Until Dr. Suprun became the Minister nobody seemed to be making any real attempt to change the organization of health care in Ukraine, - Henry Marsh
An interview with British neurosurgeon Henry Marsh.
- А few days ago you had a meeting with Ulana Suprun and why did you want to talk with her?
It had been suggested two years ago that we should meet. I’ve been coming to Ukraine for many years, and there has been some real progress in medicine - in terms of equipment and the skills of some of the But until Dr. Suprun became the Minister, nobody seemed to be making any real attempt to change the organization of health care. We all know that Ukrainian health care is chaotic. And of course, as we say in English “all change is difficult” and there are always winners and the losers…she has many enemies in Ukraine because if health care is reformed, some people will lose money. But a greater number of people at the bottom of the social system will benefit. It is quite clear that she has achieved a lot –especially in reducing corruption in the Ministry itself over the procurement of drugs and equipment. This has saved millions of dollars which have been put back into the health care system and she deserves a lot of praise for that. The people who benefitted from the corruption, of course, are not happy. Many doctors here in Ukraine, especially the older ones, just don’t want to see or recognize that medicine in the rest of Europe is much better. Polish medicine was as bad as Ukrainian medicine 30 years ago. Poland has made a real progress, why can’t Ukraine?
I haven’t quite decided yet whether to write a newspaper or magazine article about all this or include it in the third book I have started to write.
- Why do you think our reform of health care system will be interesting for people in Britain for people in the USA, for people in Europe?
In might not be (laughing). I have always felt that Ukraine was an important country - it is so balanced between the despotism, corruption and authoritarianism of the East and the more liberal and open societies of western Europe. I think the story of the problems she is having is of universal interest and I hope people might be interested to read about it.
- But do you feel interest of British people for example, your colleagues about Ukrainian reform?
Not, not very much I’m afraid. I wish they did. With Maidan, with all these incredible images on the BBC news, people in Britain realized for a while why Ukraine was so important and so unstable.
- How many years did Poland spent to reform it`s health care system?
I don’t know the details, but it has taken I think 25 years - a long time. If you have a complicated problem, you cannot expect things to get quickly better, as so many people do. People need to understand that the problems with Ukrainian healthcare are complicated, difficult problems. They are as much about mental and psychological attitudes as they are about equipment and money and there is no quick fix.
What Dr Suprun is trying to do is implement changes that had already been agreed before she became Minister. There are many vested interests, particularly senior doctors, who fear they will lose money. When the National Health Service was introduced in Britain in 1947 there was strong opposition to it from the doctors, and Nye Bevan, the Health Minister, overcame it by – as he famously said – “stuffing their mouths with gold”. They were allowed to private work in their own time outside their contracted work for the government.
And in some extent the same needs to be done here. You have to accept that medicine is very valuable, people are ready to pay a lot of money for it.
But the important point is to try to make it payment over the table rather than under the table. The problem in Ukraine is you have the worst of both worlds, you have an underfinanced state system and unregulated, untaxed under the table private payments. This easily leads to patients being exploited – with unnecessary operations and treatments, as some doctors (but by no means all) become more interested in making money than in helping patients. So you need to have a system which allows doctors to make money from private practice, but legally, but also pay them well enough in the government hospitals, and make sure they fulfill their contracts with the government.
- Now the ministry of a health care is trying to do something like that, I mean every doctor has its own practice and has legal money from this practice.
This is, I believe, for primary care doctors. The problems will come when you try to change the hospital system - the secondary, tertiary care systems, because there some of the doctors make a lot of money. There are also far too many hospitals. It’s ridiculous that in Lviv, with a population of 1 million, that there are 3 children’s hospitals. It would make much more sense to have one children’s hospital with good facilities instead of three with poor facilities.
Doctors prefer to be big fishes in a little pond and they didn’t like to be little fishes in a big pond. And in England as well it’s often very difficult to close hospitals and rationalize them. And patients often don’t understand that they will get better specialist treatments in a large, centralized hospital than in many small ones.
- I guess our patients don’t understand this at all.
- A lot of people still think that «Ulana is trying to kill the nation»…
It’s so stupid. She’ s a doctor, she is trying to help patients and to make things better.
- Tell me please, you have already heard about court decision to clamp down ministry`s work, and what do you think about this case? What is it?
