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Науковий вкник НЛТУ УкраУни. - 2012. - Вип. 22.1
6. ОСВ1ТЯНСЬК1 ПРОБЛЕМ!! ВИЩО1 ШКОЛ!
УДК 332:351:61 Prof. M.M. Mykolaychuk1, doctor of sciences;
senior researcher V. V. Zasadko2, Ph.D.; senior lecturer M.P. Tyshchenko3, Ph.D.
CHALLENGERS FOR HEALTH CARE SECTOR REFORM AT THE LOCAL LEVEL IN UKRAINE
The article is devoted to some important and actual aspects of reforms in healthcare sector such as private payments for healthcare services, family medicine and efficiency of doctors' work and necessity of public control in health care. The proposals for successful result of the reform in health care sector of Ukraine at the local level are developed.
Keywords: healthcare sector, healthcare system reform, local government, financing, quality of medical service.
Introduction. The necessity of identifying main goals for development health protection of Ukraine's population is due to real political and socio-economic processes, in particular: democratization of society and the integration of Ukraine into the world community, global structural processes in the economy, reducing the level and deteriorating quality of life of most citizens; critical demographic situation; unsatisfactorily condition of population health; low economic efficiency of using resources for health care, imperfect system of remuneration of doctors and other health workers, disparities in the development of outpatient and inpatient care, unsatisfactory ecological situation complicated by the consequences of the Chernobyl disaster.
For several decades in the health care system of Ukraine prevailed extensive way of development, which is characterized by an increasing number of hospital beds, number of physicians and other medical professionals. Improving of quality of this system was expected in its further specialization, the disproportionate increase in the number of doctors 'narrow' specialties. But, these ways of health care were not adequately supported by financial and logistical support. This is especially close to the suffering population, the most massive, accessible and economical outpatient polyclinic care, although there start and end of treatment about 80 percent of patients, especially its primary part - the primary health care. Due to this situation was observed compensatory development of more costly types of care (emergency, hospital), which led to inefficient spending in health sector.
Disparities in the development of outpatient and inpatient, primary and specialized medical care has become one of the main reasons that led to the reorganization of the health care system in Ukraine through the priority development of primaries health care (PHC) and the corresponding rationalization and optimization specialist and inpatient care.
1 Odessa Regional Institute Public Administration of National Academy of Public Administration, Office of the President of Ukraine;
2 Regional Branch of the National Institute for Strategic Studies in Lviv;
3 Kyiv National Economic University named after Vadym Hetman
6. Осв1тянськ1 проблеми вищоУ школи
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This paper aims to raise the problems concerning the inadequate level of quality of healthcare services in Ukraine that causes necessity of reforms. This cross-sectional study was conducted as a part of a survey on the population's health behavior, health attitudes and satisfaction with health care services in two Ukrainian regions. The data consisted of a representative random sample of the adult population of such cities: Bilhorod-Dnistrovsky, Teplodar, Pervomaysk, Izmail, Voz-nesensk and Yuzhne. Personal face-to-face interviews were conducted in 2010 for the randomly selected sample of inhabitants aged 18 years and older. The main theme of questionnaire was level of satisfaction (dissatisfaction) by service in health care institutions and reasons for these answers.
Financial responsibilities of local government in healthcare sector. In Ukraine a large amount of its budget resources on health, mainly spends through local governments. However, for the large amount of resources the budget spends on healthcare services, Ukrainians do not obtain good value. In part, this is due to the acute inefficiency of service provision in this sector, which generates underspending on quality-enhancing expenditures.
However, a whole number of issues remain unregulated, in particular: providing aid on a paid basis, safety of medical service, obtaining information from the executor of service and service itself, obtaining information by patients as to reasons that may influence the quality of medical service, choice and application of sanctions in case of non-fulfillment of agreement on provision of medical service and meeting the deadlines for provision of medical services by the executor.
The resolution of the Cabinet of Ministers of Ukraine of September 13, 2008 No. 828 "On Approval of Forecast of Indicators of Consolidated Budget of Ukraine by basic types of proceeds, expenditures and financing for 2010-2012" envisages expenditures for healthcare in 2010 at the level of 3.39 % of the country's Gross Domestic Product (GDP); 3.41 % of the GDP in 2011 and 3.43 % of the GDP in 2012. However, statistics of expenditures for healthcare in developed countries shows that this indicator must be at least 5 %. This proves that healthcare system in Ukraine requires additional sources of financing or reduction of non-substantiated expenditures in order to provide services properly on the territory of Ukraine, not in certain large oblast centers and in the capital.
