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Original article

Scope of preventive services provided by chosen doctors in primary health care, in the Republic of Serbia, in the period between 2013 and 2017

Mirjana Milošević1, Marina Topalović1, Aleksandra Jović-Vraneš2

ABSTRACT

Introduction: In the Republic of Serbia, the capitation formula was introduced in 2012, as a payment for performance model for chosen medical doctors based on the number of patients, number of visits, financial value of prescribed prescriptions, as well as on the basis of the number of preventive health services provided in public primary health care facilities.

Aim: The aim of this paper is to analyze the scope of preventive health services provided, which is used to evaluate the performance and to pay selected doctors according to the capitation formula, in primary health care institutions, in the Republic of Serbia, in the period between 2013 and 2017.

Methods: The available data of the Institute of Public Health of Serbia ‘Dr Milan Jovanović – Batut’ (IPHS ‘Batut’), in terms of the coverage of certain populations with health services, were analyzed, namely twenty-three different indicators, i.e., preventive services provided by chosen medical doctors in the area of health services for adults, children, and women's healthcare, in 166 primary health care institutions to which the payment model based on the capitation formula is applied (158 primary healthcare centers, three institutes for the health care of university students, and five institutes for the health care of workers). The trend of coverage of the above-mentioned services, in the period between 2013 and 2017 was examined, as well as the increase in the volume of preventive services, with fixed-base and chain indices.

Results: Three out of twenty-three different health services showed a declining trend, namely the coverage of infants with ultrasound examinations for early detection of hip dysplasia, coverage of schoolchildren with preventive examinations at the ages of 8, 10, 12, and 14 years, as well as coverage of the adult population (older than 35 years) with preventive services. All other services had a stable trend in terms of coverage of target populations in the period from 2013 to 2017.

Conclusion: Although most of the observed preventive health services had a stable trend of population coverage, their coverage was far below the recommended level, in the observed period.


INTRODUCTION

In the healthcare system, the providers of primary healthcare services have the role of ‘gatekeepers’, which primarily applies to general practitioners (GPs), pediatricians, gynecologists, and dentists, and each analysis of their work in relation to the needs expressed by the service users, provides a better insight into the possible directions of further development. According to the data of the Primary Health Care Performance Initiative, patients should satisfy 80% of their healthcare needs at the level of primary healthcare, which is, at the same time, an indicator of good organization within the healthcare system of a country [1]. The comparison of indicators of unmet healthcare needs has shown that the citizens of the Republic of Serbia are in a less favorable position as compared to European Union citizens (EU). In Serbia, in 2016, the rate of unmet healthcare needs related to medical examinations and treatment amounted to 10.5%, while in the EU this rate was 5%, in the same year [2].

As of 2005, in keeping with the Law on Health Care and the Law on Health Insurance, insured persons have the right to choose their physician at the levels of healthcare for adults, healthcare for preschool children and schoolchildren, healthcare for university students, healthcare for women, and dental healthcare [3],[4]. These laws, amended and improved in 2019 [5],[6], ensure continuity and comprehensiveness of healthcare provided to patients and insured persons by the chosen doctors, which is, in fact, the goal of quality primary healthcare [7],[8]. When visiting the chosen doctor, the patient comes into contact with the healthcare system at the primary level, and, if this is the patient’s first visit in the given calendar year, the patient is provided a complete physical examination, and he/she begins with preventive services and curative treatment, as well as with health education and counseling provided by his/her chosen doctor. The chosen doctor, who is familiar with the health status of his/ her patient, further coordinates the health services required by his/her registered patient. With every subsequent visit, the chosen physician improves his/her knowledge regarding the patient, by gaining new information on the health status, lifestyle, and circumstances wherein the patient takes care of his/her health, which is far better than the previous practice, when the patient often encountered a different doctor with every new visit to the community healthcare center. The services provided by the chosen physician can be divided into two groups: 1) curative health services and 2) preventive health services

As of the beginning of the third millennium, the reforms of the healthcare system of the Republic of Serbia have been implemented with loans from the World Bank [9]. Changes have also been made in the domain of the financing of healthcare service providers. Generally speaking, the salaries (wages) in the public sector are calculated on the basis of coefficients defined for the education level (level of qualifications) and the monetary value of the base for different professions [10]. The reform provides that the salary base of chosen doctors in community healthcare centers is corrected with a coefficient. Thus, the chosen physicians have a fixed portion of the base salary and a smaller, variable portion of their base salary. Namely, in 2012, through the collaboration of the Ministry of Health (MH) and the Republic Fund of Health Insurance (RFHI), for the purpose of calculating the salaries of chosen doctors in primary health care, the following decree, defining the capitation formula, was adopted: ‘Decree on the Corrective Coefficient, the Highest Percentage Increase in the Base Salary, the Criteria and Weights for the Portion of the Salary that is Realized on the Basis of Performance, as Well as the Method of Calculation of the Salaries of Employees in Healthcare Institutions’ [11]. According to this decree, the variable portion of the salary was defined as dependent solely on performance and independent of supplements to the base salary. The aim of introducing this variable portion of the salary was to improve the performance of chosen physicians. The performance of the physicians is calculated on the basis of criteria and weights defined with the aim of providing financial incentives for chosen doctors to have as many registered patients as possible, to reduce the number of prescriptions issued, to improve efficiency, i.e., the number of patient visits, and, most importantly, to improve the quality of healthcare, primarily with respect to the increase in the scope of the implementation of preventive measures. In this way, the doctors and nurses in community healthcare centers have become the first, and to this day the only employees in the public sector, whose performance directly affects the amount of their salary. To date, several amendments to the Decree on the corrective coefficient have been made, however, the essential change to the capitation formula criteria and weights was made only in 2019, within the Second Serbia Health Project [12].

