Health Care System of the Republic of Serbia in the Period 2004 – 2012

Introduction The backbone of Serbian health system forms the public healthcare provider network with 355 institutions and around 112,000 employees, owned and controlled by the Ministry of Health and financed mainly by the Republican Health Insurance Fund. The law recognizes private practice that was not included, till recently, in the public funding scheme. New Health Insurance Law (2005) decreased the number of entitlements in the basic health service package. It abolished the right to dental health care for adults (exceptions are: children, older than 65, pregnant women and emergency cases) as well as the right to compensate travel expenses. The aim of this study was to evaluate the effects of health care system of the Republic of Serbia and indicate parameters that determine the state of health of the population, on the ground of data obtained by the Institute of Public Health of Serbia. Results In the period 2004–2012, cardiovascular diseases represented the main cause of illness in Serbia (50%). In 2012 digestive system diseases were on the second place. Neoplasm and nervous system diseases were on the third place. From 2007 to 2012 there was slight decline in the birth rate and number of deaths, but the death rate increased from 13.9 to 14.2. Health care system in Serbia is funded through the combination of public finances and private contributions. Primary care is provided in 158 health care centres and health care stations, secondary and tertiary care services are offered in general hospitals, specialized hospitals, clinics, clinico-hospital centers and clinical centres. Conclusion A significant but not satisfactory progress has been achieved in the field of health status indicators as the most important outcome of the final performance of the health system. The transition of public health care system in Serbia since the communist period to present and slow integration with European Union is unfinished process.


INTRODUCTION
Until the end of eighties, Serbia as the part of former Yugoslavia has followed global epidemiological trends.Health status of the population in Serbia in the mid-nineties was largely affected by political and economic isolation.The lack of basic medications and weakness of immuno-biological response of the organism as a result of cumulative effect of negative factors as well as inappropriate nutrition brought back almost forgotten infectious diseases.
The Ministry of Health (MH) is the owner of public health facilities and regularly monitors and controls their work as well as finances public health activities performed in Public health institutes.MH is responsible for developing and implementing national health policy, preventive programs, health promotion activities, special programs for some groups of citizens, Red Cross operations and non-government organization support, capital investments and health care for prisoners.
The backbone of Serbian health system forms the Public healthcare provider network, with 355 institutions and around 112,000 employees, owned and controlled by the Ministry of Health and financed mainly by the Republic Health Insurance Fund (RHIF) [1].The law recognizes private practice which can be funded only by private payments.Until recently, private health care sector was not included in public funding scheme and as such does not offer any service to insurers.
The aim of this work was to evaluate the effects of the health care system of the Republic of Serbia and indicate parameters that determine health condition of the population, based on data of the Institute of Public Health of Serbia (IPH).

HEALTH INSURANCE SYSTEM
Serbia has the health care system oriented towards securing availability of all health care services to the entire population.Insurance coverage is provided to all employed, retired and self-employed people and farmers who are contributor payers, including spouses and dependent children.Government transfers to the RHIF ia a guarantee that health insurance is also available to unemployed and refugees, as well as to people who belong to other sensitive categories.A special system of health insurance coverage is applied to the army, army civilians and retired and their family members and dependants.The RHIF offers a generous package of health services, including special services, such as medical treatment abroad and in military hospitals, or compensations for goods purchased on the private market.Besides, there are other categories of transferring healthcare-related funds, such as sick leave costs.New Health Insurance Law (2005) decreased the number of entitlements in the basic health service package.It stopped dental health care (with the exception of children, people over the age of 65, pregnant women and emergency cases), and travel expenses compensation.According to the new law, common-law partners get the right to insurance only after two years.Currently there is no additional private health insurance which could enrich the existing scarce financial resources of the system.
The number of private health care services, although limited, is increasing, particularly in certain areas such as dentistry and diagnostic services.However, it should be pointed out that private sector is insufficiently regulated mainly by employing consultants from public sector on temporary basis.The absence of private health insurance has created an unbalanced market system where private service providers, rather than powerful finance institutions, negotiate prices with individual beneficiaries (patients).

HEALTH SYSTEM FINANCING
Health care system in Serbia is funded by the combination of public funds and private contributions.The most important source of financing is the RHIF.Funds from employees and employers are collected directly to the RHIF sub-account.Ministry of Finance also has access to that account; it is their sub-account as well.RHIF is financed also with supplementary financing from other budgetary sources, such as Pension Fund, Ministry of Finance unemployment fund etc.The appropriate compilation of these public financial flows provides not only the basis for the Serbian Health Account but also for analysis of financial stability of the system.
Health care funds for insured persons are provided by the RHIF, whereas funds for the health care of the uninsured citizens, health promotion, and prevention of illnesses, special programmes and health protection measures for the whole population are provided by the Republican budget.More than 90% of public costs are financed through the RHIF or inter-departmental transfers via the RHIF [2].Similar coverage is envisaged for those who are entitled to health care services by military service providers.Due to absence of private health care insurance, private funding is more or less completely based on outof-pocket payments and it is supplemented by contributions from a small number of large companies which offer health care services for their employees on their cost.

