Section 1. Monitoring of the implementation of recommendations on reform priorities for 2020 - May 2021
1. To initiate the assessment of the quality of primary health care (PMC) provision and introduce appropriate changes and adjustments to the volume of PHC provision based on its results.
Partially done
As of today, the quality of medical care is regulated by the Procedure for providing primary care, approved by the order of the Ministry of Health of Ukraine (hereinafter - the MH) dated March 19, 2018 № 504.
In addition, in 2021 the National Health Service of Ukraine (hereinafter - NHSU), in order to bring medical care closer to the patient, has developed and implemented a new package of medical services "Support and treatment of adults and children with tuberculosis at the primary care level", which not only expands access to patients in this category of medical services, but also motivates medical staff PHC ( due to the establishment of adjustment factors) to provide such services. The resource "Open data portal" is also created, the administrator of which, among other things, is the NHSU, which makes it possible to monitor the performance of PHC in real time.
Threats
To date, there has been no comprehensive assessment of the quality of medical services, which would contain both an objective component - compliance with standards, and a subjective - survey of patients on various aspects of PHC. The lack of such an assessment at this stage does not allow to adequately respond to the problems in the provision of PHC that arise in the reform process, as a result they may "accumulate" and become systematic when the declared quality does not correspond to the real situation.
2. To complete the implementation of new financial mechanisms on a “Money follow the patient” basis at the level of specialized and highly specialized medical care (ambulatory and inpatient levels) for all HCFs without exception from 2021.
Partially done
In Ukraine, since April 2020, the Program of medical guarantees at all levels of medical care has been launched. Currently, the guaranteed package includes the following medical services: PHC, emergency medical care, specialized and highly specialized medical care, medical rehabilitation, palliative care, medical care in connection with pregnancy and childbirth, the State Reimbursement Program, as well as four additional medical services, related to the care and suspicion of patients with COVID-19.
At the same time, conditions for competition in the market of medical services have been created: providers of both state/communal ownership, as well as private providers and individual entrepreneurs (hereinafter referred to as IE) may participate in the Medical Guarantees Program. In 2020, the NHSU paid more than UAH 622 million to private institutions and private doctors. 21% of the total number of concluded contracts are private institutions.
In 2020, the NHSU signed 3,119 agreements with healthcare institutions, including: 232 private medical institutions; 401 IE; 2,486 utilities. This trend is also observed in 2021. Thus, in the first quarter of this year, the NHSU concluded 3,081 contracts with healthcare institutions, including: 221 private medical institutions, 392 private doctors and 2,468 medical institutions of communal property.
Threats
The issue of ensuring the sustainability of adequate funding in line with the needs of the industry remains acute. The delay in funding leads to a delay in the payment of healthcare institutions for the provided medical services, and accordingly - to the "compensation" of underfunding by patients.
3. To perfect the mechanism of patient routing.
Partially done
The routes of patients are to some extent elaborated: in the Program of medical guarantees in one direction or another, which specifies the requirements for the organization of medical services, and in the standards of medical care for certain ICDs. The very concept of "clinical route of the patient" is enshrined in Methodology for developing and implementing medical standards of evidence-based medical care, approved by the order of the Ministry of Health of September 28, 2012 № 751.
At the same time, a clear algorithm of actions of doctors at different levels of care, which would be guided by doctors when referring patients, is not elaborated yet. However, it should be noted that the specialists of the NHSU have developed a chatbot Likuysya (“Medicate”) for cancer patients. It will help everyone who is diagnosed with breast cancer to find out which medical facility, which medical services and to what extent can be obtained free of charge. This applies to both services for the diagnosis of cancer and their treatment. The chatbot user will be able to select the service, receive step-by-step instructions and the necessary information.
The route of the patient is clearly elaborated in the Standards of medical care "Coronavirus disease (COVID-19)" (decree of the Ministry of Health of March 28, 2020 № 722).
