Brošura u pdf. formatu - PALGO centar

KA REFORMI
JAVNOG ZDRAVSTVA
U SRBIJI
Toward Health Care Reform in Serbia

KA REFORMI JAVNOG ZDRAVSTVA U SRBIJI
TOWARD HEALTH CARE REFORM IN SERBIA
SADRŽAJ / SUMMARY:
Uvod / Introduction... Dejan Pavlović... 1...
Finansiranje zdravstvene zaštite / Financing Health Care... Kenneth Davey... 3...
Decentralizacija u sistemu zdravstvene zaštite
Decentralization of the Health Care System... Snežana Simić... 5...
Sistem finansiranja zdravstva RS
System of Financing Health Care in Serbia... Svetlana Vukajlović... 14...
Šta donose novi zakoni u zdravstvu?
What will the New Laws on Health Care bring?... Hajrija Mujović-Zornić... 21...
Zdravlje Romkinja / Health of Roma Women... Đurđica Zorić... 25...
Zdravlje žena / Women’s Health... Hajrija Mujović-Zornić... 30...
Zaključci konferencije / Conference Communiqué... 32...
Ova brošura objedinjuje prikaze pet konferencija na temu javnog zdravstva u Srbiji i autorske priloge
nastale tim povodom. Održavanje konferencija i izdavanje ove brošure pomogli su:
Fond za otvoreno društvo iz Beograda i Institut za otvoreno društvo iz Budimpešte.
**
This brochure brings together the previews of five conferences on Public Health issues in Serbia and
articles of participating experts related to them. The organization of conferences and publishing of this
brochure were supported by the Fund for an Open Society (Belgrade) and the Open Society Institute
- Local Government and Public Reform Initiative (Budapest).
Izdavač: PALGO centar, Beograd
Za izdavača: Dušan Damjanović
Lektor/korektor: Radomir Glušac
Prevod: Lexica, Beograd
Beograd, 2006.

Uvod
Introduction
Nema lakih tranzicija, niti je njihov teret ravnomerno
raspodeljen na sve društvene grupe. Iako je teško osporiva
nužnost reformi u zemljama koje su devedesetih doživele
drastične socio-političke promene, njihova dinamika i modaliteti
su veoma osetljiva pitanja. Javno zdravstvo je očigledan primer.
Ukoliko se do pred poslednju deceniju XX veka moglo reći
da postoji relativno ujednačen pristup zdravstvenoj zaštiti
nezavisno od socijalnog statusa, efektivna zdravstvena zaštita
je danas teško dostižni element kvaliteta života. U društvu
postoji očigledna diskrepanca između očekivanja korisnika
zdravstvene zaštite, naviklih na visok kvalitet usluga i
značajno subvenicioniranu zdravstvenu zaštitu i realnosti u
kojoj zdravstvene ustanove nemaju materijalnih sredstava
da obezbede neophodne preduslove za pružanje zdravstvene
zaštite, uz očigledno slabljenje društvene kohezije i poljuljano
poverenje u institucije.
U takvom društvenom miljeu svaka odluka kreatora javne
politike u pogledu obima, kvaliteta i cene usluga zdravstvene
zaštite može naići i nailazi na zid neodobravanja, pa i osude.
Otvaranje javne debate o ključnim reformskim pitanjima, kako u
domenu zdravstvene politike, tako i u domenu ostalih sektorskih
politika, a naročito onih sa izraženim socijalnim efektima, čini
se veoma racionalnim i svrsishodnim.
PALGO centar je u saradnji sa Institutom za otvoreno društvo
iz Budimpešte i Fondom za otvoreno društvo iz Beograda u
periodu maj 2005. – jun 2006. organizovao seriju konferencija o
vitalnim pitanjima zdravstvene politike u Srbiji. Vođeni idejom
da je najlošija ona politika koja se formuliše tajno i jednostrano,
bez plana i procene njenih efekata, organizovali smo javne
debate usmerene na pojašnjavanja, kritičke analize i polemiku
sa samim kreatorima zdravstvene politike Srbije.
