Policy Note on Belarus Hospital Optimization Prepared under the Belarus Hospital Optimization Advisory Services and Analytics December 2020 Report No: AUS0002035 . Belarus Hospital Optimization Policy Note on Belarus Hospital Optimization . December 2020 . HEALTH NUTRITION POPULATION EUROPE CENTRAL ASIA REGION . ii . © 2017 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Attribution—Please cite the work as follows: “World Bank. {YEAR OF PUBLICATION}. {TITLE}. © World Bank.� All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e- mail: pubrights@worldbank.org. iii Contents Acknowledgements....................................................................................................................................... 1 Acronyms and abbreviations ........................................................................................................................ 2 Executive summary ....................................................................................................................................... 3 Introduction .................................................................................................................................................. 6 Chapter 1. Overview of Belarus’s health system .......................................................................................... 9 1.1. Burden of disease, morbidity, and mortality ................................................................................. 9 1.2. Highlight of key issues of effectiveness, efficiency, and inadequate attention to NCDs............. 14 1.3. Structure of the health care system ............................................................................................ 18 1.4. Prehospital and emergency medical services .............................................................................. 22 1.5. Physical and human resources..................................................................................................... 24 Chapter 2. Health financing in Belarus ....................................................................................................... 30 2.1. Imbalances in financing of the health system ............................................................................. 31 2.2. Current health financing mechanism........................................................................................... 32 Chapter 3. Government’s plans on creation of interregional and interdistrict centers ............................. 33 3.1. Proposed optimization plan of the Government (main purpose, key points) ............................. 33 3.2. Government’s approach to address NCDs ................................................................................... 35 3.3. Interregional and interdistrict centers/hospitals as part of the health care delivery system (roles and functionality).............................................................................................................. 37 Chapter 4. International experience ........................................................................................................... 38 4.1. Tackling similar health care issues ............................................................................................... 38 Case study 1 - Estonia ................................................................................................................. 38 Case study 2 - Finland ................................................................................................................. 40 Other successful international health care reforms experiences............................................... 41 4.2. Experiences on consolidation of hospital care and creation of specialized care like cardiovascular centers (treatment of stroke, myocardial infarction) ........................................ 43 Chapter 5. Options for changes in the organization and delivery of hospital services in Belarus ............. 45 5.1. Patient referral process and care pathways ................................................................................ 46 5.2. Division of roles between different levels of care with recommendations toward improvements with a focus on regional-level hospitals ..................................................................................... 47 5.3. Hospital system optimization as part of the healthcare reforms ................................................ 50 ANNEX 1. Addressing physical inactivity in Belarus .................................................................................... 55 iv List of figures Figure 1. Belarus population pyramid........................................................................................................... 9 Figure 2. Population by broad age groups .................................................................................................... 9 Figure 3. Life expectancy at birth - regional comparison............................................................................ 10 Figure 4. Life expectancy at birth in Belarus by gender .............................................................................. 10 Figure 5. Death rate by causes, % ............................................................................................................... 10 Figure 6. Causes for DALYs, % ..................................................................................................................... 10 Figure 7. Top causes for DALYs in Belarus, 2017 ........................................................................................ 11 Figure 8. Comparison of IHDs death rate, regional and income group level .............................................. 12 Figure 9. Comparison of IHDs and ischemic stroke as causes of DALYs, per 100,000 people .................... 12 Figure 10. Morbidity by main groups of diseases (newly emerged cases), 2019 ....................................... 13 Figure 11. Death rate per 100,000 people in Belarus and Estonia for 1990–2017 and forecasting for 2021–30 ...................................................................................................................................................... 14 Figure 12. Morbidity and mortality rates at country and regional levelsa .................................................. 15 Figure 13. Myocardial infarction and stroke incidence rate (per 100 000) among adult population (age 18 and above) .................................................................................................................................................. 16 Figure 14. Selected diseases incidence rate per 100,000 population ........................................................ 17 Figure 15. Mortality rate per 100,000 population by causes, 2019 ........................................................... 18 Figure 16. Inpatient care discharges per 100 people ................................................................................. 20 Figure 17. Number of outpatient and inpatient health care facilities, 2010–19 ........................................ 25 Figure 18. Indicators of hospital bed availability, bed occupancy, and ALOS (per 10,000 people) ............ 26 Figure 19. Hospitalization rate (per 100 residents) and doctor visitsa (per resident) in 2010–19 ............. 27 Figure 20. Hospital staff per 1,000 people in 2018 ..................................................................................... 28 Figure 21. Hospital beds per 100,000 people ............................................................................................. 28 Figure 22. Availability of nurses and physicians per 1,000 people with filled vacancy (%) at country and regional levels ............................................................................................................................................. 29 Figure 23. Shares of out-of-pocket expenditures in Belarus and its neighbors (latest available year, 2017) ........................................................................................................................................................... 30 Figure 24. Numbers of physicians per 1,000: surgical and therapeutical (excluding pediatricians, diagnostic specialties, preventive care physicians, and dentists)............................................................... 31 Figure 25. Stroke interventions international comparison ......................................................................... 44 List of boxes Box 1. EMS in Belarus.................................................................................................................................. 23 Box 2. Summary model of new roles and responsibilities in service provision at the oblast level ............ 49 List of maps Map 1. Planned IRCs and adjacent territory where they provide services ................................................ 34 v List of diagrams Diagram 1. Health services organization .................................................................................................... 19 Diagram 2. Health services new organization structure under IRCs .......................................................... 35 Diagram 3. Health sector reforms............................................................................................................... 51 Diagram 4. Patient centered Integration of services in Belarus ................................................................. 53 vi Acknowledgements This note was prepared by a team led by Elvira Anadolu, Task Team Leader (HECHN) under the general direction of Tania Dmytraczenko, Practice Manager (HECHN), and Alexander Kremer, Country Manager (ECCBY). The team included staff from HECHN: Anna Koziel, Senior Health Specialist; Olena Doroshenko, Health Economist; Parviz Ahmadov, Consultant; Pavel Fountikov, Consultant; and Veranika Adamchuk, Team Assistant (ECCBY). Special thanks to Siarhei Strakha, Consultant, for research and data collection. While all efforts have been made to utilize the most recent and trustworthy data, the World Bank does not guarantee the accuracy of the data used in this report. The note is not a full or independent evaluation. It was prepared in a relatively brief period, with additional impact of COVID-19 pandemic, that created constrains for additional data collection and comprehensive discussions with the Government. 1 Acronyms and abbreviations ACS Acute Coronary Syndrome ALOS Average Length of Stay ALS Advanced Life Support ASA Advisory Services and Analytics BLS Basic Life Support BMI Body Mass Index BOOST Better Outcomes for Older adults through Safe Transitions/Balanced, Observed, Objective, Specific, Timely CIS Commonwealth of Independent States CT Computed Tomography CVDs Cardiovascular Diseases DALY Disability-Adjusted Life Year DRGs Diagnostic-Related Groups EMS Emergency Medical Services EU European Union FTE Full-time Equivalent GDP Gross Domestic Product ICU Intensive Care Unit IDC Interdistrict Center IHD Ischemic Heart Disease IRC Interregional Center LTC Long-term Care MOH Ministry of Health MRI Magnetic Resonance Imaging NCD Noncommunicable Disease OECD Organization for Economic Co-operation and Development PCI Percutaneous Coronary Intervention PHC Primary Health Care TBI Traumatic Brain Injury UHC Universal Health Coverage UMIC Upper-middle-income Country WDI World Development Indicators WHO World Health Organization 2 Executive summary The objective of the Advisory Services and Analytics (ASA) is to provide policy recommendations to the Government of Belarus to facilitate enhanced understanding of the vision on hospital optimization for 2021–25 based on analysis and lessons learned from Europe and Central Asian countries. The World Bank health team reviewed Government’s plan to create interregional hospitals, analyzed the healthcare delivery system of the country and selected regions, examined experiences of other countries that had similar hospital optimization strategies, and provided recommendations for Government’s consideration. Though Belarus has achieved improvements in key health outcomes, it faces a growing burden of non- communicable diseases (NCDs). Demographic processes in the Republic of Belarus are accompanied by a high rate of NCDs, with cardiovascular diseases (CVDs) being a leading cause of mortality and morbidity in the country. These diseases are one of the principal causes of disability and play a significant role in reducing the average life expectancy of the population in the country. Although mortality rates due to CVDs in Belarus have been slowly decreasing over the past ten years, all-cause mortality in the country is still significantly higher than the European average. This gap is largely attributable to the higher mortality from CVDs and the growing mortality rates due to other NCDs. Many hospitals in the country have low treatment volume. Almost every district in the country—even those as small as 15,000 people—has a general hospital, called a central district hospital, and often additional district hospitals and nursing facilities. The central district hospital offers the whole range of hospital services, including complex surgeries and maternity care. Therefore, the numbers of surgical procedures and interventions performed in many hospitals are too low to provide good-quality care. The average capacity of central district hospitals is 221 beds, and most cases treated in such hospitals are of a nonsurgical nature. Surgical activity is low in many hospitals. The number of surgeries with general anesthesia averaged less than 49 per year in 46 percent of central district hospitals. Almost each hospital maintains an intensive care unit (ICU) and employs staff for complex surgical interventions, but caseloads do not necessarily justify available beds and equipment. Because of the lack of investment and other constraints, very few hospitals can provide complex care (for example, complex heart surgeries or advanced cancer treatment), thus there is a need to reconsider a potential and profile for such small hospitals. Consolidation of complex care in select hospitals can help address issues of financial efficiency and access to quality hospital care. With limited financial resources distributed across an oversized hospital sector and not optimally used, there is room for efficiency. The budget of medical institutions is dominated by fixed costs, leaving little space for innovations and quality improvements. Rightsizing of hospitals and concentrating complex care in select hospitals can help allocate investments rationally and provide access to quality and technologies in hospital care closer than only at the level of oblast hospitals. Implementation of hospital optimization may start with consolidation of myocardial infarction (MI) and stroke care by taking this function from the rest of the hospitals in the network and organizing it in the interregional or interdistrict hospitals. Thus, the interregional centers (IRCs) become specialized centers for urgent treatment of MI and stroke. To do so, many hospitals may need to adjust and reprofile their services, downsize existing capacities, or convert to a primary care, rehabilitation, or long-term care (LTC) 3 center. It is expected that there will be a subsequent optimization of hospitalizations in the smaller hospitals or their reprofiling to mainly serve non-acute patients and provide outpatient services. Community-based care – care provided closer to home delivered in an integrated manner – could be one of the options to consider in hospital services reorganization. The evidence suggests that better integrated health and social care for older people contributes to better health outcomes at a cost equivalent to usual care, thereby giving a better return on investment than more familiar ways of working. Geriatric assessments, coordination of care plans, and regular support to keeping the elderly in good health, including rehabilitation services, if needed, should be conducted as close to home as possible in the outpatient settings. International best practices demonstrate that the concentration of services and minimum volume standards – for myocardial infarction, stroke, and surgical procedures – bring health and efficiency gains. Therefore, it is recommended to introduce a minimum volume threshold for selected procedures. Tertiary/teaching hospitals, with coverage of up to one million population, serving as IRCs, applying professional and volume standards, could provide (i) major vascular procedures; (ii) neurosurgery; (iii) cancer care; (iv) transplantation; (v) cardiac surgery and angioplasty; (vi) neonatal intensive care; (vii) specialist pediatric surgery; (viii) stroke care, including mechanical thrombectomy; and (ix) obstetrics. Additional surgical procedures with volume standards could cover pancreatic surgery, esophageal surgery, hepatic and biliary tract, various lower gastrointestinal tract procedures, spinal surgery, and bariatric surgery. The Government should also strengthen the primary health care (PHC) system. Strengthening the PHC system in the country will address patient flow problems and other healthcare concerns associated with aging and a growing burden of NCDs in a cost-effective manner. In healthcare theory, the PHC system should serve as a gatekeeping mechanism for patients, but in Belarus, there is free access to secondary and specialist care. General practitioners and district internists play a limited role in the coordination of care and do not fulfill the gatekeeping function. Also, traditionally, patients prefer to go directly to a specialist when they have health problems. If family physicians were the first contact, they would not only guide the patient through the system but could also provide more comprehensive consultations, address NCD risk factors, and identify NCDs at an early stage. The need for well-qualified family physicians who can provide patient-centered comprehensive care is even more urgent for patients with multiple chronic conditions. In addition, the emergency medical system (EMS) needs comprehensive reform to improve its efficiency and quality. The current system of emergency care should be assessed, and recommendations on upgrading the system could be provided. The World Bank has been supporting the improvement of EMS worldwide, including countries in this region—Romania, Croatia, and Uzbekistan. Along with the upgrade of the emergency care health facilities, modern equipment for ambulances—Advanced Life Support (ALS) and Basic Life Support (BLS), training of doctors and paramedics on new triage systems for prehospital and hospital levels, and a modern dispatch system will allow efficient, timely, and quality care for emergency services without misuse of emergency care on non-urgent cases. In this reform, the Government could also consider an integrated emergency response bringing together police, firefighter, and medical units. 