HUMAN RESOURCES
The number of health care providers employed in public health sector was 112,587 in 2012 [1].26,967 of them had university education, 20,960 (78%) were doctors, 2,160 (8%) dentists, 2,130 (7.9%) pharmacists and 2,163 (8%) other professionals.Of all doctors in the Republic of Serbia 5,651 were non-specialists (27%) and 2,399 were involved in speciality training (11%).The total number of specialists was 15,309 (73%).The structure of employed doctors according to gender was: 35% were male and 65 % female doctors.Out of the total number of 2,160 dentists, 55% were specialists whereas out of 2,163 pharmacists 334 (15%) were specialists.
8,502 health workers had college education of whom 4,533 (53%) were nurses-medical technicians whereas 49,217 health workers and associates had high school education, 35,179 (71%) of them were nurses-medical technicians.Health care institutions employed a total of 27,533 non-medical staff, of whom 9,110 (33%) were administrative staff and 18,423 (67%) were technical staff.

PROVIDING HEALTH CARE SERVICES
Primary health care is provided in 158 health care centres and health care stations throughout the country, according to the IPH.The primary health care is relatively decentralized and services for children and women are offered by paediatricians and gynaecologists along with general practitioners.Apart from primary health centers, primary health care is provided also at: institutes for emergency medical care, gerontology, dentistry, pulmonary diseases and tuberculosis (TB), and institute for skin and venereal diseases, as well as pharmacies which carry out pharmaceutical health care activity.General practice is a service within primary health centers and is the basic provider of health care for population over 19 years old.
The total number of diseases, conditions and injuries diagnosed in general practice in 2012 was 9,137,037.The most commonly recorded morbidities were: circulatory system diseases (18%), diseases of respiratory system (18%) and diseases of musculoskeletal system and connective tissue (9%).Gynecology provides specific health care to the female population over 15.Child health service provides primary health care to children age 0 to 6. School children and youth health service provides primary health care to children and youth between 7 and 19 years of age.Some health care centres offer speciality consultation in internal medicine, pneuomophtisiology, otorhinolaryngology, ophthalmology, psychiatry, physical medicine and general rehabilitation.
Secondary and tertiary health care services are offered to both inpatients and outpatients in a string of health institutions across the country, including general hospitals, specialized hospitals, clinics, clinico-hospital centers and clinical centres.Hospitals or stationary health care providers are health institutions that offer inpatient and specialist consulting health care activities as the continuation of diagnostics, treatment and rehabilitation commenced at the primary level, or when complexity and severity of diseases require special conditions in terms of staff, equipment and accommodation.According to the IPH, in 2012, inpatient (hospital) health care was provided by 1,267 health institutions in the Republic of Serbia.These are: inpatient departments in primary health care centres (19), general hospitals (41), special hospitals (36), institutes (16), clinics (7), clinical-hospital centres (4) and clinical centres (4).In 2012, hospitals employed 8,128 doctors (of which 6,573 were specialists), 3,822 health staff with college education and 21,738 employees had high school education.The total number of beds in hospital institutions in 2012 was 41,268 i.e. 5.7 beds per 1,000 population.This number also includes day hospitals (1,625 beds), dialysis and neonatology.The total number of beds (excluding day hospitals) was distributed as follows: inpatient departments in primary health care centres -432 (1.1%), general hospitals -15,311 (38.6%), special hospitals -8,747 (22.1%), institutes ("zavod") -50 (0.1%), clinics -1,057 (2.7%), institutes -4,202 (10.6%), clinical-hospital centres -2,442 (6.1%), clinical centres -7,402 (18.7%).The total number of beds (excluding day hospitals) was distributed by purpose as follows: internal medicine -12,283 (31%), surgery -9,691 (24.4%), paediatrics -2,735 (6.9%), gynaecology -3,530 (8.9%), psychiatry 5,268 (13.3%), rehabilitation -6,122 (15.5%).
Private sector included 1,220 medical offices and clinics, 1,227 dental offices, 1,835 pharmacies and 149 laboratories.However, there were 46 hospitals and 97 policlinics.

EFFECTS OF HEALTH SYSTEM
In the period from 2004 to 2012, cardiovascular diseases represented the main cause of illness and the largest share of health funding all around the world including Serbia [3].Unlike Serbia where infectious and parasitic diseases were the second largest cause of illness and expenditure in the period from 2004-2009, followed by diseases of digestive, nervous system and cancers, in Australia, Canada, France, Germany and Netherlands, nervous system diseases represented the second largest share of funding, followed by digestive, musculoskeletal system diseases and tumors [4].In 2012, digestive system diseases were just after cardiovascular diseases with regards to the cost followed by malignant diseases and diseases of nervous system, which brings Serbia closer to world consumption trends.Life expectancy at birth is one of basic indicators of health status of the population and unfortunately it is still showing a significant gap between Serbian and EU population (Table 1).Another important indicator, Infant mortality rate is a significant and delicate indicator of both, health status and health care of the population, as well as socioeconomic status of the society (Table 2).Infant mortality rate increased in 90-ies of the 20 th cen-tury.However, it dropped from 14.6 in 1991 to 6.2 in 2012, but is still higher than in EU 15 countries (4.6).The most frequent causes of infant death are respiratory distress and congenital anomalies.
The data from the IPH for the period 2007-2012 showed: • • The mortality rate per 1000 population increased from 13.9 (2007) to 14.2 (2012).Cardio-vascular diseases are the cause of more than half of deaths.Neoplasm, mainly of respiratory tract and colon are the second leading cause of death.Violence and injuries are still lower compared to other European countries.Deaths from infectious and parasitic diseases account for less than 1% of deaths.Most common causes of death are non-communicable diseases as the result of unhealthy lifestyle, as indicated by the fact that 30 percent of adult population in the Republic of Serbia are smokers, which is one of the highest rates in Europe.The most common causes of death in 2012 are the following disease groups (according to ICD-10) [5]: • Diseases of circulatory system 53.7% (men 48.8%, women 58.8%).• Neoplasm 21.2% (men 23.8%, women 18.5%).
• Diseases of respiratory system 4.9% (men 5.7%, women 3.4%).• Symptoms, signs and abnormal clinical and laboratory findings 4.5% (men 4.6%, women 4.4%).• Diseases of digestive system 3.3% (men 3.7%, women 3.0%).Although communicable diseases no longer represent major cause of death and deformities, some of them still pose an important social health issue, like illnesses caused