Threats
The lack of a developed, approved and mandatory route of the patient can lead to "delays" in determining the diagnosis and treatment, as well as, which is a constant practice - the lack of feedback in the chain of narrow specialists - PHC doctor, which, on the one hand on the one hand, increases the cost of the service, and on the other hand - leads to the fact that PHC doctors "lose" such patients.
4. To establish an effective emergency medical care system that meets the international standards: to develop and adopt the Good Samaritan Law, to update the technical, information and personnel support of the service, to equip dispensaries and intensive care hospitals in accordance with the international standards.
Partially done
In December 2020, the resolution of the Cabinet of Ministers of Ukraine (hereinafter - the CMU) "About the standard of arrival of crews of emergency (ambulance) medical care on a scene», which once again laid the foundations for changes in the provision of emergency medical care from 2021, was adopted. According to it, to optimize the work of emergency care, the emergency calls will be divided into four categories depending on the patient's condition: critical, emergency, non-emergency and non-core.
The condition of the patient and the circumstances of the call will be determined by the operator of the dispatching service of the emergency medical care center. The rate of arrival of the ambulance crew will depend on it. At the same time, such categorization is generalized, normative documents with clear algorithms of actions for the dispatcher, criteria for assessing the patient's condition, qualification requirements for the dispatcher are not approved. No training programs have been developed for the operators.
Threats
A similar division has been in place since 2013, when the law on emergency medical care was passed, according to which calls were divided into emergency and non-emergency. As the regulations were not approved, the planned changes were ineffective.
5. To complete the digitization of the industry - ensure complete electronic flow of documents in the healthcare system.
Partially done
The process of digitalization is widely used in the health care system. The greatest successes in this direction have been achieved in the field of circulation of medicines: the State Register of Medicines of Ukraine, which allows to check the registration status of any medicine in Ukraine and get other information about it; Register of licenses for wholesale and retail trade in medicines, where one can check the data on issued licenses for wholesale and retail trade in medicines; License register for import of medicines, etc.
In general, information systems are already working in the field of public health, procurement of drugs, the structure of the NHSU. From April 2021, a new body - European Health and Digital Executive Agency, HaDEA was launched. At the same time, full digitalization of the industry has not yet been achieved.
Threats
The issue of protection of personal data and registers from distortion and hacker attacks remains acute.
6. To establish the transplant system and ensure its development in Ukraine.
Partially done
Organ transplant surgeries in Ukraine have been possible since April 2019, when the Law of Ukraine “On Amendments to Certain Legislative Acts of Ukraine Concerning the Application of Human Anatomical Material Transplantation” came into force, which, inter alia, regulates organ transplantation from a deceased person.
Since then, according to the Ministry of Health, the number of organ transplants in Ukraine has been growing every year: in 2019, 78 organ transplantation surgeries were performed: 71 - kidney, 6 - liver, 1 - heart; in 2020 - 118 organ transplants: 8 - heart, 19 - liver, 91 - kidney, as well as 138 bone marrow transplant surgeries. Since January 2021, 37 kidney transplant, 7 liver transplant, and 4 heart transplant surgeries have been performed. In 2021, transplant expenditures also increased significantly (in almost five times): from 112 to 502 million UAH; the number of medical institutions that can perform transplantation surgeries in Ukraine has doubled.
From January 1, 2021, in accordance with the decision of the Government, the Unified State Information System of Organ and Tissue Transplantation (USIST) was launched. It compares the waiting list of patient and donor organs. It is expected that thanks to this system, Ukraine will be able to achieve full transplant independence in three years, when Ukrainians will not have to go abroad for surgeries.
7. To continue the development of a public health system, especially in areas such as the prevention of non-communicable diseases, the strengthening of tobacco control legislation through the implementation of the WHO Framework Convention on Tobacco and EU Directives 2014/40 / EC and 2011/64 / EC implementing the European standards and practices in the blood system as well as in the surveillance system for infectious diseases, ensuring maximum coverage by immunoprophylaxis.