4 Finally, a multifaceted phased approach is necessary to ensure the success of health care reform in the country. Rightsizing the hospital sector goes beyond strategic planning and requires an enabling environment with reform of the legal framework, distribution of adequate human resources, development of protocols, setting up of the right financial incentives, and improved governance of hospitals. Estonia could be used as a good example, where the World Bank provided support for the design and the implementation of the health care reform. During the planning of their network, the health ministry used this concept to ensure that patients could access a facility to benefit from specialized care within an hour. Beyond the planning of the infrastructure, several reforms were implemented that set quality and performance standards, with closure or reprofiling of substandard hospitals, corporatization of hospitals with greater autonomy and accountability, strategic purchasing with contracting between a purchaser – health insurance fund – and hospitals, and a move toward output-based and performance- based financing. 5 Introduction This paper was developed under the Belarus Hospital Optimization (P173516) Advisory Services and Analytics (ASA) based on the analytical work, consultations with stakeholders, and international experience relevant to Belarus. The objective of the ASA was to help the Government in developing an understanding of the vision on hospital optimization for 2021–25, considering lessons learned from other Europe and Central Asian countries. The World Bank received a request from the Government to finance the hospital optimization plan based on the creation of interregional and interdistrict medical centers/hospitals. The World Bank health team reviewed the Government plan, analyzed the hospital delivery system in the two selected regions of Brest and Gomel—in agreement with the Ministry of Health (MOH), and examined experiences of other countries that had similar hospital optimization strategies. Therefore, the paper concentrates on the analysis of the Government’s plans to create interregional hospitals, considering existing challenges, country context, available data, experience of other countries, possibilities to address issues, and recommendations for the way forward. The paper starts with Chapter 1, defining the epidemiological profile of Belarus, its burden of diseases, organization of hospital service delivery, and utilization of these services in a manner that sets the stage for the subsequent discussion. Since the interregional hospitals will also serve as emergency hospitals, it is important to understand the current structure of pre-emergency and emergency medical services (EMS) and the role that the new centers will play in patient flow. The analyses of the two regions describe the hospital sector with information on the number of hospitals, beds, and human resources; the most frequent reported diseases; and the prevalence of stroke and myocardial infarction. Connection of hospital services to services at other levels of care—primary health care (PHC), tertiary care, rehabilitation, and long-term care (LTC)—is based on a desk review and was not part of the two regions’ study. Following the introduction of the health system structure of the Republic of Belarus, the paper continues with Chapter 2 on the explanation of the health financing mechanism in the country and provides information on imbalances in the financing of the health system in Belarus, referring to the Belarus Health Public Expenditure Review (2018). The paper includes a discussion of the shortcomings of the current cost accounting system, which are a barrier to conducting cost-effectiveness analyses in a systematic manner to inform policy decision-making and enable better management of hospital care. Chapter 3 of the paper describes the Government proposal on the creation of the interregional centers (IRCs) and interdistrict centers (IDCs) and how these centers fit into the health care delivery system and their role and functionality. Following the epidemiological situation and noncommunicable disease (NCD) prevalence in the country, laid out in the previous chapters, this chapter discusses how the new centers will address these issues. It is important to understand how the overall hospital network will change and what role other hospitals will play in relation to these new centers. One hospital in Pinsk in the analyzed region of Brest has been performing as a prototype of an interregional hospital, and preliminary results of the performance and functionality are presented in the report. Chapter 4 shares international practice, to understand how countries such as Estonia, Finland, Denmark, Germany, Netherlands, and Australia are dealing with similar health care issues and how their health care services are organized to address cardiovascular morbidity and mortality. In addition, it is vital to learn 6 about the experiences from select countries in relation to the creation of IRCs and consolidation of specialized hospital care and specifically for cardiovascular diseases (stroke and myocardial infarction) and what could be applicable for Belarus from those experiences. The countries selected faced challenges similar to Belarus; in some cases, the health system development pattern is similar and was requested as a benchmarking by Belarusian counterparts. Chapter 5 proposes some potential options for changes in the organization and delivery of hospital services, based on the discussions and issues raised in the previous chapters as well as on the analysis of hospitals in the two regions of Brest and Gomel. The chapter also looks at issues that might be solved or not solved with the Government’s plan of IRCs. Among the essential elements of the changes in the organization of the health care system deals with the patient referral process, care pathways, and follow- up. Therefore, it is important to propose appropriate division of roles between different levels of care with recommendation toward improvements. The follow-up analysis of the functionality of the health care network and care pathways is required to propose a valid health care optimization plan that would cover all levels of care from primary to tertiary care and LTC. The methodology of the analytical work included: • Kaplan and Norton’s theory linking performance measurement and management by aligning vision, strategy, goals, and performance initiatives.1. • Six dimensions for assessing hospital performance: clinical effectiveness, safety, patient centeredness, production efficiency, staff orientation, and responsive governance. Based on the available data, only production efficiency was incorporated. • On efficiency: appropriateness of services, input related to outputs of care, and use of available technology for the best possible care. • BOOST – Better Outcomes for Older adults through Safe Transitions/Balanced, Observed, Objective, Specific, Timely. To identify gaps in hospital care provision in Belarus, a screening for potential inefficiencies of the system was performed. Based on the Organisation for Economic Co-operation and Development (OECD) report, inefficiencies occur in the following areas: • Nonoptimal treatment covers avoidable instances. This includes duplicate services – the same services in several places – and preventable clinical adverse events, such as when inappropriate care for a chronically ill patient at the PHC and specialist level may result in avoidable hospitalization. Other examples include incorrect prescription of medication or fragmentation of care. Another example may be wrong-site or delayed surgery, or many infections acquired during treatment as well as low-value care, such as unnecessary caesarean sections or imaging tests from a clinical point of view. • Operational/process occurs when care could be provided using fewer resources within the system while maintaining the health benefits. Examples include situations where pharmaceuticals 1 https://hbr.org/1992/01/the-balanced-scorecard-measures-that-drive-performance-2. 7 or medical services are discarded or unused or where lower prices could be obtained for specific goods or services—for instance, by using generic drugs. Another example of paying more when less could be paid is visits to hospital emergency departments; patients under regular care in a PHC often seek emergency care at hospital emergency departments. Preventive measures or incentives could reduce waste of hospital resources. • Governance pertains to resources that do not directly contribute to patient care but are significant in terms of effectiveness of spending and organization as well as safety of processes, including treatment. Examples are unneeded administrative procedures and paperwork; contradictory requirements; and fraud, abuse, and corruption, all of which divert resources from the pursuit of the health care systems’ goals. To exploit a hospital’s productive capacity to the maximum, it is necessary to correctly manage both the supply of services, pursuing high levels of flexibility, as well as their demand. This paper looks at hospital optimization from the perspective of creation of specialized healthcare centers—interregional and interdistrict—for acute intervention and treatment of MI and stroke, redistribution of roles, and responsibilities of the rest of the hospitals in the healthcare network and provision of accessible health services to population. Data used in the policy paper include those from international and national levels as well as from the two selected regions—for drilling down to the health system at the regional level. There were only a few cases where the regional-level indicators were very different from the national average. 8 Chapter 1. Overview of Belarus’s health system Belarus is an upper-middle-income country with an estimated gross domestic product (GDP) per capita of US$6,757 in 2019. The country has a population of about 9.5 million (WDI 2019).2 The population of Belarus is rapidly ageing, and this has negative consequences such as rising health care expenditure and declining labor productivity. Currently, there are 2.3 million elderly people (post-working age) in Belarus, of whom 1.4 million are over the age of 65 years. In 1990, 10.7 percent of people were ages 65 years and above; by 2019, this share had increased to 15.2 percent, and it is projected to grow to 25 percent by 2050. The share of people over the age of 80 years is projected to grow from 3.5 percent to 7.5 percent over the same period. By 2025, the proportion of the population over age 65 years will exceed the proportion of people aged 0–14 years (Figure 1 and Figure 2). Figure 1. Belarus population pyramid Figure 2. Population by broad age groups Source: United Nations, World Population Division 2019. 1.1. Burden of disease, morbidity, and mortality Belarus has achieved significant improvements in key health outcomes. Life expectancy at birth increased from 68.9 years in 2000 to 74.2 years in 2018, while under-five mortality declined from 12.7 deaths per 1,000 live births in 2000 to 3.2 deaths per 1,000 live births in 2019 (WDI 2019). Despite substantial improvements, Belarus still lags countries of similar income levels as well as the European Union and the Europe and Central Asia (including high-income countries) region’s average life expectancy. Also, life expectancy is much lower for men (69.3 years) than women (79.4 years) the 10.1 years difference mostly due to the growing incidence of NCDs, particularly cardiovascular diseases (CVDs), poor diet, smoking, alcohol consumption, and sedentary lifestyles among men (Figure 3 and Figure 4). 2World Development Indicators 2019. Washington, DC: World Bank. https://databank.worldbank.org/source/world- development-indicators. 9 Figure 3. Life expectancy at birth - regional Figure 4. Life expectancy at birth in Belarus by gender comparison Source: WDI and Belarus National Statistical Committee. Belarus is now facing a growing burden of NCDs that have become the major causes for mortality and illness among the population. A recent study by the World Health Organization (WHO) indicates that the Belarusian economy loses 5.4 percent of GDP each year due to premature deaths, morbidity, and disability caused by NCDs (WHO 2018a, 21).3 NCDs are responsible for 91 percent of the mortality rate and 83 percent of the morbidity rate in the country. Injuries account for seven percent of the mortality rate while communicable, maternal, perinatal, and nutritional conditions account for two percent (Figure 5 and Figure 6). CVD causes 63 percent of all deaths in the country. Although almost half of the adult population (45 percent) has hypertension, 53 percent of adults who have hypertension are not taking antihypertensive medication.4 Figure 5. Death rate by causes, % Figure 6. Causes for DALYs, % Source: Institute of Health Metrics and Evaluation, 2018. Note: DALY = Disability-adjusted life year. 3 WHO. 2018a. Prevention and Control of Non-communicable Disease in Belarus: The Case for Investment. https://www.euro.who.int/__data/assets/pdf_file/0010/367561/bizz-case-bel-eng.pdf?ua=1. 4 Institute for Health Metrics and Evaluation: Global Health Data Exchange. http://ghdx.healthdata.org/gbd-results-tool. 10 NCDs also contribute significantly to DALYs in the country. CVDs, neoplasm, and unintentional injuries are the main attributors to the DALY rate in Belarus (Figure 7). Figure 7. Top causes for DALYs in Belarus, 2017 Source: Institute of Health Metrics and Evaluation, 2018. The incidence of ischemic heart diseases (IHDs) is very high in the country. While IHD accounted for only 35 percent of the total death rate in 1990, the share rose to 44 percent in 2017. The rate is higher than the Europe and Central Asia region and the same income level group countries’ average rate (Figure 8). IHD is also a top cause for DALYs, accounting for 34 percent of morbidity in the country. 11 Figure 8. Comparison of IHDs death rate, regional and income group level 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1991 1998 2005 2012 1990 1992 1993 1994 1995 1996 1997 1999 2000 2001 2002 2003 2004 2006 2007 2008 2009 2010 2011 2013 2014 2015 2016 2017 Belarus ECA Upper-middle income Source: Institute of Health Metrics and Evaluation, 2018. Higher mortality in Belarus translates into economic losses. DALYs per 100,000 in Belarus attributed to IHD and stroke are higher than in comparator countries, though the trend decreased over the last 10 years (Figure 9). If Belarus keeps the same trajectory of decrease, it can save more lives. Lives saved, if converted to DALYs, will amount to over 416,000 averted loss of DALYs. Each DALY can be valued at GDP per capita (US$6757 in 2019), offering a significant estimated economic effect of improved mortality at about US$2.6 billion over the course of 10 years. Figure 9. Comparison of IHDs and ischemic stroke as causes of DALYs, per 100,000 people Source: Institute of Health Metrics and Evaluation, 2018. There is a significant gender difference in the key indicators for NCDs in the country. The probability of dying before the age of 70 years is more than twice as high for men as for women, and the age- standardized mortality rate due to NCDs was twice as high in men (991.8 per 100,000) as in women (479.5 per 100,000) in 2017. There is also a geographical gradient in NCDs outcomes: the rural population of 12 Belarus has lower life expectancy and higher premature mortality rates than those living in urban areas. In some rural areas, male life expectancy is as low as 65.6 years. The differences in male–female mortality are attributable to the male population’s greater exposure to behavioral NCD risk factors, especially tobacco use and harmful use of alcohol. Diseases of the circulatory system and neoplasm are the leading cause of morbidity in Belarus. According to the National Statistical Committee of the Republic of Belarus, in 2019, diseases of the circulatory system with 42 percent and neoplasms with 25 percent (newly emerged cases) were the main drivers for the high morbidity rate in the country. It was followed by diseases of the musculoskeletal system and connective tissue with 7 percent and mental and behavioral disorders with 5.6 percent (Figure 10). Figure 10. Morbidity by main groups of diseases (newly emerged cases), 2019 Endocrine, nutritional and metabolic diseases 3.2% Injury, poisoning and certain other consequences of 3.6% external causes Diseases of the eye and adnexa 3.8% Diseases of the nervous system 4.8% Mental and behavioural disorders 5.6% Diseases of the musculoskeletal system and 7.3% connective tissue Neoplasms 24.7% Diseases of the circulatory system 42.3% 0% 10% 20% 30% 40% 50% Source: National Statistical Committee of the Republic of Belarus, 2019. Lifestyle factors and risky behaviors are the main risk factors influencing health concerns in the country. Prevalence of smoking is high and largely concentrated among men—almost 49 percent of the male population smoke compared to 12.6 percent of women. The alarming trend is that the smoking rate increased among women from 3.6 percent in 1995 to 12.6 percent in 2017 (WHO 2018a, 13). In addition, alcohol consumption in Belarus is among the highest in the world, although there are some signs of improvement: the most recent data suggest that total alcohol consumption dropped to 11.2 liters per capita in 2016 from 15.3 liters per capita in 2005. However, this is still behind the European region average of 9.8 liters per capita (WHO 2018b, 45).5 High levels of metabolic factors—such as blood pressure, body mass index (BMI), or blood lipid levels— are another main health concern that leads to the increase in the risk of CVDs in the country. Almost 45 5WHO. 2018b. Global Status Report on Alcohol and Health. https://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng.pdf?ua=1. 