EASO
UkraineFFM report –healthcare reform andeconomic accessibility
Medical Country of Origin Information
ReportFebruary 2021

More information on the European Union is available on the Internet (http://europa.eu)
ISBN 978-92-9485-862-7

doi: 10.2847/190187

BZ- 04-21-035-EN-N© European Asylum Support Office, 2021
Cover photo EASO, 2020
Reproduction is authorised provided the source is acknowledged. For any use or reproduction of photos orother material that is not under the EASO copyright, permission must be sought directly from the copyrightholders.

Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Acknowledgements
EASO is the drafter of this report.
The following departments and organisations have reviewed the report:•••

Belgian Desk on Accessibility (BDA);Country of Origin Information Division, Office for Foreigners, Poland; andCOI Information Desk, Federal Office for Migration and Refugees, Germany.

It must be noted that the review carried out by the mentioned departments, experts or organisations
contributes to the overall quality of the report, but does not necessarily imply their formal
endorsement of the final report, which is the full responsibility of EASO.

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Contents
Acknowledgements................................................................................................................................. 3Contents .................................................................................................................................................. 4
Disclaimer................................................................................................................................................ 6
Glossary and Abbreviations .................................................................................................................... 7
Introduction ............................................................................................................................................ 9
Methodology ...................................................................................................................................... 9
Defining the terms of reference ..................................................................................................... 9
Collecting information .................................................................................................................... 9
Sources ............................................................................................................................................... 9
Quality control .................................................................................................................................. 11
Structure and use of the report ........................................................................................................ 11
Map ....................................................................................................................................................... 12
1.

Healthcare system and reform..................................................................................................... 13
1.1.

Background to the reform ................................................................................................... 13

1.2.

The healthcare reform implementation .............................................................................. 13

1.3.

Challenges and critical outcomes of the reform ................................................................. 14

1.3.1. Phase 1: Changes in primary healthcare ............................................................................ 14
1.3.2. Phase 2: Secondary care reform and COVID-19 outbreak ................................................. 16
1.3.3. Changes in health facility infrastructure ............................................................................ 19
1.3.4. Changes to HIV and TB services ......................................................................................... 20
1.3.5. Data collection in healthcare ............................................................................................. 20
1.3.6. Opposition to the reform ................................................................................................... 21
1.3.7. Political changes’ impact on the reform ............................................................................ 22
1.4.

Quality practices .................................................................................................................. 23

2. Health insurance ............................................................................................................................... 24
2.1. National Health Service Ukraine (NHSU) ................................................................................... 24
2.2. Public healthcare insurance treatment coverage ..................................................................... 24
2.2.1. Included population groups ............................................................................................... 26
2.2.2. Coverage for oncology treatment ...................................................................................... 26
2.2.3. Coverage for patients with Crohn’s disease and Parkinson disease .................................. 27
2.2.4. Coverage for patients with TB, Hepatitis and HIV .............................................................. 28
2.2.5. Coverage for paediatric patients ........................................................................................ 28
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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

2.3. Affordable Medicines Programme ............................................................................................ 28
2.4. Private sector ............................................................................................................................. 30
2.5. Private insurance ....................................................................................................................... 31
3.

Out of pocket (OOP) payments .................................................................................................... 31

4.

Pharmaceutical sector .................................................................................................................. 34

5.

4.1.

Essential Medicines List (EML)............................................................................................. 34

4.2.

Accessibility of medication .................................................................................................. 35

4.3.

Registration and procurement of medication ..................................................................... 36

4.4.

Pharmacies .......................................................................................................................... 38

4.5.

Not registered medication .................................................................................................. 39

Accessibility for specific groups ................................................................................................... 40
5.1.

Discrimination and societal groups ..................................................................................... 40

5.2.

IDPs and the situation in the non-government-controlled areas........................................ 40

5.3.

Patients with mental health disorders ................................................................................ 41

5.4.

HIV patients ......................................................................................................................... 43

5.4.1.

Funding for HIV services ............................................................................................. 43

5.4.2.

Availability of treatment and medications ................................................................. 44

5.4.3.

Access to treatment .................................................................................................... 45

5.4.4.

Cost of treatment........................................................................................................ 46

5.4.5.

Consequences of the reform ...................................................................................... 47

5.5.

TB patients ........................................................................................................................... 47

5.6.

Oncology patients ................................................................................................................ 48

5.6.1.

Availability of treatment and medication ................................................................... 49

5.6.2.

Access to treatment .................................................................................................... 51

5.6.3.

Cost of treatment........................................................................................................ 52

5.7.

Paediatric patients ............................................................................................................... 52

Annex 1: Bibliography ........................................................................................................................... 55
Annex 2: Terms of Reference ................................................................................................................ 58

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Disclaimer
This report was written according to the EASO COI Report Methodology (2019). 1 This report is basedon carefully selected, publicly available sources of information as well as anonymous sources based in
the country of origin. All sources used are referenced.
The information contained in this report has been researched, evaluated and analysed with utmost
care. However, this document does not claim to be exhaustive. If a particular event, person ororganisation is not mentioned in the report, this does not mean that the event has not taken place orthat the person or organisation does not exist.
Furthermore, this report is not conclusive as to the determination or merit of any particularapplication for international protection. Terminology used should not be regarded as indicative of aparticular legal position.
‘Refugee’, ‘risk’ and similar terminology are used as generic terminology and not in the legal sense as
applied in the EU Asylum Acquis, the 1951 Refugee Convention and the 1967 Protocol relating to the
Status of Refugees.
Neither EASO nor any person acting on its behalf may be held responsible for the use which may bemade of the information contained in this report.
The drafting of this report was finalised in November 2020. Any event taking place after this date is
not included in this report. More information on the reference period for this report can be found in
the methodology section of the Introduction.

1

The 2019 EASO COI Report Methodology can be downloaded from the EASO COI Portal url.

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Glossary and Abbreviations
Abbrev.

Explanation

AMP

Affordable Medicines Programme

ANTAC

Anti-Corruption Action Centre

ART

Anti-retroviral therapy

ARV

Antiretroviral

CBT

cognitive behavioural therapy

CT

Computed Tomography

DOT

Directly Observed Therapy

EMA

European Medicines Agency

EMDR

Eye Movement Desensitization and Reprocessing

EML

Essential Medicines List

FDA

U.S. Food and Drug Administration

GDP

Gross Domestic Product

GMP

Good Manufacturing PracticeHIVhuman immunodeficiency virus

HTA

Health Technology Assessment

INN

International Non-proprietary Names

MDR TB

Multidrug resistant tuberculosis

MoH

Ministry of Health

MRI

Magnetic Resonance Imaging

MRTD

Measles-Rubella-Tetanus-Diphtheria

MS

Multiple sclerosis

NCSP Okhmatdyt
Children’s Hospital

National Children’s Specialised Hospital “Okhmatdyt”

NEDL

National Essential Drug List

NHSU

National Health Service of Ukraine

OblastRegion. There are 24 administrative units, oblasts, in Ukraine.

OOP

Out of pocket

OST

Opioid Substitution Therapy

PCR

Polymerase chain reaction

PET

Positron Emission Tomography

Raion

The second level of administrative division in Ukraine, below oblasts.

TB

Tuberculosis

7Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Verkhovna Rada

The parliament of Ukraine

XDR TB

Extensively drug resistant tuberculosis

8Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Introduction
This report, written by EASO, is the result of a Fact-Finding Mission (FFM) to Ukraine from 9 March
2020 to 13 March 2020 and supplemented by further desk research. The report draws on carefully
selected sources that are referenced in the report. The information provided has been researched,evaluated and processed with utmost care within a limited time frame.

Methodology
This report is produced in line with the EASO COI Report Methodology (2019) 2 and the EASO COI
Writing and Referencing Style Guide (2019). 3

Defining the terms of reference
The main objectives of the fact-finding mission were to study the implementation of the healthcare
reform and to collect information in general on the state of the healthcare sector, its limitations andits capacity, as well as finding information on the accessibility of the Ukrainian public healthcare
system, especially in terms of economical access (cost to the patient to access treatments andmedications), was also included in the objectives. See also Annex 2: Terms of Reference.

Collecting information
The FFM took place in Kiev between 9-13 March 2020. A mixture of interlocutors were interviewed toget multiple viewpoints on the topics included in the scope. Representatives from governmental
ministries, NGOs, public healthcare facilities, private healthcare facilities, and internationalorganisations were included in the programme. In addition, desk research took place between 28
October and 25 November 2020 to collect supplementary information. Additional interviews focusedon the third phase of the reform took place via video link on 23 and 25 November 2020. Following
suggestions from peer reviewers, more information on healthcare insurance coverage was collectedin an interview via video link with the National Health Services of Ukraine (NHSU) on 26 January 2021.

Sources
The EASO delegation met with representatives from the following organisations (brief descriptions ofeach organization based on the information provided on their websites):
NGOs:
A joint meeting with CF Patients of Ukraine and representatives of various patient organisations,representing patients with Multiple Sclerosis (MS), Parkinson disease, mental health disorders,haemophilia, juvenile arthritis, oncologic diseases, and Crohn disease.
CF Patients of Ukraine: a Charitable Foundation launched in late 2010. It is a specialised association ofpatients that allows them to lobby their interests in front of the State and of pharmaceuticalcompanies. 4

2

EASO, EASO Country of Origin Information (COI) Report Methodology, June 2019, url
EASO, Writing and Referencing Guide for EASO Country of Origin Information (COI) Reports, June 2019, url
4
CF Patients of Ukraine, [website], n.d., url
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9Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Anti-Corruption Action Centre (ANTAC): a civic society organisation fighting corruption in Ukraine. It
also develops legislation, seeks to prosecute corrupt officials, and supports partners to make efficientsystemic changes in Ukraine. 5
International Renaissance Foundation: one of the largest charitable foundations in Ukraine. It works
towards the protection of human rights and towards the use of positive change for the citizens’
benefit. It is part of the Open Society Foundations network. 6
100% Life: the largest patient-led organisation in Ukraine, working to improve access of care forpatients with HIV and TB. It developed the e-health system and is the leading partner of Ukraine’s
government in the implementation of the healthcare system reform. 7
International organisations:
UNAIDS: a Joint United Nations Programme on HIV and AIDS. 8
International Organization for Migration (IOM): the leading inter-governmental organisation in thefield of migration; it works closely with governmental, intergovernmental and non-governmental
partners. It is part of the United Nations system. 9
World Health Organization: its main role is to direct and coordinate international health within the
United Nations system. 10
State actors:
National Health Service of Ukraine (NHSU): the central executive body that implements state policy inthe field of state financial guarantees for healthcare services of the population. The NHSU’s activities
are directed and coordinated by the Cabinet of Ministers of Ukraine through the Minister of Health. 11
Oleksandra Ustinova: Opposition Member of Parliament (Verkhovna Rada), member of the Verkhovna
Rada Committee on the Prevention and Counteraction of Corruption.
Public Health Center: a state institution responsible for maintaining and strengthening public healththrough the control of infectious diseases, health promotion, and research. 12
State Expert Center: the main function of the State Expert Center of the Ministry of Health of Ukraine
is to provide scientific and organisational support for the justification of the permit for medical use of
only high-quality, effective and safe drugs. The State Expert Center functions as the national
registration authority of medication. 13
HTA Department of the State Expert Center: this department performs Health Technology
Assessments (HTA). An HTA reviews the medical, economic, organisational, social and ethical issues
related to the use of a certain health technology in a systematic and multidisciplinary way. This
includes the impact and the cost-effectiveness of medicines, medical devices, and treatment regimens
for state coverage.

5

ANTAC (Anticorruption Action Centre), [website], n.d., url
IRF (International Renaissance Foundation), [website], n.d., url
7
100% Life, [website], n.d., url
8
UNAIDS, [website], n.d., url
9IOM (International Organization for Migration), [website], n.d., url
10
WHO (World Health Organization), [website], n.d., url
11
NHSU (National Health Service of Ukraine), [website], n.d., url
12
Public Health Center, [website], n.d., url
13
State Expert Center, [website], n.d., url
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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Healthcare facilities:
Specialised Hospital for Children Okhmatdyt: a diversified diagnostic medical institution that provides
specialised high-quality medical care for children. 14
A pharmacist working at a private hospital pharmacy.
Clinic Boris, Andrey Raschupkin (Head of clinic): Clinic Boris is a private healthcare clinic in Kiev
delivering a wide range of medical services. 15
National Cancer Institute: a clinically and research-accredited oncology centre. 16
The first draft of the report or the notes were sent to the interviewed sources. All suggested changes
from the sources were implemented in the report.
In addition, desk research was conducted and its findings were included in the report. Desk research
was conducted using open source and publicly available information. Desk research was used to either
cover any gaps in the information provided after the interviewing process or to include more up todate, if available, information, following the FFM. Desk research was not the primary method of
information collection for this report.

Quality control
In order to ensure that the EASO COI Report Methodology and the EASO Writing and Referencing
Guide were respected, a review was carried out by COI specialists from Belgium, Poland and Germany,and by EASO staff. Additionally, the first draft of the report and/or interview notes were sent to theinterlocutors in Ukraine for comments. All comments made by the reviewers and interlocutors weretaken into consideration.

Structure and use of the report
The report is divided into five main chapters, covering the reform and general information of thehealthcare system in the first chapter, and the National Health Insurance Services (NHSU) of Ukraine
and health insurance aspects in the second. In the third chapter the focus is on out of pocket
payments, and in the fourth the pharmaceutical sector is described. Lastly, the accessibility for specificgroups are examined. The selection of these groups was based on the information needs of users of
the MedCOI services as well as what information was provided during the FFM: discriminated groups;
IDPs and the population in the non-government-controlled areas of Ukraine; patients with mental
health disorders, patients with HIV/AIDS, patients with Tuberculosis (TB), patients with oncologic
diseases, and paediatric patients.

14

NCSP Okhmatdyt, [website], n.d., url
Clinic Boris, [website], n.d., url
16
National Cancer Institute, [website], n.d., url
15

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Map

Map 1: Ukraine © United Nations. 17

17

United Nations, Ukraine, Map. No. 3773 Rev. 6, March 2014, url

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

1. Healthcare system and reform
1.1. Background to the reform
Ukraine inherited the Soviet centralised healthcare system, which in theory meant free healthcare forall. In practice, according to the Ministry of Health, this meant the ‘budget deficits, economic crises,
and a lack of reform resulted in a “parallel world” where one had to solve healthcare problems throughout-of-pocket informal payments and bribes’ and nevertheless received ‘rather disappointing’ medical
treatment results. 18 Α 2018 article published by the Friedrich Ebert Foundation noted that the
postponement of the healthcare sector reform resulted in crises in the healthcare sector, with people
having to pay themselves for over 50% of medical services. 19 Similarly, the Ministry of Health of
Ukraine (MoH) has stated that, under the old system, individuals had to pay themselves for healthcare
or even resort to bribing. 20
Therefore, in late 2017, a law was passed by the Verkhovna Rada (Ukrainian parliament) to reform thehealthcare system. 21 According to a 2020 article on healthcare transformations, the main goals of thereform in Ukraine were the following: at the primary level to ‘objectify’ the procedure of medical careprovision, to link the medical care provision to the financing of the medical services, and to better
control the expenditure of healthcare funds. 22 In order to achieve these goals, the National HealthService of Ukraine (NHSU) was established on 1 April 2018 23 (see also section: Role of NHSU).
The same 2020 article further pointed out that ‘[t]he transition of PHC [primary healthcare] to theprinciples of general practice (family medicine) is the main direction of the reform of the Ukrainian
national healthcare system.’ 24

1.2. The healthcare reform implementation
The reform is to be implemented in phases. The first phase, initiated in April 2018, mainly concerned
the primary healthcare system. Through an information campaign created by the NHSU, thepopulation of Ukraine was asked to choose a family doctor. This doctor could be based anywhere, notjust in the area of residence. By March 2020, 30 million people chose a family doctor (about 80% of
the population) 25 and by September 2020, 610 000 more made their choice. 26
Starting in July 2018, primary healthcare facilities received financing according to the services they
provide. This is according to the adoption of a so-called ‘money-follows-the-patient model,’ which
replaced the old structure of state-funded facilities. The new funding is organised by the NHSU. Family

18
19

1.

Ministry of Health of Ukraine, Healthcare reform, n.d., url.
Yakovenko, I., Healthcare reform in Ukraine: initial results pending, Friedrich Ebert Foundation, November 2018, url, p.

