No. 021 – 01 – 390 /202 5 -02 date: 11.3.2025.
INSTITUTE FOR EMERGENCY MEDICAL CARE BELGRADE
Goran Čolaković, Director
11000 BELGRADE
Boulevard Franche d’Eperée No. 5
Subject : Recommendation of measures for achieving equality and protection against discrimination
Dear Mr. Čolaković,
The Commissioner for the Protection of Equality received a complaint from BB, filed on behalf of VV, against the Institute for Emergency Medical Care Belgrade. According to the complaint, ninety-four-year-old VV was discriminated against on the basis of her age in the most difficult moments for her, when her daughter GG passed away. As the complainant stated, VV’s daughter fell ill, which is why they called the Institute for Emergency Medical Care Belgrade, i.e. the Emergency Medical Service, whose team arrived and stated that “it will pass”. However, GG passed away a few hours later. The complainant believes that the the Emergency Medical Service operator acted in a discriminatory manner toward V.V. because of her age, as it was clear from her voice that she was a very elderly person, which requires special attention in handling, not belittling a call for help. As further stated in the complaint, after the first visit by the the Emergency Medical Service, V.V.’s daughter’s health condition drastically deteriorated and she lost consciousness, after which V.V. repeatedly called the the Emergency Medical Service, speaking in a weak, broken, elderly voice, while they kept her on hold. When an operator finally answered, she was told: “What do you want, we’ve already been there,” “We have other patients too,” and similar remarks. When they realized that G.G. was unconscious, they dispatched a team; however, upon arrival, they confirmed her death. The complainant requested the Commissioner for the Protection of Equality to take appropriate action within their competence or, based on this specific case, to issue a public statement drawing attention to the inappropriate behavior of the Emergency Medical Service operators toward elderly persons, along with an appeal to prevent such situations from recurring.
The Commissioner for the Protection of Equality received a statement from the Institute for Emergency Medical Care Belgrade, No. 672, in which it was emphasized that the conversations were conducted in accordance with the Protocol on the Work of the Institute’s Call Center and the Institute’s Code of Conduct, as well as with the provisions of legal and sub-legal regulations governing the ethical conduct of healthcare professionals. Attached to the statement was the report of the Commission for Extraordinary Internal Quality Control of Professional Work, prepared at the request of the competent health inspector, the electronic record of received calls related to the provision of assistance to the now late G.G., audio recordings of the said conversations, transcripts of the phone calls, and medical reports regarding the field intervention and the provision of medical assistance to the patient.
During the proceedings, it was first established that the subject of the complaint is the conduct of the operator of the Institute for Emergency Medical Care toward V.V. as an elderly person. The Commissioner points out that, had the complaint referred to the quality of healthcare provided to the now deceased G.G., this body would not have been competent to act, as the prohibition of discrimination against a natural person represents a personal, non-transferable, non-pecuniary right, which ceases upon the death of the individual. In this regard, the Health Inspectorate is the competent authority to determine whether appropriate healthcare was provided, within the internal control procedure that has already been initiated.
An analysis of the allegations in the complaint, the statement, and the submitted evidence unequivocally shows that the Emergency Medical Service responded to the elderly person’s first call and, in that sense, it cannot be concluded that the dispatch of the emergency team was causally related to age as a personal characteristic. However, the analysis of all submitted evidence revealed a lack of understanding, empathy, and even respect on the part of the Emergency Medical Service operator toward the 94-year-old woman who called for assistance following the deterioration of the health condition of her now late daughter. As also stated in the Report of the Commission for Extraordinary Internal Quality Control of Professional Work, prepared at the request of the competent health inspector (No. 9677, dated October 18, 2024), the communication was partially hindered due to the caller’s age and distress, which clearly required a different approach toward her.
The Commissioner for the Protection of Equality is not authorized to examine the medical aspect of the provided healthcare, but observes that seventeen minutes passed from the first to the last call by V.V. (when requesting the second intervention), during which she called the Emergency Medical Service multiple times. Based on the submitted audio recordings, it can be concluded that during these conversations the operators of the Call Center of the Emergency Medical Service should have acted with greater patience and a higher level of consideration for the extremely stressful situation in which the 94-year-old caller found herself.
