MEDICAL CORRUPTION: CAUSES AND
MEASURES OF COMBATING
Olha S. Bondarenko, Maryna S. Utkina
Sumy State University, Sumy, Ukraine
Email: [email protected]
|
KEYWORDS Corruption; medical field; anti-corruption;
СOVID-19 |
ABSTRACT After the Ukrainian
crisis, many renewal processes took place in Ukraine. One of the most
important reforms was anti-corruption. The issue of medical corruption has
gotten worse in the context of the global pandemic caused by Сovid-19. The
aim of the article is a criminological characteristic of the causes and
measures to combat corruption in the medical field in Ukraine. Methodology is
a conjunction of approaches, principles, and specific methods, which are used
by the scientist. We used exactly those elements of the methodology that
allowed us to ensure the consistency and objectivity of the combating
corruption in the medical field in Ukraine study. The authors outline and characterize the main causes of
medical corruption in Ukraine. Measures to combat medical corruption are
proposed as follows: modernization of the model of medical field financing;
commissioning of a special procedure for purchasing pharmaceuticals at public
expense; overcoming the corruption component in the cooperation of pharmaceutical
companies and medical workers; reforming the remuneration system of medical
workers; educational activities. |
INTRODUCTION
According to the Constitution of Ukraine, Ukraine is a
state governed by the rule of law (constitutional state) (Article 3 of the
Constitution of Ukraine), where the principle of the rule of law is recognized
and effective (Article 8 of the Constitution of Ukraine) (Constitution of
Ukraine, 1996). Reducing the corruption level is one of the most important and
significant reforms for Ukraine today. After the Ukrainian crisis, many
novelization processes took place in Ukraine. Anti-corruption reform became one
of the most important reforms. The medical field was recognized as one of the
main directions of the reform, as medical corruption is second only to
political corruption in terms of the public danger level. Such a significant
negative "key opinion leader" of corruption in this field is due to
the fact that, along with management relations, it has a negative impact on the
highest social value in the state – human life and health (Perelyhina &
Kozyr, 2019).
Major levels of corruption in the medical field are
typical for many countries in the world, as annual spending on this sector is
about 4 trillion. dollars. This fact is extremely attractive for corruption
schemes (Reznik &
Ovcharenko, 2017). Assessing medical corruption abundance is extremely
complicated by the social and legal ambiguity of informal relations in this
field. However, despite the latency of corruption practices in the medical
field, more than 90% of the more than UAH 120 million in damage caused to the
state and exposed by detectives of the National Anti-Corruption Bureau of
Ukraine during investigations of corruption criminal offenses in the social
sphere relate to criminal offenses in the medical field (National Anti-Corruption Bureau of Ukraine,
2020). Corruption in the medical field can be
divided into the following main levels: from the patient to the doctor or other
health worker; within the hospital - from the medical institutions’ employee to the management of the
hospital; at the state level on public procurement of pharmaceutical drugs (Bilyk & Novikova,
2016). The aim of the article is a criminological
characteristic of the causes and measures to combat corruption in the medical
field in Ukraine.
RESEARCH METHOD
The right methodology selection is one of the
important elements for successful research conducting. The methodology is a
conjunction of approaches, principles, and specific methods, which are used by
the scientist. We used exactly those elements of the methodology that allowed
us to ensure the consistency and objectivity of the combating corruption in the
medical field in Ukraine study. The main principles of this study were
determinism, objectivity, specificity, complexity, relevance, and a combination
of achievements in theory and practice. In addition, institutional and systemic
approaches were used. As to research methods, its branched complex and the
multilevel structure was proposed. First, philosophical methods were used:
analytical, phenomenological, hermeneutic, and dialectical. Three levels in the
structure of general scientific methods were defined. The first is the methods
of empirical research (descriptive, comparative, generalization). The second
level is represented by the methods of theoretical cognition: ascent from the
abstract to the concrete and hypothetical deductive. The third level of general
scientific methods is general logical methods (method of system analysis;
analysis and generalization; modeling; system-structural method;
abstract-logical). The last type of methods that were used are specifically
scientific methods: formal-legal, comparative, statistical analysis).
