Health: A series of scandals without proper conclusions

Andrei Vitushka

Summary

In 2018, the health care system was in the center of attention due to corruption and other scandals, as well as due to the criticism from the President. Several figures of the industry leadership lost their positions and freedom.

Against this background, the administrative pressure on the system has eased, and the performance of the industry improved. The Ministry announced the increase of transparency in state procurement and the expansion of the rights of managers to purchase equipment and consumables.

The transfer of clinics to the principle of a general practitioner continues but without a sufficient retraining of specialists.

Hopes for improving the health care of the population are thrown onto E-health and the modernization of polyclinics. At the same time, the program of health care reform with the justification of the planned changes and indicators of their implementation is not presented either to the professional community or to the society.

Trends:

Demographics

The trends of previous years continued: the birth rate decreased (from 10.8 to 10.0 per 1000 people),1 although not as much as in 2017 (falling from 12.4 to 10.8). A record low infant mortality rate is fixed – 2.4 in 1000 live births (a decline from 3.2 in 2017). This is significantly less than in the European Union as a whole (3.6 per 1,000 live births) and is comparable to the indicators of the Scandinavian countries – recognized leaders in maternal and child health.2 Maternal mortality is also very low.

The total mortality rate has not changed since 2017 and reached 12.6 deaths per 1,000 citizens. The loss of population increases: 25.6 million versus 16.8 in 2017.

The main non-communicable diseases (NCDs – heart and blood vessels diseases, cancer, diabetes and chronic diseases of respiratory organs) are the cause of 89% of all deaths in Belarus, which exceeds the global death rate from these causes (71%).

There were no official data on the life expectancy of the population of Belarus for 2018 as of April 2019. The Ministry of Health Care announced the figure of 75.3 years (growth of almost for a year from 2017). The difference between the life expectancy of men and women, including in rural areas, has decreased.

The priorities of the health system

As in 2016–2017, the priority is the development of primary medical care. The transition to the organization of outpatient service on the principle of a general practitioner continued. If in 2017 40% of therapeutic sites worked on this principle, in 2018 they were already 64% across the country with a maximum in Brest region – 76.5%.

The transition mechanism is simple: voluntary-compulsory training of district therapists at short-term refresher courses, as well as the distribution of medical graduates after a year of training. This duration of training of general practitioners in Belarus contrasts strongly with other countries, where the postgraduate training of such a family doctor takes at least 2–3 years.

Family-based primary care is a hallmark of most successful health systems in the world. At the first contact with such a universal specialist for children and adults, about 80% of health problems are solved, such a doctor knows the history of the patient and his/her family and can choose the most individualized and effective treatment.

They put high hopes onto general practitioners for improving medical care to the population. It is planned that the nurse and the assistant will take over the initial examination, paperwork and some of the functions of preventive work. As a result, the time that the doctor can devote to the patient will increase. The standards of admission time were also increased: from 15 to 20 minutes for the initial visit,3 which is almost consistent with the practice of developed countries (for example, 62% of doctors in the US spend 16 to 25 minutes per patient).4 Also, centralized purchases of additional equipment for offices were carried out and the standard number of patients assigned to the general practitioner was reduced: 1500 instead of 1700 from the district therapist.

Meanwhile, nothing is said about the integration of the child population into the sphere of responsibility of the family doctor, as is customary in the world. No gradual reduction in the number of children’s clinics was announced, and recruitment for the specialty “Pediatrics” in the country’s universities continues to grow. In addition, there is no information about reducing the number of “narrow specialists” in clinics, the function of which, according to the Minister, should take the general practitioner.

Another bet on improving the work of the industry is informatization: the creation of a single space, including an electronic prescription, an electronic patient card, a system of remote consultations of medical specialists among themselves (“telemedicine”) etc. It is believed that E-health will relieve clinics by reducing the list of reasons for their visit.

So far, the electronic recipe is not in demand. Thus, in 2018 they were allocated only 6.5 million times (growth from 4.9 million in 2017)5 with the number of more than 100 million visits to clinics in Belarus.

The stated increase in the number of telemedicine consultations from 469 to 7824 should be seen as a positive development that brings high-quality care from the main clinical centers closer to the regions of the country. However, a clear increase was achieved by administrative means.

A potential “cherry on the cake” of the optimization of outpatient care should be the project “Caring clinic”6 with the reorganization of outpatient institutions on the principles of “savings production” (Lean Manufacturing) – a clone of the Russian program “Lean Polyclinic”.

The pilot project in Minsk began with an increase in the number of medical registrators answering the calls of patients. Next, it is planned to introduce the position of administrator near the registry, as well as the removal of barriers between patients and the registry. They promise the redistribution of work of health workers, an exception of excess movements of patients. It is expected that doctors will have more opportunities to communicate with the patient, now this communication takes only about 20% of their working time.

The scandals and the reaction to them

In 2018, the health care system became the center of the largest corruption scandal in the history of Belarus. 95 criminal cases were initiated, which involved about 100 people – Deputy Minister Lasitsky, the head of Hrodna regional health department Stryzhak, Director of “Belpharmacia” and “Belmedtechnika”, Republican scientific and practical centers, chief physicians of large hospitals, businessmen, etc. As a result of the case, he lost his post of Deputy Prime Minister, the last Minister of Health Care Zharko. During the searches, USD 500-600 thousand was seized from some suspects, and the amount of bribes reached more than USD 10 thousand. Some cases were completed and their defendants received long prison terms (for example, Lasitsky – 6 years of strict regime, and Stryzhak – 7.5 years).

