Health Policy 118 (2014) 166–172
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Primary care principles and community health centers in the countries of former Yugoslavia ˇ Darinka Klanˇcar ∗ , Igor Svab Department of Family Medicine, Medical school, University of Ljubljana, Ljubljana, Slovenia
a r t i c l e
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Article history: Received 6 August 2012 Received in revised form 25 August 2014 Accepted 26 August 2014 Keywords: Primary health care Health care reform Former Yugoslavia Community health center
a b s t r a c t Background: Many countries implement primary health care (PHC) principles in their policies. The community-oriented health center (COHC) has often been identified as an appropriate organizational model for implementing these ideas. The countries of former Yugoslavia have a long tradition of health centers which have been part of their official policies, but they face the challenge of reforming their health care systems. The aim of the study was to describe the extent of the principles of primary care in these countries and the new role of medical centers. Methods: This qualitative study was carried out between 2010 and 2011. A questionnaire was sent to two key informants from each of the six former Yugoslavian countries. The set of questions encompassed the following categories: organization and financing, accessibility, patient/community involvement, quality control and academic position of primary care. Results: Primary care is officially declared as a priority and health centers are still formally responsible for implementing primary care. Different organizational approaches to primary care were reported: predominant independent practices, health centers as an exclusive form and forms health centers and independent practices coexist. We could not find a unique pattern of covering primary care principles in different organizations. Conclusion: Formally, health centers still play an important role in the countries of former Yugoslavia, but major differences between PHC policies and their implementation have appeared. A consensus about an appropriate delivery of medical care to cover the primary care principles no longer exists. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The organization of healthcare delivery is of utmost importance for the post-modern world [1]. Scientific
Abbreviations: BiH, Bosnia and Herzegovina; CME, continuous medical education; COHC, community oriented health center; FYR, Former Yugoslav Republic; GP, general practitioner; HC, health center; PHC, primary health care; USA, United States of America; WHO, World Health Organization; Wonca, World organization of family doctors. ∗ Corresponding author at: Cesta pod Slivnico 21, 1380 Cerknica, Slovenia. Tel.: +386 41706973; fax: +386 17050552. E-mail address: [email protected] (D. Klanˇcar). http://dx.doi.org/10.1016/j.healthpol.2014.08.014 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
research has provided evidence on benefits of welldeveloped primary care systems, in the field of better coordination and continuity of care and better opportunities to control costs [2,3]. Current tendencies that shape conventional health systems include a disproportionate focus on specialist and tertiary care, fragmentation, and commercialization of health care in unregulated health systems [4]. Although many countries agree on the importance of primary care, its goals have largely not been achieved [5]. In 2008, a new declaration was launched by the WHO [4] in order to implement the PHC principles of justice, accessibility, patient/community involvement, quality care, safety
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and efficiency in everyday medical care at the primary level [6–10]. The declaration stresses the importance of person-centredness, comprehensiveness, integration and continuity of care with a regular point of entry into the health system. Many countries look for appropriate organizational forms to implement these ideas. In the USA, the idea of a community oriented health center has recently re-emerged as a concept of a medical home [11–14]. In Europe, community oriented medical practices are increasingly seen as a method of ensuring that patients have access to the right care at the right time in the right place [15,16]. The countries of the former Yugoslavia have a long tradition of a similar concept which has been considered successful and the most efficient organizational model for implementing these principles [17–19]. They followed ˇ Andrija Stampar’s ideas on community oriented primary care, which was first implemented in 1920s and became a national policy of organizing primary care after the Second World War. According to this policy, primary care centers were established in every commune with the aim of covering a defined area and a defined population. The role of primary care centers was to ensure primary care service, prevention and public health service. There was a free access for all people and some population groups (e.g. children, pregnant women) were given special attention. This system was very effective in solving some of the important health care issues in the first half of the 20th century, but confronted problems by the end of the century [20–26]. Yugoslavia claimed that their health care system was as original as their political system and that it was neither private nor state-run [27]. Since the beginning of the 1960s the policy of primary care faced serious problems. The core problems were: inadequate education of health professionals about health promotion and disease prevention, unsatisfactory economic and social status of primary care professionals and low interest of citizens taking care of their own health through disease prevention [28]. On the other side costs were rising, especially as the volume and intensity of hospital-based care increased. The Yugoslavian system as nominally universal in coverage, health services still were used more by the better-off, and efforts to reach the poor were often incomplete. The 1990s was a decade of major reforms in national health systems. All countries were struggling to develop adequate prevention models to reduce the burden of disease that can bankrupt a national health system [29]. This process coincided with the collapse of political system, when important changes have taken place which is apparent from the economic and political situation (Table 1). In the new circumstances dilemmas about the appropriateness of the concept of health centers have arisen. Furthermore, in many countries reforms introduced new policies in this field. So far there have been only a few articles/documents describing the situation in primary care in these countries after the collapse of socialism [30–40]. To our knowledge, no studies have dealed with these countries in a systematic way. The aim of study is to describe the new role of medical centers and to what extent the principles of primary care are present in ex-Yugoslavian countries.
