In early April, the Health Committee of the Ukrainian Parliament approved a draft decree on a dismissal of Acting Minister of Health Ulana Suprun. The reasons for this decision (quote): “heightened societal tension caused by the disruption of international drug procurement in 2016 due to likely negligence of duties, and in relation to professional ineptitude.”
On the same day, Olga Bogomolets, the Committee Chair and MP from Bloc of Petro Poroshenko, explained on her Facebook page why she supported the idea of Suprun’s dismissal: “We need to figure out the cause of our healthcare catastrophe — whether it is due to the acting minister’s professional ineptitude or conscious government policy, since the government’s performance in healthcare was also deemed unsatisfactory by the Committee”.
Next, in ten paragraphs, the politician explains what is wrong with Ulana Suprun’s work and why Bogomolets stands for her dismissal.
These accusations towards the Ministry of Health present the complete anatomy of today’s situation of Ukrainian healthcare and arguments of most critics of the Ministry of Health. VoxCheck not only fact-checked Bolomolets’ statements but also explained why and when our medical system has ended up in such a state.
By the way, Ulana Suprun and her team keep working in the Ministry of Health, since in reality the Commitee’s decision was of advisory — or rather — of political nature.
“1. The die-off of Ukrainians has accelerated — in 2016 deaths exceeded births by 175 thousand, and in 2017 this figure increased to 198 thousand.”
It is not accurate to draw conclusions about the dynamics of a demographic or economic indicator from two-year data. Considering more long-term periods is more correct —then we will find out that the decline of the population of Ukraine has been observed for a very long time. One of the reasons is that fewer Ukrainians are born than die. For example, last year the number of deaths exceeded births by 210 thousand. This number is slightly higher than the one in 2016 due to a decline in the birth rate in 2017. However, as we see from the chart below, in general the population decline is gradually slowing down.
By the way, Bogomolets gives data that include both natural and migratory population growth/decrease (i.e. the number of people who have arrived in Ukraine or left abroad), while the politician implies the situation of the national health and not the migratory movement.
“2. Roughly 70,000 medical practitioners have moved abroad in the past two years. If the Ministry of Health continues with its current healthcare policies, another 50,000 will leave over the next few years.”
It is impossible to fact-check this statement due to the lack of official data on the number of medical practitioners who had left abroad. Olga Bogomolets’ statements are the only source of information about the emigration of medical practitioners. VoxCheck requested the politician to clarify her statements but received no response. We also failed to find evidence in support of Olga Bogomolets’ data on our own.
Most likely, medical practitioners go abroad for the same reasons as representatives of other professions do: they look for higher salaries, better quality of infrastructure and ecology, etc. That is, the healthcare reform and the work of the Ministry of Health in the last two years have nothing to do with it. Read more about labor migration from Ukraine in VoxUkraine article “2.5 million, or every tenth adult Ukrainian, work abroad. That’s a lot but not a disaster.”
“3. The nation’s collective immunity has been destroyed: vaccination rates have dropped below rates last seen in the 1990s.”
If Olga Bogomolets gave these data beyond blaming Suprun for “destroying the nation’s collective immunity”, this statement would be true. But the politician blames the current leadership of the Ministry of Health for vaccination problems, while this problem has persisted for many years.
The immunization rates of Ukrainian children are really low. Here are the World Bank data on immunization as of 2016: diphtheria and tetanus toxoids and pertussis vaccine (DPT) — 19% of children, hepatitis B — 26%, measles, mumps, rubella (MMR) — 42%. There are two global causes for this.
Some periods of Ukrainian independence were characterized by a short supply of vaccines. Immunization failures, for example, took place in the early 2000s as a result of both disruptions in delivery of vaccines to certain regions and insufficient funding of procurement in general. According to the Accounting Chamber, the need for immunobiological drugs for the prevention of infections was never met for 100% throughout 2009-2014.
Sometimes vaccines were imported but were not properly stored and spoiled as a result (for example, see the report of the Accounting Chamber for 2008).
