16. The right to health care
Urgent need for a new medical reform
Despite the principles proclaimed by the Constitution of Ukraine and the international obligations of the state the health system Ukraine does not provide for the right of everyone to the highest attainable standard of physical and mental health and equal free access to quality health services.
To solve this problem, in 2011 the government launched an ambitious project of reforming the health care system in accordance with the program of the President of Ukraine “Ukraine for the people”, State Program of Economic and Social Development of Ukraine for 2010 and Program of Economic Reforms for 2010-2014 “Prosperous Society, Competitive Economy, and Effective State”.
The legislative basis for reform in the first stage was the adoption of the Law of Ukraine of 07.07.2011 no. 3612 “On the procedure for health system reform in Vinnytsia, Dnipropetrovsk, Donetsk, and Kyiv oblasts” (hereinafter - the Law “On the Procedure for…”) and the Law of Ukraine no. 3611 of 07.07.2011 “On Amendments to the Basic Laws of Ukraine on Health Care for the Improvement of Medical Care”.
But the reforms were implemented without identifying sources of funding, without reform plan clear for the public and health professionals which worsened the access to health services, especially in rural areas, and deteriorated their quality. The voluntaristic, “reformist” introduction of a family doctor plan replacing the current system of outpatient primary care; lack of sufficient sources of funding violated the years-long system of doctor- patient interaction. Hasty adoption and implementation of the Law “On urgent medical care” without substantial upgrading of equipment and fleet replacement, without sufficient funding, without allowing for the existing infrastructure of cities and towns ruined the system of first aid and urgent medical care. The economic reform program for 2010-2014 in the field of medicine has not reached the stated purpose and indeed failed.
Demographics and infant mortality
As of December 1, 2013, the population of Ukraine amounted to 45,439.8 thousand. During January-November 2013 the population size decreased by 113.2 thousand people. However, in ten regions the population size increased.
During this period, 140.7 thousand people died (in 2012 15.7 thousand less). The birth rate dropped from 11.5 to 11.1 births per 1,000 of existing population.
Between January and November 2013 in 10 regions the migration gain was registered, in 17 regions the size migration decreased. Throughout the country, the migration gain of 27.5 million people was registered.
Among those who arrived in Ukraine in January--November 2013, the immigrants from the CIS accounted for 58.2%, while the rest (41.8%) were from other countries. Among those who left Ukraine 39.6% went to the CIS and 60.4% to other countries.
At the age of 1 year 3693 children died. The mortality rate of children under 1 year of age decreased from 8.6 to 7.9 deaths per 1,000 births.
The main causes of death in children under 1 year of age were certain conditions arising in the perinatal period: congenital malformations, deformations and chromosomal abnormalities, external causes of death, neuropathy, respiratory diseases, and some infectious and parasitic diseases. There remain a significant proportion of infants whose cause of death was not established: 4.4%.
Financing of Health Care
The item of expenses of the State 2014 Budget for the Ministry of Health of Ukraine makes ₴10,083,900.7 thous, including the general fund expenses to the tune of ₴8024 985.1 thous and special expenses to the tune of ₴2,058,915.6 thous. This is 2.12% more than it was planned in the draft state budget for 2014, and 0.82% compared with the size of expenses item in 2013.
The item of expenditures of the Ministry of Health of Ukraine includes staff costs which have increased by 2.46% compared with the draft 2014 budget (₴210,000 thous more) amounting to ₴8,741,501.2 thous (20% more than in the last year's budget); the State Service of Ukraine on Medicinal Products in the amount of ₴63,799.3 thou (45.3% below the expenses planned by state 2013 budget); the State Sanitary and Epidemiological Service in the amount of ₴1,268,980.2 thous (less than 31.3% compared with the last year's budget).
The expenses of the State Service for Control of HIV/AIDS of and Other Socially Dangerous Diseases have doubled compared with the last year's budget. So, if last year they made ₴4,157.8 thous, now according to the State 2014Budget they amount to ₴9,620.0 thous (more by 131.37% compared to the state budget for 2013).
The State 2014 Budget provides subvention to local budgets for partial reimbursement of the cost of medications to treat people with hypertension the total amount of which, like last year, makes ₴191,636.3 thousand. The biggest subsidy for 2014 will go to Donetsk Oblast: ₴18,357.6 thousand or ₴54.1 thousand less than last year. The budget of Chernivtsi Oblast will get the least amount of ₴3,796.7 thous or ₴55.8 thousand more than this year. The municipal budgets of Kyiv and Sevastopol shall receive partial reimbursement of the cost of medications to treat people with hypertension to the tune of ₴11959.0 and ₴1997.5 thous accordingly.
