Effectiveness of Serbian Health Care System in 2014

SUMMARY The European Health Consumer Index (EHCI) is a project that since 2006 has been comparing and ranking health care systems of European countries, from the perspective of patients (consumers) - users of the health care system. Its purpose was to set standards for well functioning and organized health care. The aim of this study was to assess the state of Serbian health care system from the perspective of the European health consumer index and propose recommendations for its improvement and functioning in accordance with European standards. The assessment of the health care system is based on pre-determined forty-eight indicators divided into six groups. According to these indicators, scoring and ranking of countries was done (maximum score for a particular indicator was 3, and the minimum was 1). As per European Health Consumer Index the Republic of Serbia is ranked at 33rd place, with total of 473 points, while Netherlands has been found on the top of the list for years (this year 898 points).


INTRODUCTION
Due to medical advances people are expected to live longer and in the case of diseases to receive the most effective medications as well as necessary diagnostic and medical procedures, both in detection and treatment of disease. Throughout the Europe the incidence of chronic diseases is on the rise and, consequently financial burden related to health care. There is a growing concern of politicians and health experts that existing health systems might not be able to respond to the growing demands of health care. Most countries are now reforming their health care systems in the direction of putting the patient in the focus of health care, trying to preserve and improve functioning of their health systems with less allocation of public funds.
The European Health Consumer Index (EHCI) is a project that had started in 2006 and since then its goal is to compare and rank health systems of European countries, from the perspective of patients (consumers) -users of the health care system with basic aim to set standards for well-functioning and organized health care. In 2014 there were 36 countries included in EHCI estimation, among them was the Republic of Serbia.
The aim of this study was to assess the state of Serbian health care system from the perspective of EHCI compared to neighbouring countries and countries of the European Union and propose recommendations for its improvement and functioning in accordance to European standards.

INDICATORS OF THE HEALTH CARE SYSTEM EFFICIENCY
The assessment of health care system was made on the basis of pre-determined forty-eight indicators, divided into six groups: • The first group included indicators that describe the rights of patients and their awareness; • The second group of indicators assessed the availability of health care (waiting times for the treatment); • The third group of indicators evaluated the outcomes of the treatment; • The fourth group observed the range and scope of services provided in health care; • The fifth group assessed prevention; • The sixth group assessed pharmaceuticals use. Based on the indicators scoring and ranking of countries was done, where the highest score for a given indicator was 3 and the lowest 1. The resulting points were multiplied by a coefficient determined for each group of indicators, so that the total sum amounted 1000. The score in each individual group is shown in the Table 1. The current study compared the health care system of the Republic of Serbia with health care systems of the neighbouring countries (Croatia, Montenegro, Macedonia, Bulgaria, Albania and Slovenia) and highly developed countries of European Union with the highest scores (Italy, Spain, Netherlands). In order for Serbian health services to become more accessible, it is necessary to determine objective and subjective reasons for difficult access to specialists as well as necessary diagnostic, operational procedures and therapy. Macedonia could serve as an example to Serbia how to improve availability of health services (with possibility of same day access to family doctor) (score 3).
Group III -The third set of indicators evaluated treatment outcomes through the following indicators: Treatment outcomes, as the most important indicators for well functioning health care system, clearly distinguished economically stronger countries such as Netherlands (23), Spain (19), Italy (16) and Slovenia (15), from our neighbouring countries. Netherlands leads with twenty-three points in this category, with nearly three times more points than Serbia as the last one (8). Outcomes of treatment were also somewhat better in Croatia (15) Montenegro (15), followed by Bulgaria (12), Albania (10) and Macedonia (10) ( Table 4).
Devastating output effects of the Serbian health care system, with no single parameter that achieved good or excellent score, suggests need for serious reform of the health care system. Ten years of reforming health care system, with large financial investments through various projects and donations has not produced progress in any of indicators.
In the following period these questions should be answered: • Why is Serbia so much behind other European countries and countries in the region? • Why such large investments in reforming the health care system have not produced the expected effects? • Is economic inferiority of the country the main reason for poor output effects in the functioning of health care system?
