Project held its MiddleTerm National Conference

6-7 November 2008 the Project held its Middle Term National Conference reviewing the progress and results of the Project’s work in the pilot regions and on the national level at its midway point.The event was held to present and review activities of the project in partnership with the Ministry of Health and other Project partners in pilot regions with regard to the main goal of the Project – support to the establishment of an efficient, cost-effective and equitable healthcare system in Ukraine.  

 

Among the participants of the event were: the Deputy Minister of Health Mr. Vasyl Lazoryshynets, the Director of the Healthcare organization department of the MoH Ms. Myroslava Zhdanova, the Deputy Director of the HR, education and science department Mr. Olexandr Volosovets, the Head of the State regulation of the social insurance and interaction with the medical insurance market players department Ms. Lyudmyla Pidgorna, the coordinator of the social sector projects of the European Commission's Delegation to Ukraine Mr. Sergiy Polyuk, the Project Director Oxana Abovskaya, the consortium representative from NICO Fiona Coyle, and from ECORYS Arthur ten Have, the Head of the international activity and European integration department Ms. Zhanna Tsenilova, the representatives of pilot oblast healthcare departments of the Project: Mr. Victor Lysak, Mrs. Alla Bredikhina, Mrs. Valentyna Gryshchuk, the representatives of higher medical post-graduate education institutions: Mrs. Nina Goyda, Mr. Yuriy Voronenko, Mrs. Larisa Babintseva, Mrs. Valeriya Lekhan, as well as representatives from Kharkiv and Zaporizhzhya medical academies of postgraduate education, the representatives from: the National Academy of Public Administration under the Office of the President of Ukraine Mr. Ivan Solonenko, the Institute of Strategic Research of the MoH Mr. Gennadiy Slabkyi and Mrs. Maryna Shevchenko, Deputy head of section for projects development and implementation of the Ministry of Finance, Tetyana V. Kostyniuk, the Chief Doctors of central, rayon and city hospitals involved in the implementation of the Project, international and Ukrainian experts of the Project, journalists from central and regional mass media.

Mrs. Myroslava Zhdanova addressed the audience with the opening speech, in which she pointed out that healthcare reforms are a long-term and dynamic process aimed at the reorientation of the healthcare system from the needs of the HC facilities to the needs of the patients. Secondary healthcare remains mainly unaffected by the reform process and still consumes inadequately large part of the state budget allocated to healthcare and retention of staff. Due to the scarcity of state resources there is a problem of balancing the constitutional guarantees of providing the population with medical services and the economic capability of the state. Hence the process of secondary healthcare reform acquires significant importance.

Mr. Sergiy Polyuk, the coordinator of the social sector projects of the European Commission's Delegation to Ukraine, welcomed the conference participants and stated that social sector and healthcare are the priority areas of provision of aid by the European Commission in its intent to build a society which could easily integrate into the European community. Thus the action plan approved by both the European Commission and Ukraine covers such collaboration in the healthcare sector. Due to this reason the European Commission funded this Project, providing consulting support to the government of Ukraine, viz. to the Ministry of Health with the intent of developing an effective model embracing the best European experience. He also expressed his hope that the Conference will provide the possibility to summarize the achievements of the Project’s activity in the regions and elaborate further recommendations on healthcare reform for the MoH.

The Project Director Ms. Oxana Abovskaya stressed that one of the aims of the Conference was to introduce the main healthcare management trends in different countries of the EU to the participants and explain how these trends were reflected in the recommendations of the Project.

The reforms of healthcare systems take place within a certain social-economic environment and affect the interests of not only the professionals but of the wider sections of society which have established notions of what social guarantees on medical services should be provided by the state. Hence it is important to take into consideration the perception of the Project’s recommendations by different social groups.

