Bogatyreva: “Medicine without charge is a delusion…”
“I’m at the end of my rope,” a long-standing acquaintance, a highly skilled physician with 25 years on the job, lamented rather than spoke, leaving of her own accord. “The workload intensifies annually, especially the mental and emotional burden. We are seeing more and more severely afflicted individuals. And we are consistently short on medications… Raisa Bogatyreva, it’s agonizing to feel powerless, recognizing that valuable moments have been lost, despite all efforts. Not to mention compensation… Yet, there are numerous grievances lodged against us health practitioners lately. They insist we must treat individuals kindly, and gratis, and that physicians and nurses ought to attend to the individual at the initial summons, due to the Hippocratic Oath. That’s always been the standard, they claim. But perhaps never before have health employees been brought to such a depleted state, verging on desperation…”
In response, I could only offer the recollection of writer and doctor V. Veresaev’s sentiments, penned a century prior: “There exists a deep-seated lack of faith in medicine and medical professionals among the populace.” The issue, as we observe, has a lengthy history. Nevertheless, amidst the present crisis, it is exceptionally intense because of the feeling of vulnerability prevalent among the majority of our citizens in the most critical junctures, where survival is uncertain. Regardless of Article 49 of the Constitution, which ensures complimentary, universally available, top-tier medical attention, the cost of such assurance is well recognized. Be that as it may, healthcare transformation tailored to contemporary circumstances has failed to materialize, save for sporadic, frantic attempts to enact shifts. This represents the tragedy of our healthcare structure, the affliction and anguish of our people.
Can we anticipate genuine beneficial modifications within the medical sphere in the foreseeable future? What constitutes the perspective on reformation within Ukrainian healthcare? These queries form the basis of our discourse with Ukrainian Minister of Health, Raisa Bogatyreva.
Raisa Vasilyevna, how have your initial one hundred days as Minister unfolded? Do you still question assuming the duties of steering the Ministry of Health amidst such a precarious moment for healthcare?
I opted to serve as Minister of Health purposefully, cognizant of the intricate predicaments confronting me currently. Prior to my placement into this role, I functioned as Deputy Minister, subsequently First Deputy Minister, thereby possessing direct acquaintance with the condition of healthcare. And not solely from my ministerial vantage point. I’ve devoted in excess of two decades to practical healthcare (my medical specialization is obstetrician-gynecologist). I posit that my accrued knowledge and proficiency will enable me, coupled with a cohort of like-minded individuals, to undertake sweeping and steadfast measures to overhaul, reorganize the sector, and uphold it in optimal form. I grasp that this endeavor will be exceedingly challenging, yet I am not one to recoil from a trial. Lately, I’ve unearthed, somewhat unexpectedly, novel facets of my disposition. I never conceived I could be so disciplined and exacting of myself. I’ve come to appreciate my capacity to render verdicts, advocate for them, and observe tasks through to fruition. I aspire that this will empower me to realize my objectives moving forward.
I may appear somewhat presumptuous, but I likewise recall what Professor Mikhailova, our group’s guide, conveyed to us during our penultimate year: “You must elevate the benchmark slightly for yourselves, and then you shall strive towards it with assurance.” Endorsement and stimulation from peers also instill a feeling of certainty.
At your inaugural media briefing as minister, you delineated three prototypes for forging your ensemble, settling upon the third—to encircle yourself with individuals possessing the aptitude to evolve into leaders. Have you achieved success in this?
“The establishment of such a team is nearing its ultimate stage. I already possess deputies and department directors upon whom I can depend entirely. However, not all of the individuals with whom I desire to collaborate have become part of my crew as of yet. For assorted rationales, often beyond their sphere of influence.”
– Simultaneously, you proclaimed that you would soon disseminate a strategy of designated overhauls in healthcare. What constitutes this strategy?