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2. Methods 2.1. Study design This qualitative study was conducted between 2010 and 2011. The key informant method of obtaining data from persons whose professional and/or organizational roles imply they have knowledge about specific characteristics of the population being studied as well as potential pathways and constraints for community change, was used [41,42]. The informants were suggested by Wonca (World organization of family doctors) national representatives in these countries, except for Montenegro, which was not a Wonca member in the time of the study. In this case, the informants were suggested by the Ministry of Health of Montenegro. The people we asked for suggestions were informed about the nature of the study and asked to name experts and leading specialists in the field of primary care. Two key informants from each of the six countries of former Yugoslavia were invited to participate in the study. They were considered to correspond to the characteristics of the most ideal key informant: they had adequate knowledge of the topic, were willing to participate, were impartial and were able to communicate [43]. They were all general practitioners with academic background.
2.2. Data collection The informants were given a semi structured questionnaire covering the areas of primary care described in the WHO documents: organization and financing of primary care, accessibility, equity and patient/community involvement. We asked for their opinion on planning and financing the contents and extent of contractor’s work in health care related to the health needs of the community in balance with available resources. Quality control and academic status of primary care were also included as well as the role of health centers. The questionnaires, written in English, were sent by e-mail. The terminology used in questionnaire was clear enough to be understood by chosen informants.
2.3. Analysis After the information had been received, the records were transcribed verbatim and organized thematically. In the first data analysis, the answers from both informants from each country were compared by the two authors (D.K. and I.S.) and inconsistencies and discrepancies were identified. In the second stage, the interpretations with a list of inconsistencies were sent back to the key informants with some additional information; in some instances definitions were added (e.g. ‘mostly’ was over 50%, ‘almost all’ was more than 80%) and consensus was sought. When consensus was not possible, this was noted and described later in the paper. In the third stage, the informants were given a draft version of the results and asked to clarify the remaining dilemmas. The final version of the results was then sent to the informants for confirmation. All the informants approved the final version of the results.
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Table 1 EU membership status, GDP, health expenditure and physicians supply in 2009 in countries of former Yugoslavia. Country
EU membership
Great national income per capita (PPP international$)
Health expenditure per capita (PPP international$)
Number of physicians per 1000 population
Bosnia and Herzegovina Croatia FYR Macedonia Montenegro Serbia Slovenia
No Realized in 2013 No No No Yes
8.880 19.260 11.040 12.870 10.890 26.620
934 1.556 763 1.215 1.162 2.551
1.64 2.60 2.63a 2.10 2.11 2.51
Source: WHO data base. Available at: http://apps.who.int/gho/data/?vid=92000# a Data for 2008.
3. Results 3.1. Organization of health care Primary care is declared as a priority in official documents (strategies, action plans, etc.) in all the countries except in Slovenia, where this is declared in the conclusions of expert conferences. The WHO principles of primary care (justice, accessibility, patient/community involvement, quality of care, safety, efficiency) are also defined in official documents of these countries. In addition, health centers are accredited and responsible for the realization and coordination of these objectives. Formal procedures for establishing a primary care organization differ from country to country. In Montenegro, for instance, only the Ministry of Health may establish these organizations, whereas in other countries whether the state, region, local community or an individual can do it, although the formal responsibilities are defined by the state. Health centers and independent practices are the organizational models at the primary level. In Montenegro health centers are the exclusive health care providers of the state funded health care. In Bosnia and Herzegovina and Serbia health centers are almost exclusive forms, in Croatia and Slovenia health centers and independent practices coexist and are both funded by the state. In Macedonia, practically all doctors at the primary level work in private independent practices, meanwhile health centers are rare (Table 2). Most health centers also provide secondary care (e.g. ophthalmology, dermatology, internal medicine) and some (rarely) provide long-term care (e.g. Montenegro). In all the countries general practitioners, occupational medicine specialists, pediatricians, gynecologists, home care nurses and psychiatrists are the providers of primary care. 3.2. Financing In all the countries primary care is predominately funded by the state, usually through the national insurance company. Smaller sources of income may include local community, region contributions or those made by individuals. Payment is mostly made through a contract, based on capitation and fees for service (as in Croatia, Montenegro, Serbia and Slovenia). In Bosnia and Herzegovina the providers are paid by flat rate, whereas in Macedonia they are paid by capitation only (Table 2).
In all the countries organization and financing has changed in the last 10 years. The informants from Bosnia and Herzegovina, Montenegro, Serbia and Slovenia consider the organization of care to be slightly better, but financing is worse than 10 years ago. Only the respondents from Croatia thought that the changes were for the worse in both areas, mainly due to disorganization, fragmentation, lack of maintenance and faulty systems of financing that have led to an increased competition for patients and consumerism. The opinion of the Macedonian respondents was quite the opposite: organization has deteriorated in the last 10 years, but the payment is better, especially for the doctors who have enough patients. 3.3. Role of health centers Health centers were reported to be the providers and coordinators of primary care activities. This was stated in Bosnia and Herzegovina, Serbia and Slovenia. The informants from Croatia mentioned that the health center is the provider and coordinator of the primary medical care activities only in official documents, however the reality is different. The informants from Montenegro reported that it is only the provider but not the coordinator of the primary medical care activities. In Macedonia the health centers have no role in coordinating the work of independent practice doctors. The respondents from Montenegro and Serbia reported that practically all medical care at the primary level is delivered by health centers, whereas the estimate for Croatia was only about 25% and 50% for Slovenia. The Bosnian and Macedonian informants were not able to give an estimate. Team compositions in primary care centers have not changed. Secondary care specialists are still present in health centers (internists, psychiatrists. . .). In Montenegro the centers also provide long term hospital care in remote areas. In general, quality control systems in health centers are the same as at the primary level; only few health centers were reported to be included in quality control projects (in Bosnia and Herzegovina, Croatia, Macedonia, and Slovenia) as later seen in Table 2. The most frequent control mechanism is the financial control through national insurance (in Croatia and Serbia). The informants from Montenegro reported that a health center manager annual report was the only quality control system in health centers. The centers mostly have an association which is a forum for exchanging opinions and has no formal power. In Bosnia
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Table 2 Differences in primary care. Country
Predominant organizational form
Financing
Barriers
Community involvement
Quality control
Education and research
BiH
Health center almost exclusive form Independent practices mostly Independent practices almost exclusive form
Flat rate
Geographic Financial Geographic Human resources Geographic Human resources
No
AC OPC AC OPC AC OPC
Montenegro
Health center exclusive form
Capitation and fee for service
Geographic
No
AC
Serbia
Health center almost exclusive form Health center mostly
Capitation and fee for service Capitation and fee for service
Geographic Financial Human resources
Partly
AC
No
AC IQC OPC SC
Undergraduate and postgraduate Undergraduate and postgraduate Undergraduate, postgraduate only as CME Undergraduate and postgraduate (being prepared) Undergraduate and postgraduate Undergraduate and postgraduate
Croatia FYRMacedonia
Slovenia
Capitation and fee for service Capitation
Partly No
Legend: SC, self-control; IQC, internal quality control; AC, administrative control; OPC, organized professional control.
