Continuing medical education in Serbia with particular reference to

Background/Aim. Continuing Medical Education (CME), conceptualised as lifelong learning (LLL) aims at improving human resources and continuing professional development. Various documents of European institutions underline its key importance. This paper therefore tries to analyse the current status of CME and the main deficits in the delivery of LLL courses at medical faculties in Serbia with special consideration of the Faculty of Medicine in Belgrade with detailed financial data available. Methods . Data of 2,265 medical courses submitted in 2011 and 2012 for accreditation were made available, thereof 403 courses submitted by 4 medical faculties in Serbia (Belgrade, Kragujevac, Niš, Novi Sad). A subset of more detailed information on 88 delivered courses with 5,600 participants has been provided by the Faculty of Medicine, Belgrade. All data were transferred into an Excel file and analysed with XLSTAT 2009. To reduce the complexity and possible redundancy we performed a principal component analysis (PCA). Correlated component regression (CCR) models were used to identify determinants of course participation. Results. During the 2-year period 12.9% of all courses were submitted on pre-clinical and 62.4% on clinical topics, 12.2% on public health, while 61.5% of all took place in Belgrade. The subset of the Faculty of Medicine, Belgrade comprised 3,471 participants registered with 51 courses accredited and delivered in 2011 and 2,129 participants with 37 courses accredited and delivered in 2012. The median number of participants per course for the entire period was 45; the median fee rates for participants were 5,000 dinars in 2011 and 8,000 in 2012, re-sulting together with donations in a total income for both years together of 16,126,495.00 dinar or almost 144,000.00 euro. This allowed for a median payment of approximately 90 eur per hour lectured in 2011 and 49 euro in 2012. The 2 factors, D1 (performance) and D2 (attractiveness), identified in the PCA for Medical Faculties in Serbia, explain 71.8% of the variance. Most relevant are the duration of the courses, credit points, and hours per credit point gained by lecturers and participants respectively. In the PCA for Belgrade D1 and D2 explain 40.7% of the total variance. The CCR on the number of participants reveals the highest positive impact from the number of lecturers per course and the expenditure on amenities, the highest negative impact from the total income collected per participant. Conclusion. The faculties of medicine in Serbia should reconsider the entire structure of their organisation of CME, especially to improve the quantity and quality of registration limit the course fee rates per hour and reduce administrative and other costs request lecturing in CME programmes as obligatory for academic promotion and organise a focussed marketing.

ered in 2012. The median number of participants per course for the entire period was 45; the median fee rates for participants were 5,000 dinars in 2011 and 8,000 in 2012, resulting together with donations in a total income for both years together of 16,126,495.00 dinar or almost 144,000.00 euro. This allowed for a median payment of approximately 90 eur per hour lectured in 2011 and 49 euro in 2012. The 2 factors, D1 (performance) and D2 (attractiveness), identified in the PCA for Medical Faculties in Serbia, explain 71.8% of the variance. Most relevant are the duration of the courses, credit points, and hours per credit point gained by lecturers and participants respectively. In the PCA for Belgrade D1 and D2 explain 40.7% of the total variance. The CCR on the number of participants reveals the highest positive impact from the number of lecturers per course and the expenditure on amenities, the highest negative impact from the total income collected per participant. Conclusion. The faculties of medicine in Serbia should reconsider the entire structure of their organisation of CME, especially to improve the quantity and quality of registration limit the course fee rates per hour and reduce administrative and other costs request lecturing in CME programmes as obligatory for academic promotion and organise a focussed marketing.

Introduction
Continuing Medical Education (CME) is probably the most developed field of lifelong learning (LLL), increasingly also termed continuing professional development (CPD); the variant terminology has been discussed in extenso, e.g. by Aspin and Chapman, 2007 1 . The concept is linked to the idea of improving human resources in the field of professional competences and securing professional development, which will lead to better and accountable performance. It is generally accepted that LLL is an imperative for individuals and professional groups in a knowledge-intensive society and that it has far-reaching positive effects that go beyond simple economic issues 2, 3 .
