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HEALTH CARE: STATUS QUO ABOVE ALL Andrei Vitushka
Summary
2016 was characterized by a relatively favorable continued demographic situation, but natural population growth is still out of reach. There were no significant changes in the functioning of the health care system, which is preserved the way it is. Proposals were made to improve it by a range of cosmetic measures but without adequate support of the needed resources.
Trends:
• Attempts to preserve the old model of health care are made and any reform of the sector is reduced to cosmetic changes;
• State funding does not increase, the orientation on self-financing is intensified, the problem of shortage of working capital in the system grows and salaries of health care personnel are on the decline.
• There are cases when dissatisfied groups of patients and physicians start to articulate their interests.
Demographic indicators and health of the population of Belarus
The demographic situation in 2016 in Belarus developed in a similar way as in 2014—2015, when the birth rate was almost equal to mortality. First Deputy Prime Minister, former Minister of Health Care Vasily Zharko at the final board of the Ministry of Health Care said that "in 2017, we need to preserve the natural population growth"1. In fact, in 2015 the overall mortality rate did not change (12.6 per 1000 people), with some reduction in birth rate (from 12.5 to 12.4 per 1000 people). A positive balance cannot yet be achieved, although the population increased a little (from 9480.9 thousand in 2015 to 9498.4 thousand at the beginning of 2017), as earlier, due to migration. The mortality rate slightly decreased (0.1 per 1000 people — 0.1%) in Brest region,
«Коллегия Минздрава. Итоги года 2016. Василий Жарко: не останавливаться ни на миг.» МедВестник.Ьу. 02 Feb. 2016. Web. 05 Apr. 2017. <http: //www. medvestnik.by/ru/ officially/view/vasilij -zharko-ne-ostanavlivatsja-ni-na-mig-16124-2017/>.
Viciebsk region, Homiel region and Minsk, by 0.2% — in Minsk region, it did not change in Mahiliou region and increased by 0.2% in Hrodna region. The difference in mortality between Minsk (8.7%) and other regions (from 12.6 in Brest region to 14.6% in Viciebsk region)2 remains impressive. This situation is explained both by the younger age of Minsk residents and by regional differences in the development of medical care. The leading causes of death are still cardiovascular and oncological diseases, as well injuries and poisoning, but some reduction in these positions is achieved in all regions of Belarus.
The main paradox of the national medical statistics in 2016 is zero maternal mortality. For comparison: in Scandinavian countries which occupy 5 top positions in the ranking of the best places for giving birth to children, which is made up by the competent international organization Save the Children, somewhere from 3 to 6 women die during childbirth per 100 000 live births.3 However, last year, the media presented the facts of the deaths of 2 women after childbirth in 2015—2016 in one hospital in Maladziecna. It is also known about two more cases of women's death in the postpartum period last year, but this fact did not become known to the public.
The reason for this discrepancy is simple: the indicator is included in different international rankings, and as such cases are really rare (5 per year across the country), the temptation of manipulation is very high. This situation does not add professionals' trust to the national medical statistics, and the concealment of such facts interferes with sincere and thorough professional analysis of these situations.
It is expected that the average life expectancy of Belarusians in 2017 (the integral indicator of the effectiveness of the health
"Demography." National Statistical Committee of the Republic of Belarus. Web. 05 Apr. 2017 <http://www.belstat.gov.by/en/ofitsialnaya-statistika/ social-sector/demografiya_2/>.
See: "Save the Children. State of the World's Mothers." Save the Children. Web. 05 Apr. 2017 http://www.savethechildren.org/atf/ cf/%7B9def2ebe-10ae-432c-9bd0- df91d2eba74a%7D/SOWM_ EXECUTIVE_SUMMARYPDF >;"Maternal mortality ratio (modeled estimate, per 100,000 live births)." The World Bank. Web. 05 Apr. 2017. <http://data.worldbank.org/indicator/SH.STA.MMRT>.
