THE FOUNDATION OF AN EFFECTIVE HEALTH CARE SYSTEM OF UKRAINE – FAMILY MEDICINE
Wprowadzenie systemu efektywnej opieki medycznej na Ukrainie – medycyny rodzinnej
Oleh G. Shekera
Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
The article discusses approaches to the reforming of the Health Care System of Ukraine, the key objectives of which are: the strengthening of preventive services, the increasing of availability and quality of health care, the enhancement of primary health care, the improving of personnel maintenance, infrastructure upgrading and the equity in health care. Conclusions: Any measures aimed at the modernization of the health care system should be accompanied by joint efforts of all parties (patients, the medical community, legislative and executive authorities, as well as local authorities) to ensure the interest of health workers and the population in an effective health care system in Ukraine.
Key words: the reforming of the Health Care System, primary health care, family medicine, the Institute of Family Medicine, health
Wiad Lek 2019, 72, 1, 107-111
Human health is the basis for the formation of a harmonious and fully developed personality, and therefore can be recognized as one of the greatest values and objective needs of the evolution of any community. The famous German philosopher Schopenhauer wrote: “Health before exceeds all other benefits of the person that truly the healthy beggar is happier than the sick king”. The world health organization (who) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is generally accepted.
In the 21st century the importance of health is significantly rethought, taking into account its understanding as an inalienable right, from the point of view of existing threats and challenges, the growing requirements for the quality of health, technological and financial capabilities of its provision.
Despite the significant progress made in recent years in terms of promoting health and life expectancy, the relative improvement among countries and at the level of individual countries had varied. Globally, more than 400 million people still lack access to basic health services. Where they are available, these health services are often fragmented or of poor quality, leaving the health system’s response to these problems and satisfaction with health services in many countries low. For example, in Ukraine, as in most European countries, a significant problem is the prevalence of chronic non-communicable diseases and their risk factors. The high prevalence of chronic non-communicable diseases is a priority public health problem that has a negative impact on the health and demographic situation and leads to high levels of morbidity, disability, mortality, poor quality of life and short life expectancy. Poor health of the population is characterized by low birth rate, high mortality, negative natural growth and demographic aging, increasing the overall burden of disease.
In accordance with resolution WHA62.12 health Assembly primary health care, including the strengthening of the health system and other relevant resolutions the Secretariat of the world health organization has developed a framework for integrated, socially-oriented health services. The framework includes five independent strategic goals for more comprehensive and people-centred health services. It provides for the necessity of reforms with a view to reorienting health services so that they were completely focused on the needs of individuals, families, carers and communities and receive support from responsive services that more fully meet their needs and would coordinate their work within the framework of the health sector and beyond, regardless of the context or status of development of the country. These reforms also include an appropriate human rights approach that enshrines access to health care as a fundamental human right without any distinction based on ethnicity, religion, gender, age, disability, political beliefs, and economic or social conditions [1, 2].
Today, the total mortality of the population and mortality from individual causes in Ukraine is twice higher than the corresponding indicators of the European Union. Of particular concern is the problem of premature mortality of men of working age, which is 3.5 times higher than that of the female population. In 2016, life expectancy in Ukraine was 7.7 years shorter than the average in the European Union, and in men – almost 12.1 years. The average life expectancy of the population is 70.1 years, which causes its gap with the European average of 6, and with the indicators of the EU countries – up to 10.3 years.
According to resolution WHA62.12, (Strategy 3). Reorientation of the model of health means creating conditions in which effective and efficient health services are developed, financed and provided in accordance with innovative models of health in which priority is given to primary and community health services and collective action for health promotion. This implies a shift in the focus of inpatient care to polyclinic care and outpatient care (primary care), as well as a shift from treatment to prevention.
The peculiarity of health care is that the user of its services is the entire population. Each person during his life repeatedly becomes a patient of medical institutions. Every year in Europe in hospitals hospitalized about 18 % of the population, or one in five. In outpatient institutions (for primary care) patients annually treated, on average, about 6-10 times. Emergency services in different countries during the year are used by 10.0 to 25.0% of the population, that is, every fifth – tenth resident. Chronic pathology affects up to 60% of adults and almost 20% of children. The trend towards the deterioration of the health status of young people, the increase in the frequency of socially dangerous diseases, including tuberculosis and HIV/AIDS, mental disorders and the like, is of concern.
The situation, which has developed as a result of a number of objective and subjective reasons, is a real threat to the emergence and development of irreversible processes in the state of physical and mental health of the population of the country and, as a result, can adversely affect the socio – economic, political, spiritual development of the Ukrainian nation as a whole, which poses a threat to the national interests of the state.
