Serbian
MEDICAL CARE S P E C I A L
E D I T I O N
2016
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TEST WITHOUT RISK Our genetic basis consists of two sets of 23 chromosomes. In certain cases, an error occurs in the formation of these basics, leaving the baby with a surplus or deficit of chromosomes (aneuploidy). Nature has arranged for the vast majority of these genetically defective foetuses to be rejected, but occasionally a child is born with intellectual and physical development problems. Because of this, routine screenings are carried out to determine the individual risk pregnant women for the most common aneuploidy. These are the double, triple and Q tests.
ROLE OF SCREENING TESTS One of every 156 live births has a chromosomal abnormality, with up to 80 per cent of these abnormalities relating to the so-called trisomy 13th, 18th and 21st pairs of chromosomes and aneuploidies sex chromosomes. Screening tests are tasked with separating pregnancies with an increased risk of these disorders, in order for follow-ups with other methods to confirm whether these abnormalities are really present in the foetus.
NON-INVASIVE METHOD DETECTS ANOMALIES The new generation of prenatal tests, such as the Tranquillity Test, separates the foetal (baby) DNA from a sample of maternal blood, then detects whether there is extra chromosomal material that is the result of excess chromosomes and reveals its origin. In this way it can be accurately determined whether or not the foetus has the tested chromosomal abnormality. The test is carried out from the 10th week of pregnancy, while the non-invasive method involves only taking a blood sample from the pregnant women, thus ensuring there is no risk of miscarriage.
EFFECTIVENESS OF SCREENING The effectiveness of certain screening tests are based on the detection rate (the percentage of detected faults compared to the actual number of foetuses with disorders) and the rate of falsepositive results (indicating high risk, while the foetus actually has no disorder). The real rate of detection of current screening methods is 80-90%,
whereby a foetus really has a disorder in one of every 25-29 screenings of positive cases. In all positive cases, it is advisable to reach a definitive diagnosis by conventional chromosome analysis (karyotyping) of materials obtained by the invasive prenatal procedure.
HIGH DETECTION RATE Non-invasive prenatal testing is very reliable. Various tests in this group have a detection rate for Down’s syndrome of over 99%. Specifically, the detection rate with the Tranquillity Test is 99.9%, with a false positive rate of 0.01%. The crucial advantage is its extremely low rate of false negative results and better identification of cases in which invasive testing should be considered. With this, the number of invasive procedures is reduced significantly, and along with that the complications they cause. However, one should not rule out the double test, primarily due to the ultrasound examination, which is its essential part and is very important for the diagnosis of major structural anomalies, predictions of pre-eclampsia, conditions of raised blood pressure of the mother, or a halt in the development of the fetus in the early stages of pregnancy.
FOR WHOM IT’S RECOMMENDED All mothers aged over 35, or if the screening test is positive. It is good to do the test if the ultrasound identifies an increased risk of aneuploidy. Testing is also recommended when the risk measured by the double test is moderate (according to international standards, that is between 1:100 and 1:2,500), because in that way a significantly higher number of affected foetuses are detected and at the same time the number of unnecessary invasive procedures is reduced. Although the risk of miscarriage in invasive procedures (CVS, amniocentesis) ranges from 0.2 to two per cent, for a number of pregnant women, especially those with high-risk pregnancies or pregnancies resulting from in vitro fertilisation, the risk is too great and, as such, the Tranquillity Test is a good solution.
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INTERVIEW
PROFESSOR VIŠESLAV HADŽI-TANOVIĆ M.D., cardiologist
Private Practice
■ By Ivan MIŠKOVIĆ ■ Photo: Zoran PETROVIĆ
STILL NOT RECOGNISED
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here isn’t a country in the EU that has not incorporated private health care practice into the mandatory health insurance system. There are different formats in existence and they are all performing well. We don’t need to invent something new in this area but just implement one of the systems that is the most fitting to our country’s economic potential. If we are talking about the developed EU countries, there are the German, British, French, Norwegian and other models to apply. As for our neighbours, we can implement the Slovenian or Macedonian format. Any of these will do as long as we finally transcend this 70-yearold ancient model of the monopolistic Communist health insurance which violates patients’ rights – says the famous cardiologist and president of the Serbian Medical Association of Private Doctors professor Višeslav Hadži-Tanović, M.D., at the beginning of our interview.
