Lena Slobodian has just finished her master’s degree in social sciences in Humboldt University of Berlin. In her research Lena focuses on Eastern Europe, healthcare and science communication. She interviewed nurses, doctors and union leaders about their work environment as well as their opinions about the changes in the Ukrainian healthcare system. In this article she presents the opinions of healthcare workers about the Ukrainian health care reform and its shortcomings. She argues that while the soviet Semashko healthcare system needed to be reformed and some good changes in the system were made, the reform left huge gaps in the field of preventive medicine, in addition to increasing exploitation of medical workers and opening up possibilities for unlawful practices by local administrations of hospitals.
Reforming healthcare during multiple crises
Starting from 2017, the Ukrainian healthcare system has been undergoing the first comprehensive reform since the beginning of independence. The reform happened to be connected to various turbulences and crises from its very beginning: the strategy underlying it was developed directly after the Maidan revolution, the implementation of the reform itself was happening during the presidential election of 2019, the Covid pandemic and finally the Russian invasion. All this had an impact, mostly on resources available in the system and through the pressure exerted on medical workers.
The reform itself was supposed to be a transition from the soviet Semashko system to a version of the British NHS-type healthcare system. The Semashko system was primarily characterised by state ownership of the whole infrastructure, state financing based on hospital bed capacities and staff sizes of the time. The infrastructure was big and hospitals had big stationary capacities. Since nowadays such a system would be expensive and also inefficient in combating challenges such as increase in chronic illnesses, it was decided that a reform is necessary.
Ukraine has been allocating a very small amount of its GDP (around 3%) annually for healthcare compared to other countries, especially ones in the EU. It was furthermore one of the last countries of the former Soviet Union to introduce any kind of reform to the healthcare system. Most of the other countries had legally introduced reforms such as elements of private financing to their systems, while in Ukraine the official financing came only from the state but was insufficient, which led to establishment of petty corruption. Other than corruption, the heritage of the Semashko system was high concentration of doctors in big cities and high specialisation of these doctors. This led to an inequality between big cities and smaller ones as well as rural areas and to general weakness of primary healthcare.
The reform concentrated on 4 aspects: introduction of family medicine to strengthen primary care, financing based on the amount of services provided rather than hospital capacities, introduction of “service packages” that would define bundles of services that can be provided in hospitals in various fields and introduction of international standards to the system.
A special institution, the Ukrainian analogue to british NHS, was introduced – the Ukrainian national health service. UNHS is responsible for contracting hospitals that wish to get financing for certain service packages and checking whether a hospital is eligible to get such contracts. Certain criteria have to be met in order to be able to get funding form UNHS – they concern, for example, available equipment, accessibility and other aspects.
At first, I was shocked that we were not doing treatment but “providing services”, and now we are also making money.
The implementation of the reform began in the so-called “first link” (primary care) with the introduction of family medicine. Earlier, patients were to be treated in certain hospitals that were assigned to them based on their address. Now patients can choose their family physician anywhere in Ukraine and have to sign a contract with them. Digitalisation was also actively pushed in the first link.
Further implementation, including the introduction of specialist doctors in the “second link”, was happening during the pandemic. Currently, since the beginning of the full scale Russian invasion, new developments of the reform are being carried out, such as the formation of a “single medical space”. This policy consists of forming the “medical districts”, where medical facilities of various degrees of specialisation would operate based on population size to avoid extra costs and maintenance of unnecessary facilities.
Many old and new issues
Common criticism of the reform is that it doesn’t solve the problems of scarce resources and corruption in healthcare. Criticism came from various groups, including certain political parties and the broader public but also doctors and other workers of the healthcare sector, including the nurses union. There were multiple demonstrations by the union of healthcare workers. Support was voiced by some Ukrainian NGOs as well as international institutions such as WHO, The World Bank and others.
In my thesis on the subject I wanted to base my analysis of the reform on interviews with various actors in the healthcare system. The feeling of being disrespected is widely spread among medical workers. It is felt not just because of low salaries and abrupt lay-offs. It is also due to a lack of communication and a general exclusion from the reform process, with union demands being ignored and support as well as safety nets lacking for those who lost jobs because of facility closures. My interviews with experts showed that lack of resources is one of the biggest concerns of both supporters and critics of the reform. The other big problem is the exclusion of some parts of the expert and medical community, particularly nurses and doctors.
Salaries of workers are one of the prime targets of cuts. With the reform and transfer of many responsibilities from the state to local level and the hospitals themselves, there is no fixed amount of budget that has to be spent on salaries. Workers are often exploited, mostly through significant delay of payments (sometimes lasting for months). During the war multiple anti-labor laws were passed, labor inspections were suspended and the practice of forcing healthcare workers to work more hours than they are officially paid for became common. The current salaries of medical workers are perceived as a devaluation of their labor and are insufficient to sustain livelihood.