20

Ukraine, Ministry of Health of Ukraine, Key steps to transforming Ukrainian healthcare, n.d., url.
Ministry of Health of Ukraine, Healthcare reform, n.d., url, accessed 14 July 2017.
22
Ahiyevets, S. et al., Primary Healthcare Under Transformation in 3 Eastern European Countries: Quality Satisfaction as
Rated by Students, Osong Public Health and Research Perspectives, 2020, url.
23
Ahiyevets, S. et al., Primary Healthcare Under Transformation in 3 Eastern European Countries: Quality Satisfaction as
Rated by Students, Osong Public Health and Research Perspectives, 2020, url; WHO and World Bank (the), Ukraine Review
of health-financing reforms 2016–2019, April–July 2019, url, p.4.
24
Ahiyevets, S. et al., Primary Healthcare Under Transformation in 3 Eastern European Countries: Quality Satisfaction as
Rated by Students, Osong Public Health and Research Perspectives, 2020, url.
25
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
26
Ukraine, Government Portal, Medical reform, n.d., url.
21

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

doctors are paid according to how many patients (declarations) they take on, limited to a maximumof 2,000 adult patients and 1,800 child patients for regular reimbursements. Signing on patientsbeyond that grants lower reimbursement. 27 Higher fees are provided for elderly and child patients. 28
The second phase was launched on 1 April 2020 and involves a reform of the secondary level ofhealthcare (hospital care). At the time of the FFM interview, the NHSU was in the contracting phasebut stated that facilities contracted with the NHSU by that time would receive payments through the
NHSU. The facilities will receive payment per treated case. 29 Judyth Twigg, a professor with experiencein global health with a focus on Ukraine, 30 noted that as of April 2020, hospitals are reimbursed basedon the actual conditions and diseases they treat, and it would be up to the patients to select a facility
based on the care offered and the outcomes. 31 Facilities not under contract received funding fromlocal authorities. By March 2020, some 9,000 second line proposals had been received, as well as
proposals from 1,722 specialist care facilities. 32
The third phase of the reform is planned for implementation in 2021 and will involve tertiary facilities,
such as NCSP Okhmatdyt Children’s Hospital and the National Cancer Institute. In 2020, these facilities
still remain in the old reimbursement system (budget based on number of beds). 33 Other plannedchanges for 2021 include changes in medication procurement. It is currently handled by the MoH, acentral state authority or local authority. A separate procurement department will take over theseduties. 34

1.3. Challenges and critical outcomes of the reform
1.3.1. Phase 1: Changes in primary healthcare
Official survey results, available in the National Health Index, indicate that 87% of the population in
the last few years is satisfied with primary healthcare. 35 The World Health Organization (WHO) also
noted that the result of the Health Index Ukraine 2019 survey showed high satisfaction levels. 36 On 5
November 2020, the MoH of Ukraine and the WHO signed a Cooperation Agreement. This Agreement
will allow the development and implementation of strategies and reforms of health financing, withthe goal being universal healthcare services coverage. In addition, the Agreement will improve accessto essential medications, vaccines, primary healthcare equipment and diagnostics and the country’s
preparedness for emergencies. 37
The interlocutors for WHO expressed optimism for the reform of the primary healthcare system,
noting that it provides a good base for developments and that the already implemented phase one
works. A challenge, however, is the decentralisation aspect of the reform. Local authorities are nottrained or prepared to take on the decision-making responsibility, as they have historically always

27

National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
World Health Organization (WHO), interview, Kiev, 10 March 2020.
29
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
30
Virginia Commonwealth University, Judyth Twigg, Ph.D., n.d., url.
31
Twigg, J., Ukraine’s healthcare system is in critical condition again, Atlantic Council, 21 July 2020, url.
32
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
33
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
34
State Expert Center, interview, Kiev, 11 March 2020.
35
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
36
World Health Organization (WHO), interview, Kiev, 10 March 2020.
37
Ukraine, Government Portal, Ministry of Health of Ukraine and the WHO have signed a two-year Cooperation
Agreement, 5 November 2020, url.
28

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

received instructions from central authorities. 38 This sentiment was echoed by a representative of the
Public Health Centre, who stated that as money follows the patient, facilities will have to attract
patients themselves. As they are not used to being responsible, this could result in chaos. 39 A
representative of WHO noted the same risk for mental health care, where local authorities now needto take decisions but still tend to wait for ministry decisions and orders. 40
With the reform, one source noted that family doctors’ monthly earnings increased from USD 200 to
USD 450 on average, and up to USD 1 000-1 200 in some cases. The family doctors are therefore
concerned the reform will be stopped. 41 The International Renaissance Foundation (IRF)
representative estimated that salaries for family doctors have increased from USD 200 (plus USD 200
in informal payments) to USD 500-700, so there is no need to ask for additional payments frompatients. There is high satisfaction from patients with the family doctors after the reform. One
consequence of the reform is that patients now consider it a bribe when doctors ask for payment forhome visits, as these are not reimbursed by the NHSU. Patients do not need to pay for consultations
with family doctors anymore. 42
Interlocutors from WHO pointed out that family doctor salaries have doubled or even tripled, and afamily doctor now earns around UAH 16 000, or USD 500. This has resulted in an increase in thenumber of family doctors. As the reform had at the time of the interview not yet been implemented
at the secondary level, WHO stated that salaries there were still low. 43
According to Ustinova, there were early on instances of family doctors who tried to trick NHSU, but
NHSU keep track and will act if any fraud is detected. 44
Following the reform, family doctors will be responsible for testing and treating HIV patients. The
doctors are encouraged to use rapid tests, the money for which must be paid through the money
assigned to the doctor for the patient. 45 Complicated cases will be referred to the second level (e.g.
hospitals) and a specialist. 46 Previously, only infectiologists could prescribe antiretrovirals (ARVs), butwith the change family doctors will be able to prescribe it as well. The family doctors are provided
with a list of questions to identify patients that should be tested. There is also a law in place which
specifies which people should be tested for HIV, based on their history, symptoms, behaviour, and soon. 47 Before the reform, HIV testing was usually only offered in specialised clinics. 48 Once this change
was implemented, HIV testing is now performed at each level of the healthcare system. The system
of HIV testing includes three stages: screening, which is provided in all facilities; confirmation(sometimes using rapid tests), done in all facilities; and identification, which is done in specialised
facilities. 49
Family doctors are supposed to refer patients to the regional levels, after which they can be referredto specialist tertiary hospitals like Okhmatdyt, after consultation with the head of department
whether the patient should be treated at the hospital. Paediatricians should be available in the
primary care facilities. While on paper a referral is needed to be treated at a tertiary hospital, the38World Health Organization (WHO), interview, Kiev, 10 March 2020.
Public Health Centre, interview, Kiev, 10 March 2020.
40
World Health Organization (WHO), interview, Kiev, 10 March 2020.
41
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
42
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
43
World Health Organization (WHO), interview, Kiev, 10 March 2020.
44
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
45
UNAIDS and IOM, interview, Kiev, 13 March 2020; Public Health Centre, interview, Kiev, 10 March 2020.
46
UNAIDS and IOM, interview, Kiev, 13 March 2020.
47
Public Health Centre, interview, Kiev, 10 March 2020.
48
World Health Organization (WHO), interview, Kiev, 10 March 2020.
49
Public Health Center, e-mail, 24 December 2020.
39

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

representative from Okhmatyt explained that this is not always followed, though the aim is a strict
referral system. 50 The representative from the National Cancer Institute also stated that while patientson paper need referrals from their family doctor to a secondary facility, and then referral to thetertiary Institute, this does not work in practice and some patients come directly to the Institute on
their own. One third of the patients are sent by regional oncology centres, as the cases are regarded
as too complex. 51

1.3.2. Phase 2: Secondary care reform and COVID-19 outbreak
1.3.2.1. Brief overview of COVID-19 situation in Ukraine
In the period between 3 January 2020 and 1 January 2021 there were 1 055 047 confirmed cases and
18 680 confirmed deaths from COVID-19 in Ukraine. 52 According to a Universal Health CoveragePartnership 53 September 2020 article, Ukraine acted rapidly to ensure that its population would nothave to pay for COVID-19 treatment and testing. 54

1.3.2.2. The second phase of the reform and impact of COVID-19
The second stage of the healthcare reform mainly concerned a new health financing system. Before
April 1st, 2020, money was allocated to the regions based on per capita, then allocated to the local
councils to purchase health services from facilities. This system was described by NHSU as fragmented
and inefficient, as one city could have both a city hospital, a raion hospital and an oblast hospital,
often overlapping in functions. Service delivery budget was therefore concentrated in one pool whichpurchased the service for the whole population. 55
A specification of services was introduced, where each service was defined and described. For
instance, a person hospitalised for palliative care would have access to pain management, medicines
for treatment of co-morbidities, etc. All services were structured in 27 packages of services, some ofwhich are very specific and others which are more general. Each package of service is defined andselection criteria for providers are described. Before the reform, this was not regulated so for instancedeliveries could be done in facilities without anaesthesiologists. 56
The start of the pandemic coincided with a new cabinet of ministers, and some argued that the reformneeded to be stopped. However, no new financing options were introduced, so instead new packagesof services were introduced. 57 These provided support to poor performing hospitals that according to
the reform should have instead received reduced funding. 58 According to the IRF interlocutor, thebiggest achievement of the NHSU and MoH was to launch the second phase of the reform in April

50

NCSP Okhmatdyt, interview, 12 March 2020.
National Cancer Institute, interview, Kiev, 13 March 2020.
52
WHO, Ukraine: WHO Coronavirus Disease (COVID-19) Dashboard, 25 November 2020, url.
53
The Universal Healthcare Partnership consists of “a broad mix of health experts working hand in hand to promote UHC
by fostering policy dialogue on strategic planning and health systems governance, developing health financing strategies
and supporting their implementation, and enabling effective development cooperation in countries.”. It is supported andfunded by the following: the World Health Organization (WHO), the European Union, the Grand Duchy of Luxembourg,
Irish Aid, the French Ministry for Europe and Foreign Affairs, the Government of Japan, the UK Department forInternational Development (DFID) and Belgium. Source: Universal Health Coverage Partnership, About, n.d., url.
54
Universal Health Coverage Partnership, Ukraine working towards universal health coverage while responding to COVID19, 24 September 2020, url.
55
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
56
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
57
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
58
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021; International RenaissanceFoundation (IRF), interview via Webex, 23 November 2020; CF Patients of Ukraine, interview via Zoom, 25 November 2020.
51

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2020, despite the COVID outbreak in Ukraine and the lockdown instituted in late March and in April
2020. The representative further noted that in the situation with the emerging COVID outbreak, thiswas probably the best consensus to be reached. The compromise gave the actors a chance to optimise
their systems, although the interlocutor noted that ineffective standards and practices cannot change
overnight. 59
The four additional COVID-19-related packages of services were for mobile teams taking samples for
PCR testing at people’s homes; additional funding for emergency care; temporary funding for hospitals
that in April 2020 received COVID-19 patients but were not meant to continue doing it as they did nothave enough ventilators, anaesthesiologists, infectious disease specialists, etc.; and lastly, a big
package of services was provided for the COVID-designated network. The MoH selected about 400
hospitals that had enough staff, oxygen, and ventilators, and specifically contracted them for COVID19 care. During this time it was also revealed that the country only had 18 infectious disease hospitals,
ranging from small district hospitals to large, oblast-level, well-performing hospitals. All those are now
designated COVID-19 hospitals. 60 The IRF interlocutor pointed out that key hospitals should have been
audited for their supplies earlier on. Now, Ukraine has beds for COVID-19 patients, but not sufficient
oxygen concentrators in all dedicated units. There are cases of patients that are placed in beds withintravenous therapy and not with steady and uninterrupted oxygen supply. 61
Additionally, the IRF interlocutor stated that in reality most patients visited their family doctors andnurses rather than specialised facilities. Primary care was not included in the service package, andpersonal protective equipment (PPE) was mainly distributed to specialised facilities, not primary carefacilities where most cases were discovered. This resulted in many health staff getting infected, andin some cases leaving their jobs for the private sector instead. The private sector has increased theirprices slightly, about 10-15%, to cover for protective measures implemented. 62
The outbreak caused other issues, such as hospitals having to cancel planned treatments for chronic
disease care due to the lockdown, and hence deviate from the planned treatment plan the funding
was based on. During the lockdown, emergency services functioned as normal, but the rest ofhealthcare services struggled as they could not meet expected targets. Patients were not referred,
and the government had taken a decision to minimise planned care in this period. 63
There was also an initiative to in parallel give extra payment to doctors and nurses involved in COVID
care, to result in a 300% salary increase. Operationally, this has proven a very weak measure,according to the IRF representative. It caused additional administrative burden, was difficult to track
and could be manipulated. Payments were not issued to the healthcare staff for several months, but
supposedly COVID-funds were used for this measure. 64
The representative from Patients of Ukraine noted that a key part of the reform is that patientsreferred by their family doctor to a hospital should not need to pay. However, there is still a lot of outof pocket (OOP) payments which the representative believes is due to two reasons: patients do notunderstand the reform, as there have been no information campaigns from the MoH to explain thispart of the reform to the general public. Secondly, doctors do not explain the new system to patients.
The doctors are used to a tradition of receiving ‘thank you’-payments from patients, and it is hard to

59

International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
61
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
62
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
63
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
64
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
60

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibilitychange this behaviour from one day to the next. Time is needed to change behaviours, but more
concrete communication from the MoH is also needed. 65
The IRF representative stated that NHSU has stood strong throughout this period, while the Ministerof Health has opposed the agency. The representative explained that there is a risk that the changes
on the minister post will limit the transparency of the reform. Legislation passed in response to the
COVID-19 outbreak allowed the temporary and quick appointments to government positions. 66 The
representative of Patients of Ukraine noted that the MoH plays a less prominent role in the reformthan it did during the first phase, and due to the changes in the ministry position are no longer driving
the reform. NHSU is, according to the representative, the one state body committed to continue thereform. The fact that the MoH no longer plays this role contributes to the difficulty to change thebehaviour of patients and doctors. 67
The system is still in late 2020 a hybrid system. The plan for the second phase of the reform was for2020 to be a transition year where reliable data would be obtained via the newly introduced E-healthsystem. The aim of this transition year was to reveal the real numbers and obtain accurate statistics.
With the E-health system, it is possible to trace what treatments a patient has received, and whichfacilities they have visited. 68 NHSU expected more data to become available in the E-health system in
2020, which would be used when planning new contracts. Due to the pandemic, hospitals wereallowed to reduce their reporting to the E-health system, so there is now less data in the system than
anticipated. The reduction of services in this period may also have had an impact. 69
Another purpose of having a transition year and of keeping a mixed system at first was to give someflexibility to hospitals, who may otherwise struggle to estimate their needs. 70 Referring to the 20212023 NHSU strategy plan, the representative from CF Patients of Ukraine also noted that 2020 was
originally planned as a transition year. Starting from 2021 the new payment system for hospitals will
be implemented with a money follows the patient approach. This approach is well implemented in
the primary healthcare system. 71
There are attempts to implement the same budgetary exemptions as were granted to infectious
disease wards to TB and mental health care. The interlocutor for IRF noted that TB was still exempt inNovember 2020 from the second phase of the reform. For now, it is a debated issue and the systemremains mixed. 60% of the budget comes from the historic budget. 72
In 2021, the programme of medical guarantees (further explained in section 2.2. Public healthcare
insurance treatment coverage) will continue and NHSU will elaborate on it following lessons learnedin 2020. 73 The interlocutor from IRF noted that the changes implemented so far cannot be easily
reversed and continuing the reform is easier, but hopes it will not remain at this stage as it is not
functioning optimally. The health system is in a critical point in the middle of the transition and risks
falling apart if nothing is done from this point. The reform will also deteriorate if nothing is done, andthis deterioration will go fast due to the situation with the COVID-19 outbreak. 74

65

CF Patients of Ukraine, interview via Zoom, 25 November 2020.
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
67
CF Patients of Ukraine, interview via Zoom, 25 November 2020.
68
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
69
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
70
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
71
CF Patients of Ukraine, interview via Zoom, 25 November 2020.
72
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
73
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
74
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
66

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

1.3.3. Changes in health facility infrastructure
Currently, according to an interlocutor from the NHSU, there are many specialised clinics in Ukraine,but not enough money to pay for them. The reform is intended to move money away from facilities
that do not work, to facilities that are more efficient. 75 Local administrations have been tasked with
the implementation of the second phase of the reform, but the IRF interlocutors pointed out that anissue is that they do not have the full national picture and instead focus on local needs. For instance,
while on a larger scale it may make sense to close a particular hospital that is not highly used, this may
be an inconvenience for the local residents. 76 Oleksandra Ustinova stated that one consequence ofthe reform is likely to be that 30-40% of medical clinics will need to close, as there are currently hugeclinics placed in small towns. In order to survive, these clinics may need to rent out space, as thegovernment will no longer pay for the facility but only for the treatments given. This will make thesystem more efficient, and while it is not popular and will upset people, the current system costs toomuch money. 73% of the money from the government is spent on facilities and salaries, somethingwhich will change with the reform. 77 The interlocutor with UNAIDS noted that it is likely smaller
facilities may fold or merge with other small facilities. The facilities will also now have to prove theytreat patients in order to get paid. 78
The money follows the patient principle is intended to ensure the state pays for treatments and notfor empty beds. A consequence of this is according to Ustinova that the situation for the clinics will be
more competitive, especially in large cities. As medications are included in the tariffs, clinics will bekeener to purchase cheaper medications and in that way lessen the costs for state healthcare. The
model ensures the clinics are cost efficient. 79 The UNAIDS representative explained that facilities will
now have to prove they treat patients in order to get paid. 80 A representative from Public HealthCenter noted that doctors are not used to treating many patients. 81 The interlocutor from IRF
mentioned that in some maternal units, only two deliveries are done per day, only on weekdays andnot on the weekends, and no complicated deliveries. As a doctor in a larger city will be paid around
USD 500 in informal fees from the patient, and USD 500 will be paid to other staff, doctors can get
more money through informal payments and with a lower workload, so most are against the reform. 82
The representative of Boris Clinic believed the reform will reduce the beds in the public sector with
about 30-40%. 83
Another issue of the current system according to Oleksandra Ustinova is that doctors in smaller clinics
are sometimes not skilled enough, because they are not treating enough patients to practice all
medical elements. 84 The news agency Vox Ukraine pointed out that an additional issue that the reform
is facing is the lack of doctors in the countryside. More specifically, in small towns and villages there
is a very limited or no choice of doctors. 85

