Reforms in the Health Care System of Ukraine

Anna Koval

, Oksana Mischenko

, Valentyn Orlov

, Kateryna Savostikova

and Viktoria Poliakova

Lviv State University of Life Safety, Lviv, 79007, Ukraine

State University of Economic and Technology, Kryvyi Rih, 50086, Ukraine

Executive Committee of Kryvyi Rih City Council, Kryvyi Rih, 50050, Ukraine

orlov_vv@kneu.dp.ua

Keywords: Health, Medicine, Healthy Society, Ordinary Health Professionals, Financial and Personnel Shortage, State.

Abstract: The health care system of the country is in the conditions of constant transformational changes. The health of

the citizens along with the standard of living is one of the criteria for determining the development of the state.

Also, it determines the state’s preparation for being included in the processes of globalization as an equal

participant. Unfortunately, in Ukraine, there was a system that had a number of defects for a long time.

Financial and personnel shortages were accompanied by a lack of focus on the final result. This led to the fact

that even with the availability of funds it was not possible to spend them rationally. As well as the loss of

truly qualified professionals despite their availability, due to the lack of motivation for quality work.

Improving the quality and efficiency of the health care system is recognized as one of the best investments,

since healthy citizens and a healthy society, in general, are more prone to economic growth. In general, much

has been done to reform the health care system, but this is just the beginning. There is still a lot of work to be

done, both on the part of regulatory managers in this area and ordinary health professionals, who will

implement the adopted programs and contact patients directly.

1 INTRODUCTION

Ukraine, had experienced social upheavals and shifts

in 2013-2014, once it has chosen to develop towards

the European path. The Association Agreement

between Ukraine and the European Union, ratified by

the Law of Ukraine of 16.09.2014 №1678-VІІ,

defined the directions of modernization of the state,

in particular the need for health care reform.

The health care system of the country is in the

condition of constant transformational changes. As a

multi-level and diversified structure, the system is

forming complex approaches to define governance

mechanisms in the public and private health sectors.

In them the state reproduces a new system of

governance mechanisms, which need to be

considered in the aggregate of influences of meso-,

macro- and micro-factors with the emergence of new

forms of governance at all levels.

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2 RELATED WORKS

The National Strategy for Reforming the Medical

System of Ukraine for the period 2015-2020

identifies key issues, potential directions and ways to

solve them in order to form a new state policy in the

field. This includes in-depth protection of normative

standards for human rights. Under such conditions,

the country's medical system should be based on three

basic principles: focus on the human, on the result and

on the implementation of the best technologies, as

well as the best experience in providing medical

services.

During the years of independence, the Ukrainian

health care system has practically failed to switch to

the health insurance system. Only in 2017, the first

step in this direction has been taken. Thus, on

December 27, 2017, the Law of Ukraine “On State

Financial Guarantees for the Provision of Medical

310

Koval, A., Mischenko, O., Orlov, V., Savostikova, K. and Poliakova, V.

Reforms in the Health Care System of Ukraine.

DOI: 10.5220/0011354600003350

In Proceedings of the 5th International Scientiﬁc Congress Society of Ambient Intelligence (ISC SAI 2022) - Sustainable Development and Global Climate Change, pages 310-317

ISBN: 978-989-758-600-2

Services and Medical Devices” of October 19, 2017,

№ ° 2168 III was signed. While in Poland the Law on

Compulsory Health Insurance, which initiated the

reform of Polish health care financing, was adopted

in 1997. As a result, Ukraine may find it useful to use

foreign stages of the introduction of insurance

medicine.

In a broader context, the problems of public health

management were considered by domestic scientists

N. Kryzina, C. Mokretsov, O. Prikhodko, J. Radish,

N. Ringach, I. Solonenko, N. Yarosh and others.

Considering the importance and scientific value

of existing research, it should be recognized that the

analysis of scientific literature showed the lack of

comprehensive developments to critically evaluate

the experience of implementing health care reform.

3 PROPOSED APPROACHES

Protecting the health of the country's citizens is the

primary duty of the state. It is the first social function

and a condition for sustainable development.