Although certain indicators of healthcare (in particular, child and mother death rate) have improved in Ukraine over the past several years, other indicators remained unchanged or deteriorated (for example, death rate of man aged 2539 and spread of tuberculosis and HIV). In addition, Ukraine continues to face challenges in terms of ensuring wider results and consequences of healthcare system operation, such as improvement of effectiveness of service provision, changing the trend of decrease of live expectancy to increase of life expectancy, decrease of catastrophic for patients' expenditures for healthcare and lowering inequality in access to effective services of healthcare.
The dates, which combined in Table show that share of expenditures on healthcare in local budgets is more than in state budget. But high percent of expenditures on healthcare don't correlate with annual expenditures on healthcare per capita and share of salary in total expenditures on healthcare.
Table. The main indicators of expenses in Ukrainian healthcare system (on the example of small cities which have own local budget)
Bilgorod-Dnistrovsky Vozne-sensk Izmail Pervo-maysk Teplo-dar Yuzhne
Expenditures on healthcare, % from sum total city budget 17,1 21,5 30,9 22,3 14,8 11,9
Annual expenditures on healthcare per capita, NOK. 340,37 229,41 366,22 242,96 226,67 385,85
Share of salary in total expenditures on healthcare, % 81,1 75,0 83,2 83 77,2 69,7
Steps of Ukrainian healthcare system transformation. Political instability, frequent changes of government and of the leadership of the Ministry of Health have led to numerous revisions of the course of reforms [1]. During first 10 years after Act of Independence, in Ukraine about 3000 (include General Declaration of Human Rights and Constitution of Ukraine) statutory acts were valid in the healthcare sphere, such us: 59 Laws, the most important of which were passed straight away declaration of independence: "On disease prevention with acquired immune deficiency syndrome (AIDS) and social protection of population" (1991), "Fundamental Legislative Principles on Healthcare of Ukraine" (1992), "On guaranteeing of sanitary and epidemic prosperity of population" (1994 p.), " On Environmental Protection " (1991) etc.; 91 Decrees of the President of Ukraine; 400 Decrees and Resolutions of the Government of Ukraine; 2050 Orders of Ministry of Health Protection of Ukraine (include former Ukrainian Soviet Socialist Republic) and 306 Orders of Ministry of Health Protection of former USSR.
At the first stage of bill activity main attention devoted to legislative bases revision. It was done for providing of evolutional change to new forms and methods for implementation of public policy in health protection sphere and international integration of Ukraine. Besides working out and adoption laws of Ukraine, some legislative regulations on health protection developed by decrees of President of Ukraine. Some of them: National program "Childes of Ukraine" and program "Health of elderly people" (Decrees of the President of Ukraine of 10.12.1997 N 1347 (1347/97) and of 18.01.1996 N 63 (63/96)).
According to main goals of public policy in health protection sphere, by the leading specialists of Ukraine, was created the program of development of sphere to 2010 year, which was approved the college of Ministry of health Ukraine on December, 10, 1999 and passed on claim of Cabinet Ukraine.
By this program the development of Health protection of Ukraine's population was carried out in following priority areas: prevention-oriented health system to a healthy lifestyle, a healthy working conditions and life, ensuring sanitary and epidemiological welfare of population; forming a new system of management in healthcare sphere, based on the principles of market economy, democracy, civil society; the introduction of state-guaranteed level free of charge medical care and its state standard; involvement additional, except state budget, sources for financing of health care; introduction health insurance as a new form of medical and social and economic relations in health care; restructuring of primary health care by application of the family medicine and restructuring of specialized health care; the
introduction various ownership in the health sector, liberalization of conditions for private sector development; organization of a rational system of medicinal and technical maintenance in health care sphere; the reform of higher medical education, reorientation of training general practitioners (family doctors), the improvement of human resources and innovation policies and systems for implementation of scientific medical advances in practice.
