"Labirynt" TV program

The ‘Labirynt’ Public Political Talk-Show, Kharkiv Regional State Television and Radio Company

Aired on 26.08.2008

(excerpts from the text version)

TV program host: Olha Hryhorivna Kravchenko

In the Kharkiv region, the Memorandum on the Creation of an Inter-District Hospital Corporation has been signed – a groundbreaking experience for Ukraine. The pathways towards realizing this project within the framework of the secondary healthcare reform will be charted by healthcare professionals from Germany and from the Ukrainian cities of Kyiv and Kharkiv in the course of today’s program.

I welcome the guests in our studio and the TV viewers. As usual, we begin with some information for you.

Host assistant:

We welcome you to the ‘Labirynt’ program of the Kharkiv Regional State Television and Radio Company. You are welcome to join in today’s discussion. All you need to do is dial the studio number at 705 09 42. Callers from outside Kharkiv city should remember to dial the city area code 057 before the number. I will be accepting all calls in the course of the program. Please feel free to call us.

TV Host Olha Hryhorivna Kravchenko:

So, the Memorandum has confirmed the fact that the reform of the secondary healthcare sector is under way. So who was it signed by, and for what purpose? This may well be the first issue discussed in today’s program. I invite Mr. Halatsan to join the discussion.

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

Good afternoon TV viewers, good afternoon esteemed host, colleagues and program participants in the studio. Before I touch upon the memorandum issue directly, I should also mention that, as time and tide wait for no man, a new international project has been launched on the platform of our native Kharkiv region. One should also bear in mind that, in the course of summarizing and analyzing the annual results of the healthcare branch during the concluding meeting of MoH officials, major priorities in the healthcare branch for the year 2008 were outlined. Among these priorities, mention was made of support to the further development of the primary medical-sanitary sector, including family medicine, and the prospective development of the secondary sector, i.e. the secondary level of healthcare. Here we mean, firstly, the level of central district and city hospitals, as well as the rural districts of the region. Having presented its achievements and ideas in the studio before, this Project aims to foster the development and reforming of the secondary level of healthcare – that is, central district hospitals. Needless to say, development in this area is  only possible due to coordination and methodological framework, (managerial and regulatory) influence on behalf of the region’s chief healthcare facility, namely, the regional clinical hospital which, as a tertiary-level healthcare facility, is a provider of specialized medical care. With its professionals, the facilities and departments it has at its disposal, the hospital provides round-the-clock assistance to central district hospitals, district and city hospitals, and the city of Kharkiv itself, in solving highly complex healthcare issues, including emergencies. Furthermore, the healthcare system in the region, as well as in Ukraine as a whole, has been shaped in a way that produced certain inequalities of economic development possibilities among healthcare facilities. The network, its structure, peculiarities and differences have all been molded historically. Viewing things from an objective and realistic standpoint, we realize that there is no way that Valky and Zmiiv district, Derhachiv and Kharkiv district hospitals can be absolutely equal. If we go on to explain to the viewers what our vision of cooperation between healthcare professional in the Blyzniuky and Lozova district is, the starting point is that each of these districts has its own peculiar material grounding, healthcare network structure, managerial capacities in realizing the state policy, and human resources – and that in all these, they are not equal or uniform. It is a certainty for us (as well as for Project directors and experts) that we should strive to unite, coordinate, systematize and channel the efforts of healthcare workers in the Blyzniuky and Lozova districts into a certain gateway to help improve healthcare services and management, to learn to capitalize on the available financial, human, material, technical, transport and energy resources. The outcome, then, will be much better – and the final essential goal of this branch is to provide quality healthcare that is accessible for the general population, for the public, as well as for us, the Regional Council members, and the general public – the inhabitants of the region’s districts. Now I will give the floor to Volodymyr Myroslavovych Rudyi, Project national expert, to develop and build on the ideas that have just been voiced.

HOST: Of course, I support that, but I would really like more emphasis to be placed specifically on the corporation of hospitals. Mr. Rudyi, please give us your expert vision of this.

Volodymyr Myroslavovych Rudyi, national coordinator in healthcare policy and legislation, EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

Thank you. Indeed, in the end of June this year the first memorandum on the creation of a communal, non-commercial hospital corporation was signed between several administrative-territorial units of the Kharkiv region.

