Implementation of Family Medicine in Central and Eastern Europe: Experience and Lessons for Ukraine

The reform of the healthcare system in Ukraine is a prime necessity, which is due to the lack of clear structural transformations since independence. However, today the implementation of reform measures generates a number of negative reviews in the society related to the lack of awareness of citizens with the main vectors of change. In addition, the closure of hospitals leaves the population without proper medical care, while the general introduction of family medicine is met with caution as the special field “family medicine” is new and unpopular for Ukraine. Lack of sufficient knowledge about the basic principles of the functioning of family medicine and the absence of professional family doctors gives rise to further distrust of the people in the primary healthcare unit. Therefore, the medical reform instead of separating powers between all levels and areas of medical care and achieving global goals and results for the whole society and socio-economic development of the country is failing. In our study, we defined the concept of family medicine in its theoretical and practical application, proving that family medicine is the basis of the general well-being of society. And its development, modernization and popularization can become the first element in the general system of healthcare. An example of Central and Eastern European countries has shown that the phased introduction of family medicine is positively reflected in indicators of welfare and mortality rates, as well as on indicators of social and economic development of countries, etc. However, the lack of sufficient knowledge and the corresponding level of government interest in reforming the primary healthcare unit generates a zero effect from all actions taken. At the same time, nonprofessional family doctors invalidate the importance of the primary unit in the healthcare system. Within the framework of the study special attention was paid to the problems encountered by Ukraine on the way of implementation of medical reform. The basic components of such a problem, which originated in the absence of a clear and coordinated work of state authorities and local self-government was analyzed. Based on the foregoing, and on the experience of foreign countries, we have been offered ways to solve such problems and improve the general mechanism of primary healthcare.


І. INTRODUCTION
Health is one of the most important values of a person, which determines the possibilities for the realization of all his / her aspirations, both personal and social. Health is not only the absence of illness. World science has developed a holistic view of health as a phenomenon that integrates at least four of its components -physical, mental, social and spiritual. All these components are inseparable from one another, they are closely interconnected and only in aggregate determine the state of human health (Skrinnik, 2019).
The development and popularization of the primary healthcare unit in general, and family medicine in particular, has a positive effect on the healthcare sector. However, such a positive effect is only possible in the case of the efficiency and availability of medical services at this stage, when the family doctor is able to provide the required range of services in a qualitative and comprehensive manner, co-operate with other doctors, and also conduct preventive and preemptive measures at a high level. The principles on which family medicine is built create prerequisites for competing among doctors for patients, which directly affects the quality of services provided.
Ukraine has ignored for a long time the recommendations of international organizations, the recommendations of World Health Organization, on the need to reform the medical sector. Experts determine that only starting from 2010 it is possible talk about the slow, volatile, unplanned beginning of the reformist actions. After all, in 2010, according to official statistics of the State Statistics Committee of Ukraine, the expenses of the state on healthcare amounted to 1042 UAH for one Ukrainian, while each citizen spent more than 750 UAH on the purchase of medicines. In comparison, the average salary of 1 medical worker was 1778 UAH, which is about 43% less than the salary of 1 employee in the field of industry and 67% less than in the financial sphere (Yanchuk, 2019).
M. V. Shevchenko and R. V. Bohatyrova agree that overall public health financing was ineffective, and wages did not meet global standards. For example, in 2010 in Finland a health worker received in average 2536 euros, in Portugal -898 euros, in Lithuania -800 euros, in Bulgaria -572 euros (Shevchenko, 2012).
Thus, the reform of the healthcare sector and the clear allocation of the primary healthcare unit became a real necessity for the socio-economic development of Ukraine. Since this time, the country has been gradually introducing major reform measures. In our opinion, the most valuable for Ukraine is the experience of the countries of Central and Eastern Europe, which have passed the period of development similar to Ukraine: joining the USSR, gaining independence and electing the vector of independent development.
The object of this study is the social relations that arise in the field of the introduction of family medicine in Ukraine and the countries of Central and Eastern Europe.
The subject of the study is the experience of introducing family medicine in the countries of Central and Eastern Europe.
The purpose of the study is to determine the basic problems for Ukraine and to suggest ways to solve them basing on the experience of the countries of Central and Eastern Europe in introducing family medicine.
Methods of research are selected taking into account the object, subject, and purpose of the study. General scientific and special methods of legal science were used in the course of the study. The basic method of research is a dialectical method that substantiates the interconnection and interdependence of all processes in the introduction of family medicine. The general methods of synthesis, comparison, analysis, induction, deduction, analogy were used when clarifying the terminology apparatus on the introduction of family medicine in Ukraine and in the world. Also, the methodological foundations of the study are the following scientific methods: formal-dogmatic, with the help of which the external scientific processing of empirical material took place, definition of the concept, principles and methodology of family medicine; systematic and structural, historical and comparative, logical methods are the basis of the study of the medical reform development in the countries of Central and Eastern Europe.

