Aspects of the Family Medicine Concepts in South Eastern

DOI: 10.5455/msm.2014.26.277-286 Published online: 26/08/2014 Received: 16 March 2014; Accepted: 28 June 2014 Published print: 08/2014 © AVICENA 2014

CASE STUDY Mater Sociomed. 2014 Aug; 26(4): 277-286

Public Health Aspects of the Family Medicine Concepts in South Eastern Europe

Izet Masic1, Miran Hadziahmetovic1, Doncho Donev2, Azis Pollhozani2, Naser Ramadani3, Amira Skopljak1, Almir Pasagic1, Enver Roshi4, Lejla Zunic5, Muharem Zildzic5

Faculty of medicine, University of Sarajevo, Bosnia and Herzegovina1 Faculty of medicine, University of Skopje, Republic of Macedonia2 Publih health institute of Kosova, Prishtina, Kosova3 Faculty of Public health, University of Tirana, Albania4 Faculty of Health Sciences, University of Zenica, Bosnia and Herzegovina5 Corresponding author: Prof. Izet Masic, MD, PhD. Department of Family medicine, Faculty of medicine, University of Sarajevo, Bosnia and Herzegovina. E-mail: [email protected]

ABSTRACT Introduction: Family medicine as a part of the primary is devoted to provide continuous and comprehensive health care to the indi- viduals and families regardless of age, gender, types of diseases and affected system or part of the body. Special emphasis in such holistic approach is given to the prevention of diseases and health promotion. Family Medicine is the first step/link between doctors and patients within patients care as well as regular inspections/examinations and follow-up of the health status of healthy people. Most countries aspire to join the and therefore adopting new regulations that are applied in the European Union. Aim: The aim of this study is to present the role and importance of family medicine, or where family medicine is today in 21 Century from the beginning of development in these countries. The study is designed as a descriptive epidemiological study with data from 10 countries of the former Communist bloc, Slovenia, Croatia, Bosnia and Herzegovina, Serbia, Montenegro, Macedonia, Kosovo, Albania, Bulgaria, , Czech Republic, and , just about half of them are members of the EU. We examined the following variables: socio-organizational indicators, health and educational indicators and health indicators. The data used refer to 2002 and as a source of data are used official data from reference WebPages of family medicine doctors associations, WONCA website (EURACT, EQuiP, EGPRN), WebPages of Bureau of Statistics of the countries where the research was con- ducted as well as the Ministries of Health. Results: Results indicates that the failures and shortcomings of health care organizations in Southeast Europe. Lack of money hinders the implementation of health care reform in all mentioned countries, the most of them that is more oriented to Bismarck financing system. Problems in the political, legal and economic levels are obstacles for efficient a problem reconstructing health care system toward family medicine and primary prevention interventions. The population is not enough educated for complicated enforcement for and prevention of diseases that have a heavy burden on the budget. Health insurance and payment of health services is often a problem, because the patients must be treated regardless of their insurance coverage and financial situation. The decrease in production and economic growth, as well as low gross national income in the countries with economic crisis, lead to the inability of treatment for a large number of the population. Such situation a system leads to additional debts and loans to healthcare system. Measures implemented for provision of acute curative care largely did not lead to improvements in the health status of the population. Educational and preventive measures, as well as higher standards for quality and accessibility of health care services for entire population in each country, especially those struggling are bound to joining the European Union and their implementation must start. The most A large number of medical institutions are is inefficient in health education and health promotion and must work to educate patients and families and increase the quality of preventive health services. Modernization of health care delivery and joining the European Union by increasing overall economic stability of countries is one of the primary goals of all countries in Southeast Europe. Key words: primary health care, modernization, education, health care objectives, financing, payment for health care services

1. INTRODUCTION discipline; Family Medicine is the first step between doctors and pa- ■■ The first contact with the health care system; tients within care for the sick as well as regular inspections ■■ Provides comprehensive services to all family members, of healthy people. By WONCA definition from March 2002 regardless of the type of problem, age, sex; which was adopted in Noordwick, Netherlands family medicine ■■ Provides continuous care over time and in different en- is: (1) vironments; ■■ Clinical specialization and separate academic/scientific ■■ Has its own specific epidemiology and uses a specific

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process in making decisions; ist . Vulnerable groups of patients are entitled to a basic ■■ Deals with health problems in their physical, psychologi- set of free healthcare. Still, the system itself is not as effective cal, social and cultural dimensions; and work must be done to improve it. Financing of health care ■■ Provides access to the care that is oriented towards the institutions is provided by the Ministry of Health. Almost patient and which is characterized by creating a close re- 92% of Bulgaria’s population is covered by compulsory health lationship, over time, between doctor and patient; insurance. ■■ Promote good health and well-being through appropriate, 1.2. safe and effective interventions; Romania until 1960 had a system that was based on the Eu- ■■ Makes effective and safe use of resources through coor- ropean health care systems. Since 1960 until 1990 the health dination of care, management and referral of patients by care system started to stagnate. Emphasis is on 1990 and major establishing contact with other professionals. changes that have led to unemployment and poor health care. Over the past two decades in the Southeast European After joining the European Union started new reforms to im- countries there has been a great change. In addition to the prove the health care system (4). economic, political, geographic we also saw a changes on the Romania has started the health care reform and decentral- healthcare plan. ization over law on healthcare reform from 1991 (4), when was Countries in transition after the collapse of socialism are formed 42 departments that are taking care about the health faced with problems of the citizens insurance, reduced employ- care. The reforms that have been implemented in the 1990s ment, reduced number of jobs, outdated equipment and a small were financed by the World Bank under the leadership of the number of health care institutions (2). Experts are searching for . After the reform the family medicine doc- an effective and feasible way of financing health care through a tors are working in their offices completely separate from the variety of funds, in order to provide relief to courtiers budgets. system of the private sector. Social health burden is growing In addition to the disintegration of socialism, war events that constantly with 64.6% in 1998 to 82.7% of the total health occurred in the former Yugoslavia setback also a healthcare sys- services costs in 2004. tem. Additionally began the privatization of health systems, the The source of payment is a capitation, payment for services as opening of private health funds modeled on the Western system well as bonuses that realize the doctors (4). After adjusting laws and the introduction of family medicine among the population. were in 1997 districts were reformed and they are required to Before the collapse of the communist bloc in Eastern Eu- control the financing of primary health care. Health Insurance rope, began the reforms that were visible in the early ‘80s in is mandatory for a basic set of health care and the protection the United Kingdom during the reign of Margaret Thatcher of affected populations. Privatization included pharmaceutical (2). Many of these ideas are still not implemented. On the ter- activity and dentists while most of the other medical care are ritory of Yugoslavia the reason was war, while in Bulgaria and in the public sector, while the private sector is less represented. Romania the reason was political turmoil and lack of majority 1.3. of votes in the government (2). Albania before World War II had a small number of doctors. 1.1. Healthcare in Bulgaria Also, the number of institutions in Albania was small. Apart In Bulgaria, the first health law, which came into practice from doctors also religious representatives had their own hospi- was written 1918 (3). In 1924 the government has enacted the tals. Between 1945 and in 1960 the doctors were educated in the first law on health insurance which covered all the people em- Soviet Union as well as in some European countries (5). Between ployed in the private and state companies. In 1925 is adopted the the 1960 and 1970 begins the reform. In 1980 comes the law on Act on the Protection of persons who are unemployed. In the health insurance of the population. In 1990 the progress still period from 1945 up to 1990 was passed several laws related to did not occurred due to poor nutrition, poor health system, etc health care of the population. After the collapse of communism, (5). Due to the breakup of Yugoslavia, the collapse of the com- it was obvious that the health system is in complete collapse. munist system in Albania condition was bad. In 2000 was given World Bank for development and the European Union have 160 million US$ to improve the health system in Albania (5). initiated various actions and programs for the reconstruction Financing of health care in Albania before in 1990 was dis- of the healthcare system. Besides this, the acts are passed for creet. Each province was paying for health care services through privatization of the health sector. employee salaries. In political sense health was separated from Bulgaria health care reform began in 1989 (4). In addition the rest of the state funding. Hospital managers had to go to to the decentralization of the healthcare system in the system the Minister of Health regarding the salaries, employment of is included also the private sector. Financing of healthcare re- personnel, etc. Today, the health ministry has set aside a special mained the responsibility of the state until the 1998 when was fund for the payment of health workers and the maintenance passed the law on financing whose application started in 2000. of health facilities. Each province fund health institutions in HIF was established that coordinates the work of 28 institutes their region. across the country. The HIF is funded by revenues from insur- In Albania HIF was established in 1995 (4). The system is ance of the employees, while also the self-employed have to pay managed by social insurance for primary health care, hospital for health insurance. The HIF provides a basic set of health care as part of the essential drugs list. Data from 2008 say that insurance in the state or private institutions. 80% of people is still not covered by health insurance in Albania, Primary health care is paid by capitation and the principle while 60% paid health insurance by themselves (4). Primary of payment for services (4). Primary health care is the guardian health care is provided to endangered part of population, such of the passage of patients to specialized branches in , as the unemployed, pensioners, children, etc. although patients themselves can immediately go to a special-