Reforming the health care system affects all levels of

government. After the introduction of the program-

target method, the targeted funding of the Ministry of

Health and programs related to health care in Ukraine

has increased. Unfortunately, the allocated funds are

used inefficiently. Therefore, not only the health care

system and the Ministry of Health need to be

improved, but also the procedure for financing

programs, their control and evaluation of results.

Following the adoption of the Association

Agreement, Ukraine is gradually bringing its

healthcare system closer to European standards and

trying to implement international programs.

All institutions of the Ministry of Health are

budgetary, meaning that they are financed from the

states and local budgets. The system of extra-

budgetary health insurance is poorly developed.

Inefficient use of limited budget resources is

primarily due to the funding of military and national

medicine, as well as research institutions and various

departments and commissions. Thus, it is not the

health of citizens that is financed, but medicine.

Among the main problems of the health care

system of Ukraine, experts have identified the

following:

- Insufficient funding for health care;

- lack of a list of free services;

- lack of connection between the financing of

public health care institutions and the final results of

their work;

- lack of effective resource management and

indicators for their definition;

- corruption.

The Organization for Economic Co-operation and

Development (OECD) spends about 9% of GDP on

health care. The leader is the United States - 17.2% of

GDP, but despite this, their system has certain

shortcomings, and funding is growing every year with

declining efficiency. Switzerland - 12.4% and

Germany - 11.3%. The lowest expenditures in Turkey

are 4.3% of GDP. However, the cost of medical care

does not guarantee the quality of medical services.

For instance, although the United States spends the

most money on the treatment of its citizens, the

effectiveness of their use is questionable

(Karamishev, 2006).

After analyzing the information collected in the

table 1 shows how similar the systems and the

problems of medicine of the former Soviet countries

are. Like all industries in the USSR, health care was

controlled and planned. However, this system was

working and has even been effective. Almost all

Soviet sanatoriums, clinics, hospitals, and prevention

facilities are still operating. Unfortunately, most

countries have failed to preserve and reform what was

functioning. Only the updated health care system in

Poland has improved, in contrast to the improved

systems of Russia and Bulgaria, which have received

more problems than benefits after the introduction of

new strategies.

Table 1: Characteristics and shortcomings of the medical

system of post-Soviet countries.

Cou

ntry

Characteristics of the

system

Disadvantages

Pola

According to the

Law on Compulsory

Health Insurance,

regional state

insurance funds,

such as health

insurance funds,

finance medical care

on a contractual

basis by reimbursing

medical institutions.

Expenditures on the

industry increased by

2%, and fundraising

at health insurance

funds was lower than

expected. lack of

uniform standards

and approved list of

medical care, lack of

uniform standards

that define insurance

guarantees,

inconsistency of

tariffs for medical

services make it

impossible to control

the level of costs.

Imperfect controls

have led to an

increase in the chain

Reforms in the Health Care System of Ukraine

311

of medicines, medical

equipment and

medical supplies.

Russ

All citizens are

subject to

compulsory health

insurance. Insurance

contribution

is 3.6% of the

payroll and is paid

y the employer. The

contribution to the

MHI is provided in

the single social tax.

Instead, a citizen of

the Russian

Federation receives a

medical insurance

policy, with which

he is obliged to seek

medical care.

Russia's healthcare

system is in crisis.

The resource

provision of the

industry not only

does not meet the

needs for medical

care but also brings

the health care system

to a final collapse.

Compulsory health

insurance does not

compensate for the

reduction of state

budget allocations for

health care.

Bulg

aria

The meaning of the

reforms was to

ensure the

transition to

contractual

relations between

health care

providers and the

Health Insurance

Fund, as well as

with commercial

structures of health

insurance. The

consequence of

such a

transformation of

health care was the

transformation of

the industry into a

profitable sector of

the economy,

improving the

quality of medical

services.

In the European

Union, health

contributions account

for 7-8% of GDP, and

in Bulgaria - about

4%. The allocated

funds do not cover all

costs, which leads to

underfunding of the

system. Lack of

competition in the

health insurance

system. Ineffective

mechanism for

protecting patients'

rights. Corruption.

According to the funding in post-Soviet countries

has clearly been insufficient. Thus, per capita

expenditures range from $400 - 500. In the USA, the

highest figure in Poland is $629. USA (Some issues

of improving the health care system: Resolution of

the Cabinet of Ministers of Ukraine of February 17.

