Health Care: End of the welfare state

Andrej Vitushka

Summary

After the critical 2011, last year was stable for health care in favorable demographic conditions. Medicine was developing along the established lines: with preference for high technologies and their development in regions. The trend for limiting the range of free medical services persisted as the sector management devised amendments to the Law on Public Health stipulating that citizens who were hospitalized in a state of alcohol or drug intoxication have to pay for their own treatment. Meanwhile, the Ministry declared the invariability of the present health care model and unacceptability of insurance medicine in the short term period. The private medical care sector saw no changes toward liberalization.

The amount of paid medical services in state health care institutions and the import substitution of drugs have increased. Nevertheless, it is obvious that the five-year plan is not going to be fulfilled.

Trends:
Demographic indicators and health level of the population

The National Statistics Committee (Belstat) reported that as of early 2013 the population of Belarus was 9463.8 thousand 1 and the population loss amounted to almost 1900 people. Meanwhile, last year showed positive demographic dynamics: the birth rate increased from 11.5 to 12.2 and the death rate reduced from 14.3 to 13.4 per thousand people. 2 As a result, president Lukashenko gave the Ministry of Health the task to reach the level of population increase. The official optimism was not marred even by the fact that during the first two months of 2013 the population declined by 2 thousand (more than in 2011 altogether) despite the increased birth rate. The leading causes of death remained traditional - heart problems (almost 53%), malignant neoplasms (14%) and “external factors” – injuries and intoxications. 3 The generally recognized factor of high death rate is a high level of alcohol consumption (10.22 liters of pure ethyl alcohol per capita), which significantly exceeds the UNO-established threshold indicator of 8 liters.

According to Belstat, the majority of the population evaluates their health as “satisfactory” (62.1%). Only 29.9% have a good health. The number of people doing physical exercises on a regular basis is constantly increasing (from 16.3% in 2000 to 24.7%) but remains small despite the significant state financing of the sector.

The key indicator of the living standard is the life expectancy at birth. In 2012, it was 70.6 years, including 76.7 years for women and 64.7 years for men, which is visibly lower than that in the EU and hardly reaches the level of 1990 in the Belarusian Soviet Republic. 4 The 12 year difference in life expectance for men and women remains too large as the “natural” difference established by the UNDP is 5 years.

Belarusian authorities especially pride themselves in reducing the infant mortality to 3.4 per thousand live births. This indicator is the lowest among the CIS countries; it shows positive dynamics and is comparable to the “old” EU countries. Nevertheless, the national estimations are different from those of the WHO Regional Office for Europe. For example, in 2009 they estimated the infant mortality at 11 per 1,000 live births (whereas the national statistics stated 4.7 per thousand), which is better than the average among CIS countries (24.1 per 1,000) but significantly lower than that of the EU (3.9 per thousand). 5

Among infectious diseases, international experts are most worried about tuberculosis and HIV. Belarus remains one of the world leaders in spread of the drug-resistant TB; HIV is also growing (by 2.3% in 2012). The majority of HIV-infected (59%) are young people aged 15–29 and the main transmission method is sexual contact (77.7%), which proves the system of fighting the spread of the disease ineffective. 6

Financing of health care

The state budget expenses on health care amounted to 3.6% of the gross domestic product. Eventually, the expenses reached 3.9% of the GDP, and in real terms the growth was 23.2%. 7 Out of the total BYR 18.2 trillion, BYR 14.4 trillion were sent to local medical institutions, as most national clinics had already been modernized.

Traditionally, the main recipient of financing are hospitals, as Belarus holds the first place in Central and Eastern Europe in the number of hospital beds per capita. Presently non-infectious chronic pathologies dominate among reasons for temporary disabilities that require long-term individual treatment, which calls for moving the focus of the health care onto outpatient departments, which in the EU countries receive up to 80% of financing. The WHO experts more than once have drawn attention to the fact that this imbalance should be dealt with to secure the sector’s financial stability and reducing its sensitivity to external factors. Local medical authorities more than once expressed their agreement with this opinion and underlined the necessity to develop the primary level of public health, for which, according to minister Zharko, 40% of the 2013 medical budget is to be allocated (compared to 30% in 2012). Nevertheless, the number of hospital beds is not being reduced, which is motivated by the need to develop hi-tech medical help in regions.

