no. 011-00-00029/2024-02 date: 2.10.2024.
MINISTRY OF HEALTH
Dr. Zlatibor Lončar, minister
11000 BELGRADE
Nemanjina 22-26
Subject: Initiative for amendments to the Law on Health Care or adoption of a special act that would regulate the work of emergency services in more detail
Dear Mr. Lončar,
The Commissioner for the Protection of Equality, within the competences prescribed by the Law on Prohibition of Discrimination,[1] monitors the implementation of laws and other regulations and initiates the adoption or amendments of laws to promote equality and protection against discrimination. In this regard, bearing in mind the addresses of citizens, the practice of the Commissioner, and the available analysis and research, we are addressing you with the initiative to consider amendments to the Law on Health Care or the adoption of a special act that would regulate the work of the emergency services in more detail.
Article 21 of the Constitution of the Republic of Serbia[2] prohibits any discrimination, direct or indirect, on any basis, in particular based on race, gender, nationality, social origin, birth, religion, political or other belief, property status, culture, language, age, and psychological or physical disability.
The constitutional prohibition of discrimination is elaborated in more detail in the Law on Prohibition of Discrimination, which in the provisions of Article 2 prescribes that an act of discrimination means any unjustified distinction or unequal treatment, i.e., omission (exclusion, limitation, or giving priority), concerning persons or groups as well as members of their families, or persons close to them, openly or covertly, based on race, color, ancestry, citizenship, national affiliation or ethnic origin, language, religious or political beliefs, sex, gender, gender identity, sexual orientation, gender characteristics, income level, property status, birth, genetic specifics, health status, disability, marital and family status, convictions, age, appearance, membership in political, trade union and other organizations and other real or assumed personal characteristics[3]. The principle of equality is elaborated in Article 4 of this Law, which stipulates that everyone is equal and enjoys equal status and equal legal protection, regardless of personal characteristics, and that everyone is obliged to respect the principle of equality, that is, the prohibition of discrimination. Furthermore, Article 27 stipulates that it is prohibited to discriminate against a person or a group of persons in view of their health condition, as well as of their family members. Discrimination from paragraph 1 of this article exists especially if a person or a group of persons is unjustifiably denied the provision of health services due to their characteristics, if special conditions are set for the provision of health services that are not justified by medical reasons, a diagnosis is refused and information about the current state of health and undertaken or intended measures of treatment or rehabilitation is denied, as well as in the case of harassment, insulting and belittling during the stay in a health institution.
Article 83, paragraph 1 of the Law on Health Care stipulates that the Institute for Emergency Medicine is a health institution that provides emergency medical assistance at the site of a medical emergency, in the Institute for Emergency Medicine, during the transport of the sick and injured to the appropriate health institution for definitive care and treatment, as well as emergency medical transport and transportation of dialysis patients. Paragraph 2 of the same article stipulates that the Institute for Emergency Medicine performs non-emergency medical transport when it is justified and medically necessary, following the regulations governing mandatory health insurance, while Paragraph 3 stipulates that the Institute for Emergency Medicine is established for the territory of one or more local self-government units. Paragraph 4 of this article stipulates that the minister prescribes the manner and organization of performing the health activity of emergency medical assistance from paragraph 1 of this article and Article 76, paragraph 1 of this Law.
Following this Law, the Institute, as well as other healthcare institutions, can conclude contracts with other healthcare institutions, both in public and in private ownership, which can be provided with medical assistance when, for justified reasons, medical intervention of the attending physician is not possible, and the intervention does not represent the primary activity of the mobile medical team.
Certain aspects of the provision of emergency medical assistance, such as examinations and treatment in case of injuries and illnesses, are also prescribed by the Law on Health Insurance (Article 55, paragraph 1, point 1). The Rulebook on the Conditions and Methods of Internal Organization of Health Institutions is also important[4], the Rulebook on Detailed Conditions for the Performance of Healthcare Activities in Health Institutions and other Forms of Health Service, as well as the Rulebook on the Manner and Procedure of Exercising Rights from Compulsory Health Insurance, are also important.
The Commissioner’s practice is diverse and shows various problems in the field of health care provision, including in the provision of emergency medical assistance. In previous years (which was to be expected considering the coronavirus pandemic), one of the most common reasons for addressing the Commissioner was based on the state of health as a personal characteristic[5], and most often in the health care field. Some of the complaints, as well as other addresses from citizens, related to the work of the emergency services, indicating that help was not provided on time or that it was not provided at all because, for example, it was an elderly person, that the ambulance did not arrive to the premises because it was a remote rural place, or a baby’s parents were recommended to bring the baby to a health facility even though it was an emergency, etc. In addition, the complainants believed that they were discriminated against by the treatment of the medical staff towards members of the Roma national minority, people living with HIV, etc. Although in most cases, it was not a matter of violation of rights from the Law on Prohibition of Discrimination, the practice of the Commissioner shows that it is necessary to improve the regulations in this area, both in providing adequate and timely assistance throughout the country, and achieving greater understanding in terms of the functioning of these services. It is undeniable that the number of vehicles and medical personnel is limited, while on the other hand, the needs of citizens are great, as well as their expectations regarding what constitutes a timely and adequate response of the health care system.
It should also be understood that the health care system is not a system by itself and that it largely depends on the functioning of other systems, such as the system of social protection and education, the development of infrastructure, regional development, etc.
When analyzing the situation to understand the problems in this field, it can be concluded that there is not enough data, neither qualitative nor quantitative, about the work of emergency services, and that some more data can only be found at the level of individual local self-governments that are competent to create work and development plans for the provision of this type of medical assistance.