Various documents of European institutions underline the growing importance of LLL since the early 2000s (e.g. European Parliament and the Council, 2006 4 ). Universities of Europe are strongly encouraged to develop a lifelong learning approach to education. This is further supported by the endorsement of the "European Universities' Charter on Lifelong Learn-ing" in 2008 5 . In March 2010 the European Ministries of Education have adopted the Budapest-Vienna Declaration on the European Higher Education Area 6 . Among the priorities of higher education in the decades to come, LLL is listed there as the second priority after equal access to and completion of education. In the same line are all actions of the European Union (EU) in the field of higher education, starting from the Lisbon Strategy and "The role of education in a fully-functioning knowledge triangle" 7 . Among the priorities listed are of special relevance: "Partnership between universities and business and other relevant stakeholders" as well as "Creating incentives for universities to develop transferable knowledge". The "Strategic framework for European cooperation in education and training" 8 calls for "Making Lifelong Learning and mobility a reality" and out of the five European benchmarks Adult participation in LLL is targeted as follows: "By 2020, an average of at least 15% of adults  should participate in lifelong learning" and "By 2020, the share of 30-34 year olds with tertiary educational attainment should be at least 40%".
The movement for LLL is also presented in a Green Paper from the EU Commission calling for bigger investment in workforce planning and training whilst the EU Council has called for greater priority to be given to LLL as 'a basic component of the European social model' 9 . The European universities are reporting on their organization of LLL under the umbrella of higher education institutions 7 . Despite recognition of LLL as one of the most important activities safeguarding the future of European universities, progress in the delivery of CPD is still not satisfactory (35% of educational institutions had strategies for development of LLL in 2003 with only a slight improvement in 2010 -39%).
In Serbia as well as in the other successor states of the former Yugoslavia, publications on the organisation and management of CME are still rare, usually case studies respectively be-fore/after evaluation of specific courses 10-12 . In the light of the European development even less has been published 13 . Nevertheless, following the Bologna process and the new Law on Higher Education in Serbia 14 , during the last years important strategies in support to LLL are developed and endorsed, such as the Na-tional Strategy for Development of Adult Education 15 .
Considerable efforts have been invested during the first decade of the 21st century in order to implement in Serbia the Bologna principles in academic education and training at the level of bachelor, master and doctoral studies, less has been done in relation to continuing education in all fields. However, to support CPD, in 2007 the Ministry of Health introduced by-laws on CME based on the systems' laws such as the Law on Chambers of the Health Workforce and the Law on Health Care 16, 17 , prescribing, among other conditions, the types of courses and the related credit points of CME. The legislation on the health professional chambers16 is supporting further development of LLL by imposing obligatory relicensing every seven years, requesting a min imum number of CME credits. These changes open an at-tractive market for many providers of educational services. Since both private and public providers compete for customers with a broad spectrum of different types of CME.
Following the new trends, medical faculties in Serbia are also engaged in the organisation of LLL. Particularly the Faculty of Medicine, Belgrade (FMB) has a long tradition in leading CME 13 . Between 2003 and 2010, FMB alone delivered 492 courses 18 . The University of Bel-grade permanently offers favourable conditions for the improvement of LLL including a re-cently endorsed Strategy for development of LLL 19 . The aim of this strategy is to promote a culture of education and training, to strengthen cooperation and networking at a national and international level, to develop generic competences as preconditions for contemporary literacy, and to support social development and decrease unemployment by a flexible and acces-sible environment for education and training. Nevertheless, since the establishment of a na-tional accreditation system by the Health Council of Serbia in 2009 20 and the appearance of a competitive market, reorganization of CME and adaptation to the new situation became man-datory if stagnation and outclassing of the medical faculties should be avoided.