Comparing funding of power structures, judicial system and social and medical care for the population of Ukraine, the question arises whether the State 2014 Budget is socially-oriented which is constantly stated by the officials.
Lack of blended financing of the health care system through the introduction of national compulsory health insurance
On the face of it, the creation of national fund of compulsory medical insurance would improve funding for the healthcare industry in general. Over the past decade, the Verkhovna Rada of Ukraine received numerous projects regarding health insurance. But not all experts believe that there appear to be sufficient reasons at this time to implement this additional (or main) mechanism of funding. For example, the publication of the Institute for Economic Research and Policy Advice maintains that the postponement of the decision to introduce compulsory health insurance is the right step. From the point of view of the author, the main reasons are as follows.
Firstly, the health system is not ready for this: in the first instance, it would be expedient to go over to the system of payments for services (financing available infrastructure).
Secondly, we should begin with optimizing network structure (for which all regions should develop and adopt plans for optimization of institutions).
Thirdly, the level of payroll tax is already high. Accordingly, additional 3% payroll taxation would lead to even greater burden on wages and drive wages further into the shadows (while the government announced its intention to reduce the burden on the payroll).
Consequently, the more important task today is to increase the efficiency of the health system in terms of its structure and funding principles. It is necessary to pay more attention to the provision of health care at the primary level (which is one of the goals of health care reform), and preventive health care.
It is also worth noting that in due time the Constitutional Court failed to define the denotations of “medical aid” and “medical services”. It is worthwhile to finally differentiate these concepts now, which might help to develop voluntary (optional, not compulsory) medical insurance.
Complaints from the public about the deteriorating access to health care due to the implementation of health reform in Ukraine
All complaints can be divided into those that are based on concern about the deterioration of the population access to health care, and those which have a real foundation.
The first type of complaints, for example, was established in the course of monitoring visit by the representatives of the Office of the Commissioner of the Verkhovna Rada of Ukraine on Human Rights following the applications of the citizens of one of the regions of Poltava Oblast, which found no evidence of decreasing number of existing treatment facilities: in fact, there were changes in the names of medical institutions, some branches were closed but in general, all key specialists remained in their jobs.
The second type of complaints that have objective grounds include numerous complaints from pilot regions of Ukraine, where reform was carried out.
The most impressive complaints are received from citizens' associations defending their right to medical care (“For our children”, Dnipropetrovsk Oblast).
Also there is also evidence of deterioration of access to medical care in Volyn Oblast, Chernihiv Oblast, Lutsk, Kremenchuk and other cities and oblasts.
On April 17 and May 22, 2013, the Kyiv City Rada established 27 medical institutions of a new type (19 centers of primary public health care and 8 consultative and diagnostic centers) as legal entities in another eight districts of the capital in addition to Darnytsia and Dniprovsky district centers.
The officials see the results of their activities as follows.
Primary medical aid geographically close to the residents:
- 81 general practice outpatients' clinics opened;
- the doctor reachability radius diminished from 2-7 km to 0.5-0.7 km;
- the number of general practitioners increased.
Better quality and reachability of medical aid:
- Primary-period detection of tuberculosis patients increased by 6%
- The number of patients with neglected visual forms of cancer diminished by 25%.
- The number of lab tests Increase was 135 thousand higher (1.2%);
- Women's screening increased from 78.2% to 84.5%;
- The number of calls to the chronically ill and inappropriate calls fell by 4%.
And here is the opinion about “improving the quality and accessibility of medical aid” by cancer patients, who for their health condition require narcotic analgesics.
Here is a direct speech of the relative of the cancer patient which is suffering from acute pain syndrome and sought medical attention to be prescribed a scheme of analgesic therapy.
“It turns out that in Holosiyiv District of Kyiv the reform has been carried out already. The Holosiyiv District Central Outpatients’ Hospital has become a non-profit municipal enterprise “Advisory and Diagnostic Center” of the Holosiyiv District, Kyiv (hereinafter CDC). Two centers of primary medical and sanitary aid were singled out.