Theoretical aspect of the formation of family medicine as a primary healthcare unit
Family medicine is a key link in primary healthcare. The main purpose of family medicine is to provide quality medical healthcare to patients in the initial stages, while quality acts as a complex concept that includes strengthening the knowledge base in the field of primary healthcare, developing precise special diagnostic algorithms and providing timely, adequate medical care (Shevchenko, 2012).
Therefore, the question of the necessity and importance of the development of family medicine is no longer debatable. In the Netherlands, Australia, the United States, Canada, UK and other countries there are schools and institutes for conducting medical MD / PhD programs in family medicine, epidemiology, ethics, and medical informatics. Research programs are aimed at determining the long-term outcomes of diseases, the effectiveness of diagnostic and therapeutic interventions, the quality of medical care, etc. (Shevchenko, 2012).
The official documents of the World Health Organization and the World Organization of Family Doctors state that family medicine is the foundation of the entire health system of each state, as well as for society as a whole. The optimal construction and functioning of the appropriate family medicine model in the world ensure the comprehensiveness and accessibility of healthcare and is derived from basic medical care directed at each person and additional care provided to groups of people with general medical problems (Shevchenko, 2012).
At the same time, experts from the World Health Organization (WHO) state that the most optimal, effective and such a system that would be able to meet the needs of the entire society is not built in any country. However, the Strategy for the Development of the World Health Organization for the population of the European region declares the development of the concept of family medicine as a basis for healthcare. This concept is recognized by all international organizations (Mazhak, 2009). Domestic scientists Y.Y. Latyshev and Y.I. Avhustynovych argues that world scholars and experts have agreed on the identity of the concept of "family doctor", which should be understood as a doctor who has undergone a special post-graduate multifunctional training on provision of primary medical family care to patients and members of their families, regardless of gender and age (Latyshev, 2016).
Modern family medicine is a branch of medicine that has accumulated advanced developments in the field of biology, behavioral sciences and clinical science. Domestic scientist I. Mazhak proves that it actually returns a holistic approach to the person and problems of his / her health. Family medicine can not be limited to a single set of diseases, a set of actions and behavior. In fact, family medicine is aimed at solving a set of problems of the patient and his family. The methodology of family medicine is based on recognition of the determining role of the family in the formation of health and illness of all its members, which is due to socio-cultural and biological factors (Mazhak, 2009).
The basic principles of family medicine are: -continuity of provision of medical services to the consumers on a continuous basis; -sufficient level of health care; -preventive and preemptive aspects of medical care; -the comprehensiveness of medical care, which means that medical services are provided to all citizens regardless of sex, disease, religion, age and other characteristics; -the family doctor has basic knowledge and skills of other medical specialties (Mazhak, 2009). However, the family medicine gained recognition as a separate industry only in the beginning of the XXI century. By the 60's of the XX century there was a keen discussion about the essence of family medicine and its role in the healthcare system of the developed countries of the world. Finally, after conducting a series of scientific studies at the end of the XX century, family medicine became the foundation of the healthcare system of the United States, Canada, the countries of the European Union and Central and Eastern Europe. In each of these countries there is a domestic family medicine model with certain characteristics, but in many respects they are similar. World medical science, according to the quantitative criteria, defines three main models of family medicine: For Ukraine family medicine is not a new phenomenon, but its formation actually took place after the official approval of the special field "family medicine" at the end of the XX century. At a later stage the leading medical universities in Ukraine began training specialists in this special field. Gradually, the opening of the first domestic practices of family doctors took place. Scientific-practical conferences of family doctors and family doctors' congresses began to be held. In December 1997, the Ukrainian Family Medicine Association (UFMA) was founded, which currently has more than 10,000 members. The main purpose of the UFMA activity is to improve the health of Ukrainians by improving the quality of providing medical care to the Ukrainian population on the basis of family medicine (Avhustynovych, 2016) In fact, today in Ukraine the family doctor is the first-contact doctor, whose duties include the provision of primary healthcare services. Until recently, the duties of family doctors in medical institutions of Ukraine were performed by therapists and pediatricians, treating minor illnesses and injuries, carrying out easy operations and preventive activities for the prevention of diseases. Such a model of family medicine was left as an inheritance from the USSR, when the task of these doctors was equated with the functions of the dispatcher and coordinator on the referral of patients to specialized doctors. This led to situation, when the patient stopped consulting a therapist or pediatrician, and on his own visited the appropriate specialist. This circumstance directly influenced the state and quality of medical services provision in the primary healthcare unit and the very fact of its existence and development in Ukraine.
The use of such a model of family medicine has actually led to the loss of the primary healthcare unit and the quality of the provision of medical services. The poor state of healthcare has led to a decrease in the average life expectancy in the country to 68 years, which is 10 years less compared to the life expectancy of EU residents. Also, the infant mortality rate is 2.5 times higher than in Central European countries, and the premature mortality rate is higher more than 3 times (Ruskykh, 2012).
In 2010, a sociological survey was conducted in Ukraine in which one third of the respondents identified the state of the provision of health services and the general state of healthcare in the state as unsatisfactory; 70% of respondents pointed to the urgent need for reform in this area; about 50% of the respondents confirmed that doctors refuse to provide free assistance; about 20% were not able to receive medical care at all because of the absence of professional physicians and specialist doctors (Zaporozhan, 2016). Therefore, society itself has forced the Ukrainian government to begin reforming the healthcare system, since Ukraine is perhaps the only country in the post-socialist camp, in which no reform of the medical sector has taken place since independence.
Thus, at the end of 2017, a medical reform was launched in Ukraine after the Verkhovna Rada of Ukraine voted for the Law No. 2168-VIII "About the state financial guarantees of medical attendance of the population" and thus gave "green light" to the reform of the financial system of medicine. In January 2018 the Ministry of Health has already begun implementing changes in healthcare spherenamely, the first stage of the reform -a new mechanism for financing medical institutions that provide primary healthcare. After all, family doctors, therapists and pediatricians are those medical workers whom Ukrainians should contact the first (Baloshenko, 2012).
It is rather difficult now to state whether this reform will be effective for ordinary Ukrainians, but the very fact that, for the first time in 27 years of Ukraine's independence, it has begun giving hope that the healthcare system in our country will improve. However, we believe that a qualitative implementation of the reform measures and real changes in the healthcare sector will only be possible if there is a deep study of international experience on this issue.
In our opinion, the most valuable for Ukraine is the experience of the countries of Central and Eastern Europe, which have passed the period of development similar to Ukraine: joining the USSR, gaining independence and electing the vector of independent development.

