M Yabluchansky - The adviser's theme - страница 1

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THE ADVISOR THEME FANTASIES

(The beta-version)

To Ex-Minister from Ex-Adviser

The fantasies. On the advisor theme. The real and made-up experiences. With a practical goal. To support the administrative reform. Of the Central Executive Organs too. With the aim to improve standards of ordinary Ukrainians lives. Obligatory to improve life of Ukrainian officials. In order it to be with dignity - as they deserve.

CONTENT

Not to be put aside Entry Sources

Look from below The ministry The ministry board Know-how

The informational letter To take of control

Mud

All the misfortunes in bad management

The National seminar

I should apologize

The World Bank

Tuberculosis and AIDS

I love you, Eliot

The new

Verchovna Rada

Need for conception

About transitional processes: optimal ones and others

One hundred days

Separated?

Look from above

My report

Dismissal

Afterward

Not to be put aside

We are living only once. At least in this life. I don't know about the others, but as for me - I feel life's rhythm intensively. And this feeling is heightening day after day. Because above all is willingness to lose as little time as possible, the desire to have time do a little more.

I do not know exactly who had turned on this chronometer. My Medical School old physiology professor probably. It was quite a long time ago, during my student years, when I was second year student...

Remember that warm and tender spring morning. While I was running from one school building to another I suddenly met the grey-haired professor in his well known black with wide brims hat whose long-long slightly stoop figure gravely approached to me: "How is your dying going?"

- ???

But, the old man was right. With every passed day less and less days left____So, how is my dying?

That spring morning, the school path and the professor had been engraved on my heart forever.

Since that time my chronometer is turned on. It is rigorous and painfully frank chronometer. "We are not living, we are dying" And with every other day we have less and less time left. Thus, one has to harry up.

Yes, I am harrying up.

The first thought that I will have the possibility to write this book and should do this came with the first proposal to become the advisor of Health Minister.

I accepted the proposal. That appeared possibility to write and publish

this book played important role in my decision.

***

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Almost a month has passed since I am not Ministerial Adviser any

more. Minister had gone and the Adviser followed her.

***

For somebody else this time may be not the best time to cool down, to receive the right for soberly and comprehensively appraising all I have gone through. To promulgate that experience. Because the true experience is always important.

Now I recall me being in the Ministry as something happened a long-long time ago. This is because of the fact that after nine months as an adviser, I have completely returned to "normal" everyday university activities. This university life is restless, but that makes it attractive, interesting, because this life reflects interests of students, departments, the faculty, and the whole university.

That happened the day before yesterday. Without any visible reason. That day in the morning I visited the faculty, then went to the hospital. While on the midway to hospital I "saw" the book, all from the very beginning to the end.

As soon as I had seen the book I understood that I should "put" it on paper. And not to be put aside".

05.02.2000 Author

Entry

The process of become an adviser was very easy. I received a proposal, thought it through, and consulted about it. The Head of the University supported me. Give his consent to my transfer to the Ministry. So I was transferred and officially admitted as councilor.

We are in the Ministry study. The two new advisors. Later we ave worked together. Many ideas in this book were chosen from our mutual efforts.

- So what, guys, we need to work in such a way, that_

- Our intentions are very serious.

The main orientations were received. The conflict with "the view from below" was avoided. That created the basis for the future fruitful work in the Ministry. It is impossible for me to work in other way.

But I am not completely sincere when completely denying the conflict. The "slippery" point was connected with me being the head of a medical faculty in a classical university. The educational sector. It means a foreigner. But at the same time a doctor too. It was always a question in the health ministry about the place of medical education. Where should it belong? To the educational sector or to the of health care? Since a very long time my principal attitude to that problem is that medical education should belong to the ministry of education. I suppose this may help to overcome the conflict of interests between the educational and practical medicine sectors and turn the number of future doctors to be estimated by the needs of practical medicine.

This topic is the favorite for our ministry's sarcasm. That's why I tried not to raise this question by myself.

However somewhere in the depth of my soul I believe that this attitude of mine in some circumstances prevented my Lady- Patron from accepting the right (as I see now) advises. I suspect, she was reminded. Who her adviser was.

It is my fault that I failed to close this topic.