and Herzegovina and Macedonia, health centers have no formal form of association. In all the countries, the director of a health center is predominantly a doctor of medicine. If the director is an economist or a lawyer, the assistant director has to be a doctor. No specific training is needed for this position, except in Macedonia.
Herzegovina have experienced improvement regarding an increased number of doctors. Furthermore, patients have the right to a free choice of their doctor. In the future an improvement is to be expected, though this is uncertain (Table 2). 3.5. Patient/community involvement
3.4. Barriers, accessibility and justice The respondents from all countries reported about certain barriers in accessing primary care. They include geographical barriers due to transportation, poor roads, old vehicles, bad medical vehicles and long distances between clinics in rural areas (except in Slovenia). In Bosnia and Herzegovina the war devastation of infrastructure was still considered a source of problems. In Croatia family medicine is rather extensively available, but the islands and mountain areas create a problem in terms of availability of primary care. The respondents from several countries (Croatia, Macedonia, Montenegro and Slovenia) did not report any serious financial barriers in accessing primary care. This is still thought to be a problem in Bosnia and Herzegovina with a considerable number of people without health insurance. The respondents from Serbia also reported the existence of financial obstacles, especially in rural areas which are twice as poor as urban areas and where 14.7% of the population are unemployed and have no health insurance. There is a reported lack of doctors in Croatia, Slovenia and partly in Macedonia, where it is more noticeable in rural regions. Only the respondents from Serbia and Montenegro have not seen this as a problem. There was no consensus about human resources in Bosnia and Herzegovina. In most countries the average doctor’s workload is similar and reaches about 1600–2000 patients per GP. The informants chiefly stated that accessibility to primary care had deteriorated in the last 10 years. The informants from Croatia and Slovenia said that the problem of a lack of doctors had worsened in rural areas. The informants from Macedonia mostly described a restricted financial situation, meanwhile those from Montenegro and Bosnia and
In all the countries the activities in primary care are defined by the state, meanwhile local authorities are not involved. Only the respondents from Serbia and Croatia reported that some local communities and regions participate in this area (in preventive programs, health service for tourists in tourist areas) (Table 2). In most cases, the content and extent of provider services are defined by the state or the national health insurance company and medical care providers cannot independently change or extend the range of services (Macedonia, Montenegro, Serbia and Slovenia). In the countries where this is possible, the additional work is not paid for (Bosnia and Herzegovina) or the payment is made by the patient alone (Croatia). The respondents from Croatia and Macedonia reported that patient and community involvement had deteriorated in the last 10 years. The respondents from Bosnia and Herzegovina, Montenegro and Serbia said that patient and community involvement had improved. The Slovene informants observed that there had been no change in this respect. 3.6. Quality of care Four categories of quality control were identified from the transcripts. The respondents identified self-control, internal quality control, administrative control performed by the official bodies (ministries of health, medical chamber and national health insurance company). In this category, the informants from Croatia reported that the control by the national health insurance was by far the most important. In Macedonia only the state performs health care quality control. Respondents from only few countries
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reported to have some organized quality control projects (in Bosnia and Herzegovina, Croatia, Macedonia, and Slovenia) (Table 2). The informants described different methods of accreditations: technical regulations in terms of workplace, medical professional licenses, ISO standards (Bosnia and Herzegovina, Serbia, and Slovenia). In Croatia, Macedonia and Montenegro there are only state requirements for adequate technical standards for accreditation of practices. The main problem of quality control seems to be a lack of expertise (Macedonia) and inadequate quality indicators (Slovenia). The respondents from Bosnia and Herzegovina described financial barriers, namely a lack of money for accreditation process. The respondents from Croatia reported that the main problem with quality control seemed to be that the main controller is the national insurance company, which puts economy in the first place. The control is predominantly administrative and financial. Professional control in its true sense hardly exists. In Montenegro there are no quality demands, except for technical standards and even these are not adhered to. The respondents mostly agreed that a feedback is given on the basis of routine data. Most information is available for health care managers (Montenegro). In Bosnia and Herzegovina, Croatia, Macedonia, Serbia and Slovenia, providers do get a feedback about their work, which is mostly statistical and financial. Generally, there is no professional and scientific feedback information available. The opinions regarding quality control were varied. Informants from Bosnia and Herzegovina, Montenegro and Serbia claimed that it had improved, others described a deterioration (Macedonia), some estimated there had been no improvements (there is interest but no conditions for implementation) (Croatia and Slovenia).