Despite the increased financing, the sector traditionally experienced a deficit of expendables as their consignments for 2012 arrived only in September. The issue of unsatisfactory provision of even national hospitals was raised during hot lines with the Ministry of Health, for example, the patients complained about the absence of prosthetic heart valves in the National Center Cardiology. 8 The explanation is simple. It is impossible to maintain a ramified system of hospitals, claim to have the European level of health care and allocate two times less financing than in Europe (4.5% of the GDP in Belarus vs. 7–9% in the EU).

Search for reserves and saving resources

Last year saw an active and multi-level search for means to save resources and define the inter-sector reserves to make ends meet. The trend was set by the sector supervisor in the government Deputy Prime Minister Anatoly Tozik. He proposed taking the symbolic BYR 5,000 for a visit to a polyclinic, not to support the outpatient sector but rather to relieve it. The proposal drew a wide public response as contradicting the present Constitution that guarantees a free treatment in state health care institutions. 9 But the idea imprinted deeply in the minds of the functionaries and in autumn the Minister of Health Vasil Zharko recollected it as reasonable and speculated what groups could be exempt from paying (for example, children). But he also pointed out that its implementation would be difficult as violating the norms of the Constitution.

The Deputy Minister of Finance Maksim Yermalovich continued discussing the issue of saving money in July. His opinion was that to secure non-deficit state budget, the current expenses for public health and education should be reduced by “placing these sectors into the real economy at the most possible degree and boosting the effects of their economic activities.” 10 In other words, no more free health care and education. The first to pay for their medical treatment are likely to be those who suffered an injury while being intoxicated by alcohol or drugs. This is the norm in the new version of the Law on Public Health introduced to the parliament by the Ministry of Health. It is almost definite that the changes will be passed, bringing estimated economic gain. International estimates of the injuries associated with alcohol consumption put figures as high as 30% of all injuries in Minsk. 11

The “trend of saving” was concluded by its setter, Mr. Tozik, who in his statement in late December declared that “the social sphere must not and has no more right to burden the real sector of economy and should find reserves inside its sectors.” According to the functionary, public health wastes up to 15% of its budget. 12

Reforms in health care: Promoting accessibility of the primary medical aid

Early in the year the Deputy Prime Minister Tozik demonstrated that he is a constructive critic of the Ministry of Health. The sector was reprimanded for being closed to public, absence of critical appraisal of its effectiveness and bad financial management. 13 Unfortunately, the deep understanding of the systemic problems of the sector found no realization in positive changes of its functioning or management. The Ministry confined itself to skin-deep changes. It stated once again that in the near future insurance medicine is not going to be introduced, though optional medical insurance was recommended. To improve the present financing mechanism, they proposed a pilot project in Mahiliou region and the city of Minsk to confer more financial freedom on local medical administrations.

As in 2011, there were many discussions that citizens abuse the accessibility of medical care, as the average number of visits to polyclinics per capita is twice as big as that in the neighboring countries. Besides the above mentioned proposal to introduce a symbolic fee for a visit to a polyclinic, the Ministry also suggested to introduce an improved system of making appointments, including the Internet, and some changes in writing out prescriptions and medical certificates. As a result, the validity of prescriptions for patients suffering from chronic diseases that have to be on constant medication was prolonged up to 6 months; doctors also received the right to write out a sick note for up to 10 days on a single case basis. In 7 metropolitan policlinics they introduced a know-how of writing out computer-generated prescriptions for chronic patients. The question of giving the private medical centers legal rights to write out sick leaves was once again positively rejected by minister Zharko in September 2012, but in late 2012 and especially in early 2013 news started arriving that this permission would be issued. 14

