One of the main challenges of the health care system today is the outflow of qualified medical personnel. Due to the occupation and forced migration, as of the beginning of 2023, according to the report “Healthcare at War” (1 - in the list of references below), about 90,000 qualified medical workers left Ukraine. Of them, about 14,000 are doctors and pharmacists, 33,000 are nurses and about 21,000 are obstetricians. As of April 2023, in Poland alone, Ukrainian doctors submitted about 3383 applications to practice medicine, of which 2369 were approved. This trend of forced migration of Ukrainians in different countries is only growing. As for the internal forced migration of doctors, in the Poltava Oblast alone, there is a slight increase (by 3%) of doctors compared to 2021.
In light of the war-related crisis faced by Ukraine’s health care system, the significant change in the demographic profile of the population, the migration of medical personnel, the extensive destruction of the medical infrastructure, a rapid change in statistical indicators of infectious and non-infectious diseases, prevention and immunisation, the World Bank, the World Health Organization (hereinafter the WHO) and a number of other international projects are continuously working on the analysis of the current situation and the preparation of recommendations for adapting the health care system to these new conditions and challenges. Today, one of the main recommendations given by these institutions is the development of accessible primary health care with extended services at the municipality level, expanding the powers of nurses and integration with other social services (2).
Having taken these recommendations for deeper analysis, the WHO prepared the Report on Primary Health Care in Ukraine: A Situation Analysis and Policy Considerations (3), which was published in October 2023. This report highlighted key recommendations for possible next steps for developing PHC in Ukraine. Based on the report, the following directions can be identified:
- Detailing the role of local self-government bodies in financing primary health care to reduce duplication with the Medical Guarantee Programme and encourage local self-government bodies to give more focus on financing specific local needs.
- Initiating a comprehensive monitoring system to track and analyse various aspects of primary health care provision, including an assessment of its existing barriers. Developing solutions together with the owners of health care facilities, which will include both the necessary changes in services and the use of financial incentives.
- Reviewing capacity criteria for PHC provider contracting to offer a full package of services in accordance with contracting specifications and avoid abusing referrals to speciality physicians by developing clear referral criteria.
- Ensuring that contracting mechanisms account for meeting certain baseline contracting requirements by PHC providers, including geographic availability and service quality level.
- Strengthening the role, responsibility and clinical skills of all PHC team members to optimise the provision of health care, especially in the context of managing chronic diseases and needs caused by the effects of war.
The report also indicates the steps that reflect requests from municipalities to include utilities in the capitation rate, re-evaluate capitation rate coefficients based on the age group 65+, introduce additional coefficients for areas with low population density and long distances to primary health care facilities.
Taking into account these recommendations, which are already somewhat reflected in Resolution of the Cabinet of Ministers of Ukraine No. 1093 dated 17 October 2023 “On Amendments to Resolution of the Cabinet of Ministers No. 410 dated 25 April 2018” (5) regarding the monitoring by the National Health Service and the requirements for contracting the National Health Service in 2024, you can see that the traditional approaches to assessing the capacity of health care facilities are being transformed, and competent medical services are becoming the focus. Therefore, it is now vital for local self-government bodies to rethink the medical services provided to the population of the municipality, primarily in terms of their availability and accessibility. So, what are the services in question? They include:
- basic emergency care,
- general clinical services,
- assistance to mothers and newborns,
- children’s health,
- non-communicable diseases,
- communicable diseases,
- mental health,
- sexual and reproductive health,
- complete treatment of minor injuries.
It is also critical to understand how these services are provided for the population of your municipality, taking into account geographic accessibility, free-of-charge basis and compliance with the contracting requirements of the National Health Service of Ukraine. Furthermore, you have to understand the obstacles to the development of a capable network of medical services:
- lack of medical equipment,
- lack of medicinal products,
- lack of medical personnel,
- lack of training of medical personnel,
- lack of financing.
In our realities of critically limited financial resources, the focus on a competent medical service rather than the availability of a health care facility is essential for making further management decisions. Despite the limited resources, developments such as the training of nursing and hospital staff, restructuring of internal processes in health care facilities with an emphasis on the provision of competent medical services, work on the prevention of non-communicable diseases, access to pharmacies operating under the Affordable Medicines Programme reach a new level in every municipality. Keep in mind that the priority here should be given to the acquisition of additional competencies by the medical staff, because following the definition of the criteria for providing referrals to speciality physicians, primary health care physicians will be the ones to take over some of the consultations. In turn, the nursing staff will have to acquire additional competencies and, having their powers expanded, take over part of the routine work that is currently carried out by PHC physicians. Acquiring additional competencies and deepening existing knowledge and skills require time and resources, which is why it should be considered now.
No one can argue that today, local self-government bodies face a large number of challenges. In the conditions of war, constant changes and uncertainty, the capacity of the health care system and the availability of medical services for the population of a municipality can only be maintained through joint efforts both within the municipality and beyond, as well as through joint advocacy of needs for building, developing and maintaining a capable network of medical services. A realistic assessment of resources, analysis of population needs and systemic forecasting that account for the development vectors of the health care reform should be reflected in the management decisions and budgets of every single municipality for the next period. Whether the municipality will be able to have an affordable medical service in the future will depend on the quality and reasonable nature of these decisions and their implementation.
References:
1. Report “Healthcare at war: The Impact of Russia’s full-scale Invasion on the Healthcare in Ukraine”, April 2023. International Renaissance Foundation, Agency of Legislative Initiatives, Ukrainian Healthcare Center.
2. Report “Health Financing Reform in Ukraine Progress and Future Directions” 2022 International Bank for Reconstruction and Development / The World Bank and World Health Organization.
3. “Primary health care financing in Ukraine: a situation analysis and policy considerations”, October 2023, WHO/EURO:2023-8138-47906-70792.
4. Joint discussion paper “Priorities for health system recovery in Ukraine”, 2023. WHO, the European Union Delegation to Ukraine, the U.S. Agency for International Development (USAID) Mission in Ukraine, and the World Bank.
5. Resolution of the Cabinet of Ministers of Ukraine No. 1093 dated 17 October 2023 “On Amendments to Resolution of the Cabinet of Ministers No. 410 dated 25 April 2018”.