Considering this state of affairs, the Commissioner inspected the procedures prescribed for providing emergency medical assistance.
Article 83, paragraph 1 of the Law on Health Care[1] stipulates that the Institute for Emergency Medical Care is a healthcare institution that provides emergency medical assistance at the scene of a medical emergency, in the Institute for Emergency Medical Care, during the transport of sick and injured persons to an appropriate healthcare institution for definitive care and treatment, as well as emergency medical transport and transport of dialysis patients. Paragraph 2 of the same article stipulates that the Institute for Emergency Medical Care also provides non-emergency medical transport, when justified and medically necessary, in accordance with the regulations governing compulsory health insurance.
According to the provisions of the Health Insurance Law, sick or injured insured persons, depending on medical indications and expert-methodological and doctrinal positions, are provided with, among other things: emergency medical assistance at the scene of a medical emergency or in a health institution or private practice; emergency medical transport in the event of an illness or injury that is life-threatening to the insured person; non-emergency medical transport, when justified and medically necessary.[2]
The Code of Conduct of the City Institute for Emergency Medical Care – Belgrade prescribes the duty of employees to treat persons with disabilities and persons with “special needs” with particular care[3] and to grant them priority in the provision of healthcare services, provided that such priority does not jeopardize the interests of other patients and is not contrary to the law and by-laws adopted for the implementation of the law.[4] In professional communication, it is necessary to speak clearly and distinctly. The tone of conversation should be friendly and open. Anger, nervousness, and aggressiveness must not be expressed during professional communication.The person speaking must not be interrupted before presenting their problem or question, and the conversation should be concluded by the person who initiated the call. In case the caller is excessively verbose, the conversation should be politely but firmly brought to an end.[5]
The Commissioner’s practice is diverse and shows various problems in the field of providing health care. Some of the complaints and other appeals from citizens related to the work of the Emergency Medical Service and difficulties in exercising the right to emergency health care. Citizens indicated that they were not provided with assistance on time or not provided at all because they were elderly, because they were in a remote rural area, etc. Although in most cases there was no violation of the rights under the Law on the Prohibition of Discrimination, the Commissioner’s practice shows that it is necessary to improve the regulations in this area in terms of providing adequate and timely assistance throughout the country, but also in order to achieve greater understanding in terms of the functioning of these services. It is undeniable that the number of vehicles and medical staff is limited, while on the other hand, the needs of citizens are great in terms of an adequate response from the health care system. There is not enough research on the work of emergency services, and somewhat more publicly available data can only be found at the level of individual local governments that are responsible for adopting work and development plans for the provision of this type of medical assistance.[6]
In this regard, on October 2, 2024, the Commissioner for the Protection of Equality sent an initiative to the Ministry of Health for amendments to the Law on Health Care or the adoption of a special regulation that would regulate the work of the emergency services in more detail, in order to regulate the efficient functioning of this system, as a very important segment of health care, in the most comprehensive manner possible.[7] Improving regulations related to the work of emergency services is one of the recommendations for achieving equality contained in the Regular Annual Report for 2024,[8] which the Commissioner submitted to the National Assembly.
The work of the emergency services, in addition to the quantitative and qualitative capacities of these services, largely depends on the work of all health services in the system.
