Building a more effective, efficient and equitable healthcare system in Ukraine
By Dafina Gercheva, UNDP Ukraine Resident Representative to Ukraine
Access to medicines is essential for achieving access to health as a fundamental human right. As such, it is included in the United Nations Sustainable Development Goals and is recognised as key-element for scaling-up access to health services towards universal health coverage. Medicinal procurement is not restricted to the logistical component of treatments or testing systems availability. It also includes management and quality of services, and promotion of adequate use of medicines. The availability of medicines, however, is the crucial component without which other health care interventions are very likely to fail.
In this regard, the COVID-19 pandemic, which is a multifaceted crisis that altered the morbidity and mortality patterns globally, lead to questioning the existing healthcare systems and their effectiveness and preparedness for adequate response to stochastic challenges and economic burden. People recognised that medical institutions need upgrading, there is a need for additional training of medical staff, and, above all, we all need timely supply of necessary treatments, tests and vaccines.
Ukraine was not spared these processes and COVID-19 has understandably shifted the focus of the debate to current risks and immediate needs, and away from the long-term impact of the healthcare reform, which was launched few years ago by the Ministry of Health and is supported by development partners, civil society and international experts. Yet had it not been for these pre-pandemic reforms, the situation in 2020/21 could have been way worse. As a key actor in the healthcare developments in Ukraine, UNDP is looking back and assessing the results of the reform and identifying key achievements, lessons learned, and areas that might need further work.
In 2013-2014, public health procurement in Ukraine was plagued by the inefficient use of state funds, constant delays in procuring medicines and medical devices, and widespread corruption. This undermined the credibility of governmental institutions, caused pharmaceutical shortages, and raised costs that citizens had to pay for healthcare to levels beyond the means of the average person. This ultimately took a high toll on human lives.
After the protests of 2013–2014, a group of civil society activists with the support of patients, anti-corruption NGOs, lawyers, economists, MPs and government agency representatives developed a strategy and a legislative package to temporarily transfer the procurement of vital medical products to international organisations. After the respective laws were adopted in March 2015, UNDP became one of the international organisations that began procuring medicines that meet the highest international standards for quality. UNDP also started providing vital support to government institutions and civil society to develop their capacity in effective and efficient medical procurement.
Procuring life-saving medicines: the results
Looking at UNDP’s emergency support to the Ministry of Health in the cost-effective and timely procurement of medicines and medical devices over the last six years, the results speak for themselves.
Since 2015, UNDP has procured and delivered medicines and medical products worth more than UAH 16 billion (U.S. $618 million). This allowed the government to provide equal and unhindered access to vital treatments for two million Ukrainians, especially those from the most vulnerable groups.
The key factors that have contributed to the success of this programme include: 1) ensuring transparency throughout the procurement process; 2) procuring generics/biosimilars; 3) helping producers register products on the Ukrainian market; and 4) procuring from producers directly. In addition, UNDP established several long-term agreements (LTAs) for various health programmes, attracting new manufacturers, thereby increasing competition and driving down prices, and as a result, saving taxpayers’ money.
For example, UNDP established LTAs to procure tuberculosis medicines at a discount across a portfolio of over 22 different medicines. This has allowed the government to achieve savings of $5.8 million. Furthermore, UNDP established LTAs to buy cancer medicines at a reduced price across a portfolio of over 96 medicines.
UNDP has also made pooled orders and provided support to producers with the registration of medicines and medical devices, thus increasing competition and driving down prices as a consequence. The organisation significantly changed the procurement paradigm by cutting out intermediary suppliers and purchasing directly from producers. UNDP also introduced novel treatments that aligned Ukrainian practices of clinical management of patients with those of the countries with the best healthcare systems.
Even more important than the public money that has been saved, the reforms have made it possible to provide more patients with lifesaving medications and therapies. This is particularly crucial, given that many patients, such as those with rare diseases, need expensive, continuous treatment to maintain their life.
One of them is 10-year-old Yegor, who is among 2,500 Ukrainians living with haemophilia. He would like to become an IT specialist one day and travel all around the world. However, he needs to have injections 2-3 times a week to live a fulfilling and happy life and make his dreams come true.
“I want future funding for people with haemophilia to be stable and transparent, as it has been in recent years, thanks to public procurement and UNDP,” says Yegor’s mom.
Another to benefit is 23-year-old Olya, who for most of her life has had juvenile rheumatoid arthritis, a chronic joint disease. In the past, she used to experience problems getting medicines and at times had to stay at home. As a consequence, her right leg shortened by 4 centimetres, and she now walks on her tiptoes.
“I’m extremely happy that thanks to UNDP the delivery of medicines to Ukraine has improved,” Olya said. “Thanks to this, I’m living a fulfilling and active life. I dream of having a family and children. I want to have three children, and adopt twins from an orphanage, because neither I nor my boyfriend had twins in our families.”
For Yegor, Olya, and thousands of other Ukrainian patients, the timely procurement and delivery of medicines provides the opportunity to live an active life, not to be afraid to dream and, more importantly, to actually be able to fulfil their dreams.
