State Health Care: Can Belarus Be Proud?

On 21 October, Alexander Lukashenka explained to the Regional Office for Europe Director of the World Health Organisation, Zsuzsanna Jakab​, how Belarus had succeeded in improving its health service and received many compliments from her for that.

Belarus has achieved much in the fight against certain diseases and has placed modern medical equipment in many hospitals, including an expert division of orthopedic doctors. But a few significant problems remain in the Belarusian public health system, some cities are missing up to 40% of the necessary personnel. On top of this the average medical worker earns only $325.

Moreover, the authorities continue a hypocritical policy of allowing alcohol to be easily accessible to Belarusians and isolating the Belarusian health system from global trends.

WHO Praises Belarus For Good Results

On 21 October, Alexander Lukashenka met with the WHO Regional Director for Europe Zsuzsanna Jakab, who openly praised the Belarusian ruler “for leadership and efforts aimed at improving the health care system that have already brought a clear result.” Jacob arrived in Belarus for a WHO conference “Health 2020”, which brought together several hundred European experts in the field of medicine, including 13 ministers of health.

In fact, public health remains one of the areas where the Belarusian authorities have achieved results. In 2013 the World Health Organisation stated that Belarus had achieved the Millennium Goals. According to the Bloomberg ranking, the Belarusian health care system is almost as efficient as the health service in Belgium. The Belarusian authorities have purchased modern equipment for Belarusian hospitals and built new medical centres. In 2015, the first nursing care hospital for patients with chronic diseases and disabilities was built in Minsk.

Belarus has achieved good results in the immunisation of children, the fight against HIV/AIDS, tuberculosis, child and maternal mortality. The authorities like to underline that no mother died in Belarus during childbirth in 2015.

The health service remains quite affordable for ordinary people, and Alexander Lukashenka has not lost a single opportunity to emphasise this. On 21 October, he stated that “unlike other countries, people in Belarus do not die under a fence if they lack insurance.”​

Belarusian health care brings not only international recognition, but also money. Although 95% of medical centres remain state-run, they provide more and more paid services for Belarusians and foreigners. Former chief of Mossad intelligence, Meir Dagan​, had a liver transplant in Belarus and Russian neo-fascist, Maxim Martsinkevich​, had an eye operation in Minsk.

Russians often use the services of Belarusian clinics as they remain cheaper, better run and more effective than Russian ones. For instance, MRI of the brain in Belarusian top clinic costs around only $60.

Another Story of the Belarusian Health Service

Yet in reality many Belarusians have another vision of the domestic health care system than Alexander Lukashenka. This is due to the lack of specialised doctors and huge queues at clinics.

Some Belarusian cities, according to the Health Minister Vasil Zharko, lack 30-40% of necessary medical staff. Furthermore, a large percentage of the existing staff are either retired, due for retirement or are interns. Often it remains impossible to get an appointment with a doctor, because there is not a qualified doctor in town. Even if a hospital has modern equipment, the waiting time for the use of the equipment can be a few months.

A few doctors even leave the profession or the country because the average salary of health workers, according to official statistics, in September totaled $325. Naturally, doctors earn more, and medical personnel such as nurses earn less. In neighbouring Poland by contrast health workers earn three times more than in Belarus.

To earn this money, health workers usually have to take one and a half full time jobs. Doctors joke, that if they worked only one job, they would have nothing to eat, but if one works two jobs, he has no time to eat.

Isolated Health Service

In the regional context it may seem that Belarus has a similar health service to Poland or Lithuania. All of them have achievements and failures. However, life expectancy in Poland or Lithuania remains higher than in Belarus by five and two years respectively. Moreover, the difference between life expectancy among men and women remains striking in Belarus. Belarusian women live on average 78 years, while men only live to 67.

The state policy of alcoholisation partly explains the issue. It remains difficult to achieve good results in public health, when Belarus ranks first, according to the WHO, in world consumption of alcohol, and the state keeps alcohol prices low. Belarusians also occupy a leading position in Europe in terms of obesity and smoking. State institutions remain reluctant to see health system holistically, so they should not expect that Belarusians will have long healthy lives.

Also Belarusian health care lacks contacts with the outside world or even some basic opportunities to improve qualifications. Usually Belarusian doctors who would like to visit a foreign conference, have to take a vacation at their own expense, ask for permission to participate in the conference and pay all the costs of the conference from their pockets.