Nowadays in Ukraine there is a tendency to delegate social care services to secondary healthcare medical facilities. This results in engaging highly qualified personnel and infrastructure in providing non-medical, non-therapeutic services in medical facilities. At the same time, in Ukraine, as all over the world, there is a trend for increase in costs of medical technology due to the rising costs of medical equipment and communal services. In the late 1980’s almost all countries of the European community moved away from the policy of administering the system of medical services provision in favour of more autonomy of the medical facilities, endowing the latter with the ability to independently decide the issues of equipment acquisition, defining necessary medical staffing levels, as well as the right to sign agreements with communal services providers. Local self-governing authorities have received the right to determine the quantity and location of medical facilities for the population to receive timely and quality medical services. All that has improved the quality of medical services, as all medical facilities are functioning within the legal framework established by the state, which established strict control over the quality of services, as well as over the usage of financial and other resources. Solutions proposed by the Project for the existing problems of the medical services provision system are based on the knowledge and experience of both the Project experts and the consortium implementing the Project.

The presentation by the Head of the Connecting and Coordinating department of the Federal Ministry of Health of Germany Mr. Boris Velter «Some facts about the German healthcare system» was concerned with the characteristics of the German healthcare system. In particular, Mr. Velter has analyzed German state system of medical insurance in detail. He described the distribution of functions between the provider and the purchaser of the services, as well as the role of the state in the health insurance system. According to Mr. Velter the state prescribes the rules for the players to follow (regulatory and legal framework), intervenes when broader interests or economy and society might be neglected, supervises main actors (limited to the question of legality), and distributes power between federal and state authorities. In Germany there are two options of insurance: state and private, which cover the whole population of the country. Features are: 10% of the citizens have private medical insurance, the patient has the right to choose the doctor, the system of unofficial payments to the doctors doesn’t exist, there are 200 different funds of medical insurance that work under the supervision of the Ministry of Health, patients sign the agreements with the insurance funds.

The current healthcare system of Germany evolved over many decades. In 2003 and during the period of 2006/2007, Germany achieved healthcare reform which consisted of four elements:
Structural reform, organisational reform, funding reform and the reform of private health insurance.

The Team Leader of the Project Dr. Greta Ross informed the audience about the objectives and directions of activities of the Project. She presented the Project’s main achievements over the last 14 months and explained the approaches elaborated by the Project for developing the strategy of secondary healthcare reform.

In particular Dr. Ross spoke about the main directions of activities in the pilot oblasts:

Poltava: master planning at oblast level with facility reprofiling and SHC ‘okrug’ development initiatives.
Zhitomir: support by project to redistribution of specific services across oblast as part of Zhitomir’s master planning for hospital networking and service reconfiguration
Kharkiv: developing a model of rayon level restructuring of service provision and initiation of inter-territorial hospital economic union
The project also promoted the idea of forming regional (and later national) hospital federations.

Dr. Ross listed the major factors that are necessary for the successful achievement of secondary healthcare reform:
• Political will at government level – longterm sustainable strategic plan irrespective of changes in leaderships
• Political will at regional level – willingness of stakeholders to work together towards same end and solve obstacles
• Political will at local level – willingness of hospital staff and professionals to work differently, and to give up certain custom and practices; willingness of local councils to review local systems and spheres of influence
• Political will at professional levels: new mechanisms and incentives to raise quality of care, training and ethics
• Legal and financial facilitation, investment in health.

The representatives of the pilot regions – Mr. Victor Lysak, Head of Poltava Oblast Healthcare Department and Mrs. Valentyna Gryshchuk, the Head of HR and work organizing department of the Healthcare Department of the Zhytomyr Oblast State Administration, and Mrs Larisa Poliukova, Chief Doctor of Blizniuki rayon hospital in Kharkiv –reported on the progress of the reform in the mentioned oblasts and informed the audience about the activities that took place in the oblast with Project’s support. Mr. Lysak explained how Poltava oblast uses the experience of Italy in restructuring medical facilities, in particular the experience of expert evaluation of the performance of medical facilities, gained during the study tour organised within the framework of the Project implementation. Ms. Valentyna Gryshchuk reported that, within the framework of the Project activities in the oblast, a master plan was elaborated , which would allow the oblast to plan the network of medical facilities in the oblast more effectively.

