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PUBLIC HEALTH:
CONSOLIDATION AND PERSISTENCE Andrej Vitushka
Summary
2015 was characterized by a continuing favorable demographic situation, but population growth did not take place. The main public health problem in Belarus is a high mortality rate, especially among men, in the absence of systematic and comprehensive work with risk factors. For the second year in a row, outpatient service has become the priority of medical assistance; however neither funding nor maintenance increased. The health system continued working in an austerity regime due to the devaluation of the national currency with no prospects of improvement.
Trends:
• A trend for 'waiting out' the crisis and the funding of the industry without any notable changes;
• A policy of strengthening of the public health system through limitations in activities of commercial medicine and the active use of shadow administrative methods for solving assigned tasks.
Demographic indicators and population health
In 2015, demographic trends of 2014 on the convergence of fertility and mortality continued (12.5 newborns compared with 12.6 deaths per 1000 people — birth rate has not changed, mortality rate has decreased by 0.2%). Thus, the 'closing of the demographic scissors' has not been yet achieved (Belarus lost about 1000 people1), despite the cautious optimism of the Minister of Health. President Lukashenko turned out to be the most optimistic, as always, when in April in his annual message to the people and the National Assembly he said that "the
«Численность и естественный прирост населения.» Национальный статистический комитет Республики Беларусь. Web. 11 May 2016. <http://www.belstat.gov.by/ofitsialnaya-statistika/solialnaya-sfera/ demografiya_2/g/chislennost-i-estestvennyi-prirost-naseleniya/>.
number of Belarusians exceeded 9.5 million"2, which was proven wrong by the National Statistical Committee at the end of the year, as they counted 9498 thousand people. It is safe to say that the new year of 2016 will meet those optimistic demographic expectations.
As before, population growth is observed only in the Minsk and Brest regions, while the difference between births and deaths in Minsk is more than 3.5 times (2.8% vs 0.8%). These indicators have almost equaled in Homiel region and Minsk region (the difference is 0.2% and 0.7% respectively). From a demographic point of view, the least attractive is Viciebsk region, where the birth rate is the lowest (11.2 per 1000 people) and the mortality is the highest (14.7 per 1000 people). While fertility rates in the capital and in Viciebsk region are almost the same (11.6 and 11.2, respectively), but the mortality rate in Minsk is 1.7 times less, it was the same two years ago, which describes the healthcare system as far from being the best in the country3. The structure of causes of mortality has not changed — cardiovascular diseases, external factors, and cancer traditionally make up the top three.
Evaluation of the Belarusian health system
According to international criteria, about 50% of the assessment of the health system in each country is life expectancy at birth. In Belarus this figure has slowly grown since 2009 and was 68.6 years for men and 78.9 years for women in 2015 (67.8 and 78.4 years respectively in 2014)4. This is still much less than the data for developed countries, where the numbers are 76 years for
«Обращение с Посланием к белорусскому народу и Национальному собранию.» Официальный интернет-портал Президента Республики Беларусь. 29 Apr. 2015. Web. 11 May 2016. <http://president.gov.by/ ru/news_ru/view/obraschenie-s-poslaniem-k-belorusskomu-narodu-i-natsionalnomu-sobraniju-11301/>.
«Демография.» Национальный статистический комитет Республики Беларусь. Web. 11 May 2016. <http://www.belstat.gov.by/ofitsialnaya-statistika/solialnaya-sfera/demografiya_2/>.
«Забота о нации. Ликвидировать очереди в поликлиниках и ещё раз поднять пенсионный возраст.» Naviny.by. 21 Apr. 2016. Web. 11 May 2016. <http://naviny.by/rubrics/society/2016/04/21/ic_ar-ticles_116_191501/>.
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men and 82 years for women. By the way, the life expectancy of men in Belarus is of particular concern, as it is hardly greater than the average indicator for all countries of the world — from Swaziland to Japan (68 years). Also the difference between the life expectancy of men and women is not growing smaller (10 years in Belarus vs. 6 in developed countries).
The participants of the WHO European Ministerial Conference on the Life-course Approach in the Context of Health 2020 which was held in Minsk last October turned their attention to the low life expectancy, high mortality rate at a birth rate that is very decent for the region. The participants of the meeting praised Belarus for its low child mortality, universal access to immunization and medical aid (without regard to its quality) and were mildly critical. The Director of the Division of Non-communicable Diseases of the WHO European Office, Gauden Galea said: "A big difference between the life expectancy in Belarus and the average one in Europe is caused by early mortality from non-communicable diseases. For its reduction it is important to determine the prevalence of risk factors among different population groups. In order to do this we work together with the Ministry and examine the population until the end of 2016". It is hoped that the cooperation has been established and will bear fruit.