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1.4. Healthcare in the former Yugoslavia professor Andrija Stampar which is one of the pioneers of fam- The health system of Yugoslavia was created before World ily medicine in Yugoslavia (11). In Croatia​​ during 1968 there War II. It is made by the Ministry of Health under the direc- were 960 GPs. Their scope of action was majorityepidemiology tion of Andrija Stampar. It was based on health centers and and preventive medicine. staff working within them. In addition to GPs also worked After the breakup of Yugoslavia, there was a formation of specialists of different professions as well as secondary medical a new organization of the health system. In 1993 the Act is personnel (6). designed to address the health care system under the guidance Specialization in family medicine was introduced in 1960. and control of the Croatian Ministry of Health. Among other Still an increasing role in the treatment of patients except for things, the Act prescribes medications that are on the essential specialists of various profiles were family doctors. The system list and surgical procedures covered by the health insurance was centralized until 1974 when it was transformed into a de- fund. centralized system. The main executive bodies of the state con- The primary responsibility for financing and payment have trolled the operation of all other bodies or managers of primary, Institute for Insurance. The funding is almost normal practice secondary and tertiary health care (7). Since 1974 the governing in case of vulnerable populations (children, old population, body is elected at the local government level, state or commu- the unemployed, war veterans) covered by the health insurance nity. Since 1980 in Slovenia and Croatia began implementation fund. In addition to this there is an additional service package of a system of state-private ownerships. The idea was that each of health insurance for those who want to improve their basic patient can choose a private practice or doctor for their medi- care. From 2002 the benefit to the new health insurance law cal treatment and diagnostics, while the health insurance fund that changes some of the principles of health insurance and refunded and paid to private practice. With the arrival of the introduces some new things (4). In 2005 the amendment was reforms and the war this type of health care has never come to placed on the law from the 2002. By this amendment every pa- life in its fullest extent. tient, unless patients under 18 years of age or over 80% disabled Slovenia people with a disability, have to pay 0.83 U.S.$ or 1.66 U.S.$ to Slovenia is one of the states of the former Yugoslavia. The first obtain the required services in health institutions. In addition specialization in family medicine was started in 1960, although to this part of the law was added and part of the participation of then called primary health care. Among the first was granted patients during transport and during funeral services by whose independence and first admitted to the European Union. decree reducing the proportion that is required to pay the HIF. Slovenia’s population is about 2 millions (8). In 1991 after the Bosnia and Herzegovina dissolution and separation from Yugoslavia, there have been Historical development of health care goes back in 1879 major political changes as well as changes in the health system during the Austro-Hungarian rule. The first law was passed in of the state. In 1992 the health care system is changed to a de- 1888. Organization of health care was like in other parts of the centralized system (9, 10). At the end of 2006 Slovenia has had world under the rule of the Austro-Hungarian Empire. After the 29 hospitals that were mostly built in the 1970s, but have been arrival of the Kingdom of Yugoslavia in 1918 was enacted sev- renovated. Number of beds has increased by 33% between the eral laws on health care. The health care was developed equally 1980 and 2007. Number of hospital days decreased from 10.4 throughout the territory of the Kingdom of Yugoslavia (12). days in 1995 to 6.8 days in 2007. Number of health centers has Regional Hospital in Sarajevo, opened on the July 1st 1894, increased since 1990 and now within 20km there are health and was the largest hospital facility in the region and had four centers throughout the territory of the Republic of Slovenia (10). department (204 beds) (13). The network of health institutions The main role still has the Ministry of Health which coor- and ratio of medical staffs per 1000 inhabitants at the end of dinates the operation and development of the health sector. First World War in B&H was very confort. From 1923 in B&H Institute for health care system is one and it insures all residents. opened a lot of health centers and dispensaries for providing Only the units of health care such as hospitals and clinics are lo- primary health care with concept of health promotion, home cated partly in the private sector. Health Insurance Fund covers care and polyvalent patronage based on the ideas of professor 80% of all claims for payment for medical services (10). At the Andrija Stampar as well as the entire territory of Yugoslavia. present time the biggest problem is the gap between private and From 1976 in Sarajevo, Mostar and Banja Luka till 1990 was public property. Regulation of payment in these two institutions organized Family Practice Health Care Units with model of has not yet been agreed with the government and the Ministry providing family practice at home - home care, paliative care, of Health. In July 2008 is adopted the Act on the Reform and health promotion, polyvalent patronage and health education Objectives of Health Care and Care for the period 2008-2013. of patients at home, schools, work place. Concept was based on Nowadays, after health care reform there are two depart- motto: “whole family with all members at one place of health ments of family medicine at Medical Faculties in Ljubljana care protection” and “all medical data about family members and Maribor. Educators in primary care today numbering over on one family registration card/medical record linkage” (13). 2000 trained and certified doctors that pass their knowledge to In Bosnia and Herzegovina affected by the war in 1992-1995 new generations. The family doctor has an obligation to provide there was a specific organization of the health system after the medical care within 24 hours. breakup of Yugoslavia. Each ethnic group in their area had a Croatia specially designed health care system. In Croatia, the development of health care and insurance After the signing of the Dayton Agreement established are for the population reaches to the 1922 when appeared the first the two Entities and the Brcko District which together form the private insurance companies modeled on European regula- Bosnia and Herzegovina. In the Federation of Bosnia and Her- tions. The period between the 1920 and 1930 was marked by zegovina has been proposed health care system modeled on the

