The healthcare system is a complex concept that includes all aspects of social health care, from the legal framework, vision and strategy, through financing, infrastructure development, to personnel, i.e. healthcare professionals and their education, the health care they provide, etc. Health care, which a citizen sees as a product of the healthcare system, therefore depends on numerous other, if not all other, social aspects. For example, the lack of legal regulations, or constitutional and legal restrictions that are not directly related to healthcare, such as gender issues, discrimination based on gender, sexual or some other identity, directly affect health care, as is the case with financial power, i.e. the political sphere of a society.
Due to its complexity, it is not possible to briefly explain the basic elements of a healthcare system, but from the perspective of a citizen, it is based on four principles:
1. Firstly, all elements of health care provision must be available. For example, a femur X-ray cannot be done without an X-ray machine, accompanying material, healthcare professionals with specialized knowledge, a facility where the machine will be placed, etc.
2. Next, health care – or a “service”, if roughly speaking in market terms – must be available to every citizen. This also applies to elderly people who, for example, live in mountain villages without paved roads, mobile phone signals, health insurance or permanent income, who most often live alone and have health problems (we should also mention a case when a family doctor refers the patient to a vascular surgeon who works in a clinical center where examinations are scheduled only once a month and in person; a citizen who lives 100 km away from a clinical center and does not have his own car, essentially has no limited access, but the clinical center is actually inaccessible).
3. Even when health care can be provided and it is available to everyone, under equal circumstances, it must also be acceptable to citizens. A certain form of health care may be unacceptable to someone due to his religious, ethical and other beliefs.
4. In addition, health care must always respect the dignity of every citizen, his personal integrity, identity (ethical, cultural, linguistic, etc.) and be the best possible within the limits of current knowledge and preventive and therapeutic possibilities. This requires many things, from the constant encouragement of the development of medical science and research, through the existence of good practice guides based on evidence, to educated healthcare personnel involved in continuous medical education, quality control mechanisms, and the like.
Certain segments of the healthcare system the significance of which is of particular importance include qualified and motivated healthcare professionals, adequately equipped and maintained infrastructure, reliable supply of medicines and technologies, adequate financing, making long-term plans and emphasizing evidence-based healthcare policy. We shall focus on two areas: healthcare financing and personnel.
When it comes to healthcare financing, the amount of invested funds is not always proportional to the desired outcomes. The USA spends the most on healthcare, and there is no doubt that this country has excellent health care, but it is not evenly distributed, i.e. it is available primarily to the privileged ones. According to the share allocated to healthcare in GDP, Switzerland, Norway and Iceland follow the USA, while Serbia takes the 72nd place, behind most European countries, as well as behind Uruguay, Panama, Argentina, Cuba, Brazil, Oman, but ahead of Russia and China1. The countries of Western Europe allocate about 12% of GDP to the healthcare sector (the USA about 17%, Serbia 8,5%),2 of which about 85% comes from public revenues3 – the budget and health insurance (In Serbia, it is 59%), while citizens’ payments “out of their own pockets”4 range from 10 to 15% with a decreasing trend (in Serbia, it is 38%, with an increasing trend)5.
There has been a global crisis related to healthcare professionals for many years. African countries, decades after decolonization, have surprisingly few available healthcare professionals, and the problem of their workload is present even in the most developed countries. Research6 in the USA showed that a primary care physician works an average of 51 hours a week. In Novi Sad, one primary care physician provides health care to an average of 2,700 patients7. In order to provide quality service to the 2500 patients he covers, he would have to work 21.7 hours a day8. Since this is not possible, the quality of health care is dissatisfying. Globally, the average visit to a physician lasts less than five minutes9.
Altschuler et al.10 estimated that one physician in the USA can adequately provide health care to 983 patients, i.e. slightly over 1000 if he shares part of his responsibility with other members of his team, whereby it is believed that a physician works 43 hours a week and a little over 47 weeks a year. If we start from the idea of a desirable reduction of working hours and extension of annual leave, as part of a general strategy that involves less professionalization and greater humanization of work (people work to live, do not live to work!), as well as from the need for a healthcare professional to spend part of his working hours in acquiring new knowledge and doing scientific research, i.e. abstracting the specific health problems of the population and the impact of the Covid-19 pandemic, one physician, in order to be effective enough, should be responsible for 500 citizens, work six hours a day and four days a week.