3.7. Education and research In Bosnia and Herzegovina, Croatia, Montenegro, Serbia and Slovenia, education for doctors in primary care takes place at undergraduate and postgraduate levels (Table 2). Only Montenegro does not yet have a formal program of vocational training for family medicine, but t it is being prepared and will start in 2013. The specialization for family medicine is obligatory only in Slovenia. In Macedonia, education for medical doctors in primary care is provided only as continuous medical education (CME). In all the countries CME is organized by medical health associations, the ministries of health, pharmaceutical companies, associations of primary medical care providers, medical faculty chambers, clinics and associations of family physicians. Associations of medical care providers at the primary level exist in all the countries. They are a place for discussion and exchanging opinions. There is no consensus about their actual role. Family medicine is recognized as an academic discipline in all the countries. The informants described circumstances in education and academic work at the primary level in various ways: as an improvement (Bosnia and Herzegovina, Croatia, Macedonia, Montenegro, and Slovenia) and as a stagnation (Serbia).
4. Discussion We have seen that in these countries, which have the same health system and a long tradition of health centers, important changes have taken place. Considerable differences were noticed between the countries. Most of them are due to the predominant organizational form in primary care (Table 2). Three broad categories can be identified: the coexistence of health centers and independent practices (the predominant one), the still maintained exclusivity of the health center and the case where practically all doctors at the primary level work in private independent practices, whereas health centers are being abandoned (in one country). The consensus about an appropriate delivery of medical care to cover the primary care principles no longer exists. Overall, the principles of primary care and health centers are still listed in the official documents, but the implementation of these principles is variable. The countries have been faced with the challenges of fragmentation and commercialization, which is in conflict with the principles of primary care. It seems that inconsideration of these principles has been the most evident in the countries where independent practices are the predominant model. Financing is centralized in all the countries, which all struggle to maintain a stable financing of the health care system. It can be said that the countries have managed to keep the principle of accessibility and equity, but the economic crisis seems to be eroding this as well, because the countries are unable to cover all the costs of health care. Therefore, outofpocket payments and people who cannot afford primary care are becoming a reality, especially in poorer countries. The content and extent of provider services are defined by the state. There is very little community participation, which is supposed to be a hallmark of quality primary care. Quality control practically seems to be done only by the payer in almost all the countries. Obviously, there is little consideration for primary care expertise and, moreover, health centers have no influence on policy makers. Academic primary care has a strong tradition in Croatia and Slovenia [44,45] but it struggles to develop also in other countries, although even these countries aspire to introduce academic primary care. The position of health centers has changed considerably: health centers in some countries (Croatia and Macedonia) have lost their predominant role in the primary care. The second group includes two countries where health centers have maintained their virtual exclusivity as the only organizational form at the primary level, nevertheless, they have also included specialist and even hospital care (Montenegro and Serbia). In these countries, health centers have developed into almost Semasko-type polyˇ clinics that have little in common with Stampar’s idea of community oriented primary care. The countries in the third group try to reinvent the new role of health centers, but they struggle to do so (Bosnia and Herzegovina, Slovenia). Every qualitative study brings concerns about the validity and relevance of respondents’ perceptions. This is
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especially true when questions are raised about healthcare services. There is a danger that the opinions become politicized, without being supported in a rigorous scientific approach. The key informant survey, based on the WHO principles of primary care, is a reflection of opinions by the key primary care professionals in the countries we have covered in the study. It is aimed at gathering information and ideas that need to be validated in further research. The wellknown limitations of the key informant strategy [46] still need to be considered. By adhering strictly to the principles of the methodology, we have minimized these risks. On the other hand, the two key informant method used in the study has proven to be effective enough to get a global insight into the primary care systems in the researched countries. We therefore feel that the survey has fulfilled this goal and given us valuable ideas for future research in this area. Further quantitative validation is necessary to find out whether the statements reflect the beliefs of key informants or whether it is an accurate account of the situation. In order to do that, this study needs to be followed with quantitative analysis of the healthcare systems, probably by using some internationally available dataset, aimed specifically at primary care [47]. 5. Conclusion Bearing this important limitation in mind, one can say that in the changed systems of the former Yugoslavia, the principles of primary care still formally exist in all the countries. However, the changes in their systems have led to the development of different policies and practices that are often very different from the declarations that are accepted. From the information we have received, we could not identify a unique pattern of covering primary care principles in different organizational forms. The extent of the principles in the countries where health centers are still the exclusive or predominant organizational form is comparable with the countries where only independent practices exist. The most critical area seems to be the area of community involvement. The impact on planning and financing the content and extent of contractors’ work in health care related to the health needs of the community in balance with available resources received least attention. From the information we have received, we see that policies of primary care should take into account the community orientated health centers, which have a long tradition in these countries. Conflicts of interest All authors declare that no conflicts of interest exist. Acknowledgments We are grateful for the contributions made by the key informants from six southeastern European countries: ˇ Obrdalj and Melida Hasanagic´ from Bosnia and Edita Cerni Herzegovina, Milica Katic´ and Dragomir Petric from Croˇ atia, Ljubin Sukriev and Zoran Stojanovski from Macedonia,
