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Strategic orientation of public health in transition: Challenges in Serbia

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JPH - Year 7, Volume 6, Number 1, 2009

ITALIAN JOURNAL OF PUBLIC HEALTH

Strategic orientation of public health in transition: challenges in Serbia

Vesna Bjegovic-Mikanovic1, Dejana Vukovic1, Milena Santric-Milicevic1, Zorica Terzic1,
Sandra Sipetic-Grujicic2
1
Centre School of Public Health, Institute of Social Medicine, School of Medicine, University of Belgrade,
Belgrade, Serbia; 2Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia
Correspondence to: Vesna Bjegovic-Mikanovic, Centre School of Public Health, Institute of Social Medicine, School of Medicine,
University of Belgrade, Dr Subotica 15, 11000 Belgrade, Serbia. E-Mail: [email protected]

Abstract

Strategic Management, Public Health Information, Public Health Legislation, as well as Public Health Training
and Research are considered essential elements of a coherent public health strategy for Serbia, a republic of
the former Yugoslavia.
Whereas the strategic framework in Serbia is outlined in detail, which includes an action plan that is linked
with local pilot initiatives, the information base is well developed but not yet sufficiently related to the
strategic objectives. The transformation of strategic considerations and information into meaningful
legislative acts stands at halfway and has to cope with a heritage of unrelated and dysfunctional laws. A big
step forward was made with the establishment of a modern School of Public Health in Belgrade in 2004, which
acts as a brain-trust for the New Public Health in Serbia.
The multi-professionalism at the Institutes of Public Health and the corresponding inter-disciplinarity at the
academic Schools of Public Health provide an adequate institutional environment if the resources of skills,
knowledge and experience are adequately managed – in a participatory and supportive system representing
a flat hierarchy.

Key words: public health strategy, legislation, information, school of public health, Serbia

The public health setting in Serbia 1990s. Years of life under severe stress and a
“Nowadays, the entire spectrum of public trauma-ridden environment have brought
health is enormously complex and public health depression and hopelessness, followed by general
activities are oriented to many challenges related negligence towards health and increased risk
to health. Evidence from countries in which behaviour. During the last decade of the 20th
public health is well developed suggests that it century, the health status of the population of
can make an important contribution to the health Serbia was harmfully influenced by numerous
status of the population. In fact, the health gain of factors, but especially by the general situation in
public health activities is far greater than the the country: the long lasting economic crisis, the
impact of curative services, although the latter consequences of war in the surrounding
usually consumes over 90% of the funds available countries and in Serbia as well, and the wide range
for health care. However, in the eye of the public of economic and diplomatic sanctions [3].
and also of many physicians, public health does Nowadays the total population of Serbia is
not hold the position it deserves, because it is less according to the 2002 census 7.875.380 [4]. The
“visible”: keeping healthy people healthy is less population of Central Serbia has declined by
spectacular than treating the sick” [1]. approximately 25.000 over the last decade, while
Nevertheless the link between the modern the population of Vojvodina has increased by
practices of public health, democracy and more than 77.000. Literacy rates of 15-24 years
sustainable health development is real and based olds is 99.4%, which is similar to that of other SEE
on four principles of equity, participation, countries, while the percentage of population
subsidiarity and good governance [2]. living below poverty line was 10.6 in 2003. Serbia
Looking at Serbia, public health experienced entered the crisis of the 1990s with the overall
many social and economic threats during the population profile of a developed country. The

