Problems and priorities of the formation of public management mechanisms for the development of rehabilitation system in Ukraine

У статті на основі проведеного аналізу встановлено роль і значення системи реабілітації у розвитку та реформуванні системи охорони здоров'я в Україні, сучасний стан системи реабілітації, теоретично обґрунтовано нагальну необхідність трансформації системи реабілітації з урахуванням реформи охорони здоров'я, яка проходить в країні. Нами наведено новий погляд і підхід до розвитку системи реабілітації в охороні здоров'я як реалізації цілей сталого розвитку суспільства, проголошених Організацією об'єднаних націй, зокрема цілі 3 щодо забезпечення належного стану здоров'я для усіх верств населення та вікових груп. Наголошено на необхідності реформування системи реабілітації як складової національної парадигми громадського здоров'я.

В статті наведено результати оцінювання іноземними експертами-медиками сучасного стану системи реабілітації в Україні з рекомендаціями щодо її реформування з огляду на медичну та освітню (підготовка фахівців у галузі) складові. Зроблено аргументовані висновки, зокрема про те, що оптимальним варіантом вирішення вищезазначених проблем є формування нових механізмів публічного управління, насамперед організаційного, вирішення питань політики та законодавства щодо осіб з обмеженнями життєдіяльності та їх реабілітації; належного збору та аналізу статистичних даних для планування обсягу реабілітаційної допомоги, реалізації принципів доступності реабілітаційної допомоги для усіх верств населення, реорганізації вже існуючих реабілітаційних центрів та створення нових згідно основних принципів реформування системи охорони здоров'я.

Ключові слова: реформування системи охорони здоров'я, система реабілітації, державне управління, Україна.

With the health and demographic trends that characterize the 21^st century, health systems face new challenges; people are living longer and with higher levels of disability. Strengthening health systems to provide rehabilitation services helps ensure people not only live longer but live well (World Health Organization (WHO), 2017) [1].

In February 2017 WHO hosted Rehabilitation 2030: a call for action, which brought together over 200 rehabilitation experts from 46 different countries. The meeting highlighted the urgent need to address the profound unmet needs for rehabilitation around the world, and the necessity of rehabilitation in achieving Sustainable Development Goal 3 to «ensure healthy lives and promote well-being for all at all ages» [1].

The main problems in rehabilitations sphere due to analyses of WHO are [1]:

1. density of skilled rehabilitation practitioners is less than 10 per 1 million population in many low- and middle- income countries;

2. 75 % of the total number of years lived with disability in the world are linked to health conditions for which rehabilitation is beneficial;

3. prevalence of health conditions associated with severe disability has increased by 23 % since 2005.

The 2015 Global Burden of Disease Study (GBD) - the source of the most consistent global, regional and national epidemiological evidence for all diseases and injuries in the current period - shows that 74 % of the total number of years lived with disability (YLDs) in the world is linked to health conditions for which rehabilitation is beneficial [2]. These conditions include non-acute conditions associated with significant disability such as noncommunicable diseases, musculoskeletal conditions (such as low back pain), maternal and perinatal conditions, nutritional deficiencies and injuries, as well as certain communicable diseases. Furthermore, 15 % of the total number of YLDs in the world is caused by health conditions such as epilepsy, multiple sclerosis, and cancer that are associated with severe levels of disability. The prevalence of these conditions and the absolute numbers of associated YLDs has increased dramatically over the last decade. The prevalence of health conditions associated with severe disability today has increased by nearly 183 million compared to 2005, a 23 % increase. The number of YLDs for these conditions has risen since 2005 by more than 17 million that grounds Global need for rehabilitation [2].

The Sixty-sixth World Health Assembly (WHA) in resolution WHA66.9 endorsed a coordinated global action plan by all stakeholders to «strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation» [3].

The essential working areas for action are set out in the Joint commitment to action for rehabilitation document, to be adopted by all participants at the 2017 WHO meeting on Rehabilitation 2030: A Call for Action. The research conducted for this background paper indicates that [4]:

1. The need for rehabilitation is projected to increase in the following decades due to the ongoing demographic, epidemiological and nutrition transitions, as well as improved acute care and better survival.

2. Better data showing the actual number of health professionals generally, and rehabilitation professionals specifically, are needed. These data are especially important for evidence informed policy for rehabilitation.

3. There is a need for research to estimate and predict the future number of health professionals per 1 million population required to satisfy the demands for rehabilitation.

