Ukraine. Healthcare system flowcharts. Health expenditures
The State Statistics Committee of Ukraine is the main source of health expenditure data, but the official data underestimate total health expenditure, as they do not fully reflect unofficial payments for health services. National Health Accounts (NHA) have only recently been introduced to better summarize, describe and monitor health care financing. Based on the approach to the creation of NHA developed by the OECD in 2000, an investigation was completed on total health expenditure from 2003–2004, with particular regard to the funding of services for people living with HIV/AIDS (Gotsadze et al., 2006). In this report, official data from the State Statistics Committee of Ukraine were used to investigate the expenditures of state and private companies. To estimate donor activity in financing, data were collected through interviews with donors and the analysis of various reports from national and international organizations.
The investigation of out-of-pocket payments used data from a special household survey undertaken in 2003–2004. The survey included 10 238 households and 26 675 respondents. It covered the entire population except for servicemen, convicts, permanent residents of boarding schools and nursing homes, and the marginal population (homeless people etc.). Nevertheless, it was felt that the data on out-of-pocket expenditure were underestimated in this study (Gotsadze et al., 2006). Consequently, the State Statistics Committee of Ukraine was advised to revise its methods when conducting household surveys for future estimates in NHA.
The NHA project materials formed the basis for the Methodological recommendations on compiling National Health Accounts, which was approved by Order No. 137 of the State Statistics Committee of Ukraine on 10 May 2007. As a result, the State Statistics Committee of Ukraine compiled a generalized table of NHA for the first time in 2005. This chapter uses primarily the official data of the State Statistics Committee of Ukraine. Data from before 1996 are impossible to compare with the subsequent period.
Health care expenditure increased rapidly in 2000 after the prolonged economic crises of the 1990s. Between 1999 and 2006, official health care expenditure per capita calculated by the State Statistics Committee of Ukraine increased 5.1 times. NHA data showed that total health expenditure grew 3.4 times. However, trends in real expenditure levels, which take inflation into account, are lower (only 1.3 times higher for the period 2003–2008). In 1999, the annual increase in total health expenditure was about 9% less than the
previous year as a result of the 1998 financial crisis, which affected nearly all CIS countries. From 2000 to 2003, health care expenditure increased annually (by 9.3% in 2000 up to 24.9% in 2003), which reflected the rapid growth of the Ukrainian economy. Political crisis in 2004 slowed economic growth and brought negative growth of health care spending in 2005 (by 2.6%). In 2006, the level of expenditure increased by 8.1% (and by 7.7% in 2007 and 4.3% in 2008) compared with the previous years (see Table 1). Total health expenditure as a percentage of GDP remains comparatively low for a country in the WHO European Region.
2004 was 7.0% of GDP, and 6.4% of GDP in 2008. However, NHA data include under-the-table payments in total health care expenditure, whereas the rate of GDP is calculated based only on official data without including the informal sector, which is substantial, so this may overestimate the level of total health expenditure as a proportion of GDP. For example, in the first quarter of 2007, the integrated informal sector accounted for 26% of official GDP (Ministry of Economy, 2007).
Official health expenditure data show that expenditure fluctuated between 4.5% and 6.0% of GDP between 1996 and 2006, reaching its nadir in 1999–2000 (4.5–4.6% of GDP). Health expenditure increased from 2001 to 2003, but in 2004–2005 it fell again from 7.0% to 6.4% (see table 1). Overall, growth in total health expenditure as a percentage of GDP did not match the speed of economic growth in Ukraine.
Total health expenditure as a proportion of GDP fell in most countries of the CIS following independence from the USSR, and in some countries, including Ukraine, overall expenditure levels have remained low (see Fig. 1.). In terms of PPP, health expenditure per capita in Ukraine is one of the lowest in the WHO European Region, which shows the low priority that health care has been afforded in the country.Based on official statistics, the share of public revenues in total health expenditure was over 80% in 1996, but fell to 62% from 2000 to 2002. Only between 2003 and 2006 was there some increase in the share of government health expenditure in total health expenditure (66–68%). NHA, which include informal payments, show that government expenditure in 2003–2008 fluctuated around 60% of total health expenditure. This is low for countries of the WHO European Region.