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British system while the money to enable the implementation a single, centralized Health Insurance Fund within the newly provided the World Bank development fund (4). Health Care created Ministry of Health (15-20). Ministry of Health asked Act and the Law on health insurance is adopted in 1997. Each of the World Bank for assistance for further implementation of the the 10 cantons has its own health insurance fund, which is filled reform, and Macedonia became a member of the World Bank in by tax revenues and contributions from employed population. December 1993. In 1996, a comprehensive health care reform The fund is filled by contributions of the employed population was undertaken when the World Bank awarded the Ministry of in the state sector, the private sector, employed as farmers as Health a loan of US$19.4 million in order to achieve universal well as payment of certain services. access to high quality health care through developing a capita- Primary health care, which included one doctor and one tion plan for primary health care (PHC) providers and concept nurse was made in 2001, and payment on the principle of capi- of family medicine in PHC, as well as to establish cost effective tation in 2005 brought a reform which covered the majority of finance and delivery systems (16, 17). The Health Insurance Law the population. was adopted in March 2000 and the Health Insurance Fund Serbia (HIF) was established as an independent institution outside The health care system in Serbia after the changes in 1990 of the Ministry of Health. PHC reform has increased patient suffered great stagnation and degradation. After integration in choice through patient enrolment and capitation-based pay- 2000 is adopted a set of laws and regulations for health sector ment to physicians. The capitation is calculated on the basis of reform. Health Care Act and the Health Insurance Act was numbers of insured persons that have chosen a certain physician adopted in 2005. as their own primary care physician, the determined number of The mere reform of family medicine involved the selection points for each category of population group and the determined of doctors for each person individually in their health center. value of each point. Additional incentive is provided for physi- Ownership and financing is decentralized to the municipali- cians’ practices that are located in remote rural areas. ties. However, if the reform itself well designed and financed The paradigm of family medicine offers effective, efficient and by the European Agency for the Development of reform itself financially sustainable primary health care. The first initiatives was not accepted by the best medical specialists of different for introducing family medicine concept in R. Macedonia ap- profiles. The law protecting endangered population as well as peared in mid 1990s. The Government of Macedonia in 2007 the principle of capitation payment. For the majority of the adopted a document “Health Strategy of R. Macedonia by 2020 population is needed additional payment for medical services. with decision for introducing specialized family physicians as Health Insurance does not cover the full scope of costs. For the leading team members (“team leaders”) that provide health primary health care is spent 24.6% and 19.1% of the budget is services at the PHC (19, 20). Currently different profiles of spent on health centers (14). The local community participates doctors are working at the PHC level (general practitioners, with 4.4% and 0.2% from donations. Another 11.6% is earned specialists in general medicine, pediatricians, school medicine by commission from other services such as–provision of services specialists, occupational medicine specialists, gynecologists), and renting space. From this 70% is spent on salaries, 14.5% on whose qualifications are also different, which might be an ob- training and services while the medicines, equipment and other stacle to providing a comprehensive and holistic health care to supplies consumed 15%. the population (19). The decision of the Government to intro- In 2009 is published plan for the development of the medical duce highly trained specialists in family medicine in primary sector in which it concluded that today’s health care system is health care is in compliance with the global policies for achieving too large, inefficient, outdated, out of control medical, person- quality standards for offering a good, equal and quality health nel and other resources and the need to urgently launch reforms care to the whole population, in accordance with the WHO for its improvement (14). Strategy “Health for All in 21st Century” and toward the inte- Montenegro gration process of R. Macedonia for reaching the standards of The health system of Montenegro was incorporated into the European Union. According to these standards, all medical the system of Serbia until the 2006 (4). After the separation practitioners should have undergone appropriate postgraduate the system is based on the free choice of family medicine doc- training before they would be allowed to practice family medi- tors and dentists in a region that Health Center covers where cine independently. Two crucial elements in this regard need patients live. There are four types of selection for the popula- to be emphasized: tion (4) doctors for children up to 15 years (pediatric), women - Specialization in family medicine was introduced in Octo- health (gynecologists), doctors and dentists for adults. The ber 2009 and, until the end of 2012, 82 physicians passed the higher health care is possible in health centers. The system final exam and become specialist in family medicine (19, 20); of payment is provided in part through capitation and partly - Additional education, i.e. additional training for doctors through performance-related payment (4). working at the PHC level to achieve level of specialists in fam- System of insurance relies on the Health Insurance Fund of ily medicine, started from the mid 2010 through the Center Montenegro which covers around 97% of the population (4). of Family Medicine within the Faculty of Medicine in Sko- After obtaining the funds from the European Development pje. Duration of the training is from 3-12 months. Training Fund started the further modernization of health care system. consists of three different categories and locations (Center for FYR Macedonia continuous medical education, hospitals and outpatient doctors’ Health care reforms were needed in the Republic of Mace- offices). The Center was supplied with appropriate equipment donia from early phase of transition. Immediately after political by the Ministry of Health of Macedonia and the expert and changes in 1991, the Government initiated a program for health educational support was provided by the Department of Family care reforms by adopting new Health Care Law and establishing Medicine at the Faculty of Medicine in Ljubljana. A Working

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Group of selected experts from the Faculty of Medicine and 1990 until 1994 the emphasis is given to primary health care from university clinics in Skopje created clinical guidelines and as the first contact of the patient and the doctor, the principle protocols (clinical pathways) in nine priority fields for practicing of capitation payment, choosing a family doctor. In 2001 the evidence based medicine at PHC level. Until the end of 2012 Law was introduced on the basic package of health insurance more than 130 doctors completed additional training in family for every citizen. In the period until 2011 was introduced a medicine (19, 20). new reorganization of the health system, which is a image of In November 2013 the strategy of the HIF from 2014 to the system in the European Union. 2015 was presented publicly. The area that concerns doctors 1.6. Healthcare in the Czech Republic of choice at the PHC level is called “More health services at Czech health care system until 1990 was organized by the one door” with goal to introduce family doctors in the health communist system according to Semashko. Czech Republic system in Macedonia in 2015 with broadening the scope of after the breakup met with a number of problems of payment health services to be available at PHC level (echo diagnostics, for services, outdated systems and little trained personnel (24). measurement of blood sugar, lung capacity, some services from Such a system demanded reforms that began in 1990. Payment the general surgery i.e. placing cannulas, replacement of stoma of health care services differed depending on whether person bags and litter, removing suture-threads, as well as eyesight is an employee or employer, and depending on whether they measurement, examination of the skin, removing foreign bod- allocated money for health care. Since 1992 begins the work ies from ears, taking microbiological samples etc.). In addition, of a small private health insurance companied. Their number HIF promoted some incentive measures for doctors and teams until 1995 increased to 27. Due to the impossibility of payment during the first 18 months of their practice and, especially for most of them are closed. In order to prevent such events has been doctors practicing in rural areas. Introducing electronic diary, established insurance fund. electronic health card and abolishing health books by replacing Health care reform began implementation during the 2005 them with electronic health record at the PHC level was pro- and 2006. In addition to hospitals, reform cover also primary moted as project entitled “Less administration–more time for health care. In January 2009 reform have been completed (24). patients”. HIF announced to start a campaign to promote health 1.7. in cooperation with all stakeholders in the health system and Slovakia during 1990s passed turbulent years after the col- non-governmental organizations which aims to raise awareness lapse of communism in that country. Besides Bismarck system about certain good habits such as proper diet, physical exercise began the privatization of hospitals. Due to the high corrup- and healthy lifestyle, and to combat harmful habits (smoking, tion and malfeasance system was brought to the bankruptcy. overweight etc.) and their impact on health (20). Between the 2002 and 2006 there have been significant reforms. Kosovo In 2007 year began reforms and projects related to health educa- Health care reform in Kosovo was conducted by UNMIK tion and promotion of healthy lifestyles (25). after the war in 1999. The new health care system started from According to international statistics Slovakia has a progres- “scratch” by a committee appointed by the WHO. The system sive gross national income. Indirect taxes and paying out of itself is based on the European model of health care system (21). pocket increased in the period 2002-2005. The reforms that have This way of ensuring health care consists of family medicine been implemented have improved the health care system and its doctor that serve as entry into system to further treatment and financing (25). After the elections in 2010 have been adopted care for the patient. The problem is the dualism between Alba- a new decision on further upgrading the health care system in nians and Serbs living in the same area (22). The private sector Slovakia as a standard diagnostic entering the basic insurance, is legalized in Kosovo, and in the absence of the state sector in new directions in medicine based on evidence, accreditation of some parts it replaces functioning of health care (4). The World health institutions, supervision of medical institutions, as well Bank has given the money as part of the reconstruction program. as prescribing medications and providing basic medicines to In addition to prevent fraud has signed agreements with some those who are not insured (25). institutions for primary health care. 1.5. 2. GOAL Hungary has a long tradition of health care that originated The Goal of this study is to present the role and importance from the 11th century. Ambulances were led by monks. The first of family medicine, or where is family today in the 21st Century hospital was built in Selmec 1422. The first act on the health care since the beginning of development in these countries. system was passed in the 1876. In 1840 the act was passed on health insurance of workers and farmers. By the 1940 the health 3. MATERIAL AND METHODS care system is carried out through the private sector, as well as The study was designed as adescriptive epidemiological study through some state hospitals. In 1949 the communist system with data from 10 countries of the former Communist bloc: brings about the health care law, which says that the health of Slovenia, Croatia, Bosnia and Herzegovina, Serbia, Montene- national concern. During 1950’s, 60’s and 70’s the system has gro, Macedonia, Kosovo, Albania, Bulgaria, Romania, Hungary, had great difficulty with the payment and the maintenance of Czech Republic and Slovakia. health care (23). The following variables were observed:(1) Economic and After the fall of communism was established the new govern- organizational data, (2) health and educational indicators (3) ment. The law that they voted is based on the reconstruction of Health indicators. health care from 1990 to 1994 (23). The model has allowed the The data used refer to the period 2002-2012, and as a source differentiation of local government of the state, authority over of data were used official data from reference web pages of hospitals, clinics and health centers. During the period from associations of family medicine doctors, WONCA website

Mater Sociomed. 2014 Aug; 26(4): 277-286 • CASE STUDY 281 The highest claims for health care per capita per U.S. dollar exchange rate have: Slovenia Resultssults and the Czech Republic, while the lowest has: Serbia and Montenegro. Bosnia and

1.1. Economic andand organizationalorganizational indicatorsindicators Herzegovina is located in the lower part of the table (Figure 4) (22,23,24,53).