Formation and development of family medicine in the countries of Central and Eastern Europe
The reform of the family medicine system in Ukraine takes place much later, in comparison with the post-Soviet countries and countries of Central and Eastern Europe, as most countries began reforming this sphere in the 90's of the XX century. At the same time, such countries set specific tasks that needed an immediate solution: increasing the number of family doctors, popularizing the special field, effectively organizing the work process, increasing the amount of funding for this area. Together with the realization of such tasks and studying the experience of the countries that went through a similar path of reform, it was determined that this process is extremely cumbersome, lengthy and not always able to produce a positive effect (Ruskykh, 2012).
Experts from the World Health Organization (WHO) in the 90's of the XX century conducted a study the conclusion of which was the outline of the poor state of the primary healthcare unit and the activities of therapists, pediatricians and family doctors in Central and Eastern Europe. Taking into account the WHO recommendations, the governments of these countries have developed appropriate measures to overcome health problems in relation to the three main areas identified in Table 1.

Directions of realization of reform measures in the countries of Central and Eastern Europe
raising the living standards of the population improvement of ecological conditions and socio-economic indicators in the country improving the mechanism for providing medical services Source: compiled by the author.
According to the WHO conclusions and according to the results of the carried out measures, the greatest success in the process of reforming the sphere of medical healthcare was reached by Estonia, while the lesser results were shown by Poland, Lithuania, Hungary, the Czech Republic, Moldova is at the initial stage of reform, while Romania and Bulgaria experienced the failures.
The world concept of the development of higher medical education is focused on the training of specialists capable of developing and implementing a complex of therapeutic, prophylactic and rehabilitation measures within the framework of their special field, to assess the characteristics of mental and physical health of a person, to analyze and demonstrate the effectiveness of their own professional activities, to predict ways and directions of its improving and increasing efficiency (Korotych, 2017).
Family medicine was defined as a special field in Estonia in 1993, and in 1995 there was the introduction of residency training in the sphere of family medicine. A similar situation occurred in Poland. Since 1994 the special field "family medicine" has become one of the most popular in medical educational institutions. Courses for the training of family doctors have been opened in Lithuania since 1991, which lasted 33 months, and since 1993 there have been courses for retraining for doctors, lasting 52 weeks. In Bulgaria there was the course "Family Medicine" lasted 1 year in medical schools for all students. The implementation of the state program on the training of family doctors and the promotion of this special field began in Moldova in 1996. The State Medical University opened the Faculty of Family Medicine. With the support of UNICEF family doctors were trained on maternal and child health (Ruskykh, 2012).
However, all countries of Central and Eastern Europe met the problem of training specialists. Therefore, the solution to this problem was the organization of appropriate courses for the training of family doctors. There were completely different courses in each country, as indicated by their varying lengths. For example, in Moldova, these were 4-week courses, in Bulgaria and Poland -6 months courses, in Lithuania -33-month courses. We consider it necessary to note that the short term of retraining provoked a considerable amount of distrust of patients both to the doctors and to the reform itself. The lack of sufficient knowledge of such family doctors has become a prerequisite for increasing the work of specialized doctors. In order to avoid responsibility for determining the wrong diagnosis, family doctors subscribed an unreasonable number of appointments to other specialists.
In order to overcome this problem Hungary, Lithuania, Slovakia, Latvia focused on conducting family medicine courses, which were included in the program for the training of all medical students. In Poland, the Czech Republic, Slovenia, they went even further. In these countries, in higher medical schools, the opening of departments of family medicine was held, and for the working doctors a lot of courses were offered with state support for the improvement of professional qualifications and retraining of doctors. The most popular were distance courses in this field (Ruskykh, 2012).
Short-term retraining courses for doctors have become a problem in Ukraine as well. However, as indicated by the implementers of medical reform, such courses are a direct necessity, which become a prerequisite for expanding the range of medical services that can be provided by former therapists and pediatricians. It should be noted that unlike the European countries, since the beginning of medical reform, and till today, Ukraine has not solved the problems of building a scientific basis for conducting medical reform and expanding scientific research and development; improvement of university programs for the training of family doctors; thorough preparation of advanced training courses and improvement of their educational potential; harmonization of the field of medical education with the requirements of the EU. And these are probably the biggest problems of domestic medical reform.
Today one of the main tasks in the medical sphere is increasing the level of doctor's education as a factor of his / her competitiveness. This creates high requirements for the quality of training and retraining of medical specialists in the system of higher medical education (Zhdan, 2017).
The competitiveness of the medical profession at this time depends directly on the desire and ability to constantly raise their skills or receive new, and improve the quality of education in general.
Recently, in the countries of Central and Eastern Europe, including Ukraine, the organization and demonstration of master classes are becoming more and more popular, such as seminars on the exchange of experience, training of craftsmanship, etc. According to the literary data, the most important features of the master class are: a new approach to the philosophy of learning that breaks the stereotypes; use of the method of independent work in groups that allows to exchange the ideas; setting problematic questions and solving it through creating different situations; the ability of each participant to join the proposed methodological material. A. A. Kapustianska, N. V. Moiseieva, A. V. Vakhnenko, M. O. Rumiantseva and G. Y. Ostrovska indicates that the use of master classes in medical education will have a positive effect on the overall educational process, which in turn will increase the competitiveness of the medical profession "family doctor", popularize the profession of a doctor, and enhance the culture of communication in the medical sector (Kapustianska, 2017).
