Changes in the Ukrainian healthcare system are underway
We wrote this Manifesto for activists – responsible people with an active life position. Here, we talk about the health sector, how it should change in 10 years, by 2030. For our children. For ourselves, who in ten to twenty years will need it more and more
In our Manifesto, person is seen not as a resource but as an unconditional value, the main thing we have.
It is the independent person as an individual, citizen, owner, taxpayer, doctor, patient, manager, or government official – that is, in all possible roles – who is the central goal of our aspirations.
The path of change begins with the belief that if it can be so, then so it will be. The struggle for values and structural change is not an easy task. But if you have a vision of the ultimate goal and place of everyone in the new just system of free people, nothing is impossible for you.
There are many of us, and we do not start from scratch. Our next step is this Manifesto. Hopefully, yours too! Let’s act together!
Our future is human capital, not minerals
Can a child born this year expect to have the best education and good health when they reach adulthood? How many healthy years will they live, realizing their potential at work, in family, creativity, sports, state service, or in the army?
If you don’t like the answer, then our health system and the country as a whole still need immediate and radical changes.
We want human capital to be the main thing for our country in ten years, not minerals. For this to happen, the next ten years must be a time of radical reforms in health and education, as well as unprecedented investment in them.
Revamped healthcare in 2030 means first and foremost:
– an effective health system for children,
– a reliable National Health Service that protects families from excessive treatment costs, and
– modern health infrastructure for the elderly.
With such priorities, Ukraine will become a dynamic modern country in ten years. After 2030, it will be able to join the Baltic States, Scandinavia, or Southeast Asia and be among the 30 countries with the best human capital index.
State is about Security
To build our human capital, we must first be safe. Creating and guaranteeing security is the main job of the state.
The modern world offers many opportunities, but also creates many threats that an individual or enterprise is unable to overcome on their own: man-made and natural disasters, epidemics of infectious diseases, social unrest, or armed conflict.
The state formulates general rules and concentrates resources to create an appropriate level of security for its citizens. This can happen after the partial or temporary restriction of the individual freedom of each of us.
So that the need for security does not threaten our basic freedoms, the use of coercion by the state has clear and strict boundaries. Within these boundaries, each of us must strictly follow the instructions. Beyond these boundaries is our private life, in which the state has no right to interfere. The boundaries themselves are set only through democratic mechanisms.
To respond successfully to dangers, the state must move from a “mobilization only in times of danger” approach to a “ready for danger every day” approach. To do this, these three functions need to be strengthened:
– Intelligence (intelligence and analysis). Powerful intellectual and technological resource for risk management and anticipation. This resource must function continuously and be the “eyes and ears” of the system for timely detection of health threats.
– Militarization. It is needed to implement quick solutions based on predefined algorithms. The main factor of successful response is discipline and developed skills of behavior in critical situations.
– Subsidiarity. It is the ability to make instant local decisions for rapid resource mobilization. It requires organic links with communities and local authorities.
State: smart, efficient, compact
There is no free medicine or education. The role of the state is not to create their semblance, but to maintain social justice. To do this, it finances the basic medical needs of people and protects them from the excessive costs associated with the loss of health. The cost of medical care must be reimbursed to the service provider of any form of ownership based on rules that are transparent and uniform for all.
The state must regulate the system so that the rich pay for themselves and the poor, those who work, pay for those who worked before or are not yet working, as well as for those who do not work temporarily. This is how the founding principle of solidarity in the Manifesto is realized.
To stimulate the development of human capital, the state can provide services, finance services, and regulate the provision of services. These methods are different in cost for taxpayers: regulation is the cheapest but requires appropriate competencies from the state apparatus; provision is the most expensive, and besides, the state is not the best provider.
Traditionally, the Ukrainian state maintains a huge apparatus to provide services, hardly finances them and regulates them very poorly. This pyramid should be turned upside down. Services, with some exceptions, must be provided by competing independent providers. The state must finance the services guaranteed by it (through the mechanisms of strategic procurement on contractual terms). The main thing that the state will do is regulation, namely, the creation of fair rules of the game.
To do this, the state should not rely on an army of officials, but on small professional teams of modern, educated, and well-paid politically neutral civil servants.
