Authors:

Tetyana Yurochko — head of the School of Healthcare at the National University "Kyiv-Mohyla Academy," candidate of sciences in public administration, associate professor;

Oleksandr Bablyak —head of the cardiac surgery department, deputy medical director for cardiac surgery at LLC "Medical Center "Dobrobut-Polyclinic";

Tymofiy Badikov — executive director of the NGO "Parents for Vaccination";

Valentyn Skybchyk — healthcare consultant in the IT field. Contragents: WB, WHO, ULEAD, JICA, eGA, 100%Life;

Dmytro Kupyra — executive director of the NGO "Zhyttia" (Life);

Volodymyr Kurpita — former general director of the Center for Public Health of the Ministry of Health of Ukraine (2nd stage).

Group manager:

Yuriy Mykytyuk — regional coordinator and advocacy manager of the RPR Coalition.

1. STATE OF AFFAIRS IN THE HEALTHCARE SYSTEM AS OF EARLY 2023, INCLUDING MEASUREMENT INDICATORS OF ITS STATE. SYSTEMIC ISSUES

The systemic problems in the healthcare system that prompted the development and implementation of the healthcare reform strategy in previous years have not been resolved, and the reform plans have not been implemented even by half. In times of war, the layer of unresolved problems has become even more acute. The question now is: what should the healthcare system look like after the war? Do we need a recovery strategy, as well as a healthcare development plan that will meet the current medical and demographic trends and socio-economic structure of the country? It is impossible to build strategies without analyzing the current state of affairs. This document presents the results of an analysis of the healthcare system in Ukraine in recent years, with an emphasis on the changes that have occurred during the war.

In 2021, Ukraine was ranked 99th in the Health Care Index 2021 with a score of 0.72 in the overall world healthcare assessment. The low ranking is a result of problems with the healthcare system, accessibility and quality of medical care, and population health indicators. 

In particular: 

• According to the State Statistics Service of Ukraine, Ukraine loses more than 500 thousand citizens every year; 

• According to the UN, approximately one-third of Ukrainians die before the age of 65; 

• The mortality rate of men of working age exceeds the same indicator even in countries with a gross national product lower than in Ukraine;

• The average life expectancy of our population, which in 2021 amounted to 69.7 years (65.2 for men and 74.4 for women), is 11 years lower than that of EU residents (8 years for women and 12 years for men). The main factor behind these differences is the high mortality rate from diseases of the circulatory system. Mortality from circulatory system diseases in Ukraine (according to the standardized coefficient) is on average 1.8 times higher than in the European Union and twice as high as in the WHO European Region. 

• According to the WHO, in 2018, Ukraine ranked first in the world in terms of childhood alcoholism; the incidence of alcoholism has increased by 38% over the past 10 years, and the medical sector has so far only recorded this alarming trend and has little to no impact on its development

• Infant mortality, which is twice as high in Ukraine as in European countries in 2020: 6.9 and 3.2 per 1000 live births).

Thus, we see that transformations in the healthcare sector are accompanied by a number of problems: low accessibility (both financial, structural, and geographical) and low quality of medical care (detection of cancer at late stages, access to special treatment, etc.), low quality of higher medical education in Ukraine (Ukrainian higher education medical institutions are not included in international rankings), low culture of health protection among the population (low vaccination rate in Ukraine, which in turn leads to high mortality), low quality of healthcare services, and the continuation of the vicious practice of providing the declared guarantees of accessible free medical care to the population at the expense of patients – about 50% of all expenditures in the healthcare system are covered through patients’ personal funds.  

The status of Ukrainians as an unhealthy nation with a steadily declining quality of life hinders economic development. Stopping the healthcare reforms carries an even greater risk of further complete degradation of the healthcare sector. We understand that the continuation of the reforms that have been launched promises to be long and difficult and can show significant positive results only in 5-10 years. The success of the reform process will depend heavily on effective governance, improved human capital of the healthcare system, and adequate financing of the sector.

Organization and funding of the healthcare system

First and foremost, it should be noted that as of early 2022, the problem of healthcare funding had not been resolved. In Ukraine, as in other countries of the world, the healthcare system is experiencing a budget shortfall. Therefore, it is necessary to use mechanisms to raise additional funds, including insurance premiums. 

To date, some steps have been taken: 

• In pursuance of Chapter 8 Public Procurement, the ProZorro electronic procurement system was created and is now used to award all contracts with a value equal to or exceeding UAH 50,000.

On October 25, 2018, the State Enterprise “Medical Procurement of Ukraine” (SE MOH, SE “Medzakupili Ukrainy”) was established as the only national agency that ensures centralized procurement of quality pharmaceuticals and medical devices with state budget funds. 

• In pursuance of Article 427 of the EU-Ukraine Association Agreement, systemic changes are being made in the healthcare sector, including the adoption of the following normative documents: 

- On Amendments to Certain Legislative Acts of Ukraine on Improving Legislation on the Activities of Healthcare Institutions No. 2002 dated April 06, 2017; 

- On State Financial Guarantees of Medical Attendance of the Population No. 2168-VIII dated October 19, 2017; 

- On Improving the Accessibility and Quality of Medical Services in Rural Areas, No. 2206-VIII of November 14, 2017; 

- On Amendments to the Budget Code of Ukraine No. 2233-VIII of December 07, 2017.

• Medical care packages have been developed, according to which, starting in 2020, the state, represented by the unified state procurement institution (NHSU), will purchase services from providers on the basis of medical service agreements.

This is essentially the first attempt to link healthcare financing to clearly defined public health priorities, including the burden of disease, and to allocate funding to primary, specialized, and emergency care. Ukraine is implementing the outlined reform steps even in the face of war.

At the same time, there has been no effective functioning of the Medical Guarantee Programs that would take into account the burden of disease when planning strategic procurement. 

At the hospital level of medical care, the NHSU tariffs do not correspond to the actual costs of treating patients, which in turn facilitates the creation of charitable funds for medical and non-medical expenses by healthcare facilities or related structures and leads to the spread of the practice of "voluntary" payments to the above funds or in the form of unofficial payments.

The collection of timely and reliable statistical data is a major issue and perhaps the weakest link in the healthcare expenditure planning process in Ukraine: statistical information is not collected following a unified methodology, and in some cases, data is still collected on hard copies. This delays the process of generalization of statistical information for several years, which is critical in the context of the introduction of medium-term budget planning as the basis for the drafting of annual budgets. 

To date, there has been no comprehensive assessment of the quality of medical services, which would include both an objective component - compliance with standards - and a subjective component - patient surveys on various aspects of medical care. The absence of such an assessment at this stage makes it impossible to respond appropriately, in line with the identified gaps, to problematic aspects of healthcare provision that arise in the course of reform implementation, and, thus, to "consolidate" them, which will ultimately lead to systemic problems when the declared quality does not correspond to the objective situation.

Not all regions provide healthcare services uniformly, and service quality depends, among other things, on the political will of local authorities. 

In December 2020, the Cabinet of Ministers of Ukraine adopted the Resolution On the Standard of Arrival of Emergency (Ambulance) Medical Teams at the Scene of an Incident, which yet again laid the foundation for change in the provision of emergency medical care from 2021 and took the first steps in categorizing patients depending on their condition. At the same time, the emergency medical care reform remains incomplete, and no regulations have been adopted that would clearly define the algorithm of actions for the dispatcher, the criteria for assessing the patient's condition, and the qualification requirements for the dispatcher.

