MEDICAL AND ECONOMICAL PATIENTS ACCOMPANIMENT AS NEW FORM OF HOSPITAL INTERFACE IN UKRAINE

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MEDICAL AND ECONOMICAL PATIENTS ACCOMPANIMENT
AS NEW FORM OF HOSPITAL INTERFACE IN UKRAINE

• Biryukov Viktor MD, PhD
• Head of Department Social
• Medicine and Medical
• Management Odessa State
• Medical University
• Odessa 65082, Ukraine
• E-mail viktor_biryukov_at_sgs.com

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CHANGING HOSPITAL INTERFACES

• Background
• Transition of country from the state planning to
  the market economy violated the folded balance
  between the necessities of health protection (10
  GDP) in Ukraine and real budgetary facilities
  selected by a government (from 2,5 to 2,8 of
  GDP).
• Quality of medical services became worse sharply.

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Mean time of Life from the Birth
Ukraine
Ukraine man - 58,3, woman - 71,2 in 2003
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Aims

• Harmonization contradictory processes in the
  Health Care System of Ukraine on the basis
  estimation development markets relations in the
  system of Primary Medical Care

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Setting

• Territory
• West and South of Ukraine (Lviv, Zhitomir,
  Odessa regions and 22 areas of the Odessa Region)
• Establishments of health care
• 22 districts hospitals, regional hospitals in
  Odessa, Zhitomir and Lviv areas, policlinic ?29
  in Odessa, 411 combat hospital Odessa

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Setting

• Medical insurance Organizations
• Insurance companies Respect, Tekom,
  INTO-SANA, Odessa and Zhitomir Hospital Kasa
  (as Kranken kassa), University Clinic in Odessa
• Patients
• Rural population from 22 districts of Odessa
  area and Odessa habitants

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Methods -Quantitative

• SWOT-analysis
• Requirements of standards series
• ISO 90002000
• Financial statements of insurance companies
• Estimation of medical care quality
• on the questionnaire basis
• Analysis the routes of patients
• Monitoring the conflicts situations

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Methods - Qualitative

• Focus groups Patients, Staff Nurses, Doctors of
  private and state hospitals, Medical
  Administrators, representatives of
  nongovernmental organizations
• Semi-structured interviews Questionnaire
  Physicians, Regional administration, Patients

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Administrative Structure of Ukraine

• Population 46 mln.
• The Capital Kiev (4 mln)
• 1 autonomous republic Crimea
• 24 regions (oblasts), 490 areas (rayon's), 446
  cities, 907 settlements of city type and 10196
  villages.

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Ukrainian State System of Health Care has a
clear administrative vertical
Republics medical establishments
Ministry of Health Care
Regional Health Care Administration (HCA)
Regions medical establishments
Areas HCA
Areas medical establishments
Cities medical establishments
City municipal HCA
Villages Administrations
Villages medical establishments
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Each level of vertical is presented by different
type of medical establishments (horizontal
infrastructure)
- Obstetric points - Medical assistants
points - Rural ambulatory - Rural district
hospitals
PC
Villages medical establishments
PC,SC
Areas medical establishments
- Areas polyclinics - Areas hospitals - Central
areas Hospital - Ambulance
PC, SC,TC
Cities medical establishments

• - Cities polyclinics
• - Hospitals and clinics
• - Health Centers
• Diagnostic Centers
• - Ambulance

Note PC - Primary Care SC- Secondary Care TC-
Tertiary Care
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Description of rural medical area
D I S T R I C T H O S P I T A L
1
1
Areas hospital (out-patients
Department) (in-patients
Department)
2
2
3
4
3
5
6
4 Areas Ambulatory
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Rural medical points
Pre-doctors medical care
Doctors Primary Medical care
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Pre-doctors medical care

• 1. Carried out by personnel of medical
  assistant's (feldsher) and obstetric (accoucher)
  point (FAP)
• medical assistant (feldsher)
• accoucheur
• junior nurse
• 2. Serves up to 37 rural population
• 3. 30 working hours spend for prophylactic
  measures
• 4. 68 patients get a help in FAP, 32 - at home

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Pre-doctors medical care (cont.)

• Medical assistant's obstetric point (FAP) is
  organized in villages, if
• number of habitants less 300, and village is
  located a more than 6 km from central village
• number of habitants more than 700, and village
  is located a more than 2 km from central village

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Patients Route in the rural area
D I S T R I C T H O S P I T A L
O P D
Medical assistant's And Obstetric Point
Areas ambulatory
Patient
IPD
Areas hospital
Pre-doctors medical care
Primary doctors care
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Patients Route in the City

• 1.
• 2.

