The challenge of modernising maternal and child health services in Ukraine
Von Andrei Solodarenko & Martin Raab / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
The past decade of economic, political and social transformation has severely affected Ukraine’s health services and the health status of the population. An Ukraine – Swiss cooperation aims at facilitating the changes necessary to achieve international standards.
In 1991, Ukraine began moving towards building an independent state. The country declared its intents to the world community to build a democratic society based on a market economy and social guarantees for the population.
In the first decade of its independent history, Ukraine, like nearly all former USSR republics, had experienced a persisting and painful crisis caused by the dismantling of former political and socio-economic structures. The crisis was certain to affect the health care system as well. The most ‘telling’ implications of the deteriorated situation had been a strong increase in morbidity and mortality.
The striking rise in Ukrainian mortality is beyond the peacetime experience of industrialised countries. Many factors appear to be operating simultaneously, including social instability, high rates of tobacco and alcohol consumption, poor nutrition, depression and a deterioration of the health care system. Overall, cardiovascular diseases, infectious diseases (pneumonia, tuberculosis) and injuries (motor vehicle crashes, suicides, homicides) account for most of the mortality increase. Of particular concern is the high incidence of HIV-infection which ranks top among the Eastern European countries. Another major source of concern is the significant decrease in birth rates.
Maternal and child health in focus
Amongst current problems in maternal and child health (MCH) of Ukraine, sterility comes to the front (currently there are around 1 million sterile married couples in Ukraine), as well as miscarriages and premature births (nearly 10%), a high number of ”pathological pregnancies” (1 in 3), maternal mortality, birth defects, birth trauma and other neonatal disabilities. The rural areas are confronted with insufficient health services such as inadequate efficiency of family planning services, perinatal screening, vaccination, lack of general practitioners-paediatricians and problems with transportation of neonates to hospitals. Disease prevention and health promotion activities are funded inadequately.
Since independence, the country reaffirmed its adherence to UN fundamental declarations and instruments on human rights (e.g. UN Convention on the Rights of the Child), with a right to health services being a key one. Ukraine approved a number of legislative acts designed to address the most critical health issues and committed itself to reform the health system (including MCH). Up to now, a number of Presidential Decrees have been issued to improve MCH. Also, a law ”On Child Welfare” was adopted in 2001. As a result, several national programmes have been implemented or are still under implementation (”Family Planning”, 1995; ”Children of Ukraine”, 1996; Genetic Monitoring”, 1999; ”Reproductive Health”, 2001, etc.).
Despite all these efforts, the results are far below the expectations of politicians, health professionals and the population. One obvious reason for this is inadequate funding of the health system. Another important reason that impedes health system reforms and improvement are inadequate management skills and capacity. Parallel service structures, irrational utilisation of resources (e.g. equipment, pharmaceuticals, facilities, personnel), the disproportion between urban and rural health services, and weakness of health information systems and related meaningful statistics are all factors that limit health system performance.
In order to succeed in reforming maternal and child health services, a combination of prerequisites is needed: the availability of a modern legislative framework, sufficient funding, a well trained workforce, an appropriate infrastructure, an adequate supply of materials and drugs as well as adequate management systems including modern quality assurance systems.
Maternal and child health services: A slow but steady improvement
Despite all the problems listed above, the situation for maternal and child health services is not static and decision makers and health professionals are making constant efforts to improve the system. Some indicators are listed to document a positive trend in health outcomes:
- Neonate mortality rate (per 1000 live births): 14,7 (1995) – 11,3 (2001)
- Perinatal mortality rate (per 1000 births): 14,2 (1990) – 11,3 (1998) – 6,6 (2000)
- Infant mortality rate (per 1000 live births): 12,2 (1995) – 9,6 (2001)
- Number of abortions: 1million (1990) – 0,4 million (2001)
Economically, there have been positive developments in recent years. Ukraine ranks first among the Eastern European countries in terms of GDP growth rate. As the national economic indicators increase, so will health funding capacities.
The Ukrainian health system is financed through two major funding sources: a central budget and local or regional budgets. The central budget finances programmes with a high national priority, e.g., vaccination, diabetes, tuberculosis, oncology, haematology, AIDS control. The local budgets add funding to national programmes and cover the running costs for the local health services. However, it is obvious that these current domestic funding sources are not sufficient. Health insurance systems have not yet been introduced.
The Ukrainian MCH system receives assistance through international cooperation programmes and maintains partnership relationships with international bodies such as UNICEF and WHO. The UNICEF ”Breast Feeding” programme had a significant positive impact on neonatal health indicators.
Ukraine – Swiss collaboration: Towards a multi-centred project
The Swiss Centre for International Health (SCIH) of the Swiss Tropical Institute (STI) can look back on five years of collaboration with Ukrainian partners, mainly with the Ministry of Health. In 1997, a project financed by the Swiss State Secretariat for Economic Affairs (seco) was launched to improve neonatology services in the five regions of Kiev, Ivano Frankievsk, Rivne, Volyn and Donetsk. In the scope of this project, appropriate clinical equipment for 141 first, second and third line health facilities was procured. Also, a number of clinicians and nurses received training in Switzerland and Poland. This project succeeded in increasing the capacities and the quality of services for new-borns.
In 2001, a new project, financed by the Swiss Agency for Development and Cooperation (SDC), was started to build on the achievements of the neonatology project. Whereas the neonatology project had a strong bias on hardware and infrastructure, a new follow-up project, the Perinatal Health Programme, was designed to include further aspects that impact on mortality and morbidity of new-borns. As a result, a multi-centred project combining the fields of neonatology, obstetrics and gynaecology was set-up and agreed upon.
The principal components of the Perinatal Health Programme focus on knowledge and ”Skills Upgrading” for clinical staff, on disease prevention and health promotion, on public health training, on appropriate equipment and maintenance systems and on health systems management.
Work is underway on many ”construction sites” such as the development of clinical guidelines, the conception of a training plan for clinical and public health training, the implementation of campaigns for healthier lifestyles, the improved integration of neonatal and obstetric services and the set-up of medical equipment maintenance systems. Also, an innovative telemedicine approach to engage a partnership between a Swiss and a Ukrainian hospital will be conceptualised and tested. An internet based telemedicine platform will be used to exchange information and diagnostic images, to get a second opinion and to diagnose diseases.
Different cultures, different views
The first neonatology project was more straightforward in the sense that agreement concerning approaches and strategies between the two partner sides was relatively easy to reach due to the bias towards hardware orientation and the limited number of training courses. The new Perinatal Programme is different since it focuses much more on training contents, on behavioural issues, on quality standards of health services and directions of reforms. All those issues imply change in the way of practising medicine, of planning and managing systems, and of setting priorities. Naturally, the Swiss and Ukrainian partners have different views reflecting their different cultural settings and socio-economic backgrounds. During the first year of implementation, it became therefore clear that an intense dialog between Ukrainian and Swiss experts was required to agree on common approaches, strategies and ways to tackle problems. This ongoing process is rarely an easy one - but definitely challenging and stimulating for both sides.
*Andrei Solodarenko is the head of the Project Implementation Office for the Swiss-Ukrainian Perinatal Health Programme. Martin Raab is a scientific collaborator at the Swiss Centre for International Health (SCIH) of the Swiss Tropical Institute (STI) and the project manager for the Perinatal Programme. Contact: http://www.sti.unibas.ch/personel/RAABM.htm