• Could you rate the results of the private practice in Serbia considering it has been in existence for a quarter of a century? - The situation in the Serbian health care sector is worse now than it was in 1990. The political regimes that have
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When asked about the strategy of the Serbian Medical Association of Private Doctors, Dr HadžiTanović had the following to say: “One of the Association’s main strategies is continuously providing professional training for private practice doctors. The first private medical practice conference was held in Belgrade, on 27th April, 1990. The second one was held in Herceg Novi, Montenegro, in 1991. In the last 25 years we made sure that we had conferences every year and we brought the top experts from all over the world to participate.”
been in power in Serbia for the past 25 years were not interested in changing health care. They have been hampering the development of the private sector by isolating it from the health insurance system and discriminating against it, while at the same time, they have violated patient’s rights to freely choose the insurance, doctor and treatment anywhere in Serbia.
• Could you remind us what was it like when you started private practice in Belgrade a quarter of century ago? - It was the patients who dispelled the
Private medical practice in the former Yugoslavia and Serbia was reinstated when doctor Višeslav Hadži-Tanović opened the first private clinic – “International Heart Clinic, Dr Hadži-Tanović” - at 43 Hadži-Milentijeva Street, near Belgrade's St. Sava Temple in 1990 doubt that private practice could not be successful and they were the ones who couldn’t wait for private medical practitioners to be allowed to work again. I remember an older lady from Belgrade who came for a check-
up to my office back in 1990 who said: “You know, doctor, back in the ‘old’ Yugoslavia, prior to World War II, we had our family doctor who had a private practice in our street and this is what we have been missing all along. Thank you for opening a private clinic and for being brave enough to bring our private family doctor back.” After the print and electronic media reported about the opening of the first private clinic, we had patients coming from all over ex-Yugoslavia.
• How did other medical professionals react? - At first, the medical professionals, who had been raised in Communism, were skeptical and did not believe that private medical practice would survive in competition with the state-run health care system. They were particularly skeptical about patients opting to pay a private doctor considering that they already have health insurance paid by the state. I remember some of my colleagues, also cardiologists, coming to check whether I really had any patients and them being pleasantly surprised when they saw for themselves how many people were actually came to see a private doctor.
• Back then you were advocating huge
cardiology clinics, followed by gynaecological, ophthalmic, dermatological and psychiatric clinics. Community health centres are also being opened, which is a foreign concept elsewhere in the world. In terms of private hospitals, the majority of them are practicing plastic surgery, gynaecology and ophthalmology, followed by general surgery and orthopaedics. Ophthalmic surgery has been on the rise, particularly lens implants, and correction of congenital and acquired anomalies of vision. Endoscopic laparoscopic procedures in gallbladder and hernia surgery dominate in the field of abdominal surgery.
changes in the healthcare system. - In January 1990, when I returned from my cardiology specialisation at the Texas Heart Institute in Houston, the US, I gave an interview about how I saw the development of the healthcare system in Yugoslavia and Serbia in my capacity as a young doctor who completed medical specialisation and lived in Paris and America. Back then, Yugoslavia was just starting its transformation from a Communist, one-party-regime to a multi-party, democratic political system. Everything I said and suggested back then regarding the healthcare reform and development is also true today – a quarter of a century later. Unfortunately, nothing has changed for the better in the last 25 years. Serbian healthcare, which used to be one of the best in Europe, is stagnating and, today, we can say it is the worst in Europe.
