Challenges in organizing integrated care for the population in Belarus

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Introduction

In recent decades, the international community has been concerned with issues related to the organization of medical and social assistance for citizens with disabilities based on an integrated approach, due to the growing demand for such assistance among the population. The main factors influencing this increase in demand are the aging population and the rise in chronic diseases. The intensification of demographic aging, the emergence of new needs and opportunities for older people, and the need to create conditions for them to realize their potential have led to the development of national strategies aimed at improving their quality of life¹.

The provision of medical and social assistance to this category of citizens (older people with chronic diseases) is usually fragmented, both within and between the health and social protection sectors, accompanied by an increased burden on medical and social services and requiring additional resources, including financial and human resources. Reforming the systems for providing medical and social assistance in order to more effectively meet the needs of people in need involves a transition to a model that allows for better coordination of the work of specialists and institutions and ensures the active participation of the service recipients themselves and their caregivers in this process.

Overcoming inconsistencies and fragmentation and forming an integrated healthcare and social protection system has become an independent area of public policy in various countries around the world. Research is being conducted to identify areas and mechanisms for integration, taking into account the specific characteristics of national health care and social protection systems, and to assess the readiness of health care and social protection systems and non-governmental structures to implement an integrated approach to providing medical and social assistance to citizens in need.

The purpose of the study is to assess the readiness of the healthcare and social protection system and non-governmental structures to implement an integrated approach to the provision of medical care, including medical-social and palliative care, and social services (hereinafter referred to as readiness to implement an integrated approach) to citizens in need.

Materials and Methods

Sociological (questionnaire) and statistical methods were used in the study.

The sociological research methodology included a questionnaire survey of employees of the healthcare system, social protection system, and Belarusian Red Cross in two districts of the Republic of Belarus: Ostrovets District in Grodno Region and Vileika District in Minsk Region. The research tool used was the Scaling integrated care in context questionnaire, SCIROCCO, developed as part of the SCIROCCO Exchange EU Capacity Action for integrated care project, which is used in European countries to assess the readiness of the healthcare and social protection systems and non-governmental organizations to introduce and implement integrated care [1].

At the time of preparing the study, there was no Russian-language version of this tool. The English-language version of Scaling Integrated Care in Context (SCIROCCO) was translated and socially adapted, and its validity and reliability were assessed. The Russian-language version of the Scaling Integrated Care in Context (SCIROCCO) questionnaire includes 10 questions. It does not include two questions from the original questionnaire that relate to the assessment of the criteria "Removing barriers" and "Innovative management". A positive expert opinion was received on the adapted questionnaire as a tool that meets the requirements for conducting sociological research.

The questionnaire uses the term "integrated care" with the explanation that it refers to the organization of long-term medical care and social services, including individual care, based on a comprehensive approach to providing them to citizens in need and coordinating the activities of healthcare organizations, social services, non-governmental and other organizations, with the aim of improving the efficiency of service delivery and the quality of life of their recipients.

Respondents were asked to rate the criteria characterizing readiness to implement an integrated approach on a six-point scale. Readiness was measured on a scale from 0 points (corresponding to "not fulfilled", "absent/unavailable") to 5 points (corresponding to "fully fulfilled", "fully present/available").

The study covered 411 observations, which corresponds to a high-precision study (at a significance level of p = 0.05) [2]. The study involved 325 (79.1%) employees of health care agencies and organizations, 78 (19.0%) employees of social service institutions, and 8(1.9%) employees of the medical and social service of the Belarusian Red Cross "Dapamoga" (hereinafter referred to as the medical and social service of the Red Cross).

Women predominate among respondents, accounting for 89.1% of the total. The average age of respondents is 42.8 (95% CI 41.6–43.9) years. In terms of age structure, 15.3% of respondents are under 30 years old, 39.2% were aged 30–44, 39.2% were aged 45–59, and 6.3% were aged 60 and older. The average length of service of the respondents was 17.7 (95% CI 16.5–18.9) years. The proportion of respondents with up to 5 years of work experience is 18.2%, from 5 to 15 years – 27.3%, from 15 to 25 years – 24.3%, and 25years and above – 30.2%.