An additional problem is the centralization of specialized health care in large centers, which makes it hardly available and demotivates primary care physicians to build their careers outside of large centers. A solution could be found in strengthened health centers under the auspices of local self-government11 through a combination of providing health care in terms of general medicine and specialist services: each chosen physician would also be a specialist in a certain field, he would partly work with patients who chose him as their physician, and partly provide specialist services both to his own patients and to the patients of colleagues from other specialties who chose them as their physicians.
When it comes to the number of health professionals at all levels, the differences all over the world are huge. In many African countries, there is one physician and only a few medical and obstetrics nurses and technicians per 10,000 inhabitants; in Switzerland there are 218 per 10,000; in Norway 211; in Germany 175; in the USA 172. In Serbia, there are 90 healthcare professionals per 10,000 inhabitants. When it comes to physicians, Cuba has the most per 10,000 inhabitants – 84 (29 in Serbia), while Switzerland has the most technicians per 10,000 inhabitants – 175 (61 in Serbia).12,13
Therefore, in order to be sustainable and socially efficient, the healthcare system requires an allocation of 15-20% of GDP, with at least 90% of funds covered by public revenues, with 400 healthcare professionals per 10,000 inhabitants (of which one physician and 3 technicians). At the same time, one physician should cover 500 inhabitants and deal with both general medicine and specialised health care, participate in professional development and scientific research, with decentralised health care brought closer to citizens.
Radiography of the situation
Yugoslavia had a special experience with the organization of health care and the consequences of these specificities are deeply rooted in the post-Yugoslav healthcare systems. According to Andrija Štampar’s vision, even before the World War II, the establishment of health centers started in 1923, and after the end of the war and the abolition of private practice, the emphasis was placed on health centers established for the territories of municipalities. With the decentralization of health care, by placing primary health care at the center of the healthcare system, efforts were made to bring health care closer to citizens, especially during the 1970s14. The introduction of the self-management system in the same decade was aimed at employees taking greater responsibility for the management of social activities, which included healthcare. Thus, the self-governing health communities of interest – made up of both those who provided health care and those who were the beneficiaries – developed their own healthcare programs at the municipal level, which were adopted by the assemblies of the self-governing communities of interest15,16.
The healthcare system in Yugoslavia had exceptional achievements. Thus, the percentage of people covered by health care increased from 25% in 1952 to over 80% in 1984; the number of physicians increased from 8136 in 1955 to 45869 in 1987, and there was also a significant increase in the total number of health professionals17. The number of hospital beds more than doubled between 1955 and 1987, many infectious diseases that caused death in the first half of the 20th century were eliminated and the number of patients and deaths drastically reduced. Through the development of the principle of solidarity within the mandatory health insurance system, health care became available to everyone.
Still, Yugoslavia’s healthcare system had its difficulties. Huge differences between urban and rural areas in terms of access to health care were not eliminated. There were also large, apparent differences in the availability and quality of health care between republics and provinces. For example, Slovenia had almost three times more physicians and hospital beds in relation to the number of inhabitants than Kosovo. While in Slovenia almost every birth took place in the presence of qualified medical personnel, in Kosovo it happened in only 60% of cases18. Between 1965 and 1970, a third of those who graduated from the medical faculty sought work abroad19.
Generally speaking, the greatest contribution to the improvement of health care in Yugoslavia reflected in the system of mandatory inclusion in health insurance with the principle of solidarity, reliance on primary health care through health centres and decentralisation, but the effects were limited by the lack of motivation of healthcare professionals to work in rural areas, as well as by the slow reduction of inequality between republics and provinces and between rural and urban areas.
