In a country where citizens shell out large sums of money for health insurance, tens of thousands of people still wait years for basic medical interventions. During that time, the President of Serbia proposed populist and long-term unsustainable measures. Is there a cure for endless waiting lists?
"I went for my first examination in 2017. I operated on my first knee at the Military Medical Academy in 2019, when I was promised that in six months I would operate on another. However, first the implants disappeared, and then the coronavirus pandemic hit. My doctor has since retired. I waited for the second operation until 2023, so a total of six years passed from that first examination to the moment when I had both functional knees," a pensioner whose name is known to the editors told "Vreme".
One might be surprised by the fact that it is a man waited an average of three years for knee surgery on one leg. Someone else would have exclaimed: "Six years for two knees!" Well, that's nothing!"
And he would be right. At the moment of writing this text, 19266 people are waiting for the installation of a knee prosthesis in Serbia. There are 12886 people waiting for a hip prosthesis. Officially, there are a total of 56998 people on waiting lists in Serbia, according to the records of the Republic Health Insurance Fund (Tuesday, November 19).
At the bottom of the list at the Military Medical Academy is a person enrolled in 2017 - she will receive a prosthesis, if nothing changes, in 2031. By the time it's his turn, a decade and a half has passed.
How then did the interlocutor of "Vremen" manage to operate on both knees in a mere six years? The answer is - extremely strong connections that speed up the whole process.
And so we come to the question - if someone with a thick backside needs six years and countless calls and examinations to operate on two knees, what is left for the ordinary citizen, left at the mercy of the system? What can the average person do, condemned to swallow painkillers and wait their turn? Hoping that, maybe, one day they will meet him.
NO WORRY, THE SOLUTION IS COMING
After 12 long years in power, Serbian President Aleksandar Vučić finally realized that endless waiting lists are a serious problem for the Serbian healthcare system.
"For us, those waiting lists are not decreasing, which is why I was shocked. I asked the Minister of Health, Zlatibor Lončar, why we built entire hospitals if nothing is being done in them to reduce the list. The waiting lists are scary, I didn't believe it myself", the president was surprised at the beginning of September, and then announced the solutions.
It will be until the end of the month, he promised. Then, however, he traveled to New York on business, leaving the Minister of Health, Zlatibor Lončar, to take care of his department without supervision - which is too much for a minister, after a decade of ministry. Faced with the question of how to abolish the waiting list, Lončar cried that he will have the answers after the president returns from the white world.
"I need his help. Together we will make a plan. The result will be that we have no or minimal waiting lists. I would like the citizens of Serbia to support us in this", said the Minister of Health for RTS.
However, the president returned to Serbia, and the waiting lists remained - pending. Until October 18 and the announcement by Tatjana Pašić, MP of the Freedom and Justice Party, in which she reminded Minister Lončar that Vučić had long since returned from his North American trip, and that there was no sign or voice of the announced joint solutions.
At first, this angered the relevant minister, and then the president, who a few days later suggested (read: tried to order) journalist Zoran Stanojević in a broadcast on RTS to ask him about the lists. Although colleague Stanojević did not do so, Vučić certainly gave an answer to the unasked question. After 12 years of deep consideration, it was decided that this serious systemic problem will be solved - with supplementary work, on Saturdays in two shifts. Although, what could be expected from the president, a known vacation hater, besides "more work"?
A month later, everything remained on the president's words. The Ministry of Health has still not adopted concrete measures. It is not known whether and when he will do it. "Vreme" did not receive an answer to that question until the end of this issue.
A SHORT JOURNEY TO THE PAST
Why, however, is additional work not the right solution to the problem that has been settling in healthcare for a quarter of a century? There are two main reasons, Dr. Draško Karađinović from the self-financing non-governmental organization "Doctors Against Corruption" explains for "Vreme".
"It is simply unbelievable to me that the president is talking about supplementary work again, within the framework of the existing legal norms. Let's remember the monstrous affair of trade in waiting lists at the Institute of Oncology of Vojvodina in 2009. Then, by law, a group of directors organized supplementary work, and those who could pay were irradiated, while those who could not pay were not irradiated. We are talking here about the most serious diseases", says the interlocutor of "Vremena".
