Ukraine is a country of science. Dozens of Ukrainians have won Nobel and other prestigious international scientific awards over the past 100 years. The scientific potential of the country is encapsulated by the National Academy of Sciences, which was formed in 1918 when Ukraine was previously an independent state. With its national branch Academies, such as those for agriculture, medicine, and several others it unites dozens of scientific institutes, enterprises, clinics, and even nuclear research institutes.
Ukraine inherited most of its scientific institutions from Soviet times when the country played an important role in all aspects of the USSR. As much as to 30% of Soviet defense capability was concentrated here including large numbers of leading technological, aviation, and medical institutions, almost half its nuclear power plants, and a quarter of all scientific bodies.
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However, since gaining independence, Ukraine has been unable to reform the large scientific capacities it retained from the Soviet era. Science is not cheap - chronic lack of funding has led to the decline of its classical scientific institutions. Despite this science, particularly medical science, continued its work – dissertations were defended, scientific papers were written, and clinics were able to develop the highest levels of specialized and high-tech care for patients.
Recently the state has voiced an intention to reform medicine and its scientific medical institutions, which has not been met with joy among scientists. Kyiv Post thinks it knows why.
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Opposing interests
We spoke to Valentina Vasylenko, a PhD, who is director of the laboratory of the radiation clinic that is part of the National Research Center for Radiation Medicine.
This is a unique laboratory that combines science and medicine – here they keep a register of all the people who suffered from the Chornobyl disaster – evacuated residents, their children, liquidators, and firefighters – all of whom passed through this center.
Here they carefully measure the amount of different radionuclides in their bodies, and the change in their amount over time, and in the clinic, which is located nearby, radiologists monitor the development of pathologies that can be caused by radioactive damage or prolonged exposure to radiation and determine the necessary treatments.
Representatives of the Center have amassed unique experience, and are consulted by many foreign representatives dealing with such issues. Its members worked to address the consequences of the Fukushima disaster in Japan in 2011, the radiation pollution from which had much in common with that from Chornobyl.
However, now the activity of this entire system is under threat from the new budget of Ukraine, where medical reform will also impact on scientific institutions – which Vasylenko and other scientists see as a problem.
“Some of my employees can be fired. In this case, I could be left without some [essential] workers,” she says.
The essence of the problem is that starting from the new year, funding for the treatment of patients should be carried out under a program of medical guarantees similar to those in other European countries.
An institution enters into an agreement with the National Health Service of Ukraine on the provision of services in certain areas, the so-called “service packages,” for which it will receive funding from the state. This principle of “money following the patient” is the opposite of the current widespread system used in Ukraine before – the so-called Semashko system, where the state-financed every bed held by a medical facility, regardless of the level of occupancy or treatments on offer.
This represented a risk of corruption risks and led to the dispersion of funds. Ukraine has attempted to reform this methodology in recent years. The leadership of the National Academy of Medical Sciences (NAMS) says, however, that the proposed changes are not suitable for large “mono-profile” institutes.
“For example, the Institutes of ENT, Surgery, and Cardiovascular Surgery deal very intensively with narrow issues – both in scientific terms and in practical terms. In scientific terms, these institutes address their specialties globally. They consist of teams of people who are the best in their profession. In ordinary life, a narrow specialist will not survive, but here – he is the king and God, honing his skills as much as possible,” NAMS president Vitaly Tsymbalyuk said.
In these circumstances, he says, there is a risk that not all such institutions will be able to survive – because they cannot get the necessary number of service packages.
“This medical reform program will be generally effective for multidisciplinary hospitals that can sign many packages for several services – gastroenterology, cardiology, vascular surgery, etc. Here the money goes after the patient – a good idea for those regular hospitals that have developed successfully while others have closed.
“Nnarrow-profile institutions, scientific institutes, cannot afford to work in such conditions, and the National Health Service has now begun to understand us because scientific institutes that receive only one or a maximum of two narrow-profile packages will not receive enough to finance their activities,” Tsymbalyuk said.
For example, the Radiation Safety clinic of the previously mentioned Institute will, according to its director Anatoliy Chumak, only receive around 30–35 percent of the funding it needs from NHS packages.
“Firstly, these are quite small amounts of funding. Secondly, hospitals are communal institutions, and local communities help them, but we will not have such support. Finally, the NAMS has patients on whom scientific research is also done, that is, on whom we collect data, and we don’t know if that will be funded. We are the only place that can treat complex cases in the event of a man-made nuclear disaster leading to cases of radiation sickness. Against the background of threats of nuclear escalation, this reduction in funding looks strange,” Chumak says.
