Where does the money go, how is the money used, and what are produced results in the health sector? II Tracking Health Resources in Ukraine Executive Summary III Report No: ACS21387 © International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Internet: www.worldbank.org; Telephone: 202 473 1000 This work is a product of the staff of The World Bank with external contributions. Note that The World Bank does not necessarily own each component of the content included in this work. The World Bank therefore does not warrant that the use of the content contained in the work will not infringe on the rights of third parties. The risk of claims resulting from such infringement rests solely with you. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or other partner institutions or the governments they represent. 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License: Creative Commons Attribution CC BY 3.0 IGO Translations – If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by The World Bank and should not be considered an official World Bank translation. The World Bank shall not be liable for any content or error in its translation. All queries on rights and licenses should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington DC, 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. 2 Tracking Health Resources in Ukraine Executive Summary 3 ACKNOWLEDGMENTS This study was conducted by a joint team from the World Bank and Kyiv School of Economics. Feng Zhao (Program Leader, Human Development, World Bank) provided overall guidance to the design and implementation of the assessment. He helped with the analytical framework and provided overall quality control. Hanna Vakhitova (Assistant Professor and Senior Researcher at Kyiv School of Economics) led the design and organization of the survey and data analysis. Olena Doroshenko (Health Economist, the World Bank) worked extensively on the report and contributed significantly to the different phases of the fieldwork and data analysis; she was the main author for the chapter on facilities’ costs and productivity. Ilona Sologoub, Maksym Obrizan, Pavlo Iavorskiy, and Natalia Shapoval (Kyiv School of Economics) contributed to various chapters. Vadym Biziaev (Kyiv School of Economics) was responsible for collecting and analyzing financial and statistical data. Oleksandr Dyshlevyi and eight interviewers from the Kyiv International Institute of Sociology were responsible for the fieldwork of the survey. Bernard Gauthier (International Consultant on Public Expenditure Tracking Surveys (PETS)) provided invaluable support and suggestions for organization of the findings. Special appreciation goes to Natalya Lukyanova from the United Nations Development Programme (UNDP) in Ukraine for support of the study in government control areas of Donetsk and Luhansk oblasts (Donbas region), and useful comments to the draft report. The World Bank provided funding for the study in Lviv and Poltava oblasts through the Department for International Development (DFID) Trust Fund/Ukraine Governance Reform Program Technical Assistance, specifically the Programme for Improving Effectiveness in Human Development and Social Accountability. UNDP financed the study in Donbas region. The joint team would like to acknowledge the valuable contributions of all our key informants, including government representatives, public sector service providers, health managers, and physicians in Donetsk, Lviv, Luhansk, and Poltava oblasts, who participated in in-depth interviews, for their cooperation, contributions, and time spent with the research team to prepare and discuss the results of the assessment. This assessment and report were carried out to assist the Ministry of Health, Ukraine, in the development of its health financing reform concept and advise steps of its implementation at the national and regional levels. The Ministry of Health (MoH) and regional health departments provided timely feedback on the report, particularly on the initial results. 4 Tracking Health Resources in Ukraine Executive Summary 5 TABLE OF CONTENTS > > OVERALL RESOURCE AVAILABILITY PERCEPTION OF OBLAST AND RAYON OFFICIALS 61 62 ACKNOWLEDGMENTS 1 B DELAYS AND INEFFICIENCIES 76 LIST OF TABLES 5 > INFORMATION FROM TREASURY TRANSACTIONS 77 C PROCUREMENTS 83 LIST OF FIGURES 6 6 HUMAN RESOURCE MANAGEMENT 86 EXECUTIVE SUMMARY 12 A USE OF PHYSICIANS’ TIME 86 1 INTRODUCTION 20 > PATIENTS’ ENTRY POINT 86 2 STUDY METHODOLOGY 24 > TIME SPENT ON PAPERWORK 87 > PATIENT CONSULTATION TIME 91 A STUDY STEPS AND INSTRUMENTS 24 B PHYSICIANS’ SALARIES AND COPING MECHANISMS 92 B RESEARCH QUESTIONS AND APPROACH 24 C. MOONLIGHTING OR SECONDARY JOBS 94 C DATA SOURCES 26 > CHARGING PATIENTS FOR TREATMENT AND PARALLEL FINANCING OF HEALTH CARE 97 > PETS/QSDS SURVEY DATA 26 7 FACILITIES’ COSTS AND PRODUCTIVITY 104 > SCOPE AND SAMPLING 26 > TYPES OF FACILITIES AND SERVICES 104 > ADMINISTRATIVE AND FINANCIAL DATA 28 > ALLOCATION OF HUMAN RESOURCES ACROSS > COST AND PRODUCTIVITY DATA 29 FACILITIES AND DEPARTMENTS 104 D LIMITATIONS 30 > PERFORMANCE AND PRODUCTIVITY 109 > SERVICE COSTS 116 3 OVERVIEW OF THE HEALTH SECTOR 32 8 READINESS TO REFORM AND IMPACTS OF CONFLICT 122 A ORGANIZATION AND FINANCING OF THE HEALTH SECTOR 32 A READINESS TO REFORM 122 B BUDGET PLANNING AND EXECUTION 34 B IMPACTS OF THE CONFLICT 130 4 BUDGET MANAGEMENT IN THE HEALTH SECTOR 40 9 CONCLUSIONS AND RECOMMENDATIONS 132 A THE HEALTH BUDGET 40 B PREPARATION OF THE HEALTH BUDGET AND CONTROLS 49 SUGGESTIONS AND RECOMMENDATIONS 136 > BUDGETARY DISCIPLINE 56 ANNEX A SAMPLE 138 C ANALYSIS OF LEAKAGES 56 ANNEX B HEALTH CARE PROVISIONS AND 5 MANAGEMENT OF MATERIAL INPUTS 62 EXPENDITURES IN THE STUDIED OBLASTS, 2015 139 A AVAILABILITY OF PUBLIC RESOURCES 62 ANNEX C LEAKAGES AND INCONSISTENCIES 140 > BED CAPACITY 62 ANNEX D FINANCIAL FLOWS IN THE STUDIED OBLASTS 157 6 Tracking Health Resources in Ukraine Executive Summary 7 LIST OF TABLES LIST OF FIGURES TABLE 1. SAMPLE (SHORT DESCRIPTION): NUMBER OF FACILITIES SAMPLED BY TYPE AND OBLAST 27 FIGURE 1. FINANCIAL FLOWS IN THE HEALTH CARE SECTOR 39 TABLE 2. MEDICAL SUBVENTIONS TO LOCAL BUDGETS FIGURE 2. PUBLIC AND TOTAL HEALTH EXPENDITURES IN 2015 AND 2016 (UAH MILLION) 46 IN UKRAINE, 2004–2016 40 TABLE 3. PLANNED AND ACTUAL HEALTH BUDGET FIGURE 3. HEALTH SECTOR EXPENDITURES: BY FUNCTIONAL CLASSIFICATION 2015 AND 2016, POLTAVA AND LVIV OBLASTS, 2015 42 WITH EXECUTION RATES 48 FIGURE 4. HEALTH SECTOR EXPENDITURES: TABLE 4. MAIN ACTORS OF THE BUDGETING DONETSK AND LUHANSK OBLASTS, 2015 44 PROCESS AND THEIR FUNCTIONS 50 FIGURE 5. STRUCTURE OF UKRAINE’S HEALTH TABLE 5. WERE THERE DELAYS IN DISBURSEMENT OF EXPENDITURES BY FUNCTIONAL CLASSIFICATIONS 47 FINANCES, DRUGS, OR OTHER SUPPLIES DURING 2016? SHARE OF “YES” ANSWERS OF PHYSICIANS-MANAGERS FIGURE 6. COMPOSITION OF PER CAPITA SPENDING IN DONETSK AND LUHANSK OBLASTS 77 IN 2015 (FROM THE LOCAL HEALTH BUDGETS), UAH 48 TABLE 6. ACTUAL AND PLANNED MONTHLY BUDGET INFLOWS ON HOW FIGURE 7. DO YOU HAVE A GENERAL UNDERSTANDING (SALARIES): ILLUSTRATION FOR A CENTRAL RAYON HOSPITAL, THE BUDGET OF YOUR DEPARTMENT/AMBULATORY/FOP IS THOUSAND UAH (2014 AND 2015) 78 DETERMINED? (PERCENT OF POSITIVE ANSWERS AMONG PHYSICIANS) 51 TABLE 7. DIFFERENCE BETWEEN ACTUAL AND PLANNED FIGURE 8. IS YOUR EXPERIENCE WITH CERTAIN DRUGS ANNUAL BUDGET INFLOWS (SALARIES AND MEDICATION), CONSIDERED DURING BUDGET PLANNING? BY FACILITIES: POLTAVA OBLAST (2014 AND 2015) 80 (PERCENT OF POSITIVE ANSWERS AMONG PHYSICIANS) 51 TABLE 8. “EARLY” USAGE AND PERSPECTIVES ON FIGURE 9. WHAT DO YOU TAKE INTO ACCOUNT WHEN PROZORRO, BY RAYONS/CITIES AND FACILITIES (IN PERCENTAGE) 84 PLANNING YOUR BUDGET? (PERCENT OF RESPONDENTS FROM PHYSICIANS-MANAGERS WHO SELECTED CERTAIN TABLE 9. DISTRIBUTION OF STAFF POSITIONS IN ANSWER; SEVERAL ANSWERS COULD BE PROVIDED) 53 SAMPLED FACILITIES 105 FIGURE 10. FACTORS REPORTED USEFUL FOR SUCCESSFUL TABLE 10. ALLOCATION OF PERSONNEL IN FACILITIES ADVOCACY (PERCENT OF PHYSICIANS-MANAGERS WHO PER 1,000 POPULATION 105 SELECTED CERTAIN ANSWER, SEVERAL ANSWERS WERE POSSIBLE) 54 TABLE 11. COMPARISON OF UTILIZATION OF CARE FIGURE 11. HOW WOULD YOU LIKE TO CHANGE THE NUMBER OF IN POLYCLINICS IN CITIES AND RAYONS OF PERSONNEL AT THIS FACILITY? (ANSWERS FROM PHYSICIANS- LVIV AND POLTAVA OBLASTS 107 MANAGERS IN DONETSK AND LUHANSK OBLASTS) 55 TABLE 12. UTILIZATION AND PRODUCTIVITY RATES FIGURE 12. HOW OFTEN ARE ALL BEDS OCCUPIED AT IN HOSPITAL FACILITIES OF THE SAMPLE 112 THIS FACILITY (BY OBLAST AND FACILITY TYPE)? (PHYSICIAN RESPONSES) 61 TABLE 13. PRODUCTIVITY OF PHYSICIANS WORKING IN INPATIENT FACILITIES, NUMBER OF FIGURE 13. SHARE OF HEALTH CARE NEEDS COVERED BY THE CASES TREATED PER PHYSICIAN PER YEAR 113 OBLAST/RAYON/CITY BUDGET: RAYON AND OBLAST OFFICIALS’ RESPONSES 63 TABLE 14. BUDGET STRUCTURE OF THE CLINICAL 114 DIVISIONS OF THE SAMPLED FACILITIES FIGURE 14. SHARE OF NEED IN DRUGS AND MEDICAL SUPPLIES REPORTED COVERED BY THE FACILITY BUDGET (PHYSICIANS-MANAGERS ANSWERS BY FACILITY LEVEL) 64 TABLE 15. AVERAGE COST OF CASE TREATMENT IN SAMPLED INPATIENT DEPARTMENTS 120 FIGURE 15. DONETSK AND LUHANSK OBLASTS, COVERAGE OF NEEDS BY FACILITY BUDGET TABLE B1. POLTAVA OBLAST 139 (FACILITY MANAGERS’ REPORTS) 65 TABLE B2. LUHANSK OBLAST 140 FIGURE 16. SHARE OF DRUG NEEDS COVERED BY FACILITY BUDGET (PHYSICIANS’ ANSWERS) 66 TABLE B3. DONETSK OBLAST 141 FIGURE 17. SHARE OF MEDICAL SUPPLY NEEDS TABLE B4. LVIV OBLAST 142 COVERED BY FACILITY BUDGET (PHYSICIANS’ ANSWERS) 67 TABLE C1. LEAKAGE ESTIMATES AND INCONSISTENCIES IN FINANCIAL FIGURE 18. SHARE OF EQUIPMENT COVERED BY REPORTS—LVIV OBLAST, MILLION UAH 143 FACILITY BUDGET (PHYSICIANS’ ANSWERS) 68 8 Tracking Health Resources in Ukraine Executive Summary 9 FIGURE 19. OF TOTAL COST OF TREATMENT, FIGURE 38. EXISTENCE OF OUT-OF-POCKET FEES FOR SHARE COVERED FROM DIFFERENT SOURCES 70 SOME SERVICES AT THE FACILITY (PERCENT OF PHYSICIANS WHO REPORT EXISTENCE OF FEES), BY FACILITY TYPES FIGURE 20. HOW OFTEN DID YOU FACE SHORTAGE OF AND OBLASTS (PHYSICIANS’ ANSWERS) 97 FINANCIAL RESOURCES, DRUGS, VACCINES, OR OTHER MEDICAL SUPPLIES IN 2015? (PHYSICIANS-MANAGERS) 71 FIGURE 39. EXISTENCE OF CHARITABLE FUND AT THE FACILITY (PHYSICIANS’ ANSWERS) 98 FIGURE 21. DONETSK AND LUHANSK OBLASTS: FREQUENCY OF SHORTAGE OF FINANCIAL RESOURCES FIGURE 40. SHARE OF PATIENTS CONTRIBUTING TO (PHYSICIANS-MANAGERS PERSPECTIVE) 72 THE CHARITABLE FUND (PHYSICIANS’ ANSWERS REPORTING EXISTENCE OF A CHARITABLE ACCOUNT AT THEIR FACILITY) 99 FIGURE 22. DONETSK AND LUHANSK OBLASTS: FREQUENCY OF SHORTAGE OF DRUGS FIGURE 41. COMPOSITION OF REVENUES REPORTED (PHYSICIANS-MANAGERS PERSPECTIVE) 73 BY SOME PHYSICIANS-MANAGERS IN LVIV AND POLTAVA OBLASTS (HERE “OTHER FUNDS” IMPLY FIGURE 23. IN CASE OF SHORTAGES, OPTIONS PHYSICIANS CHOOSE CHARITABLE FUNDS, LIKARNIANA KASA, AND OTHERS) 100 (BY PERCENT) 74 FIGURE 42. COMPOSITION OF REVENUES REPORTED FIGURE 24. DO YOU HAVE A RESERVE OF [EMERGENCY] DRUGS? BY SOME PHYSICIANS-MANAGERS IN DONETSK AND LUHANSK OBLASTS 101 SHARE OF “YES” ANSWERS OF PHYSICIANS-MANAGERS 76 FIGURE 43. DO YOU THINK PATIENTS ARE READY TO PAY FIGURE 25. AVERAGE MONTHLY DEVIATIONS OF ACTUAL FOR ADDITIONAL SERVICES? (PHYSICIANS-MANAGERS ANSWERS) 103 AND PLANNED MONTHLY BUDGET INFLOWS (SALARIES AND MEDICATION) BY FACILITIES: FIGURE 44 AVERAGE UTILIZATION AND WORKLOAD AT PHCS, POLTAVA OBLAST (2014 AND 2015) 79 BY TYPE (ERROR BARS FOR STANDARD DEVIATION) 106 FIGURE 26. MONTHLY ACTUAL BUDGET ALLOCATION (BLUE LINE) FIGURE 45 AVERAGE UTILIZATION AND WORKLOAD AT PHCS, AND EXPENDITURE (RED LINE) (SALARY), BY OBLAST (ERROR BARS FOR STANDARD DEVIATION) 106 ILLUSTRATION FOR A CENTRAL RAYON HOSPITAL (2015) 81 FIGURE 46. NUMBERS OF VISITS PER PERSON LIVING IN FIGURE 27. MONTHLY ACTUAL BUDGET ALLOCATION (BLUE LINE) THE CATCHMENT AREA TO POLYCLINICS SPECIALISTS AND EXPENDITURE (RED LINE) (MEDICATION), PER YEAR, BY FACILITY TYPE 108 ILLUSTRATION FOR A CENTRAL RAYON HOSPITAL (2015) 81 FIGURE 47. NUMBER OF PATIENTS SEEN BY PHYSICIAN FIGURE 28. DIFFERENCE OF ACTUAL RECEPTION PER DAY IN DIFFERENT POLICLINICS FACILITIES OF THE SAMPLE 109 AND EXPENDITURE AT THE FACILITY LEVEL, IN PERCENT (POLTAVA OBLAST) 82 FIGURE 48. COMPARISON OF VISITS PER ONE PERSON PER YEAR TO OUTPATIENT SPECIALISTS IN POLYCLINICS FIGURE 29. REPORTED PHYSICIANS WORKING TIME AND PRODUCTIVITY OF SPECIALISTS IN TERMS OF PATIENTS PER MONTH, BY FACILITY TYPES AND OBLAST 87 SEEN PER DAY IN LVIV AND POLTAVA OBLAST HOSPITALS 110 FIGURE 30. DO YOU OFTEN WORK OVERTIME? 89 FIGURE 49. NUMBERS OF LABORATORY AND X-RAY EXAMINATIONS PER MEDICAL PERSONNEL PER DAY IN DIFFERENT FACILITIES FIGURE 31. WOULD YOU BE ABLE TO PROVIDE (ERROR BARS FOR STANDARD DEVIATION) 111 BETTER TREATMENT IF SOMEONE TOOK ON PAPERWORK? 90 FIGURE 50. COST OF VISIT TO PHCS IN TWO OBLASTS 115 FIGURE 32. WOULD YOU BE ABLE TO PROVIDE BETTER TREATMENT IF YOU WERE PROVIDED A COMPUTER? 90 FIGURE 51. AVERAGE COST OF THE PATIENTS’ VISIT IN POLYCLINICS IN TWO OBLASTS AND BY TYPE OF FACILITY 116 FIGURE 33. AVERAGE CONSULTATION TIME PER PATIENT (IN MINUTES), BY FACILITY TYPES AND OBLASTS FIGURE 52. AVERAGE COSTS OF A VISIT TO ENT, (PHYSICIANS’ RESPONSES) 92 SURGERY, AND TRAUMA DEPARTMENTS OF POLYCLINICS 117 FIGURE 34. FAIR SALARY: WHAT WOULD BE THE DECENT FIGURE 53. AVERAGE COSTS OF DIAGNOSTIC SALARY FOR A PERSON IN YOUR POSITION? (UAH PER MONTH) 93 PROCEDURES IN SAMPLED FACILITIES 118 FIGURE 35. IF TOMORROW YOUR SALARY RISES FIVE TIMES, FIGURE 54. AVERAGE COST OF A BED-DAY IN WOULD YOU AGREE TO SERVE TWICE AS MANY PATIENTS? SAMPLED INPATIENT DEPARTMENTS 119 (PHYSICIANS’ ANSWERS) 94 FIGURE 55. AVERAGE COST OF CASE TREATMENT IN FIGURE 36. SHARE OF PHYSICIANS WHO REPORT HAVING SAMPLED INPATIENT DEPARTMENTS 120 ANOTHER JOB, BY FACILITY TYPE AND OBLAST 95 FIGURE 56. OPTIMAL DISTRIBUTION OF FACILITIES’ FIGURE 37. CORRELATION BETWEEN WORKING HOURS REVENUE SOURCES (PHYSICIANS-MANAGERS PERSPECTIVE) 123 PER MONTH AT THE MAIN JOB (X AXIS) AND SUPPLEMENTARY JOB (Y AXIS), (PHYSICIANS’ ANSWERS) 96 10 Tracking Health Resources in Ukraine Executive Summary 11 FIGURE 57. AT WHICH LEVEL IS THE HEALTH CARE SYSTEM THE LEAST EFFICIENT? SHARES OF ANSWERS OF OFFICIALS AND PHYSICIANS-MANAGERS (THIS QUESTION WAS ASKED ACRONYMS ONLY IN DONETSK AND LUHANSK OBLASTS) 124 ALOS AVERAGE LENGTH OF STAY FIGURE 58. OPINIONS OF OBLAST AND RAYON/CITY OFFICIALS ON HEALTH CARE SYSTEM DESIGN 126 CMU CABINET OF MINISTRIES OF UKRAINE FIGURE 59. DO YOU HAVE EXPERIENCE WITH . . . 127 DFID DEPARTMENT FOR INTERNATIONAL DEVELOPMENT FIGURE 60. SHIFT IN CASH FLOW PATTERN WHEN DRG DIAGNOSIS-RELATED GROUP AN AMALGAMATED HROMADA IS FORMED (A HYPOTHETICAL EXAMPLE) 128 ENT EARS, NOSE, AND THROAT FIGURE 61. THE BELIEVED LEVEL OF THE HEALTH CARE FINANCING SYSTEM IN UKRAINE (PHYSICIANS-MANAGERS’ ANSWERS) 129 FOP AU: PLEASE SUPPLY FIGURE 62. CHANGES IN PARAMETERS COMPARED TO THE BEGINNING OF 2014, AT YOUR FACILITY 130 FTE FULL-TIME EQUIVALENT FIGURE D1. FINANCIAL FLOWS IN LVIV OBLAST 150 HR HUMAN RESOURCES FIGURE D2. FINANCIAL FLOWS IN POLTAVA OBLAST 152 IDP INTERNALLY DISPLACED PERSON FIGURE D3. FINANCIAL FLOWS IN DONETSK OBLAST 154 IT INFORMATION TECHNOLOGY FIGURE D4. FINANCIAL FLOWS IN LUHANSK OBLAST 156 KIIS KYIV INTERNATIONAL INSTITUTE OF SOCIOLOGY LSA LOCAL STATE ADMINISTRATION MOF MINISTRY OF FINANCE MOH MINISTRY OF HEALTH NCD NONCOMMUNICABLE DISEASE PETS PUBLIC EXPENDITURE TRACKING SURVEY PFR PUBLIC FINANCE REVIEW PHC PRIMARY HEALTH CARE QSDS QUANTITATIVE SERVICE DELIVERY SURVEY R&D RESEASRCH AND DEVELOPMENT RDA RAPID DATA ASSESSMENT SDCA STEP-DOWN COST ACCOUNTING SFI STATE FINANCIAL INSPECTION SPSS AU: PLEASE SUPPLY STS STATE TREASURY SERVICE TB TUBERCULOSIS UAH UKRAINE CURRENCY UNDP UNITED NATIONS DEVELOPMENT PROGRAMME 12 Tracking Health Resources in Ukraine Executive Summary 13 EXECUTIVE SUMMARY utility bills. The current system is providing inadequate incentives that are associated with various inefficiencies in resource use and the creation of shadow parallel financing flows, which affects the quality and accessibility of health services. Planning and allocation of the health budget Public financing contributes to only about half of total health expenditure in Ukraine. BACKGROUND Public health spending of USD 77 (2015) in per capita terms is the lowest among While Ukraine has spent a significant amount of resources on health, its health outcomes European countries. During the latest economic and political crisis, the health budget as fare poorly when compared with other European countries. For example, average a share of the total budget declined to 9 percent in 2016 from 12 percent in 2013. life expectancy at birth in Ukraine has improved from the lowest, 66.8 years in 1995 The limited health budget is mostly consumed by one of the most oversized hospital to 71.4 years in 2016, but is still nine years behind the EU average of 80.6 years. The infrastructures in Europe, with 0.4 hospitals, 7.4 beds, 4.4 physicians, and 8.6 nurses country has much higher death rates related to noncommunicable diseases (NCD) than per 1,000 people. Lviv oblast, with 8.6 beds per 1,000 people, presents one of the highest the neighboring countries on their west. The suboptimal health outcomes point to the bed ratios among Ukrainian regions. inefficient use of public resources, which is magnified by the shortage of funds during the recent economic crisis and conflicts. However, although the Public Finance Review (PFR) The execution rate of the planned health budget is relatively low despite excessive has been conducted recently to assess the allocation and effectiveness of public spending, control and regulations, but has increased somewhat in the last two years. In 2014, there is no study to track the resource flows in order to identify the magnitude of the the health budget execution rate was 88 percent, progressing to 94 percent and 96 inefficiency and waste in the health sector. percent in 2015 and 2016, respectively. Still, the 4 percent execution gap in 2016 represented 3 billion hryvnias (Ukraine currency) of the planned budget not allocated This study aims at tracking the resource flows and identifying inefficiencies in the to the health care sector. allocation and use of public resources in Ukraine’s health sector. It examines potential bureaucratic capture, resource leakage, and problems in the deployment of human and Health sector spending is biased toward hospital services instead of primary health in-kind resources, and provides practical recommendations for improvement. care, which provides low-cost preventive care. General and specialized hospitals represent 64 percent of the public health budget, while PHCs receive about 10 percent. The study was conducted in partnership between the World Bank, UNDP, and the Kyiv In the Donetsk oblast, for example, 70 percent of the budget is allocated toward hospital School of Economics. The Kyiv International Institute of Sociology conducted fieldwork care, while PHC services represent only 13 percent. Separately standing secondary and in 2016 and 2017 among primary health care (PHC) facilities, hospitals, and health tertiary care outpatient facilities are allocated 3 percent and 6 percent, respectively. administrations in selected rayons (administrative divisions) of Poltava and Lviv oblasts, as well as in government-controlled areas of Donetsk and Luhansk oblasts. Complementary funding of the MoH budget by local administrations, representing on average one-fourth of total public health expenditure, varies significantly from one This report summarizes findings from the Public Expenditure Tracking Survey (PETS) oblast and rayon to another. Oblasts and rayons with larger tax revenues (i.e., those and Quantitative Service Delivery Survey (QSDS). For the survey, data were collected which have profitable enterprises in their territory) tend to provide more health care from interviews with local health care officials, managers, and physicians of sampled funding than others with less local revenues. health care facilities in the four regions, and reviews of treasury reports on central and local budgets, as well as in-depth expenditure and cost analyses at the hospital Inequality in health expenditure across oblasts and rayons are associated with the and facility levels. historical input-based financing system, which is designed to support the existing infrastructure and staff. While in some rayons facility optimization has already been implemented (for instance, Mykolaiv rayon in Lviv oblast), in most rayons staffing MAIN FINDINGS schedules based on the number of beds and fixed maintenance costs affect overall costs and introduce inequalities across localities. The main findings of the study are organized in the following categories: (i) planning and allocation of health resources, (ii) analyses of leakages, (iii) resource use, and (iv) Budgetary resources allocated to health facilities are essentially based on expected input incentives, parallel employment, and the financing system. Overall, the findings suggest levels for specific facility types and sizes, without reference to actual output levels. Hence, that despite stringent existing controls to make financial flows in the formal sector health facilities of similar size and levels tend to receive similar budget allocations, accountable, resources are used differently by providers, mostly to cover wages and 14 Tracking Health Resources in Ukraine Executive Summary 15 despite differences in service types and volumes, as well as in performances. Use of available public resources Furthermore, performance-based incentives or penalties are not currently in practice in Rigid budget category guidelines restrict hospitals and health facilities’ capacity to the current allocation of resources. manage spending according to needs and resource availability. Until 2017, there was The spending patterns in different expenditure categories (e.g., personnel, medication) no flexibility for the management of the hospitals to reallocate funds between line items show significant variations across localities. Human resource expenditure, which until the local councils approved reallocations. This gave little to no incentive to optimize constitutes the largest share of the health budget (about 60 percent), presents significant costs across categories, or plan spending according to the actual needs. In addition, very variations at the regional level, despite centrally regulated wage scales and hiring norms few resources were allocated to capital investments and maintenance of capital assets. for health personnel. This variation is mainly associated with different compositions in Therefore, facilities tried to use additional accounts (other than a single treasury account) types of health personnel and non-medical staff across regions. to accumulate funds, which they could spend with more flexibility. Data on inflows and outflows of funds for several facilities in Poltava oblast showed that while salaries Final budget allocation to decentralized levels is often decided with delays, affecting were completely financed by state or local budget funds, between 37 to 40 percent of health providers’ financial management. Oblast, rayon, and municipality budgets are medication expenditures were financed by sources other than the single treasury account. usually approved in January to February of the current year, after the central government These could be either special fund account or some other “charitable” accounts that a budget is adopted and the amounts of medical and educational subventions are facility holds. communicated to local governments. Decentralized health administrations and health providers are hence informed of their budgets after the beginning of the fiscal year (which The existing budget execution system does not give local authorities and hospitals runs January 1 to December 31),which affects financial management. much financial management power. Although the decision-making power on how the medical subvention should be spent stays within each local authority, there is little room Centrally supplied medications for health facilities show unpredictability, affecting for actual fund management because of the numerous and rigid norms in practice. For service delivery. Even when information is available at the facility level about the nature example, central level policies are used to dictate the maximum number of hospital beds, and quantities of drugs and medical supplies expected from a centralized supply, there is salary scales, etc. Although some of the norms have been removed, the financing system little confidence on dates of delivery, and that affects continuity and quality of services. remains rigid and plagued with inertia. Service providers’ budgets are mostly spent to cover wage and utility bills. Analysis of leakages Respondents in sampled facilities reported insufficient public funding was used mainly Based on an analysis of treasury accounts in the four regions and a case study in to cover staff salaries and utilities, with little left for maintenance of equipment, Poltava oblast, the study did not find evidence of direct leakage. Despite a small consumables, and medication. number of inconsistencies observed in the data, the absence of evidence of leakages could be associated with financial allocations and usage being controlled through treasury The management of the medication budget faces various inefficiencies related to poor accounts. Each public facility, as well as health administration units (oblasts, rayons, and planning, untimely expenditure and purchase, and delivery sometimes not linking municipalities), have their own treasury accounts, which forms a vertically integrated with priority needs. Physicians and managers interviewed have reported drug supplies electronic payments system where all revenues and disbursements are registered. This to be unreliable, and therefore, facilities cannot effectively plan essential medication budget management system integrates various control and verification mechanisms, procurement. For example, centralized drug procurements are often delivered with reducing risks of unaccounted for public funds at all levels. delays, which are not properly explained to facilities, and the actual supplies delivered may differ from the expected delivery. The absence of direct leakages in financial transfers between the state and lower administrative levels in the health system, however, does not imply absence of Despite spending on average 10 to 11 percent of their budget on medication, and leakages in other forms in the health sector. The leakages could exist in particular receiving about the same value of medication in kind from the central drug supplies, within in-kind transfer flows, such as drugs, equipment, and materials, which were health facilities face shortages of essential medication. Overall, about 50 percent of not examined in this study. The possibility of other potential sources of leakage from the staff surveyed reported periodic shortages of drugs at the hospital and PHC levels. the local budget, special funds, and patients’ out-of-pocket payments also cannot be In most facilities, less than 25 percent of medication needs are reported covered, with ruled out. Furthermore, other forms of rent capture, such as “kickback” payments for winning tenders, private capture, and reselling of drugs and materials, etc., were also not examined in this study. 16 Tracking Health Resources in Ukraine Executive Summary 17 only special social categories of patients having secured access to drugs. About two- The lack of public resources from central and local governments also give rise to thirds of physicians report asking patients to buy drugs on their own, and more than a parallel system of cofinancing of health services. In some cases, the cofinancing a quarter of physicians reported sometimes buying medical supplies and drugs for system is legitimate and regulated by the MoH—including charity payments from patients, patients themselves. business enterprises, and international organizations, and from a likarniana kasa a quasi-insurance scheme. In other cases, the parallel system, which likely emerged Significant productivity differentials are observed among hospitals and other provider to circumvent restrictive official procedures (e.g., rigid budget line categories) and to types across regions. For instance, one secondary care municipality hospital in the supplement insufficient state financing, is shadowed. It includes, for example, informal oblast of Lviv treated 69 percent more patients per 100,000 UAH, Ukraine currency, of out-of-pocket payments for services. expenditure in 2015 than the same type of facility in the oblast of Poltava. Furthermore, important health staff workload differentials are also observed across facilities and Revenues accruing to the “charitable account,” which can represent from 5 to 25 localities. For instance, in a district secondary care facility in Poltava, the number of visits percent of a facility’s budget, are generally not accounted for, nor transparently to the outpatient surgery (consultation) unit was 2.4 more than in a similar facility in Lviv. managed at the facility level, despite their importance. As reported by physicians and managers, most of these additionally generated funds tend to be used for the While these differences in health staff and facility-level productivity could sometimes maintenance of equipment and infrastructure, or for the purchase of essential medication. reflect overreporting by the physician respondents on the number of services, in other However, actual use of these resources remains unclear as they are not formally cases, the load reported is so low that it is questionable whether it is cost effective to accounted for at the facility level or reported in official treasury accounts. maintain the unit. For instance, the lowest number of cases treated per day in our sample has been reported in a Lviv district secondary level facility at 8 patients per day (per The parallel system of financing is associated with patients often being required 100,000 population of the capture area), and the maximum in another comparable Lviv to cofinance their treatment. Respondents report that about 50 percent of patients facility at 65 patients per day. provide informal payments. While the survey did not collect information on fees (formal and informal) paid at the facility level, out-of-pocket fees for services are Associated with these productivity gaps, substantial cost differentials are observed reported to be substantial. across facilities and regions. For instance, cost differences reach a factor of 5 to 1 between the most and the least expensive feldsher points of Poltava and Lviv aggregated In addition, patients often have to bear costs for medication officially covered by sample, while cost differential of visits in Poltava and Lviv is 1.6 to 1. the health budget in the presence of stock outs at the facilities. Indeed, according to the survey, 63 percent of physicians report asking patients to purchase the required These cost differentials among facilities and regions lead to inequity in health care medications when they are unavailable in the health care facility. access across different localities. The access of residents in different oblasts and rayons depends on facilities’ overall efficiency as well as local authorities’ financial support. The non-transparent parallel out-of-pocket fee systems can have a negative impact Humanitarian and socioeconomic consequences of the military conflict created significant on patients’ access to care. Even when asked to pay for a service officially to the health challenges to access health care services in Donbas. facility cashier, patients might not be able to differentiate between what is legally required and what is technically optional (informal). Furthermore, while it is not known exactly Incentives, parallel employment, and financing structures how much additional funds patients are requested to contribute, as well as whether such informal contributions are compulsory to obtain access to health care services, the Salaries of health personnel are far below expected levels, which could affect prevalence of parallel financing systems raises the question of equitable access to health health workers’ productivity and staff moral, and generate inadequate incentive and care and its quality. alternative behaviors, such as moonlighting and informal payments. Physicians, in particular, report that their expected salary is only 33 percent of the actual level in the most moderate cases. Suggestions and recommendations We identified several suggestions and recommendations to improve the health Moonlighting affects a large proportion of health facility staff. In hospitals’ inpatient financing component of the health system, including the use of public funds. Some departments, about 4 out of 10 physicians and 1 out of 3 in outpatient departments of the recommendations are more strategic, therefore requiring implementation of occupy other jobs, often not necessarily related to the health sector. By facility type, 47 systemic reforms, while others are more operational. Operational recommendations percent of physicians at oblast-level hospitals, 32 percent in rayon-level facilities, and 28 can be introduced at the lower levels, such as at regional health administrations or percent of physicians at primary health care report moonlighting activities. Such parallel health facilities. employment may affect staff availability, productivity, and service provision. 