Text by: Alisa Makarikhina, Health Care Expert at U-LEAD with Europe, and Volodymyr Harasiuk, Health Care Advisor at U-LEAD with Europe

The experts of the U-LEAD with Europe Programme analysed Law 2347-IX dated 1 July 2022 “On Amendments to Certain Legislative Acts of Ukraine to Improve the Provision of Medical Care” adopted by the Verkhovna Rada of Ukraine (hereinafter Law 2347-IX) and developed clarifications and practical recommendations for local self-government bodies regarding the implementation of its innovations and changes.

First it must be said that the innovations introduced by this law will have a direct impact on the organisation of medical care for the population of the entire country and will directly affect every citizen. That is why this article will highlight the principles and approaches to the implementation of these novelties by local self-government bodies at the municipal level, regardless of whether the municipality owns a healthcare facility.

Among the main changes introduced by Law No. 2347-IX is establishing, at the legislative level, a framework for forming a capable network of specialised healthcare facilities and determining their status and role. In practice, this means that the entire territory of Ukraine will be divided into certain service areas, the so-called hospital districts. In turn, hospital districts will be divided into smaller service areas, hospital clusters. According to the Law, the boundaries of hospital districts and hospital clusters, the procedure for their definition and operation, as well as the procedure for determining cluster, supercluster and other types of healthcare facilities included in the effective network of healthcare facilities of the hospital district, are determined by the Cabinet of Ministers of Ukraine (CMU). This means establishing a unique and capable network of healthcare facilities for each hospital district. So far, the Ministry of Health (MOH) has determined that each region constitutes one hospital district.

Capable networks of hospital districts, which will be established by the resolution of the CMU, are currently being created at the regional levels. They are based on the experience of hospital councils, the results of an expert analysis based on several years’ worth of data, approaches to and principles of creating capable networks as a critical medical infrastructure of healthcare facilities at the national level. Since at the time of writing this article, the resolution of the CMU defining and establishing the above is yet to be approved, the figures below are indicative. However, it is already known for certain that the network will consist of three types of hospitals, which are defined in Law 2347-IX, namely:

• general hospital means geographically nearest healthcare facility serving the territory with a population of 40,000 to 80,000. It offers a basic scope of 6-11 medical services such as general medicine, gynaecology, traumatology, outpatient clinic, rehabilitation and restorative care, etc.
• cluster healthcare facility will, according to the estimates, offer services to at least 150,000 people residing in the service area within 90 minute-drive from the hospital. Such facilities will be capable and multidisciplinary, offer at least 13 medical services and will be able to provide the widest possible range of priority services in the directions such as cardiology, neurology, general medicine, orthopaedics, infectious diseases, obstetrics and gynaecology, intensive care of newborns, inpatient rehabilitation in the subacute period, etc.
• supercluster hospital is the most capable facility in the region — usually a regional hospital — encompassing all highly specialised facilities of the region, such as cardiology clinics.

Here, it should be noted that although Law 2347-IX does not state that contracting by the National Health Service of Ukraine (NHSU) will be on the basis of the defined status of healthcare facilities in a capable network, the officials of the MOH and NHSU clearly regulate this very approach to contracting in their statements:

• Interview of Nataliia Husak, Head of the NHSU, dated 27 September 2022, “Operation of the NHSU during the war. Part 4” 27:30 min. https://www.youtube.com/watch?v=5AOyZ5Q_E8U&list=PLRFxABzJYfq_HwzpnOkhVHZkXfQHGFwO1&index=2
• Interview of Nataliia Husak, Head of the NHSU, dated 24 November 2022, “Operation of the NHSU during the war. Part 5» 2:36 min https://www.youtube.com/watch?v=Q6WecGkktV0&t=511s
• Facebook post of Nataliia Husak, Head of the NHSU, dated 15 August 2022 https://www.facebook.com/100000239605381/posts/pfbid028cCv11Yhx7vJMpbm1wTgFdj24UajVY9nSJRmXwbhuLGyRi2LVGU4a8NZ8fmdv8n6l/
• Interview of Oleksii Yaremenko, Deputy Minister of Health for European Integration, “Healthcare Reform: Hospital Districts, Clustering of Hospitals” 13:00; 54:08 https://www.youtube.com/watch?v=Mr0lGBzLHQU&t=147s
• Facebook post of Oleksii Yaremenko, Deputy Minister of Health for European Integration, dated 20 August 2022 https://www.facebook.com/oleksii.iaremenko

Therefore, determining the status of facilities that will enter the capable network, whether it is a general hospital or a cluster hospital, will build new ways for each patient to receive specialised medical services. Another important innovation is reformatting ambulance routes based on the new typology of healthcare facilities, so emergency hospitalisation will be exclusively in a designated facility according to the patient’s condition. Since the implementation of changes in healthcare often causes a degree of resistance, local self-government bodies should inquire with the hospital board of their district in advance about the configuration of a capable network of their hospital cluster and exact ambulance routes, so that there is enough time to organise logistics routes for the residents of the municipality to the relevant healthcare facilities and to inform the public about relevant changes.

What will happen to those healthcare facilities that are not included into the identified capable networks? Law 2347-IX defines them as other healthcare facilities, and their place in the new system is yet to be determined. Officially, the NHSU does not plan to deny contracting to such facilities if they meet the stated requirements. However, given the general approach to contracting according to the status of the healthcare facility, we can assume that healthcare facilities outside a capable network will have a rather limited scope of available packages for contracting with the NHSU. Therefore, if your municipality is the owner of such a facility, or if residents of your municipality use the services of a facility that will potentially be excluded from a capable network, now is the time to think about how you can organise the receipt of these services in the future. Possible approaches can include inter-municipal cooperation in the field of healthcare for the joint financing of a certain healthcare facility; merger of a number of facilities into a consolidated one with certain departments or branches based on those facilities that did not become part of a capable network; entering into an agreement on public-private partnership on the basis of the healthcare facility. Other possibilities to consider and model include implementing local programmes to provide a wider range of emergency care at the primary level, attracting additional specialised professionals to offer consultations, developing additional specialisations among primary-level doctors and introducing telemedicine technologies.

Here it is worth keeping in mind that the owners and partners of municipal a healthcare facility, when planning its operation, must take into account the development plans of the hospital district for the facility. Such plans are currently being developed at regional levels and are expected to be approved by hospital boards in 2023. Thus, the proactive and informed position of local self-government regarding the planning for the development of hospital districts, as well as the creation of capable networks of healthcare facilities, are important challenges faced by local self-government bodies in the healthcare sector today.

Finally, it should be added that Law 2347-IX laid the foundations of one of the most extensive changes in health care. This means that its implementation by local self-government bodies will take time, care, consolidation of efforts and new approaches in the management of healthcare facilities. This is necessary, first and foremost, to ensure the sustainable provision of quality medical services to the population of municipalities, taking into account the multi-vector trends regarding the centralisation of specialised level and decentralisation of the primary level of medical care.