Free health care in Ukraine has long been fiction, and the national health care system fails to meet the needs of a contemporary society. The solution is seen in introducing family medicine, which has traditionally been practiced in the West, and in enhancing the quality of medical services. Hospitals have a “blown-up” number of beds, a leftover from the USSR, and call for reorganization so that funds are spent more efficiently. According to Tetiana Bakhteyeva, chairman of the VR committee on health care, 80% of budget funds go to in-house treatment, 15% to outpatient care and a mere 5% to first aid. Paradoxically, first aid is what 75% of the population needs, according to the Ministry of Public Health. Thus, a new concept of national health care has been proposed which puts emphasis on first aid and charges family doctors with providing it.
There will be tangible positive changes as soon as 2012, government officials promise. Medicine must become more accessible and ambulance service faster. A unified system of emergency medical aid will be set up, and the network of ambulance cars will be expanded. They will be required to arrive within 10 minutes in cities and towns and within 20 minutes in the countryside after being called. The innovations will be tested in the pilot regions mentioned above. If the experiment proves successful, the rest of the country will follow suit.
FAMILY DOCTORS
The pilot regions are close to completing the first stage of the reform, and the system of medical services will start to reform in early 2012. It has three levels. On the first level, family practice centers will be set up where primary care, pre-doctor care and emergency medical services will be provided. While family doctors are being trained, First Aid Centers will employ, concurrently, neighborhood pediatricians and physicians. If necessary, a family doctor will refer a patient to a specialist at the second or third level.
Family doctors are supposed to fully replace physicians and pediatricians by 2020. They have to be knowledgeable in about 20 areas of medicine and take care of 1,200-1,500 patients from birth to death. Patients will have the right to choose their family doctor. Vladyslav Hryn, head of the Department for General Practice of Family Medicine at Maksim Gorky Donetsk National Medical University and director of the Institute of Urgent and Plastic Surgery, told The Ukrainian Week that his university offers degrees in family medicine to interns (two years of studies) and medical workers who are changing their area of specialization (six months of training). “We have to provide 400 family doctors to Donetsk Region by 2012. To compare, our department issued around 530 general practitioner diplomas in the past seven years. Furthermore, to train family doctors and nurses efficiently, we need to have training centers where they can acquire practical skills. We have none so far,” he says.
Olha Bohomolets, chief doctor of the Laser Medicine Clinic at the Institute of Dermatology and Cosmetology, supports introducing family medicine and optimizing the network of hospitals. However, she says that the reform itself will not be able to fundamentally change the deplorable situation with the sickness and death rate in the country. “A person has to have a desire to be healthy. Today the biggest social problem is chronic depression among Ukrainians. This is a consequence of economic and political instability. People who see no future for themselves in their own country are not motivated to be healthy,” Bohomolets says.
“WE’LL BLOCK THE HIGHWAY”
This experiment has already hurt service in the countryside. Rural areas have sorely lacked doctors, and now part of the service staff and medical workers are being dismissed, even though those behind the project promised no job cuts in the many interviews they gave. Doctors in Donetsk Region admit off the record that at the moment the essence of the reform boils down to redistributing material resources and financial austerity. Ordinary patients will not, of course, experience any changes for the better. People and countryside doctors do not believe that a gynecologist or otolaryngologist can be trained to become a family doctor within six months. Nor do they trust that family medicine centers will have better equipment. Imagine what it means for an entire district when a neighborhood hospital is essentially closed – what remains is a dozen beds for in-patients and a couple of doctors and nurses. Doctors with narrow specialties will be moved to cities that are district centers and will be hard to reach – travelling worn-down country roads on one's own is a challenge in winter when one cannot count on an ambulance arriving. Unless roads are fixed and the jalopies used by hospitals are replaced with new ambulances, it will be impossible for them to arrive within 20 minutes of being called.