Of the total numbernumber ofof observedobserved countriescountries ofof SouthSouth EasternEastern EuropeEurope (n=12), (n=12), the the Ofhighest highest the gross totalgross number of observed countries of Southeast Europe (n=12), Bosnia and The highest claims for health care per capita per U.S. dollar exchange rate have: Slovenia domestic product (GDP) per capita has Croatia ($ 9,000), followed by SloveniaHerzegovina ($ 8,400), has the highest claims for health care in the private sector (63.2%), followed by domestic product (GDP) per capita has Croatia ($ 9,000), followed by Slovenia ($ 8,400),and the Czech Republic, while the lowest has: Serbia and Montenegro. Bosnia and Public Health Aspects of the Family Medicine Concepts in SouthAlbania Eastern (35.4%), Europe Slovenia (25.1%) and Hungary (25.0%), while the lowest claims in the Serbia ($($ 8,200),8,200), whilewhile thethe countrcountriesies withwith thethe lowestlowest GDPGDP are are:: Albania Albania ($ ($ 3.700), 3.700), Bulgaria BulgariaHerzegovina ($ ($ is located in the lower part of the table (Figure 4) (22,23,24,53). 4800)4800) andand SlovakiaSlovakia ($($ 5,700).5,700). BosniaBosnia andand HerzegovinaHerzegovina isis locatedlocated inin thethe middle middleprivate of of the the table, Ofsectortable, the totalhave number the Czechof observed Republic countries (8.6%) of Southeast and SlovakiaEurope (n=12), (10.7%) Bosnia (Figure and 5) with itsits GDPGDP perper capitacapita ofof $$ 7,5007,500 (Figure(Figure 1)1) (22,23,24,53)(22,23,24,53). . (22,23,24,53)Herzegovina. has the highest claims for health care in the private sector (63.2%), followed by Albania (35.4%), Slovenia (25.1%) and Hungary (25.0%), while the lowest claims in the Bosnia and Herzegovina 36,8 63,2 CroatiaCroatia 90009000 private sector have the Czech Republic (8.6%) and Slovakia (10.7%) (Figure 5) Albania 64,6 35,4 SloveniaSlovenia 84008400 (22,23,24,53). Slovenia 74,9 25,1 SerbiaSerbia 82008200 Hungary 75,0 25 MontenegroMontenegro 78007800 Bosnia and Herzegovina 36,8 63,2 Montenegro 75,4 24,6 BosniaBosnia andand HerzegovinaHerzegovina 75007500 Albania 64,6 35,4 Romania 79,2 20,8 CheckCheck RepublicRepublic 74007400 Slovenia 74,9 25,1 Serbia 79,2 20,8 HungaryHungary 68006800 Hungary 75,0 25 CroatiaMontenegro 75,481,8 24,6 18,2 FYRFYR ofof MacedonicaMacedonica 68006800 BulgariaRomania 82,179,2 20,8 17,9 RomaniaRomania 65006500 FYR of Macedonica Serbia 79,284,9 20,8 15,1 SlovakiaSlovakia 57005700 Croatia 81,8 18,2 Slovakia 89,3 10,7 BulgariaBulgaria 48004800 Bulgaria 82,1 17,9 Check Republic 91,4 8,6 AlbaniaAlbania 37003700 FYR of Macedonica 84,9 15,1 Slovakia0% 10% 20% 30% 40%89,350% 60% 70% 80% 10,790% 100% 00 10001000 20002000 30003000 40004000 50005000 60006000 70007000 80008000 900090001000010000 Check Republic 91,4 8,6 GDPGDP ($) ($) per per capita capita General governmental claims for health care Private claims for health care 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

General governmental claims for health care Private claims for health care Figure 1. GDPFigureFigure per 1 1capita.. GDPGDP in perper countries capitacapita inofin countriesSEcountries Europe of of SE SE Europe Europe Figure 5Figure. Claims 5. Claimsfor health for carehealth from care state from and state the and private the privatesector sectorin the in countries the of South countriesFigure 5. Claimsof South for Eastern health care Europe fromEastern state andEurope the private sector in the countries of South Eastern Europe SloveniaSlovenia 821,0%821,0% 24063 Check Republic 23886 177 24063 CheckCheck RepublicRepublic 407,0%407,0% Check Republic 1610 23886 177 Bosnia and Herzegovina 16101477 CroatiaCroatia 394,0%394,0% Bosnia and Herzegovina 133 1477 133 577 Hungary 577 Hungary 345,0% Hungary 577 Hungary 345,0% 577 The largest number of state owned health institutions was415415 recorded in Hungary (n=577) and Slovakia 216,0% Albania Albania Slovakia 216,0% 415415 158158 MontenegroMontenegro 120,3%120,3% Albania (n=415),Serbia whileSerbia the data for the registered private institutions was available only for 158158 64 Romania 117,0% Slovenia 64 Romania 117,0% the Czech RepublicSlovenia (n=23,886) and Bosnia64 and Herzegovina (n=1477) (Figure 6) 3664 FYRFYR ofof MacedonicaMacedonica 115,0%115,0% Croatia 36 Croatia 36 Bosnia and Herzegovina is located in the middle of the bottom part of the table(22,23,24,53) with 85%. 1836 Total number of registered heath institutions Bosnia and Herzegovina 85,0% Montenegro Bosnia andBosnia Herzegovina and Herzegovina is located 85,0%in the middle of the bottom part of the table with 85% 18 18 Total number of registered heath institutions Montenegro 16 Number of registered private institutions (Figure 2) (22,23,24,53)BulgariaBulgaria. 81,0%81,0% The highest density Slovakiaof health facilities18 per 100,000 citizens is found in the Czech Republic 16 16 NumberNumber of of state registered owned health private institutions institutions (Figure 2) (22,23,24,53). Slovakia 4 Albania 48,0% Romania Albania 48,0% 4 16 Number of state owned health institutions (232.1), followed by: Bosnia 4and Herzegovina (42.7) and Albania (13.2), while countries Serbia 7,0% Romania Serbia 7,0% 1 4 10 100 1000 10000 100000 The largest expenditures for health care by U.S. dollar exchange rate has Slovenia,such as RomaniaCzech (0.02), Slovakia (0, 29) and CroatiaLogarithmic (0.82) scale are the countries with the lowest The largest expenditures for0 health100 care200 by 300U.S. 400dollar500 exchange600 700rate has800 Slovenia,900 Czech 1 10 100 1000 10000 100000 0 100 200 300 400 500 600 700 800 900 Republic and Hungary, while the lowest have: Serbia, Albania and Bosnia anddensity. Herzegovina Data for other countries covered byLogarithmic the study scale were not available (Figure 7) Republic FigureandFigure Hungary, 2. Total 2. Total whileexpenditure expenditure the lowest per percapita have: capita in Serbia, the in countriesthe Albania countries of SEand of Europe BosniaSE Europe and HerzegovinaFigure 6. Number of health facilities by type of sector in the countries of South (Figure 3) (22,23,24,53)Figure 2. Total. expenditure per capita in the countries of SE Europe(22,23,24,53) Figure. 6. Number of health facilities by type of sector in the countries of South Eastern (Figure 3) (22,23,24,53). Eastern Europe Europe Figure 6. Number of health facilities by type of sector in the countries of South Eastern The highest total expenditure per capita has Slovenia (821%), Czech Republic (407%) and The highest total expenditureSlovenia per capita has Slovenia (821%), Czech Republic1545,0 (407%) and Check Republic 232,0679 Slovenia 1545,0 Europe Croatia (394%), Checkwhile Republic Serbia has the lowest (7%), Albania (48%)1290,0 and Bulgaria (81%). Croatia (394%), Checkwhile Republic Serbia has the lowest (7%), Albania (48%)1290,0 and Bulgaria (81%).Bosnia and Herzegovina 42,7444 Hungary 914,0 Hungary 914,0 Croatia 726,0 Albania 13,1526 Croatia 726,0 Slovakia 681,0 Hungary 5,7742 Slovakia 681,0 Montenegro 582,2 Montenegro 582,2 Slovenia 3,1681 Romania 460,0 Romania 460,0 Serbia 2,1286 FYR of Macedonica 331,0 FYR of Macedonica 331,0 Bulgaria 303,0 Croatia 0,8152 Bulgaria 303,0 Bosnia and Herzegovina 268,0 Bosnia and Herzegovina 268,0 Slovakia 0,2960 Albania 150,0 Albania 150,0 Romania 0,0188 Serbia 26,0 Serbia 26,0 0 200 400 600 800 1000 1200 1400 1600 1800 0 50 100 150 200 250 0 200 400 600 800 1000 1200 1400 1600 1800