This implies the need to invest in an integrated and comprehensive health system, including health promotion and the implementation of strategies to prevent health deterioration that help to maintain health and well-being at the appropriate level, and respect gender and cultural advantages in the planning and operation of health services.
REVIEW AND DISCUSSION
Today, the health care system of Ukraine does not fully meet the needs of the population in affordable, high-quality and effective medical care. Previous reforms in the field of health care have not produced the desired result due to the fact that they were inconsistent, mostly fragmented, in General, without changing the outdated system of health care since the time of the planned economy, which made it impossible to adapt it to market relations.
In this regard, it is necessary to develop a strategic approach to the development of the health care system in Ukraine and to identify priorities in the field of medical services based on the needs throughout the life cycle. This approach means assessing the full range of health services that are offered at different levels of the health system, based on the best available data and designed for the entire life cycle. This involves the appropriate combination of methods to understand how the specific needs of the population in the areas of health, including social benefits and costs of alternative interventions on the level of the health system, which should serve as a guide in the decision-making process on the allocation of resources to health care.
Policy options and interventions: assessment of local health needs based on existing characteristics of communicable and non-communicable diseases; full range of services for all population groups, defined through a transparent process of joint decision-making; strategic approach to procurement; public health care; assessment of health technologies.
Reassessment of the principle of health promotion, prevention and public health. This approach means an increased focus on prevention and the quality of health care in activities and in the allocation of health resources.
Policy options and interventions: monitoring the health status of the population; stratification of the population by level of risk; surveillance, research and control of risks and threats to human health; increasing financial and human resources allocated to health promotion and disease prevention; regulatory and legal regulation of public health relations and their enforcement.
Establishment of reliable systems based on primary health care. To reach the entire population and guarantee universal access to services, a reliable system of services based on primary health care is needed. The establishment of such a health system requires adequate funding, adequate training and links with other services and sectors. This approach involves strengthening the coordination and delivery of health care on a continuous basis over a long period of time for those people who have health problems, which contributes to the adoption of the necessary measures in the field of health at all levels. In addition, it involves the establishment of a comprehensive health system focused on the needs of the individual, the family and the community, as one of the main areas of practice with a focus on disease prevention and health promotion.
Policy options and interventions: services in the field of primary health care focused on the needs of the individual, family and community; multidisciplinary approach to primary care; General practitioners and family doctors; coordination with the aim of providing access to other types of medical care; increasing the share of budget funds (medical subsidy) on primary health care.
A shift in the focus of work towards health care at the level of primary health care centres and outpatient clinics. This is the process of replacing one type of care with another, more effective for the health system. This approach is to find the right balance between emergency, primary care, secondary (specialized), tertiary (highly specialized) care, palliative care and medical rehabilitation, while recognizing that each of these types of care plays an important role in the health system.
Policy options and interventions: medical care at the patient’s place of residence; health care facilities for patients with chronic and incurable diseases; reorientation of second-level hospitals only to provide medical care in case of acute and complex conditions; outpatient surgery; day hospital; provision of medical care to patients in the acute period of the disease.
Update and implementation of new technologies. Rapid technological progress makes it possible to develop and implement innovative technologies in the health care system. In case of proper use they can provide the continuity of the recording information, to track the quality of health care, facilitate empowerment of patients and reach communities living in conditions of geographical isolation (mountain areas and remote rural settlements).
Policy options and interventions: the electronic medical record that is used on a joint basis (the patient and healthcare institution); telemedicine; timely medical assistance.
In this regard, in modern conditions, the health system is faced with new challenges to strengthen preventive services, improve the availability and quality of health care, improve primary health care, improve staffing, modernize infrastructure and ensure equity in health care. The existing health problems are not easy to solve, have a multidimensional complex nature, which necessitates the updating of health policy, the development and implementation of new strategies and programs. Modernization of health care concerns important professional and moral issues, affects the interests of many stakeholders, including medical staff and patients. Their opposition to innovations strengthens the conservatism of the industry.
Family medicine plays a decisive role in solving public health problems and improving its determinants, reducing the prevalence of risk factors, in the introduction of modern strategies for the prevention of chronic noncommunicable diseases and the formation of a healthy lifestyle. General medical practice should be considered as one that provides long-term care for the health of the patient and all members of his family, regardless of the nature of the disease, the state of organs and systems of the body, age, psycho-emotional, professional and other features.
In order to ensure the qualitative results of the reforms in the field of health care, it is necessary to conduct a detailed analysis of the improvement of health care in previous years.
