European Network of Health Care Chaplaincy
Establishment and development of
palliative care in Ukraine
A glimpse of the health situation in Ukraine today
The population of Ukraine is about 47,000,000. Kyiv, with its 4,000,000
inhabitants, is a powerful pole of attraction for the population of the
surrounding countryside, who flock into the city in search of work. The
weakening of the Ukrainian social fabric – broken families, large numbers of
street children (about 200,000 in the country as a whole), and the loss of
bearings following the collapse of the Soviet régime – is particularly
visible in Kiev. Ukrainians are trapped in ambivalent feelings, where
nostalgia for the stability of the Soviet regime conflicts with dislike for
the so-called “Soviet” mentality that has left its mark on officialdom,
hospitals and medical practitioners. Omnipresent advertising has replaced
the propaganda of the past: posters and video screens in public transport
and in the street show a lifestyle and a standard of living that is
inaccessible to the average Ukrainian. The official language is Ukrainian,
but both in private and in official meetings, Russian is just as likely to
be used.
The health situation is catastrophic: at present the country is in the grip
of a tuberculosis epidemic, and the AIDS epidemic is one of the worst in
Europe. A major programme to help drug addicts is under way, implemented by
the French Red Cross. According to the WHO, the volume of internet purchases
of counterfeit pharmaceuticals in Ukraine is considerable. Public
advertising of pharmaceuticals is widespread. Statistics are scarce, and
what is available is unreliable. Public health institutions lack adequate
budgets for the financing of internal documentation, let alone information
campaigns to target the public. In fact, most public health information is
published by charities or NGOs.
In Ukraine, 98% of hospitals are public institutions. The health service
collapsed along with the Soviet regime. There are about 100 public hospitals
in Kiev. The maximum stay tends to be two weeks. Hospitals do not try to
keep patients in – on the contrary, they do their best to get rid of them
according to a Professor of the medical academy who claims not to know where
people die: at home? somewhere else? One of the preoccupations of the NGO
All-Ukrainian Council for Patients’ Rights and Security is the control of
nosocomial (hospital acquired) infection. During my stay, it was announced
on television that there had been no hospital deaths for five years. This
was apparently part of an effort by the authorities to allay people's fear
of going into hospital. One of the doctors in charge of implementing
palliative care remarked: “We are not able to give our patients the means to
survive; the least we could do is to give them decent conditions for dying.”
There are approximately 20 palliative care insitutions and 422 palliative
care beds in Ukraine. A pilot project is under way in Kharkiv. There is no
adequate access to morphine and it is available just in one form –
injections. Indeed the collapse of the Soviet régime has led to a legal
vacuum in health matters, especially in the field of palliative care.
Hospice staff have not yet acquired the palliative care mind-set, or rather
philosophy. Although some palliative care professionals have been trained
abroad, hospices are still just places to die. According to one Orthodox
theologian patients are still subject to a Soviet approach to medical
practice, where they are regarded as passive rather than active. This is one
of the major issues for the NGO (All-Ukrainian Council for Patients’ Rights
and Security) which is seeking to establish an approach to palliative care
and a hospice philosophy where the patient is an active partner.
The Pan-Ukrainian Council for patient rights and safety
The Pan-Ukrainian Council for patient rights and safety is an NGO with two
main objectives: to improve the rights and safety of patients in Ukraine and
to develop and establish a palliative care programme. The Council would like
to reform the public health service, introduce a comprehensive view of
public health, and persuade the authorities and legislators to modernise the
relevant legislation. Under a Ministerial Order of 6 July 2006, the Council
is officially responsible for establishing palliative care.
The status of the Churches
The Ukrainian constitution clearly stipulates the separation of Church and
State. It is not always easy to obtain authorisations for the Churches'
work. Because of the administrative problems posed by ecumenical projects,
each Church pursues its own deaconry programme. Relationships between State
and Church are of judicial order. Political instability does not make the
work of deaconry bodies any easier. It is difficult to obtain authorisation
for projects put forward by Church foundations. (A distinction is made that
is possibly comparable to that made in France between associations governed
by the 1905 Act on the one hand and the 1901 Act on the other). Churches can
collaborate on logistics and financial matters. For example, the deaconry of
the Orthodox Church has the legal status of Charity Foundation and therefore
is considered non ecumenical. This status gives it some margin for manoeuvre
and in reality it is an inter-Church programme. It is important to remember
that the Churches have been growing for only about fifteen years. There is
some competition, but also attempts at cooperation. But the term
“ecumenical” is shunned, as its connotations are too theological, both for
the authorities and for the Church representatives.
The role of the hospital chaplain in Ukraine
The role of chaplain in Ukrainian hospitals is very traditional, and may
even be a mere formality. Frequently, a parish and a chapel will be
associated with a public hospital. The chaplain is usually appointed as a
function of affinities between the priest and the hospital director,
regardless of denomination. Chaplains are unpaid. There are no legal
provisions governing patients' rights to spiritual or religious support.
The Ukrainian doctors who are members of the NGO (Pan-Ukrainian Council for
patients’ rights and safety) have quite a different vision. They expect a
chaplain to be trained, capable of working in an interdisciplinary situation
and attentive to respect for patients' rights.
Conclusions
One of the present aims of the NGO (Pan-Ukrainian Council for patient rights
and safety) is to elaborate guidelines and hospital documents for palliative
care that could then be applied to other areas of hospital practice. They
are also interested in setting up training programs for doctors and other
hospital professionals as well as for hospital chaplains.
We are hoping for a French – Polish –Ukrainian cooperation in these
different areas.
Anne Miller-Lauprete
22 August 2007