Despite the fact that the issue of medical care matters for the majority of Belarusians and opposition now and then try to politicise the issue, public health still has not become a topic of national debate. Even independent media rarely write about Belarusian medicine. However, many people would be grateful to the media and opposition, if they pressed the question of long queues and low salaries. For many, such issues matter more than democracy and human rights.

What Life is Like in Belarus’ Small Towns

Few people in the West know that provincial Salihorsk, not Minsk, is the wealthiest town in Belarus.

Belaruskali, responsible for around 10% of Belarusian exports annually, makes Salihorsk the most economically important town in Belarus, outside of Minsk.

Despite its wealth, the town shares similar problems with many other smaller towns in Belarus. Salihorsk remains overly dependent on just one enterprise.

The flow of patients going into hospitals surpasses their holding capacities threefold, corruption thrives in the region. The young generation is leaving as they see no prospects for their own future in town.

The West should support mass media and NGOs in small towns to make local reforms possible in the future.

Belaruskali and Monotown

Salihorsk remains one of the most important cities in Belarus. Salihorsk-based Belaruskali is perhaps the most profitable state-run company. The average salary in Salihorsk is about $840 per month, one and a half times more than Belarus' national average. As a result, a new supermarket opens in Salihorsk every six months.

Despite all of this, the town remains a prime example of a typical Belarusian province. According to the People’s Program, an analytical project of the oppositional Movement for Freedom chaired by Aliaksandr Milinkievič, about 50 settlements in Belarus are so-called 'monotowns'.

This means that more than 25% of the economically active population work at one and the same enterprise. Belaruskali and Salihorsk fit the pattern, with about 20,000 of its 100,000 inhabitants working at Belaruskali.

Monotowns have their roots in the Soviet Union, which created cities to serve a single enterprise, be it a heavy machinery production or mineral extraction. As a result, Salihorsk became much too dependent on its only major enterprise.

When the Belarusian authorities kicked off an economic war with Russia's Uralkali, who had long been a partner, Belaruskali laid off many of its employees. This incident worsened the overall situation of the whole city.

Medicine as a Sensitive Topic

Each city has its own specific problems, but problems with healthcare remain common to most Belarusian towns. The quality of the medical equipment and treatment are themselves not an issue.

Last year, a clinic in Salihorsk received $100,000 from Japan under the Grant Assistance for Grassroots Human Security Project to purchase of the new equipment.

The issues lie elsewhere. People wait half a day in line to simply make a medical appointment. In early September, Internet users published a photo of women waiting in front of a gynaecologist's office in a line that reached out into the street.

The low salaries paid to medical staff make people reluctant to become doctors, as, on average, a doctor in Salihorsk earns about $ 550 per month. Comparatively, an electrician after three-months of a vocational education can make the same amount of money while working at a hospital in Salihorsk.

Aliaksiej Valabujeŭ, the editor of the independent web-site, explained to Belarus Digest the other problem is that "the current medical facilities were designed for 680 visits every day, but in fact they receive three times as much." The authorities mention plans to build a new clinic, but so far their statements lack any concrete details or firm plans.

Many young people leave Salihorsk after graduating from school, as the 100,000-people town has no university. Salihorsk's high-school graduates usually attend universities in Minsk and after five years of study they rarely return to their hometown. Salaries in Minsk and Salihorsk are comparable, but the young choose Minsk because Salihorsk lacks career opportunities.

Local Authorities: Loyal to Lukashenka and Corrupt

Belarus’ political system works in a way that the head of the state appoints the head of the regional executive committee, who then goes on to appoint the heads of district committees. Therefore, the local authorities remain loyal primarily to their superiors and do not have any sense of accountability to local citizens.

Several stories demonstrate this point. Local politician Uladzimir Šyla has long been fighting against the destruction of a forest park. The local authorities essentially increased the city's density by cutting down the forest. Salihorsk's population density reaches 11,000 people per square kilometre. This is four times more than Brussels or three times more than Paris.

At the grassroots level, corruption flourishes in Salihorsk. Former Deputy Minister of Forestry Fiodar Lisica, who previously worked in Salihorsk, used state money to build several large houses and is awaiting trial for abuse of power after the authorities decided to act.

