Health care governance – how to measure it? A Ukrainian pilot study

By Tetiana Stepurko, National University of Kyiv-Mohyla Academy and invited speaker at the School of Law and Government seminars, and Paolo Carlo Belli, World Bank expert

Full version of the report is available via http://fisco-id.com/?module=an&action=preview&id=136

 

Ukraine is currently facing immense challenges in health care. In 1970 and 2010 life expectancy at birth remained the same– 70 years, and in 2014 it was 71.19 years (66.25 for men and 76.37 for women), approximately six years lower than the WHO European region average, which includes not only rich western countries but also the Central Asian Republics of the former Soviet Union (World Bank, 2017)[1]. The lowest life expectancy value has been registered in 1995 – 66.89 since then the life expectancy is increasing and the lack of essential improvement of life expectancy at birth reflects a worsening of adult health.

The major challenge for health in Ukraine is the hybrid epidemiological country profile: people are mostly dying from non-communicable diseases but infectious diseases are still not managed well either. Indeed, child immunisation levels for vaccine-preventable diseases have been falling since 2000: for example, measles immunisation coverage decreased from 99 to 56 percent from 2000 to 2014 (World Bank, 2017)[2]. A threat to the overall national security system has happened with the polio outbreak (Toole, 2016)[3]. Problematic supply of vaccines, public mistrust to immunisation and high level of corruption are underlined by Holt (2013)[4] as the reasons of low immunisation rate specifically in Ukraine.

All these flashily low health indicators of one of European countries are produced in the health care system which has not yet been reformed to respond to these challenges. The health service delivery system in place is still the one inherited from the Soviet Union, publicly financed and owned, hospital-centered, with extremely fragmented governance, and with services focused on individual acute treatments and minimal prevention, and yet, there have been no systematic attempts at restructuring it.

Considering these trends, it is not surprising that the level of satisfaction with Ukrainian health care system is one of the lowest in the world: Ukraine together with Brazil and Russia show one of the lowest levels of satisfaction. In 2007, 2 out of 10 and in 2014 almost 3 out of 10 reported satisfaction with health care system in Ukraine (OECD, 2015)[5].

To turn these trends in the other direction and to improve health care in Ukraine, international organisations like the World Bank, UN organisations, Swiss Development and Cooperation Office in Ukraine as well as voices in the Ukraine call for innovating the governance of Ukraine. New governments as well as grown up civil society after Orange revolution in 2004 and revolution of Dignity in 2013-14 are aimed to foster the process which would lead to improved access to and quality of public services, including more accountable practices (e.g. e-procurement system), decentralisation, empowering communities and sharing the resources and responsibilities with bottom-up initiatives. In this study we will explore governance in Ukrainian health care and pilot the methodology of its measurement.

Considering the gap in knowledge on details of Ukrainian system of health care service provision, the study is aimed at revealing the policies and practices in the mentioned arena. In this study the central role is given to health care facility which is seen as the ship, and governance is practically management of this ship, where not only internal resources but also external factors are taken into the account.

Both desk (analysis of key laws, orders) and empirical (qualitative and quantitative) study were conducted.  Data was collected in several regions of Ukraine during summer 2012. About 130 face-to-face interviews with physicians, nurses and administrators of both health care facilities (chief doctors, their deputies and heads of departments) and regional health care departments have provided rich and conspicuous data.

The research instrument was developed by the team of the researchers and included three major sections and in the end of the study procurement issue was revealed to have high importance for the Ukrainian context.  For each of these sub-areas of public service provision, several indicators have been offered and assessed. For example, human resource sub-area  included recruitment, personnel management and retaining staff:

  • human resources, including ‘are vacancies transparently advertised’, ‘is hiring generally conducted competitively and according to meritocratic criteria’, ‘are job descriptions used to hold staff accountable’, ‘how does career management system work’ etc.;
  • planning, budgeting and financing: ‘is planning evidence-based’, is the planning cycle linked with budgeting’, is performance based budgeting used’, ‘ how are financial management controls/audit perceived at facility level’ etc.;
  • medical information management: ‘how is the system of collection, validation and use of information organised’, ‘is there information on performance’, ‘what is monitoring and evaluation capacity at local and central level’ etc.;
  • and later procurement part has been added: ‘’how frequent are open tenders for drugs and/or equipment’. ‘how long does it take to go through procurement process’, ‘is there quality assurance system for drugs’ etc.

