"Guaranteed package" and equity in health for Ukraine

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“GUARANTEED PACKAGE” AND EQUITY IN HEALTH FOR UKRAINE

Olena Oseychuk Tetyana Semigina

Abstract

guaranteed package healthcare medical

The objective of this paper is to analyze modern approaches to equality in healthcare, to outline the situation in Ukraine, and to identify the vision of Ukrainian experts' regarding the "guaranteedpackage" of free healthcare as a means of ensuring social justice. The paper is based on a desk-review (legal and policy papers, literature, and research reports) and semi-structured interviews with 13 experts. The paper considers the issues of equality in healthcare from the perspective of the normative approach and understanding health as a societal good.

Currently the World Health Organization (WHO) provides concepts of “universal coverage" and a “guaranteed package" of free medical care. These concepts and practice based on the policy are viewed as policy instruments for ensuring equality in healthcare. In Ukraine, policy of social benefits in healthcare is being barely implemented, and people do not feel socially secure. The interviewed experts do not have a coherent vision of the scope of free medical care and targeted social groups to be covered by the “guaranteed package".

One of the important challenges facing the health policy in Ukraine is the necessity to understand what groups of population have to be covered at the expense of the state budget, or what can be provided as free of charge basic services to all citizens. This problem is difficult to deal with in the context of the populist political culture and a lack of a meaningful vision from the representatives of the health sector. Taking into account the controversial public perception, it would be politically wise 1) to initiate a national debate about the scope of free medical care and social justice in healthcare, to articulate possible solutions to the problem of inequality; 2) to implement a massive information campaign and outreach to health professionals, health workers, and the whole population of Ukraine. Such activities may be carried out by civil society organizations.

Key words: social justice; healthcare, “guaranteed package" of free medical care.

Анотація

У статті охарактеризовано сучасні підходи до забезпечення справедливості в охороні здоров'я, зокрема, концепції «універсального покриття» та «гарантованого пакету» безоплатної медичної допомоги, які пропонує Всесвітня організація охорони здоров'я (ВООЗ). Стаття грунтується на аналізі літератури, вивченні нормативно-правових та політичних документів, а також на матеріалах 13 інтерв'ю з фахівцями з 12 організацій, в ході яких з'ясовувались їх думки щодо безоплатної медичної допомоги (її пріоритетів, цільових груп, виключень, механізмів фінансування тощо).

Визначено, що Україні соціальні гарантії в сфері охорони здоров'я практично не виконуються і населення не почувається соціально захищеним. Фахівці не мають узгодженого бачення щодо обсягів безплатної медичної допомоги та пріоритетних соціальних груп Результати дослідження засвідчують, що одне з важливих завдань, яке стоїть перед політикою охорони здоров'я Україною, - це сформувати бачення «гарантованого пакету» безоплатної медичної допомоги, аби зрозуміти, яку частину населення

Ключові слова: соціальна справедливість; охорона здоров'я, «гарантований пакет» безоплатної медичної допомоги.

Introduction

The policy of reducing social inequality and injustice in healthcare, strengthening the state's responsibility to guarantee free access to medical services and guarantees of free medical care are the basis of WHO recommendations (WHO, 2012). According to these recommendations of the key actor of the global health policy development should be ensured, in particular, through the implementation of the principle of universal coverage and access to a definite minimum ("guaranteed package") of medical services.

The “Guaranteed package” of free healthcare is associated with the understanding of social goods within a particular society, equal distribution, and fair access to healthcare services. The understanding of social justice by a definite society is of extreme value in the determination of the state guarantees, including in healthcare, which is considered to be one of the key tools of social protection.

In Ukraine, medical services are not accessible by many people (Semigina, 2015; Semigina & Mandrik, 2017). The public discussions on health system reforms have been going on for years, while patients' level of dissatisfaction with healthcare remains high (State Statistical Committee of Ukraine, 2013; Stepurko, Anufriyeva, Tymoshevska, 2017), and the health status of population is low compared to other European countries (Lekhan, Rudiy, Shevchenko, Nitzan & Richardson, 2015). It is worth noting that the hierarchically structured system of healthcare, its outdated governance (World Bank, 2015), as well as the political, economic and social principles of health policy have remained mainly unchanged since the Soviet times. At the same time, marketization of all areas of life in Ukraine resulted in new formal and informal economic practices within the system of healthcare (Health index. Ukraine, 2016; Pavlova, Gryga, Murauskiene & Groot, 2015). All these processes raise questions about social justice within the Ukrainian healthcare system.

