Pavlo Kovtonyuk: Supporters and Opponents of Hospitals Autonomy

Pavlo Kovtonyuk: Supporters and Opponents of Hospitals Autonomy

Reformators project
Recent initiatives on autonomy of medical institutions should become the first step in a long-awaited healthcare reform. Everyone requires changes, but when it comes to practical steps, the discussions always arise. For better understanding of how the reform is perceived by its direct on-site participants, the Project Office together with the Ministry of Healthcare and NGOs decided to hold a number of focus groups in the regions

Pavlo Kovtonyuk, project manager of healthcare reform of National Reform Council, shares the results of the meetings.

 - Why have you decided to go to regions?

After drafting legislation on the autonomy of medical institutions there was a necessity to get an honest feedback on this topic from those who will directly participate in the implementation of innovations. I mean, first of all, the doctors, chief medical officers as well and local officials (healthcare authorities). In the ministry there was a clear understanding that the process of formal approval of law drafts does not give any information about their real perception. Therefore, we have chosen informal meetings with the regions to get the feedback.

But even in the first city, where we arrived, it became clear that visits in form of so called "official delegation" (there was Deputy Minister of Healthcare with us) wouldn’t give the desired result. Such delegations are perceived in a very particular way in regions – we failed to have an open discussion. Realizing this, the rest of regions we visited without officials, and this considerably facilitated the dialogue.

 - Which cities you managed to visit?

Vinnytsia, Odesa, Kharkiv, Lviv.

 - In what format have you had the meetings?

We held focus groups with three ranges of people: chief medical officers, usual doctors, as well as  with local officials (heads and specialists of departments of healthcare of regions and cities).

 - What  were the conclusions?

The main question concerned the autonomy of hospitals. This topic is widely discussed at the national level, but very few know about the perception of changes in the regions.

Visits to even four regions was enough to get a clear understanding of who is an ally of the reform and who will resist. It was a surprise that the chief medical officers are the ones who see in the reform a possibility qualitative changes and are willing to contribute actively to its implementation. This group is the most familiar with the content of the reform of hospitals and the readiest for it. They know what are the drafts of laws all about and are well aware of the main stages, advantages and problems.

Chief doctors do realize that autonomization will give them much more freedom in operational management of hospitals. Currently, every cost item of the budget is preset and approved from the "top". This procedure binds the hands of managers, especially the most progressive, who are willing to develop their institution. They perceive autonomy as getting new opportunities for development.

During our focus groups we were modeling the situation - what will happen after getting new powers. It turned out that almost every chief medical officer had clear understanding of how he/she would change the work of the institution. It happened so that many of them have already been having "in the table" plans for development and optimization of their hospitals and were only waiting for an opportunity to get the freedom to implement them.

 - In which way?

For example, the redistribution of hospital beds and doctors’ quantity. Currently the CMO guides not by the real needs of patients but by regulations. In one of hospitals there have to be 15 gynecologists, but the same amount of medical services can be provided by six doctors. But critical issue is the increase of number of surgeons. However, the CMO can not reduce the number of the first ones and increase the second.

Another example. Most managers are ready to outsource non-core services, such as laundry, meals or laboratory tests. In one hospital there is a source of water right on its territory - they can make an independent water supply. But without the autonomous status these efforts of better conduction its economy causes more trouble with the officials than the actual benefit.

- Who is the opponent of reform?

In all four regions, we revealed the opposition - explicit or hidden - from local officials. I should confess, I was waiting for a very different situation.

 - What is the problem with the officials?

Firstly - and this was a shock for me - they understand the content of the reform very poorly. Sometimes we had the impression that they did not even read the drafts and heard about them for the first time from us. The exception was only Lviv, where we saw readiness for constructive conversation.

Secondly, I didn’t see any faith in the prospect of reform from these officials, although its success depends mainly on them. Perhaps the reason is that the officials of departments has not been changing for many years, and these people developed a certain style of behavior that allowed to survive successfully under various governments.

- Is there a general trust to the reform?

Overall, I have a positive impression - the reform can be successful, despite the ambiguous position of local officials. Regarding the reaction of usual doctors, of course, they have a number of justified concerns. But they understand why the reform is important because they realize that it will lead to higher legal salaries and greater freedom. There won’t be tough dependency on wage rates, and the chief medical officer will be able to set the salary depending on qualifications of aa specialist. On the other hand, the reform will create a free medical labor market. Each of them will have to fight for job, but not to "sit" hours at work. And doctors understand that the better you work, the more advantages and you can have and  get higher legal wage.

- What actions are needed at the next stage of reform?

The most important thing - to stop populism around the reform, adopt needed laws and to move quickly to resolution of the technical issues related to the new status of medical institutions.

In the regions we heard a lot of such technical problems. But they don’t include issues of mass privatization of institutions, by which some politicians in Kiev have already started to frighten the public. In regions we’ve got the confirmation that most local councils will grant their institutions the status of municipal non-profit enterprise. But to remove even the theoretical possibility of manipulations with hospitals ownership – this is the technical task for lawyers.

Instead, there are many issues that are very well realized by people practically working in the sphere, and which should be processed, but which are lost in political discussions. For example, CMOs and doctors are concerned about changes to labor laws in order to avoid confusion in the establishment of new relationships between doctors and institutions as well as potential reductions in personnel.

Another issue that needs regulation, - support for hospitals that can find themselves in a difficult situation after getting the autonomy. We can’t allow bankruptcies hospitals, but we also don’t have any special procedures for autonomous hospitals as independent businesses.

There is more than a dozen of such issues, and there are new to come. Efforts of all stakeholders should focus on their immediate prevention and resolution. The healthcare reform is too complex and broad to dissipate the energy for political debate.

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Маркович Галина Богданівна - координатор напрямку місцеві бюджети Проектного офісу секторальної децентралізації
19 December 2016
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