The beginning of reforms was preceded by enormous preparatory work in the countries of Central and Eastern Europe. Thus, before conducting a cardinal medical reform, the Estonian authorities identified the actual need for family doctors for the country's population. In order to do this, general practitioners were obliged to register as independent individuals and to register the full list of patients which was freely available at the beginning of the reform. All family doctors were given 4 years to perform all legislative requirements regarding the peculiarities of their practice organization (Ruskykh, 2012).
The reform took place even calmer in Lithuania, as the state left medical ambulatories and polyclinics under its control and management, and about 80% of all doctors in general medicine remained employed as hired workers in state medical institutions. Poland went a different way and on absolutely equal terms supported both the private practice of doctors and the practice of individuals as hired workers. In Hungary the work of family doctors in state policlinics and centers was equated to work in the public service. In Romania, the Czech Republic, Bulgaria the private practice of family doctors was predominant, while in Slovenia and Moldova the most popular work was at state polyclinics and centers, and family doctors remained in the status of hired workers.
Today, family doctors are equated with the kind of "guard" doctors, because in most countries of Central and Eastern Europe a family doctor should provide a survey and arrange an appointment in case of such a necessity before visiting a specialist. An exception was, for example, the Czech Republic, where the responsibilities of family doctors did not include this kind of work, and contacting the specialists is possible at any time (Ruskykh, 2012).
But the process of any reform, and especially the health-related reform, is not cheap and requires significant funding. The experience of Central and Eastern European countries has shown that the stage of attracting foreign funds is one of the most important steps in the implementation of medical reform in the country, because the State Budget of the country is unable to finance additional expenses related to medical reform on its own, because medicine on 90% is funded by the state.
Cooperation with foreign entities in attracting credit funds should have a positive impact on the economic and social life of the country, as it provides an opportunity to obtain relatively cheap loans in the short term and on preferential terms. The attraction of such funds takes place after the signing of international agreements on attracting funds from foreign countries, governments, international financial institutions, etc. (the programs of UN, WHO, USAID, EU).
However, international financial assistance in Ukraine is not alright. Thus, one of the largest projects in the healthcare sector in Ukraine is the project "Improvement of health care in the service of people", which is carried out by the Ministry of Health of Ukraine in accordance with the Loan Agreement between Ukraine and IBRD for the total amount of 214.7 million US dollars. The implementation of this project has become one of the most failing. During the first year and a half, the funds used by the executor (Ministry of Health of Ukraine) were almost equal to the amount of budget funds paid by our state to IBRD for loan servicing, which is 1.2 million US dollars.
In connection with the untimely selection of loans, which is traditional for Ukrainian executors, Ukraine also paid commission fees for reservation in the amount of 26 thousand US dollars. In fact, this amount is a loss of budget funds for Ukraine. However, any official person in Ukraine was held responsible for his actions, which caused such losses (Kitura, 2017).
As a result of the audit of this project, it was established that the feasibility study did not include calculations and a list of measures for the implementation of the project. In almost two first years, there were not created groups of executors (consultants) of the project that were responsible for the implementation of control measures of persons. Reporting is carried out at an inappropriate level and in violation of the requirements of the Loan Agreement Project "Improving Health at the Service for People". However, contracts were concluded with individual executors with payment for actually time worked, and not for the received results -238 thousand US dollars (Kitura, 2017). There are no other large-scale projects for attracting international financial assistance for the implementation of medical reform and the separation of primary and secondary medical healthcare units in Ukraine.
Since 2018, the issue of remuneration for family doctors has been recognized in Ukraine as the most discussed issue with regard to the implementation of medical reform and the work of the primary healthcare unit. In the speeches of acting Minister of Health of Ukraine Ulyana Suprun it is noted: "Funds should go for the patient". Within the framework of the implemented medical reform, this implies that the salary of the family doctor is carried out by mixing the basic components: patient fee, program bonuses, payment for the provision of the relevant services, payment for the provision of additional services. Such a system is intended to stimulate doctors to work, study, further training, retraining, etc. For example, today the family doctor has the right to participate in children's immunization programs, care programs for patients including chronically ailing patients, programs for the protection of women's health, etc. Taking into account the fact that the main element of family doctor's salary monetization is the payment for a patient, there is a problem in the doctor's desire to improve his financial position by imposing excessive (2 thousand and more) declarations on patient care, despite the fact that an excessive number of patients will be negatively affect the quality of its services. To avoid such situation, in Bulgaria, for example, the fee is reduced for each new patient in case of exceeding the standards for the number of people.
The family doctor's salary system for each individual patient is the basis of medical reform in the countries of Central and Eastern Europe. It is typical for Bulgaria, Hungary, the Czech Republic, Estonia, Romania, Poland, Moldova, Lithuania. However, the following components of payment for labor are not typical for all countries. For example, payment for the implementation of child health programs, women's health care, monitoring chronic diseases, and preventing female and childhood illnesses are typical in Bulgaria (11%) and Romania (15%); payment for the implementation of preventive measures and emergency care at home is introduced in the Czech Republic (30%), Romania (15%) and Poland (Stefanchuk, 2019).

