Ukraine: “the fastest reformer in the health system in Europe”
“Health is a human right and condition for everybody prosper and to develop” – Head of WHO Office in Ukraine
On 12 December world is commemorating Universal Health Coverage Day, this date is the anniversary of the first unanimous United Nations resolution calling for all nations to provide for their citizens affordable, quality health care.
UN in Ukraine met with chief WHO person in Ukraine to discuss situation with health coverage in the country, improvements and potential challenges that health system in Ukraine is facing nowadays.
Kyiv, Ukraine – 12 December 2019 – published by WHO Office in Ukraine
Dr. Jarno Habicht, 43, graduated as medical doctor and received PhD in health services research in Estonia. At the age of 27 he was appointed as a Head of WHO country office in Estonia, becoming at that time the youngest Head of WHO country office in the world. Since then he worked in WHO to support health system development and in particular at country level in different countries as Estonia, Moldova, Kyrgyz Republic until last year he became WHO Representative in Ukraine.
Dr. Jarno Habicht. Photo: UN Ukraine/Volodymyr Shuvayev
UN: Before you came to Ukraine and started working here as WHO Representative, how did you prepare totaking the office? Some courses on country specific?
J: – Every country is unique, especially when it comes to health issues. I read [about Ukraine – UN] and tried to understand as much as possible. Even though I have been working in a health care for over 20 years, every time you need to start learning all over again. In each country you gain some experience, but over the years I learned not to have any blind assumptions. To be a Head of WHO country office is an interesting and privileged position. In our job, every three to five years we start cycle in a new country all over again, which I also find exciting.
I started following more closely the news from Ukraine when I was working and living in Moldova in 2011-2015. Then it was part of our everyday business to follow what our neighbours are doing. Also, because there were many collaborative areas of work between Moldova and Ukraine. Delegations, including Parliamentarians, officials and experts from Ukraine used to visit Moldova often. We were hosting them in WHO Office, discussing health reforms. Or when we got to know the ministers or other colleagues from Moldova coming to Ukraine, there was an exchange of ideas.
Now, while in Kyiv I think, the last few years were full of exciting times when Ukraine has started doing health reforms and the changes were moving in the right direction. Of course, everyone wants to see changes very quickly and feel improvement, but we have to be realistic in how much can be achieved in a very short period.
Dr. Jarno Habicht. Photo: UN Ukraine/Volodymyr Shuvayev
UN: This September the UN’s General Assembly adopted Political Declaration on Universal Health Coverage. It was called in media the most comprehensive agreement ever on the global health. UN’s Secretary General also described it as an important landmark to our journey to health for all. Why is this document so important, in your opinion?
J: – Health is a fundamental human right and one of the most basic conditions to prosper and to develop. In the past decades at the UN level there were declarations related to HIV/AIDS, tuberculosis, antimicrobial resistance, non-communicable diseases, but the aim of current Declaration bring them all together thru health system lens. What we need is to have a systematic approach that helps to move forward and accelerate the process towards the achievement the SDGs targets. So, that is why the UN Secretary General calls it comprehensive – because it takes multiple health aspects together. For example, we need to invest more in the primary health care, close to where we live, close to the community. That helps health system to become responsive and patient-oriented. On Alma-Ata Conference in 1978, more than 40 years ago WHO, UNICEF and other partners convened the world around primary health care. As we look back, it was the first time when at high level we started to talk more about social and other determinants also influencing our health and every decade we revisited the ideas, but we have witnessed that progress is not even across the whole world. That is why, I think, it was very important to raise it at the UN level. And the Declaration that has been adopted is not just for one country, one town, it’s for and about comprehensive progress in heath care on the planet.
UN: So, basically, the Declaration targets every country?
J: – All UN Member States are committed to it. During the preparations of the declarations there was a long consultation process while developing this Declaration, as it was adopted by consensus. And it is called political – because decision on it was made by the heads of states. Health is political choice and we have to prioritize it.