When it comes to Serbia, its healthcare system has been continuously collapsed during the past three decades with different motives and by different political groups. The collapse during the 1990s was part of the general destruction of society, which also affected healthcare. On the one hand, a significant number of healthcare professionals moved abroad, the management of health care was left to political party members, professional training was difficult due to the lack of communication with the rest of the world, and party criteria were established as crucial for professional advancement. That was also the time of the first major financial frauds in healthcare.
The first decade of the 2000s was marked by an aggressive neoliberal policy in all social spheres, including healthcare, which was seen as a budget consumer. Not only was getting employed made difficult, but employees were encouraged to leave state health institutions, which began to provide services on a commercial basis as well. Dental health care was almost completely removed from state institutions, and it was followed by the separation and privatization of pharmacies. The state-owned pharmaceutical industry was almost completely destroyed and/or privatized. The banning of specializations for doctors of medicine was an attempt to solve the problem of uneven staff distribution. Some faculties began to offer health care studies, but the status of those who completed these programs remained unregulated. It was also a missed opportunity to depoliticize healthcare management, i.e. to stop it from being an element of the partocratic way of managing social resources.
In the second decade of the 2000s, the neoliberal trend continued, with additional centralization. The founding rights over the health centers were transferred to the republic, which excluded the possibility of having more direct responsibility to the citizens. The new, so-called “master plan” – intended for the next 8-15 years – included additional centralisation, whereby 196 of the existing 313 health institutions would cease to exist by being integrated into a kind of mastodons. This makes centralization unequal: the number of health institutions in Belgrade would decrease by 24%, in Vojvodina by 4.2 times, and in the rest of Serbia by 3.3 times.
The last three decades in Serbia have also been marked by citizens’ payments for health care “out of their own pockets” (in addition to payments for mandatory health insurance-indirectly-through taxes), so just in 2000 alone, the allocations for healthcare “out of citizens’ pockets” amounted to almost 30%. A small improvement in this regard could be noticed only in the first two years after the democratic changes that occurred on October 5th, but since 2003, the negative growth trend of allocations “out of citizens’ pockets” continued. The share of compulsory health insurance payments in total health expenditure thus went from 67% in 2003 to 47% in 2015, with a slight increase thereafter, so in 2018 it was close to 50%. At the same time, allocations from the budget went from 5.39% in 2003 to 2.76% of total health expenditures in 2010. Yet, since 2014, the share of budget funds has increased and in recent years has amounted to 9-10% of the total expenditure on healthcare21.
The last two decades have also been marked by policies detrimental to the healthcare professionals. The multi-year restriction on the approval of new specializations not only led to a lack of specialists in some areas, but also demotivated doctors in general. The practice of young doctors volunteering at clinics for years has become regular. Restrictions on employment, low wages, rigid hierarchy, few opportunities for professional development, nepotism and political partisanship, as well as a general disincentive climate for intellectuals and experts have forced many healthcare professionals to pursue their careers abroad. According to the data of the Institute of Public Health of Serbia, from 2010 to 2019, the number of health professionals and associates in Serbia decreased by 7% – from 85,363 to 79,485, with 1,170 doctors (of which 728 were specialists) and 3,161 nurses and technicians less22,23.
One of the relevant indicators of people’s health is the healthy life expectancy at age 60. This is a reflection of the quality of the healthcare system, the environment (air, water, soil pollution), nutrition, etc., and it could be interpreted as a measure of the success of health preservation (against the effects of treatment), i.e. prevention. According to this indicator, the leading are East Asian countries (Japan, Singapore, Republic of Korea), Mediterranean countries (France, Spain, Italy, Cyprus, Malta), Switzerland, Ireland and Scandinavian countries. An exception is Costa Rica, which takes the 12th place. As opposed to Japan (where people who are 60 years old can expect to live another 20.4 years), Serbia ranks 86th in the world with another 13.9 years of life expectancy, and is at the very bottom compared to other European countries (only Moldova, Georgia, North Macedonia and Azerbaijan are ranked lower, while Slovenia takes 24th place, Croatia 36th, Albania 44th, Romania 79th, Bosnia and Herzegovina 77th, Bulgaria 78th, Montenegro 85th)24.
