Reform of the primary link: whether will begin hunting for patients in Ukraine

From March to June, every Ukrainian must choose a family doctor and sign a contract for providing services to him. As part of the reform of primary link of medicine, each month, the government will allocate UAH 250 to family physicians for each patient, who signed a contract. About the strengths and weaknesses of the reform of primary link read the article of the consultant of the Institute for Social and Economic Research Igor Yakovenko.

How will the reform of the primary link look?

As we can learn from government documents and plans, voiced by the government, the following algorithm laid in the reform of the primary link. During March-June every Ukrainian has to decide, who will be his family doctor and sign a contract for providing services to him. Thus, it could be any doctor who works at the primary link, regardless of the region in which it conducts his activity, works in a polyclinic (Primary medical care centres or - PMCC) or is self-employed.

At the same time, the state must approve the guaranteed package of services for primary care, so that the doctor and the citizen, concluding an agreement between themselves, should clearly understand what they can expect. Also, the maximum until July, the state should create a new agency that will be the sole manager and the customer of the budget funds, and enter into contracts with all possible providers of primary health care. These providers may be primary medical care centres (PMCC), outpatient clinics, doctors who work as private entrepreneurs.

The state will pay for the services of family doctors based on the so-called capita rates - a single rate per one citizen. This rate is currently forecasting at around UAH 250 per person. However, one doctor cannot serve more than 2,000 people. In this way, an individual doctor will receive an average of UAH 40 thousand per month or UAH half a million per year. The Ministry plans to move to a new system of funding in the second half of the year.

How to choose a family doctor?

The reform of the primary link looks well thought out, but there are several factors that can prevent its implementation. Since 2011, in Ukraine were conducted pilot projects in family medicine, but the majority of Ukrainian never choose a family doctor. Therefore, for some people, it will be problematic to make such a choice due to a lack of complete information about doctors of their medical district. The lack of information immediately gives ground for the nonobjective, distorted impact of advertising. For example, some doctors may artificially gain fame, or even make so-called "sorting" of people in nearby homes, selecting only healthy patients and avoiding sick ones. As a result, the most problematic and most complex patients can be distributed for the "residual" principle. It is also difficult to imagine that people will choose doctors from remote districts from him, as far it will be difficult for a medic to get to the patient. Besides, it is unknown whether in this case, he will take someone else on the same day?

Insufficient number of family doctors

Another problem may be the insufficient number of family doctors needed to implement the reform. Today the Ministry of Health proposes to set the limit number of patients for one family doctor at the level of 2,000 or 2,500 maximum persons. If you simply divide the number of population of Ukraine, that according to the State Statistics reached 42.603 million, to this ratio, we get the need for a little more than 17 thousand family doctors. According to the data of 2011, we had 8,140 of them. Over the years that have passed, this figure is unlikely to substantially increased, on the contrary, because doctors are one of the most active groups of labour migration. How to be with those who will leave without a doctor?

Insufficient qualification of family doctors

Also, you should not forget that our medicine is still administering by the Soviet principles. Now, physicians of the primary link care, as we beautifully call them family doctors, in fact, are ordinary district physicians of polyclinics, called PMCC now. It is unlikely that for such PMCC it will be interesting to promote differentiation of contracts and earnings. For many people, it is much easier to leave everything as it is now - doctors attached to neighbourhood residents, and wages did not significantly vary so as not to cause strife within the team. Therefore, the entire contractual process by July 1, that it is currently advertised as a new step in the reforms, the most likely, will be held under the tight administrative control of the management of polyclinics-PMCCs.

What is a guaranteed package of services?

A formation of a package of guaranteed services began 15 years ago, with the adoption of the Government Resolution № 955 of July 11, 2002, which approved the program of guaranteed medical care. Unfortunately, it’s creation is still failed. At the same time, government officials declare that they will form a guaranteed package of services for primary medical care by mid-summer.

In early February, the Ministry of Health submitted a draft of a number of documents for a discussion, including the rules of providing primary health care (PHC), the list of necessary equipment, the main tasks of the PHC doctor, the list of diagnostic procedures and laboratory tests within PHC. The documents also provide a provision of almost all basic services that a person may need when referring to a doctor, including a wide range of examinations, tests and diagnostic procedures. At the same time, they do not include drugs, even though the government previously promised that the funding medicines would be in prior. Now the Ministry of Health described promises to provide medicines with the modest phrase - "provision of medicines according to the state and municipal programs".

The majority of items, listed in the draft documents, is not something "revolutionary". A distinctive feature of a guaranteed package is that two conditions should be fully implemented: these are the availability of diagnostic and procedural manipulation bases for the performance of requirements for the family doctor.

Whether will be the diagnostics free?

In many countries, a reception at the primary link physician is only possible if the patient has passed at least a blood test. Applying this principle to Ukraine, it turns a sad situation. It is logical to assume that every patient at least once a year passes the blood test. Additionally, it will be necessary to pass a urine test, a blood test for sugar or fluorography. If for each person per year UAH 250 will be allocated, and the blood test in the laboratory, trusted by the population, now costs about UAH 200, quite low of funds remains on salaries for family physicians. Even if from payments on each patient attached to a doctor will remain UAH 10 for salaries, it will be only UAH 20 thousand per year.

Overall, there are problems in the field of medical diagnostics in Ukraine. The family doctor may prescribe a bunch of appropriations to tests, but each of us really understands that you should go through a huge queue before 9:00 am, the number of reactants is limited, and the most important is there are serious doubts about the reliability of the results. So, the most of the people pass tests for an additional fee, the more that these paid services are available in every clinic and there is a well-developed network of private laboratories.

Even bigger problem is the free passage of more complex diagnostics. So, they should not promise "guaranteed castles in the air" on the diagnosis but within the reform to seek ways to ensure the performance of realistic promises in this area. You can start with the principle "money follows the person" by the family doctor issuing vouchers to the patient. The financial coverage should be performed by funding the primary link.

Ways of financing

Finally, let’s talk about the new funding system. The model, proposed by the Ministry of Health, provide that the newly established agency will determine the amount of funding for per capita rate. However, still, it is no clear who will receive funds: the doctor or the institution? If funds will be credited to the account of the institution, it seems, that the institution itself will divide received money counting about 40 thousand per month per physician. They will give a part of it to doctors for their quantitative and qualitative results, and the remaining funds will go to the maintenance of apparatus, procurements, salaries for junior staff and non-medical staff. It is all clear, but whether it was necessary to fuss because about the same thing exists now?

If the money flows to the doctor, he must continue to pay for all the areas above, in most cases, under pressure from his superiors in PMCC that will want more money for themselves and the institution. To implement the second approach, it is necessary to write out a very complex legal and financial mechanism. Given that two months already have passed, and the new budget format should be established at least until July 1, there are great doubts about the implementation of plans for the introduction of a new financing system in 2017.

The reform of health care is one of the most sought for Ukrainians. Insufficiently adjusted and unweighted steps can undermine people's trust and left reformers without any support.

(The Article was published at the Liga.net on March 6, 2017)