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The number of Serbian citizens who rate their personal health as being bad or very bad is twice the average of EU member states. Simultaneously, indicators that could monitor the quality of health, comparable to European and global criteria, are often non-existent or are monitored in Serbia in a way that is incomparable with those parameters

The deterioration of health in Serbia occurs relatively early, during the most active years of life, and is connected with diseases that also confront the EU population, such as diabetes or coronary type diseases, but with increased instances of fatality.

Statistics that indicate a significant shortfall in the quality of health care/services that Serbia’s healthcare system provides to its users and what would be possible with the invested medical knowledge and resources are also shown in the level of mortality of mothers and children, but also the high rate of mortality as a result of diseases that are relatively easy to treat, such as breast and cervical cancer, due to the weakening of prevention. Moreover, statistics show growth in the percentage of citizens who don’t have healthcare protection for some reason, despite needing it.

As a consequence of this state of affairs, there is a widespread impression among the citizenry that the quality of healthcare is decreasing. And this dissatisfaction is not due entirely to a lack of means or resources. In terms of spending on health as a share of GDP, Serbia is – on the basis of allocations (10.4%) – ranked alongside the richer and more developed countries that are, as a rule, able to allocate a larger share of GDP to healthcare. While expenditure from public funds in Serbia is within the average/expected range (6.3% of GDP), payments from pockets accounted for as much as 41.9% of total healthcare costs in 2015, i.e. 4% of GDP, which is among the highest rates in Europe.

Researchers point to a problem that exists with the efficiency of resource utilisation in healthcare services. This problem could worsen in the future, when demand for healthcare services rises among the older population, while the available financial resources become simultaneously more modest.

  • What are the core measures for improving the efficiency of the public health system?
  • How can existing resources (both human and medical) be better utilised?
  • How should Serbia improve disease prevention and contribute to the longevity of its population?

Healthcare is a two-way process

The great interest and massive response of citizens to free preventative check-ups is the best confirmation that Serbian citizens recognise the importance of this action of the Health Ministry, but above all that public awareness of the importance of prevention as a basis for the preservation of health has grown exponentially in our society.

The Ministry of Health has, for the last four years consecutively, been conducting various activities and measures aimed at establishing a faster, more efficient and higher quality healthcare system in Serbia. In this direction, alongside the construction of new clinical centres and hospitals, the procurement of state-of-the-art medical equipment and apparatus, the Ministry is decisively implementing the policy of strengthening the personnel of the healthcare system, employing young medical workers and approving the professional further training, or specialisations, of doctors.

On the other hand, we must consider that health care is a two-way process. So, as the state allows the provision of health services through the health system, so every citizen must take care of their own health. Thus, if you spend your whole life eating fatty food, don’t engage in physical activity, don’t properly maintain hygiene and smoke, you can’t expect from the state that the health system will prevent the emergence of disease. And prevention is the foundation of preserving health.

Around 100 of the best medical school graduates received an opportunity from the state to work in our health centres, enrol in specialist studies and learn from their older colleagues

As a nation, we – through tradition – have a specific and, I would say, not so responsible attitude towards health, which is best reflected in the fact that the vast majority of Serbian citizens only go to the doctor when they get sick with something. Well, we want to change that, to raise public awareness about the importance and possibilities of prevention.
One step is timely health education and counselling for the preservation and improvement of one’s own health, through learning from an early age.

In parallel with this, the state and the Ministry of Health implement measures and activities directed towards preventing, detecting early and controlling diseases, which implies national screening for breast, colon and cervical cancer as a type of preventative check-up of the population. In addition to this, the Ministry of Health organised free preventative check-ups in the past year on every last Sunday of the month at health centres throughout Serbia, under the auspices of which a total of more than 220,000 Serbian citizens have been checked to date.

Dejana Vukovic DEJANA VUKOVIĆ PhD.



More Efficient Financing Leads to Better Health Options

If we want to secure the financial sustainability of the healthcare system we need to work on better inclusion of the private health system and enable citizens to opt for different voluntary health insurance schemes. One option for doing that would be public-private partnerships.

Given that spending related to the delivery of healthcare services and out-of-pocket payments are on the rise, our health system is facing future problems with its financial sustainability.