Almost 73% of respondents have a qualification category (including 26.2% with a second category, 30.4% with a first category, and 16.1% with the highest category), while 27.3% do not have a qualification category. The highest proportion of respondents with qualification categories is among healthcare workers (78.5%), and the lowest is among social service workers (51.3%) (Chi-square test: χ² = 42.6; р = 0.00001). Half of the employees of the Belarusian Red Cross have a qualification category: 4 out of 8respondents (50%).

Statistical analysis of the data obtained was performed using nonparametric research methods, including descriptive statistics and reliability assessment methods (Chi-square test: χ², р). The description of the mean values was performed using the median (Ме, Q₂₅–Q₇₅). Statistical data processing was performed using the Statistica 10 software package.

Results and Discussion

Most respondents (91.7%) recognize the need to develop integrated care, including 92% of healthcare workers, 89.7% of social protection workers, and 100% of Belarusian Red Cross workers.

The average level of assessment of the readiness of the healthcare and social protection system to implement an integrated approach to providing medical, social, and palliative care to citizens in need differed statistically significantly depending on the category of workers (Kruskal – Wallis test: Н = 22,3; p₃ = 0,0001). The highest assessment of the readiness of the healthcare and social protection system to implement an integrated approach was given by social protection workers, with a median (Me) of 3.2 points (Q₂₅ = 1.6; Q₇₅ = 4.0), while the lowest rating was given by healthcare workers (Me = 1.9 points (Q₂₅ = 1; Q₇₅ = 3)). The rating given by Red Cross medical and social service workers is higher than that given by healthcare workers but lower than that given by social protection workers, at 2.7 points (Q₂₅ = 1.7; Q₇₅ = 3).

There is statistical significance in the differences in the levels of assessment of criteria characterizing the readiness of the health care and social protection system for the development of integrated care (hereinafter referred to as the criteria for readiness for the development of IC) among health care workers in the pilot regions) (Kruskal–Wallis test: Н = 101,4; p = 0.0001). The highest rating is given to the criteria "potential of the existing healthcare and social protection system to assess health risks and predict citizens' demand for IC" (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)) and "coordination (vertical and horizontal) of IC provision" (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)); the lowest rating was given to the criteria "readiness of structure and management for IC" (Me = 1 point (Q₂₅ = 1; Q₇₅ = 3)), "readiness of digital infrastructure for IC" (Me = 1 point (Q₂₅ = 1; Q₇₅ = 3)), "coordination of IC provision processes within the existing health and social protection system" (Me = 1 point (Q₂₅ = 1; Q₇₅ = 3)), "IC financing system" (Me = 1 point (Q₂₅ = 0; Q₇₅ = 3)), "readiness of the existing healthcare and social protection system to motivate citizens to participate in decision-making processes concerning their health and the provision of IC services" (Ме = 1 point (Q₂₅ = 0; Q₇₅ = 3)).

Among Belarusian Red Cross workers, there is a statistically significant difference in the assessment of IC readiness criteria (Kruskal–Wallis test: H = 101.4; p = 0.0001) for the following criteria. The highest ratings are for the criteria "IC financing system" (Me = 3 points (Q₂₅ = 2.5; Q₇₅ = 3.5)), "level of coordination (vertical and horizontal) of the IC represented" (Me = 4 points (Q₂₅ = 3; Q₇₅ = 4)), "the ability of IC to strengthen the health care and social assistance system, other organizations, including improving the professional level of workers, introducing new technologies, introducing new professions, improving the quality of medical care and social services for citizens in need" (Ме = 3 points (Q₂₅ = 2; Q₇₅ = 3,5)). The lowest scores were given to the criteria "readiness of the existing healthcare and social protection system to motivate citizens to participate in decision-making processes concerning their health and the provision of IP services" (Me = 1 point (Q₂₅ = 1; Q₇₅ = 2)) and "readiness of the structure and management for IC" (Ме = 1,5 points (Q₂₅ = 1; Q₇₅ = 3)).

Among social protection workers, there is a statistically significant difference in the assessment of IC readiness criteria (Kruskal–Wallis test: H = 101.4; p = 0.0001) for the following criteria. The highest rating is for the criteria "level of coordination (vertical and horizontal) of the IC represented" (Me = 4 points (Q₂₅ = 4; Q₇₅ = 5)), "the potential of the existing health care and social protection system to assess health risks and predict citizens' demand for IC" (Me = 3 points (Q₂₅ = 2; Q₇₅ = 5)), "the ability of IC to strengthen the healthcare and social assistance system and other organizations, including improving the professional level of workers, introducing new technologies, introducing new professions, and improving the quality of medical care and social services for citizens in need" (Me = 3 points (Q₂₅ = 2; Q₇₅ = 4)); the lowest – for the criterion "readiness of the structure and management for IC" (Ме = 2 points (Q₂₅ = 1; Q₇₅ = 4)).