Strong and independent institutions
When we say “state”, we mean political bodies of public authority, as well as professional independent institutions: the National Health Service, the Public Health Center, the State Enterprise “Medical Procurement of Ukraine”, etc. The future health system will be based on them.
The role of the elected legislature (the Verkhovna Rada of Ukraine) and the top executive branch, appointed by the Verkhovna Rada (the Cabinet of Ministers, MoH), in the field of health care is to articulate and operationalize the public procurement. They answer the question of what the public consensus on the needs of citizens is, how it should be reflected in public policies, what should be the design of the system and the architecture of institutions within it. Their decisions will have an effect in the case of sustainable implementation for 3-5 years.
The role of institutions is to ensure the ability of the state to put this or that vision into practice. Independent institutions accumulate industry expertise and experience, as well as ensure longevity in the process of implementing public policies. The absence of such institutions dooms any government policy to failure due to lack of operational capacity.
Professional institutions must be protected from political cyclicality. Transparent and honest procedures for their formation and election of leadership, stable management processes will help here, and direct communication between institutions and people will ensure their legitimacy.
A responsible owner who cares about people's health
Human health is not just a matter of doctors, it is actually a much broader issue. Today, the community is the main owner of communal medical enterprises. However, communities need to become responsible owners not only legally but also in everyday life.
The main factors in maintaining good health are the way and conditions of human life, and medicine only partially influences this. The community must take care of the health of its residents: support and encouragement of healthy habits, infrastructure for a healthy lifestyle, ecology, employment structure, leisure structure, etc. Managing these factors should be a priority for local governments. Creating effective targeted local programs to maintain health, improve the quality and quantity of social services, care for vulnerable people (the elderly, people with disabilities, children), families with palliative patients, involving such families in active self-realization in the community, creating infrastructures for a healthy lifestyle create a healthy community. Communities should also receive the necessary tools and standards to design such programs.
What are healthy relationships between the community, the hospital, and the doctors?
Hospitals are autonomous enterprises. Doctors are independent specialists. The community should set doctors the task of preserving and restoring the health of their population as part of a community strategy and in collaboration with other businesses and services.
When investing in hospitals, the community should not violate managerial autonomy; for instance, by telling the director who can be fired and who can’t, or how to distribute hospital budget money. The director of the hospital is responsible to the owner for its financial capacity, quality of services, and satisfaction of the population. How it achieves this is an internal matter of the autonomous institution.
At the same time, the community should make sure that a professional manager is involved in the management of the institution based on a transparent competition. It should promote the effective work of corporate governance through the creation of a supervisory board, active participation in creating a clear strategy for the development of the institution, considering the unique needs of the community.
Management at the regional level should create conditions for cooperation and joint efforts of all medical institutions of the region and their work as one network to preserve the health of residents throughout the region.
The basis of the new health system is independent doctors
An independent doctor is an entity with a sense of dignity who works in the best interests of the patient, the profession, and the institution. An independent doctor cannot be forced to do something against their own will or principles. An independent doctor cannot be forced to do meaningless work. An independent doctor will not be silent when they see that something is going wrong or not honestly.
The doctor’s independence is based on two pillars: self-government, which supports and protects them, and the status of an independent profession, which allows the doctor to legally receive remuneration and be less dependent on the employer.
The medical chamber will grant doctors the right to practice medicine and will thoroughly examine them. The doctor will become equal among equals in the independent community of professionals. Each doctor will be able to enter the chamber’s office or delegate there someone they trust. The doctor’s professional actions, including mistakes, will be evaluated by their colleagues, not by officials behind closed doors.
Following the doctors, the nursing profession will also begin to organize its own self-government. From a doctor’s secretary, a nurse should become an independent professional who can work in a team with a doctor or independently.
Hospitals as efficient independent enterprises
After being symbols of downfall, mismanagement, and corruption, health care facilities will be transformed into effective autonomous enterprises.
Medical enterprises (hospitals of various levels, primary care centers) are also independent subjects of the health system. Autonomy enables each hospital to become unique in solving the problems of its community.
