Serbia: Sick Health Service Needs First Aid

At the Belgrade Institute of Urology, head nurse Liljana Nikolic takes unusual measures to compensate for years of underinvestment in the nation’s hospitals.

Touring the luxurious foreign-owned hotels in the new part of the city, she asks them to donate their spare linen, which they no longer need because it is torn or blemished. The building where she works is crumbling and crowded. "It’s all falling apart," she said, pointing to a ward where 30 patients – most with cancer - share one bathroom and two toilets.

With its ravaged 80-year-old façade, warehouse-style entrance, grey corridors and crowded lavatories, the urology institute is a symbol of Serbia’s failing health service. Virtually ignored under Slobodan Milosevic’s 12-year regime, when money was channelled into nationalist military projects, the health service is on its last legs.

Money is short. Whereas Britain annually spends 1,500 US dollars per person on health, Serbia and Montenegro spends 50. The monthly salaries of the country’s 26,000 doctors average 20,000 dinars, or around 300 euro - a fraction of what counterparts earn in the West.

The 130,000 workers in the state health system are a demoralised army. From October 2 until late December last year about half were on strike, demanding pay increases. The government could not even consider their demands, as the budget for 2004 had not been adopted owing to early parliamentary elections in December 2003. The health service unions have warned they will resume their strike the moment a new government is formed.

Although health workers’ salaries are low, they consume 60 per cent of the 1 billion euro total health budget. Many officials are demanding staff cuts. "The system we have now is excessive,” said the health minister, Dragomir Marisavljevic. “It is too bulky and inert. It must be reshaped.”

In the meantime, underpaid hospital staff work part-time in private clinics to make ends meet - to the detriment of their jobs in the state sector.

Milan Spuran has worked for 13 years at the state-run Serbian Clinical Centre in Belgrade. “Even including night shifts, my salary is only 24,000 dinars (350 euro)," he complained. In spite of holding down a key job, he cannot buy an apartment, which is why he works part-time elsewhere. "I do private medical examinations at times and also provide consulting services,” he said. “Hopefully, our salaries will soon be higher and our equipment repaired and replaced.”

But Spuran’s hopes are unlikely to be realised soon. Though some new equipment has been purchased, including X-ray machines, ambulances and new operating theatres, real structural improvement depends on continued foreign aid.

According to the health ministry, foreign aid for health has so far amounted to about 100 million euro. Another 50 million euro is in the pipeline in the form of a loan from the European Investment Bank. But this money has been held up in parliament after some opposition deputies complained it was adding to the country’s massive foreign debt.

Health care representatives are demanding ratification of the loan, pointing out that there is no time limit on the repayment. They warn that without the money, they might soon be unable to provide even a minimum service.

Surgery and basic hospital care remain free of charge in Serbia and Montenegro, but patients already have to pay for an increasing percentage of their medical bills. For people on low salaries, these sums are frightening.

Milinko, 52, is not only concerned about whether he will survive complex surgery but about the cost of post-operative medications. A doctor has sent his family a long list of drugs and therapies that he will need to purchase for himself.

"I have already spent about 10,000 dinars (150 euro) on medication and other materials before surgery," said Milinko, who earns 17,000 dinars monthly. After, he says he will have to spend several thousand more, "I will have to pay for it all, so my family is economising on other things."

Milinko appears confused by his plight. His small hospital room is decrepit with dirty walls on which paint has peeled away. On a beside table lies the remains of a meagre hospital meal, which Milinko has not eaten.

Even when the sums required of patients amount only to a few hundred dinars, it is a heavy burden, especially to people on pensions or refugees. Vojo, 55, a refugee from Drvar, in north-west Bosnia, was trying to beg for 200 dinars from passers-by in front of a clinic where his wife is undergoing treated for cancer. “So far I've paid more than 150 euro for examinations and now the doctors have told me to buy medication which costs 200 dinars,” he said. “It embarrasses me to beg but I have no one here in Belgrade to borrow from.”

The grinding poverty afflicting patients and health workers alike creates a fertile breeding ground for bribery. In January, a police anti-corruption unit detained Laslo Svirtlih, head of the Miroslav Zotovic clinic, on suspicion of demanding unauthorised payments from his patients.

Svirtlih was accused of insisting on a down payment of 300 euro to admit a patient to his hospital and then another 100 euro to extend his treatment few days later. The police caught him receiving money, having been informed beforehand. The family of the patient had marked the banknotes that they handed over. He is currently awaiting trial.

Zoran Ilic, leader of a union with many health worker members, says combating crime within the system should be a priority, but that "small progress has been made in this respect". In reality, petty corruption has been part of the health system for years. Patients often expect to routinely hand doctors “gifts” in cash or objects to secure proper treatment.

Tomica Milosavljevic, a former health minister, insists Serbia still possesses a relatively well developed network of health institutions and that the problem comes down to poor maintainance. “Many of our problems are simply banal ones,” he said, “like burst pipes, windows that won’t shut, inadequate heating and poor food for patients.”

Milosavljevic blames a relatively low level of health insurance, which is mandatory but only 11 per cent of incomes, as opposed to a European average of at least 13 per cent. He also wants to see higher percentage of public spending going towards health care.

While he and his successor, Dragomir Marisavljevic, predict an upturn in the Serbian health service over the next decade, the patients of today will have to make do with run-down facilities and overstretched staff. As one 58-year-old woman waiting for treatment in a Belgrade clinic remarked, ruefully, “People with no money can't afford to get ill.”

Zelimir Bojovic is a Deutsche Welle correspondent in Belgrade.