Figure 3Figure. Health 3. Healthexpenditures expenditures per U.S. per dollar U.S. dollarexchange exchange rate in rate the in countries the countries of SE Figure EuropeFigure 7. The 7. density The density of health of health facilities facilities per 100,000per 100,000 inhabitants inhabitants in countries in countries of South Figure 3. Health expenditures per U.S. dollar exchange rate in the countries of SE Europe of SE Europe of South Eastern Europe Eastern Europe

Slovenia 1157,0 2. Health and educational indicators Slovenia 1157,0 12 Check Republic 1031,0 Check Republic 1031,0 8 Hungary 686,0 Hungary 686,0 The countries withCheck the Republic highest number of public medical7 faculties are: Romania (n=12), Slovakia 608,0 Slovakia 608,0 Bosnia and Herzegovina 5 Croatia 593,0 Bulgaria (n=8) and CzechAlbania Republic (n=7). 4Following, Bosnia and Herzegovina (n=5), Croatia 593,0 Romania 365,0 Hungary 4 Romania 365,0 Albania, Hungary, Croatia and Serbia (n=4), Slovakia and Macedonia (n=3), Slovenia has FYR of Macedonica 281,0 Serbia 4 FYR of Macedonica 281,0 Bulgaria 248,0 two medical faculties andCroatia Montenegro has one4 medical school (Figure 8) (22,23,24,53). Bulgaria 248,0 Bosnia and Herzegovina 99,0 Slovakia 3 Bosnia and Herzegovina 99,0 FYR of Macedonica 3 Albania 97,0 Albania 97,0 Slovenia 2 Montenegro 16,9 Montenegro 16,9 Montenegro 1 Serbia 16,0 Serbia 16,0 0 2 4 6 8 10 12 14 0 200 400 600 800 1000 1200 1400 0 200 400 600 800 1000 1200 1400 Number of medical faculties

Figure 4. FigureClaims 4. for Claims health for per health capita per per capita U.S. per dollar U.S. exchange dollar exchange rate in ratethe countriesin the of SouthFigureFigure 8. The 8. The number number of ofmedical medical faculties faculties in the in states the statesof SE ofEurope SE Europe Figure 4. Claims for health per capita per U.S. dollar exchange rate in the countries of South Eastern Europe countries of South Eastern EuropeEastern Europe

a purpose-created database. The data were analyzed by using 600 (EURACT, EQuiP, EGPRN), web page of the Bureau of Sta- Microsoft RomaniaOffice 2010 (8). 816 115 Bosnia and Herzegovina 126 tistics of the countries where the research was conducted as well 100 Slovakia 100 as the Ministries of Health (21). 4. RESULTS 90 Check Republic 100 80 Data collected in the above manner were then entered in EconomicHungary and organizational80 indicators 50 Croatia 50 25 Serbia 30 CASE STUDY25 • Mater Sociomed. 2014 Aug; 26(4): 277-286 282 Slovenia 30 11 Albania 11 10 FYR of Macedonica 10 0 200 400 600 800 1000 Number of residents Number of persons who started residency in family medicine Number of residents who completed education in family medicine

Figure 9. The number of participants and of those who completed residency in family medicine in the countries of South Eastern Europe

In Macedonia, Albania, Croatia, Hungary and Slovakia all students who begin training in family medicine complete the specialization. Of the total number of participants in the education in family medicine in Bosnia and Herzegovina (n=126), 115 of them or 91.3% complete residency in family medicine. Of the total number of participants at the beginning of specialization in the Czech Republic a total of 90% of them complete the specialization, in Slovenia and Serbia 83.3% and 73.5% in Romania (Figure 9) (22,23,24,53). 12 8 Check Republic 7 Bosnia and Herzegovina 5 Albania 4 Hungary 4 Serbia 4 Croatia 4 Slovakia 3 FYR of Macedonica 3 Slovenia 2 Montenegro 1

0 2 4 6 8 10 12 14 Public Health Aspects of the Family MedicineNumber Concepts of medical in faculties South Eastern Europe

Figure 8. The number of medical faculties in the states of SE Europe

Of the total number of observed countries of South Eastern 600 Romania 816 Europe (n=12), the highest gross domestic product (GDP) per 115 Bosnia and Herzegovina 126 100 capita has Croatia ($ 9,000), followed by Slovenia ($ 8,400), Slovakia 100 90 Serbia ($ 8,200), while the countries with the lowest GDP are: Check Republic 100 80 Albania ($ 3.700), Bulgaria ($ 4800) and Slovakia ($ 5,700). Hungary 80 50 Croatia 50 Bosnia and Herzegovina is located in the middle of the table, 25 Serbia 30 25 with its GDP per capita of $ 7,500 (Figure 1) (22,23,24,53). Slovenia 30 11 The highest total expenditure per capita has Slovenia (821%), Albania 11 10 Czech Republic (407%) and Croatia (394%), while Serbia has FYR of Macedonica 10 the lowest (7%), Albania (48%) and Bulgaria (81%). Bosnia and 0 200 400 600 800 1000 Number of residents Herzegovina is located in the middle of the bottom part of the Number of persons who started residency in family medicine In Montenegro, Serbia,Number Croatia of residents and who Slovenia completed educationspecialization in family medicine in family medicine lasts four table with 85% (Figure 2) (22,23,24,53). years, unlike Slovakia, where specialization is 3.5 years. In the Czech Republic, Romania, The largest expenditures for health care by U.S. dollar ex- Figure 9. The number of participants and of those who completed residency in Bulgaria, Hungary, Macedonia and Bosnia and Herzegovina specialization lasts three years, change rate has Slovenia, Czech Republic and Hungary, while family medicine in the countries of South Eastern Europe the lowest have: Serbia, Albania and Bosnia and Herzegovinabut Figureonly in 9 Albania. The number last two of yearsparticipants (Chart and10) of(22,23,24,53) those who completed. residency in family (Figure 3) (22,23,24,53). medicine in the countries of South Eastern Europe 4,0 The highest claims for health care per capita per U.S. dollar 4,0 In Macedonia, Albania, Croatia, Hungary and Slovakia all students who begin training in exchange rate have: Slovenia and the Czech Republic, while the 4,0 family medicine complete the specialization. Of the total number of participants4,0 in the lowest has: Serbia and Montenegro. Bosnia and Herzegovina is Slovakia 3,5 located in the lower part of the table (Figure 4) (22,23,24,53).education in familyCheck medicine Republic in Bosnia and Herzegovina (n=126),3,0 115 of them or 91.3% Of the total number of observed countries of Southeast completeEu- residency in Romaniafamily medicine. Of the total number of participants3,0 at the beginning Bulgaria 3,0 rope (n=12), Bosnia and Herzegovina has the highest claimsof for specialization in theHungary Czech Republic a total of 90% of them complete3,0 the specialization, in health care in the private sector (63.2%), followed by AlbaniaSlovenia and SerbiaFYR of Macedonica 83.3% and 73.5% in Romania (Figure 9) (22,23,24,53)3,0 . (35.4%), Slovenia (25.1%) and Hungary (25.0%), while the low- Bosnia and Herzegovina 3,0 Albania 2,0 est claims in the private sector have the Czech Republic (8.6%) 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 and Slovakia (10.7%) (Figure 5) (22,23,24,53). Duration of residency (years) The largest number of state owned health institutions was recorded in Hungary (n=577) and Albania (n=415), while the Figure 10. Duration of residency (years) in family medicine in the countries data for the registered private institutions was available onlyFigure for 10of. DurationSouth Eastern of residency Europe (years) in family medicine in the countries of South Eastern 300 Europe the Czech Republic (n=23,886) and Bosnia and Herzegovina 259

