NGO actors in the sphere of healthcare in Belarus
“Healing” healthcare in Belarus
The Pontis Foundation organized a working visit to Belarus in March to map out the activities of non-governmental organizations and civic initiatives in the sphere of healthcare. Our goal was also to assess the potential for further development of their activities and advocacy work. The assessment focused only on groups active directly in the field of healthcare, not those working on social services in general; although the boundaries between the two are sometimes blurred and there are very few NGOs specializing only on the healthcare. The assessment was carried out by a Slovak health policy expert.
The Pontis Foundation and the Slovak expert met 11 representatives of organizations active in the area of healthcare (NGOs in Minsk and Mahylau, and representatives of the World Health Organization in Belarus). The report does not aim to provide a full picture of the problems in Belarusian healthcare; that would require substantially more research. But it does outline key challenges for Belarusian healthcare as identified by leading NGOs and initiatives active in the field and provides recommendations on how international partners could assist in strengthening the work of local actors in order to bolster their advocacy work and increase their impact.
The state of healthcare in Belarus
Access to healthcare in Belarus is universal and healthcare is free at the point of use. Provision of healthcare services is primarily ensured by the state, which uses general taxation to raise necessary funds. Most of them come from revenues of state-owned enterprises rather than payroll taxes. While Ministry of Health is the key player and main regulator, it is the local authorities which ensure funding for healthcare. At the same time regional and district governments lack legally defined limits of authority and guaranteed financing amounts. Consequently, although responsibility for the provision of healthcare services rests with the local governmental bodies, this mandate is frequently not matched by appropriate resources and a legal entitlement to generate revenue for the local budget. Hence, there are profound disparities in quality of healthcare services in poorer and richer regions in Belarus.
Patients are assigned to medical centers based on their place of residence. The state is the biggest employer of the medical staff; each citizen is entitled to a medical check-up (usually once a year). Yet, average life expectancy of Belarusian population has been declining. Equally important is the fact that Belarus is one of the few European countries where tuberculosis is on the rise, and still has not been contained: in 2005, more than 10% of deaths were caused by tuberculosis.
The following challenges were identified by a majority of interviewees as most pressing and crucial for improving the overall quality of the healthcare system in Belarus. They are:
· State´s strong hand in the sector: patients are compulsory linked to a doctor/polyclinic, based on their place of residence. Doctors are state employees who work where they were assigned by the state authorities. Their contracts are short-term, what oftentimes becomes a tool for pressure. According to an opinion poll of doctors’ trade unions, 80% of doctors say their rights are violated.
· Under-financing: low salaries of medical personnel, insufficient investment in new medical equipment (average wage in healthcare ranks 11th out of 13th sectors in Belarusian economy. Doctors work overtime to cover their living costs or take on second jobs. Generally, a doctor in hospital earns $700, in ambulatory care $500. An average salary in heavy industry is $1,000)
· Regional disparities in medical equipment: in practice, differences between various regions do not provide for an equal access to a free quality healthcare (e.g. access to mammography is generally available only for 1% of the target group women in Mahylau)
· Insufficient protection of patients’ rights: in theory, patients may bring their case to a court. In practice, there is a lack of independent experts and doctors as well as lawyers specializing on the area of healthcare, because all doctors are employed by the state or the Ministry of Health. Those patients who succeed in bringing their cases to the court are oftentimes labeled enemies of the state.
· Corruption: informal payments are commonly tolerated and widespread (in hospitals, a patient pays minimum $50 per surgical intervention; minimum payment for obstetrics is $300-400. The Union of Doctors estimates that informal payments amount to $300 million annually). The recent Gallup poll in Belarus has revealed that healthcare sector is publicly perceived as the most corrupt.
· Lack of reliable data: most independent experts agree that while the official data of the Ministry of Health cannot be trusted, independently obtained reliable data is practically non-existent. This considerably undermines the ability of the system to respond to the real needs of the population. Importantly, this also enables to formulate only general proposals on how the system should work to address the genuine needs.
Overall, the healthcare in Belarus is state-managed and centralized. It is not, for all practical purposes, free. Because of problems outlined above, current system produces inefficiencies against which it is almost impossible to appeal. As one Belarusian expert put it, “in fact, today’s system puts up new barriers for access to the healthcare, because what is accessible to everyone is of poor quality.”
Issues outlined are also addressed by local NGOs and civic associations in various ways: some demand better treatment of blood donors, other represent doctors and lobby for improvement of their working conditions, or strive to persuade local officials to commercialize healthcare. These groups operate in different environments and have different needs. But in general, their work would benefit from assistance in the following areas:
Institutional capacity:
A) Personnel:
Most of the civic groups which focus on the abovementioned issues are also active in other sectors (e.g. provision of free legal assistance, human rights protection, social services). The staff mainly works on voluntary basis and carries out their activities in addition to their regular job. Thus, the expertise of various groups differs substantively and portion of time devoted to their work is oftentimes inadequate.