PRINCIPAL HEALTH REFORMS
In August 2002, representatives of Ministry of Health, RHIF and IPH of Serbia decided on overall health vision for the health sector in Serbia.Health care reform in the period between 2004 and 2012 aimed to reform and put the focus on primary health care service and preventive measures versus curative, in order to decrease rate of preventable diseases and also reduce health expenditures.It also aimed to reconfigure hospitals to more effectively respond patients' needs and develop new basic package of health services that will be in balance with available resources.Financing system was supposed to change money flow as so as it doesn't follow the existing structure and staff but patient's movement through the system.The capitation was chosen as an option for primary health care and the model of Diagnostic Related Groups for payments in secondary health care.RHIF is the principal payer of the public health providers.Every year RHIF contracts necessary funding to health care facilities based on the number of employees.The number of health staff is controlled based on the institutional plan.
Patients can choose general medical doctor, pediatrician, occupational health specialist, dentist and gynecologist and those doctors are paid according to the capitation.The application of capitation formulas in health, which includes performance-related pay, began in November 2012 in primary health care institutions in Serbia.Capitation is the formula by which the physician receives the salary established in October 2012 with four percent increase, based on the number and age of registered patients.All doctors in primary health care cannot be paid less than they were paid in October 2012; the only difference is the size of variable part, weight factor which leads to wage increase.Weight factor is calculated based on patients' age.The average age was obtained on the basis of live statistics, where it is anticipated that a person 65 years old visits a doctor three times a year, a person from 45 to 65 twice, and one from 25 to 45 years old only once.Variable portion is calculated based on the number of enrolled patients and performed preventive examinations; it has increased to 4% recently.Some problems have been noticed with capitation formula which is still in the process of adjusting.Problems have been detected in the application of capitation for elderly and chronically ill patients.Although these patients should provide physicians greater capitation weight, in practice due to the large number of prescriptions given to these patients, doctors are usually financially penalized and overlooked in the percentage of salary.All other specialist in ambulatory health care and hospitals are paid by salaries.One of important goals was also integration and better oversight over the provision of private health care services.
One of the biggest problems at the beginning of health reform was deficit of reliable data that would build the baseline and enable evidence-based policy making and monitoring within the health sector.Policy-makers have realized that if they wanted to develop policies to enhance the performance of their systems, they needed reliable information on the quality of financial resources used for health, their sources and the way they were used.As National health accounts (NHA) could produce evidence to help policy makers and health managers to understand their health systems and improve their performance, Serbian Government decided to implement NHA in Serbian health system.Work on development, implementation and institutionalization of NHA, as a tool to help policy makers to better manage their health resources started at the end of 2004 under Ministry of Health project called: "Serbia Health Project, " financed by the World Bank.New department for NHA production in the Republican Institute of Public Health was formed after the project with WB was finished.NHA became an assigned programmatic job of MH, with new established financial line for NHA production.Significant reform accomplishment was achieved after the Agency for Accreditation was established in 2008 which formation was facilitated by joint forces of the World Bank, Ministry of Health and the European Union.In 2011 accreditation standards were adopted for institutions at all levels of health care and after obtaining the approval of the Assembly, great base for improving the quality of health care facilities was created.

CONCLUSION
The analysis showed some but insufficient progress achieved in the area of health status indicators as the most important final outcome of the health system performance gratifying efforts and resources invested in this sector.Life expectancy of the population increased, infant mortality rate decreased, the incidence of pulmonary TB is more than halved, and the population was given the option of using private pharmaceutical sector.Mortality in patients with diarrhea caused by Clostridium difficile showed more than double increase in 2012 compared to 2010, which is worrying and puts into question the adequacy of basic hygiene measures.Regarding the main causes of death, differences between Serbia and the EU are still the same, however investing in prevention and changing lifestyles has to continue and improve.The transition of Serbia's public healthcare system from the communist period to the present-day and slow integration with the European Union is proving to be a very delicate process.