18 Tracking Health Resources in Ukraine Executive Summary 19 Key recommendations: There is no publicly available information or register of health financing approved As confirmed by the study, health facility outputs are not linked to the public resources or actual budgets. Access to expenditure data from health facilities is only possible they receive. It is recommended to accelerate the implementation of the health financing through specific official requests, and only aggregated data, without department- reform, as defined in the new health financing concept developed by the MoH and specific expenditures. It is recommended to start publishing expenditures for all types endorsed by the government, including a shift toward results-based financing. of facilities at the level of clinical departments together with selected performance Implementation of output-based contracting will allow linking specific outputs of health indicators (e.g., number of discharges for hospitals, outpatient visits for specialized care providers to their revenues and thus improving both quality of service and efficiency policlinics, and number of population served at primary care facilities) to ensure of resource use. better transparency and accountability of health care providers. Access to data and benchmarking the performance of different facilities are two effective mechanisms to It is currently unclear what volumes and what types of cases are expected to be taken improve efficiency of service delivery. care of by each specific type of health facility. Duplication of service delivery is observed, leading to unnecessary duplication of capacities. Explicit definition of health benefit At present, data on health facility performance, expenditures, and human and other packages, together with implementation of contracting mechanisms, will help better resources are kept in various registers, without electronic data exchange, leading to channel available public resources to provide guaranteed services to citizens. This will slow and non-transparent information flows. The financing entity responsible for health also help to clarify for patients the guaranteed level of coverage by the state budget and care expenditures needs to have direct electronic communication with health providers influence the uncertainty of expected contributions from the patients. and have actual data on key performance indicators. Speeded up implementation of electronic exchange of data will help improve accountability in outputs and better As reported in the key findings, a parallel health facility financing structure exists in link costs to provided services. Information technologies may be used as an effective the form of (formal and informal) charity contributions managed at the facility level. tool to reduce inefficiencies in planning, allocation of resources, and analyses of It could be that patients generally accept the idea of cofinancing health services by patients’ outcomes. making additional payments to providers. However, the existing mechanisms are not transparent. Formalizing co-payment mechanisms can help cover financial gaps and Health facility managers and physicians report that they cannot adequately plan make providers more accountable for the additional revenues. Moreover, allowing deliveries from centralized procurement. Because of frequent shortages, patients health care providers to officially charge for services outside the guaranteed package bear a high burden through out-of-pocket payments for the essential but unavailable would encourage patients to buy insurance policies, and for hospitals to accept medications or consumables. It is recommended to continue improving public payments from insurance companies. procurements efficiency, increase supplies of medicines, and expand the effective reimbursement programs of medication at the out-patient level. It would also be useful As observed in this study, stringent control in financing health facilities does not result to monitor drug stocks at the facility level in order to: (a) have actual information at the in better efficiency of health spending. Providing more flexibilities and autonomy central level about available drugs; and (b) inform medical professionals and patients in financial management can actually stimulate more rational spending at the about access to medical products in health facilities. decentralized level. We suggest that after ensuring a minimum standard of services and quality across regions, providers be given more freedom to manage resources by: deciding the number of staff and their salaries, controlling the load, and linking the intensity and volumes of care to other required inputs. A large potential for savings lies in optimizing the facility network, space within facilities, and utility payments. Improved financial management skills and routine use of simplified cost accounting tools can help providers better use available resources in the organization and management of facilities. Uncertainties that currently exist at the local and facility levels regarding financing, as well as budgeting on an annual basis, reduce the possibility for strategic longer term planning at the oblast and rayon/city levels. A shift toward a three-year medium-term budget would help provide greater clarity on budget limits at the local and facility levels and incentives to improve efficiency and health provision. 20 Tracking Health Resources in Ukraine Introduction 21 1. INTRODUCTION 1.1 Context and objectives Although the Government of Ukraine is spending a significant part of public resources on health, health outcomes remain unsatisfactory. In particular, life expectancy of 71.2 years (2015) is much lower than on average in Europe (79.6 years). People have to directly cofinance health services through out-of-pocket spending almost at the same level as the Evidence has shown that the shortage of public resources in the Ukrainian health sector government, putting many households at risk of catastrophic health care expenditures. is magnified by their inefficient use. The issue of better governance and more efficient Currently, public health spending of USD 77 (2015) in per capita terms is the lowest use of the existing resources in the sector hence becomes a priority for improving health among European countries. During the latest economic and political crisis, the health services and producing better health outcomes. budget as a share of the total budget declined to 9 percent in 2016 from 12 percent This study aims at identifying inefficiencies in the allocation and use of public resources in 2013. in the health sector in Ukraine. It makes use of a Public Expenditure Tracking Survey In the near future, Ukraine will likely continue to experience a shortage of resources to (PETS) combined with a Quantitative Service Delivery Survey (QSDS) to examine potential adequately finance health services. Indeed, given the weak economic perspectives and bureaucratic capture, resource leakage, and problems in the deployment of human and ongoing military conflict in Eastern Ukraine, it is unlikely that the level of health spending in-kind resources, and provides practical recommendations for improvement. will considerably increase anytime soon. Moreover, even if Ukraine pours more resources In 2016, the World Bank commissioned the Kyiv School of Economics to conduct a PETS/ into the system, there are serious doubts that they will translate into better health QSDS among a sample of health care facilities in Lviv and Poltava oblasts. Interviews outcomes. For instance, between 1995 and 2010, the level of per capita health spending among local health care officials, as well as facility managers and physicians, were to be in Ukraine more than doubled in constant international dollars. However, health outcomes complemented with the analysis of financial and budgetary reports and statistics at the worsened during the same period (with the exception of maternal and child health). national and regional levels. The most plausible explanation for this weak relationship between health expenditures The geographical coverage of the study was extended in November 2016, with financial and outcomes is inefficient use of resources in the health sector. In particular, the support of UNDP, to areas of Donetsk and Luhansk oblasts under governmental control. relatively small public health spending supports one of the most oversized health The objective was to increase regional representation and investigate the use of public infrastructures in Central Europe, with 0.4 hospitals, 7.4 beds, 4.4 physicians and 8.6 funds and quality of health services in the armed conflict zones. This second round of the nurses per 1,000. Lviv oblast, with 8.6 beds per 1,000, presents one of the highest bed PETS/QSDS study was implemented using the same methodology and general approach ratios among Ukrainian regions. as during the first round. A previous World Bank study “How is it working?” (2015) identified planning, budgeting, This report presents the results of the PETS/QSDS conducted in the four regions, as and financial management in the Ukrainian health sector as major areas requiring better well as reviews of treasury reports on central and local budgets, and in-depth expenditure governance. Furthermore, reform of the health sector is one of the priority areas for the and cost analyses at the hospital and facility levels. government. The recently endorsed Health Financing Concept defines the need for new financing mechanisms in the health sector. The main findings of the study relate to planning and allocation of health resources, resource use, and incentives, parallel employment, and financing systems. They At the request of the government, the World Bank supported the analysis of public suggest that despite stringent control, scarce resources and inadequate incentives expenditure toward health facilities in selected rayons of Lviv and Poltava oblasts using lead to various inefficiencies in resource use, thereby affecting quality and accessibility PETS and QSDS survey tools. The geographical coverage of the study was later extended of health services. to areas of Donetsk and Luhansk oblasts under governmental control with UNDP support. In comparison with the rest of the country, military occupation of parts of Donetsk and Luhansk oblasts in 2014 worsened the socioeconomic situation in these oblasts. Because both oblast centers were in occupied territories, some oblast-level health facilities were not financed nor controlled by the Ukrainian administration, while services 22 Tracking Health Resources in Ukraine Introduction 23 in others were transferred toward government-controlled area hospitals. These facilities now confront equipment and infrastructure shortages as well as financial constraints due to lower tax revenues in these oblasts. Concurrently, given the conflict, larger than usual flows of donor and humanitarian assistance have been available to fill the gap. The main objective of the study is to assist the government in identifying existing inefficiencies in health financing and use of public funds in the health sector. The PETS and QSDS instruments have proven useful in identifying bureaucratic captures, leakages, and problems in the deployment of human and in-kind resources. PETS traces financial and material flows from the Ministry of Health (MoH) and local governments to hospitals and health facilities with the purpose of identifying inefficiencies and potential leakages that could reduce the quantity of resources reaching frontline service providers. QSDS additionally explores service delivery and resource use, budget planning and execution, and prevalence of supplementary financial flows. 24 Tracking Health Resources in Ukraine Study Methodology 25 2. STUDY METHODOLOGY Interviews also provided information on resource allocation (whether facilities receive everything they need, and, if there are shortages, what the reasons are and how they are addressed) and timeliness of disbursement. Regularity and delays of payments toward decentralized administrations and facilities were also studied. 2. How does public funding reach frontline facilities? Are there potential leakages from This chapter presents the study methodology. It discusses the research questions, the the central budget to actual medical service providers? sampling strategy, and survey instruments. This issue was investigated in three steps. The aggregated country-level expenditures were first analyzed. Then, financial data from the State Treasury Service (central level) A. STUDY STEPS AND INSTRUMENTS and local state administrations (at oblasts and rayon/city levels) for all four oblasts and all subordinated rayons/cities were aggregated and compared. Finally, a single case study The study relied on various instruments and proceeded in multiple steps. An initial in a randomly chosen rayon (Poltavsky rayon in Poltava oblast) was conducted to assess desk review of health care institutional arrangements, financing, and policy context resources reaching facilities, and then compared to total health care expenditures of was realized to understand the policy and administrative arrangements governing the facilities (derived from facilities’ balance sheets) and rayon health care expenditures, as allocation of resources within the health sector. Following the definition of the survey reported by the local treasury department. scope and design of survey instruments, semi-structured interviews using PETS/ 3. Are personnel allocation and time use efficient? We analyzed whether facilities QSDS survey instruments were conducted among oblast and rayon-level health care have enough personnel, and whether personnel allocation is efficient, as well as human administrations in Lviv and Poltava oblasts, as well as managers and physicians at the resources usage. In particular, physicians-managers at hospital and facility levels were facility levels, to understand actual practices and procedures in the health system. asked whether they would like to modify the number of staff, composition, or allocation The instruments were revised for the second wave of the survey in Donetsk and across departments at their facilities or if the current allocation was optimal. Physicians Luhansk oblasts that took place in December 2016. In particular, revisions included were asked to provide details of their work schedule, including the average number of adaptations for the introduction of the Prozorro e-procurement system in August 2016. patients admitted per shift, whether they work elsewhere or overtime, and how much Some questions were structured (closed) while still allowing respondents to provide time they spend per patient on average. comments on most questions. Furthermore, a section was included on the impacts of the 4. What are the service cost variations between similar facilities and how could these armed conflict and humanitarian crisis in the government-controlled areas of Donetsk differences be explained? and Luhansk oblasts. To answer these questions, expenditures of the health facilities in the sample were The PETS/QSDS survey instruments were complemented with financial data from analyzed using a cost-accounting methodology and step-down allocation of costs to public reports and special financial data requests to the Treasury. These included the service centers. It allowed for estimation of cost per service at the facility level and facility balance sheets, budget reports, treasury accounts information, and special comparison of costs across facility types. requests to formally track facilities’ inflows and outflows. Facility-level costs and output data were used to study facility performance using a step-down cost accounting (SDCA) 5. Are health professionals aware of planned health care reforms, and if so what are approach, comparing the cost of services and cost structure across health facilities. their opinions about these reforms? To answer these questions, the PETS/QSDS instruments included a set of questions to B. RESEARCH QUESTIONS AND APPROACH stakeholders on proposed health care reforms (see Box 1 for an overview of current reforms). In addition, an open-ended question was asked to respondents on possible ways Various research questions and hypothesis are examined throughout the study, to increase service delivery efficiency. in particular: 1. Are planning and allocation of resources toward service providers efficient? To assess the resource planning process toward service providers, the stakeholders were identified, as well as the various factors considered in the planning process and the main decision-making points. The information is based on in-depth PETS/QSDS interviews of the oblast- and rayon-level health care administrations, facility managers, and physicians. 26 Tracking Health Resources in Ukraine Study Methodology 27 C. DATA SOURCES Donetsk and Luhansk oblasts were selected for the second round of the survey. It should be noted that these two regions were combined for sampling purposes and presented The main primary and secondary data sources used in this study are as follows: together in the report. During the first round of the survey, interviews were conducted in 25 locations and PETS/QSDS survey data 37 points of health service delivery in the Lviv and Poltava oblasts. Interviews were The Kyiv School of Economics, in cooperation with the World Bank, customized the conducted during the second round in 11 locations and 50 points of service delivery in public expenditures tracking survey (PETS) and Quantitative Service Delivery Survey Donetsk and Luhansk oblasts. Table 1 presents the sample by facility types and oblast (QSDS) instruments. Prior to the fieldwork, a training for interviewers was organized. (A more complete description of the sample is presented in Annex A). Questionnaires were tested during a pilot stage among all categories of respondents Table 1. Sample (short description): number of facilities sampled by (not a part of the sample). A team of interviewers from the Kyiv International Institute of type and oblast Sociology (KIIS) then conducted the two waves of the survey. The first wave of the survey in Lviv and Poltava took place between June 14 to July 31, 2016, and the second wave in TOTAL NUMBER OF Donetsk and Luhansk in December 2016. OBLAST AND NUMBER OF SAMPLED SIMILAR FACILITIES FACILITY TYPE FACILITIES WITHIN THE OBLAST Ukrainian and Russian versions of the questionnaires were used during fieldwork. Lviv oblast The instruments were made of four different questionnaires, corresponding to the type of respondents: Oblast-level hospital 2 (+2 polyclinics) 13 Rayon/city-level hospital or 4 (+3 polyclinics) + 1 Oblast health management team questionnaire polyclinic 1 city polyclinic 27 2 Rayon/municipality health management team questionnaire 50 3 centers of family medicine + Primary care facility 204 ambulatories, 3 ambulatories + 3 FOPs 3 Health facility management questionnaire 1,004 feldsher posts 4 Health worker (physician, paramedics, nurse) questionnaire Poltava oblast Oblast-level hospital 2 (+2 polyclinics) 4 The survey questionnaire consisted of the following parts: Rayon/city-level hospital 4 (+3 polyclinics) + 1 city polyclinic 28 1 Resource planning Primary health care center 3 25 2 Resource flows (except questionnaire 4) 327 ambulatories, Primary care facility 4 ambulatories + 2 FOPs 3 Resource utilization 619 feldsher posts Donetsk oblast 4 Financial supervision from the central and oblast/rayon government (except questionnaire 4) Oblast-level hospital 0 7 5 Shortages of resources Rayon/city-level hospital or 7 (+7 polyclinics) 79 polyclinic 6 Budget adjustments (except questionnaire 4) 5 primary health care Primary care facility centers (10 ambulatories and 21 7 Performance (questionnaire 4 only) 4 FOPs within them) 8 Current and planned reforms Luhansk oblast 9 Socio-demographic profile of the respondent (except questionnaires 1 and 2) Oblast-level hospital 2 (+2 polyclinics) 14 Rayon/city-level hospital 2 (+2 polyclinics) 8 Scope and sampling Rayon territorial medical unit 2 (+2 polyclinics) 9 The PETS/QSDS survey was limited in scope. It was administered in four selected 3 PHCs (6 ambulatories and regions. Lviv oblast in the western part of the country and Poltava oblast in the center Primary care facility 16 4 FOPs within them) were initially selected in the first round of the survey. The government-controlled areas of Note: Data source for Lviv and Poltava—aggregated Form 20, for Donetsk and Luhansk oblasts—contact list of health care facilities provided by local administrations. 28 Tracking Health Resources in Ukraine Study Methodology 29 In each of the sampled oblasts, the following respondents were interviewed: Data were obtained from the Central Treasury on planned and actual revenues and expenditures at the state, oblast, and rayon/city level on a monthly basis. 1 A head (or a deputy head in economic affairs) of the oblast state administra- Accompanying reports included adjustments to the planned budget made by Parliament tion health department and local councils during the year. 2 A head (or a deputy head in economic affairs) of the rayon/municipality ad- ministration health department Ministry of Finance reports were also collected providing information on financial 3 A chief physician, deputy chief physician, chief economist, chief of the poly- and in-kind resource flows from the Central Budget to oblast, municipality, and clinic division, chief of the PHC or ambulatory head rayon budgets. 4 In hospitals: physicians from the following categories: department chief phy- State Treasury Service (STS) budget execution reports at the oblast, rayon, and sician (when possible); physicians from different departments (therapeutic municipality levels provided detailed information on health resources within regions. vs. specialized); physicians dealing mostly with the inpatients, with day and These reports were compared to similar data from the local state administrations night shifts; physicians dealing mostly with outpatients (LSA) for triangulation purposes. 5 In polyclinics: one department chief physician (when possible), physicians from different departments (therapeutic vs. specialized) For the second stage, a case study was realized for a single rayon, Poltava rayon of Poltava oblast, for which financial data of all health care facilities within the rayon were 6 In ambulatories: family practice physician collected. Finally, transaction-level data from the government open data portal were 7 In FOPs: a medical worker. collected and analyzed for one randomly chosen hospital in each oblast. Within these various categories, overall 300 respondents were surveyed, including: Cost and productivity data 1 4 chiefs/acting chiefs of oblast health department Detailed cost data were provided by health facility by cost centers and purpose (i.e., 2 21 chiefs/acting chiefs of city/rayon health department salaries, utilities, etc.) in two oblasts, Lviv and Poltava, to allow cost and productivity 3 67 chiefs of the facility/polyclinic division/urban outpatient family practice analysis. center/rayon primary health care center Cost data provided by health facilities include the following cost centers: 4 188 hospital/polyclinic’s physicians/family physicians/medical assistants/ nurses A Administrative Group—including administration, accounting, human resources management, planning and economic departments SPSS software was used for analysis of close-ended (coded) and open-ended questions and involved the use of 40–50 logical conditions depending on the type B Support Group—laundry, kitchen, computer maintenance, department of statistics, information and analytic department, engineering units, etc. of the questionnaire. C Paraclinic Group—laboratories, diagnostics units, operating and anesthesiology rooms, intensive care rooms, blood transfusion services, etc. Administrative and financial data In addition to the primary data collected through the PETS/QSDS survey instruments, D Ambulatory-Polyclinic Group supplementary administrative and financial data were collected to analyze financial E Inpatient Care flows and identify potential inefficiencies and leakages in the existing budgeting and F Polyclinic Group allocation process in the four sampled regions. G Day Inpatient Care The data collected analyzed fund flows in the Ukrainian health system from (i) the Ministry H Perinatal Center of Finance to local administrations and then (ii) from local administrations to facilities, according to the budget allocation formula proposed by the MoH. Data were collected at I Subordinated primary care facilities both stages to examine potential leakages. Within the first stage, budgetary data were collected for all four oblasts on all health expenditures at oblast and rayon/city levels (129 budgets) for the fiscal years 2014 and 2015. 30 Tracking Health Resources in Ukraine Study Methodology 31 D. LIMITATIONS The current study presents some limitations. In particular, the limited scope of the survey sample, which uses a convenient case study approach at the oblast level and disproportionally stratifies according to the type of respondents, restricts the generalization of the study findings. Indeed, the Ukrainian health care organizational structure differs among oblasts and sometimes even among rayons within an oblast, forbidding generalization of the study results to the entire country. Also, the use of qualitative open-ended questions, where respondents were asked to share their experiences, may have had unexpected effects. While aiming at obtaining the most comprehensive information on the various topics of the survey, an open-ended approach, however, is a complex and time-consuming process. Open- ended questions require significant effort from respondents, as well as for data entry, cleaning, and analysis. During interviews, transitions back and forth between quantitative and qualitative questions may have also hampered interviewees’ responses. In future research, these limitations could potentially be mitigated through extended introduction to respondents on survey structure and themes. It should also be noted that presence of sensitive themes in the survey–in particular budgetary allocation and usage, as well as informal payments, which are not entirely socially acceptable subjects—may have led to information withholding, especially with regard to hospital parallel financing systems. 32 Tracking Health Resources in Ukraine Overview of the Health Sector 33 3. OVERVIEW OF THE (hromada). In total, there are 490 rayons and 180 cities. The number of hromadas is growing during decentralization reform: from 85 at the end 2015 to 660 in 2017. With over HEALTH SECTOR a thousand different recipients of medical subvention, health funding is very fragmented. The central MoH is in charge of both policy making and management of national- level health hospitals and facilities. MoH’s responsibilities include the development This chapter presents an overview of the health sector in Ukraine. It describes the and implementation of the national health policy, supervision of medical educational and organization and financing of the public health system, and discusses the official process research institutions, pharmaceutical regulation, and disease protection. The MoH also of planning, budgeting, and allocation of financials and in-kind resources toward various manages and centrally finances highly specialized tertiary care-level hospitals and health levels of health facilities. Three main elements are examined: (i) organization and clinics (such as National Childcare Hospital “Okhmadyt,” Kharkiv Cardiovascular Surgery financing of the health sector, (ii) budget planning, and (iii) budget execution. Center, etc.), sanatoria, and orphanages for children under the age of three. While the central MoH is a key regulator and policy maker, health care services are A. ORGANIZATION AND FINANCING OF THE mainly provided by locally owned and managed hospitals and health clinics. In each HEALTH SECTOR oblast center, oblast-level hospitals provide tertiary care-level treatments. Secondary- level treatments are provided by hospitals serving a rayon, a town, or a district in a city. As stipulated by Ukrainian laws, the government has the obligation to finance and Primary care services (polyclinics, ambulatories, or feldsher points) are organized at provide access to health care for all Ukrainian citizens. Responsibility for financing villages, towns, or districts in cities. At that level, physicians or pediatricians perform health care expenditures is shared between central and local governments (Articles examinations and, if needed, send patients to specialists or to hospitals. Quite often 87–90: articles of the Budget Code). Overall, public health services are financed from the though, patients consult specialists directly to save time. national budget, local (oblast, rayon, municipal, and community) budgets, health insurance While during the Soviet period patients could only consult the physician “attached” funds, charity funds, and any “other sources not prohibited by law.” to the district where the person lived, since 2011, Ukrainians are allowed to obtain Public financing covers health care services delivered by publicly owned health clinics primary care at any primary facility of their choice. This option was first piloted and hospitals, as well as costs related to education and research in the sector. According in 2011–2013 as part of the reform of primary care implemented in Dnipropetrovsk, to the law, national health financing is based on a per capita allocation. The annual Donetsk, Vinnytsia, and several rayons of Kyiv city. Starting April 2017, patients can budgeting process in the health sector is described in the Ukrainian Budget Code. choose their family doctors by signing and registering a delacration with them. The current structure of the Ukrainian health care system still mostly resembles Given the current absence of a single database of patients, this may result in some the Soviet era model. It takes its roots in the Semashko universal coverage system patients being “attached” to several facilities. Furthermore, current allocation of similar to the Soviet model introduced at the beginning of the twentieth century. At the resources is linked to statistical number of patients living in certain areas, and not the time, the system was mainly designed to respond to war casualties and the spread number of patients actually receiving services in a particular facility serving that territory. of infectious diseases. An emphasis on universal coverage was placed through the With regard to financing, the MoH manages most of the national health budget. availability of at least a feldsher or a physician within each village/locality, and hospital MoH expenditures include ministry spending for itself, its subordinated services and beds to treat the wounded or those suffering from infectious diseases. This system poorly institutions, and inter-budgetary transfers (medical subventions) going from the Ministry addressed modern health challenges, the main of which was the spread of of Finance to the lower-level budgets (oblast, rayons, municipalities, hromadas) and non-transmittable diseases. expenditures on state-level health-related programs (e.g., a program on diabetes, a Today, the State remains the major provider of health care services. Private program on HIV/AIDS, and others). sector’s role is relatively small, with estimated share at below 10 percent of total Administration and financing of health care at the local level is the responsibility of health expenditures. territorial administrative units. Local-level authorities are key decision makers on the The structure of the public health system is organized at three administrative management of resources received, such as the medical subvention. Each of 25 oblasts levels: central, oblast, and rayon/city/united community. Decentralization reform and the city of Kyiv has departments of health responsible for managing oblast-level implemented since 2014 created an additional administrative level of communities (tertiary care) hospitals. Rayons and municipalities are responsible for management of 34 Tracking Health Resources in Ukraine Overview of the Health Sector 35 Box 1. Brief overview of current health care reforms The need to reform the health care system in Ukraine has been recognized long ago. secondary-level facilities and primary health care centers (PHCs). In their turn, primary Various attempts have been put forward, but most previous reforms have lacked a healthcare centers or rayon/city hospitals where PHCs are not formed run ambulatories systemic approach and have faced great resistance. and FOPs. The most notable element of the current reform program has been the singling out of the Complementary funding is provided by local administrations representing on average importance of primary health care through the creation of Primary Health Care Centers one-fourth of total public health expenditure. Local contributions vary significantly from and the introduction of family doctors. This reform was first introduced in 2011 on a pilot one oblast and rayon to another. Oblasts and rayons with larger tax revenues (i.e., those basis in some regions. The new wave of primary health care reform is due to start in which have profitable business enterprises on their territory) are able to provide more mid 2018. It is expected to introduce age-adjusted per capita financing (i.e., each citizen health care funding than others. Furthermore, local authorities tend to favor visible capital is required to sign a contract with his/her family doctor, and the revenues of the family expenditures and attractiveness of facilities to local elected officials. practice will depend solely on the number of patients served). With this reform, doctors In 2015, the government introduced new specialized instruments of inter-budgetary will be paid a fixed amount per year per patient and be able to take up to 2,000 patients, transfer for the health and educations sectors. The medical subvention is an earmarked implying a 5–7 times potential (pretaxed) salary increase. The primary aim of the reform budget transfer for the health sector toward decentralized administrations, which is the creation of an efficient “filter” of entry in the health care system, i.e., the family replaced general equalization grants to the regions. doctor decides which patients to treat at home, and which should be sent to secondary or tertiary level hospitals. In addition, programs of reimbursement of certain prescribed Medical subvention is transferred twice a month to Treasury accounts of oblasts, drugs to be purchased by patients (e.g., for diabetes, asthma, heart diseases) have been rayons, cities, and hromadas; the size of the medical subvention for each unit introduced and will be extended to other illnesses to help prevent severe illnesses (e.g., is defined by the MoH according to a formula. Oblast administrations can control heart attacks). implementation of budgets of rayons, cities, and hromadas. However, they generally do not intervene in the management of resources within rayons, cities, and hromadas, which Another milestone of the current reform program will be the introduction of health is the responsibility of respective authorities. care facilities autonomy, eventually turning them from budgetary institutions into state- or communal-owned (nonprofit) enterprises (now hospitals are so-called budgetary Formally, local budgets finance about 80 percent of health services. They execute institutions, i.e., they are currently financed from state or local budgets based on this delegated function within the allocated resource of the medical subvention and their needs). When hospitals become enterprises, they are financed on a pay-per- contributions from the local budgets. service basis, and can receive payments both from the State Health Care Agency (a newly created ordering customer of health care services) and from private insurance The size of the medical subvention for each oblast and other transfers depends on the companies. In addition, facilities will be able to introduce fees for certain services total amount of medical subvention and the formula used for its distribution. The exact and compete with private clinics. For this, three types of health care services will be amount of allocated funds is determined by the Ministry of Finance, based on an allocation defined—those completely financed by the state (primary, emergency, palliative care, formula proposed by the MoH. The formula is a function of the (i) population size in the most common types of secondary care), those partially financed by the state, and those respective administrative-territorial unit; (ii) coefficients for the oblast and lower level not financed by the state (e.g., cosmetic surgery, dental services except for urgent territorial units, for rural and urban territories; (iii) correction coefficients which account cases, etc.). In order to ensure efficient use of public funds, medical protocols will be for age and gender structure of population, and several morbidity factors; and (iv) updated, and doctors will be required to provide treatment according to them. The laws peculiarities of health care services delivery in mountain areas. to implement this reform were adopted by the parliament in the end of 2017. The final component of the current reform program is the introduction of the “money B. BUDGET PLANNING AND EXECUTION follows the patient” principle replacing the current system, which finances facilities according to the inputs or number of people in an area. To facilitate this transformation, Health facilities’ budgets are planned from the bottom up but with stringent limits an electronic patient registry system (e-Health) is currently under development. Besides of funding from the central level. Each health facility—the lowest level spending the network of medical facilities that will be optimized—so called “hospital districts” will unit—initiates a budget request which then goes through several stages of approval by be created with the main hospital in the district treating the most complicated cases and local financial authorities, local governments, and the Treasury of the respective levels. other hospitals performing auxiliary functions. In a hospital district, a patient should be During these stages, budget requests, budget ceilings, and monthly installment plans are able to arrive (or be delivered) to a main hospital within an hour. approved. 