Cardiovascular Disease in Ukraine
Defintion:
Environmental Aspect – Geography, access, pollution, exploitation of natural resources.
The Ukrainian health care system has been primarily the same since the Soviet era. The policies currently in place do not reflect the health care needs of the population, or account for regional characteristics of health services.
Since their independence, their economic crisis has led to a significant fall in state income, which also had a substantial impact on health care funding. Although Health care finance and expenditure the actual share of the health care budget is about the same now as it was at the time of independence – at about 3% of the GDP – the sharp decline in GDP has meant a drop of over 60% in real-level health expenditures. Also, while nominal spending almost doubled between 1996 and 2000, because of the high rate of inflation, real spending in 2000 constituted only 70% of the 1996 level. This shortage of public funds is increasingly leading to patients being indirectly charged for services in public facilities, camouflaged as “donations” or “voluntary cost recovery”. Under the current rules, the population is still bombarded by expenditures not covered by the state, such as pharmaceuticals, medical devices and hospital food.
About thirty three percent of the population in Ukraine live in rural areas, some only sparsely populated at around 30–70 people per km2. As you would assume, this would pose great problems in the provision of health care, such as access to these small rural areas. This also limits the number of doctors and nurses that can be distributed throughout the area. An example of this problem would be the fact that per population sizes 1000-1300, they are only prescribed one physician, providing basic healthcare. Since these areas are very remote, some physicians have to take on the responsibility for emergency care.
There has been a substantial fall in the access to proper health care. A representative survey of 9478 Ukrainian households undertaken by the State Statistics Committee in October 2002 showed that more than a quarter (27.5%) of households were unable to obtain necessary health care for any member of the family. Although this proportion is somewhat lower than the figure for 2000 (35.3%), little has changed since 2001 (28.7%). for the majority of respondents (88%–97%) this was mainly because of exceptionally high costs for drugs, devices for homecare and health services. (Lekhan, Valeria, Rudiy, Nolte, 2004)
Also, “about 9% of households were unable to consult a doctor because of financial difficulties, and another 5% were unable to obtain necessary inpatient treatment for the same reason. The study also demonstrated that a substantial number of hospital patients were charged for drugs (92.9%), food (83.0%) or bed linen (63.9%), the very services that the state health system is by law supposed to provide”. (Lekhan, Valeria, Rudiy, Nolte, 2004)
Environmental Aspect
Economic Aspect
Economic aspects of cardiovascular disease in Ukraine refers to the costs/benefits, employment, fiscal policy, production, distribution, and consumption of goods and services all related to the problem of CVD in Ukraine. They are the aspects of the economy that affect the problem. According to Meagan Clark (2014), there are 10 things you need to know about Ukraine’s economy:
1) Gross domestic product has been flat for two years
2) The unemployment rate is 7.5%
3) The Ukrainian central bank has yet to offer a sustainable plan
4) Consumer confidence is low
5) Reforms could release more agricultural potential
6) Ukraine is energy efficient
7) The services sector is the largest
8) Industrial production fell in 2013
9) The labor market is shrinking
10) Ukraine ranks low for foreign investment
The income and spending of Ukrainian households took a sharp decline in 2009 (disposable income: $39,000, consumer expenditure: $35,000) as their country was hit by global economic crisis in 2008-2009 (Hodgson, 2012). 2011 brought signs of recovery based on lower unemployment rate (from 9.5% to 7.5%) and higher export earnings/foreign investment. Disposable income rose to $47,000 and consumer expenditure rose to $44,000. Ukrainian households still remain the poorest in Europe, devoting all of their expenditure to household essentials (Hodgson, 2012). Unfortunately, health-care is not included in the category of “household essentials.” According to An Hodgson, the chart below indicates Ukrainian household consumer expenditure by category. The small portion red portion of the chart shown below shows money spent on Health Goods and Medical Services.
Historical Aspect
According to the U.S. National Library of Medicine, noncommunicable diseases (NCDs), including cardiovascular disease (especially ischemic heart disease), are the leading cause of death and disability worldwide. Their prevalence is seen to be on the rise in low-and-middle income countries like Ukraine, where out-of-pocket payments are especially high in regards to medical treatments (Murphy, Mahal, Richardson, Moran, 2013).
About 40.5% of Ukrainians pay for medicine out-of-pocket. In Ukraine where, in 2009, 16.1% of the population did not earn a living wage and 14.4% of the population live below the national poverty line, it is likely that the effect of out-of-pocket payments on patient households is great (Murphy et al., 2013). A study done by Adrianna Murphy, Ajay Mahal, Erica Richardson, and Andrew E. Moran showed that despite evidence of high prevalence of noncommunicable disease factors and a health care system that has proved to be unable to meet the needs of it’s patients, Ukraine has been relatively ignored in the public health literature.
The Ukrainian government is needed to fund hospitals in order to update their outdated and hazardous hospital technologies, while also increasing their salaries of surgeons and assistant personnel (Rudnieva, 2003). All Ukranians are entitled to a guaranteed package of health care services provided free of charge at the point of use; however, resource constraints have led to attempts by the government to limit the range of services covered in this package (Murphy et al., 2013).