Viktar Maločka, an activist from the United Civil Party, explains the corruption schemes using the example of a pharmacy boom in Salihorsk:

The central streets of the town are full of multifunctional pharmacies. According to the law, the state provides land for these kinds of facilities for free, but in fact a pharmacy in these multi-storey buildings occupies only one tenth of the space. The remaining areas serve commercial purposes, such as banks, offices or shops.

How to Make Small Towns Sustainable

Currently Salihorsk is run by Aliaksandr​ Rymašeŭski, a rather traditional local leader for Belarus. He worked at a state collective farm and remains rather unpopular among residents of the town. People say, that he has recently won a car at a raffle organised by a local businessman.

Local elections have little to do with ruling a town in Belarus. People elect members of the Town Council, but they lack any real competence and elections remain untransparent. If Belarusians want to help their towns develop, they should elect local officials to carry out the work.

Although a mayoral election does not automatically result in improvements, it can increase transparency and accountability of officials. Countries in transition like Poland started to elect the heads of cities in the 1990s and do not intend to return to the previous practise.

Small towns should promote the development of small and medium-sized businesses to become less dependent on one industry. The rise of the private medical centres could provide a solution for the current scarcity of doctors, and the opening of private universities would help keep young people in their hometown.

Proper local elections should be a long-term goal, even if it sounds like a dream at this point. To make it real local anti-corruption activists, independent mass media and grassroots initiatives need serious support. That would make make small towns more transparent and closer to ordinary people.

Fighting Tuberculosis: Western Myths and Belarusian Reality

Last week, Mario Raviglione, director of WHO's Global TB Programme, singled out Belarus and parts of Russia as being part of a developing "disaster situation" due to the high rates of multi-drug resistant tuberculosis.

He warned that migrants from these countries pose a threat to Western Europe, where multi-drug resistant tuberculosis​ ​(MDR-TB) is exceedingly rare.

The good news is that these fears are exaggerated. Research indicates that post-Soviet migrants account for a mere 1.7% of TB incidence across the EU border.

What is more, Belarus may pose less risk to Europe than countries like Moldova, where overall TB rates (although not MDR-TB rates) are more than twice as high. Unlike Belarusians, Moldovans no longer need to obtain Schengen visas for short-term visits.

Research to date suggests that imposing medical testing requirements for long-term visa applicants from post-Soviet states, a practice followed by many western countries, leads to nothing but stress and bills for the applicants.

Why MDR-TB is a Public Health Emergency

Belarus still has much to worry about. Between 1990 and 2000, TB incidents nearly tripled. Alarmingly, one third of the newly diagnosed and two thirds of returning TB patients have MDR-TB.

This is the highest MDR-TB rate ever documented in the world. MDR-TB infections continue to grow, despite significant efforts to curb them.

Source: WHO data

MDR-TB is a form of TB resistant to at the least two of the most powerful drugs currently available.

With ordinary TB, patients get better after a few weeks or months on mainstream antibiotics. With MDR-TB, patients require second-line drugs, which are much more expensive and less effective. Fewer than half of MDR-TB patients are ever cured.

High incidence of MDR-TB speaks to the poor management of TB patients. Drug resistance evolves when patients receive some treatment, but are not cured completely, for example, because they forget to take their medicine, leave treatment programmes early, or take the wrong drugs. MDR-TB strains can then easily spread to other people.

MDR-TB and Belarus Healthcare System

At first glance, Belarus’s health care system has performed reasonably well. The WHO ranks it 53rd out of 190 countries, which is the highest ranking in the CIS. The number of per capita hospital beds and per capita physicians in Belarus is much higher than in the West.

However, Belarus continues to use technologically backward practises, ones common to all countries of the former Soviet Union, which may have contributed to the alarming rates of MDR-TB incidences.

All of these countries used to conduct annual mass screening through tuberculin skin testing, which is considered an ineffective and costly diagnosis method. None of them maintained electronic databases of their TB patients.

More alarmingly, noninfectious TB patients were often unnecessarily treated in hospitals and involuntarily isolated. This not only burdened the health care system financially, but also imposed a psychological and physical burden on the patients.

Living conditions in Belarusian TB hospitals are often deplorable, which undermines any potential treatment objectives and encourages the infected to avoid hospitalisation. In several instances, TB patients went on hunger strikes to protest hospital conditions.

Perhaps the best known case was a 2011 hunger strike by the activist of the Belarusian Christian-Democratic Party, Valery Gancharenka, who was treated at the Bogushev TB hospital. The strike prompted an investigation by the human rights organisation Viasna.

