ADOPTION OF THE GOVERNMENTAL AFFORDABLE MEDICINES PROGRAMME BY UKRAINIANS

Adoption of the governmental affordable medicines programme by ukrainians. Shevchenko M.V., Yurochko T.P., Skrypnikova O.S. Ensuring that the local population has access to medicines is one of the functions of a modern democratic state and an important element of social policy. The question of the affordability of medicines to the public is extremely important. This is also due to the fact that, unlike in European countries, Ukraine did not have a system of medicines reimbursement. To date, the reimbursement Affordable Medicines Programme has been in effect since April 2017 and is applicable to patients with cardiovascular disease, bronchial asthma, and type II diabetes. In total, 258 medicines are included in the Programme, 64 of which can be obtained free of charge and the others with a small extra payment. The respondents' perceptions of the Programme were conducted through a secondary analysis based on the third wave of the «Health Index. Ukraine» which was held in 2018 by the International Renaissance Foundation, the School of Public Health of the National University of Kyiv Mohyla Academy, and the Kyiv International Institute of Sociology. This study aims to present the results of the research of the attitude of Ukrainians to the government Affordable Medicines Programme and their perception of its implementation. The total number of respondents to this survey totaled more than 10,000 household representatives. The results of the research indicate a positive assessment of the respondents who participated in the survey «Health Index. Ukraine» (76% in 2018), which is confirmed by other research of the Kyiv International Institute of Sociology (63% in 2019) and by international experts. The results of the survey do not allow us to draw any official conclusions about the impact of the Programme on the health of Ukrainians, but during the interview 60.6% of the respondents said that the Programme «helped improve health»; in addition, positive changes in health were indicated by the most financially vulnerable categories of the population. It is also noted that 80–82% of prescriptions were reimbursed to Programme participants. Реферат. Сприйняття українцями урядової програми «Доступні ліки». Шевченко М.В., Юрочко Т.П., Скрипнікова О.С. Забезпечення доступу місцевого населення до лікарських засобів є однією з функцій сучасної демократичної держави та важливим елементом соціальної політики. Питання доступності лікарських засобів для населення залишається надзвичайно важливим. Це також пов’язано з тим, що, на відміну від європейських країн, в Україні не було системи відшкодування лікарських засобів. На сьогодні Програма «Доступні ліки» діє з квітня 2017 року і застосовується для пацієнтів із серцево-судинними захворюваннями, бронхіальною астмою та діабетом II типу. Загалом до Програми включено 258 лікарських засобів, 64 з яких можна отримати безкоштовно, а інші з невеликою доплатою. Сприйняття респондентами Програми проводилось за допомогою вторинного аналізу даних третьої хвилі загальнонаціонального опитування «Індекс здоров’я. Україна», яку провели у 2018 р. Міжнародний фонд «Відродження», Школа громадського здоров’я Національного університету «КиєвоМогилянська академія» та Київський міжнародний інститут соціології. Це дослідження має на меті представити результати вивчення ставлення українців до урядової програми. Загальна кількість респондентів цього опитування становила понад 10 тисяч представників домогосподарств. Результати дослідження свідчать про позитивну оцінку респондентів, які брали участь в опитуванні (76% у 2018 році), що підтверджується іншими дослідженнями, зокрема Київського міжнародного інституту соціології та міжнародними експертами. Результати опитування не дозволяють зробити жодних офіційних висновків щодо впливу Програми на здоров'я українців, проте під час інтерв'ю 60,6% респондентів указали, що Програма «допомогла покращити здоров'я»; окрім того, позитивні зміни в здоров’ї зазначили найбільш фінансово незахищені категорії населення. Також зазначається, що вартість 80-82% виписаних рецептів було відшкодовано учасникам Програми.

The European experience in the construction of reimbursement systems testifies to their functioning, taking into account a number of specific principles of medicine price regulation: direct control over the costs of pharmaceutical market participants, price regulation, and control over profits. A significant step in increasing the availability of medicines to the public can only be done if a cost-effective mechanism of reimbursement of their value is developed and implemented in parallel with government regulation of their prices and proper control over these processes [10,12].
The affordability of medicines to the population in both the hospital and retail segments of the pharmaceutical market is extremely important, as «approximately 600,000 households suffer catastrophic health care costs every year in Ukraine» [1]. This is also due to the fact that, unlike in European countries, Ukraine did not have a system of medicines reimbursement [10, 12, с. 11 ].