B) Scope of activities and impact:
Majority of non-state associations of doctors or medical specialists are regional organizations. As healthcare is centralized and vertically managed, the fact that there is no independent nationwide organization advocating for a reform of the healthcare or for strengthening protection of patients’ rights greatly limits potential impact of civic initiatives, which are active on the local level. Nevertheless, some organizations have managed to convince local authorities to make certain small scale improvements, such as more intensive and joint cooperation to support blood donations in one of the regions. According to the interviewees, the technique of ‘selling our ideas as theirs’ (local officials’) is likely to be the most successful in accomplishing their objectives, at least on the regional level. Some civic groups run websites informing about their activities and about their vision of how healthcare system should be organized in Belarus. These small efforts often make them more ‘people-friendly’ than most of the government-run health-related sites.
Plans of the organization ‘Drop of Life’ to expand their activities on the nationwide level by 2010 may bring about some progress and increase the impact of their work in the upcoming period. A Mahylau-based association of medical specialists hopes to expand its membership from the current 50 to 2000. These efforts should be further supported.
C) Finances:
Some organizations are financed by external sources (usually through foreign governments’ funds allocated for development assistance or international NGOs). Member fees form a minor and insufficient part of the organizations’ budgets and these groups receive no support from the state budget. Representatives of an economic think-tank which includes healthcare among its social policy studies mentioned that the organization had no financial means to carry out independent collection of data in the area of healthcare. Thus, besides the Ministry of Health (MoH), the only organization providing such data in Belarus is the World Health Organization (WHO). However, although some data differ from those of the MoH, WHO representatives still work with data provided by other state institutions. This may undermine their reliability.
Specialist education in the area of health policy is available only abroad. Vast majority of local organizations or individuals simply lack funds either to provide such trainings in Belarus or to provide their members or partners a possibility to enhance their expertise abroad.
D) Expertise:
Lack of access to specialist education for local NGOs weakens their credibility vis-à-vis the government bodies. Although several individuals (leader of ‘Drop of Life’ organization, leader of the Union of doctors in Mahylau, Association of Belarus medical specialists) have clear vision of how the healthcare system in Belarus should be organized, their knowledge of health policies or tools and instruments necessary to implement this vision is limited. There is no concept for an overall healthcare reform in today’s Belarus. Lack of reliable data further complicates formulation of this vision.
Financial support for domestic research on how to improve the current system is scarce and does not provide neither for suitable conditions nor for the time necessary for a preparation of a complex concept of reform of healthcare system.
Furthermore, there are simply no experts who would be currently able to do it. Lack of expertise also applies to the groups which focus on patients’ rights protection: currently, there are no lawyers with specialization in this field. Studies covering some parts of the healthcare system (usually related to analyses of public spending) are mostly prepared by independent economists; however, as mentioned, these are based on official data.
Recommendations:
In Belarus, healthcare is publicly perceived as the most corrupt public sector today. Free healthcare is part of the social contract between the state and the society. However, current level of public spending does not provide quality comparable to that in the neighboring countries. Some of the illnesses which are almost non-existent in the EU are on the rise in Belarus; especially tuberculosis. The pressure to increase efficiency of the healthcare system and improve quality of services is likely to mount. If the government is to respond to these growing tensions and at the same time continue to provide healthcare without additional payments from the patients’ pockets, it is likely to be more open to proposals on how to improve efficiency of the existing system.
It is therefore important to assist initiatives which have the potential to formulate a vision of how to reform the current healthcare system, and those which are able to engage in partnerships or cooperation with other stakeholders. The Pontis Foundation recommends that capacities of the key organizations and groups active in the sphere of healthcare should be further developed in following fields:
· Expertise in health care policies (opening access to international educational programs, fellowships and trainings for key individuals who would become experts in the area of health policies, and/or strategic support for those analytical groups/centers which aim to develop their expertise in this sector)
· Advocacy/Communication skills (to increase engagement of these groups in dialogue with local authorities, state agencies, producers of medical equipments and drugs, unions of medical staff as well as media, both on local and national level, as well as with general public and to enhance public awareness of the activities carried out by these initiatives.
· Networking (assistance should be provided to those organizations which aim to work on a national level and those organizations which create links between various components of the overall healthcare system – e.g. between unions of doctors, NGOs advocating for patients’ rights, etc., as well as those which have links to their foreign counterparts)
· Financial support (funds should not only come from foreign donors; active cooperation with local businesses, initiation and creation of partnerships between these initiatives and companies should be actively encouraged. Cooperation between think-tanks, NGOs and companies could - in the future - result in additional funds not only for provision of alternative health services but potentially also bring in more resources in research and policy formulation).
Pontis Foundation, June 2009