Zahvalni smo nosiocima javnih funkcija, pre svega
predstavnicima Ministarstva zdravlja, što nisu izbegavali da
se upuste u otvoren dijalog o pitanjima koja često nemaju ni
tačan ni pogrešan odgovor. Na pitanje da li je decentralizacija
zdravstvene zaštite dobar ili loš koncept i koji nivo zdravstvene
zaštite država mora garantovati i kakvim mehanizmom, nije
odgovoreno ni u razvijenijim društvima. Srbija dakako mora
voditi računa o svim građanima, ali posebnu pažnju mora
posvetiti onima kojima ni minimum često nije pristupačan
(romska populacija) ili je taj minimum nedovoljan. Korupcija je
globalni fenomen i zdravstvo u Srbiji nije na njega imuno, ali je
siguran poraz o istoj ćutati.
Javne rasprave o sistemu finansiranja javnog zdravstva,
decentralizaciji sistema, transparentnosti i suzbijanju korupcije,
kao i razmatranja položaja ranjivih grupa, neće po sebi rešiti
ove probleme, ali su pravilno postavljena pitanja i ispravne
dijagnoze često najvažniji elementi terapije.
Naredne stranice pružaju uvid u održane javne rasprave
i nude osvrte stručnjaka na teme pokrenute na pomenutim
okruglim stolovima. Njihova vrednost je u tome što omogućuju
uvid šire javnosti u određena pitanja, ali i u tome što nude
alternativna rešenja za postojeće probleme. ■
There are no easy transitions, nor is their burden equally
distributed to all social groups. Even though it is hard to dispute
the necessity of reforms in countries that had undergone drastic
socio-economic changes in the 1990ies, their dynamics and
modalities are a very sensitive issues. Public health is a manifest
example. Even if it was possible to say prior to the last decade
of the 20 th century that there was a relatively unified approach
to health care regardless of the social status, effective health
care today is an element of the quality of life that it is difficult
to attain. Within the society, there is an evident discrepancy
between the expectations of beneficiaries of health care, used
to high quality services, and a considerably subsidised health
care, and the reality in which health institutions do not have
funds to form the necessary preconditions for providing health
care, which is acccompanied by the evident loosening of social
cohesion, and the undermined trust in institutions.
In such a social environment, any decision of creators of
public policies in the domain of the scope, quality, and prices
of health care, can be faced with a wall of lack of approval, and
even condemnation. The initiating of a public debate on key
reform issues, both in the domain of health care policies, and
in the domains of policies within other sectors, especially those
having pronounced social effects, seems to be very sensible and
rational.
PALGO Center, in cooperation with the Open Society
Institute from Budapest, and the Fund for an Open Society
from Belgrade, has organized in the period May 2005 – June
2006, a series of conferences on vital issues of health care
policy in Serbia. Guided by the idea that the worst policy is a
policy formulated secretly and unilaterally, without any plan
or assessment of its effects, we have organized public debates
with the goal to clarify, critically analyze, and debate with the
creators of the health care policy in Serbia.
We are grateful to public officials, primarily to representatives
of the Ministry of health, for not evading an open dialog about
questions that frequently have no right or wrong answer. The
question if the decentralization of health care is a good or
a bad concept, and what level of health care the state must
guarantee, and by what mechanism, has not been answered
even in developed societies. Naturally, Serbia must take care
of all its citizens, but it must devote special attention to those
for whom even the minimum is frequently out of reach (the
Roma population), or for whom this minimum is not sufficient.
Corruption is a global phenomenon, and health care in Serbia is
by no means immune to it, but surrounding it with silence results
in certain defeat.
Public debates on the system of financing of public health
care, on the decentralization of the system, on transparency, and
on supressing corruption, as well as the review of the position of
vulnerable groups, will not in themselves solve these problems,
however, right questions and a good diagnosis are often the most
important elements of therapy.