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care systems) will be more than 74 years (when this article was written there was no official data available). At the 5th all-Be-larusian People Assembly A. Lukashenka said that by 2020 this figure will have been at least 75 years.4 The Council of Ministers clarified this position in the state program People s Health and Demographic Security for 2016—2020, having focused on 75.3 years.5 Given the recent trends (an increase by 4—6 months in 2014—2015), it is easy to imagine that the task will be fulfilled, but even then the lifetime will be significantly lower than in the EU countries. Aging of population will not only reduce revenues from income tax (to partially offset this factor the decision to raise the retirement age was adopted in 2016), but it will create an additional burden for the health care system due to the accumulation of chronic diseases.
A big difference in life expectancy of men and women remains (women live for almost 10 years longer), as well as between urban and rural population (rural inhabitants live 5 years less). It should be noted that in 2015 and 2014, this difference decreased till 4.8 and 4.6 years, respectively, but remained significantly greater than, for example, in 'the turbulent 90s' (2.7 years in 1995) or at the beginning of the 2000s (3.9 years). For comparison, in neighboring Poland the difference is about 1 year, in the USA it is about 2 years, and in the UK, villagers live 2 years longer than urban dwellers. The persistent difference in life expectancy in the city and in rural areas eloquently describes the 'successes' of the Belarusian state medicine which for 15 years has given priority to the development of medicine in the regions.
In addition to life expectancy, essential meaning in the assessment of the health care system in the country is given to
«Вступительное слово и доклад Президента на пятом Всебело-русском народном собрании.» БелТА. 22 June 2016. Web. 05 Apr. 2017. <http://www.belta.by/president/view/vstupitelnoe-slovo-i-doklad-prezidenta-vmeste-za-silnuju-i-protsvetajuschuju-belarus-na-pjatom-198664-2016/>.
«Правительство "обязало" белорусов жить почти на год дольше.» Sputnik Belarus. 23 Feb. 2017. Web. 05 Apr. 2017. <https://sputnik.by/ society/20170223/1027579311/pravitelstvo-obyazalo-belorusov-zhit-pochti-na-god-dolshe.html>.
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healthy life expectancy, i.e. the number of years which a citizen can live in a good health without disabilities. In Belarus the figure is 65.2, which is 5 years less than in the EU (70.3 years).6
Funding health care and priorities of medical care
In early 2016, it was stated that despite economic difficulties, expenses on health care would be increased by 5 trillion BYN before the denomination. But in dollar terms the funding did not increase and as in 2015 it was about 200 dollars per citizen annually. Methods of maintaining and increasing the amount of money in the system remained the same: saving the budget and resources, extra-budgetary activities (mainly paid services in public health institutions for Belarusian citizens) and exports of services (rendering them to non-citizens of Belarus).
Contrary to the statements of the officials concerning the fact that "the whole world comes to us for treatment", paid services to foreigners are still not a mass phenomenon and, accordingly, a minor source of budget funding. Viciebsk doctors, who work with Russians who come for examination, treatment and birth giving, earned only 2 million dollars in 2016, and their Minsk colleagues (together with oncologists and transplantologists, whose treatment in the whole world is expensive) earned 10.5 million dollars.
However, the financing of the sector from non-budgetary sources is constantly growing (in Viciebsk region it increased from 6.3% in 2010 to 15.2% in 2016)7, all regions reported about the overfulfillment of the plans. This trend shows a continued departure from free medicine. In conditions of deep-rooted deficit of personnel in state medicine, it is inevitable that paid services will substitute free ones.
«Беларусь отстаёт от Европы на 5 лет здоровой жизни.» Naviny.by. 16 Nov. 2016. Web. 05 Apr. 2017. <http://naviny.by/ article/20161116/1479317176-belarus-otstaet-ot-evropy-na-pyat-let-zdorovoy-zhizni>.
