Serbia: health system review

Vol. 21 N o. 3 2019 Health System s in Transition: Serbia Print ISSN 1817-6119 Web ISSN 1817-6127 The Observatory is a partnership, hosted by WHO/Europe, which includes other international organizations (the European Commission, the World Bank); national and regional governments (Austria, Belgium, Finland, Ireland, Norway, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and the Veneto Region of Italy); other health system organizations (the French National Union of Health Insurance Funds (UNCAM), the Health Foundation); and academia (the London School of Economics and Political Science (LSE) and the London School of Hygiene & Tropical Medicine (LSHTM)). The Observatory has a secretariat in Brussels and it has hubs in London (at LSE and LSHTM) and at the Berlin University of Technology. HiTs are in-depth profiles of health systems and policies, produced using a standardized approach that allows comparison across countries. They provide facts, figures and analysis and highlight reform initiatives in progress. Vol. 21 No. 3 2019 Health Systems in Transition Serbia Health system review Vesna Bjegovic-Mikanovic Milena Vasic Dejana Vukovic Janko Jankovic Aleksandra Jovic-Vranes Milena Santric-Milicevic Zorica Terzic-Supic Cristina Hernández-Quevedo C M Y CM MY CY CMY K 61575 Serbia HiT_covers_3WEB.pdf 1 16/03/2020 13:29 The publications of the European Observatory on Health Systems and Policies are available at www.healthobservatory.eu Cristina Hernández-Quevedo (Editor) and Ewout van Ginneken (Series editor) were responsible for this HiT Editorial Board Series editors Reinhard Busse, Berlin University of Technology, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene & Tropical Medicine, United Kingdom Elias Mossialos, London School of Economics and Political Science, United Kingdom Ewout van Ginneken, European Observatory on Health Systems and Policies Series coordinator Anna Maresso, European Observatory on Health Systems and Policies Editorial team Jonathan Cylus, European Observatory on Health Systems and Policies Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Dimitra Panteli, Berlin University of Technology, Germany Wilm Quentin, Berlin University of Technology, Germany Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Anna Sagan, European Observatory on Health Systems and Policies Anne Spranger, Berlin University of Technology, Germany Juliane Winkelmann, Berlin University of Technology, Germany International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Harvard University, United States Armin Fidler, Management Center Innsbruck Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, National Institute for Health and Welfare, Finland William Hsiao, Harvard University, United States Allan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Soonman Kwon, Seoul National University, Republic of Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Nata Menabde, World Health Organization Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Federal Statutory Health Insurance Physicians Association, Germany Igor Sheiman, Higher School of Economics, Russian Federation Peter C. Smith, Imperial College, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland C M Y CM MY CY CMY K 61575 Serbia HiT_covers_3WEB.pdf 2 16/03/2020 13:29 Vesna Bjegovic-Mikanovic Centre School of Public Health, University of Belgrade Milena Vasic Institute of Public Health of Serbia “Dr Milan Jovanovic Batut” Dejana Vukovic Centre School of Public Health, University of Belgrade Janko Jankovic Centre School of Public Health, University of Belgrade The European Observatory on Health Systems and Policies supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory is a partnership, hosted by WHO/Europe, which includes other international organizations (the European Commission, the World Bank); national and regional governments (Austria, Belgium, Finland, Ireland, Norway, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and the Veneto Region of Italy); other health system organizations (the French National Union of Health Insurance Funds (UNCAM), the Health Foundation); and academia (the London School of Economics and Political Science (LSE) and the London School of Hygiene & Tropical Medicine (LSHTM)).The Observatory has a secretariat in Brussels and it has hubs in London (at LSE and LSHTM) and at the Berlin University of Technology. Aleksandra Jovic-Vranes Centre School of Public Health, University of Belgrade Milena Santric-Milicevic Centre School of Public Health, University of Belgrade Zorica Terzic-Supic Centre School of Public Health, University of Belgrade Cristina Hernández-Quevedo European Observatory on Health Systems and Policies, LSE Health Health Systems in Transition Serbia Health System Review 2019 KEYWORDS: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration SERBIA © World Health Organization 2019 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies). All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publication to: Publications, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/en/what-we-publish/ publication-request-forms). The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. 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 European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. 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 European Observatory on Health Systems and Policies 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. The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed and bound in the United Kingdom. Suggested citation: Bjegovic-Mikanovic V, Vasic M, Vukovic D, Jankovic J, Jovic-Vranes A, Santric-Milicevic M, Terzic-Supic Z, Hernández-Quevedo C. Serbia: Health system review. Health Systems in Transition, 2019; 21(3):i-211. Print ISSN 1817-6119 Vol. 21 No. 3 Web ISSN 1817-6127 Vol. 21 No. 3 CONTENTS Preface v Acknowledgements vii List of abbreviations ix List of tables, figures and boxes xi Abstract xv Executive summary xvii 1 Introduction 1 1.1 Geography and sociodemography 2 1.2 Economic context 4 1.3 Political context 6 1.4 Health status 7 2 Organization and governance 13 2.1 Historical background 14 2.2 Organization 16 2.3 Decentralization and centralization 26 2.4 Planning 29 2.5 Intersectorality 34 2.6 Health information systems 38 2.7 Regulation 42 2.8 Person-centred care 51 3 Financing 61 3.1 Health expenditure 62 3.2 Sources of revenue and financial flows 67 3.3 Overview of the statutory financing system 70 3.4 Out-of-pocket payments 78 3.5 Voluntary health insurance 82 3.6 Other financing 84 3.7 Payment mechanisms 86 iv Health Systems in Transition 4 Physical and human resources 93 4.1 Physical resources 94 4.2 Human resources 101 5 Provision of services 115 5.1 Public health 116 5.2 Patient pathways 125 5.3 Primary care 128 5.4 Specialised care/inpatient care 130 5.5 Urgent and emergency care 133 5.6. Pharmaceutical care 136 5.7 Rehabilitation/intermediate care 138 5.8 Long-term care 139 5.9 Services for informal carers 141 5.10 Palliative care 141 5.11 Mental health care 143 5.12 Dental care 144 5.13 Health care for specific populations 145 6 Principal health reforms 147 6.1 Analysis of recent reforms 148 6.2 Future developments 154 7 Assessment of the health system 157 7.1 Health system governance 158 7.2 Accessibility 161 7.3 Financial protection 163 7.4 Health care quality 165 7.5 Health system outcomes 167 7.6 Health system efficiency 172 8 Conclusions 177 9 Appendices 179 9.1 References 179 9.2 Principal legislation 201 9.3 Useful websites 205 9.4 HiT methodology and production process 206 9.5 The review process 208 9.6 About the authors 208 PREFACE The Health Systems in Transition (HiT) series consists of country-based reviews that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific coun- try. Each review is produced by country experts in collaboration with the Observatory’s staff. In order to facilitate comparisons between countries, reviews are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a report. HiTs seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used to: ƒ learn in detail about different approaches to the organization, financing and delivery of health services, and the role of the main actors in health systems; ƒ describe the institutional framework, process, content and imple- mentation of health care reform programmes; ƒ highlight challenges and areas that require more in-depth analysis; ƒ provide a tool for the dissemination of information on health sys- tems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries; and ƒ assist other researchers in more in-depth comparative health policy analysis. Compiling the reviews poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of differ- ent sources, including the World Health Organization (WHO) Regional Office for Europe’s European Health for All database, data from national vi Health Systems in Transition statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, data from the International Monetary Fund (IMF), the World Bank’s World Development Indicators and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate review. A standardized review has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages because it raises similar issues and questions. HiTs can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situations. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improve- ment of the HiT series are most welcome and can be sent to info@obs.euro. who.int. HiTs and HiT summaries are available on the Observatory’s website (http://www.healthobservatory.eu). ACKNOWLEDGEMENTS The HiT on Serbia was produced by the European Observatory on Health Systems and Policies. This edition was written by Vesna Bjegovic-Mikanovic (Centre School of Public Health, University of Belgrade), Milena Vasic (Institute of Public Health of Serbia “Dr Milan Jovanović Batut”), Dejana Vukovic, Janko Jankovic, Aleksandra Jovic-Vranes, Milena Santric-Milicevic and Zorica Terzic-Supic (Centre School of Public Health, University of Belgrade). It was edited by Cristina Hernández-Quevedo, working with the support of Ewout van Ginneken, Berlin Hub Coordinator of the European Observatory of Health Systems and Policies. Internal review of the report was provided by Bernd Rechel and Anna Maresso (European Observatory on Health Systems and Policies). The authors would like to thank Professor Dr Nebojsa Lalic and Professor Dr Tatjana Pekmezovic for their comments on a previous version of the report. The authors would also like to thank Marijan Ivanusa at the WHO Country Office in Serbia for his support and guidance. Thanks are also due to the Ministry of Health for providing comments on an earlier version of the report and for facilitating the latest data. Thanks are also extended to the WHO Regional Office for Europe for their European Health for All database from which data on health services were extracted; to the OECD for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries, and the European Commission for the Eurostat database. The HiT used data available on June 2019, unless otherwise indicated. The HiT reflects the organization of the health system and the data availability, unless otherwise indicated, as it was in June 2019. The Observatory is a partnership that includes the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Spain, Sweden, Switzerland and the United Kingdom; the Veneto Region of Italy; the French National Union of Health Insurance Funds (UNCAM); the World viii Health Systems in Transition Health Organization; the European Commission; the World Bank; the Health Foundation; the London School of Economics and Political Science (LSE); and the London School of Hygiene & Tropical Medicine (LSHTM). The partnership is hosted by the WHO Regional Office for Europe. The Observatory is composed of a Steering Committee, core management team, research policy group and staff. Its Secretariat is based in Brussels and has offices in London at LSE, LSHTM and the Technical University of Berlin. The Observatory team working on HiTs is led by Josep Figueras, Director; Elias Mossialos, Martin McKee, Reinhard Busse (Co-directors); Richard Saltman, Ewout van Ginneken and Suszy Lessof. The Country Monitoring Programme of the Observatory and the HiT series are coordinated by Anna Maresso. The production and copy-editing process of this HiT was coordinated by Jonathan North, with the support of Caroline White, Andrea Kay (copy-editing) and Steve Still (design and layout). LIST OF ABBREVIATIONS AIDS Acquired immunodeficiency syndrome ALIMS Medicines and Medical Devices Agency ALOS Average length of stay ATC Anatomical Therapeutic Chemical Groups AZUS Agency for Accreditation of Health Care Institutions BMI Body mass index CAQA Commission for Accreditation and Quality Assurance CDC Central Drug Committee CPR Cardiopulmonary resuscitation CT Computerized tomography DDD Defined daily dose DILS Delivery of Improved Local Services DRG Diagnosis-related group DTP Diphtheria, tetanus and pertussis EC European Commission ECDC European Centre for Disease Prevention and Control ECTS European Credit Transfer and Accumulation System EHR Electronic Health Record EAR European Agency for Reconstruction EIB European Investment Bank EMA European Medicines Agency ESSPROS European System of Integrated Social Protection Statistics EU European Union EUR Euro FFS Fee-for-service GDP Gross domestic product GP General practitioner HIV Human immunodeficiency virus x Health Systems in Transition HPV Human papillomavirus HTA Health technology assessment ICT Information communication technology IHIS Integrated health information system INN International nonproprietary name IPA Instruments for pre-accession IPH Institute of Public Health IT Information Technology MICS Multiple Indicator Cluster Survey MMR Measles, mumps and rubella MRI Magnetic resonance imaging  NCD Noncommunicable diseases NGO Nongovernmental organization NHIF National Health Insurance Fund OECD Organisation for Economic Co-operation and Development OOP Out-of-pocket PET Positron emission tomography PPP Purchasing power parity SCTM Standing Conference of Towns and Municipalities SDR Standardized death rate SEEHN South-eastern Europe Health Network SILC Survey on Income and Living Conditions SIPRU Social Inclusion and Poverty Reduction Unit SORS Statistical Office of the Republic of Serbia SSI State Sanitary Inspectorate TB Tuberculosis THE Total Health Expenditure UN United Nations UNICEF United Nations Children’s Fund USD US Dollars VAT Value Added Tax VHI Voluntary Health Insurance YLL Year of Life Lost WB World Bank WHO World Health Organization LIST OF TABLES, FIGURES AND BOXES Tables TABLE 1.1 Trends in population/demographic indicators, 1990–2018 (selected years) 4 TABLE 1.2 Macroeconomic indicators, 1995–2018 (selected years) 5 TABLE 1.3 Mortality and health indicators, 1995–2017 (selected years) 9 TABLE 1.4 Morbidity and factors affecting health status, 2000–2016 (selected years) 12 TABLE 2.1 Patient information 54 TABLE 2.2 Patient choice 54 TABLE 2.3 Patient rights 58 TABLE 3.1 Trends in health expenditure in Serbia, 1995–2017 (selected years) 63 TABLE 3.2 Health expenditure by service programme in Serbia, 2017 67 TABLE 3.3 Insured persons in Serbia, 31 December 2017 72 TABLE 3.4 Co-payment fees for health services in Serbia, 2019 74 TABLE 3.5 Share of certain types of health expenditures in total OOP payments, 2013 79 TABLE 3.6 Provider payment mechanisms in Serbia, 2019 89 TABLE 4.1 Diagnostic equipment in Serbia and the EU, per 100 000 population, 2017 99 TABLE 4.2 Health workers in the public sector per 100 000 population, 1991–2016 (selected years) 103 TABLE 5.1 The network and employees of the Network of Institutes of Public Health 118 xii Health Systems in Transition TABLE 5.2 Vaccination coverage for selected vaccines, 2007–2016 122 TABLE 6.1 Major health reforms in Serbia, 2000–2019 148 TABLE 7.1 Number of complaints filed in state health institutions in Serbia, 2016 159 TABLE 7.2 Self-reported unmet needs for medical examination due to expense (%), by labour status for Serbia and selected countries, 2017 164 Figures FIGURE 1.1 Map of Serbia 3 FIGURE 2.1 Overview of the health system in Serbia 17 FIGURE 3.1 Current health expenditure as a share (%) of GDP in the WHO European Region, 2016 64 FIGURE 3.2 Trends in health expenditure as a share (%) of GDP in Serbia and selected countries, 2000–2016 65 FIGURE 3.3 Current health expenditure in US$ PPP per capita in the WHO European Region, 2016 66 FIGURE 3.4 Percentage of total expenditure on health according to source of revenue, 2017 68 FIGURE 3.5 Financial flows 69 FIGURE 4.1 Curative care beds in hospitals per 100 000 population in Serbia and selected countries, 2000–2016 95 FIGURE 4.2 Practising nurses and physicians per 100 000 population, 2014 106 FIGURE 4.3 Number of physicians per 100 000 population in Serbia and selected countries, 1995–2016 107 FIGURE 4.4 Number of nurses per 100 000 population in Serbia and selected countries, 2000–2016 107 FIGURE 5.1 Organizational structure of the system of public health in Serbia 117 FIGURE 5.2 Patient pathway in Serbia 126 FIGURE 7.1 Population in Serbia who reported to have some long- term disease/health problem by wealth index quintile, 2013 170 xiiiSerbia Boxes BOX 3.1 Is health financing fair? 76 BOX 5.1 Are public health interventions making a difference? 125 BOX 5.2 Patient pathway for services covered by the National Health Insurance 127 BOX 5.3 What do patients think of the care they receive? 183

ABSTRACT This analysis of the Serbian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The health of the Serbian population has improved over the last decade. Life expectancy at birth increased slightly in recent years, but it remains, for example, around 5 years below the average across European Union countries. Some favourable trends have been observed in health status and morbidity rates, including a decrease in the incidence of tuberculosis, but population ageing means that chronic conditions and long-standing disability are increasing. The state exercises a strong governance role in Serbia’s social health insurance system. Recent efforts have increased centralization by transfer- ring ownership of buildings and equipment to the national level. The health insurance system provides coverage for almost the entire population (98%). Even though the system is comprehensive and universal, with free access to publicly provided health services, there are inequities in access to primary care and certain population groups (such as the most socially and economically disadvantaged, the uninsured, and the Roma) often experience problems in accessing care. The uneven distribution of health professionals across the country and shortages in some specialities also exacerbate accessibility problems. High out-of-pocket payments, amounting to over 40% of total expenditure on health, contribute to relatively high levels of self-reported unmet need for medical care. Health care provision is characterized by the role of the “chosen doctor” in primary health care centres, who acts as a gatekeeper in the system. Recent public health efforts have focused on improving access to preventive health services, in particular, for vulnerable groups. Health system reforms since 2012 have focused on improving infrastructure and technology, and on implementing an integrated health information system. However, the country lacks a transparent and comprehensive system for assessing the benefits of health care investments and determining how to pay for them.

EXECUTIVE SUMMARY Population health is generally improving but cancer incidence rates have increased Serbia is situated in south-east Europe with a population of slightly below 7 million people. A range of indicators shows that the health of the popula- tion has improved over the last few decades. In 2017 average life expectancy reached 73.6 years for males and 78.7 years for females. The overall aver- age (76.1 years in 2017), however, is lower than the average life expectancy found across European Union countries. Positive trends can be seen in the reduced incidence of tuberculosis as well as of HIV, and in infant and maternal mortality. However, cancer incidence rates are increasing, making it one of the main causes of death, along with ischaemic coronary diseases and cerebrovascular diseases. Tobacco consumption remains high, with 34.7% of the population being daily smokers in 2013, while the obesity rate among adults (21.1%) is slightly below the EU average (22.5%). After democratic changes in 2000, the health sector obtained urgently needed humanitarian aid from abroad (e.g. through the European Stability Pact); projects for infrastructure renewal; and financial and technical support for institutional and professional capacity-building to support the develop- ment of health services and to improve the health of the population. At the same time, economic reforms were started, involving the privatization of large companies, privatization and consolidation of banks, re-establishment of capital markets and infrastructure development. Accession negotiations with the European Union (EU) officially started in January 2014, but health projects and programmes have not yet been discussed. xviii Health Systems in Transition The state exercises a strong governance role in the social health insurance system The health system is based on compulsory health insurance, with contribu- tions as the main source of financing and broad population coverage. The state owns the majority of health facilities and equipment. The main pur- chaser of publicly funded health services is the National Health Insurance Fund (NHIF). The basic infrastructure and organization of the health system was inher- ited from the period when the country was part of the former Yugoslavia. Since 2000, general health reforms have attempted to rehabilitate and mod- ernize health facilities and equipment and to improve technology, supported by extensive international humanitarian aid. National legislation allows private health care providers to operate, but their services are covered pre- dominantly by private out-of-pocket payments. The health system’s administrative structure is characterized by central- ized state governance with an unregulated private sector, which has developed without much control or state support. Prior to 2019, the state had transferred ownership of primary care facilities and equipment to local government, along with responsibility for the management, capital investment, and development of specific health care plans and local public health programmes aligned to the needs of the local population. However, the recently approved Health Care Law (2019) envisions re-centralization by transferring ownership of buildings and equipment of primary care institutions to the national level. Both this Law and the 2019 Health Insurance Law reinforce the need for patients to have a “chosen doctor”, that is, a designated primary care doctor who provides them with health services and acts as a gatekeeper to higher levels of care. Broad population coverage is accompanied by high private spending on health Serbia spends a considerable amount of its resources on health care. In 2017, total health expenditure accounted for 8.8% of GDP. This translates to US$ 1 319 per capita (adjusted for differences in purchasing power). Public sources of health funding have steadily decreased over the last decade, reaching 57.6% xixSerbia of total expenditure on health in 2017. Consequently, private expenditure on health is a significant source of financing, amounting to 42.4% of total health expenditure in 2017. Out-of-pocket (OOP) payments by patients, in the form of co-payments and direct payments, make up the overwhelming majority of this private spending (around 96% of it) while voluntary health insurance (VHI) makes up less than 1% of total health spending. Compulsory health insurance contributions, from the nationally pooled health insurance fund, the NHIF, represent the largest share of total health revenue from public sources (94%). At present, the system of social health insurance financing is highly regressive, placing most of the financing burden on public employees and the smallest portion on the self-employed, who are often the wealthier segments of the population. Serbian citizens, as well as people with permanent or temporary resi- dence, have the right to access publicly financed health services. Almost the entire population (98%) is covered by health insurance. This includes the 20% of the population whose health insurance contributions are financed from the central state budget (2017 data). Mandatory health insurance includes the right to health care, the right to salary reimbursement during temporary work disability and the right to having health-related travel costs reimbursed. Payment of health services is determined by annually renewed contracts between the NHIF and health care providers. Financing is input-oriented, based on line-item budgets (for all health care providers except pharmacies, rehabilitation hospitals and public health institutes). Capitation payments were introduced in 2012 in primary health care institutions that provide services by a “chosen doctor” (e.g. General Practitioners (GPs), paediatri- cians, gynaecologists), while a new model of payment based predominantly on diagnosis-related groups (DRGs) was introduced for hospitals in 2019. Investment in health infrastructure is increasing A total of 355 facilities made up the country’s network of publicly provided health care institutions, organized at the primary, secondary and tertiary levels, in 2016. The number of acute beds in hospitals fell by around 16% between 1990 and 2016. In 2016, there were 462 acute beds per 100 000 population, the average length of stay in acute hospitals was 6.6 days, and the bed occupancy rate was 63.8%. While these figures indicate generally lower xx Health Systems in Transition efficiency in acute inpatient care, the introduction of a DRG payment system is expected to kick-start improvements in the performance of acute hospitals. As part of health care reforms in 2003, the technical condition and level of equipment in health care institutions were upgraded through the assistance of numerous international projects. Initiatives for e-health are promoted by the government, but are still at an early stage of development. The numbers of physicians and nurses per 100 000 inhabitants increased between 1991 (212 and 431, respectively) and 2016 (302 and 605, respec- tively); this increase is in line with other neighbouring countries such as Romania and Slovenia, but below the average for the EU (339 and 756, respectively). Serbia currently does not have an official health workforce strategy. The distribution of health professionals is unequal across the country and there is a shortage of some specialities. Current health workforce policies aim to maintain present staffing levels while trying to address these short- ages. Certificates issued to allow health professionals to work abroad give an indication of their intention of work abroad, but information on actual workforce migration trends is lacking. An extensive network of state-owned providers delivers the majority of care The Ministry of Health is the main body responsible for regulating and supervising health care and public health, in both the state and private sectors. Health services are provided through a wide network of health institutions. The most important for public health at the regional level are the Institutes of Public Health (IPHs), which are coordinated at the national level by the Institute of Public Health of Serbia “Dr Milan Jovanović Batut”. Health care is organized at three levels: primary, secondary and terti- ary. Services at the primary level are provided by a state-owned network of primary health care centres. Primary care is provided by a “chosen doctor” (who is either a medical doctor or a specialist in general medicine, in occu- pational medicine, in paediatrics, in gynaecology or a dentist). Patients are assigned to the primary care centre in the area where they live. Secondary care includes outpatient or inpatient care in hospitals. Tertiary care has the most specialized personnel and technological equipment and provides diag- nostic and curative services. All three levels are closely interconnected, and xxiSerbia patient pathways are well organized. Emergency care is organized within two functionally linked sub-systems: prehospital emergency medical care and inpatient emergency care. The Health Care Law (2019) also regulates pharmaceutical services together with the Health Insurance Law (2019) and the Law on Medicines and Medical Devices (2010). In 2016, domestic manufacturers held 38% of the pharmaceutical market share. The NHIF covers pharmaceuticals which are on the Positive List of Drugs. Long-term and palliative care is mainly provided by family members and private organizations. The Ministry of Health established a Commission for Palliative Care in 2004, resulting in the creation of the 2009 National Strategy for Palliative Care and an Action Plan for implementation. For mental health care there are five special psychiatric hospitals with 3 250 beds. A Law on the Protection of Persons with Mental Disabilities was passed 2013. Health system reform has been imbedded in wider public sector reforms Since 2000, significant progress has been made in the development of health policy. The aim of an ambitious reform programme, undertaken from 2004 to 2010, was to strengthen preventive services with the view to decreasing rates of preventable diseases and total health care costs. After 2012, reforms focused on improving infrastructure, technology and implementing an inte- grated health information system. Reforms also included the restructuring of hospitals to respond more effectively to patient needs and the development of a new basic package of health services aligned with existing resources. The reform of the payment system for primary care has focused on introducing capitation (starting with primary health care centres that provide services by a “chosen doctor”), while a model of DRGs has been introduced for payments in hospitals. However, implementation of some reforms is still pending, such as the establishment of municipal health councils as multidisciplinary bodies to support health, or the establishment of a realistic plan for human resources. xxii Health Systems in Transition Several challenges need to be met to improve health system performance Serbia’s health system is characterized by high debt, given the low income derived from social health insurance contributions (which are not enough to cover operational expenses) and insufficient funds from the state budget. This situation, as well as the high reliance on private expenditure (42.4% of total health spending), mainly derived from patient OOP payments, poses an important challenge for the financial sustainability of the health system. In addition, informal payments are used, with the health system perceived to be one of the public sectors most susceptible to corruption. Important anti-corruption measures (such as legislative amendments, strengthened inspection capacities, improvements in quality control and information sys- tems) included in the 2013–2018 National Anti-corruption Strategy, as well as the establishment of the Anti-corruption Agency in 2010, are initiatives designed to tackle this endemic problem. In terms of accessibility, Serbia has a comprehensive universal health system with free access to health care services at the primary level, but there are inequalities in the utilization of health services, with the most disadvantaged, uninsured and Roma people experiencing more problems in accessing care. Financial constraints are the main reason for unmet needs for medical care, which are more frequent among people with lower educational attainment and the poorest sector of the population. In addition, a survey on catastrophic OOP payments among the population found that 2.3% of respondents were affected, with higher prevalence rates in rural areas, larger households, the poorest households and for those who are chronically ill. Long waiting times also impede accessibility of health services. Although the National Health Survey (2013) shows that citizens are generally satis- fied with public and private health care services, nearly half of patients who underwent an intervention in 2013 had to go on a waiting list, and only one third of the listed patients received treatment. There is scope for improving health system performance in terms of technical and allocative efficiency. The present system of financing encour- ages inefficiency in the use of resources and provides few incentives for improved service volume and quality. The provider payment system for both primary and hospital care remains input-based, with few if any incentives for quality or efficiency, although it is being slowly changed to a capitation xxiiiSerbia system in primary care and a DRG model for hospital care. Health care has generally been underfunded for many years due to resource constraints, and publicly funded health services are generally of lower quality than in EU countries. Moreover, Serbia lacks a transparent and comprehensive system for assessing the benefit of health care investments and determining how to pay for them. For example, the use of Health Technology Assessment (HTA) is not systematically applied using criteria such as clinical efficacy and cost–effectiveness to aid decision-making on health technologies and health services reimbursement, although it is used in more systematic way for assessing medicines. Finally, although Serbia spends 8.8% of its GDP on health, this spend- ing is not fully translating into positive health outcomes. The highest burden of disease in Serbia is due to noncommunicable diseases (NCDs), namely cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, with standardized death rates from cardiovascular disease and cancer being among the highest in Europe. High mortality rates can partly be explained by lack of timeliness in visiting a doctor and subsequent diagnosis at a later stage of the disease when treatment is less successful and death is more likely, as well as, for example, lack of access to the newest drugs for all cancer patients in need, and longer waiting lists for radiotherapy. The coverage of target populations for cancer screening at national level is still very low, despite national programmes being in place. Tobacco and alcohol consumption rates have been increasing since 2006, as have obesity rates among adults, with these risk factors contributing to the population’s disease burden. There are no national strategies addressing alcohol or obesity but the government has made attempts to respond to the high smoking rates through a smoking ban in public and in workplaces as well as on public transport, although the ban currently excludes the hospitality sector (and thus does not apply in restaurants, bars, etc.). Higher cigarette prices were also imposed, along with health warnings on cigarette packs and a ban on advertising and sponsorship by the tobacco industry.

1 Introduction Summary ƒƒ Serbiaƒ isƒ situatedƒ atƒ theƒ crossroadsƒofƒ centralƒ andƒ south-eastƒ Europe,ƒwithƒaƒpopulationƒofƒnearlyƒ7ƒmillionƒpeople,ƒalthoughƒ theƒpopulationƒhasƒdecreasedƒsteadilyƒinƒtheƒlastƒdecade,ƒlargelyƒ dueƒto outmigration. ƒƒ ƒMacroeconomicƒ indicatorsƒ showƒaƒ stableƒ increaseƒ inƒGDPƒinƒ 2005–2018,ƒonlyƒchangingƒduringƒtheƒeconomicƒcrisis,ƒwhichƒ severelyƒaffectedƒtheƒfinancialƒstabilityƒofƒSerbia.ƒSerbiaƒstartedƒ economicƒreformsƒinƒ2000,ƒwhichƒincludedƒtheƒprivatizationƒofƒ large companies. ƒƒ ƒSerbiaƒisƒaƒparliamentaryƒdemocracy,ƒbasedƒonƒtheƒseparationƒofƒ executive,ƒlegislativeƒandƒjudicialƒpowers;ƒitƒisƒaƒcandidateƒcountryƒ forƒtheƒEU.ƒAfterƒdemocraticƒchangesƒinƒ2000,ƒtheƒhealthƒsectorƒ obtainedƒurgentlyƒneededƒhumanitarianƒaidƒ fromƒabroadƒandƒ differentƒprojectsƒwereƒfundedƒtoƒimproveƒinfrastructureƒasƒwellƒasƒ toƒdevelopƒhealthƒservicesƒandƒimproveƒtheƒhealthƒofƒthe population. ƒƒ ƒHealthƒstatusƒhasƒimproved,ƒwithƒaverageƒlifeƒexpectancyƒatƒbirthƒ increasingƒ sinceƒ 2000ƒ andƒ reachingƒ76.1ƒ yearsƒ inƒ 2017,ƒwithƒ ischaemicƒcoronaryƒdiseases,ƒcerebrovascularƒdiseasesƒandƒcancerƒ beingƒtheƒmainƒcausesƒof death. 2 Health Systems in Transition ƒƒ ƒRiskƒfactorsƒsuchƒasƒtobaccoƒconsumptionƒremainƒhighƒ(34.7%ƒinƒ 2013),ƒandƒ16%ƒofƒtheƒpopulationƒreportedƒbingeƒdrinkingƒinƒ2013,ƒ whileƒobesityƒisƒbelowƒtheƒEU average. ƒƒ ƒOtherƒpositiveƒtrendsƒcanƒbeƒseenƒinƒtheƒreductionƒofƒtheƒincidenceƒ ofƒtuberculosisƒasƒwellƒasƒofƒHIV,ƒandƒinƒ infantƒandƒmaternalƒ mortality,ƒalthoughƒcancerƒincidenceƒisƒincreasing.ƒ 1.1  Geography and sociodemography Serbiaƒisƒsituatedƒatƒtheƒcrossroadsƒofƒcentralƒandƒsouth-eastƒEurope.ƒItƒisƒ locatedƒinƒtheƒBalkans,ƒaƒregionƒofƒsouth-eastƒEuropeƒ(aboutƒ75%ƒofƒtheƒter- ritory)ƒandƒinƒtheƒPannonianƒPlain,ƒaƒregionƒofƒcentralƒEuropeƒ(aboutƒ25%ƒ ofƒtheƒterritory).ƒItƒbordersƒHungaryƒtoƒtheƒnorth,ƒRomaniaƒandƒBulgariaƒtoƒ theƒeast,ƒNorthƒMacedoniaƒtoƒtheƒsouth,ƒMontenegroƒtoƒtheƒsouthwest,ƒandƒ BosniaƒandƒCroatiaƒtoƒtheƒwest.ƒTheƒterritoryƒofƒKosovoƒ*ƒbordersƒAlbaniaƒinƒ theƒnorthwestƒ(Fig.ƒ1.1).ƒAfterƒtheƒbreak-upƒofƒtheƒSocialistƒFederalƒRepublicƒ ofƒYugoslaviaƒinƒ1991,ƒSerbiaƒandƒMontenegroƒremainedƒtogetherƒasƒtheƒ FederalƒRepublicƒofƒYugoslaviaƒ(FRY)ƒuntilƒ2003,ƒwhenƒtheyƒwereƒrenamedƒ asƒStateƒUnionƒofƒSerbiaƒandƒMontenegroƒuntilƒ2006.ƒOnƒ21 May 2006,ƒaƒ referendumƒinƒMontenegroƒledƒtoƒitsƒfinalƒseparationƒandƒSerbiaƒbecameƒanƒ independentƒstate.ƒ Serbiaƒcoversƒaƒtotalƒofƒ88 361ƒkm2,ƒincludingƒKosovo,ƒwithƒ10 908 km2.ƒ Serbiaƒisƒaƒlargelyƒmountainousƒcountryƒ(38.5%ƒofƒtheƒtotalƒarea);ƒtheƒmoun- tainousƒterrainƒcoversƒsouthernƒSerbia,ƒwhichƒisƒroughlyƒoneƒthirdƒofƒtheƒ country’sƒterritory.ƒTheƒPannonianƒPlainƒcoversƒoneƒquarterƒofƒtheƒSerbianƒ territory.ƒTheƒcentralƒpartƒofƒtheƒcountryƒisƒcalledƒSumadijaƒandƒitsƒterrainƒ consistsƒmainlyƒofƒhillsƒand rivers. Serbiaƒcoversƒfourƒstatisticalƒregions:ƒVojvodina,ƒBelgrade,ƒSumadijaƒandƒ westernƒSerbia,ƒandƒsouthernƒandƒeasternƒSerbia.ƒTheƒcapitalƒofƒSerbiaƒisƒ Belgrade,ƒwithƒ1 962ƒinhabitantsƒ(SORS,ƒ2016a).ƒTheƒpopulationƒofƒSerbia,ƒ accordingƒtoƒtheƒlatestƒcensusƒfromƒ2011,ƒwasƒ7 519,ƒwithƒ59.44%ƒlivingƒinƒ urbanƒcentresƒ(SORS,ƒ2011a).ƒInƒ2018,ƒtheƒpopulationƒwasƒestimatedƒatƒ6 084ƒ (seeƒTableƒ1.1).ƒInƒtheƒperiodƒbetweenƒtheƒlastƒtwoƒcensusesƒ(2002–2011),ƒ *ƒ AllƒreferencesƒtoƒKosovoƒinƒthisƒdocumentƒshouldƒbeƒunderstoodƒtoƒbeƒinƒtheƒcontextƒofƒtheƒ UnitedƒNationsƒSecurityƒCouncilƒResolutionƒ1244/99ƒ[http://www.un.org/docs/scres/1999/ sc99.htm]. 3Serbia theƒnumberƒofƒinhabitantsƒhasƒbeenƒdecreasingƒcontinuously,ƒandƒthisƒtrendƒ continuedƒafterƒtheƒ2011ƒcensus.ƒPopulationƒgrowthƒwasƒtheƒlowestƒinƒtheƒ southernƒandƒeasternƒregionsƒin Serbia. FIGURE 1.1 Map of Serbia ƒ Source: Based on UN, 2007 4 Health Systems in Transition Theƒnumberƒofƒasylum-seekersƒbetweenƒ2006ƒandƒ2015ƒdecreasedƒfromƒ 98 997ƒtoƒ35 332.ƒBetweenƒ2015ƒandƒ2016,ƒtheƒwesternƒBalkansƒexperiencedƒ aƒhugeƒmovementƒofƒmigrantsƒandƒrefugeesƒtowardsƒtheƒEU.ƒSerbia’sƒroleƒ hasƒmainlyƒbeenƒthatƒofƒaƒtransitƒcountryƒ(GovernmentƒofƒSerbia,ƒ2015). TABLE 1.1 Trends in population/demographic indicators, 1990–2018 (selected years) 1990 1995 2000 2005 2010 2015 2018 Total population 7 000 7 357 7 346 7 769 7 436 7 383 6 084 Population aged 0–14 (% of total) 23.8 22.1 20.5 18.6 17.3 16.7 16.3 Population aged 65 and above (% of total) 9.6 11.4 13.5 14.6 14.5 16.3 17.9 Population growth (annual %) 0.1 −1.4 −0.3 −0.3 −0.4 −0.5 −0.6 Population density (people per km2) 86.7 87.2 85.9 85.1 83.4 81.1 79.8 Fertility rate, total (births per woman) 1.80 (1991) 1.70 1.48 1.45 1.40 1.46 1.46 (2017) Urban population (% of total) 50.4 51.8 53.2 54.5 55.2 55.6 56.1 Source: World Bank, 2019a Inƒtheƒ2011ƒcensus,ƒ83.32%ƒofƒtheƒpopulationƒself-identifiedƒasƒethnicƒ Serbs.ƒTheƒdominantƒminorityƒgroupsƒwere:ƒHungariansƒ(3.53%),ƒRomaƒ (2.05%),ƒandƒBosniaksƒ(2.02%).ƒOtherƒminoritiesƒincludedƒCroats,ƒSlovaks,ƒ Montenegrins,ƒVlachs,ƒRomaniansƒandƒothersƒ(SORS,ƒ2011b). TheƒofficialƒlanguageƒofƒtheƒcountryƒisƒSerbian.ƒLanguagesƒofƒminorityƒ groupsƒ includeƒHungarian,ƒBosnian,ƒCroatian,ƒ Slovakian,ƒAlbanian,ƒ RomanianƒandƒBulgarian.ƒMembersƒofƒminorityƒgroupsƒcanƒfreelyƒuseƒtheirƒ language,ƒbothƒprivatelyƒandƒpublicly.ƒTheƒlanguageƒofƒeachƒminorityƒisƒinƒ officialƒuseƒinƒanyƒterritoryƒwhereƒtheƒethnicƒminorityƒreachesƒ15%ƒofƒtheƒ totalƒpopulationƒaccordingƒtoƒtheƒlastƒcensusƒ(SORS,ƒ2011b). 1.2  Economic context Serbiaƒisƒanƒupperƒmiddle-incomeƒeconomyƒ(WorldƒBank,ƒ2019b).ƒAfterƒ politicalƒchangesƒinƒ2001,ƒSerbiaƒstartedƒaƒperiodƒofƒtransitionƒtowardsƒaƒ marketƒeconomy.ƒEconomicƒreformsƒinvolvedƒprivatizationƒofƒlargeƒcompa- nies,ƒprivatizationƒandƒconsolidationƒofƒbanks,ƒre-establishmentƒofƒcapitalƒ 5Serbia marketsƒandƒinfrastructuralƒdevelopmentƒ(Arandarenkoƒ&ƒMijatović,ƒ2008).ƒ TheƒSerbianƒeconomyƒisƒbasedƒmainlyƒonƒservicesƒwhichƒaccountedƒforƒ 51%ƒofƒtheƒGDPƒinƒ2018.ƒIndustryƒcontributedƒtoƒ25.9%ƒofƒtheƒGDPƒandƒ agricultureƒtoƒ6.2%ƒofƒtheƒGDPƒ(WHO,ƒ2019). TheƒGrossƒDomesticƒProductƒ(GDP)ƒincreasedƒsteadilyƒinƒtheƒperiodƒ 2005–2018ƒ(seeƒTableƒ1.2),ƒexceptƒinƒ2009,ƒwhenƒitƒdroppedƒ3.12%ƒbecauseƒ ofƒtheƒnegativeƒeffectsƒofƒtheƒglobalƒeconomicƒcrisisƒ(ChamberƒofƒCommerceƒ andƒIndustryƒofƒSerbia,ƒ2017a).ƒTheƒglobalƒfinancialƒcrisisƒseverelyƒaffectedƒ Serbia.ƒItƒledƒtoƒaƒdeclineƒinƒtheƒavailabilityƒofƒforeignƒfunds,ƒwhichƒresultedƒinƒ aƒslowdownƒofƒeconomicƒgrowthƒwithƒcorrespondingƒnegativeƒconsequencesƒ forƒinvestment,ƒsecuringƒadditionalƒcapital,ƒloans,ƒemploymentƒandƒlivingƒ standardsƒ(Prascevic,ƒ2013). Inƒ2015,ƒtheƒfinancialƒsystemƒregainedƒstability,ƒmainlyƒdueƒtoƒaƒreduc- tionƒofƒtheƒdeficitƒinƒtheƒcurrentƒbalanceƒofƒpayments,ƒwhichƒatƒtheƒendƒofƒ 2015ƒwasƒ4.8%ƒofƒGDP.ƒHowever,ƒthereƒwasƒanƒincreaseƒinƒtheƒshareƒofƒ publicƒdebtƒ(fromƒ41.8%ƒofƒannualƒGDPƒinƒ2010ƒtoƒ72.9%ƒinƒ2016).ƒTheƒ latestƒdataƒshowƒthatƒtheƒlevelƒofƒpublicƒdebtƒisƒsignificantlyƒaboveƒtheƒlimitƒ definedƒbyƒtheƒ2009ƒLawƒonƒtheƒBudgetƒSystemƒ(seeƒsectionƒ6.1)ƒ(45%ƒofƒ GDP)ƒatƒ61.6%ƒofƒGDPƒinƒDecemberƒ2017ƒ(MinistryƒofƒFinance,ƒ2017). TABLE 1.2 Macroeconomic indicators, 1995–2018 (selected years) 1995 2000 2005 2010 2015 2018 GDP per capita (current US$) 2 196.6 870.1 3 720.5 5 735.4 5 585.1 7 234.0 GDP per capita, PPP (current international US$) 4 880.1 5 725.2 9 181.7 12 797.3 14 922.1 16 433.4 (2017) GDP average annual growth rate (%) 2.43 (1996) 7.8 5.5 0.7 1.8 4.3 Public expenditure (Government expenditure as % of GDP) 17.3 18.2 19.5 19.1 16.4 16.7 Public debt (% of GDP) a – 201.2 50.2 41.8 74.7 61.6 (2017) Unemployment, total (% of labour force) 13.4 12.6 20.9 19.2 17.7 12.7 Poverty rate b – – – – 26.7 c 24.3 c Income inequality (Gini coefficient) – 32.0 (2002) 36.5 29.0 28.5 – Note: a Ministry of Finance of Serbia, 2017; b The share of persons with an equivalized disposable income below the risk-of-poverty threshold, which is set at 60% of the national median equivalized disposable income (after social transfers); c Eurostat, 2019 Source: World Bank, 2019a 6 Health Systems in Transition TheƒGiniƒcoefficient,ƒasƒaƒmeasureƒofƒinequalityƒofƒincomeƒorƒwealth,ƒ decreasedƒslightlyƒfromƒ32ƒinƒ2002ƒtoƒ28.5ƒinƒ2015.ƒTheƒat-risk-of-povertyƒ rateƒwasƒ24.3%ƒinƒ2018ƒ(seeƒTableƒ1.2).ƒInƒ2013,ƒthoseƒmostƒexposedƒtoƒ povertyƒriskƒwereƒpersonsƒlessƒthanƒ18ƒyearsƒofƒageƒ(29.7%),ƒwhileƒpersonsƒ agedƒ65ƒandƒoverƒhadƒtheƒlowestƒat-risk-of-povertyƒrateƒ(19.4%).ƒUnemployedƒ personsƒandƒhouseholdsƒwithƒtwoƒadultsƒandƒthreeƒorƒmoreƒchildrenƒhadƒtheƒ highestƒat-risk-of-povertyƒrateƒ(48.4%ƒandƒ44.4%,ƒrespectively),ƒfollowedƒbyƒ self-employedƒpersonsƒ(38.3%)ƒ(SORS,ƒ2013). TheƒHumanƒDevelopmentƒIndexƒforƒSerbiaƒinƒ2018ƒwasƒ0.799ƒandƒtheƒ countryƒwasƒrankedƒ63ƒoutƒofƒ189ƒcountriesƒworldwideƒ(UNDP,ƒ2019).ƒ 1.3  Political context Serbiaƒisƒaƒparliamentaryƒdemocracy.ƒTheƒformƒofƒtheƒgovernmentƒisƒaƒ republic,ƒbasedƒonƒtheƒdivisionƒofƒpowersƒbetweenƒtheƒexecutive,ƒtheƒlegisla- tiveƒandƒtheƒjudicialƒpowers.ƒ TheƒPresidentƒofƒSerbiaƒisƒtheƒheadƒofƒstate.ƒTheƒpresidentƒrepresentsƒtheƒ Republicƒandƒisƒtheƒsupremeƒcommanderƒofƒitsƒarmedƒforces.ƒInƒpractice,ƒtheƒ president’sƒpositionƒisƒprimarilyƒceremonial,ƒwithƒlittleƒgoverningƒpower.ƒTheƒ presidentƒisƒelectedƒbasedƒonƒpopularƒvoteƒandƒcanƒbeƒelectedƒforƒaƒmaximumƒ ofƒtwoƒtermsƒofƒ5ƒyears each. Executiveƒpowerƒisƒexercisedƒbyƒtheƒcabinetƒofƒpresentlyƒ21ƒministers,ƒ whichƒisƒheadedƒbyƒtheƒprimeƒminister.ƒTheƒprimeƒministerƒisƒchosenƒonƒ theƒproposalƒofƒtheƒpresidentƒbyƒtheƒNationalƒAssembly.ƒTheƒgovernmentƒ establishesƒandƒpursuesƒpolicies,ƒexecutesƒlegislation,ƒadoptsƒregulations,ƒ proposesƒtoƒtheƒNationalƒAssemblyƒlegislation,ƒdirectsƒandƒadjustsƒtheƒworkƒ ofƒpublicƒadministrationƒbodiesƒandƒperformsƒsupervisionƒofƒtheirƒworkƒandƒ administersƒotherƒaffairsƒstipulatedƒbyƒtheƒConstitutionƒandƒLawƒ(Serbianƒ Constitution,ƒArticleƒ123). Legislativeƒpowerƒisƒvestedƒinƒtheƒparliament,ƒknownƒasƒtheƒNationalƒ Assembly,ƒwhichƒisƒcomposedƒofƒ250ƒproportionallyƒelectedƒdeputies.ƒTheƒ NationalƒAssemblyƒalsoƒwieldsƒconstitutionalƒauthority.ƒTheƒcurrentƒpar- liamentƒwasƒchosenƒinƒelectionsƒinƒ2016ƒandƒconsistsƒofƒ250ƒmembers,ƒoutƒ ofƒwhichƒ158ƒareƒmaleƒ(63.2%)ƒandƒ92ƒareƒfemaleƒ(36.8%).ƒThereƒareƒ16ƒ parliamentaryƒgroups;ƒtheƒlargestƒoneƒisƒtheƒSerbianƒProgressiveƒPartyƒwithƒ 40.8%ƒofƒall representatives. 7Serbia TheƒjudicialƒpowerƒisƒvestedƒinƒtheƒCourtsƒandƒisƒindependentƒfromƒ theƒlegislativeƒandƒexecutiveƒpowers.ƒTheƒCourtsƒhaveƒgeneralƒandƒspecialƒ jurisdictionƒandƒtheyƒareƒpublicƒauthorities,ƒindependentƒandƒautonomousƒ inƒtheir work. Serbiaƒwasƒrankedƒ87ƒofƒ180ƒcountriesƒbyƒTransparencyƒInternationalƒ inƒ2019,ƒwithƒaƒscoreƒofƒ39/100.ƒThisƒscoreƒrepresentsƒperceivedƒlevelƒofƒ publicƒsectorƒcorruptionƒonƒaƒscaleƒofƒ0ƒ(highlyƒcorrupted)ƒtoƒ100ƒ(veryƒclean)ƒ (TransparencyƒInternational,ƒ2019). Serbiaƒisƒaƒmemberƒofƒnumerousƒinternationalƒorganizationsƒsuchƒasƒ theƒCouncilƒofƒEurope,ƒtheƒOrganizationƒforƒSecurityƒandƒCo-operationƒ inƒ Europe,ƒ UNDP,ƒ UNICEF,ƒ theƒWorldƒ Bank,ƒ theƒWorldƒHealthƒ Organization,ƒandƒisƒaƒcandidateƒcountryƒforƒtheƒEUƒ(MinistryƒofƒForeignƒ Affairs,ƒ2018a).ƒTheƒformalƒstartƒofƒSerbia’sƒEUƒaccessionƒnegotiationsƒwasƒ onƒ21 January 2014,ƒbutƒChapterƒ28ƒonƒhealthƒhasƒstillƒnotƒbeenƒopenedƒ inƒtheƒnegotiationƒprocess.ƒTheƒGovernmentƒofƒSerbiaƒhasƒalsoƒratifiedƒaƒ rangeƒofƒinternationalƒandƒregionalƒhumanƒrightsƒtreaties,ƒrecognizingƒtheƒ rightƒtoƒhealthƒandƒotherƒhealth-relatedƒrightsƒ(MinistryƒofƒForeignƒAffairs,ƒ 2018a,ƒ2018b).ƒ 1.4  Health status  SimilarlyƒtoƒotherƒcountriesƒinƒcentralƒandƒeasternƒEurope,ƒSerbiaƒhasƒaƒ lowƒbirthƒrate,ƒaƒlowƒfertilityƒrate,ƒaƒlowƒrateƒofƒpopulationƒgrowthƒandƒanƒ increasingƒlifeƒexpectancy,ƒleadingƒtoƒtheƒageingƒofƒtheƒpopulation.ƒWhileƒ theƒcrudeƒbirthƒrateƒdecreasedƒfromƒ11.9ƒperƒ1 000ƒpopulationƒinƒ1991ƒtoƒ9.3ƒ inƒ2016,ƒtheƒtotalƒfertilityƒrateƒdecreasedƒfromƒ1.8ƒinƒ1991ƒtoƒ1.5ƒinƒ2015,ƒ farƒbelowƒtheƒreplacementƒlevelƒ(IPHƒBatut,ƒ2016a).ƒTheƒpercentageƒofƒtheƒ populationƒagedƒ65ƒandƒaboveƒincreasedƒfromƒ9.6%ƒinƒ1990ƒtoƒ17.6%ƒinƒ2016,ƒ whileƒtheƒpopulationƒagedƒlessƒthanƒ14ƒyearsƒoldƒdecreasedƒfromƒ23.8%ƒinƒ 1990ƒtoƒ16.6%ƒinƒ2016ƒ(WorldƒBank,ƒ2017).ƒ 1.4.1  Life expectancy Lifeƒexpectancyƒatƒbirthƒhasƒincreasedƒslightlyƒinƒrecentƒdecades,ƒfromƒ71.5ƒ yearsƒinƒ1991ƒtoƒ76.1ƒyearsƒinƒ2017,ƒremainingƒbelowƒtheƒEUƒaverageƒofƒ 81.ƒFemalesƒliveƒonƒaverageƒlongerƒ(78.7)ƒthanƒmalesƒ(73.6)ƒ(2017ƒdata).ƒ 8 Health Systems in Transition Atƒ5.1ƒyearsƒinƒ2017,ƒtheƒgenderƒgapƒforƒlifeƒexpectancyƒatƒbirthƒinƒSerbiaƒ hasƒremainedƒfairlyƒconstantƒ(seeƒTableƒ1.3).ƒLifeƒexpectancyƒisƒunequalƒ acrossƒregions.ƒComparingƒdistricts,ƒtheƒhighestƒlifeƒexpectancyƒisƒfoundƒinƒ Belgradeƒ(total:ƒ76.3,ƒmen:ƒ74.2,ƒwomen:ƒ79.0ƒyears),ƒandƒtheƒlowestƒinƒtheƒ SevernobanatskiƒdistrictƒinƒVojvodinaƒ(total:ƒ72.9,ƒmen:ƒ69.7,ƒwomen:ƒ76.3ƒ years)ƒ(IPHƒBatut,ƒ2017d). 1.4.2  Mortality Theƒmainƒcausesƒofƒdeathƒinƒ2015ƒwereƒcardiovascularƒdiseasesƒandƒcancers,ƒ accountingƒforƒalmostƒthreeƒquartersƒofƒallƒdeaths.ƒDiseasesƒofƒtheƒcirculatoryƒ systemƒareƒtheƒmostƒcommonƒcauseƒofƒdeath,ƒwithƒaƒstandardizedƒdeathƒrateƒ (SDR)ƒofƒ448.77ƒperƒ100 000ƒpopulationƒinƒ2015ƒandƒrepresentingƒ52.5%ƒ ofƒallƒcausesƒofƒdeathƒ(males:ƒ47.4%,ƒfemales:ƒ57.6%).ƒTheseƒareƒfollowedƒbyƒ cancersƒ(21.10%;ƒmales:ƒ24.24%,ƒfemales:ƒ17.90%),ƒandƒrespiratoryƒdiseaseƒ (5.36%;ƒmales:ƒ6.23%,ƒfemales:ƒ4.48%).ƒFurthermore,ƒ2.9%ƒofƒdeathsƒwereƒ aƒconsequenceƒofƒinjuryƒandƒpoisoning,ƒ2.9%ƒaƒconsequenceƒofƒdiabetesƒ complications,ƒwhileƒ2.6%ƒcanƒbeƒattributedƒtoƒobstructiveƒlungƒdiseaseƒ (IPHƒBatut,ƒ2016a).ƒAmongƒmales,ƒtheƒmostƒcommonƒtypeƒofƒcancerƒinƒ 2013ƒwasƒlungƒcancer,ƒaccountingƒforƒ20.2%ƒofƒallƒcancers,ƒfollowedƒbyƒ colorectalƒcancerƒ(12.8%)ƒandƒprostateƒcancerƒ(11.0%).ƒForƒfemales,ƒtheƒmostƒ commonƒtypeƒofƒcancerƒwasƒbreastƒcancer,ƒrepresentingƒ20.2%ƒofƒallƒcancers,ƒ followedƒbyƒcolorectalƒcancerƒ(9.0%)ƒandƒcervicalƒcancerƒ(6.9%)ƒ(IPHƒBatut,ƒ 2016a).ƒInƒ1996,ƒaƒpopulation-basedƒCancerƒRegistryƒinƒcentralƒSerbiaƒwasƒ re-established;ƒbeforeƒ1996,ƒtheƒepidemiologicalƒsituationƒofƒmalignantƒ tumoursƒwasƒmonitoredƒonlyƒonƒtheƒbasisƒofƒmortality data. SDRsƒforƒallƒagesƒperƒ100 000ƒinhabitantsƒforƒcirculatoryƒdiseasesƒ decreasedƒfromƒ657.3ƒinƒ2000ƒtoƒ444ƒinƒ2015,ƒwhichƒwasƒmoreƒthanƒtwoƒ timesƒhigherƒthanƒtheƒEUƒaverageƒofƒ189ƒinƒ2015.ƒIschaemicƒheartƒdiseasesƒ andƒcerebrovascularƒdiseasesƒareƒtheƒleadingƒcausesƒofƒdeathƒinƒthisƒgroupƒofƒ diseasesƒ(seeƒTableƒ1.3).ƒTheƒSDRƒfromƒmalignantƒneoplasmƒasƒtheƒsecondƒ causeƒofƒdeathƒhasƒincreasedƒandƒisƒhigherƒthanƒtheƒEUƒaverageƒ(198ƒversusƒ 160ƒinƒ2015).ƒTheƒcancerƒincidenceƒinƒSerbiaƒincreasedƒfromƒ292.33ƒperƒ 100 000ƒinhabitantsƒinƒ2000ƒtoƒ492.59ƒinƒ2013,ƒwhichƒwasƒonlyƒslightlyƒ lowerƒthanƒtheƒEUƒaverageƒofƒ556.04.ƒTheƒSDRƒforƒbreastƒcancerƒwasƒhigherƒ thanƒtheƒEUƒaverageƒinƒ2015,ƒwithƒ29.3ƒperƒ100 000ƒinhabitantsƒinƒSerbiaƒ 9Serbia comparedƒwithƒ21.5ƒperƒ100 000ƒinhabitantsƒinƒtheƒEU.ƒTheƒSDRƒfromƒ cervicalƒcancerƒwasƒalmostƒthreeƒtimesƒhigherƒthanƒtheƒEUƒaverageƒ(8.4ƒ perƒ100 000ƒinhabitantsƒinƒSerbiaƒversusƒ3.0ƒinƒtheƒEU).ƒDiabetesƒisƒoneƒ ofƒtheƒmostƒfrequentƒchronicƒnoncommunicableƒdiseases.ƒTheƒSDRƒfromƒ diabetesƒ(24.7ƒinƒ2015)ƒisƒalmostƒtwoƒtimesƒhigherƒthanƒinƒtheƒEU.ƒTheƒ SDRƒfromƒexternalƒcauses,ƒinjuryƒandƒpoisoningƒdecreasedƒfromƒ49.5ƒperƒ 100 000ƒinhabitantsƒinƒ2000ƒtoƒ33.4ƒinƒ2015,ƒwithƒtheƒSDRƒforƒsuicideƒandƒ self-inflictedƒinjuryƒdecreasingƒfromƒ17.9ƒinƒ2000ƒtoƒ11.8ƒinƒ2015,ƒwhichƒ wasƒaboveƒtheƒEUƒaverageƒofƒ9.6ƒ(WHO,ƒ2019).ƒ TABLE 1.3 Mortality and health indicators, 1995–2017 (selected years) LIFE EXPECTANCY (YEARS) 1995 2000 2005 2010 2015 2017 Life expectancy at birth, total 72.0 a 71.6 72.8 74.3 75.3 76.1 Life expectancy at birth, male 69.6 a 68.9 70.2 71.8 72.8 73.6 Life expectancy at birth, female 74.6 a 74.4 75.6 77.0 77.9 78.7 Life expectancy at 65 years, male – – 13.5 b 14.0 14.4 14.5 Life expectancy at 65 years, female – – 15.6 b 16.2 16.8 17.0 MORTALITY (PER 100 000 POPULATION) All-cause mortality c – 946 909 948 896 – Ischaemic coronary disease c – 126.9 139.2 108.6 81.0 – Cerebrovascular disease c – 183.3 166.5 136.4 100.4 – Malignant neoplasms c – 189.1 199.4 206.8 198.0 – Suicide c – 17.9 16.2 13.2 11.8 – External causes (unintentional accidents) c – 49.5 44.2 38.3 33.4 – Pneumonia c – 10.44 6.72 5.74 11.63 – Infant mortality rate (per 1000 live births) 17.80 10.64 8.02 6.73 5.30 5 Maternal mortality rate (per 100 000 live births) 12.98 9.49 13.85 17.57 12.00 – Note: a 1997 data; b 2006 data; c WHO, 2019 Source: World Bank, 2019a 10 Health Systems in Transition Regardingƒmaternalƒmortality,ƒSerbiaƒhasƒexperiencedƒaƒdecreaseƒsinceƒ 2010,ƒfromƒ17.57ƒinƒ2010ƒtoƒ12.0ƒdeathsƒperƒ100 000ƒliveƒbirthsƒinƒ2015ƒ(seeƒ Tableƒ1.3).ƒMortalityƒfromƒperinatalƒdeathsƒperƒ1 000ƒbirthsƒdecreasedƒfromƒ 15.44ƒinƒ1995ƒtoƒ6.2ƒinƒ2015.ƒNeonatalƒdeathsƒperƒ1 000ƒliveƒbirthsƒdecreasedƒ fromƒ7.69ƒinƒ2000ƒtoƒ3.7ƒinƒ2017ƒandƒpost-neonatalƒdeathsƒperƒ1 000ƒliveƒ birthsƒdecreasedƒfromƒ2.96ƒinƒ2000ƒtoƒ1.5ƒinƒ2015.ƒTheƒinfantƒmortalityƒ rateƒalsoƒdeclined,ƒfromƒ17.8ƒinƒ1995ƒtoƒ5ƒinƒ2017ƒ(seeƒTableƒ1.3),ƒalthoughƒ itƒwasƒstillƒhighƒinƒcomparisonƒtoƒtheƒEUƒ(3.5)ƒ(WHO,ƒ2019).ƒTheƒunder-5ƒ mortalityƒrateƒdeclinedƒalmostƒthreeƒtimes,ƒfromƒ19.7ƒperƒ1 000ƒliveƒbirthsƒ inƒ1995ƒtoƒ5.7ƒinƒ2017ƒ(WorldƒBank,ƒ2019a). 1.4.3 Morbidity Theƒincidenceƒofƒtuberculosisƒ(TB)ƒdecreasedƒfromƒ43.1ƒinƒ2005ƒtoƒ21.0ƒ inƒ2016ƒ(seeƒTableƒ1.4).ƒSerbiaƒhasƒsuccessfullyƒimplementedƒtheƒDirectlyƒ ObservedƒTreatmentƒ(DOT)ƒstrategyƒsupportedƒbyƒWHO,ƒalmostƒhalvingƒ theƒincidenceƒrateƒ(WHO,ƒ2018a). TheƒimmunizationƒcoverageƒisƒcompulsoryƒagainstƒTB,ƒdiphtheria,ƒ tetanus,ƒpertussisƒandƒpolioƒimmunization,ƒhepatitisƒB,ƒmeasles,ƒmumps,ƒ rubella,ƒHaemophilusƒinfluenzaƒtypeƒbƒandƒpneumococcusƒ(IPHƒBatut,ƒ 2017a).ƒTheƒtargetƒcoverageƒrateƒisƒ95%,ƒbutƒisƒnotƒachievedƒforƒsomeƒdiseases.ƒ Theƒincidenceƒofƒmeaslesƒdroppedƒfromƒ12.18ƒperƒ100 000ƒinhabitantsƒinƒ 1998ƒtoƒ0ƒinƒ2012,ƒbutƒincreasedƒsinceƒthen,ƒreachingƒ5.37ƒperƒ100 000ƒ inhabitantsƒinƒ2015,ƒdueƒtoƒtheƒrefusalƒofƒparentsƒtoƒvaccinateƒtheirƒchildren.ƒ Theƒincidenceƒofƒpertussisƒremainedƒlowƒthroughoutƒthisƒperiod,ƒatƒ1.25ƒperƒ 100 000ƒinhabitantsƒinƒ2015ƒ(WHO,ƒ2019). 1.4.4 Maternal and child health InƒSerbia,ƒabortionƒisƒlegalƒandƒpermitted;ƒitƒisƒregulatedƒbyƒtheƒLawƒonƒ AbortionƒinƒHealthƒCareƒInstitutions.ƒTheƒrateƒofƒabortionsƒperƒ1000ƒliveƒ birthsƒdecreasedƒfromƒ573.75ƒinƒ2000ƒtoƒ257.0ƒinƒ2015,ƒwhichƒisƒsimilarƒtoƒ theƒEUƒaverageƒofƒ203.0ƒinƒ2015ƒ(WHO,ƒ2019). 11Serbia 1.4.5 Lifestyle factors TOBACCO Theƒpercentageƒofƒdailyƒsmokersƒdecreasedƒfromƒ33%ƒinƒ2000ƒtoƒ29.2%ƒinƒ 2013,ƒbutƒthisƒisƒstillƒanƒincreaseƒfromƒ26.2%ƒinƒ2006.ƒTheƒpercentageƒofƒ smokersƒ(dailyƒorƒoccasional)ƒremainsƒhigh,ƒatƒ34.7%ƒinƒ2013.ƒSmokingƒisƒ moreƒfrequentƒamongƒmenƒ(37.9%)ƒthanƒwomenƒ(31.6%)ƒ(IPHƒBatut,ƒ2016b).ƒ Onlyƒ35.2%ƒofƒsmokersƒreceivedƒadviceƒfromƒtheirƒGPƒtoƒquitƒsmokingƒinƒ 2013ƒ(IPHƒBatut,ƒ2014b).ƒMoreƒthanƒ50%ƒofƒtheƒpopulationƒagedƒoverƒ15ƒ reportedƒexposureƒtoƒtobaccoƒsmoke,ƒandƒalmostƒhalfƒofƒtheƒnon-smokingƒ populationƒ(47.1%)ƒreportedƒconcernƒforƒtheirƒhealthƒasƒaƒconsequenceƒofƒ exposureƒtoƒtobaccoƒinƒ2013ƒ(IPHƒBatut,ƒ2016b). ALCOHOL Drinkingƒalcoholicƒbeveragesƒisƒsociallyƒaccepted,ƒwithƒpureƒalcoholƒcon- sumptionƒperƒcapitaƒincreasingƒoverƒtime,ƒfromƒ7.4ƒinƒ2000ƒtoƒ9.1ƒlitresƒinƒ 2014ƒ(seeƒTableƒ1.4).ƒInƒ2013,ƒ53.9%ƒofƒtheƒpopulationƒinƒSerbiaƒdrankƒalcoholƒ (occasionallyƒorƒdaily).ƒTheƒlargestƒpercentageƒofƒthoseƒwhoƒconsumedƒalcoholƒ wereƒagedƒ25–34ƒyearsƒ(66%);ƒdailyƒconsumptionƒofƒalcoholƒwasƒreportedƒbyƒ 4.7%ƒofƒtheƒpopulationƒinƒ2013,ƒhigherƒthanƒinƒ2006ƒ(3.4%),ƒwithƒtheƒhighestƒ prevalenceƒamongƒtheƒpoorestƒsectorƒofƒtheƒpopulation.ƒInƒ2013,ƒmenƒdrankƒ sixƒtimesƒmoreƒfrequentlyƒthanƒwomenƒonƒaƒdailyƒbasis.ƒBingeƒdrinking,ƒatƒ leastƒonceƒaƒmonth,ƒwasƒpresentƒbothƒamongƒtheƒgeneralƒpopulationƒ(16%)ƒ andƒamongƒadolescentsƒ(IPHƒBatut,ƒ2014b). OBESITY Theƒprevalenceƒofƒobesityƒhasƒincreasedƒconsistentlyƒinƒtheƒlastƒdecade,ƒ fromƒ15.5ƒinƒ2000ƒtoƒ21.1%ƒinƒ2015,ƒstillƒbelowƒtheƒaverageƒforƒtheƒWHOƒ EuropeanƒRegionƒ(22.9%)ƒandƒtheƒEUƒaverageƒ(22.5%).ƒAƒconsiderablyƒ higherƒpercentageƒofƒoverweightƒpersonsƒhasƒbeenƒrecordedƒamongƒtheƒ poorestƒsectorƒofƒtheƒpopulation,ƒtheƒleastƒeducatedƒpopulationƒandƒthoseƒwhoƒ 12 Health Systems in Transition liveƒinƒnon-urbanƒsettlements.ƒInƒ2013,ƒobesityƒratesƒwereƒhigherƒinƒwomenƒ (22.2%)ƒthanƒinƒmenƒ(20.1%),ƒwhileƒtheƒoppositeƒappliedƒtoƒbeingƒoverweightƒ (41.4%ƒinƒmenƒversusƒ29.1%ƒinƒwomen)ƒ(MinistryƒofƒHealth,ƒ2014). TABLE 1.4 Morbidity and factors affecting health status, 2000–2016 (selected years) SELECTED INDICATORS 2000 2005 2010 2014 2015 2016 Incidence of tuberculosis per 100 000 inhabitants – 43.1 32.0 25.5 23.0 21.0 Incidence of HIV per 100 000 inhabitants 0.9 1.4 2.0 1.8 3.0 2.0 Incidence of cancer per 100 000 inhabitants 294.3 327.5 515.0 495.0 – – Incidence of female breast cancer per 100 000 inhabitants 70.3 68.5 1210 101.0 – – Incidence of cervix uteri cancer per 100 000 inhabitants 25.9 24.8 36.1 30.7 – – Pure alcohol consumption, litres per capita, age 15+ 7.4 9.6 9.6 9.1 – – Age-standardized prevalence of obesity (BMI≥ 30kg/m2) in people aged 18 years and over 15.5 17.3 19.2 20.7 21.1 – Source: WHO, 2019 2 Organization and governance Summary ƒƒ ƒTheƒlatestƒdevelopmentsƒofƒtheƒhealthƒsystemƒareƒcloselyƒlinkedƒtoƒ theƒbreak-upƒofƒYugoslaviaƒinƒ1991ƒandƒpoliticalƒchangesƒinƒ2000,ƒ afterƒwhichƒSerbiaƒwasƒsupportedƒbyƒexternal agencies. ƒƒ ƒWhileƒtheƒMinistryƒofƒHealthƒandƒrelatedƒagenciesƒareƒinƒchargeƒofƒ theƒadministrativeƒandƒregulatoryƒfunctionsƒofƒtheƒhealthƒsystem,ƒ thereƒareƒsomeƒfunctionsƒdevolvedƒtoƒtheƒlocalƒlevelƒ(e.g.