2010 № 208). In Ukraine, the procedure for allocating

funds for the health care system is regulated by the

Law of Ukraine "On State Financial Guarantees of

Medical Care" (Solonenko et al., 2017).

One of the main requirements of Ukraine's

European integration, in addition to compliance with

international agreements and standards in the field of

health care and cooperation with world organizations,

is the creation of a patient and health-oriented system.

This system has to be capable of creating conditions

for disease prevention and treatment. Ukraine has the

lowest level of life expectancy.

Also, except for increasing the cost of medical

care, it is necessary to develop projects and programs

that are aimed at creating a quality European health

care system by using their specifics and experience of

the leading countries (Table 2).

Table 2: The health care system and its financing in some

countries of the world.

Country Characteristics of the health

care s

ste

France France's health protection system is

centralized. Control over the efficiency of

the health protection system Ministry of

Health and Social Security. The region

has a single insurance organization–

National Health Insurance Fund with

ranches. It is also voluntary insurance.

The main problem in the organization of

health care in France - is the rapid growth

of spending on the industry. They are

growing faster than the general welfare of

the country.

The UK provides free medical care to all

who have the right to reside in the

country, regardless of income and

nationalit

The

United

Kingdo

Provides significant benefits for the

purchase of medicines. They are provided

free of charge to certain categories of

citizens. For retirees, there is a system of

discounts on pharmaceuticals, which is

determined

depending on the size of the pension and

the level of welfare.

Sweden Sweden's public health policy aims to

ensure equal opportunities for health care

and a healthy lifestyle for all members of

society.

USA The health care system in the country is

organized according to the market model.

There is no nationwide program to provide

health care to the working population in

the United States.

The negative features of the organization

of the health care system in the United

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States are its high prominence and lack of

social orientation.

German

The country has historically developed a

system of health insurance, which copes

with its tasks autonomy and independently

of the state budget. In the health insurance

system, the number of contributions

corresponds to the financial ability of the

insured. Medical services are provided in

accordance with the patient's state of health

and do not depend on the number of his

ersonal contributions.

The main disadvantages: a large

administrative apparatus, an increase in

unnecessary services, the maintenance of

too large hospitals.

Italy The main disadvantages: are large

administrative apparatus, an increase in

unnecessary services, the maintenance of

too large hospitals. Medical health care

service is available to all citizens. Health

care systems are financed from the state

budget and contributions from employers

and the workin

ulation.

Switzerl

and

The organization of health care in the

country is built on the principle of

compulsory health insurance for every

citizen. Health insurance funds provide

both types of insurance: compulsory and

voluntar

Austria There is no planning for federal hospitals

in Austria. The Ministry of Health and the

Environment has no direct authority over

local health services. They are

subordinated to local

overnments.

Medical programs in Ukraine:

- state target program "Diabetes";

- a national program of immunoprophylaxis and

protection of the population from infectious diseases;

- state program for the development of the system

of medical care for patients with nephrological

profile;

- a national program to combat cancer;

- reproductive health of the nation;

- program to combat cancer;

- a program of immunoprophylaxis and protection

of the population from infectious diseases;

- program to combat tuberculosis;

- a program of prevention, diagnosis and treatment

of viral hepatitis;

- HIV/AIDS prevention program (Kaminska,

2006).

Most health programs in the world focus on

the fight against HIV, cancer, smoking, pollution and

promote healthy eating and lifestyle, reduce mortality

and increase life expectancy.

The main programs that are currently operating in

Ukraine:

- "Available drugs";

- "Treatment abroad";

- "Ohmatdit";

- "Reimbursement of the cost of insulin drugs";

- "Development of a network of cardio centers";

- "Free diagnostics".

The program "Reproductive Health of the Nation"

gave positive results, which, by conducting

informational activities and providing modern

contraceptives, prevented unwanted pregnancies and

abortions. Unfortunately, “in terms of a healthy

lifestyle and parenthood", as well as family planning,

Ukraine is inferior not only to the United States,

France and Germany but also to Poland, Bulgaria and

the Czech Republic. This requires continued funding

for a program aimed at improving the reproductive

health of citizens " (Pak, 2011).