As for systematic work with risk factors, the state did not dare taking more or less consistent measures. On the one hand, a ban on open display of cigarettes in retail outlets was introduced, and on the other — the state does not introduce a complete ban on smoking in public places and does not raise the cost of tobacco products drastically, although the latter, according to the international practice, is the most effective measure. As for alcohol, the president demanded to unload stocks of domestic wine and vodka5, which resulted in the repeal of a ban on alcohol sale in the evening and at night, and in the reduced maximum allowance for Belarusian products in cafes
«Лукашенко провёл совещание по вопросам правового регулирования оборота алкогольной продукции.» БелТА. 22 Mar. 2016. Web. 11 May 2016. <http://www.belta.by/photonews/view/lukashenko- provel-so-veschanie-po-voprosam-sovershenstvovanija-pravovogo-regulirovanija-oborota-alkogolnoj-produktsii-2689>.
and restaurants. The explanation of such measures, of course, is in the weird economic logic. It relates to 'economic' because alcohol manufacturers are in the top 10 of taxpayers and their sales decreased by 18%, only during the first quarter of 2015 and it relates to 'weird' because, according to experts of the National Academy of Science and the Centre of Mental Health, to overcome the consequences of drinking and alcoholism, the government allocates up to 4.5% of gross domestic product (GDP), while the profit from the alcohol sale is only 2.3%.
According to the Minister of Health Zharko, the high place of Belarus in the international rankings is an international recognition of national success in this sphere. According to last year's results the success is rather modest: in the UN human development index we 'saved' three positions which had been lost in 2014, and in the Bloomberg health care effectiveness index we 'slipped' to the 1st position.
Residents of Belarus regard their medicine system with less enthusiasm. According to IISEPS, only 20% of respondents agree with President Lukashenko's statement that the country established an advanced system of health, and according to the survey of the project REFORUM, the health system was named the first candidate for reform. Even according to a survey conducted in 2015 by the Information and Analytical Centre of the Presidential Administration, more than half of the respondents considered the level of health care to be low.
The financing of health care, the priority of provision of medical assistance
At the end of 2015 Minister Zharko said: "Wfe kept the budget system of health care financing by bringing few changes, and it confirmed its effectiveness, providing dynamic development, equal access for all citizens"6. Unlike in previous years, the performance indicators were not presented, except for positions
«Качественное управление, индикаторы премирования, культура здоровья.» Медицинский вестник. 4 Feb. 2016. Web. 11 May 2016. <http://www.medvestnik.by/ru/officially/view/na-kollegii-minzdrava-ministr-vasilij-zharko-podvel-itogi-raboty-otrasli-v-2015-godu-i-opre-delil-1455-14555-2016/>.
in the mentioned international rankings. Special structural development was not observed either. As big events of 2015 one could mention the opening of the Center of Positron Emission Tomography in the Republican Center for Oncology and the 'cutting of the ribbon' at the new maternity building of the 5 th city hospital of Minsk (it was operational only two months later). It is significant that the construction of a new building of intensive therapy of newborns of the Republican Center Mother and Child that has been repeatedly approved and projected did not start. Moreover, it became one of the projects for which the funding requires international donors (the World Bank).
Like the year before, in 2015, health care costs rose by 0.2% and amounted 4.4% of GDP, but this did not bring any results due to the devaluation of the national currency. To be able to continue purchasing imported supplies for medical equipment the state had to lower salaries in the health system (and to return to the salary which medical personnel got 5 years ago in dollar terms)7. In absolute terms, the indicator of budgetary security per inhabitant in Belarus amounted about USD 200, which is still very little for the development of the system (according to the WHO recommendations it should not be less than USD 1000).