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Primary care principles and community health centers in the countries of former Yugoslavia ˇ Darinka Klanˇcar ∗ , Igor Svab Department of Family Medicine, Medical school, University of Ljubljana, Ljubljana, Slovenia
a r t i c l e
i n f o
Article history: Received 6 August 2012 Received in revised form 25 August 2014 Accepted 26 August 2014 Keywords: Primary health care Health care reform Former Yugoslavia Community health center
a b s t r a c t Background: Many countries implement primary health care (PHC) principles in their policies. The community-oriented health center (COHC) has often been identified as an appropriate organizational model for implementing these ideas. The countries of former Yugoslavia have a long tradition of health centers which have been part of their official policies, but they face the challenge of reforming their health care systems. The aim of the study was to describe the extent of the principles of primary care in these countries and the new role of medical centers. Methods: This qualitative study was carried out between 2010 and 2011. A questionnaire was sent to two key informants from each of the six former Yugoslavian countries. The set of questions encompassed the following categories: organization and financing, accessibility, patient/community involvement, quality control and academic position of primary care. Results: Primary care is officially declared as a priority and health centers are still formally responsible for implementing primary care. Different organizational approaches to primary care were reported: predominant independent practices, health centers as an exclusive form and forms health centers and independent practices coexist. We could not find a unique pattern of covering primary care principles in different organizations. Conclusion: Formally, health centers still play an important role in the countries of former Yugoslavia, but major differences between PHC policies and their implementation have appeared. A consensus about an appropriate delivery of medical care to cover the primary care principles no longer exists. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The organization of healthcare delivery is of utmost importance for the post-modern world [1]. Scientific
Abbreviations: BiH, Bosnia and Herzegovina; CME, continuous medical education; COHC, community oriented health center; FYR, Former Yugoslav Republic; GP, general practitioner; HC, health center; PHC, primary health care; USA, United States of America; WHO, World Health Organization; Wonca, World organization of family doctors. ∗ Corresponding author at: Cesta pod Slivnico 21, 1380 Cerknica, Slovenia. Tel.: +386 41706973; fax: +386 17050552. E-mail address: [email protected] (D. Klanˇcar). http://dx.doi.org/10.1016/j.healthpol.2014.08.014 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
research has provided evidence on benefits of welldeveloped primary care systems, in the field of better coordination and continuity of care and better opportunities to control costs [2,3]. Current tendencies that shape conventional health systems include a disproportionate focus on specialist and tertiary care, fragmentation, and commercialization of health care in unregulated health systems [4]. Although many countries agree on the importance of primary care, its goals have largely not been achieved [5]. In 2008, a new declaration was launched by the WHO [4] in order to implement the PHC principles of justice, accessibility, patient/community involvement, quality care, safety
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and efficiency in everyday medical care at the primary level [6–10]. The declaration stresses the importance of person-centredness, comprehensiveness, integration and continuity of care with a regular point of entry into the health system. Many countries look for appropriate organizational forms to implement these ideas. In the USA, the idea of a community oriented health center has recently re-emerged as a concept of a medical home [11–14]. In Europe, community oriented medical practices are increasingly seen as a method of ensuring that patients have access to the right care at the right time in the right place [15,16]. The countries of the former Yugoslavia have a long tradition of a similar concept which has been considered successful and the most efficient organizational model for implementing these principles [17–19]. They followed ˇ Andrija Stampar’s ideas on community oriented primary care, which was first implemented in 1920s and became a national policy of organizing primary care after the Second World War. According to this policy, primary care centers were established in every commune with the aim of covering a defined area and a defined population. The role of primary care centers was to ensure primary care service, prevention and public health service. There was a free access for all people and some population groups (e.g. children, pregnant women) were given special attention. This system was very effective in solving some of the important health care issues in the first half of the 20th century, but confronted problems by the end of the century [20–26]. Yugoslavia claimed that their health care system was as original as their political system and that it was neither private nor state-run [27]. Since the beginning of the 1960s the policy of primary care faced serious problems. The core problems were: inadequate education of health professionals about health promotion and disease prevention, unsatisfactory economic and social status of primary care professionals and low interest of citizens taking care of their own health through disease prevention [28]. On the other side costs were rising, especially as the volume and intensity of hospital-based care increased. The Yugoslavian system as nominally universal in coverage, health services still were used more by the better-off, and efforts to reach the poor were often incomplete. The 1990s was a decade of major reforms in national health systems. All countries were struggling to develop adequate prevention models to reduce the burden of disease that can bankrupt a national health system [29]. This process coincided with the collapse of political system, when important changes have taken place which is apparent from the economic and political situation (Table 1). In the new circumstances dilemmas about the appropriateness of the concept of health centers have arisen. Furthermore, in many countries reforms introduced new policies in this field. So far there have been only a few articles/documents describing the situation in primary care in these countries after the collapse of socialism [30–40]. To our knowledge, no studies have dealed with these countries in a systematic way. The aim of study is to describe the new role of medical centers and to what extent the principles of primary care are present in ex-Yugoslavian countries.
