Patient and provider perspectives on quality and health system effectiveness in a transition economy: Evidence from Ukraine

Highlights

• Effective health care systems are needed to address the burden of noncommunicable diseases.

• Policies to improve health system effectiveness should consider the perspectives of different stakeholder groups.

• Policies that directly target the quality of care require objective measures.

• In Ukraine, adults and physicians agree that the health system should be reformed.

• Policies aimed at improving quality and affordability can align diverse stakeholders, including patients and physicians.

Abstract

Facing a severe population health crisis due to noncommunicable diseases, Ukraine and other former Soviet republics and Eastern European countries have a pressing need for more effective health systems. Policies to enhance health system effectiveness should consider the perspectives of different stakeholder groups, including providers as well as patients. In addition, policies that directly target the quality of clinical care should be based on objective performance measures. In 2009 and 2010 we conducted a coordinated series of household and facility-level surveys to capture the perspectives of Ukrainian household members, outpatient clinic patients, and physicians regarding the country's health system overall, as well as the quality, access, and affordability of health care. We objectively measured the quality of care for heart failure and chronic obstructive pulmonary disease using CPV^® vignettes. There was broad agreement among household respondents (79%) and physicians (95%) that Ukraine's health system should be reformed. CPV^® results indicate that the quality of care for common noncommunicable diseases is poor in all regions of the country and in hospitals as well as polyclinics. However, perspectives about the quality of care differ, with household respondents seeing quality as a serious concern, clinic patients having more positive perceptions, and physicians not viewing quality as a reform priority. All stakeholder groups viewed affordability as a problem. These findings have several implications for policies to enhance health system effectiveness. The shared desire for health system reform among all stakeholder groups provides a basis for action in Ukraine. Improving quality, strengthening primary care, and enhancing affordability should be major goals of new health policies. Policies to improve quality directly, such as pay-for-performance, would be mutually reinforcing with purchasing reforms such as transparent payment mechanisms. Such policies would align the incentives of physicians with the desires of the population they serve.

Introduction

Two decades after independence, many former Soviet republics and Eastern European countries continue to face severe population health challenges. In Ukraine and neighboring countries, an unprecedented mortality crisis is driven by noncommunicable diseases (NCDs) and unhealthy behaviors (Mackenbach et al., 2013, World Bank, 2009). Effective health care systems will be essential to address this crisis (Institute of Medicine, 2010, Kruk et al., 2010).

Policies to enhance overall health system effectiveness increasingly consider diverse sources of data. Specific information on perceptions of quality, access, and affordability, while often not used, can supplement more general surveys of health system performance (Rockers et al., 2012). Understanding the perspectives of different stakeholder groups, including providers as well as patients, is important for setting policy priorities, mobilizing support for health care financing and delivery reforms, and for aligning different groups to achieve common objectives once policies are implemented (Peabody et al., 1999).

Policies directly target the quality of clinical care (Jamison et al., 2006), in addition to ensuring sustainable financing and modernized governance mechanisms (Rechel and McKee, 2009). Developing such policies requires objective measures, because patients have limited ability to assess technical quality (Sofaer and Firminger, 2005).

Our study was designed to include perceptions of stakeholders and use these to inform policies to enhance health system effectiveness in Ukraine, a large transition economy. We obtained data on health system satisfaction and reform priorities from large national samples of adults (via a household survey) and physicians and on quality, access, and affordability from household respondents and outpatient clinic patients. We also collected objective data on the quality of care for NCDs. Below we first review existing knowledge about stakeholder perspectives and health systems effectiveness in the region, and describe Ukraine's health system. We then present our findings regarding multiple stakeholders' perspectives on reform priorities, quality of care, access, and affordability in Ukraine, and reflect on the implications of these results for policy.

Compared to Western Europe or other high-income countries (Papanicolas et al., 2013), data on satisfaction with health systems in Ukraine and other transition economies remains fragmented. Studies measure varying aspects of patients' direct experience of care, including waiting times, communication with providers, staff courtesy, facility amenities, and perceived quality. For example, when asked about “the overall state of health services in your country,” Ukrainians reported satisfaction levels significantly lower than the other 23 Western and Eastern European countries (Golovakha et al., 2007). Footman et al. (2013) recently found that the proportion of household respondents who were quite or definitely dissatisfied with the health system was higher in Ukraine (at 82.6%) than in the other 8 former Soviet republics surveyed, including Russia; the proportion who saw a health provider (among those who had an illness in the previous 4 weeks) in Ukraine was lower than in 6 of 7 other former Soviet republics (Balabanova et al., 2012). In another study, however, Ukraine's scores on several access and provider communication measures among primary care and hospital patients were roughly comparable to those in 11 other European countries (Kerssens et al., 2004).

Data on physician satisfaction in former Soviet republics and Eastern Europe are extremely limited. Studies have examined job satisfaction (O'Leary et al., 2009) and perceptions of evidence-based medicine (Geltzer, 2009) among Russian physicians. Published reports of satisfaction or reform perceptions among clinicians in other countries, including Ukraine, are very rare (Bobko and Barishpolets, 2002, Wallace and Brinister, 2010).

Strikingly few studies systematically describe the perspectives of multiple stakeholder groups within a country. Akinci et al. (2012) conducted interviews with government organizations and provider associations to inform the implementation of a new phase of health reform in Turkey. Other studies solicited population or primary care patient perspectives on health systems in Brazil (Atkinson and Haran, 2005), Estonia (Polluste et al., 2004), and Slovenia (Kersnik, 2001). Studies that solicit perspectives from both patients and providers who care for them are quite rare. One study compared patient and general practitioner assessments of quality in the Netherlands (Jung et al., 2002), and another compared patient and primary care physician views of communication during visits in 4 Central and Eastern European countries (Zebiene et al., 2008).

