HEALTH CARE REFORM IN UKRAINE

SAG ROLE AND RESPONSIBILITY

Presentation outlines • SAG goal and objectives• National Health Policy• National Health Care Strategy• Plans and ownership over reform implementation

Health SAG• Health SAG was established by MOH order № 552 as of

24 July 2014

• Goal - coordination of the efforts of government, international projects and civil society to support restructuring of the new national health care system.

• Objective – create a policy document which must be a guide to reforming for 2015-2025

Health SAG

Coordination Council

Governmental constituency – Minister

International constituency – WHO, WB, IRF

Community constituency – professional association, patients’ union

Expert group

National experts - I.Yakovenko, O.Petrenko M.Prodanchuk, R.Fischuk, T.Dumenko, A.Huk, V.Kurpita

International experts - Alexander Kvitashvili (Georgia), Robert Yates (UK)Tihomir Stritsrep (Croatia), Antonio Duran (Spain), Ain Aaviksu (Estonia)

Secretariat

Support to group

What has been done• August 19 - the constitutive meeting of the group was held

• 45 reports and records were analyzed

• September 13-14 - the vision, values, principles and strategic challenges were discussed, the strategic approaches on health reform have been considered

• October 13-14 - reform objectives defined and strategic framework approved

• Health reform strategy (zero draft) developed

Centralized and fragmented

Outdated high-level health institutions

Performance measured using statistic standards dated 60-70th

Lack of continuity, coherence, subsidiarity

Extremely cost ineffective

Health System and Health Challenges

• Poor Health Outcomes

• Unequal access to Health Care

• Unclear quality of Health Services

• Poor effectiveness and efficiency

• Patient financial vulnerability

Financing for Health in Ukraine

Total Health Expenditure within 2012 State Budget remained 4.2% of GDP and 12.7% of Total State Expenditure

Most health funds are spent by local governments, not the MoH

Measuring governance in the health sector in Ukraine, WB, FISCO, 2013

But while funds are allocated per capita, spending rules are strictly input-based

Facilities face a schizophrenic situation where they need to reconcile imposed norms with fiscal reality

Measuring governance in the health sector in Ukraine, WB, FISCO, 2013

The burden for patient• Share of respondents who did not use health care services

because they could not afford it

Болгарія Угорщина Литва Польща Румунія УкраїнаКонсультації лікаря 2.75 2.45 2.33 2.45 3.35 2.70

Ст.пох. 0.13 0.13 0.14 0.14 0.29 0.10к-сть відп. 307 257 214 215 284 465

Госпіталізації 1.57 1.30 1.38 1.26 1.81 1.95Ст.пох. 0.17 0.16 0.15 0.14 0.13 0.13

к-сть відп. 60 27 32 23 94 165

Bulgaria Hungary Lithuania Poland Romania Ukraine

Physician visits

Hospitalizations

Т.Степурко Платежі пацієнтів в Україні та країнах Центральної та Східної Європи, НаУКМА, 2012

Focus on the hospital segment with an excessive amount of beds

Constitution of UkraineArticle 49 • Everyone has the right to health protection, medical care and medical insurance.

• Health protection is ensured through state funding of the relevant socio-economic, medical and sanitary, health improvement and prophylactic programmes.

• The State creates conditions for effective medical service accessible to all citizens. State and communal health protection institutions provide medical care free of charge; the existing network of such institutions shall not be reduced. The State promotes the development of medical institutions of all forms of ownership.

• The State provides for the development of physical culture and sports, and ensures sanitary-epidemic welfare.

Article 95

• Any state expenditures for the needs of the entire society, the extent and purposes of these expenditures, are determined exclusively by the law on the State Budget of Ukraine.

HEALTH CARE STRATEGY

Strategic principles of reforming• Consumers’ freedom of choice should become the driving force of

reform;

• The Government's financial obligations regarding healthcare should be in compliance with the country's ongoing economic capacity and budgetary resources and limited to policy development, control and surveillance functions;

• Health care delivery sector, including pharmaceutical and insurance sectors, should be set free from bureaucratic overregulation, to enable private investments into the system, as well as increase the efficiency and effectiveness of the public spending.

Goal• To transform health system to ensure improving the

efficiency and effectiveness of the system and establishing consumer’s right to equal access to affordable, quality public health services.

• However, the vital requirement of the reform success is that the transition from an old to a new system should be as smooth, manageable and in line with other government's economic recovery initiatives as possible.

Health System Values • People-centred

• Outcomes-oriented

• Implementation-focused

Health system principles• Comprehensiveness - establishment of a single medical space

with a clear defenition of roles and responsibilities at all levels• Continuity - the development and support of primary health

care, which provides medical care throughout the life• Subsidiarity - solving health problems at the lowest possible

level of health care• Accessibility - the geographical location of health facilities that

ensures equal opportunities for citizens to access services, regardless of education level, economic status, religious beliefs or other personal and social circumstances

• Humanity - provided through respect to the patient as a person who has the right to physical and mental integrity and protection of the identity, including respect for the private life, philosophy, moral and religious beliefs

Reform Objectives

1. Enhancing individual responsibility for citizens’ own health;

2. Guaranteeing free choice of service providers;

3. Creating business friendly environment in the healthcare market;

4. Providing targeted assistance to the most disadvantaged part of the population.

Health System Architecture

Finance

Governance

Recourse mobilization

Service provision

Effectiveness

Financial protection

Efficiency

Health outcomes

Patients

satisfaction

Service provision• Providers of all organizational forms and ownership should

have an opportunity to freely enter the market and compete "on a levelled playing field", on equal footing for public funding, as long as they meet due requirement of safety and quality.