In this paper, the research results refer to the period prior to the change in the structure of the capitation formula, in 2019, and the study aims to evaluate whether this payment model has proven its role in strengthening preventive healthcare services, in the period between 2013 and 2017. In the Republic of Serbia, preventive healthcare services include preventive examinations by age groups, vaccination services, and screening services related to diseases such as diabetes mellitus, cardiovascular diseases, depression, colon cancer, breast cancer, and cervical cancer. The scope and content of these services is defined by the Rulebook [13]. The above stated healthcare services are used to calculate the performance of the chosen physicians within the capitation formula payment model, which is why they are the subject of observation.

The structure of the capitation formula in the Republic of Serbia in the period between 2012 and 2018

The capitation formula, as a method of calculating the variable portion of the salary of chosen doctors has been in official use since 2013, from the moment that the Decree on the corrective coefficient came into force. The Decree stipulates that the base salary of the chosen doctor is determined by multiplying the base for calculating the salary with the corrective coefficient (Figure 1). It is prescribed that the corrective coefficient shall amount to 0.9612, i.e., that the variable portion of the salary shall amount to 4.04%, which means that the chosen physician can achieve a maximum increase in base salary of 8.08% [11].

In keeping with the Decree on the corrective coefficient from 2013, for a chosen physician who achieves a capitation score of zero (0), only the guaranteed portion of the salary (96.12%) is calculated. A chosen doctor who scores five (5) can achieve 100% of the salary, while a chosen physician scoring ten (10) achieves 104.4% of the salary (Figure 1).

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Figure 1. Illustration of the guaranteed and variable portion of the salary of the chosen doctor Source: Second Serbia Health Project

According to predefined capitation formula criteria and weights, the capitation score is calculated for every chosen doctor, each quarter. This score directly affects the variable portion of the salary, i.e., the total salary of the doctor, but also of the nurses, as a nurse receives the same score as the doctor in whose team the nurse is working. The calculation of the scores is performed by the RFHI, on the basis of data from the electronic invoice and the tables with scores, which are freely available on the RFHI website [14],[15]. The electronic invoice, on services rendered, the medical staff who provided the services, the persons (ensured persons) who received the services, as well as on the consumption of drugs and medical supplies, is submitted to the RFHI by healthcare institutions, on a monthly level.

The basic capitation formula criteria for evaluating the work of the chosen doctors, applied in in the period between 2012 and 2018, were as follows:

  1. Registration – number of patients who registered with the chosen doctor
  2. Prevention – number of preventive services provided by the chosen doctor
  3. Rationality – value of the medication prescribed by the doctor
  4. Efficiency – number of patient visits to the doctor

For each of these four criteria, the chosen doctor is, based on performance, awarded a score between zero (0) and ten (10). For the criterion ‘registration’ (40% of the total capitation score), for the criterion ‘prevention’ (30% of the total capitation score), and for the criterion ‘efficiency’ (10% of the total capitation score), the score is calculated in relation to the average score for an individual healthcare institution in the related medical area. For the criterion ‘rationality’ (20% of the total capitation score), the score is calculated in relation to the average value in the Republic of Serbia, in the related medical area (general medicine, pediatrics, gynecology, and dental medicine). The total capitation score is calculated by adding up the scores for the criteria, which are previously weighted by factors of participation in the total score, as shown in Figure 2.

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Figure 2. Illustration of the calculation of the total capitation score

AIM

The aim of this paper is to analyze the scope of preventive health services provided, which is used to evaluate the performance and to pay selected doctors according to the capitation formula, in primary health care institutions where this payment model is applied, in the Republic of Serbia, in the period between 2013 and 2017, at the same time bearing in mind that, formally, the impact of the capitation formula on salaries started in May 2013, as well as that IPHS data from year 2018 are not publicly available.