One of the most significant initiatives of the Ministry of Health was a campaign to enforce control over the over-the-counter drugs, which would supposedly reduce the number of self-medications and side effects. The response was really significant: both citizens and doctors expressed worries that, despite the rightness of the idea itself, the deficit of doctors in polyclinics would make the waiting lines even longer. As a result, the control was reportedly “tightened,” but practically it was relaxed by enlarging the list of over-the-counter drugs by 20%, including popular antibiotics and antihypertensive drugs. The benefits are obvious, the Ministry improved its image in the face of the people and the government, without burdening the primary level, as had been feared. The disadvantages are less obvious but none the less significant. As the 2011 study in the USA showed, almost one-quarter of all antibiotic prescriptions made by pediatricians “probably or definitely did not call for antibiotics.” 15 Besides intoxication, uncontrolled use of antibiotics raises the risk of antibiotic-resistant infections, complications, potential deaths and higher costs of therapy.

Directions of health care development

Transplantology showed significant achievements last year: the liver–heart complex was first transplanted in January and heart–kidney complex in February. Belarusian professionals have also made general arrangements for transplantation of lungs and heart; they also assisted in the first transplantation of a liver in Kazakhstan.

Belarus holds the first place in the world both by volume of hospitalization (every year around 30% of its population is treated in hospitals) and by the number of days a patient spends in hospital (circa 4 days a year for each citizen). 16 As noted above, this hospital domination makes the system resource-intensive, reduces its efficiency and raises susceptibility to external factors. Despite the stated goals to develop hospital-substituting technologies in polyclinics and direct more finances to outpatient services, little is being done in this direction. The focus is traditionally on developing high technologies, especially in regions: providing a wider spectrum of cardiac surgeries, endoprosthesis of joints, and developing regional transplantation centers. There is no doubt that hi-tech medical treatment should be developed, but in Belarus this development is growing more and more asymmetrical, when one sphere is developed at the cost of others and people still go for medical help to over-crowded polyclinics.

The danger of excessive promotion of high technologies in regions was demonstrated by the chief transplant surgeon Aleh Rumo. He said that the mortality rate after transplantation of liver in Belarus is lower than in Germany because operations are being performed in one place with respective technologies and trained specialists. 17 Now around 70 people are waiting for a liver transplantation in Belarus and all of them can be operated in one place only. The situation is quite the opposite with kidney transplantation. Now nearly 600 patients are on the waiting list and the number is growing. Last year only 201 operations were performed, therefore kidney transplantation should be developed in regions. On the other hand, kidneys have been transplanted in Belarus since the 1970s and Belarusian specialists are familiar with the procedure.

Paid services in public medicine

In 2012, paid services in public health institutions were offered more consistently. Unlike 2011, the economy was more stable, no devaluation took place, Belarusian money was not devaluated as fast, and therefore, plans for providing paid services were not increased. Over 10 months of 2012 Belarus export of medical services equaled almost USD 22 million exceeding the performance in 2011 by 16%. 18 It is worth noting that medical services formed only circa USD 5 million, the rest came from higher and post-graduate medical education (around USD 10 million), seminars, conferences, consultations and master classes.

Metropolitan doctors earned over USD 6 million in 2012, exceeding the results of 2012. 19 But this amount makes up only 9.6% of the sector budget.

Yearly results showed that by going at this rate the export of medical services is unlikely to be increased by 3.5 times as the Program for social and economic development of Belarus until 2015 indicates. Unlike the critical year of 2011, when the need for hard currency was very acute, this issue was hardly touched upon both in public and professional discourse in 2012. Little was said about marketing this product either inside or outside the country. As before, state medical institutions are underrepresented in the advertising landscape, not to speak about professional positioning strategies. There were also no reports that Belarus presented its medicine in the Customs Union countries.

Moreover, in the majority of institutions paid services have not become more comfortable. It is not rare that the agreement is signed in one cabinet, payment is made in another, and treatment is provided in a third one (often together with “free” patients).

It seems like with a better economic situation and reduced financial tension the sector managers’ interest for this issue began to flag, despite that the government regards paid services as an important reserve for raising salaries in medicine.

