Author: Hennadii Zubko, Vice Prime Minister – Minister of Regional Development, Construction Housing and Communal Services of Ukraine for "Censor.NET"
On 14 November the Verkhovna Rada adopted the law 7117 "On improving the availability and quality of healthcare in rural areas", initiated by the President of Ukraine Petro Poroshenko. It is intended to solve the problem on the deplorable state of primary healthcare in the countryside, which has not been resolved for decades, make healthcare service high-quality one, bring it closer to rural residents, whose number exceeds 13.1 million in Ukraine, as in some areas even more than 60% of the population is rural. The law actually initiated the reform of rural healthcare. The main purpose of the law is to provide high-quality medical examination in rural areas, timely detection of diseases, first of all genetic ones at the early stages, systemic supervision of certain groups of patients, carrying out of preventive and sanitary measures. After all, one issue is the level of healthcare in Kyiv or a regional center, and rural healthcare is quiet another one. The overall success of the reform depends on the ability of the state and society to change the situation with the quality and accessibility of healthcare services for the inhabitants of the countryside. Therefore, the state’s primary task is to integrate quality healthcare services directly into rural areas. I am sure that a significant part of the expected changes will actually be implemented in a year or two.
Rural healthcare realities: coma is the diagnosis
When we say that 35% of the population of Ukraine lives in rural areas, we do not always understand that this is only “an average temperature”. We have 7 oblasts with over 50% of rural population, and 8 oblasts, where this indicator is about 40% or more. Thus, for example, in the Lviv oblast we have the highest rate: 959 residents live in villages and rural settlements. Besides, there are 5 oblasts with rural population of less than 30%. In addition, this year 665 AHs have been already established within the framework of the decentralization reform in Ukraine. They make up 26% of the country’s territory with 5.7 million people living on it. Moreover, the overwhelming majority – 3.6 million residents – is the rural population, and over 8 thousand villages and rural settlements are amalgamated into hromadas. It is obvious that decentralisation forms a new model of rural development with a new management system and new economic relations in Ukraine. It is important to understand that when we talk about the development of rural areas, we are not merely implying the development of administrative units. We are talking about the development of human potential as the main goal of the reform. Thus, rural residents need special attention of the state.
Therefore, the main task of the state is to provide high-quality and affordable services to all citizens, regardless of their place of residence. The first service of this kind is healthcare. At the same time, we have disappointing statistics: 80% of patients immediately receive help at the second or third level, bypassing the primary link – outpatient clinics and family doctors. Instead, in the EU countries, the ratio of patient referrals to primary and other levels of medicine is fundamentally the opposite and accounts for 70% of applies to the primary healthcare link, and 30% - to the secondary one.
Why is this happening? We have to state that basic healthcare in the countryside is currently practically eliminated. And therefore, no doctor, even the one with a God-given talent, is unable to provide high-quality treatment in the present conditions. There are 4,000 outpatient clinics and 12,700 health posts in 23 thousand villages and rural settlements. Their technical condition is deplorable. 71% of them lack water supply, 75% do not have sewage system, and 82% of rural outpatient clinics do not have bathroom and lavatory facilities. The health post has become an intermediate point, through which the patient is transported from point “A” to point “B” – thus, to a rayon or oblast with a certain healthcare level. Thus, health posts do not function as a primary healthcare link.
From hospital capacity indicator to preventive healthcare
In this regard, Law No 7117 is intended to establish an effective model of primary healthcare through the formation of a network of primary links of rural healthcare institutions and introduction of modern technical solutions and motivational benefits for the doctors.
In order to create an effective network of primary healthcare in the village, we need to understand how to build it at the district level. After all, our task is to provide a primary level healthcare service in the entire rural territory. Currently, together with the Ministry of Health, local self-government bodies and doctors we are developing a methodology to form an effective network of outpatient units. We have to reorient the primary link directly to the outpatient clinic with a doctor, equipment, transport and high-quality primary healthcare. The model of the rural “primary” we must reach presupposes doctor’s load to be 1.5 thousand patients, and an outpatient clinic within 5 km reach.
At the time the maximum increase in the number of primary healthcare institutions is required. It is about reconstruction, technical re-equipment, personnel strengthening. We will build new institutions, where there is a vital need of them. As a builder I know that, in many cases, it's easier, faster and more cost-efficient to build a new object from scratch than to repair an old one. Therefore, in MinRegion we are currently developing typical projects of healthcare institutions of the primary level (feldsher's station, health post, outpatient clinic), that can be quickly and efficiently constructed all over the country.
