Conception:

The necessity of introducing changes into the Ukrainian medical care system appeared long ago. This necessity is proved both by sociological researches among Ukrainian population, the majority of it being dissatisfied with the present situation in the given sphere, its accessibility level and medical care quality, and by correspondent statements made by politicians of various levels.

Creation and implementation of the social health insurance system is one of the most important and efficient instruments that may serve for reforming the health sector.

The mandatory health insurance scheme is based on citizens' individual contributions which are accumulated in a special fund created exclusively for purposes of financing heath services for population. The main advantage of the system is that it is more transparent and allows less political bargaining if compared with budgetary financing. The system allows to provide for:

• more adequate determination of the need for resources necessary for the health care system functioning and more efficient application of these resources;
• high quality of medical care and a high level of public control over activities within the health care sector as a whole and over the use of resources in particular;
• increasing responsibility of each member of the society for maintaining his/her health;
• the optimal ratio between satisfaction of patient's interests and interests of the medical staff.

At the same time, implementation of such a system needs to be understood as a lingering and dynamic process. In the course of the process, it is necessary to create legal, economic and social conditions, to provide for corresponding educational and informational activities among politicians, managers, medical staff and the general public on the whole that would help them understand advantages of the new system.

The overall objective of the Project consists in contributing into development of an effective and efficient health care financing and management system in Ukraine.

Project activities include:

Analysis of the current health care system with the purpose of finding out and eliminating its negative characteristics and providing for the maximally efficient use of its positive ones;

Development of two pilot projects in Kharkiv and Zhytomyr oblasts with the purpose of implementing the "best practices";

Development and testing in practice of the health insurance system key components, especially the contracting process to be held between medical service providers and purchasers;

Substantiating the content of the guaranteed medical services package, i.e. the list of services that are to be provided at the expense of public financial resources, as well as implementation in medical institutions of new financial and managerial procedures able to increase the level of efficiency of the health care system;

Development and implementation of sustainable training processes for specialists in the field of health management and financing;

In cooperation with the MoH, development of strategic and business plans for organization of the future health insurance system;

Implementation of procedures of monitoring and control over financing and management processes within the health care system.

Carrying out the Project will contribute into independent and more efficient control over medical institutions' activities.

• Governmental officials of all levels
• Administrators of medical institutions
• Medical staff
• Mass media
• General public

Components of the Project:

• To build capacity within the MoH to prepare the pre-requisite conditions for introduction of social health insurance.
• To develop two pilot projects to demonstrate efficient and effective world heath insurance "best practices".
• To develop sustainable training processes for specialists in the field, medical institutions' administrators and experts related to the HIF.
• To provide for positive perception of the reform among population by means of implementing a wide-scale public awareness campaign in mass-media.

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Health Financing and Management: Necessity of Changes

Excerpted from the interview of the EU Project Team Leader Dr. Antonis Malagardis given to the "Vashe Zdorovja" newspaper (completed, modified, can be used by mass media)

From January, 29 2004, the European Union Project "Health Financing and Management in Ukraine" began its activity in Ukraine. The Project is designed for two and a half years, and it will finish its work in April, 2006.

The Project Objective.

The project is a part of the European Union technical assistance initiative. The Project's objective consists in providing assistance for development of effective and efficient financing and management in the public health sector, including by means of creating favorable conditions for future implementation of social health insurance. All this is supposed to contribute into fulfillment of the strategic goal that is so extremely important for the society, i.e. improvements of quality and availability of health services and, as a result, improvement of the health status of the population.

Spheres of the project's activity:

• One of the major spheres of the Project's activity is working out of new models of medical services and the health system management on the basis of two pilot regions (Popilnjansky Rayon of Zhytomyr Oblast and Zolochivsky Rayon of Kharkiv Oblast) that were selected in cooperation with the Ministry of Health of Ukraine. For this purpose, it is planned to use modern strategies that have proved their efficiency in other countries, including the countries that until recently had public health systems similar to the Ukrainian one. The objective of this sphere of the Project's activity is to demonstrate effectiveness and efficiency of the new model of the health system financing and management using concrete examples of pilot regions.
• Organisation and realizations of trainings for persons who are responsible for political and administrative decision-making, heads of medical facilities. For experts in the field, trainings will be organized during which practical approaches necessary for more effective health financing and management will be explored.
• Extensive explanatory work with the population dealing with possible ways of making the system of health financing and management more effective, stable and transparent, clarifying what health insurance is, what advantages it has, how it is going to work in practice and how it may bring to reality expectation of the population connected with the health system.
  Only then, when every person has the necessary information and becomes aware of what health insurance is, what its objective is and how it works, insurance will become a usual thing - as usual as, say, communal payments for hot water. We understand, though, very well that for this purpose we need some time (and, maybe, quite a long time). A health system reform in any country is quite a long lasting, or, to be more precise, a permanent process which is constantly in the state of development. Achievement of even insignificant results in the course of this process sometimes requires more than one year.