Yes, is obviously ridiculous - totally absurd. I hope it will back fire, and people stand up to support Dr Suprun because it’s so stupid to say she isn’t competent, it’s obviously ridiculous. Sometimes, when stupid people behave stupidly, they damage themselves, so I hope this will strengthen Doctor Suprun’s position rather than weaken it.
- And now thousands of Ukrainians supported Suprun on Facebook messages, on Facebook posts and if you actually have had an opportunity to support her what would you say to Ulana and to Ukrainians to support these people who want to have this reform?
I would say that Ukrainian health care system compares very badly with other countries in Europe with national income levels. They have to look at what’s happening outside of Ukraine, to see that. Doctor Suprun is trying to make things better, why would she want to make things worse? Why would she want to kill Ukrainians when she saved so many lives with better emergency kit for Ukrainian soldiers on the front line? That’s stupid, that’s silly. Change is difficult, but people need to understand that things could be much better if they look at what has been happening with other eastern European countries. People get better health care, doctors are less corrupt, the system is more efficient, why not in Ukraine? And if they criticize Dr Suprun, do they have any alternative suggestions to make healthcare better. It’s always easy to criticize and much more difficult to make real plans and try to change things for the better, but that’s what Dr Suprun is trying to do.
- What would you say to the people who’re trying to make a pressure on her now?
I would say: the great problem in Ukraine is a very small number of people own most of the wealth. The country is being run in the interest of this small number of people rather than for the great majority of the public. They have the Russian contempt with the little man. The oligarchs are making lots of money – in effect they are stealing money from the country and the money then goes to the banks in places like the City of London and is washed I am deeply ashamed of the role of the British banks in facilitating corruption in Ukraine. But I must add that inequality is a big problem in Britain and America as well, but not as bad as here in Ukraine.
- I’m afraid after one another this incident with pressure on her, she will say “oh, ok, have fun with your medicine and good luck with to your health care, goodbye”.
I don’t know, but she struck me as very tough and very determined. I hope she doesn’t do that. I hope she goes on fighting. But as far as I can see the criticism of her is stupid, emotional rubbish.
- You’re coming to Ukraine since 1992 and do you see some signs of recovery of our system or things are getting worse?
I think it’s much better when I first came. The young Ukrainians I meet are better educated and have much more awareness of what is going on outside Ukraine. Putin has been very helpful - he has produced a much stronger sense of Ukrainian identity then existed before, by invading Krym and Donbass. So I see in many ways a more united country than when I first came here. Much less under the influence of Russia. So I see a lot of change, real progress.
In a health care, there has been progress in bit and pieces, in little islands. But there are profound problems, serious problems in organization and particularly in education. Сompared to Europe and America, there is no proper system for training doctors once they leave medical school – what we call post graduate medical education.
- We used to think that we have great medical education…
- Its terrible, it’s awful, it is a disaster, it’s non existent and the doctors themselves say so. The only system they have is that of the professor and his son, which dates back to the Soviet time. Too many of the professors don’t want to share their skills with anybody else. They are in competition with other doctors. And because the patients are all paying under the table for treatment they expect to be treated by the senior doctor, reducing the possibility for training young doctors… But the young doctors are the next generation of doctors and they are the future of healthcare. They not being properly trained and instead they have to go to the west if they want to learn modern medicine.
The healthcare system here very uneven - you have a few good places and many bad places and many shortages of equipment and medicines. It’s very difficult to change. On paper it’s obvious what needs to be done. You need a proper state license and a proper system of training with proper examinations. But the problem is the politics of actually implementing these changes.
In Ukrainian medical schools they now have proper examinations where you cannot bribe the examiners. But many students are unhappy. In the past, if they paid enough money, they could pass the exam without working at all. Now they actually have to work to pass the exam! And the teachers are unhappy because they can’t get bribes from the students. So we can see why there is so much opposition to changing things. And who loses out if changes are not made? The patients lose this out, the poor patients lose out. If you are not poor then you can afford to get the best professor or even go abroad.
The first step to making a problem better is to admit there is a problem.. Too many Ukrainian doctors are sitting in a dark hole and refusing to admit there is sunshine outside – but you have to look west to see the sunshine and it is painful to admit that things are better there. It is easier to deny it.. They would rather be in the dark than admit that the things get better elsewhere. It’s painful to admit that maybe your system is not that very good. This was typical of the Soviet Union and typical still of many of the senior professors I have met.