Ukraine was one of the first to sign the WHO

Framework Convention on Tobacco Control. Due to

this, in the period 2008-2013, we managed to reduce

the number of smokers by 2 million people.

Also, with the support of the Government of the

Swiss Confederation, the Maternal and Child Health

Program (On approval of normative documents on the

use of telemedicine in the field of health care: Order

of the Ministry of Health of Ukraine of October 19,

2015 № 681) has been implemented (Zlepko, 2017).

The winning project has been developed and

implemented to implement international standards for

the circulation and production of medicines. The

program "Association of French-Ukrainian

Cooperation in Health and Pharmacy" is also in action

(Gorachuk, 2012).

The number of growing projects target combating

non-communicable diseases, aimed at improving the

skills of doctors and conducting information

activities.

The WHO-Ministry of Health of Ukraine project

"Non-communicable diseases (NCDs): prevention

and health promotion in Ukraine" (Moskalenko,

2008) of the Swiss Agency for Development and

Cooperation is very important for Ukraine. Its main

objectives are to reduce premature mortality from

NCDs through prevention and treatment, especially

due to cardiovascular disease.

International cooperation in the field of medicine

is becoming more and more popular over time,

commissions and programs are being created that

unite states to fight the "common enemy" - diseases.

Reforms in the Health Care System of Ukraine

313

According to the official website of the Ministry

of Health in Ukraine, there are international programs

in the medical field, grouped in the table. 3.

Table 3: International medical programs.

Program

name

Dono

Execute

Content

Ukrainian-

Swiss

Maternal

and Child

Health

Program

Swiss

Agency for

Developmen

t and

Cooperation,

represented

in Ukraine

by the Swiss

Bureau

Cooperation

Swiss

Institute of

Public

Health and

Tropical

medicine

(Basel,

Switzerlan

d),

Represente

d in

Ukraine b

ythe

Program

Implement

ation

Office

Improve

thequality,

efficiency and

accessibility

of maternal

and child

health services

Support for

the

development

of the

medical

standards

system in

Ukraine

European

Commission

NI-CO,

Ireland

Improve the

quality and

efficiency of

medical care

through the

introduction

of a unified

methodologyf

or the

development

of medical

standards

based on the

principles of

evidence-

based

medicine

Financing

and

management

in the field

of healthcare

in Ukraine

European

Commission

GVG/CII/E

POS,

Germany

Promoting the

developmento

f effective and

efficient

financing and

management

in the field of

healthcare in

Ukraine

Preventivean

d primary

healthcarem

easures

European

Commission

CII Group

and EPOS

Consortiu

Promoting

healthcare

reforms in

date effective

prevention

and primary

health care in

Ukraine

adapted tone

socio-

economic

conditions

Changes that have been foreseen by the reform of

the medical system of Ukraine:

- introduction of the state-guaranteed package of

medical care;

- introduction of the principle "money follows the

patient";

- budget program "Affordable Medicines" and

others;

- reform of medical education;

- exercise of the local authority in the field of

medicine;

- transparent and efficient purchases of medicines;

- development of the state program of medical

guarantees.

Therefore, based on the above, we can formulate

further actions of the Government:

- Continuation of reforming the system of

financing of the health care system within the PCM;

- introduction of the program "Free diagnostics";

- continuation of the budget program "Affordable

Medicines";

- development of a network of reperfusion and

cardiac centres;

- continuation of funding for the modern medical

and diagnostic complex NDSL "Okhmatdyt";

- the transformation of medical education;

- improving the quality of emergency medical

care;

- control over the use of budget funds by

conducting inspections and audits of budget programs

(Zhalilo, 2003).

Health care reform is one of the main reforms that

can really change Ukrainian society. Anti-corruption

or education reform is undoubtedly also extremely

important.

However, health is more important than ever

when most people have a critical time in their lives.

When we grow old, this always happens, but young

people sometimes need medical attention, for

example, if they suddenly become ill or injured due

to various reasons.

A smarter, stronger and more productive society

among young people creates a healthy lifestyle and

quality medical care.

All other problems take a back seat when we face

health problems. People need only one thing at any

age - effective, high-quality, affordable health care

provided by an effective health care system.