• That was back then. Do you have different views today? How should we reform health insurance? - My suggestion for the Serbian Government and the Health Minister would be to rally together health insurance specialists from the EU with the aim of putting in place a health insurance system that would enable Serbian citizens to freely choose one or several mandatory health insurance policies, and have the right to choose their doctor – be they private or state funded. The principle behind changing the strategy and management of health insurance is actually quite simple. • Who is considered the foundation of the private medical practice in Serbia? - These are medical professionals who have specialised in various medical branches and who provide over 90 per cent of health services in private practice. Most of them work at internal medicine-
It has been estimated that over €3 billion has been invested in private medical practice in Serbia in the past 25 years
• What benefits could we gain by incorporating private practice into the mandatory health insurance system and in the overall healthcare system in Serbia? - Patients would be given the right to choose a doctor anywhere in Serbia, be they private or state-funded. Waiting lists would also be eliminated, which means that patients would be given treatment on the same day, and at a time that best suits them. Private doctors would have more patients and state doctors would be encouraged to move to the private sector, because the money is better. The state would benefit from drastically reduced healthcare spending through cutbacks on investments in healthcare (construction and reconstruction of hospitals) or through spending less on new equipment, because such
equipment is already available in private practice. However, the most important benefit would be curbing corruption in the Serbian healthcare system which is currently at the very top in the world. Additionally, the number of non-medical staff would be reduced by 30% which would be a significant relief for the state healthcare budget. As you can see, everybody would benefit from incorporating private practice into the state health insurance system, which is all the more reason why we should do it sooner rather than later.
• Could you tell us how well-equipped private practice is today? - Private medical practice in Serbia has the latest diagnostic equipment, i.e. over 1,500 ultrasound machines and more than 100 scanners and MRIs. Serbia has over 100 private hospitals where all sorts of surgery is performed, except for brain and heart surgeries. People in Serbia have recognised all the benefits of private healthcare and more than 50% of patients are now using private medical services, while over 60% use diagnostic and specialised services; 65% of patients are using gynaecological services, while 80% of them use laboratories and dental services provided by private medical practitioners.
• Which segments of society use private healthcare in Serbia the most? - Every one of them, including pensioners. Patients are respected and nobody is violating their rights. They are free to choose their doctors. There are no waiting lists in private medical practice and patients can schedule a checkup whenever they want. The services are of good quality and provided by very knowledgeable people, which are some of the reasons why patients choose private practices.•
Radiologija, interna medicina, neurologija, ginekologija, anesteziologija sa reanimatologijom. +381 11 78 57 555; +381 62 288 470 www.panaceapoliklinika.com office@panaceapoliklinika.com
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INTERVIEW
VESNA JOVANOVIĆ
Director of the Serbian Medical Chamber ■ By Ivan MIŠKOVIĆ ■ Photo: Private PHOTO ARCVIHE
Linking State and Private
HEALTHCARE VITAL I am advocating for a uniform national healthcare development strategy which would prevent the problems with enrolment figures and allocation of specialisations in medical schools in the long run. The same applies to other issues that are important for the optimal functioning of the Serbian healthcare system
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he members of the Serbian Medical Chamber are all licenced doctors working in both the state-run and private healthcare sectors. The Chamber is doing everything in its power to incorporate private medical facilities into regular healthcare segments in Serbia. Following World War II, private medical doctors were banned from practicing medicine privately. The Serbian Medical Chamber was also banned, which was a great injustice both for our profession and for the healthcare benefits of our people – says Vesna Jovanović Ph.D., Director of the Serbian Medical Chamber.
• Does Serbia need both state and private medical professionals? - Serbia needs every single available medical professional it can get.
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Through its activities and negotiations with the institutions that could change, or at least influence changes, in the current legislation, the Serbian Medical Chamber will do everything in its power to adequately involve our
The Serbian Medical Chamber plans to establish closer cooperation with the World Health Organisation, in order to prevent outbreaks of infectious and non-infectious diseases. Our aim is for Serbian doctors to also apply this knowledge in their everyday practices medical peers from the private healthcare sector in regular healthcare segments in Serbia, which is a crucial pillar in providing the best possible medical services to patients.