36 Tracking Health Resources in Ukraine Overview of the Health Sector 37 The budget planning process is highly formalized and requires facilities to respect the spending unit network and ends with the releasing of funds from the accounts of numerous normative procedures. The set of requirements to be followed by facilities in Spending Units and Recipients of Budget Funds. The State Financial Inspection (SFI) is preparing their budgets includes: responsible for regular inspections to monitor financial accuracy, legislative compliance, and to some extent, performance and value for money achieved by the spending units, as 1 Use of precise templates and sequences; the structure of expenditures must well as financial audits. Overall, more than 30 agencies could launch financial inspections correspond to key classifications and templates defined by the of health facilities. Ministry of Finance (MoF) (Order No 57 of 28.01.2002). Financial transfers in the health system are disbursed from the State Treasury to 2 Rules for defining the number of staff and their salary levels (Staff Sched- relevant treasury accounts of oblasts, rayons, municipalities, and hromadas, based ule) (the MoF Order No 57, the MoH Order No 33); Terms of Pay for Medical on the medical subvention formula. Oblast administrations then allocate funds among Workers Ministry of Labor and Social Policy, Ministry of Health Care Order No oblast-level (tertiary) hospitals, while rayon administrations allocate funds among rayon- 308/519 of 05.10.2005 “On establishing ordered arrangements for defining level hospitals and PHCs, and similarly for municipalities and hromadas, according to the terms of pay for the workers of health facilities and Social Care institutions.” budget allocation formula proposed by the MoH. 3 Expenditure norms and rules for calculating all other types of recurrent and By law, all publicly owned health facilities are required to report their financial capital expenditures based on the MoH’s Methodological recommendations transactions and make use of the state treasury system. Publicly owned facilities can on planning and utilizing budget funds for provision of medical help by generate additional revenues from fee-paid services or receive other financial (charitable) health facilities. contributions, but these revenues are also required to be deposited and flow through 4 Prioritizing “protected expenditure items.” A particular list of Protected Ex- treasury accounts. penditures is established within the Budget Code (Article 55). Figure 1 illustrates the main sources of revenues in the health sector and financial The health sector budget planning process is backward-looking. Planning for the next flows toward health facilities. As observed, the main sources of revenues and flows year is based on historical figures of the number of patients and most frequent illnesses. include: The previous-year budget is used as a baseline and adjusted for factors such as inflation and population growth (e.g., new patients to be provided with subsidized drugs). First, 1 National Budget. In 2015, UAH 46.4 billion was allocated for inter-budgetary transfers from the central budget level (the Ministry of Finance) to public local administrations approve facility budgets. After adoption of the State budget, final health facilities (including UAH 46.2 billion of so called “medical subvention”) medical subvention limits are known, and local administrations and facilities adjust their via local government budgets. In addition, the MoH allocated UAH 8.1 billion budgets accordingly. Also, facilities try to raise additional money from local councils, budgetary programs and directly subordinated health facilities, including business enterprises, and private individuals. UAH 3.4 billion for centralized purchases of drugs and medical equipment through the program “Provision for health components of certain govern- The budget planning process is still largely input-based. It follows the MoH 2011 ment programs and for complex medical programs.” Since the end of 2015 guidelines which are very detailed and prescribe exactly how the funds should be planned until 2019, procurement for several programs (e.g., HIV/AIDS, tuberculosis for each budget item code. Drug and medical goods budgets are to be determined by the (TB), hepatitis, child hemophilia, oncology, and specialized nutrition for chil- number of beds and bed-days (for inpatient clinics) or the number of visits and people dren with rare diseases) was transferred from the Ministry of Health to the international organizations. who have the right for free drugs (for outpatient clinics). Expenses on salary are planned according to the Unified Tariff Scale, which should include mandatory bonuses (normally 2 Local budgets (oblast level or rayon/municipality/amalgamated hromada one monthly salary per year). level). Oblasts, rayons, municipalities, and hromadas can finance health programs and disburse funds to health facilities from local budgets revenues With regard to execution of the budget and financial reporting for the use of public (from locally levied taxes) and intergovernmental transfers. funds, strict procedures are also defined. One of the core legal requirements and 3 Funds generated by the health facility transiting through the treasury the basis for authorization and release of funds for all facilities is activating a monthly account. Health facilities could officially receive fees for services provided installment plan over the course of the year, approved by local financial authorities and according to a defined list, as well as accumulate funds from other sources the State Treasury. (e.g., rent, charitable contributions, grants and presents, etc). The use of public funds is subject to extensive control and inspection by different 4 Funds received in [non-treasury] accounts. Most health facilities maintain so-called “charitable funds,” consisting in “contributions” made by patients agencies. The State Treasury monitors and maintains control over budget expenditures for various services, with funds deposited in commercial banks. These funds at all stages of budget planning and implementation. It starts with the formation of are managed independently and are not accounted for in facilities’ official financial statements. 38 Tracking Health Resources in Ukraine Overview of the Health Sector 39 In addition to these financial allocations, health facilities receive medication and Figure 1. Financial flows in the health care sector medical supplies transfers in kind from centralized procurements. Procurement of medical supplies is organized at different levels in the Ukrainian health care system. The MoH, through several specialized national programs (vaccination, HIV, TB, etc.), Other Ministries allocates various drugs and supplies to hospitals and health clinics. Local-level health Data for budgeting administrations (oblast, rayon, or municipalities) also procure and allocate in-kind The Ministry The Ministry of Finance The Ministry of Health of Finance supplies and drugs to facilities according to health care facilities’ requests. Finally, facilities themselves (except PHCs and polyclinics) also purchase various drugs The and supplies. National Budget Special Budget programs According to The funded from the National Law on State Budget National taxes budget Medical subvention and other healthcare subventions Oblast taxes Oblast Oblast health Oblast financial department Budget department Local taxes Oblast programs Municipal, rayon, and Financial department Health department community budget National health programs Own Revenues National Health Agencies Patient’s personal National Healthcare payment and insurance facilities Oblast Healthcare International Funds facilities Municipal, rayon, and community Healthcare facilities Industrial Health systems (i.e. health facilities of the Ukranian Railways infrastructure) Source: Developed by the authors based on the Budget Code and other legislative data. 40 Tracking Health Resources in Ukraine Budget Management in the Health Sector 41 4. BUDGET MANAGEMENT Figures 3 and 4 present the levels and shares of health expenditure at different levels in FY2015 overall and for the four sampled regions. We observe that the largest IN THE HEALTH SECTOR part of resources allocated in the health system is channeled through the medical subvention mechanism directly to local budgets. About 35–40 percent of all health care expenditures are spent at the oblast level, while the rest go to rayon/municipality/ community levels. We also see that in all oblasts except Donetsk slightly more than half of This chapter discusses the findings of the PETS/QSDS based on central Treasury the health-care budget is spent by rayons and communities. In Donetsk, over 80 percent budget information and interviews of oblast and rayon managers, as well as facility is spent by municipalities due to the specific structure of Donetsk oblast, which consists physicians. It first presents the level and structure of the 2015 health budget, in mostly of industrial cities, towns, and few rural areas. particular the medical subvention and composition of the health budget in the four sampled regions. It then discusses the main planning and control process stages as reported by managers and physicians. A. THE HEALTH BUDGET In 2015, total public health spending in Ukraine was UAH 71 billion (U.S.$3.25 billion). Public spending on health as a share of GDP has been rather stable during the recent years, but has declined to 3.2 percent of GDP in 2016 from 4.5 percent in 2013 (Figure 2). Figure 2. Public and total health expenditures in Ukraine, 2004–2016 80 9.0 70 8.0 7.0 60 6.0 50 5.0 40 4.0 30 3.0 20 2.0 10 1.0 0 0.0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 public health care expenditures, billion UAH public health care expenditures, % of GDP (right axis) total health care expenditures, % of GDP (right axis) Source: State Treasury Service and World Bank data. 42 Tracking Health Resources in Ukraine Budget Management in the Health Sector 43 Figure 3. Health sector expenditures: Poltava and Lviv oblasts, 2015 Specialized programs Specialized programs Centralized Procurement: Centralized Procurement: 4,098,857,700 4,098,857,700 Poltava Oblast Poltava Oblast Lviv Oblast Lviv Oblast H: 2,151,819,357 H: 2,151,819,357 H: 3,465,934,833 H: 3,465,934,833 Other Other MS: 1,671,843,401MS: out 1,671,843,401 of 1,718,526,517 out of 1,718,526,517 MS: 2,857,071,799MS: of 2,924,694,100 out 2,857,071,799 out of 2,924,694,100 Ministries 4.7% Ministries 4.7% OS: 6,373,433 OS: 6,373,433 OS: 52,770,890 OS: 52,770,890 The Central budget The Central budget OR: 473,602,523 OR: 473,602,523 OR: 556,092,144 OR: 556,092,144 H: 3,343,940,069 H: 3,343,940,069 16% 16% 8,106,477,313 H: 11,450,417,382H: 11,450,417,382 8,106,477,313 The Ministry of The Ministry of Oblast budgets: Oblast budgets: Oblast Budget Oblast Budget Oblast Budget Oblast Budget Health: Health: 76.7% 76.7% MS: MS: 40% 40% 41% 41% 16,236,061,229 out 16,236,061,229 out H: 54,488,770,161H: 54,488,770,161 of 17,998,489,155 of 17,998,489,155 H: 853,297,204 H: 853,297,204 H: 1,438,231,101 H: 1,438,231,101 MS: MS: 696,353,607 out 696,353,607 of 723,159,417out of 723,159,417 out 1,176,885,400 MS: 1,176,885,400MS: out of 1,231,834,800 of 1,231,834,800 Including Including OS: OS: OS:6,373,433 OS:6,373,433 OS: 52,770,890 OS: 52,770,890 Health expen- Health expen- 46,382,292,848 46,382,292,848 205,269,250 205,269,250 OR: 150,570,164 OR: 150,570,164 OR: 208,574,811 OR: 208,574,811 ditures (H) ditures (H) subvention Medical Medical subvention Local budgets Local budgets (MS): (MS): 71,001,121,122 71,001,121,122 4,177,023,598 4,177,023,598 84% 84% Other health Other health Municipal, Municipal, rayon, and community rayon, and community budgets budgets Municipal, Municipal, rayon, and community budgets rayon, and community budgets H:59,550,703,739H:59,550,703,739 suventions (OS): suventions (OS): 205,269,250 205,269,250 60% 60% 59% 59% MS: MS: 43,785,901, 233 43,785,901, 233 H: 1,298,522,152 H: 1,298,522,152 H: 2,027,703,732 H: 2,027,703,732 out of out of MS: MS: 957,489,793 out of 957,489,793 995,367,100 out of 995,367,100 MS: 1,680,395,898MS: of 1,692,859,299 out 1,680,395,898 out of 1,692,859,299 46,177,023,598 46,177,023,598 OR: 323,032,359 OR: 323,032,359 OR: 347,307,834 OR: 347,307,834 Municipal, rayon Municipal, rayon and community and community OS: 205, 269, 250 OS: 205, 269, 250 budgets budgets OR: OR: MS: MS: Rayon and Rayon and Rayon and Rayon and 15,754,802, 506 15,754,802, 506 27,549,840,002 out27,549,840,002 out Municipal budgets community Municipal budgets community Municipal budgetsMunicipal community budgets community Local Budgets Local Budgets of 28,178,534,441 of 28,178,534,441 budgets budgets budgets budgets (own resources, (own resources, 48% 48% 47% 47% OR) OR) 52% 52% 53% 53% H: 624,241,516 H: 624,241,516 H: 958,740,666 H: 958,740,666 18.5% 18.5% H: 674,280,636 H: 674,280,636 MS: 430,675,946 MS: 430,675,946 H: 1,068,963,066 H: 1,068,963,066 MS: 728,014,795 MS: 728,014,795 out of 431,359,690 MS: 544,813,847 out of 431,359,690 MS: 544,813,847 out of 730,863,799out of MS: 923,440,502 MS: 923,440,502 730,863,799 13,168,410,892 13,168,410,892 out OR: 193,881,826 OR: 193,881,826 of 564,007,410out of 564,007,410 OR: 230,725,871 OR: out 230,725,871of 933,043,900out of 933,043,900 OR: 129,466,789 OR: 129,466,789 OR: 145,522,564 OR: 145,522,564 44 Tracking Health Resources in Ukraine Budget Management in the Health Sector 45 Figure 4. Health sector expenditures: Donetsk and Luhansk oblasts, 2015 Specialized programs Specialized programs Centralized Procurement: Centralized Procurement: 4,098,857,700 4,098,857,700 Donetsk Oblast Donetsk Oblast Luhansk Oblast Luhansk Oblast H: 3,106,331,974 H: 3,106,331,974 H: 1,080,690,408 H: 1,080,690,408 Other Other out 2,267,958,763 MS: 2,267,958,763MS: out of 2,607,064,197 of 2,607,064,197 MS: 790,134,340 out MS: of 975,116,200 790,134,340 out of 975,116,200 Ministries 4.7% Ministries 4.7% OR: 821,572,511 OR: 821,572,511 OS: OS: 7,960,576 out of 7,960,576 out of 7,960,576 7,960,576 The Central budget The Central budget OS: 16,800,700, out of 16,800,700, OS: 16,800,700 out of 16,800,700 OR: 282,595,492 OR: 282,595,492 H: 3,343,940,069 H: 3,343,940,069 16% 16% 8,106,477,313 H: 11,450,417,382H: 11,450,417,382 8,106,477,313 The Ministry of The Ministry of Oblast budgets: Oblast budgets: Oblast Budget Oblast Budget Oblast Budget Oblast Budget Health: Health: 76.7% 76.7% MS: MS: 36.8% 36.8% 41% 41% 16,236,061,229 out 16,236,061,229 out H: 54,488,770,161H: 54,488,770,161 of 17,998,489,155 of 17,998,489,155 H: 1,145,101,355 H: 1,145,101,355 H: 445,513,987 H: 445,513,987 MS: MS: 690,631,222 out of 933,103,165 690,631,222 out of 933,103,165 MS: 281,884,984 out MS: of 431,906,800 281,884,984 out of 431,906,800 Including Including OS: OS: OS: 16,800,700 outOS: of 16,800,700 out of 16,800,700 OS: OS: 7,960,576 out of 7,960,576 out of 7,960,576 7,960,576 Health expen- Health expen- 46,382,292,848 46,382,292,848 205,269,250 205,269,250 OR: 437,845,900 OR: 437,845,900 OR: 155,668,428 OR: 155,668,428 ditures (H) ditures (H) Medical subvention Medical subvention Local budgets Local budgets (MS): (MS): 71,001,121,122 71,001,121,122 46,177,023,598 46,177,023,598 84% 84% Other health Other health Municipal, Municipal, rayon, and community rayon, and community budgets budgets Municipal, Municipal, rayon, and community budgets rayon, and community budgets H:59,550,703,739H:59,550,703,739 suventions (OS): suventions (OS): 205,269,250 205,269,250 63.2% 63.2% 59% 59% MS: MS: 43,785,901, 233 43,785,901, 233 H: 1,961,230,618 H: 1,961,230,618 H: 635,172,421 H: 635,172,421 out of out of MS: 1,577,327,540MS:out 1,577,327,540 out of 1,673,961,032 MS: 508,249,356 out of 1,673,961,032 MS:of 543,209,400 508,249,356 out of 543,209,400 46,177,023,598 46,177,023,598 OR: 383,726,611 OR: 383,726,611 OR: 126,927,064 OR: 126,927,064 Municipal, rayon Municipal, rayon and community and community OS: 205, 269, 250 OS: 205, 269, 250 budgets budgets OR: OR: MS: MS: Municipal budgets Rayon and Rayon and Rayon and Rayon and 15,764,802, 506 15,764,802, 506 Municipal budgets 27,549,840,002 out 27,549,840,002 out community community Municipal budgetsMunicipal community budgets community Local Budgets Local Budgets of 28,178,534,441 of 28,178,534,441 81.7% budgets budgets budgets budgets (own resources, (own resources, 81.7% 44.7% 44.7% OR) OR) 18.3% 18.3% 55.3% 55.3% H: 604,084,810 H: 604,084,810 H: 284,435,090 H: 284,435,090 18.5% 18.5% MS: 1,251,454,864MS: 1,251,454,864 H: 357,145,807 H: 357,145,807 H: 350,737,330 H: 350,737,330 MS: 220,455,047 MS: 220,455,047 out of out of MS: 325,872,676 MS: 325,872,676 out of 224,628,900 MS: 287,794,308 MS: 287,794,308 out of 224,628,900 13,168,410,892 13,168,410,892 1,297,894,732 1,297,894,732 out of 376,066,300out of 376,066,300 OR: 63,980,043 OR: 63,980,043out of 318,580,500out of 318,580,500 OR: 352,629,946 OR: 352,629,946 OR: 31,273,131 OR: 31,273,131 OR: 92,943,022 OR: 92,943,022 Source: Authors’ calculations based on the Ministry of Finance data. 46 Tracking Health Resources in Ukraine Budget Management in the Health Sector 47 According to Figures 3 and 4, total public health sector resources are composed of 15.7 percent of the budget is allocated toward hospital care, while PHC services represent only percent of funds managed centrally by the Ministry of Health (UAH 11.5 billion), about 62 13 percent; 3 percent and 6 percent respectively are allocated to secondary and tertiary percent locally managed through the medical subvention mechanisms (UAH 43.8 billion), outpatient services. and 22 percent also managed locally as a part of local budget funds (UAH 15.7 billion). Budget planning, while characterized by wide control and regulation, does not secure Besides general medical subvention, local budgets can receive subventions for specific complete execution of planned health allocations. The execution rate of the planned purposes as defined by the Ministry of Health, (see Table 2) but these additional health budget is relatively low, but has increased somewhat in the last two years. In subventions are very small compared to the main subvention. Table 2 illustrates that 2014, the health budget execution rate was 88 percent, progressing to 94 percent and in some cases oblasts can receive financing from the Central budget even for specific 96 percent in 2015 and 2016, respectively. Still, the 4 percent execution gap in 2016 hospitals (usually these are capital expenses). Such “specific” subventions appear in the represented 3 billion hryvnia of the planned budget not allocated to the health care sector. budget for two reasons—to ensure provision of certain goods (e.g., subvention to purchase Execution rates were below sector average for expenditures related to orphanages and drugs for anesthesia makes sure that every hospital has at least some amount of such research and development (R&D) in both years (Table 3). drugs since this money cannot be spent on anything else) and to simplify control over Figure 5. Structure of Ukraine’s health expenditures by funds use. functional classifications Table 2. Medical subventions to local budgets in 2015 and 2016 (UAH million) 80,000 70,000 TYPE OF MEDICAL SUB- 2015 2016 VENTION PLAN ACTUAL PLAN ACTUAL 60,000 Medical subvention 46,177 46,177 44,434 44,434 50,000 Subvention to reform regional health care 40,000 systems within the IBRD 130 6 180 180 30,000 project "Serving People Improving Health" 20,000 Subvention for purchase of drugs and medical 10,000 138 136 138 136 supplies for emergency care 0 plan actual plan actual Subvention for 2015 2016 purchase of medical 19 18 19 18 disposables and drugs Polyclinics Sanitoriums for anesthesia Emergency rooms Prophylactic and epiemiology Subvention to Lviv PHCs and FOPs R&D oblast for reconstruction 45 45 - - General hospitals Other, inluding orphanages of a perinatal center Specialized hospitals, incl. maternity hospitals Source: Treasury report on consolidated budget. Source: Treasury reports Figure 6 presents the composition of health care expenditures overall and in per capita Figure 5 and Table 3 present the structure of health expenditures by functional terms in two regions. By economic categories, salaries account for the largest share of classification in 2015 and 2016. (More details on the structure of health expenditures public health expenditure. The other main expenditure categories are medications and in the four oblasts are provided in Annex B). We observe that health sector spending is utilities. biased toward hospital services instead of primary health care that provides low-cost preventive care. General and specialized hospitals represent 64 percent of the public health budget, while PHCs receive about 10 percent. In Donetsk oblast for example, 70 48 Tracking Health Resources in Ukraine Budget Management in the Health Sector 49 Table 3. Planned and actual health budget by functional B. PREPARATION OF THE HEALTH classification 2015 and 2016, with execution rates BUDGET AND CONTROLS EXECUTION RATE As explained by officials and physicians-managers during interviews, the budget % (ACTUAL AS planning process usually starts in August–September of the previous year and takes 2015 (UAH) MILLION 2016 (UAH MILLION) PERCENTAGE OF several months, generally being completed in January–February of the current year, PLANNED BUDGET) when final amounts of medical subvention are communicated to oblasts/rayons and then Expenditure items Planned Actual Actual % Planned Actual Actual, % 2015 2016 to various health care facilities. Polyclinics 4,560.6 4,482.7 6.0 5,683.1 5,546.0 7.2 98.3 97.6 The biggest drawback of the current planning process, as reported by officials and Emergency 3,486.3 3,338.1 4.6 3,617.6 3,456.6 4.6 95.7 95.6 physician-managers, is the absence of middle-term planning—despite over 10 years of care stations discussions of the need to introduce three-year budgeting, budgets at all levels are still PHCs and FOPs 6,640.1 6,398.1 8.8 7,784.4 7,406.6 9.9 96.4 95.1 planned for just one year ahead. This results in very poor, essentially no, planning of General hospitals 32,574.2 31,631.2 43.2 31,389.7 30,319.1 39.8 97.1 96.6 capital expenses such as new equipment. Specialized hospitals, including maternity 13,926.4 13,147.7 18.5 15,334.7 14,790.8 19.4 94.4 96.5 The budget planning process is the responsibility of a physician-manager and hospitals an economist or a chief accountant of a facility. Budget planning proceeds in the Sanatoriums 1,272.8 1,234.4 1.7 1,320.7 1,299.0 1.7 97.0 98.4 following stages: Prevention and 1,209.0 1,143.8 1.6 1,230.5 1,198.0 1.6 94.6 97.4 1 Department or ambulatory heads, together with the chief nurse who is re- epidemiology sponsible for medications, collect the needs of their department or ambula- R&D 457.9 412.0 0.6 404.7 354.3 0.5 90.0 87.6 tory facility. They may consult the physicians in the process. Other, including 11,316.2 92,13.2 15.0 12,131.1 11,133.1 15.4 81.4 91.8 2 Department or ambulatory heads provide this information to the physi- orphanages cian-manager and economist or chief accountant of a facility, who review and Total 75,443.6 71,001.1 100 78,896.5 75,503.4 100 94.1 95.7 aggregate the information and compile a facility budget. Source: Treasury reports. 3 Drafted facility budget is sent to respective health department (rayon/city for Figure 6. Composition of per capita spending in 2015 rayon or city hospitals, oblast for oblast-level hospitals). (from the local health budgets), UAH 4 Health department reviews the budget and approves it. Before approval, there can be negotiations between facility managers and regional officials— usually the latter ones try to reduce the facility budget, whereas facility managers try to advocate for a budget increase. Lviv region 924 144 105 total 1,368 5 Likewise, rayon and city health care budgets are reviewed and approved by Poltava 830 144 119 total 1,495 region oblast health care departments. Ukraine 747 152 103 total 1,397 6 After the ultimate sum of medical subvention is communicated to the regions average (upon approval of the state budget by the Parliament), oblasts, rayons/cities, 0 200 400 600 800 1000 1200 1400 1600 and facilities adjust their budgets accordingly (usually they receive less mon- ey than they ask for, therefore they redistribute the budget). Salaries Research and State (regional programs) Equipment Drugs Social Security Food Other expenditures Other Services Construction and Renovation Utilites Capital transfers Source: Author calculations, data from BOOST. 50 Tracking Health Resources in Ukraine Budget Management in the Health Sector 51 Main actors of the budget process and their functions are described in Table 4. Figure 7. Do you have a general understanding on how the budget of your department/ambulatory/FOP is determined? (percent of positive Table 4. Main actors of the budgeting process and their functions answers among physicians) Usually is not involved in the budget process although may take part in discussions of department/FOP Medical staff needs Head of an Total Collects the needs of her department/facility based on the number of patients they served, drugs spent in the ambulatory or a department previous year and also needs for equipment repair and renovation, and provides to the chief physician Physician-manager of Together with chief accountant (economist) collects the needs of departments/ambulatories and compiles the ambulatory/ a health facility budget; then sends it to rayon/oblast health care department for review FOP Reviews budgets of respective health facilities Reports the needs of hospitals in local councils; sometimes advocates additional financing from local raion/ budgets; fundraises for hospitals among businesses and local hromadas city hospital Rayon/city health Advocates corrections of hospital budgets during the year at local council; sets the price list for facilities’ paid care department services (approved by local council) oblast hospital Distributes medical subvention and local budget funds to oblast/rayon/city facilities Oblast councils review health care budgets of rayons and cities 0 10 20 30 40 50 60 70 80 Define the amount of medical subvention Ministry of Health Define the formula for distribution of medical subvention together with the Donetsk+Luhansk Ministry of Finance Define the parameters, including financing, of state-level health care programs (e.g. HIV, diabetes etc) Poltava Review oblast health care budgets Lviv Source: Compiled on the basis of interviews. Weak coordination is reported between physicians and facility management with regard to budget planning. About a half of respondents, mostly physicians and nursing Figure 8. Is your experience with certain drugs considered during personnel, reported that they are not involved in the budget planning process, and about budget planning? (percent of positive answers among physicians) 30 percent of respondents report not having a clear understanding of the budget planning process (Figure 7). However, 70 percent of physicians report being involved in the planning of drug purchase (see Figure 8). ambulatory/FOP raion/city hospital oblast hospital 0 20 40 60 80 100 Donetsk+Luhansk Poltava Lviv 52 Tracking Health Resources in Ukraine Budget Management in the Health Sector 53 Managers and physicians involved in budget planning generally report using the previous Figure 9. What do you take into account when planning your budget? year’s budget as a basis for the current yearly needs (only one oblast specialized hospital (percent of respondents from physicians-managers who selected cer- reported that they make some forecast of the number of patients based on the long-term tain answer; several answers could be provided) trend). From that baseline, inflation is accounted for as well as specific priorities. Although some respondents report taking into account facility’s capture area and average number of people in the region number of patients per year, planning is heavily based on staff level (see Figure 9). By considering capture area, it is conceivable that facility managers try to forecast the number amount of medical subvention they will likely obtain. of personnel Most physicians in managerial positions report that general and special fund planning is not very different, both being historical and largely based on the last last year budget yearly budget. Complaints were voiced about small special funds availability and lack of advanced knowledge of amounts attributed, especially in the context of uncertain “charitable contributions.” number of patients Furthermore, facilities tend to not develop any strategic plans given the general absence of capital expenditures in the planning process in the context of the unavailability of normative documents immobilization funds. In their planning process, facilities tend first to protect some basic expenses (i.e., salaries and utilities) and then priority drugs (i.e., anesthesia, emergency and lifesaving drugs which are often not available in drugstores). Facilities reports of doctors then compile a “wish list” for infrastructure maintenance and renovation or equipment purchase. They also try to fundraise among local administrations and businesses, and 0 10 20 30 40 50 60 70 sometimes among international or charitable organizations. Renovation is performed predominantly using local budgets, charitable funds, or facilities’ own earnings. Donetsk+Luhansk Some physicians-managers reported that facilities are not allowed to spend medical Poltava subvention funds on renovation. Lviv Advocacy for additional financing Oblast and rayon/city officials, as well as facility managers, generally request local councils for additional funding from local budgets. However, funding in addition to state medical subvention tends to depend on the relative wealth of localities. Additional local support is sometimes financial, but is generally in kind, through for instance the delivery of equipment or goods (e.g., food, fuel, renovations of infrastructure). About 60 percent of physicians-managers in Poltava and 80 percent in the other three oblasts report approved facility budgets to be lower than requested. In that context, almost all facility managers try to advocate for increased financing of their facilities once the medical subvention is officially announced. The main factor reported for successful advocacy is the support of local authorities (see Figure 10). Other factors are less frequently cited, such as the importance of personal relations with local deputies and heads of local enterprises for fundraising. 