Accessible endoprostheses for all. Who profited in the turf battle following the "orthopedic surgeons case"?

In March 2022, 35 orthopedic traumatologists were detained in Belarus as part of the "orthopedic surgeons case". The doctors were accused of receiving commissions for lobbying for endoprostheses from certain foreign manufacturers. The detainees were released shortly thereafter but were given three conditions: they had to admit guilt, pay damages, and accept a job placement determined by the Ministry of Health. 

This investigation was supported by the CyberPartisans hacker group.

But you're old

Viktar (name changed at his request), a retired man, first encountered issues with his hip joint about 10 years ago. His daughter told BIC: 

"I went to see the district (physician). The doctor said, ‘Fair enough, you’re old.’ We got kicked off. Then I noticed that he started limping. I said, ‘Why are you limping?’ He started telling me that his hip hurt."

At a follow-up consultation, they were told there was initial destruction of the joint, that the issue had to be controlled, but there was nothing serious yet. Four years later, the man could no longer stand on his foot. The pensioner’s daughter raised concerns, but the doctors said: "You still can walk, so what’s the problem?" 

"Getting a full examination was not possible even through the head physician of the clinic,” the daughter said.  We had to pay money for an ultrasound scan and follow-up tests. It turned out that the disease was progressing."

"Through several quarrels, I finally got them to at least put my father on the waiting list (for endoprosthesis replacement)".

But In the spring of 2023, when the man could no longer walk without a cane, it turned out his data was not included in the waiting line general database. Through friends, the daughter got her father an appointment for endoprosthesis replacement at the Republican Scientific and Practical Center of Traumatology and Orthopedics. 

"(At the Republican Scientific and Practical Center), Dad was given a piece of paper with a diagnosis. They diagnosed him with grade 3-4 (joint degeneration)".

In the winter he was informed that he would have surgery in a few months. The exact date would be set closer to that time. 

"They said we could choose between a Belarusian or Indian-made implant. There are no other options. They gave me a list of what I needed to buy for the surgery: some elastic bandages, tights. That is what our free health care looks like."

In May 2022, 1,998 people were on the waiting list for hip replacement surgery in Minsk alone, and 2,423 for knee joint replacement. As of January 1, 2024, 2,491 people were on the list for hip surgery and 3,492 awaited knee joint replacement.

As this piece is being published, at the Republican Scientific and Practical Center of Traumatology and Orthopedics, those who have been waiting since January 2022 were finally called for hip joint surgery, and those waiting since February 2023 were called in for knee joint replacement. In the 6th City Clinical Hospital in Minsk, operations are now being done on those who have been waiting since June 2021 and April 2019, respectively.

In Kyiv hospitals, the waiting list for a free endoprosthesis is usually several months. This is according to Ukrainian orthopedic traumatologist Oleksandr Haluzinski, medical director of the Center for Complex Endoprosthetics, Osseointegration and Bionics at the Mirum Clinic. He explained that, in addition to severe pain, which is difficult to relieve with painkillers, there are other consequences for a long wait: 

"While waiting for the surgery, a person does not step on their foot for quite a while, and they only walk on crutches. This can lead to muscle atrophy, and to contracture, which means a restriction of joint mobility. So, what will we have as a result if this situation lasts for many months or even years? The surgery itself will prove more difficult for the surgeon, while for the patient, rehabilitation after such a surgery will be way more difficult." 

You can get a locally produced implant in Belarus for free. You will have to pay for imported implants. In the case of replacement of a destroyed joint, both the prosthesis and the operation will be paid for and there is no waiting list.

The cost of endoprosthetics in public Belarusian hospitals has increased. In May 2022, the surgery could be done for 8,400 Belarusian rubles ($3,000). Now the skip-the-line hip replacement in Minsk state medical institutions costs from 12,000 to 17,000 Belarusian rubles. At the Merci clinic, the only private clinic in Belarus where endoprosthesis replacement is performed, the service and implant cost about 19,000 Belarusian rubles. This amounts to nearly 10 average salaries. Most Belarusians earn less than that monthly average. 