4. Efficient models of rehabilitation care are needed in high-income countries, and more research to identify the causes for underutilization of rehabilitation services is necessary.

5. There is a need for global action by professional organizations, development agencies and civil society to work towards developing and maintaining a sustainable workforce for rehabilitation.

The article aim is to analyzes the М_ета role and importance of the rehabilitation system in the development and reformation of the health care system in Ukraine, the current state of the system of rehabilitation and ground the necessity for transformation of the rehabilitation system by means of formation of new mechanisms of public administration taking into account the health care reform in the country.

Presenting article main body

Creating an effective and comprehensive rehabilitation system (medical, psychological, social, employment) in Ukraine is a matter of national importance. The pressing problems of modern society are the aging of the population, the increase in the number of people with disabilities, the percentage of disabling diseases and conditions, injuries and traumas, wounds etc. Further social rehabilitation and employment of people with disabilities (including children with cerebral palsy) and their psychological support are necessary.

Rehabilitation is a socially necessary functional: medical and social rehabilitation of patients and disabled that is carried out by comprehensive medical, psychological, pedagogical, professional, legal, state, public and other measures, with the help of which it is possible to return disabled to active life and work. So the main purpose of rehabilitation is the quickest return of a patient or disabled person to a full-fledged social life and the most complete recovery of lost work capacity. health ukraine administration

This fully corresponds to the main priority aspects of the effectiveness of rehabilitation - economic and social.

The problem of creating an effective rehabilitation system in Ukraine and the professional training of specialists working in the field of health promotion in profile centers is complex and relevant to the Ukrainian society. By the official statistics data on the beginning of 2017 in Ukraine there are more than 2.6 million people with disabilities, including about 157 thousand children, the number of persons with disabilities is calculated per 1000 population is 61 in 2017, while in 2001 - 53 [5].

The necessity of forming new mechanisms of public administration for the development of the rehabilitation system in Ukraine is outlined in the following strategic and regulatory documents: Decree of President of Ukraine dated January 12, 2015, No. 5/2015 «On the Strategy of Sustainable Development «Ukraine-2020»; Cabinet of Ministers of Ukraine Resolution No. 442 of September 10, 2014 as last amended by the Resolution of the Cabinet of Ministers of Ukraine dated April 20, 2016, No. 299 «On Optimization of the System of Central Executive Bodies»; National strategy for reforming the health care system in Ukraine for the period of 2015-2020, Concept of financing health care reform in Ukraine; Draft Strategy for the Development of the Social Services System in Ukraine for the period up to 2022; Draft Law of Ukraine «On Disability Prevention and the Rehabilitation System in Ukraine»; WHO Report «Assessment of the Rehabilitation System in Ukraine in 2015».

In particular, according to a WHO assessment in 2015 the current system of rehabilitation in Ukraine faces a number of problems [6]: 1) the harmonization of the term «disability» in our country with the international understanding of limitation of life and functioning; 2) the need to change the legislation regarding the rehabilitation system; 3) coordination between authorized ministries and organizations; 4) the absence of an integrated system of rehabilitation assistance covering all phases and levels of medical care for all segments of the population; 5) bringing the staffing of the rehabilitation sphere to European standards.

The socio-economic preconditions for reforming the current state system of rehabilitation in the direction of forming new mechanisms of public administration for its development are the low efficiency of the system of rehabilitation and provision of social and medical services, which is manifested in the following [6]:

1. Rehabilitation services are traditionally provided in the resort environment. Ukraine does not have a comprehensive rehabilitation system that will cover all phases and levels of assistance, rehabilitation services are not available to many people who need them. There are several rehabilitation services, but there is no systematic rehabilitation plan in emergency care facilities in the suburban and long-term stages. There is no relationship between the various stages of the provision of medical care (due to different departmental subordination of rehabilitation institutions). At the same time, provision of auxiliary resources is separated from health-related rehabilitation services, resulting in inadequate results and waste of resources;

2. Low level of coordination between authorized ministries and organizations - responsibility for social services for people with disabilities and rehabilitation of this category, working sick and retired, divided between two ministries: the Ministry of Health (responsible for the «medical» component of rehabilitation) and the Ministry of Social Policy (which is responsible for social compensation and provision of auxiliary means). The systemic problem is the discrepancy between the organizational structure of the department and the area of its functional responsibility.