• What about the new Healthcare Law and the innovations it introduces? - Changes and amendments to the Healthcare Law were passed on 26th November 2015. The Serbian Chamber of Commerce was involved in this process and the new law more precisely defines the status of those doctors who practice medicine in schools and at colleges, and this is something that wasn't previously specified at all. Moreover, the relations between all actors in the Serbian healthcare system have been regulated, and by “actors” we mean medical facilities, users of medical services and the State Healthcare Insurance Fund. There is a more detailed explanation regarding medical professionals working in the healthcare systems and their internships and passing the state licence exam, as well as a more detailed expla-
pendently of one another, complement each other? - It is vital to link the two systems, even if only partially, so that the patients, who are at the forefront of our work, are not forced to wait, but rather can be provided with the best and most professional healthcare services. Medical experts in this country are certainly ready to provide such services in an appropriate environment, with the latest medical equipment and sufficient quantities of medical supplies.
nation of licences that all doctors and other medical professionals have to have in order to provide medical services in the Republic of Serbia.
• When can we expect private medical workers to be incorporated into the state system? - As the Health Ministry says, it is vital to first create a uniform IT system that will consolidate both sectors. Once this is done, waiting lists will be much shorter. The waiting lists are one of the main indicators of the quality of a state's healthcare system, which is something we have already discussed with Mr. Björnberg, the representative of Health Consumer, an institution that rates medical facilities in Europe. He told us that the waiting lists in Serbia were not that long and that some countries more economically developed than Serbia have waiting lists almost twice as long.
• In which areas could these two systems, which currently operate inde-
Medical experts in this country are certainly ready to provide such services in an appropriate environment, with the latest medical equipment and sufficient quantities of medical supplies
• What role does the Serbian Medical Chamber play in all of this? - We have been actively participating in writing laws and bylaws and have had excellent collaboration with the institutions that are important for the medical profession, as well as with the Health Ministry. We have been investing a lot of effort into improving the status of both doctors and patients, as well as all vulnerable population categories, and we provide medical care and forensic exam-
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ination services. We have been quite engaged in implementing a project about the legalisation of hospices in collaboration with the Serbian Orthodox Church, because there are none in Serbia at the moment. In cooperation with the World Health Organisation, the World Medical Association and the Standing Committee of European Physicians, our doctors provide expert opinions on all relevant aspects regarding various crises, prerequisites and developments influencing global health, the prevention of adverse effects or disasters.
• The existing capacities of staterun medical facilities do not cover all medical needs of the Serbian population. How many new clinics/hospitals do we actually need? - I believe that number is not as high as many presume. Existing capacities could be used in a much better, or rather a more planned, fashion, while both medical and non-medical staff could be allocated more rationally, in order to achieve the best possible effect in providing the best possible healthcare to people. • What is the Serbian Medical Chamber's stance on reducing the number of state medical workers? - I think that apart from incorporating private healthcare institutions into the state system in Serbia, it is also necessary to make a more comprehensive plan to better allocate existing medical workers. I am fully supportive of the efforts exerted by the Health Ministry, which is doing everything in its power to utilise the knowledge of all the medical experts who have been schooled in this country.
• What will happen to the doctors who haven't collected enough points to renew their licence? - Through mutual agreement with all medical chambers, and in collaboration with the Health Ministry, we have come up with a solution for this unpleasant situation, and our solution will contribute to ensuring the smooth functioning of our healthcare system. We cannot allow so many doctors
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and other medical workers to be left unable to renew their medical licences, which would ultimately jeopardise the provision of quality medical servic-
Serbia has a sufficient number of physicians. However, in cooperation with the Health Ministry, we need to develop a quality plan to ensure better allocation of existing staff in the medical facilities around the country es to our population. Doctors who do not meet the requirements for licence renewal will be able to take a licence exam in front of a committee comprising medical school professors, under conditions determined by the health minister, thereby enabling them to demonstrate that they are acquainted with the latest medical advances.
• Which of the results achieved by the Chamber in 2015 make you most proud? - Getting to know how this institution works was a challenge of sorts, as was overcoming minor difficulties in the Chamber itself. This is a personal achievement that I am proud of. I consider the Chamber's achievements in 2015
as my personal achievements, as well as the achievements of everybody in the Chamber. We have launched many public projects and established impeccable cooperation with all relevant partners here and abroad. We are very satisfied with being able to position ourselves in the chamber system and establish daily communication with all medical chambers. We have also exchanged ideas with non-medical chambers, like the Serbian Engineering Chamber. Cooperation with the Health Ministry was fruitful and together we have managed to instigate changes to controversial articles of the Healthcare Law. This will enable us to properly position and protect our peers, who did not have a clearly defined status, and we have gone through the heaviest period of licencing that is now being successfully drawn to a close. We have been cooperating successfully for a number of years with the Serbian Medical Council and have been giving them the required professional and technical assistance. This cooperation has grown even bigger in 2015, and has been validated through an official cooperation memorandum.
