Prosthetics in Ukraine: what’s behind scandals and why veterans raise money for prosthetics themselves - conversation with Antonina Kumka, CEO of Protez Hub
Regularly in the public sphere, there are announcements about fundraising for a prosthesis for a veteran of the Russian-Ukrainian war. Or for their travel abroad for further prosthetics. In the third year of the great war and the eleventh year of the war with Russia, has Ukraine failed to organize high-quality prosthetics for its soldiers?
Censor.NET talks to Antonina Kumka, CEO of Protez Hub, Advisor to the Minister of Social Policy (pro bono), about the reasons for such fundraisers and what is behind them.
Since 2014, she has been paving the way for world-class prosthetics standards in Ukraine, and she has achieved this: today, Ukrainian prosthetists are able to perform work at the highest level, several modern prosthetics centers have been established, and state funding programs have been developed. Thanks in large part to Antonina, the monopoly in this market has been overcome, so that there is healthy competition between prosthetists, and thus quality improves.
After Russia's full-scale attack on Ukraine, Kumka and like-minded people created Protez Hub, a community that provides all available information and analysis about prosthetics in Ukraine and continues to improve the field.
PREVIOUSLY, WHEN A PROSTHESIS FAILED, A GENERAL REPAIR WAS PROVIDED FOR, AND THERE WAS A DRIVE UP FOR HUNDREDS OF THOUSANDS OF HRYVNIAS
- Recently, several veterans have stated that state funding does not cover the repair of prostheses for high amputations, so patients are forced to raise hundreds of thousands of hryvnias on their own. This is quite scandalous, as it is believed that the state fulfills its obligations in this area. So what is the reality?
- It's a strange story because the guys involved in the scandal know both me and representatives of the Ministry of Social Policy (and now there are really people there who take personally that everything should be well defined in the regulatory framework for prosthetics). In the scheme for the upper part of the prosthesis - the stump sockets (the part that attaches the prosthesis - ed.) - that was publicly announced, there was the use of public funds by enterprises on an excessive scale.
Previously, the relevant resolution provided for a single term - "repair" - for the case when a prosthesis failed. In other words, individual parts were not allocated, and the company provided services and indicated the amount of repair. The Fund for Social Protection of Persons with Disabilities analyzed these calculations. Sometimes they reached 200-300 thousand hryvnias for the processing of one stump socket, while the entire prosthesis costs about 500 thousand hryvnias. Therefore, it was decided to separate the processing of prosthetic sockets, which were probably subject to the highest drive-up, from general repairs. The new version of the resolution stipulates that a person can receive a replacement prosthetic socket as part of the repair, but that all the funds allocated for the repair of the prosthesis for the year should not be depleted at once. In other words, they stipulated that the prosthetic socket should be replaced as a separate part.
-The veterans' claims were about the red tape with the conclusions of the medical commission...
- If the prosthetist did his or her job poorly, the prosthetic socket should be replaced free of charge. If the person's anthropometric data changed, and the stump socket was not made in a hurry, then this requires a medical opinion that the person's anthropometric data has changed. And the problems began in this vein. Currently, the resolution stipulates that this document is the conclusion of several medical authorities, including the MMC. The process was not thought out from the point of view that when a patient is discharged from the hospital and a year has passed, he has lost contact with the multidisciplinary team of doctors who served him. However, after a year, he needs to seek a medical conclusion. I have been approached by veterans more than once to explain how to do this. Moreover, they sometimes created problems for themselves by including a family doctor in this chain. They need to contact those with whom they underwent rehabilitation. I know that many people don't even go to doctors physically, but send photos and videos of measurements. On the basis of this, they had no problem issuing a conclusion with which the person applied to the prosthetic company.
But some people took a more complicated route, which is why this problem arose. And when a problem is repeated systematically, I address it to the Ministry of Social Affairs. Therefore, at the time of the scandal, the process of amending the resolution was already underway. The changes were in development and had already been submitted for consideration. The next stage is public discussions, and this takes time - each time it takes from a month to three months for the amendment to go through all the instances and procedures.
- So what exactly is this regulatory change?
- If the replacement of the prosthetic socket does not exceed a certain amount (I think 15% of the cost of the product), then a medical commission's opinion is not required. But if the repair costs more, then a conclusion is required.
- Did you then talk to the veterans who were involved in the scandal? Did they understand the situation?
- They understood. Ms. Vereshchuk called a meeting, and we all came to it, including these veterans. We explained to them that changes were taking place. In general, it was a strange story.