Not only the Faculty of Medicine, University of Belgrade, but all higher academic institutions in Serbia and in the South-Eastern European Region are to revisit their LLL activities in order to take the chance of offering competitive programmes for a wider audience in national language and based on the standards according to the Bologna process. In addition the offer of programmes in English for a European and global audience has been considered, supported by distance learning formats. This paper therefore tries to analyse the present status of CME and the main deficits in the delivery of LLL courses at medical faculties in Serbia with special consideration of the FMB where detailed financial data are available.

Methods
Data of 2,265 courses for CME, submitted in 2011 and 2012, have been analysed on the basis of the documentation provided by the accrediting authority, the Health Council of Serbia 21 . Thereof 403 courses were offered by 4 medical faculties in Serbia: Belgrade, Kragujevac, Niš, and Novi Sad. The Medical Faculty in Kosovska Mitrovica did not accredit any course during the period under consideration while the Faculty of Medicine the Military Medical Academy did not apply for accreditation as an independent higher education institution 22 . A subset of courses actually accredited and delivered in the same year by the FMB could be analysed in more detail on the basis of the documentation provided by the administrative office of the Faculty: 51 course sheets were collected for courses delivered in 2011 and 37 for courses in 2012, together 88 courses. The database for Serbia comprised 26 variables, the subset for Belgrade 26 partly different variables of together 5,600 participants in 2011 and 2012.
The basic analyses have been performed with XLSTAT 2009. For the description median and inter-quartile-range (IQR, the distance between the 25th and the 75th percentile) were preferred because of the heterogeneity of the datasets.
As there were many lecturers reading repeatedly we counted the number of lecturers per course but sum-up across all courses as "lec-torates". As of 1 January 2013 the national currency of dinars is traded against the euro at a rate of 112 dinars/euro 23 .
For the analysis we used a two-step approach. First, we conducted principal component analysis (PCA) in order to reduce the number of variables without giving up relevant information. PCA is especially recommended when planning regression analysis where the number of independent variables is large relative to the number of observations, or, if it can be assumed that the independent variables are highly correlated 24 . Employing PCA for our dataset allowed to reduce the number of independent variables and to replace highly inter-correlated variables by fewer and independent factors. In the second step we calculated the actual regression model to identify the determinants of course participation. We applied a relatively new approach -correlated component regression (CCR) -which takes into account still remaining multicollinearity 25,26 . Remaining multicollinearity would have increased the standard errors of the correlation coefficients and led to false interpretation by missing significant differences. Table 1 shows the basic composition of the data according to organisers and classification of CME. A total of 2,265 courses were submitted for accreditation in 2011 and 2012 together and almost all certified (98.6%), which does not imply that they were also delivered in the year of accreditation or even later. Almost two thirds of the submitted programmes were in the field of clinical medicine (62.4%) and likewise almost two thirds came from organisers in Belgrade (61.5%). The majority of programmes, i.e. 57.3%, were offered by state institutions and 35. The median duration of all courses in Serbia was 6 hours, the median number of credit points for lecturers 10 and for participants 5. Per credit point a lecturer reads 0.67 hours, a participant attends for 1.33 hours; this is not very different between Serbia in general, medical faculties alone and the FMB specifically. Likewise the average lecturing time per domestic lecturer is 2 hours for all courses in Serbia and not much higher, e.g. for the FMB with 3 hours. However, the rates for participants differ considerably, between 1,500 dinar in Serbia overall, 4,000 for medical faculties and even 5,000 in Belgrade with broad interquartile ranges (IQR). Correspondingly, the rates per hour and per credit point are higher in the programmes of medical faculties.