Pages that follow offer an insight into the public debates that
have taken place, as well as the opinions of experts pertaining
to topics initiated during mentioned round table discussions.
Their value is contained in the fact that they afford to the general
population an insight into certain issues, but also in the fact that
they offer alternative solutions to existing problems. ■
1

1.
Ka efikasnijem sistemu
zdravstvene zaštite u
Srbiji
Toward More Efficient
Public Health Sector in
Serbia
PALGO centar je, u saradnji sa Institutom za
otvoreno društvo iz Budimpešte, 10. maja 2005.
godine u hotelu Palas u Beogradu, organizovao
Međunarodnu konferenciju o reformi zdravstvenog
sektora u Srbiji.
On May 10 th 2005, PALGO Center organized,
in cooperation with LGI/OSI Budapest, the
International Conference on Public Health
Reform, held in Hotel Palace in Belgrade.
Prepodnevni deo konferencije je bio posvećen
pitanju decentralizacije zdravstvenog sektora u
Srbiji, a poslepodnevna sesija je u fokusu imala
mogućnosti uspostavljanja finansijski održivog
sistema zdravstvene zaštite u Srbiji. Konferenciju
je otvorio Mijat Damjanović (predsednik PALGO
centra), a svoja izlaganja u okviru prepodnevne
sesije imali su Snežana Simić (pomoćnica ministra
zdravlja), Kenet Dejvi (LGI) i Silviu Radulesku
(Svetska banka, kancelarija u Bukureštu). U
drugom delu konferencije izlagali su Tomica
Milosavljević (ministar zdravlja) i Svetlana
Vukajlović (direktorka Zavoda za zdravstvenu
zaštitu). ■
The morning session was dedicated to the
issue of decentralization of health care system
in Serbia, while the afternoon session related
to the possibilities of establishing a financially
sustainable health care system in Serbia. Mijat
Damjanović (President of PALGO Center) greeted
the guests and delivered the introductory note, and
in the morning session the speakers were Snežana
Simić (Assistant Minister of Health), Kenneth
Davey (LGI) and Silviu Radulescu (World Bank,
Bucharest Office). In the afternoon session the
speakers were Tomica Milosavljević (Minister of
Health) and Svetlana Vukajlović (Director of the
Serbian Health Insurance Fund). ■
2

Finansiranje zdravstvene
zaštite
Kenet Dejvi
Uloga oporezivanja i zdravstvenog osiguranja
Uloge oporezivanja i zdravstvenog osiguranja se značajno
razlikuju u različitim zemljama. U Skandinaviji i Velikoj
Britaniji, na primer, ne postoji obavezno zdravstveno osiguranje,
a nacionalni sistem zdravstvene zaštite se finansira opštim
oporezivanjem. Dobrovoljno privatno zdravstveno osiguranje
može jednostavno da predstavlja alternativnu zaštitu u privatnom
sektoru uz ubrzan tretman, privatna odeljenja u bolnicama, itd.
Postoje dva modela sistema koje finansira zdravstveno
osiguranje. Model u SAD jeste konkurentsko tržište na kojem
je tip polise osiguranja koji se kupuje povezan sa nivoom
zaštite koja se pruža. Evropski (“Bizmarkov”) model socijalnog
osiguranja je obavezan i povezuje uplate sa nivoom prihoda,
često (ali ne uvek) zahtevajući doprinose i od poslodavaca i od
zaposlenih. Usluga je besplatna za pacijenta na mestu gde se
pruža, a nivo zaštite nije povezan sa uplaćenim doprinosima.
Evropsko socijalno osiguranje, zbog svoje povezanosti sa
zaradom i zbog nedostatka povezanosti sa koristi koju pruža,
zapravo predstavlja alternativni oblik oporezivanja. Moglo
bi se zameniti i višim porezima na lične prihode i na prihode
korporacija. Ono ima sve prednosti u odnosu na ovo drugo
rešenje; politički je atraktivnije od povećanja opšteg poreza,
a njegovi rezultati se povezuju sa izdacima za zdravstvenu
zaštitu.
