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1 February, 2020  ▪  Уляна Супрун

Healthcare defense

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. 

 

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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 thanUkraine’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 revealedthat 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. 

 

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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. 

Translated by Anna Korbut 

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