Partially done
The global pandemic COVID-19 made its adjustments in the development of the public health system in Ukraine: most of the efforts (both organizational and financial) in 2020-2021 were aimed at overcoming the pandemic, building anti-epidemic organizational structures. On February 4, the Parliament adopted the bill № 4142 "On the public health system", which aims to create a full-fledged national epidemiological service.
Simultaneously, in 2020–2021, progress was made in other public health issues, in particular: on June 1, 2021, the Parliament adopted in the first reading a comprehensive anti-tobacco bill № 4358which is based on the WHO Framework Convention on Tobacco Control and Directive 2014/40/EU, which restricts the use of marketing technologies by the tobacco industry to increase the attractiveness of tobacco products, stimulate sales and create the illusion of a lesser harm. On September 30, 2020, the Parliament adopted the bill № 3648 “On safety and quality of donor blood and blood components» which will allow the implementation of European standards and practices in the blood system in Ukraine. However, the issues of counteracting non-communicable diseases have not been resolved yet.
In order to reduce the availability of all tobacco products, without exception, from January 1, 2021 excise duties on tobacco products for heating and cigars were increased and harmonized with excise rates on cigarettes, and excise duties on liquids (with and without nicotine) for electronic cigarettes were introduced for the first time.
The implementation of the 7-year plan to increase taxes on tobacco products 2018-2025 in accordance with the requirements of Directive 2011/60/EU continues to demonstrate its effectiveness. Due to the annual increase in excise duties on tobacco products by 20%, the number of daily smokers decreased from 6.3 billion in 2017 to 5.5 billion in 2020 according to the State Statistics Service, and tax revenues to the State Budget increased from UAH 39.9 billion to 54.7 billion respectively.
In pursuance of the Government’s priority action plan for 2021, in accordance with Commission Regulation (EU) 2019/649 “On Amendments to Annex III to Regulation (EU) № 1925/2006 of the European Parliament and of the Council on trans-fatty acids other than animal fat trans-fatty acids", on June 2, 2021 the Parliament registered the draft Law of Ukraine № 5543 “On Amendments to Certain Laws of Ukraine on Restricting the Content of Trans Fatty Acids in Food Products”.
In accordance with the fight against chronic non-communicable diseases, in 2021, the Ministry of Health of Ukraine approved the National Strategy for Cancer Control until 2030
Threats
Delaying the adoption of the bill № 4358 jeopardizes implementation of Directive 2014/40/EU.
Adoption of the Law of Ukraine № 3648 "On safety and quality of donor blood and blood components» of June 12, 2020 has not yet led to the reform of the blood safety system, probably due to the lack of regulations, as well as new approaches to financing of blood centers and other institutions.
8. To create a single biosafety and biosecurity system aimed at protecting human health and the environment from the effects of hazardous biological agents, in particular those that could lead to emergencies and threaten national and international security; to initiate drafting the Law of Ukraine "On Biosafety".
Partially done
The CMU adopted a Strategy for Biosafety and Bioprotection based on the principle of "single health" until 2025 and approved an action plan on its implementation (order of the Cabinet of Ministers of November 27, 2019 № 1416-r). in order to gradually create a unified system of biosafety and biological protection, protection of human and animal life and health, prevention of the spread of dangerous infectious diseases, timely response to outbreaks of infectious diseases in accordance with the obligations under the Association Agreement between Ukraine, on the one side, and the European Union, the European Atomic Energy Community and their Member States, on the other side, at the end of 2019.
The implementation of the Strategy is aimed at: improving national biosafety legislation; improving control over the spread and compliance with the rules of work with hazardous biological substances; to eliminate gaps in personnel potential; developing and implementing information and educational activities for both the population and the professional community; updating the methods of work with hazardous biological substances and appropriate engineering and communication networks. In addition, in December 2020, the composition of the Commission on Biosafety and Biological Protection under the National Security and Defence Council of Ukraine was renewed by the decree of the President of Ukraine (of December 10, 2020 № 560/2020). It should become an effective working body and platform for the creation of strategic documents in the field of biosafety and biological protection in Ukraine.