The next step of improving the legal framework of health, working out and adoption of laws and regulations that regulate the financing, organization and activities in and regulate relations in the health care system based European standards and economic opportunities in Ukraine was the adoption and launch of a National program for healthcare reform.
In addition to the above, program included: prioritizing of health care and the establishment of state-guaranteed level of medical care for citizens of Ukraine; introduction of effective system of multi-source for funding health care sphere; improvement of salaries of medical workers on the basis of their qualifications, scope, quality and performance; processing standards of medical technology while providing preventive, diagnostic, therapeutic and rehabilitative care; making a system of quality control and medical care based on standards developed by quality; development rational system of accreditation of medical schools and licensing doctors who would not restrain, and contributed to the development of different types of medical care; creation of information system of health care based on extensive use of computer technology, unification of methods and media, development of information networks, improvement of medical and statistical services; improving forms and methods of health at the state and local level; improving health care of rural population through adoption and implementation of interdisciplinary programs; implementation of measures to ensure legal insurance patients and health professionals through appropriate laws and regulations; development and implementation in practice of modern medical technology, effective methods of diagnosis, prevention, treatment and rehabilitation; information about necessity of reform in health care sphere, its purpose and methods of implementation among different population groups, including the public, politicians, journalists and entrepreneurs; providing training highly qualified specialists in public health able to reform the sector; improving medical education according to modern requirements by reviewing and improving training programs.
This stage of reforms should be considered the adoption of the development of public health of Ukraine (hereinafter - the Concept), which was aimed at implementing the provisions of the Constitution and laws of Ukraine regarding the available qualified medical staff sources for support every citizen of Ukraine, introduction of new efficient financing mechanisms and management in health care, and promoting a healthy lifestyle.
The deficit of money not able to compensate organizationally administrative technologies for changing and saving system which are inculcated in industry (reduction of stationary beds, expansion of network of forms for hospital substitute, revision of regular norms of medical personnel, is in establishments of health protection, priority development of primary medical-sanitary help on principles of domestic medicine).
Remained the key problems of health protection population: unsatisfactory state of health of population; insufficient medicinal and material and technical providing of establishments of health protection; inefficient organization of the system of grant of medical care, disproportion of it primary, second and tertiary levels; shortage of modern medical technologies, insufficient domain by them; a low level of being informed is about modern medical technologies, facilities of maintenance of health and active leisure; inefficiency of public policy is in relation to forming of healthy way of life; insufficiency of financial and above all things budgetary, resources for providing of effective activity of the system of health protection; practical absence of market of medical services; imperfection normatively legal acts which influence on conditioning for the improvement of the state of health of population and increase of efficiency of the use in the system of health protection human, material and technical and financial capitals in the conditions of market economy.
Reformation of economic principles of the system of health protection will head for creation of transparent financial and economic mechanisms of having a special purpose accumulation and address use of money, necessary for realization in full of constitutional rights for citizens on a health protection, medical care and medical insurance. Government declares, that sourcing of health protection must be a money state and local budgets, money of obligatory state social medical security and voluntarily medical insurance, money of story funds of territorial societies and benevolent funds, eleemosynary payments and offerings of legal and physical entities, money, got at the grant of requiring payment medical services, and also other sources, not forbidden a legislation.
Local budgets, money of obligatory state social medical security will be financial subsoil of providing of population public medical care within the limits of certain organizational level of grant of medical care and assured volume him medicinal and technological providing (farther is a base standard of quality of popular medical care). The money of voluntarily medical insurance, story funds of territorial societies, will head for satisfaction of individual necessities of population in medical services over the base standard of quality of public medical care.
Private informal payments as a reason of dissatisfaction by quality of medical service in public healthcare institutions. People's health is one of the highest values of the society that form the foundation of economic and spiritual development of a country. The Constitution of Ukraine reads that "...healthcare is provided for by government financing of corresponding socio-economic, medical-sanitary and recreational and prevention programs." Therefore, the government has undertaken an obligation to provide free of charge medical services in the state and municipal healthcare institutions. Moreover, Ukraine's score is among the lowest of all transition economies when it comes to rating the quality of health services, as shown in the EBRD-World Bank Life in Transition Survey [2].
