ESPN Thematic Report on Inequalities in access to healthcare Serbia 2018 Ljiljana Pejin Stokic June 2018 EUROPEAN COMMISSION Directorate-General for Employment, Social Affairs and Inclusion Directorate C — Social Affairs Unit C.2 — Modernisation of social protection systems Contact: Giulia Pagliani E-mail: [email protected] European Commission B-1049 Brussels EUROPEAN COMMISSION European Social Policy Network (ESPN) ESPN Thematic Report on Inequalities in access to healthcare Serbia 2018 Ljiljana Pejin Stokic, Economics Institute, Belgrade Directorate-General for Employment, Social Affairs and Inclusion 2018 The European Social Policy Network (ESPN) was established in July 2014 on the initiative of the European Commission to provide high-quality and timely independent information, advice, analysis and expertise on social policy issues in the European Union and neighbouring countries. 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More information on the European Union is available on the Internet (http:www.europa.eu). © European Union, 2018 Reproduction is authorised provided the source is acknowledged Inequalities in access to healthcare Serbia Contents SUMMARY/HIGHLIGHTS ................................................................................................. 4 1 DESCRIPTION OF THE FUNCTIONING OF THE COUNTRY’S HEALTHCARE SYSTEM FOR ACCESS ................................................................................................................... 5 2 ANALYSIS OF THE CHALLENGES IN INEQUALITIES IN ACCESS TO HEALTHCARE IN THE COUNTRY AND THE WAY THEY ARE TACKLED ............................................................... 8 3 DISCUSSION OF THE MEASUREMENT OF INEQUALITIES IN ACCESS TO HEALTHCARE IN THE COUNTRY ........................................................................................................ 10 REFERENCES .............................................................................................................. 11 ANNEX ....................................................................................................................... 12 3 Inequalities in access to healthcare Serbia Summary/Highlights Serbia has a compulsory healthcare insurance scheme which in 2016 covered 97.5% of the population; this high rate of coverage has been maintained for several decades. The following categories are included under the compulsory insurance scheme: employed persons with fixed or temporary contracts, farmers and pensioners. There are two insurance funds, the army fund and the republic health insurance fund (HIF), the latter being the main public entity for managing the provision of healthcare. Serbia does not have a national system of health accounts, and for that reason the only available official data on healthcare expenditure come from HIF financial reports. Data on out-of-pocket payments (outside the state healthcare system) are not available, since the private healthcare sector does not provide this information and there are no official records on over-the-counter spending for pharmaceuticals. Due to the economic crisis and ongoing austerity measures, HIF revenues have been constantly decreasing since 2008. In real terms, revenues in 2017 were equal to half those in 2008. The reduction of resources has had a negative effect on the maintenance of the healthcare infrastructure and conditions of work. Drainage of the healthcare workforce is becoming a serious obstacle to improving the availability of healthcare services in public institutions. The network of state healthcare institutions is evenly distributed across the country, where primary healthcare centres are the first point of contact. Private healthcare is developing rather randomly, with minimal cooperation with the state healthcare system. Private health insurance is underdeveloped: in 2017 only about 0.02% of the population had private insurance. Within the compulsory healthcare insurance system, special support is given to vulnerable population groups to ensure proper access to healthcare. For individuals who are not regularly insured, their contribution payments are covered from the state budget. The Health insurance Law sets out a wide range of eligibility criteria for inclusion on the list of vulnerable groups, relating to: financial status, age, gender, ethnicity and medical condition. The majority of the vulnerable population groups are exempted from any co- payments, which are also subject by law to a maximum annual amount. The proportion of persons who have ‘self-reported unmet need for medical care’ has been decreasing since 2013, and reached 4.5% in 2016, while healthcare comprised 3% of household spending. Inequalities in access to healthcare are mostly caused by issues which originate outside the healthcare sector. The evasion of compulsory health insurance contributions by employers leaves employees without healthcare protection. The most prominent arrears for contribution payments are those accumulated by public companies and farmers. Efforts to enhance healthcare accessibility are hindered by the lack of a proper information system to educate patients about their rights. Available research results show that a majority of patients are not well informed about their rights. Another relevant issue is the unlawful practice of ‘under-the-table’ payments; in 2017 the Ministry of Health established a commission for fighting corruption. Overall it can be concluded that there is no significant evidence for the presence of inequalities in access to healthcare in Serbia. At the same time, the high coverage of the population with a very broad basic package of healthcare services, when combined with very constrained resources, is affecting the quality of healthcare services. Demographic projections are for a further increase in demand for healthcare, due to population ageing. Under the present conditions it is essential to initiate a reform of the healthcare sector in order to prevent its further deterioration and preserve its sustainability. 4 Inequalities in access to healthcare Serbia 1 Description of the functioning of the country’s healthcare system for access Serbia has a compulsory healthcare insurance scheme which in 2016 covered 97.5% of the population.1 There are two public health insurance funds: the army fund and the republic health insurance fund (HIF). Compulsory healthcare insurance covers every person who is employed under a permanent or temporary work contract, farmers and pensioners. Dependent family members (children, spouses and parents) who live in the same household as the insured person are also covered, if not covered otherwise. The Health Insurance Law regulates the rights and obligations of insured persons.2 Those persons and their family members covered by compulsory health insurance are entitled to the full range of healthcare protection services. The insured person attains all rights after three months of continuous payment of contributions, or after six months of contributions payments with interruptions during an 18-month period. Specific support is given to the healthcare protection of vulnerable population groups. Under article 22 of the Health Insurance Law, “an additional consideration is given for persons who are at higher risk of ill-health, for socially vulnerable persons and for treatments of diseases which have social or medical significance”. If these persons are not regularly insured the state supports their coverage and inclusion in the compulsory health insurance scheme (Annex, Table 1). Payment of insurance contributions for these persons is provided by the state budget; in 2016 20% of all insured persons were covered by this provision. Registered beneficiaries of financial social assistance are among those vulnerable population groups included on this list, as well as registered unemployed persons. All persons on this list are also exempted from co-payments for healthcare services or pharmaceuticals. The HIF adopts ‘rules on the contents and volume of rights for healthcare from compulsory health insurance and on participation payments’ (the rules) for each calendar year. Insured persons are entitled to the following: (1) healthcare protection; (2) sick and maternity leave payments; and (3) reimbursements of travel costs related to healthcare. The HIF is a public entity which operates through 31 regional branches and their local offices. Its main responsibilities are: (i) collection of compulsory contributions and other revenues; (ii) contracting of healthcare institutions