Ukraine has not created the conditions for the broad involvement of the private medical sector in the healthcare system under the Guaranteed Healthcare Package, as the NHSU tariffs are not economically feasible for use in private medical institutions, especially at the level of specialized care. And there is no reimbursement of costs to private healthcare facilities for medical care provided, so investments in the private healthcare sector carry increased risks.

This significantly reduces the accessibility of medical care for the population and increases the risk of household impoverishment in case of illness.

The lack of a transparent market for medical services, the absence of a market for medical facilities, and the presence of an unknown percentage of unofficial payments in healthcare delay the introduction of health insurance. At the same time, the non-existence of health insurance reduces the accessibility of medical care to the population.

Legal relations in the healthcare system of Ukraine

The legal status of doctors does not correspond to the status of a free professional, which is a common practice for a doctor according to European standards. A physician has only one form of labor relationship with a hospital – an employment contract – and cannot enter any other form of labor or civil law relationship with healthcare institutions. In fact, according to the current legislation, a doctor does not have the right to provide medical services to a patient on his/her own. A doctor can open their own practice, even for a consultation appointment, only after registering as a self-employed person and obtaining a medical practice license, which is an additional investment that most doctors cannot afford.

The real salaries of medical professionals remain in the gray area, as unofficial payments remain widespread. 

The law of Ukraine on medical self-government has not yet been adopted, so there is no institution to represent the interests of medical professionals.

As a healthcare provider, a healthcare facility has only one form of labor relationship with a doctor – an employment contract, which creates problems with staffing, problems with the economic efficiency of the facility, problems with the formation of contracts with the NHSU without the availability of relevant specialties on staff.

 Development of the public health (PH) system in Ukraine

In recent years, there have been frequent paradigm shifts in the policy for building the public health system in Ukraine: from complete decentralization of the system to building a clear vertical management structure. As a result, there is a lack of a unified vision and understanding of the implementation of the PH functions in accordance with WHO recommendations. In 2022, in pursuance of Article 427(b), (c) of the EU-Ukraine Association Agreement, the Law of Ukraine On the Public Health System was adopted, which takes effect on October 1, 2023, and requires the adoption of a number of bylaws (three levels of response - operational, medium-term, long-term plan).

The implementation of the Law and bylaws will help solve the problem of an unstable and unbalanced structure of public health management, and will clearly delineate the functions of institutions in the public health system. 

A low level of personal responsibility for maintaining one's own health remains a challenge: the prevalence of "unhealthy behaviors" and insufficient coverage of prophylactic vaccinations. The public health education sector is extremely underdeveloped.

The problem of vaccination remains acute, and it has worsened in the midst of the war: most of the main indicators of routine vaccination coverage are lower than in the same period in previous years. For example, the polio vaccination coverage rate as of October 1, 2022, is 44-47%, whereas in 2019-2021, as of October 1, the coverage rate reached 61-67%. The MMR vaccine coverage rate is currently at about 54%, while in previous years it ranged from 62-80%. The coverage rate for diphtheria, tetanus, and pertussis vaccination is also lower than in previous years. The existing regulations and legal framework for the cold chain of immunobiological products in Ukraine do not meet the requirements of time and the new standards of international and European practice. Due to the ongoing hostilities and the destruction of infrastructure, vaccine logistics, and cold chain compliance conditions on de-occupied territories and territories affected by active hostilities have been disrupted. Nevertheless, as of early 2022, a draft Strategy for the Development of Immunization and Protection of the Population from Infectious Diseases Preventable by Immunization for the period up to 2030 and an action plan for its implementation were prepared. The document is currently being prepared for approval.

In terms of the implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC), Ukraine has made significant progress in implementing the WHO FCTC and tobacco control measures. Consistent with the obligations assumed, Ukraine is implementing the provisions of the WHO FCTC into national legislation. A number of Ukrainian laws provide for the relevant provisions:

- Law of Ukraine No. 2899-IV On Measures to Prevent and Reduce the Use of Tobacco Products and Their Harmful Effects on Public Health;

- Law of Ukraine No. 481/95-ВР On State Regulation of Production and Distribution of Ethyl Alcohol, Cognac and Fruit Alcohol, Alcoholic Beverages and Tobacco Products;

- Law of Ukraine No. 270/96-В On Advertising;

- The Code of Ukraine on Administrative Offenses.

However, the issue of HTPs remains unresolved, which has a negative impact on the prevalence of tobacco use, especially among young people.

Developing a public health system involves fostering cross-sectoral cooperation aimed at preserving public health. In this context, it is important to note that in pursuance of Article 64 of the Association Agreement and the SPS Strategy, the following were adopted (Chapter 4 Sanitary and Phytosanitary Measures):

- The Law of Ukraine On Basic Principles and Requirements for Food Safety and Quality (No. 771, as revised by the Law of Ukraine No. 1602 of 22.07.2014), in force since September 2015.

- The Law of Ukraine On State Control Conducted to Verify Compliance with the Legislation on Food and Feed, Animal Health and Welfare (No. 2042 of 18.05.2017), in force since April 2018.

- The Law of Ukraine On Information for Consumers about Food Products (No. 2639 dated 06.12.2018) will take effect in August 2019 and other regulatory documents. 

In addition, procedures are being introduced according to the HACCP system (Hazard Analysis and Critical Control Point - a system of analysis of risks, hazards, and control of critical points).

The HACCP system helps ensure product safety by identifying and controlling hazards.

On September 20, 2018, Section VII of the Law of Ukraine On Basic Principles and Requirements for Food Safety and Quality came into force, which will complete the second stage of the transition of businesses to the new HACCP food safety control system.

A competent authority in the field of sanitary and phytosanitary measures, the State Service of Ukraine on Food Safety and Consumer Protection (SSUFSCP), was created (launched on April 6, 2016). 

• In pursuance of Article 426 of the Agreement, on October 15, 2021, the President of Ukraine approved the Strategy for Biosafety and Biological Protection, which defines the goals, objectives, and main directions of state socio-economic policy to ensure biosafety and biological protection of the state as a component of Ukraine's national security.

• In pursuance of Chapter 21 Cooperation on Employment, Social Policy and Equal Opportunities of the EU-Ukraine Association Agreement, the National Classifier of Functioning, Disability and Health was adopted in April 2022.  Therefore, the process of determining disability will be based on the principles of the ICF, adapted into the National Classifier. To this end, an electronic module for assessing the level of functioning, limitation of living, and health of a person will be developed. A combination of these solutions will allow for the creation of an integrated rehabilitation system.

• In pursuance of Article 21 Cooperation In the Fight Against Illicit Drugs, and on Precursors and Psychotropic Substances of the EU-Ukraine Association Agreement. 

The legal framework for fighting drugs in Ukraine includes special legislation and provisions of the Criminal Code, which provide for criminal and administrative sanctions. They are partially harmonized with the EU acquis. Ukraine is a party to the relevant conventions in the field of international drug control, including the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances.

The last national drug policy strategy expired in 2020, and Ukraine has not yet adopted a new strategy. The Center for Mental Health and Drug and Alcohol Monitoring serves as the European point of contact on drugs in accordance with EU Regulation 1920/2006. 

Ukraine does not have a national early warning system for psychoactive substances. In 2010, a Memorandum of Understanding was signed between the European Monitoring Center for Drugs and Drug Addiction (EMCDDA) and the Ministry of Health of Ukraine, which provided a framework for cooperation with the Center for Mental Health and Drug and Alcohol Monitoring of the Ministry of Health of Ukraine. In 2018, it was revised and signed by EMCDDA, but has not yet been signed by Ukraine. 

