by Kostyantyn Maleoniuk
A second phase of the medical reforms has begun in Ukraine in the midst of the COVID-19 pandemic.
The reform will cut off some hospitals from funding and in no way improve the situation of others. The main object of the reform is to divert the scant state funding to private medical centres. In this case, the reduction of medical staff, which, as the epidemic has shown, is sorely lacking, will continue. Health trade union are opposing this reform. We publish below an analysis from the independent left media site Politychna Krytyka (Політична Критика) on 25 March, on the situation.
The coronavirus pandemic is a social problem. It exposes lacunas in state labour legislation and in the field of health. Ukrainians are at the moment asking themselves: will I be paid my wages if my workplace has shut down due to the quarantine? Will I have money to pay the rent and utility bills? When will the testing for coronavirus arrive in my city? Will there be the necessary equipment for treatment of the COVID patients in the infectious diseases clinic? What will happen if I get ill, and I don’t have enough money for the treatment? Will the state help me?
These are completely reasonable questions, since a free health system is guaranteed under the Constitution. It’s a different matter that the reality differs greatly from those de jure rights. Often Ukrainians are forced to do without those rights, if their or their loved ones have a heart attack or a stroke or are diagnosed with cancer. Thus, changes to this situation were meant to be instituted through the reform of the health system.
“MONEY FOLLOWS THE PATIENT”: THE BASIS FOR THE REFORM[YY1]
The reform of the health system was introduced by the Ministry of Health under the leadership of Ulyana Suprun in 2016. In December 2017 the National Health Service of Ukraine (NHSU) was created – a key element in the reform of financing the health care system. The first stage of the reform began in April 2018 and tackled primary health care: in order to get free medical help the patient must sign a declaration with a family doctor, therapist or pediatrician. A system of electronic documentation called eHealth and a programme of “affordable medication” were also introduced free or at a fraction of the cost for people with cardiovascular problems, Type 2Diabetes or in need of asthma medication .
The second stage, which was to begin on 1 April 2020, foresees changes in the medical practices/clinics according to the “money follows the patient” principle. That is to say the NHSU will finance clinics not on the basis of the numbers of beds but on the number and nature of the medical services provided to a concrete number of patients. In order to obtain financing a medical clinic must reorganise itself into a Community Non-commercial Enterprise (KNP). In this way the clinic becomes a seller of medical services, and the NHSU the buyer. The clinic then decides how to spend the money received from the NHSU.
The main regulation of the health service reform is the law “On financial guarantees of public medical services by the state”. The law lists the medical services, which the state will pay in full for a given patient according to set financial tariffs: primary healthcare, emergency services, childbirth, in-patient hospital stay, at-home care services, the services of specialist doctors in the clinics and palliative care. Excluded from the free care are the services such as infertility treatment; dental care, the treatment of alcoholism and drug addiction and such. Doctors’ wages are not regulated by the state and they are not tied to the tariffs. They are regulated by collective labour agreements – this can be a percentage of the cost of services provided to patients or a fixed sum per month. The wages of some primary healthcare doctors have increased a lot and could even reach 30,000 hryvni (circa £900 per month). In others it hasn’t changed at all. But it is doubtful that abandoning the tariff framework and the lowering of tariffs for medical services will lead to an increase in wages for the doctors on the second or third health care tiers Thus medical staff were forced to take protest actions.
THE GAPS IN THE HEALTH SERVICE REFORM. WHAT FACTORS DID THE GOVERNMENT NOT TAKE ACCOUNT OF?
The trade unions of the healthcare staff began their protests against the introduction of the reform of the health service three years ago. The movement of nurses called Be like Nina appeared in December 2019, fighting for an increase of wages of the middle to junior medical personnel. At the moment they get on average 3,000 hryvni a month (circa £90 a month). The authors of the reform knowingly ignored them, which is why the second protest of the nurses focussed on the reform.
The optimization drive, which was proposed by the government, foresaw a decrease of personnel numbers, a closure of regional medical hospitals, many tuberculosis and psychiatric clinics throughout the country. Doctors fear that the lack of finances means that the state will not be able to pay for the state guaranteed medical services and therefore patients will continue to have to line doctor’s pocket to get treatment. And although ministry officials are insisting on the progressiveness of the reform which they simply don’t understand, and President Volodymyr Zelenskyi has stated that the reform process must be completed, the head of the Free Trade Union of medical workers of Ukraine Oleh Panasenko calls this reform “a ruination of the health sector of our country”.