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2. Methods 2.1. Study design This qualitative study was conducted between 2010 and 2011. The key informant method of obtaining data from persons whose professional and/or organizational roles imply they have knowledge about specific characteristics of the population being studied as well as potential pathways and constraints for community change, was used [41,42]. The informants were suggested by Wonca (World organization of family doctors) national representatives in these countries, except for Montenegro, which was not a Wonca member in the time of the study. In this case, the informants were suggested by the Ministry of Health of Montenegro. The people we asked for suggestions were informed about the nature of the study and asked to name experts and leading specialists in the field of primary care. Two key informants from each of the six countries of former Yugoslavia were invited to participate in the study. They were considered to correspond to the characteristics of the most ideal key informant: they had adequate knowledge of the topic, were willing to participate, were impartial and were able to communicate [43]. They were all general practitioners with academic background.
2.2. Data collection The informants were given a semi structured questionnaire covering the areas of primary care described in the WHO documents: organization and financing of primary care, accessibility, equity and patient/community involvement. We asked for their opinion on planning and financing the contents and extent of contractor’s work in health care related to the health needs of the community in balance with available resources. Quality control and academic status of primary care were also included as well as the role of health centers. The questionnaires, written in English, were sent by e-mail. The terminology used in questionnaire was clear enough to be understood by chosen informants.
2.3. Analysis After the information had been received, the records were transcribed verbatim and organized thematically. In the first data analysis, the answers from both informants from each country were compared by the two authors (D.K. and I.S.) and inconsistencies and discrepancies were identified. In the second stage, the interpretations with a list of inconsistencies were sent back to the key informants with some additional information; in some instances definitions were added (e.g. ‘mostly’ was over 50%, ‘almost all’ was more than 80%) and consensus was sought. When consensus was not possible, this was noted and described later in the paper. In the third stage, the informants were given a draft version of the results and asked to clarify the remaining dilemmas. The final version of the results was then sent to the informants for confirmation. All the informants approved the final version of the results.
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Table 1 EU membership status, GDP, health expenditure and physicians supply in 2009 in countries of former Yugoslavia. Country
EU membership
Great national income per capita (PPP international$)
Health expenditure per capita (PPP international$)
Number of physicians per 1000 population
Bosnia and Herzegovina Croatia FYR Macedonia Montenegro Serbia Slovenia
No Realized in 2013 No No No Yes
8.880 19.260 11.040 12.870 10.890 26.620
934 1.556 763 1.215 1.162 2.551
1.64 2.60 2.63a 2.10 2.11 2.51
Source: WHO data base. Available at: http://apps.who.int/gho/data/?vid=92000# a Data for 2008.
3. Results 3.1. Organization of health care Primary care is declared as a priority in official documents (strategies, action plans, etc.) in all the countries except in Slovenia, where this is declared in the conclusions of expert conferences. The WHO principles of primary care (justice, accessibility, patient/community involvement, quality of care, safety, efficiency) are also defined in official documents of these countries. In addition, health centers are accredited and responsible for the realization and coordination of these objectives. Formal procedures for establishing a primary care organization differ from country to country. In Montenegro, for instance, only the Ministry of Health may establish these organizations, whereas in other countries whether the state, region, local community or an individual can do it, although the formal responsibilities are defined by the state. Health centers and independent practices are the organizational models at the primary level. In Montenegro health centers are the exclusive health care providers of the state funded health care. In Bosnia and Herzegovina and Serbia health centers are almost exclusive forms, in Croatia and Slovenia health centers and independent practices coexist and are both funded by the state. In Macedonia, practically all doctors at the primary level work in private independent practices, meanwhile health centers are rare (Table 2). Most health centers also provide secondary care (e.g. ophthalmology, dermatology, internal medicine) and some (rarely) provide long-term care (e.g. Montenegro). In all the countries general practitioners, occupational medicine specialists, pediatricians, gynecologists, home care nurses and psychiatrists are the providers of primary care. 3.2. Financing In all the countries primary care is predominately funded by the state, usually through the national insurance company. Smaller sources of income may include local community, region contributions or those made by individuals. Payment is mostly made through a contract, based on capitation and fees for service (as in Croatia, Montenegro, Serbia and Slovenia). In Bosnia and Herzegovina the providers are paid by flat rate, whereas in Macedonia they are paid by capitation only (Table 2).
In all the countries organization and financing has changed in the last 10 years. The informants from Bosnia and Herzegovina, Montenegro, Serbia and Slovenia consider the organization of care to be slightly better, but financing is worse than 10 years ago. Only the respondents from Croatia thought that the changes were for the worse in both areas, mainly due to disorganization, fragmentation, lack of maintenance and faulty systems of financing that have led to an increased competition for patients and consumerism. The opinion of the Macedonian respondents was quite the opposite: organization has deteriorated in the last 10 years, but the payment is better, especially for the doctors who have enough patients. 3.3. Role of health centers Health centers were reported to be the providers and coordinators of primary care activities. This was stated in Bosnia and Herzegovina, Serbia and Slovenia. The informants from Croatia mentioned that the health center is the provider and coordinator of the primary medical care activities only in official documents, however the reality is different. The informants from Montenegro reported that it is only the provider but not the coordinator of the primary medical care activities. In Macedonia the health centers have no role in coordinating the work of independent practice doctors. The respondents from Montenegro and Serbia reported that practically all medical care at the primary level is delivered by health centers, whereas the estimate for Croatia was only about 25% and 50% for Slovenia. The Bosnian and Macedonian informants were not able to give an estimate. Team compositions in primary care centers have not changed. Secondary care specialists are still present in health centers (internists, psychiatrists. . .). In Montenegro the centers also provide long term hospital care in remote areas. In general, quality control systems in health centers are the same as at the primary level; only few health centers were reported to be included in quality control projects (in Bosnia and Herzegovina, Croatia, Macedonia, and Slovenia) as later seen in Table 2. The most frequent control mechanism is the financial control through national insurance (in Croatia and Serbia). The informants from Montenegro reported that a health center manager annual report was the only quality control system in health centers. The centers mostly have an association which is a forum for exchanging opinions and has no formal power. In Bosnia
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Table 2 Differences in primary care. Country
Predominant organizational form
Financing
Barriers
Community involvement
Quality control
Education and research
BiH
Health center almost exclusive form Independent practices mostly Independent practices almost exclusive form
Flat rate
Geographic Financial Geographic Human resources Geographic Human resources
No
AC OPC AC OPC AC OPC
Montenegro
Health center exclusive form
Capitation and fee for service
Geographic
No
AC
Serbia
Health center almost exclusive form Health center mostly
Capitation and fee for service Capitation and fee for service
Geographic Financial Human resources
Partly
AC
No
AC IQC OPC SC
Undergraduate and postgraduate Undergraduate and postgraduate Undergraduate, postgraduate only as CME Undergraduate and postgraduate (being prepared) Undergraduate and postgraduate Undergraduate and postgraduate
Croatia FYRMacedonia
Slovenia
Capitation and fee for service Capitation
Partly No
Legend: SC, self-control; IQC, internal quality control; AC, administrative control; OPC, organized professional control.
