Since the collapse of the Soviet Union, Ukraine has been slow to make any substantial improvements in the national health care system. While the center still controls almost all aspects of health care, from the education curriculum for doctors to licensing and local budgets, there is an inadequate level of funding and accountability between the center and local levels to allow for effective delivery of services and responses to need. In theory, health care is ‘free to all’ as it was during the USSR but the entire system and each aspect of service is based on bribes (which can be expected when doctors earn around $150 USD per month). I was told by the head of one private hospital that many public doctors only work ¼ time only to have access to equipment for bribes.
International donors have been a more reliable source of funding for many projects and NGOs keep telling me that HIV/AIDS is receiving the bulk of international funding. When I visited the HIV/AIDS Clinic in Kherson and it was unclear where all of that money was going. In Kherson there is one clinic for the entire oblast that can provide ARVs. While seemingly clean, the equipment was old and open vials of blood were sitting-in-wait for their turn on the test. Around 10 staff members work at the clinic which is a ways away from the center of town and I do not recall any sign on the building to indicate the AIDS clinic was there.
In Lviv, the regional HIV/AIDS clinic only opened 3 years ago because the regional government could not come up with the necessary funds; other neighboring regional clinics have been in operation for 11 plus years.
Back to Soviet Centralization or on to Privatization?
Many doctors and citizens in Ukraine have told me that the health system was better under the USSR because everyone was guaranteed free health care. Regardless of whether this was actually the case, or if it was high quality care, it is a widespread memory and an important comparison point to the system now. Deputy Head of the Department of Youth Policy, Elza Volodymyrivna Leschenko, said that from her personal point of view, health education at least should be implemented as it was in Soviet times. Previously there was mandatory physical education and healthy lifestyles classes but those programs no longer exist. Today kids have a small program on health but it is not about personal decisions and internal factors that influence health but rather on external factors such as snake bits, crossing the road, etc. In Lviv there are optional health classes on sex and healthy behaviors but parents often do not let their children attend (lest they hear about condoms from an authoritative source).
Additionally, rapid staff turn-over was not a significant problem in the Health Ministry as it is now. Continual change in leadership and staff has meant very little progress and a lot of confusion in the ministry. It also leads to the Ministry spending a lot of time and money working on small problems that can be handled in short periods of time but not tackling endemic issues that need a longer period to address. Staff vacancies also put a hold on progress and one international organization told me that they have problems giving trainings because individuals in the ministry need central approval in order to attend and frequently their supervisors are absent. This raises another point of the wasted time and money that has been pumped into the Health Ministry only to have those people who received the training leave.
It seems that the soviet health care system is still in the process of it’s inevitably and timely – however unfortunately slow – death, and yet it refuses to let go of some of its control with its final bits of strength. The intricacies of remaining centralization are amazing. ISIDA private maternity hospital (detailed later) told me that people have certain doctors and areas assigned to them for verifying sick leave from work to the government. ISIDA still does not have the ability to grant sick leave for its patients.
The Ministry of Finance is responsible for deciding the budget of each Ministry, including that of the Health Ministry. This is typically down to the line items, and in many instances, equipment is bought centrally and then distributed to the regions. In addition to providing an opportunity for skimming off the top, it is difficult for the central ministries to have a complete understanding of what is needed at the regional or local level. In other cases the local health ministries can make up their own budget but it still has to be approved by the central government. And the disconnect between local needs and the central authority extends beyond the budget process. Local facilities receive minimal funds but they are not allowed to cut staff or close facilities on their own decision. The extra facilities also spread out resources and in Ukraine there are two times the doctors in Germany and three times the number in France.
ISIDA Private Maternal Hospital
ISIDA hospital in Kyiv is recognized as the best private maternal hospital in the country and the facilities are excellent. The clientèle is limited to those who can afford the top services, but the general manager, Mr. Valery Kidon, indicated a few ways the hospital is beneficial for the entire population. Primarily, the hospital provides another option for those who can pay. In many other areas of health care there are no equivalent services and people who want good care have to go to another country to find it, which is both extremely costly and dangerous. Additionally, the high level of service at ISIDA raises the standards demanded from other facilities.
Dr. Kidon said that ISIDA is frequently audited and not viewed favorably by the Ministry of Health. In part he attributed this to the Ministry’s concern of backlash after they have repeatedly said that a higher level of service and private hospitals are not feasible in Ukraine at present.
I asked Dr. Kidon what he thought foreign governments and foundations should do to strengthen the health care system and without hesitation the answer was to create equal conditions for private and public business. The Ministry of Health should be in a position of providing overall direction and then let the smaller, local issues be taken care of privately. Private health care now covers less than 1 percent of the market (there are 5 private clinics, 1 in Odessa and 4 in Kyiv).
One of the biggest issues in privatizing health care is finding good managers of the facilities. Dr. Kidon said one place to look is in the pharmaceutical business which now employs many doctors who left when their salary was insufficient. These individuals have medical knowledge, pharmaceutical competency and business education
Traditional Provider-Oriented Services
Another problem in the Ukraine health system is that services remain provider-oriented verses patient-oriented. Simple medical problems are met by long stays in the hospital and intensive treatment. And furthermore, all areas are compartmentalized and doctors and clinics are over-specialized for cost effective treatment. One ob-gyn sees a patient for infertility problems but sends them to another for STIs, another for HIV/AIDS and yet another for family planning consultations. This fracturing is not only ineffective and expensive but it means that many problems go undiagnosed and deters patients from seeking services.
ISIDA hospital is an unethical organization that will harvest left over embryos for experimentation and not get permission for the parents if the embryos. They also give bogus and illegal advice to woman who want to use Surrogates they tell these woman to lie to their consulates. They have also aided and abetted kidnappers in the trafficking of a newborn American child.
Posted by: Sally | October 16, 2009 at 08:34 PM