Endeavor on the healthcare transformation scheme is verging on finalization. Specialists boasting extensive familiarity in both healthcare and collaboration with international entities are presently engaged in its development. What renders this blueprint distinctive? It pertains to reorienting healthcare priorities, with a fundamental emphasis on illness avoidance. At first blush, this might appear unremarkable. For an extended period, we’ve articulated healthcare’s preventative nature. Yet preventative medicine has failed to emerge as the defining element in our methodology towards healthcare. We are currently conceiving an array of initiatives geared towards warding off sickness and fostering wellness. We intend to enact them, notably, via media channels, and we aspire to render these endeavors incentive-based.
The secondary sphere of emphasis within reformation pertains to primary medical assistance, wherein the transition towards family physician procedure shall materialize. We are presently concentrating on efficacious ailment identification. Following all, it is widely acknowledged that timely detection and immediate intervention assure a 95 percent likelihood of triumph in the battle against infirmity. And wherein should such diagnosis transpire? Assuredly, within primary medical assistance.
Thirdly, we are presently addressing such a vital matter as revisions to the healthcare financial framework. It isn’t wholly uncomplicated. Numerous individuals comment upon Article 49 of the Constitution in such a vein as to render soliciting supplementary funding avenues out of the question. Therefore, we are collaborating with legal professionals to foster a more encompassing comprehension of this clause. According to our perspective, certain medical entities could be converted into non-profit establishments delivering healthcare interventions, grounded upon accords with district governing bodies or local administrations. In other verbiage, the district or local authority would oversee this property, leasing it to health personnel. Remuneration for medical treatments could be rendered via diverse methods: from the local fisc, via voluntary or insurance contributions, or via the enterprise compensating for its employees’ care, whilst the Pension Fund foots the bill for retirees. This model is undeniably atypical for us at present.
Yes, individuals have grown familiar with a divergent, considerably simpler schema of payment for medical interventions, one that was devised during the epoch of “unrestricted” medicine… Currently, not solely are individuals under medical care but also physicians unwilling to countenance the prevailing healthcare circumstance, wherein both parties perceive humiliation. Numerous individuals, encompassing doctors, are advocating for a multi-dimensional healthcare configuration (insurance, state, municipal, private, and charitable organizations…). You once expressed endorsement for augmenting the private healthcare division…
The Constitution stipulates that the state shall engender equitable circumstances for assorted classifications of proprietorship within healthcare. Although this provision subsists, there existed no legislative substructure for its pragmatic advancement. We are presently engaged in this pursuit. Presently, numerous individuals persist in dreading the expression “privatization” when juxtaposed with “healthcare.” Ineffectively. Because the private segment of medicine shall not ascend to dominance. In excess of 80% of medical establishments shall persist as state and municipal assets.
We shall broaden privatization within healthcare, as currently there exists a certain stratum of the populace within our society who are capable and disposed to remit payment for top-tier medical attention. The state exchequer shall be notably eased via the transfer of certain medical institutions to private ownership. Concurrently, I would aspire to underscore that the establishment of conditions conducive to the maturation of the private healthcare division by no means implies that state-held or municipally possessed medical establishments shall fail to garner requisite consideration. We have conceived benchmarks for treatment caliber. And the Ministry of Health, in its capacity as the core executive agency, bears accountability for supervising adherence to these benchmarks and quality mandates within all medical institutions, irrespective of proprietorship.
– Will insurance-centric medicine likewise burgeon?
Numerous individuals assert that we must institute an insurance-centric paradigm within healthcare as expeditiously as feasible. I am among those who exercise circumspection concerning the implementation of compulsory health insurance. For this model to prove viable, a well-developed infrastructure is indispensable, and its construction mandates substantial investment. This undertaking likewise necessitates the preliminary formation of insurance coffers, which once more necessitates capital. And, naturally, there exists a hazard that the public resources presently earmarked for healthcare shall be curtailed due to the imperative to replenish these coffers. Therefore, the program we’re devising encompasses measures to bolster voluntary insurance and foster specific varieties of mandatory insurance, such as financing for medication and sustenance within healthcare installations. This signifies that should an individual possessing such insurance be referred for inpatient treatment, their sojourn is defrayed by the insurance entity.