• What are the Serbian Medical Chamber’s plans for 2016? - We will continue working to improve the Serbian healthcare system, the status of our doctors and their working conditions, as well as continuing to raise the quality of healthcare services, which is a never-ending job. Generally speaking, we shall continue investing a lot of effort. This is process that cannot stop, because if it does we run the risk of the entire established system malfunctioning. The Serbian Medical Chamber plans to continue maintaining good communication with all institutions with which we have cooperate successfully to date. We are also planning to organise a traditional gathering of our doctors from the diaspora at an event called the ‘Days of the Serbian Medical Diaspora’, which we will organise together with the Foundation of Her Royal Highness Princess Katherine. •
COMMENT
HEALTHCARE SITUATION UNCHANGED
Private Doctors Ready, But State
■ By Ivan MIŠKOVIĆ
FAILS TO INCLUDE THEM While waiting for private and state medical practices to be granted equal treatment, private medical professionals are celebrating the 25th anniversary of the existence of private medical practice in Serbia. Studies have shown that a third of people in Serbia are being treated by private medical workers
A
ccording to the World Health Organisation (WHO), Serbians spend $196 per capita on healthcare annually. This implies that patients’ rights, which are guaranteed by mandatory health insurance, and the services we should be receiving in state-run healthcare facilities, only exist on paper. Estimates have shown that, in Belgrade alone, half a million people visit private doctors every year. Statistical data shows that patients usually seek private gynaecologists and cardiologists, as well as using the services of private laboratories. Early in 2015, the Serbian Health Ministry promised that private medical practice would be incorporated into the state-run healthcare system and that this would initially take place in those segments where waiting lists are the longest – usually MRIs and scanners. The Ministry also promised that by year’s end patients with state-funded medical insurance would be able to use the services of private gynaecologists, paediatricians and GPs, as well as that millions of patients would be able to obtain the documents necessary for paid sick leave or hospital referrals from private doctors. Unfortunately, these remain in the realm of promises, with no progress hav-
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ing been made towards integrating the public and private health sectors in 2015. Experts agree that there is no rational explanation why the private sector, which employs over 9,000 doctors, dentists and pharmacists, and which provides medical services to millions of people, does not have treatment equal to that of the state healthcare sector in the eyes of the State Health Insurance Fund, which is a public fund that is financed by taxpayers. Serbian citizens, who turn to privately run healthcare fa-
Estimates have shown that close to 40 per cent of all patients use private medical services. This could increase to 80 per cent if citizens with state health insurance were allowed to use private medical services cilities for most of their medical services, are not even given an opportunity to take their medical files from a state-run medical facility and give them to their private doctors, i.e. they cannot use the option of a “selected” or “chosen” doctor if that doctor is working privately. The gap between these two sectors is even more obvious given the fact that the medical opinions and referrals of pri-
vate doctors are not recognised at statefunded healthcare facilities, particularly in cases when patients decide to continue their treatment at a state hospital. When asked about this, the Health Ministry said that that was an exception rather than a rule, adding that this could only be the case if medical documentation brought by patients to a state-run medical facility failed to meet the relevant standards and new analyses had to be performed. Experts also point out that such a disorderly situation could jeopardise patients, asking whether the same doctor could perform as well in a state medical facility as a private one that hired them as a consultant, all in the same day. Doctors often point out that this chaotic situation suits their colleagues who don't work much and operate rarely, since the state healthcare system doesn't have a uniform IT system that would show both the volume and quality of their work. It is these doctors that are actually obstructing the idea of competition and the incorporating of private doctors into the state system. Professor Danica Grujičić, M.D., from the Clinical Centre of Serbia, says that incorporating the private sector hasn’t started yet and that the monopolistic po-
