****Written in response to the recent crisis in Ukraine.
Certainly, the world’s eyes are focused on the political unrest in the Ukraine this week. As a physician, I am concerned about the health and well being of the Ukrainian people. Healthcare in Ukraine is substandard at best. Life expectancies in this region are well below standards that we see in the US and other developed nations. For many throughout the world, the tensions and threat of military violence have created a great deal of anxiety. After years of cooperation with Russia, it appears we may be on the brink of more Cold War type diplomacy. Although the world is more interdependent and connected than ever, the international political events of the last week remind many of us of the events leading up to other world encompassing conflicts such as the second World War. While the attention of the media and the world is focused on the military action and political rhetoric associated with the coup de etat in Ukraine and the Russian invasion of Crimea, the people of the region continue to suffer. I wonder if the world’s leaders would feel the same way about the region if they had friends and family in Ukraine and knew first hand of the suffering and senseless deaths (due to the broken healthcare system). It is easy to sit in power and remain out of touch with those that you claim to want to help.
Government Managed Healthcare in Ukraine
Healthcare in Ukraine is certainly far from what we in the US expect. Overall, the healthcare system is neglected and there is an extreme shortage of adequate facilities, medicines and qualified physicians. While some physicians are highly skilled and well trained, the majority of clinicians in practice never completed full courses of study but are thrust into service prematurely due to extreme need. I am appalled by the lack of competency and training and I am concerned about the impact these practitioners may have. Ultimately, I believe that the responsibility to provide adequate care in this particular system lies with the single payor–the government. By law, all employed citizens contribute to the cost of the national helathcare system and all citizens have a legal right to healthcare access. However, in reality, access to care is a significant issue. The healthcare system is funded almost entirely by government revenues–citizens must play a fee for dependents and those who are self employed must also pay additional premiums. For the most part, the government funds all healthcare fees. However, physician wages are very low and many clinicians charge additional fees to patients, thus further limiting access to care for many citizens. I believe that the lack of coordination of healthcare and the lack of reimbursement to providers significantly contributes to the poor state of care in the Ukraine.
Physicians and Facilities
Physicians in Ukraine are not well compensated. General practitioners are the first point of contact for Ukranian citizens with the healthcare system. According to the law, citizens may choose a physician they wish to see but must make sure that each provider is covered as part of the state controlled network. Most doctors require additional fees for care that are collected from the patient at the time of surgery. Waiting times are significant and urgent care may be difficult to obtain and may also require pre-payment. I understand, given the poor wages, the need for physicians to collect fees up front. However, it is difficult to imagine a system where compensation comes before care. Hospitals throughout Ukraine are substandard facilities. Even though there is a great need, there are few locations that have advanced equipment and supplies. Hospitals are often very dirty and poorly staffed. I believe this is another reason for the poor state of health in the Ukraine and the fact that the death rate continues to exceed the live birth rate–resulting in depopulation of the region over the last decade.
For those with means, there are private clinics that are funded either through cash payments or private insurance. These clinics provide better access to care as well as better availability of specialists and specialized services or procedures.
Disease and Life Expectancy
Since achieving independence in 1991, Ukraine has seen one of the most significant demographic declines in the world–the population has been reduced by nearly 6 million. The overall population has been reduced by nearly 12%–higher death rates are outpacing female fertility rates and depopulation has been the result over the last decade. Men are dying prematurely and suffer very high disability rates due to chronic, non communicable disease. Nearly one third of the population dies before age 65 and there are a disproportionate number of working age males with chronic, non communicable diseases.
Diseases such as HIV/AIDS and Tuberculosis are rampant and occur at much higher rates than anywhere else in Europe or Asia–these diagnoses account for nearly 90% of deaths from communicable disease Due to government bias against homosexual behavior as well as high rates of prostitution, drug abuse and addiction, HIV rates in the Ukraine continue to rise. There are virtually no programs in place for treatment or prevention of HIV related illness and many who are infected have little hope for treatment. I believe that in order to succeed in reducing deaths and improving health status, the government of Ukraine must make treatments for HIV available and remove the negative legal and political stigma associated with the disease.
In addition, there is a very high rate of alcoholism (the highest in all of Europe in Asia) and many of the alcohol related premature deaths also occur in men. I believe that much of this is due to the overall poverty in the nation and the associated depression of its citizens. The average life expectancy of a male adult in the Ukraine is only 64 years old–72 for women. Birth rates in the country continue to decline and live births are virtually outpaced by the premature deaths.
According to the WHO and World Bank, nearly 50% of all premature deaths in Ukraine could be prevented by regular and adequate preventative healthcare. This is an astounding number and I see this as a real call to action for international healthcare agencies
Unfortunately, the political unrest and potential Russian occupation is going to do very little to improve care for the Ukrainian people. Prior to the current uprising, the previous regime had a plan to revamp and reform the broken healthcare system beginning in 2014. I worry that unless wholesale changes are made soon, Ukranian citizens will continue to suffer premature death and battle with chronic and preventable disease. It is my hope that as the world focuses on the politics of the region that we also focus on the people and their plight. Healthcare is just one issue that must be addressed but is essential to the recovery of the nation.