EXPLORING PATHWAYS TO EQUITY IN HEALTH : A CASE STUDY OF UKRAINE

OLENA HANKIVSKY, PHD: SIMON FRASER UNIVERSITY

WORKSHOP: EFFECTIVENESS OF PUBLIC HEALTH PROGRAMMES/POLICIES IN COMBATING SEVERE POPULATION HEALTH CRISIS IN UKRAINE JULY 23 2015

HEALTH CRISIS• Even before current events , political and economic transitions have affected

human health and the health care system

• Classified as middle-income country, number of unique distinctions:

One of the world’s worst demographic declines

An internationally recognized population health crisis

Life expectancy more than 9 years less than citizens of EU

More than 10 years life expectancy gap between males and female

Health care system weak and unable to perform basic functions

Health reform to date ineffective

Inadequate education, training for health professionals, policy actors and decision makers

EXPLORING PATHWAYS TO EQUITY IN HEALTH REFORM: A CASE STUDY OF UKRAINE

International Team:

Tatiana Andreeva – Kyiv- Mohyla University Ukraine, William Cockerham, University of Alabama at Birmingham, WHO –Ukraine, USAIDS, Ministry of Health Ukraine

Anna Vorobyova Simon Fraser University; Nastia Salnykova University of British Columbia/ Kyiv-Mohyla University; Setareh Rouhani University of Ottawa

FUNDER: Canadian Institutes of Health Research

GOALS

1) to conduct an in-depth mixed methods analysis of the differential effects and experiences of the health crisis in Ukraine

2) to generate evidence that will inform the development of strategies to reduce inequitable health outcomes pervasive within the Ukrainian population

OMNIBUS SURVEY

Secondary analysis of Omnibus Survey (2040 residents over age of 18) to identify and explore inequities in health status, experiences with the health care system and services

gender, SES, and age produced our key findings.

• low SES women reported the worse health

• women in the general population are the most disadvantaged with respect to the primary obstacle of out of pocket costs

• Age intersects with gender in terms of health care affordability

COMMUNITY CONSULTATIONS

Further explore and explicate systemic and structural mechanisms, pathways, and risk factors perpetuating health inequities in Ukraine

• Conducted in 2012 over a 4 month period

• 21 community consultations (with over 800 citizens)

• 11 representative regions of Ukraine’s demographics and geography:• Autonomous Republic of Crimea, Cherkasy, Dnipropetrovsk,

Donetsk, Kherson, Kyiv, Lviv, Sumy, Zaporizhia, Vinnytsia, and Zhytomyr

METHODOLOGY

• The consultations targeted consumers, health service providers, and local government representatives, and were held in an equal mix of rural and urban settings

• Advertisement was by invitation and public advertisement (facilitated by local NGOs), and specifically targeted a diversity of representation, especially from marginalized and vulnerable groups

• Each forum was attended by 35-50 persons representing diverse ages and occupations participated in the consultations

• Female participants accounted for 2/3

METHODOLOGY

• The guiding questions for the community consultations were informed by the Omnibus survey analysis, and were organized around the central themes of the project: • health status• experiences with the health care system and services• key issues of health concern and priority

• The coding of the community consultations consisted of identifying and describing patterns, themes, categories and relationships informed by the theoretical framework of intersectionality

• Data coding and analysis assisted by MAXQDA 10 software

COMMUNITY CONSULTATIONS

COMMUNITY CONSULTATIONS

COMMUNITY CONSULTATIONS

COMMUNITY CONSULTATIONS

BARRIERS IN ACCESSING HEALTHCARE

What are the main barriers in your community to accessing health care?

• Financial

• Unprofessional doctors

• Lack of trust in doctors

• Lack of medication and equipment in medical facilities

• Corruption in medical facilities

• Expensive and poor quality medication

HEALTH IN COMMUNITIES

• How would you describe the health of people in your community?

• Overall evaluation:

• Unsatisfactory, poor

• Tendency of general decline

• Regional differences:

• Residents of the more industrial regions (Donetsk and Dnipropetrovsk) gave a “worse than in other regions” evaluation to their health

QUALITY OF LIFE: DETERMINANTS

KEY FACTORS:

• Environment

• Political Instability

• Economic Hardship

• Geography: Rural/Urban divide

QUALITY OF LIFE

“Are there reasons to smile? People are so unsure about what will happen tomorrow that they have no reasons to smile. And this instability, uncertainty affects our health” (person from Dzankoj), “

… there are too many people who are depressed because of the general situation in the country, especially elderly people, they have no faith in tomorrow, no confidence in how they will live tomorrow” (participant from Sumy)

“….all illnesses are starting because of stress – this is our problem because we have no assurance in the days to come, we have no certainty, and we are constantly worried about our lives. All these negative emotions make us sick” (participant from village of Okhirmivka)

HEALTH EVALUATION

• Lack of infrastructure in communities, few resources and facilities to promote health and wellness, especially in rural settings

• Negative effect on the health of the population particularly among children and youth

• Many talked the declining health status of the population, and that individuals of previous generations were healthier than today

• Concern over the prevalence of non-healthy behaviours (e.g. smoking and substance abuse, lack of exercise)

RECOMMENDED CHANGES

• What would you change (if you could) to improve people’s health in your region/community?

• Health care system: increase financing of the health care system, the number of available and affordable services and physician salaries. Elimination of out of pocket expenses, improving the quality of education by eliminating corruption in medical schools

• More generally: focus on health promotion and prevention of disease, more effective government regulations, (especially in relation to environment) and improved services in communities

KEY FINDINGS SUMMARY

• Research demonstrates:

interactions of age, region, urban/rural location, ethnicity, socioeconomic status, gender

structural effects of economic crisis, political instability and corruption

• Citizens understand and want to take action on social determinants of health

• Don’t have much faith in government reform or system changes

• Special concern about the health of children and future prospects of youth