Outpatient drugs have never been included in this package. Ischemic heart disease (a type of cardiovascular disease) was found to cause about 80% of deaths in 2008 in Ukraine (Murphy et al., 2013). Hospitalization and death can be avoided but only through the a daily drug regimen which is not included in the health care services package, giving Ukrainians only a few options to pay for their prescriptions. As a result, a huge burden is put of households of people with ischemic heart disease due to out-of-pocket payments for health care, and many were turning to distress financing (borrowing, sale of assets) to cover these costs (Murphy et al., 2013).
Many families even without the stress of paying for the numerous medications needed for ischemic heart disease patients are still under the constant mental and emotional stress regarding paying other medical prescription bills. Being constantly stressed over finances leads to bad habits like smoking and drinking which are both huge risk factors for cardiovascular disease. This stress also leads to the consumption of foods rich in salt, fat, and cholesterol; foods that have a huge contribution to the diagnosis of cardiovascular disease.
Concluding the study done by Adrianna Murphy, Ajay Mahal, Erica Richardson, and Andrew E. Moran, households of ischemic heart disease patients in Ukraine are more likely to engage in distress financing to cover the cost of treatment, and a high proportion of patients do not acquire prescribed medicines because they cannot afford them. This ultimately results in hospitalization and death, a huge reason why CVD is a big problem in Ukraine.
Historical aspects of cardiovascular disease refers to how the history of the people in Ukraine affect the problem of cardiovascular disease. History alludes to the story of something through time; how the past affects the present. Ukraine has a high death rate of 16.3 deaths/1,000 population (Health in Ukraine, 2014). Contributing to this high mortality rate are two main factors, both which are considered risk factors for CVD: alcohol poisoning and smoking (Health in Ukraine, 2014).
According to the 2010 World Bank study, 36% (28.6% is the average in Europe) of Ukrainians smoke tobacco, including 31% of those who smoke every day. Ukraine has a very high smoking prevalence for the size of their country. As we know, smoking is a huge risk factor for cardiovascular disease, along with alcohol abuse. Can we see a correlation here? Does Ukraine’s history of smoking (and also alcohol use) contribute to their high number of cases of CVD?
Today, cigarettes can be found on almost every street corner even in the poorest countries like Ukraine and cost almost next to nothing (What’s on Kyiv, 2013). According to the newspaper “What’s on Kyiv”, smoking is known as one of the few things that actually brings Ukrainians from all backgrounds together.
The habit of smoking is maybe one of the few things which the beautiful young Kyivlanka has in common with the grizzled Donbas miner (What’s on Kyiv, 2013). The young Kyivlanka are beautiful young dancers that dress up in extravagant costumes and entertain people by dancing. This is done in celebration of the diplomatic relations between Sri Lanka and Ukraine (Vlasova, 2013).
In contrast, Donbas miners are grizzled coal miners of the Donets Basin, a region of Eastern Ukraine (Donets Basin, 2014). Smoking is the only things these two completely different groups of people have in common, and they pride themselves in it. Smoking has been a way of socializing for the people of Ukraine. As we can see from contemporary paintings, the Cossacks were never seen without their saber, bandora and pipe (photo below).
Tobacco grew in abundance around the Black Sea and it was therefore only natural that the Cossacks should light up (What’s on Kyiv, 2013). The Cossacks are a group of predominantly East Slavic people who became known as members of democratic, semi-military communities, predominantly located in Ukraine and in Southern Russia. They played an important role in the historical and cultural development of both Russia and Ukraine (Cossacks, 2014).
It seems to be that all Ukrainians pick up smoking at an early age. Due to the direct correlation with high numbers of smokers and high numbers of CVD, maybe things will change. The fact is that tobacco is cheap and a great way to escape the Ukrainians stressful day to day lives and it will forever be associated with the glamour of the Cossacks (What’s on Kyiv, 2013).
According to “What’s on Kyiv”, smoking will remain one of the country’s favorite pastimes. Excessive alcohol consumption is another risk factor of cardiovascular disease. It is also listed as one of the most preventable causes of death in Ukraine (Health in Ukraine, 2014). Alcohol consumption in Ukraine goes back to the 15th century where the North West region of contemporary Ukraine (Volyn region) was famous for producing very good Horilka (Alcohol History, 2014). “Horilka” is the Ukrainian word for “vodka.” According to an old folklore, it was known that people use to drink up to a liter or more of Hoilka. Interestingly, Horilka was only half as strong as the vodka made today (Alcohol History, 2014).
Rumors say that when the Austrian army was approaching a distillery town in the North West of Ukraine, the owner, being determined not to let the enemy steal his profit, ordered all the alcohol to be thrown into the river (Alcohol History, 2014). When locals heard about this, they ran to the liver with buckets or even drank straight out of the river. It is known that Horilka is the drink of Ukraine and that it is served at parties, gatherings, and celebrations (Alcohol History, 2014). The history of Horilka is something that is held close to the hearts of Ukrainians. They find it part of their history and have no shame in consuming it daily, which have the potential to correlate to the alcohol abuse problem and high rates of CVD.