Ukraine has joined the path, so now the question is how to implement it into everyday action. How people in Vinnytsia, in Kramatorsk, or, for example, in Lviv can have better health? How the health system reaches vulnerable and people with highest health needs. This is a challenge we need to address.
Dr. Jarno Habicht. Photo: UN Ukraine/Volodymyr Shuvayev
UN: How would you explain the term ‘Universal Health Coverage’ itself? I believe, we still don’t have the Ukrainian equivalent of it…
J: – I think Ukrainian is not the only language, that has the problems with the translation [smiling]. Universal health coverage means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This meant that health service should not be seen as just surgery in the hospital, the service could be also that your school nurse gives you an advice on healthy nutrition, the community health worker gives you a public health advice, or even if you are simply informed on how to stay healthy or nowadays using digital devices and solutions for health improvement.
UN: Has any country achieved 100% Universal Health Coverage?
J: – I see 100% of Universal Health Coverage as an ambitious goal. I would say, it is the journey towards the mountain we never actually reach, but we will always move towards that direction when we improve health systems. There are many reasons as medicine develops, we innovate and learn more about human health. Of course, we can measure the progress, and that is why we should measure progress. First is to measure coverage with health services. Second is the financial protection – how much do we need to pay out of pocket when we use the health care services and does it cause financial hardship. Before large scale transformation, in 2015 every seventh household in Ukraine had catastrophic health expenditures and many fall to poverty due to health service use. In simple way, we can measure it as an share how much of the resources are coming directly from the pocket of patients. We know that everyone should pay for the health services and medicines, but the question is overall share. For example, in Europe we suggested that direct payment out of patient’s pocket should not exceed 15% of overall health financing, while in Ukraine it’s still around 50%.
WHO Office in Ukraine. Photo: UN Ukraine/Volodymyr Shuvayev
UN: Over the past few years, we witnessed tremendous changes in Ukraine health care system. Family doctorappeared, procurement of medicines was delivered to international organizations which helped to buy additional medicines for patients for saved funds... What else should be improved? Maybe health insurance? For example, in the USA every employee is insured by its employer.
J: – I see that Ukraine has made big steps forward in the recent years, becoming the fastest reformer in the health system in Europe. The country has taken the right course over the financing reforms, established single purchaser [National Health Service of Ukraine], moving gradually to the health care with start from primary health care, also looking how to make medicines more affordable, as the last one is extremely important.
To transform health system, a dedicated institution has to set up to purchase health services on behalf of population– it’s good to have a single place, where the funds are pooled together, and to be one strategic purchaser. After development of a health service of Ukraine, government has made a right decision to invest more into national health system. So, in principle, Ukraine has created a health insurance system, using not employer-based taxes, but general taxes, which I consider a wise choice. This way Ukraine does not increase tax burden on the business and takes into account the labor force aspects.
If to use simplification, what we see in Europe is two ways to arrange “health insurance system”, but they become more and more blended. There are countries with more relying on labor force taxation and we are used to call them insurance-based systems – like Germany, that has moved gradually to ensure that everybody has a insurance coverage. There are systems where everybody has a coverage from the very beginning. So I think Ukraine has learned a lot from financial crisis 2008-2009 that happened in Europe. What we see is that most of the countries are pooling together funds from general taxes, employer-employee based taxes to one purchaser.
UN: Can we say that the level of state health insurance that is provided in Ukraine is enough to meet all the needs of Ukrainian patients?
