The Soviet health system was considered as being one of the best in the world. All that’s left of it in Ukraine are memories. The level of public health provision has dropped greatly over the last few years, and the hospitals are desperately under-resourced. In the east of the country, at war since 2014, healthcare staff are struggling to meet the growing needs of patients. A report.

Large black plastic sheeting taped to windows does not prevent daylight from seeping through. The gloomy glow of old yellowish bulbs is reflected on a faded tiled wall. A woman wearing a face-mask makes her way past the antiquated equipment, throwing a cloth dripping with blood onto the floor before taking her place at the operating table to assist the three surgeons, at work on an unconscious man. "It’s an aorta operation", explained Konstantyn Zougan from the door. "The conditions aren’t that ideal, but at least you’re among our top specialists."

"And in this operating theatre, at least they’re using one of our new operating lamps. In another room, we’re still working with a model dating back to 1973 …" Konstantyn Zougan, a urologist and head surgeon at the city hospital in Rubizhne, took his visitor on a tour of his operating theatres. "We’ve no decent sterilisation equipment and no air compressors. And we’ve only got one working defibrillator. As you can see, nothing has changed here since the 1970s-1980s, the Soviet era. Even the wheelchairs belong in a museum."

An inexorable decline made worse by the war

Speaking with Konstantyn Zougan, you notice a certain resignation in the face of the precariousness of his working conditions. Since Ukraine gained its independence in 1991, the country’s health system has been hit by a political wait-and-see attitude, a severe lack of modernisation and endemic corruption. Over the course of his 10-year practice, Dr Zougan has watched his hospital slowly but surely decline. The situation became even more complicated in 2014, at the time of the first skirmishes between Ukrainian troops and pro-Russian separatists and Russian forces. After four years of a war with a death toll of more than 10,300 according to the UNO, Rubizhne is now just 60 kms away from the front line separating the oblast (region) of Luhansk. The skirmishes remain regular – and deadly.

Despite all this, Konstantyn Zougan’s operating theatres run 24 hours a day, 7 days a week. "We’ve got no choice", he remarked. There are more than 50,000 people living in Rubizhne, an industrial city. Ravished by a permanent economic depression and bruised by the conflict, the city is also the home of many thousands of displaced persons. The latter "have left everything behind them. They are living in precarious conditions, and not eating properly. They are subject to stress and all sorts of psychological complications", the surgeon went on. "The additional workload is substantial. But you can’t turn people away."

The urologist takes comfort in the stability of his team and in the humanitarian aid which ensures regular supplies of drugs, medical equipment and which sometimes even allows the decaying infrastructure to be refurbished. Pride of place in the Rubizhne city hospital is taken by the second-floor maternity unit, completely refurbished in 2014. Reaching the top of a dusty staircase, we find ourselves in a sterile corridor painted with fresh colours. The doors have been widened to allow the modern hospital beds to get through. Each room has large windows and its own bathroom.

"It’s even warm in the winter now"; enthused Svitlana Niskaradiva, a doctor who has been working in Rubizhne for 25 years. For the last 12 years, she has been in charge of the maternity unit, supervising a team of 12 midwives and 7 nurses. She clearly notices the difference. "The new-born babies get all the care they need", she explained, showing us the state-of-the-art incubators and test instruments. "The refurbishment has had a positive effect on the overall state of health, including that of the mothers. But also on the working conditions and on patient relations. The young mothers are less worried in such an environment, making it easier for us to assist them."

In Rubizhne and the surrounding area, this return to normal maternity standards is salutary, as "the overall level of public health has dropped in recent years", said Svitlana Niskaradiva. "You won’t find any children here in the region without a health problem", she continued. This is due to the serious industrial pollution, the badly-insulated flats and schools, chronic malnutrition and the low vaccination rate. Some of the illnesses, such as diabetes mellitus, used to be treated in the regional capital, Luhansk, explained Svitlana Niskaradiva. "We needed to restructure many of our departments after the region was divided."

Uncertainties

Carrying on speaking, the doctor went down the stairs to the first floor, emerging into a dark corridor, the walls with the plaster coming off, the floors covered with scraps of PVC carpet tiles. A typical postcard picture of a post-Soviet hospital. On this floor, pregnant women remain under observation until they give birth. "We jokingly motivate them: give birth and you can move up to the refurbished floor", laughed Svitlana Niskaradiva. On a more serious note, the doctor deplored the fact that the refurbishment of this ante-natal ward was not yet planned. "We are doing the maximum possible", said Christian Carrer, head of the AICM-Ukraine foundation, one of the most active humanitarian aid organisations in Rubizhne. "But needs are just immense, and Rubizhne is far from being the only hospital in the region in distress."

