Despite starting under similar conditions as its neighbors, Ukraine has seen its health care system deteriorate over the years.
While funding continues to be a major issue, experts note that knowing how to spend the money wisely is at least as important as the amount itself.
While Ukrainians’ health has clearly improved since the 1990s, it is still far below that of their neighbors. At 68 years, the country ranks 120th in terms of life expectancy.
The outlook for men alone is even bleaker: A life expectancy of about 62 years places Ukraine between North Korea and Pakistan, both failing states.
Nation squanders best parts of Soviet legacy
The toxic brew of high mortality rates, destitution and growing tuberculosis and AIDS epidemics has led to a demographic disaster.
Despite an inflow of ethnic Ukrainians after the Soviet collapse that gave Ukraine the world’s fourth largest foreign-born population in 2005, the country has nonetheless lost 6 million citizens in its 20 years of independence.
Yet it is not the dismal state of health care in Ukraine that is surprising, but rather how poorly the country is faring given its relatively solid fundamentals. Indeed, the Soviet system, for all its faults, left behind a large number of highly trained personnel and a decent primary care infrastructure.
Nor is this solely an issue of funding. According to the World Health Organization, in previous years total health spending in Ukraine amounted to 7 percent of gross domestic product, comparable to Ireland or the Czech Republic.
As Dr. Igor Pokanevych, WHO country head for Ukraine, points out, half of this money comes from private citizens or non-state sources, while the other is often misspent.
Indeed, having inherited a highly centralized post-Soviet health care system, the independent state decided to decentralize.
According to Pokanevych, the central authorities found themselves unable to foot the health bill and decided to mobilize resources at lower levels of government to respond to local needs.
This, however, ignored local financing limitations and created a fragmented system unable to effectively make use of the available resources.
As a result, hospital administrations became bloated, eating up much of the state funds received.
Moreover, Pokanevych said, hospital funding is based on the number of beds and staff, rather than effectiveness and efficiency. “This is why Ukraine has almost two times more beds per capita than the EU average,” he explained.
Meanwhile, the private sector, which saw a boom in numerous Central European countries, is still at the fledgling stage in Ukraine.
Pointing to the fact that Ukraine’s pharmaceutical market is worth just 2 million euros, a fraction compared to neighboring Poland, Krzysztof Siedlecki, country manager for the international pharmaceutical giant Astellas Pharma, also highlighted the upside.
“The market is profitable, but more than that, it has an almost exclusive prospect – immense growth possibilities,” he said.
Yet while this may appeal to investors, it also reflects the failures of the state. “The idea of free medical services is a fiction,” Siedlecki said, “Practically the whole pharmaceutical market is paid for out-of-pocket.”
Moreover, the small size of the market is a constraint for growth. After 18 years of working in Ukraine, Boris, a private health service provider, managed to open clinics in Kyiv which serve 300-400 patients per day on average. It hopes to open two clinics, in Kharkiv and Donetsk, by the end of this year.
“We have only one main barrier for expansion. This is the financial situation of the nation. The more solvent the population in Ukraine is, the further we will be able to expand,” said Mykhaylo Radutsky, president of Boris.
One consultation with a specialist in Boris clinic costs Hr 400, close to half the minimum monthly wage. Radutsky said their services are for representatives of the middle and upper-middle class, which is growing very slowly.
Corruption is the next biggest problem. “It’s bribes, it’s money in pockets, it’s when a doctor works in the state hospital, uses state equipment, but takes money from the patient for the treatment,” Radutsky said. He also deplored the lack of a compulsory medical insurance.
The absence of a proper legal environment is indeed a major barrier. Ponakevych noted that hospitals could benefit by outsourcing non-essential services, such as cooking and cleaning, through private-public partnerships, but that current rules made this impossible.
He also pointed to an even more absurd case: private clinics cannot issue certificates of illness, needed by employers and insurances services. As the Kyiv Post found out, in order to bypass this barrier, clinics use a foggy legal procedure of going through other private, unlicensed entities.
Yet others think mentality is also blocking the way to better health for Ukrainians.
“We have one key problem. It is not even money. It is the silent patient,” said Viktor Serdyuk, president of the All-Ukrainian Council For Patients’ Rights and Safety.
“People have kind of phobia, that if they say something they will be treated badly. That’s why they do not stand up for their rights and don’t know how to do that.”
Serdyuk’s council consults people about the possible risks of certain medical procedures and gives legal support if their health was damaged during treatment.
Over 10 years, Serdyuk has heard many horror stories of medical procedures gone wrong. To improve the situation, his council — together with state officials – is currently developing a national action plan on patients’ security which should be adopted by 2015, so as to meet Ukraine’s obligations to the Council of Europe.
Indeed, experts are united in their calls for a clear national program to improve health care. According to Pokanevych, managerial and financial functions should also be moved from the regional to oblast (state) level, where they can be better coordinated, and hospitals should create networks, each specializing in certain areas.
This is one of the key factors behind the recent success of Moldova and Kyrgyzstan, he said.
President Viktor Yanukovych has developed a program focusing on four key issues: access, quality, financing and creating a culture of healthy living.
The program, which involves greater emphasis on primary care, will be tested in four regions: Donetsk, Vinnytsia and Dnipropetrovsk oblasts, as well as Kyiv. Depending on its success, it will go national after 2014.
Pokanevych, however, remains skeptical. “We always hope it will be successful, and the WHO is assisting in the reform process, but a national strategy is lacking. What we have is an economic program, but no clear plan, with clear actions and responsibilities,” he said.
Meanwhile, the draft 2012 budget shows that total health expenditures for up to one million civil servants are set at Hr 2.6 billion, or more than a quarter of all health spending – a sign of where the priorities lie.
Staff writers Jakub Parusinski and Oksana Faryna can be reached at [email protected], [email protected]
