys­tem was sched­uled for 2020, but the Health­care Min­istry de­cided to post­pone it for a year and to launch sys­tem test­ing in April 2020.

But the launch of trans­plan­ta­tion is not purely tech­ni­cal. It never worked prop­erly in Ukraine, so there is no de­vel­oped cul­ture of donor­ship. Both pa­tients and doc­tors have many ar­ti­fi­cial moral bar­ri­ers. The topic has been si­lenced for years, or it has been a source of fake per­cep­tions and fears. In ad­di­tion to de­vel­op­ing the trans­plan­ta­tion net­work, Ukraine should lift the taboo from this theme and have a civ­i­lized pub­lic dis­cus­sion on it.

The great­est chal­lenge of the com­ing years for Ukraine’s so­ci­ety is to start speak­ing about things as they are and fi­nally ad­mit that free health­care does not ex­ist. There is bud­get fund­ing com­prised of our taxes, but it is not enough to pro­vide uni­ver­sal health coverage. More­over, no coun­try in the world has enough money to pay for all med­i­cal ser­vices needed by its cit­i­zens. There­fore, Ukraine should learn pub­lic-pri­vate part­ner­ship in par­al­lel to in­creas­ing pub­lic fund­ing in or­der to at­tract more non-pub­lic fund­ing. This can be rea­son­able char­ity rather than a hand­out of 200 am­bu­lances; hu­man­i­tar­ian as­sis­tance from other coun­tries and at­trac­tion of pru­dent funds. Health­care should be a pri­or­ity of pro­fes­sional rou­tine work, not just of pop­ulis­tic dec­la­ra­tions dur­ing elec­tion races. It should be rec­og­nized as a mat­ter of na­tional se­cu­rity as lives and health of mil­lions de­pend on it.

As long as Ukraine shares a bor­der with Rus­sia, it should al­ways be ready for con­fronta­tion in a hy­brid war. It is im­por­tant to un­der­stand that Rus­sia’s ag­gres­sion is not lim­ited to mil­i­tary, in­for­ma­tion, en­ergy or eco­nomic losses. Ukraine’s eastern neigh­bor at­tacks it on a more ba­sic level, un­der­min­ing its hu­man cap­i­tal as the most valu­able as­set. By lim­it­ing ac­cess to mod­ern med­i­cal ser­vices in the oc­cu­pied ter­ri­tory and spread­ing dis­in­for­ma­tion on the In­ter­net, Rus­sia cre­ates the dan­ger of push­ing Ukraine and the global com­mu­nity into dark times. Coun­ter­ing the ag­gres­sor across all fronts re­mains the great­est chal­lenge for Ukraine.

Safe and free. From 2016 to 2018, the level of vac­ci­na­tion against measles in one-year olds grew from 44.5% to 91% in Ukraine

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