Unfortunately, not only within its borders but also

beyond its borders, Ukraine is an example of how

badly this system can work.

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When patients in Ukraine seek help from a regular

district clinic, they are almost always ready for the

fact that basic medical equipment is in poor condition

and is lacking, and sometimes not present at all.

Patients are well aware of the salaries of the doctors

they trust their health with, so corruption is not

perceived as a reward for doctors. Patients are often

forced to buy their own medicines, gloves for doctors

or even bring food. All these sometimes ineffective

payments are a burden on patients and stop many

from seeking medical care.

Ukrainian medicine lacks numerous

improvements, but what is most shocking is the lack

of a clear course on what to do with the sad state of

the health care system.

Citizens of Ukraine are not able to fully enjoy

access to affordable and high-quality medical

services, despite the relatively high level of health

care costs.

In Europe, life expectancy, especially for men, is

much higher than in Ukraine, and Ukrainians are

forced to bear half of all costs to ensure good health.

Therefore, the population has many questions.

Europe's neighbours have much higher incomes than

Ukrainians. However, it is Ukrainians who pay the

largest share of medical expenses out of their own

pockets. Compared to the wealthier people of the

European Union, this amount is even a larger share of

their income.

Dangerous infectious diseases, such as

tuberculosis, cholera, etc., appeared on the way to the

development of society. They have returned and

continue to spread. The prevalence of multidrug-

resistant tuberculosis, poliomyelitis and HIV is

particularly dangerous, and at this stage COVID 19.

As mentioned earlier, life expectancy in Ukraine is

much lower than in the EU. Nevertheless,

unfortunately, the level of public access to quality,

free medical services remains very low.

But despite all the above, there is a bright side -

we have recently seen real political determination and

the will to make changes in the country. Medical

reform is a big, though initial step towards better

change, after all, it is the primary responsibility of all

states to ensure the right of citizens to health care.

Based on the best international experience, a

Comprehensive Health Care Reform Strategy has

been developed (Fig. 1).

Changes provided by the reform of the medical

system of Ukraine:

- introduction of the state-guaranteed package of

medical care;

- introduction of the principle "money follows the

patient";

- budget program "Affordable Medicines" and

others;

- reform of medical education;

- exercise of the local authority in the field of

medicine;

- transparent and efficient procurement of

medicines;

- development of the state program of medical

guarantees.

Figure 1: Component Strategies for Reforming the Health

Care System in Ukraine.

The government supports the necessary health

care reform strategy. In the field of accessibility,

availability and quality assurance in the health care

system in Ukraine, step by step ensures the work of

parliamentarians and government decisions that

apply political will and implement theoretical

concepts in action that will be implemented and can

deliver real results.

The key project was "On state financial

guarantees of medical care". This law offers a

radically new vision of the health care system. It will

radically change the entire health care system and

provide for all categories of citizens, without

discrimination, to improve access to quality medical

services.

This law changes the approach and provides a

better balance between public and private interests.

Such a system works well in other countries and in

Ukraine's ability to significantly improve the health

care system in line with international best practices.

As noted, in October 2017, a significant event

took place in Ukraine - more than 226 people's

deputies trusted the new team of the Ministry of

Health (MOH) of Ukraine and made the right choice.

They voted for the law "On state financial guarantees

of medical care" (Lehan, 2005). It came into force in

2018 and has given impetus to the current changes in

Reforms in the Health Care System of Ukraine

315

healthcare. These include state financial guarantees,

the program of medical guarantees, the National

Health Insurance Fund, raising the status of primary

health care (PHC), the emergence of contracts.

According to Art. 95 of the Constitution stipulates

that "all expenditures of the state for public needs are

carried out within the funds provided for this in the

State Budget" (Petrashik, 2014). As it is limited, there

was a

need for mechanisms that would ensure

compliance with the Constitution. However, it did not

provide an opportunity to promise what the state

would never be able to do. The decision was a new

law, which introduced the concept of "state financial

guarantees". Currently, the state guarantees payment

from the budget in full for medical services, but only

those that are included in the Medical Guarantee

Program.

