Therefore, the main advantages that point to the need for the introduction of OSMS are the presence of the targeted nature of contributions and thus strengthening the financial base of the CSO and ensuring a high degree of solidarity, regardless of a person’s financial ability. At the same time, a number of key points that significantly complicate the introduction of OSMS in the near future remain unresolved and need to be finalized in Ukraine, namely:

1. Risks related to the situation on the labor market, in particular:

– Low wages of the country’s population, high level of payroll deductions (41.5%, of which 3.5% is paid by the hired worker, and 38% by the employer).

– High level of shadow wages (according to the World Bank, Ukraine has the largest informal sector, which reaches 50% of GDP).

2. Risks associated with the current state of health care, in particular:

– Legislative inconsistency between the Fundamentals of the legislation of Ukraine on health care, Article 49 of the Constitution of Ukraine and the decision of the Constitutional Court of Ukraine in the case of free medical assistance in matters of determining the volume of medical services to be provided to the population of Ukraine free of charge at the expense of public sources of financing and complicity population in paying the cost of medical services (including at the expense of social health insurance).

– Absence of unified state tariffs for medical services, in accordance with the quality standards of health care services, which can lead to an uncontrolled increase in prices for health care services without a corresponding increase in quality.

– Regional and organizational disparity in the equipment of medical institutions, which complicates the process of ensuring equality and solidarity in the provision of quality health care services and will become more acute in the conditions of the introduction of insurance medicine.

– Widespread practice of unofficial payment for medical services (according to some data, it sometimes accounts for more than half of doctors’ incomes).

3. Risks associated with the medical and demographic crisis in Ukraine, in particular:

– Rapid aging of the population. If in 1991 the share of the population aged 60 and older was only about 19%, then as of the beginning of 2010 it was more than 21%. Which, firstly, leads to the aggravation of depopulation processes (even if the birth rate increases), and secondly, the burden on the working population and the state increases.

– High level of general morbidity of the population against the background of significant spread of disease risk factors, unpopularity of a healthy lifestyle among the population (prevalence of tobacco smoking, alcohol consumption, etc.).

– There is a pronounced difference in the morbidity rates of wealthy and poor population groups (more than 3 times), with a high specific weight of the poor population in Ukraine (26.4%, while in the Volyn, Kirovohrad, Sumy, and Kherson regions of Ukraine, this indicator is 40 %, and in the last two, almost half of the population lives below the poverty line.

Therefore, the stage of reforming the Ukrainian health care system through the introduction of the OSMS should be preceded by significant preparatory work to increase the effectiveness of the existing state health care system with the parallel promotion of the development of voluntary health insurance.

Based on the above, the implementation of the following steps is necessary to increase the effectiveness of the existing state POP:

1. Improvement of the legislative provision of POPs:

– In order to provide state-guaranteed free medical care at the legislative level, define the basic package of state-guaranteed medical services, which will later become the basis for the introduction of medical insurance.

− To finalize and adopt draft laws that are at the stage of public discussion, namely: “On conducting an experiment on reforming the health care system in the Vinnytsia, Dnipropetrovsk and Donetsk regions”, “On making changes to the Fundamentals of Ukrainian legislation on health care” , “On the peculiarities of the activity of health care institutions”, including, in order to prevent different interpretations of key terminologies in the formation of the legal framework regulating the activities of health care facilities, to agree on the terminology: “health care institution”; “health care”.

– In order to ensure the legal protection of the rights of patients and medical workers in Ukraine: adopt the Law of Ukraine “On the Protection of Patient Rights”, which is at the stage of public discussion; introduce medical self-government in Ukraine.

– In order to increase the effectiveness of the mechanisms for the implementation of the current legislation, introduce a system of monitoring and tracking the quality and appropriateness of the implementation of normative legal acts regulating the activities of POPs.

2. Strengthening the resource provision of POPs:

− Introduce mechanisms for innovative financing of POPs by, for example, introducing a mechanism for targeted use of excise duties on products harmful to health (alcohol, tobacco products, drinks with a high sugar content, etc.) for health care needs.

– In order to improve the procedure of state provision of the population of Ukraine with a basic package of medicines, create the State register of prices for medicines; at the state level, introduce a system of fixing prices for a number of the most socially important medicinal products with the simultaneous introduction of a state order for their production.