What was the reasoning behind this? We believe this to be one of the tools that will improve the quality of healthcare provided to the population of the Lozova and Blyzniuky districts, as well as Lozova town itself, which is a town of regional significance with its own healthcare budget and city hospital. The purpose of this is a smoother amalgamation of financial, material, technical and human resources, which will contribute to the solidarity of healthcare system financing, that is, to enhancing the financing per se, since the efforts of the three districts will be united in this way. The solution will also help the rational distribution of responsibility among the three hospitals for the sake of providing this or that type of medical service to the conglomerate’s population. At this stage, we do not yet know how exactly this will be happening – that will be for our partners to decide. One of the hospitals will undertake to provide services in obstetrics and gynecology, or assistance to parturient women. Another will restrict itself to surgical treatment of pathologies – the most complicated cases – yet another will be treating chronic cases and provide, as is the way of putting it, nurse care. That is, these services will be provided by those who can do it best, and most efficiently. On the one hand, this will generate savings. On the other hand, the money will be channeled into solving priority tasks. Apart from that, it is our plan and that of our partners to change to active strategic contract-based procurement of medical services by the state. This will facilitate the methods of payment motivating each physician, nurse and the staff as a whole, towards providing better services and utilizing resources more rationally. Therein lies the true essence of the strategy. We think of it as transitional state towards the introduction of hospital districts to Ukraine. These have long existed in Europe, incorporating powerful, amalgamated hospital units that can provide services to population conglomerates 100-200 thousand large. How come? Such large, powerful hospitals have more experienced personnel with practical skills. They deal with more surgeries, more deliveries, and as a result physicians are professionally fit and do not lose their qualifications. That is not normally the case in small hospitals. Unfortunately, in Ukraine we have a number of small facilities which cannot provide quality healthcare in the European sense of the term. On the whole, this is the first step we make towards a strategy of hospital districts.

HOST: Thank you for such in-depth coverage, everything seems to be clear now. Please explain why the Lozova and Blyzniuky district specifically were chosen, why did it have to be the healthcare facilities of these two specific districts?

Volodymyr Myroslavovych Rudyi, national coordinator in healthcare policy and legislation, EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

I should say, first of all it was our own expert suggestion we arrived at when we saw these administrative-territorial units are close to each other. The transport connection is adequate, meaning the quality of roads. These districts contain hospitals whose functions more or less duplicate each other. E.g. the town of Lozova has both a central district hospital and a city hospital. Yes, this is a city of regional significance, but out of about 6 or 7 such cities in the Kharkiv region, it is the only one where both such hospitals have been preserved. We suggest not closing one of the hospitals, but re-profiling it through an allocation of different functions to each of these two hospitals. That is, one of the Lozova hospitals will be responsible for this range of healthcare services, and the other will deliver services of a different profile, both extending services over the whole of the territorial conglomerate. Consequently, functions will no longer be duplicated, quality of healthcare will be raised as the same personnel is capable of delivering more services and utilizing resources more rationally. Politically this will be backed up by the decisions of the local authorities. After our negotiations, they consented to the experiment, which we hope will prove successful, and from protocols of intention we will move on to real action.

HOST: I understand. The curious thing is, are the healthcare facilities themselves ready for the implementation of the Project and for the creation of corporations? Ms. Polikova, Head of the Blyzniuky Central District Hospital is here now and about to join into the discussion – Mr. Halatsan, you wanted to add something?

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

Yes, Mr. Volodymyr Myroslavovych has my total support when he says that none of this - the implementation of the Project as such, the signing of the memorandum and its further implementation, much less creating this functional consortium to allocate functional tasks to specific units, or its successful operation, would have been possible if it wasn’t for the support and understanding of the local authorities. That is why I would like to use this opportunity to thank the Lozova state administration and the Lozova town mayor, as well as the top officials of the Bluzniuky district state administration for their understanding and for their support of the innovative developments we are about to introduce to the region’s healthcare system.

HOST: Could you please specify in which way they should contribute actively? Has some help already come your way?