At present, the procedure in this system is as follows:
1. The patient goes to the CDC oncologist.
In our case, the daughter came along with the documents and on their basis the oncologist put her mother on record. This happened before the reform, they refused to put her mother on the record referring to the fact that the patient was treated not at the place of registration (she was diagnosed in Israel and underwent palliative chemotherapy at a private clinic); “they made the daughter worried, but eventually put her mother on the record”.
2. With manifestation of the pain syndrome the CDC oncologist prescribes the symptomatic therapy, if necessary, with the use of narcotics (our patient also had a prescription dated October 14, 2013). When the pain intensified, a friend of the family (!) took the documents and went to see the district physician (family doctor), s/he said that s/he had experience with the tableted morphine and s/he did not know how to prescribe it, moreover s/he had no recipe forms.
3. Today I was told that the CDC oncologist only indicates in the prescription form that “the symptomatic therapy is indicated” and in what follows the CDC takes no part.
4. The medical officers say: “You need to go to the Center of primary medical and sanitary aid no. 2 (CPMSA) to the therapist to get a prescription. But currently they have no budgetary financing for this and therefore they cannot write out a recipe; so they’ll send you back to us, to the CDC, and the oncologist will write out a prescription as far as we still have money. So, you go straight to the oncologist and he will write out”. After many assurances that the oncologist did wright out prescriptions and we will get one, I checked the doctor’s hours and sent for the daughter of the patient. We waited over an hour around the door which is a usual story at the outpatients’ clinic. At long last, the patient’s daughter came out telling that in fact the oncologist prescribes nothing, and we’d better call a therapist tomorrow to get her/him in. The entry in the medical card reads as follows: The condition is aggravating, hypoxia and pain syndrome increases; recommended: seeing the therapist to get prescription for doses”. Well, to be sure!
I stayed, because I wanted to sort it out myself and understand how the CPMSA and therapists work. No way. It was already almost 3pm.
The head of the department of internal diseases received patients until 13:00, our family doctor received patients until 11:00.
I asked whether the patient (given the seriousness of the condition) might be visited today by another therapist who is now carrying out house-to-house visits; they answered that only therapist assigned to this district was authorized to prescribe opiates; therefore it might be done the next day only.
And that meant more than 12 hours of suffering. The circle closed up: the next day the therapist will come and tell that s/he had no expertise to prescribe morphine tablets, s/he neither knew how to prescribe it, not he had prescription forms”.
Implementing health care reform causes opposition from the public and medical professionals in the pilot regions due to a bunch of objective and subjective factors.
Implementation of the first phase of medical reform took place without sufficient legal and economic analysis that would serve the stated purposes: improvement of the quality of medical aid, better accessibility of medical aid, and, as an expected result, improvement of health of population.
Creation of CPMSA took place without the development and approval of plans for network parameters optimizing on the level of regions and individual regions.
The negative effects that reflected the deterioration of the situation with the rights of patients in Ukraine:
1. Unconstitutional closure of medical institutions under the banner of “optimization” (illegitimate predominance of the norms of the Law of Ukraine “On the Procedure…”).
2. Reduced availability of SHC despite ideas to improve the accessibility by separation of the primary level of medical aid.
3. Reduced accessibility of the quality medical aid (secondary) for the rural population which means the most negative violation of patients' access to care.
4. The destruction of the pediatric service, the place of which in the reform of the existing model has not been defined.
5. Existence on the same premises (where previously an outpatients’ clinic was) of two or more treatment facilities, such as TSPSMD and CDC.
6. Administrative ambiguity of medical institutions of the network, for example, one cannot get a sick-leave certificate or other medical documentation: in one and the same town you need to go for the seal to another building.
Information support for the reform remains low
There is no doubt that a rational optimization of the network of medical institutions is needed, but the process requires measured judgment by local administrations in the first place. None of the actual health care institutions, medical establishments should be closed; they can only be reorganized and / or reoriented to meet the needs of the population, as stated in the guidelines of the Ministry of Health of Ukraine “Modernizing the network of health facilities that provide primary medical aid”.
Unfortunately, except for invoking the initiative of the President of Ukraine concerning the desire to improve the health of the nation, increase access to health care, the goal of reform “on the ground” is incomprehensible to most people and medical officers and so on. References to the rational use of money against the background of “corruption scandals”, existence of free medicine only in the perception of medical officers looks unconvincing. The population does not understand the difference between the old district doctor and the family doctor, which must first contact the CPMSA, then the CSD, and to get a medical certificate you have to go to a third place.