In 2023, NALED conducted a survey on the satisfaction of citizens and doctors with the healthcare system,[9] which, among other things, stated that 54% of the surveyed citizens were satisfied with the quality of healthcare services, while the biggest problems in healthcare were listed as: poor organization of healthcare institutions (too long waiting times for examinations/admissions at scheduled times, inability to schedule appointments); lack of professional/quality staff and insufficiently motivated and insufficiently dedicated healthcare workers. This survey also stated that more than half of the citizens who visited doctors in public healthcare institutions over the past five years almost always or mostly had to bring previous medical documentation in paper form, because doctors were unable to access it electronically through the system. This situation also complicates the work of the doctors themselves, who spend a significant portion of their working time dealing with documentation. In the part of the survey that relates to doctors’ satisfaction with the healthcare system, doctors identify the biggest problems in healthcare as the overload of medical staff (50%) and low salaries, too much administration and paperwork (33%), damaged reputation of the profession (28%), while 21% believe that inadequate equipment in institutions is the biggest problem. As the best aspects of the healthcare system, they mention the dedication and expertise of doctors (60%), territorial coverage (26%), trust in the state healthcare system (24%), the existence of electronic services in healthcare (21%), new infrastructure (15%), etc.
Within the focus groups held as part of the research The position of elderly women in Serbia[10], participants highlighted several problems they face when exercising their right to health care – such as using emergency services, long waits for specialist services, unkindness and disrespect from specialist doctors.[11]
According to information available on the official website of the Medical Chamber of Serbia,[12] the shortcomings of the current emergency medical care system in the Republic of Serbia include: insufficiently trained medical personnel, the absence of clearly profiled staff designated to work in emergency services, the lack of treatment protocols and basic medical equipment for emergency situations, the absence of clearly defined pathways for urgent patients through the healthcare system, poor territorial coverage by emergency teams and radio communication, and weak communication and coordination among all services involved in emergency situations.
From the perspective of professionals, the problems also include, among other things, low salaries, poor working conditions, overburdened staff, and an insufficient number of ambulances, computers, and similar resources.
An insight into the Analysis of the Efficiency of the Work of the Belgrade Emergency Medicine Institute published by the civil society organization “Meri Movement” states , among other things, that “Serbia is the only country in the region that does not have a law (or by-law) regulating the work of the emergency medical service.” The analysis states that this deficiency affects the uneven practice of providing emergency health care and that the provision of this assistance depends on the employees in each specific place/settlement.
According to the Analysis of the Efficiency of the Work of the Institute for Emergency Medical Care – Belgrade, published by the civil society organization “Movement Meri”, it was stated, among other things, that “Serbia is the only country in the region that does not have a law (nor a by-law) regulating the work of the emergency medical service.” The analysis notes that this legal gap leads to inconsistent practices in the provision of emergency healthcare, and that the delivery of such care depends on the staff in each specific municipality or settlement.[13]
As the Republic of Serbia is classified among the demographically old countries, with the prospect of further aging and an increasing life expectancy of its population, dynamic and significant demographic changes pose major societal challenges related to both healthcare and the provision of various services for this group of the population to the necessary extent.[14] The practice of the Commissioner and the results of various studies show that older people face numerous problems, but they less frequently turn to the authorities, as they believe that “such a position is inevitably their fate.” Therefore, it is especially important to emphasize the need to ensure that older people can fully enjoy all their rights, while respecting their position and age.
The Constitution of the Republic of Serbia,[15] in Article 21, prohibits any discrimination, direct or indirect, on any grounds, and in particular on the grounds of race, gender, nationality, social origin, birth, religion, political or other belief, property, culture, language, age, and mental or physical disability.
The constitutional prohibition of discrimination is further elaborated by the Law on the Prohibition of Discrimination, which in Article 2, paragraph 1, item 1, stipulates that discrimination and discriminatory treatment mean any unjustified distinction or unequal treatment, or omission (exclusion, restriction or giving priority), in relation to persons or groups, as well as to members of their families, or persons close to them, in an open or covert manner, and which is based on race, skin color, ancestry, citizenship, national affiliation or ethnic origin, language, religious or political beliefs, sex, gender, gender identity, sexual orientation, sexual characteristics, income level, property status, birth, genetic characteristics, health status, disability, marital and family status, convictions, age, appearance, membership in political, trade union and other organizations and other real, or presumed personal characteristics. 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, i.e. the prohibition of discrimination. Direct discrimination exists if a person or a group of persons, due to their personal characteristic, is placed, by any act, action, or omission, in a less favorable position in the same or a similar situation, or could be placed in a less favorable position. Furthermore, Article 27 stipulates that discrimination based on the health condition of a person or group of persons, as well as the health condition of their family members, is prohibited.