The most realistic methods to help improve sustainability include better inclusivity of the private sector and enabling citizens to opt for different voluntary health insurance schemes.

There are a number of possibilities for better inclusion of the private sector, one option being public-private partnerships at the municipal level, where costs and expenditures would be shared between the two sectors.

Enabling citizens to opt for different voluntary health insurance schemes would lead to reduced out-of-pocket payments. Further support to the future financial sustainability of the system must be orientated towards more efficient use of financial resources through the improvement of payment mechanisms.

We have hyper-production of freshly schooled healthcare professionals, many of whom are left without employment. As a result, we are facing increasing emigrations to EU countries or the private sector.

Strengthening primary care, ensuring that most healthcare needs are met at the primary care level and reducing referrals could contribute significantly to more efficient healthcare.

In order to achieve that, payment mechanisms should be modified, with stronger incentives for the better performance of primary care and the provision of preventative measures.
When it comes to hospital-based care, it is expected that introducing new payment mechanisms through diagnosis-related groups will improve efficiency, though close monitoring of the effects will be necessary. There are evident problems in our current human resources for health with regard to improper planning.

To begin with, we have hyper-production of freshly schooled healthcare professionals. However, the opportunities for these professionals to secure employment are scarce, which leaves many of them unemployed. This creates an imbalance that forces the increasing emigration of these professionals to EU countries or the private sector. More adequate planning of human resources is essential in addressing this problem.



Increased Investments in Prevention Would Lead to Multiple Savings

Serbia has extremely high mortality rates from illnesses like cervical and breast cancer, which indicates a problem that doesn’t arise from limited resources, rather from a lack of efficiency in the preventative care system.

Serbia invests substantial financial resources in the health sector and has significant physical and human infrastructure resources that are poorly maintained and irrationally deployed. The results achieved, such as life expectancy of 75.6 years in Serbia – which is shorter than in any EU member state with the exceptions of Romania, Bulgaria, Latvia and Lithuania – indicate a serious disproportion compared to the invested funds, the inherited health system and the high level of medical knowledge that exists in Serbia (see Graph).

In order for the system to be more efficient, the allocation of the substantial resources invested in healthcare (10.4% of GDP, as much as 4% of which comes from citizens’ pockets) must be guided by a process that targets the full utilisation of funds spent. Serbia is currently attempting to simultaneously maintain an obsolete system that was built decades ago, when the demographic picture of Serbia was completely different, simply by augmenting it with high-tech and expensive methods.

While the state system doesn’t adapt to priorities, the private sector keeps growing as a formalised supplement (speeding up tests and issuing expensive drugs when healthcare units lack adequate equipment).

In order to avoid a situation in which basic necessities become a luxury for those unable to pay extra, clear rules for the operations of the private and public sectors need to be established and applied consistently in practice.

In order to avoid a situation in which basic necessities become a luxury for those unable to pay extra, clear rules for the operations of the private and public sectors need to be established

The institutional efficiency of health institutions could also be advanced through the better use of current resources, both human and infrastructure. With the better allocation of resources, we could reduce the workloads of doctors who cover a large number of people and increase the efficiency of those currently working with a smaller number of the general population. We also often tend to rely on more qualified healthcare workers for activities that could be carried out by less qualified employees.

What we need to understand is that increased investment in prevention would eventually result in multiple savings compared to the funds required for treatment once an illness occurs or develops. Serbia has extremely high mortality rates for illnesses like cervical and breast cancer, which indicates a problem that does not arise from limited resources, rather from a lack of efficiency in the preventative care system. Greater preventative care creates the possibility to detect those cancers earlier on and treat them, thus improving the possibility of reducing the mortality rate.



Thorough Analysis of the System Would Show the Directions of Action

Improving the efficacy of the public health system requires a serious analysis of the utilisation of staff and equipment, analysis of the causes of long waiting lists for specific services, as well as analysis of all individual costs to the health system.

Comparing Serbia to the countries of the region shows that budgetary allocations for public health, expressed as a percentage of GDP, are higher in Serbia than in the regions other countries. On the other hand, one of the key indicators of health system effectiveness – life expectancy – is shorter in Serbia than in comparable countries of the region. These two statistics together indicate that the funds invested in public health are not being used efficiently.