Persevering implementation of family physicians gives rise to doubt
The situation is complicated by the fact that the family doctors (formerly district doctors) are called for mainly by elderly, pensioners, or people of working age who need a medical certificate. In the event of illness, acute or chronic, the population turns to the secondary or tertiary level of medical aid which, given the existing system of paid for/free medicine, presents no impediments.
Therefore, the agreement between the local authorities and secondary medical aid institutions (hereinafter: the SMAI) to provide medical care for people without family doctor’s referral during the transition period and the reluctance of SMAI doctors to admit patients without referrals relates to the most vulnerable strata: seniors, temporarily unemployed, and rural dwellers.
Thus, given the above facts, it was not at all studied the needs of the population in the institution of the family doctor, especially given the focus on high-tech modern medicine methods of diagnosis and treatment.
What kind of a doctor do we need? Personnel policy.
Despite the fact that the top medical higher schools for many years kept preparing physicians in the specialty “General Practice, Family Medicine (GPFM)” all medical aid centers cannot be staffed with appropriate medical personnel. So from the very start of reform it was proposed to retrain doctors of other professions in the course of 6-month period by branch regulations. But in the opinion of many experts, based on international experience, it is impossible to adequately retrain appropriate family doctor (GPFM), especially taking into account the volume of required knowledge in many areas of medical science. And most importantly: during such retraining is impossible to obtain clinical experience (and, perhaps, theoretical as well) in pediatrics, while the family physician should also treat children in her/his district.
In order to ensure continuous professional training of medical practitioners in primary care according to the guidelines of Ministry of Health of Ukraine “Upgrading the network of health facilities that provide primary care” the oblast training or practical training centers will be set up. It would be advisable to organize such center at the “model” outpatients’ clinic. In this center the scheduled short-term practical training for doctors and nurses in primary care would be held according to a range of issues and competence of the trainees. These trainings should be extended to all healthcare providers of primary medical aid. Where possible such practical training centers should be established both in the regional centers and cities of oblast subordination. The aim of these centers should be to facilitate the organization of short-term thematic on-job courses for health professionals of medical aid centers by providing premises and logistical resources needed for the implementation of the educational process by the educational institution or distance learning.
However, currently we have no information on the establishment of such centers.
Emergency medical aid does not perform its duties because it lacks funds for medicines and loses skilled health workers
As of January 1, 2013 the Law of Ukraine “On emergency medical care” entered into force.
In addition to the approved law the Cabinet of Ministers ruled “On the standards of arrival of emergency (ambulance) medical care crews on the scene” according to which the ambulance car should arrive upon the scene 10 minutes after the call, and 20 minutes in rural areas. According to the document, the standards may be exceeded only by 10 minutes, and then only in the case of bad weather.
Moreover, from now on there will be effective criteria according to which the dispatcher receiving a call of the patient must determine whether it is an emergency call and immediately send him an emergency medical aid team (ambulance) or redirect the call to the relevant public health care institution of the primary medical and sanitary aid.
Thus, the brigade of special medical aid should be sent to patients who are in a state that is accompanied by fainting, seizures, sudden respiratory distress, sudden pain in the heart, blood vomiting, acute pain in the abdomen, external bleeding, signs of acute infectious diseases, severe mental disorders that threaten the life and health of the patient or other people. Also, the ambulance will go to the patient's with injuries, including those resulting from traffic accident, accident at work or a natural disaster. It will be sent to patients with hypothermia, heat stroke, electric or lightning shock, victims of animal bites. The ambulance will also attend pregnant women with advanced labor or any other breach of normal pregnancy.
The category of non-urgent calls now includes patients with abruptly increased body temperature with cough, running nose, sore throat, headache, dizziness and weakness observed, increased blood tension or pain syndrome in cancer patients. This same category comprises exacerbation of chronic diseases of the digestive system and hypertension. This call should be answered by a family or a district doctor. If this is not possible, the patient will have to wait an hour for an ambulance or go to the hospital by her/himself.
What are the negative consequences of this division between the emergency service and ambulance?
1. The dispatcher of the emergency service center Manager is to determine by ear what kind of help you need to provide on-call aid, which worsens the quality of medical aid, it becomes very subjective and results in the following paragraph.
