July 28, 2017

Patients lose in battle over health care in Ukraine


Health Ministry of Ukraine

Dr. Ulana Suprun in her grandmother’s embroidered blouse that she wore when she was appointed as Ukraine’s acting minister of health on August 1, 2016.

KYIV – Ulana Suprun wore the blouse in which her grandmother got married at the age of 17 before having to flee Ukraine during World War II when she was appointed as first deputy health minister of Ukraine on July 22, 2016.

The Detroit-area native and U.S.-trained radiologist took a selfie dressed in that blouse with Prime Minister Volodymyr Groysman upon her appointment. She wore it again when she got appointed as acting minister of health on August 1, 2016, and again during Parliament’s first session in September of that year after summer break.

“It was a proud moment that look, ‘your grandmother left Ukraine and now her granddaughter came back’ …and she came back as first deputy minister,” Dr. Suprun told The Ukrainian Weekly in her office on July 18.

Now acting health minister for nearly a year, the Ukrainian American has been accused of trying to commit “genocide” against the Ukrainian nation for her vision of overhauling a failing health care system that the Group of Seven industrialized democracies, the World Health Organization (WHO) and the World Bank have backed.

Furthermore, her ministry has, over the course of a year, faced corruption probes – based on allegations from lawmakers opposed to her plans, including from the pro-presidential factions – by the Prosecutor General’s Office, the Security Service of Ukraine and Parliament’s Audit Chamber.

A third, unprecedented parliamentary audit was under way when The Ukrainian Weekly interviewed the acting minister this month. It took place when key members of the Verkhovna Rada derailed a vote for her bill to improve a system that sees Ukrainians die 10 years earlier than their European Union peers, according to World Bank data.

Stiff resistance by vested interests has thwarted Dr. Surprun’s hopes of changing how health is financed. The Soviet-era approach still allocates funds based on the number of beds and hospital infrastructure instead of the number of patients treated. The country’s Ministry of Health, according to experts at the civil society groups Center.ua and the Reanimation Package of Reforms, has not been reformed since independence was re-established in 1991.

Dr. Suprun, who moved to Ukraine in 2013, soon discovered the pushback to change when she first addressed Parliament during a weekly government question-and-answer session on September 9, 2016.

“I walked into Parliament for the first time as acting minister. This is cool, you know, we’re going to work with our buddies in the legislature… and it was basically an onslaught of questions and insults and screaming from Parliament,” Dr. Suprun recalled. “I was a little taken aback by this. Because it was the opening session by Parliament. They first sang the national anthem… and then I couldn’t even hear myself over the speakers, nothing.”

The annual budget for Ukraine’s health-care system swallows up 7.6 percent of gross domestic product, her deputy Pavlo Kovtonyuk told The Ukrainian Weekly in the same interview. About half comes from out-of-pocket expenses in a system that constitutionally is supposed to ensure free treatment to every citizen. Dr. Suprun says that 136,000 Ukrainians die yearly – lives a normally functioning medical system would save. Indeed, with 15.6 deaths per 1,000 people, Ukraine last year had the third highest death rate in the world after South Africa and Russia, according to the WHO.

It’s also a system rife with rent-seeking schemes that drains millions of hryvni from the state budget, according to Oleksandra Ustinova, a board member of the Anti-Corruption Action Center in Kyiv.

Dr. Suprun’s journey to alter the status quo with billions of hryvni and millions of lives at stake highlights the daunting task some reformers in Ukraine encounter.

Building coalitions

To counter the resistance, she built coalitions with key stakeholders in and outside Ukraine that were publicized on social media. International organizations, local patient advocacy groups and even renowned Ukrainian physicians like Kharkiv-based pediatrician Yevhen Komarovsky backed the plan.

It centers on changing how health care is financed – and, with it, how patients are treated.

The main principle is to have money follow the patient through a newly created National Health System like in the United Kingdom. Patients would be allowed to choose which doctor at which hospital they want to treat them. In turn, the newly created body would conclude contracts with hospitals for services based on “international protocols” of clinical guidelines that must be followed for primary care.

“Right now, the current system treats medical problems, not patients,” Oleksandr Yabchanka, a pediatrician who is a medical expert for the Reanimation Package of Reforms, told The Ukrainian Weekly by phone.

The acting minister’s vision is to have palliative, emergency and primary care services paid for by the state. According to research, these account for about 80 percent of all patient referrals to clinics. Co-payment would be introduced for other care, whereas plastic and cosmetic surgery would be totally out of pocket.

Those who can’t afford co-payment would be subsidized by private insurance, local budgets, as well as the mandatory social medicine insurance program.

First of two readings for bill

On June 8, Parliament narrowly – by two votes – passed Dr. Suprun’s vision, albeit already in a diluted form. A working group that was formed struck out free health care for Donbas war veterans, as well as co-payment. She received the same treatment from lawmakers during a three-minute speech that the legislature’s speaker gave her as she had gotten nine months earlier: a chorus of boos.