I’ve been coming here for many years and I understand, as we say in English “why should we show us our dirty underwear to visitors?”. But I have been coming here for so many years that people are more open and honest with me and share the problems of Ukrainian healthcare with me. But I wouldn’t keep on coming up to Ukraine if I didn’t feel optimistic about the future and I feel optimistic about the future because of the people like you, because of the people like my colleague Dr Andrij Myzack - people who can see things that things could be better. People who will take many little steps, trying to make things a little better.
- Our system of health care shall look like British as I understand and its mostly free for patient, but it is not like in Soviet system, when budget is spending not only at list of services provided but on we-do-not-know-what, exactly. So can you name the best and the worst sides of British system that exists more than 60 years?
- The worst aspect is that doctors have no financial incentive to be nice to patients. They can be rude and unpleasant to patients, and the patients have to accept that, because they have no choice. That is a potential drawback, but you compensate for that by paying doctors a good salary, by good medical education and good professional ethics. And although that there will be some doctors who are not very good or polite to patients, on the whole, most of the time the system in England works well, quiet well. Doctors are nor very well paid, bankers make national money.
And then you have to have a strong educational system where you stress the importance of treating patients well. But you see in England, most doctors don’t see medicine as business n for making money. We get paid a good salary, so we don’t have to think about money and what we think most about is what’s good for our patients.
- And that is why the system is not corrupted?
- Yes, because the doctors are paid enough. They don’t need to be bribed. The same applies to judges. The rule of law depends on paying judges high salaries!
I was talking about how procurement for drugs in Ukraine has been organized by a British organization called the Crown Agents. I was talking with them at a meeting in London about Ukraine two weeks ago, and they said when they started working here they were amazed. Their work was saving Ukraine millions of dollars, and yet there was a huge media campaign against them. They learned that they had to fight back with their own media campaign. It was very surprising for them - they thought they were helping Ukraine and they were accused of being capitalists and exploiters which is complete rubbish.
By taking the procurement of drugs outside the Ministry, the corrupt bureaucrats in the Ministry were losing money. The Ministry had been paying for anti-tuberculosis drugs, for example, three times the market price. So there was a huge profit going into certain people’s pockets. And Ukrainian patients were dying as a result - it’s intolerable.
- You have been in a different countries and saw different health care systems, do you think that Ukrainian is the most corrupt or not?
- No, probably not. Well, it’s certainly one of the most corrupt. The problem of corruption is a secret, so corrupt people do not publish their accounts, and it’s difficult to judge. I don’t regard the under the table payments to doctors in Ukraine as corruption, because they cannot live without them. It becomes corrupt if doctors charge big sums of money for doing unnecessary operations but that is immoral, that is wrong.
- But can you compare our system not only with Russia, with another countries system?
- No, every country has different health care systems and ultimately health care systems reflect the society. So in Scandinavia, in Denmark, Sweden, Norway, Finland, they are very efficient and totally not corrupt, very good value for money. That is because they are smaller countries with ethnically homogenous populations, and less income and wealth inequality than anywhere else in the world. They are wealthy and accept high rates of taxation, and they pay their taxes. Ukrainian society is chaotic, so the health care system is chaotic.
- And we don’t like to pay taxes.
- Well not paying taxes is fair enough if the government is corrupt. It’s a vicious circle. Because the government is corrupt, people don’t pay taxes, and therefore the government cannot afford to pay doctors properly and run a good healthcare system, which makes everybody even more reluctant to pay taxes. It goes round and round and round. Then you have someone like Suprun who is actually trying to make things better, and instead she gets criticism.
-As we said, she has more and more pressure on her, the Crown Agents also are under the pressure. How do you think, can we feel optimistic or we can lose this chance?
- No, we have a moral duty to be optimistic. If we stop being optimistic, we stop trying to make things better. We have to be optimistic.
-But I mean have we passed the point of non-return in this reform?
- For better? Well, I don’t know. I hope so, but time will tell. Nobody can predict the future. All I know is that this is very important but people must stand up to support Suprun. She is trying to make things better.
-She already makes.
- But she needs to be supported, because she is trying to change things. Think of the Orange Revolution, think of EuroMaidan, think of the growth of civic society in Ukraine. This is all about young people. So I feel optimistic. But there are many problems!