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HEALTH CARE:
UNDER THE PRESSURE OF OPTIMIZATION Andrej Vitushka Summary
2013 was characterized by a relative stability of economic indicators in the development of the country and therefore by the absence of considerable incentives for changes in the system of health care. There was no revision of the principles of free medicine for some categories of citizens which had been planned for a new edition of the law On health care. Meanwhile at the level of by-laws some essential changes were introduced. For the first time in the power discourse one could hear that citizens are responsible for their own health and not the doctor, which is an essential innovation in the Belarusian health care. The priority of the medical care for the first time became the primary health care, but this declarative reorientation had no essential changes in resources and staff. Many speeches were devoted to the optimization of the structure and mechanisms of the branch functioning - except for the ‘educational’ work with the population on prevention of abuse of the availability of medicine, and important by-laws were adopted, which affected the functioning of the primary health care level. The most burning issues of the medical system led to Belarus’ first mass appeals of emergency doctors in order to protect their rights.
Trends:
• Essential growth of paid medical services;
• Optimization of the health care structure and functions based on the stated purpose of additional resources for motivation of the personnel;
• Reductions in the branch which reduced rather than increased the material motivation in the system;
• The statements on global reformatting of the system, starting from the rising of the responsibility of the population for health; the change of primary level, comprehensive medical audit and a personnel motivation reform.
Demographic indicators
and health status of the population
In 2013 the tendency of insignificant stabilization of demographic indicators proceeded, since 2012 the birth rate continued to grow (from 12.2 to 12.5 newborns per 1000 people), and mortality decreased (from 13.4 to 13.3 dead per 1000 people), but the demographic balance remained negative, though reached the minimum
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values (minus 6.3% (7409 people) against 9.2% in 2012). Thus, the Ministry of Health Care did not cope with the task to bring about an increase of the population, set by the country leaders.1 However, there was not a single chance for that, at least because according to the criteria of the World Health Organization (WHO) the condition of the medical care determines only about 10—15% of human health, while the way of life determines more than half. Meanwhile according to the last year researches in the country 91.3% of men and 85.7% of women of labor pool have from 1 to 5 of ‘behavioral risk factors’ which worsen the health state. Therefore the task of increasing population was performed by migration in the results of which 11,643 people were added, which provided the increase of the number of citizens by 4,200 people in comparison with the beginning of the last year.1 2
Nevertheless, the Ministry of Health does not shy away from ambitious tasks and does not hesitate to report about its achievements. Thus, the Minister Zharko, analyzing the system development in 2013, pointed out a series of positive results: the already mentioned decrease in mortality by 0.1%, the growth of birth rate by 0.3%, life expectancy by 9.5 months, and also the decrease of the number of deaths from the most serious diseases — heart and coronary (by 0.4%), neoplasm (by 2.6%), and also external factors (by 10.6%). Besides the physicians can add to their achievements one more—the decrease of mortality from oncology as a result of work with doctors of the primary level on purposeful identification of malignant tumors.
There is nothing to be proud of about the stabilization of indicators of mortality rate caused by heart problems and strokes, because for example, in the neighboring Poland it is one third times less than ours (the decrease began in the 1990s), and in the countries of ‘Old Europe’ it is 3—4 times less (decrease since 1980). An undeniable merit of the system in the terminations of this type of mortality is the rise by 20% of the number of cardiac interventions, lots of which are carried out at acute myocardial infarctions, which makes us closer to the civilized world. Among
1 http://www.belta.by/ru/all_news/soclety/V-Belarusl-v-2012-godu-slozhllls-nalluchshle-demograflcheskle-pokazatell-za-poslednle-10-let_i_629063.html
2 http://belstat.gov.by/homep/ru/lndlcators/pressrel/demographlcs.php
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important preventive measures which can improve situation is the development of the bill On protection of public health from consequences of tobacco consumption3, because after the introduction of anti-tobacco laws in the developed countries the number of smokers and, respectively, infarcts and strokes decreased significantly.
