SFU Thesis Template Files

Tackling Health Inequities in Rural Ukraine: Evidence Based Approach by Anna Vorobyova M.A. (Political Science), Simon Fraser University, 2009 B.A., National University of Kyiv-Mohyla Academy, 2005 Capstone Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Policy in the School of Public Policy Faculty of Arts and Social Sciences Anna Vorobyova 2014 SIMON FRASER UNIVERSITY Spring 2014 Approval Name: Anna Vorobyova Degree: Master of Public Policy Title of Thesis: Tackling Health Inequities in Rural Ukraine: Evidence Based Approach Examining Committee: Chair: Dominique M. Gross Professor, School of Public Policy, SFU Olena Hankivsky Senior Supervisor Professor Judith Sixsmith Supervisor Professor John Calvert External Examiner Associate Professor Faculty of Health Sciences Date Defended/Approved: March 17, 2014 ii Partial Copyright Licence iii Ethics Statement iv Abstract Ukraine is experiencing an internationally recognized health crisis. Rural residents bear a disproportionate burden of this crisis due to challenging socioeconomic conditions in villages and disintegration of rural health care. Currently, Ukraine is piloting its first major health care reform, focused on changing the health care system from the patient-specialist to the primary care model. The reform has been critiqued for lack of attention to the social determinants of health and insufficient public consultation. Also, little is known from the Ukrainian rural population about their health concerns. This study attempts to bridge this knowledge gap in rural health policy in Ukraine. Fourteen interviews with health professionals and local representatives were conducted to identify the intermediate results of the pilot reform and barriers in accessing primary care in villages. The secondary analysis of five community consultations (funded by the Canadian Institutes of Health Research, PI – Dr. Olena Hankivsky) presents a picture of health concerns in rural Ukraine. Together, these findings inform the final recommendation, which combines community-level health initiatives, the creation of the Rural Health Framework and reviving the profession of a feldsher (analogous to a nurse practitioner) in Ukraine. Keywords: Health care reform; access to primary care; social determinants of health; community-led health initiative; rural Ukraine; feldsher v Dedication To my sons – Bohdan and Nazariy, who inspire me to live out my Ukrainian identity so far from home. vi Acknowledgements This research project would not have been possible without the ongoing encouragement and thoughtful guidance of my senior supervisor, Dr. Olena Hankivsky, who challenged me to exceed my own expectations. I am also grateful to her for sharing the unique data from community consultations and her insights about health inequities, which enriched this writing. I would like to acknowledge Marfa Skoryk, Larysa Populiakh, and Olena Morhun, my NGO collaborators in Ukraine, who assisted me with the recruitment of the research participants for this study. Without their help, this project would not have relied on the same important evidence for developing policy options. The financial support of the Canadian Institute of Ukrainian Studies was much appreciated in the course of writing this capstone project. They considered my research valuable and awarded me with the Marusia and Michael Dorosh Master’s scholarship in the final year of my studies. Also, the SFU Graduate Student Society chose me as a recipient of their travel grant that assisted in conducting the interviews in Ukraine. Finally, a heartfelt thank you goes to my family: my parents in Ukraine who raised me to love my country and who prayed for me to accomplish this project; to my husband who has been always so patient and supportive; and to my family in Canada who helped in so many practical ways during the completion of my degree. vii Table of Contents Approval .......................................................................................................................... ii Partial Copyright Licence................................................................................................ iii Ethics Statement ............................................................................................................ iv Abstract ........................................................................................................................... v Dedication ...................................................................................................................... vi Acknowledgements ........................................................................................................vii Table of Contents .......................................................................................................... viii List of Tables ................................................................................................................... x List of Acronyms ............................................................................................................. xi Executive Summary .......................................................................................................xii Chapter 1. Introduction ............................................................................................... 1 1.1. Policy Problem ....................................................................................................... 3 1.2. Health Care Organization in Ukraine ........................................................................ 4 1.3. Pilot Health Care Reform in Ukraine ......................................................................... 6 1.4. Health Status and Health Care Challenges in Rural Ukraine ................................ 11 1.4.1. Rural Health and Socioeconomic Conditions .............................................. 11 1.4.2. Access to Rural Health Care ....................................................................... 16 1.4.3. Quality of Rural Health Care ....................................................................... 20 Chapter 2. Methodology............................................................................................ 24 2.1. Phone Interviews .................................................................................................. 26 2.2. Recruitment .......................................................................................................... 28 2.3. Rapport Building ................................................................................................... 29 2.4. Data Limitations .................................................................................................... 30 Chapter 3. Data Analysis .......................................................................................... 32 3.1. Thematic Analysis and Application ....................................................................... 32 3.2. Critique of the pilot reform .................................................................................... 34 3.3. Pilot reform as a step in the right direction ............................................................ 37 3.4. Budgetary considerations ..................................................................................... 39 3.5. Community involvement in health care ................................................................. 42 3.6. Rural problems ..................................................................................................... 45 Chapter 4. Policy Objectives and Options ............................................................... 48 4.1. Community Town Hall Meetings ........................................................................... 49 4.2. Rural Health Framework ....................................................................................... 52 4.3. Rural Primary Care Centralization ........................................................................ 56 4.4. Increasing the Numbers of Rural Health Professionals ......................................... 58 4.4.1. Reviving the Feldsher ..................................................................... 59 4.4.2. Motivating Physicians to Work in Rural Areas ................................. 60 viii Chapter 5. Policy Analysis ........................................................................................ 63 5.1. Criteria and Measures .......................................................................................... 63 5.1.1. Acceptability .................................................................................... 63 5.1.2. Effectiveness ................................................................................... 64 5.1.3. Ease of Implementation................................................................... 64 5.1.4. Equity .............................................................................................. 65 Chapter 6. Evaluation of Policy Options .................................................................. 67 6.1. Community Town Hall Meetings ........................................................................... 68 6.1.1. Effectiveness ............................................................................................ 68 6.1.2. Ease of Implementation ............................................................................ 68 6.1.3. Acceptability .............................................................................................. 69 6.1.4. Equity .......................................................................................................

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