Tamo gde postoji obavezno zdravstveno osiguranje, ono
ne pokriva sve troškove zdravstvene zaštite, pa izvesno često
značajno opterećenje pada i dalje na opšte poreze. Normalno
je, na primer, da državni ili lokalni budžeti plaćaju troškove
za epidemiološku kontrolu, medicinsko osoblje i istraživanje.
Izgradnja i održavanje zgrada i kupovina veće opreme obično
pada na teret države, ili često lokalnih budžeta. Vlada, ili
povremeno lokalne vlasti, treba da plate troškove osiguranja za
one koji ne zarađuju – penzionere, decu, invalide, nezaposlene,
itd.
Jedan problem koji se često javlja, jeste da poslodavaci
koji imaju finansijske teškoće ne uplaćuju obavezne doprinose
u fondove zdravstvenog osiguranja, a i vlade ne daju uvek
adekvatne uplate za svoje doprinose za one koji samo ne vrše
uplatu. To otvara ciklus dugovanja u kojem fondovi ne vrše
uplate bolnicama, lekarima opšte prakse i drugim davaocima
usluga, koji sa svoje strane odlažu uplate troškova dobavljačima,
poput kompanija koje isporučuju lekove i energente.
Plaćanje zdravstvene zaštite
Postkomunističke reforme su uglavnom izvršile privatizaciju
primarne zdravstvene zaštite, dok su bolnice postale institucije
koje su samoupravne i koje vrše sopstvene obračune, mada su i
dalje u posedu bilo države ili lokalnih vlasti.
Normalna praksa jeste da oni koji vrše primarnu zdravstvenu
zaštitu primaju standardnu uplatu po glavi stanovnika za
pacijente koji se kod njih registruju. Pošto se to ne menja u
odnosu na kvantitet pruženih usluga, javila se tendencija da to
podstiče preterano upućivanje pacijenata u bolnice ili ambulantne
jedinice za specijalističko zbrinjavanje. To je u suprotnosti sa
opštom politikom podsticanja prenosa zdravstvene zaštite ka
primarnom nivou, kako radi efikasnosti, tako i pogodnosti.
Neki pokušaji se čine, u Velikoj Britaniji na primer, da se tome
suprotstavi nuđenjem pogodnosti putem variranja uplata po
Financing Health Care
Kenneth Davey
Roles of Taxation and Health Insurance
The respective roles of taxation and health insurance
vary considerably between states. In Scandinavia and UK,
for example, there is no compulsory health insurance and
the national system of health
care is financed from general
taxation. Voluntary private
health insurance may simply
offer alternative private sector
care with accelerated treatment,
private wards etc.
There are two models
of health insurance funded
systems. The US model is of
a competitive market in which
the type of insurance policy
purchased is linked to the level
of care provided. The European
model (“Bismarkian”) of social
insurance is compulsory and links payments to the level of
income, often (but not always) requiring contributions from
both employers and employees. The service is free to the patient
at the point of delivery and the level of care provided is not
linked to the contributions made.
The European social insurance is effectively an alternative
form of taxation, because of its linkage to earnings and its
delinking from benefit. It could be replaced by higher levels
of personal and corporate income tax. It has two advantages
over the latter; it is more politically attractive than increases
in a general tax and its yields are earmarked to expenditure on
health care.
Where compulsory health insurance exists it does not cover
all health care costs and some, often substantial burden still falls
on general taxes. It is normal, for example, for state or local
budgets to meet the costs of epidemiological control, medical
staff training and research. Construction and maintenance of
buildings and purchase of major equipment normally falls on
state or often local budgets. Government, or occasionally local
government should meet the insurance costs of non-earners
– pensioners, children, the handicapped, the unemployed etc.