On the last working day my Minister was absolutely frank. I believe, that was not the last working day for my Lady - Patron. I'm sure of her fruitful future. The world is nonlinear. Especially today, when the whole country is a strange attractor. The next step will be ours.

Sources

I didn't plan to work at the Ministry. Though I am acquainted with the Ministry work as a work of sector quite well.

After graduation from the Donetsk Medical School I worked as a Deputy Director on Science Issues in the Ukrainian National Research Institution of Internal Medicine and in the Kharkiv Research Institution of Microbiology and Immunology for a period of five years in each place. This means that I will be pretty acquainted with the Ministry and its subordinate's environment.

For the last eight years I was working as a Dean of Fundamental Medicine Faculty in Karazin Kharkiv National University.

I was glad to take part in re-establishment of the classical universities right to train medical students, the right that was taken away by the Bolsheviks a long time ago. It was an honor for me becouse after Donezk Medical Institute I studied in the Department of Mathematics and Mechanics in the very University. My decision was supported by my Kharkiv teachers and by world-famous scientists and doctors as well.

Working as a Dean appeared not to be easy. It cost me a lot of blood. And it is understandable why. It was an encroachment to the monopoly. In order to defend the aim of including the medical education in the educational sector I approached the media. My articles were published in the "Medical Newspaper of Ukraine", "Mirror Weekly ", "Governmental Courier" and other newspapers. Three of these publications from "Mirror Weekly " are included in this book. These articles are interesting. They were published before the decision to be the Minister's Advisor was made. Published several years ago, those articles are still topical.

Two years ago we came to graduation of our first group of doctors, doctors that were trained in our very classical university. The problem we

were faced to was minimal. To get permission from the Health Ministry for our graduates to work as doctors. "Dislove" of the "First"[1] was expressed in delaying of the permission. We were pressed by the timeframe of the undergraduate course. We had to hurry...

Good occasion, the "First" is on vacations, and my Minister, at that time the Deputy Minister, performed the Minister duties. The meeting was set up.

It's nice to remember. The waiting - room was crowded but I was the first one to come in the study.

- What is a problem?

- It's not a problem... We just need a letter...

- I will help.

She called somewhere: "... will visit you, please help". Then to me: "No, they will not help". Then she called again: "I need you in my office".

Another replica: "For more reliability I will ask them to go with you".

***

She did not know that her prediction was correct. The letter was not ready. It was prepared much later. Signed it was, as appropriate, by the "First", as usually in the bureaucratic sphere. The nonwritten rule of the national bureaucrat.

***

I was glad to have my first publicist experiences in the approached to reform the sector and the meeting with the future Minister. These were the entrances in the position of the Advisor. If I didn't have them, I would not be ready to accept the offer, which appeared to be interesting and very useful.

I did not ask for that position. I did not predict that in a half a year, I would be in those shoes. For advisor is the governmental employee. Even thought his rank isn't too high.

View from below

It is now the right time to introduce the respectful reader with my understanding of the sector's problems and the ways to solve them. The understanding that I had three years ago, the time that seems to be far away from me nowadays. When I did not know that I would be in the Ministry and even on the Advisors position. Those thoughts of mine are well reflected in the article "Exit is one - to cut, or the ambitions for the cool position in the shadow Cabinet", which was published in "Mirror Weekly " ("Zekralo Nedeli", 1997, # 27 (143)).

I am making only a small edition of that article in order to make it mach the book. The epigraph taken from Bukmullin "That absolutely dispassionateness can be only the piece of the metal" reflects the authors feelings related to the raised topic.

So, here is the article.

Country is in difficult economic situation. Health Care too. It does not require many words. The media uncovers its bad condition. By "Mirror Weekly "("Zerkalo Nedeli", 1997, #10 (127)). Article # 46[2] of The Ukrainian Constitution was buried. Looks like now the Health Care will be in the same condition. Mr. A. Mostipan with the sharpness of Nostrodomus predicted ongoing processes in his article "Medicine of Ukraine today and tomorrow" ("Medytsyna Ukrainy"[3], 1996, #3).

That period had proved that nobody listened to the predictions. There was a lot of talking about reforms. But in reality they are absent.

Having an understanding that alternative programs are needed and supporting the idea of the Shadow Cabinet of the Ministers (SCM), I have enough courage to nominee myself on the position of the Health Minister (HM) in the Shadow Cabinet of Ministers.