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economic crisis led to a smaller number of births, development of laboratories and microbiological
increased emigration of young people and services as an additional source of financing.
increased immigration of the elderly (among 3. Training. Specialist knowledge is still
refugees and internally displaced persons). Today contained within different specialist branches
the major trend is a rapid ageing of the that communicate little among themselves
population. According to the data from 2002, (Epidemiology, Hygiene, Social Medicine, and
somewhat over 16.5% of residents are aged 65 Occupational Medicine).The entire field of public
years or more, thus the dominance of chronic health is strongly medically driven with very little
cardiovascular and malignant diseases is as input from other professions. The appropriate
expected [5]. The life expectancy at birth for institutional format common in Europe, as
males born in 1997/98 is 67.69 in Vojvodina and independent university-based “School of Public
69,96 in Central Serbia, while for females it is Health” has only recently been established.
higher: 73,24 and 75,00 respectively.The mortality In this paper we discuss elements necessary for
rate of children under 5 years decreased from 18.3 the successful implementation of a new public
in 1990 to 9,2 in 2005 [6]. The exposure to risky health system in Serbia drawing on the
lifestyles (smoking, alcohol use, inadequate experience of other countries in SEE [10] but also
nutrition, the lack of physical activity) is with the intention to consider the Serbian case as
widespread, as well as the exposure to an exemplification of some key issues of general
environmental risk factors [7]. relevance. To this aim we adopt the methodology
Serbia benefits from the well developed health of strategic planning [11]. Summarizing our
system in the former Yugoslavia which was experience since the Serbian democratic changes
nevertheless based on the traditional hygienic in 2000 we identified the following strategic
approach to public health as in all former elements of transition whose interplay as a system
communist countries. It is astonishing how Serbia we shall analyze at the end: Strategic Management,
managed, in spite of the heavy burden of civil war, I) Public Health information,
with a severe deterioration of the public health II) Public health legislation,
infrastructure, to maintain its level of health from III) Public health training and research.
the eighties and even to improve it, e.g. infant
mortality from almost 22 in 1992 to just over 10 Strategic management
per 1000 life births one decade later and then to In Serbia the development of a strategic
8 in 2005. Slovenia however - ranking best –came orientation for the reform of the health system
down to less than 4 exemplifying, that began with a document entitled “Health Policy of
increasingly neighbouring countries leave Serbia Serbia” [12] which was adopted by the
behind [8]. By now the former merits have turned government early in 2002. In the document strong
into drawbacks in Serbia when, for example, more support is expressed for the implementation of
than half of the staff in the 23 institutes of public health promotion, partnerships for health,
health is working in the laboratories and in preventive activities, and health education. Also in
administration and only a few in health promotion a subsequent strategy paper on health care reform
and health management [9]. There are several [12-13] the public health is highly recognized. As
needs for reforming the system of public health in due to the instability of the political situation the
Serbia: adoption of this strategy was repeatedly
1. Performance. The current specialist oriented postponed; a modified second draft was finalized
system is not able to address the growing health in June 2005 [14]. Following the meanwhile
problems related to living environment and life adopted Health Care Law of the Republic of
styles of the population. The spectrum of the “Old Serbia [15-16], the revised version is re-structured
Public Health” still exists with only a moderate in line with the Essential Public Health Functions
orientation towards epidemiology of chronic as published by the Pan American Health
diseases, health promotion, health system Organization together with the Center of Disease
research, management and health policy (“New Control in Atlanta and WHO [17]. Reference is
Public Health”). made to the following strategic framework of
2. Financing. Within the current situation, the public health:
importance of public health is still not recognized, 1) Reduction f the Burden of Disease and Injury
and the Public Health Institutes suffer from the 2) Control of Social Determinants
consequences of inadequate and scarce financing 3) Action upon Lifestyle Related Factors
throughout the years, which – in line with the 4) Integrated Strategic Approaches
biomedical orientation – led to the excessive 5) Strategic Activities

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Whereas items 1, 2 and 3 deal with the standard The systematic hierarchy of goals, objectives
issues of specific disease categories, social and actions is exemplified in the actions to be
inequalities and health behaviours, items 4 and 5 taken for the accomplishment of the firs sub-
focus on population risk reduction, individual risk objective until 2015 (Table 1).
reduction, empowering primary health care and An example of local strategy development is the
support of the referral system as integrated project on “Community Health – Development
strategic approaches (item 4) and on the and Implementation of Local Public Health
development of public health policy, support to Strategies”. It is managed by the Centre - School of
the environment and to the community, Public Health and the Institute of Social Medicine
enhancement of individual skills and reorientation within the School of Medicine in Belgrade for the
of health services as strategic activities of public benefit of 4 districts in Serbia, funded through the
health (item 5). Ten goals with several sub- Open Society Institute, coordinated by the Center
objectives are finally listed and are meant to be of Disease Control, Atlanta, USA [18] and has been
specific, measurable, achievable, relevant and time awarded for its excellence in applied public
framed [14]. health management learning.
As the fourth goal related to “Promotion, These developments in Serbia correspond to
Development and Support to Public Health the regional framework. In August 2004 more than
Policy” is of greater interest here, it is discussed in 40 public health professionals from all countries
detail including its sub-objectives: of South Eastern Europe convened in Belgrade,
a) Development of a new public health policy, its capital of Serbia to discuss their national public
implementation and the evaluation of impact health strategies and a common regional
on the health of the population. framework for them. The results are published in
b) Providing sustainable funding and fiscal stimuli the format of a teaching book to enter them into
for public health activities. the regular public health training programmes in
c) Development of a public health information the region [18- 19]. The main methodic approach
system and improvement of information was SWOT analysis in combination with the
and knowledge. nominal group technique. Given the severe
d) Development of capacities and establishment weaknesses identified and overwhelming threats
of partnership between research centres and persisting in the region a strategic option of
academic institutions for research work within ‘Comparative advantage maximizing Strengths
and out of the health sector. and Opportunities’ turned out to be the preferred

