Oleksandr Kvitashvili was the Health Minister in Georgia and then in Ukraine. Now Kvitashvili is working on healthcare reform (де?). VoxCheck asked a former government official about the main goals of healthcare reform in the world and the experience of healthcare development in Ukraine.
The material was created within the framework of the project “Do not Believe Myths” with the support of the International Renaissance Foundation.
On main goal of healthcare
Kvitashvili was the Ukrainian Minister of Health from December 2014 to April 2016. At that time, he listedthe transfer of public procurement to international organizations, simplification of re-registration of medicines and products, transfer of departmental hospitals into a single structure his main goals. Part of it was succeeded, but the change in the management of hospitals — as well as further reform with financial guarantees from the state has already happened during the term of Ulyana Suprun.
Kvitashvili: Our goal is to give every citizen of Ukraine access to quality medicine. Period. How to provide this access is a matter of state. The financing system must be transparent and, most importantly, fair. That is where the reform in Ukraine is headed. And I hope to see the first shifts in the secondary care, that is, in the hospital sector, in 2020. You see, if you do nothing, then there will be no problems, right? And when you do something, there will always be some mistakes and shortcomings or something. Therefore, you need to correct them and go forward.
On market healthcare model
Prior to working in Ukraine, Kvitashvili was the head of the Georgian Ministry of Labor, Health and Welfare for nearly 2 years. His reforms from 2008 to 2010 made the healthcare system more decentralized. The cornerstones were the deregulation and expansion of the market mechanism
Kvitashvili: There are some relationships in healthcare where the market mechanisms work, and there are some where they don’t. For example, what was the problem in Georgia? When it comes to paying for a service, not at a primary level, but, for example, childbirth. There is a certain amount of labors and the hospital receives money for it. If it is in a city, then normal, and if in a village or in mountainous areas of Georgia? There, for example, are three babies born per month, and a doctor, the obstetrician-gynecologist who works there, will receive money for three labors. It will be very small sum, of course, it is impossible to live on it. Meanwhile, the colleague of this doctor who works in the city will receive much more, because the amount of births is much higher. That is why there is a state to cover such issues. In Georgia, we directly took a look at where this situation takes place, and directly funded these clinics. To keep a doctor there so that a doctor would sit there and perform two deliveries, or one, does not matter, the main thing — that there will be a doctor. If we pay according to the market principle, we do not get fair access to quality medicine there, so we need to keep people there. The state needs to have a good understanding of the whole healthcare system.
On managing the hospitals
Українські лікарні досі під керівництвом головних лікарів. Іноді це може створювати проблеми для самого персоналу медзакладу. Наприклад, журналісти BBC поспілкувалися з лікарями Шевченківського району Києва – ті з усіма доплатами і преміями отримували всього 4-6 тис. грн на місяць. Незадоволеним, зазначають у виданні, погрожують звільненням.
Ukrainian hospitals are still headed by the chief doctors. This can sometimes be a problem for the medical staff themselves. For example, BBC journalists spoke with doctors in the Shevchenkivskyi district of Kiev who received only UAH 4-6 thousand with all the surcharges and bonuses per month. The dissatisfied staff, said in the publication, threatened to quit.
Kvitashvili: We need to create a competitive environment. Easy. The first problem is that the doctor is under some heavy and unfair obligations or conditions. Right? That’s number one. Secondly, if a person can choose to stay at this clinic to go to another, where the pay is better, then it will automatically change something. The problem of head doctors is purely managerial. Since during the last hundred years under the Soviet system and the post-Soviet system there was no transparent environment to make money legally, then there’s no surprise people came up with different schemes. Obviously. In general, I think that the proper management of the hospital should not be in the hands of the chief doctor or the best doctor, because it requires knowledge of mathematics, economics, finances and more. The doctor should treat patients. And getting stents, medicines or toilet paper — should be the task someone else has to deal with, it’s not a doctor’s business.
On personal healthcare spending
In 2006, when the reform in Georgia had just begun, the share of out-of-pocket medical expenses in total healthcare expenditures was 78.7%. This share has gradually decreased and in 2016 it was 61.2%. In Ukraine, in 2006, out-of-pocket spending on medicine reached 39.1%, and in 2016, before the primary care reform was launched, it grew to 56.8%.
Kvitashvili: In Georgia, all of these out-of-pockets are legal. You either pay extra for your health insurance, that is, upgrade your policy, or you have some co-payment — the state pays 80%, and you pay 20% out of your pocket. Georgia also has very low medicine costs. I do not know how personal expenses in Ukraine were calculated. Because in Ukraine, constitutionally, healthcare is free. Without a formal co-payment system all these out-of-pocket calculations are very difficult to determine. There is a large population in Georgia that receives all medical services at 100% free of charge. These are people who are in a socially disadvantaged category — that’s about a million people, if I’m not mistaken. They receive an insurance policy that they use through private insurance companies, from the state. They have 100% coverage there. Georgia is a poor country, that is, it cannot cover everything at 100%. No country can do this and that is why it uses insurance that is provided through private insurance companies. Insurance is not the panacea I want to say. Health insurance or Insurance healthcare — whichever term you prefer — is one of the mechanisms used for financing the healthcare system. One of, but not the only one.
On continuing the healthcare reform
Healthcare reform started in Ukraine on January 1, 2018 from the primary level. More than 28 million Ukrainians have already signed declarations with family doctors, therapists or pediatricians. Polls in May 2019 show that over 70% of Ukrainians are satisfied with their services. However, changes are being implemented unevenly across the country.
Kvitashvili: I think we will see much faster steps very soon. The success of such reforms depends not only on factors connected to healthcare, but also on other reforms, starting with tax reform and ending with police reform, and also on their continuity. That is, every new team must not not build something fundamentally new, because if there already are some small changes and the course is already laid out, you should move forward with it. I believe that this course is the right one, it moves in the right direction, and should not be averted under any circumstances, we don’t need any experiments or “let’s do this or that”. There already is a well-written strategy. I do not see any risks even with the change of power. I do not know who should come to power in Ukraine to bring back the Soviet system, I can’t imagine it. So my mood is very optimistic.
The authors do not work for, consult to, own shares in or receive funding from any company or organization that would benefit from this article, and have no relevant affiliations