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

The further unraveling of the Project can only take place with respective orders of the district state administrations, and with respective decisions of the Lozova city council, with adequate budgeting and the orders of the healthcare department of the Blyzniuky district state administration. Of course, we on the regional level also lend our support to the process. The legal acts we issue will be in support of the innovations. But of utmost importance is, primarily, the support and understanding of the local authorities.

Volodymyr Myroslavovych Rudyi, national coordinator in healthcare policy and legislation, EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

And it is not only the executive, but also the representative authorities: Olexandr Viktorovych has made mention of the Lozova city council, but the Blyzniuky district and village councils will pass their own decisions as well.

HOST: I see. Ms. Polikova, at long last you can contribute to our discussion. Please, as Head of your hospital, tell us about your facility. To what extent is its basis adequate for the creation of the hospital corporation, and to what extent you are ready to join in the effort? You are welcome.

Larysa Volodymyrivna Polikova, Head of the Blyzniuky Central District Hospital:

Good evening viewers and esteemed colleagues. The reforms in the Blyzniuky region have been under way since 2005. Now it 2008, we have behind us 2.5 years of experience in improving healthcare delivery. We have some preconditions for a union between legally independent hospitals. Lozova is 20 km away with a good transportation network. Year in, year out we cooperate with heads of both the city and the central district hospitals. In the past the Blyzniuky Central District Hospital has had to deal with two great disastrous events – an automobile and a railway accident. In both cases help from Lozova’s traumatological department reached us in about 15-20 minutes.

Blyzniuky central district hospital is a non-commercial communal enterprise with independent management and financing. Within this enterprise, I as Hospital Head have large competence in efficacious budget cost utilization. Transactions with Lozova hospitals, when they are communal enterprises, will be contract-based. Then we need not wait for any decisions of the local authorities – all issues will be solved by the hospital heads. In healthcare, this means timely and speedy delivery of quality healthcare.

The issue in human resources provision is also on the agenda. In central district hospitals, such as the ones in Lozova and Blyzniuky, we run into recurring problems every time there is need for specialized assistance. Sometimes a relevant specialist relocates, or reaches retirement age, and thus the district no longer can provide a certain type of healthcare. Educating a specialist takes time. However, in an inter-district hospital corporation, such issues can be promptly solved by hospital heads, whether it be ophthalmologic, urologic or traumatologic care. Everything is suited to the doctrine of speedy and timely delivery of services.

Volodymyr Myroslavovych Rudyi, national coordinator in healthcare policy and legislation, EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

Most of the healthcare-related issues for the three administrative divisions, including financing, will be solved within the corporation. It will be headed by a respective body or authority and a board of directors with all the hospital heads as members. All this will truly be solved within the corporation without any procrastination related to solving issues in district councils or district administration, which is the case now. The route will be much shorter, and more efficient. But above all, we will have a redistribution of responsibility. Perhaps the Blyzniuky district will provide a specific type of service to all, and Lozova district or city hospital will also provide the services to all. These will be financed from the specialized funds of the corporation, created particularly to implement common functions and goals.

HOST: Fine. Now I would like to have some feedback from you, Mr. Berezka. There have been so many references to you as Head of the regional clinical hospital. How would you define the merits and flaws of such hospital corporations? How essential are they really, and what do you see as their essence? You are welcome.

Mykola Ivanovych Berezka, Head of the Kharkiv Regional Clinical Hospital:

Thank you for asking. Good evening, all viewers.

Neither the population, nor we doctors are satisfied with the level of healthcare we see in Ukraine today. The current approaches need to be developed together. It is very good to see both MoH professionals and our European colleagues participate in the experiment. They can share their experience and knowledge, and we will use the cumulative proposals and experience they have to select the options that suit us, the Kharkiv region. We will select the best, the most essential, and in view of these proposals we will solve the issues in healthcare delivery in our region.

HOST: Thank you. I think this is high time to have an international expert join this exchange. From the standpoint of international experience, which advantages does the Kharkiv region already have?

Bela Kaunzinger, international expert in healthcare financing of the EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

Thank you. Good evening, ladies and gentlemen. The Ukrainian regional healthcare network today is faced by unique challenges. The issue of lack of young specialists in district hospitals is familiar to us all. However, despite the lame financing (the budget covers only about 50% of all hospital expenditures), hospitals most continue to provide medical services to the population.