54 Tracking Health Resources in Ukraine Budget Management in the Health Sector 55 Figure 10. Factors reported useful for successful advocacy planning system is efficient, while in other oblasts, about half of them support this view. (percent of physicians-managers who selected certain answer, However, at the same time, about 70 percent to 80 percent of respondents report that several answers were possible) personnel is used efficiently at their facility. In Donetsk and Luhansk oblasts, about 60 percent of physicians-managers support of local interviewed report that they would recommend an increase in number of physicians government at their facilities. However, despite having sufficient FTEs, they have difficulty recruiting physicians to fill these positions. Specialists are especially needed, in particular argumented cardiologists, anesthesiologists, and surgeons, etc. Pediatricians and other children presentation of needs specialists are also in high demand. A common complaint by facility managers is the difficulty to attract young staff to last year budget hospitals because of low salaries. On the other end, unproductive physicians cannot be fired, even when having reached pension age according to physicians-managers in Lviv epidemiologic and Poltava. situation Regarding other personnel, respondents report the relative scarcity of support staff emergencies (see Figure 11) Figure 11. How would you like to change the number of personnel support of political at this facility? (answers from physicians-managers in Donetsk and parties Luhansk oblasts) personal qualities of doctor-manager Support sta ecological situation Administration sta 0 10 20 30 40 50 60 70 Nurses Doctors Donetsk+Luhansk Poltava 0 20 40 60 80 100 Lviv increase no change Human resources planning decrease no answer Budget planning for personnel within health facilities depends on the number of full-time equivalent (FTE) positions at the facility. FTE positions tend to depend on Expenditures on utilities for the next year are planned based on previous consumption, current or historical numbers of beds rather than current population. Staff bonuses are taking into account potential tariff increases. When the government unexpectedly raised planned within the limits of the law and are paid at the end of the year in the presence energy tariffs in 2014 and 2015, facilities had to cover the difference either from their of leftover resources. own earnings (special fund) or from the funds provided by the local budget. Respondents Despite widespread knowledge that “Order 33” of the MoH has been abolished, most reported saving energy and resources in different ways to reduce their utility bills—from physicians in managerial positions report that they still plan staffing “within the limits replacing light bulbs with energy-saving ones and installing plastic windows to replacing of the order.” In the absence of such order, they do not know how to plan for personnel or central heating and gas boilers with wood/palette boilers. they do not perceive that they have the latitude to make major personnel changes. In Lviv oblast for instance, only a third of physicians-managers think that the current personnel 56 Tracking Health Resources in Ukraine Budget Management in the Health Sector 57 Budgetary discipline realized in a single rayon, Poltava rayon of Poltava oblast, to compare the budgets reported by all facilities in the rayon with the overall health care budget provided by There is a well-established bottom-up reporting system for facility expenditures. the local rayon treasury. Monitoring and control over local- and facility-level expenditures at all stages of budget planning and implementation are maintained by the central Treasury. The Local State The leakage assessment between central and local levels was investigated in three Treasury Service verifies that transactions correspond to their planned classification, steps. First, the aggregated country-level health expenditure was estimated. Second, approves them, and regularly provides budget execution reports. State Financial aggregated financial data from the State Treasury Service (central level) toward local Inspection (SFI) is responsible for the comprehensive financial audits, which include state administrations (at oblasts and rayon/city levels) for all four oblasts and all regular inspections to monitor financial accuracy, legislative compliance, and to some subordinated rayons/cities were assessed. Finally, to assess resources reaching facilities, extent, performance and value for money achieved by the spending units. a single case study was conducted in a randomly chosen rayon of Poltava in the oblast of Poltava, in which total health care expenditures of facilities (derived from facilities’ In addition, frequent financial inspections are reported. About 60 percent of physicians- balance sheets) were compared with the rayon health care expenditures, as reported by managers in each oblast report that their facility was inspected every quarter by a the local Treasury department. This rayon study did not find evidence of leakages similar controlling agency. Although some respondents complain about the time taken by to those found in other countries—i.e., all funds designated for a certain facility reached inspections, most physicians in managerial positions in Lviv and Poltava report that the that facility. inspections did not have impacts on planning or resource usage. All transactions between state-owned institutions and central and local budgets in the In Donetsk and Luhansk oblasts, financial inspections are less frequent. About a third Ukrainian health sector are recorded in a single electronic system. In that context, in of physicians-managers reported at least one inspection every quarter in both 2015 and a perfectly functioning system, there should be no discrepancies between disbursed 2016. Also, about a third of managers report a single or no inspection of the facility during funding by the State Treasury and received transfers by oblasts/rayons/cities and the last two years. The perception of potential positive impact of these inspections on facilities, which would reflect an absence of leakage. resource planning and utilization is reported by about a half of respondents. We used three measures to match figures from central Treasury reports to the same The budget is perceived as very inflexible due to rigid budget regulations. For instance, indicators in local Treasury reports. These measures are the executed health budget, transferring funds between budget lines within the general budget needs to be approved medical subvention sent/received, and medical subvention actually spent. by the local council by voting on it at their monthly session (e.g., funds saved on energy during a warm winter could not be easily transferred to medicine). Funds of the Special The most common reason for discrepancies is blind spots in medical transfers controlled Fund can be used more flexibly. This rigidity could lead to inefficient budget usage and to by the Treasury (Tables 5-8). The Treasury does not track some transactions within/ facilities trying to accumulate money within their Special Funds to have some reserve for between oblasts (e.g., from rayons to cities), but local administrations usually provide unexpected expenses. Since 2017, the General Fund has been made more flexible with consistent reports. This lack of tracking is responsible for 54 percent of medical only two budget lines—’salaries’ and ‘everything else’. subvention discrepancies (14 out of 26 cases). Unreported and mostly minor spending in the Treasury system is responsible for 38 percent of discrepancies. C. ANALYSIS OF LEAKAGES Discrepancies in public health expenses are more common and mostly due to unreported payments. However, there are 11 cases with significant differences which are not In several countries where PETS were conducted, one of the most important explained by local administrations. inefficiencies identified in public expenditure was the evidence of public resource leakage. Leakage is broadly defined as the share of resources earmarked to specific In Lviv and Poltava oblasts, discrepancies between state and local budget reports were beneficiaries, which fail to reach them. This phenomenon was generally associated with minor (Table 5 and Table 6) and can be explained by transfers between cities/rayons inadequate incentives and improper monitoring and enforcement within the service as well as peculiarities of accounting. For example, some expenses planned in 2016, delivery system. incurred in 2017. Thus, they were attributed by the Treasury to “actual” expenses of 2017, not of 2016. Also, transfers of medical subvention funds between different administrative To identify potential leakage of resources in the health sector in Ukraine, the units are not recorded in Treasury accounts (such transfers are frequent in Donetsk assessment focused on financial transfers between central government and lower oblast—see Figure D3 in Annex D and Table C3 in Annex C). level administrations and facilities. More specifically, data on financial resources disbursed by the Central Treasury were compared with funds received by local administrations and facilities in all four regions. In addition, a case study was 58 Tracking Health Resources in Ukraine Budget Management in the Health Sector 59 Overall, in 22 cases out of 42 rayons and cities studied, all the figures matched perfectly extent, the situation is determined by the presence of a vertically integrated electronic or with insignificant deviations. There are 20 cases that can be classified as leakages payments system in the form of unified Treasury accounts, which is accompanied by a according to our definition of leakage, but which were really inconsistencies, blind spots, well-established bottom-up reporting system. Each public health facility, as well as local and improperly reported health expenditures. oblast, rayon, and municipal administration, has its own single treasury account and, officially, all financial transactions have to be processed through this system. Most deviations between received and used medical subvention have been identified (after double checking with officials) as transfers between oblasts or more frequently It should be noted that the absence of evidence of direct leakages on financial within oblasts (e.g., from one rayon/city to another within the same oblast or from rayon/ transfers between the state and lower administrative levels in the health system does city budget to oblast budget). However, in one case, State and local treasuries report not imply, however, absence of leakages overall and in other forms, in particular on significantly different figures, so this case requires further investigation. in-kind transfers such as medication, equipment, and material provided centrally. Table 5 shows that in Lviv oblast discrepancies between the data reported by the Also, the analysis does not comprise potential leakage on health resources from Treasury and local authorities are minor. One case (Lviv city) is explained by the fact that local budgets, special funds, and patients’ fees. Furthermore, other forms of leakages, a transaction was made on December 31st and for some reason (probably a computer such as “kickback” payments for winning tenders, private capture, reselling of drugs and error) it never appeared in the electronic system. Sambir town transferred its entire materials, etc., also could not be tested in this study. medical subvention to Sambir rayon, and hence Sambir rayon hospital also serves town dwellers. Pustomytiv rayon provided some funds to the rayon hospital from the local budget, but for unknown reason this transaction was never reflected in Treasury files. The only significant discrepancy in Poltava oblast (Table 6) is explained by the transfer from Poltava oblast budget to Kharkiv oblast budget to pay for medical services. In Donetsk oblast (Table 7) transfers between rayons and towns are more frequent. In addition, some departments of certain hospitals serve people from the entire oblast. These inter-budgetary transfers mainly explain the differences in the data from Treasury and local administrations in this oblast. In Luhansk oblast (Table 8) such transfers are less frequent—hence, there are only four cases of minor inconsistencies. There are 8 cases of significant differences in total health care expenditures in Donetsk and Luhansk oblasts and three in Lviv oblast, which unfortunately are not explained by local administrations. Furthermore, to assess the presence of leakage at the lower level, a case study was conducted in the rayon of Poltava. The sum of all health care facility budgets as reported by facilities in the rayon was compared to the overall health care budgets provided by the local rayon treasury. We observed that the sums of expenditures of health care facilities, by economic classification codes, were equal to those presented in the rayon level budget execution report. Hence, our comparison of data from different sources does not provide evidence of direct leakages in financial transfers in four oblasts examined and specifically for one rayon at the lower level. A small number of inconsistencies that are present in the data may not be due to leakages, but seem to reflect the complexity of the control system. Indeed, based on findings from the interviews and after processing financial information at various levels, we were convinced that particularities of the health care system in Ukraine prevent direct leakages that were found in many PETS. To a large 60 Tracking Health Resources in Ukraine Management of Material Inputs 61 5. MANAGEMENT OF Figure 12. How often are all beds occupied at this facility (by oblast and facility type)? (physician responses) MATERIAL INPUTS facilities Donetsk+Luhansk oblast- level Poltava oblast Lviv oblast This chapter discusses the findings of the PETS/QSDS on adequacy of provision of Donetsk+Luhansk primary financing and inputs. Based on interviews of local officials, facility managers, and care Poltava oblast physicians, it describes coping strategies in face of medication and medical supply Lviv oblast scarcity (e.g., the buying in priority emergency drugs, drug reserves). It first discusses raion/city hospitals Donetsk+Luhansk overall resource availability in the perspective of local administrators and physicians, Poltava oblast including excess bed capacity, and then examines more specifically various inputs, in Lviv oblast particular medication. 0 20 40 60 80 100 A. AVAILABILITY OF PUBLIC RESOURCES almost never over 50% of time less than 50% of time almost always The survey included questions on the perception of oblast and rayon officials, physicians- managers, and frontline physicians on overall public resources availability, in particular Contradiction in responses were also observed as most physicians report an efficient use about infrastructure and capacity. of beds at their facilities, while about half of rayon/city hospitals’ physicians-managers (chief doctors) believe that about one-tenth to one-fifth of their hospital patients could be Bed capacity treated as outpatients. There is a common perception that Ukraine has too many hospital beds. Indeed, at the beginning of 2016, the official norm was reduced from 80 to 60 beds per 10,000 of Most physicians estimate the share of socially vulnerable patients at their facilities to population, but has not been fully implemented yet, while the EU average is 53 beds be low, with a slightly higher share in winter. Surveyed facilities hence appear not to be per 10,000. used for social care according to physicians (or at least not extensively used). However, managers of sampled facilities did not agree regarding the existence of a Overall resource availability bed excess supply. Some specialized hospital managers even claimed on the contrary The survey included questions on the perception of oblast and rayon officials, that they needed additional units. Physicians at oblast-level hospitals report not having physicians-managers and frontline physicians on overall public resources availability. enough beds to admit patients and the existence of a waiting list for hospitalization. Practically all the physicians report that in their facilities, all beds are occupied either All categories of respondents (rayon and oblast officials, physicians, physicians- 100 percent or over 50 percent of the time (see Figure 12). managers) report insufficiency of health resources and substantial variations in covered health care needs by the health budget between oblasts and rayons/cities within oblasts. Given that actual resource availability is lower than needs in their regions, health managers from local administrations try to proportionately distribute available funds between regional facilities. Larger proportions of funds are reported to be allocated to facilities providing prenatal and child services, and specialized hospitals treating acute diseases. 62 Tracking Health Resources in Ukraine Management of Material Inputs 63 Overall, estimates of resource shortages differ by regions and localities. These Figure 13. Share of health care needs covered by the oblast/rayon/ differences could be explained mainly by different abilities of local administrations to city budget: rayon and oblast officials’ responses provide additional funds. Reported shortages also vary by facility types and levels. For 120 example, primary care facilities probably have lower needs and therefore report higher coverage of needs; oblast-level facilities appear to be better supported, while secondary- 100 level hospitals report the most shortages. 80 The perception of shortages also varies by category of respondents. For example, facility managers report greater equipment shortages than physicians, which could be potentially 60 due to managers’ greater knowledge of additional services that could be provided with additional and more modern equipment. 40 Perception of Oblast and rayon officials 20 Figure 13 presents rayon and oblast officials’ perception of the share of health care needs covered by the health budget. As observed, in health officials’ perspective, 0 Donetsk oblast is relatively better financed regarding the perceived needs, while Poltava raion/city 1 raion/city 2 raion/city 3 raion/city 4 raion/city 5 raion/city 6 raion/city 7 raion/city 8 raion/city 9 raion/city 10 raion/city 11 raion/city 12 raion/city 13 raion/city 14 raion/city 15 raion/city 16 raion/city 17 raion/city 18 raion/city 19 oblast presents the lowest perceived coverage of needs (65 percent and 30 percent respectively). Two main underlying factors could explain these levels and variations in coverage: Light blue bar: Lviv oblasts; Dark blue bars: Poltava oblast; Orange bars: Donetsk oblast; Gray bars: Luhansk oblast, insufficient provisions of financing and different perception of needs. For example, a red line - average for four oblasts rayon official from Luhansk oblast explained that “almost all of our needs are covered but we do not ask too much.” At the same time, officials from rural rayons in Lviv and Poltava Perception of physician-managers oblasts say that medical subvention does not take into account that in their areas travel Figure 14 presents the physicians-managers’ perception of the health budget costs, both for medical personnel and patients, are higher than in cities—therefore they coverage of the needs in drugs and medical supplies, by oblasts and facility types. have to ask local businesses to provide cars and/or gasoline. Furthermore, variations in Note that the choice of response was presented by categories of coverage (“less than 25 needs coverage could be associated with decentralized additional health financing at the percent,” “25–50 percent,” “50–75 percent,” “75–90 percent,” and “more than 90 percent”). local level. Indeed, facilities located in wealthier rayons and cities with profitable business activities tend to receive greater additional funding from local administrations, in the We observe that in Lviv oblast, perceived coverage of drugs and medical supplies’ context of insufficient central level medical subvention to cover basic needs. needs is lower than in the other oblasts. Furthermore, in all sampled oblasts, lower perceived coverage is reported in rayon/city hospitals compared to other facility categories—with only about a quarter of drugs and medical supplies needs covered by the available budget. Primary level facilities and polyclinics report better provision of drugs and medical supplies, which could be associated with the fact that they are not supposed to provide basic drugs to patients—except in an emergency. Oblast hospitals’ needs in drugs and medical supplies are reported to be better covered. In Donetsk and Luhansk oblasts, where questions on perception of covered needs were asked separately for drugs, medical supplies, and equipment, we observe that needs appear to be better covered for medical supplies than drugs, with equipment coverage faring the worst (Figure 15). Shortage or obsolescence of equipment is a commonly reported problem at most facilities and could be explained by their relatively expensive nature and “unprotected” expenditure category. In that regard, some facility managers report equipment dating from the 1960s–1970s with the financing of spare 64 Tracking Health Resources in Ukraine Management of Material Inputs 65 parts using funds collected within the department. Several facility managers and Figure 15. Donetsk and Luhansk oblasts, coverage of needs by physicians mention that they have to send patients to other facilities (public or private) for facility budget (facility managers’ reports) some advanced diagnostics (e.g., MRIs or some types of ultrasound). 100 90 Perception of physicians Needs in drugs 80 Figures 16–18 present physicians’ perception of covered needs for drugs, medical 70 ‹ 25% supplies, and equipment separately, by oblast and facility types. 25% – 50% 60 Figure 14. Share of need in drugs and medical supplies reported 50 50% – 75% covered by the facility budget (physicians-managers answers by 40 75% – 90% facility level) 30 › 90% Lviv Oblast Poltava oblast 20 averages 10 100 0.6 0 90 all facilities PHCs raion/city hospitals polyclinics oblast hospitals 0.5 80 70 0.4 100 60 90 50 0.3 Needs in medical supplies 80 40 ‹ 25% 70 0.2 25% – 50% 30 60 50% – 75% 50 20 0.1 75% – 90% 40 10 › 90% 30 0 0.0 averages 20 all facilities all facilities raion/city hospitals polyclinics oblast hospitals PHCs raion/city hospitals polyclinics oblast hospitals 10 0 all facilities PHCs raion/city hospitals polyclinics oblast hospitals ‹ 25% ‹ 25% 25% – 50% 25% – 50% 100 75% – 90% 50% – 75% 90 average by › 90% Needs in equipment 80 facility type averages 70 ‹ 25% 60 25% – 50% 50 50% – 75% 40 75% – 90% 30 › 90% 20 averages 10 0 PHCs raion/city hospitals polyclinics oblast hospitals total 66 Tracking Health Resources in Ukraine Management of Material Inputs 67 Figure 16. Share of drug needs covered by facility budget (physi- Figure 17. Share of medical supply needs covered by facility budget cians’ answers) (physicians’ answers) Lviv 100 100 80 90 ‹ 25% Lviv 60 80 25% – 50% 40 ‹ 25% 70 50% – 75% 25% – 50% 60 20 75% – 90% 50% – 75% 50 › 90% 0 40 all facilities amb./FOPs raion/city hospitals polyclinics oblast hospitals averages 75% – 90% 30 › 90% 20 averages 10 Poltava 100 0 amb./FOPs raion/city hospitals polyclinics oblast hospitals total 80 ‹ 25% 60 25% – 50% 40 50% – 75% 100 20 90 75% – 90% Poltava › 90% 0 80 all facilities PHCs raion/city hospitals polyclinics oblast hospitals averages 70 ‹ 25% 60 25% – 50% 50 50% – 75% 40 Donetsk+Luhansk 100 75% – 90% 30 › 90% 80 ‹ 25% 20 averages 60 10 25% – 50% 40 0 50% – 75% PHCs raion/city hospitals polyclinics oblast hospitals total 20 75% – 90% › 90% 0 all facilities PHCs raion/city hospitals polyclinics oblast hospitals averages 100 90 Donetsk+Luhansk 80 ‹ 25% 70 25% – 50% 60 50 50% – 75% 40 75% – 90% 30 › 90% 20 averages 10 0 PHCs raion/city hospitals polyclinics oblast hospitals total 68 Tracking Health Resources in Ukraine Management of Material Inputs 69 Figure 18. Share of equipment covered by facility budget We observe in Figures 16–18 that primary-level facilities (PHCs, ambulatories, FOPs) (physicians’ answers) appear to be better supplied with medical supplies and equipment relative to their 100 needs compared to higher level facilities. However, as mentioned above, this appears 90 to be due mainly to lower needs. Indeed, physicians in polyclinics and ambulatories/FOPs Lviv 80 report simply having to prescribe drugs, without direct provision from the facility. PHCs, ‹ 25% 70 hence, only require availability of basic medical supplies (e.g., bandages, cotton balls) 25% – 50% 60 and emergency kits, which are usually available. Coverage of needs also differs by type of drugs and departments. Intensive care, prenatal, and newborn care are reported to 50% – 75% 50 be better covered because of being priorities in local officials’ and physician-managers’ 75% – 90% 40 budget allocation. Furthermore, physicians report coverage above 90 percent for essential › 90% 30 lifesaving drugs, while nonessential drugs are reportedly covered at less than 20 percent, averages 20 and expensive drugs (e.g., chemotherapy) at less than 5 percent of needs. 10 0 Provision of medical supplies is reportedly better covered than drugs, given their amb./FOPs raion/city hospitals polyclinics oblast hospitals total usual lower cost. Across sampled oblasts, drug needs coverage by facility budget is about 40 percent. For medical supplies, reported coverage in Lviv is the lowest among studied regions—below 50 percent, and the highest it is in Poltava oblast 100 (about 60 percent). 90 Poltava Equipment presents the highest coverage of needs. However, estimation of equipment 80 ‹ 25% provisions differs substantially between physicians-managers and frontline physicians 70 with the former reporting coverage at about 30 percent of needs compared to about 25% – 50% 60 40 percent to 60 percent by physicians. This could be due to the fact that physicians- 50% – 75% 50 managers have a wider perspective and knowledge of potential services than new 75% – 90% 40 equipment could allow, such as extended diagnostics currently provided only by private › 90% 30 facilities. While some basic equipment is present in all facilities, physicians often averages 20 complain that equipment is obsolete or has high maintenance costs. Since equipment 10 financing occurs after all other necessary expenses are covered, the medical subvention 0 is often exhausted and equipment is financed by local budgets (if the funds are available) all facilities PHCs raion/city hospitals polyclinics oblast hospitals or delivered in kind by charitable organizations. Thus, facilities cannot plan an advance purchase of necessary equipment, and very often a piece of equipment is purchased only when some equipment is broken and cannot be repaired. 100 All polyclinics complained about absence of vaccines, which were not provided until 90 Donetsk+Luhansk the fall of 2016. One rayon official in Poltava oblast reported that they had to purchase TB 80 vaccine using rayon budget funds, and officials from two rayons in Lviv oblast reported ‹ 25% 70 vaccine purchases by physicians in Poland (such as anti-rabies vaccines), who then 60 25% – 50% provided patients with a fee. 50 50% – 75% 40 A few physicians-managers were asked to evaluate coverage of the total cost of treatment 75% – 90% 30 from different sources. According to their estimates, about 70 percent of the cost of › 90% 20 treatment is covered by patients (Figure 19). They explain that patients buy drugs and averages 10 medical materials (except for urgent cases), while hospitals pay for communal services and salaries of medical staff. This figure provides another piece evidence on the share of 0 need covered by actual facility budgets. all facilities PHCs raion/city hospitals polyclinics oblast hospitals 70 Tracking Health Resources in Ukraine Management of Material Inputs 71 Figure 19. Of total cost of treatment, share covered Figure 20. How often did you face shortage of financial from different sources resources, drugs, vaccines, or other medical supplies in 2015? (physicians-managers) 100 PHC 1 90 hospital 5 80 Lviv oblast 70 hospital 4 permanently 60 hospital 3 once a week 50 hospital 2 never 40 hospital 1 30 20 0 10 20 30 40 50 60 70 80 90 100 10 state funds fee-paid services charitable funds 0 raion/city hospitals polyclinics oblast hospitals total co-payments of rent of premises patients 100 Shortage of financing, drugs and supplies 90 Physicians-managers and physicians were also asked more specifically about the 80 frequency of shortages in financing, materials, and drugs. As emphasized above, Lviv Poltava oblast 70 oblast health facilities appear relatively less supplied relative to their needs than in Poltava oblast, while tertiary-level facilities experience more frequent shortages than 60 once a week other categories, potentially because of greater needs and the use of more expensive 1-2 times a month 50 drugs to treat more serious cases (Figure 20). 1-2 times a quarter 40 In Donetsk and Luhansk oblasts, questions on the frequency of shortages over the last 1-2 times a year or never 30 two years were asked separately for financing, drugs, and other supplies (Figures 21–22). 20 Note that only answers for financial resources and drugs are presented, given that 10 answers for other supplies were very similar to those of drugs. 0 raion/city hospitals polyclinics PHCs oblast hospitals total 72 Tracking Health Resources in Ukraine Management of Material Inputs 73 Figure 21. Donetsk and Luhansk oblasts: Frequency of shortage of Figure 22. Donetsk and Luhansk oblasts: frequency of shortage of financial resources (physicians-managers perspective) drugs (physicians-managers perspective) 100 100 90 90 80 80 2015 2015 70 70 every day 60 every day 60 1–2 times per month 50 1–2 times per month 50 1–2 times per quarter 1–2 times per quarter 40 40 1–2 times per year 1–2 times per year 30 30 never never 20 20 10 10 0 0 PHCs raion/city hospitals polyclinics oblast hospitals total PHCs raion/city hospitals polyclinics oblast hospitals total 100 100 90 90 80 80 2016 2016 70 70 every day 60 every day 60 1–2 times per month 50 1–2 times per month 50 1–2 times per quarter 1–2 times per quarter 40 40 1–2 times per year 1–2 times per year 30 30 never never 20 20 10 10 0 0 PHCs raion/city hospitals polyclinics oblast hospitals total PHCs raion/city hospitals polyclinics oblast hospitals total 74 Tracking Health Resources in Ukraine Management of Material Inputs 75 Donetsk and Luhansk oblasts ask a patient to buy drugs Various strategies are used by facilities to deal with drug shortages. Weekly requests or complaints (calls or letters) from facilities to obtain drug supplies are reported by about one-third of rayon/city officials. Other than formal and informal administrative requests, about 60 percent of sampled physicians request patients to purchase their buy drugs/supplies myself own drugs when facing drug shortages. Alternatively, physicians report buying drugs for patients or their department. In Lviv oblast, about half of respondents make use of this approach compared to one-fourth in Donetsk and Luhansk, and only 10 percent in Poltava. send a patient to About one-tenth of patients are asked to return later or are sent to another physician/ another facility facility when drugs are not available on site (Figure 23). Figure 23. In case of shortages, options physicians choose ask a patient to come (by percent) later Lviv oblast 0 10 20 30 40 50 60 70 ask a patient to buy ambulatories/FOPs all facilities drugs oblast hospitals raion/city hospitals polyclinics buy drugs/supplies myself Poltava oblast send a patient to another facility ask a patient to buy drugs ask a patient to come later buy drugs/supplies myself 0 20 40 60 80 100 send a patient to ambulatories/FOPs all facilities another facility oblast hospitals raion/city hospitals polyclinics ask a patient to come later 0 20 40 60 80 100 120 ambulatories/FOPs all facilities oblast hospitals raion/city hospitals polyclinics 76 Tracking Health Resources in Ukraine Management of Material Inputs 77 Existence of Emergency Reserves Information from PETS interviews Given the drug budget constraint, facilities tend to prioritize their purchasing of Facility respondents and local officials reported that there were considerable delays medications based on perceived needs to react to emergencies. Facilities reported that in 2013 and 2014 in nonwage financing disbursed by the Treasury, but that transfers they first buy essential lifesaving drugs for emergency cases. Practically all facilities keep were on schedule in 2015 and 2016. Salaries, as well as local budget transfers, were a reserve of such emergency drugs (Figure 24). The majority of facility managers report reported on schedule in 2015 and 2016, although there were delays of salaries in 2014. that the reserve is replenished as needed, when drugs are consumed or expire. Considerable delays are reported with regard to centralized drug deliveries in 2015, Figure 24. Do you have a reserve of [emergency] drugs? Share of which could be explained by a transition period associated with the introduction of “yes” answers of physicians-managers new rules of procurement through international organizations (e.g., UNDP). In particular, two-thirds of physicians-managers from Lviv oblast and 36 percent in Poltava oblast reported delays of either funds disbursement or of centralized supplies oblast hospitals of drugs or other goods in 2015. Drugs were most often delayed (36 percent of answers) followed by financial resources (28 percent of answers). PHCs Only three physicians-managers reported provision of funds delays on the side of the Treasury; these delays happened 1–2 times a year and lasted about 7–9 days. In particular, at the end of 2016 there was a hacker attack on the Ukrainian Treasury, due to polyclinics which all transactions were frozen for several days. Since interviews in Luhansk and Donetsk oblasts were conducted at the end of 2016, raion/ city hospitals physicians-managers there were asked about 2016, and the question was more detailed. Their answers are presented in Table 5. 