Since 2013 statements have been made about the priority of developing primary health service (outpatient hospitals, day clinics, ambulances) as the most demanded by the population (used by more than 90%). In proportion to the increasing problems with funding the leadership of the system held talks on the development of 'hospital replacing technologies' in outpatient clinics, which is natural, because one day in hospital cost on average USD 30 in 2015, and a visit to the out-patient clinic cost about USD 5. However, the cost of financing for the health sector did not increase again, having made, as in the previous year, about 40% of the total amount given to the industry. The illustration of the readiness of primary medical services in terms of resources to a qualitatively new level of work in 2015 is, for example, the 'exposing' of the situation
«Зарплаты врачей в Беларуси. Прошлое возвращается.» Naviny.by. 12 Feb. 2016. Web. 11 May 2016. <http://naviny.by/rubrics/soci-ety/2016/02/12/ic_articles_116_190976/>.
typical for the whole country by the State Control Committee of Mahiliou region, when ambulance service miss vital equipment (electrocardiographs, defibrillators, etc.). To eliminate personnel shortages in primary care all medical students get their postgraduate work assignment there.
It is the third year, when the system has lived in the mode of 'austerity' and 'budgetability'. The results of the year are savings of BYR billion 309,6, which looks modest compared to the BYR 33,7 trillion spent. Throughout the year, hospitals suffered a shortage of supplies, especially on top of the devaluation. Last year it became a regular and massive practice, when patients were asked to make the necessary research in the clinic on a fee basis due to the lack of 'free' reagents and consumables.
According to the officials responsible for medicine, the economy mode will only be increased. The ways of existence in these conditions are the same as for other sectors of the economy — clenching one's teeth to ride out the crisis with iron discipline under the personal responsibility of managers. Avoiding duplication of tests in clinics and hospitals, in-patient facility replacement, as well as the development of informatization in the region, the money for which will need to come from the World Bank, were called for as innovative measures.
Consolidation of the public health system
Last year all sorts of public discussions on the need for alternatives to public health were stopped. If in 2014 there were talks (even at the highest level) on the need of developing insurance medicine, in 2015 they finished. However, voluntary health insurance was gaining popularity — despite the economic difficulties, the number of policyholders increased by almost 50% and reached 286 thousand people. If not for the instability of the national currency, this market could have developed rapidly. The reluctance of regulators to facilitate this process and increase contributions to the budget (corporate insurance for medium-sized companies from Belgosstrakh starts from USD 180 per year) is probably explained by the reluctance for greater transparency in the financing of expenditures on health and by the fear to lose control over them.
The policy concerning private medicine was aimed at further restriction of this segment. The beginning of the year was marked by a positive signal, which gave hope for the revival of commercial medicine and the opportunity to contribute to the discharge of the state system: private medical centers were allowed to issue sick leaves. But in November Presidential Decree No. 475 was issued which required the commercial medical centers to have specialists only of the first and the highest categories in their staffs. Thus, most of the medical centers were under threat of closure, which led to mass application of their owners and staff to the Ministry of Health. Health workers threatened with a joint appeal to the International Labour Organization, and the rental market of premises suitable for accommodating private medical institutions, which slightly revived amid lower rental rates because of the crisis, froze once again. The majority of experts stick to the idea that through changes in the activities of commercial medicine the Ministry of Health seeks to 'get rid of competitors and also contribute to the solution of personnel problems, hiring dismissed health workers in public institutions.
The case with the implementation of the domestic pharmaceuticals is best described by the working methods in the area. In 2014, the Ministry of Health was given the task to have 50% from the sale of medicines in Belarus, which would be of drugs of domestic production. The task is very difficult, given the low popularity of our medicines among the population, their low cost (most cost less than USD 1 per pack), weak marketing at the enterprises of pharmaceutical industry and tight terms.
Surely, the solution came with the overall impoverishment of the population, but officials did not 'rest on their oars'. Every pharmaceutical distributor under pain of deprivation of their license got the 'plan' which listed how many domestic medicines a commercial company had to buy. In order to make sure enough funds remain the purchase of imported drugs was unofficially but effectively banned in the fourth quarter of 2015. If someone bought drugs and gave a new party to a compulsory examination, there were discrepancies in the documents or other reasons not to issue certificates. Thus, at the end of the year, the sale of domestic medicines was 52% in monetary terms.
This consolidation of the public health system with a clear desire to get rid of other forms of financing and organization of medical care, as well as solving tasks by administrative methods, threatens the stability of the system to have reduced funding on the background of another economic crisis.
Conclusion
Last year the Belarusian health care system demonstrated stability in the deepening of the old systemic problems with the active unwillingness of the leadership of the industry to change anything in the their approach. Time will tell if this stability is a sign of mastery in changing economic conditions.