Informal payments in the health sector in Ukraine are emerging as a fundamental aspect of health care financing and a serious impediment to health care reform. Informal payments can be defined as (1) payments to individual and institutional providers, in kind or in cash, that are made outside official payment channels and (2) purchases that are meant to be covered by the health care system [4]. The former encompass "envelope" payments to physicians and "contributions" to hos-
pitals, and the latter the value of medical supplies purchased by patients and drugs obtained from private pharmacies that should be provided by government-financed health care services. Voluntary purchases from private providers are not considered informal payments, but a market transaction at the discretion of the consumer.
Estimates for informal payments for healthcare services in Ukraine vary considerably: up to 3 percent of GDP [5]. This is mainly because different sources cover different components of informal spending. The full value of private expenditures is composed of official user charges, drugs purchased outside of health clinics, under-the-table payments, costs of transportation, food and lodging. Private payments in health are substantial in Ukraine and carry significant inequalities.
Private payments to public doctors, nurses, and other health personnel have created what is essentially an informal market for health care within the confines of the public health care service network. Such payments exist outside the financial control, policy rubric, and audits of national health care systems, and, like the informal sector generally, are often illegal and unreported. In effect informal payments are a form of corruption.
Availability of human resources is a key factor in the functioning of the health care sector. The quality of health care, and accessibility to it, depend on the network adequately staffed and qualified health facilities. Moreover, costs related to personnel constitute the largest component of health care spending, making human resources an important economic factor to be considered in implementing reforms. Finally, performance in the health care sector ultimately depends on the skills and motivation of health care staff [6].
The healthcare workforce is a key element in the process of reform. The healthcare system is labor intensive and reform must address the number, type and skill levels of stuff. World Bank publications argue that Ukraine should reduce the size of health sector in particular due to retired doctors in line with its diminished financial circumstances [5], [7]. There is a question about retired doctor's skills. What happens if a retired doctor's cognitive or physical skills begin to slip because of age and illness, putting the patient at risk? [8] In contrast to that, sometimes the long-time doctor who decided to retire at 60 is asked to stay on long enough to train his replacement and finally retires at 65-70, still beloved and still apparently competent [9]. Often patients trust older doctor more than to the young though skilled doctor. For these reasons there is a necessity to learn this debatable question in more details.
It is actually possible to distinguish three basic types of information that must be given to the consumer in a clear and accessible form: (1) information about health of patient (results of medical researches or reviews); (2) information about essence, basic consumer properties and risks of medical interferences, that is offered by a treating doctor at a concordance with the patient of plan of treatment; (3) information about the performer of medical services [11]. Patients do not know often, where to apply with a complaint about violation of rights in the field of health care services. Among the most frequent examples of violation of rights for citizens in the field of grant of health care services are: not grant of reliable information about the possible methods of treatment and complete information about the appo-
HayKOBHH BicHHK M.IT > YKpaÏHH. - 2012. - BHn. 22.1
inted preparations and their influence on the organism of patient; a refuse to provide service in a state hospital; wrong diagnose; scornful attitude toward a patient.
The constitution of Ukraine declares that citizens shall have the right to health care services and medicine free of charge in governmental and municipal organizations. But, at present days, the level of satisfaction by quality of medical service isn't high, even in small cities (answers "Good") is in average equal to 26,8 % (Figure 1). On the other hand, approximately half of all citizens (47,6 %) evaluate the level of satisfaction by quality of medical service as "Average", that means both indifference to this problem and availability of alternative choice.
Yuzhne Teplodar Pervomaysk Izmail Voznesensk Bilgorod-Dnistrovsky
41
46
=T"25 124
:T37 32
44
47
3 60
Good □ Average Bad
20
30
□ 45
28
□ 52
Figure 1. Overall impression from quality of health care services in public medical institutions (%)
~l-1-1-r
0 10 20 30 40 50 60 70 Then authors try to analyze reasons of low level of satisfaction by quality of medical service. The first of them is informal payments. The law stipulates the right of local authorities to include specific chargeable services in the set of services provided by governmental health facilities Today, a client may receive a service free of charge, or pay an official service fee (formal payment), or make a shadow payment, i.e. give money or gifts to the medical staff unofficially (informal payment).