J: – For the past few years Ukrainian health care system started to run very fast in the beginning instead of learning how to walk. So, honestly, I would allocate a little bit more time for all the developments to start to see all the results. My question is to what extent, actually, Ukraine has a fiscal space to invest into health? In many countries governments started investing more into health. I understand the challenge – currently Ukraine needs to invest into economic growth and in defence. But when I look from human capital perspective, I would suggest that investing more in the health and health services . For example the burden from non-communicable diseases costs to many countries around 3% of GDP, while with good health promotion and timely access to services part of the burden can be avoided.The key question is how to ensure fiscal space and increase public funding for health. In countries like Ukraine allocating a certain proportion from general taxes to health coverage ensures much more stability, compared to labor taxation. Very often, when people are young, they don’t seek help from a doctor, but at the age 45-50 men have the first heart attack. At the same time we need also services to ensure good immunization coverage or good access to services during reproductive age. So, there are different health needs and a system should be in place to cover the services during whole life-course and for everybody.
UN: How did other countries where the insurance is provided by employer, resolve the issue when the person is retired?
J: – Many countries have simply created either the national health service, or a national health insurance funds – for example, Estonia, Lithuania are covering 95 – 96% of their population. And there is a level of solidarity in the system. In Estonia, for example, until recently we had a high level of solidarity. In the nineties there was an agreementthat those, who are actively in the labor force, should contribute for the benefit of those who are not active. So, majority of population is covered by health insurance. Almost eveybody has access to services, but that is exactly because there is solidarity between healthy and sick, rich and poor, as well over the active and inactive period of life in labor force. However, last year Estonia made a decision that the government will start allocating additional resources from the general taxes funds to the same pool, a so-called Estonian Health Insurance Fund, to cover partially on behalf of the pensioners. This change aims to make health financing system more sustainable in the future as population is aging and labor market is also changing and even in Estonia it has been becoming challenging to finance health system only through labor taxes. So, in Estonia, a country that started with insurance system, we actually moved closer to the system that Ukraine has. My suggestion is that maybe Ukraine has been learning from lessons learnt of the others and is creating something that is more stable for the future. What should be solved now in Ukraine, in my opinion, is how to have a better access to medicines, better performing primary health care, restructure specialized care for more efficient health services and that there is people-oriented health services, where people can be a part of the prevention and care process.
UN: Since announcing the SDG Agenda 2030 in 2015 the UN Agencies worldwide started working jointly with the government, civil society organizations and many other actors towards achieving the Global Goals. WHO’s main SDG is #3 – Good Health And Well-Being. How WHO works in Ukraine now on this SDG?
J: – Everything that we do in Ukraine is related to the SDGs, actually within the WHO we count every dollar and every working hour to the SDGs. We work more on the health system strengthening, we make sure that immunization system gets stronger, our work is focusing on non-communicable diseases, so our investment to the different SDGs is varying. If each of us continues business as usual, we do not reach the SDG targets, so we need to think what in the next 10 years we can do differently, do something more or do something less, where we should unite and work together. At the end of the day, what we measure is how much healthier the society becomes.
It might be a tricky question, but do you personally follow healthy lifestyle, recommended by WHO?
– I am trying to sleep enough, eat healthy, be physically active, be vaccinated and also do healthy choices in my life. But when it comes to health, I must admit that doctors are not always the role models, but I think we should be the mirror and set high standards ourselves, because that’s very important since we are advising these standards to the others. Personally, I try to do every day at least 30 minutes of exercises, to eat 5 different fruits and vegetables of different color per day. In our office currently we are trying to invest into our own work environment, for example, we have ergonomic tables for every staff member, we make sure that we don’t sit too long. Over the summer and autumn we had a competition with teams on daily counting steps and this united teams across the whole world where you record how many steps you made and all other sport activities. I’ve seen my colleagues in the team who have doubled their gym visits, now they are doing around 20 thousand steps per day, so of course I find it difficult to even challenge them. But also we pay attention at own mental health and to find good work and life balance.
About month ago we had a discussion with the mayor of Kyiv and asked that it would be nice to have much more cross-country skiing places in winter. I came from Estonia, where we do cross-country skiing in winter and over the years there are more opportunities to ski, run and walk in also in urban setting. So, I think health depends much about the environment we are living in our everyday life. Yes, it’s about good personal choices, but also it’s about having the environment that allows you to do these healthy choices.