ƒcitiesƒandƒ municipalities). ƒƒ ƒTheƒ2005ƒHealthƒCareƒLawƒandƒtheƒ2007ƒLawƒonƒLocalƒSelf- Governanceƒincreasedƒtheƒresponsibilityƒofƒlocalƒgovernmentsƒinƒ decision-makingƒandƒgovernanceƒinƒprimaryƒcare.ƒHowever,ƒtheƒ latestƒ2019ƒHealthƒCareƒLawƒaimsƒtoƒrecentralizeƒtheƒownershipƒ ofƒbuildingsƒand equipment. ƒƒ ƒTheƒ2019ƒHealthƒCareƒLawƒandƒ2019ƒHealthƒInsuranceƒLawƒfosterƒ theƒconceptƒofƒtheƒ“chosenƒdoctor”,ƒwhichƒwasƒestablishedƒbyƒtheƒ 2005ƒHealthƒCareƒLawƒtoƒpromoteƒaƒcultureƒofƒcontinuousƒqualityƒ improvementƒatƒallƒlevelsƒofƒhealth care. ƒƒ ƒTheƒNationalƒHealthƒInsuranceƒFund,ƒasƒwellƒasƒtheƒNationalƒ InstituteƒofƒPublicƒHealthƒ“DrƒMilanƒJovanovićƒBatut”ƒandƒtheƒ regionalƒInstitutesƒofƒPublicƒHealthƒareƒ involvedƒinƒtheƒannualƒ planningƒof activities. 14 Health Systems in Transition ƒƒ ƒTheƒmostƒ relevantƒdocumentƒ leadingƒtheƒdevelopmentƒofƒ theƒ healthƒsystemƒisƒtheƒ2010ƒHealthƒCareƒDevelopmentƒPlan,ƒwhichƒ includesƒpriorityƒareasƒforƒtheƒprotectionƒandƒimprovementƒofƒtheƒ healthƒstatusƒofƒtheƒpopulation,ƒwhileƒtheƒbasicƒregulationƒhasƒbeenƒ recentlyƒupdatedƒwithƒtheƒ2019ƒHealthƒCare Law. ƒƒ ƒTheƒhealthƒsystemƒisƒimprovingƒinformationƒforƒpatientsƒonƒtheirƒ rightsƒandƒtheirƒrolesƒinƒdecision-makingƒprocesses.ƒPatientƒchoiceƒ isƒlinkedƒtoƒtheƒconceptƒofƒtheƒ“chosenƒdoctor”ƒinƒprimaryƒcare,ƒ whoƒactsƒasƒaƒgatekeeperƒtoƒotherƒlevelsƒof care. 2.1  Historical background RecentƒdevelopmentsƒinƒtheƒSerbianƒhealthƒsystemƒhaveƒbeenƒinfluencedƒbyƒ theƒbreak-upƒofƒYugoslaviaƒinƒ1991ƒ(seeƒsectionƒ1.2).ƒSerbiaƒandƒMontenegroƒ (FRƒYugoslavia)ƒwereƒkeptƒunderƒUnitedƒNationsƒsocialƒandƒeconomicƒsanc- tionsƒbasedƒonƒtheƒResolutionƒofƒUNƒSecurityƒCounselƒNo.ƒ757.ƒHugeƒeffortsƒ wereƒnecessaryƒtoƒpreserveƒtheƒnetworkƒandƒcapacitiesƒofƒhealthƒinstitutionsƒ andƒtheƒachievedƒlevelƒofƒhealth care. Inƒsuchƒcircumstances,ƒthereƒwereƒnoƒopportunitiesƒtoƒmakeƒradicalƒ changesƒinƒtheƒhealthƒsystem.ƒDuringƒthisƒperiod,ƒasƒaƒresultƒofƒwar,ƒsanctions,ƒ theƒeconomicƒcrisisƒwithƒhyperinflation,ƒandƒtheƒinternationalƒisolationƒofƒtheƒ country,ƒtheƒstructureƒandƒresourcesƒofƒtheƒhealthƒsystemƒwereƒalmostƒcom- pletelyƒdevastatedƒwithƒdrasticƒconsequencesƒforƒtheƒhealthƒandƒtheƒqualityƒ ofƒlifeƒofƒcitizensƒ(Bukelic,ƒ1994).ƒInƒthisƒpolitical,ƒsocialƒandƒeconomicƒ climate,ƒtheƒLawƒonƒHealthƒCareƒwasƒadoptedƒinƒ1992.ƒThisƒLawƒintroducedƒ aƒhighlyƒcentralizedƒsystemƒofƒfinancingƒandƒmanagementƒinƒtheƒhealthƒ system,ƒwithƒfoundingƒrightsƒoverƒallƒhealthƒinstitutionsƒinƒSerbiaƒentrustedƒ toƒtheƒrepublic level. WithƒtheƒpoliticalƒchangesƒinƒOctoberƒ2000ƒ(thatƒis,ƒtheƒreplacementƒofƒ Milosevic’sƒregimeƒandƒtheƒnewƒdemocraticƒgovernmentƒcomingƒintoƒpower),ƒ conditionsƒandƒopportunitiesƒforƒaƒfundamentalƒre-examinationƒandƒreformƒ ofƒhealthƒpolicyƒwereƒdeveloped.ƒInƒthatƒperiod,ƒSerbiaƒwasƒsupportedƒbyƒ extensiveƒinternationalƒhumanitarianƒaid,ƒdonationsƒinƒtheƒformƒofƒtechni- calƒassistanceƒforƒtheƒrehabilitationƒandƒmodernizationƒofƒhealthƒfacilitiesƒ andƒequipmentƒandƒcapacity-buildingƒinƒallƒsectorsƒofƒtheƒhealthƒsystem.ƒ 15Serbia Inƒaddition,ƒloansƒ(mainlyƒfromƒtheƒEUƒthroughƒtheƒEuropeanƒInvestmentƒ Bankƒ(EIB),ƒbutƒalsoƒfromƒtheƒWorldƒBank)ƒandƒdonationsƒforƒtheƒrecoveryƒ ofƒtheƒhealthƒsystemƒ(alsoƒprovidedƒbyƒtheƒEUƒthroughƒtheƒEuropeanƒAgencyƒ forƒReconstructionƒ(EAR))ƒbecame available. Theƒreformsƒundertakenƒinƒthisƒperiodƒaimedƒtoƒincreaseƒtheƒacces- sibilityƒofƒhealthƒservices,ƒimproveƒequityƒinƒtheƒuseƒofƒresources,ƒenhanceƒ theƒqualityƒofƒhealthƒservices,ƒandƒincreaseƒtheƒefficiencyƒofƒtheƒsystem.ƒ Theƒreformƒprocessƒalsoƒaimedƒtoƒstrengthenƒprimaryƒcareƒandƒpreventiveƒ measuresƒversusƒcurativeƒservices,ƒinƒorderƒtoƒdecreaseƒtheƒrateƒofƒpreventableƒ diseasesƒandƒreduceƒhealthƒexpenditure.ƒReformsƒalsoƒaimedƒtoƒreconfigureƒ hospitalsƒtoƒmoreƒeffectivelyƒrespondƒtoƒtheƒneedsƒofƒpatientsƒandƒtoƒdevelopƒ aƒnewƒbasicƒpackageƒofƒhealthƒservicesƒinƒbalanceƒwithƒavailableƒresources.ƒ Capitationƒwasƒchosenƒasƒanƒoptionƒforƒprimaryƒcareƒandƒintroducedƒinƒ 2013,ƒandƒtheƒmodelƒofƒdiagnosis-relatedƒgroupsƒ(DRGs)ƒforƒpaymentsƒinƒ secondaryƒcareƒwasƒintroducedƒinƒ2019,ƒafterƒseveralƒyearsƒofƒpiloting.ƒOneƒ ofƒtheƒimportantƒgoalsƒwasƒalsoƒtheƒintegrationƒandƒbetterƒoversightƒoverƒtheƒ provisionƒofƒprivateƒhealth services. Atƒtheƒsameƒtime,ƒtheƒgovernmentƒbeganƒtheƒprocessƒofƒadoptingƒmajorƒ healthƒandƒmultisectoralƒdocuments.ƒTheƒpolicyƒdocumentƒHealthƒCareƒ PolicyƒofƒSerbiaƒwasƒadoptedƒinƒ2002,ƒfollowedƒbyƒtheƒStrategyƒforƒtheƒ ReformƒofƒtheƒHealthƒCareƒSystemƒ(withƒtheƒActionƒPlanƒinƒ2003ƒasƒaƒdraft)ƒ andƒseveralƒotherƒstrategicƒdocuments.ƒAlso,ƒconsolidationƒinƒtheƒsystemƒofƒ compulsoryƒhealthƒinsuranceƒandƒtheƒworkƒofƒtheƒNHIFƒwasƒachieved,ƒandƒ costsƒwereƒreducedƒbyƒpassingƒaƒseriesƒofƒregulatoryƒmechanismsƒforƒphar- maceuticalsƒandƒmedicalƒdevices.ƒInƒthisƒway,ƒtheƒpreconditionsƒwereƒcreatedƒ forƒaƒcomprehensiveƒchangeƒinƒhealthƒpolicyƒandƒtheƒreformƒofƒtheƒhealthƒ systemƒthroughƒtheƒadoptionƒofƒtheƒso-calledƒsystemƒofƒlawsƒ(HealthƒCareƒ Law,ƒHealthƒInsuranceƒLaw,ƒandƒLawƒonƒChamberƒofƒMedicalƒWorkers). Significantƒassistanceƒinƒcarryingƒoutƒreformsƒwasƒprovidedƒbyƒtheƒ internationalƒcommunity,ƒinƒparticularƒtheƒWorldƒBankƒandƒtheƒEuropeanƒ Unionƒthroughƒtheirƒagencies,ƒbutƒalsoƒbyƒaƒnumberƒofƒcountriesƒinƒtheƒ formƒofƒbilateralƒcooperation.ƒAsƒanƒexample,ƒtheƒWorldƒBankƒhadƒseveralƒ generationsƒofƒtheƒHealthƒProjectƒ(Serbia).ƒTheƒobjectiveƒofƒtheƒAdditionalƒ FinancingƒforƒtheƒHealthƒProjectƒforƒtheƒRepublicƒofƒSerbiaƒwasƒtoƒbuildƒ capacityƒtoƒdevelopƒaƒsustainable,ƒperformance-orientedƒhealthƒsystem,ƒ whereƒprovidersƒareƒrewardedƒforƒqualityƒandƒefficiencyƒandƒhealthƒinsur- anceƒcoverageƒensuresƒaccessƒtoƒaffordableƒandƒeffectiveƒcareƒ(WorldƒBank,ƒ 2003,ƒ2014,ƒ2015a). 16 Health Systems in Transition Duringƒthisƒperiod,ƒtheƒassistanceƒofƒtheƒinternationalƒcommunityƒtookƒ placeƒinƒseveralƒstages:ƒtheƒfirstƒwasƒrelatedƒtoƒemergencyƒhumanitarianƒaid,ƒ andƒmeasuresƒtoƒimproveƒsanitationƒandƒavailabilityƒofƒmedicines,ƒfollowedƒ byƒprojectsƒandƒprogrammesƒaimedƒatƒrestoringƒhealthƒsystemƒinfrastructure,ƒ withƒtheƒreconstructionƒofƒbuildingsƒandƒtheƒpurchaseƒofƒnewƒequipment,ƒ andƒfinallyƒsupportƒforƒinstitutionalƒreformsƒtoƒstrengthenƒtheƒcapacityƒofƒ theƒhealthƒsystemƒtoƒrespondƒeffectivelyƒtoƒtheƒneedsƒof users. 2.2  Organization Theƒhealthƒsystemƒisƒorganizedƒandƒmanagedƒbyƒthreeƒinstitutions:ƒtheƒ MinistryƒofƒHealth,ƒtheƒNationalƒHealthƒInsuranceƒFund,ƒandƒtheƒInstituteƒ forƒPublicƒHealthƒ“DrƒMilanƒJovanovićƒBatut”.ƒTheƒorganizationalƒstructureƒ ofƒtheƒhealthƒsystem,ƒbasedƒonƒcurrentƒlegislationƒ–ƒtheƒ2019ƒHealthƒCareƒ Lawƒ(OfficialƒGazette,ƒ2019a),ƒtheƒ2017ƒDecreeƒonƒtheƒPlanƒofƒtheƒHealthƒ Institutions’ƒNetworkƒ(OfficialƒGazetteƒRS,ƒ114/2017),ƒtheƒ2019ƒStatuteƒofƒ theƒNationalƒHealthƒInsuranceƒFundƒ(OfficialƒGazetteƒ25/2019)ƒandƒtheƒ 2017ƒLawƒonƒHigherƒEducationƒ(OfficialƒGazette,ƒ2017a)ƒ–ƒisƒillustratedƒ inƒFig.ƒ2.1. 2.2.1 Statutory systems framework Administrativeƒandƒregulatoryƒfunctionsƒofƒtheƒhealthƒsystemƒareƒtheƒrespon- sibilityƒofƒministriesƒandƒstateƒagencies.ƒInƒaddition,ƒsomeƒrelevantƒhealthƒ careƒfunctionsƒareƒentrustedƒtoƒlowerƒgovernmentƒlevels.ƒThisƒmeansƒthatƒ atƒaƒ“macro”ƒlevel,ƒtheƒhealthƒsystemƒinƒSerbiaƒisƒpredominantlyƒsteeredƒbyƒ governmentƒinstitutions,ƒwhereasƒsomeƒselectedƒfunctionsƒareƒdevolvedƒtoƒ theƒlevelƒofƒtheƒ2007ƒLawƒonƒtheƒTerritorialƒOrganizationƒofƒtheƒRepublicƒ ofƒSerbiaƒ(OfficialƒGazette,ƒ2007a):ƒ ƒƒ ƒtheƒAutonomousƒProvinceƒofƒVojvodinaƒandƒitsƒsixƒcitiesƒandƒ39ƒ municipalities:ƒtheƒgoverningƒbodiesƒareƒtheƒProvinceƒGovernmentƒ ofƒVojvodina,ƒtheƒProvinceƒSecretariatƒforƒHealthƒSocialƒPolicyƒandƒ DemographyƒandƒtheƒProvinceƒHealthƒInsurance Fund; ƒƒ ƒtheƒCityƒofƒBelgradeƒandƒitsƒ17ƒmunicipalities:ƒtheƒgoverningƒbodiesƒ areƒtheƒCityƒCouncilƒwithƒtheƒMayor,ƒDeputyƒMayorƒandƒmembers,ƒ andƒtheƒCityƒSecretariatƒforƒHealthƒCare;ƒand, 17Serbia FIGURE 2.1 Overview of the health system in Serbia Re pu bl ic Pa rli am en t Re pu bl ic Go ve rn m en t M in ist ry o f H ea lth He al th a nd F am ily C om m itt ee Ex pe rt Co m m is si on s He al th C ou nc il of S er bi a M in ist ry o f E du ca tio n, Sc ie nc e an d Te ch no lo gi ca l De ve lo pm en t M ed ici ne s a nd M ed ica l D ev ice s A ge nc y Ag en cy fo r A cc re di ta tio n of H ea lth C ar e In st itu at io ns o f S er bi a M in ist ry o f L ab ou r, Em pl oy m en t, Ve te ra n an d So cia l A ffa irs Et hi ca l B oa rd N at io na l C ou nc il fo r H ig he r E du ca tio n Hi er ar ch ic al re la tio n Co nt ra ct ua l r el at io n Pr of es si on al s up er vi si on Ad vi so ry re la tio n Ex pe rt W or ki ng G ro up s Ot he r m in ist rie s Co m m is si on fo r A cc re di ta tio n an d Qu al ity A ss ur an ce Cl in ic al C en tre s Cl in ic al H os pi ta l C en tre s Cl in ic s, In st itu te s Ge ne ra l H os pi ta ls – 41 Sp ec ia l H os pi ta ls – 3 6 In st itu te s – 16 Ph ar m ac ie s – 35 He al th Am bu la nc es He al th St at io ns Re pu bl ic F un d of He al th In su ra nc e Re gi on al B ra nc he s of He al th In su ra nc e – 31 Br an ch o ffi ce s in m un ic ip al iti es – 1 62 Pr iv at e vo lu nt ar y in su ra nc e In st itu te o f P ub lic H ea lth o f Se rb ia “ BA TU T” Re gi on al In st itu te s of Pu bl ic H ea lth – 2 4 Te rti ar y Le ve l Se co nd ar y Le ve l Pr im ar y Le ve l Pr iv at e sp ec ia lis ts p ra ct ic e Pr iv at e ge ne ra l o ffi ce s of p hy si ci an s Pr iv at e ph ar m ac ie s M in ist ry o f D ef en se PU BL IC HE AL TH M un ici pa lit y h ea lth co un cil s Ch am be rs o f H ea lth W or ke rs HE AL TH C AR E PR OV ID ER S PU RC HA SE R HE AL TH P RO VI DE R Pr im ar y He al th C ar e Ce nt re s “D om zd ra vl ja -s ” - 1 58 M ili ta ry H os pi ta l M ili ta ry M ed ica l Ac ad em y M ili ta ry M ed ica l Ce nt re s Note: Besides the network of Institutes of Public Health, health institutions providing health services at multiple levels of health care are: Institute of Blood Transfusion, Institute of Occupational Medicine, Institute of Forensic Medicine, Institute of Virology, Vaccines and Serums, Institute for Antirabies Protection, Institute of Psychophysiological Disorders and Speech Pathology, and Institute of Biocide and Medical Ecology. Sources: Compiled from the Health Care Law (Official Gazette RS 25/2019), Decree on the Plan of the Health Institutions’ Network (Official Gazette RS 114/2017), Statute of the National Health Insurance Fund (Official Gazette RS 25/2019), and Law on Higher Education (Official Gazette RS 88/2017). 18 Health Systems in Transition ƒƒ ƒcities,ƒ inƒ totalƒ 23ƒ (includingƒ thoseƒ inƒ Vojvodina),ƒ andƒ 150ƒ municipalitiesƒ(includingƒthoseƒinƒVojvodina):ƒtheƒgoverningƒbodiesƒ areƒtheƒcityƒandƒmunicipalityƒauthorities.ƒTheƒrecentlyƒestablishedƒ municipalityƒhealthƒcouncilsƒ(underƒtheƒ2013ƒLawƒonƒtheƒPatients’ƒ Rights)ƒhaveƒpredominantlyƒadvisoryƒrolesƒ inƒpublicƒhealthƒandƒ patientƒrightsƒ(seeƒsectionƒ5.1). Atƒtheƒ“meso”ƒlevelƒ(facility/institutionalƒlevel),ƒgovernanceƒisƒperformedƒ byƒtheƒManagerialƒBoardƒofƒeachƒfacility/institution.ƒAlso,ƒsomeƒgovernanceƒ functionsƒwithƒveryƒweaklyƒdefinedƒrolesƒandƒresponsibilitiesƒatƒtheƒinstitu- tionalƒlevelƒareƒperformedƒbyƒtheƒSupervisoryƒBoard.ƒAtƒtheƒ“meso”ƒlevel,ƒ managementƒisƒperformedƒbyƒaƒDirectorƒandƒtheirƒmanagementƒteam.ƒAtƒtheƒ “micro”ƒlevel,ƒonlyƒsimpleƒmanagementƒprocessesƒcanƒbeƒobservedƒ(planning,ƒ organizing,ƒstaffing,ƒleadingƒandƒcontrollingƒofƒeverydayƒperformanceƒandƒ deliveryƒofƒhealthƒservices).ƒAccordingƒtoƒsurveyƒresultsƒamongƒdirectorsƒofƒ healthƒinstitutionsƒinƒSerbia,ƒpriorityƒobjectivesƒforƒmanagersƒare:ƒimprovingƒ healthƒcareƒquality,ƒincreasingƒpatientƒsatisfactionƒandƒprofessionalƒdevel- opment,ƒasƒwellƒasƒimprovingƒemployeeƒsatisfactionƒandƒworkƒorganizationƒ (Bjegović-Mikanović,ƒ2016). Publiclyƒownedƒhealthƒinstitutionsƒcompriseƒaƒwideƒnetworkƒatƒtheƒ primary,ƒsecondaryƒandƒtertiaryƒlevelƒandƒareƒoverseenƒbyƒtheƒMinistryƒ ofƒHealthƒ(Fig.ƒ2.1).ƒAsƒofƒlateƒ2016,ƒthisƒnetworkƒcomprisedƒ355ƒhealthƒ institutionsƒwithƒaƒtotalƒofƒ104 007ƒemployeesƒinƒtheƒpubliclyƒownedƒhealthƒ sectorƒ(theƒ2017ƒDecreeƒonƒtheƒPlanƒofƒtheƒHealthƒInstitutions’ƒNetwork;ƒ IPHƒBatut,ƒ2017d,ƒp.ƒ64). Primaryƒcare,ƒorganizedƒatƒmunicipalityƒlevel,ƒincludes:ƒpreventiveƒcare,ƒ emergencyƒcare,ƒgeneralƒmedicine,ƒhealthƒcareƒforƒwomenƒandƒchildren,ƒ dentalƒcare,ƒoccupationalƒmedicine,ƒphysicalƒmedicineƒandƒrehabilitation,ƒ theƒhealthƒvisitorƒservices,ƒasƒwellƒasƒlaboratoryƒandƒotherƒdiagnosticsƒ(forƒ details,ƒseeƒsectionƒ5.2).ƒAlso,ƒprimaryƒcareƒphysiciansƒtakeƒcareƒofƒmentalƒ healthƒasƒtheƒfirstƒpointƒofƒaccess.ƒIfƒnecessary,ƒtheyƒcanƒreferƒthoseƒpatientsƒtoƒ secondaryƒandƒtertiaryƒclinics.ƒHealthƒcareƒatƒtheƒprimaryƒlevelƒisƒprovidedƒbyƒ 158ƒstate-ownedƒprimaryƒcareƒcentresƒ(calledƒDom zdravljaƒinƒtheƒsingular),ƒ withƒaƒwell-developedƒnetworkƒofƒoutpatientƒfacilitiesƒandƒoffices,ƒcoveringƒ theƒterritoryƒofƒoneƒorƒmoreƒmunicipalitiesƒorƒtowns,ƒinƒaccordanceƒwithƒ theƒDecreeƒonƒtheƒPlanƒofƒtheƒHealthƒInstitutions’ƒNetwork.ƒApartƒfromƒ primaryƒcareƒcentres,ƒprimaryƒlevelƒservicesƒareƒprovidedƒbyƒ16ƒinstitutesƒ renderingƒprimaryƒhealthƒservicesƒtoƒspecificƒgroups,ƒsuchƒasƒstudentsƒorƒ 19Serbia skinƒandƒvenerealƒdiseaseƒpatients.ƒPrimaryƒcareƒisƒperformedƒbyƒaƒ“chosenƒ doctor”ƒwhoƒisƒeitherƒaƒgeneralƒpractitionerƒ(GP)ƒorƒaƒspecialistƒinƒgeneralƒ medicine,ƒoccupationalƒmedicine,ƒpaediatrics,ƒgynaecologyƒorƒdentistryƒ(theƒ 2019ƒHealthƒCareƒLawƒandƒtheƒ2019ƒHealthƒInsuranceƒLaw)ƒ(seeƒsectionƒ 5.3).ƒTheƒentireƒprimaryƒcareƒnetworkƒisƒnowƒequippedƒwithƒInternet,ƒ computers,ƒprinters,ƒbar-codeƒreadersƒandƒcardƒreadersƒ(SerbiaƒHealthƒ Projectƒ–ƒAdditionalƒFinancing)ƒ(DILS,ƒ2011;ƒMilenkovicƒetƒal.,ƒ2012). Secondaryƒandƒtertiaryƒhealthƒservices,ƒorganizedƒatƒtheƒregionalƒandƒ nationalƒlevel,ƒareƒprovidedƒbyƒhospitalsƒasƒtheƒcontinuationƒofƒdiagnostics,ƒ treatmentƒandƒrehabilitationƒinitiatedƒatƒtheƒprimaryƒlevel,ƒorƒwhenƒspe- cializedƒcareƒisƒrequiredƒ(forƒdetailsƒseeƒsectionƒ5.3).ƒThereƒareƒ41ƒgeneralƒ hospitals,ƒ36ƒspecialƒhospitalsƒforƒacuteƒandƒchronicƒconditionsƒandƒreha- bilitation,ƒ16ƒinstitutes,ƒfourƒclinical–hospitalƒcentres,ƒfourƒclinicalƒcentresƒ andƒ25ƒInstitutesƒofƒPublicƒHealthƒ(differentƒfromƒtheƒprimaryƒhealthƒcareƒ institutions,ƒInstitutesƒofƒPublicƒHealthƒofferƒpublicƒhealthƒservices,ƒthoughƒ vaccinationsƒandƒcounsellingƒbelongƒtoƒhealthƒcareƒservices). 2.2.2 Actors in the health system Theƒmainƒactorsƒresponsibleƒforƒtheƒplanning,ƒregulation,ƒorganizationƒandƒ financingƒofƒtheƒhealthƒsystemƒinƒSerbiaƒareƒtheƒMinistryƒofƒHealthƒandƒ theƒNHIF.ƒHowever,ƒthereƒareƒotherƒministriesƒwithƒcertainƒroles,ƒasƒwellƒ asƒstateƒagenciesƒatƒnational level. Atƒtheƒlevelƒofƒtheƒparliamentƒ(theƒNationalƒAssembly),ƒthereƒisƒaƒHealth and Family Committee,ƒwhichƒhasƒanƒadvisoryƒrole.ƒTheƒHealthƒandƒFamilyƒ Committeeƒmayƒorganizeƒpublicƒhearingsƒforƒtheƒpurposeƒofƒobtainingƒ information,ƒorƒprofessionalƒopinionsƒonƒproposedƒlegalƒacts,ƒwhichƒareƒinƒ theƒparliamentaryƒprocedure,ƒclarificationƒofƒcertainƒprovisionsƒfromƒanƒ existingƒorƒproposedƒact,ƒclarificationƒofƒissuesƒofƒimportanceƒforƒpreparingƒ theƒproposalsƒofƒactsƒorƒotherƒissuesƒwithinƒtheƒcompetencesƒofƒtheƒcom- mittee,ƒasƒwellƒasƒforƒtheƒpurposeƒofƒmonitoringƒtheƒimplementationƒandƒ applicationƒofƒlegislation;ƒthatƒis,ƒtheƒrealizationƒofƒtheƒoversightƒfunctionƒ ofƒtheƒNationalƒAssembly.ƒTheƒprocedureƒforƒorganizingƒpublicƒhearingsƒisƒ regulatedƒbyƒtheƒNationalƒAssemblyƒRulesƒof Procedure. TheƒMinistryƒofƒHealthƒisƒtheƒcentralƒauthorityƒandƒhasƒoperationalƒ unitsƒforƒhealthƒserviceƒorganization,ƒhealthƒinsurance,ƒpublicƒhealthƒandƒpro- grammedƒhealthƒcare,ƒEuropeanƒintegrationƒandƒinternationalƒcooperation,ƒ 20 Health Systems in Transition pharmaceuticalsƒandƒmedicalƒdevices,ƒcontrolledƒpsychoactiveƒsubstancesƒandƒ precursors,ƒinspectionƒoperations,ƒbiomedicineƒandƒtheƒinternalƒauditƒgroupƒ (MinistryƒofƒHealth,ƒ2018).ƒItsƒmandateƒisƒregulatedƒbyƒtheƒ2017ƒLawƒonƒ Ministriesƒandƒtheƒ2019ƒHealthƒCareƒLaw.ƒItƒisƒtheƒmajorƒdecision-makerƒ inƒtheƒSerbianƒhealthƒsystem,ƒresponsibleƒforƒdeterminingƒhealthƒpolicy,ƒ planningƒandƒoversight,ƒpassingƒhealthƒcareƒstandards,ƒdeterminingƒqualityƒ controlƒmechanisms,ƒcontrollingƒtheƒqualityƒofƒhealthƒcare,ƒandƒdevelopingƒ andƒimplementingƒpublicƒhealthƒprogrammesƒand investments. The Ministry of Healthƒisƒalsoƒinƒchargeƒofƒhealthƒinsurance,ƒsafeguard- ingƒandƒimprovingƒpopulationƒhealth,ƒhealthƒinspectionƒandƒsupervisionƒ ofƒhealthƒservices.ƒTheƒMinistryƒofƒHealthƒhasƒprimaryƒresponsibilityƒforƒ healthƒsystemƒgovernance,ƒbutƒthereƒareƒoverlapsƒwithƒotherƒinstitutionsƒ andƒagencies,ƒsuchƒasƒAZUSƒ(AgencyƒforƒAccreditationƒofƒHealthƒCareƒ InstitutionsƒinƒSerbia)ƒthatƒisƒresponsibleƒforƒtheƒqualityƒofƒhealthƒcareƒandƒ accreditation,ƒandƒALIMSƒ(MedicinesƒandƒMedicalƒDevicesƒAgencyƒofƒ Serbia),ƒresponsibleƒforƒpharmaceuticalsƒ(seeƒbelow).ƒTheƒMinistryƒofƒHealthƒ hasƒaƒtotalƒofƒ270ƒemployeesƒ(outƒofƒ302ƒjobƒposts)ƒ(asƒofƒSeptemberƒ2018),ƒ organizedƒintoƒsixƒsectors,ƒincludingƒsectorsƒforƒOrganizationƒofƒHealthƒ Services;ƒHealthƒInsurance;ƒPublicƒHealthƒandƒProgrammaticƒHealthƒCare;ƒ DrugsƒandƒMedicalƒMaterialsƒandƒDevices;ƒInspection;ƒandƒaƒMinistryƒ ofƒHealthƒSecretariat.ƒOfƒtheseƒemployees,ƒmoreƒthanƒhalfƒareƒworkingƒ on inspections. TheƒMinistryƒofƒHealthƒhasƒadvisoryƒsupportƒbyƒtheƒHealthƒCouncil,ƒtheƒ EthicsƒBoardƒandƒdifferentƒnationalƒprofessionalƒcommissionsƒinƒparticularƒ fieldsƒofƒmedicineƒandƒhealthƒcare,ƒharmonizingƒopinionsƒofƒstakeholdersƒ andƒsuggestingƒproposalsƒforƒdevelopmentƒofƒclinical guidelines. The Health CouncilƒservesƒasƒtheƒcoreƒadvisoryƒbodyƒtoƒtheƒMinistryƒofƒ Healthƒforƒlong-termƒstrategyƒandƒplanning.ƒTheƒ15ƒmembersƒofƒtheƒHealthƒ CouncilƒareƒappointedƒbyƒtheƒNationalƒAssembly,ƒbasedƒonƒnominationsƒbyƒ theƒgovernmentƒandƒrelevantƒinstitutionsƒ(facultiesƒofƒmedicine,ƒpharmacies,ƒ dentistry,ƒchambersƒofƒhealthƒworkersƒandƒtheƒNHIF).ƒItsƒmandateƒincludesƒ monitoringƒofƒtheƒhealthƒsystemƒandƒhealthƒinsurance,ƒalignmentƒwithƒEUƒ andƒinternationalƒstandards,ƒsuggestingƒmeasuresƒforƒimprovementƒofƒhealthƒ careƒandƒhealthƒprotection,ƒandƒevaluatingƒandƒaccreditingƒprogrammesƒofƒ continuingƒmedicalƒandƒpublicƒhealthƒeducation.ƒTheƒadministrationƒofƒtheƒ CouncilƒisƒprovidedƒbyƒtheƒMinistryƒofƒHealthƒ(2019ƒHealthƒCareƒLawƒ–ƒ Articlesƒ135–140). 21Serbia Theƒ2004ƒLawƒonƒMedicinesƒandƒMedicalƒDevicesƒandƒtheƒHealthƒCareƒ Lawƒhaveƒprovidedƒsinceƒ2005ƒopportunitiesƒforƒestablishingƒtwoƒnationalƒ agenciesƒwithƒparticularƒrolesƒinƒtheƒhealthƒsystem:ƒMedicinesƒandƒMedicalƒ DevicesƒAgencyƒ(ALIMS)ƒandƒtheƒAgencyƒforƒAccreditationƒofƒHealthƒCareƒ Institutionsƒ(AZUS). The Medicines and Medical Devices Agencyƒ(ALIMS)ƒwasƒfoundedƒ inƒ2004.ƒTheƒmissionƒstrivesƒforƒtheƒaccomplishmentƒofƒtheƒbasicƒhumanƒrightƒ ofƒaccessibilityƒtoƒquality,ƒefficaciousƒandƒsafeƒmedicinesƒandƒmedicalƒdevices,ƒ asƒwellƒasƒtoƒpromoteƒandƒenhanceƒpublicƒandƒanimalƒhealthƒthrough:ƒissuingƒ marketingƒauthorizationsƒofƒsolelyƒquality,ƒsafeƒandƒefficaciousƒmedicinesƒ andƒmedicalƒdevices,ƒprovidingƒadequateƒinformationƒinƒorderƒtoƒensureƒ safeƒandƒrationalƒuseƒofƒsuchƒmedicinesƒandƒmedicalƒdevices,ƒandƒqualityƒ controlƒofƒmedicinesƒandƒmedicalƒdevicesƒwhichƒisƒinƒfullƒcomplianceƒwithƒ nationalƒandƒinternationalƒlawsƒandƒstandards.ƒALIMSƒhasƒresponsibilityƒ forƒmonitoringƒmedicinesƒandƒmedicalƒdevicesƒinƒbothƒtheƒpublicƒandƒprivateƒ sector,ƒincludingƒlicensingƒandƒapprovalƒofƒnewƒmedicinesƒandƒdevices.ƒInƒ 2016,ƒALIMSƒhadƒ173ƒemployeesƒ(ALIMS,ƒ2018). The Agency for Accreditation of Health Care Institutionsƒ(AZUS)ƒ wasƒfoundedƒinƒ2008ƒwithƒEUƒfinancialƒandƒprofessionalƒsupport.ƒItsƒroleƒisƒ toƒperformƒprofessional,ƒregulatoryƒandƒdevelopmentƒactivitiesƒinƒtheƒprocessƒ ofƒaccreditationƒofƒhealthƒcareƒinstitutions.ƒTheƒmainƒsourceƒofƒfundingƒforƒ AZUSƒisƒtheƒnationalƒbudgetƒandƒpaymentƒfromƒhealthƒinstitutionsƒunder- goingƒtheƒprocessƒofƒaccreditation.ƒSinceƒ2010,ƒtheƒMinistryƒofƒHealthƒhasƒ transferredƒtheƒgovernanceƒofƒtheƒRepublicanƒScientificƒCommitteeƒforƒ ClinicalƒGuidelinesƒdevelopmentƒandƒimplementationƒtoƒAZUS.ƒSinceƒ2012,ƒ theƒAZUSƒisƒtheƒRegionalƒHealthƒDevelopmentƒCentreƒforƒtheƒSouth-easternƒ EuropeƒHealthƒNetwork.ƒNowadays,ƒtheƒaccreditationƒprocessƒremainsƒanƒ optionalƒchoiceƒforƒhealthƒcareƒproviders,ƒandƒtheƒAZUSƒhasƒonlyƒaƒlimitedƒ coreƒbudgetƒandƒstaffƒ(inƒtotalƒ11ƒjobƒposts)ƒtoƒcarryƒoutƒitsƒresponsibilitiesƒ (AZUS,ƒ2018). BesidesƒtheƒMinistryƒofƒHealth,ƒotherƒministriesƒhaveƒcertainƒrolesƒ directlyƒandƒindirectlyƒrelatedƒtoƒtheƒhealth system. TheƒMinistryƒofƒFinanceƒoverseesƒapprovingƒtheƒbudgetƒofƒtheƒMinistryƒ ofƒHealthƒandƒtheƒNHIF,ƒandƒhasƒotherƒrolesƒrelatedƒtoƒfinancialƒf lows,ƒ includingƒapprovalƒofƒtheƒbudgetƒforƒallƒstrategicƒandƒoperationalƒhealthƒ policiesƒbeforeƒtheir adoption. 22 Health Systems in Transition TheƒMinistryƒofƒEducation,ƒScienceƒandƒTechnologicalƒDevelopmentƒ isƒresponsibleƒforƒallƒmattersƒrelatedƒtoƒtheƒeducationƒofƒhumanƒresourcesƒ forƒhealthƒandƒscientificƒresearchƒinƒtheƒfieldƒofƒmedicine,ƒhealthƒcareƒandƒ publicƒhealth.ƒAlso,ƒthisƒMinistryƒhasƒtheƒresponsibilityƒforƒownershipƒofƒ higherƒeducationƒinstitutions,ƒtheirƒfinancing,ƒenrolmentƒpoliciesƒandƒtheƒ nationalƒaccreditationƒbothƒofƒeducationalƒandƒresearchƒentitiesƒandƒacademicƒ programmesƒaimedƒtoƒtheƒproductionƒandƒdevelopmentƒofƒfiveƒrecognizedƒ healthƒcareƒprofessions:ƒphysicians,ƒnurses,ƒdentists,ƒpharmacistsƒandƒbio- chemists.ƒTheƒNationalƒCouncilƒforƒHigherƒEducationƒisƒresponsibleƒforƒ securingƒtheƒdevelopmentƒandƒtheƒimprovementƒofƒtheƒqualityƒofƒhigherƒ educationƒthroughƒitsƒCommissionƒforƒAccreditationƒandƒQualityƒAssuranceƒ (CAQA).ƒCAQAƒwasƒformedƒinƒ2006ƒbyƒtheƒ2005ƒLawƒonƒHigherƒEducationƒ asƒanƒindependentƒbodyƒofƒtheƒNationalƒCouncilƒforƒHigherƒEducation.ƒItƒ isƒtheƒonlyƒformallyƒrecognizedƒbodyƒresponsibleƒforƒtheƒexternalƒqualityƒ assuranceƒforƒhigherƒeducationƒinƒSerbiaƒwhichƒfollowsƒtheƒBolognaƒProcess.ƒ CAQAƒobtainsƒfundingƒbyƒaccreditationƒfees,ƒwhileƒtheƒMinistryƒresponsibleƒ forƒeducationƒprovidesƒtechnicalƒandƒadministrativeƒsupport.ƒCAQAƒhasƒ operationalƒandƒdecision-makingƒindependenceƒfromƒallƒstakeholdersƒ(e.g.ƒ ministryƒinƒchargeƒofƒeducationƒasƒwellƒasƒotherƒministries,ƒNationalƒCouncilƒ forƒHigherƒEducation,ƒhigherƒeducationƒinstitutions). TheƒMinistryƒofƒDefenceƒholdsƒownershipƒandƒaƒgovernanceƒfunctionƒ overƒhealthƒcareƒservicesƒprovidedƒforƒmilitaryƒpersonnelƒandƒpension- ers.ƒAlso,ƒthisƒMinistryƒisƒresponsibleƒforƒtheƒMilitaryƒMedicalƒAcademy,ƒ whichƒprovidesƒhealthƒcareƒatƒtertiaryƒlevel,ƒeducationƒandƒresearchƒinƒ theƒfieldƒofƒmedicine,ƒasƒwellƒasƒprimaryƒandƒsecondaryƒlevelƒofƒcareƒforƒ military personnel. TheƒMinistryƒofƒLabour,ƒEmployment,ƒVeteranƒandƒSocialƒAffairsƒisƒinƒ chargeƒofƒhealthƒandƒsafetyƒatƒwork.ƒTheƒLabourƒInspectorateƒwithinƒthisƒ Ministryƒperformsƒinspectionsƒofƒworkƒconditionsƒinƒtheƒfieldƒofƒlabour,ƒ labourƒrelationsƒandƒsafety,ƒandƒhealthƒatƒwork,ƒasƒwellƒasƒtheƒinspectionƒ ofƒfatal,ƒseriousƒandƒcollectiveƒinjuriesƒatƒwork.ƒInƒcollaborationƒwithƒtheƒ MinistryƒofƒHealth,ƒthisƒMinistryƒoverseesƒhealthƒservicesƒprovidedƒinƒpen- sioners’ƒhomesƒ(nursingƒhomesƒforƒolderƒpeople)ƒandƒhomesƒforƒpeopleƒlivingƒ withƒdisabilities.ƒAlso,ƒinstitutionsƒofƒsocialƒcareƒcollaborateƒwithƒhealthƒcareƒ institutionsƒinƒtheƒprovisionƒofƒhelpƒforƒhomelessƒpeopleƒandƒtheƒrecognitionƒ andƒpreventionƒofƒdomestic violence. Otherƒministriesƒperformingƒcertainƒimportantƒexecutiveƒfunctionsƒ andƒprogrammesƒ relatedƒ toƒpublicƒhealthƒ andƒ vulnerableƒpopulationsƒ 23Serbia are:ƒtheƒMinistryƒofƒtheƒInteriorƒ(healthƒinƒprisonsƒandƒorganizationƒofƒ rapidƒresponseƒtoƒemergencyƒsituations),ƒtheƒMinistryƒofƒEnvironmentalƒ Protection,ƒtheƒMinistryƒofƒAgriculture,ƒForestryƒandƒWaterƒManagement,ƒ theƒMinistryƒofƒYouthƒandƒSport,ƒtheƒMinistryƒofƒPublicƒAdministrationƒ andƒLocalƒSelf-Government,ƒandƒtheƒMinisterƒwithoutƒportfolioƒresponsibleƒ forƒdemographyƒandƒpopulationƒpolicyƒ(whoƒnowƒoverseesƒtheƒimplemen- tationƒofƒtheƒSustainableƒDevelopmentƒGoals).ƒInƒtheƒlightƒofƒtheƒEUƒ accessionƒprocess,ƒtheƒMinistryƒofƒEuropeanƒIntegrationƒhasƒtheƒimportantƒ roleƒofƒcommunicatingƒprogressƒrelatedƒtoƒconsumerƒandƒhealthƒprotectionƒ toƒtheƒEuropeanƒCommission,ƒtheƒEuropeanƒParliament,ƒtheƒCouncil,ƒ theƒEuropeanƒEconomicƒandƒSocialƒCommitteeƒandƒtheƒCommitteeƒofƒ theƒRegions,ƒnegotiatingƒChapterƒ28ƒofƒtheƒStabilisationƒandƒAssociationƒ Agreementƒ(SAA)ƒbetweenƒSerbiaƒandƒtheƒEU,ƒwhichƒenteredƒintoƒforceƒ inƒSeptemberƒ2013ƒandƒwasƒimplementedƒinƒ2014ƒ(EuropeanƒCommission,ƒ 2016).ƒChapterƒ28ƒrelatesƒtoƒEUƒrules,ƒwhichƒprotectƒconsumersƒinƒrelationƒ toƒproductƒsafety,ƒdangerousƒimitationsƒandƒliabilityƒforƒdefectiveƒproducts.ƒ TheƒEUƒalsoƒensuresƒhighƒcommonƒstandardsƒforƒtobaccoƒcontrol,ƒblood,ƒ tissues,ƒcellsƒandƒorgans,ƒpatients’ƒrightsƒinƒcross-borderƒhealthƒcare,ƒandƒ seriousƒcross-borderƒhealthƒthreatsƒincludingƒcommunicableƒdiseases,ƒasƒwellƒ asƒmedicinesƒforƒhumanƒandƒveterinaryƒuseƒ(EuropeanƒCommission,ƒ2018). TheƒgovernmentƒestablishedƒtheƒSocialƒInclusionƒandƒPovertyƒReductionƒ Unitƒ(SIPRU)ƒinƒ2009,ƒmandatedƒtoƒstrengthenƒgovernmentƒcapacitiesƒtoƒ developƒandƒimplementƒsocialƒinclusionƒpoliciesƒbasedƒonƒgoodƒpracticesƒ inƒEurope.ƒTheƒsocialƒinclusionƒprogrammesƒincludeƒvariousƒcashƒbenefitsƒ (pensions,ƒunemploymentƒbenefits,ƒsocialƒassistance,ƒetc.)ƒandƒservicesƒ(forƒ olderƒpeople,ƒchildren,ƒfamilies,ƒpersonsƒwithƒdisabilities,ƒetc.). Atƒtheƒinstitutionalƒlevel,ƒtheƒmostƒimportantƒactorsƒinƒtheƒhealthƒsystemƒ areƒtheƒNationalƒHealthƒInsuranceƒFundƒandƒtheƒInstituteƒofƒPublicƒHealthƒ ofƒSerbiaƒ“DrƒMilanƒJovanovićƒBatut”. The National Health Insurance Fundƒ(NHIF)ƒisƒaƒnational,ƒpublicƒ andƒnon-profitƒorganizationƒthroughƒwhichƒSerbianƒcitizensƒexerciseƒtheirƒ healthƒinsuranceƒrightsƒ(NHIF,ƒ2018a).ƒTheƒactivitiesƒofƒtheƒNHIFƒareƒ conductedƒinƒitsƒorganizationalƒunits:ƒDirectorateƒofƒtheƒInstitute,ƒProvincialƒ HealthƒInsuranceƒFund,ƒregionalƒbranchesƒofƒtheƒNHIFƒ(inƒtotalƒ31,ƒoutƒ ofƒwhichƒfiveƒatƒtheƒterritoryƒofƒKosovoƒandƒMetohija)ƒandƒsub-branchƒ officesƒinƒmunicipalitiesƒ(137ƒinƒtotal,ƒaccordingƒtoƒtheƒlatestƒStatuteƒofƒtheƒ NationalƒHealthƒInsuranceƒFund).ƒTheƒNationalƒHealthƒInsuranceƒFundƒ isƒtheƒmainƒpurchaserƒofƒhealthƒservicesƒresponsibleƒfor:ƒfinancesƒnecessaryƒ 24 Health Systems in Transition forƒtheƒfunctioningƒofƒhealthƒcareƒatƒallƒlevels;ƒcontractingƒtheƒprovisionƒ ofƒservicesƒwithƒpublicƒinstitutionsƒandƒtheƒprivateƒsector;ƒcontrollingƒtheƒ implementationƒofƒcommitmentsƒundertakenƒwhenƒcontracting,ƒandƒdefiningƒ theƒbasicƒpackageƒofƒhealthƒservicesƒ(seeƒsectionƒ3.3.1). EnteringƒintoƒcontractsƒwithƒtheƒfacilitiesƒnotƒincludedƒinƒtheƒNetworkƒ PlanƒisƒsubjectƒtoƒreviewƒbyƒtheƒInstituteƒofƒPublicƒHealthƒofƒSerbiaƒ“DrƒMilanƒ JovanovićƒBatut”,ƒwhileƒtheƒapprovalƒforƒenteringƒintoƒcontactsƒisƒgrantedƒ byƒtheƒMinistryƒofƒHealth.ƒEachƒyear,ƒtheƒNHIFƒadoptsƒtheƒactualƒhealthƒ careƒplanƒunderƒcompulsoryƒhealthƒinsuranceƒasƒaƒstrategicƒandƒoperationalƒ documentƒinƒtheƒimplementationƒofƒcompulsoryƒhealthƒinsurance policy. TheƒNHIFƒisƒunderƒtheƒoversightƒofƒtheƒMinistryƒofƒHealth.ƒBesidesƒ theƒresponsibilityƒforƒpoolingƒandƒpurchasing,ƒasƒtheƒonlyƒinsurerƒforƒman- datoryƒhealthƒinsurance,ƒitƒhasƒsomeƒresponsibilitiesƒforƒfinancialƒoversightƒ ofƒhealthƒinstitutionsƒfinancedƒbyƒtheƒNHIF.ƒTheƒNHIFƒconsistsƒof:ƒtheƒ BoardƒofƒDirectors,ƒtheƒSupervisingƒBoardƒandƒtheƒDirector.ƒAsƒofƒtheƒendƒ ofƒ2016,ƒtheƒNHIF,ƒincludingƒallƒregionalƒbranchesƒandƒbranchƒoffices,ƒhadƒ 2 059ƒemployeesƒtakingƒcareƒofƒ7 027 150ƒinsuredƒpeopleƒ(equivalentƒtoƒ3 413ƒ insureesƒperƒemployee)ƒ(NHIF,ƒ2017c). The Institute of Public Health of Serbia “Dr Milan Jovanović Batut” (IPH Batut),ƒandƒtheƒ25ƒregionalƒInstitutesƒofƒPublicƒHealthƒ(IPHs),ƒhaveƒaƒ wideƒrangeƒofƒactivitiesƒandƒmandates,ƒincludingƒforƒhealthƒsystemƒplanning,ƒ andƒmonitoringƒ(seeƒsectionƒ5.1).ƒTheƒIPHƒBatutƒisƒorganizedƒintoƒsevenƒ departmentsƒwithƒ194ƒstaff,ƒincluding:ƒtheƒCentreƒforƒPreventionƒandƒControlƒ ofƒDiseases;ƒtheƒCentreƒforƒHealthƒPromotion;ƒtheƒCentreƒforƒHygieneƒandƒ HumanƒEcology;ƒtheƒCentreƒforƒInformaticsƒandƒBiostatistics;ƒtheƒCentreƒ forƒMicrobiology;ƒtheƒCentreƒforƒAnalysis,ƒPlanning,ƒandƒHealthƒCareƒ Organization;ƒandƒtheƒServiceƒforƒLegal,ƒAdministrativeƒandƒTechnicalƒ Support.ƒTheƒIPHƒBatutƒreceivesƒcoreƒfundingƒfromƒtheƒstateƒbudget,ƒfromƒ theƒNHIFƒforƒprovidingƒspecificƒservices,ƒasƒwellƒasƒprojectƒfinancingƒ(inƒ theƒcaseƒofƒIPHƒBatut,ƒtheƒNHIFƒaccountsƒforƒ30%ƒofƒfunding,ƒ30%ƒisƒ fromƒtheƒstateƒbudgetƒandƒ30%ƒfromƒprojectƒandƒself-financing).ƒTheƒ25ƒ regionalƒIPHsƒareƒlargelyƒindependentƒofƒIPHƒBatutƒandƒreceiveƒaƒsubstantialƒ portionƒofƒtheirƒfundingƒfromƒtheƒNHIFƒforƒprovidingƒspecificƒservices,ƒsuchƒ asƒhealthƒstatusƒassessment,ƒenvironmentalƒandƒotherƒlaboratoryƒservices.ƒ Accordingƒtoƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ2016ƒPublicƒHealthƒLaw,ƒ IPHƒBatutƒcoordinatesƒandƒmonitorsƒtheƒprofessionalƒworkƒofƒallƒIPHsƒandƒ otherƒparticipantsƒinƒpublicƒhealthƒactivitiesƒinƒSerbia.ƒIPHƒBatut’sƒmainƒ 25Serbia areasƒofƒactivityƒare:ƒanalysis,ƒplanningƒandƒorganizationƒofƒhealthƒcare,ƒ developingƒhealthƒinformationƒsystems,ƒhealthƒpromotion,ƒdiseaseƒcontrolƒ andƒprevention,ƒhygieneƒandƒhumanƒecology,ƒand microbiology. 2.2.3 The private sector Nationalƒlegislationƒhasƒallowedƒprivateƒhealthƒcareƒservicesƒtoƒoperateƒsinceƒ 2005,ƒbutƒtheirƒoperationƒisƒpoorlyƒregulated.ƒPrivateƒhealthƒcareƒservicesƒareƒ coveredƒbyƒOOPƒpayments,ƒasƒadditionalƒprivateƒhealthƒinsuranceƒisƒlargelyƒ lackingƒ(seeƒsectionƒ3.5).ƒThisƒleadsƒtoƒaƒpowerƒimbalance,ƒwhereƒprivateƒ healthƒcareƒprovidersƒareƒnegotiatingƒpricesƒdirectlyƒwithƒindividualƒusersƒ (patients),ƒinsteadƒofƒinstitutionsƒwithƒmoreƒleverage.ƒProvisionƒofƒprivateƒ healthƒcareƒservicesƒisƒstillƒlimitedƒbutƒincreasing,ƒespeciallyƒasƒregardsƒdentalƒ servicesƒandƒdiagnostics.ƒAlso,ƒprivateƒhealthƒcareƒprovidersƒemployƒmedicalƒ professionalsƒfromƒtheƒpublicƒsectorƒwhoƒworkƒonƒaƒtemporary,ƒconsultancyƒ basis.ƒInƒ2016ƒtheƒprivateƒsectorƒincludedƒ2 650ƒinstitutions:ƒ2 205ƒoutpatientƒ medicalƒofficesƒandƒclinics,ƒincludingƒ1 387ƒdentalƒoffices.ƒAlso,ƒthereƒareƒ252ƒ pharmacies,ƒ144ƒdiagnosticƒofficesƒandƒlaboratoriesƒandƒ41ƒprivateƒhospitalsƒ providingƒsecondaryƒlevelƒhealthƒservicesƒ(IPHƒBatut,ƒ2017a).ƒHowever,ƒtheƒ volumeƒofƒservicesƒprovidedƒbyƒtheƒprivateƒsectorƒremainsƒsmall,ƒandƒrarelyƒ surpassesƒ5%ƒofƒservicesƒprovidedƒbyƒtheƒpublicƒsectorƒbecauseƒfacilitiesƒareƒ much smaller. 2.2.4 Professional associations and trade unions Sinceƒ2005,ƒafterƒtheƒadoptionƒofƒtheƒ2005ƒLawƒonƒChambersƒofƒHealthƒ Workers,ƒfiveƒchambersƒhaveƒbeenƒfoundedƒtoƒimproveƒtheƒconditionsƒforƒ theƒpracticeƒofƒtheƒfiveƒregulatedƒprofessionsƒofƒmedicalƒdoctors;ƒdoctorsƒ ofƒdentistry;ƒgraduateƒpharmacists;ƒgraduatesƒofƒmedicalƒbiochemistryƒ andƒmedicalƒdoctorsƒspecializingƒinƒclinicalƒbiochemistry;ƒandƒnursesƒandƒ healthƒtechnicians.ƒCodesƒofƒprofessionalƒethicsƒofƒchambersƒstipulateƒthatƒ healthƒworkersƒhaveƒtheƒrightƒandƒduty,ƒthroughƒtheirƒprofessionalƒandƒotherƒ organizations,ƒtoƒadvocateƒforƒproperƒevaluationƒofƒtheirƒwork,ƒasƒwellƒasƒtoƒ insure,ƒpersonallyƒorƒthroughƒanƒemployer,ƒagainstƒclaimsƒforƒdamagesƒinƒ theƒperformanceƒofƒtheirƒprofessionalƒduties.ƒChambersƒareƒresponsibleƒforƒ licensingƒandƒre-licensingƒofƒhealth workers. 26 Health Systems in Transition Besidesƒchambers,ƒhealthƒprofessionalsƒinƒSerbiaƒhaveƒnumerousƒotherƒ associationsƒsuchƒasƒtheƒSerbianƒMedicalƒSocietyƒservingƒtoƒimproveƒtheƒ rolesƒandƒstatusƒofƒtheƒprofession.ƒAlso,ƒtheyƒhaveƒtradeƒunions,ƒsuchƒasƒtheƒ TradeƒUnionƒofƒEmployeesƒinƒHealthƒandƒSocialƒCareƒofƒSerbiaƒandƒtheƒNewƒ HealthƒUnionƒofƒSerbia,ƒthatƒrepresentsƒhealthƒworkersƒaskingƒforƒsolidarity,ƒ unityƒandƒstruggleƒforƒtheƒauthenticƒinterestsƒofƒemployeesƒinƒhealth,ƒsocialƒ andƒpharmaceutical services. Recently,ƒsinceƒ2014,ƒprivateƒhealthƒcareƒprovidersƒhaveƒorganizedƒtheirƒ AssociationƒofƒSerbianƒPrivateƒHealthƒCareƒProviders,ƒgatheredƒaroundƒtheƒ missionƒofƒmainstreamingƒprivatelyƒownedƒhealthƒservicesƒandƒimprovingƒ theirƒintegrationƒintoƒtheƒhealth system. 2.2.5 Other associations Duringƒrecentƒyears,ƒnongovernmentalƒorganizationsƒ(NGOs)ƒhaveƒbecomeƒ moreƒimportantƒasƒpartnersƒofƒtheƒMinistryƒofƒHealthƒinƒdeliveringƒpublicƒ healthƒprogrammesƒaimingƒtoƒpreventƒdiseasesƒorƒimprovingƒtheƒhealthƒofƒ vulnerableƒgroupsƒ(e.g.ƒtheƒRomaƒpopulation,ƒpeopleƒlivingƒwithƒdisabilitiesƒ orƒwithƒparticularƒdiseasesƒsuchƒasƒdiabetesƒorƒAIDS).ƒInƒorderƒtoƒimproveƒ theƒqualityƒofƒhealthƒcare,ƒsinceƒ2012,ƒtheƒNHIFƒtakesƒintoƒaccountƒtheƒ viewsƒandƒsuggestionsƒofƒpatients,ƒtheirƒassociationsƒandƒrepresentativesƒ (seeƒsectionƒ2.8).ƒInƒorderƒtoƒensureƒcooperationƒwithƒpatients’ƒassociationsƒ andƒenableƒthemƒtoƒbeƒfullyƒinvolvedƒinƒmakingƒdecisionsƒregardingƒtheƒ exerciseƒofƒtheƒrightƒtoƒhealthƒcareƒwithinƒcompulsoryƒhealthƒinsurance,ƒ theƒNHIFƒhasƒestablishedƒaƒCentreƒforƒCooperationƒwithƒInsuredƒPersons,ƒ Patients’ƒAssociations,ƒPersonsƒwithƒDisabilitiesƒandƒPublicƒInformation.ƒ Associationsƒandƒtheirƒrepresentativesƒcanƒbeƒinvolvedƒinƒtheƒworkƒofƒtheƒ NHIFƒbyƒprovidingƒtheirƒquestions,ƒsuggestionsƒandƒadviceƒinƒwrittenƒform.ƒ Asƒofƒ2017,ƒtheƒNHIFƒhasƒestablishedƒcollaborationƒwithƒ19ƒpatients’ƒasso- ciationƒ(NHIF,ƒ2018a). 2.3  Decentralization and centralization TheƒdominatingƒfactorƒinƒrecentƒSerbianƒpolicyƒreforms,ƒintroducedƒbyƒ healthƒlegislationƒinƒ2005ƒ(theƒ2005ƒHealthƒCareƒLaw)ƒ(seeƒsectionƒ6.1),ƒ wasƒtheƒdevelopmentƒofƒdecentralization.ƒWithƒregardƒtoƒhealthƒpolicies,ƒ 27Serbia decentralizationƒimpliedƒthatƒtheƒprimaryƒhealthƒcentresƒbecomeƒtheƒresponsi- bilityƒofƒlocalƒgovernments.ƒTheƒlocalƒgovernmentƒbecameƒobligedƒtoƒprepareƒ aƒlocalƒhealthƒcareƒplanƒandƒtoƒformulateƒspecificƒprogrammesƒtailoredƒtoƒ theƒneedsƒofƒtheƒlocalƒpopulation;ƒitƒalsoƒbecameƒresponsibleƒforƒgoverningƒ theƒprimaryƒhealthƒcentresƒ(seeƒsectionƒ5.2).ƒHowever,ƒtheƒlackƒofƒfinancialƒ resourcesƒandƒtheƒeconomicƒcrisisƒhasƒslowedƒdownƒtheseƒprocesses,ƒthereforeƒ decentralizationƒremainsƒpredominantlyƒinƒtheƒphaseƒofƒdevolution,ƒwithoutƒ financialƒresponsibilityƒatƒtheƒlocal level. TheƒMinistryƒofƒHealthƒhasƒretainedƒownershipƒofƒhospitals,ƒwithƒ hospitalƒdirectorsƒandƒmanagingƒboardsƒappointedƒbyƒtheƒgovernment/ MinistryƒofƒHealth.ƒPrimaryƒcareƒcentresƒwereƒdecentralizedƒtoƒlocalƒgovern- mentsƒbyƒtheƒ2005ƒHealthƒCareƒLaw,ƒandƒlocalƒgovernmentsƒareƒresponsibleƒ forƒappointingƒdirectorsƒandƒhaveƒformalƒresponsibilityƒforƒtheƒperformanceƒ ofƒtheƒprimaryƒcareƒcentre.ƒHowever,ƒgovernanceƒatƒtheƒlevelƒofƒmunicipali- tiesƒhasƒbeenƒpredominantlyƒconfinedƒtoƒtheƒappointmentƒofƒtheƒdirectors,ƒ deputyƒdirector,ƒtheƒmembersƒofƒtheƒmanagementƒboardƒ(boardƒofƒdirectors),ƒ andƒtheƒsupervisoryƒboardsƒofƒhealthƒcareƒinstitutions.ƒExecutionƒofƒfinancialƒ functionsƒatƒtheƒmunicipalityƒlevelƒcouldƒbeƒseenƒwithinƒsomeƒmunicipalitiesƒ inƒtheirƒannualƒprogrammeƒbudgetƒplanning,ƒwhichƒengagesƒresourcesƒmainlyƒ toƒmeetƒinfrastructureƒneeds/capitalƒinvestmentƒinƒprimaryƒcareƒatƒtheƒlocalƒ level.ƒAsƒwellƒasƒtheƒadoptedƒ2007ƒLawƒonƒLocalƒSelf-Governance,ƒwhichƒ providesƒdecisionƒspaceƒforƒlocalƒauthoritiesƒtoƒexerciseƒmoreƒresponsibilityƒinƒ governanceƒatƒtheƒlocalƒlevel,ƒsomeƒinternationallyƒfundedƒprojectsƒhaveƒaimedƒ toƒincreaseƒtheƒcapacityƒofƒinstitutionalƒactorsƒandƒbeneficiariesƒinƒorderƒtoƒ improveƒaccessƒtoƒandƒefficiency,ƒequityƒandƒqualityƒofƒlocalƒdeliveryƒofƒhealth,ƒ educationƒandƒsocialƒprotectionƒservices,ƒinƒaƒdecentralizing environment: ƒƒ ƒtheƒEU-fundedƒ programmeƒ implementedƒ byƒ theƒCouncilƒ ofƒ Europeƒ–ƒtheƒ2009–2012ƒSupportƒtoƒLocalƒSelf-governmentƒinƒ Decentralizationƒprojectƒ(managedƒbyƒSCTM)ƒ(CouncilƒofƒEurope,ƒ 2009);ƒand ƒƒ ƒtheƒ2015ƒonƒtheƒDeliveryƒofƒImprovedƒLocalƒServicesƒ(DILS)ƒ project,ƒmanagedƒbyƒtheƒProjectƒImplementationƒUnitƒ(PIU)ƒofƒ ministriesƒwithƒjurisdictionƒforƒhealth,ƒeducation,ƒlabourƒandƒsocialƒ policiesƒ(WorldƒBank,ƒ2015a). BothƒprojectsƒareƒstillƒongoingƒwithƒtheƒleadershipƒofƒSCTMƒandƒwithƒtheƒ participationƒofƒcitiesƒandƒmunicipalities.ƒForƒexample,ƒtheƒcapacity-buildingƒ 28 Health Systems in Transition programmeƒisƒnowƒbeingƒimplementedƒforƒtheƒdevelopmentƒofƒlocalƒpublicƒ health strategies. Severalƒfactorsƒcontributedƒtoƒtheƒdevolvementƒofƒgovernanceƒatƒtheƒ centralƒlevel,ƒwhichƒdoesƒnotƒprogressƒtowardsƒfullƒdecentralization.ƒAtƒfirst,ƒ Serbiaƒisƒstillƒinƒaƒdeepƒeconomicƒcrisis,ƒinheritedƒfromƒtheƒpastƒandƒaggra- vatedƒbyƒtheƒworldƒeconomicƒcrisis.ƒTheƒpoorƒperformanceƒofƒtheƒeconomyƒ hasƒaƒdeepƒnegativeƒimpactƒonƒtheƒsocialƒsectors,ƒincludingƒtheƒhealthƒsector.ƒ Politicalƒinvolvementƒatƒalmostƒallƒadministrativeƒlevelsƒhasƒalsoƒaffectedƒinƒaƒ negativeƒwayƒtheƒproperƒgovernanceƒandƒmanagementƒofƒtheƒhealthƒsystem.ƒ Itƒinducedƒfrequentƒchangesƒinƒtheƒmanagementƒstructuresƒ(especiallyƒtopƒ managers),ƒaffectingƒtheƒcontinuityƒofƒgovernanceƒandƒstrategicƒthinkingƒatƒ theƒ“macro”ƒandƒ“meso”ƒlevels. Inƒconsequence,ƒthoseƒhealthƒcareƒfacilitiesƒthatƒareƒstateƒfundedƒareƒ stillƒfinancedƒinƒaccordanceƒwithƒtheƒ2006–2018ƒDecreeƒonƒtheƒPlanƒofƒ theƒHealthƒInstitutions’ƒNetworkƒ(OfficialƒGazette,ƒ2006b)ƒadoptedƒbyƒtheƒ stateƒgovernmentƒandƒnotƒbyƒlocalƒself-governance.ƒTheƒMinistryƒofƒHealthƒ isƒcontinuouslyƒinvestingƒeffortsƒinƒimprovingƒqualityƒofƒcareƒatƒtheƒlocalƒ levelƒwithƒvariousƒstrategiesƒandƒguidelines,ƒsuchƒasƒtheƒguidelinesƒforƒgoodƒ clinicalƒpracticeƒinƒmanyƒareasƒofƒhealthƒcare.ƒSinceƒ2010,ƒtheƒsystemƒforƒ monitoringƒhealthƒcareƒindicatorsƒhasƒbeenƒsignificantlyƒimproved,ƒwhichƒ allowsƒbetterƒinsightƒintoƒtheƒworkƒofƒhealthƒservicesƒ(adoptionƒofƒtheƒ2010ƒ RulebookƒonƒHealthƒCareƒQualityƒIndicators)ƒ(OfficialƒGazette,ƒ2010d). Withƒtheƒnewƒ2019ƒHealthƒCareƒLaw,ƒaƒprocessƒofƒcentralizationƒwasƒ introduced,ƒtransferringƒownershipƒofƒbuildingsƒandƒequipmentƒtoƒtheƒ national/republicƒlevel.ƒHowever,ƒanƒimportantƒplayerƒatƒmacroƒlevelƒwillƒ continueƒtoƒbeƒVojvodinaƒProvince,ƒwithƒitsƒSecretariatƒforƒHealthƒSocialƒ PolicyƒandƒDemography,ƒasƒreportedƒbyƒtheƒ2019ƒHealthƒCareƒLaw.ƒSocialƒ responsibilityƒforƒhealthƒatƒtheƒlevelƒofƒanƒautonomousƒprovince,ƒaƒmunicipal- ityƒorƒcityƒincludesƒmeasuresƒforƒtheƒprovisionƒandƒimplementationƒofƒhealthƒ careƒaccordingƒtoƒtheƒinterestƒofƒtheƒcitizensƒinƒtheƒterritoryƒasƒregulatedƒbyƒ theƒ2019ƒHealthƒCareƒLawƒ(Articlesƒ8–15): ƒƒ ƒMonitoringƒofƒtheƒhealthƒstatusƒofƒtheƒpopulationƒandƒtheƒoperationƒ ofƒtheƒhealthƒserviceƒinƒtheirƒrespectiveƒterritories,ƒasƒwellƒasƒlookingƒ afterƒtheƒimplementationƒofƒtheƒestablishedƒprioritiesƒinƒhealth care. ƒƒ ƒCreatingƒconditionsƒforƒaccessibilityƒandƒequalƒuseƒofƒprimaryƒcareƒ inƒtheirƒrespective territories. 29Serbia ƒƒ ƒCoordinating,ƒ encouraging,ƒ organizingƒ andƒ directingƒ theƒ implementationƒofƒhealthƒcare,ƒwhichƒisƒexercisedƒbyƒtheƒactivitiesƒ ofƒtheƒ localƒself-governmentƒunits,ƒcitizens,ƒenterprises,ƒsocial,ƒ educational,ƒandƒotherƒfacilitiesƒandƒother organizations. ƒƒ ƒPlanningƒ andƒ implementationƒ ofƒ ownƒ programmesƒ forƒ theƒ preservationƒandƒprotectionƒofƒhealthƒfromƒaƒpolluted environment. ƒƒ ƒProvidingƒtheƒfundsƒforƒperformanceƒofƒtheƒprimaryƒhealthƒcareƒ institutionsƒinƒtheirƒrespectiveƒterritoriesƒinƒcomplianceƒwithƒtheƒ 2019ƒHealthƒCareƒLawƒandƒwithƒtheƒ2006–2018ƒDecreeƒonƒtheƒPlanƒ ofƒtheƒHealthƒInstitutions’ƒNetwork,ƒwhichƒincludesƒconstruction,ƒ maintenance,ƒandƒequippingƒofƒhealthƒcare facilities. ƒƒ ƒCooperationƒwithƒhumanitarianƒandƒprofessionalƒorganizations,ƒ unionsƒandƒassociations,ƒinƒtheƒaffairsƒofƒhealth development. 2.4  Planning TheƒgovernmentƒandƒtheƒMinistryƒofƒHealthƒareƒresponsibleƒforƒtheƒstrategicƒ planningƒinƒtheƒhealthƒsectorƒinƒcooperationƒwithƒotherƒministries,ƒparticu- larlyƒtheƒMinistryƒofƒFinanceƒandƒtheƒMinistryƒofƒPublicƒAdministrationƒandƒ LocalƒSelf-Government.ƒTheƒHealthƒCouncilƒhasƒanƒadvisoryƒrole,ƒtogetherƒ withƒtheƒparliamentarianƒHealthƒandƒFamilyƒCommitteeƒ(seeƒsectionƒ2.2).ƒ Strategicƒplanningƒcontinuesƒtoƒtakeƒadvantageƒofƒtheƒhealthƒpolicyƒdocumentƒ “HealthƒPolicyƒofƒSerbia”ƒadoptedƒbyƒtheƒgovernmentƒinƒ2002ƒ(Ministryƒofƒ Health,ƒ2003).ƒAfterƒtheƒdemocraticƒchangesƒinƒSerbiaƒinƒ2000ƒ(seeƒsectionƒ 2.1),ƒthisƒdocumentƒwasƒtheƒresultƒofƒtheƒneedƒtoƒdefineƒprimaryƒgoalsƒandƒ directionsƒofƒhealthƒcareƒdevelopment:ƒitƒwasƒtheƒoutcomeƒofƒanƒexpert-ledƒ consultativeƒprocess.ƒGeneralƒgoalsƒofƒtheƒpolicyƒhaveƒaƒfocusƒonƒpopula- tionƒhealth,ƒequitableƒaccessƒtoƒhealthƒservicesƒ(especiallyƒforƒvulnerableƒ populations),ƒaƒpatient-centredƒhealthƒsystem,ƒselectiveƒdecentralizationƒ inƒtheƒfieldƒofƒresourcesƒmanagement,ƒcontinuousƒqualityƒimprovement,ƒaƒ betterƒdefinitionƒofƒtheƒroleƒofƒprivateƒsectorƒandƒstrengtheningƒofƒhumanƒ resourcesƒfor health. Followingƒtheƒhealthƒpolicyƒatƒnationalƒ level,ƒoverƒ theƒpastƒyears,ƒ numerousƒstrategies,ƒplansƒandƒprogrammesƒhaveƒstartedƒinƒSerbiaƒtoƒensureƒ theƒimplementationƒofƒactivitiesƒandƒtheƒoverallƒsustainableƒdevelopmentƒofƒ theƒhealthƒsystem.ƒStrategiesƒandƒplansƒareƒusuallyƒendorsedƒbyƒtheƒgovern- ment,ƒexceptƒtheƒ2010ƒPlanƒforƒDevelopmentƒofƒHealthƒCareƒinƒtheƒRepublicƒ 30 Health Systems in Transition ofƒSerbia,ƒwhichƒwasƒpassedƒbyƒdecisionƒofƒtheƒparliamentƒinƒ2010ƒ(Officialƒ Gazette,ƒ2010c).ƒThisƒPlanƒisƒbasedƒonƒanalysesƒofƒpopulationƒhealth,ƒtheƒ assessmentƒofƒhealthƒcareƒneeds,ƒandƒavailableƒhuman,ƒfinancialƒandƒotherƒ recourses.ƒThisƒPlanƒhasƒtwoƒpriorityƒareasƒaccompaniedƒwithƒobjectivesƒandƒ plannedƒactivities:ƒ1)ƒpreservingƒandƒimprovingƒtheƒhealthƒofƒtheƒpopula- tion;ƒandƒ2)ƒtheƒorganizationƒandƒfunctioningƒofƒhealthƒcare.ƒInƒorderƒtoƒ implementƒtheƒPlan,ƒtheƒSerbianƒGovernmentƒpassedƒnationalƒprogrammesƒ forƒhealthƒcare,ƒsuchƒasƒprogrammesƒofƒimmunization,ƒprogrammesƒforƒrareƒ diseasesƒandƒprogrammesƒforƒtheƒpreventionƒofƒtypeƒ2ƒdiabetes.ƒInƒaddition,ƒ anƒautonomousƒprovince,ƒaƒmunicipalityƒorƒaƒcityƒcanƒimplementƒsomeƒspecialƒ programmesƒinƒtheƒareaƒofƒhealthƒcare,ƒwhichƒareƒnotƒpassedƒorƒimplementedƒ atƒnationalƒlevel,ƒforƒspecificƒpopulationƒgroupsƒorƒillnessesƒspecificƒforƒtheƒ localƒlevelƒ(ProvincialƒSecretariatƒforƒHealthƒCare,ƒ2018). Atƒtheƒnationalƒlevel,ƒtheƒMinistryƒofƒHealthƒandƒtheƒgovernmentƒhaveƒ responsibilitiesƒforƒplanningƒhumanƒresourcesƒandƒinfrastructure.ƒThisƒ functionƒisƒsubjectƒtoƒhealthƒlegislation,ƒsuchƒasƒtheƒDecreeƒonƒtheƒPlanƒ ofƒtheƒHealthƒInstitutions’ƒNetworkƒ(OfficialƒGazette,ƒ2006b).ƒThisƒPlanƒ specifiesƒtheƒnumber,ƒstructure,ƒcapacitiesƒandƒspatialƒdistributionƒofƒhealthƒ careƒfacilitiesƒandƒtheirƒorganizationalƒunitsƒbyƒlevelsƒofƒhealthƒcare,ƒtheƒ organizationƒofƒemergencyƒcare,ƒasƒwellƒasƒotherƒissuesƒofƒimportanceƒforƒ theƒorganizationƒofƒhealthƒservicesƒinƒtheƒcountry.ƒBesidesƒtheƒadoptedƒ2007ƒ LawƒonƒLocalƒSelf-Governance,ƒwhichƒprovidesƒforƒdecisionƒandƒplanningƒ spaceƒforƒlocalƒauthoritiesƒtoƒexerciseƒmoreƒresponsibilityƒinƒgovernanceƒatƒ theƒlocalƒlevel,ƒdecisionƒandƒplanningƒcapacityƒatƒtheƒlocalƒlevelƒstaysƒlimited.ƒ Onlyƒsomeƒmunicipalitiesƒhaveƒusedƒtheƒopportunityƒtoƒdevelopƒlocalƒpublicƒ healthƒstrategies,ƒwhileƒmunicipalƒplanningƒatƒtheƒoperationalƒlevelƒ(annualƒ planning)ƒoccasionallyƒincludesƒcapitalƒinvestmentsƒforƒprimary care. TheƒNHIFƒandƒIPHƒBatutƒwithƒitsƒnetworkƒofƒregionalƒIPHsƒhaveƒanƒ importantƒroleƒinƒstrategicƒandƒoperationalƒplanningƒthroughƒcontributingƒ toƒtheƒworkingƒgroupsƒofƒtheƒMinistryƒofƒHealthƒwithƒhealthƒneedsƒassess- ments,ƒmakingƒproposalsƒofƒnationalƒprioritiesƒandƒestablishingƒconsensusƒ throughƒpublicƒhearingsƒandƒdebates.ƒAlso,ƒtheƒNHIFƒhasƒanƒimportantƒroleƒ inƒannualƒoperationalƒplanningƒbyƒformulatingƒandƒadoptingƒeachƒyearƒaƒplanƒ ofƒhealthƒcareƒcoveredƒbyƒmandatoryƒhealthƒinsuranceƒ(NHIF,ƒ2017a).ƒTheƒ mainƒobjectivesƒofƒhealthƒcareƒandƒtheƒtypeƒandƒvolumeƒofƒhealthƒcareƒservicesƒ coveredƒbyƒmandatoryƒhealthƒinsuranceƒshouldƒbeƒbasedƒonƒanƒassessmentƒ ofƒhealthƒneedsƒandƒpriorities,ƒandƒbeƒinƒlineƒwithƒtheƒobjectivesƒofƒhealthƒ 31Serbia policies.ƒHowever,ƒthisƒannualƒplanƒisƒstillƒmainlyƒbasedƒonƒinputs.ƒTheƒ IPHƒBatutƒandƒtheƒnetworkƒofƒregionalƒIPHsƒareƒsupportingƒtheƒprocessƒofƒ annualƒplanningƒbyƒprovidingƒtheƒsituationƒanalysisƒasƒtheƒfirstƒstepƒinƒtheƒ processƒof planning. Sinceƒ2008,ƒwithƒtheƒintroductionƒofƒtheƒAgencyƒforƒAccreditationƒofƒ HealthƒCareƒInstitutionsƒofƒSerbia,ƒhealthƒinstitutionsƒhaveƒbeenƒsubmit- tingƒinstitutionalƒstrategicƒplansƒasƒpartƒofƒtheƒaccreditationƒprocess.ƒAnƒ institutionalƒstrategicƒplanƒencompassesƒtheƒorganization’sƒmission,ƒvision,ƒ objectivesƒandƒactionƒplansƒaimedƒatƒachievingƒtheseƒobjectives.ƒInƒaddition,ƒ followingƒtheƒ2009ƒLawƒonƒEmergencyƒSituationsƒ(OfficialƒGazette,ƒ2009c),ƒ healthƒinstitutionsƒhaveƒbeenƒpassingƒplansƒonƒemergencyƒresponsesƒasƒpre- parednessƒmeasuresƒforƒallƒtypesƒof hazards. Duringƒtheƒlastƒdecade,ƒmanyƒmultisectoralƒandƒsectoralƒstrategiesƒhaveƒ beenƒdeveloped.ƒInternationalƒpartners,ƒespeciallyƒtheƒEuropeanƒUnionƒandƒ theƒWorldƒBankƒGroup,ƒhaveƒfrequentlyƒsupportedƒtheƒprocessƒofƒdevelopingƒ strategicƒplans,ƒtoƒsupportƒtheƒmanagementƒandƒcoordinationƒofƒhealth- relatedƒinternationalƒdevelopmentƒassistance.ƒHowever,ƒtheƒcoexistenceƒofƒ aƒnumberƒofƒstrategiesƒcreatesƒpotentialƒoverlapƒthatƒcanƒleadƒtoƒconflict- ingƒobjectivesƒandƒmeasures,ƒasƒwellƒasƒmissingƒobjectives.ƒAsƒanƒexample,ƒ improvingƒhealthƒcareƒqualityƒandƒpatientƒsafetyƒformƒanƒimportantƒstrandƒ ofƒthisƒstrategicƒapproach,ƒreflectedƒinƒtheƒ2009ƒStrategyƒforƒContinuousƒ ImprovementƒofƒHealthƒCareƒQualityƒandƒPatientƒSafetyƒ(OfficialƒGazette,ƒ 2009d).ƒHowever,ƒtheƒexistingƒ2009ƒstrategyƒdoesƒnotƒmentionƒcorruptionƒ once,ƒwhichƒisƒlikelyƒtoƒbeƒaƒmajorƒfactor.ƒInƒthisƒrespect,ƒtheƒframeworkƒforƒ healthƒplanningƒneedsƒtoƒlinkƒtoƒtheƒanti-corruptionƒthemeƒofƒtheƒjusticeƒ sector.ƒMoreƒattentionƒshouldƒalsoƒbeƒappliedƒtoƒtheƒefficiencyƒofƒhealthƒ expenditureƒ(CEVES,ƒ2016).ƒSupportƒtoƒtheƒhealthƒsectorƒisƒlikelyƒtoƒbeƒ onƒacquis-relatedƒissuesƒorƒprovidedƒindirectly;ƒforƒexample,ƒthroughƒsocialƒ inclusionƒmeasuresƒ(EuropeanƒCommission,ƒ2014). Basedƒonƒtheƒ2016ƒPublicƒHealthƒLaw,ƒeachƒIPHƒinƒcooperationƒwithƒ otherƒactorsƒ(healthƒandƒsocialƒcareƒinstitutions,ƒotherƒgovernmentalƒandƒ nongovernmentalƒorganizationsƒ–ƒpublicƒorƒprivate)ƒproposesƒprogrammesƒinƒ theƒpublicƒhealthƒareaƒtoƒtheƒlocalƒself-government.ƒLocalƒself-governmentƒ unitsƒfinanceƒactivitiesƒwhichƒtheƒIPHƒimplementsƒandƒcoordinatesƒindividu- ally,ƒorƒinƒcooperationƒwithƒotherƒactorsƒatƒtheƒlocalƒlevel.ƒActivitiesƒinclude:ƒ preparingƒtheƒcity/municipalityƒpublicƒhealthƒplan,ƒimprovingƒtheƒqualityƒ ofƒhealthƒcare,ƒconductingƒepidemiologicalƒsurveillance,ƒearlyƒdetectionƒandƒ diseaseƒcontrol,ƒandƒotherƒareasƒofƒpublic health. 32 Health Systems in Transition Althoughƒcomprehensiveƒplanningƒforƒcross-borderƒmobilityƒofƒpatientsƒ andƒhealthƒworkersƒdoesƒstillƒnotƒexistƒinƒSerbia,ƒthereƒareƒprogrammesƒandƒ projectsƒforƒbilateralƒorƒmultilateralƒmobility.ƒSomeƒexamplesƒare:ƒtheƒCross- BorderƒCooperationƒProgrammeƒCroatia–Serbiaƒ2014–2020ƒ(https://razvoj. gov.hr/UserDocsImages/Arhiva/Vijesti/HR-RS%202014-2020_Draft_ Cooperation_programme.pdf),ƒtheƒ2016–2020ƒCross-BorderƒCooperationƒ ProgrammeƒbetweenƒSerbiaƒandƒNorthƒMacedoniaƒ(http://www.kt.gov. rs/en/news/news-archive/a-new-program-of-2016-2020-cross-border- cooperation-between-serbia-macedonia-adopted/),ƒandƒtheƒWHOƒprojectƒ onƒstrengtheningƒcollaborationƒtoƒimproveƒcross-borderƒhealth opportunities. 2.4.1 Stated objectives of the health system Theƒ2006ƒConstitutionƒofƒtheƒRepublicƒofƒSerbiaƒ(OfficialƒGazette,ƒ2006a)ƒ setsƒoutƒtheƒrightƒtoƒhealthƒcareƒinƒArticleƒ68,ƒwhich stipulates: ƒƒ ƒTheƒrightƒtoƒprotectionƒofƒeveryone’sƒmentalƒandƒphysical health. ƒƒ ƒTheƒprovisionƒofƒpubliclyƒfundedƒhealthƒcareƒforƒchildren,ƒpregnantƒ women,ƒmothersƒonƒmaternityƒleave,ƒsingleƒparentsƒwithƒchildrenƒ underƒ7ƒyearsƒofƒageƒandƒolderƒpeople,ƒunlessƒthisƒcareƒisƒprovidedƒ inƒsomeƒotherƒmannerƒinƒaccordanceƒwithƒthe law. ƒƒ ƒTheƒregulationƒofƒhealthƒinsurance,ƒhealthƒcareƒandƒandƒhealthƒ careƒfundsƒaccordingƒtoƒthe law. Inƒ2002,ƒtheƒSerbianƒGovernmentƒstartedƒreformingƒtheƒhealthƒsystemƒ (seeƒsectionƒ6.1).ƒItƒwasƒsetƒasƒaƒnationalƒpriorityƒandƒdevelopedƒwithinƒaƒ contextƒofƒEuropeanƒintegrationƒandƒpublicƒsectorƒreformƒ(assistanceƒinƒtheƒ reformƒprocessƒwasƒprovidedƒbyƒtheƒEUƒandƒtheƒWorldƒBank). Theƒmainƒobjectivesƒofƒtheƒhealthƒsystemƒreformsƒinƒgeneralƒwereƒtoƒ increaseƒtheƒaccessibilityƒofƒhealthƒservicesƒtoƒtheƒpopulation,ƒtoƒimproveƒtheƒ equityƒinƒtheƒuseƒofƒexistingƒfinancialƒresources,ƒandƒtoƒimproveƒtheƒqualityƒ ofƒhealthƒcareƒandƒtheƒefficiencyƒofƒtheƒoverallƒsystemƒ(WorldƒBank,ƒ2009).ƒ Inƒ2002,ƒtheƒgovernmentƒadoptedƒaƒNationalƒHealthƒPolicy,ƒbasedƒonƒtheƒ principleƒthatƒtheƒhealthƒofƒtheƒpeopleƒisƒofƒgeneralƒpublicƒinterestƒandƒtheƒ mostƒimportantƒresourceƒforƒtheƒdevelopmentƒofƒaƒcountry.ƒTheƒdocumentƒ 33Serbia positionsƒhealthƒhighƒonƒtheƒlistƒofƒpriorities,ƒrecognizesƒtheƒlinkƒbetweenƒ healthƒandƒallƒsectorsƒofƒsocietyƒandƒconsidersƒundertakingƒspecificƒactivitiesƒ inƒthisƒdirectionƒbyƒapplyingƒaƒhealthƒpromotionƒapproach.ƒHealthƒpolicyƒ arisesƒandƒreliesƒonƒtheƒoverallƒsocioeconomicƒpolicyƒandƒhasƒtheƒfollowingƒ sevenƒnationalƒgoalsƒ(MinistryƒofƒHealth,ƒ2003): ƒƒ ƒProtectionƒandƒimprovementƒofƒtheƒhealthƒstatusƒofƒtheƒpopulationƒ andƒstrengtheningƒtheƒhealthƒpotentialƒofƒthe nation. ƒƒ ƒEquitableƒ andƒ equalƒ accessƒ toƒ healthƒ careƒ forƒ allƒ citizensƒ ofƒ Serbia,ƒforƒtheƒsameƒneeds,ƒasƒwellƒasƒimprovingƒtheƒhealthƒcareƒ ofƒvulnerableƒpopulation groups. ƒƒ ƒPlacingƒusersƒ(patients)ƒatƒtheƒcentreƒofƒtheƒhealth system. ƒƒ ƒHealthƒsystemƒsustainability,ƒwithƒ transparencyƒandƒselectiveƒ decentralizationƒinƒtheƒfieldƒofƒresourceƒmanagement,ƒandƒtheƒ disseminationƒofƒsourcesƒandƒwaysƒof financing. ƒƒ ƒImprovingƒtheƒfunctioning,ƒefficacyƒandƒqualityƒofƒtheƒhealthƒ system,ƒthroughƒdefiningƒspecificƒnationalƒprogrammesƒinƒtheƒ fieldƒofƒhumanƒresources,ƒtheƒnetworkƒofƒinstitutions,ƒtechnologyƒ andƒmedical supplies. ƒƒ ƒDefiningƒtheƒroleƒofƒtheƒprivateƒsectorƒinƒprovidingƒhealthƒservicesƒ toƒthe population. ƒƒ ƒImprovementƒofƒtheƒhealthƒpersonnelƒdatabaseƒ(humanƒresourcesƒ forƒhealth). Theƒemergenceƒofƒinternationalƒpartnersƒhasƒimposedƒtheƒneedƒtoƒ formulateƒaƒclearƒvisionƒforƒtheƒdevelopmentƒofƒtheƒhealthƒsystem.ƒTheƒ MinistryƒofƒHealth,ƒinƒitsƒ2003ƒpublicationƒBetterƒHealthƒforƒAllƒinƒtheƒThirdƒ Millennium,ƒpresentedƒaƒstrategyƒforƒtheƒreformƒprocessƒinƒtheƒhealthƒsystemƒ untilƒ2015ƒtogetherƒwithƒanƒActionƒPlan,ƒandƒaƒVisionƒofƒtheƒHealthƒSystemƒ inƒSerbia,ƒwhichƒhasƒnineƒleadingƒprinciplesƒandƒwasƒformulatedƒwithƒtheƒ participationƒofƒallƒstakeholdersƒinƒtheƒhealthƒsystemƒ(MinistryƒofƒHealth,ƒ 2003).ƒAccordingƒtoƒtheƒvisionƒtheƒhealthƒsectorƒreliesƒonƒseveral premises: ƒƒ ƒTheƒ futureƒhealthƒsystemƒ inƒSerbiaƒwillƒ evolveƒ fromƒexistingƒ capacitiesƒandƒinheritedƒtraditionƒ(thatƒis,ƒdestroyedƒbasicƒcapitalƒ–ƒ buildingsƒandƒequipment,ƒlackƒofƒdrugsƒandƒmedicalƒsupplies,ƒpoorƒ qualityƒofƒhealthƒservices,ƒinformalƒpaymentsƒandƒcorruption). 34 Health Systems in Transition ƒƒ ƒTheƒprincipleƒofƒsolidarityƒwillƒbeƒtheƒmostƒimportantƒforƒdecision- makingƒandƒchoiceƒofƒdiagnosticƒandƒtreatmentƒoptions,ƒandƒmustƒ beƒcontinuouslyƒrespectedƒatƒall levels. ƒƒ ƒInƒorderƒtoƒensureƒtheƒbestƒpossibleƒhealthƒcare,ƒdevelopmentƒ inƒ upcomingƒ yearsƒ shouldƒ considerƒ theƒ financialƒ constraintsƒ conditionedƒbyƒtheƒavailableƒfundsƒofƒthe country. ƒƒ ƒTheƒjointƒactionƒofƒtheƒpublicƒandƒprivateƒsectorƒinƒtheƒprovisionƒ ofƒhealthƒservicesƒwillƒprovideƒtheƒpopulationƒwithƒaƒhealthƒsystemƒ inƒwhichƒequalƒaccessƒtoƒtheƒbasicƒpackageƒofƒhealthƒservicesƒ isƒ ensuredƒacrossƒtheƒpopulationƒthroughƒeffectiveƒorganizationƒandƒ inƒaccordanceƒwithƒavailable resources. Atƒtheƒendƒofƒ2005,ƒtheƒlegislationƒsupportingƒtheƒreformƒwasƒcompletedƒ byƒadoptingƒthreeƒlaws:ƒtheƒ2005ƒHealthƒCareƒLawƒ(OfficialƒGazette,ƒ2005a);ƒ theƒ2005ƒHealthƒInsuranceƒLawƒ(OfficialƒGazette,ƒ2005b);ƒandƒtheƒ2005ƒ ChambersƒofƒPhysiciansƒLawƒ(OfficialƒGazette,ƒ2005c).ƒInƒ2019,ƒtheƒnewƒ HealthƒCareƒLawƒandƒHealthƒInsuranceƒLawƒintroducedƒsomeƒchangesƒ (OfficialƒGazette,ƒ2019a,ƒ2019b)ƒ(seeƒChaptersƒ5ƒandƒ6). Probably,ƒtheƒmostƒimportantƒdocumentƒforƒtheƒdevelopmentƒofƒtheƒ healthƒsystemƒinƒtheƒcountryƒisƒtheƒ2010ƒHealthƒCareƒDevelopmentƒPlanƒ ofƒSerbiaƒ(OfficialƒGazette,ƒ2010a),ƒwhichƒdirectedƒtheƒdevelopmentƒofƒ theƒhealthƒsystemƒforƒtheƒperiodƒ2010–2015.ƒThisƒPlanƒstillƒconstitutesƒ anƒinstrumentƒforƒtheƒimplementationƒofƒchangesƒwithƒdefinedƒgoalsƒandƒ directionsƒforƒtheƒdevelopmentƒofƒhealthƒcare.ƒPriorityƒfieldsƒforƒtheƒprotec- tionƒandƒimprovementƒofƒtheƒhealthƒstatusƒofƒtheƒpopulationƒare:ƒpreventionƒ andƒcontrolƒofƒnoncommunicableƒdiseases,ƒpreventionƒandƒcontrolƒofƒinfec- tiousƒdiseasesƒandƒhealthƒcareƒforƒvulnerableƒgroups,ƒwhileƒpriorityƒfieldsƒofƒ organizationƒandƒfunctioningƒofƒhealthƒcareƒincludeƒintegratedƒcare,ƒhumanƒ resourcesƒforƒhealth,ƒintegratedƒhealthƒinformationƒsystems,ƒqualityƒofƒcare,ƒ andƒpatientƒsafetyƒandƒfinancing.ƒTheƒimplementationƒofƒtheƒPlanƒhasƒnotƒ beenƒofficiallyƒevaluatedƒandƒitƒisƒthereforeƒdifficultƒtoƒassessƒwhetherƒitsƒ goalsƒhaveƒbeen met. 2.5  Intersectorality Sinceƒ2002,ƒnumerousƒmultisectoralƒstrategiesƒhaveƒbeenƒadopted,ƒwithƒ implicationsƒforƒtheƒdevelopmentƒofƒtheƒhealthƒsystem,ƒinƒparticularƒtheƒ qualityƒofƒhealthƒcareƒandƒtheƒpreventionƒofƒnoncommunicableƒdiseases,ƒ 35Serbia asƒwellƒasƒsector-specificƒstrategicƒdocumentsƒthatƒdirectlyƒdetermineƒtheƒ developmentƒofƒtheƒhealth system. Theƒmostƒrelevantƒintersectoralƒstrategiesƒinclude:ƒtheƒ2003ƒPovertyƒ ReductionƒStrategyƒofƒtheƒRepublicƒofƒSerbia,ƒtheƒ2004ƒNationalƒActionƒ PlanƒforƒChildren,ƒtheƒ2006ƒNationalƒStrategyƒonƒAgeing,ƒtheƒ2007ƒTobaccoƒ ControlƒStrategy,ƒ theƒ2018ƒBirthƒPromotionƒStrategy,ƒ theƒ2015–2025ƒ NationalƒYouthƒStrategy,ƒtheƒ2009ƒStrategyƒforƒtheƒPreventionƒandƒProtectionƒ ofƒChildrenƒagainstƒViolence,ƒtheƒ2009ƒNationalƒStrategyƒforƒImprovingƒtheƒ PositionƒofƒWomenƒandƒPromotingƒGenderƒEquality,ƒtheƒ2014ƒActionƒPlanƒ forƒRomaƒHealthƒwithinƒtheƒframeworkƒofƒtheƒStrategyƒforƒtheƒPromotionƒ ofƒtheƒStatusƒofƒRoma,ƒtheƒ2009–2012ƒOccupationalƒSafetyƒandƒHealthƒ StrategyƒinƒtheƒRepublicƒofƒSerbia,ƒtheƒ2013–2017ƒStrategyƒonƒSafetyƒandƒ HealthƒatƒWorkƒinƒtheƒRepublicƒofƒSerbia,ƒtheƒ2014–2021ƒStrategyƒforƒtheƒ DrugƒAbuseƒPrevention,ƒandƒtheƒ2009ƒNationalƒStrategyƒforƒPalliative Care. Allƒ sevenƒpublicƒhealthƒprioritiesƒ inƒSerbia,ƒaccordingƒtoƒtheƒnewƒ 2016–2025ƒPublicƒHealthƒStrategyƒ(seeƒsectionƒ5.1),ƒareƒaimedƒatƒachievingƒ intersectoralƒcooperationƒ(OfficialƒGazette,ƒ2018).ƒThese are: ƒƒ ƒImprovingƒhealthƒandƒreducingƒhealth inequalities. ƒƒ ƒImprovingƒtheƒenvironmentƒandƒworking conditions. ƒƒ ƒPreventingƒandƒcombatingƒmajorƒdiseasesƒandƒhealthƒrisksƒforƒ the population. ƒƒ ƒDevelopingƒactionsƒtoƒpromoteƒhealthƒinƒthe community. ƒƒ ƒSupportƒ forƒ theƒ developmentƒ ofƒ accessible,ƒ high-qualityƒ andƒ efficientƒhealth care. ƒƒ ƒDevelopingƒ theƒ systemƒ ofƒ publicƒ healthƒ basedƒ onƒ evidenceƒ from research. ƒƒ ƒImprovingƒleadership,ƒcommunicationƒandƒpartnershipƒforƒtheƒ implementationƒofƒtheƒapproachƒ“HealthƒinƒAllƒPolicies”. Temporaryƒworkingƒgroupsƒconsistingƒofƒrepresentativesƒfromƒdifferentƒ sectorsƒsupportƒtheƒdevelopmentƒofƒintersectoralƒdocuments.ƒInƒadditionƒtoƒ policyƒdocuments,ƒseveralƒlegalƒactsƒhighlightƒintersectoralityƒandƒfollowƒ theƒinitiativeƒofƒtheƒMinistryƒofƒHealthƒtoƒimplementƒintersectoralƒcol- laboration.ƒAsƒanƒexample,ƒtheƒ2011ƒLawƒonƒSocialƒProtectionƒregulatesƒ theƒestablishmentƒofƒjointƒsocial–healthƒcareƒinstitutionsƒandƒsocialƒhealthƒ careƒorganizationalƒunitsƒforƒbeneficiariesƒwhoƒneedƒbothƒsocialƒcareƒandƒ permanentƒhealthƒcareƒ(suchƒasƒhomesƒforƒpeopleƒlivingƒwithƒdisabilitiesƒorƒ 36 Health Systems in Transition homesƒforƒwomenƒexposedƒtoƒfamilyƒviolence).ƒTheƒ2009ƒLawƒonƒFoodƒSafetyƒ isƒaƒresultƒofƒintersectoralƒactionsƒofƒagriculture,ƒenvironmentalƒprotection,ƒ healthƒandƒeconomicƒsectors.ƒInƒ2013,ƒtoƒspeedƒupƒinterventionsƒbasedƒonƒ theƒ“HealthƒinƒAllƒPolicies”ƒapproachƒ(WHO,ƒ2013),ƒfollowingƒtheƒinitiativeƒ ofƒtheƒMinistryƒofƒHealth,ƒtheƒgovernmentƒestablishedƒanƒintersectoralƒbodyƒ forƒtheƒcoordinationƒofƒactivities.ƒInƒ2016,ƒtheƒparliamentƒpassedƒtheƒ2016ƒ PublicƒHealthƒLaw,ƒwhichƒemphasizesƒanƒintersectoralƒapproach.