MATERIALS AND METHODS

Analyzed units

The study investigated the work of chosen physicians employed in three different primary healthcare departments, in 166 primary health care institutions to which the payment model based on the capitation formula is applied (158 primary healthcare centers, three institutes for the health care of university students, and five institutes for the health care of workers) in Serbia, namely: the department of preschool children and schoolchildren healthcare, department of adult healthcare, and the department of women’s healthcare. Within the above-mentioned departments, the following indicators of the chosen doctors’ work, which are also a part of the capitation formula, were observed:

  • Department of preschool children and schoolchildren healthcare
    • Coverage of infants with ultrasound examinations for early detection of hip dysplasia
    • Coverage of preschool children (at the age of two years) with preventive examinations
    • Coverage of preschool children (at the age of four years) with preventive examinations
    • Coverage of preschool children (at the ages of six and seven years) with preventive examinations
    • Coverage of schoolchildren (at the ages of eight, ten, twelve, and fourteen years) with preventive examinations
    • Coverage of schoolchildren (at the ages of sixteen and eighteen years) with preventive examinations
    • Coverage with vaccination against tuberculosis (BCG)
    • Coverage with vaccination against diphtheria, tetanus, and pertussis (DTP)
    • Coverage with vaccination against polio (OPV)
    • Coverage with vaccination against hepatitis B (HB)
    • Coverage with vaccination against diseases caused by Haemophilus influenzae type b
    • Coverage with vaccination against measles, mumps and rubella (MMR)
  • Department of adult healthcare
  • Coverage of the adult population (between the ages of 19 and 34 years) with preventive examinations
  • Coverage of the adult population (above the age of 35 years) with preventive examinations
  • Coverage of the adult population (as of the age of 18 years) with screening for the early detection of depression
  • Coverage of the adult population (above the age of 35 years) with screening for the early detection of diabetes
  • Coverage of the adult population (women between the ages of 45 and 69 years and men between the ages of 36 and 69 years) with screening for the early detection of cardiovascular diseases
  • Coverage of the adult population (between the ages of 50 and 69 years) with screening for the early detection of colon cancer
  • Department of women’s healthcare
  • Coverage of women (15+ years) with preventive gynecological examinations
  • Coverage of women (between the ages of 25 and 69 years) with screening for early cervical carcinoma detection
  • Coverage of women (between the ages of 49 and 69 years) with screening for early breast cancer detection
  • Coverage of women (between the ages of 15 and 49 years) with preventive family planning examinations
  • Coverage of expectant mothers with preventive examinations in the first trimester

As a parameter for the assessment of the quality of the work of chosen doctors in community healthcare centers, in relation to indicators defined in this analysis, RFHI documents were used, namely the ‘Rulebook on the Content and Scope of the Rights to Healthcare Pertaining to Compulsory Health Insurance and on Patient Co-pay for the Year 2017’, as it prescribes the scope of the rights exercised by insured persons regarding preventive services (it defines the number of services that the insured person is entitled to within a certain period of time), as well as the document written by a group of Serbian experts, ‘Expert Methodological Instructions for Implementing the Decree on the National Health Care Program for Women, Children and Youth’, wherein, based on the National Good Clinical Practice Guideline, recommendations are made regarding the annual number of healthcare services provided to women, children and youth [13],[16].

The source of the data for the present study were publications issued by the Institute of Public Health of Serbia ‘Dr Milan Jovanović – Batut’ (IPHS ‘Batut’), namely the ‘Analysis of the Planned and Realized Scope and Content of the Rights of Insured Persons to Primary Healthcare’, for the period between 2013 and 2017 [17],[18],[19],[20],[21].

Descriptive and analytical statistical methods were used for data processing. The data are presented in percentages, while trend analysis was used for analyzing the change of parameters related to preventive healthcare services in the five-year period. The threshold of statistical significance was p < 0.05. SPSS 21 (IBM) and Excel (MS Office) were used for statistical data processing and graphical representation. The trend of coverage of the above-mentioned services, in the period between 2013 and 2017 was examined, as well as the increase in the volume of preventive services, with fixed-base and chain indices.

RESULTS

The scope of provided selected preventive healthcare services, in the Republic of Serbia, in the period between 2013 and 2107, changed in the following manner:

  • As compared to the year 2013, the coverage of infants with ultrasound examinations of the hips dropped by 20%, in 2017 (Graph 1).
  • Except for the population group of preschool children aged six/seven years, where there was a rise in coverage of 8.89%, in year 2017, as compared to the base year 2013, in preschool children aged two and four years, a drop in the coverage with preventive examinations of 2.5% and 5.7%, respectively, was registered (Graph 2).
  • An 8.6% drop in the coverage with preventive examinations was registered in schoolchildren as well (aged eight, ten, twelve, and fourteen years), in 2017, while in the group of schoolchildren aged sixteen and eighteen an increase of 16.7% in the coverage was registered, in years 2015 and 2017 (Graph 3).
  • Although the fixed-base index was zero, in 2017, as compared to 2013, the chain index showed a decrease in coverage with the BCG vaccine, with each following year. A drop in coverage was recorded for all other vaccines analyzed in this study, with the exception of the vaccination against Haemophilus influenzae type b, for which a slight increase was recorded, namely 0.53%, in 2017, as compared to 2013. The greatest drop, when compared to 2013, was registered for the coverage with the MMR vaccine (-12.53%), in 2016, however, the situation somewhat improved in 2017, by 5.2% (Graphs 4 and 5).
  • A drop of 16.7% was registered in the coverage with preventive examinations of adults, in 2017, with this drop being as much as 50% in the adult population group aged 35 years and above, as compared to 2013 (Graph 6).
  • The coverage of target population groups with screening examinations registered a significant increase, when base indices are observed. Namely, the screening coverage for early detection of diabetes increased by 200% in 2017, as compared to 2013. Screening coverage for the early detection of cardiovascular diseases increased by 50%, also in 2017, while the coverage of screening for the early detection of depression increased by 100%, in the same year. The exception was coverage with screening examinations for early detection of colon cancer, which dropped by 28.6% (Graph 7).
  • The coverage of women with preventive gynecological examinations and preventive family planning examinations dropped. A drop of 10%, i.e., 33.3%, respectively, was registered, in 2017 (Graph 8).
  • The coverage with screening examinations for the early detection of breast cancer was unchanged in 2017, as compared to 2013, while the coverage with screening for the early detection of cervical cancer dropped by 11% (Graph 9).
  • The coverage of expectant mothers with preventive examinations in the first trimester registered an increase of only 3.3%, in 2017, as compared to 2013 (Graph 10).

