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Cite as: Archiv EuroMedica. 2022. 12; sp: e1. DOI 10.35630/2022/12/sp.iss.6
,
Nataliia
Lipovska The article investigates special features of health care policies under martial law conditions. It determines that the national model of the health care system management has been in an active phase of the medical reform since 2015. The reform covers about 20,000 health care facilities. Under COVID19 pandemic conditions, the national model of health care management operates on the principles of synchronous action of all entities at all levels of management. In the conditions of the full-scale war, since February 24, 2022, the national model of the health care system has undergone structural and functional changes and its facilities operate as critical infrastructure institutions in an asynchronous mode. The health care institutions management in an asynchronous mode is mainly entrusted to local self-government bodies, and ensuring the sustainability of medical institutions depends on the operational situation in the area where medical institutions are located. At the central level of branch administration, a number of measures of legal, economic and organizational support for the implementation of Ukraine’ state policy aimed at the availability and quality of medical care under martial law conditions have been introduced.
Keywords: public management and administration, health care, Ukrainian state, war, medical institutions
The 2022 armed aggression of the Russian state against Ukraine forced a radical change in the management system in many spheres of public life [1], with health care being one of them.
In the field of health care, which bears an enormous social and professional responsibility to society under martial law conditions, the following management principles remain unchanged:
These principles are the foundation for public management activities to ensure the uninterrupted operation of all health facilities in order to meet both the needs of the civilian population and the needs for medical support of the Armed Forces of Ukraine.
In the conditions of full-scale aggression, Ukrainian health care workers, whose total number exceeds 1 million people, with their everyday work bring the victory of the Ukrainian state closer. First of all, we are talking about medical personnel who at every turn demonstrate examples of true heroism in the workplace working under regular shelling targeted at the civil infrastructure and often having to deal with massive numbers of injured military and civilians brought in simultaneously in the conditions of frequent power and water supply disruptions.
Until the start of the full-scale war, for two years Ukraine’s national health care system had been in a state of long-term transformational changes, which, on the one hand, were caused by the need for structural and functional reorganization within the framework of the medical reform launched in 2015. In a short time, the national system of health care institutions had to change the operational format for about 20,000 medical institutions and establishments.
On the other hand, under the impacts of the 2020-2021 COVID-19 pandemic Ukraine’s medical system has undergone probably the most powerful internal system transformation since 1991, when Ukraine gained its independence. The goal of the anti-epidemic monofunctional system restructuration envisaged a new model of the system management; in which both links of the system (ambulatory and inpatient care) work in a synchronous mode to preserve the life and health of patients with COVID-19 infection. At that time, the national health care system operated as a single infectious disease hospital. This was achieved due to activity coordination between the central bodies of executive power in the form of the government or the relevant ministry and local health care management entities. In fact, we can say that the epidemic situation was almost similar in all regions of Ukraine, and the regional models of health care management were almost identical.
With the start of the full-scale Russian military invasion on February 24, 2022, the healthcare system has undergone radical changes. They were caused by the significant shortage of medical personnel due to the conscription of doctors into the military. In addition, conditions for the operation of medical institutions have changed - without water and electricity supply, under shelling and during air raid alerts, with the simultaneous arrival of a large number of wounded from the battlefield, etc. Under such conditions, operation of medical institutions in different regions of Ukraine has certain differences, in particular, in regions of "relative peace", such as the western regions of Ukraine, and in the front-line areas or occupied regions (part of Zaporizhzhya Oblast, Dnipropetrovsk Oblast, Kharkiv Oblast, etc.). This is where asynchronous models of health care institutions management at the regional level come in.
In February 2022, during the first weeks of the full-scale invasion, the Ministry of Health of Ukraine adopted a number of organizational and legal acts that made it possible to ensure the stable operation of the health care facilities under new conditions [2]. That is, a rapid transformation of the health care infrastructure took place, which allowed to increase the level of functional capacity of medical institutions for the provision of medical services and medical assistance under martial law conditions.
