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12ОРГАН1ЗАЦ1Я МЕДИКО-ПРОФ1ЛАКТИЧНО1 СЛУЖБИ
УДК 314.44:616-082:001.8(477)
DOI http://dx.doi.org/10.5281/zenodo.3465917
V. V. Shafransky1, G. O. Slabky2
REVISITING THE PROBLEM OF STAFFING THE SYSTEM OF THE PRIMARY
MEDICAL CARE IN UKRAINE
1O. O. Bogomolets National Medical University, Kiev, Ukraine;
2Uzhgorod National University, Ukraine
Summary. Shafransky V. V., Slabky G. O. REVISITING THE PROBLEM OF STAFFING THE SYSTEM OF THE PRIMARY MEDICAL CARE IN UKRAINE. The
analysis of availability of primary health care institutions in the regions of Ukraine and provision of the population with the positions of doctors of general practice - family doctors, the availability of these positions and the level of their staffing is presented. The availability of positions of junior specialists with medical education at rural health posts (RHP) and their level of staffing is analyzed as well. The low level of staffing of general practitioners-family doctors with a reliable difference of this indicator by region is shown. It was noted that this situation reason is the lack of motivation in medical workers.
Key words: primary health care, priority development, medical personnel, staffing level.
Реферат. Шафранский В. В.1, Слабкий Г. О.2 К ВОПРОСУ КАДРОВОГО ОБЕСПЕЧЕНИЯ СИСТЕМЫ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ В УКРАИНЕ - 'Национальний медицинский университет им. А. А. Богомольца; 2Ужгородський национальный университет. Развитие первичной медико-санитарной помощи (ПМСП) на принципах общей врачебной практики-семейной медицины является приоритетным направлением реформы здравоохранения в Украине. Отработка современной модели ПМСП проводилось в пилотных регионах Винницкой, Днепропетровской, Донецкой областях и г. Киеве в 2012-2014 г. г. За время пилотного проекта была проведена структурная перестройка с разграничением первичного и вторичного уровней оказания медицинской помощи и формированием юридически самостоятельных центров ПМСП, а также внедрены современные механизмы финансирования. В пилотных регионах был отработан механизм свободного выбора населением семейного врача и законодательно ему предоставлено право определять медицинский маршрут пациента. Также был разработан и введен мотивационный механизм для обеспечения эффективной и качественной работы медицинскими работниками первичного звена, особенно профилактического. При этом особое внимание уделяется кадровой политике. Цель: изучить и проанализировать состояние кадрового обеспечения системы первичной медико-санитарной помощи в Украине. Материалами исследования стали данные отраслевой статистической отчетности за период 2013-2016 г. г. При выполнении исследования использованы статистический и библиосемантичний методы. Результаты и выводы. В результате проведеного исследования показан низкий уровень укомплектованности должностей врачей общей практики - семейных врачей с достоверной разницей показателя в разрезе регионов. Отмечено, что причиной данного состояния кадрового обеспечения первичного звена медико-санитарной помощи является отсутствие мотивации медицинских работников к работе именно на первичном уровне медицинской помощи.
Ключевые слова: общая врачебная практика, семейная медицина, кадровое обеспечение, мотивация медицинских работников.
© Shafransky V. V., Slabky G. O.