Therefore, the objective of this paper is to overview the current approaches to reaching social justice in healthcare and to outline the situation in Ukraine, as well as to clarify the vision of the "guaranteed package” by Ukrainian experts as a means of ensuring social justice in healthcare. The paper starts off with a review of modern literature on equity in health and problems of social injustice in healthcare, followed by the highlights from the overview of the Ukrainian legislation and findings from the interviews with experts. The discussion section provides insights arising from the comparison of Ukrainian and international visions of the "guaranteed package” of health services and health equity.

Conceptual framework

The issues of equity in health and social justice in healthcare has been studied by various researchers and from different perspectives, among which are: A. Sen (2002), M. Powers (2006), R. Rosamond, M. Battin and A. Silvers (2012) and others. The theoretical framework for our study is mainly based on the ideas of J. Ruger (2010) and N. Daniels (2001) who believe that in order to reduce the injustice in healthcare it is necessary to decrease the inequality in access to healthcare services and improve the living conditions of people.

Ruger (2010) has proposed "health capability paradigm", which originated from the idea of providing free access to servicies that can prevent disease and premature death. This paradigm is a combination of philosophical, social and political theories and practices that can provide convincing arguments for a society and create a system to achieve the best possible health. The researcher offers a wide interpretation of "major drivers" of health. She interprets the "major drivers" as healthcare, prevention and precaution, clean air, safe drinking water and nutritious food. At the same time Ruger raises the question of allocation of resources from rich to poor, from the healthy to the sick. However, according to the author's vision, social justice in healthcare is not so much about the availability of resources as the real people with their specific, very personal problems. That's why social justice in healthcare is a system that deals with the needs of a patient and aims to resolve his or her personal problems related to health.

Daniels (2001) is focused on searching for answers to different questions. One of them is how to combine equal access to health services and endless needs with limits of resources in the sector.

For the purposes of operationalisation, equity in health is considered in this paper as the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/ disadvantage--that is, wealth, power, or prestige (WHO, 2008). It was important for us to take into account the views of P. Braveman and S. Gruskin (2003) who point out that healthcare has become more expensive, and yet not any more efficient, nor progressive. This is why the questions whether the resources are distributed properly and whether equal access to them is provided, have arisen. Currently, this area needs additional financial investments, but it does not solve the healthcare problems, as it is commonly believed that the root of the problem is unequal access to resources rather than improper resource management. The analysis of the available literature (Cole, 2001; Marmot, 2006; Marmot & Allen, 2014) demonstrates that in the modern world injustice in health is characterized by two aspects: health problems could be avoided and prevented. This brings forth an obvious need for adequate government management and a policy of reducing social inequities in healthcare.

International organizations consider universal health coverage an important mechanism of social justice, which is defined as an established list of services available to the population without any additional payment. Universal coverage means that all people receive basic, needed healthcare services of the proper quality without the risk of getting into financial difficulties. It should be noted that despite the idea of being basic, the concept involves sensitivity to the individual needs of each patient, otherwise, it would be wrong to say that universal health coverage is a standard list or a minimum of the same medical services for everyone. According to WHO's experts, the most effective mechanism for funding this package is to establishment a single pool for medical purposes. WHO recommendations emphasize the development of the healthcare system on the principle of universal health coverage and are feasible for both small and large countries, since it is about the effective management of resources and introduction of the mechanisms of financial security (WHO, 2012; WHO, 2013).

The implementation of the ideas of the "guaranteed package" and "universal health coverage" varies significantly from country to country. However, we can identify several approaches to building the system of "universal health coverage" and improving access to healthcare. One of the approaches is an introduction of a list of services and programs available to the population free of charge. Suggested services are covered by public funds, regardless of the financial capability of citizens. It could be described as a "medical minimum of services" that all citizens receive free of charge, regardless of sociodemographic characteristics. Another way of compiling the "basic health package" is to cover the needs of only the vulnerable groups by state funds (WHO, 2008). Identifying services that will be included in the basket are always up for public discussion, which requires public understanding and willingness to accept the fact that some people will not get free access to treatments they need.

