Primary care in Ukraine: an international fellowship perspective

Orest Mulka; Philip Evans

doi:10.3399/bjgp22X720149

In 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; the World Health Organization, other countries in Europe, the US, 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 healthcare system was based on that of the USSR. Primary care practitioners worked 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 outcome from the GP’s management. They were not able to treat patients with paediatric or gynaecological problems and, as a whole, the system was very bureaucratic with little personal responsibility for individual patients. This encouraged a high referral rate, which reduced the risks of mistakes and minimised the workload, providing more time for second jobs.

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

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 Royal College of General Practitioners (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 came from a wide variety of countries, but particularly from Eastern Europe, the Middle East, Asia, and South America.

A FORMAL RELATIONSHIP OF COOPERATION

Following an assessment visit to Ukraine in 1993, the RCGP and the Ukraine Ministry of Health agreed a formal relationship of cooperation 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 (a bilateral technical assistance programme for post-communist countries in Central and Eastern Europe, administered by the British Foreign Office). The principles of the Fellowship Programme were:

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

A UK GP was appointed as the Ukraine Fellow by the RCGP with initial responsibility for the Lviv region, and after 2 years a second Fellow with special responsibility for developments in the Kyiv region. The Fellows pursued the listed objectives over the next 5 years, through regular visits to Ukraine along with 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 GPs; and
membership of WONCA Europe

The Fellowship Programme was successful with regard to these objectives, laying a firm foundation for future developments. We felt that given the current war in Ukraine and the need for support and cooperation between the UK and our medical colleagues as well as the citizens of Ukraine, it would be of value to describe a successful previous cooperative process, even though it is now almost 30 years ago.

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