Group IV -The fourth group assessed the range and scope of services provided by the following indicators: 1. Equity of health care systems 2. Cataract operations per 100 000 people age 65+ 3. Kidney transplants per million of population 4. Is dental care included in the public healthcare offering? 5. Informal payments to doctors 6. Long term care for elderly 7. % of dialysis done outside of clinic 8. Caesarean Sections In the fourth group which evaluated the range and scope of services provided in the health care system, the highest score was awarded to Netherlands (24), followed by Spain (18), Slovenia (18), Croatia (16), Macedonia (15) and Italy (14) with the least points achieved by Albania and Bulgaria (9). The range and scope of services provided in Serbia were assessed with 11 points, slightly more than Albania and Bulgaria (Table 5). Indicator five (informal payments to doctors) showed clearly corruption problem in countries of the region, and a small number of kidney transplantations. The number of kidney transplantations demonstrates again the best results in the Netherlands and Spain, and from countries in the region good results are only in Croatia. Compliment to Serbian health care system is slightly higher percentage of dialysis undertaken out of the clinics in comparison to all other countries in the region. This shows the consistency of the policy shift towards satisfying the needs of population with cheaper and more effective methods of treatment.
Group V -The parameters related to the output effects of prevention:  The highest score in this group of parameters achieved Spain (18), followed by Macedonia and Italy with 16 points and Slovenia with 15 points. The lowest score was achieved in Croatia (10). Serbia is somewhere in the middle with 13 points (Table 6). Surprisingly, Macedonia achieved higher score on prevention than Netherlands. Smoking prevention did not yield expected results in any country in the region, not even in the Netherlands. This calls for certain corrections, in order to achieve better efficiency.
In Serbia, there is room for improving output effects of preventive activities by increasing the percentage of vaccinated infants, greater engagement in the prevention of smoking and alcohol consumption, especially in the "National Program for Teens" implementation. Compared to the neighbouring countries Serbia's highlights are good results of the activities undertaken on physical activity and reduction of high blood pressure among population.  In this group of parameters, Netherlands was again at the first place, with total of 18 points achieved followed by Macedonia (15), Spain (14), Slovenia (14) and Croatia (13). The lowest score was achieved by Montenegro and Albania (11) while Italy, Bulgaria and Serbia reached a little bit higher score (12) ( Table 7).
In the assessment of indicators and use of pharmaceutical products paid by public subsidies, Serbia received poor marks. The rate of application of specific new concepts and new drugs for the treatment of cancer in Serbia must improve, as well as the use of drugs for arthritis treatment, in order to get closer to European Union countries' standards.

CONCLUSION AND RECOMMENDATIONS
Health care system in Serbia, according to the European Health Consumer index (EHCI), was placed on 33rd place with 473 points out of a maximum 1000. At the top of the list for years is Netherlands with the total of 898 points achieved this year. This ranking and applied parameters, provide clear insight into what is good in health care system of Serbia and what needs to be improved in order to reach the ultimate goal -satisfied and healthy userconsumer of health care system.
Positive developments in Serbia have been made in improving the access to primary health care, information about medicines, increased percentage of dialysis performed outside the clinics, as well as good results of activities undertaken to reduce the high rates of high blood pressure among population.
In order for users of health care in the Republic of Serbia to be healthy and happy with health care system the following parameters should be improved: • involvement of patients in health policy and increased patients' awareness, • activities on prevention and promotion, • activities to reduce adverse treatment outcomes, • activities to increase access to health care, • activities to reduce infant mortality, • activities to reduce the percentage of patients with cancer, • activities aimed to prevent corruption in health care Evaluation of Serbian health care system effectiveness from the perspective of EHCI allows us to define recommendations in order to comply with European standards, and ultimately, achieve satisfaction of users/consumers.

