A pandemic might not seem like the best time to reform a country’s medical system. But in Ukraine, years of attempts at revamping hospital financing collided with the outbreak of COVID-19 this March. Some Ukrainian medical staff stress that the overhaul of the state-run financing system means that their hospitals now lack adequate funds to pay the very people risking their lives to treat thousands of coronavirus patients.
On May 20, President Volodymyr Zelenskiy conceded that the pandemic has shown that Ukraine is “medically naked.” Stressing that reforms should not mean firing doctors or closing hospitals, he called for a rethink of the country’s health-care reforms, but his exact plans remain unclear.
The reforms’ so-called second stage, which targets state financing for specialty hospitals, began on April 1, just as Ukraine’s COVID-19 tally reached 794 cases and 20 deaths. Those numbers now stand at 19,706 cases and 579 deaths.
Just over a month into the changes, President Zelenskiy predicted that the reforms could lead to the dismissal of 50,000 doctors and the closure of 332 hospitals.
The government traditionally had financed hospitals based on their number of beds. Now, the funds will be allotted based on the number of patients treated. To arrive at the sum, the National Health Service, the government agency overseeing the distribution of funds, calculates how much one patient would cost a hospital to treat, also factoring in prices for food, medical personnel’s salaries, and utilities.
“Those medical institutions which have the necessary equipment, the necessary specialists, historically have provided a large range of services to the population, they justifiably received more,” explained National Health Service chief spokesperson Tetyana Boiko.
As such, the more patients a doctor has, the more money his or her hospital will receive from the government.
But while some hospitals have seen their funding increased, the Health Ministry stated earlier this month that nearly a thousand – around half of the country’s 2,200-some hospitals -- are underfinanced.
Consequently, many facilities have slashed their number of physicians and thousands of doctors have had their wages cut.
Dr. Inessa Shevchenko, director of central Ukraine’s Dnipropetrovsk Regional Rehabilitation Hospital, went on a hunger strike in late April to protest the amount of financing her own hospital had received.
That month, the National Health Service slashed the facility’s monthly financing by more than five times, she told Current Time: from 2 million hryvnia, or about $75,224, to 237,000 hryvnia or $8,914.
Other doctors in Dnipro and other cities also opted for hunger strikes.
The reform also affected facilities not involved in treating infectious diseases.
Barely holding back tears, Dr. Lyudmyla Groshilina, who has worked for 20 years at Kyiv’s Pavlov Hospital for psychiatric patients, said in late April that her hospital was told that it needs to lay off 450 employees, including nurses and paramedics. The staff that remained were required to sign an agreement about a pay cut, she claimed. All part-time jobs or moonlighting outside the hospital to supplement its wages have been banned, she added.
“Those who will stay as staff will begin to look for other jobs for themselves,” said Groshilina, a department manager. “And already now, they say that if they’ll find work – and they’ll find it – that then we’ll be left without personnel.”
Since the financing reform began, “I haven’t slept or eaten,” she added.
A nurse who gave her name as Svetlana is among those thinking about resigning. She has worked in the psychiatric hospital for 12 years. Up at 3 a.m., she arrives at the hospital by 8 a.m.
Before the reforms, she said she received a hryvnia-denominated monthly salary of around $250; as of late April, that pay had fallen to just $120 per month.
“It’s a very small salary for work with people as ill as we have,” Svetlana remarked.
President Zelenskiy, elected in 2019 on a landslide, again emphasized on Wednesday that he understands such medical professionals’ predicament.
"If all psychiatric hospitals and [tuberculosis] dispensaries go on strike because they’re closing them, this is the wrong reform. It is unwise,” he said. “It’s not for people. It is definitely not for doctors. It’s for no one.”
The president’s May 4 assurances on this count prompted Dr. Shevchenko, who says she does not oppose reforming the healthcare system, to end her hunger strike. But, apart from a commission of experts who assessed the reforms, no major changes appear to have been made since then.
The National Health Service already has stated that it is auditing Ukraine’s medical facilities so that more hospitals do not close.
