Abstract
This article includes a personal history of a family physician working in Ukraine. In June 2012, Pavlo Kolesnyk, Ukrainian Assistant Professor and a Family Doctor was awarded the second Montegute Scholar grant and had the chance to attend the Wonca Europe Conference 2012 in Vienna. In many developed countries, family medicine is already well established. In Ukraine, which has the legacy of a socialist health care system the implementation of the discipline started only at the end of the last century. The changes in the health care system were of greater importance in primary care and family medicine. It gave greater decentralization of the health care system and supported investment in primary care. This article describes the development of family medicine in undergraduate and postgraduate education. Whilst family medicine is officially a priority of health care policy, there is still a long process ahead. Family medicine needs financial support from the government and doctor's wages have to be increased, to prevent this branch of medicine being unpopular among graduating medical students.
KEY MESSAGE:
The introduction of modern family medicine is one of the cornerstones of the health care reform in Ukraine
The implementation is often hampered by the characteristics of the existing health care system and its tradition
The challenges of achieving academic recognition, adequate remuneration, and the political and financial support of this new discipline have still not been met.
Despite many remaining challenges, the outlook for the future is bright, given the many positive current initiatives taken by the discipline itself.
INTRODUCTION
In many developed countries, where family medicine/general practice (FM/GP) has been developing for more than half a century, it has become the single largest specialty in medicine. Family doctors in Great Britain, Canada, France and Germany constitute half of the total number of doctors (Citation1). There is a profound difference both in the quality of life and the health care system between Western Europe and the former socialistic countries of Central Europe as well as between the countries of Eastern Europe (Citation2).
This article includes a personal history of a family physician working in Ukraine. In June 2012, the author—Ukrainian Assistant Professor and a Family Doctor—was awarded the second Montegut Scholar grant and had the chance to attend the Wonca Europe Conference 2012 in Vienna (Box 1).
The Montegut Global Scholars Programme (MGSP) was established by the American Board of Family Medicine Foundation (ABFM-F), in April 2010. It was named in honour of Alain Montegut, MD, a member of the Board of Directors of the ABFM from 2005 to 2010 and WONCA North America region president from 2007 to 2010.
The MGSP was established to foster international education, research and collaboration, in the specialty of family medicine. It supports the attendance of one family physician from each of the seven regions of the international organization of family physicians (Wonca) to their regional meetings or to the international meeting in the year when it is held. In years when the local region does not hold a meeting, it will be permissible for the nominee from that region to use the scholarship to attend a meeting in another region.
(www.globalfamilydoctor.com/News/DrPavloKolesnykofUkraine-MontegutScholar.aspx).
The aim of this article is to describe the implementation of family medicine (FM) in Ukraine with an emphasis on the training of doctors, especially family doctors (FDs). In addition, I outline the main challenges and give an outlook for the future development of FM in Ukraine according to my personal experience in this field.
THE UKRAINIAN HEALTH CARE SYSTEM
The government of Ukraine fully controls the health care system. The Ministry of Health co-ordinates and finances the health care system through both national and local budgets. According to the Constitution of Ukraine, medical services are to be provided free of charge.
Until the end of twentieth century, the previous health care system was based on public service providers. Patients were allocated to local or regional providers according to their place of residence. Direct access to outpatient clinical specialists was usual. Informal payment (tipping) was commonplace to obtain better access to higher quality of medical services.
The number of doctors per capita in Ukraine is 47 doctors per 10 000 population, which is twice as high as in Western Europe. In large cities, such as Kiev, Donetsk and Dnipropetrovs'k, this figure was larger: 80 doctors per 10 000 population. Only 3% of doctors were FDs (Citation1). The system of primary care has been mostly provided by a large number of paediatric and internal medical doctors, who collaborated with medical specialists at the secondary care level (Citation5).