0 20 40 60 80 100 Table 5. Were there delays in disbursement of finances, drugs, or other supplies during 2016? Share of “yes” answers of Donetsk+Luhansk physicians-managers in Donetsk and Luhansk oblasts Poltava FINANCES DRUGS OTHER SUPPLIES Lviv From central budget 22 56 22 From oblast budget 15.6 25 19 From rayon/ municipal/ B. DELAYS AND INEFFICIENCIES hromada budget 12.5 9 9 In this section, we examine the presence of delays and inefficiencies using data from the PETS interviews in the four sampled regions, as well as data on Treasury transactions in one region, Poltava oblast. All polyclinics and maternity houses report the absence of centralized delivery of vaccines during the last two years. The situation was reported as threatening public Delays and corresponding inefficiencies may come from two main sources: financing health with, in particular, a shortage of TB and anti-rabies vaccines. Improvements in bodies and health facilities themselves. In the former case, financing bodies may delay vaccine supply was reported to have taken place toward the end of 2016. disbursement of funds, creating potential wage arrears and supply interruption. In the latter case, facilities may inefficiently plan expenditures leading, for instance, to delay in Information from Treasury transactions procurement or a contrary accumulation of drug stocks. In addition to delays reported in PETS interviews, a case study was realized in Poltava oblast using Treasury transactions comparing actual and planned levels of transfers to facilities. To assess budget execution and delays in the flow transfers toward facilities, more than 50,000 financial transactions from the Treasury toward each facility in Poltava 78 Tracking Health Resources in Ukraine Management of Material Inputs 79 oblast in 2015 were compared to monthly budget planning. The results of this analysis As an indicator of potential inefficiency in budget execution and delays, we use the are presented below. The presence of delays in transferred amounts is assessed using average monthly deviations in transfers—both positive and negative. It is measured the deviation between actual and planned monthly expenditures (in percentage of planned as the sum, in absolute value, of monthly deviation relative to planned transfers (as expenditure) on (i) wages and salaries, and (ii) medication. a proportion of planned transfers). We observe average deviation of 6.6 percent and 15.6 percent in 2014 and 2015 respectively, indicating relatively important variations in As an illustration, Table 6 presents measurement of budget execution and delays in monthly transfers, especially in 2015 (Table 10). wage transfers for the case of a Central Rayon Hospital in Poltava oblast. It shows actual wage reception, planned monthly wage budget, and deviations between the two in Figure 25 presents the average monthly deviation (in absolute value) of salaries and 2014 and 2015. We observe that in 2015 important salary delays were present in January medication for Poltava oblast, for each sampled facility in 2014 and 2015. We observe (–62.8 percent), followed by an excess monthly reception of 21.6 percent in February. This substantial monthly deviations between actual and planned transfers, especially in 2015, excess transfer did not compensate for the previous month underspending leaving a gap with average deviation from planned expenditure of 32.2 percent on medication and 11.8 of 4.2 percent of expenditure transfer compared to the planned budget. In 2014, delays percent on salaries during the year. in salary expenditure transfer where observed during the first 10 months, then fully The delays and budget execution problems illustrated in the case of the Central Rayon compensated by surplus budget reception during the last two months of the year. Hospital seem also to be observed overall across facilities in Poltava region, and at Table 6. Actual and planned monthly budget inflows (salaries): an even larger scale with regard to the medication budget. Indeed, average deviations illustration for a Central Rayon Hospital, thousand UAH (in absolute value) between actual and planned monthly inflows of medication budget (2014 and 2015) were 32.2 percent in 2015 (22.2 percent in 2014). Average differences in salary reception across the region were 11.8 percent in 2015 (7 percent in 2014). This evidence may 2014 2015 be indicative of inefficient planning and disbursement of financial resources to health DEVIATION, DEVIATION, PLANNED ACTUAL PLANNED ACTUAL facilities in the oblast. PERCENT PERCENT Jan 1,218 1,217 0% 1,283 478 -62.8% Figure 25. Average monthly deviations of actual and planned monthly Feb 1,228 1,191 -3.0% 1,334 1,623 21.6% budget inflows (salaries and medication) by facilities: Poltava oblast (2014 and 2015) Mar 1,292 1,273 -1.5% 1,322 1,298 -1.8% 48% Apr 1,305 1,302 -0.2% 1,373 1,479 7.7% 50% 45% 44% May 1,450 1,389 -4.2% 1,474 1,511 2.5% 42% Jun 1,463 1,460 -0.2% 1,416 1,420 0.3% 40% 33% 33% 32% 32% Jul 1,402 1,339 -4.5% 1,301 1,301 0.0% 28% 30% 25% Aug 1,273 1,179 -7.4% 1,209 1,209 0.0% 22% 22% Sep 1,229 1,073 -12.7% 2,037 1,244 -39.0% 17% 20% 16% 14% 13% Oct 1,139 1,097 -3.7% 1,530 1,966 28.5% 12% 12% 11% 10% 10% 10% 9% 8% 7% Nov 1,000 1,169 16.9% 1,562 1,771 13.4% 10% 6% 6% 6% 6% 4% 4% Dec 1,246 1,558 25.0% 2,206 1,999 -9.4% 0% 0% Total 15,245 15,245 0.0% 18,048 17,298 -4.2% oblast oblast raion/ raion/ raion raion/ raion/ Average, Average absolute hospital 1 hospital 2 city city city ciy ciy all 6.6% 15.6% hospital 1 hospital 2 hospital 3 hospital 4 hospital 5 facilities monthly deviation (polyclinics) in Poltava Oblast Salaries 2014 Medications 2014 Note: Deviations between actual and planned expenditures are computed for each month as: Deviationmonth i = (Actual Expendituremonth i – Planned Expendituremonth i) * 100%/Planned Expendituremonth i Salaries 2015 Medications 2015 Source: Authors from Treasury data. 80 Tracking Health Resources in Ukraine Management of Material Inputs 81 Deviation in percentage in yearly transfer in 2014 and 2015, for each facility type, Figure 26. Monthly actual budget allocation (blue line) and for Poltava oblast is presented in Table 7 presents salary and medication budgets. expenditure (red line) (salary), illustration for a Negative deviation indicates underspending for each budget items. Central Rayon Hospital (2015) Overall, we observe underspending of the budget for both years, especially with 2,500,000 regard to the medication budget (2.7 percent and 1.2 percent in 2014 and 2015, respectively), while underspending of the wages budget was less than 1 percent for 2,000,000 both years. Important variations are observed across health facilities within the oblast, with actual vs planned medications transfers varying between –14.4 percent to 10.7 1,500,000 percent and salaries from –4.2 percent to 2.3 percent (2015). 1,000,000 Table 7. Difference between actual and planned annual budget inflows (salaries and medication), by facilities: Poltava oblast 500,000 (2014 and 2015) SALARIES MEDICATIONS 0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Facility 2014 2015 2014 2015 Rayon/city hospital 1 2.0% -3.5% -11.0% 10.7% Source: Own calculations from Treasury data. Oblast hospital 1 0.0% 0.0% 0.0% 0.9% Figure 27. Monthly actual budget allocation (blue line) and Oblast Hospital 2 0.6% 0.0% 0.0% -14.4% expenditure (red line) (medication), illustration for a Rayon/city hospital 2 0.0% -4.2% -8.0% -6.0% Central Rayon Hospital (2015) Rayon/city hospital 3 300,000 -3.0% 2.3% 0.0% 0.0% (polyclinics) Rayon/city hospital 4 0.0% 0.0% 0.0% 0.8% 250,000 Rayon/city hospital 5 -3.7% -0.7% 0.0% 0.0% Average -0.6% -0.9% -2.7% -1.2% 200,000 Source: Authors from Treasury data. 150,000 Turning now to deviations, at the facility level, between actual budget reception and expenditure, Figure 26 presents an illustration for the selected Central rayon hospital 100,000 in the Poltava oblast of the monthly reception of the wage budget (blue line) and wage expenditure. We observe that expenditure for salaries almost coincide with budget 50,000 reception in 2015, except for January. 0 With regard to the medication budget of the selected Central rayon hospital (Figure Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 27), we observe that expenditures outpace actual reception in 2015, indicating that the medication budget (from MoH and local governments) is supplemented by other sources Source: Own calculations from Treasury data. of financing. Indeed, facilities generate revenues from sales of services and goods (e.g., out-of-pocket fees, charitable fund contributions, rental fees, etc.). Many of such inflows For all sampled health facilities in Poltava oblast, the ratio of budget allocation to do not have assigned economic classification codes (e.g., 2220: “Drugs and materials”), expenditure by facilities is constructed, by facility types for salaries and medication in but may be used by hospitals to purchase medications. 2014 and 2015 (Figure 28). As observed, salary budget reception and expenditure balance relatively well, with reception at the facility level on average 1 percent to 2 percent below expenditure. However, medication budget reception covers only about two-thirds of medication expenditure among Poltava facilities, and in some cases (rayon city hospital 82 Tracking Health Resources in Ukraine Management of Material Inputs 83 1) less than one-fifth. This could be explained by the fact that while salaries (and Overall, substantial deviations and delays observed between actual and planned utilities) are covered by medical subvention, medications are purchased partly through spending in Poltava region may signal the need for improved budgeting and allocation self-generated funds. In the case of Poltava oblast hospital 1, which hosts a cardiology practices for health facilities. Furthermore, the problem of public underfinancing is unit, priority purchases of emergency drugs could explain the greater public financing especially apparent with regard to medication expenditure. Government support covers observed. about two-thirdsd of facility actual expenditures on drug spending, with user fees and other sources providing complementary funding. A problem of proper classification Figure 28. Difference of actual reception and expenditure at the of expenditure categories was also uncovered, as many revenue inflows (from facility level, in percent (Poltava oblast) nongovernment sources) do not have assigned economic codes. raion Average, city all These potential inefficiencies associated with planning and allocation problems are raion/ raion/ hospital 3 raion/ raion/ facilities probably even more acute in reality relative to actual expenditure, given that health oblast oblast city city (polyclin- ciy ciy in Poltava hospital 1 hospital 2 hospital 1 hospital 2 ics) hospital 4 hospital 5 Oblast facilities generally hold unaccounted for bank accounts. These funds are not reported or accounted for in the Treasury data used for this exercise. In that context, proper control 10% by the state over public health facilities activities and expenditures is far from adequate. 0% C. PROCUREMENTS -10% As discussed earlier (see section Budget Planning and Execution), a share of medication is centrally supplied in kind to health facilities. Hospitals in particular receive medications -20% through various state-level programs (e.g., drugs for cancer treatment). Deliveries of those drugs are reportedly plagued by frequent delays, especially in 2015. -30% However, overall medications used at health facility levels are mostly purchased and -40% procured by facilities themselves, using funding coming generally from central and local budgets. -50% Oblast and rayon officials, as well as physicians-managers, report that when procuring drugs, several hospitals split drug procurement into smaller orders. Doing so, they -60% seek to avoid public tenders, which are associated with longer procedures and delivery periods (more than 2 months). Overall, the most important items procured by facilities are -70% communal services (i.e., water and plumbing, electricity, telephone, etc). -80% With regard to the new e-procurement system Prozorro, some facilities report having started using Prozorro even before it became mandatory on August 1, 2016. About -90% two-thirds of surveyed facilities in Lviv oblast, a half in Donetsk and Luhansk oblasts, and 40 percent in Poltava oblast report an early use of the e-procurement system (see Table 8). More than half of physician and public officials (city/raion/oblast administration) report Salaries 2014 Medications 2014 savings using Prozorro. Salaries 2015 Medications 2015 However, facility managers and officials also expressed a number of concerns Note: Negative numbers indicate that the facility spent less on budgetary item than it received. Positive number regarding the e-procurement system. These include (i) quality of goods supplied: given indicate that, in addition, the facility used some other sources of funding. that firms within Prozorro compete only on price, quality of goods offered is hard to control; (ii) reliability of suppliers: since most firms can enter competition in Prozorro, respondents expressed concerns that some dubious firms may ultimately win tenders, but would be unable to meet conditions; cases of Prozorro winners unable to supply the needed quantities and tenders having to be rerun were cited; (iii) conditions of delivery: 84 Tracking Health Resources in Ukraine Management of Material Inputs 85 some drugs have to be shipped under defined conditions (e.g., cold chain), and some respondents expressed doubts about the ability of suppliers to respect these conditions; and (iv) economy of scale: small facilities have difficulties attracting suppliers since they face higher transaction (and delivery) costs. Sixty percent of facilities in Donetsk and Luhansk oblasts, 50 percent in Poltava oblast and 33 percent in Lviv oblast, mostly small ones, experience hardship in attracting suppliers because of relatively large transaction costs. Framework agreements, when some agency (i.e., rayon or oblast administration or a centralized procurement agency) procures drugs for several facilities, could mitigate this problem. Table 8. “Early” usage and perspectives on Prozorro, by rayons/ cities and facilities (in percentage) LVIV POLTAVA DONETSK + LUHANSK Rayons/cities using prozorro BEFORE 60 67 64 01.08.2017 (%) AND had some economy 100 100 29 with Prozorro AND are optimistic about 100 100 14 Prozorro # of observations 5 3 11 Facilities using Prozorro 67 33 50 BEFORE 01.08.2017 (%) AND had some economy 50 100 100 with Prozorro AND are optimistic about 0 100 43 Prozorro # of observations 6 9 14 86 Tracking Health Resources in Ukraine Human Resource Management 87 6. HUMAN RESOURCE Some cases of entry point noncompliance involve patients who were previously treated at the hospital and continue to be supervised by the same physician. MANAGEMENT Physicians who are sharing time between a hospital and an adjacent polyclinic, report admitting their patients at the hospital as well. Patients not wanting to wait in lines in polyclinics sometimes seek care directly in hospitals. Furthermore, physicians report patient admittance outside of polyclinics opening hours or those arriving from In this chapter, we examine human resource use at the facility level, examining first distant locations. physicians’ time, salary aspirations, and then evidence of moonlighting. Time spent on paperwork A. USE OF PHYSICIANS’ TIME Figure 29. Reported physicians working time per month, by facility types and oblast Physicians interviewed at facility levels report working on average about 170 hours 500 per month, (42–43 hours per week). Such a reported workload is significantly longer than official guidelines of 33 to 38.5 hours per week for physicians. Between oblasts, 450 physicians in Lviv report working the least number of hours, with an average about 150 hours per month compared to 170 hours in Poltava and about 180 hours in Donetsk and 400 Luhansk oblasts. Across facility types, the longest workload is reported by physicians in Donetsk and Luhansk oblasts rayon/city hospitals with 231 hours per month on average, and the least for the same facility type hospital in Lviv with about 140 hours (180 hours in 350 Poltava). Among these three regions, Poltava oblast presents the narrowest distribution of physicians working time, while Lviv shows the greatest variation (Figure 27). 300 Could physician’s time be perceived as used efficiently? The answer to this question is 250 probably no given in particular that (i) neither patients nor physicians respect the health system entry point, and (ii) available time for patients’ health is severely reduced by heavy 200 paperwork and bureaucratic requirements 150 Patients’ entry point Patients often do not respect the National Health Policy recommendation that PHCs 100 should be the entry point of patients in the health system. Hospitals’ emergency and inpatient departments admit walk-in patients who have not sought care in 50 lower-level facilities. In addition, patients tend to consult specialists without prior generalist’s referrals. Indeed, approximately 90 percent of physicians in Lviv oblast 0 working in hospitals’ inpatient departments report admitting patients who have not Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk been referred by a family physician or by a lower-level facility (e.g., polyclinics). In the other sampled regions, this practice is reported by about 70 percent of the hospital physicians interviewed. Patients’ noncompliance of entry points places pressure on Primary Level Raion Hospital Polyclinic Oblast Hospital hospital resources, inducing inefficient use of time of highly qualified physicians and infrastructure. In particular, it often leads to physicians having to work overtime, with Note: Black presents mean, dark blue is mean +- one st.dev., light blue present min and max about 40 percent of physicians in Lviv and Poltava reporting working overtime every day or frequently (Figure 28). In addition to a greater load from entry point misalignments, time spent on paperwork absorbs a non-negligible share of a physician’s workday, reducing available health care services to be provided. On average, physicians report spending about 30 percent of their working time in facilities on activities not directly related to treating patients. 88 Tracking Health Resources in Ukraine Human Resource Management 89 These activities include writing illness histories and various reports—for example, on Figure 30. How often do you work overtime? usage of insulin, but also related to various reporting systems. In particular, strict control systems on medication and other medical supply usage are reported at the facility level, which involves keeping track of these inputs in various journals (some physicians Lviv mention up to 10 to 20 journals to regularly update). While nurses usually take care of this reporting, some physicians share this burden, which takes a substantial amount of time all facilities and sometimes requires completion after their normal workday. oblast hospitals Time spent on paperwork and reporting varies among specialties and departments, with physicians in intensive care units spending up to 60 percent of their time on raion/city hospitals paperwork compared to about 10 to 20 percent for physicians in polyclinics, and polyclinics hospitals’ inpatient departments and family physicians somewhere in the middle. ambulatory/FOP Reduced paperwork as well as making use of information technologies, such as computers, could lead to improved quality of care according to a majority of managers 0 20 40 60 80 100 and physicians (Figures 31 and 32). However, as emphasized by some respondents, introduction of computers could have the perverse effect of even increasing overall Poltava required reporting time in an environment where information technologies have not yet been integrated as part of an overall technology system (e.g., e-health), and in this context all facilities could lead to duplication of paper and electronic reporting. oblast hospitals raion/city hospitals polyclinics 0 20 40 60 80 100 Donetsk + Luhansk all facilities oblast hospitals raion/city hospitals polyclinics ambulatory/FOP 0 20 40 60 80 100 almost every day sometimes often never 90 Tracking Health Resources in Ukraine Human Resource Management 91 Figure 31. Would you be able to provide better treatment if someone Patient consultation time took on paperwork? On average, physicians report spending between 15 and 30 minutes per patient visit, with slightly longer consultations in hospitals and shorter ones in outpatient clinics oblast hospitals – Don+Luh (Figure 33). In hospitals, about 70 percent of physicians report currently being able to oblast hospital – Poltava devote sufficient consultation time per patient, while in outpatient clinics, about half view oblast hospitals – Lviv their available consultation time as insufficient. Physicians in polyclinics in particular primary level – Don+Luh view the 12 minutes guidelines per patient as insufficient to provide quality care. primary level – Poltava Thus, physicians often work overtime; at the same time, half of them report having too primary level - Lviv little time per patient, which affects health care service quality. polyclinics – Don+Luh polyclinics – Poltava Two main factors could be associated with inefficient use of physicians’ time in the polyclinics – Lviv Ukrainian context: raion/city hospital – Don+Luh i Responsibilities between different levels of health care are blurred and raion/city hospital – Poltava rarely known by patients. In that context, patients often prefer seeking raion/city/hospital – Lviv care directly to secondary level hospitals rather than through his/her fam- ily physician, both in an effort to save time and to potentially receive better 0 20 40 60 80 100 treatment. Physicians tend to accept this practice because admitting these bypassing patients provides them with extra [unofficial] earnings. yes ii The absence of an electronic identification system leads several physicians no to provide consultations and prescriptions for the same illnesses episodes. In addition, the absence of appointment time for patients generates long Figure 32. Would you be able to provide better treatment if you waiting hours for consultations. were provided a computer? oblast hospitals – Don+Luh oblast hospital – Poltava oblast hospitals – Lviv primary level – Don+Luh primary level – Poltava primary level - Lviv polyclinics – Don+Luh polyclinics – Poltava polyclinics – Lviv raion/city hospital – Don+Luh raion/city hospital – Poltava raion/city/hospital – Lviv 0 20 40 60 80 100 yes no 92 Tracking Health Resources in Ukraine Human Resource Management 93 Figure 33. Average consultation time per patient (in minutes), by Figure 34. Fair salary: What would be the decent salary for a per- facility types and oblasts (physicians’ responses) son in your position? (UAH per month). 160 100,000 140 80,000 120 60,000 100 40,000 80 20,000 60 0 40 -20,000 Poltava Poltava Poltava Poltava Poltava Luhansk Donetsk+ Luhansk Donetsk+ Luhansk Donetsk+ Donetsk+ Luhansk Lviv Donetsk+ Luhansk Lviv Lviv Lviv Lviv 20 0 Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk Lviv Poltava Donetsk+ Luhansk primary level polyclinics raion/city hospital oblast hospital all facilities primary Level polyclinics raion/city hospital oblast hospital all facilities Note: Two outliers (UAH 180,000 per month) were excluded. Lighter red bars present min and max, dark red bars present mean ±1 standard deviation.. Note: Physicians were asked to provide minimal and maximal times that they spend on examination of one patient. Furthermore, a question in the survey asked physicians about the potential effect Light blue bar present minimum and maximum of obtained responses, dark blue bar present means of obtained of a salary increase on their services. Almost half of the physicians in outpatient responses (i.e., lower boundary of rectangle is mean of minimum time per service, upper boundary of rectangle is mean of responses on maximal time with one patient). departments and clinics report that in the presence of an important salary increase, they would admit more patients (Figure 35). However, about 40 percent report currently using all their available time and that the increase would have no effect on productivity. These Among potential remedies are: the introduction of information technology (IT) into the answers do not differ significantly by oblasts. sector, with simultaneous training of physicians who do not have strong computer skills; strengthening of the primary care level; and referral of family physician/generalist a necessary condition for admission to a higher level facility. B. PHYSICIANS’ SALARIES AND COPING MECHANISMS Physicians were asked their view on a fair or decent salary for their position. Physicians, as expected, reported noncompetitive official salaries in the sector. Physician’s opinion on a fair salary ranged from UAH 4,500 (US$174) to UAH 180,000 (US$7,086) per month, with an average UAH 16,600 (US$654) per month. This is almost five times the average official salary for health care personnel. Wage aspirations of physicians working in primary-level facilities and polyclinics are somewhat lower than those in hospitals (Figure 34). 94 Tracking Health Resources in Ukraine Human Resource Management 95 Figure 35. If tomorrow your salary rises five times, would you Figure 36. Share of physicians who report having another job, by agree to serve twice as many patients? (physicians’ answers) facility type and oblast Donetsk+Luhansk Poltava total Poltava Lviv Lviv polyclinics primary care oblast-lvel Donetsk+Luhansk facilities Donetsk+Luhansk Poltava Lviv 0 20 40 60 80 100 Donetsk+Luhansk Poltava yes don’t know / no Lviv answer no Donetsk+Luhansk Poltava Lviv Perception of unfairness in compensation may induce physicians and other health Donetsk+Luhansk raion/city hospitals workers to adopt coping mechanisms to get what they think they deserve. Among Poltava the coping mechanisms identified in the literature (Akerlof and Yellen 1998; Dabalen Lviv and Wane 2008), are in particular moonlighting and informal charges, which are examined here. 0.0 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50 at another public institution C. MOONLIGHTING OR SECONDARY JOBS private clinic/private consultations It is quite common for health workers in Ukraine to have a secondary employment to at a non-medical institution supplement their low income at another medical (e.g., a private clinic) or nonmedical Most managers report using some form of control of presence of physicians at the institution. According to the survey, the highest rate of moonlighting is observed workplace. This could take the form of journals of presence or timesheets, but there are in Lviv, with almost 50 percent of physicians reporting working outside the facility, no standardized mechanisms in place across facilities and regions. Those who do not mainly in private clinics (Figure 36). Physicians in Poltava oblast report the lowest level have an opportunity to personally control presence (e.g., PHCs managers responsible for of moonlighting with about 28 percent admitting they have a secondary employment. several village ambulatories or FOPs) control presence by phone, and make weekly visits In Donetsk and Luhansk oblasts, the share of medical workers whose secondary to facilities. employment is found in another public health facility is relatively higher—probably because there are fewer opportunities in the private sector. Reported nonmedical work Late arrivals are reported to be relatively rare (ranging from 0 to 10 percent). Still, is mostly subsistence farming. much higher rates are reported in a certain number of facilities. For instance, in a rayon hospital in Lviv oblast, the facility manager reports late arrivals for about 50 percent of It should be noted that in Ukraine, it is not illegal for physicians working in public physicians, 10 percent of nurses, and about 30 percent of administrative staff. In another facilities to work in another job, as long as they work the required number of hours rayon hospital in Poltava oblast, these late arrivals are reported to affect 50 percent of at their public facility. Required number of hours are determined by physicians’ FTE physicians and 25 percent of other staff. numbers. Facility managers are aware that physicians have secondary employment. Despite being legal, moonlighting has potential effects on health workers absenteeism and productivity. While the survey did not collect information on absenteeism, it included questions on late arrivals at work, as well as presence of control mechanisms. 96 Tracking Health Resources in Ukraine Human Resource Management 97 Figure 37. Correlation between working hours per month at the main job (X axis) and supplementary job (Y axis), (physicians’ answers) A negative significant relationship is observed between the number of hours worked by the physician in the additional employment and hours worked at the main job Lviv 150 (Figure 37). The more an employee moonlights, the less hours are reported in his main employment. This negative significant correlation is observed in the three regions. hours outside month fitted values Charging patients for treatment and parallel financing of health care 100 Although public health care services are officially free in Ukraine, patients tend to incur costs when seeking care. This section looks at the reported prevalence of these informal charges in the perspective of the facility managers and physicians. It examines in particular the parallel financing structures developed as a response to low workers’ 50 wages and budget shortages. A parallel financing system has developed to compensate for low wages and gaps between facilities’ needs and public funding. Some part of the parallel financing 0 system is legal, such as official out-of-pocket payment from patients for some uncovered services (e.g., tests) and likarniana kasa (a quasi-insurance scheme). Another part is not 50 100 150 200 250 300 legitimate and is constituted of gifts, in cash and nature, from patients. These informal payments by patients are either channeled through a so-called “charitable funds” or paid Poltava 150 directly by patients to the health worker. Up to now, the magnitude and patterns of these informal payments have not been well documented, and mostly not accounted for. hours outside month fitted values Figure 38. Existence of out-of-pocket fees for some services at the 100 facility (percent of physicians who report existence of fees), by facility types and oblasts (physicians’ answers) polyclinics primary care Donetsk+Luhansk 50 Poltava Lviv Donetsk+Luhansk Poltava 0 Lviv 50 100 150 200 250 300 Donetsk+Luhansk raion/city hospitals Poltava Lviv Donetsk+Luhansk 100 Donetsk+Luhansk hospitals oblast Poltava hours outside month Lviv fitted values Donetsk+Luhansk 50 total Poltava Lviv 0 10 20 30 40 50 60 70 0 0 100 200 300 400 98 Tracking Health Resources in Ukraine Human Resource Management 99 With regard to official fees, the survey included questions for physicians about With regard to informal payments, physicians-managers were asked about the official out-of-pocket fees charged to patients for services provided at the facility existence of a “charitable fund” in which patients are required to contribute informal level. Figure 38 summarizes the prevalence of official fees reported by physicians by payments to receive services at the facility level. Figure 39 summarizes the answers. type of facilities and regions. Paid services are reported not to occur in PHC facilities Although a much lower share of hospitals offer paid services as compared to polyclinics, and rarely in oblast hospitals. However, in polyclinics, official fees for services are hospitals especially tend to have “charitable funds” collecting patients’ informal reported by one-third to two-thirds of respondents, as well as by 10 percent to 30 contributions for services. Physicians from Lviv, except those practicing at the oblast percent of respondents in rayon hospitals. hospital, are less likely to report existence of a charitable account at their facility than in the other sampled oblasts. The most common out-of-pocket fees for services reported at the facility level are for medical examinations (e.g., annual health check of employees), and laboratory According to physicians-managers, up to 50 percent of patients provide informal analysis (e.g., blood test, urine test). Furthermore, physicians report requesting additional payments through a contribution to the charitable fund at the facility level (Figure payments for patients arriving from other cities/oblasts. These fees are justified by 40). Physicians from Donetsk and Luhansk oblasts report lower prevalence of such the necessity to pay for communal services while this patient stays at a hospital (since contributions compared to the other oblasts. medical subvention is calculated based on the number of people in a given area, it does Figure 40. Share of patients contributing to the charitable fund not cover services for people from other areas, and the mechanism for mutual payments (physicians’ answers reporting existence of a charitable account at between oblasts and rayons is not flawless). This practice creates a potential additional their facility) barrier to health care access for internally displaced people from Eastern Ukraine. Official fee-for-service payments by patients are typically reportedly received as a polyclinics primary care Donetsk+Luhansk “charity” via a special account. Moreover, price lists for paid services are approved by Poltava local councils, and some hospitals even view these funds as that they belong to the local Lviv council. This situation only encourages informal payments from financially able visitors. Donetsk+Luhansk Figure 39. Existence of charitable fund at the facility Poltava (physicians’ answers) Lviv Donetsk+Luhansk raion/city hospitals Poltava polyclinics primary care Donetsk+Luhansk Lviv Poltava Lviv Donetsk+Luhansk hospitals oblast Poltava Donetsk+Luhansk Lviv Poltava all facilities Lviv Donetsk+Luhansk Poltava Donetsk+Luhansk raion/city hospitals Lviv Poltava Lviv 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Donetsk+Luhansk hospitals oblast Poltava almost all single cases Lviv › 50% don’t know Donetsk+Luhansk ‹ 50% total Poltava Lviv 0 10 20 30 40 50 60 70 80 90 100 100 Tracking Health Resources in Ukraine Human Resource Management 101 In addition to patient’s informal contribution to the facility‘s charitable fund, some Figure 42. Composition of revenues reported by some physicians-man- physicians admitted receiving informal payments directly from patients. Although agers in Donetsk and Luhansk oblasts there was no specific question in the survey on these direct informal payments by patients, according to physicians’ answers in semi-structured discussions, these informal PHC 5 payments equal or even exceed physicians’ official salary. PHC 4 PHC 3 Revenues accruing to the “charitable account” can represent from one-twentieth to as much as one-fifth of a facilities’ budget (Figure 41 and Figure 42). According to PHC 2 physicians surveyed, patient’s contributions per visit generally do not exceed UAH 300, hospital 12 with a minimum ranging from UAH 5–10 in Donetsk, Luhansk, and Poltava oblasts to hospital 11 about UAH 50 in Lviv oblast. hospital 10 (oblast) hospital 9 (oblast) Figure 41. Composition of revenues reported by some physicians- hospital 8 managers in Lviv and Poltava oblasts (here “other funds” imply hospital 7 charitable funds, likarniana kasa, and others) hospital 6 0 10 20 30 40 50 60 70 80 90 100 raion/city hospital 7 raion/city hospital 6 state funds fee-paid services PHC 1 charitable funds co-payments of patients raion/city hospital 5 oblast hospital 4 rent of premises local budget oblast hospital 3 The management and use of facilities “charitable accounts” and other self-generated raion/city hospital 4 funds remain unregulated, and it remains unclear how patients’ specific contributions raion/city hospital 3 are determined. According to the survey, physicians working at hospitals report that raion/city hospital 2 patients’ informal out-of-pocket payments to the charitable accounts do not depend raion/city hospital 1 on level or quality of services received, while on the contrary a majority of polyclinics’ oblast hospital 2 physicians believe that level of patient’s informal fees are function of service received. oblast hospital 1 Hence, in that sense, patients’ informal “charitable contributions” in polyclinics could be 0 10 20 30 40 50 60 70 80 90 100 viewed as a replacement of a service fee. Despite their importance, few of the revenues accruing to the facility “charitable state funds other funds fund” are formally accounted for at the facility level or reported in official treasury fee-paid services co-payments of patients accounts. Figures 39 and 40 show that facilities officially declare very small amounts of own earnings, with formal out-of-pocket payments (fee-for-services) and own revenues (including “charitable fund”), officially representing between 1 percent and 15 percent of total revenues among facility types. The level and usage of resources accruing to this parallel out-of-pocket fee system remain unclear. While the funds in the charitable account are reported to generally be used for the maintenance of equipment and infrastructure, the purchase of essential medication, or staff bonuses, given the absence of accountability and transparency in these additionally collected resources, including various informal direct payments, the potential misuse of these resources and rent captured by health personnel cannot be discounted. 