KRATAK SADRŽAJ
Evrop ski zdrav stve ni po tro šač ki in deks (EH CI) je pro je kat ko jim se od 2006. go di ne po re de i ran gi ra ju zdrav stve ni si ste mi evrop skih ze ma lja iz ugla pa ci je na ta (po tro ša ča) -ko ri sni ka zdrav stve nog si ste ma, s osnov nim ci ljem po sta vlja nja stan dar da za do bro funkci o ni sa nje i or ga ni za ci ju zdrav stva. Cilj ovog ra da je bio da se pro ce ni sta nje srp skog zdrav stva iz ugla EH CI i pred lo že pre po ru ke za nje go vo una pre đe nje i funk ci o ni sa nje u skla du s nor ma ma evrop skih stan dar da. Pro ce na zdrav stve nih si ste ma je ura đe na na osno vu una pred od re đe nih 48 po ka za te lja, ras po re đe nih u šest gru pa. Na osno vu ovih po ka za te lja je ura đe no bo do va nje i ran gi ra nje ze ma lja (naj ve ća oce na za od re đe ni po ka za telj bi la je 3, a naj ma nja 1). Re pu bli ka Sr bi ja je, pre ma EH CI, za u ze la 33. me sto sa 473 bo da, dok je na vr hu li ste već go di na ma Ho lan di ja (ove go di ne sa 898 bo do va). Ključ ne re či: zdrav stve ni si stem; evrop ski zdrav stve ni po tro šač ki in deks; po ka za te lji zdrav stve nog si ste ma UVOD Za hva lju ju ći na pret ku me di ci ne oče ku je se da se ži vi du že, a ka da na stu pi bo lest, da se do bi ja ju naj de lo tvor ni ji le ko vi, od no sno da se pri me ne neo p hod ne di jag no stič ke i me di cin ske teh no lo gi je, ka ko u ot kri va nju, ta ko i u le če nju ra znih bo le sti. Ši rom Evro pe se s po ve ća njem ži vot nog ve ka sta nov ni štva po ve ća va i in ci denci ja hro nič nih bo le sti, a sa mim tim i fi nan sij ska op te re će nost ve za na za zdrav stve nu za šti tu. Ra ste za bri nu tost ka ko po li ti ča ra, ta ko i zdrav stve nih struč nja ka, da po sto je ći zdrav stve ni si ste mi ne će mo ći da od go vo re na sve ve će po tre be ko ri sni ka zdrav stvene za šti te. Ve ći na ze ma lja po kre će re for me svo jih zdrav stve nih si ste ma u prav cu sta vlja nja pa ci jen ta u fo kus zdrav stve ne za šti te, po ku ša va ju ći da sa sve ma njim jav nim fi nan sij skim sred stvi ma oču va ju i una pre de funk ci o ni sa nje zdrav stve nog si ste ma.
Evrop ski zdrav stve ni po tro šač ki in deks (engl. Euro pean Health Con su mer In dex -EH CI) je pro je kat ko jim se od 2006. godi ne po re de i ran gi ra ju zdrav stve ni si ste mi evrop skih ze ma lja iz ugla pa ci je na ta (po tro ša ča) -ko ri sni ka zdrav stve nog si ste ma, s osnov nim ci ljem nje go vog do brog funk ci o ni sa nja i or ga ni za ci je. Ovom pro ce nom je 2014. go di ne bi lo ob u hva će no 36 ze ma lja, me đu ko ji ma je bi la i Re pu bli ka Sr bi ja.
Cilj ovog ra da je bio da se pro ce ni sta nje srp skog zdrav stva iz ugla EH CI, upo re di sa ze mlja ma u okru že nju i ze mlja ma Evropske Uni je i pred lo že pre po ru ke za nje go vo una pre đe nje i funkci o ni sa nje u skla du s nor ma ma evrop skih stan dar da.

POKAZATELJI EFIKASNOSTI ZDRAVSTVENOG SISTEMA
Pro ce na zdrav stve nih si ste ma je ura đe na na osno vu una pred od re đe nih 48 po ka za te lja, ras po re đe nih u šest gru pa: • pr vu gru pu su či ni li po ka za te lji ko ji go vo re o pra vi ma paci je na ta i nji ho voj in for mi sa no sti; • dru ga gru pa po ka za te lja oce ni la je do stup nost zdrav stve ne za šti te (če ka nje na le če nje); • tre ća gru pa po ka za te lja pro ce ni la je is ho de le če nja; • če tvr ta gru pa je po sma tra la ras pon i do met pru že nih usluga u zdrav stve noj za šti ti; • pe ta gru pa po ka za te lja oce ni la je pre ven ci ju; • še sta gru pa se ba vi la pro ce nom ko ri šće nja far ma ce u ti ke.