With the collapse of the Soviet Union at the beginning of the 1990s, most Eastern European countries have tried to develop an insurance-based and decentralized health care system and introduce FM as a new specialty (Citation3). Ukraine has also introduced health care reform. The need to integrate Ukraine into Europe prompted radical changes in financing and searching for new methods in medical education whilst at the same time creating a new system of primary health care. The new government of Ukraine was forced to seek more cost-effective health care services that would be able to meet society's expectations (Citation1). After the change in the political system, there was a need to change the system of primary health care (PHC) as the state budget could not support a large number of medical specialists nor a poorly developed primary health care system.
During 2000–2001, the Ministry of Health developed a plan allowing the gradual transition to a PHC orientated system, which would be based on the principles of FM by approving several documents regulating different aspects of the organization of PCH work. The government support was mostly declarative (Citation8). Among the most important planned reforms of Ukrainian health care were:
Support of primary care based FM. The declared goal is that by the end of 2020, certified FD will be the only physicians working in primary care.
Decentralization of PHC and the foundation of decentralized self-financed Primary Medical Care Centres, which are going to become independent structures.
Increased financial support of primary care, with primary care receiving up to 30% of the total health care budget.
Additional income for FDs: on top of their salary, which is based on a capitation of 1200–1500 patients, FD will also get a capitation fee for extra patients. It will increase their salary as most FDs in Ukraine provide medical service for over 2500–3000 patients.
FAMILY MEDICINE IN UKRAINE
Current situation
The introduction of FM is the cornerstone of the Ukrainian Health Care reforms. The legislative framework for the development of FM in the country was founded in 1999–2000. According to the Ukrainian legislation, a FD in towns has to provide medical care to 1500 citizens and in the villages to 1200 citizens of any age. Since 2000, the number of trained FDs has grown rapidly. By the end of 2004, 4057 vacancies for 3354 possible FDs were established. By the end of 2010, the number of FDs has increased to 4581. To date, more than 7000 FDs have been trained. However, the deficit in FDs in Ukraine is still over 13 400 (Citation4). Currently, more than 6000 FDs are of retirement age. Only 23% of 4327 graduates of medical institutes start their career as FD outside major cities.
More than 5000 FM clinics have been organized all over the country, especially in rural areas. Unfortunately, many of them are ‘re-named’ clinics and rural hospitals with poor equipment. Over 33% of them use old buildings that are often more than 50 years old. Only 35% of the rural FM clinics are appropriately equipped. Some practices have been equipped by the regional government from the local budget, but most do not have such equipment, and as such it is left to the FD to purchase equipment. This includes basic equipment like oto- ophthalmoscope, stethoscope, tonometer, glucometer, reflex hammer, tuning fork, some otolaryngological instruments, peak flow-meter or nebulizer. The expenses associated with buying this equipment need to be covered from the FD's individual salary; which is difficult since the salary of FDs currently is very low (i.e. approximately €100–€150 per month).
Furthermore, FDs have problems providing certain services because there is competition with other specialists. Health care of children of pre-school and school age is often provided by paediatricians, especially in the cities. In addition, there are many surgeons and gynaecologists in Ukraine competing to provide minor surgery and obstetric and gynaecological care.
Strategy for the future
According to the new strategy, declared by the President of Ukraine in 2013, self-financed Primary Medical Care Centres (PMCC) based on a FM model should be created all over Ukraine. Currently, they are organized in four pilot regions. Every PMCC consists of several separated satellite FM clinics situated across the region (or in the different districts of a large city). With the exception of small satellite clinics, the ‘heart’ of the PMCC is located in a polyclinic or village hospital. It includes resources including a laboratory, X-ray and ultrasound equipment.
In small towns, one PMCC will provide care to a population of 15 000 people. Over 15 FDs will work in such centres. In cities, one PMCC will provide medical care to a population of 100–150 000. Over 100 FDs will work in such centres. In rural areas, one PMCC will provide medical care to a population of 100 000. Over 100 FDs will work in such centres.
Financing primary medical care
The government is supposed to spend 25–30% of the health care budget to support PMC. The number of specialists in the PMC system will decrease and the number of FDs is going to increase. The wage level of the FD will depend upon capitation, and number of medical services that is to be provided. Large increases in salary are anticipated. FM clinics will become separate fund-holding organizations. Insurance-based FM is going to be organized in the country. Citizens have to sign agreements with FDs concerning PMC, which can be provided in their clinic.