So, in 2004 the program of activity of the Cabinet of Ministers of Ukraine “Sequence was recognized as satisfactory. Efficiency. Responsibility”, approved by the Decree of the Verkhovna Rada of Ukraine on 16.03.2004. N 1602-IV, including, on health protection. By the decree of the President of Ukraine of 28.04.2004 N 493/2004 the Strategy of economic and social development of Ukraine “By European integration” for 2004 – 2015 was approved .
For development and introduction of system of an assessment and quality control of primary health care on the principles of family medicine in Komsomolsk of the Poltava region experiment (the order of Ministry of health of Ukraine of 16.01.2004 N 16) on implementation of the project of development of local government which consisted in creation of modern innovative model of rendering high-quality medical services to the population was carried out.
In these years, according to the order of the Ministry of health of Ukraine from g 17.02.2004. H 88, also the experiment was conducted in five regions of Ukraine to develop a method of differentiated distribution of funds by levels of medical care, taking into account the needs of primary health care on the principles of family medicine.
In addition, in cooperation with the European Union, the experiment was conducted, according to the order of the Ministry of health of Ukraine from 06.07.2004. N 338 “about carrying out experiment with the international participation on introduction of modern model of family medicine in the Autonomous Republic of Crimea, Zaporozhye and Khmelnytsky areas”.
In the future, new, responsible tasks for the further development of family medicine were outlined in the “National program for the development of primary health care on the principles of family medicine for the period up to 2011”, approved by the Law of Ukraine from 22.01.2010 N 1841-VI; Resolution of the Cabinet of Ministers of Ukraine “Some issues of improving the health care system” d from 17.02.2010. H 208; Laws of Ukraine “on amendments to the Basics of the legislation of Ukraine on health care regarding the improvement of medical care” from 07.07.2011. 3611 n-you “on the procedure for reforming the healthcare system in Vinnytsia, Dnipropetrovsk, Donetsk regions and Kyiv” from 07.07.2011 g N 3612-VI. [3, 6]
In order to create appropriate conditions for the implementation of the principles of family medicine in the activities of primary health care institutions, the Ministry of health of Ukraine has developed and approved a package of normative documents regulating the technology of family medicine. Further development of family medicine in Ukraine was focused on the achievement of the European level, according to the strategy of the world health organization “Fundamentals of health policy for all in the European region” (“Health-XXI”).
Health 2020 is the Foundation of the new European health policy. It aims to support the actions of the entire state and society to “significantly improve the health and well-being of the population, reduce health inequalities, strengthen public health and ensure the availability of universal, sustainable and high-quality human-centred health systems”.
The formation and implementation of an integrated intersectoral approach is an important prerequisite for the successful implementation of modern strategic objectives in the field of health, including preventive measures to eliminate the negative impact of social determinants of health, creating conditions for the preservation and strengthening of public health, healthy lifestyles, the formation of responsible attitude of each person to personal health. In Ukraine, the optimization of the system of medical care to the population is supposed to be carried out through the priority development of primary and emergency medical care, differentiation of inpatient medical care, improvement of the system of rehabilitation, palliative care and medical rehabilitation with the transition from public funding of health institutions to the financing of measures to provide medical care to the population, based on its needs.
On 06.04.2017, the Verkhovna Rada of Ukraine adopted the Law of Ukraine” on amendments to some legislative acts of Ukraine on improvement of legislation on health issues”. The need for the adoption of this Law is caused by the following.
The existing health care system in Ukraine does not meet the needs of the population in the field of health care, because it is outdated and such that it is slowly implementing international experience and trends in strengthening health systems, which in turn limits the access of all citizens to the provision of health care of appropriate quality. Households spend a significant part of the funds for the purchase of medicines and medical services. All this creates financial barriers to access to health care, especially for the poor, and often leads to financial crisis and impoverishment.
The discrepancy between the health care system and the needs of the population is largely due to the structural inefficiency and critical condition of its main institutional component – health institutions.
Today, the majority of health care institutions, which exist in the form of budgetary institutions, do not have a sufficient level of autonomy in decision-making on the current management and activities of the institution. Health facilities are limited in their ability to set goals and priorities for the use of budgetary resources. Directions of use of budgetary funds are strictly regulated according to the estimates. Even in case of emergency, health facilities cannot reallocate funds from one budget line to another.
At the same time, the available scientific evidence suggests that in health systems, and especially in the European region, there is a tendency to use strategic (“active”) procurement as a mechanism for financing health care providers to ensure the best results in terms of improving public health. Mechanisms for concluding contracts (contracts) and payment on the basis of the volume and quality of services provided are Central elements of an effective system of procurement of medical services. More active procurement (where buyer and supplier roles are differentiated) can improve the quality and effectiveness of health systems by taking into account the needs of the population for health care, regional differences, interventions and services that best meet the needs and expectations of the population, the amount of resources available, procurement mechanisms, including contractual arrangements and supplier payment systems. The introduction of strategic procurement is closely connected with the issue of changing the economic status of health institutions.