RESULT AND DISCUSSION
Causes of Corruption in The Medical Field in
Ukraine
First, we would like to highlight that the task of
combating corruption in the medical field is particularly acute for the need to
confront the global threat of COVID-19. The pandemic has forced the redirection
of funds from other government needs to the medical field, and therefore the
possibility of corruption has also shifted. In Ukraine, Anti-COVID-19
Fund was established. This Fund was established ad hoc to prevent the spread of
this disease in Ukraine, and within 30 days from the date of cessation the
quarantine. In addition to the new direction of corruption practices in the
medical field, the “old” ones remained. We offer to analyze each of them.
Despite the declarative catchwords, free health care
has never existed in our country. According to research, every second patient
refuses treatment or postpones it due to a lack of money. Experience over the
past 12 months shows that a third of those who applied to healthcare settings
reported that they had not encountered situations involving informal payments
or practices that could be considered corrupt. At the same time, almost every
second (47.9%) clients of healthcare settings confirmed
that they had to buy pharmaceutical drugs for emergency care at their own
expense 40% indicate that unofficial expenses that were direct payments to
doctors, managers, and other health care workers (National Agency on
Corruption Prevention, 2020).
In 2020, at the request of the Kharkiv Regional State
Administration, a regional study on the existence of corruption in the medical
field was conducted. The study showed that improper
advantage from patients or their relatives were provided for the following
services: a) for obtaining a sick leave certificate or other certificates – 75%
of respondents; b) for high-quality patient surgery, medical services,
consultations – about 50% of respondents (in this case, the patient was assured that he was
guaranteed quality pre- and postoperative care, the use of the best
pharmaceutical drugs, medical devices, out of turn checkup, the best conditions
of stay in a health care institutions); c) for a doctor prescribing the
required medication order – 10% of respondents; d) for confirmation or
concealment of certain medical facts – less than 10% (more often than not,
doctors can confirm / hide the presence of maims, bodily blows, etc .); e) for
halfway discharge of the patient from the hospital or, conversely, extension of
his stay – 5%; f) for the issuance of the necessary certificates of the
patient’s mental health – 15%; g) for distorting the true cause of death. In
this case, the size of the improper advantage is the
largest in the medical field, as it may be concealment of criminal death. There
are only a few such cases (Corruption in the medical sphere: eradicate, prevent,
defeat, 2020). In our opinion, a change in the national approach to defining
the essence and approach of financing the provision of healthcare will be able
(if not completely eradicate) at least to limit corruption abusive action the
part of medical professionals and patients.
The
healthcare field in Ukraine is one of the lowest-paid fields and it is another
issue. According to the State Statistics Service of Ukraine, the average wages
of medical professions are about 224 Euros, less received only in the field of
temporary accommodation (hotels) and catering – 221 Euros (Radio Liberty of Speech, 2021). Low wages are combined with high liability for human
life and health and the possibility of infecting COVID-19. All of this also
increases the tension within the medical system. All these reasons led to the
mass lay-offs of qualified health workers in 2020 and the need to review the
health workers’ level of wages. At the same time, the promises of officials
about a significant increase in the level of material security, unfortunately,
were declarative. After all, as always, the bureaucratic component intervened,
because from April 1, 2020, hospitals began to get the financing from the
budget institution– the National Health Service of Ukraine, with which hospitals
directly executed contracts. So, if previously the source of funds were
government subsidies, which were distributed by region according to the number
of places in hospitals, now the money is charged by the National Health Service
for specific services provided. The issue of upgrading and rebooting the
Soviet-style health care system is long overdue. One of the key directions of
such an update was the introduction of compulsory state social health
insurance. Compulsory state social health insurance will be an effective and
forceful means to cover the costs of treatment, prevention, aftercare in case
of ill ileum or accident. At the same time, despite the glaring urgency of this
issue at the regulatory level, it is still not regulated. Several legislative
drafts exhibited to the Verkhovna Rada of Ukraine, however, none of them has
been adopted yet. According to S. Kozmenko and I. Okhrimenko, the main issue
hindering the adoption of the law final version is the lack of a holistic
comprehensive approach to reforming the modern mechanism of financing the
domestic health care sector based on compulsory health insurance (Kozmenko, 2012).
