Changes in health
systems in South
A fairy tale
What has happened next
Where are we now
Predicting the future
What are we talking about?
Divisions in Europe
Central and Eastern Europe
Central and Eastern Europe is a term describing former communist
states in Europe, after the collapse of the iron curtain in 1989/90.
It includes all the Eastern bloc countries west of the post - World war II
border with the former Soviet Union, the independent states in former
Yugoslavia (which were not considered part of the Eastern bloc), and the
three Baltic States: Estonia, Latvia and Lithuania.
Belarus, Ukraine, Moldova and Russia are members of CIS
(Commonwealth of Independent States) and are not included in CEE.
..is a relatively recent political designation for the Balkan peninsula
states. There are no clear and universally accepted geographical or
historical divisions that delineate this region. The countries located fully
in the peninsula are the following: Albania, Bosnia and Herzegovina,
Kosovo, Bulgaria, Greece, Macedonia and Montenegro. The geographic
definition may also include countries which are significantly located in the
peninsula: Croatia (1/2) and Serbia (up to 2/3) and some countries which
are located mostly outside the peninsula as defined by the rivers:
Slovenia(1/5), Romania (6%) and Turkey (3%).
6 (7) countries, that
became independent after
the breakup of former
• Bosnia and Herzegovina
• FYR Macedonia
Dramatic changes since
Relative lack of
How it all began?
A FAIRY TALE
A long, long time ago, in a country far,
International Conference on Primary Health Care,
Alma-Ata, USSR, 6-12 September
Primary health care is the key to attaining health for all.
All governments should formulate national policies, strategies
and plans of action to launch and sustain primary health care
as part of a comprehensive national health system and in
coordination with other sectors.
the whole world community should support national and
international commitment to primary health care and channel
increased technical and financial support to it, particularly in
MAIN MODELS IN THE
THE SEMASKO MODEL
Based on policlinics
Salaried GPs with low
recognition of primary
Based on community
based primary health
officially recognised as
a speciality, not always
What happened next?
CRISIS: AN INABILITY TO
KNOW WHICH DIRECTION TO
“I’m all for progress,
it’s change I can’t cope
Reasons: major societal trends
Loss of belief in figures in authority and downfall of heroic
Knowledge explosion through popular books, media, and
Rise of consumerism
Rise in litigation
Rise of managerialism
New concepts in medicine
Patient empowerment, patient autonomy,
Academic family medicine
Quality of care
Some titles from: Buetow S, ed.: Ideological Debates in Family Medicine
Collapse of communist
War in the Balkans
The crisis of medicine
• Ability to pay
• Control of medical profession
• Consumerism and leo-liberalism
Crisis of academic medicine
Where are we now?
DESCRIPTION OF THE
Do we know
where we are?
SOURCES OF INFORMATION
The FATMEE study
The “Post - YU PHC”
Two key informants from each country
Both medical schools with
university departments since
Obligatory VT (4 years)
Health care reform aimed at
University departments at all
10 years no VT!!
Reaffirmation of discipline
At least 3 organisations of
Hebrang A, Henigsberg N, Erdeljic V, Foro S, Turek S, Zlatar M. Privatization of the Croatian health care
system: effect on indicators of health care accessibility in general medicine] Lijec Vjesn. 2002 Aug-
Personal information Mladenka Vrcić Keglević, Milica Katić, Dragomir Petric 26
BOSNIA AND HERZEGOVINA
University departments and teaching
Family medicine re-establishmnet
through numerous programs
Canadian family medicine
Problems with infrastructure, and
Godwin M, Hodgetts G, Bardon E, Seguin R, Packer D, Geddes J.
Primary care in Bosnia and Herzegovina. Health care and health status in general practice ambulatory care centres. Can
Fam Physician. 2001 Feb;47:289-97.
University position within
10 years of isolation
Family medicine at
undergraduate level at most
Personal information by Smiljka Radić 28
Health care reform, started in
Re-training of doctors and nurses
Implementation of full
specialisation and formal retraining
Health care reform
Introducing family medicine
oriented primary care
Re-training all PHC doctors
Establishment of department etc.
Source: Svab I. The blind spot issue. Eur J Gen Pract 2011.
A course was developed by the WHO,
which became the first year of a two year
specialisation in family medicine.
Family medicine unit in the university
21 candidates on the specialisation
programme enrolled on a MSc in family
The unit has now become the Centre for
the Development of Family Medicine
with responsibility for developing
academic family medicine
Source: Hedley R, Maxhuni B. Development of family medicine in Kosovo. BMJ 2005
Summary of findings 1
Formally family medicine exists as a separate and a recognized specialty in all
countries and its position is legally recognized.
The practical implementation of these principles is a problem.
Positive effects of EU regulation
In most countries, family medicine is just one of the many medical specialities in
This is especially true for the care of children and women, which are taken care of
by paediatricians and gynaecologists, leaving family medicine as a specialty for
adults in some of the countries.
Summary of findings 2
Mostly family medicine is provided by solo practices.
Health centres have remained on different levels with different roles in
There are no common European standards of family medicine, but EU is
important in setting standards.
Where are we going?
PREDICTING THE FUTURE
The age of primary care is in front of us, not behind us *
Larry Green, October 4, 2007. BMJ Listserver discussion
PREDICTING THE FUTURE
Increased cooperation among the countries
• CSAKOS initiative
• Association of family medicine of Southeast
• The EURACT Bled course