KRATAK SADRŽAJ
Uvod Osno vi cu zdrav stve nog si ste ma Re pu bli ke Sr bi je či ni zdrav stve na mre ža od 355 dr žav nih zdrav stve nih usta no va i oko 112.000 za po sle nih ko ji su pod kon tro lom Mi ni star stva zdra vlja, a fi nan si ra ju se pre ko Re pu blič kog fon da zdrav stve nog osi gu ra nja.Za kon po zna je i pri vat ni sek tor, ko ji do sko ra ni je bio uklju čen u she mu jav nog fi nan si ra nja.Za kon o zdrav stve nom osi gu ra nju iz 2005.go di ne sma njio je pra va u osnov nom za ko nu zdrav stve nih uslu ga i uki nuo pra vo na sto ma to lo šku zdrav stve nu za šti tu (s iz u zet kom de ce, oso ba sta ri jih od 65 go di na, trud ni ca i hit nih slu ča je va), od no sno pra vo na na kna du put nih tro ško va u ve zi s ostva ri va njem pra va na zdrav stve nu za šti tu.Cilj ovog ra da je bio da se na osno vu po da ta ka In sti tu ta za jav no zdra vlje Sr bi je "Dr Mi lan Jo va no vić Ba tut" pro ce ne efek ti zdrav stve nog si ste ma Re pu bli ke Sr bi je i uka že na pa ra me tre ovo ga si ste ma ko ji od re đu ju sta nje zdra vlja sta nov ni štva.Re zul ta ti Od 2004.do 2012.go di ne kar di o va sku lar ne bo le sti su bi la naj če šća obo lje nja u Sr bi ji (50%).U 2012. go di ni bo le sti di gestiv nog si ste ma bile su na dru gom me stu.Na tre ćem me stu su ma lig ne i bo le sti ner vnog si ste ma.U pe ri o du 2007-2012.za be le žen je i blag pad na ta li te ta, sma njio se i broj smrt nih slu ča je va, ali je sto pa mor ta li te ta po ra sla sa 13,9 na 14,2.Si stem zdrav stve ne za šti te u Sr bi ji se fi nan si ra kroz kom bi na ci ju dr žav nih fi nan si ja i pri vat nih do pri no sa.Pri mar na zdrav stve na za šti ta se od vi ja u 158 do mo va zdra vlja, zdrav stve nih sta ni ca i am bu lan ti, a se kun dar ne i ter ci jar ne slu žbe ra de u op štim i spe ci jal nim bol ni ca ma, in sti tu ci ja ma, kli ni ka ma i kli nič ko-bol nič kim cen tri ma.Za klju čak Zna ča jan, ali ne do vo ljan, na pre dak po stig nut je u obla sti po ka za te lja zdrav stve nog sta nja, kao naj va žni jeg ko nač nog is ho da učin ka zdrav stve nog si ste ma.Tran zi ci ja dr žav nog si ste ma zdrav stve ne za šti te u Sr bi ji od ko mu ni stič kog pe ri o da do da nas i uspo re no in te gri sa nje s Evrop skom Uni jom je ne do vr šen pro ces.Ključ ne re či: zdrav stve ni si stem Re pu bli ke Sr bi je; si stem zdrav stve nog osi gu ra nja; si stem fi nan si ra nja; zdrav stve ne re for me UVOD Do kra ja osam de se tih go di na dva de se tog ve ka Sr bi ja je, kao deo biv še Ju go sla vi je, pra ti la svetske epi de mi o lo ške tren do ve.Zdrav stve no sta nje sta nov ni štva u Re pu bli ci Sr bi ji sre di nom de ve de se tih go di na bi lo je u ve li koj me ri pod uti ca jem po li tičke i eko nom ske izo la ci je.Ne do sta tak osnov nih le ko va i ukup na sla bost imu no bi o lo ških si ste ma po pu la ci je, kao re zul tat ku mula tiv nog efek ta ne ga tiv nih fak to ra ko ji ma je sta nov ni štvo Sr bi je bi lo iz lo že no u po sled njoj de ce ni ji dva de se tog ve ka, kao i nepri klad na is hra na, vra ti lo je sko ro za bo ra vlje ne za ra zne bo le sti u cen tar zdrav stve ne pro ble ma ti ke.
Pod okri ljem Mi ni star stva zdra vlja (MZ) su dr žav ne zdravstve ne usta no ve i MZ re dov no pra ti i kon tro li še nji hov rad, pruža nje zdrav stve nih uslu ga i fi nan si ra nje zdrav stve nih ak tiv nosti ko je se oba vlja ju u ovim usta no va ma.MZ je od go vor no za raz voj i pri me nu Na ci o nal ne zdrav stve ne po li ti ke, pre ven tiv nih pro gra ma, ak tiv no sti pro mo ci je zdra vlja, po seb nih pro gra ma za po seb ne gru pe gra đa na, za po ma ga nje ak tiv no sti Cr ve nog kr sta, ne vla di nih or ga ni za ci ja, za ka pi tal ne in ve sti ci je i zdrav stve nu za šti tu za tvo re ni ka.
Oko sni cu zdrav stve nog si ste ma Re pu bli ke Sr bi je pred sta vlja zdrav stve na mre ža dr žav nih zdrav stve nih usta no va, ko ju či ne 355 in sti tu ci ja i oko 112.000 za po sle nih, ko je su u vla sni štvu i pod kon tro lom MZ, fi nan si ra nih uglav nom pre ko Re pu blič kog fon da za zdrav stve no osi gu ra nje (RF ZO) [1].Za kon pri zna je privat nu prak su, ko ja mo že bi ti for mi ra na sa mo pri vat nim sred stvima.Do ne dav no či tav pri vat ni sek tor zdrav stve ne za šti te ni je bio uklju čen u she mu dr žav nog fi nan si ra nja i kao ta kav ni je predsta vljao do dat nu kom po nen tu ovom si ste mu, ni ti nu dio osi gura ni ci ma mo guć nost da ostva re pra va iz oba ve znog osi gu ra nja.Cilj ovog ra da je bio da se na osno vu po da ta ka In sti tu ta za jav no zdra vlje Sr bi je "Dr Mi lan Jo va no vić Ba tut" (IZJZ "Ba tut") pro ce ne efek ti zdrav stve nog si ste ma Re pu bli ke Sr bi je i uka že na pa ra me tre ovo ga si ste ma ko ji od re đu ju sta nje zdra vlja stanov ni štva.