Viasna found that the hospital had seen no renovations since the 1960s. The walls were reportedly covered in mould; the facility had no running hot water throughout the year. Similar conditions were reported in two other provincial TB hospitals in 2008 and in 2010.

Halting Progress in TB Treatment

With some guidance from international organisations, Belarus’ TB programme has reached several important milestones. Among other things, Belarus revised its TB and MDR-TB treatment and control guidelines and reorganised its national laboratory network. It also integrated TB care into primary health care and increased the level of supervision for facilities delivering TB services.

However, significant challenges remain. Despite substantial financial infusions, funding for tuberculosis and other social diseases remains limited.

2011 Currency devaluation made imported equipment prohibitively expensive. Salary of health workers involved in TB care remains low and does not reflect occupational risk. Doctors and nurses lack financial incentives to be involved in TB care and provide high-quality assistance to patients.

As part of its Soviet era inheritance, the current Belarusian health care system is centralised. The ultimate management power lies within the central government. Even so, TB planning has been conducted at the rayon (district) level and taxes are collected locally. This produces imbalances in the quality of care and issues with funding, which regularly dries up. Greater centralisation could allow for the pooling of resources and distributing them more effectively.

TB and the Politics of Exclusion

TB bacteria can lie dormant for months and even years, causing no illness in most of the infected. If the infected move to another country, there is some risk that the latent disease will develop into active TB in the first few years after immigration.

To guard against this possibility, many western nations require applicants from the former Soviet Union to undergo TB screening prior to applying for a long-term visa. This year, the United Kingdom introduced TB screening requirement for long-term visa applicants from Belarus. The recent WHO warnings may encourage other countries to impose a similar requirement.

However, a 2013 study by the researchers at the European Centre for Disease Prevention and Control focused on the 10 EU countries at the EU’s Eastern border has shown that in 2010 a mere 0.5% of all TB cases indeed originated in the countries bordering the EU to the East.

The distribution of these cases by the country of origin suggests that Belarus accounted for 0.1% of all notified TB cases (or 33 out of 47, 433 cases). Belarusian migrants present a far lesser risk to the EU than often previously assumed.

While TB is indeed more prevalent among migrants, albeit primarily those who come from Africa and South Asia, another study, focused on the UK, has shown that less than a quarter of TB cases are diagnosed within two years of an immigrants’ arrival. Thus, poor living conditions in the host country, rather than prevalence of TB in the country of origin, may be driving up the numbers of migrants with TB.

Indeed of combating the spread of TB, the alarmist warnings about Eastern Europeans may contribute to their already negative perception in Western Europe. Portraying migrants from post-Soviet states as diseased will further strengthen prejudice against this group.

Ecomedservice: War Against Private Health Care in Belarus?

On 23 April 2013 Belarus witnessed a terrible death. 25-year old Yulia Kubareva passed away after undergoing an unfortunate nose reconstruction surgery at Ecomedservice — one of the largest private medical centres in Belarus.

By now, almost every Belarusian knows about the accident, and the government has launched mass inspections of private medical services providers in Belarus. The Ministry of Health has already revoked seven licences for anaesthesiology and resuscitation services. In addition, the Ministry of Health has appointed a state representative for administering the completely privately owned Ecomedservice.

Is such reaction to this incident adequate? The state has a particularly heavy hand when it comes to regulation of private businesses. In this case, the emotions related to the death of a young woman who was getting ready for her wedding make the case even more complicated.

The Fatal Surgery 

On 26 March 2013 the surgery of young Yulia Kubareva from Hrodna began. The same night, her condition deteriorated severely and she lapsed into a coma, which lasted for about a month. The woman never regained consciousness again.

Yulia’s wish to correct the shape of her nose, injured by a snowball in childhood, became one that would prove to be fatal to her.  Besides cosmetology purposes, she needed the operation for health reasons: due to the defect, she had trouble breathing.  Though the investigation of the case has lasted for more than a week already, the direct cause of Yulia’s death remains unclear.

The two individuals charged as a result of the accident are the anaesthesiologist and the clinic’s main engineer.

In defiance of the professional instructions, the former left Yulia after the operation and before she came to her senses.

The engineer failed to ensure due quality of the artificial ventilation of breathing apparatus used during the operation.