Unfolding of the anti-vaccination campaign: people ceased trusting vaccines, and not only in Ukraine. People do not trust immunization because they suspect the low quality of vaccines and/or improper storage. Throughout recent years, vaccination hesitancy increased because of articles in media which blamed vaccination for children deaths although none of the cases had been proved in a court.
Why do people fight with immunization?
However, the situation in Ukraine has been improving since 2017. For example, the planned MMR vaccination rate at the beginning of 2018 has reached 93,3%, which almost meets the standards of the World Health Organization. The situation of the DPT and hepatitis B immunization is worse — today’s planned vaccination is 52% and 57%, respectively (let us remind you that these figures were below 50% in 2016). So, the exposure of Ukrainians to such diseases as hepatitis, diphtheria etc. is rather high.
“4. International procurement of medicines has been disrupted. Citizens have had to spend UAH 6.7 billion of their own savings over the past two years on medications which were supposed to be provided free of charge through state funds allocated to hospitals”
It is another accusation towards today’s leadership of the Ministry of Health for the problem rooted in 2014-2015 when the ministry was headed by Oleg Musiy, the current MP and critic of the healthcare reform, who was followed by Alexander Kvitashvili.
In early 2015 Parliament adopted amendments to the law on the transfer of centralized medical procurement to international organizations. However, drug procurement agreements were only signed in October 2015. Hence, procurement of medicines from the 2015 budget and their delivery to hospitals actually occurred later, in 2016.
Ulana Suprun took charge of the ministry in August 2016. The signing of the agreements on the drug procurement-2016 with international organizations started in October (see the data on UNICEF, UNDP, Crown Agents).
Ukraine still keeps buying medicines with a great delay, although this year the situation is going to improve — at least, the Ministry of Health counts on it. The procurement for 2017 started last August. The agreements for 2018 were signed in late April.
As for the amount of UAH 6.7 billion. We found the explanation of this figure in the deputy’s appeal to the prime minister from Olga Bogomolets and a number of MPs. According to the document, due to continuous delays of procurement and supply of medicines, as of January 1, 2018, the Ministry’s accounts receivable for international procurement amounted to UAH 6.7 billion (the budget program 2301400).
So, it is true that international organizations did not spend UAH 6.7 billion on drug procurement as of the beginning of 2018, although this money was transferred to them earlier. In general, in 2015-2017 they received about UAH 12 billion — that is, about half of the public funds were spent.
The Ministry of Health explains this by the fact that these funds were partly saved thanks to more efficient procurement (as demonstrated in the report of the Accounting Chamber), and partly they were not spent due to the long-standing problem of disrupted procurement back in 2015.
At the same time, it is inaccurate to say that people spent UAH 6.7 billion for unsupplied medications — Ukrainians might have spent more and less than this amount because our fellow citizens have always bought some medications at their own expense, even if they were available in hospitals.
“5. The key areas of cancer treatment and cardiovascular diseases, which together cause 80% of all deaths in Ukraine received only 27% and 30% of earmarked funds, respectively.”
Indeed, over the last three years, the Ministry of Health never received the budget necessary for the drug procurement according to its calculations and, consequently, was not able to meet 100% of its needs.
The manipulation in Olga Bogomolets’ statement is that financing of healthcare in Ukraine is limited to the state budget. That is why requesting the Ministry of Health to be able to meet all needs of the sector is an exaggeration. Moreover, Suprun’s team is aware of the problems raised. In 2017, the Ministry reallocated UAH 100 million from other programs for the treatment of adult oncology patients. Moreover, in April 2017, the Ministry launched the “Affordable Drugs” program, which reimburses the cost of medicines for cardiovascular disease, asthma and diabetes in order to prevent the development of complications from these diseases.
“6. The timely implementation of medical institution autonomy and the “money follows the patient” principle established in Law № 2002-VIII of 06.04.2017, which I prepared, has been disrupted.”