Реферат. Шафранский В. В.1, Слабкий Г. О.2 ДО ПИТАННЯ КАДРОВОГО ЗАБЕЗПЕЧЕННЯ СИСТЕМИ ПЕРВИННО1 МЕДИКО -САН1ТАРНО1 ДОПОМОГИ В УКРА1Н1 - 1Нац1ональний медичний утверситет ¡м. О. О. Богомольця; 2Ужгородський нацгональний унгверситет. Розвиток первинно! медико-саштарно! допомоги (ПМСД) на засадах загально! лжарсько! практики-амейно! медицини е прiоритетним напрямком реформи охорони здоров'я в УкраЫ. Вiдпрацювання сучасно! моделi ПМСД проводилося в пiлотних репонах Вiнницькiй, Днiпропетровськiй, Донецьк1й областях та м. Киевi в 20122014 р. р. За час тлотного проекту було проведено структурну перебудову з розмежуванням первинного та вторинного рiвнiв надання медично! допомоги та формуванням юридично самостiйних Центрiв ПМСД i запроваджено сучаснi механiзми фшансування. В пiлотних регiонах було вщпрацьовано механiзм вiльного вибору населениям амейного лiкаря та законодавчо надано йому право визначати медичний маршрут пащента. Також було розроблено та запроваджено мотивацшш мехашзми для забезпечення ефективно! та яшсно! працi медичними пращвниками первинно! ланки, особливо профшактично!. При цьому надзвичайно важлива увага придметься кадровiй полiтицi. Мета: вивчити та проаналiзувати стан кадрового забезпечення системи первинно! медико-саштарно! допомоги в Укра!ш. Матерiалами дослiджения стали данi галузево! статистично! звiтностi за перiод 2013-2016 р. р. При виконанш дослщження використано статистичний та бiблiосемантичний методи. Результата та висновки. В результата дослiджения, що проведено показано низький рiвень укомплектованостi посад лiкарiв загально! практики-амейних лiкарiв з достовiрною рiзницею показника в розрiзi регiонiв. Вiдмiчено, що причиною даного стану кадрового забезпечення первинно! ланки медико-саштарно! допомоги е вiдсутнiсть мотивацi! медичних працiвникiв до роботи саме на первинному рiвнi медично! допомоги.
Ключовi слова: загальна лiкарська практика, амейна медицина, кадрове забезпечення, мотивацiя медичних пращвнишв.
In Ukraine health care reform is being implemented [10], its priority direction is the development of primary medical and sanitary care (PMSC) on the basis of general medical practice - family medicine [2, 6]. Perfection of modern PMSC model was carried out in pilot regions by health system reform in the country - Vinnytsia, Dnipropetrovsk, Donetsk regions and Kyiv in 2012-2014 [8]. During the pilot project, a structural reorganization was conducted with the distinction between primary and secondary levels of medical care provision and the formation of legally independent centers of primary medical care [11, 12] and modern financing mechanisms [4] were introduced. In the pilot regions the mechanism of free choice of the family doctor [13] was worked out and the doctor was legally granted the right to determine the medical route of the patient [7]. Motivational mechanisms have also been developed and introduced to provide effective and quality work for primary care professionals, especially for preventive care [5, 9]. In this case special attention was paid to human resources policy [1, 3].
The objective: To study and analyze the state of staffing of the primary medical care system in Ukraine.
Materials and methods. The materials of the study were the data of sector statistical reporting for 2013-2016. In the course of the study statistical and bibliosemantic methods were used.
Results and discussion
In 2016, the development of primary health care on the basis of family medicine remained a priority in the process of reforming the health care sector in Ukraine. The urgent task of optimizing the primary health care activities was to provide the population with affordable and quality primary health care. This can be achieved through further development of the PMSC's network and the provision of primary care facilities by qualified medical personnel.
The development of primary health care in Ukraine in 2016 from the above positions has been analyzed.
Table 1 provides data on the number of PMSC centers in the regions of Ukraine and the availability of medical outpatient clinics and rural health posts (RHPs).
Table 1
Centers of primary medical and sanitary care and their structure, 2016
Administrative territories Independent Centeres of PMSC Including rural administrative districts In the structure of independent centeres of PMSC
Outpatient clinics RHPs
Ukraine 616 445 5233 11177
Vinitsa Region 34 28 325 837
Volyn Region 20 15 138 758
Dnepropetrovsk Region 54 23 418 392
Donetsk Region 33 11 247 325
Zhitomir Region 26 24 214 688
Transcarpathian Region 13 11 232 235
Zaporozhye Region 38 27 277 357
Ivano-Frankovsk Region 5 5 56 119
Kiev Region 29 24 292 618
Kirovograd Region 24 20 162 475
Lugaansk region 16 12 128 236
Lviv Region 4 4 28 111
Mykolayev Region 28 19 220 381
Odesa Region 40 26 279 450
Poltava Region 34 26 328 618
Rivno Region 22 18 166 614
Sumy Region 19 15 112 341
Ternopol Region 16 15 203 650
Kharkiv Region 33 31 332 496
Kherson Region 20 19 159 342
Khmelnitsk Region 23 22 212 887
Cherkasy Region 18 15 127 380
Chernovtsy Region 14 12 168 205
Chernigov Region 25 23 153 662
Kiev 28 257
In Ukraine, the network of PMSC Centers is practically completely formed as legally independent health care institutions. In total, 616 PMSC Centers function in the country, out of which 445 (72.2%) operate in rural areas. In the structure of the centers operate 5233 outpatient clinics and 11177 RHPs.