“While the medical reform was being introduced and the law passed about the financing of medical guarantees, we as a trade union put forward proposals”, said Serhiy Kubanskyi, the head of the Kyiv Council of the city trade union of health service workers. “It’s understood that the changes in the system were long overdue. The situation did not satisfy neither the doctors nor the patients. There were many good things included in the law.”
Among the main positive changes Serhiy underlined the legal stipulations of the rates of financing of the state-guaranteed medical services at no less than 5% of the GDP. Whereas in the past no more than 4% was allocated to finance the health service of the country.
Another positive initiative was the inclusion of coefficients in formulating tariffs for medical services, which would go towards paying the doctors’ wages. And as of 1 July 2019 the rate of doctor’s wages would constitute 250% of the average wage in Ukraine. This is 27,495 hryvni. This rate was secured in law.
Serhij continued, “The problem is that in the third year of the reform all these rates are still not being implemented. In 2018 the health service was financed by 3.7% of the GDP, and in 2019 3.2%. When we saw this year’s budget, we carried out protest actions at the Verkhovna Rada and the Cabinet. Instead of the 5%, the funding of the health service was 2.9%. At a the very minimum the medical guarantees require 220 billion hryvni, but only 72 billion were allocated – this is 1.6% of the GDP.” The financing of the tariffs of health services was decreased, and the coefficients of the increments to doctors’ wages were not included. Thus, according to the NHSU tariffs, the visits to an ENT specialist or an optometrist in the clinic would cost 49 hryvni. Within this sum, besides paying the doctor, the costs of paying the nurses, the cleaners, cost of the medical clothing, the administration and other personnel of the clinic out to be included. As it is not possible to cover all these costs of the medical service at the set rate, the patient has to supplement the costs to the doctor or go to the pharmacy to buy the necessary medication with own money. This is despsite the former leader of the NHSU Oleh Petrenko’s assurances to the patients that medical services would be free.
“The NHSU is proposing inadequate tariffs: 16,000 hryvni to cover the treatment of strokes, although a minimum of 80,000 is needed. The treatment of one tooth is allocated 9 hryvni, but today it costs a minimum of 500 hryvni,” according to Oleh Panasenko, the head of the Free trade union of medical workers of Ukraine. “Our trade union is participating in protest actions against the health service reforms of 2017. We warned even then that the law on the government financial guarantees is deceiving our citizens. This is a concentration of money in the hands of one organisation. The NHSU is a monopoly. It decides how to allocate the money, but neither parliamentary deputies nor the Health ministry have the right to verify whether the money is being spent properly. The state is handing over its responsibility to protect health to the NHSU. This is called decentralisation, but the money is still being allocated to one place.”
“BE LIKE NINA”. NURSES FOR A WAGE THEY DESERVE
The first protest action by nurses took place on 19 December 2019. Nina Kozlovska initiated this movement; she is working at the Kyiv-Svyatoshinskyi central regional hospital. She said, “I have worked for 25 years at a senior level and a higher category, but my pay is 3323 hryvni (circa £100). Because of this wage, many nurses have left the service and gone to work abroad. We are being forced to work day and night. One day I came home exhausted from work and I wrote a post expressing my hurt: no one is paying attention to us, let’s go out and declare about our problems. Within two days the post got 20,000 hits. Colleagues started to write to me and we formed a group on Facebook.”
Parallel to the protest action took place in Kyiv and in Lviv. The Nina movement was supported by Oksana Slobodyana, who works as a nurse in the Lviv City children’s medical clinic/hospital. She explained: “I read Nina Kozlovksa’s post and I saw in the comments that many people were attacking her. I got angry about this. I wrote a supportive post, and after this we started to collaborate. We phoned colleagues and asked whether they would come out with us, I thought maybe 15 people or so would. We were very surprised that there were some 300 people.”
For assistance in organising the meeting, Oksana turned to human rights defender Iryna Yuzyk from the CSO “Narodna Diya Lviv”. With the support of the anarchistic initiative “Black banner” they helped the nurses organise their first protest action.