Thus, we will look at the ''guaranteed package” of health services in Ukraine through the lense of allocation of resources and (re)distribution within the health policy in order to advance promotion of health equity in Ukraine.

Methodology. The paper is based on the analysis of the literature and regulations, as well as interviews with 13 experts from 12 organizations. The interviews were focused on the experts' opinions on free medical care (sphere priorities, target groups, exclusion mechanisms, financing, etc.).

The study was conducted in 2016. It was carried out from the perspectives of: 1) normative approach to policy-making; 2) consideration of health as a public good, for ensuring and the distribution of which the government is responsible according to the egalitarian views on healthcare (Semigina, 2013). The results of the research are presented in the descriptive analysis. We are aware of the limitations of this analysis based on the qualitative methods of research.

Findings. Legislation in Ukraine and the reality of`free medical care'. The Constitution of Ukraine (Verkhovna Rada of Ukraine, 1997) guarantees all citizens a right to `free medical care' that should be ensured by the state support of healthcare provision within the state and municipal settings. However, Ukrainian legislation does not clearly interpret such terms as "state social guarantees in healthcare", "guaranteed package of healthcare" and "guaranteed medical care". Guaranteed healthcare was determined indirectly by Order "On approval of the Program of the state-guaranteed free medical care for the citizens" (Cabinet of Ministers of Ukraine, 2002). According to this document, the state guarantees emergency aid and inpatient care.

However, even today this partial list of services is not being implemented by the state - according to the experts, legal guarantees and the health system regulated by them exist completely independently and in isolation from each other. Hospitals have to resort to semi-legal schemes to attract additional funds under the conditions of unsustainable budgetary funding (creationing of so-called charity funds at hospitals; doctors receive money for services directly from patients or their relatives, etc.).

Existing legislative innovations and strategies, including the "National Strategy of healthcare reform in Ukraine for the period of 2015-2020" (Strategic Advisory Group on Healthcare Reforms in Ukraine, 2014), consider not only a fundamental change in the health system as a way of changing the allocation of funds and financial mechanisms, but also (?) an introduction of specific and adequate scope of free medical care.

Experts' views on guaranteed package of healthcare. Interviews conducted with the experts demonstrate that the vision of a guaranteed healthcare package differs somewhat from its definition by the international organizations and the experience of other countries. The experts see it as a broad package of services, except for certain procedures and medical conditions that could only be treated for an additional fee, while the authors of the "National strategy of construction of new healthcare system in Ukraine for the period of 2015-2025" consider it simply as a tool of social justice and define it as a limited set of basic services and emergency conditions (Strategic Advisory Group on Healthcare Reforms in Ukraine, 2014).

The experts highlight the principles of forming a "guaranteed package” in Ukraine: 1) the prioritization of healthcare system (maternity and childhood, cardiovascular disease, cancer, socially dangerous diseases); 2) feasibility; 3) the scientific evidences of its scope.

Selection of someone out of a certain group following specific criteria is the usual practice in the Ukrainian healthcare system. As a priority Ukrainian experts single out such groups as children up to 5 years old, pregnant women, and the elderly. In addition, all experts agree that the number of privileged people must be reduced (in Ukraine, based on various criteria besides medical diagnosis, nearly 65% of the population are entitled to benefits).

However, 8 out of 13 respondents stressed the importance of taking into account the level of development of our country. In particular, the following opinion was expressed:

"We can follow the recommendations of the WHO, EU, One Health, Health in all policies, European Health 2020. These strategies are the guidance for understanding the latest trends in healthcare. But the Ukrainian way will be unique, different. We are at a different stage of development. Many of our doctors, managers are from the Soviet times, while we want to introduce top "European" standards of quality and the highest standards of treatment. This is nonsense. It's impossible."

This position indicates a conservative healthcare system and the desire to limit incremental changes. The interviews confirm that the absence of healthcare reforms is quite convenient for medical doctors and healthcare managers who serve in this system which formally is still (post)socialist and based on free-of-charge services, but in reality is market-driven and non-transparent, with a high level of informal payments by patients.

Every interviewed expert introduced a significantly different concept of the scope of free medical care. The same applies to politicians and political parties represented at the Ukrainian parliament. Their programmes are all based on the `free medical care' mottos (Central Elections Committee of Ukraine, 2014), however, only a few specified what they mean by `free care' and how this can be achieved in the context of marketization of all areas of life in Ukraine.