13 percent of the adult population have high blood pressure (systolic blood pressure ≥ 140 mm Hg), three- fifths (62.9 percent) of adults are overweight (BMI ≥ 25 kg/m2), and a quarter (26.6 percent) are obese (BMI ≥ 30 kg/m2).6 The average incidence of myocardial infarction in Belarus is 178.3 per 100,000 people, with the lowest in Brest region at 155.5 per 100,000. The incidence of brain strokes is lowest in the capital city, Minsk and one-and-a-half to two times higher in other regions. According to the WHO, most CVDs can be prevented by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, and harmful use of alcohol using population-wide strategies. Such interventions are mostly the responsibility of the primary care level, and hospital optimization will not have a major effect on strengthening such preventive measures. However, hospital-based interventions are also required to treat CVDs; these include diagnostic services, coronary artery bypass, balloon angioplasty, valve repair and replacement, heart transplant, and artificial heart operations. Medical devices such as pacemakers, prosthetic valves, and patches for closing holes in the heart are also required to treat CVDs in certain cases. There are lots of opportunities to prevent avoidable deaths from CVDs. If Belarus were able to reduce death rates in the next 10 years from IHDs and strokes to those in the neighboring Estonia (see proposed projection presented in Figure 11), the country could save more than 150,000 lives in the proposed below period. Figure 11. Death rate per 100,000 people in Belarus and Estonia for 1990–2017 and forecasting for 2021–30 Projection for Ischemic heart 2021-2030 700 disease, BLR 600 500 Ischemic heart 400 disease, EST 300 200 Stroke, BLR 100 0 Stroke, EST 2004 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source: Institute for Health Metrics and Evaluation and author calculation. Note: Projection for Estonia is based on the average trend over the last 10 years, and for Belarus, it is based on an assumed 5 percent decrease annually. 1.2. Highlight of key issues of effectiveness, efficiency, and inadequate attention to NCDs There is some indication that having a concentration of services in big cities like Minsk allows for better disease detection. The highest incidence of both new disease cases and overall morbidity, according to data for 2019, was registered in Minsk and significantly exceeded similar indicators for other regions and the Republic of Belarus as a whole. This occurs due to the concentration of all types of specialized medical 6 WHO. Global Health Observatory Data. 14 care in the country’s capital—almost all the Belarus research centers are located in Minsk, high resource availability including staffing of medical personnel, and the multidisciplinary nature of health care facilities that provide medical care in both inpatient and outpatient settings. At the same time, mortality is lower in the city of Minsk compared to other regions and the national average value. The lower mortality could be attributed to better efficiency, different care seeking behavior among the educated population of Minsk, and the fact that many patients travel to Minsk for treatment but return home afterward (Figure 12). Figure 12. Morbidity and mortality rates at country and regional levelsa 250,000 1,473 1,600 Mortality rate per 100,000 population 1,382 1,397 1,371 Disease incidence per 100,000 1,353 1,280 1,273 1,400 200,000 1,200 population 150,000 897 1,000 800 100,000 600 400 145,297 149,600 155,193 146,979 217,911 111,896 155,430 133,816 163,054 69,775 71,559 76,969 72,636 78,587 59,984 80,506 50,000 200 - - Brest Vitebsk Gomel Grodno Minsk city Minsk Mogilev Republic oblast oblast oblast oblast oblast oblast of Belarus Total mortality Overall disease incidence Primary disease incidence Source: Belarus Statistical Reporting 2019. Note: a. Overall disease incidence rate—overall of all diseases present in the population, both first detected in a given calendar year and registered in previous years, for which patients again applied in a given year. It is possible to have multiple diseases per patient. Myocardial infarction and strokes remain one of the main health issues of the Belarusian population. In 2019, there were 358 cases of strokes and 178 myocardial infarctions per 100,000 population in the country. The Vitebsk region seems to be an outlier in both diseases, with higher rates than any other region in the country and the national average. Minsk, on the other hand, had the lowest reported cases in 2019, at 215 cases of strokes and 198 myocardial infarctions per 100,000 population (Figure 13). 15 Figure 13. Myocardial infarction and stroke incidence rate (per 100 000) among adult population (age 18 and above) 500 438 450 406 380 382 390 382 400 358 350 # of incidence 300 250 215 200 198 198 195 200 178 156 142 153 150 100 50 0 Brest Vitebsk Gomel Grodno Minsk city Minsk Mogilev Republic region region region region region region of Belarus myocardial infarction stroke Source: Belarus Statistical Reporting, 2019. Over the past years, Belarus has prioritized financing and development of high-tech and specialized medical care for CVD. Such investment in technology enhancement of medical care contributed to reduce CVD incidence and stroke rate. However, morbidity rate for IHD per 100,000 population hit highest in Belarus in 2017. The country’s IHD rate was almost twice the average rate of OECD countries and the incidence rates of Poland, Sweden, and the United Kingdom (Figure 14). At the same time, looking at a much shorter life expectancy than all the mentioned countries – by as much as 12 years in the case of Sweden – it can be assumed that prevention of risk factors and detection and treatment of those diseases at the PHC level and on an outpatient, basis needs improvement. This could be confirmed also by the high mortality rates due to those diseases. 16 Figure 14. Morbidity of selected diseases per 100,000 population 3000 700 Ischemic heart disease and stroke, Cardiovascular diseases, blue bars 2500 600 orange and green bars 500 2000 400 1500 300 1000 200 500 100 0 0 Belarus Croatia Denmark Estonia OECD Poland Sweden United countries Kingdom Cardiovascular diseases Ischemic heart disease Stroke Source: Institute for Health Metrics and Evaluation, 2017. Though Belarus has an abundance of capital stock in its health system, efficiency of the Belarusian health care system, as measured by mortality rates due to CVDs, requires further improvements. Compared to high-income countries such as Estonia, Denmark, Poland, Sweden, and the United Kingdom (UK), the mortality rate in Belarus is much higher—30 percent higher than in Estonia, for example. Stroke causes 115 deaths per 100,000 population in Belarus, whereas this figure is 47 in Denmark and 43 in Sweden. Similarly, the highest death rate for Belarus is observed in circulatory diseases, with 935 cases per 100,000 population, while Denmark reported 192 cases in 2018 (Figure 15). 17 Figure 15. Mortality rate per 100,000 population by causes 1273 1400 1200 959 935 895 1000 799 763 707 800 600 438 400 399 233 193 192 115 200 73 52 49 47 43 37 33 29 28 23 20 0 Belarus Poland Denmark United Kingdom Sweden Estonia All causes of death Deaths due to acute myocardial infarction Deaths due to cerebrovascular diseases (Belarus: cerebral infarction) Deaths due to circulatory diseases Source: Belarus Statistical Reporting, 2019 and WHO data base 2016. 1.3. Structure of the health care system Universal Health Coverage (UHC) Index—access to healthcare facilities and services without any financial hardship—scored 76 out of a possible 100 in Belarus in 2017, which is higher than the average UHC index of the Europe and Central Asia region – excluding high-income countries – at 72.7 However, the health delivery system faces major constraints. Financing and organization of the health system continues to follow the Soviet Semashko model based on centralized planning of resources and personnel, primary public ownership of health care facilities, input-based allocations of funds, and no clear provider- purchaser split. The MOH is responsible for the provision of services, while the Ministry of Finance and local authorities provide public funding from general revenues. Local authorities, financed by the central government, allocate budgets to health facilities using historical line-item budgeting largely based on inputs (that is, doctors and beds). The country provides universal and extensive health coverage to the population, free at the point of use, and health services are provided at four levels in the country (Diagram 1): • Republican and interregional (interregional): republican and interregional specialized centers. • Regional (regional): regional hospitals and dispensaries and specialized regional hospitals. • Interdistrict and city: interdistrict centers and departments, city hospitals, and dispensaries. • District: village outpatient facilities and village hospitals, central regional hospitals, and polyclinics. 7 World Bank: Health, Nutrition and Population Data Dashboard http://datatopics.worldbank.org/health/health. 18 Diagram 1. Health services organization Highly qualified, high-tech specialized consulting, Republican and diagnostic, and therapeutic medical care interregional level (republican and interregional specialized centers) Highly qualified consulting and specialized inpatient multi-profile medical care (regional Regional level hospitals, dispensaries, and regional specialized hospitals) Highly qualified consulting, diagnostic, and Interdistrict and city therapeutic specialized medical care with the level use of widely spread technologies for diagnosis and treatment (interdistrict centers and departments, city hospitals, and dispensaries) PHC, qualified outpatient and polyclinic care, District level and specialized inpatient care Source: Authors’ analyses, 2020. The health care delivery system is skewed toward hospital care, and the country has an oversized hospital network with over 10 beds per 1000 population, while Estonia has 4.5, Denmark 2.4, Poland has 6.5 beds, and Sweden has 2.1. According to the National Statistical Committee of the Republic of Belarus, as of 2019, there were 609 hospitals and 2,288 outpatient and polyclinic facilities in the country.8 However, Belarus lacks the strong primary care system that is necessary to address the health challenges associated with an aging population and high burden of NCDs. There are discrepancies in the internal efficiency of hospitals, with significant variations in the average length of stay (ALOS) and unit costs for similar treatments across the country. Enhancing the efficiency and quality of services as well as the use of public resources requires strengthening PHC services to manage the growing incidence of NCDs – especially in the context of an aging population, eliminate disparities in health care provision between urban and rural areas, reorganize and reprofile the hospital network, improve the integration of care between different levels of services, and meet the increasing need for LTC. Many general hospitals are low-capacity facilities. Every district in the country—even those with only 15,000 people—has a general hospital, called a central district hospital, and often additional district hospitals and nursing facilities. The central district hospital offers the whole range of hospital services, including complex surgeries and maternity care. Therefore, the number of surgical procedures and interventions performed in each hospital is too low to provide good-quality care. The average capacity of central district hospitals is just 221 beds, and most cases are of a nonsurgical nature. The number of surgeries with general anesthesia averaged less than 49 per year in 46 percent of central district hospitals. Each hospital maintains an intensive care unit (ICU) and employs staff for complex surgical interventions, 8National Statistical Committee of the Republic of Belarus. https://www.belstat.gov.by/en/ofitsialnaya-statistika/Demographic- and-social-statistics/Health/. 19 but beds and equipment are unevenly distributed across the country. Because of the lack of investment and other constraints, very few hospitals can provide complex care—for example, complex heart surgeries or advanced cancer treatment. With limited resources distributed across an oversized hospital sector, most of the hospitals are not sufficiently supplied, and their use of resources is far from optimal. The budget of medical institutions is dominated by fixed costs, leaving little space for innovations and quality improvements. Utilization of health services is reasonably high in the country. Belarus has the highest utilization rate of inpatient care compared to other countries in the region, 31 inpatient care discharges per 100 people, which is almost 50 percent higher compared to the EU-15 (Figure 16). Health sector expenditures associated with inpatient care made up about 44 percent of the total public spending in the health sector in 2017, which is higher than in countries with much stronger economies—38 percent on average for the OECD in 2015. Also, the 2017 figure of 14 outpatient care discharges per 100 people is substantially twice that of the EU average of 7.1 outpatient discharges per 100 people.9 The number is largely explained by existing requirements for regular checkups. However, a recent study by the WHO (WHO 2018a, 22)10 shows that despite frequency of outpatient visits, identification and follow-up of patients from risk groups are not effective to address the current challenges of the aging population and growing rate of NCD burdens. The study also found that only 47.5 percent of men and 64.6 percent of women with diagnosed hypertension were taking medication prescribed by a doctor. Figure 16. Inpatient care discharges per 100 people 35 31.0 Inpatient care discharges per 100 30 25 19.0 19.6 20 16.6 16.8 16.8 17.5 17.5 18.6 18.6 16.1 15 13.3 13.9 11.6 10 5 0 Source: WHO, European Health for All database, 2017. In rural areas, medical services are provided at the district level. At the district level, medical services are provided through central district hospitals—currently 107 in various regions of the Republic of Belarus, nine district hospitals, hygiene and epidemiology centers, district dispensaries, and other facilities. Activities of these facilities cover an area with a service radius of approximately 40 km, with the aim to 9WHO. 2017a. Health for All. https://gateway.euro.who.int/en/hfa-explorer/. 10WHO. 2018a. Prevention and Control of NCDs in Belarus: The Case for Investment. https://www.euro.who.int/__data/assets/pdf_file/0010/367561/bizz-case-bel-eng.pdf?ua=1. 