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oblast, 2019 and 2021
FIGURE 1.5
Number of pharmacies participating in the AMP per 100,000 people, by oblast, 2019 and 2021
35
Number of pharmacies participating in the AMP per 100,000 people 30
25
20
15
10
5 30
28 28 27 27 26
25 25 24 24 24 22 222222 22 21 21 21 20 20 19 19 18 17
0 Khmel ‘nyts’ka’Zhytomyrs’ka’Kharkivs’ka’Misto KyivL’vivs’ka’Kyivs’ka’Rivnens’ka’ Ivano-frankivs’ka’Dnipropetrovs’ka’Poltavs’ka’Ternopil’s’ka’Chernivets’ka’Odes’ka’Volyns’ka’Vinnyts’ka’ Kirovohrads’ka’Luhans’ka’Chernihivs’ka’Sums’ka’Mykolaivs’ka’Khersons’ka’Cherkas’ka’Zaporiz’ka’Zakarpats’ka’Donets’ka’ 2019 Q1 2021 Q1
Source: Data from the National Health Service of Ukraine. Note: AMP = Affordable Medicines Program; Q1 = first quarter.
The PMG for specialized outpatient, prehospital emergency, and hospital inpatient care was introduced at a point when the health care system was still highly hospital-centric. Despite a reduction in hospitalization rates since the hospital right-sizing initiatives of 2015, which brought hospitalization rates for curative care in Ukraine to levels similar to those in its EU13 neighbors, the average length of stay (ALOS) remains substantially higher for Ukraine (10.3 days) than its neighbors (6.6 days).10 Ukraine also maintains a segregated system of general and disease-specific hospitals, which treat many patients who could potentially be treated on an outpatient basis. For example, 4.1 percent of hospital beds in Ukraine are used to treat TB patients, with an ALOS of 85.6 days in 2019, and a large network of psychiatric hospitals accounts for 11.4 percent of all hospital beds.
Specialized outpatient care is delivered by outpatient units in hospitals, clinical-diagnostic centers (reformed former polyclinics), specialized monoprofile outpatient clinics, and private solo practices. There is not yet sufficient coordination between PHC and specialized outpatient care or adequately comprehensive attempts to shift ambulatory-sensitive conditions out of the hospital setting, although some progress has been made on mental health. The new e-referral system provides an opportunity to analyze the flow of different types of referrals and improve the right-sizing of care.
In early 2020, the government approved a list of 212 “hub hospitals” to constitute the network of providers—the “Capable Network”—to be developed in the future. The move represents an important step toward a more rational and efficient approach to investment in the hospital sector, but care needs to be taken to ensure that the list of hospitals is optimal. Still lacking is an approved formal strategy that lays out the vision for an integrated model of service delivery across
all types of care, potentially building on the (draft) White Paper on Health Service Delivery Model in Ukraine.
Specialized care services within the PMG are divided into service packages, each contracted separately with providers. As of 2020, there were 29 specialized care packages. They include four COVID-19 packages for testing by mobile brigades, prehospital emergency care, hospitalization, and a COVID–related salary top-up, which were added in response to the pandemic. Sixteen packages relate to medical conditions, such as acute stroke, childbirth, mental health, TB, HIV, and COVID-19; they cover a comprehensive set of services to treat them. Nine packages are defined as service inputs (colonoscopy, hemodialysis, radiotherapy), which can be used to treat a variety of conditions. Four packages are broadly defined by the provider setting—inpatient surgical, inpatient nonsurgical, outpatient, and emergency care—to cover all care that does not fall into the other groups. All specialized care packages in the PMG except outpatient care explicitly cover medicines. In practice, many medicines are purchased out-of-pocket by inpatients. In 2020, a new referral requirement was adopted, to improve the integration of specialized care and primary care within the PMG. In order to receive specialized treatment free of charge, the patient requires an electronic referral from a primary care or other specialized care provider. Contracting is optional; providers can pick and choose which packages to apply. This system exacerbates existing inefficiencies, as providers apply only for packages that are most economically attractive. It also contributes to geographic inequities in access to care.
To be contracted by the NHSU, providers must meet a range of service delivery requirements. They include universal requirements, including those related to legal status, licensing, and e-health functionalities; package-specific requirements, related to facility characteristics, medical personnel, and equipment; and additional relevant licenses (for nuclear medicine or narcotics, for example). Services provided outside the contracted packages are not necessarily reported. Contracted facilities are required to be legally autonomous from the state, to create a purchaser/provider split, and to remove potential conflicts of interest. As part of the reform, hospitals may also open bank accounts at commercial banks rather than the Treasury. This new autonomy requires new governance and accountability arrangements, and new regulations are needed to strengthen it. Between April and December 2020, the NHSU contracted and made payments to 1,681 specialized providers, including 59 private facilities and 25 oblast-level emergency medical care centers for its specialized care packages.
In 2020, most of the specialized care in the PMG—81 percent of specialized care and 67 percent of the total PMG budget—was purchased using global budgets. These purchases included all emergency care, all surgical care, all nonsurgical hospital care not paid for using DRG–based payments, and select procedures that are by fee-for-service (figure 1.6). For each PMG package contracted on a global budget, the NHSU has defined a “base rate” per service unit, which is adjusted to account for variation in service costs. For example, the outpatient base rate is multiplied by 9.713 for surgical procedures and 0.186 for a dental care intervention and then multiplied by the number services that the contractor provided the previous year to obtain the global budget paid to each contracted facility. A global budget is also used for the new COVID-19 packages, because of the lack of predictability of case numbers.