The program of medical guarantees, the draft of

which is currently being worked on by the National

Health Insurance Fund. It will be approved by the

Ukrainian Parliament as part of the Law on the State

Budget of Ukraine for the year and will contain a clear

list of services referred to as art.4 of the law "On a

state financial guarantee of medical care (Lehan,

2005), as well as tariffs.” Most likely, it will be part

of one of the annexes to the Law on the State Budget

to prevent a rapid change in tariffs for medical

services. However, the possibility to change them is

provided: tariffs should be fixed in the Law on State

Budget, but the Ministry of Health of Ukraine will

have the right to approve adjustment factors (Order of

the Ministry of Health of Ukraine, mandatory agreed

with the Ministry of Finance). During the transition

period, they are approved by the Cabinet of Ministers

of Ukraine (CMU), and since 2020 this right has

appeared in the Ministry of Health (Marchuk, 2016).

Every citizen of Ukraine is affected by changes in

the health care system. The purpose of the

transformation is to have the patient at the centre of

the health care system and to ensure equal access to

quality medical services for all citizens of Ukraine.

According to experts, the modernization and

reform of the health care system should outline goals

and objectives, the implementation of which will help

realize social aspirations and values in the direction

of the traditions of developed democracies. The

human right to have good health care must be based

on economic and social development and, most

importantly, on political stability.

Ukraine requires an effective functioning of

managerial, organizational, structural, legal,

economic, financial, information and communication

institutions. That is required to achieve optimal

results for the health of citizens (level, average

duration, etc.), financial security when receiving

medical care, as well as prompt satisfaction of

citizens' requirements and expectations and overall

efficiency of the industry.

In the long run, the system should be guided by

the following principles:

1. Guaranteed package of services available to

every citizen.

2. Compliance with national standards of quality

and professionalism.

3. Mutual respect for patients and medical staff.

4. Cooperation of various sectors of the economy,

services, organizations in the interests of patients,

communities and the population (intersectoral

cooperation).

5. Value for money and the most efficient, fair and

sustainable use of limited resources.

6. Accountability to communities and patients

(Kaminska, 2006).

That is, it is assumed that medical care services

are guaranteed in accordance with the constitution

without discrimination on the basis of age, sex,

national, religious, political or other characteristics.

Moreover, the state should address the issue of

providing medical services to more vulnerable

categories of citizens to ensure the necessary living

conditions. Today this is quite relevant, as Ukraine

lags far behind developed countries in these

indicators.

4 CONCLUSIONS

A study of the state of theoretical support for health

care reform in Ukraine and abroad suggests that

specific data on the state of society in a country

dictates ways and means to improve the organization

of the health care system and its state regulation.

Changing economic and social relations create the

conditions for the existence of different types of

health care systems.

Any health care system has a goal, which can be

formulated as providing affordable, high-quality

medical care to the population, improving the health

of society as a whole and each individual citizen.

Obviously, there is no ideal health care system

outside of a particular political and economic

situation. The development of society, science, and

health care practice forces to carry out reforms in this

area, to try to increase the efficiency of the country's

health care system, to improve its structure, to specify

the functions of the elements in health care systems,

optimize their interaction. Society determines the

features of the health care system, its legal basis,

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mechanism, and ways to meet the needs of citizens in

health care, providing these needs with the necessary

resources. Healthcare is a dynamic system so this area

is constantly evolving, improving and reforming.

In a view of all the above, we can list the tasks that

usually need to be addressed in the process of health

care reform:

- creation of a new legislative framework for

health care, meets the requirements of the time and

the current economic situation.

- development of mechanisms for adapting the

health care system to work in new conditions.

- bringing in line with the goals and objectives of

the reform of methods of interaction between health

and the economy - development of mechanisms for

financing health care.

- development and implementation of

organizational principles of functioning of health care

institutions in new conditions.

European countries have also been identified as

having problems with their health care systems.

However, due to the long path of development and

focus on quality medical services, there are effective

systems that can ensure a high standard of living and

quality medical care.

Improving the health care system involves a

number of measures and the introduction of modern

mechanisms of state regulation of health care in

Ukraine. Among the main mechanisms are

professional and personnel fulfilment of the health

care sector, logistics and information mechanism, as

well as the mechanism of financial support of state

regulation of the health care system.

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