Recently, the Union of Doctors and Pharmacists announced that about 6.000 doctors have left Serbia in the past ten years and that this negative trend continues. Statistically, there are 283 doctors per 100.000 inhabitants in our country, which is significantly below the European average, and that number could soon decrease further. Are years of bad health policies now yielding final, cataclysmic results? Will there be someone to treat the citizens, those who do not have enough money for private or foreign clinics?
We talk about the state of the healthcare system in Serbia, and not only in Serbia, with expert Predrag Đurić, who is an epidemiologist by profession and the first doctor of medical sciences in the field of public health at the University of Novi Sad. In one period, he was the head of the Department of Epidemiology at the Faculty of Medicine in Novi Sad, and he worked as a consultant for several international organizations. He currently teaches at the University of Wolverhampton, England.
"Serbia has already experienced its cataclysm, only no one told her about it. With the coming to power of Slobodan Milosevic, a stake was driven into the heart of modern, European Serbia. Everything after that is just more or less painful nuances. It was Milošević who installed imperialist nationalism (today we would say – a trial balloon for what has been happening in Russia for the last two decades) and his government abolished social ownership of property and started privatization. Not to mention bloody wars and war crimes. Subsequent governments, until one, followed that ideological matrix - the transfer of social and then state property and, finally, a significant part of the budget into private hands, under the guise of some concern for the people and the territory or economic development. Health was just one, but perhaps the most impressive collateral damage," says Predrag Đurić at the beginning of the interview with "Vreme". "I believe that today's healthcare system survives as much as possible only thanks to humanity, the extraordinary efforts and sacrifice of healthcare workers. We can give them a lot of well-deserved criticism, but we must not forget the kind of system they work in. I would blame them primarily for not fighting. But knowing the challenges they face every day, I partly understand them."
"WEATHER" What are the key reasons for the departure of doctors and other medical workers from Serbia, except for low wages? In one research, you stated that in Novi Sad, one selected doctor takes care of about 2.700 patients. From what I understand from your analysis, he would have to work as much as 23 hours a day to provide quality service to his patients!
PREDRAG ĐURIĆ: One of the factors is: the impossibility of providing maximum quality health care to all citizens and reducing it to providing either the most necessary, for life-threatening patients, or lower quality health care, or not providing it at all - for example, through long waiting lists or non-conduct of preventive examinations. Certainly, this is also the reason why health workers go to places where there is a greater opportunity to provide better health care, but also to achieve their professional goals, to improve themselves and to progress in their careers, in institutions and in a system where obedience, loyalty and "seeing one's own job" are not the only criteria for employment, successful work and advancement. The majority of health workers, as well as others, are honest, educated and intelligent people, who certainly find it difficult to submit to party mediocrity - I'm talking about all the authorities from 1988 to the present day - and people devoid of any integrity. You only have to look at how many personnel from Milosevic's era are today in leadership positions in healthcare, and how many of those who replaced the jersey of the Democratic Party, Democratic Party of Serbia or G17+ with such charming ease with the jersey of one of the ruling parties today.
However, not all reasons for going abroad are related to the profession. It is difficult to live in a country that is constantly on the brink of armed conflict, in which no perspective is offered beyond subservience to the ruling party (both current and previous), in a country that is heavily armed and in conflict with neighboring countries, that is preparing to re-introduce of military service, in which national hatred, intolerance towards dissenters and those who are different, in which war criminals and crimes are glorified, in which pseudo-religious organizations create curricula and in which a significant percentage of the population succumbed to decades of Kremlin and pseudo-holy propaganda. Perhaps the most difficult thing is to watch the passivity, silence, patience and abandonment of those closest to you. Putinism is rapidly and finally consolidating in Serbia, and this is not something that any reasonable person who has an alternative would wish for their children.
When it comes to the percentage allocation of budget money for healthcare, where Serbia is in relation to developed countries? This is often cited as a problem.