PROSTHETICS IN UKRAINE ARE A HOT TOPIC WHERE YOU CAN MAKE MONEY
- Protez Hub reports say that there are about 80 prosthetic companies in Ukraine today, and there are some unscrupulous ones among them. Can you name them?
- It's hard to name them. To be honest, every company probably does something imperfectly, but there are those that heavily resort to fraud. For example, they submit documents about people who have already died, or overestimate the cost, or produce frankly low-quality products. We try to focus on patient feedback. We have a very detailed form on our website that we ask patients to fill out. Our rating of companies is based on these reviews. If we receive five or more reviews for one company, we form a rating as an arithmetic mean. However, not all of them have reviews.
- You are very insistent on prosthetics in Ukraine. In particular, for the reason that it is more affordable to have repairs or make fit in Ukraine. Is it possible to compare prosthetics here and abroad in terms of quality?
- There are good and bad service providers in both countries. In both Europe and the US, there are prosthetic centers that are either jury-rig or are not qualified to deal with such severe injuries as in Ukraine. We have specialists who have more experience with traumatic amputations. In countries that have not fought or actively participated in military campaigns, amputation experience is mostly occupational injuries or routine surgeries for diabetes, cardiovascular disease, and other common illnesses. Germany, for example, has a high level of experience with amputations but has virtually no recent experience with amputations as a result of combat. The United States or the United Kingdom have more experience, but again, the question arises that not everyone is honest and not everyone wants the best for our military. Nowadays, prosthetics are a hot topic for Ukraine, and one can make money on it. Someone is using this opportunity to develop their private business with donor funds, presenting it as a charitable activity.
CURRENTLY, UKRAINE DOES NOT REGULATE HOW MUCH A DISTRIBUTOR OF PROSTHETIC COMPONENTS CAN DRIVE UP FOR THEIR SERVICES
- Now there are complaints that the maximum prices for prostheses with increased functionality (for example, microprocessor knees) set in Ukraine are insufficient, meaning that such prostheses are more expensive. Why is this the case?
-In some cases, this is true. However, an interesting phenomenon is that if we consider the cost of manufacturing such a prosthesis in the United States, the funds allocated in Ukraine are sufficient, even taking into account the more expensive payment for the work of a specialist.
Photo is provided by Antonina Kumka
- How can this be if Ukrainian specialists receive significantly less money for their work?
- From what I can see, manufacturers set different prices for different regions. Plus, if components for prosthetic devices are sold in Ukraine through distributors, there is no regulation of how much the distributor will drive up for their services. This means that if the government triple the price of such prostheses tomorrow, distributors can quadruple their prices and say they don't have enough money. How can this problem be solved? We believe that it is necessary to change the principle of payment for prostheses. Today, the state pays for the entire prosthesis, for example, a lower leg prosthesis, without breaking it down into components. In my opinion, we should start doing this and say that the foot should cost a certain amount, the calf should also cost a certain amount, and so on. Then it will be clearer to see where the drive-up is happening. And why it turns out that in the United States you can get a prosthesis for the same amount of money, but not in Ukraine.
- Is there any data on the percentage of Ukrainian veterans who received prosthetics abroad?
-"We compared the numbers of people who received prostheses and those who received them under the state programme. It turned out that as of August 2023, 2.3% of veterans had received a prosthesis abroad. The rest received prostheses in Ukraine.
It should also be noted that in 80% of cases, those who go abroad to get a prosthesis receive it in Ukraine at the same time. Some have five prostheses from different charitable initiatives.
- Perhaps they differ in functionality? To what extent does the state guarantee the broad use of prostheses paid for by it? For example, is it possible to run or swim in them?
- There are four levels of human mobility, and depending on this, the state pays for the prosthesis - this is the case all over the world. Abroad, our veterans receive the same treatment as in Ukraine. Sometimes, when they raise money, they can install, say, an electric knee. This is also possible in Ukraine, but we need to improve the calculation system so that more services can fit into the marginal cost. However, the problem is not so much in the marginal cost as in the way different components are distributed within the marginal cost.
As part of the state program, a person first receives a simpler functional prosthesis, i.e. one that allows the most necessary movements. And to be honest, many people stop there. It suits people - they get a Volkswagen, not a Mercedes, but it better meets their daily needs. In a year, if there are indications, a person can apply for a prosthesis with the latest technology - increased functionality.
Although the concept of increased functionality is individual in each case. For a person with amputation of both arms, a bionic prosthesis on both limbs will not increase functionality. For them, conventional mechanical prostheses will allow for more active activities.
- And if the amputation is high, say, at the shoulder level, do you still have to wait to get a prosthesis of higher quality?