and Herzegovina and Macedonia, health centers have no formal form of association. In all the countries, the director of a health center is predominantly a doctor of medicine. If the director is an economist or a lawyer, the assistant director has to be a doctor. No specific training is needed for this position, except in Macedonia.
Herzegovina have experienced improvement regarding an increased number of doctors. Furthermore, patients have the right to a free choice of their doctor. In the future an improvement is to be expected, though this is uncertain (Table 2). 3.5. Patient/community involvement
3.4. Barriers, accessibility and justice The respondents from all countries reported about certain barriers in accessing primary care. They include geographical barriers due to transportation, poor roads, old vehicles, bad medical vehicles and long distances between clinics in rural areas (except in Slovenia). In Bosnia and Herzegovina the war devastation of infrastructure was still considered a source of problems. In Croatia family medicine is rather extensively available, but the islands and mountain areas create a problem in terms of availability of primary care. The respondents from several countries (Croatia, Macedonia, Montenegro and Slovenia) did not report any serious financial barriers in accessing primary care. This is still thought to be a problem in Bosnia and Herzegovina with a considerable number of people without health insurance. The respondents from Serbia also reported the existence of financial obstacles, especially in rural areas which are twice as poor as urban areas and where 14.7% of the population are unemployed and have no health insurance. There is a reported lack of doctors in Croatia, Slovenia and partly in Macedonia, where it is more noticeable in rural regions. Only the respondents from Serbia and Montenegro have not seen this as a problem. There was no consensus about human resources in Bosnia and Herzegovina. In most countries the average doctor’s workload is similar and reaches about 1600–2000 patients per GP. The informants chiefly stated that accessibility to primary care had deteriorated in the last 10 years. The informants from Croatia and Slovenia said that the problem of a lack of doctors had worsened in rural areas. The informants from Macedonia mostly described a restricted financial situation, meanwhile those from Montenegro and Bosnia and
In all the countries the activities in primary care are defined by the state, meanwhile local authorities are not involved. Only the respondents from Serbia and Croatia reported that some local communities and regions participate in this area (in preventive programs, health service for tourists in tourist areas) (Table 2). In most cases, the content and extent of provider services are defined by the state or the national health insurance company and medical care providers cannot independently change or extend the range of services (Macedonia, Montenegro, Serbia and Slovenia). In the countries where this is possible, the additional work is not paid for (Bosnia and Herzegovina) or the payment is made by the patient alone (Croatia). The respondents from Croatia and Macedonia reported that patient and community involvement had deteriorated in the last 10 years. The respondents from Bosnia and Herzegovina, Montenegro and Serbia said that patient and community involvement had improved. The Slovene informants observed that there had been no change in this respect. 3.6. Quality of care Four categories of quality control were identified from the transcripts. The respondents identified self-control, internal quality control, administrative control performed by the official bodies (ministries of health, medical chamber and national health insurance company). In this category, the informants from Croatia reported that the control by the national health insurance was by far the most important. In Macedonia only the state performs health care quality control. Respondents from only few countries
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reported to have some organized quality control projects (in Bosnia and Herzegovina, Croatia, Macedonia, and Slovenia) (Table 2). The informants described different methods of accreditations: technical regulations in terms of workplace, medical professional licenses, ISO standards (Bosnia and Herzegovina, Serbia, and Slovenia). In Croatia, Macedonia and Montenegro there are only state requirements for adequate technical standards for accreditation of practices. The main problem of quality control seems to be a lack of expertise (Macedonia) and inadequate quality indicators (Slovenia). The respondents from Bosnia and Herzegovina described financial barriers, namely a lack of money for accreditation process. The respondents from Croatia reported that the main problem with quality control seemed to be that the main controller is the national insurance company, which puts economy in the first place. The control is predominantly administrative and financial. Professional control in its true sense hardly exists. In Montenegro there are no quality demands, except for technical standards and even these are not adhered to. The respondents mostly agreed that a feedback is given on the basis of routine data. Most information is available for health care managers (Montenegro). In Bosnia and Herzegovina, Croatia, Macedonia, Serbia and Slovenia, providers do get a feedback about their work, which is mostly statistical and financial. Generally, there is no professional and scientific feedback information available. The opinions regarding quality control were varied. Informants from Bosnia and Herzegovina, Montenegro and Serbia claimed that it had improved, others described a deterioration (Macedonia), some estimated there had been no improvements (there is interest but no conditions for implementation) (Croatia and Slovenia).