Like President Zelenskiy, Deputy Health Minister Viktor Lyashko appears frustrated by how the reforms have reduced medical professionals’ salaries and hospital budgets.
In a May 3 interview with Current Time, Lyashko, the country’s chief physician, conceded that Ukraine’s financing for hospitals’ infectious-disease sections is “a complete failure.” He disparaged the concept of financing hospitals based on previous patient cases.
“That shouldn’t happen because, after this [pandemic], flare-ups of infectious diseases will occur and the healthcare system, the hospital system, won’t be ready to take infected patients.”
He emphasized that doctors should not be laid off as a way to cope with financial shortfalls. “As today’s experience has shown us,” he said, “we should protect our doctors. They’re on the front line, they’re working.
In response to complaints from medical professionals that they have not received promised bonuses for working with coronavirus patients, Zelenskiy pledged on May 20 that their salaries would be increased by 300 percent this week.
The supplement already has been distributed to 15 regions, he claimed, blaming unspecified “technical problems” for why all of Ukraine’s 27 regions have not yet received the money.
Kyiv has transferred all the necessary funds for medical assistance to local officials, he said.
The National Health Service has advised financially strapped hospitals to turn to these officials for help.
In the southwestern region of Chernivtsi, which has Ukraine’s highest COVID-19 infection rate, Oleksiy Kaspruk, mayor of the region’s eponymous administrative center, indicated that the city still has not received the funds for the 300-percent salary increase.
But it has financed the salary supplements that Chernivtsi’s municipal Hospital No. 1 pays out of its own budget. The bonuses include 15,000 hryvnia for doctors (a bit over $561), 10,000 hryvnia ($374) for nurses, and 7,000 hryvnia ($262) for assistant medical personnel.
The monthly salary for doctors at the Chernivtsi hospital currently ranges between 18,000 and 25,000 hryvnia ($673-$935), Kaspruk estimated.
Both the mayor and a hospital physician were cautious, however, about President Zelenskiy’s promise of a 300-percent increase in medical workers’ salaries.
“This is all still in the works,” said Dr. Anna Rybarchuk, an anesthesiologist at Hospital No. 1. “They promise that it’ll happen, but, for now, there’s no 300 percent.”
“Now, the [central] government should compensate the hospital for this money [paid as bonuses] because this money was not included in the program for the fight against COVID,” stressed Mayor Kaspruk.
The mayor, a member of the liberal opposition Front of Changes party, did not identify why the state had not paid the money for bonuses to date. “They’ve promised, and now they’re promising, promising, that everything will be fine. The virus doesn’t wait. For that reason, we’re fighting today and waiting for tomorrow.”
Hospital No. 1’s outlay comes amidst medicine shortages for diseases or conditions other than COVID-19, such as diabetes, renal failure, and cardiovascular problems, he noted.
Sometimes, he added, the hospital must ask relatives of a patient to buy the medicine themselves. “That’s the reality, from which no one can hide and it’s impossible to conceal,” he said.
Whatever its domestic budgetary problems, Ukraine expects to receive considerable international assistance for overcoming weaknesses in its health-care system.
On May 19, the U.S. Department of State announced that it will allot $15.5 million to Ukraine to help with combating the pandemic. The bulk of the assistance, $13.1 million, will go to enhancing “the ability of local health care institutions to care for the sick and combat further spread of COVID-19,” it announced.
These funds come on top of 30 million euros (just over $32.9 million) from the European Union for purchasing medical equipment and supplies as well as bolstering skills among Ukrainian medical professionals and at the Health Ministry.
Perhaps those funds helped boost Zelenskiy’s confidence when assessing Ukraine’s COVID-19 record on May 20.
When compared with countries of comparable size and population, Ukraine is “one of the best” for rates of infections, deaths, and recoveries, Zelenskiy asserted. (Both France and Spain, close to Ukraine in size and population, have registered far higher numbers. )
“We’re champions in the fight with the coronavirus,” he proclaimed.