In accordance with our research, in all cities patients says that paid for medical services. Mostly this practice is widespread in Bilhorod-Dnistrovsky and least in Teplodar (Figure 2).
Yuzhne Teplodar Pervomaysk Izmail Voznesensk Bilgorod-Dnistrovsky
0
1 10
22
26
26
-1-1-1-1-1- - 3
5
10 15 20 25 30 35 40 Figure 2. Have you had any extra expenses during getting of medical service by doctor / in policlinic / in hospital?. (Percentage of responds "Yes").
The extent of formal and informal payments may have important policy implications in Ukraine. Informal payments can distort the priorities of the health system, reduce access to health services and impede health reforms. They can also provide undesirable incentives and encourage unprofessional behavior, including rent-seeking behavior by health workers.
3
Informal payments exist for several reasons, including economic ones such as a general scarcity of financial resources in the public system; and socio-cultural ones, such as the lack of trust in government and a culture of tipping. Health system characteristics that may help explain the prevalence of informal payments include an excess supply of capital and human resources, low salaries, lack of accountability and government oversight, and an overall lack of transparency. Human resource shortages may also drive informal payments as it may lead to providers giving priority to those patients that can afford to pay. A paucity of private services may also drive informal payments, as wealthier patients have fewer options outside of the public system. Also, the population may not be adequately informed of the health services they are entitled to free of charge.
But as a result of more detail analyze we can see that informal payment is not a significant reason for dissatisfaction by health care system in Ukraine. Comparing main indicators from Table with results from figure 1 illustrates that those factors have average correlation dependence (correlation coefficients are 0,56; 0,67 and 0,70 for different types of answer). Moreover, the point "high costs of services" took forth place between reasons of stop to use the medical services but this factor doesn't have correlation dependence with level of satisfaction by medical service. The real reasons of dissatisfaction by health care system (and this conclusion is confirmed by high level of correlation dependence) are: bad quality of medical services, non professionalism of the doctors (medical staff) and not good technical equipment (Figure 3).
24,2
Yuzhne
Teplodar
Pervomaysk
Izmail
Voznesensk
Bilgorod-Dnistrovsky
6,1
J 3
36,4 3,3
12,1 12,1
3,3 41,4
44,4 44,4 42,1 43,9
=1=
445
50
78,6 81
3,8
58,3
4
60
H Not good technical equipment | | High costs of services
I I Non professionalism
of the doctors / medical staff
□ Bad quality of services
0 20 40 60 80 100 Figure 3. Reasons of dissatisfaction by quality of medical service in public healthcare institutions (percent answered "Yes")
According to premises, main issues in Ukrainian healthcare system connected with dissatisfaction by quality of medical service (based at the vote of no confidence to doctor and technical equipment) and, from other hand, with inadequacy of motivation for improvement of prestige and quality of medical staff work.
Ways and means for improvement health care system at the local level in Ukraine. The main goals for making mechanism of management, coordination and interaction between medical institutions which offered by participants of the Health Care Efficiency Network, working in the frame of the Norwegian-Ukraini-
an project, are: making the system of unified medical information field; implementation of new methods for treatment and diagnostics, based on the using of modern technical equipment; strengthening of interaction between all healthcare systems; making of additional sources for financing of modern medical service; mutually beneficial using of communities recourses.
The results of public opinion poll confirmed that population ready to reform and want take an active participation in solving problems in healthcare system in Ukraine (Figure 4). At the other hand public opinion poll shows that peoples are not clearly informed about abilities, institutes, qualities and costs in medical service. However each of potential consumers of health care services must be informed in relation to their quality, essence, safety and other properties due to Ukrainian legislation. Existing state of affairs reduced to situation then citizens agree with role of participants in solving of financial problems in healthcare system, but they expect strong public control in medical sphere (Figure 4).
Yuzhne Teplodar Pervomaysk Izmail Voznesensk Bilgorod-Dnistrovsky
27
85
□ 67
344
□ 80 78
45
32
88
66
30
99
52
68
| | Approving of strengthening of public control (Percent answered "Yes").
I | Satisfaction by information about medical service: abilities, institutes, qualities, costs (Percent answered "Not at all").
| | Readiness to partially payment for medical service. (Percent answered "Yes").