For those who do not remember this affair - more than a decade ago, an investigation was launched against a group of directors of the Institute of Oncology of Vojvodina due to the suspicion that they enabled supplementary work to be organized at the Institute and that foreign nationals were added to the waiting list for radiation therapy. After the case became public, in 2011, the Department for the Suppression of Economic Crime submitted evidence to the Public Prosecutor's Office in Novi Sad for indictment against the Institute's managers. However, three years later, the prosecution determined that there were no grounds for prosecuting those responsible for the alleged trade in waiting lists. In the end, there was no legal epilogue.
What guarantee do the citizens of Serbia have that a similar case will not happen again?
The second reason lies in the paradox - if you work less during regular working hours, you will be rewarded, explains Dr. Karađinović.
"The introduction of supplementary work on weekends also means that some branches of surgery that work well and do not have waiting lists will be penalized compared to surgical branches that have low productivity and waiting lists. The less you work in public health and the longer the waiting list, the more likely you are to have additional work and be paid for it. On the other hand, those who do well and don't have waiting lists - well, nothing. It is absurd", he adds.
POPULIST MEASURE
Then why did the president of Serbia propose supplementary work? By the way, adding that it will cost the state a lot.
The interlocutor of "Vremena" believes that it is a populist measure. "I think that the president is extremely attentive to research and polls, that he saw that the citizens were dissatisfied, so he offered some instant solutions," says Dr. Karađinović.
Indeed, numerous public opinion surveys show that when it comes to citizens' dissatisfaction, healthcare is always at the top. In the Demostat survey published in 2023, as many as 56 percent of respondents stated that they were "mostly dissatisfied" with health care. The survey conducted by CeSID-USAID from 2018 to 2021 showed that the largest percentage of citizens consider healthcare to be the most corrupt system in Serbia.
Constantly bad numbers gave Vučić a reason to, after years of Lončar's unfulfilled promises to abolish waiting lists, finally get involved in the issue himself. In the end, the long-announced solution on which the Minister of Health and the President of the State worked together turned out to be very superficial. Does it take 12 years for someone to get the idea that they "must" work more?
LEGALIZED CONFLICT OF INTEREST
At the same time, Vučić is not the only one who offered a solution. A month and a half before the President of Serbia explained to the citizens on public service that their problems will be solved by the additional work of doctors, the association "Doctors Against Corruption" in an appeal addressed to Vučić stated concrete steps that could be taken to heal this cancer of Serbian healthcare. Despite the fact that the steps were announced by the profession, to which the president in some other areas wholeheartedly appeals, the proposals of the Association remained unanswered.
The steps are, at least on paper, quite simple. First, the amendment of Article 60 of the Law on Health Care, which would abolish the possibility of supplementary private work by a state doctor, says Dr. Karađinović.
"Waiting lists are a systemic problem in Serbia. The Law on Health Care allows a state doctor to work in the private sector at the same time. The doctor does not do what he could do before noon in the state hospital, but puts him on the waiting list, and then refers him to the private sector, where he usually works himself - more precisely, he refers the patient from the state hospital to himself. It is completely clear to everyone that this is a legalized conflict of interest."
This phenomenon has been discussed before. In March of this year, the then Minister of Health, Danica Grujičić - she did not live to see the new mandate - said that she believes that waiting lists for operations are created deliberately so that people would pay for them privately. These are fabulously high prices for the average person's pocket. For example, the aforementioned installation of a knee prosthesis, which is covered by the Fund in state hospitals, costs from 600.000 dinars and upwards in private clinics. The second step would be an amendment to the Law on Health Insurance, which would imply the integration of the private health sector into the RFZO, through the financing of the basic package of services. This, adds the "Vremena" interlocutor, would mean the demonopolization of healthcare financing. In other words, it would allow the average citizen to go to both state and private doctors with his health card, and the money from the contribution would accompany him.
