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HEALTH CARE: GOOD INTENTIONS BuT OLD METHODS
Andrei Vitushka
Summary
2017 was characterized by a decrease in the birth rate with a relatively stable mortality and other demographic and health indicators. For the first time in Belarus the main factors of health risk of the population were defined according to international methodology. The informatization of the medical sphere was declared as a way to improve its situation (aside from budget cuts). The structure of the system and the relation of its elements remain predominantly vertical and command with the explicit desire to apply 'manual control' to it.
Trends:
• Important measures to improve medical system functioning were announced (the development of the institution of general practitioners, the expansion of e-Health, etc.);
• Changes are implemented by commanding and administrative methods without involvement of industry workers to solve its problems;
• The process of optimizing the structure of the health system is almost scaled down (reduction in hospital beds).
Demographic indicators and health status of the population of Belarus
At the beginning of 2017 at the final Board of the Ministry of Health the first Deputy Prime Minister, former Minister of Health V. Zharko said that 'in 2017 we need to maintain the natural increase of the population'.1 It is unknown where he received that information about the population growth, as according to the National Statistics Committee in 2016 the birth rate was minus 1.6 thousand people, and in 2017 it was minus 16.8 thousand people. Thus, the population decreased from
«Коллегия Минздрава. Итоги года 2016. Василий Жарко: не останавливаться ни на миг.» МедВестник. 2 Feb. 2017. Web. 30 Apr. 2018. <http://www.medvestnik.by/ru/officially/view/vasilij-zharko-ne-ostanavlivatsja-ni-na-mig-16124-2017/>.
9505 to 9492 thousand people2. Therefore, it is not possible to talk about growth; moreover the rate of loss was not fixed. As in the last 7 years, the labor pool declined by about 60 thousand in the year, while the number of citizens of retirement age annually increases by about 40 thousand. It should be noted that the number of people under the age of 15, during 2017 increased by 28 thousand, which is due to the increase in the birth rate that occurred prior to 20153 but this trend is not long-term because the thin generation of the 1990s entered the child-bearing age.
The birth rate last year dropped predictably by 12.9 percent: from 12.4 to 10.8 per 1,000 of population. Traditionally, the leader is Brest region (11.8 per 1,000 of population), followed by Minsk region (11.5 per 1000) and the worst indicator is in Viciebsk region and in Minsk (9.6 and 9.8 respectively).
The ratio of the overall mortality rate was 12.5 per 1000 (decreased by 0.1 to the level of 2015). The mortality rate of the working population remains high and is 3.8 per 1000 population (0.1 lower than in 2016) with a significant difference between Minsk and the regions (2.7, against 4.2 in Minsk, Homiel and Viciebsk regions). In Minsk almost one in five deaths occurs in pre-retirement age.4
The mortality of males under the age of 60 (international index) in Belarus is 3—4.5 times higher than in the 'old' EU countries.
The leaders of the cause of death have not changed — they are heart and blood vessels diseases (about 63%), the incidence of which rose by 4.3% last year, while the number of revealed cases is 18.2%. Overall mortality from these causes also increased, but not significantly — by 0.4%, while it fell by 0.1% among citizens of working age. The second place is taken by
«Численность и естественный прирост населения.» Национальный статистический комитет РБ. Web. 30 Apr. 2018. <http://www. belstat.gov. by/ofitsialnaya-statistika/soHalnaya-sfera/demografiya_2/g/ chislennost-i-estestvennyi-prirost-naseleniya/>.
«1нфографика "Рождаемость в Беларуси".» БелТА. 15 Aug. 2017. Web. 30 Apr. 2018. <http://www.belta.by/infographica/view/rozhdaemost-v-belarusi-8763/>.
«Минск в 2017 году.» МедВестник. 16 Feb. 2018. Web. 30 Apr. 2018. <http://www.medvestnik.by/ru/officially/view/minsk-v-2017-godu-17387-2018/>.
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cancer (approximately 14%), the overall mortality rate has no tendency to decrease (about 83 cases per 100 000 population).