2. The number of emergency crew rides goes down or even increases, as patients name over the phone symptoms of diseases belonging to the emergency category.
The emergency medical services in 2013 worked in total underfunding conditions, which are the main reason for reducing the number of brigades, poor technical state of vehicles, lack of modern medical equipment, medicine, communication facilities, and gas.
Practically the brigades missed their deadlines: urban traffic jams, lack of GPRS, absence of driveways to the buildings, absence of number plates on the houses; in rural areas it happened because of the poor road conditions.
Insufficient funding has caused:
1. The emergency crews had not the required set of medications.
2. The absence of proper medical equipment in cars: defibrillators, intubation equipment, and more.
These factors have worsened providing emergency assistance in general. Before reform there were the so-called line brigades (not very well equipped) and special brigades, which had the necessary equipment; after the reform there often remained empty cars with doctors and lack of medicines.
All of these factors and the deterioration of working conditions in general (insufficient equipment and accessories), “fines” for “spelling errors”, withdrawal of allowances for non-compliance with standard deadlines for coming to the patient), and lead to the loss of the skilled medical personnel.
In connection with the “reform” some emergency medical aid centers work without the narcotic and psychotropic drugs
During the year the branch “Vyshhorod Station of Emergency Medical Aid”, which is located in Bucha, Kyiv Oblast, had no license to use narcotic drugs, psychotropic substances and precursors prevents any emergency medical aid to residents of the territory of service established by Order of the Ministry of Health no. 24 of 17.01.2005 “On approval of the protocols of medical aid in the specialty “Medical of emergency conditions”, including acute coronary syndrome, seizures, cardiac asthma and pulmonary edema, trauma and others. All listed emergency life-threatening conditions require immediate injection of narcotic or psychotropic medical preparations. Failure to provide qualified emergency medical assistance violates the inalienable right to life, as guaranteed by the Constitution of Ukraine, European Convention on Human Rights, UN conventions etc.
Destruction of preventive medicine on the factory floor
One of the problems covered by the medical reform is the low level of disease prevention.
In Ukraine, annually they record from 5 to 8 thousand occupational diseases and up to 10.5 thousand accidents at work.
The increase in occupational diseases is caused by exposure to harmful factors of working environment. Hazardous working conditions in enterprises due to deficiencies of engineering processes, neglect of hygienic standards, and non-use of personal protective equipment. In the coal industry, mechanical engineering, mineral resource industry, agricultural industry and non-state enterprises (farms) the number of objects that do not meet health standards ranges from 35.6% to 57.7%. In general, only 29.1% of Ukrainian facilities meet sanitary code. Rising levels of occupational diseases are also due to insufficient attention to compliance with applicable legislation and technological discipline, sharp reduction in funds for occupational safety, use of hazardous substances and process equipment without the proper certification and sanitary examination, and low industrial and personal hygienic purity.
Over the past 20 years the country system of preventive medicine at work, which existed before, was destroyed, the number of physicians decreased by more than 10 times, number of aid stations at enterprises become less than in 1928, the quality of health care for working people deteriorated, prevention technologies controlling occupational diseases and illnesses are not implemented.
Gaps in prevention of occupational diseases have a negative effect not only on workers and their families, but on society as a whole. These entail economic losses due to decreased productivity and increased pressure on the social security system. It should be noted that the prevention of occupational diseases is much more effective and less costly than treatment and rehabilitation of victims. That is why we must take concrete steps to enhance the prevention of occupational diseases.
The need for urgent changes in the current legislation of Ukraine
We have repeatedly pointed out in our publications to the inconsistencies of many provisions of the law no. 3612 of 07.07.2011 “On the procedure of…” with the norms of the Constitution of Ukraine, Budget Code of Ukraine, Economic Code of Ukraine, Civil Code of Ukraine, Code of Ukraine on Labor, and Law of Ukraine “On Labor”.
But we must remind once more that with the purpose of enshrining strategies of reform in the field of health care on 07.07.2011 the Verkhovna Rada of Ukraine adopted the Law of Ukraine “On Amendments to the Basic Laws of Ukraine on health care for the improvement of medical aid”. This law was gaining force on 1 January 2012, except for the fourth paragraph of clause 7 and clause 14 of section 1 of this Law, which will enter into force on January 1, 2015. It stipulates gradual modification in the successful practice of reforming the healthcare industry in accordance with the Law "On the Procedure…”
The Law of Ukraine “Basic Laws of Ukraine on health care” (hereinafter: “Basic Laws…”) for its legal nature is a major industry statute, because the definiteness of its articles is an absolute need for the existence and development of health care system in Ukraine and ensuring of the rights of patients.