«Витебская область в 2016 году. Итоговая коллегия.» МедВестник.by. 28 Mar. 2016. Web. 05 Apr. 2017. <http://www.medvestnik.by/ru/officially/ view/vitebskaja-oblast-v-2016-godu-itogovaja-konegija-16326-2017/>.
Unlike in previous years, in 2016 there were no openings and launching of significant hospitals and centers covered by state media with the participation of the county's highest leadership. Worth mentioning might be the appearance of two new outpatient clinics in Minsk residential areas and the opening of a new building of the capital's pathoanatomical bureau (which is not the best occasion to invite the Prime Minister).
Last year for the first time the President of Belarus said that state medicine is the most productive system that serves the population in the best way.8 Thus, it can be assumed that the state decided on the model for further development of the health care system and that the discussions about the introduction of universal health insurance in Belarus have a purely academic value.
In previous years, much had been said about the need to reduce hospital beds (Belarus is one of the leaders in the world in the number of beds per capita). It was said that up to 80% of health problems should be solved during the prehospital stage, such arguments were mentioned as the international experience (in developed countries, 80% of the funds are spent on the development of primary care medicine) and economic calculations (in Minsk a visit to hospital costs BYN 13.26 on average, and a day of hospitalization — BYN 103.7). But since 2013, the reduction process has gone very slowly, and, as the new Minister of Health Care Mr. Malashka said, "in the development of hospital-replacing technologies in outpatient organizations the number of patients does not increase due to the lack of availability of outpatient services". As a result, according to the Minister, "the follow-up care mortality is growing; weekends and holidays drop out of rehabilitation activities."9
Also a symptom of imperfect work of primary care in Minsk is the late detection of malignant tumors (so-called 'oncological neglect'). In 2016, 19.2% of patients were diagnosed with late
«Итоговая коллегия 2016. Под особым контролем.» МедВестник.Ьу. 02 Feb. 2016. Web. 05 Apr. 2017. <http://www.medvestnik.by/ru/news/ view/pod-osobym-kontrolem-16125-2017/>.
«Больные в коридорах, и один туалет на отделение. Что не так с минскими больницами.» Naviny.by. 21 Feb. 2016. Web. 05 Apr. 2017. <http://naviny.by/article/20170221/1487655189-bolnye-v-koridorah-i-odin-tualet-na-otdelenie-chto-ne-tak-s-minskimi>.
i.e. stage 3 and 4 of cancer, and in 2015 this number had been 15.3%. Patient survival for 3 years with stage 4 of cancer is 5.0%, with stage 3 - 50.0%, while from 80.0% to 100.0% percent of patients with stage 1 and 2 survive.10
2016 saw a slight decrease (2%) in the number of written requests to the Ministry of Health Care, according to the survey of patients of Minsk hospitals only 70% of the respondents estimated their work as positive.
It is significant that at the final board of the Ministry of Health Care among the topical challenges which the industry faced was "the relevance of optimization of the route of a patient, taking into account the features of the national model, where along the low funding the development of primary care with focused specialists, day hospitals, emergency medical service and the high level of hospital care with elements of medical-social care are developed in parallel". Simply put it means that so far no magic bullet has been found to make "the unique Belarusian model of health care" work effectively without any changes.
Optimization of the functioning of the health care, personnel problem
A reduction in visits to outpatient clinics, better use of IT and the development of the institution of the general practitioner were announced as means to improve the functioning of the system.
According to Deputy Prime Minister Mr. Zharko, in 2016 the number of visits to clinics decreased by 25% due to improvements in administrative procedures. The better use of IT in the industry is a correct technical measure, which, however, requires significant investments, advanced training and can bear fruit only in the presence of trained and motivated staff. An eloquent example of the implementation of informational technologies in medicine is the Electronic Prescription system, which was planned to be implemented throughout the country in 2016, but in reality it functioned only in Minsk at the end of the year.