Letting the humanitarian organisations and local authorities get on with piecemeal modernisation projects, the central government is focusing on the impact of a general overhaul of the health system. Supported by Ulana Suprun, the American-Ukrainian Minister of Health in office since October 2017, the aim of this initiative is to develop an Anglo-Saxon way of running the system upon the ruins of the inefficient post-Soviet system. In the firing line is an overhaul of hospital financing, making it needs-based instead of size-dependent. Also on the agenda is the establishment of a social security and health insurance system, as well as a strengthening of a GP’s gateway role, with patients registered strictly according to their place of residence.

Planned to be rolled out by the end of 2020, the new system is supposed to give healthcare professionals and patients greater autonomy and flexibility and to make the whole system more efficient. It is also supposed to put an end to the habit of giving "gifts", sums of cash handed over by patients to the doctors to top up their meagre wages. Under the current system, junior doctors, like nurses, get a fixed wage of 3,200 hryvnias (about €104) for 24 days a month, 8 hours a day. This obviously encourages all sorts of corrupt practices. Henceforth, each GP will be given 370 hryvnias (or 12 euros) per year for each patient registered with him. "Patients will no longer need to hand over 'gifts', as doctors will now be well-paid. And healthcare professionals will be motivated to provide better care as a way of attracting new patients", explained Inna Boiko, head of the "Ukraine Patients" NGO.

However, Konstantyn Zougan in Rubizhne has his doubts. "This reform is set to greatly upset our – already very difficult – work. It is International news 3/7 under-funded and takes little account of current structures. One of the first steps for instance involves registering patients, doctors and hospitals in the online e-health database. "But we haven’t got either a computer or Internet", the urologist said derisively. He nevertheless remained hopeful: "As long as we can keep our team of professionals together, we’ll be able to carry on helping our patients. That’s the main thing."

Working in a forgotten corner of Ukraine

A solidarity not found everywhere. 140 kms to the south of Rubizhne, head doctor Valeriy Ivanov has to make do with just 50% of his doctors and 48% of his nursing staff at the Stanitsa Louhanska hospital. "It’s a disaster", he said, slumped in an old office chair. "Nobody wants to come here to take the place of the missing professionals. And I can understand why … Just a few hundred metres away from the hospital, the Siverskiy Donets river marks the front line. On its other side, just fifteen kms down the road, lies Luhansk, capital of one of the self-proclaimed separatist republics." Under regular bombardment, prospects for the future are more than uncertain.

Isolated at the eastern end of Ukraine, between the front line and the Russian border, Stanitsa Luhanska remains the main hospital for the remaining population of 48,000, most of them pensioners. Numbers are swelled by some 15,000 displaced persons. "We treated more than 18,000 patients in the first three months of this year", said Valeriy Ivanov. However, of the three surgeons he had in 2014, just one is still there, and one out of two traumatologists has left. The radiologist comes from another raïon (district), but only when he can manage it. "We can’t pay him to come here, as the law forbids doctors to draw salaries in different raïons", added Valeriy Ivanov. As for the anaesthetist, he is a military doctor standing in for his civilian counterpart. At Stanitsa Louhanska, as with other front-line hospitals, the Ukrainian army has requisitioned a hospital wing.

Here as well, any modernisation of facilities takes place in a piecemeal manner. Valeriy Ivanov feels abandoned by the humanitarian organisations, other than the International Committee of the Red Cross or Doctors of the World which organise distributions of drugs. "The regional authorities have just given us a new X-ray system, replacing the two antiquated systems installed in 1983. But if a patient needs an MRI, we have to go elsewhere", i.e. to take a trip of at least 80 kms along pot-holed roads punctuated by military checkpoints. The hospital has two vehicles at its disposal, one of them a 1994 Toyota. "That one deserves a medal, as a tribute to its services! But at the moment, we’ve got to make do with it", said Valeriy Ivanov ironically.

Despite its highly sensitive situation, the hospital receives no preferential treatment from the State. Hit by shelling in 2014, the building but had to wait until the spring of 2018 for the repair work to be done. Its last complete refurbishment was in 1973. It would need 7 million hryvnias (about €229,000 euros) to get it back up to standard. "Nobody’s got that sort of money here", said Serhiy Ivanov with a sad note in his voice. His office with its plywood walls boasts neither air-conditioning nor computer. "I am well aware that the State gives priority to large regional centres. But that’s no reason to forget the people here, in this remote corner of the country."

Valeriy Ivanov and his team cannot forget their patients, for the most part pensioners, sleeping six to a room on antique spring base beds. In a small canteen upstairs, a team of nurses spoon their soup with a smile, patiently confirming that they’ll be staying on despite the war. "The staff we’ve got here now all went through a terrible spell in 2014-2015 which welded them together. They’ll never leave", said Valeriy Ivanov, whose family is now scattered between Luhansk and Kiev. "But what is more worrying is the fact that no young staff are coming to take their place. Nothing in the world would get them to come and work here."