The Covid-19 pandemic also confirmed the complete lack of integrity of the managers of Serbian health institutions (in terms of informing the public, protecting employees who disagree with the ruling policy, the lack of protective equipment at the beginning of the pandemic, etc.), as a consequence of the dependence of the healthcare system on the government, not only through financing, but also through the selection of managers, administrative and supervisory boards. As in other cases, obedience is the main desirable characteristic of the manager of a Serbian healthcare institution. It is not a system that was put in place under this government, but the pinnacle, that is, the perfected version of the environment we have been living in for the last 30 years or more.
What needs to be done?
There are many requirements for a successful reform of the healthcare system: changing the existing neoliberal ideological matrix and accepting health as an absolute priority, establishing sustainable healthcare financing, citizen participating in defining local health policy, having quality personnel, adequately managing the healthcare system, integrating existing health care that is privately owned, as well as placing the citizen at the center of the healthcare system. The challenges of the reform are also numerous and, as a consequence, such reforms that are entirely successful are rare. They include the possibility of continuous education and the participation of healthcare staff in scientific and research work, the influence and importance of social determinants of health, as well as the appropriate position of the citizen in the social system, in the local community and in the workplace.
In the last few decades, the initial obstacle has been the dominant neoliberal ideological matrix that shifts the responsibility completely to the individual, without taking into account the socio-economic factors that affect him. The health of a population can be seen as the most important resource of mankind, and health care, carried out through the healthcare system, as a priority to which all other social activities are adapted. Yet, healthcare, as a set of elements of the healthcare system, is seen as a significant “budget consumer”, blocking funds that could be invested in the development of the economy and, along with education and culture, most often becomes the first choice for all authorities that would like to implement the so-called “belt tightening” in the budget. Twisted socio-Darwinist pseudo-arguments, which those who are economically successful declare to be superior as they confirm their belief that they became rich thanks to their own talents and not their privileged position, often blame citizens with impaired health for their condition due to their unhealthy lifestyle, ignoring the fact that bad habits are not the cause, but the consequence of social marginalization, economic inferiority, the impossibility of education, adequate housing and nutrition, or deep social inequalities. Changing this wrong mantra and accepting the idea of health as an absolute priority, whereby investment in health is not seen as an expense, but as an investment in a better life for both the individual and the community, is a necessary prerequisite for any reform.
Sustainable health financing is the next requirement. As mentioned above, the quality of health of a population is not necessarily directly proportional to the total wealth of the country. Still, it is clear that poor countries can hardly provide a quality healthcare system. Public expenditure would have to amount to at least 90% of total healthcare expenditure, with a share of at least 15% of GDP allocated to health and a tendency to increase in the coming decades to 20%. The effectiveness of healthcare should not be sought in the reduction of money allocated to healthcare, the reduction of healthcare staff and the centralization of the healthcare system, as is currently the case. Significant savings can be made by encouraging innovations and applying modern technologies (for example, digital or remote medicine), prioritizing prevention rather than curative medicine, encouraging and supporting the local production of medicines, medical supplies, equipment, improving public procurement procedures, etc.
The citizens’ participation in defining local health policy is necessary for healthcare that would be at the service of citizens, rather than at the service of the market and speculators. Instead of the centralization, further decentralisation should be implemented, so that citizens can receive most healthcare services where they live and from healthcare professionals with whom they can develop a long-term friendly relationship through direct and intensive contact.
Having quality personnel is the next condition for a socially desirable healthcare system. The education of healthcare personnel in Serbia, especially doctors, is carried out in an elitist manner, which is obvious in the enrollment policy of faculties. Like healthcare in general, the education of staff should be decentralized and new medical faculties should be opened in new places (Subotica, Pančevo, etc.) in the coming years. The number of teaching staff at the existing faculties is more than sufficient for the opening of new faculties, and in the first years, local experts would have the opportunity to be involved in teaching and scientific work.