«В Минске растёт онкологическая запущенность.» Naviny.by. 18 Feb. 2016. Web. 05 Apr. 2017. <http://navmy.by/article/20170218/1487413740-v-minske-rastet-onkologicheskaya-zapushchennost>.
Last year the requirement was made to transfer primary care physicians of outpatient clinics to the work according to the principle of the general practitioner till 2020. In fact, the idea is good (at least because the effectiveness of the work of such broad specialists is 1.3 times higher than that of a primary care physician), but it has no chance to be successful in Belarus. Such 'universal' doctors of primary care medicine require specialized and extensive training, as well as adequate compensation for their work (their salary is 2—2.5 times more than the average in the country). Meanwhile, the salary of general practitioners is not more than BYN 600, which is comparable with the wage of a nurse in Minsk.
According to first Deputy Minister of Health Care D. Pinie-vich, the coefficient of compatibility of domestic physicians is 1.3, and that of advanced practice workers is 1.4. Thus, one can say that the situation with the personnel of the industry does not change (quotient reduction by 0.1 during five years). Once again the promises to solve the personnel problem were given (this time in 2017), now it is planned to do it by means of increasing target enrollment in medical schools (40% of the total number of budget positions). It should be noted that such a solution to the staff problem has been promised for at least three times over the last 5 years.
Meanwhile, the salary in the medical sector in 2016 returned to the level of the salary a decade ago with no prospects of significant growth due to a deep-rooted lack of funds. Newly appointed leadership in the sector recognizes that salaries in the system are 18% less than in sectors in the economy, but they do not articulate any plans to increase employee motivation.
Public pressure on the health care system
Due to the growing influence of social media last year, there were some significant cases of actualization of socially important problems in the field of health care.
In October 2016 the online magazine Names published an article about the absence of special nutrition and rehabilitation in a specialized boarding school for children, which re-
sulted in a clear underweight of patients with hypotrophy on the background of neurological disease.11 The reason for the publication was the post of a pediatrician from that special boarding school on a social network about a charity football match, with the help of which it was planned to raise money to buy special enteral nutrition. As a result, the publication received a great response, the first half of the required sum was collected during one day, similar institutions across the country were inspected and the special nutrition started to be bought from state funds. The achieved changes as well as the fact that doctors who showed their civic stand and went against the authorities, could keep their jobs (due to public pressure) create a precedent for the successful struggle of doctors for patients' rights.
Also last year there was a headline-making round table on the problems of diabetes in Belarus, where patients shared the difficulties they face in everyday life.12 According to the results of the round table discussion, which was covered by all key independent electronic media, it became clear that there is a violation of the principle of fairness in the provision of medical care to these patients (which leads to many violations of their rights), also a substantial lagging behind of the domestic endocrinology in the treatment of this internationally significant pathology was identified.
A less resonant, but not less important event was a series of articles in the media about the problems of children with phenylketonuria, where the violation of the principle of equity in providing medical care and implementation of social policy for this category of patients was also found.
Thus precedents for the articulation of interests of dissatisfied patients were created, which promotes the restoration of a disturbed feedback in the health care system.
«В 27 лет Артём весит как трёхлетний ребёнок. Почему полсотни сирот в минском интернате не могут набрать вес?» Имена. Web. 05 Apr. 2017. <http://imenamag.by/ne-mogut-nabrat-ves>. «Недоступные помпы и белорусско-китайский инсулин. Больные диабетом рассказали о своих проблемах.» TUT.by. 19 Nov. 2016. Web. 05 Apr. 2017. <https://news.tut.by/society/520169.html>.
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Conclusion
In 2016, the leadership of the industry was concerned about performing the most important task which the entire governmental system of Belarus faced, i.e. how to develop without changing anything. However, it is clear that this paradigm is not compatible with the construction of health care according to modern standards adopted in our part of the world. But if there is relative macroeconomic stability, this tendency will continue in 2017.