In the context of the regions, the number of PMSC centers and the established medical clinics and RHPs depends on the population size, its settlement, which determines the administrative-territorial structure of the region, the level of development of primary health care on the basis of general medical practice - family medicine in the region. Thus, the largest number of PMSC centers was formed in Dnipropetrovsk region (54), and the smallest in Lviv (4) and Ivano-Frankivsk (5) regions.
One of the indicators that determines the availability of primary health care is the presence of the medical outpatient clinics in the structure of PMSC's centers. The largest number of outpatient clinics is in the Dnipropetrovsk region (418), Kharkiv (332) and Poltava (328) regions, and the smallest in the Lviv (28) and Ivano-Frankivsk (56) regions.
The largest number of RHPs operates in Vinnytsia (837), Volyn (756) and Zhytomyr (688)
regions.
Further, data on the availability of GPs - family doctors positions and their employment in 2016 were studied. The results obtained are presented in Table 2
Table 2
The positions of general practitioners - family doctors and their employment in 2016
Physical Difference between Difference between % Staffing % Staffing
Administrative Full-time Filled persons full-time full-time level of level of
territories! job vacancy at the filled vacancies jobs and filled vacancies jobs and physical persons full-time jobs + secondary job full-time post with physical persons
Ukraine 18719.25 15 976.75 13696 2 742.50 5 023.25 85.35 73.17
Vinitsa Region 1 143.50 920.75 819 222.75 324.50 80.52 71.62
Volyn Region 504.25 452.00 384 52.25 120.25 89.64 76.15
Dnepropetrovsk Region 1 821.75 1 597.25 1350 224.50 471.75 87.68 74.10
Donetsk Region 816.00 612.50 510 203.50 306.00 75.06 62.50
Zhitomir Region 775.00 685.25 561 89.75 214.00 88.42 72.39
Transcarpathian Region 713.00 665.75 637 47.25 76.00 93.37 89.34
Zaporozhye Region 855.00 744.00 623 111.00 232.00 87.02 72.87
Ivano-Frankovsk
Region 464.75 425.25 400 39.50 64.75 91.50 86.07
Kiev Region 836.00 703.50 592 132.50 244.00 84.15 70.81
Kirovograd Region 426.50 325.25 253 101.25 173.50 76.26 59.32
Lugaansk region 229.50 179.25 150 50.25 79.50 78.10 65.36
Lviv Region 994.50 963.25 921 31.25 73.50 96.86 92.61
Mykolayev Region 600.00 474.50 377 125.50 223.00 79.08 62.83
Odesa Region 1 453.25 1 156.50 981 296.75 472.25 79.58 67.50
Poltava Region 892.00 720.50 598 171.50 294.00 80.77 67.04
Rivno Region 412.25 377.50 339 34.75 73.25 91.57 82.23
Sumy Region 427.00 377.50 320 49.50 107.00 88.41 74.94
Ternopol Region 645.50 568.75 529 76.75 116.50 88.11 81.95
Kharkiv Region 1 001.00 863.75 716 137.25 285.00 86.29 71.53
Kherson Region 417.25 305.75 224 111.50 193.25 73.28 53.68
Khmelnitsk Region 603.25 535.50 480 67.75 123.25 88.77 79.57
Cherkasy Region 598.00 503.00 398 95.00 200.00 84.11 66.56
Chernovtsy Region 480.25 443.00 374 37.25 106.25 92.24 77.88
Chernigov Region 478.00 395.50 321 82.50 157.00 82.74 67.15
Kiev 1 131.75 981.00 839 150.75 292.75 86.68 74.13
In 2016, the Ministry of Health of Ukraine introduced 1871925 posts of general practitioners - family doctors, of which 1597675 are employed with 13696 physical persons of the given profile. At the same time, the level of staffing of full-time positions is only 85.35%, and the level of staffing posts by individuals is 73.17%. At the same time, in 16 (64.0%) regions, the level of staffing by individuals is less than 75%, which, according to evidence-based management, does not empower to render affordable and quality primary health care for the entire population. The lowest is the level of staffing by individuals in the following regions: Kherson (53.68%), Kirovograd (59.32%), Donetsk (62.50%), Mykolaiv region (62.83%). In Kyiv, the level of staffing of staff posts by individuals is 74.13%.