The assessment of the criterion "readiness to change the existing healthcare and social protection system for the development of IC" differed statistically significantly among different categories of employees (Kruskal–Wallis test): Н = 21.5; p = 0.0001). The level of assessment of this criterion by Red Cross health and medical-social service workers corresponded to the opinion of respondents that work is being done to achieve consensus among interested parties and that a strategy for the development of integrated care is being developed, with a median score of 2 points (Q₂₅ = 1; Q₇₅ = 3) and 2 points (Q₂₅ = 2; Q₇₅ = 2). The level of assessment of this criterion by social service workers was higher than that of health care workers and Red Cross medical and social service workers; among them, the proportion of respondents who rated this criterion at 4 and 5 points prevailed, accounting for 24.4% and 15.4%, respectively. This indicates that the IC development strategy has been developed and approved, and the parties responsible for its implementation have been identified (Ме = 3 points (Q₂₅ = 2; Q₇₅ = 4)).

The assessment of the criterion "readiness of the structure and management in the existing health care and social protection system for the development of IC" differed statistically significantly among different categories of employees (Kruskal – Wallis test: Н = 13.1; p = 0.0014). The level of assessment of this criterion by Red Cross health and medical-social service workers, the median of which was 1 (Q₂₅ = 1; Q₇₅ = 3) and 1.5 points (Q₂₅ = 1; Q₇₅ = 3), respectively, corresponds to the opinion of the respondents that there is an understanding of the need to transform the management system and structures for the provision of IC. The level of assessment of this criterion by social protection workers was higher (Me = 2 points (Q₂₅ = 1; Q₇₅ = 4)) than among healthcare workers and Red Cross medical and social service workers; among them, the proportion of respondents who rated this criterion at 4 and 5 points prevailed, accounting for 20.5% and 10.3%, respectively. This indicates that the organizations and algorithm for IC provision have been defined. This assessment corresponds to the opinion of respondents that a comprehensive program with funding has been approved, the powers of management bodies and structures for IC provision have been defined (20.5%); an action plan for IC development has been developed and adopted by stakeholders (10.3%).

The assessment of the criterion "readiness of the digital structure of the existing healthcare and social protection system for the development of IC" differed statistically significantly among different categories of employees (Kruskal–Wallis test: H = 18.3; p = 0.0001). Healthcare workers gave the lowest rating for this criterion, reaching 1point (Q₂₅ = 1; Q₇₅ = 3), which indicates that there is an understanding of the need to use digital technologies, but there is no strategy and/or plan to develop a unified digital infrastructure to support IC. The median rating given by Red Cross medical and social service workers was 2.5 points (Q₂₅ = 1; Q₇₅ = 4) and corresponds to the opinion of respondents that plans for the implementation of digital infrastructure at the regional/national level, including a set of agreed technical standards in the health care and social protection system, have been defined but not yet implemented. The level of assessment of this criterion by social protection workers was higher (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)) than among healthcare workers and Belarusian Red Cross workers; among them, the proportion of respondents who rated this criterion at 4 and 5points prevailed, accounting for 17.9% and 21.8%, respectively. The assessment level obtained indicates that the digital infrastructure to support IC is being implemented on a trial basis but does not yet cover the entire region; there is a set of agreed standards allowing for joint procurement of new systems; work is underway to integrate information and communication technologies.