At the end of December the members of the movement Be like Nina handed in documentation to the Justice Ministry to create the all-Ukrainian union of medical staff, but the ministry is dragging its feet on this and by mid-March they had still not been registered.
The second protest action took place on 26 February 2020. A resolution was adopted at the meeting, which was then sent to Zoryana Skaletskya, then Minister of Health, with demands to stop the closure of medical facilities and the decrease of medical personnel and to conduct a parliamentary hearing with the participation of medical professionals from the whole country and from the Ministry of Health. The members of the movement Be like Nina were planning a further protest action in March, but they were forced to abandon their plans because of the quarantine, which will last until at least 3 April [at the time of writing].
Nevertheless, Nina Kozlovska has no intention of stopping: “we want to believe that we will achieve a result, because this is a problem for the whole of Ukraine. I like medicine, I like my job, I like to help people. I do not want to resign. It would be better if the state would change its attitude to the medical profession and begin to pay the wages we deserve. The medical profession already sees what the reform will lead to, but the patients can’t see it yet.”
“THE REFORM WILL SPELL BLOOD ” – THE OPTIMIZATION OF MEDICAL FACILITIES.
Ulyana Suprun, carrying out her duties at the Ministry of Health, declared that the treatment of tuberculosis was not necessary to be carried out in hospitals. Thus from 1 April 2020 the reform of the tuberculosis clinics will begin. Now an ill person can be treated within the home by the family doctor, and the tuberculosis clinics (there are currently 93 in Ukraine) will be “optimised” This in its turn will lead to mass sackings, so the workers of the tuberculosis clinics are already protesting across the whole country. Many have joined actions in Kyiv and Lviv. After a meeting in Lviv the representative of the city department of public health stated that the medical staff would be transferred to other hospitals/clinics. But a decrease in staff is taking place in those hospitals/clinics too. Thus according to one of the officials, optimization cannot take place without some losses. “The reform will spell much blood”.
Other medical workers are also threatened with losing their jobs. Medical workers in all of Ukraine in February began to receive “letters of joy” about either cuts in their wages or even job losses. Serhiy Kubanskyi from the Kyiv city trade union of medical professionals in the health service said: “these warnings were unlawful, because no director of a medical facility knows what they will receive on 1 April 2020. Our union has turned to the Kyiv city state administration which listened to and supported us, after which these letters became less widespread in Kyiv as elsewhere in Ukraine.”
Another problem has arisen: the small clinics cannot work with the NHSU, because they do comply with the criteria of the specification of a given service. As explained by Serhiy Kubanskyi: “There are supposed to be three anaesthetists in a medical facility, but in a district hospital there is only one, because only one is needed. Also in each neurological department there should be a computerized (tomography device, but this is very expensive equipment.” If these requirements are not met, the medical facility cannot sign a contract with NHSU and obtain funding.
THE EPIDEMIC HAS UNDERMINED THE REFORM OF THE HEALTH SERVICE
On 22 March the Minister of Health Illya Yemets proposed to postpone the implementation of the reform for three months, in order “not to close those clinics which at the moment are working”. As an example he pointed to the Kyiv clinic of microsurgery (the “Eye”) which carries out 17,000 operations on eyes, mainly pensioners’. The clinic had not signed a contract with NHSU, and as of 1 April should have lost its funding. At the moment, according to the Minister, the clinic would not be closed down. However, the following day information appeared on mass media that Illya Yemets may be leaving his post. But irrespective of the name of the Ministry, it is obvious that the health sector of Ukraine was not prepared for the pandemic. After the introduction of the quarantine, the medical staff faced additional problems. The closure of inter-city transport hit many doctors and nurses who struggle to get to work. The doctors don’t have protective equipment against the virus, there are not even enough ordinary masks for everyone, not to speak of other protective clothing. Tests are lacking as well as other equipment necessary for treatment. Thus today medical staff are risking their lives while caring for their patients – and they are doing this without adequate wages, normal working conditions or an assurance that in the near future they will not be “optimised”.
The artist is the creator of beautiful things. To reveal art and conceal the artist is art’s aim. The critic is he who can translate into another manner or a new material his impression of beautiful things.