The National Classifier will ensure the implementation of the Medical Guarantees Program to provide care during acute, post-acute, and long-term rehabilitation periods at primary, secondary, and tertiary levels of medical care in healthcare facilities, rehabilitation facilities, and out-of-hospital settings.

Electronic healthcare system

Ukraine has a legal and regulatory framework for the development of electronic healthcare. However, the main regulatory documents governing E-Health have historically been created as a tool to support financial reform, which, given the further development of the digital healthcare system, needs to be reconsidered rationally from the perspective of a global digital state.

Currently, the E-Health system does not yet possess centralized and universal functionality for collecting and analyzing all statistical indicators.

There are no comprehensive patient tracking tools in the electronic system approved by the technical requirements for HIS (hospital information system). Patients are tracked only when they interact with family doctors and specialists as to whether or not they have been provided with medical services.

The patient's family doctor has access to all electronic medical records to analyze the patient's condition. Other doctors have access to their own records, records related to their specialty, and critical information about the patient. Items related to critical information are being updated and will be defined later.

Referrals between levels of medical care for patients with NCDs are currently no different from referrals between levels of medical care for patients with other diseases and conditions.

Currently, the NHSU has mainly administrative data available for analysis: how many patients visited their family doctors, how many patients received a referral for a consultation with a specialist, how many referrals have been "closed" (i.e., a specialist has already seen a patient following a referral from a family doctor), and the breakdown of types of interactions between a specialist and a patient (consultation, diagnosis, procedure).

Warfare has revealed specifics that need to be taken into account when introducing martial law. The issues of security, data storage, data access policies on temporarily occupied territories, as well as information exchange for patients who were forced to leave the country, have grown particularly acute and require further investigation, analysis, and development.

An important issue is the use of data for analysis and managerial decision-making. The data recorded in the system is still not accessible to the general public and is rarely analyzed by the NHSU (especially in terms of medical data), as the data set is not comprehensive and representative. Moreover, the tools for analyzing and visualizing this information on the National Health Service website in the "E-data" section are currently insufficient.

Human capital in Ukrainian healthcare 

In Ukraine, there is no traditional practice of assessing the needs of the population for healthcare professionals or planning healthcare resources based on urgent health problems or new challenges in the healthcare system. 

The problem of the social status of healthcare workers has not been resolved: although official salaries of healthcare workers in state and municipal healthcare facilities have increased in recent years, they still remain uncompetitive. This, in turn, supports the practice of unofficial payments in the healthcare system, leads to professional burnout of medical staff, demotivates young people from choosing the medical profession, leads to the migration of our doctors and nurses abroad, or prompts them to quit the profession.

Poor quality of higher medical education (Ukrainian medical universities are not in the top 100 of international rankings). This problem has been exacerbated by the three-year state of emergency: medical students in Ukraine, like other students, have mostly switched to remote learning, which is unacceptable for quality medical education.

There are no university clinics in Ukraine as a platform for medical education and science.

According to the Resolution of the Cabinet of Ministers of Ukraine No. 53 of February 1, 2017, program 229 "Public Health" was added to the list of fields of knowledge and specialties in which higher education students are trained, and was included in the field of knowledge 22 "Healthcare". However, in terms of its content and competencies (recommended by ASPHER - Association of Schools of Public Health in the European Region), program 229 "Public Health" is multidisciplinary. This has created obstacles to the development of science in public health, as only applicants with prior medical education are currently eligible to apply for a Ph.D. in public health.

The status, responsibilities, and functions of nurses do not meet the requirements of modern medicine

The involvement of social workers in the provision of social and medical services is limited and occurs mainly at the specialized level of medical care (in the fields of the HIV/AIDS and tuberculosis response, narcology, palliative care, and mental health). The main reason for the low level of involvement of social workers in social and medical services is legislative inconsistencies: the main regulatory document on the activities of social workers (the Law of Ukraine On Social Services, 2019) does not define the concept of medical, social or clinical social work; the referral system between healthcare facilities and social services or NGOs providing social services works only in certain sectors; there is no understanding of the role and function of social workers in healthcare facilities; educational programs for social workers do not offer specialization in either socio-medical services or clinical social work.

2.  VISION OF THE HEALTHCARE SYSTEM IN 2030, INCLUDING MEASURABLE INDICATORS OF ITS STATE

The post-war period up to 2030 has become a time not for rebuilding, but for creating a European-standard healthcare system (HHS) that ensures accessibility, affordability, and quality of healthcare services aimed at improving the health and well-being of the Ukrainian population.

In 2030, the life expectancy and healthy life expectancy of the Ukrainian population will be close to the European average.

Ukraine will meet the indicators of the UN Sustainable Development Goals set out in the National Health Report by 2030: “enabling healthy life and well-being for everyone, at all ages”.

Organization and funding of the healthcare system

Medical practice (medical care) in Ukraine is provided by healthcare institutions of various forms of ownership, self-employed individuals, and free professional entities (doctors, nurses/brothers). All of the above-mentioned medical practice entities that have declared their compliance with the requirements approved by the CMU are authorized to practice medicine. 

Institutionally, the HCS is comprised of the Ministry of Health, the NHSU, the state enterprise “Medical Procurement of Ukraine”, the state enterprise “State Expert Center”, the state enterprise “Electronic Health”, the state institution “Public Health Center of the Ministry of Health of Ukraine”, the Self-Governance Body of Healthcare Professionals (doctors, nurses), and the Association of Public Health Professionals.

In terms of functions:

• The Ministry of Health of Ukraine (MoH) shapes and coordinates the implementation of healthcare policy; monitors the compliance of medical practice entities with the procedure for medical practice in Ukraine.

• The NHSU is an autonomous financial agency within the HCS; it procures medical services from healthcare providers.

• SE “Medical Procurement of Ukraine” is an autonomous structure responsible for strategic and high-value procurement at the state level through a transparent, anti-corruption mechanism for identifying needs, respective medical and technical requirements, and control over the efficiency of the use of the supplied goods and services.  

• The Public Health Center of the Ministry of Health of Ukraine is a scientific and analytical organization that creates the basis for the formation of public health policy, elaboration of national health standards, and development of new knowledge in health and biosafety issues. 

• SE “State Expert Center” is an autonomous expert agency within the healthcare system; regulation of clinical trials and state registration of medicines; pharmacovigilance, standardization of medical care; evaluation of medical technologies.

• SE “Electronic Health” - the administrator and coordinator of the digital healthcare platform development, which follows the ideology of sustainable development and interoperability, in line with the WHO principles and international best practices. Through balancing the participants (patients, doctors, software developers, insurance companies, the Ministry of Health, the Ministry of Digital Transformation, the State Enterprise “Electronic Health”, the Public Health Center, scientists, non-profit organizations, cyber police, etc.), a constant harmonious need for functionality and standardization arises, which is met by both the market and the state. 

• State-owned and municipally owned healthcare institutions have acquired a legal status that provides them with financial and organizational autonomy, which will facilitate their development.

• The medical self-governance body is a non-governmental, non-profit professional organization that unites all doctors of Ukraine and is established to ensure the fulfillment of the objectives of medical self-governance. The self-governance body is responsible for the physician's access to the profession, continuous professional training, organizational and professional independence, provides mechanisms of professional responsibility, and advocates for the interests of physicians. The self-governance body of other healthcare professionals (nurses, rehabilitation specialists, public health specialists, etc.) was established on the same principle.