One frequent problem is the failure of employers in financial
difficulties to pay over obligatory contributions to health
insurance funds and governments do not always make adequate
provision for their contributions in respect of non-payers.
This commences a cycle of debt in which Funds then default
on payments due to hospitals, general practitioners and other
providers, who in turn delay reimbursement of suppliers such as
drug and utility companies.
Payment of Health Care Providers
Post Communist reforms have generally privatised primary
health care, while hospitals have become self managing, self
accounting institutions, although still owned in most cases by
either state or local government.
The normal practice is for primary care practices to receive a
standard capitation fee in respect of those patients who register
with them. Since this does not vary with the amount of service
provided, there has been a tendency for this to encourage
3

glavi stanovnika kako bi lekari formirali grupne ordinacije i
pružali dodatne usluge, poput fizioterapije, EKG testova, itd.
Pokazalo se da je vrlo teško pronaći zadovoljavajuće osnove
za plaćanje bolničkog zbrinjavanja. Komunistički sistemi
su normalno plaćali prema inputima, poput plata za osoblje,
grejanja, lekova, itd., uz primenu normi za plaćanja koje nisu
bile u bliskoj vezi sa potražnjom. Mnoge zemlje su pokušale da
izvrše reformu tako što su plaćale prema rezultatima, u smislu
pruženog tretmana. To se pokazalo jednako neefikasnim, time
što je jednostavno podsticalo maksimalni prijem pacijenata,
boravak u ustanovama, ispitivanja krvi, rendgenskih snimanja,
itd. – bilo čega što donosi novac. Nije nađeno kompletno
rešenje, ali se velika nada polaže u primenu DRG sistema – tj.
standardnog plaćanja za tretman specifičnih medicinskih stanja
na bazi prosečnih troškova.
Racionalizacija
Većina bivših komunističkih zemalja je nasledila prevelik
broj bolničkih kreveta i predug boravak pacijenata u njima
radi zbrinjavanja. Pokušaji da se to smanji nailaze na otpor
menadžera u zdravstvenoj zaštiti, što ne iznenađuje.
Pokušani su razni metodi racionalizacije. U Mađarskoj, na
primer, Fond zdravstvenog osiguranja formira budžet za ukupan
broj kreveta koji će se finansirati u svakoj grofoviji za svaku
od vrsta medicinskog zbrinjavanja - kardiologiju, ginekologiju,
onkologiju, itd. - i potom, nakon procesa kompetitivnog tendera,
sklapa sa pojedinačnim bolnicama godišnje ugovore za njihovo
pružanje. Poljska vlada je ustanovila fond za restrukturiranje
kapitalnih izdataka vezanih za pripajanja i adaptacije; provincije
se za njih prijavljuju pripremanjem planova racionalizacije.
Decentralizacija
U većini zemalja Centralne i Istočne Evrope i bivšeg
Sovjetskog Saveza, donekle je izvršena decentralizacija
odgovornosti zdravstvene zaštite ka regionalnim i lokalnim
nivoima samouprave. To je često bio deo opšte politike prenosa
ovlašćenja na lokalne vlasti, a ne toliko reforma zdravstvene
zaštite sama po sebi.
Kada se kombinuje, što je često slučaj, sa uvođenjem
finansiranja zdravstvenog osiguranja i prenosom prava
samoupravljanja na bolnice, ordinacije opšte prakse i druge
institucije koje vrše zdravstvenu zaštitu, ovaj prenos na lokalnu
samoupravu ima tendenciju da bude i nejasan i delimičan. Mada
uključuju izvesno vlasništvo nad imovinom i opšti nadzor,
politički i tehnički kapaciteti gradonačelnika da kontrolišu
lekare su veoma ograničeni. Finansijska odgovornost se može
u velikoj meri svesti na odgovornost za izgradnju i održavanje
objekata i kupovinu opreme, a ne mora biti u većoj meri
konkretno priznata u formulama koje upravljaju ujednačavanjem
i transferima između nivoa vlasti. Finansijsko preopterećenje se
može pojačati kada opštine finansiraju bolnice koje opslužuju
regione koji su izvan njihove jurisdikcije i osnove sa koje
ostvaruju prihode.