3.7. Education and research In Bosnia and Herzegovina, Croatia, Montenegro, Serbia and Slovenia, education for doctors in primary care takes place at undergraduate and postgraduate levels (Table 2). Only Montenegro does not yet have a formal program of vocational training for family medicine, but t it is being prepared and will start in 2013. The specialization for family medicine is obligatory only in Slovenia. In Macedonia, education for medical doctors in primary care is provided only as continuous medical education (CME). In all the countries CME is organized by medical health associations, the ministries of health, pharmaceutical companies, associations of primary medical care providers, medical faculty chambers, clinics and associations of family physicians. Associations of medical care providers at the primary level exist in all the countries. They are a place for discussion and exchanging opinions. There is no consensus about their actual role. Family medicine is recognized as an academic discipline in all the countries. The informants described circumstances in education and academic work at the primary level in various ways: as an improvement (Bosnia and Herzegovina, Croatia, Macedonia, Montenegro, and Slovenia) and as a stagnation (Serbia).
4. Discussion We have seen that in these countries, which have the same health system and a long tradition of health centers, important changes have taken place. Considerable differences were noticed between the countries. Most of them are due to the predominant organizational form in primary care (Table 2). Three broad categories can be identified: the coexistence of health centers and independent practices (the predominant one), the still maintained exclusivity of the health center and the case where practically all doctors at the primary level work in private independent practices, whereas health centers are being abandoned (in one country). The consensus about an appropriate delivery of medical care to cover the primary care principles no longer exists. Overall, the principles of primary care and health centers are still listed in the official documents, but the implementation of these principles is variable. The countries have been faced with the challenges of fragmentation and commercialization, which is in conflict with the principles of primary care. It seems that inconsideration of these principles has been the most evident in the countries where independent practices are the predominant model. Financing is centralized in all the countries, which all struggle to maintain a stable financing of the health care system. It can be said that the countries have managed to keep the principle of accessibility and equity, but the economic crisis seems to be eroding this as well, because the countries are unable to cover all the costs of health care. Therefore, outofpocket payments and people who cannot afford primary care are becoming a reality, especially in poorer countries. The content and extent of provider services are defined by the state. There is very little community participation, which is supposed to be a hallmark of quality primary care. Quality control practically seems to be done only by the payer in almost all the countries. Obviously, there is little consideration for primary care expertise and, moreover, health centers have no influence on policy makers. Academic primary care has a strong tradition in Croatia and Slovenia [44,45] but it struggles to develop also in other countries, although even these countries aspire to introduce academic primary care. The position of health centers has changed considerably: health centers in some countries (Croatia and Macedonia) have lost their predominant role in the primary care. The second group includes two countries where health centers have maintained their virtual exclusivity as the only organizational form at the primary level, nevertheless, they have also included specialist and even hospital care (Montenegro and Serbia). In these countries, health centers have developed into almost Semasko-type polyˇ clinics that have little in common with Stampar’s idea of community oriented primary care. The countries in the third group try to reinvent the new role of health centers, but they struggle to do so (Bosnia and Herzegovina, Slovenia). Every qualitative study brings concerns about the validity and relevance of respondents’ perceptions. This is
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especially true when questions are raised about healthcare services. There is a danger that the opinions become politicized, without being supported in a rigorous scientific approach. The key informant survey, based on the WHO principles of primary care, is a reflection of opinions by the key primary care professionals in the countries we have covered in the study. It is aimed at gathering information and ideas that need to be validated in further research. The wellknown limitations of the key informant strategy [46] still need to be considered. By adhering strictly to the principles of the methodology, we have minimized these risks. On the other hand, the two key informant method used in the study has proven to be effective enough to get a global insight into the primary care systems in the researched countries. We therefore feel that the survey has fulfilled this goal and given us valuable ideas for future research in this area. Further quantitative validation is necessary to find out whether the statements reflect the beliefs of key informants or whether it is an accurate account of the situation. In order to do that, this study needs to be followed with quantitative analysis of the healthcare systems, probably by using some internationally available dataset, aimed specifically at primary care [47]. 5. Conclusion Bearing this important limitation in mind, one can say that in the changed systems of the former Yugoslavia, the principles of primary care still formally exist in all the countries. However, the changes in their systems have led to the development of different policies and practices that are often very different from the declarations that are accepted. From the information we have received, we could not identify a unique pattern of covering primary care principles in different organizational forms. The extent of the principles in the countries where health centers are still the exclusive or predominant organizational form is comparable with the countries where only independent practices exist. The most critical area seems to be the area of community involvement. The impact on planning and financing the content and extent of contractors’ work in health care related to the health needs of the community in balance with available resources received least attention. From the information we have received, we see that policies of primary care should take into account the community orientated health centers, which have a long tradition in these countries. Conflicts of interest All authors declare that no conflicts of interest exist. Acknowledgments We are grateful for the contributions made by the key informants from six southeastern European countries: ˇ Obrdalj and Melida Hasanagic´ from Bosnia and Edita Cerni Herzegovina, Milica Katic´ and Dragomir Petric from Croˇ atia, Ljubin Sukriev and Zoran Stojanovski from Macedonia,
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