sition of the State Health Insurance Fund is an obstacle. She claims that everybody should pay private supplemental health insurance and that the emphasis should be on primary health care, while the state health insurance fund should pay only for the most expensive surgical interventions (like cardio and neurosurgical). “We would need only €50 per capita annually to cover the costs of primary healthcare and create a service package that would cover the needs of all patients. By this I primarily mean preventative check-ups, since it all starts with and relies on family doctors. In translation, we need to urgently conduct primary healthcare reform and involve insurance companies in that,” emphasises Dr Grujičić. She adds that there must be a registry containing the names of all doctors who work in state and private practice, and that the two sectors need to cooperate and refer patients to facilities that have free capacities, in order to avoid waiting for checkups and medical procedures. Dr Draško Karađinović, from NGO “Doctors Against Corruption”, points out that no progress has been made in giving equal treatment to these two parallel system in the Serbian healthcare sector, and we are already at the end of 2015. “By having a free choice to select a doctor, and by abolishing the monopoly of the state healthcare system, the basic corruption mechanism will be limited drastically in terms of patients. Such change will instantly lead to higher quality and productivity across the entire healthcare system, since many unwarranted and unnecessary waiting lists will be abolished. What most disappoints me are the amendments to the Healthcare Law that are cur-
Dr. Sladjana Radan
specijalista oralne hirurgije i implantologije
Sve usluge na jednom mestu Makedonska 32/II, 11000 Beograd tel: +381 1132-29-582, 33-74-095 +381 63 30-36-56, 65 33-03-655 e-mail: dr.osmeh@eunet.rs
PRIVATE FACILITIES READY TO OFFER THEIR CAPACITIES
Private medical professionals say that, in terms of diagnostic equipment, they can make their capacities available immediately. This primarily refers to scanner diagnostics, for which there is a several-month waiting list in the state sector. Private health centres could be incorporated into the state system via selected or chosen doctors, while private hospitals could be involved in taking care of patients with kidney stones or those who have been waiting for a very long time for hernia or gallbladder operations in the state sector.
rently being considered by parliament and which don't even mention this crucial aspect. We should also finally define who the healthcare system actually serves: patients or several thousand privileged medical professionals who are sitting on sever-
There are approximately 4,000 private doctors registered in Serbia. We should consider that most private clinics also employ nurses and administrative staff, which means that, realistically speaking, the number of people working in the private healthcare sector is around 10,000 al chairs, so to speak. We should also not forget that Serbia spends 11 per cent of its GDP on healthcare, which is much more than neighbouring countries in the region, but with worse medical results,” says Dr Karađinović, adding that patients should finally have the right to choose where they are goi n g to be treated, since they are payi n g for that. Professor Dušan Milisavljević, M.D., who is both an otolaryngologist at the Medical Centre Niš and a member of parliament, adv o - cates equal treatment for private and state healthcare sectors and adds that Serbia is one of the few countries that don’t even recog-
nise the existence of the private healthcare sector. According to him, the private sector has been around for a long time, developing steadily and making gains in terms of quality. “It is completely irrational for the state to turn its head away from the private healthcare sector when there are so many waiting lists for numerous procedures in the state sector. I am all for clearly informing citizens or insured parties about what kind of service package they can get for the money they are paying into the state healthcare fund, and offering them a choice of medical facilities. The monopolistic behaviour of the State Health Insurance Fund needs to stop and we should give a chance to other insurance companies to get involved,” suggests Dr Milisavljević strongly, adding that it is vital to have several types of health insurance and to definitively incorporate the private health sector into them. Although money is often cited as the reason private doctors are not incorporated into the healthcare system, Dr Milisavljević thinks this should not be an excuse. He notes that the Health Ministry does have the will to embark on the process of equalising the status of the two parallel healthcare systems and he is waiting for the first tangible moves to be made. Until that happens, he points out that he is also very concerned by the discrimination suffered by his colleagues from the private sector. As often happens, medical analyses and check-ups performed by private doctors are not considered valid in the state sector. These procedures then need to repeated, which he says is a waste of both time and money. “When this happens, it further burdens the State Health Insurance Fund and this practice is just not good. What I advocate is stricter control of the work performed by doctors in both sectors,” insists Dr Milisavljević.•
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