Those with university degrees who are not doctors should take over part of the responsibilities of doctors and become equal partners in the implementation of health care.
Adequate management of the healthcare system is also necessary for improving the situation in society and in the country. It is essential to establish mechanisms that would enable the independence of health institutions, and a transparent and independent process of electing managers, administrative and supervisory boards, based on competence and integrity, with the participation of elected representatives of local communities in the governing bodies of health institutions.
In order for Serbian healthcare system to meet existing social needs, the healthcare that is currently privately owned needs to be fully reintegrated into it. The form of ownership should be neither an advantage nor a limitation. In other words, privately owned health care should be a non-profit, i.e. low-profit activity financed by mandatory health insurance, and every citizen must have the right to choose the services of the health institution that best suits his needs. The provision of health care and its quality should not be dependent on the economic or employment status of citizens. Every health service, whether it is carried out in a state or private institution, would be paid from the mandatory health insurance, and the remaining funds would be covered from the budget. Dental health care, as well as pharmacy stores, should also be reintegrated into health centers.
Finally, the citizen must be at the center of health care, which can only be achieved by changing the relationship between the health professional and the patient, i.e. the prevailing culture in which the citizen must be grateful for receiving health care, but also by creating social conditions in which the healthcare professionals themselves will be motivated to work. Only a healthcare professional who has time for patients, the necessary resources to provide them with the appropriate service and who is adequately rewarded for his work (not just financially), can develop an adequate humane and friendly relationship with his patients.
Although they are crucial, the quality of health care does not depend only on the above-mentioned factors, but it is necessary to work on developing two additional elements: continuous medical education and scientific and research work. A healthcare professional with work overload will not have enough time for his patients, therefore it is essential to introduce a different approach to work, whereby one working day of a healthcare professional per week will be dedicated exclusively to checking the latest knowledge in medicine, as well as participating in scientific and research work. The condition is the hiring of new healthcare personnel and the reduction of working hours, which will allow healthcare professionals, as well as all other employees, enough time for private life, rest and training. Monitoring the quality of health care should become an integral part of the healthcare system, with the main goal of improving health care.
It is particularly important to emphasize the fact that health is not a reflection of the quality of the healthcare system alone. Man is in constant interaction with nature and society, which leads to the preservation, improvement or impairment of health. All the efforts of the healthcare system will not be effective enough if there is environmental pollution, the inability to provide regular and healthy food and drinking water, adequate housing conditions and the possibility of recreation, leisure and participation in cultural and social activities. In order to preserve health, each individual needs to feel accepted in his community, to be able to have social interactions, to make friends, build partnerships and a family of his choice, as well as to take care of elderly family members. It is equally important that the individual has the freedom of movement and the possibility to leave the community, i.e. change his residence.
Preserving health at the workplace is not only about physical safety, but also about creating an encouraging environment, in which every employee can demonstrate his abilities, be valued and participate in decision-making.
The basic form of health care provision should be a partnership created at the local level. The first form of partnership is the one that citizens create between themselves – it is about the preservation of the environment, respect for the individual and his differences. Next is the one between citizens and the community – through their elected representatives, but also personally, when citizens participate in defining local health policy and support the implementation of healthcare programs. The third form of partnership is the one created by healthcare professionals in the community. The first “ring” of that partnership is the one between the doctors and other healthcare professionals, who make up the healthcare team. The second one is between chosen doctors of certain specialties. Through this partnership, each chosen doctor works 2-3 days a week with his own patients, and 1-2 days as a specialist with his own and his colleagues’ or partners’ patients. The fourth form of partnership is that between healthcare professionals and the community, through which both segments contribute to improving the scope and quality of health care.
1 World Bank. World Bank Open Data. Available at: https://data.worldbank.org (accessed on April 16, 2021).
2 World Bank. World Bank Open Data. Available at: https://data.worldbank.org (accessed on April 16, 2021).
3 Allocations for healthcare can come from public sources (mandatory health insurance and the budget), private sources (private health insurance, contributions that private companies pay for their employees on their own or through public-private partnerships), citizens’ payments “out of their own pockets”, or from foreign sources of financing.