Today this branch and the Health Minister are practically managing the Health Care, medical education and medical science. So it would be appropriate consider the reforms in all these directions.

1.     Reform of the practical Health Care

Existing system of the practical Health Care is weak: too big, low effectiveness, high cost. The level of the medical help in the whole state sector, excluding several centers, is somewhere in the middle of the century. But the most important thing is failing of the existing system to overcome the limited governmental financial support often only promised but usually not reaching the practical medical institutions. Let us imagine the situation. When the value of financial support of the sector in the whole country is 54% of the one needed. But, this planned sum is restricted in the real life and only half of it is actually provided. All this accelerates only the process of Health Care sector degradation. There are rumors about its complete crash forthcoming. For example, let us look how the institutions of emergency medicine work. Very often the emergency doctors do not have even the most simple medications to help their patients.

To overcome the stagnation in the sector of Health Care one should use the radical for 100% "surgical" actions. Today we do not have any time for reflections. The time of profound restructurization has come. The way to solve the problem is not in restricting the state Health Care network but in stimulating the non-governmental or private sectors of Medical Care. I believe that in today's reality one should concentrate on the existing state system of Medical Care and on the half of the promised financial support. For this can't be enough for completely solving the problem it can show that some positive changes are possible.

There is urgent need for priorities. First of all, the fundamental rebuilding of the hospital-based medical care. This care should be concentrated exclusively on the urgent "beds" such as surgical, obstetrical, infectious diseases. For so called somatic patients, the "beds" for them should be settled only in case of critical state. The restricted number of hospital beds should be served by highly qualified personal with high moral principals and very serious attitude to the work. The departments should be highly specialized. For their work the personal should receive appropriate reward. Let us analyze situation: in the West countries the ordinary surgeon operates around 1000 times a year, while in our country the ordinary surgeon performs less then 200 operations a year. This is possible because there are more than enough surgeons in our country. Among them are good and not very good ones.

From my point of view the necessary number of hospital beds is around 20% of those existing today. Even more, there is a popular system in

Ukraine of so-called daytime hospitals and daytime care in outpatient institutions. Without any doubts, a great part of these beds is devoted to fulfill social functions. But one should remember that social-functioning beds have different goals and should be transferred to specialized institutions. This will be cheaper than to manage them by ourselves.

The emergency medicine should be reviewed. It is very expensive to have physicians and even nurses in the ambulance teams. The functions of such teams should be fulfilled by other structures such as police or firefighters institutions like it is in Western countries.

The existing outpatient medical care should be rebuilt. As an alternative one may propose the family medicine. But this health care institution should be functioning on different organization principles. Otherwise, there will be nothing else, but profanation again.

Today in the big cities the institutions of private medicine are in the process of being established. In Kyiv and Kharkiv, for example, the home-based medical care and private first aid care are quite successfully functioning. One can't say that these services are completely inaccessible for people with low incomes. In the competition world the costs for this private services are going to become lower. I want to believe that the depression economic will not stay forever. Besides, the low-income part of the population may be received medical care through the system of green cards. For the state today can pay only for some restricted needs of medical care.

Medical care in our country is delivered also by means of the Special Administrations Sector. Different departments created these medical institutions to achieve there special goals. This system does not have to be treated as an anachronism for it exists also in other well-developed countries. It was created in our country in a quite a long time ago before the Bolsheviks came to power.

I would not be rising up this problem with Administrative Medicine, if there were no attempts to "gulp it" completely. As usual there are some exclusions. But, in general, the question with Administrative Medicine should be solved within administration itself. The administration should "survive" and take care of its medicine services.

Quite important problem is with the pharmaceutical industry and other services. I think that the advent of rich medical market has many advantages. The demonopolization of the medical market will push-out lower quality products and low the prices. If one central institution will manage both the medical market and the whole system of health care then very soon everywhere throughout the country one will be able to find no more then one or two medical products.

The question about the place of medical insurance is being discussed intensively now. Some are looking forward it. Want the medical insurance to be established exclusively in the state health care sector. But that experience we just have survived. The bureaucrat will "swallow" the money and the ordinary Ukrainian will not find even trace of it. In fact, the system of medical insurance should be controlled by the state institutions and may completely belong to state. But the ordinary citizen need to have a chance to decide whether the insurance money go to state or to private hospital? If insurance money is not enough for private hospital care but one wants to be treated in the private facility then one should add money to cover extra expenses. If there is no additional money, one may be treated in state medical facility, where treatment is cheaper. Nobody but the patient have the right to decide where to be treated.