SISTEM ZDRAVSTVENOG OSIGURANJA
Sr bi ja je na sle di la zdrav stve ni si stem ori jen ti san ka obez be đi vanju la ke do stup no sti svih zdrav stve nih uslu ga za či tav na rod.U prin ci pu, osi gu ra nje je obez be đe no za sva za po sle na li ca, pen zio ne re i sa mo za po sle ne lju de i po ljo pri vred ni ke ko ji su ob ve zni ci pla ća nja, uklju ču ju ći su pru žni ka i de cu za ko ju po sto ji oba ve za iz dr ža va nja.Bu džet ski tran sfe ri za RF ZO su ga ran ci ja da zdravstve no osi gu ra nje pru ža mo guć nost za šti te ne za po sle nim osoba ma, in ter no-ra se lje nim li ci ma i iz be gli ca ma, kao i lju di ma ko ji pri pa da ju ugro že nim ka te go ri ja ma sta nov ni štva.Po se ban si stem zdrav stve nog osi gu ra nja se pri me nju je na voj sku, voj nim ci vi li ma i pen zi o ne ri ma oru ža nih sna ga i čla no vi ma nji ho vih po ro di ca.RF ZO nu di ve li ko du šan pa ket zdrav stve nih uslu ga, uklju ču ju ći i po seb ne uslu ge, kao što su le če nje u ino stran stvu i voj nim bol ni ca ma, ili kom pen za ci je za ro bu ku plje nu na privat nom tr ži štu.Po red to ga, po sto je i dru ge ka te go ri je pre no sa zdrav stve no ve za nih sred sta va, kao što su tro ško vi bo lo va nja.Za kon o zdrav stve nom osi gu ra nju iz 2005.sma njio je broj pra va u osnov nom pa ke tu zdrav stve nih uslu ga.On uki da pra vo na stoma to lo šku zdrav stve nu za šti tu (s iz u zet kom de ce, lju di sta ri jih od 65 go di na, trud ni ca i hit nih slu ča je va) i pra vo na na kna du put nih tro ško va u ve zi s ostva ri va njem pra va na zdrav stve nu za šti tu.Pre ma tom za ko nu, van brač ni part ne ri sti ču pra vo na osi gu ra nje po sle dve go di ne ži vo ta u za jed ni ci.U ovom tre nutku u Re pu bli ci Sr bi ji ne po sto ji do dat no, do pun sko, pa ra lel no pri vat no zdrav stve no osi gu ra nje ko je mo že da obo ga ti po sto je će oskud ne fi nan sij ske re sur se si ste ma.
Pri vat no pru ža nje zdrav stve nih uslu ga, iako ogra ni če no, sve je če šće, na ro či to u obla sti ma kao što su sto ma to lo gi ja i di jagno stič ke uslu ge.Me đu tim, tre ba na gla si ti da je pri vat ni sek tor ne do volj no re gu li san i da uglav nom za po šlja va kon sul tan te iz dr žav nog sek to ra na pri vre me noj osno vi.Iz o sta nak tr ži šta privat nog zdrav stve nog osi gu ra nja stvo ri lo je ne u rav no te žen sistem tr ži šta, gde si stem pri vat nih pru ža la ca zdrav stve nih uslu ga, pre ne go moć ne fi nan sij ske in sti tu ci je osi gu ra nja, pre go va ra ju ce ne s in di vi du al nim ko ri sni ci ma (pa ci jen ti ma).

SISTEM FINANSIRANJA ZDRAVSTVENE ZAŠTITE
Si stem zdrav stve ne za šti te u Sr bi ji se fi nan si ra kroz kom bi naci ju dr žav nih fi nan si ja i pri vat nih do pri no sa.Naj va žni ji iz vor fi nan si ra nja zdrav stve ne za šti te u Sr bi ji je RF ZO.Sred stva od za po sle nih i po slo da va ca se pri ku plja ju di rekt no na pod ra čun RF ZO.Mi ni star stvo fi nan si ja ima pri stup tom na lo gu, ta ko da je to nji hov pod ra čun ta ko đe.RF ZO se do pun ski fi nan si ra iz raz li či tih bu džet skih iz vo ra, kao što su Fond PIO, Mi ni star stvo fi nan si ja -Fond za ne za po sle ne itd.Od go va ra ju ća kom pi la cija ovih dr žav nih fi nan sij skih to ko va pru ža ne sa mo osno vu za iz ra du na ci o nal nog zdrav stve nog ra ču na, već i za ana li ze fi nansij ske sta bil no sti si ste ma.
Sred stva za zdrav stve nu za šti tu osi gu ra nih li ca su obez be đena iz RF ZO, a sred stva za zdrav stve nu za šti tu neo si gu ra nih građa na, pro mo ci ju zdra vlja i pre ven ci ju bo le sti, po seb ne pro gra me i me re zdrav stve ne za šti te za ce lu po pu la ci ju iz re pu blič kog budže ta.Vi še od 90% dr žav nih tro ško va fi nan si ra se pre ko RF ZO [2].Slič na po kri ve nost zdrav stve nom za šti tom pred vi đe na je za one ko ji ima ju pra vo na uslu ge zdrav stve ne za šti te voj nih pru ža la ca uslu ga.Zbog ne po sto ja nja pri vat nog zdrav stve nog osi gu ra nja, pri vat no fi nan si ra nje je vi še ili ma nje pot pu no zasno va no na pla ća nju "iz dže pa", osim fi nan si ra nja ma log bro ja ve li kih kom pa ni ja ko je sa me or ga ni zu ju zdrav stve nu za šti tu za svo je za po sle ne.
Za be le že na su i 8.502 zdrav stve na rad ni ka i sa rad ni ka s vi so kim obra zo va njem u zdrav stve nim usta no va ma, od ko jih su 4.533 (53%) bi le me di cin ske se stre i me di cin ski teh ni ča ri.Sred nju struč nu spre mu ima lo je 49.217 zdrav stve nih rad ni ka i sa rad ni ka, od ko jih su 35.179 (71%) bi li me di cin ske se stre i me di cin ski teh ni ča ri.Zdrav stve ne usta no ve su za po šlja va le ukup no 27.533ne me di cin ska rad ni ka, od ko jih je 9.110 (33%) bi lo ad mi ni stra tiv no oso blje, a 18.423 (67%) teh nič ko oso blje.

