Primary care in Ukraine – an international fellowship perspective

Dr Orest Mulka is former Chair of British /Ukraine Medical Association and former RCGP Ukraine Fellow.

Dr Philip Evans is former Chair RCGP International Committee and former President WONCA Europe.

I[n the early 1990s after the fall of the Berlin Wall many Central and Eastern European countries, including Russia, sought to review the funding and organisation of health care. Given the appetite for reform, they turned to many different sources for advice, WHO, other countries in Europe, the USA and Canada. There was a particular interest in reforming primary health care.

Ukraine became independent of the old Soviet Union in 1991. At that time its primary health care system was based on that of the USSR. Primary care practitioners working in large polyclinics, based in cities. Their training was limited and their work very circumscribed. They were poorly paid and could be disciplined for failing to refer patients to a specialist at the same polyclinic if there had been an unfavourable clinical outcome. They were also not able to treat patients with paediatric or gynaecological problems. The system was very bureaucratic. There was little personal responsibility for individual patients. This encouraged a high referral rate, which reduced the risks of mistakes and cut down the work-load, providing more time for second jobs.¹

These problems had been recognized in Ukraine before independence. In Lviv, Western Ukraine, starting in 1988, progress was made by setting up training schemes for general practitioners/family doctors. This was due more to the skill and interest of forward-thinking individuals than any central organization. In 1990 Ukraine had a low and falling life-expectancy (65.6 years  for males) and  high levels of preventable conditions such as infectious diseases indicated an inadequate health care system.²

Between 1990 and 1993 the British/Ukraine Medical Association developed a series of contacts with the Ukrainian Ministry of Health and individual doctors in the country. As a result, help was sought from the RCGP to move to a system of Family Doctor based care, with similarities to the UK system. It was ironic that some UK politicians within government in the 1990s were smitten with the concept of polyclinics in the UK^.

In the early/mid 1990s the RCGP International Committee set up a new system for responding to the numerous requests it received for information, advice and practical assistance,  – The International Primary Care Development Programme. Requests were made from a wide variety of countries, but particularly from Eastern Europe, the Middle East, Asia and South America.

Following an assessment visit to Ukraine in 1993 the RCGP and the Ukraine Ministry of Health agreed a formal relationship of co-operation to improve primary care in Ukraine. From this an RCGP/Ukraine Fellowship Programme was developed, with funding from the British Government’s Know How Fund (this was a bilateral technical assistance programme for post-communist countries in central and eastern Europe, administered by the British Foreign Office).³

The principles of the Fellowship Programme were:

1. To concentrate efforts on the initial steps already made in Ukraine, in the Lviv and Kyiv areas
2. To maintain co-operation with the Ukrainian Ministry of Health
3. To identify ‘champions’ for General Practice in both Lviv and Kyiv
4. To promote General Practice as a career to medical students and junior doctors
5. To develop schemes of postgraduate GP training
6. To establish a university department of general practice, to act as a focus for professional development and cooperative links with other departments
7. To establish a professional association of general practitioners. This would enhance the status of family doctors and allow further cooperation with other countries.
8. To encourage academic research and publications and a local academic journal.

A UK general practitioner was appointed as the Ukraine Fellow by the RCGP with initial responsibility for the Lviv region, and after two years a second Fellow with special responsibility for developments in the Kyiv region. The Fellows pursued the listed objectives over the next five years, through regular visits to Ukraine and reciprocal visits by leading Ukrainians to the UK and subsequently to European and International GP conferences.

The aim of the Fellowship programme was to make Ukrainian general practice self-sustaining, in order for this to be achieved the following elements were necessary:

• Accredited schemes of general practice training
• Viable models of working general practice
• Academic departments of general practice throughout the country
• A national Association of general practitioners
• Membership of WONCA Europe

The fellowship programme was successful with regard to these objectives and laid a firm foundation for future developments.^4,5,6

We felt that given the current war in Ukraine and the need for support and co-operation between the UK and our medical colleagues and the citizens in Ukraine, it would be of value to describe a successful previous co-operative process, even though now almost thirty years ago.

We understand the RCGP is currently developing ideas to support Ukraine in the near future and when announced hope they will encourage further support and involvement.

References

1. Toon PD, Southgate LJ, Kossovoi A Simbertsev S. In the steps of Peter the Great – building links between London and St Petersburg Eur J Gen Pract 1996;2:75-6
2. Highlights on health in Ukraine, Denmark WHO Publications 1993
3. Evans P. Proposal for RCGP/Ukraine Fellowship in Family Medicine Development. 1994. RCGP International Committee Archive
4. The RCGP Ukraine Fellowship Programme 1993-1997. T Gibbs, O Mulka, E Zaremba. European Journal of General Practice.Jan1 1998. 4.2(1998)84-87
5. Family Medicine in Ukraine: changing theory into practice and completing the circle. T Gibbs, L Khimion, G Lysenko, BJGP Sept 2008. 58.554(2008) 654-657
6. Background Paper: Ukrainian general practitioners; the next steps. T Gibbs, O Mulka, E Zaremba, G Lysenko. European Journal of General Practice 5:1 29-32 11 July 2009.

Links

• RCGP www.rcgp.org.uk
• WONCA Europe. www.woncaeurope.org

Featured image by Marjan Blan | @marjanblan on Unsplash