The system responded to this challenge by changing regulations to resolve possible conflicts of interest in procurement. Changes were introduced to the procedure of tenders, and the powers of heads of medical institutions for the independent (without a tender) purchase of consumables and equipment were expanded (the cost threshold was increased from approx. USD 5700 to USD 23000).

A second significant scandal is the situation with the vaccine of Eupenta, after the injection of which a child died as a result of anaphylactic shock. Soon after the tragedy in Ezhednevnik the material was published, which proved that the vaccine was not properly registered in Belarus and seemed to be imported for clinical trials on our children.7 The publication caused a considerable outrage in society.

The Ministry of Health Care responded to the rise of anti-excitatory sentiment by posting a press release on the website with a reference to previous publications, as well as information about the appeal to the Prosecutor General's office about the “damage to the national security environment of Belarus in the field of health care”.8 The briefing of the specialists without the permission for the audience to ask questions failed to contribute to relieve information tension and added to the arguments to vaccination sceptics. This case revealed the inefficiency of the traditional one-way communication of the Ministry of Health Care with journalists and the public.

As a result, the public was informed about vaccination and comments for journalists were made not by officials – but by doctors concerned about the possible increase in the number of vaccine-controlled diseases as a result of anti-vaccination moods – associate Professor of the Department of children's infectious diseases of BelMAPO Nikolai Galabarodzka9 and head of the intensive care unit of the City children's infectious diseases hospital of Minsk Maxim Acharetni10 with the help of colleagues from Ukraine. Speeches of colleagues on the portal tut.by, the BelaPAN Agency’s website and other media took place on their own initiative, and this can be considered a civil act in the conditions of increasing negative attitude of people to the health service and in the situation of an unspoken ban on uncoordinated comments within the system. Summing up the results of the year, Minister Valery Malashka confirmed the inefficiency of the Department in the media and noted that “few health workers take the liberty of speaking out in support of their colleagues and the system as a whole.”

Evaluation of the performance of the health system and its response

In September, Alexander Lukashenko gave a negative assessment of health care. The President raised long-standing, but essential issues of communication “patient – health worker” and people's attitude to the system.

The dissatisfaction of the population can be indirectly judged by the number of complaints about the activities of the health sector. As reported by Deputy Minister Bogdan, for the first 6 months of 2018, the number of appeals to the Ministry increased by almost 20%. The main topics- were the work of clinics and poor attitude on the part of health workers.

The system responded to the accusations with the adoption of new rules of medical ethics, the opening of courses on bioethics and the requirement for system managers not to allow indifference. The material motivation of health workers increased slightly: the ratio of wages in the health system and the national average has changed from 77.8 to 80.2%.

Last year, experts of the world health organization presented a landmark study for Belarus devoted to the economic analysis of losses from major non-communicable diseases, as well as identifying the most effective investments to combat them.11 The paper indicates that in 2015, economic losses due to NCDs and their risk factors amounted to 5.4% of the gross domestic product of the country, exceeding public health spending (about 4.0%). Losses to the Belarusian economy exceed the direct costs of fighting these diseases by 13 times, which is significantly more than in Kyrgyzstan (4:1) and Vietnam (4:1) – countries for which such studies were recently conducted. At the same time, the main share of expenditures is related to losses for the economy, which are caused by premature death (73%) and a decrease in productivity in the formal presence at work (19%).

The study analyzed the effectiveness of preventive measures against NCDs in the health system. It is noted that in Belarus the effectiveness of hypertension detection by medical examination remains low, the Ambulance system for heart attacks and strokes is satisfactory, corresponds to international practice, secondary prevention of myocardial infarction in principle exists, and the practice of “schools of diabetes” in clinics and monitoring the results of their work are not standardized, their impact on the health of patients cannot be assessed.

It is shown that the impact with the highest coefficient of investment in public health is a package of measures to reduce salt consumption (BYN 28.8 and 94.0 per ruble invested for 5 and 15 years, respectively).

Reducing the consumption of tobacco and alcohol will have an effect of BYN 8.4 and BYN 3.2 for 5 years, and BYN 31.1 and BYN 12.0 for 15 years, and clinical interventions aimed at diseases of vessels and heart and diabetes, give a very small coefficient of treatment of investments for the year (BYN 1.2) and no effect for 15 years, which is associated with high treatment costs of diseases.

The number of lives saved as a result of the implementation of these measures for 15 years ranges from 124,702 with a decrease in salt consumption to 62,301 and 50,680 – in the fight against tobacco and alcohol. Despite a detailed explanation of the mechanisms that should be used to achieve maximum damage reduction, a year after the presentation of the study to officials of various departments, there is no indication that the recommendations voiced have become the Foundation of comprehensive state programs.

Conclusion

2018 was a difficult year for the health system, sharply outlining numerous problems in its functioning. Measures taken to improve the quality of care are the Institute of General practitioner, informatization, and the project “Caring clinic”, all can have an effect in improving the quality of health services and satisfaction of the population. But this effect cannot be lasting.

According to experts of the world health organization, the key problems of Belarusian medicine are the threat to its financial stability and the lack of monitoring of the effectiveness of measures in this area. Public spending on health remains low (about 4% of GDP), and its distribution is inefficient. In particular, a large share of these funds is consumed by the stationary sector, the number of beds in which remains one of the largest in the world. Meanwhile, the real funding of outpatient care increases slightly from year to year.

Continued measures to improve the health of the population are reminiscent of the slogans and declarations without justification of effectiveness of innovations and affect the structural and procedural aspects, without an adequate focus on improving the patient-nurse relationship and without the legitimization and promotion of scheduled changes in the medical community and in society. If there are any changes after the stressful 2018, 2019 will show.