The greatest fact is that after amending the “Basic Laws…” the concept of primary, secondary and tertiary medical aid, which had been set out in art. 35 of the “old” “Basic Laws…” and a new kind of health care, i.e. palliative care, became blurred for areas of Ukraine, which were not covered by the experiment. This situation will change only from January 1, 2015, but by that time in the country there will be only an emergency medical care, as provided in Art. 35 of the current “Basic Laws…” despite the fact that art. 8 declares the right of every citizen to primary care, secondary (specialized) medical care, tertiary (highly specialized) medical care, palliative care and more.
Health care reform plan has not been completed
The Decree of the President of Ukraine “On the National Action Plan for 2013 to implement the program of economic reforms in 2010 - 2014 “The Prosperous Society, Competitive Economy, Effective State” no. 128 of 12.03.2013 had to promote the second stage of the health care reform, but it was not implemented in the key fundamental areas. On this basis, we believe that the termination of health reform is possible and will not worsen the provision of medical aid as medical reform ceased of its own accord in 2013. These are the following items of the National Action Plan for 2013 that have not been fulfilled.
P.22.3. Supply the missing parts of equipment for the establishment of primary health aid according to the material and technical equipment sheet in order to complete 100% of plan of equipping of primary medical aid establishments (December 2013).
P.22.4. Coverage in the pilot regions by medical examination of 80 per cent of registered patients attached which is a positive trend in detection of visual forms of cancer in advanced stages and detection of TB cases in advanced stages (December 2013).
P.22.5. Completion of implementation in pilot regions of the electronic registry of patients, as well as buying computer hardware and servers for its operation: input of 100% of the population in the pilot areas to the electronic registry of patients (October 2013).
P.22.8. The conclusion in 2014 of contracts of public health service between medical aid centers and related budget owners: more efficient use of budget funds, valuation of health care cost provided under the contract allowing for its size and quality (December 2013).
P.22.9. Evaluation of the effectiveness of draft on budgetary funds in the pilot regions following the analysis of performance of indicators of the budget program “Primary medical aid” (including payment of wage rises to medical professionals for the quality and amount of work) for the second six months of 2012 and first six months of 2013.
P.22.12. Quarterly (April, July, October, and December) monitoring of the modernization of primary medical aid and preparation of relevant reports.
P.22.13. Audit of the implementation of the electronic registry of patients and its efficiency in the pilot regions. Executor: Ministry of Health of Ukraine, preparation of the report (July 2013).
P.24.2. Definition of health care establishments to create diversified hospitals of intensive care with departments of emergency (emergency) medical care in March 2013).
P.24.3. Determination of resource support multidisciplinary intensive care hospitals with emergency departments: determination of the amount of financing of the listed hospitals and sources of funding (May 2013).
P.24.11. Facilitation of the reallocation of budget funds by health care providers rendering secondary (specialized) medical aid through funding of health care expenditures according to two economic classification-of-expenditures codes.
P.24.1. Approval according to the regulation of the Cabinet of Ministers of Ukraine dated October 24, 2012 no. 1113 “On approval of the creation of hospital districts in Vinnytsia, Dnipropetrovsk, Donetsk, and Kyiv oblasts” of outlines of the hospital districts and perspectives of health care establishments providing secondary (specialized) medical aid for the period until 2014.
Implementation of health care reform at the national level (except for the pilot regions). Completion of the reorganization of primary medical care.
P.26.1. Modernization of the network of health care providers in primary care regions. Result: satisfaction of needs of the primary medical (medical and sanitary) aid centers in essential equipment (including motor vehicles) at the level of 50%. Deadline: December 2013.
P.26.4. Facilitation of the reallocation of budget funds by health care establishments that provide primary medical aid through funding of health care expenditures according to two economic classification-of-expenditures codes.
Formation of a single medical space
P.29.2. Placing for consideration of the Verkhovna Rada of Ukraine of the draft Law of Ukraine about the features of the activities of health care establishments. Executors: Prime Minister of Ukraine, Ministry of Health of Ukraine. Deadline: March 2013 (extended until November 2013).