The following is the staffing level per 10 000 people by general practitioners-family doctors in the dynamics in 2013-2016 by regions.
Table 3
Staffing level by general practitioners - family doctors per 10 000 of general population
Administrative territories! Per 10 000 of general population
2013 2014 2015 2016
УкраТна 2.67 2.89 3.13 3.40
Vinitsa Region 4.62 5.19 5.50 5.61
Volyn Region 2.70 3.02 3.40 3.78
Dnepropetrovsk Region 3.09 3.81 4.05 4.25
Donetsk Region 2.00 1.08 2.56 2.65
Zhitomir Region 4.07 4.27 4.46 4.72
Transcarpathian Region 4.54 4.68 4.82 5.07
Zaporozhiye Region 2.32 2.93 3.10 4.03
Ivano-Frankovsk Region 1.99 2.67 3.02 3.33
Kiev Region 2.02 2.46 3.02 3.38
Kirovograd Region 1.75 1.63 2.06 2.73
Lugaansk Region 1.16 0.60 2.11 2.23
Lviv Region 2.87 3.11 3.34 3.88
Mykolayev Region 2.25 2.74 3.08 3.38
Odessa Region 3.32 3.81 3.98 4.32
Poltava Region 3.96 4.02 4.13 4.33
Rivno Region 1.78 2.03 2.47 3.10
Sumy Region 2.17 2.42 2.53 2.97
Ternopol Region 4.81 5.00 5.19 5.28
Kharkiv Region 2.66 2.68 2.72 2.85
Kherson Region 1.43 1.65 1.93 2.22
Khmelnitsk Region 2.71 3.13 3.61 3.88
Cherkasy Region 2.73 2.87 3.18 3.32
Chernovtsy Region 4.90 5.14 5.18 5.17
Chernigov Region 2.31 2.62 3.09 3.22
Kiev 1.96 2.56 2.95 3.21
During this period there was an increase in the index of general population provision by
GP's - family doctors in Ukraine from 2.67 in 2013 to 3.40 in 2016 in all regions of the country. This indicator has significant differences.
Despite the positive dynamics in 2012-2016, the staffing level of primary health care link by GPs - family doctors, a significant number of rural medical outpatient clinics with nonreplaced by a physician (main worker) posts are registered. Table 4.
Table 4
The number of rural medical clinics with nonreplaced positions of a doctor
(the main worker)
Administartive territories 2012 2013 2014 2015 2016
Ukraine 374 489 386 380 484
Vinitsa Region - -- - -
Volyn Region 5 12 12 8 9
Dnepropetrovsk Region 32 39 38 38 39
Donetsk 19 3 12 11 93
Zhitomir Region 28 22 17 15 19
Transcarpathian Region 6 12 16 14 6
Zaporozhye Region 27 25 14 14 14
Ivano-Frankovsk Region - -- - - 1
Kiev Region 7 7 30 28 22
Kirovograd Region 23 17 17 15 15
Lugaansk Region 11 10 - - -
Lviv Region 10 9 3 5 6
Mykolayev Region 35 35 34 29 21
Odessa Region 31 31 26 27 32
Poltava Region 15 58 51 62 66
Rivno Region 11 3 - - -
Sumy Region 8 30 36 26 32
Ternopol Region 6 7 2 9 7
Kharkiv Region - 100 21 22 33
Kherson Region 14 14 14 12 25
Khmelnitsk Region 14 20 18 20 21
Cherkasy Region 18 33 25 25 23
Chernovtsy Region - - - - -
Chernigov Region 47 - - - -
For the years under analysis in general the number of rural medical clinics with nonreplaced positions doctor's has some changes, but over the past three years it has a tendency to increase and in 2016 there were 484 outpatient clinics of such a type. In five regions such clinics are not registered. The largest number of such clinics exists in Donetsk (93), Poltava (66), Dnipropetrovsk (39), Kharkiv (33) and Odesa (32) regions. It should be noted that in the regional centers of these regions there are higher medical education institutions of the IV level of accreditation.