A particular difficulty is the need to rehabilitate victims of armed conflict in eastern Ukraine [7]. On the one hand, there are a high number of wounded soldiers, who in many cases also have a serious mental trauma. Armed conflict has also led to the emergence of wounded and injured civilians in need of rehabilitation assistance. Rehabilitation of patients and victims during hostilities - a process requiring qualified specialists of various profiles, expansion of state programs, active involvement of modern technologies in the rehabilitation process, and the creation of modern multidisciplinary rehabilitation centers. The multifaceted nature of the tasks of medical, physical and psychological rehabilitation of victims in combat requires the effective functioning of this system as an independent direction of clinical and social medicine [7].

Unresolved issues are the financing of rehabilitation services: various funds are responsible for financing rehabilitation services for different segments of the population; rehabilitation facilities are traditionally concentrated in health resorts - this is national peculiarity of organization of rehabilitation service in Ukraine and it is due to a considerable number of sanatorium and health resorts in all regions of Ukraine, distribution throughout the country of natural healing resources, which are traditionally used in rehabilitation programs in health resorts (sanatoriums).

Since rehabilitation is an essential Ви_сн0вки component of the health care strategy and at the same time requires close coordination of services from different sectors (medical, social, educational, legal), the optimal solution for the above problems is the formation of new mechanisms of public administration, primarily organizational, which involves the establishment of a separate Department of Rehabilitation and health resort (sanatorium) treatment in one ministry, whose activities are due to a number of the following necessary but not available services today:

• in matters of politics and legislation on persons with limitation of vital functions and rehabilitation; collection and analysis of statistical data on the need for rehabilitation measures for certain diseases and conditions; adaptation and implementation of international definitions and diagnostic tools in rehabilitation practice [8];

• for the medium-term planning of rehabilitation services, an urgent database on the epidemiology of disability (including those with acute and chronic diseases, psychological disorders) and rehabilitation needs is needed;

• health-related rehabilitation services should be implemented at all levels of health care (primary, secondary, tertiary) and for all stages of care (acute, sub-chronic, long-term). The primary health care sector should play a stronger role in long-term rehab and become the starting point for specialized rehabilitation services;

• integrated provision and integration of auxiliary facilities into medical rehabilitation programs;

• training of professionals in the field of rehabilitation in accordance with the standards of the European Council for Physical and Rehabilitation Medicine [6,8];

• inventory of existing rehabilitation institutions, their certification according to international standards;

• provision of rehabilitation sphere with scientific and practical support (development of criteria for evaluation of existing rehabilitation institutions in accordance with European standards, clinical protocols, equipment tables according to the specialization of rehabilitation institutions, training of specialists of the branch) at the expense of existing research institutions in the rehabilitation sphere (which are concentrated in the Ministry of Health) .

It should be noted that in order to build a comprehensive system of rehabilitation, the draft law of Ukraine No. 4458 «On the prevention of disability and the rehabilitation system in Ukraine» [9] provides for the development and approval of standards for rehabilitation. Its adoption will allow the introduction of a legal basis for the implementation of effective measures for the national system of rehabilitation, prevention of disability and outline the range of people who receive such rehabilitation; to define the powers of state authorities in this area, and to establish the levels and mechanism of rehabilitation.

References

1. World Health Organization. Rehabilitation 2030: A Call for Action. URL: http://www.who.int/rehabilitation/ rehab-2030/en/.

2. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016. 388(10053). Р 1545-602.

3. WHO global disability action plan 2014-21: Better health for all people with disability. Geneva: World Health Organization, 2015. URL: http://www.who.int/disabilities/ actionplan/en/.

4. The need to scale up rehabilitation. URL: http://www. who.int/disabilities/care/NeedToScaleUpRehab.pdf?ua=1

5. Соціальний захист населення України: Статистичний збірник; Від. за вип. О. О. Кармазіна. Державна служба статистики України, 2017. 123 c.

6. Golik V., Syvak O. Assessment of national disability, health and rehabilitation system in Ukraine. Reflections disability and rehabilitation subcluster meeting, march 11, 2016 Український вісник медико-соціальної експертизи. 2016. № 1 (19). С. 26-62.

7. Реабілітація постраждалих в умовах надзвичайних ситуацій та бойових дій. Посттравматичний стресовий розлад; За ред. К. Д. Бабова, І. Я. Пінчук, В. В. Стеблюка. Одеса: Пальміра, 2015. 217 с.

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