In 2012-2013, the Government and the Ministry of Health of Ukraine launched a pilot project on the introduction of state regulation of the prices of medicines for the treatment of persons with hypertension [6]. However, the pilot project did not show significant positive results for a variety of reasons [3].
To date, the Reimbursement Programme for Medicines -the Affordable Medicines Programme (AMP) -has been renewed in a slightly different format since April 2017 and applies to patients with cardiovascular disease, bronchial asthma, and type II diabetes. According to analysts, the implementation of the Programme has led to an increase in consumption of medicines, the cost of which is fully or partially reimbursed by the state while reducing their weighted average cost [7,9]. Also, WHO experts [12] generally evaluate this Programme positively.
Ongoing monitoring and, in particular, the evaluation of this Programme by consumers is extremely relevant, especially in terms of the experience of consuming medicines under this Programme, monitoring the effectiveness of its implementation, which will improve the level of financial availability of medicines it provides for the population.

MATERIALS AND METHODS OF RESEARCH
This research aims to present the results of the survey of the attitude of Ukrainians to the govern-ment Affordable Medicines Programme and perception of its implementation. The respondents' perceptions of the Programme were conducted through a secondary analysis based on the third wave of the longitudinal quantitative empirical study «Health Index. Ukraine» that was held in 2018 by the International Renaissance Foundation, the School of Public Health of the National University of Kyiv Mohyla Academy, and the Kyiv International Institute of Sociology (КІІS). The sample is random, multistage, and representative for the adult population of Ukraine (18 years and older), as well as for each oblast and Kyiv. The theoretical sampling error for the array as a whole does not exceed 1.0%. At the first stage of sampling within each oblast, settlements were randomly selected in proportion to the number of inhabitants. The second stage involved the random selection of polling stations in the territories of the selected settlements. In each of the selected stations, streets, houses, and apartments were randomly selected. The final stage was the selection of the respondent within the household and the direct survey through an individual in-person interview (the questionnaire contained mostly closed questions). The obtained data were compared with the estimated data of the State Statistics Service of Ukraine on the share of individual sex-age groups in the structure of the population of Ukraine (as of 01.01.2017). The field phase of the study was conducted by KIIS in collaboration with the Center for "Social indicators" from June to July 2018 [8, p. 6].
The total number of respondents to this survey totaled more than 10,000 household representatives. In 2018, 787, or 18.7% of outpatient respondents indicated that they had received medicines on the Programme. Since the research was conducted on a multistage sample, random at each stage of the selection, it makes possible to assert the representativeness of the obtained data [8].
It should be noted that in 2018 there were some changes in the format of the questionnaire in order to clarify the individual parameters and tools of the Programme implementation, as well as to evaluate the Programme and self-assessment of health of its participants. Therefore, in connection with «changes in questions placement in the questionnaire that may have some impact on the results of the research, namely the frequency of response distribution» [8, p. 102], data for 2018 were used in the analysis. 20/ Том XXV / 2 Among all respondents (787), 20.1% are men, 79.9% are women (tab. 1). Almost 68% of the respondents are aged 60 and over. Two thirds of respondents who indicated that they had participated in the Programme reside in urban areas (61.8%), and one third (38.2%) lives in rural areas. Most respondents have either general education (25.5%) or incomplete secondary or secondary education (30%). Almost half of the respondents rate their health status as mediocre. The characteristics of respondents to the Programme are somewhat different among outpatient care users. In particular, regarding selfassessment of health: the overwhelming majority of respondents to the outpatient care programme assessed their health as poor (40.4%) and very poor (35.9%). На умовах ліцензії CC BY 4.0

RESULTS AND DISCUSSION
According to the analysis, 7.7% (787 out of 3301) of respondents who indicated that they had consumed medical care in the last year had experience of receiving medication under the Programme. According to other studies, 28% of those surveyed (in October 2018 -19%) said they personally or their close relatives (spouse, children, grandparents, siblings, etc.) participated in the Affordable Medicines Programme [4]. According to КІІS [2, p. 7], 18.8% of respondents said that they personally or their close relatives participate in the Programme.
«Health Index. Ukraine» data indicates that there were 21% of women in the Programme in 2018 and 14% of men, the age of respondents -36% of 60 and over and 18% of 45-59 years. According to KIIS [2], 27% of respondents of age 60 and over reported participating in this government Programme.