Medical institution autonomy and the “money follows the patient” principle have been a challenging story, and Olga Bogomolets, the MP of the Verkhovna Rada profile committee, has a lot to do with that.
The timeline for the adoption of this document was following. The corresponding package of draft laws was developed back in 2015 under Alexander Kvitashvili. Later on, the new Ministry of Health headed by Ulana Suprun submitted to the Verkhovna Rada a very similar version of the draft law. According to the document, the mandatory autonomy had to be have been completed for all medical institutions by a particular date. Olga Bogomolets submitted another draft law, which was very similar to the one developed by the Ministry. According to it, the autonomy was not mandatory anymore, while this MP and a number of profile committee members blocked the Ministry’s draft law. Finally, the Ministry of Health accepted Bogomolets’ version in order to push the reform forward. This very document was adopted in April 2017 and came into force in last November.
This document also contained the “money follows the patient” principle, which was also approved in the Law “On State Financial Guarantees of Public Health Care” later.
Therefore, there are several manipulations in Bogomolets’ statement.
- the autonomy started only in late 2017;
- it is impossible to disrupt it since it is not mandatory, according to the document developed by Bogomolets herself;
- Olga Bogomolets was rather actively involved in the development of this law — unfortunately, not always in a constructive way.
Nowadays, all the regulatory acts that launch the autonomy have been approved. There are some successful examples of medical institutions which have changed their status and adopted a new form of management.
In July, the National Health Service has to start paying family doctors according to the new principle “money follows the patient”. Primary care physicians in autonomous institutions or private entrepreneurs will be able to receive financing according to the new principle.
“7. According to approved State Budget of Ukraine expenditures for medical workers salaries, which the Ministry of Health of Ukraine approved, Ukrainian doctors receive the lowest salary in the world. Moreover, the Cabinet of Ministers of Ukraine equalized the salaries of physicians, nurses, and nurse’s assistants, effectively removing any incentives for personal and professional development”
Bogomolets is right when saying that official salaries of doctors are extremely low. In February 2018, the average official salary of medical professionals was UAH 5288, while the national salary average was 7828 UAH.
The reason for the temporary approximation of wages of doctors and junior medical staff was the increase in the minimum wage — first to UAH 3200 and later to UAH 3723, while doctors’ wage rate scale remained the same.
However, we would like to point out that this particular reform seeks to change this situation. Starting from 2018, primary care physicians who conclude an agreement with a sufficient number of patients will experience wage increase. Secondary and tertiary care physicians will be able to experience changes no sooner than 2020.
“8. The Accounting Chamber uncovered violations by the Ministry of Health over the course of the “Serving People, Improving Health” project, for which the World Bank provided a 215 million dollar loan, in the organization of centralized government procurement involving specialized international procurement organizations, and in the spending of funds earmarked for countering Ukraine’s tuberculosis epidemic and for providing medical treatment to Ukrainian citizens abroad”
The quote contains four statements:
- on violations in the “Serving People, Improving Health” project
- on violations by the Ministry of Health in the organization of international procurement of medicines
- on violations in the spending of funds earmarked for countering the tuberculosis epidemic
- on violations in the spending of funds earmarked for medical treatment to Ukrainians abroad.
Bogomolets is mostly right, but the violations first of all relate to previous ministers’ work and not to the work of Suprun and her team.
1) On violations in the “Serving People, Improving Health” project
The report by the Accounting Chamber does indicate the poor status of this project implementation, and, more specifically, it highlights a major delay in its implementation. The project was developed between April 2013 and March 2015. The profile ministers during this period were Raisa Bogatyrova, Oleg Musiy, Alexandr Kvitashvili. Their deputies who were responsible for the project also rotated throughout this time. However, the loan agreement was signed only in March 2015. The project implementation started in June 2015.
According to the Accounting Chamber, the reasons for poor implementation were:
- incomplete preparation of the project
- mistakes in the project organization
- lack of the due monitoring of the project
The Accounting Chamber also points out that both the Ministry of Health and local government authorities (regional healthcare departments) are responsible for the poor performance of the project.