The process of rebuilding the health care system undoubtedly will negatively reflect on the medical personal. But, from other point, avoiding radical changes will lead to complete and irreversible stagnation and total crash of medical care service. Moreover, medical personal suffers a lot from payment delays and very low estimation of their work. The motivation to work was lost by many. Many medical workers just wait for appropriate moment to leave medicine. Many have already found the new sources of incomes, not connected with medicine. This aspect is very painful, but should be discussed and solved.

The restructurization of practical health care system will vacate the main funds, first of all the large buildings and it's surroundings. And this potentially free buildings and territories are located usually in the best places in our cities and transport lines. It should be wise to sell these free facilities through the stock and afterwards use the money for the needs of the health care system.

As we may see, my project of rebuilding the practical health care system doesn't go against to the Constitution. The declared free of charge medical care, necessary for life is, thus, guaranteed. And it is going to be much better, than what we have today. After reconstruction of practical health care system financing by means of the government can solve its main problems. If reconstruction of the practical health care system will be delayed, the cumbersome monster of practical medicine will devour itself and other state departments. It is clear, that crash of this system will be catastrophic for all the country.

In case of me becoming a Minister in the Shadow Cabinet of Ministers I consider my first step as the urgent, profound reconstruction of practical health care system.

2. Reform of the medical education

All over so-called "civilized" world the medical education is delivered by the system of universities, which in our country is known as classical. This name covers the best part of universities and should not be applied to the number of institutions, those are also called the universities, but have a much lower level of education. The classical universities are managed by the Ministry of Education. But, that is O.K. In this country the medical departments were separated from the universities and left on the budget of the Health Care Ministry. That happened a long time ago in 20-years of the XX century when the Soviet rule came to power. As a result our people do not trust our doctors, at least many of them.

The problem of medical education as any other education should be solved. The methods should be democratic. If there is overproduction of physicians the state demand has to be restricted or even ceased for some time. The future doctor will have to be trained and educated mainly not for the state money. And the state will even get the revenue from the medical education.

Removal of state demand of physicians will lead to real decrease of recruitment in the most medical universities. For example, the recruitment may be decreased up to 100 persons a year. With such low enlistment of students many universities may not survive financially. The only way for

them to overcome the difficulties is to cooperate with classical universities or to become their departments.

If you can't imagine yourself how such medical department within the classical university works, than you are welcome to visit our university. We don't have more then 60 students a year. The state demand for them is 20 doctors a year. The mathematics is taught by a professor of mechanical-mathematical university department, physics by the professor of university department of physics, chemistry by the professor of university chemistry department, the foreign languages by the professor of university department of foreign languages, biology by the professor of university department of biology. Only medical sciences, the pure medicine are taught by doctors. A student in such a university appears to be in a "multicolored" atmosphere. A student has possibilities to visit the elective courses at his own desire. While a medical student, he or she may be student of other departments of the same or other university. For the state budget such a system of medical education is one hundred percent economically profitable. Today in USA, for example, around 150 medical schools in 150 universities are functioning in such way.

In Ukraine an anachronism exists not only with graduate, but also with postgraduate medical education. In Western countries the postgraduate education is the responsibility of social institutions but not the state ones as in this country. If you want to be certified as a family doctor, you should pass exams, for instance, proposed by the Canada College of Family Medicine. If you want to be a cardiologist (while you are in USA), you should pass the appropriate examinations, provided by American College of Cardiology. These institutions are so called social institutions and these Colleges will really take care about the image of future physicians.

- Why such system of postgraduate medical education is profitable for the state?

- Because, the state is not responsible any more for this education and should not support it financially. Moreover, the state may receive the taxes from these institutions, thus be at an advantage.

For the Health Ministry it is unnatural to be responsible for medical education because of the so-called interests conflict: the Ministry itself have to order some standards of education and have to control it.

On the first day of my work as a Health Minister (let us imagine it) I will pass the responsibilities of medical education from the Health Ministry to the functioning Ministry of Education.