• All local authorities in Ukraine are responsible for improving the health of their population by providing health policy recommendations and building health infrastructure, as well as funding regional/local public health programs.

Healthcare is universally accessible to the population, regardless of the socioeconomic and geographical circumstances of each citizen, without disastrous costs to their welfare. 

Accessibility of medical care is rising due to increased funding and, consequently, there is an expansion of medical guarantee packages (MGPs). The increase in funding is driven by an upsurge in government spending on healthcare, as well as other sources of funding, including voluntary health insurance. 

Voluntary health insurance is actively developing. Citizens who wish to access additional medical services and medications or enjoy greater convenience in accessing those services and medications can purchase voluntary health insurance policies in addition to the state-guaranteed healthcare packages. 

The NHSU guarantees payment for basic medical services and medications of proper quality at all levels of medical care. 

At the primary healthcare level, funding is provided in a mixed form, mainly based on the capitation rate, as well as payments for quality indicators. 

At the level of specialized medical care, funding is based mainly on the amount of medical care provided. 

The list of procured pharmaceuticals, medical devices, and other medical technologies is developed using the health technology assessment methodology, which allows public procurement based on clinical effectiveness, economic feasibility, and organizational concerns of their use.

Illnesses in psychiatry, rehabilitation, palliative care, rare diseases, and epidemic diseases are covered by separate (protected) funding channels. 

Anyone in need of life-saving medication can receive it free of charge or with a small surcharge at pharmacies or during a hospital stay - the list of medicines sponsored through the Affordable Medicines program is expanding every year.

The hospital network has been radically modernized. The hospitals are equipped in accordance with the requirements of the NHSU and are ready to provide care around the clock at the highest European standards with a strong level of evidential support. 

The damaged medical infrastructure is being restored depending on the medical and demographic composition of the population and the analysis of needs in the spheres of medical care.

An extensive network of palliative and hospice care centers, as well as long-term care units of various forms of ownership and funding, has been developed. 

A network of rehabilitation centers of the highest European standards has been created in accordance with the current needs for different forms of rehabilitation. Rehabilitation therapists are trained in accredited European programs.

Legal relations in the healthcare system of Ukraine

Doctors have legal standing, which means that they can choose how they practice medicine: as self-employed individuals; as employees under an employment agreement (contract); as free professional entities; or under a civil law contract with a healthcare institution of any form of ownership. 

Equality of rights, broad opportunities in choosing a place of work, and the ability to choose the form of economic relations with other entities promote professional fulfillment and competition, thereby improving the quality of medical services and eliminating the preconditions for unofficial payments. 

The growing autonomy of medical institutions and the licensing of individual medical practice allows patients to freely choose not only the medical institution (of any form of ownership) but also the doctor and the insurance company.

Patients' access to healthcare is expanding due to patients' awareness of their rights, the necessity of routine examinations, and the geographical accessibility of facilities where they can receive medical care. 

Patients are interested in maintaining their own health by following recommendations on healthy lifestyles, preventing diseases, and undergoing screening programs in a timely manner.

Electronic healthcare system

In 2030, a digital health platform (DHP) was created, which follows the ideology of sustainable development and interoperability, in line with WHO principles and international best practices. 

By balancing the participants, which include patients, doctors, software developers, insurance companies, the Ministry of Health, the Ministry of Digital Transformation, the State Enterprise “Electronic Health”, the Central Public Health Service, scientists, charitable organizations, cyber police, and others, a constant harmonious need for functionality is created which is met by both the market and the state. In turn, government agencies are more focused on developing policies, quality control, implementing standardization, and creating a stimulating environment for software companies that can freely create new functions and services under rules they understand. The state can implement the best and most effective solutions under the public-private partnership principle. The solution-oriented platform allows different companies to freely provide products and services.

The DHP cooperates seamlessly with various national registries and systems through the national data bus (trembita.gov.ua).

Structured integrated communication tools contribute to improving the quality of interaction between participants.

Modern computer equipment and networks are being installed in healthcare institutions and maintained by highly professional administrators. Streamlined information is available for managerial decision-making and real-time management of healthcare facilities through various programs and services.

The NHSU receives all the necessary data in real time to make managerial decisions, provide recommendations to healthcare facilities, make payments, and coordinate private insurance companies via the core E-Health tool, which is tightly integrated with the DHP.

Patients are offered a variety of features to help them both prevent illness (prevention) and select a doctor and healthcare facility based on their rating, as well as monitor the course of treatment and rehabilitation. By monitoring their electronic health records, patients help the NHSU identify faulty services and, by providing feedback in general, quickly identify any gaps or issues.

The patient holds ownership of their data, which is stored using security technologies (e.g., blockchain). The patient's medical data can be transferred or sold, open or closed, upon the consent of the owner, however, any access to sensitive data is always logged.

The State Enterprise “Electronic Health” is an independent, stable organization that coordinates all technical issues of support, development, and implementation that also deals with standardization, provides advice, and is actively involved in the development of the DHP.

The digital healthcare environment creates favorable conditions for human resources motivation and professional development, as well as for the development of healthcare facilities and regional institutions, provides cutting-edge services for all stakeholders in a balanced manner, and creates an open market for solutions that are compatible and relevant, in particular, to the EU.

Development of the public health (PH) system in Ukraine

An effective public health system has been created that facilitates the reorientation of healthcare from the policy of treatment to the policy of prevention and promotion/preservation of human health. 

The institutional functioning of the Centers for Disease Control and Prevention has been ensured. 

Public health is one of the core values of the state. The WHO policy "Health in every policy" is the basis for the development and implementation of state policy in Ukraine at all levels of government and in all sectors of public life. A communication campaign to promote public health and improve health literacy is underway in society. The medical culture has grown among the general public as a result of citizens' awareness of risks and their responsible attitude to their health.

A unified system of biosafety and biosecurity has been established to protect human health and the environment from the effects of hazardous biological agents, including those that could lead to emergencies and threaten national and international security.

European standards and practices were introduced for the blood system and the infectious disease control system, ensuring maximum immunization coverage.

The National Fund for Public Health was founded, which finances measures aimed at preventing and reducing the impact of chronic noncommunicable diseases on human health through targeted programs. The fund is replenished by allocating 1% of the state budget revenues from the excise tax on tobacco products, e-cigarette liquids, alcoholic beverages, sugary beverages (after the introduction of the excise tax on sugary beverages), and products containing trans fats above the permitted levels.

Ukraine has fully implemented the WHO Framework Convention on Tobacco Control, its Guidelines, and the decisions of the parties to overcome the epidemic of tobacco and nicotine use, which will make it possible to launch the implementation of the Ending the Tobacco Era policy in 2030.

Human capital in Ukrainian healthcare 

In line with European standards, medical education has been reformed at all levels - from nursing to doctors to management.

The medical profession is well respected, and average salaries in the healthcare system reflect the complexity and responsibility expected of the profession. 

Higher medical education in Ukraine meets the European standards of quality higher education, as evidenced by the students’ high performance at final exams, the academic quality of the teaching staff, scientific accomplishments, etc.  The path of a doctor's professional development (from undergraduate training to obtaining a license to practice medicine) is lengthy and meets the educational standards of the European Union. Medical institutions of higher education are among the hundred most prestigious higher education institutions in the world.

