The National Healthcare Reform Strategy covers the period from 2015 to 2020. As for the five-or ten-year period after that, no such document exists yet, which means that for the past 4 months this industry has been without a vision, strategy or tactics. Instead, we’re witnessing a systematic offensive on key institutions established in the post-revolution period according to a fundamentally new design and based on the value of human life, namely the National Health Service and the State Enterprise “Medical Procurement of Ukraine (Medzakupivli”).
Unable to dismiss the possibility that the the current government might “forget” that a new Strategy is needed, a group of experts that have been involved in the reform since 2014 - Pavlo Kovtoniuk, Victoria Tymoshevska, Oleg Petrenko, Volodymyr Kurpita, Arsen Zhumadilov, Tetyana Gavrysh and Mykhailo Dovgopol - met last summer to develop a framework document that would serve as a basis for the next Strategy. “Its 2021 already and yet we still live in the previous decade. Nothing fundamentally new is
being done. That why we went out and tried to face today’s realities like adults,” says Pavlo Kovtoniuk, co-founder of the Ukrainian Health Center.
The document was titled Health Manifesto. Our conversation with its authors took place in anticipation of interviews that are to be held as part of the contest for the position of the head of the National Health Service of Ukraine (NHS). The Manifesto’s authors believe this event to be just as important as a presidential election, since this agency’s work concerns all of us.
We spoke with the Manifesto team about the document’s purpose as well as the next steps that they believe should be taken to create a new Strategy: what society can do to protect the new institutions; can they by hampered in their efforts or turned into political puppets if people with different values and priorities are put in charge. Finally, what exactly do they mean when they mention words like “free person” and “responsible community” many times in the document.
Make our life safe: why the public should be demanding a new Health Strategy
Victoria Tymoshevska, director of the Public Health Program of the International Renaissance Foundation, says what, she feels, should have been obvious back in early 2020: the Healthcare Reform Strategy needs to be revised, taking into account the victories and failures so far. There have been several attempts to develop a new Strategy, but no actual documents have been made available to the public. Victoria believes, this shows either that there’s no clear vision for the future, or that the stakeholders have been unable to agree on the issue of values, or that there have been too many distractions, namely the pandemic and the current economic and political climate, which necessitated allocating a lot of resources (human, financial, intellectual) elsewhere.
Yet the expert asks, “Can there be a victory without strategy and tactics? It would just be a random battle. Not a gradual move forward but a struggle with a high chance of failure, where the price of defeat - as in any war - will be people’s lives and health. Our Manifesto is a list of fundamental values where compromise is unacceptable, because it would shift focus from the people, their health, safety and dignity to individual agendas and political or financial gains.”
According to Victoria Tymoshevska, all stakeholders should be involved in the development of
the Strategy and tactics - the Ministry of Healthcare, the responsible Parliament committee as well as the general public. The international community could act as a neutral commentator. “It could be an independent platform of experts, serving as a safeguard against interference of certain groups with the Strategy’s development. The Health Ministry would be the one to kickstart the process. The arbiter could be the Office of Simple Reforms, which doesn’t work right now, or someone from the President’s office.”
The Manifesto’s authors believe that health is a much broader issue than just “healthcare”, and that the Strategy should take into account various social and economic factors and the global challenges of our time. Thus, the Manifesto addresses such issues as epidemiological safety, technological development, the relationship between the healthcare and the IT markets, as well
as the human capital index. It also emphasizes the key role of communities in healthcare and stresses that healthcare is a complex process with a multitude of factors, and the government must take all of them into account. For instance, caring for the elderly is a security issue for the state. When this task falls solely on the shoulders of their families, it sets off a chain of reaction
of inherited poverty.
Therefore, the system should be designed based on the actual needs of the public.
“We as a society should be all over the relevant committee of the Verkhovna Rada, the Health
Ministry, all those who determine health policy,” says Tetyana Gavrysh, managing partner at the
ILF law firm and coordinator of the Kharkiv Expert Group for Healthcare Reform. “It’s not
them, mandated by the powers that be, who should give us a formula for us to squeeze in with all
our illnesses, fears, anxieties … We ourselves should come to them and say, see, this is what we
need. Please make our life safe. Take care of infections and financial issues. Create clear,
transparent instruments of financial security so that we won’t have to cower in fear whenever we
get sick. So that we won’t end up hereditary bankrupts because our families spent all their money
on treatment for Grandpa ...”
The authors are planning to discuss the ideas set out in the Manifesto with the general public, since it’s us taxpayers who are the healthcare system’s main sponsors. It is the authors’ hope that the role of the Manifesto’s ambassadors will be filled by intellectuals - journalists, philosophers, historians - all those whose voice carries weight in our country.
