Ukrainians are hot people. We see this every day through permanent “fights” “for an idea” in social networks, which, sometimes, are transferred to the physical space. So, in the Sumy region, they still remember how the Akhtyr and Trostyanets mayors fought a month ago. They say that Trostyanets and Akhtyrka have old accounts. This time, the cluster hospital became the infamous Kaydash's " The mayors could not agree on which of them in the city it will be located.

Back in early July 2022, the Ministry of Health announced the start of infrastructure reform. Then the Law “On Amendments to Certain Legislative Acts of Ukraine on Improving the Provision of Medical Care” was adopted.. On February 28, 2023, the Resolution of the Cabinet of Ministers No. 174 "

Plans for a wealthy network of medical institutions and the development of hospital districts by regional and city state administrations were to be submitted to the Ministry of Health for approval by May 1, 2023. But, apparently, problems at the stage of their preparation arose not only among the mayors of Akhtyrka and Trostyanets.

On what infrastructure reform would mean for patients; how is it happening now; what to do with the " UA spoke with co-founder of the Ukrainian Health Center (UHC) Pavel Kovtonyuk.

- Pavel Anatolyevich, the vast majority of our fellow citizens do not understand well or at all what this means and what the consequences will be for them. What, in theory, should the infrastructural stage of the medical reform mean for the patient? And why should it be good?

“Today, a patient cannot be sure that in a hospital where he will be taken in case of some serious situation or where he himself will come, he will be able to receive quality care according to some normal standards, and will not suffer at the same time.”. And people are looking for dating experts.

This happens because in Ukraine, historically, there are much more hospitals than competent doctors who have the equipment and a team to help a person.. That is, there is no resource to provide all existing hospitals with quality conditions for providing care.. This is not a problem of recent years and not even 30 years of independence.. Such a system was built under the USSR.

Therefore, since 1991, when we inherited all this, it has been on the agenda to do something with our network of hospitals.. Either provide them all with a bunch of doctors, equipment and drugs, or reduce their number.. But in the first variant, medical services will not improve anyway, because doctors simply will not have enough patients (since 1991, the population of Ukraine has almost halved), and, consequently, normal practice to gain the necessary experience.. Because of this, it often happens that a person goes to the hospital, and something terrible happens there.. My whole life is filled with situations when I have to save a person from some hospital, where they can’t cure him, and they don’t send him anywhere. He just lies and dies.

Therefore, the reduction of hospitals has always been on the agenda.. But since this topic is politically very sensitive, it was almost never approached, letting the situation flow somehow organically.. The number of hospital beds has gradually decreased over time, but not by much. 'Cause in a lot of places those beds just weren't needed.. The number of hospitals in our country almost did not decrease.. That is, all the hospitals built in the USSR for 52 million people (of which there were too many then), remained for 37 million people as of February 24, 2022. And now we have 30–31 million people, and in 15 years there will be even fewer. Therefore, the further this problem is postponed, the more radical and less popular its solution will be..

The first, so to speak, approach to the projectile occurred just at the time of our team. Back then we did such a thing as hospital districts. This was an attempt to streamline the hospitals, concentrate equipment and specialists in the flagship hospitals, which we then called " Weaker hospitals, which would be donors of specialists for a larger hospital, had to be repurposed into something more outpatient that would not need serious technologies and narrow specialists. But our initiative was not successful. Although the idea was right, in its implementation we encountered a number of problems that hung up this reform, and it failed..

The current law and regulation de facto are a repetition of our practice. Only with some nuances and name changes. Now " But the essence of this does not change. The idea is the same - the concentration of technology and specialists in large hospitals, where there will be a large flow of patients. And then building a route so that patients are immediately taken there.

And so I predict: with this initiative there will be the same problems as they were with hospital districts.. It is already impossible not to implement this part of the reform at the current stage.. But the approach that the government has now chosen is unpromising.. And the first steps already show it.

— Yes, regional, city state (military) administrations had to develop and submit for approval to the Ministry of Health (within two months) a wealthy network of healthcare institutions and plans for the development of hospital districts by May 1, 2023. And the problems started already at the development stage.. The mayors of Akhtyrka and Trostyanets had a fight during a meeting. In the Zaporozhye region, in general, it is not known what is happening. The health department was liquidated there, and instead of implementing the reform, there are litigations. Scandals of greater or lesser intensity occur in all areas. Why? Something went wrong?

- I will name a few problems with this law and regulation that need to be solved.. Otherwise, the government will again fall into the trap of failure, and the idea of \u200b\u200breforming the network of hospitals will become more and more toxic..

The first problem is that the ruling is very conservative.. The requirements for general cluster and super-cluster hospitals are so modest that in fact it will not change anything for the patient. For example, the general should serve 50 thousand people, the cluster - 120-150 thousand, the super-cluster (region) - one million people.