The main bonuses in the payment for family doctors' labor are:
-Estonia -payment for the implementation of indicators for the care of chronically ill patients and immunization of children (2-3%); -Hungary -payment for the achievement of the determined quality indicators; -Lithuania -payment for low level of hospitalization, achievement of high index of children's immunization, high rate of visits to the patient, early diagnosis of cancer and cardiovascular diseases (13-14%); -Romania -payment for achieving higher than 95% immunization level; -Moldova -additional payment for the supervision of children under 5 years, regular preventive visits to children, supervision of certain patients (diabetes, tuberculosis, cancer, hepatitis, etc.) (Stefanchuk, 2019).
General salary of family doctors may include other indicators of their professional activities, in particular:

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Hungary -an additional payment if the doctor has the appropriate qualification; if the family doctor has been practicing for more than 25 years; the doctor sees unregistered patients; -Estonia -for laboratory tests, retention of practice and own cabinet, located at a distance of more than 20-40 km from the state hospital, ambulatories, polyclinics, etc; -Bulgaria -for work in remote areas and under complicated conditions; -Lithuania -for work in the countryside; -Romania -for professional level (Stefanchuk, 2019).
According to the report of Health and long-term care in Europe Union, the average satisfaction rate for Central and Eastern European citizens in reforming the primary care unit is 84% (Diagram 1). However, this level does not indicate the absolute success of medical reform. It can only mean that the work of the new system is somewhat better in comparison with the work of the post-socialist system of medical care and the work of pediatricians and therapists at the end of the last century.
Researchers also note that patients today do not fully understand the functions of a family doctor. During sociological surveys, some respondents stated that the main responsibility of the family doctor is to subscribe the appointments to specialists, rather than direct provision of medical services aimed at treatment and preventive measures.