Table 1. Action Plan 2005-2015: Objective 4.1 “Development of a new public health policy, its implementation and evaluation of
impact on the health of the population”.

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Table 2. Suggested strategic goals for Regional Public Health Strategy in South Eastern Europe.

choice. The goals were identified as common which can timely monitor health service
priorities (Table 2). utilization, changes in population health and
The regional strategy as described still lacks control of all the financial input and output. One
adoption of the action plan as it is available for of the crucial factors for implementation of such
some national strategies notably the Serbian one. reform projects is the development and
In its present form it shares a common weakness application of an integrated information system
of policy proposals: an overall guidance to based on indicators for management support.
implementation, monitoring and evaluation. The Today increasing attention is focusing on
process of adoption may take at least as long as evidence based public health management and
the national one, however, what is most important the benchmark approach as a new tool for policy
is the development of a common language and analysis [21]. Delegating the responsibility for the
personal familiarity of the public health recognition of the needs for health of specific
professionals, scientists and decision makers in populations and their satisfaction at lower
the neighbouring countries of the region. To this referential levels also requires that managers are
aim the support provided by the institutions and educated in public health, including statistics and
programmes of the European Union has been epidemiology. They should be acquainted with
essential in terms of financial support but also in the methodology of assessing the health status, in
providing a harmonizing framework. programming for health, and in the techniques of
monitoring and evaluation. Hence, the efficiency
Public health information of the management itself, beside theoretical
Two information bases have been instrumental knowledge and training, mainly depends upon the
for the strategy development described above: existing evidence on possibilities of acting upon
The Serbian Burden of Disease Study, SBDS (4) and health care performance. A “complete manager” in
the comparative analysis of the Minimum Health an evidence based health system should possess,
Indicator Set, MHIS (28) assembled in the Stability apart from general managerial skills, evidence
Pact framework. Whereas the SBDS indicates the based decision making skills, as well [22].
highest burdens as measured by Disability
Adjusted Life Years (Figure 1) the indicators of the Public health legislation
MHIS allows for a comparison with the other In Serbia, the most important institutions of
countries in the region (Figure 2). Recently Serbia public health are the Institutes of Public Health
decided to adopt the health monitoring system (IPHs), with a long tradition in former Yugoslavia.
developed with EUROSTAT [20] but functional They were developed from the specialised
implementation will not be achieved for some institutions for preventive medicine known as
years to come. Institutes of Hygiene. Today there are 23 IPHs.
The public health management has to be Beside these there are a large number of
modernized by improving information systems institutions working in the field of public health,

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Figure 1. Burden of selected diseases, by sex (DALYs per 1.000 population), Serbia without Kosovo and Metohia.

Source: Atanasković-Marković Z et al. [5]

such as primary health care, training, and research municipalities in Serbia, without Kosovo is 161).
institutions. In primary health care, they cooperate with the
According to the Health Care Law, the IPHs regional IPH.
monitor, investigate and study the health status Keeping in mind that health has been included
and health culture of the population, status and by WHO in the “Hexagon of Natural Rights”,
quality of the environment, incidence and together with the right to freedom, property,
prevalence of diseases of socio-medical intellectual products, justice, and the lawful state,
significance, the influence of ecological factors on and that health itself is determined by many
health, and also the organization, work and factors, it is understandable that legislative
development of the health services with the regulations related to Public Health can be found
purpose to undertake the corresponding in many other legislative areas [23].A separate law
measures related to the health protection and on Public Health doesn’t exist yet as of today in
promotion. Dom Zdravlja (Health Centres) play an Serbia, unlike to some other countries. Despite the
important role in the health promotion and field is regulated indirectly in many ways, starting
disease prevention. They cover the area of one or from the highest legislative act “The Republic
more municipalities (the total number of Constitution”, the regulations regarding Public

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Figure 2. Life expectancy at birth, in years, female, SEE-countries, 1990-2004.