(n=1477) (Figure 6) (22,23,24,53). 250 235

218 The highest density of health facilities per 100,000 citizens 206 195 192

3. Health indicators200 186 178 167 is found in the Czech Republic (232.1), followed by: Bosnia 163 163

The lowest 150mortality rate in the age group <5 years for males have Slovenia and the Czech and Herzegovina (42.7) and Albania (13.2), while countries 132 110 108

Republic (5.0/100,000), while the highest98 mortality rates in this age group for males is in such as Romania (0.02), Slovakia (0, 29) and Croatia (0.82) are 94 94 90 100 89 79 72 72 71 the countries with the lowest density. Data for other countriesAlbania (27/100.000) and Romania 68 (22.0/100,000) and Bosnia and Herzegovina Mortality per 100,000 inhabitantns 100,000 per Mortality 50 27

covered by the study were not available (Figure 7) (22,23,24,53). 23 22 20

(20.0/100,000). The lowest mortality rate in the age group <5 years19 for females also have 17 17 17 15 15 15 14 13 11 10 10 9 9 8 7 5 5 4 4 Health and educational indicators Slovenia and0 the Czech Republic (4.0/100,000), while the highest mortality rates in this age The countries with the highest number of public medical fac- SLO CRO BIH SRB MNE MKD HUN ALB BGR ROU CZE SVK group is in Albania (23/100.000) and Romania (19.0/100.000), and Bosnia and Herzegovina, ulties are: Romania (n=12), Bulgaria (n=8) and Czech Republic <5 yrs. Male <5 yrs. Female 15-59 yrs. Male 15-59 yrs. Female Macedonia and Bulgaria (15.0/100,000) (22,23,24,53). (n=7). Following, Bosnia and Herzegovina (n=5), Albania, FigureFigure 11. 11. Mortality by bythe the age agegroups groups per 100.0000 per 100.0000 inhabitants inhabitants in countries in of countries South Hungary, Croatia and Serbia (n=4), Slovakia and Macedonia Eastern Europe of South Eastern Europe (n=3), Slovenia has two medical faculties and Montenegro has The lowest mortality rate in the age group 15-59 years for males is in Montenegro one medical school (Figure 8) (22,23,24,53). Bulgaria 21,7% (132.0/100,000), SloveniaCroatia and the Czech Republic (163.0/100,000), while the21,7% highest In Macedonia, Albania, Croatia, Hungary and Slovakia all mortality rates inHungary this age group for males are in: Hungary (259/100,000),20,0% Romania Slovenia 19,8% students who begin training in family medicine complete the (235/100,000) and Bulgaria (218.0/100,000). The lowest mortality rate in the age group 15- Romania 18,9% specialization. Of the total number of participants in the edu- 59 years forCheck females, Republic too, have Montenegro (68.0/100,000), Slovenia (71.0/100,000),18,8% Czech cation in family medicine in Bosnia and Herzegovina (n=126), Republic and MontenegroCroatia (72.0/100,000), while the highest mortality rates in this18,6% age group for is 115 of them or 91.3% complete residency in family medicine. in Hungary (110/100.000)Serbia and Romania (108.0/100,000) (22,23,24,53). 18,4% FYR of Macedonica 17,6%

Of the total number of participants at the beginning of special- Slovakia 15,5% ization in the Czech Republic a total of 90% of them complete In Bosniapercent and, the Herzegovina highest mortality in the population above 60 years15,3% of age was observed in the specialization, in Slovenia and Serbia 83.3% and 73.5% in Bulgaria and CroatiaAlbania (27.1%), while the lowest9,5% in Albania (9.5%) and Bosnia and Romania (Figure 9) (22,23,24,53). Herzegovina (15.3%) (Figure0 12) (22,23,24,53)5 . 10 15 20 25 Mortality in age group >60 years In Montenegro, Serbia, Croatia and Slovenia specialization in family medicine lasts four years, unlike Slovakia, where Figure 12. Mortality in age group over 60 years in countries of South Eastern specialization is 3.5 years. In the Czech Republic, Romania,Figure 12. Mortality in age group over 60 years in countries of South Eastern Europe Europe Bulgaria, Hungary, Macedonia and Bosnia and Herzegovina specialization lasts three years, but only in Albania last Intwo all the countriesThe lowest of SE Europe,mortality the ratemost in common the age aregroup cardiovascular <5 years for disease maless, with the years (Chart 10) (22,23,24,53). highest ratehave of incidenceSlovenia in and Bulgaria the Czech(4.478/100.000), Republic Hungary (5.0/100,000), (4.193/100.000) while and Bosnia Health indicators and Herzegovinathe highest (4.016/100.000). mortality Therates lowest in this rate age of developinggroup for cardiovascularmales is in Al disease- are in Slovenia (1.602/100.000) and Croatia (2.373/100.000). The highest incidence rate of Mater Sociomed. 2014 Aug; 26(4): 277-286 • CASE STUDY developing respiratory diseases is in Hungary (695.0/100,000) and Czech283 Republic (639.0/100,000) , while the lowest rates are in Bulgaria (320.0/100,000) and Romania (368.0/100,000). The highest incidence rate of developing malignancies have Hungary (3,044.0/100,000), Czech Republic (2,571.0/100,000) and Slovakia (2.144/100.00), while the lowest rate are in Bosnia and Herzegovina (1,429.0/100,000) and Bulgaria (1540.0/100,000). The highest incidence rate of developing genitourinary diseases have Macedonia (196.0/100,000 ) and Albania (195.0/100,000), while the lowest rates are in Slovenia (58.0/100,000) and Croatia (76.0/100,000). The highest incidence rate of developing diabetes mellitus have Hungary (369.0/100,000) and Bulgaria (349.0/100,000), while the lowest rates are in Croatia (172.0/100,000) and Albania (177.0/100,000) (22,23,24,53).

The highest incidence rate of developing musculoskeletal disorders are in Hungary (760.0/100,000), and Slovakia (753.0/100,000), while the lowest rates are in Croatia (396.0/100,000) and Slovenia (402.0/100,000) (22,23,24,53).

Romania (58.0/100,000) and Albania (55.0/100,000), while the lowest mortality rates have Serbia and the Czech Republic (9.0/100,000), as well as Croatia and Slovakia (10.0/100,000). Bosnia and Herzegovina is located in the middle of the table with a maternal Romania (58.0/100,000) and Albania (55.0/100,000), while the lowest mortality rates have mortality rate of 31.0/100,000 (Figure 15) (22,23,24,53). Public Health Aspects of the Family Medicine Concepts in SouthSerbia Eastern and Europe the Czech Republic (9.0/100,000), as well as Croatia and Slovakia Bulgaria 320 129 349 666 4478 1540 (10.0/100,000). BosniaRomania and Herzegovina is located in the middle of the table58 with a maternal Albania 55

Hungary 96 695 369 760 4193 3044 mortality rate of 31.0/100,000 (Figure 15) (22,23,24,53). Bulgaria 32 Bosnia and Herzegovina

431 168 223 666 Bosnia and Herzegovina 31

Bulgaria 4016 1429 349 320 129 666 4478 1540 Romania 58 Slovenia 17

FYR MacedoniaHungary 96 760 369 695 466 196 289 665 4193 3044

3836 1826 Albania 55 FYR of Macedonica 13 Bosnia and Herzegovina Bulgaria 32 666 223 431 168 4016 Albania 1429 Hungary 11 386 195 177 677 3696 1665 Bosnia and Herzegovina 31 FYR Macedonia 10 466 665 289 196 Slovakia 3836 Serbia 1826

416 150 287 675 Slovenia 17 Albania 2615 1922 Croatia 10 386 677 195 177 3696 1665 FYR of Macedonica 13 Romania Check Republic 9 368 101 258 666

