Rural Round-up: Reformation of Rural PHC in Ukraine

A/Prof Victoria Tkachenko, from Kiev, in Ukraine, writes on the new wave of reformation in primary health in her country.
See more about Victoria.

The implementation of family medicine in Ukraine started in 1986-1987. Many positive interventions have been introduced since then, but the results have been insufficient.

A more effective wave of health system reorganisation took place between 2011-2014, when independent primary care centres began to be created - independent of secondary care. These centres contained several primary care clinics, emergency care points and administrative centres in their structure. In addition, approximately 125 national guidelines and protocols for the management of common diseases and syndromes in primary care were developed and approved, together with a new financing structure for GPs’ work. This led to a significant increase in the number of general practitioners (up to approximately 14,000) and nurses, in general practice. However, it was still not enough to provide primary care for the whole Ukrainian population of 42 million.

Other problems such as limited resources, insufficient equipment in primary care centres, paper medical records with low levels of computerisation, low salaries (made worse by the economic crisis), and recent military conflict, have resulted in a reduction in the number of GPs and in their status within the health system.

In 2017-2018, another wave of health care reorganisation was introduced, and aimed to give priority to the development of rural primary care. The two specific national laws were "State Financial Guarantees of Medical Care of the Population" and "Increasing the Availability and Quality of Rural Primary Care”. The new per capita funding mechanism for primary care is based on the principle that money follows the patient - resulting in decentralisation and greater local control over the health care.

The National Health Service of Ukraine (NHS) has been created, and the communal primary care centres began their reorganisation to be communal non-profit enterprises. Primary care doctors and patients started to sign their agreement for medical services. An e-Health system and electronic registry of patients were implemented. Training in ICPC-2 use for trainers and doctors was provided with support of WONCA International Classification Committee (WICC) and EURIPA (The European Rural and Isolated Practitioners Association).

The Ministry of Health reports that about 50% of population have chosen their primary care doctor, and about 623 primary care establishments (including 85 private primary centres) have signed payment agreements with the NHS and received per capita funding, until the end of 2018. However, such changes have led to staff reductions in some places.

Further steps will be the computerisation of primary care (especially in rural areas), improvement in the availability of primary care equipment, implementation of electronical medical records with ICPC-2, e-receipt, internet, and telemedicine (consulting and GP support). Also planned are measures to improve rural recruitment and retention in the villages and rural territory such as better salary, different discounts, etc.

In collaboration with WICC the two ‘train the trainer’ sessions on the implementation and use of ICPC-2-E were conducted. The last two-day training for teachers in academic departments of family medicine was provided by Dr Jean K Soler (Malta) and Dr Nicola Buono (Italy) by distance learning, in December 2018. The educated trainers actively shared this knowledge with other primary care doctors in regions of Ukraine.

Conclusion: The first steps of the reformation of rural primary care in Ukraine have had positive and negative aspects. The reform will continue until the end of 2020, so that the impact on the quality of rural primary health care from each step can be analysed and evaluated.