The experience of one of the former socialist states,
the Republic of Poland, has been demonstrative in introducing compulsory health
insurance. According to the Law on Compulsory Health Insurance, from January 1,
1999, every citizen pays a compulsory insurance premium, which is compensated
by a corresponding reduction in income tax, which means a reduction in state
budget revenues by contributions to compulsory health insurance. Initially,
this contribution was paid in the amount of 7.5% of gross income, and since
January 2001 - in the amount of 7.75% of this indicator. Specified funds are
accumulated by the Pension Fund, which apportioned them among the 16 fully
autonomous regional (at the level of each of the provinces) and 1 departmental
(designed to waiting for military population, police, and employees of other
paramilitary formations) compulsory health insurance funds (16 regional) and 1
branch of the so-called “sick pay”). Herewith, each of the patients has the
right to choose the patient's health insurance, which is limited to one of two
possibilities. However, most commonly, the choice is limited to the regional
fund of patients in the territory of residence of the insured. Unemployed
members of the contributors’ families are also considered the insured. Retirees pay
a contribution from the pension they receive. The unemployed during the period
they receive state unemployment assistance, independently pay the insurance
premium for this benefit, which is considered income, and after the termination
of benefits, the cost of medical services provided to them is covered by the
budget. For health care provided by persons without a specific place of
residence not covered by the system of compulsory medical insurance, the fee is
paid from the budgets of the lowest level of self-government at the request of
the relevant medical service providers (The Experience of European Countries in Financing Healthcare Lessons
for Ukraine, 2021).
We are positive that improving the health care of all
persons involved in health insurance through the introduction of health
insurance as an independent system of commodity-market relations in the medical
field is a priority of the modern health care system of Ukraine. The
implementation of compulsory insurance in our country should be based on the
attachment of the insured person to a certain territory served by the insurance
institution, at the same time, it is necessary to determine the procedure for
providing transfers to certain territories to equalize the financial
capabilities of different regions (Danylʹchenko, 2017). All of this will remove the corruption component in
the relationship between the health worker, as a subject of medical services
and the patient, as a person receiving such service or third parties (relatives
of the patient).
Measures to Combat Corruption in The Medical
Field in Ukraine
As to the areas of combating corruption in the medical
field, we propose to apply a comprehensive approach, which will include several
main directions. First, Ukraine for a long period of time had an outdated
command-and-control model of health care inherited from the Soviet Union.
Health care facilities were budget institutions and were owned by the state or
local communities. Estimates of the revenues and expenditures of these health
care facilities were approved by the same authorities in which they were
located, consequently, the authorities are encouraged to act in the interests
of the institutions concerned and not in the interests of the individual
patient. These institutions were financed according to a strict itemized budget
based on outdated infrastructure standards. This deprived health care managers
of managerial flexibility and motivation to improve outcomes (Reform,
2016). Therefore, the Ministry of Health
has started funding the medical field so that every Ukrainian can receive
quality medical care. Thus, under the Law of Ukraine "On State Financial
Guarantees of Medical Care" from January 1, 2020, the implementation of
state guarantees of medical care under the program of medical guarantees is
carried out for all types of medical care through the authorized central
executive body implementing state policy in the sphere of state financial
guarantees of medical care – the National Health Service of Ukraine.
Institutions operating in the form of a municipal non-profit enterprise will be
able to sign an agreement with the National Health Service of Ukraine and join
the program of medical guarantees under the Law of Ukraine "On Amendments
to Certain Legislative Acts of Ukraine to Improve Legislation on Health Care
Institutions". The creation of this executive body will remove the
corruption component in the distribution of budget funds in the financing of
certain health care facilities. It is possible because the National Health
Service as a strategic purchaser analyzes the needs of citizens in medical
services, determines the most effective methods of payment for various types.
services, as well as select those medical institutions that can provide safe
and quality care. With direct contracts with health authorities, the National
Health Service can respond quickly to what happens with the provision of
services. This is a particular advantage for countries in difficult situations,
such as the COVID-19 pandemic.
By now the National Health Service of
Ukraine has entered contracts for the patient’s care management with COVID-19
and suspected case with 25 emergency medical care centers, 316 inpatient care
authorities treating patients with COVID-19, and 935 medical authorities, in
which mobile teams are formed, and go to people with a suspicion of COVID-19
(these authorities employ almost 1,600 mobile teams). Payments from the
National Health Service were also received by 151 health care facilities that
provided institutional care to patients with COVID-19 in April, but were not
included in the list of hospitals designated for hospitalizing (Government Portal, 2021). Now, therefore, the first step
towards the transformation of the medical field into a service field is
considered successful. Organizational innovation will really serve to eliminate
the corruption component in the distribution of funding in the medical field.