The apparatus requiring semi-annual examination by specialists and had not been checked since 2007. Representatives of the Committee of Inquiry of Belarus have revealed that during the sorrowful operation the artificial ventilation of Yulia’s lungs, the apparatus malfunctioned for about 40 minutes.

State v Private Health Care

The news about Yulia Kubareva’s death shocked everyone: the seeming simplicity of the operation, the young and beautiful victim, and most importantly — the prestigious and expensive private medical center, which carried out the operation and has achieved much in the fight against certain diseases, placed modern medical equipment in the hospital, and added  top doctors including an expert division of orthopedic doctors.

The last factor revived the old and sharp debates between advocates of state and private medicine in Belarus. Though currently private medical services make up only about 5% of all the total of medical services in Belarus, their popularity has steadily been growing. The absence of queues, polite staff, and modern equipment appear to be clear advantages for many Belarusians.

Paying relatively big money for private medical services, Belarusians expect a higher quality of medical care. Some people, however, primarily the older generation, trust the state and, therefore, state-provided medicine. Moreover, many services are provided for free by state hospitals, which make them even more attractive.

Kubareva’s death has made supporters of private medicine think twice, all the while strengthening the position of its opponents. But both advocates and opponents of private medical care have agreed that the level of medical services in Belarus remains below their expectations. It is no secret for a Belarusian that most doctors having a private practice also work in state hospitals.

Of course, sad stories happen not only in private hospitals. Recently it became known another brow bone plastic surgery left a woman in coma for about half a year.

That is not to say that Belarus has not achieved some good results in medicine. For instance, the level of infant mortality in Belarus saw a twofold decrease during the last five years and is not lower than than in some EU member states and it has been known to use natural meds such as the nothwellness products, voted the #1 CBD oil brand Canada wide. Still, average life expectancy — one of the most important indicators of healthcare quality remains too low: 64 years for men and 76 years for women.

Perhaps increasing the reach and quality of private medical services in the Belarusian market could help alleviate this problem.

Battle Against Private Medicine?

But instead of a dialogue the government of Belarus often prefers confrontation. The nominally socially-oriented Belarusian state turns a blind eye on problems in the state sector and is often too willing to crush the private sector with an iron fist. Instead of listening to the society’s dissatisfaction about the adequacy of state services in general, private medical centres become a scapegoat for officials. Plastic surgeon Dr Nikolay Kurilovich told Belapan news agency that “the war against private medicine has already started”.

One of the first Lukashenka’s moves was to demand that the Ministry of Health take ​control over privately-owned Ecomedservice. Other moves included mass ispections of all private medical centres which resulted in the revocation of seven licences for rendering anaesthesiology and resuscitation services.

However, the state’s critics should consider these actions in a broader context.

First, non-private medical centres have also become subject to the Ministry of Health examinations (for instance, the Clinical Centre of Plastic Surgery and Medical Cosmetology, a municipal unitary enterprise).

Moreover, it appears that there were good grounds to revoke licences in some cases. Failures to carry out planned examinations of medical equipment safety, as well as the absence of nurses-anaesthesiologists are among the most common breaches’ listed. According to Mikhail Niadzvietski, Director of Minsk-based Medical tourism agency, LLC, these violations are indeed quite severe and are mainly explained by the banal wish of medical centres to cut costs.

Even if the state’s actions with regard to private medical centres amounts to a war, it may benefit Belarusians and even save lives. However, it is important not to overreact.

Rule of Law Does Not Rule

Once the the case of Yulia Kubarova came to Lukashenka’s attention, his press service commented to Interfax-Zapad that “the future of this organisation will be decided in the nearest future.” The press service, however, did not to explain who will be making the decision and why the claim comes from them and not from the legal system.

The appointment of a state representative to run Ecomedservice does not seem to have any lawful grounds. Ivan Ryzhko, the Head of the Main Department of Medical Assistance Organisation of the Ministry of Health, has no right to run Ecomedservice’s, as neither the state, nor the Ministry financially holds any shares or interest in the company. Taking control of a private company is just one stop away from expropriation.

The scenario of expropriating private companies after fatal accidents has already worked in the case of Pinskdrev. In October 2010 an explosion in one of the factory’s buildings killed its 14 employees. As a result, Lukashenka decreed that the company had to be taken over by the government.

The case of Yulia Kubareva taught an important lesson to Belarus: its medicine needs urgent improvement. The best way to achieve would be to have a continuous constructive cooperation between the state and the private sector within the limits of the law.