 


The Chief Doctor of Zolochiv Central Rayon Hospital (Kharkiv oblast) Mr. Olexiy Gavva gave an account of the work of the first in Ukraine communal non-profit enterprise «Zolochiv Central Rayon Hospital», which was created with the support of the EU project «Financing and Management in Healthcare» and has been functioning for 4 years already. In this period of time the enterprise established the interaction with tax and finance authorities. The enterprise works within the framework of the global budget. All outpatient departments and feldsher-midwife stations have been included into the new enterprise, which enabled the centralisation of medical facilities’ management. Mr. Gavva also said that such mode of work found support with the medical community and proved to be effective. Further planned activities include the creation of inter-rayon hospital corporation with the Dergachiv CRH.

The Project expert in HR&Organizational development Mr. Vasyl Y. Ananiev delivered a presentation «HR development within the context of EU Project propositions regarding the reform of secondary healthcare in Ukraine». He spoke of the main approaches, being taken by the Project regarding the HR development strategy on both micro and macro levels. On the macro level the Project, together with the MoH, develops the national HR development strategy in healthcare. Based on this, and on the Project outcomes in the pilot oblasts (in particular, the establishment of inter-rayon hospital corporation), the regional development strategies will be elaborated.

Mr. Ananiev said the introduction of changes in healthcare system and the implementation of new models will require new approaches to education. In particular, he said that the increase in autonomy of healthcare facilities is giving management new functions and responsibilities. The Project is working on new qualification characteristics for specialists in healthcare organisation and management (job description), , as well as assisting the design of new curricula on the basis of this qualification. The project also is supporting capacity building for the introduction of the new curriculum by the postgraduate faculties. The Project is supporting the development of the set of study modules for the training of health service managers.

Mr. Genndiy Slabkyi, the Director of Ukrainian Institute of Strategic Research of the MoH, presented on the HR provision for healthcare in Ukraine. In his opinion, the improvement of public medical services quality is a complex problem and rational HR policy is one of the components of this problem’s solution. Mr. Slabkyi named the main reasons why managers of healthcare facilities are not ready for reform, defined through research conducted by the Ukrainian institute of strategic research of the MoH of Ukraine:
• Absence of training in economic issues– 57,2%
• Absence of training in legal issues – 59,4%
• Absence of information on the reforms – 48,3%
• Incondite legal framework – 61,5%
• Absence of the protection mechanisms of professional activities – 74,8%

According to Mr. Slabkyi at present in Ukraine we can see a lack of qualified HR provision for healthcare. The quantity and quality of the HR entering the system is falling and at the same time the size of HR leaving the healthcare system is growing. There is a whole set of factors which influence the changes in healthcare and raise the demands on the system.

The presentations by Prof. George Harmat, member of the Presidential Committee of the European Federation of Hospitals (HOPE), «Hungarian experience in the European Hospital and Healthcare Federation», "Hospital federations: benefits of links with HOPE"  introduced the work of HOPE in Hungary to the conference participants. HOPE is the non-governmental European hospital association, which was founded in 1966, and since 1995 is an international non-profit association. There are 27 member-associations in HOPE.

The Hungarian Hospital Association was founded in 1931. Hungary became a member of HOPE in 1992 and is very active in this organisation. Main priorities of HOPE are:
• Cross border patient movement
• Patient Safety
• Pharmaco-economy
• Human resources
• Quality care of Cancer Patients
• Waiting lists, introducing DRG-system
• Social inequalities in the Healthcare
• IT in Healthcare etc.