Coverage of infants with ultrasound examinations for early detection of hip dysplasia

Trend analysis of the coverage of infants with ultrasound examinations for early detection of hip dysplasia shows a decrease, as of 2015, however, this drop is not statistically significant (y = - 0.062x + 1.102; p = 0.068).

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Graph 1. Coverage of infants with ultrasound examinations for early detection of hip dysplasia

Coverage of preschool children (at the age of two, four, six/seven years) with preventive examinations

With regards to the coverage of preschool children (at the age of two years) with preventive examinations, the results show that there was no statistically significant change, between 2013 and 2017 (y = - 0.009x + 0.793; p = 0.236). There was no statistically significant change in the coverage of preschool children (at the age of four years) with preventive examinations, between 2013 and 2017 (y = - 0.016x + 0.72; p = 0.139). The same result was obtained when trend analysis was applied to the coverage of preschool children (at the age of six/seven years, prior to starting school) with preventive examinations, between 2013 and 2017 (y = 0.008x + 0.916; p = 0.661).

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Graph 2. Coverage of preschool children (at the age of two, four, six/seven years) with preventive examinations

Coverage of schoolchildren (at the ages of eight, ten, twelve, fourteen, sixteen, and eighteen years) with preventive examinations

As opposed to the younger population, in schoolchildren (at the ages of eight, ten, twelve, and fourteen years), a statistically significant decreasing trend in coverage was observed, between 2015 and 2017 (y = - 0.0203x + 0.8341; p = 0.050). Analysis of the results show that there was no statistically significant change in the observed period (y = 0.02x + 0.58; p = 0.308) when it comes to older school children (at the age of sixteen and eighteen years).

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Graph 3. Coverage of schoolchildren (at the ages of eight, ten, twelve, fourteen, sixteen, and eighteen years) with preventive examinations

Coverage with vaccination against tuberculosis, diphtheria, tetanus, pertussis, and polio

Trend analysis of the coverage with vaccination against tuberculosis (BCG), demonstrated that there was no statistically significant change in the vaccination trend, between 2013 and 2017 (y = 0.0003x + 0.9763; p = 0.843). It was also determined that, for vaccination against diphtheria, tetanus, and pertussis (DTP), there was no statistically significant change in the vaccination trend, between 2013 and 2017 (y = - 0.0052x + 0.9664; p = 0.222), as was the case with the vaccination against polio (OPV), (y = 0.0007x + 0.9455; p = 0.683).

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Graph 4. Coverage with vaccination against tuberculosis, diphtheria, tetanus, pertussis, and polio

Coverage with vaccination against hepatitis B, Haemophilus influenzae type b, and against measles, mumps and rubella

Trend analysis of vaccination against hepatitis B and vaccination against Haemophilus influenzae type b, showed that there was no statistically significant change in the trend for the above-mentioned vaccinations, between 2013 and 2017 (vaccination against hepatitis B: y = - 0.0054x + 0.9396; p = 0.267); (vaccination against Haemophilus influenzae type b: y = -0.0005x + 0.9473; p = 0.850). The examination of trend analysis results related to the vaccination against measles, mumps, and rubella, leads to the conclusion that there was no statistically significant change in the trend of vaccination, between 2013 and 2017 (y = - 0.0196x + 0.916; p = 0.165).

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Graph 5. Coverage with vaccination against hepatitis B, Haemophilus influenzae type b, and against measles, mumps and rubella

Coverage of the adult population with preventive examinations

When coverage of the adult population with preventive examinations is observed, the conclusion is that, in the population aged between 19 and 34 years, there was no statistically significant change in the coverage trend, between 2013 and 2017 (y = - 0.004x + 0.076; p = 0.332), while, in the adult population above the age of 35 years, there was a statistically significant decrease in coverage with preventive examinations, between 2013 and 2017 (y = - 0.012x + 0.104; p = 0.024).

