When the Ukrainian Health minister announced the start of the country’s most ambitious healthcare reform of its post-soviet history, 32 years-old doctor Svetlana Bulatova could not hide her anxiety. In the state polyclinic where she works – a moth-eaten building with an imperial façade and a large classical staircase in the centre of Odessa– talks of an imminent restructuring has left many wondering if they would still have a job in a few months time.
For the long-suffering health workers reforms just adds another layer of uncertainty to an already difficult job: “Reforms is very suitable, especially for our patients,” Bulatova said. “But… it means we have to destroy everything in order to create something new, and every time this happens, things get very difficult for everyone.”
Uncertainty has been the key word as Ukraine attempts to overhaul its corrupt, inefficient, Soviet-era healthcare system. Although the country spends about 7% of its GDP on healthcare (most developed countries spend between 9% and 12%; the US being the exception with 17%), Ukraine has among the lowest life expectancy in Europe (71 years, ten years less than the European average). Abysmal vaccination rates have also lead to multiple epidemics, including a wave of measles that killed 8 people last winter.
But despite a general consensus on the pressing need to upgrade healthcare, pushback has been strong, due to political pressure, the influence of vested interests in the pharmaceutical business and the concerns of medical professionals. It took Ukraine’s reformist government almost four years to vote in new legislation on healthcare: adopted in October 2017, the reform implementation began on April 1st this year.
Since the country’s independence, healthcare has never ceased to be a sensitive political issue. In 27 years, Ukraine went through 22 Health ministers, with most attempts at change ending dead in the water.
The in 2014 the revolution began. Dr Ulana Suprun was appointed as Health Minister and took over the ministry in July 2016. Her arrival was described by civil society as an unprecedented opportunity to transform the system. Suprun, a Ukrainian-American who first worked in 2014 with an NGO that distributed medical equipment to Ukrainian soldiers, certainly contrasts with the rest of Ukraine’s political class. The American accent, long blond hair casually falling over her shoulders, and her outsider status (she was never involved in Ukrainian politics before 2014) are all things rarely seen in a Ukrainian political office.
Talking to bne IntelliNews in late March, Suprun described a chaotic arrival at a ministry that had been largely vacated by the staff of the previous minister, Viktor Shafransky. Shafransky lasted only three months before being shown the door because of alleged corruption by one of his deputies. “I walked into the ministry with no transition period at all, I didn’t even know where my office was or what documents I was supposed to sign,” Suprun said, calling it her “baptism of fire.”
But even she hasn’t been immune from political boondoggling: she is still officially considered “acting minister” as disputes in the parliament prevented her from being duly appointed.
More money and less corruption
The first component of the reform kicked off at the start of this month with the creation of the “family doctor” concept. Instead of the current system where Ukrainians can go visit any doctor, they will now have to choose one general practitioner who will follow them over the long-term.
This new relationship between doctor and patient also entails a new type of healthcare financing aimed at reducing corruption while raising doctors’ revenues. Doctors will now be paid UAH370 ($14) a year for each patient they treat, with a maximum number of patients capped at 2,000 for general practitioners. The scheme is currently limited to primary care doctors, but authorities plan to extend this to specialists and hospitals in the next three years.
This step is described by Ukrainian authorities as a way not only to enhance the quality of the healthcare but also to reduce corruption. In the current system, an average monthly salary of $200 for the doctors means the overwhelming majority of medical workers rely on bribes or shady deals with pharmaceutical businesses to complement their income.
The latter is very common according to Andrii Dynjak, an internal medicine doctor working in one of Kyiv’s state hospitals: “You prescribe some drugs to a patient for a couple of weeks, the patient spends maybe UAH3,000 or UAH4,000 on this, and at the end of the month the pharmaceutical company gives you 10% of the total. […] It’s the most common way for doctors to make money.”
It’s also a major source of revenue for healthcare facilities. In Dynjak’s hospital, a naked concrete building in the outskirts of Kyiv, the pharmacy is the first thing patients see when entering. Despite free healthcare being guaranteed by the Constitution, patients are systematically forced to pay for their medication, often at the hospital’s pharmacy.
