Where to study and where to find a doctor?

Local authorities, as well as local voters, have received a big share of responsibility for the quality of school education and primary healthcare. To be continued with higher education and other levels of healthcare.

Where to study and where to find a doctor?

Where to study and where to find a doctor?

Figure 1. Number of students per school and students per teacher

Source: State Statistics Service of Ukraine

Figure 2. Distribution of schools by the number of students

Source: Institute of Educational Analytics

  1. Medical facilities have to become not budgetary institutions but communal or state-owned non-profit enterprises. This shift provides them with much more autonomy and control over their budgets. Thus, they can establish the list of fee-paid services (while previously the price-list for them had to be approved by local governments), set the salaries (while for budgetary institutions the salaries are defined by the Unified Tariff Scale set by the central government), and to officially fundraise (while budgetary institutions can get additional funding only through semi-official charitable funds). Currently all of the primary level facilities and about 50% of secondary and tertiary level facilities became non-profit enterprises (the share differs by oblasts). Certainly, this transition provides much more room for decision-making of facility managers. At the same time, it increases their responsibility and skill requirements (among other, they need to develop managerial skills).
  2. A ‘pay-per-service’ scheme has to be introduced. Ukraine chose to have a centralized model – thus, a single government agency (National Healthcare Service) established in March 2018 makes payments to all the facilities or doctors for the services they provide. Furthermore, ‘pay-per-service’ financing requires defining the list of services financed completely by the government, co-financed by patients and completely financed by patients, as well as the calculation of prices for services. At the primary level (family doctors) Ukraine has a fixed payment per patient who signed the declaration with her family doctor (payments for children and elderly patients are higher than for middle-age adults). At the secondary and tertiary level, the DRG system will be gradually introduced.
  3. For ‘pay-per-service’ to become operational, the e-Health system has to be established – so that the National Healthcare Service sees which services were provided to a patient by a certain facility or a family doctor. Thus, payment to this facility or doctor is delivered automatically within the contract with NHS. Ukrainian e-Health is a two-tier system whereby the government controls the central database and private companies can provide interface, i.e. the systems through which doctors can access this central database. There is already a dozen of interface systems on the market.
  4. Then, the local governments have to make decisions on the hospital network. In Ukraine, the network is abundant (Figure 3), and many hospitals cannot provide a decent level of services. With payment-per-service scheme ‘good’ hospitals (i.e. those with many patients) will receive more money than those to which patients do not apply. Thus, local governments will have to decide on hospital concentration within hospital districts – in a similar way they decide on school concentration within educational districts. They will also be able to provide additional support to local medical facilities. Some local governments already do this at the primary level. For example, they provide cars to family doctors so that they could visit patients or renovate premises where they work. By doing this, local officials are earning ‘electoral points’ in the eyes of their voters.

Figure 3. Number of hospital beds per 100k people in Ukraine and in other countries

Source: State Statistics Service, the World Bank

[1] The school hub with branches compared to several small schools provides savings on administrative cost (thus, school hub needs just one principal), and also allows to optimize teacher workload (thus, a teacher may be teaching one day at one branch, another day at another branch etc. while traveling between schools is usually not possible).

[2] Thus, in 2018 the cost per student in a small school was estimated at UAH 58 thousand, while Ukraine average is UAH 15 thousand.

[3] The healthcare reform Strategy was developed in 2015. Current reform mainly proceeds along the lines of the Strategy. The details of healthcare reform and next steps can be found in the Ministry of Health Transition book.

[4] Financing according to the number of beds, number of doctors or square meters of the facility.

[5] Currently, the pilot project with secondary care facilities is implemented in Poltava oblast. The results show reduction of the length of stay of patients in hospitals and increase of the share of complicated cases (which implies reduction of unnecessary hospitalizations).

[6] Ministry of Health developed the Strategy of development of medical education in Ukraine.

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