To do this, first, it is necessary to protect, defend, and expand the autonomy of hospitals. The state regulates the market of medical services, but cannot “manually” manage the finances, people, or other activities of hospitals. Volunteers, patient communities, and other community members will be able to participate in the management of the hospital through boards of trustees or supervisors. Management positions will be open to the best instead of the inner circle due to open competition procedures and competition for the patient. The manager in medicine will become a separate recognized and respected profession.
This will break down the barrier to the sacredness and secrecy of hospitals. Community members, managers, doctors, and local authorities will be jointly responsible for increasing human capital in each community. The community and staff will be proud of their hospital.
Digital rights, innovative technologies, and artificial intelligence
are integral components of the modern health system
In today’s world, we generate and use a large amount of data and, consciously or subconsciously, form huge pools of data, including medical, that contain personal and personalized information. The availability of these data and the possibility of their processing for analysis and conclusions are the foundation of balanced and sound decisions for the benefit of the individual and the community in a mature and open society. But at the same time, this situation contains risks that we must be aware of and try to manage.
Dialogue without taboos and forbidden topics
In the field of health, there are many problematic issues, but there should be no forbidden topics, as there is no place for the culture of victimhood.
Unspoken taboos on painful and sensitive topics hinder the development of health care and leave the worst problems unresolved for years. In recent decades, the culture of victimhood has taken root in this area. Doctors or patients are considered to be humiliated groups. Politicians are willing to strengthen this image, hoping for cheap popularity.
In the new system there can be no taboos on the discussion of corruption and informal payments, low professionalism due to poor education, medical error, conflicts of interest in the communities of doctors, patients, and others.
Self-respect, which comes from inner freedom, respect for the opponent, which comes from the belief that everyone acts in the interests of the patient, and dialogue will be a tool for revealing and solving these problems.
The soft power of civil society
In our recent past, there is clear evidence that Ukrainian civil society can influence the government to achieve the desired results. This principle of soft power is based on the fundamental values of the Ukrainian nation. That is why the state must support and expand the trust, capacity, and opportunities of civil society to influence the formation of public policy.
Civil society should include professional associations, patient associations, religious and human rights organizations, business associations, and so on. We believe that investing in civil society will contribute to the ability of every citizen to become a full-fledged subject of the new system.
News and events
Українська медицина: нічого святого. Харків’яни визначили, якою хочуть бачити систему охорони здоров’я за 10 років
Managing Partner in ILF Law Firm. Expert in public-private partnership and investment consulting
Створення Маніфесту є результатом глибокого осмислення процесів, що відбуваються у нашому суспільстві, світових трендів, суспільного запиту, помилок та досягнень реформ. Це крок до фундаментальних змін країни, де людина є супер-цінністю …
Co-founder of Kharkiv Expert Group in Healthcare Reform, independent management consultant
В роботі над Маніфестом мене надихала можливість створення орієнтиру розвитку для всіх, кому не байдуже, хто не шукає простих рішень, хто вірить в майбутнє України
General Manager at State Enterprise Medical Procurement of Ukraine
За поточними питаннями та проблемами є ризик втратити довшу перспективу – «завалити горизонт». Водночас саме в охороні здоров’я наявність довгострокового планування та стратегії є критично важливою
In 2016-2019 Deputy Minister of Health of Ukraine
Робота над Маніфестом важлива для мене як пошук нових орієнтирів на майбутнє – для галузі здоров’я, для країни, для самого себе…
In 2018-2019 Director General in Center for Public Health of the Ministry of Health of Ukraine
Завжди у часи випробувань народжуються нові ідеї та стратегії. Для мене Маніфест є дороговказом, як нам продовжувати рухатися у напрямі європейських цінностей
Co-author of National Health Reform Strategy for Ukraine /2015-2020/, founder of National Health Service of Ukraine
Маніфест – це завжди виклик і завжди його зміст про суттєву корекцію усталеного порядку речей, новий незвичний дискурс. Цей Маніфест… – він про справжнє, про людину
public health program director in International Renaissance Foundation
Робота над Маніфестом – це інвестиція в те, якою буде Україна, та вироблення справді спільного уявлення про це. Чи відповідатиме вона нашим прагненням, чи буде наслідком нашої інтелектуальної, моральної та фізичної бездіяльності? Нам усім – кожному на своєму місці – варто відповісти на ці питання!