Suprun argued this effort to reduce corruption in the healthcare sector was one of the main reason behind the opposition to the reform: “In the last years, we were able to decrease the price of medication by 40% using international procurement. That’s money that someone in Ukraine is not making anymore,” she said.
And she is serious about tackling the issue. Suprun was recently approached by Andriy Bohachyov, an aide to the controversial Radical Party leader Oleh Lyashko, who offered Suprun a new apartment in Odesa in exchange for assigning some expensive medical equipment to a particular hospital. She immediately reported Bohachyov to the National Anti-Corruption Bureau of Ukraine (NABU) officers, the Kyiv Post reports. NABU launched a sting operations and Suprun played along, even going to inspect the apartment, all of which was secretly filmed. The video was released and aired on the TSN television channel on April 6 leaving Bohachyov to rapidly backtrack: he claims there was no connection between the apartment and the medical equipment and he was only trying to help Suprun out. Imported medical equipment is valuable and comes with money for maintenance that is often stolen, before the equipment is also stolen and sold.
Critics and fear
Critics argue that the reform could leave millions of Ukrainians without proper healthcare as some services become more expensive. Olga Bohomolets, a doctor and Rada deputy from the Petro Poroshenko Bloc party as well as the head of the parliament’s healthcare commission, wrote on Facebook the vote for the reforms would lead to “the closure of hospitals, the reduction in the numbers of doctors, and the disappearance of rural medicine.” Ukraine’s Health minister promised subsidies for those unable to pay while the government announced a 12% increase in health spending this year, but details on the subsidies remain unclear.
Suprun, who only received Ukrainian citizenship in 2015 but is fluent in Ukrainian, has been heavily involved in communicating about the reform: the day she met with bne IntelliNews at the Health Ministry, she was chaining interviews with Ukrainian journalists in an attempt to counter the often negative narrative about the reform in local media. Her Facebook page is also filled with educational content, from explanations about the reform and myth-busting claims about the dangers of vaccines to calls for doctors to stop using photofluorography to diagnose tuberculosis.
Opposition to the reform has been fierce every step of the way, despite a recent poll claiming 65% of Ukrainians supported it. The bill on healthcare was voted in October 2017 after months of negotiations and heated debates, with Bohomolets writing the reform could lead to “genocide.”
In early January, as the launch date of the reform loomed closer, criticism of Suprun was ramped up. The issue was ostensibly about Suprun’s request to fire the rector of Kyiv’s medical university after she had reportedly failed to organize an exam. In response, a group of students organized a strike calling for Suprun’s resignation, which, according to some local media, received the support of the university. Suprun herself complained on her Facebook page of having received death threats.
“For me, it’s like a canary in a coal mine,” Suprun said. “When attacks against me get stronger, I take it that we’re doing something right.”
In early April, two days after the launch of the reform, the healthcare committee in Ukrainian parliament called for Suprun to resign, claiming she had failed to uphold the 2016 procurement program. Suprun declined.
Resistance is real at other levels too. As money will now be flowing directly from the state budget to the healthcare facilities, the reform calls for the closure of regional departments that have, until now, been tasked with distributing the state budget to local hospitals, clinics and doctors. “So they are not the most enthusiasts about the reform,” Suprun acknowledged.
For doctors, and despite official promises of higher salaries, anxiety in face of the scope of the reform is strong. Some aspects of the new legislation are largely welcomed, such as a drive to digitalize what remains a heavily paper-centric system thanks a brand new database called “e-Health.” Instead of thick stacks of papers, often hard to read and easy to lose, all the information about a patient will be stored in an electronic database.
But even then, issues remain: back in Odessa, Bulatova is supposed to start registering patients electronically by early April. But in her small cabinet, there is no computer… and no internet connection. “The government promised to help us,” she said, “but so far there has been no support.” After years of battling to get a legislation voted, the actual implementation of the reform will likely prove no less of a struggle for Ukraine’s health reformers.