P.29.3. Placing for consideration of the Verkhovna Rada of Ukraine of the draft Law of Ukraine on Amendments to the Tax Code of Ukraine regarding the features of the taxation of health care establishments created as nonprofit public utility companies, as non-profit enterprises.
Verkhovna Rada of Ukraine shall
1. Amend art. 49 of the Constitution of Ukraine concerning the abolition of the provisions of health services free of charge.
2. Amend the Constitution of Ukraine introducing a point on ensuring provision of free emergency medical care and the list of free medical services for certain strata of the population defined by the legislation of Ukraine.
3. Legislate the sources of health care financing: budget, fund of compulsory medical insurance, and voluntary health insurance.
4. Cancel the Law of Ukraine of 07.07.2011 no. 3612 “On the procedure…”
5. Determine in the Law of Ukraine “Basic Law of Ukraine on Health Care” the concept of primary, secondary (specialized) and tertiary (highly specialized) medical care specified in art. 35 of the “old” “Basic Laws…” and palliative aid, a new type of medical care.
6. Anticipate financing of air ambulance by the State Budget of Ukraine.
Ministry of Health shall
7. Optimize the network of medical institutions taking into account the existing infrastructure in administrative-territorial units: state of the roads and public transport in the first place and also after consultations with the public on the basis of information about the feasibility of the changes proposed.
8. Assess in the pilot regions the effectiveness of drafts on budgetary funds following the results of the analysis of indicators of the budget program “Primary medical aid” (including the wage rises to medical professionals for the quality and amount of their work) during 2013.
9. Continue to gradually introduce the institute of family doctor taking into account international experience and terms of personnel training (up to 8 years).
10. Create regional training centers for continuous education of medical personnel for the centers of primary medical and sanitary aid.
11. Complete the set of components according to the sheet of material and technical equipment for the established Centers of primary medical and sanitary aid. Develop primary medical and sanitary aid centers based on their staffing with specially trained experts with appropriate qualifications. Complete staffing of primary health care centers in the pilot regions with district doctors and pediatricians only.
12. Increase the "transparency" of decision-making by the Ministry of Health and hold public discussions about normative legal instruments the adoption of which requires the use of such mechanism of implementation.
13. Create a system of medical and doctors’ self-rule, which will also a body controlling the activities of the Ministry of Health of Ukraine. To this end, develop new provisions relating to the powers of the Public Council of the Ministry of Health of Ukraine, which will provide for its participation in the preparation and adoption of departmental normative legal instruments.
14. Hold an international audit of the activities of the Ministry of Health of Ukraine and of the industry as a whole with the assistance of international experts and a plan for "real" reforms.
15. Extend the conversion of government-financed health establishments into the independent subjects of economic relations.
Public organizations shall
16. Conduct public hearings on the right to health realization with the participation of the representatives of the Ministry of Health.
17. Take up the work of the Public council at the Ministry of Health of Ukraine, oblast state administrations, local self-government authorities in order to prevent violations of the right to health.
18. Participate in the creation of the doctors’ self-government bodies like professional associations of lawyers.
19. Look into the problem of expediency of trade unions of doctors and the possibility of combining (merging) merging them with the doctors’ self-government bodies.
 Prepared by Andriy Rokhansky, NGO "Institute for Legal Research and Strategies". This section was supplemented after the resignation of the government of Azarov, but at the time when possible changes to the state budget of Ukraine were not introduced yet. Therefore it reflects the state of health care financing that existed at the end of January 2014.
 State Statistics Service of Ukraine. Report "Socio-economic situation of Ukraine in 2013".
 Decision of the Constitutional Court of Ukraine of 29 May 2002 no. 10-rp/2002.
 O.Betliy. "Health insurance: not yet".
 http://www.hvilya.com/news/komu_vpoperek_gorla_dilnichna_likarnja/2013-02-14-1885, http://www.gorod.cn.ua/news_43332.html
 Course of Health Reform in Kyiv for the first half of 2013. http://kievcity.gov.ua/news/9080.html
 Dnipropetrovsk and Vinnytsia oblasts, "Health Care Reform: Preliminary findings on the first stage of reform," Institute for Economic Research and Policy Consulting, Kyiv, 2013.
 "Emergency aid: reform or Terror of medics", http://innocentsukr.blogspot.com/2013/09/blog-post_7272.html.
 "Human Rights in Health Care--2011", "Human Rights in Health Care--2012".