Još jedan problem decentralizacije je tendencija
fragmentisanja odgovornosti za različite tipove zdravstvene
zaštite (specijalističke bolnice, opšte bolnice, primarno
zbrinjavanje, itd.) između nivoa regionalnih i opštinskih vlada.
To postavlja institucionalne prepreke prebacivanju tretmana
između davalaca usluga koji usled napretka medicinske
tehnologije postaju poželjni i efikasni.
Prenos ovlašćenja može, međutim, da poboljša opštu
odgovornost, u smislu da su lokalne vlasti u mogućnosti da
intervenišu kada se pojavi veliki broj pritužbi na lokalne
usluge. ■
4
excessive referral of patients to hospitals or ambulatory
specialist care units. This is opposed to the general policy of
encouraging a shift of health care provision towards the primary
level, for the sake of both efficiency and convenience. Some
attempts are being made, in UK for example, to counter this
by offering incentives through variation in capitation fees for
doctors to form group practices and provide additional services
such as physiotherapy, ecg tests etc.
Finding a satisfactory basis of payment for hospital care
has proved widely difficult. Communist systems normally
paid according to inputs such as staff salaries, heating, drugs
etc, using norms of provision which were not closely related
to demand. Many countries tried to reform this by payment
according to output in terms of treatments given. This has proved
equally inefficient in simply encouraging the maximisation of
admissions, inpatient stays, blood tests, xrays etc – anything that
earns money. No complete solution has been found, but much
faith is being put in the use of DRG systems – i.e. standard
payments for the treatment of specific medical conditions, based
on averaged costs.
Rationalisation
Most ex-Communist countries have inherited excessive
provision of hospital beds and periods of inpatient care.
Attempts to reduce these meet unsurprising resistance from
health care managers.
Various methods of rationalisation have been attempted.
In Hungary, for example, the Health Insurance Fund budgets
for the total number of beds to be funded in each county for
each type of medical care, - cardiology, gynaecology, oncology
etc- and then contracts annually with individual hospitals to
provide these after a process of competitive tender. The Polish
Government has established a restructuring fund for the capital
expenses involved in amalgamations and adaptations; provinces
bid for these by the preparation of rationalisation plans.
Decentralisation
In most CEE and FSU countries, there has been some
decentralisation of health care responsibilities to regional and
local levels of self government. This has often formed part of a
general policy of devolving power to local government, rather
than health care reform per se.
When combined, as so often, with the introduction of health
insurance funding and the award of self managing powers to
hospitals, general practices and other health care providers, this
devolution to local self government tends to be both unclear
and largely residual. Although it involves some ownership
of assets and general oversight, the political and technical
capacity of mayors to control doctors is very limited. Financial
responsibility may be largely for construction and maintenance of
buildings and purchase of equipment and may not receive much
specific recognition in the formulae which govern equalisation
and intergovernmental transfers. Financial overload may be
exacerbated where municipalities fund hospitals which serve
catchment areas beyond their jurisdiction and revenue base.
Another problem with decentralisation is the tendency
to fragment responsibility for different types of health care
(specialist hospitals, general hospitals, primary care etc)
between tiers of regional and municipal government. This
poses institutional obstacles to the shifts of treatment between
providers which advances in medical technology make desirable
and efficient.