20 deliver health care services within an hour to the rural population. To ensure access to health services for all citizens in rural areas, the Government also has mobile clinics that provide medical services to seasonal farmworkers and citizens in remote and hard-to-reach areas. To improve the availability of health care services and address various diseases in rural areas, the Government has also developed a road map.11 The Government has developed and approved instructions for organizing a multilevel system of medical care in the country. These instructions provide guidelines and procedures for organizing medical care for profile-specific patients in health care facilities at various technical levels, coordination and interaction between health care facilities, and the procedure for referring/transferring patients to health care facilities. Each outpatient health care organization has developed regulations for providing medical care as well. In large cities that have an extensive network of hospitals, and especially in Minsk, each outpatient facility is assigned a multidisciplinary hospital organization. Medical care for patients is provided based on clinical protocols approved by the MOH. The requirements of the clinical protocol are mandatory for legal entities and individual entrepreneurs engaged in medical activities in accordance with the procedure established by law. The procedure for referring patients to receive medical care in health care facilities at various technological levels is clearly regulated, and patient routes are designed to improve the availability and quality of medical care, including high-technology care. The recent COVID-19 pandemic’s burden on health systems, with patients needing intensive critical care, is putting a huge additional strain on hospitals regardless of the capacity before the pandemic. As international examples present, while fighting with emergencies such COVID-19 very few health systems have sufficient capacity. Those who managed relatively well focused not only on treatment but mostly on public health functions such as tracking and tracing. A key element of the health care system is therefore its resilience understood as the capacity of health institutions, health community, and populations to prepare for and effectively respond to crises, maintain core functions when a crisis hits and, informed by lessons learned during the crisis, reorganize if conditions require it. Although Belarus’ health system has enough beds and hospitals, it was unprepared and lacked ICU capacity, adequate modern equipment, treatment protocols, trained physicians to effectively respond to the pandemic. Further adjusting to pandemics like COVID-19 would require even more urgent shifting of care, such as simple surgical procedures, management of chronic conditions, and chemotherapy to outpatient departments and clinics, and the use of home care. Reducing or even eliminating inpatient stay for many surgical procedures may be beneficial from both the short- and long-term perspectives. Therefore, the current pandemic also provides an opportunity to optimize hospital care. This could involve reforms including, among others, modernizing infrastructure and equipment, developing adaptive approaches to scale up ICU capacity in existing hospitals at short notice to meet increased inflows during pandemics such as COVID-19, strengthening financial management and fiscal discipline, bundling clinical and managerial capacity, and incentivizing management and staff to maintain high levels of efficiency and quality of care. Attaining such gains, however, requires substantial initial capital and human resource investments. 11Guidelines on the provision of medical care to the patients with acute cerebrovascular disorders (Road Map). http://minzdrav.gov.by/ru/dlya-spetsialistov/normativno-pravovaya-baza/baza-npa.php. 21 1.4. Prehospital and emergency medical services In Belarus, there is countrywide ambulance-centered Emergency Medical Services (EMS). Its coverage is available 24 hours a day, 365 days a year. The provision of EMS is based on a geographically distributed network of 134 EMS stations and (substations) that provide medical care on the principle of regional administrative allocation of patients. Though Belarus has enough ambulances providing prehospital emergency care – of which 1,103 are basic life support (BLS) vehicles and 57 are ambulances of advanced life support (ALS), most of the current fleet is unsuitable for providing modern prehospital emergency medical care. Ambulance stations are usually situated in a separate building away from the hospital in large cities or are connected to hospitals or polyclinics in smaller district centers. Specialized evidence-based protocols for acute myocardial infarction and stroke are available. Availability of specialized ambulance teams (cardiac, trauma, or neurological, including stroke) is higher in urban areas, especially in Minsk, than in rural areas. The standard of EMS provision for regions is two EMS teams for regions with population of up to 15,000; three EMS teams for regions with population of 15,000–35,000; in regions with population of more than 35,000, three EMS teams with an additional EMS team for every 12,000; and for the city of Minsk, one EMS team for every 12,000 people. In administrative-territorial units with a population of less than 100,000, where there are no psychiatric EMS teams, another EMS team may be sent in response to a call to attend to patients with mental disorders/diseases or with suspected cases of mental disorders. In the regional centers and the city of Minsk, there is a consolidation of hospitals that provide specialized medical care. If there is a need to perform complex interventions or provide highly specialized medical care, patients are transported from the regions directly to the target health care organizations assigned to the administrative territories—bypassing the central district hospital and going straight to the regional hospital. In the regions, the EMS are part of the central district hospitals and provide medical services for citizens based on their assigned territories. In case of medical emergency, patients are transported to central district hospitals for emergency medical care. The place of residence is not considered at the time the call for EMS is made. For example, it is possible to make a call outside residential areas—medical care is provided based on the shortest distance from the EMS station. The country’s EMS system is structured into four divisions: EMS stations, EMS substations, EMS departments, and EMS units. It operates in three modes: emergency, high-alert, and regular. • EMS station is a state health care organization that is established in residential areas with a population of more than 100,000. • EMS substation is a structural unit of the EMS station and is established in city districts and other administrative divisions with a population of 50,000–100,000. • EMS department is a structural unit of a state health care organization that provides EMS. • EMS unit is established as part of the EMS station (substation or department) as its structural unit by the decision of the head of the state health care organization. 22 EMS teams are classified as physician EMS teams and divided into the following categories: • Resuscitation EMS team. • Intensive care EMS team. • Pediatric EMS team. • Psychiatric EMS team. Box 1. EMS in Belarus The organization of EMS work in the Republic of Belarus is regulated by the Decree No. 2 of the MOH of the Republic of Belarus, “On issues of the organization of emergency medical services work� dated 4 January 2020, which approves the instruction on the procedure of organization of EMS work. EMS performs the following activities: • Receiving calls and forwarding them to EMS teams. • Ensuring that in case of emergency priority, when the EMS team is called, the waiting time for the EMS team does not exceed 20 minutes within the city limits and 35 minutes within other destinations, from the moment of registration of the call until the arrival of the EMS team at the corresponding address. • Ensuring that in case of immediate priority, when the EMS team is called, except for calls for medical transportation (evacuation) of patients or to declare the fact of death, the waiting time for the EMS team does not exceed 75 minutes within the city limits and 90 minutes within other destinations from the moment of registration of the call until the arrival of the EMS team at the corresponding address. • Providing EMS at the corresponding address. • Ensuring that in cases of high priority, when the EMS team is called for medical transportation (evacuation) of patients or to declare the fact of death, the waiting time for the EMS team does not exceed 135 minutes within the city limits and 150 minutes within other destinations from the moment of registration of the call until the arrival of the EMS team at the corresponding address. • Ensuring that in cases of immediate priority, when the EMS team receives a message from the operational and duty service of the internal affairs agencies to declare the fact of death, the waiting time for the EMS team does not exceed 75 minutes within the city limits and 90 minutes within other destinations from the moment of registration of the call until the arrival of the EMS team at the corresponding address. • Organizing and providing EMS, including calls requesting a home doctor’s visit and associated call for the EMS team. • Organizing patient flow management during their transportation through the hospitalization department of the EMS station. • Ensuring quality control of EMS provision. • Ensuring continuity in work with other state health care organizations and interaction with local government and self-government agencies, internal affairs agencies, emergencies management agencies, and departments. The calls to EMS can be made in the following ways: • By dialing 103 (by telephone). • Via text messages (for people with hearing or speech impairments). 23 • When the patients themselves or a third party is visiting the EMS station (substation, department, or unit) or is directly approaching the EMS team. • Through direct communication lines with the state agency’s operation centers and emergency subdivisions. Cardiovascular emergencies are the most common reason for calling an ambulance in the country (32.6 percent of calls) (WHO 2017b, 15).12 However, there is overall a very large number of ambulance calls — more than 300 ambulance visits per 1,000 population per year, or every third person calls an ambulance at least once per year, with a very low rate of hospitalization after arrival of the ambulance. A significant proportion of the ambulance calls is related to high blood pressure, which would not happen if patients had free and uninterrupted access to hypotensive drugs. Though Belarus has a relatively large number of ICU beds, critical care and emergency services have capacity limitations to address the COVID-19 pandemic. According to the MOH, Belarus has 2,575 ICU beds across 360 hospitals with ICU capacity. This is equivalent to 26 beds per 100,000 population. By comparison, Germany has 33 beds per 100,000 population, and the United States 20, while Moldova, Poland, and the UK report much lower numbers of intensive care beds—respectively 16, 9, and 6 beds. But the ICU beds in Belarus are unevenly distributed across the country, and ICU’s equipment is not functional and outdated. In general, a Level 1 ICU is capable of providing oxygen, non-invasive monitoring, and more intensive nursing care than on a ward; a Level 2 ICU can provide invasive monitoring and BLS for a short period; and a Level 3 ICU provides a full spectrum of monitoring and life support technologies.13 The capacity level of the beds available in Belarus is not known. The MOH has modified 38 hospitals to serve as COVID-19 response facilities with a total of 11,500 ICU beds. If necessary, 2,140 additional beds could be reprofiled. With respect to emergency services, although Belarus has enough ambulances, of which 1,103 are BLS vehicles and 57 provide ALS, most of the current fleet is unsuitable for providing modern prehospital emergency medical care. 1.5. Physical and human resources Belarus has an abundance of capital stock—human and physical resources—reasonably distributed across the country. The demand for essential services is fulfilled, with the availability of hospital beds and physicians among the highest globally. To recap, service delivery is hospital centered, with the use of hospital care much higher than the regional peers, and accounts for most of the health care spending. The hospital network is very dense with duplicate functions. Outpatient care is not fully effective in addressing the challenges of the aging, with fragmented facilities and limited access to free medication. Both chronic care and LTC facilities are underdeveloped elements of the Belarus health care system. Most hospital beds are composed of acute care beds, compared with the few for chronic care (rehabilitation services, geriatrics, and LTC). The majority of the LTC is provided within the family, with no additional resources, poor knowledge of the care process, and almost no oversight by health professionals. 12 WHO. 2017b. Review of Acute Care and Rehabilitation Services for Heart Attack and Stroke in Belarus. https://www.euro.who.int/__data/assets/pdf_file/0007/342655/Belarus-CVD-report.pdf. 13 https://pubmed.ncbi.nlm.nih.gov/27612678/. 24 The number of outpatient health care facilities over the last 10 years still remains at 1,400, while the number of inpatient facilities has decreased by 7.3 percent (Figure 17). Figure 17. Number of outpatient and inpatient health care facilities, 2010–19 1600 1400 1393 1408 1421 1414 1414 1414 1410 1408 1400 1400 1200 1000 800 646 644 639 632 626 623 619 612 602 599 600 400 200 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Outpatient healthcare facilities Inpatient healthcare facilities Source: MOH 2019. Very few hospitals can provide complex care – for example, complex heart or brain surgeries or advanced cancer treatment – due to lack of investments and other constraints. With limited financial resources thinly distributed across the oversized hospital sector, most of the hospitals are not supplied sufficiently and the use of the resources is not optimal. The costs for the medical institutions are dominated by fixed costs, leaving little space for innovations and quality improvements. The country has an abundance of beds for short-term use. For instance, in 2019, the short-term hospital bed availability per 10,000 people in the Belarus was 82.4, significantly higher than in neighboring countries— Latvia (56.7), Lithuania (72.6), and Poland (65.2). Belarus has 100.2 hospital beds per 10,000 people, with a bed occupancy of 317.3 days and the average length of bed occupancy of 10.5 days. Bed utilization differs not only between regions but also between districts within a region. For instance, in Brest region, with some beds under repair, hospital bed availability is 99.9, and the bed occupancy is 320.4 days/year. In Gomel region, bed utilization rates exceed the national average: hospital bed availability is 106.4, bed occupancy is 330 days (some beds are under repair), and average length of bed occupancy is 10.2 days (Figure 18). Although there are no major differences between the regions, detailed analysis of patients’ profiles, distribution of diseases, and cost implications could explain these variations. 25 Figure 18. Indicators of hospital bed availability, bed occupancy, and ALOS (per 10,000 people) 10.2 length of stay in bed 10 10.5 32.3 bed turnover 32 30.3 106.4 number of beds per 10,000 99.9 100.2 330 bed occupancy 320.4 317.3 0 50 100 150 200 250 300 350 number of beds Gomel region Brest region Country level Source: World Bank analysis based on Belarus statistical data 2018 and WHO database 2016. There are supply and demand concerns for health care services and facilities in some regions. For example, there is increasing demand for therapeutic beds in thinly populated regions—a low level of specialized small bed occupancy and a high load on multi-specialty hospitals. On the other hand, in some regions, low utilization of specialized beds is associated with a high average length of hospital bed occupancy. As an implication, potential patient’s reallocation towards the primary care, development of inpatient-replacement technologies in thinly populated areas and increase in the capacity of multi-profile large facilities through the consolidation should be considered. The population of Belarus uses doctor consultations more often compared to other countries. The number of outpatient visits (Figure 19) per person was 12.6 in 2019. This is one of the highest rates not only among European countries but also Commonwealth of Independent States (CIS) countries – this indicator was 6.9 in Kazakhstan, 5.9 in Latvia, 8.7 in Lithuania, and 9.0 in Poland – –despite a clear downward trend, as a result of the introduction of the principle of maximum provision of medical care per visit. The hospitalization rate per 100 residents in 2019 was 30.3, which is also one of the highest rates among European countries, indicating far from optimal use of hospital resources both economically as well as considering patient’s needs, burden of disease, and safety and quality of treatment (Figure 19). 26 Figure 19. Hospitalization rate (per 100 residents) and doctor visitsa (per resident) in 2010–19 35 29.8 30 30.3 30 29.6 30 30.2 30.2 30.1 30.3 30 Number of patients 25 20 15 13.4 13.2 13.2 13.2 13.1 13.3 12.7 12.7 12.7 12.6 10 5 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Hospitalization rate per 100 residents All visits to doctor per resident Source: Belarus Statistical Reporting, 2019. Note: a. These include home visits, dentist visits, and ambulance stations and emergency medical centers’ visits. Compared to the rural population, urban people have better access to specialized care with a network of specialized facilities and more reference hospitals in all areas of medical care. Specialized medical care is provided to the rural population through central regional hospitals, where mainly therapeutic beds are located, and only emergency surgical care is provided in surgical beds. Access to regional and city-level centers is available for district residents, but their geographical location, which is at considerable distances from the patients’ place of residence, causes barriers to access and ultimately delay in the provision of care. One of the strengths of the Belarusian health system is a large number of medical personnel. As of January 1, 2020, there were 49,018 doctors in the Republic of Belarus, and 115,030 nursing staff. At the start of 2020, the availability of specialist doctors was estimated at 5.2 per 1,000 people, which is higher than that indicator in the European Union (3.3) and CIS countries (3.8). The availability of nursing staff at that time was estimated at 12.2 per 1,000 people, which is higher than that indicator in the European Union (8.7) and CIS countries (6.2). The average age of staff employed in the sphere of health care is 43.7 years. Compared to Croatia, Denmark, Estonia, Poland, and the UK, Belarus has a higher number of doctors working in hospitals, with 3.1 doctors per 1,000 people. The lowest rate among the mentioned countries struggling with medical personnel inefficiencies is Estonia with 1.1 doctors per 1,000 people in 2018 (Figure 20). 