PRUŽANJE USLUGA
Pri mar na zdrav stve na za šti ta je, pre ma po da ci ma IZJZ "Ba tut", obez be đe na u 158 do mo va zdra vlja, zdrav stve nih sta ni ca i ambu lan ti ši rom ze mlje.Pru ža nje pri mar ne zdrav stve ne za šti te sta nov ni štvu u Sr bi ji je re la tiv no de cen tra li zo va no, a uslu ge za de cu i že ne nu de pe di ja tri i gi ne ko lo zi, kao i le ka ri op šte me dici ne.Po red do mo va zdra vlja, ak tiv no sti na pri mar nom ni vou ob u hva ta ju za vo de, zdrav stve ne usta no ve ko je pru ža ju uslu ge pri mar ne zdrav stve ne za šti te za spe ci fič ne gru pe sta nov ni štva, kao što su za vo di za hit nu me di cin sku ne gu, ge ron to lo gi ju, stoma to lo gi ju, pluć ne bo le sti i tu ber ku lo zu, za vod za ko žne i ve nerič ne bo le sti, te apo te ke, ko je oba vlja ju far ma ce ut sku de lat nost zdrav stve ne za šti te.Op šta prak sa se pru ža u okvi ru pri mar nog zdrav stve nog cen tra i osnov ni je pru ža lac zdrav stve ne za šti te sta nov ni ka sta ri jih od 19 go di na.
Uku pan broj utvr đe nih obo lje nja, sta nja i po vre da di jag nosti ko van u op štoj prak si u 2012.go di ni bio je 9.137.037.Naj če šće su za be le že ni: bo le sti si ste ma kr vo to ka (18%), bo le sti si ste ma za di sa nje (18%) i bo le sti mi šić no-ko šta nog si ste ma i ve ziv nog tki va (9%).Gi ne ko lo ška zdrav stve na slu žba pru ža zdrav stve nu za šti tu de voj ka ma sta ri jim od 15 go di na i že na ma.Deč ja zdravstve na slu žba pru ža pri mar nu zdrav stve nu za šti tu de ci uz ra sta do šest go di na.Zdrav stve na slu žba za de cu škol skog uz ra sta i mla de pru ža pri mar nu zdrav stve nu za šti tu de ci i omla di ni uzra sta 7-19 go di na.Ne ki do mo vi zdra vlja pru ža ju spe ci ja li stič ke kon sul ta ci je u obla sti in ter ne me di ci ne, pne u mof ti zi o lo gi je, otori no la rin go lo gi je, of tal mo lo gi je, psi hi ja tri je, fi zi kal ne me di ci ne i re ha bi li ta ci je.
Pri vat ni sek tor ob u hva ta 1.220 me di cin skih kan ce la ri ja i kli ni ka, 1.227 or di na ci ja op šte sto ma to lo gi je, 1.835 apo te ka i 149 la bo ra to ri ja.U pri vat nom sek to ru po sto ji 46 bol ni ca i 97 po li kli ni ka.

EFEKTI ZDRAVSTVENOG SISTEMA
Od 2004.do 2012.go di ne kar di o va sku lar na obo lje nja su bi la glav ni uzro ci bo le sti i naj ve ći deo tro ško va za le če nje obo le lih lju di ši rom sve ta, uklju ču ju ći i Sr bi ju [3].Za raz li ku od Sr bi je, gde su za ra zne i pa ra zit ske bo le sti dru gi naj ve ći uzro ci ras hoda u pe ri o du 2004-2009, pra će ne bo le sti ma di ge stiv nog si stema, ner vnog si ste ma i ma lig nih obo lje nja, u Austra li ji, Ka na di, Fran cu skoj, Ne mač koj i Ho lan di ji bo le sti ner vnog si ste ma su na dru gom me stu po ude lu fi nan si ra nja, za tim bo le sti di ge stiv nog si ste ma, bo le sti mi šić no-ske let nog si ste ma i ma lig na obo lje nja [4].U 2012. go di ni bo le sti di ge stiv nog si ste ma na la ze se na drugom me stu (po sle kar di o va sku lar nih bo le sti) po tro ško vi ma za le če nje bo le sti u Sr bi ji, a pra te ih ma lig ne i bo le sti ner vnog siste ma, što pri bli ža va Sr bi ju svet skim tren do vi ma po tro šnje za le če nje lju di.Oče ki va no tra ja nje ži vo ta na ro đe nju je je dan od osnov nih po ka za te lja zdrav stve nog sta nja sta nov ni štva, ko ji, naža lost, i da lje po ka zu je zna ča jan jaz iz me đu Re pu bli ke Sr bi je i sta nov ni štva EU (Ta be la 1).Još je dan va žan po ka za telj je sto pa smrt no sti odoj ča di, ko ji je zna ča jan i de li ka tan po ka za telj kako zdrav stve nog sta nja i zdrav stve ne za šti te sta nov ni štva, ta ko i so ci o e ko nom ske sna ge dru štva (Ta be la 2).Sto pa smrt no sti odoj ča di je ozbilj no po go đe na to kom kri ze de ve de se tih go dina dva de se tog ve ka.Od 14,6 u 1991.go di ni pa la je na 6,2% u 2012, ali je i da lje znat no ve ća u po re đe nju sa EU15 ze mlja ma (4,6).Naj če šći uzro ci smr ti odoj ča di su re spi ra tor ni dis tres i uro đe ne ano ma li je.