I immediately emphasise that it is not about “customising” old houses or unfinished premises. We offer a project of a modern institution (regardless of whether it is a reconstruction or construction), taking into account the requirements of the healthcare institution to provide people with high-quality services. It is based on the standards and sanitary requirements recognised internationally. For each primary level healthcare institution a mandatory list of equipment will be approved according to the services provided, with means of telecommunication, informatisation, high-speed Internet connection and mobile communication.
The financial resource to develop the rural healthcare network is UAH 4 billion. This sum is envisaged in the 2017 state budget and the draft budget for 2018.
How to quench the personnel thirst for healthcare professionals: a motivational package
Personnel provision is a separate acute issue for resuscitation of rural healthcare, as far as formation of the network is possible only with its clear provision with healthcare staff. We have a catastrophic situation with the aging of the rural medical personnel. Rural youth, even after graduation from a medical institution with appropriate education, is in no hurry to return to the village.
We have to solve the problem simultaneously at different levels by involving not only the Ministry of Health, but also the Ministry of Education and Science. In particular, we need to update training programmes for future doctors and health workers – from the school desk and further to the universities, advanced training institutes and postgraduate education. For example, career counselling of future school graduates is among the initiatives. It is about creating specialised preparatory departments for rural residents in non-medical institutions of higher education in cities, and establishment of specialised classes in rural schools. The advantage will be the right for priority admittance to the medical universities granted to the applicants, who have signed an agreement to work for at least 3 years in their rural hromadas. It is also possible to consider the option of increasing the scholarship for such students, possibly partially at the expense of hromadas, where they will work in future.
In addition, we provide a motivational package for healthcare personnel. The legislative initiative proposes to provide the rural doctor not only with a workplace in the modern outpatient clinic, but also with decent salary and accommodation. First of all, it concerns primary healthcare doctors. According to the calculations, the salary of a rural primary healthcare doctor will amount to UAH 15 - 30 thousand, and that of the nursing personnel – to up to UAH 4-8 thousand, depending on the number of patients.
Another important aspect of solving the personnel issue is the provision of accommodation. We are aware that it is humiliating for a rural doctor to rent a corner in a foreign house. That is why apart from medical facilities the typical project of a rural outpatient clinic provides a comfortable service housing for a doctor. Besides, local self-government bodies are also able to provide the doctor with accommodation.
In addition, it is clear that many rural settlements are difficult to access and are remote from each other. Therefore, the rural doctor will have to take responsibility for several villages in the village. This issue can be resolved if is the doctor is provided with automobile transport as additional motivation. At present, only 17% of rural health posts and outpatient clinics are provided with transport. The state will invest and is already investing in construction and reconstruction of roads connecting rural outpatient clinics with rayon and oblast hospitals. Currently we have funds for the development of transport infrastructure. This is a resource of the state budget and local budgets, money from the “customs experiment”, State Fund for Regional Development, subventions for the AH infrastructure development, and since 2018 – the Road Fund in addition.
It is clear that an integrated approach to personnel, including salary, accommodation and transport, will solve the personnel issues once and for all. We will return a dignified social status of a doctor, and thus, a traditional respect of the Ukrainian society.
Modern equipment and telemedicine
It is important to realise that rural healthcare implies not only a room and a doctor, but also modern equipment and medicines. Rural outpatient clinics should be provided with portable cardiographs, tonometers, pulse oximeters, laboratory equipment for instant urine and blood tests, which can transmit data via Internet, Rott apparatus, nebulizers, and other equipment for quality healthcare, as well as a list of medications and medicines under the “Available Medication” programme.
An important direction is the introduction of telemetry medicine, envisaged by law 7117. Due to it, the doctor of the village outpatient clinic will be able to receive on-line consultation from a secondary and tertiary healthcare institution, transmit patient’s tests and research results. The next steps implying the use of the Internet are the use of up-to-date on-line services – training, advanced training ones, as well as connection to the eHealth system, and introduction of the electronic patient cards.
I would like to note that this is not about the treatment “via the Internet”. It concerns advisory support provided to the health post personnel by the doctors of a higher level, which allows the specialist “at a distance” to be able to consult the patient.
In addition, the provision of rural high-speed Internet connection (necessary for the development of telemetry network) is important not only for the development of primary healthcare. We consider it as an incentive for the integrated development of rural areas, as an additional opportunity for preschool educational institutions, schools, community centres, as possibility of introducing online education, various trainings and courses, including those dedicated to foreign language teaching.
I would like to note that the rural development programme meets the general concept of reforming the health system and primary healthcare strengthening as one of its basic provisions. The success of its implementation depends on coordinated and rapid action of all involved line departments: MinRegion, Ministry of Health, Ministry of Education, as well as local authorities.
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