27 Figure 20. Hospital staff per 1,000 people in 2018 8 7.2 7 6.5 6.2 6 5 4.7 4 3.5 3.1 3 2.5 2.4 2.1 2.1 2 1.3 1.1 1 0 Belarus Croatia Estonia Poland Denmark United Kingdom Medical doctors employed in hospitals Nursing professionals employed in hospitals Source: World Bank analyses based on the MOH and OECD database. Looking at hospital beds per 100,000 people in countries such as Denmark with 253 beds or Germany with 826 beds (Figure 21), Belarus has the highest number of hospital beds per capita in Europe and employs more medical staff than peer countries relative to the population (Figure 22). All available medical positions are currently occupied, and Belarus is among the countries with the highest ratios of health care professionals, with 5.2 nurses and 12.2 physicians per 1,000 people. The country's average staffing level, as proportion of positions available, of physicians is 95.5 percent, and the staffing level of nursing staff is 97.3 percent. The regions that are the least staffed with medical specialists are Grodno region (93.3 percent) and Minsk region (94.3 percent). The regions that are the least staffed with nursing staff are Minsk region (95.4 percent) and Grodno region (95.8 percent). Figure 21. Hospital beds per 100,000 people Belarus 1083 Germany 826 Poland 652 European region average 553 Estonia 500 United Kingdom 274 Sweeden 254 Denmark 253 0 200 400 600 800 1000 1200 Source: WHO, European Health for All database 28 Figure 22. Availability of nurses and physicians per 1,000 people with filled vacancy (%) at country and regional levels Source: Belarus Statistical Reporting, 2019. 29 Chapter 2. Health financing in Belarus Public expenditures of the health system are financed through the general taxation mechanism. Budget spending on health care on average accounted for 4.6 percent of GDP in 2013–18, which is above the median level for Europe and Central Asian countries and is closer to countries with per capita income level higher than in Belarus. The share of out-of-pocket payments in 2017 was reported at 27.5 percent, which is lower than in many other countries in the same region (Figure 23). The Belarusian per capita spending for health care is on par with upper-middle-income countries (UMICs) but lower than its regional peers, both as a share of GDP and in nominal values—US$1,129 purchasing power parity and US$342 in 2017. Figure 23. Shares of out-of-pocket expenditures in Belarus and its neighbors (latest available year, 2017) 52.3 42.0 40.5 32.3 27.5 23.7 Belarus Estonia Lithuania Latvia Russian Ukraine Federation Source: WDI. In addition to playing the role of main purchaser, the Government owns health infrastructure and decides on its placement and capacities. Health facilities belong to regional and district governments; they are also key stakeholders given that they are responsible for financing the system at their level. The central- level (republican) budget is used to finance the national-level service providers, centralized procurement of medications and equipment, and the national-level health programs. The local budgets are responsible for financing the facilities located on their territory. There is a financing normative that needs to be adhered to in terms of per capita spending by each ‘oblast’ (region). Financing of providers of care is based on the line-item principle, which offers strong administrative controls of input resources. Legally defined norms dictate the numbers of staff employed by facilities of different levels, bed capacity of health care facilities, and other resources. Salaries of health personnel employed in the publicly owned facilities are determined by a salary scale and adjusted based on the number of years of work experience and qualification level. Salary bonuses are paid to staff employed in the rural areas. Health care is provided free of charge to patients in public facilities, based on their residence. Patients are expected to use services in the nearby providers of care. If a facility in the catchment area does not provide the needed services, the patient is referred to a higher-level facility within the same region and, if needed, to the republican level facilities in Minsk. Citizens living in urban areas and capital cities of regions usually have access to more advanced providers or care than residents of rural remote areas. 30 2.1. Imbalances in financing of the health system The health system is hospital centered. Health sector expenditures associated with inpatient care made up about 44 percent of the total public spending in the health sector in 2017, which is higher than in countries with stronger economies—38 percent on average for countries of the OECD in 2015.14 Hospitals and specialized outpatient polyclinics are located in almost all cities and rayons of the country, regardless of the size of such territorial units. For example, 63 out of total 114 rayons have population of less than 30,000. Each administrative unit of rayon level and above has a variety of inpatient facilities, often with duplicative functions. Maintenance of an extensive hospital network is demanding in terms of providing adequate level of technologies and staffing in each facility, which creates pressure to sustain health expenditures at the existing levels. Within the existing fiscal space, the country cannot offer attractive earnings to staff in the health sector. Belarus employs more medical staff than peer countries relative to the population, but the remuneration is not competitive compared to the other sectors of the economy. The average monthly wage in the health sector in 2018 was 31 percent lower than the country average. Moreover, the medical personnel are working more than one full-time equivalent (FTE) to earn additional money—1.36 FTE for physicians and 1.26 FTE for nurses in 2017. At the same time, the numbers of physicians were growing in absolute numbers compared to the population size (Figure 24). Figure 24. Numbers of physicians per 1,000: surgical and therapeutical (excluding pediatricians, diagnostic specialties, preventive care physicians, and dentists) 1.22 1.25 1.26 1.14 1.18 1.55 1.60 1.66 1.72 1.73 2014 2015 2016 2017 2018 Physicians of therapeutical profile per 1,000 Physicians of surgical profile per 1,000 Source: Authors calculations using data of the Statistical Yearbook ‘Public Health in the Republic of Belarus’, 2018. 14 Health at a Glance 2017: OECD Indicators. Paris: OECD Publishing. http://dx.doi.org/10.1787/health_glance-2017-en. 31 2.2. Current health financing mechanism Currently, financial incentives in the system are based on inputs. The allocation of funds to providers depends on inputs such as number of beds and personnel. Availability of resources to cover health expenditures at the local level depends on whether they can substantiate the need for maintenance of facilities. Such a mechanism suggests that each location will try to organize as many health facilities as possible. Local health facilities are a part of social infrastructure; they offer possibilities for employment, increase social attractiveness of the location, and provide other benefits to citizens. However, no incentives are offered to encourage efficiency in the allocation of financing. The existing financing mechanism suggests that accounting of inputs and data for their justification are well established, but the data on outputs are limited. For example, since the financing is input based, accounting of staff, visits, beds, and admissions is very detailed. The system incentivizes reporting more visits and more admissions to justify operations of providers overall and in small territorial units. But there is no incentive to account for complexity of patients treated, number of services per physician and nurse, cost of service delivery, and quality of care provided. Availability of patient-level data is limited since the country is in the beginning of implementation of a comprehensive eHealth system. Belarus is considering the introduction of outputs-based payments of hospital services. The results of a joint assessment of the efficiency of hospital care conducted in 2018 by the MOH and the World Bank reported a major variation in costs of the typical services that are provided by different hospitals, whereas smaller hospitals were sometimes more expensive in terms of cost per bed-day for a similar case than their larger peers located nearby. To prepare for strategic payments for services, the country is implementing a pilot project for case-based reporting in select hospitals.15 The data on specific cases, their complexity, and conduced procedures will be collected to construct diagnosis-related groups (DRGs). It is planned that by 2025, the country will start nationwide payment of hospital services using DRGs. The shift to output-based payments may help make more rational decisions on payments for hospital care if strategic purchasing, based on quantitative and qualitative performance indicators, is introduced. For the providers, the shift from input-based to output-based financing can help rationalize the structure of expenditures and seek for internal efficiency. 15 The implementation of the pilot started in 2019; it is supported by the World Bank with financing provided by the Korea- World Bank Group Partnership Facility. 32 Chapter 3. Government’s plans on creation of interregional and interdistrict centers The primary goals of implementing the hospital optimization reforms in Belarus are to improve health outcomes of the citizens and to reduce high rates of morbidity and mortality. Modernization of selected hospitals that will provide accessible, comprehensive, tertiary level care will contribute to timely treatment and prevention from complications. Acute episodes will then receive faster and efficient management with lower mortality rates as a result. Since CVDs are responsible for the largest share of morbidity in the adult population – 35 percent of total reported diseases – and these are contributing the most to mortality of the Belarusian people. For example, from the total standardized mortality rate per 100,000 of 1,273, blood circulatory causes are responsible for 62 percent of total deaths., Therefore, it is expected that hospital optimization may help improve care delivery and achieve better health outcomes for patients with CVDs. Additionally, the Government is expecting to reduce the number of acute cardiovascular events by timely interventions to prevent the development of acute infarctions, reduce mortality after admissions for acute cardiovascular conditions, and minimize recurrent hospitalizations after interventions for acute conditions. 3.1. Proposed optimization plan of the Government (main purpose, key points) As a part of the health reforms, the Government is planning to develop IRC and IDC hospital networks with modern surgical and emergency services to provide efficient and quality emergency care for the Belarusian population based on a concept named “Creation of Interregional Centers and Centers for Collective Use of Specialized and High-tech Medical Care in the Republic of Belarus for 2018–2025.�. The Government plans to implement this through the restructuring and redistribution of functions between health care organizations within a 70 km zone (Map 1). 33 Map 1. Planned IRCs and adjacent territory where they will provide services16 Source: MOH, 2020. The objective of the concept is to ensure maximum accessibility of specialized medical care for patients primarily but not exclusively with acute coronary syndrome (ACS), acute cerebral circulation disorders, and traumatic brain injuries (TBIs). The focus would be on vascular surgery and cardiology services, cerebrovascular accident injury and TBI, brain surgeries, and early treatment of strokes. The IRCs and IDCs would provide regular inpatient medical care to patients, including those with acute secondary-level care conditions – requiring simpler procedures – and other types of services from gynecology to rehabilitation. Thus, these centers will combine the provision of cardiology, cerebrovascular, and cancer services. The full description of the functions to be provided is presented in Diagram 2. Health services new organization structure under IRCs. 16 This map is conditional to illustrate the general concept of creating IRCs. Big red dots demonstrate location of planned IRCs, while small red dots demonstrate IDCs. The circles present the coverage area of their services. 34 Diagram 2. Health services new organization structure under IRCs Source: Authors’ analyses, 2020 The Government has already begun the process to implement the abovementioned concept nationwide, and the demand for health care services has increased in pilot sites. For instance, a recent study of Gomel region indicated that currently there are 19 functioning IDCs in the region providing outpatient and advisory medical care within 15 profiles, 15 providing inpatient medical care, 7 providing chronic hemodialysis, and 5 having interdistrict pathology departments. Compared with 2018, in 2019, the volume of medical care provided in outpatient settings in the region increased by 30.3 percent (from 3,941 to 5,135 visits). A total of 5,836 patients were treated at the hospital in Gomel, which is 17.8 percent more than in 2018 (4,956). These indicators showed the demand for interdistrict and interregional (providing highly specialized types of medical care) levels of medical care in the region. Therefore, the Government expects that with establishment of the IDCs/IRCs, the number of patients treated in such hospitals will increase. However, the cost of treatment in the IDCs/IRCs will be higher due to the use of more advanced technologies, more expensive materials for interventions, and higher cost of staff. 3.2. Government’s approach to address NCDs Creation of IRCs for interventional cardiology and acute cerebrovascular accident (stroke) tasks includes the following: • Developing the endovascular surgery service to achieve the volume of percutaneous coronary interventions (PCI), comparable with European indicators: total number of PCI—up to 1,500 procedures/1 million population/year; PCI for ACS—up to 600 procedures/1 million population/year. 35 • Ensuring the availability of modern ACS therapy—increase in the volume of thrombolytic therapy with modern thrombolytics and interventional cardiology with the subsequent transfer of patients for pharmaco-intervention strategy. • Phasing out thrombolytic therapy—incomplete reperfusion requiring intervention after the therapy. • Increasing interregional availability of pharmaco-intervention strategy in ACS without ST elevation —small focal myocardial infarction and unstable angina pectoris, prevention of repeated myocardial infarction and sudden death. • Ensuring coordination and logistics of hospitalization of patients as well as ensuring coordination between emergency medical teams, health care organizations, and intervention centers. • Improving the system of staged medical care for patients with stroke or tuberculosis. • Developing the service of endovascular surgery to achieve the volume of interventions performed for cerebral infarction, comparable with the European indicator (total number of endovascular surgical interventions - up to 150 procedures/1 million population/year. • Ensuring the availability of modern methods of treatment for stroke—increasing the volume of thrombolytic therapy with modern medicines for thrombolysis. • Decreasing the incidence of stroke due to the active introduction of secondary prevention. • Ensuring coordination and logistics of hospitalization of patients with stroke and TBI as well as ensuring coordination between emergency teams, health care organizations, and centers for the provision of medical care to patients with stroke and TBI. • Providing rehabilitation services. • Providing post-hospitalization continuity of care.17 • Developing primary and secondary prevention of CVD. To equip the IRCs/IDCs, the Government has estimated the needed quantities of additional procurement of equipment and supplies. The proposed quantities were used to estimate the cost of preliminary equipment and supplies procurement. The cost of major equipment totals US$60,000,000 It is assumed that maintenance cost, estimated at about 10 percent of the cost of the equipment, would be considered from the third year after the equipment is installed. The training cost for the staff will be estimated at 10 percent of the total cost of investment. These costs are preliminary estimates, and the cost of the additional small equipment and supplies, costs of renovation of premises, depreciation rate, and other related costs that may be incurred during setup of IDCs/IRCs should be also considered. 17 The organization and provision of medical care for patients with stroke is regulated by the order of the MOH of the Republic of Belarus dated January 24, 2018, No. 47, “Instructions for the provision of medical care to patients with acute cerebrovascular accident (Road Map);� a resolution of the MOH of the Republic of Belarus of January 18, 2018, No. 18, “On approval of the clinical protocol - Diagnosis and treatment of patients with diseases of the nervous system (adult population);� and a resolution of the MOH of the Republic of Belarus dated May 1, 2017, No. 55, “On approval of the clinical protocol - Diagnosis and treatment of patients with non-traumatic intracranial hemorrhage.