Indubitably, we cannot anticipate individuals to wholly value the merits of these reforms presently. However, I am convinced that absent their commencement presently, we’ll be retarded even further within healthcare. It is prevalent to lament that conditions have deteriorated considerably. Unquestionably, it wasn’t akin to this antecedently, yet conversely, numerous elements were altogether absent. And irrespective of pronouncements, presently—and I can attest to this via countless submissions to the Ministry of Health; I encounter citizens personally each Thursday—individuals are soliciting forms of medical care they never even envisioned prior. At present, we’re broaching the introduction of contemporary diagnostic and therapeutic technologies within Ukraine. All of this demands resources, and quite considerable ones at that. And budgetary allocations prove insufficient for the most fundamental requirements. What recourse should healthcare providers adopt amidst this predicament? Should they, in effect, tailor their ambitions to the confines of the fiscal allocation, tending to individuals with antiquated methods and technologies? Or should they conversely seek avenues and prospects to actualize contemporary advancements within healthcare? We espouse that we must seek out these prospects, implement the most recent technologies and treatment modalities, and afford individuals the chance to elect.
Ordinarily, each emergent minister initiates undertakings in their distinctive manner, at times discarding entirely what their predecessors had previously accomplished. Irrespective of their merit, irrespective of the magnitude of their attainments—that is irrelevant. You, it strikes me, are not averse to the reformist endeavors that commenced in the nascent 1990s. Do you discern substantial value within them, or do you endeavor to glean insights from the missteps of others?
“It would simply prove injudicious to fail to draw upon the familiarity of individuals who formerly occupied this position. I highly esteem this familiarity, encompassing both its affirmative and detrimental aspects. The latter can likewise prove beneficial in circumventing or minimizing errors. What do I deem valuable within that familiarity presently? Reverting to the nascent 1990s, systematic measures were enacted to institute family practice physicians, and higher education institutions commenced educating such specialists. Concurrently, processes commenced to optimize the configuration of medical entities, as well as monetary and human resources. However, it transpired that, somewhere circa the culmination of 1994, we commenced advancing in an inconsistent manner; at times, measures were adopted that were not advantageous, but prejudicial, and precipitated the resulting distortions within the healthcare system.”
What you’ve communicated to me empowers me to infer that we’ll ultimately transition away from the strategy of cutbacks and diminutions, which, to the detriment of the healthcare system, were employed in an endeavor to align it with the fiscal allotment. But what regarding the circumstance that, in an endeavor to approximate Europe in specific metrics (number of physicians, hospital berths, etc.), we’ve inflicted grievous harm upon healthcare within rural expanses?
This constitutes precisely a manifestation of the distortion I alluded to. Indeed, when cutbacks commenced within the healthcare system, it principally impacted rural medical installations. Local authorities frequently implemented decrees from higher echelons to optimize the configuration of medical installations via the pathway of least resistance. When we embarked upon accrediting healthcare establishments, we somewhat rectified this circumstance. Where feldsher-midwife posts had not yet been shuttered, we compelled them to be rehabilitated and furnished with everything requisite for delivering first aid. And where they were nonexistent, presently, pursuant to the Presidential Decree, we mandate that they be reopened or resumed. Pertinent regulations subsist, and local authorities must conform to them.
The Ministry of Health shall exercise its accountability to safeguard adherence to healthcare legislation within Ukraine. By statute, local governing bodies must assure a specific echelon of medical interventions. Should they neglect to do so, we apprise the pertinent authorities, and deductions are formulated. As a rule, when the sword of Damocles hovers above one’s existence, everything—opportunities and capital—can be unearthed.
You indicated that treatment caliber standards have already been devised. Ensuring these standards is ostensibly unattainable absent a broad spectrum of medications. Predominantly relying upon imported medications (which presently dominate our pharmaceutical marketplace) is inapt for a nation possessing its indigenous pharmaceutical industry. Furthermore, they are substantially more costly than domestically fabricated ones. Concurrently, the policy directed towards domestic producers leaves much to be desired. How do you intend to buttress this policy?