Secondly, it is important to
implement maximum publicity during public procurement procedures of
pharmaceutical drugs. The field of public procurement has always been the most
attractive for corruption practices. Due to non-transparent and inefficient
public procurement procedures, a significant amount of budget allocations is
spent with numerous violations. A significant number of violations are
accompanied by public procurement procedures of pharmaceutical drugs and medical devices, which are a special
subject of public procurement, as the quality of purchased drugs depends on the
health and even life of people (Tarasenko, 2016).
According to experts, the annual losses from corrupt
abuses in public procurement amount to 10-15% of the state budget expenditure,
or UAH 35-50 billion (Ivanov, 2014) A similar situation is typical of most post-Soviet
states. Thus, according to a survey by EU representatives, up to 40% of the
budget of all public procurement in Moldova settles in the pockets of corrupt
officials. In this country, the most prone to corruption is the purchase of
pharmaceuticals and medical equipment (Surzhiu, 2019).
In Ukraine, corruption offenses in the field of public
procurement take place both by managers of public funds and by bidders. The
most common abuses are the intentions of customers to purchase goods from a
certain predetermined manufacturer. In turn, this result can be achieved both
by avoiding competitive procurement procedures and by giving an undue advantage
to one of the bidders (Melnikov, 2016).
In order to eliminate the corruption component during
the procedures of public procurement of medicines, in 2015 the Ministry of
Health of Ukraine began to carry out centralized procurement of medicines at
public expense through international organizations. According to the Accounting
Chamber of Ukraine, the new effective and transparent procedures have saved up
to 40% of budget money and purchased some drugs ten times cheaper. The
effectiveness of international procurement as opposed to procurement through
the Prozorro system (online public procurement) is shown by local tenders:
regional oncology dispensaries and government agencies purchase drugs up to
300% more expensive than international organizations (according to the results
of monitoring drug procurement for cancer patients).
At the end of
2018, the State Enterprise “Medical Procurement of Ukraine” was established to
make the most transparent procurement of medicines. This agency should become
the main purchasing organization and ensure transparent, high-quality and
timely supply of drugs (Ministry
of Health of Ukraine, 2020).
The task of the State Enterprise "Medical Procurement of Ukraine" is
to facilitate the verification of needs, based on statistical and demographic
data, taking into account the data provided by the
regions on the type of disease, its severity, patient weight, age, etc. This
year, for the first time, the need for expensive drugs is formed individually, taking into account the specific medical data of each
seriously ill patient. Verification allows to form an objective and realistic
need by regions and to purchase only those drugs and in the quantity in which
patients really need. At the same time, despite the generally positive
dynamics, there are still some delays and problems in the interaction between
the Ministry of Health and the State Enterprise "Medical Procurement of
Ukraine". Thus, to ensure the uninterrupted supply of medicines, the order
of the Ministry of Health from February 28, 2020 brought to the State Enterprise
"Medical Procurement of Ukraine" 14 areas of prevention, treatment
and diagnosis. However, due to the delay by the State Enterprise "Medical
Procurement of Ukraine" in preparing documents for competitive bidding,
such bidding did not take place and were postponed for 46 names of drugs for
cancer patients (Ukrainian
Pravda, 2020).
Third, it is important to overcome the corruption
component through the cooperation of pharmaceutical companies and doctors. It
is a common situation in Ukraine when a doctor prescribes a specific drug,
guided not by the interests of the patient, but by the selfish purpose of receiving
gifts or illegal benefits from employees of pharmaceutical companies. In
Ukraine the activities of medical sales representatives of pharmaceutical
companies are widespread. Their communication with HCPs occurs regularly, but
it is carried out in a legal vacuum, without any law regulation. Experts note
that, as a rule, medical sales representatives are not perceived by doctors as
high-level professionals, carriers of new knowledge about medicines (Gutorova et al., 2019).