Given long waiting lists and high costs, some patients prefer to have surgery in Russia. A Belarusian woman who needed both hip joints replaced would have had to wait two years for free surgery in Belarus. It would very expensive to undergo surgery for a fee at the presidential hospital. The woman went to see a Belarusian doctor in a Russian city. Surgery on one joint cost her $3,600 (about 11,300 Belarusian rubles at the current exchange rate) and the second cost $3,000 (9,450 rubles). The patient was happy with the surgery.

We studied prices for endoprosthesis replacements on websites of Russian clinics and contacted some of them. Even in Moscow one could get endoprostheses cheaper than in Minsk. For instance, in the private clinic SM-Klinika, costs for a surgery and an implant produced by the American company DePuy started at 12,900 Belarusian rubles.  

In Russian government agencies, prices are even lower. At the Kirov City Clinical Hospital No. 3 in Astrakhan, you can get a German-American or French-made endoprosthesis for 8,200 to 8,900 Belarusian rubles. At the Saratov Regional Clinical Hospital, an American-made prosthesis costs 7,100 Belarusian rubles.

Ukrainian orthopedic traumatologist Oleksandr Haluzinski said that in his country the prices companies offer to patients or private clinics "have not changed all this time, ... at least over the last 10 (years)".

New procurement system

In September 2022, it was reported that endoprostheses in Belarus could be purchased only through Belmedtekhnika, a state monopolist in the market for extending medical devices to healthcare institutions. It turned out that the company purchases implants from suppliers much cheaper than it then sells them to patients. That is the case with state medical institutions as well. 

The Belarusian Investigative Center found that Belmedtekhnika purchases Indian-made prostheses for 2,000 to 4,500 rubles per kit. Swiss-made prostheses cost from 2,500 to just over 5,500 rubles. At the same time, Belarusians who have waited their turn for a joint replacement are asked to pay almost twice the purchase price for an Indian (6,000 rubles) or Swiss-made (9,000 rubles) prosthesis. 

The procurement scheme was changed after the "orthopedic surgeons case". Hospitals were barred from directly purchasing implants by order of the Ministry of Health.

According to waiting list data, this task was not accomplished, despite the fact that Belmedtekhnika spent more on the purchase of endoprostheses in 2023 than at any time in the last five years — 32 million rubles (9.9 million euros).

Profitable redistribution

The "orthopedic surgeons case" and changes in the procurement system hurt patients, but others made money. 

In our previous investigation, "Unknown orthopaedic clinic gains from crackdown on private medicine", we searched for an answer to the question of who benefited most from the endoprostheses scandal. At that time, the facts led us to the Merci private clinic. Having analyzed procurement data and talked with a Belarusian doctor, we found out who else benefited from the market redistribution.

"Here's the thing. There is a Belarusian plant that produces prosthetics. For the plant to function, ongoing purchasing by hospitals must be secured. That is, a hospital must purchase a certain volume of products. Their quality is significantly worse: They are larger in size than imported ones, making the surgery an even bloodier process. And many patients themselves asked for imported ones. These last longer, there is less incision and tissue trauma, and the recovery period is shorter," a Belarusian doctor who wished to remain anonymous told BIC.

Based on Belmedtekhnika procurement data, nearly one-third of the endoprosthesis market in Belarus now belongs to Altimed, a Belarusian manufacturer of hip endoprostheses. Though it is not a state-owned company, the project to develop its first endoprosthesis was partially funded by the government budget. 

Altimed ranks second on the list of suppliers of endoprostheses to Belmedtekhnika. At the same time, doctors raised questions concerning their quality, Lidzia Tarasenka, coordinator of the Medical Solidarity Fund, told the BIC: "We talked a lot with doctors, with patients, with doctors who put on joints in the first place. <...> They say that Altimed is a far cry from top-level quality."

In 2023, Altimed had contracts with Belmedtekhnika worth nearly 19.3 million rubles (5.9 million euros) — almost one-third of the total endoprostheses purchased by Belmedtekhnika during this period. This is 3.3 times more than in 2022, when the value of Belmedtechnika’s transactions with Altimed amounted to about 5.77 million rubles. In 2021, Belmedtekhnika did not purchase a single endoprosthesis from the Belarusian manufacturer. 