The assessment of the criterion "coordination of processes for providing IC within the existing health care and social protection system" differs statistically significantly among different categories of workers (Kruskal – Wallis test: Н = 24.3; p = 0.0001). Healthcare workers gave the lowest rating to this criterion, with a score of 1 (Q₂₅ = 1; Q₇₅ = 3), indicating that stakeholders are developing some guidelines and recognize the need to standardize coordination processes in IC delivery, but there are no formal plans to develop them. Among healthcare workers, the majority of respondents believe that stakeholders are developing some guidelines and recognize the need to standardize coordination processes in IC delivery, but there are no official plans to develop them, and there are no formal instructions, descriptions, agreements, or standards for the implementation of innovative coordination processes in the provision of IC, either available or under development, hence, respectively, 35.1% and 18.2%. The rating of this criterion by Red Cross medical and social service workers was 2.5 points (Q₂₅ = 1.5; Q₇₅ = 3.5) and corresponds to the opinion of respondents that some standardized coordination processes are implemented in the provision of IC; instructions are used, some initiatives and coordination processes are formally described, but a systematic approach is not planned. The level of assessment of this criterion by social protection workers was higher (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)) than that of healthcare workers and the Belarusian Red Cross; among them, the proportion of respondents who rated this criterion at 4 and 5 points prevails – 28.2 and 20.5%. This indicates that the services, methods, and processes of coordination in the provision of IC are officially described by the stakeholders in a standardized form, the development of standards is planned, but they have not been implemented.

Statistically significant differences were found in respondents' assessments of the criterion "IC financing system within the existing healthcare and social protection system" depending on the category of workers (Kruskal–Wallis test: Н = 23.3; p = 0.0001). The lowest rating for the criterion "IC financing system" was observed among healthcare workers, with a median value of 1 point (Q₂₅ = 0; Q₇₅ = 3); among them, the proportion of respondents who rated this criterion at 0 and 1 points prevails – 31.7 and 25.8 percent. This indicates that funding is available, but mainly for pilot projects and testing. The level of assessment of this criterion by employees of the Belarusian Red Cross (Me = 3 points (Q₂₅ = 2.5; Q₇₅ = 3.5)) and social protection (Mean = 3 points (Q₂₅ = 1; Q₇₅ = 4)) was higher than that of health care workers and corresponds to the opinion of respondents that funding is available from the national/local budgets, or international funding, or within the framework of public-private partnerships to expand the scale of activities.

The level of assessment of the criterion "potential of the existing health care and social protection system to assess health risks and predict citizens' demand for IC" differed statistically significantly among different categories of workers (Kruskal–Wallis test: Н = 8.8; p = 0.012). The level of assessment of this criterion by healthcare workers (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)) and social protection workers (Me = 3 points (Q₂₅ = 2; Q₇₅ = 5)) was higher than that of Belarusian Red Cross workers (Ме = 2,5 points (Q₂₅ = 1,5; Q₇₅ = 4,5)), and indicates that health risk assessment in the provision of IC is used for specific groups, such as those at risk of becoming frequent users of IC services (the elderly, people with chronic diseases, disabilities, or reduced functional abilities). The rating of this criterion by Belarusian Red Cross workers was 2.5 points (Q₂₅ = 1.5; Q₇₅ = 4.5), indicating that health risk assessment in IC provision is used in some projects on an experimental basis.

Respondents' assessment of the criterion "readiness of the existing healthcare and social protection system to motivate citizens to participate in decision-making processes concerning their health and the provision of IC services" differed statistically significantly among workers in different categories (Kruskal – Wallis test: Н = 18.7; p = 0.0001). The level of assessment by healthcare workers (Me = 1 point (Q₂₅ = 1; Q₇₅ = 3)) and the Belarusian Red Cross (Me = 1 point (Q₂₅ = 1; Q₇₅ = 2)) of this criterion was quite low and corresponds to the opinion of respondents that citizen participation is recognized as an important element of IC provision, but measures to empower citizens are still in the development stage. The level of assessment of this criterion by social protection workers was higher (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)) than that of health care workers and the Belarusian Red Cross; among them, the proportion of respondents who rated this criterion at 4 and 5 points prevailed – 16.7 and 10.3%. This indicates that consultations with citizens on the provision of IC are being conducted and that citizens have access to medical information and data on their health status.

Respondents' assessment of the criterion "use of methods for evaluating the quality and effectiveness of IC development" differed statistically significantly among different categories of workers (Kruskal–Wallis test: Н = 11.9; p = 0.002). The level of assessment of this criterion by healthcare workers and the Belarusian Red Cross, the median of which was 2 points, respectively (Q₂₅ = 1; Q₇₅ = 3), this corresponds to the opinion of respondents that the quality of IC provision is assessed, but not systematically. The level of assessment of this criterion by social protection workers was higher (Me = 3 points (Q₂₅ = 2; Q₇₅ = 4)) than that of health care workers and the Belarusian Red Cross, indicating that the quality of some IC services is assessed systematically.