3. Reform of the medical science

The situation with medical science is quite simple. I agree with Amosov and Zerbino, when they say that in this country the performance of medical science was never good. At least since 1917. Of course there were great scientists and they exist now. To have great scientists does not mean to have great science. Medical science today is in such a bad condition than it is better not to start analyzing it. Almost in all scientific branches the delay seems to be forever: in medical biochemistry, genetics, immunology, transplantation science and many - many others. The best diagnostic and research equipment does not reach even exhibitions: too expensive for this country to buy. With a lot of difficulties our institutions manage to buy second-hand research equipment. Even new immune diagnostic instrumentation can be bought with great efforts.

The most unpleasant thing in this situation is the fact, that the Ministry of Health order itself the goals of medical science and estimates the achievement of those goals. The situation is similar to the one in medical education field. That's why we always have the same questions to discuss, the same persons, the same results. However, it is not clear, why we talk about some kind of achievements in this field, while in practical medicine there is total stagnation.

So, what to do? The decision is quite simple: to pass the medical science to the Ministry of Science. The Ministry of Health will concentrate only on the problems of health care, it's main goals of activity. Due to that reform the medical science will be "ordered" by Ministry of Health, but fulfilled by other ministry. Thus, the Ministry of Health may demand the results of its work seriously: "What did you, guys from the Ministry of Science, give us?"

The Medical Research Scientific Institutions should be managed by the Ministry of Health. These institutions should receive the appropriate financing support from this Ministry. Scientists from these institutions

should compete for financial grants. The grants have to be different and given in accordance to scientific results.

The problem exists with Ukrainian Academy of Medical Science. In whole "civilized" world such Academies are social not state-managed institutions. One should pay for the membership. In this country the situation is quite opposite. At the time of the USSR, there were just two state systems of Academies in the whole world, one in the USSR and the other in Spain. With the default of USSR the amount of Academies increased. But even more independent states were formed. As soon as the status of Medical Academy changes and the new Academy will not be dependent on the state financing, I will stand for its member. Otherwise I can't perceive it as the Academy of Medical Sciences.

If I am the Health Ministry, I will refuse to manage medical science and will concentrate exclusively on the practical health care. Real relief!

4. Health Care management

Thus, Health Care management was discussed quite in detail. To manage Health care is easy: just to stop the unusual functions and concentrate on the problems of health care. There are more than enough problems.

I see the main goal of the Health Ministry to make a prognosis in the field of medical care. To achieve this goal it is necessary to make management simpler. To avoid the situations when the most important decisions to be made by the Minister stand for from "below" and the "upper" structures discuss some insignificant administrative problems.

In the beginning of my career I planned to concentrate only on medical science and education. But today I am aware that for medical science, education, health care system and the whole state to be established it is necessary to take part in state affairs. That's why I announce my willingness to become Health Minister in the Shadow Cabinet of the Ministers.

After editing my article I saw that almost everything in it was written correctly. What I have written two years ago is still important today. The

problem is with reforms: urgently needed they are still absent. Soon I will tell the reader my reasons and understanding of that matter.

The Ministry

-Do not spit in the well....

-I don't, I live in that well myself...

The Ministry was in deep depression. That was my impression on my entry to the Health Minister adviser position and latter on when I worked as an adviser.

Many things in the Ministry had so-called "Soviet" image on them. I think that image will not disappear in the nearest future. I like the expression I found in a book of a Russian academician N. Moiseev: "The new trends are accepted in the society not due to their victory over the old ones, but rather due to the fact the bearers of the old ideas die out". The process of dying out of old Soviet stereotype bearers promised to be long lasting.

On the other hand, the changes were felt everywhere. Many were afraid of those changes. But the changes were forthcoming with their new functional investigations, reduction of apparatus and other frightening rumors.

The new type of personnel came to the Ministry. These staff members have the obstinate features of thinking. The most obstinate are new staff members, accepted during the last years. As usual, these people are slowly adapting to the surroundings. They also have "in the blood" the formula "think one do other", but in some situations this new generation may do and think the same and correctly. At least this is good.

It is a pity that such situations don't appear too often and the number of the new thinking staff members is not enough for forming the critical mass. The system where this new personal works change the people, bring them up, teach how to behave, otherwise throw away. The time when everything is changing is far from being smooth.

It is understood that these problems exist not only in the Health Ministry but also in the whole administrative system. Or why then the President has a plan to reform the executive power central institutions.

