Health Care: Patching up old problems with old methods

Andrei Vitushka

Summary

In 2019, the priorities for the development of the health system were still to increase the availability and quality of medical care, and this process was slow. The rhetoric about countering bribery and optimizing the healthcare procurement system unfolded against the backdrop of a high-profile corruption case involving sector executives.

A proven way to provide healthcare personnel was re-employed, increasing enrollment in the medical universities. A salary increase remained out of reach.

The sector changed its Minister, but the change of personalities to less odious and more qualified ones is not the only prerequisite for transformations in the system. The Ministry of Health once again became one of the most closed departments for society, and a few attempts of the sector’s new leadership to communicate more actively with the population were quickly curtailed.

Trends:
Demographics

As in 2018, in 2019 the birth rate continued to decline – from 9.9 to 9.3 per 1000 population.1 The impact on the situation from the perspective of health was realized through a mandatory pre-abortion counseling (the purpose of which is to prevent termination of pregnancy), as well as work on the preparation of proposals for the allocation of state support for in vitro fertilization, which, according to former Health Minister Valery Malashka, can “provide” a thousand additional births per year. As a result, the decision on budget financing was made in 2020.2

The overall mortality rate increased slightly – from 12.7 to 12.8 deaths per 1000 population (an increase of 0.1 per year has continued since 2017). There is still an incomparable difference between the death rate and birth rate in the capital (8.9 vs. 7.9 per 1000 population) and in the regions (the leaders are Viciebsk region with figures of 15.1 vs 9.3 and Mahilioŭ region – 14.0 vs. 9.4 per 1000 population). The smallest difference between the birth rate and death rate among the regions of Belarus is in Brest region – 13.1 against 10.9 per 1000 population. Population losses continue to increase – 32.9 thousand against 26 thousand in 2018.3

Last year, infant mortality updated the historical minimum of 2.4 per 1,000 live births (decreased from 2.5 in 2018). This is still significantly less than in the EU as a whole (3.5 per 1000 live births in 2018), and is comparable to the indicators of the Scandinavian countries – generally recognized leaders in maternal and child health.4

Also, maternal mortality was at a minimum level – 1.1 per 100,000 population. For the entire year, only one case of death of a woman due to reasons related to childbirth was registered. This is certainly the best indicator in Europe, which indicates the quality of medical care for pregnant women in Belarus. Paradoxically, this does not affect the level of satisfaction of Belarusian women with the conditions for childbirth in hospitals in the country. According to the public initiative “Radziny” cases of ignoring the rights of expecting mothers from the medical staff is a rule rather than an exception.5 It should be noted that minimizing the chances of death for pregnant women is not only an achievement of Belarusian medicine. In Latvia, for example, only two cases of obstetric-related pregnancy deaths were registered in 2018.

Non-communicable diseases (heart and vascular diseases, cancer, diabetes and chronic respiratory diseases) still account for 89% of all deaths in Belarus, which exceeds the global mortality rate from these causes (71%). The probability of premature death (under 70 years of age) from these pathologies for a citizen of Belarus is 28.6%.6

Data on the life expectancy of the population of Belarus in 2019 at the time of writing the review was not yet available. In 2017, it was 74.4 years, in 2018 – 74.5 years, the plan in the country's budget was designated as 75 years,7 and the socio-economic development Program has 75.3 years until the end of 2021. Meanwhile, the new Health Minister Uladzimir Karanik said that there were plans to increase life expectancy in Belarus to 80 years (as in Germany in 2016), but did not specify how long this might take.

High technologies are closer to people, and quality is under control

The creation of inter-district centers for high-tech assistance is a progressive step aimed primarily at the practical implementation of the modern “golden hour” principle, which means in 60 minutes after an emergency (regardless of whether it is an injury or a heart attack or a stroke), the patient is delivered to a medical institution, and he/she is provided with up-to-date assistance and in full.

It is planned to create such centers on the basis of existing hospitals and provide assistance to the nearest population there, even if the patient lives on the territory of a neighboring district. For this purpose, “road maps” of assistance to the rural population on where what type of pathology would be treated were developed. For 2020, it is announced that medical institutions will be accredited for their ability to provide a particular type of care at the appropriate level.8 It is also planned to re-equip hospitals for new tasks.

Informatization of health care

The state of informatization of the sector, which, according to Deputy Prime Minister Ihar Petryshenka, is designed to improve the level and quality of medical care, is evidenced by the situation with its simplest component – the “electronic prescription” system, which was used by more than 10 million patients last year. Given that the system has been in use for several years and there are about 13 visits to a polyclinic per year per every citizen of Belarus, this is a fairly modest figure.

The same applies to telemedicine consultations: 255 healthcare organizations are connected to this system, and over the past year about 30 thousand consultations9 were held – on average about 10 per medical institution per month, which also eloquently illustrates the demand for this method of professional communication among doctors in Belarus. There are several reasons for this situation: the technical imperfection of the system and the unregulated legal status of these consultations, but most importantly, doctors do not need them.

As for such an important component of the e-health system as the Central software platform, where medical information about citizens of Belarus will be stored and exchanged, it was planned to find a developer for it in the first half of 2019. The results of these aspirations have not yet been reported.

Primary medical care

The process of improving primary health care by transferring district therapists to work on the principle of a doctor of general practice, working at the head of the team “doctor – assistant – nurse”, in 2019 was as follows. At the beginning of the year, the number of general practitioners was 60.8% of all district therapists and increased to 74.0% at the end of the year.10 It was planned that by the end of 2020, all therapists should be transferred to a new form of work, but it is unlikely to happen, given the pace of 2019 and the COVID-19 epidemic.

