From optimization to decentralization of healthcare

A new plan to reform health care in Serbia leaves doubts about how much optimization of rights and accessibility of care it will bring

November 18, 2022 by Predrag Đurić
Serbia healthcare

The COVID-19 pandemic, in addition to needlessly claiming millions of lives, has also highlighted numerous cracks in healthcare systems around the world. Even the richest countries met the pandemic unprepared, but the consequences of the pandemic were more devastating in countries with insufficiently developed health systems, especially those with authoritarian regimes which quickly resorted to the most drastic containment measures, while the basic anti-pandemic measures (e.g. wearing a mask, vaccination) were implemented inconsistently and with little success.

The pandemic also represented an opportunity to learn and to start implementing reforms based on pandemic lessons, which would aim not only to prevent the disastrous consequences of pandemics in the future, but also to build health systems that would meet the needs of citizens, health workers, as well as society as a whole.

There were attempts to “optimize” healthcare in Serbia before and during the pandemic itself. A “master plan” was drawn in the midst of the pandemic, following public consultations that lasted merely 12 days, which envisages the merging of numerous health institutions, especially those in smaller municipalities and cities, into mammoths that would have hundreds, even over a thousand employees and which would cover the territories of the entire district, newly formed region or province. Although the basis for “optimization” is the improvement of the quality, accessibility and efficiency of health care, especially given the context of an increasingly pronounced aging of the population, the key arguments cited in the plan are also “significant savings,” “improvement of the efficiency of the national health budget,” “more rational use of resources,” and “improvement of the financing system.”

This “optimization” of the healthcare system in Serbia would lead to two outcomes. First of all, there would be a centralization in management and decision-making, with further distancing of health institutions from citizens (e.g., instead of the existing primary health centers at the municipal level, there would be only one primary health center at the district level, and instead of the public health institute at the district level, only an institute for public health at the level of a province or a newly created “region,” community primary health centers in larger cities would be merged into large primary health centers, etc.). The influence of citizens and the community on the policy of such health institutions, on management and decision-making, on monitoring the results of prevention, diagnostics, treatment and rehabilitation, would be minimal. To this, we should add another lesson that we learned during the pandemic: the determination of the management of health institutions to remain silent in response to the requests of citizens and the public for timely and complete information.

Another outcome of such optimization would be additional pressure on health workers, who are seen as passive resources that need to circulate within the health system (like, say, Fiat workers). Thus, it is foreseen that the health worker no longer chooses their place of work, but they, previously employed in the primary health center as a specialist, are assigned to a general hospital, and then sent every week to circulate around the departments of the newly created mega primary health centers. At the same time, the already few doctors will be obliged to spend a fifth of their working time in the patient’s home. One should not doubt the good intentions of the authors of this optimization plan, who are aware of the lack of specialist doctors in local communities, as well as the difficult accessibility of health institutions for elderly and immobile citizens. However, the solution is sought in an extremely liberal-capitalist manner: through adding additional burden on the shoulders of healthcare workers and the concentration of management and decision-making. On the contrary, the solution would have to be sought in a drastic increase in the number of health workers, motivating doctors from smaller communities to stay in those communities (by opening up space for all specialties in small communities, and not by additionally concentrating them in large centers), as well as the participation of citizens in planning and deciding on their own health and priorities at the community level.

In parallel with “optimization”, another retrograde process in healthcare was taking place. Namely, after founding rights over primary health centers, the basic units of healthcare were transferred from the state level to local governments in 2007-2008. At the end of 2019 and during 2020, they were again returned to the Republic of Serbia and the Autonomous Province of Vojvodina. 

According to the state secretary in the Ministry of Health, the main reasons for these are to be found in the financial problems of primary health centers, but the causes are much more complex and were visible even in the results of research dating from 2015. On the one hand, local self-governments took over the founding rights without sufficient professional and organizational capacities, and with minimal allocations for health from local budgets (below 0.8%, with almost 20% of local governments without any budgetary allocations for health, against the European average of about 7%, and up to 27% in Finland). This kind of “decentralization” was not accompanied by an adequate reform of regulation, control and supervision of health institutions, partly due to unclear powers and partly due to a lack of human and financial resources.

In other words, as we have seen so many times in other contexts, a certain entity was given enormous responsibility, but almost no resources and mechanisms to fulfill it, thus leading to an inadequate result. Because of that, the entity is declared incapable of managing the functions entrusted to it, which are then taken away from it. And, really, who wouldn’t want to run away from such responsibility and limited resources?

What was necessary to do instead? A decade and a half after the transfer of responsibilities to local governance, it was necessary to decentralize budget revenues and significantly increase local budgets, with the commitment of a significantly higher percentage being allocated to health. Next, it was necessary to strengthen local personnel resources for health management, through the establishment of health administrations and qualified local health, sanitary and financial inspections, and strong and professional administrative and supervisory committees, which would not be just an extended arm of local party branches. Finally, it was necessary to involve citizens in creating local health policy and defining priorities, as well as monitoring the quality of healthcare and the results of local health programs. The almost forgotten self-management communities created in the 1970s, with all the imperfections they had because they were created at an extremely unfavorable moment, represent one of the possible models for the inclusion of both citizens and health workers in the definition and implementation of effective health care at the local level.

Allocating 10% from local budgets until 2025 and 20% until 2035 would represent a prerequisite for true “optimization” of health care, while preserving primary health centers at the community (municipality, city) level as the basic unit of health care. This would include the employment of about 6,000 additional doctors to ensure the ratio of one general practitioner per 500 inhabitants, who would work six hours a day, four days a week. These doctors would act as a family physician for their patients, and spend 1-2 days a week as a specialist caring for a wider pool of patients. A prerequisite for achieving this vision is the abandonment of the “optimization” plan and the annulment of the legal provisions that deprived local governments of their founding rights over primary health centers and other health institutions at the local level.

This article was originally published by the Centre for Politics of Emancipation.

Predrag Đurić is an public health professional and independent consultant.

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