ƒFollowingƒ thisƒLaw,ƒtheƒgovernmentƒestablishedƒtheƒNationalƒPublicƒHealthƒCouncil,ƒ composedƒofƒrepresentativesƒfromƒrelevantƒministries,ƒInstitutesƒofƒPublicƒ Health,ƒlocalƒauthorities,ƒnongovernmentalƒassociationsƒandƒprivateƒinstitu- tions,ƒtoƒadvanceƒcooperationƒamongƒdifferentƒsectors,ƒorganizations,ƒkeyƒ actorsƒandƒparticipantsƒinƒtheƒpublicƒhealthƒsystem.ƒSoƒfar,ƒthereƒhasƒbeenƒ noƒoverallƒimpactƒassessmentƒofƒintersectoralƒwork,ƒalthoughƒtheƒIPHƒBatutƒ performsƒsurveysƒonƒspecificƒchallenges,ƒsuchƒasƒtheƒintersectoralƒresponseƒ forƒtheƒpreventionƒofƒdrugƒabuseƒand violence. Theƒmostƒrecentƒandƒprominentƒexampleƒofƒintersectoralƒcooperationƒ isƒonƒtheƒpreventionƒofƒviolenceƒagainstƒchildren.ƒViolenceƒagainstƒchildrenƒ contributesƒtoƒaƒsignificantƒburdenƒofƒdiseaseƒandƒinjuryƒinƒSerbia.ƒTheƒYearsƒ ofƒLifeƒLostƒ(YLL)ƒrateƒdueƒtoƒself-harmƒandƒinterpersonalƒviolenceƒasƒcausesƒ ofƒprematureƒmortalityƒamongƒboysƒagedƒ0–19ƒareƒatƒsixthƒplaceƒamongƒallƒ causes,ƒandƒtheƒseventhƒforƒgirlsƒofƒtheƒsameƒageƒ(IHME,ƒ2016).ƒAmongƒ childrenƒagedƒ0–19ƒyears,ƒYLLsƒpointƒtoƒconditionsƒwhichƒareƒpreventableƒ andƒtheƒsubjectƒofƒcost-effective,ƒintersectoralƒpublicƒhealthƒinterventions.ƒ Preventionƒofƒviolenceƒagainstƒchildrenƒandƒitsƒpublicƒhealthƒconsequencesƒ belongsƒ(asƒanƒoperationalƒobjective)ƒtoƒtheƒfirstƒpriorityƒofƒtheƒnewƒ2018ƒ PublicƒHealthƒStrategyƒinƒSerbiaƒ(Goalƒ1:ƒImprovingƒhealthƒandƒreducingƒ healthƒinequalities).ƒTwoƒimportantƒeventsƒhaveƒboostedƒtheƒactivitiesƒforƒtheƒ protectionƒofƒchildrenƒfromƒviolenceƒinƒSerbiaƒandƒhighlightedƒtheƒneedƒforƒ strengtheningƒpolicy.ƒFirstly,ƒunderƒtheƒinitiativeƒofƒtheƒCommitteeƒonƒtheƒ RightsƒofƒtheƒChild,ƒtheƒUnitedƒNationsƒpublishedƒaƒglobalƒstudyƒonƒviolenceƒ againstƒchildrenƒinƒ2006ƒ(https://www.unicef.org/violencestudy/reports/SG_ violencestudy_en.pdf).ƒSecondly,ƒtheƒregionalƒprojectƒProtectionƒofƒChildrenƒ fromƒViolenceƒinƒSouthƒEastƒEuropeƒ(EU-UNICEFƒinitiative)ƒisƒcurrentlyƒ beingƒconductedƒinƒfourƒcountriesƒ(Albania,ƒBosniaƒandƒHerzegovina,ƒSerbiaƒ andƒTurkey)ƒwithƒtheƒobjectiveƒofƒstrengtheningƒtheƒsystemƒofƒrecognizingƒ andƒmonitoringƒviolenceƒagainstƒchildren,ƒandƒtoƒfightƒagainstƒitƒthroughƒ efficientƒpartnershipƒbetweenƒcivilƒsocietyƒandƒdecision-makersƒatƒtheƒstateƒ levelƒ(http://europa.eu/rapid/press-release_IP-11-822_en.htm).ƒManyƒlegalƒ 37Serbia documentsƒhaveƒbeenƒdevelopedƒsoƒfarƒbasedƒonƒtheƒinternationalƒConventionƒ onƒtheƒRightsƒofƒtheƒChildƒ(UN,ƒ1990)ƒandƒtheƒ2006ƒConstitution.ƒTheƒ 2004ƒNationalƒActionƒPlanƒforƒChildren,ƒaƒstrategicƒdocumentƒwhichƒtheƒ governmentƒadoptedƒinƒFebruaryƒ2004,ƒdefinesƒtheƒcountry’sƒgeneralƒpolicyƒ towardsƒchildrenƒforƒtheƒperiodƒuntilƒ2015.ƒOneƒofƒtheƒspecificƒobjectivesƒofƒ thisƒplanƒwasƒtheƒestablishmentƒofƒanƒeffective,ƒoperational,ƒmultisectoralƒ networkƒforƒtheƒprotectionƒofƒchildrenƒfromƒabuse,ƒneglect,ƒexploitationƒ andƒviolence.ƒToƒrealizeƒthisƒgoal,ƒtheƒGeneralƒProtocolƒforƒtheƒProtectionƒ ofƒChildrenƒfromƒAbuseƒandƒNeglectƒhasƒbeenƒcreatedƒ(Governmentƒofƒ Serbia,ƒ2005),ƒwhichƒtheƒgovernmentƒadoptedƒinƒAugustƒ2005.ƒInƒaccord- anceƒwithƒtheƒ2004ƒNationalƒActionƒPlanƒforƒChildren,ƒtheƒGeneralƒProtocolƒ contributesƒtoƒstrengtheningƒtheƒreportingƒandƒregistrationƒofƒallƒformsƒofƒ childƒabuseƒandƒneglect.ƒTheƒGeneralƒProtocolƒenvisionsƒtheƒdevelopmentƒ andƒexpansionƒofƒtheƒnetworkƒcomposedƒfromƒmultidisciplinaryƒteamsƒforƒ theƒprotectionƒofƒchildrenƒinƒtheƒlocalƒcommunity,ƒandƒtheƒimplementationƒ ofƒaƒunifiedƒmodelƒofƒpreventionƒatƒtheƒmunicipalƒlevelƒthroughoutƒSerbia.ƒ Allƒreportsƒofƒsuspectedƒchildƒabuseƒandƒneglectƒshouldƒbeƒdirectedƒtoƒtheƒ CentresƒforƒSocialƒWorkƒ(SCW)ƒthatƒneedƒtoƒorganizeƒtheƒserviceƒforƒtheƒ rapidƒassessmentƒorƒtriageƒofƒreceivedƒreports,ƒindicatingƒsuspectedƒchildƒ abuseƒandƒneglectƒandƒinitiatingƒtheƒrelevantƒinterventionsƒofƒtheƒpolice,ƒ emergencyƒandƒhospitals,ƒandƒtheƒpublicƒprosecutor.ƒFollowingƒadoptionƒofƒ theƒGeneralƒProtocol,ƒrelevantƒministriesƒjoinedƒinƒtheƒadoptionƒofƒspecificƒ protocolsƒfor:ƒsocialƒcareƒinstitutionsƒ(2006),ƒpoliceƒ(2006,ƒamendedƒinƒ2012),ƒ theƒeducationalƒsystemƒ(2007),ƒtheƒhealthƒsystemƒ(2009)ƒandƒtheƒjudiciaryƒ (2009).ƒSpecialƒProtocolsƒareƒgovernedƒbyƒinternalƒproceduresƒwithinƒtheƒ systemƒandƒindividualƒinstitutionsƒ(e.g.ƒhospitals,ƒschools,ƒetc.). AnƒincreasingƒnumberƒofƒNGOsƒareƒactivelyƒinvolvedƒinƒintersectoralƒ cooperation.ƒTheyƒhaveƒtheƒpotentialƒtoƒbecomeƒsignificantƒpartnersƒinƒ these activities. Otherƒexamplesƒofƒaƒsuccessfulƒintersectoralƒapproachƒareƒtransportƒ policies,ƒincludingƒroadƒsafety.ƒDuringƒtheƒlastƒdecade,ƒseveralƒmeasuresƒ haveƒbeenƒtakenƒtoƒimproveƒtrafficƒsafetyƒ(Jovicƒetƒal.,ƒ2018).ƒTheƒ2009ƒ LawƒonƒTrafficƒSafetyƒonƒRoadsƒ(OfficialƒGazette,ƒ2009k),ƒinƒadditionƒtoƒ alreadyƒexistingƒmeasuresƒ(seatƒbeltsƒforƒdriversƒandƒpassengers),ƒimplementedƒ majorƒchangesƒsuchƒas:ƒintroductionƒofƒnegativeƒpoints,ƒprohibitionƒofƒuseƒofƒ mobileƒphonesƒandƒotherƒcommunicationƒdevicesƒbyƒdriversƒandƒpedestriansƒ whileƒcrossingƒtheƒstreet,ƒtheƒpermittedƒalcoholƒlevelƒinƒbloodƒwasƒreducedƒ toƒ0.03 g/dl,ƒandƒtheƒmaximumƒspeedƒinƒpopulatedƒareasƒtoƒ50 km/h.ƒAlso,ƒ 38 Health Systems in Transition inƒ2015,ƒSerbiaƒbeganƒimplementingƒEUƒdirectivesƒandƒrecommendationsƒ onƒRoadƒInfrastructureƒSafetyƒManagementƒ(seeƒEUƒDirectiveƒat:ƒhttps:// eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A32008L0096).ƒ Thisƒincludesƒestablishingƒandƒimplementingƒproceduresƒofƒroadƒsafetyƒ impactƒassessments,ƒroadƒsafetyƒaudits,ƒtheƒmanagementƒofƒroadƒnetworkƒ safety,ƒandƒsafetyƒinspectionsƒ(Jovic-Vranesƒetƒal.,ƒ2018). 2.6  Health information systems Theƒhealthƒinformationƒsystemƒisƒregulatedƒbyƒlaw.ƒTheƒmostƒimportantƒonesƒ areƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ2014ƒLawƒonƒHealthƒRecordsƒandƒ ReportingƒinƒtheƒFieldƒofƒHealth,ƒsupportedƒbyƒotherƒbylawsƒ(seeƒsectionƒ 6.1.4).ƒTheƒsystemƒofƒhealthƒreportingƒservesƒtheƒmonitoringƒandƒanalysisƒofƒ theƒhealthƒstatusƒofƒtheƒpopulation,ƒtheƒplanningƒandƒprogrammingƒofƒhealthƒ care,ƒtheƒmonitoringƒandƒevaluationƒofƒtheƒimplementationƒofƒhealthƒcareƒ plansƒandƒprogrammes,ƒstatisticalƒandƒscientificƒresearchƒandƒother needs. Allƒactorsƒinƒtheƒpublicƒsystemƒareƒobligedƒtoƒreportƒregularlyƒtoƒtheƒ InstitutesƒofƒPublicƒHealthƒ(IPHs)ƒonƒtheirƒactivitiesƒrelatedƒtoƒpublicƒhealthƒ andƒhealthƒcareƒservicesƒatƒprimary,ƒsecondaryƒandƒtertiaryƒlevel.ƒIPHƒBatutƒ isƒresponsibleƒforƒtheƒcollectionƒofƒdataƒonƒpopulationƒhealth,ƒtheƒworkƒofƒ healthƒinstitutionsƒ(thatƒis,ƒclassicalƒindicatorsƒrelatedƒtoƒhealthƒservicesƒsuchƒ asƒvaccinationƒrates,ƒoutpatientƒandƒinpatientƒvisits,ƒaverageƒlengthƒofƒstayƒinƒ hospitalƒ(ALOS),ƒindicatorsƒofƒhealthƒcareƒquality,ƒcancerƒscreeningƒcoverage,ƒ etc.),ƒtheƒanalysisƒofƒcollectedƒhealthƒindicators,ƒtemplatesƒofƒmeasuresƒtoƒ improveƒpublicƒhealthƒ(forƒexample,ƒinƒhealthƒpromotion:ƒtheƒnumberƒofƒ mass-mediaƒcampaignsƒperƒregionalƒIPHƒorƒhealthƒeducationƒinterventions,ƒ orƒinƒtheƒfieldƒofƒenvironmentalƒhealth:ƒtheƒnumberƒofƒtestsƒperformedƒtoƒ detectƒairƒpollution,ƒorƒnumberƒandƒtypeƒofƒtestsƒtoƒdetectƒsafetyƒofƒdrinking- waterƒperƒwaterƒsource,ƒetc.),ƒandƒforƒproposingƒanƒannualƒworkplanƒforƒ theƒdevelopmentƒofƒhealthƒandƒcoordinationƒofƒtheƒHealthƒInformationƒ System.ƒIPHsƒareƒobligedƒtoƒsubmitƒreportsƒtoƒIPHƒBatutƒonƒpopulationƒ health,ƒmorbidityƒandƒmortalityƒ(includingƒdataƒforƒregistriesƒofƒspecificƒ priorityƒdiseases),ƒqualityƒofƒhealthƒcareƒandƒhealthƒcareƒfinancing.ƒThisƒ reportingƒincludesƒinformationƒonƒallƒtheirƒactivitiesƒinƒtheƒareaƒofƒpublicƒ health,ƒasƒwellƒasƒonƒactivitiesƒofƒotherƒparticipantsƒinƒtheƒpublicƒsystem.ƒ IPHsƒinƒtheƒprovinceƒofƒVojvodinaƒalsoƒsubmitƒtheirƒreportsƒtoƒIPHƒBatut,ƒ whichƒdrawsƒupƒandƒsubmitsƒreportsƒonƒpopulationƒhealthƒtoƒtheƒMinistryƒ 39Serbia ofƒHealthƒ(onceƒaƒyear,ƒbutƒinƒtheƒcaseƒofƒepidemicsƒitƒcouldƒbeƒseveralƒ timesƒperƒday).ƒThisƒinformationƒservesƒasƒtheƒfoundationƒforƒplanningƒ healthƒpolicy.ƒSimilarly,ƒbasedƒonƒdataƒgathered,ƒIPHsƒprepareƒreportsƒonƒ theƒhealthƒconditionƒofƒtheƒpopulationƒonƒtheirƒterritory.ƒAllƒreportsƒareƒ availableƒtoƒtheƒpublicƒonƒtheƒInstitute’sƒwebsiteƒ(http://www.batut.org.rs/ index.php?lang=1).ƒIPHsƒcooperateƒandƒexchangeƒinformationƒaboutƒtheƒ healthƒofƒtheƒpopulationƒwithƒlocalƒself-governmentƒunitsƒonƒtheƒterritoryƒforƒ whichƒtheyƒhaveƒbeenƒestablished.ƒBasedƒonƒindividualƒreportsƒfromƒhealthƒ institutionsƒsubmittedƒtoƒtheƒregionalƒIPHs,ƒIPHƒBatutƒholdsƒregistriesƒofƒ diseasesƒwithƒparticularƒpublicƒhealthƒsignificanceƒ(inƒtotalƒ17ƒdiseasesƒandƒ conditions,ƒincludingƒregularƒpublishingƒofƒreportsƒonƒdiabetes,ƒcancerƒandƒ acuteƒcoronaryƒsyndrome)ƒ(OfficialƒGazette,ƒ2016b;ƒIPHƒBatut,ƒ2018). InƒadditionƒtoƒIPHƒBatut,ƒimportantƒplayersƒwithinƒtheƒhealthƒinforma- tionƒsystemƒinƒSerbiaƒareƒtheƒNHIF,ƒwhichƒholdsƒaƒfinancialƒdatabase,ƒandƒtheƒ StatisticalƒOfficeƒofƒtheƒRepublicƒofƒSerbiaƒ(SORS),ƒwhichƒholdsƒdatabasesƒ onƒsociodemographyƒandƒmortality.ƒIPHƒBatutƒandƒSORSƒareƒresponsibleƒforƒ reportingƒtoƒWHO,ƒOECD,ƒEurostat,ƒECDCƒandƒtheƒEuropeanƒMonitoringƒ CentreƒforƒDrugsƒandƒDrugƒAddiction.ƒAƒnationalƒCommunicationƒCentreƒ forƒsurveillanceƒisƒestablishedƒinƒIPHƒBatut,ƒbasedƒonƒtheƒEuropeanƒCentreƒ forƒDiseaseƒPreventionƒandƒControlƒ(ECDC)ƒmethodology,ƒwhichƒprovidesƒ onlineƒcommunicationƒinƒtheƒcaseƒofƒpandemicsƒinƒorderƒtoƒcoordinateƒtheƒ nationalƒnetworkƒofƒIPHsƒandƒtoƒbeƒinƒcontactƒwithƒECDCƒ(inƒlineƒwithƒ Regulationƒ(EC)ƒNoƒ851/2004). Sinceƒ2010,ƒpositiveƒchangesƒhaveƒtakenƒplaceƒinƒnationalƒstatistics,ƒ facilitatingƒimprovedƒmonitoringƒofƒhealthƒbehaviourƒandƒsocialƒinclusion,ƒ includingƒthroughƒtheƒGlobalƒYouthƒTobaccoƒSurveyƒ(GYTS),ƒtheƒEuropeanƒ SchoolƒSurveyƒProjectƒonƒAlcoholƒandƒOtherƒDrugsƒ(ESPAD),ƒtheƒMultipleƒ IndicatorƒClusterƒSurveyƒ(MICS),ƒSILC,ƒtheƒEuropeanƒSystemƒofƒIntegratedƒ SocialƒProtectionƒStatisticsƒ(ESSPROSƒdatabase),ƒEuropeanƒQualityƒofƒLifeƒ Surveysƒ(EQLS),ƒtheƒ2014ƒStructureƒofƒEarningsƒSurvey,ƒandƒtheƒMappingƒofƒ SocialƒCareƒServicesƒwithinƒtheƒMandateƒofƒLocalƒGovernments.ƒHowever,ƒ thereƒisƒstillƒaƒlackƒofƒdisaggregatedƒadministrativeƒdataƒthatƒwouldƒhelpƒ identifyingƒdisparitiesƒregardingƒethnicity,ƒdisabilityƒandƒgenderƒorƒbetweenƒ urbanƒandƒruralƒpopulations.ƒDataƒavailabilityƒatƒtheƒmunicipalƒlevelƒwasƒ enhancedƒsignificantlyƒwithƒtheƒlaunchƒofƒtheƒnewƒMunicipalƒDevInfoƒ databaseƒinƒ2012.ƒThisƒdatabase,ƒdevelopedƒbyƒSORSƒinƒcooperationƒwithƒ UNICEF,ƒcontainsƒ142ƒsocioeconomicƒindicatorsƒdisaggregatedƒbyƒgenderƒ 40 Health Systems in Transition andƒotherƒvariablesƒforƒallƒ168ƒSerbianƒmunicipalities,ƒandƒenablesƒanalysisƒofƒ multipleƒregionalƒdisparitiesƒatƒtheƒnationalƒlevelƒforƒhealthƒvariablesƒsuchƒasƒ childƒsurvival,ƒhealthƒcare,ƒimmunization,ƒsafeƒmotherhoodƒandƒtuberculosisƒ (http://devinfo.stat.gov.rs/Opstine/libraries/aspx/Home.aspx). Regardingƒhealthƒcareƒqualityƒindicators,ƒhighlyƒrelevantƒindicatorsƒ includeƒscreeningƒforƒ(colon,ƒcervicalƒandƒbreast)ƒcancer,ƒasƒwellƒasƒtheƒ survivalƒrateƒafterƒcancerƒtreatment.ƒFullyƒreliableƒandƒcomparableƒdataƒ onƒtheƒentireƒpopulationƒ(ratherƒthanƒonlyƒtheƒpopulationƒcoveredƒbyƒtheƒ NationalƒCancerƒScreeningƒProgramme)ƒareƒcurrentlyƒunavailableƒ(SIPRU,ƒ 2017).ƒNevertheless,ƒIPHƒBatutƒpublishesƒannualƒreportsƒonƒhealthƒcareƒ qualityƒindicators.ƒInƒrecentƒyears,ƒtheƒsystemƒforƒmonitoringƒhealthƒcareƒ qualityƒandƒoutcomesƒhasƒbeenƒmarkedlyƒimproved,ƒwhichƒallowsƒbetterƒ insightsƒintoƒtheƒworkƒofƒhealthƒservicesƒ(theƒ2010ƒRulebookƒonƒHealthƒ CareƒQualityƒIndicators)ƒ(OfficialƒGazette,ƒ2010d).ƒTheƒnationalƒsurveyƒonƒ patientƒsatisfactionƒhasƒbeenƒongoingƒsinceƒ2004.ƒTheƒsurveyƒshowedƒthatƒ theƒsatisfactionƒofƒpatientsƒincreasedƒoverƒtimeƒwhichƒseemsƒtoƒindicateƒthatƒ reformsƒareƒyielding results. Overƒtheƒlastƒdecade,ƒtheƒMinistryƒofƒHealthƒhasƒinvestedƒsignificantƒ efforts,ƒthroughƒseveralƒprojectsƒsupportedƒbyƒinternationalƒpartnersƒ(pre- dominantlyƒEU-funded),ƒtoƒdevelopƒanƒintegratedƒhealthƒinformationƒsystemƒ (IHIS)ƒbasedƒonƒtheƒelectronicƒhealthƒrecordƒ(EHR).ƒSerbiaƒhasƒaƒlegalƒbasisƒ forƒtheƒintroductionƒofƒtheƒEHR,ƒwhichƒalsoƒprovidesƒaƒreasonableƒlevelƒofƒ privacyƒprotection.ƒInƒ2015,ƒtheƒMinistryƒofƒHealthƒestablishedƒtheƒUnitƒ forƒIntegratedƒHealthƒInformationƒSystemƒ(UIHIS)ƒtoƒcoordinate,ƒmonitorƒ andƒevaluateƒallƒdevelopments,ƒprojectsƒandƒinitiativesƒinƒtheƒhealthƒsystemƒ inƒSerbiaƒinƒtheƒfieldƒofƒhealthƒinformaticsƒandƒe-health.ƒInƒadditionƒtoƒtheƒ introductionƒofƒtheƒEHRƒinƒalmostƒallƒprimaryƒcareƒcentresƒ(Dom zdravlja-s),ƒ significantƒimprovementsƒinƒhospitalsƒstartedƒwithƒtheƒIntegratedƒHealthƒ InformationƒSystemƒ(EU-IHIS)ƒprojectƒ(EU-IHIS,ƒ2015),ƒwhichƒaimedƒtoƒ establishƒinterconnectivityƒbetweenƒhospitalsƒandƒprimaryƒcareƒcentresƒbasedƒ onƒtheƒEHRsƒ(seeƒsectionƒ4.1.3).ƒTheƒprojectƒlastedƒ3.5ƒyearsƒandƒenabledƒ IHISƒimplementationƒinƒ19ƒhealthƒcareƒinstitutionsƒthroughoutƒSerbiaƒasƒ wellƒasƒfurtherƒdevelopmentƒofƒtheƒEHR,ƒwithƒEUƒfinancialƒsupport,ƒinƒ cooperationƒwithƒtheƒMinistryƒofƒHealth,ƒtheƒWHOƒCountryƒOfficeƒandƒ theƒUnitedƒNationsƒOfficeƒforƒProjectƒServicesƒ(UNOPS). Currently,ƒmoreƒthanƒ200ƒhealthƒcareƒinstitutionsƒinƒtheƒpublicƒsector,ƒ fromƒaƒtotalƒofƒ355,ƒhaveƒEHRs.ƒOutƒofƒ158ƒprimaryƒcareƒcentres,ƒ152ƒhaveƒ electronicƒinformationƒsystemsƒthatƒareƒinƒuse,ƒasƒwellƒasƒtheƒelectronicƒ 41Serbia historyƒofƒtheƒdiseaseƒinƒoverƒ50ƒhospitalsƒ(EY,ƒ2016).ƒAllƒsoftwareƒisƒcom- pliantƒwithƒtheƒnationalƒstandard,ƒtheƒ2009ƒRulebookƒonƒtheƒContentƒofƒ TechnologicalƒandƒFunctionalƒRequirementsƒforƒEstablishingƒtheƒIntegratedƒ HealthƒInformationƒSystemƒ(OfficialƒGazette,ƒ2009h).ƒInƒspiteƒofƒtheseƒ developments,ƒhealthƒcareƒinstitutionsƒareƒstillƒobligedƒtoƒkeepƒbothƒpaperƒ andƒelectronicƒrecordsƒbasedƒonƒtheƒprovisionsƒofƒtheƒ2014ƒLawƒonƒHealthƒ RecordsƒandƒReportingƒinƒtheƒFieldƒofƒHealthƒ(OfficialƒGazette,ƒ2014b). IHISƒmanagesƒinformationƒonƒhealthƒserviceƒactivitiesƒatƒdifferentƒ levelsƒofƒtheƒhealthƒsystem.ƒAnƒexampleƒofƒgoodƒpracticeƒisƒwaitingƒlistsƒofƒ theƒNHIF,ƒavailableƒat:ƒhttp://www.rfzo.rs/index.php/osiguranalica/liste- cekanja.ƒWaitingƒlistsƒareƒaccessibleƒforƒpatientsƒandƒphysicians.ƒInƒSerbia,ƒ electronicƒwaitingƒlistsƒhaveƒbeenƒestablishedƒsinceƒ2005ƒforƒtheƒfollowingƒ medicalƒinterventionsƒandƒproceduresƒthatƒareƒnotƒurgentƒ(NHIF,ƒ2018a): ƒƒ ƒmagneticƒresonanceƒimagingƒ(MRI) ƒƒ ƒcomputerizedƒtomographyƒ(CT) ƒƒ ƒdiagnosticƒcoronaryƒangiography ƒƒ ƒcardiacƒcatheterization ƒƒ ƒrevascularizationƒofƒmyocardium ƒƒ ƒimplantationƒofƒpermanentƒartificialƒheart ƒƒ ƒimplantationƒofƒcardioverterƒdefibrillator ƒƒ ƒimplantationƒofƒartificialƒheartƒvalves ƒƒ ƒimplantationƒofƒgraftsƒofƒsyntheticƒmaterials ƒƒ ƒimplantationƒofƒendovascularƒprostheses ƒƒ ƒimplantationƒofƒhipƒandƒkneeƒendoprostheses ƒƒ ƒinstrumentalƒsegmentalƒcorrectionƒofƒspinalƒdeformityƒinƒchildren ƒƒ ƒophthalmicƒ interventionsƒ (cataractƒ surgery,ƒ intraocularƒ lensƒ implantation). Onlyƒtheƒpatientƒcanƒseeƒhis/herƒplaceƒonƒtheƒwaitingƒlistƒinƒorderƒtoƒ protectƒprivacyƒinƒaccordanceƒwithƒtheƒ2013ƒLawƒonƒPatients’ƒRightsƒ(Officialƒ Gazette,ƒ2013a).ƒTheƒpatient’sƒplaceƒonƒtheƒlistƒcanƒbeƒseenƒinƒaƒhealthƒ institutionƒwhereƒtheƒhealthƒserviceƒforƒwhichƒhe/sheƒisƒwaitingƒisƒbeingƒ provided,ƒorƒbyƒcheckingƒtheƒNHIFƒwebsiteƒbyƒenteringƒaƒprotectedƒpersonalƒ identificationƒnumberƒfromƒtheƒIDƒcard,ƒwhoseƒfirstƒsevenƒdigitsƒasƒwellƒasƒ theƒlastƒdigitƒareƒexposed.ƒImprovementsƒareƒstillƒongoingƒtoƒdevelopƒtheƒ interconnectivityƒofƒhospitals,ƒandƒtoƒincludeƒprivateƒhospitalsƒinƒtheƒIHIS,ƒ soƒthatƒtheƒsearchƒforƒoptimalƒsolutionsƒforƒeachƒpatientƒisƒavailableƒbeforeƒ 42 Health Systems in Transition schedulingƒonƒtheƒwaitingƒlist.ƒAccordingƒtoƒtheƒWorldƒBankƒandƒNHIFƒ data,ƒinƒ2013ƒnearlyƒhalfƒ(46.6%)ƒofƒpatientsƒwhoƒunderwentƒanƒinterventionƒ inƒSerbiaƒhadƒtoƒgoƒonƒaƒwaitingƒlist,ƒandƒonlyƒoneƒthirdƒofƒlistedƒpatientsƒ (36%)ƒreceivedƒtreatmentƒasƒwaitingƒlistsƒwereƒtooƒlong.ƒAverageƒwaitingƒtimesƒ wereƒ450ƒdaysƒforƒhipƒreplacement,ƒcomparedƒwithƒ101ƒdaysƒonƒaverageƒinƒ OECDƒcountries,ƒandƒ707ƒdaysƒforƒkneeƒreplacementƒ(123 daysƒinƒOECD)ƒ (EY,ƒ2016). 2.7  Regulation Theƒhealthƒsystemƒisƒregulatedƒbyƒnationalƒpolicyƒandƒlegalƒinstruments.ƒ Furthermore,ƒmanyƒinternationalƒandƒEUƒdocuments,ƒinstruments,ƒhealthƒ policiesƒandƒstrategiesƒhaveƒanƒimpactƒonƒtheƒdevelopmentsƒinƒtheƒhealthƒ systemƒin Serbia. Theƒreformƒofƒtheƒhealthƒsystemƒwasƒinitiatedƒinƒ2005ƒwithƒtheƒadoptionƒ ofƒtheƒHealthƒCareƒLaw,ƒtheƒHealthƒInsuranceƒLaw,ƒandƒtheƒLawƒonƒHealthƒ ProfessionalƒChambers.ƒTheseƒthreeƒlaws,ƒinƒadditionƒtoƒtheƒLawƒonƒDrugsƒ andƒMedicalƒProductsƒadoptedƒinƒ2004,ƒmakeƒupƒtheƒbasicƒframeworkƒforƒ transitionƒofƒrelevantƒEU legislation. TheƒmainƒchallengeƒforƒSerbiaƒinƒtheƒyearsƒtoƒcomeƒwillƒnotƒonlyƒbeƒ theƒtranspositionƒofƒtheƒaquisƒbutƒalsoƒitsƒfullƒimplementationƒandƒapplica- tion.ƒSerbiaƒisƒfacedƒwithƒanƒobligationƒtoƒimplementƒandƒapplyƒaƒveryƒlargeƒ volumeƒofƒlegalƒregulationsƒinƒtheƒpublicƒhealthƒsectorƒ(Bjegović-Mikanović,ƒ McGuinnƒ&ƒPetrovic,ƒ2013).ƒTheƒcompetentƒauthorityƒforƒtheƒimplementa- tionƒofƒtheƒpublicƒhealthƒacquisƒisƒtheƒMinistryƒofƒHealth.ƒItsƒDepartmentƒforƒ EuropeanƒIntegration,ƒtogetherƒwithƒotherƒrelevantƒinstitutions,ƒisƒdirectlyƒ workingƒonƒmonitoringƒharmonizationƒinƒtheƒfieldƒofƒhealth.ƒEUƒrulesƒ protectƒconsumersƒinƒrelationƒtoƒproductƒsafety,ƒdangerousƒimitationsƒandƒ liabilityƒforƒdefectiveƒproducts.ƒTheƒEUƒalsoƒensuresƒhighƒcommonƒstand- ardsƒforƒtobaccoƒcontrol,ƒblood,ƒtissues,ƒcellsƒandƒorgans,ƒpatients’ƒrightsƒinƒ cross-borderƒhealthƒcare,ƒandƒseriousƒcross-borderƒhealthƒthreatsƒincludingƒ communicableƒdiseases,ƒasƒwellƒasƒmedicinesƒforƒhumanƒandƒveterinary use. 43Serbia 2.7.1 Regulation and governance of third-party payers Theƒ2019ƒHealthƒInsuranceƒLawƒcontainsƒprovisionsƒonƒcompulsoryƒhealthƒ insurance,ƒaimingƒtoƒguaranteeƒequityƒandƒsolidarityƒinƒhealthƒfinancingƒandƒ theƒprovisionƒofƒhealthƒcareƒforƒtheƒwholeƒpopulation,ƒwithƒpriorityƒgivenƒ toƒvulnerableƒgroups.ƒTheƒorganizationalƒrelationshipƒbetweenƒtheƒmainƒ purchaserƒ(NHIF)ƒandƒprovidersƒisƒcontract-basedƒandƒcentralized,ƒandƒ theƒgovernmentƒplaysƒaƒregulatoryƒroleƒthroughƒsteeringƒtheƒ2017ƒHealthƒ CareƒPlanƒfromƒCompulsoryƒHealthƒInsuranceƒinƒSerbia,ƒwhichƒisƒadoptedƒ eachƒyear.ƒItƒprovidesƒtypesƒandƒvolumeƒofƒhealthƒservices,ƒwhichƒwillƒbeƒ providedƒbyƒtheƒcompulsoryƒhealthƒinsurance.ƒTheƒMinistryƒofƒHealthƒ givesƒitsƒopinionƒaboutƒprioritiesƒinƒthisƒPlan,ƒandƒtheƒMinistryƒofƒFinanceƒ scrutinizesƒitsƒfinancialƒimplications.ƒNevertheless,ƒtheƒPlanƒservesƒforƒtheƒ individualƒcontractingƒprocessƒbetweenƒtheƒNHIF,ƒthroughƒitsƒregionalƒ branchesƒandƒeachƒproviderƒatƒprimary,ƒsecondaryƒandƒtertiaryƒlevel,ƒtoƒ determineƒtheƒfinalƒcontentƒofƒcontracts.ƒTheƒcontractsƒalsoƒconsiderƒtheƒ financialƒplanƒofƒtheƒNHIF,ƒasƒwellƒasƒplansƒofƒeachƒindividualƒprovider.ƒ Eachƒcontractƒcontainsƒtype,ƒvolumeƒorƒquantityƒofƒhealthƒservices,ƒmeasuresƒ forƒensuringƒtheƒqualityƒofƒhealthƒcareƒprovidedƒtoƒinsuredƒpersons,ƒonƒtheƒ basisƒofƒnormsƒofƒstaffƒandƒstandardsƒofƒworkƒnecessaryƒforƒtheƒrealizationƒ ofƒhealthƒcare,ƒtheƒcompensationƒorƒpriceƒpaidƒbyƒtheƒregionalƒbranchƒorƒ theƒNHIFƒforƒtheƒprovidedƒhealthƒservices,ƒtheƒmethodƒofƒcalculationƒandƒ payment,ƒcontrolƒandƒresponsibilityƒforƒperformingƒobligationsƒunderƒtheƒ contract,ƒtheƒdeadlineƒforƒtheƒimplementationƒofƒtheƒundertakenƒobligations,ƒ mannerƒofƒresolvingƒtheƒdisputedƒissues,ƒterminationƒofƒtheƒcontract,ƒasƒwellƒ asƒotherƒmutualƒrightsƒandƒobligationsƒofƒtheƒcontracting parties. Regulatoryƒarrangementsƒrelatingƒtoƒcross-borderƒhealthƒcareƒpurchasingƒ andƒprovisionƒareƒbasedƒonƒtheƒinternationalƒsocialƒinsuranceƒcontractsƒandƒareƒ definedƒinƒtheƒ2005ƒHealthƒInsuranceƒLawƒ(Articleƒ29),ƒwithƒcontinuationƒ inƒtheƒ2019ƒHealthƒInsuranceƒLaw.ƒTheƒNHIFƒadoptsƒaƒgeneralƒactƒeachƒ year,ƒafterƒapprovalƒofƒtheƒgovernment,ƒwhichƒcloselyƒregulatesƒtheƒcondi- tions,ƒmethodƒandƒprocedure,ƒasƒwellƒasƒtheƒtypesƒofƒdiseases,ƒconditionsƒorƒ injuriesƒforƒwhichƒtreatmentƒabroadƒmayƒbe authorized. 44 Health Systems in Transition 2.7.2 Regulation and governance of provision Theƒbasicƒregulationƒandƒgovernanceƒofƒproviders,ƒbothƒhealthƒinstitutionsƒ andƒhealthƒprofessionals,ƒareƒsubjectƒtoƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ 2006–2018ƒDecreeƒonƒtheƒPlanƒofƒtheƒHealthƒInstitutions’ƒNetwork,ƒwhichƒ servesƒforƒtheƒestablishmentƒofƒpubliclyƒownedƒhealthƒinstitutions.ƒTheƒ2018ƒ PlanƒofƒtheƒHealthƒInstitutions’ƒNetworkƒdeterminesƒtheƒnumber,ƒstructure,ƒ capacitiesƒandƒdistributionƒofƒhealthƒinstitutionsƒandƒtheirƒorganizationalƒ unitsƒbyƒlevelsƒofƒhealthƒcare,ƒandƒtheƒorganizationƒofƒemergencyƒmedicalƒ services.ƒTheƒMinistryƒofƒHealthƒperformsƒtheƒregulatoryƒfunction.ƒBasedƒ onƒtheƒdecisionƒbyƒtheƒMinistryƒofƒHealthƒonƒtheƒfulfilmentƒofƒconditionsƒ forƒperformingƒhealthƒcareƒactivities,ƒtheƒhealthƒinstitutionƒisƒregisteredƒinƒ theƒregistryƒwithƒtheƒcompetentƒcourt,ƒinƒaccordanceƒwithƒtheƒ2019ƒHealthƒ Care Law. Sinceƒ2005,ƒmunicipalityƒself-governanceƒbodies,ƒsuchƒasƒmunicipalƒ governmentsƒandƒparliaments,ƒhaveƒtheƒownershipƒandƒmanagementƒrightsƒ forƒtheƒstateƒprovidersƒofƒprimaryƒcare,ƒwhileƒinstitutionsƒatƒsecondaryƒandƒ tertiaryƒlevelƒareƒunderƒtheƒownershipƒandƒgovernanceƒofƒtheƒMinistryƒofƒ Health.ƒTheƒ2019ƒHealthƒCareƒLawƒintroducesƒaƒgreaterƒdegreeƒofƒcen- tralizationƒbyƒtransferringƒownershipƒforƒprimaryƒcareƒinstitutionsƒandƒ responsibilityƒforƒmanagementƒ(nominationƒofƒdirectorsƒofƒprimaryƒhealthƒ careƒinstitutions)ƒfromƒtheƒmunicipalityƒtoƒtheƒprovincialƒandƒnationalƒlevelƒ (seeƒsectionƒ2.6).ƒTheƒmainƒargumentƒbyƒtheƒMinistryƒofƒHealthƒforƒthisƒrefersƒ toƒbetterƒorganization,ƒbetterƒstaffingƒandƒdistributionƒofƒhumanƒresourcesƒ withƒtheƒpossibilityƒtoƒincreaseƒefficiency.ƒAdditionalƒchangesƒareƒenvisionedƒ inƒplanningƒmechanisms.ƒForƒexample,ƒtheƒ2010ƒPlanƒforƒDevelopmentƒofƒ HealthƒCareƒinƒtheƒRepublicƒofƒSerbiaƒwasƒendorsedƒbyƒtheƒparliamentƒinƒ 2010,ƒwhileƒaccordingƒtoƒtheƒnewƒ2019ƒHealthƒCareƒLaw,ƒitƒwillƒbecomeƒ theƒresponsibilityƒofƒtheƒgovernmentƒinƒthe future. Eachƒstateƒhealthƒinstitutionƒhasƒaƒstatuteƒwhichƒregulatesƒitsƒmainƒactivi- ties,ƒtheƒinternalƒorganization,ƒtheƒmanagement,ƒbusiness,ƒandƒconditionsƒforƒ appointmentƒandƒdismissalƒofƒdirectors,ƒtheƒdeputyƒdirectorsƒorƒtheƒassistantƒ directorƒforƒeducationalƒandƒscientificƒresearchƒwork,ƒasƒwellƒasƒotherƒissuesƒofƒ importanceƒforƒtheƒworkƒofƒtheƒinstitution.ƒTheƒfoundersƒofƒtheƒstateƒhealthƒ institutionsƒapproveƒtheƒstatuteƒhavingƒobtainedƒagreementƒfromƒtheƒMinistryƒ ofƒHealth.ƒEachƒstateƒhealthƒinstitution,ƒprescribedƒbyƒtheƒ2019ƒHealthƒCareƒ Law,ƒhasƒinternalƒmechanismsƒtoƒensureƒthatƒprofessionalƒstaffƒachieveƒcertainƒ 45Serbia standardsƒofƒcompetenceƒandƒethicalƒbehaviour,ƒwithƒperformanceƒassess- mentƒbeingƒtheƒresponsibilityƒof:ƒtheƒProfessionalƒCouncilƒ(responsibleƒforƒ continuingƒprofessionalƒdevelopment);ƒtheƒprofessionalƒcollegiumƒ(issuingƒ professionalƒstatements);ƒtheƒethicalƒboardƒ(concernsƒforƒallƒethicalƒissuesƒ includingƒclinicalƒresearch);ƒandƒtheƒCommissionƒforƒContinuousƒQualityƒ Improvementƒ(workingƒonƒhealthƒcareƒqualityƒassurance,ƒmonitoringƒandƒ control,ƒinƒcooperationƒwithƒtheƒMinistryƒofƒHealthƒinspectionƒservicesƒandƒ AZUS). Theƒchambersƒofƒfiveƒregulatedƒprofessionsƒ(physicians,ƒnursesƒandƒ medicalƒtechnicians,ƒdentists,ƒbiochemistsƒandƒpharmacists),ƒasƒprofessionalƒ associationsƒofƒhealthƒworkers,ƒhaveƒformulatedƒCodesƒofƒProfessionalƒ Ethics,ƒwhichƒestablishƒethicalƒprinciplesƒ inƒ theƒperformanceƒofƒ theirƒ professionalƒduties.ƒTheyƒissueƒlicencesƒandƒre-licensesƒforƒworkƒforƒeachƒ healthƒprofessional,ƒwhichƒisƒregulatedƒbyƒtheƒ2005ƒLawƒonƒChambersƒofƒ HealthƒWorkersƒ(OfficialƒGazette,ƒ2005a). SinceƒadoptionƒofƒtheƒHealthƒCareƒLawƒinƒ2005,ƒtheƒmovementƒforƒ continuousƒimprovementƒofƒhealthƒcareƒqualityƒhasƒstarted.ƒTheƒgovern- mentƒhasƒendorsedƒaƒStrategyƒforƒContinuousƒImprovementƒofƒHealthƒCareƒ QualityƒandƒPatientƒSafetyƒ(OfficialƒGazette,ƒ2009)ƒinƒ2009,ƒwithƒfiveƒ strategic objectives: 1. ƒCreatingƒconditionsƒforƒconsumers/patientsƒtoƒbeƒatƒtheƒcentreƒofƒ theƒhealth system. 2. ƒImprovingƒtheƒprofessionalƒknowledgeƒofƒhealthƒworkersƒandƒ raisingƒawarenessƒaboutƒtheƒimportanceƒofƒcontinuousƒimprovementƒ ofƒhealthƒcareƒqualityƒandƒdevelopmentƒofƒspecificƒknowledgeƒ and skills. 3. ƒCreatingƒ conditionsƒ thatƒ promoteƒ theƒ cultureƒ ofƒ continuousƒ improvementƒofƒhealthƒcareƒqualityƒandƒpatientƒsafetyƒinƒhealthƒ care institutions. 4. ƒProvidingƒ safety,ƒ securityƒ andƒ cost–effectivenessƒ ofƒ health technologies. 5. ƒProvidingƒfinancialƒ incentivesƒforƒcontinuousƒ improvementƒofƒ healthƒcareƒqualityƒandƒpatient safety. Inƒ2010,ƒtheƒMinistryƒofƒHealthƒintroducedƒregularƒmonitoringƒofƒhealthƒ careƒqualityƒindicatorsƒinƒstateƒhealthƒinstitutionsƒwithƒtransparentƒreport- ingƒ(availableƒtoƒtheƒpublic)ƒpublishedƒbyƒIPHƒBatut.ƒTheƒ2010ƒRulebookƒ 46 Health Systems in Transition onƒHealthƒCareƒQualityƒIndicatorsƒpresentsƒoverƒ120ƒprocessƒandƒoutcomeƒ indicatorsƒ(OfficialƒGazette,ƒ2010d)ƒ(forƒdetailsƒseeƒsectionƒ7.4). WithƒEUƒfinancialƒsupport,ƒtheƒAgencyƒforƒAccreditationƒofƒHealthƒCareƒ Institutionsƒ(AZUS)ƒwasƒfoundedƒinƒ2008,ƒstartingƒitsƒworkƒinƒ2009ƒ(AZUS,ƒ 2018)ƒ(seeƒsectionƒ2.2).ƒInƒ2010,ƒoverƒ90ƒexternalƒauditorsƒwereƒtrained.ƒ Inƒ2017,ƒ100ƒadditionalƒexternalƒsurveyorsƒgainedƒcontinuingƒtrainingƒbyƒ AZUSƒinƒcooperationƒwithƒUNICEFƒ(AZUS,ƒ2018).ƒTheƒAgencyƒformedƒ aƒspecialƒworkingƒgroupƒinƒ2010ƒforƒtheƒdevelopmentƒofƒstandardsƒforƒlabo- ratories,ƒpharmaciesƒandƒdiagnosticƒimaging.ƒForƒtheƒdesignƒofƒtheƒSerbianƒ accreditationƒsystem,ƒISQuaƒ(InternationalƒSocietyƒforƒQualityƒinƒHealthƒ Care)ƒstandardsƒwereƒadoptedƒbyƒAZUSƒasƒtheƒbenchmark.ƒAZUSƒadoptedƒ theƒSecondaryƒandƒTertiaryƒHealthƒCareƒAccreditationƒStandardsƒandƒtheƒ PrimaryƒHealthƒCareƒAccreditationƒStandardsƒandƒgovernmentƒapprovalƒwasƒ obtainedƒinƒ2010.ƒInƒ2010,ƒtheƒaccreditationƒprocessƒstartedƒinƒ82ƒprimaryƒ careƒcentresƒ(Dom zdravlja-s),ƒofƒwhichƒ70ƒhaveƒsuccessfullyƒobtainedƒqualityƒ certificatesƒ(MinistryƒofƒHealth,ƒ2015).ƒSinceƒ2010,ƒAZUSƒhasƒhostedƒtheƒ RepublicƒScientificƒCommitteeƒ(RSC)ƒforƒClinicalƒGuidelinesƒdevelopmentƒ andƒimplementation.ƒDuringƒ2011,ƒeightƒnewƒnationalƒgoodƒclinicalƒpracticeƒ guidelinesƒwereƒdeveloped:ƒdiagnosingƒandƒtreatingƒlipidƒdisorders,ƒischae- micƒheartƒdisease,ƒischaemicƒstroke,ƒlungƒcancer,ƒdepression,ƒhypertension,ƒ treatmentƒofƒadultƒherniaƒandƒthyroid dysfunction. TheƒMinistryƒofƒHealthƒandƒtheƒNHIFƒhaveƒestablishedƒincentivesƒforƒ healthƒinstitutionsƒinƒ2013ƒtoƒseekƒaccreditation:ƒpriorityƒinƒtheƒcontractingƒ withƒtheƒNHIFƒandƒitsƒregionalƒbranchesƒisƒgivenƒtoƒhealthƒinstitutionsƒthatƒ areƒaccreditedƒbyƒAZUSƒ(Articleƒ179ƒofƒtheƒ2005ƒHealthƒInsuranceƒLaw). 2.7.3 Regulation of services and goods BASIC BENEFIT PACKAGE Theƒstatutoryƒbenefitsƒpackageƒisƒbroadlyƒdefinedƒinƒtheƒ2005ƒHealthƒ InsuranceƒLawƒandƒincludes,ƒinƒadditionƒtoƒtheƒrightƒtoƒallƒtypesƒofƒhealthƒ careƒservices,ƒtheƒrightƒtoƒcompensationƒofƒearningsƒduringƒtemporaryƒabsenceƒ fromƒworkƒdueƒtoƒillnessƒandƒreimbursementƒofƒtransportƒcostsƒrelatedƒtoƒ useƒofƒhealthƒcareƒbyƒtheƒinsuredƒperson.ƒTheƒrightƒtoƒhealthƒcareƒcoveredƒ byƒcompulsoryƒhealthƒinsuranceƒspecifically includes: 47Serbia ƒƒ ƒmeasuresƒforƒtheƒpreventionƒandƒearlyƒdetectionƒof diseases; ƒƒ ƒexaminationsƒ andƒ treatmentƒ ofƒ womenƒ inƒ relationƒ toƒ familyƒ planning,ƒasƒwellƒasƒduringƒpregnancy,ƒchildbirthƒandƒmaternity,ƒ upƒtoƒ12ƒmonthsƒafter delivery; ƒƒ ƒexaminationsƒandƒtreatmentƒinƒcaseƒofƒillnessƒand injury; ƒƒ ƒexaminationsƒandƒtreatmentƒofƒdental diseases; ƒƒ ƒmedicalƒrehabilitationƒinƒcaseƒofƒillnessƒand injury; ƒƒ ƒmedicinesƒandƒmedicalƒdevices;ƒand ƒƒ ƒdevicesƒforƒmovement,ƒstandingƒandƒsitting,ƒaidsƒforƒvision,ƒhearing,ƒ speech,ƒdentalƒallowances,ƒandƒother aids. HEALTH TECHNOLOGY ASSESSMENT (HTA) Serbiaƒhasƒnoƒagencyƒforƒhealthƒtechnologyƒassessmentƒ(HTA).ƒAccordingƒtoƒ theƒ2019ƒHealthƒCareƒLaw,ƒtheƒHTAƒCommitteeƒestablishedƒbyƒtheƒMinistryƒ ofƒHealthƒinƒ2006ƒcarriesƒoutƒHTA,ƒbasedƒonƒtheƒanalysisƒofƒmedical,ƒethical,ƒ socialƒandƒeconomicƒconsequencesƒandƒimpactƒofƒdeveloping,ƒdisseminatingƒ orƒusingƒhealthƒtechnologiesƒinƒtheƒprovisionƒofƒhealthƒcare.ƒMembersƒofƒtheƒ HTAƒCommittee,ƒwithƒ5-yearƒmandates,ƒareƒprominentƒhealthƒexpertsƒwhoƒ haveƒmadeƒaƒsignificantƒcontributionƒtoƒtheƒdevelopmentƒofƒcertainƒfieldsƒofƒ medicine,ƒdentistry,ƒpharmacy,ƒtheƒapplicationƒandƒdevelopmentƒofƒhealthƒ technologies,ƒorƒinƒtheƒperformanceƒofƒhealthƒcare services. Inƒ2003,ƒtheƒMinistryƒofƒHealthƒacknowledgedƒtheƒneedƒtoƒestablishƒ transparencyƒinƒdecision-makingƒprocessesƒregardingƒtheƒintroductionƒofƒ innovativeƒpharmaceuticalsƒorƒtechnologiesƒandƒtheirƒdistributionƒinƒtheƒ healthƒsystemƒinƒtheƒframeworkƒofƒbothƒSerbiaƒHealthƒProjectsƒsupportedƒ byƒWorldƒBankƒloansƒ(WorldƒBank,ƒ2003,ƒ2014). Yet,ƒHTAƒisƒstillƒnotƒroutinelyƒusedƒinƒdecision-makingƒprocesses,ƒatƒ leastƒnotƒinƒaƒsystematicƒwayƒusingƒcriteriaƒsuchƒasƒefficacyƒandƒcost–effective- ness.ƒSeveralƒarticlesƒofƒtheƒ2019ƒHealthƒCareƒLawƒ(Articlesƒ48–52)ƒindicateƒ theƒobligationƒtoƒapplyƒHTA,ƒbutƒtheƒapproachƒappliedƒinƒSerbiaƒisƒmoreƒ concernedƒwithƒmonitoringƒandƒcoordinatingƒtheƒcurrentƒuseƒofƒhealthƒtech- nologiesƒthanƒwithƒaffordability.ƒEvidenceƒofƒquality,ƒsafety,ƒandƒefficiencyƒ ofƒhealthƒtechnologyƒisƒveryƒoftenƒacceptedƒasƒprovidedƒbyƒthe applicant. Theƒsituationƒregardingƒdrugsƒisƒmoreƒpreciselyƒdefinedƒandƒconsider- ablyƒcloserƒtoƒaƒusualƒHTAƒprocess.ƒTheƒdrugƒmarketƒinƒSerbiaƒshowsƒaƒ steadyƒgrowthƒandƒhasƒincreasedƒalmostƒthreeƒtimesƒduringƒtheƒpastƒ10ƒyearsƒ 48 Health Systems in Transition (ChamberƒofƒCommerceƒandƒIndustryƒofƒSerbia,ƒ2016).ƒInƒ2015,ƒgenericƒ drugsƒaccountedƒforƒ79%ƒofƒtheƒmarketƒ(countedƒinƒpacks)ƒorƒ55%ƒofƒtheƒ marketƒinƒfinancialƒtermsƒ(seeƒsectionƒ2.8.4). TheƒscopeƒofƒworkƒofƒtheƒHTAƒCommitteeƒ(MinistryƒofƒHealth)ƒisƒ mostlyƒrelatedƒtoƒtheƒanalysisƒofƒinvestmentƒneedsƒandƒcoversƒtheƒintroduc- tionƒofƒcapitalƒinvestmentsƒallƒaroundƒtheƒcountry.ƒMoreƒoften,ƒitƒdealsƒwithƒ problemsƒassociatedƒwithƒplanningƒhealthƒcareƒservicesƒandƒsystems,ƒratherƒ thanƒimplementingƒtechnologyƒassessments.ƒThereƒareƒnoƒclearƒproceduresƒ withƒobjectiveƒandƒverifiableƒcriteriaƒrelatedƒtoƒtheƒeffectiveness,ƒcost–effec- tiveness,ƒorƒbudgetƒimpact,ƒinƒtheƒprocessƒofƒlistingƒmedicalƒdevicesƒorƒhealthƒ careƒservicesƒatƒtheƒNHIFƒorƒtheƒMinistryƒof Health. TheƒscopeƒofƒworkƒofƒtheƒCentralƒDrugƒCommitteeƒ(CDC)ƒinƒtheƒNHIFƒ isƒconsiderablyƒcloserƒtoƒtheƒconceptƒofƒHTA,ƒbutƒisƒfocusedƒonlyƒonƒdrugs.ƒ CDCƒoperatesƒwithƒlimitedƒresourcesƒinƒtermsƒofƒitsƒfinancingƒandƒexpertƒ capacity,ƒoperationallyƒaimingƒatƒaƒveryƒ“rapidƒassessment”.ƒSometimesƒtheƒ Committeeƒmakesƒdecisionsƒthatƒareƒmoreƒexpert-basedƒthanƒevidence-basedƒ (especiallyƒwhenƒitƒcomesƒtoƒclinicalƒeffectivenessƒorƒcost–effectiveness). Inƒdecision-making,ƒthereƒisƒnoƒopportunityƒforƒtheƒinclusionƒof,ƒorƒ forƒinputƒfrom,ƒcivilƒsocietyƒorƒpatientƒgroups’ƒrepresentatives.ƒCriteriaƒthatƒ specifyƒtheƒprocessƒofƒprioritizationƒofƒeitherƒpriorityƒareaƒorƒdrugsƒareƒnotƒ developedƒandƒapplied.ƒInheritedƒwaysƒofƒtheƒdistributionƒofƒfundsƒwhichƒ haveƒbeenƒcollectedƒbyƒtheƒcompulsoryƒhealthƒinsuranceƒhaveƒnotƒinvolvedƒ principlesƒofƒefficacyƒandƒcost–effectiveness.ƒAƒlargeƒamountƒofƒroutinelyƒ collectedƒdataƒremainsƒunused.ƒTheƒlackƒofƒknowledgeableƒpersonnelƒinƒtheƒ areaƒofƒhealthƒeconomics,ƒtogetherƒwithƒtheƒlackƒofƒclearƒandƒverifiableƒcriteriaƒ forƒprioritizationƒasƒwellƒasƒforƒinclusionƒorƒexclusionƒofƒservicesƒinƒtheƒbasicƒ package,ƒtogetherƒwithƒbroadlyƒdefinedƒhealthƒcareƒrights,ƒalsoƒcompromisesƒ theƒdecision-makingƒprocessƒ(Atanasijevicƒ&ƒZah,ƒ2017). 2.7.4 Regulation and governance of pharmaceuticals MarketingƒauthorizationƒofƒdrugsƒinƒSerbiaƒisƒharmonizedƒwithƒEUƒregula- tionsƒandƒimplementedƒbyƒtheƒMedicinesƒandƒMedicalƒDevicesƒAgencyƒofƒ Serbia,ƒwhileƒpricingƒandƒreimbursementƒareƒsetƒatƒtheƒnationalƒlevelƒ(theƒ2010ƒ LawƒonƒMedicinesƒandƒMedicalƒDevices).ƒDrugƒpricesƒinƒSerbiaƒareƒunderƒ stateƒcontrolƒandƒregulatedƒbyƒtheƒ2005ƒDecreeƒonƒCriteriaƒforƒFormationƒofƒ 49Serbia PricesƒforƒDrugsƒforƒUseƒinƒHumanƒMedicine,ƒwhichƒareƒunderƒaƒprescrip- tionƒregimen.ƒTheƒdecisionƒonƒtheƒhighestƒpricesƒofƒdrugsƒforƒuseƒinƒhumanƒ medicine,ƒwhichƒareƒissuedƒbyƒprescription,ƒisƒusuallyƒissuedƒtwiceƒaƒyearƒ (Atanasijevicƒ&ƒZah,ƒ2017). Afterƒtheƒgovernmentƒmakesƒaƒdecisionƒonƒtheƒmaximumƒpermittedƒ wholesaleƒpriceƒofƒaƒdrug,ƒtheƒmarketingƒauthorizationƒholderƒhasƒtheƒoptionƒ toƒapplyƒforƒtheƒdrugƒtoƒbeƒprescribedƒandƒissuedƒatƒtheƒexpenseƒofƒtheƒcom- pulsoryƒhealthƒinsuranceƒ(DrugƒList).ƒHowever,ƒtheƒregulationsƒstipulateƒ that,ƒinƒtheƒcaseƒofƒinclusionƒinƒtheƒDrugƒList,ƒtheƒNHIFƒestablishesƒaƒfinalƒ price,ƒbasedƒonƒtheƒminimalƒpriceƒinƒtheƒreferenceƒcountriesƒ(thatƒis,ƒItaly,ƒ SloveniaƒandƒCroatia).ƒInƒthisƒway,ƒanyƒdrugƒonƒtheƒDrugƒListƒgoesƒthroughƒ theƒadministrativeƒprocedureƒforƒdeterminingƒtheƒpriceƒtwice.ƒThereafter,ƒifƒ theƒdrugƒgetsƒplacedƒonƒtheƒDrugƒList,ƒitsƒfinalƒ(third)ƒpriceƒonƒtheƒmarketƒ isƒtheƒpriceƒachievedƒinƒtheƒprocessƒofƒcentralizedƒpublicƒprocurement.ƒThatƒ ruleƒalsoƒappliesƒtoƒall,ƒgenericsƒandƒinnovative/original drugs. TheƒCentralƒDrugƒCommitteeƒhousedƒwithinƒtheƒNHIFƒassessesƒallƒ applicationsƒforƒinclusionƒofƒnewƒpharmaceuticalsƒonƒtheƒreimbursementƒ list,ƒinƒaccordanceƒwithƒtheƒcurrentƒRulebookƒonƒtheƒconditions,ƒcriteria,ƒtheƒ methodsƒandƒprocedureƒforƒplacingƒtheƒdrugƒonƒtheƒDrugƒList,ƒamendingƒ theƒDrugƒList,ƒorƒforƒremovingƒtheƒdrugƒfromƒtheƒDrugƒListƒ(Rulebook)ƒ (OfficialƒGazette,ƒ2014c).ƒAllƒmembersƒofƒtheƒCentralƒDrugƒCommitteeƒ areƒrequiredƒtoƒsignƒaƒstatementƒonƒconflictƒofƒinterest;ƒtheƒentireƒprocessƒ ofƒmakingƒdecisionsƒsubstantiallyƒcorrespondsƒtoƒtheƒprocedureƒof HTA. Theƒkeyƒinformationƒrequiredƒbyƒtheƒ2014ƒRulebookƒis:ƒevidenceƒofƒ safetyƒandƒefficacy,ƒtogetherƒwithƒaƒpharmaco-economicƒassessment,ƒcostƒofƒ definedƒdailyƒdose,ƒandƒbudgetaryƒimpact.ƒFurthermore,ƒcost–effectivenessƒ analysisƒisƒrequired,ƒevenƒthoughƒitƒisƒstillƒnotƒaƒroutineƒpartƒofƒtheƒassess- mentƒcarriedƒoutƒbyƒthe NHIF. Duringƒtheƒdecision-makingƒprocess,ƒtheƒCentralƒDrugƒCommitteeƒ takesƒintoƒconsiderationƒadviceƒfromƒ1)ƒapproximatelyƒ20ƒExpertƒCommitteesƒ (establishedƒbyƒtheƒMinistryƒofƒHealth)ƒcomposedƒofƒmedicalƒspecial- ists,ƒmostlyƒprofessorsƒfromƒAcademia,ƒandƒ2)ƒtheƒPharmaco-economicƒ Committeeƒinƒthe NHIF. First-in-classƒmedicinesƒbasedƒonƒnovelƒmechanismsƒmustƒdemonstrateƒ superiorƒefficacy/safetyƒandƒmustƒnotƒbeƒpricedƒhigherƒthanƒtheƒlowestƒpub- lishedƒwholesaleƒpriceƒinƒSlovenia,ƒItalyƒorƒCroatiaƒ(OfficialƒGazette,ƒ2014c).ƒ Newƒdrugsƒwithinƒanƒexistingƒtherapeuticƒclassƒmayƒbeƒaddedƒtoƒtheƒlistƒifƒ 50 Health Systems in Transition thereƒisƒnoƒeffectƒuponƒtheƒexistingƒbudget.ƒAccordingƒtoƒtheƒRulebook,ƒ genericsƒlowerƒtheƒpriceƒ(10ƒtoƒ30%)ƒofƒalreadyƒlistedƒdrugsƒwithƒtheƒsameƒ internationalƒnonproprietaryƒnameƒ(INN);ƒthatƒis,ƒaccordingƒtoƒtheƒ2014ƒ Rulebook,ƒaƒfirstƒgenericƒcouldƒreachƒaƒmaximumƒofƒ70%ƒofƒtheƒpriceƒofƒ theƒoriginalƒdrugƒalreadyƒlisted;ƒaƒsecondƒgenericƒwithƒtheƒsameƒINNƒcouldƒ haveƒaƒmaximumƒofƒ90%ƒofƒtheƒpriceƒofƒtheƒfirstƒgenericƒdrugƒonƒtheƒlist;ƒ likewise,ƒtheƒthirdƒandƒfourthƒgenericsƒareƒpricedƒatƒ90%ƒofƒtheƒforegoingƒ generic.ƒAllƒadditionalƒentriesƒofƒdrugsƒwithƒtheƒsameƒINNƒareƒdeterminedƒ atƒtheƒlevelƒofƒpriceƒofƒtheƒfourth generic. Althoughƒtheƒregulationsƒofƒtheƒ2014ƒRulebookƒallowƒforƒusingƒmanagedƒ entryƒagreementsƒasƒaƒwayƒtoƒenterƒtheƒDrugƒList,ƒthisƒoptionƒhasƒneverƒ beenƒusedƒuntilƒtheƒendƒofƒ2017.ƒInƒOctoberƒ2016,ƒbasedƒonƒtheƒprioritiesƒ definedƒbyƒtheƒExpertƒCommittees,ƒtheƒCentralƒDrugƒCommitteeƒadoptedƒ theƒproposalsƒofƒ23ƒoriginal/innovativeƒdrugsƒforƒnewƒindicationsƒinƒfourƒ prioritizedƒareasƒ(children,ƒtransplantation,ƒhaematologyƒandƒoncology).ƒForƒ 18ƒofƒtheseƒdrugs,ƒspecialƒagreementsƒwereƒsigned.ƒBecauseƒinvisibleƒpricingƒisƒ notƒanƒoption,ƒtwoƒtypesƒofƒagreementsƒwereƒimplemented:ƒ1)ƒcross-product,ƒ givingƒsomeƒpercentageƒofƒdiscountƒonƒtheƒdrugƒalreadyƒlistedƒifƒtheƒnewƒ drugƒentersƒtheƒlist;ƒandƒ2)ƒnaturalƒrebate.ƒItƒwasƒtheƒfirstƒtimeƒthisƒtypeƒofƒ budgetƒcontrolƒwasƒimplementedƒtoƒallowƒpatientsƒtoƒgetƒtheƒtopƒexpensiveƒ medicines.ƒTheƒMinistryƒofƒHealthƒapprovesƒtheƒDrugƒListƒtogetherƒwithƒ theƒMinistryƒofƒFinanceƒandƒthe government. SomeƒdrugsƒthatƒareƒnotedƒbyƒtheƒNationalƒInstituteƒforƒHealthƒasƒ “notƒcost-effectiveƒevenƒatƒaƒzeroƒprice”ƒ(Davis,ƒ2014)ƒcouldƒbeƒfoundƒinƒtheƒ SerbianƒDrugƒListƒwithoutƒanyƒadditionalƒexplanatoryƒnotesƒ(e.g.ƒcetuximabƒ forƒheadƒandƒneckƒcancerƒorƒbevacizumabƒforƒmetastaticƒcolorectalƒcancer)ƒ (Atanasijevicƒ&ƒZah,ƒ2017).ƒ CurrentƒmechanismsƒforƒlistingƒmedicinesƒonƒtheƒDrugƒListƒareƒnotƒ efficientƒenoughƒtoƒmeetƒrequirementsƒbyƒtheƒEUƒTransparencyƒDirectiveƒ 89/105/EECƒ(CouncilƒofƒtheƒEuropeanƒUnion,ƒ1989)ƒ(e.g.ƒreproducibilityƒ ofƒdecisionsƒrelatedƒtoƒtheƒavailabilityƒofƒobjectiveƒinformation,ƒsuchƒasƒ theƒinclusionƒandƒexclusionƒcriteriaƒasƒwellƒasƒhealthƒcareƒprioritiesƒbasedƒ onƒrealƒpopulationƒneeds).ƒHowever,ƒthereƒisƒnoƒspecificƒformƒtoƒstartƒanƒ appealƒagainstƒtheƒdecisionƒofƒtheƒCentralƒDrugƒCommitteeƒ(Atanasijevicƒ &ƒZah, 2017). 51Serbia 2.7.5 Regulation of medical devices and aids Regulationƒofƒmedicalƒdevicesƒandƒaidsƒmeetsƒtheƒspecifiedƒconsumer/ patients’ƒrightsƒinƒSerbia.ƒInƒparticular,ƒtheƒ2005ƒHealthƒInsuranceƒLawƒ andƒtheƒ2010ƒLawƒonƒMedicinesƒandƒMedicalƒDevicesƒprescribeƒthatƒanƒ insuredƒpersonƒhasƒtheƒrightƒtoƒobtainƒmedicalƒdevicesƒandƒaidsƒforƒprovidingƒ support,ƒpreventingƒtheƒoccurrenceƒofƒdeformitiesƒandƒcorrectingƒexistingƒ deformities,ƒandƒfacilitatingƒtheƒperformanceƒofƒbasicƒlife functions. Throughƒaƒgeneralƒact,ƒtheƒNHIFƒdeterminesƒtheƒtypeƒofƒmedicalƒ devicesƒandƒaids,ƒasƒwellƒasƒindicationsƒforƒtheirƒuse,ƒtheƒstandardsƒofƒtheƒ materialsƒfromƒwhichƒtheyƒareƒmade,ƒtheƒtimeƒlimits,ƒtheƒprocurement,ƒ maintenanceƒandƒtheirƒretrieval,ƒasƒwellƒasƒtheƒmannerƒandƒprocedureƒofƒ exercisingƒtheƒrightƒtoƒmedical-technicalƒassistance.ƒArticleƒ131ƒofƒtheƒ2019ƒ HealthƒInsuranceƒLawƒoffersƒtheƒlistƒofƒconditionsƒforƒwhichƒtheƒinsuredƒ personƒwillƒhaveƒmedicalƒdevicesƒandƒaidsƒcoveredƒatƒ100%,ƒ95%,ƒ80%ƒandƒ 65%ƒofƒtheƒprocurement price. 2.8  Person-centred care 2.8.1 Patient information Theƒlegalƒframeworkƒforƒbetterƒinformationƒforƒpatientsƒincludesƒtheƒ2013ƒ LawƒonƒPatientƒRights,ƒtheƒ2019ƒHealthƒCareƒLaw,ƒandƒtheƒ2019ƒHealthƒ InsuranceƒLaw.ƒArticleƒ7ƒofƒtheƒ2013ƒLawƒonƒPatients’ƒRightsƒstatesƒthatƒ theƒrightƒtoƒinformationƒimpliesƒthatƒpatientsƒhaveƒtheƒrightƒtoƒallƒinforma- tionƒrelatedƒtoƒtheirƒhealth,ƒhealthƒserviceƒandƒwaysƒofƒusingƒit,ƒasƒwellƒasƒtoƒ allƒavailableƒinformationƒbasedƒonƒresearchƒandƒtechnologicalƒinnovations.ƒ Patientsƒareƒentitledƒtoƒinformationƒaboutƒtheƒnameƒandƒprofessionalƒstatusƒofƒ healthƒcareƒprovidersƒparticipatingƒinƒtheirƒtreatment.ƒInƒadditionƒtoƒmedicalƒ information,ƒtheyƒareƒentitledƒtoƒinformationƒrelatedƒtoƒhealthƒinsuranceƒandƒ proceduresƒforƒexercisingƒthoseƒrightsƒ(seeƒTableƒ2.1).ƒPatientsƒareƒentitledƒ toƒpromptƒinformation,ƒprovidedƒinƒtheirƒbestƒinterestƒ(OfficialƒGazette,ƒ 2013a).ƒThereƒisƒalsoƒanƒobligationƒofƒprovidingƒbroaderƒinformationƒrelatedƒ toƒtheƒpreservationƒofƒhealthƒandƒhealthyƒlifestyles,ƒasƒwellƒasƒonƒharmfulƒ factorsƒofƒlivingƒandƒworkingƒenvironments,ƒwhichƒmayƒhaveƒnegativeƒcon- sequencesƒforƒhealthƒ(Bjegović-Mikanović,ƒŠantrićƒ&ƒOverall,ƒ2015).ƒTheƒ 52 Health Systems in Transition rightƒtoƒinformationƒcorrelatesƒtoƒtheƒobligationƒofƒhealthƒinstitutionsƒandƒ otherƒlegalƒsubjectsƒtoƒprovideƒthatƒinformation.ƒInformationƒmayƒbeƒrelatedƒ toƒtheƒissuingƒofƒmedicalƒresults,ƒcertificates,ƒdischargeƒpapersƒandƒotherƒ documentsƒrelatedƒtoƒtreatment.ƒTheƒ2014ƒLawƒonƒHealthƒRecordsƒandƒ ReportingƒinƒtheƒFieldƒofƒHealthƒexplicitlyƒregulatesƒbothƒpatient’sƒobliga- tionsƒandƒrightsƒtoƒobtainƒdischargeƒpapersƒwithƒepicrisisƒ(thatƒis,ƒaƒcriticalƒ orƒanalyticalƒsummaryƒofƒaƒmedicalƒcaseƒhistory)ƒafterƒtreatment,ƒchildbirthƒ orƒrehabilitationƒissuedƒbyƒinpatientƒinstitutionƒ(OfficialƒGazette,ƒ2014b). Theƒ2003ƒHealthƒSystemƒReformƒStrategyƒenvisagedƒplacingƒtheƒcitizen/ user/patientƒinƒtheƒcentreƒofƒtheƒhealthƒsystemƒofƒSerbia,ƒandƒclarifyingƒtheƒ behaviourƒofƒkeyƒactors:ƒtheƒusers,ƒtheƒserviceƒproviders,ƒtheƒinsuranceƒsystemƒ andƒtheƒMinistryƒofƒHealth,ƒwithƒtheƒaimƒofƒdevelopingƒaƒsustainableƒsystemƒ forƒtheƒ21stƒcenturyƒ(MinistryƒofƒHealth,ƒ2003).ƒHavingƒbetter-informedƒ citizensƒ(patients)ƒonƒtheirƒrightsƒandƒtheirƒrolesƒinƒtheƒdecision-makingƒ processes,ƒsecuresƒimplementationƒofƒtheirƒsocialƒandƒindividualƒrightsƒinƒ theƒhealthƒsystemƒandƒtheƒdevelopmentƒofƒbetterƒrelationshipsƒwithƒhealthƒ staffƒbasedƒonƒrespectƒofƒpersonalityƒandƒparticipatoryƒrightsƒofƒpatients/ƒ consumersƒ(MinistryƒofƒHealth,ƒ2003).ƒAccordingƒtoƒtheƒ2019ƒHealthƒCareƒ Law,ƒpatientsƒshouldƒbeƒadequatelyƒinformedƒaboutƒtheƒwaysƒofƒpreservingƒ andƒimprovingƒhealth,ƒpreventionƒandƒtreatmentƒofƒdiseases,ƒrehabilitationƒ andƒqualityƒofƒhealthƒservicesƒprovidedƒinƒhealthƒinstitutionsƒofƒtheƒstateƒ andƒprivateƒsectorƒinƒtheƒcountry.ƒTherefore,ƒaƒpersonƒ(knownƒasƒ“patient’sƒ counsellor”ƒorƒ“insurer’sƒrightsƒprotector”)ƒisƒidentifiedƒinƒeachƒmunicipal- ityƒandƒhealthƒcareƒinstitutionƒwhomƒtheƒpatient/beneficiaryƒmayƒaddressƒ forƒinformationƒandƒprotectionƒofƒpatient/insurersƒrightsƒ(OfficialƒGazette,ƒ 2019a). TheƒMinistryƒofƒHealthƒhasƒlaunchedƒpatientƒrightsƒcampaignsƒinƒ2013ƒ (“You’reƒright”ƒandƒ“Healthƒisƒaƒsmileƒspread”).ƒThereƒwereƒalsoƒprojectsƒforƒ cooperationƒbetweenƒtheƒstateƒandƒpatientƒorganizationsƒinƒ2013ƒ(forƒexample,ƒ theƒprojectƒofƒcooperationƒbetweenƒtheƒRedƒCrossƒofƒSerbiaƒandƒtheƒHealthƒ CareƒSystemƒforƒTBƒcontrol,ƒfromƒ2010ƒtoƒ2015,ƒ(Mandic,ƒCurcicƒ&ƒSagic,ƒ 2013)ƒandƒProtectionƒofƒPatients’ƒRightsƒatƒtheƒLocalƒLevel). Articlesƒ8–26ƒofƒtheƒ2019ƒHealthƒCareƒLawƒprescribeƒthatƒcitizensƒofƒtheƒ countryƒhaveƒtheƒrightƒtoƒinformationƒthatƒisƒnecessaryƒforƒtheƒpreservationƒofƒ healthƒandƒtheƒacquisitionƒofƒhealthyƒlivingƒhabitsƒ(OfficialƒGazette,ƒ2019a). Anƒimportantƒsourceƒofƒinformationƒthatƒguidesƒcitizensƒthroughƒtheƒ healthƒsystemƒisƒtheƒNationalƒHealthƒInsuranceƒFundƒ(NHIF).ƒTheƒNHIFƒ 53Serbia publishesƒonƒitsƒwebsiteƒ(http://www.rfzo.rs)ƒanƒinsurer’sƒhealthƒbookletƒ thatƒcontainsƒinformationƒaboutƒhowƒresidentsƒcanƒsettleƒtheirƒcompulsoryƒ healthƒinsuranceƒstatusƒinƒlineƒwithƒtheƒ2005ƒHealthƒInsuranceƒLaw.ƒItƒ alsoƒpublishesƒtheƒrightsƒofƒinsuredƒpersons,ƒtheƒrightsƒofƒpregnantƒwomenƒ underƒtheƒcompulsoryƒhealthƒinsurance,ƒtheƒprovisionƒofƒhealthƒcareƒabroadƒ andƒtheƒurgentƒmedicalƒcareƒthatƒisƒprovidedƒtoƒforeignƒcitizensƒduringƒtheirƒ temporaryƒstaysƒinƒSerbia,ƒasƒwellƒasƒtheƒapprovedƒDrugƒList.ƒInsurersƒcanƒ alsoƒreviewƒtheƒstatusƒofƒaƒpaymentƒclaim,ƒandƒcheckƒtheƒ“chosenƒdoctor”ƒ andƒinsuranceƒcertificate.ƒTheƒNHIFƒprovidesƒnationalƒelectronicƒmonitor- ingƒofƒwaitingƒlistsƒforƒeachƒinstitution,ƒwhichƒisƒexpectedƒtoƒprovideƒmoreƒ preciseƒandƒcomprehensiveƒdataƒinƒtheƒnearƒfuture,ƒandƒtheƒmajorityƒofƒhealthƒ institutionsƒupdateƒtheƒinformationƒonƒaƒmonthly basis. 2.8.2 Patient choice Inƒaccordanceƒwithƒtheƒ2019ƒHealthƒCareƒLaw,ƒtheƒ2019ƒHealthƒInsuranceƒ Law,ƒandƒtheƒ2013ƒLawƒonƒPatientƒRights,ƒaƒpatientƒhasƒtheƒrightƒtoƒfreeƒ choiceƒofƒaƒmedicalƒdoctor,ƒaƒdentist,ƒandƒhealthƒfacilities,ƒasƒwellƒasƒtoƒfreeƒ choiceƒofƒproposedƒmedicalƒmeasureƒbyƒtheƒphysicianƒ(seeƒTableƒ2.2). Inƒprimaryƒcare,ƒadultƒpatientsƒmustƒchooseƒaƒmedicalƒdoctorƒorƒspecial- istƒinƒgeneralƒmedicineƒasƒaƒpersonalƒgeneralƒpractitionerƒwhoƒwillƒprovideƒ themƒwithƒservicesƒforƒadultƒhealthƒcare.ƒTheyƒalsoƒhaveƒtoƒchooseƒaƒpersonalƒ dentistƒwhoƒmayƒbeƒaƒdoctorƒforƒdentalƒhealthƒ(dentistƒwithoutƒspecializa- tion)ƒorƒaƒspecialist,ƒandƒwomenƒhaveƒtoƒchooseƒaƒgynaecologistƒasƒaƒ“chosenƒ doctor”ƒforƒtheƒwomen’sƒhealthƒcareƒservice.ƒTheseƒprimaryƒcareƒphysiciansƒ areƒcalledƒ“chosenƒdoctors”ƒwhoƒactƒasƒgatekeepersƒ(seeƒsectionƒ5.3),ƒasƒtheyƒ provideƒaccessƒtoƒsecondaryƒandƒtertiaryƒcare.ƒPatientsƒcanƒchooseƒtheirƒ secondaryƒorƒtertiaryƒproviderƒanywhereƒinƒtheƒcountryƒeveryƒtimeƒtheyƒareƒ givenƒa referral. CompulsoryƒhealthƒinsuranceƒisƒprovidedƒonlyƒbyƒtheƒNHIF.ƒCompulsoryƒ healthƒinsuranceƒcoverageƒincludesƒhealthƒinsuranceƒinƒcaseƒofƒillnessƒandƒ injuryƒnotƒrelatedƒtoƒworkƒandƒhealthƒinsuranceƒinƒcaseƒofƒwork-relatedƒinjuryƒ orƒoccupationalƒdiseaseƒ(seeƒsectionƒ3.3.1).ƒTheƒ2019ƒHealthƒInsuranceƒLawƒ enablesƒvoluntaryƒhealthƒinsuranceƒ(VHI),ƒbutƒtheƒdemandƒforƒitƒinƒSerbiaƒ isƒratherƒsmallƒ(seeƒsectionƒ3.5). 54 Health Systems in Transition TABLE 2.1 Patient information TYPE OF INFORMATION IS IT EASILY AVAILABLE? (Y/N) COMMENTS Information about statutory benefits Y Legal acts Information on hospital clinical outcomes N – Information on hospital waiting times Y NHIF website Comparative information about the quality of other providers (for example, GPs) Y/N GP is able to see his/her own performance indicators and compare to other GPs; however, it is not possible for hospital care Patient access to own medical record Y Law on patients’ rights Interactive web or 24/7 telephone information Y Website Information on patient satisfaction collected (systematically or occasionally) Y Annual survey Information on medical errors N – TABLE 2.2 Patient choice TYPE OF CHOICE IS IT AVAILABLE? (Y/N) DO PEOPLE EXERCISE CHOICE? ARE THERE ANY CONSTRAINTS (FOR EXAMPLE, CHOICE IN THE REGION BUT NOT COUNTRYWIDE)? OTHER COMMENTS? Choices around coverage Choice of being covered or not N Through compulsory health insurance Choice of public or private coverage N Citizens are all covered by the NHIF, but additional private insurance is available Choice of purchasing organization N The NHIF Choice of provider Choice of primary care practitioner Y The concept of “chosen doctor” Direct access to specialists N Referral from GP Choice of hospital N – Choice to have treatment abroad N – 55Serbia Choice of treatment Participation in treatment decisions Y – Right to informed consent Y – Right to request a second opinion Y – Right to information about alternative treatment options Y – 2.8.3 Patient rights Patients’ƒrightsƒinƒSerbiaƒareƒsummarizedƒinƒTableƒ2.3.ƒInƒ1999,ƒtheƒunofficialƒ CharterƒofƒPatients’ƒRights,ƒproposedƒbyƒaƒgroupƒofƒpublicƒhealthƒexpertsƒ (aƒsortƒofƒthinkƒtank),ƒwasƒtheƒfirstƒdocumentƒinƒSerbiaƒthatƒpointedƒoutƒ theƒimportanceƒofƒtheƒpatientƒ(http://www.pravni.edu.rs/prof/Materijali/ dramar/v.stambolovic.prava%20pacijenta.pdf).ƒSeveralƒyearsƒlater,ƒtheƒ2005ƒ HealthƒCareƒLawƒ(OfficialƒGazette,ƒ2005a)ƒmodelledƒtheƒdoctor–patientƒ relationshipƒfollowingƒtheƒmodelƒofƒtheƒ2002ƒEuropeanƒCharterƒofƒPatients’ƒ Rightsƒandƒinƒaƒseparateƒchapterƒitƒhighlightedƒtheƒ12ƒpatients’ƒrightsƒinƒlineƒ withƒtheƒ1990ƒConventionƒonƒtheƒRightsƒofƒtheƒChildƒandƒwithƒFamilyƒLaw.ƒ TheƒLawƒonƒPatients’ƒRightsƒwasƒadoptedƒinƒ2013.ƒItƒguaranteesƒtheƒpatientƒ withƒtheƒrightƒtoƒqualityƒandƒcontinuousƒhealthƒprotectionƒinƒaccordanceƒ withƒtheirƒstateƒofƒhealth,ƒgenerallyƒacceptedƒprofessionalƒstandardsƒandƒ ethical principles. Theseƒrightsƒmustƒbeƒrespectedƒbyƒallƒhealthƒcareƒproviders,ƒpublicƒorƒ private.ƒThese include: ƒƒ ƒtheƒrightƒtoƒaccessƒhealth care. ƒƒ ƒtheƒrightƒto information. ƒƒ ƒtheƒrightƒtoƒpreventive measures. ƒƒ ƒtheƒrightƒtoƒqualityƒhealth services. ƒƒ ƒtheƒrightƒtoƒpatient safety. ƒƒ ƒtheƒrightƒtoƒinformationƒonƒproposedƒmedical measures. ƒƒ ƒtheƒrightƒtoƒfreeƒchoiceƒof provider. ƒƒ ƒtheƒrightƒtoƒanotherƒexpert opinion. ƒƒ ƒtheƒrightƒtoƒprivacyƒand confidentiality. ƒƒ ƒtheƒrightƒto consent. 56 Health Systems in Transition ƒƒ ƒtheƒrightƒtoƒaccessƒmedical records. ƒƒ ƒtheƒrightƒtoƒconfidentialityƒofƒpatientƒhealth information. ƒƒ ƒtheƒrightƒtoƒparticipateƒinƒmedical research. ƒƒ ƒtheƒrightƒofƒaƒchildƒtoƒbeƒaccommodatedƒforƒhospital treatment. ƒƒ ƒtheƒrightƒofƒtheƒpatientƒtoƒleaveƒinpatient institutions. ƒƒ ƒtheƒrightƒtoƒalleviateƒsufferingƒand pain. ƒƒ ƒtheƒrightƒtoƒrespectƒforƒtheƒpatient’s time. ƒƒ ƒtheƒrightƒto complain. ƒƒ ƒtheƒrightƒto compensation. Theƒ2013ƒLawƒonƒPatients’ƒRightsƒalsoƒsetsƒoutƒpatientƒobligationsƒinƒ relationƒtoƒtheƒresponsibilityƒforƒpersonalƒhealth,ƒtowardsƒotherƒusers,ƒhealthƒ careƒproviders,ƒhealthƒworkers,ƒorƒhealthƒcareƒassociates,ƒasƒwellƒasƒotherƒ employeesƒinƒtheƒhealthƒinstitutionƒandƒprivate practice. Accordingƒtoƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ2019ƒHealthƒInsuranceƒ Law,ƒinsureesƒhaveƒtheƒrightƒtoƒhealthƒcare,ƒtheƒrightƒtoƒcompensationƒofƒ earningsƒduringƒtemporaryƒabsenceƒfromƒworkƒandƒtheƒrightƒtoƒreimburse- mentƒofƒtransportƒcostsƒrelatedƒtoƒtheƒuseƒofƒhealth care. PUBLIC PARTICIPATION Thereƒareƒseveralƒmechanismsƒforƒdirectƒpublicƒparticipationƒinƒhealthƒcareƒ andƒforƒexercisingƒpatientƒrights.ƒAnƒimportantƒmechanismƒforƒpatientƒpar- ticipationƒinƒhealthƒcareƒisƒtheƒ2009ƒStrategyƒforƒContinuousƒImprovementƒ ofƒHealthƒCareƒQualityƒandƒPatientƒSafetyƒ(OfficialƒGazette,ƒ2009d),ƒwhichƒ includesƒroutineƒsupervisionƒoverƒtheƒworkƒofƒhealthƒinstitutionsƒandƒstaffƒandƒ anƒannualƒsurveyƒofƒpatientƒsatisfactionƒwithƒqualityƒofƒhealthƒcareƒservicesƒ andƒpatientƒsafetyƒmeasures.ƒPatients’ƒexperiencesƒinƒhealthƒcareƒareƒregu- larlyƒsurveyedƒandƒIPHƒBatutƒpublishesƒoverallƒpatients’ƒsatisfactionƒscoresƒ inƒannualƒreportsƒthatƒareƒachievedƒforƒeachƒhealthƒinstitutionƒatƒprimary,ƒ secondaryƒandƒtertiaryƒcareƒlevel.ƒInƒgeneral,ƒtheƒexperienceƒofƒpatientsƒseemsƒ toƒbeƒveryƒpositive:ƒinƒ2015,ƒtheƒaverageƒscoreƒofƒuserƒsatisfactionƒwithƒprimaryƒ careƒwasƒ3.96ƒoutƒofƒ5.00,ƒwhileƒwithƒhospitalƒtreatmentƒitƒwasƒ4.30ƒoutƒofƒ 5.00ƒ(IPHƒBatut,ƒ2015).ƒOnƒaverage,ƒinƒprimaryƒcare,ƒpatientsƒwereƒmoreƒ satisfiedƒwithƒtheƒworkingƒhoursƒofƒtheƒhealthƒinstitution,ƒshorterƒwaitingƒ timesƒandƒwebsiteƒinformation,ƒbutƒlessƒsatisfiedƒwithƒtheƒinformationƒtheyƒ 57Serbia getƒfromƒhealthƒprofessionalsƒ(thatƒis,ƒtheƒdoctorƒdoesƒnotƒallocateƒenoughƒ timeƒtoƒtalkƒtoƒthem,ƒtheƒdoctorƒdoesƒnotƒlistenƒtoƒthemƒcarefullyƒandƒtheyƒ doƒnotƒreceiveƒclearƒexplanationsƒaboutƒtheƒmedicinesƒprescribedƒforƒthem)ƒ andƒwithƒtheƒkindnessƒofƒtheƒnursesƒatƒtheƒcounterƒ(IPHƒBatut,ƒ2015).ƒInƒ hospitals,ƒpatientsƒwereƒmostƒsatisfiedƒwithƒtheƒkindnessƒofƒtheƒstaff,ƒwithƒ nursingƒcareƒandƒdoctors’ƒservicesƒandƒleastƒsatisfiedƒwithƒtheƒwaitingƒtimeƒ atƒtheƒcounterƒandƒhospitalƒnutrition.ƒTheƒscoresƒareƒsimilarƒtoƒtheƒresultsƒ obtainedƒinƒpreviousƒyearsƒ(IPHƒBatut,ƒ2018c). Allƒproposedƒlawsƒandƒregulationsƒundergoƒpublicƒdebate,ƒandƒpatients,ƒ patients’ƒorganizationsƒandƒusersƒofƒhealthƒcareƒservicesƒmayƒdirectlyƒpar- ticipateƒinƒtheƒdefinitionƒofƒhealthƒlegislationƒduringƒpublicƒhearingsƒbyƒ participatingƒinƒdebatesƒorƒbyƒsending comments. Inƒtheƒprocessƒofƒpurchasingƒhealthƒservices,ƒhowever,ƒpatientsƒandƒ patients’ƒorganizationsƒcanƒparticipateƒonlyƒindirectly,ƒvoicingƒtheirƒconcernsƒ andƒsuggestionsƒinƒtheƒmediaƒandƒpublicƒdebates.ƒRecently,ƒtheƒmanagementƒ ofƒtheƒNHIFƒhasƒopenedƒaƒcallƒforƒpermanentƒcontactƒwithƒcitizensƒandƒ insureesƒandƒinvitedƒthemƒtoƒsubmitƒwrittenƒsuggestions,ƒremarks,ƒcompli- mentsƒandƒadviceƒrelatedƒtoƒtheƒqualityƒofƒworkƒofƒthe NHIF. Asƒofƒ2015,ƒtheƒNHIFƒhadƒestablishedƒcooperationƒwithƒinsuredƒpersons,ƒ patientƒassociations,ƒandƒpersonsƒwithƒdisabilitiesƒsoƒtoƒinvolveƒthemƒfullyƒ inƒdecision-makingƒregardingƒtheƒexerciseƒofƒtheƒrightƒtoƒhealthƒcareƒatƒtheƒ expenseƒofƒcompulsoryƒhealthƒinsurance.ƒTheƒmanagementƒofƒtheƒNHIFƒ hasƒestablishedƒtheƒCentreƒforƒCooperationƒwithƒInsuredƒPersons,ƒPatients’ƒ Associations,ƒPersonsƒwithƒDisabilitiesƒandƒPublicƒInformationƒwithinƒtheƒ directorateƒofƒtheƒNHIFƒandƒtwoƒofficesƒinƒitsƒbranchƒinƒtheƒcapitalƒ–ƒtheƒ OfficeƒforƒCooperationƒwithƒAssociationsƒofƒPersonsƒwithƒDisabilities,ƒ andƒtheƒOfficeƒforƒCooperationƒwithƒPatients’ƒAssociations.ƒInƒ2015,ƒ28ƒ representativesƒofƒdifferentƒpatients’ƒorganizationsƒhadƒmeetingsƒwithƒtheƒ managementƒofƒtheƒNHIF.ƒTheƒpatients’ƒandƒusers’ƒrequestsƒwereƒmostlyƒ relatedƒtoƒtheƒincreaseƒinƒtheƒscopeƒofƒtheƒrightƒtoƒhealthƒcare,ƒwhichƒisƒ financedƒbyƒcompulsoryƒhealthƒinsurance,ƒtoƒprovideƒfinanceƒforƒnecessaryƒ therapyƒandƒextendedƒrehabilitation,ƒasƒwellƒasƒchangesƒinƒtheƒproceduresƒforƒ exercisingƒtheƒrightƒtoƒhealthƒcareƒandƒtoƒamendƒtheƒRulebookƒonƒMedicalƒ TechnicalƒAid Devices. 58 Health Systems in Transition COMPLAINTS PROCEDURES Patientsƒcanƒchooseƒbetweenƒvariousƒinstitutionsƒtoƒfileƒtheirƒcomplaint;ƒtheƒ choiceƒdepends,ƒaboveƒall,ƒonƒwhatƒkindƒofƒrightƒisƒperceivedƒtoƒhaveƒbeenƒ violated.ƒPatientsƒmayƒaskƒassistanceƒforƒtheƒimplementationƒandƒprotectionƒ ofƒtheirƒrightsƒfromƒmanagersƒandƒpatientƒrights’ƒguardiansƒinƒeachƒhealthƒ institution,ƒfromƒhealthƒinspectorsƒofƒtheƒNHIFƒandƒtheƒMinistryƒofƒHealth,ƒ committeesƒatƒhealthƒprofessionalsƒchambers,ƒlegalƒcounsellorsƒatƒtheƒlocalƒ governmentƒlevel,ƒtheƒOmbudsmanƒofƒtheƒRepublicƒofƒSerbia,ƒtheƒNationalƒ OfficeƒofƒtheƒPresidentƒofƒtheƒRepublicƒofƒSerbiaƒasƒwellƒasƒfromƒpatientsƒ organizations,ƒnongovernmentalƒandƒinternationalƒbodiesƒandƒtheƒCourtƒofƒ Justiceƒ(Bjegović-Mikanović,ƒŠantrićƒ&ƒOverall,ƒ2015). TABLE 2.3 Patient rights Y/N PROTECTION OF PATIENT RIGHTS Does a formal definition of patient rights exist at national level? Y Are patient rights included in specific legislation or in more than one law? Y Does the legislation conform with WHO’s patient rights framework? Y PATIENT COMPLAINTS AVENUES Are hospitals required to have a designated desk responsible for collecting and resolving patient complaints? Y Is a health-specific Ombudsman responsible for investigating and resolving patient complaints about health services? Y Other complaint avenues? Y LIABILITY/COMPENSATION Is liability insurance required for physicians and/or other medical professionals? N Can legal redress be sought through the Courts in the case of medical error? Y Is there a basis for no-fault compensation? Y If a tort system exists, can patients obtain damage awards for economic and non-economic losses? Y Can class action suites be taken against health care providers, pharmaceutical companies, etc.? N 59Serbia Accordingƒ toƒ theƒ2013ƒLawƒonƒPatientƒRights,ƒ theƒprotectionƒofƒ patients’ƒrightsƒisƒprovidedƒandƒfinancedƒbyƒaƒlocalƒself-governmentƒunit,ƒ whichƒdeterminesƒaƒpersonƒwhoƒcarriesƒoutƒtheƒdutiesƒofƒCounsellorƒforƒ Patients’ƒRights,ƒandƒtheƒlocalƒHealthƒCouncil.ƒAccordingƒtoƒtheƒ2019ƒ HealthƒInsuranceƒLaw,ƒtheƒprotectionƒofƒtheƒrightsƒofƒtheƒinsuredƒpersonƒ isƒ providedƒ andƒ financedƒbyƒ theƒ organizationƒ ofƒ healthƒ insuranceƒ byƒ appointingƒtheƒProtectorƒofƒPatients’ƒRightsƒinƒeachƒhealthƒinstitution.ƒ TheƒCounsellorƒforƒPatients’ƒRightsƒperformsƒaƒdualƒrole:ƒtheyƒactƒuponƒtheƒ patient’sƒcomplaintƒandƒprovideƒnecessaryƒadviceƒandƒinformationƒonƒpatients’ƒ rights.ƒTheƒCounsellorƒforƒPatients’ƒRightsƒisƒobligedƒtoƒreactƒtoƒtheƒpatientƒ complaintƒwithoutƒdelay.ƒThisƒmeansƒthat,ƒwithinƒ5ƒworkingƒdays,ƒtheƒhealthƒ professionalƒandƒtheƒmanagementƒteamƒofƒtheƒhealthƒinstitutionƒhasƒtoƒ provideƒallƒtheƒinformationƒrequested,ƒdataƒandƒopinionsƒtoƒtheƒCounsellor.ƒ TheƒCounsellorƒforƒPatients’ƒRightsƒformulatesƒtheƒopinionƒandƒreportsƒ backƒtoƒtheƒpatient,ƒtheƒheadƒofƒtheƒorganizationalƒunitƒandƒtheƒdirectorƒofƒ theƒhealthƒinstitutionƒwithinƒ3ƒdaysƒ(thisƒisƒsometimesƒdelayedƒandƒcanƒtakeƒ 2–3ƒweeks).ƒTheƒdirectorƒofƒtheƒhealthƒinstitutionƒisƒobligedƒtoƒreportƒaboutƒ theƒmeasuresƒthatƒwillƒbeƒtakenƒinƒconnectionƒwithƒtheƒobjectionƒwithinƒ5ƒ workingƒdaysƒofƒreceivingƒaƒreportƒfromƒaƒpatientƒcounsellor.ƒIfƒaƒpatientƒisƒ dissatisfiedƒwithƒtheƒreport,ƒhe/sheƒmayƒaddressƒtheƒHealthƒCouncilƒandƒ theƒHealthƒInspectorate,ƒorƒtheƒcompetentƒbodyƒofƒtheƒhealthƒinsuranceƒ organizationƒwhereƒtheƒpatientƒis insured. Theƒprotectionƒofƒtheƒrightsƒofƒinsuredƒpersonsƒisƒregulatedƒbyƒtheƒ2013ƒ RulebookƒonƒtheƒMannerƒandƒProcedureƒforƒtheƒProtectionƒofƒtheƒRightsƒ ofƒtheƒInsuredƒPersonsƒofƒtheƒNHIFƒ(OfficialƒGazette,ƒ2013h).ƒProtectionƒ ofƒtheƒrightsƒofƒinsuredƒpersonsƒisƒperformedƒbyƒemployeesƒofƒtheƒNHIF,ƒ so-calledƒProtectorƒofƒRightsƒofƒtheƒInsuredƒPersons,ƒatƒtheƒpremisesƒofƒtheƒ health institutions. Theƒaimƒisƒtoƒprovideƒaƒtransparentƒandƒclearƒframeworkƒtoƒsupportƒtheƒ fastƒandƒeffectiveƒresolutionƒofƒdisputes.ƒSinceƒ2014,ƒtheƒreportsƒofƒprotectorsƒ haveƒbeenƒpublishedƒeachƒyear.ƒAsƒanƒexample,ƒduringƒ2016,ƒtheƒProtectorsƒofƒ theƒRightsƒofƒInsuredƒPersonsƒaddressedƒ18 850ƒpersonsƒwithƒquestionsƒandƒ problemsƒinƒexercisingƒrightsƒfromƒtheƒcompulsoryƒhealthƒinsurance,ƒwhileƒ atƒtheƒsameƒtimeƒ297ƒclaimsƒforƒviolationƒofƒinsuree’sƒrightsƒwereƒsubmit- tedƒ(NHIF,ƒ2016).ƒInƒ2017,ƒtheƒnumberƒofƒquestionsƒwasƒsimilar;ƒhowever,ƒ theƒnumberƒofƒclaimsƒdecreasedƒtoƒ75ƒ(NHIF,ƒ2018f),ƒprobablyƒlinkedƒtoƒ 60 Health Systems in Transition improvementsƒinƒqualityƒofƒhealthƒcare,ƒalthoughƒtheƒnumberƒofƒsuccessfulƒ claimsƒisƒunknown.ƒTheƒmostƒcommonƒreasonƒforƒfilingƒaƒcomplaintƒwasƒtheƒ inabilityƒtoƒexerciseƒtheƒrightƒtoƒspecialist-consultativeƒcareƒor examination. 