Respondents rated the criterion "coordination (vertical and horizontal) of IC services" highest compared to other criteria, with statistically significant differences between different categories of workers providing certain IC services (Kruskal–Wallis test: Н = 18.9; p = 0.0001). The level of assessment of this criterion by healthcare workers was lower (Me = 3 points (Q₂₅ = 1; Q₇₅ = 4)) than that of Belarusian Red Cross workers (Me = 4 points (Q₂₅ = 3; Q₇₅ = 4)) and social protection workers (Me = 4 points (Q₂₅ = 4; Q₇₅ = 5)), which corresponds to the opinion of respondents that interaction has been achieved between levels of care (between different types of medical care, e.g., primary, specialized, medical-social, and palliative care) or between levels of social protection. The level of assessment of this criterion by workers of the Belarusian Red Cross and social protection indicates that coordination in meeting the needs of the health care and social protection systems has improved.

Respondents' assessment of the criterion "the ability of IC to strengthen the healthcare and social assistance system, other organizations, including improving the professional level of workers, introducing new technologies, introducing new professions, improving the quality of medical care and social services for citizens in need" differed statistically significantly among different categories of workers (Kruskal–Wallis test: Н = 16.5; p = 0.0003). The level of assessment of this criterion by healthcare workers was lower than that of Belarusian Red Cross and social protection workers, whose median was 2 points (Q₂₅ = 1; Q₇₅ = 3), and corresponds to the opinion of respondents that cooperation on capacity building for IC development in the region is expanding. The level of assessment of this criterion by Belarusian Red Cross workers (Me = 3 points (Q₂₅ = 2; Q₇₅ = 3.5)) and social protection workers (Me = 3 points (Q₂₅ = 2; Q₇₅ = 4)) indicates that training on IC provision is being carried out, but is not being implemented universally.

Conclusions

Thus, respondents' assessment of the readiness of the healthcare and social protection system to implement an integrated approach to providing medical care and social services to citizens in need varies statistically significantly depending on the category of workers, which must be taken into account when organizing these types of assistance. The results obtained during the study can be used in the preparation of regulatory legal acts on the organization of medical, social, and palliative care, including the development of a strategy for implementing an integrated approach to the provision of medical, social, and palliative care; developing and implementing standards for medical and social care, including home care; developing algorithms for interaction between the health care and social services systems and non-governmental organizations in the provision of medical, social, and palliative care and social services to citizens in need (the elderly, people with chronic diseases, people with disabilities, people with reduced functional abilities)^[2].

Funding. The study was conducted as part of a Belarusian Red Cross project with financial support from the Swiss Red Cross (foreign grant aid).

Conflict of interest. The authors declare no conflict of interest.

Author contributions:

Moroz I.N. – concept definition, research, data processing, data analysis, writing the draft article, reviewing and editing the manuscript.

Svetlovich T.G. – concept definition, research, data processing, data analysis, writing the draft article, reviewing and editing the manuscript.

All authors approved the version for publication and agreed to be responsible for all aspects of this work, ensuring proper consideration and resolution of issues related to the accuracy and integrity of any part of it.

Study limitations. The study complies with the standards of the Declaration of Helsinki and has been approved by the Ethics Committee of the Ye.A. Vagner State Medical University, protocol No. 6 dated September 10, 2025.

¹ National Legal Internet Portal of the Republic of Belarus. National Strategy of the Republic of Belarus "Active Longevity – 2030", available at: https://pravo.by/document/?guid = 3871&p0 = C22000693

² State Program "Public Health and Demographic Security" for 2021–2025 (Appendix 7), available at: https://minzdrav.gov.by/upload/dadvfiles/letter/22100028_1611349200.pdf

About the authors

I. N. Moroz

Author for correspondence.
Email: moroz_iri@bk.ru
ORCID iD: 0000-0002-7430-3237

DSc (Medicine), Professor, Head of the Department of Public Health and Healthcare

T. G. Svetlovich

Email: moroz_iri@bk.ru
ORCID iD: 0009-0006-5414-0190

PhD (Medicine), Associate Professor, Leading Researcher of the Department of Scientific and Methodological Support for State Expertise

References

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