Serbia 3481 1640 416 675 150 287 2615 1922 Hungary 11 Serbia 9 SlovakiaRomania Slovakia 10 401 147 301 753 368 666 258 101 3422 2144 3481 1640 0 10 20 30 40 50 60 70 Croatia 10 Slovakia 401 753 301 147 Maternal deaths per 100,000 inhabitants 3422 Check Republic 2144 639 129 269 507 3358 2571 Check Republic 9 Check Republic 639 507 269 129 2571 3358 Serbia 9

Croatia 76 596 172 396 2373 1761 Graph 15. Maternal mortality rate per 100,000 inhabitants in the countries of South Eastern

Croatia 76 596 396 172 1761 2373 0 10 Europe20 30 40 50 60 70 Slovenia 58 528 234 402 1602 1699

Slovenia 58 Maternal deaths per 100,000 inhabitants 528 402 234 1699 1602 0 0 10001000 20002000 30003000 40004000 50005000 6000 60007000 70008000 90008000 100009000 10000 The highest prevalence of TB has Romania (189.0/100,000) and Bosnia and Herzegovina Number per per 100,000 100,000 inhabitants inhabitants Graph 15Graph. Maternal 15. Maternal mortality mortality rate per 100,000 rate per 100,000inhabitants inhabitants in the countries in the countries of South Eastern

Cardiovascular diseases Respiratory diseases Malignant diseases (76.0/100,000), while the lowest rates are inEurope the Czech Republic (13.0/100,000) and Slovenia Cardiovascular diseases Respiratory diseases Malignant diseases of South Eastern Europe Genitourinary diseases Diabetes mellitus Musculoskeletal diseases Genitourinary diseases Diabetes mellitus Musculoskeletal diseases (23.0/100,000) (Figure 16) (22,23,24,25). Figure 13. The most common diseases in the population at 100,000 inhabitants in theThe highest prevalence of TB has Romania (189.0/100,000) and Bosnia and Herzegovina FigureFigure 13. The 13. mostThe commonmost commoncountries diseases diseases of South in the in Eastern thepopulation population Europe at 100,000at 100,000 inhabitants in the inhabitants in the countriescountries of South of South Eastern Eastern Europe Europe (76.0/100,000), while Romaniathe lowest rates are in the Czech Republic (13.0/100,000)189 and Slovenia Bosnia and Herzegovina 76 Slovakia 99,0% (23.0/100,000) (Figure Croatia16) (22,23,24,25). 73 Hungary 99,0% Slovakia 99,0% FYR of Macedonica 68 Romania 98,0% Romania 189 CheckHungary Republic 97,0% 99,0% Bulgaria 67 Bosnia and Herzegovina 76 RomaniaAlbania 95,0% 98,0% Serbia 65 Croatia 73 Croatia 94,0% Slovakia 34 Check Republic 97,0% Slovenia 94,0% FYR of MacedonicaHungary 33 68 Albania 95,0% FYR of Macedonica 92,0% BulgariaAlbania 30 67 Croatia 94,0% Bosnia and Herzegovina 92,0% SloveniaSerbia 23 65 SloveniaBulgaria 90,0% 94,0% Check RepublicSlovakia 13 34 FYR of MacedonicaSerbia 90,0% 92,0% Hungary 33 0 20 40 60 80 100 120 140 160 180 200 Bosnia and Herzegovina 84 86 88 90 92 92,0%94 96 98 100 Albania 30 Number of TBC peatients per 100,000 inhabitants Figure 14. TheBulgaria coverage of immunization of children90,0% against rubella aged <1 year in the Slovenia 23 countries of South Eastern Europe Check Republic 13 Serbia 90,0% FigureFigure 16. The 16. prevalence The prevalence of of tuberculosis per 100,000per 100,000 inhabitants inhabitants in countries in of South 0 20 40 60 80 100 120 140 160 180 200 Best coverage of immunization84 against86 rubella88 among90 children92 <194 year of96 age have98 Slovakia100 countries of South Eastern Europe.Eastern Europe Number of TBC peatients per 100,000 inhabitants and Hungary (99.0%), while the lowest coverage is in Bulgaria (90%), Serbia (90%) and Figure Figure14. The 14. coverage The coverage of immunization of immunization of children of children against against rubella rubella aged

284 CASE STUDY • Mater Sociomed. 2014 Aug; 26(4): 277-286 Public Health Aspects of the Family Medicine Concepts in South Eastern Europe

rates are in the Czech Republic (13.0/100,000) and Slovenia The largest number of educational medical institutions is (23.0/100,000) (Figure 16) (26, 27, 28). in Romania, Bulgaria and the Czech Republic. Bosnia and Herzegovina is located at the 4 place. The number of students 5. DISCUSSION who choose to specialize in family medicine is the largest in Overview of the development of family medicine in the Romania, Bosnia and Herzegovina and the Czech Republic. countries of Southeast Europe provides the possibility of under- The reason for these results lies in the fact that the number of standing also the development of health care in these countries. physician specialists in deficit and that a larger number of new Comparison of the system of education in undergraduate and family medicine doctor (12). postgraduate studies, the number of illnesses and the state of Period of residency in family medicine varies depending on the global population health in areas that have been investigated state in which residency takes place. also allow the comparison that is the basis for health care the The mortality rate of children under 5 years is highest in system. Cross-section of the results provides insight into the Albania, Romania and Bosnia and Herzegovina and the lowest further development of family medicine and the problems that mortality rate is in Slovenia and Croatia. The reason for these should be focused. results is associated with improper parenting, lack of parents The highest gross national income of the countries in the education as well as poor health care. The lowest mortality in region has Croatia, followed by Slovenia, Serbia, Bosnia and the group of 15-59 years has Montenegro and Slovenia. The Herzegovina which is located in the middle of the scale. Croatia reason for this is a good standard, health promotion, as well as unlike Bosnia and Herzegovina has developed summer tourism, regular health check-ups in health care institutions. The highest which contributes to filling the budget, and thus more payments mortality rate in this age group have Romania and Serbia. The in the health sector. Croatia is the only country that is after the reason for this situation are factors such as population migra- breakup of Yugoslavia held the growth of tourism (29, 30, 31). tion, poorly monitored and planned pregnancies, poor health Slovenia unlike the Croatia, by entering the European Union care, poor health and safety, etc (30). The population that has has lost markets and regulation that had before. Albania, Bul- the highest mortality rate is over 60 years old and most are garia and Romania are the countries affected by the transition represented in Bulgaria and Croatia. Factors that are the most after, the collapse of communism. Weak growth of production common causes of death are obesity, cardiovascular disorders, and investment have led to a low GDP. cancers. When talking about the expenditure, the highest are in Slo- The most common diseases are cardiovascular diseases, and venia, followed by Czech Republic and then Croatia. The prepa- their number is proportionate in all the neighboring coun- rations for Slovenia’s entry into the European Union have led to tries. Has the highest rate of Bulgaria, Hungary and Bosnia the need for alignment of regulations with European standards and Herzegovina. The reason for this is Improper diet, lack of in healthcare (11). Croatia also due to the aspirations for the enforcement and poor prevention of cardiovascular disease as European Union have a need to improve its health care system. well as a little sports. Countries that have been developed such Czech Republic, which is in the European Union prepares its as Croatia, Slovenia and the Czech Republic have the lowest health insurance system compatible with Europe. Serbia, Al- rate of cardiovascular disease. bania and Bosnia and Herzegovina as a countries in which the The highest rate of respiratory diseases has Croatia and reconstruction of health system has not yet been completed, as Slovenia. The reason is that these are developing countries and well as harmonization of standards with EU standards has the the air pollutants are increased. Countries in transition such as lowest cost for health care in the region (32-35). Bulgaria and Romania have the lowest rate, due to the regulated Demand for health services is highest in Slovenia, the Czech production and reduced factors that lead to respiratory diseases. Republic and Hungary. European funds and education of the Injuries of the musculoskeletal system are most present in population have led to an increase in demand of the population Albania and Serbia. The reason lies in the reduced road and for health services (12). Bosnia and Herzegovina is located on workplace safety because the work equipment is outdated and the bottom. The reason for these results lies in the fact that the poorly inspection of safety at work (16). majority of citizens is uninsured and only in emergencies seek Immunization against rubella is the best in Slovakia and doctor’s help. Hungary. The reason for this lies in the fact that they imple- The largest number of medical institutions is registered in mented numerous educations of the population under the the Czech Republic, Bosnia and Herzegovina and Hungary. The auspices of the European Union (12). The minimum coverage reason for these results is the large number of private funds in is in Bulgaria, Serbia and Bosnia and Herzegovina. The rate of the Czech Republic, unregulated market of health services in maternal mortality is the highest in Romania and Albania, while Bosnia and Herzegovina, insufficient investment in the health it is lowest in Serbia, the Czech Republic, Slovakia and Croatia. sector in Bosnia and Herzegovina, as well as a lack of person- The reasons for reduced mortality is prevention and education nel (24). Moreover big problem is the failure to report the exact as well as births in hospitals (24). number of visits to private institutions in order to reduce the The prevalence of TB is highest in Romania and Bosnia and tax on services. Herzegovina. A large number of Roma citizens is not insured. The highest density of medical institutions is located in Poor living conditions have led to an increased number of pa- the territory of the Czech Republic, Bosnia and Herzegovina tients suffering from tuberculosis (24). Slovenia and the Czech and Albania. The number of medical institutions in Bosnia Republic have the lowest incidence of tuberculosis (26, 27, 30). and Herzegovina and Albania is inversely proportional to the The prevention, inspections and standard of living have led to number of quality health services and customer satisfaction a small number of patients. with these services.