Na osno vu po ka za te lja je iz vr še no bo do va nje ze ma lja i rangi ra nje, pri če mu je naj ve ća oce na za od re đe ni po ka za telj bi la 3, a naj ma nja 1. Do bi je ni bo do vi su po mno že ni utvr đe nim koe fi ci jen tom za sva ku gru pu po ka za te lja, ta ko da uku pan zbir iz no si 1.000. Te žin ska vred nost po je di nih gru pa je pri ka za na u ta be li 1.
U ovom ra du je iz vr še no po re đe nje zdrav stve nog si ste ma Re pu bli ke Sr bi je sa zdrav stve nim si ste mi ma ze ma lja iz okruže nja (Hr vat ska, Cr na Go ra, Ma ke do ni ja, Bu gar ska, Al ba ni ja i Slo ve ni ja), od no sno vi so ko ra zvi je nim ze mlja ma Evrop ske Uni je s naj vi še osvo je nih bo do va (Ita li ja, Špa ni ja, Ho lan di ja). I grupa -Prava pacijenata i njihova informisanost su procenjeni na osnovu sledećih pokazatelja: 1. Zdrav stve ni za kon za sno van na pra vi ma pa ci je na ta 2. Or ga ni za ci je pa ci je na ta 3. Osi gu ra nje od gre ške u le če nju 4. Pra vo na dru go mi šlje nje 5. Pri stup svom zdrav stve nom kar to nu 6. Re gi star sa ve snih le ka ra 7. 24-ča sov ni te le fon za zdrav stve nu po moć 8. Me đu gra nič na ne ga fi nan si ra na od stra ne ze mlje u ko joj je oso ba dr ža vlja nin 9. Ka ta log pru ža la ca uslu ga s oce na ma 10. Do stup nost elek tron skog kar to na pa ci jen tu 11. Mo guć nost on li ne za ka zi va nja po se te le ka ru 12. Elek tron ski re cep ti Ka da je reč o pra vi ma pa ci je na ta i nji ho voj in for mi sa no sti, naj ve ći broj bo do va je ostva ri la Ho lan di ja (35), a za tim Ma ke doni ja (33), ko ja se ovim po ka za te ljem iz dva ja ne sa mo od osta lih ze ma lja u re gi o nu, već i od Ita li je (25) i Špa ni je (23). U ovom seg men tu od Sr bi je (20) je bi la sla bi ja sa mo Bu gar ska (19). U tabe li 2 se uoča va da je od biv ših ju go slo ven skih re pu bli ka sa mo Ma ke do ni ja po sti gla od lič ne re zul ta te u ve ći ni po ka za te lja ko ji go vo re o pra vi ma pa ci je na ta i nji ho voj in for mi sa no sti.
Sr bi ja, iako pret po sled nja sa 20 bo do va, na do brom je pu tu, s tim što je po treb no još da: -una pre di uklju če nost pa ci je na ta u zdrav stve nu po li ti ku kroz po di za nje nji ho ve in for mi sa no sti; od pr vo pla si ra ne Ho lan di je. Pre ven ci ja pu še nja ni je da la oče kiva ne re zul ta te ni u jed noj ze mlji u okru že nju, pa ni u Ho lan di ji, što zah te va od re đe ne ko rek ci je, ka ko bi se po sti gla bo lja efi kasnost tra že nih pa ra me ta ra. U Sr bi ji ima pro sto ra za po bolj ša nje iz la znih efe ka ta pre ventiv nih ak tiv no sti kroz po ve ća nje pro cen ta vak ci ni sa ne odoj ča di, ve ćeg an ga žo va nja na pre ven ci ji pu še nja i kon zu mi ra nja al koho la, a na ro či to u re a li za ci ji Na ci o nal nog pro gra ma za ti nejdžer ke. U od no su na ze mlje iz okru že nja, Sr bi ja se is ti če do brim re zul ta ti ma spro ve de nih ak tiv no sti na fi zič koj ak tiv no sti i smanje nju vi si ne krv nog pri ti ska kod sta nov ni štva.