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By Prof. Oleksii Korzh from Kharkiv University
In 1992, the Laws of Ukraine about health protection adopted by the Ukrainian Parliament, identified priority development of primary health care. Since then the Ukraine began to develop the regulatory framework for the widespread introduction of primary care. Departments for training of family physicians and professional associations were established.
This introduction of a system of family medicine in the Ukraine began rather late in comparison with the countries of Central and Eastern Europe and even some countries of the former Soviet Union started earlier.
Ukraine has developed a network of primary care (centers of primary health care and ambulatories) mainly based on already available polyclinics and other medical institutions. Repairs were made in a lot of ambulatories, financially supported by subsidies from the state budget and local finances. This Primary Care network received basic equipment, including the purchase of vehicles for the family doctors. In 2012 a payment system was introduced based on capitation payment and allowances for additional services (immunizations, x-ray, screening tests for certain cancers, etc.). However, these changes were only the beginning and the basis for further change.
According to the Ukrainian legislation, a family physician in larger towns has to provide medical care to 1500 citizens and in the smaller villages to 1200 citizens of any age. More than 5000 family medicine clinics have been organized all over the country, especially in rural areas. Unfortunately, many of them are “re-named” polyclinics and rural hospitals with poor equipment.
The economic support of the primary health care system remains inadequate. The state spends only 5-7% of the whole health care budget for primary health care, which is not reaching the targeted 30%.
Some problems of regulatory support and the efficient functioning of primary health care remain unresolved, including the decision what proportion of public funds should be allocated to finance primary health care, too complicated mechanism of economic incentives, lack of regulations regarding the role of nurses in providing primary care, many of the facilities have problems with equipment, geographical accessibility and limited availability of transport. Partly because of prevailing struggle between primary and secondary level of health care for leadership and impact on the budget allocation. Local governments are not always considering the functioning and development of primary health care among its priorities.
Interns preparing to become a Family doctor in Ukraine are spending for two years of internship, and internists and pediatricians receive only an extra six-month course to become family doctors. Proposed short-term retraining courses for family doctors provoke mistrust of the population to the new specialty. Doctors also fear to be retrained and to be burdened with more responsibility for the patients as a family doctor. One must learn what knowledge family doctors are lacking in order to improve retraining program with the specialty program, to introduce additional courses (distance learning, short cycles) and to consider the possibility of involvement of technical assistance from international organizations. If trust of patients to family doctors does not rise, they continue to avoid the primary level, ignoring the formal rules.
The coming years the government should focus on equipping, repair and adjustment of primary healthcare facilities. Family physicians will continue to be trained at universities and at six-month training courses for pediatricians and internists. Stimulating the introduction of payment for performance is now difficult to apply in practice. In the absence of a reliable administration of patient information, a Family Doctor doesn’t know the number of patients attached to his/her practice, their age distribution and disease patterns and in addition the follow up of the performance of Family Doctors on certain quality indicators is impossible. Therefore, in the coming years, the work with the introduction of an electronic registry will continue despite a number of difficulties: imperfect software, recording patient data into the database, unreliable protection of personal data and medical information of patients and others.
A long-term objective in Ukraine will be to improve academic education, including those of family medicine. The task for the future is full computerization of primary and secondary units as a condition of improving their cooperation and coordinated work.
Thus, today, we see a large number of complicating factors towards the success of the reform of the primary healthcare in Ukraine. This indicates the duration and severity of reform. Understanding the complexities of reform and work with them are essential to achieve the desired results, because reform is necessary for the health care of Ukraine due to serious condition and for preventing further deterioration.
Author: Prof. Oleksii Korzh, MD, PhD, Head of Department of General Practice - Family Medicine at Kharkiv Medical Academy of Postgraduate Education, chairman of the Kharkiv Association of Family Physicians, member of WONCA, EFPC, AAFP.