– In order to improve the efficiency of spending on health care, implement a monitoring system that would evaluate the effectiveness of public spending from the point of view of qualitative consequences for the health of society, and not based on the statistics of visits to medical institutions or the length of stay and inpatient treatment.

– Promote the development of social partnership between the state and representatives of private medicine by involving them in social programs: construction and financing of hospices, financing of anti-tuberculosis programs, etc.

3. Stimulation of the development of voluntary health insurance.

– In order to ensure the principle of multi-channel financing of health care, to promote the further development of voluntary health insurance, hospital funds; to more widely use the resources of private medical institutions.

– In order to stimulate the use of the system of official co-payments of the population in the process of medical care, establish income tax benefits for those who use private medical services.

– In order to work out the system of improving the quality of medical care, purposeful and controlled use of funds, to promote the further development of hospital funds, the involvement of enterprises, institutions, and organizations regardless of ownership. At the same time, enterprises can pay part of the contributions or their full amount for their employees.

– With the aim of wider use of voluntary health insurance, lower prices for its services, to introduce mechanisms for financing preventive measures by insurance companies, aimed at reducing the risks of morbidity, increasing the level of health of the population and thereby reducing the number of insurance cases.

4. Improving the quality of health care services.

– In order to strengthen public control, to build a two-way connection between the state, the sphere of health care and civil society in the field of health care, to strengthen the role of the Public Council of the Ministry of Health of Ukraine by ensuring its active involvement in analytical work on the study of the impact of reform mechanisms on activities POPs, population satisfaction with reform results; provision of professional public expertise of industry legislation, etc.

– In order to ensure the quality, safety and efficiency of medicinal products and their rational use, to widely implement the formulary system of medicinal products and the methodology of its monitoring and quality assessment developed by the Ministry of Health of Ukraine.

– To ensure the development of new and updating of existing medical standards and clinical protocols for the provision of medical care based on evidence-based medicine with parallel provision of the control procedure of the Ministry of Health of Ukraine, local executive authorities, local self-government bodies and civil society institutions over the implementation and observance of these standards.

– In order to improve the efficiency of the use of resources in health care facilities, to introduce a system of differentiated incentive remuneration in health care facilities and a system of contractual state procurement of medical services by concluding contracts between providers of health care services (medical institutions, private doctors) and the payer – state management bodies with referring to the quality and scale of complexity of providing medical care.

– Create a program of continuous improvement of the quality of health care services (including through distance learning, computerization of doctors’ workplaces, etc.), which are applied at different levels of health care facilities, improvement of the non-departmental (licensing, accreditation, certification) and departmental system control (independent examination) of quality.

− Strengthen motivational mechanisms for improving the quality of service provision, in particular: strengthen social protection measures for employees of the health care system, primarily at the primary level (provision of housing, provision of soft loans, etc.); to raise the salary level; introduce an incentive payment system for preventive activities, etc.

5. Improvement of the quality of personnel support of the Health and Safety Organization.

– In order to eliminate the disparity in the staffing of health care facilities, introduce a long-term forecasting system by categories of medical personnel in accordance with the needs of health care, taking into account the strategy and pace of systemic transformations of the industry, external and internal migration processes and natural attrition of personnel.

– To provide advanced training and retraining of general practice doctors / family medicine, family nurses, secondary medical personnel with higher education. For this purpose, the State Budget for 2012 should include a corresponding article of funding.

6. Creation of a national health care model.

In order to find the most optimal national health care model for Ukraine, whose activities and infrastructure will meet the needs of the population, and take into account the geographical, historical and cultural features of Ukraine, ensure:

– conducting current and retrospective analysis of elements of modern global health care models that have proven effective;

− optimization of the system of collection and analysis of statistical data, in particular coordination of the procedure for the provision and circulation of information between the Ministry of Health, Regional Centers of Medical Statistics and the State Committee for Statistics;

– introduction of a quality assessment system for the provision of medical services to the end user and effective feedback for the development of scientifically and economically justified mechanisms for reforming the domestic POPs.

7. Development of compensatory mechanisms.

With the aim of further reforming the health care system in the direction of introducing OSMS, the Ministry of Health of Ukraine, in cooperation with the Ministry of Finance, trade unions and the Federation of Employers of Ukraine, should develop possible compensatory mechanisms to balance the growing fiscal burden on employers.