The international expert of the Project in HR& organisational development Ms. Elena Novichkova in her presentation «Quality management system: Project support to implementation process» reflected the point of view of the Project on the problem of quality within medical services. She noted that in the past few years the interest in this issue has grown. This is explained by both the growth of public demand for quality medical services and by the need of medical professionals themselves to provide quality medical care. The development of evidence-based medicine has considerably influenced the development procedure of standards, clinical protocols, clinical guidelines. There are many quality accreditation systems, three of which are more widely applied:
• European Fund of Quality Management (EFQM)
• International Society for Quality in Health Care Inc. (ISQua)
• ISO 9001 International Standardization Organization

Ms. Novichkova then referred to the current state of medical services quality in Ukraine. The centralised system of quality management has stayed intact from the times of the Soviet Union, and evaluation of the quality of medical services is carried out in retrospect. This system calls for changes. The Project is working on recommendations for the improvement of quality in secondary healthcare facilities. Through the project the MoH and QIS of Scotland have signed a Memorandum of Cooperation. On the national level therefore the Project has offered the MoH support with work on developing approaches for QMS in SHC, including:
- Recommendations for revision of accreditation needs of healthcare facilities
- Specifications concerning oblast and rayon hospitals
- Support to drafting national medical standards and local protocols
- Methodology for healthcare technology assessment
- Professional training

On the regional level, the project is providing training for hospital personnel, and recommendations on implementation of quality management system elements in pilot hospitals

The discussion of medical services quality issues was carried on by Dr. Stefan Dornheim, Chief Executive, EPOS Health Consultants (Germany), in his presentation «The Need To Improve Quality in Healthcare». He pointed out that medicine has a longer tradition in quality than industry or other sectors of our society. In 1997 the Health Committee of the Council of Europe recommended that governments of member states should “create policies and structures, where appropriate, that support the development and implementation of quality improvement systems, ie systems for continuously assuring and improving the quality of health care at all levels”

 

Mr. Bela Kaunzinger, international expert in health finance, gave a presentation «Regional strategic hospital development plans as step forward to improve secondary health care in Ukraine». In Ukraine there is an excessive number of hospitals which do not match the needs of the population, excessive (normative-driven) numbers of specialized beds and hospitals irrespective of actual need and little functional differentiation between hospitals for different levels of care (e.g. some general hospitals functioning as social care institutions or providing Primary Health Care services; some oblast hospitals offering tertiary as well as secondary level care, for relatively small catchment populations). Parallel systems of inpatient care (departmental, governmental) are still intact and also a high admission rate at specialized hospitals is present. Too long periods of hospital stay (ALOS) in comparison with EU countries were also highlighted.

Mr. Kaunzinger presented the project’s regional strategic hospital development plan. The strategic plan covers:
• Reorganization of hospital as economic and autonomous providers that are responsible for the delivery of well performed secondary health care according to the demand of its population within reconfigured catchment areas.
• Specialization and co-operation or merging between individual hospitals using new types of task-sharing methods between individual hospitals or within inter-territorial hospital unions (obstetric/neonatology centers, specialized surgery centers, etc).
• Restructuring of hospital wards for long term care or social care or ambulatory care
• Increase of home-based and day bed inpatient facilities as alternatives to hospital inpatient care
The expert has also noted that hospital planning will always reflect the current political shape of a country and its ability to make clear and necessary decisions.

Mr. Christian Bonhomme, project international expert in health financing/management and hospital management, gave the characteristics of the current state of the medical facilities in Ukraine and spoke about the ways of achieving the reform of secondary healthcare in the pilot oblasts (Zhytomyr, Poltava, Kharkiv). The Project has begun working with accountants, economists, hospital directors or deputies in particular health facilities in Poltava and Kharkiv
• to reconcile existing line-budget with full chart of accounts & with EU standards
• to build up a simulated 2009 budget based on this new system
• to design and propose financial reporting tools and accounts
The Project experts also work with oblast/rayon health authorities in order to ensure the understanding and checking of the top-down allocation of budget and its breakdown, as well as evaluation of the existing assets as per bookkeeping recordings in view of amortizing them and developing an investment plan.

Mr. Sergiy Dyachenko, project expert in information technology and economic-statistical analysis, spoke on the main objectives of the information technologies in secondary healthcare and presented the economic-statistical analysis of the work of a sample of medical and prophylactic institutions in the pilots.