102 Tracking Health Resources in Ukraine Human Resource Management 103 The non-transparent parallel out-of-pocket fee systems can have a negative impact Figure 43. Do you think patients are ready to pay for additional on patients’ access to care. Even when asked to pay for a service officially to the health services? (physicians-managers answers)2 facility cashier, patients might not be able to differentiate between what is legally required and what is technically optional (informal). Furthermore, while it is not known Donetsk+Luhansk hospitals oblast exactly how much additional funds patients are requested to contribute, and whether Poltava such informal contributions are compulsory to obtain access to health care services, Lviv the prevalence of a parallel financing system raises the question of equitable access to polyclinics primary care Donetsk+Luhansk health care and its quality. Poltava Furthermore, neither patients nor physicians think that it is immoral for physicians Lviv to receive payments directly from the patients. Most physicians do not think that they Donetsk+Luhansk should abstain from looking for other sources of revenues (both formal and informal). Poltava Another implication of this situation is that young graduates are usually reluctant to Lviv work at facilities in small towns or villages where it is harder to find a supplementary Donetsk+Luhansk raion/city hospitals source of income. Because of this, the medical specialty is the only one where so-called Poltava “distribution” —mandatory allocation to the first job after graduation—exsisted until the Lviv end of 2016. There is anecdotal evidence that young people leave their first jobs and move to larger cities as soon as they find a job there. If the situation does not change, the future 0 10 20 30 40 50 60 70 80 90 100 of the health care in small towns and rural areas seems quite dismal. yes Over 50 percent of physicians in Lviv and Poltava oblasts think that patients could no pay for additional services, such as extended diagnostics, improved conditions at a partyly (only 10-20% of patients) hospital, or physician home visits (Figure 43). Only about a quarter of physicians in Donetsk and Luhansk oblasts share this belief; they explain that patients at their regions are very poor. 104 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 105 7. FACILITIES’ COST Table 9. Distribution of staff positions in sampled facilities % SHARE OF AND PRODUCTIVITY TYPE OF DIVISION MANAGERS PHYSICIANS AND INTERNS NURSES TOTAL STAFF POSITIONS TOTAL STAFF IN SAMPLED FACILITIES This section presents an analysis of costs of services and productivity using facility-level Administrative 55 50 + 9 109 1,633 16% and auxiliary data from the same sample of facilities in Lviv and Poltava oblasts. It first examines types and volumes of services provided by sampled facilities. Second, it looks at productivity PHC 26 141 + 8 416 771 8% indicators across different types of facilities, and reviews variation in costs of services Diagnostics and 6 328 + 24 822 1,605 16% using step-down cost allocation. procedural To analyze productivity and costs across different types of facilities and medical Polyclinics 4 637 + 10 667 1,586 16% specialties, we focus on the analysis of selected indicators of productivity and cost. We Inpatient 16 847 + 27 2,003 4,514 45% also pay attention to the utilization levels to test the assumption that higher productivity Total 107 2003 + 77 4,017 10,108 100% will be observed in facilities that patients trust more. For the analysis of productivity, these indicators include: (i) health facility productivity (such as the number of patients More similarities can be seen in oblast-level general hospitals and polyclinics in terms of treated for various types of illnesses), and (ii) staff productivity (such as number of human resources engaged: almost equal numbers of physicians and nurses are working there, patients per employee or qualified employees, for various types of illnesses). For the if calculated per 1,000 population of each oblast. However, in Poltava, more staff per 1,000 analysis of costs, we compare the cost of a visit to outpatient facilities, cost of the are working in the oblast hospital if all staff positions are taken together (0.69 versus 0.59 diagnostics test, or cost of the case treated in an inpatient facility, as relevant. per 1,000). On the rayon level, there is a lot of similarity among both regions in terms of staff allocation for rayon polyclinics. In rayon and city hospitals more physicians and nurses are Key findings of this section include observations of high variability in utilization rates of observed working in Poltava oblast facilities (0.56 and 1.45 per 1,000 in rayons; 0.37 and 0.96 health care services across providers, and large variation in terms of staff productivity in cities) compared to Lviv oblast (0.31 and 1.07 per 1,000 in rayons; 0.21 and 0.62 in cities). An and costs of services across facility types (city, rayon, oblast levels) in two regions. interesting concentration of staff is seen in Lviv city polyclinics, probably at the expense of the PHC facilities. Considerably more staff engaged in Poltava oblast PHCs are observed compared Types of facilities and services with Lviv oblast. This can be explained by a separation of PHC institutions in Poltava oblast The sample of facilities was analyzed using available accounting data on expenditures from policlinics and hospitals, while in Lviv oblast this process is still ongoing. and the use of resources, performance data on the number of patients visits, diagnostics and clinical procedures, bed-days, and hospital cases treated at the level of departments Table 10. Allocation of personnel in facilities per 1,000 population or separate units of facilities. In total, data of 970 units in 17 health care providers PHYSICIANS PER TOTAL STAFF PER were analyzed, of which 490 units were in Poltava oblast and 480 units in Lviv oblast. TYPE OF FACILITY REGION NURSES PER 1,000 1,000 1,000 These units included 221 administrative and auxiliary divisions, 183 PHC divisions, 149 Lviv oblast 0.12 0.27 0.59 diagnostics departments, 262 polyclinics, and 148 hospital departments. oblast hospital Poltava oblast 0.15 0.30 0.69 Allocation of human resources across facilities and departments Lviv oblast 0.02 0.02 0.05 oblast polyclinics The team of researchers analyzed distribution of personnel in different types of divisions Poltava oblast 0.02 0.003 0.05 of our sample. Table 9 summarizes allocation of personnel by the type of staff positions Lviv oblast 0.31 1.07 2.43 rayon hospital and shows that most staff positions are engaged in the provision of inpatient care. Poltava oblast 0.56 1.45 3.12 Allocation of human resources across facilities of different types is not even (see Table Lviv oblast 0.21 0.62 1.45 city hospital 15). Overall, more people are employed in Poltava facilities of our sample compared to Poltava oblast 0.92 1.20 2.53 facilities in the Lviv oblast sample. In Lviv oblast’s sample of facilities, physicians are Lviv oblast 0.30 1.01 1.82 more concentrated in city facilities, but for nurses the tendency is reversed. In Poltava PHC Poltava oblast 0.84 2.01 3.88 oblast, in contrast, more physicians are working in rayon hospitals, and the same is observed for nurses. 106 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 107 Performance and productivity On average, we observe that people living in the catchment area of sampled PHC facilities were making about 7.4 visits to PHC per year, and PHC facilities were seeing on average The report compares productivity among facilities by examining performance 11.2 patients per working day. There was no significant difference between the numbers indicators at the level of departments in outpatient, inpatient, and diagnostics of visits to PHC ambulatories and feldsher posts (see Figure 44). We also found only divisions. The researchers rely on reported numbers of staff without a possibility weak correlation (r=0.32) between the frequency of visits per patient per year and load to confirm their accuracy. of patients per physician and nurse in PHC facilities. We note that there are slightly less visits per person in Lviv but given lower staff availability, the number of visits per staff is PHC higher (Figure 45). Productivity at the PHC facilities is measured by the number of patients’ visits received during the year together by both nurse and physician, to avoid mismatches in facilities Interestingly, the reported number of 7.4 visits to PHCs per person per year are rather where no physicians are working. We also look at the numbers of visits per year per high. The number of visits per patient per year in the United States was approximately person living in the catchment area, taking utilizations levels as a proxy for productivity 1.6 in 2013, in England the crude rate of 5.4 consultations at PHCs per person per year for PHC facilities. The comparison of utilization and productivity for PHC facilities gives a was reported in 2008. We assume that the count of visits might have included remote more accurate picture of whether higher productivity is determined by higher utilization consultations with patients or interactions for administrative purposes (e.g., to set up rates, since medical personnel working in PHC usually are the first point of care for appointment, extend prescriptions, etc.). In this case, the load of visits per physician and patients living in a specific area. nurse per day might be lower. Figure 44. Average utilization and workload at PHCs, by type Polyclinics (error bars for standard deviation) We analyze utilization and productivity of outpatient care overall in city and rayon facilities Figure 45. Average utilization and workload at PHCs, by oblast within both oblasts. Utilization of polyclinics services in Lviv oblast facilities is higher in (error bars for standard deviation) cities than in rayon facilities (5.9 visits per person per year in city facilities versus 2.9 visits in rayons). In Poltava oblast, polyclinics facilities utilization was similar for cities 14 14 and rayons, but productivity of physicians in terms of patients seen per working day is the highest in Poltava rayon polyclinics with 31.4 visits per physician daily (see Table 11). 12 12 Table 11. Comparison of utilization of care in polyclinics in cities 10 10 and rayons of Lviv and Poltava oblasts 8 8 OUTPATIENT CARE LVIV OBLAST POLTAVA OBLAST IN CITIES 6 6 Polyclinic visits 768,681 555,256 4 4 Visits per person per year in 5.9 4.1 polyclinics 2 2 Polyclinics visits per 12.4 11.9 10.6 23.8 20.0 7.8 9.4 7.1 6.8 7.9 0 0 physician per day ambulatories feldsher posts Average of visits Average of visits per person per per physician and Outpatient care in rayons year nurse per day Polyclinics 573,726 580,470 Average of visits per person per year Lviv Visits per person per Average of visits per physician 2.9 4.6 and nurse per day Poltava year in polyclinics Polyclinics visits per 19.9 31.4 physician per day 108 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 109 We also observe an We also observe an important variation in the utilization rates Figure 47. Number of patients seen by physician per day in differ- of outpatient polyclinics services across different service providers. In one city, ent policlinics facilities of the sample polyclinics of Lviv oblast and one rayon polyclinic in Poltava oblast, we observe 60 much higher utilization rates compared to other polyclinics facilities. Figure 46 60 55 shows variation in utilization as measured in terms of visits per person annually 53 to physicians, by type of facility, for three specialties: surgery, traumatology, and 50 48 46 otolaryngology (ear, nose, and throat [ENT] specialty). 42 42 39 40 40 Figure 46. Numbers of visits per person living in the catchment 33 32 32 area to polyclinics specialists per year, by facility type 30 1.0 20 10 0.8 0.66 0.64 0 0.6 city average city average rayon average rayon average 0.51 Lviv oblast Poltava oblast Lviv oblast Poltava oblast 0.40 0.4 0.36 0.37 0.29 ENT visits per physician per day 0.22 0.24 0.22 0.19 0.2 surgery visits per physician per day 0.12 trauma visits per physician per day 0 city average city average rayon average rayon average Lviv oblast Poltava oblast Lviv oblast Poltava oblast In oblast level polyclinics, we observe higher utilization in a Poltava oblast hospital compared to the similar hospital in Lviv oblast (0.9 versus 0.5 visits per person per ENT visits per person per year year). Figure 48 (right panel) shows that similar utilization rates are only typical to surgery visits per person per year ENT, ophthalmology specialties, endocrinology, and traumatology. The productivity of trauma visits per person per year outpatient divisions in oblast hospitals is similar for both oblast hospitals, with most visible difference observed in endocrinology consultations (39 visits per day in Lviv oblast polyclinics versus 16 visits in the Poltava oblast facility), and surgery (8 visits per day in The productivity of specialists in polyclinics as measured by number of patients seen Lviv oblast versus 21 visits in the Poltava oblast polyclinics). daily also presents significant variations. For comparability purposes, the same three specialties are examined as for utilization rates (Figure 47). The specialist working in one facility could see more than 1.5 times more patients a day on average compared to a peer in the other facility: for example, trauma visits in rayon facilities in Lviv and Poltava compared with city facilities (55 and 53 visits per day in rayons versus 33 and 32 visits per day in cities), and 60 visits per day to surgery specialists in Poltava rayon facilities versus 40 visits in Lviv rayons. It should be noted that some reported frequencies do not seem realistic. For instance, it is unlikely that a physician can see more than 50 patients per day, because this would mean that one consultation would last less than 8 minutes on average, provided that physician spends all working time on patients’ consultations. One of the possible explanations for high reported levels of visits is that a significant number of these visits is more a formality visit that does not imply medical examination or consultation, as for example, formal employee checkup rounds. For such rounds physicians reported spending 3–5 minutes per patient. 110 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 111 Figure 48. Comparison of visits per one person per year to outpa- Diagnostics and clinical procedures departments tient specialists in polyclinics and productivity of specialists in The variation in productivity for diagnostics and clinical procedure departments is terms of patients seen per day in Lviv and Poltava oblast hospitals significant in terms of numbers of diagnostics and laboratory examinations per medical personnel employed in these departments. We illustrate these variations with two 0.008 parameters: number of laboratory tests in clinical laboratories and number of x-ray 0.007 examinations in sampled facilities. Figure 49 presents the numbers of tests conducted per day per medical staff position in different facilities for these two types of diagnostics 0.006 procedures. Visits per person 0.005 Figure 49. Numbers of laboratory and x-ray examinations per year per medical personnel per day in different facilities 0.004 (error bars for standard deviation) Lviv oblast 0.003 Poltava oblast 193 250 0.002 169 212 189 0.001 200 170 0.000 120 ENT ophtalmology dermatology pulmonology and TB cardiology endocrinology neurology ob/gyn trauma urology 150 100 38 45 33 40 42 50 18 40 10 35 0 city average city average city average city average city average city average Lviv oblast Poltava oblast Lviv oblast Poltava oblast Lviv oblast Poltava oblast Visits per physican 30 per day 25 number of lab tests Lviv oblast 20 number of x-rays Poltava oblast 15 10 Hospitals 5 For the analysis of hospitals productivity, we first review average utilization rates and numbers of cases treated per physician annually in each facility. The average number 0 of cases treated per 1,000 population living in the catchment area varied a lot across ENT ophtalmology dermatology pulmonology and TB cardiology endocrinology neurology ob/gyn surgery trauma urology all types of facilities (see Table 12). The difference between the least and highest utilization rates in city and rayon hospitals was more than threefold. There was a slightly higher utilization of oblast hospital care in Poltava compared to Lviv oblast. In terms of productivity measured as an average number of inpatient care cases per physician annually, the highest productivity of 477 cases was observed in the smallest rayon in 112 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 113 Poltava oblast, and the lowest average productivity of 136 was present in the largest Table 13. Productivity of physicians working in inpatient city hospital of the same oblast sample, which also has the second highest utilization facilities, number of cases treated per physician per year of hospital care. REGION TYPE OF FACILITY NEUROLOGY OB/GYN SURGERY THERAPY Table 12. Utilization and productivity rates in hospital facilities of the sample Poltava oblast city 251 153 112 Poltava oblast city 473 619 CASES PER 1,000 CASES PER REGION TYPE OF FACILITY POPULATION PHYSICIAN Poltava oblast rayon 294 209 354 Lviv oblast city 123 267 Lviv oblast rayon 191 205 158 525 Poltava oblast city 141 136 Lviv oblast rayon 145 204 Poltava oblast city 49 367 Lviv oblast city 208 46 Lviv oblast rayon 98 334 Lviv oblast rayon 118 339 482 Lviv oblast rayon 132 326 Lviv oblast rayon 720 709 67 Lviv oblast rayon 163 308 Poltava oblast rayon 190 614 Poltava oblast rayon 108 167 average 173 180 146 157 Poltava oblasst rayon 123 217 Poltava oblast rayon 113 477 Service costs Lviv oblast oblast general 15 119 We analyze cost structure and unit costs in sampled facilities using the step-down cost allocation principle. In this regard, we reviewed costs at the level of departments in Poltava oblast oblast general 19 108 outpatient, inpatient, and diagnostic divisions. Costs are based on formal expenditures oblast specialized Lviv oblast 8 198 reported by health care facilities, without accounting for informal patient contributions (oncology) paid at the point of care or to “charitable” accounts associated with providers. Another oblast specialized limitation is that the cost accounting only captured recurrent costs; depreciation of Poltava oblast 3 383 (cardiology) assets is not included in our calculation, which might have significantly reduced our cost estimates. Additional attention was paid to the analysis of the productivity within selected We observe in the costs structure presented in Table 14 that wages represent the largest specialized departments of hospitals in cities and rayons within the sample. Four share in clinical divisions’ direct expenditures. Wage expenditures share is lower in main inpatient departments were selected: neurology, ob/gyn, therapy, and surgery. We oblast level facilities, mainly because of the higher share of medications and supplies in observed variation in productivity across facilities, but also across specialties within these facilities. A relatively small share of direct expenditure goes to utilities (3 percent facilities (see Table 13). In particular, we observed that in one rayon facility in Lviv oblast for polyclinics, 4 percent for hospitals, and 9 percent for PHCs on average). The share of one nuerologist on average has treated 720 cases per year, or 4 times the average load additional indirect expenditures (including costs of administrative units; internal services for such a specialist; the surgery specialist in the same facility treated 709 cases per year such as laundry, food, etc.; and costs of diagnostics and procedures department) varied compared to the average of 146 cases. In one Poltava city facility 473 cases were treated significantly across facilities, with most additional expenditures observed in polyclinics. by ob/gyn specialists on average while in all other facilities the average was two to three This can be explained by high indirect expenditures on diagnostics and procedural times lower. services allocated to specialized inpatient and polyclinics departments. 114 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 115 Table 14. Budget structure of the clinical divisions of Figure 50. Cost of visit to PHCs in two oblasts the sampled facilities Cost of a visit in ambulatories Cost of a visit in feldsher posts % SALARIES % MEDICATIONS % UTILITIES % ADDITIONAL BUDGET 250 250 OBLAST LOCATION TYPE BUDGET IN BUDGET IN INDIRECT IN DIRECT DIRECT COSTS DIRECT COST ALLOCATION COSTS 200 200 Lviv city hospitals 79% 2% 2% 33% 150 150 rayon hospitals 86% 7% 9% 35% oblast hospitals 55% 27% 3% 31% 100 100 Poltava city hospitals 61% 21% 5% 41% 50 50 rayon hospitals 85% 11% 14% 39% oblast hospitals 32% 60% 2% 21% 0 0 Lviv oblast Poltava oblast Lviv oblast Poltava oblast Average hospitals 50% 38% 4% 29% Lviv city polyclinics 78% 14% 1% 40% rayon polyclinics 83% 2% 4% 38% Feldsher posts’ costs by visits vary significantly with facilities in Lviv, presenting on oblast polyclinics 48% 36% 4% 30% average lower costs than those in Poltava (25 UAH and 41 UAH, respectively) (see Figure 50). Feldsher’s costs per visit vary from 12 UAH to 57 UAH per visit (or sixfold). The Poltava city polyclinics 76% 4% 2% 51% relation between the productivity of patients seen per medical staff per day and cost of rayon polyclinics 79% 9% 7% 41% the visit in feldsher posts is less strong: the correlation coefficient is –0.36. oblast polyclinics 76% 5% 3% 58% Interestingly, the costs of a visit to either ambulatory or feldsher posts was on average Average polyclinics 73% 12% 3% 43% relatively the same among Poltava PHC facilities, whereas there are significant variations Lviv city PHCs 83% 10% 1% 28% across PHC among Lviv facilities. This implies that PHC service costs are relatively the rayon PHCs 87% 2% 7% 15% same in ambulatories and FOPs in Poltava, while the cost of the feldsher post’s visit is almost twice lower compared to ambulatory visits in Lviv. Poltava rayon PHCs 75% 4% 13% 10% Average PHCs 82% 3% 9% 15% Polyclinics The analysis of costs in polyclinics focuses on cost of a visit to a specialist. Despite high We further analyze costs of specific services in various sampled facility types. variation across facilities, we observe relatively similar average costs for a polyclinic visit in Lviv and Poltava (42.6 UAH and 42.8 UAH respectively) (Figure 51). A greater difference PHC is observed in the cost of the visit to oblast facilities (100 UAH) when compared to city and rayon level polyclinics (47 and 40 UAH respectively). At the PHC level, we analyze separately cost of visits to feldsher points and PHC ambulatories in both oblasts (Figure 50). There were several outliers. Polyclinics departments with very low costs per visit (below 20 UAH) are all located in Poltava. The productivity and number of visits per physician per We observe that the average cost of ambulatory visits is significantly higher in Lviv day in these departments varies from 63 to 78, which is very high. The small cost of a visit ambulatories compared to Poltava facilities (59 UAH and 46 UAH per visit, respectively). could be due to error or overreporting of visits. The outliers on the higher end were all The variation in costs is high (24 UAH in Lviv oblast, 27 UAH in Poltava oblast). We observe related to a lower productivity in terms of patients seen per day. The correlation between a correlation of –0.48 between the number of patients seen per day by medical staff the productivity of polyclinics departments and the cost of a consultation was –0.45. in ambulatories and visit cost, which supports the assumption that more productive ambulatories are also more efficient. 116 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 117 Figure 51. Average cost of the patients’ visit in polyclinics in two Figure 52. Average costs of a visit to ENT, surgery, oblasts and by type of facility and trauma departments of polyclinics 600.00 450.00 119 120 400.00 107 101 500.00 100 94 350.00 90 81 400.00 300.00 80 250.00 60 300.00 200.00 39 40 40 34 33 32 30 31 30 25 28 29 200.00 150.00 25 20 100.00 100.00 50.00 0 city average city average rayon average rayon average oblast average oblast average 0.00 0.00 Lviv oblast Poltava oblast Lviv oblast Poltava oblast Lviv oblast Poltava oblast Lviv Poltava city rayon oblast ENT As in the productivity section above, we analyze costs in three specialized polyclinics surgery departments: ENT, surgery, and trauma. The variation of costs within three specialties trauma between city, rayon, and oblast levels is presented in Figure 52. We observe that the distribution of the costs across facilities mostly followed the same pattern as the distribution of means overall: slightly higher costs in city facilities compared to rayon Diagnostics and procedures departments facilities, and averages on the oblast level close to the average of all visits in the polyclinics (i.e., 100 UAH). Comparison between regions shows that at the level of city Regarding the costs of the diagnostic procedures, the average cost for a laboratory test and rayon facilities, costs are slightly lower in Lviv; however, at the oblast level the was on average 2.7 UAH for the whole sample, with relatively little variation across trend is the opposite, i.e., in Lviv oblast polyclinics the cost of a visit to specialists are facilities (see Figure 53, left side). Two exceptions are observed. On average, laboratory higher than in Poltava oblast, with the exception for visits to trauma specialists. costs in Poltava oblast city facilities are lower, although there was a lot of variation across facilities, and the average cost in the Poltava oblast hospital was the highest, even when compared to the similar facility in Lviv oblast. The average cost of the x-ray examination was 60.3 UAH for the whole sample, based on the formal recurrent expenditures of x-ray departments (see Figure 53, right side). The variation of the average costs was significant (standard deviation of 40 UAH, min 26.7 UAH, max 162.3 UAH). 118 Tracking Health Resources in Ukraine Facilities’ Costs and Productivity 119 Figure 53. Average costs of diagnostic procedures in the median is 350 UAH. The most expensive hospital stay was in the cardio department sampled facilities (645 UAH), neonatal department (1,339 UAH), hematology (3,260 UAH), and hemodialysis 6 departments (from 350 UAH and 626 UAH to 2,280 UAH) of the oblast general hospitals. Figure 54. Average cost of a bed-day in sampled 5 inpatient departments 4 2.8 3,500 3.6 2.4 2.0 3 2.4 2.7 3,000 2 2,500 1 2,000 0 1,500 city average city average rayon average rayon average oblast average oblast average Lviv oblast Poltava oblast Lviv oblast Poltava oblast Lviv oblast Poltava oblast 1,000 Cost of a lab test 500 36.9 100 0.00 93.7 rayon city oblast specialized oblast general 68.2 80 33.3 The unitary cost of treatment in hospital departments is directly related with the 60 average length of stay (ALOS) in these departments (correlation coefficient of 0.6). 39.6 The average mean ALOS for our sampled hospitals was 13 days (median 10.3 days). 40 27.9 By type of facility, it varies from 10.7 days in rayon hospitals, 10.6 in city hospitals, and 14.8 in oblast hospitals. 