The norms of the USSR were almost identical and even greater. The district hospital (the equivalent of " " "

That is, de facto we remain at the soviet, very outdated coverage standards. In European practice, an institution serving less than 300 thousand people is no longer a hospital, because it does not have a sufficient flow of patients. Doctors of district hospitals can see some difficult cases once a year. I am currently reading a book by doctor Ivan Chernenko " He very vividly describes situations when there were cases with complications in their district hospital in the Odessa region.. It caused panic because the doctors had never seen anything like it..

Second problem. In the post-war period, when we will have a civilizational demand for change (after all, Ukraine has already made a final decision that we are part of the European Union in some perspective), we must actively integrate into Western society. And to do this with the hospitals that we have, no matter how we rearrange them, does not make sense.. Even the best we have is hopelessly outdated. Most hospitals built between 1960 and 1980.

The real agenda for the hospital network in Ukraine is its modernization. And the infrastructural stage of the reform, it seems to me, should be about this. Gradually, this will stretch for 10-20 years, but the network should be modern not just today, but also in 10-15 years.

And the best time for such changes and bolder plans is post-war.. Investments will come to Ukraine. The attention of the world will be riveted to it, it will be actively integrated into Europe.

And the proposed law and resolution actually streamline what is. Make a cluster hospital based on a certain city - some improvement. But this is the same old hospital, where it is simply impossible to make something of high quality and modern architecturally, because it was created in a different era, with different technologies..

The third problem is the one you described. The same one that we faced in due time and on which we burned ourselves. It's a property issue. When you enlarge a medical institution, it must be located in some kind of bulk. In which, if there are several applicants? After all, this cluster institution will invest money, concentrate doctors, equipment.

And the " I have recently been there and there. Hospital in Trostyanets heavily bombed. Akhtyrka was bombed as a city, but the hospital was not. What is the problem there? Geographically, Akhtyrka is in the best location for the hospital. And in Trostyanets, which is away from the main roads, the hospital is much better, because the mayor has been investing in it for many years. And what to do?

The communities begin to fight among themselves. We went through this at one time too.. The state should not be the judge of who to choose. This will not lead to anything good, it will just make the reform toxic. All local government will become its enemy. And in small towns, local government and medical teams are in very close contact.. This means that the enemies of the reform will be doctors. And consequently, patients. So it's a road to nowhere.

I think a third solution is needed. And, in my opinion, it consists in the construction of new hospitals for investment, where there will be a different ownership structure - collegiate and collective. They will not belong to a particular community. They will be led by a supervisory board, which includes the communities that such a hospital serves, and not only them.. There may also be patient organizations, the government, and so on.. So it will be common. This is the corporate management of new hospitals.

But the plans have already been submitted..

— It takes 10-15 years to build a hospital. These are analysis, project, contractor, search for managers, search for personnel and their training. In a modern hospital with modern processes inside, design, other patient flows, technologies, there must be people who know how to use and manage this. And there are very few of them in Ukraine. So it's a long process.. But the sooner we start, the sooner we'll finish..

I believe that these laws and regulations have no prospects. The maximum that can happen is to restructure the network a little at the cost of huge losses.. But the result won't be worth it.

Fourth problem. The project solves a smaller part of the problem - with the enlargement of hospitals outside the cities. But the largest number of extra hospitals and hospital beds in Ukraine is in big cities, for example, in Kyiv, Kharkov, Lvov.

How to reduce the network in cities, the law does not answer this question at all. Lviv is actually doing this on its own by creating two territorial medical associations - two reference hospitals per city instead of a dozen only city ones. But there are still a bunch of regional institutions, some departmental and private hospitals. Given that two for a city like Lviv is quite enough. In Kyiv (where there are about two dozen general city hospitals per city), if we take the standard for 400 thousand people, ten.

And there are even more hospitals in Kharkiv. There they are now declining naturally, because the population has greatly decreased.

And how to put it together? The law ignores this issue..

“There should be hospital districts….

- These will be urban districts, if we use the word " or coverage area. There are different terms that mean the same thing.

- When dividing into which, as the decree mentions, four indicators must be taken into account. We have already remembered the boundaries of administrative-territorial units. Next - geographical features and the state of roads.

- Yes. For example, in order not to carry patients across the Dnieper River in Kyiv, not to climb into the center. In a modern city, everything is built along bypass roads, that is, an ambulance travels around the city, and not through the center..

- One of the indicators - the optimal clinical routes of patients should be taken into account.

— As I said, there are clearer criteria for clustering outside the cities. Everything is based on new districts. General rule: the cluster hospital is located in the center of the new district. A more or less clear and understandable approach and, accordingly, a clinical route - a person is not taken to the nearest hospital, but immediately to the district.

But when we take a big city, there is no clarity with the clinical route, because there large institutions can duplicate each other. For example, a cardiology center and a strong hospital with a good cardiology department. Where to take a person with a heart attack? The decision is made according to the situation.

In addition, one must understand that large cities are agglomerations.. That is, the real coverage area of \u200b\u200btheir medical institutions is larger than the boundaries of the city. All the suburban population that can drive to a major city will go there, because it is better there by definition. But this is also not in the law, and this creates a lot of fuzziness, which will be another problem..