Decrease of the general mortality affected the rise of life expectancy till 72.2 years. At such rate, in a couple of years we will be able to reach the maximum indicators of the BSSR in 1969 — 72.9 years. Then the next step could be China or Estonia — where the life expectancy is about 73 years, and further — the European Union, where this number reaches 76 years4. As for the external causes mortality, its decrease can be explained by the reduction of the number of road accidents with lethal outcome (by 14%), and also murders (by 6.5%)5.
The demographic situation and last year’s indicators of Belarusians’ health again showed the importance of the primary level of the medical care where there is an identification and treatment of socially important and most lethal diseases. Also it became clear that with all statements about the preventive orientation of our medicine under conditions of insignificant financing (5% of the budget in comparison with 50% in developed countries6) and chronic overload of medical employees by duties the efficiency of preventive programs cannot but remain low. Meanwhile, in early 2013 an important message about the need to raise the responsibility of citizens for their own health came from the nation’s leadership.7 But as these words did not become the guide to actions, employees in this sector still feel they are being blamed for the poor state of health care in Belarus.
Economical economy of the branch
According to the deputy prime minister Anatoly Tozik, “the government observed the promises to finance the branch with
3
4
5
6 7
www.belta.by/ru/all_news/soclety/Belorussklj-antltabachnyj-zakon-
ogranichit-dostupnost-sigaret_i_646863.html
http://www.mednovostl.by/journal.aspx?artlcle=5050
http://mvd.gov by/ru/maln.aspx?guld=8141
http://cardio.by/page/view/statyasldorenko_page
http://ng.by/ru/issues?art_id=72753
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not less than 4% of GDP (in 2013 it was 4.09%, and in 2012 — 3.6%)”8. The position of the WHO as usual was not voiced, according to which the health system (in particular a state one) can develop only when not less than 5% is spent for it. Governmental officials promise a further but small rise therefore the principle ‘poor but pure’ will remain topical for a long time for Belarusian medicine. While governing bodies of the branch occupy the minds of the top leadership and their subordinated with the idea of saving funds, referring to WHO data that 20—40% of financing of medicine is wasted. The campaign of rationalization of resources use should have been begun with personnel decisions, but our solution was as the proverb says “an old ox makes a straight furrow” therefore last year in the medical public discourse a lot of attention was paid to traditional means of funds saving such as ‘spare water, turn off the light’ with some innovations.
It is worth noticing that there was no revision of the principles of free medicine for certain categories of citizens about which so much was said from different tribunes and which was awaited in the new edition of the law On health care.
Nevertheless, the problem of partial compensation to the state of expenses on treatment of drunken patients was solved much more elegantly. At the end of June the resolution of the Council of Ministers approved a new regulation9 concerning the sick pay according to which the person does not get any pay during the first 6 days if the incapacity to work was a result of a disease or trauma caused by alcohol or drugs intake. Thus it was succeeded to keep the concept of ‘free medicine’ intact and to create the base for receiving compensations.
Ways to optimize the branch
The other way to save funds was a declared by the nation’s leadership ‘optimization and removing of the unnecessary’. During 2013, 1.4 thousand of health care workers, mainly from administration, personnel, economic, accounting and other non-medical departments were dismissed.10 At the same time
8 http://medvestnik.by/ru/issues/a_10104.html
9 For the text of the document see: http://www.pravo.by/main.aspx?guid= 3871&p0=C21300569&p1 = 1.
10 http://www.pravo.by/main.aspx?guid=3871&p0=C21300569&pl=l
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it was said that the dismissed administrative workers would strengthen an outpatient level. It is interesting that the purpose of ‘optimization’ was declared as a search of additional resources for medical workers payment. However in practice the salary even became lower. So at the end of 2012 the doctor’s salary made 90.8% of an average salary around the country, and in late 2013 only 87.7%.
The old way of ‘optimization’ of the system continued to be breaking the habit of abusing the availability of medical care. The idea is not new11, but in 2013 every medical official — from ministers to deputies — considered it their duty to reproach people for frequent appeals to day hospitals, unreasonable hospitalization and excessive calls to ambulances.
There were some financial measures as well. For example, a new norm was introduced into the above mentioned regulation on sick pay, according to which the sick pay, equal to 80% of an average salary, is extended from 6 to 12 days. As the majority of sick leaves are given for the term till 12 days, no wonder that day hospitals at once experienced a decrease in the number of patients at the expense of elimination of those who want to have a full salary without going to work. As a result the expenses on financing of temporary disability decreased, which, probably, will make citizens be more attentive to doctors’ advice.
