EV ALUA TION OF TH E O R G A NIZ A TION A ND P R OVI S ION OF P R IM AR Y C ARE IN BELARUS EValuaT I O N O F T H E O R G A NIZ AT I O N A N D P R OVI S I O N O F P R IM ar Y C are I N BELARUS A survey-based project in the regions of Minsk and Vitebsk Primary care in the WHO European Region Cover photo Oleg Jarovenko Design, layout & production Phoenix Design Aid, Denmark EV alua T I O N O F T H E O R G A NIZ A T I O N A N D P R OVI S I O N O F P R IM ar Y C are I N BELARUS A survey-based project in the regions of Minsk and Vitebsk AbsTraCT In many countries in transition, health reforms are part of profound and comprehensive changes in essential societal functions and values. Reforms of (primary) care are not always based on evi- dence, and progress may be driven by political arguments or the interests of specific professional groups, rather than by the results of sound evaluations. However, policy-makers and managers nowadays increasingly demand evidence of the progress of reforms and the responsiveness of services. The implementation of the WHO Primary Care Evaluation Tool (PCET) aims to provide a structured approach towards this by drawing on the health systems functions such as governance, financing and resource generation, as well as the characteristics of a good primary care service delivery system: accessibility, comprehensiveness, coordination and continuity. This report gives an overview on the findings for Belarus, including aspects of the provision of tuberculosis and reproductive health services. The project was implemented in Belarus in 2008 and 2009 in the framework of the Biennial Col- laborative Agreement between the WHO Regional Office for Europe and the Ministry of Health of the Republic Belarus 2008-2009, an agreement that lays out the main areas of work for collaboration between the parties. Further partners were the Netherland Institute for Health Services Research (NIVEL) – a WHO Collaborating Centre for Primary Care – and other stakeholders in the Belarus health system, such as national policy experts, managers, medical educators, primary care physi- cians and their patients. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permis- sion to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). Keywords PRIMARY HEALTH CARE EVALUATION STUDIES HEALTH SYSTEMS PLANS – organization and administration HEALTH CARE REFORM HEALTH POLICY TUBERCULOSIS REPRODUCTIVE HEALTH SERVICES QUESTIONNAIRES BELARUS © World Health Organization 2009 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concern- ing the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the informa- tion contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Table OF CONTENTS Abbreviations . 4 Acknowledgements . 5 Foreword . 6 Executive Summary . 7 1 Evaluating primary care: backgrounds and application . 15 1.1. The theoretical framework of the Primary Care Evaluation Tool . 15 1.2. Overview of the development and pilot testing of the Primary Care Evaluation Tool . 23 1.3. Overview of the implementation of the Primary Care Evaluation Tool in Belarus . 25 2 Introduction to Belarus . 28 2.1. The country . 28 2.2 . Population and health . 29 2.3. The health care system . 30 3 Primary care in Belarus: national situation and context Results based on the national level questionnaire . 33 3.1. Stewardship aspects . 33 3.2 . Resource generation aspects . 45 3.3. Financing aspects . 49 3.4. Aspects of primary care service delivery . 50 3.5. TB and reproductive health services . 51 3.6. Actual topics in primary care development . 54 4 GPs and district therapists about their position in primary care Results of the survey . 57 4.1. Respondents’ characteristics . 57 4.2. Accessibility of care . 59 4.3. Continuity of care . 62 4.4. Coordination of care . 63 4.5. Comprehensiveness of care . 67 4.6. TB and reproductive health services . 81 5 Patients about primary care in the regions of Minsk and Vitebsk Results of the survey . 91 5.1. Respondents’ characteristics . 91 5.2. Accessibility of care . 93 5.3. Continuity of care . 98 5.4. Coordination of care . 102 6 Summary, conclusions and recommended actions . 105 Annex 1 Glossary of terms on primary care . 116 Annex 2 Reproductive health services . 118 References . 135 AbbreVIATIONS BCA biennial collaborative agreement between WHO Europe and Member States DOT directly observed treatment of TB DOTS the basic package that underpins the Stop TB Strategy GP general practitioner IUD intrauterine device MDR TB multi-drug resistant TB MoH Ministry of Health NGO non-governmental organization NIVEL Netherlands Institute for Health Services Research PC primary care PCET primary care evaluation tool RH reproductive health STI sexually transmitted infection TB tuberculosis WHO World Health Organization Evaluation of the organization and provision of primary care in Belarus 4 ACKNOWleDGEMENTS The World Health Organization (WHO) Regional Office for Europe expresses appreciation to all those who contributed to the achievements of this project. The project implementation team: Principal writers: Wienke G.W. Boerma, NIVEL Martina Pellny, WHO Regional Office for Europe Therese A. Wiegers, NIVEL Dionne S.Kringos, NIVEL Valentin Rusovich, WHO Regional Office for Europe, Belarus Reviewers and contributors: Pierpaolo de Colombani, WHO Regional Office for Europe Gunta Lazdane, WHO Regional Office for Europe Elena Voronko, BelMAPO, Belarus Ludmila Zhilevich, Ministry of Health of Belarus Valuable inputs and advice were provided by the national working group of this project: Ludmila Zhilevich, MoH, Department of primary health care Ludmila Gurinovich, MoH, Department of primary health care Alexander Barsukov, MoH, Head gynaecologist Elena Adamenko, MoH, Head therapist Galina Volzhankina, MoH, Department of the organization of medical care Eduard Glazkov, MoH, Department of international relations Hennady Hulup, BelMAPO, Rector Elena Voronko, BelMAPO, Department of general practice Ludmila Bogush, Specialist in general practice Vladislav Podpalov, Vitebsk University, Department of continuous medical education for therapists Konstantin Egorov, Vitebsk University, Department of polyclinic therapy Raisa Hursa, Minsk State Medical University, Department of polyclinic therapy Taissia Borovaya, Health Care Authorities Minsk Region, Department of medical care Stepan Zhukov, Health Care Authorities Vitebsk Region Elena Scrahina Research institute for pulmonology and TB Oleg Kalechic, Research institute for pulmonology and TB Vjacheslav Grankov, Trade union of medical workers Michail Kiselev, Belarussian Association of Physicians Egor Zaitsev, Head of the WHO Country Office in Belarus The project is grateful for the participation of all patients, primary care providers, field workers and local organizers in the regions of Minsk and Vitebsk, Belarus. Evaluation of the organization and provision of primary care in Belarus 5 FOreWORD Primary health care embodies the values and principles that WHO pursues in its world- wide effort to help countries strengthen their health systems efficiently and equitably. WHO renewed its commitment to global improvements in health, especially for the most disadvantaged populations, in the recent World health report 2008, which urges countries to act on evidence that access to primary care services forms the core of an efficient and appropriate health care system. The title of the report underscores the urgency of its message: Primary health care – Now more than ever. Over the past 30 years, health in the 53 WHO Member States in the European Region has improved considerably overall, despite significant changes in the patterns and trends in disease occurrence, demographic profiles and exposure to major risks and hazards in a rapidly evolving socioeconomic environment. In addition, the Region has seen trends towards more integrated models of care and greater pluralism in the financing and organization of health systems. Governments are continuing to rethink