The first outbreaks of protest have already infected Donetsk Region. In the city of Kirovske, local council members refused for a long time to launch the reform. In Zuhres, people came to protests, trying to save the surgical department of a local hospital from being shut down. In Spartak, Yasynuvata District, about 500 people signed a petition to MP Bakhteeva and Minister of Public Health Oleksandr Anishchenko demanding that they take “all possible steps to protect countryside medicine during the experiment.”
Residents of Kleban-Byk, Kostiantynivka District, threatened to go on a hunger strike and block a highway if a local hospital is shut down. “They tell us: There are only pensioners here. But aren’t we people? Our doctor has been doing enough work to keep three people busy for a long time now. He helps everyone, while in the city where they will force us to go later, no one will care about us. We have been trying to defend our hospital for three months now. We had a protest, but it didn’t help. If they don’t listen to us, we’ll block the highway to Donetsk,” Nina Soroka, 75, resident of village Katerynivka, says with resolve. The local hospital serves 19 settlements within a range of 40 km. Its in-patients are seriously ill pensioners, mostly very advanced in age, who find it impossible to travel to a city hospital 20 km away. Moreover, according to Volodymyr Shalimov, a local physician, that hospital sometimes sends back sick collective farm workers even after they have had a stroke. In theory, buses run to the city three times a day, but in fact they even fail to deliver bread for days in a row during stretches of bad weather in the winter. If the reform is carried through, the hospital will keep an out-patient care unit, 15 beds for in-patients, one family doctor and just half of its current support staff. Shalimov believes that what does require cuts is the amount of everyday paperwork which stands in the way of providing quality services. The experiment does not address this problem or that of increasing doctors’ responsibilities and counteracting corruption.
WHAT WILL BE LEFT?
Serhiy Severyn, chairman of the Donetsk Region Family Doctors Association, suspects that primary care will be handed over to private businesses that will enter the market. “They are cutting not only medical workers but also the service staff: security guards, sanitary workers, registering clerks and drivers. From now on doctors and nurses will have to miraculously perform also these functions while treating patients. Where is there any improvement of medical services in this?” he asks rhetorically. For over a decade he has headed one of the first family medicine centers in Donetsk Region – in Spartak, Yasynuvata District. He has submitted his critical comments and recommendations to top officials in the health care system and to the Ministry of Public Health. All his questions and proposals have gone unanswered.
The ideologues of the reform stubbornly ignored even the criticism from the Verkhovna Rada Chief Legal Directorate. Its experts emphasized that the Law “On Introducing Changes to the Foundations of Health Care Legislation in Ukraine to Improve Medical Service Provision,” which will enter into force on January 1, 2012, “does not contain mechanisms to organize and provide primary, secondary, tertiary and emergency medical aid or clear and understandable conditions for referring patients to institutions where they will be provided free secondary, tertiary or emergency aid.” Nor does it say anything about punishment for a failure to provide such aid.
Severyn is greatly concerned over the crisis that may soon overwhelm the urgent medical aid sector: “Order No. 645 of the Ministry of Public Health says nothing on the organizational structure of the emergency medical aid service. Whereas the ministry mentioned in its previously-issued documents that such stations would be set up in out-patient units in cities and districts, there is not a word about them now. Primary health care institutions will be forced to also provide emergency aid. The ambulance used to partly perform functions of this kind when it came to help patients complaining of a headache or high blood pressure or children suffering from fevers, etc. After the emergency medical aid service is set up, calls will be filtered to a greater extent, so patients without symptoms of vital functions being damaged will have to turn to a family doctor or physician assistants. However, there are no plans so far to increase the staff of medical workers, the ambulance fleet or fuel supplies to make sure this aid is duly provided.”
According to a poll of experts, with the advancement of the reform we can expect medical workers to actively leave for other countries. This would be a continuation of the already stable emigration trend to Russia and Europe in the sector. Even now patients in cities and villages line up to be seen by knowledgeable retired doctors. However, they will stop working sooner or later, while young specialists who have not gone abroad will escape into the pharmaceutical business. Meanwhile, medical workers and NGOs in Donetsk Region are trying to get through to the government to ensure changes are made to the law.