Among the legal mechanisms for managing Ukraine’s health care in wartime, first of all, attention should be paid to the Law of Ukraine “On Amendments to Certain Laws of Ukraine on Increasing the Availability of Medical and Rehabilitation Assistance in the Period of Martial Law”. This law legitimizes the availability of medical and rehabilitation assistance to the military and the civilian population during martial law and for 6 months after its end. The content of the law establishes that medical and rehabilitation assistance is provided in accordance with medical indications. The law defines the categories of medical workers involved in providing medical care during martial law:
The law establishes that during the period of martial law, medical and rehabilitation assistance may be provided outside the registered locations of commercial medical practice activities.
The law allows the provision of medical and rehabilitation assistance on a voluntary basis. For this purpose, it has been made possible to engage foreign medical workers as well as rehabilitation professionals (except for citizens of the Russian federation or the republic of Belarus) or stateless persons who arrived in Ukraine to provide such assistance by the invitation of a health care institution or another enterprise, organization, or institution that has such authority. Such medical workers and rehabilitation professionals must meet the requirements to education and professional qualifications and have relevant certified documents.
During the period of martial law, the legislation of Ukraine developed a number of organizational management approaches. This includes:
Certain adjustments were also made regarding economic management mechanisms. The National Health Service of Ukraine has changed the method of financial calculations for the services provided as part of the medical guarantees package. At the national level of administration, it was decided that the medical services provided by institutions in accordance with concluded contracts for the provision of specialized medical care will be financed on a monthly basis at the level of 1/12 of the budget of the annual contract. At the level of primary medical care, payment for the provided medical services was carried out in accordance with the number of concluded declarations, which was recorded as of March 1, 2022. In addition, the introduction of new packages to finance received medical services became a management innovation introduced by the National Health Service of Ukraine in wartime. Thus, medical assistance to victims of military operations was provided for by the following packages:
At all stages of care, the patient is provided with free medicines under the "Affordable Medicines" program. Postoperative care and assistance is a component of a free medical service and includes round-the-clock medical and nursing supervision, postoperative monitoring and drug therapy, consultations of doctors of various profiles, medical rehabilitation measures in the early postoperative period, etc.
Since the beginning of the full-scale war on February 24, 2022 and until July 2022, more than 45,000 patients with injuries caused by shelling, explosions, missile fragments, etc., sought help from Ukrainian medical institutions. According to the Head of the National Health Service of Ukraine, more than 8,000 Ukrainians with injuries caused by military actions received medical assistance under the Medical Guarantee Program. Over 5,000 people of them have received medical assistance in the front-line zone or in areas where active hostilities continue.
The highest number of patients with injuries of a military nature, as evidenced by the data of the E-Health system, was treated in the hopitals of the following regions of Ukraine: Dnipropetrovsk (3283 people); Cherkasy (837 people); Kharkivska (543 people); Donetsk (320 people); Zaporizhzhia (923 people). All patients received free medical care as part of the abovementioned package of medical guarantees [3]. As you can see, more than 55% of the wounded were treated in hospitals of the Dnipropetrovsk region. The Zaporizhzhia region provided assistance to about 15% of patients. That is, these two regions of Ukraine have the greatest challenge of war for the regional health care system (60% of all cases).
The service of psychological support for persons directly affected by the war in Ukraine is viewed as a separate category. After all, individuals often do not realize that there is a need for psychological support and help. This service is also a separate package guaranteed by the state and is free of charge for patients. As part of this service, the patient gets unimpeded access to a psychologist or family doctor trained in mental health.
The study of challenges for health organisations management in Ukraine showed that the national model of management is extremely plastic and capable of rapid transformation depending on external and internal challenges. In the conditions of the COVID-19 pandemic, the national model of health care management operated on the principles of synchronous action of entities at all management levels. Under martial law conditions, the national model of the health care system management operates in an asynchronous mode. Local self-government bodies are entrusted with the functions of operational healthcare facilities management in an asynchronous mode. In other words, the management of the uninterrupted operation of medical institutions depends on the operational situation in the area where the medical institutions are located. The greatest organizational and functional load is placed on medical institutions in the front line regions such as Dnipropetrovsk, Cherkasy, Kharkiv, Donetsk and Zaporizhia regions. At the central level of branch administration, a number of legal, economic, and organizational support measures for the implementation of the state policy of Ukraine have been introduced. Such functional division provides affordable and high-quality medical care to the civilian population and effective medical support for the Armed Forces of Ukraine under martial law conditions.
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