2.8.4 Patients and cross-border health care Personsƒwhoƒareƒtemporarilyƒstayingƒabroadƒhaveƒtheƒrightƒtoƒemergencyƒ medicalƒassistanceƒandƒareƒentitledƒtoƒhealthƒservicesƒabroadƒinƒlineƒwithƒ internationalƒagreements.ƒSerbiaƒhasƒconcludedƒinternationalƒagreementsƒ withƒ20ƒcountries,ƒdefiningƒcooperationƒinƒtheƒfieldƒofƒhealth insurance. However,ƒforƒanƒinsuredƒpatientƒexplicitlyƒseekingƒhealthƒcareƒabroad,ƒ theƒcompulsoryƒhealthƒinsuranceƒinƒSerbiaƒmayƒcoverƒtheƒtreatmentƒaccordingƒ toƒtheƒ2007ƒRulebookƒonƒtheƒConditionsƒandƒMethodƒofƒSendingƒInsuredƒ PersonsƒforƒTreatmentƒAbroadƒ(OfficialƒGazette,ƒ2007c). Duringƒ2015,ƒ485ƒinsuredƒpatientsƒwereƒsentƒforƒtreatmentƒabroad,ƒ largelyƒinƒtheƒfieldƒofƒneurosurgery,ƒgastroenterology,ƒhaemato-oncologyƒandƒ cardiacƒsurgery.ƒReferralƒofƒaƒbiologicalƒsampleƒforƒanalysisƒabroadƒbecauseƒ ofƒsuspicionƒofƒaƒrareƒgeneticƒdiseaseƒwasƒapprovedƒforƒ169ƒpatients.ƒDuringƒ theƒsameƒtimeƒperiod,ƒforeignƒexpertsƒcameƒtoƒSerbiaƒforƒtheƒtreatmentƒofƒ 28ƒinsured persons. Foreignƒcitizens,ƒasƒwellƒasƒSerbianƒcitizensƒwhoƒliveƒandƒworkƒabroad,ƒ duringƒtheirƒtemporaryƒstayƒinƒSerbia,ƒhaveƒtheƒrightƒtoƒurgentƒmedicalƒ assistance.ƒForƒinsuredƒpersonsƒfromƒcountriesƒwithƒwhichƒSerbiaƒhasƒanƒ internationalƒagreementƒonƒhealthƒinsurance,ƒtheƒrightƒtoƒurgentƒmedicalƒ protectionƒinƒSerbia exists. 3 Financing Summary ƒƒ ƒTotalƒhealthƒspendingƒreachedƒ8.8%ƒofƒGDPƒinƒ2017,ƒatƒ1 319ƒ US$ƒ(PPP)ƒperƒcapitaƒspending.ƒHowever,ƒpublicƒexpenditureƒonƒ healthƒhasƒsteadilyƒdecreasedƒinƒtheƒlastƒdecade,ƒatƒ57.6%ƒofƒtotalƒ expenditureƒonƒhealthƒ inƒ2017,ƒwhileƒprivateƒexpenditureƒhasƒ increasedƒ(42.4%ƒinƒ2017). ƒƒ ƒRevenueƒflowsƒtoƒtheƒhealthƒsystemƒthroughƒcompulsoryƒhealthƒ insuranceƒcontributions,ƒgeneralƒtaxation,ƒOOPƒspending,ƒVHIƒ premiumsƒ andƒ internationalƒ donor-basedƒ fundingƒ initiatives.ƒ Compulsoryƒhealthƒinsuranceƒcontributionsƒrepresentƒtheƒlargestƒ shareƒofƒtotalƒrevenueƒforƒhealthƒfromƒpublicƒsourcesƒ(94%).ƒPatients’ƒ contributions,ƒmostlyƒinƒtheƒformƒofƒOOPƒpayments,ƒareƒaƒmajorƒ sourceƒofƒprivateƒfinancing,ƒamountingƒtoƒ42.4%ƒofƒcurrentƒhealthƒ expenditureƒin 2017. ƒƒ ƒAlmostƒtheƒentireƒpopulationƒ(98%)ƒisƒcoveredƒbyƒhealthƒinsurance.ƒ Mandatoryƒhealthƒinsuranceƒrightsƒincludeƒtheƒrightƒtoƒhealthƒcare,ƒ theƒrightƒtoƒsalaryƒreimbursementƒduringƒtemporaryƒworkƒdisabilityƒ andƒtheƒrightƒtoƒtheƒreimbursementƒofƒtravelƒcostsƒrelatedƒtoƒusingƒ healthƒcare services. ƒƒ ƒPaymentƒofƒhealthƒservicesƒisƒdeterminedƒbyƒaƒcontractƒbetweenƒtheƒ NHIFƒandƒhealthƒcareƒproviders.ƒTheƒrequirementƒforƒcontractingƒ isƒthatƒhealthƒcareƒprovidersƒsubmitƒannualƒworkplansƒtoƒtheƒNHIF,ƒ 62 Health Systems in Transition orƒitsƒbranches,ƒfollowingƒtheƒmethodologyƒdefinedƒbyƒtheƒInstituteƒ ofƒPublicƒHealthƒof Serbia. ƒƒ ƒCapitationƒ wasƒ introducedƒ inƒ 2012ƒ inƒ primaryƒ healthƒ careƒ institutionsƒthatƒprovideƒtheƒservicesƒofƒaƒ“chosenƒdoctor”ƒ(e.g.ƒGP,ƒ paediatrician,ƒgynaecologist,ƒandƒchildrenƒandƒpreventiveƒdentist),ƒ whileƒaƒnewƒmodelƒofƒpaymentƒbasedƒonƒDRGsƒwasƒintroducedƒatƒ hospitalƒlevelƒin 2019. ƒƒ ƒFundingƒ providedƒ byƒ donorƒ agenciesƒ asƒ wellƒ asƒ loansƒ fromƒ developmentƒbanksƒhaveƒhelpedƒrebuildƒhealthƒ infrastructure,ƒ provideƒtrainingƒforƒhealthƒprofessionals,ƒandƒhaveƒsupportedƒtheƒ introductionƒofƒcapitationƒpayments,ƒDRGs,ƒasƒwellƒasƒdevelopƒ integratedƒITƒsystemsƒinƒhealthƒcare,ƒamongƒotherƒimprovementsƒ inƒtheƒSerbianƒhealth system. 3.1  Health expenditure Inƒ2017,ƒSerbiaƒspentƒ8.8%ƒofƒGDPƒinƒhealth,ƒandƒperƒcapitaƒspendingƒwasƒ 1 319ƒUS$ƒ(PPP)ƒ(IPHƒBatut,ƒ2018d,ƒ2018e).ƒAfterƒtheƒcontinualƒincreaseƒ inƒtheƒproportionƒofƒGDPƒallocatedƒtoƒhealthƒinƒSerbiaƒfromƒ2001ƒtoƒ2014,ƒ aƒsimilarƒorƒhigherƒshareƒofƒGDPƒspendingƒonƒhealthƒwasƒreachedƒinƒ2014ƒ thanƒthatƒofƒtheƒmajorityƒofƒcentralƒandƒsouth-easternƒEuropeanƒcountriesƒ (Figs.ƒ3.1ƒandƒ3.2).ƒFromƒ2015,ƒaƒdecreaseƒinƒTHEƒasƒaƒpercentageƒofƒGDPƒ hasƒbeenƒnoticed,ƒwithƒtheƒlowestƒvalueƒinƒ2017ƒ(8.8%),ƒbeingƒtheƒsameƒ asƒitƒwasƒinƒ1995ƒ(Tableƒ3.1).ƒHealthƒexpenditureƒperƒcapitaƒisƒstillƒoneƒofƒ theƒlowestƒinƒtheƒWHOƒEuropeanƒRegionƒ(Fig.ƒ3.3)ƒdueƒtoƒtheƒlowƒGDP.ƒ However,ƒthereƒhasƒbeenƒanƒimportantƒincreaseƒinƒspendingƒonƒhealthƒinƒ absoluteƒterms:ƒtotalƒhealthƒexpenditureƒperƒcapitaƒincreasedƒfromƒ335ƒUS$ƒ (PPP)ƒinƒ1995,ƒtoƒ1 319ƒUS$ƒ(PPP)ƒinƒ2017,ƒtheƒhighestƒinƒtheƒlastƒtwoƒ decadesƒ(IPHƒBatut,ƒ2018d). Healthƒfinancingƒfromƒpublicƒsourcesƒisƒbasedƒonƒaƒnationallyƒpooledƒ healthƒinsuranceƒsystem,ƒwithƒcompulsoryƒhealthƒinsuranceƒaccountingƒforƒ 94%ƒofƒpublicƒexpenditureƒonƒhealthƒ(IPHƒBatut,ƒ2018d).ƒPublicƒexpenditureƒ onƒhealthƒconsistsƒofƒcompulsoryƒhealthƒinsuranceƒexpenditure,ƒandƒnationalƒ andƒlocalƒgovernmentƒexpenditures.ƒAccordingƒtoƒnationalƒhealthƒaccountsƒ data,ƒtheƒpublicƒshareƒofƒtotalƒhealthƒexpenditure,ƒincludingƒgeneralƒrevenueƒ 63Serbia andƒcompulsoryƒhealthƒinsuranceƒsources,ƒhasƒdecreasedƒfromƒ79.2%ƒinƒ 1995ƒtoƒ57.6%ƒinƒ2017.ƒInƒ2017,ƒpublicƒexpenditureƒonƒhealthƒamountedƒtoƒ 516ƒUS$ƒ(1 319ƒatƒPPP)ƒperƒcapita.ƒTheƒshareƒofƒpublicƒfundsƒhasƒremainedƒ inƒtheƒrangeƒbetweenƒ4.3%ƒofƒGDPƒinƒ2000ƒandƒ5.1%ƒinƒ2017,ƒwithƒtheƒ highestƒvalueƒinƒtheƒlastƒtwoƒdecadesƒreachedƒinƒ2010ƒ(6.2%)ƒ(WHO,ƒ2019)ƒ (Tableƒ3.1). ExpenditureƒofƒtheƒMinistryƒofƒHealthƒfromƒtheƒstateƒbudgetƒandƒ expenditureƒofƒtheƒmunicipalitiesƒthroughƒcommunityƒbudgetsƒaccountƒforƒ aƒsmallƒshareƒofƒpublicƒexpenditureƒonƒhealth.ƒInƒ2017,ƒnationalƒgovernmentƒ healthƒexpenditureƒaccountedƒforƒ4.05%ƒandƒofƒtheƒProvinceƒofƒVojvodinaƒ andƒallƒlocalƒgovernmentsƒinƒSerbiaƒforƒ1.92%ƒofƒpublicƒexpenditureƒonƒ healthƒ(IPHƒBatut,ƒ2018d). Privateƒhealthƒexpenditureƒisƒrelatedƒtoƒexpenditureƒinƒvoluntaryƒhealthƒ insuranceƒ(VHI),ƒOOPƒexpenditure,ƒandƒotherƒprivateƒhealthƒexpendi- ture.ƒPrivateƒexpenditureƒonƒhealthƒinƒ2017ƒreachedƒ42.4%ƒofƒtotalƒhealthƒ expenditure,ƒwhichƒisƒtwoƒtimesƒhigherƒthanƒinƒ1995.ƒTheƒmainƒshareƒofƒ privateƒexpenditureƒisƒOOPƒexpenditure,ƒreachingƒ96%ƒinƒ2017,ƒwhileƒVHIƒ accountedƒforƒlessƒthanƒ1.73%ƒofƒprivateƒexpenditureƒonƒhealthƒthatƒyearƒ (WHO,ƒ2019;ƒIPHƒBatut,ƒ2018d)ƒ(Tableƒ3.1). TABLE 3.1 Trends in health expenditure in Serbia, 1995–2017 (selected years) EXPENDITURE 1995 2000 2005 2010 2015 2016 2017 Total health expenditure in US$ PPP per capita 335 553 771 1 193 1 275 1 261 1 319 Total health expenditure as % of GDP 8.8 9.6 8.7 10.1 9.4 9.0 8.8 Public expenditure on health as % of total expenditure on health 79.2 78.5 66.0 61.9 58.1 58.0 57.6 Private expenditure on health as % of total expenditure on health 20.8 21.5 34.0 38.1 41.9 42.0 42.4 Government health spending as % of total government spending 22.3 24.0 14.3 14.3 12.0 11.7 11.7 Government health spending as % of GDP – 4.3 5.7 6.2 5.4 5.3 5.1 OOP payments as % of total expenditure on health – 29.6 29.8 36.4 40.6 40.5 40.7 OOP payments as % of private expenditure on health 84.8 84.7 88.0 95.5 96.8 96.3 96.0 VHI as % of total expenditure on health – – 0.54 0.33 0.42 0.58 0.73 VHI as % of private expenditure on health – – 1.58 0.87 0.99 1.39 1.73 Source: WHO, 2019; IPH Batut, 2018d 64 Health Systems in Transition FIGURE 3.1 Current health expenditure as a share (%) of GDP in the WHO European Region, 2016 12.2 11.5 11.1 10.9 10.5 10.4 10.4 10.4 10.4 10.0 9.9 9.8 9.5 9.3 9.2 9.1 9.1 9.0 9.0 8.9 8.5 8.5 8.4 8.3 8.2 7.6 7.4 7.4 7.3 7.2 7.1 7.1 7.0 6.9 6.9 6.7 6.7 6.7 6.7 6.6 6.6 6.5 6.4 6.3 6.3 6.3 6.2 6.2 5.3 5.0 4.3 3.5 1.7 0 3 6 9 12 15 2016 Monaco Kazakhstan Turkey Romania Russian Federation Latvia Luxembourg Belarus North Macedonia Uzbekistan San Marino Poland Kyrgyzstan Turkmenistan Albania Estonia Lithuania Ukraine Azerbaijan Cyprus Tajikistan Czech Republic Slovakia Croatia Israel Hungary Ireland Montenegro Bulgaria Iceland Georgia Greece Slovenia Italy Republic of Moldova Spain Portugal Serbia Bosnia and Herzegovina Malta Finland United Kingdom Armenia Belgium Andorra Austria Denmark Netherlands Norway Sweden Germany France Switzerland % of GDP Source: WHO, 2019 65Serbia FIGURE 3.2 Trends in current health expenditure as a share (%) of GDP in Serbia and selected countries, 2000–2016 3 4 5 6 7 8 9 10 11 Serbia Croatia Bulgaria Romania Hungary Slovenia EU28 20162015201420132012201120102009200820072006200520042003200220012000 ■■ Serbia ■■ Slovenia ■■ EU28 ■■ Bulgaria ■■ Hungary ■■ Croatia ■■ Romania % o f G DP Source: WHO, 2019b 66 Health Systems in Transition FIGURE 3.3 Current health expenditure in US$ PPP per capita in the WHO European Region, 2016 7867.40 6374.20 6203.50 5463.30 5386.70 5299.70 5295.20 5251.20 5093.00 4978.70 4782.30 4667.90 4245.10 4177.80 4112.10 3832.00 3511.10 3427.30 3259.80 3019.10 2843.00 2778.40 2772.20 2484.60 2270.80 2261.20 2172.20 1987.70 1978.30 1963.20 1784.40 1705.20 1589.70 1577.90 1333.90 1329.30 1322.60 1193.10 1152.20 1151.40 1123.40 1116.90 1089.20 934.60 876.90 858.80 797.20 759.70 534.20 480.40 416.90 240.20 208.50 0 1000 2000 3000 4000 5000 6000 7000 8000 2016 Tajikistan Kyrgyzstan Uzbekistan Republic of Moldova Ukraine Albania Georgia Kazakhstan Armenia North Macedonia Turkey Turkmenistan Bosnia and Herzegovina Belarus Romania Azerbaijan Serbia Russian Federation Montenegro Bulgaria Latvia Croatia Poland Hungary Lithuania Estonia Slovakia Greece Cyprus Czech Republic Slovenia Portugal Israel Monaco Spain Italy Malta San Marino Finland United Kingdom Iceland Belgium France Andorra Denmark Netherlands Austria Ireland Sweden Germany Norway Luxembourg Switzerland US$ PPP per capita Source: WHO, 2019 67Serbia Availableƒpublicƒhealthƒexpenditureƒdataƒbyƒservicesƒinƒ2017ƒshowƒtheƒ highestƒshareƒofƒexpenditureƒonƒcurativeƒcareƒ(atƒallƒthreeƒlevelsƒofƒcare),ƒ thenƒdrugsƒandƒmedicalƒdevices,ƒrehabilitationƒandƒancillaryƒservicesƒ(IPHƒ Batut,ƒ2018d)ƒ(Tableƒ3.2). TABLE 3.2 Health expenditure by service programme in Serbia, 2017 SERVICE PUBLIC EXPENDITURE ON HEALTH (%) TOTAL EXPENDITURE ON HEALTH (%) Curative care 62.14 43.38 Rehabilitation 6.81 5.40 Long-term care 1.02 0.97 Ancillary services 6.71 8.78 Drugs and medical devices 14.75 32.59 Public health 6.70 7.80 Government administration 1.87 1.08 Source: IPH Batut, 2018d 3.2  Sources of revenues and financial flows Revenueƒflowsƒtoƒtheƒhealthƒsystemƒthroughƒcompulsoryƒhealthƒinsuranceƒ contributions,ƒgeneralƒtaxation,ƒOOPƒspending,ƒVHIƒpremiumsƒandƒinter- nationalƒdonor-basedƒfundingƒinitiativesƒ(Fig.ƒ3.5). Theƒcentralizedƒcompulsoryƒhealthƒinsuranceƒsystemƒisƒadministeredƒ byƒtheƒNationalƒHealthƒInsuranceƒFundƒ(NHIF)ƒandƒfundsƒfromƒcom- pulsoryƒhealthƒinsuranceƒcontributionsƒrepresentƒtheƒlargestƒshareƒ(94%)ƒ ofƒtotalƒrevenueƒforƒhealthƒfromƒpublicƒsourcesƒ(IPHƒBatut,ƒ2018e).ƒTheƒ legalƒframeworkƒobligesƒtheƒNHIFƒtoƒguaranteeƒuniversalƒaccessƒtoƒaƒfreeƒ packageƒofƒhealthƒservices.ƒAccordingƒtoƒtheƒ2019ƒLawƒonƒHealthƒCare,ƒ fundsƒtoƒassureƒprovisionƒofƒhealthƒcareƒtoƒpersonsƒwhoƒareƒnotƒcoveredƒbyƒ compulsoryƒhealthƒinsuranceƒ(uninsuredƒpersons,ƒrefugeesƒandƒinternallyƒ displacedƒpersons,ƒsocialƒassistanceƒrecipientsƒandƒothers)ƒisƒprovidedƒfromƒ theƒstateƒbudget,ƒwhichƒisƒtransferredƒtoƒtheƒNHIFƒ(2.9%ƒofƒpublicƒhealthƒ expenditure)ƒ(IPHƒBatut,ƒ2018d). 68 Health Systems in Transition TheƒNHIFƒdevelopsƒtheƒfinancialƒplanƒeachƒyear.ƒTheƒlegalƒbasisƒandƒ obligationƒforƒthisƒisƒcontainedƒinƒtheƒyearlyƒLawƒonƒtheƒBudgetƒofƒtheƒ RepublicƒofƒSerbiaƒ(OfficialƒGazette,ƒ2018d).ƒTheƒNHIFƒhasƒtoƒsubmitƒtheƒ annualƒfinancialƒplan,ƒwhichƒregulatesƒsourcesƒofƒrevenuesƒandƒexpenditures,ƒ toƒtheƒMinistryƒofƒHealth,ƒwhichƒisƒrequiredƒtoƒsubmitƒitƒtoƒtheƒMinistryƒ ofƒFinance.ƒApprovalƒofƒtheƒannualƒfinancialƒplansƒofƒtheƒNHIFƒhasƒtoƒbeƒ doneƒbyƒtheƒNationalƒAssemblyƒ(seeƒsectionƒ1.3). Theƒmainƒsourceƒofƒrevenueƒinƒtotalƒhealthƒexpenditureƒisƒsocialƒhealthƒ insuranceƒwhichƒprovidesƒ54.2%.ƒTwoƒfifthsƒ(40.66%)ƒofƒtotalƒexpenditureƒ onƒhealthƒcomesƒfromƒprivateƒOOPƒexpenditure,ƒwhileƒaƒveryƒsmallƒamountƒ (0.73%)ƒcomesƒfromƒVHIƒpremiumsƒ(Fig.ƒ3.4). Nationalƒandƒlocalƒbudgetƒrevenuesƒmainlyƒcoverƒcostsƒforƒcapitalƒinvest- ment,ƒpublicƒhealthƒprogrammes,ƒetc.ƒAccordingƒtoƒtheƒ2017ƒBudgetƒLaw,ƒ 40.12%ƒofƒtheƒMinistryƒofƒHealthƒbudgetƒwasƒallocatedƒtoƒtheƒdevelopmentƒ ofƒinfrastructureƒofƒhealthƒinstitutions,ƒwhileƒ7.98%ƒwasƒallocatedƒtoƒpreven- tiveƒprogrammesƒ(OfficialƒGazetteƒRSƒ113/2017). FIGURE 3.4 Percentage of total expenditure on health according to source of revenue, 2017 Other Voluntary health insurance Social health insurance Out-of-pocket payment Transfer from government ■ Transfer from government ■ Out-of-pocket payment ■ Social health insurance ■ Voluntary health insurance ■ Other Transfer from government, 3.44% Out-of-pocket payment, 40.66% Social health insurance, 54.20% Voluntary health insurance, 0.74% Other, 0.96% Source: IPH Batut, 2018d 69Serbia FIGURE 3.5 Financial flows payer 0 payer 1 payer 2 payer 3 State budget ta x s ub sid ie s N ATION AL, REGION AL AN D LOCAL GOVERN M EN T SERVICE PROVIDERS governmental financing system social insurance financing system SOCIAL HEALTH IN SURAN CE [A] taxes [B] social insurance contributions [C] private payments private financing system transfers within system transfers between systems Primary Health Care Institutions Hospital (gener., special). clinical centres Rehabilitation hospitals Public health Institutes Military Health Care Institutions Private health care providers Private/ voluntary health insurers Other Ministries Ministry of Health Local budgets payer 6 Regional budget Regional Health Authority of Vojvodina National Health Insurance Fund Military Health Insurance Fund NHIF Regional branches payer 4 payer 5 PRIVATE Population [B] [B] [C] direct payments [C] cost sharing for services covered by NHIF [C] Employed Insured NHIF, National Health Insurance Fund Source: Authors 70 Health Systems in Transition 3.3  Overview of the statutory financing  system 3.3.1 Coverage BREADTH: WHO IS COVERED? TheƒmainƒsystemƒforƒpopulationƒhealthƒcoverageƒinƒSerbiaƒisƒtheƒcompulsoryƒ employee/employerƒbasedƒsocialƒhealthƒinsuranceƒthatƒwasƒestablishedƒbyƒtheƒ 1992ƒLawƒonƒHealthƒCareƒandƒLawƒonƒHealthƒInsuranceƒandƒoperatesƒonƒ theƒprinciplesƒofƒcommitment,ƒsolidarityƒandƒmutualityƒ(OfficialƒGazette,ƒ 1992a,ƒ1992b). Theƒ2019ƒLawƒonƒHealthƒInsuranceƒ(OfficialƒGazette,ƒ2019b)ƒdesignatesƒ whichƒgroupsƒareƒresponsibleƒforƒpayingƒaƒcertainƒpercentageƒofƒtheirƒincomeƒ toƒtheƒNHIFƒasƒwellƒasƒwhoƒisƒcoveredƒbyƒhealthƒinsurance.ƒInƒprinciple,ƒ insuranceƒcoverageƒisƒprovidedƒtoƒallƒindividualsƒpermanentlyƒorƒtemporarilyƒ residingƒinƒSerbiaƒ(2019ƒHealthƒCareƒLaw;ƒOfficialƒGazette,ƒ2019a). Thereƒareƒ28ƒcategoriesƒofƒinsuredƒpersonsƒdefinedƒinƒArticleƒ11ƒofƒtheƒ 2019ƒHealthƒInsuranceƒLawƒ(allƒkindƒofƒemployedƒpersonsƒ–ƒpublic,ƒprivate,ƒ self-employed,ƒfarmers,ƒsportsman,ƒpriestsƒandƒpensioners).ƒInƒadditionƒtoƒ theƒcontributingƒgroups,ƒfamilyƒmembersƒandƒmembersƒofƒtheƒhouseholdƒofƒ aƒcontributingƒpersonƒareƒentitledƒtoƒhealthƒcareƒcoverage.ƒGroupsƒofƒpersonsƒ whoƒdoƒnotƒfulfilƒtheƒconditionsƒforƒacquiringƒtheƒstatusƒofƒinsuredƒpersonsƒ andƒwhoƒdoƒnotƒfulfilƒtheƒconditionsƒtoƒbeƒinsuredƒasƒmembersƒofƒtheƒfamilyƒ ofƒinsuredƒpersonsƒshallƒbeƒconsideredƒasƒinsuredƒpersons.ƒTheseƒgroupsƒare:ƒ ƒƒ ƒChildrenƒupƒtoƒ18ƒyearsƒofƒage,ƒschoolƒchildrenƒandƒstudentsƒuntilƒ theƒendƒofƒstatutoryƒschooling,ƒandƒupƒtoƒ26ƒyearsƒofƒageƒmaximum,ƒ inƒcomplianceƒwithƒthe law. ƒƒ ƒPersonsƒrequiringƒ familyƒplanningƒservices,ƒasƒwellƒasƒduringƒ pregnancy,ƒ childbirthƒ andƒ maternity,ƒ upƒ toƒ 12ƒ monthsƒ after childbirth. ƒƒ ƒPersonsƒoverƒ65ƒyearsƒof age. ƒƒ ƒPersonsƒwithƒa disability. ƒƒ ƒPersonsƒreceivingƒtreatmentƒforƒcertainƒdiseasesƒthatƒareƒdefinedƒ byƒaƒspecialƒlawƒregulatingƒtheƒprotectionƒofƒtheƒpopulationƒfromƒ infectiousƒ diseases,ƒ malignantƒ diseases,ƒ diabetes,ƒ psychosis,ƒ 71Serbia epilepsy,ƒmultipleƒsclerosis,ƒpersonsƒinƒtheƒterminalƒphaseƒofƒchronicƒ renalƒinsufficiency,ƒsystemicƒautoimmuneƒdiseases,ƒrheumaticƒfever,ƒ addictionƒdiseases,ƒpatientsƒwithƒrareƒdiseases,ƒandƒpersonsƒcoveredƒ byƒhealthƒcareƒinƒconnectionƒwithƒtheƒtransplantationƒofƒorgans,ƒ cellsƒand tissues. ƒƒ ƒMonksƒand nuns. ƒƒ ƒBeneficiariesƒofƒ financialƒsocialƒassistance,ƒorƒbeneficiariesƒofƒ accommodationƒinƒsocialƒ institutionsƒorƒotherƒfamilies,ƒorƒusersƒ ofƒspecialƒfinancialƒcompensationƒforƒparents,ƒinƒaccordanceƒwithƒ the law. ƒƒ ƒBeneficiariesƒofƒtheƒfamilyƒdisabilityƒallowance,ƒaccordingƒtoƒtheƒ regulationsƒonƒtheƒprotectionƒofƒveterans,ƒmilitaryƒandƒcivilianƒ invalidsƒofƒwar,ƒasƒwellƒasƒmembersƒofƒtheirƒfamiliesƒifƒtheyƒareƒnotƒ health insured. ƒƒ ƒUnemployedƒpersonsƒwhoseƒmonthlyƒincomeƒearningsƒareƒbelowƒ incomeƒearningsƒestablishedƒinƒcomplianceƒwithƒtheƒlawƒgoverningƒ health insurance. ƒƒ ƒBeneficiariesƒ ofƒ cashƒ benefitsƒ forƒ familyƒ membersƒ whoseƒ breadwinnerƒisƒdoingƒmilitary service. ƒƒ ƒPersonsƒofƒRomaƒethnicityƒwho,ƒdueƒtoƒtheirƒtraditionalƒlifestyle,ƒ doƒnotƒhaveƒpermanentƒorƒtemporaryƒresidenceƒinƒthe Republic. ƒƒ ƒDomesticƒviolence victims. ƒƒ ƒPeopleƒtrafficking victims. ƒƒ ƒPersonsƒtoƒwhomƒtheƒcompetentƒauthorityƒhasƒestablishedƒtheƒ statusƒofƒaƒrefugeeƒorƒexiledƒpersonƒfromƒtheƒformerƒrepublicsƒofƒ theƒSocialistƒFederalƒRepublicƒofƒYugoslaviaƒ(SFRY)ƒorƒtheƒstatusƒ ofƒaƒdisplaced person. ƒƒ ƒVictimsƒof terrorism. ƒƒ ƒVeteransƒwhomƒthisƒstatusƒisƒdeterminedƒinƒaccordanceƒwithƒtheƒ regulationsƒonƒtheƒprotectionƒof veterans. Theƒgovernmentalƒ budgetƒ transfersƒ toƒ theƒNHIFƒguaranteeƒ thatƒ healthƒ insuranceƒ coverageƒ isƒ alsoƒ providedƒ toƒ theƒ above-mentionedƒ population groups. AccordingƒtoƒNHIFƒdata,ƒ6 402ƒcitizensƒwereƒinsuredƒinƒSerbiaƒoutƒofƒ 7 272ƒinhabitantsƒ(byƒ31 December 2017),ƒthatƒis,ƒanƒalmostƒfullƒcoverageƒofƒ theƒpopulationƒ(98%)ƒ(NHIF,ƒ2017c).ƒTheƒtotalƒnumberƒofƒinsuredƒpersonsƒ 72 Health Systems in Transition includesƒ1 651ƒ(20%)ƒpersonsƒwhoseƒinsuranceƒisƒfinancedƒfromƒtheƒbudgetƒ ofƒSerbiaƒ(NHIF,ƒ2017c).ƒAmongƒtheƒinsuredƒcitizens,ƒ71%ƒwereƒinsuranceƒ carriers,ƒwhileƒ29%ƒwereƒfamilyƒmembersƒ(Tableƒ3.3). TABLE 3.3 Insured persons in Serbia, 31 December 2017 INSURANCE BASIS TOTAL NUMBER OF INSURED PERSONS INSURANCE CARRIERS FAMILY MEMBERS Employees 2 675 1 849 1 826 Unemployed who receive compensation 46 323 35 372 10 951 Retired persons 1 002 1 378 210 624 Self-employed 304 503 181 475 123 028 Farmers 204 628 104 709 99 919 Insured from the state budget a 1 651 924 532 402 119 Other 167 700 133 922 33 778 Total 6 402 4 237 1 245 Note: a Insured from the state budget includes migrants, Roma, unemployed, among others; Voluntary Health Insurance (VHI) is mostly complementary and purchased to cover co-payments. However, there are also VHI packages offered to cover higher standards of care and/or a scope of benefits not included in the basic package provided by compulsory coverage, as well as the full coverage for persons who are not covered by compulsory health insurance Source: National Health Insurance Fund, 2017c SCOPE: WHAT IS COVERED? Compulsoryƒhealthƒinsuranceƒrightsƒincludeƒtheƒrightƒtoƒhealthƒcare,ƒtheƒ rightƒtoƒsalaryƒreimbursementƒduringƒtemporaryƒworkƒdisabilityƒandƒtheƒ rightƒtoƒreimbursementƒofƒtravelƒcostsƒrelatedƒtoƒusingƒhealthƒcareƒservicesƒ (OfficialƒGazette,ƒ2019b). Compulsoryƒhealthƒinsuranceƒprovidesƒfullƒcoverageƒforƒtheƒfollowingƒ health services: 1. ƒMeasuresƒofƒpreventionƒandƒearlyƒdetectionƒof disease. 2. ƒExaminationsƒ andƒ treatmentƒ inƒ theƒ caseƒ ofƒ familyƒ planning,ƒ biomedicalƒ assistedƒ fertilizationƒ andƒ frozenƒ embryoƒ transfer,ƒ examinationƒandƒtreatmentƒinƒtheƒcaseƒofƒpregnancy,ƒchildbirthƒ 73Serbia andƒinƒtheƒperiodƒofƒ12ƒmonthsƒafterƒdelivery,ƒincludingƒterminationƒ ofƒpregnancyƒforƒmedical reasons. 3. ƒExamination,ƒtreatmentƒandƒrehabilitationƒinƒcaseƒofƒdiseaseƒorƒ injuryƒprovidedƒforƒchildren,ƒpupilsƒandƒstudentsƒupƒtoƒageƒ26ƒforƒ asƒlongƒasƒtheyƒattendƒschool,ƒorƒolderƒpersonsƒwithƒsevereƒphysicalƒ orƒmental disorders. 4. ƒExaminationƒandƒtreatmentƒofƒoralƒdiseaseƒforƒchildren,ƒpupilsƒandƒ studentsƒupƒtoƒageƒ26ƒforƒasƒlongƒasƒtheyƒattendƒschoolƒ(exceptƒforƒ complicationsƒofƒcariesƒandƒtoothƒextractionƒasƒaƒconsequenceƒofƒ cariesƒandƒifƒtheyƒdoƒnotƒrespondƒtoƒpreventiveƒmeasures),ƒolderƒ personsƒwithƒsevereƒphysicalƒorƒmentalƒdisorders,ƒwomenƒinƒtheƒ caseƒofƒpregnancy,ƒchildbirthƒandƒinƒtheƒperiodƒofƒ12ƒmonthsƒafterƒ delivery,ƒexaminationƒandƒtreatmentƒofƒtheƒoralƒdiseasesƒwithinƒtheƒ preoperativeƒandƒpostoperativeƒtreatmentƒofƒmalignantƒdiseasesƒ ofƒtheƒmaxillofacialƒregionƒandƒthoseƒwithƒcongenitalƒorƒacquiredƒ facial deformities. 5. ƒExaminations,ƒ treatmentƒandƒtheƒ implementationƒofƒmeasuresƒ toƒpreventƒspreadƒofƒHIVƒinfectionƒandƒotherƒinfectiousƒdiseasesƒ definedƒby law. 6. ƒExaminationsƒandƒtreatmentƒofƒmalignantƒdiseases,ƒhaemophilia,ƒ diabetes,ƒpsychosis,ƒepilepsy,ƒmultipleƒsclerosis,ƒneuromuscularƒ disorders,ƒcerebralƒpalsy,ƒparaplegia,ƒquadriplegia,ƒchronicƒrenalƒ failureƒ inƒwhichƒdialysisƒorƒkidneyƒtransplantationƒisƒ indicated,ƒ cysticƒfibrosis,ƒsystemicƒautoimmuneƒdiseases,ƒrheumaticƒdiseasesƒ andƒits complications. 7. ƒExaminationsƒandƒtreatmentƒrelatedƒtoƒtheƒdonationƒandƒtranƒs- plantationƒofƒtissuesƒand organs. 8. ƒExaminations,ƒtreatmentƒandƒrehabilitationƒofƒinjuriesƒatƒworkƒandƒ occupational diseases. 9. ƒEmergencyƒ medicalƒ andƒ dentalƒ servicesƒ andƒ ambulanceƒ transportation. 10. ƒMedical-technicalƒaids,ƒimplantsƒandƒmedical devices. 11. ƒOxygenƒconcentratorƒandƒnon-invasiveƒventilationƒ(NIV). 12. ƒOcularƒprosthesis,ƒeyeglasses,ƒcontactƒlensesƒwithƒdioptersƒ±9ƒandƒ telescopic glasses. Theƒ2019ƒLawƒonƒHealthƒInsuranceƒ(OfficialƒGazette,ƒ2019b)ƒdefinesƒ 24ƒtypesƒofƒhealthƒcareƒservicesƒwhichƒareƒnotƒcoveredƒbyƒcompulsoryƒhealthƒ 74 Health Systems in Transition insurance.ƒAmongƒothers,ƒtheyƒinclude:ƒcosmeticƒsurgicalƒinterventions,ƒ terminationƒofƒpregnancyƒforƒnonmedicalƒreasons,ƒmedicalƒdetoxificationƒinƒ theƒcaseƒofƒacuteƒalcoholƒorƒpsychoactiveƒsubstancesƒintoxication,ƒmethodsƒ andƒproceduresƒofƒalternativeƒandƒcomplementaryƒmedicine,ƒdrugsƒoutƒofƒtheƒ listƒofƒdrugs,ƒdiagnosticƒandƒtreatmentƒproceduresƒthatƒareƒinƒtheƒresearchƒ orƒexperimentalƒphases,ƒandƒotherƒtypesƒofƒhealthƒservicesƒnotƒcoveredƒbyƒ compulsoryƒhealth insurance. DEPTH: HOW MUCH OF BENEFIT COST IS COVERED? Dependingƒonƒtheƒtypeƒofƒservice,ƒtheƒshareƒtakenƒonƒbyƒcompulsoryƒhealthƒ insuranceƒforƒservicesƒthatƒareƒnotƒfullyƒcoveredƒrangesƒfromƒ65%ƒtoƒ95%.ƒForƒ someƒservices,ƒco-paymentƒbyƒinsuredƒpersonsƒisƒdefinedƒasƒaƒfixedƒamountƒ andƒvariesƒfromƒ0.5ƒtoƒ9ƒeurosƒperƒserviceƒ(Tableƒ3.4). TABLE 3.4 Co-payment fees for health services in Serbia, 2019 TYPE OF HEALTH SERVICE CO-PAYMENT FEE (EUR) Inpatient treatment – per hospital day 0.5 Day hospital 0.5 Inpatient rehabilitation – per hospital day 0.5 Examination by “chosen doctor” (except preventive) 0.5 Home visit per day 0.5 Ambulance transportation 0.5–1.5 All laboratory tests requested by “chosen doctor” 0.5 Roentgen examination requested by “chosen doctor” 0.5 Ultrasound examination 1 CT examination 3 PET CT examination 9 MRI examination 6 75Serbia Other diagnostic services (endoscopy, spirometry, ECG) 0.5 Surgical corrections 5% of price up to 300 EUR Implants in cardio surgery, vascular surgery and orthopaedic surgery 5% of price up to 300 EUR Other implants 20% of price up to 300 EUR Orthopaedic devices and appliances 10–20% of price Dental visit, examination or denture 10–35% of price Gender reassignment surgery due to medical indications 35% of price Note: 1 euro is 119 RSD according to exchange rate at 20 September 2017, so lowest co-payment fee is about half of the euro Source: Official Gazette, 2019c 3.3.2 Collection TheƒmainƒrevenueƒsourceƒforƒhealthƒfinancingƒinƒSerbiaƒareƒtheƒcompulsoryƒ healthƒinsuranceƒcontributionsƒcomingƒfromƒemployee’sƒwagesƒandƒemployer’sƒ profit.ƒTheƒ2019ƒLawƒonƒContributionsƒforƒCompulsoryƒSocialƒInsuranceƒ (OfficialƒGazette,ƒ2019d)ƒdefinesƒtheƒrateƒofƒcontributionsƒincludingƒtheƒrateƒ forƒcompulsoryƒpensionƒandƒdisabilityƒinsuranceƒ(26%),ƒforƒmandatoryƒhealthƒ insuranceƒ(10.3%),ƒandƒforƒunemploymentƒinsuranceƒ(0.75%).ƒContributionsƒ forƒcompulsoryƒpensionƒandƒdisabilityƒinsuranceƒandƒforƒunemploymentƒ insuranceƒalsoƒpartiallyƒgoƒtoƒtheƒNHIF,ƒthroughƒtheƒcontributionsƒofƒtheƒ PensionƒandƒDisabilityƒFundƒandƒtheƒNationalƒServiceƒfor Employment. Collectionƒofƒsocialƒcontributionsƒforƒhealthƒinsuranceƒisƒunderƒtheƒ jurisdictionƒofƒtheƒTaxƒAdministration.ƒTheƒcollectedƒrevenuesƒfromƒsocialƒ contributions,ƒtogetherƒwithƒotherƒrevenuesƒareƒpooledƒinƒtheƒNHIFƒaccount,ƒ administeredƒbyƒtheƒState Treasury. Generalƒtaxationƒisƒnon-earmarkedƒrevenue.ƒTheƒcentralƒbudgetƒtaxƒ revenueƒincludesƒrevenueƒfromƒIndividualƒIncomeƒTax,ƒCorporateƒIncomeƒ Tax,ƒValueƒAddedƒTax,ƒExciseƒTaxƒandƒCustomsƒDuty,ƒwhichƒareƒcollectedƒ byƒtheƒTaxƒAdministrationƒofƒtheƒRepublicƒofƒSerbia.ƒMunicipalƒbudgetƒtaxƒ revenueƒisƒaccumulatedƒfromƒlocalƒtaxesƒandƒisƒcollectedƒbyƒtheƒmunicipalities.ƒ Theƒamountƒofƒtheƒtaxƒrevenueƒallocatedƒforƒhealthƒbothƒnationallyƒandƒatƒ theƒmunicipalityƒlevelƒisƒnotƒfixedƒbutƒisƒdefinedƒannuallyƒbyƒnationalƒandƒ local parliaments. 76 Health Systems in Transition BOX 3.1 Is health financing fair? The Serbian health system is based on the principles of equity and solidarity and is predominantly financed by compulsory social insurance contributions. The role of the National Health Insurance Fund (NHIF), as a state agency which collects contributions (see section 2.3), is to make the health system equal for every citizen, regardless of their status, but in practice this is not always the case. Wage-based health insurance contributions from employers, employees, and the self-employed represented the largest share of the NHIF income in 2018 (64.04%), followed by contributions from the pension and disability insurance fund (21.46%) and revenues from the state budget (12.39%), while other revenues made up 2.11% of the total NHIF income (NHIF, 2019b). In 2017, approximately 6.9 million of individuals were insured. Among them, health insurance for 20% of persons has been financed from the budget of Serbia (NHIF, 2017c). The fiscal burden on wages in the period 2001 to 2006 can be best described as proportional, and slightly progressive in the period since 2007. Income tax represents one quarter of the fiscal burden, while the remaining three quarters are contributions to compulsory social insurance. Contribution rates for pension and disability insurance are 26%, for health insurance, 10.3%, and for unemployed insurance, 1.5%. The minimum contribution base in Serbia equals 35% of the average salary, while the maximum contribution base is five times the average monthly salary. Concerning the fact that all insured people exercise the same rights to health care services, there is an implicit progressive redistribution of income; that is, those with higher salaries subsidize health care for those with lower salaries (Altiparmakov, 2013; Government of Serbia, 2017b). The expansion of the sources of financing refers to the introduction of the so-called “tobacco dinar”; that is, money that went into the Ministry of Health budget for every sold cigarette pack. These funds were spent on health promotion and disease prevention activities advocating against cigarette smoking as well as for diagnostics and treatment of cardiovascular and malignant diseases (Simic, 2012). Earmarking of revenues from tobacco products that had been established in 2005 was cancelled in 2012 (Farrington et al., 2018). 77Serbia 3.3.3 Pooling and allocation of funds ALLOCATION FROM COLLECTION AGENCIES TO POOLING AGENCIES TheƒmainƒpoolingƒmechanismƒisƒrepresentedƒbyƒtheƒNHIFƒwhichƒisƒrespon- sibleƒforƒpoolingƒofƒcollectedƒrevenuesƒfromƒsocialƒcontributions,ƒtogetherƒwithƒ otherƒrevenues.ƒTheƒNHIFƒisƒaƒsoleƒproviderƒofƒcompulsoryƒhealth insurance. TheƒMinistryƒofƒFinanceƒhasƒitsƒroleƒinƒtheƒpoolingƒofƒfundsƒandƒalloca- tionƒofƒmoneyƒtoƒtheƒMinistryƒofƒHealthƒandƒotherƒministriesƒaccordingƒtoƒ theƒyearlyƒlawƒonƒtheƒbudgetƒ(OfficialƒGazette,ƒ2018d). Withinƒeachƒannualƒfinancialƒplan,ƒtheƒNHIFƒdefinesƒaƒmaximumƒ overallƒspendingƒonƒhealthƒservicesƒbyƒcompulsoryƒhealthƒinsuranceƒcon- tributionsƒforƒtheƒupcomingƒyear.ƒTheƒprospectivelyƒdeterminedƒannualƒ NHIFƒbudgetƒforƒhealthƒservicesƒisƒdefinedƒaccordingƒtoƒcurrentƒandƒfutureƒ macroeconomicƒconditions,ƒsuchƒasƒexpectedƒgrowthƒofƒGDP,ƒrateƒofƒinfla- tion,ƒexpectedƒgrowthƒofƒwagesƒandƒpensionsƒandƒtheƒrateƒofƒunemployment;ƒ thatƒis,ƒthoseƒindicatorsƒthatƒinfluenceƒtheƒamountƒofƒcontributionsƒpaidƒbyƒ insuredƒindividualsƒandƒotherƒrevenuesƒofƒthe NHIF. TheƒNHIFƒfinancialƒplanƒforƒ2019ƒdefinesƒtheƒoverallƒrevenue/spendƒonƒ healthƒcareƒasƒ2.23ƒbillionƒeuros,ƒandƒthisƒplanƒisƒmostlyƒbasedƒonƒpreviousƒ expendituresƒ(NHIF,ƒ2018g).ƒTheƒNHIFƒfinancialƒplanƒisƒadoptedƒbyƒtheƒ ManagingƒBoardƒofƒtheƒNHIFƒandƒapprovedƒbyƒtheƒNational Assembly. ALLOCATING RESOURCES TO PURCHASERS TheƒbasicƒpurchaserƒofƒhealthƒservicesƒinƒSerbiaƒisƒtheƒNHIFƒwithƒitsƒorgani- zationalƒunitsƒ(ProvincialƒHealthƒInsuranceƒFundƒandƒbranchƒandƒsub-branchƒ officesƒestablishedƒforƒtheƒterritoryƒofƒaƒmunicipality,ƒcityƒorƒdistrict).ƒTheƒ RulebookƒonƒtheƒContractingƒofƒHealthƒCareƒfromƒCompulsoryƒHealthƒ InsuranceƒwithƒHealthƒCareƒServiceƒProviders,ƒadoptedƒeachƒyearƒ(NHIF,ƒ 2018h),ƒdefinesƒtheƒconditionsƒforƒmakingƒaƒcontractƒforƒtheƒprovisionƒofƒ healthƒcareƒfromƒcompulsoryƒhealthƒinsuranceƒtoƒinsuredƒpersonsƒforƒtheƒ upcomingƒyearƒbetweenƒtheƒNHIFƒandƒprovidersƒofƒhealthƒservicesƒ(healthƒ institutions,ƒprivateƒpracticeƒandƒotherƒlegalƒentities),ƒcriteriaƒforƒdeterminingƒ theƒremunerationƒforƒtheirƒwork;ƒthatƒis,ƒtheƒmannerƒofƒpaymentƒofƒhealthƒ servicesƒandƒotherƒcostsƒinƒaccordanceƒwithƒtheƒlaw,ƒtheƒfinalƒsettlementƒ 78 Health Systems in Transition procedureƒwithƒtheƒprovidersƒofƒhealthƒservices,ƒtheƒdeadlinesƒinƒwhichƒ theyƒwillƒconcludeƒcontractsƒandƒotherƒissuesƒofƒimportanceƒforƒtheƒprocessƒ of contracting. 3.3.4 Purchasing and purchaser-provider relations TheƒhealthƒcareƒproviderƒmayƒconcludeƒaƒcontractƒwithƒtheƒNHIFƒifƒitƒ meetsƒtheƒrequirementsƒforƒperformingƒaƒhealthƒcareƒactivityƒdefinedƒbyƒtheƒ RulebookƒonƒDetailedƒConditionsƒforƒPerformingƒHealthƒCareƒActivitiesƒ inƒHealthƒInstitutionsƒandƒOtherƒFormsƒofƒHealthƒCareƒServicesƒ(Officialƒ Gazette,ƒ2006c).ƒTheƒhealthƒcareƒprovider,ƒinƒorderƒtoƒconcludeƒaƒcontract,ƒ submitsƒtoƒtheƒNHIFƒorƒitsƒBranchƒOfficeƒanƒofferƒorƒplanƒofƒworkƒforƒ theƒupcomingƒyear.ƒToƒbeƒeligibleƒtoƒmakeƒaƒcontractƒwithƒtheƒNHIF,ƒtheƒ healthƒcareƒprovidersƒhaveƒtoƒreceiveƒtheƒapprovalƒofƒtheirƒplanƒfromƒtheƒ regional IPHs. Theƒtypeƒandƒscopeƒofƒhealthƒservicesƒthatƒareƒpresentedƒinƒtheƒofferƒorƒ theƒworkplanƒareƒbasedƒonƒaƒgeneralƒactƒthatƒidentifiesƒtheƒhealthƒcareƒplanƒ fromƒcompulsoryƒhealthƒinsuranceƒforƒupcomingƒyearƒadoptedƒbyƒthe NHIF. AƒcontractƒwithƒaƒhealthƒcareƒproviderƒthatƒisƒnotƒincludedƒinƒtheƒHealthƒ CareƒInstitutionƒNetworkƒPlanƒmayƒbeƒconcludedƒinƒaccordanceƒwithƒtheƒ lawƒregulatingƒpublicƒprocurementƒ(OfficialƒGazette,ƒ2012a)ƒorƒbyƒsendingƒ aƒpublicƒcallƒforƒcontractƒconclusionƒwithƒallƒprovidersƒofƒhealthƒservicesƒthatƒ meetƒtheƒdefinedƒconditionsƒforƒtheƒprovisionƒofƒhealthƒservicesƒthatƒareƒtheƒ subjectƒofƒthe contract. 3.4  Out-of-pocket payments OOPƒpaymentsƒareƒtheƒmostƒdominantƒprivateƒsourceƒofƒexpenditure.ƒOOPƒ paymentsƒareƒmainlyƒdirectƒoutlayƒbyƒindividuals,ƒincludingƒgratuitiesƒandƒ in-kindƒpaymentsƒtoƒhealthƒpractitionersƒandƒsuppliers.ƒOOPƒpaymentsƒareƒ alsoƒusedƒtoƒfinanceƒservicesƒpurchasedƒinƒmilitaryƒfacilitiesƒbyƒtheƒcivilianƒ populationƒwhenƒservicesƒareƒnotƒcoveredƒbyƒthe NHIF. Theƒ2018ƒHouseholdƒBudgetƒSurveyƒdeterminedƒthatƒ4.4%ƒofƒhouseholdƒ revenueƒwasƒspentƒasƒOOPƒexpenditureƒonƒhealthƒinƒ2017ƒ(SIPRU,ƒ2018).ƒItƒ doesƒnotƒprovideƒinformationƒonƒwhichƒpercentageƒofƒthisƒamountƒcomprisesƒ OOPƒuserƒfeesƒandƒwhichƒpercentageƒcomprisesƒinformal payments. 79Serbia Accordingƒtoƒtheƒ2013ƒNationalƒHealthƒSurveyƒ(IPHƒBatut,ƒ2014b),ƒ inƒtheƒ12ƒmonthsƒprecedingƒtheƒSurvey,ƒ51.6%ƒofƒtheƒtotalƒpopulationƒhadƒ expendituresƒforƒhealthƒcare.ƒOverƒhalfƒofƒtheseƒpaymentsƒforƒhealthƒcareƒ wereƒforƒmedicationsƒ(Tableƒ3.5). TABLE 3.5 Share of certain types of health expenditures in total OOP payments, 2013 TYPE OF HEALTH SERVICES SHARE IN TOTAL OOP (%) Outpatient services (public) 2.1 Outpatient services (private) 3.9 Dental services (public) 2.0 Dental services (private) 14.2 Diagnostic services (public) 2.8 Diagnostic services (private) 8.0 Payments for drugs (total) 55.6 Other expenses 11.4 Source: IPH Batut, 2014b 3.4.1 Cost-sharing (user charges) Cost-sharingƒinƒSerbiaƒoccursƒinƒtheƒformƒofƒco-payments,ƒthroughƒwhichƒ patientsƒareƒchargedƒaƒfixedƒamountƒorƒtheƒpercentageƒremainingƒupƒtoƒtheƒ totalƒpriceƒofƒhealthƒcareƒservices.ƒInƒthisƒscheme,ƒpatientsƒformallyƒshareƒaƒ partƒofƒtheƒcostƒburdenƒandƒtheƒNHIFƒcoversƒtheƒremainderƒofƒtheƒutiliza- tionƒfee.ƒDependingƒonƒtheƒspecificƒtypeƒofƒservices,ƒtheƒshareƒtakenƒonƒbyƒ compulsoryƒhealthƒinsuranceƒforƒservicesƒthatƒareƒnotƒfullyƒcoveredƒrangesƒ fromƒ65%ƒtoƒ100%.ƒAlthoughƒtheseƒfeesƒareƒlow,ƒextensiveƒexemptionsƒareƒ appliedƒforƒvulnerableƒpopulationƒgroupsƒ(seeƒbelow)ƒand,ƒinƒpractice,ƒitƒwasƒ estimatedƒthatƒexemptionsƒappliedƒupƒtoƒ50–60%ƒofƒthe population. Theƒ2019ƒHealthƒInsuranceƒLawƒ(OfficialƒGazette,ƒ2019b)ƒdefinesƒ co-paymentsƒofƒupƒtoƒ35%ƒofƒtheƒpriceƒofƒhealthƒcareƒservices.ƒTheƒNHIFƒ stipulatedƒinƒtheƒby-lawƒonƒcontentƒandƒscopeƒofƒhealthƒbenefitsƒfromƒ 80 Health Systems in Transition obligatoryƒhealthƒinsuranceƒandƒco-paymentƒfeesƒforƒ2019ƒ(OfficialƒGazette,ƒ 2019c)ƒthatƒtheƒco-paymentƒfeeƒisƒchargedƒbyƒtheƒproviderƒafterƒtheƒprovisionƒ ofƒhealthƒservices.ƒTheƒamountsƒofƒco-paymentƒfeesƒforƒhealthƒservicesƒinƒ SerbiaƒareƒpresentedƒinƒTableƒ3.4. Theƒamountƒofƒco-paymentsƒbyƒanƒinsuredƒpersonƒinƒaƒcalendarƒyearƒmayƒ notƒexceedƒhalfƒofƒtheƒmonthlyƒsalaryƒorƒhalfƒofƒtheƒpensionƒofƒtheƒinsured,ƒ paidƒtoƒtheƒinsuredƒinƒtheƒlastƒmonthƒinƒtheƒcalendarƒyearƒ(OfficialƒGazette,ƒ 2019c).ƒForƒinsuredƒpersonsƒwithƒnoƒsalaryƒorƒpensionƒ(e.g.ƒunemployed),ƒ theƒhighestƒannualƒamountƒofƒco-paymentƒisƒdeterminedƒbyƒtheƒamountƒofƒ halfƒofƒtheƒaverageƒofƒtheƒnetƒearningsƒinƒSerbiaƒpaidƒinƒtheƒlastƒmonthƒofƒ theƒcalendar year. Theƒhighestƒannualƒamountƒofƒco-paymentsƒshallƒnotƒ includeƒtheƒ co-paymentsƒpaidƒforƒimplants,ƒmedicalƒdevices,ƒandƒco-paymentsƒforƒdrugsƒ definedƒasƒaƒpercentageƒofƒpricesƒfromƒtheƒDrugƒListƒ(OfficialƒGazette,ƒ 2019c). Certainƒcategoriesƒofƒcitizensƒareƒexemptƒfromƒco-paymentsƒforƒmedicalƒ servicesƒ(e.g.ƒexaminationƒbyƒtheƒ“chosenƒdoctors”,ƒdrugsƒforƒwhichƒaƒfixedƒfeeƒ ofƒ0.5ƒeurosƒapplies,ƒlaboratoryƒanalysis,ƒrehabilitation,ƒpercentageƒshareƒofƒtheƒ costƒofƒimplants,ƒmedical-technicalƒequipment,ƒetc.).ƒPaymentsƒareƒexemptedƒ forƒdisabledƒveterans,ƒcivilianƒwarƒinvalids,ƒblindƒpersonsƒandƒpermanentlyƒ handicappedƒpersons,ƒbloodƒdonorsƒwhoƒdonatedƒbloodƒ10ƒorƒmoreƒtimesƒ (permanentlyƒexempted),ƒexceptƒforƒdrugsƒfromƒtheƒPositiveƒListƒandƒmedicalƒ devices.ƒPaymentsƒareƒalsoƒexemptedƒforƒpeopleƒwhoƒhaveƒdonatedƒbloodƒ fewerƒthanƒ10ƒtimesƒinƒ12ƒmonthsƒafterƒaƒbloodƒdonation.ƒCo-paymentsƒareƒ alsoƒexemptƒforƒotherƒvulnerableƒgroupsƒsuchƒasƒtheƒunemployed,ƒrefugees,ƒ displacedƒandƒexiledƒpersons,ƒpersonsƒoverƒ65ƒyearsƒofƒageƒwithƒnoƒactualƒ rightƒtoƒretirementƒandƒtheƒRomaƒpopulation.ƒInƒadditionƒtoƒtheseƒcategories,ƒ allƒcitizensƒandƒtheirƒfamiliesƒwhoseƒmonthlyƒincomeƒdoesƒnotƒexceedƒtheƒ prescribedƒthresholdƒforƒexemptionƒfromƒco-paymentsƒareƒalsoƒexemptedƒ (OfficialƒGazette,ƒ2019c). 3.4.2 Direct payments DirectƒpaymentsƒinƒtheƒSerbianƒhealthƒsystemƒincludeƒpayments for: ƒƒ ƒmedicalƒexaminationsƒinƒorderƒtoƒdetermineƒhealthƒstatus,ƒphysicalƒ impairmentƒandƒdisabilityƒforƒtheƒexerciseƒofƒcertainƒrightsƒwithƒ otherƒbodiesƒandƒorganizationsƒ(forƒinsuranceƒcompanies,ƒCourts,ƒ 81Serbia criminalƒandƒpre-trialƒproceedings,ƒ forƒ issuingƒcertificatesƒ forƒ driversƒofƒmotorƒvehicles,ƒdeterminingƒtheƒhealthƒcompetenceƒonƒ theƒproposalƒofƒtheƒemployer,ƒmeasuresƒrelatedƒtoƒsafetyƒandƒhealthƒ atƒwork,ƒetc.),ƒexceptƒforƒexaminationsƒasƒinstructedƒbyƒprofessionalƒ medical authorities; ƒƒ ƒmedicalƒexaminationsƒrequiredƒforƒtheƒenrolmentƒinƒhighƒschool,ƒ college,ƒuniversityƒandƒcourses,ƒforƒobtainingƒhealthƒcertificatesƒtoƒ startƒto work; ƒƒ ƒpersonalƒcomfortƒandƒspecialƒaccommodationƒandƒpersonalƒcareƒ inƒhospitalƒinpatientƒfacilitiesƒwhichƒareƒmedicallyƒunnecessaryƒorƒ providedƒonƒpersonal request; ƒƒ ƒhealthƒserviceƒforƒdetoxificationƒinƒacuteƒdrunkennessƒandƒacuteƒ useƒofƒpsychoactive substances; ƒƒ ƒcosmeticƒ proceduresƒ aimingƒ toƒ improveƒ appearanceƒ withoutƒ restoringƒbody functions; ƒƒ ƒpregnancyƒterminationƒforƒnonmedical reasons; ƒƒ ƒdentalƒservicesƒnotƒincludedƒunderƒtheƒmandatoryƒhealth insurance; ƒƒ ƒmedicinesƒwhichƒareƒnotƒonƒtheƒDrug List; ƒƒ ƒotherƒkindƒofƒhealthƒcareƒservicesƒnotƒestablishedƒasƒentitlementsƒ derivingƒfromƒcompulsoryƒhealth insurance. Aƒsignificantƒamountƒofƒdirectƒpaymentsƒtargetsƒtheƒgrowingƒprivateƒ healthƒsector.ƒSinceƒ1989,ƒdentistsƒhaveƒbeenƒallowedƒtoƒopenƒprivateƒofficesƒ andƒsinceƒ1992,ƒprimary,ƒsecondaryƒandƒtertiaryƒcareƒphysiciansƒandƒphar- macistsƒhaveƒbeenƒallowedƒtoƒopenƒprivate practices. 3.4.3 Informal payments TheƒscopeƒofƒinformalƒpaymentsƒinƒSerbiaƒisƒdifficultƒtoƒascertainƒasƒtheyƒareƒ illegalƒandƒlargelyƒunreported.ƒTheƒresultsƒofƒtheƒNationalƒHealthƒSurveyƒ fromƒ2013ƒshowƒthatƒinƒtheƒ12ƒmonthsƒprecedingƒtheƒSurvey,ƒhealthƒservicesƒ wereƒdirectlyƒpaidƒforƒbyƒ0.1%ƒofƒtheƒpopulation,ƒwhoƒincurredƒcostsƒforƒhealthƒ care,ƒwhileƒ0.7%ƒofƒtheƒpopulationƒpaidƒtheƒhealthƒcareƒstaffƒonƒtheirƒownƒ initiativeƒ(IPHƒBatut,ƒ2014b).ƒHowever,ƒonlyƒaƒsmallƒnumberƒofƒrespondentsƒ answeredƒtheƒquestionsƒaboutƒdirectƒpaymentsƒtoƒhealthƒcareƒstaffƒforƒhealthƒ services.ƒInƒaddition,ƒthereƒisƒindicativeƒinformationƒthatƒmoreƒthanƒoneƒthirdƒ (34.5%)ƒofƒtheƒpopulationƒofƒSerbiaƒrefusedƒtoƒpayƒforƒaƒhealthƒserviceƒuponƒ 82 Health Systems in Transition requestƒofƒtheƒhealthƒcareƒstaff,ƒwithƒaƒlargeƒpercentageƒofƒsuchƒpersonsƒinƒ southernƒandƒeasternƒSerbiaƒ(50.9%)ƒcomparedƒwithƒVojvodinaƒandƒBelgradeƒ (25.5%ƒandƒ25.1%,ƒrespectively)ƒ(ACAS,ƒ2012). FromƒtheƒreportƒofƒtheƒAnti-corruptionƒAgencyƒofƒtheƒRepublicƒofƒSerbiaƒ (ACAS,ƒ2012)ƒonƒForms,ƒCausesƒandƒRisksƒofƒCorruptionƒinƒtheƒhealthƒ systemƒitƒarisesƒthatƒtheƒfieldsƒofƒriskƒofƒcorruptionƒareƒpublicƒprocurement,ƒ doctor’sƒsupplementaryƒwork,ƒspendingƒfunds,ƒreceivingƒgifts,ƒconflictƒofƒ interest,ƒwaitingƒlists,ƒrelationshipsƒbetweenƒpharmaceuticalƒcompaniesƒandƒ doctors,ƒandƒtheƒprocessƒofƒemploymentƒinƒhealthƒinstitutions.ƒTheƒcauseƒofƒ theseƒrisksƒwasƒlackƒofƒsystemƒlawsƒthatƒregulateƒthese issues. TheƒnewƒStrategyƒforƒtheƒPreventionƒandƒFightƒAgainstƒCorruptionƒ (2013)ƒforƒtheƒperiodƒ2013–2018ƒ(OfficialƒGazette,ƒ2013k)ƒandƒitsƒActionƒ Planƒhaveƒbothƒaƒstructuralƒapproachƒcoveringƒissuesƒsuchƒasƒgoodƒgovern- ance,ƒindependentƒinstitutions,ƒinternalƒcontrolƒandƒexternalƒaudit,ƒandƒ protectionƒofƒwhistleblowers,ƒandƒaƒsectorƒapproachƒaddressingƒcorruptionƒinƒ mostƒsensitiveƒsectorsƒsuchƒasƒpublicƒprocurement,ƒspatialƒplanning,ƒjudici- ary,ƒpolice,ƒeducationƒandƒhealth.ƒAƒspecificƒfocusƒwasƒonƒaƒcross-sectoralƒ approach,ƒtheƒprincipleƒofƒparticipation,ƒknowledgeƒtransferƒandƒ“zeroƒtoler- ance”ƒto corruption. 3.5  Voluntary health insurance 3.5.1 Market role and size Accordingƒtoƒtheƒ2019ƒLawƒonƒHealthƒInsuranceƒ(OfficialƒGazette,ƒ2019b),ƒ VoluntaryƒHealthƒInsuranceƒ(VHI)ƒisƒhealthƒinsuranceƒthatƒcoversƒfasterƒ accessƒtoƒcareƒandƒenhancedƒconsumerƒchoiceƒofƒproviderƒandƒamenitiesƒ (supplementaryƒmarketƒrole);ƒinsuranceƒcoveringƒtheƒcostsƒofƒhealthƒcare,ƒ thatƒis,ƒhealthƒservices,ƒmedicines,ƒmedicalƒdevices,ƒuserƒcharges,ƒetc.,ƒwhichƒ areƒnotƒcoveredƒbyƒcompulsoryƒhealthƒinsuranceƒ(complementaryƒmarketƒ role);ƒinsuranceƒofƒcitizensƒnotƒinsuredƒunderƒcompulsoryƒhealthƒinsuranceƒ (substitutiveƒmarketƒrole). VHIƒisƒbeingƒcontractedƒasƒlong-termƒinsuranceƒforƒaƒperiodƒwhichƒ cannotƒbeƒlessƒthanƒ12ƒmonthsƒfromƒtheƒdateƒofƒbeginningƒtheƒinsurance.ƒ VHIƒisƒorganizedƒandƒcarriedƒoutƒbyƒtheƒNHIFƒandƒinsuranceƒcompaniesƒ dealingƒwithƒinsuranceƒactivitiesƒinƒaccordanceƒwithƒtheƒ2008ƒDecreeƒonƒ 83Serbia VoluntaryƒHealthƒInsuranceƒ(OfficialƒGazette,ƒ2008),ƒasƒwellƒasƒbyƒtheƒ investmentƒfundsƒforƒVHI,ƒinƒaccordanceƒwithƒtheƒ2014ƒLawƒonƒInsuranceƒ (OfficialƒGazette,ƒ2014e).ƒUponƒaƒproposalƒofƒtheƒMinisterƒofƒHealth,ƒtheƒ governmentƒregulatesƒtheƒtypesƒofƒVHI,ƒtheƒconditions,ƒtheƒmannerƒandƒ proceduresƒofƒorganizingƒandƒimplementing VHI. NHIFƒoffersƒVHIƒinƒorderƒtoƒenableƒcitizens,ƒunderƒtheƒbestƒcondi- tions,ƒtoƒenjoyƒrightsƒthatƒareƒnotƒcoveredƒbyƒtheƒcompulsory/mandatoryƒ healthƒinsuranceƒ(OfficialƒGazette,ƒ2019b).ƒThereƒareƒalsoƒseveralƒprivateƒ insurance companies. 3.5.2 Market structure VHIƒinƒSerbiaƒisƒofferedƒbyƒtheƒNHIFƒandƒ12ƒinsuranceƒcompaniesƒ(includingƒ threeƒthatƒonlyƒofferƒtravelƒhealthƒinsurance)ƒ(NationalƒBankƒofƒSerbia,ƒ 2019a).ƒInƒ2018,ƒtheƒtotalƒpremiumƒforƒVHIƒamountedƒtoƒ3.5%ƒofƒallƒinsur- anceƒpremiums,ƒtheƒlargestƒshareƒsinceƒVHIƒwasƒintroduced.ƒAmongƒtheƒ insuranceƒcompanies,ƒtheƒlargestƒmarketƒplayersƒareƒGenerali,ƒUniqaƒandƒ WienerƒStatdische.ƒMostƒofƒtheirƒclientsƒareƒcorporateƒclientsƒwhoƒcontractƒ thisƒtypeƒofƒinsuranceƒforƒtheirƒemployeesƒ(aboutƒ70%),ƒwhileƒtheƒrestƒareƒ individualsƒwhoƒcontractƒVHIƒforƒthemselvesƒandƒtheirƒfamilyƒmembersƒ (EY,ƒ2016). However,ƒtheƒVHIƒmarketƒinƒSerbiaƒisƒstillƒatƒaƒveryƒlowƒlevelƒofƒdevel- opment.ƒOneƒofƒtheƒbarriersƒisƒtheƒlowƒinformationƒlevelƒofƒtheƒpopulationƒ aboutƒVHIƒmodels.ƒItƒisƒarguedƒthatƒVHIƒisƒquiteƒexpensiveƒandƒsomethingƒ thatƒonlyƒaƒsmallƒnumberƒofƒpeopleƒcanƒaffordƒ(EY,ƒ2016). 3.5.3 Market conduct Inƒorderƒtoƒsignƒcontractsƒwithƒinsuranceƒcompanies,ƒhealthƒcareƒprovidersƒ haveƒtoƒreachƒcertainƒstandardsƒinƒtheƒprovisionƒofƒhealthƒservices,ƒincludingƒ theƒqualityƒofƒservicesƒprovidedƒandƒsatisfactionƒofƒclients.ƒTheƒmajorƒpartƒofƒ contractedƒVHIƒservicesƒareƒoutpatientƒservicesƒ(aroundƒ70%ƒofƒcontractedƒ riskƒcoverages),ƒwhileƒinpatientƒservicesƒcoverƒaboutƒ30%ƒofƒallƒcontractedƒ policiesƒ(EY,ƒ2016).ƒOtherƒhealthƒservicesƒ(examinations,ƒphysicalƒtherapy,ƒ dentalƒcare,ƒmedicines)ƒcanƒbeƒincludedƒinƒanyƒVHI package. 84 Health Systems in Transition 3.5.4 Public policy RegulationƒofƒVHIƒ(OfficialƒGazette,ƒ2008)ƒdefinesƒthatƒtheƒMinistryƒofƒ Healthƒissuesƒopinionsƒonƒtheƒfulfilmentƒofƒtheƒconditionsƒforƒorganizingƒandƒ performingƒaƒspecificƒtypeƒofƒVHI.ƒAlongƒwithƒtheƒMinistryƒofƒHealth,ƒtheƒ NationalƒBankƒofƒSerbiaƒ(NBS)ƒisƒalsoƒresponsibleƒforƒhealthƒinsurance.ƒTheƒ NBS,ƒuponƒtheƒpositiveƒopinionƒofƒtheƒMinistryƒofƒHealth,ƒissuesƒlicensesƒ toƒinsurance companies. 3.6  Other financing InƒadditionƒtoƒtheƒNHIF,ƒthereƒareƒotherƒsourcesƒofƒpublicƒfinancing.ƒItƒ hasƒalreadyƒbeenƒmentionedƒthatƒfundsƒareƒtransferredƒtoƒtheƒNHIFƒfromƒ theƒgovernmentalƒbudgetƒforƒinsuranceƒcoverageƒofƒvulnerableƒpopulationƒ groups,ƒincludingƒsocialƒwelfareƒbeneficiaries,ƒtheƒlong-termƒunemployed,ƒ theƒolderƒpopulationƒasƒwellƒasƒtheƒyoungƒandƒinternallyƒdisplacedƒpersonsƒ (IDPs)ƒand refugees. 3.6.1 Parallel health systems TheƒMinistryƒofƒDefenceƒoperatesƒaƒparallelƒhealthƒinsuranceƒfundƒwhichƒ enablesƒmilitaryƒpersonnelƒtoƒreceiveƒservicesƒinƒmilitaryƒhealthƒfacilities;ƒ thatƒis,ƒmilitaryƒhealthƒcentres,ƒmilitaryƒhospitalsƒandƒtheƒMilitaryƒMedicalƒ Academyƒ(MMA).ƒTheƒmilitaryƒhealthƒinsuranceƒfundƒcoversƒsoldiers,ƒ veteransƒandƒtheirƒfamilies.ƒDueƒtoƒaƒsurplusƒofƒMMAƒcapacityƒafterƒtheƒ breakƒupƒofƒtheƒformerƒYugoslaviaƒandƒtheƒshortageƒofƒservicesƒandƒhospitalƒ bedsƒinƒsomeƒmedicalƒdisciplinesƒofƒtheƒpublicƒhealthƒsectorƒ(seeƒsectionƒ2.1),ƒ theƒNHIFƒcontractsƒwithƒtheƒMMAƒforƒthoseƒservices.ƒInƒ2008,ƒtheƒMMAƒ hasƒbeenƒincludedƒinƒtheƒHealthƒCareƒInstitutionƒNetworkƒPlanƒwithƒpartƒofƒ itsƒcapacitiesƒ(500ƒbeds)ƒand,ƒsinceƒthen,ƒhasƒexpandedƒtheƒofferƒtoƒtheƒcivilƒ sectorƒforƒadditionalƒhealthƒcareƒplansƒandƒcomprehensiveƒbenefitƒpackagesƒ andƒhasƒconcludedƒcontractsƒforƒbusinessƒandƒtechnicalƒcooperationƒwithƒ publicƒandƒprivateƒcompanies,ƒsportsƒclubsƒand others. 85Serbia 3.6.2 External sources of funds Externalƒsourcesƒofƒfundingƒhaveƒbeenƒreceivedƒinƒtheƒformƒofƒin-kindƒdona- tions,ƒcapitalƒexpenseƒcoverageƒandƒhumanƒcapacityƒtrainingƒprogrammesƒ throughƒbilateralƒandƒmultilateralƒdonorƒagenciesƒasƒwellƒasƒloansƒfromƒ regionalƒandƒinternationalƒdevelopment banks. Initiallyƒ(sinceƒ2000),ƒtheƒfocusƒofƒinternationalƒdonors’ƒaidƒwasƒonƒemer- gencyƒassistanceƒtoƒaddressƒaƒcrisisƒinƒtheƒhealthƒsector,ƒinƒparticular,ƒcriticalƒ shortagesƒinƒkeyƒmedicinesƒandƒmedicalƒsuppliesƒ(ECHO,ƒ2003).ƒThisƒwasƒ followedƒbyƒprogrammesƒdesignedƒtoƒhelpƒrebuildƒsomeƒofƒtheƒhealthƒsectorƒ infrastructureƒ(e.g.ƒhospitals),ƒbutƒsinceƒ2002ƒthereƒhasƒalsoƒbeenƒaƒcontinuousƒ emphasisƒonƒsupportingƒinstitutionalƒreformƒofƒtheƒhealthƒsystem.ƒAllƒthisƒ wasƒdoneƒthroughƒtheƒEARƒHealthƒcardsƒprogrammeƒ(fromƒ2000ƒtoƒ2008). Inƒ2008,ƒtheƒSerbianƒGovernmentƒsignedƒtheƒfinancingƒagreementƒ withƒtheƒEuropeanƒCommissionƒrelatedƒtoƒtheƒInstrumentƒofƒPre-Accessionƒ (IPA)ƒassistance. InternationalƒdonorsƒincludeƒtheƒEU,ƒthroughƒtheƒEuropeanƒAgencyƒforƒ Reconstructionƒ(EAR)ƒ(nowƒtheƒEuropeanƒDelegation),ƒtheƒGlobalƒFundƒ toƒFightƒAIDSƒandƒTuberculosis,ƒWorldƒBank,ƒtheƒCanadianƒInternationalƒ DevelopmentƒAgencyƒ(CIDA),ƒtheƒWorldƒHealthƒOrganization,ƒUNICEF,ƒ theƒInternationalƒRedƒCrossƒandƒaƒnumberƒofƒbilateralƒdonorsƒ–ƒNorway,ƒ ChinaƒandƒJapan,ƒbeingƒtheƒmost important. Sinceƒ2000,ƒmoreƒthanƒ50ƒprojectsƒhaveƒbeenƒimplementedƒinƒtheƒhealthƒ sectorƒwithƒtheƒfinancialƒandƒtechnicalƒsupportƒofƒexternalƒagencies.ƒTheseƒ projectsƒhaveƒbeenƒdirectedƒtowardsƒtheƒpromotionƒofƒprimaryƒcare,ƒtheƒ reconstructionƒofƒgeneralƒhospitals,ƒprovidingƒequipmentƒtoƒhealthƒinsti- tutions,ƒtheƒreformƒofƒhealthƒinsuranceƒfunding,ƒtheƒpromotionƒofƒdrugsƒ managementƒpolicy,ƒtheƒdevelopmentƒofƒtheƒbasicƒhealthƒservicesƒpackage,ƒ andƒtheƒintroductionƒofƒaƒnewƒmodelƒofƒpaymentsƒforƒhealthƒworkersƒ–ƒpri- marily,ƒtheƒintroductionƒofƒcapitationƒpaymentsƒandƒtheƒdevelopmentƒofƒ integratedƒITƒsystemsƒinƒhealth care. 86 Health Systems in Transition 3.7  Payment mechanisms 3.7.1 Paying for health services Fundingƒforƒhealthƒcareƒremainsƒinput-oriented,ƒlargelyƒbasedƒonƒline-itemƒ budgetsƒforƒallƒhealthƒcareƒproviders,ƒexceptƒpharmacies,ƒrehabilitationƒhos- pitalsƒandƒtheƒInstitutesƒofƒPublic Health. Inƒorderƒtoƒbeƒpaidƒforƒtheƒprovisionƒofƒhealthƒservices,ƒtheƒhealthƒcareƒ providerƒconcludesƒaƒcontractƒwithƒtheƒNHIF.ƒTheƒconditionsƒforƒcontractingƒ areƒdefinedƒbyƒtheƒ2006ƒRulebookƒonƒDetailedƒConditionsƒforƒPerformingƒ HealthƒCareƒActivitiesƒinƒHealthƒInstitutionsƒandƒOtherƒFormsƒofƒHealthƒ CareƒServicesƒ(OfficialƒGazette,ƒ2006c).ƒTableƒ3.6ƒsummarizesƒproviderƒ payment mechanisms. Healthƒcareƒprovidersƒincludeƒpublicƒandƒprivateƒinstitutions.ƒPublicƒ healthƒinstitutionsƒareƒorganizedƒthroughƒtheƒNetworkƒofƒHealthƒCareƒ Institutions.ƒTheƒDecreeƒonƒtheƒHealthƒCareƒInstitutionƒNetworkƒPlanƒ (OfficialƒGazette,ƒ2006b)ƒdetermines:ƒtheƒnumber,ƒstructureƒandƒcapacitiesƒ accordingƒtoƒtheƒterritorialƒdistributionƒforƒallƒstateƒhealthƒcareƒinstitutions.ƒ NHIFƒconcludesƒcontractsƒonƒprovidingƒhealthƒservicesƒwithƒpublicƒhealthƒ institutionsƒthatƒareƒincludedƒinƒtheƒfinancialƒplanƒofƒtheƒNHIFƒforƒaƒperiodƒ ofƒ1 year. HealthƒinstitutionsƒsubmitƒannualƒworkplansƒtoƒtheƒNHIF,ƒinƒaccord- anceƒwithƒtheƒmethodologyƒdefinedƒbyƒIPHƒBatut.ƒTheƒannualƒworkplanƒ ofƒeachƒinstitutionƒconsistsƒofƒseveralƒpartsƒ(theƒplanƒofƒhealthƒservicesƒtoƒ beƒprovided,ƒnumberƒofƒstaffƒthatƒwillƒprovideƒtheseƒservices,ƒmedicines,ƒ medicalƒsupplies,ƒetc.).ƒTheƒhealthƒinstitutionsƒareƒobligedƒtoƒsendƒanƒelec- tronicƒinvoiceƒtoƒtheƒNHIF.ƒTheƒinvoicedƒamountƒisƒcalculatedƒonƒtheƒbasisƒ ofƒtheƒactualƒnumberƒofƒprovidedƒservicesƒduringƒtheƒyearƒandƒtheƒpriceƒlistƒ determinedƒbyƒthe NHIF. PRIMARY CARE NHIFƒpaymentsƒtoƒprovidersƒofƒhealthƒservicesƒinƒprimaryƒcareƒareƒbasedƒ onƒline-itemƒbudgetsƒ(paymentsƒforƒsalariesƒforƒcontractedƒemployees,ƒcostsƒ forƒmedicinesƒandƒmedicalƒsupplies,ƒenergyƒcosts). Theƒcapitation-basedƒpaymentƒsystemƒisƒaƒrelativelyƒnewƒpaymentƒ methodƒwhichƒhasƒbeenƒpartiallyƒintroducedƒ(seeƒsectionƒ6.1.6).ƒTheƒpaymentƒ 87Serbia isƒrelatedƒtoƒtheƒnumberƒofƒpatientsƒregisteredƒwithƒaƒdoctor.ƒInƒaddition,ƒ performanceƒindicatorsƒofƒefficiencyƒandƒqualityƒofƒcareƒareƒused.ƒTeamsƒofƒ doctorsƒandƒnursesƒareƒalsoƒrewardedƒforƒtheƒperformanceƒofƒcertainƒpreven- tiveƒexaminationsƒ(suchƒasƒpapƒtestsƒwithƒgynaecologistsƒinƒprimaryƒcare). Theƒcalculationƒofƒhealthƒworkers’ƒsalariesƒisƒregulatedƒbyƒtheƒ2013ƒ LabourƒActƒandƒtheƒRegulationƒonƒCoefficientsƒforƒCalculationƒandƒPaymentƒ ofƒSalariesƒofƒPublicƒEmployees.ƒInƒgeneral,ƒsalariesƒareƒestablishedƒbyƒappli- cationƒofƒaƒcoefficientƒforƒeducation,ƒwhichƒcanƒbeƒincreasedƒbyƒaƒdegreeƒ ofƒexpertiseƒ (e.g.ƒ specialist,ƒprimarius)ƒorƒacademicƒdegreesƒ (Master’s,ƒ PhD).ƒInƒaddition,ƒworkƒexperienceƒcountsƒforƒ0.4%ƒperƒyearƒofƒexperience.ƒ Furthermore,ƒthereƒareƒsupplementsƒforƒshiftwork,ƒweekendƒduty,ƒovertimeƒ andƒfieldworkƒ(e.g.ƒhomeƒvisits).ƒTheƒcapitationƒformulaƒcontainsƒtheƒfol- lowingƒfourƒelements:ƒtheƒnumberƒofƒregisteredƒpatients,ƒandƒtheƒdegreeƒofƒ rationalityƒinƒprescribingƒdrugs,ƒefficiency,ƒandƒpreventiveƒservices.ƒInƒruralƒ areasƒaƒcorrectionƒcoefficientƒisƒappliedƒtoƒtheƒnumberƒofƒregisteredƒpatients.ƒ Inƒpreparationƒforƒtheƒnewƒfundingƒscheme,ƒtheƒRulesƒonƒtheƒConditions,ƒ CriteriaƒandƒStandardsƒforƒtheƒConclusionƒofƒContractsƒwithƒProvidersƒofƒ HealthƒServicesƒwereƒamendedƒinƒ2009,ƒwithƒincentivesƒaddedƒforƒdoctorƒ andƒnurseƒteamsƒtoƒstimulateƒregistrationƒofƒpatientsƒwithƒaƒ“chosenƒdoctor”. DENTAL HEALTH SERVICES Theƒhealthƒinstitutionsƒprovidingƒdentalƒservicesƒareƒpaidƒbyƒline-itemƒ budgetsƒ(forƒsalaries,ƒmedicinesƒandƒmedicalƒsupplies,ƒandƒforƒmaterialƒandƒ otherƒcosts). PHARMACY TheƒcontractƒwithƒtheƒpharmacyƒfromƒtheƒNetworkƒPlanƒisƒconcludedƒforƒtheƒ purposeƒofƒsupplyingƒinsuredƒpersonsƒwithƒmedicinesƒfromƒtheƒDrugƒListƒ andƒcertainƒtypesƒofƒmedicalƒsuppliesƒthatƒcanƒbeƒprescribedƒandƒissuedƒunderƒ compulsoryƒhealthƒinsurance.ƒTheƒremunerationƒforƒpharmaciesƒincludesƒ theƒpriceƒofƒtheƒmedicinesƒachievedƒinƒtheƒcentralizedƒpublicƒprocurementƒ procedureƒimplementedƒbyƒtheƒNHIF,ƒtheƒcostsƒforƒretailƒ(forƒtheƒprescribedƒ medicines)ƒinƒtheƒamountƒofƒ12%ƒ(exceptƒforƒtheƒtreatmentƒofƒHIVƒinfectionƒ 88 Health Systems in Transition andƒhepatitisƒBƒwhichƒretailƒcostsƒareƒ6%),ƒpriceƒofƒmedicalƒsuppliesƒachievedƒ inƒtheƒcentralizedƒpublicƒprocurementƒprocedureƒimplementedƒbyƒtheƒNHIFƒ includingƒretailƒcostsƒofƒ4%ƒ(NHIF,ƒ2018h). HEALTH CARE INSTITUTIONS AT THE SECONDARY AND TERTIARY LEVEL OF CARE Paymentƒtoƒhealthƒcareƒprovidersƒatƒtheƒsecondaryƒandƒtertiaryƒlevelƒofƒcareƒ (exceptƒforƒrehabilitationƒhospitals)ƒisƒbasedƒonƒline-itemƒbudgetsƒ(paymentsƒ forƒsalariesƒforƒcontractedƒemployees,ƒcostsƒforƒmedicinesƒandƒmedicalƒ supplies,ƒforƒmaterialƒandƒotherƒcosts,ƒcostsƒofƒenergy,ƒcostsƒofƒimplantsƒ(forƒ orthopaedics,ƒcardioƒsurgery,ƒophthalmology,ƒetc.),ƒfeesƒforƒbloodƒandƒlabileƒ bloodƒproducts,ƒfeesƒforƒdialysisƒsuppliesƒandƒmedicinesƒforƒdialysis,ƒcostsƒ ofƒdrugsƒforƒhaemophiliaƒmedication,ƒcostsƒofƒcytostaticƒdrugs,ƒandƒfeesƒforƒ nutritionƒinƒaƒhealthƒinstitution). Asƒofƒ1ƒJanuaryƒ2019,ƒinƒtheƒpublicƒhospitalsƒinƒSerbia,ƒtheƒcompensa- tionƒtoƒhealthƒinstitutionsƒforƒsecondaryƒandƒtertiaryƒlevelsƒofƒhealthƒcareƒ basedƒonƒDRGs’ƒperformancesƒandƒqualityƒindicatorsƒhasƒbeenƒintroduced.ƒ Currently,ƒtheƒpaymentƒbasedƒonƒDRGs’ƒperformancesƒandƒqualityƒindica- torsƒamountsƒtoƒ5%ƒofƒtheƒoverallƒbudgetƒofƒeachƒhospitalƒasƒenforcedƒinƒ 2018ƒ(NHIF,ƒ2018h). REHABILITATION HOSPITALS Paymentƒofƒrehabilitationƒhospitals/specialƒhospitalsƒforƒrehabilitationƒisƒ basedƒonƒtheƒnumberƒofƒbedƒdaysƒandƒFFSƒforƒambulatory/outpatient services. INSTITUTES OF PUBLIC HEALTH TheƒIPHsƒareƒpaidƒforƒservicesƒprovided,ƒdependingƒonƒtheƒtypesƒofƒservicesƒ andƒsourcesƒofƒfinancing.ƒInƒtheƒdomainƒofƒmicrobiology,ƒparasitologyƒandƒ virology,ƒtheyƒareƒpaidƒbyƒtheƒNHIFƒbasedƒonƒFFS.ƒTheƒactivitiesƒrelatedƒtoƒ compulsoryƒimmunizationƒandƒotherƒactivitiesƒinƒtheƒareaƒofƒsocialƒmedicineƒ andƒepidemiologyƒareƒdefinedƒasƒprogrammes,ƒandƒareƒpaidƒbyƒtheƒNHIF.ƒ Forƒservicesƒinƒtheƒareaƒofƒpublicƒhealthƒmicrobiology,ƒcommunicableƒandƒ 89Serbia noncommunicableƒdiseasesƒpreventionƒandƒcontrol,ƒhealthƒpromotion,ƒhealthƒ informaticsƒandƒbiostatisticsƒandƒhealthƒservicesƒplanningƒandƒorganization,ƒ theƒInstitutesƒofƒPublicƒHealthƒprovideƒtheƒprogrammesƒofƒgeneralƒinterestƒ underƒtheƒannualƒcontractsƒwithƒtheƒMinistryƒofƒHealth.ƒTheseƒprogrammesƒ areƒdefinedƒbyƒtheƒ2019ƒLawƒonƒHealthƒCareƒ(OfficialƒGazette,ƒ2019a). Inƒtheƒdomainƒofƒsanitaryƒmicrobiologyƒandƒecotoxicologyƒ(aƒdisciplineƒ combiningƒmethodsƒofƒecologyƒandƒtoxicologyƒinƒstudyingƒtheƒeffectsƒofƒ toxicƒsubstances),ƒpublicƒhealthƒinstitutesƒhaveƒtoƒcompeteƒonƒtheƒmarketƒ withƒotherƒpublicƒandƒprivateƒinstitutionsƒtoƒprovideƒtheseƒkindƒof services. HEALTH CARE IN SOCIAL CARE INSTITUTIONS Paymentƒforƒhealthƒcareƒservicesƒprovidedƒbyƒsocialƒcareƒinstitutionsƒisƒbasedƒ onƒline-itemƒbudgetsƒthatƒincludeƒpaymentsƒforƒsalariesƒforƒpredefinedƒstaff,ƒ accordingƒtoƒnormsƒdefinedƒbyƒtheƒMinistryƒofƒHealthƒ(OfficialƒGazette,ƒ 2006c),ƒandƒforƒmedicinesƒandƒmedical supplies. TABLE 3.6 Provider payment mechanisms in Serbia, 2019 PROVIDER PAYMENT MECHANISM Primary care Line-item budget/capitation/FFS Hospitals Line-item budget/DRGs/FFS • Rehabilitation hospitals Bed days/FFS • Institutes of Public Health FFS/programmes • Social care institutions Line-item budget Note: FFS, fee-for-service; DRG, Diagnostic-related group Source: Authors 3.7.2 Paying health workers HealthƒworkersƒinƒSerbianƒhealthƒinstitutionsƒareƒpaidƒbyƒsalaries.ƒTheƒcal- culationƒofƒhealthƒworkers’ƒsalariesƒisƒregulatedƒbyƒtheƒLabourƒActƒ(Officialƒ Gazette,ƒ2005f)ƒandƒtheƒDecreeƒonƒCoefficientsƒforƒCalculationƒandƒPaymentƒ 90 Health Systems in Transition ofƒSalariesƒofƒPublicƒEmployeesƒ(OfficialƒGazette,ƒ2001b).ƒSalariesƒofƒallƒ professionalsƒemployedƒinƒhealthƒinstitutionsƒ(doctors,ƒnursesƒandƒmidwives,ƒ dentistsƒandƒdentalƒauxiliaries,ƒpharmacists,ƒotherƒhealthƒworkersƒandƒnon- medicalƒstaff)ƒareƒestablishedƒbyƒapplicationƒofƒaƒcoefficientƒforƒeducation,ƒ whichƒcanƒbeƒincreasedƒbyƒaƒdegreeƒofƒexpertiseƒ(e.g.ƒspecialist)ƒorƒacademicƒ degreesƒ(Master’s,ƒPhD).ƒInƒaddition,ƒworkƒexperienceƒcountsƒforƒ0.4%ƒ perƒyearƒofƒexperience.ƒFurthermore,ƒthereƒareƒsupplementsƒforƒshiftwork,ƒ weekendƒduty,ƒovertimeƒandƒfieldworkƒ(EY,ƒ2016). SinceƒOctoberƒ2012,ƒaƒnewƒmodelƒforƒpaymentƒofƒhealthƒworkersƒbasedƒ onƒcapitationƒhasƒbeenƒintroducedƒinƒprimaryƒcareƒinstitutionsƒinƒSerbiaƒ (OfficialƒGazette,ƒ2011a).ƒItƒrepresentsƒaƒcombinationƒofƒfixedƒsalaryƒ(whichƒ isƒaƒmajorƒpart)ƒandƒaƒmuchƒsmallerƒpartƒthatƒisƒvariableƒandƒperformanceƒ based.ƒTheƒcapitation-basedƒpaymentƒisƒappliedƒtoƒ“chosenƒdoctors”ƒ(GPs,ƒ paediatricians,ƒgynaecologists,ƒandƒchildrens’ƒandƒpreventiveƒdentists).ƒTheƒ variableƒpartƒofƒtheƒsalariesƒofƒnursesƒthatƒareƒinƒaƒteamƒwithƒaƒ“chosenƒ doctor”ƒisƒbasedƒonƒ“chosenƒdoctor’s”ƒperformanceƒandƒisƒcalculatedƒasƒtheƒ sameƒpercentageƒasƒforƒtheƒ“chosenƒdoctor”.ƒTheƒvariableƒpartƒofƒsalariesƒofƒ otherƒemployeesƒinƒprimaryƒcareƒinstitutionsƒthatƒprovideƒservicesƒofƒ“chosenƒ doctors”ƒisƒcalculatedƒbasedƒonƒtheƒaverageƒperformanceƒofƒtheƒ“chosenƒ doctors”ƒ(OfficialƒGazette,ƒ2011a). Theƒcapitationƒformulaƒ(variableƒpartƒofƒsalary)ƒcontainsƒtheƒfollowingƒ fourƒelements:ƒtheƒnumberƒofƒregisteredƒpatients,ƒefficiency,ƒdiagnostic- therapeuticƒproceduresƒandƒ theƒqualityƒofƒhealthƒcare.ƒTheƒcorrectiveƒ coefficientƒisƒappliedƒinƒrelationƒtoƒtheƒageƒofƒtheƒpatientsƒandƒtheƒpopula- tionƒdensity.ƒTheƒvariableƒpartƒofƒtheƒsalaryƒcannotƒovercomeƒ8.08%. TheƒaverageƒsalaryƒinƒtheƒhealthƒsectorƒinƒSerbiaƒinƒSeptemberƒ2018ƒ wasƒ565ƒeurosƒperƒmonth,ƒwhichƒwasƒinƒlineƒwithƒtheƒtotalƒaverageƒsalaryƒ inƒtheƒcountry,ƒbutƒ70–80%ƒlowerƒthanƒinƒfinancing,ƒinsuranceƒandƒICTƒ sectorsƒ(SORS,ƒ2019). Inƒorderƒtoƒreduceƒtheseƒdifferences,ƒtheƒSerbianƒGovernmentƒdecidedƒtoƒ increaseƒtheƒsalariesƒinƒpublicƒhealthƒinstitutionsƒfromƒJanuaryƒ2019ƒonwards.ƒ Theƒsalariesƒwereƒincreasedƒbyƒ10%ƒforƒdoctors,ƒdentist,ƒandƒpharmacists,ƒ 12%ƒforƒnursesƒandƒ7%ƒforƒotherƒemployeesƒ(GovernmentƒofƒtheƒRepublicƒ ofƒSerbia,ƒ2019). Theƒnewƒpaymentƒsystem,ƒinƒwhichƒaƒportionƒofƒtheƒsalariesƒforƒprimaryƒ careƒteamsƒwillƒbeƒdirectlyƒlinkedƒtoƒperformanceƒbasedƒonƒ10ƒqualityƒindi- cators,ƒwillƒbeƒintroducedƒinƒ2020.ƒTheƒMinistryƒofƒHealthƒandƒtheƒHealthƒ 91Serbia Unionsƒhaveƒcomeƒtoƒanƒagreementƒthatƒallƒfurtherƒsalaryƒincreasesƒinƒtheƒ healthƒsectorƒwouldƒcountƒtowardsƒtheƒvariableƒorƒperformance‐basedƒportionƒ ofƒtheƒsalaryƒ(WorldƒBank,ƒ2018c).ƒFurtherƒmonitoring,ƒevaluationƒandƒ upgradingƒofƒtheƒfinancingƒformulaƒisƒofƒutmostƒimportanceƒforƒtheƒsuccessƒ ofƒthisƒreform;ƒandƒtheƒregulatoryƒframeworkƒneedƒupdatingƒtoƒrecognizeƒ andƒallowƒforƒsuch changes.