Source: Bardehle D. [48]

Health and health promotion are mainly codified Health Insurance Fund (HIF) i.e. from insurance
as social rights of the citizens, and therefore can fees. The state’s interest in the activities of the
be found even more often in the legislative areas Institutes is not defined.Therefore, there is regular
that regulate the protection of the external confusion on how big the shares from the
environment, food, and the sectors outside the government i.e. the Ministry of Health and from
health system in general (work legislation, the HIF should be. It should be noted that the
education legislation, drug sales, industrial public health service is mainly, if not exclusively,
production and consumption). In addition to financed from taxation even in countries with a
republic laws concerning the health system, there Bismarckian system like Croatia or Germany [27-
are numerous legislative acts containing 28].
regulations applicable to the Public Health [24]. The agreement on a new strategic orientation
According to the current register of the made it clear that the public health service and its
Republic Legislation in Serbia, the total number of institutions - firstly the 22 regional and local
legislative acts that are related to the Public Institutes of Public Health (IPH) in Serbia and
Health (laws, decrees, decisions, regulation book, especially the Republic Institute of Public Health
orders, by-laws) is more than 170 [25]. The “Milan Jovanovic Batut” (RIPH) in its national lead
number of existing legislative acts does not say role - need to reorganize in order to manage the
much about their implementation in practice. On new tasks [29-30]. This followed along two lines:
the contrary, the numerous violations of these acts (a) the drafting of a new public health legislation
are obvious, with just incidental sanctioning often and (b) the elaboration of a detailed proposal for
classified in the civil legislation and not the change management [31].
criminal one.
The structural characteristics and the Public health training and research
functioning of the Institutes of Public Health in It is widely accepted that education of public
Serbia are not yet regulated by a separate law or health professionals should include “not only the
legislative act, but they are regulated by the basic long recognized five core components of public
laws and their amendments (the Health Care Law health (i.e. epidemiology, biostatistics,
and the Health Insurance Law) [26] and also by a environmental health, health services
set of about 32 legislative acts primarily relating to administration, and social & behavioural sciences)
other areas. The IPHs are financed from the but that it also encompasses eight critical new
governmental budget i.e. tax money and by the areas: informatics, genomics, communication,

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cultural competence, community-based a base for the provision of a postgraduate master

participatory research, policy and law, global of public health and for continuing education
health, and ethics” [32]. The ethical basis of the adopting the basic modules contained in the
New Public Health approach and professional programme for a degree of a European Master of
education are equity, solidarity, subsidiarity, Public Health [36- 38]. The list of those modules
sustainability, participation, efficiency, justice and includes the following five key areas of education
peace [33]. At the same time, these values provide in the domain of public health:
a cornerstone of the framework for the strategic • Public health in Europe,
orientation of Public Health in Serbia. • Epidemiology and biostatistics,
In such environment the School of Public • Health policy and management,
Health was founded in the summer of 2004 - with • Health promotion, health education and social
support from the European Union and its sciences,
European Agency for Reconstruction (EAR) • Environment and health.
through one of the components of their project Programmes of continuing education intended
“Support to the Public Health Development in for public health workers of different professions,
Serbia (SPHDS)”- as a functional unit of the School coming from different institutions, are organised
of Medicine and under the umbrella of the on the basis of previously developed modules.
University of Belgrade.At the macro level the most During a two period more than 550 public health
important step was a Health Policy Document professionals passed through a programme of 3 to
adopted in 2002, with a definition of the main 5 days of continuing education. The Public Health
directions for sustainable development, being a Summer Campus 2005 in Belgrade started as a
continuous process within the transition of the pilot dedicated to five important and future-
entire socio-economic system. It presupposes the oriented Public Health topics, coordinated by
“Improvement of the human resources for health international experts:
development” [11]. In the same year of 2002 a • The Health Policy of the European Union
comprehensive assessment of public health • Public Health Genetics
training needs was performed in Serbia [12]. The • Working with the Private Sector
main obstacles for change identified by the • Quality Management of the Health Services
Directors of the Institutes of Public Health were: • Public Health Pharmacotherapy and Public
inappropriate legislation (100%), the lack of Health Nutrition.
financial resources (85%), and the lack of properly Development of partnerships and joining the
trained staff (50%). Also the need was noticed for network of health institutions are significant
more communication and collaboration between elements of the School of Public Health’s success
the Institutes of Public Health and sometimes [39]. The Centre – School of Public Health in
even between the departments of the same Belgrade is a model for new structures in training
institute. and research. The format described here we
The “School of Public Health” was therefore believe can together with the other new schools
established in Serbia to support postgraduate as in South Eastern Europe serve as a model of how
well as continuing education in public health, to establish new structures in a rigid inherited
health policy and the management of health system.
services [34]. Starting from the results of this
situation analysis regarding training needs, a Conclusions
position paper on the establishment of a Centre – Today the public health systems are far too
School of Public Health was agreed [35] outlining complex to be managed only centrally.The more it
the following operational objectives: is essential to establish an ongoing public debate
• Education of capable experts in the field of and a responsive political process that is
public health, grounded on evidence based information and
• Improvement of knowledge in the health training. However, as financial and intellectual
sciences, resources are limited everywhere it is mandatory
• Health promotion in cooperation with the local to set strategic priorities and give direction to this
communities, process. This is the task of strategy formulation
• Training of competent researchers in the field of and consensus building among all stakeholders.
public health, The main infrastructure for this permanent
• Improvement of the process of decision-making process, i.e. the Institutes of Public Health and
and policy formulation. Schools of Public Health, their rights and duties,
The organizational structure is set up to provide have to be formalized and confirmed through