Last year, the project “Caring polyclinic” continued, which provided for optimizing the work of the institution with an emphasis on assistance in the office of a general practitioner. The initiative, which is a copy of a similar project in the Russian Federation, started in 2018 on the basis of the 30th Minsk polyclinic and in 2019 expanded to two more polyclinics.

The biggest problem for general practitioners in Belarus is the time of their training (one year after University) and retraining from district therapists (courses last several months). In the countries of the European Union and even the former USSR, the training of such complex specialists takes several years. Also, all over the world, such a doctor is called “family doctor”, because he/she treats the entire family – from small children to the elderly. Our general practitioners do not deal with children, which once again raises the question of the effectiveness of this form of primary care.

According to former Minister Valery Malashka, from 2020, medical universities in the country will increase the number of students in pediatric specialties.11 This means that the introduction of the child population into the sphere of responsibility of general practitioners is not planned in the near future.

Talking about raising salary, countering “brain drain”

Since the beginning of 2019, there have been active public discussions about improving the payment system for medical workers, which is provided for by President Lukashenko’s decree No. 27 of January 18 (concerning the payment of employees of budget organizations). It was also stated that wages would increase by 20% in 2020 and double by 2025.12 Increasing the income of doctors by half and bringing the salary of doctors to 150% in the economy is considered by the sector leadership as a serious tool to counter the departure of specialists abroad.

However, the issue of the departure of Belarusian doctors (the announced figures are about 200 specialists a year), as Alexander Lukashenka put it, “worries local officials, but does not stress them out”. In addition to the increase in salaries, the traditional solution is proposed (as it was 10 and 20 years ago) – an appeal to local authorities to provide housing for doctors.

A change in the Minister's personality doesn't change much

In June 2019, there was a change of the Minister of Health: Valery Malashka, who had worked in this position for only 2.5 years, was replaced by Uladzimir Karanik. The claims that were put forward by President Lukashenka to the former Minister were not very specific: "he is a good doctor, seems to have proved himself well in the second roles, but here he somehow did not orient himself.”13 There is an opinion that Valery Malashka suffered instead of his predecessor Vasily Zharko, who had headed the Department for ten years and, according to many Belarusian experts, could not but was aware that many things were solved “not quite legally” in the Ministry.

According to the new Minister, modern medicine requires new approaches to management. Examples of a recent solution include a request to citizens to report on the difference in prices for medicines in Belarus and the near abroad via the Ministry’s Facebook page, as well as a statement on the possible creation of a permanent online platform where citizens could communicate with the Ministry on the availability and quality of medicines in the country and abroad. At the time of writing the review (10 months after the announced plans), the platform was not created, but even the discussion on Facebook seems to have significantly reduced the prices of some medicines and developed a mechanism that can ensure the stability of the range of medicines in pharmacies, even if they are not Belarusian and do not have domestic analogues. Time will show how these solutions will work.

Other initiatives of the new Minister in one way or another repeat solutions of the old Minister and his predecessors – the increased control of the sector, accounting and control of the use of medical equipment, increasing transparency and simplification of procurement procedures in the system, as well as ultra-traditional requirement of strengthening discipline and observance of rules of deontology and medical ethics (for 2019 the number of complaints to the Ministry once again increased by 21%).14

The case of Malashka – Karanik shows that the change of personalities in the main chair of the health system does not change the essence of the system's functioning, regardless of who holds this position – a former pediatrician with a long experience of administrative work, or a former resuscitator who passed all the steps of the nomenclature ladder, or a surgeon with many years of practice – “golden hands”, and then an effective manager, chief doctor of a large Minsk hospital – despite the clarity of understanding of the problems which the sector faces and outstanding personal qualities.

Conclusion

Long-term problems of the Belarusian health care system are its underfunding, non-optimal structure, weak involvement in the prevention of risk factors for major diseases, the general low level of education of Belarusian doctors, low motivation for their work, the lack of high-quality public medicine, the closeness of the system, the lack of communication with society and within the system itself.

As before, the health system does little to address these problems. In this sense, Dr. Karanik’s reaction to the goals set by the country's top leadership for the Ministry of Health – to increase life expectancy and improve the health of the population – is indicative. The new Minister is a specialist-oncologist with a great experience – he knows well about the relationship between risk factors (e.g. smoking) and non-communicable diseases (e.g. cancer) which cause about 90% of deaths of Belarusians, and that 40% of human health is due to lifestyle. But during Uladzimir Karanik’s time in office, there are no signs of significant activation of preventive work.

The stated increase in funding for the sector by 27% in 202015 will be “eaten up” by the epidemic of a new coronavirus infection, which clearly outlined all the advantages and disadvantages of the local health system, and the increase in funding in 2021 is highly questionable due to the economic consequences of COVID-19. And 27% does not significantly solve the problem of bringing Belarusian medicine at least to the average standard in the European Union (about 7.0% of GDP is spent on healthcare there, compared to 4.2% in Belarus).

A few attempts of the new Ministry to communicate with the population, unfortunately, ended quickly: Valery Malashka’s initiative to activate the work of the Department in social networks and a greater involvement of doctors in public discussions did not continue. Moreover, in connection with the COVID-19 epidemic, there were cases of pressure on some socially active specialists to prevent them from speaking in the media about the new infection. According to a study by the Belarusian Association of Journalists, the Ministry of Health is still one of the most closed domestic departments to the media.16

Thus, it is possible to assume that the old problems of the sector will be solved by the same old methods. Accordingly, the results will be the same.