Researchers indicate an extremely low level of implementation of individual elements while studying the effect of medical reform and the level of effectiveness of implementing innovative measures in
Central and Eastern European countries. In particular, it is noted that the popularization of medical special field -family medicine is at an extremely low level.
The proportion of family doctors to the total number of doctors has remained low in countries such as Hungary, Poland, and Bulgaria. In the last 10 years, the cost of primary healthcare per one person has increased compared with the cost of inpatient treatment in Estonia (by 7.1%), Hungary (by 2.7%), which positively characterizes the implementation of medical reform in these countries. However, the opposite result is characteristic for Poland, Slovenia and the Czech Republic (increased costs for inpatient care, which makes it possible to talk about lowering the quality of service provision in the primary link).

Diagram 1. Information on the effect of reforming the primary healthcare unit in Central and Eastern Europe.
Source: compiled based on Health and long-term care in European Union data and K. Ruskykh's information (Baloshenko, 2017).
For Bulgaria the mistrust of patients to primary healthcare and family doctors has been characteristic for a long time, due to the short term of study in the field of family medicine and the presence of many doubts in the qualifications of specialists. This led to the fact that the functions of the family doctor were reduced to the subscribing appointments to specialized doctors and the issuance of recipes for the purchase of drugs and medicines. Bulgaria is a country in Central Europe, in which the medical reform is considered to be unsuccessful and showing the lowest results.
A similar situation occurs in Romania, where family doctors were left out of the administrative-legal component of the reform. The functioning of the primary unit is defined as unsatisfactory, and the performance of duties by family doctors is inappropriate. According to official information, only 25% of all appeals to specialist doctors are justified. In all other cases, the provision of medical services is also possible by family doctors. However, according to the shortcomings in the organization of work and its payment, family doctors themselves are not interested in servicing more patients.
All medical services in Poland are more focused on the treatment of diseases, rather than on preventive medical measures. The main problems in the work of family doctors are the following: insufficient salary, excessive workload of working family doctors both in state clinics and in the field of private practice, lack of sufficient number of doctors.
Summarizing the results of our study, taking into account the experience of Central and Eastern European countries regarding the reform of the healthcare system, we can identify the main problems encountered by countries in the implementation of medical reform: lack of family doctors; -lack of effective training in the field of family medicine and good advanced training system; -consistent harmonization of university education with the major "family medicine" in accordance with the requirements of EU legislation; -absence of an effective system of monitoring of quality indicators of primary healthcare; -lack of clear coordination with public and local authorities and effective cooperation on the popularization of the primary healthcare unit; -lack of stable political support for carrying out reforms as it was most expressed in Lithuania and Latvia; -lack of a clear methodology for developing a strategy for reforming the healthcare sector and making decisions in the process of such reformation; -introduction of a clear system of restraining and countervailing, system of incentives and rewards; -development of analytical and technical capacity of local authorities in monitoring the results of primary healthcare; -the existence of a clear long-term reform plan and the development of a regulatory framework (Voronenko, 2005).
Each of the aforementioned aspects is extremely important for Ukrainians, since it indicates what problems our state can meet or have met already. The beginning of medical reform in Ukraine was indicated by the adoption of the Law of Ukraine "On the Procedure for Reforming the Health Care System in Vinnitsa, Dnipropetrovsk and Donetsk Regions, and in the City of Kyiv". The adoption of this law is connected with the beginning of the reform of medical healthcare on the principles of family medicine in 3 pilot oblasts and in Kyiv.
Today in Ukraine there is discussion on the fragmentary and ill-considered reformation of primary healthcare, while the introduction of changes takes place without specifying goals, results, tasks, a defined action plan, criteria for monitoring and control. Following a study on the state of medical reform in Ukraine, the Institute for Economic Research and Policy Consulting identified that Ukraine is characterized by: realization of the reform without approval of a new model of provision of medical services; -the goals of medical reform in Ukraine are not specified and tactical ways to achieve such goals are not defined (the only programs are economic reform programs for 2011-2014 years); -criteria for the introduction of changes aimed at optimization of medical institutions and the selection of the primary medical healthcare unit are not defined; -the establishment of centers for provision of primary medical healthcare was carried out without a coherent plan for optimizing medical institutions. In most cases, even an inventory did not take place; -there are no criteria for the reorganization of rural district hospitals in the ambulatories of family medicine; -political instability, which has a direct impact on the implementation of medical reform measures, since the reform process is long-term; -low level of socio-economic development in Ukraine; -the existence of a stable relationship between doctors and patients, which creates preconditions for the direct referral of patients to specialists, and not to family doctors (Vakhnenko, 2017). We believe that the success of the reform of the primary healthcare unit depends entirely on the professionalism of family physicians themselves. However, this circumstance is one of the most problematic in comparison with the above mentioned. Thus, about 60% of all doctors (therapists and pediatricians) in Ukraine are people of pre-retirement and retirement age, which challenges the expediency of their retraining for family doctors, as well as the quality of such retraining.
According to current realities, the obtaining of specialization of a family doctor is possible for a person after a short-term course. In our opinion, courses lasting in 4-6 months give rise to distrust of such doctors. We believe that the chosen training course for a short-term program, as in the example of Bulgaria, is an unsuccessful way of implementing medical reform. Another incorrect aspect of the whole process is the issue of personnel planning. Currently the Government of Ukraine does not pay enough attention to this issue, namely: there is no promotion of the special field "family medicine", there is no improvement of university programs of training and qualitative preparation of postgraduate, distance and advanced training courses. At the legislative level, it is just outlined that the need for a sufficient number of family doctors for the effective functioning of the primary healthcare unit will take place due to the re-training of all therapists and pediatricians by 2020.
One of the aspects of the work of family doctors is the implementation of preventive measures. However, experts from the Institute for Economic Research and Policy Consulting have shown after conducted study that family doctors in Ukraine do not take any preventive measures. This is primarily due to the lack of sufficient knowledge on this issue (Vakhnenko, 2017).
Ukraine among the stages of healthcare reform has highlighted an extremely important stage -the implementation of pilot projects that was not typical for most Central and Eastern European countries. Implementation of such projects should be a prerequisite for effective and targeted reformation throughout Ukraine, the development of tactical and strategic plans, and a clear definition of goals and objectives. However, 2018 showed that Ukraine has gone through the way of introduction the changes without planning, discussion and disclosure.