Pharmaceutical market and import substitution

Last year, the pharmaceutical market in Belarus overcame recession and grew by 2.88% in physical terms; and in money terms – by 25% in hard currency and even by 124% in Br. 20 This disproportion is accounted for the double devaluation in 2011 and gradual development of prices down to the pre-crisis level. In 2012 expenses on drugs grew from USD 69 to 86 per capita a year, while for the last five years they had remained stable (around 0.02% of the consumer goods basket). The share of domestic drugs increased insignificantly and equaled appr. 59% in packages. The market share in money terms amounted to 25% according to the marketing agency Intellix M and to 30.6% according to the director of the Department for Pharmaceutical Industry Henadz Hadavalnikau. 21 As since 2010 the share of domestic drugs in the market has increased by 1% a year, the ambitious goal of 50% seems absolutely unreal. The results of import substitution remained modest. Last year Belarus launched production of over 50 new drugs and saved nearly USD 73 million, which is rather unimpressive with a market capacity of USD 813 million.

This is partially accounted for by the low costs of domestic drugs (retail price of USD 1 for a package of domestic drugs and USD 4 – for imported). Nevertheless, the top two of most profitable pharmaceutical producers are Belmedpreparaty and Borisov Plant of Medical Preparations.

The market share of domestic drugs can be improved in two ways. Firstly, by raising prices and therefore reducing availability. Secondly, by launching production of new drugs. The latter is impossible without attracting investments, which, in is turn, has always been a sensitive issue for our country.

Staffing issue. Motivation of personnel

In 2012 the Minister of Health made a peremptory statement regarding the lack of qualified personnel in medicine. This problem was to be solved in 2014 when 3,200 young specialists of the largest intake of medical students in the history of the independent Belarus finish their practical training. Gradually the deadline was extended to 2015, but it is obvious that the bosses pin great hopes on their future colleagues. The latter are to work on the primary level of medical help where lack of staff is most severe. All in all, the degree of staffing in the sector is 94%, which is possible due to total job combining.

The situation with the staff deficit and chances for its elimination through raising the number of medical graduates is illustrated by the following “Minsk case.” In early 2012, medical functionaries reported a deficit of 700 doctors and 1,000 nurses, afterwards, 516 doctors and 378 nurses were placed. Finally, at the beginning of the summer the personnel deficit equaled 1,000 doctors and 1,700 nurses. 22

According to minister Zharko, at the moment 32 thousand doctors are employed (32 doctors per 10 thousand people), which corresponds to the European norms of 30 doctors per 10 thousand people. Although no one mentions that our citizens visit policlinics three times more often than Europeans and receive more treatment in hospitals than anybody else in the world.

Over the last year the average salary in health care amounted to BYR 3 million 76 thousand, which is 27.2% less than in industry and 17.8% less than in all economic activities. The average salary of doctors equaled BYR 5 million 46.3 thousand, with a job combining factor of 1.4, and that of nurses – Br 2 million 992.2 thousand, with a combining factor of 1.2. If we calculate these figures for a 40-hour week (as most people in the country work), the salary of the doctor will be 14.6% less than the average in industry and that of a nurse – 41% less.

The salary growth averaged 20.4% (21.5% for doctors and 22.4% for nurses), which correlates with the country’s average of 20.6%. The most significant growth was achieved for nurses engaged in high-tech operation and intensive therapy after them. The increment for high-tech work is up to 160% of the salary but only 10% of all nurses receive it. These new bonuses improved the situation with nurses in intensive wards in regional capitals but helped little in Minsk (81% and 61% of staffing respectively).

The most important improvement of working conditions for medical staff might be the norm of compulsory life and health insurance of medics in the new version of the Law on Public Health.

Nevertheless, as said before “the social sphere has no more right to burden the real sector of economy”; therefore, salaries in health care are not going to increase more than the average in the country.

Conclusion

Public health requires reformation, just like in previous years. But the present management is not ready to abandon the course set as far back as in 1994 and will continue playing the game of “health care of a world level” without any deep transformations of the sector. In the near future the tendency for widening the number of paid services at the cost of free ones and implementation of high technologies, including in regions, will increase.