4 Out-of-pocket payment means citizens’ direct payment for the health service to the service provider. Citizens pay for the provision of health care that is not covered by compulsory insurance.
5 World Health Organization. Global Health Expenditure. Available at: https://apps.who.int/nha/database/country_profile/ Index/en (accessed on April 19, 2021).
6 The Physicians Foundations 2018 survey on American’s physician. Available at: https://physiciansfoundation.org/wp-content/ uploads/2018/09/physicians-survey-results-final-2018.pdf (accessed on April 26, 2021).
7 Institute of Public Health of Vojvodina. Health of the people of the City of Novi Sad in 2019. Available at: http://www.izjzv.org.rs/publikacije/
8 Truls Østbye, Kimberly S. H. Yarnall, Katrina M. Krause, Kathryn I. Pollak, Margaret Gradison & J. Lloyd Michener, “Family physicians as team leaders: ’time’ to share the care”, Prev Chronic Dis, 2009, vol. 6, no. 2, p. 59.
9 Greg Irving, Ana Luisa Neves, Hajira Dambha-Miller, et al., “International variations in primary care physician consultation time: a systematic review of 67 countries”, BMJ Open, vol. 7, 2017.
10 Justin Altschuler, David Margolius, Thomas Bodenheimer, Kevin Grumbach, “Estimating a reasonable patient panel size for primary care physicians with team-based task delegation”. Ann Fam Med, vol. 10, no. 5, 2012, pp. 396-400.
11 Geoffrey Meads, “Finland: world class primary care”, Quality in Primary Care, vol. 14, 2006, pp. 107–10.
12 World Health Organization. World Health Statistics 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/332070/9789240005105-eng.pdf (accessed on April 16, 2021).
13 Institute of Public Health of Serbia Dr Milan Jovanović Batut, Health statistical yearbook of Serbia 2019.Available at: http://www.batut.org.rs
/download/publikacije/pub2019a.pdf (accessed on April 22, 2021).
14 “Primary health care in Yugoslavia”, European Journal of Public Health, Vol. 2, no. 3-4, 1992, p. 211.
15 Donna E. Parmelee, “Whither the State in Yugoslav Health Care?”, Social Science & Medicine, vol. 21, no. 7, pp. 719–728.
16 Momčilo Dimitrijević, “Basic issues of constitution and functioning of self-governing communities of interest”, in: Collection of Papers of the Faculty of Law in Niš, Niš: Faculty of Law, 1976, pp. 149–167.
17 Glenn Eldon Curtis, Yugoslavia: A Country Study, Washington: Library of Congress, 1992.
20 Optimization of the Network of Health Care Institutions of Serbia. Available at: https://optimizacijazdravstva.rs (accessed on April 16, 2021).
21 World Health Organization. Global Health Expenditure. Available at: https://apps.who.int/nha/database/country_profile/ Index/en (accessed on April 16, 2021).
22 Institute of Public Health of Serbia Dr Milan Jovanović Batut, Health statistical yearbook of Serbia 2019. Available at: http://www.batut.
org.rs/download/publikacije/pub2019a.pdf (accessed on April 14, 2021).
23 Institute of Public Health of Serbia Dr Milan Jovanović Batut, Health statistical yearbook of Serbia 2019. Available at: http://www.batut.
org.rs/download/publikacije/pub2010.pdf (accessed on April 16, 2021).
24 World Health Organization. The Global Health Observatory. Available at: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-age-60 (accessed on April 19, 2021)
(This is a translation of a text published by Institute for Philosophy and Social Theory, University of Belgrade and Institute for Democratic Engagement of Southeast Europe (Ivica Mladenović, Srđan Prodanović and Gazela Pudar Draško, eds.) in 2021. Available in Serbian here: https://rifdt.instifdt.bg.ac.rs/handle/123456789/2440;jsessionid=CF1C07E1B234E09BAE6AF004A9400301