Devolution may, however, improve general accountability,
insofar as local governments are able to intervene where local
services become subject to widespread complaint. ■

Decentralizacija u sistemu
zdravstvene zaštite
Decentralization of the
Health Care System
Snežana Simić
Uvod
Decentralizacija se može definisati kao prenos vlasti,
rukovođenja i donošenja odluka sa nacionalnog nivoa na
subnacionalne nivoe ili sa višeg na niže nivoe vlasti (državne
uprave). Sam termin obuhvata širok spektar koncepata koji
se moraju pažljivo analizirati pre bilo kakve odluke o tome
da li bi predloženi projekti ili programi trebalo da podrže
reorganizaciju sa decentralizacijom neke funkcije u sistemu
zdravstvene zaštite kao što su finansiranje, ili obezbeđivanje
zdravstvenih usluga stanovništvu.
Decentralizacija nije sama sebi svrha. Ona je
sredstvo da se dostigne širi spektar ciljeva. Često
se ističe da je decentralizacija veoma važan korak
u promovisanju demokratije. Zasnovana delom
na stavovima liberala, ova tvrdnja sugeriše da
učešće lokalne zajednice u izborima programa
ili uspostavljanju prioriteta na lokalnom nivou
predstavlja kamen temeljac demokratije. Različiti
ciljevi se mogu navesti kao razumna osnova za
decentralizaciju. Ona se često doživljava kao politički
ideal koji obezbeđuje način za učešće zajednice u
odlučivanju i postizanju samosvesti/samopouzdanja
lokalne zajednice, kao i za povećanje odgovornosti
(polaganja računa) državnih službenika na nižim
administrativnim nivoima. Mnogobrojne političke
inicijative koje su uvele decentralizaciju širom sveta
bile su inspirisane ovim idejama.
U sistemu zdravstvene zaštite, argumenti kojima se
afirmiše decentralizacija koriste se za dokazivanje da se
putem nje mogu postići i važni ciljevi, kao što su delotvornost
(efektivnost), pravednost, efikasnost, kvalitet, finansijska
odgovornost i uvažavanje lokalnih preferencija. Ovi ciljevi
odslikavaju naše opšte prihvaćene vrednosti - bliske ciljevima
utilitarne i egalitarne liberalne pozicije (tabela 1).
Kada govorimo o delotvornosti ili uspešnosti (efektivnosti),
ističe se da lokalni zvaničnici znaju više o specifičnim uslovima
povezanim sa zdravljem stanovništva na svojoj teritoriji, te da
zbog toga mogu donositi bolje odluke kao odgovor na njihove
zdravstvene potrebe nego udaljene birokrate. Ovo je još
očiglednije u situacijama kada nacionalne zdravstvene politike
ne uzimaju dovoljno u obzir specifične probleme lokalnog
stanovništva. Ipak, trebalo bi naglasiti da povezanost između
instrumenta - kao što je decentralizacija, i cilja - delotvornosti,
nije jasno demonstrirana u praksi decentralizacije. Postoji malo
dokaza koji podržavaju ovu povezanost, i mnogo više onih koji
sugerišu da delotvorno donošenje odluka zahteva visok nivo
sofisticiranih procena i odgovarajućih intervencija, što su
veštine često nedovoljno razvijene na lokalnom nivou.
Ističe se da decentralizacija može povećati pravičnost
u sistemu zdravstvene zaštite davanjem više moći i resursa
lokalnim zajednicama, dok se centralizovanom raspodelom
resursa često favorizuju centri moći. Lokalni zvaničnici bolje
znaju ko su siromašni članovi zajednice i mogu da usmere
resurse ka njima, tako da na lokalnom nivou postoje bolje
mogućnosti za donosioce odluka u smanjivanju nejednakosti
medu građanima. Nažalost, brojni dokazi iz razvijenih
Snežana Simić
Introduction
Decentralization can be defined as the transfer of power,
management, and decision making from the national level to
subnational levels, or from higher to lower levels of power
(state administration). The term encompasses a broad spectrum
of concepts that must be carefully analyzed before any decision
is made if suggested projects or programs should support
reorganization and decentralization of a function within the
health care system, such as financing, or providing health care
services to the population.
