Ukraine’s Hybrid Healthcare System

By Gabriel Gatehouse, BBC News

To coincide with the 60th anniversary of Britain’s National Health Service, the BBC looks at models of healthcare around the world. In Ukraine, a hybrid system - a mixture of public and private - is starting to take root.

In a hospital in the Ukrainian capital, Kyiv, neurosurgeon Igor Kurylets, is working on a patient’s back.  An 18-year-old woman lies face down on the operating table, with about 30cm of spine exposed.

The operation may look somewhat primitive: there is a lot of rather violent bashing, scraping and screwing going on. But this is in fact a state-of-the-art procedure. During the four-hour operation, the patient’s spine will be realigned from an inverted S-shape to a straight, ordinary looking back. Holding it all in place will be rods and screws, designed in the United States and imported to the patient’s specifications.

This is the only clinic in the former Soviet Union which uses this pioneering technique. It is located inside a much larger hospital, which is run by the Ukrainian Security Service (Sluzhba Bezpeky Ukrainy - SBU) - the successor organisation to the Soviet KGB.

“It is a state hospital”, Dr. Kurylets explained, as he continued working on the patient’s spine, “but we cannot run, for example, this surgery from the [state] budget, because we need different types of screws, different instruments and things like that.”

All the basic medical provisions are supplied by the state-run hospital. All the high-tech extras - the screws and rods, the specialised x-ray equipment - are paid for separately by the patient.

Dr. Kurylets was one of the people who pioneered this hybrid system in Ukraine 10 years ago. And the idea is slowly catching on. Until then, it was illegal to pay for any medical services in a state hospital.

Gratitude Money

But the vast majority of Ukrainians, when they fall ill, still use the system that the country inherited from the Soviet Union, whose ideal was and remains free public healthcare for all.

The corridors of the vast, state-run October Hospital in central Kyiv are bare and sparse. They are clean though, and well maintained. But that is largely because the doctors themselves contribute to the hospital’s upkeep.

One surgeon on the urology ward agreed to speak to the BBC on condition of anonymity.

“Each of us puts in $100 or $200,” he said. “And with that money we pay to have the walls painted, replace some sanitary facilities, and varnish these floors, and so on.”

And it’s not just cosmetic improvements that the medical staff has to pay for.

Reaching into his desk drawer, the doctor pulled out a handful of catheters and tubes wrapped in sterile medical packaging: his own personal stash.

“It’s got to the stage now where we are buying things we need in order to perform an operation.”

But how does a doctor like this one, on a salary of about US$250 per month, pay for all of this? It turns out that the free healthcare provided by the state isn’t entirely free after all.

“A patient will come to me and ask: `Doctor, how much will this cost?` I leave it to the patient to thank me as he sees fit in return for my work.

“The level of gratitude can range from `thank you doctor`, to a $4 bottle of cognac. Or it can be a certain sum of money. A fairly large sum. Several times larger than my monthly salary.”

Hospital Upkeep

Dr. Kurylets believes that his hybrid clinic maximises the potential of the immense but crumbling state-run infrastructure.

In return for the use of the SBU`s medical facilities, he treats security service personnel for free. And his clinic contributes to the upkeep of their hospital.

“We pay for their hospital, so they have additional money to change windows and doors, to redecorate the hospital. It is positive economic co-operation,” Dr. Kurylets said.

Patients who are not employees of the SBU do have to pay, though. The 18-year-old with the curved spine would be charged around $10,000.

And while that may seem like a lot of money, it is a fraction of what a similar operation would cost in Western Europe or the United States.