“Choosing the head of the NHS is like choosing the President”: why it’s important to preserve the independence of new institutions
As a reminder: the reform’s first stage saw the creation of two full-fledged independent institutions: State Enterprise Medzakupivli and the National Health Service of Ukraine. According to Medzakupivli director Arsen Zhumadilov, they are the ones most at risk right now.
“These two institutions are most important for Ukrainians' access to medical services,” says Arsen Zhumadilov. “Yet for the past year we’ve been hanging by a thread. A year ago the NHS was under serious pressure; they are choosing a new head right now, and one of the candidates is against reforms. So I just don't understand how this person plans to fill that position.”
The first stage of the contest for the position of NHS head took place on April 2, leaving three candidates. Although the law prescribes a 45-day period after the contest’s announcement (April 30), interviews with the candidates still have not been scheduled. This suggests that the Ministry of Health might have its own priorities which are incompatible with the needs of patients. The Manifesto team suspects that the Ministry has plans for the NHS.
Not to forget, the last time the contest was held, back when Zoriana Skaletska was Minister, it failed, and since then we have had to make do with an acting chairperson rather than an actual one. This allows the Ministry to pull the agency’s strings and hinder its work whenever needed.
“The NHS is a new breed of institution,” says Tetyana Gavrysh. “Its processes, its transparency are tailored to fit the needs of the public and the citizen. Communities are already accustomed to being able to easily consult the team of any regional department. Choosing the head of the NHS is no less important than choosing the President, because this person represents the institution which is supposed to have our best interests in mind.”
However, cautions the lawyer, should this institution end up with someone in charge for whom the government’s needs outweigh those of the public, such a leader may agree to redirect funds from the guaranteed medicines program (formed from our tax money) to something else.
“The year will end, there will be no money left, and all this burden will fall on the shoulders of communities, which will either turn a blind eye to the black healthcare market or will try to make do some other way. Meanwhile patients will be facing greater burdens on their wallets and greater risks to their health.”
“Politicians must make a decision: say they are going to overcome a dangerous epidemic that is a threat to society in 5 years, or reduce disability or death rates from a certain illness. Based on such tasks, a course of action is determined which the NHS must follow as efficiently as possible and which should be formulated in the Strategy. It doesn’t exist though. Because of this, the NHS is in a suspended state. That is why we needed the Manifesto,” says Arsen Zhumadilov.
The system could harm the NHS simply and brutally, experts say, for instance, by cutting funding. Every year a portion of the budget is allocated for the state program of medical guarantees. This year it’s so small as to be almost insignificant - 2.63% of the GDP (118.5 billion), while, according to experts, it should be at least 4-5%. The funding may be reduced even further, just like it was with the “COVID-19 funds” that Minister Stepanov took from the state guarantees program, or with the 6.5 billion UAH for vaccines (5.2% of the program budget, taking into account the funds from the special vaccination fund), of which the Parliament returned to the program 3.35 billion on April 29.
The state should have reserves. “In a country where huge amounts are allocated for large-scale construction, cutting from the pie those tiny slices that served as a bonus for doctors working amidst the pandemic, with that pie already barely focused on the needs of the patients - this is simply prioritizing the Minister's PR over people’s needs. It’s immoral and irresponsible,” says Tetyana Gavrysh. The same populism had money that belonged to the program of medical guarantees taken away to support “struggling” hospitals - those unable to provide a proper level of medical services. As a result, effective doctors are not getting proper incentives, and patients are being deprived of quality services.”
Just as important as the NHS and the state guarantees program, experts say, is the independence of Medzakupivli whose task is to eliminate corruption in the procurement of medicines, which has always plagued Ukraine. After all, when all processes and money flows are concentrated in one place, such things are inevitable.
Head of Medzakupivli Arsen Zhumadilov, "Minister Stepanov reads my messages but doesn’t respond to them"
“When one institution deals with everything at once, including something that’s outside their employees’ expertise, it leads to problems with logistics, communication, registration. Thus, it took the Ministry of Health months to agree on the purchase of vaccines,”says Arsen Zhumadilov. “When it’s up to a single person in an agency to decide what to buy and from whom, it becomes tempting to buy something that only a certain company offers. We’ve been through that already - the corruption share back then was up to 40% of the funds. Meanwhile, we [Medzakupivli - ed.], once we started working in earnest in 2020, have received 14 billion from the budget and saved 3 billion hryvnias.”
Drug procurement could be outsourced to an international organization, but it’s fee would be higher than the cost of maintaining a state enterprise. In addition, when Medzakupivli buys something, the prices are transparent, and this puts pressure on the market.