� Organization and provision of medical care for patients with head injury is carried out in accordance with the order of the MOH of the Republic of Belarus of September 24, 2012, No. 1110, “Instructions for the provision of medical care to patients with traumatic brain injury.� 36 3.3. Interregional and interdistrict centers/hospitals as part of the health care delivery system (roles and functionality) Creation of IRCs and IDCs is part of the Government’s health care optimization plan, as it will lead to redistribution of services and reconfiguration of health facilities. It is expected that subsequently there will be optimization of hospitalizations in the smaller hospitals or reprofiling them to mainly serve non- acute patients and provide outpatient services. With the IRCs playing the role of specialized centers for urgent treatment of myocardial infarction and stroke and taking this function from the rest of the hospitals in the network, there will be adjustment of those hospitals to reprofile their services, consolidate with other ones, downsize, or become a primary care, rehabilitation, or LTC center. The IRCs and IDCs will have close links with the PHC facilities, EMS, rehabilitation centers, and LTC centers. As needed, the patient pathway will connect to all these different levels of health services at various periods of patients’ health condition. For instance, a patient with stroke is diagnosed by a primary care physician and then referred to IRC, where a surgery is performed. Then the patient, depending on the condition, would be transferred either to the rehabilitation center or back home to be under the supervision of the primary care physician. An LTC facility will be involved in the patient pathway in case the patient is an elderly person from that facility who would receive treatment at the IRC and be sent back to the LTC center. EMS will continue to play a critical role in the detection of an emergency, providing transportation and first aid to the patient with myocardial infarction or stroke to the IRC. 37 Chapter 4. International experience It is undeniable that the Belarus Government has built health centers and hospitals to increase citizens’ access to the health care facilities in the country. However, access to these services is not enough to address NCDs in the country. Successful case studies from developed countries such as Denmark, Estonia, Finland, France, the Netherlands, and the UK demonstrate that better prevention and detection of NCDs, combined with increased access to decent quality medical care, could help control the increasing morbidity and mortality rates in Belarus. 4.1. Tackling similar health care issues Case study 1 - Estonia After regaining independence in 1991, one of the main policy objectives for Estonia was to make substantial reforms in the health sector. Since the 1990s, various structural and managerial reforms have been implemented, aiming to establish primary care at the center of service delivery. The Estonian reforms included preparation of the hospital master plans and then revising them after a few years). This included: introduction of the “golden hour� principle providing equal access to care within a geographical area (70 km) for basic services, increase in outpatient and day care services; development of nursing care services to enable more efficient use of acute care (bed blockers); decentralization of the health system; expansion of the rights of nurses and other mid-level health professionals to prescribe a limited number of medicines mainly for chronic conditions; strengthening of the e-health system; equipping of all hospitals with computers and internet access; changing of the legal status of the hospitals to autonomy under private corporate law; consolidation of public hospitals; hospital mergers;18 and change in the health services purchasing model/masterplan hospitals. The Estonian reforms also resulted in LTC development, more diverse home care services, and increased availability of home care and institutional care. In the 19 acute care hospitals that are currently operational, the integration and coordination of care have been strengthened, with the hospitals within the network cooperating with each other and providing essential services based on needs assessments. The two tertiary-level hospitals also serve as competence centers, teaching hospitals that provide specialized care and support the lower-level facilities. In Estonia, in the 1990s, there were more than 120 main hospitals. In 2000, there were 78, and now, this number is around 30 per 100,000 population. These hospitals are categorized in descending order of size as regional, central, general, and local hospitals. This hierarchy of hospitals is related to the spectrum of specialist medical care and specific services that each hospital is expected to provide. The geographical location of hospitals has been chosen to ensure that treatment is available to everyone within a 70-km or a 60-minute drive. Regional hospitals provide a full range of health care services. Central hospitals deliver most services but some, such as cardio surgery, neurosurgery, and certain oncological services, are excluded. General hospitals provide 24-7 emergency care as well as intensive care and some surgical and medical specialties. Local hospitals deliver 24-hour doctor-based emergency care but no surgeries. Ambulatory specialist care is provided mostly by hospital outpatient departments and by specialists 18Most small hospitals have been closed, merged, or turned into nursing homes operated by municipalities to provide social services. 38 practicing independently. Specialized outpatient care providers may be joint-stock companies or private entrepreneurs. In addition to the reforms, the Estonian Government has purchased high-technology medical devices such as computed tomography (CT) scanners and magnetic resonance imagining (MRI). Investments in medical equipment have enabled medical staff to provide an increasing number of high-technology diagnostic and curative services to the population. At present, the Estonian rates per population of coronary angioplasty, hip and knee arthroplasty, endoscopic surgery, and cataract surgery are comparable with the OECD countries and EU averages or are even higher. As a part of the Estonian reforms, the Government strengthened the PHC system in the country. The PHC system has been effective in helping prevent hospital admissions for several ambulatory care sensitive conditions. Avoidable hospital admission rates for asthma and chronic obstructive pulmonary disease are among the best in Europe; they are about average for congestive heart failure and diabetes. As a result of strengthening the PHC system in Estonia, a patient pathway takes patients from their first contact with the health system, through referral, to the completion of the treatment. The first point of contact with the health system is usually the family physician with whom the patient is registered. Family physicians have a partial gatekeeping function. Patients need a family doctor’s referral to see most specialists and to be admitted to nonemergency inpatient care. Depending on the health problem, the pathway can differ, as there are some specialties that are directly accessible without referral. Simultaneously with health reforms, the Estonian Government launched behavioral change programs to address root causes of health problems—to reduce alcohol consumption and prevalence of daily smoking and promote a healthy lifestyle. Additional policy measures were implemented such as increasing excise taxes, limiting opening hours of alcohol vendors and banning outdoor advertising, and banning smoking indoors, both in workplaces and public spaces. As a result, consumption of alcohol declined from 14.4 liters per capita in 2007 to 9.9 liters per capita (age 15+) in 2016, while the prevalence of daily smokers (age 15+) has declined from 33.5 percent in 2000 to 21.3 percent in 2016. Overall levels of physical activity among adults during leisure time have improved; the percentage of adults ages 18 years and above exercising for at least half an hour two or more times a week has increased from 29.8 percent in 1996 to 43.4 percent in 2016. All the abovementioned health reforms and behavioral change programs contributed significantly to Estonian health indicators. For instance, Estonian average life expectancy has risen more rapidly than in any other EU country, from 66.5 years in 1994 to 78.4 years in 2019, and it is now rapidly approaching the EU average (80.4 years). Since 2000, IHD mortality rates have declined 63 percent.19 The number of mortalities related to NCDs has decreased significantly, from 18,452 per 100,000 population in 1994 to 14,871 per 100,000 population in 2019, while the NCD-related DALYs rate decreased from 36,385 per 100,000 population in 1994 to 29,943 per 100,000 population in 2019. Following emergency services reforms, the burden of deaths from injuries reduced from 12.4 percent in 1995 to 4.4 percent in 2019, while attributions of it to DALYs decreased from 20.3 percent to 9.8 percent.20 From an average of 250,000 annual hospitalizations in the period 1995–2008, the annual number of hospitalizations decreased to 19 Health at a Glance 2019: OECD Indicators, page 74. https://doi.org/10.1787/4dd50c09-en. 20 Institute for Health Metrics and Evaluation: Global Health Data Exchange. http://ghdx.healthdata.org/gbd-results-tool. 39 225,000 by 2016. This was achieved by drastically shortening the ALOS to 5.5 days and increasing the role of outpatient care. The ALOS in Estonian hospitals is one of the shortest in the EU, while the proportion of Estonian acute hospital beds is about the EU average. Case study 2 - Finland Health promotion and disease prevention are cornerstones of the Finnish health system. Three main laws—the Primary Health Care Act (1972), the Act on Specialized Medical Care (1991), and the Health Care Act (2010)—set most of the framework for regulation and governance of health services in Finland. The 2010 Health Care Act covers the service delivery aspect, while the acts on primary and specialized care define administrative structures. The reforms that have taken place in the past decade have been incremental and focused on modifying existing features, without fundamentally changing the structure of the health system. Earlier reforms in the health care system changed the focus of financing and other incentives from expansion to maintenance. Further reforms in the late 1980s and the early 1990s increased municipal self-governance and autonomy, giving greater powers to local governments in the allocation of resources. They resulted in more devolution and delegation and greater variation in service provision. This was complemented by the reintroduction of user fees in primary care in 1992, allowing local governments a means to seek further funds through service users and representing in practice a partial privatization of health financing. As a result, there are three parallel systems for health service provision. The principal system is publicly financed and organized by the municipalities, for all levels of care. The others are private and occupational health care, mostly providing ambulatory primary and some specialist services. The role of the state is to oversee and steer the system’s functioning through legislation, decrees, and the provision of information. Infrastructure and facilities for health care provision have undergone marked changes in the 2000s. As part of the health reforms in the 2000s, in some larger municipality-owned hospitals, beds were reprofiled to provide selected services, such as cancer care and rehabilitation. Currently, the public hospital network, including 15 central hospitals and five university hospitals, is owned by the country’s 20 hospital districts— federations of municipalities. The municipalities and hospital districts also run and finance a network of primary and secondary care facilities as well as separate psychiatric care institutions. Municipalities act as purchasers and are responsible for the financing of their functions, even if the service arrangement has been transferred to another municipality or a joint municipal authority. Primary care is organized by one or several municipalities, and specialist care is organized by 20 regional federations of municipalities, called hospital districts. Hospital districts have invested heavily in new buildings and worked toward rationalizing resources, resulting in closures and mergers of smaller hospitals. The Government started to acquire advanced health technologies in the 2000s. The most expensive devices, such as MRI units, are in hospitals but are increasingly found in mobile units as well. In 2016, the ratio of CT scanners to population (2.4 per 100,000 population) was just above the EU average (2.2 per 100,000 population), while the ratio for MRI units and mammographs in Finland (2.6 and 3.1 per 100,000 population, respectively) is among the highest in the EU (1.4 and 2.3 per 100,000 population, respectively). 40 The Government heavily invested in information and communication technology systems to assist data collection, harmonization, and coordination of care. As a result, electronic patient records are widely used in all PHC centers, hospitals, and other specialized health care units. Paper-based documents are nowadays mainly used for the storage of historical data. The electronic patient record systems are multifunctional and include administrative functions; continuous narrative documents of diagnostics, treatment, and care; order entries for laboratory and radiological exams; tools for reviewing results; and inter-organizational data exchange. All specialized hospitals maintain digital records. Information exchange between primary and specialized health care organizations takes place principally by electronic referrals and consultations. Primary and specialist care providers use electronic referrals and electronic consultations. Simultaneously, the Finnish Government took initiatives on tobacco and alcohol control to address the root cause of the problem and promote healthy lifestyle among citizens. For instance, the Government introduced legislation to tackle smoking and alcohol consumption. As a result, in Finland, about 23 percent of adults were daily smokers in 2000, and this dropped to 12 percent in 2016, which was lower than the EU average, 18 percent. In 2016, Finland introduced legislation to tackle smoking, aiming to make the country smoke-free by 2030. The new law prohibits sales of flavored and some other tobacco products, treats electronic cigarettes (e-cigarettes) in the same way as tobacco products, bans all advertising, standardizes packaging, and is expanding smoke-free areas. In terms of alcohol consumption, the sharp increase in alcohol consumption and alcohol-related deaths in the 2000s coincided with a marked decrease in alcohol excise duties – by 44 percent for spirits, 32 percent for beer, and 10 percent for wine – in Finland in March 2004. In 2007–08, a series of measures were adopted to restrict alcohol sales hours and advertising that led to reduction of the alcohol consumption rate to 8.4 liters per capita in 2016 from 10.5 liters per capita in 2007. Overall, health reforms and related initiatives contributed to Finland’s health indicators significantly. Since 1995, life expectancy in Finland has increased by 5 years and reached 81.7 years, which is higher than the EU average of 80.9 years, as care for many chronic conditions has improved substantially. Other successful international health care reforms experiences Besides the abovementioned case studies, the Belarus Government should consider the following successful international health reforms experiences from Australia, Denmark, France, Germany, the Netherlands, and the UK to address the growing burden of NCDs and implement hospital optimization in the country successfully. Emergency care organization is a crucial factor contributing to the hospital occupation rate, health outcomes, and financial sustainability of the inpatient services. To rationalize the use of emergency care, based on examples from Australia, Denmark, France, Germany, the Netherlands, and the UK, the following conclusions for improvement are made: (i) extending the availability of urgent primary care; (ii) concentrating and centralizing the provision of primary care; (iii) improving coordination between urgent primary care and emergency care; and (iv) concentrating emergency care provision at fewer institutions. 