eHealth is a step-by-step digitalization of all interactions in the medical sphere up to the latest technology, interoperability & requirements. With a bottom-up approach civil society, state and business are creating an effective IT tool to fight corruption in healthcare before all legislation is in place. GoU sets up the rules and standards, while business creates final interfaces for users.
eHealth system will fight pervasive corruption in the health sector by means of step-by-step digitalization of all interactions in the medical sphere – providing transparent and checkable information on all budget spending in the sector. Background:
• The average life expectancy in Ukraine in 2015 was 71.1 years
• Public health facilities receive financing based on existing infrastructure (number of hospital beds, staff, and building size)
• Such a financing system very inefficient
• 4th country in the world for the number of hospital beds per population (879 hospital beds per 100,000 people)
• 1/3 hospitalizations in Ukraine are unnecessary
• Hospitals are outdated, poorly maintained and equipped
• According to the Constitution of Ukraine, health care services should be free of charge
• Total health spending constituted 7.4% of Gross Domestic Product (GDP) in 2014
• Only 46% of health spending coming from public sources
• Doctors often have to “buy” their position (doctor’s formal salary appr. $200/month, some positions cost $10,000 to $25,000)
• 9/10 Ukrainians have a fear of financial hardship in case of an episode of illness.
Health Care System has not been reformed since the independence of Ukraine. Corruption across healthcare is a pervasive and persisting problem in Ukraine. It results in the loss of a significant portion of limited health care resources and ultimately contributes to poor health outcomes. The victims of the current situation are patients, required to “contribute” to semi-formal hospital “charity funds”, prescribed brand name drugs to receive a kickback from pharmaceutical companies, asked to buy and bring necessary drugs and materials into the hospital, while still receiving substandard care from a run-down facility with obsolete medical equipment and unhappy medical personnel.
To solve this problem, the current team of the Ministry of Health of Ukraine (MoH) has started the fundamental change of the payment principles in the system - financing reform. It will replace outdated Soviet planning system with transparent and highly motivated “money follows the patient” system for doctors payroll. It will take into account doctor's’ efficiency, real involvement, patient satisfaction, and reliable data. It will change the entire logic of the relationship between the state, hospitals, doctors, and patients. First it will be implemented for the primary health care with the introduction of capitation. Later introducing fee for service and DRG based payment for the entire scope of medical services in the country.
According to the Cabinet of Ministers of Ukraine resolution (November 2016) there is a state program “Affordable Medicines”. It provides a range of reimbursed drugs, but the provision is completely paper-based. The distribution process is uncontrollable and there is no control whether the patient really received the drugs for free. MoH realizes a high risk of failure of any reform with paper-based implementation due to the enormous risk of data falsification (Experience of other countries shows that paper-based reports may lead to the budget overruns in 2-3 times). Consequently, it was decided to start off the reforms that are backed up by the digital support. MoH has set an inquiry to start creating an efficient and transparent eHealth system with the following objectives:
• Creating the fundamental services for eHealth system that simultaneously will support reforms implementation in health care • Enhancing transparency, accountability, and responsiveness of the health care system
• Improving health sector governance
• Supporting evidence-based decision-making on every level of health care
• Boosting the health system as a significant sector of Ukraine’s economy
• Improving instruments for policy making and governance in health sector for all actors
• Fighting corruption in the sphere of health care.
Key principles laid the foundation of the system are:
- Safety and security of information is a priority
- utility, and value for all actors
- Integrity and continuity of health records
- Convenience and reliability
- Management and financial transparency
- Information and knowledge management
- Interoperability and standardization
- Free market and fair competition
- Possibility for further expansion of system
- Equal access across Ukraine.
All citizens: ability to chose a doctor regardless of age, gender, social status and registration - ensure equal access to higher quality medical services.
Medical personnel: higher wages depending on the number of patients – strong intention to be “patient-oriented” and provide better services.
Business: open market and fair competition: conditions for medical eServices development. Government: to be capable of meeting the health needs of the Ukrainian people, tackling corruption.
NGOs: transparency by mean of digitalization: control over efficient budget money spending.
What Makes Your Project Innovative?
There are several Medical Information Systems (MISs), but they are not interoperable. Thus, there is no national, integrated and functional eHealth system that creates an excellent ground for corruption. MoH has announced eHealth project as the priority. There is a lack of capacity and stability within the Ministry itself to implement such a project (4 Ministers were removed in 3 years). Due to the legislative barriers and resistance from corrupt bureaucrats, the decision was made to start eHealth system development on the basis of non-governmental organizations (NGOs). So, we used the bottom-up approach creating IT product before all legislation will be in place.
What is the current status of your innovation?