The draft Law of Ukraine “On Biosafety and Biological Protection” was developed by an OSCE expert group with the participation of representatives of the Ministry of Health, Public Health Center and other institutions, and submitted for consideration of the Ministry of Health.
Threats
The adoption of a comprehensive Law of Ukraine "On Biosafety and Biological Protection" on the Single Health principle requires significant consolidation of both the expert community and political will. In addition, no system will work without adequate government funding.
Another threat is that the Law of Ukraine "On Biosafety and Biological Protection" is closely related to the Law of Ukraine "On Public Health", which also is not considered by the Parliament due to the lack of a common expert and strategic vision of this system.
9. To ensure the development of a system for the evaluation of medical technologies that will allow to implement effective strategic in the field of health care based on indicators of clinical effectiveness, economic feasibility and organizational problems of the use of pharmaceuticals, medical devices and other medical technologies.
Done
2020 was a productive year for the development of the system of evaluation of medical technologies in Ukraine, the relevant legal documents were developed. Currently the following are approved: order of the Cabinet of Ministers of December 23, 2020 № 1300 "On approval of the Procedure for state assessment of medical technologies" and Guidelines for state assessment of medical technologies for medicines (order of the Ministry of Health of March 29, 2021 № 593).
It will allow to rationally spend the state budget and use only those medical technologies that have the highest value for each patient and society. In this case, the value will be determined by clear rules, transparently and objectively, covering the interests of all stakeholders.
10. To complete the reform of medical education at all levels in line with European standards – for nurses, physicians, and management.
Not done
So far, the issues of health education reform remain the subject of discussion and declarations. Draft order of the Ministry of Health "On approval of the Regulations on internship" has not been approved. The main requirements for the organization of the internship process continue to be based on the Regulation on specialization (internship) of graduates of higher medical and pharmaceutical educational institutions of III-IV levels of accreditation of medical faculties of universities, approved by the order of the Ministry of Health "On approval of the Regulations on pharmaceutical educational institutions of III-IV level of accreditation of medical faculties of universities" of June 19, 1996 № 291, registered in the Ministry of Justice of Ukraine on December 3, 1996 № 696/1721.
Threats
The lack of health education reform significantly hampers the introduction of systemic changes in the health care system of Ukraine. Effective personnel policy is one of the most important components of reforming the industry, as only well-trained professionals can implement health care reforms in line with current challenges on the path to Ukraine's European integration.
11. To introduce a system of professional licensing for physicians and ensure the development of medical self-government as an institution for regulating the quality of health care services and protecting the rights of healthcare professionals.
Partially done
Back in 2019, the order of the Ministry of Health of February 22, 2019 was approved № 446 "Some issues of continuous professional development of doctors", which provides changes in the procedure of attestation of doctors in the context of their continuous professional development (hereinafter - CPD): from January 1, 2020, each doctor must score at least 50 CPD points during the year.
Points are awarded for various types of training, which the doctor freely chooses on the basis of the list of activities proposed by the Ministry of Health. In general, the number of points is not limited, but the annual mandatory minimum is 50 points. Physicians who significantly exceed the quantitative and qualitative requirements for CPD may receive a priority higher category. From now on, the doctor must record his/her education in the educational portfolio every year and certify it with the head of his/her institution. Points in the portfolio are accounted for in accordance with Annex 5 to the Procedure for attestation of doctors. In practice, this often turns into a "race for certificates", when no one cares about the content.
The issue of medical self-government remains open - the effective operation of specialized associations, which would undertake professional development, and participation in accreditation/licensing, and protection of the rights of members of associations, etc., has not been ensured yet.
Threats
The lack of an effective system of licensing and accreditation, as well as medical self-government poses a threat to the quality of medical services.
12. To ensure implementation of the International Classification of Functioning, Disability and Health (ICF) and launch a full-fledged rehabilitation and disability determination reform (MSEC).