Also, 27% of respondents with incomplete general secondary education, 23% of respondents with complete general secondary education, and 20% of respondents with vocational education indicated participation in the Programme. In addition, more Programme consumers are among those who rate their health status as bad (40% rate as «very bad», 36% rate as «bad», and 19% rate as «mediocre»). Consumers of the Programme are almost equally represented among urban and rural residents (18% and 19%, respectively) [8, p. 102]. Moreover, 86% of those who had experience in the Programme received free or co-pay medicines for the treatment of cardiovascular disease, type II diabetes, and bronchial asthma by prescription. Overall, 86% (677) of Programme participants used it on the suggestion of a primary care physician. And this pattern is typical for all categories of respondents, regardless of gender, age, type of settlement, and income (tab. 2).
According to the Ministry of Health of Ukraine [9], «258 medicines are included in the Programme, 64 of them are free for patients, others -with a small additional cost. The cheapest medicine, which is 100% reimbursed by the state, costs 4.76 UAH, the most expensive -898.22 UAH».
The results indicate that outpatient care users noted an increase in the availability of medicines (63%) and improved health (61%) [8, p. 106-107]. Men more positively evaluated the availability of medicines than women (68.6% and 60.2%, respectively). Responses about improving health were virtually indistinguishable between men and women (60.2% and 60.7%, respectively). Respondents in the age group 60 years and over (61.3%) gave a positive assessment of the Programme in terms of improving financial accessibility (62.3%) and their own health status (61.5%). Respondents aged 30-44 years (74.4%) gave the highest rating for the availability of medicines included in the Programme, although improvements in health status were noted by only 50.3% of respondents of this age category.
In general, 62.2% of respondents living in urban settlements indicated a positive assessment of the financial accessibility of the Programme, and 60.7% of respondents indicated that they were improving their health. Of the rural residents, 63.2% indicated a positive assessment of the financial availability of the Programme and 60.3% indicated a health improvement. Respondents with a household income level of up to 1,000 UAH and those who rated their health status as «bad» (69.6%) gave a more positive assessment of the availability of medicines in the Programme. Significant differences in respondents' perceptions of changes in the affordability of medicines and improved health through the Programme among respondents living in urban and rural areas were not identified.
Quite a similar assessment of the success of the Programme was obtained by a questionnaire of researchers of the KIIS [2]. 63% of respondents said that they considered the Affordable Medicines Programme successful.
This assessment is the same as the Programme's evaluation by physicians. In particular, according to WHO experts, «physicians who prescribe medicines reported a high level of satisfaction with the Programme, as they noted improved patient access to medicines. Over 8 million Ukrainian citizens have used the Programme during its implementation» [11, p. 23]. The results of the questionnaire indicate that mostly male (53%), respondents aged 60 and over (47%) received free medicines under the Affordable Medicines Programme. Female respondents should have paid extra (56%) for medicines, respondents aged 45-59 years (59%) should have done the same. There is no correlation between the place of settlement (urban or rural) and the availability of medicines for free or at an extra payment. 69% of respondents with «very poor», 50% with «poor», and 57% with «mediocre» health status indicated that they received medicines by extra payment.
WHO experts indicate that «as of September 2018, most of the medicines dispensed under the Programme were fully reimbursed or covered by less than 20% extra payment. For the patient participating in the Programme, the annual amount of surcharges decreased by 1020 UAH (32 euros) compared to the period before the launch of the Affordable Medicines Programme» [11, p. 29]. According to the KIIS questionnaire [2], among those who receive medicines within the Programme, there 20/ Том XXV / 2 is an increase in the level of satisfaction with the quality of medicines. Thus, 66% of respondents are satisfied with the quality of medicines, 57.8% -with their availability in pharmacies, and 60% -with the territorial availability of pharmacies.
Despite the overwhelmingly positive perception of the government program by Ukrainians, problems with universal access to medicines remain. They are complex and interconnected, also require solutions at the national level because fragmented solutions are ineffective. Therefore, in order to improve the affordability of medicines for Ukrainians, it is necessary to have some tools to monitor and evaluate decisions that were made. Such tool could be the National survey «Health Index.Ukraine» because it is a longitudinal (repeatable) tracking of changes over time.