75

National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
77
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
78
UNAIDS and IOM, interview, Kiev, 13 March 2020.
79
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
80
UNAIDS and IOM, interview, Kiev, 13 March 2020.
81
Public Health Center, interview, Kiev, 10 March 2020.
82
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
83
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
84
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
85
Vox Ukraine, Unchangeable? How medical reforms work and where they slow down, 13 December 2019, url.
76

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Oleksandra Ustinova pointed out that the reform is likely to lead to longer lines. In the old system,
patients could pay to receive immediate care. In the past, clinics could charge for everything.
Consequently, patients who could not pay did not receive care. 86
A doctor at Boris Clinic, a private facility in Kiev, expressed some opinions that illustrated the fears
some actors have for this reform. He stated that while the primary health care reform was positive,
he had some reservations about the second part. In particular, he feared there may be negative
consequences due to closure of clinics for psychiatric patients and clinics for TB patients. Many TB
sanitoriums and psychiatric institutions are being closed during the reform, and he does not know
where patients will be treated. 87 A representative from WHO noted that there is a fear among the
public of the closure of sanatoriums. The representative further commented that moving away froma system based on beds will have a large effect on mental health care, and there will be less need tokeep patients institutionalised. 88

1.3.4. Changes to HIV and TB services
According to the Public Health Center, with the reform the NHSU will implement programmes on HIV,
TB, and OST (Opioid Substitution Therapy). The government will then issue payments for each patientand for certain services. At primary level, testing and distribution of medicines to treat HIV, also called
antiretrovirals (ARTs), by family doctors, as well as management of OST patients (provide drugs, adjust
dosage, do screenings, and make referrals to other specialists). For the second phase of the reform,
from April 1, 2020, some facilities on secondary level will handle OST, HIV testing, ART provision, andTB services. In December 2020, over 200 facilities on the secondary level implemented the OST
programme. The Public Health Center noted that the laboratory package for HIV needs to be enlarged
and revised, as the funds are too small. There is a belief among the representatives that quality
indicators may improve through the reform. 89 TB hospitals will after the reform change into somethingcloser to infectious disease hospitals, also treating other diseases. 90
A major anticipated change within the new system relates to AIDS centres or ARV cabinets, as theprovision of treatment for HIV and TB will be done differently. A possible consequence may according
to UNAIDS be that some centres close permanently, as payment will be per patient. The interlocutor
commented, however, that before implementation has taken place, this is only speculation. 91 An
interlocutor from the Public Health Centre noted that if ART centres close, patients may findthemselves in a more difficult situation to find another treatment facility. The regions will be able tochoose themselves if the duties should be shared over several centres or if they should be centralised
in one centre, something which could overwhelm the one remaining centre. 92

1.3.5. Data collection in healthcare
Representatives of the NHSU explained that there was previously no clear overview of the number offacilities in the healthcare system, but as a side-effect of contracting individual facilities in the reform
exercise, the healthcare system has been mapped simultaneously. 93 The representative of 100% Life

86

Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
88
World Health Organization (WHO), interview, Kiev, 10 March 2020.
89
Public Health Centre, interview, Kiev, 10 March 2020, Public Health Center, e-mail, 24 December 2020.
90
UNAIDS and IOM, interview, Kiev, 13 March 2020.
91
UNAIDS, interview, Kiev, 13 March 2020.
92
Public Health Centre, interview, Kiev, 10 March 2020.
93
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
87

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

noted that with the e-health system, information is centralised and duplication is avoided. 94 However,even after the implementation of the second stage of the reform, the IRF interlocutor explained that
it is likely that there is still a significant manipulation of data occurring in hospital reporting and in
health statistics. For instance, there is a discrepancy in the bed occupancy rate and in the number ofsurgeries performed. Bed occupancy rate appears to be calculated not in relation to intensive care but
in relation to extended hospital stay before and after the surgery. 95
Several interlocutors mentioned the lack of accurate data as an obstacle for planning. 96 An
interlocutor with WHO noted that data gaps are an issue in Ukraine. 97 According to a representativeof the NHSU, about 30 million people have declared their family doctor, which is about 80% of the
population. Recent official data states the population of Ukraine is 37 million. 98 A representative of
the State Expert Center mentioned, however, that the population number is incorrect and this means
their calculations will not be correct. 15 years ago, the population was 52 million. Today, without
counting the occupied territories, the population is estimated to be a bit less than 42 million. 99 This
was also raised by an interlocutor with the IRF, who noted that not only were the actual population
statistics different from the official demographic numbers, but the patient flow in the healthcare
system also differs from the official statistics. Patients do not go to the hospitals only in their own
region/raion, which also impacts calculations on patient uptake for different facilities. 100 The
representative from 100% Life stated that due to the uncertainty around demographics, they do notknow their target numbers. In some oblasts (regions), the targets are too high compared with theactual population. 101
A representative from the Public Health Center highlighted that there are separate registers in theregions for patients with hepatitis, so the centre does not have a complete picture of the situation in
the country. 102 The main source is from the annual reports of health care departments. 103 The Public
Health Center further acknowledged that haemodialysis patients tend to ‘fall between the chairs’, so
the Center does not know the incidence and prevalence of this group. 104

1.3.6. Opposition to the reform
According to a representative from ANTAC, many highly placed people in major hospitals have beensuspected of corruption and are now in a position to criticise the reform, and people actively against
the reform are now in charge of several important institutions. 105 This sentiment was echoed by theinterlocutor from UNAIDS who noted that the reform is in the hands of people who may not agreewith all of it. 106 In general, Oleksandra Ustinova noted that ‘top doctors’ are opposed to the reform
because official salaries are too low. In the old system second line doctors had high wages, so they94

100% Life, interview, Kiev, 10 March 2020.
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
96
World Health Organization (WHO), interview, Kiev, 10 March 2020; State Expert Center, interview, Kiev, 11 March 2020;
International Renaissance Foundation, interview, Kiev, 11 March 2020.
97
World Health Organization (WHO), interview, Kiev, 10 March 2020.
98
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
99
State Expert Center, interview, Kiev, 11 March 2020.
100
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
101
100% Life, interview, Kiev, 10 March 2020.
102
Public Health Centre, interview, Kiev, 10 March 2020.
103
Public Health Centre, e-mail, 24 December 2020.
104
Public Health Centre, interview, Kiev, 10 March 2020.
105
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
106
UNAIDS and IOM, interview, Kiev, 13 March 2020.
95

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

will see a decrease in salaries with the reform. Regional doctors are in general more positive to thereform than urban doctors. 107
Other arguments against the reform is that the funds allocated are not enough for the reform and will
result in health facilities down-sizing or closing due to insufficient funding - the funds would need toincrease from 3.2% to 5% GDP. However, the representative from IRF stated that some health facilities
are underperforming and will lose money if the funds are allocated per patient, so they are keen to
keep the old system where they are paid per bed, even if the beds are empty. According to therepresentative, there is room to compensate and the budget is realistic. 108 The interlocutor from
UNAIDS explained that facilities believe the NHSU is underestimating the cost of treatments and thattariffs will have to be revised. This will not be proven until it is put in practice, however. 109

1.3.7. Political changes’ impact on the reform
One challenge for the reform involves changes in government. In late March 2020, the Minister of
Health was replaced, which could be a threat to the second stage of the reform. 110 More specifically,in the period between August 2019 and November 2020, there were four Ministers of Health, 111 with
Maxim Stepanov being the fourth and current one (in November 2020). 112
Minister of Health Stepanov stated in a briefing on 7 June 2020 that ‘[t]he Ministry of Health of Ukraine
is conducting a detailed examination of the entire medical infrastructure for further reforming andcorrecting the mistakes made by previous management”. 113 Professor Judyth Twigg claimed in a blog
post that Health Minister Stepanov ‘seems determined to unravel most of the progress that has beenmade’. 114
The minister appointed in September 2019, Zoriana Skaletska, was described by the interlocutor from
UNAIDS as often mentioning the need to eliminate OOP payments, but the replacement minister Illya
Yemets, appointed in March 2020, had a different background and had not prioritised this topic in his
public messages about the health financing reform. 115 The interlocutor from ANTAC mentioned that
Yemets had connections to the old Yanukovych regime, and while a doctor, is unknown as amanager. 116 This was echoed by member of parliament Oleksandra Ustinova, who stated that thepolitical will from the Ministry of Health is weak. She further noted that while the first stage of thereform has been successful, there had been moves from parliamentarians to block the continuationof the reform. 117 The interlocutor from ANTAC pointed out that due to the change in Minister of Healthjust before the initiation of phase two, it was unclear how the reform would develop. The interlocutor
was also of the opinion that the greatest challenge was setting up the NHSU. As beneficiaries in chargeof a lot of money and the reimbursement system, the NHSU is the driver of the reform and the only
agency who can contract doctors to the new system. 118 The WHO interlocutors stated that while they107

Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
109
UNAIDS, interview, Kiev, 13 March 2020.
110
100% Life, interview, Kiev, 10 March 2020.
111
These Ministers were Ulana Suprun (dismissed in August 2019), Zoriana Skaletska, Illia Yemets and Maxym Stepanov.
Source: Euromaidan Press, Ukraine’s ambitious health reform now hangs by a thread, 28 May 2020, url.
112
Euromaidan Press, Ukraine’s ambitious health reform now hangs by a thread, 28 May 2020, url.
113
Ukraine, Ministry of Health of Ukraine, The Ministry of Health of Ukraine has begun developing and approving new
governmental standards for medical care, 7 June 2020, url.
114
Twigg, J., Ukraine’s healthcare system is in critical condition again, Atlantic Council, 21 July 2020, url.
115
UNAIDS, interview, Kiev, 13 March 2020.
116
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
117
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
118
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

try to keep their own programmes on track, the changes in government risk putting things off track. 119
Other things in the pipeline, such as procurement of medication by an independent central
procurement agency – a change which would save money – may also not be implemented. 120
The outbreak of COVID-19 in Ukraine coincided with, according to Oleksandra Ustinova, the most vital
part of the reform. The reform’s second stage is by Ustinova predicted to be ‘tough’, but she fears thereform will not continue if it is halted now. With a stable government it could have been postponed
for six months, but that would be too risky in the current political climate. 121 See also section 1.3.2.2.
The second phase of the reform and impact of COVID-19.

1.4. Quality practices
The interlocutor from the HTA pointed out that the use of international practices and guidelines is an
important step in the reform. 122 From March 2020, health care providers should not use outdated
national protocols, as they had not been updated in almost ten years and there was no practice ofrevision of the protocols. The representative of Boris Clinic stated that the clinic follows international
treatment guidelines, as national guidelines run the risk of becoming outdated. 123 The representativeof the National Cancer Institute explained that treatments are provided according to international andnational guidelines. The national guidelines are adapted from the ESMA/US system, while othercentres only use national guidelines. 124 The interlocutor at Okhmatdyt hospital explained that if
existing national protocols do not cover a rare, complicated case, approved and certified international
protocols are used. The hospital is also ISO9001-certified and has an internal quality control with aperson responsible for the controls and a methodology to follow. 125
In terms of advanced training, doctors need to obtain 50 accredited points each year throughattending conferences, giving lectures, writing articles and so on. This system is controlled by the MoH.
In the public sector however, the staff need to pay for this training themselves or receive grants froma charitable organisation. This continuous medical education can be done in Ukraine or abroad. 126 The
representative from the National Cancer Institute explained that the Institute is underfunded, so they
are not able to send staff abroad. To participate in conferences, the staff have to pay for it themselves
or get sponsored by pharmacological companies. 127 The representative from Boris Clinic confirmed
this, and also noted that the budget is too small in the public sector for doctors to upgrade
qualifications continuously. The staff at the private facility have the opportunity to study abroad,financed by the clinic. 128

119

World Health Organization (WHO), interview, Kiev, 10 March 2020.
UNAIDS and IOM, interview, Kiev, 13 March 2020.
121
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
122
Health Technology Assessment (HTA) Department at State Expert Center, interview, Kiev, 12 March 2020.
123
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
124
National Cancer Institute, interview, Kiev, 13 March 2020.
125
NCSP Okhmatdyt, interview, 12 March 2020.
126
NCSP Okhmatdyt, interview, 12 March 2020.
127
National Cancer Institute, interview, Kiev, 13 March 2020.
128
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
120

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2. Health insurance
2.1. National Health Service Ukraine (NHSU)NHSU is funded through taxation and gives guarantees for free healthcare, and was founded on the
Cabinet of Ministry Decree No 65. 129 The idea of the NHSU was to create a strong primary healthcare
sector with a referral system. 130 The representative of ANTAC described the NHSU as the ‘drivers of
the reform’, and hence a key player. Setting NHSU up was the greatest challenge of the reform
according to ANTAC. NHSU is rumoured to be down-sized soon, and the architect of the reform left
the NHSU in December 2019. 131 The representative from UNAIDS observed that with the departure of
the team of architects of the reform, it will be ‘painful to continue [the reform], but probably more
painful to reverse [it].’ 132 On the website of NHSU, real-time data of the implementation of the reform
is continually updated (in Ukrainian: https://nszu.gov.ua/en/pro-nszu). 133

Picture 1: Exterior of National Health Service of Ukraine (NHSU)

Oleksandra Ustinova commented that the NHSU reimbursement system works well, with payments
issued each month to facilities as planned. The Covid-19 outbreak poses a problem however, as all
budgets will be cut. 134

2.2. Public healthcare insurance treatment coverage
As explained on the NHSU website, ‘primary care, palliative care, and emergency medical care are
100% funded by the state. Besides, the state provides reimbursement for medicines for cardiovasculardiseases, asthma, and type 2 diabetes.’ 135 Further, ‘[t]he government pays for the guaranteed benefit
129

National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
World Health Organization (WHO), interview, Kiev, 10 March 2020
131
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020. See also Euromaidan Press, Ukraine’s
ambitious health reform now hangs by a thread, 28 May 2020, url.
132
UNAIDS and IOM, interview, Kiev, 13 March 2020.
133
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
134
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
135
Ukraine, Ministry of Health of Ukraine, Key Steps To Transforming Ukrainian Healthcare, n.d., url
130

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

package of healthcare services for individuals, and healthcare providers compete for these funds.
Services beyond the guaranteed package can be paid or co-paid for by patients directly or by other
health insurance types.’ 136 The Verkhovna Rada (Ukrainian parliament) each year approves a Medical
Guarantee Programme, starting in 2019 with approval for the 2020 programme. 137 The Medical
Guarantee Programme determines the state coverage of treatments, and can differ from year to year,
depending on the budget and on lessons learned. The 2021 budget only increased by 6%, which does
not compensate for inflation, according to the NHSU. 138
Most services are covered, except for non-urgent care without referral and some other minor services.
The NHSU plan for the same number of services which were historically provided in the system. In
2019, there were 8 million hospitalisations, so the same was planned for in 2020. NHSU noted that
there are many misunderstandings on what is included in the packages. For instance, providers haveerroneously believed only patients in treatment are covered, and declined free treatment to newpatients. These misunderstandings are communicated to patients, which then communicates them topatient organisations. 139
What was included in 2020 is available (in Ukrainian) on the NHSU website, 140 called the Packages ofServices, and each package describes what is included. In very general terms, consultations of doctors
are included in every package, diagnostic treatments, etc. 141 A draft programme for 2021 is alsoavailable. 142
The Medical Guarantee Programme for 2020 includes:
1. Primary medical care
2. Emergency medical care
3. Ambulatory secondary and tertiary medical assistance for adults and children, including
medical rehabilitation and dental care
4. Mammography of breast
5. Hysteroscopy (diagnostic / with endoscopic manipulation)
6. Oesophago-gastro-duodenoscopy (diagnostic / with endoscopic manipulation)
7. Colonoscopy (diagnostic / with endoscopic manipulation)
8. Cystoscopy (diagnostic / with endoscopic manipulation)
9. Bronchoscopy (diagnostic / with endoscopic manipulation)
10. Haemodialysis in outpatient conditions
11. Inpatient surgical interventions for adults and children
12. Inpatient care for adults and children without surgical operations
13. Medical care for acute stroke
14. Medical care for acute myocardial infarction