4 Physical and human resources Summary ƒƒ ƒInƒ2016,ƒthereƒwereƒ355ƒhealthƒcareƒ institutionsƒ inƒtheƒpublicƒ sectorƒinƒSerbia.ƒOfƒthese,ƒ79%ƒofƒinpatientƒcareƒinstitutionsƒwereƒ dedicatedƒtoƒacuteƒcare.ƒInƒ2016,ƒthereƒwereƒ462ƒcurativeƒbedsƒperƒ 100 000ƒpopulation.ƒHowever,ƒtheƒintroductionƒofƒtheƒDRGƒsystemƒ isƒexpectedƒtoƒimproveƒtheƒperformanceƒofƒacute hospitals. ƒƒ ƒInternationalƒprojectsƒhaveƒbeenƒkeyƒtoƒ improveƒtheƒtechnicalƒ conditionƒandƒtheƒlevelƒofƒequipmentƒofƒhealthƒcareƒinstitutions,ƒasƒ partƒofƒtheƒ2003ƒhealthƒcareƒreform.ƒSignificantƒinvestmentsƒhaveƒ beenƒmadeƒinƒdiagnosticƒimagingƒtechnologies,ƒbut,ƒdespiteƒthis,ƒ theirƒdensityƒperƒpopulationƒinƒSerbiaƒisƒstillƒlaggingƒbehindƒtheirƒ densityƒinƒmanyƒneighbouring countries. ƒƒ ƒInitiativesƒforƒe-healthƒareƒpromotedƒbyƒtheƒgovernment,ƒwhichƒ includeƒe-prescriptions,ƒe-referralsƒandƒaƒ systemƒofƒelectronicƒ patientƒrecords.ƒTheƒuseƒofƒITƒinƒhealthƒcareƒ isƒ increasing,ƒbutƒ integrationƒofƒITƒintoƒtheƒnationalƒhealthƒinformationƒsystemsƒhasƒ notƒbeenƒcompleted. ƒƒ ƒTheƒnumberƒofƒphysiciansƒandƒnursesƒperƒ100 000ƒinhabitantsƒ increasedƒfromƒ1991ƒ(212ƒandƒ431,ƒrespectively)ƒtoƒ2016ƒ(302ƒandƒ 605,ƒrespectively),ƒbutƒtheseƒratesƒareƒsubstantiallyƒlowerƒthanƒtheƒ EUƒaverageƒ(339ƒandƒ756,ƒrespectively). 94 Health Systems in Transition ƒƒ ƒSerbiaƒcurrentlyƒdoesƒnotƒhaveƒanƒofficialƒhealthƒworkforceƒstrategy.ƒ Theƒcurrentƒpolicyƒaimsƒtoƒmaintainƒpresentƒstaffingƒ levelsƒ inƒ theƒ system,ƒdespiteƒ theƒ shortageƒofƒ someƒspecialists,ƒunequalƒ geographicalƒdistributionƒofƒmedicalƒworkersƒacrossƒtheƒcountryƒ andƒhigh unemployment. ƒƒ ƒThereƒ isƒevidenceƒofƒhighƒintentionƒtoƒworkƒabroad,ƒalthoughƒ informationƒonƒworkforceƒmigrationƒtrendsƒis lacking. 4.1  Physical resources 4.1.1 Infrastructure, capital stock and investments INFRASTRUCTURE Inƒ2016,ƒ127ƒhealthƒinstitutionsƒprovidedƒinpatientƒcareƒinƒtheƒpublicƒsectorƒ (IPHƒBatut,ƒ2017d).ƒThoseƒinstitutionsƒincluded:ƒ41ƒgeneralƒhospitals,ƒ 35 specialƒhospitals,ƒ19ƒinpatientƒdepartmentsƒinƒprimaryƒcareƒcentres,ƒ 16 inpatientƒdepartmentsƒinƒinstitutes,ƒsixƒinpatientƒdepartmentsƒinƒclinics,ƒ fourƒclinical–hospitalƒcentres,ƒfourƒclinicalƒcentresƒandƒtwoƒinstitutesƒ(zavodi).ƒ Theseƒinstitutionsƒhad,ƒinƒtotal,ƒ41 788ƒhospitalƒbeds,ƒincludingƒ1 874ƒbedsƒinƒ dayƒhospitals,ƒdialysisƒandƒneonatologyƒbedsƒ(IPHƒBatut,ƒ2017d).ƒTheƒcurrentƒ numberƒofƒbedsƒisƒ15.9%ƒlowerƒthanƒitƒwasƒinƒ1990ƒ(IPHƒBatut,ƒ2018a). Inƒtheƒperiodƒ1990–2016,ƒtheƒhighestƒdecreaseƒinƒtheƒnumberƒofƒhospitalƒ bedsƒwasƒrecordedƒduringƒtheƒpublicƒhealthƒcareƒsectorƒreformƒ(2003–2006),ƒ whichƒencompassedƒtheƒimplementationƒofƒhospitalƒcareƒrestructuringƒ projectsƒasƒenvisagedƒbyƒtheƒstrategyƒandƒtheƒActionƒPlanƒofƒtheƒhealthƒ careƒsectorƒreformƒ(seeƒsectionƒ6.1).ƒTheƒnumberƒofƒhospitalƒbedsƒwasƒcutƒ byƒ5.1%ƒinƒ2003/2004,ƒbyƒ3.0%ƒinƒ2004/2005,ƒandƒbyƒ4.3%ƒinƒ2005/2006ƒ (calculatedƒaccordingƒtoƒIPHƒBatutƒ(2018a)ƒelectronicƒdata).ƒSomeƒincreasesƒ inƒhospitalƒbedƒratesƒperƒpopulationƒwereƒprobablyƒtheƒmixedƒeffectsƒofƒaƒ decreaseƒinƒpopulationƒsizeƒandƒincomplete/inappropriateƒreportingƒonƒtheƒ numberƒofƒbedsƒ(someƒinstitutions/departmentsƒhadƒdelaysƒinƒreportingƒorƒ wereƒcountingƒbedsƒinƒphysicians’ƒoffices). Fig.ƒ4.1ƒillustratesƒthatƒtheƒnumberƒofƒacuteƒbedsƒinƒhospitalsƒinƒSerbiaƒ fellƒbyƒaroundƒ16%ƒbetweenƒ1990ƒandƒ2016.ƒInƒ2016,ƒthereƒwereƒ461.5ƒacuteƒ 95Serbia bedsƒperƒ100 000ƒpopulation,ƒwhichƒisƒhigherƒthanƒinƒneighbouringƒcountriesƒ suchƒasƒSloveniaƒ(418.8)ƒandƒCroatiaƒ(348.26)ƒbutƒfewerƒthanƒinƒRomaniaƒ (516.6)ƒandƒBulgariaƒ(603.1)ƒ(Eurostat,ƒ2019). FIGURE 4.1 Curative care beds in hospitals per 100 000 population in Serbia and selected countries, 2000–2016 300 350 400 450 500 550 600 650 Serbia Croatia Bulgaria Romania Hungary Slovenia blank 20162015201420132012201120102009200820072006200520042003200220012000 ■■ Bulgaria ■■ Romania ■■ Serbia ■■ Hungary ■■ Slovenia ■■ Croatia Be ds p er 1 00 0 00 p op ul at io n Source: Eurostat, 2019. Theƒlargestƒshareƒofƒbedsƒ(excludingƒdayƒhospitalsƒbeds)ƒareƒinƒgeneralƒ hospitalsƒ(15 509ƒbeds;ƒ38.9%),ƒspecialƒhospitalsƒ(8 442;ƒ21.2%)ƒandƒclinicalƒ centresƒ(7 445;ƒ18.7%)ƒ(IPHƒBatut,ƒ2017d).ƒTheƒremainingƒtypesƒofƒinstitu- tionsƒinƒtheƒpublicƒsectorƒhaveƒaƒshareƒofƒ10%ƒorƒlessƒofƒallƒhospital beds. Inƒ2016,ƒalmostƒhalfƒofƒtheƒcurrentƒbedƒcapacityƒinƒtheƒpublicƒsectorƒ (55%)ƒwasƒmainlyƒusedƒtoƒmanageƒacuteƒdiseasesƒandƒconditions.ƒTheseƒ bedsƒwereƒlocatedƒinƒinternalƒmedicineƒ(12 198;ƒ30.6%)ƒandƒsurgeryƒ(9 743;ƒ 24.4%)ƒdepartmentsƒ(IPHƒBatut,ƒ2017d).ƒOneƒthirdƒofƒbedsƒwereƒdistributedƒ inƒlong-termƒcareƒdepartments,ƒsuchƒasƒrehabilitationƒ(6 217;ƒ15.6%)ƒandƒ psychiatryƒ(5 393;ƒ13.5%).ƒTheƒremainingƒbedsƒwereƒlocatedƒinƒgynaecologyƒ (3 432;ƒ8.6%),ƒpaediatricsƒ(2 830;ƒ7.0%)ƒandƒotherƒdepartmentsƒ(101;ƒ0.3%)ƒ (IPHƒBatut,ƒ2017d). 96 Health Systems in Transition CURRENT CAPITAL STOCK TheƒmajorƒproviderƒofƒhealthƒcareƒservicesƒinƒSerbiaƒisƒtheƒMinistryƒofƒ Health,ƒthroughƒaƒwideƒnetworkƒofƒpublicƒhealthƒcareƒinstitutionsƒ(“Network”ƒ hereafter)ƒestablishedƒunderƒtheƒDecreeƒonƒtheƒHealthƒCareƒInstitutionƒ NetworkƒPlanƒ(OfficialƒGazette,ƒ2006b)ƒandƒexcludingƒinstitutionsƒfromƒ KosovoƒandƒMetohijaƒProvince.ƒInƒthisƒNetwork,ƒthereƒareƒ351ƒpublicƒhealthƒ careƒinstitutionsƒandƒfourƒmilitaryƒmedicalƒinstitutions,ƒwhichƒareƒcon- tractedƒtoƒtheƒNationalƒHealthƒInsuranceƒFundƒ(NHIF)ƒtoƒprovideƒhealthƒ careƒservices.ƒTheƒterritorialƒdistributionƒofƒhealthƒcareƒinstitutionsƒinƒtheƒ Networkƒisƒunevenƒ(IPHƒBatut,ƒ2017d).ƒPopulationƒcoverageƒisƒsmallerƒinƒ Vojvodina,ƒthanƒinƒcentralƒSerbia,ƒthatƒis,ƒthereƒisƒnoƒclinical–hospitalƒcentreƒ inƒVojvodina,ƒwhileƒthereƒareƒfourƒofƒthemƒinƒcentralƒSerbia,ƒallƒlocatedƒ in Belgrade. InƒadditionƒtoƒtheƒNetwork,ƒotherƒministriesƒ(e.g.ƒdefence,ƒjustice,ƒetc.)ƒ governƒtheirƒownƒhealthƒcareƒinstitutionsƒwhichƒprovideƒprimaryƒcareƒandƒ hospitalƒcareƒservicesƒforƒspecificƒpopulation groups. Mostƒhospitalsƒinƒtheƒpublicƒsectorƒdateƒfromƒtheƒ1980s.ƒAppraisalsƒofƒ theƒconditionƒandƒperformanceƒofƒpublicƒhealthƒcareƒinstitutionsƒfeedƒintoƒ planningƒfutureƒstrategiesƒandƒinvestments,ƒincludingƒthroughƒinternationalƒ assistanceƒprojects.ƒTheƒreconstructionƒofƒfourƒclinicalƒcentresƒhasƒbeenƒ initiatedƒin 2006. REGULATION OF CAPITAL INVESTMENT Capitalƒinvestmentsƒinƒtheƒhealthƒsystemƒareƒfinancedƒtoƒaƒlargeƒextentƒ fromƒtheƒstateƒbudget,ƒtheƒbudgetƒofƒtheƒautonomousƒprovinceƒandƒtheƒ localƒself-governanceƒbudgetƒ(atƒtheƒmunicipalityƒlevel),ƒasƒwellƒasƒfromƒ funds,ƒdonationsƒandƒloansƒ(mainlyƒtheƒWorldƒBankƒandƒtheƒEuropeanƒ InvestmentƒBank,ƒbutƒalsoƒbilateralƒdonationsƒofƒsomeƒgovernments).ƒWithinƒ theƒprocessƒofƒaccreditation,ƒtheƒstateƒandƒprivateƒhealthƒcareƒinstitutionsƒareƒ obligedƒtoƒprovideƒstrategicƒplansƒcontainingƒdetailsƒaboutƒcapitalƒinvestmentsƒ withinƒspecificƒobjectivesƒdedicatedƒtoƒtheƒimprovementƒofƒtheƒdeliveryƒofƒ health services. TheƒMinistryƒofƒHealthƒisƒresponsibleƒforƒcapitalƒinvestmentsƒbasedƒ onƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ2009ƒLawƒonƒtheƒBudgetƒSystem,ƒ 97Serbia includingƒcontrolsƒofƒacquisitionsƒinƒcooperationƒwithƒtheƒMinistryƒofƒFinanceƒ andƒtheƒMinistryƒofƒPublicƒAdministrationƒandƒLocalƒSelf-Government.ƒ AccordingƒtoƒtheƒLawƒonƒtheƒBudgetƒSystemƒ(OfficialƒGazette,ƒ2009b),ƒeachƒ healthƒinstitutionƒisƒresponsibleƒtoƒsubmitƒandƒtheƒNHIFƒtheƒshort-termƒ andƒmedium-termƒgoalsƒofƒtheirƒfinancialƒplansƒtoƒtheƒMinistryƒofƒHealth,ƒ includingƒaƒplanƒofƒpublicƒprocurementƒofƒcapitalƒinvestmentsƒforƒaƒperiodƒ ofƒ3ƒconsecutiveƒyearsƒtoƒbeƒincludedƒinƒtheƒfiscalƒpolicyƒofƒtheƒgovernment.ƒ Theƒprocessƒofƒpurchasing/procurementƒcapitalƒinvestmentsƒisƒregulatedƒbyƒ theƒ2012ƒLawƒonƒPublicƒProcurementƒ(OfficialƒGazette,ƒ2012a).ƒPrivateƒ healthƒcareƒinstitutionsƒdoƒnotƒhaveƒsuchƒobligationsƒandƒpredominantlyƒ baseƒtheirƒcapitalƒinvestmentsƒonƒtheƒmarketƒandƒhealthƒneeds assessment. TheƒMinistryƒofƒHealthƒfollowsƒtheƒ2006ƒPlanƒofƒtheƒHealthƒInstitutions’ƒ Networkƒtoƒoverseeƒtheƒgeographicalƒdistributionƒandƒtheƒrightƒbalanceƒacrossƒ differentƒlevelsƒof care. INVESTMENT FUNDING Capitalƒinvestmentƒinƒhealthƒcareƒisƒdeterminedƒatƒtheƒcentralƒlevelƒbyƒtheƒ MinistryƒofƒHealthƒandƒfundedƒfromƒgovernmentƒfundsƒandƒinternationalƒ agencies.ƒForƒexample,ƒfromƒ2003,ƒtheƒWorldƒBankƒapprovedƒloansƒtotal- lingƒjustƒunderƒ80ƒmillionƒdollarsƒforƒrestructuringƒandƒmodernizationƒinƒ healthƒcareƒ(EY,ƒ2016).ƒTheƒlevelƒofƒcapitalƒinvestmentsƒrangedƒbetweenƒ 2%ƒ(inƒ2003)ƒandƒ3.8%ƒ(inƒ2017)ƒofƒtotalƒhealthƒexpenditureƒ(THE)ƒ(IPHƒ Batut,ƒ2018c).ƒInƒ2014,ƒalthoughƒtheƒlevelƒofƒcapitalƒinvestmentsƒasƒaƒshareƒ ofƒTHEƒwasƒtheƒhighestƒeverƒsinceƒ(3.99%),ƒitƒwasƒstillƒbelowƒtheƒaverageƒ levelƒofƒcapitalƒinvestmentsƒforƒtheƒcountriesƒofƒsouth-easternƒEuropeƒ(5.55%ƒ ofƒTHE)ƒ(WHO,ƒ2019). Accordingƒtoƒtheƒlistƒofƒprojectsƒinƒtheƒhealthƒsectorƒinƒtheƒperiodƒ1995– 2012ƒ(MinistryƒofƒHealth,ƒ2017b,ƒ2017c),ƒtheƒmostƒimportantƒexternalƒdonorƒ wasƒtheƒEUƒwithƒoverƒ380ƒmillionƒeuros,ƒmainlyƒthroughƒcreditsƒforƒaƒrangeƒ ofƒservicesƒ(technicalƒsupport,ƒassessments,ƒmedicines,ƒmedicalƒdevices,ƒ equipment,ƒetc.),ƒforƒhospitals,ƒemergency,ƒbloodƒtransfusionƒandƒpharma- ceuticalƒsector,ƒpublicƒhealthƒandƒpreventiveƒservices,ƒhealthƒinformationƒ system,ƒhealthƒinsuranceƒfund,ƒandƒMinistryƒofƒHealth.ƒAssistanceƒwasƒalsoƒ providedƒbyƒUNICEF,ƒtheƒCanadianƒInternationalƒDevelopmentƒAgencyƒ (CIDA),ƒtheƒSwedishƒInternationalƒDevelopmentƒAgencyƒ(SIDA),ƒIreland,ƒ 98 Health Systems in Transition Norway,ƒJapan,ƒSwitzerland,ƒNetherlands,ƒFrance,ƒTheƒGlobalƒFundƒtoƒFightƒ AIDS,ƒTuberculosisƒandƒMalariaƒ(GFTAM),ƒtheƒUnitedƒStatesƒAgencyƒforƒ InternationalƒDevelopmentƒ(USAID),ƒwhileƒoverƒUS$ƒ31ƒmillionƒcreditƒ cameƒfromƒtheƒWorldƒBankƒforƒimprovingƒtheƒenergyƒefficiencyƒofƒSerbianƒ healthƒinstitutionsƒandƒforƒdeliveryƒofƒimprovedƒservicesƒatƒtheƒlocal level. Moreƒrecently,ƒtheƒSecondƒSerbiaƒHealthƒProjectƒ2018–2021ƒ(P129539,ƒ commitmentƒamountƒUS$ƒ40ƒmillion)ƒaimsƒtoƒfacilitateƒtheƒimprovementƒ ofƒtheƒefficiencyƒandƒqualityƒofƒtheƒpublicƒhealthƒsystemƒbyƒstrengthening:ƒ (1)ƒhealthƒfinancing,ƒpurchasing,ƒandƒmaintenanceƒsystems;ƒandƒ(2)ƒqualityƒ improvementƒsystemsƒandƒmanagementƒofƒselectedƒpriorityƒnoncommuni- cableƒdiseasesƒ(OfficialƒGazetteƒ2014d,ƒ2018a;ƒWorldƒBank,ƒ2017,ƒ2018a).ƒ Throughƒitsƒfourƒcomponents,ƒtheƒprojectƒisƒcurrentlyƒfinancingƒgoodsƒandƒ equipment,ƒandƒsupportsƒupgradingƒofƒinformationƒtechnologyƒcapacityƒtoƒ improveƒfinancialƒreportingƒandƒperformanceƒmonitoringƒatƒcentral,ƒhospitalƒ andƒprimary levels. PUBLIC–PRIVATE PARTNERSHIPS Asƒpartƒofƒtheƒ2003ƒhealthƒreformƒ(seeƒsectionƒ6.1),ƒtheƒMinistryƒofƒHealthƒ hasƒdefinedƒitsƒroleƒinƒtheƒcontrolƒandƒregistrationƒofƒtheƒprivateƒsectorƒasƒwellƒ asƒonƒtheƒcontrolƒofƒexpensiveƒhealthƒtechnologiesƒ(OfficialƒGazette,ƒ2005a).ƒ InƒadditionƒtoƒtheƒLawƒonƒPublic–PrivateƒPartnershipƒandƒConcessionsƒ (OfficialƒGazette,ƒ2011c),ƒthereƒisƒaƒmanualƒforƒimplementationƒofƒpublic– privateƒpartnershipsƒforƒlocalƒgovernmentƒ(Cvetkovićƒ&ƒSredojevic,ƒ2013).ƒ Mostƒpublic–privateƒpartnershipƒprojectsƒwereƒdevelopedƒforƒtheƒeconomicƒ developmentƒofƒinfrastructureƒinƒvariousƒsettingsƒ(Vlaskovicƒetƒal.,ƒ2018). 4.1.2 Medical equipment REGULATION OF MEDICAL DEVICES AND AIDS Accordingƒtoƒtheƒ2019ƒHealthƒCareƒLaw,ƒitƒisƒtheƒresponsibilityƒofƒtheƒstate,ƒ autonomousƒprovince,ƒmunicipalityƒorƒcityƒtoƒprovideƒfundsƒforƒtheƒcon- structionƒandƒequippingƒofƒstate-ownedƒhealthƒinstitutions,ƒwhichƒinclude:ƒ capitalƒinvestment,ƒinvestmentƒforƒmaintenanceƒofƒpremises,ƒmedicalƒandƒ nonmedicalƒequipmentƒandƒmeansƒofƒtransport,ƒorƒprocurementƒofƒmedicalƒ 99Serbia andƒotherƒequipmentƒnecessaryƒforƒtheƒoperationƒofƒhealthƒinstitutionsƒandƒ meansƒofƒtransport,ƒasƒwellƒasƒtheƒprocurementƒofƒequipmentƒforƒtheƒdevelop- mentƒofƒanƒintegratedƒhealthƒinformationƒsystem,ƒandƒforƒotherƒobligationsƒ determinedƒbyƒlawƒandƒtheƒfoundingƒactƒ(OfficialƒGazetteƒ2019a,ƒArticlesƒ 8ƒandƒ15). EQUIPMENT INFRASTRUCTURE TheƒMinistryƒofƒHealthƒestimatesƒtheƒnationalƒneedsƒforƒexpensiveƒmedicalƒ equipmentƒandƒcapitalƒinvestments,ƒsetsƒcriteria,ƒpreparesƒnationalƒinvest- mentsƒplansƒandƒtenderƒprocedures,ƒandƒapprovesƒcosts.ƒThroughƒtheƒhealthƒ budget,ƒtheƒMinistryƒofƒHealthƒcoversƒtheƒneedsƒofƒtheƒhealthƒcareƒinstitutionsƒ inƒtheƒNetworkƒforƒexpensiveƒmedicalƒequipmentƒandƒcapitalƒinvestments.ƒ Inƒaddition,ƒinvestmentsƒinƒother,ƒnon-expensiveƒmedicalƒequipmentƒareƒ theƒresponsibilityƒofƒtheƒownerƒofƒtheƒparticularƒhealthƒcareƒfacility.ƒDespiteƒ significantƒinvestments,ƒSerbiaƒisƒstillƒbehindƒtheƒEUƒaverageƒregardingƒ diagnosticƒimagingƒtechnologiesƒ(Tableƒ4.1),ƒwhichƒmayƒpartiallyƒcontributeƒ toƒlongerƒwaitingƒtimesƒ(IPHƒBatut,ƒ2017g). TABLE 4.1 Diagnostic equipment in Serbia and the EU, per 100 000 population, 2017 SERBIA EU AVERAGE Computed tomography scanners 0.96 2.2 Magnetic resonance imaging units 0.31 1.4 Source: Eurostat, 2019; IPH Batut, 2017b 4.1.3 Information technology and e-Health Inƒ2018,ƒ73%ƒofƒhouseholdsƒinƒSerbiaƒusedƒandƒhadƒaccessƒtoƒtheƒInternet,ƒ wellƒbelowƒtheƒEUƒcountriesƒaverageƒ(89%),ƒorƒtheƒhighestƒrankedƒcountry,ƒ Icelandƒ(99%)ƒ(Eurostat,ƒ2019).ƒAƒ2016ƒStatisticalƒOfficeƒofƒSerbiaƒsurveyƒ showedƒthatƒInternetƒconnectionsƒwereƒmoreƒavailableƒinƒtheƒcapitalƒ(73.1%),ƒ thanƒinƒVojvodinaƒ(68.7%)ƒandƒcentralƒSerbiaƒ(57.9%),ƒandƒmoreƒinƒurbanƒ (72.5%)ƒthanƒinƒruralƒareasƒ(53.8%)ƒ(Kovacevic,ƒPavlovicƒ&ƒSutic,ƒ2016). 100 Health Systems in Transition Theƒ2016ƒNationalƒStatisticalƒOfficeƒsurveyƒonƒtheƒusageƒofƒinforma- tionƒandƒcommunicationƒtechnologiesƒfoundƒthatƒ71.7%ƒofƒrespondentsƒwereƒ searchingƒtheƒInternetƒforƒhealth-relatedƒinformationƒ(e.g.ƒinjuries,ƒillness,ƒ nutrition,ƒhealthƒimprovement,ƒetc.),ƒbutƒonlyƒ7.9%ƒhadƒusedƒitƒforƒmakingƒanƒ appointmentƒwithƒphysiciansƒviaƒhospital/healthƒcentreƒwebsitesƒ(Kovacevic,ƒ Pavlovicƒ&ƒSutic,ƒ2016). Inƒ lineƒwithƒ theƒ2006–2010ƒStrategyƒ forƒ theƒDevelopmentƒofƒ anƒ Informationƒ Society,ƒ inƒ 2006ƒ theƒMinistryƒ ofƒ Healthƒ adoptedƒ theƒ ProgrammeƒofƒOperation,ƒDevelopmentƒandƒOrganizationƒofƒIntegratedƒ HealthƒInformationƒSystemƒ–ƒe-Healthƒ–ƒforƒtheƒperiodƒ2009–2015ƒ(Officialƒ Gazette,ƒ2009f).ƒWithinƒthisƒprogrammeƒthereƒareƒtwoƒstrategies,ƒ2006– 2009ƒandƒ2010–2020.ƒThisƒprogrammeƒenhancedƒtheƒdevelopmentƒofƒtheƒ conceptƒofƒpatient-centredƒcareƒandƒtheƒrationalƒuseƒofƒresourcesƒbyƒenablingƒ theƒusageƒofƒinformationƒandƒcommunicationƒtechnologiesƒ(IT)ƒforƒautomatedƒ communication,ƒmonitoringƒandƒevaluationƒofƒallƒadministrativeƒproceduresƒ andƒprocessesƒwhichƒaccompanyƒtheƒmainƒactivitiesƒofƒtheƒhealthƒsystem.ƒInƒ 2012,ƒtheƒMinistryƒofƒHealth,ƒusingƒEU/IPAƒfundsƒandƒwithƒWHOƒsupportƒ (administrativeƒandƒlogisticƒsupportƒwasƒbyƒprovidedƒbyƒUNOPS),ƒstartedƒ toƒimplementƒaƒ2.5ƒmillionƒeuroƒIntegratedƒHealthƒInformationƒSystemƒ (EU-IHIS)ƒprojectƒ(Bošković,ƒ2015).ƒThisƒ5-yearƒprojectƒ(2010–2015)ƒaimsƒ toƒimplementƒaƒhealthƒinformationƒsystemsƒ(HIS)ƒinƒ19ƒselectedƒhospitalsƒ throughoutƒSerbiaƒandƒtoƒintroduceƒtheƒuseƒofƒelectronicƒhealthƒrecords.ƒTheƒ project’sƒaimsƒareƒ(https://www.mojdoktor.gov.rs/about)ƒto: ƒƒ ƒprovideƒpatientsƒwithƒlifelongƒelectronicƒhealth records; ƒƒ ƒenableƒ healthƒ providersƒ toƒ recordƒ andƒ easilyƒ accessƒ healthƒ care-related data; ƒƒ ƒestablishƒgatheringƒofƒinformationƒthatƒcanƒbeƒusedƒtoƒoptimizeƒandƒ improveƒperformanceƒofƒSerbianƒhospitalsƒandƒtheƒhealth system; ƒƒ ƒassistƒinƒtheƒestablishmentƒofƒaƒsustainableƒITƒbackboneƒforƒtheƒ Serbianƒhealth system. AtƒtheƒbeginningƒofƒSeptemberƒ2016,ƒtheƒMinistryƒofƒHealthƒinformedƒ allƒhealthƒinstitutionsƒthatƒtheyƒareƒobligedƒtoƒenterƒandƒupdateƒtheirƒdataƒ inƒtheƒIHISƒ(MinistryƒofƒHealth,ƒ2016),ƒwhichƒisƒaƒmodernƒInternetƒportalƒ thatƒservesƒtoƒcentralizeƒtheƒcollectionƒandƒuseƒofƒresourceƒdataƒ(i.e.,ƒdataƒ onƒtheƒinstitutionƒandƒdataƒonƒemployees)ƒandƒtheƒcodesƒusedƒinƒtheƒhealthƒ systemƒ(EU-IHIS,ƒ2014). 101Serbia Electronicƒhealthƒinsuranceƒcardsƒforƒallƒhealthƒinsuranceƒusersƒwereƒ alsoƒintroduced.ƒTheseƒeffortsƒhaveƒintegratedƒtheƒprimaryƒcareƒITƒsystemsƒ withƒhospitalƒcareƒfacilitiesƒforƒtheƒpurposeƒofƒestablishingƒanƒappointmentƒ bookingƒsystem;ƒhowever,ƒtheƒe-prescriptionƒsystemƒisƒnotƒyetƒfunctioning,ƒ thereƒareƒnoƒconnectionsƒbetweenƒhospitals,ƒnoƒe-referralsƒinƒbiochemicalƒ laboratoriesƒandƒtheƒdataƒmonitoredƒvariesƒamongƒinpatientƒfacilities.ƒItƒisƒ expectedƒthatƒtheseƒproblemsƒwillƒbeƒsolvedƒinƒtheƒfutureƒandƒthatƒpaperƒ medicalƒrecordsƒofƒpatientsƒinƒtheƒhealthƒcentres,ƒandƒinƒhospitalsƒwithƒhistoryƒ ofƒillness,ƒasƒwellƒasƒallƒreportsƒ(specialistƒreports,ƒlaboratoryƒresults,ƒradio- logicalƒdigitalƒimages,ƒlettersƒofƒdischarge,ƒetc.)ƒwillƒbeƒcompletelyƒreplacedƒ byƒelectronicƒhealthƒrecordsƒ(EHRs)ƒ(EU-IHIS,ƒ2014). 4.2  Human resources 4.2.1 Planning and registration of human resources Theƒ2019ƒHealthƒCareƒLawƒstipulatesƒthatƒhealthƒcareƒprovidersƒcannotƒ carryƒoutƒindependentƒworkƒuntilƒtheyƒcompleteƒtheirƒinternshipƒandƒpassƒ theƒprofessionalƒexam.ƒAnƒinternshipƒforƒhealthƒworkersƒwithƒaƒuniversityƒ degreeƒlastsƒ12ƒmonths,ƒexceptƒforƒmedicalƒdoctorsƒwhoseƒbasicƒintegratedƒ studiesƒofƒmedicineƒforƒaƒperiodƒofƒ6ƒyearsƒinƒaƒfacultyƒofƒmedicineƒrequireƒanƒ internshipƒwhichƒlastsƒ6ƒmonths.ƒTheƒnextƒstepƒisƒtheƒregistrationƒwithinƒtheƒ appropriateƒChamber,ƒwhichƒissuesƒlicensesƒandƒholdsƒanƒelectronicƒdatabaseƒ ofƒallƒlicensedƒhealth workers. ContinuingƒeducationƒaccreditedƒbyƒtheƒHealthƒCouncilƒofƒSerbiaƒisƒaƒ conditionƒforƒperiodicƒre-licensingƒ(eachƒfifthƒyear).ƒAccordingƒtoƒtheƒ2019ƒ HealthƒCareƒLaw,ƒeachƒstateƒandƒprivateƒhealthƒinstitutionƒisƒresponsibleƒforƒ providingƒfavourableƒcircumstancesƒforƒcontinuingƒtheƒprofessionalƒdevelop- mentƒofƒtheirƒhealthƒworkers,ƒincludingƒspecialization,ƒsub-specializationƒ andƒcontinuingƒeducation,ƒbasedƒonƒtheƒinstitutionalƒplanƒdevelopedƒbyƒtheƒ Professional Council. HigherƒeducationƒisƒbasedƒonƒtheƒBolognaƒDeclaration,ƒwhichƒSerbiaƒ hasƒsignedƒandƒfullyƒimplemented,ƒincludingƒmutualƒrecognitionƒofƒacademicƒ degrees.ƒWithinƒtheƒpreparationƒforƒtheƒEUƒaccession,ƒtheƒMinistryƒofƒ Health,ƒinƒcooperationƒwithƒeducationalƒinstitutionsƒandƒtheƒMinistryƒ responsibleƒforƒeducation,ƒrecognizesƒprofessionalƒqualificationsƒaccordingƒ 102 Health Systems in Transition toƒDirectiveƒ2005/36/ECƒandƒ2013/55/EUƒonƒtheƒrecognitionƒofƒprofes- sionalƒqualificationsƒandƒRegulationƒ(EU)ƒNo.ƒ1024/2012ƒonƒadministrativeƒ cooperationƒthroughƒtheƒInternalƒMarketƒInformationƒSystemƒ(Europeanƒ ParliamentƒandƒCouncil,ƒ2013). Atƒtheƒnationalƒlevel,ƒtheƒMinistryƒofƒHealthƒdevelopsƒaƒplanƒofƒtheƒ numberƒofƒhealthƒprofessionalsƒinƒhealthƒinstitutionsƒbasedƒonƒtheƒNetworkƒ Planƒ(OfficialƒGazette,ƒ2006b),ƒwhichƒcomprisesƒtheƒemployeesƒcoveredƒbyƒ theƒindividualƒhealthƒplansƒofƒhealthƒinstitutions.ƒTheƒplanƒofƒcontinuingƒ professionalƒdevelopmentƒofƒpersonnelƒincludesƒ(asƒspecifiedƒinƒtheƒ2019ƒ HealthƒCareƒLaw):ƒtheƒprogrammeƒofƒprofessionalƒtrainingƒofƒhealthƒworkersƒ andƒhealthƒcareƒassociates;ƒtheƒnumberƒofƒspecializationsƒandƒsubspecializa- tionsƒthatƒareƒapprovedƒonƒanƒannualƒbasis;ƒcriteriaƒandƒcloserƒconditionsƒforƒ approvingƒspecializationsƒandƒsubspecializations;ƒandƒotherƒissuesƒofƒrelevanceƒ forƒtheƒprofessionalƒdevelopmentƒofƒhealthƒworkersƒandƒhealthƒcare associates. TheƒpublicƒsectorƒisƒtheƒmajorƒemployerƒofƒhealthƒworkersƒinƒSerbia.ƒ Thereƒisƒofficialƒinformationƒaboutƒtheƒnumberƒandƒdistributionƒofƒemployedƒ physicalƒpersonsƒinƒtheƒpublicƒhealthƒcareƒsector;ƒhowever,ƒthereƒareƒnoƒ estimatesƒaboutƒtheƒtotalƒnumberƒofƒfull-timeƒequivalentƒstaffƒorƒfullƒdataƒ onƒtheƒsizeƒofƒtheƒworkforceƒ(practising,ƒactiveƒ(thatƒis,ƒlicensedƒforƒpracticeƒ mayƒnotƒbeƒemployed,ƒthereforeƒnotƒpractising),ƒetc.)ƒandƒtheirƒdistributionƒ (age,ƒsex,ƒurban/ruralƒlevelƒandƒdistrict)ƒinƒprivateƒandƒotherƒsectorsƒthanƒtheƒ publicƒhealthƒcareƒsector.ƒInformationƒonƒtheƒtrendsƒinƒworkforceƒmigrationƒ isƒnotƒavailable,ƒalthoughƒresearchƒprovidesƒevidenceƒonƒhighƒintentionƒtoƒ workƒabroadƒ(Šantrić-Milicevicƒetƒal.,ƒ2014,ƒ2015b;ƒGacevicƒetƒal.,ƒ2018). Serbiaƒdoesƒnotƒhaveƒanƒofficialƒhealthƒworkforceƒstrategy.ƒTheƒcurrentƒ healthƒworkforceƒpolicyƒ(OfficialƒGazette,ƒ2015b)ƒaimsƒtoƒmaintainƒtheƒ presentƒstaffingƒlevelsƒinƒtheƒhealthƒsystem,ƒwhileƒreversingƒtheƒshortageƒ ofƒsomeƒspecialistsƒbyƒallowingƒvoluntaryƒ(self-financed)ƒspecializationsƒ (MinistryƒofƒHealth,ƒ2015)ƒasƒwellƒasƒofferingƒpermanentƒjobsƒforƒtheƒ bestƒgraduatesƒofƒmedicalƒfaculties.ƒHowever,ƒthereƒisƒnoƒofficialƒhealthƒ workforce strategy. 4.2.2 Trends in the health workforce Tableƒ4.2ƒpresentsƒratesƒofƒtheƒmainƒcategoriesƒofƒtheƒhealthƒworkforceƒperƒ 100 000ƒpopulationƒinƒtheƒpublicƒsectorƒinƒtheƒperiodƒ1991–2016.ƒInƒtheƒ publicƒnetworkƒinƒ2016,ƒtheƒratesƒofƒphysiciansƒandƒnurses/midwivesƒwereƒ 103Serbia 302ƒandƒ641ƒperƒ100 000ƒinhabitants,ƒrespectively,ƒwithƒaƒratioƒofƒphysiciansƒ toƒnurses/midwivesƒbeingƒ1:2.1ƒ(IPHƒBatut,ƒ2018a). Thereƒwereƒtwoƒcyclesƒofƒrationalizationƒ(inƒ2005/2006ƒandƒ2007)ƒasƒ partƒofƒtheƒhealthƒsectorƒreformƒ(seeƒsectionƒ6.1).ƒAsƒofƒ2014,ƒtheƒgovernmentƒ imposedƒaƒmaximumƒnumberƒofƒpostsƒperƒtypeƒofƒhealthƒinstitution.ƒTheƒlastƒ nationalƒhealthƒworkforceƒstrategyƒinƒSerbiaƒwasƒforƒtheƒperiodƒ2006–2010. TABLE 4.2 Health workers in the public sector per 100 000 population, 1991–2016 (selected years) HEALTH WORKERS 1991 1998 2002 2005 2010 2016 Medical doctors non-specialists (including residents on specialization) 83 74 71 79 98 92 Specialist physicians 153 177 196 196 204 210 Dentists 51 46 45 45 32 26 Pharmacists 31 23 25 27 30 31 Nursing professionals (including paediatric nurses) 431 470 519 558 591 605 Midwives 33 34 37 35 36 36 Health technicians 216 215 243 225 216 205 Note: Data refer to physical persons, licensed, active, and practising in the Network Source: Rate of health workers per 100 000 population are calculated according to data of IPH Batut (IPH Batut, 1992, 1999, 2003, 2017d, 2017h) and mid-term population estimates (SORS, 2017b) Recentƒresearchƒshowedƒinequityƒinƒtheƒdistrictƒdistributionƒofƒhealthƒ careƒstaffƒ(Šantrić-Milicevicƒetƒal.,ƒ2015a).ƒTheƒmedicalƒworkforceƒtendsƒ toƒbeƒallocatedƒinƒurbanƒareasƒwithƒbetterƒinfrastructureƒandƒconcentratedƒ withinƒmedicalƒuniversitiesƒandƒhighlyƒspecializedƒmedicalƒcentres.ƒInƒ2015,ƒ theƒvariationƒofƒtheƒmedicalƒworkforceƒdensityƒatƒdistrictƒlevelƒversusƒtheƒ nationalƒaverageƒratesƒwasƒmostƒprominentƒforƒgeneralƒmedicalƒprofessionalsƒ onƒspecializations,ƒandƒforƒmidwiferyƒprofessionalsƒ(−59%;ƒ+62%)ƒ(Šantrić- Milicevicƒetƒal.,ƒ2015a).ƒTheƒhighestƒdifferenceƒbetweenƒdistrictƒratesƒwasƒ forƒmidwiferyƒprofessionalsƒandƒmedicalƒdoctorsƒonƒspecializationsƒ(3.6:1)ƒ (Šantrić-Milicevicƒetƒal.,ƒ2015a).ƒTheƒlowestƒdifferenceƒbetweenƒdistrictƒratesƒ wasƒforƒnursingƒprofessionalsƒ(1.8:1)ƒandƒhealthƒtechniciansƒ(1.9:1).ƒInƒ2015,ƒ femaleƒworkersƒwereƒ76.7%ƒofƒallƒworkers,ƒwhileƒstaffƒyoungerƒthanƒ35ƒyearsƒ compriseƒ26.9%ƒofƒallƒworkersƒ(Šantrić-Milicevicƒetƒal.,ƒ2015a). 104 Health Systems in Transition PHYSICIANS Inƒ2016,ƒphysiciansƒmadeƒupƒ19.3%ƒofƒtheƒtotalƒpersonnelƒinƒtheƒNetworkƒ (outƒofƒthese,ƒ14.3%ƒwereƒmedicalƒspecialists).ƒInƒ2016,ƒ65%ƒofƒtheƒtotalƒ numberƒofƒphysiciansƒwereƒfemaleƒ(IPHƒBatut,ƒ2017h).ƒInƒ2015,ƒtheƒaverageƒ ageƒofƒpermanentlyƒemployedƒphysiciansƒ(94.4%ƒofƒallƒphysicians)ƒwasƒ47.42ƒ years,ƒwhileƒitƒwasƒ33.97ƒyearsƒforƒthoseƒwithƒtemporaryƒemploymentƒ(IPHƒ Batut,ƒ2017h). NearlyƒhalfƒofƒphysiciansƒinƒtheƒNetworkƒ(49.6%)ƒworkedƒinƒhospitalsƒinƒ 2015ƒ(IPHƒBatut,ƒ2017h),ƒwhichƒwasƒbelowƒtheƒaverageƒforƒtheƒEUƒ(56.8%ƒ inƒ2014)ƒ(WHO,ƒ2016a).ƒInƒ2015,ƒtheƒ10ƒleadingƒspecializationsƒwereƒinƒ theƒfieldƒofƒinternalƒmedicineƒ(13.3%),ƒpaediatricsƒ(11.3%),ƒgeneralƒmedicineƒ (11.1%),ƒobstetricsƒandƒgynaecologistsƒ(7.6%).ƒAnaesthesiologists,ƒradiolo- gistsƒandƒgeneralƒsurgeryƒcomprisedƒaboutƒ5%ƒeach,ƒphysicalƒmedicineƒ3.8%,ƒ whileƒpsychiatryƒandƒurgentƒmedicine,ƒaboutƒ3%ƒeachƒ(IPHƒBatut,ƒ2017d). ThereƒisƒnoƒfamilyƒmedicineƒspecializationƒinƒSerbia.ƒInsteadƒofƒaƒfamilyƒ medicineƒdoctor,ƒinƒ2005,ƒaƒ“chosenƒdoctor”ƒwasƒintroducedƒtoƒactƒasƒaƒ “gatekeeper”ƒinƒaƒteamƒwithƒnursesƒatƒtheƒprimaryƒhealthƒcareƒcentreƒ(Dom zdravlja).ƒAccordingƒtoƒtheƒcurrentƒHealthƒCareƒLawƒ(OfficialƒGazette,ƒ 2019a),ƒaƒpatientƒagedƒoverƒ19ƒisƒobligedƒtoƒchooseƒtheirƒownƒgeneralƒprac- titionerƒ(thatƒis,ƒtheƒnon-specialistƒdoctor,ƒtheƒgeneralƒmedicineƒspecialist,ƒ orƒtheƒoccupationalƒmedicineƒspecialist)ƒandƒdentalƒmedicineƒdoctor,ƒwhileƒ womenƒadditionallyƒmustƒchooseƒoneƒgynaecologist.ƒChildren,ƒthroughƒ theirƒparentsƒorƒtheirƒschool,ƒmustƒchooseƒtheirƒownƒpaediatriciansƒ(Officialƒ Gazette,ƒ2019a). Aƒtotalƒofƒ6 416ƒ“chosenƒdoctors”ƒwereƒworkingƒinƒprimaryƒcareƒcentresƒinƒ Serbiaƒinƒ2017ƒ(NHIF,ƒ2017c).ƒThisƒisƒtheƒtotalƒnumberƒofƒ“chosenƒdoctors”ƒ thatƒprovideƒhealthƒcareƒservicesƒinƒtheƒfieldƒofƒgeneralƒmedicine,ƒforƒtheƒpro- tectionƒofƒwomen’sƒhealth,ƒchildren,ƒyouthƒandƒdentalƒhealth.ƒThisƒnumberƒ equalsƒtoƒapproximatelyƒ0.91ƒ“chosenƒdoctors”ƒperƒ1 000ƒpopulationƒ(calcu- latedƒaccordingƒtoƒpopulationƒdataƒfromƒSORSƒ(2017a),ƒandƒdataƒonƒ“chosenƒ doctors”ƒtakenƒfromƒtheƒNHIFƒ(2017c)). Sinceƒ1991,ƒtheƒrateƒofƒphysiciansƒperƒ100 000ƒpopulationƒhasƒbeenƒ steadilyƒincreasing,ƒtoƒ295.44ƒinƒ2016.ƒThisƒwasƒbelowƒtheƒEUƒaverageƒ (360.98ƒinƒ2016)ƒandƒaboveƒotherƒneighbouringƒcountriesƒsuchƒasƒCroatia,ƒ BulgariaƒandƒSloveniaƒ(seeƒFig.ƒ4.3).ƒHowever,ƒcomparativeƒdataƒonƒworkforceƒ 105Serbia numbersƒbyƒcountryƒsufferƒfromƒsignificantƒdifferencesƒinƒtheƒwayƒinƒwhichƒ theseƒfiguresƒareƒrecorded,ƒtheƒmajorƒdifferencesƒbeingƒwhetherƒtheƒprivateƒ sectorƒisƒincludedƒandƒwhetherƒthoseƒworkingƒinƒotherƒsectorsƒare included. Inƒ2014,ƒSerbiaƒrankedƒamongƒtheƒtopƒfiveƒcountriesƒinƒcentralƒandƒ south-easternƒEuropeƒforƒtheƒnumberƒofƒphysiciansƒandƒnursesƒperƒ100 000,ƒ andƒthisƒfigureƒwasƒaboveƒtheƒaverageƒforƒSEEHNƒcountries,ƒbutƒsignificantlyƒ belowƒtheƒaverageƒforƒtheƒWHOƒEuropeanƒRegionƒandƒtheƒEUƒaverageƒ (Fig.ƒ4.2). TheƒsituationƒforƒphysiciansƒinƒSerbiaƒisƒcharacterizedƒbyƒcontradictions:ƒ overƒ2 000ƒphysiciansƒareƒunemployedƒ(mainlyƒyoungƒprofessionals),ƒandƒ thereƒisƒaƒshortageƒofƒspecialistsƒ(surgeons,ƒanaesthesiologists,ƒreanimatologyƒ andƒintensiveƒtherapy;ƒradiationƒoncologists;ƒotorhinolaryngologists,ƒetc.),ƒ asƒwellƒasƒanƒunequalƒgeographicalƒdistributionƒ(MinistryƒofƒHealth,ƒ2015). NURSES Theƒshareƒofƒnursesƒinƒtheƒpublicƒnetworkƒincreasedƒtoƒ37.1%ƒinƒ2016,ƒ amountingƒtoƒ605ƒperƒ100 000ƒpopulationƒ(Tableƒ4.2).ƒInƒ2016,ƒaboutƒ13%ƒ ofƒofƒtheƒtotalƒnumberƒofƒnursesƒinƒtheƒNetworkƒhadƒcollegeƒdegreesƒandƒtheƒ restƒwereƒnursesƒwithƒsecondaryƒeducation.ƒFurther,ƒ96%ƒofƒcollegeƒnursesƒ wereƒgeneralƒnurses,ƒ3%ƒwereƒmidwivesƒandƒlessƒthanƒ0.5%ƒwereƒpaediatricƒ nurses;ƒ87.0%ƒofƒallƒnursesƒwereƒfemalesƒandƒ31%ƒwereƒagedƒbelowƒ35ƒyearsƒ (IPHƒBatut,ƒ2017h).ƒAccordingƒtoƒtheƒSerbianƒNurseƒandƒHealthƒTechnicianƒ Chamber’sƒdata,ƒtheƒnumberƒofƒlicensedƒnursesƒandƒmidwivesƒwasƒ78 517ƒinƒ 2015,ƒoutƒofƒwhichƒ89.4%ƒwereƒworkingƒinƒtheƒpublicƒsectorƒ(Chamberƒofƒ NursesƒandƒHealthƒTechnicianƒofƒSerbia,ƒ2017). Forƒ2016ƒ(theƒlatestƒyearƒofƒavailableƒdataƒforƒinternationalƒcomparisons),ƒ theƒnumberƒofƒnursesƒperƒ100 000ƒpopulationƒinƒSerbiaƒ(634.9)ƒwasƒlowerƒthanƒ theƒEUƒaverageƒ(864.4)ƒ(seeƒFig.ƒ4.2),ƒandƒbelowƒneighbouringƒcountriesƒsuchƒ asƒHungaryƒ(660.14),ƒCroatiaƒ(673.37)ƒandƒRomaniaƒ(682.85)ƒ(seeƒFig. 4.4).ƒ Inƒ2014,ƒ61.2%ƒofƒallƒnursesƒwereƒemployedƒinƒpublicƒhospitalsƒwhichƒisƒinƒ lineƒwithƒtheƒEUƒaverageƒofƒ61.3%,ƒbutƒhigherƒthanƒtheƒSEEHNƒcountriesƒ averageƒofƒ57.4%ƒ(WHO,ƒ2016a).ƒHowever,ƒasƒnotedƒabove,ƒcomparativeƒ dataƒonƒworkforceƒnumbersƒbyƒcountryƒsufferƒfromƒdifferencesƒinƒtheƒwayƒ inƒwhichƒtheseƒfiguresƒare recorded. 106 Health Systems in Transition FIGURE 4.2 Practising nurses and physicians per 100 000 population, 2014 0 500 1000 1500 2000 2500 3000 SEEHN EU members since May 2004 CIS WHO European Region EU EU members before May 2004 Averages Tajikistan Turkmenistan Armenia Kyrgyzstan Russian Federation Georgia Republic of Moldova Ukraine Azerbaijan Kazakhstan Uzbekistan Belarus CIS Countries Albania North Macedonia Bosnia and Herzegovina Montenegro Romania Poland Latvia Bulgaria Slovakia Croatia Estonia Serbia Hungary Slovenia Czech Republic Lithuania Central and south-eastern Europe Turkey Andorra Cyprus Israel Spain Greece Italy Portugal United Kingdom Netherlands Malta Belgium Austria France San Marino Luxembourg Ireland Sweden Finland Germany Iceland Denmark Norway Switzerland Monaco Western Europe ■■■■■ Physicians ■■■■■ Nurses 664.49 1998.78 411.44 1781.33 442.00 1740.63 365.84 1685.66 377.55 1628.41 412.54 1347.86 301.71 1454.16 411.69 1192.12 282.07 1260.91 292.01 1232.57 636.20 854.59 322.68 1060.47 514.97 819.22 297.10 1016.15 390.76 866.79 335.16 855.57 280.57 843.62 442.55 637.74 394.54 647.52 625.47 343.99 381.90 535.81 361.90 526.37 337.57 528.50 315.60 368.99 174.93 251.88 433.04 795.12 368.92 832.64 276.47 861.06 331.57 656.82 307.08 628.80 331.56 597.10 312.56 614.12 300.14 607.82 399.94 486.51 322.32 503.18 227.05 573.72 236.26 552.42 234.27 534.69 187.87 559.31 280.04 421.13 128.04 Not Available 407.05 1090.29 245.12 1164.66 327.39 802.10 340.15 635.08 299.95 667.72 290.55 608.31 477.60 382.08 330.64 457.24 185.38 598.56 280.26 499.44 229.14 456.00 171.40 472.88 368.60 934.80 350.79 867.60 322.44 740.89 308.73 620.04 283.18 612.46 281.02 546.56 Note: CIS, Commonwealth of Independent States; SEEHN, South-eastern Europe Health Network Source: WHO, 2019 107Serbia FIGURE 4.3 Number of physicians per 100 000 population in Serbia and selected countries, 1995–2016 150 200 250 300 350 400 450 Serbia Croatia Bulgaria Romania Hungary Slovenia EU28 20 16 20 15 20 14 20 13 20 12 20 11 20 10 20 09 20 08 20 07 20 06 20 05 20 04 20 03 20 02 20 01 20 00 19 99 19 98 19 97 19 96 19 95 19 94 19 93 ■■ Bulgaria ■■ EU28 ■■ Croatia ■■ Hungary ■■ Slovenia ■■ Serbia ■■ Romania Ph ys ic ia ns p er 1 00 0 00 p op ul at io n Source: Eurostat, 2019 FIGURE 4.4 Number of nurses per 100 000 population in Serbia and selected countries, 2000–2016 300 400 500 600 700 800 900 1000 Serbia Croatia Bulgaria Romania Hungary Slovenia blank 20162015201420132012201120102009200820072006200520042003200220012000 ■■ Slovenia ■■ Romania ■■ Croatia ■■ Hungary ■■ Serbia ■■ Bulgaria Be ds p er 1 00 0 00 p op ul at io n Note: Nurses and midwives (practising) Source: Eurostat, 2019 108 Health Systems in Transition 4.2.3 Professional mobility of health workers HealthƒworkforceƒmobilityƒinƒSerbiaƒisƒnotƒmonitoredƒinƒsuchƒaƒwayƒtoƒ provideƒaƒpreciseƒsetƒofƒindicatorsƒonƒannualƒnetƒinflowƒandƒoutflowƒofƒhealthƒ professionals.ƒThereƒisƒnoƒprofessionalƒauthorityƒthatƒorganizesƒandƒrecordsƒ theƒmobilityƒofƒhealthƒworkersƒinƒSerbia.ƒTheƒcountryƒhasƒnotƒimplementedƒ theƒ2010ƒWHOƒGlobalƒCodeƒofƒPracticeƒonƒtheƒInternationalƒRecruitmentƒ ofƒHealthƒPersonnelƒ(WHO,ƒ2010a)ƒthatƒrequiresƒtheƒestablishmentƒofƒaƒ nationalƒauthorityƒforƒorganizingƒandƒrecordingƒtheƒmobilityƒofƒhealthƒcareƒ workers.ƒHowever,ƒthereƒareƒotherƒsourcesƒofƒinformationƒsuchƒasƒresearchƒ studies,ƒorƒhealthƒprofessionalƒrecordsƒandƒemploymentƒoffices,ƒnoneƒofƒ whichƒisƒprovidingƒcomprehensiveƒorƒreliable information. Accordingƒtoƒaƒstudyƒfromƒ2006,ƒ10 000ƒhealthƒprofessionalsƒwereƒ workingƒabroadƒthatƒyear,ƒmostlyƒinƒGermanyƒandƒSwitzerlandƒ(Djikanovic,ƒ 2006),ƒwhileƒ3%ƒwereƒinƒHungaryƒandƒlessƒthanƒ3%ƒworkedƒinƒotherƒcountriesƒ (e.g.ƒUnitedƒKingdom,ƒNorway,ƒAustralia,ƒNetherlands,ƒSlovenia,ƒLibya,ƒ UnitedƒArabƒEmirates,ƒetc.)ƒ(Djikanovic,ƒ2006). Theƒregisteredƒunemploymentƒrateƒofƒhealthƒworkersƒ(20%)ƒwasƒhigherƒ thanƒtheƒaverageƒforƒtheƒcountryƒ(NES,ƒ2017).ƒHalfƒofƒtheƒunemployedƒ workersƒareƒyoungƒhealthƒprofessionals.ƒInƒJanuaryƒ2017,ƒtheƒNationalƒ EmploymentƒServiceƒregisteredƒ24 376ƒunemployedƒhealthƒworkers;ƒofƒwhichƒ 77.5%ƒwereƒfemales.ƒTheƒmajorityƒareƒmedicalƒdoctors,ƒnursesƒandƒhealthƒ techniciansƒ(18 455),ƒdentistsƒ(3 483)ƒandƒpharmacistsƒ(2 438). Dataƒonƒpotentialƒleaversƒfromƒtheƒhealthƒsectorƒisƒavailableƒfromƒtheƒ healthƒprofessionalƒchambers,ƒmeasuredƒbyƒtheƒnumberƒofƒpersonsƒrequestingƒ CertificatesƒofƒGoodƒStanding.ƒAƒhealthƒprofessionalƒrequiresƒthisƒcertificateƒ toƒapplyƒtoƒworkƒorƒcontinueƒprofessionalƒeducationƒabroad.ƒTheƒpercentageƒ ofƒlicensedƒprofessionalsƒthatƒhaveƒrequestedƒCertificatesƒofƒGoodƒStandingƒ fromƒtheirƒhealthƒprofessionalƒchambersƒwas:ƒ1.2%ƒofƒlicensedƒbiochemistsƒ inƒtheƒperiodƒ2009–2016,ƒ0.6%ƒdentistsƒinƒ2016,ƒandƒ3.04%ƒofƒlicensedƒ physiciansƒinƒ2017ƒ(ChamberƒofƒBiochemistsƒofƒSerbia,ƒ2017;ƒChamberƒ ofƒDentistsƒofƒSerbiaƒ2017;ƒMedicalƒChamberƒofƒtheƒRepublicƒofƒSerbia,ƒ 2017).ƒHowever,ƒneitherƒtheƒChamberƒofƒNursesƒandƒHealthƒTechniciansƒ ofƒSerbiaƒnorƒtheƒChamberƒofƒPharmacistsƒofƒtheƒRepublicƒofƒSerbiaƒhaveƒ dataƒonƒworkers’ƒmigration.ƒTheseƒdataƒprovideƒonlyƒaƒpartialƒpictureƒofƒ theƒsituation,ƒasƒtheƒdataƒdoesƒnotƒshowƒwhetherƒhealthƒcareƒprofessionalsƒ haveƒactuallyƒmigratedƒandƒdoesƒnotƒincludeƒthoseƒhealthƒworkersƒwhoƒhaveƒ decidedƒtoƒworkƒinƒcountriesƒoutside Serbia. 109Serbia Toƒworkƒabroad,ƒSerbianƒphysiciansƒareƒusuallyƒrequiredƒtoƒpassƒtheƒ recognitionƒandƒequivalenceƒassessmentƒ(nostrification)ƒprocedureƒwhereas,ƒ accordingƒtoƒtheƒacquis communautaire,ƒhealthƒprofessionalsƒwhoƒareƒEUƒ citizensƒmayƒuseƒaƒgeneralƒsystemƒforƒtheƒrecognitionƒofƒhigherƒeducationƒ diplomasƒ(EuropeanƒParliamentƒandƒCouncilƒofƒtheƒEuropeanƒUnion,ƒ2013). MostƒSerbianƒnursingƒcategoriesƒareƒnotƒrecognizedƒinƒtheƒEUƒbecauseƒ theyƒdoƒnotƒqualifyƒforƒconsiderationƒunderƒDirectiveƒ2005/36/ECƒ(Europeanƒ ParliamentƒandƒCouncilƒofƒtheƒEuropeanƒUnion,ƒ2013)ƒforƒseveralƒreasons,ƒ mostlyƒbecauseƒofƒtheƒdegreeƒandƒcompetenciesƒacquiredƒduringƒschoolingƒ asƒwellƒasƒtopicsƒcoveredƒandƒnumberƒofƒpracticalƒhoursƒduringƒschooling.ƒ SinceƒmostƒSerbianƒnursesƒdoƒnotƒholdƒaƒhigherƒeducationƒdegree,ƒtheyƒmostlyƒ migrateƒtoƒworkƒinƒnursingƒhomesƒforƒolderƒpeopleƒandƒrehabilitationƒcentresƒ inƒItaly,ƒtheƒUnitedƒKingdom,ƒAustralia,ƒCanadaƒandƒSwitzerland,ƒthoughƒ thereƒisƒnoƒdataƒon this. Aƒ2016ƒsurveyƒindicatedƒthatƒ29.1%ƒofƒemployeesƒwouldƒnotƒchangeƒ theirƒworkplaceƒinƒtheƒNetworkƒduringƒtheƒnextƒ5ƒyears,ƒwhileƒ6.9%ƒwouldƒ leaveƒtheƒhealthƒsystem,ƒ3.7%ƒwouldƒworkƒinƒtheƒprivateƒhealthƒsector,ƒandƒ 14.7%ƒintendƒtoƒgoƒabroadƒforƒworkƒ(Horozovic,ƒ2016).ƒAƒrecentƒstudyƒdem- onstratedƒthatƒ22.6%ƒofƒtheƒrespondentsƒtoƒaƒ2015ƒsurveyƒofƒemployeesƒinƒtheƒ NetworkƒwereƒdissatisfiedƒwithƒtheirƒjobsƒinƒtheƒNetwork,ƒ11.7%ƒreportedƒ dualƒpractice,ƒandƒ14.3%ƒhadƒanƒintentionƒtoƒworkƒabroadƒ(Gacevicƒetƒal.,ƒ 2018).ƒPhysiciansƒandƒnursesƒyoungerƒthanƒ55ƒyearsƒofƒageƒfromƒaƒtertiaryƒ healthƒcareƒinstitutionƒandƒmalesƒwereƒmoreƒlikelyƒtoƒbeƒdissatisfiedƒthanƒ otherƒworkers.ƒPoorƒmanagementƒandƒworkingƒconditionsƒincreasedƒjobƒ dissatisfaction,ƒwithƒincreasedƒoddsƒforƒdualƒpracticeƒandƒintentionƒtoƒworkƒ abroadƒbyƒ1.5ƒandƒ3.6ƒtimes,ƒrespectivelyƒ(Gacevicƒetƒal.,ƒ2018). Highƒintentionƒtoƒworkƒabroadƒisƒalsoƒclearƒamongƒstudents:ƒ81%ƒofƒ931ƒ medicalƒstudentsƒ(84%ƒofƒfifth-yearƒstudentsƒandƒ78%ƒofƒfirst-yearƒstudents)ƒ reportedƒaƒhighƒintentionƒofƒworkingƒabroadƒ(Šantrić-Milicevicƒetƒal.,ƒ2014)ƒ andƒinƒaƒsampleƒofƒ719ƒnurseƒgraduates,ƒ70%ƒofƒcollegeƒnursesƒandƒ66%ƒofƒ specialistƒnursesƒreportedƒaƒhighƒintentionƒtoƒworkƒabroadƒ(Šantrić-Milicevicƒ etƒal.,ƒ2015b). 4.2.4 Training of health personnel Afterƒprimaryƒschoolƒ(8ƒyears),ƒandƒsecondaryƒschool,ƒwithƒ4ƒyearƒpro- grammesƒ(gymnasiumsƒandƒvocationalƒmedicalƒschools),ƒthereƒareƒthreeƒ 110 Health Systems in Transition stagesƒinƒtheƒtertiaryƒtrainingƒofƒhealthƒprofessionals:ƒundergraduateƒmedicalƒ educationƒ(atƒcollegeƒorƒuniversity),ƒpostgraduateƒmedicalƒeducationƒ(spe- cialist,ƒsub-specialist,ƒMaster’sƒorƒdoctoralƒstudies)ƒandƒcontinualƒprofessionalƒ educationƒ(CPD). Theƒdurationƒofƒsecondaryƒ(middle)ƒmedicalƒeducationƒforƒaƒnurse,ƒ midwifeƒandƒhealthƒtechnicianƒqualificationƒisƒ4ƒyears.ƒStudiesƒatƒtheƒcollegeƒ lastƒ2ƒyearsƒ(120ƒcreditsƒECTSƒequivalents);ƒ3ƒyearsƒ–ƒspecialistƒstudiesƒ (180ƒcreditsƒECTSƒequivalents)ƒ–ƒforƒaƒtitleƒofƒhigherƒnurse,ƒmidwifeƒandƒ health technician. Asƒofƒ2000,ƒtheƒhigherƒeducationƒinstitutionsƒinƒSerbiaƒfollowƒtheƒ Europeanƒtrendsƒofƒreformsƒandƒharmonizationƒinƒtheƒfieldƒofƒhigherƒedu- cationƒknownƒasƒtheƒBolognaƒProcess.ƒConsiderableƒreformsƒhaveƒbeenƒ launchedƒsinceƒSerbiaƒsignedƒtheƒBolognaƒDeclarationƒinƒSeptemberƒ2003.ƒ TheƒcurrentƒLawƒonƒHigherƒEducationƒ(OfficialƒGazette,ƒ2017a)ƒisƒinƒlineƒ withƒBolognaƒProcessƒactionƒlinesƒandƒtheƒLisbonƒConvention,ƒandƒitƒadoptsƒ theƒthree-cycleƒstructureƒprescribedƒbyƒtheƒLawƒonƒHigherƒEducationƒofƒ Serbiaƒ(OfficialƒGazette,ƒ2017a)ƒtoƒbeƒestablishedƒinƒallƒuniversityƒhigherƒ educationƒinstitutions.ƒTheƒimplementationƒofƒtheƒBolognaƒProcessƒwasƒ formallyƒinƒplaceƒsinceƒtheƒacademicƒyearƒ2006/2007.ƒAtƒuniversityƒlevel,ƒ theƒdurationƒofƒtertiaryƒlevelƒstudiesƒcanƒbeƒ(OfficialƒGazette,ƒ2013d): ƒƒ ƒ3ƒyearsƒ(180ƒcreditsƒECTSƒequivalents)ƒforƒhealthƒprofessionalsƒ (e.g.ƒbasicƒstudiesƒinƒoralƒhygiene); ƒƒ ƒ1ƒtoƒ3ƒyearsƒ(60–180ƒcreditsƒECTSƒequivalents)ƒofƒspecialists’ƒ professionalƒstudiesƒforƒhigherƒeducatedƒnursesƒand physiotherapists; ƒƒ ƒ4ƒyearsƒofƒbasicƒacademicƒstudiesƒinƒnursingƒ–ƒbachelorƒ(240ƒcreditsƒ ECTSƒequivalents); ƒƒ ƒ5ƒyearsƒofƒ integratedƒstudiesƒ inƒpharmacyƒ(300ƒcreditsƒECTSƒ equivalents); ƒƒ ƒ6ƒyearsƒofƒintegratedƒstudiesƒinƒmedicineƒandƒdentistryƒ(360ƒcreditsƒ ECTSƒequivalents); ƒƒ ƒ1ƒyearƒofƒspecialistƒacademicƒstudiesƒ(60ƒcreditsƒECTSƒequivalents); ƒƒ ƒ1ƒ yearƒ ofƒ specialistƒ professionalƒ studiesƒ (60ƒ creditsƒ ECTSƒ equivalents); ƒƒ ƒ1ƒyearƒofƒMaster’sƒstudiesƒ(60ƒcreditsƒECTSƒequivalents); ƒƒ ƒ3-yearƒPhDƒstudiesƒ(180ƒcreditsƒECTSƒequivalents); 111Serbia ƒƒ ƒ3ƒtoƒ6ƒyearsƒofƒhealthƒspecializationƒstudiesƒinƒoneƒofƒ70ƒdisciplinesƒ forƒmedicalƒdoctors,ƒdoctorsƒofƒdentistryƒandƒpharmacists;ƒand ƒƒ ƒ1ƒyearƒofƒsub-specializationƒstudiesƒforƒspecialistƒmedicalƒdoctors/ doctorsƒofƒdentistry/ƒpharmacists. Healthƒassociatesƒ(e.g.ƒphysicists,ƒbiologists,ƒetc.)ƒcanƒspecializeƒinƒoneƒ ofƒ17ƒpostgraduateƒtrainingƒprogrammesƒofferedƒwhichƒlastƒ3ƒyearsƒ(Officialƒ Gazette,ƒ2013d)ƒorƒtakeƒaƒMaster’sƒorƒPhDƒinƒPublicƒHealthƒ(e.g.ƒaccreditedƒ andƒorganizedƒatƒtheƒFacultyƒofƒMedicine,ƒUniversityƒofƒBelgrade)ƒorƒHealthƒ Managementƒ(e.g.ƒaccreditedƒandƒorganizedƒasƒaƒjointƒstudyƒprogrammeƒ byƒtheƒFacultyƒofƒMedicineƒandƒtheƒFacultyƒofƒOrganizationalƒSciences,ƒ UniversityƒofƒBelgrade). Allƒhealthƒscienceƒgraduatesƒmustƒcompleteƒanƒinternshipƒatƒaƒhealthƒ institutionƒthatƒfulfilƒcertainƒcriteriaƒobligedƒbyƒtheƒRulebookƒonƒInternshipƒ andƒProfessionalƒExamsƒ forƒHealthƒWorkersƒandƒAssociatesƒ (Officialƒ Gazette,ƒ2006d).ƒAsƒwellƒasƒtheƒfinalƒexam,ƒdiploma,ƒdoctorsƒhaveƒtoƒpassƒ theƒstateƒ(professional)ƒexamƒinƒorderƒtoƒobtainƒaƒcertificateƒforƒprofes- sionalƒqualification.ƒThatƒexamƒconsistsƒofƒtwoƒpartsƒ(knowledgeƒonƒhealthƒ systemƒandƒhealthƒcareƒskills)ƒandƒisƒcarriedƒoutƒbyƒtheƒspecialƒCommissionƒ atƒtheƒMinistryƒofƒHealth.ƒHealthƒworkersƒneedƒtoƒregisterƒtoƒaƒChamberƒ forƒaƒlicense,ƒbeforeƒtheyƒapplyƒatƒtheƒNationalƒEmploymentƒOfficeƒforƒaƒ vacant post. Theƒgoverningƒbodiesƒforƒuniversityƒeducationƒinƒhealthƒsciencesƒareƒtheƒ NationalƒCouncilƒforƒHigherƒEducationƒ(NCHE,ƒ2018),ƒwhichƒisƒelectedƒbyƒ theƒparliament,ƒtheƒCommissionƒforƒAccreditationƒandƒQualityƒAssuranceƒ (whoseƒmembersƒareƒelectedƒbyƒtheƒNationalƒCouncilƒforƒHigherƒEducation),ƒ andƒtheƒConferenceƒofƒUniversities,ƒwhichƒconsistsƒofƒtheƒrectorsƒandƒviceƒ rectorsƒofƒallƒuniversitiesƒ(OfficialƒGazette,ƒ2017a).ƒIndividualƒfaculties,ƒbyƒ theƒLawƒonƒHigherƒEducationƒ(OfficialƒGazette,ƒ2017a),ƒmayƒactƒasƒlegalƒ body,ƒwhichƒmeansƒthatƒtheƒconceptƒofƒaƒfullyƒintegratedƒuniversityƒhasƒstillƒ notƒbeenƒembraced.ƒHowever,ƒtheƒuniversityƒisƒgivenƒcertainƒintegrativeƒ functionsƒandƒsomeƒofƒtheseƒare:ƒstrategicƒplanning,ƒtheƒadoptionƒofƒstudyƒ programmes,ƒqualityƒassuranceƒandƒcontrol,ƒandƒenrolment policy. Serbiaƒoperatesƒanƒintegratedƒnationalƒqualityƒassuranceƒsystemƒcom- plyingƒwithƒtheƒStandardsƒandƒGuidelinesƒforƒQualityƒAssuranceƒinƒtheƒ EuropeanƒHigherƒEducationƒArea.ƒTheƒCommissionƒforƒAccreditationƒ andƒQualityƒAssessmentƒ(CAQA)ƒisƒlegallyƒresponsibleƒforƒorganizingƒandƒ 112 Health Systems in Transition monitoringƒtheƒqualityƒassuranceƒschemeƒforƒallƒhigherƒeducationƒinstitu- tionsƒinƒSerbia.ƒCAQAƒwasƒestablishedƒ(inƒJuneƒ2006)ƒasƒanƒindependentƒ expertƒbodyƒofƒtheƒNationalƒCouncilƒforƒHigherƒEducation.ƒCAQAƒdesignsƒ standards,ƒprotocolsƒandƒguidelinesƒforƒtheƒNationalƒCouncilƒforƒHigherƒ Education’sƒapprovalƒandƒhelpsƒinstitutionsƒinƒcreatingƒtheirƒrespectiveƒqualityƒ management systems. 4.2.5 Physicians’ career paths HealthƒworkersƒinƒSerbiaƒcanƒhaveƒprofessional,ƒacademicƒorƒmanagerialƒ careersƒpaths.ƒTheseƒpathsƒareƒnotƒseparateƒforƒsomeƒpractisingƒhealthƒ workers.ƒTheyƒmayƒadvanceƒprofessionallyƒbyƒundergoingƒspecialistƒtraining,ƒ Master’sƒorƒPhDƒtrainingƒ(whichƒentailsƒtheƒassumptionƒofƒmoreƒresponsi- bilities)ƒorƒbyƒbeingƒpromotedƒtoƒmanagerialƒpositions.ƒForƒexample,ƒnursesƒ andƒmidwivesƒmayƒbeƒpromotedƒtoƒchiefƒnurseƒorƒmidwifeƒinƒaƒward,ƒpartƒofƒ aƒward,ƒorƒinƒaƒhospital.ƒTheƒprofessional,ƒtheƒmanagerialƒand,ƒtoƒaƒcertainƒ extent,ƒtheƒacademicƒcareerƒpathsƒhaveƒaƒgeneralƒregulatoryƒframeworkƒbasedƒ onƒtheƒ2019ƒHealthƒCareƒLawƒ(OfficialƒGazette,ƒ2019a).ƒSpecialƒrulesƒapplyƒ toƒteachersƒandƒresearchersƒatƒinstitutionsƒofƒhigherƒeducationƒandƒatƒresearchƒ institutesƒ(academicƒpath).ƒTheƒacademicƒcareerƒpathƒisƒregulatedƒinƒdetailƒ byƒtheƒLawƒonƒHigherƒEducationƒ(OfficialƒGazette,ƒ2017a),ƒbutƒtheƒscaleƒ ofƒtheƒvariousƒpositionsƒisƒcontainedƒinƒtheƒStatutoryƒActƒofƒeach faculty. Accessƒtoƒtrainingƒisƒdeterminedƒbyƒtheƒmanagementƒofƒtheƒhealthƒ facilityƒwhereƒtheƒphysicianƒworks.ƒTheƒProfessionalƒCouncilƒofƒaƒhealthƒ careƒinstitutionƒproposesƒtheƒplanƒforƒprofessionalƒdevelopment,ƒforƒwhichƒ fundsƒareƒcoveredƒbyƒtheƒemployersƒ(OfficialƒGazette,ƒ2019a).ƒDecisionsƒ aboutƒpromotionsƒatƒworkƒareƒmadeƒatƒtheƒlocalƒlevelƒandƒtheƒdirectorƒofƒtheƒ facilityƒhasƒanƒimportantƒroleƒinƒgrantingƒpromotions.ƒProfessionalƒdevelop- mentƒisƒmonitoredƒatƒtheƒinstitutionalƒlevel,ƒwhileƒtheƒMinistryƒofƒHealthƒ eachƒyearƒapprovesƒtheƒnumberƒofƒspecializationsƒforƒhealthƒcareƒinstitutionsƒ inƒthe Network. 113Serbia 4.2.6 Other health workers’ career paths Atƒpresent,ƒregisteredƒnurses,ƒregardlessƒofƒtheirƒeducationalƒbackground,ƒ areƒentitledƒtoƒtakeƒspecialist,ƒMaster’sƒorƒPhDƒtrainingƒcourses.ƒAsƒofƒ 2010,ƒtheƒRulebookƒforƒtheƒListƒofƒVocational,ƒAcademicƒandƒScientificƒ Titlesƒdeterminesƒtheƒdifferentƒqualificationsƒforƒnurses:ƒvocationalƒnurse,ƒ theƒcollegeƒnurse,ƒtheƒnurseƒgraduatedƒinƒnursingƒorganization,ƒspecialistƒ vocationalƒnurse,ƒMaster’sƒofƒnursing,ƒMaster’sƒofƒnursingƒorganizationƒandƒ PhDƒinƒnursing.ƒNursesƒandƒmidwivesƒwithƒBachelor’sƒandƒMaster’sƒdegreesƒ specializingƒinƒhealthƒcareƒmanagementƒcanƒapplyƒforƒmanagerialƒpostsƒ (seniorƒnurse/midwife,ƒchiefƒnurse/midwife,ƒdirectorsƒofƒpublicƒnurseries).

5 Provision of services Summary ƒƒ ƒHealthƒservicesƒareƒprovidedƒthroughƒaƒwideƒnetworkƒofƒhealthƒ institutions.ƒTheƒmostƒimportantƒinstitutionsƒforƒpublicƒhealthƒatƒ theƒregionalƒlevelƒareƒtheƒInstitutesƒofƒPublicƒHealthƒ(IPHs).ƒTheirƒ workƒisƒcoordinatedƒatƒtheƒnationalƒlevelƒbyƒtheƒInstituteƒofƒPublicƒ HealthƒofƒSerbiaƒ“DrƒMilanƒJovanovićƒBatut”. ƒƒ ƒHealthƒcareƒisƒorganizedƒatƒthreeƒlevels:ƒprimary,ƒsecondaryƒandƒ tertiary.ƒHealthƒcareƒatƒtheƒprimaryƒlevelƒisƒprovidedƒbyƒtheƒstate- ownedƒnetworkƒofƒprimaryƒcareƒcentres.ƒPrimaryƒcareƒisƒpubliclyƒ providedƒbyƒaƒ“chosenƒdoctor”ƒ(whoƒisƒeitherƒaƒmedicalƒdoctor,ƒaƒ dentistƒorƒaƒspecialistƒinƒgeneralƒmedicine,ƒoccupationalƒmedicine,ƒ paediatrics,ƒorƒgynaecology),ƒwithƒpatientsƒassignedƒaccordingƒtoƒ theƒareaƒtheyƒlive in. ƒƒ ƒTheƒ“chosenƒdoctor”ƒactsƒasƒaƒgatekeeperƒandƒrefersƒtheƒpatientƒ toƒsecondaryƒcareƒ(outpatientƒorƒ inpatientƒcare)ƒ ifƒ theƒprimaryƒ healthƒcareƒcentreƒisƒunableƒtoƒprovideƒadequateƒcare.ƒHigh-qualityƒ diagnosticƒ andƒ curativeƒ servicesƒ areƒ providedƒ byƒ theƒ tertiaryƒ levelƒofƒcare,ƒwhichƒisƒcloselyƒ interconnectedƒwithƒprimaryƒandƒ secondary care. ƒƒ ƒEmergencyƒcareƒisƒorganizedƒwithinƒtwoƒfunctionallyƒlinkedƒsub- systems:ƒprehospitalƒemergencyƒcareƒandƒinpatientƒemergencyƒcare.ƒ AverageƒwaitingƒtimesƒinƒtheƒAccidentƒandƒEmergencyƒunitsƒwasƒ 11ƒminutesƒinƒ2017ƒ(IPHƒBatut,ƒ2018a). 116 Health Systems in Transition ƒƒ ƒTheƒ2019ƒHealthƒCareƒLawƒalsoƒregulatesƒpharmaceuticalƒservicesƒ togetherƒwithƒtheƒ2019ƒHealthƒInsuranceƒLawƒandƒtheƒ2010ƒLawƒonƒ MedicinesƒandƒMedicalƒDevices.ƒInƒ2016,ƒdomesticƒmanufacturersƒ heldƒ38%ƒofƒtheƒmarket share. ƒƒ ƒLong-termƒcareƒandƒpalliativeƒservicesƒareƒprovidedƒtoƒaƒ largeƒ degreeƒbyƒfamilyƒmembersƒandƒprivateƒorganizations.ƒTheƒMinistryƒ ofƒHealthƒestablishedƒaƒCommissionƒforƒPalliativeƒCareƒinƒ2004,ƒ whichƒcreatedƒtheƒ2009ƒNationalƒStrategyƒforƒPalliativeƒCareƒandƒ aƒ2009ƒActionƒPlanƒforƒitsƒimplementation.ƒForƒmentalƒhealthƒcareƒ thereƒareƒfiveƒspecialƒpsychiatricƒhospitalsƒwithƒ3 250ƒbeds.ƒAƒLawƒ onƒtheƒProtectionƒofƒPersonsƒwithƒMentalƒDisabilitiesƒwasƒpassedƒ in 2013. 5.1  Public health Publicƒhealthƒservicesƒareƒprovidedƒthroughƒaƒwideƒnetworkƒofƒpublicƒhealthƒ institutionsƒorganizedƒatƒdifferentƒlevelsƒ(Fig.ƒ5.1). Theƒ25ƒInstitutesƒofƒPublicƒHealthƒ(IPHs)ƒ(includingƒtheƒNationalƒ InstituteƒofƒPublicƒHealthƒofƒSerbiaƒ“DrƒMilanƒJovanovićƒBatut”)ƒareƒorgan- izedƒatƒtheƒnational,ƒdistrictƒandƒcityƒlevel.ƒTheirƒtaskƒisƒtoƒcoordinateƒtheƒ wholeƒfieldƒofƒpublicƒhealthƒandƒtoƒparticipateƒdirectlyƒinƒhealthƒpromotion,ƒ diseaseƒpreventionƒandƒprotectionƒofƒtheƒenvironment.ƒPrimaryƒcareƒcentres,ƒ whichƒareƒresponsibleƒforƒtheƒworkƒatƒtheƒlocalƒlevel,ƒalsoƒhaveƒaƒsignificantƒ roleƒinƒpublicƒhealthƒ(seeƒsectionƒ5.3).ƒInspectionƒservicesƒareƒaƒprominentƒpartƒ ofƒpublicƒhealthƒservicesƒ(thatƒis,ƒhealthƒcare,ƒsanitaryƒinspection,ƒcommunalƒ inspection,ƒmarketƒinspectionƒandƒveterinaryƒcare),ƒasƒwellƒasƒinstitutionsƒforƒ educationƒ–ƒespeciallyƒfaculties,ƒcollegesƒandƒsecondaryƒschoolsƒforƒhealthƒ professionalsƒandƒotherƒrelevantƒprofiles,ƒthen,ƒprimaryƒschools,ƒpreschoolƒ institutionsƒandƒsocialƒcare institutions. 117Serbia FIGURE 5.1 Organizational structure of the system of public health in Serbia Re pu bl ic Pa rli am en t He al th a nd F am ily C om m itt ee Re pu bl ic Go ve rn m en t N at io na l P ub lic H ea lth C ou nc il (re pr es en ta tiv es o f r el ev an t m in is tri es ) Ex pe rt co m m is si on s Ex pe rt w or ki ng g ro up s M in is try o f H ea lth In st itu te o f P ub lic H ea lth o f S er bi a “B AT UT ” Ot he r m in is tri es re sp on si bl e fo r e du ca tio n, e nv iro nm en t, so ci al w el fa re , s ci en ce , sp or t, ag ric ul tu re , e co no m y, em pl oy m en t, in te rn al a ffa irs , e tc . Co m m is si on fo r A cc re di ta tio n an d Qu al ity A ss ur an ce N at io na l C ou nc il fo r Hi gh er E du ca tio n Ch am be rs o f He al th W or ke rs M un ic ip al ity H ea lth C ou nc ils In st itu te s at p rim ar y le ve l – 16 Co un se lli ng s er vi ce s ce nt re s fo r p re ve nt iv e he al th s er vi ce s Po ly va le nt p at ro na ge co m m un ity n ur si ng s er vi ce s Pa rtn er s in th e co m m un ity N GO S Sc ho ol s Ol d pe op le ’s ho m es Ce nt er s fo r s oc ia l w or k Et c. .. Re gi on al In st itu te s of P ub lic H ea lth – 24 St at e Sa ni ta ry In sp ec tio n Hi er ar ch ic al re la tio n Pr of es si on al s up er vi si on Ad vi so ry re la tio n Pr im ar y he al th c ar e ce nt re s Do m zd ra vlj a- s – 15 8 Ch os en d oc to rs Sources: Compiled from the Health Care Law (Official Gazette 25/2019), Decree on the Plan of the Health Institutions’ Network (Official Gazette 42/2006, 119/2007, 84/2008, 71/2009, 85/2009, 24/2010, 6/2012, 37/2012, 8/2014, 92/2015, 111/2017 and 114/2017), and Public Health Law (Official Gazette of 15/2016) 118 Health Systems in Transition TheƒpublicƒhealthƒworkforceƒinƒSerbiaƒincludesƒaƒvarietyƒofƒemployees.ƒ IPHƒBatutƒ(theƒnationalƒlevel)ƒemploysƒ231ƒemployeesƒatƒdifferentƒpositions,ƒ whileƒtheƒnetworkƒofƒ24ƒIPHsƒ(atƒtheƒprovincialƒandƒregionalƒlevel)ƒemploysƒ 2 485ƒworkersƒ(IPHƒBatut,ƒ2016a)ƒ(Tableƒ5.1). TABLE 5.1 The network and employees of the Network of Institutes of Public Health ORGANIZATIONAL UNIT NUMBER OF EMPLOYEES % Centres for health promotion 87 3.5 Centres for analysis, planning and organization of health care & centres for informatics and biostatistics 217 8.7 Centres for disease control and prevention 314 12.6 Centres for hygiene and human ecology 743 29.9 Centres for microbiology 503 20.2 Health management and support personnel 621 25.0 Total 2 485 100 Source: Official Gazette, 2016c TheƒPublicƒHealthƒStrategyƒ(2018–2025),ƒadoptedƒinƒAugustƒ2018ƒ (OfficialƒGazette,ƒ2018b),ƒidentifiesƒsevenƒpublicƒhealth priorities: 1. ƒImprovingƒhealthƒandƒreducingƒhealth inequalities. 2. ƒImprovingƒtheƒenvironmentƒandƒworking conditions. 3. ƒPreventingƒandƒcombatingƒmajorƒdiseasesƒandƒhealthƒrisksƒforƒ the population. 4. ƒDevelopingƒactionsƒtoƒpromoteƒhealthƒinƒthe community. 5. ƒSupportingƒ theƒ developmentƒ ofƒ accessible,ƒ high-qualityƒ andƒ efficientƒhealth care. 6. ƒDevelopingƒ theƒ systemƒ ofƒ publicƒ healthƒ basedƒ onƒ evidenceƒ from research. 7. ƒImprovingƒleadership,ƒcommunicationƒandƒpartnershipƒforƒtheƒ implementationƒofƒtheƒapproachƒ“HealthƒinƒAllƒPolicies”. 119Serbia 5.1.1 Environmental and communicable disease control function Atƒtheƒnationalƒlevel,ƒthreeƒinstitutionsƒareƒinƒchargeƒofƒcommunicableƒ diseaseƒcontrol:ƒtheƒMinistryƒofƒHealth,ƒtheƒStateƒSanitaryƒInspectorateƒ (SSI),ƒandƒtheƒIPHƒBatut.ƒTheƒMinistryƒofƒHealthƒsupervisesƒimplementa- tionƒthroughƒtheƒSSI,ƒwhichƒinƒturnƒassessesƒandƒcontrolsƒtheƒperformanceƒofƒ theƒcompetentƒinstitutionsƒthroughƒregionalƒservices.ƒTheƒIPHƒBatutƒtakesƒ responsibilityƒforƒcommunicableƒdiseasesƒthroughƒtheƒCentreƒforƒDiseaseƒ ControlƒandƒPrevention,ƒwhichƒisƒanƒorganizationalƒunitƒofƒIPHƒBatutƒ(IPHƒ Batut,ƒ2014a). InƒSerbia,ƒtheƒprimaryƒdiagnosticƒtestingƒserviceƒisƒperformedƒbyƒ61ƒ microbiologyƒlaboratories.ƒDiagnosticƒmicrobiologyƒlaboratoriesƒareƒlocatedƒatƒ 25ƒgeneralƒhospitals,ƒ24ƒregionalƒIPHs,ƒandƒ13ƒtertiaryƒcareƒcentresƒandƒinsti- tutes.ƒInƒmajorƒurbanƒcentres,ƒprivateƒlaboratoriesƒalsoƒprovideƒthese services. 5.1.2 Mechanisms for notification and surveillance of disease outbreaks Underƒtheƒ2016ƒLawƒonƒProtectionƒofƒtheƒPopulationƒfromƒCommunicableƒ Diseases,ƒconfirmedƒcasesƒofƒoverƒ50ƒcommunicableƒdiseasesƒmustƒbeƒreportedƒ onƒaƒdailyƒbasis.ƒTheseƒreportsƒareƒsentƒtoƒtheƒIPHƒnetwork,ƒandƒthenƒtoƒ IPHƒBatut,ƒwhichƒpublishesƒaƒreportƒeachƒyear.ƒInƒtheƒcaseƒofƒanƒoutbreak,ƒ IPHƒBatutƒprovidesƒaƒreportƒeachƒday.ƒTheƒlistƒofƒdiseasesƒandƒhealthƒeventsƒ requiredƒtoƒbeƒreportedƒatƒEUƒlevelƒareƒfullyƒcoveredƒ(EuropeanƒCommission,ƒ 2012).ƒRoutineƒactiveƒsurveillanceƒandƒaggregatedƒreportingƒisƒcomplementedƒ byƒurgentƒcase-basedƒreportingƒforƒdefinedƒdiseasesƒofƒpublicƒhealthƒimpor- tance.ƒThereƒareƒtwoƒadditionalƒparallelƒsurveillanceƒsystemsƒ–ƒoneƒforƒTBƒ andƒtheƒotherƒforƒHIVƒ–ƒandƒaƒsentinelƒsurveillanceƒsystemƒforƒinfluenza.ƒ KeyƒnationalƒdiseaseƒprogrammesƒforƒHIVƒandƒTBƒhaveƒbeenƒestablishedƒ asƒwellƒasƒtheƒNationalƒProgrammeƒofƒAntimicrobialƒResistanceƒ(AMR)ƒ surveillance,ƒsupportedƒbyƒtheƒMinistryƒofƒHealthƒandƒcoordinatedƒbyƒtheƒ IPH Batut. Serbianƒlaboratoriesƒareƒableƒtoƒdetectƒandƒconfirmƒ75%ƒofƒEU-notifiableƒ communicableƒdiseasesƒaccordingƒtoƒEUƒcaseƒdefinitions.ƒNationalƒrefer- enceƒlaboratoriesƒforƒTB,ƒHIV,ƒinfluenza,ƒmeasles,ƒpoliomyelitis,ƒandƒAMRƒ activelyƒparticipateƒinƒlaboratoryƒsurveillanceƒnetworksƒandƒprojectsƒledƒbyƒ WHOƒorƒtheƒEuropeanƒCentreƒforƒDiseaseƒPreventionƒandƒControlƒ(ECDC). 120 Health Systems in Transition 5.1.3 Mechanisms for surveillance of the population’s health and well-being Theƒsurveillanceƒofƒtheƒpopulation’sƒhealthƒandƒwell-beingƒisƒtheƒrespon- sibilityƒofƒtheƒMinistryƒofƒHealth,ƒwhileƒtheƒIPHƒBatutƒisƒinƒchargeƒofƒ organizingƒtheƒNationalƒHealthƒSurveyƒtoƒmonitorƒhealthƒdeterminants,ƒ healthƒstatus,ƒlifestyles,ƒfunctionalƒcapabilities,ƒtheƒutilizationƒofƒhealthƒcareƒ andƒhealthƒcareƒcostsƒ(IPHƒBatut,ƒ2007,ƒ2014b).ƒOtherƒsurveysƒsuchƒasƒtheƒ GlobalƒYouthƒTobaccoƒSurveyƒ(GYTS),ƒtheƒEuropeanƒSchoolƒSurveyƒProjectƒ onƒAlcoholƒandƒOtherƒDrugsƒ(ESPAD),ƒtheƒMultipleƒIndicatorƒClusterƒ Surveyƒ(MICS),ƒtheƒSurveyƒonƒIncomeƒandƒLivingƒConditionsƒ(SILC),ƒtheƒ EuropeanƒSystemƒofƒIntegratedƒSocialƒProtectionƒStatisticsƒ(ESSPROSƒ database),ƒtheƒMappingƒofƒSocialƒCareƒServicesƒwithinƒtheƒMandateƒofƒ LocalƒGovernments,ƒserveƒforƒsurveillanceƒofƒtheƒpopulation’sƒhealthƒandƒ well-beingƒ(seeƒsectionƒ2.6). 5.1.4 The organization of occupational health services OccupationalƒhealthƒservicesƒinƒSerbiaƒareƒregulatedƒbyƒtheƒ2019ƒHealthƒCareƒ Lawƒandƒtheƒ2005ƒLawƒonƒSafetyƒandƒHealthƒatƒWork.ƒInƒaddition,ƒseveralƒ documentsƒ(strategies,ƒprogrammes,ƒbylaws)ƒofƒnationalƒimportanceƒreferƒ toƒhealthƒprotectionƒofƒtheƒworkingƒpopulation.ƒTheƒmostƒimportantƒisƒtheƒ StrategyƒforƒSafetyƒandƒHealthƒatƒWorkƒofƒSerbiaƒwhichƒwasƒadoptedƒforƒtheƒ periodƒ2013–2017ƒandƒisƒpendingƒrenewalƒ(OfficialƒGazetteƒRSƒ100/2013).ƒ TheƒoverallƒobjectiveƒofƒtheƒStrategyƒisƒtoƒpromoteƒandƒmaintainƒtheƒhealthƒ ofƒtheƒactiveƒable-bodiedƒpopulation,ƒand/orƒtoƒpromoteƒworkingƒconditionsƒ toƒpreventƒinjuriesƒatƒworkƒandƒwork-relatedƒandƒoccupationalƒdiseasesƒandƒ minimizingƒand/orƒeliminatingƒprofessionalƒrisks.ƒGovernanceƒofƒhealthƒ servicesƒrelatedƒtoƒoccupationalƒhealthƒisƒtheƒresponsibilityƒofƒtheƒMinistryƒ ofƒHealth.ƒInƒaddition,ƒsomeƒhealthƒandƒsafetyƒservicesƒareƒtheƒresponsibilityƒ ofƒtheƒMinistryƒofƒLabour,ƒEmployment,ƒVeteranƒandƒSocial Affairs. 5.1.5 The organization of preventive services Primaryƒcareƒcentresƒ(158ƒdomova zdravlja)ƒareƒpredominantlyƒresponsibleƒforƒ theƒdeliveryƒofƒpreventiveƒservices.ƒ“Chosenƒdoctors”ƒtargetƒtheirƒpopulationƒ 121Serbia withƒpreventiveƒservicesƒeachƒyearƒinƒattemptsƒtoƒaccomplishƒtheƒgoalsƒestab- lishedƒbyƒtheƒ2017ƒHealthƒCareƒPlanƒfromƒCompulsoryƒHealth Insurance. Asƒwellƒasƒtheƒregularƒworkƒwithƒtheƒpopulationƒoverƒ19ƒyearsƒofƒage,ƒ theƒ“chosenƒGP”,ƒperformsƒpreventiveƒservicesƒwithinƒtheƒpreventiveƒcentres.ƒ PreventiveƒcentresƒareƒfunctionalƒformsƒthatƒhaveƒbeenƒestablishedƒinƒDom zdravlja-sƒsinceƒ2005ƒwithinƒtheƒprojectƒofƒtheƒMinistryƒofƒHealthƒandƒtheƒ EuropeanƒAgencyƒforƒReconstructionƒ(ImprovingƒPreventiveƒHealthƒServicesƒ inƒSerbia).ƒAsƒwellƒasƒhealthƒpromotionƒandƒhealthƒeducationƒactivities,ƒ “chosenƒGPs”ƒperformƒotherƒpreventiveƒactivitiesƒforƒtheƒadultƒpopulationƒ inƒthoseƒcentres:ƒimmunizationƒwhenƒnecessary,ƒcontrolƒofƒbloodƒsugar,ƒcho- lesterolƒandƒtriglycerides,ƒanthropometricƒmeasurements,ƒriskƒassessmentƒforƒ diabetesƒandƒotherƒdiseasesƒ(particularlyƒcardiovascularƒdiseases,ƒmalignantƒ neoplasmƒandƒdepression),ƒclinicalƒexaminationƒandƒbreastƒexaminationƒinƒ women.ƒSomeƒofƒtheƒpreventiveƒcentresƒhaveƒwell-establishedƒmobileƒunitsƒ forƒdeliveryƒofƒpreventiveƒservicesƒinƒthe community. “Chosenƒgynaecologists”ƒareƒresponsibleƒforƒpreventiveƒservicesƒamongƒ womenƒofƒreproductiveƒage,ƒincludingƒcounsellingƒforƒfamilyƒplanning,ƒante- natalƒcareƒduringƒpregnancyƒandƒpostnatal,ƒmaternityƒcare,ƒand screening. Asƒwellƒasƒtheirƒregularƒwork,ƒ“chosenƒpaediatricians”ƒperformƒpreven- tiveƒservicesƒ(e.g.ƒimmunizationƒandƒearlyƒdiseaseƒdetection),ƒandƒtheyƒworkƒ inƒtwoƒcounsellingƒservicesƒ(preschoolƒchildrenƒandƒyouth). Theƒhealthƒcareƒsectorƒhasƒformulatedƒaƒnumberƒofƒstrategiesƒandƒprojectsƒ toƒimproveƒtheƒaccessibilityƒofƒpreventiveƒhealthƒservicesƒandƒtheƒoverallƒ healthƒstatusƒofƒvulnerableƒgroups,ƒespeciallyƒtheƒRomaƒpopulation.ƒAƒpar- ticularlyƒsuccessfulƒinitiativeƒhasƒinvolvedƒhiringƒRomaƒhealthƒmediatorsƒ assignedƒtoƒmultidisciplinaryƒteamsƒofƒprimaryƒcareƒcentresƒwhichƒconductƒ homeƒvisitsƒinƒ59ƒtownsƒandƒmunicipalitiesƒinƒSerbia.ƒAllƒofƒtheƒ75ƒmediatorsƒ soƒfarƒareƒfemale,ƒliveƒinƒRomaƒsettlements,ƒhaveƒchildrenƒofƒtheirƒown,ƒandƒ haveƒfinishedƒelementaryƒschoolƒatƒleast.ƒTheirƒtaskƒisƒtoƒbeƒaƒlinkƒbetweenƒ theƒRomaƒcommunityƒandƒhealthƒinstitutions,ƒbutƒtheyƒalsoƒprovideƒassist- anceƒandƒadviceƒinƒotherƒareasƒrelatingƒtoƒeducationƒandƒsocialƒprotectionƒinƒ orderƒtoƒcopeƒwithƒtheƒnumerousƒdifficultiesƒfacedƒbyƒtheƒRoma,ƒespeciallyƒ theƒchildrenƒ(Dinkićƒ&ƒBranković,ƒ2011).ƒSignificantƒprogressƒinƒaccessƒtoƒ primaryƒhealthƒcareƒservicesƒhasƒbeenƒrecordedƒforƒRomaƒchildrenƒinƒquali- tativeƒstudiesƒconductedƒbyƒNGOsƒ(Praxis,ƒ2011). Theƒmostƒprominentƒpreventiveƒservices,ƒandƒthoseƒwhichƒhaveƒbeenƒ carriedƒoutƒforƒtheƒlongestƒperiod,ƒareƒwithinƒtheƒnationalƒprogrammeƒforƒ immunization.ƒPaediatriciansƒareƒfullyƒresponsibleƒforƒtheƒimmunizationƒ 122 Health Systems in Transition ofƒchildrenƒfromƒ0ƒtoƒ18ƒyearsƒofƒage,ƒwhileƒGPsƒareƒresponsibleƒforƒtheƒ populationƒoverƒ19ƒyearsƒofƒage.ƒSerbiaƒroutinelyƒperformsƒobligatoryƒchild- hoodƒimmunizationsƒagainstƒtuberculosis,ƒdiphtheria,ƒtetanus,ƒpertussis,ƒ polio,ƒhepatitisƒB,ƒmeasles,ƒmumps,ƒrubellaƒandƒHaemophilusƒinfluenzaƒ typeƒbƒ(OfficialƒGazette,ƒ2017b).ƒSinceƒMarchƒ2018,ƒobligatoryƒvaccinationƒ againstƒpneumococcusƒwasƒintroducedƒandƒfromƒ1 April 2019ƒallƒchildrenƒ haveƒbeenƒvaccinatedƒasƒpartƒofƒtheƒroutineƒprogrammeƒ(OfficialƒGazette,ƒ 2017b;ƒWHO,ƒ2019a).ƒAlso,ƒthereƒisƒaƒrecommendationƒforƒvaccinationƒ againstƒhumanƒpapillomavirusƒinƒgirlsƒ(Nikolicƒetƒal.,ƒ2015;ƒStamenkovicƒ etƒal.,ƒ2017).ƒAƒstrategyƒforƒtargetingƒmeaslesƒandƒrubellaƒeliminationƒandƒ preventionƒofƒcongenitalƒrubellaƒinfectionƒhasƒbeenƒformallyƒwrittenƒandƒ updated,ƒaccordingƒtoƒtheƒ2012ƒWHOƒstrategicƒpaperƒ(WHO,ƒ2012),ƒbutƒ isƒstillƒpendingƒadoption.ƒTheƒtargetƒdateƒforƒtheƒeliminationƒofƒmeaslesƒ hasƒbeenƒpostponed,ƒbutƒtheƒnewƒtargetƒdateƒhasƒnotƒbeenƒformallyƒadoptedƒ byƒhealthƒauthoritiesƒatƒtheƒnationalƒlevelƒalthoughƒtheƒdefinedƒtargetƒisƒ usedƒ(93%ƒMCV1,ƒ90%ƒforƒMCV2ƒandƒ93%ƒforƒRCV1ƒ(WHO,ƒ2019a)).