Exploitation and devaluation of this kind have been present in the system for a very long time even before the full scale war or the COVID pandemic. Many respondents described how the exploitation and low wage issues that have not been solved by the reform also solidify the long normalized corruption between patients and doctors (nurses usually can’t even profit from bribes by patients). At the same time they see it as a kind of adaptation behaviour that was forced on them rather than as malicious intent towards patients. Many workers I interviewed expressed the thought that higher official salaries would eliminate the need for informal payments and legitimise the crackdown on corruption in the medical field.
According to nurse Oksana Slobodiana, one of the leaders in Ukrainian medical workers movement “Be Like Nina”, the local administration reduces the workforce by using intimidation tactics. She recounts how when the reform began, hospitals started getting closed. They are being “unified” or merged, with one or two of them getting closed after each merger. Meanwhile the authorities are late with salaries for several months, thus putting people on idle time and creating such conditions that they simply leave. This means that the authorities don’t have to bother laying people off. Especially in the districts, they are taking advantage of people’s tepidness. It is under this pressure that hospitals are closed, beds and departments are reduced. According to Oxana, “this is very mean and very unfair to the doctors who have been devalued to such a level for all their lives”.
Making money instead of providing treatment
The problems of low salaries and corruption are tied to systemic problems that the reform was supposed to solve. As seen from the last comment from a nurse, the reform and its austerity policy for workers leads to commodification of healthcare. Many comments from various respondents make it clear that, in tune with the neoliberal character of the reform, the role of the state and its capacity to regulate the healthcare system decreased drastically. The old Semashko system was deliberately discredited in the media and its goals were simplified so as to insinuate that it merely strived to be as broad and costly as possible. In this system the state used to fulfil regulatory and coordination functions, and since adequate alternatives were not developed neither after the fall of Soviet Union nor with the reform there is much awareness about this systemic problem outside of expert circles.
There is a demand among expert communities and workers for a more unified and well thought out approach to reforming healthcare. One of the respondents described the problem as a very drastic change in the role of the state: the Semashko system connected and intertwined the curative and preventive healthcare. Furthermore this organisational element was present at various levels – city level, regional level and so on. The current system concentrates overwhelmingly on the curative aspect, aiming on treating diseases after they occur, instead of preventing them. The Semashko system was redundant but included preventive elements in its structure – for example special hospitals for infectious diseases and a broad vaccination plan. It also had a special department of healthcare to deal with infectious diseases which was dismantled in 2014 without an adequate alternative. In the 2010’s even such basic measures of prevention as vaccines were not implemented properly in Ukraine – the percentage of population vaccinated against measles was 42% in 2016, while in the previous decade it was over 90%. For vaccination against tuberculosis, the figure has dropped from over 90% to only 39% in 2015.
As mentioned before, workers feel excluded from any kind of dialogue with the Ministry of Healthcare or other governmental institutions. According to them, when confronted with the issues, the ministers would claim that because of the decentralization of the system, they should voice them to administrations of their local hospitals. As one worker explains, if you try to address the ministry about the problems of exploitation, you will get a response that “we have decentralization, we have transferred everything to the local level, so you can deal with it on the ground”. The worker says that that raises the question, what is the ministry for? What is its purpose?
Currently NHSU only does contracting and potentially financial monitoring, while the state decides over the general budget available for healthcare. Allocation of resources was outsourced to the local level. This leads to mutual blame shifting when workers try to resist exploitation. Not only was the role of the state not adequately adopted, but the general strategy of the development of the healthcare system is vague and dictated overwhelmingly by international organisations such as WHO without attention to local context.
The focus of the system is on reducing mortality from leading causes of death, while neglecting preventive medicine and (often costly and dependant on highly specialized expertise) treatments of chronic and rare diseases. This leads to commodification of the medical profession and catastrophic lack of resources.
One worker says that nurses are often laid off in order to save money, which makes it impossible to cope with the amount of work required. However, when requested for an additional nurse, the authorities would reply that there isn’t enough money to hire nurses. According to the worker, instead of providing treatment, hospitals now seek to make money. “At first, I was shocked that we were not doing treatment but “providing services”, and now we are also making money.”
The role of healthcare during wartime
The critique of the current reform that the workers make does not mean they do not see the incompatibility of the Semashko system and current developments or the lack of economic capacity to support a broad infrastructure. They rather argue that those responsible for austerity politics in healthcare don’t have the needs of patients in sight.
Ukrainian medical professionals showed great courage – they continued to work under very harsh circumstances, such as operating on patients during power outages and near to frontlines. Their interest is not to profit off the wartime but at least to get adequate appreciation and to stop the systemic cuts that are allegedly justified during the war effort.
Healthcare is a part of critical infrastructure. In addition to being necessary for preventing social collapse, its adequate maintenance is very important for treating injured soldiers and civilians, thus allowing for the reduction of losses during war. Furthermore, in the long term perspective, medical professionals will leave Ukraine, especially with the new possibilities for integration created for Ukrainian refugees in western countries. This will make the rebuilding of Ukraine very difficult.