136

Ukraine, Ministry of Health of Ukraine, What Services Do Patients Pay For?, n.d., url
Ukraine, Ministry of Health of Ukraine, Громадянам - Які медичні послуги будуть платними для пацієнтів? [To thecitizens – what medical services will be paid for patients?], n.d., url
138
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
139
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
140
NHSU (National Health Service of Ukraine), Вимоги ПМГ 2020 [PMG 2020 Requirements], n.d., url.
141
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
142
NHSU (National Health Service of Ukraine), Вимоги ПМГ 2021 [PMG 2021 Requirements], n.d., url.
137

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

15. Medical care for childbirth
16. Medical care for new-born in complex neonatal cases
17. Diagnosis and chemotherapeutic treatment of oncological diseases in adults and children
18. Diagnosis and radiological treatment of oncological diseases in adults and children
19. Psychiatric care for adults and children
20. Diagnosis and treatment of adults and children with TB
21. Diagnosis, treatment and maintenance of persons with HIV
22. Treatment persons with mental and behavioural disorders due to use of opioids with drugs
substitution therapy
23. Inpatient palliative medical care for adults and children
24. Palliative medical care for adults and children at place of residence
25. Medical rehabilitation of infants born prematurely and / or sick, during the first three yearsof life
26. Medical rehabilitation of adults and children from three years old with disabilities of themusculo-skeletal system
27. Medical rehabilitation of adults and children from three years old with damaged nervous
system
28. Emergency medical care of patients with suspected or established disease with acuterespiratory disease COVID-19 caused by the coronavirus sars-cov-2
29. Medical care provided by mobile medical teams created to respond to COVID-19
30. Inpatient care for patients with COVID-19 in the period from 1 to 30 April 2020
31. Inpatient care for patients with COVID-19. 143

2.2.1. Included population groups
NHSU representatives explained that all citizens get benefits through the NHSU, and citizens who have
lived abroad get access to the benefits as soon as they move back to Ukraine. Foreigners with legal
stay permits, including asylum seekers, are covered as well. IDPs access the system on the same
premise as other citizens, as there are no area restrictions in terms of which facility to use. A person
needs a passport in order to obtain access and prove their citizenship. 144

2.2.2. Coverage for oncology treatment
Much oncologic medication, including targeted therapy, is not part of the benefit package but is partof the budget for centrally procured medication. There is not sufficient medication for all patients whoneed it, so once the medication runs out patients need to pay. For oncology patients, full coveragewith targeted therapy or innovation therapies will likely never be economically possible. 145
The representative from the National Cancer Institute explained that 80% of treatments are covered
and patients pay the rest, usually materials. Emergencies are fully covered. 60% of chemotherapy

143

NHSU (National Health Service of Ukraine), Вимоги ПМГ 2020 [PMG 2020 Requirements], n.d., url
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
145
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
144

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

drugs are covered by the state, and the patients buy the rest. Most targeted and immunotherapy 146
provided at the National Cancer Institute are paid by the patients whereas chemotherapy is covered
up to 60%. Paediatric oncologic treatments are covered completely, except for targeted therapy. 147
To clarify the situation regarding targeted therapy, the representative from CF Patients of Ukraine
explained that basic medications are procured via the state budget and is free for the patient, whilemore expensive targeted therapy in most cases would need to be covered by the patients themselves.
The patient representative deemed that some treatments are still ‘affordable’ for patients. The
situation is similar e.g. for MS medication, where only the more regular medication for simple cases isfree for the patient while patients will have to pay for more complex medication themselves. 148
A patient representative confirmed that most aspects of the treatment are provided for free for adultoncology patients, but more expensive and efficient medication is not accessible. Oncology patientsneed to pay for tests to get a diagnosis, immunotherapy is not free for the patients, basic targeted
therapy is provided for free and chemotherapy is mostly free. Surgery is paid by the patients. For thisreason, treatments of patients could be discontinued as they cannot afford it or go abroad to gettreatment. The representative specifically mentioned that melanoma patients often cannot continue
their treatment due to the costs. Innovative treatments for patients with stage 3 or 4 melanoma
cancer can cost up to USD 4 000. There are waiting lists for radiation therapy as the equipment is old
and there are not enough machines. Palliative care is also an issue due to lack of staff. The
representative also stated that there are many reports of wrong prescriptions and misdiagnosis. Staff
may lack knowledge and provide the wrong treatment in local hospitals. 149
Patients for some diseases get a disabled status, and the disability pension is UAH 1 500 (about EUR
44). 150 How long they remain classified as disabled can vary though. For instance, breast cancer
patients retain their status as disabled, but must reapply every 2 years. Oncology patients who receive
targeted therapy lose their status as disabled once the treatment continues with hormone therapy.
As treatment is no longer covered, patients stop treatment. A patient who loses their disability statusloses both pension and social security. Patients with mental health disorders need disabled status inorder to get treatment, but the disability status does not always match the diagnosis and severity ofthe patient’s condition, and there are administrative barriers to sort this out. Both a diagnosis anddisability status are needed to obtain treatment. 151

2.2.3. Coverage for patients with Crohn’s disease and Parkinson disease
A representative of patients with Crohn’s disease stated that children who are considered disabledaccording to the law, have right to free treatment. However, the responsibility is relegated to local
authorities and as there is not enough money, there is no automatic free access for children who muststruggle to get free treatment. Adult patients suffering from Crohn’s disease do not receive freetreatment, and many patients discontinue treatment as they cannot afford it. Patients who do not get
treatment will need surgery, which also costs money. Furthermore, the representative noted that it isdifficult to get the initial diagnosis, especially in rural areas as they tend to lack colonoscopy and colon
biopsy. The patients must also pay for the biopsy tests. 152

146

Targeted cancer therapies block the growth and spread of cancer and immunotherapy helps the immune system fightcancer.
147
National Cancer Institute, interview, Kiev, 13 March 2020.
148
CF Patients of Ukraine, interview via Zoom, 25 November 2020.
149
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
150
Xe.com, Xe Currency Converter, 2 February 2021, url. Conversion rate at the time of writing (February 2021) is EUR 1 =UAH 33.87.
151
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
152
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Patients with Parkinson need medication which costs UAH 7 000, 20 % of which is covered by local
budget. There is no state financing for the disease. 153

2.2.4. Coverage for patients with TB, Hepatitis and HIV
TB patients are diagnosed and receive treatment at the family doctor. Both diagnosis and medication
are free, and the medication includes new drugs. 154 The UNAIDS representative describes TB and
MDR-TB as major concerns, as TB is the number one cause of for death for people living with HIV. All
TB cases are tested for HIV, and all newly discovered HIV patients get tested for TB. 155
New hepatitis B and C medication is provided for free to patients, and screening of viral hepatitis
markers is also provided free of charge by family doctors. Consultation with a specialist is also free,though there are waiting lists as there are not enough infection specialists and lack of procured
medications at the scale needed. However, the Public Health Center noted that other doctors cantreat these patients in case no infectious disease specialists are available. The patient will have to pay
for the PCR test as it is done in private laboratories. 156
Viral load laboratory tests and CD4 tests are available free of charge, and patients with HIV receive
free ART treatment in Ukraine. 157 Order 504 from 19 March 2018, ‘On approval of the Procedure forproviding primary care’, states that family doctors have to provide free testing for HIV and viral
hepatitis. 158

2.2.5. Coverage for paediatric patients
According to the interlocutor from the paediatric hospital Okhmatdyt, the state budget finances mostmedications, and charitable organisations buy some. The paediatric patients rarely need to buy
medication, though sometimes the parents do co-payments. Most treatments at the hospital are free.
One exception is reconstructive spinal surgery, like scoliosis, which must be paid for. There are
officially no co-payments at the hospital. 159

2.3. Affordable Medicines Programme
The design and implementation of the Affordable Medicines Programme constitute a key aspect of
the healthcare sector reform in Ukraine. 160 Prior to the introduction of the Affordable Medicines
Programme (AMP), there was no centralised system in place in Ukraine for public reimbursement ofprescription medication in the outpatient sector, resulting in the majority of outpatient medication
not being publicly subsidized. 161
The Affordable Medicines Programme started in April 2017 and includes medication for cardiovasculardiseases, diabetes type II and bronchial asthma. To access it, a prescription using the International
Non-proprietary Names (INN), not a trademark name, from the family doctor is needed. The patient153

CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
Public Health Center, interview, Kiev, 10 March 2020.
155
UNAIDS and IOM, interview, Kiev, 13 March 2020.
156
Public Health Center, interview, Kiev, 10 March 2020; Public Health Center, e-mail, 24 December 2020.
157
UNAIDS and IOM, interview, Kiev, 13 March 2020.
158
Public Health Center, e-mail, 24 December 2020.
159
NCSP Okhmatdyt, interview, 12 March 2020.
160
WHO, Evaluation of the Affordable Medicines Programme in Ukraine, 2019, url, p. 4.
161
WHO, Evaluation of the Affordable Medicines Programme in Ukraine, 2019, url, p. 2.
154

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

can then choose which brand to use. The medication will be free or with a co-payment. 162 The list
contains 23 INNs. 163 The medications have reference prices, which are approved by the Minister of
Health. This list is renewed every 6 months. 164 The list of medication included in the Affordable
Medicines Programme, including reference price, can be accessed via the NHSU’s website. 165
In a 2019 report, the WHO stated that the implementation of the AMP increased the affordability ofthe medications covered. Approximately 20% of the generic medications included are fully covered
without the patients having to pay a contribution. For another 20% of the medications included, thepatients have to pay a contribution smaller than 20% of the medication’s price. 166
Insulin is currently reimbursed in a similar way as the medication covered under Governmental Ordernumber 1 303 (see below), where patients need to go on the first of every month to get the
medication, before the money runs out. The plan is for insulins to be included in the Affordable
Medicines Programme from 1 July 2021, and mental health medications from 1 October 2021. The
programme will be expanded, but as only medication included in the EML can be reimbursed, this is
not fully within NHSU’s control. Only pharmaceutical manufacturers can apply for expansion of the
EML, and the MoH decides on expansion of the list. 167
Paper prescriptions have been replaced by e-prescriptions, which are connected to a central databasewhich pharmacies have access to. The patients get a code to bring to any pharmacy in Ukraine with
an NHSU agreement. 7 000 pharmacies are included in the system and are recognisable through an
Affordable Medicines sign. According to representatives of the NHSU, there should always be anaffiliated pharmacy within 1 km. 168 In addition, through the e-prescription system, personalized
information is collected on prescription, provision and reimbursement of medications in the
Affordable Medicines Program. The database links information on prescribed medication withpatients, health providers and pharmacies and ‘should allow the introduction of the prescription andbudget control systems.’ 169 Outpatients in private hospitals with NHSU contracts can also be
reimbursed. Outpatients at private hospitals without a NHSU contract are not eligible forreimbursement. 170 The e-prescription system is ‘working quite well’, according to the representativeof the State Expert Center. 171
The representative of the State Expert Center acknowledged that it is possible in many pharmacies tobuy medication without prescription. Due to this, there is a huge problem with overmedication, eventhough all medication is quality checked. In particular, this is a problem with antibiotics as people aredeveloping resistance. It is hard to encourage patients to visit a doctor when they can obtain the
medication directly from a pharmacy. In this regard, the new reimbursement system will encourage
patients to visit a doctor as a prescription is needed for reimbursement. 172
According to the NHSU, early on there was a huge initial demand of the medications, bigger than
expected by the MoH, which led to stock problems. Now, the sector can keep up with the demand. 173
According to a pharmacist, there is no shortage of stock for medication included in the list, and the162

National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
Health Technology Assessment (HTA) Department at State Expert Center, interview, Kiev, 12 March 2020.
164State Expert Center, interview, Kiev, 11 March 2020.
165
NHSU (National Health Services of Ukraine), Affordable Medicines Program, n.d., url
166
WHO, Evaluation of the Affordable Medicines Programme in Ukraine, 2019, url, p. 28.
167
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
168
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
169
WHO and World Bank (the), Ukraine Review of health-financing reforms 2016–2019, April–July 2019, url, p. 36.
170
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
171
State Expert Center, interview, Kiev, 11 March 2020.
172
State Expert Center, interview, Kiev, 11 March 2020.
173
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
163

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

reimbursement system is working. 174 A representative of the State Expert Center noted that relatively
few medications are reimbursed by the state, and more than 85 % of all medications are paid OOP. 175
Before the introduction of the AMP, reimbursements were handled via the local health departments
and the money came from the local budget. 176 As is still the system in some post-Soviet countries,
certain population groups may receive discounts or free medications (e.g. Chernobyl victims, people
with war disabilities, mothers with 5 children under 15 years of age, and so on). 177 Based on the Orderof the Government number 1 303 from 1998, 178 local councils or the central budget should provide
medicines free of charge to all patients listed in the order. However, NHSU representatives noted thatthe wide range of patients with different kinds of diseases included means that the central budget
would never have money to cover it. Local budgets tend to provide for those considered more eligible
to get the free medicines. The system is described as ‘very non-transparent’ and ‘a very locally createdsystem,’ and the implementation differs between local councils. A patient organisation with influenceon the local council may secure medication to its members, or some other council would provide coverfor specific population groups. This vulnerability-based local programme still exists in some local
councils, but it is underfinanced with too wide a scope. In practice, some people at the beginning of
the month will get medication before the monthly budget runs out. Other issues include that somemedication is not evidence-based, and others used in the system are not effective. The system only
works for patients that can stand up for their rights, and more vulnerable patients may not be able toget their medication. 179 The representative from IRF confirmed that the funds are too low and tend to
run out at the end of the month. The process is also described as intricate by the representative, so
patients need to understand the process in order to access the free medication. That means they arelikely to remain in the old mindset and will give informal payments to their family doctor. 180

2.4. Private sector
Private facilities can contract with the NHSU on the same conditions as public facilities. According torepresentatives of the NHSU, there are only a few private specialised hospitals in Ukraine, as well asa limited number of private primary care facilities. Official figures state that 3.6% of the population
visit private healthcare facilities (not including dentists). 181 The medical director of the private Boris
Clinic noted that, while the facility is contracted with NHSU for primary care, this is mostly done outof charity as the facility barely makes even on it. The facility will not be involved in the second part of
the reform as they would lose too much money if they participated. 182
Many private facilities have official price lists for procedures. According to the representative from
IRF, the private sector respects these price lists and no informal payments are asked. 183 The
representative of Boris Clinic noted that the online price list is kept updated and adjusted every time
prices change. There are no charities connected to the facility. The inpatient services at the clinic tend
174

Pharmacist, interview, Kiev, 12 March 2020.
State Expert Center, interview, Kiev, 11 March 2020.
176
State Expert Center, interview, Kiev, 11 March 2020.
177
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
178
Ukraine, Cabinet of Ministers Resolution No 1303, Про впорядкування безоплатного та пільгового відпуску
лікарських засобів за рецептами лікарів у разі амбулаторного лікування окремих груп населення та за певними
категоріями захворювань [About streamlining of free and preferential release of medicines according to prescriptions ofdoctors in case of out-patient treatment of separate groups of the population and on certain categories of diseases], 17August 1998, url
179
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
180
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
181
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
182
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
183
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
175

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

to belong to higher income population groups, while the outpatient services are described as more
affordable for all. 184
The private sector in Ukraine is growing while the public sector is shrinking. According to therepresentative of Boris Clinic, patients are not satisfied with the level of qualification of doctors in the
public sector. However, about 50% of doctors work in both private and public facilities. 185
According to the same source, the facility seldom has shortages of supplies of medications and medical
devices. An exception are some medical devices like gastrostomy devices and naso-gastric-tubes (PEG
tubes). In 2018-19 the facility experienced some problems with the availability of certain vaccines, but
in general there are no medication shortages. The facility uses what is available in the domestic
market. 186

2.5. Private insurance
Private health insurance, Voluntary Health Insurance, is available but is not relevant in the context of
NHSU. The coverage concerns private facilities only. NHSU also monitors that no agreements are madebetween clinics in order to circumvent the system in any way. 187 At the private Boris Clinic, mostpatients pay the treatment themselves and a small percentage, about 20%, has private healthinsurance. 188

3. Out of pocket (OOP) payments
Co-payments for services are illegal, though the NHSU know that informal payments are still prevalent.
They believe it is not just that staff salaries are too low, but that other policy measures will need to be
applied in order to eliminate catastrophic expenditures for health. 189
The representative from IRF observed that while the general levels of corruption in the country
decreased after the 2014 Maidan protests, it has returned under new forms. One example of this is
an increase in informal payments, where about 80% of patients are estimated to pay informal
payments and there is reportedly a fear among patients of not paying enough. 190 According to a Joint
World Bank and WHO 2019 Report, before the reform, 54% of per capita health spending rates
originated from OOP. 191 The ANTAC representative explained that people know what they are entitled
to for free. Some OOP payments disappeared with the reform, but payments are still given to
specialists at secondary level. The interlocutor believes the second stage of the reform will likely
reduce the OOP payments. However, the mindset of people will not change, and especially old people
are not used to going to the doctor without paying. 192 Also the interlocutor from IOM noted that
informal payments are part of the Ukrainian culture. 193 The UNAIDS interlocutor stated that the184

Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
186
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
187
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
188
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
189
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
190
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
191
WHO and World Bank (the), Ukraine Review of health-financing reforms 2016–2019, April–July 2019, url, p. 23.
192
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
193
UNAIDS and IOM, interview, Kiev, 13 March 2020.
185

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

message from the government is that patients are not meant to pay, but at the same time a culturalimperative exists where patients pay to obtain better treatment. 194
According to the interlocutor of the IRF, patients may need to keep paying informal payments, if thereform is stopped. Studies show that in 2016, 32% of patients delayed care due to lack of financial
means. Now the figure is at around 20-22%. People paying out of pocket may need to take bank loans,a practice which the reform is asked to reduce. 195
The ANTAC interlocutor highlighted that a hurdle to fight corruption is that it is difficult to dosomething against highly respected doctors in key positions. 196 Oleksandra Ustinova pointed out thatcurrently, almost all healthcare staff are taking bribes, as salaries are too low. This is a custom datingback to the Soviet era, and patients will pay ‘thank-you-money’ even when not prompted to do so.
Corruption is described as a system of its own, and the only way to change it is by changing the system(a change NHSU oversees). Because of the reform, it is believed it will be more difficult for doctors tomake additional charges, as patients will know that the state has already paid for the treatment. Clinics
may risk losing a patient if they ask for extra payments. Ustinova acknowledges that there are a lot offears over the reform, but states that there are also doctors who welcome it and are relieved they nolonger have to ask for bribes. 197 The representative from IRF also noted that there are a lot of doctors
who are trying to change the current situation, but it is difficult as the whole system has been
undermined for a long time. 198
Another form of OOP payment is when patients are ‘recommended’ to give to a charity. ANTAC
research done in 2017 showed that there was a ‘black box office’ at charities, in order to bypass
taxation authorities. This makes it hard to see where the money actually goes to. 199
According to studies by the IRF, 85-92% of people provide informal payments for treatments. The
amount differs, especially geographically. Healthcare providers will demand higher payments in urban
areas, but patients will pay more for medication in rural areas. The informal payments vary between
facilities and services, and patients ask each other to find out the rate for a specific hospital. Theinterlocutor further explained that the informal payments do not correlate with the prices in private
sector. As an example of informal payments, the IRF representative noted that a delivery in a largecity would cost about USD 500 for the doctor, and USD 500 in additional fees. 200 A 2019 Joint Reportby the World Bank and WHO also observed that patient OOP spending on prescription medicationvary across health facilities, which results in significant inequalities for care affordability. 201 The ANTAC
representative noted that there is a hierarchy of who pays whom in hospitals. 202 The representativefrom UNAIDS commented that inpatients in addition need to pay the nurse, materials and so on. 203
The representative of the organisation for patients with juvenile idiopathic arthritis noted that for atreatment that may cost USD 1 500 (of which the state covers 60% of the costs), paediatric patients
must give several hundred USD in informal payments. The representative is not aware of what bribes
an adult patient may need to pay. 204

194

UNAIDS and IOM, interview, Kiev, 13 March 2020.
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
196
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
197
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
198
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
199
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
200
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
201
WHO and World Bank (the), Ukraine Review of health-financing reforms 2016–2019, April–July 2019, url, p. 47
202
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
203
UNAIDS and IOM, interview, Kiev, 13 March 2020.
204
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
195

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

According to the representative from IRF, there are imposed informal payments in the healthcare
system. For some patients this can be deadly, for instance for patients with oncologic disorders. The
informal payment for an MRI in a public facility can be almost as much as the price to get an MRI in a
private facility. 205
On the question if OOP payments change over time, the representative of haemophilia patients
replied that it depends on supply and demand and will go up and down. The representative of Patientsof Ukraine observed that ‘the more there are free medication, the more there are bribes.’
Furthermore, the representatives noted that corruption is institutionalised and there is little
confidence in government action against bribes. Additionally, the position of patients is weak. Patient
representatives of MS patients explained that there is a reasonable fear from patients that they will
not receive the treatment if they do not pay bribes. In order to get the treatment, patients follow the‘rules.’ The patient organisation for haemophilia representative explained that if patients makeenough ‘noise’ they may get treatment for free, but this tactic can also backfire. In general, patients
pay to ensure continuity in the treatment. The representative of the organisation for patients withjuvenile idiopathic arthritis added that it is more difficult in small cities to organise patients against
corruption. 206 Additionally, the ANTAC representative explained that parents of sick children do notmake it public if they are asked to pay. 207
According to the interlocutor from ANTAC, it is a common complaint that patients at the National
Cancer Institute must pay the doctors and pay for procedures that have already been paid for, as wellas pay very high prices for oncologic medication. This resulted in the two previous Directors having toresign. The ANTAC representative also noted that reports of patients having to pay had reduced
significantly. 208 An NHSU interlocutor stated that oncologic treatment is ‘highly corrupt,’ which was
the case also before the reform. 209 A representative from the National Cancer Institute explained thatthe institute does not receive enough budget from the state to cover all necessary treatments, so
often patients need to pay part of the treatment/medication/medical device themselves. 210
A representative of an oncology patient organisation exemplifies the corruption with a story of apatient who was asked to pay UAH 100 000 (about EUR 2 950 211) for a needed surgery, twice the priceof the same procedure in a private facility while the procedure should be free in public facilities. The
patient was told they would be banned if they went public with the story. The representative fromPatients of Ukraine noted that ‘doctors see patients as money; as long as they have money, they aretreated’ and that without money, they may not receive treatment. The representative assesses thatabout 1-2 % of doctors are honest, and that less than 5 % do not ask for money. 212
The representative for 100% Life informed that for patients with HIV, treatment and medication ismostly free, with no additional OOP payments. Additional diagnostics are ‘mostly free’, though therepresentative explained that diagnostics are free at the organisation’s own facilities. 213 A
representative from WHO confirmed that treatment and ARVs are free though laboratory tests are
not free. 214 The representative from UNAIDS also claimed that there had been no reports of informal

205

International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
207
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
208
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
209
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
210
National Cancer Institute, interview, Kiev, 13 March 2020.
211
Xe.com, Xe Currency Converter, 2 February 2021, url.
212
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
213
100% Life, interview, Kiev, 10 March 2020.
214
World Health Organization (WHO), interview, Kiev, 10 March 2020.
206

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

payments for anti-retroviral treatment. 215 A representative from the Public Health Center noted thatthe procedure for hepatitis is problematic, as in general HIV patients have to be tested for hepatitis,
but the hepatitis test must be paid for by the patients. 216
A representative for WHO pointed out that in mental health care, informal OOP payments exist, butalso that people without resources will receive care. 217

4. Pharmaceutical sector
4.1. Essential Medicines List (EML)The Essential Medicines List (EML) is the list of essential medication that should be available for
inpatient care in hospitals, 218 containing over 400 international non-proprietary name (INNs)
medications. 219 It entails central procurement of more expensive medication, which is then free forpatients. The EML is under oblast responsibility, 220 though it is controlled by a committee in the MoH(institute of pharmacology and toxicology). 221 It is approved by a Cabinet of Ministers decree and isdetermined in the Law of Financial Guarantees. The list was last updated in 2017; the MoH decides
when to update, though it should be updated at least once a year. There are currently over 100
applications to the EML, listed on the State Expert Center’s website. The representative from the HTA
Department stated that 50% of the medication in the EML were fully available in 2018. 222 A
representative from the NHSU noted that the EML often contain older medication, and regards
including more modern medication or combination drugs as a future task for the agency. 223
For inpatient treatments, all medications on the list should be free, and the reimbursement
programme (Affordable Medicines Programme) is used for outpatients. 224 The medications includedin the Affordable Medicines Programme are based on the EML for the included disease groups. 225 The
representative of the IRF noted that 95% of inpatients would still need to pay for some medications.
According to a household survey, 70% have had to borrow money to pay for medication ortreatment. 226 Representatives of the NHSU informed that there are currently informal payments for
medication on the EML on the tertiary level, but the reform is intended to fix this. 227
The oncology patients’ representative noted that the medication on the EML list is not enough fortreatments, and that doctors encourage patients to use medication off the list as the EML medications‘are not effective.’ Patients are instead encouraged to choose other targeted therapies that are notprovided for free. The representative claimed doctors push patients to buy from specific providers.
215

UNAIDS and IOM, interview, Kiev, 13 March 2020.
Public Health Centre, interview, Kiev, 10 March 2020.
217
World Health Organization (WHO), interview, Kiev, 10 March 2020.
218
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
219
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
220
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
221
State Expert Center, interview, Kiev, 11 March 2020.
222
Health Technology Assessment (HTA) Department at State Expert Center, interview, Kiev, 12 March 2020.
223
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
224
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020; Health Technology Assessment (HTA)
Department at State Expert Center, interview, Kiev, 12 March 2020.
225
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020; International Renaissance Foundation(IRF), interview, Kiev, 11 March 2020.
226
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
227
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
216

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Patients have no access to complaint mechanisms and due to a lack on oncologists, it is not possible
to change doctors. While the system has gotten more transparent and there is no shortage, doctors
still encourage patients to buy medication as the doctors receive a percentage of the sales. 228

4.2. Accessibility of medication
The representative of the State Expert Center explained that availability of medication is not a problem
in Ukraine; the affordability is. The main medications are registered and available. The GDP is less than
USD 300, and the medication market is not price-regulated in general. The representative was of theopinion that too much price regulation risked taking medications off the market. The medications
included in the EML are price-regulated however, and there are limitations on mark-ups. 229 A 2019
WHO Report noted that the pricing mechanism was criticised by pharmaceutical manufacturers on
the basis that the Affordable Medicines Programme calculates prices per defined daily dosage, and as
a result combination medication are in most cases not considered eligible for the reimbursement
list. 230
A representative of a MS patient organisation noted that while both treatment and medication aresupposed to be free, in reality patients need to pay. Both the representative of the MS organisationand the representative of Patients of Ukraine agreed that only about 10% of patients entitled to it
receive medication for free. 231
Another issue is that the medications procured by the state tend to be older, classic medicines. Newer
medication is often not reimbursed. Some of the representatives stated that the available medication
tends to be older generation drugs, and, while they are supposed to be free, in practice they are‘absolutely not free’. For patients with mental health disorders, only first-generation medications areavailable for free. Newer medications must be paid for by the patients. 232 According to the WHO
representative, psychiatric patients will pay for newer medicines. 233 The representative of a
haemophilia patient organisation noted that while supplies are available, they are ‘not good’.
Medication to prevent bleedings is not available; in the regions only curative injections for when a
bleeding has started is available in practice. Due to budget cuts, there is not enough money available
for the medication. The representative of Patients of Ukraine pointed out that while the quantity of
haemophilia medication is sufficient in Kiev and in 4-5 oblasts, the quantities are too low in all otherregions and only for emergency cases. 234
The geographical access in the regions is another concern. A representative of a haemophilia patientorganisation explained that patients in the regions may need to travel 200 km to obtain the
medication. While the medication is free, in some regions medications are not handed over to thepatients who have to go to the hospital which may be located far away. 235 The patient representativeof patients with juvenile idiopathic arthritis added that an important problem is the underrepresentation of specialists and medical facilities in small cities. 236
Medication for 38 disease programmes are procured with the state budget. The representatives ofthe different patient organisations noted that the available state support differed between patient228

CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
State Expert Center, interview, Kiev, 11 March 2020.
230
WHO, Evaluation of the Affordable Medicines Programme in Ukraine, 2019, url, pp. 12-13.
231
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
232
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
233
World Health Organization (WHO), interview, Kiev, 10 March 2020.
234
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
235
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
236
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
229

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

groups. The representative of patients with juvenile idiopathic arthritis stated that 90% of the needed
treatments are available in Ukraine, and central financing from MoH and local bodies cover 60% of
treatment costs for the patients. The 20% most severe cases require a 28-day treatment course whichcosts USD 1 000-1 500. The state coverage does not include rehabilitation. Since 2019, treatment andmedication are provided to adult patients as well, but a lot of bureaucratic and logistical efforts arenecessary to obtain it. The representative of the haemophilia organisation informed that paediatrichaemophilia patients receive the needed support as well. 237
The representative of patients with Parkinson reported that, in general, their patients buy medicationand get treatment abroad, as it is 2-3 times cheaper in other countries like Poland, Hungary, and Egypt.
Prescription is provided in Ukraine and the medication is bought in another country. The
representative of Patients of Ukraine further explained that there is a monopoly on thepharmaceutical market which drives up prices in Ukraine. A draft law on parallel import did not receive
enough support, so was never approved for vote in the parliament. There is no legislative restriction
on prices of medicines. 238
According to the representative from the National Cancer Institute, patients do not pay for treatment,
but as the medical system is underfunded only about 60% of chemotherapy drugs are covered by thestate and the patients pay the rest. Targeted and immuno-therapy are paid by the patients. Traditional
chemotherapy is covered up to 60%. Paediatric oncologic treatments are covered completely, except
for targeted therapy. Targeted therapy is bought directly from the medical companies. Staff costs are
low, so patients do not need to pay for surgery, though they sometimes need to pay for one use
materials. 239

4.3. Registration and procurement of medication
The State Expert Center prepares applications for the registration of new medication, although thefinal decision on registration is taken by the MoH. The State Expert Center functions as the national
registration authority of medication. 240
There are different procedures for registering medication, depending on the type of medication andvolume of the medication:•••

Standard procedures – the procedure is harmonised with EU procedures (83 EU Directive).
The time frame is 110 days and the procedure costs UAH 100 000 (about EUR 2 950 241).
Generic medication registration takes 90 days to process.
Simplified procedures – international procedures, where medication has been registrated by
EMA, the Swiss national registry, or FDA. The procedure takes 7 days if no expertise from theCenter is needed. If expertise is needed, the procedure takes 45 days. WHO prequalified
medications for oncology, hepatitis, rare diseases and TB do not require expertise.
2017 EBR procedure – Ministry of Health will take a decision on registration based on a reportavailable on their website. 242

237

CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
239
National Cancer Institute, interview, Kiev, 13 March 2020.
240
State Expert Center, interview, Kiev, 11 March 2020.
241
Xe.com, Xe Currency Converter, 2 February 2021, url.
242
State Expert Center, interview, Kiev, 11 March 2020.
238

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

In 2019, a total of 900 registrations were done through the standard procedure. 70 medications wereregistered through the simplified procedure. In general, EU manufacturers tend to be used for the
Ukrainian market as FDA registered medications are quite expensive to bring to Ukraine. 243
A suggestion for electronic applications was with the MoH at the time of the interview (March 2020),
which, if approved, will reduce the time and logistics of the process. 244
7 % of registered medicines are only available through one manufacturer (for instance medication forrare diseases). Other medicines have many manufacturers, like diclofenac with over 30 brand names.
There are 100 licensed manufacturers in Ukraine. Half of the medications are for external use (e.g.
ointments). 10 of the manufacturers are quite big and also sell medication in other countries. In theSoviet era the focus was on Eastern Europe, which is still the case for Ukrainian manufacturers. Mostof the medications are generics that are needed on the internal market. 245
Importers and Ukrainian manufacturers have equal rights and they must all be Good Manufacturing
Practice (GMP) certified to get the products registered. State Services of Medicines handle GMP
certification. Chinese and Indian manufacturers often register in Ukraine first and then in the EU; 80%of the simplified procedure concerns medication from India. The State Expert Center has a WHO
certified medicine lab, one of nine in Ukraine, where chemical and physical properties can be tested.
The laboratory can also test immunobiological medication and vaccines. Vaccines have a special levelof control and are controlled both before registration as well as after each import batch. There are
four pharmabio laboratories/pharmacokinetics laboratories in Ukraine, three of which are private.
Manufacturers can choose to be tested anywhere, also abroad. 246
The representative of IRF mentioned that medication procurements tend to operate on budgets, noton needs, which means that patient groups advocate in order to assure their groups get medication.
This has varying results; in some regions the input from rights groups is regarded as important while
the advocacy is disliked in other regions. Hospital budgets are in general too low to procure enoughmedications, so the chief doctors negotiate with the MoH. The outcome depends on relations
between the doctors and ministry officials. 247
The interlocutor from the Children’s Hospital Okhmatdyt stated that onco-haematology drugs andexpensive medicines are obtained through central procurement at the Ministry of Health. The delivery
is not always well-timed, which can cause problems. Other medication is bought with the hospital’s
budget. In terms of supply, the representative noted that while the supply for onco-haematology is
problematic, the supply of insulin is fine. 248
According to an ANTAC representative, the old procurement system was flawed; it was nottransparent and favoured a few distributors. This could result in the state paying high above market
price for certain medicines. After the 2014 Maidan protests, the system was reformed and the
ProZorro system 249 was introduced. As a result, 40-50% of the budget was saved on procurement
orders. Hospitals are also now mandated to report the stock of medication each week. Through the
ProZorro system, it is possible to see if the medication was purchased by the hospital. 250