0 20 40 60 80 100 120 Figure 4. Indicators of readiness to reform measures
In Ukraine, the access to and quality of publicly funded health care services may be under serious threat due to the current unclear, non-transparent financial rules. This may lead to deterioration of the quality of governmental free health care services in general because institutions that provide both chargeable and free services will tend to develop those services that bring more financial benefits.
While the problem of informal payments for public health care services is acute in Odesa and Mykolayiv regions, the same challenges are most probably also faced by other administrative regions in Ukraine. More importantly, the informal payments in Ukraine may increase the regional inequality among service users if citizens in poorer regions need to make more informal payments than those in richer regions.
While commercialization may cause an increase in prices of health services in general in Ukraine, the open market, if it is truly open, circumscribes the need for unofficial payments by bringing the different fees into the light. If the legal payments were more beneficial for both patients and health professionals, there would be no need to make unofficial payments. More than half of the respondents in this study reported willingness to pay for diagnostic and treatment services, and for anonymity and convenience, which may reflect a common belief among the po-
pulation that money will help to ensure quality and privacy of services. It may also reflect the readiness of the population to condone the out-of pocket contributions.
If the government defines: a minimum set of free-of-charge health services (free health care benefit package), population groups entitled to free services provided in excess of the minimum package and, population categories who will have to fully or partially compensate the cost of services provided in excess of the free benefit package, informal payments will become less prevalent, but will not disappear at all. Provision of chargeable and free-of-charge services by the same health care institution will make doctors/nurses intentionally reduce the quality of free services in order to make their recipients pay.
If health care providers get divided into those who may, and those who may not provide chargeable services (that is, if public health institutions will not be officially allowed to charge fees for services), the health care delivery system will become polarized. As a result, health care facilities will be divided into "clinics for the rich" and "clinics for the poor". And the gap between the quality of services provided by the two groups will continue to grow.
Conclusions. Analysis of public opinion of small cities of South Ukraine, which take part in projects, testifies to the low level of satisfaction by quality of grant of medical services and his dependence on the social and economic stability.
Analysis of activity financing of the system of health protection is given by possibility to define the key problems of industry. To them, foremost, belong:
• insufficient financing of industry, conditioned this low level of payment of labour of medical workers, shortage of facilities for providing of accessible, high-quality and effective medical care; inefficient organization of medical care, disproportion in development ambulatory policlinic and stationary, primary and specialized help, connection and following is unsatisfactory in their grant;
• imperfection and weakness of the legal providing of activity of the system of health protection; insufficiency, uncoordinated and inefficiency of measures, directed on a maintenance and strengthening of health of population;
• a requirement is in the improvement of preparation, retraining, and in-plant training doctors and other workers of health protection, improvement of terms of their work, its quality and efficiency;
• insufficiency of modern medical technologies, insufficient domain by them, unsatisfactory medicinal and material and technical providing of establishments of health protection; a low level of the informative providing and management of health protection the system is on different levels.
The following recommendations for state policy-makers can be made based on the outcomes of the survey:
1. Legalization of illegal payments for health services will not be an only satisfactory solution to the current problem of mismatch between declared amount of state guarantees and that of available public funds. There is no win-win solution to the problem. An option should be chosen that will have the minimum negative impact. Possible solutions may include the following: - assure sufficient funding of only one of the two parts of the government guarantees program (i.e. free health care benefits program), specifically, the mandatory health insurance (MHI) program (package); - revise the list of health services to be provided under the MHI program, but try to avoid a large-scale legalization of informal payments.
Науковий вкник Н.1Т У Укра'1'ни. - 2012. - Вип. 22.1
2. The government should more clearly define its obligations regarding free-of-charge health services to be included in the MHI package. The contents of that benefit package should be made more clear and specific (what services, drugs, etc. must be provided free of charge to patients with specific conditions) and represent a set of attainable medical and economic standards based on realistically available resources. Thus, the government needs to clearly define health services which can actually be provided free of charge to the population under the mandatory health insurance program. Again, the benefit package may not contain more services than the government will actually be able to pay for.
3. Attempts to use administrative or criminal prosecution against those who make or accept under-the-table payments for services excluded from revised MHI program will be ineffective. We recommend that indirect measures should be used instead, such as: provide support to legitimate chargeable health care services and regulate prices of monopolized health services (i.e. services provided with the use of unique/high-tech equipment and technologies available to only few health institutions) so that officially-set prices could limit the growth of the "shadow" prices for the same services.