Altimed has not yet reported its earnings for 2023. Its revenue in 2022 increased by 38% compared to 2021 and amounted to 6.6 million rubles (2.4 million euros). Altimed's net profit in 2022 reached nearly 1.5 million rubles. The company ended 2021 with losses of 96 thousand rubles. [*] [*]

Altimed production is located in Asipovichi. In 2012, it was visited by Lukashenko. Over the years, he has been saying that Belarus should focus on import substitution, and often visits such enterprises. His tour of Altimed was personally guided by Anatoly Dosta. In 2018, the CEO of Altimed received an honorary award from the Council of Ministers. 

In his March 2023 message to the people and the National Assembly, Lukashenko once again said that "import substitution and increasing the share of innovative production are among the most pressing tasks. We should not depend on the whims of Western political elites that limit the freedom of civilized business." 

Young player 

Another Belarusian manufacturer on the list of suppliers of implants to Belmedtekhnika is the scientific and technological park BNTU Politekhnik. News that it recently started making knee joint endoprostheses appeared last December. In August 2023, Belmedtekhnika purchased 600 kits of prostheses from Politekhnik worth 1.8 million rubles, about 3,000 rubles per kit. 

The Belarusian Ministry of Health claims Politekhnik endoprostheses are not inferior in quality to imports.However, the authors of the Telegram channel of the Belarusian medical initiative "Belye Khalaty" wrote that clinical trials of samples of these implants were performed on one corpse and two living people at the Republican Scientific and Practical Center of Traumatology and Orthopedics and at the 6th City Clinical Hospital in 2022 and 2023. 

"Of course, no one will provide you with long-term results, survival rate, changes in bone tissue, functionality and other indicators during this time," noted the authors of the channel.

Delivered from India with a stopover in America

Despite government attempts to oust imports from the Belarusian market for endoprostheses and replace them with domestic-made implants, so far the top supplier to Belmedtekhnika is Indian implants sold by Neotech Solutions. The government-owned enterprise purchased nearly one-half of all endoprostheses from Neotech Solutions in 2023 and paid almost 30 million rubles. 

Neotech Solutions turned out to be a company with a share capital of $20 not involved in implant production. Neotech Solutions' postal address leads to Monroe Township in the US state of New Jersey. Based on data provided by the US state of Nevada business registry (that’s where the company is registered), seven key positions in the company are held by the same person, Natalie Rombalski. [*] [*] [*] She now has US citizenship, but based on her LinkedIn profile, she received her higher education at the Belarusian State University of Informatics and Radioelectronics. [*] [*]

The head of the representative office of Neotech Solutions in Belarus Natalya Shamanovskaya graduated from the Academy of the Ministry of Internal Affairs. [*] She indicated this information on her social media account. [*] Shamanovskaya knows General of the Ministry of Internal Affairs of the Republic of Belarus Leonid Gluhovskiy. In 2008, they traveled to Poland in a car together. [*] Gluhovskiy previously served as Deputy Minister of Internal Affairs and headed the Investigative Committee, and was also a member of the House of Representatives of the National Assembly.

At the same address what Neotech Solutions has in contacts, there is a house owned by Natalie along with Vitali Rombalski. [*]

A person with the same name owns a company called Cybernet Enterprises at the same address in Monroe. [*] [*]

Based on a description on the Cybernet Enterprises website, it is engaged in information and medical technologies. The company also participates in tenders for the supply of medical goods in Belarus. In a 2021 procurement, Cybernet Enterprises and Neotech Solutions appeared as winners for two different lots. The agreement with Belmedtekhnika on behalf of Cybernet Enterprises was signed by Vitali Rombalski.

We tried to call Natalie Rombalski to find out how her American company managed to increase the supply of Indian-made endoprostheses to Belarus. To no avail. We also sent her a written request, but have not yet received a response.

Common interest

In 2023, the third-largest supplier of prostheses to Belmedtekhnika was the Swiss HAB Invest AG, which sold implants worth just under 8.7 million rubles (2.7 million euros). In 2022, it sold 13.2 million rubles (4.8 million euro).

