Annex 16:

E-4PR: Developing Mechanisms of Management Decentralization in Regional and Local Health Systems with the Aim of Optimizing the Functioning of the Odessa Oblast’s Medical Institutions.

1. Project description

2.  Project purposes and goals

            As the outcome of the initial joint NASPAA-NISPAcee project (4PR), the Oblast Health Administration Agency (OHAA) and the Odessa Regional Institute of Public Administration of Ukrainian Academy of Public Administration (ORIPA UAPA) began to work together to develop proposals for reforming the regional health service system.  The policy paper, “Health Policy Improvement: Issues of Decentralization and Citizens Involvement”, produced as the part of the original project, has been reviewed at a meeting of the Oblast Health Agency from the point of view of developing a Programme for Medical Service System Reform in the South Ukraine Region; comments from the agency have been received.

            Partially as a consequence of the issues raised in the discussion of the NASPAA/NISPAcee policy paper and other concerns, the Odessa Oblast government has appointed a Coordinating Council on Implementation of the Program of Reforming Medical Service in the Odessa Oblast which includes, among its membership, virtually all of the key officials concerned with health policy reform in the Oblast including the team leader of  NASPAA/NISPAcee project, Dr. Alexander Korvetsky, Dean of Public Administration at ORIPA. 

The positive acceptance of outputs of the original project led to the immediate objective to extend it and develop a  comprehensive blueprint that will lead to the establishment of a system of participative, accountable and decentralized decision-making regarding health policy formulation, resource allocation and program implementation for the Odessa Oblast. Its long-term goal is to help improve the quality of the health care received by the Ukrainian people, and the efficiency with which it is delivered to them, by encouraging systems reforms that will make decisions about the allocation of scarce resources more responsive to the real needs of the populace. 

In an expanded project, a process of several steps was proposed.  The first was, in conjunction with and under the guidance of the Coordinating Council, to establish a project team that will be assigned by the Coordinating Council to focus specifically upon the implementation of its key objectives.  The group would review the large number of complex national and Oblast level laws and decrees related to issues of health policy reform in the Ukraine and the Odessa Oblast.  The project team would carry out this activity in a two-step process.  First, all relevant laws and decrees would be reviewed and a single, comprehensive, easy-to-understand document dealing with the overall legislative framework for both the managing and reforming of the Oblast health  care system would be developed and distributed throughout the Oblast. 

At the second step, a four-person project team was proposed. They were to conduct a series of six meetings in different regions of the Oblast with key medical and health personnel and civil society representatives from throughout the Oblast (Professor Rosenbaum being a part of the first two-team visits).  The purpose of these meetings was to discuss with those involved in the actual implementation of Oblast health policy what they perceive to be the key areas needing reform and the best approaches to achieving reform that will encourage decentralized policy-making, improved health system management and greater community involvement in decision-making for that system. 

The first two steps were expected to serve as the basis to produce a set of specific recommendations for reform of the system based both upon its analysis of the legislative and regulatory framework, as well as the information and recommendations obtained through the meetings that were a part of its field visits. Subsequent to the development of these recommendations, two working groups were planned to be established by the Coordinating Council and two 1- or 2-day, workshops were planned at which each of the two working groups will review the proposals put forward by the project team. 

3. Project realization

No major problems occurred during the project realization. The project team actively cooperated with the regional and local government officials. In most aspects, the project implementation went as planned. All team members actively cooperated in the project and fulfilled their roles and responsibilities on time and with quality work.

Some changes were made as regards in the project schedule. To ensure that the findings developed in the Odessa Oblast are highly relevant for the rest of the country, extra comparative research in two other oblasts, Kherson and Mykolaiv, were carried out.

4. Project outputs, outcomes and impacts

            During project implementation, new data was received which characterized the following points:

-          The state of current healthcare laws and regulations guaranteeing management decentralization by medical establishments;

-          The special features of medical establishments in the transition to decentralization;

-          The ideas of managers of health bodies and establishments about approaches to improving health systems according to citizens’ interests in the new environment;

-          The psychological and professional readiness of local powers and health establishments’ management to work within a decentralized framework of medical care;

-          The substance of activities of Oblast health bodies, taking into consideration their influence on regional health policy information and implementation.

This pack of documents, which was submitted to the Health Agency and approved at the two workshop meetings, is now under consideration at the Coordinating Council. As one of outcomes, in accordance with the Order of the Health Board of Odessa Oblast State Administration #187 on April 27, 2004, medical establishments of Odessa Oblast are carrying out the appropriate steps to optimize activities of these establishments.

          The project contributed significantly to Odessa Regional Institute development through:

-          elaborating new methods and approaches to research in the sphere of health management;

-          acquiring new information and data which define modern processes of health management and organization; thus, the faculties  of the Health Management and Valeology Department liberalized their professional knowledge;

-          enhancing and widening contacts with researchers and professionals in the field;

-          using the collected and analyzed information while teaching courses within the MPA program, health management specialization;

-          strengthening links and cooperation with local authorities, NGOs, and self-governments, medical establishments and research institutes and heightening the Institute prestige.

-          students of MPA program (health management) were highly engaged in the investigations and discussions;

-          collected data and information are included in revised teaching materials.

In addition, during project implementation, the Department of Health Management and Valeology, ORIPA, strengthened the scientific and business links with health bodies and establishments. For example, the project investigator and Assistant Professor of the Department of Health Management and Valeology, ORIPA, Akim Litvak, is providing scientific and methodological assistance to the managerial staff of the Oblast Specialized Hospital on the process of conducting self-evaluations of its managerial activities by utilizing those methods developed during the project.

Immediately following the project’s completion, the results were used as a foundation for educational strategy correction at the Department of Health Management and Valeology, ORIPA. The change of strategy is designed to strengthen the preparation of managers for health bodies and establishments, and to provide them the necessary tools which will enable them to work within a democratized health sphere. In addition, the project results are included in teaching materials for the disciplines taught by the faculties of the Department of Health Management and Valeology, ORIPA.

Agreements have been made with two NGOs, the Public Council for Public Health and Face-to-Face. According to the agreements, ORIPA will assist in clarifying the roles of these NGOs in expediting citizen involvement for improving health systems at the local level.

ORIPA and the Coordinating Council of Odessa Oblast State Administration drafted a plan of further mutual activities to make the project results sustainable. Those include:

§          School on (1) approaches to enhance the management and ensure reform of the health sector through the delegation of identified responsibilities and functions from central health authorities to local health departments and medical institutions; and (2) decentralization of management of medical institutions by delegating to them the right to make decisions accounting for their structure, capacity and resource allocations for health managers;

§          Training of skills to analyze managerial decisions fixed in orders for the Health Agency experts;

§          Carrying out analysis of managerial activities in certain rayons of Odessa Oblast.

As another outcome, ORIPA in combination with the Health Board of the Odessa Oblast State Administration is designing a project with the objective of making the current system of organization and management in rural healthcare consistent with the Ukrainian Law on Local Self-Government. Also, the Odessa Oblast State Administration together with ORIPA has developed and submitted an application to the Gateway Development Foundation (USA).  Its aim is to guarantee the educational constituent of e-Government.

Project results include an evaluation of the general problems characteristic of healthcare in the Ukraine. They contain recommendations, most of which can be implemented at the national level. As for foreign countries, the project materials can also be utilized in those countries where up to the present time the main organizational principles of the Soviet health care system are still being applied. This creates considerable potential for large-scale impacts.