We need to react to that by creating new managerial structures that will foster official cooperation and a new allocation of tasks between districts and the city authorities. The inter-hospital cooperation model will redetermine the role of each individual participating hospital. Consequently, the limited resources will be distributed in a more efficacious manner, as will be hospital department profiles and specialized healthcare services, i.e. obstetrics, planned surgeries, specialized diagnostics. The more medical services are concentrated in one place, the more surgeries can be carried out, which lends quality and efficiency to hospital care. Multiple research in European countries has proven that fact. Let me also say that even now, Blyzniuky and Lozova districts, as well as the town of Lozova, are making a significant contribution into further healthcare development in Ukraine.

HOST: I see. Experience is another issue we can touch upon today, Mr. Havva, please join us here. As Head of the Zolochiv District Hospital, please inform us of the current situation in your facility.

Oleksij Volodymyrovych Havva, Head of the Zolochiv Central District Hospital:

Good evening, esteemed viewers and guests. You all know that Zolochiv has come a long and tough way from a budget establishment to a communal enterprise. Here I would like to stress the invaluable help that EU Projects have been providing in the reforming. In my view, further reforming of healthcare cannot take place unless budgetary establishments are converted into communal enterprises, which is best adapted to market conditions. No other unit can function as effectively. In this sense I would like to thank the EU Project for the priceless help and guidance. It involved yearlong, meticulous effort, and the results are already being harvested in the Zolochiv region. Zolochiv Central District Hospital is ready for any changes in the healthcare system of Ukraine.

HOST: Thank you for sharing your thoughts and the information with us. Let us now hear what questions have been put forward. Please, Ira.

Host assistant: Welcome once again, viewers of the ‘Labyrint’ program. I greet you all, and our guests. So, here is the list of questions we have now:

1. Where did the idea of an international hospital corporation come from, and are other hospitals going to follow the initiative?
2. Do you think the corporation will go a certain way towards combating corruption, or will it, conversely, favor it?
3. Does the creation of a corporation mean that the region will have fewer problems with medical equipment?
4. Who is financing this experiment?
5. Are you familiar with prior experience of such corporations, and if you are, where have they been practiced?
6. The memorandum has been signed, when will the corporation be created in reality?
7. Will there be changes in the hospital personnel, or will it remain the same?
8. What are the major issues with the creation of the corporation?

Thank you very much, viewers.

HOST: We thank you viewers once again, and are ready to answer. Please, Mr. Rudyi.

Volodymyr Myroslavovych Rudyi, national coordinator in healthcare policy and legislation, EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

This Project is financed by the European Commission within the framework of the TACIS technical assistance program. How did we arrive at the idea of such a corporation? Firstly, it is based on the evaluation of the international European experience we have today. Why? At the start of this program I believe I mentioned that creating large, powerful hospital unions that both provide a better quality of healthcare and use resources more efficiently, is long regarded as pertinent in Europe. To a certain extent, it takes away the unnecessary duplication of certain expenditures and services. As a result, we save costs that may be used for solving the real priority tasks. This experience prevails everywhere in Europe. The approach may be fit into various models. At the beginning I already mentioned the prevalent practice of hospital districts in Europe. It is – I emphasize this – a model of interdistrict, not international corporations, or, even more precisely, of interterritorial medical – hospital – corporations. We arrived at the idea after analyzing the Commercial Code of Ukraine, which defines perfectly legal ways of starting such economic unions of healthcare enterprises. This is, in a nutshell, an answer to some of the questions.

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

To carry on with the questions at hand: in general, viewers appear to be genuinely interested in the information that was voiced here in this studio. Let me also draw your attention to the fact that Oleksij Mykolajovych Havva, Head of the Zolochiv Central District Hospital, which is, by the way, a non-commercial communal enterprise, has a point. Everything must begin with a change of status: a budgetary healthcare establishment must be converted into a non-commercial, not-for-profit enterprise. And then it is the board of directors, the top-manager, the head, the director, or president – however one calls the person – is authorized to solve the current and strategic items in the enterprise’s functioning and development. At a later stage, this will entitle him to solving the question of, say, entering any union, or consortium, or any other type of union with like functions. I believe that he may enter the union, and in some time he may leave it if the local community is not satisfied with the results. This is an extremely interesting experience. I believe that it does not merely deserve a chance – it will spread like wildfire both in our region and across all of Ukraine. Here is the crucial question to us as managers: “Is this the next step, so to say, in the ongoing march of corruption, or will it help fight it?” I say that any economic form of enterprise can be controlled and checked, provided it has proper, stable management. A variety of controlling structures with widely different functions are designated for this. There is the system of auditing an internal supervision. Mr. Bela Kaunzinger here is economics expert of the Project, if we had more time he could tell you how it is done in Europe. But in my view, this union – an interdistrict union once again – will provide not only for some transparency of medical services and financial resources provision. It is going to raise the quality and accessibility of healthcare, which is, as I have said before, our final goal.