The beginning of reform was good. But we have already seen plenty of reforms started. I recall A. Kosygin in this respect. Others. All of them have failed.

I hope it won't happen this time.

The changing, reduction, enlargement, centralization, renaming of the administration are nothing but a bluff. The staff should be changed. Only professionals should work in the ministry. The working conditions should help ministry staff receive only profits from the everyday activities. And staff itself will have advantages, but the advantages for state should be priorities. There should be serious competition for ministry staff positions. And none of the Peter Principles should be taken into account. All this should be applied not only for one ministry, but also to the whole administrative system.

The most problems derive not from the staff itself and from the administrative system. How can the system work, when there is lack of time for Deputy-Ministers to introduce the decisions of the Minister? This shortcoming I observed everywhere: in the Health Ministry itself, in the offices of Deputy-Ministers, in the offices of department managers, common bureaucrats, etc.

Everything was done by urgent measures.

It is easy to criticize. Challenging is to realize the positive changes. For that realization we have worked...

Many stones were put in the basis of future Ministry. A lot of efforts were made to have the Ministry "suited" for the administrative reform in this transition period.

I hope that new ideas and efforts will be productive.

The Ministry Board

The Ministry Board is the "creams" of the sector. Board is very potent instrument. Or should be potent.

But I was unfortunate with the Boards, which I have visited.

I would like to give an example of the work of one Board, where one can't understand almost anything.

So, once there was a Board session. It was an extended Board. This means, that a lot of officials were asked to come, and, accordingly paid for their missions.

The work of that particular Board was quite usual: first questions, than presentation, than discussion, than the decision project and final decision. Such procedure took place on every question.

Here I will allow myself a small step aside. I was always surprised by this country's medical activities, especially in hospitals, when medical care concerned an individual patient. The common situation: patient is by himself, the chart by itself, the list of medications and procedures by itself and the doctor is by himself. Many times I observed how doctors prescribed new medications or procedures in the last day just before discharge from the hospital and while in the hospital no changes were made. One may think that the state of patient was still and completely unchanged during treatment. Why to change in the last day?

The same situation occurred during that Board session. The ideas, expressed in presentations differ from ideas, expressed in discussions. The decision was prepared beforehand. Thus, the opinions of those who discuss were of little value and did not reflect the final decision. That discrepancy wasn't even noticed.

Strange Board.

The Board Session should be thoroughly prepared and should be planned only if really needed.

That was something else, but not the Board. Many officials have expressed the same thoughts, but I do not remember, regarding this Board or other one.

How we need the wind of changes, of administrative changes, of course.

Know-how

Structure "Know-how" exists in Great Britain.    In Ukraine its representatives is situated in the Embassy of Great Britain.

I had a possibility to become acquainted with the officials from this structure directly in the Ministry. First, they met with Deputy-Ministries, then with the Advisers. We have discussed the problems; have dreamed together about the project of attractive financial management within the sector. I was told that the project would begin in February. Now is near the end of February, so, presumably the project is in process.

We have prepared thoroughly to the future project with "Know-how". For every project one should prepare carefully in order to reach the goal by evolution method, not by the revolution one.

In the process of correspondence, we were informed about three stipendiums for health care management courses in York. The only requirement was good English language skills. It was desirable for Ministry officials to go. Unfortunately we failed to find appropriate candidates with a good enough knowledge of English.

I do not condemn the Ministry officials. They just need help in their desire to advance their professional level, by means of different educational mechanisms. They should receive assistance in foreign language education, first of all.

The informational letter

- What about the informational letter?

- Something strange, nonsense from the Soviet times. Just for "report".

Typically people having different scientific degrees make up such letters of so-called confirmation of pseudo-scientific practical sense of their work.

The idea of informational letter is to provide information to everybody about something new, interesting.

There should be practical advantage from such a letter. Of course, if the letter is unbiased, without Soviet "influence" on it.

The Ministry has some problems in reforming the sector. The reforms being outspoken, but not done very much about it, unfortunately...

The Ministry is sleeping as well as the regions too. But there is some exclusion.

In some regions management of health care system is quite good. There the officials started to provide reforms by themselves, on their own risk.

