Primary Care in Serbia

By Mirjana Zivkovic-Sulovic, MD

 

Researcher in Centre for Analysis, Planning and Organisation at Institute of Public Health of Serbia

In the former Yugoslavia, health care had reached a relatively high standard by the 1970s. But with the break-up of the country and the political conflicts, economic decline and sanctions in the '90s, health care deteriorated sharply. By the time democratic changes took hold in Serbia in 2000, the health service was in disarray. The government knew it had to restructure the health services to meet the needs of citizens in sometimes dramatically changed circumstances - to face the new realities.

In 2000, the prime challenge was the shortage of essential medicines, poor conditions of equipment, old technology, lack of continuous medical education, evidence based medicine, clinical guidelines and strategies for development.

With help of the EU, Canadian International Development Agency, World Bank, etc. the government made a legal framework for forward transformation of the health system.

One of the guiding principles of the reform is a priority that is given to prevention and to primary health care, which forms the basis of the health system and assumes the function of "gate keeper" to enter into the health system.

Health care in Serbia is mainly financed by mandatory contributions to a social health insurance scheme. The National Health Insurance Fund (HIF) is responsible for financing the system. We have a co-payment system (0,5 EUR) for health services and per prescribed box of basic medicine (a large group of patients / vulnerable groups, poor, tissue and organ donors, etc/  are free of participation), but for some services or medicine patients have to co-pay more (% of real cost) or full price (not-standard services). Another source of financing is private expenditures for health, mainly out-of-pocket payments for medicines and some services in private sector. We have the lowest appropriation for health care per capita in Europe (about 260 EUR).

Primary level of health care in the Republic of Serbia is provided in 157 state-owned primary health centres, which cover the territory of one or more municipalities or towns, with a developed network of outpatient facilities and offices.

PHC is based on the selected doctor, or "chosen doctor", and the team of chosen physicians, which consists of doctors of general medicine and occupational medicine specialist for the adult population, pediatrician for children of preschool and school age (including antenatal care, immunizations, preventive programs in the health care of children ), gynecologists for women over 15 years and dentists. In addition there are emergency services, diagnostic services, certain specialist-consultative out-patient health care services, community nursing services etc.

A primary (community) health centre, depending on the number of citizens in a municipality, as well as on their health needs, distance to the nearest general hospital, and/or existence of other health care facilities in the municipality, may also engage in some other specialist and consulting activity, as well as that of a maternity clinic and diagnostics hospital and treatment of acute and chronic diseases.
From about 20.000 doctors (public) in Serbia, 18% are working in PHC. Per doctor in PHC there are 1112 citizens. Total visits per doctor in PHC are 5876 (varies from service to service).

In the last decade the most changes were in PHC. We started with information systems and electronic medical billing services since 2009, new scope of services in PHC, new quality indicators, new payment schema for dentists (they have to earn money on market), all strategies and national programs are based on medical staff in PHC.

Preventive health care services had formed the cornerstone of PHC in former Yugoslavia. During the '90s the percentage of preventive services decrease to a minimal level. So, these days, all efforts are aimed at strengthening medical professionals to increase the proportion of prevention services into their daily activities.

Health workers have gone through the licensing system and for the third year they have obligations to collect scores for CME. A National committee had developed about thirty guidelines for preventive interventions and disease treatment and doctors in PHC  apply them daily in their work. At this moment we have a project to introduce electronic records in PHC and other HC facilities and this process should be completed by 2015. They are also ready for new financing, capitation, with incentives for preventive services.
Doctors from PHC are also very interested in health management and health quality training. After almost twenty years of domination of hospitals, PHC regains its role.

But much remains to be done. We have to research population health needs and to provide new services, to recognize stakeholders, make new partnerships with them, develop new services and new financial sources.  Also, doctors have to develop new skills and nurses have to get a more important role in PHC, especially in community work.

So, if we compare this with EU states, where is PHC in Serbia? Evaluation of PHC by WHO (2009), and some previous analysis can tell us that we are moving in the right way, but very slow.

References

1. "Health statistical year book of Republic of Serbia 2009". Institute of Public Health of Serbia "Dr Milan Jovanovic Batut", 2010.
2. Mirjana Zivkovic-Sulovic, Danka Gajic. "PHC in Republic of Serbia", Institute of Public Health of Serbia Dr Milan Jovanovic Batut, 2009.
3. Analysis of work and utilization of primary health care in the Republic of Serbia in 2009. Institute of Public Health of Serbia Dr Milan Jovanovic Batut, 2009.
4. Wienke G.W. Boerma, Martina Pellny, Dionne S. Kringos, "Evaluation of the organization and provision of primary care in Serbia", WHO, 2010.
5. "EU support to health care in Serbia.", EAR, 2007.