OSNOVE ZDRAVSTVENIH REFORMI
U av gu stu 2002.go di ne pred stav ni ci MZ, RF ZO i In sti tu ta "Batut" iz ne li su op štu zdrav stve nu vi zi ju za zdrav stve ni sek tor u Sr bi ji.Cilj zdrav stve ne re for me u pe ri o du 2004-2012.go di ne je da re for mi še zdrav stve nu slu žbu i u ži žu sta vi pri mar nu zdrav stve nu za šti tu i pri me nu me ra pre ven ci je u od no su na ku ra tiv no le če nje, ka ko bi se sma nji la sto pa iz le či vih bo le sti, od no sno sma nji li ras ho di zdrav stve nog si ste ma.Ona ta ko đe ima cilj da se re or ga ni zu ju bol ni ce ka ko bi efi ka sni je od go vo ri le na po tre be pa ci je na ta, te da se raz vi je no vi osnov ni pa ket zdravstve nih uslu ga ko ji će bi ti u rav no te ži s ras po lo ži vim re sur si ma.Pred vi đe no je da pro me ne na stra ni fi nan si ra nja zdrav stve nog si ste ma pra te to ko ve fi nan sij skih sred sta va, ta ko da se ne fi nansi ra ju po sto je ća struk tu ra i oso blje, već kre ta nje pa ci jen ta kroz si stem.Ka pi ta ci ja je iza bra na kao op ci ja za pri mar nu zdravstve nu za šti tu i mo del di jag no stič ki srod nih gru pa za pla ća nja u se kun dar noj zdrav stve noj za šti ti.RF ZO, kao glav ni fi nan si jer dr žav nih zdrav stve nih uslu ga, sva ke go di ne ugo vo ra neo p hod na fi nan sij ska sred stva za zdrav stve ne usta no ve na osno vu bro ja rad ni ka.Broj zdrav stve nih rad ni ka je kon tro li san na osno vu in sti tu ci o nal nog ka drov skog pla na.
Pa ci jen ti mo gu da bi ra ju le ka ra op šte prak se, pe di ja tra, speci ja li stu me di ci ne ra da, sto ma to lo ga i gi ne ko lo ga kao iza bra nog dok to ra, a ti le ka ri su pla će ni u skla du s ka pi ta ci jom.Pri me na kapi ta ci o ne for mu le u zdrav stvu, ko ja pod ra zu me va pla te po učinku, po če la je u no vem bru 2012.u usta no va ma pri mar ne zdravstve ne za šti te.Ka pi ta ci ja je for mu la pre ma ko joj le kar do bi ja na pla tu utvr đe nu ok to bra 2012.go di ne do če ti ri od sto po ve ća nja na osno vu bro ja i sta ro sti opre de lje nih pa ci je na ta.Svi le ka ri u pri mar noj zdrav stve noj za šti ti ne mo gu do bi ti ma nje pla te ne go što im je pla ta bi la u ok to bru 2012; je di na raz li ka je u ve li či ni pro men lji vog de la, te žin skog fak to ra ko ji do vo di do po ve ća nja pla te.Te žin ski fak tor se iz ra ču na va u od no su na sta rost pa ci jena ta.Pro seč na sta rost je do bi je na na osno vu sta ti sti ke ži vih, gde se pred vi đa da čo vek od 65 go di na po se ti le ka ra tri pu ta go di šnje, čo vek sta ro sti od 45 do 65 go di na dva pu ta, a čo vek sta ro sti od 25 do 45 sa mo jed nom.Pro men lji vi deo je iz ra ču nat pre ma broju upi sa nih pa ci je na ta i oba vlje nih pre ven tiv nih pre gle da, ko ji je u po sled nje vre me po ras tao na 4%.Pri me će ni su pro ble mi s ka pi ta ci o nom for mu lom, ko ja je još u fa zi for mi ra nja, a pro mene su u to ku.Pro ble mi se ti ču pri me ne ka pi ta ci je kod sta ri jih pa ci je na ta i hro nič nih bo le sni ka.Iako ova vr sta pa ci je na ta tre ba da obez be di le ka ri ma ve ći ka pi ta ci o ni pon der, u prak si, zbog većeg bro ja re ce pa ta na pi sa nih tim te škim bo le sni ci ma, iza bra ni dok to ri obič no bu du fi nan sij ski ka žnje ni i ne do bi ju pre vi đe ni pro ce nat na dok na de na pla tu.Svi dru gi spe ci ja li sti u zdrav stvu, i u am bu lan ta ma i u bol ni ca ma, pri ma ju sa mo pla tu.Va žan cilj je i in te gra ci ja pri vat nog sek to ra pru ža la ca zdrav stve nih uslu ga i bo lji nad zor nad pru ža njem pri vat nih zdrav stve nih uslu ga.
Je dan od naj ve ćih pro ble ma na po čet ku zdrav stve ne re for me bio je de fi cit po u zda nih po da ta ka ko ji bi stvo ri li osno vu ko ja će omo gu ći li kre i ra nje zdrav stve ne po li ti ke za sno va ne na do ka zima.Kre a to ri zdrav stve ne po li ti ke su shva ti li da su im, uko li ko že le da raz vi ju po li ti ku ko jom mo gu da do ve du do po bolj ša nja per for man si svo jih si ste ma, po treb ni po u zda ni po da ci o fi nansij skim sred stvi ma upo tre blje nim za zdrav stve nu za šti tu.Ka ko Na ci o nal ni zdrav stve ni ra čun (NZR) mo že da pro iz ve de do ka ze i po mog ne kre a to ri ma po li ti ke i zdrav stve nim me na dže ri ma da shva te svo je zdrav stve ne si ste me i po bolj ša ju svo je per forman se, Vla da Re pu bli ke Sr bi je je od lu či la da pri me ni NZR u zdrav stve nom si ste mu Sr bi je.Rad na raz vo ju, im ple men ta ci ji i in sti tu ci o na li za ci ji NZR, kao ala ta za po moć kre a to ri ma po li ti ke da bo lje sa gle da ju svoj si stem i upra vlja ju svo jim zdrav stve nim re sur si ma, po čeo je kra jem 2004.go di ne u okvi ru pro jek ta MZ pod na zi vom "Raz voj zdrav stva Sr bi je", ko ji je fi nan si ra la Svetska ban ka.For mi ra nje no vog od se ka za NZR u In sti tu tu "Ba tut" je re form sko do stig nu će, po što je pro je kat za vr šen 2008.go di ne.
NZR je po stao po ve ren pro gram ski po sao In sti tu ta "Ba tut", s novom utvr đe nom fi nan sij skom li ni jom za iz ra du NZR.Osim to ga, ju na 2013.go di ne obra zo va ni su rad na gru pa i In ter sek to ral ni ko mi tet za na ci o nal ni zdrav stve ni ra čun.Zna čaj no re form sko do stig nu će je po stig nu to i osni va njem Agen ci je za akre di ta ci ju 2008.go di ne, či je for mi ra nje je, osim Svet ske ban ke i MZ, pot pomo gla i EU.Go di ne 2011.usvo je ni su akre di ta ci o ni stan dar di za usta no ve svih ni voa zdrav stve ne za šti te i do bi je no je odo bre nje Skup šti ne, što je stvo ri lo od lič nu osno vu za po bolj ša nje kva li te ta ra da zdrav stve nih usta no va u na šoj ze mlji.