Current reality is different, yet. The economic support of the primary health care system remains inadequate. The local government budgets are largely inadequate. The state spends only 5–7% of the whole health care budget for PHC, which is far away from the targeted 30%. The primary care system is still dominated by specialists, the deficit in FDs is apparent. FDs remain the lowest paid specialty in the Ukrainian health care system.
TRAINING FOR FAMILY MEDICINE
Undergraduate
Facts. The current undergraduate medical course lasts for six years and includes a total of 51 subjects. At graduation, every student gets the diploma of a medical doctor. Students in the sixth year of study have a right to choose their specialty, as well as their working place (depending on their grades). According to the legislation, they have to work at least three years before they get their specialization.
Challenges. Usually students take the FM course in polyclinics by observing patients under guidance of a variety of specialists. Exposure to FD's is unusual. Young doctors often do not know the role of the FD; therefore, it is difficult for them to make this decision to pursue a career in FM.
Residency (internship)
Facts. Since 1998, most Ukrainian universities have organized postgraduate departments with a purpose to have:
Post-graduate education of FD/GP for recently graduated students of the medical institutes (two years internship/residency).
Re-training of qualified physicians (six months vocational training courses).
Residency (internship) is considered the best way to provide post-graduate FD training. FD's residency/internship lasts for two years, during which time residents have to spend time training in different clinical specialties including internal medicine, paediatrics, otolaryngology, ophthalmology and neurology. The average number of FM residents in Ukraine every year is approximately 300–400.
Training methods include standardized patient training, follow-up exams, small group training and brain-storming techniques. Residents complete the national qualification exam, which consists of an oral exam, evaluation of practical skills and a computerized multiple choice exam. The format of the national qualification exam is consistent across Ukraine whilst the educational tools during the internship can differ.
Challenges. Not all of the academic departments of FM in Ukraine have already begun the implementation of the new forms of educational work and these techniques are not used often. Trainers of FM (tutors) have to start training in the FM clinics. Residents have to spend most of their training time working in the FM clinics.
Specialty training and re-training
Facts. The postgraduate training of doctors to become FD in Ukraine includes re-training qualified physicians (internists, paediatricians and some other specialists) over a six-month long training courses.
Challenges. The weakness of these courses is that they are too short and are not focused on proper training. Training courses are organized in secondary care.
Continuous professional development
Facts. Ukraine provides a system of continuous professional development for all doctors. In Ukraine, FDs are assessed once every three-to-five years. Evaluation of the quality of Ukrainian FDs is provided according to three categories. After their graduation, they get the lowest qualification level called ‘Specialist.’ Within three-to-five years they can increase their qualification level (second, first and high category) after passing one-month courses in postgraduate faculties and taking exams in the regional health care administration. The new education programme of continuous medical accreditation has been established for the recertification of PHC professionals. For the first five-year cycle of recertification, physicians are required to earn 150 credits (one credit for one hour participation in a CME/CPD activity).
Challenges. The system of continuing medical education is still neither standardized nor compulsory and is often very haphazard. It is estimated that 50% of the trained FDs leave the service every year, often pursuing careers in more lucrative work such as the pharmaceutical industry.
PERSONAL EXPERIENCE: A CAREER AS A FAMILY DOCTOR IN UKRAINE
I started my practice as a FD and a FD trainer 13 years ago. Since then, I have taken an active part in the organization and the development of regional health care based on FM and FD's training.
Health care development
Since starting work at the only FM clinic in my town, FM has started to become more popular among both the general population and medical trainees. Our FM clinic is perhaps the only one in the Trans-Carpathian region that is actively promoting the values of FM. The FM clinic where I work includes 10 FDs and 12 nurses who give medical care to more than 15 000 patients. We try to promote our clinic experience as a model for a new organized system of primary care. To support this activity, my wife and I became the founders of the Charity Foundation ‘Family’ that was launched in 2005 (http://cffamilyen.wordpress.com/).