Developing capacities of government organisations
Our job at UNDP, in this sector and in all others, is ultimately to work ourselves out of a job by developing the capacity of our local partners so we can step back when the time is right. The procurement of vital medical products was always considered a temporary measure to gain the time needed to implement the required reforms in public health procurement. Our objective is to aid the Ministry of Health in developing enough capacity to ensure transparency, accountability and effectiveness in the medicines supply system.
To achieve this goal, since 2015 UNDP has organized numerous training workshops for staff at the Health Ministry and the state-owned enterprise Medical Procurement of Ukraine. The training has centred on sharing world best practices in effective procurement, along with measures to address corruption.
As part of our effort to develop the capacity of the relevant government institutions, we have involved analytical centres, such as KPMG Ukraine, to monitor health reform implementation and provide reports and recommendations. We have sought and shared expert opinions on strengthening the national health system, and sent our own advisors to participate in government working groups. Through this programme, from 2015 to 2017 dozens of specialists from the Ministry of Health and other institutions have gained new knowledge and improved their capacities to attain the highest standards of transparency, accountability, cost-efficiency and sustainability in public procurement and supply chain management in the healthcare sector.
In 2019, UNDP helped secure CIPS (Chartered Institute on Procurement and Supply) procurement certification for employees of the state-owned enterprise Medical Procurement of Ukraine. This Medical Procurement of Ukraine learning exercise also trained participants in medicines market intelligence.
UNDP recently finalized regional health procurement capacity assessments in 31 medical establishments in Donetsk, Luhansk, Poltava, Rivne and Volyn oblasts. This regional research project provided an overview of the health procurement structure at the regional level, and identified gaps and opportunities faced by regional authorities.
Another UNDP capacity-development initiative is to strengthen the technical capacity of the E-Liky online platform, which operates in all regions of Ukraine and allows patients to check the availability of medicines in health facilities.
Strengthening cooperation with civil society
Another essential component of UNDP’s comprehensive approach to creating a fair and transparent national health procurement process is cooperation with civil society organizations. We strongly believe that the community of patients should be one of the driving forces behind health sector reform. Their voices need to be heard.
Over the past six years, UNDP has actively involved community and patient organisations in discussions and consultations on all initiatives in health procurement reform in Ukraine. Moreover, UNDP has been working with patient groups and other civil society actors to build a system of “checks and balances” to help ensure public control over the national procurement agency’s future activities.
Since 2017, UNDP has provided small grants to patient organisations to monitor the availability and use of medicines procured. This has made it possible for patients to monitor procurement process, and thus contribute to their improvement.
During the last four years of monitoring, the number of participants, types of diseases and the number of regions covered has increased. The programme started with just two diseases and four regions in 2017 (see Public Monitoring Guidelines “Delivery, Availability and Use of Medicines at the Local Level”). By 2019 the monitoring of medicines covered 13 diseases in 11 regions. In 2020, six NGOs analysed the availability of medicines in 17 regions of Ukraine and in the city of Kyiv.
We believe that the direct participation of patient groups not only makes them more visible and lets their voices be heard, but that it also helps to protect patients’ rights, prevents discrimination and allows patients to be active, informed and meaningful participants in their own healthcare.
Responding to COVID-19
Throughout most of history, necessity has always been the mother of invention and innovation. New health challenges and the risks they pose to society require organisations to look for new approaches and tools. This is especially true in the COVID-19 pandemic, during which the world, challenged by a voracious virus, has sometimes had to take draconian measures to reduce the spread of infection. Moreover, the virus brought with it the added ills of social isolation, misinformation and a rapid drop in most social and economic indicators.
To address the most pressing issues, UNDP cooperated with the Ministry of Health of Ukraine and is using a repurposed loan from the World Bank to develop contact tracing systems that could monitor (and thus contain) the spread of the novel coronavisrus. UNDP is also supporting the government of Ukraine with its operational and policy response to the COVID-19 pandemic. The four main areas of activities included:
- Involving patients organisations in disseminating information on the prevention of COVID-19 and counselling communities with limited access to information and/or vulnerable groups;
- Developing an IT solution for COVID-19 contact tracing;
- Creating an information and analytical module for monitoring, forecasting and responding to the spread of COVID-19;
- Developing a learning module for medical professionals to manage contaminated waste, and conducting training sessions for personnel who handle this waste.
Although we have come a long way with our support for Ukraine’s public health procurement systems, there remain several areas where we must stay engaged. First and foremost among these is ensuring that the country’s vulnerable and marginalized populations have dependable access to COVID-19-related services. UNDP will also continue to ensure equal and uninterrupted access to high-quality and cost-efficient medicines and medical devices until the national institutions are fully armed with all necessary skills and have the necessary capabilities. We will continue to closely cooperate with health and procurement stakeholders, strengthening their capacities to promote sustainable public procurement. For instance, by the end of 2021, UNDP will finalize an environmental impact assessment and legal review of Ukraine’s healthcare waste management systems. We believe this initiative will support Ukraine’s transition to the sustainable manufacture, consumption and disposal of medicines and medical materials.
UNDP believes that a comprehensive human rights-based approach, combined with the joint efforts of international organizations, government institutions and civil society, will help overcome Ukraine’s current health challenges. In this way, we will undoubtedly succeed in building an effective, efficient and equitable healthcare system centred on patients and their needs.