ZAKLJUČAK
Ana li za je po ka za la zna ča jan, ali ne do vo ljan, na pre dak po stignut u obla sti po ka za te lja zdrav stve nog sta nja, kao naj va žni jeg ko nač nog is ho da učin ka zdrav stve nog si ste ma uz od re đe ne napo re i sred stva ulo že na u ovom sek to ru.Oče ki van ži vot ni vek sta nov ni štva je po ve ćan, sma nje na je sto pa smrt no sti odoj čadi, in ci den ci ja pluć ne tu ber ku lo ze je vi še ne go pre po lo vlje na, a sta nov ni štvo je do bi lo mo guć nost ko ri šće nja pri vat nog farma ce ut skog sek to ra zdrav stve ne za šti te.S dru ge stra ne, smrt ni is hod oso ba obo le lih od en te ro ko li ti sa uzro ko va nog mi kro or gani zmom Clo stri di um dif fi ci le vi še ne go dvo stru ko je bio če šći u 2012.go di ni u od no su na 2010, što za bri nja va i do vo di u pi ta nje ade kvat nost pri me ne osnov nih hi gi jen skih me ra.Ka da se uzmu u ob zir glav ni uzro ci smr ti sta nov ni štva, tren do vi iz me đu Srbi je i EU su i da lje isti, ali ne iz be žan za klju čak je da ula ga nje u pre ven ci ju i pro me nu ži vot nih sti lo va mo ra da se na sta vi u po ve ća nom obi mu.Tran zi ci ja dr žav nog si ste ma zdrav stve ne za šti te u Sr bi ji od ko mu ni stič kog pe ri o da do da nas i uspo re no in te gri sa nje sa EU se is po sta vlja kao ve o ma bo lan pro ces.

Table 2 .
Infant Fatal outcome in patients with diarrhea caused by Clostridium difficile showed more than double increase in 2012 compared to 2010.The incidence of pulmonary tuberculosis decreased from 27.2% in 2007 to 15.58% in 2012 per 100,000 populations.This is the consequence of organized control and treatment of patients through the project "Tuberculosis Control in Serbia", as well as the strategy of directly observed therapy.Although official statistics shows that the current AIDS rate in Serbia is low, Global Fund financial resources are used to solve this health problem.
Pad sto pe na ta li te ta u Sr bi ji: sma nje nje bro ja ži vo ro đe nih