41 The design of a payment system for urgent primary care and for emergency care is often aligned to support these reforms.21 In Denmark, the number of acute hospitals was reduced from about 40 to 21, with new joint acute facilities that included emergency care wards. The objectives of this reform were to create large administrative units at the secondary level that would allow for the creation of larger hospitals and increase the quality of care. The increased size of the hospitals would allow municipalities to take more responsibility for health in the region and provide some efficiency gains. Denmark’s reform was conducted over the course of several years, with extensive discussions and negotiations between national-level authorities and the local-level stakeholders, with the strong presence/involvement of the medical community. In-depth discussions led to decisions on the type of specialty care that will be available in specific hospitals. Because most hospital patients in 2015 required acute care, joint acute care facilities, putting patients on a fast track without unnecessary hospitalizations, were created. An important reform element was also the distinction between high-specialty services and low-specialty services regarding services to access.22 Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality.23 In Germany, from 2009 to 2014, 1.1 million patients were treated for acute myocardial infarction. Risk-adjusted mortality was 8.9 percent at 95 percent confidence interval 8.8 to 9.0 in the very- high-volume quintile, versus 11.4 percent (11.3 to 11.6) in the very-low-volume quintile. An increment of 50 cases per year was associated with reduced odds of death. The minimum hospital volume where risk of mortality would fall below the average mortality of 9.8 percent was calculated as 309 cases per year. Out of 137 patients hospitalized for acute myocardial infarction, one death would be prevented if annual volumes in treating hospitals were at least 309.24 Stroke accounts for about 2-4 percent of the total health care expenditure in developed countries. Moreover, stroke incurs substantial costs outside the health care system, reflecting the survivors’ high rates of disability and dependence.25 A similar case is found with myocardial infarction. It is estimated that cost per patient in the developed countries could be between US$6,000 and US$20,000, where the 21 Baiera, N., Alexander Geissler, Mickael Bech, David Bernstein, Thomas E. Cowling, Terri Jackson, Johan van Manen, Andreas Rudkjøbing, and Wilm Quentin. “Emergency and Urgent Care Systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing Organization, Payment and Reforms.� Health Policy. 2019 Jan;123(1):1-10. doi: 10.1016/j.healthpol.2018.11.001. Epub November 10, 2018. 22 Christiansen, Terkel and Karsten Vrangbæk. 2017. “Hospital Centralization and Performance in Denmark—Ten Years On.� Health Policy. 2018 Apr;122(4):321-328. doi: 10.1016/j.healthpol.2017.12.009. Epub 2018 Feb 9. 23 Ross, J. S., S. L. Normand, Y. Wang, et al. 2010. “Hospital Volume and 30-day Mortality for Three Common Medical Conditions.� N Engl J Med. 362 (12): 1110–1118. doi:10.1056/NEJMsa0907130. 24 Nimptsch, U., and T. Mansky. 2017. “Hospital Volume and Mortality for 25 Types of Inpatient Treatment in German Hospitals: Observational Study Using Complete National Data from 2009 to 2014.� BMJ Open. 7 (9): e016184. doi:10.1136/bmjopen-2017- 016184. 25 McKee, M., Sherry Merkur, Nigel Edwards, and Ellen Nolte. 2020. The Changing Role of the Hospital in European Health Systems. Cambridge University Press and the European Observatory on Health Systems and Policies. doi:10.1017/9781108855440. 42 myocardial infarction average exceeds US$11,000.26 Almost any prevention measure would therefore be cost-efficient. 4.2. Experiences on consolidation of hospital care and creation of specialized care such as cardiovascular centers for treatment of stroke, myocardial infarction Consolidation of hospitals and concentration of highly technological care in specialized centers can be observed in a wide range of countries. Hospitals with specialized services are crucial for effective stroke treatment. Integrated specialized care provision for stroke patients can result in higher chances of staying alive after the stroke and also on independence and living at home one year after the stroke.27 Acute care in the stroke unit involves (i) medical assessment and diagnosis, (ii) early assessment of nursing and therapy needs, (iii) monitoring of physiological and neurological status, (iv) screening and prevention of complications, (v) mobilization, and (vi) rehabilitation therapy—physiotherapy, occupational therapy, and speech and language therapy. All those services require trained medical personnel, implementation of clearly defined and executed clinical protocols, and equipment such as CT scans and MRI that can be provided in specialized centers. In addition to serving as a specialized care center, a mobile stroke team of the center is considered to ensure adequate service delivery and access. Specialized hospital care for stroke patients should take place in a specialist stroke unit.28 A stroke unit consists of a discrete area of a hospital ward that exclusively or exclusively takes care of stroke patients and is staffed by specialists. As part of their stroke management, a small proportion – less than 5 percent – of patients will require ICU care or surgical interventions such as neurosurgical management of exceptionally large ischemic strokes and intracerebral hemorrhages or vascular surgery. However, most patients should spend most of their inpatient stay on either an acute stroke unit or a rehabilitation stroke unit.29 Most patients dying of acute stroke do not die directly from the brain injury but from the complications of immobility and impairment. Therefore, rehabilitation, along with strong collaboration between the PHC and specialist care to provide support in the hospitals and outside the hospitals, along with health status monitoring would be required to increase the chances of survival and the quality of life after a stroke. Countries organize the care provision for stroke patients in diverse ways. Much depends on how the hospital service provision is organized and financed in general and on the capacity of medical personnel (Figure 25). 26 Nicholson, G., S. R. Gandra, R. J. Halbert, A. Richhariya, and R. J. Nordyke. 2016. “Patient-level Costs of Major Cardiovascular Conditions: A Review of the International Literature.� Clinicoecon Outcomes Res. 8: 495–506. doi:10.2147/CEOR.S89331. 27 Stroke Unit Trialists' Collaboration. 2007. “Organised Inpatient (Stroke Unit) Care for Stroke.� Cochrane Database of Systematic Reviews 4: CD000197. doi:10.1002/14651858.CD000197.pub2. Issue 4. 28 Rudd, A. G., A Bowen, G. R. Young, and M. A. James. 2017. “The latest national clinical guideline for stroke.� Clin Med (Lond). 2017;17(2):154-155. doi:10.7861/clinmedicine.17-2-154. 29 McKee, M., Sherry Merkur, Nigel Edwards, and Ellen Nolte. 2020. The Changing Role of the Hospital in European Health Systems. Copublished by Cambridge University Press and the European Observatory on Health Systems and Policies. doi:10.1017/9781108855440. . 43 Figure 25. Stroke interventions international comparison Source: From Nigel Edwards’ presentation, during World Bank workshop in Kiev, 2020. 44 Chapter 5. Options for changes in the organization and delivery of hospital services in Belarus Hospitals in Belarus currently consume a large portion of public funding. At the same time, a sizable portion of the services provided by hospitals should be delivered in the outpatient setting. It will be vital to enhance the performance of health service delivery to achieve better health outcomes with similar resources while protecting individuals from catastrophic health expenditures and inequalities. This transformation process should be driven by enhancing quality and strengthening patient safety. A multifaceted and phased approach is necessary to ensure the success of health care reform. Rightsizing the hospital sector goes beyond strategic planning and also requires an enabling environment with reform of the legal framework, distribution of adequate human resources, development of protocols, setting up of the right financial incentives, and improved governance of hospitals. Reforms in Estonia could be used as a good example, where the World Bank provided support for the design and the implementation of the health care reform. During the planning of the network, the ministry used the approach to ensure that patients could access a facility to benefit from specialized care within an hour. However, in Estonia, beyond planning the infrastructure, several reforms were implemented that set quality and performance standards, in addition to closure or reprofiling of substandard hospitals, corporatization of hospitals with greater autonomy and accountability, strategic purchasing with contracting between a purchaser – health insurance fund – and hospitals, and a move toward output- based and performance-based financing. Building a new facility alone will not be enough to achieve greater value for money. International examples and literature clearly point out to the need for a comprehensive approach in the reform of health care systems and hospital services delivery when faced with the high burden of NCDs. Health reforms are driven by country stakeholders and political economy, time frames, fiscal sustainability, and overall capacity to implement reforms. Therefore, committed leadership and political will are key to achieving successful reforms. It is important to prepare a health system development strategy with short- and midterm action plans, where hospital service concentration such as IRCs could be proposed. Other elements of the strategy, such as strong emphasis on PHC, should play an integral part. Comprehensive reform of the emergency medical system should be considered to improve efficiency and quality in the provision of emergency care. The current system of emergency care should be assessed, and recommendations on upgrading the system could be provided. The World Bank has been supporting the improvement of EMS worldwide, including countries in this region—Croatia, Romania, and Uzbekistan. Along with the upgrade of the emergency care health facilities, modern equipment for ambulances – ALS and BLS, training of doctors and paramedics on new triage systems for prehospital and hospital levels, and a modern dispatch system will allow efficient, timely, and quality care for emergency services without misuse of emergency care on non-urgent cases. In this reform, the Government could also consider an integrated emergency response, including police, fire, and medical together. 45 5.1. Patient referral process and care pathways Belarus should take strategic approach for capacity and economic efficiency gains in the hospital sector, increase of life expectancy and improvement of health services quality. Hospital optimization is part of the broader healthcare network reforms that will require restructuring and strengthening primary health care, long term care and emergency care to create a comprehensive patient-centric healthcare system. Patient referral process and care pathways should provide an easy route for patient to navigate seamlessly from one level of care to another. The role of hospitals, and therefore the organization of the service delivery model, as in any health system is constantly reforming to improve. Changes could include introduction of new treatment protocols to assure the quality of care and align with the organization of care. New treatments, such as thrombolysis for patients with myocardial infarction, could be initiated in prehospital emergency care – for example, in ambulances – on the way to the hospital, thereby reducing delays in this time-critical treatment.30 Additionally, a new triage system, standards, indicators, and a new dispatch system should be introduced in Belarus. Behavior changing communication activities should encourage use primary care services so as not to overburden the emergency services and hospitals with non-urgent and non- emergency cases. The PHC system in Belarus needs to be strengthened to address patient flow problems, as well as health challenges associated with aging and a growing NCD burden in a cost-effective manner. The PHC level should serve as a gatekeeping mechanism for patients and refer to secondary and specialist care if necessary. General practitioners and district internists should play a bigger role in the coordination of care and fulfil the gatekeeping function. Traditionally, patients prefer to go directly to a specialist when they have health problems. If family physicians were the first contact, they would not only guide the patient through the system but could also provide more comprehensive consultations, address NCD risk factors, and identify NCDs at an early stage. The need for well-qualified family physicians who can provide patient- centered comprehensive care is even more urgent for patients with multiple chronic conditions. The Government also should consider the following recommendations to address NCD-related morbidity and mortality rates in Belarus: • Screen for early detection of NCDs. This includes regular cancer screening but also diabetes or hypertension for selected target groups. • Introduce actions to modify risk factors, such as tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity. Annex 1 provides an example for strengthening physical activity in the population. This could include education activities, tobacco cessation support, and screening or raising taxes on tobacco products and sugar beverages. Increasing tobacco taxes is a good example of a measure to be taken, which could help in NCD prevention and increase in revenue. • Introduce new stratification system for predicting events such as unplanned hospital admissions, which are undesirable, costly, and potentially preventable. Risk stratification can link people 30McCaul, M., A. Lourens and T. Kredo. 2014. “Pre-hospital versus in-hospital thrombolysis for ST-elevation myocardial infarction.� Cochrane Database Syst Rev. 2014 Sep 10;2014(9):CD010191. doi: 10.1002/14651858.CD010191.pub2. 46 identified at the highest risk of health deterioration to the most appropriate service delivery level. Efficient stratification of patients will require new clinical pathways, better data management together with IT functions such as Electronic Health Record (EHR), and interconnectivity between providers. • Improve chronic care at the lowest level possible, including full implementation of the chronic care clinical protocols (pathways). As a result of hospital optimization, some hospitals will be reprofiled or become long-term care hospitals. Thus, patient pathways from PHC to emergency or hospital care or LTC should be well identified and implemented. • Introduce or modify the clinical pathways in Belarus, which would require an analytical and practical approach where clinicians, together with process management experts and practitioners, would develop a new protocol of care for a specific disease following evidence- based medicine and application modalities in the country. Clinical protocols should be accompanied by quality indicators. • Improve diagnostics capacity at all levels of care including diagnostic capacity increase and flexibility in the time of crisis such as COVID-19. • Strengthen primary care (PHC) and specialized ambulatory care to ensure care coordination and continuity, with a special emphasis on prevention and treatment of chronic care and rehabilitation. In addition, a new PHC financing model – capitation based – with additional purchasing mechanisms such as bundled payments should be implemented. • Broaden health financing reforms to change purchasing models on all levels of care and connect them with financial incentives and quality control measures • Provide essential and preventive medications to the population, especially at PHC level. • Strengthen public health capacities, including data monitoring and management and development of health information systems. 5.2. Division of roles between different levels of care with recommendations toward improvements with a focus on regional-level hospitals Reorientation of the health care system, including inpatient service provision, is a necessity. Concentration of selected highly specialized services in the IRCs in Belarus by integrating substantial volume of patients in one place with trained staff equipped with modern technologies aims at: (i) improving the availability of high-quality care, especially for the rural population; (ii) supporting reduction of mortality and disability of patients with NCDs; (iii) balancing the distribution of medical resources, including equipment and medical staff; and (iv) further developing integrated multidisciplinary medical care—emergency, planned, and specialized high-technology medical care. Integration of care for patients with CVDs, in particular strokes and myocardial infarction, could be organized in Belarus around specialist care centers (IRCs, including outpatient services). With diseases like myocardial infarction and stroke, there could be many insufficiencies influencing health outcomes and even mortality rates. Therefore, Belarus will obtain satisfactory results through concentration of care in properly mapped facilities if it secures adequate provision of high tech equipment and trained staff, sufficient risk factor controls, sufficient and timely cardiac rehabilitation, optimal pharmacotherapy, 47 timely complete myocardial revascularization, and rehabilitation, psychological counselling, or timely access to thrombolysis or thrombectomy. The IRCs in Belarus will be able to provide access to specialized medical care and technologies for diagnostics such as CT, MRI, and positron emission tomography; treatment—coronary angiography, stenting, aorto-coronary bypass surgery, and endoprosthesis as well as screening and early diagnosis of cancer. Although cancer IRCs and IDCs are included in the Government’s plan for service concentration, it would be advisable for the MOH to conduct additional analyses and explore international examples of the cancer care service delivery model. With the growing burden of NCDs in Belarus, stroke units and myocardial infarction coordination units could be the starting point of the shift from hospital-based acute care to care coordination across all levels of care, including prevention. Concentration of services in IRCs and IDCs in Belarus should be accompanied by shifting services to the lower levels of care.31 Some hospital services should be shifted to primary care, others -to LTC facilities or reprofiled in accordance with demography and morbidity of each region. Thus, the healthcare network will be reconfigured accordingly. Interventions will then be introduced to change the referral behavior of patient and the primary care practitioners – purchasing mechanisms, coordination, EHR – without reducing outpatient activity or risking reduced quality. The ongoing Belarus Health System Modernization Project that supports e-health platform in Belarus will assist digitalization of clinical pathways and monitoring systems to assure the quality of care. The creation of IRCs in Belarus will lead to the redistribution of functions at secondary and tertiary care levels. Thus, creation of these centers should lead to their strengthening. Effective PHC, performing regular prevention, detection, and early treatment of NCDs will decrease the number of patients with complications, late stages of diseases, myocardial infarction, and stroke. PHC services should be aligned to fit the new model of consolidated hospitals and specialized centers—interregional and interdistrict hospitals, rehabilitation centers, and LTC hospitals. Tackling public health problems such as healthy lifestyle, smoking, alcohol, and obesity will not be addressed by the IRCs and IDCs but by the primary care health system. The EMS network will ensure that the waiting time for emergency calls in the city is no more than 20 minutes from the moment of calling an ambulance—in other localities, 35 minutes. Also, this organizational measure will not affect the pharmaceutical network (pharmacies and pharmacy chains). In general, the creation of IRCs will not change the vertical governance of health management in the Republic of Belarus. 