3. KEY ISSUES TO BE SOLVED IN  THE HEALTHCARE SYSTEM  TO ACHIEVE THE DESIRED OUTCOMES

The Constitution of Ukraine declares a person, their life, and health to be the ultimate social value.

The goal of the healthcare system in Ukraine is to ensure that people have a right to universal access to quality healthcare without financial hardship, as well as protection in the event of health emergencies and good health and well-being at any age.

In order to attain the post-war benchmarks for building a European-style healthcare system in Ukraine, as described in Section 1, a number of challenges need to be faced and appropriate management decisions need to be made.

1. To ensure competition in the healthcare market, which will not only serve as a tool for transparent pricing and financing of the HCS but will also significantly contribute to improving the quality of medical care, it is necessary to:

- Adopt the Law of Ukraine On Professional Licensing of Healthcare Professionals, which will legislate the procedures for introducing licensing of healthcare professionals, involving not only obtaining a permit to practice the profession after graduation but also legally establishing the possibility of choosing the form of medical practice (as a self-employed person, under an employment or civil law contract with a healthcare institution, under a civil law contract with a patient). It will also ensure the professional development of a licensed healthcare professional and make them responsible for operating within the scope of their licensed professional activity, while making information about the healthcare professional fully accessible to the patient. Introduce legislative mechanisms of liability in case of medical error and violation of the terms of the permit for individual medical practice.

- Adopt the Law of Ukraine On Medical Self-Governance, which should establish a medical self-governance body – an independent body representing doctors and overseeing the quality of medical care.

- Revise regulatory documents governing the operation and legal status of state-owned and municipally-owned healthcare institutions to ensure their financial and organizational autonomy.

2. To develop a digital healthcare environment in accordance with WHO standards and international best practices:

- Bring the legislation regulating E-Health in Ukraine to the modern level of digitalization (without the need for any hard copies in general), budgeting for financing the relevant processes, engaging experts to formulate a strategy, standardization, and motivational environment for participants (the outdated legal framework not only prevents the implementation of effective solutions and does not allow to stay up to date, but also forces to pursue compromise and outdated solutions).

- Review the approach to centralization and decentralization of the E-Health system. The system architecture should be flexible, capable of supporting centralized and decentralized services, with strong security and rigorous control of data access, displaying these access facts in the respective accounts of citizens/patients/doctors.

- Create a balanced platform for sustainable development of E-Health (digital health platform - DHP), which will be evolving based on the interests of stakeholders, including patients, doctors, associations, businesses, public and charitable organizations, the Ministry of Health, the Central Public Health Service, the Ministry of Digital Transformation, the NHSU, insurance companies, the State Enterprise "Electronic Health", scientists, educators, cyber police, and independent experts. The current E-Health system is still being developed as a tool for the NHSU to implement financial reform.

- Introduce a fully digital document management system in the HCS, along with modern digital tools, specifically, standardized digital medical records, structured digital medical records, virtual doctors' offices, digital consulting between specialists, etc. thus allowing to plan and manage documentation more efficiently, save time and improve the quality of clinical and managerial decision-making, as well as to track errors in medical care transparently and promptly and to prevent them in the future through the use of digital services. Ensure full interoperability of the DHP with various national registries, systems, and institutions through the national data bus (trembita.gov.ua).

- For clear patient identification, enforce the use of the national citizen identifier (id.gov.ua) and implement the Master Patient Index technology for unidentified people or foreigners.

- Actively develop the “Diia” platform as the interface for interaction with citizens regarding its application for HCS.

- Ensure that the business can be involved in the development and market penetration of services, products, and solutions without bureaucratic restrictions and without any dependence on monopolies.

- Build a motivating environment for data generation. Integrating this data with performance indicators for payments and systems that help doctors to make decisions, consult and treat, using appropriate protocols, can be a significant motivator. The healthcare human capital has to be used more efficiently, so it is necessary to motivate the deployment of physician assistants in healthcare facilities, including for entering medical records, and appropriate digital tools for this. Optimize medical forms for digital use.

- Control over the data should be entrusted to the participant with the greatest stake in objectivity - the patient, such as through the patient's personal account. This will help build a balanced, human-centered system in which the patient is the owner of their medical data of value. If patients save their data on preventive activities, sports achievements, and healthy lifestyle, which can be shared with insurance companies, they will be able to get the best deal on commercial insurance.

- Install modern computer equipment and networks in healthcare facilities and ensure their maintenance by highly professional administrators. Provide licensed software packages required by healthcare facilities. Create competitive parameters for quality software and hardware components as well as maintenance services for the relevant typical tasks, in order to develop high-quality IT infrastructure in the healthcare sector.  

- Create opportunities for attracting professionals through market-based financial remuneration, reducing bureaucratic barriers to the implementation of modern ideas and effective cooperation with associated institutions. 

- Introduce digital auditing and monitoring tools that will allow an assessment of the effectiveness of expensive medical products so as to identify potential demand.

All of the above will allow the collection of reliable, timely, structured information as a basis for real-time managerial decision-making through various programs, and services. In doing so: 

1. The NHSU receives all the necessary data in real time for managerial decision-making, providing recommendations to healthcare facilities, making payments, and coordinating private insurance companies, using the main E-Health tool, which is closely integrated into the DHP;

2. Insurance healthcare delivered through digital technologies is connected to healthcare facilities, doctors, and patients, and motivates patients to take preventive measures while incentivizing doctors and healthcare facilities to improve the quality of services provided;

3. Patients benefit from a variety of features that help them both prevent diseases (prevention) and choose a doctor and healthcare facility based on their rating, as well as monitor the course of treatment and rehabilitation. Moreover, by monitoring their electronic health records, they can help the healthcare quality control body identify faulty services and, by providing feedback in general, quickly identify gaps and issues.

3. In order to strengthen the impact of the public health system, measures aimed at preserving the health of the population as the strategic capital of the state should be implemented:

- Introduce a systematic approach to solving current public health problems, including through intersectoral cooperation.

- Develop and adopt a number of bylaws and regulations that will allow for the implementation of the provisions enshrined in the Law of Ukraine On the Public Health System.

- Provide an itemized financing of public health in the State Budget. 

- Given the limited funding for healthcare, establish the National Public Health Fund for the purpose of finding additional sources of funding and securing sustainable financing of measures intended to prevent the spread of chronic noncommunicable diseases. Ensure that the fund is replenished by allocating 1% of the state budget revenues received from the excise tax on tobacco products (including e-cigarette liquids), alcohol, sugary beverages, and products containing trans fat.

- In order to overcome the epidemic of tobacco and nicotine use, fully comply with the WHO Framework Convention on Tobacco Control, its Guidelines, and the decisions of the parties.

- In order to lower the level of alcohol consumption, fully comply with the WHO policies and initiatives on alcohol consumption (SAFER).

- Create conditions for the implementation of Goal 3 "Good health and well-being" of the UN Sustainable Development Goals by 2030.

- By 2024, complete the implementation of the Association Agreement with the EU in the field of public health.

4. In order to solve the problem of healthcare staffing, develop and adopt a state-level framework for healthcare staffing policy in Ukraine engaging all stakeholders. The framework should address the following issues:

- Improvement of personnel training (undergraduate and postgraduate education), in particular, practical training of specialists and their competitiveness on the international labor market. Create a network of university clinics and hospitals in Ukraine in accordance with international best practices. Envisage a revision of the Regulation on the University Clinic, which should expand opportunities for involving healthcare facilities in the system of medical training.