– Current and projected demographics should also be taken into account.

— Yes, demography and epidemiology, that is, what is the incidence profile. When we talk about network planning, first of all, we are talking about general multidisciplinary hospitals, which are the main place for the treatment of most of the diseases that are standard for the region (in terms of epidemiology). But at the same time, the number of population matters, we have already mentioned this..

Let's talk more about demographics. Now there are no statistics either on the number of existing population or on the number of medical staff in a particular region. For example, almost all institutions from the occupied territory moved to Zaporozhye (which is 80%). Now there is a surplus of institutions and doctors. This issue is not resolved and there is no policy regarding this. That is, in fact, there is no information on the geographical location of institutions and medical staff.. As well as the condition of the equipment. This is true?

- So. But I can't say that this is a problem that needs to be addressed immediately.. Until the situation has stabilized, we cannot fix this in any region.

- But this is one of the indicators that you need to focus on when distributing.

- Right. You named the fifth reason why the reform with clusters is inappropriate and untimely - we do not know the geographical location of the population. Today, internal migration in Ukraine is huge.. We have no idea what these geography and demographic distribution will be like when the situation stabilizes.. For example, how will the territories be populated after the de-occupation. Therefore, I do not consider it a problem not to make these decisions now.. Specific, detailed, at the operational level. We will know the distribution of the population by territory only after the end of hostilities and stabilization of the situation.

- The National Health Service of Ukraine should probably be talking about a new network of wealthy hospitals, because this is its network.

— Yes, NSZU would have to come up with and say what kind of network it wants. Because it's the only organization that knows everything, it has the most data. But today she does not do this, because she does not have the opportunity.

Service degrades at a tremendous rate. Over the past two years, NSZU funding has almost halved. This year, in absolute terms, it is less than it was at the time of its creation, when a dozen people worked there.

NSZU somehow supports the basic current work, but the management does not think in terms of strategic purchases. The service has lost its main function.

And in the perspective of post-war reconstruction, this worries me much more than specific things that fall into the mainstream of news and discussion..

- Then let's talk about what to do. How possible is the infrastructural stage of medical reform in such conditions? And what to do so that an essentially good idea comes to life, and the patient wins, and does not suffer even more?

— I believe that we need a unifying idea, not one that will cause conflicts. And the unifying idea is the modernization of hospitals by building new ones or, in very isolated cases, the modernization of old ones.. The timing is perfect for this..

And under this idea, you need to start a discussion - both about demography, and about routes, and about where to unite whom. This is a huge work that will mobilize and unite the medical community, society and become part of our integration into the EU.

- I understand correctly: we need to discard what has just been announced, and start discussing a completely different concept.?

- you understand correctly. There may be some preliminary steps. It is necessary to unite certain institutions, form teams of specialists, concentrate equipment, and train managers right now. When we talk about the general population and general trends, we can already say a lot here.. Different specialists, including our team, make their own calculations, and most of them coincide. There are estimates of certain general trends. Can't wait for the end of the war. Need to make plans. They must be ready on the day the war or hostilities end..

In addition, we are now starting a large educational program - a master's program for managers at the Kyiv-Mohyla Academy. Now, during the war. So that when the time comes, she will already be. The same goes for hospitals.. So that when the hostilities end, investors will come and ask for investment projects, we already had them. This is what needs to be done now.

And it is very important to prepare for post-war integration into the West by strengthening our state institutions.. We need a strong state. The weak will not be able to integrate into the European Union, will not be able to carry out all the necessary changes, and we will again find ourselves a backward country on the outskirts of civilization.

The encapsulation of the system and the transition from development to the stage of simply supporting some operational processes is a big problem.. And this is observed in absolutely all areas - from eHealth to primary care, to the NSZU apparatus and monitoring, which is almost absent. Therefore, we have a lot of abuses that we discuss so zealously..

Now we are talking loudly about the importance of rehabilitation, about mental health. But I have a question: we understand that entire systems must be formed for this.? That we should not talk about a separate rehabilitation center, but about a multi-level rehabilitation system, which begins, if we are talking about the military, from the hospital where they were brought by the medevak. Where the military had an operation. Straightaway. This is the only way to achieve the greatest results in rehabilitation.. We are not doing this, but a rehabilitation center, because it is beautiful, something is being built. But after the rehabilitation center, a person finds himself in a community where he must continue rehabilitation for a long time.. There must be conditions. But they are not there, and infrastructure - too.

Same mental health problem. And these risks to our post-war success are far greater than the scandals that make the news..

These problems will not be solved by a separate initiative or a public organization that has built some kind of rehabilitation center. They can only be solved at the level of the state system, because we are talking about millions of people. This should solve the construction of entire blocks of the program of medical guarantees and infrastructure for them, which can only be done by an organization such as the National Health Service. And today she is not able to do this.. And it needs to be addressed.