How one may neglect the reforms when there are financial reductions in the sector. Otherwise the slow degradation of the sector and the whole state economy will occur inevitably. We already have experienced such degradations, but this one probably may be the last one.

How manage to do successful reforms? The question is not the easy one. All available forces and instruments should be used in the process of reforms.

One of the most important tools to achieve success in the future reforms is the positive experience of those, who are in the front lines, i.e. the leader's experience. These people are taking risks. These people have some positive results - changes in their local health care systems. Not the best ones, but at least much better than in surrendering.

Why the informational letter can't be used?

The Minister has signed the request for such informational letter.

Some officials have responded.

Thanks to God, the first step was done.

The informational letter was sent. The back response was not received, because the Minister had left.

I hope that this informational letter was useful.

To take off control

-This is under control?

-How many controls do you have?

-Did you take off control?

The control. This is the main problem the common Ministry official is interested in.

The controlling process occupies the whole creature of bureaucrat. There is not time for other questions to be solved. The process of control is the standard of evaluation of the effectiveness of bureaucrat's work. If official have delayed to take something off control he or she will be punished.

The unpleasant picture, isn't it? Maybe one thinks that in reality everything is different? And this control dependence is only a fantasy? No, unfortunately it is true. I have on my table "The report about functional investigation of the Health Care Ministry": more than 80% of the working time official is busy with taking something "off the control".

There are many things under control in the Ministry: everything that income to Ministry from the President Administration, from the Cabinet of Ministry, from Verchovna Rada, from the parallel and lower power organs, from the ordinary citizens, from the upper power organs, many so-called appeals from the citizens. For example, somebody appealed to the Parliament. This request was turned to the Cabinet of Ministry, then to Health Ministry. Usual soccer.

The bureaucrat is very skilled in providing the control process. But this process of controlling is strewing the official, restricting all his activities. Especially busy the bureaucrats are during different electing campaigns. One middle level bureaucrat has told me that there is completely lack of time during elections, nothing else, but the controlling process.

One of the important problems to be solved during the apparatus meeting: control.

The control is like a trap for bureaucrat. If something is not right with the control, the guilty one will be punished. That's why the bureaucrats are thinking only about the control and do not have time and stimulus for something else.

For me the controlling process is like "The woman in sands" Kobo Abe, if you remember this artist. Once one becomes a bureaucrat he has a lot of great plans. Then on the process of everyday work he realizes that to be a bureaucrat is not so easy. One starts struggle. The control struggle. But, time passes and one day bureaucrat understands that he has got used to the need for controlling everything. Time passes. Finally comes the moment when bureaucrat can't live without controlling, when controlling is feeling like some sort of bliss. With the next "taking of the control" the bureaucrat starts feeling like some substances like endorphins concentrate inside. Thus, the controlling process for bureaucrat is something like drug dependence.

The problem of control - is not the only problem of bureaucrat, but the problem of Ministry, moreover the problem of Ministers!

The Ministry should work on introduction and realization of its politics. By its bureaucrats forces. But the bureaucrat is very busy with the control process and does not have time for the cardinal problems. Thus, so happened, those proposals for the World Bank from our Ministries come from the Advisers, not from the Minister's officials, as they should to.

So, what to do? There is need for good management: officials should work on their bureaucracy business, and one or two specialists on the process of taking off the control and everything will be O.K. I wrote a report to the Minister. Maybe the new Minister will introduce it.

Who knows, maybe this control is something like destiny for the bureaucrats...

Mud

The life in Ministry is dull. The mud one calls it.

How to live and built the mighty plans, if every bureaucrat should first of all search for the piece of bread every day.

The payments bureaucrats receive are far from being enough to support their families.

That' s why there are many different rumors. That's why bureaucrats are looking around...

The Ministry reminds me of an old clock mechanism, working correctly, but a very old mechanism, closed to any new winds. For winds of changes.

That is right. Many Ministry bureaucrats are correct, when they say that the changes didn't take place in the past, are absent today and will happen in the future. These people are correct, because their experience taught them. They really did not make a mistake. At least up to the moment.

-You with your ideas will leave, but I will stay and work here. That was the response of one bureaucrat on my proposals.

That bureaucrat is a very nice person. He is quite open to new ideas. Suddenly he may loose control, shine for a second, but soon becomes dark again. "What I am doing? They (carriers of new ideas) will be gone, but I will stay."

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