ƒ Vaccinationƒcoverageƒlevelƒisƒnotƒavailableƒperƒbirthƒcohortƒtoƒcheckƒforƒ possibleƒimmunizationƒgapsƒbecauseƒanƒelectronicƒimmunizationƒregisterƒisƒ notƒavailable.ƒSerbiaƒhasƒanƒannualƒimmunizationƒreportƒinƒaccordanceƒwithƒ theƒrulesƒforƒimmunizationƒwhichƒisƒpublishedƒeachƒyearƒonƒtheƒIPHƒBatutƒ websiteƒ(IPHƒBatut,ƒ2018b).ƒDespiteƒgoodƒcoverage,ƒtheƒnationalƒtargetsƒ ofƒ95%ƒforƒsomeƒobligatoryƒvaccinesƒ(suchƒasƒMMRƒvaccine)ƒhaveƒstillƒnotƒ beenƒreachedƒ(Tableƒ5.2).ƒAlso,ƒthereƒhasƒbeenƒaƒslightƒdeclineƒinƒvaccinationƒ rates,ƒpredominantlyƒinfluencedƒbyƒaƒstrongƒanti-vaccination movement. TABLE 5.2 Vaccination coverage for selected vaccines, 2007–2016 COVERAGE (%) VACCINATION PERFORMED 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Diphtheria, tetanus, pertussis 98 98 97 97 98 94 97 95 95 94 MMR 96 96 96 96 97 90 93 86 84 81 Hepatitis B in the 1st year 92 94 95 95 96 93 93 94 92 91 Hepatitis B in the 12th year 57 78 62 76 87 83 74 78 73 64 Note: MMR, measles, mumps and rubella vaccine Source: IPH Batut, 2017c 123Serbia 5.1.6 Established programmes of health promotion and education Programmesƒofƒhealthƒpromotionƒandƒeducationƒtargetingƒriskƒbehaviourƒandƒ vulnerableƒgroupsƒhaveƒaƒlongƒtraditionƒinƒSerbia.ƒGovernanceƒofƒnationwideƒ programmesƒisƒtheƒresponsibilityƒofƒtheƒMinistryƒofƒHealthƒwithƒfinancingƒ fromƒtheƒstateƒbudget.ƒSeveralƒnationalƒprogrammesƒsupportƒhealthƒpro- motionƒandƒeducationƒwithinƒtheirƒscopeƒandƒpurpose,ƒsuchƒasƒtheƒ2009ƒ RegulationƒonƒtheƒNationalƒProgrammeƒofƒHealthƒCareƒforƒWomen,ƒChildrenƒ andƒAdolescents,ƒandƒtheƒ2009ƒRegulationƒonƒtheƒNationalƒProgrammeƒofƒ PreventiveƒDentalƒCare.ƒCurrently,ƒaƒpopulation-basedƒinterventionƒaimingƒ toƒpreventƒNCDsƒandƒdecreasingƒtheirƒburdenƒisƒinƒfocusƒ(e.g.ƒpreventionƒ ofƒtobaccoƒsmokingƒandƒalcoholƒabuse,ƒpromotionƒofƒhealthyƒnutritionƒandƒ physicalƒactivity);ƒhowever,ƒtheseƒprogrammesƒareƒstillƒwaitingƒforƒaƒmoreƒ efficientƒimplementation.ƒDuringƒ2017ƒandƒbeginningƒofƒ2018,ƒfourƒnewƒ programmesƒwere adopted: ƒƒ ƒtheƒNationalƒProgrammeƒforƒtheƒPreservationƒandƒImprovementƒ ofƒtheƒHealthƒofƒtheƒOlderƒPopulationƒ(OfficialƒGazetteƒ8/2017); ƒƒ ƒtheƒNationalƒProgrammeƒforƒtheƒPreventionƒofƒHarmfulƒAlcoholƒ UseƒandƒAlcohol-InducedƒDisordersƒinƒSerbiaƒ(OfficialƒGazetteƒ 115/2017); ƒƒ ƒtheƒNationalƒProgrammeƒforƒtheƒProtectionƒandƒPromotionƒofƒ SexualƒandƒReproductiveƒHealthƒofƒtheƒCitizensƒofƒSerbiaƒ(Officialƒ Gazetteƒ120/2017); ƒƒ ƒtheƒNationalƒProgrammeƒforƒPreventionƒofƒObesityƒinƒChildrenƒ andƒAdultsƒ(OfficialƒGazetteƒRSƒ9/2018). IPHƒBatutƒhasƒaƒcoordinationƒroleƒforƒtheƒstateƒprogrammesƒatƒtheƒ nationalƒlevelƒthroughƒitsƒCentreƒforƒHealthƒPromotionƒdepartment.ƒThisƒ Centreƒwasƒestablishedƒbyƒtheƒ2005ƒHealthƒCareƒLawƒfollowingƒtheƒresultƒ ofƒseveralƒEUƒprojectsƒaimingƒtoƒimproveƒhealthƒpromotionƒandƒdiseaseƒ preventionƒbyƒstrengtheningƒcapacitiesƒofƒtheƒIPH network. Also,ƒallƒ24ƒregionalƒIPHsƒhaveƒtheƒsameƒstructureƒforƒtheƒdeliveryƒofƒ healthƒpromotionƒandƒeducationƒatƒregionalƒandƒmunicipalityƒlevel.ƒIPHsƒ cooperateƒwithƒnongovernmentalƒorganizationsƒusuallyƒestablishedƒforƒpre- ventionƒofƒspecificƒdiseasesƒandƒhealthƒpromotionƒamongƒspecificƒpopulationƒ groups.ƒSinceƒ2002,ƒtheƒSerbianƒPublicƒHealthƒAssociationƒhasƒalsoƒbeenƒ activeƒinƒdifferentƒprogrammes.ƒDuringƒrecentƒyears,ƒactivitiesƒatƒtheƒlocalƒ 124 Health Systems in Transition levelƒareƒimplementedƒwithƒtheƒsignificantƒhelpƒofƒtheƒStandingƒConferenceƒ ofƒCitiesƒandƒMunicipalitiesƒ(SCTM,ƒ2018),ƒwhichƒestablishedƒaƒmovementƒ forƒtheƒdevelopmentƒandƒimplementationƒofƒlocalƒpublicƒhealthƒactionƒplansƒ inƒallƒmunicipalitiesƒ(Mijatovicƒetƒal.,ƒ2017). Nevertheless,ƒmanyƒhealthƒpromotionƒandƒeducationƒprogrammesƒ haveƒhadƒdecreasedƒvisibilityƒandƒsufferedƒfromƒlowƒattentionƒfromƒhealthƒ policy.ƒThisƒisƒdueƒtoƒaƒlackƒofƒsupportƒfromƒotherƒsectorsƒoutsideƒofƒtheƒ healthƒsystem,ƒpoorƒrecoursesƒandƒlackƒofƒfinancialƒresources.ƒForƒexample,ƒ theƒCouncilƒforƒTobaccoƒControlƒofƒSerbiaƒwasƒestablishedƒinƒ2006ƒbutƒ ceasedƒtoƒbeƒactiveƒafterƒ2011,ƒandƒtheƒearmarkingƒofƒrevenuesƒfromƒtobaccoƒ productsƒwasƒestablishedƒinƒ2005ƒbutƒcancelledƒinƒ2012ƒ(0.9%ƒwasƒdedicatedƒ toƒsmokingƒpreventionƒinƒ2012),ƒbecauseƒVATƒexcisedƒonƒtobaccoƒproductsƒ wasƒdirectedƒtoƒotherƒsectorsƒinƒneed,ƒratherƒthanƒonƒhealthƒandƒsocialƒcare.ƒInƒ fact,ƒactionsƒtakenƒtoƒimplementƒtheƒTobaccoƒControlƒpolicyƒareƒfragmented:ƒ fourƒdifferentƒlawsƒareƒinƒplaceƒtoƒregulateƒtobaccoƒsales,ƒconsumption,ƒasƒ wellƒasƒtaxesƒandƒTAPSƒ(tobaccoƒadvertising,ƒpromotionƒandƒsponsorship).ƒ Theƒnewƒ2016–2025ƒStrategyƒofƒTobaccoƒControlƒhasƒbeenƒdrafted,ƒandƒtheƒ 2016–2020ƒActionƒPlanƒhasƒbeenƒpreparedƒbyƒtheƒNationalƒCommitteeƒforƒ TobaccoƒControlƒofƒtheƒMinistryƒofƒHealth,ƒalongƒwithƒtheƒnewƒ2018–2026ƒ PublicƒHealthƒStrategyƒinƒSerbiaƒandƒtheƒcorrespondingƒAction Plan. 5.1.7 National screening programmes Serbiaƒstartedƒtheƒgradualƒintroductionƒofƒorganizedƒscreeningƒforƒcervical,ƒ colorectalƒandƒbreastƒcancerƒinƒ2012.ƒHowever,ƒnoƒdataƒisƒavailableƒtoƒassessƒ howƒfarƒthisƒscreeningƒisƒorganizedƒorƒopportunistic.ƒAccordingƒtoƒcurrentƒ cancerƒincidenceƒdata,ƒSerbiaƒisƒatƒ12thƒplaceƒinƒtheƒWHOƒEuropeanƒRegionƒ (age-standardizedƒrate,ƒbothƒsexesƒinƒ2018:ƒ307.8)ƒandƒaccordingƒtoƒcancerƒ mortalityƒdataƒatƒ2ndƒplaceƒ(age-standardizedƒrate,ƒbothƒsexesƒinƒ2018:ƒ 150.7)ƒ(InternationalƒAgencyƒforƒResearchƒonƒCancer,ƒ2018).ƒThisƒclearlyƒ indicatesƒtheƒneedƒforƒgreaterƒinvolvementƒinƒtheƒprevention,ƒearlyƒdetectionƒ andƒtreatmentƒofƒcancer.ƒPrimaryƒhealthƒcentresƒareƒinƒchargeƒofƒconductingƒ screeningƒinƒtheirƒterritoryƒ(NationalƒCancerƒScreeningƒOffice,ƒ2018).ƒTheƒ CancerƒScreeningƒOffice,ƒestablishedƒinƒ2013ƒwithinƒIPHƒBatut,ƒcoordinates,ƒ organizes,ƒmonitorsƒandƒevaluatesƒtheƒimplementationƒofƒscreeningƒandƒ providesƒtrainingƒandƒtechnicalƒassistanceƒtoƒotherƒparticipantsƒinƒorganizedƒ 125Serbia screening.ƒTheƒdataƒareƒcollectedƒandƒregisteredƒatƒtheƒtimeƒandƒplaceƒtheyƒ occur,ƒcompletingƒtheƒprotocolƒ(clinicalƒpathway)ƒforƒeachƒparticipantƒinƒ screeningƒindividually.ƒSummaryƒperiodicƒdataƒareƒforwardedƒtoƒIPHƒBatutƒ andƒtheƒCancerƒScreeningƒOffice.ƒInƒSerbia,ƒopportunisticƒscreeningƒpro- grammesƒareƒcarriedƒoutƒpredominantlyƒwithinƒtheƒnetworkƒofƒ158ƒprimaryƒ careƒcentres.ƒHowever,ƒdespiteƒgoodƒcoverageƒwithƒpreventiveƒservices,ƒ opportunisticƒscreeningsƒareƒalsoƒbelowƒtheƒdesiredƒlevel.ƒThereƒisƒroomƒ toƒimproveƒcoordinationƒamongƒprovidersƒatƒeachƒstageƒofƒtheƒscreeningƒ process.ƒIndicatorsƒareƒcollectedƒbutƒmonitoringƒandƒevaluationƒisƒnotƒwellƒ developedƒ(Farringtonƒetƒal.,ƒ2018). BOX 5.1 Are public health interventions making a difference? The share of women in the first trimester of pregnancy who benefit from modern preventive health services has increased from 54.3% in 2000 to 70.6% in 2010, reaching 93.9% in 2014 (the Millennium Development Goal for Serbia was 85%). However, Multiple Indicator Cluster Surveys (UNICEF, 2007, 2012; SORS & UNICEF, 2014) also reveal that there are significant disparities, not only in the coverage, but also in the content of antenatal and post-neonatal health care available to women from marginalized groups (Janevic et al., 2015; Stojanovski et al., 2017; Popovic et al., 2017). The accessibility of additional counselling services is still not adequate and does not meet the requirements of a child and adolescent friendly system (Cvejic´ et al., 2010; Bogdanovic´ et al., 2016), but no measures are planned in this regard. 5.2  Patient pathways Forƒpatientsƒwithƒconditionsƒthatƒdoƒnotƒrequireƒemergencyƒcare,ƒthereƒareƒ twoƒroutesƒtoƒaccessƒhealthƒcare.ƒOneƒisƒprovidedƒbyƒpublicƒhealthƒcareƒinsti- tutionsƒunderƒtheƒNHIFƒscheme,ƒwhereƒpatients’ƒentitlementsƒareƒtheƒsameƒ throughoutƒSerbia;ƒtheƒsecondƒ(forƒpatientsƒwhoƒareƒnotƒinsuredƒorƒwantƒtoƒ goƒtoƒprivateƒpractice)ƒisƒtoƒobtainƒandƒpayƒout-of-pocketƒforƒtreatmentƒinƒ privateƒhealthƒcare institutions. FollowingƒtheƒNHIFƒpathway,ƒprimaryƒcareƒphysiciansƒ(GPs,ƒpaediatri- ciansƒandƒgynaecologists)ƒareƒusuallyƒtheƒfirstƒpointƒofƒcontactƒforƒpatientsƒ withinƒtheƒhealthƒsystem,ƒactingƒasƒgatekeepersƒtoƒmoreƒcomplexƒmedicalƒ 126 Health Systems in Transition care.ƒTheƒrecentlyƒimplementedƒinformationƒsystemƒpreventsƒpatientsƒcir- cumventingƒprimaryƒcare.ƒHowever,ƒsomeƒpatientsƒareƒstillƒusingƒemergencyƒ departmentsƒtoƒaccessƒspecializedƒservicesƒdirectly,ƒalthoughƒthereƒisƒnoƒ publishedƒevidenceƒfor this. Inƒtheƒcaseƒofƒaƒsuddenƒthreatƒtoƒtheirƒhealthƒorƒlife,ƒpatientsƒcanƒalsoƒ accessƒmedicalƒemergencyƒservices,ƒprovidedƒinƒprimaryƒcareƒcentresƒorƒ hospitalƒemergency departments. Patientƒpathwaysƒareƒtheƒsameƒacrossƒtheƒwholeƒcountryƒ(Fig.ƒ5.2).ƒ A typicalƒpatientƒpathwayƒisƒdescribedƒinƒBoxƒ5.2. FIGURE 5.2 Patient pathway in Serbia GP/Paediatrician Emergency department Outpatient specialist Admission to hospital Tertiary care institution Gynaecologist Pharmacy Team of primary health care centres Tertiary care Secondary care Primary care Patient Source: Authors 127Serbia BOX 5.2 Patient pathway for services covered by the National Health Insurance A woman in need of a hip replacement due to arthritis would take the following steps: • After a visit to the GP with whom she is registered, the GP refers her to the orthopaedic department of an outpatient hospital. The co-payment for the visit to the GP is 50 dinars (approximately 0.40 euros), except for patients older than 65, or pertaining to certain vulnerable categories, defined by the regulations of the NHIF, which do not pay. • The patient has free access to the closest public hospital to where she lives; in case of emergency, she can be referred to any public hospital including a tertiary level hospital; her GP makes an appointment through the e-platform (Integrated Health Information System) (see section 2.6) and the patient obtains the exact date, time and institution for further treatment. • If she does not want to wait at all, she can choose to go to a private hospital for which she has to pay out-of-pocket as these services, unless in exceptional cases (for some diagnostics procedures where waiting lists are long in public sector), are not covered by the NHIF. Currently, only a handful of patients would choose this option. • Her GP prescribes any necessary medication; for prescribing certain medicines, the GP needs to obtain a specialist’s report. • After referral, the patient may have to wait for 1 month or more for an outpatient hospital appointment to be examined by a specialist. Depending on the required service, waiting times can vary from 1 day to 3 months. • After this, she will have to wait for inpatient admission and surgery. Waiting lists are publicly available, and waiting times are up to 2 years. However, if the health condition significantly deteriorates, the operation could be rescheduled for an earlier date. For the hospital stay, she would have to pay a fixed co-payment of 50 dinars per day (approximately 0.40 euros) and a co-insurance of 5% of the cost of the implant (the ceiling for payment is set to 30 000 dinars, approximately 250 euros); if the patient were 65 years or older or belonging to certain defined vulnerable groups, she would not have to pay any co-payment. • Following surgery and primary rehabilitation at the hospital, the patient goes home, or to a specialist hospital for rehabilitation (or long-term care). Her GP receives her discharge summary from the hospital and is responsible for further follow-up, such as referral to a physiotherapist or for hospital rehabilitation (a co-payment of 50 dinars (0.40 euros) per day will apply for these services under the NHIF scheme). 128 Health Systems in Transition 5.3  Primary care Healthƒcareƒatƒtheƒprimaryƒlevelƒisƒprovidedƒbyƒprimaryƒcareƒcentres,ƒwhichƒ coverƒtheƒterritoryƒofƒoneƒorƒmoreƒmunicipalitiesƒorƒtowns.ƒPrimaryƒcareƒ centresƒmayƒbeƒrelativelyƒlargeƒstructures,ƒincludingƒseveralƒattachedƒhealthƒ centres,ƒpharmaciesƒandƒinstitutes.ƒAmbulatoriesƒareƒstaffedƒaccordingƒtoƒtheƒ sizeƒandƒneedsƒofƒtheƒpopulationƒtheyƒserve,ƒvaryingƒfromƒseveralƒfull-timeƒ teamsƒofƒdoctorsƒandƒnurses,ƒdentistsƒandƒpharmacistsƒworkingƒinƒshiftsƒtoƒ oneƒorƒtwoƒweeklyƒdoctorƒvisitsƒinƒremoteƒambulatories.ƒAccordingƒtoƒofficialƒ normsƒ(thatƒis,ƒrecommendations),ƒcitizensƒshouldƒhaveƒaccessƒtoƒaƒprimaryƒ careƒcentreƒorƒambulatoryƒwithinƒaƒ15-minuteƒtravel distance. Accordingƒtoƒtheƒ2019ƒHealthƒCareƒLaw,ƒaƒprimaryƒcareƒcentreƒpro- videsƒminimumƒpreventiveƒhealthƒcareƒtoƒallƒcategoriesƒofƒtheƒpopulation,ƒ emergencyƒcare,ƒgeneralƒmedicine,ƒhealthƒcareƒforƒwomenƒandƒchildren,ƒ aƒdomiciliaryƒcareƒservice,ƒasƒwellƒasƒlaboratoryƒandƒotherƒdiagnostics.ƒ Primaryƒcareƒcentresƒalsoƒprovideƒpreventionƒandƒtreatmentƒforƒdentalƒcare,ƒ healthƒcareƒofƒemployees,ƒoccupationalƒmedicineƒandƒphysicalƒmedicine,ƒandƒ rehabilitation.ƒThisƒisƒonlyƒtheƒcaseƒifƒaƒcertainƒhealthƒcareƒactivityƒisƒnotƒ organizedƒinƒanotherƒfacilityƒinƒtheƒterritoryƒthatƒtheƒprimaryƒcareƒcentreƒ covers.ƒAƒprimaryƒcareƒcentreƒalsoƒprovidesƒambulanceƒtransportƒifƒthatƒ serviceƒisƒnotƒorganizedƒinƒaƒhospitalƒorƒinƒanotherƒhealthƒcareƒfacility;ƒalso,ƒ primaryƒcareƒcentresƒengageƒinƒpharmaceuticalƒhealthƒcareƒactivities.ƒIfƒaƒ municipalityƒhasƒaƒprimaryƒcareƒcentreƒandƒaƒgeneralƒhospitalƒthatƒareƒstateƒ owned,ƒtheƒlaboratory,ƒradiologicalƒexaminations,ƒandƒotherƒdiagnosticsƒmayƒ beƒorganizedƒonlyƒwithinƒoneƒhealthƒcare facility. Aƒprimaryƒcareƒcentre,ƒdependingƒonƒtheƒnumberƒofƒcitizensƒinƒaƒmunici- palityƒasƒwellƒasƒonƒtheirƒhealthƒneedsƒ(e.g.ƒdistanceƒtoƒtheƒnearestƒgeneralƒ hospital,ƒand/orƒexistenceƒofƒotherƒhealthƒcareƒfacilitiesƒinƒtheƒmunicipality),ƒ • If she needs home care after hospital treatment or rehabilitation (such as home nursing) and/or home assistance, it will be prescribed by the hospital (and approved by her GP) and provided. • A follow-up hospital visit is likely to take place, but it will only be free of charge if she obtains a GP referral. 129Serbia mayƒalsoƒengageƒinƒsomeƒotherƒspecialistƒandƒconsultingƒactivityƒ(internalƒ medicine,ƒophthalmology,ƒotorhinolaryngology,ƒpsychiatry,ƒsocialƒmedicineƒ withƒinformatics),ƒwhichƒisƒnotƒrelatedƒtoƒhospitalƒtreatment.ƒInƒsomeƒcases,ƒ inƒterritoriesƒwithƒspecificƒneedsƒwhereƒtransportƒandƒgeographicalƒcondi- tionsƒjustifyƒit,ƒmaternityƒservicesƒandƒinpatientƒclinicsƒforƒdiagnosticsƒandƒ treatmentƒmayƒbeƒorganizedƒinƒaƒprimaryƒcare centre. Aƒprimaryƒhealthƒcareƒcentreƒisƒbasedƒonƒtheƒselectedƒdoctorƒorƒ“chosenƒ doctor”,ƒwhichƒrequiresƒpeopleƒtoƒregisterƒwithƒaƒphysicianƒofƒtheirƒchoice.ƒ Patientsƒshouldƒfirstƒvisitƒtheirƒ“chosenƒdoctor”ƒbeforeƒtheyƒcanƒseeƒaƒmedicalƒ specialistƒ(byƒreferral).ƒTheƒ“chosenƒdoctor”ƒcanƒbe:ƒaƒdoctorƒofƒmedicineƒ orƒaƒdoctorƒofƒmedicineƒwhoƒisƒaƒspecialistƒinƒgeneralƒmedicineƒ(GP),ƒorƒaƒ specialistƒinƒoccupationalƒmedicine;ƒaƒdoctorƒofƒmedicineƒwhoƒisƒaƒspecialistƒ inƒpaediatrics;ƒaƒdoctorƒofƒmedicineƒwhoƒisƒaƒspecialistƒinƒgynaecology;ƒorƒ aƒdoctorƒofƒdentalƒmedicine.ƒTheƒ“chosenƒdoctor”ƒpracticesƒhealthƒcareƒinƒaƒ teamƒwithƒhealthƒcareƒpractitionersƒofƒadequateƒmedicalƒqualifications.ƒTheƒ “chosenƒdoctor”ƒmayƒalsoƒbeƒaƒdoctorƒofƒmedicineƒofƒsomeƒotherƒspecialty,ƒ underƒtheƒconditionsƒspecifiedƒbyƒtheƒ2019ƒHealthƒInsuranceƒLaw.ƒTheƒ “chosenƒphysician”ƒisƒobligedƒto:ƒorganizeƒandƒimplementƒmeasuresƒforƒtheƒ preservationƒandƒimprovementƒofƒtheƒhealthƒofƒindividualsƒandƒfamilies;ƒworkƒ onƒdetectionƒandƒcontrolƒofƒtheƒfactorsƒofƒriskƒforƒonsetƒofƒdiseases;ƒadministerƒ diagnosticsƒandƒtimelyƒtreatmentƒofƒpatients;ƒprovideƒemergencyƒcare;ƒreferƒ patientsƒtoƒtheƒrelevantƒhealthƒcareƒfacilityƒsubjectƒtoƒmedicalƒindicationsƒorƒ toƒaƒdoctorƒspecialistƒandƒshallƒharmonizeƒtheƒopinionsƒandƒproposalsƒforƒ theƒcontinuationƒofƒtreatmentƒofƒtheƒpatient;ƒprovideƒhomeƒtreatment,ƒhealthƒ care,ƒandƒpalliativeƒcare,ƒasƒwellƒasƒtreatmentƒofƒpatientsƒwhoƒdoƒnotƒrequireƒ hospitalƒtreatment;ƒprescribeƒdrugsƒandƒmedicalƒdevices;ƒprovideƒhealthƒcareƒ inƒtheƒareaƒofƒmental health. Healthƒinstitutionsƒareƒobligedƒtoƒdevelopƒannualƒplansƒforƒinternalƒ professionalƒmonitoring.ƒOneƒthirdƒofƒprimaryƒcareƒcentresƒareƒinvolvedƒinƒ externalƒmonitoringƒ(byƒexpertƒcommissionsƒofƒtheƒMinistryƒofƒHealth).ƒTheƒ SerbianƒMedicalƒSocietyƒhasƒdevelopedƒskillsƒtestingƒonƒanƒexperimentalƒ basis,ƒwhichƒhasƒalsoƒbeenƒusedƒtoƒidentifyƒtheƒeducationalƒneedsƒofƒphysi- ciansƒinƒprimaryƒcareƒcentres.ƒFurthermore,ƒthereƒareƒregularƒchecksƒofƒ medicalƒdocumentation.ƒInƒcaseƒofƒirregularitiesƒorƒcomplaints,ƒtheƒHealthƒ Inspectorateƒcanƒapplyƒexternalƒcontrol mechanisms. 130 Health Systems in Transition 5.4  Specialized care/inpatient care 5.4.1 Specialized ambulatory care Specialistƒandƒconsultingƒactivitiesƒatƒtheƒsecondaryƒlevelƒincludeƒmoreƒ complexƒmeasuresƒandƒproceduresƒofƒdetectionƒofƒdiseasesƒandƒinjuriesƒasƒ wellƒasƒtreatmentƒandƒrehabilitationƒofƒtheƒdiseasedƒandƒinjured.ƒHospitalƒ healthƒcareƒactivitiesƒincludeƒplacementƒinƒhospitals,ƒdiagnostics,ƒtreatmentƒ andƒrehabilitation,ƒandƒpharmaceuticalƒprovisionƒinƒtheƒhospital pharmacy. Healthƒcareƒactivitiesƒatƒtheƒtertiaryƒlevelƒincludeƒprovisionƒofƒtheƒmostƒ complexƒformsƒofƒhealthƒcare:ƒspecialist,ƒconsulting,ƒandƒhospitalƒhealthƒcareƒ asƒwellƒasƒscientific,ƒresearch,ƒandƒeducational activities. Theƒ2019ƒHealthƒCareƒLawƒregulatesƒallƒactivitiesƒwithinƒtheƒframeworkƒ ofƒsecondaryƒandƒtertiary care. SECONDARY HEALTH CARE SERVICES UnderƒtheƒHealthƒCareƒLaw,ƒtheƒhospitalƒisƒengagedƒinƒhealthƒcareƒactivitiesƒ atƒtheƒsecondaryƒlevel,ƒasƒaƒcontinuationƒofƒdiagnostics,ƒtreatmentƒandƒreha- bilitationƒinƒanƒoutpatientƒdepartment,ƒthatƒis,ƒwhenƒdueƒtoƒtheƒcomplexityƒ andƒseriousnessƒofƒaƒdisease,ƒspecialƒconditionsƒareƒrequiredƒwithƒrespectƒtoƒ staff,ƒequipment,ƒaccommodationƒand drugs. Aƒsecondaryƒhospitalƒalsoƒcooperatesƒwithƒtheƒoutpatientƒdepartmentƒofƒ theƒhealthƒcentreƒandƒprovidesƒitƒwithƒprofessionalƒassistance.ƒAccordingƒtoƒ theƒplanƒofƒtheƒnetworkƒofƒhealthƒinstitutionsƒ(OfficialƒGazette,ƒ2006b),ƒtheƒ dayƒhospital,ƒasƒaƒspecialƒorganizationalƒunitƒwithinƒtheƒhospital’sƒpolyclinic,ƒ isƒorganizedƒtoƒperformƒdiagnostic,ƒtherapeuticƒandƒrehabilitationƒservicesƒ forƒoutpatientsƒinƒtheƒfollowingƒareas:ƒnephrologyƒ(haemodialysisƒandƒperi- tonealƒdialysis)ƒandƒotherƒbranchesƒofƒinternalƒmedicineƒ(primarilyƒforƒtheƒ applicationƒofƒparenteralƒandƒinhalationƒtherapy);ƒperformanceƒofƒsurgicalƒ interventionsƒandƒoperationsƒofƒdayƒsurgery;ƒandƒpsychiatryƒ(protectionƒofƒ mentalƒhealthƒforƒtheƒapplicationƒofƒcombinedƒmeasuresƒofƒpsychotherapy,ƒ sociotherapy,ƒoccupationalƒandƒworkƒtherapyƒandƒpsychosocialƒsupportƒforƒ patientsƒandƒmembersƒofƒtheirƒfamilies).ƒ Aƒhospitalƒhasƒtoƒorganizeƒitsƒworkƒinƒsuchƒaƒwayƒthatƒtheƒmajorityƒofƒ patientsƒareƒtestedƒandƒtreatedƒbyƒtheƒpolyclinicalƒserviceƒandƒinpatientƒtreat- mentƒisƒprovidedƒonlyƒwhenƒnecessary.ƒAƒhospitalƒmayƒhave,ƒorƒorganize,ƒ specialƒorganizationalƒunitsƒforƒextendedƒhospitalƒcareƒ(geriatrics),ƒpalliativeƒ 131Serbia careƒofƒpeopleƒinƒtheƒterminalƒstagesƒofƒdisease,ƒasƒwellƒasƒforƒtreatmentƒofƒ patientsƒinƒtheƒframeworkƒofƒtheƒdayƒhospital.ƒAƒhospitalƒmayƒbeƒaƒgeneralƒ and/orƒaƒspecialty hospital. Aƒgeneralƒhospitalƒprovidesƒhealthƒcareƒtoƒpersonsƒofƒallƒagesƒsufferingƒ fromƒdifferentƒkindsƒofƒdiseases.ƒState-ownedƒgeneralƒhospitalsƒareƒfoundedƒ forƒtheƒterritoryƒofƒoneƒorƒmoreƒmunicipalities.ƒAsƒaƒminimum,ƒaƒgeneralƒ hospitalƒmustƒhaveƒorganizedƒservices for: ƒƒ ƒadmittanceƒandƒmanagementƒofƒemergency states; ƒƒ ƒengagingƒinƒtheƒspecialistƒandƒconsultingƒandƒinpatientƒhealthƒ careƒactivityƒ inƒinternalƒmedicine,ƒpaediatrics,ƒgynaecologyƒandƒ obstetrics,ƒandƒgeneral surgery; ƒƒ ƒlaboratory,ƒ X-ray,ƒ andƒ otherƒ diagnosticsƒ inƒ accordanceƒ withƒ its activity; ƒƒ ƒanaesthesiologyƒwith resuscitation; ƒƒ ƒoutpatientƒunitƒfor rehabilitation; ƒƒ ƒpharmaceuticalƒhealthƒcareƒactivityƒthroughƒtheƒhospital pharmacy. Aƒgeneralƒhospitalƒalsoƒprovidesƒeitherƒonƒitsƒownƒorƒthroughƒanotherƒ healthƒcare facility: ƒƒ ƒambulanceƒtransportƒforƒpatients’ƒreferralƒtoƒtheƒtertiary level; ƒƒ ƒsupplyƒwithƒbloodƒandƒproductsƒproducedƒfrom blood; ƒƒ ƒserviceƒforƒpathological anatomy. Aƒgeneralƒhospitalƒmayƒalsoƒbeƒengagedƒinƒspecialistƒandƒconsultingƒ activitiesƒfromƒotherƒbranchesƒofƒmedicine.ƒAƒgeneralƒhospitalƒthatƒhasƒbeenƒ foundedƒforƒtheƒterritoryƒofƒseveralƒmunicipalities,ƒasƒwellƒasƒaƒhospitalƒatƒtheƒ seatƒofƒaƒcounty,ƒmayƒalsoƒengageƒinƒhospital-basedƒhealthƒcareƒactivitiesƒofƒ otherƒbranchesƒof medicine. Aƒspecialtyƒhospitalƒprovidesƒhealthƒcareƒtoƒcertainƒageƒgroups,ƒorƒtoƒ thoseƒsufferingƒfromƒcertainƒdiseases.ƒAƒspecialtyƒhospitalƒisƒengagedƒinƒ specialized,ƒconsulting,ƒandƒinpatientƒhealthƒcareƒinƒtheƒfieldƒforƒwhichƒitƒ hasƒbeenƒfoundedƒincludingƒlaboratoryƒandƒotherƒdiagnostics,ƒasƒwellƒasƒ theƒpharmaceuticalƒexpertiseƒthroughƒtheƒhospitalƒpharmacy.ƒAƒspecialtyƒ hospital,ƒinƒaccordanceƒwithƒtheƒactivityƒitƒisƒengagedƒin,ƒmustƒalsoƒprovideƒ ambulanceƒtransportƒforƒpatients’ƒreferralƒtoƒtheƒtertiaryƒlevel,ƒsupplyƒofƒbloodƒ 132 Health Systems in Transition andƒproductsƒproducedƒfromƒbloodƒandƒservicesƒforƒpathologicalƒanatomyƒtheƒ followingƒservices,ƒeitherƒonƒitsƒownƒorƒthroughƒanotherƒhealthƒcare facility. TERTIARY HEALTH CARE SERVICE Whenƒtheƒhealthƒproblemƒexceedsƒtheƒtechnicalƒcapacityƒofƒtheƒsecondaryƒ hospitalƒorƒexpertƒopinionƒisƒneeded,ƒtheƒpatientƒisƒreferredƒtoƒtheƒtertiaryƒ levelƒofƒcare.ƒTertiaryƒcareƒisƒprovidedƒatƒclinics,ƒinstitutes,ƒclinicalƒhospitalsƒ andƒclinical centres. Aƒclinicƒisƒaƒhealthƒcareƒfacilityƒthatƒisƒengagedƒinƒhighlyƒspecialized,ƒ consultingƒandƒinpatientƒcareƒfromƒaƒcertainƒbranchƒofƒmedicineƒor dentistry. Anƒinstituteƒprovidesƒhighlyƒspecializedƒspecialist,ƒconsulting,ƒandƒ inpatientƒcare,ƒorƒonlyƒhighlyƒspecializedƒconsultingƒcareƒinƒoneƒofƒseveralƒ branchesƒofƒmedicineƒor dentistry. Aƒclinicalƒhospitalƒisƒaƒhealthƒcareƒfacilityƒthatƒprovidesƒhighlyƒspecial- izedƒconsultingƒandƒinpatientƒcareƒatƒtheƒtertiaryƒlevelƒinƒoneƒorƒseveralƒ branchesƒofƒmedicineƒandƒhasƒtoƒmeetƒtheƒrequirementsƒspecifiedƒinƒtheƒ 2019ƒHealthƒCare Law. Aƒclinicalƒcentreƒisƒaƒhealthƒcareƒfacilityƒthatƒunifiesƒtheƒactivitiesƒofƒthreeƒ orƒseveralƒclinicsƒinƒsuchƒaƒwayƒthatƒitƒleadsƒaƒfunctionalƒunity,ƒorganizedƒandƒ capableƒtoƒsuccessfullyƒadministerƒtheƒaffairsƒandƒcarryƒoutƒtasksƒrelatedƒto:ƒ engagingƒinƒhighlyƒspecialized,ƒconsulting,ƒandƒinpatientƒcare;ƒeducationalƒ andƒteachingƒactivities;ƒscientificƒandƒresearchƒactivities.ƒAƒclinicalƒcentreƒ providesƒspecializedƒpolyclinicƒandƒhospitalƒhealthƒcareƒactivityƒinƒseveralƒ branchesƒofƒmedicine,ƒand/orƒareasƒofƒhealth care. Clinics,ƒinstitutes,ƒclinicalƒhospitalsƒandƒclinicalƒcentresƒmayƒbeƒfoundedƒ onlyƒatƒaƒuniversityƒwithƒaƒmedicalƒfaculty.ƒState-ownedƒclinics,ƒinstitutes,ƒ clinicalƒhospitals,ƒandƒclinicalƒcentres,ƒinƒlocationsƒwhereƒthereƒisƒnoƒgeneralƒ hospital,ƒareƒalsoƒtheƒactivityƒofƒaƒgeneralƒhospitalƒforƒtheƒterritoryƒforƒwhichƒ theyƒhaveƒbeen founded. 5.4.2 Day care Dayƒcareƒisƒdefinedƒasƒpartƒofƒtheƒhealthƒsystemƒthatƒfunctionsƒwithinƒanƒ existingƒhealthƒcareƒinstitutionƒwithƒspeciallyƒdesignedƒbedƒplacesƒorƒasƒanƒ independentƒinstitution,ƒwithƒtheƒpatientƒstayingƒforƒaƒperiodƒofƒlessƒthanƒ 133Serbia 24ƒhours.ƒTheƒmostƒcommonƒareasƒwereƒdayƒcareƒisƒprovidedƒareƒinternalƒ medicine,ƒpsychiatry,ƒsurgery,ƒgynaecology,ƒphysicalƒmedicine,ƒrehabili- tationƒandƒchemotherapy.ƒTheƒworkingƒhoursƒofƒdayƒcareƒhospitalsƒareƒ usuallyƒ5ƒdaysƒaƒweek.ƒManyƒdayƒcareƒinstitutionsƒhaveƒaƒproblemƒwithƒ inadequate equipment. Accordingƒtoƒtheƒavailableƒdata,ƒtheƒnumberƒofƒpatientsƒdischargedƒfromƒ dayƒcareƒinƒ2018ƒwasƒ197 730,ƒcomparedƒwithƒ585 009ƒdischargedƒhospitalƒ patientsƒ(IPHƒBatut,ƒ2018g).ƒHowever,ƒdataƒaboutƒconsultationsƒprovidedƒ inƒdayƒcareƒandƒduringƒhospitalizationsƒareƒnot available. BOX 5.3 What do patients think of the care they receive? Data from the latest Serbian National Health Survey conducted in 2013 showed that, in total, 53.8% of citizens were satisfied (44.5% satisfied and 9.3% very satisfied) with public health care services, while 64.6% were satisfied (49.8% satisfied and 14.8% very satisfied) with private health care services. Lower educated persons, the poorest ones, as well as the residents of rural settlements were the most satisfied with state health care services, while the most educated, the richest and urban residents were the least satisfied. Regarding the satisfaction with private health care, the most satisfied were residents of Belgrade, the richest and more educated persons (Ministry of Health, 2014). 5.5  Urgent and emergency care Emergencyƒcareƒisƒdefinedƒinƒtheƒ2005ƒHealthƒInsuranceƒLawƒasƒdirectƒ andƒpromptƒmedicalƒhelpƒprovidedƒtoƒavertƒdangerƒtoƒtheƒlifeƒofƒtheƒinsuredƒ party,ƒthatƒis,ƒirreversibleƒorƒseriousƒweaknessƒorƒdamageƒtoƒhealth,ƒasƒwellƒ asƒdeath.ƒEmergencyƒcareƒisƒdefinedƒasƒmedicalƒcareƒwhichƒisƒrenderedƒ withinƒ12ƒhoursƒofƒtheƒmomentƒofƒadmissionƒtoƒtheƒhealthƒinstitution.ƒTheƒ 2017ƒRulebookƒonƒtheƒContentƒandƒScopeƒofƒtheƒRightƒtoƒHealthƒCareƒforƒ CompulsoryƒHealthƒInsuranceƒandƒCo-Paymentƒ(OfficialƒGazette,ƒ2017c)ƒ furtherƒregulatesƒemergencyƒcareƒtoƒbeƒmedicalƒcareƒprovidedƒatƒtheƒsiteƒofƒ emergency,ƒhealthƒcareƒinstitutionƒorƒprivateƒpractice,ƒtransportƒtoƒtheƒnearestƒ healthƒcareƒinstitutionƒequippedƒtoƒprovideƒtheƒnecessaryƒhealthƒcare.ƒAtƒtheƒ placeƒofƒinjuryƒorƒillness,ƒhealthƒcareƒinƒemergencyƒmedicalƒcasesƒencom- passes:ƒfirstƒaid,ƒphysicalƒexamination,ƒmedicalƒtreatmentƒandƒdrugƒtherapyƒ 134 Health Systems in Transition asƒwellƒasƒtransport.ƒInƒhealthƒinstitutions,ƒhealthƒcareƒinƒemergencyƒmedicalƒ casesƒincludes:ƒfirstƒaid,ƒphysicalƒexamination,ƒtheƒnecessaryƒdiagnosticƒandƒ laboratoryƒexaminations,ƒmedicalƒtreatmentƒandƒappropriateƒcare,ƒasƒwellƒ asƒtherapy treatment. TheƒNetworkƒPlanƒforƒhealthƒinstitutionsƒregulatesƒemergencyƒcare,ƒ organizingƒitƒaccordingƒtoƒtwoƒfunctionallyƒlinkedƒsub-systems:ƒprehospitalƒ emergencyƒcareƒandƒinpatientƒemergency care. 5.5.1 Prehospital emergency care Prehospitalƒemergencyƒcareƒisƒtheƒcontinuousƒactivityƒofƒhealthƒinstitutionsƒ atƒtheƒprimaryƒcareƒlevel.ƒItƒencompassesƒtheƒprovisionƒofƒmedicalƒcareƒatƒtheƒ pointƒofƒinjury/illnessƒandƒinƒtheƒhealthƒinstitution,ƒtheƒmedicalƒtransportƒ ofƒseverelyƒillƒandƒinjuredƒpeopleƒtoƒmedicalƒinstitutionsƒandƒtheƒcontinuousƒ monitoringƒofƒhealthƒandƒtheƒprovisionƒofƒnecessaryƒhelpƒduring transport. Essentially,ƒitƒisƒpartƒofƒtheƒregularƒactivityƒofƒtheƒphysicianƒandƒtheirƒ associatesƒbutƒatƒnight,ƒonƒSundaysƒandƒduringƒstateƒholidays,ƒprehospitalƒ emergencyƒcareƒformsƒpartƒofƒtheƒworkƒofƒtheƒphysicianƒonƒcall.ƒInƒmunici- palitiesƒwithƒoverƒ25 000ƒinhabitants,ƒprimaryƒcareƒcentresƒcanƒestablishƒ emergencyƒcareƒunitsƒforƒcontinuousƒadmissionsƒandƒemergencyƒcareƒ(Officialƒ Gazette,ƒ2006b).ƒPrehospitalƒemergencyƒcareƒisƒalsoƒprovidedƒthroughƒinsti- tutesƒforƒemergencyƒcareƒinƒBelgrade,ƒNis,ƒKragujevac,ƒandƒNovi Sad. 5.5.2 Inpatient emergency care Inpatientƒemergencyƒcareƒisƒprovidedƒbyƒexpertƒteamsƒofƒtheƒaccidentƒandƒ emergencyƒunitsƒofƒgeneralƒhospitals,ƒclinics,ƒinstitutes,ƒclinicalƒhospitalsƒandƒ clinicalƒcentresƒinƒtheƒcaseƒofƒadmissionƒforƒhospitalƒtreatment.ƒEmergencyƒ careƒisƒfullyƒcoveredƒbyƒtheƒNHIFƒforƒall insured. AnalysesƒconductedƒbyƒtheƒIPHƒBatutƒshowedƒthatƒinƒ2015,ƒthereƒwereƒ 1 612 013ƒexaminationsƒinƒemergencyƒcareƒunitsƒinƒprimaryƒcareƒcentres,ƒ outƒofƒwhichƒ301 272ƒwereƒatƒtheƒpointƒofƒinjuryƒorƒdisease,ƒandƒ356 093ƒ examinationsƒinƒtheƒinstitutesƒforƒemergencyƒcare,ƒoutƒofƒwhichƒ179 558ƒwereƒ performedƒatƒtheƒpointƒofƒinjuryƒorƒdiseaseƒ(IPHƒBatut,ƒ2015). Inƒ2013,ƒtheƒMinistryƒofƒHealthƒ(2013)ƒpublishedƒnationalƒguidelinesƒ forƒprehospitalƒemergency care. 135Serbia TheƒqualityƒofƒemergencyƒcareƒisƒmonitoredƒbyƒIPHƒBatutƒaccordingƒtoƒ theƒRulebookƒonƒHealthƒCareƒQualityƒIndicatorsƒ(OfficialƒGazette,ƒ2010d).ƒ Theƒanalysisƒshowedƒthatƒinƒ2015,ƒthereƒwereƒ88 238ƒcallsƒforƒlife-threateningƒ situationsƒ(16.87%ƒofƒallƒcallsƒtoƒemergencyƒcare).ƒMeanƒactivationƒtimeƒforƒ life-threateningƒsituationsƒ(timeƒfromƒcallƒreceivedƒtoƒnotified/activatedƒ emergencyƒcareƒteam)ƒwasƒ1.11ƒminutes,ƒreactionƒtimeƒ(timeƒfromƒemergencyƒ careƒteamƒnotified/activatedƒtoƒarriveƒatƒpatient)ƒwasƒ8.02ƒminutes,ƒandƒ prehospitalƒtimeƒintervalƒ(timeƒintervalƒfromƒarrivedƒatƒpatientƒtoƒuntilƒleftƒ sceneƒorƒpatientƒdelivered)ƒwasƒ20.50ƒminutes.ƒTheƒresponseƒtimeƒintervalƒ (sumƒofƒtheƒactivationƒandƒreactionƒtime)ƒwasƒ9.13ƒminutes,ƒinƒlineƒtoƒtheƒ EU,ƒwhereƒforƒmostƒcountriesƒitƒisƒ15ƒminutesƒorƒlessƒ(IPHƒBatut,ƒ2015;ƒBosƒ etƒal.,ƒ2015).ƒTheƒtotalƒnumberƒofƒcardiacƒarrestƒcasesƒtreatedƒbyƒemergencyƒ careƒteamsƒatƒtheƒsiteƒwasƒ6 281ƒ(5 144ƒbeforeƒtheƒemergencyƒcareƒteamƒ arrived).ƒTheƒpercentageƒofƒsuccessfulƒcardiopulmonaryƒresuscitationƒ(CPR)ƒ proceduresƒinƒcardiacƒarrestƒoccurredƒbeforeƒtheƒemergencyƒcareƒteamƒarrivedƒ wasƒ18.85%,ƒandƒ39.29%ƒifƒcardiacƒarrestƒoccurredƒinƒtheƒpresenceƒofƒtheƒ emergencyƒcareƒteamƒ(IPHƒBatut,ƒ2016c).ƒTheƒhighƒpercentageƒofƒcardiacƒ arrestƒoccurringƒbeforeƒtheƒarrivalƒofƒemergencyƒcareƒteamsƒindicatesƒtheƒ needƒforƒorganizedƒtrainingƒinƒCPRƒforƒtheƒgeneralƒpopulationƒandƒespeciallyƒ relativesƒofƒhigh-risk patients. Forƒhospitalƒemergencyƒcare,ƒthreeƒindicatorsƒwereƒanalysed:ƒestablishedƒ writtenƒprotocolsƒforƒsevereƒmultipleƒtraumaƒcare,ƒmeanƒwaitingƒtimesƒinƒ emergencyƒcareƒunitƒofƒtheƒhospitalƒandƒpercentageƒofƒsuccessfulƒCPRsƒ(IPHƒ Batut,ƒ2016c).ƒInƒ2015,ƒonlyƒ27ƒhealthƒcareƒinstitutionsƒhadƒwrittenƒprotocolsƒ forƒsevereƒmultipleƒtrauma,ƒwhichƒisƒnotƒsatisfactory,ƒespeciallyƒasƒoutƒofƒallƒ theƒclinical–hospitalƒcentresƒandƒclinicalƒcentres,ƒonlyƒtheƒClinicalƒCentreƒ ofƒSerbiaƒhadƒestablishedƒa protocol. Meanƒwaitingƒtimesƒinƒemergencyƒcareƒunitsƒinƒhospitalsƒwasƒ11.7ƒ minutes.ƒTheƒpercentageƒofƒsuccessfulƒCPRƒwasƒ56.4%ƒinƒgeneralƒhospitals,ƒ 36%ƒinƒclinical–hospitalƒcentresƒandƒ44.1%ƒinƒclinicalƒcentres.ƒItƒhasƒbeenƒ notedƒthatƒtheƒpercentageƒofƒsuccessfulƒCPRsƒinƒsecondaryƒandƒtertiaryƒcareƒ institutionsƒisƒdecreasingƒ(IPHƒBatut,ƒ2016c). Emergencyƒcareƒisƒorganizedƒinƒsuchƒaƒwayƒthatƒitƒ isƒaccessibleƒtoƒ everyone,ƒincludingƒvulnerableƒgroupsƒofƒtheƒpopulation.ƒThereƒareƒnoƒ officialƒdataƒthatƒsomeƒgroupsƒofƒpeopleƒuseƒservicesƒmoreƒthanƒothers.ƒ Theƒproblemƒwithƒoverutilizationƒofƒemergencyƒcareƒunitsƒinƒhospitalsƒwasƒ noticed,ƒasƒaƒsignificantƒpercentageƒofƒpatientsƒaccessingƒemergencyƒunitsƒ 136 Health Systems in Transition wereƒnotƒemergencyƒcases.ƒCurrentƒproblemsƒareƒlackƒofƒresources:ƒhumanƒ resources,ƒadequateƒandƒmodernƒequipment,ƒandƒfinancialƒresources.ƒInƒ2017,ƒ aƒnewƒtriageƒsystemƒofƒemergencyƒcasesƒwasƒinitiatedƒinƒtheƒClinicalƒCentreƒ ofƒSerbiaƒbutƒitƒisƒstillƒnotƒfully implemented. 5.6  Pharmaceutical care Theƒkeyƒplayersƒinƒtheƒimplementationƒofƒpharmaceuticalƒpolicyƒareƒtheƒ MinistryƒofƒHealth,ƒtheƒNationalƒHealthƒInsuranceƒFundƒandƒtheƒMedicinesƒ andƒMedicalƒDevicesƒAgencyƒofƒSerbiaƒ(ALIMS). Inƒtheƒdomesticƒpharmaceuticalƒsector,ƒfourƒleadingƒmanufacturersƒ combinedƒ(Hemofarm,ƒPharmaƒSwiss,ƒGalenikaƒandƒActavis)ƒcoverƒ70%ƒofƒ theƒdomesticƒproductionƒofƒmedicines.ƒInƒ2016,ƒdomesticƒmanufacturersƒheldƒ 38%ƒofƒtheƒmarketƒshareƒbyƒfinancialƒvalueƒandƒ61%ƒbyƒvolumeƒ(Chamberƒofƒ CommerceƒandƒIndustryƒofƒSerbia,ƒ2017b).ƒPharmaceuticalƒpricesƒareƒunderƒ stateƒcontrolƒandƒareƒregulatedƒbyƒby-lawƒ(theƒ2015ƒDecreeƒonƒtheƒCriteriaƒ forƒtheƒFormationƒofƒPricesƒforƒDrugsƒforƒUseƒinƒHumanƒMedicine,ƒwhichƒ AreƒUnderƒaƒPrescriptionƒRegimen)ƒ(OfficialƒGazetteƒRSƒ86/2015). Pharmaceuticalsƒcanƒbeƒdistributedƒtoƒpatientsƒthroughƒpharmaciesƒasƒ wellƒasƒhospitalƒpharmaciesƒwhichƒoperateƒwithinƒhospitalsƒatƒsecondaryƒandƒ tertiaryƒlevelƒofƒcare.ƒAccordingƒtoƒtheƒDecreeƒonƒtheƒPlanƒofƒtheƒHealthƒ Institutions’ƒNetworkƒ(OfficialƒGazette,ƒ2006b),ƒpublicƒpharmaciesƒareƒestab- lishedƒtoƒcoverƒatƒleastƒ40 000ƒpopulation,ƒandƒpharmacyƒbranchesƒ(publicƒ institutions,ƒseparateƒfacilitiesƒbutƒpertainingƒtoƒaƒpharmacy)ƒcoverƒatƒleastƒ 10 000ƒpopulation.ƒAlongƒwithƒpublicƒpharmacies,ƒthereƒareƒaƒsignificantƒ numberƒofƒprivateƒpharmaciesƒwithƒtheirƒbranches,ƒbutƒtheirƒtotalƒnumberƒ isƒnotƒavailable.ƒPharmaceuticalsƒcoveredƒbyƒtheƒNHIFƒareƒdistributedƒbyƒ bothƒpublicƒandƒprivateƒpharmacies.ƒTheƒNHIFƒhasƒcontractsƒwithƒoverƒ 2 400ƒprivateƒpharmaciesƒ(thisƒnumberƒcomprisesƒpharmaciesƒandƒtheirƒ branches).ƒWhileƒtheƒnetworkƒofƒpharmaciesƒinƒtheƒcountryƒisƒsufficient,ƒ thereƒisƒaƒquestionƒofƒwhetherƒtheyƒareƒwellƒdistributedƒacrossƒtheƒterritory,ƒ asƒprivateƒpharmaciesƒtendƒtoƒbeƒmoreƒconcentratedƒinƒmoreƒaffluentƒurbanƒ areas.ƒAccordingƒtoƒtheƒChamberƒofƒCommerceƒandƒIndustryƒofƒSerbia,ƒtheƒ marketƒshareƒofƒprivateƒpharmaciesƒincreasedƒfromƒ41%ƒinƒ2012ƒtoƒ68%ƒinƒ 2016ƒ(ChamberƒofƒCommerceƒandƒIndustryƒofƒSerbia,ƒ2016). TheƒNHIFƒcoversƒpharmaceuticalsƒwhichƒareƒonƒtheƒDrugƒListƒ(withƒaƒ co-paymentƒofƒapproximatelyƒ0.40ƒeurosƒforƒpharmaceuticalsƒonƒtheƒPositiveƒ 137Serbia Listƒandƒ10–90%ƒforƒother).ƒTheƒDrugƒListƒisƒsetƒbyƒtheƒNHIFƒwithƒanƒ agreementƒfromƒtheƒgovernment.ƒCertainƒdefinedƒcategoriesƒofƒtheƒpopula- tionƒareƒexemptedƒfromƒco-paymentƒ(childrenƒandƒstudentsƒupƒtoƒtheƒageƒ ofƒ26;ƒwomenƒduringƒpregnancy,ƒlabourƒandƒ12ƒmonthsƒafterƒdelivery;ƒwarƒ invalids;ƒandƒblindƒandƒpermanentlyƒdisabledƒpersons). TheƒNHIFƒcoversƒonlyƒpharmaceuticalsƒprescribedƒbyƒphysiciansƒ workingƒinƒtheƒpublicƒhealthƒsystem;ƒhowever,ƒtheyƒcanƒbeƒobtainedƒinƒ publicƒandƒprivateƒpharmaciesƒwhichƒareƒcontractedƒbyƒthe NHIF. Physiciansƒcanƒprescribeƒmedicinesƒinƒprivateƒpractices,ƒwhichƒareƒtoƒbeƒ paidƒfullyƒbyƒtheƒpatient.ƒForƒacuteƒdiseases,ƒmedicalƒdoctorsƒcanƒprescribeƒ medicinesƒupƒtoƒ30ƒdays.ƒExceptionally,ƒforƒchronicƒconditions,ƒunderƒtheƒ conditionƒthatƒtreatmentƒhasƒnotƒchangedƒforƒ1ƒyearƒatƒleast,ƒmedicinesƒcanƒ beƒprescribedƒforƒupƒtoƒ60 days. TheƒMedicinesƒandƒMedicalƒDevicesƒAgencyƒofƒSerbiaƒisƒinƒchargeƒ ofƒoverseeingƒandƒmonitoringƒtheƒconsumptionƒofƒmedicinesƒandƒtheƒpro- motionƒofƒtheirƒrationalƒuse.ƒInƒorderƒtoƒcontrolƒhealthƒcareƒcosts,ƒnewƒ paymentƒmechanismsƒforƒphysiciansƒinƒprimaryƒcareƒwereƒintroducedƒinƒ 2013.ƒPhysiciansƒobtainƒaƒbasicƒsalaryƒandƒincentivesƒbasedƒonƒperform- ance.ƒTheƒcostƒofƒprescribedƒmedicinesƒisƒpartƒofƒtheƒperformanceƒcriteria.ƒ However,ƒtheƒincentiveƒisƒlow,ƒandƒtheƒtotalƒincentiveƒcannotƒexceedƒ8.08%ƒ ofƒtheƒsalaryƒ(NHIF,ƒ2013)ƒ(seeƒsectionƒ3.7). Consumptionƒofƒmedicinesƒhasƒincreasedƒfromƒ2010ƒand,ƒinƒ2015,ƒ reachedƒ1 609ƒDDDƒperƒ1 000ƒpopulationƒperƒdayƒ(ALIMS,ƒ2018).ƒInƒ2015,ƒ medicinesƒusedƒforƒcardiovascularƒdiseasesƒ(ATCƒgroupƒC)ƒhadƒtheƒhighestƒ shareƒinƒmedicinalƒconsumptionƒ(701.41ƒDDD/1 000ƒpopulationƒperƒdayƒ orƒ43.59%ƒofƒtotalƒconsumption).ƒThisƒisƒfollowedƒbyƒmedicinesƒusedƒforƒ bloodƒandƒbloodƒformingƒorgansƒ(ATCƒgroupƒB)ƒwithƒ18.07%ƒshareƒinƒtotalƒ consumptionƒ(290ƒDDD/1 000ƒpopulationƒperƒday).ƒOutƒofƒtotalƒconsump- tion,ƒmedicinesƒusedƒforƒtheƒnervousƒsystemƒ(ATCƒgroupƒN)ƒhadƒaƒshareƒ ofƒ11.52%ƒ(185.36ƒDDD/1 000ƒpopulationƒperƒday)ƒandƒmedicinesƒusedƒforƒ theƒalimentaryƒtractƒandƒmetabolismƒ(ATCƒgroupƒA)ƒhadƒ10.58%ƒshareƒ (170.22ƒDDD/1 000ƒpopulation/day).ƒAllƒotherƒgroupsƒhadƒaƒsignificantlyƒ lowerƒshareƒinƒmedicinalƒconsumptionƒ(ALIMS,ƒ2016). NHIFƒexpendituresƒforƒmedicinesƒareƒapproximatelyƒ30ƒeurosƒperƒ insuredƒperson.ƒAccordingƒtoƒavailableƒdata,ƒtheƒshareƒofƒcostsƒforƒprescribedƒ medicinesƒcoveredƒbyƒtheƒNHIFƒdecreasedƒfromƒ89.15%ƒinƒ2010ƒtoƒ81.5%ƒ inƒ2014ƒ(NHIF,ƒ2018b). 138 Health Systems in Transition 5.7  Rehabilitation/intermediate care Rehabilitationƒisƒorganizedƒatƒprimary,ƒsecondaryƒandƒtertiaryƒcareƒlevel.ƒAtƒ primaryƒcareƒlevel,ƒprimaryƒcareƒcentresƒprovideƒservicesƒinƒphysicalƒmedicineƒ andƒrehabilitationƒunlessƒthoseƒservicesƒareƒprovidedƒbyƒanotherƒspecializedƒ institutionƒsuchƒasƒaƒhospitalƒinƒtheƒterritoryƒcoveredƒbyƒtheƒprimaryƒhealthƒ care centre. Hospitalsƒprovideƒearlyƒrehabilitationƒduringƒhospitalƒtreatment,ƒasƒwellƒ asƒrehabilitationƒinƒdayƒcareƒandƒoutpatientƒdepartments.ƒAtƒtheƒsecondaryƒ level,ƒeachƒgeneralƒhospitalƒhasƒanƒoutpatientƒdepartmentƒforƒrehabilitation.ƒ Prolongedƒrehabilitationƒasƒcontinuationƒofƒtreatmentƒandƒrehabilitationƒ isƒdeliveredƒinƒhospitalsƒspecializedƒforƒrehabilitationƒofƒcertainƒdiseases/ injuriesƒinƒpatientsƒwhenƒfunctionalƒlimitationsƒcannotƒbeƒeffectivelyƒtreatedƒ inƒoutpatientƒcareƒorƒwithinƒhospitalƒtreatmentƒofƒtheƒdisease.ƒProlongedƒ rehabilitationƒisƒprovidedƒexclusivelyƒafterƒcompletionƒofƒearlyƒacuteƒreha- bilitationƒtreatmentƒinƒhospitalsƒforƒacute care. State-ownedƒhospitalsƒspecializedƒforƒrehabilitationƒhaveƒbeenƒestablishedƒ withƒaƒtotalƒofƒ3 800ƒbeds,ƒorƒ0.5ƒbedsƒperƒ1 000ƒpopulationƒinƒ20ƒspecializedƒ hospitalsƒandƒtwoƒinstitutesƒ(DecreeƒonƒtheƒPlanƒofƒtheƒHealthƒInstitutions’ƒ Network)ƒ(OfficialƒGazette,ƒ2006b). Inƒadditionƒtoƒtheƒabove-mentionedƒspecializedƒhospitals,ƒspecializedƒ rehabilitationƒisƒdeliveredƒinƒtertiaryƒhealthƒcareƒinstitutions:ƒclinicalƒcentres,ƒ clinical–hospitalƒcentres,ƒandƒinstitutes.ƒAnƒinstituteƒforƒpsychophysiologicalƒ disordersƒandƒspeechƒpathologyƒhasƒbeenƒestablishedƒforƒdetection,ƒtreat- mentƒandƒrehabilitationƒofƒpatientsƒwithƒdevelopmentalƒdisorders,ƒhearingƒ impairmentsƒinƒchildrenƒandƒyouth,ƒasƒwellƒasƒspeechƒpathologyƒofƒpatientsƒ inƒallƒages,ƒandƒvisionƒimpairmentƒofƒpreschool children. TheƒNHIFƒcoversƒcostsƒforƒmedicalƒrehabilitationƒinƒtheƒcaseƒofƒdiseaseƒ orƒinjuryƒinƒorderƒtoƒimproveƒorƒrestoreƒfunctionƒlostƒorƒimpairedƒasƒanƒ outcomeƒofƒacuteƒdiseaseƒorƒinjury,ƒaggravationƒofƒchronicƒdisease,ƒmedicalƒ intervention,ƒ congenitalƒ anomalyƒorƒdevelopmentalƒdisorder.ƒMedicalƒ rehabilitationƒcomprisesƒkinesiotherapyƒandƒallƒtypesƒofƒphysicalƒtherapy,ƒ occupationalƒtherapyƒandƒspeechƒandƒhearingƒtherapyƒasƒwellƒasƒcertainƒtypesƒ ofƒaidsƒincludingƒtrainingƒforƒimplementationƒofƒthe aid. 139Serbia 5.8  Long-term care Long-termƒcareƒforƒolderƒpeople,ƒpeopleƒwithƒphysicalƒdisabilities,ƒpeopleƒ withƒchronicƒdiseasesƒandƒpeopleƒwithƒlearningƒdisabilitiesƒisƒprovidedƒ throughƒtheƒhealthƒsystemƒandƒtheƒsocialƒcare system. Theƒhealthƒsystemƒprovidesƒhomeƒcareƒasƒwellƒasƒinpatientƒcareƒwithinƒ healthƒcareƒinstitutionsƒforƒolderƒpersons,ƒtheƒchronicallyƒill,ƒandƒpeopleƒ with disabilities. Homeƒvisitƒservicesƒofƒprimaryƒcareƒcentresƒshouldƒprovideƒatƒleastƒoneƒ homeƒvisitƒperƒyear.ƒHowever,ƒaƒstudyƒfromƒtheƒInstituteƒofƒPublicƒHealthƒ showedƒthatƒinƒ2015,ƒthereƒwereƒ0.22ƒvisitsƒperƒpersonƒagedƒ65ƒandƒabove.ƒ However,ƒtheƒnumberƒofƒhomeƒvisitsƒperƒolderƒpersonƒvariesƒsignificantlyƒ andƒinƒsomeƒprimaryƒhealthƒcentresƒisƒonlyƒ0.01ƒperƒolderƒperson.ƒThisƒsmallƒ numberƒofƒvisitsƒmayƒbeƒdueƒtoƒtheƒlackƒofƒpersonnelƒinƒpatronageƒservicesƒofƒ someƒprimaryƒcareƒcentresƒbutƒcouldƒalsoƒbeƒattributedƒtoƒtheƒpoorƒorganiza- tionƒandƒlackƒofƒclearƒproceduresƒandƒpracticeƒguidelinesƒ(IPHƒBatut,ƒ2016c). Regardingƒhomeƒvisitsƒtoƒchronicallyƒillƒpeople,ƒonlyƒ8%ƒwereƒcoveredƒ byƒhomeƒvisitsƒinƒ2015.ƒCoverageƒofƒdisabledƒpersonsƒwithƒhomeƒvisitsƒcouldƒ notƒbeƒcalculated,ƒasƒpreciseƒdataƒonƒtheƒnumberƒofƒpersonsƒwithƒdisabilitiesƒ areƒnotƒavailableƒ(IPHƒBatut,ƒ2016c). 5.8.1 Long-term inpatient care Prolongedƒhospitalƒstaysƒdueƒtoƒtypeƒofƒdiseaseƒandƒlevelƒofƒdisabilityƒofƒ hospitalizedƒpatientsƒupƒtoƒ30ƒdaysƒisƒdefinedƒasƒprolongedƒhospitalƒcare,ƒ andƒhospitalƒcareƒlongerƒthanƒ30ƒdaysƒisƒdefinedƒasƒlong-termƒcare.ƒForƒ prolongedƒandƒlong-termƒcareƒofƒpatientsƒwithƒtuberculosis,ƒnonspecificƒ pulmonaryƒdiseasesƒandƒotherƒchronicƒconditionsƒ(excludingƒmentalƒillnessƒ describedƒinƒsectionƒ5.11),ƒthereƒareƒ912ƒhospitalƒbedsƒinƒSerbia,ƒorƒ0.12ƒperƒ 1 000ƒpopulationƒ(DecreeƒonƒtheƒPlanƒofƒtheƒHealthƒInstitutions’ƒNetwork)ƒ (OfficialƒGazette,ƒ2006b). 140 Health Systems in Transition 5.8.2 Social care Withinƒtheƒsocialƒcareƒsystem,ƒservicesƒareƒprovidedƒforƒpersonsƒwithƒdisabili- ties,ƒchildrenƒandƒyouthƒwithƒdisabilities,ƒandƒforƒolderƒpeople.ƒLong-termƒ careƒservicesƒprovidedƒbyƒtheƒstate-ownedƒnetworkƒofƒsocialƒcareƒinstitutionsƒ include:ƒhelpƒatƒhome,ƒdayƒcareƒandƒcareƒwithinƒinstitutionsƒ(residentialƒcare). Thereƒareƒseveralƒinstitutionsƒprovidingƒdayƒcareƒforƒchildrenƒandƒyouthƒ withƒdisabilitiesƒandƒbehaviouralƒproblems.ƒAccordingƒtoƒtheƒ2011ƒSocialƒ CareƒLaw,ƒdayƒcareƒshouldƒbeƒorganizedƒbyƒlocalƒcommunities.ƒTherefore,ƒ community-ownedƒdayƒcareƒinstitutionsƒdependƒlargelyƒonƒtheƒabilityƒandƒ interestƒofƒlocalƒcommunitiesƒtoƒprovideƒthem.ƒOnƒtheƒotherƒhand,ƒseveralƒ dayƒcareƒinstitutionsƒforƒchildrenƒandƒyouthƒwithƒdisabilitiesƒhaveƒbeenƒestab- lishedƒbyƒprivateƒindividualsƒorƒnationalƒandƒinternationalƒNGOs.ƒResidentialƒ careƒisƒprovidedƒforƒchildrenƒandƒyouthƒwithƒdevelopmentalƒdisabilitiesƒinƒ18ƒ institutions.ƒOutƒofƒthese,ƒtwoƒprovideƒcareƒforƒadultsƒwithƒcommunicationƒ problemsƒasƒwell,ƒandƒinƒthreeƒinstitutions,ƒalongƒwithƒchildrenƒwithƒdevel- opmentalƒdisabilities,ƒcareƒisƒprovidedƒforƒadultsƒwithƒintellectualƒandƒmentalƒ disabilitiesƒ(inƒtwoƒfacilities,ƒchildrenƒandƒadultsƒareƒseparated)ƒ(Ministryƒofƒ Labour,ƒEmployment,ƒVeteranƒandƒSocialƒAffairs,ƒ2017). Thereƒ areƒ 16ƒ publiclyƒ ownedƒ institutionsƒ forƒ adultƒ personsƒwithƒ disabilities,ƒoutƒofƒwhichƒ13ƒareƒforƒadultsƒwithƒintellectualƒandƒmentalƒdis- abilities,ƒtwoƒforƒadultsƒwithƒphysicalƒdisabilitiesƒandƒoneƒforƒpersonsƒwithƒ sensory disabilities. 5.8.3 Care for older people Thereƒisƒaƒnetworkƒofƒ43ƒpubliclyƒownedƒinstitutionsƒprovidingƒcareƒforƒolderƒ peopleƒinƒnursingƒhomes.ƒSomeƒofƒthemƒprovideƒdayƒcareƒasƒwellƒasƒhomeƒ careƒforƒolderƒpeople.ƒTheyƒareƒsubsidizedƒandƒOOPƒpaymentsƒforƒclientsƒ dependƒonƒtheirƒfinancialƒstatus.ƒSomeƒlocalƒcommunitiesƒorganizeƒhelpƒatƒ homeƒforƒolderƒpeopleƒinƒtheirƒlocalƒcommunities.ƒTrainedƒprovidersƒsupportƒ olderƒpeopleƒ(sometimesƒalsoƒpersonsƒwithƒdisabilities)ƒinƒdailyƒactivitiesƒ (e.g.ƒprocurementƒandƒpreparationƒofƒfood,ƒmaintainingƒpersonalƒhygiene,ƒ helpƒwithƒhouseƒwork,ƒheatingƒandƒotherƒservices)ƒforƒ2–3ƒhoursƒperƒdayƒ3ƒ toƒ5ƒtimesƒper week. Nursingƒhomesƒalsoƒprovideƒresidentialƒcareƒforƒolderƒpeopleƒwithƒ differentƒlevelsƒofƒdisabilities.ƒEvenƒthoughƒservicesƒinƒpubliclyƒownedƒ 141Serbia gerontologyƒcentresƒareƒsubsidized,ƒfeesƒareƒrelativelyƒhigh,ƒandƒexceedƒtheƒ averageƒpension.ƒThereƒisƒalsoƒanƒincreasingƒnumberƒofƒprivatelyƒownedƒ nursing homes. Inƒpubliclyƒownedƒsocialƒcareƒinstitutions,ƒhealthƒcareƒisƒprovidedƒifƒ neededƒandƒisƒregulatedƒaccordingƒtoƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ 2019ƒHealthƒInsurance Law. TheƒMinisterƒofƒLabour,ƒEmployment,ƒVeteranƒandƒSocialƒAffairsƒintro- ducedƒlicensingƒforƒsocialƒcareƒprovidersƒinƒ2014,ƒwithƒtheƒaimƒtoƒimproveƒ andƒstandardizeƒtheƒqualityƒofƒsocialƒcare.ƒLicencesƒareƒobligatoryƒforƒpubliclyƒ andƒprivatelyƒowned institutions. 5.9  Services for informal carers InformalƒcareƒisƒwidespreadƒinƒSerbia.ƒTheƒbiggestƒshareƒofƒhomeƒcareƒisƒ providedƒbyƒinformalƒcarers,ƒalthoughƒnoƒofficialƒdataƒisƒavailableƒonƒtheƒ exactƒpercentage.ƒSimilarƒtoƒmostƒotherƒcountries,ƒinformalƒcaregiversƒareƒ usuallyƒfamilyƒmembers,ƒfriends,ƒorƒrelativesƒofƒtheƒcareƒrecipient.ƒWithinƒ informalƒcare,ƒmothersƒareƒusuallyƒseenƒasƒtheƒ“natural”ƒprimaryƒcaregiversƒ forƒchildren.ƒOthers,ƒsuchƒasƒgrandparents,ƒfathers,ƒandƒsiblings,ƒcanƒalsoƒ beƒinformalƒcaregivers.ƒInformalƒcareƒofƒolderƒpeopleƒisƒoftenƒundertakenƒbyƒ adultƒchildren,ƒtheirƒspouse,ƒand/orƒhouseholdƒmembers.ƒInformalƒcaregiversƒ usuallyƒhelpƒinƒcarryingƒoutƒeverydayƒactivities,ƒasƒwellƒasƒotherƒformsƒofƒ careƒwithinƒtheir capabilities. Theƒprovisionƒofƒspecialƒsupportƒtoƒtheƒfamilyƒcarersƒofƒolderƒpeopleƒ andƒdependentƒmembersƒhasƒbeenƒdefinedƒasƒoneƒofƒtheƒchallengesƒaheadƒ inƒSerbia,ƒasƒitƒisƒexpectedƒthatƒtheƒroleƒofƒinformalƒcaregiversƒcouldƒbecomeƒ increasinglyƒimportantƒinƒlineƒwithƒtheƒdemographicƒtrendsƒthatƒincludeƒanƒ increaseƒinƒtheƒnumberƒofƒolderƒpeople.ƒItƒisƒalsoƒplannedƒtoƒpromoteƒsystemsƒ ofƒsupportƒfromƒrelatives,ƒfriendsƒorƒneighbours,ƒasƒwellƒasƒcoordinationƒandƒ moreƒintensiveƒcooperationƒamongƒdifferentƒpartsƒofƒtheƒcareƒsystemƒandƒ family carers. 5.10  Palliative care Inƒtheƒlastƒdecade,ƒpalliativeƒcareƒhasƒbeenƒfurtherƒdevelopedƒthroughƒtheƒ projectƒDevelopmentƒofƒPalliativeƒCareƒinƒSerbiaƒ(Marchƒ2011–Aprilƒ2014),ƒ 142 Health Systems in Transition financedƒbyƒtheƒEU.ƒTheƒaimƒofƒthisƒprojectƒwasƒtoƒsupportƒtheƒMinistryƒofƒ Healthƒinƒtheƒimplementationƒofƒaƒcomprehensiveƒandƒmodernƒsystemƒforƒ palliativeƒcare,ƒwithƒtechnicalƒsupportƒforƒimplementationƒofƒaƒStrategyƒforƒ PalliativeƒCareƒandƒanƒActionƒPlanƒwhichƒfollowedƒtheƒstrategy,ƒbothƒadoptedƒ inƒ2009ƒ(Downingƒetƒal.,ƒ2012).ƒAccordingƒtoƒtheƒNationalƒStrategy,ƒinƒ Serbia,ƒtheƒestablishmentƒofƒservicesƒforƒspecificƒpalliativeƒcareƒwasƒforeseenƒ atƒthreeƒlevelsƒofƒhealth care: ƒƒ ƒPrimary care:ƒ allƒ primaryƒhealthƒ careƒ centresƒwhichƒ coverƒ aƒ populationƒofƒoverƒ25 000ƒresidentsƒ(inƒtotalƒ88ƒoutƒofƒ157ƒprimaryƒ healthƒcareƒcentresƒinƒSerbia),ƒshouldƒestablishƒteamsƒforƒpalliativeƒ care,ƒasƒaƒpartƒofƒhomeƒtreatmentƒandƒcare services; ƒƒ TheƒEstablishmentƒofƒaƒCentreƒforƒCoordinationƒofƒhomeƒ treatmentƒandƒcareƒservicesƒinƒtheƒInstituteƒforƒGerontology,ƒ HomeƒTreatmentƒandƒCare,ƒBelgrade. ƒƒ ƒSecondary level:ƒ theƒestablishmentƒofƒ30ƒspecializedƒunitsƒ forƒ palliativeƒcare,ƒinƒtheƒterritoryƒofƒSerbia,ƒasƒaƒpartƒofƒdepartmentsƒ forƒprolongedƒtreatmentƒand care. ƒƒ ƒTertiary care:ƒestablishmentƒofƒconsultativeƒteamsƒforƒpalliative care. Aƒteamƒforƒpalliativeƒcareƒatƒtheƒprimaryƒlevelƒshouldƒconsistƒofƒaƒmedicalƒ doctor,ƒaƒspecialistƒinƒgeneralƒmedicine,ƒaƒnurse,ƒaƒpatronageƒnurse,ƒaƒphysi- otherapist,ƒaƒsocialƒworker,ƒandƒaƒwiderƒteamƒofƒaƒpsychologist/psychiatrist,ƒaƒ priestƒandƒaƒvolunteerƒshouldƒalsoƒbeƒavailable;ƒonƒtheƒsecondaryƒandƒtertiaryƒ care,ƒtheƒteamƒshouldƒconsistƒofƒaƒmedicalƒdoctorƒ–ƒinternalƒmedicineƒorƒ otherƒspecialistƒ–ƒand nurses. Educationƒandƒtrainingƒofƒhealthƒprofessionalsƒneededƒforƒpalliativeƒ careƒdevelopmentƒwereƒheldƒthroughƒtheƒ2017ƒprojectƒPalliativeƒCareƒinƒ Serbia,ƒfinancedƒbyƒtheƒMinistryƒofƒHealthƒinƒcollaborationƒwithƒtheƒIPHƒ Batut.ƒIPHƒBatutƒconductedƒ25ƒcoursesƒofƒcontinuousƒmedicalƒeducationƒ betweenƒJulyƒandƒDecemberƒ2015ƒandƒeducatedƒ643ƒhealthƒworkersƒandƒ healthƒassociatesƒ(119ƒmedicalƒdoctors,ƒ520ƒnursesƒandƒtechniciansƒandƒfourƒ healthƒassociates)ƒ(IPHƒBelgrade,ƒ2017). Theƒnewƒ2019ƒHealthƒCareƒLawƒincludesƒaƒmodificationƒwithƒrespectƒtoƒ theƒ2005ƒone,ƒwhichƒenablesƒtheƒestablishmentƒofƒnewƒtypesƒofƒhealthƒcareƒ facilitiesƒ–ƒinstitutesƒforƒpalliativeƒcareƒ(OfficialƒGazette,ƒ2019a).ƒFurtherƒ improvementƒofƒimplementationƒofƒpalliativeƒcareƒintoƒregularƒhealthƒcareƒ 143Serbia services,ƒfurtherƒeducationƒforƒpractisingƒhealthƒcareƒprofessionalsƒonƒtheƒ principlesƒofƒpalliativeƒcareƒandƒmonitoringƒofƒprovidedƒservicesƒremainƒ as challenges. 5.11  Mental health care ThereƒareƒfiveƒspecialƒpsychiatricƒhospitalsƒinƒSerbiaƒ(ofƒasylumƒtype)ƒinƒ NoviƒKnezevac,ƒVrsac,ƒKovin,ƒGornjaƒToponicaƒandƒPsychiatricƒClinicƒ“Drƒ LazaƒLazarevic”ƒinƒBelgrade,ƒwhichƒhaveƒ3 250ƒbedsƒallƒtogetherƒ(Officialƒ Gazette,ƒ2013b).ƒOutƒofƒthisƒtotal,ƒ1 500ƒbedsƒareƒintendedƒforƒtreatmentƒ ofƒpatientsƒwithƒacuteƒpsychoticƒdisorders,ƒaddictions,ƒforensicƒpsychiatry,ƒ psychogeriatric,ƒandƒpsychosocialƒrehabilitation,ƒwhileƒtheƒremainingƒ1 750ƒ bedsƒareƒintendedƒforƒhospitalizationƒofƒchronicƒpsychiatric patients. Psychiatricƒcareƒisƒorganizedƒinƒgeneralƒhospitals,ƒwhereƒthereƒareƒ psychiatricƒwards,ƒ specializedƒconsultativeƒcare,ƒdispensaries,ƒandƒdayƒ hospitals,ƒandƒinƒclinicsƒandƒtheƒInstituteƒforƒPsychiatryƒ(seeƒsectionƒ5.4).ƒ Thereƒareƒsomeƒpsychiatricƒofficesƒinƒprimaryƒcareƒcentresƒwhichƒareƒnotƒ yetƒcompletely abolished. Inƒ2015ƒthereƒwereƒ5 300ƒhospitalƒbedsƒforƒpsychiatricƒpatientsƒinƒSerbiaƒ (IPHƒBatut,ƒ2016a).ƒInƒ29ƒgeneralƒhospitalsƒ(outƒofƒ40),ƒthereƒwereƒ1 126ƒ hospitalƒbeds.ƒTheƒlengthƒofƒstayƒforƒpsychiatricƒpatientsƒinƒgeneralƒhospitalsƒ variedƒbetweenƒ10.2ƒdaysƒandƒ37.1ƒdays.ƒThereƒareƒ6.41ƒpsychiatristsƒinƒSerbiaƒ perƒ100 000ƒresidentsƒalongƒwithƒ4.32ƒneuro-psychiatristsƒperƒ100 000ƒ(IPHƒ Batut,ƒ2016e).ƒNeuropsychiatristsƒdealƒwithƒbothƒpsychiatricƒandƒneurologi- calƒpatients,ƒespeciallyƒinƒsomeƒpartsƒofƒthe country. Inƒ2007,ƒtheƒSerbianƒGovernmentƒadoptedƒtheƒStrategyƒforƒMentalƒ Healthƒ(OfficialƒGazette,ƒ2005c)ƒandƒtheƒNationalƒCommitteeƒforƒMentalƒ HealthƒsubmittedƒtheƒdraftƒforƒtheƒLawƒonƒProtectionƒofƒPersonsƒwithƒ MentalƒDisabilities,ƒwhichƒwasƒpassedƒinƒ2013ƒ(OfficialƒGazette,ƒ2013a).ƒ TheƒStrategyƒwasƒtheƒfirstƒtoƒdefineƒtheƒvision,ƒvaluesƒandƒprinciplesƒofƒ reformsƒinƒtheƒareaƒofƒmentalƒhealth,ƒandƒoneƒofƒtheƒmainƒprinciplesƒwasƒ that:ƒ“mentalƒhealthƒcareƒservicesƒshouldƒprovideƒmodern,ƒcomprehensiveƒ treatmentƒwhichƒincludesƒaƒbio-psycho-socialƒapproachƒandƒwhichƒshouldƒ beƒdoneƒinƒtheƒcommunity,ƒasƒcloseƒtoƒtheƒfamilyƒofƒtheƒpatientsƒasƒpossible”ƒ (OfficialƒGazette,ƒ2005c).ƒAsƒaƒresult,ƒtheƒfirstƒpilotƒcentreƒforƒmentalƒhealthƒ inƒtheƒcommunity,ƒunderƒtheƒspecialƒhospitalƒforƒpsychiatricƒdisordersƒGornjaƒ 144 Health Systems in Transition Toponica,ƒwasƒestablishedƒinƒtheƒmunicipalityƒofƒMedianaƒinƒNisƒ(Helsinkiƒ CommitteeƒforƒHumanƒRightsƒinƒSerbia,ƒ2014). BasedƒonƒtheƒLawƒonƒtheƒProtectionƒofƒPersonsƒwithƒMentalƒDisabilitiesƒ thatƒwasƒpassedƒinƒ2013,ƒtheƒMinistryƒofƒHealthƒofƒSerbiaƒadoptedƒtwoƒlawsƒ toƒregulateƒtheƒbasicƒprinciples,ƒorganizationƒandƒprovisionƒofƒmentalƒhealthƒ services,ƒtheƒmodesƒandƒacts,ƒorganizationƒandƒconditionsƒofƒtreatmentƒandƒ hospitalizationƒofƒpersonsƒwithƒmentalƒdisordersƒinƒhealthƒcareƒinstitutionsƒ (OfficialƒGazette,ƒ2013b,ƒ2013c). 5.12  Dental care Dentalƒcareƒisƒorganizedƒandƒprovidedƒthroughƒbothƒtheƒpublicƒandƒprivateƒ sector.ƒDentalƒservicesƒareƒprovidedƒatƒtheƒprimaryƒcareƒlevelƒ(inƒprimaryƒcareƒ centres,ƒinstitutesƒofƒoccupationƒmedicine,ƒtheƒInstituteƒforƒStudents’ƒHealthƒ care,ƒandƒtheƒInstituteƒforƒGerontologyƒandƒPalliativeƒCareƒofƒBelgrade)ƒandƒ otherƒinstitutionsƒatƒsecondaryƒandƒtertiaryƒcareƒ(e.g.ƒFacultyƒofƒDentistryƒ inƒBelgradeƒandƒdentalƒclinicsƒinƒNoviƒSad,ƒNisƒandƒKosovskaƒMitrovica)ƒ (OfficialƒGazette,ƒ2012b). Dentalƒservicesƒatƒallƒlevelsƒofƒtheƒhealthƒsystemƒareƒavailableƒforƒcertainƒ populationƒcategoriesƒ(OfficialƒGazette,ƒ2019b):ƒchildrenƒbeforeƒtheƒageƒ ofƒ18,ƒpregnantƒwomenƒandƒwomenƒ12ƒmonthsƒpostpartum,ƒandƒdisabledƒ individuals.ƒSomeƒotherƒcategoriesƒareƒalsoƒincluded:ƒstudentsƒuntilƒtheƒageƒ ofƒ26,ƒandƒsociallyƒexcludedƒindividualsƒandƒsomeƒotherƒcategoriesƒ(olderƒ people,ƒindividualsƒwithƒsevereƒmentalƒorƒphysicalƒdisability,ƒindividualsƒ withƒsevereƒcongenitalƒorƒacquiredƒfacialƒofƒjawƒdeformities,ƒetc.)ƒ(theƒlistƒofƒ categoriesƒofƒtheƒpopulationƒwhoƒhaveƒdentalƒservicesƒavailableƒatƒallƒlevelsƒ wasƒexpandedƒinƒ2014).ƒChangesƒinƒhumanƒresourcesƒincludedƒtheƒtransitionƒ ofƒexperiencedƒdoctorsƒofƒdentistryƒfromƒprimaryƒcareƒintoƒearlyƒretirementƒ orƒtheƒprivateƒsectorƒ(Markovicƒetƒal.,ƒ2014). Inƒ2015ƒmoreƒthanƒhalfƒofƒtheƒpopulationƒagedƒoverƒ15ƒ(54.2%)ƒhadƒ aƒ“chosenƒdentist”,ƒ26.9%ƒofƒtheƒpopulationƒinƒtheƒpublicƒsectorƒandƒ31%ƒ inƒtheƒprivateƒsector.ƒTheƒhighestƒpercentageƒofƒpopulationƒwithƒaƒ“chosenƒ dentist”ƒisƒfoundƒinƒBelgradeƒ(72.3%),ƒinƒurbanƒsettingsƒ(61.9%),ƒinƒpopula- tionƒgroupsƒwithƒcollegeƒandƒfacultyƒeducationƒ(76.4%),ƒandƒinƒtheƒrichestƒ quintileƒ(77.6%).ƒSinceƒ2012,ƒthereƒhasƒbeenƒaƒreductionƒinƒtotalƒnumbersƒofƒ fillingsƒperƒvisit,ƒandƒanƒincreaseƒinƒtheƒnumberƒofƒtreatedƒteeth,ƒindicatingƒ thatƒpatientsƒdoƒnotƒvisitƒaƒdentistƒinƒaƒtimelyƒmannerƒ(IPHƒBatut,ƒ2016a). 145Serbia 5.13  Health care for specific populations Underƒtheƒ2019ƒHealthƒCareƒLaw,ƒsocialƒcareƒandƒhealthƒcareƒareƒdefinedƒ toƒprovideƒhealthƒcareƒtoƒthoseƒgroupsƒofƒtheƒpopulationƒwhoƒareƒexposedƒ toƒincreasedƒrisksƒofƒcontractingƒdiseases,ƒhealthƒcareƒofƒpersonsƒrelatedƒ toƒprevention,ƒcontrol,ƒearlyƒdetection,ƒandƒtreatmentƒofƒdiseasesƒofƒmajorƒ socialƒandƒmedicalƒimportance,ƒasƒwellƒasƒtheƒhealthƒcareƒofƒtheƒsociallyƒ vulnerable population. 5.13.1 Health care for the Roma population Accordingƒtoƒtheƒ2011ƒcensus,ƒthereƒareƒ147 604ƒRomaƒinƒSerbia,ƒamountingƒ toƒ2.05%ƒofƒtheƒpopulation,ƒalthoughƒitƒisƒworthƒnotingƒthatƒRomaƒtendƒtoƒbeƒ undercountedƒinƒcensuses.ƒPoverty,ƒpoorƒhousingƒconditions,ƒlackƒofƒeduca- tion,ƒprejudiceƒandƒdiscriminationƒnegativelyƒaffectƒRomaƒaccessƒtoƒhealthƒ care.ƒAdministrativeƒobstaclesƒmakeƒitƒdifficultƒforƒRomaƒwithoutƒpersonalƒ documentsƒtoƒobtainƒhealthƒcare,ƒevenƒthoughƒtheyƒareƒinƒtheƒmostƒvulnerableƒ category.ƒManyƒRomaƒsettlementsƒareƒlocatedƒonƒtheƒperiphery,ƒsoƒtheyƒareƒ farƒfromƒhealthƒinstitutions,ƒmeaningƒthatƒresidentsƒareƒoftenƒforcedƒtoƒpayƒ publicƒtransportƒcosts.ƒLimitedƒknowledgeƒofƒtheƒSerbianƒlanguageƒmayƒbeƒ anƒobstacleƒinƒaccessingƒimportantƒinformationƒconcerningƒhealthƒcare.ƒAllƒ theseƒobstaclesƒpointƒtoƒtheƒnecessityƒofƒadoptingƒspecialƒmeasuresƒtoƒimproveƒ theƒaccessibilityƒofƒhealthƒcareƒtoƒtheƒRomaƒpopulation.ƒTheƒMinistryƒofƒ HealthƒlaunchedƒtheƒHealthƒMediatorsƒProjectƒinƒ2008,ƒseekingƒtoƒimproveƒ theƒhealthƒandƒqualityƒofƒlifeƒofƒRomaƒinƒSerbiaƒ(seeƒsectionƒ5.1).ƒ