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Graph 6. Coverage of the adult population (between the ages of 19 and 34 years and aged 35 years and above) with preventive examinations

Coverage of the adult population with screening examinations

Trend analysis of the coverage of the adult population with screening examinations shows that there was no statistically significant change in the trend of coverage with any of the screening programs, in the observed period, specifically:

  • For the coverage of the adult population above the age of 18 years with screening for early detection of depression, it was found that there was a change which was near the conventional threshold of statistical significance (y = 0.003x + 0.007; p = 0.058).
  • For the coverage of the adult population aged 35 years and above with screening for early detection of diabetes, no statistically significant change in the trend was observed, between 2013 and 2017 (y = 0.003x + 0.015; p = 0.358).
  • For the coverage of the adult population (women between the ages of 45 and 69 years and men between the ages of 36 and 69 years) with screening for the early detection of cardiovascular diseases, no statistically significant change in the trend was observed, between 2013 and 2017 (y = 0.002x + 0.024; p = 0.450).
  • For the coverage of the adult population (between the ages of 50 and 69 years) with screening for the early detection of colon cancer, no statistically significant change in the trend was observed, between 2013 and 2017 (y = - 0.005x + 0.077; p = 0.278).

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Graph 7. Coverage of the adult population with screening examinations for the early detection of depression, diabetes, cardiovascular diseases, and colon cancer

Coverage of women with preventive gynecological examinations and with preventive family planning examinations

In the observed period, between 2013 and 2017, no statistically significant change in the trend of the coverage of women (15+ years) with preventive gynecological examinations was observed (y = - 0.002x + 0.108; p = 0.638). The trend analysis of the coverage of women with preventive family planning examinations showed no statistically significant change, between 2013 and 2017 (y = -0.007x + 0.101; p = 0.188).

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Graph 8. Coverage of women (aged 15 years and above) with preventive gynecological examinations and the coverage of women (aged between 15 and 49 years) with preventive family planning examinations

Coverage of women with screening examinations for early cervical carcinoma detection and for early breast cancer detection

The coverage of the target population of women with screening programs for early cervical carcinoma detection and for early breast cancer detection showed no statistically significant change in the trend, between 2013 and 2017, specifically:

  • Screening for early cervical carcinoma detection (y = -0.003x + 0.111; p = 0.783)
  • Screening for early breast cancer detection (y = 0.032; p = 1.000).

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Graph 9. Coverage of women with screening examinations for early cervical carcinoma detection and for early breast cancer detection

Coverage of expectant mothers with preventive examinations in the first trimester

No statistically significant change in the trend of the coverage of expectant mothers with preventive examinations in the first trimester was registered, between 2013 and 2017 (y = - 0.005x + 0.6426; p = 0.734).

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Graph 10. Coverage of expectant mothers with preventive examinations in the first trimester

DISCUSSION

This study has shown a stable trend of the coverage of target populations with preventive healthcare services. However, the values in the observed period were below the ones recommended. According to IPHS data, in 2017, the coverage of infants with preventive ultrasound hip examinations was 80%. However, the aforementioned Rulebook on the Content and Scope of the Rights to Healthcare as well as the Professional Methodology Instructions, prescribe that the optimum coverage for this service is 100%, bearing in mind its significance for the future quality of life of the children [13],[16]. Also, the recommended value of the coverage of children with preventive examinations is no less than 95%, while the results achieved were below this mark. The exception was only the coverage of preschool children (at the age of six/seven years, prior to starting school) with preventive examinations, which was near the recommended value in the observed period. As the doctor’s report on the preventive examination is a part of compulsory documentation submitted at elementary school enrolment, it was to be expected that this service would be widely covered in the children population. Children of elementary and high school age had a coverage with preventive examinations of 73.1% and 70%, respectively, which is well below the recommended minimum of 95%. Since the vaccines prescribed by the Calendar of Mandatory Immunization are compulsory, it goes without saying that the recommended coverage is 100%, i.e., very close to 100%, when cases where there is a contraindication to a vaccine are taken into account. However, apart from the BCG vaccine, which registered a coverage of 97.4%, in 2017, the remaining vaccines registered a coverage of around 95% (DTP vaccine: 95.1%; OPV vaccine: 95.2%; vaccine against pneumonia caused by Haemophilus influenzae type b: 95.2%; vaccine against hepatitis B: 92.4%). The divergence from the recommended coverage with the MMR vaccine is especially prominent, since, in 2017, it was as low as under 90% (more precisely 85.2%), which leads us to acknowledge the influence of the so called ‘anti-vaccination movement’ and to conclude that the medical and educational efforts of chosen doctors did not achieve the desired effect [22].

The low coverage with preventive examinations at the department for women’s healthcare, and especially for the care of expectant mothers, indicate that, perhaps, women in the Republic of Serbia are turning more and more to the private sector or are neglecting to have preventive examinations, as almost 40% of women did not visit their chosen gynecologist for a preventive examination during their pregnancy (only 63.4% of expectant mothers were covered by preventive examinations in 2017). The coverage of women above the age of 15 years with preventive examinations was below the recommended 20%, and in 2017, it was 9%. When screening programs for target populations of women are observed, in 2017, 3% of women were covered with screening for early breast cancer detection, while 8% of women were covered with screening for the early detection of cervical cancer. The recommendations are 50% and 30%, respectively, amongst women within the defined age range.