Specialist 1
District Doctor
Patient 1
H O S P I T A L
Specialist 2
Patient 2
Specialist 3
Patient 3
Specialist 1
Patient 1
Family Physician
Specialist 2
Patient 2
Specialist 3
Patient 3
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Structure of district Hospital
Head of Hospital
25 therapy beds
Auxiliary services
Out-patients Department
In-patients Department
20 pediatric beds
Physician, Pediatrician, Dentist
Diagnostic room
Laboratory
Physio- therapy
X-ray room
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Structure of Central District Hospital
Administration
Out-patients Department
In-patients Department
Auxiliary services
15-17 specialities
7 types
Laboratory
X-ray room
Pathologic Anatomy Dep.
Ambulance Depart
Physio- therapy
Diagnostic Depart.
Inf. Analyt. Depart.
Kitchen
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PROFESSIONAL BARRIERS

• In our case there is the clear concurrency
  between general practitioners and specialists of
  policlinics and hospitals.
• The lack of competence family physician and
  narrow-mindedness of his diagnostic and
  therapeutic possibilities is interpreted as low
  quality activity (GP-interviews).

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PROFESSIONAL BARRIERS (cont.)?
Information 2
Information 1
Information 3
OPD Specialist
Hospital Specialist
GP
Blood test USG
Blood test USG
Blood test USG
1
2
3
Patient
Patients Route
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PROFESSIONAL BARRIERS (cont.)?

• The doctors of diagnostic centers in large towns
  or regional hospitals does not trust to the
  information got at the inspection of patients in
  rural hospitals with the out-of-date equipment
  and after reception patients in department, begin
  a new laboratory and instrumental inspections
  (Hospital Specialist).
• It conduces to the additional financial and
  financial expenses from the state and insurance
  companies (Insurance consultant).

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Informative Barriers

• Visit to specialists in Diagnostic Centers or
  Scientific Clinics, from one side, is quit
  expensive. It is strong limits availability of
  medical services.
• From other side, their academic conclusions are
  obscure. So, we had to ask the PC-Nurse or
  GP-doctor to re-explain it again. (Patient)

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The single medical field in Ukraine
Competition for income
Private Sector
State Sector
Solidarity Sector
Private Insurance
Low Effectiveness Health care System
Sector
Vectors of Activity
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Creation and Implementation Quality Competition
Department of Quality control
Ministry of Health Care
Regional Health Care Administration (HCA)
Regional Department of Quality control
Areas HCA
Areas Department of Quality control
Cities Department of Quality control
City municipal HCA
Villages Administrations
Quality control groups
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Solidarity sector

• Type Solidarity system of mutual insurance.
• Differs from insurance organization - that are
  not profitable organizations. It returns of
  facilities achieves 75-85.
• Organizations give monthly account to trade
  unions about expended sums and reasons.
• Execute the functions of accompaniment at time of
  referring insured patient in permanent
  establishment or policlinic.
• Creats and implements quality competition

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The single medical field in Ukraine
Creation Quality Competition
Private Sector
State Sector
Private Insurance Sector
Solidarity Sector
Vectors of Activity
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Discussion

• All Barriers are arising mainly due the market
  competition for patient, and system-level factors
  that promote seamless care are related to
  specific GP-level practices

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Objective changes in interface health care
strengthening of PHC link and confluence of it
with the second
Primary HC
Secondary HC
Tertiary HC
Specialize HC
Universal (Integrative) HC ?
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Conclusion

• The tendency of confluence primary care with the
  second is obvious.
• Why does it take place?
• 1. If its evolutional process, this is
  appropriately. Then confluence of primary and
  second care testifies appearance some new
  structure Universal Care. In this case the
  forming of primary and second care is stage A,
  and their dynamic integration characterizes the
  stage B

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Conclusion (cont.)

• 2. It is possible that the process of confluence
  reflects the deficiency clear specification of
  primary and second care. In this case it is
  necessary more expressly to define their
  characteristic scopes.
• 3. In the third, the hypertrophy primary sectors
  growth is result of administrative enthusiasm. In
  this case it is necessary to find compromise
  balance.

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Conclusion (cont.)

• The laws of market competition in the Health Care
  System are create different types of barriers on
  the way of realization seamlessness' health care
  in a PHC-sector

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Thank you!
Odessa 2008