4. One of the ways for solving problems with financing of hospitals - using Norwegian experience in making semi-centralized National health care system.
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Миколайчук М.М., Засадко В.В., Тищенко М.П. Виклики для ре-формування системи охорони здоров'я УкраТни на мкцевому piitiii
Розглянуто деяю важливi та актуальш аспекти реформування системи охорони здоров'я, тага як: приватш платежi за медичш послуги, амейна медицина, ефектив-шсть роботи лiкарiв i необидшсть громадського контролю у сферi охорони здоров'я. Розроблено пропозици для забезпечення позитивних результапв реформування системи охорони здоров'я в Укра1ш на мюцевому рiвнi.
6. Осв^янськ проблеми вищо'Т школи
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Ключовi слова: охорона здоров'я, реформа системи охорони здоров'я, мюцеве самоврядування, фшансування, ягасть медичного обслуговування.
Миколайчук М.М., Засадко В.В., Тищенко М.П. Вызовы для реформирования системы здравоохранения Украины на местном уровне
Рассмотрены некоторые важные и актуальные аспекты реформирования системы здравоохранения, такие как: частные платежи за медицинские услуги, семейная медицина, эффективность работы врачей и необходимость общественного контроля в сфере здравоохранения. Разработаны предложения для обеспечения положительных результатов реформирования системы здравоохранения в Украине на местном уровне.
Ключевые слова: здравоохранение, реформа системы здравоохранения, местное самоуправление, финансирование, качество медицинского обслуживания.
УДК 336.152 (477) Доц. Н.В. Савчук, канд. екон. наук; маг1странт
Х.В. Радкевич; магктрант Л.Л. Зозуля -Львгвська державна фтансова академш
ПРОБЛЕМИ Ф1НАНСОВОГО ЗАБЕЗПЕЧЕННЯ СОЩАЛЬНО1 СФЕРИ УКРА1НИ ТА ШЛЯХИ IX ВИР1ШЕННЯ
Розглянуто актуальш проблеми фшансування сощально! сфери Укра1ни, про-аналiзовано !х значущють, а також видшено низку пропозицш, яга могли б вивести функщонування сощально! сфери на яюсно новий рiвень.
Ключовi слова: сощальна сфера, фшансове забезпечення, охорона здоров'я, ос-в™, проблеми фшансування, мехашзм сощального замовлення, державнi видатки.
Сощальна политика держави покликана забезпечити громадянам га-рантоваш Конститущею Укра!ни права: на життя, безпечш умови пращ, ви-нагороду за працю, захист им'!, вщпочинок, освпу, житло, охорону здоров'я та медичну допомогу, сощальне забезпечення та сприятливе навколишне се-редовище.
Питання щодо надежного р1вня державного фшансування сощально! политики протягом тривалого часу залишаеться суперечливим, як у розвине-них, так 1 в бщних кра!нах. 1люзп "держави загального добробуту з макси-мальним р1внем державного забезпечення сощальних програм останшм часом зам1нюються прагматичною концепщею неспроможносп навпъ найба-гатшого бюджету задовольнити вс сощальш проблеми без загрози виникнен-ня кризових тенденцш в економщь
Актуальн1сть обраноУ теми полягае в тому, що формування в Украш ринкових засад господарювання та необхщнють забезпечення громадян кра!ни належним р1внем сустльних послуг потребують побудови ефективно! системи гарантш населения. Потр1бно зазначити, що на фшансування сощально! сфери з бюджету витрачаеться близько 40 % вщ загального обсягу видатюв.
Анал1з попередшх досл1джень. Науков1 дослщження з питань сощального захисту населення та вдосконалення практично! д1яльносп держави в цьому напрям1 проводили в1тчизняш й заруб1жш вчеш та фах1вщ. Серед них: В. Вакуленко, I. Гнибщенко, Т. Лопушняк, О. Пищулша, С. Салига, Ю. Ску-лиш, Й. Хендшель, П. Таундсен, Ю. Шклярський та багато шших. Проте, нез-
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Збiрник науково-технiчних праць