The department for the healthcare of adults registered coverage of services which had a stable trend in the observed period, but which was below the recommended values. Thus, in 2017, only 5% of adults were covered with preventive examinations. The coverage with screening programs particularly deviated from the recommended values. The recommended coverage for early detection of depression is 33%, while, in 2017, only 2% of the adult population received this service. Similarly, 33% is the recommended coverage with screening for early diabetes detection, however, in 2017, it was carried out in as little as 3% of adults. In the same year, 5% of the target population was covered with screening for the early detection of colon cancer, which is ten times less than the recommendation, while a total of 3% of the population was screened for cardiovascular diseases, while the recommendation is that 20% should be covered with this service.

Based on IPHS data, in the Republic of Serbia, the overall mortality rate has increased from 9.2 per 1,000 population, in 1969, to 13.2 per 1,000 population, in 2018. Almost every second person dies from cardiovascular disease, while every fifth person dies of a malignancy, which are preventable diseases and can be successfully treated, if diagnosed on time. This is, in fact, achieved through preventive examinations and screening programs [23].

The question remains as to why the payment for performance model, which is believed to be the best for financing and stimulating the increase in the efficiency of primary healthcare, did not fulfil its goals in the Republic of Serbia. One of the potential reasons is obviously the fact that the variable portion of the salary, which is affected by the capitation formula, is a mere 4.04%, which probably does not represent enough of an incentive for doctors to strive towards higher capitation scores. The second potential reason lies in the structure of the capitation formula itself, i.e., in its criteria and weights. This is why, in 2019, the capitation formula was improved with key changes necessary for transforming the criterion of ‘prevention’ into the criterion ‘quality’. The way that this change was implemented can best be explained through the example of quality indicators related to screening for the early detection of diabetes. According to the old formula, described in this paper, the records were kept as to the number of screening examinations related to early detection of diabetes which the doctors had provided during the observed period. As this is only quantitative measurement, the doctors were motivated to provide as many of these services as possible, but not to provide them to as many patients as possible, rather the services were provided to the same patients, who visited the doctor regularly, which is why the IPHS recorded a small coverage.

The new capitation formula measures the percentage of patients registered with a doctor who have received a screening service. An increase in coverage is being pushed forward, which is aimed at motivating doctors to better organize their work and reach more patients, as this is the way that the doctor will achieve a better score, which further has a positive effect on accessibility and quality of healthcare services and on achieving a wider coverage of the population with healthcare services. It is expected that the new capitation formula will contribute to an increase in the trend of coverage with preventive healthcare services, in the coming period, as well as promote the quality of primary healthcare, as was the case in Estonia [24]. With an increase in the variable portion of the salary, which the capitation formula affects, the impact of the capitation formula would be significantly greater.

CONCLUSION

Although most of the analyzed preventive healthcare services have demonstrated a stable coverage trend, this cannot be considered a favorable result, since the coverage of the different services, which has been maintaining the same levels throughout the years, is below the nationally recommended values as well as below the values observed in other European countries. This is why much is expected of the new and improved capitation formula.

  • Conflict of interest:
    None declared.

Informations

Volume 3 No 3

Volume 3 No 3

September 2022

Pages 300-316
  • Keywords:
    primary health care, payment for performance, chosen doctor, preventive health services, capitation formula
  • Received:
    23 August 2022
  • Revised:
    11 September 2022
  • Accepted:
    14 September 2022
  • Online first:
    25 September 2022
  • DOI:
Corresponding author

Mirjana Milošević
Ministry of Health of Republic Serbia
1 Pasterova Street, 1000 Belgrade, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.



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5. Zakon o zdravstvenoj zaštiti. Sl. glasnik RS, br. 25/2019. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2019/25/2/reg [HTTP]

6. Zakon o zdravstvenom osiguranju. Sl. glasnik RS, br. 25/2019. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/ SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2019/25/2/reg [HTTP]

7. Starfield B. Primary care: Balancing health needs, services, and technology. 1998. Oxford University Press. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1484414/ [HTTP]

8. WONCA Working Party on the Environment. Declaration calling for family doctors of the world to act on planetary health. 2019. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.wonca.net/site/DefaultSite/filesystem/documents/Groups/Environment/2019%20Planetary%20health.pdf [HTTP]

9. Drugi projekat razvoja zdravstva Srbije. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.zdravlje.gov.rs/tekst/335731/drugi-projekat-razvoja-zdravstva-srbije.php [HTTP]

10. Zakon o platama u državnim organima i javnim službama. Sl. glasnik RS, br. 113/2017. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2001/34/1/reg/20190101 [HTTP]

11. Uredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovama. Sl. glasnik RS, br. 46/2013. [Internet]. [Pristupljeno: 16.12.2019.]. Dostupno na: https://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/viewdoc?uuid=16ae9b10-7631-4675-a22e-5498d6a9d0d3 [HTTP]

12. Uredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovama. Sl. glasnik RS, br. 10/2019. [Internet]. [Pristupljeno: 16.12.2019.]. Dostupno na: https://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/viewdoc?uuid=-896c8a78-9626-4842-810aa45519814fa8

13. Pravilnik o sadržaju i obimu prava na zdravstvenu zaštitu iz obaveznog zdravstvenog osiguranja i o participaciji za 2017. godinu. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: https://www.paragraf.rs/izmene_i_dopune/230617-pravilnik_o_izmeni_pravilnika_o_sadrzaju_i_obimu_prava_na_zdravstvenu_zastitu_iz_obaveznog_zdravstvenog_osiguranja_i_o_participaciji_za_2017_godinu.htm [HTTP]

14. Republički fond za zdravtveno osiguranje, Sekcija kapitacija. [Internet]. [Pristupljeno: 15.12.2019.]. Dostupno na: http://rfzo.rs/index.php/davaocizdrusluga/kapitacija-actual-16 [HTTP]

15. Republički fond za zdravstveno osiguranje, Uputstvo za korišćenje K tabele za izabrane lekare, verzija 5.6. [Internet]. [Pristupljeno: 15.12. 2019.]. Dostupno na: https://www.lat.rzzo.rs/download/kapitacija/uputstva/Uputstvo_za_koriscenje_Ktabele-5.6-24092014.pdf

16. Ministarstvo zdravlja Republike Srbije, Republička stručna komisija za zdravstvenu zaštitu žena dece i omladine, Stručno metodološko uputstvo za sprovođenje Uredbe o Nacionalnom programu zdravstvene zaštite žena, dece i omladine, Beograd, 2010. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: https://www.imd.org.rs/files/strucno-metodolosko-uputstvo.pdf [HTTP]

17. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2013. godini, Beograd, 2014. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/izvestaji/2013AnalizaObimaISadrzajaStacionarna.pdf [HTTP]

18. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2014. godini, Beograd, 2015. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/izvestaji/2014Analiza%20obima%20i%20sadrzaja.pdf [HTTP]

19. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2015. godini, Beograd, 2017. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/Analiza%20obima%20i%20sadrzaja%20PPZ%202015.pdf [HTTP]

20. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2016. godini, Beograd, 2017. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/Analiza%20obima%20i%20sadrzaja%20PPZ%202016.pdf [HTTP]

21. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut ”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2017. godini, Beograd, 2018. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/Analiza%20PPZ%202017.pdf [HTTP]

22. Institut za javno zdravlje Srbije „Dr Milan Jovanović-Batut”, Kalendar obavezne imunizacije u Republici Srbiji. [Internet]. [Pristupljeno: 11.01.2020.]. Dostupno na: http://www.batut.org.rs/download/aktuelno/nedeljaImunizacijeKalendarObavezneImunizacijeURepubliciSrbiji.pdf [HTTP]

23. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Zdravstveno-statistički godišnjak Republike Srbije, 2017. Beograd, 2019. [Internet]. [Pristupljeno: 15.12.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/pub2017v026.pdf [HTTP]

24. World Health Organization. Pay-for-performance in Estonia: A transformative policy instrument to scale up prevention and management of noncommunicable diseases. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.euro.who.int/__data/assets/pdf_file/0005/287096/Good-practice-brief-pay-for-performance-in-Estonia.pdf [HTTP]

1. Veb stranica Inicijative za ostvarivanje primarne zdravstvene zaštite. [Internet]. [Pristupljeno: 10.01.2020.]. Dostupno na: https://improvingphc.org/why-primary-health-care [HTTP]

2. Vlada Republike Srbije, Treći nacionalni izveštaj o socijalnom uključivanju i smanjenju siromaštva u Republici Srbiji za period 2014 – 2017. godine. Beograd, 2019. [Internet]. [Pristupljeno: 11.01.2020.]. Dostupno na: http://socijalnoukljucivanje.gov.rs/wp-content/uploads/2019/02/Treci_nacionalni_izvestaj_o_socijalnom_ukljucivanju_i_ smanjenju_siromastva_2014%E2%80%932017_eng.pdf [HTTP]

3. Zakon o zdravstvenoj zaštiti. Sl. glasnik RS, br. 107/2005. [Internet]. [Pristupljeno: 15.12.2019.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/ SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2005/107/9/reg [HTTP]

4. Zakon o zdravstvenom osiguranju. Sl. glasnik RS, br.107/2005. [Internet]. [Pristupljeno: 15.12.2019.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2005/107/5/reg [HTTP]

5. Zakon o zdravstvenoj zaštiti. Sl. glasnik RS, br. 25/2019. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2019/25/2/reg [HTTP]

6. Zakon o zdravstvenom osiguranju. Sl. glasnik RS, br. 25/2019. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/ SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2019/25/2/reg [HTTP]

7. Starfield B. Primary care: Balancing health needs, services, and technology. 1998. Oxford University Press. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1484414/ [HTTP]

