The third meeting of the National Work Group on development of the National Strategy of Secondary Health Care Reform

On the 18th of December 2008, in the Ministry of Health took place the third meeting of the National Work Group on development of the National Strategy of Secondary Health Care Reform.
 
The Director of Health Care Organization Department, Ms. Myroslava Zhdanova opened the meeting, focusing on the importance of the work carried out by the Project for the implementation of secondary health care reform.

The Project legal issues expert Ms. Anna Nechai in her presentation «Main Steps towards the Secondary Health Care Reform in Ukraine: the Project Vision» defined five main stages of health care system reform. In her opinion, the separation of primary and secondary health care (SHC) together with the augmentation of the primary health care (PHC) role in the system of health care of Ukraine are the first step of the health care reform process. This must also be accompanied by the separation of the budgets (and the process of the expenditure budgeting) of the primary and secondary health care and establishment of the PHC facilities and services as separate autonomous legal entities. It’s also necessary to increase the ratio funding of PHC as compared to the SHC funding, taking into consideration the actual needs of PHC, which requires the transformation of hospitals into communal non-commercial enterprises, which act by the Commercial Code and other corresponding legislation of Ukraine, and the introduction of state purchase contracts for medical services between the hospitals and local self-government bodies (including the specialization of hospitals on providing different types of SHC services and taking this specialization onto account when signing state contracts) in order to increase the efficiency of funds expenditure. As well, it’s necessary to increase the funding of preventive PHC activities, taking into consideration the results of monitoring the defined performance indicators of the PHC service providers.

On the second stage of the reform, the restructuring of SHC facilities should be done and state contracts for medical services purchase introduced. The restructuring of SHC facilities and the introduction of contracting would facilitate the optimization of the hospital network. The restructuring of SHC facilities requires the change of legal status of hospitals to the communal non-commercial enterprises. After that, it is possible to move to the introduction of state purchase contracts for the medical services provision. Contacting may also become the basis for medical insurance in future.

The introduction of state purchase contracts for the medical services provision, in its turn, requires:
• The elaboration of gradual strategy for the transition to contracting (together with defining the order of priority for the types of medical services to be purchased on the basis of such contracts in the coming 3-5 years);
• The elaboration of framework contracts for the medical services purchase;
• The elaboration of monitoring procedure of the fulfillment of such contracts on the basis of a new system of accountability and established professional standards (services provision quality indicators, including the requirements of the clinical protocols).

On the third stage, a new system of accountability should be created and professional standards established which would require:

1) The elaboration of criteria for the assessment of medical services provision quality, which are to be used for monitoring the fulfillment of the medical services purchase contracts;

2) Establishment of indices, according to which the statistics is to be provided, as well as statistics reporting techniques and the definition of verification methods for such reporting;

3) Establishment, on the rayon level (and in some cases – oblast level) the department for monitoring the fulfillment of medical services purchase contracts. Such departments would also perform the system functioning analysis, elaborate the propositions for the improvement of medical services provision quality indicators (which are stated in the contracts) and update the plan  of gradual introduction of state purchase contracts for all types of medical services, basing on the results of reporting year;

4) Improvement of the financial planning, management and accountability (including the introduction of fair economic value calculation for the medical services), basing on the reported statistic data. In order to do so, on the level of rayons and oblasts there will be established institutions, responsible for the quality control issues of contract fulfillment.

Statistic data collection and analysis would allow to more clearly see how different functions should be reallocated between hospitals. The SHC facilities network optimization through the establishment of communal enterprise hospitals would become the forth stage of the reform. It requires:

• The establishment of hospital corporations for efficient reallocation of functions and improved efficiency of the available resources usage;
• The rationalization of hospital classification in accordance with all existing types of care (medical and social) provided by them. The “legalization” of non-medical types of services provision by the hospitals and their further taking into consideration during the financial and other resources planning, as well as during the reallocation of functions between the corporation members;
• Clear demarcation between the medical, social and socio-medical services provided by the hospitals (including their differentiation within the framework of one and the same  hospital, as well as introducing the specialization of SHC facilities on different socio-medical services – hospices, rehabilitation centers, day care nurseries, etc);
• Introduction of financial incentives for the hospitals and their staff for achieving the best performance indicators of the professional standards (quality indicators) during the monitoring evaluation. Such incentives may be funded with the money saved due to better performance and reorganization of hospital management;
• Gradual revision of the hospitals’ staffing headcount with regard to their actual need of specialists of different types;
• Raising the professional standards of SHC through the introduction of clinical protocols for all types of SHC and the establishment of a system for new professional trainings for the staff;
• Introducing hospital management on the contractual basis (transition to the system of professional hospital management with clear distinction between medical and administrative staff).