Qualification and competency characteristics as the basis for the development of specialized care.
In most countries of Central and Eastern Europe, the profession of "family doctor" employs 30-50% of the total number of health workers. Therefore, in Ukraine the whole medical field was aimed at the development and improvement of specialized care for a long time, which has lowered the role and quality of the provision of services by therapists, pediatricians, family doctors, urgent changes to state standards for training specialists in the field of "family medicine" and bring them in line with European ones.
The Family Medicine Association "European Wonca" has developed competencies and qualification characteristics for a family doctor. The competencies and qualifications of family doctors are generally accepted as European standards. Taking into account the pro-European vector of development of Ukraine, we consider it necessary to emphasize the priority of the compliance of domestic family doctors with below indicated competences and qualifications.

Competences of the family doctor:
-responsibilities for managing the primary healthcare unit; -medical care is directed at the individual and his / her family, and is carried out on a continuous basis; -providing a wide range of health services that are associated with chronic and concomitant diseases; -a comprehensive approach is directed at the implementation of preventive measures, treatment and care of patients; -orientation towards society, which implies a general responsibility for the health of the whole society in general and each citizen separately; -fulfilling of duties on the basis of a holistic approach, which provides for solving health problems in biomedical, psychological, social and cultural aspects (Tkachenko, 2015).

Qualification characteristics of the family doctor:
-the primary unit of health care is publicly available for the entire population of the country; -individual patients should be provided with individual medical care, however, generally accepted standards and peculiarities of the family and social environment should be taking into account; -the use of the resources of the state health care system should be at the level of their effective, purposeful and professional use; -the family doctor during the provision of medical services cooperates not only with the individual, as a member of the family, but with the whole family, examines the health of the whole family. This circumstance creates preconditions for the emergence of trust relationships between family and family doctor; -the family doctor has the opportunity to solve the problem of diseases on preclinical level, by taking preventive measures; -the family doctor is fully responsible for the consistency, continuity and completeness of medical care according to the patient's needs.; -a family doctor has his / her own unique type of clinical thinking and way of decision making that is determined by statistical and epidemiological indicators of health and morbidity; -has sufficient qualification, knowledge and skills to solve problems of acute and chronic diseases; -the family doctor is fully responsible to the law and society for the quality and effectiveness of the medical care provided; -has appropriate skills in teaching patients a healthy lifestyle (Tkachenko, 2015).