8. WONCA Working Party on the Environment. Declaration calling for family doctors of the world to act on planetary health. 2019. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.wonca.net/site/DefaultSite/filesystem/documents/Groups/Environment/2019%20Planetary%20health.pdf [HTTP]

9. Drugi projekat razvoja zdravstva Srbije. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.zdravlje.gov.rs/tekst/335731/drugi-projekat-razvoja-zdravstva-srbije.php [HTTP]

10. Zakon o platama u državnim organima i javnim službama. Sl. glasnik RS, br. 113/2017. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: http://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/zakon/2001/34/1/reg/20190101 [HTTP]

11. Uredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovama. Sl. glasnik RS, br. 46/2013. [Internet]. [Pristupljeno: 16.12.2019.]. Dostupno na: https://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/viewdoc?uuid=16ae9b10-7631-4675-a22e-5498d6a9d0d3 [HTTP]

12. Uredba o korektivnom koeficijentu, najvišem procentualnom uvećanju osnovne plate, kriterijumima i merilima za deo plate koji se ostvaruje po osnovu radnog učinka, kao i načinu obračuna plate zaposlenih u zdravstvenim ustanovama. Sl. glasnik RS, br. 10/2019. [Internet]. [Pristupljeno: 16.12.2019.]. Dostupno na: https://www.pravno-informacioni-sistem.rs/SlGlasnikPortal/viewdoc?uuid=-896c8a78-9626-4842-810aa45519814fa8

13. Pravilnik o sadržaju i obimu prava na zdravstvenu zaštitu iz obaveznog zdravstvenog osiguranja i o participaciji za 2017. godinu. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: https://www.paragraf.rs/izmene_i_dopune/230617-pravilnik_o_izmeni_pravilnika_o_sadrzaju_i_obimu_prava_na_zdravstvenu_zastitu_iz_obaveznog_zdravstvenog_osiguranja_i_o_participaciji_za_2017_godinu.htm [HTTP]

14. Republički fond za zdravtveno osiguranje, Sekcija kapitacija. [Internet]. [Pristupljeno: 15.12.2019.]. Dostupno na: http://rfzo.rs/index.php/davaocizdrusluga/kapitacija-actual-16 [HTTP]

15. Republički fond za zdravstveno osiguranje, Uputstvo za korišćenje K tabele za izabrane lekare, verzija 5.6. [Internet]. [Pristupljeno: 15.12. 2019.]. Dostupno na: https://www.lat.rzzo.rs/download/kapitacija/uputstva/Uputstvo_za_koriscenje_Ktabele-5.6-24092014.pdf

16. Ministarstvo zdravlja Republike Srbije, Republička stručna komisija za zdravstvenu zaštitu žena dece i omladine, Stručno metodološko uputstvo za sprovođenje Uredbe o Nacionalnom programu zdravstvene zaštite žena, dece i omladine, Beograd, 2010. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: https://www.imd.org.rs/files/strucno-metodolosko-uputstvo.pdf [HTTP]

17. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2013. godini, Beograd, 2014. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/izvestaji/2013AnalizaObimaISadrzajaStacionarna.pdf [HTTP]

18. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2014. godini, Beograd, 2015. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/izvestaji/2014Analiza%20obima%20i%20sadrzaja.pdf [HTTP]

19. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2015. godini, Beograd, 2017. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/Analiza%20obima%20i%20sadrzaja%20PPZ%202015.pdf [HTTP]

20. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2016. godini, Beograd, 2017. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/Analiza%20obima%20i%20sadrzaja%20PPZ%202016.pdf [HTTP]

21. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut ”, Analiza planiranog i ostvarenog obima i sadržaja prava osiguranih lica na primarnu zdravstvenu zaštitu u 2017. godini, Beograd, 2018. [Internet]. [Pristupljeno: 20.11.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/Analiza%20PPZ%202017.pdf [HTTP]

22. Institut za javno zdravlje Srbije „Dr Milan Jovanović-Batut”, Kalendar obavezne imunizacije u Republici Srbiji. [Internet]. [Pristupljeno: 11.01.2020.]. Dostupno na: http://www.batut.org.rs/download/aktuelno/nedeljaImunizacijeKalendarObavezneImunizacijeURepubliciSrbiji.pdf [HTTP]

23. Institut za javno zdravlje Srbije „Dr Milan Jovanović – Batut”, Zdravstveno-statistički godišnjak Republike Srbije, 2017. Beograd, 2019. [Internet]. [Pristupljeno: 15.12.2019.]. Dostupno na: http://www.batut.org.rs/download/publikacije/pub2017v026.pdf [HTTP]

24. World Health Organization. Pay-for-performance in Estonia: A transformative policy instrument to scale up prevention and management of noncommunicable diseases. [Internet]. [Pristupljeno: 15.01.2020.]. Dostupno na: https://www.euro.who.int/__data/assets/pdf_file/0005/287096/Good-practice-brief-pay-for-performance-in-Estonia.pdf [HTTP]


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