2) On violations by the Ministry of Health in the organization of international procurement of medicines
The report of the Accounting Chamber for the period of 2015-2016 and the first half of 2017 highlighted a number of weak points in the internal processes and procedures during the procurement process. They largely refer to a poor accounting of drug stocks and needs calculations in the regions.
To solve this problem, the Ministry of Health is already introducing an electronic registry of medicines. Moreover, most medical institutions inform patients about available drugs on their websites or bulletin boards.
In general, drugs procurement through international organizations saved up to 40% of the respective budget, which allowed to earmark the saved funds for additional procurement of medicines. By the way, the Accounting Chamber also wrote about this.
3) On violations in the spending of funds earmarked for countering the tuberculosis epidemic
In their report, the auditors of the Accounting Chamber highlight numerous cases of non-compliance with the anti-tuberculosis program of 2012-2016. It means it was another false accusation.
In its report, the Accounting Chamber blames the Ministry of Health for the inefficient work related to nearly all areas of the Ministry’s work in 2015-2016. At the same time, Chamber auditors acknowledged that UNDP, which managed the procurement of anti-tuberculosis drugs, was a better administrator of funds than the Ministry of Health had been.
Today, the situation of the fight against tuberculosis has improved. In 2017, the tuberculosis incidence decreased by 5.5% compared to 2016 and fell to 29 thousand people. As for the adoption of regulatory acts, the Ministry of Health took into consideration the Chamber’s remarks and approved the concept of the National Targeted Social Program for Countering Tuberculosis in 2018-2021.
4) On violations in the spending of funds earmarked for medical treatment to Ukrainians abroad
The relevant conclusions of the Accounting Chamber in this regard showed that the funds earmarked for medical treatment of Ukrainians abroad in 2013-2015 were spent inefficiently. However, it is worth emphasizing that it comes about the period when Suprun hadn’t taken charge of the ministry yet.
Further reports of the Accounting Chamber are yet to come, but the program of medical treatment to Ukrainians abroad has not been fully implemented yet, not least because of lack of funding from the state budget.
“9. The state anti-cancer program is a failure. The previous program expired in 2016, and no new program has been developed, exacerbating the suffering of Ukraine’s 1 million cancer patients”
It is true that there are over a million oncology patients in Ukraine, while the state anti-cancer program expired in 2016. The new program has not been developed due to a resolution of the Cabinet of Ministers in 2014, which prohibited to develop new targeted programs and prolong the ongoing ones that require additional funds from the state budget.
However, when the program expires, it does not mean that patients do not receive the necessary medicines. The state continues buying medicines for oncology patients. So, UAH 750 million were earmarked in 2016 for this area, UAH 1.3 billion were earmarked in 2017, and projected expenditures for 2018 are UAH 1.2 billion.
“10. The Ministry of Health prepared the Law of Ukraine “On State Financial Guarantees of Public Health Care” of 19.10.2017 № 2168-VIII, which violates 10 articles of the Constitution of Ukraine”
Indeed, the draft law developed by the Ministry of Health was incompatible with 12 articles of the Constitution of Ukraine (see critical comments of the Main Legal Department of the Verkhovna Rada). The main remark towards the content of the law was related to free healthcare — in fact, the Ministry of Health proposed to repeal free healthcare and introduce a copayment for medical services by the state and patients. However, after the draft law was finalized, this principle was removed, and the current law does not contain the provision on copayment.
The true situation is that there has been no free healthcare in Ukraine for a long time. According to the Health Index 2018, in the past year, 58% of respondents paid for outpatient services and 86% paid for inpatient services.
In this case, VoxCheck also tended towards a “Manipulation” verdict — although the Ministry’s draft law violated the Constitution formally, the very essence of healthcare in Ukraine has been violating it for a long time. However, after a discussion and voting, the project participants decided to deliver a “Truth” verdict.
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