Who is going to take over?

Indeed, young doctors "are free to go where they want", confirmed Petro Kondratenko, rector of Donetsk university medical faculty and working in exile at Kramatorsk on Ukrainian territory. According to him, it is up to local authorities to attract young people through offering them good accommodation and working conditions, and sometimes even wage supplements – a luxury out of reach of the Stanitsa Louhanska hospital. "I well understand the difficulties they are having down there. But you can’t ask our young doctors to give up everything at the start of their careers", said Petro Kondratenko.

In his office in the former technical faculty of Kramatorsk, the rector has to cope with his own problems. "We used to have 6,000 students in Donetsk. Now we’re down to 3,000, and half of them come from abroad." Forced to leave Donetsk in 2014, the university also lost two-thirds of its teaching staff and all its equipment. "We’re just about managing to get things going again", he explained. The rector has no lack of projects, one of which is to develop courses in English and French. A promising initiative, but one possibly encouraging young doctors to emigrate. For students Myroslav Mikhalusov and Yevhen Lysenko, their choice seems clear. "Canada or Germany", they sing in chorus at the university entrance. Even if, added Myroslav cautiously, "leaving is a difficult decision. Everything depends on how the situation here develops, and what impact the reform has".

"The goal of the State’s policy has got to be to keep young doctors here, stopping them from emigrating", said Serhiy Neschyotny, head doctor at the city hospital 2 in Droujkivka, 20 kms south of Kramatorsk. "I know of a young doctor from here who went off to do an internship in Slovakia. He never came back. After just two years, he was able to buy an apartment! It’s obvious why they’re leaving …"

At the hospital in Drujkivka since 1986 and its head doctor since 1999, Serhiy Neschyotny was nearing the end of his career and had no intention of going anywhere. He was staying put, managing a team of 25 doctors and 75 nurses and care staff. The team serves a population of more than 100,000, as well as a further 11,000 displaced by the war. As in the other hospitals in the region, he complained of infrastructures creaking with age, of shortages of staff, medical supplies and drugs, and of the general decline in the level of public health. He as well found hope in humanitarian donations and irregular modernisation measures, such as the modernisation of the children’s and psychological wards, finished in January 2018.

But what concerned him was the uncertainty attached to the health reform. A budget of 8 billion hryvnias (€261 million) has been earmarked for developing a new National Health Service (NHS). How much of this budget could his hospital hope for? Would departments be merged or transferred elsewhere? How would medical tests be booked? What would be the role of his care staff visà-vis a GP? In Kiev, deputy health minister Pavlo Kovtoniouk promised that the situation would improve "once the reform is on track". But at Droukjkivka, Serhiy Neschyotny had no idea how to declare his hospital under the new NHS. In July 2018, 149 health institutions in Ukraine had signed agreements with the NHS. These included just 9 in the part of the Donetsk region under government control and none in the Luhansk region.

In the sober office of "his" building at the hospital entrance, family doctor Vadim Dotsenko echoed these uncertainties. A hospital doctor for 20 years, he had switched to being a family doctor in 2013, "by learning on the job how to deal with ailments ranging from chiropody to infectious diseases". He deplored the lack of the equipment needed to come up with a correct diagnosis and then send a patient to the appropriate specialist. Vadim Datsenko was also worried about the numbers of new patients coming from the surrounding countryside. "As few family doctors are setting up shop in the villages, patients are having to come here. But given the state of the roads and the cost of transport, 20-30 kms is quite a long way." His fear of seeing rural areas deprived of all health services is one of his main criticisms of the reform.

"We’re already finding it difficult to attract young specialists here to a big town like Droujkivka, so just imagine what it’s like in isolated parts of the country", criticised deputy head doctor Hennadiy Iefremov. He saw the reform as being symptomatic of a reform in a rich country, little reflecting Ukrainian reality. "Our situation is already difficult. I’m afraid that it’s going to get a lot, lot worse." Hennadiy Iefremov similarly felt in his flesh the decline of the health system, conjuring up memories of his three years spent in Cuba, as a specialist posted to a Soviet contingent. "In those days, we went out to teach other countries …"

"Yes, our situation is difficult. Yes, the reforms raise many questions. But we need to battle on", said Serhiy Neschyotny. "To carry on applying for international scholarships, soliciting humanitarian organisations, calling for young specialists. Working for the good of our patients. You know what they say here: hope dies last."•

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In East Ukraine, antiquated hospitals, with equipment ripe for a museum, serve an impoverished population

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