243

State Expert Center, interview, Kiev, 11 March 2020.
State Expert Center, interview, Kiev, 11 March 2020.
245
State Expert Center, interview, Kiev, 11 March 2020.
246
State Expert Center, interview, Kiev, 11 March 2020.
247
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
248
NCSP Okhmatdyt, interview, 12 March 2020.
249
The ProZorro is an online public procurement platform that ensures open access to public procurement (tenders) in
Ukraine.
250
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
244

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

An interlocutor at the National Cancer Institute explained that the MoH makes central purchases ofchemotherapeutics (e.g. cytostatics) through the ProZorro system, the hospital buys somemedication, and some foreign companies make some purchases. Later, once the new procurement
department at the MoH is established, it will handle all medication purchases. The interlocutor
believes the hospital needs liberty to buy from different companies to circumvent corruption, and also
as the hospital knows what they need, they prefer to control some purchases themselves. Bulk
medicines should be bought centrally, though. Currently they try to ensure all needed medicines arepurchased in advance by the MoH, but now they get medication bought two years ago. 251
The ANTAC representative stated that there were systemic problems with procurement in the field of
oncology, with tenders agreed in advance and too high or too low prices. 252

4.4. Pharmacies
There are many pharmacies in Ukraine – according to the representative of the State Expert Center,
there are five times as many per inhabitant as in Denmark. In the past ten years the ownership of thepharmacies has changed, going from individually owned to chain pharmacies. The pharmacies can give
rebates for customers, as can holders of the Kiev Citizen Card (the card also gives other social benefits,
like rebate for public transport). 253 A pharmacist in Kiev informed that pharmacies in Ukraine areclimate controlled. 254

Picture 2: Pharmacy sign in Kiev

Pricing on medication is free in general; it is only regulated for a few medicines. Medication on the
Essential Medicine List have a limit on mark-ups. 255 This was confirmed by a pharmacist who statedthat while medication not on the NEDL are not regulated, medication included in state programmes
have the same price everywhere. On other medication, prices will vary depending on area, as prices
are affected by supply and demand. 256 The price of medication is consistent within one pharmacy

251

National Cancer Institute, interview, Kiev, 13 March 2020.
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
253
State Expert Center, interview, Kiev, 11 March 2020.
254
Pharmacist, interview, Kiev, 12 March 2020.
255
State Expert Center, interview, Kiev, 11 March 2020.
256
Pharmacist, interview, Kiev, 12 March 2020.
252

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

chain, though. 257 Following a direct question on online pharmacies, the pharmacist stated that online
pharmacy prices can be regarded as reliable and mentioned tabletki.ua as one site where patients canorder medication for delivery or pickup at a pharmacy. 258
A pharmacist explained that there are seldom stock issues in private pharmacies and patients can go
to a private pharmacy if the hospital pharmacy is running out of the medication. The pharmacy where
this interlocutor works at has a computerised programme that gives a warning when stock is running
low on certain medication. 259
According to the pharmacist in Kiev, pharmacists in Ukraine do not have any mechanisms for detecting
or preventing contra-indications of medication, as this is considered to be solely the duty of thetreating physician. 260
Opiate medication is strictly controlled. For instance, morphine, tramadol and opioid substitution
treatment are all ‘rigorously’ regulated, a legacy from the Soviet era. According to the IRF
representative this can lead to accessibility problems when doctors may not prescribe the medicationand some local authorities may not wish to fund this medication. This means the patient needs to pay
full price. Only certain pharmacies have licences to operate such controlled medication, and in someoblasts there are only one or two with these licenses. It is regarded as not profitable, so it is notdesirable for pharmacies to apply for the licence. There is no legislation to regulate the amount ofcontrolled medication at each pharmacy. The patient will receive the address of the pharmacy
together with the prescription, not before. The representative further noted that some unlicensed
pharmacies sell these medicines as well, but it is done under the table. There can be consequences
because of the strict opiate policy. The IRF have documented cases of oncologic patients who need toget black market alternatives, or who commit suicide because they were not able to access pain
medication. 261

4.5. Not registered medication
Medication that is not registered can be easily obtained, according to representatives from the Public
Health Center, but the problem is that the quality is not guaranteed. 262 A representative of the State
Expert Center pointed out that according to official statistics about 1-2% of medication on the market
is counterfeit. Lists of medication which are suspected of being counterfeit are published on the State
Service on Medicines’ website. The State Drugs and Medications Control Service issues GMP
certificates, licenses pharmacies and distributors, and controls them. The agency also monitors forcounterfeit drugs and is able to stop the sale of medicines if the safety is in doubt. 263 A pharmacist
interviewed in Kiev mentioned that the authorities do a lot of controls of pharmacies and patients can
ask for certificates for medication. Due to all these controls, counterfeit drugs are not a problem,
according to the pharmacist. 264
The following three procedures, which are regulated by law, set out the legal import of unregistered
medications. Via a procedure in the MoH, medication can be imported as humanitarian aid. Patients
can also themselves bring medication into the country, which is controlled by Customs. Lastly,
medication can be brought within the scope of national and international clinical trials, approved by
257

State Expert Center, interview, Kiev, 11 March 2020.
Pharmacist, interview, Kiev, 12 March 2020.
259
Pharmacist, interview, Kiev, 12 March 2020.
260
Pharmacist, interview, Kiev, 12 March 2020.
261
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
262
Public Health Centre, interview, Kiev, 10 March 2020.
263
State Expert Center, interview, Kiev, 11 March 2020.
264
Pharmacist, interview, Kiev, 12 March 2020.
258

39

Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

the MoH. For a doctor to prescribe not registered medication in a legal way, they must prove that the
medication is only intended for an individual patient. Any other way of import is prohibited. 265

5. Accessibility for specific groups
5.1. Discrimination and societal groups
On the topic of discrimination, the representative of the IRF explained that Roma are discriminatedagainst and can be refused care or receive worse care than other patients. For LGBT patients, there is
not a lot of discrimination unless they need to disclose their status, for instance in reproduction andfamily planning. The situation is the same for drug users, who may experience discrimination in e.g.
the field of pain management. The discrimination could take the form of denial of treatment, being
told to go to other facilities, etc. 266 This was confirmed by the representative from UNAIDS, who
explained that at risk population (LGBT, sex workers, drug users, etc.) are discriminated against in
general. The interlocutor noted that rural areas differ from Kiev, where people in general are more
open. HIV patients can face stigma, and among some HIV patients there is the fear that, following thereform, they will need to go to general hospitals, where their health status may become known in thecommunity or doctors may have negative attitudes to HIV patients. There is a history of not respecting
the confidentiality of medical diagnosis in the healthcare system. 267 Similarly, the interlocutor from
WHO explained that the population at risk of HIV transmission in Eastern Europe are drug injecting
people, the incarcerated population, sex workers and LGBT communities, and a second wave ofheterosexual transmissions. There is still a lot of stigma and discrimination for these groups, especiallyoutside of Kiev. 268

5.2. IDPs and the situation in the non-government-controlled areas
The reform has, according to a representative from IOM, improved access to healthcare for IDPs. In
the past it could be difficult to get treatment, but as people can register with a general practitioner
anywhere now, access has improved. 269 This was also highlighted by the representative from 100%
Life. 270 For the people living in the non-government controlled areas, it may however be difficult to
get the declaration signed with a general practitioner. If an IDP is not registered, they cannot get freetreatment. The representative from UNAIDS noted that it is important to distinguish between IDPs
settled in government-controlled areas and those remaining in the non-government-controlled areasof Ukraine. The NHSU focuses on the government-controlled areas and population living there,
whereas people living in the non-government-controlled areas have no access to NHSU treatment onthat side of the contact line. However, people living with HIV on the non-government-controlled
territories can get anti-retroviral therapy there too, paid for from the grant to Ukraine from the Global
Fund to fight HIV, TB, and malaria (and distributed by 100% Life, see below). It should be noted that,since 2014, Crimea is part of Russia and internationally considered illegally annexed. UN agencies canaccess the non-government-controlled areas in Donetsk and Luhansk, but not Crimea. 271

265

State Expert Center, interview, Kiev, 11 March 2020.
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
267
UNAIDS and IOM, interview, Kiev, 13 March 2020.
268
World Health Organization (WHO), interview, Kiev, 10 March 2020.
269
UNAIDS and IOM, interview, Kiev, 13 March 2020.
270
100% Life, interview, Kiev, 10 March 2020.
271
UNAIDS and IOM, interview, Kiev, 13 March 2020; UNAIDS, email, 8 December 2020.
266

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

The representative from 100% Life explained that the organisation procures ARV medication forpatients on the other side of the contact line in Donbass, as the government cannot do this. The
organisation also transfers HIV medication to the territory. Reports are quite positive, though asmonitoring is difficult in that area, the NGO only has estimates. 272 The interlocutor from UNAIDS also
confirmed that the government does not provide ARV medication in the non-government-controlledareas, though patients can pick up medication on the other side of the contact line provided they areable to cross. 273
According to WHO representatives, HIV and TB services ‘were not unduly affected’ by the conflict, but
addiction services have been. As methadone is not provided in Russia, methadone substitution
therapy has stopped in Donbass. 274

5.3. Patients with mental health disorders
A representative from WHO explained that Ukraine still has a post-Soviet mental health system, withasylum-like hospitals with many human rights violations. 275 According to a 2017 World Bank Report,
the mental health care system in Ukraine is centralised and the services are provided mostly throughpsychiatric clinics, while 90% of the funding goes towards psychiatric hospitals. There is an absence ofmental healthcare on a community-level. In addition, the provision of mental health care support by
non-specialised staff such as general practitioners and family physicians is very limited. 276 The
centralised system includes psychiatric and narcological hospitals (for addiction problems), outpatient
clinics, psychiatric departments in hospitals, psychiatric agencies linked to other governmental
ministries, polyclinics possibly having psychiatrists or psychologists on staff, and a few private healthcare facilities. 277
In the public sector, psychiatric treatment is currently provided at secondary level, even though acouple of regions have introduced it at primary level. There is a growing awareness of mental healthcare at primary level, according to a WHO representative. Primary mental health care includes
psychosocial support, intervention, simple diagnosis, basic treatment and medicine. Recently a systemof referral has been introduced, where the first contact at primary level will refer a patient tospecialised care/psychiatrist. Currently, supervision of a family doctor by a psychiatrist is absent in the
public sector, while in the private sector supervision is known. The idea is that when first level staff
acquire the necessary skills, they can manage more psychiatric patients themselves. This is a new
system for the country and is not fully implemented yet, though the development is more pronounced
in the fields of mental health and HIV/TB. 278
For patients with schizophrenia, all costs were covered by a social benefit package, and both in- andoutpatient care was free. Due to the decentralisation of healthcare in the reform, it is not known if
this will still be the case. Local budgets should cover treatments, but the local authorities are notalways prepared for this. 279

272

100% Life, interview, Kiev, 10 March 2020.
UNAIDS and IOM, interview, Kiev, 13 March 2020.
274
World Health Organization (WHO), interview, Kiev, 10 March 2020.
275
World Health Organization (WHO), interview, Kiev, 10 March 2020.
276
World Bank Group (the), Mental health in transition. Assessment and Guidance for Strengthening Integration of Mental
Health into Primary Health Care and Community-Based Service Platforms in Ukraine, 2017, url, p. 11.
277
World Bank Group (the), Mental health in transition. Assessment and Guidance for Strengthening Integration of Mental
Health into Primary Health Care and Community-Based Service Platforms in Ukraine, 2017, url, p. 44.
278
World Health Organization (WHO), interview, Kiev, 10 March 2020.
279
World Health Organization (WHO), interview, Kiev, 10 March 2020.
273

41

Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

A psychiatric patient representative stated that there are no facilities or specialists outside the big
cities. Some mental diseases are not treated or supported in the country at all. 280 Local budgets do
not always provide enough funds for psychiatric treatment. 281 According to the WHO representative,
rehabilitation and recovery has been recently introduced and it is more about arts and crafts than reallife skills. There is a general lack of understanding of what rehabilitation is, so there is not muchsupport available on e.g. how to apply for jobs or other necessary skills. 282
The treatment is medication oriented 283 and patients are often prescribed drugs only. While
psychotherapy, behavioural therapy, cognitive behavioural therapy (CBT) and EMDR exist, they are
not common in the whole country. Different types of psychotherapy are available, but they are almost
all paid OOP and are often only available in the private sector. Staff in the public sector cannot afford
the training to specialise in e.g. EMDR. Nurses in Ukraine are not trained for medical procedures orfor psychiatric cases. 284
The representative from IRF explained that the psychiatric sector utilises closed facilities that may be
hard to access without paying bribes. Patients can be tied to beds or badly treated. 285 Article 14 of the
Law of Ukraine ‘On Psychiatric Care’ states that a person suffering from a mental disorder can be
hospitalised without their consent or without the consent of their legal guardian or representative if
inpatient treatment is possible and if they have a severe mental disorder making them a direct danger
to themselves or to others or if they cannot meet their basic needs in order to ensure their livelihood.
This article was amended in 2016 and a court order is required for involuntary admission. 286 In 2017,
the government developed a mental health concept note, with a strategy to create an alternative
community-based service and day institutionalisation (day care). The action plan has gotten stuck,
however. 287
On the question if a patient in a closed facility can experience problems getting released, therepresentative from IRF explained that if a patient is declared ‘incompetent’, the responsibility for arelease is with the guardian, which is often the Chief Doctor. In that case, a patient may not be released
when they wish. If the patient’s family want them released and declared ‘competent’, there are noissues leaving the facility. Some patients stay in facilities as they have nowhere to go; they would behomeless if released. Acute cases are normally admitted for 2-4 weeks in a facility, according to the
IRF representative. 288
Psychiatric patients report facing discrimination in outpatient settings, according to the representativefrom IRF. Not all family doctors want to sign their declaration or provide prescriptions. Some of thepsychiatric medications are restricted, which requires a different prescription. 289
A mental health patient spokesperson explained that patients with mental health disorders may noteven be notified of their diagnosis. The information is passed between doctor and therapist, bypassing
the patient, who must ‘fight’ to find out the diagnosis. Patients also avoid medical committees, as

280

CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
282
World Health Organization (WHO), interview, Kiev, 10 March 2020.
283
World Health Organization (WHO), interview, Kiev, 10 March 2020; International Renaissance Foundation (IRF),
interview, Kiev, 11 March 2020.
284
World Health Organization (WHO), interview, Kiev, 10 March 2020.
285
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020. (IRF), interview, Kiev, 11 March 2020.
286
Law of Ukraine, “On Psychiatric Care” (2000), in Ukrainian url, cited in World Bank Group (the), Mental health intransition. Assessment and Guidance for Strengthening Integration of Mental Health into Primary Health Care andCommunity-Based Service Platforms in Ukraine, 2017, url, p. 38.
287
World Health Organization (WHO), interview, Kiev, 10 March 2020.
288
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
289
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
281

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

these committees can suggest for a person to work from home, which can create problems with thepatient’s employer. 290

5.4. HIV patients
5.4.1. Funding for HIV services
There is a transition plan for the government to take over procurement of ARVs. 291 Global Fund has
funded USD 130 million for HIV treatment over 3 years in Ukraine. 292 The current annual budget for
TB/HIV treatments in Ukraine is USD 70 million, which has been the case for the past ten years. 293
Over time, the Ukrainian state has promised to transition from donor funding to national funding for
TB/HIV treatments, until in the long term no international funding will be needed. 294 About half wasnationally funded in 2020. 295
Initially, the funding from Global Fund 296 was given to the government, but later this changed and thefunding was given to NGOs (Alliance for Public Health and 100% Life are equal partners). This was thefirst time Global Fund gave funds to NGOs. 297
If the government underbudgets and treatment is missing, 100% Life steps in; something which
recently happened. There is no problem currently in Ukraine with the procurement, delivery andsupply of ARV’s, and most are available. The procurement of ARVs is done according to WHO protocol,and they are only able to procure what is included in the WHO protocol. WHO protocols on testingand prescription should be implemented soon. 298 Innovative testing equipment would be procured by
the government, as it cannot done with the international funding. 299
Regarding HIV prevention, the government picks up the services, but donors are paying for condoms,
needles, staff resources, etc. According to the representative from UNAIDS, it is a good understanding
but with the changes in government it is difficult to know how commitments are maintained. 300
As of last year, Ukraine provides free ARVs to Ukrainians. IDPs and citizens in the non-governmentcontrolled areas also receive free antiretroviral medication, though the supply is donor-funded. It isalso possible to pick up the medication in government-controlled areas, as long as it is possible tocross the contact line. ARVs (e.g. Truvada) for preventive use instead of for treatment are funded by
NGOs. Some ARVs are purchased via donor funding for innovation programmes, but the expectationis that the government will pay for this as well, if it is scientifically proven. 301
All procured ARVs are on the national essential drug list. The Centre of Public Health makes annual
estimates on how many therapies will be needed. 100% Life also procures for the occupied regions in