Table 3.2 shows data on the main categories of health care spending in Ukraine as a proportion of total health expenditure in 2003, 2004 and 2008. More than half of total health care expenditure goes towards providing medical services. About a quarter of expenditure on health care goes to inpatient care; about 13–14% to out patient care (including pr imar y care and specialized outpatient consultations). Both types of services are financed primarily from public sources. Ukraine spends a relatively small proportion of current health expenditure on outpatient care in comparison with other countries in the WHO European Region. It has been argued that this reflects an inefficient use of resources as patients who could have been treated as outpatients are instead hospitalized (Gotsadze et al., 2006). Significant sums (about 7%) are spent on rehabilitation care provided primarily in sanatoria – a remnant of the Soviet era – where patients spend their vacations and receive restorative treatments. Ancillary services receive about 4.5% of total health care expenditure.
Government sources cover about half of spending on rehabilitation and a quarter of spending on ancillary services: laboratory tests, X-rays and other diagnostic procedures. This shows that three-quarters of ancillary services are covered by out-of-pocket payments. A relatively small proportion of spending goes to treatment in psychiatric facilities, addictions clinics and day-care hospitals, as well as long-term medical care, where almost all the expenses are covered by public financing.
The share of spending on drugs and medical supplies accounts for a rather large proportion of total health care expenditure (33%). State resources cover only a small part of that expenditure (about 0.5–1%). The population carries the main burden here, as both inpatients and outpatients have to pay for most drugs and medical supplies out-of-pocket. Public health and prevention activities receive only 3.5–4% of total health expenditure. This is very low, especially considering the scale of current public health problems: population decrease, HIV/AIDS and TB epidemics, high mortality from cardiovascular diseases and so on.
The investigation of out-of-pocket payments used data from a special household survey undertaken in 2003–2004. The survey included 10 238 households and 26 675 respondents. It covered the entire population except for servicemen, convicts, permanent residents of boarding schools and nursing homes, and the marginal population (homeless people etc.). Nevertheless, it was felt that the data on out-of-pocket expenditure were underestimated in this study (Gotsadze et al., 2006). Consequently, the State Statistics Committee of Ukraine was advised to revise its methods when conducting household surveys for future estimates in NHA.
The NHA project materials formed the basis for the Methodological recommendations on compiling National Health Accounts, which was approved by Order No. 137 of the State Statistics Committee of Ukraine on 10 May 2007. As a result, the State Statistics Committee of Ukraine compiled a generalized table of NHA for the first time in 2005. This chapter uses primarily the official data of the State Statistics Committee of Ukraine. Data from before 1996 are impossible to compare with the subsequent period.
Health care expenditure increased rapidly in 2000 after the prolonged economic crises of the 1990s. Between 1999 and 2006, official health care expenditure per capita calculated by the State Statistics Committee of Ukraine increased 5.1 times. NHA data showed that total health expenditure grew 3.4 times. However, trends in real expenditure levels, which take inflation into account, are lower (only 1.3 times higher for the period 2003–2008). In 1999, the annual increase in total health expenditure was about 9% less than the
previous year as a result of the 1998 financial crisis, which affected nearly all CIS countries. From 2000 to 2003, health care expenditure increased annually (by 9.3% in 2000 up to 24.9% in 2003), which reflected the rapid growth of the Ukrainian economy. Political crisis in 2004 slowed economic growth and brought negative growth of health care spending in 2005 (by 2.6%). In 2006, the level of expenditure increased by 8.1% (and by 7.7% in 2007 and 4.3% in 2008) compared with the previous years (see Table 1). Total health expenditure as a percentage of GDP remains comparatively low for a country in the WHO European Region.
Table 1.
The expenditure in US$ PPP (purchasing power parity) per capita reveals trends similar to the real level of expenditures for health in national currency with the decline at the end of the 1990s and the following growth in the first decade of the 21st century. According to WHO estimates (WHO, 2010), the full scale of changes from 1996 to 2008 is slightly greater, with expenditures increasing from $176 PPP in 2006 to $488 PPP in 2008.