Administrative and legal basis for the reform of family medicine in Ukraine.
In our opinion, only scientifically justified measures based on the positive experience of developed European countries can bring the effect of reform implementation, so the results of our research are among the first of its kind, and their use will be important for medical reform in Ukraine. In the course of our research, we proved that prior to the reform, the Government of our country, together with domestic scientists, would have to draw up a clear action plan for reforming the medical sector, as it was done in Estonia, Slovenia, Hungary and the Czech Republic. This plan should be based on the results of the pilot projects received from the proposed reforms in separate administrative units. To do this, the Cabinet of Ministers of Ukraine and the Ministry of Health of Ukraine should develop and approve at the normative level: the model of provision of medical care in Ukraine, the goals of medical reform and ways to achieve such goals, the strategy of reforming the health sector.

IV. DISCUSSION
The analysis of the implementation and realization of the medical sector reform in Central and Eastern European countries shows that the overall process is quite lengthy and requires a clear statement of goals and objectives. The reform process itself requires constant changes to previously made decisions and adjustment of new proposals. Particular attention is paid to the issues of teaching students, their qualitative training, retraining, advanced training, participation in conferences, seminars, symposiums, roundtable discussions, etc. on the effectiveness of providing primary healthcare and popularization of the special field "family medicine".
To determine the statistics on the ratio of doctors and patients, it is necessary to create a single base of patients. This question at the level of legislative consolidation has risen for the first time in Ukraine in 2012. However, no changes have been made till nowadays. We should note that the electronic registry is absent now. During the implementation of this measure there were difficulties with the very procedure for data entry into such a database, its creation and software, the absence of reliable and effective mechanism for protection of the patients' data (both medical and personal).
The question of the ratio of primary (family doctors' work) and secondary healthcare is still discussible. We believe that the main task for Ukraine should be the informatization of both units of medical care, which is a prerequisite for deepening their cooperation and coordination of work. Moreover, K. Ruskykh notes that the continuation of primary healthcare reform in Ukraine should take place simultaneously with the optimization of the secondary unit, the reform of emergency medical care and the reform of the system of financing the industry (Ruskykh, 2012).

V. CONCLUSION
Health care reform was a necessity for Central and Eastern European countries as in the 60's and 90's of the XX century the state of health of citizens and the conditions for provision of medical services were unsatisfactory. Such a state of health is associated with low living standards, socio-economic development of countries, ecological status, poor state of health and the implementation of preventive and preemptive measures. In most countries, healthcare was funded by the residual principle, since it was not defined as important. Management in this area was ineffective (Ruskykh, 2012).
Determining the model of management of primary health care centers was one of the main goals of medical reform in post-soviet European countries. Thus, in most countries of Central and Eastern Europe, except to Slovenia and Lithuania, initiators and implementers of medical reform tried to change the ownership form from state to private. Such privatization of primary healthcare centers was planned as a mechanism to stimulate competition between family doctors, stimulating the continuous improvement of their professional knowledge and skills in the market for medical services. However, such reform measures achieved no significant effect. We note that in Ukraine this direction is not defined for the purpose of realization of medical reform, however, there is encouragement of family doctors to private practice.
World experience has shown that the path to reforming the healthcare system is the most successful and expedient, since professional family doctors can solve up to 90% of all patients' problems. It positively affects not only the social component of society life, but also the economic situation in the country. Moreover, Y.V. Voronenko conducted a study that showed that an increase in the number of family doctors, for example 1 medical worker per 10,000 of population, could reduce the death rate by 9% from the overall indicator in the region (Voronenko, 2005).
In the course of our study, we analyzed the mechanisms of carrying out pilot medical reform projects in Dnipropetrovsk, Vinnitsa, Donetsk regions and two districts of Kyiv, but failed to monitor their results due to their absence. Therefore, it is practically impossible to determine the effect of the reforms proposed by the Government of Ukraine. Taking this fact into account, we can argue that, along with the adoption of strategically important legislative acts, an effective system of monitoring indicators of quality of primary healthcare and implementing measures aimed at developing analytical and technical capabilities of state authorities and local self-government bodies should be built in Ukraine.
The experience of the countries of Central and Eastern Europe proves that an important step in the implementation of medical reform is the cooperation of countries with international financial organizations, the attraction of which is an important financial complement to the overall mechanism of reforms. We believe that it is extremely important for Ukraine to fulfill its preliminary healthcare commitments in international agreements on international financial assistance, which will create the preconditions for increasing the interest in Ukraine and inflow of financial resources, which in fact is "blood" of medical reform in the country.