Three Scenarios For The Primary Care: Zero Game, Bad and Good

On October, 19, the Parliament voted for the health-care reform. The Ministry of the Health-Care expects that the President will sign the law till the end of November, and it will enter into force in 2018. The first stage of the reform will involve the primary care setting. In practice, the heath-care reform implementation at the level of the primary care will happen upon one of the three scenarios.

            The reform at the primary level should start with assigning a family doctor for every Ukrainian.  Everybody chooses a doctor on their own and sign the contract. Basically, the Ministry announced in the beginning of 2017 that such contracts should be signed before 1st of July. Unfortunately, personal contracts with family doctors were not signed and it is doubtful this process can be finished before January, 1, 2018.

            After the contracts are signed, family doctors will obtain funds depending on the number of patients registered. Tthe normative amount is approx. 370 UAH per person. As such, a family doctor will obtain up to 60 thousand UAH monthly, including around 15 thousand UAH for the doctor’s remuneration, and the rest to be spent on medical and non-medical workers:  administrations of facilities, nurses, etc, as well as financing diagnostics, laboratories, preventive treatment, physiotherapy treatment, vaccination, drips, day patient facilities etc.

            The principal aspect is canceling subventions as a guaranteed mechanism of funds distribution based primarily on the population quantity. The funds will be distributed among the doctors by a newly established public body: Public Health Service. This Service is expected to evaluate realistically how many patients are registered for each family doctor and to transfer money to the doctors accordingly. It has been promised to establish this Service immediately after the law enters into force, and, for instance, in 2018, it will disburse over 13 bln UAH.

 First Scenario: Zero Game

             According to our rough estimations, after all the contracts with the family doctors will be signed, it will reveal that the divergence from an actual distribution of neighborhood doctors of the  polyclinics in districts is not exceeding 1%. We guess, only one out of hundred citizens might want to change their neighborhood doctor. It might be predicted that the managers of the polyclinics (that are now officially called Centers for Primary Medical&Sanitary Help) will “take actions” and arrange a formal signing of contracts within a current network of doctors and distribution of patients  according to their addresses; then this data will be submitted to the new distributing body for obtaining finances. When distributing funds from upside down, the newly established body will use basically the same principle as distributing money via subventions. Everyone will get more or less the same money like last year. Obviously, it will be some raise in salaries, but this could be done without the reform.

Concerning procurement of free medical testing and diagnostics, it is to take into account that capacity of laboratories, X-ray rooms, ECG spots is not going to change, thus, the level of free servicing will remain the same. Those who manage to get a slip, will obtain a free service, those who fail, will go “to voluntarily pay for a service”.

 Second Scenario: Bad

The newly created body will be authorized to assess the service provisioning and then decide, how much and whom to give money to. Well, it seems that the number of people who have signed the contract with the family doctors is the only obvious marker. However, the new body might not want to be just a cash-point technically giving out money but to remember the whole toolkit of operation of a corrupted post-Soviet controlling body.

There is a risk of permanent inspections of the service provision quality, based on fake claims. Some offices of the new body “sitting on the big bag with money” might start trading with finances: those who manage to make a deal, will obtain everything in time, those who fail will keep improving endless defects. The most interesting is that such manual management of the cash flow can be presented to the public in a very nice wrapping called “fighting for the service quality”. Another possible abusive practice is paying for fake service purchase when contracts exist only on paper.

A situation might be predicted when the same people willing to earn money will sign several contracts with all the physicians in the polyclinic. It might even become a kind of half-legal business because the adopted legislation does not stipulate any administrative liability for such “multi-tasking”. It is also an issue to check this all since the electronic accounting system has just been started implemented. Far-fetched redirection of the flows to FOPs (private entrepreneurs) who can easily withdraw the cash is also possible.

Third Scenario: Good

 Family doctors will compete to show the best health care servicing. People will notice it and will ignore administrative distribution upon the address registration and will sign the contracts with the really best doctors. In their turn, the doctors will exercise their right to regulate their maintenance and will hire the best nurses and administrative workers. Doctors will financially support the test services so that people can be diagnosed for free. Family doctors will really work on prevention, to establish effective connections with the secondary health care level. The financial and administrative component might play a major role as is expected within the reform. The family doctors will be interested in working with even more people. In addition, a correctly organized bonus system will allow getting additional money for early detection of severe illnesses, for effective care for patients,  for disease prevention. Further development of this aspect of the reform will show if the current primary health-care management structure is effective, stimulating its rationalization.

 Unfortunately, the third scenario looks low probable since it is not enough to just declare the principle “money following the patient” in the “reformatory” law but the bureaucratic impediment must be removed: huge overstaffed polyclinics with regulatory pressure and disapproval of those who follows the trends better than others.

It is the time to re-orient to out-patient departments capable to care for 10 to 20 thousand citizens. Such out-patient departments should include family doctors in the number according to the regulatory standard: one doctor per 2 thousand citizens maximum, one pediatrician per maximum 1200 children under 16 years of age, one gynecologist per 1500 women maximum, a surgeon, medical attendants and administrative workers, the positions and number of which is to be defined by the department itself.

The out-patient department should have the status of the health-care facility. It also should include a ward or day-patient facility in reliance (on the regulation one bed per 2500 citizens), testing equipment, operating room for small scale surgeries. In the countryside, there should be also a car  for doctor visits to villages for the follow-up examinations, house calls or emergency medical aid.

Therefore, to ensure an effective functioning of the primary health-care mechanism, several regulatory acts are to be adopted, including upgraded provisions on the out-patient department, regulations on the distribution of funds on different types of expenditure within a primary care facility, establishment of the jointly financed fundations for some general spending at the cost of the contributions by every family doctor, creating the bonus budget for the best performance in preventing and monitoring the dangerous diseases, and many other documents. And only then we can be sure that this optimistic scenario will work, if not since 1st of January, then at least since 1st of July 2018.