Immediately after the Fifth of October, there was a drastic increase in allocations for healthcare from public sources, so according to World Bank data, in 2002, more than 72 percent of all expenses in healthcare in Serbia were paid with "state" money (budget, health insurance). 24 percent from citizens' pockets, and the rest from other, mostly international sources. In the following years, when the G17+, personified by Minister Tomica Milosavljević, led the health sector, there was a drastic decline, so that in the period from 2006 to 2012, public funds covered about 62 percent of health-related costs. After 2012 and the establishment of a new government, there is a further decrease in the participation of public funds in the financing of health care, with a record low in 2017, when only 57 percent of health costs were covered by funds from public sources, and citizens paid 41 percent out of their own pockets.
photo: Milan Stojanović...
Record public allocations for healthcare in terms of percentage of gross domestic product (GDP) were recorded in 2002 and 2008 (5,7 and 5,9 percent), and in the period 2012–2017. drastically and continuously decrease to a minimum of 4,7 percent of GDP. Although the situation after 2018 is somewhat better, according to these indicators, it is nowhere near what it was before 2012. For example, in 2020, in Serbia, 5,3 percent of GDP was allocated for healthcare from public sources, while in Germany and France around 10 percent was allocated, and at the EU level 8,4 percent. On the other hand, in 2020, the French paid only about 9 percent for health care out of their own pockets, the Germans about 12, at the EU level it was slightly less than 16 percent, and in Serbia 36 percent. However, the real picture is obtained when looking at Serbia's lagging behind the European Union through the percentage of GDP allocated to health from public sources. Thus, in 2002, Serbia lagged behind the EU in public allocations for health by 0,76 percent of GDP, in 2012 it was 1,51 percent, in 2017 it was a tragic 2,68 percent, and in 2020, for which the latest data are available, it would lag behind by record levels. 3,06 percent of GDP.
These indicators indicate that healthcare in Serbia is probably not a priority for the government. Unfortunately, it seems that there is neither the determination of the government nor the determination of the opposition for greater implementation. Health care, as we have seen, was not the topic of the previous elections at all. But let's remember that this is something that the majority of citizens who go to the polls vote for. The consequences are insufficient availability of health care and a negative impact on its quality, i.e. forcing citizens, those who can afford it, to seek help in the private sector and pay for services out of their own pockets.
What are the other problems of the Serbian healthcare system?, apart from the lack of staff and money and the social environment you talked about?
I would say that a major problem is the absence of a clear and elaborated vision, around which professional and general social consensus has been reached, in which direction the reform of the health care system should move. The question is how much capacity there is for that in the competent health bodies, but also in general both in the government and in the opposition. In Serbia, there have been ongoing election or mid-election processes for years, and all this affects instability and insecurity. Fortunately, it seems that the further centralization of the health system through the merger of numerous institutions, which was proclaimed a few years ago, has been abandoned. However, local self-governments were almost completely deprived of competence in the area of health care, and I am afraid that the development of capacities that would implement local health policy was also not taken into account.
Health institutions traditionally function like military institutions - with a distinct hierarchy and subordination. To that should be added the trend of corporate management developed over the last two decades, where directors are now some sort of managers whose main task is to reduce spending and keep workers under control, as well as, if possible, to make a profit. Under such circumstances - hierarchy and management instead of cooperation and leadership - it is difficult to make quality changes, and the system itself favors the emergence of opportunism, mediocrity, and careerism. Certainly, a lot could be said about the public procurement system as well if we were to engage in a deeper analysis. But also other problems...
During the pandemic, but unfortunately also after it, the healthcare system proved to be completely unprepared for modern forms of communication with citizens, including communication via the Internet and social networks. It is still mostly communicated through military-style press releases, so it is not surprising that citizens are primarily informed by conspiracy theorists. Overall, the healthcare system seems to have been completely dominated by defeatism, chronic fatigue and resignation.
On the other hand, One of the main points of the continuous political campaign of the ruling SNS and Vučić is photography, that is, the opening of renovated and new health facilities and procurement of medical equipment?