Discussions. Efforts of the actors of global health policy aimed at overcoming inequality in the access to health care and at improving the living conditions of people (Rugers, 2010; WHO, 2012; WHO, 2013). Nowadays the social justice in healthcare is mostly achieved not by increasing funding and raising additional funds in the industry, but by effective resource management, development of programmes to ensure universal access to healthcare, and introduction of a "guaranteed package" of free medical care. It reflects the idea that the concept of equity is an ethical principle and is closely related to a human rights paradigm that is disputable per se (Beauchamp & Childress, 1994; Braveman & Gruskin, 2003).

The controversial political and public discourse on `free medical care' and introduction of a `guaranteed package' of health services are not unique for Ukraine. So far this process can be observed within all post-Soviet and post-socialist countries (Rechel et al., 2013). The experience of Czech Republic (WHO, 2012), Estonia (Habicht & Kunst, 1999), Georgia (Gotsadze, Murphy, Shengelia & Zoidze, 2015) and Poland (Kozierkiewicz, Romaszewski & Gilewski, 2005), where health reforms have been implemented, social health insurance was introduced and the list of free medical services is being constantly revised, confirms that the formation of a "guaranteed package" of free healthcare (what services are available and for which groups of population) reflects not only the economic possibilities of the countries, but the idea of social justice, public awareness of equality and fair access to health services. At the same time, as Selvaraj (2012) stresses, the introduction of health insurance does not automatically means the equity in health. Each society, including Ukrainian, has a variety of options for ensuring the social justice, using the "health capability paradigm" (Rugers, 2010), and finding its own answers to questions about balance between equality, inequility and resources within healthcare (Daniels, 2001).

The findings of this study confirm the well- known belief that the policy priorities in the area of health always seem to be extremely controversial (Bauer, 2014; Levy & Sidel, 2013; Sen, 2002). When we are talking about a “guaranteed package”, society must decide what it is willing to pay, and for whom exactly. Idealistically, the political decision should be based on mathematical calculations taking into account the scientifically proven effectiveness of medical procedures. However, the public perception of social justice has significant importance today for shaping health policy priorities, determining what health services the state will provide for its citizens, and what it will not, (repetition). So, the agenda setting in the field of healthcare provision is highly value-based.

Our study reveals that the Soviet ideas of social justice are still being implemented in the Ukrainian legislation, to some extend improved on by the WHO suggestions on universal access to healthcare, and supported by the local experts. But the WHO does not push for definite political tools, while local Ukrainian policy-makers insist on keeping public ownership in healthcare and state-controlled practices. As White (2010) pointed out, many of the values of the Soviet period remain intact within the post-Soviet societies.

This causes a lot of contradictions. In the Ukrainian case, many of the political groups promoting free healthcare and opposing social health insurance are calling for the defense of entrepreneurship and tax reduction. The public opinion on healthcare is ambivalent (Health index. Ukraine, 2016).

In our opinion, the community of healthcare professionals, with an understanding of controversial perception of the healthcare reorganization in Ukraine, should initiate the next steps for the successful implementation of the idea of a "guaranteed package” as a basic concept of the future healthcare system: 1) NGOs and patient organizations should initiate a national discussion on the scope of free medical care and understanding of the social justice in healthcare, articulating possible solutions to the problem of inequality; 2) health policy stakeholders should introduce a powerful information campaign and outreach for healthcare professionals, specifically for healthcare workers and the population of Ukraine as a whole. Society must be able to articulate its position specifying what it wants to see in a package of free healthcare: effective social interventions such as programmes for disease prevention, vaccinations, screenings, physical examinations, or such medical intervention as emergency medical care and treatment of critical conditions).

Concluding remarks. The current state of the healthcare system does not allow Ukraine to fully ensure the right of citizens to healthcare at the level defined by international standards and the laws of Ukraine. Social guarantees in healthcare do not get fulfilled and remain declarative law.

One of the urgent challenges facing health policy in Ukraine is to design a vision of a free healthcare "package" in order to identify the percentage of population that can be covered by the state budget, or which basic services can be provided to all citizens free of charge. This task is difficult to implement within the current populist political culture exacerbated by a lack of a coherent vision for healthcare from health experts and policy-makers.

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