In 2017 the first national survey of risk factors of non-communicable diseases (which are responsible for almost 80% loss of population) in the history of Belarus was completed among the population aged 18-69 (STEPS study).
The level of risk factors of non-communicable diseases remain high: about half of the male population and 13% of female are smokers, the level of alcohol consumption is high (up to 17.4 liters of pure alcohol per capita), a significant number of respondents are overweight (30% of women and 20% of men), they eat little fruit and vegetables and significantly overuse the consumption of salt. A combination of three or more risk factors were identified in 40.5% of the respondents, none of the factors was found only in 5.6% of participants.5
The STEPS study found that in Belarus the arterial hypertension is not controlled well enough, which is an important risk factor for heart attacks and strokes6 (almost half of the respondents (44.9 per cent) showed high blood pressure and more than half (53,4%) of respondents with high blood pressure said that they did not take antihypertensives regularly).
Life expectancy in Belarus in 2017 rose to 74.3 years (growth by 0.2 years as in 2015-2016). Slightly (by 0.2 years) decreased the difference in life expectancy between men and women, which is 10-12 years and a peak for Europe. 'At the pan-European picture, we look good', the Minister of Health Valery Malashka7 commented on these figures. To be more precise, we look better than Russia (72.5 years), Moldova and Ukraine
«Распространённость факторов риска неинфекционных заболеваний в Республике Беларусь (STEPS 2016 (2017).» Всемирная организация
здравоохранения. Web. 30 Apr. 2018. <http://www.euro.who.int/__
data/assets/pdf_file/0020/348014/STEPS-Report-for-site-RU-webpage-29082017.pdf?ua=1>.
«Преимущество в комплексном подходе.» МедВестник. 23 Mar. 2018. Web. 30 Apr. 2018. <http://www.medvestnik.by/ru/officiaUy/view/ preimuschestvo-v-kompleksnom-podxode-17528-2018/>. «Ожидаемая продолжительность жизни в Беларуси в 2017 году достигла 74,3 года.» БелТА. 1 Feb. 2018. Web 16 March 2018. Web. 30 Apr. 2018. <http://www.belta.by/society/view/ozhidaemaja-prodolzhitelnost-zhizni-v-belarusi-v-2017-godu-dostigla-743-goda-287432-2018/>.
(71 years), but worse than the European average indicators (77.2 years), and directly ahead of us is Albania (over 75 years).
The priorities of the health system
According to Minister Malashka, the main priorities of the Ministry in 2018 are activities aimed at improvement of medical-demographic situation. This is a difficult task, because to increase the birth rate is nearly impossible due to the small number of young women. The infant mortality rate is at a low level and has virtually no scope for reduction, and medical workers alone cannot affect non-communicable disease risk factors.
They plan to improve the situation by means of the work of the 'interdepartmental councils on demographic security, improvement of work with personnel, effective work of the obstetric-therapeutic-pediatric councils, etc'.8
Little is known about the specific content of interagency cooperation, but the improvement of work with the personnel was expressed in the introduction of additional reporting to the higher bodies in the form of weekly written reports by Fax to the Ministry of Health about all extremely bad patients in intensive care units across the country. Two months later, the order was canceled.
The best way to reduce the non-communicable diseases is to affect behavioral risk factors: smoking, alcohol consumption, low physical activity, unhealthy diet etc. The main burden of these tasks falls on the primary care. It was announced that preventive action in primary care should occupy at least 30% of the time, but it's unclear where to get it with all the amount of paper work, which health care providers should deal with.