During the COVID-19 year, Medzakupivli have done everything in their power to purchase vaccines and more. However, the Ministry of Health, citing internal regulations and procedures, was delaying giving answers and approval ad infinitum,” recalls Tetyana Gavrysh. “And yet no one at the NHS or Medzakupivli slammed the door and left.”
Victoria Tymoshevska is convinced that the fact that the key institutions created for the reform’s implementation have survived thus far proves the resilience of changes, of these organizations and the people who work there. “COVID-19 has been a real test. Yes, there were instances when not all processes worked effectively, when some patients didn’t get medical care immediately and in full, didn’t get medicines for free, yet strategically, the new institutions have passed the test.
According to Tetyana Gavrysh, it’s no longer an attack on a specific institution or even a specific sector. “We’re seeing an attack on similar institutions in other spheres, like culture: Ukrainian Cultural Foundation, Ukrainian State Film Agency, Dovzhenko Center, Suspilne … They all share similar values with a focus on people. The current government is trying to end them. The sustainability of these institutions is an investment in changing corporate culture in the state as a whole. What can we do? Press on. It’s a problem that should unite society.”
Ivan Kozlenko, “Democratic procedures in the field of culture no longer matter”
Consequently, the NHS must have a protected and independent voice, and the head of the NHS should enjoy a certain level of immunity and be free to pursue the agency’s policy and strategy, experts say. “This post must be no less respected than that of the head of the Supreme Court or the Minister of Interior, for the decisions of this individual directly impact the quality of life of every single resident of Ukraine.”
Some on the team have a more optimistic outlook though. “Institutions cannot be completely destroyed because they are protected by the law of common sense,” says Volodymyr Kurpita, director general of the Health Ministry’s Public Health Center in 2018-2019. “Political conflicts may lead to the decline of some institutions, but they also stimulate the emergence of new ones. Those institutions that survive will be stronger for it, they will find safeguards and master communication skills.”
Politicians plan within their term, institutions plan decades ahead,” stresses Arsen Zhumadilov. “Political officials have this illusion that they represent public interests. However, it’s institutions, which work with the recipients of their services for years, that truly understand the people (including by conducting research, in-depth surveys of public opinion, as well as testing new ideas) and actually represent them.
Today's attacks on institutions seems like a continuation of the “corporate culture of the state”, with each subsequent political elite trying to destroy everything that was done under the previous government.
“Communities are more likely than the government to appreciate the importance of a healthy person”
The new system was formed as a result of the decentralization and healthcare funding reforms, so it’s the communities that own medical institutions. About 60% of a community's budget comes from taxes paid by people working there, and it’s usually the healthy ones that do most of the work. This means that communities are very invested in having as many healthy people as possible, so they are more likely than the government to appreciate the importance of a healthy person.
Public health is a factor that affects, among other things, the level of attractiveness for investment. Employers considering where to open a farm or factory want to know what kind of infrastructure will be available to their employees. Good medical care, disease prevention as well as medical and social services programs are always a plus here.
Victoria Tymoshevska encourages community leaders to learn how exactly healthcare gets its funding, what is guaranteed at the national level and what the community must provide for itself, what their needs are, what tools are available for raising additional funds and ensuring effective governance and decision making.
“We’re seeing plenty of examples where good leadership by heads of local medical institutions and active cooperation with local governments yields phenomenal results. Of course, there are other examples too, when local governments appoint leaders based on their own interests and when hasty decisions resulting from hands-on supervision are meant to plug holes in a sinking ship. It’s noticeable by the way you are greeted at the registration desk, or from the list of medicines which you must pay for,” says Victoria Tymoshevska.
“Even the best clinic administrators, insist the Manifesto’s authors, won’t be able to transform their institutions without cooperation with the local community, because it’s the communities that ultimately influence all the key aspects: prices of paid services, renovation, equipment, even the amount of services a hospital can provide, since all of this is determined by the conditions and investments that the community provides to the hospital.”
“There’s allegedly no money for healthcare, yet 16 billion UAH paid to clinics by the NHS last year still remain on the clinics’ bank accounts,” says Pavlo Kovtoniuk. “Clinics have no idea what to do with this money. They used to get instructions from those up the chain of command, but now the “accursed healthcare reform” has done away with that. The vision must come from the public, not from the powers that be. It is the communities that clinics belong to. What do they want from them? What should they be like in five years? So far, only a few are thinking in these terms, yet even those few have been a great success. The current government should be trying to turn these few into tens and hundreds, but instead they are busy fighting these institutions. For them, the reform is not the mission but a burden.”