Paid services which are traditionally perceived as a resource of additional financing of the branch, showed last year an essential growth from USD 23.7 million in 2012 to more than USD 30 million in 2013. Meanwhile, even the enlarged indicators together with other off-budget earnings constituted 10% of the total amount of financing of the branch, which is not so bad, because a more active commercialization of state medicine at its limited resources surely would limit the accessibility of medical care.
Thus, the reasonable idea of optimization of the structure of health care connected with the search of reserves for the motivation of medical workers about the need of which international experts spoke so much, failed. It failed in the sense of compliance with a set target which, however, did not surprise
11 Vitushka A. Health Care: End of welfare state // Belarusian Yearbook 2012. Minsk, 2013. P 205—216.
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anybody — it was instantly clear that resources are looked not for the motivation of workers, but for the system to live ‘hand to mouth’. On the other hand, last year showed that profile officials can not only do ‘persuasion and educational work’, but also suggest rational mechanisms how to solve problems.
Emphasis on the development of primary medical care
Last year for the first time in Belarus it was clearly declared about placing emphasis on the development of primary medical care.
In order to financially support this extremely important branch statements were made about the growth of expenses on it from 30% to 40%, and it was promised to liquidate staff shortages (from 30% to 40% in different regions) in 2014. The problem of personnel imbalance (in Belarus only about 13% of doctors work at the primary level, whereas in the countries of the European Union this number is twice more) has not even been looked into. Among new measures for relieving the work load of doctors working at day hospitals is the introduction of the position of a medical assistant (who is appointed from nursing staff), but the number of newly created positions hardly exceeds 10% of the number of primary care doctors in Belarus. Therefore it cannot be considered as an essential factor of out-patient load reduction.
As well as in previous years, the question about relieving the work load of state day hospitals due to the permission to issue sick-leaves by private health centers was discussed. But as earlier it reached the form of a farce — at first they almost announced this permission, and after 4 days publicly expressed mistrust and rejected the idea until the right time comes.
2013 important events in the health care sector
At the end of the year doctors of several first-aid stations in Minsk and their colleagues from Baranavicy signed appeals to the Ministry of Health Care and other decision-making centers at the state level where they outlined the problems of the branch and made demands on higher salaries and improvement of working conditions. This event was fixed in public consciousness as ‘a strike of emergency doctors’. Though there was no strike (they
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did not stop working, and there were no other forms of struggle except for the appeals), nevertheless it was the first organized action of medical workers for their rights.
As a result the personnel of ambulances received from the government a promise of higher salaries but only in 2014. The branch trade union submitted to the Ministry of Health Care detailed suggestions on how to raise salaries and improve working conditions. The society actively discussed working conditions of doctors. Medical workers of Minsk achieved a pay rise of BYR 160,000—500,000 per month starting in 2014, but at the same time the first deputy chairman of the Health Care Committee of Minsk city executive committee Ihar Yurkevich said that reserves for pay rise of ambulance personnel in the framework of the legislation are already exhausted.12 The pay rise in 2014 promised by the government turned out to be a recommendation to local executive authorities to raise ambulance personnel salaries by 40% since April at the expense of local budgets.
Conclusion
One could call the decisions of the final investigating committee of the Ministry of Health Care with the participation of deputy Prime Minister Anatoly Tozik concerning the work of the branch in 2013 as sensational — so many worthy suggestions on optimization of work of the branch. Here one could find a revision of cases when a patient can address day hospitals, when a patient should be taken to hospital, when he/she can call the ambulance, and even plans how to raise salaries to medical workers up to 150% of the level in industry, etc. But the strong feeling of deja vu prevents any rejoicing. A lot of things were once subjects of discussion at the levels of the prime minister and his deputies both last year, and two years ago. The j oy caused by the fact that the government understands the problems of the branch gave way to expectations and demands on real actions, often with a very negative emotional coloring.
12 http://doktora.by/novosti-mediciny/srednyaya-zarplata-minskogo-vracha-prevysila-7-mln-rubley-soobshchili-v