Volodymyr Myroslavovych Rudyi, national coordinator in healthcare policy and legislation, EU Project ‘Support to Secondary Healthcare Reform in Ukraine’:

I also wanted to touch upon the question of corruption that has just been asked. On the contrary, this form of commercial activity in hospitals will favor transparency. Why? The hospitals themselves will have a vested interest in this transparency. All the costs saved by more efficient management will go into increasing salaries for personnel, into purchasing new equipment and solving other pertinent tasks. The next important thing is, Olexandr Viktorovych here has touched upon the need in changing hospital legal status. Oleksij Volodymyrovych and Larysa Volodymyrivna can support this as well, since all hospitals with communal enterprise status are supervised by the public council that represents the district’s population. A number of decisions can’t be made by hospital head or director, unless respective decisions and conclusions are made by this steering council – if the process is not transparent and the community sees the money is going in the wrong direction, it simply can’t be done.

HOST: I see. More questions from viewers: will there be changes in hospital staffing, or will everything remain as it is?

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

Of course, this is an evolving system, so we can’t progress without any changes. The union is being created even now. This is a new system for our healthcare network. Hospital heads and personnel will be expected to do more than just receive them, but also to introduce alterations into internal structure, into the management of both commercial and non-commercial enterprises and their unions. So yes, I can see some changes in the personnel, but the issue of human resources deficit remains topical as well, as Larysa Volodymyrivna said earlier. I am sure that we are not dealing with prospects of layoffs, to be certain. Meant here is human resources redistribution for the sake of more efficient management. Another question that Volodymyr Myroslavovych has approached without answering it yet as he dealt with the previous question: Will we have more medical equipment? Esteemed viewers and colleagues, these new approaches that create new economic conditions by converting budget establishments into communal enterprises really will help save financial resources. And I am positive about the fact that, in a while, we will be sitting here in this studio discussing strategic investment plans. We will be raising issues of renewing the technical basis, equipment and medical technology; introducing new approaches and developments bringing our healthcare system closer to the best of its foreign counterparts. This is not fantasy but reality, and in this we hope for support on behalf of the whole community, for understanding on all levels and in all branches of authority, including deputies. But above all, we need the support of our colleagues in this studio, and the ones that run healthcare facilities in different districts and cities, whatever be their age, level, an qualifications. The goals that we have set can only be achieved as a result of teamwork.

HOST: Thank you. And now for the last question voiced by the viewers – I think it could be the subject of a separate issue of our program. Which major hurdles does the corporation encounter? Please mind that we have about one minute until the program is over. If we run out of time, we will devote the next issue to this.

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

Yes, it would be good to save it until the next program. By that time we will have the experience to discuss the issues that, no doubt, we will run against.

HOST: And yet one more question. Are other regions ready to join in the hospital corporation initiative?

Olexandr Viktorovych Halatsan, Head of the Kharkiv Regional State Administration’s Main Healthcare Department:

During MoH meetings, I have spoken to colleagues, to principals, to heads of healthcare departments and other local authorities from the regions of Ukraine. They are very pleased to see our region break new ground here, and they envy us good-naturedly because of the opportunity we have for introducing and implementing such novel management technologies. I am positive that the outcomes we have will be made use of in other parts of Ukraine. As for other districts – I am sure that the authorities there can hear us now and they support us totally.

HOST: Thank you very much for joining us today. Now our program has come to an end. However, reforming in the secondary healthcare branch is already under way. The first steps have already been made. What will the results be? We will keep you tuned to that in the following issues. Goodbye for now – until Tuesday!