On all stages it is important to conduct informative-explanatory campaigns, which would lead to the understanding of the essence of the reform by all target groups.

National health policy and legal coordinator of the EU Project “Support to Secondary Health Care Reform in Ukraine” Dr. Volodymyr Rudiy in his presentation “Increasing the Level of Hospital Autonomy and Optimizing the Network” identified the main problems of the hospital care organization in Ukraine and the key decisions, which can initiate the reform in Ukrainian hospitals.

Dr. Rudiy defined the autonomyzation of the medical services providers as the process, which is raising the level of the managerial and financial autonomy of the medical services providers.

Autonomyzation, as a rule, requires the change of legal status of such entities in order to create the grounds for ensuring wider and freer opportunities for managerial and financial decision-making regarding the organization of work. The advantage of autonomyzation lies in ensuring the flexibility in decision-making regarding the management of received state funding, defining its own organizational structure (departments, beds, staffing), as well as in giving the possibility to choose innovative approaches to the organization of staff work payment. The transition to operating in the environment of state purchase contracts for medical services allows introducing new, result-oriented and motivation-inducing methods of payment for the hospital services.

Dr. Rudiy said that the Project is considering the establishment of inter-rayon communal hospital corporations to be one of the possible instruments of hospital care system reform in Ukraine, which would facilitate:
• the introduction of new approaches to planning and optimization of hospital networks within the framework of current legislation;
• further development of the hospital autonomyzation process and achievement of other related positive changes in the hospital care sector;
• the elimination of resources fragmentation in hospital care and in the whole system of health care in Ukraine;
• the adjustment of cooperation between the bodies of local self-government in order to improve the efficiency of health care system resource usage, the quality of hospital care and, through that, ensuring the effective fulfillment of the state function of organizing public health care, which is delegated to the local government.

The establishment of hospital corporations would allow to clearly allocate between the members of corporation the functions of providing certain types of health services to the whole catchment population and ensure functional restructuring of the number of beds, as well as the continuity between medical and social care, their gradual integration.
Due to the more effective organization of management of property, human and financial resources, available for the members of the corporation, the quality of medical services would rise and the provision expenditures would be optimized. The quality improvement of health care would also be ensured by concentrating the provision of certain types of medical services, resources pooling and increasing the efficiency of their usage. 
Rural population would have a real possibility to receive quality hospital care.
The establishment of hospital corporations would allow the introduction of simplified funding due to the rejection of highly inconvenient and red-tape system of funds transfer approving and agreeing their movement between different budgets with the Ministry of Finance of Ukraine. Also that would eliminate the necessity of making unpopular decisions, related to the optimization of the hospital network (hospitals – corporation members – are not getting shut down or stuff cut, each of them keeps the status of a separate legal entity, however, there are stimuli for the optimization of expenditures related to ineffective usage of the capital assets, provision of ineffective services, etc.).
     Together with the establishment of the inter-rayon communal hospital corporation there will take place the change of allocated functions funding scheme. In which case the funds, allocated for the funding of reallocated functions, would be received by the local budget, which would be financing each hospital disregarding the reallocation of functions. Each of the member-hospitals would receive funds under the state contract for the provision of the full scope of services, including the necessary funding for the provision of services, which within the corporation are delegated to its other members. Each of the member-hospitals would be obliged to transfer to the account of the corporation the funds, assigned for the financing of reallocated functions. The corporation takes responsibility for organizing the financing of reallocated functions, directing the funds to the hospitals, which actually provide such functions. Funding the reallocated functions through the established corporation simplifies the process of financing.
     In case of the perspective transfer to the planning of financial resources and hospital activities payment on the basis of real value calculations for the provided services, the corporation would be able to amend the payment, basing on the actual volume of the services provided, thus making impossible either hidden subsidizing or overpayment for reallocated functions. As a result, the process of financing becomes less of a burden for the local authorities, as well as more transparent for the hospitals.
     The Project expert Sergey Dyachenko in his presentation “Economic-statistical analysis as the instrument for decision-making aimed at the improvement of the efficiency of resource usage and the quality of hospital care” recounted how the reallocation of funds is done between the departments of the health care facility and what the inner monitoring of the HCF is, as well as presented the model of “hospital okrug”. Mr. Dyachenko also defined the aim and objectives of economic-statistical analysis of HCF activities.