Considering all of the above, and especially taking into account the importance of timely response by healthcare professionals, the Commissioner, in accordance with Article 33, item 9 of the Law on the Prohibition of Discrimination, sends the following recommendation to the Institute for Emergency Medical Care Belgrade for measures to achieve equality:
– To include the category of elderly persons in the Code of Conduct of the City Institute for Emergency Medical Care – Belgrade, which stipulates the duty of an employee to treat persons with disabilities with special care and to provide them with priority in providing healthcare, provided that this does not jeopardize the interests of other patients and that such priority is not in conflict with the law and by-laws adopted for the implementation of the law, and to comply with this duty in practice.
– To organize training for employees on awareness-raising in working with the elderly, in order to adequately obtain the necessary information about their health status and the need for emergency medical assistance.
The City Institute for Emergency Medical Care – Belgrade is required, within 30 days from the date of delivery of this recommendation for measures, to notify the Commissioner of the action taken pursuant to the given recommendation.
[1] “Official Gazette of the Republic of Serbia”, Nos. 25/19 and 92/23 – authentic interpretation
[2] Law on Health Insurance (“Official Gazette of the Republic of Serbia”, Nos. 25/19 and 92/23) , Article 55, paragraph 1.
[3] The Commissioner points out on this occasion that the term “Persons with special needs” is inappropriate and offensive, because every person has the same needs, they just realize them in different ways, regardless of whether they have a disability or not.
[4] Article 18 of the Code of Conduct No. 2091/1 of March 13, 2008 (Available at: https://www.beograd94.rs/images/pdf_dokumenta/pos_kod.pdf )
[5] Article 58 of the Code of Conduct No. 2091/1 of March 13, 2008 (Available at: https://www.beograd94.rs/images/pdf_dokumenta/pos_kod.pdf )
[6] Regular annual report on the work of the Commissioner for the Protection of Equality for 2024, available at: https://ravnopravnost.gov.rs/izvestaji/
[7] Available at: https://ravnopravnost.gov.rs/594-24-inicijativa-za-izmene-i-dupune-zakona-o-zdravstvenoj-zastiti-ili-donosenje-sebenog-propisa-kojim-bi-se-detaljnije-uredio-rad-sluzbi-hitne-pomoci/
[8] Available at: https://ravnopravnost.gov.rs/izvestaji/
[9] Survey of citizen and doctor satisfaction with the healthcare system, NALED, 2023, available at: https://naled.rs/htdocs/Files/12608/Zadovoljstvo-gradjana-i-lekara-zdravstvenim-sistemom-u-Srbiji_NALED.pdf
[10] The position of eldelry women in Serbia, Belgrade, 2019, available on the website: http://ravnopravnost.gov.rs/wp-content/uploads/2019/08/Polozaj-starijih-zena-u-Srbiji-10.4.2019.-digitalna-verzija.pdf
[11] Special report of the Commissioner for the Protection of Equality on discrimination against elderly citizens, available at: https://ravnopravnost.gov.rs/posebni-izvestaji/
[12] Regionalization of the Serbian Emergency Medical Service – an acceptable reform model https://www.lks.org.rs/images/Documents/finansije/3.%20Regionalizacija%20slu%C5%BEbe%20hitne%20medicinske%20pomo%C4%87i%20%E2%80%93prihvatlj.pdf
[13] https://pokretmeri.org.rs/home/2023/02/20/analiza-efikasnosti-rada-zavoda-za-urgentnu-medicinu-beograd/
[14] Special report of the Commissioner for the Protection of Equality on discrimination against eldelry citizens, available at: https://ravnopravnost.gov.rs/posebni-izvestaji/
[15] “Official Gazette of the Republic of Serbia”, Nos. 98/06 and 115/21
COMMISSIONER FOR THE PROTECTION OF EQUALITY
Brankica Janković