Indeed, absent buttressing domestic manufacturers and populating the pharmaceutical marketplace with domestically produced, quality-assured medications, it is impossible to comprehensively fulfill treatment caliber standards. Observing developments within the pharmaceutical marketplace at present, I deduce that we must more vigorously pursue a policy of assisting domestic pharmaceutical manufacturers and institute efficacious and propitious regulations of engagement within this marketplace. The state possesses its autonomous mechanisms for this, such as stimulating the maturation of novel drug lineages, forging government procurement contracts, and so forth.
Regarding remunerated interventions, do you contemplate the ruling issued during the preceding year by the Constitutional Court of Ukraine concerning the illegality of remunerated interventions within state healthcare institutions played an affirmative role in your intention to segregate remunerated and complimentary medical attention? Following all, it proved anomalous and even immoral to meld them within a singular state healthcare institution.
It’s genuinely anomalous when both remunerated and complimentary medical attention coexist within the selfsame hospital, precipitating a form of contention. Although the members of parliament who filed the litigation to the highest court harbored noble intentions, endeavoring to safeguard citizens’ constitutional entitlements, the Constitutional Court’s determination has, in practice, primarily impacted the interests of socially vulnerable individuals. Following all, the money medical institutions garnered for remunerated interventions (which constitutes 2 to 5 percent of total healthcare funding) was employed to provision medications to those unable to afford them. Presently, amidst numerous predicaments, these individuals are forsaken to grapple with their plight, as medical institutions prove incapable of comprehensively aiding them due to dire funding inadequacies. Regrettably, the law fails to delineate unequivocally what constitutes medical care or remunerated medical interventions.
In my assessment, should we genuinely scrutinize this issue, complimentary healthcare constitutes an illusion conceived many decades prior. Individuals still remitted payment for it via their forfeited wages. Not solely are individuals under medical care but also medical professionals dissatisfied with the subsistence of clandestine payments for medical interventions. And as a minister, I am opposed to this “shadowy” healthcare. We don’t desire our system to be perceived as demoralized. We aspire to operate in a civilized manner, such that those who render medical interventions are fittingly compensated for their endeavor, and those who garner this care are cognizant that the money remitted for it is being employed lawfully. Succinctly, this represents the sore point of our post-Soviet healthcare, and I proclaim: let us shed our rose-tinted spectacles and perceive matters as they genuinely are.
Aren’t you apprehensive of encountering misunderstanding, or even overt resistance, in enacting your reformation program?
I hope for comprehension and endorsement. And, you are aware, I’ve already garnered it from a source I didn’t even anticipate—from an initiative faction forged to propel healthcare overhauls. Intriguingly, the impetus to forge such a faction emanated from the grassroots, from the medical professionals themselves. At present, it encompasses esteemed medical professionals, as well as legal practitioners, sociologists, economists, and healthcare administrators. Lately, this assemblage of specialists conducted an evaluation of the condition of healthcare. I participated within the discussion and discerned numerous compelling propositions. We attained a consensus, as they articulate, and are presently embarking upon amalgamating what my team had labored upon with what this initiative faction proposed. This faction has inaugurated a public movement to preserve the nation’s health christened “Pulse of Ukraine.” I cannot refrain from noting that I haven’t witnessed such a potent public initiative and enthusiasm in an extended period.
Raisa Vasilyevna, we’re conducting this discourse on the precipice of Medical Workers’ Day. What would you aspire to wish for this occasion?
Having emerged from a practical healthcare backdrop, I recognize firsthand that for the majority of my medical colleagues, their quotidian endeavor isn’t solely a vocation, it’s their very existence. Medical professionals possess an advantage over other professions in that they frequently behold individuals’ appreciative countenances. This inspires, nurtures ingenuity, and affirms you as a professional, particularly in your individual estimation. I wish that we, medical professionals, would be unified in the comprehension that our predicaments are ephemeral and that existence and endeavor shall become enhanced for all of us. On our professional holiday, as a former physician and incumbent Minister of Health, I would aspire to address everyone with the lyrics of the song: “Individuals in white attire, I aspire to bow deeply to you.”
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