31Sibbald, B., Ruth McDonald, and Martin Roland. 2007. “Shifting care from hospitals to the community: A review of the evidence on quality and efficiency.� Journal of health services research & policy. 2007 Apr; 12(2):110-7. doi: 10.1258/135581907780279611. 48 Box 2. Summary model of new roles and responsibilities in service provision at the oblast level Primary Health Care roles summary (Primary heath care centers, some policlinics, public health centers): 1. Preventive programs: • Planned and implemented with targeted audiences—schools, workplaces. • Effective recruitment of community workers—non-medical personnel) and implementation with teams-based approach (not only doctor. • Preventive interventions on a large scale. 2. Disease Management (DM) based on clinical pathways: • Clinical guidelines and pathways. • Individual Medical Care Plan. • Specialist consultations (if needed) and diagnostics. • Coordination of care across the facilities. • Patient education and empowerment. • Greater application of e-health and telemedicine. 3. Rehabilitation: • Patient: education on self-healing and prevention of pain incidents. • Family physician/PHC: diagnosing the reasons of pain and simple interventions to alleviate the pain. • Physiotherapist: consultation, education, physiotherapy treatment in PHC. • Rehabilitation services—facility and home-based. • Post-acute care rehabilitation management. 4. Long-term care: • Health status assessment. • Long term care provision at home. • Cooperation with LTC facilities. Ambulatory care roles summary (polyclinics and outpatient units at the rayon and oblast hospitals): • Chronic care based on clinical pathways. • Enhanced diagnostics. • One-day procedures—one day surgery, emergency orthopedics. • Rehabilitation for acute care patients. • Antibiotic infusions. • Blood and platelet transfusions. • IV hydration. • PICC line placement/maintenance. • Port-A-Cath care and maintenance. • Remicade. Hospital care proposed scope of interventions include: • Transformation of oblast level hospitals into the ICR (one per 1 million population). • Inter district hospitals: Secondary level hospital’s development to provide at least g eneral surgery, internal medicine, gynecology and obstetrics, neonatology, pediatrics, anesthesiology, intensive care, cancer care. • Rayon hospitals providing services in general surgery, internal medicine, narrow scope gynecology and obstetrics, neonatology, pediatrics. • Rayon hospitals transformation towards rehabilitation center or LTC center. 49 In some facilities, the absence of e-health tools and databases and the wide use of paper for health records further complicate the coordination of services. This also leads to duplication of laboratory and diagnostic procedures at each level of care, wasting financial resources and making follow-up after acute episodes less than optimal. Introduction of the e-health platform in Belarus will ultimately eliminate these insufficiencies. In response to the disruption of services due to the COVID-19 outbreak, and to prevent economic and time losses in the future, the digitalized system will enable follow up with citizens without visiting health care facilities, and delivery of good quality of health care services through the e-health platforms, including telemedicine, video consultations, and exchange of medical data. Roles and responsibilities of the IRCs (up to 1 million population) level health facility: • Centers to be based on existing health care facilities with appropriate infrastructure. • Full ‘coverage’ of the territory of Belarus, to ensure the provision of emergency medical care for life-threatening conditions during the “golden hour.� The centers will serve populations of other districts of the regions and districts of other regions located within a radius of 70 km from the planned center. • Highly qualified medical staff. • High-technology equipment. • Use of approved innovative methods of diagnosis and treatment. • Reorganization of clinical pathways serving stronger clinical integration of services. • Reorganization of the patient’s routing, ensuring continuation of care between all settings and types of care—prevention, primary care, specialist services, inpatient acute care, rehabilitation, and psychological care. Specific requirements should be developed for each center considering the number of beds/wards, department profiles, equipment, space requirements, and staff requirements such as number and specialists. Patient flows and pathways should be organized with an emphasis on PHC, through introduction of the general medical practices with the replacement of certain types of specialized medical care – neurological, otorhinolaryngological – in cases where constant monitoring of narrow specialists and specialized hospitalization is not required, as well as the creation of multidisciplinary teams to provide comprehensive medical services. 5.3. Hospital system optimization as part of the healthcare reforms The hospital system optimization is the multifaceted and multiphased process that includes not only transformation of hospital network but also its financing mechanisms, human resource strategies, and supply of pharmaceuticals and medical equipment. As shown on Diagram 3, each direction of reforms will require additional and further actions aligned to the overall reform agenda. These actions should be well designed for timing and phases of reforms. 50 Diagram 3. Health sector reforms Source: Authors’ analyses, 2020. The direct impact of the health reforms is on the service delivery and care providers such as primary health, rehabilitation services, EMS, and LTC. The creation of the IRCs and IDCs is the first step in the reform process, which requires restructuring of the hospital network and the entire healthcare network. Concentration of services within IRCs and IDCs will change the provision and organization of health services delivery at all levels of care with smaller hospitals being consolidated, reprofiled or becoming an LTC facility. The role of PHC is becoming extremely important in provision of care. 51 As the evidence from France, Germany, the UK, and other countries shows, the concentration of services and minimum volume standards for myocardial infarction, stroke, and surgical procedures bring health and efficiency gains. Therefore, it is recommended to introduce a minimum volume threshold for selected procedures. Tertiary/teaching hospitals, with coverage of up to one million population), serving as IRCs and applying professional and volume standards, could provide (i) major vascular procedures, (ii) neurosurgery, (iii) cancer care, (iv) transplantation, (v) cardiac surgery and angioplasty, (vi) neonatal intensive care, (vii) specialist pediatric surgery, (viii) stroke care, including mechanical thrombectomy; and (ix) obstetrics. Additional surgical procedures with volume standards could cover (i) pancreatic surgery, (ii) esophageal surgery, (iii) hepatic and biliary tract, (iv) various lower gastrointestinal tract procedures, (v) spinal surgery, and (vi) bariatric surgery. Small hospitals, covering up to 300,000 population in a district or rayon in Belarus, might consider the following types of inpatient care: (i) emergency department, (ii) internal general medicine, (iii) some specialist medicine, (iv) general surgery (not vascular), (v) urology, (vi) obstetrics and gynecology, (vii) orthopedics, (viii) pediatrics, and (ix) chemotherapy and dialysis support—care coordination and main treatment in the specialist cancer center. Outpatient services should be provided as well, including diagnostics and basic laboratory services. As to cancer care, district-level hospitals could support: (i) screening, scoping, imaging, and biopsy; (ii) surveillance and selected chemotherapy; and (iii) rehabilitation and coordination of end-of-life care. When thinking about challenges related to aging, in most countries, a fundamental shift in the focus of clinical care for older people is needed. Instead of trying to manage numerous diseases and symptoms in a disjointed fashion, the emphasis should be on interventions that optimize older people’s physical and mental capacities over their life course and that enable them to do the things they value. Substantial change, in the way that services are organized, needs to take place to adjust the health and social systems to the needs of the population. Community-based care – care close to home delivered in an integrated manner – could be one of the ways forward when thinking about hospital services reorganization. The evidence suggests that better integrated health and social care for older people contributes to better health outcomes at a cost equivalent to usual care, thereby giving a better return on investment than more familiar ways of working. Geriatric assessments, coordination of care plans, and regular support to keeping the elderly in good health including rehabilitation services, if needed, should be conducted as close to home as possible, in outpatient settings. Transformation of the health and social care service delivery model for the aging population through the service delivery model and a policy that would develop new and redistribute already existing responsibilities and funding for the elderly would be advised. All types of care – specialist care, hospitals, home health agencies, nursing homes, and stakeholders such as community, family, and community- based services, should be brought together by means of either real or virtual integration. PHC facilities providing support to chronic patients could be the care coordination center. This new service delivery system is in line with, and could be benefitting from, the other two presented below with the readjustment of resources freed from the district hospitals as well as strengthening primary and ambulatory care (Diagram 4). 52 Clinical pathways as a quality and safety measure would need to be followed and adjusted to reflect modern technologies, new skills of health personnel, and the growing needs of the population. Standardization of the process of care, reduction of variations in practice, improvement of interdisciplinary cooperation, and care integration should lead to improving health outcomes. Clinical pathways should work across all levels of care and different facilities facilitated by information exchange and quality and management systems. In areas of low-density population with a high proportion of elderly population, local hospitals could be reprofiled/restructured to provide important nursing, social, and palliative care as well as rehabilitation and other specialist outpatient care (Diagram 4). This will Diagram 4. Patient centered Integration of services in Belarus IDCs (tertiary care) IRCs (tertiary Patient care) PHC/ambulatory centered chronic care care District level Emergency hospitals + rehablitation + LTC Source: Authors’ analyses, 2020. improve the quality of life of patients, especially in rural areas, and their rehabilitation process, after long- term hospitalization for patients with TBI, acute cerebrovascular accident, and myocardial infarction. Care coordination for hospitalized patients discharged and under the care of the PHC could also use a transitional coordinator—a nurse, social worker, community health worker, or other health professional—who performs a comprehensive patient/family assessment before discharge, leads the development of a discharge plan, delivers patient and family education, and helps patients to take a more active and informed role in their transition. An inclusive approach would be advised, specifically • Enhanced communication between hospital, acute care, and post-acute care providers to ensure critical information follows the patient through the transition—for example, facilitation of a discharge conference between acute and post-acute teams to ensure that discharge records are complete and received by post-acute care providers. • Increased patient family and community engagement in the implementation of the discharge plan including assistance with follow-up appointments, rehabilitation, home visits to assess the home environment and provide feedback to family and caregivers on their delivery of care, and care coordination between multiple providers. To address the high rate of NCDs in the country, it is also important to strengthen interagency cooperation. For instance, within the broad area of NCD control, there are many fields where interagency 53 cooperation is critical. The most obvious include the control of risk factors, such as tobacco use, alcohol misuse, and unhealthy diets and lifestyles. However, cooperation between agencies and departments is also vital for coordinating public health messages and incentives between individual and population-based services, for example, for CVD and diabetes. Close cooperation among many actors is also needed to strengthen the role of basic services, such as PHC, in the early detection and management of CVD and diabetes. 54 ANNEX 1. Addressing physical inactivity in Belarus To promote a healthy lifestyle and address one of the abovementioned health concerns —physical inactivity among citizens—the Belarus Government should adopt cost-effective solutions. For instance, fitness facilities can obtain tax-exempt status to provide affordable gym membership fees to all citizens. Tax exemption is usually granted for fitness facilities because they provide health benefits (that is, positive externalities) to the community. To provide a benefit to the community and earn tax-exempt status, fitness facilities must offer membership rates that make membership financially available to the general community. The actual prices charged should vary with the demographics of the community the facility intends to benefit. The facilities might also provide other community benefits, such as daycare and youth development in addition to providing recreational services. Experiences from Europe and the United States, for example, demonstrate that gym facilities receive benefits such as preferred loan terms from banks, sales tax exemption, customs fee exemption for imported gym equipment, exemption from local property tax, and low rate of profit tax to expand their businesses and provide citizens with affordable fitness centers. In return, all these tax exemptions and deductions will reduce the operational cost of the gym facilities, which will lead to a reduction of their monthly membership fees and make them affordable to all citizens. Heading out to engage in physical activity often is easier for people when they can join with others in groups and support and motivate each other. By engaging citizens in physical activity, they can share knowledge about the benefits of physical activity, develop awareness about opportunities to be physically active, and overcome barriers and negative attitudes that may exist about exercise. The Government should also launch several initiatives that citizens can adopt to successfully encourage and increase amounts of physical activity to help manage and mitigate chronic health diseases, high blood pressure, and cholesterol. Community access to opportunities for physical activity is extremely important. Constructing walking and bike trails, pools, fields, and gyms helps provide citizens with more opportunities to exercise. Reducing fees for access to facilities and providing low or no-cost programming and coaching also helps eliminate barriers to exercise. Simply placing motivational signs by elevators and escalators can remind residents and office workers to use nearby stairs to improve health and promote weight management. Community-wide media campaigns through television, radio, and newspapers promote screenings and educational workshops at worksites, schools, and other community locations. Social support interventions in the community—buddy systems, group walks, and fitness classes—also help steer physical behavior in a positive direction while strengthening community bonds and friendships. 55 References Baiera, N., Alexander Geissler, Mickael Bech, David Bernstein, Thomas E. 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