We have found that although Ukraine has numerous regulations in health care service provision, some areas are more regulated and audited for consistencies between the rules and practices, e.g. financing, while some others, e.g. hiring medical staff or employee performance assessment, rely only on the good will and competences of the supervisors and chief doctors. Indeed, de facto dimension is based on very subjective management as national system is not designed in a responsive to the actors needs and thus lacks of trust. The goals of health care facilities as well as the national health care priorities exist mostly in the documents, while health care personnel do not have these goals as guiding line in their professional life. As a result, the ship-health care facility is sailing without the system-linked destination point or without crew’s awareness of it, and we assume that the goals of the system are substituted by other individual priorities. Therefore, all other elements of health care facility performance can be seen chaotic but only in case if individual interests are not considered. Indeed, respondents reports on having  ‘good’ practices of hiring medical staff, e.g. presence of competition, interview, and presenting documents, however, at the same time they indicate on the lack of information on vacancies, only a quarter of employees does not give bribes or use connections for being appointed.

I myself was in such a situation: my wife was pregnant, and I was expected to move to [an] other city. There were no free places [at the facility I needed] till the moment when I brought an envelope (anesthetist, 36 years).

In Soviet time, it was extremely difficult, referral could be assigned everywhere. If there is no your own family and uncle who could resolve the issue, internship in the city was as realistic as science fiction (surgeon, 53 years).

In our facility we do not have vacant job positions, but from time to time new staff appears [. . .] nobody informs others how they have got that position but I am sure they are employed with a reason behind it [. . .] My son had to move to Zhytomyr because we could not find any vacant position in Lviv as here the competition among physicians is extremely high. (in-patient physician)

Medical personnel are also expected to contribute their own funds (earned as informal income that is tolerated by administration) in order to maintain the department (light bulbs, disinfectant supplies, renovation of the building etc.). When the formal structure is weak, informal practices can become a crutch for the system of health care service provision. The latter has been blossoming during last decades and it has taken so deep roots that informal practices now represent a new parallel to formal system. It leads to double efforts of the health care sector actors to maintain two systems which have quite different goals.

Health care sector is not an exceptional sector of economy of Ukraine which shows poor performance in terms of health of the population. In general, the country is characterised by high rate of corruption, low rate of political stability and a very moderate level of economic development (Worldwide governance indicators, 2014)[6]. During sociopolitical changes in 90s, a rise in ‘self-help’ coping strategies is seen as a response to the distrust and skepticism toward public institutions. For example, during the armed conflict in Eastern Ukraine that started in 2014 as well as during EuroMaidan, people were giving charity cash and in-kind donations (food, clothes, blankets) to support military, medical and other service providers (Stepurko et al., 2014)[7]. Practically, from the providers’ point of view, “using public office for private purpose” is seen as the only option to survive and at the same time users can still fulfill their needs in public services even when the State fails to do this. Ukraine demonstrates de facto privatisation of health care services. Physicians get major income from ‘individual patients’ (Stepurko et al., 2013)[8] and additional hospital budgets are generated from doctors’ informal income in a “post-Soviet type on public-private”, which is not so much a “partnership” than a “forced union”. As Polese et al. (2017)[9] underline ‘instead of state not being there, the state might be trying to get there, but it is unclear when or whether it will. The state might be doing something that is perceived as not enough, there might be weak measures taken or considered insufficient or there might be a tactic understanding that people should take care of things themselves’ (p. n/a). Whether this solution for an absent or stagnated state will improve population health in the longer rung, can be doubted.

 

[1] World Bank (2017). http://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2014&locations=UA&start=1963  Accessed 5th February 2017.

[2] World Bank (2017). http://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2014&locations=UA&start=1963  Accessed 5th February 2017.

[3] Toole, M. J. (2016). So close: remaining challenges to eradicating polio. BMC medicine, 14(1), 1.

[4] Holt, E. (2013). Ukraine at risk of polio outbreak. The Lancet, 381(9885), 2244.

[5] OECD (2015). Available at: http://www.oecd-ilibrary.org/docserver/download/4215081e.pdf?expires=1486385891&id=id&accname=guest&checksum=853783880AED2F635055D3AF10BF637C Accessed 6th February 2017.

[6] Worldwide Governance Indicators (2014). Rule of law and government effectiveness. Available at: http://info.worldbank.org/governance/wgi/index.aspx#home

[7] Stepurko, T., Vitiuk, V., Kvit, A., Kovtonyuk, P. (2014). Medical Care on the Euromaidan: Who have saved the lives of the protesters? Social, Health, and Communication Studies Journal Contemporary Ukraine: A case of Euromaidan, 1(1).

[8] Stepurko, T., Pavlova, M., Levenets, O., Gryga, I., & Groot, W. (2013).Informal patient payments in maternity hospitals in Kiev, Ukraine.The International journal of health planning and management, 28(2), e169-e187.

[9] Polese, A. et al. (2017) Informality ‘in spite of’ or ‘beyond’ the state: evidence from Hungary and Romania. Forthcoming

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