Scientists see the Parliamentary Committee on health as their main opponent – they say that it forced their transition to the program of medical guarantees. However, it may not be that simple.
Reform or competition?
The parliamentary committee notes that the medical reform is the same for everyone. And there can be no exceptions because where there are exceptions and individual prices for services, there is the potential for corruption and other problems.
“Medical reform is a single space where all medical services should be available at the same price. We have had cases of complaints from patients from the tuberculosis dispensary within the NAMS system, from whom money was taken for services that the state had already paid for. Moreover, these services were provided at a higher cost than even in private clinics. This is not normal,” says Olha Stefanyshyna, a member of the committee, and the former deputy minister of health of Ukraine.
According to her, issues for those institutions who have narrow specializations can be solved by merging, teaming arrangements, or other forms of integration within the NHS.
Sources tell Kyiv Post say that the current state of affairs is a consequence of the 30 year disregard for the need to reform the scientific industry by successive Ukrainian governments. Now, the problem is the unwillingness of scientists and functionaries to let someone affect their individual post-Soviet environments, which for separate if limited funding had been received over a long period. There is also a fear that a rapid transition to market conditions will lead to the collapse of the remaining scientific work.
Stefanyshyna describes this unwillingness to switch to a system of medical guarantees as “sabotage.”
“There are examples of other mono-institutions that have even improved their position. For example, the Cancer Institute has doubled its revenue. The bottom line is that they don't want to reform; they don't want to show real statistics, and they can't provide comprehensive annual data. We constantly discuss this with them at committee, but they do not meet us halfway, even though state funding for their scientific research remains,” Stefanyshyna says.
NAMS denies the accusation of sabotage, claiming that their activities are being limited, allegedly to shift some of their qualified care to private clinics – where many of their researchers already work part-time. This dual employment often occurs as scientists seek additional income because of the underfunding of scientific work in Ukraine. For instance, this year NAMS received only UAH 900 million (approximately $25 million) for scientific work and activities – spread across dozens of scientific institutions.
“I don't want to think this way, but there is a suspicion that malicious intent may be behind it. Before this, the law on the elimination of specialized medical care was issued, some . might have already been preparing for the change. I don't want to believe that we are interfering with anyone, but we might be competing with private clinics because we create competition for them,” Tsymbalyuk says.
At the same time, the chairman of the parliamentary health committee, Mykhailo Radutskyi, bluntly states that the committee has no conflict with NAMS. But they must fall in line with the unified system of medical guarantees in the medical sector, like everyone else.
“The state is interested in the institutions continuing to provide highly specialized medical care, including to our wounded defenders. Therefore, we allow institutes to work without changing their organizational and legal form - the legislation requires the transfer of institutions to a state-owned non-profit enterprise – by postponing this norm for a year. We also provided a separate package of medical guarantees aimed at supporting institutions in the first months of 2025. The entry of all departmental institutions and institutes of NAMS into a single medical space is set for January 1, 2025, as per the legislation. Our committee insists that the Academy's institutes, like all other departmental institutions that were previously funded separately, should be funded through the medical guarantee program," Radutskyi says.
So, what now?
The NAMS leadership states that they are not opponents of the reform but are concerned about the state of Ukrainian science, which is becoming increasingly difficult to maintain.
“There are 27 National Institutes of Health in the United States. These are analogs of our scientific institutes. They receive $33 billion a year in funding for research and functionality, according to last year's data. We had 1 billion 600 million UAH, that is – half a billion dollars. Over time, we have used UAH 7 million, and now we have only UAH 900 million left for science. We must earn everything else by providing medical services under the packages of the medical guarantee program,” Tsymbalyuk says.
What is the possible way out?
According to both parties, one way would be to provide separate NHS packages that are more focused on narrow-profile assistance. However, their implementation will take time, and according to scientists, the rapid transition to the program of medical guarantees can negatively affect scientific institutions. However, their opponents say that these discussions have been ongoing for several years, and there was time to prepare.
Another option is to merge institutions. Thus, the Shalimov National Research Center for Surgery and Transplantation is a leading institute that deals with surgery, gastroenterology, vascular problems, and similar areas while its clinic also includes hematological and oncological departments. However, even these efforts may not be sufficient to secure the necessary funding under the NHS packages, not to mention the challenges faced by other institutions.
One way or another, the institutes continue their work with the National Health Service, hoping that the state will additionally meet them halfway during this complex transformation.
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