Results
For the subset of Belgrade with 88 course sheets collected all together 3,471 participants registered in 2011 with a median of 51 per course, and 2,129 in 2012 with a median of 39. Per course a median of 6 lecturers is counted, equivalent to a total of 665 "lectorates" in both years together. The median fee rates for participants (partly supported directly by sponsors) were 5,000 dinars in 2011 and 8,000 in 2012 resulting, together with donations, in a total income of 11,463,122.00 dinar in 2011 and 4,663,373.00 in 2012, which is 16,126,495.00 dinar for both years together or equivalent to 143,987.00. In fact only 89.7% of the total charges due have been collected. The reduction of income in 2012 is owed to the reduced number of participants whereas the median income rate per participant (including donations) remained stable between 4,086 and 4,284 dinars. The median rates per hour and per credit point oscillate between 417 and 769 dinar.
The FMB charged 10.0% as a special charge on CME and 13.0% on administration by the Faculty, together 23. The classification of the variables of main interest, i.e. the number of participants, faculty earnings, and surplus per lecturer according to preclinical courses, clinical courses, courses in public health, and courses of other types indicates a considerable variance between less attended preclinical programmes (median 5.5) and a quite numerous participation in the clinical (median 85) and public health (median 24) courses. Nevertheless, the surplus per lecturer after deduction of all expenditures is quite similar across all programmes (median overall 12,639.00 dinar or 113 euros) with the exception of the preclinical courses (2.506.00 dinar). Faculty earnings, however, vary much more (overall median 36,527.00 -IQR 297,031.00 dinar).
For the year 2012 also 779 participant's evaluation forms from 19 courses in Belgrade were available. The average ranking of the 19 courses was between 4.47 and 5.00 (from a scale ranging from 1 to 5, the best). Between 56.4 and 100% of participants in a specific course gave rank 5; 2 courses reached even an average of 5 (i.e. all participants voted 5); only 31.6% or 6 out of the 19 courses got the ranks < 4.75. Figure 1 shows the result of the PCA performed for all 4 registered medical faculties in Serbia together. The remaining variables constitute the factors D1 (performance) and D2 (attractiveness) and together explain 71.8% of the data variance. Most relevant in this context are the duration of the courses, the credit points, and the hours per credit point gained by lecturers and participants respectively. The fee rates are also relevant but to a mod-erate extend only. Figure 2 shows how the Belgradian courses with their more detailed data, especially including financial information, being scattered by the two factors identified in the PCA (see annexed Table A2). The first factor (D1 -performance) accounts for 23.3% of the total variance and is derived from seven variables; income related variables loading highest. The second factor (D2 -attractiveness) accounts for 17.4% of the variation and is derived from six variables, describing time and effort. Together the two factors explain 40.7% of the total variance. A high proportion of the courses (observations) lies in the third and fourth quadrant (order of quadrants is clockwise, starting from the upper left corner). This means that these courses are rated low in attractiveness and largely also in performance. We can see that clinical courses (#2) are mostly located in the third quadrant, with an outlier in the second quadrant with high attractiveness and relatively high performance. Preclinical courses (#1), Public Health courses (#3), and "Other courses (#4) are located more in the fourth quadrant. They are relatively unattractive and performing below average.
In a second step the variables included in the CCR calculation were selected according to the outcome of the PCA.
We calculated four models with varying assumptions but quite consistent results (two of them are shown in the annexed Table  A3). Accordingly, the highest positive impact on the number of participants comes from the money spent on amenities like meals etc. (here listed under "all other declared expenses", see also annexed Table A1), and "the number of lecturers per course". The highest negative impact comes from the variable "income per participant" which includes all donations. In fact, the "per capita income" is not an appropriate measure of operating efficiency here, as a decreasing number of participants will increase the ratio. However, together with the variable "official rate" (course fee) it signifies the financial burden to the participants.

Discussion
The conceptual framework for today's continuing medical education largely has been set towards the end of the first decade of this century 27 as discussed in the introduction. The recent call for a competence-based framework 28 requires a national if not European response [29][30][31] , transforming CME in the next years. Medical faculties are best suited to set the standard for CME as far as it is obligatory for medical professionals.
