This document summarizes a study exploring pathways to equity in health reform in Ukraine. It describes Ukraine's population health crisis, with life expectancy over 9 years lower than EU countries and a 10+ year gap between males and females. The study conducted a survey and 21 community consultations across Ukraine to understand health inequities. It found that low SES women reported the worst health. Financial barriers, distrust in doctors, and lack of infrastructure negatively impact health. Participants called for increased healthcare funding and prevention to address social determinants of declining population health.

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. COMMUNITY CONSULTATIONS

10. COMMUNITY CONSULTATIONS

11. COMMUNITY CONSULTATIONS

12. COMMUNITY CONSULTATIONS

13. 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

14. 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

15. QUALITY OF LIFE: DETERMINANTS
KEY FACTORS:
• Environment
• Political Instability
• Economic Hardship
• Geography: Rural/Urban divide

16. 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)

17. 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)

18. 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

19. 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