Improving the efficacy of the public health system requires a serious analysis of the utilisation of staff and equipment, analysis of the causes of long waiting lists for specific services, as well as analysis of all individual costs to the health system. In terms of personnel, it would be necessary to analyse the percentage and number of doctors with different specialisations and their workload, as well as waiting times for consultations with individual specialists.

Furthermore, in some EU countries it is the norm for nurses and other medical staff (technicians/midwives / medical support staff) to take on greater responsibilities and obligations in dealing with patients compared to staff in Serbia, thereby easing the burden on doctors, so analysis should be carried out on the responsibilities and obligations of doctors and other medical personnel, with possible consideration given to the reassigning of these obligations.

Ernst & Young’s analysis of the efficiency of Serbia’s healthcare system showed that inefficiencies exist in medical institutions when it comes to the use of equipment and that the auditing of public procurement processes is very poor and the control of the public procurement system is insufficient.

Nurses and other medical staff could take on greater responsibilities and obligations in dealing with patients, thereby easing the burden on doctors based on the example of other European countries

In order to improve the efficacy of the system, it is necessary to carry out a comprehensive analysis and develop a long-term plan to improve the public health system.

In terms of the system of prevention, it is necessary to use media campaigns to promote healthy nutrition and regular physical activity among children and adults. The percentage of smokers in Serbia is high and the State should work to reduce the number of smokers by imposing higher excise taxes, banning smoking in hospitality venues and implementing other policies that have helped reduce the numbers of smokers in other countries. The state should encourage and promote regular preventative check-ups (e.g. systematic check-ups, gynaecological check-ups etc.) on a larger scale, as well as investing more money in equipment for preventative medicine.



With so many sick patients, doctors don’t have time to deal with the healthy

Today, due to an excessive number of sick patients, allocated doctors don’t have enough room for preventative work with a healthy population. If this relationship were to be reversed in favour of preventative check-ups, we would be able to say that we are on the right track – to successful prevention.

In comparing – back in 2014 – the standardised mortality rates for the leading causes of death in the Republic of Serbia compared to the European country with the lowest rate and the EU’s average rate for citizens aged from 0 – 64, per 100,000 inhabitants, it is notable that the values were highest in the Republic Serbia: ischemic heart disease (rate of 25.6 in the Republic of Serbia, compared to 6.6 in Israel and the EU average of 15.8), cerebrovascular disease (rate of 17.3 in the Republic of Serbia, compared to 2.1 in Luxembourg and the EU average of 7.2) and malignant neoplasms (rate of 101.6 in the Republic of Serbia, compared to 44.2 in Finland and the EU average of 66.7).

A logical question that emerges is why so many more people in Serbia die as a result of these diseases compared to the countries of Western Europe? The answer is clear: it is because these countries started dealing intensively with the prevention, organised screening and early detection of diseases back in the late 1980s, while Serbia is lagging behind. If the disease is detected on time, during the initial stages, treatment is more successful and prevents complications leading to fatalities.

Systematic and targeted check-ups are today only free for categories of the population who are insured by the Health Insurance Fund, while in the future competent institutions should also cover the costs of preventative check-ups for the uninsured

Another reason is the poor raising of awareness among citizens regarding the importance of healthy lifestyles, care for their own health and the importance of regular preventative check-ups. Although they can schedule preventative check-ups with their selected doctor at health centres, only a very small percentage of the “healthy” population utilise this service. Organised screenings have been conducted for certain diseases in recent years, but the level of response among these target groups at the national level is still unsatisfactorily low.
Prevention should be started as early as pregnancy (prenatal care), in order for our offspring to be born healthy. Preventative activities should be directed as a priority at the youngest age and maintained in continuity throughout their lives.

Preventative activities should also target the active working population, as that represents the target group that fails to control its health regularly. Some countries have even applied sanctions for those who don’t attend check-ups (e.g. by refusing to stamp healthcare booklets if they fail to have a check-up).
Another problem is that today’s assigned doctors have so many patients who are ill that they have little room for preventative work with members of the healthy population. On average, during one daily shift, every assigned doctor has around 35 patients who already have a diagnosis and expressed complications requiring treatment and three-to-four systematic or targeted check-ups.

When this ratio shifts to the benefit of preventative check-ups, we will then be able to say that we are on the right track – towards successful prevention.

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