The Project and the Ministry of Health.

Within the MoH of Ukraine, the Project closely cooperates with the group of experts responsible for improvement of the model of health financing and management. Our task is to help them to create a legislative base which in the future would allow to implement an effective, fair and transparent system of mandatory health insurance using for this purpose the best practices and strategies proven by the European and universal experience.

We suggest new mechanisms of health management and financing to the MoH, we advise on how it is possible to use these mechanisms to make the sphere of health services both economically stable, qualitative and acceptable for patients, doctors and managers, i.e. for all categories of society that come face to face with it.

On the other hand, we aspire that people understood that free of charge medical services do not exist, that each of these services has its cost that must be compensated for the one who renders the service. Another thing is that a set package of the most vital medical services from the social and medical points of view should be covered at the expense of socially generated public sources (taxes, fees paid into the system of social insurance), while other services which are not included into this package and, as a rule, represent, so to say, "subjects of medical luxury" should be covered at the expense of individual means of the person who wishes to receive them. It is one of the basic requirements necessary for development of the systems of public health in any civilized country.

Health insurance.

According to the Project's experts who base their opinion on the world best practices, the most adequate and weighed way of further development and improvement of the model of health financing Ukraine is future implementation of social health insurance, within the framework of which the state must guarantee to everybody equal rights for access to necessary medical services. It is the fairest of all models of financing of the health sector existing in the world, which, at the same time, also allows providing for the target character of financing.

" As it was emphasized above, a package of guaranteed, accessible for everybody medical services should be developed. It will not include specific types of medical service provision. The advantage of the guaranteed package will consist in that it will be the same for all people insured, irrespective of the actual size of insurance contribution which is determined on the basis of the income level of each person insured (unlike insurance programs which are offered by commercial private insurance companies within the framework of voluntary health insurance, where the list and quality of medical services accessible for a concrete person insured depend, first of all, on the size of the insurance contribution, namely on the sum that this or that person is able to pay for the insurance program). In the case of social health insurance, the deciding factor for medical services provision is the state of health of a person insured, not his/her solvency.

• So, the most important principles of the social insurance system are principles of solidarity: at the expense of payments made by the employed, medical services for students and children will be covered. Concerning unemployed people - a certain part of money will, probably, arrive from the Fund of Insurance against Unemployment. And pensioners will be cured at the expense of means from the Pension Fund. For this purpose, it is necessary to adjust interaction of all social structures of the society.
• Insurance should be automatically provided at a person's place of work. At the place of work, a certain percent of everybody's salary will be raised, these means will be collected within the Health Insurance Fund (HIF), and from it the cost of medical services provided for a person insured will be covered, the doctor's salary will be paid, etc.
• Between the provider of medical services (a medical facility) and the HIF, a contract will be signed (in the future - on the competitive basis), in which conditions of medical services provision and compensation of their cost to the provider will be precisely defined. A doctor's salary will depend on the number of his/her patients, therefore good experts who will have a plenty of patients will have quite a significant additional income. In its turn, creation of competition among providers of medical services will contribute into improvement of health services' quality - weaker specialists will be objectively compelled to concede their place to more competent, well prepared doctors attentive to people and to patient's needs.
• The basic principles should be efficiency and quality of medical service provision, creating the most adequate balance between effective and accessible treatment and expenses connected with it. This should be a counterbalance to the present irrational patients' long-term stay in hospitals and ineffective from the economic and clinical points of view diagnostic and medical procedures, weakening of attention to prophylaxis, etc.

The Project Team.

The project is carried out by international and local experts in the spheres of health policy, legislation, economics, as well as in the sphere of information technologies and public relations. In the course of our work, experience of health system reforming and of implementation of health insurance in countries of Europe, in particular in Germany, Netherlands (as well as in the Czech Republic, Poland and Estonia, were international technical assistance projects similar to ours contributed into achievement of positive results in reforming national systems of public health services) will be used.

The Project team includes highly qualified experts from Spain, Estonia, Poland, Sweden, Finland, and Ukraine. Besides, experts from other countries are also involved when necessary.