Now that the Verkhovna Rada has adopted the draft laws 6327 and 6604 (in the first reading), there is a legal basis for the medical reform. Experts from the Kharkiv Expert Group in Health Care Reform suggest the representatives of communities and district administrations to study out how the financing of medical institutions will change and how to modify the system of provision of medical services on the ground.

How will financing change?

Medical subvention for primary health care will not come to the communities since the very January 2018. The money the state will allocate for primary medicine needs will be included in the "Primary health care" state program, approved together with the state budget. Ministry of Health (MOH), and later – the National Health Service of Ukraine (NHSU) – will be the main program budget controlling unit.

Providers of health services – health care institutions of any form of ownership and private practitioners – will be the recipients of funds under this state program. Thus, in the new system, not only health care institutions of communal ownership will provide primary health care for budget funds. It is enough to conclude a relevant agreement with the main funds controller in order to obtain the status of the medical services provider for budget funds. The law prohibits the Ministry of Health to refuse or refrain from concluding such agreements, although if the primary health care provider violates the terms of the agreement, it may be dissolved or terminated.

The role of the territorial community in the new conditions

In spite of a certain "detachment" of the primary link of the medical services provision from the financing process (since the money will go past community budgets directly to the service providers that have concluded declarations with clients), the communities cannot be considered eliminated from public health issues. It is the territorial community, or more precisely the community administration (hereinafter – the community), who is responsible for the development of the public health system.

Here it should be noted that the issue of preserving the health of the population goes beyond the medical component and also includes lifestyle, access to sports infrastructure, leisure and social life, etc.

The task of the community management team is to formulate a strategy for the development of the community health system with involvement of stakeholders and identification of the place of each health care services provider in the community and beyond it. According to this strategy, the community forms a request to primary health care institutions and provides funding for health-related initiatives.

The community also has a controlling function, in particular, the community representative has to participate in the work of the board of trustees at medical institutions (formed at communal enterprises).

The community is the owner of the infrastructure of healthcare institutions and invests in its support and development.

A separate task for the development of family medicine in communities is the renewal of the staff, and in particular, involvement of young family practitioners in the community work. The decision on this issue goes beyond the capabilities of a separate medical institution, therefore, the community, in the framework of the strategy, can create conditions for a comfortable living of a medical specialist (accommodation, infrastructure for a young family (kindergarten, school, etc.)), can finance specialist’s resettlement and (co) finance the studies of the students from the community with a major in "family medicine" (provided they work in the community after graduation).

In order to perform all these functions, a community division or position (e.g., deputy head of the community on health issues) should be formed in the community administration. Officials of these divisions do not necessarily have to be doctors by profession, but they should be familiar with the issues of strategic planning, communication, understand the new system of relations in the system of public health care.

New players

Newly created communities often set up their own Primary Health Care Centers or outpatient clinics of family medicine, although, in our opinion, such a decision is not always economically reasonable. The community makes this step because of the lack of alternatives.

The new system will provide the alternatives:

1. OWN HEALTH CARE INSTITUTION – communal enterprise (hereinafter – CE)
2. PRIVATE HEALTH CARE INSTITUTION
3. PRIVATE PRACTITIONER – individual entrepreneur

Now the community has a choice to:

1. Create own communal enterprise (CE)
2. Make an arrangement with the CE of the neighbouring community by concluding an agreement on cooperation of territorial communities. It will allow to decrease administrative expenses for property maintenance and increase doctors’ salaries.
3. Make an arrangement with a private healthcare institution. For instance, the community will lease premises for the placement of doctors on concessional terms, and a private medical institution will provide medical services to the community.
4. Make an agreement with a doctor or doctors-individual entrepreneurs, who will take care of the process of provision of primary health care and its quality. The community, for example, in addition to the privileged lease of premises, may, within the framework of the local target program, allocate funds for the prevention of a disease or vaccination against the flu.

The following list of options is not exhaustive. Their combination is possible. Thus, the community can create its own CE, and this CE can conclude an agreement with a doctor (doctors)-individual entrepreneur in order to serve a part of the population. While choosing an option, it is necessary to take due account of the geographical features of the community, the age and needs of people, as well as the preparation of the administrative team of the community.

What should the community administrative team do right now?

• create a community vision: the way you see the state of health of the community residents in 3-5 years in case of its successful development,
• conduct a comprehensive audit of the health care system. In particular, ask the population about what they lack, analyze the effectiveness of the use of premises, human resources, equipment condition, etc.

Different viewpoints within the framework of the audit allow to choose the right focus of efforts and investment. Thus, according to the results of our research in various districts, the population is primarily dissatisfied with queues and an uncomfortable schedule of doctors’ working hours,

• analyze the experience of other communities that have already solved the problems your community faced (for example, the introduction of mobile brigades of family doctors to provide medical care in remote areas, involvement of young doctors, etc.),
• create financial models of medical services provision to the residents of the community, plan a search for additional investments into the healthcare system development (including grant projects).

The main thing is not to wait

Now you already have all the necessary information and legal mechanisms to increase the efficiency of medical institutions and lay the foundations for improving the health of the population.

Mykhailo Dovhopol, business consultant, expert of the Kharkiv Expert Group in Health Care Reform

Olena Khytrova, head of medicine and pharmacy practice at ILF, expert of the Kharkiv Expert Group in Health Care Reform

Olena Reshetnyak, business consultant on management and finance, expert of the Kharkiv Expert Group in Health Care Reform