The year of 2014 was characterized by a relatively favorable demographic situation. The functioning of the health care system went in a mode of costs optimization and savings. As a result it became possible to slightly reduce the load of outpatient and inpatient management. Outpatient service once again was named a priority of medical care but its funding has not increased. The reduction of procurement of foreign medical equipment, consumables items and imported components for equipment of domestic production continued. As before nothing has been done to optimize the use of the existing equipment. The staffing issue, which they had promised to address to in 2014, was not resolved. Measures of financial stimulation of employees did not have any significant effect.
- There is still a trend for saving resources and their optimization;
- The emphasis on the development of primary care is stated, which is however not supported by resource provision and staffing support;
- There is still no systemic vision of the reforming of the sector that would correlate with modern challenges and threats.
Demographic and health care indicators of the Belarusian population
According to the Minister of Health Care Vasil Zharko, in 2014 Belarus “came closer to ‘demographic entrapment’: the birth rate is almost equal to the mortality rate (12.5 newborns against 12.8 deaths per 1,000 people, respectively it is minus 2.9 thousand Belarusians per year). This fact was repeatedly praised by officials of different rank, as well as the fact that two regions of the country (Minsk and Brest regions) were marked by a population increase of 3.0 and 0.8 per 1,000 people respectively. It should be noted that the birth rate had not changed for a year and the mortality rate decreased by 0.5%.
Population growth in the capital is predictable (it attracts young people from all over the country, and it has one of the lowest mortality rates), and modest achievement of Brest region can not cheer up, especially against neighboring Hrodna region where the number of children born was 296 children less than last year. 1 However there is no hope for a significant increase in birthrate in the near future because the economic situation is not getting better, and a generation that now enters the intense childbearing age is non-numerous that appeared during the crisis in the 1990s.
The mortality rate in 2014 in Belarus is a perfect illustration of relativity of an “average temperature in hospital”, as in Viciebsk region it is 1.7 times more than in Minsk. If to compare mortality rate with the neighboring countries it is also not in our favor: Belarus is significantly ahead only of Ukraine (15.7), a little bit ahead of Russia and Latvia (13.03 and 13.6 per 1,000 people, respectively), and Poland with Lithuania are only 1.5% away from us. Diseases of the circulatory system, external causes and oncological diseases traditionally make the top three. What worries is a trend of overall mortality from cardiovascular disease, which is twice higher than in Poland and 1.3 times higher than in Lithuania. The reduction of mortality rate by 4.1% from heart attacks and strokes among people of working age achieved in 2014, looks more than modest because the mentioned indicator is 10 times higher in Belarus than in France or Switzerland. 2
The ways to longer life expectancy and reduction of mortality rate are known and identical on both an individual level and within the country. They are the reduction of alcohol and tobacco consumption, a healthy diet with less salt and optimal physical activity. Belarus has nothing to be proud of concerning these points. Many years of significant investment in sports do not lead to a substantial increase in mass physical activity. As the economic situation will continue worsening, the population will increasingly switch not to very healthy but available potato with cured pork instead of fruits and vegetables with sea fish. Still almost half of Belarusian men smoke. Also the number of tobacco users among young women is growing. Meanwhile, the draft law On protection of population from consequences of tobacco consumption and exposure to tobacco smoke prepared in 2013, which imposes serious restrictions on smoking in public places, for some mysterious reasons was not included in the work plan for 2015 of the House of Representatives.
The alcohol topic was a bit embarrassing. According to the World Health Organization (WHO), last year Belarus came in first place in alcohol consumption in the world with a rate of 17.5 liters per citizen over the age of 15 (a ‘safe’ level of consumption is 8 liters). The national Ministry of Health complained loudly about the announced results and the methodology, but the fact remains.
According to the WHO criteria, about 50% of the assessment of the health care system in each country is life expectancy at birth. In 2013 this figure reached 67.3 years for Belarusian men, 3 and 77.9 years for women (average – 72.6). According to the National Statistics Committee since 1995 life expectancy in Belarus has grown by 4 years (with an average annual growth rate of 0.3%) and almost reached the maximum values of the BSSR (72.9 years). It is 6 years less than the average rate for developed countries and 10 years less than the indicators for the Nordic countries. A record difference in life expectancy of men and women remains (10–12 years, at the norm of 5–6).
Life expectancy is a component of several international rankings, in particular the human development index, which is annually prepared by the UNDP. Belarus traditionally ranks among states with a high value of this index, ahead of all countries, which is constantly used as patriotic propaganda to illustrate our success in the international dimension. Over the past year the situation in Belarus has deteriorated (53rd position instead of 50th), but the leadership among the countries of the Customs Union is preserved. Meanwhile, our Western neighbors are in the highest group of countries (with a very high index value).
Health funding, priorities of medical care
In 2013 World Bank experts noted that government spending on health care in Belarus is higher than in CIS countries (with an average of 2.7% of GDP) but it remains significantly lower than in 10 new EU countries (5.4%). In 2014 it was planned to use 4.2% of GDP. According to the operative data of the Ministry of Finance, the expenditure on social services amounted to more than 98%, so probably that is why they were funded.