Facilities and equipment certainly represent important conditions for enabling health care, but they are neither the only, nor often enough, to provide overall health care to everyone who needs it, when it is needed - and of the highest possible quality. In addition to sufficiently qualified and satisfied health workers, vision, organization, programs, especially preventive ones, as well as monitoring and improvement of the quality of health care, are also necessary. However, buildings and equipment are the only things that can be photographed, so it is not surprising that they are so popular among politicians. Successful prevention programs often produce results only after several years, which is too much for one mandate. That is why they are insignificant for most politicians.
Are those who say that the citizens of Serbia and the entire region are completely unequal in access to healthcare?? Those who have money have adequate protection, and the others are left at the mercy of public institutions.
The aforementioned data on how much citizens spend out of their own pockets indicate that many, if not most, are forced to pay for necessary health care. Of course, those who cannot afford it are condemned to live with an untreated disease. Therefore, it is not surprising that, according to United Nations data, the number of expected years that sixty-five-year-olds can expect to live on average in Serbia is among the lowest in Europe: men 12,2 and women 15,1. Only citizens of Bulgaria, Ukraine and Moldova (for men and Georgia) can hope for a shorter life in Europe, and in the leading European countries the expected remaining life expectancy of sixty-five-year-olds is almost ten years longer than in Serbia. In the absence of a vision, organization of health care and adequate funding, almost all attention is paid to treatment and minimal to prevention, and this is, unfortunately, to a large extent the health education system, which educates doctors and other health workers with little awareness of the importance of their role in health promotion and disease prevention, not just treatment.
And to what extent do the citizens of Western countries also face this problem?
The situation in the world rests on the same foundations, but in a slightly different realization. Namely, already during the seventies of the last century, neoliberal theories and practices in the economy began to be imposed, which were then inevitably reflected in healthcare and remain dominant to this day. This approach implies treating healthcare as a budgetary consumer and, consequently, measures should be primarily focused on savings. At the same time, all responsibility is shifted from the now almost non-existent society to the individual - it is claimed that everyone is responsible for their behavior and the consequences it brings, and health disorders (for example, obesity or the consequences of smoking) are seen as a well-deserved punishment for an unhealthy life , and not on the consequences of numerous social factors that promote the emergence of the disease (impossibility of education, poverty, lack of support, etc.) from a weakened, impoverished and overworked citizen, who no longer has time even for his family not even for himself, now he is expected to find ways to eat healthy, be physically active, take care of mental health... All this with the aim of depriving the institutions of responsibility, and therefore of funding, which is then directed into other streams - for example subsidies to private companies.
The countries on the western side of the "Iron Curtain" fared relatively well. In fear of communism, the governments of these countries in the first decades after the Second World War were forced to "buy" their citizens a relatively high-quality health care system, which nevertheless proved to be somewhat resistant to neoliberal attacks, especially in the eighties and partly in the nineties of the last century (but not and in the wings of neoliberalism - the USA and Great Britain). The countries on the other side of the "Iron Curtain" rushed right into the jaws of neoliberalism in the 19s, and the same thing happened in Serbia after the Fifth of October. Instead of combining the best achievements of socialism and Western democracy, there was deregulation, liberalization and, of course, privatization, which finally ended in an ineffective system of public health care, almost complete privatization of certain segments (dentistry, pharmacies), various prohibitions or controlled approval specialization, employment, severance pay, and even privatization of the pharmaceutical industry, the disastrous consequences of which were particularly visible during the recent pandemic. Should it be surprising that these former countries of "people's socialism" had the worst time during the covid XNUMX pandemic?
During the pandemic, there was a real explosion of conspiracy theories. The pharmaceutical industry played a leading role. How many of those theories actually have foundations in reality? And how much did the problems you are talking about affect citizens' distrust of traditional medicine, which is most reflected in anti-vaxxers and the flourishing of alternative treatment methods?