20 In rayon hospitals, the unitary cost of treatment is 2,256 UAH (2,471 UAH in city 0 hospitals). The unitary cost in specialized oblast facilities is 4,286 UAH compared to city average city average rayon average rayon average oblast average oblast average 8,125 UAH in general oblast hospitals, with some extreme values influencing the mean Lviv oblast Poltava oblast Lviv oblast Poltava oblast Lviv oblast Poltava oblast (median 3,147 UAH). Cost of an x-ray test With regard to costs of a case in different departments, Table 15 presents average cost for the main departments within sampled facilities. We observe that the treatment of a case in oblast level hospitals is often more than two times more expensive than in rayon and Hospitals city hospitals, which can be explained by a higher complexity of cases treated at oblast In the analysis of hospital costs, we examine the cost of a bed-day and a cost of level facilities. However, the costs are not very much different for the treatment of cases a case treatment. in ob/gyn departments with most expensive cost of a treatment in city facilities. Also, cost of treatment of cases in surgery and urology departments of city facilities (3,973 and We observe in Figure 54 that the average cost of a bed day is lowest for rayon facilities 2,854 UAH) are close to those of oblast facilities (4,221 and 3,353 UAH respectively). at 208 UAH, with little variability. The average cost of a bed day in city facilities is 282 UAH, which could be explained by a more variety of specializations in city hospitals compared to rayon ones. The cost of a one-day stay in oblast specialized hospitals is on average 349 UAH compared to 509 UAH in oblast general hospitals on average, although 120 Tracking Health Resources in Ukraine Readiness to Reform and Impacts of Conflict 121 Figure 55. Average cost of case treatment in sampled inpatient departments 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0.00 rayon city oblast specialized oblast general Table 15. Average cost of case treatment in sampled inpatient departments TYPES OF HOSPITAL AVERAGE FOR STD DEV FACILITY / DEPART- CITY RAYON OBLAST GENERAL ALL TYPES FOR AVERAGE MENT Cardio 1,686 1,992 4,608 3,468 2,108 ENT 1,475 3,677 2,943 1,287 Neurology 1,887 1,570 4,390 2,267 1,646 Obstetrics / gynecology 3,462 3,356 3,129 3,303 883 Ophthalmology 1,532 2,167 2,009 340 Surgery 3,973 2,732 4,221 3,704 1,229 Therapy 1,630 1,562 3,803 1,806 849 Trauma 2,687 4,871 3,415 1,467 Urology 2,854 1,370 3,353 2,733 1,032 122 Tracking Health Resources in Ukraine Readiness to Reform and Impacts of Conflict 123 8. READINESS TO REFORM Figure 56. Optimal distribution of facilities’ revenue sources (physicians-managers perspective) AND IMPACTS OF CONFLICT Lviv and Poltava oblasts Preferred compsition of revenues, % The survey included semi-structured question addressed to physicians and managers PHC average about their perspective on the current health care reform process in the country as well city average as identification of some impact of the armed conflict in Eastern Ukraine. This section first presents awareness of managers and physicians on the main reform agenda and then rayon average discusses implications of the armed conflict on facilities in Donetsk and Luhansk oblasts. oblast average A. READINESS TO REFORM 0 20 40 60 80 100 Generally, physicians agree that the health care system in Ukraine should be state budget paid services (o cial) charitable funds or other co-payments of patients reformed. Most often, they mention health insurance or some other form of cofinancing of revenues medical services by patients and the need to abandon Article 49 of the Constitution, which states that health care in Ukraine should be free. Only a few physicians from emergency Donetsk + Luhansk oblasts care departments think that their services should be fully financed by the state. Preferred compsition of revenues, % Physicians were asked to identify the optimal cost sharing arrangements among the oblast hospital various revenues sources. Figure 56 presents the “ideal” (or desired) distribution of revenues across facility types for Lviv and Poltava, as well as for Donetsk and Luhansk rayon/city hostpial oblasts. This figure shows that facility managers have quite different perceptions on how PHCs facilities should be financed. They agree that the share of state-provided funds should be substantial—from 50 percent to 100 percent. However, various cost sharing arrangements 0 20 40 60 80 100 are favored by a portion of managers, especially in hospitals. state budget charitable contributions paid services rent of premises co-payments of local budget patients other Note: “Other funds” refer to charitable funds, likarniana kasa, etc. Local health official and physician-managers were also asked what administrative level in the health system is in their perspective currently the least efficient. A majority believe that greater inefficiencies lie at the central MOH level (Figure 57). 124 Tracking Health Resources in Ukraine Readiness to Reform and Impacts of Conflict 125 Figure 57. At which level is the health care system the least “There should be so-called pooling, i.e. all financing of in-patient efficient? Shares of answers of officials and physicians-managers secondary and tertiary health care should be pooled. This would allow (this question was asked only in Donetsk and Luhansk oblasts) optimizing the network because some health care facilities are used with low intensity, especially during weekends” the entire system is ine cient – Oblast health care department representative the system Oblast and rayon/city officials also believe that payment for service provided is a good is e cient idea (physicians at oblast-level hospitals mention diagnosis-related groups (DRGs) in this respect). They agree that the salaries of physicians should be differentiated according to hromada the volume of services that they provide. Right now no surveyed facility has introduced DRGs, but over 50 percent of health care officials say they had some experience or have raion heard of DRGs (Figure 59). oblast “…Introduction of a legal notion of “medical service” would pull out of shadow huge resources. Some time ago we took the number of patients in our oblast, the data on protocols and the cost of treatment and MoH received very rough estimates that the shadow turnover in the health care in the oblast is … twice higher than the official health care budget…” – Oblast health care department representative 0 20 40 60 80 100 With regard to equity and accessibility considerations, informal payments for services physicians-managers should be discouraged and properly monitored. Still, as a way to attract more private raion/city o cials funding for hospital development, including from insurance companies, regulated oblast o cials cofinancing systems could be considered. This may also improve the overall quality of services. Although not asked about this directly, almost every respondent mentions health Officials from oblast (4 respondents) and rayon/city (21 respondents) health care insurance as a way to improve health care financing. departments were asked a few questions on the setup of the health care system. Their Figure 59 also suggests that the main components and concepts of new health care answers are presented in Figure 56. Both rayon/city and oblast officials see potential for reform program have not been well disseminated among health officials and that further efficiency increase at higher levels of the system—MoH and oblast. information in that regard would be beneficial. Oblast officials think that the lowest level of the health care budget should be the MoH, oblast, or rayon/city levels, while rayon/city-level officials are more supportive Overall, decentralization reform is perceived as beneficial for better endowed of transferring budgets to lower levels. The most common answer to this question is constituencies (i.e., areas benefiting from higher tax revenues from profitable economic “hromada” (Figure 58). Probably since hromadas are very recent, the officials are cautious activities on their territory) and detrimental to poorer ones. For example, urban health with their expectations. One person explains that there are both positive and negative facilities report that local budgets cover practically all their needs in drugs, while rural sides to transferring health care responsibilities and budgets to hromadas. On the one facilities report very little funding from local budgets. hand, hromada knows better which services and which specialists its people need, on With regard to hromadas’ budgets, when amalgamated the medical subvention the other hand, hromada may not have sufficient revenues to finance these services, and is based on their population while the level of rayon hospital funding is reduced hromada management may not be qualified enough to define the needs and efficiently (see example presented in Figure 60). Because hromadas are not straightforward provide the services. at funding rayon hospitals, clearer transfer formulas would be required, as well as between oblasts and rayons. Under a cofinancing or “pay for services” system, these issues would be less salient. 126 Tracking Health Resources in Ukraine Readiness to Reform and Impacts of Conflict 127 Figure 58. Opinions of oblast and rayon/city officials on health Figure 59. Do you have experience with . . . care system design Do you have experience with... At what level is there the highest potential for health care e ciency increase? ...framework agreements? all levels Raion/city o cials facilities oblast o cials Raion/city 0 10 20 30 40 50 60 70 80 90 100 oblast yes no don’t know MoH ...global budgets? 0 10 20 30 40 50 Raion/city o cials At what lowest level should health care budget be? oblast o cials hromada 0 10 20 30 40 50 60 70 80 90 100 Raion/city yes no don’t know oblast MoH ...DRGs or payment per treated case? 0 10 20 30 40 50 Raion/city o cials Which level of subordinance of facilities is the most e cient? oblast o cials hromada 0 10 20 30 40 50 60 70 80 90 100 Raion/city yes no don’t know oblast 0 10 20 30 40 50 Answers of raion/city o cials Answers of oblast o cials Your opinion on transferring of responsibilities and budgets to provide health care services to hromadas* answers of raion/city o cials answers of oblast o clas 0 20 40 60 80 100 positive negative no defined opinion Note: *this question applies only to officials in Donetsk and Luhansk oblasts (2 oblast and 11 rayon/city officials) 128 Tracking Health Resources in Ukraine Readiness to Reform and Impacts of Conflict 129 believe that separation of primary and secondary levels has worsened the situation. Figure 60. Shift in cash flow pattern when an amalgamated hromada In that regard, some physicians report that family physicians prefer to send patients is formed (a hypothetical example) to secondary level facilities (even patients who do not need inpatient treatment), while others complain that family physicians treat patients themselves. Since family Before After physicians cannot be “specialists in everything,” their treatment is inadequate and may worsen a patient’s condition. A physician from one rayon hospital said that in their rayon, Central budget Central budget separation of primary and secondary levels was a mistake—since their rayon (and hospital) is very small, all the physicians remained at the secondary level facility, while no physicians—only nurses and feldshers—were found at the primary level. All patients are hence treated at the hospital given the absence of physicians to make home visits. 100 33 While this situation could exist in other small rayons, the creation of a district hospital Rayon administration Rayon administration should partly solve this problem. Almost 90 percent of physicians-managers believe that the health care system is currently financed at less than half of its needs, and 40 percent believe that it receives 70 30 23 10 less than a quarter of its required financing (Figure 61). We observe in particular that Rayon hospital Rayon PHCC Rayon hospital Rayon PHCC physicians-managers are more positive in their evaluation of health care financing in the Poltava oblast, while rayon/city level facilities report the lowest financing relative to their needs. 67 10 10 10 10 Figure 61. The believed level of the health care financing system Amalgamated hromada FOP1 FOP2 FOP3 FOP3 in Ukraine (physicians-managers’ answers) (FOP1 + FOP2) Donetsk+Luhansk total Note: 100 is the amount of medical subvention based on rayon population, and there are three villages of equal size Poltava in a rayon, two of which form an hromada Lviv Physicians-managers mostly agree that “payment per treated case” should be introduced, Donetsk+Luhansk hospitals oblast with also a majority of physicians supporting this view, with some reservations. Some Poltava mention that service quality should be taken into account. In the case of chronic illnesses, Lviv how would such a “treated case” be measured? A few physicians believe that with such a polyclinics primary care Donetsk+Luhansk system, primary level physicians would not tend to refer patients to higher levels in order Poltava not to share patients’ fees, which could affect patient care. For one physician, primary- Lviv level financing should be based not on treated cases, but on the number of cases that Donetsk+Luhansk were treated at an early stage or prevented. Poltava The likarniana kasa system in place in the Poltava oblast is well regarded by Lviv physicians in the oblast. Likarniana kasa, which is a type of voluntary local small Donetsk+Luhansk raion/city hospitals insurance fund based on regular contribution by members, currently encompasses Poltava about 10 percent of the oblast population. The fund covers drug costs prescribed to its Lviv members. In that context, physicians could prescribe the most efficient drugs instead of 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% simply the cheapest or those available at the facility. When answering the questions on health care efficiency and financing, physicians often by ‹ 25% of the need by 50%-75% of the need express opinions on health care reform in general. For instance, some physicians hold by 25%-50% of the need by ›90% of the need the view that the introduction of family physicians has been positive overall, while others 130 Tracking Health Resources in Ukraine Readiness to Reform and Impacts of Conflict 131 B. IMPACTS OF THE CONFLICT With regard to medication availability, provision is reported to have improved in all facility types, except for oblast hospitals, which report worsening in the centralized The survey included some questions on the impact of the conflict on facilities’ activities in provision of drugs. On the contrary in other facility types, improved centralized deliveries Donetsk and Luhansk oblasts. are reported as well as an increased stream of humanitarian aid—both from volunteers and international organizations. Physicians-managers and physicians in the two oblasts were asked in particular about perceived changes at their institutions since the beginning of the conflict. Figure 62 As for staffing, most facilities report decreased availability in 2015. In about one-half summarizes answers with regard to (a) financing of facilities, (b) medication availability, of cases, this happened because physicians left the region. Some respondents also blame (c) staffing, and (d) demand for services. reorganization (either reduction of the number of beds or separation of primary levels) as a reason for staff decrease. A few physicians complained that because of low salaries, it Figure 62. Changes in parameters compared to the beginning of 2014, is hard to attract young personnel. The only exception where staff has not systematically at your facility decreased is reported in polyclinics where, in a few cases, physicians arrived from Financing Drugs Provision occupied territories or volunteers supported the hospital. With regard to patients’ demand for services, about half of physicians report that the PHCs (8) number of patients increased by less than a quarter, 36 percent—that it increased polyclinics (12) by 25–50 percent. Some physicians (11 percent) say that their facilities see the 50–100 percent increase in the number of patients; all these institutions are located in a large city oblast hospitals (2) which hosts a relocated hospital and a significant number of internally displaced persons raion/city hospitals (11) (IDPs). Only 16 physicians from three city hospitals report a decrease in the number of patients (by no more than 50 percent). 0 20 40 60 80 100 0 20 40 60 80 100 The reasons for increases in the number of patients are (1) people arriving from the occupied territories and (2) IDPs. Very few facilities now serve soldiers, although they Number of Sta Number of patients used to do this in 2014–2015. Now soldiers are served in specialized military hospitals. PHCs (8) The reasons for lower number of patients is outflow of people from the territory as well as poverty—physicians say that people do not go to hospitals since they cannot pay for polyclinics (12) treatment anyway. oblast hospitals (2) raion/city hospitals (11) 0 20 40 60 80 100 0 20 40 60 80 100 increased decreased unchanged As reported by facility managers and physicians, the conflict has impacted oblast hospitals and other types of facilities differently. While oblast hospitals have seen a decrease in financing, medication provision, staffing, and demand for services, lower level facilities, on the contrary, have seen during the same period an increase in financing, medication, and demand for services. More specifically, with regard to financing, PHCs, policlinics and rayon hospitals have seen, in the perspective of physicians, a financing increase in 2015 compared to 2014, while financing for oblast hospitals has decreased. 132 Tracking Health Resources in Ukraine Conclusions and Recommendations 133 9. CONCLUSIONS AND or maintenance costs for medical equipment. Administrative units (municipalities and rayons) with larger revenues (i.e., those which have profitable enterprises in their RECOMMENDATIONS territory) are able to provide more money for health care, while the poorer ones can provide practically nothing. The existing system of planning health care budgets does not provide local authorities As this report shows, the Ukrainian health system faces several inefficiency problems and hospitals with enough financial management power. Although the ultimate decision- and would benefit from various reforms. The following conclusions could be drawn making power on allocation of the medical subvention toward health providers rests from the study. within each local authority, little management discretion could be exercised given the extensive set of rules and norms in practice. For instance, state-level policy dictates the With the information available, no direct leakage of public resources has been maximum number of hospital beds, defines planning of staff by organizing staffing norms, observed. Given that all official resources are managed through the treasury accounts and specifies salary scales, etc. Although some of the norms are currently removed, past system, the disbursement and spending of public resources tends to be accurately dependency and inertia in the financing system remain. accounted for. However, access to expenditures data is not open, and much more extensive information would be necessary to draw a proper picture of expenditures in the Despite the government’s clearly stated responsibility to finance health care for health system. citizens, a lot of uncertainties exist regarding funding level and stability. Health sector expenditures are defined on an annual basis in the state budget, and they are not fixed as Most resources allocated as part of the medical subvention mechanism are spent a proportion of the total government spending. The recent economic crisis and conflict in for service delivery. According to the State Consolidated Budget, 85 percent of public East Ukraine affected budget allocation, decreasing spending on health to 8–9 percent of funding in the health sector was spent for various levels of care in 2015. The share of the total government expenditures in 2016 from 12 percent in 2013. Other uncertainties primary care expenditures is about 15 percent, while general and specialized hospitals relate to the following factors: (i) final decision on the volume of medical subvention is expenditures account for about 64 percent. communicated to oblasts, rayons, and cities in January–February of the actual year, after Health care providers’ budgets are mostly spent on covering wage and utility bills. the state budget is adopted, which usually requires adjusting previous budgeting plans; Surveyed facilities complained about insufficient funding, explaining that medical (ii) facilities cannot properly plan centralized deliveries of medical products because they subvention is mainly used to cover low staff salaries and utilities, leaving little to nothing never know the expected delivery date of such supplies; and (iii) quite often provided for drugs. This small drug budget is mainly used by providers to keep stock of lifesaving funds are not enough to cover all of the facilities’ needs, so salaries and utilities are first and anesthesia drugs, while patients are required to pay for the other required drugs covered, followed by other priority needs. for their treatment. Equipment is mostly supplied on an ad hoc basis. When something Facilities cannot fully formalize their nonpublic revenues because they are limited by is really broken, facility managers and regional authorities try to find some funds in the bureaucracy and complex regulations. Facilities have little power deciding the types of budget to replace it or fund raise among local businesses or charitable organizations. activities for which they can charge patients. The list of such activities is very limited and Inputs-based planning based on historical trends allows no room for effective decision typically includes medical examinations, abortions, and dental services. There is no clarity making on resource management. The backwards-looking budget planning process on paid services and co-payment mechanisms. Furthermore, there is no incentive for concentrates on planning inputs, often defined by norms. The need at the facility level to facilities to account for additional nonpublic revenues. obtain budget approval from local authorities on any reallocation between budget lines Most importantly, there is a parallel financing system that has developed in response does not provide sufficient room for reconsideration of public resource use. to rigid health spending norms, to fill the gap between public funding and needs. Medical subvention is usually supplemented by funding from local budgets. However, One part of this parallel system is not legal, including informal patients’ out-of-pocket these decentralized allocations are dependent on local political will and vary largely from payments, while another part is somewhat legitimate. Being largely limited in the ability to one location to another. Local authorities are not officially mandated to co-finance health charge fees legally (some physicians even place blame on the constitutional right to free care, and their decisions to allocate additional medical subvention resources to health health care), facilities and physicians chose to evolve in a somewhat grey zone—in which care are context specific. Usually, additional allocations from local budgets are used for payments are made to a facility charitable account—or alternatively a black zone—where capital investments, such as procurement of equipment and reconstruction of facilities, payments are made directly to physicians. The more legitimate scheme relies on different mechanisms such as the likarniana kasa, and legitimate charity donations. The share of shadow revenues can be significant in size. So far, its magnitude, patterns, and trends are not well documented. According to the survey, half of physician-managers and 41 percent 134 Tracking Health Resources in Ukraine Conclusions and Recommendations 135 of physicians report that there is a charitable account at their facility, and that up to 50 The analysis of personnel productivity and service utilization showed a lot of percent of patients are contributing to that account. These charitable contributions may variation. Large variance is observed in terms of utilization rates of outpatient services constitute between 10–30 percent of facilities’ overall revenues. in the context of the high level of outpatient services utilization. PHC services in particular present a rather high utilization rate of 7.4 visits per capita per year, similar As revenues and expenditures of the charitable funds are not accounted for in the to PHC ambulatories and feldsher posts in both oblasts. PHC physician and nurses were state treasury, there is little information on volume and use of these additional funds. each treating on average 11–12 patients per working day. The utilization of polyclinics There is also no common approach in establishing contributions to these funds; therefore, outpatient care was highest in cities of Lviv oblast with 5.9 visits per capita per year, it is questionable whether contributions by patients are indeed voluntary. The size of the almost twice that of rayon polyclinics. The visits to polyclinic facilities in Poltava oblast expected contribution varies by facilities. Based on survey’s responses, this “charitable” range between 4.1 and 4.6. visits per capita. contribution is often related to the services provided to a patient in polyclinics, while in hospitals it is more often a flat fee. Some facilities make additional earnings by leasing Service accessibility between cities and rayons tend to differ. In particular, the premises or participating in drug tests. This shadow financing system allows publicly utilization rate of laboratory tests and x-ray diagnostics is higher in cities. Also, the owned and financed facilities to be used for fund generation and non-transparently use average number of cases treated per 1,000 population living in the catchment area varies funds collected from citizens, who de jure should receive health care for free. significantly across facility types. The difference between the least and highest utilization rates in city and rayon hospitals was more than threefold. Introduction of IT solutions into the health care system could potentially greatly reduce inefficiencies along several lines. Currently, all recording and reporting systems Unit costs at facility and department levels show important variations mainly are semi-digital, still relying heavily on paper documents. Also, there is no publically attributed to services provided. Although much of the unit cost is explained by the wage available data on health facilities’ spending and outputs, although they are publicly component, the share of additional indirect expenditures (including costs of administrative owned. Any request for data has to go through different managers’ authorizations, since units, internal services such as laundry, food, etc., and costs of the diagnostics and usually there is no easy electronic tracking of resources and expenditures. In particular, procedures department) varied significantly among facilities. At the PHC level, costs per providers cannot properly keep account of the costs and performance of their different visit can vary sixfold, especially at lowest level facilities (e.g., feldsher points); on average subdivisions. Therefore, greater reliance on electronic data exchange within facilities and the cost of a visit to an ambulatory or feldsher post are similar. The unit cost of a visit across administrative levels could facilitate more efficient management of resources. to a policlinic at the rayon/municipality level is relatively similar across specialties and regions, with an outpatient consultation at an oblast level facility being almost 2.5 times Remuneration schemes for physicians tend to discourage high-quality work, stimulate higher than that at secondary level facilities. At hospitals, the cost of a treated case was partial skill waste, and promote informal payments. Facilities are limited in their ability largely dependent on the level of facility (secondary or tertiary) and ALOS. to provide bonuses for personnel (i.e., local councils have to approve relevant changes in the budget), hence, salary is not related to performance. Furthermore, physician A lack of understanding of proposed health financing reforms is observed among salaries are very low—a third lower than in the industrial sector—leading physicians health personnel. While many interviewed physicians are supportive of health financing to search for additional earnings through working overtime, accepting more than a reform, their knowledge of the actual reform contents is often limited. For instance, they full-time position, working at other institutions, or accepting informal payments. About often report that the main goal of the reform is to attract additional funding. Physicians half of physicians report being overloaded and that they would not be able to treat more believe that as a result of the reform patients will cofinance some services or that some patients even with a large salary increase. In that context, facilities would benefit from insurance schemes will be introduced. being granted more autonomy and being allowed to reallocate their budgets in order to pay personnel bonuses. The allocation of human resources across regions and facility levels is uneven. A concentration of health personnel is observed in hospitals. In Lviv oblast for instance, more physicians per capita are working in city facilities compared to rayon facilities, although in Poltava the distribution of physicians is more equal. On the contrary, allocation of nurses per capita is higher in rayon facilities. 136 Tracking Health Resources in Ukraine Conclusions and Recommendations 137 SUGGESTIONS AND Implementing the e-Health system can also improve accountability in outputs and link costs to provided services. Currently, there is no electronic data exchange, thus RECOMMENDATIONS information flow is often slow and non-transparent. IT solutions (such as electronic patient cards and electronic appointments, etc.) may be used as effective tools to reduce inefficiencies in planning, allocation of resources, and analyses of patients’ outcomes. In this section, we formulate various suggestions and recommendations to improve health The explicitly defined health benefit package will help to clearly link public resources financing and the use of public funds. Some of the recommendations are more strategic to guaranteed services. One of the major inefficiencies that currently exists is the lack and need implementation of systemic reforms; others are more operational, and can be of clarity for patients of what services are covered by the public health system. This introduced at the lower levels—regional health administrations or health facilities. situation leads to implicit rationing, which takes place at the point of care. The explicitly defined list of diseases, interventions, drugs, and supplies should help reallocate The new health financing concept and health reforms bills developed by the MoH resources and improve availability of guaranteed services. This should also help hold various promises. The reform suggests transforming the approach through which clarify for patients the guaranteed level of coverage by the state budget and reduce the facilities are funded, moving away from financing inputs to financing outputs. Purchaser- uncertainty surrounding their expected contribution. provider split and implementation of contractual relations with health care providers should improve accountability of the resources spent in the sector. The implementation of contracting for health facilities should be done with the recognition that there is currently a wide variation in service costs incurred by The use of a results-based financing system is one of the key measures to address facilities. In view of the existing variations, the determination of a price for contracting public health financing. Strategic purchasing as the effective mechanism of results- service providers may be difficult. Still, efficiency should be the priority in the optimization based financing will help to introduce competition between providers and better planning process of health care service provision. for expected deliverables. It will also help link payment to specific outputs of health care providers, which is presently one of the main factors of inefficiency in the sector. Formalized co-payment mechanisms and voluntary insurance schemes could help to cover financial gaps. Given that the current funding gap to cover essential care More transparency and access to health data will help improve efficiency. In the course will likely continue in the near future, voluntary private insurance could be a tool to of implementation of the new financing mechanisms, it is important to ensure better increase resources in the sector and more adequately protect against catastrophic access to public expenditure on health. Information should be available for all health expenditures. The likarniana kasa, which represents the local insurance plan (i.e., facilities and units, allowing to track both resources spent and performance indicators. sickness fund) for drugs, and which is financed by regular member contributions, is Access to data and benchmarking the performance of the various facilities is one of most one example of a successful reform intervention in the health sector. The national effective mechanisms to improving service delivery efficiency. and local level governments could potentially incentivize the use of other voluntary More financial management freedom should be granted. A capitation-based financing insurance mechanisms. at the primary health level and a global budgeting approach at other levels, with expected Further improvements in medication supplies and public procurements efficiency outputs specified at the early stages of strategic purchasing, can be an effective tool should be put forward. Prozorro, the new system of public procurement, allows more to move away from line-item budgeting. New financing mechanisms will also allow transparency in procurements as well as cost savings compared to the estimated price. providers more freedom to manage resources: determining the number of staff and However, despite these improvements, lack of medications is still one of the major their salaries, controlling the load, and linking the intensity and volumes of care to other reported problems at the facility level. Therefore, additional effort would be needed to required inputs. A large potential for savings lies in optimization of facility networks, improve planning and supplies of medication procured through national and regional utilization of space within facilities, and utility payments. Improved financial management funds. It would also prove useful to monitor drug stocks at facility levels to ensure drug skills combined with routine use of simplified cost accounting tools can help providers availability for patients and medical professionals. better utilize available resources in the organization and management of facilities. Facility managers could benefit from training and capacity building in financial management and forecasting methods for planning. In particular, in the context of ongoing conversion of hospitals into state or communal-owned organizations, it is essential that facility managers improve their managerial skills (among them planning and fundraising skills). 