New WHO report outlines concrete steps to make health care more accessible for people in Ukraine

Catastrophic health spending means a household can no longer afford to meet its basic needs – food, housing and electricity – because of having to pay out of pocket for health care. In Ukraine households with catastrophic health spending are mainly those with low incomes and those headed by pensioners or in rural areas.

Launched at the 2023 WHO Barcelona Forum on Financial Protection, the new report “Can people afford to pay for health care? New evidence on financial protection in Ukraine”, shows that financial hardship due to out-of-pocket payments is almost entirely driven by spending on medicines and inpatient care. Medicines are the main driver in poorer households and inpatient care in wealthier households. Inpatient care plays a much larger role in driving catastrophic health spending in Ukraine than in most other countries in Europe.

This new analysis reflects the state of financial protection (affordable access to health care) in Ukraine before the Russian Federation’s invasion in 2022. Drawing on survey data from 2009 to 2021, it explores the impact of health financing reforms initiated in 2017, finding that there was a small but consistent decline in catastrophic health spending between 2018 and 2021. This positive trend is likely to be reversed by the devastating effect of the invasion on economy, health system, household poverty and people’s health.

“Since 2017, the Government of Ukraine has taken measures to reduce out-of-pocket payments by increasing public spending on health and through health financing reforms that aim to improve equity and efficiency in the health system. It is good to see some positive impact from these changes, although more remains to be done to address the challenge of out-of-pocket payments, particularly for people with low incomes and others at high risk of catastrophic health spending,” said Dr Jarno Habicht, WHO Representative in Ukraine.

“The strengths of health coverage policy in the current system – near universal population coverage and very limited use of co-payments – are increasingly important in the context of the war,” said Alona Goroshko, lead author of the WHO report. “The report recommends that the Government continues to support the National Health Service of Ukraine so that it is better able to reduce out-of-pocket payments for medicines and inpatient care in ways that improve financial protection. This is likely to increase trust in the health system and foster confidence in the Government’s capacity to improve people’s lives amid the challenging context of war.”

WHO’s new report notes that coverage policy in Ukraine has three features that are associated with stronger financial protection.

First, entitlement to publicly financed health services is based on residence, ensuring that most of the population is covered, unlike in health systems that link entitlement to payment of contributions, where many people can lack coverage.

Second, the introduction of the Affordable Medicines Program (AMP) in 2017 and the Program of Medical Guarantees (PMG) in 2018 (with further expansion in 2020) was an important attempt to explicitly link publicly financed health benefits to health needs and available resources.

Third, user charges (co-payments) are kept to a minimum, especially in primary care.

Despite these important positive features, informal payments and other out-of-pocket payments are widespread in the health system. This is due to low levels of public spending on health and other inefficiencies, including the following factors:

• People frequently pay out-of-pocket for outpatient medicines because the AMP introduced in 2017 still only covers a relatively small number of conditions and is accessed by a small share of the population. There is also some geographical inequity in access to AMP benefits.
• Although the law requires outpatient medicines to be prescribed by active ingredient (international non- proprietary name), in practice this is not the norm. In addition, a significant share of medicines prescribed and purchased out of pocket are not of proven efficacy.
• People are generally expected to provide their own medicines and other supplies in hospital due to persistent underfunding of the PMG relative to the range of services it covers, the limited scope of the Ukrainian essential medicines list (UEML, which defines covered inpatient medicines), failures in procuring or distributing centrally procured medicines and medical products and low levels of provider accountability.

The report highlights five ways in which the Government of Ukraine can strengthen financial protection:

• Prioritize public spending on comprehensive primary care, which includes funding for better access to medicines and diagnostic tests, and strengthen the prescribing, dispensing, price regulation and availability of medicines.
• Reduce informal payments for inpatient care.
• Improve the governance of the PMG by making the process for its design and expansion more explicit, transparent and inclusive of a range of perspectives.
• Strengthen the capacity of the NHSU to be an active purchaser of services, which will allow it to make better use of public resources; and
• Implement policies to enhance protection for households with low incomes and others at high risk of catastrophic health spending.

About the report

The report draws on data from household budget surveys conducted between 2009 and 2021 and information on coverage policy (population coverage, service coverage and user charges) up to the end of 2022. It assesses the state of financial protection in Ukraine before the Russian Federation’s invasion in February 2022. Ukraine is one of the few countries in Europe providing evidence on financial protection up to 2021.

The report can be downloaded at:

https://www.who.int/europe/publications/i/item/9789289060165  

Media inquiries:

Alona Volinsky, Head of Communications Unit, WHO Ukraine, volinskya@who.int