6 Principle health reforms Summary ƒƒ ƒDemocraticƒ changesƒ inƒ2000ƒ andƒ theƒ adoptionƒofƒ theƒpolicyƒ documentƒHealthƒPolicyƒofƒSerbiaƒ inƒ2002ƒinitiatedƒsignificantƒ progressƒinƒhealthƒpolicyƒinƒSerbia.ƒTheƒaimƒofƒanƒambitiousƒreformƒ programme,ƒundertakenƒfromƒ2004ƒtoƒ2010,ƒwasƒtoƒstrengthenƒ preventiveƒhealthƒcareƒservicesƒwithƒtheƒviewƒtoƒdecreaseƒratesƒofƒ preventableƒdiseasesƒandƒtotalƒhealthƒcare costs. ƒƒ ƒAfterƒ 2012,ƒ reformsƒ focusedƒ onƒ improvingƒ infrastructure,ƒ technologyƒandƒimplementingƒanƒintegratedƒhealthƒinformationƒ system.ƒTheƒreformsƒalsoƒincludedƒtheƒrestructuringƒofƒhospitalsƒ toƒrespondƒmoreƒeffectivelyƒtoƒpatientƒneedsƒandƒtheƒdevelopmentƒ ofƒ aƒ newƒ basicƒ packageƒ ofƒ healthƒ careƒ servicesƒ alignedƒwithƒ existing resources. ƒƒ ƒAƒreformƒofƒtheƒpaymentƒsystemƒforƒprimaryƒcareƒhasƒstartedƒtoƒ introduceƒcapitation,ƒwhileƒaƒmodelƒofƒdiagnosis-relatedƒgroupsƒ (DRGs)ƒisƒbeingƒintroducedƒforƒpaymentsƒforƒsecondaryƒhealth care. ƒƒ ƒHowever,ƒimplementationƒofƒsomeƒreformsƒisƒstillƒpending,ƒsuchƒasƒ theƒestablishmentƒofƒmunicipalƒhealthƒcouncilsƒasƒmultidisciplinaryƒ bodiesƒtoƒsupportƒhealth,ƒorƒtheƒestablishmentƒofƒaƒrealisticƒplanƒ forƒhuman resources. 148 Health Systems in Transition 6.1  Analysis of recent reforms Afterƒdemocraticƒchangesƒinƒ2000ƒandƒtheƒadoptionƒofƒtheƒpolicyƒdocumentƒ HealthƒPolicyƒofƒSerbiaƒinƒ2002ƒ(MinistryƒofƒHealth,ƒ2003),ƒnewƒlegislationƒ setƒtheƒmainƒdirectionsƒofƒhealthƒreformsƒthroughƒtheƒ2005ƒHealthƒCareƒ Law,ƒtheƒ2005ƒHealthƒInsuranceƒLawƒandƒtheƒ2005ƒLawƒonƒChambersƒofƒ HealthƒWorkers.ƒTheseƒlaws,ƒenforcedƒinƒ2005,ƒidentifiedƒtheƒreformƒofƒtheƒ healthƒsectorƒasƒoneƒofƒtheƒnationalƒpriorities,ƒandƒbroughtƒseveralƒsignificantƒ changesƒtoƒgovernance,ƒserviceƒdelivery,ƒtheƒhealthƒworkforce,ƒtheƒhealthƒ informationƒsystem,ƒmedicalƒproducts,ƒvaccinesƒandƒtechnologies,ƒandƒhealthƒ financingƒ(WHO,ƒ2010b). Theƒgovernmentƒcommittedƒitselfƒtoƒcarryingƒoutƒhealthƒreformsƒwithinƒ theƒwiderƒcontextƒofƒEUƒintegrationƒandƒpublicƒsectorƒreformsƒ(Ministryƒofƒ Health,ƒ2003).ƒTheƒmajorityƒofƒtheƒrequiredƒstrategicƒdocumentsƒhasƒbeenƒ drawnƒup,ƒbutƒtheirƒimplementationƒhasƒbeenƒdelayed,ƒasƒtheyƒdependƒonƒ financialƒsupportƒfromƒinternationalƒagenciesƒandƒdonorsƒ(CEVES,ƒ2017).ƒ Majorƒreformsƒandƒpolicyƒinitiativesƒsinceƒ2000ƒareƒpresentedƒinƒchronologi- calƒorderƒinƒTableƒ6.1. TABLE 6.1 Major health reforms in Serbia, 2000–2019 YEAR MAIN DOCUMENTS AND THEIR IMPLICATIONS 2000 Health Policy of Serbia 2002 Law on Local Self-government 2005 Health Care Law, Health Insurance Law and Law on Chambers of Health Workers 2005 Law on Safety and Health at Work 2006 Strategy for Youth Development and Health 2006 Constitution of Serbia 2006 Decree on the Plan of Health Institutions Network 2006 Law on Financing of Local Self-governments 2007 Law on Local Self-government 2007 Tobacco Control Strategy of Serbia 149Serbia 2007 Strategy on the Development of Mental Health Protection 2008 Decree on Voluntary Health Insurance 2008 National Strategy on the Protection of Children Against Violence 2008 Strategy for the Promotion of Childbirth 2009 Special Protocol of the Health System To Deal Efficiently with the Cases of Violence, Abuse and Neglect of Children 2009 Strategy on the Development of e-Government in Serbia for the Period 2009–2013 2009 Law on the Budget System 2009 National Sustainable Development Strategy 2009 Law on Emergency Situation 2009 Public Health Law and Public Health Strategy 2009 Strategy for Continuous Improvement of Health Care Quality and Patient Safety 2009 Strategy for Fight Against Drugs in the Serbia 2009 Strategy for Prevention and Control of Chronic Noncommunicable Diseases (NCDs) 2009 National Strategy for Improving the Position of Women and Promoting Gender Equality 2009 Strategy for Improving the Status of Roma 2009 National Programme of Health Care of Women, Children and Adolescents 2009 National Programme of Preventive Dental Care 2009 Strategy for Palliative Care 2012 Law on Public Procurement 2013 Strategy for Safety and Health at Work 2013 Law on Patient Rights 2013 Decree of Rules on the Corrective Coefficient, the Highest Percentage of Increase in Basic Salaries, Criteria and Norms for the Part of the Salary that is Realized on the Basis of Work Performance as well as the Method of Calculation of Salaries of Employees in Health Institutions 2014 Law on Health Records and Reporting in the Field of Health 2016 New Public Health Law 150 Health Systems in Transition 2018 Law on the Transplantation of Human Organs and Law on Human Cells and Tissues 2018 Public Health Strategy 2019 The New Health Care Law and Health Insurance Law 6.1.1 Leadership and governance TheƒfirstƒstepƒtoƒmodernizeƒtheƒSerbianƒhealthƒsystemƒwasƒtoƒintroduceƒ theƒdocumentƒHealthƒPolicyƒofƒSerbiaƒinƒ2000ƒ(MinistryƒofƒHealth,ƒ2003)ƒ (seeƒsectionsƒ2.1ƒandƒ2.5)ƒwhichƒcreatedƒtheƒconditionsƒtoƒreformƒtheƒhealthƒ system.ƒAfterƒthen,ƒitƒtookƒ3ƒyearsƒforƒtheƒparliamentƒtoƒendorseƒnewƒlawsƒ (thatƒis,ƒHealthƒCareƒLaw,ƒHealthƒInsuranceƒLawƒandƒLawƒonƒChambersƒ ofƒHealthƒWorkers),ƒrecognizingƒtheƒimportanceƒofƒdecentralizationƒinƒtheƒ decision-makingƒprocess.ƒTheƒroleƒofƒlocalƒgovernmentsƒwasƒalsoƒstrength- enedƒthroughƒtheƒadoptionƒofƒtheƒ2006ƒConstitutionƒandƒaƒseriesƒofƒotherƒlawsƒ includingƒonƒterritorialƒorganizationƒandƒlocalƒelectionsƒ(OfficialƒGazette,ƒ 2007a).ƒPrimaryƒcareƒcentresƒ(Dom zdravlja-s)ƒwereƒdecentralizedƒtoƒlocalƒ governments,ƒandƒasƒsuch,ƒtodayƒlocalƒgovernmentsƒareƒstillƒresponsibleƒ forƒappointingƒdirectorsƒandƒhaveƒformalƒresponsibilityƒforƒperformanceƒofƒ primaryƒcareƒcentres.ƒDespiteƒdecentralizationƒhappeningƒaƒdecadeƒago,ƒlocalƒ governmentsƒhaveƒbeenƒslowƒtoƒtakeƒfinancialƒandƒoversightƒresponsibilityƒforƒ primaryƒhealthƒcareƒservices.ƒThereƒisƒaƒbroadƒconsensusƒthatƒthisƒdecentrali- zationƒwasƒundertakenƒwithoutƒadequateƒpreparationƒofƒlocalƒgovernmentsƒ (seeƒsectionƒ2.4)ƒ(EY,ƒ2016).ƒTherefore,ƒtheƒnewƒ2019ƒHealthƒCareƒLawƒisƒ movingƒagainƒtowardsƒcentralizationƒ(seeƒsectionƒ2.3). Whileƒtheƒnationalƒregulationƒrecognizedƒtheƒroleƒofƒtheƒpublicƒandƒ privateƒsectors,ƒinƒpracticeƒtheseƒareƒmanagedƒasƒparallelƒsystems.ƒHowever,ƒ theƒprivateƒsectorƒisƒnotƒstrategicallyƒcoordinatedƒwithƒdecisionsƒinƒtheƒ publicƒsector,ƒandƒreferralsƒmadeƒbyƒprivateƒdoctorsƒareƒnotƒrecognizedƒinƒ theƒpublicƒsystemƒ(CEVES,ƒ2017).ƒSeveralƒbodiesƒwereƒestablishedƒtoƒplayƒ stewardshipƒroles,ƒsuchƒasƒtheƒSerbianƒHealthƒCouncil,ƒtheƒMedicinesƒandƒ MedicalƒDevicesƒAgencyƒandƒtheƒAgencyƒforƒAccreditationƒofƒHealthƒCareƒ InstitutionsƒofƒSerbiaƒ(seeƒsectionƒ2.4).ƒAtƒtheƒlocalƒlevel,ƒdecentralizationƒwasƒ supportedƒbyƒtheƒestablishmentƒofƒtheƒHealthƒCouncilƒasƒaƒmultidisciplinaryƒ andƒintersectoralƒadvisoryƒbodyƒresponsibleƒforƒpublicƒhealthƒactionƒatƒtheƒ localƒlevelƒinƒeachƒmunicipality.ƒAtƒtheƒsameƒtime,ƒchangesƒonƒregulationƒ 151Serbia inƒotherƒsectorsƒalsoƒsupportedƒchangesƒinƒstewardship;ƒforƒexample,ƒinƒtheƒ educationalƒsector,ƒnewƒbodiesƒwereƒestablishedƒsuchƒasƒtheƒNationalƒCouncilƒ forƒHigherƒEducationƒandƒitsƒCommissionƒforƒAccreditationƒandƒQualityƒ Assurance.ƒThisƒchangeƒhadƒaƒmajorƒimpactƒonƒtheƒhealth workforce. Soƒfar,ƒthereƒhasƒnotƒbeenƒaƒformalƒevaluationƒofƒtheƒimplementationƒ ofƒtheƒHealthƒPolicyƒofƒSerbia.ƒHowever,ƒitƒisƒpossibleƒtoƒassessƒitsƒimpactƒ throughƒevidenceƒfromƒtheƒNationalƒHealthƒSurveyƒandƒhealthƒserviceƒ assessment,ƒparticularlyƒanƒassessmentƒofƒqualityƒofƒcareƒ(carriedƒoutƒeachƒ year).ƒSinceƒtheƒadoptionƒofƒtheƒHealthƒPolicyƒofƒSerbia,ƒinternationalƒpar- ticipationƒsupportedƒitsƒimplementationƒthroughƒseveralƒprojectsƒ(bothƒbyƒ theƒEuropeanƒUnionƒandƒtheƒWorldƒBank)ƒ(EuropeanƒCommission,ƒ2018;ƒ WorldƒBank,ƒ2018a). 6.1.2 Service delivery Recentƒreformsƒcalledƒforƒtheƒoptimizationƒofƒtheƒnetworkƒofƒhealthƒcareƒ institutionsƒinƒSerbiaƒinƒorderƒtoƒaddressƒregionalƒinequalitiesƒandƒdispari- tiesƒinƒtheƒaccessibilityƒofƒhealthƒcareƒservicesƒ(Jankovic,ƒJanevicƒ&ƒvonƒdemƒ Knesebeck,ƒ2012). Theƒmostƒprominentƒreformƒinƒserviceƒdeliveryƒintroducedƒtheƒconceptƒofƒ “chosenƒdoctor”ƒinƒprimaryƒcareƒinƒ2005ƒwithƒtheƒHealthƒCareƒLaw,ƒandƒalsoƒ supportedƒbyƒtheƒ2019ƒHealthƒCareƒLaw.ƒTheƒ“chosenƒdoctors”ƒareƒgeneralƒ practitionersƒ(GPs)ƒorƒspecialistsƒinƒgeneralƒmedicine,ƒspecialistƒpaediatri- cians,ƒspecialistƒgynaecologistsƒandƒdentistsƒ(OfficialƒGazette,ƒ2019a,ƒ2019b). Theƒreformƒprocessƒalsoƒmadeƒitƒpossibleƒtoƒsetƒupƒcounsellingƒservicesƒ eitherƒforƒvulnerableƒgroupsƒofƒtheƒpopulationƒorƒforƒpeopleƒwithƒspecificƒ diseasesƒsuchƒasƒdiabetes.ƒCounsellingƒservicesƒaddressedƒaƒrangeƒofƒhealthƒ risksƒandƒbehavioursƒ(e.g.ƒnutrition,ƒphysicalƒactivity,ƒsubstanceƒuse,ƒpreven- tion,ƒmentalƒhealth,ƒetc.). Theƒreformƒprocessƒhasƒfurtherƒacknowledgedƒtheƒvisitingƒnurses’ƒ networkƒinƒSerbia,ƒwhichƒisƒrecognizedƒasƒoneƒofƒtheƒbestƒinƒtheƒregionƒandƒ oftenƒpromotedƒasƒgoodƒpractice.ƒForƒexample,ƒtheirƒcontributionƒtoƒtheƒcareƒ ofƒpregnantƒwomenƒandƒneonatesƒisƒveryƒwellƒrecognized,ƒreconfirmedƒbyƒ continuationƒduringƒtheƒreformƒprocessƒ(WHO,ƒ2010a).ƒTheƒreformƒestab- lishedƒanƒimportantƒroleƒforƒtheƒvisitingƒnurses’ƒnetworkƒinƒidentifyingƒhealthƒ andƒpsychosocialƒrisksƒandƒreferringƒfamiliesƒatƒriskƒtoƒneededƒservices.ƒInƒ 152 Health Systems in Transition orderƒtoƒsupportƒpreventionƒinƒtheƒhealthƒsystem,ƒtheƒMinistryƒofƒHealthƒ establishedƒpreventiveƒcentresƒplacedƒinƒprimaryƒcareƒ(seeƒsectionƒ5.1.5). TheƒMinistryƒofƒHealthƒhasƒmadeƒconsiderableƒprogressƒinƒadoptingƒ legislationƒandƒinterventionsƒthatƒrecognizeƒtheƒvulnerabilityƒofƒtheƒRomaƒ populationƒ(OfficialƒGazette,ƒ2009j).ƒAƒparticularlyƒsuccessfulƒinitiativeƒhasƒ involvedƒhiringƒRomaƒhealthƒmediatorsƒtoƒbeƒassignedƒtoƒmultidisciplinaryƒ teamsƒinƒprimaryƒcareƒcentresƒwhichƒconductƒhomeƒvisitsƒ(seeƒsectionƒ5.1). Toƒsupportƒbetterƒmanagementƒofƒspecificƒdiseases,ƒtheƒCommissionƒ forƒClinicalƒGuidelinesƒandƒGoodƒPracticesƒundertookƒnecessaryƒstepsƒforƒ theƒintroduction,ƒnotƒonlyƒofƒguidelines,ƒbutƒalsoƒofƒclinicalƒpathwaysƒforƒ theƒmajorƒhealthƒconditionsƒcontributingƒtoƒtheƒburdenƒofƒdisease,ƒstartingƒ sinceƒ2010ƒandƒcurrentlyƒongoingƒ(AZUS,ƒ2018)ƒ(seeƒsectionƒ2.2.2). Significantƒeffortsƒwereƒseenƒinƒtheƒintroductionƒofƒtheƒ2019ƒHealthƒ CareƒLawƒofƒWaitingƒListsƒforƒspecificƒmedicalƒproceduresƒandƒexpensiveƒ interventionsƒinƒorderƒtoƒprovideƒequalƒdistributionƒofƒhealthƒcareƒdelivery,ƒ andƒtoƒprovideƒaƒrationalƒuseƒofƒvaluableƒresourcesƒforƒallƒcitizensƒonƒequalƒ terms.ƒThisƒmeasureƒhasƒnotƒbeenƒassessedƒyet.ƒPatientsƒplacedƒonƒtheƒlistƒ canƒbeƒseenƒinƒaƒhealthƒinstitutionƒwhereƒaƒhealthƒserviceƒhasƒtoƒbeƒprovided.ƒ WaitingƒlistsƒareƒpubliclyƒavailableƒonƒtheƒNHIFƒwebsiteƒ(2018). 6.1.3 Health workforce Theƒbiggestƒreformƒstepƒinƒtheƒhumanƒresourceƒfieldƒwasƒtheƒintroductionƒofƒ relevantƒchambersƒforƒfiveƒregulatedƒprofessionsƒ(physicians,ƒnurses,ƒdentists,ƒ pharmacistsƒandƒbiochemists)ƒandƒlicensingƒproceduresƒinƒ2005ƒ(Officialƒ Gazette,ƒ2005c).ƒCapacity-buildingƒprogrammesƒwereƒinitiatedƒforƒhealthƒ workersƒalignedƒwithƒnewlyƒestablishedƒnationalƒguidelines,ƒtoƒprovideƒtheƒ continuingƒprofessionalƒdevelopmentƒnecessaryƒforƒtheƒrenewalƒofƒlicencesƒ implementedƒthroughoutƒSerbiaƒ(Šantrić-Milicevicƒetƒal.,ƒ2015a).ƒEmbracingƒ theƒBolognaƒProcess,ƒSerbianƒuniversitiesƒintroducedƒnewƒprogrammesƒsuchƒ asƒMaster’sƒinƒPublicƒHealth,ƒMaster’sƒinƒHealthƒManagementƒandƒacademicƒ programmesƒforƒnursingƒonƒallƒthreeƒlevelsƒofƒBologna degrees. 153Serbia 6.1.4 Health information system Sinceƒ2000,ƒtheƒMinistryƒofƒHealthƒhasƒinvestedƒeffortsƒtoƒdevelopƒhealthƒ informationƒsystemsƒ(HISs)ƒsupportedƒbyƒinternationalƒagenciesƒ(EUƒandƒ theƒWorldƒBank).ƒHowever,ƒessentialƒreformingƒstepsƒcameƒintoƒforceƒonlyƒ withƒtheƒ2014ƒLawƒonƒHealthƒRecordsƒandƒReportingƒinƒtheƒFieldƒofƒHealthƒ (OfficialƒGazette,ƒ2014b),ƒwhichƒintroducedƒconditionsƒforƒtheƒelectronicƒ healthƒrecordƒ(EHR).ƒInƒ2015ƒtheƒMinistryƒofƒHealthƒintroducedƒaƒunitƒ responsibleƒforƒpolicyƒoversightƒofƒhealthƒinformation,ƒaimedƒtoƒguideƒtheƒ overallƒdevelopmentƒandƒassureƒconsistentƒdataƒandƒnomenclatureƒstandardsƒ andƒinter-operabilityƒofƒsystemsƒ(EU-IHIS,ƒ2015)ƒ(seeƒsectionƒ2.6). Afterƒtheƒadoptionƒinƒ2009ƒofƒtheƒProgrammeƒofƒWork,ƒDevelopmentƒ andƒOrganizationƒofƒtheƒIntegratedƒInformationƒSystemƒ–ƒ“E-Health”ƒ (OfficialƒGazette,ƒ2009f),ƒanƒe-healthƒunitƒwasƒestablishedƒinƒtheƒMinistryƒ ofƒHealthƒinƒJuneƒ2014ƒtoƒdealƒwithƒinformationƒtechnologyƒdevelopmentƒandƒ regulationƒinƒtheƒsector.ƒOverƒtheƒyears,ƒsignificantƒfinancialƒassistanceƒhasƒ beenƒprovidedƒinƒSerbiaƒforƒtheƒdevelopmentƒofƒe-health.ƒTheƒcreationƒofƒaƒ fullyƒintegratedƒhealthƒinformationƒsystemƒisƒtheƒfinalƒgoal.ƒAƒcommitteeƒwasƒ establishedƒinƒSeptemberƒ2014ƒtoƒsupportƒtheƒprocess;ƒinƒaddition,ƒaƒworkingƒ groupƒforƒdevelopingƒanƒe-healthƒNationalƒPlanƒwasƒestablishedƒinƒDecemberƒ 2014ƒandƒfundingƒhasƒbeenƒrecentlyƒsecuredƒtoƒthisƒeffect,ƒbutƒtheƒPlanƒhasƒ notƒyetƒbeenƒdeveloped.ƒCollectionƒandƒanalysisƒofƒinformationƒhasƒremainedƒ fragmentedƒandƒtheƒavailableƒinformationƒisƒnotƒcurrentlyƒusedƒtoƒstrategicallyƒ steerƒtheƒhealthƒsystem.ƒTheƒnationalƒandƒregionalƒIPHsƒhaveƒprimaryƒ responsibilityƒforƒcollectingƒandƒanalysingƒhealthƒsystemƒdata,ƒbutƒtheseƒ reportsƒtypicallyƒareƒcompletedƒaƒyearƒlater.ƒFacilityƒmanagersƒsendƒdataƒtoƒ theirƒregionalƒIPHsƒbutƒreceiveƒlimitedƒorƒnoƒfeedbackƒorƒanalysis.ƒTheƒNHIFƒ hasƒenormousƒdataƒonƒserviceƒcostsƒandƒprovisionƒandƒhasƒstartedƒcollectingƒ performance-basedƒinformation,ƒDRGsƒandƒotherƒcostsƒinformation,ƒbutƒ theseƒdataƒareƒnotƒbeingƒusedƒtoƒanalyseƒtheƒefficiencyƒof facilities. 6.1.5 Medical products, vaccines and technologies Despiteƒbeingƒoneƒofƒtheƒlargestƒinƒtheƒsouth-easternƒEuropeanƒRegion,ƒ evidenceƒshowsƒthatƒtheƒSerbianƒpharmaceuticalƒmarketƒstillƒneedsƒdevelop- ment,ƒparticularlyƒinƒtheƒsupplyƒofƒregularƒmedicinesƒandƒlongƒwaitingƒtimesƒ forƒprocedures,ƒasƒthereƒisƒaƒlackƒofƒsophisticatedƒequipmentƒ(EY,ƒ2016). 154 Health Systems in Transition Sinceƒ2012,ƒtheƒprocessƒofƒpublicƒprocurementƒofƒmedicinesƒandƒmedicalƒ devicesƒhasƒbeenƒstrictlyƒregulated,ƒresultingƒinƒsignificantƒsavingsƒinƒtheƒ NHIFƒbudget.ƒHowever,ƒtheseƒsavingƒwereƒnotƒdivertedƒintoƒexpansionƒofƒ innovativeƒmedicinesƒandƒtherapiesƒ(comparedƒwithƒsimilarƒcountries,ƒSerbiaƒ stillƒhasƒlimitedƒnumbersƒofƒinnovativeƒmedicinesƒcoveredƒbyƒtheƒNHIF)ƒ (Lončar,ƒ2016).ƒAlso,ƒindividualƒinstitutionalƒplansƒareƒnotƒbasedƒonƒrealƒ needsƒforƒmedicinesƒandƒmedicalƒsuppliesƒbutƒonƒtheƒhistoricalƒplanningƒ rules,ƒasƒregulatedƒbyƒtheƒ2019ƒHealthƒCareƒLawƒandƒtheƒ2019ƒHealthƒ Insurance Law. 6.1.6 Health system financing TheƒperformanceƒofƒSerbia’sƒpublicƒ financialƒmanagementƒsystemƒhasƒ improvedƒinƒrecentƒyearsƒwithƒtheƒadoptionƒofƒnewƒregulationsƒandƒtheƒ establishmentƒofƒaƒstrongerƒinstitutionalƒframework,ƒincludingƒtheƒFiscalƒ CouncilƒandƒtheƒStateƒAudit Institution. Longƒawaitedƒchangesƒinƒtheƒremunerationƒsystemƒforƒprimaryƒcareƒ professionalsƒhaveƒbeenƒintroduced,ƒwithƒtheƒassistanceƒofƒinternationalƒ organizations.ƒUnderƒtheƒnewƒsystem,ƒenforcedƒfromƒ2013,ƒ“chosenƒdoctors”ƒ areƒpaidƒbasedƒonƒtheirƒperformance,ƒinsteadƒofƒfixedƒsalaries,ƒasƒtheƒpaymentƒ systemƒgraduallyƒtransitionsƒtowardsƒcapitation.ƒPaymentƒofƒservicesƒprovidedƒ forƒhospitalƒcareƒisƒalsoƒnowƒbeingƒmadeƒbasedƒonƒDRGs,ƒinƒcombinationƒ withƒfee-for-service.ƒTheƒnewƒsystemƒofƒpaymentƒforƒhospitalsƒhasƒbegunƒ toƒbeƒimplementedƒinƒ2019,ƒalthoughƒitƒstillƒcoversƒonlyƒaƒsmallƒshareƒofƒ hospital procedures. 6.2  Future developments 6.2.1 Leadership and governance Theƒleadershipƒandƒgovernanceƒofƒtheƒhealthƒsystemƒisƒfocusedƒtowardsƒ improvingƒhealthƒandƒreducingƒtheƒhealthƒinequalitiesƒofƒtheƒSerbianƒpopu- lationƒ(CEVES,ƒ2017).ƒForƒthatƒpurpose,ƒallƒself-governmentƒauthoritiesƒinƒ Serbiaƒ(inƒtotalƒ158)ƒareƒexpectedƒtoƒestablishƒmunicipalityƒhealthƒcouncilsƒ 155Serbia asƒmultidisciplinaryƒbodiesƒtoƒsupportƒhealthƒ(OfficialƒGazette,ƒ2018a).ƒThisƒ policyƒhasƒbeenƒrecentlyƒadoptedƒ(2018)ƒandƒitsƒimplementationƒisƒpending.ƒ Also,ƒallƒself-governmentƒauthoritiesƒareƒcommittedƒtoƒproduceƒandƒpublishƒ anƒannualƒanalysisƒofƒhealthƒstatusƒonƒtheƒbasisƒofƒhealthƒindicators,ƒlivingƒ andƒworkingƒenvironmentƒindicators,ƒdemographicƒandƒsocialƒdeterminantsƒofƒ health.ƒFurtherƒtoƒtheƒestablishmentƒofƒtheƒNationalƒPublicƒHealthƒCouncil,ƒ aƒmechanismƒofƒintegratedƒmanagementƒforƒimplementingƒHealthƒinƒAllƒ Policiesƒisƒexpectedƒtoƒbeƒdeveloped.ƒHowever,ƒtheƒestablishmentƒofƒstrongƒ partnershipsƒbetweenƒdecision-makers,ƒresearch,ƒacademicƒandƒpublicƒhealthƒ institutionsƒwillƒbeƒtheƒmain challenge. Theƒdirectionƒforƒtheƒfutureƒdevelopmentƒofƒtheƒhealthƒsystemƒinƒtheƒ senseƒofƒeitherƒcentralizationƒorƒdecentralizationƒisƒtoƒbeƒdeterminedƒ(EY,ƒ 2016).ƒCentralizationƒofƒtheƒstateƒownershipƒofƒprimaryƒcareƒinstitutionsƒ (exceptƒpharmacies)ƒhasƒbeenƒregulatedƒinƒtheƒ2019ƒHealthƒCareƒLawƒ (OfficialƒGazette,ƒ2019a)ƒ(seeƒsectionƒ2.3). TheƒMinistryƒofƒHealthƒalsoƒaimsƒtoƒinvolveƒpatients’ƒorganizationsƒandƒ otherƒNGOsƒinƒdecision-makingƒregardingƒtheƒdevelopmentƒofƒtheƒhealthƒ systemƒ(NHIF,ƒ2018a;ƒMinistryƒofƒHealth,ƒ2018). 6.2.2 Service delivery TheƒMinistryƒofƒHealthƒandƒtheƒcurrentƒgovernmentƒaimƒtoƒdevelopƒgoodƒ qualityƒandƒefficientƒhealthƒcare,ƒincludingƒthroughƒinternationalƒsupportƒ (WorldƒBankƒproject,ƒSecondƒSerbiaƒHealthƒProject)ƒ(WorldƒBank,ƒ2018a).ƒ Theƒintentionƒisƒtoƒperformƒtheƒaccreditationƒofƒhealthƒcareƒinstitutionsƒatƒ allƒlevelsƒbyƒ2026.ƒInƒaddition,ƒtheƒMinistryƒofƒHealthƒisƒplanningƒtoƒdevelopƒ onƒaverageƒthreeƒnewƒclinicalƒguidelinesƒperƒyear,ƒwithƒparallelƒrevisionƒ ofƒtwoƒexistingƒclinicalƒguidelinesƒperƒyearƒ(OfficialƒGazette,ƒ2018c).ƒToƒ improveƒtheƒproceduresƒassuringƒcomplianceƒwithƒpatients’ƒrights,ƒpublicƒ healthƒservicesƒwillƒhaveƒaƒsignificantƒroleƒinƒsupportingƒtheƒimprovementƒ processƒ(monitoringƒandƒreporting),ƒasƒstatedƒinƒtheƒrecentlyƒadoptedƒ2018ƒ PublicƒHealth Strategy. 156 Health Systems in Transition 6.2.3 Resources for health Atƒpresent,ƒSerbiaƒhasƒaƒstrongƒfocusƒtowardsƒtheƒdevelopmentƒofƒinfra- structureƒandƒmedicalƒtechnologies,ƒasƒseenƒinƒtheƒgovernmentalƒplansƒforƒ reconstructionƒofƒhealthƒcareƒfacilities.ƒThisƒdevelopmentƒcouldƒbeƒseenƒinƒ effortsƒinvestedƒtoƒfurtherƒimproveƒtheƒintegratedƒhealthƒinformationƒsystemƒ andƒtoƒbuildƒandƒequipƒtertiaryƒhealthƒcareƒinstitutions.ƒAnƒexampleƒisƒtheƒ constructionƒofƒtheƒUniversityƒClinicalƒCentreƒinƒNis,ƒandƒsimilarƒactionsƒareƒ foreseenƒinƒBelgrade,ƒNoviƒSadƒandƒKragujevacƒ(MinistryƒofƒHealth,ƒ2018). Anƒimportantƒchallengeƒisƒtheƒmismatchƒbetweenƒtheƒproductionƒandƒ theƒemploymentƒcapacitiesƒforƒphysiciansƒandƒnurses,ƒcontributingƒtoƒhighƒ unemploymentƒandƒmigrationƒ(Šantrić-Milicevicƒetƒal.,ƒ2015b).ƒSerbiaƒsoƒfarƒ hasƒreliedƒentirelyƒonƒcentralizedƒstaffƒplanning;ƒhowever,ƒaƒstrategicƒhumanƒ resourcesƒplanƒforƒpopulationƒhealthƒimprovementƒdoesƒnotƒexist.ƒProducingƒ aƒrealisticƒplanƒforƒhumanƒresourcesƒforƒhealthƒcareƒwillƒbeƒessential,ƒasƒcur- rently,ƒmanyƒSerbianƒhealthƒcareƒprofessionalsƒworkƒinƒEUƒcountriesƒandƒ Serbiaƒmightƒfaceƒevenƒbiggerƒoutmigrationƒinƒtheƒfutureƒ(Šantrić-Milicevicƒ etƒal.,ƒ2014;ƒGacevicƒetƒal.,ƒ2018)ƒ(seeƒsectionƒ4.2). 6.2.4 Health system financing Currently,ƒtheƒhealthƒsystemƒinƒSerbiaƒisƒnotƒfinanciallyƒsustainableƒinƒtheƒ longƒrun,ƒasƒspendingƒrelatedƒtoƒtheƒdeliveryƒofƒhealthƒcareƒservicesƒisƒcon- stantlyƒincreasing,ƒasƒareƒout-of-pocketƒ(OOP)ƒpaymentsƒ(Lončar,ƒ2016)ƒ(seeƒ sectionƒ3.4.1).ƒItƒisƒhopedƒthatƒaƒbetterƒinclusionƒofƒtheƒprivateƒsector,ƒbothƒbyƒ moreƒefficientƒcontractingƒwithƒhealthƒcareƒprovidersƒandƒbyƒenablingƒcitizensƒ toƒoptƒforƒdifferentƒVHIƒschemesƒ(bothƒprivateƒandƒpublicƒinƒtheƒNHIF),ƒ willƒallowƒaƒbetterƒalignmentƒtoƒtheƒactualƒneedsƒofƒtheƒinsuredƒandƒreduceƒ OOPƒpayments.ƒWithƒregardƒtoƒtheƒimprovementƒofƒpaymentƒmechanisms,ƒ theƒWorldƒBankƒSerbiaƒSecondƒHealthƒProjectƒisƒpilotingƒDRGsƒforƒhospitalƒ care,ƒwhileƒtheƒNHIFƒisƒdevelopingƒaƒperformance-basedƒpaymentƒsystemƒ inƒprimaryƒcareƒ(WorldƒBank,ƒ2018a;ƒNHIF,ƒ2018a). 7 Assessment of the health system Summary ƒƒ ƒSerbiaƒhasƒaƒcomprehensiveƒuniversalƒhealthƒsystemƒwithƒfreeƒaccessƒ toƒhealthƒcareƒservicesƒatƒtheƒprimaryƒlevel,ƒbutƒthereƒareƒinequalitiesƒ inƒtheƒutilizationƒofƒhealth services. ƒƒ ƒPatients’ƒ rightsƒ areƒ protectedƒ byƒ aƒ rangeƒ ofƒ regulationsƒ andƒ monitoredƒbyƒtheƒlocalƒhealthƒcouncils.ƒHowever,ƒthereƒisƒnoƒfullƒ participationƒofƒtheƒpopulationƒinƒdecision-makingƒinƒtheƒhealthƒ system,ƒandƒcomplaintsƒusuallyƒfocusƒonƒtheƒconductƒofƒhealthƒ workersƒandƒtheƒorganizationƒofƒtheƒhealth system. ƒƒ ƒFinancialƒconstraintsƒareƒtheƒmainƒreasonƒforƒunmetƒneedsƒforƒ medicalƒcare,ƒwhichƒareƒmoreƒfrequentƒamongƒlowerƒeducatedƒ peopleƒandƒtheƒpoorest people. ƒƒ ƒSerbiaƒspendsƒ8.8%ƒofƒ itsƒGDPƒonƒhealth,ƒwhichƒisƒoneƒofƒtheƒ highestƒpercentagesƒinƒtheƒBalkanƒregion.ƒHowever,ƒtheƒcoverageƒofƒ theƒtargetƒpopulationƒbyƒscreeningƒatƒnationalƒlevelƒisƒstillƒveryƒlowƒ andƒtobaccoƒandƒalcoholƒconsumptionƒratesƒhaveƒbeenƒincreasing.ƒ Thereƒisƒaƒneedƒtoƒinvestƒin prevention. ƒƒ ƒCatastrophicƒOOPƒpatientƒpaymentsƒareƒreportedƒfromƒ2.3%ƒofƒ respondents,ƒwithƒhigherƒprevalenceƒratesƒ inƒruralƒareas,ƒ largerƒ 158 Health Systems in Transition households,ƒ amongƒ theƒ poorestƒ peopleƒ andƒ chronicallyƒ sickƒ household members. ƒƒ ƒTheƒpresentƒsystemƒofƒfinancingƒencouragesƒ inefficiencyƒinƒtheƒ useƒofƒresourcesƒandƒprovidesƒfewƒincentivesƒforƒimprovedƒserviceƒ volumeƒandƒquality.ƒTheƒproviderƒpaymentƒsystemƒforƒbothƒprimaryƒ andƒhospitalƒcareƒremainsƒinput-based,ƒalthoughƒitƒisƒbeingƒslowlyƒ changedƒtoƒaƒcapitationƒsystemƒinƒprimaryƒcareƒandƒdiagnosis- relatedƒgroupsƒ(DRGs)ƒforƒhospital care. 7.1  Health system governance Serbiaƒlacksƒaƒtransparentƒandƒcomprehensiveƒsystemƒofƒassessingƒtheƒvalueƒofƒ healthƒcareƒinvestmentsƒandƒdeterminingƒhowƒtoƒpayƒforƒthem.ƒContributionsƒ ofƒcompulsoryƒhealthƒinsuranceƒofƒemployedƒcitizensƒareƒnotƒenoughƒtoƒcoverƒ operationalƒexpendituresƒofƒtheƒhealthƒsectorƒand,ƒhence,ƒhealthƒcareƒisƒalsoƒ financedƒfromƒtheƒstateƒbudget.ƒLowƒincomeƒfromƒinsuranceƒpaymentsƒandƒ insufficientƒfundsƒfromƒtheƒstateƒbudgetƒhaveƒcreatedƒaƒcycleƒofƒdebtƒinƒwhichƒ theƒNHIFƒdoesƒnotƒrefundƒmoneyƒtoƒhospitalsƒandƒotherƒproviders,ƒwhoƒ inƒturnƒdelayƒpaymentƒtoƒsuppliersƒsuchƒasƒdrugsƒandƒutilitiesƒcompanies.ƒ Contributionƒevasionƒ(avoidanceƒofƒhealthƒinsuranceƒpayments)ƒaccountsƒ forƒalmostƒhalfƒofƒtheƒNHIFƒfundsƒcollectedƒonƒanƒannualƒbasis.ƒOneƒthirdƒ ofƒtheseƒfundsƒareƒunprofitableƒ(notƒyieldingƒfinancialƒgain)ƒbecauseƒtheƒ companiesƒareƒplacedƒintoƒliquidation,ƒcompaniesƒwhichƒareƒinƒrestructuringƒ oweƒhalfƒtheƒdebt,ƒwhileƒpublicƒenterprisesƒoweƒaƒportionƒofƒthe debt. Theƒpopulationƒdoesƒnotƒfullyƒparticipateƒinƒdecision-makingƒprocessesƒ inƒtheƒhealthƒsector.ƒCooperationƒwithƒcivilƒsocietyƒorganizationsƒisƒmainlyƒadƒ hocƒinƒtheƒdomainsƒofƒdefiningƒhealthƒpolicy,ƒprogrammeƒimplementation,ƒ monitoringƒandƒevaluationƒthroughƒconsultations,ƒmeetings,ƒconferences,ƒ roundƒtableƒandƒpublicƒdiscussions.ƒItƒseemsƒtoƒbeƒdifficultƒtoƒestablishƒ cooperationƒbetweenƒrepresentativesƒofƒtheƒstateƒandƒcivilƒsocietyƒorganiza- tions,ƒespeciallyƒinƒtheƒprocessƒofƒmonitoringƒandƒevaluatingƒhealthƒpoliciesƒ (BelgradeƒCentreƒforƒSecurityƒPolicy,ƒ2013). Patients’ƒrightsƒprotectionƒisƒsupportedƒbyƒtheƒ2013ƒLawƒonƒPatients’ƒ Rightsƒ(OfficialƒGazette,ƒ2013a),ƒwhichƒpromulgatesƒ19ƒgeneralƒpatients’ƒ rightsƒ(seeƒsectionƒ2.8).ƒFollowingƒthisƒlegislation,ƒtwoƒnewƒinstitutionsƒwereƒ 159Serbia establishedƒinƒeachƒmunicipality:ƒanƒadviserƒforƒtheƒprotectionƒofƒpatients’ƒ rights,ƒwhoƒisƒresponsibleƒforƒallƒcitizensƒ(insuredƒandƒuninsured),ƒandƒaƒ HealthƒCouncil.ƒTheƒmainƒroleƒofƒtheƒHealthƒCouncilƒisƒtoƒmonitorƒandƒ reportƒonƒtheƒprotectionƒofƒpatients’ƒrightsƒtoƒtheƒMinistryƒofƒHealthƒandƒ theƒOmbudsman.ƒInƒparallel,ƒtheƒNHIFƒfundsƒaƒProtectorƒofƒtheƒRightsƒ ofƒInsuredƒPersons,ƒwhoƒisƒemployedƒinƒeachƒhealthƒinstitutionƒandƒhelpsƒ insuredƒpeopleƒinƒexercisingƒtheirƒrights.ƒTheƒnumberƒofƒcomplaintsƒfiledƒ byƒpatientsƒinƒstateƒhealthƒinstitutionsƒinƒ2016ƒareƒpresentedƒinƒTableƒ7.1.ƒ Theƒmostƒfrequentƒcomplaintsƒreferredƒtoƒtheƒconductƒofƒhealthƒworkersƒandƒ healthƒcareƒassociates,ƒfollowedƒbyƒtheƒorganizationƒofƒhealthƒservicesƒandƒ patients’ƒrights.ƒEvidenceƒsuggestsƒthatƒfurtherƒworkƒinƒraisingƒawarenessƒ andƒempowermentƒofƒpatientsƒis needed. TABLE 7.1 Number of complaints filed in state health institutions in Serbia, 2016 TYPE OF COMPLAINT NUMBER OF COMPLAINTS FILED SHARE (%) Quality of health services 172 11.6 Conduct of health workers and health care associates 363 24.5 Method of charging health services 15 1.0 Organization of health services 332 22.4 Waiting time for health services 205 13.8 Refund of funds 48 3.2 Patients’ rights 295 19.9 Other 51 3.4 Total 1 481 100 Source: IPH Batut, 2017i Nearlyƒthreeƒquartersƒofƒrespondentsƒtoƒaƒ2013ƒsurveyƒconsideredƒtheƒ healthƒsystemƒtheƒmostƒcorruptƒpartƒofƒsociety,ƒafterƒtheƒcountry’sƒpoliti- calƒpartiesƒ(TheƒEconomistƒIntelligenceƒUnit,ƒ2016).ƒThereƒareƒinformalƒ payments,ƒincludingƒbribes.ƒImportantƒanti-corruptionƒmeasuresƒinƒtheƒhealthƒ sectorƒ(suchƒasƒlegislativeƒamendments,ƒbuildingƒcapacitiesƒforƒinspection,ƒ 160 Health Systems in Transition improvementƒinƒcooperationƒbetweenƒinstitutionsƒrelevantƒtoƒfightƒcorrup- tionƒinƒtheƒhealthƒsystem,ƒqualityƒcontrolƒimprovement,ƒuniqueƒinformationƒ system)ƒwereƒincludedƒinƒtheƒ2013–2018ƒNationalƒAnti-corruptionƒStrategyƒ (OfficialƒGazette,ƒ2013o)ƒandƒActionƒPlanƒ(OfficialƒGazette,ƒ2013p).ƒTheƒ Anti-corruptionƒAgency,ƒcreatedƒinƒ2010ƒ(http://www.acas.rs/home-5/),ƒ isƒanƒautonomousƒgovernmentalƒbodyƒwithƒwide-rangingƒauthorityƒinƒtheƒ fieldƒofƒcorruptionƒprevention.ƒItƒalsoƒsupervisesƒtheƒimplementationƒofƒtheƒ StrategyƒandƒtheƒActionƒPlan,ƒresolvesƒconflictsƒofƒinterest,ƒkeepsƒaƒregisterƒofƒ officials,ƒandƒperformsƒactivitiesƒregulatingƒtheƒfinancingƒofƒpoliticalƒpartiesƒ andƒimplementsƒanti-corruptionƒprogrammesƒ(UNODC,ƒ2011). TransparencyƒofƒtheƒworkƒofƒtheƒMinistryƒofƒHealth,ƒtheƒNHIFƒandƒtheƒ healthƒinstitutionsƒhasƒbeenƒimprovedƒbyƒsettingƒupƒandƒupdatingƒwebsitesƒ withƒallƒsupportingƒdocumentsƒ(legislation,ƒpublicƒinvitations,ƒprojects,ƒstatis- tics,ƒreports,ƒsurveyƒresults,ƒfill-inƒforms),ƒactivitiesƒandƒlatestƒnews.ƒInƒ2010,ƒ eminentƒpublicƒandƒprivateƒhealthƒprofessionalsƒfoundedƒ“Doctorsƒagainstƒ corruption”ƒ(http://www.healthcareanticorruption.org/),ƒanƒNGOƒwhichƒ isƒseenƒasƒanƒimportantƒplayerƒinƒtheƒfightƒagainstƒhealthƒcareƒcorruption.ƒ Theirƒmainƒgoalƒisƒtoƒfightƒcorruptionƒandƒpromoteƒethicalƒandƒprofessionalƒ standardsƒamongƒhealthƒworkersƒandƒhealthƒcareƒpayers.ƒTheirƒactivitiesƒareƒ aimedƒatƒdetectingƒandƒdisclosingƒimproperƒbehaviourƒinƒtheƒhealthƒsystem.ƒ Theyƒalsoƒapplyƒconstantƒpressureƒonƒtheƒgovernmentƒbyƒengagingƒinƒpublicƒ dialoguesƒandƒdebatesƒtoƒchangeƒcurrentƒpoliciesƒandƒlawsƒrelatedƒtoƒhealthƒ care.ƒ“SerbiaƒonƒtheƒMove”ƒ(SoM;ƒhttp://en.srbijaupokretu.org/)ƒisƒanotherƒ NGOƒcreatedƒinƒ2009ƒthatƒhasƒbroughtƒmanyƒcorruptionƒissuesƒinƒhealthƒ careƒtoƒtheƒforefront.ƒItƒisƒworkingƒtowardsƒeliminatingƒcorruptionƒinƒtheƒ healthƒsectorƒandƒimprovingƒtheƒqualityƒofƒserviceƒforƒpatientsƒbyƒpromotingƒ transparencyƒempoweringƒpatientsƒtoƒraiseƒtheirƒvoicesƒagainst corruption. Keyƒperformanceƒindicatorsƒforƒhealthƒinstitutions,ƒespeciallyƒinƒfinan- cialƒterms,ƒhaveƒnotƒbeenƒestablishedƒnorƒmonitored.ƒHealthƒinstitutionsƒ areƒobligedƒtoƒsubmitƒtheirƒownƒfinancialƒreportsƒtoƒtheƒNHIF,ƒbutƒthereƒ areƒnoƒlegalƒsanctionsƒforƒtheƒnon-establishmentƒofƒfinancialƒmanagementƒ andƒcontrollingƒsystems,ƒnorƒforƒtheƒfailureƒtoƒsubmitƒanƒannualƒreport.ƒInƒ 2013,ƒ86%ƒofƒhealthƒcareƒinstitutionsƒdidƒnotƒsubmitƒtheirƒannualƒreportsƒ (EY,ƒ2016).ƒInternalƒauditƒdepartmentsƒ(insideƒhealthƒinstitutions)ƒdoƒnotƒ followƒtheƒlaw.ƒHealthƒcareƒstewardshipƒisƒinƒtheƒhandsƒofƒtheƒMinistryƒofƒ Health,ƒwhichƒdoesƒnotƒconductƒanyƒtypeƒofƒfinancialƒcontrolsƒinƒindividualƒ healthƒcareƒinstitutions,ƒnorƒtheƒwiderƒhealthƒsystem.ƒTheƒMinistryƒonlyƒ 161Serbia monitorsƒtheƒrestrictedƒuseƒofƒfundsƒofƒindividualƒhealthƒcareƒinstitutionsƒ basedƒonƒagreementsƒconcludedƒwithƒthem.ƒEachƒyear,ƒtheƒMinistryƒofƒ Healthƒpublishesƒaƒpublicƒinvitationƒtoƒapplyƒforƒprogrammesƒ(forƒpreventionƒ andƒcontrolƒofƒleadingƒchronicƒnoncommunicableƒdiseases,ƒpreventiveƒhealthƒ care,ƒamongƒothers).ƒIndividualƒinstitutionsƒareƒfreeƒtoƒapplyƒforƒsomeƒofƒtheseƒ programmes.ƒAfterƒthat,ƒtheƒMinisterƒestablishesƒaƒcommitteeƒthatƒsuggestsƒ priorityƒareasƒofƒfinancingƒfromƒallƒsubmittedƒapplications.ƒAƒgeneralƒruleƒisƒ thatƒhealthƒcareƒinstitutionsƒfromƒpoorerƒareasƒwouldƒhaveƒhigherƒchancesƒ ofƒreceivingƒfundsƒforƒtheƒstatedƒpurposesƒ(EY,ƒ2016). Currently,ƒthereƒisƒnoƒconcreteƒdataƒaboutƒpatientƒinvolvementƒinƒtreat- mentƒdecisions,ƒeitherƒaboutƒtheƒimpactƒofƒreformsƒorƒtheƒinitiativesƒtoƒ improveƒuserƒexperience.ƒFurther,ƒaƒSituationalƒAnalysisƒofƒtheƒWesternƒ BalkanƒCountriesƒbyƒtheƒEuropeanƒPatientsƒForumƒinƒ2017ƒshowedƒthatƒ patients’ƒsphereƒofƒinfluenceƒandƒtheirƒparticipationƒinƒdecision-makingƒ processesƒisƒweakƒinƒSerbia.ƒThus,ƒsharingƒbestƒpracticesƒonƒhowƒtoƒimproveƒ patients’ƒinvolvementƒintoƒdecision-makingƒprocessesƒisƒrecognizedƒasƒaƒtopƒ priority,ƒincludingƒtheƒtrainingƒinƒpatients’ƒrightsƒandƒmonitoringƒofƒrelatedƒ lawsƒ(EuropeanƒPatients’ƒForum,ƒ2017). 7.2  Accessibility Accordingƒtoƒtheƒ2019ƒHealthƒCareƒLawƒ(OfficialƒGazette,ƒ2019a),ƒtheƒ principleƒofƒaccessibilityƒtoƒhealthƒcareƒforƒallƒcitizensƒinƒSerbiaƒ(thatƒis,ƒallƒ peopleƒlegallyƒrecognizedƒasƒsubjectsƒofƒtheƒstateƒofƒSerbia)ƒisƒassuredƒbyƒ providingƒappropriateƒhealthƒcareƒwhichƒisƒphysically,ƒcommunicationally,ƒ geographically,ƒandƒeconomicallyƒaccessible,ƒespeciallyƒforƒpeopleƒwithƒdis- abilities.ƒPatientsƒhaveƒtheƒrightƒtoƒequalƒaccessƒtoƒhealthƒservicesƒwithoutƒ discriminationƒbyƒincome,ƒplaceƒofƒresidence,ƒtypeƒofƒdiseaseƒorƒtimeƒofƒaccess.ƒ However,ƒtheoryƒandƒpracticeƒdifferƒinƒtheƒSerbianƒcontext.ƒEvenƒthoughƒ Serbiaƒhasƒaƒcomprehensiveƒuniversalƒhealthƒsystemƒwithƒfreeƒaccessƒtoƒhealthƒ careƒservicesƒatƒtheƒprimaryƒcareƒlevel,ƒinequitiesƒinƒtheƒutilizationƒofƒhealthƒ servicesƒareƒpresentƒandƒwidespreadƒ(Jankovic,ƒSimicƒ&ƒMarinkovic,ƒ2010;ƒ MinistryƒofƒHealth,ƒ2014). Evidenceƒsuggestsƒthatƒbenefitsƒareƒnotƒequalƒacrossƒtheƒpopulation:ƒ certainƒpopulationƒgroupsƒsuchƒasƒtheƒmostƒdisadvantaged,ƒtheƒuninsuredƒ andƒRomaƒexperienceƒproblemsƒaccessingƒprimaryƒcareƒservices,ƒwhichƒ 162 Health Systems in Transition negativelyƒaffectsƒtheirƒhealthƒ(SORS,ƒ2008;ƒIdzerdaƒetƒal.,ƒ2011;ƒJankovic,ƒ 2015).ƒTheƒmainƒobstacleƒforƒnotƒusingƒhealthƒcareƒisƒofƒaƒfinancialƒnature,ƒ thatƒis,ƒpaymentƒofƒmedicalƒservices,ƒthenƒadministrativeƒbarriers:ƒsomeƒofƒ theƒRomaƒareƒnotƒregisteredƒwithƒtheƒNHIFƒdespiteƒtheƒrightƒtoƒfreeƒhealthƒ care,ƒdueƒtoƒlackƒofƒtrust,ƒeducationƒandƒtime,ƒlanguageƒbarriers,ƒgeographi- calƒbarriers,ƒdiscriminationƒbyƒhealthƒworkers,ƒpreviousƒbadƒexperiencesƒ andƒlackƒofƒknowledgeƒaboutƒavailabilityƒofƒservicesƒ(Jankovic,ƒ2015).ƒTheƒ ongoingƒMinistryƒofƒHealthƒprojectƒRomaƒHealthƒMediators,ƒimplementedƒ sinceƒ2008,ƒtogetherƒwithƒhealthƒinstitutionsƒandƒassociationsƒofƒRomaƒcivilƒ societyƒprovideƒinsightƒintoƒtheƒhealthƒstatusƒofƒRomaƒandƒcontributeƒtoƒ improvedƒaccessƒtoƒprimaryƒhealthƒcareƒservicesƒthroughƒvariousƒactivitiesƒ (MinistryƒofƒHealth,ƒ2018)ƒ(seeƒsectionƒ5.1). Inƒ2013,ƒ9ƒoutƒofƒeveryƒ10ƒcitizensƒofƒSerbiaƒ(91.6%)ƒhadƒtheirƒownƒGPƒ (“chosenƒdoctor”)ƒwhichƒisƒaƒsignificantƒincreaseƒcomparedƒwithƒ2006,ƒwhenƒ 50.6%ƒhadƒtheirƒownƒGPƒ(MinistryƒofƒHealth,ƒ2014).ƒMenƒwereƒfoundƒtoƒ haveƒaƒGPƒsignificantlyƒlessƒfrequentlyƒthanƒwomenƒ(MinistryƒofƒHealth,ƒ 2014).ƒAlso,ƒbothƒmalesƒandƒfemalesƒwhoƒbelongƒtoƒdisadvantagedƒclassesƒ andƒmalesƒwhoƒhadƒlowerƒeducationƒwereƒlessƒlikelyƒtoƒhaveƒvisitedƒaƒGP,ƒ regardlessƒofƒtheirƒhealthƒstatusƒ(Jankovic,ƒSimicƒ&ƒMarinkovic,ƒ2010). Respondentsƒwithƒhigherƒincome,ƒhigherƒlevelsƒofƒeducation,ƒemploy- ment,ƒandƒthoseƒlivingƒinƒurbanƒareas,ƒespeciallyƒinƒBelgrade,ƒhaveƒprivilegedƒ positionsƒconcerningƒvisitsƒtoƒdentistsƒandƒprivateƒdoctor’sƒservices,ƒwhichƒisƒ probablyƒrelatedƒtoƒtheirƒabilityƒtoƒpayƒ(Jankovic,ƒ2008;ƒJankovic,ƒSimicƒ&ƒ Marinkovic,ƒ2010;ƒMinistryƒofƒHealth,ƒ2014). Financialƒconstraintsƒwereƒreportedƒbyƒ24.8%ƒofƒtheƒpeopleƒsurveyedƒ asƒtheƒunderlyingƒreasonƒforƒnotƒseekingƒhealthƒcare,ƒthatƒis,ƒlackƒofƒmoneyƒ forƒpayingƒhealthƒservices,ƒandƒitƒwasƒmoreƒcommonƒamongƒlowerƒeducatedƒ peopleƒandƒtheƒpoorestƒ(MinistryƒofƒHealth,ƒ2014). Serbiaƒlacksƒaƒnationalƒframeworkƒtoƒclearlyƒestablishƒobjectivesƒandƒ prioritiesƒforƒdifferentƒsectorsƒatƒallƒlevels.ƒAƒcomprehensiveƒhealthƒpolicyƒ prioritizingƒtheƒequitableƒutilizationƒofƒhealthƒservices,ƒregardlessƒofƒsocio- economic,ƒdemographicƒandƒhealthƒstatusƒdifferencesƒisƒpendingƒinƒSerbia,ƒ withƒaƒprimaryƒfocusƒonƒtheƒmostƒdisadvantagedƒsocioeconomic groups. 163Serbia 7.3  Financial protection Accordingƒtoƒtheƒ2013ƒSerbianƒNationalƒHealthƒSurveyƒ(latestƒsurvey),ƒ duringƒtheƒ12ƒmonthsƒpriorƒtoƒtheƒsurvey,ƒ51.6%ƒofƒtheƒpopulationƒexperi- encedƒOOPƒexpendituresƒonƒhealthƒcareƒwhichƒwasƒmoreƒthanƒinƒtheƒ2006ƒ Surveyƒ(44.1%).ƒPeopleƒfromƒsouthernƒandƒeasternƒSerbiaƒhadƒtheƒhighestƒ OOPƒpaymentsƒforƒhealthƒcareƒ(58.8%)ƒwhileƒtheƒsmallestƒproportionƒwasƒ recordedƒinƒBelgradeƒ(48.4%)ƒ(MinistryƒofƒHealth,ƒ2014). OOPƒspendingƒaccountsƒforƒalmostƒ40%ƒofƒtotalƒhealthƒexpenditureƒinƒ Serbiaƒ(TheƒEconomistƒIntelligenceƒUnit,ƒ2016).ƒTheƒhighestƒOOPƒhouse- holdƒspendingƒwasƒonƒpharmaceuticalsƒ(55.6%),ƒfollowedƒbyƒcostsƒforƒprivateƒ dentalƒ(14.2%)ƒandƒprivateƒdiagnosticƒservicesƒ(8%).ƒPublicƒoutpatientƒandƒ publicƒdentalƒservicesƒaccountƒforƒtheƒlowestƒpercentagesƒofƒOOPƒpaymentsƒ (2.1%ƒandƒ2.0%,ƒrespectively)ƒ(MinistryƒofƒHealth,ƒ2014). Inƒ2013,ƒtheƒpercentageƒofƒtheƒpopulationƒthatƒhadƒOOPƒexpendituresƒ forƒhealthƒcareƒservicesƒinƒpublicƒinstitutionsƒwasƒsignificantlyƒsmallerƒthanƒ inƒ2006,ƒi.e.ƒcostsƒforƒvisitingƒdoctors’ƒofficesƒandƒcostsƒforƒhospitalƒtreat- mentƒwereƒ2.4%ƒ(7.4%ƒinƒ2006)ƒandƒ1.2%ƒofƒtheƒpopulationƒ(2.6%ƒinƒ2006),ƒ respectively.ƒRegardingƒprivatelyƒownedƒinstitutions,ƒ1.3%ƒofƒtheƒpopulationƒ hadƒcostsƒforƒoutpatientƒtreatmentƒ(2.3%ƒinƒ2006)ƒandƒ0.6%ƒforƒinpatientƒ treatmentƒ(0.4%ƒinƒ2006)ƒ(MinistryƒofƒHealth,ƒ2014). Theƒgreatestƒobstacleƒforƒcoveringƒtheƒhealthƒcareƒneedsƒisƒfinancialƒ availability:ƒ24.8%ƒofƒpeopleƒinƒtheƒ2013ƒhealthƒsurveyƒstatedƒthatƒtheyƒ couldƒnotƒaffordƒhealthƒcareƒforƒfinancialƒreasons.ƒObtainƒdentalƒhealthƒcareƒ wasƒtheƒmostƒdifficultƒ(19.3%)ƒfollowedƒbyƒobtainingƒmedicalƒhealthƒcareƒ (18.0%)ƒandƒprescriptionƒofƒmedicinesƒ(14.2%)ƒ(MinistryƒofƒHealth,ƒ2014).ƒ Theƒpercentageƒofƒpeopleƒthatƒforewentƒmedicalƒhealthƒcareƒdueƒtoƒlackƒ ofƒfinancialƒresourcesƒinƒ2017ƒisƒhigherƒinƒSerbiaƒ(2.9%)ƒthanƒinƒotherƒEUƒ countriesƒ(0.6%ƒinƒCroatia,ƒ0.2%ƒinƒAustria,ƒwithƒanƒEUƒaverageƒofƒ1.0%).ƒ Thisƒwasƒtrueƒforƒpeopleƒinƒallƒlabourƒstatusƒcategoriesƒ(Eurostat,ƒ2019)ƒ (Tableƒ7.2).ƒInƒSerbia,ƒwomenƒ(33.1%),ƒlowerƒeducatedƒpeopleƒ(35.9%)ƒandƒ theƒpoorestƒonesƒ(40.1%)ƒareƒsignificantlyƒmoreƒlikelyƒnotƒtoƒbeƒableƒtoƒmeetƒ theirƒhealthƒneedsƒ(MinistryƒofƒHealth,ƒ2014). 164 Health Systems in Transition TABLE 7.2 Self-reported unmet needs for medical examination due to expense (%), by labour status for Serbia and selected countries, 2017 EMPLOYED UNEMPLOYED RETIRED OTHER INACTIVE PERSONS TOTAL Serbia 1.7 5.1 2.7 2.9 2.9 North Macedonia 0.8 2.7 1.1 2.3 1.6 Slovenia 0.1 0.9 0.3 0.0 0.2 Croatia 0.1 1.5 1.0 0.8 0.6 Austria 0.1 0.6 0.2 0.4 0.2 France 0.7 3.0 0.4 1.0 0.8 EU 28 countries 0.5 2.5 1.3 1.3 1.0 Source: Eurostat, 2019 InƒtheƒSerbianƒpublicƒhealthƒsector,ƒthreeƒtypesƒofƒOOPƒpatientƒpaymentsƒ canƒbeƒdistinguished:ƒofficialƒco-payments,ƒpaymentsƒforƒ“boughtƒandƒ broughtƒgoods”ƒ(i.e.ƒpaymentsƒforƒhealthƒcareƒgoodsƒbroughtƒbyƒtheƒpatientƒ toƒtheƒhealthƒcareƒfacility)ƒandƒinformalƒpaymentsƒ(under-the-tableƒpaymentsƒ inƒcashƒorƒin-kindƒgifts)ƒ(Hubrechtƒ&ƒNajman,ƒ2005). Inƒorderƒtoƒstrengthenƒtheƒfinancialƒprotectionƒofƒtheƒpublicƒhealthƒ system,ƒinƒ2002,ƒasƒpartƒofƒtheƒhealthƒcareƒreform,ƒtheƒSerbianƒGovernmentƒ introducedƒofficialƒco-paymentsƒforƒservicesƒcoveredƒbyƒtheƒmandatoryƒ healthƒinsuranceƒaccompaniedƒbyƒanƒexemptionƒmechanism.ƒTheƒamountsƒ ofƒco-paymentsƒrangedƒfromƒUS$ƒ0.59ƒupƒtoƒUS$ƒ30ƒ(WorldƒBank,ƒ2009).ƒ Accordingƒtoƒ2019ƒSerbianƒHealthƒInsuranceƒLawƒArticleƒ16ƒ(Officialƒ Gazette,ƒ2019b),ƒthereƒareƒseveralƒpopulationƒgroupsƒthatƒareƒexemptedƒfromƒ OOPƒpatientƒpayments:ƒchildrenƒupƒtoƒ18ƒyearsƒofƒage,ƒpregnantƒwomen,ƒ theƒelderlyƒoverƒ65ƒyearsƒofƒage,ƒphysicallyƒandƒmentallyƒdisabledƒpersons,ƒ personsƒwithƒinfectiousƒdiseasesƒandƒchronicallyƒillƒpeople,ƒmonksƒandƒnuns,ƒ personsƒwithƒlowƒfamilyƒincome,ƒunemployedƒpersons,ƒpeopleƒonƒmilitaryƒ service,ƒpersonsƒofƒRomaƒethnicityƒwithoutƒaƒpermanentƒresidence,ƒvictimsƒ ofƒdomesticƒviolence,ƒtrafficking,ƒandƒterrorismƒandƒveterans.ƒAnƒassess- mentƒbyƒArsenijevic,ƒPavlovaƒ&ƒGrootƒ(2014)ƒshowedƒthatƒtheseƒpopulationƒ groupsƒreportedƒvariousƒtypesƒofƒOOPƒpaymentsƒforƒoutpatientƒandƒinpatientƒ 165Serbia hospitalƒcare.ƒThus,ƒevenƒthoughƒoneƒofƒtheƒmainƒobjectivesƒofƒtheƒhealthƒ systemƒreformƒisƒtoƒimproveƒequityƒinƒhealthƒcare,ƒtheƒimplementationƒofƒ theƒexemptionƒmechanismƒfailsƒtoƒprotectƒtheƒtargeted groups. InformalƒpaymentsƒareƒaƒcommonƒpracticeƒinƒtheƒSerbianƒhealthƒsystem,ƒ withƒnegativeƒeffectsƒonƒfinancialƒprotectionƒandƒconsumersƒinƒhealthƒcareƒ (CFED,ƒ2015).ƒAccordingƒtoƒtheƒEuroƒHealthƒConsumerƒIndexƒreport,ƒinƒ 2016ƒSerbiaƒhadƒoneƒofƒtheƒlowestƒscoresƒofƒtheƒindicatorƒ“Under-the-tableƒ paymentsƒtoƒdoctors”,ƒwhichƒmeansƒthatƒpatientsƒwereƒfrequentlyƒexpectedƒ toƒmakeƒunofficialƒpaymentsƒtoƒdoctorsƒforƒtheirƒservicesƒ(Björnberg,ƒ2017).ƒ Serbianƒwomenƒwereƒmoreƒlikelyƒtoƒpayƒa bribeƒin-kindƒ(foodƒandƒdrink),ƒ whileƒmenƒwereƒmoreƒlikelyƒtoƒuseƒmoney.ƒCashƒaccountsƒforƒ52%ƒofƒallƒ bribesƒinƒSerbiaƒandƒisƒapproximatelyƒ205ƒeurosƒperƒpersonƒperƒyearƒ(Theƒ EconomistƒIntelligenceƒUnit,ƒ2016).ƒTheƒgovernmentƒhasƒnoƒabilityƒtoƒcontrolƒ informalƒpaymentsƒandƒthusƒtheyƒremainƒunregistered.ƒPaymentsƒforƒ“boughtƒ andƒbroughtƒgoods”ƒareƒpositiveƒinƒtheƒviewƒofƒhealthƒcareƒusers,ƒandƒtheyƒ takeƒtheƒhighestƒshareƒofƒtheƒtotalƒannualƒhouseholdƒbudgetƒ(Arsenijevic,ƒ Pavlovaƒ&ƒGroot,ƒ2015). TheƒstudyƒbyƒArsenijevic,ƒPavlovaƒ&ƒGrootƒ(2015)ƒfoundƒthatƒ93.9%ƒofƒ healthƒcareƒusersƒinƒSerbiaƒreportedƒsomeƒtypeƒofƒOOPƒpaymentsƒforƒpublicƒ healthƒcareƒservices.ƒMostƒofƒthemƒreportedƒofficialƒco-paymentsƒ(84.7%)ƒ andƒpaymentsƒforƒ“boughtƒandƒbroughtƒgoods”ƒ(61.1%),ƒwhereasƒonlyƒ5.7%ƒ paidƒinformally.ƒTheƒWorldƒBankƒreportedƒthatƒtheƒincidenceƒofƒcatastrophicƒ paymentsƒinƒ2010ƒisƒthreeƒtimesƒhigherƒinƒtheƒpoorestƒquintile.ƒNearlyƒ25%ƒ ofƒolderƒcitizensƒhaveƒhadƒtoƒdealƒwithƒcatastrophicƒpayments,ƒmostlyƒforƒ medicinesƒ(WorldƒBank,ƒ2015b). 7.4  Health care quality Qualityƒofƒcareƒisƒrecognizedƒbyƒtheƒgovernmentƒasƒoneƒofƒtheƒmostƒimportantƒ characteristicsƒofƒtheƒhealthƒsystemƒinƒbothƒtheƒpublicƒandƒprivateƒsector.ƒ Continuousƒqualityƒandƒpatientƒsafetyƒimprovementsƒareƒanticipatedƒtoƒbeƒ anƒintegralƒpartƒofƒeverydayƒactivitiesƒofƒallƒemployeesƒinƒtheƒhealthƒsystemƒ (OfficialƒGazette,ƒ2009d). Inƒ2009,ƒtheƒGovernmentƒofƒSerbiaƒadoptedƒtheƒNationalƒStrategyƒforƒ ContinuousƒStrategyƒforƒContinuousƒImprovementƒofƒHealthƒCareƒQualityƒ andƒPatientƒSafetyƒ(OfficialƒGazette,ƒ2009d)ƒwithƒobjectivesƒtoƒreduce:ƒtheƒ 166 Health Systems in Transition unevenƒqualityƒofƒhealthƒservices;ƒtheƒunacceptableƒlevelƒofƒvariationƒinƒhealthƒ outcomesƒofƒtreatedƒpatients;ƒtheƒineffectiveƒuseƒofƒhealthƒtechnologies;ƒ waitingƒtimesƒforƒmedicalƒproceduresƒandƒinterventions;ƒtheƒdissatisfactionƒ ofƒusersƒwithƒprovidedƒhealthƒservices;ƒtheƒdissatisfactionƒofƒemployeesƒinƒ theƒhealthƒsystem;ƒandƒtheƒcostsƒincurredƒdueƒtoƒpoor quality. Inƒ2007,ƒaƒRulebookƒonƒHealthƒCareƒQualityƒIndicatorsƒwasƒadoptedƒ andƒcameƒintoƒeffectƒinƒ2010ƒ(OfficialƒGazette,ƒ2010d),ƒwithƒtheƒpurposeƒofƒ establishingƒbasicƒqualityƒindicatorsƒinƒhealthƒcare.ƒTheƒIPHƒBatutƒproducedƒ methodologicalƒguidelinesƒforƒtheƒreportingƒofƒhealthƒcareƒqualityƒindica- torsƒbyƒhealthƒinstitutions,ƒwithƒdefinedƒmethodsƒofƒcollecting,ƒmonitoring,ƒ calculatingƒandƒreportingƒhealthƒcareƒquality indicators. Sinceƒ2004,ƒtheƒMinistryƒofƒHealthƒhasƒcarriedƒoutƒreformsƒtoƒimproveƒ qualityƒofƒcare,ƒincluding:ƒtheƒreconstructionƒofƒhealthƒcareƒcentresƒandƒsomeƒ hospitalsƒandƒclinicalƒcentres,ƒtheƒupgradingƒofƒmedicalƒequipment,ƒtheƒ creationƒofƒprofessionalƒchambersƒ(doctors,ƒnurses,ƒdentists,ƒpharmacists)ƒ inƒchargeƒofƒlicensingƒhealthƒprofessionals,ƒandƒtheƒcreationƒofƒtheƒPublicƒ AgencyƒforƒAccreditationƒandƒContinuousƒQualityƒImprovementƒofƒHealthƒ Careƒin Serbia. Theƒpercentageƒofƒchildrenƒunderƒ1ƒyearƒwhoƒhaveƒreceivedƒthreeƒdosesƒ ofƒtheƒcombinedƒdiphtheria-tetanus-pertussisƒvaccineƒ(DTP)ƒinƒ2017ƒwasƒ 94%,ƒforƒtheƒfirstƒdoseƒofƒMMRƒwasƒ81%ƒandƒforƒtheƒsecondƒdoseƒwasƒ91.1%ƒ (IPHƒBatut,ƒ2018g).ƒCompleteƒimmunizationƒcoverageƒofƒchildrenƒatƒtheƒ ageƒofƒ15ƒwasƒ78.7%ƒ(IPHƒBatut,ƒ2018e).ƒInƒ2012ƒtheƒgoalƒofƒ99%ƒcoverageƒ forƒallƒchildrenƒwithƒcompleteƒimmunizationƒwasƒnotƒachievedƒforƒtheƒfirstƒ timeƒdueƒtoƒaƒshortageƒofƒvaccinesƒwhichƒledƒtoƒaƒhigherƒincidenceƒratesƒ ofƒvaccineƒpreventableƒdiseasesƒinƒtheƒyearsƒfollowing.ƒTheƒshareƒofƒtheseƒ diseasesƒinƒtotalƒreportedƒcasesƒofƒcommunicableƒdiseasesƒwasƒ0.14%ƒinƒ2016ƒ andƒ0.23%ƒinƒ2012ƒcomparedƒwithƒ0.09%ƒinƒ2010ƒ(IPHƒBatut,ƒ2018g).ƒFullƒ immunizationƒcoverageƒforƒchildrenƒinƒRomaƒsettlementsƒisƒsignificantlyƒ lowerƒ(44%)ƒdueƒtoƒaccessƒbarriersƒthanƒforƒtheƒgeneralƒpopulation,ƒwhileƒ DTPƒandƒmeaslesƒimmunizationƒcoverageƒratesƒareƒ64.5%ƒandƒ63.3%,ƒrespec- tivelyƒ(SORSƒ&ƒUNICEF,ƒ2014).ƒTheƒGovernmentƒofƒSerbia,ƒasƒaƒpartƒofƒ theƒMillenniumƒDevelopmentƒGoals,ƒproposedƒandƒimplementedƒmeasuresƒ toƒreachƒtheƒgoalƒofƒ99%ƒcompleteƒimmunizationƒcoverageƒforƒallƒchildren.ƒ Measureƒimplementedƒincluded:ƒactivitiesƒonƒsocialƒmobilization,ƒinvolve- mentƒofƒallƒrelevantƒpartnersƒinƒtheƒimplementationƒofƒtheƒimmunizationƒ programmes,ƒharmonizationƒofƒtheƒworkƒwithƒtheƒneedsƒofƒtheƒcommunityƒ 167Serbia (e.g.ƒmobileƒteamsƒforƒtheƒvaccinationƒofƒRomaƒchildren),ƒcontinuationƒofƒtheƒ currentƒgoodƒpracticesƒ(localƒ“ImmunizationƒDays”)ƒandƒestablishmentƒofƒaƒ monitoringƒsystemƒ(GovernmentƒofƒSerbia,ƒ2006).ƒTheƒcoverageƒofƒinfluenzaƒ vaccinationƒforƒpeopleƒoverƒ65ƒyearsƒofƒageƒinƒSerbiaƒisƒ12.0%ƒ(IPHƒBatut,ƒ 2018e)ƒwhichƒisƒlowerƒthanƒinƒmostƒEUƒcountriesƒ(ECDC,ƒ2017). Patientƒsafetyƒhasƒbeenƒmeasuredƒusingƒ13ƒdifferentƒindicatorsƒaccord- ingƒtoƒtheƒRulebookƒonƒHealthƒCareƒQualityƒIndicatorsƒ(OfficialƒGazette,ƒ 2010d).ƒTheƒlackƒofƒhigh-qualityƒdataƒdueƒtoƒincompleteƒrecordingƒandƒ reportingƒofƒadverseƒeventsƒandƒincidentsƒinƒtheƒhealthƒsystemƒisƒproblematic.ƒ Healthƒprofessionalsƒdoƒnotƒrecognizeƒneedƒforƒrecordingƒandƒanalysingƒsuchƒ eventsƒandƒitƒisƒveryƒimportantƒtoƒraiseƒtheirƒawarenessƒonƒtheseƒmatters.ƒ Unfortunately,ƒthereƒareƒnoƒincentivesƒsupportingƒthis.ƒTheƒsameƒisƒtrueƒforƒ theƒrecordingƒofƒhospitalƒandƒsurgicalƒwoundƒinfectionsƒ(averageƒratesƒforƒ inpatientƒinstitutionsƒinƒ2016ƒwereƒ1.5ƒandƒ1.2,ƒrespectively).ƒSterilizationƒ controlƒinƒhealthƒinstitutionsƒisƒnotƒbeingƒundertakenƒfrequently,ƒthatƒis,ƒtheƒ regulationsƒthatƒrequireƒtheƒcontrolƒofƒtheƒfrequencyƒofƒbiologicalƒsteriliza- tionsƒareƒnotƒfullyƒrespected,ƒwhichƒconsequentlyƒleadsƒtoƒhigherƒnumbersƒ ofƒhospitalƒandƒsurgicalƒwoundƒinfections.ƒDecubitusƒulcersƒandƒthrom- boembolicƒcomplicationƒratesƒduringƒhospitalizationƒperƒ1 000ƒdischargedƒ patientsƒhaveƒdecreasedƒinƒrecentƒyearsƒandƒwereƒ2.1ƒandƒ0.3ƒinƒaverageƒinƒ 2017,ƒrespectivelyƒ(IPHƒBatut,ƒ2018e). Inƒtermsƒofƒindicatorsƒforƒdrugƒprescribingƒwhichƒmeasureƒqualityƒofƒ prescribingƒinƒprimaryƒcare,ƒtheƒaverageƒannualƒnumberƒofƒprescriptionƒ drugsƒperƒinsuredƒpersonƒwasƒ12ƒtoƒ14ƒinƒtheƒperiodƒ2001–2013,ƒwhichƒisƒ aboutƒtwiceƒtheƒaverageƒofƒEUƒcountries.ƒThisƒsuggestsƒover-prescriptionƒofƒ medicines,ƒespeciallyƒantibioticsƒ(EY,ƒ2016).ƒIn-hospitalƒmortalityƒratesƒandƒ avoidableƒhospitalƒadmissionƒratesƒforƒchronicƒdiseasesƒandƒpatient-reportedƒ outcomeƒmeasuresƒareƒnotƒbeing monitored. 7.5  Health system outcomes Sinceƒ2004,ƒSerbiaƒhasƒmadeƒconsiderableƒprogressƒregardingƒlifeƒexpectancyƒ andƒtheƒreductionƒofƒinfantƒmortality,ƒalthoughƒitƒstillƒlagsƒbehindƒtheƒEUƒ average.ƒInfantƒmortalityƒratesƒhaveƒdeclinedƒsteadilyƒ(fromƒ7.4ƒinƒ2006ƒtoƒ 4.7ƒinƒ2017;ƒEUƒaverageƒofƒ3.6ƒinƒ2017),ƒwhereasƒlifeƒexpectancyƒatƒbirthƒ increasedƒtoƒ75.6ƒyearsƒinƒ2017ƒ(73.4ƒinƒ2006;ƒEUƒaverageƒofƒ81.0ƒinƒ2017)ƒ (Eurostat,ƒ2019). 168 Health Systems in Transition TheƒhighestƒburdenƒofƒdiseaseƒinƒSerbiaƒisƒdueƒtoƒnoncommunicableƒ diseasesƒ(NCDs).ƒTheyƒareƒestimatedƒtoƒaccountƒforƒ95%ƒofƒtotalƒdeaths.ƒ Cardiovascularƒdiseasesƒareƒtheƒleadingƒcauseƒofƒdeathƒ(54%),ƒfollowedƒbyƒ cancersƒ(22%),ƒchronicƒrespiratoryƒdiseasesƒ(5%)ƒandƒdiabetesƒ(3%)ƒ(WHO,ƒ 2018b).ƒStandardizedƒdeathƒratesƒfromƒcardiovascularƒdiseaseƒandƒcancerƒ perƒ100 000ƒpopulationƒareƒamongƒtheƒhighestƒinƒEurope,ƒandƒinƒ2013ƒwereƒ 991ƒforƒmalesƒandƒ836ƒforƒfemalesƒforƒcardiovascularƒdiseaseƒ(Townsendƒetƒ al.,ƒ2015),ƒandƒinƒ2016ƒwereƒ388ƒforƒcancerƒforƒmalesƒandƒ232ƒforƒfemalesƒ (Eurostat,ƒ2019).ƒHighƒmortalityƒratesƒcanƒpartlyƒbeƒexplainedƒbyƒlackƒofƒ timelinessƒinƒvisitingƒaƒdoctorƒandƒsubsequentƒdiagnosisƒatƒaƒlaterƒstageƒofƒ theƒdiseaseƒwhenƒtreatmentƒisƒlessƒsuccessfulƒandƒdeathƒisƒmoreƒlikelyƒ(e.g.ƒ diagnosisƒofƒstrokeƒafterƒtheƒpointƒinƒtimeƒwhenƒthrombolyticƒtherapyƒorƒ mechanicalƒthrombusƒextractionƒfromƒtheƒcloggedƒbloodƒvesselƒcouldƒhaveƒ givenƒresults,ƒorƒinoperableƒstagesƒofƒbreast,ƒcervicalƒandƒcolorectalƒcancers).ƒ Asƒinƒotherƒmiddle-incomeƒEuropeanƒcountriesƒinƒtheƒregion,ƒtheƒhealthƒ systemƒisƒunableƒtoƒrespondƒadequatelyƒtoƒallƒchallengesƒofƒNCDs.ƒTheƒ inabilityƒtoƒuseƒtheƒnewestƒdrugsƒforƒallƒcancerƒpatientsƒinƒneed,ƒasƒwellƒasƒ longerƒwaitingƒlistsƒforƒradiotherapyƒ(WorldƒBank,ƒ2018c),ƒareƒjustƒsomeƒ ofƒtheƒreasonsƒforƒhigherƒmortalityƒrates.ƒDespiteƒtheƒexistenceƒofƒnationalƒ programmesƒforƒearlyƒdetectionƒofƒbreast,ƒcervicalƒandƒcolorectalƒcancersƒ andƒEUƒprojectsƒthatƒsupportedƒtheƒorganizationƒofƒscreeningƒforƒselectedƒ municipalitiesƒinƒSerbiaƒ(e.g.ƒopeningƒofƒtheƒNationalƒCancerƒScreeningƒ Office)ƒ(seeƒsectionƒ5.1.7),ƒtheƒcoverageƒofƒtheƒtargetƒpopulationƒisƒstillƒlowƒ (e.g.ƒ11.4%ƒforƒbreastƒcancer,ƒ15.8%ƒforƒcervicalƒcancer,ƒ5.0%ƒforƒcolorectalƒ cancer)ƒ(IPHƒBatut,ƒ2018e).ƒThereƒisƒnoƒavailableƒdataƒinƒSerbiaƒforƒ5-yearƒ cancerƒsurvivalƒratesƒ(forƒbreast,ƒcervicalƒandƒcolorectalƒcancers),ƒneitherƒforƒ mortalityƒamenableƒtoƒmedical intervention. TheƒhighƒburdenƒofƒNCDsƒisƒrelatedƒtoƒaƒhighƒprevalenceƒofƒriskƒfactorsƒ suchƒasƒtobaccoƒuse,ƒalcoholƒconsumption,ƒunhealthyƒdiet,ƒobesityƒandƒhighƒ bloodƒpressure,ƒamongƒothersƒ(seeƒsectionƒ1.4).ƒTheƒNationalƒHealthƒSurveyƒ inƒ2013ƒshowedƒthatƒ35.8%ƒofƒadultsƒwereƒsmokers,ƒhigherƒthanƒinƒtheƒ previousƒsurveyƒinƒ2006ƒ(33.6%),ƒbutƒlowerƒthanƒinƒ2000ƒ(40.5%).ƒAlso,ƒ theƒprevalenceƒrateƒofƒdailyƒsmokersƒshowedƒaƒsignificantƒincreaseƒinƒtheƒ 6-yearƒperiodƒ(29.2%ƒinƒ2013ƒversusƒ26.2%ƒinƒ2006).ƒAƒhigherƒpercentageƒ ofƒsmokingƒwasƒrecordedƒinƒmenƒcomparedƒwithƒwomenƒ(39.4%ƒversusƒ 32.4%),ƒinƒurbanƒsettlementsƒandƒamongƒpersonsƒwithƒtheƒlowestƒincome.ƒ Moreƒthanƒhalfƒofƒtheƒpopulationƒ(54.4%)ƒwasƒexposedƒtoƒtobaccoƒsmokeƒinƒ closedƒpremisesƒinƒ2013ƒ(MinistryƒofƒHealth,ƒ2014).ƒInƒSerbia,ƒinƒtheƒlastƒ 169Serbia 15ƒyears,ƒseveralƒsmoke-freeƒlawsƒhaveƒbeenƒintroduced,ƒwhichƒproposedƒ exciseƒandƒlabelsƒonƒtobaccoƒproducts,ƒhigherƒpricesƒforƒcigarettes,ƒobliga- toryƒhealthƒwarningsƒonƒcigaretteƒpackagesƒandƒaƒbanƒonƒadvertisingƒandƒ sponsorshipƒbyƒtheƒtobaccoƒindustryƒ(MinistryƒofƒHealth,ƒ2007).ƒInƒ2010,ƒ theƒSerbianƒGovernmentƒadoptedƒtheƒnewƒ2010ƒLawƒonƒProtectionƒfromƒ ExposureƒtoƒSecond-HandƒSmokeƒ(OfficialƒGazette,ƒ2010e)ƒwhichƒbansƒ smokingƒinƒallƒpublicƒandƒworkplacesƒandƒinƒpublicƒtransportƒ(althoughƒtheƒ hospitalityƒsectorƒwasƒexempted).ƒResultsƒfromƒtheƒsurveyƒinƒ2013ƒpointedƒ outƒaƒneedƒtoƒimproveƒenforcementƒofƒexistingƒlegalƒregulations,ƒasƒwellƒasƒ toƒintroduceƒtheƒbanƒonƒsmokingƒinƒtheƒhospitalityƒsector,ƒasƒsmokingƒinƒ cafes,ƒrestaurantsƒandƒpubsƒisƒstillƒallowedƒ(seeƒsectionƒ5.1). Theƒprevalenceƒofƒdailyƒalcoholƒdrinkersƒwasƒ4.7%ƒinƒ2013,ƒanƒincreaseƒ overƒ2006ƒ(3.4%).ƒMenƒareƒalmostƒsixƒtimesƒmoreƒlikelyƒtoƒdrinkƒalcoholƒ thanƒwomenƒ(8.3%ƒversusƒ1.3%).ƒAlso,ƒtheƒhabitƒofƒdailyƒdrinkingƒisƒtheƒ highestƒamongƒtheƒpoorestƒpopulation.ƒRegardingƒbingeƒdrinkingƒatƒleastƒ onceƒaƒweekƒ(definedƒasƒmoreƒthanƒsixƒalcoholicƒdrinksƒperƒoccasion),ƒtheƒ prevalenceƒrateƒwasƒ4.3%,ƒwhileƒ16%ƒofƒtheƒpopulationƒengagedƒinƒbingeƒ drinkingƒatƒleastƒonceƒaƒmonthƒ(MinistryƒofƒHealth,ƒ2014).ƒTheƒmainƒchal- lengeƒisƒtheƒlackƒofƒaƒnationalƒpolicy,ƒstrategyƒorƒactionƒplanƒtoƒreduceƒtheƒ harmfulƒuseƒof alcohol. Inƒ2013,ƒ40.4%ƒofƒpersonsƒ(aboveƒ15ƒyears)ƒwereƒofƒnormalƒweightƒ andƒmoreƒthanƒhalfƒ(56.3%)ƒwereƒoverweightƒinƒSerbia,ƒaccordingƒtoƒtheirƒ measuredƒBMI.ƒThereƒwasƒaƒsignificantƒincreaseƒinƒtheƒprevalenceƒofƒobesityƒ betweenƒtheƒtwoƒnationalƒhealthƒsurveysƒ(fromƒ17.3%ƒinƒ2006ƒtoƒ21.2%ƒinƒ 2013).ƒAƒconsiderablyƒhigherƒpercentageƒofƒoverweightƒpeopleƒwasƒrecordedƒ amongƒtheƒpoor,ƒleastƒeducatedƒpopulationƒandƒthoseƒwhoƒliveƒinƒnon-urbanƒ settlements.ƒObesityƒratesƒwereƒhigherƒinƒwomenƒ(22.2%)ƒthanƒinƒmenƒ (20.1%),ƒwhileƒtheƒoppositeƒappliesƒtoƒoverweightƒ(41.4%ƒinƒmenƒversusƒ 29.1%ƒinƒwomen)ƒ(MinistryƒofƒHealth,ƒ2014). Almostƒhalfƒofƒtheƒadultƒpopulationƒ(47.5%)ƒhadƒdiastolicƒand/orƒsystolicƒ hypertensionƒinƒ2013,ƒwithƒaƒhigherƒprevalenceƒratesƒamong men. 7.5.1 Equity of outcomes Serbiaƒexperiencesƒlargeƒhealthƒinequalities,ƒwhichƒrepresentƒaƒgreatƒchal- lenge.ƒTheƒresultsƒofƒseveralƒstudiesƒshowedƒaƒclearƒassociationƒbetweenƒ sociodemographicƒdeterminantsƒ andƒhealthƒ statusƒ andƒconfirmedƒ theƒ 170 Health Systems in Transition presenceƒofƒsocioeconomicƒinequalitiesƒinƒmorbidityƒ(Jankovic,ƒMarinkovicƒ &ƒSimic,ƒ2011;ƒJankovic,ƒJanevicƒ&ƒvonƒdemƒKnesebeck,ƒ2012;ƒJanevic,ƒ Jankovicƒ&ƒBradley,ƒ2012).ƒComparedƒwithƒpeopleƒwithƒhigherƒeducation,ƒ lowerƒeducatedƒpeopleƒhaveƒaƒ4.5ƒtimesƒhigherƒchanceƒofƒassessingƒtheirƒ healthƒasƒpoor.ƒAlso,ƒtheƒunemployed,ƒinactive,ƒandƒtheƒmostƒdeprivedƒpeopleƒ areƒmoreƒlikelyƒtoƒreportƒpoorƒself-perceivedƒhealthƒthanƒemployedƒpersonsƒ andƒtheƒmostƒaff luentƒgroupƒ(Jankovic,ƒJanevicƒ&ƒvonƒdemƒKnesebeck,ƒ 2012).ƒAccordingƒtoƒanotherƒstudy,ƒwomen,ƒolderƒpeople,ƒthoseƒwhoƒliveƒinƒ urbanƒsettings,ƒandƒthoseƒwithƒlowerƒeducationƒhaveƒhigherƒmorbidityƒscoresƒ (Jankovic,ƒMarinkovicƒ&ƒSimic,ƒ2011).ƒAccordingƒtoƒtheƒlastƒNationalƒHealthƒ Survey,ƒwomen,ƒpeopleƒwithƒbasicƒorƒlowerƒlevelƒofƒeducationƒandƒpersonsƒinƒ theƒpoorestƒcategoryƒofƒtheƒwealthƒindexƒ(lowestƒwealthƒindexƒquintile)ƒareƒ moreƒlikelyƒtoƒreportƒchronicƒdiseasesƒ(MinistryƒofƒHealth,ƒ2014)ƒ(Fig.ƒ7.1). Inƒ2013,ƒmoreƒthanƒhalfƒtheƒpopulationƒ(57.8%)ƒconsideredƒtheirƒhealthƒ asƒgoodƒ(significantlyƒmoreƒinƒBelgradeƒ–ƒ61.7%),ƒ26.6%ƒasƒaverage,ƒandƒ 15.6%ƒassessedƒtheirƒhealthƒasƒpoorƒ(considerablyƒmoreƒinƒsouthernƒandƒ easternƒSerbiaƒ–ƒ18.3%).ƒAlso,ƒaƒsignificantlyƒhigherƒpercentageƒofƒpersonsƒ withƒaƒlong-termƒdisease/healthƒproblemƒwasƒinƒtheƒgroupƒofƒthoseƒwhoƒliveƒ inƒsouthernƒandƒeasternƒSerbiaƒ(43.6%)ƒ(MinistryƒofƒHealth,ƒ2014). FIGURE 7.1 Population in Serbia who reported to have some long-term disease/ health problem by wealth index quintile, 2013 0 10 20 30 40 50 60 TotalFifth (richest) FourthThird SecondFirst (poorest) % 50.5 43.1 40.3 35.8 29.5 40.0 Wealth index quintile Source: Ministry of Health, 2014 171Serbia Highƒprevalenceƒratesƒforƒriskƒfactorsƒsuchƒasƒsmoking,ƒalcoholƒconsump- tionƒandƒhypertensionƒareƒconcentratedƒamongƒmen,ƒpoorƒcitizensƒandƒpeopleƒ withƒlowerƒeducationalƒlevelƒ(MinistryƒofƒHealth,ƒ2014). Theƒhealthƒstatusƒofƒvulnerableƒpopulationƒgroups,ƒespeciallyƒRoma,ƒ isƒcompromised.ƒJanevicƒetƒal.ƒ(2012)ƒobservedƒthatƒRomaƒareƒmoreƒthanƒ twiceƒasƒlikelyƒasƒnon-Romaƒtoƒdeclareƒpoorƒself-reportedƒhealth.ƒTheƒinfantƒ mortalityƒrateƒandƒtheƒunder-5ƒyearsƒmortalityƒrateƒinƒRomaƒsettlementsƒareƒ moreƒthanƒtwoƒtimesƒhigherƒcomparedƒwithƒtheƒdomicileƒpopulationƒandƒ areƒestimatedƒatƒ12.8ƒandƒ14.4ƒinƒ2014,ƒrespectivelyƒ(SORSƒ&ƒUNICEF,ƒ 2014).ƒAlso,ƒsmokingƒprevalenceƒamongƒRomaƒisƒhigherƒthanƒinƒnon-Romaƒ communities.ƒAƒstudyƒconductedƒinƒ2010ƒbyƒtheƒUnitedƒNationsƒPopulationƒ FundƒamongƒoneƒthousandƒrespondentsƒlivingƒinƒRomaniƒsettlementsƒshowedƒ thatƒ53.8%ƒofƒRomaƒareƒsmokers,ƒwhichƒisƒsignificantlyƒhigherƒthanƒinƒtheƒ generalƒpopulationƒ(34.7%)ƒ(UNFPA,ƒ2010). 7.5.2 Reducing inequalities in health TheƒEuropeanƒintegrationƒprocess,ƒasƒtheƒmainƒmechanismƒforƒleadingƒ dialogueƒonƒtheƒprioritiesƒofƒSerbiaƒinƒtheƒfieldƒofƒsocialƒpolicyƒandƒemploy- ment,ƒisƒcontributingƒtoƒreductionƒofƒinequalitiesƒinƒhealthƒ(SIPRU,ƒ2018).ƒ TheƒEmploymentƒandƒSocialƒReformƒProgrammeƒ(ESRP)ƒwasƒofficiallyƒ launchedƒinƒSeptemberƒ2013ƒbyƒtheƒGovernmentƒofƒSerbiaƒandƒcoversƒtheƒ issuesƒofƒlabourƒmarketƒandƒemployment,ƒhumanƒcapitalƒandƒskills,ƒsocialƒ inclusionƒandƒsocialƒwelfare,ƒandƒpensionƒandƒhealthƒsystems.ƒSpecificƒfocusƒ isƒonƒyouthƒemploymentƒdueƒtoƒaƒhighƒunemploymentƒrateƒamongƒyouth.ƒ Theƒmostƒrelevantƒcross-sectorƒstrategiesƒwhichƒtackleƒsocialƒinclusionƒandƒ henceƒinequalitiesƒare:ƒtheƒ2013ƒStrategyƒforƒPreventionƒandƒProtectionƒ againstƒDiscriminationƒ(OfficialƒGazette,ƒ2013q),ƒtheƒ2016ƒStrategyƒforƒ SocialƒInclusionƒofƒRomaƒforƒtheƒperiodƒ2016–2025ƒ(OfficialƒGazette,ƒ2016e)ƒ andƒtheƒ2009ƒNationalƒStrategyƒforƒImprovingƒtheƒPositionƒofƒWomenƒandƒ PromotingƒGenderƒEqualityƒ(OfficialƒGazette,ƒ2009o). 172 Health Systems in Transition 7.6  Health system efficiency 7.6.1 Allocative efficiency Thereƒareƒcurrentlyƒnoƒsystemsƒinƒplaceƒtoƒmonitorƒtheƒperformanceƒofƒtheƒ healthƒsystemƒinƒgeneral,ƒandƒtoƒassessƒitsƒefficiency.ƒForƒexample,ƒthereƒ isƒnoƒinformationƒonƒwhetherƒtheƒdecisionsƒtoƒexpandƒtheƒsocialƒhealthƒ insuranceƒbenefitƒpackageƒorƒreimburseƒnewƒexpensiveƒdrugsƒorƒproceduresƒ areƒcost-effective.ƒDespiteƒtheƒfactƒthatƒSerbiaƒspendsƒ8.8%ƒofƒitsƒGDPƒonƒ healthƒ(2017ƒdata),ƒthereƒisƒaƒmismatchƒbetweenƒhealthƒspendingƒandƒhealthƒ outcomes,ƒdueƒtoƒfactorsƒsuchƒasƒcorruption,ƒoldƒequipmentƒandƒfacilities,ƒ inefficiencyƒinƒhospitals,ƒpoorƒqualityƒofƒservicesƒandƒwaitingƒlists,ƒallƒleadingƒ toƒpoorƒhealthƒoutcomesƒ(TheƒEconomistƒIntelligenceƒUnit,ƒ2016;ƒWorldƒ Bank,ƒ2015b). Curativeƒandƒrehabilitativeƒservicesƒaccountƒforƒaboutƒhalfƒofƒtotalƒhealthƒ expenditure,ƒwhichƒisƒsimilarƒtoƒtheƒOECDƒaverage,ƒwhileƒspendingƒonƒpre- ventionƒandƒpublicƒhealthƒservicesƒ(aroundƒ7.5%)ƒisƒhigherƒthanƒtheƒOECDƒ averageƒ(aroundƒ2.7%)ƒ(WorldƒBank,ƒ2015b). Regardingƒtheƒallocationƒofƒresourcesƒtoƒdifferentƒsectors,ƒhospitalsƒ accountƒforƒtheƒlargestƒshareƒofƒtheƒNHIFƒbudget,ƒwithƒ51%ƒofƒtotalƒexpensesƒ inƒ2014ƒ(expensesƒforƒsecondaryƒandƒtertiaryƒlevelƒofƒhealthƒcare).ƒHealthƒcareƒ spendingƒforƒprimaryƒhealthƒcareƒinstitutionsƒwasƒtwoƒandƒaƒhalfƒtimesƒlowerƒ thanƒforƒhospitalsƒ(20.3%ƒofƒtotalƒNHIFƒexpenses)ƒ(EY,ƒ2016).ƒBudgetsƒareƒ allocatedƒbasedƒonƒhistoricalƒvolumes,ƒwithƒnoƒgeneralƒneeds-basedƒresourceƒ allocationƒformulaƒorƒappliedƒmethodology.ƒTheƒsystemƒreliesƒexcessivelyƒ onƒinpatientƒcare,ƒadmittingƒpatientsƒtoƒhospitalsƒforƒproceduresƒthatƒcouldƒ beƒhandledƒinƒprimaryƒcare.ƒItƒisƒalsoƒpossibleƒthatƒhospitalsƒareƒnotƒusingƒ theƒmostƒcost-effectiveƒcombinationƒofƒfactorsƒinƒprovidingƒcareƒ(Worldƒ Bank,ƒ2009). PharmaceuticalsƒareƒanƒimportantƒdriverƒofƒspendingƒinƒSerbia.ƒTheƒ latestƒdataƒfromƒ2013ƒshowƒthatƒtotalƒpharmaceuticalƒspendingƒ(publicƒandƒ private)ƒasƒaƒshareƒofƒtotalƒhealthƒspendingƒthatƒyearƒwasƒhigherƒinƒSerbiaƒ (31%)ƒthanƒtheƒaverageƒforƒtheƒwesternƒBalkansƒregionƒ(18.4%)ƒorƒtheƒEUƒ averageƒ(20.4%)ƒ(MinistryƒofƒHealth,ƒ2014).ƒThereƒareƒhighƒprivateƒOOPƒ paymentsƒonƒdrugsƒdespiteƒhighƒgovernmentƒspending,ƒwhichƒindicatesƒgapsƒ andƒinefficienciesƒinƒpublicƒsectorƒprovisionƒ(WorldƒBank,ƒ2015b). TheƒfinancingƒofƒtheƒSerbianƒpublicƒhealthƒsystem,ƒasƒwellƒasƒtheƒprep- arationƒandƒadoptionƒofƒtheƒbudgetƒandƒfinancialƒplansƒofƒtheƒNHIFƒisƒ 173Serbia regulatedƒbyƒtheƒ2009ƒLawƒonƒtheƒBudgetƒSystemƒ(OfficialƒGazette,ƒ2009b).ƒ However,ƒplanningƒandƒbudgetingƒinsideƒtheƒhealthƒsystemƒareƒnotƒalignedƒ withƒtheƒbudgetƒcalendarƒandƒfiscalƒstrategy.ƒNoteƒthatƒtheƒprocessƒofƒprepa- rationƒandƒadoptionƒofƒtheƒbudgetƒandƒfinancialƒplansƒofƒorganizationsƒforƒ mandatoryƒsocialƒinsuranceƒisƒcarriedƒoutƒaccordingƒtoƒtheƒbudgetƒcalendar,ƒ andƒ15ƒDecemberƒisƒtheƒfinalƒdateƒwhenƒtheƒNationalƒAssemblyƒdecidesƒ onƒtheƒapprovalƒofƒtheseƒfinancialƒplans;ƒtheƒfiscalƒstrategyƒisƒadoptedƒbyƒ theƒNationalƒAssemblyƒinƒJanuary.ƒInƒtheƒmeantime,ƒallƒpublicƒinstitutionsƒ haveƒanƒobligationƒtoƒdeliverƒdraftsƒandƒfinalƒbudgetƒplansƒprescribedƒbyƒtheƒ law.ƒHence,ƒplanningƒandƒbudgetingƒinsideƒtheƒsystemƒisƒnotƒfunctioningƒ properlyƒandƒthisƒisƒofƒcrucialƒimportanceƒforƒtheƒfinancialƒsustainabilityƒofƒ theƒsystemƒ(EY,ƒ2016). Theƒ useƒ ofƒ Healthƒ Technologyƒ Assessmentƒ (HTA)ƒ toƒ increaseƒ cost–effectivenessƒisƒnotƒyetƒcommonƒinƒSerbia,ƒthereƒisƒnoƒofficialƒHTAƒ AgencyƒandƒSerbiaƒisƒnotƒaƒmemberƒofƒtheƒEuropeanƒNetworkƒforƒHealthƒ Technology Assessment. 7.6.2 Technical efficiency IndicatorsƒforƒmeasuringƒefficiencyƒinƒtheƒSerbianƒhealthƒsystemƒshowƒthatƒ SerbiaƒdoesƒnotƒperformƒasƒwellƒasƒEUƒcountriesƒforƒbothƒprimaryƒandƒ inpatient care. Thoughƒoutpatientƒcontactƒratesƒareƒrelativelyƒhigh,ƒthatƒisƒnotƒtrueƒ forƒpreventiveƒandƒprimaryƒhealthƒcareƒservices,ƒdespiteƒtheƒrelativelyƒhighƒ spendingƒonƒprevention.ƒTheƒshareƒofƒpreventiveƒcheck-upsƒinƒtheƒtotalƒ numberƒofƒallƒcheck-upsƒatƒprimaryƒhealthƒcareƒlevelƒinƒ2015ƒwasƒ4%,ƒwhichƒ isƒaƒgreatƒconcern.ƒBudgetsƒallocatedƒtoƒoutputsƒareƒnotƒlinkedƒtoƒqualityƒ ofƒcare,ƒwhichƒshowƒtheƒneedƒforƒproviderƒpaymentƒreformsƒtoƒstimulateƒ efficiencyƒinƒprimaryƒcareƒ(WorldƒBank,ƒ2015b;ƒIPHƒBatut,ƒ2017i). Theƒhospitalizationƒrateƒ(hospitalƒdischarges)ƒinƒSerbiaƒ(179ƒperƒ1 000)ƒ isƒhigherƒthanƒtheƒOECDƒaverageƒ(156ƒperƒ1 000)ƒandƒtheƒaverageƒforƒtheƒ westernƒBalkansƒ(117ƒperƒ1 000)ƒ(2013ƒdata).ƒTheƒreasonƒforƒthisƒmightƒ include:ƒtheƒageingƒprofileƒofƒtheƒpopulation,ƒunnecessaryƒhospitalƒadmis- sions,ƒtheƒexistingƒshortcomingsƒinƒprimaryƒcare,ƒtheƒexcessiveƒuseƒofƒacuteƒ careƒbedsƒforƒlong-termƒcareƒandƒtheƒinadequateƒuseƒofƒdayƒsurgeriesƒ(Worldƒ Bank,ƒ2015b). 174 Health Systems in Transition Inƒ2016,ƒtheƒnumberƒofƒacuteƒhospitalƒbedsƒperƒ100 000ƒpopulationƒ wasƒ461.5ƒ(Eurostat,ƒ2019).ƒInƒ2014,ƒtheƒaverageƒlengthƒofƒacuteƒcareƒstayƒ perƒpatientƒwasƒ8.4ƒdays,ƒhigherƒthanƒtheƒEUƒaverageƒ(6.4).ƒTheƒaverageƒ hospitalƒbedƒoccupancyƒrateƒhasƒdroppedƒfromƒ80–85%ƒinƒ2005–2006ƒtoƒ 68%ƒinƒ2014,ƒlowerƒthanƒtheƒEUƒaverageƒofƒ77%ƒ(WHO,ƒ2019).ƒConcurrentƒ withƒpaediatricsƒandƒdermatologyƒdepartmentsƒatƒhospitalsƒbeingƒhalfƒempty,ƒ thereƒareƒshortagesƒofƒbedsƒforƒgeriatricsƒandƒpalliativeƒcare,ƒwhichƒpointƒ toƒaƒrigidƒstructureƒthatƒisƒunableƒtoƒadaptƒtoƒtheƒneedsƒofƒtheƒpopulation,ƒ poorƒmanagementƒandƒlowƒworkƒproductivity.ƒThereƒisƒscopeƒtoƒmakeƒacuteƒ inpatientƒcareƒmoreƒefficientƒbyƒloweringƒbedƒcapacityƒandƒadmissionƒratesƒ throughƒreformsƒtoƒreinforceƒprimaryƒandƒpreventiveƒcareƒandƒrationalizeƒ theƒprovisionƒofƒacuteƒandƒlong-termƒcareƒservicesƒ(WorldƒBank,ƒ2015b). Thereƒhaveƒbeenƒlimitedƒeffortsƒtoƒbringƒinƒreformsƒtoƒtheƒhealthƒsystemƒ thatƒcouldƒhelpƒtoƒimproveƒitsƒefficiency.ƒTheƒgovernmentƒhasƒintroducedƒaƒ capitationƒsystemƒinƒprimaryƒcareƒandƒhasƒlaunchedƒpaymentƒmechanismsƒ basedƒonƒdiagnosis-relatedƒgroupsƒ(DRGs)ƒforƒhospitalƒcare.ƒHowever,ƒtheƒ providerƒpaymentƒsystemƒforƒbothƒprimaryƒandƒhospitalƒcareƒremainsƒlargelyƒ input-based,ƒwithƒfewƒifƒanyƒincentivesƒforƒqualityƒorƒefficiency.ƒAƒcapitationƒ paymentƒsystemƒforƒprimaryƒcare,ƒ“chosenƒdoctors”,ƒwasƒintroducedƒinƒ2013ƒ withƒmodestƒperformance-basedƒpayments,ƒinƒwhichƒtheirƒsalaryƒvariedƒbyƒ 4%ƒbasedƒonƒprogressƒtowardsƒmeetingƒserviceƒvolumeƒandƒcoverageƒindi- catorsƒ(WorldƒBank,ƒ2015b).ƒHowever,ƒitƒcausedƒgreatƒdiscontentƒamongƒ healthƒprofessionalsƒandƒwasƒcriticizedƒforƒitsƒhugeƒadministrationƒcosts,ƒitsƒ complicatedƒcalculationƒsystem,ƒandƒtheƒhugeƒvariationƒinƒworkloadƒandƒ qualityƒofƒhealthƒservices.ƒTheƒoutput-basedƒpaymentƒreformsƒforƒacuteƒcareƒ atƒhospitalsƒ(basedƒonƒDRGs)ƒhaveƒonlyƒbeenƒimplementedƒveryƒrecently,ƒsoƒ hospitalsƒareƒstillƒlargelyƒpaidƒaccordingƒtoƒline-item budgets. Inefficienciesƒpersistƒinƒpublicƒspendingƒforƒpharmaceuticals;ƒthatƒis,ƒ roughlyƒoneƒquarterƒofƒtheƒpublicƒbudgetƒforƒhealthƒwasƒspentƒonƒpharma- ceuticalsƒinƒ2013ƒversusƒanƒEUƒaverageƒofƒ12.3%.ƒThereƒisƒinadequateƒcontrolƒ onƒvolumesƒofƒoutpatientƒprescriptionƒdrugsƒ(over-prescription,ƒespeciallyƒofƒ antibiotics)ƒandƒincreasedƒuseƒinƒhospitalsƒofƒhigh-cost,ƒpatentedƒmedicinesƒ (WorldƒBank,ƒ2015b).ƒTheƒimplementationƒofƒcentralizedƒprocurementƒ wasƒintroducedƒinƒ2013,ƒresultingƒinƒsomeƒpriceƒreductions,ƒparticularlyƒinƒ theƒcaseƒofƒhigh-volumeƒproductsƒandƒgenerics.ƒTheƒintentƒofƒtheƒcentralƒ procurementƒsystem,ƒwhichƒincludesƒbothƒpublicƒandƒprivateƒpharmacies,ƒ wasƒtoƒimproveƒtransparencyƒandƒcombatƒcorruptionƒ(Stosicƒ&ƒKaranovic,ƒ 175Serbia 2014).ƒTheƒintroductionƒofƒe-prescriptionsƒinƒ2016ƒ(namedƒMojDoktorƒinƒ Serbia)ƒhasƒtheƒpotentialƒtoƒbringƒaboutƒsubstantialƒsavings,ƒandƒoneƒpartƒofƒ Serbia’sƒhealthƒsystemƒprogressƒinƒ2017,ƒaccordingƒtoƒtheƒEuropeanƒHealthƒ ConsumerƒIndex,ƒisƒtheƒeffectƒofƒitƒ(Björnberg,ƒ2018).ƒAccordingƒtoƒtheƒ WorldƒBankƒpublicƒfinanceƒreviewƒinƒ2015,ƒforƒoutpatientƒprescriptionƒdrugs,ƒ Serbiaƒshouldƒconsiderƒreformsƒtoƒreimbursementƒpoliciesƒ(e.g.ƒintroduceƒflatƒ dispensingƒfeesƒorƒaƒregressiveƒmarginƒforƒmedicines),ƒandƒbetterƒmonitorƒ prescriptionƒandƒdispensingƒpracticesƒtoƒcontrolƒvolumes.ƒForƒhigher-costƒ patentedƒdrugs,ƒtheƒrecommendationƒisƒtoƒadoptƒinnovativeƒnegotiationƒ strategiesƒ(suchƒasƒprice-volumeƒagreements)ƒtoƒbringƒdownƒcostsƒ(Worldƒ Bank,ƒ2015b). Serbiaƒdoesƒnotƒcurrentlyƒhaveƒaƒhealthƒworkforceƒstrategyƒandƒeducationƒ policyƒhasƒnotƒbeenƒcoordinatedƒwithƒtheƒneedsƒofƒhealthƒcare,ƒsoƒtheƒnumberƒ ofƒunemployedƒdoctorsƒhasƒbeenƒincreasingƒinƒrecentƒyearsƒ(seeƒsectionƒ4.2).ƒ Currentƒpolicyƒaimsƒatƒmaintainingƒpresentƒstaffingƒlevelsƒinƒtheƒsystem,ƒ despiteƒtheƒshortageƒofƒsomeƒspecialistsƒ(radiologists,ƒanaesthesiologists,ƒ cardiacƒsurgeons,ƒetc.),ƒandƒhighƒunemployment.ƒLowƒsalariesƒandƒhighƒ unemploymentƒcreateƒanƒincentiveƒforƒdoctorsƒtoƒmoveƒtoƒotherƒcountriesƒ withƒbetterƒworkƒconditionsƒ(Stosicƒ&ƒKaranovic,ƒ2014).ƒInformationƒonƒ workforceƒmigrationƒtrendsƒisƒlacking.ƒAlso,ƒlittleƒhasƒbeenƒdoneƒtoƒaddressƒ previouslyƒmentionedƒproblemsƒandƒstrategicƒplanningƒforƒhuman resources.