First steps have been made with the National Strategy for Development of Adult Education in Serbia 15 and a subsequent regulation of the FMB 32 . In 2009 the FMB adopted also a bylaw on organization and delivery of CME courses 33 , aiming to stimulate involvement of teaching staff in management and delivery of CME as well as a better administrative and financial organization, most relevant for the motivation of teaching staff.
Medical faculties in Serbia contribute to CME only with 17.8%, the FMB being the biggest supplier among all the academic institutions.
The reasons for the rather minor role of the medical faculties in general can be better under-stood looking at the data from Belgrade. Already from the descriptive analysis it becomes obvious that far less than half of the 883 lecturers employed at the FMB (as of 15 November 2012) engage in CME, e.g. with 279 "lectorates" in 2012. Although 613 are authorised to coordinate a programme for CME, only 37 or 6.0% did so in 2012, alone or together with colleagues. However, the reasons for the limited interest in CME are also obvious: the financial reward per lecturer and per hour lectured for most of them is not attractive as half of them earn less than 12,639.00 dinar in total and less than 7,282.00 per lecture hour delivered. Also there is an alarming reduction between 2011 and 2012, by about 1/3 of the surplus per lecturer and even close to 1/2 per hour lectured. The cost of certificates alone amounts to almost 2.5 mio dinar which could increase the remaining total surplus of 6.7 mio dinar for 2011 and 2012 together by up to 36.8%. One can safely assume that the situation is not substantially different with regard to other medical faculties in Serbia as the comparable variables indicate.
Although we could not determine reliably the contribution of donors to the total income (partly by paying fee rates of selected participants, partly by direct contribution to the course budget) we estimate that up to 75% of the total income originates from donors like pharmaceutical industry and government, implying a potential lack of autonomy. There is also an enormous variation in terms of remuneration per hour taught or attended, be it by credit points earned per hour or cost per credit point. Surprisingly low is the participation in preclinical courses. The best explanation for this observation is a high and possibly stimulated private competition. It is difficult to judge the quality of the courses delivered as we have evaluation sheets by participants only from 19 courses in Belgrade, admittedly with very high rankings. On the other hand the low rate of 1.4% of non-accredited programmes seems to indicate the lack of strict criteria.
The limitations of this analysis lay mainly in the data quality which required careful consid-eration of how to deal with missing or insecure information. A related factor is that full registration of data and even of entire courses is missing. Therefore we could analyse only Belgrade courses, which are accredited and delivered in the same academic year. The PCA shows convincingly that most courses have a low performance and attractiveness, mainly determined by financially related variables. This is confirmed by the CCR which leaves in addition to financial variables only the number of lecturers per course with a potential impact upon the number of participants.
The importance of life long learning has been recognised in recent discussions within the Association of Schools of Public Health in the European Region, based on the results of the ASPHER survey 34,35 and our analysis of continuing medical education in Serbia.

Conclusion and Recommendations
More comprehensive and sufficiently funded studies in the field are required in order to improve delivery of continuing medical education, based on a priori collection of more detailed and comprehensive data and covering also other health professions as especially nurses.
In summarising this first analysis the authors conclude that the faculties of medicine in Serbia and especially the Faculty of Medicine in Belgrade may reconsider the entire structure of their organisation of CME regarding performance and attractiveness: Administrative Organisation -Improve the data quality of the registration especially to include data on final delivery; Limit the course fee rates per hour; Reduce the percentage of obligatory payments to the administration and arrange for a cheap production of certificates in order to save money for remuneration; Request lecturing in CME programmes of the faculties of medicine as obligatory for academic promotion together with an increase of remuneration.
Innovative development -Going online towards blended learning; Adopt best practice from a competitive market; Increase attractiveness for participants from South Eastern Europe (especially from the former Yugoslavia) and from abroad in general (if English speaking); Invest in bilateral agreements with big organisations; Organise a focussed publicity.
Medical faculties of Serbia should develop their national and international standing also by providing CME to a larger professional community irrespective of financial gains.