Mater Sociomed. 2014 Aug; 26(4): 277-286 • CASE STUDY 285 Public Health Aspects of the Family Medicine Concepts in South Eastern Europe

6. CONCLUSION WHO. 2006; 3: 23-42. Results indicate the failures and shortcomings of health care 12. Cain J, Duran A, Fortis A, Jakubowski E. et al. Health Care Systems in organizations in Southeast Europe. Example of the most com- Transition: Bosnia and Herzegovina. 2002; 1: 1-13. mon diseases, quality of care, the number of health facilities 13. Mašić I. Porodicna medicina - principi i praksa. Avicena. Sarajevo, and the number of doctors who are located in a particular area 2007: 7-35. of the country compared to the rest of the region. The number 14. Gajic S, Ivanovic I, Zivkovic Sulovic M. et al. Evaluation of the organi- of health facilities in the area would have to be reduced to the zation and provision of primary care in Serbia, WHO. 2010; 4: 52-66. norms of the European Union as in Croatia and Slovenia. The 15. Ivanovska Lj, Ljuma I. et al. Health Sector Reform in the Republic of biggest stumbling block is the funding and low gross national Macedonia, Croat Med J. 1999; 40(2): 181-189. Available at: http:// income. Terms of payment, insurance and levels of health care www.cmj.hr/1999/40/2/10234060.htm. Accessed: Feb 18, 2014. have to be in accordance with European standards and thus 16. Donev D. Health Insurance System in the Republic of Macedonia. to economic development of the country to improve health Croat Med J. 1999; 40(2): 175-180. Available at: http://www.cmj. care. Number of family medicine doctor must be increased hr/1999/40/2/10234059.htm Accessed: Feb 18, 2014. and provide an incentive for choosing specialization in family 17. Donev D. Health insurance system and provider payment reform in the medicine. The introduction of new technologies to diagnose Republic of Macedonia. Italian Journal of Public Health. 2009; 6(1): diseases is necessary to promptly diagnose the disease and reduce 30-39. Available at: http://ijphjournal.it/article/view/5801 the inflow of patients to secondary and tertiary levels of health 18. Ministry of Health of the Republic of Macedonia. Family Medicine in care. In this way the savings in the budget will be increased. Macedonia. [In Macedonian]. Available at: http://zdravstvo.gov.mk/ The modernization of information systems and connectivity in semejnata-medicina-vo-makedonija/ Accessed: Feb 18, 2014. a single whole would reduce the number of patients waiting as 19. Parnadzieva Zmejkova M. New reforms in healthcare in Macedonia. well as the issuance of findings. Prevention of diseases that are Maxim MK, Nov 8, 2013. [In Macedonian]. Available at: http://maxim. most common is the most important item, since chronic disease mk/zmejkova-gi-prezentirashe-novite-reformi-vo-zdrastvoto Accessed: are one of the major problems of family medicine. Networking Feb 19, 2014. of doctors and pharmacies will facilitate prescribing a sufficient 20. Plus Info MK. Famly physicians will come in 2015. [In Macedonian]. number of recipes would improve the management of chronic Available at: http://www.plusinfo.mk/vest/113522/Semejnite-lekari- diseases. Education of patients suffering from chronic diseases kje-dojdat-vo-2015-godina Accessed: Feb 19, 2014. is very important because the proper lifestyle can reduce the 21. Morikawa Masahiro J. et al, Primary Care Training in Kosovo, Fam consumption of medications and thus lead to a decrease in cost. Med. 2003; 35(6): 440-444. The 24 hours operation at the level of family medicine would 22. Dedushaj I, Raka L. et al. Medical Education in Kosova. Medical teacher. lead to a reduction in spending on secondary and tertiary levels 2011; 33: e173-e177. and significantly improve the level of health care and citizen 23. Gaál P, Szigeti S, Csere M. et al. Hungary- Health system review, WHO. satisfaction . 2011; 2: 17-52. 24. Bryndová L, Pavloková K, Roubal T. et al. Czech Republic- Health system CONFLICT OF INTEREST: NONE DECLARED. review. WHO. 2009; 3: 29-47. REFERENCES 25. Szalay T, Pažitný P, Szalayová A, Frisová S. et al.Slovakia - Health system 1. http://porodicnamedicina.com/site/index.php/ (accessed 20.12.2013). review. WHO. 2011; 2: 13-44. 2. Bartlett W, Bozikov J, Rechel B. et al. Health Reforms in South-East 26. http://www.woncaeurope.org/ (accessed 31.12.2013). Europe. Palgrave Macmillan, 2012; 1: 12-20. 27. Hoekstra M. et al. Attracting and retaining health workers in the 3. Georgieva L, Salchev P, Dimitrova R, Dimova A , Avdeeva O. et al. Bul- Member States of the South-eastern Europe Health Network. WHO. garia Health system review. WHO. 2007; 9(1): 14-22. 2011; 1: 12-13. 4. Vlădescu C, Scîntee G , Olsavszky V. et al. Romania Health system 28. http://euract.eu/resources/specialist-training (accessed 20.12.2013). review. WHO. 2008; 10(3):12-32. 29. http://www.who.int/medical_devices/countries/en/ (accessed 5. Nuri B. et al. Health Care Systems in Transition - Albania. WHO. 20.12.2013). 2010; 4(6): 110-145. 30. http://www.who.int/gho/countries/en/ (accessed 20.12.2013). 6. Shardt A. et al. Family medicine in Yugoslavia today. Canadian Family 31. http://www.euro.who.int/en/data-and-evidence/interactive-atlases/ Physician. 1968 Nov; 13): 123-129. atlases-of-burden-of-disease (accessed 20.12.2013). 7. Katić M, Jureša V, Orešković S. et al. Family Medicine in Croatia: Past, 32. Barić V. et al. Mogućnosti kontrole zdravstvene potrošnje - primjer Present, and Forthcoming Challenges. Croat Med J. 2004; 45: 543-549. Hrvatske. Ekonomskifakultet Sveučilišta u Zagrebu 2011; (2): 5-10. 8. Švab I. Progress in Family Medicine in Slovenia. Middle East Journal of 33. http://www.croatia.org/crown/articles/4446/1/E-Tourism-generate- Family Medicine. 2004; 2(2): 65-72. 22-of-Croatias-GDP.html (accessed 23.12.2013). 9. Kolšek M. et al. Implementing Electronic Medical Record in Family 34. Lawters AG, Rozanski BS, Nizakowski R, Rys A. Using patient surveys to Practice in Slovenia and Other Former Yugoslav Republics: Barriers and measure the quality of outpatient care in Krakow, Poland. International Requirements, Srp Arh Celok Lek. 2009 Nov-Dec; 137(11-12): 664-669. Journal for Quality in Health Care. 1999; 11: 497-506. 10. Švab I. Primary health care reform in Slovenia: first results. Soc Sci Med. 35. http://www.stat.si/doc/pub/IVZ-angl.pdf (accessed 30.12.2013). 1995; 41: 141-144. 11. Voncina L, Jemiai N, Merkur S. et al. Croatia Health system review,

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