As promised, last year costs rose but only slightly (0.11%). The ratio of the budget provision expenditure on health per capita was just over BYR 3 million, which at the beginning of the year corresponded (an optimistic estimate) to about USD 322. The point of view of WHO experts, according to which the health care system (especially public) can develop only if not less than 5% is spent, and also the opinion that the implementation of the biological possibilities of a citizen for at least 75% the amount of costs should be close to USD 1000, again were not updated.
An important criterion of the effectiveness of the health care system is an indicator of equitable funding so that funds allocated from the budget are spent on ensuring the right of most citizens to the preservation of health. Most effectively this right is guaranteed through the development of primary health care, which is used by up to 90% of the population, which is why it is usual to allocate most funds here.
In 2013, the leaders of the medical sphere announced the shift of the development of medical aid to its primary health care level. Last year, much was said about the reorientation of the flow of patients to outpatient and ambulant clinics, about their importance for the health maintenance of the population. But the talks did not receive any adequate financial support: if in 2013 the share of the primary health care level in total funding for the sphere increased from 30 to 40%, in 2014 this growth was not observed. The reflection of tension at the primary health care level is the increase of the number of complaints about the work of out-patient hospitals by 25% last year.
Still Belarus ranks first in the world by the number of hospital beds per capita, and their reduction goes very slowly. A large stationary segment takes a lot of resources (an average day stay at Minsk hospital last year was worth 652 thousand BYR, while the visit to a clinic was about BYR 92 thousand). Meanwhile, the indicators of high-tech care (what hospitals should do) is not satisfactory: the queue for replacement of joints is at least 1.5–2 years; emergency cardiac interventions carried out, for example, at myocardial infarction and that have life-saving value occur only in regional cities and also there are waiting lists for them.
According to experts, the lack of funds in the stationary segment of medical care will continue to increase. It is worth recalling that the state program on reconstruction and re-equipment of operating rooms and intensive care units, the results of which are a reason of pride for the national medical authorities, was carried out in 2006-2007. This means that the majority of the equipment acquired at that time, is almost worn out and requires replacement. Now the country needs 500 anesthetic machines, 500 lungs ventilation devices, 22 substitutive renal therapy apparatus, 811 monitors of patient's condition and a certain number of less valuable equipment. 4
There is no way to solve the problem through import: according to the chief non-staff anesthesiologist-resuscitator of the Ministry of Health Alexander Dziadko, during five years of work of the Republican Center of Transplantation of Organs and Tissues most of domestic equipment supplied there is out of order. The devaluation of the beginning of 2015 significantly reduced the opportunities for the purchase of imported equipment, and a number of companies canceled previously concluded contracts. Audit of the use of the already purchased equipment could solve the problem, and main specialists have insisted on that for many years.
Optimization of the medical sphere and staffing problem
The trend of 2013 in seeking additional funding mechanisms of the system from the pockets of citizens came to an end in 2014 (symbolic fees for visits to outpatient hospitals, denial of disability benefits as a result of alcohol intoxication, etc.). Still there is a lack of a systematic approach and clear objectives and models of reforming the sector, every year it is replaced by different campaigns ending with ‘-tion’. In 2013 there was ‘modernization’, in 2014 –‘optimization’. According to the Minister Zharko, ‘excessive’ visits to outpatient hospitals, hospitalization norms, emergency calls were revised. As a result the pressure on the health care system declined, but not dramatically: the average annual number of visits to outpatient hospitals decreased from 13 to 12 for each person (for example, in Lithuania this number is 7), the number of hospitalizations decreased from 6 to 5 per year and the average duration of treatment – from 10 to 9 days. However, according to the Minister, “the preparatory work on creation of conditions for the intensification of the treatment process was done”. As it can be seen, the wording itself shows hyper-readiness to quick and quality responses to system calls of the economic crisis of 2015.
The lack of a systematic approach is vividly demonstrated in the most resonant events of 2014 in healthcare – Decree No. 66 of the Ministry of Health Care which significantly changes the procedure for prescribing, making patients visit outpatient hospitals more often and making doctors spend more time for prescriptions. It is no secret that reducing the number of visits to the outpatient hospitals was achieved partly due to the allowance to give to patients with chronic diseases prescriptions of a repeated use for a longer period. After the Decree entered into force, this order was cancelled: people started to make scandals in pharmacies, and immediately there appeared queues in outpatient hospitals at the expense of patients who need a prescription. Now to solve this problem, they propose to introduce electronic prescriptions, but it is unknown whether there will be money for its development and whether the staff will have a desire to learn. It is known that the document aims to make doctors prescribe Belarusian drugs and to make pharmacies sell them, but as usual they forgot to take ‘side effects’ into account.
Many domestic and foreign experts agree that the strength of the system is ensured by the capacity of its staff, who continue to do their work regardless of changing circumstances. The staffing issue, which was planned to address to in 2014, was not solved, however, much attention was paid to the improvement of financial incentives in the system: they promised a ‘decent’ salary increase at the expense of extra-budgetary activities and economize resources. As a result a twofold increase in salaries raised the income by an amount less than the rent for a one-room apartment in Minsk, and at the end of the year officials struck into the old song about the oath of Hippocrates and service to people. The Russian-Ukrainian conflict and the deteriorating economic situation of the Eastern neighbor slowed down the emigration of Belarusian doctors.
The previous year did not bring any positive changes. Old systemic problems were not solved, and the attitude of the leadership of the sector was absolutely not critical. In the end, we missed a year of a relative economic stability and the next chance for positive changes. Further it will get all the worse.