The work of emergency services, in addition to their quantitative and qualitative capacities, largely depends on the work of all health services in the system.
During 2023, NALED surveyed the satisfaction of citizens and doctors with the health care system[6] in which, among other things, it was stated that 54% of the surveyed citizens were satisfied with the quality of health care services, and the biggest problems in health care listed were poor organization of health care institutions (waiting too long for examinations/admission at the scheduled time, impossibility to schedule an appointment); lack of professional/quality personnel and insufficiently motivated and insufficiently dedicated healthcare workers. In this research, it was also stated that more than half of the citizens who visited doctors in state health institutions in the previous five years almost always or mostly had to carry their previous health documentation in paper form because the doctors could not see it in electronic form in the system, which complicates the work of the doctors themselves, who devote a large part of their working time to documentation. In the part of the research that relates to doctors’ satisfaction with the health care system, doctors identify, as the biggest problem, the overload of medical staff (50%) and low wages, too much administration and paperwork (33%), the impaired reputation of the profession (28%), while 21% consider that inadequate equipment in institutions is the biggest problem. The best aspects of the health system are the dedication and expertise of doctors (60%), territorial coverage (26%), trust in the state health system (24%), the existence of electronic services in health (21%), new infrastructure (15%) and others.
In the announcement of the World Health Organization on the occasion of World Health Day[7] it was pointed out that quality, accessible, and affordable primary health care is the most effective and cost-effective way to bring health services closer to people and that it must reach and engage those with the greatest, often unrecognized needs, in all age categories. The World Health Organization pointed out that it is important that primary health care respects the principles of fairness and gender sensitivity, as well as the rights-based principle, in the daily activities of providing health services through specific programs intended for vulnerable groups.
The public health strategy in the Republic of Serbia for the period from 2018-2026, as well as the corresponding action plan, do not explicitly contain plans for the development of the emergency medical assistance service. Instead, focus is placed on general plans for improving the provision of each type of medical assistance, which is certainly necessary and commendable but insufficient from the aspect of emergency medical services work.
Information is available through the Internet presentation of the Medical Chamber of Serbia[8] in which it is stated that the shortcomings of the existing system of emergency medical assistance in the Republic of Serbia are insufficiently educated health personnel, the absence of clearly profiled personnel who should work in the service, the absence of treatment protocols and basic medical equipment for emergencies, the absence of a clearly defined movement of an emergency patient through health system, poor territorial coverage by emergency teams and radio communication, weak communication and coordination of all services participating in emergencies. From the perspective of experts, it was stated that the problems are, among other things, low wages, poor working conditions, overload, insufficient number of ambulances, computers, etc.
By an insight into the Information Publication on the Work of the Institute for Emergency Medicine Belgrade[9], it can be stated that although there is a section (number 10) in the Information Publication entitled “Procedure for the provision of services”, that section mainly contains telephone numbers for certain sector units, although the term “procedure” is associated with a completely different type of information.
By an insight into the Analysis of the Efficiency of the Work of the Institute for Emergency Medicine in Belgrade published by the civil society organization “Movement Meri,” among other things, it was stated that “Serbia is the only country in the region that does not have a law (or by-law) regulating the work of emergency services.” In the analysis, it was stated that this lack has an impact on uneven practice in the provision of emergency health care and that the provision of this assistance depends on the employees in each specific settlement.[10]
In the comparative legal practice of the countries in the region, regulation in this area is governed by legal acts as well as various by-laws. Analyzing this practice, it can be concluded that the Republic of Serbia is one of the few countries that does not have a separate law on emergency medical care or any other more detailed regulation that fully regulates the functioning of the emergency care system.
Bearing in mind the importance of emergency services and based on the competencies prescribed by Article 33, paragraph 1, item 7 of the Law on Prohibition of Discrimination, the Commissioner submits this initiative to regulate the efficient functioning of this system in the most comprehensive way possible as a very important segment of health care in general.
The Ministry should inform the Commissioner about the action taken on this initiative.
[1] “Official Gazette of the RS”, nos. 22/09 and 52/21, Article 33, paragraph 1, item 7, in connection with item 5.
[2] “Official Gazette of the RS”, nos. 98/06 and 115/21.
[3] “Official Gazette of the RS” nos. 22/09 and 52/21
[4] “Official Gazette of the RS”, nos. 43/06 and 126/14
[5] Regular annual report on the work of the Commissioner for the Protection of Equality for 2023 https://ravnopravnost.gov.rs/izvestaji/
[6] Survey of citizens’ and doctors’ satisfaction with the health care system, NALED, 2023, available at: https://naled.rs/htdocs/Files/12608/Zadovoljstvo-gradjana-i-lekara-zdravstvenim-sistemom-u-Srbiji_NALED.pdf
[7] Available at: https://www.zdravlje.org.rs/index.php/lat/aktuelne-vesti/1201-svetski-dan-zdravlja-2023
[8] Regionalization of the emergency medical service of Serbia – an acceptable model of reform https://www.lks.org.rs/images/Documents/finansije/3.%20Regionalizacija%20slu%C5%BEbe%20hitne%20medicinske%20pomo%C4%87i%20%E2%80%93prihvatlj.pdf
[9] https://www.beograd94.rs/%D0%BE-%D0%BD%D0%B0%D0%BC%D0%B0/%D1%81%D1%82%D0%B0%D1%82%D1%83%D1%82
[10] https://pokretmeri.org.rs/home/2023/02/20/analiza-efikasnosti-rada-zavoda-za-urgentnu-medicinu-beograd/
COMMISSIONER FOR THE PROTECTION OF EQUALITY
Brankica Janković
