A Healthy Future

In early November Kyiv will host a nationwide conference on mandatory health insurance. This will be one way of convincing Ukrainian society that free health care is completely bankrupt and that paid medical services will be more effective and not all that costly. Yet the question of whether it is worth replacing the traditional practice with something that has not been tested in real life remains open.

What will insured health care give us? The Day asked Nestor Belei, Meritorious Doctor of Ukraine and head of the cardiology unit at Kyiv Oblast Hospital No. 2: “If a patient can’t afford medication, it is very difficult for him to survive or be cured, given the current level of health care funding. What little money the hospital receives is used to pay wages and utility bills. The remainder is spent on drugs and medical equipment. I think the future belongs to health insurance. But I would also like to know who will pay the insurance fees.”

It appears that most questions related to insured health care are baffling to both doctors and patients, which is no surprise: Ukraine has yet to pass a bill on mandatory health insurance. Instead we have presidential decrees “On Additional Measures to Improve Medical Services for the Ukrainian Population” and “On Health Care Development Concepts,” both of which mention mandatory medical insurance. However, the Health Ministry and other government agencies whose mandate includes health insurance have yet to show any palpable progress in this direction. However, as the Health Ministry press service enthusiastically reported to The Day, mandatory health insurance will make it possible to pool budgetary and extrabudgetary funds to ensure stable funding for health care and clearly define government guarantees, and will make doctors more accountable. In a word, the health care system will become more effective.

This explanation didn’t sound too convincing, since all of these assumptions are mostly based on Western experience. Indeed, in countries where health care is not formally free, as in Ukraine’s case, but is based on public participation in the financing of health care institutions, medicine does not appear to be a forgotten stepchild of the economy nor are our patients indigent beggars.

One unresolved question is who will fund insured health care. It is clear that after it is introduced, doctors will receive money only in the form of payment for services provided to patients. Bills waiting to be enacted propose a simple solution: social programs, including the funding of psychiatric, tuberculosis, and drug addiction clinics, as well as AIDS, hepatitis, and diabetes research, will be funded by the government. The remaining services will be covered by insurance. Employers, the Pension or Unemployment Funds, or citizens themselves will pay fees to insurers.

However, insurance companies are concerned that mandatory insurance will be introduced without an adequately elaborated system of financing. “In principle, we do not expect the introduction of mandatory health insurance to result in any profit for us,” said European Insurance Alliance deputy CEO Tetiana Baryshpil. “Instead, we are hoping that the numbers of people who want to sign up for insurance policies will increase, because it is unlikely that the packages of services covered by the government or employers will fully meet people’s needs.”

Packages offered by insurance companies are an entirely different matter. They can be very simple ones that provide coverage for such services as medical counseling, hospitalization for a certain period, and routine medical operations. Clearly, the less complex the services covered by the insurance policy, the smaller the insurance premium to be paid to the insurer. Meanwhile, wealthier clients can be insured for treatment or stays at health resorts abroad. Of course, the high cost of treatment is the most complex problem of insured medicine. This question should be solved together with the taxation problem by giving tax breaks to people and companies that invest in the health of their employees. Some attempts in this direction have been made in income tax for individuals, but these changes have yet to take effect. Only very large and thriving companies provide insurance coverage for their personnel, as they can easily afford to pay the monthly fee of $300, the average cost of an insurance package in Kyiv. Industrial enterprises prefer the old practice of supporting medical institutions at subsistence level with barely enough funds for their upkeep.

Meanwhile, medium businesses haven’t even begun to consider health insurance. “I’ve been thinking about taking out an insurance policy for my employees, but I can’t afford it. Most probably I will provide insurance coverage for my employees only after the law is passed,” says Budmatservis director Oleksiy Dybenko.

So, how much longer before this law is passed?

“I think that mandatory health insurance will be introduced in 2006,” says Serhiy Sribny, vice-president of the Skaid West Insurance Company and chairman of the medical insurance committee at the League of Ukrainian Insurance Organizations. “More time is needed to prepare the legislative basis and all the documents. But we should not delay this any longer, because the existing system of health care funding has exhausted itself and must be replaced with something new.”

Still the first steps toward insured health care have been made. An EU and TACIS pilot project, Funding and Management in Health Care in Ukraine, has been launched in Zhytomyr and Kharkiv oblasts, its goal being to improve the effectiveness of funding and management in the health care system and to introduce mandatory health insurance. According to Serhiy Sribny, the biggest advantage of this program is that without waiting for necessary legislation to be passed, it has shown how the existing laws can be used to introduce new approaches to the funding of health care institutions, increase the status of municipal hospitals, introduce financial incentives for companies that provide medical services, and improve monitoring and medical auditing methods.

Among the patients lined up at a Kyiv polyclinic to see a doctor is 33-year-old Tamara Semenko, who says, “I would like them to introduce mandatory health insurance. I can’t afford to pay premiums to insurance companies, but I realize that it’s better to pay five hryvnias every month than cough up five hundred when I get sick.”