HAB Invest AG was founded by Swiss citizen Hermann Alexander Beyeler, the honorary consul of Belarus in Switzerland and a wealthy businessman.

Beyeler also has business interests in Belarus not confined to the medical field. In August 2019, then-Belarus First Deputy Prime Minister Alexander Turchin proposed to Beyeler, president of Ceres Group Holding AG and chairman of the board of directors of the BUSS industrial park, to create a Swiss sub-park in the Great Stone Industrial Park. The businessman replied that it would be an honor. Such cooperation in mutual investment attraction was also discussed in 2020.

In July 2022, Beyeler said that, before sanctions were imposed on the supply of Belarusian timber to Europe, one of his companies purchased domestic lumber. On May 18, 2023, Beyeler met with Dmitry Pinevich, who was a Minister of Health of Belarus at that time. Around the time when Lukashenko expressed dissatisfaction with the waiting lists for endoprosthetics, Pinevich and Beyeler discussed the possibility of producing medical equipment in Belarus by Swiss companies, as well as direct purchases of endoprostheses from Western manufacturers.

We sent a request to HAB Invest but have not yet received a response.

Tricky transformation

The supplies from the American company Neotech Solutions, the Belarusian Altimed and the Swiss HAB Invest AG, are large shipments of standard endoprostheses. But some patients require unique ones that take into account their anatomical features. Such prostheses are often ordered by the Republican Scientific and Practical Center for Pediatric Oncology, Hematology and Immunology. Children need them if there is significant bone destruction by a tumor. 

Such endoprostheses are purchased from Tekhnomedicina. In 2022, this company supplied six individual prostheses for 540,000 rubles. All were intended for the Republican Scientific and Practical Center. 

In 2022, Tekhnomedicina’s revenue amounted to 8.8 million rubles (3.2 million euros). After deducting expenses, the company lost 507,000 rubles. It also lost money in 2021. [*]

Businessman Vitali Bely was the owner of the company prior to its liquidation last fall. [*] [*] A former physician, in 2003 he worked at the Psychoneurological Boarding Home for the Elderly and Disabled No. 1. [*]

Bely now owns several companies related to medical products. 

Despite past cooperation, relations between Tekhnomedicina and Belmedtekhnika now seem to be strained. Tekhnomedicina was a defendant in 19 trials in the Economic Court over claims filed by Belmedtekhnika. There was a lawsuit over non-fulfillment or improper fulfillment of obligations under contracts of sale and purchase or supply of goods. 

Amid these concerns, Tekhnomedicina was apparently reincarnated twice into another company. On October 10, 2023, founder Vitali Bely was replaced by Sergei Bazuev, a former State Control employee and owner of the consulting firm Business Opora. [*] [*] [*] [*]

Within one day, Tekhnomedicina merged into RosMedInstrument. [*] A little more than a month later, it merged into the newly established Avatarial. [*] [*]

Force Majeure Circumstances

All purchases, in which the three largest sellers of Belmedtekhnika - Neotech Solutions, Altimed and HAB Invest AGВ - became suppliers, were carried out following the single-source procedure. That is, with no tender. To purchase endoprostheses according to this principle, Belmedtekhnika either announced an auction and declared it invalid, or referred to force majeure circumstances.

"When tenders are deliberately made unsuccessful and purchases are then made from a single source for various reasons, because the tender did not take place or some other reasons are made up, this means that people feel their absolute impunity. And that is why the procurement procedure is carried out in this way," said Vladimir Kovalkin, head of Open Tenders, in a commentary to the BRC.

We sent a request to the Ministry of Health with a request to comment on the situation with endoprosthetics in Belarus. It was left without consideration on its merits. The department explained the refusal by saying that our application did not meet the requirements — “in particular, documents confirming the applicant’s authority were not attached.” We received the same answer to our request as part of our previous investigation “More Expensive for Belarusians? Checking Whether Ukrainians and Russians pay less for medications, and exploring the reasons for the discrepancy ”

The BIC also sent requests to the persons involved in the investigation: the Belmedtekhnika Unitary Enterprise and the Altimed company. At the time of publishing this article, we had not received any responses.