|Home | About | Journals | Submit | Contact Us | Français|
Hare: ‘Are we going around in circles?’
Tortoise: ‘Well, that's a good question!’
Hare: ‘If I didn't ask it, it wouldn't be a question.’
Tortoise: ‘And it must be a good question if you bothered to ask it!’
Hare: ‘Are we going around in circles?’
The last two and a half decades have seen major changes in health care within Eastern Europe and the previous Soviet states, particularly in their attitude to primary care.1–3 Just as the UK is now talking about the emergence of polyclinics to cope with the pressures of primary care,4 these countries have abandoned, or are abandoning the polyclinic concept. Health care, which had previously been founded upon consultations with highly specialised consultants, is now moving towards a general practice/family medicine-led service in community-based, integrated clinics.5
Ukraine was one of these former Soviet states that agreed to rationalise its health care, using a model described ably by John Horder (Box 1),9 assisted by experienced UK GPs and ably supported by the Royal College of General Practitioners.10,11
‘The personal doctor can offer care which is accessible, of broad range, relatively continuous, and above all, integrative. Not one of these characteristics is easily provided by a specialist; in combination they can only be provided by a generalist. This forms a distinctive role which people value as a basis to which specialist care can be added when necessary. In this way specialists and generalists can relate to each other, not as two people doing the same job, one better than the other, but as two people doing complementary jobs of equal status within the profession and society more widely.’9
To date, major achievements have been made by the proportionally small number of Ukraine family doctors (Box 2), very often against strong opposition from secondary care specialists and with intermittent support from the Ministry of Health who still remain only semiconvinced as to family medicine's future; however the theory is in place.
Although there have been several significant developments in family medicine, there are still obstacles to be overcome (Box 3). Some of them are of major importance and at least four are inhibitory to further developments:
These problems have led to an active healthcare provider who, within a developing organisation and despite seeing and managing patients, provides a less than comprehensive service with patients still wishing referral to secondary care, and a very disillusioned workforce; the theory is in place but practice does not support it. Personal observation suggests that little has changed in a majority of new practices since the reported activity of 1999.11
In order to be able to influence the appropriate authorities with the idea that family medicine is capable of affecting population health care, two specific activities were developed. These are described below, together with their purpose, their intended outcomes, and areas of potential influence.
In a country that is second only to Russia in size within Europe, but a population that is less than the UK (46.7 million)12 it still remains very difficult to obtain true health statistics from Ukraine. However, in a population where 19.4% of females and 7.4% of males are clinically obese (BMI >30 kg/m2) and 60% of deaths are linked to cardiovascular or cerebrovascular problems,13 it is hardly surprising that the chronic conditions of diabetes and hypertension rank high in the population's morbidity figures. Personal observation suggests that although these conditions are actively treated, the wide variation in treatment protocols is driven by the pharmaceutical companies rather than any evidence base and it is accepted as a very cost-inefficient system. Major inroads into a cost-effective and morbidity lowering service could be theoretically possible with the introduction of clinical guidelines based upon evidence-based medicine and practice.
A 2-day course was arranged for May 2007 which brought together specialist cardiologists and endocrinologists from the secondary sector and family doctors, together with representatives from the Ministry of Health. Instruction was given on Clinical Guidelines, the concept of SIGN14 and NICE,15 and evidence-based health care and its implementation into UK family practice. Ukraine family doctors and officials from the Ministry of Health spoke about the present Ukraine health situation and its current prescribing policies and statistics. The majority of the workshop was arranged as a small group, with interprofessional discussion on the development of two potential guidelines; management of adult hypertension and management of type 2 diabetes mellitus. It was hoped that this workshop would:
From a worldwide perspective, there are factors that place today's adolescents in a heightened position for poor health outcomes: society's changing expectations, changing behaviours of adolescents, and peer pressure. Health trends among the youth of Ukraine reflect the pressures that their global neighbours share. Ukraine is within the top five European countries for teenage abortion, where only 2.8% of fertile females use hormonal contraception.16 Ukraine is experiencing one of the fastest growing HIV epidemics in the world, 1.4% of people aged between 15 and 49 years are HIV positive, (known to be a gross underestimate) and 45% of new cases are found in teenage drug abusers.17 Although youth friendly clinics have been developed, opinion suggests that they are not effective, especially in dealing with the mental health problems of Ukraine youth18 and many believe a more suitable positioning for these services would be in primary care.