- Training and transparent selection of managerial staff capable of working under market economy conditions;

- Improvement of the planning system for medical workers’ needs, which would correspond to the current state and progress of the healthcare sector on a national level, as well as in the regional and local context. To do this, create a complete database of medical workers (including private medical institutions);

- Raising the prestige of the medical profession, improvement of the system of remuneration and social protection of medical workers.

5. Develop and recommend the implementation of standard labor and civil law contracts between medical workers and healthcare facilities which would ensure differentiation of remuneration of medical workers depending on their level of qualification, scope, quality, complexity, efficiency of their work as well as their working conditions. 

To this end, clinical quality indicators should be introduced broadly.

4. POLICY FOR ADDRESSING ISSUES IN THE HEALTHCARE SYSTEM IN THE PERSPECTIVE OF 2030

4.1 Defining healthcare policy

1. Regulatory and legal framework

• To ensure that the task of establishing a medical self-governance body is fulfilled, the Law of Ukraine On Medical Self-Governance should be drafted and adopted, which will enable Ukraine to comply with Chapter 22 Public Health of the Association Agreement between Ukraine and the European Union, regarding “.... strengthening the healthcare system of Ukraine and its potential, in particular through the implementation of reforms. ...”, the execution of the Resolution of the 27th World Medical Assembly (Munich, 1973) as amended by the Resolution of the 35th World Medical Assembly (Venice, 1983), as well as the realization of the provisions of the Concept of Reforming the Institute of Self-Regulation in Ukraine, approved by the Order of the Cabinet of Ministers of Ukraine No. 308 of May 10, 2018. The working conditions of healthcare professionals should be determined by the opinions of medical societies, doctors should be guaranteed moral, economic and professional independence, and medical societies should be adequately represented in all state institutions. The law should establish the rights of doctors to free professional activity, namely: a procedure for entering the profession, obtaining the right to practice medicine, and the right to choose the form of medical work (in other words, medical practice, medical care). This law should regulate the relations arising in the process of establishment and operation of the medical self-governance body.

• In order to ensure the high quality of medical care and increase the autonomy of the medical profession, the following laws should be drafted and adopted: “On Professional Licensing of Healthcare Workers”, “On Medical Malpractice Insurance”, “On the Body for Quality Control of Medical Care”. Thus, having granted doctors the status of legal entities with the right to practice medicine, the legislation should also regulate the relations that emerge between medical practice entities, medical professionals, patients, insurance companies, and competent state authorities within the course of medical practice and clinical work. Also, amend the laws of Ukraine: “On Licensing of Economic Activities” (to exclude “medical practice” since access to medical practice will be covered by the new law), “Fundamentals of Ukrainian Legislation on Healthcare” in respect of legislative support for the suspension of a license for a business entity to carry out certain types of economic operations in the healthcare sector, as well as to change the definitions of “medical service” and “medical care” since the entities entitled to provide medical services are changing; “On Insurance”, by establishing regulation of civil liability insurance for doctors as subjects of the medical profession and medical practice, as well as the relationship between doctors and insurers.

• In order to regulate the issue of medical training and continuous professional development, it is necessary to develop and approve a strategy for human capital development within the healthcare system. This should include a plan for the development of human capital in the healthcare sector, based on the needs of the sector and the socio-economic development of Ukraine.

• To ensure quality control over the implementation of changes and monitoring of the quality of medical care, introduce the practice of regular evaluation of the provision of the guaranteed package of medical services at the primary healthcare level with appropriate changes to the primary healthcare packages based on the evaluation conducted on the basis of quality indicators.

• In order to promote the development of E-Health in Ukraine, in accordance with WHO recommendations and international best practices, develop and approve a strategy for the development and utilization of E-Health. The strategy should address the issues of architecture, infrastructure, standardization and terminology, professional staffing, financing, devising an appropriate regulatory framework for E-Health development, creating conditions for regulating cybersecurity, information security policy, data integrity and security, patient confidentiality, mechanisms of doctor-patient interaction, digital management and public control, integration with state registries, identification systems, etc.

• In an effort to control incidence and mortality from chronic non-communicable diseases, develop and approve a national strategy for the prevention and control of NCDs, which necessarily incorporates the link between risk factors and the occurrence of NCDs. Prioritize its implementation in the policy of development of the Ukrainian healthcare system.

• Impose stricter liability for violations of laws on tobacco, alcohol, trans fats, etc. in the Criminal Code of Ukraine.

• In order to improve the quality and accessibility of mental health services, develop and approve a strategy for the development of the mental health system in Ukraine. The strategy should envisage: cross-sectoral issues, infrastructure development (in particular, decentralizing and developing outpatient care, establishing a crisis counseling system; improving the provision of professional mental health support at the primary healthcare level; reorganization of the process of receiving care in medical institutions at the level of specialized medical care; introducing a clear referral mechanism between existing services, building multidisciplinary teams, developing the mental healthcare system, which would involve the level of territorial communities), standardization of methodologies of mental healthcare in line with international standards, improvement of training and continuous professional development of specialists in this area (including nurses, doctors, clinical psychologists, rehabilitation specialists, as well as social workers and other specialists), as well as securing targeted funding for the development of this sector.

• In order to standardize the norms of domestic legislation in accordance with WHO standards and international best practices, eliminate a number of legal inconsistencies on vaccination, fighting the spread of tuberculosis and diseases caused by the human immunodeficiency virus (HIV), and make appropriate amendments to the Law of Ukraine On Protection of the Population from Infectious Diseases.

• In order to reduce alcohol use and minimize its harmful social effects, fully implement the WHO policies and strategies on alcohol use (SAFER). Design and adopt an agenda for preventing and fighting the negative effects of alcohol use by the population, tailored to the national context.

• In order to implement Article 21 Cooperation In the Fight Against Illicit Drugs, and on Precursors and Psychotropic Substances of the EU-Ukraine Association Agreement: design and adopt a national drug policy strategy; establish a national early warning system for psychoactive substances.

• In order to fully implement the WHO Framework Convention on Tobacco Control, its Guidelines, and the decisions of the parties, revise Article 15 of Directive 2014/40/EU on the implementation of a tobacco traceability system and adjust the national legislation accordingly.

• In order to build a Ukrainian public health system consistent with the norms and standards of the European Union, draft and adopt the legal acts necessary for the implementation of the Law of Ukraine On the Public Health System, adopt the Law of Ukraine On Biological Safety and Biological Protection, the Law of Ukraine On Eliminating Tuberculosis in Ukraine; harmonize Ukrainian legislation with the EU legislation on sanitary and phytosanitary norms, food safety; improve the legislation on the prohibition of advertising and other types of promotion alcoholic beverages, food products with excessive amounts of sugar and salt.

• In order to ensure the effective functioning of the civil protection system, review the legal framework governing coordination between the public health, emergency medicine, and disaster medicine systems, as well as structures governing emergency situations, food safety, nuclear regulation, ecology, border protection, security, and safety.

• In order to promote the development of blood donation in Ukraine, support the development and adoption of a regulatory document on the functioning of the Blood System Information Space, as well as regulate the issue of reimbursement for donated blood components within the framework of the medical guarantee program.

• In order to form an evidence-based foundation for the public health policy, promote the development of science in healthcare, as well as secure a protected expenditure item in the State Budget of Ukraine to fund science in the healthcare system, specifically, run a cohort study on the effects of war on the health of the population of Ukraine.