• multi-shaped network of public and private health care facilities should be established based on the follow principles • the cycle of the disease (preventive, therapeutic, rehabilitative...); • the technology involved (surgical, lab, imaging); • the intensity of the process of care (routine, intensive, emergency care); • the main target recipient (paediatric, females, geriatric, etc.)

• Service providing networks, corporations will be established, with their own managerial autonomy

• Health Care Management should be introduced

Services

Services

individual

Specialized care

Hospital based care

Primary care

population Public Health

Primary care• a balanced system of primary care will take years to establish• doctors should care for several patients -individuals and families-

related to each other, who live and/or work in close proximity and whose lives are interrelated

• promoting general practitioners as privately operated businesses / private entrepreneurs

• the exclusive right of the PHC doctors to refer patients to specialists ("gatekeeping")

• Hybrid payments could be approached using mix formula with • risk-adjusted capitation, • fee for service • pay for performance and quality

• Law on Medical Services in 2015

Privatisation of the PHC

Reform of the PHC financing

Introduction of family medicine

Informatisation of PHC

¨ Private practices

¨ concession ¨ PPP

¨ Capitation,¨ Fee for

service¨ KPI¨ QI

¨ Harmonization of Family Medicine Service with European Standards

¨ e-prescription¨ e-referrals¨ e-medical

records

Hospital Care• The number and the structure of hospitals in Ukraine needs to be urgently

optimized• Specialized, single profile institutions could be transformed into multi-

functional medical centres• Three levels of care provision – local hospitals, regional hospitals and

central referral hospitals - could be proposed for the network• "Parallel health systems" will be abolished • sub-national Hospital Master Plans will document the existing resources

and needs and provide suggestions for network optimization• Image and diagnostic services, or non-medical services (food, laundry,

etc.) are natural candidate in terms of PPPs• NGOs could be used for leading some services , although this would

probably require social debate

• Law on Medical Institution – 2015

Global budget FFS PPTP DRG

¨ Fee-for-service (FFS) system based on hotel services, procedure services, and drugs and other materials, payment in advance

¨ PPTP (Payment Per Therapeutical Procedure) - broad-case grouping system (surgery, internal medicine), partially payment in advance with final payment

¨ DRG – payment per case (disease related group)

Highly specialized care

• National reference center • Service procurement from national level• Payment per case• Public-private partnership

Public Health

• Public health services and activities will be rationalized and legislation streamlined with the principal responsibility of health promotion, social participation and emergency preparedness against health threats

• The existing population services and responsibilities will be expanded to include communicable and non-communicable diseases and work on the social determinants of health

• Outreach initiatives on reducing main risk factors, creating smoking-free environments, discouraging trans-fats, using helmets in motor vehicles etc. will be fostered

• Institutions will be merged with the National Center for Disease Control and Public Health

• Law on Public Health - 2016

• If the government will be leaning towards a full privatization decision, there are several possibilities or their different combinations: • Selling medical facilities through public auction; • Employees could become the owners of facilities through direct

sale for a symbolic price; • Various non-governmental charitable organizations, including

religious organizations could become the owners of facilities through direct sale for a symbolic price;

• And finally local authorities could become the owners of some of them too.

Finance

Revenue

• General taxation

• Earmarked taxes

Function spilt

• Purchaser - Provider split

• Purchasing Agency

Resource pooling

• Recourse pooling at community level for PHC, Regional level for hospital care and national level for highly specialized

Budgeting

• Shift from input-based funding toward output-based purchasing

Health insurance

• Middle term perspectives

Governance• Reform of The Ministry of Health

• Institutional Re-Profiling to support analytical and communication component of health care/ public health

• Provider autonomy and introduction of professional management

Reform of The Ministry of Health

• Health system steering through policy leadership and strategy development

• Regulatory oversight of all health related activities, including procurement

• Ensuring Health Intelligence, Transparency and Accountability including Surveillance/ Emergency Response

Essential helth system inputs • Human Resources contracts

• Human Resources training and refreshment

• Pharmaceutical Sector

• Improving Health Information; E-Health and IT

Proposed action plan

Short-term (2015-2016)

Piloting new financing model

Provider autonomy

Merging facilities

Middle-term (2017-2020)

FFS

Standarts and guidelines

Service procurement

Human Recourses

Long term (2019-2022)

Health insurance

Medical practice licensing

Legislation

Expected outcomes• Clearly separate the responsibilities between the state and

individual; • The government's healthcare commitments will be balanced

with the country's economic potential and make political obligations enforceable;

• States’ financial resources will be predominantly targeted to the vulnerable population;

• Optimized network of service providers (laboratories, primary care facilities, hospitals, etc.), which will be upgraded and provide higher quality health services;

• Reduced pharmaceutical prices per item consumed; • healthcare expenditures will be legalized, no unofficial payments

will plague the system;• Drastically decrease the corruption

Measurable indicators

Health outcomes

Financial protection

Patient satisfaction

• Life expectancy• Mortality

• Share of the poorest  households spending more than 25% of their total non food expenditure on health

• do you have confidence in healthcare or medical systems

Challenges • MOH leadership and ownership over reform

• Support unpopular reform by Parliament and Health Committee of Verkhovna Rada

• Communication strategy to • Citizens• Professionals • Business• Donors

ANY QUESTIONS