"That would significantly reduce the potential for corruption. As soon as you introduce the principle of competition and productivity, you immediately reduce the possibility of corruption", emphasizes Dr. Karađinović and states that some other countries in transition, such as the Czech Republic and Slovakia, have successfully introduced this model.
TOP OF THE ICEBERG
However, although the association's proposals are reasonable, they would solve only part of the problem. All these problems cumulatively have the effect of increasing the number of people on waiting lists. For example, in some cases, the speed of the operation does not depend on the doctor himself. One surgeon from the interior, who wished to remain anonymous, tells "Vreme" that the waiting list for surgical interventions is minimal in the hospital where he works. He adds that patients often wait longer for their turn for an MRI or scanner, which are overbooked, than they wait for the surgery itself. He cites the lack of radiologists as the reason. At the same time, the aforementioned hospital has two magnetic resonance imaging units that work in two shifts. During the day, one MRI can be used by up to 10 people, which has an additional negative effect on the number of people waiting.
This interlocutor also says that he is aware that in his hospital, as well as in the whole of Serbia, there are the longest waiting lists for orthopedic procedures - hip and knee prostheses. When asked if lists are created artificially in that hospital in order to increase the volume of work in the private sector, he says - no.
"Of course, I can't claim anything for the rest of Serbia, especially for Belgrade. But in our city there is no private clinic where these operations can be performed. The only address for such a thing is the state hospital," the surgeon points out.
As potential reasons for the huge waiting lists for orthopedic procedures, he cites the possibility that there is an insufficient number of prostheses, and that they are, at the same time, extremely expensive.
IS THERE A MEDICINE FOR HEALTH?
Health services are expensive, which was also discussed by the Minister of Health Lončar in June, with the proposal that in the future every patient should receive information on "how much it all costs" upon leaving the state hospital.
"They will not pay for it, but they should know", said the minister at the time.
The assumption that citizens do not know how much treatment costs is offensive in itself. The average gross salary in Serbia is 133373 dinars. Of that amount, 46750 dinars go to taxes and contributions to the state, of which 13736 dinars are allocated only for health insurance from the average salary. That is, on an annual basis, about 1400 euros per capita. In addition, the state's investments in healthcare are huge - only in the recent rebalancing of the budget for the year 2024, an additional 20 billion dinars are foreseen for healthcare. Where does the budget come from? From taxes, contributions and levies paid by citizens.
Officials boast of the largest investments in healthcare in the history of Serbia, but the results are persistently lacking. Change, apart from a superficial make-up, is not even in sight.
"Wrongly set systemic solutions have created a strong corrupt scheme of interest groups in the healthcare itself, in the bureaucracy of the regulatory bodies of the Ministry of Health and RFZO and political structures connected to business circles. The change in health care would have to come from the outside, because the health system itself does not have the strength to do it," concludes Dr. Draško Karađinović.
Finally, the government's measures are best illustrated by one piece of data. In September, Minister Lončar boasted that the waiting lists for CT scanners in the whole of Serbia had been abolished with additional work during one weekend.
On November 18, 226 people are waiting for the same service. Of course, at the level of the whole of Serbia, this number is not large. But he, day by day, slowly but surely - is growing again.
Although the official data of the Republic Health Insurance Fund states that there are currently around 60.000 people on the waiting lists for healthcare, Dr. Karađinović believes that the real number is much higher.
"There are still many services that are waiting for, which RFZO does not keep records on its website. These are, first of all, services in ambulatory medicine, which also affect people terribly. When will you be able to do a biochemical analysis at the health center? Very difficult. There are also dentists, gynecologists... People have long since left these services, for which they normally pay contributions, to the private sector," he points out.
Official data from the Institute for Public Health of Serbia "Dr. Milan Jovanović Batut" show that around 700.000 citizens of Serbia - that is, more than ten percent of the population - do not have a single tooth.
"And that is a type of disability. Those people are entitled to two prostheses at the expense of the Fund. When are they going to get those braces? Never. There are a million other services in healthcare that the Fund does not list", concludes the interlocutor of "Vremena".
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