This happened although at least four public opinion polls conducted over the past year show that Ukrainians are willing to pay up to 30 percent out of pocket of the cost for certain medical services.

The vote on the bill’s first reading was hailed as a victory by Dr. Suprun’s team, although she had hoped to get the final reading passed before Parliament went on vacation until September 5.

By changing how health care is financed, the Health Ministry wants to change the patronage-client relationship when a patient enters a clinic.

“It’s a huge a huge civilizational step,” Deputy Health Minister Oleksandr Linchevskyy told The Ukrainian Weekly with Dr. Suprun. Previously, “We had only created Potemkin Villages,” he explained, while now, “We change relations between members of society. We say that life and health have the biggest value. We began to calculate the value of existential life.”


It was Opposition Bloc National Deputy Tetyana Bakhteyeva, a member of the Health Care Committee, who first invoked “genocide.”

She told journalists on June 8 and afterwards, when the first of two readings of the health bill was voted on, that Parliament passed it “on its knees.”

As a lawmaker in the disgraced ex-President Viktor Yanukovych’s Party of Regions, Ms. Bakhteyeva headed the vital committee in 2007-2012.

Thus, the second and final vote never took place because key national deputies on the almighty Health Care Committee “sabotaged” it, said Ms. Ustinova of the Anti-Corruption Action Center.

During the Rada’s last session on July 11-13 before its break, committee Chairwoman Olha Boholomets of the Petro Poroshenko Bloc and Vice-Chair Oleh Musiy were fundamental in ensuring the bill didn’t get to a vote, alleged Dr. Suprun, Dr. Yabchanka and Ms. Ustinova.

By then the bill had been further diluted with more than 800 amendments made by the working group attached to the committee. Also taken out were the international protocols that were supposed to ensure treatment guidelines, as well as other modern practices. The hope was that some key measures could have been reversed once the bill got to Parliament and lawmakers would have been able to vote for packages of amendments for inclusion.

National Deputy Boholomets, a dermatologist, did not answer four phone calls seeking comment for this article. For years she headed the Health Care Committee on Kyiv’s City Council. According to Ms. Ustinova, her clinic leases property for her private clinic downtown at “two to three times” below the market rate.

National Deputy Musiy said by phone that that the acting minister’s vision only “changes financing” and has no “relation to health care.”

He admitted that the overall vision is based on his strategy when he was health minister following the Maidan Revolution in February 2014 – something that Ms. Ustinova and Dr. Yabchanka accuse of him of opposing now because he won’t get the “political benefit.”

A political leftover from self-exiled former President Viktor Yanukovych’s presidency, Mr. Musiy had headed the public advisory council within the Health Ministry during his truncated term.

Mr. Musiy believes that creating a National Health System – the nationwide insurance program – will “funnel money into one corrupt mega structure.” He also said that, in its current form, the bill “contradicts 20 articles of the Constitution – I can’t support this.” He did not, however, offer examples.

According to Dr. Yachbanka, who spoke with The Ukrainian Weekly by phone, Mr. Musiy “got nothing done while he was minister [until October 2014)”. He was replaced by a Georgian national whose similar version also got stalled in Parliament until he resigned in April 2016.

Sequence of events

That crucial week when the bill was diluted, Dr. Suprun still tried working with the Health Care Committee that she described as mostly “split.” Dr. Bohomolets had missed 75 percent of the committee’s meetings that she was supposed to chair on July 11-12 before sending the legislation to Parliament.

Under her purview, the committee stubbornly decided to vote on each of the 800 amendments individually and only got through about 50. Then, the committee decided to vote for them in packages while Dr. Bohomolets was absent, and Mr. Musiy left when he realized that there was political will for a quorum on the committee.

Once Dr. Suprun had secured a positive final assessment to send the legislation to Parliament’s legal department on July 12, the chairwoman was nowhere to be found for the crucial signature, although her voting card was registered in the legislature.

“She [Dr. Bohomolets] hid from everybody and refused to sign it,” Dr. Suprun said.

The chairwoman eventually ended up in an elite state-run hospital for lawmakers that same day, after apparently losing consciousness in the building, according to numerous accounts by her colleagues, including National Deputy Hanna Hopko, who confirmed the episode to The Ukrainian Weekly.

“That was abysmal for her [Dr. Bohomolets] to do that, but then again, there is no abyss in Ukrainian politics,” Dr. Yabchanka said, adding that the absent lawmaker was still voting on bills based on the legislature’s computer system.

Instead, committee Vice-Chair Oksana Korchynska signed the final assessment for transfer to the legal department.