-No, such a person does not have to wait a year and can immediately receive a prosthesis created using the latest technology.
- Proper medical preparation should precede prosthetics. How many cases do you know of when a damaged limb was not properly prepared for wearing a prosthesis?
-Unfortunately, this often happens. At the beginning of 2022, when we did our analytics, a lot of guys claimed that the hospital did nothing at all about this. Now it's a little better.
However, the situation remains where the attention of Ukrainian and Western donors is focused on some prosthetic institutions, while others are ignored. There is an irrational distribution of charitable funds: some people know about some of them and bring them money in bags, while some regional hospitals may not be known, although there are also guys with amputations, but they are in no hurry to provide equipment or improve the skills of specialists. Or a new rehabilitation center is being built in a certain city, although the local hospital does not have the necessary things to prepare people for prosthetics. That's why whenever we organize professional exchanges for specialists, we try to involve people from remote regions or from district hospitals as much as possible.
Preparation for prosthetics is 50% of the success. If a person cannot move properly or if the residual limb is poorly formed, then there are big problems with prosthetics.
Photo is provided by Antonina Kumka
UKRAINE HAS CREATED A NEW PROFESSION OF "PROSTHETIST-ORTHOTIST", WHICH IS AVAILABLE IN ALL WESTERN COUNTRIES
-You pay a lot of attention to the training of prosthetics specialists. Tell us more about these programs.
- We are trying to develop a multidisciplinary approach to working with patients and constantly emphasize that different specialists should cooperate. In practice, this does not always work, but we should strive for it. We analyze what is currently urgent - for example, there are waves when there are especially many hand amputations. In response, we try to organize professional exchanges to improve our work.
For example, in March, we exchanged with the Americans on occupational therapy, daily living skills, and prosthetics for bilateral upper limb amputees. All the occupational therapists, even the experienced ones, said that it was the first time they had participated in training at this level. The whole exchange was very focused on a particular type of amputation and returning these people to an effective and independent existence in society.
As for prosthetists, an extremely important process is underway to change the system of training of top-level prosthetists. In fact, we are talking about creating a new cadre of specialists who are more clinical than technical. This is how it is in the United States, Europe, and it should be in our country because it is effective and helps to improve the provision of services to people.
- How long will such changes take?
- I have been personally working on this issue since April 2022. In 2023, the Ministry of Social Policy of Ukraine supported the initiative to create a new clinical profession of "prosthetist-orthotist" in the healthcare sector, the National Qualifications Agency approved the professional standard of "prosthetist-orthotist" in accordance with international standards, the Ministry of Health of Ukraine issued relevant orders and we, in cooperation with the Jönköping University and Kharkiv National Medical University, with the support of the Charitable Foundation Patients of Ukraine within the framework of the War Trauma Rehabilitation project, the American Certification Board, the American Board of Orthotics, and the American Society for Orthotics and Prosthetics, have already managed to accredit the first 14 experienced professionals in accordance with the new standard. Now, with the support of the Nova Ukraine Foundation, we are developing an educational standard for this profession at the master's level. This means that we are creating a new level of prosthetists, orthotists who will not just learn in a workshop but will have knowledge of anatomy, pathology, biomechanics, and multidisciplinary work. In addition, they will base their practical skills on the relevant theoretical medical knowledge, which greatly improves their understanding of how a person functions and how to make a prosthesis.
This is a separate category of changes. In September 2024, three such programmes are to be launched at different universities - Lviv National Medical University, Shupyk National University of Health and Kharkiv National Medical University.
A separate pathway has been developed for experienced prosthetists with the appropriate level of education. They can confirm their qualifications by completing a course and passing an international exam.
Photo is provided by Antonina Kumka
- From what you say, it seems that there is a shortage of prosthetists in Ukraine and quite a lot of them. Is this true?
- There is a certain shortage. Our calculations and comparison of different systems and WHO requirements show that by 2027 Ukraine needs to reach the level of 250-300 highly qualified prosthetists and orthotists, and slightly more prosthetic technicians. This number can be increased gradually.
On the other hand, a new problem is arising: prosthetists and prosthetic technicians are being issued draft notices, and several have already been taken away. If an enterprise faces a critical shortage of specialists, it stops working.
- You also highlight the problem that state funding is not enough for civilians.
- Civilians have always had a lower marginal cost than the military. It is enough for good prostheses, but civilians cannot afford bionic prostheses under the state program. It is worth noting that programs in other countries work in a similar way. For civilians, if necessary, the prosthesis can be financed by philanthropists.
Olha Skorokhod, Censor. NET