290

CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
100% Life, interview, Kiev, 10 March 2020.
292
World Health Organization (WHO), interview, Kiev, 10 March 2020.
293
UNAIDS and IOM, interview, Kiev, 13 March 2020.
294
UNAIDS and IOM, interview, Kiev, 13 March 2020; World Health Organization (WHO), interview, Kiev, 10 March 2020.
295
World Health Organization (WHO), interview, Kiev, 10 March 2020.
296
The Global Fund is an international organization that aims to accelerate the end of AIDS, tuberculosis and malaria asepidemics. Source: Global Fund (the), Overview, 14 September 2020, url.
297
World Health Organization (WHO), interview, Kiev, 10 March 2020.
298
100% Life, interview, Kiev, 10 March 2020.
299
100% Life, interview, Kiev, 10 March 2020.
300
UNAIDS and IOM, interview, Kiev, 13 March 2020.
301
UNAIDS and IOM, interview, Kiev, 13 March 2020.
291

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Donbass, as the government cannot provide for people there. The NGO is transferring medication overthe contact line. 302
100% Life, founded in 2001, is the biggest patient-based organisation in Ukraine with 15,000
members. It is financed by Global Fund, the EU, Pepfar 303 and others. It represents HIV positive andother vulnerable groups and advocates for human rights and access to treatment. The mandate has
increased over the years. The organisation works in four areas: service provision, advocacy,
innovation, and strategic communication with stakeholders. 304
In terms of service provision, the NGO works with:
−
−
−
−
−
−
−
−

identification/diagnosis of HIV and ART procurement.
Identification/diagnosis of TB (together with Center of Public Health), social services.
identification, social services and antiretroviral medicines procurement (ART procurement)
and prescription for HIV, TB, Hepatitis C and B patients.
penitentiary system – testing and social and medical support. Opioid substitution therapy.
development of a medical information system for HIV patients, which can be installed in all
medical facilities.
registration of HIV cases in the country. All patients are registered to provide epidemiological
data and new patients can be added directly through index testing.
working on systems for labs.
procurement of ARVs/ART therapy, which is provided by medical centres. The NGO work with
MoH and NHSU in this capacity and do not provide medical treatments as a service. 305

100% Life have also established a non-profit, self-sustained Community Medical Center, which
provides only primary health care services for HIV positive patients and for the general population inthese areas: gynaecology, paediatrics, narcology (addiction problems), vaccination, family doctor. 306
In addition, 100% Life has advocated for testing and prescription of ARVs to be handled by family
doctors. The legal act is signed but the change is yet to be implemented. The organisation is working
on de-stigmatisation and have developed an online, distance learning tool for family doctors on antistigma and anti-discrimination. They have also created a map of friendly family doctors, so patients
can know e.g. who to sign a declaration with. Other areas of advocacy include decriminalisation of sex
work and drug use, and providing legal support for LGBT persons. Human rights in Ukraine for HIV
positives, drug users and LGBT is still sensitive, according to the interlocutor. 307

5.4.2. Availability of treatment and medications
There are less than 400 ART sites/HIV centres in 24 regions. Each region has a regional centre which
coordinates these services. While there are 50 centres in the Kiev Dnipro region, there is only 1 centre
in Chernivtsy, a small region. This means that in rural areas, patients may need to travel a few hours. 308

302

100% Life, interview, Kiev, 10 March 2020.
Pepfar stands for the U.S. President’s Emergency Plan for AIDS Relief. Source: USDoS, The United States President’s
Emergency Plan for AIDS Relief, n.d., url.
304
100% Life, interview, Kiev, 10 March 2020.
305
100% Life, interview, Kiev, 10 March 2020.
306
100% Life, interview, Kiev, 10 March 2020.
307
100% Life, interview, Kiev, 10 March 2020.
308
Public Health Centre, interview, Kiev, 10 March 2020.
303

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

ARVs are only available in the AIDS centre pharmacies, not yet in general pharmacies and incommunity medical centres. This will change soon though. 309 The representative from WHO expresseda hope that ARVs would be available in regular pharmacies in the future. 310
According to a WHO representative, the situation for people living with HIV has improved greatly inthe last years. Approximately 100 000 people are now on ARV treatment, while in 2007 there were
only 4 000. An estimation is that 70% of cases have a diagnosis and 80% of those are treated. The
curve of people getting treatment is very good. 311 The Public Health Center informed thatapproximately 113 000 are treated on ARVs. According to the government agency, there are 130 000
HIV cases registered in government-controlled areas, but it is estimated there are 240 000 cases intotal (including non-government controlled areas). Mortality has decreased but prevalence (the total
number of cases) has increased. 15 000 new cases are found every year; this incidence is stable. It is
however difficult to detect cases in rural areas. 312
The electronic medical system centrally monitors patients with HIV, to see how effective thetreatment is. Indicators are received on regional levels for TB and HIV and can then be analysed. 313

5.4.3. Access to treatment
HIV testing is usually only offered in special clinics (ART sites and HIV centres). According to a WHO
representative, 20% of those diagnosed with HIV do not receive treatment. This is mostly because ofnon-compliant patients, complicated hurdles patients need to pass through, and economic barriers.
Among people not receiving treatment for HIV, there is an overrepresentation of the marginalised
populations, as services are not always adapted to their needs. It might be a matter of increasing the
opening hours at the testing sites and not asking for documentation, for instance. Another obstacle isthat people get counselling first and do the test, instead of the other way around. People can be
regarded as non-compliant and get kicked out, when e.g. they were not able to make it to theappointment. They may then have to check and pay for a viral load test before getting ARVs. They may
also need to get a TB test somewhere else before getting ARVs. WHO has tried to ensure the mindset
changes, so patients can get treated. 314
For the marginalised population, especially injecting drug users, there are difficulties accessing
treatment. WHO supports opioid substitution therapy, also as a way to retain ARV treatment. Ukraine
has the biggest state-financed opioid substitution programme in Eastern Europe, but it would stillneed to be bigger as it reaches only 7 000 out of over 60 000 who really need it. Dosages are too low,
despite being the best in Eastern Europe. In general there is no methadone in Russia, so substitution
with methadone stopped in the occupied region Donbass. HIV and TB services ‘were not unduly
affected’ by the conflict, but addiction services were affected. 315 In a clarification, a representativefrom the Public Health Center explained that 14 296 patients are included in the programme and the
known number of opioid users is 278 318, making the coverage 5.1 %. The dosage is prescribed on an
individual basis. 316

309

100% Life, interview, Kiev, 10 March 2020.
World Health Organization (WHO), interview, Kiev, 10 March 2020.
311
World Health Organization (WHO), interview, Kiev, 10 March 2020.
312
Public Health Centre, interview, Kiev, 10 March 2020.
313
Public Health Centre, interview, Kiev, 10 March 2020.
314
World Health Organization (WHO), interview, Kiev, 10 March 2020.
315
World Health Organization (WHO), interview, Kiev, 10 March 2020.
316
Public Health Center, e-mail, 24 December 2020.
310

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

A representative from the Public Health Center pointed out that, historically, marginalised groups withHIV have been the responsibility of NGOs. They become the responsibility of the healthcare system
when patients approach it. The NGOs are still important in reaching out to certain key populations. 317
The interlocutor for 100% Life stated that the organisation had difficulties in reaching patients outside
the traditional groups, but the organisation has a new project on that. The NGO also saw a need toreduce time between diagnosis and prescription of ARVs. The second 90 (in the 90-90-90 UN target 318)
is a challenge and protocols still need to be adopted. Additionally, there is a need to ensure people
are not ‘lost’ after the initial testing. In general though, the NGO have positive results on adherence. 319
There is a law which lists which people should be tested for HIV, based on their history, symptoms,
behaviour, and so on. Currently, only infectiologists can prescribe ARVs and only at ARV sites, thougha draft law is in process which will enable family doctors to prescribe ARVs. 320 The intention of thehealthcare reform was for family doctors to do HIV tests and prescribe first line medication. The
payment to the family doctors includes HIV rapid tests in their cabinets. Complicated cases could bereferred to second level/hospitals and a specialist. 321 UNHCR ensures asylum seekers get tested andget access to treatment for HIV or get to continue treatment when in Ukraine. 322 The HIV centres haveinfectious disease specialists who can focus on TB (pulmonologist) or HIV. 323 For referrals, a family
doctor will refer the patient to a regional (raion level) AIDS centre, who can then refer to oblast level
AIDS centre, after which the patient if needed can be referred to a specialist hospital. 324
The interlocutor from WHO explained that the population at risk of HIV transmission in Eastern Europe
are drug injecting people, the incarcerated population, sex workers and LGBT communities, and asecond wave of heterosexual transmissions. 325

5.4.4. Cost of treatment
Viral load and CD4 tests are available free of charge, and a person with HIV can get free ARV treatment
in Ukraine. 326 The state also covers treatment for patients with viral hepatitis and TB, as well as OST(Opioid Substitution Therapy). 327 Follow-up laboratory tests are not free. 328
Incurred costs may involve travel, or if the patients chose to go to private clinics to get faster service. 329
There have been no reports of informal payments for ARTs. 330

317

Public Health Centre, interview, Kiev, 10 March 2020.
By 2020, 90% of all people living with HIV will know their HIV status.
By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. Source: UNAIDS, 90–90–90: An
ambitious treatment target to help end the AIDS epidemic, n.d., url.
319
100% Life, interview, Kiev, 10 March 2020.
320
Public Health Centre, interview, Kiev, 10 March 2020.
321
UNAIDS and IOM, interview, Kiev, 13 March 2020.
322
UNAIDS and IOM, interview, Kiev, 13 March 2020.
323
UNAIDS and IOM, interview, Kiev, 13 March 2020.
324
Public Health Center, e-mail, 24 December 2020.
325
World Health Organization (WHO), interview, Kiev, 10 March 2020.
326
UNAIDS and IOM, interview, Kiev, 13 March 2020; World Health Organization (WHO), interview, Kiev, 10 March 2020;
Public Health Centre, interview, Kiev, 10 March 2020.
327
Public Health Centre, interview, Kiev, 10 March 2020; Public Health Center, e-mail, 24 December 2020.
328
World Health Organization (WHO), interview, Kiev, 10 March 2020; Public Health Centre, interview, Kiev, 10 March
2020.
329
UNAIDS and IOM, interview, Kiev, 13 March 2020.
330
UNAIDS and IOM, interview, Kiev, 13 March 2020; 100% Life, interview, Kiev, 10 March 2020.
318

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

In order to get better treatment, people go to the private sector. The WHO representative noted thatpublic sector is lacking compared to the private sector, but it is improving. Incorporating private
facilities is in the plan of NHSU. At the last tender for HIV package, there were 500 successful bidders,
100 of which were new on the market. Some facilities are private, and they participate under the same
conditions as public ones. The service will be free at the point of delivery in private facilities too, but
the facility may offer other services at a cost, e.g. recommend other medications. 331 In general HIV
patients have to be tested for hepatitis, but the patients need to pay for the hepatitis test in somehealth facilities (the interlocutor estimates patients need to pay in about 50% of facilities). 332
The WHO have encouraged an optimisation of treatment, to increase cost effectiveness and efficiency.
By moving to standardized WHO regimen in first line, the cost of medicine was reduced. Before there
was too much choice in medication, including combinations that were never used. Now there is astandard first line treatment. There are 36 first line regiments, and ideally the patient is given only
one pill a day (containing several ARV’s). They are still reducing the use of some formulations and are
moving towards the standardized regimen. The procurement still contains ARVs not recommended by
WHO (e.g. lopinavir is 25 times more expensive than the ARV recommended by WHO). WHO wants to
reduce the use of overpriced medications and have tried for years to reduce the number of
medication. 333

5.4.5. Consequences of the reform
There are concerns from HIV patients that with the closure of specific AIDS centres and related
integration of HIV/AIDS services into regular clinics, the patients may risk encountering more doctors
with negative attitudes towards HIV patients. The UNAIDS interlocutor further explained that the atrisk population is discriminated against in general (gay, sex workers, drug users, etc.). 334
The representative from UNAIDS noted that people with HIV face stigma, but also that it varies overtime. Among the patients there is a fear that after step two of the reform has been implemented, theHIV patients must go to general hospitals. There is a history of not respecting the confidentiality of
medical diagnosis in the healthcare system, so the patients’ health status may become known to theircommunity. There is also fear that the staff at the general hospital will not be specialised or as qualified
as in the current centres. 335
The interlocutor for 100% Life highlighted a concern related to political insecurity, which is an issue ingeneral for the programmes. Additionally, there is a challenge to identify new HIV positive cases. As
demographics are unknown, they do not know their target numbers (see also section 1.3.5. Data
collection in healthcare). 336

5.5. TB patients
TB incidence (number of new cases) is decreasing; in 2019 there was a 3% decrease, and the trend forthe past seven years has been a decrease. MDR TB incidence decreased as well in 2020, after someyears of stabilisation. 337 However, the UNAIDS representative reported that TB and MDR TB are big

331

World Health Organization (WHO), interview, Kiev, 10 March 2020.
Public Health Centre, interview, Kiev, 10 March 2020; Public Health Center, e-mail, 24 December 2020.
333
World Health Organization (WHO), interview, Kiev, 10 March 2020.
334
UNAIDS and IOM, interview, Kiev, 13 March 2020.
335
UNAIDS and IOM, interview, Kiev, 13 March 2020.
336
100% Life, interview, Kiev, 10 March 2020.
337
Public Health Centre, interview, Kiev, 10 March 2020.
332

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

concerns in Ukraine, with TB being the number one cause of death for people living with HIV. 338 All TB
patients are tested for HIV, and the yield is quite high. All newly discovered HIV patients get tested forTB. 339
All TB patients get diagnosis and treatment for free, including the new drugs for MDR and XDR TB. 340
For complicated MDR TB, the usual DOT (Directly Observed Therapy) strategy is provided by 100%
Life. The NGO provides the services which are not provided by the government. A strategy on
combatting TB was signed last year. 341
Treatment of TB is changing into a public health approach, like for HIV, with more rapid testing, test
& treat (limit the time before treatment starts), standardised regimens, and multi-month prescriptions. 342 All TB programmes and treatment standards are coordinated by the Public HealthCenter. The new standards of care for TB are similar to EU standards, but adapted to WHO
recommendations. 343
As a result of the reform, TB hospitals will branch out to become something closer to infectious disease
hospitals 344 (see section 1.3.4. Changes to HIV and TB services), but there is a lot of resistance to a
public health approach for TB treatment. With the ongoing reform, there is a fear among the publicof the planned sanatorium closures. The current system keeps patients locked up with their family fornine months in a sanatorium. 345
There is a reluctance to use short-term medication. For regular TB, the situation is improving andsuccess rates are increasing. For MDR TB, the results are worse due to for example incomplete
treatments. There are many reasons why MDR and (extra multi-resistant) XDR TB is prevalent, suchas an over-use of certain medications, incomplete treatment schedules and not doing follow-ups.
Complicated antibiotics for MDR/XDR TB are available. The WHO promotes a standardised approach,but there is a lot of reliance on the old system. 346
Regarding co-infection HIV/TB, there is good communication between the two systems in charge,
according to the Public Health Center. For TB, there are regional TB dispensaries, and for HIV there
are 74 regional medical facilities which coordinate the ART sites. The MoH will be making a new
regime/protocol for co-infection, as the old one is no longer valid. 347

5.6. Oncology patients
The National Cancer institute is a tertiary oncology hospital, accepting referrals from all over Ukraine.
On paper this is the leading oncology centre in Ukraine, but the representatives note that each region
has one oncology centre and, in reality, the same treatment can be provided in each of the 24 regions.
However, the regions tend to send complicated cases to the Institute. One third of patients are sentby regional oncology centres. In theory patients need to be referred from a family doctor, to secondary

338

UNAIDS and IOM, interview, Kiev, 13 March 2020.
UNAIDS and IOM, interview, Kiev, 13 March 2020.
340
Public Health Centre, interview, Kiev, 10 March 2020.
341
100% Life, interview, Kiev, 10 March 2020.
342
World Health Organization (WHO), interview, Kiev, 10 March 2020.
343
Public Health Centre, interview, Kiev, 10 March 2020.
344
UNAIDS and IOM, interview, Kiev, 13 March 2020.
345
World Health Organization (WHO), interview, Kiev, 10 March 2020.
346
World Health Organization (WHO), interview, Kiev, 10 March 2020.
347
Public Health Centre, interview, Kiev, 10 March 2020.
339

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

level, and then on to the Institute, but people still come directly to the tertiary level (bypassing thereferral system). 348
The National Cancer Institute treats all oncologic diseases, except central nervous system tumoursthat must be sent to a specific centre. There is also a specific oncology centre for children at Okhmadyt
Hospital. Leukaemia is treated in a separate centre, and the haematology department at the Institutetreats lymphomas only. 349 While the National Cancer Institute has a paediatric ward, solid tumours
can also be treated at Okhmatdyt for paediatric patients. At Okhmatdyt, there are no specialists inonco-haematology, but instead a general paediatrician with additional knowledge treats thesepatients. The hospital has child haematologists, though. An onco-haematological specialisation isplanned, but for now the specialists are either focused on oncology or haematology. 350

5.6.1. Availability of treatment and medication
The representative of the National Cancer Institute noted that in general the availability and supply of
chemotherapeutics (e.g. cytostatics) is fine, but for example the availability of radiation therapy is
problematic as there are only a few working machines in the country and the institute has one. 351
The Institute has one machine for linear radiation therapy (external beam radiation treatments), andthere can be two months’ waiting time. There are five linear accelerators in Kiev in total. The machines
are expensive, so buying another one would spend most of the budget. For the past five years, theInstitute has only bought medicines from their budget. 352
The Institute has one PET (Positron Emission Tomography) Scan with glucose tracer, used to detect
metastasis. There are only three PET-CT scans (two in private, one in public) in Kiev, but more areavailable in other parts of the country. The Institute does not have radio tracers or do proton therapy.
The hospital has two CT machines and one MRI. There is a two-month queue for diagnostics. 353
At the National Cancer Institute, doctors are stationed in one part, e.g. the inpatient clinic, but they
will also assure the follow-up of patients after discharge from the inpatient ward. In the old inpatient
wards, there are six beds per room (separate wards for men and women). A new block was opened
eight years ago (the construction of the building was delayed due to lack of funds). In the new sections,
there are two patients per room. The hospital has about 600 beds in total. All doctor positions arefilled, but they lack nurses. The hospital has 17 operating theatres. The interlocutors explained that a
lot of the equipment, like beds, is old and donated from other European hospitals. Food for inpatients
is cooked centrally in the hospital. The representative explained that not all hospitals have kitchens,

348

National Cancer Institute, interview, Kiev, 13 March 2020.
National Cancer Institute, interview, Kiev, 13 March 2020.
350
NCSP Okhmatdyt, interview, 12 March 2020.
351
National Cancer Institute, interview, Kiev, 13 March 2020.
352
National Cancer Institute, interview, Kiev, 13 March 2020.
353
National Cancer Institute, interview, Kiev, 13 March 2020.
349

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

in which case inpatients must bring their own food. Department are organised according to the typeof cancer and each has its own pharmacy. 354

Picture 3: A room in the inpatient ward in the old part of the National Cancer Institute.