Mr. Dyachenko said that information technologies, as an important instrument of healthcare reform support, provide the institution’s manager and the purchaser (of services) with a management instrument for transferring to the global budget and other result-oriented methods; for analyzing the quality of medical services; and for carrying out the transparent analysis of resource placement efficiency.

He also determined main pre-requisites for best utilization of hospital information systems:
• change in chief doctor’s thinking from being a ‘director’ to being a ‘manager’
• HR capacity building
• training for software users
• implementation of complex systems

The presentation of national health policy and legal coordinator Dr. Volodymyr Rudiy «Establishment of inter-territorial communal hospital economic unions as a possible tool for reforming of secondary healthcare, facility management on the hospital level and general hospital network planning» was a summary of the Project recommendations regarding the changes necessary for further achievement of the secondary healthcare reform. There are three key decisions needed to start the reform in Ukrainian hospitals: expansion of hospital autonomy, implementation of public contracts for healthcare service procurements at hospitals and implementation of new approaches in hospital network planning.

Dr. Rudiy pointed out that at the moment there are a number of obstacles in Ukraine that hamper the decision making process in changing the legal status of hospitals and implementation of the model of “hospital okrugs”:
• Obviously, current legislation is not pushing local authorities to making relevant decisions (as a result, we observe so called “waiting policy”)
• Leaders and decision-makers on the national and local level are not well informed of European experience and possible positive results of its application
• There exists insufficient understanding among local leaders, as well as the population, of the ineffectiveness for keeping oversized general hospitals and the negative effect of this on the quality of services provided
• Fear of making decisions aimed at reducing the number of hospitals, which may appear unpopular for the majority of local administrations and population
• Fear of being accused of contravening the Constitution of Ukraine, which forbids reducing the number of state and communal health facilities
• Management and medical hospital staff may turn into opponents of the reform and provoke opposition among local population without clear understanding of the ‘hospital districts’ strategy because of fear of losing their positions or jobs

Ms. Anna Nechai, project legal expert, gave the presentation «Establishing Hospital Corporation: Legal Issues», in which she specified the steps to take and decisions to make which are necessary for the establishment of the hospital corporation:
• Approval of the corresponding decisions by local councils (hospital owners);
• Legal registration of the corporation in compliance with the legislation requirements;
• Elaboration of the regulatory framework for the corporation.
Current legislation of Ukraine allows the establishment of the public corporations with hospitals as members (Commercial Code of Ukraine – hereinafter CC).

Local councils would need to take decisions :
• on the change of the legal status of the hospitals: changing them into public non-profit enterprises (art. 24, 52, 78 of the CC);
• on the establishment of the corporation and approval of the Charter of the corporation by each local council separately (art. 70, 118, 119, 120 of the CC);
• on endowing the Boards of the hospitals with the right to execute actions concerning the legal registration and functioning of the corporation;
• on the electing of the managing bodies of the corporation and the representatives of each local council in the managing bodies of the corporation (Managing Board, Executive director) – in accordance with the Charter of the corporation;
• on endowing the Boards of the hospitals with the right to sign the agreements with the corporation concerning the issues stipulated by the Charter of the corporation, including the funding of distributed functions.

During the two-day course of the conference, very active exchanges of ideas took place regarding the ways forward for solving the existing problems of healthcare: the quality of medical services, HR provision of the health sector, reorganisation of medical facilities, introduction of modern information technologies.

The conference participants noted the time-relevance of the event in view of further planning of the healthcare reform implementation. «The work carried out by the EU Project for the support of secondary healthcare reform is extremely important. The healthcare change scenarios presented by the Project during this conference are very interesting, especially the establishment of communal hospital corporations. It is new to Ukraine. In my opinion, this issue calls for further, wider discussion», - said Mrs. Valeriya Lekhan, professor of Dnipropetrovsk Medical Academy.

Mrs. Zhdanova outlined the MoH's plan for reform on both PHC and SHC levels, and supported the direction the project was taking.