It seems to me that there are several types of conspiracy theories. Some are induced from certain interest centers with the aim of subverting existing systems and ideologies (for example, numerous Kremlin narratives), and others, traditionally, are based on ignorance and available half-information or the inability to correctly interpret information (although everything often happens together). The pharmaceutical industry today is part of the capitalist system, just like any other industry. However, one rarely hears conspiracy theories against, say, the automotive or arms industry, or the chemical or food industry. I believe that their actions do much more harm to society. It is therefore an interesting question why the pharmaceutical industry stands out so much. At the same time, most of those who believe in these theories completely ignore the fact that the largest number of pharmaceutical billionaires are of Chinese origin. Rather, it seems that it is only an easy target for anti-Western propaganda.
As mentioned, in the conditions of the market economy, everything is a commodity, including medicines and health and personal data of citizens, and profit is the only driving force of business. The problem in the former countries of "people's socialism" is that, at least those generations that lived before the fall of the Berlin Wall, witnessed and accepted the state's concern for their health, among other things, through free health care. Voting in a plebiscite for capitalism, they agreed to give up all of that, including state or social ownership of the pharmaceutical industry. Unfortunately, there is no such thing as capitalism with a human face, nor is there such a thing as soft, sensitive capitalism. Swedish standards, Hollywood soap operas, soft drugs, human rights and rock and roll - they were all Trojan horses in the fear of communism.
On the other hand, in recent decades we have witnessed great achievements in the treatment of many diseases. The pharmaceutical industry is largely responsible for that. Medicines cannot be produced in a garage or in a shack or in one's own apartment, even the vast majority of medicines that we know and use today. Therefore, the pharmaceutical industry is one of the most important factors in modern health care. I am personally of the opinion that the production of medicines, vaccines, diagnostics and medical equipment should be socially owned. These are strategic resources, such as water, air, land... The availability of medicines and the speed of research should not depend on market interests and profits. Health is a public good, and so are medicines and vaccines.
In an interview, you said that distrust in the health system and traditional medicine is actually a consequence of a general decrease in trust in institutions?
Distrust in the pharmaceutical industry and, more and more often, more and more loudly and rudely, and in healthcare workers, is a consequence of the growing distrust in state institutions. Namely, for decades, the term "state" meant state institutions formed to work in the interests of citizens. Then, when it became clear that this is no longer the case, that they work primarily or exclusively in the interest of the government (when the "state" became equal to the government), that is, of the interest groups that stand behind the government or with it, many citizens, especially those who found themselves on the margins of society or those deeply disturbed by the collapse of the state as it was perceived until then (the appearance of a "stolen" state), and under the influence of the mentioned factors, they indiscriminately directed their indignation at those who can defend themselves the hardest. However, let's not forget the great commercial interest behind numerous sellers of fog and some alternative ways of treatment. It is also a very developed industry.
In any case, if we agree that today's pharmaceutical industry is driven by profit, the financial dependence of health workers, professional associations and institutions (through various privileges, benefits, direct or indirect funding) on pharmaceutical companies becomes ethically questionable. It is impossible, and probably harmful, to break the ties between those two parties, but it is necessary to regulate this area, to reduce to a minimum the commercial influence on health workers and to oblige each of them to publicly declare their connection with certain pharmaceutical companies, with the elimination of sponsoring or any compensations, except for scientific and research work. At the same time, the authorities must more generously support the continuous medical education of health workers so that the current funds spent by pharmaceutical companies on, say, professional education, are replaced by budget funds.
At the end, speaking of conspiracy theories, what do you think about the phenomenon of Branimir Nestorović?, which is in the spotlight these days?
I see Dr. Nestorović's social and political engagement as a marginal and irrelevant phenomenon. Only great media attention, unfortunately also from pro-opposition newspapers, gives it importance. It's the same thing as with, say, Rio Tinto and lithium. It seems to me that all of this primarily serves to confuse and divert attention from key topics. And when it comes to Serbia, these are human, civil and political freedoms, wild and unregulated capitalism, clero-nationalism, revision of the past, organized anti-Westernism and the malignant influence of Russia and China. Of course, it would have to be completely unacceptable for any healthcare professional to advocate unscientific views and there would have to be sanctions for that. The same as for any case of stigmatization or discrimination.