8 Conclusions Sinceƒ2000,ƒsignificantƒprogressƒhasƒbeenƒmadeƒinƒtheƒdevelopmentƒofƒhealthƒ policyƒinƒSerbia.ƒAlthoughƒsomeƒinitialƒstepsƒwereƒmadeƒafterƒtheƒbreakƒupƒ ofƒtheƒYugoslavƒRepublicƒinƒ1991,ƒitƒwasƒnotƒuntilƒaƒpoliticalƒchangeƒ9ƒyearsƒ laterƒwhenƒanƒambitiousƒhealthƒreformƒprogrammeƒwasƒdeveloped.ƒTheƒ mainƒaimsƒofƒtheƒfirstƒreformsƒfromƒ2004–2010ƒwereƒtoƒdecreaseƒhealthƒcareƒ costsƒandƒtoƒstrengthenƒprevention,ƒwhileƒafterƒ2012ƒreformsƒfocusedƒonƒ improvingƒinfrastructureƒandƒtechnologyƒandƒimplementingƒanƒintegratedƒ healthƒinformationƒsystem.ƒMeasuresƒalsoƒincludedƒtheƒrestructuringƒofƒ hospitalsƒtoƒrespondƒmoreƒeffectivelyƒtoƒpatientƒneedsƒandƒtheƒdevelopmentƒ ofƒaƒnewƒbasicƒpackageƒofƒhealthƒcareƒservicesƒalignedƒwithƒexistingƒresources.ƒ Whileƒsomeƒprogressƒhasƒbeenƒmade,ƒtheƒSerbianƒhealthƒsystemƒremainsƒ underfunded,ƒdespiteƒdedicatingƒ8.8%ƒofƒGDPƒtoƒhealthƒcare:ƒthisƒisƒdueƒtoƒ lowƒGDPƒandƒlowƒcontributionƒrevenueƒflowingƒtoƒtheƒNHIF.ƒTheƒhealthƒ systemƒalsoƒremainsƒpoorlyƒmanaged,ƒandƒwithƒaƒhighƒpublicƒperceptionƒofƒ corruption,ƒwhichƒinvolvesƒbothƒpatientsƒandƒdoctors.ƒInƒfact,ƒreformsƒtoƒ improveƒtheƒperformanceƒandƒtransparencyƒofƒtheƒhealthƒsystemƒareƒstillƒ pending,ƒandƒthereƒareƒaƒnumberƒof challenges. Firstly,ƒthereƒareƒinequalitiesƒinƒtheƒuseƒofƒhealthƒservices,ƒconcentratedƒ inƒtheƒworse-off,ƒwhoƒexperienceƒbarriersƒtoƒaccessingƒprimaryƒservices.ƒ Theƒmainƒreasonƒthatƒpatientsƒforegoƒhealthƒcareƒisƒlackƒofƒaffordability.ƒInƒ theƒareaƒofƒpreventiveƒservices,ƒwhileƒinvestmentsƒsupportedƒbyƒEuropeanƒ projectsƒhaveƒimprovedƒcancerƒtreatment,ƒnationalƒscreeningƒratesƒareƒstillƒ veryƒlow.ƒTheƒproblemƒisƒthatƒtheƒlevelƒofƒinvestmentƒinƒorganizedƒscreen- ingƒprogrammesƒisƒstillƒnotƒenoughƒandƒconsequently,ƒimplementationƒandƒ responseƒremainƒinsufficient.ƒItƒwillƒalsoƒbeƒessentialƒtoƒstepƒupƒpreventionƒ effortsƒtoƒdealƒwithƒlifestyleƒfactorsƒsuchƒasƒtobaccoƒusage,ƒalcoholƒconsump- tionƒand obesity. 178 Health Systems in Transition Secondly,ƒthereƒhasƒnotƒbeenƒadequateƒdevelopmentƒofƒhumanƒresourcesƒ forƒtheƒhealthƒsystemƒoverƒseveralƒdecadesƒandƒtheƒsupplyƒofƒhealthƒworkersƒ hasƒnotƒbeenƒinƒlineƒwithƒneeds.ƒThisƒhasƒresultedƒinƒanƒincreasingƒnumberƒ ofƒunemployedƒhealthƒworkersƒinƒsomeƒareas,ƒinƒparallelƒwithƒanƒinsufficientƒ numberƒofƒsomeƒspecialists.ƒThis,ƒtogetherƒwithƒlowƒsalariesƒ(amongƒotherƒ reasons)ƒhasƒcreatedƒanƒincentiveƒforƒdoctorsƒandƒnursesƒtoƒemigrate.ƒSoƒfar,ƒ noƒstrategyƒhasƒbeenƒimplementedƒtoƒaddressƒthis issue. Thirdly,ƒthereƒisƒfurtherƒscopeƒtoƒimproveƒtransparency,ƒwhichƒinvolvesƒ bothƒpatientsƒandƒdoctorsƒandƒultimatelyƒaffectsƒqualityƒofƒcare.ƒWhileƒsomeƒ progressƒhasƒbeenƒmadeƒinƒthisƒregard,ƒsuchƒasƒwithƒtheƒpublicationƒofƒtheƒListƒ ofƒLicensedƒMedicalƒPractitionersƒonƒtheƒSerbianƒMedicalƒChamber’sƒwebsiteƒ (whichƒuntilƒthenƒwasƒnotƒavailableƒtoƒcitizens),ƒout-of-pocketƒpaymentsƒ remainƒaƒpracticeƒinƒtheƒcountryƒandƒcontributeƒtoƒtheƒfinancialƒburdenƒforƒ householdsƒthatƒneedƒtoƒaccessƒpubliclyƒfunded services. Finally,ƒvalue-basedƒhealthƒcareƒisƒstillƒtoƒbeƒdevelopedƒinƒSerbiaƒandƒ HealthƒTechnologyƒAssessmentƒisƒnotƒcurrentlyƒusedƒtoƒaidƒdecision-makingƒ onƒservicesƒandƒincreaseƒcost–effectiveness.ƒInƒaddition,ƒunder-fundingƒofƒ healthƒcareƒoverƒmanyƒyearsƒhasƒresultedƒinƒaƒgenerallyƒlowerƒqualityƒofƒpublicƒ healthƒcareƒservicesƒbeingƒavailableƒfor users. Itƒisƒexpectedƒthat,ƒinƒtheƒcomingƒyears,ƒSerbiaƒwillƒcontinueƒtoƒdevelopƒ policiesƒfocusedƒonƒreducingƒbarriersƒtoƒaccessingƒhealthƒcareƒandƒimprov- ingƒtheƒefficiencyƒofƒtheƒsystem,ƒsupportedƒbyƒinternationalƒorganizationsƒ andƒinƒtheƒcontextƒofƒSerbia’sƒcontinuingƒEUƒaccessionƒnegotiations.ƒOtherƒ developmentsƒareƒ tiedƒ toƒ theƒ2019ƒHealthƒCareƒLawƒwhichƒenvisionsƒ movementƒtowardsƒcentralizationƒbyƒtransferringƒownershipƒofƒbuildingsƒ andƒequipmentƒbackƒtoƒtheƒnationalƒlevel.ƒTheƒintroductionƒofƒtheƒcapita- tionƒsystemƒinƒprimaryƒcareƒisƒtheƒfirstƒmajorƒpaymentƒreformƒmeasureƒinƒ Serbia,ƒwhereƒresourcesƒareƒbeginningƒtoƒbeƒbasedƒonƒpatientƒneedsƒandƒnotƒ onƒstaffƒnumbersƒandƒstructures.ƒReformingƒhospitalƒpaymentƒmechanismsƒ byƒintroducingƒDRGsƒisƒanotherƒmeasureƒfromƒwhichƒefficiencyƒgainsƒareƒ expected,ƒasƒwellƒasƒbyƒincreasingƒefficacyƒandƒtransparencyƒwhenƒcontract- ingƒhealthƒcare services. 9 Appendices 9.1  References ACASƒ(2012).ƒIzvestaj o oblicima, uzrocima i rizicima korupcije u sistemu zdravstvaƒ [Reportƒ onƒforms,ƒcausesƒandƒrisksƒofƒcorruptionƒinƒtheƒhealthƒsystem]ƒ[website].ƒBelgrade:ƒAnti- CorruptionƒAgencyƒofƒSerbia.ƒ(http://www.acas.rs/izvestaj-zdravstvo/,ƒaccessedƒ08ƒFebruaryƒ 2020). 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NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2013).ƒUredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovamaƒ[Decreeƒ onƒtheƒcorrectiveƒcoefficient,ƒtheƒhighestƒpercentageƒincreaseƒinƒtheƒbasicƒsalary,ƒtheƒcriteriaƒ andƒweightsƒforƒtheƒpartƒofƒtheƒwageƒthatƒisƒrealizedƒonƒtheƒbasisƒofƒtheƒperformance,ƒasƒwellƒasƒ theƒmethodƒofƒcalculationƒofƒsalariesƒofƒemployeesƒinƒhealthƒinstitutions].ƒBelgrade:ƒRepublicƒ FundƒofƒHealthƒInsurance.ƒ(https://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/ eli/rep/sgrs/vlada/uredba/2011/100/11/reg,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2016).ƒFinancialƒReportƒforƒ2016.ƒBelgrade:ƒRepublicƒ FundƒofƒHealthƒInsurance.ƒ (http://www.rfzo.rs/download/fin_plan/Izvestaj_poslovanje_ finplana2016.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2017a).ƒPlan zdravstvene zaštite iz obaveznog zdravstvenog osiguranja u Republici Srbiji za 2017. godinuƒ [Healthƒ Careƒ Planƒ fromƒ CompulsoryƒHealthƒInsuranceƒinƒRepublicƒofƒSerbiaƒforƒ2017].ƒBelgrade:ƒRepublicƒFundƒ ofƒHealthƒInsurance.ƒ(http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/ sgrs/drugidrzavniorganiorganizacije/plan/2017/119/1/reg,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2017b).ƒKapitacijaƒ[Capitation].ƒBelgrade:ƒRepublicƒ FundƒofƒHealthƒInsurance.ƒ(http://rfzo.rs/index.php/davaocizdrusluga/kapitacija-actual-16,ƒ accessedƒ28ƒJanuaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2017c).ƒDokumenta. Statistika i izveštaji. Broj osiguranika [Documents.ƒStatisticsƒandƒreports.ƒNumberƒofƒ insuredƒpeople].ƒBelgrade:ƒ RepublicƒFundƒofƒHealthƒInsurance.ƒƒ(http://www.rfzo.rs/index.php/broj-osiguranika-stat,ƒ accessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2017d).ƒIzveštaj o finansijskom poslovanju RFZO za 2016. godinuƒ[FinancialƒoperationsƒreportƒofƒRepublicƒFundƒforƒHealthƒInsuranceƒinƒ 2016].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(http://rfzo.rs/download/fin_plan/ Izvestaj_poslovanje_finplana2016.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018a).ƒNationalƒHealthƒInsuranceƒFundƒ[website].ƒ Belgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(http://www.eng.rfzo.rs/,ƒaccessedƒ08ƒFebruaryƒ 2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018b).ƒProvincialƒHealthƒInsuranceƒFund.ƒBelgrade:ƒ RepublicƒFundƒofƒHealthƒInsurance.ƒ(http://www.eng.rfzo.rs/index.php/about,ƒaccessedƒ08ƒ Februaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018c).ƒConsumptionƒofƒdrugs.ƒBelgrade:ƒRepublicƒ FundƒofƒHealthƒInsurance.ƒ(http://www.rfzo.rs/index.php/potrosnja-lekova-stat,ƒaccessedƒ 08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018d).ƒSadržaj i obim preventivnih mera u oblasti zdravstvene zaštiteƒ[Theƒcontentƒandƒscopeƒofƒpreventiveƒservicesƒinƒtheƒfieldƒofƒhealthƒcare].ƒ Belgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(http://www.rfzo.rs/download/pravilnici/ obim-sadrzaj/TABELA1-2013.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018e).ƒRegistracija izabranog lekara [Reportsƒonƒ Registrationƒwithƒ“chosenƒdoctors”,ƒMarchƒ2018].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒ Insurance.ƒ(http://www.rfzo.rs/index.php/ril-stat,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018f ).ƒIzveštaj o finansijskom poslovanju republičkog fonda za zdravstveno osiguranje za 2017. godinu [FinancialƒreportƒofƒRepublicƒFundƒofƒHealthƒ Insurance,ƒAprilƒ2018].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(https://www.rfzo. rs/download/fin_plan/Izvestaj_poslovanje_finplana2017.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). 191Serbia NHIFƒ–ƒNationalƒHealthƒ InsuranceƒFundƒ (2018g).ƒFinansijski plan republičkog fonda za zdravstveno osiguranje za 2019. godinuƒ [Financialƒplanƒofƒ theƒRepublicƒFundƒofƒHealthƒ Insuranceƒ forƒ2019].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ (https://www.rfzo. rs/download/fin_plan/PLAN%202019.%20ODLUKA.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2018h).ƒPravilnik o ugovaranju zdravstvenu zastite iz obaveznog zdravstvenog osiguranja sa davaocima zdravstvenih usluga za 2019. godinuƒ[Ruleƒ bookƒonƒtheƒcontractingƒofƒhealthcareƒfromƒcompulsoryƒhealthƒinsuranceƒwithƒhealthcareƒ serviceƒprovidersƒforƒ2019].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(https://www. rfzo.rs/index.php/pravilnici,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2019a).ƒListe čekanja – Dnevni prosek [Reportsƒonƒ waitingƒlistsƒ–ƒdailyƒaverage].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(http://rfzo. rs/index.php/osiguranalica/listecekanja/lc-dnevni-presek,ƒaccessedƒ08ƒFebruaryƒ2020). NHIFƒ–ƒNationalƒHealthƒInsuranceƒFundƒ(2019b).ƒIzveštaj o finansijskom poslovanju republičkog fonda za zdravstveno osiguranje za 2018. godinu [FinancialƒreportƒofƒRepublicƒFundƒofƒHealthƒ Insurance,ƒAprilƒ2019].ƒBelgrade:ƒRepublicƒFundƒofƒHealthƒInsurance.ƒ(https://www.rfzo. rs/download/fin_plan/18.04.2019.%20Izvestaj%20o%20finansijskom%20poslovanju%20 RFZO%20za%202018.%20godinu.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). NikolicƒZƒetƒal.ƒ(2015).ƒFactorsƒinfluencingƒtheƒrecommendationƒofƒtheƒhumanƒpapillomavirusƒ vaccineƒbyƒSerbianƒpediatricians.ƒJƒPediatrƒAdolescƒGynecol.28(1):12–18.ƒdoi:ƒ10.1016/j. jpag.2014.01.107. OfficialƒGazetteƒ(1992a).ƒZakon o zdravstvenoj zastitiƒ[HealthƒCareƒLaw].ƒOfficialƒGazetteƒRS,ƒ 17/1992,ƒ50/92ƒandƒ52/93. OfficialƒGazetteƒ(1992b).ƒZakon o zdravstvenom osiguranjuƒ[HealthƒInsuranceƒLaw].ƒOfficialƒ GazetteƒRS,ƒ18/1992. OfficialƒGazetteƒ(2001a).ƒZakon o porezu na dohodak gradjanaƒ[LawƒonƒPersonalƒIncomeƒTax].ƒ OfficialƒGazetteƒRS,ƒ24/2001,ƒ80/2002,ƒ80/2002,ƒ135/2004,ƒ62/2006,ƒ65/2006,ƒ31/2009,ƒ 44/2009,ƒ18/2010,ƒ50/2011,ƒ91/2011,ƒ7/2012,ƒ93/2012,ƒ114/2012,ƒ8/2013,ƒ47/2013,ƒ48/2013,ƒ 108/2013,ƒ6/2014,ƒ57/2014,ƒ68/2014,ƒ5/2015,ƒ112/2015,ƒ5/2016.,ƒ7/2017,ƒ113/2017,ƒ7/2018,ƒ 95/2018,ƒandƒ4/2019. OfficialƒGazetteƒ(2001b).ƒUredba o koeficijentima za obracun i isplatu plata zaposlenih u javnim sluzbama [Decreeƒonƒcoefficientsƒforƒcalculationƒandƒpaymentƒofƒsalariesƒofƒpublicƒemployees].ƒ OfficialƒGazetteƒRS,ƒ44/2001,ƒ15/2002,ƒ32/2002,ƒ69/2002,ƒ78/2002,ƒ61/2003,ƒ121/ƒ2003,ƒ 130/ƒ2003,ƒ67/ƒ2004,ƒ120/2004,ƒ5/2005,ƒ26/2005,ƒ81/2005,ƒ105/2005,ƒ109/2005,ƒ27/2006,ƒ 32/2006,ƒ58/2006,ƒ82/2006,ƒ106/2006,ƒ10/2007,ƒ40/2007,ƒ60/2007,ƒ91/2007,ƒ106/2007,ƒ 7/2008,ƒ9/2008,ƒ24/2008,ƒ26/2008,ƒ31/2008,ƒ44/2008,ƒ54/2008,ƒ108/2008,ƒ113/2008,ƒ 79/2009,ƒ25/2010,ƒ91/2010,ƒ20/2011,ƒ65/2011,ƒ100/2011,ƒ11/2012,ƒ124/2012,ƒ8/2013,ƒ 4/2014,ƒ58/2014,ƒ113/2017. OfficialƒGazetteƒ(2002).ƒUredba o zdravstvenoj zaštiti stanovništva od zaraznih bolestiƒ[Programmeƒ forƒtheƒprotectionƒofƒpopulationƒagainstƒinfectiousƒdiseases].ƒOfficialƒGazetteƒRS,ƒ29/2002. OfficialƒGazetteƒ(2004).ƒZakon o doprinosima za obavezno socijalno osiguranje [Lawƒonƒmandatoryƒ socialƒ securityƒcontribution].ƒOfficialƒGazetteƒRS,ƒ84/2004,ƒ61/2005,ƒ62/2006,ƒ5/2009,ƒ 52/2011,ƒ101/2011,ƒ7/2012,ƒ47/2013,ƒ108/2013,ƒ6/2014,ƒ57/2014,ƒ68/2014,ƒ5/2015,ƒ 112/2015,ƒ 5/2016,ƒ 7/2017,ƒ 113/2017ƒ andƒ 7/2018.ƒ (https://www.paragraf.rs/propisi/ zakon_o_doprinosima_za_obavezno_socijalno_osiguranje.html,ƒaccessedƒ08ƒFebruaryƒ2020). OfficialƒGazetteƒ(2005a).ƒZakon o zdravstvenoj zaštitiƒ[HealthƒCareƒLaw].ƒOfficialƒGazetteƒRS,ƒ 107/2005,ƒ72/2009ƒ–ƒanotherƒlaw.ƒ88/2010ƒandƒ99/2010,ƒ57/2011,ƒ119/2012,ƒ45/2013ƒ–ƒ anotherƒlaw,ƒ93/2014,ƒ96/2015,ƒ106/2015ƒandƒ113/2017ƒ–ƒother law. OfficialƒGazetteƒ(2005b).ƒZakon o zdravstvenom osiguranjuƒ[HealthƒInsuranceƒLaw].ƒOfficialƒ GazetteƒRS,ƒ107/2005ƒandƒ109/2005ƒ–ƒcorrigendum,ƒ57/2011,ƒ110/2012ƒdecisionƒofƒtheƒ ConstitutionƒCourt,ƒ119/2012,ƒ99/2014,ƒ123/2014,ƒ126/2014ƒ–ƒdecisionƒofƒtheƒConstitutionƒ Court,ƒ106/2015ƒandƒ10/2016ƒ–ƒanotherƒlaw.ƒ OfficialƒGazetteƒ(2005c).ƒZakon o komorama zdravstvenih radnika [LawƒonƒChambersƒofƒHealthƒ Workers].ƒOfficialƒGazetteƒRS,ƒ107/2005,ƒ99/2010ƒandƒ70/2017. 192 Health Systems in Transition OfficialƒGazetteƒ(2005d).ƒZakon o bezbednosti i zdravlju na raduƒ[LawƒonƒSafetyƒandƒHealthƒatƒ Work].ƒOfficialƒGazetteƒRS,ƒ101/2005,ƒ91/2015ƒandƒ113/2017. OfficialƒGazetteƒ (2005e).ƒStrategija razvoja zaštite mentalnog zdravlja [Strategyƒ forƒMentalƒ HealthƒCareƒDevelopment].ƒOfficialƒGazetteƒRS,55/2005,ƒcorrectionƒ71/2005. OfficialƒGazetteƒ(2005f ).ƒZakon o raduƒ[LaborƒAct].ƒOfficialƒGazetteƒRS,ƒ24/2005,ƒ61/2005,ƒ 54/2009,ƒ32/2013,ƒ75/2014,ƒ13/2017,ƒ113/2017,ƒandƒ95/2018 OfficialƒGazetteƒ (2006a).ƒUstav Republike Srbije [Constitutionƒofƒ theƒRepublicƒofƒSerbia].ƒ OfficialƒGazetteƒRS,ƒ98/2006.ƒ (https://www.paragraf.rs/propisi/ustav_republike_srbije. html,ƒaccessedƒ08ƒFebruaryƒ2020). OfficialƒGazetteƒ (2006b).ƒUredba o planu mreže zdravstvenih ustanovaƒ [Decreeƒonƒ theƒPlanƒ ofƒtheƒHealthƒInstitutions’ƒNetwork].ƒOfficialƒGazetteƒRSƒ42/2006,ƒ119/2007,ƒ84/2008,ƒ 71/2009,ƒ85/2009,ƒ24/2010,ƒ6/2012,ƒ37/2012,ƒ8/2014,ƒ92/2015,ƒ111/2017,ƒ114/2017,ƒ 13/2018ƒandƒ15/2018.ƒ OfficialƒGazetteƒ (2006c).ƒPravilnik o bližim uslovima za obavljanje zdravstvene delatnosti u zdravstvenim ustanovama i drugim oblicima zdravstvene službeƒ [Rulebookƒonƒdetailedƒ conditionsƒforƒperformingƒhealthƒcareƒactivitiesƒinƒhealthƒinstitutionsƒandƒotherƒformsƒofƒ healthƒcareƒservices].ƒOfficialƒGazetteƒRS,ƒ43/2006,ƒ112/2009,ƒ50/2010,ƒ79/2011,ƒ10/2012,ƒ 22/2013.ƒ OfficialƒGazetteƒ(2006d).ƒPravilnik o pripravničkom stažu i stručnom ispitu zdravstvenih radnika i zdravstvenih saradnikaƒ[Rulebookƒonƒinternshipƒandƒprofessionalƒexamsƒforƒhealthƒworkersƒ andƒassociates].ƒOfficialƒGazetteƒRS,ƒ50/2006,ƒ112/2009,ƒ50/2010,ƒ31/2012ƒandƒ1/2016.ƒ OfficialƒGazetteƒ(2007a). Zakon o teritorijalnoj organizaciji Republike Srbijeƒ[LawƒonƒTerritorialƒ OrganizationƒofƒtheƒRepublicƒofƒSerbia].ƒOfficialƒGazetteƒRS,ƒ129/2007ƒandƒ18/2016. OfficialƒGazetteƒ (2007b).ƒStrategija kontrole duvanaƒ [TobaccoƒControlƒStrategy].ƒOfficialƒ GazetteƒRS,ƒ8/2007.ƒ OfficialƒGazetteƒ (2007c).ƒPravilnik o uslovima i načinu upućivanja osiguranih lica na lečenje u inostranstvoƒ[Rulebookƒonƒtheƒconditionsƒandƒmethodƒofƒsendingƒinsuredƒpersonsƒforƒ treatmentƒabroad].ƒOfficialƒGazetteƒRS,ƒ44/2007,ƒ65/2008,ƒ36/2009,ƒ32/2010,ƒ50/2010,ƒ 75/2013,ƒ110/2013,ƒ113/2014ƒandƒ49/2016.ƒ OfficialƒGazetteƒ(2008).ƒUredba o dobrovoljnom zdravstvenom osiguranjuƒ[DecreeƒonƒVoluntaryƒ HealthƒInsurance].ƒOfficialƒGazetteƒRS,ƒ108/2008ƒandƒ49/2009.ƒ OfficialƒGazetteƒ (2009a).ƒZakon o zaštiti prava i sloboda nacionalnih manjinaƒ [Lawƒonƒ theƒ ProtectionƒofƒtheƒRightsƒofƒNationalƒMinorities].ƒOfficialƒGazetteƒRS,ƒ72/2009ƒandƒ97/2013.ƒ OfficialƒGazetteƒ(2009b).ƒZakon o budžetskom sistemuƒ[LawƒonƒtheƒBudgetƒSystem].ƒOfficialƒ GazetteƒRS,ƒ54/2009,ƒ73/2010,ƒ101/2010,ƒ101/2011,ƒ93/2012,ƒ62/2013,ƒ63/2013,ƒ108/2013,ƒ 142/2014,ƒ68/2015,ƒ103/2015,ƒ99/2016ƒandƒ113/2017.ƒ OfficialƒGazetteƒ (2009c).ƒZakon o vanrednim situacijamaƒ [LawƒonƒEmergencyƒSituations].ƒ OfficialƒGazetteƒRS,ƒ111/2009,ƒ92/2011ƒandƒ93/2012.ƒ OfficialƒGazetteƒ(2009d).ƒStrategija za stalno unapređenje kvaliteta zdravstvene zaštite i bezbednosti pacijenta [Strategyƒforƒcontinuousƒqualityƒimprovementƒinƒhealthƒcareƒandƒpatientƒsafety].ƒ OfficialƒGazetteƒRS,ƒ15/2009.ƒ OfficialƒGazetteƒ(2009e).ƒStrategija za palijativno zbrinjavanjeƒ[Strategyƒforƒpalliativeƒcare].ƒ OfficialƒGazetteƒRS,ƒ17/2009.ƒ OfficialƒGazetteƒ(2009f ).ƒUredba o programu rada, razvoja i organizaciji integrisanog zdravstvenog informacionog sistema – „E-Zdravlje“ [RegulationƒonƒProgramƒofƒWork,ƒDevelopmentƒandƒ OrganizationƒofƒIntegratedƒHealthƒInformationƒSystemƒ–ƒ“E-Health”].ƒOfficialƒGazetteƒ RS,ƒ55/2009.ƒ OfficialƒGazetteƒ (2009g).ƒUredba o nacionalnom programu preventivne stomatološke zaštiteƒ [Regulationƒonƒnationalƒprogramƒofƒpreventiveƒdentalƒcare].ƒOfficialƒGazetteƒRS,ƒ22/2009.ƒ OfficialƒGazetteƒ (2009h).ƒPravilnik o bližoj sadržini tehnoloških i fukncionalnih zahteva za uspostavljanje integrisanog zdravstvenog informacionog sistemaƒ[Rulebookƒonƒtheƒcontentƒofƒ technologicalƒandƒfunctionalƒrequirementsƒforƒestablishingƒtheƒIntegratedƒHealthƒInformationƒ System].ƒOfficialƒGazetteƒRS,ƒ55/2009. 193Serbia OfficialƒGazetteƒ(2009i).ƒUredba o nacionalnom programu zdravstvene zaštite žena, dece i omladineƒ [DecreeƒonƒtheƒNationalƒProgramƒforƒtheƒHealthƒCareƒofƒWomen,ƒChildrenƒandƒYouth].ƒ OfficialƒGazetteƒRS,ƒ28/2009.ƒ OfficialƒGazetteƒ(2009j).ƒStrategija za unapređivanje položaja Roma u Republici Srbijiƒ[Strategyƒ forƒimprovingƒtheƒpositionƒofƒRoma].ƒOfficialƒGazetteƒRS,ƒ27/2009.ƒ OfficialƒGazetteƒ(2009k).ƒStrategija za prevenciju i kontrolu hroničnih nezaraznih bolestiƒ[Strategyƒ forƒtheƒpreventionƒandƒcontrolƒofƒchronicƒnon-communicableƒdiseases].ƒOfficialƒGazetteƒ RS,ƒ22/2009.ƒ OfficialƒGazetteƒ(2009l).ƒUredba o nacionalnom programu prevencije i rane detekcije tipa 2 dijabetesaƒ [Nationalƒprogrammeƒforƒtheƒpreventionƒandƒearlyƒdetectionƒofƒtheƒtypeƒtwoƒdiabetes].ƒ OfficialƒGazetteƒRS,ƒ17/2009.ƒ OfficialƒGazetteƒ (2009m).ƒUredba o nacionalnom programu “Srbija protiv raka”ƒ [Nationalƒ programmeƒ“Serbiaƒagainstƒcancer”].ƒOfficialƒGazetteƒRS,ƒ20/2009.ƒ OfficialƒGazetteƒ(2009n).ƒStrategija javnog zdravlja Republike Srbijeƒ[Publicƒhealthƒstrategyƒofƒ theƒRepublicƒofƒSerbia].ƒOfficialƒGazetteƒRS,ƒ22/2009.ƒ OfficialƒGazetteƒ(2009o).ƒNacionalna strategija za poboljsanje polozaja zena i unapredjivanje rodne ravnopravmostiƒ[Nationalƒstrategyƒforƒimprovingƒtheƒpositionƒofƒwomenƒandƒpromotingƒ genderƒequality].ƒOfficialƒGazetteƒRS,ƒ15/2009. OfficialƒGazetteƒ(2010a).ƒZakon o lekovima i medicinskim sredstvimaƒ[LawƒonƒMedicinesƒandƒ MedicalƒDevices].ƒOfficialƒGazetteƒRS,ƒ30/2010ƒandƒ107/2012.ƒ OfficialƒGazetteƒ(2010b).ƒStrategija razvoja informacionog društva u Republici Srbiji do 2020. godineƒ[StrategyƒforƒDevelopmentƒofƒInformationƒSocietyƒinƒtheƒRepublicƒofƒSerbiaƒupƒtoƒ 2020].ƒOfficialƒGazetteƒRS,ƒ51/2010.ƒ OfficialƒGazetteƒ(2010c).ƒOdluka o planu razvoja zdravstvene zaštite Republike Srbijeƒ[Decisionƒ onƒtheƒplanƒforƒdevelopmentƒofƒhealthƒcareƒinƒtheƒRepublicƒofƒSerbia].ƒOfficialƒGazetteƒ RS,ƒ88/2010.ƒ OfficialƒGazetteƒ(2010d).ƒPravilnik o pokazateljima kvaliteta zdravstvene zaštiteƒ[Rulebookƒonƒ healthƒcareƒqualityƒindicators].ƒOfficialƒGazetteƒRS,ƒ49/2010.ƒ OfficialƒGazetteƒ(2010e).ƒZakon o zaštiti stanovništva od izloženosti duvanskom dimuƒ[Lawƒonƒ ProtectionƒfromƒExposureƒtoƒSecond-HandƒSmoke].ƒOfficialƒGazetteƒRS,ƒ30/2010.ƒ OfficialƒGazetteƒ(2011a).ƒUredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovama [Decreeƒofƒrulesƒonƒtheƒ correctiveƒcoefficient,ƒtheƒhighestƒpercentageƒofƒincreaseƒinƒbasicƒsalaries,ƒcriteriaƒandƒnormsƒ forƒtheƒpartƒofƒtheƒsalaryƒthatƒisƒrealizedƒonƒtheƒbasisƒofƒworkƒperformance,ƒasƒwellƒasƒtheƒ methodƒofƒcalculationƒofƒ salariesƒofƒemployeesƒ inƒhealthƒ institutions].ƒOfficialƒGazetteƒ RS,100/2011,ƒ63/2012,ƒ101/2012,ƒ46/2013.ƒ OfficialƒGazetteƒ(2011b).ƒStatut Republičkog fonda za zdravstveno osiguranje [LawƒonƒPublic- PrivateƒPartnershipƒandƒConcessions].ƒOfficialƒGazetteƒRS,ƒ88/2011,ƒ15/2016ƒiƒ104/2016.ƒ OfficialƒGazetteƒ(2011c).ƒZakon o javno-privatnom partnerstvu i koncesijama [Statuteƒofƒ theƒ RepublicƒFundƒofƒHealthƒInsurance].ƒOfficialƒGazetteƒRS,ƒ81/2011,ƒ57/2012,ƒ89/2012,ƒ 1/2013,ƒ32/2013ƒandƒ23/2015.ƒ OfficialƒGazetteƒ(2012a).ƒZakon o javnim nabavkamaƒ[LawƒonƒPublicƒProcurement].ƒOfficialƒ GazetteƒRS,ƒ124/2012,ƒ14/2015ƒandƒ68/2015.ƒ OfficialƒGazetteƒ(2012b).ƒPravilnik o normativima i standardima rada i cenama zdravstvenih usluga za prevenciju, preglede i lečenje bolesti usta i zuba koje se obezbeđuju iz sredstava obaveznog zdravstvenog osiguranjaƒ [Rulebookƒonƒnormativeƒandƒstandardsƒofƒworkƒandƒpricesƒofƒ prevention,ƒassessmentƒandƒtreatmentƒofƒoralƒdisease,ƒwhichƒareƒpaidƒbyƒmandatoryƒhealthƒ insurance].ƒOfficialƒGazetteƒRS,ƒ12/2012.ƒ OfficialƒGazetteƒ (2012c).ƒPravilnik o nomenklaturi laboratorijskih zdravstvenih usluga na primarnom, sekundarnom i tercijarnom nivou zdravstvene zastite [Rulebookƒonƒnomenclatureƒ ofƒlaboratoryƒhealthƒservicesƒonƒprimary,ƒsecondaryƒandƒterritoryƒlevelƒofƒhealthƒcare].ƒOfficialƒ GazetteƒRS,ƒ59/2012. 194 Health Systems in Transition OfficialƒGazetteƒ(2013a).ƒZakon o pravima pacijenataƒ[Lawƒonƒpatients’ƒrights].ƒOfficialƒGazetteƒ RS,ƒ45/2013.ƒ OfficialƒGazetteƒ(2013b).ƒZakon o zaštiti lica sa mentalnim smetnjamaƒ[Lawƒonƒprotectionƒofƒ personsƒwithƒmentalƒdisabilities].ƒOfficialƒGazetteƒRS,ƒ45/2013.ƒ OfficialƒGazetteƒ(2013c).ƒUredba o planiranju i vrsti roba i usluga za koje se sprovode centralizovane javne nabavkeƒ[Decreeƒonƒtheƒplanningƒandƒtypeƒofƒgoodsƒandƒservicesƒforƒwhichƒcentralizedƒ publicƒprocurementƒisƒconducted].ƒOfficialƒGazetteƒRS,ƒ29/2013,ƒ49/2013,ƒ51/2013,ƒ86/2013,ƒ 119/2014,ƒ86/2015,ƒ95/2016ƒandƒ111/2017.ƒ OfficialƒGazetteƒ(2013d).ƒPravilnik o specijalizacijama i užim specijalizacijama zdravstvenih radnika i zdravstvenih saradnikaƒ [Rulebookƒaboutƒ specializationƒandƒsubspecialisationƒofƒhealthƒ workersƒandƒassociates.ƒOfficialƒGazetteƒRS,ƒ10/2013,ƒ91/2013,ƒ113/2013ƒandƒ109/2014.ƒ OfficialƒGazetteƒ(2013e).ƒPravilnik o bližim uslovima za primenu fizičkog sputavanja i izolacije lica sa mentalnim smetnjama koja se nalaze na lečenju u psihijatrijskim ustanovamaƒ[Rulebookƒonƒ physicalƒrestraintƒandƒisolationƒofƒpersonsƒwithƒmentalƒdisordersƒhospitalizedƒinƒpsychiatricƒ institutions].ƒOfficialƒGazetteƒRS,ƒ94/2013.ƒ OfficialƒGazetteƒ(2013f ).ƒPravilnik o vrsti i bližim uslovima za obrazovanje organizacionih jedinica i obavljanje poslova zaštite mentalnog zdravlja u zajedniciƒ[Rulebookƒonƒtheƒtypeƒandƒcloserƒ conditionsƒforƒtheƒfoundationƒofƒorganizationalƒunitsƒandƒtheƒconductƒofƒmentalƒhealthƒ activitiesƒinƒtheƒcommunity].ƒOfficialƒGazetteƒRS,ƒ106/2013.ƒ OfficialƒGazetteƒ(2013g).ƒPravilnik o listama čekanjaƒ[Rulebookƒonƒwaitingƒlists].ƒOfficialƒGazetteƒ RS,ƒ75/2013ƒandƒ110/2013. OfficialƒGazetteƒ(2013h).ƒPravilnik o načinu i postupku zaštite prava osiguranih lica Republičkog fonda za zdravstveno osiguranjeƒ[Rulebookƒonƒtheƒmannerƒandƒprocedureƒforƒtheƒprotectionƒ ofƒtheƒrightsƒofƒtheƒinsuredƒpersonsƒofƒtheƒRepublicƒFundƒforƒHealthƒInsurance].ƒOfficialƒ GazetteƒRS,ƒ68/2013.ƒ (http://www.rfzo.rs/download/pravilnici/zastitaprava/Pravilnik_ zastitapravaosiguranikaRFZO.pdf,ƒaccessedƒ04ƒNovemberƒ2018). OfficialƒGazetteƒ (2013i).ƒPravilnik o nomenklaturi zdravstvenih usluga na primarnom, nivou zdravstvene zastiteƒ[Rulebookƒonƒnomenclatureƒofƒhealthƒservicesƒonƒprimaryƒlevelƒofƒhealthƒ care].ƒOfficialƒGazetteƒRS,ƒ17/2013. OfficialƒGazetteƒ(2013j).ƒPravilnik o nomenklaturi zdravstvenih usluga na sekundarnom i tercijarnom nivou zdravstvene zastiteƒ[Rulebookƒonƒnomenclatureƒofƒhealthƒservicesƒonƒsecondaryƒandƒ territoryƒlevelƒofƒhealthƒcare].ƒOfficialƒGazetteƒRS,ƒ58/2013. OfficialƒGazetteƒ(2013k).ƒNacionalna strategija za borbu protiv korupcijeƒ [TheƒNationalƒanti- corruptionƒstrategy].ƒOfficialƒGazetteƒRS,57/2013.ƒ OfficialƒGazetteƒ (2013l).ƒUredba o nacionalnom programu ranog otkrivanja karcinoma grlića matericeƒ[Nationalƒprogrammeƒforƒtheƒpreventionƒofƒcervicalƒcancer].ƒOfficialƒGazetteƒRS,ƒ 73/2013ƒandƒ83/2013.ƒ OfficialƒGazetteƒ (2013m).ƒUredba o nacionalnom programu ranog otkrivanja karcinoma dojkeƒ [Nationalƒprogrammeƒforƒtheƒpreventionƒofƒbreastƒcancer].ƒOfficialƒGazetteƒRS,ƒ73/2013.ƒ OfficialƒGazetteƒ(2013n).ƒUredba o nacionalnom programu ranog otkrivanja kolorektalnog karcinomaƒ [Nationalƒprogrammeƒforƒtheƒpreventionƒofƒcolorectalƒcancer].ƒOfficialƒGazetteƒRS,ƒ73/2013.ƒ OfficialƒGazetteƒ(2013o).ƒNacionalna strategija za borbu protiv korupcije u Republici Srbiji za period od 2013. do 2018. godineƒ[Theƒnationalƒanti-corruptionƒstrategyƒinƒtheƒRepublicƒofƒ Serbiaƒ2013–2018].ƒOfficialƒGazetteƒRS,ƒ57/2013.ƒ OfficialƒGazetteƒ(2013p).ƒAkcioni plan za sprovođenje nacionalne strategije za borbu protiv korupcije u Republici Srbiji za period od 2013. do 2018. godineƒ[Theƒactionƒplanƒforƒtheƒimplementationƒ ofƒ theƒnationalƒanti-corruptionƒstrategyƒ inƒtheƒRepublicƒofƒSerbiaƒ2013–2018].ƒOfficialƒ GazetteƒRS,ƒ79/2013ƒandƒ61/2016.ƒ OfficialƒGazetteƒ(2013q).ƒStrategija prevencije i zastite od diksriminacijeƒ[Strategyƒforƒpreventionƒ andƒprotectionƒagainstƒdiscrimination]ƒOfficialƒGazetteƒRS,ƒ60/2013. OfficialƒGazetteƒ(2014a).ƒZakon o ministarstvimaƒ[LawƒonƒMinistries].ƒOfficialƒGazetteƒRS,ƒ 44/2014,ƒ14/2015,ƒ54/2015,ƒ96/2015ƒandƒ62/2017.ƒ 195Serbia OfficialƒGazetteƒ(2014b).ƒZakon o zdravstvenoj dokumentaciji i evidencijama u oblasti zdravstvaƒ [LawƒonƒHealthƒRecordsƒandƒReportingƒ inƒ theƒFieldƒofƒHealth].ƒOfficialƒGazetteƒRS,ƒ 123/2014,ƒ106/2015ƒandƒ105/2017.ƒ OfficialƒGazetteƒ(2014c).ƒPravilnik o uslovima, kriterijumima, načinu i postupku stavljanja leka na Listu lekova, izmene i dopune Liste lekova, odnosno za skidanje leka sa Liste lekovaƒ[Rulebookƒ onƒtheƒconditions,ƒcriteria,ƒtheƒwayƒandƒprocedureƒforƒplacingƒtheƒdrugƒonƒtheƒDrugƒList,ƒ amendingƒtheƒDrugƒList,ƒorƒforƒremovingƒtheƒdrugƒfromƒtheƒDrugƒList].ƒOfficialƒGazetteƒ RS,ƒ41/2014,ƒ125/2014ƒandƒ48/2015.ƒ OfficialƒGazetteƒ (2014d).ƒZakon o potvrđivanju Sporazuma o zajmu (Drugi Projekat razvoja zdravstva Srbije) između Republike Srbije i Međunarodne banke za obnovu i razvoj [Lawƒ onƒ theƒConfirmationƒofƒ theƒLoanƒAgreementƒ (SecondƒSerbianƒHealthƒDevelopmentƒ Project)ƒbetweenƒtheƒRepublicƒofƒSerbiaƒandƒtheƒInternationalƒBankƒforƒReconstructionƒ andƒDevelopment].ƒOfficialƒGazetteƒRS,ƒ11/2014.ƒ OfficialƒGazetteƒ(2014e).ƒZakon o osiguranju [Lawƒonƒinsurance].ƒOfficialƒGazetteƒRS,ƒ139/2014. OfficialƒGazetteƒ(2015a).ƒUredba o kriterijumima za formiranje cena lekova za upotrebu u humanoj medicini čiji je režim izdavanja na receptƒ[Decreeƒonƒtheƒcriteriaƒforƒtheƒformationƒofƒpricesƒ forƒdrugsƒforƒuseƒinƒhumanƒmedicine,ƒwhichƒareƒunderƒaƒprescriptionƒregimen].ƒOfficialƒ GazetteƒRS,86/2015,ƒ8/2016ƒiƒ14/2018.ƒ OfficialƒGazetteƒ(2015b).ƒOdluka o maksimalnom broju zaposlenih na neodređeno vreme u sistemu državnih organa, sistemu javnih službi, sistemu Autonomne pokrajine Vojvodine I sistemu lokalne samouprave za 2015. godinuƒ[Decisionƒonƒtheƒmaximumƒnumberƒofƒemployeesƒforƒanƒindefiniteƒ periodƒinƒtheƒsystemƒofƒstateƒbodies,ƒtheƒpublicƒserviceƒsystem,ƒtheƒsystemƒofƒtheƒAutonomousƒ ProvinceƒofƒVojvodinaƒandƒtheƒsystemƒofƒlocalƒself-governmentƒforƒ2015].ƒOfficialƒGazetteƒ RSƒ101/2015,ƒ2016ƒandƒ2017ƒandƒOff.ƒGazetteƒofƒRSƒ61/2017-17ƒandƒ82/2017. OfficialƒGazetteƒ(2015c).ƒNacionalna strategija za rešavanje pitanja izbeglica i interno raseljenih lica za period od 2015. do 2020. godine [Nationalƒ strategyƒ forƒ resolvingƒ theƒproblemsƒofƒ refugeesƒandƒ internallyƒdisplacedƒpersonsƒ forƒ theƒperiodƒ fromƒ2015ƒ toƒ2020].ƒOfficialƒ GazetteƒRS,ƒ62/2015.ƒ OfficialƒGazetteƒ(2016a).ƒZakon o javnom zdravlju [PublicƒHealthƒLaw].ƒOfficialƒGazetteƒRS,ƒ 15/2016.ƒ OfficialƒGazetteƒ(2016b).ƒZakon o zaštiti stanovništva od zaraznih bolestiƒ[Lawƒonƒtheƒprotectionƒ ofƒtheƒpopulationƒfromƒcommunicableƒdiseases].ƒOfficialƒGazetteƒRS,ƒ15/2016.ƒ OfficialƒGazetteƒ(2016c).ƒUredba o Šifarniku radnih mesta [Regulationƒonƒtheƒcodebookƒofƒjobƒ designations].ƒOfficialƒGazetteƒRS,ƒ12/2016.ƒ OfficialƒGazetteƒ(2016d).ƒZakon o budzetu Republike Srbije za 2017. godinu [Lawƒonƒbudgetƒofƒ RepublicƒofƒSerbiaƒforƒ2017].ƒOfficialƒGazetteƒRS,ƒ99/2016ƒandƒ113/2017. OfficialƒGazetteƒ(2016e).ƒStrategija za socijalno ukljucivanje Roma i Romkinja u Republici Srbiji za period od 2016. Do 2025 godineƒ[StrategyƒforƒsocialƒinclusionƒofƒRomaƒforƒtheƒperiodƒ 2016–2025].ƒOfficialƒGazetteƒRS,ƒ26/2016. OfficialƒGazetteƒ(2017a).ƒZakon o visokom obrazovanjuƒ[LawƒonƒHigherƒEducation].ƒOfficialƒ GazetteƒRS,ƒ88/2017.ƒ OfficialƒGazetteƒ (2017b).ƒPravilnik o imunizaciji i načinu zaštite lekovimaƒ [Rulebookƒonƒ immunizationƒandƒmethodƒofƒprotectionƒbyƒdrugs].ƒOfficialƒGazetteƒRS,ƒ88/2017,ƒ11/2018,ƒ 14/2018,ƒ45/2018,ƒ48/2018,ƒ50/2018,ƒandƒ104/2018. 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WHOƒ(2014b).ƒNoncommunicableƒdiseasesƒcountryƒprofilesƒ2014.ƒGeneva:ƒWorldƒHealthƒ Organization.ƒ(http://apps.who.int/iris/bitstream/10665/128038/1/9789241507509_eng. pdf?ua=1,ƒaccessedƒ08ƒFebruaryƒ2020). WHOƒ(2016a).ƒHealthƒ forƒAllƒdatabase.ƒCopenhagen:ƒWHOƒRegionalƒOfficeƒ forƒEurope.ƒ (http://data.euro.who.int/hfadb/,ƒaccessedƒ08ƒFebruaryƒ2020). WHOƒ(2016b).ƒTobaccoƒcontrolƒfactƒsheet,ƒSerbia.ƒHealthƒimpactƒofƒtobaccoƒcontrolƒpoliciesƒ inƒ lineƒwithƒ theƒWHOƒFrameworkƒConventionƒonƒTobaccoƒControlƒ (WHOƒFCTC).ƒ Copenhagen:ƒWHOƒRegionalƒOfficeƒforƒEurope.ƒ(http://www.euro.who.int/__data/assets/ pdf_file/0008/312596/Tobacco-control-fact-sheet-Serbia.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). 200 Health Systems in Transition WHOƒ(2018a).ƒWhatƒ isƒDOTS?ƒAƒguideƒ toƒunderstandingƒ theƒWHO-recommendedƒTBƒ controlƒ strategyƒknownƒasƒDOTS.ƒGeneva:ƒWorldƒHealthƒOrganization.ƒ (https://www. who.int/tb/publications/dots-who-guide/en/ƒ,ƒaccessedƒ08ƒFebruaryƒ2020). WHOƒ (2018b).ƒ Noncommunicableƒ diseasesƒ countryƒ profiles.ƒ Geneva:ƒWorldƒ Healthƒ Organization.ƒ (https://www.who.int/nmh/publications/ncd-profiles-2018/en/,ƒaccessedƒ 08ƒFebruaryƒ2020). WHOƒ(2019).ƒEuropeanƒHealthƒInformationƒGateway.ƒHealthƒforƒAllƒexplorer.ƒCopenhagen:ƒ WHOƒRegionalƒOfficeƒforƒEurope.ƒ(https://gateway.euro.who.int/en/hfa-explorer/,ƒaccessedƒ 08ƒFebruaryƒ2020). WHOƒ(2019a).ƒVaccineƒ–ƒpreventableƒdiseases:ƒMonitoringƒsystem.ƒ2019ƒGlobalƒSummary.ƒ Countryƒprofile:ƒSerbia,ƒlastƒupdatedƒ15ƒJulyƒ2019ƒ(dataƒasƒofƒ01ƒJulyƒ2019).ƒ(http://apps. who.int/immunization_monitoring/globalsummary/countries?countrycriteria%5Bcountr y%5D%5B%5D=SRB/,ƒaccessedƒ08ƒFebruaryƒ2020). WHOƒ(2019b).ƒWHOƒGlobalƒExpenditureƒDatabaseƒ (updatedƒDecemberƒ2018)ƒ [onlineƒ database].ƒGeneva:ƒWorldƒHealthƒOrganization.ƒ(http://apps.who.int/nha/database/select/ indicators/en,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2003).ƒProjectƒappraisalƒdocumentƒonƒaƒproposedƒcreditƒinƒtheƒamountƒofƒSDRƒ 14.7ƒmillionƒ(US$20ƒmillionƒequivalent)ƒtoƒSerbiaƒandƒMontenegroƒforƒaƒSerbiaƒhealthƒ projectƒ17ƒAprilƒ2003ƒ[Internet].ƒWashington:ƒWorldƒBankƒGroup.ƒ (http://documents. worldbank.org/curated/en/285761468777609155/pdf/256561YF1Serbia0Health0Proje ct.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2009).ƒSerbia:ƒDoingƒmoreƒwithƒaƒless.ƒAddressingƒtheƒfiscalƒcrisisƒbyƒincreasingƒ publicƒsectorƒproductivity.ƒReportƒNo.ƒ48620-YF.ƒWashington:ƒWorldƒBank Group. WorldƒBankƒ(2011).ƒSerbiaƒ–ƒAdditionalƒfinancingƒforƒtheƒhealthƒproject:ƒprocurementƒplanƒ (English).ƒWashington,ƒDC:ƒWorldƒBank.ƒ (http://documents.worldbank.org/curated/ en/508831468103146185/Serbia-Additional-Financing-for-the-Health-Project- procurement-plan,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2014).ƒInternationalƒbankƒforƒreconstructionƒandƒdevelopment:ƒprojectƒappraisalƒ documentƒonƒaƒproposedƒloanƒinƒtheƒamountƒofƒEURƒ29.1ƒmillionƒ(US$40ƒmillionƒequivalent)ƒ toƒtheƒRepublicƒofƒSerbiaƒforƒaƒsecondƒSerbiaƒhealthƒprojectƒ(P129539)ƒ[Internet].ƒWashington:ƒ WorldƒBankƒGroup.ƒ(http://documents.worldbank.org/curated/en/969641468102535325/ pdf/819240PAD0P129010Box382122B00OUO090.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2015a).ƒImplementationƒcompletionƒandƒresultsƒreportƒ(IBRD-75100)ƒonƒaƒloanƒ inƒtheƒamountƒofƒeuroƒ32.0ƒmillionƒtoƒtheƒrepublicƒofƒSerbiaƒforƒTheƒDeliveryƒofƒImprovedƒ LocalƒServicesƒ (DILS)ƒproject.ƒWashington:ƒWorldƒBankƒGroup.ƒ (http://documents. worldbank.org/curated/en/650621468196152992/pdf/ICR2778-P096823-Box393260B- PUBLIC-disclosed-11-30-15.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2015b).ƒRepublicƒofƒSerbia.ƒPublicƒfinanceƒreviewƒ2015.ƒTowardƒaƒsustainableƒandƒ efficientƒfiscalƒpolicy.ƒReportƒNo.ƒ96451-YF.ƒWashington:ƒWorldƒBank Group. WorldƒBankƒ(2017).ƒDisclosableƒVersionƒofƒtheƒISRƒ–ƒSecondƒSerbiaƒHealthƒProjectƒ–ƒP129539ƒ–ƒ SequenceƒNo:ƒ08ƒ(English).ƒWashington:ƒWorldƒBankƒGroup.ƒ(http://documents.worldbank. org/curated/en/934351504810313056/Disclosable-Version-of-the-ISR-Second-Serbia- Health-Project-P129539-Sequence-No-08,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2018a).ƒSecondƒSerbiaƒHealthƒProject.ƒWashington:ƒWorldƒBankƒGroup.ƒ(http:// projects.worldbank.org/P129539/second-serbia-health-project?lang=en,ƒ accessedƒ 08ƒ Februaryƒ2020). WorldƒBankƒ(2018b).ƒSecondƒSerbiaƒHealthƒProject.ƒ(Loansƒno.ƒ8338-YFƒandƒ8830-YF)ƒAide- Memoire,ƒImplementationƒSupportƒVisit.ƒBelgrade:ƒ23–27Julyƒ2018.ƒWashington:ƒWorldƒ Bank Group. WorldƒBankƒ(2018c).ƒSerbiaƒ–ƒSecondƒHealthƒProject:ƒadditionalƒfinancing.ƒWashington:ƒWorldƒ BankƒGroup.ƒ(http://documents.worldbank.org/curated/en/295561520264087205/Serbia- Second-Health-Project-additional-financing,ƒaccessedƒ08ƒFebruaryƒ2020). 201Serbia Worldƒ Bankƒ (2019a).ƒ Internationalƒ comparisonƒ programƒ database,ƒ worldƒ developmentƒ indicators.ƒWashington:ƒWorldƒBankƒGroupƒ(https://databank.worldbank.org/reports. aspx?source=2&series=SP.POP.TOTL&country=SRB,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2019b).ƒGrossƒdomesticƒproductƒ2018,ƒPPP.ƒWashington:ƒWorldƒBankƒGroup.ƒ (http://databank.worldbank.org/data/download/GDP_PPP.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). ZivkovicƒS,ƒStojanovic-AleksicƒVƒ(2015).ƒManagementƒofƒoccupationalƒsafetyƒandƒhealthƒinƒtheƒ RepublicƒofƒSerbia.ƒProceedingsƒofƒtheƒSecondƒEuropeanƒAcademicƒResearchƒConferenceƒonƒ GlobalƒBusiness,ƒEconomics,ƒFinanceƒandƒBankingƒ(EAR15SwissƒConference)ƒISBN:ƒ978- 1-63415-477-2ƒZurich-Switzerland,ƒ3–5ƒJuly,ƒPaperƒID:ƒZ599.ƒ(http://globalbizresearch. org/Swiss_Conference/pdf/Z599.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). 9.2  Principal legislation ConstitutionƒofƒtheƒRepublicƒofƒSerbiaƒ[Ustav Republike Srbije].ƒOfficialƒGazetteƒRS,ƒ98/2006.ƒ (https://www.paragraf.rs/propisi/ustav_republike_srbije.html,ƒaccessedƒ08ƒFebruaryƒ2020). HealthƒCareƒLawƒ[Zakonƒoƒzdravstvenojƒzaštiti].ƒOfficialƒGazetteƒRS,ƒ25/2019.ƒ(https://www. paragraf.rs/propisi/zakon_o_zdravstvenoj_zastiti.html,ƒaccessedƒ08ƒFebruaryƒ2020). HealthƒInsuranceƒLawƒ[Zakonƒoƒzdravstvenomƒosiguranju].ƒOfficialƒGazetteƒRS,ƒ25/2019.ƒ (https://www.paragraf.rs/propisi/zakon_o_zdravstvenom_osiguranju.html,ƒaccessedƒ08ƒ Februaryƒ2020). LawƒonƒChambersƒofƒHealthƒWorkersƒ [Zakon o komorama zdravstvenih radnika].ƒOfficialƒ GazetteƒRS,ƒ107/2005,ƒ99/2010ƒandƒ70/2017.ƒ(https://www.paragraf.rs/propisi/zakon_o_ komorama_zdravstvenih_radnika.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒConfirmationƒofƒtheƒLoanƒAgreementƒ(additionalƒfinancingƒforƒtheƒSecondƒHealthƒ SectorƒDevelopmentƒProject)ƒbetweenƒtheƒRepublicƒofƒSerbiaƒandƒtheƒInternationalƒBankƒforƒ ReconstructionƒandƒDevelopment].ƒOfficialƒGazetteƒRSƒ6/2018.ƒ(http://www.parlament.gov. rs/upload/archive/files/lat/pdf/zakoni/2018/951-18%20lat.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒDisasterƒRiskƒReductionƒandƒEmergencyƒManagementƒ[Zakonƒoƒsmanjenuƒrizikaƒodƒ katastrofaƒ iƒupravljanjuƒvanrednimƒsituacijama].ƒOfficialƒGazetteƒRSƒ87/2018.ƒ (https:// www.paragraf.rs/propisi/zakon-o-smanjenju-rizika-od-katastrofa-i-upravljanju-vanrednim- situacijama.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒHealthƒRecordsƒandƒReportingƒinƒtheƒFieldƒofƒHealthƒ[Zakonƒoƒzdravstvenojƒdokumentacijiƒ iƒevidencijamaƒuƒoblastiƒzdravstva].ƒOfficialƒGazetteƒRS,ƒ123/2014,ƒ106/2015,ƒ105/2017ƒ andƒ25/2019.ƒ (https://www.paragraf.rs/propisi/zakon-o-zdravstvenoj-dokumentaciji-i- evidencijama-u-oblasti-zdravstva.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒHigherƒEducationƒ[Zakonƒoƒvisokomƒobrazovanju].ƒOfficialƒGazetteƒRS,ƒ88/2017,ƒ 73/2018,ƒ27/2018,ƒ67/2019ƒandƒ6/2020ƒ .ƒ (https://www.paragraf.rs/propisi/zakon_o_ visokom_obrazovanju.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒMedicinesƒandƒMedicalƒDevicesƒ[Zakonƒoƒlekovimaƒiƒmedicinskimƒsredstvima].ƒOfficialƒ GazetteƒRS,ƒ30/2010,107/2012,ƒ113/2017ƒandƒ107/2017.ƒ(https://www.paragraf.rs/propisi/ zakon_o_lekovima_i_medicinskim_sredstvima.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒMandatoryƒSocialƒSecurityƒContributionƒ[Zakonƒoƒdoprinosimaƒzaƒobaveznoƒsocijalnoƒ osiguranje].ƒOfficialƒGazetteƒRS,ƒ84/2004,ƒ61/2005,ƒ62/2006,ƒ5/2009,ƒ52/2011,ƒ101/2011,ƒ 7/2012,ƒ47/2013,ƒ108/2013,ƒ6/2014,ƒ57/2014,ƒ68/2014,ƒ5/2015,ƒ112/2015,ƒ5/2016,ƒ7/2017,ƒ 113/2017,ƒ7/2018,ƒ95/2018,ƒ4/2019,ƒ86/2019ƒandƒ5/2020.ƒ(https://www.paragraf.rs/propisi/ zakon-o-doprinosima-za-obavezno-socijalno-osiguranje.html?url=zakon_o_doprinosima_ za_obavezno_socijalno_osiguranje.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒMinistriesƒ[Zakon o ministarstvima].ƒOfficialƒGazetteƒRS, 44/2014,ƒ14/2015,ƒ54/2015,ƒ 96/2015ƒandƒ62/2017.ƒ (https://www.paragraf.rs/propisi/zakon_o_ministarstvima.html,ƒ accessedƒ08ƒFebruaryƒ2020). 202 Health Systems in Transition LawƒonƒProtectionƒfromƒExposureƒtoƒSecond-HandƒSmokeƒ[Zakon o zaštiti stanovništva od izloženosti duvanskom dimu].ƒOfficialƒGazetteƒRS,ƒ30/2010.ƒ (https://www.paragraf.rs/ propisi/zakon_o_zastiti_stanovnistva_od_izlozenosti_duvanskom_dimu.html,ƒaccessedƒ 08ƒFebruaryƒ2020). LawƒonƒProtectionƒofƒPersonsƒwithƒMentalƒDisabilitiesƒ [Zakon o zaštiti lica sa mentalnim smetnjama].ƒOfficialƒGazetteƒRS,ƒ45/2013.ƒ(https://www.paragraf.rs/propisi/zakon-o-zastiti- lica-sa-mentalnim-smetnjama.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒtheƒProtectionƒofƒPopulationƒfromƒCommunicableƒDiseasesƒ[Zakon o zaštiti stanovništva od zaraznih bolesti].ƒOfficialƒGazetteƒRS,ƒ15/2016.ƒ(https://www.paragraf.rs/propisi/zakon_o_ zastiti_stanovnistva_od_zaraznih_bolesti.html,ƒaccessedƒ08ƒFebruaryƒ2020). Lawƒonƒ theƒBudgetƒSystemƒ[Zakon o budžetskom sistemu].ƒOfficialƒGazetteƒRS,ƒ54/2009,ƒ 73/2010,ƒ101/2010,ƒ101/2011,ƒ93/2012,ƒ62/2013,ƒ63/2013,ƒ108/2013,ƒ142/2014,ƒ68/2015,ƒ 103/2015,ƒ99/2016,113/2017,ƒ95/2018,ƒ31/2019ƒandƒ72/2019.ƒ(https://www.paragraf.rs/ propisi/zakon_o_budzetskom_sistemu.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒPatients’ƒRightsƒ [Zakon o pravima pacijenata].ƒOfficialƒGazetteƒRS,ƒ45/2013ƒandƒ 25/2019.ƒ (https://www.paragraf.rs/propisi/zakon_o_pravima_pacijenata.html,ƒaccessedƒ 08ƒFebruaryƒ2020). LawƒonƒtheƒPlanningƒSystemƒofƒtheƒRepublicƒofƒSerbiaƒ[Zakon o planskom sistemu Republike Srbije].ƒ OfficialƒGazetteƒRS,ƒ30/2018.ƒ(https://www.paragraf.rs/dnevne-vesti/130219/130219-vest8. html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒtheƒProtectionƒofƒtheƒRightsƒofƒNationalƒMinoritiesƒ[Zakon o zaštiti prava i sloboda nacionalnih manjina].ƒOfficialƒGazetteƒRS,ƒ72/2009,ƒ97/2013ƒandƒ47/2018.ƒ(https://www. paragraf.rs/propisi/zakon_o_zastiti_prava_i_sloboda_nacionalnih_manjina.html,ƒaccessedƒ 08ƒFebruaryƒ2020). LawƒonƒPublicƒProcurementƒ[Zakon o javnim nabavkama].ƒOfficialƒGazetteƒRS,ƒ124/2012,ƒ 14/2015ƒandƒ68/2015.ƒ(https://www.paragraf.rs/propisi/zakon_o_javnim_nabavkama.html,ƒ accessedƒ08ƒFebruaryƒ2020). LawƒonƒSafetyƒandƒHealthƒatƒWorkƒ[Zakon o bezbednosti i zdravlju na radu].ƒOfficialƒGazetteƒRS,ƒ 101/2005,ƒ91/2015ƒandƒ113/2017.ƒ(https://www.paragraf.rs/propisi/zakon_o_bezbednosti_i_ zdravlju_na_radu.html,ƒaccessedƒ08ƒFebruaryƒ2020). LawƒonƒTerritorialƒOrganizationƒofƒtheƒRepublicƒofƒSerbiaƒ[Zakon o teritorijalnoj organizaciji Republike Srbije].ƒOfficialƒGazetteƒRS,ƒ129/2007,ƒ18/2016ƒandƒ47/2018.ƒ (https://www. paragraf.rs/propisi/zakon_o_teritorijalnoj_organizaciji_republike_srbije.html,ƒaccessedƒ 08ƒFebruaryƒ2020). PublicƒHealthƒLawƒ[Zakon o javnom zdravlju].ƒOfficialƒGazetteƒRS,ƒ15/2016.ƒ(https://www. paragraf.rs/propisi/zakon_o_javnom_zdravlju.html,ƒaccessedƒ08ƒFebruaryƒ2020). 9.2.1 Regulations, decrees and rulebooks DecisionƒofƒtheƒHighestƒPricesƒofƒDrugsƒforƒUseƒinƒHumanƒMedicine,ƒWhoseƒRegimeƒIssuingƒ Prescriptionƒ[Odluka o najvišim cenama lekova za upotrebu u humanoj medicine, a čiji je režim izdavanja na recept].ƒOfficialƒGazetteƒRS,ƒ69/2019.ƒ(http://www.pravno-informacioni-sistem. rs/SlGlasnikPortal/eli/rep/sgrs/vlada/odluka/2019/18/1/reg,ƒaccessedƒ08ƒFebruaryƒ2020). DecisionƒonƒtheƒPlanƒforƒDevelopmentƒofƒHealthƒCareƒinƒtheƒRepublicƒofƒSerbiaƒ[Odluka o planu razvoja zdravstvene zaštite Republike Srbije].ƒOfficialƒGazetteƒRS,ƒ88/2010.ƒ(https:// www.pravni-skener.org/pdf/sr/baza_propisa/58.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). DecreeƒonƒtheƒCriteriaƒforƒtheƒFormationƒofƒPricesƒforƒDrugsƒforƒUseƒinƒHumanƒMedicine,ƒ WhichƒAreƒUnderƒaƒPrescriptionƒRegimenƒ[Uredba o kriterijumima za formiranje cena lekova za upotrebu u humanoj medicini čiji je režim izdavanja na recept].ƒOfficialƒGazetteƒRS,ƒ86/2015,ƒ 8/2016,14/2018ƒandƒ18/2019.ƒ(https://www.paragraf.rs/propisi/uredba_o_kriterijumima_ za_formiranje_cena_lekova_za_upotrebu_u_humanoj_medicini_ciji_je_rezim_izdavanja_ na_recept.html,ƒaccessedƒ08ƒFebruaryƒ2020). 203Serbia DecreeƒofƒRulesƒonƒtheƒCorrectiveƒCoefficient,ƒtheƒHighestƒPercentageƒofƒIncreaseƒinƒBasicƒ Salaries,ƒCriteriaƒandƒNormsƒforƒtheƒPartƒofƒtheƒSalaryƒthatƒisƒRealizedƒonƒtheƒBasisƒofƒWorkƒ Performance,ƒasƒwellƒasƒtheƒMethodƒofƒCalculationƒofƒSalariesƒofƒEmployeesƒinƒHealthƒ Institutionsƒ[Uredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovama].ƒOfficialƒGazetteƒRS,100/2011,ƒ 63/2012,ƒ101/2012,ƒ46/2013.ƒ(https://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/ eli/rep/sgrs/vlada/uredba/2011/100/11/reg,ƒaccessedƒ08ƒFebruaryƒ2020). Decreeƒonƒ theƒPlanningƒandƒTypeƒofƒGoodsƒandƒServicesƒ forƒWhichƒCentralizedƒPublicƒ Procurementƒ isƒConductedƒ[Uredba o planiranju i vrsti roba i usluga za koje se sprovode centralizovane javne nabavke].ƒOfficialƒGazetteƒRS,ƒ34/2019ƒandƒ64/2019.ƒ(https://www. paragraf.rs/propisi/uredba_o_planiranju_i_vrsti_roba_i_usluga_za_koje_se_sprovode_ centralizovane_javne_nabavke.html,ƒaccessedƒ08ƒFebruaryƒ2020). DecreeƒonƒtheƒPlanƒofƒtheƒHealthƒInstitutions’ƒNetworkƒ[Uredba o planu mreže zdravstvenih ustanova].ƒOfficialƒGazetteƒRS,ƒ5/2020.ƒ(https://www.paragraf.rs/propisi/uredba_o_planu_ mreze_zdravstvenih_ustanova.html,ƒaccessedƒ08ƒFebruaryƒ2020). DecreeƒonƒVoluntaryƒHealthƒInsuranceƒ [Uredba o dobrovoljnom zdravstvenom osiguranju].ƒ OfficialƒGazetteƒRS,ƒ108/2008ƒandƒ49/2009.ƒ(https://www.rfzo.rs/download/dobrovoljno/ Uredba_dobrovoljno_zdr_osiguranje.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). RegulationƒonƒtheƒCodebookƒofƒJobƒDesignationsƒ[Uredba o Šifarniku radnih mesta].ƒOfficialƒ GazetteƒRS,ƒ12/2016.ƒ(http://www.cekos.rs/uredba-o-%C5%A1ifarniku-radnih-mesta-2016,ƒ accessedƒ08ƒFebruaryƒ2020). Regulationƒ onƒNationalƒ Programmeƒ ofƒ PreventiveƒDentalƒCareƒ [Uredba o nacionalnom programu preventivne stomatološke zaštite].ƒOfficialƒGazetteƒRS,ƒ22/2009.ƒ (http://www. pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/sgrs/vlada/uredba/2009/22/4/reg,ƒ accessedƒ08ƒFebruaryƒ2020). RegulationƒonƒNationalƒProgrammeƒofƒHealthƒCareƒofƒWomen,ƒChildrenƒandƒAdolescentsƒ [Uredba o nacionalnom programu zdravstvene zaštite žena, dece i omladine].ƒOfficialƒGazetteƒRSƒ 28/2009.ƒ(https://pravni-skener.org/pdf/sr/baza_propisa/43.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒDetailedƒConditionsƒforƒPerformingƒHealthƒCareƒActivitiesƒinƒHealthƒInstitutionsƒ andƒOtherƒFormsƒofƒHealthƒCareƒServicesƒ [Pravilnik o bližim uslovima za obavljanje zdravstvene delatnosti u zdravstvenim ustanovama i drugim oblicima zdravstvene službe].ƒ OfficialƒGazetteƒRS,ƒ43/2006,ƒ112/2009,ƒ50/2010,ƒ79/2011,ƒ10/2012,ƒ22/2013ƒandƒ16/2018.ƒ (https://www.paragraf.rs/propisi/pravilnik_o_blizim_uslovima_za_obavljanje_zdravstvene_ delatnosti_u_zdravstvenim_ustanovama_i_drugim_oblicima_zdravstvene_sluzbe.html,ƒ accessedƒ08ƒFebruaryƒ2020). RulebookƒonƒDetailedƒConditionsƒforƒIssuance,ƒRenewalƒorƒRevocationƒofƒLicensesƒforƒMembersƒ ofƒtheƒChambersƒofƒHealthƒProfessionalsƒ[Pravilnik o bližim uslovima za izdavanje, obnavljanje ili oduzimanje licence članovima komora zdravstvenih radnika].ƒOfficialƒGazetteƒRS,ƒ119/2007,ƒ 23/2009,ƒ40/2010ƒandƒ102/2015.ƒ (https://www.paragraf.rs/propisi/pravilnik_o_blizim_ uslovima_za_izdavanje_obnavljanje_ili_oduzimanje_licence.html,ƒaccessedƒ08ƒFebruaryƒ 2020). RulebookƒonƒHealthƒCareƒQualityƒIndicatorsƒ[Pravilnik o pokazateljima kvaliteta zdravstvene zaštite].ƒOfficialƒGazetteƒRS,ƒ 49/2010.ƒ (http://www.batut.org.rs/download/uputstva/ Pravilnik%20o%20pokazateljima%20kvaliteta%20zdravstvene%20zastite.pdf,ƒaccessedƒ 08 Februaryƒ2020). RulebookƒonƒImmunizationƒandƒMethodƒofƒProtectionƒbyƒDrugsƒ[Pravilnik o imunizaciji I načinu zaštite lekovima].ƒOfficialƒGazetteƒRS,ƒ88/2017,ƒ11/2018ƒandƒ14/2018.ƒ (https:// www.paragraf.rs/propisi/pravilnik_o_imunizaciji_i_nacinu_zastite_lekovima.html,ƒaccessedƒ 08 Februaryƒ2020). 204 Health Systems in Transition RulebookƒonƒNormativeƒandƒStandardsƒofƒWorkƒandƒPricesƒofƒPrevention,ƒAssessmentƒandƒ TreatmentƒofƒOralƒDisease,ƒWhichƒAreƒPaidƒbyƒMandatoryƒHealthƒinsuranceƒ[Pravilnik o normativima i standardima rada i cenama zdravstvenih usluga za prevenciju, preglede i lečenje bolesti usta i zuba koje se obezbeđuju iz sredstava obaveznog zdravstvenog osiguranja].ƒOfficialƒ GazetteƒRS,ƒ12/2012,ƒ1/2019ƒandƒ15/2019.ƒ(https://www.paragraf.rs/propisi_download/ pravilnik_o_normativima_i_standardima_rada_i_cenama_zdravstvenih_usluga.pdf,ƒaccessedƒ 08ƒFebruaryƒ2020). RulebookƒonƒPhysicalƒRestraintƒandƒIsolationƒofƒPersonsƒwithƒMentalƒDisordersƒHospitalizedƒinƒ PsychiatricƒInstitutionsƒ[Pravilnik o bližim uslovima za primenu fizičkog sputavanja i izolacije lica sa mentalnim smetnjama koja se nalaze na lečenju u psihijatrijskim ustanovama].ƒOfficialƒ GazetteƒRS,ƒ94/2013.ƒ(http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/ sgrs/ministarstva/pravilnik/2013/94/4/reg,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒtheƒConditionsƒandƒMethodƒofƒSendingƒInsuredƒPersonsƒforƒTreatmentƒAbroadƒ [Pravilnik o uslovima i načinu upućivanja osiguranih lica na lečenje u inostranstvo].ƒOfficialƒ GazetteƒRS,ƒ44/2007,ƒ65/2008,ƒ36/2009,ƒ32/2010,ƒ50/2010,ƒ75/2013,ƒ110/2013,ƒ113/2014ƒ andƒ49/2016.ƒ(https://www.paragraf.rs/propisi/pravilnik_o_uslovima_i_nacinu_upucivanja_ osiguranih_lica_na_lecenje_u_inostranstvo.html,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒtheƒConditions,ƒCriteria,ƒtheƒWayƒandƒProcedureƒforƒPlacingƒtheƒDrugƒonƒtheƒ DrugƒList,ƒAmendingƒ theƒDrugƒList,ƒorƒ forƒRemovingƒ theƒDrugƒ fromƒtheƒDrugƒListƒ [Pravilnik o uslovima, kriterijumima, načinu i postupku stavljanja leka na Listu lekova, izmene i dopune Liste lekova, odnosno za skidanje leka sa Liste lekova].ƒOfficialƒGazetteƒRS,ƒ41/2014,ƒ 125/2014,48/2015ƒandƒ14/2018.ƒ(http://pravno-informacioni-sistem.rs/SlGlasnikPortal/ reg/viewAct/13ad6a45-550c-4dad-9253-a9b9fb97cec4,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒtheƒContentƒofƒTechnologicalƒandƒFunctionalƒRequirementsƒforƒEstablishingƒtheƒ IntegratedƒHealthƒInformationƒSystemƒ[Pravilnik o bližoj sadržini tehnoloških i fukncionalnih zahteva za uspostavljanje integrisanog zdravstvenog informacionog sistema].ƒOfficialƒGazetteƒ RS, 55/2009.ƒ(http://www.rfzo.rs/download/pravilnici/mz/Pravilnik_integrisanizdrsistem. pdf,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒtheƒContentƒandƒScopeƒofƒtheƒRightƒtoƒHealthƒCareƒfromƒCompulsoryƒHealthƒ InsuranceƒandƒCo-Paymentƒforƒ2017ƒ[Pravilnik o sadržaju i obimu prava na zdravstvenu zaštitu iz obaveznog zdravstvenog osiguranja i o participaciji za 2017. godinu].ƒOfficialƒ GazetteƒRS,ƒ8/2017.ƒ(http://www.rfzo.rs/download/pravilnici/obim-sadrzaj/2017/Pravilnik_ sadrzajobim_2017.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒtheƒDrugƒListƒPrescribedƒandƒIssuedƒatƒtheƒExpenseƒofƒMandatoryƒHealthƒInsuranceƒ [Pravilnik o listi lekova koji se propisuju i izdaju na teret sredstava obaveznog zdravstvenog osiguranja].ƒOfficialƒGazetteƒRS,ƒ43/2019,ƒ55/2019,ƒ56/2019ƒandƒ87/2019.ƒ(https://www. paragraf.rs/propisi/pravilnik_o_listi_lekova_koji_se_propisuju_i_izdaju_na_teret_sredstava_ obaveznog_zdravstvenog_osiguranja.html,ƒaccessedƒ08ƒFebruaryƒ2020). RulebookƒonƒtheƒTypeƒandƒCloserƒConditionsƒforƒtheƒFoundationƒofƒOrganizationalƒUnitsƒandƒtheƒ ConductƒofƒMentalƒHealthƒActivitiesƒinƒtheƒCommunityƒ[Pravilnik o vrsti i bližim uslovima za obrazovanje organizacionih jedinica i obavljanje poslova zaštite mentalnog zdravlja u zajednici].ƒ OfficialƒGazetteƒRS,ƒ106/2013.ƒ(http://npm.rs/attachments/049_PRAVILNIK%20o%20 formiranju%20organizacionih%20jedinica%20za%20obavljanje%20poslova%20zastite%20 mentalnog%20zdravlja%20u%20zajednici.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). StatuteƒofƒtheƒRepublicƒFundƒofƒHealthƒInsuranceƒ[Statut Republičkog fonda za zdravstveno osiguranje].ƒOfficialƒGazetteƒRS,ƒ81/2011,ƒ57/2012,ƒ89/2012,ƒ1/2013,ƒ32/2013ƒandƒ23/2015.ƒ (https://www.paragraf.rs/propisi/statut_republickog_fonda_za_zdravstveno_osiguranje. html,ƒaccessedƒ08ƒFebruaryƒ2020). StrategyƒforƒContinuousƒQualityƒImprovementƒinƒHealthƒCareƒandƒPatientƒSafetyƒ[Strategija za stalno unapređenje kvaliteta zdravstvene zaštite i bezbednosti pacijenta].ƒOfficialƒGazetteƒRS,ƒ 15/2009.ƒ(http://pravni-skener.org/pdf/sr/baza_propisa/77.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). StrategyƒforƒMentalƒHealthƒCareƒDevelopmentƒ[Strategija razvoja zaštite mentalnog zdravlja].ƒ OfficialƒGazetteƒRS 55/2005,ƒcorrectionƒ71/2005.ƒ(http://www.pravno-informacioni-sistem. rs/SlGlasnikPortal/eli/rep/sgrs/vlada/strategija/2007/8/1/reg,ƒaccessedƒ08ƒFebruaryƒ2020). 205Serbia StrategyƒforƒPalliativeƒCareƒ[Strategija za palijativno zbrinjavanje].ƒOfficialƒGazetteƒRS,ƒ55/2005,ƒ 71/2005,ƒ 101/2007,ƒ 65/2008.ƒ (https://pravni-skener.org/pdf/sr/baza_propisa/78.pdf,ƒ accessedƒ08ƒFebruaryƒ2020). StrategyƒforƒSafetyƒandƒHealthƒatƒWorkƒofƒtheƒRepublicƒofƒSerbiaƒ[Strategija bezbednosti i zdravlja na radu Republike Srbije].ƒOfficialƒGazetteƒRS,ƒ100/2013.ƒ(https://www.pravni-skener.org/ pdf/sr/domaci_zakoni/19.pdf,ƒaccessedƒ08ƒFebruaryƒ2020). TobaccoƒControlƒStrategyƒ[Strategija kontrole duvana].ƒOfficialƒGazetteƒRS,ƒ8/2007.ƒ(http://demo. paragraf.rs/demo/combined/Old/t/t2007_01/t01_0256.htm,ƒaccessedƒ08ƒFebruaryƒ2020). WorldƒBankƒ(2018).ƒTheƒWorldƒBankƒReportƒNo:ƒPAD2705.ƒTheƒWorldƒBankƒAdditionalƒ Financingƒ forƒSecondƒSerbiaƒHealthƒProjectƒ (P166025).ƒ (http://documents.worldbank. org/curated/en/295561520264087205/pdf/Serbia-Health-PP-03012018.pdf,ƒaccessedƒ 08ƒFebruaryƒ2020). 9.3  Useful websites AgencyƒforƒAccreditationƒofƒHealthƒCareƒInstitutionsƒofƒSerbia http://www.azus.gov.rs/en/ MedicinesƒandƒMedicalƒDevicesƒAgencyƒofƒSerbia https://www.alims.gov.rs/eng/ CommissionƒforƒAccreditationƒandƒQualityƒAssuranceƒofƒtheƒNationalƒ CouncilƒforƒHigherƒEducation https://www.kapk.org/en/caqa/ TheƒGovernmentƒofƒtheƒRepublicƒofƒSerbia http://www.srbija.gov.rs/ HealthƒCouncilƒofƒSerbia http://www.zdravstvenisavetsrbije.gov.rs/ InstituteƒofƒPublicƒHealthƒofƒSerbiaƒ“DrƒMilanƒJovanovićƒBatut”ƒ http://www.batut.org.rs/index.php?lang=2 MinistryƒofƒHealthƒofƒSerbia http://www.zdravlje.gov.rs/index.php NationalƒHealthƒInsuranceƒFundƒ http://www.rfzo.rs/ ParagrafƒLexƒ–ƒElectronicƒLegalƒDatabase,ƒLegalƒandƒEconomicƒIssuesƒ forƒSuccessfulƒandƒLegitimateƒBusinessƒ[Pravnaƒiƒekonomskaƒizdanjaƒzaƒ uspešnoƒiƒzakonitoƒposlovanje]ƒ https://www.paragraf.rs/ StatisticalƒOfficeƒofƒtheƒRepublicƒofƒSerbia http://www.stat.gov.rs UNICEFƒSerbia https://www.unicef.rs/ 206 Health Systems in Transition 9.4  HiT methodology and production process HiTsƒareƒproducedƒbyƒcountryƒexpertsƒinƒcollaborationƒwithƒtheƒObservatory’sƒ researchƒdirectorsƒandƒstaff.ƒTheyƒareƒbasedƒonƒaƒtemplateƒthat,ƒrevisedƒ periodically,ƒprovidesƒdetailedƒguidelinesƒandƒspecificƒquestions,ƒdefini- tions,ƒsuggestionsƒforƒdataƒsourcesƒandƒexamplesƒneededƒtoƒcompileƒreviews.ƒ Whileƒtheƒtemplateƒoffersƒaƒcomprehensiveƒsetƒofƒquestions,ƒitƒisƒintendedƒ toƒbeƒusedƒinƒaƒf lexibleƒwayƒtoƒallowƒauthorsƒandƒeditorsƒtoƒadaptƒitƒtoƒtheirƒ particularƒnationalƒcontext.ƒTheƒmostƒrecentƒtemplateƒisƒavailableƒonlineƒ at:ƒhttp://www.euro.who.int/en/home/projects/observatory/publications/ health-system-profiles-hits/hit-template-2010. AuthorsƒdrawƒonƒmultipleƒdataƒsourcesƒforƒtheƒcompilationƒofƒHiTs,ƒ rangingƒfromƒnationalƒstatistics,ƒnationalƒandƒregionalƒpolicyƒdocumentsƒ toƒpublishedƒliterature.ƒFurthermore,ƒinternationalƒdataƒsourcesƒmayƒbeƒ incorporated,ƒsuchƒasƒthoseƒofƒtheƒOECDƒandƒtheƒWorldƒBank.ƒTheƒOECDƒ HealthƒDataƒcontainƒoverƒ1200ƒindicatorsƒforƒtheƒ34ƒOECDƒcountries.ƒDataƒ areƒdrawnƒfromƒinformationƒcollectedƒbyƒnationalƒstatisticalƒbureauxƒandƒ healthƒministries.ƒTheƒWorldƒBankƒprovidesƒWorldƒDevelopmentƒIndicators,ƒ whichƒalsoƒrelyƒonƒofficial sources. Inƒadditionƒtoƒtheƒinformationƒandƒdataƒprovidedƒbyƒtheƒcountryƒexperts,ƒ theƒObservatoryƒsuppliesƒquantitativeƒdataƒinƒtheƒformƒofƒaƒsetƒofƒstandardƒ comparativeƒfiguresƒforƒeachƒcountry,ƒdrawingƒonƒtheƒEuropeanƒHealthƒforƒ Allƒdatabase.ƒTheƒHealthƒforƒAllƒdatabaseƒcontainsƒmoreƒthanƒ600 indicatorsƒ definedƒbyƒtheƒWHOƒRegionalƒOfficeƒforƒEuropeƒforƒtheƒpurposeƒofƒmoni- toringƒHealthƒinƒAllƒPoliciesƒinƒEurope.ƒItƒisƒupdatedƒforƒdistributionƒtwiceƒ aƒyearƒfromƒvariousƒsources,ƒrelyingƒlargelyƒuponƒofficialƒfiguresƒprovidedƒbyƒ governments,ƒasƒwellƒasƒhealthƒstatisticsƒcollectedƒbyƒtheƒtechnicalƒunitsƒofƒ theƒWHOƒRegionalƒOfficeƒforƒEurope.ƒTheƒstandardƒHealthƒforƒAllƒdataƒ haveƒbeenƒofficiallyƒapprovedƒbyƒnationalƒgovernments.ƒWithƒitsƒsummerƒ 2007ƒedition,ƒtheƒHealthƒforƒAllƒdatabaseƒstartedƒtoƒtakeƒaccountƒofƒtheƒ enlargedƒEUƒofƒ27 Member States. HiTƒauthorsƒareƒencouragedƒtoƒdiscussƒtheƒdataƒinƒtheƒtextƒinƒdetail,ƒ includingƒtheƒstandardƒfiguresƒpreparedƒbyƒtheƒObservatoryƒstaff,ƒespeciallyƒ ifƒthereƒareƒconcernsƒaboutƒdiscrepanciesƒbetweenƒtheƒdataƒavailableƒfromƒ different sources. AƒtypicalƒHiTƒconsistsƒofƒnine chapters. 1.ƒ Introduction:ƒoutlinesƒtheƒbroaderƒcontextƒofƒtheƒhealthƒsystem,ƒ 207Serbia includingƒgeographyƒandƒsociodemography,ƒeconomicƒandƒpoliticalƒcontextƒ andƒpopulation health. 2.ƒ Organizationƒandƒgovernance:ƒprovidesƒanƒoverviewƒofƒhowƒtheƒhealthƒ systemƒinƒtheƒcountryƒisƒorganized,ƒgoverned,ƒplannedƒandƒregulated,ƒasƒwellƒ asƒtheƒhistoricalƒbackgroundƒofƒtheƒsystem;ƒoutlinesƒtheƒmainƒactorsƒandƒtheirƒ decision-makingƒpowers;ƒandƒdescribesƒtheƒlevelƒofƒpatientƒempowermentƒ inƒtheƒareasƒofƒinformation,ƒchoice,ƒrights,ƒcomplaintsƒprocedures,ƒpublicƒ participationƒandƒcross-borderƒhealth care. 3.ƒ Financing:ƒprovidesƒinformationƒonƒtheƒlevelƒofƒexpenditureƒandƒ theƒdistributionƒofƒhealthƒspendingƒacrossƒdifferentƒserviceƒareas,ƒsourcesƒ ofƒrevenue,ƒhowƒresourcesƒareƒpooledƒandƒallocated,ƒwhoƒisƒcovered,ƒwhatƒ benefitsƒareƒcovered,ƒtheƒextentƒofƒuserƒchargesƒandƒotherƒout-of-pocketƒ payments,ƒvoluntaryƒhealthƒinsuranceƒandƒhowƒprovidersƒare paid. 4.ƒ Physicalƒandƒhumanƒresources:ƒdealsƒwithƒtheƒplanningƒandƒdistribu- tionƒofƒcapitalƒstockƒandƒinvestments,ƒinfrastructureƒandƒmedicalƒequipment;ƒ theƒcontextƒinƒwhichƒITƒsystemsƒoperate;ƒandƒhumanƒresourceƒinputƒintoƒ theƒhealthƒsystem,ƒincludingƒinformationƒonƒworkforceƒtrends,ƒprofessionalƒ mobility,ƒtrainingƒandƒcareer paths. 5.ƒ Provisionƒofƒservices:ƒconcentratesƒonƒtheƒorganizationƒandƒdeliveryƒ ofƒservicesƒandƒpatientƒf lows,ƒaddressingƒpublicƒhealth,ƒprimaryƒcare,ƒsec- ondaryƒandƒtertiaryƒcare,ƒdayƒcare,ƒemergencyƒcare,ƒpharmaceuticalƒcare,ƒ rehabilitation,ƒlong-termƒcare,ƒservicesƒforƒinformalƒcarers,ƒpalliativeƒcare,ƒ mentalƒhealthƒcare,ƒdentalƒcare,ƒcomplementaryƒandƒalternativeƒmedicine,ƒ andƒhealthƒservicesƒforƒspecific populations. 6.ƒ Principalƒhealthƒreforms:ƒreviewsƒreforms,ƒpoliciesƒandƒorganizationalƒ changes;ƒandƒprovidesƒanƒoverviewƒofƒfuture developments. 7.ƒ Assessmentƒofƒtheƒhealthƒsystem:ƒprovidesƒanƒassessmentƒbasedƒonƒ theƒstatedƒobjectivesƒofƒtheƒhealthƒsystem,ƒfinancialƒprotectionƒandƒequityƒ inƒfinancing;ƒuserƒexperienceƒandƒequityƒofƒaccessƒtoƒhealthƒcare;ƒhealthƒ outcomes,ƒhealthƒserviceƒoutcomesƒandƒqualityƒofƒcare;ƒhealthƒsystemƒeffi- ciency;ƒandƒtransparencyƒand accountability. 8.ƒ Conclusions:ƒidentifiesƒkeyƒfindings,ƒhighlightsƒtheƒlessonsƒlearnedƒ fromƒhealthƒsystemƒchanges;ƒandƒsummarizesƒremainingƒchallengesƒandƒ future prospects. 9.ƒ Appendices:ƒincludesƒreferences,ƒusefulƒwebsitesƒand legislation. TheƒqualityƒofƒHiTsƒisƒofƒrealƒimportanceƒsinceƒtheyƒinformƒpolicy- makingƒandƒmeta-analysis.ƒHiTsƒareƒ theƒ subjectƒofƒwideƒconsultationƒ 208 Health Systems in Transition throughoutƒtheƒwritingƒandƒeditingƒprocess,ƒwhichƒinvolvesƒmultipleƒitera- tions.ƒTheyƒareƒthenƒsubjectƒtoƒthe following:ƒ ƒƒ ƒAƒrigorousƒreviewƒprocessƒ(seeƒtheƒfollowingƒsection). ƒƒ ƒThereƒareƒfurtherƒeffortsƒtoƒensureƒqualityƒwhileƒtheƒreportƒ isƒ finalizedƒthatƒfocusƒonƒcopy-editingƒand proofreading. ƒƒ ƒHiTsƒ areƒ disseminatedƒ (hardƒ copies,ƒ electronicƒ publication,ƒ translationsƒandƒlaunches). Theƒeditorƒsupportsƒtheƒauthorsƒthroughoutƒtheƒproductionƒprocessƒandƒ inƒcloseƒconsultationƒwithƒtheƒauthorsƒensuresƒthatƒallƒstagesƒofƒtheƒprocessƒ areƒtakenƒforwardƒasƒeffectivelyƒas possible. OneƒofƒtheƒauthorsƒisƒalsoƒaƒmemberƒofƒtheƒObservatoryƒstaffƒteamƒ andƒtheyƒareƒresponsibleƒforƒsupportingƒtheƒotherƒauthorsƒthroughoutƒtheƒ writingƒandƒproductionƒprocess.ƒTheyƒconsultƒcloselyƒwithƒeachƒotherƒtoƒ ensureƒthatƒallƒstagesƒofƒtheƒprocessƒareƒasƒeffectiveƒasƒpossibleƒandƒthatƒHiTsƒ meet theƒseriesƒstandardƒandƒcanƒsupportƒbothƒnationalƒdecision-makingƒ andƒcomparisonsƒacross countries. 9.5  The review process Thisƒconsistsƒofƒthreeƒstages.ƒInitiallyƒtheƒtextƒofƒtheƒHiTƒisƒchecked,ƒreviewedƒ andƒapprovedƒbyƒtheƒseriesƒeditorsƒofƒtheƒEuropeanƒObservatory.ƒItƒisƒthenƒ sentƒforƒreviewƒtoƒtwoƒindependentƒacademicƒexperts,ƒandƒtheirƒcommentsƒ andƒamendmentsƒareƒincorporatedƒintoƒtheƒtext,ƒandƒmodificationsƒareƒmadeƒ accordingly.ƒTheƒtextƒisƒthenƒsubmittedƒtoƒtheƒrelevantƒministryƒofƒhealth,ƒorƒ appropriateƒauthority,ƒandƒpolicy-makersƒwithinƒthoseƒbodiesƒareƒrestrictedƒ toƒcheckingƒforƒfactualƒerrorsƒwithinƒthe HiT. 9.6  About the authors Vesna Bjegovic-Mikanovicƒ(MD,ƒMSc,ƒPhD)ƒisƒaƒfullƒprofessorƒandƒviceƒ deanƒatƒtheƒFacultyƒofƒMedicine,ƒUniversityƒofƒBelgrade,ƒheadƒofƒtheƒChairƒ ofƒSocialƒMedicine,ƒaƒmemberƒofƒtheƒHealthƒCouncilƒofƒSerbiaƒandƒnewlyƒ establishedƒNationalƒPublicƒHealthƒCouncil.ƒSheƒhasƒbeenƒtheƒfoundingƒ 209Serbia headƒofƒtheƒCentreƒSchoolƒofƒPublicƒHealthƒandƒManagementƒinƒBelgradeƒ andƒservedƒasƒtheƒpresidentƒofƒtheƒManagementƒBoardƒofƒtheƒInstituteƒofƒ PublicƒHealthƒofƒSerbiaƒ“DrƒMilanƒJovanovićƒBatut”.ƒSheƒwasƒpresidentƒofƒ ASPHERƒ(AssociationƒofƒSchoolsƒofƒPublicƒHealthƒinƒtheƒEuropeanƒRegion),ƒ andƒnowadaysƒservesƒasƒaƒmemberƒofƒASPHER’sƒHonoursƒCommittee.ƒAtƒ theƒoccasionƒofƒASPHER’sƒ50thƒAnniversary,ƒsheƒwasƒawardedƒanƒhonoraryƒ doctorateƒbyƒtheƒNationalƒSchoolƒofƒPublicƒHealth,ƒAthens.ƒHerƒscientificƒ interestƒcoversƒhealthƒpolicyƒandƒsystemsƒresearch,ƒwithƒnumerousƒpublica- tions.ƒSheƒhasƒparticipatedƒasƒconsultantƒorƒprincipalƒcoordinatorƒofƒnationalƒ andƒinternationalƒprojectsƒofƒtheƒSerbianƒministries,ƒEC,ƒUNICEF,ƒUNFPA,ƒ WHOƒandƒtheƒWorld Bank. Milena Vasicƒ (DMD,ƒMSc,ƒPhD),ƒAssociateƒProfessor,ƒ special- istƒinƒsocialƒmedicine,ƒisƒtheƒHeadƒofƒtheƒDepartmentƒforƒInternationalƒ CooperationƒandƒProjectƒManagementƒatƒtheƒInstituteƒofƒPublicƒHealthƒ ofƒSerbia.ƒSheƒholdsƒaƒMaster’sƒinƒHealthƒServicesƒManagementƒfromƒtheƒ ItalianƒNationalƒInstituteƒofƒHealthƒandƒLaƒSapienzaƒUniversity,ƒRome,ƒItaly.ƒ SheƒisƒaƒmentorƒforƒMPhƒstudentsƒatƒtheƒLongƒIslandƒUniversity,ƒNewƒYork.ƒ Sheƒhasƒbeenƒworkingƒasƒaƒconsultantƒinƒvariousƒnationalƒandƒinternationalƒ projectsƒinƒtheƒhealthƒsector,ƒsocialƒsectorƒandƒeducation,ƒwithƒdifferentƒ agencies,ƒorganizationsƒandƒdonorsƒ(WB,ƒEU,ƒWHO,ƒUNICEF,ƒICRC,ƒ GF,ƒUNFPA,ƒCEI).ƒDrƒVasicƒisƒWHOƒNFPƒforƒCoordinated/Integratedƒ HealthƒServicesƒDeliveryƒandƒNFPƒforƒHealthƒSystems.ƒTheƒmainƒareaƒofƒherƒ expertizeƒareƒHealthƒServicesƒManagement,ƒHealthƒSystems,ƒInstitutionalƒ Development,ƒQualityƒAssurance,ƒResearch,ƒMonitoringƒandƒEvaluation,ƒ Trainingƒand Education. Dejana Vukovicƒ(MD,ƒMSc,ƒPhD)ƒisƒaƒfullƒprofessorƒatƒtheƒFacultyƒofƒ MedicineƒatƒtheƒUniversityƒofƒBelgrade.ƒSheƒactivelyƒparticipatedƒinƒestab- lishingƒtheƒMaster’sƒofƒManagementƒinƒHealthƒCareƒSystemsƒasƒwellƒasƒtheƒ Master’sƒofƒPublicƒHealthƒatƒtheƒSchoolƒofƒPublicƒHealthƒinƒBelgrade.ƒAsƒaƒ consultant,ƒsheƒhasƒparticipatedƒinƒseveralƒprojectsƒinƒtheƒareaƒofƒimprovingƒ theƒorganizationƒofƒhealthƒcareƒandƒdeliveryƒandƒfinancingƒofƒhealthƒservices.ƒ Asƒaƒresultƒofƒengagementƒinƒinternationalƒprojectsƒinƒhealthƒmanagement,ƒ sheƒhasƒpublishedƒseveralƒpapersƒfocusingƒonƒtheƒcompetenciesƒofƒhealthƒ professionalsƒandƒtheirƒperformance.ƒDrƒDejanaƒVukovicƒgraduatedƒatƒtheƒ MedicalƒFaculty,ƒUniversityƒofƒBelgrade,ƒandƒcompletedƒherƒMaster’sƒofƒ ScienceƒandƒaƒPhDƒinƒSocialƒMedicineƒatƒtheƒUniversityƒofƒBelgrade.ƒInƒtheƒ frameworkƒofƒinternationalƒcooperation,ƒsheƒcompletedƒseveralƒinternationalƒ 210 Health Systems in Transition coursesƒinƒtheƒfieldƒofƒhealthƒand,ƒinƒparticular,ƒtheƒreformƒofƒtheƒhealthƒcareƒ systemƒandƒtheƒorganizationƒofƒhealthƒservicesƒinƒAustria,ƒtheƒNetherlandsƒ and Hungary. Janko Jankovicƒ(MD,ƒMSc,ƒPhD)ƒisƒaƒProfessorƒatƒtheƒInstituteƒofƒ SocialƒMedicine,ƒFacultyƒofƒMedicine,ƒUniversityƒofƒBelgrade.ƒHeƒholdsƒ anƒMScƒandƒaƒPhDƒinƒSocialƒMedicineƒfromƒtheƒUniversityƒofƒBelgrade.ƒ Coreƒareasƒofƒhisƒexpertiseƒincludeƒhealthƒdeterminants,ƒinequalitiesƒinƒ health,ƒhealthƒsystems,ƒRomaƒhealthƒandƒcardiovascularƒhealth.ƒHeƒhasƒ publishedƒ62ƒpapersƒinƒinternationallyƒrecognizedƒjournals,ƒparticipatedƒ inƒ13ƒprojectsƒandƒheƒisƒcurrentlyƒaƒprojectƒmanagerƒinƒoneƒinternationalƒ projectƒ(RHSPƒ–ƒRomaƒHealthƒScholarshipƒProgram,ƒmentorshipƒcompo- nentƒfundedƒbyƒOpenƒSocietyƒFoundationƒBudapest,ƒ2010ƒ–ƒpresent),ƒandƒaƒ memberƒofƒtheƒprojectƒteamƒinƒaƒresearchƒprojectƒfundedƒbyƒSerbianƒMinistryƒ ofƒEducation,ƒScienceƒandƒTechnologicalƒDevelopmentƒ(2011ƒ–ƒpresent).ƒHeƒ isƒaƒmemberƒofƒProgramƒCouncilƒforƒCenterƒ–ƒSchoolƒofƒPublicƒHealthƒandƒ HealthƒManagement,ƒPresidencyƒofƒtheƒSerbianƒPublicƒHealthƒAssociation,ƒ EuropeanƒPublicƒHealthƒAssociationƒandƒSerbianƒMedicalƒAssociationƒ (SectionƒofƒSocialƒMedicine). Aleksandra Jovic-Vranesƒ(MD,ƒMSc,ƒPhD)ƒisƒaƒProfessorƒofƒSocialƒ MedicineƒandƒPublicƒHealthƒatƒtheƒUniversityƒofƒBelgrade,ƒFacultyƒofƒ Medicine.ƒSheƒholdsƒanƒMScƒinƒSocialƒMedicineƒandƒaƒPhDƒinƒSocialƒ MedicineƒfromƒtheƒMedicalƒFacultyƒofƒtheƒUniversityƒofƒBelgrade.ƒSheƒisƒtheƒ headƒofƒtheƒSchoolƒofƒPublicƒHealthƒandƒHealthƒManagement,ƒmemberƒofƒ theƒSerbianƒPublicƒHealthƒAssociation,ƒEuropeanƒPublicƒHealthƒAssociation,ƒ SerbianƒMedicalƒAssociationƒ(SectionƒofƒSocialƒMedicine),ƒSerbianƒMedicalƒ Chamber,ƒandƒScientificƒandƒAcademicƒCouncilƒofƒtheƒFacultyƒofƒMedicine.ƒ Herƒresearchƒworkƒmainlyƒdealsƒwithƒareasƒofƒpublicƒhealth:ƒhealthƒissuesƒ inƒchildren,ƒadolescentsƒandƒyoungƒadults,ƒsafeƒpractices,ƒknowledgeƒandƒ attitudesƒofƒhealthƒworkers,ƒhealthƒliteracyƒandƒhumanƒrights.ƒSheƒhasƒcon- tributedƒtoƒseveralƒstudiesƒofƒenvironmentalƒfactorsƒofƒimportanceƒforƒtheƒ developmentƒofƒcertainƒdiseases.ƒSheƒcontinuouslyƒparticipatesƒinƒmanyƒ nationalƒandƒinternationalƒprojects,ƒandƒhasƒpublishedƒaƒnumberƒofƒarticlesƒ inƒpeerƒreviewed journals. Milena Santric-Milicevicƒ(MD,ƒMSc,ƒPhD)ƒisƒaƒprofessorƒatƒtheƒ FacultyƒofƒMedicine,ƒUniversityƒofƒBelgrade,ƒdeputyƒheadƒofƒtheƒChairƒ ofƒSocialƒMedicine,ƒandƒaƒViceƒPresidentƒofƒtheƒSerbianƒMedicalƒSocietyƒ SectionƒforƒSocialƒMedicine.ƒCurrently,ƒsheƒisƒViceƒChairƒofƒtheƒCA18218:ƒ 211Serbia burden-euƒandƒisƒaƒBoardƒMemberƒofƒtheƒEUPHA-HealthƒWorkforceƒ ResearchƒSection.ƒSheƒalsoƒactsƒasƒanƒexpertƒonƒburdenƒofƒdiseaseƒinƒWHO/ EBoDNƒandƒIHME-GBDƒCollaboratorsƒNetwork,ƒasƒanƒexpertƒonƒHumanƒ ResourcesƒforƒHealthƒinƒtheƒEU/JAHWPFƒ&ƒSEPENƒandƒexpertƒonƒmigra- tions/mobilityƒinƒEU/JAHHE.ƒInƒmanyƒnationalƒandƒinternationalƒprojectsƒ (SerbianƒMinistryƒofƒHealth,ƒMinistryƒofƒEducation,ƒCityƒSecretariatƒforƒ Health,ƒNGOs,ƒEC,ƒWHO,ƒWorldƒBank,ƒECDC,ƒetc.)ƒsheƒwasƒadviserƒorƒ consultantƒdealingƒwithƒhealthƒworkforceƒplanningƒandƒdevelopment,ƒhealthƒ management,ƒpolicyƒandƒservicesƒprovision.ƒHerƒscientificƒworkƒinƒHRH,ƒ BoD,ƒhealthƒpolicy,ƒmanagementƒandƒhealthƒservicesƒresearchƒisƒreflectedƒ inƒnumerous publications. Zorica Terzic-Supicƒ(MD,ƒMSc,ƒPhD)ƒisƒaƒProfessorƒatƒtheƒInstituteƒ ofƒSocialƒMedicine,ƒFacultyƒofƒMedicine,ƒUniversityƒofƒBelgrade.ƒSheƒisƒ engagedƒinƒundergraduateƒeducationƒofƒmedicalƒstudentsƒandƒinƒpostgradu- ateƒeducationƒthroughƒmasterƒandƒPhDƒprogrammesƒinƒtheƒfieldƒofƒhealthƒ managementƒandƒpublicƒhealth.ƒHerƒkeyƒresearchƒinterestsƒareƒhealthƒman- agement,ƒeconomicƒevaluation,ƒqualityƒofƒlife,ƒmentalƒhealthƒandƒlifestyle.ƒ Sheƒpublishedƒnumerousƒpapersƒinƒinternationallyƒrecognizedƒjournalsƒ andƒparticipatedƒinƒmoreƒthanƒ20ƒprojects.ƒCurrently,ƒsheƒisƒaƒmemberƒofƒ theƒprojectƒteamƒonƒaƒresearchƒprojectƒfundedƒbyƒtheƒSerbianƒMinistryƒofƒ Education,ƒScienceƒandƒTechnologicalƒDevelopmentƒinvolvedƒwithƒepidemio- logicalƒresearchƒandƒrareƒdisease,ƒandƒaƒHorizonƒ2020ƒprojectƒaboutƒmentalƒ health.ƒSheƒisƒaƒmemberƒofƒtheƒProgramƒCouncilƒforƒCenterƒ–ƒSchoolƒofƒ PublicƒHealthƒandƒHealthƒManagement,ƒSerbianƒPublicƒHealthƒAssociation,ƒ EuropeanƒPublicƒHealthƒAssociationƒandƒSerbianƒMedicalƒAssociationƒ (SectionƒofƒSocialƒMedicine).ƒSheƒisƒtheƒcountryƒrepresentativeƒofƒSerbiaƒinƒ theƒEuropeanƒLifestyleƒMedicineƒAssociationƒ(ELMO). Cristina Hernández-Quevedoƒ (BScƒ Ecs,ƒMScƒHEco,ƒ PhD)ƒ isƒ TechnicalƒOfficer/ResearchƒFellowƒatƒtheƒEuropeanƒObservatoryƒonƒHealthƒ SystemsƒandƒPoliciesƒ(WHO),ƒLSEƒHealth,ƒLondon.ƒSheƒeditsƒandƒco-writesƒ HiTƒcountryƒprofilesƒandƒworksƒonƒaƒrangeƒofƒObservatoryƒstudies.ƒSheƒholdsƒ anƒMScƒinƒHealthƒEconomicsƒandƒaƒPhDƒinƒEconomicsƒfromƒtheƒUniversityƒ ofƒYork,ƒUnitedƒKingdom.ƒHerƒresearchƒinterestsƒincludeƒinequalitiesƒinƒ healthƒandƒlifestyleƒfactors,ƒequityƒinƒaccessƒtoƒhealthƒandƒsocialƒcareƒservicesƒ andƒsocioeconomicƒdeterminantsƒofƒhealth.ƒSheƒhasƒpublishedƒarticlesƒonƒ theseƒtopicsƒinƒinternationallyƒrecognizedƒscientificƒjournals.ƒ

The Health Systems in Transition Series A series of the European Observatory on Health Systems and Policies The Health Systems in Transition (HiT) country reports provide an analytical descrip- tion of each health system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiTs are building blocks that can be used: • to learn in detail about different approaches to the financing, organization and delivery of health services; • to describe accurately the process, content and implementation of health reform programmes; • to highlight common challenges and areas that require more in-depth analysis; and • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policymakers and analysts in countries of the WHO European Region. How to obtain a HiT All HiTs are available as PDF files at www.healthobservatory.eu, where you can also join our listserve for monthly updates of the activities of the European Observatory on Health Systems and Policies, including new HiTs, books in our co-published series with Cambridge University Press, Policy briefs, Policy Summaries, and the Eurohealth journal. If you would like to order a paper copy of a HiT, please contact us at: contact@obs.who.int The publications of the European Observatory on Health Systems and Policies are available at www.healthobservatory.eu Albania (1999, 2002ag) Andorra (2004) Armenia (2001g, 2006, 2013) Australia (2002, 2006) Austria (2001e, 2006e, 2013e, 2018) Azerbaijan (2004g, 2010g) Belarus (2008g, 2013) Belgium (2000, 2007, 2010) Bosnia and Herzegovina (2002g) Bulgaria (1999, 2003b, 2007g, 2012, 2018) Canada (2005, 2013c) Croatia (1999, 2006, 2014) Cyprus (2004, 2012) Czech Republic (2000, 2005g, 2009, 2015) Denmark (2001, 2007g, 2012) Estonia (2000, 2004gj, 2008, 2013, 2018) Finland (2002, 2008, 2019) France (2004cg, 2010, 2015) Georgia (2002dg, 2009, 2017) Germany (2000e, 2004eg, 2014e) Greece (2010, 2017) Hungary (1999, 2004, 2011) Iceland (2003, 2014) Ireland (2009) Tajikistan (2000, 2010g, 2016) The former Yugoslav Republic of Macedonia (2000, 2006, 2017) Turkey (2002gi, 2011i) Turkmenistan (2000) Ukraine (2004g, 2010g, 2015) United Kingdom of Great Britain and Northern Ireland (1999g, 2015) United Kingdom (England) (2011) United Kingdom (Northern Ireland) (2012) United Kingdom (Scotland) (2012) United Kingdom (Wales) (2012) United States of America (2013) Uzbekistan (2001g, 2007g, 2014g) Veneto Region, Italy (2012) Israel (2003, 2009, 2015) Italy (2001, 2009, 2014) Japan (2009) Kazakhstan (1999g, 2007g, 2012) Kyrgyzstan (2000g, 2005g, 2011g) Latvia (2001, 2008, 2012) Lithuania (2000, 2013) Luxembourg (1999, 2015) Malta (1999, 2014, 2017) Mongolia (2007) Netherlands (2004g, 2010, 2016) New Zealand (2001*) Norway (2000, 2006, 2013) Poland (1999, 2005k, 2011, 2019) Portugal (1999, 2004, 2007, 2011, 2017) Republic of Korea (2009*) Republic of Moldova (2002g, 2008g, 2012) Romania (2000f, 2008, 2016) Russian Federation (2003g, 2011g) Slovakia (2000, 2004, 2011, 2016) Slovenia (2002, 2009, 2016) Spain ) 8102 ,0102 ,6002 ,h0002( Sweden (2001, 2005, 2012) Switzerland (2000, 2015) All HiTs are available in English. When noted, they are also available in other languages: a Albanian b Bulgarian j Estonian c French d Georgian e German k Polish f Romanian g Russian h Spanish i Turkish HiT Country Reviews Published to Date The publications of the European Observatory on Health Systems and Policies are available at www.healthobservatory.eu Cristina Hernández-Quevedo (Editor) and Ewout van Ginneken (Series editor) were responsible for this HiT Editorial Board Series editors Reinhard Busse, Berlin University of Technology, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene & Tropical Medicine, United Kingdom Elias Mossialos, London School of Economics and Political Science, United Kingdom Ewout van Ginneken, European Observatory on Health Systems and Policies Series coordinator Anna Maresso, European Observatory on Health Systems and Policies Editorial team Jonathan Cylus, European Observatory on Health Systems and Policies Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Dimitra Panteli, Berlin University of Technology, Germany Wilm Quentin, Berlin University of Technology, Germany Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Anna Sagan, European Observatory on Health Systems and Policies Anne Spranger, Berlin University of Technology, Germany Juliane Winkelmann, Berlin University of Technology, Germany International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Harvard University, United States Armin Fidler, Management Center Innsbruck Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, National Institute for Health and Welfare, Finland William Hsiao, Harvard University, United States Allan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Soonman Kwon, Seoul National University, Republic of Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Nata Menabde, World Health Organization Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Federal Statutory Health Insurance Physicians Association, Germany Igor Sheiman, Higher School of Economics, Russian Federation Peter C. Smith, Imperial College, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland C M Y CM MY CY CMY K 61575 Serbia HiT_covers_3WEB.pdf 2 16/03/2020 13:29 Vol. 21 N o. 3 2019 Health System s in Transition: Serbia Print ISSN 1817-6119 Web ISSN 1817-6127 The Observatory is a partnership, hosted by WHO/Europe, which includes other international organizations (the European Commission, the World Bank); national and regional governments (Austria, Belgium, Finland, Ireland, Norway, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and the Veneto Region of Italy); other health system organizations (the French National Union of Health Insurance Funds (UNCAM), the Health Foundation); and academia (the London School of Economics and Political Science (LSE) and the London School of Hygiene & Tropical Medicine (LSHTM)). The Observatory has a secretariat in Brussels and it has hubs in London (at LSE and LSHTM) and at the Berlin University of Technology. HiTs are in-depth profiles of health systems and policies, produced using a standardized approach that allows comparison across countries. They provide facts, figures and analysis and highlight reform initiatives in progress. Vol. 21 No. 3 2019 Health Systems in Transition Serbia Health system review Vesna Bjegovic-Mikanovic Milena Vasic Dejana Vukovic Janko Jankovic Aleksandra Jovic-Vranes Milena Santric-Milicevic Zorica Terzic-Supic Cristina Hernández-Quevedo C M Y CM MY CY CMY K 61575 Serbia HiT_covers_3WEB.pdf 1 16/03/2020 13:29