Below we present, in the terms of the regions, data on the number of RHPs and their staffing level by junior specialists with medical education. Table 5.
Table 5
Number of rural health posts and their staffing with junior specialists with medical education (including independent institutions, structural and separated structural units) in
2016
AgMirncTpaTHBHi TepuTopil ^HC^O ®AniB BCbOrO nocagu Mo^ogmnx cne^amcriB 3 MegnHHoro ocBiToro
mTarai 3aHHaTi
yKpaiHa 13133 11177 15632,00 14468,25 14 478 92,6 92,6 736
BiHHH^Ka 838 837 1049,25 958,50 989 91,4 94,3 34
Bo^HHCbKa 758 758 917,00 890,25 892 97,1 97,3 29
^HinponeTpoBCbKa 392 392 444,75 395,00 386 88,8 86,8 46
,3,OHe^Ka 325 325 367,50 310,00 287 84,4 78,1 49
^HTOMHpcbKa 804 688 886,00 828,50 822 93,5 92,8 20
3aKapnaTCbKa 285 235 356,50 325,25 341 91,2 95,7 8
3anopi3bKa 357 357 447,50 390,75 380 87,3 84,9 -
iBaHO- ®paHKiBCbKa 529 119 787,50 770,50 801 97,8 101,7 -
KniBCbKa 639 618 801,25 656,75 598 82,0 74,6 70
KipoBorpagcbKa 475 475 552,25 508,75 486 92,1 88,0 23
.HyraHCbKa 236 236 257,25 227,00 222 88,2 86,3 27
HbBiBCbKa 996 111 1157,75 1133,50 1 179 97,9 101,8 9
MHKMai'BCbKa 381 381 400,75 335,25 327 83,7 81,6 44
OgecbKa 507 450 678,25 598,50 596 88,2 87,9 52
nornaBCbKa 618 618 660,50 612,25 624 92,7 94,5 57
PiBHeHCbKa 620 614 776,00 757,00 798 97,6 102,8 5
CyMCbKa 499 341 559,00 519,50 524 92,9 93,7 63
TepHoniflbCbKa 734 650 895,00 854,50 868 95,5 97,0 13
XapKiBCbKa 496 496 531,75 494,25 482 93,0 90,6 24
XepcoHCbKa 348 342 434,75 389,75 351 89,7 80,7 19
XMe^bH^bKa 887 887 1020,25 976,25 982 95,7 96,3 41
^epKacbKa 536 380 640,50 600,75 601 93,8 93,8 47
^epmBe^Ka 211 205 279,50 267,50 273 95,7 97,7 -
^epmriBCbKa 662 662 731,25 668,00 669 91,4 91,5 56
In 2016 there were 13133 RHPs of which 11177 were in the structure of PMSC centers. There was a higher level of staffing by full-time jobs at RHPs than in rural outpatient clinics. But at the same time a significant number of RHPs without the mid-level health professionals is registered. The number of RHPs without any medical worker is 736, which makes it impossible for the rural population to receive timely medical care.
The largest number of such RHPs is registered in Kyiv (70), Sumy (63), Poltava (57), Chernihiv (56), Odesa (52) and Donetsk (49) regions.
The reason for the low staffing by primary link care workers, especially in the countryside, is the lack of housing, the actual non-standardization of working time and low wages.
Conclusions
The analysis of existence of primary health care institutions in the regions of Ukraine and provision of the population with the positions of doctors of general practice - family doctors, the availability of these positions and the level of their staffing is presented. The availability of positions of junior specialists with medical education at RHPs and their level of staffing is also analyzed. The low level of staffing of general practitioners-family doctors with a reliable difference in the indicator by regions is shown. It was noted that the reason for this situation with personnel provision of primary health care link is the lack of motivation of medical workers to work at this particular level of medical care.
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