This is unacceptable in the European Union, as
Directive 2001/83 / EC of the European Parliament and of the Council of 6
November 2001 on the Community code relating to medicinal products for human
use contains provisions on how to inform doctors of medicinal products. Paragraph
47 of the Preamble to the Directive states that the advertising of medicinal
products to persons qualified to prescribe or supply them contributes to the
information available to such persons. Nevertheless, this advertising should be
subject to strict conditions and effective monitoring, referring in particular
to the work carried out within the framework of the Council of Europe. And
paragraph 50 of the Preamble to the Directive states that persons qualified to
prescribe medicinal products must be able to carry out these functions
objectively without being influenced by direct or indirect financial
inducements. The direct prohibition of gifting or excessive hospitality for
doctors is set out in Art. 94 of the said Directive, according to which where
medicinal products are being promoted to persons qualified to prescribe or
supply them, no gifts, pecuniary advantages or benefits in kind may be
supplied, offered or promised to such persons unless they are inexpensive and
relevant to the practice of medicine or pharmacy (paragraph 1). Hospitality at
sales promotion events shall always be strictly limited to their main purpose
and must not be extended to persons other than health-care professionals
(paragraph 2). Persons qualified to prescribe or supply medicinal products
shall not solicit or accept any inducement prohibited under paragraph 1 or
contrary to paragraph 2 (paragraph 3). Existing measures or trade practices in
Member States relating to prices, margins and discounts shall not be affected
by paragraphs 1, 2 and 3 (paragraph 4) (Directive
2001/83, 2001).
To combat this type of corruption in the medical
field, the Ukrainian government has launched an "Affordable Pharmaceutical
Drugs" program. Under this program, patients with cardiovascular disease,
asthma, or type II diabetes can receive pharmaceutical drugs free of charge or
at a small additional cost. The peculiarity of this program is that doctors,
when prescribing, do not indicate the trade name of the pharmaceutical drugs,
but the active substance – the non-proprietary name. The pharmacy offers
the patient several brands that contain the active ingredient specified in the
prescription and the patient decides which brand to buy. This procedure
minimizes medical lobbying of certain brands of pharmaceutical drugs.
In addition, in 2020, the Ministry of Health of
Ukraine also approved the National List of Pharmaceutical Drugs – a short list
of essential pharmaceutical drugs with proven effectiveness, access to which
the state guarantees to all patients free of charge during inpatient treatment.
The national list includes the names of international non-proprietary names of
pharmaceutical drugs recommended by the World Health Organization for the
treatment of the most common and most dangerous diseases. Currently, this list
contains 427 actual substances. Therefore, from January this year, healthcare
settings must first purchase pharmaceutical drugs according to the National
List, and only after that each healthcare setting can and has the right to
purchase the necessary pharmaceutical drugs that are not included in it. At the
same time, healthcare settings should not buy specific trade names of
pharmaceutical drugs. This rule makes the tender process– it allows bidding to
buy effective pharmaceutical drugs at a lower price, because all pharmaceutical
manufacturers who have such pharmaceutical drugs can bid and offer a lower
price (Ukrainian Pravda, 2020).
Fourth, it is important to reform the remuneration
system for healthcare providers. The second stage of medical reform in Ukraine
started on April 1, 2020. Traditionally, the salary system of healthcare
providers has been established in terms of categories: doctors, nursing staff
and medical attendants, administrative and service staff. The salary system of
doctors was based on the establishment of a scheme salary, a system of
promotions, and allowances. The schematic salary depends on the position
(surgeon, resident, or doctors of other specialties), considering the
qualification category. Salaries also depend on the location of the healthcare
setting (Kemarska, 2015). At the same time, the new medical reform stipulates
that those who work harder, who are chosen by patients, will receive more money
for the specific work performed. That is, being a mediocre hospital or mediocre
specialist will be unprofitable, because there will be no fixed salary, and the
patient will have a choice – and will go for a consultation or a planned
operation to the specialist he chooses, whom he considers the best. And the
National Health Service of Ukraine will pay for the medical service provided to
the hospital of the patient's choice.