Association agreement between Ukraine, on the one hand, and the European Union, the European atomic energy community and their member States, on the other hand, strengthening cooperation in the field of health between Ukraine and the EU in order to improve its security and protection of human health as a prerequisite for sustainable development and economic growth (Chapter 22 “Public health”). Such cooperation should include strengthening the health system of Ukraine and its capacity, in particular through the introduction of reforms.
Today, the Shupyk National Medical Academy of Postgraduate Education operates the Institute of family medicine, which, in addition to educational, methodological, scientific and clinical work, performs a number of national tasks of organizational and methodological direction to improve the provision of primary health care on the principles of family medicine by:
1) development and implementation of new technologies to minimize the risk of diseases and create a healthy environment based on research data;
2) development of a strategy for the formation of a conscious and responsible attitude of the population to their own health and personal safety;
3) optimization of the organization of primary health care aimed at solving the real needs of the population;
4) improving the quality of staffing and the level of training of specialists in the prevention and early detection of diseases, diagnosis and treatment;
5) carrying out modern innovative scientific developments with the mandatory creation of an effective system of implementation of their results in the practice of health care;
6) conducting research on the preservation and promotion of public health, primary prevention of diseases, the study of the negative impact of risk factors and social determinants on health and ways to minimize them, the formation of public health.
The main directions of solving the problem of continuous improvement of the quality and effectiveness of primary health care on the principles of family medicine are:
– the maximum approach of family medicine specialists to the population and improving the availability of primary health care for all residents of territorial communities;
– ensuring coordination, preventive orientation, standardization and evidence-based diagnostic, therapeutic and rehabilitation assistance from General practitioners-family doctors with specialists of other types of medical care;
– significant improvement in the impact of primary health care on public health through the formation and implementation of the principles of a healthy lifestyle for different age groups (valeological approaches);
– improving the effectiveness of primary health care in the use of financial resources from different sources;
– involvement of individual citizens, their families, public associations, local Executive bodies and local self-government bodies in solving specific problems of individual and public health;
– creation of investment projects involving private capital in the development of primary health care on the principles of family medicine;
– public participation in the management of primary health care on the principles of family medicine and increasing the level of satisfaction of local communities with the quality of health care;
– the use of non-material and material means of motivation to improve the quality of primary health care by paying for the work of family medicine specialists according to the quality indicators of the medical care provided;
– training of highly qualified specialists in primary health care at the pre-and post-graduate stages, as well as in the process of their continuous professional development during the entire period of work in the field of family medicine;
– legal support for the activities of family medicine specialists and active involvement in the formation, preservation and strengthening of the health of individuals and territorial communities through public associations and local authorities, that is, the creation of the foundations of public health;
– protection of the interests of patients in the process of interaction with the health care system, the General practitioner-family doctor functions “guide” in a complex system of different types of medical care;
– active use of the complex mechanism of the state management of development of primary medical care on the principles of family medicine at the micro level in the centers of primary medical care, out-patient clinics of family medicine, medical centers of family medicine);
– scientific and innovative support, information support and automation of workplaces of family medicine specialists;
– improvement of non-departmental (external) control tools and implementation of internal professional audit .
In Ukraine, the first steps are being taken to modernize the health system, taking into account the who resolution and recommendations.
Any measures aimed at the modernization of the health care system should be accompanied by joint efforts of all parties (patients, the medical community, legislative and executive authorities, as well as local authorities) to ensure the interest of health workers and the population in an effective health care system in Ukraine.
1. WHO, the World Bank. Tracking universal health coverage: first global monitoring report. Geneva: World Health Organization; 2015,: http://apps.who.int/iris/bitstream/ 10665/ 174536/1, as at 4 April 2016
2. World health organisation. A mechanism for comprehensive people-centred health care. secretariat report. Sixty-ninth world health Assembly A69/39 Item 16.1 of the provisional agenda 15 April 2016
3. Voronenko Yu. Normative and legal support of family medicine in the light of the reform of health care in Ukraine. Public health. 2013;1:15-22.
4. Voronenko Yu. et al. Cross-sectoral interaction of education, science and practice as the key to effective training for primary care. Public health. 2014;1-2:14-24.
5. Voronenko Yu., Shekera O. G. Family medicine, led the reform of health of Ukraine. Public health. 2016;1-2:20-23.
Conflict of interest:
The Author declare no conflict of interest.
Oleh G. Shekera
Shupyk National Medical Academy of Postgraduate Education
Str. Dorohozhytska 9, 04112, Kyiv, Ukraine