A few studies report on patient assessments of quality in Ukraine and other transition economies. Among 12 European countries, Ukraine ranked lowest on primary care physician understanding of patients' problems (Kerssens et al., 2004). Lipsitz (2005) found that many Ukrainian elders do not trust physicians or hospitals, and 40% of Armenian residents expressed lack of trust in primary care clinicians (Tonoyan and Muradyan, 2012). Residents of Romania and the Baltic countries rated the quality of physician services lower than other European Union residents (Jankauskiene and Jankauskaite, 2011).

Objective data on the quality of care in former Soviet republics and Eastern Europe are quite limited, despite the impact of quality on health outcomes. Ukrainian patients were more likely to have uncontrolled blood pressure than those in 8 other Central and Eastern European countries (Grassi et al., 2011). Preventive care is one of the few types of clinical care for which patient assessments of quality are valid (Dresselhaus et al., 2000), and Roberts (2012) found poor levels of self-reported blood pressure control in 8 former Soviet republics, including Ukraine. Physicians described diabetes care resources as inadequate in Ukraine and 7 other central and eastern European countries (Donicova et al., 2011), and primary care physicians in 12 countries (including Russia) were found to have limited knowledge of COPD management (Aisanov et al., 2012).

One aspect of affordability, informal payments to health care providers, has been widely studied in the region (Aarva et al., 2009, Cockcroft et al., 2008, Ensor, 2004, Falkingham, 2004, Gaal et al., 2006). Cross-national studies have shown that these informal payments can exacerbate inequities in access to care (Balabanova et al., 2004) and contribute to reduced satisfaction with the health system (Zaidi et al., 2009). However, we are unaware of studies that asked both physicians and patients about informal payments in comparable care delivery settings.

Ukraine's population of 46 million is the second-largest of the former Soviet republics. Bordered by countries including Poland, Romania, Belarus, and Russia, Ukraine is diverse linguistically, culturally, and religiously. The past decade has seen political conflict between parties that favor greater integration with either Western Europe or the Russian Federation. Ukraine is divided into 27 oblasts, equivalent to states or provinces; administrative units within each oblast are rayons (comprising rural areas and smaller cities) and municipalities.

Ukraine is a middle-income country, with a GDP per capita of US$2974 in 2010 (World Bank, 2013). The economy was dramatically affected by the recent global recession, and negative impacts on employment, household incomes, and government spending still persist (National Ukrainian Academy of Sciences, 2011). Although Ukraine has abundant natural and agricultural resources, an educated population, and a strategic economic location, a weak institutional environment presents barriers to business growth and foreign investment (OECD, 2012) .

Death rates in Ukraine are higher than in other Eastern European countries, especially for the working age population (World Bank, 2009). Combined with high rates of morbidity, this resulted in a Health-adjusted Life Expectancy (HALE) of less than 60 years in 2007. The major causes of Ukraine's high mortality and morbidity rates are chronic NCDs such as cardiovascular and lung disease. Ukraine has very high rates of smoking and alcohol consumption, which are important avoidable risk factors for these conditions. Ukraine's health system currently falls far short in meeting this need. For example, among hypertensive adults, just over half of men and one-fourth of women were either unaware of their hypertension status or were not being treated (World Bank, 2010).

Ukraine's health care delivery system retains most organizational features of the Soviet “Semashko” model (Lekhan et al., 2010). Most outpatient care is provided in polyclinics; each citizen is assigned to one that serves his or her geographic area of residence. Private clinics provide only a small proportion of total care. Hospitals are organized into referral levels, first at the rayon or municipality level and then the oblast level. Inpatient capacity has been dramatically reduced in recent years, but hospitals operate outpatient clinics, with many patients referred from polyclinics.

Like other former Soviet republics (Antoun et al., 2011, Gordeev et al., 2011, Kutzin et al., 2010), Ukraine has seen limited health care financing reform since independence (Lekhan et al., 2010). Health care delivery is centrally funded, although management authority and budgeting have been decentralized to the oblast and rayon/municipality levels. Nevertheless, rigid budgeting rules limit reallocation of funding to meet local needs or improve quality (World Bank, 2009). Expenditures remain concentrated in hospitals, with the proportion of spending on outpatient care being below the European average. Public and private insurance contribute less than 1% of total health expenditures. Outpatient care is nominally free at the point of care, but does not include medications prescribed by physicians. Out-of-pocket spending is estimated at 40% of total health expenditures, with over half of that going for medications. Informal payments are common and comprise approximately one-fifth of households' health expenditures (Lekhan et al., 2010).

To address gaps in the existing data and literature, we analyzed results from multiple coordinated surveys to compare the perspectives of household respondents, physicians, and clinic patients on several aspects of Ukraine's health system. We focused on issues that would inform development of policies to increase that system's effectiveness, specifically the stakeholder groups' perspectives on health system satisfaction and reform priorities, quality, access, and affordability. We also present summary-level data on the quality of care for NCDs in Ukraine, and compare these objective measurements to the differing quality perspectives across stakeholder groups. We conclude by reflecting on how these stakeholder perspectives may serve to support policy directions that previous research and the objective quality data suggest are important for Ukraine.