2. Institutional changes

Institutionally, the HCS is represented by the Ministry of Health, SE “E-Health”, the Medical Self-Governance Body, a network of medical universities (with clinical bases/university clinics), the NHSU, SE “Medical Procurement of Ukraine”, SE “State Expert Center”, state institution “Public Health Center of the Ministry of Health of Ukraine”, regional centers for disease control and prevention.

In terms of functions:

The Ministry of Health of Ukraine (MoH) shapes and coordinates the implementation of the healthcare policy; monitors compliance by medical practice entities with the procedure for conducting medical practice in Ukraine.

Amend the Regulation on the Ministry of Health by removing the system of licensing medical professionals out of its jurisdiction. It should preserve the following authority:

- Licensing of medical operations of medical enterprises, institutions, organizations that are subordinated to central executive authorities;

- Licensing of medical enterprises, institutions, organizations that provide services and perform works of emergency medical care regardless of their form of ownership;

- Licensing of medical operations of enterprises, institutions, organizations of all forms of ownership, except for municipal, that provide inpatient medical care.

Establishment of a “medical self-governance body” as a non-governmental professional medical association of healthcare professionals operating on the basis of compulsory membership. This institution should:

- Include all licensed medical professionals. Membership in such a body should be a prerequisite for their work. 

- Exercise “licensing of professional activity of medical workers” – granting a permit to perform professional medical work to medical workers (doctors, nurses); 

- Make decisions on the license renewal for a further period of three or five years;

- Impose sanctions (revocation or suspension of the license);

- And so on.

The functioning of this new body of medical self-governance will reduce the administrative dependence of doctors on the management of healthcare institutions and government officials.

The medical self-governance body is a non-governmental non-profit professional organization that unites all doctors of Ukraine and is founded to ensure the accomplishment of the objectives of medical self-governance. The self-governance body is responsible for the physician's admission to the profession, continuous professional development, organizational and professional independence, provides mechanisms of professional responsibility and advocates the interests of physicians. Self-governance bodies of other healthcare professionals (nurses, rehabilitation specialists, public health professionals, etc.) have been established based on the same principle.

The state enterprise “Electronic Health” is the administrator and coordinator of E-Health development, which has an ideology of sustainable development and interoperability that is in line with WHO principles and international best practices. By balancing the participants (patients, doctors, software developers, insurance companies, the Ministry of Health, the Ministry of Digital Transformation, the State Enterprise “Electronic Health”, the Public Health Center, scientists, charitable organizations, cyber police, etc.), a constant harmonious need for functionality and standardization arises, which is met by both the market and the state.

The network of medical universities is a network of autonomous institutions of higher medical education and serves as the basis for undergraduate and postgraduate medical education and training. The clinical bases of medical universities are university hospitals and leading regional hospitals (supercluster medical institutions).

The NHSU is an autonomous financial agency in the healthcare system; it procures medical services from medical practitioners.

The state enterprise “Medical Procurement of Ukraine” is an autonomous structure responsible for strategic and high-value procurement at the state level with a transparent, anticorruption mechanism for identifying needs, relevant medical and technical requirements, and controlling the efficiency of the use of the delivered goods and services.  

The state institution “Public Health Center of the Ministry of Health of Ukraine” is a scientific and analytical organization that lays the groundwork for the formation of public health policy, the development of national health standards, and the creation of new knowledge in health and biosafety issues, which is implemented through a network of regional Centers for Disease Control and Prevention.

The state enterprise “State Expert Center” is an autonomous expert agency in the healthcare system; regulating clinical trials and state approval of pharmaceuticals; pharmacovigilance, standardization of medical care; evaluation of medical technologies.

All local authorities in Ukraine are responsible for improving the health of their populations by consulting on health policy and building health infrastructure, as well as funding regional/local health programs. 

It is necessary to create the National Public Health Fund, which will fund measures to prevent and reduce the impact of chronic noncommunicable diseases on human health via targeted programs. The fund is to be replenished by allocating 1% of the state budget revenues from the excise tax on tobacco products, e-cigarette liquids, alcohol, sugary beverages (after the introduction of the excise tax on sugary beverages), and products containing trans fats.

Establish the National Transfusion Center as a specialized state institution under the management of the Ministry of Health of Ukraine, after the issue of the Presidential Decree on the termination of the martial law regime, to ensure effective management of blood system actors and coordination of blood system operations.

Enable the involvement of employees of non-governmental organizations without medical education to perform certain activities and functions in the public health system (with the definition of mechanisms for their involvement and quality assessment standards).

3. Funding

Enable the involvement of employees of non-governmental organizations without medical education to perform certain activities and functions in the public health system (with the definition of mechanisms for their involvement and quality assessment standards). Funding for measures, programs, and services within the healthcare system should come from a range of transparent sources:

1. Budgetary (state budget and local budget)

2. Donor support

3. Commercial activity

4. Other sources of funding not prohibited by law.

Budget funds should cover basic and critical components.

Donor support should be coordinated and aimed at improving the effectiveness of sectors that require special financial support (determined based on an analysis of morbidity, mortality, and healthcare performance indicators).

Commercial activities can be conducted in terms of providing useful services, analytics, and recommendations, but not bureaucratic services (certification, approvals, permits), which hinders the development of small or honest businesses. It is also necessary to create a market for high-quality depersonalized medical data for business.

The prerequisites for improving funding in the healthcare system are:

• Fostering conditions for the elimination of unofficial payments in healthcare (providing doctors with simple and clear mechanisms of economic relations with institutions, healthcare facilities, insurers, and patients)

• Fostering conditions for attracting private investment in healthcare and effective interaction between the state and the private sector in ensuring public health (availability of reimbursement tools, data availability for analytics, and calculation of investment risks);

• Fostering conditions for the development of voluntary health insurance and prerequisites for the introduction of compulsory health insurance (reduction of the percentage of unreported salaries, increase of public confidence in the healthcare system).

The adoption of the aforementioned legislative initiatives will ensure the introduction of mechanisms for financially transparent relationships between healthcare entities, medical practitioners, patients, government agencies, and insurers (simple and accessible to providers).

The functioning of E-Health as a systemic analytic tool will enable the analysis of real data regarding the need for, the provision of, and the financing of medical services.

With new entities in the healthcare system and regulated relations between them, as well as E-Health and the ability to analyze data, a transparent market for medical services, a market for medical specialists, and a market for medical institutions will be created.

Transparent markets will provide the prerequisites for the development of private investment in the healthcare sector. And the presence of mechanisms for partial reimbursement of costs in the private sector will allow investors to enter the market with lower financial risks.

The existence of transparent markets and analytic tools will improve the conditions for the development of voluntary health insurance.

Sustained improvement of the healthcare quality in the country as a whole and the public's awareness of these changes as well as the obvious correlation between the level of healthcare funding and the quality of healthcare will enhance the public's openness to the introduction of mandatory health insurance.

In order to ensure the development of health promotion programs, it is necessary to provide for separate expenditure items in the State Budget of Ukraine, as well as to stimulate the financing of public health programs (including mental health) from regional and local budgets. Protected items of expenditure in the state budget should include expenditures for the purchase of vaccines and medical supplies to maintain the immunization program in accordance with the Vaccination Schedule for the respective year, taking into account the three-year vaccine planning and changes to the Vaccination Schedule.

