1. Health Care Reform in Serbia Health Care Reform in Serbia Ivana Mišić, MD Assistant Minister June 2 nd 2008, Halifax, Canada

2. Demographic profile of Serbia (without data for Kosovo and Metohija) Population (Census data, 2002):7 498 001 Population 65 and older:17.2% Median age- total, 2005:40,6 yrs –Male39,3 –Female41,8 Birth rate (2005):9.7 Crude death rate (2005):14.3 Life expectancy at birth (2005) - male:70,0 Life expectancy at birth (2005) - female:75,4 Total fertility rate (2004): 1,6

3. SERVICE DELIVERY Organizational structure of the public health system in Serbia Ministry of Health Health Insurance Fund Institute of Public Health of Serbia Clinical Center of Serbia Clinical Center Clinical Hospital Center Institute HIF branches Public health institutes General Hospital Primary Health Centre Health station Primary Health Centre HEALTH CENTRE General Hospital Special Hospital Spec. Institution Pharmacy Primary health care level Secondary health care level Tertiary health care level

4. The right to health care in Serbia Every citizen is entitled to health care in the Republic of Serbia Citizens realize their right to health care on the basis of a health card In order to obtain a health card every citizen has to register his/here place of residence In case of emergency health care is provided to all citizens The readmission process is currently ongoing (Low number of Roma possess personal documents, high number do not wish to obtain legal status)

5. Primary health care (PHC) situation in Serbia at the beginning of the 21 st century – a diagnosis The PHC practitioner as a “traffic policeman” having a poorer status compared to practitioner on higher levels of care Fragmentary system – jeopardizing the health care continuity Overspecialization – a polyclinic approach Low efficiency and uneven quality of services provided Absence of motivation to engage in health promotion and disease prevention Non systematic approach in including the consumers in the PHC policy decision

6. PHC quality indicators in 2006 (Institute of Public Health of Serbia “Dr Milan Jovanovic Batut”) A well-developed primary health-care institutions network - comprising 158 primary health care centers 36% of all doctors work in PHC; General practitioners make up 17% of the total number of doctors; Population coverage with PHC doctors reveals a ratio of 1049 people to one doctor; Population coverage with GPs reveals a ratio of 1149 adult citizens (over 19) to one doctor; Average use of the general practice service is 6 consultations per capita

7. Strategies of the Republic of Serbia related to health MoH participated in strategy papers development: 1.Poverty reduction strategy paper (2003) 2.Plan of action for children (2004) 3.Action plan for health of Roma population (2005) 4.Strategy of aging (2005) MoH initiated strategy papers development and Government acceptance: 1.National Strategy for Fight against HIV/AIDS (2005) 2.Strategy for Youth Development and Health in the Republic of Serbia (2006) 3.Tobacco Control Strategy (2007) 4.Strategy for the Development of Mental Health Care (2007)

8. Legal basis for system development and health care reform System laws: Law on Drugs and Medical supplies (2004) Health Care Law (2005) Health Insurance Law (2005) Medical Chambers Law (2005) By-laws and sub-laws (about 40 based on system laws): Law for communicable diseases Law on sanitary inspection Regulations based on the Law on Medicines Regulation on Co-payment fees (personal contribution of the insured population in health care expenses) Network of health institutions Continuous Quality Improvement Licensing, accreditation and CME

9. Legal basis for PHC reform Better defined health- care institutions according to levels of health care The chosen doctor concept Local community ownership of the primary health care centers Decentralization of management over PHC institutions

10. Partnerships in health system development and reform International: WHO and UNICEF, UNDP EU – EAR / the biggest one (about 100 000 000 Euros) World Bank ICRC CIDA Council of Europe Bilateral partners – Japan, Norway, France, Italy, China and others.NGOs: About 50 professional organizations and NGOs dealing with programs or project in health sector About 30 Roma NGOs as a partners of health institutions in implementation of Action plan for health of Roma population

11. Primary health care - our achievements! Pilot project “Basic health benefit package Kraljevo municipality”; - basic services package, capitation and development of information system Decentralisation and transfer of authority to the local community (municipality) Separation of the specialist-consultant service Reform of the dental health care Development of preventive centers (EAR Project Improving Preventive Health Services in Serbia) PHC system development (Balkans Primary Health Care Policy Project – CIDA

12. Public health achievements New models of financing Public Health Institutes Strengthening preventive health services (Centers for preventive care in PHC) Health promotion activities Public Health strategy paper developed, and Public Health Law-draft prepared Establishment of the Serbian Public Health Association

13. Vulnerable population groups in Serbia Roma population – Census data 108 193 (assessment is 400 000) Refugees – UNHCR data (97 953) Internally displaced persons - UNHCR data (206 789) Persons with disabilities ( assessment is 800 000) Youth (21% of the total population) Person older than 64 year (17% of the total population) Poor persons (10.6% of the total population below poverty line) Unemployed persons (26.6% of working population, data for September 2007).

14. Ministry of Health Budget allocated to vulnerable groups Covering of the health insurance for uninsured person (about 50 millions of Euros) Realization of the project regarding the Roma Decade (about 250 000 Euros) Realization of other health project by NGO (about 60 000 Euros) Implementation of Strategy for drug and alcohol abused (about 250 000 Euros) Realization of project at the Institute for students health (about 40 000 Euros) Developing of the Program for mother and child care protection (about 60 000 Euros)

15. HIV/AIDS Health Survey results: 90.5% were aware of HIV/AIDS; More than a third of the population knew where they could get tested for HIV; 4.2% of adults have been tested for HIV; In Serbia in 2006 in comparison with 2000 the increased tolerance for HIV infected people was registered; 17.8% of young aged 15 to 19 had sufficient knowledge on HIV/AIDS, i.e. identified correctly ways to prevent sexual transmission which was an 11.1% improvement over 2000. Activities of the MoH: Global Fund to Fight Against AIDS, Tuberculosis and Malaria Projects: Controlling HIV/AIDS in Serbia –Comprehensive Country Strategy and Emergency Action Plan (2003- 2007) Scaling up the national HIV/AIDS response by decentralizing the delivery of key services (2007-2011) National Strategy for Fight against HIV/AIDS (2005)

16. TOBACCO CONTROL AND SMOKING PREVENTION – Our achievements!

17. Our aimed Primary Health Care Vision !!! PHC doctor as “gate keeper” at the entry point to the health care system Comprehensiveness of services delivered to users Continuity of health care Orientation towards community and development of partnership with other actors in the public services provision to the population Coordination of services delivered on primary care and other levels of care

18. THANK YOU THANK YOU FOR FOR YOUR ATTENTION! www.zdarvlje.sr.gov.yu ivana.misic@zdravlje.sr.gov.yu