In addition to medical reform, in 2020 the medical
system of Ukraine faced another acid test – the COVID-19 pandemic. At the
regulatory level, the issue of remuneration of medical and other employees of
healthcare settings was settled on March 23, 2020, № 246 in the resolution of
the Cabinet of Ministers of Ukraine "Some issues of remuneration of
medical and other employees directly involved in the elimination of acute
respiratory disease COVID-19 caused by the coronavirus SARS-CoV-2". This
document established for the period of implementation of measures aimed at
preventing the occurrence and spread, localization and elimination of
outbreaks, epidemics and pandemics of acute respiratory disease COVID-19 caused
by coronavirus SARS-CoV-2 determined by the Cabinet of Ministers of Ukraine
spread on the territory of Ukraine of coronavirus disease (COVID-19), until the
completion of these measures is an additional surcharge of up to 300 percent of
salary (salary with increases), taking into account the statutory mandatory
surcharges and allowances: in health care facilities, who provide medical care
to patients with coronavirus disease (COVID-19) and have concluded an agreement
on medical care under the program of state guarantees of medical care according
to the relevant list and scope of medical services with the National Health
Service, medical and other employees who directly busy and on the provision of
medical services to patients with coronavirus disease (COVID-19); medical and
other employees of emergency and disaster medicine centers involved in
responding to coronavirus cases (COVID-19), and entered into a contract for
medical care under the program of state guarantees of medical care according to
the list and scope of medical services with the National Service health; in
public health facilities identified in the decisions of the relevant central
executive bodies for the provision of inpatient care for patients with
coronavirus disease (COVID-19), medical and other workers who are directly
engaged in the provision of medical care to patients with coronavirus disease
(COVID-19). These surcharges are made at the expense of funds received by
healthcare facilities per contracts for medical care under the program of state
guarantees of medical care according to the relevant list and volume of medical
services concluded with the National Health Service and local budgets (Some issues of remuneration of medical and
other workers directly involved in the elimination of acute respiratory disease
COVID-19 caused by coronavirus SARS-CoV-2, 2020).
Afterward,
to incentivize health professionals and overcome the level of layoffs that
arose after the pandemic, on June 19, 2020, the Cabinet of Ministers of Ukraine
adopted Resolution № 610. In this document, the Cabinet of Ministers of Ukraine
established from September 1 to December 31, 2020, medical and other employees
of communal health care facilities (except for doctors and / or primary care
teams) and health care facilities belonging to the Ministry of Health that
provides medical care to patients with acute respiratory disease COVID-19,
caused by the coronavirus SARS-CoV-2, and providing livelihoods: 1) doctors
(regardless of position) in the amount of 70 percent of the salary determined
by the 14th tariff category of the Unified Tariff Grid; 2) specialists who meet
the qualification requirements approved by the Ministry of Health in the amount
of 50 percent of the minimum wage established in Article 8 of the Law of
Ukraine “On the State Budget of Ukraine for 2020”; 3) assistant nurses in the
amount of 25 percent of the minimum wage established in Article 8 of the Law of
Ukraine “On the State Budget of Ukraine for 2020. However, co-payments under
this document are already made at the expense of funds allocated in the
prescribed manner from the Fund for the control of acute respiratory disease
COVID-19 caused by coronavirus SARS-CoV-2, and its consequences (Some issues of remuneration of medical and other
employees of health care institutions, 2020). Thus, the new approach to the
remuneration of medical professionals will become an important element in
preventing corruption in the medical field.
Fifth, it is important to carry out various
educational and explanatory measures on the inadmissibility of tampering
doctors. This task is exceedingly difficult because our society has
historically been accustomed to thanking doctors. We are accustomed to age-old
traditions do ut des (I give for you give). Overcoming this factor in practice is
the most difficult because it is necessary to change not only the law but also
the mentality of the people, which, of course, requires a huge amount of time
and constant targeted influence, which in today's reality is extremely
difficult (Bondarenko et al.,
2018). Reforming consciousness and forming an appropriate
level of legal culture is a complex and time-consuming process. Expecting
satisfactory results only by imposing strict bans is certainly not effective.
What is important is a comprehensive, balanced approach, a key place in which
is the education of legally conscious youth, for whom the provision of illegal
benefits will be not just an anti-legal, but completely unacceptable
phenomenon.
CONCLUSION
In summary, we believe that tackling health corruption
requires a combination of legal and other social efforts. Only in this case can
we hope for real success. We suppose that the mixing of medical and
anti-corruption reform measures will be able to ensure the real overcoming of
corruption in the medical sphere in Ukraine.
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Copyright holders:
Olha S. Bondarenko, Maryna S.
Utkina (2023)
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Devotion - Journal of Research and Community
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