For the supply of chemotherapeutics at the National Cancer Institute, the MoH buys the medication
centrally using the ProZorro system. Some drugs are bought by the hospital and some foreigncompanies purchase medication as well for all oncology departments. At the third phase of thereform, the new procurement department at the MoH will handle it. The interlocutors are not certain
this change is good, as it removes control over the medication supply from the hospital. Currently,
there is an issue that medication purchased in advance by the MoH has been bought two years ago 355(see section 4.3. Registration and procurement of medication).
The National Cancer Institute can send patients abroad for treatment, especially for transplantations.
Transplantation of bone marrow for adults is only possible through relatives, as there is no donor
registry in Ukraine. In fact, all types of transplants are only possible from relative donors. The situationis changing, though. In general, very few patients need to go abroad, usually for liver and hearttransplants or haematology cases. 356
At the private Boris Clinic, the representative noted that while it is rare for patients to go abroad fortreatment, the reason is not usually because the treatment cannot be done in Ukraine – it is usually
because the services abroad are more qualified or the patients want more qualified care. This usuallyconcerns oncology, e.g. acute leukaemia. In the past children with very specific forms of leukaemia
were sent for treatment to Helof Hospital in Tel Aviv, Israel, with which Boris Clinic has an agreement.
The government is not involved in sending patients abroad, at least not from the private clinic. The
treatment is financed by the patients. 357
At the National Cancer Institute, while most medications are available, some drugs are not registered
due to low demand. The patients should buy the medication abroad in those cases. The institute treats
25 000 patients/year and performed 10 000 surgeries last year. 358

354

National Cancer Institute, interview, Kiev, 13 March 2020.
National Cancer Institute, interview, Kiev, 13 March 2020.
356
National Cancer Institute, interview, Kiev, 13 March 2020.
357
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
358
National Cancer Institute, interview, Kiev, 13 March 2020.
355

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

The Institute does not keep electronic patient files, everything is kept on paper in journals. It is possible
to send journals abroad. 359
A representative of a patient organisation described the medication list EML as insufficient, andsometimes doctors encourage patients to purchase medications not included in the EML, by statingthat the free medication on the EML is ‘not effective.’ The doctor may instead recommend medication
sold by a particular provider. The patients do not have access to complaints mechanisms and as there
are not enough oncologists, they cannot change doctor. 360

5.6.2. Access to treatment
Much oncologic medication, including targeted therapy, is not part of the benefit package but is partof the budget for centrally procured medication. There is insufficient medication for all patients whoneed it, so once the medication runs out patients need to pay. Doctors decide who receives the free
medication, as there is currently no prioritisation on the allocation of centrally procured medicines.
The NHSU representative noted that oncologic treatment is ‘highly corrupt,’ so even before the reform
doctors would try to sell the medications to patients. This is not a problem for e.g. TB and HIV
medication, as the need for treatment is flat per number of patients. For oncology patients, fullcoverage with targeted therapy or innovation therapies will likely never be economically possible for
the Ukrainian state. 361
The current system is described by patient representatives as more transparent than in the past, andthere are no charges for basic targeted therapy (though more advanced targeted therapy must be
paid by the patient) and no shortage. However, doctors still encourage patients to buy medicationelsewhere, as they may get a percentage of the sale. The interviewed patient representative told astory about a pharmaceutical company which provided up to 200 free injections worth USD 4 000, butwould also ask detailed questions to find out if patients could afford to pay for future treatments.
Another example provided by the representative was of a patient who needed surgery which would
cost UAH 100 000 (approximately EUR 2 950 362) in a public hospital, despite the fact it should be freeon paper. The patient was told she would get banned if she went public with the incident. 363
Oleksandra Ustinova noted that there is a high level of oncologic patients in Ukraine; as there are no
early diagnostics, people end up in hospital with stage 3 or 4 cancer, which is expensive to care forand hard to cure. 364 Patients need to pay in order to receive a diagnosis, and there is a waiting list.
Innovative treatments for melanoma patients in stage 3 or 4 can cost up to USD 4 000, if the patientis part of clinical studies. A patient representative explained that for radiation therapy, there is notenough equipment, and moreover it is old, so there is a waiting list to get treatment. Surgery is paidby the patients, which many cannot afford. There is insufficient staff available for palliative therapy.
Lastly, the representative mentioned that there are many cases reported of wrong prescriptions.
Locally, the representative stated that at times medical staff lack knowledge, misdiagnose and give
the wrong treatment. 365
There is an issue that oncology patients get classified as disabled, but when, after targeted therapy,
they continue with hormone therapy they lose this qualification and as a consequence are no longer
entitled to disability benefits. Breast cancer patients on the other hand can keep their disabled status
359

National Cancer Institute, interview, Kiev, 13 March 2020.
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
361
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021.
362
Xe.com, Xe Currency Converter, 2 February 2021, url
363
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
364
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
365
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
360

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

but need to reapply every 2 years. In case patients are disqualified but still need some treatment, they
likely encounter financial problems to continue because they cannot rely on social security anymore.
Not being classified as disabled means loss of pension and social security. 366

5.6.3. Cost of treatment
80% of treatments are financially covered by the state, and patients pay 20-25%, usually for materials.
Emergencies and children are fully covered. 367 According to Oleksandra Ustinova, oncologic
medication is very expensive and the state covers up to 20% in some cases, and up to 70% forchildren. 368
A representative for a patient oncology organisation noted that, while the situation has improved, it
is still not ‘good enough’. While most aspects of the treatment are free, more expensive and efficient
medication is not as accessible. Some expensive chemotherapy is not covered and 40% of patientswith melanoma do not continue their treatment because they cannot afford it. For this reason,
patients sometimes go abroad for treatment. The representative explained of one initiative where
patients go to Spain and manage to get free treatment. 369
Patients do not pay for treatment at the National Cancer Institute; however, the medical system isunderfunded and only 60% of chemotherapy drugs are covered by the state, the patients buy the rest.
Patients often have to pay part of the treatment, medication, and/or medical devices themselves.
Targeted and immuno-therapy are paid by the patients while chemotherapy is covered up to 60%.
Paediatric treatments are covered completely, except for targeted therapy. Targeted therapy is
acquired via medical companies, and patients contact the companies directly. As staff costs are low,patients do not need to pay for surgery according to the representatives of the Institute. Patientssometimes need to pay for single-use materials. 370
There have been complaints of patients at the National Cancer Institute having to pay for procedures
which should be free, and patients who had to pay very high prices for oncological medication. This
resulted in the sacking of both previous hospital directors. The Institute has been involved in a trial
regarding a tender for maintenance and an anti-corruption body has investigated the Institute. The
representative of ANTAC noted however that reports of patients having to pay have reduced
greatly. 371

5.7. Paediatric patients
The NСSР Okhmatdyt in Kiev is the largest paediatric hospital in Ukraine, annually providing over
20,000 children with inpatient treatment, more than 28 000 with emergency medical care, and morethan 70,000 are treated in the consultative-diagnostic centre at the hospital. 2 000 specialists are
employed at NСSР Okhmatdyt. The purpose of the hospital is to provide multidisciplinary high-quality
medical care to children from all over Ukraine in accordance with international quality standards. The
hospital is also a teaching hospital. 372

366

CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
National Cancer Institute, interview, Kiev, 13 March 2020.
368
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
369
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.
370
National Cancer Institute, interview, Kiev, 13 March 2020.
371
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
372
NCSP Okhmatdyt, interview, 12 March 2020. See also the hospital website url.
367

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Picture 4: Exterior of one of NCSP Okhmatdyt’s hospital buildings

NCSP Okhmatdyt is a tertiary paediatric hospital, with a wide range of departments such as
orthopaedics (including injuries), orphan diseases department, neonatology, paediatric surgery (fornew-borns with weight starting from 600g and higher), neuro-surgery, oncology-haematology, bonemarrow transplantations (including non-related bone marrow transplants, but no organ transplants),
surgery for genetic diseases, inborn errors of metabolism/congenital diseases, neurology, andpaediatric oncology. 373
Patients can also be referred abroad, with a Special Committee at the MoH taking the decision to refer
the case to another country. The state does not cover all the costs in these cases. Some charity
organisations and the government cooperate to cover the expenses, and sometimes parents pay
themselves. Charitable organisations contribute a lot to such costs, especially for onco-haematology
cases. Usually patients are sent to e.g. Belarus, Italy, Germany, etc. It tends to concern only organtransplants, as everything else can be done at NCSP Okhmatdyt. 374
Most treatments are free, but spinal reconstruction surgeries, like scoliosis, are not free. There are
officially no co-payments at the hospital. The hospital treats patients up to 17 years, and they arecompletely covered. If patients turn 18 and need ongoing treating, they will continue the treatment
at Okhmatdyt. 375
The state budget finances most medications, and some charity organisations contribute. Theinterlocutor from Okhmatdyt explained that the parents in rare cases buy the medications
themselves; sometimes they pay co-payments. Onco-haematology and expensive medications arecentrally procured by the MoH. The delivery of the medication is not always well-timed, which causes
problems. Other medications are bought from the hospital’s budget. In case the patient or the family
pay for medication that should be free, it will not be reimbursed. Some very expensive medication canbe obtained as charity donation. The hospital cooperates with charities to obtain medication.
Treatments with not registered medication are organised as clinical trials. 376

373

NCSP Okhmatdyt, interview, 12 March 2020.
NCSP Okhmatdyt, interview, 12 March 2020.
375
NCSP Okhmatdyt, interview, 12 March 2020.
376
NCSP Okhmatdyt, interview, 12 March 2020.
374

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

The supply for onco-haematology medication is problematic, but for instance the insulin supply is fine.
There are problems with supplies of certain reactives, used for testing donors’ blood tests. They have
6 000 blood donors per year which need to be tested. Supplies are usually provided centrally from theMoH. However, the chain is always lagging. Charity organizations cover expenses to avoid delays forsurgeries. 377
Some patient groups can be classified as disabled and are therefore eligible to free treatment. In
reality, the representative for patients with Parkinson noted the classification of disability is delegatedto the local authority and there is not enough money. So, there is no automatic access to freetreatment for children, most must fight for it according to patient organisations. 378

377
378

NCSP Okhmatdyt, interview, 12 March 2020.
CF Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March 2020.

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Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

Annex 1: Bibliography
Oral sources, including anonymous sources
100% Life, interview, Kiev, 10 March 2020.
Anti-Corruption Action Centre (ANTAC), interview, Kiev, 12 March 2020.
CF Patients of Ukraine, interview via Zoom, 25 November 2020.
Health Technology Assessment (HTA) Department at State Expert Center, interview, Kiev, 12 March
2020.
International Renaissance Foundation (IRF), interview, Kiev, 11 March 2020.
International Renaissance Foundation (IRF), interview via Webex, 23 November 2020.
National Cancer Institute, interview, Kiev, 13 March 2020.
National Health Services of Ukraine (NHSU), interview, Kiev, 12 March 2020.
National Health Services of Ukraine (NHSU), interview via Webex, 26 January 2021
NCSP Okhmatdyt, interview, 12 March 2020.
Patients of Ukraine and representatives of different patient organisations, interview, Kiev, 10 March
2020
Pharmacist, interview, Kiev, 12 March 2020. The interlocutor is a pharmacist working at a private
hospital pharmacy in Kiev. The person wishes to remain anonymous for security reasons.
Public Health Center, e-mail, 24 December 2020.
Public Health Center, interview, Kiev, 10 March 2020.
Raschupkin, Andrey, medical director, Boris Clinic, interview, Kiev, 13 March 2020.
State Expert Center, interview, Kiev, 11 March 2020.
UNAIDS, email, 8 December 2020.
UNAIDS and IOM, interview, Kiev, 13 March 2020.
UNAIDS, interview, Kiev, 13 March 2020.
Ustinova, Oleksandra, member of parliament, interview via Skype, 26 March 2020.
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Annex 2: Terms of Reference
Objective
The objectives of the mission is twofold. In terms of content, a key goal is to map the changes in the
Ukrainian healthcare system over the last few years. Since some years, Ukraine has been in the
middle of a healthcare reform, and it should be established how far the initiated reform have comeand what changes are yet to be implemented.
The health care reform is focused on five areas:•

Money follows the patient•

Package of guaranteed benefits•

International standards•

Co-payment system•

Family medicine

Additionally, the FFM will collect information in general of the state of the healthcare sector, its
limitations and its capacity. The accessibility of the Ukrainian public healthcare system, in terms of
economical access (cost to the patient to access treatments and medications) and geographicalaccess (healthcare in rural areas and the referral system) will be studied. To anticipate future userneeds, a number of commonly requested treatment areas have been identified, for which treatment
options will be investigated more in detail.
A secondary objective is to set a methodology and procedure for conducting fact finding missions(FFMs) for EASO. EASO participated in a FFM led by the Belgian Desk on Accessibility (BDA) in June
2019, and in this mission the intention is to streamline the procedure further to formulate clear
internal guidelines for conducting FFMs as EASO representatives.
Mission participants
The mission will be led by Liza Backstrom, EASO information officer in COI. Aurelie Varin, EASO
research assistant in MedCOI, co-planned and will participate in the mission. In addition, Albert deVries, medical advisor at EASO, will join. An invitation to participate was extended to the EU+
countries in September 2019, but no interest was expressed.
Scope
The mission will take place in Kyiv, Ukraine over of five days.
Healthcare system
Organisation
Reforms
Public and private sector (incl. Medical bridge programmes)
Treatment areas
Paediatrics
Oncology
Psychiatry58

Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

HIV
Hepatitis
Pharmacological sector
Affordable Medicines National Prescription Drugs Cost Reimbursement Program
Essential Medicines list
Medication prices
Financial issues for patients
Health Insurance
Out of pocket payments, corruption
Intended interlocutors
The intention is to meet with a mixture of interlocutors, from the public sector and the private, inorder to get multiple viewpoints on the topics included in the scope:•

Ministries

•

NGOs

•

Public healthcare facilities•

Private healthcare facilities•

International organisations

Methodology
The EASO FFM methodology will be followed, to ensure a balanced mix of sources and aninterviewing and reporting approach that is objective and comprehensive. In order to ensure this, allparticipants will receive instructions in advance on common conduct during FFM and a clear divisionof labour between the participants will be established. To the extent possible, first hand visits tofacilities will be made and for each topic, different kinds of sources will be consulted.
Reporting
Following the mission, meeting notes from all participants will be collected. This material will then be
used as the basis for a number of thematic reports, to be produced in 2020. The reports will be publicly
available and be complemented with relevant desk research.

59Medical Country of origin information report | Ukraine: FFM Report – healthcare reform and economic accessibility

doi: 10.2847/190187

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