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appropriate and specific legislation in terms of a it is the essence of the health sciences – as the
public health law. Serbia has assembled all of the scientific dimension of public health - to cope
necessary elements, but fails to connect them in a with different paradigms developed and firmly
Framework for Public Health Development. The established over decades. In this paper we argue
regional collaboration is supported by The for an integrated approach in spite of all
Dubrovnik Pledge of 2001 [40]. Many of the conceptual and practical difficulties. The multi-
transitional changes in the country have the professionality at the Institutes of Public Health
potential to facilitate the harmonization with EU and the corresponding inter-disciplinarity at the
standards and other international public health academic Schools of Public Health provides the
policies [41]. institutional environment if the resources of skills,
However, Serbia and the region of South Eastern knowledge and experience are adequately
Europe share a number of common features that managed – in a participatory and supportive
continue to be barriers towards attracting trade system representing a flat hierarchy (“Horizontal
and investment. These include visa regimes, trade Management” [42- 44].
barriers, poor legal enforcement, organized crime The federal state of Northrhine-Westphalia in
and corruption, political instability, poor Germany has been especially successful in
transportation networks, and the yet unresolved implementing a supportive structure for
final status of Kosovo. Weaknesses constraining horizontal consensus management in health care:
the development of public health are identified in In the new health legislation of 1997 [45-47]
the fields of organization of the public health health conferences are established as well at the
system, its financing, human resources state level, chaired by the Ministry of Health itself
management, public health information system, as at the communal level, chaired by the head of
legislation and ethical issues. The organizational the local health office which also has to organize
framework of public health in Serbia and political its proceedings. Members to be invited are among
as well as economic instability are aggravating and others: Medical Chambers, Pharmacists’
perpetuating the inadequacy of resources. Chambers, Hospital Association, Health
Frequent changes in political orientation result in Insurances, Social Insurances, State Board of
lack of a proper formulation of operational plans. Counties & Cities, Employers’ Association, Trade
Furthermore, misunderstanding the regional Unions, Occupational Hazard Insurances, Social
needs by international donors and the insufficient Welfare Association, Self Help Associations,
external funding might also constrain the overall Regional Administrations, and Regional Boards.
sustainability of public health development. It is obvious that this outline applies only to
Strategic planning and stability of strategic open societies where an inter-play can develop
decision making is necessary at all levels of between the people and the administration.
government and should include the non- However, undemocratic closed societies do not
governmental sector in that process. In particular, seem to have a competitive potential for dynamic
planning should assess local public health development, at least not in the long run.
strengths and weaknesses, set goals and establish
priorities, and identify resources and organize Acknowledgments
actions to meet those goals. Local public health We are grateful to the Ministry of Health,
professionals need to enact policies to promote Republic of Serbia, Ministry of Science and
public health sustainability and development. Technological Development, Republic of Serbia
Hence, building on current potentials does not and to the EU Agency for Reconstruction for the
mean to walk in the clouds with reality out of support given to the authors in Serbia.
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