The exact level of total health expenditure in Ukraine is difficult to determine, mainly because of problems in obtaining data on health care spending in the informal sector. From 1998 to 2005, total health expenditure fluctuated between 5.0% and 6.5% of GDP, and was close to the average of the CIS countries (see Fig. 3.4). NHA data in Ukraine show that total spending on health in 2003 and
The expenditure in US$ PPP (purchasing power parity) per capita reveals trends similar to the real level of expenditures for health in national currency with the decline at the end of the 1990s and the following growth in the first decade of the 21st century. According to WHO estimates (WHO, 2010), the full scale of changes from 1996 to 2008 is slightly greater, with expenditures increasing from $176 PPP in 2006 to $488 PPP in 2008.
The exact level of total health expenditure in Ukraine is difficult to determine, mainly because of problems in obtaining data on health care spending in the informal sector. From 1998 to 2005, total health expenditure fluctuated between 5.0% and 6.5% of GDP, and was close to the average of the CIS countries (see Fig. 3.4). NHA data in Ukraine show that total spending on health in 2003 and
Figure 1.
2004 was 7.0% of GDP, and 6.4% of GDP in 2008. However, NHA data include under-the-table payments in total health care expenditure, whereas the rate of GDP is calculated based only on official data without including the informal sector, which is substantial, so this may overestimate the level of total health expenditure as a proportion of GDP. For example, in the first quarter of 2007, the integrated informal sector accounted for 26% of official GDP (Ministry of Economy, 2007).
Official health expenditure data show that expenditure fluctuated between 4.5% and 6.0% of GDP between 1996 and 2006, reaching its nadir in 1999–2000 (4.5–4.6% of GDP). Health expenditure increased from 2001 to 2003, but in 2004–2005 it fell again from 7.0% to 6.4% (see table 1). Overall, growth in total health expenditure as a percentage of GDP did not match the speed of economic growth in Ukraine.
Total health expenditure as a proportion of GDP fell in most countries of the CIS following independence from the USSR, and in some countries, including Ukraine, overall expenditure levels have remained low (see Fig. 1.). In terms of PPP, health expenditure per capita in Ukraine is one of the lowest in the WHO European Region, which shows the low priority that health care has been afforded in the country.Based on official statistics, the share of public revenues in total health expenditure was over 80% in 1996, but fell to 62% from 2000 to 2002. Only between 2003 and 2006 was there some increase in the share of government health expenditure in total health expenditure (66–68%). NHA, which include informal payments, show that government expenditure in 2003–2008 fluctuated around 60% of total health expenditure. This is low for countries of the WHO European Region.
Table 3.2 shows data on the main categories of health care spending in Ukraine as a proportion of total health expenditure in 2003, 2004 and 2008. More than half of total health care expenditure goes towards providing medical services. About a quarter of expenditure on health care goes to inpatient care; about 13–14% to out patient care (including pr imar y care and specialized outpatient consultations). Both types of services are financed primarily from public sources. Ukraine spends a relatively small proportion of current health expenditure on outpatient care in comparison with other countries in the WHO European Region. It has been argued that this reflects an inefficient use of resources as patients who could have been treated as outpatients are instead hospitalized (Gotsadze et al., 2006). Significant sums (about 7%) are spent on rehabilitation care provided primarily in sanatoria – a remnant of the Soviet era – where patients spend their vacations and receive restorative treatments. Ancillary services receive about 4.5% of total health care expenditure.
Government sources cover about half of spending on rehabilitation and a quarter of spending on ancillary services: laboratory tests, X-rays and other diagnostic procedures. This shows that three-quarters of ancillary services are covered by out-of-pocket payments. A relatively small proportion of spending goes to treatment in psychiatric facilities, addictions clinics and day-care hospitals, as well as long-term medical care, where almost all the expenses are covered by public financing.
The share of spending on drugs and medical supplies accounts for a rather large proportion of total health care expenditure (33%). State resources cover only a small part of that expenditure (about 0.5–1%). The population carries the main burden here, as both inpatients and outpatients have to pay for most drugs and medical supplies out-of-pocket. Public health and prevention activities receive only 3.5–4% of total health expenditure. This is very low, especially considering the scale of current public health problems: population decrease, HIV/AIDS and TB epidemics, high mortality from cardiovascular diseases and so on.
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