Since the beginning of the development of FM in our region, we have developed a very successful and busy out-patient clinic staffed by a talented group of physicians who are practicing FM. We have also expanded to provide a location for the clinical training of medical students and FM residents.
I was elected a President of ‘Uzhgorod (Ukraine)—Corvallis (USA) Sister City Association’ in 2011. In November 2011, we received humanitarian aid from our partners. It included medical equipment for FM development worth US $30 000. This shipment will help expand the clinic and help us to organize FM training centre in our region.
Training development
I work as the only FM mentor-trainer in the city FM clinic. Other academic specialists of my department work in hospitals and provide FD's training there. We have developed a quality training programme for FDs. Every year over 20 residents spend three weeks of their training process in this FM clinic, as do over 50 doctors attending re-training courses.
In 2010, we started our scientific research in the development of FM in the post-Soviet countries, including Ukraine. Since 2010, we have published several articles based on the results of our work on the prevention of chronic disease development. We have been prolific in efforts to improve the training of new doctors in primary care. Several articles concerning the subject have already been published, and several items have been incorporated in the routine work of FDs of the region. We have written several books and booklets, some of which are now used as the reference material for FD's training. Our most recent booklets are focused on diabetes, asthma and hypertension and are organized as a pocket reference formulary of drugs. We have developed a record form for children in the FM practice that is widely used not only in the training of residents but also into the routine work of local doctors. I am also improving the training of FP residents in interviewing and history taking, and in the basic skills of physical exam.
As recognition of my achievements in the development of FM in Ukraine, I have been awarded a scholarship by the Oregon Academy of Family Medicine (USA). Furthermore, I am often invited to speak before my colleagues in Eastern European countries on the topic of training doctors in Family Medicine in Ukraine.
Implications
After more than 20 years of independence, Ukraine still struggles to complete the health reforms needed for the provision of high quality primary care to the general population. The remaining challenges include achieving academic recognition, adequate remuneration, and the political and financial support of this new discipline.
Despite these challenges, we have managed to achieve many positive changes at the local level. We have made a big step forward in the system of FD's training (new training methods, new literature, and new FD training centre) and trained and re-trained large numbers of FDs to work in FM clinics, especially in rural areas. Our experiences are spreading across the region and throughout the country, have been recognized in other countries, and are supported by many international partners.
Conclusion
Despite many remaining challenges for family medicine in Ukraine, we are optimistic as to its future, given the many positive current initiatives taken by the discipline itself.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES
- Lekhan VM, Rudiy VM. Key strategies for further development of the health care sector in Ukraine . Joint report. Kiev, Ukraine: Scientific Publishers. 2007;160.
- Rechel B, McKee M. Health reform in central and Eastern Europe and the former Soviet Union. Lancet. 2009;374:1186–95.
- Windak A. Primary care and general practice in Europe: Central and East. Kiev, Ukraine: Oxford University Press. 2005;70–3.
- Gibbs T, Mulka O, Zaremba E, Lysenko G. Ukrainian general practitioners: The next steps. Eur J Gen Pract. 1999;5:33–6.
- Rurik I, Kalabay L. Changes in health and primary care systems of Central-Eastern European countries.
2011;40:13–9. - Oleszczyk M, Svab I, Seifert B, Krzton-Krolewiecka A, Windak A. Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia. BMC Fam Pract. 2012;13:15.
- Švab I, van Weel C. Research challenges for family medicine in a changing Europe. Reflections after an EGPRN conference on multimorbidity (Dubrovnik, 2009). Eur J Gen Pract. 2011;17: 233–7.
- Reamy J, Lovkyte L, Padaiga Z. Physician workforce planning and transition of primary health care in former socialistic countries. Cah Sociol Demogr Med. 2005;45:307–25.
- Rechel B, McKee M. Lessons from polyclinics in Central and Eastern Europe. Br Med J. 2008;337:a952.
- Rese A, Balabanova D, Danishevski K, McKee M, Sheaff R. Implementing general practice in Russia: Getting beyond the first steps. Br Med J. 2005;331:204–7.
- Rabbani F, Shaikh BT, et al. Medical education and training: responding to community needs. Med SciMonit. 2005;10:21–5.