According to eHealth roadmap for 2018-2020 we will implement services highly demanded by the patients and the doctors such as medical card (with medical records), eRefferals, ePrescription, online booking. More information on the project could be found on eHealth webpage: http://www.ehealth-ukraine.org/.
Collaborations & Partnerships
Hybrid model for eHealth system is “golden triangle of partnership”. The Ministry/ Government “sets the rules for the market” by administrating the Central Component that integrates MISs. Only MISs provide the final user interface. And all this work is performed under supervision and support of society (NGOs). Such a model has a number of advantages:
- Anti-corruption/ system not monopolized
- Creates fair competition for MIS to develop better services for the clients
- Easier, faster and cheaper to develop from the scratch
- Cheaper to maintain and up-grade development further (due to the fact that substantial part of work is done by MISs)
- Earn more support and trust from the business and society's side
– positively affects projects sustainability. Also, all eHealth system development is performed due to the financial and technical support of international donor organizations and projects. Thus, we receive expertise and support from other countries.
Users, Stakeholders & Beneficiaries
The new team in the Ministry is in process of implementation of the fundamental reform for the health care sphere (financing reform). Project Office responsible for eHealth system development is based on 2 NGOs using the principle “check and balance”: "All-Ukrainian Network of PLWH" (to follow the interests of patients) and "Transparency International Ukraine" (to provide anti-corruption activity). PO coordinates its development activities with the Ministry needs using international organizations expertise to analyze the best existing practices in the world while building the unique eHealth system. PO holding meetings continuous with MIS vendors, NGOs, different patient organization and the medical community representatives to engage and receive support from as many stakeholders as possible.
Results, Outcomes & Impacts
According to the concept, under the new health financing reform, the money will follow the patients. This will change the old input-based financing system and create incentives for improved quality through free choice and competition. Other major change is the establishment of the new national health purchasing agency – National Health Service (NHS), enhancing provider autonomy, introducing strategic purchasing (contracting) of health services from providers. Implementation of eHealth system already allows:
• Increase the effectiveness of health care system;
• Enforce the “money follows patient” principle for increased transparency and reduced fraud and corruption;
• Provide equal access to medical services regardless of gender, age, social status and registration;
• Improve health care quality and patient safety;
• Exclude informal payments from the patients;
• Build new relationships between patients and health workers.
eHealth will focus on designing new features and mechanisms to allow:
• Strengthening civil society and watchdog oversight of the ongoing reforms;
• Ensure availability of public information and patient feedback;
• Provide relevant eHealth applications for doctors (e.g. protocols and guidelines) and patients (rights, entitlements, service and drugs availability);
• Allow for generating dashboards and other infographics on clinical–epidemiological and administrative data;
• Building the analytical capability of the MOH and its relevant divisions to use and interpret data for evidence-based policy decision-making.
Challenges and Failures
MoH reforms are facing numerous barriers and challenges, met heavy resistance from medical personnel at all levels. Regional health administrators and chief doctors fear to lose their existing influence and informal benefits. But the Ministry in cooperation with social activists was motivated to implement changes. Thus, there was a decision to develop eHealth system without any legal regulation from the government to demonstrate tangible results to the public in a very short period of time. To engage business and society eHealth system was developed as an open-source code avoiding any possible attempts in corruption and preventing the conflict of interests. At the moment there are more than 30% of the primary health care facilities registered in eHealth system in the pilot mode. It was achieved with no substantial communication support and legal regulation. Even legal framework won’t be a blocking factor for eHealth system development if it will be supported by society.
Conditions for Success
- Pro-active position of society, understanding responsibility for changes even in the policies
- Support of society and NGOs
- Support of business and all engaged stakeholders
- Support of trusted, not corrupted part of the Government
- Transparency of all stages of development, open-source product
- Transparency of communication and finances
- Experienced and highly engaged and dedicated team
1. eHealth is developed as an open-source product. It can be freely downloaded by any government or NGO
2. Bottom-up approach – ideal concept for bureaucratic and corrupted governments. When changes are initiated and implemented by the social activists
3. Hybrid model concept – could be used as an approach to engage business in the project, to lower the costs for development and maintaining as well as gathering wide expertise in the sector
4. Golden triangle approach – cooperating, but not controlling government.
Not to complain about the violation of rights, but to take responsibility to make changes. Not to wait for the Laws or another regulatory framework to be in place, but to start actions. To engage as many stakeholders as possible. To receive support from the society. To make small but frequent actions to show tangible results in the short period of time. While developing the development strategy to work for the benefit of all citizens.
eHealth roadmap for 2018-2020: eRefferals for the secondary and expert care, ePrescription (registry of pharmacies, registry of pharmacies employees, despence of drugs), standardization (HL7, SNOMED and etc.) and harmonization with EU requirements, online Booking. Registry of licenses and digitalization of separate statistical forms up to request of the Ministry.