Belarus Health Profile 2012

Belarus’ highly developed welfare regime is one of the priorities of the Belarusian “social market economy” model, and is highly cost-intensive. This is because the government places priority on social services that are too indiscriminate, and are increasingly closely associated with ideological rather than social goals. Nevertheless, social benefits do not cover the cost of living. For instance, in 2008 fewer than one-half of unemployed persons qualified for benefits, which themselves were equivalent to less than 10% of the average wage.
 

Societal fragmentation remains within tolerable limits. At more than 50%, the employment rate for women is relatively high, but women are underrepresented in top positions and overrepresented in poorly paid occupations. Poverty is predominantly female in Belarus, but it also affects families with two or more children as well as the rural population. Representatives of Belarusian women’s organizations have documented the issues of domestic violence and the problematic positions of NGOs in Belarus. Sexual violence both at home and at work has increased substantially.

The Belarusian health system is hierarchical and its organization is based on territorial administrative division. While the central Government sets national health priorities, regional and district administrations oversee the organization and funding of primary and secondary care at the local level. The Ministry of Health has overall responsibility for the system, but it directly funds only highly specialized tertiary services. Although efforts to empower local health care administrations have been undertaken, there is no real experience of privatization of health care facilities or delegating regulatory functions to non-state bodies. In addition, as the responsibility for health care funding was  assigned to local authorities, inequities increased between some of the richer urban and poorer rural areas.

Financing

Since independence, health expenditure patterns remained similar to those under the prior Semashko system, while levels of total health expenditure and public sector expenditure remained relatively stable. Social health insurance has not been introduced in Belarus, and the system is mainly funded by the State through general taxation and some out-of-pocket payments. The majority of revenue is raised at the local level, with most taxes being collected from the publicly owned enterprises rather than payroll contributions. Since there are no formal user charges in Belarus, out-of-pocket payments are usually made in order to purchase pharmaceuticals and for limited private services.

Although pooling of funds is the responsibility of local authorities, the health system is still a single-payer system. Local authorities and national Government act as third-party payers for health care services and personnel. There has been a slow shift in purchasing health services from input-based to capitation-based fi nancing, which should improve resource allocation effi ciency in the longer term.

Regulation and planning

The Ministry of Health plays a key regulatory role at all levels of the highly centralized health system, issuing norms for care and standards for service provision. Although regional and district health authorities are deemed to be important stakeholders due to their responsibility for local health care fi nancing, their decision-making capacity is still limited. In Belarus, purchaser and provider functions are integrated and different levels of government purchase various kinds of care and cover the costs of public health facilities. Approaches to planning
are still based on setting norms and imposing penalties for not meeting them. The top-down policy development and implementation process leaves little room for stakeholder participation. There is also a need to improve information systems so that data and analysis can better inform policy and planning.

Physical and human resources

Since 2001 there have been attempts to reduce excess hospital capacity through fi nancing mechanisms that are based on the number of residents at the district and regional levels, rather than the number of beds. However, the country still has a higher number of hospital beds per capita than any of the other CIS and central and eastern European (CEE) countries. Stability in the numbers of beds and hospitals in Belarus can partially be explained by their reallocation from medical to social care. Capital investments favour the hospital sector and specialist care and more resources have been devoted to the refurbishment of existing capital stock, rather than building new health facilities.
Belarus has an extreme overcapacity in the supply of doctors and nurses for inpatient and specialist care, which over time has been increasing, but despite  the large overall numbers of health professionals, they are very unevenly distributed across the country and across health specialties. The broadening of alternative career opportunities and low wages for health workers mean that the country is now facing recruitment problems for key health workers in rural areas and in primary health care (PHC), as well as overcapacity in the cities and hospitals.

Provision of services

There is an extensive PHC network of providers throughout Belarus, but with an uneven distribution of health care workers. All PHC facilities are owned by the State. The PHC network has two forms of service provision: traditional polyclinics in the cities and outpatient clinics and feldsher-midwife (akusher) points (FAPs) in the rural areas. In some of the outpatient clinics general practice is emerging. Primary care in the capital, Minsk, and fi ve other regional centres is provided through the network of adult and paediatric polyclinics, where a number of prevention, diagnostic, consultation and referral services are offered.
At the secondary level of care there are district and regional hospitals. While district hospitals provide general secondary care services, regional hospitals deal with more complex cases and offer a wider choice of care. At the same time, each district and region has an outpatient polyclinic, which delivers specialized secondary care for the patients in the community. In Belarus, the use of hospital beds for social and long-term care has been formalized and is partially covered by the deductions from patients’ pensions and welfare benefi ts.

Assessment of the health system

The Belarusian health system aims to provide the entire population with universal access to care, which is free at the point of use. While there has been equity in receiving health services, distribution of health staff and facilities has been uneven between rural and urban areas. Efforts to reorient fi nancial resources from the hospital sector to primary care and to introduce technical efficiency have been slow. However, the centralized health system has proved to be effective in public immunization campaigns and lowering infant and maternal mortality. Even modest improvements in the population’s health status or demographic circumstances are embraced by policy-makers as evidence that recent initiatives and the health system as a whole are working well, as these are considered to be the key success indicators. However, these indicators are also infl uenced by factors beyond the control of the Ministry of Health, and a downturn in the economic situation could compromise any gains.