Volodymyr Kurpita insists, “It’s necessary to support communities, to create planning and monitoring mechanisms, to map out existing health infrastructure and teach them to take pride in their accomplishments. These could be local projects - support for people with disabilities, pregnant women and children, controlled treatment of tuberculosis ... “
“It’s on the NHS to pay for the services offered by the hospital; to make sure that patients won’t be fooled in a hospital by paying for something that should have come at the state’s expense. The NHS has a hotline for this which people can call to protect their rights. In time, the NHS should also start monitoring the quality of medical services.”
Then there’s the government, which can provide funding through the state program. However, its first duty is to ensure proper qualifications of doctors: provide them with good education, handle their access to practicing, and monitor the quality of their work. The government is also responsible for industry standards, which, lament the Manifesto’s authors, leave much to be desired.
Another important aspect is the issue of freedom. As Pavlo Kovtoniuk says, “Most doctors are not free thinkers, it’s our post-Soviet legacy. However, for some of them it’s no longer true, and they should be building a zone of freedom around themselves - in their ward, in their clinic, in their community. They should be banding together and fighting for what is theirs by right. They should be disgusted when a populist minister trying to buy their loyalty with empty promises of raised wages. It is the law itself, not some minister, that gives them the right to proper remuneration.”
To nurture a generation of free doctors, we must change medical education, believes Volodymyr Kurpita. We must revise the government’s entire policy in this regard. “We must finally start teaching English properly. Bring in teachers from other countries. Teach soft skills: leadership, communication, financial literacy, doctors’ rights ...”
A free doctor is someone who uses his or her skills transparently to earn a living, says Arsen Zhumadilov. “The rules must be easy for patients to understand: they should either be paying more taxes and getting free healthcare, or paying no taxes and paying for medical services. We need to stop lying and regulate two things: employment relations between the doctor and the clinic, as well as the market relations when medical services are purchased on the market.”
“Everything has changed for family doctors. As long as you’re a professional, patients will come to you. Things get more tricky when it comes to secondary care though. There’s still work to be done here to allow doctors to painlessly transfer to another clinic, one that’s more interested in them and the recognition they enjoy among patients,” says Arsen Zhumadilov.
For secondary care, the NHS should introduce monitoring measures and establish public ratings. This will allow people to find out, for instance, that there’s a great cardiologist in the town where they live, one that everyone goes to; that cardiologist will also find it easier to ask for a raise if there’s hard proof that people value his services.
“The old system is like Agent Smith from The Matrix; so what’s next?”
“The Manifesto was a chance for us to formulate the ideas and views we believe in,” says Pavlo Kovtoniuk. “We didn’t want it to be a technical document, some Development and Happiness Strategy 2030, which old-school politicians would pretend hard to be implementing. The old system is like Agent Smith from The Matrix - it can masquerade as anyone. Which is why it just loves such documents. It cherry picks words and terms under which it covers the pile of shit that this system actually is.
However, the next stage for us is technical work. My colleagues are working on the issue of hospital self-government. We at the Ukrainian Health Center are working on the issues of financial justice, hospital management, and work with communities.”
Any attempts to weave a new healthcare reform strategy with the aim of improving the old by grafting on the new are doomed, say the authors of the Manifesto. It is this approach that causes problems with the secondary care reform, so that neither clinics nor patients have felt the changes to the degree they would have if the reform’s second phase had been launched on schedule.
Pavlo Kovtoniuk believes, the public should flock to the new institutions and defend them.
“Our Manifesto is a way for progressive citizens to regroup. In 2019, some wanted to believe that everything would be like a movie. To end a war, all you need is stop shooting. You have a debt - just don’t pay it back. You’ve got poverty - just print more money. It’s time for our society to grow up and be prepared to pay a hefty price in the process.”
Experts say, those who are ready to be adults should be building a dialogue on values. “I’m counting on the leaders of public opinion and awareness-raising via representative groups,” says Volodymyr Kurpita. “Each of us has our own circle, and it’s from these circles that we should start discussing values and the future strategy.”
As for concrete actions for the development of fundamental documents, last time the team that was tasked with the development of the Strategy worked with the Cabinet of Minister and the Patients of Ukraine NGO. The process can also be initiated and adopted by the Parliament. It all depends on who’s willing to take the lead. The Cabinet and the Parliament should be working in tandem on this, as the Strategy’s implementation will require legislative initiatives and changes. A whole slew of issues will need to be addressed, including those related to medical education, access to the profession, quality of services, as well as established standards.
Yet, as the experts reiterate, the transformation processes don’t just depend on the government. The ideas of the Manifesto are a clear guide for responsible communities and their leaders, for heads of medical institutions as well as businesses that are willing to invest in the future of their communities. They are for every citizen, because the issue of healthcare has a very real individual dimension.
“The Manifesto is written for the people,” says the team. “It concerns all of us. It can be put off, but this is about our lives. So we go forth now. We have every reason to.”