As an additional source of funding and in order to ensure sustainable funding for prevention measures against the spread of chronic noncommunicable diseases, establish the National Public Health Fund. Ensure that the fund is replenished by allocating 1% of the state budget revenues received from the excise tax on tobacco products (including e-cigarette liquids), alcoholic beverages, sugary beverages, and products containing trans fats.

4. Communication of reforms to society

Effective implementation of changes is facilitated by proper communication of reforms to key stakeholders. 

It is recommended to develop a communication strategy for the implementation of changes, engaging opinion leaders at both the national and local/regional levels.

Among the communicators of the planned changes should be doctors, who are aware of the need for change, understand the results of these positive changes for patients, for doctors, and for the health of the country's population at large.

The main opponents of the planned changes may be representatives of the current bureaucratic manager-oriented medical system and representatives of the system of vertical clinical hierarchy, as well as local authorities that do not understand the importance of maintaining health as the most valuable asset.

Messages of communication should tackle the following issues:

- The incurrence of expenses during treatment, which are often catastrophic for the family budget, and the direct dependence of these expenses on the necessity of specialized treatment,

- The existence of unofficial payments in medicine,

- Searching for a specialist and the unclear cost of services provided by them,

- Corruption at the level of healthcare financing, disbelief that increased budget funding or additional financing through compulsory health insurance will increase access to healthcare and its quality.

Informing the population about their rights to access healthcare services, developing clear logistics schemes that are actively promoted at different levels using available communication channels.

5. Steps/stages of change

Step-by-step implementation:

- Development of an agenda for the implementation of the post-war recovery strategy for all constituents of the healthcare system in Ukraine;

- Development and adoption of the relevant legal framework for implementing change;

- Development of a communication strategy for implementing change and health promotion; 

- Digitalization of information in the healthcare system and functioning of E-Health as a systemic tool for data collection and analysis.

Sustainable improvement of the overall quality of healthcare in the country and public awareness of these changes and the obvious correlation between the level of healthcare financing and the quality of healthcare will increase the population's openness to the introduction of mandatory health insurance.  

Concurrently with all the aforesaid stages, the prestige of the medical profession will grow and the demand for quality medical education will increase, which will be a trigger for change in undergraduate and postgraduate medical education.

6. Criteria for assessing the success/failure of the reform

1. The single healthcare space becomes transparent and conducive to professional competition, which contributes to the improvement of the quality of healthcare.

2. The medical community, through the self-governance body and the patient feedback channel, has the tools to control the medical and ethical aspects of medical practice.

3. Purchasers of healthcare services (e.g., NHSU, insurers) receive information on clinical outcomes and activities of contracted healthcare facilities to assess the quality of contracted healthcare services.

4. Digitalization has facilitated the collection of statistical information from healthcare institutions of any form of ownership, which makes it possible to conduct an objective assessment of the healthcare sector.

5. The medical profession is prestigious, average salaries correspond to the prestige of the profession, and medical education is in high demand.

6. Indicators of organization and infrastructure:

• Availability of an up-to-date national strategy and policy for the development of the healthcare system and, in particular, of E-Health;

• Availability of standards, regulations, and a legal framework for E-Health;

• Infrastructure resources to support the development of HCS and E-Health;

• Centers for Disease Control and Prevention across the country are adequately supported with resources, among other things, some conduct enhanced epidemiological surveillance of communicable and noncommunicable diseases;

• Crisis counseling rooms are available in every territorial community;

• A modern system of rehabilitation centers has been set up in each region of Ukraine;

• A blood system, coordinated by the National Transfusion Center at the national level, has been founded. The annual rate of voluntary donation reaches 90%, and the write-off rate due to the expiration of blood components is no higher than 5%.

7. Indicators of human capital and education:

• Availability of a human capital policy for training medical workers and specialists in the field of E-Health;

• Availability of training programs and courses on E-Health for healthcare professionals and students;

• Registration of the right to practice medicine, on condition of having a diploma of higher medical education and relevant certificates of specialization, occurring within one business day via digital platforms;

• Registration of the right to practice medicine through filling out a declaration on a digital platform occurring within one business day;

• A register of medical practitioners with information on the forms of practice, contracts, private practice, etc. with varying access to the scope of information in the register.

8. Indicators of technological advancement and innovation:

• Percentage of medical institutions (including military, departmental, specialized, and private) that have implemented E-Health technologies;

• Number of innovative solutions developed and implemented in the field of E-Health;

• An available register of healthcare institutions, medical self-employed professionals, and other medical practice entities with varying access to the scope of information in the register;

• A doctor's personal account is available in the DHP system;

• A patient's/citizen's personal account containing information about insurance, examinations/treatments performed and reminders of scheduled examinations based on age and other specifics is available; 

• The interface of interaction between the PHC and citizens is user-friendly and incorporated into “Diia”.

9. Healthcare quality indicators:

• Level of patients’ and healthcare workers’ satisfaction with HCS and E-Health;

• Ensuring confidentiality, integrity, quality, and availability of medical data;

• The number of data security breaches and incidents related to E-Health.

10. Indicators of impact on public health and economic performance:

• Improved general health of the population, including through E-Health technologies;

• Increased level of disease prevention and decreased burden of chronic noncommunicable diseases;

• The issue of the presumption of consent to preventive vaccinations is enshrined in the law;

• Increased adherence to vaccination: coverage rates have reached at least 95% nationally in target groups by age according to the Vaccination Schedule;

• A nutrition monitoring system has been introduced to promote equal access to safe, healthy, and environmentally friendly food over the course of a lifetime in accordance with EU standards in the field of sanitary and phytosanitary norms and food safety.

5. RED LINES WHICH  CANNOT BE CROSSED IN THE HEALTHCARE SYSTEM

It is absolutely unacceptable: 

- To introduce manual control in the healthcare provision system, including manual elimination of competition between healthcare facilities, as well as introducing the exclusive right of certain healthcare facilities to provide specific medical services. 

- To reorganize the healthcare sector financially and structurally, ignoring the basic principles of the medical profession as a free profession. 

- To limit the autonomy of hospitals, to tighten control over their finances (return to treasury/estimated accounts) and operations.

- To limit the autonomy of the National Health Service (as well as other technical agencies), increasing its dependence on the economically unjustified political instructions of the Ministry of Health and other executive bodies. 

- To rebuild the old network of hospitals under the slogans of post-war restoration.

The following are the key threats that could compromise Ukraine's further development as a democratic liberal state and contradict its declared norms, principles, and values:

- Administrative influence and corruption in the development of the healthcare system;

-Lack of institutional memory. Abandonment of unfinished political projects undertaken by one party and their replacement by a new political party with new tasks results in huge wasteful expenditures and absolves the party of responsibility in the face of constant change;

- Corruption and abuse in the procurement of expensive medications and medical equipment at the expense of the state budget;

- Bureaucratic obstacles, specialized legislation, outdated restrictions, and non-market staffing policies systematically attract corruption and discourage professionalism.

- Changing the European vector of healthcare system development;

- Extensive development of the healthcare facilities network;

- Lack of political will to make decisions aimed at creating safe conditions and environment for human life, as well as ensuring the professional well-being of healthcare workers,

- Failure to invest in planning and management of healthcare operations,

- Lack of a protection mechanism against the risks of loss or compromise of personal and medical data of patients in E-Health. 

- Commercialization of healthcare system objectives. The priority of human health is recognized in ensuring the functioning of the healthcare system over the corporate interests of business entities.