It was stated that the central figure in primary care must become a general practitioner. Last year the number of professionals already made up 40.2% of all primary care physicians,
«Доклад министра на коллегии Минздрава "О работе органов и организаций здравоохранения в 2017 году и основных направлениях работы на 2018 год".» МедВестник. 8 Feb. 2018. Web. 30 Apr. 2018. <http://www.medvestnik.by/ru/officially/view/valerij-malashko-nasha-glavnaja-tsel-uluchshenie-demograficheskoj-situatsii-v-strane-17344-2018/>.
in 2018 it should be 60% and in 2020 the process of formation of this institution must be completed. Training and retraining are offered by all medical schools, changes were introduced in departmental staff schedule, and the current graduates of therapeutic profile are mainly general practitioners. But from conversations with freshly appointed 'multiskilled' doctors as well as re-trained therapists it becomes clear that this innovation in the Belarusian conditions is facing a serious legitimacy problem, when the doctors do not perceive themselves as 'respected universal soldiers at the cutting edge of medicine' but rather as local physicians, with expanded responsibilities for the same amount of money.
A new form of work with the population and its old contents
In 2017 to promote a healthy lifestyle in the society the Ministry of Health together with the departmental newspaper 'Medical Bulletin' created two Internet portals: 'Healthy people' (24health.by) and Teenage.by which contain information about ways of preserving health, news on the topic, there is a directory of medical institutions. As the creators say, the websites contain only correct medical content, they are eager to talk to visitors in plain language and to involve the best specialists. Thus, Belarus joined the progressive trend of so-called trustworthy health resources — websites that are made by medical associations or governmental public health agencies with the involvement of experts in various fields of medicine.
Strategy for optimization of health. Personnel problem
As in the last year, the informatisation of healthcare was declared as a significant measure that would improve the quality of medical care9. The first step in this process is the implementation of 'Electronic prescription', which in 2018 should be launched in
9 «Информатизация здравоохранения повысит качество медобслужи-вания - Малашко.» БелТА. 16 Mar. 2017. Web. 30 Apr. 2018. <http:// www.belta.by/society/view/informatizatsija-sfery-zdravoohranenija-povysit-kachestvo-medobsluzhivanija-malashko-237835-2017/>.
the operating mode throughout Belarus. By the time this article was written about 6,5 million electronic prescriptions had been issued which is not much given more than 90 million visits to doctors and clinics annually, but the growth dynamics is very positive (doubling in 2017).
The next step will be uniting of all medical institutions in a single network and establishing a common database of medical information about citizens of Belarus, which will be available from any medical institution of the country. For this purposes USD125 million were borrowed from the World Bank, and by 2019 the system will have been launched in general in Minsk. It is planned that in 2020, 100% of medical records will be in electronic form. Thus, Belarus now comes into the process which Lithuania completed in 2015, and Estonia, the leader of e-Health in our region did that as far back as in 2010.
Another component of e-Health of Belarus — consultations using telemedicine technologies — is also not yet visible: last year only 802 consultations were held, and only 30% of the connected institutions carry out such consultations on a regular basis, and some of the national centres do not have internal computer networks and ubiquitous Internet access.
Last year the process of reducing hospital beds slowed down with the transition to more efficient outpatient technology. Minister Murashka said summing up the results of the year: 'The reform is not the reduction of beds and personnel; it is a wise management of resources', which indicates a low willingness of industry leadership to address systemic structural changes. Perhaps this happened due to the increased funding for the sector in 2017 by 18%.
According to nationwide bank of vacancies in December 2017 nurses and doctors are mostly in demand among employers in Belarus (2446 and 2296 vacancies respectively)10. A shortage of 2,500 physicians is 6% of the total number of those who work. In the field the coefficient of secondary employment is very high — 1.3, and the average salary chronically falls short
10 «Рынок труда Беларуси испытывает дефицит медиков и водителей.» БелТА. 20 Dec. 2017. Web. 30 Apr. 2018. <http://www.belta.by/ society/view/rynok-truda-belarusi-ispytyvaet-defitsit-medikov-i-voditelej-281471-2017/>.
30% of the salary in industry and 20% of the average salary in the country.
Meanwhile, WHO experts have repeatedly pointed out that Belarus has a problem not with the number of health workers but with their poor distribution and shortage of primary care, especially in rural areas. until now, all measures to address this imbalance (forced distribution of young specialists, target allocation of medicals student, etc.) had no success.