“The legal department took its time. Parliament, meanwhile, voted for the budget, the pension law, for some metallurgy law, then for prosecutorial immunity of a lawmaker,” Dr. Suprun said.

The acting minister successfully pressed for an extension for the Verkhovna Rada to work until 8 p.m.

At 7:30 p.m., the legal department finally brought three bills into Parliament: on health, education and cybersecurity. None got a majority to put it to a vote and Parliament went on summer break.

Meanwhile, during the last plenary week before break, the Health Ministry and Parliament were picketed by independent medical labor unions from across the country that opposed the bill.

Ms. Ustinova said the protest was staged and planned well in advance because it involved doctors, hospital administrators and other stakeholders from across the country “who had to be bused in and used expensive equipment for sound, the stage and a podium.”

She posted videos on her social media page showing certain protesters being paid to be there and some who couldn’t answer basic questions about the purpose of the picket or details about the health bill.

Mr. Ustinova accused Dr. Todurov – a critic of health reforms and the head of the Heart Institute in Kyiv – of helping organize the picket and sending employees subordinate to him to the protest by posting Facebook posts from doctors from the clinic he heads.

The heart surgeon denied the allegation and said, “I wasn’t a co-organizer; we live in a democratic society… I don’t have the right to ban them [my subordinates] from taking part in protests.”

He added that he conducted four heart operations on the day of the picket.

Kremlin-friendly politicians and activists like Viktor Medvedchuk – whose daughter has Russian President Vladimir Putin as her godfather – have also criticized the Ukrainian American physician’s reform plan on social media.

Rent-seeking schemes

A consortium of international organizations now conducts public health procurement on the national level for medicines to treat illnesses like tuberculosis, hepatitis and HIV/AIDS. Yet many schemes still exist on the local level, and some public clinics break down their tender lots to avoid the price barrier at which they must use the new electronic ProZorro system for purchasing medicine and equipment or for other purchases.

Dr. Todurov, the reputable heart surgeon who heads the state-owned Heart Institute in Kyiv, has been a main critic of the international procurement system.

Ms. Ustinova, Dr. Suprun and others have accused him of abusing the system to make payments for medicine at the highest legal possible cost while he could have purchased items at a cheaper price, as seen when compared to similar or identical purchases other hospitals have made.

In a phone conversation with The Ukrainian Weekly, Dr. Todurov said he wouldn’t have his job if he had broken the law. “Law enforcement should react to allegations [of wrongdoing], otherwise I wouldn’t have my position,” he said.

Head doctors like Dr. Todurov are also accused of clientilism.

Since individual licensing is absent in the legal milieu of Ukraine for professionals like lawyers and doctors, and licenses are given only to clinics, the head doctors preside over miniature fiefdoms, Ms. Ustinova and Dr. Yabchanka, as well as the health minister, said in previous public statements.

Patients are beholden to the local hospital where their domicile is registered, and doctors must provide kickbacks up the ladder for the services they provide to patients, who should treated free of charge.

Since there is no legal requirement for medical students to reach a mandatory minimum score on their university exams, corruption flourishes in education as well. University heads prefer to have subpar students who pay for grades, exams and, eventually, diplomas, said Dr. Linchevskyy, another deputy at the Health Ministry.

Medical universities and departments are motivated to have “more students, [then] more staff and more money from the budget regardless of the quality and real need,” the deputy health minister said. “They don’t care about the quality of student. If the student doesn’t pass an exam or has poor grades, they pay, they pay for absence, and they pay for re-taking exams. The universities are interested in bad students because they pay.”

Dr. Linchevskyy added that only 3 percent of second-year medical intern students who took the internationally recognized United States Medical Licensing Examination over the past year passed. He also said surveys showed that less than 1 percent of Ukrainian physicians speak English, meaning they can’t read medical journals that account for about 80 percent of research and advancements in their field.

Almost as soon as Dr. Suprun was appointed, the head doctors of clinics started to criticize the procurement system with international groups. Dr. Todurov was one of them.

Whereas in 2016 Dr. Suprun said in a Facebook post that taxpayers saved 74 percent on purchased medicine – the equivalent of 917 million hrv – the heart surgeon has accused her numerous times of delaying funding to the clinic he heads.

In a phone interview with The Ukrainian Weekly, Dr. Todurov maintained his accusations despite numerous statistical and official information that the Health Ministry has publicly disclosed to counter them.

When Parliament reconvenes on September 5, Ms. Hopko, formerly of the Samopomich Party that supports health reform but today an independent, told The Ukrainian Weekly the “first thing that should be voted on is health.”

When asked who is losing out the most in the stalled reforms, Dr. Suprun responded, the “patients are, we always talk about them, but they [the opposition lawmakers] – they never do,” she said referring also to the populist Radical Party and Yulia Tymoshenko Bloc parties who also have historically voted against the bill.