A 4-day, interprofessional course, coorganised with the regional office of the World Health Organisation (WHO), was created, following the guidelines workshop dealing specifically with how a youth friendly health service could be rolled out within the family medicine clinics in Kiev. A roll-out over the whole of Ukraine was considered too large a project initially, either to manage or evaluate. Key members from the Ukraine Ministry of Health's Youth Services were present and active in discussions. If successful it was hoped that this course would:
The purpose of this exercise was to gauge the interest of the participants in both topics, and to assess whether the topics could be used to further promote the value and effectiveness of family medicine. A quantitative questionnaire of evaluation was thought unnecessary at this stage. Due to the interprofessionality and some of the language difficulties, a qualitative exercise using post-course small group discussion led by two of the authors was seen to be an appropriate method of evaluating the workshops and judging the potential of the activity.
Although there was some initial difficulty in understanding the concepts of evidencebased health care, protocols, and clinical guidelines, these were eventually understood by all participants who agreed that this was a logical step forward within family medicine. A particularly positive response was received from the representatives of the Ukraine Ministry of Health, who perceived the concept as a way of reversing or eliminating the financially adverse effects of the pharmaceutical industry in influencing prescribing.
Evidence-based medicine and evidencebased health care was very well received by primary and secondary healthcare providers alike; the workshop saw the emergence of two interprofessional working groups, who were willing to embark upon the process of developing two clinical guidelines, the progress of which will be presented at the October 2008 Conference of Ukraine Family Medicine.
The workshop groups discussed the present activities of the existing 40 adolescent clinics. However, the local health workers, including those who had worked in the clinics, considered that they were not as well attended as they could have been, or as purposeful as hoped. The delivery of such a service by the new family medicine clinics was accepted unanimously by the participants and by the Ministry of Health representatives for Youth Services. The conclusion was reached in which the WHO regional office would work with the Ministry of Health and the Ukraine Association of Family Medicine and run a pilot scheme within the Kiev Region in developing the service and evaluating it through its organisers and customers. This work will also be presented at the October 2008 Conference on Family Medicine.
The process of family medicine in Ukraine began in 1987 when a group of Russian physicians visited Lviv, Western Ukraine, to talk about the concept.19 However, it was not until the post-Soviet era in the early 1990s that the idea was truly accepted by the Ukraine government and began to gain momentum and provide the tremendous changes that were discussed earlier (Box 2). Interestingly enough, and despite some very major changes, similar obstacles described in 198719 are still present in Ukraine to this day; that is, the finances to underpin the service, the payment of the practitioners, the acceptance of the specialty and its practitioners in the eyes of the government and secondary care, and an evaluation/assessment process of the service.
Many of the former Soviet countries accepted the Alma Ata Declaration of 197820 and were happy to see it incorporated into the European Health for all Policy of 1998.21 Both have given credibility to the development of family medicine.
Although papers have been written about the various initiatives in Eastern Europe, very little evidence is emerging about the true effects of family medicine upon the health care of the country. Changes in some health statistics are improving, people are tending to live longer, and management of long-term conditions appears to be improving, but issues such as the increasing termination of pregnancy rate and the HIV explosion15 still dominate: surely areas that family medicine was supposed to address and improve through its bio–psycho–social approach to health care.
Over the many years of developing family medicine in Ukraine, it is the authors' opinions that although family medicine is present, a longitudinal approach to its development predominates. This approach allows some change to occur, but the lack of any evaluation or research, which then informs further development in a cyclical manner, limits its usefulness.
Family medicine in Ukraine, although accepted at government level, still has failed to get full recognition, either by the Ministry or secondary care colleagues. As such it remains a ‘Cinderella’ subject; poorly paid and poorly supported. Many specialists, paediatricians, obstetricians and gynaecologists still fail to recognise it as a subject and refuse to be involved with any form of vocational training (although this cannot be said to be universal, there are pockets of very strong support); hence mothers still have little confidence in the family doctor in dealing with pregnancy and their children.
The salaries of family doctors are lower than the exceptionally low salaries of other specialists. Fifty per cent of trained family doctors leave the service on a yearly basis, often pursuing careers in more lucrative work such as the pharmaceutical industry or even in the retail industry.
This short piece of work in Ukraine represents a new step in trying to bring a cyclical approach to the management of change; a different approach that will attempt to convince the government that family medicine is a viable option for effective health care. It will of course hopefully stimulate a debate about a restructuring of the pay scales for the family doctors and community health workers.
Although the two workshops described were not major pieces of communitybased research, they will hopefully give rise to a much more structured long-term evaluation and lead to further research on the subjects.
The future of Ukraine family medicine is bright; it is moving forward. This next stage of its development will hopefully develop it even further.
Without the support from its energetic and passionately supportive family doctors this initiative would not be in existence; acknowledgement is not enough but is all we can offer at present. Special thanks are given to Valentina Baltag and Anastasiya Dumcheva from the World Health Organisation.
This work was originally supported by the International Committee of RCGP. It is now supported through the Ukraine Travel Fellowship of RCGP-Scotland