Partially done
As of today, only the translation of the ICF has been approved and a number of trainings for doctors, physical therapists, occupational therapists, and policy makers on the application of ICF have been conducted. The implementation of the ICF is scheduled to take place until 2023. A full-fledged Rehabilitation and Determination of Disability reform has not taken place yet.
13. To urgently and immediately establish an effective system of procurement of medicines, including under the international contracts, involving SE "Medical Procurement" in this process.
Partially done
In October 25, 2018 the State Enterprise "Medical Procurement of Ukraine" (hereinafter - SE MPU) was created in order to ensure a transparent and efficient mechanism for the purchase of medicines. The probable conflict between the leadership of the Ministry of Health and SE MPU reduced the efficiency of this institution. There were serious problems with the purchase of vital drugs, including vaccines against COVID-19. The Accounting Chamber of Ukraine conducted an audit of the activities of the SE MPU in early 2021 (the report will be published in July 2021).
14. To provide a transparent competition for leading positions of the NHSU, the Center for Public Health, heads of the MHU structural subdivisions, in accordance with the current legislation.
Not done
Competitive selections in 2020 were held behind closed doors and in the form of a shortened procedure in connection with the COVID-19 pandemic. There is no information about the announcement of competitions on the website of the Ministry of Health for 2020. In 2021, competitive selections resumed, but were closed.
15. To introduce the general approach “Health in All Policies”, as declared in the Association Agreement between Ukraine and the European Union.
Not done
The principle of "health in all policies" - contextualization: how this decision will affect health "- is only declarative.
Section 2. The current major challenges in implementing the reform (at the time of monitoring)
Despite the fact that the Government and the President of Ukraine identify the reform of the healthcare system as one of the priority areas of reform, there are still many unresolved issues in the healthcare system. In fact, only changes at the PHC level can be called sustainable and without a qualitative component, which may ultimately have negative consequences: funding has increased, and the quality of medical services has remained at the same level.
Unresolved personnel issues: from reforming medical education (at all levels) to licensing and accreditation of medical activities, development of professional self-government, which will have a systemic negative impact. It is impossible to ensure changes in the system without providing it with highly professional staff.
The issue of continuity of quality medicines is acute. Conflicting interagency situations ultimately negatively affect the patients, leaving them without medication.
The priority of measures to overcome the COVID-19 pandemic has again shifted the emphasis towards combating infectious diseases, although the urgency of combating non-communicable diseases remains acute.
Even in the period of pandemic and actualization of the issue of strengthening anti-epidemic protection, the public health system uses old regulations that do not make sense in modern conditions. The law on public health has not been adopted.
The issue of access to medical care in the conflict zone is acute.
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Section 3. Recommendations on reform priorities for 2021–2022 (next annual period, until URC 2022)
The monitoring revealed that, despite efforts to implement changes in health care in Ukraine, no significant progress was made in key areas during 2020–2021 (the “Partially done” label mostly means only the presence of fragmentary changes, which only partially cover the relevant recommendations). Therefore, the preliminary list of recommendations (for 2020–2021) remains relevant in the future.
The priority steps in the reform of the health care system in the near future should be:
To assess the quality of primary care. To introduce quality indicators for the provision of primary health care and link them to adjustment factors.
To develop and approve patient routing.
To complete the reform of emergency medical care that would meet international standards, develop qualification requirements and training for the operators.
To develop a strategy for staffing the health care system at all levels.
To introduce the position of a nurse with extended powers.
To conduct an audit of the system of continuous professional development of doctors, to define clear criteria for certification of medical personnel.
To promote the development of professional associations.
To introduce changes into the directory of qualification characteristics of professions (especially in the section on health care managers), coordinating them with management training programs (229 - public health; 073 - health care management and 281 - public administration and administration).
To complete the implementation of the medical technology assessment system, which will allow making effective strategic decisions in the field of health care based on indicators of clinical effectiveness and evidence.
To adopt bills on public health, on biological safety and biological protection, on protection of public health from the harmful effects of tobacco (№ 4358), as well as other regulations in the public health system.
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