138 Tracking Health Resources in Ukraine Annexes 139 ANNEXES Questionnaires were tested during the pilot stage, which included interviews with seven respondents (which are not a part of the sample) who were interviewed during the Rapid Data Assessment (RDA) stage. ANNEX B. HEALTH CARE PROVISIONS AND EX- PENDITURES IN THE STUDIED OBLASTS, 2015. ANNEX A. SAMPLE Table B1. Poltava oblast In Lviv oblast: 1 1 Head of the Health Department at the Lviv Oblast State Administration; UAH MILLION PERCENT 2 4 Heads of city/rayon health department/division and 1 Chairman of the PROVISIONS PLAN ACTUAL ACTUAL/ PLANV corresponding Committee of the Rayon Rada; Medical subvention 1 718,3 1 718,5 100 3 10 chiefs of the facility (including Physicians-managers/Deputy Physi- cians-managers) /Heads of polyclinic divisions/Heads of city and rayon Subvention to purchase PHCCs); and drugs and medical 4,8 4,8 100 goods for emergency 4 and 47 hospital/polyclinic’s physicians/family physicians/nurses. service In Poltava oblast: Subvention to purchase 0,6 0,6 100 1 1 Head of the Health Department at the Poltava Oblast State Administration; drugs for anesthesia 2 4 Heads (Deputy Heads) of city/rayon health departments/divisions and 1 Subvention to reform Chairman of the corresponding Committee of the Rayon Rada; local health care within IBRD project "Improving 29,7 0,9 3 3 15 chiefs of the facility (Chief Physicians/Deputy Chief Physicians) /polyclinic divisions/city or rayon PHCCs; and health care to serve people" 4 43 hospital/polyclinic’s physicians/family physicians/medical assistants/ nurses. Contribution from local - 420,0 - budgets In Donetsk oblast: EXPENDITURES 1 1 Head of the Health Department at the Donetsk Oblast State Administration; Health care (total), of it: 2 114,5 2 144,9 101,4 2 7 Heads of city/rayon health department/division; Hospitals 1 072,3 1 114,4 103,9 3 18 chiefs of the facility (including Physicians-managers/Deputy Physi- Specialized hospitals, cians-managers) /Heads of polyclinic divisions/Heads of city and rayon incl. maternity 346,7 374,3 107,9 PHCCs); and hospitals 4 and 48 hospital/polyclinic’s physicians/family physicians/nurses. Sanatoriums 24,5 24,1 98,5 In Luhansk oblast: Emergency care 118,7 131,7 110,9 1 1 Head of the Finance Department at the Luhansk Oblast State Administra- Polyclinics 79,0 80,9 102,5 tion; PHCs and FOPs 293,6 283,3 96,5 2 2 heads of financial department of rayon administration, 1 head of health Prevention 7,1 7,1 100,1 department at city administration, 1 acting head of rayon administration; Diabetes treatment 44,0 27,6 62,7 3 14 chiefs of the facility (Chief Physicians/Deputy Chief Physicians) /polyclinic Other 128,6 101,5 79,0 divisions/city or rayon PHCCs; and 4 50 hospital/polyclinic’s physicians/family physicians/medical assistants/ Source: Oblast treasury report.  nurses. 140 Tracking Health Resources in Ukraine Annexes 141 Table B2. Luhansk oblast Table B3. Donetsk oblast UAH MILLION PERCENT UAH MILLION PERCENT PROVISIONS PLAN ACTUAL ACTUAL/ PLAN PROVISIONS PLAN ACTUAL ACTUAL/ PLAN Medical subvention 975,1 975,1 100,0 Medical subvention 2 602,9 2 607,1 100,2 Subvention to purchase Subvention to purchase drugs and medical drugs and medical 8,6 v 82,4 14,9 14,9 100,0 goods for emergency goods for emergency service service Subvention to purchase Subvention to purchase 1,0 0,9 92,1 1,9 v,9 99,7 drugs for anesthesia drugs for anesthesia Contribution from local Contribution from local - 97,6 - - 482,5 - budgets budgets EXPENDITURES EXPENDITURES Health care (total), of it: 1 152,9 1 080,7 93,7 Health care (total), of it: 3 568,6 3 106,3 87,0 Hospitals 582,0 597,2 102,6 Hospitals 1 410,5 1 346,2 95,4 Specialized hospitals, Specialized hospitals, incl. maternity 171,6 135,0 78,7 incl. maternity 512,8 473,5 92,3 hospitals hospitals Sanatoriums 10,0 5,1 51,3 Sanatoriums 55,4 53,0 95,8 Emergency care 100,3 126,3 126,0 Emergency care 458,6 368,3 80,3 Polyclinics 8,9 5,8 65,5 Polyclinics 120,1 112,6 93,8 PHCs and FOPs 145,2 136,5 94,0 PHCs and FOPs 571,4 505,4 88,4 Prevention 5,0 3,2 65,0 Prevention 10,6 8,8 83,2 Diabetes treatment 61,1 12,1 19,8 Diabetes treatment 153,4 74,3 48,4 Other 69,0 59,5 86,2 Cancer treatment 0,3 0,3 91,5 Other 275,5 163,9 59,5 Source: Oblast treasury report.  Source: Oblast treasury report.  142 Tracking Health Resources in Ukraine Annexes 143 ANNEX C. LEAKAGES AND INCONSISTENCIES Table C1. Leakage estimates and inconsistencies in financial Table B4. Lviv oblast reports—Lviv oblast, million UAH UAH MILLION PERCENT THE STATE TREASURY LOCAL STATE INCONSISTENCY: ((1)–(2))/(1), SERVICE (1) ADMINISTRATIONS (2) IN PERCENT PROVISIONS PLAN ACTUAL ACTUAL/ PLAN MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL Medical subvention 2,924.7 2,924.7 100.0 SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, TION, TURES RECEIVED TION, USED TURES RECEIVED TION, USED TURES USED RECEIVED Subvention to purchase drugs and medical Lviv oblast 0.0 0.0 0.0 0.0 0.0 0.0 (0.12) (2.53) (2.59) 6.1 6.1 99.1 goods for emergency Oblast Budget 1,438.2 1,231.8 1,176.9 1,442.2 1,306.1 1,251.2 (0.28) (6.03) (6.31) service Subvention to purchase Boryslav City 37.6 29.0 28.9 37.6 29.0 28.9 0.00 — — 1.1 1.1 99.8 drugs for anesthesia Drohobych City 99.5 78.8 78.8 99.5 78.8 78.8 0.00 — (0.00) Contribution from local — 471.3 — Lviv City 604.2 503.6 500.8 604.2 503.5 500.6 0.00 0.02 0.04 budgets EXPENDITURES Morshyn City 11.8 5.5 5.5 11.8 5.5 5.5 — — — Health care (total), of it: 3,491.6 3,403.2 97.5 Novyi Rozdil City 29.8 21.1 21.1 29.8 21.1 21.1 (0.00) — (0.00) Hospitals 1,762.7 1,746.6 99.1 Sambir City — 0.2 0.2 — — — 0 — — Specialized hospitals, Stryi City 56.8 43.9 43.9 56.8 43.9 43.9 0.00 — 0.00 incl. maternity 730.3 725.8 99.4 hospitals Truskavets City 30.2 20.2 20.2 30.2 20.2 20.2 — (0.00) — Sanatoriums 25.7 25.6 99.8 Chervonohrad 88.8 57.6 57.6 88.8 57.6 57.6 — — — City Emergency care 214.5 213.6 99.6 Brody rayon 44.8 39.2 39.2 44.8 39.2 39.2 0.00 — (0.00) Polyclinics 399.1 393.6 98.6 PHCs and FOPs 76.8 75.0 97.7 Busk rayon 34.7 31.7 31.7 34.7 31.7 31.7 — — 0.00 Prevention 11.6 11.6 99.7 Gorodok rayon 58.6 47.5 47.4 58.6 47.5 47.4 0.00 — (0.00) Diabetes treatment 65.3 40.1 61.4 Drohobych 40.8 40.8 40.1 40.8 40.8 40.1 (0.00) — (0.00) Other 205.5 171.3 83.4 rayon Zhydachiv rayon 54.0 48.7 48.5 54.0 48.5 48.3 0.00 0.44 0.44 Source: Oblast treasury report.  Zhovkva rayon 71.2 64.5 64.3 71.2 64.5 64.3 0.00 — (0.00) Zolochiv rayon 57.8 46.8 46.5 57.8 46.8 46.5 (0.00) — (0.00) Kamyanka 40.3 34.5 34.2 40.3 34.5 34.2 (0.00) — (0.00) Buzka r-n Mykolaiv rayon 41.3 36.9 36.5 41.3 36.9 36.5 (0.00) — 0.00 Mostyv rayon 38.0 35.6 35.1 38.0 35.6 35.1 (0.00) — (0.00) Peremyshlyany 31.9 28.0 28.0 31.9 28.0 28,0 (0.00) — (0.00) rayon Pustomytiv 74.8 69.2 65.3 75.0 69.2 65.3 (0.27) — 0.00 rayon 144 Tracking Health Resources in Ukraine Annexes 145 THE STATE TREASURY LOCAL STATE INCONSISTENCY: ((1)–(2))/(1), THE STATE TREASURY LOCAL STATE INCONSISTENCY: ((1)–(2))/(1), SERVICE (1) ADMINISTRATIONS (2) IN PERCENT SERVICE (1) ADMINISTRATIONS (2) IN PERCENT MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL SUBVEN- SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, TION, TION, TURES RECEIVED TION, USED TURES RECEIVED TION, USED TURES USED TURES RECEIVED TION, USED TURES RECEIVED TION, USED TURES USED RECEIVED RECEIVED Radekhiv rayon 33.1 32.0 32.0 33.1 32.0 32.0 0.00 — 0.00 Kremenchuk 35.1 28.5 27.6 35.1 28.5 27.6 (0.00) — 0.00 rayon Sambir rayon 92.1 81.3 80.9 92.1 81.5 81.1 0.00 (0.26) (0.26) Lokhvytia rayon 38.4 29.8 28.5 38.4 29.8 28.5 0.00 (0.00) (0.00) Skole rayon 38.4 37.0 36.9 38.4 37.0 36.9 (0.00) — (0.00) Lubny rayon 14.6 15.1 13.9 14.6 15.1 13.9 (0.00) — (0.00) Sokal rayon 61.5 54.3 53.8 61.5 54.3 53.8 — — — Mashiv rayon 19.5 13.3 12.7 19.5 13.3 12.7 (0.03) — 0.00 Staryi Sambir 59.2 54.7 54.7 59.2 54.7 54.7 — — — rayon Myrgorod rayon 65.7 53.4 51.0 65.7 53.4 51.0 0.00 — 0.00 Stryi rayon 51.7 34.4 34.2 51.7 34.4 34.2 0.00 — — Novi Sanzhary 28.4 23.9 22.9 28.4 23.9 22.9 0.02 — 0.00 rayon Turka rayon 45.3 42.6 42.4 45.3 42.6 42.4 0.00 — (0.00) Orzhytsya rayon 20.7 16.7 16.0 20.7 16.7 16.0 0.01 — 0.00 Iavoriv rayon 99.5 73.4 71.8 99.5 73.4 71.8 (0.00) — 0.00 Pyryatyn rayon 24.9 21.8 21.5 24.9 21.8 21.5 0.00 0.00 (0.00) Poltava oblast 0.0 0.0 0.0 0.0 0.0 0.0 0.00 (0.02) (0.02) Poltava rayon 49.4 44.9 42.9 49.4 44.9 42.9 0.00 0.00 0.00 Oblast Budget 853.3 723.2 696.4 853.3 723.6 696.8 (0.00) (0.06) (0.06) Reshetylivka 18.4 17.1 17.1 18.4 17.1 17.1 (0.00) 0.00 0.00 Horishni Plavni Rayon 59.9 36.9 36.5 59.9 36.9 36.5 (0.00) — 0.00 City Semenivka 19.9 17.8 17.8 19.9 17.8 17.8 (0.00) — 0.00 Kremenchuk rayon 230.2 155.0 154.9 230.2 155.0 154.9 — — — City Khorol rayon 29.6 24.1 24.1 29.6 24.1 24.1 — — 0.00 Lubny City 49.6 40.0 39.9 49.6 40.0 39.9 0.00 (0.00) (0.00) Chornukhy 8.5 7.8 7.8 8.5 7.8 7.8 (0.00) 0.00 0.00 Poltava City 284.6 199.5 199.4 284.6 199.5 199.4 0.00 — (0.00) rayon Velyka Chutiv Rayon 18.1 15.8 15.1 18.1 15.8 15.1 (0.00) — (0.00) Bagachanka 22.3 17.5 17.4 22.3 17.5 17.4 0.00 — 0.00 Shyshaky rayon 20.5 14.0 13.9 20.5 14.0 13.9 (0.00) — (0.00) rayon Donetsk oblast 3,106.3 2,607.1 2,268.0 3,105.0 2,604.0 2,260.9 0.04 0.12 0.31 Gadiach rayon 43.0 37.2 35.3 43.0 37.2 35.3 0.00 — (0.00) Oblast Budget 1,145.1 933.1 690.6 1,145.1 933.1 690.6 0.00 — 0.00 Globyno rayon 37.8 31.2 29.8 37.8 31.2 29.8 (0.00) — 0.00 Avdiivka City 26.3 24.1 22.7 26.3 24.1 22.7 — — — Grebinka rayon 24.6 17.5 16.6 24.6 17.5 16.6 (0.00) — 0.00 Bakhmut City 130.2 118.4 101.0 130.2 118.4 101.0 0.00 — 0.00 Dykanka rayon 14.8 12.7 12.1 14.8 12.7 12.1 0.00 — (0.00) Debaltseve City 0.3 4.2 0.0 0.0 4.2 0.0 100.00 — Zinkiv rayon 27.1 24.3 23.3 27.1 24.3 23.3 (0.00) — (0.00) Toretsk City 64.1 60.4 59.9 66.0 60.4 59.9 (3.09) — — Karlivka rayon 28.5 23.4 22.4 28.5 23.4 22.4 0.00 — (0.00) Myrnohrad City 58.6 45.7 45.3 58.8 52.3 49.1 (0.27) (14.51) (8.46) Kobelyaky rayon 34.5 29.5 29.5 34.5 29.5 29.5 — — (0.00) Kozelschyna Dobropillia City 64.7 50.6 50.3 64.7 54.5 54.3 (0.00) (7.78) (7.81) 16.0 13.7 13.1 16.0 13.7 13.1 (0.00) — 0.00 rayon Druzhkivka City 62.6 56.2 56.2 62.6 56.4 56.4 0.00 (0.36) (0.36) Koteleve rayon 14.1 13.2 12.6 14.1 13.2 12.6 0.00 — (0.00) 146 Tracking Health Resources in Ukraine Annexes 147 THE STATE TREASURY LOCAL STATE INCONSISTENCY: ((1)–(2))/(1), THE STATE LOCAL STATE INCONSISTENCY: ((1)–(2))/(1), SERVICE (1) ADMINISTRATIONS (2) IN PERCENT TREASURY SERVICE (1) ADMINISTRATIONS (2) IN PERCENT MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL MEDICAL HEALTH MEDICAL SUBVEN- SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, SUBVEN- EXPENDI- SUBVENTION, TION, TION, TURES RECEIVED TION, USED TURES RECEIVED TION, USED TURES USED TURES RECEIVED TION, USED TURES RECEIVED TION, USED TURES USED RECEIVED RECEIVED Mariupol City 459.4 379.9 376.7 456.1 379.9 376.7 0.73 — — Luhansk region 1,079.7 975.1 790.1 1,077.8 975.1 790.2 0.17 — (0.00) Novogrodovka Oblast Budget 445.5 431.9 281.9 445.5 431.9 281.9 — — — 16.3 17.3 16.0 16.3 17.0 15.8 (0.21) 1.35 1.45 City Kostiantynivka Lysychansk City 95.0 85.9 85.3 95.0 85.9 85.3 — — — 81.8 82.2 70.1 81.8 82.2 70.1 — — — City Rubizhne City 46.9 41.8 41.3 46.9 41.8 41.3 — — — Kramatorsk City 273.3 164.5 164.4 273.3 165.1 164.9 0.00 (0.39) (0.32) Severodonetsk 142.5 96.9 93.9 142.5 96.9 93.9 — — — Pokrovsk City 84.3 67.2 65.6 84.3 72.2 70.5 0.00 (7.41) (7.46) City Bilovodsk rayon 22.9 27.8 19.3 23.2 27.8 19.3 (1.19) — (0.09) Lyman City 50.0 45.3 43.1 50.3 45.3 43.1 (0.57) — 0.00 Bilokurakyno 21.0 15.3 15.2 21.0 15.3 15.2 (0.00) — 0.00 Selidove City 66.3 52.4 51.3 66.3 53.7 52.6 — (2.45) (2.41) rayon Slaviansk City 148.2 114.5 114.3 148.2 108.7 108.5 0.00 5.03 5.04 Kreminna rayon 32.0 31.5 29.5 32.0 31.5 29.5 0.01 — — Vugledar City 17.6 15.1 14.7 17.5 15.1 14.7 0.39 — 0.00 Markove rayon 13.5 10.5 10.4 13.5 10.5 10.4 (0.00) — 0.00 Oleskandrivka Milove rayon 12.8 13.8 11.9 13.0 13.8 11.9 (1.01) — — 15.4 14.4 14.2 15.4 14.4 14.2 — — — rayon Novoaidar rayon 35.4 33.0 28.2 35.4 33.0 28.2 (0.00) — — Bakhmut rayon 33.0 45.5 29.6 33.0 45.5 29.6 — — 0.00 Novopskov Velyka 29.9 24.7 24.1 29.9 24.7 24.1 — — — 39.6 36.7 31.1 39.6 36.7 31.1 0.00 — (0.00) rayon Novoselka rayon Volnovakha Popasna rayon 53.5 51.6 46.6 53.5 51.6 46.6 0.00 — — 77.7 76.3 70.1 77.7 76.3 70.1 — — 0.00 rayon Svatove rayon 33.7 26.1 25.2 31.7 26.1 25.2 5.93 — (0.00) Nikolske rayon 22.2 21.7 19.7 22.2 21.7 19.8 (0.00) — (0.16) Stanytsia 36.0 32.5 27.8 36.0 32.5 27.8 (0.00) — 0.00 Dobropillia Luhanska rayon 8.2 11.4 10.5 8.2 8.2 6.6 (0.07) 28.81 37.29 rayon Starobilsk rayon 40.9 37.1 35.4 40.9 37.1 35.4 — — — Kostiantynivka 8.4 13.6 12.1 8.4 10.1 7.9 0.00 25.86 34.79 Troitske rayon 18.2 14.5 14.2 18.0 14.5 14.2 1.51 — — rayon Pokrovsk rayon 15.9 29.5 25.0 15.9 20.0 15.3 (0.01) 32.30 38.79 Marinka rayon 74.0 60.6 56.9 74.0 60.6 56.9 (0.00) — (0.01) Marinka rayon 74.0 60.6 56.9 74.0 60.6 56.9 (0.00) — (0.01) Mangush rayon 22.8 22.3 21.1 22.8 22.3 21.1 0.12 0.00 (0.00) Mangush rayon 22.8 22.3 21.1 22.8 22.3 21.1 0.12 0.00 (0.00) Slaviansk rayon 32.1 26.5 24.1 32.1 32.1 29.7 (0.00) (21.16) (23.24) Slaviansk rayon 32.1 26.5 24.1 32.1 32.1 29.7 (0.00) (21.16) (23.24) Iasynuvata 8.0 17.6 11.4 8.0 13.6 7.9 0.00 22.78 30.38 rayon Iasynuvata 8.0 17.6 11.4 8.0 13.6 7.9 0.00 22.78 30.38 rayon 148 Tracking Health Resources in Ukraine Annexes 149 ANNEX D. FINANCIAL FLOWS IN THE STUDIED OBLASTS. Figures listed in order on following pages. Figure D1. Financial flows in Lviv oblast Figure D2. Financial flows in Poltava oblast Figure D3. Financial flows in Donetsk oblast Figure D4. Financial flows in Luhansk oblast 150 Tracking Health Resources in Ukraine Annexes 151 5,000 MS: MS: MS: 5,000 5,000 5,000 MS: MS: 5,000 Starosambir Starosambir Starosambir Starosambir Starosambir MS: MS: 54,305,500 54,305,500 MS: 54,305,500 54,305,500 MS: MS: 54,305,500 MS: MS: MS: 5,476,000 5,476,000 MS: MS: 5,476,000 5,476,000 5,476,000 51,196,600 MS: MS: 51,196,600 MS: MS: MS: 51,196,600 Rayon Rayon 51,196,600 51,196,600Rayon RayonRayon Lviv Lviv Lviv Oblast Oblast Oblast Lviv 2015 Lviv 20152015 Oblast Oblast 2015 2015 MS: MS: MS: 174,900 174,900 174,900 MS: MS: 174,900 174,900 H: 59,165,230 H: 59,165,230 H: 59,165,230 H: 59,165,230 158,000 MS: MS: H: 59,165,230 MS: 158,000 158,000 MS: MS: 158,000 158,000 MS: MS: 43,898,714 MS: 43,898,714 43,898,714 MS: MS: 43,898,714 43,898,714 Sokal Sokal Sokal Rayon Rayon Rayon Sokal Sokal Rayon Rayon Morshyn Morshyn CityCityMorshyn Morshyn City Morshyn City City 1,238,665 OS: OS: 1,238,665 OS: 1,238,665 OS: 1,238,665 OS: 1,238,665 Radekhiv Radekhiv Rayon Rayon Radekhiv Rayon Radekhiv Radekhiv Rayon Rayon OR: OR: OR: 15,266,381 15,266,381 15,266,381 OR: 15,266,381 OR: 15,266,381 H: 61,468,268 H: 61,468,268 H: 61,468,268 H: 61,468,268 H: 61,468,268 MS: MS: 27,298,800 MS: 27,298,800 27,298,800 27,298,800 MS: MS: 27,298,800MS: MS: MS: MS: 4,444,800 4,444,800 4,444,800 MS: 4,444,800 4,444,800 H: 11,849,853 H: 11,849,853H: 11,849,853 H: 11,849,853 H: 11,849,853 53,827,214 MS: MS: MS: 53,827,214 53,827,214 MS: MS: 53,827,214 53,827,214 5,471,000 MS: MS: MS: 5,471,000 5,471,000MS: MS: 5,471,000 5,471,000 H: 33,141,600 H: 33,141,600 H: 33,141,600 H: 33,141,600 H: 33,141,600 MS: MS: 278,000 MS: 278,000 278,000 MS: MS: 278,000 278,0007,641,053 OR: OR: OR: 7,641,053 7,641,053OR: 7,641,053 OR: 7,641,053 31,956,714 MS: MS: MS: 31,956,714 31,956,714 MS: MS: 31,956,714 31,956,714 33,000 MS: MS: MS: 33,000 33,000 MS: MS: 33,000 33,000 2,748,000 OS: OS: OS: 2,748,000 2,748,000 OS: 2,748,000 OS: 2,748,000 OR: OR: 1,184,886 OR: 1,184,886 1,184,886 OR: 1,184,886 OR: 1,184,886 MS: MS: 2,979,600 MS: 2,979,600 2,979,600MS: MS: 2,979,600 2,979,600 3,630,853 OR: OR: OR: 3,630,853 3,630,853 OR: 3,630,853 OR: 3,630,853 1,238,665 OS: OS: OS: 1,238,665 1,238,665 OS: 1,238,665 OS: 1,238,665 Bus’k Bus’k Bus’k Rayon Rayon Rayon Bus’k Rayon Bus’k Rayon Truskavets Truskavets Truskavets Truskavets CityCity City City City Truskavets 28,101,600 MS: MS: MS: 28,101,600 MS: MS: 28,101,600 28,101,600 28,101,600 H: 34,709,538 H: 34,709,538 H: 34,709,538 H: 34,709,538 H: 34,709,538 58,900 MS: MS: MS: 58,900 58,900 MS: MS: 58,900 58,900 H: H: 30,150,547 H: 30,150,547 30,150,547 H: 30,150,547 H: 30,150,547 31,672,884 MS: MS: MS: 31,672,884 MS: MS: 31,672,884 31,672,884 31,672,884 MS: MS: 28,736,400 28,736,400 MS: 28,736,400 MS: MS: 28,736,400 28,736,400 3,411,800 MS: MS: MS: 3,411,800 MS: MS: 3,411,800 3,411,800 3,411,800 OR: OR: 3,036,654 3,036,654OR: 3,036,654 OR: 3,036,654 OR: 3,036,654 MS: MS: 20,175,300 MS: 20,175,300 MS: MS: 20,175,300 20,175,300 20,175,300 Boryslav Boryslav Boryslav CityCityBoryslav Boryslav City City City 2,748,000 OS: OS: OS: 2,748,000 2,748,000 OS: 2,748,000 OS: 2,748,000 2,748,000 MS: MS: MS: 2,748,000 2,748,000 MS: MS: 2,748,000 2,748,000 7,257,247 OR: OR: OR: 7,257,247 7,257,247OR: 7,257,247 OR: 7,257,247 H: 37,621,446 H: 37,621,446 H: 37,621,446H: 37,621,446 H: 37,621,446 8,468,600 MS: MS: MS: 8,468,600 8,468,600 8,468,600 MS: MS: 8,468,600 MS: MS: 28,940,600 MS: 28,940,600 MS: MS: 28,940,600 28,940,600 28,940,600 MS: MS: 70,000 70,000 MS: 70,000 70,000 MS: MS: MS: MS: 36,232,000 70,000 MS: 36,232,000 MS: MS: 36,232,000 36,232,000 36,232,000 50,000 MS: MS: MS: 50,000 50,000 MS: MS: 50,000 50,000 8,680,846 OR: OR: 8,680,846 OR: 8,680,846 OR: 8,680,846 OR: 8,680,846 Oblast Oblast Oblast budget budget budget Oblast Oblast budget budget 1,529,300 OS: OS: OS: 1,529,300 1,529,300 OS: 1,529,300 OS: 1,529,300 H: 1,442,190,000 H: 1,442,190,000 H: 1,442,190,000 H: 1,442,190,000 H: 1,442,190,000 MS: MS: 20,149,400 20,149,400 MS: 20,149,400 20,149,400 MS: MS: 20,149,400 2,999,700 MS: MS: 2,999,700 MS: MS: MS: 2,999,700 2,999,700 2,999,700 1,251,171,200 MS: MS: MS: MS: MS: 1,251,171,200 1,251,171,200 1,251,171,200 1,251,171,200 Drohobych Drohobych Drohobych CityCity Drohobych City Drohobych City City 9,931,800 OS: OS: OS: 9,931,800 9,931,800 OS: 9,931,800 OS: 9,931,800 MS: MS: 44,065,800 MS: 44,065,800 MS: MS: 44,065,800 44,065,800 44,065,800 129,537,000 OR: OR: 129,537,000 OR: 129,537,000 OR: 129,537,000 OR: 129,537,000 H: 40,808,600 H: 40,808,600 H: 40,808,600 H: 40,808,600 H: 40,808,600 70,349,800 MS: MS: MS: 70,349,800 MS: MS: 70,349,800 70,349,800 70,349,800 Brody BrodyBrody Rayon Rayon Brody Brody Rayon Rayon Rayon 78,759,376 MS: MS: MS: 78,759,376 78,759,376 MS: MS: 78,759,376 78,759,376 8,680,846 OR: OR: OR: 8,680,846 8,680,846 OR: 8,680,846 OR: 8,680,846 1,365,421,276 MS: MS: MS: 1,365,421,276 MS: MS: 1,365,421,276 1,365,421,276 1,365,421,276 H: 44,793,100 H: 44,793,100 H: 44,793,100 H: 44,793,100 H: 44,793,100 52,770,890 OS: OS: 52,770,890 OS: 52,770,890 OS: 52,770,890 OS: 52,770,890 73,386,700 MS: MS: MS: 73,386,700 MS: MS: 73,386,700 73,386,700 73,386,700 MS: 39,175,892 MS: 39,175,892 MS: 39,175,892 MS: MS: 39,175,892 39,175,892 Stryi Stryi City City CityStryi Stryi Stryi City City 30,000 MS: MS: MS: 30,000 30,000 30,000 MS: MS: 30,000 Iavoriv Iavoriv Rayon Iavoriv RayonIavoriv Iavoriv Rayon Rayon Rayon 1,529,300 OS: OS: OS: 1,529,300 1,529,300 OS: 1,529,300 OS: 1,529,300 4,087,908 OR: OR: 4,087,908 OR: 4,087,908 OR: 4,087,908 OR: 4,087,908 H: 56,788,031 H: 56,788,031 H: 56,788,031 H: 56,788,031 H: 56,788,031 H: 99,479,183 H: 99,479,183 H: 99,479,183 H: 99,479,183 H: 99,479,183 MS: MS: 43,898,800 43,898,800 MS: 43,898,800 43,898,800 MS: MS: 43,898,800 MS: MS: 317,617 MS: 317,617 317,617 MS: MS: 317,617 317,617 71,819,114 MS: MS: 71,819,114 MS: MS: 71,819,114 MS: 71,819,114 71,819,114 MS:152,00 MS:152,00 MS:152,00 MS:152,00 MS:152,00 OR: OR: 12,889,231 OR: 12,889,231 12,889,231 OR: 12,889,231 OR: 12,889,231 317,617 OS: OS: OS: 317,617 317,617 OS: 317,617 OS: 317,617 27,024,849 OR: OR: OR: 27,024,849 OR: 27,024,849 27,024,849 OR: 27,024,849 41,860,900 MS: MS: MS: 41,860,900 MS: MS: 41,860,900 41,860,900 41,860,900 MS: MS: MS: 5,715,900 5,715,900 5,715,900 MS: MS: 33,431,200 5,715,900 5,715,900 MS: MS: MS: 33,431,200 33,431,200 33,431,200 MS: MS: 33,431,200 21,128,500 MS: MS: MS: 21,128,500 21,128,500 MS: MS: 21,128,500 21,128,500 3,613,600 MS: MS: MS: 3,613,600 3,613,600MS: MS: 3,613,600 3,613,600 818,800 OS: OS: OS: 818,800 818,800 OS: 818,800 OS: 818,800 602,600 OS: OS: OS: 602,600 602,600 OS: 602,600 OS: 602,600 442,100 MS: MS: MS: 442,100 442,100 442,100 MS: MS: 442,100 MS: MS: 4,741,576 MS: 4,741,576 MS: MS: 4,741,576 4,741,576 4,741,576 Horodok Horodok Rayon Horodok Rayon Horodok Horodok Rayon Rayon Rayon Skola Rayon SkolaSkola RayonRayon Skola Skola Rayon Rayon 100,000 OS: OS: 100,000 OS: 100,000OS: 100,000 OS: 100,000 Novyj Novyj Novyj Rozdil Rozdil Rozdil Novyj City Novyj City City Rozdil Rozdil City City 43,773,222 MS: MS: MS: 43,773,222 MS: MS: 43,773,222 43,773,222 43,773,222 H: 58,592,468 H: 58,592,468 H: 58,592,468 H: 58,592,468 H: 38,369,114 H: 58,592,468 H: 38,369,114 H: 38,369,114 H: 38,369,114 H: 38,369,114 1,344,000 OS: OS: OS: 1,344,000 1,344,000 OS: OS: 1,344,000 1,344,000 H: 29,844,496 H: 29,844,496 H: 29,844,496 H: 29,844,496 H: 29,844,496 Zhydachiv Zhydachiv Rayon Rayon Zhydachiv Zhydachiv Rayon Zhydachiv Rayon Rayon 21,063,800 MS: MS: MS: 21,063,800 MS: MS: 21,063,800 21,063,800 21,063,800 47,438,663 MS: MS: 47,438,663 MS: 47,438,663 MS: MS: 47,438,663 MS: MS: 47,438,663 36,859,917 MS: 36,859,917 36,859,917 MS: MS: 36,859,917 36,859,917 11,153,805 OR: OR: 11,153,805 OR: 11,153,805 OS: OS: 602,600 OR: 11,153,805 OR: 11,153,805 602,600 OS: 602,600 498,683,500 OS: 602,600 MS: MS: OS: 602,600 498,683,500 MS: MS: 498,683,500 MS: 498,683,500498,683,500 818,800 OS: OS: 818,800 OS: 818,800 OS: 818,800 OS: 818,800 H: 53,965,623 H: 53,965,623 H: 53,965,623 H: 53,965,623H: 53,965,623 MS:60,500 MS:60,500 MS:60,500 MS:60,500 MS:60,500OR: OR: 7,961,896 OR: 7,961,896 7,961,896 OR: 7,961,896 OR: 7,961,896 OR: OR: OR: OR: OR: 48,312,298 MS: MS: MS: 48,312,298 MS: MS: 48,312,298 48,312,298 48,312,298 1,344,000 OS: OS: OS: 1,344,000 1,344,000 OS: 1,344,000 OS: 1,344,000 CityCity LvivLviv LvivLviv Lviv City City City OR: OR: 4,309,325 OR: 4,309,325 4,309,325 OR: 4,309,325 OR: 4,309,325 57,631,000 MS: MS: MS: 57,631,000 MS: MS: 57,631,000 57,631,000 57,631,000 75,000 MS: MS: MS: 75,000 75,000 75,000 MS: MS: 75,000 MS: MS: 50,000 50,000 MS: 50,000 50,000 MS: MS: 50,000 H: 604,185,803 H: 604,185,803 H: 604,185,803 H: 604,185,803 H: 604,185,803 503,576,800 MS: MS: MS: 503,576,800 MS: MS: 503,576,800 503,576,800 503,576,800 100,00 OS: OS: OS: 100,00 100,00 OS: 100,00 OS: 100,00 100,509,003 OR: OR: 100,509,003 OR: 100,509,003 OR: 100,509,003 OR: 100,509,003 36,733,100 MS: MS: 36,733,100 MS: 36,733,100 MS: MS: MS: MS: 140,500 36,733,100 140,500 MS: 140,500 36,733,100 140,500 140,500 MS: MS: City Chervonohrad Chervonohrad City Chervonohrad Chervonohrad City Chervonohrad City City MS:65,000,300 MS:65,000,300 MS:65,000,300 MS:65,000,300 MS:65,000,300 MS: MS: 16,444,400 16,444,400 MS: 16,444,400 16,444,400 MS: MS: 16,444,400 34,592,000 MS: MS: MS: 34,592,000 MS: MS: 34,592,000 34,592,000 34,592,000 Stryi Stryi Stryi Rayon Rayon Rayon Stryi Stryi Rayon Rayon 495,600 OS: OS: OS: 495,600 495,600 OS: 495,600 OS: 495,600 H: 88,847,393 H: 88,847,393 H: 88,847,393 H: 88,847,393H: 88,847,393 57,628,802 MS: MS: MS: 57,628,802 MS: MS: 57,628,802 57,628,802 57,628,802 H: 51,679,001 H: 51,679,001 H: 51,679,001H: 51,679,001 MS: MS: H: 51,679,001 195,200 MS: 195,200 195,200 MS: MS: 195,200 195,200 MS:60,500 MS:60,500 MS:60,500 MS:60,500 OR: OR: MS:60,500 OR: 31,218,591 31,218,591 OR: 31,218,591 31,218,591 OR: 31,218,591 34,246,580 MS: MS: MS: 34,246,580 MS: MS: 34,246,580 34,246,580 34,246,580 Sambir Sambir Sambir Rayon Rayon Sambir Sambir Rayon Rayon Rayon Turka Turka Rayon Rayon Turka Turka RayonTurka Rayon Rayon 6,114,507 OR: OR: OR: 6,114,507 6,114,507 OR: 6,114,507 OR: 6,114,507 MS transfer MS transfer MSFrom MS transfer From MS Fromtransfer transfer From From 140,500 MS: MS: MS: 140,500 140,500 MS: MS: 140,500 140,500 H: 92,051,408 H: 92,051,408 H: 92,051,408H: 92,051,408 H: 92,051,408 150,00 MS: MS: 150,00 MS: MS: MS: 150,00 150,00 150,00 H: 45,337,700 H: 45,337,700 H: 45,337,700H: 45,337,700 H: 45,337,700 Sambir Sambir Sambir City: City:Sambir City: Sambir City:City: MS: MS: 81,514,200 81,514,200 81,514,200 MS: MS: MS: 81,514,200 81,514,200 42,420,174 MS: MS: 42,420,174 MS: MS: 42,420,174 MS: 42,420,174 42,420,174 40,896,100 MS: MS: MS: 40,896,100 MS: MS: 40,896,100 40,896,100 40,896,100 209,500 209,500 209,500209,500209,500 OS: OS:495,600 OS: 495,600 495,600 OS: 495,600 OS: 495,600 2,927,526 OR: OR: 2,927,526OR: 2,927,526 OR: 2,927,526 OR: 2,927,526 450,000 MS: MS: MS: 450,000 450,000 450,000 MS: MS: 450,000 69,631,400 MS: MS: MS: 69,631,400 69,631,400 MS: MS: 69,631,400 69,631,400 2,943,558 OR: OR: 2,943,558 OR: 2,943,558 OR: 2,943,558 OR: 2,943,558 Drohobych Drohobych Drohobych Rayon Rayon Drohobych Rayon Drohobych Rayon Rayon Pustomyty Pustomyty Pustomyty Rayon Rayon Pustomyty Rayon Pustomyty Rayon Rayon H: 40,808,600 H: 40,808,600 H: 40,808,600 H: 40,808,600 H: 40,808,600 40,118,300 MS: MS: MS: 40,118,300 MS: MS: 40,118,300 40,118,300 40,118,300 H: 51,679,001 H: 51,679,001 H: 51,679,001 H: 51,679,001 H: 51,679,001MS: MS: 40,000 MS: 40,000 40,000 40,000 MS: MS: 40,000 259,000 MS: MS: MS: 259,000 259,000 MS: MS: 259,000 259,000 MS: MS: 186,000 186,000 MS: 186,000 MS: MS: 186,000 186,000 60,000 MS: MS: MS: 60,000 60,000 60,000 MS: MS: 60,000 MS: MS: 626,000 MS: 626,000 626,000 MS: 110,000 MS: MS: MS: 626,000 626,000 MS: 110,000 110,000 MS: 110,000 MS: 110,000 MS: 100,000 MS: 100,000 MS: 100,000 MS: MS: 100,000 100,000 31,218,591 OR: OR: 31,218,591 OR: 31,218,591 OR: 31,218,591 OR: 31,218,591 34,246,580 MS: MS: MS: 34,246,580 MS: MS: 34,246,580 34,246,580 34,246,580 6,114,507 OR: OR: OR: 6,114,507 6,114,507 OR: 6,114,507 OR: 6,114,507 MS:35,847,800 MS:35,847,800 MS:35,847,800 MS:35,847,800 MS:35,847,800 MS:37,051,000 MS:37,051,000 MS:37,051,000 MS:37,051,000 MS:37,051,000 MS: MS: MS: 34,553,900 34,553,900 34,553,900 34,553,900 MS: MS: 34,553,900 Zhovkva Zhovkva Rayon Zhovkva Rayon Zhovkva Zhovkva Rayon Rayon Rayon 27,996,800 MS: MS: MS: 27,996,800 MS: MS: 27,996,800 27,996,800 27,996,800 H: 71,217,500 H: 71,217,500 H: 71,217,500 H: 71,217,500 H: 71,217,500 Peremyshilany Peremyshilany Peremyshilany Peremyshilany Peremyshilany Kamianka Kamianka Kamianka Buzka Buzka Kamianka Buzka Kamianka Buzka Buzka MS: MS: 64,258,382 64,258,382 MS: 64,258,382 MS: MS: 64,258,382 64,258,382 Rayon Rayon Rayon Rayon Rayon Mostyska MostyskaMostyska Rayon Rayon Mostyska Rayon Mostyska Rayon Mykolaiv Rayon Mykolaiv Rayon Rayon Mykolaiv Rayon Mykolaiv Mykolaiv Rayon Rayon Rayon Rayon Rayon Rayon Rayon Zolochiv Zolochiv Zolochiv Rayon Zolochiv RayonRayon Zolochiv Rayon Rayon 6,959,118 OR: OR: OR: 6,959,118 6,959,118 OR: 6,959,118 OR: 6,959,118 H: 31,940,320 H: 31,940,320H: 31,940,320 H: 31,940,320H: 31,940,320 H: 38,041,806 H: 38,041,806 H: 38,041,806 H: 38,041,806 H: 38,041,806 H: 41,281,764 H: 41,281,764 H: 41,281,764H: 41,281,764 H: 41,281,764 H: 40,276,285 H: 40,276,285 H: 40,276,285 H: 40,276,285 H: 57,814,500 H: 40,276,285 H: 57,814,500 H: 57,814,500 H: 57,814,500H: 57,814,500 65,104,600 MS: MS: MS: 65,104,600 MS: MS: 65,104,600 65,104,600 65,104,600 MS: MS: 27,953,400 MS: 27,953,400 27,953,400 MS: MS: 27,953,400 27,953,400 35,098,248 MS: MS: 35,098,248 MS: MS: 35,098,248 MS: 35,098,248 35,098,248 MS: MS: MS: 36,486,100 36,486,100 MS: MS: 36,486,100 36,486,100 36,486,100 34,161,778 MS: MS: MS: MS: MS: 34,161,778 34,161,778 34,161,778MS: MS: 34,161,778 46,529,200 46,529,200 MS: MS: 46,529,200 MS: 46,529,200 46,529,200 2,943,558 OR: OR: 2,943,558 OR: 2,943,558 OR: 2,943,558 OR: 2,943,558 4,895,664 OR: OR: OR: 4,895,664 4,895,664OR: 4,895,664 OR: 4,895,664 OR: OR: 11,285,300 11,285,300 OR: 11,285,300 OR: 11,285,300 OR: 46,930,800 MS: MS: 11,285,300 MS: MS: MS: 46,930,800 46,930,800 46,930,800 46,930,800 3,986,920 OR: OR: OR: 3,986,920 3,986,920 OR: 3,986,920 OR: 3,986,920 OR: OR: 6,114,507 OR: 6,114,507 6,114,507 OR: 6,114,507 OR: 6,114,507 152 Tracking Health Resources in Ukraine Annexes 153 Reshetylivka Rayon MS: 44,483,700 MS: 34,258,700 Globyno Rayon OS: 1,268,900 Gadiach Rayon MS: 28,756,100 MS: 17,449,700 H: 18,393,191 MS: 394,000 H: 37,827,000 Poltava Oblast 2015 MS: 17,053,681 H: 42,990,847 MS: 29,789,340 OR: 1,339,510 MS: 35,282,478 OS: 3,053,000 Poltava Rayon OS: 1,268,900 OR: 4,984,660 OR: 4,128,677 MS: 22,338,500 MS: 15,893,400 H: 49,381,639 MS: 17,464,300 MS: 115,000 MS: 42,893,814 OS: 693,400 OR: 6,487,825 Zinkiv Rayon Velyka Bahachanka Rayon MS: 2,443,300 H: 27,065,300 Chutiv Rayon Transfers from Sumy, MS: 2,934,800 MS transfer to OS: 3,053,000 MS: 23,257,754 H: 22,255,500 Kharkiv, and OR: 3,807,546 H: 18,393,191 Kharkiv Oblast MS: 17,433,423 Kropyvnytskyi MS: 17,053,681 OS: 4,128,677 OS: 1,311,500 407,582 OR: 1,339,510 3,317,200 OR: 4,128,677 MS: 16,258,800 MS: 154,991,200 MS: 1,912,700 MS: 36,822,600 Horishni Plavni City MS: 742,845,100 Kremenchuk City OS: 6,373,433 Grebinka Rayon H: 18,393,191 H: 230,229,716 MS: 17,053,681 MS: 154,881,256 MS: 22,052,300 OR: 1,339,510 MS: 1,213,700 H: 24,607,400 OR: 75,348,460 MS: 16,565,613 Oblast budget OR: 8,041,787 MS: 24,144,600 H: 853,297,204 MS: 75,100 MS: 696,353,608 Novi Sanzhary OS: 5,439,300 MS: 29,796,400 Khorol Rayon Rayon Rayon OR: 151,504,296 Lokhvytsia Rayon OS: 1,028,300 H: 29,627,487 H: 28,368,100 MS: 1,888,400 MS: 24,144,400 MS: 22,941,221 H: 38,381,400 OR: 4,383,517 OS: 1,311,500 MS: 28,501,671 OR: 5,426,879 OS: 2,334,300 MS: 17,806,200 OR: 7,545,429 OS: 77,400 Semenivka Rayon MS: 12,851,000 MS: 8,066,999 OS: 626,300 Shyshaky Rayon OS: 1,028,300 H: 19,850,080 MS: 17,791,536 H: 20,453,500 MS: 1,100,700 OS: 77,400 OR: 46,800 MS: 13,891,665 OR: 1,981,144 OS: 626,300 OS: 107,328 OR: 5,935,535 MS: 16,723,200 Chornukhy Rayon Orzhytsia Rayon MS: 49,052,200 Myrhorod Rayon H: 8,537,072 H: 20,680,400 MS: 7,779,649 MS: 16,020,206 OR: 619,095 OR: 4,660,194 H: 65,715,833 MS: 4,319,300 MS: 51,026,547 MS: 29,509,900 OR: 14,689,253 Kobeliaky Rayon MS: 21,754,500 Karlivka Rayon MS: 29,900 H: 34,454,809 MS: 29,494,942 H: 28,537,900 MS: 1,843,400 OR: 4,959,867 MS: 22,412,500 OS: 2,426,100 Pyriatyn Rayon OS: 2,463,500 MS: 13,784,800 MS: 13,707,100 OR: 3,661,900 H: 24,898,054 Kozelschyna Rayon MS: 21,528,059 MS:472,500 OR: 3,369,995 H: 16,003,300 MS: 13,052,000 MS: 21,526,300 MS: 1,018,100 OR: 2,951,300 MS: 198,781,700 MS: 212,700 OR: 37,400 MS: 32,989,500 MS: 21,769,300 MS: 13,167,900 OS: 285,900 OS: 80,000 Kotelva Rayon MS: 56,100 Poltava City Dykanka Rayon H: 14,135,100 MS: 12,621,800 Mashivka Rayon H: 284,572,183 H: 14,765,500 Lubny City OS: 80,000 MS: 199,434,500 MS: 12,060,100 OR: 1,433,300 H: 19,504,600 OR: 85,137,683 OR: 2,705,400 H: 49,566,284 MS: 12,658,200 Lubny Rayon MS: 39,886,200 OR: 6,842,100 OR: 9,680,084 MS: 28,523,100 H: 12,633,700 Kremenchuk Rayon MS: 6,711,300 MS: 13,887,400 OS: 285,900 H: 35,104,900 MS: 247,000 MS: 226,200 OR: 460,400 MS: 27,634,020 MS: 13,579,400 OS: 2,503,400 OR: 4,967,480 154 Tracking Health Resources in Ukraine Annexes 155 Dobropillia Rayon MS: 435,400 H: 8,155,693 Donetsk Oblast 2015 MS: 6,682,186 OR: 1,541,056 Transfers Kharkiv Oblast MS: 11,014,400 MS: 1,313,000 MS: 118,437,100 MS: 24,104,499 MS: 60,368,700 Dnipro Oblast Bahmut City MS: 3,933,966 MS: 1,513,800 MS: 946,148,165 H: 130,224,191 OS: 16,806,500 Toretsk City MS: 101,010,719 Avdiivka City OR: 29,213,472 MS: 50,568,900 Dobropillia City H: 66,029,945 H: 26,305,142 MS: 59,850,098 Oblast budget MS: 22,650,207 H: 64,744,137 OR: 5,659,406 OR: 3,654,936 MS: 54,280,443 H: 1,142,896,000 OR: 1,542,148 OR: 10,463,694 MS: 687,734,422 AR: 213,000 OS: 16,800,700 OR: 439,248,406 MS: 164,462,700 OR: 458,981 Iasynuvata Rayon Mymohrad City MS: 17,556,000 H: 58,780,111 MS: 45,652,100 H: 7,975,238 MS: 7,923,438 MS: 49,114,500 Kramatorsk City MS: 44,221,700 OR: 51,800 AR: 950,000 MS: 135,239 OR: 8,986,011 H: 273,323,782 MS: 3,100,000 MS: 164,885,812 MS: 681,300 AR: 2,435,338 OR: 105,685,203 Bakmut Rayon MS: 60,368,700 MS: 67,230,100 H: 33,029,272 MS: 1,276,800 MS: 116,100 MS: 12,927,300 Konstiantynivka Rayon MS: 29,638,094 OR: 3,734,043 AR: 737,000 H: 8,374,784 OR: 317,429 Pokrovsk City MS: 7,872,230 OR: 734,547 H: 84,279,000 OR: 342,866 Druzhvivka City MS: 25,123,200 MS: 70,517,500 MS: 3,525,700 AR: 20,100 H: 62,613,160 OR: 4,772,600 MS: 4,000,000 MS: 200,00 MS: 56,374,900 OR: 6,238,260 OR: 52,243 MS: 1,344,00 MS: 29,257,800 MS: 4,782,300 OR: 39,100 Slaviansk City OR: 139,756 MS: 250,000 AR: 20,100 MS: 45,346,300 MS: 681,300 H: 148,174,073 Pokrovsk Rayon Lyman City MS: 108,424,300 H: 15,874,654 OR: 39,656,773 H: 50,027,009 OR: 93,000 MS: 15,317,029 MS: 241,076 MS: 42,861,930 Selidove City OR: 557,625 OR: 7,218,078 MS: 163,300 MS: 5,600,00 H: 66,259,947 MS: 21,366,900 MS: 51,334,768 MS: 13,050,000 Slaviansk City AR: 429,091 MS: 1,235,350 OR: 13,260,737 Konstiantynivka City Mangush Rayon H: 148,174,073 MS: 114,479,200 MS: 108,424,300 H: 81,827,734 H: 22,826,662 OR: 39,656,773 Novohrodovka City MS: 74,334,824 MS: 21,060,157 Oleksandrivka Rayon MS: 30,909 OR: 7,492,910 OR: 1,766,462 H: 16,292,242 AR: 429,091 MS: 16,020,702 H: 15,366,094 MS: 1,305,200 OR: 271,540 MS: 14,206,022 OR: 1,160,072 MS: 82,162,300 MS: 972,200 MS: 52,407,800 MS: 17,260,500 MS: 2,058,700 MS: 1,665,100 MS: 2,275,600 MS: 20,911,600 MS: 804,000 MS: 376,656,252 MS: 15,066,800 MS: 34,642,300 Volnovakha Rayon H: 77,673,247 MS: 70,080,314 Marinka Rayon Nikolske Rayon Mariupol City Vuhledar City Velyka Novosilka Rayon OR: 7,592,942 MS: 58,292,400 H: 74,012,563 H: 22,190,864 H: 459,390,355 H: 17,546,579 H: 39,568,568 MS: 56,944,094 MS: 19,749,319 MS: 376,656,252 MS: 14,683,874 MS: 31,083,906 OR: 17,068,469 OR: 2,416,964 OR: 82,548,567 OR: 2,862,705 OR: 8,484,680 MS:74,657,700 156 Tracking Health Resources in Ukraine Annexes 157 MS: 26,650,500 MS: 14,801,900 Luhansk Oblast 2015 Bilovodsk City Bilokurakine Rayon H: 23,178,032 MS: 1,168,100 H: 20,986,781 MS: 19,323,959 MS: 5,749,246 OR: 3,564,485 MS: 15,237,535 OR: 2,365,353 MS: 30,468,900 AR: 289,588 MS: 443,405,800 AR: 7,960,576 Oblast budget Kreminna Rayon MS: 766,700 H: 445,513,988 MS: 5,749,246 H: 31,971,168 MS: 281,884,984 MS: 29,529,573 OS: 7,960,576 OR: 2,441,595 OR: 155,668,428 MS: 9,778,800 MS: 95,775 MS: 25,205,000 MS: 31,937,400 Markove Rayon Svatove Rayon MS: 13,236,800 OR: 193,813 H: 13,472,983 H: 33,699,000 MS: 858,000 MS: 10,428,281 MS: 25,176,045 Novoaidar Rayon OR: 3,044,701 OR: 8,472,955 MS: 1,076,700 H: 35,367,476 Milove Rayon MS: 28,164,250 OR: 7,203,226 H: 12,955,330 MS: 584,700 MS: 11,888,008 MS: 31,482,700 OR: 1,067,322 MS: 23,950,800 Stanytsia Luhanska Rayon MS: 35,778,900 MS: 1,063,400 H: 36,018,797 Novopskov Rayon MS: 27,786,001 OR: 8,232,796 MS: 796,300 H: 29,899,257 Starobilsk Rayon MS: 24,061,654 OR: 5,837,603 H: 40,850,179 MS: 1,329,000 MS: 35,391,295 OR: 5,317,728 MS: 49,801,200 Troitske Rayon MS: 13,988,600 H: 18,227,451 MS: 466,800 Popasna Rayon MS: 14,180,285 OR: 4,047,451 MS: 1,762,600 H: 53,501,178 MS: 46,645,755 OR: 6,855,423 MS: MS: 41,791,800 MS: 85,896,800 Severodonetsk City Rubizhne City Lysychansk City H: H: 46,943,071 H: 94,964,885 MS: MS: 41,295,351 MS: 85,284,687 OR: OR: 5,647,719 OR: 9,680,200 158 Tracking Health Resources in Ukraine