Resonance public discussion in the sphere of health care
The most significant public debate in health care last year was the discussion of medical care in maternity hospitals of the country and the desire of women to give birth at home. The trigger for the discussion was the case of Viciebsk, when the local Department of the Investigative Committee initiated a criminal case against Volha Sciapanava for causing death by negligence to her child who died during home birth. The woman was sentenced to 6 months of a colony settlement, but she filed an appeal, where among other things she asked to punish medical staff for wrong assistance to her child. Re-examination of the case revealed numerous inconsistencies in the testimony of the paramedics of the ambulance and those in the hospital, where the child was taken, the court took Sciapanava's side, although refused to prosecute physicians. The country's Supreme Court confirmed the acquittal.11
In the process of public discussions numerous cases of improper (according to commentators) treatment of women in maternity hospitals of Belarus were mentioned as well as the failure to provide them with information and the violation of their rights. The response from officials of the Ministry of Health was the announcement of the figure of 230 births at home in 2016 and the statement that 'to have home birth is to have no
«Верховный суд оставил в силе оправдательный приговор по делу о домашних родах в Витебске.» Naviny.by. 5 Apr. 2017. Web. 30 Apr. 2018. <https://navmy.by/new/20180405/1522915560-verhovnyy-sud-ostavil-v-sile-opravdatelnyy-prigovor-po-delu-o-domashnih>.
responsibility to the newborn'12. It is significant that the wave of public attention to the topic of the survey of women about their experiences of child birth in Belarus was conducted not by governmental agencies but by public initiative 'Radziny'13. 1,100 respondents took part in the survey, 6.3% of whom gave birth at home because of the psychological comfort and the ability to give birth without medical intervention. The survey showed a high level of satisfaction of women interacting with women's consultations, but also demonstrated the problem of the availability of some services (60% of respondents applied for paid services because they could not get them for free (30%), and paid centers provide better quality service (16%). They also found problems in communication with health workers at the stage of maternity hospitals (37% said that they were not warned about medical intervention, which was carried out by doctors).The positive results of the public debate and (possible) interaction of the state structures and public initiatives such as 'Radziny' is the decision to permit the admission of relatives to the wards of maternity hospitals14, adopted at the beginning of2018.
Conclusion
Last year for the Belarusian medicine should be recognized as a year of important words and good intentions. The development of the institution of the general practitioner, information, control and improvement of quality, personalized therapy — all these measures to improve the situation in health care were suggested by domestic and international experts (see the publica-
«Роды дома — это эгоизм, а роддом — не тюрьма. Главный акушер-гинеколог страны о домашних родах.» TUT.by. 1 Oct. 2017. Web.
30 Apr. 2018. <https://news.tut.by/society/562677.html?crnd=19158>. «Жещины выбирают домашние роды из-за психологического комфорта.» Naviny.by. 29 Sep. 2017. Web. 30 Apr. 2018. <https://naviny. by/article/20170929/1506678195-zhenshchiny-vybirayut-domashnie-rody-iz-za-psihologicheskogo-komforta>.
«Родственники смогут посещать молодых мам в палатах роддомов.» БелТА. 24 Feb. 2018. Web. 30 Apr. 2018. <http://www.belta.by/society/ view/rodstvenniki-smogut-poseschat-molodyh-mam-v-palatah-roddomov-291392-2018/>.
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tion of the World Health Organization 'Belarus. Health System Review'15) in 2008.
Progressive ideas but the same old methods of their implementation: vertical administrative-command without the desire to provide some legitimation of innovations among the employees of the system and work on their support by population are evident. On the contrary, there is a tendency to narrow even more and formalize channels of communication from 'upwards' in the system, as well as a less balanced response to the negative queries from the population. Given that the very flawed structure of the system is not changed, and little is done to motivate its employees, the significant results of these activities should not be awaited for. In the next two years while maintaining a relative macroeconomic stability, the leaders of the medical sphere will develop digital health in the IT country. Not until they will figure out something new.
Richardson, E. et al. "Belarus: Health system review." Health Systems in Transition, 2008, 10(6). 1-118. Print.