Cultural Aspect
Beliefs, values, behaviors, etc. of a group of people regarding social learning
This link has a news broadcast as well as some information about how the culture influences cardiovascular disease.
This link talks about what is wrong with Ukraine’s health and what has/needs to be done to help fix their crisis.
Design Aspect
How the problem is depicted in art, music, literature, video, etc.
These labels were put on cigarette packs so that people could see the different things it can do to them and who else it can affect
Political Aspect
Political Aspect
The Political Aspect is the process by which groups make decisions, usually relates to running government or state affairs; consist of social relationships involving authority and power.
Politics of Ukraine take place in a framework of a presidential representative democratic republic and of a multi-party system. Executive power is exercised by the Cabinet. Legislative power is vested in the parliament. Scholars have described Ukraine's political system as "weak, fractured, highly personal and ideologically vacuous while the judiciary and media fail to hold politicians to account" (Dr. Taras Kuzio in 2009). Ukrainian politics has been categorized as "over-centralized" which is seen as both a legacy of the Soviet system and caused by a fear of separatism. (Dr. Taras Kuzio in 2009).
About half of all deaths before the age of 75 in Ukraine could be avoided through adequate prevention and treatment.
Five major risk factors account for about half of the DALYs in Ukraine and all other Easter European countries in the study. High blood pressure is the biggest risk factor, with one-third of Ukrainians suffering from elevated blood pressure; unfortunately, most Ukrainians are unaware of their hypertensive status. In addition, tobacco and alcohol consumption in the country is high. Almost two-thirds of Ukrainian males above age 15 are regular and daily smokers, the highest number for countries in WHO’s European region. Many of the causes of premature death and disease in Ukraine are linked to risk-factors which are largely modifiable and preventable. Major risk factors require changes in lifestyle behavior (such as, smoking, alcohol and diet). Environmental conditions also play a key role in many diseases - including poisonings, injuries and the biggest killer in Ukraine, circulatory system diseases such as ischemic heart disease and stroke. Through adequate prevention programs targeted to modify behaviors and improve environmental conditions, along with effective treatment, about half of all deaths before the age of 75 in Ukraine could be avoided.
Ukraine’s health system is not geared to tackle the mortality crisis.
Despite the fact that most premature deaths in Ukraine are of a preventable or treatable nature and there is evidence that cost-effective targeted interventions can work, the Ukrainian health system is still designed for acute care episodic disease management and is not equipped to deal with this mortality crisis. A primary care oriented system would be ideal to deliver effective preventive interventions. Programs ongoing in other European countries show success in reducing premature mortality and morbidity through cost-effective interventions that are targeted to reducing risk-factor prevalence. Many potential life years and health life years can be gained by implementing any or some of these interventions in Ukraine."Resources For." Europe and Central Asia. N.p., n.d. Web. 29 Apr. 2014.
Ukraine's health system is complex, inefficient, highly inequitable, and of low quality. Ukraine lacks a comprehensive health reform implementation plan - though several reforms have been proposed and some have even been legislated, most have not been implemented. Political instability, frequent changes of Government and of the leadership of the Ministry of Health - with eight Ministers of Health since independence - have led to delays in institutional change in health care and the reorganization of primary health care. To addresses the health needs of the population which is becoming more NCD focused, Ukraine’s health system needs to be re-oriented from an acute care input-based model to a comprehensive disease management model that is more appropriate for NCD prevention and control. Unlike Ukraine, all Central European countries studied in this report underwent comprehensive reforms in their health systems, starting early in the transition process.
Reforms in Central European countries were guided by a series of legislations, policies and strategic plans which were constantly adapted to changing needs. In all cases, effective government stewardship was critical to ensuring success in implementation of reforms. An important element of the reforms was defining the roles and responsibilities of the various players in the health systems. Experience from Central European health reforms suggests that removing rigidities in resource allocation, emphasizing primary care, introducing referral care systems, rationalizing excess capacity at secondary and tertiary levels, and providing performance-based payments to providers should be the focus of health system reform in Ukraine.
Effective Prevention Mechanisms Would Require Collaboration Across Sectors
Changes in the composition of the burden of disease require a multi-sect oral approach to disease prevention and management. An integrated NCD control and prevention strategy can help foster multi-sect oral collaboration. In the short-term, there is a need to identify and implement priority cost-effective interventions (both within and outside the health system) that target the major risk factors. These include interventions and policy options that target the major risk factors – such as alcohol and tobacco, road safety, and diet/physical activity, within an integrated strategy for NCD prevention. This requires the development of integrated management structures that bring together representatives from all areas of the health system and beyond to ensure coordinated action for NCD prevention and control. The process should involve not only the Government but also donors and NGOs—all of whom have a substantial role in NCD prevention and control efforts. "Resources For." Europe and Central Asia. N.p., n.d. Web. 29 Apr. 2014.
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https://www.youtube.com/watch?v=nRr-nrJ7xvQ
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