Decentralization is not a goal in itself. It is a
mean to achieve a broader spectrum of goals. It is
often emphasized that decentralization is a very
important step in promoting democracy. Partially
based on liberal premises, this claim suggests that
the participation of the local community in electoral
programs or the setting of priorities at the local
level represents the cornerstone of democracy.
Various goals could be listed as a reasonable basis
for decentralization. It is frequently experienced as
a political ideal which provides a way for the local
community to participate in decision making and in
achieving pride/confidence in the local community,
as well as to increase responsibility among public
servants at lower administrative levels. Numerous
political initiatives that introduced decentralization
all over the world were inspired by these ideas.
In the health care system, arguments to affirm
decentralization are used to prove that it can be used to
achieve also important goals, such as effectiveness, fairness,
efficiency, quality, financial responsibility, and respect for local
preferences. These goals reflect our generally accepted values
- goal targeted utilitary and liberal positions (Table 1).
When speaking of effectiveness and efficiency, it is
emphasized that local officials know more about specific
conditions in connection with the health of the population on
their territory, and are therefore able to make better decisions in
response to their health care needs than far off bureaucrats.
This is even more apparent in situations when national health
care policies do not pay due attention to specific problems
of the local population. Still, it should be stressed that the
connection between the instrument - such as decentralization,
and the goal - efficacy, is not clearly demonstrated within the
practice of decentralization. There are but few arguments
that support this connection, and many more that suggest that
effective decision making requires a high level of sophisticated
assesments and adequate interventions, therefore skills that
are often not sufficiently developed at the local level.
It is emphasized that decentralization can improve fairness
within the health care system by offering more power and
resources to local communities, while centralized distribution
of resources frequently favors centers of power. Local officials
have better knowledge of who are the poor members of the
community, and can channel resources toward them, therefore
at the local level there are better potentials for decision makers
when it comes to reducing inequality between citizens.
5

federalnih sistema ukazuju na sasvim suprotne
zaključke. Bez dobrih mehanizama za redistribuciju
resursa među lokalnim vlastima, bogatije zajednice nastoje da
prigrabe više nego siromašnije i u tome često uspevaju. Takođe,
postoje dokazi da lokalne zajednice nisu dovoljno osposobljene
za preraspodelu resursa od bogatih ka siromašnijima.
Tabela 1: Preispitivanje ciljeva decentralizacije
Sa više kredibiliteta se navodi da lokalni menadžeri
mogu donositi efikasnije odluke od
birokratski nastrojenih centralnih vlasti. I
ponovo se ističe da oni imaju više znanja
i podataka o lokalnim uslovima, te su
stoga u boljoj poziciji da donose odluke
koje mogu povećati efikasnost njihovog
delovanja. U mnogim korporacijama,
delegiranje odgovornosti na niže nivoe
menadžmenta zajedno sa odgovarajućim
podsticajima i razvojem veština, može
rezultirati značajnim poboljšanjem
efikasnosti i produktivnosti. Ipak, i
ovde postoji osnova za preispitivanje
ovih argumenata. Lokalni menadžeri
su često izloženi većim pritiscima da
zadrže neefikasne kapacitete ili viškove
zaposlenih, dok centralne vlasti lakše
rešavaju ovakve zadatke.
Kvalitet zdravstvenih usluga,
posebno onaj koji korisnici lako
primećuju, kao što je čistoća prostorija, dostupnost lekova,
osnovna oprema ili ljubaznost osoblja, a koji su povezani sa
zadovoljstvom pacijenata, često su nešto za šta se lokalne
vlasti mogu smatrati odgovornim. Ako su zahtevi na lokalnom
nivou za kvalitetom jasno artikulisani lokalnim donosiocima
odluka, tada decentralizacija može obezbediti mehanizme za
unapređenje kvaliteta. Ipak, nije jasno da li korisnici mogu da
primete i druge, ključne kliničke aspekte kvaliteta, i nije jasno
da li oni mogu da upute svoje zahteve lokalnim vlastima na
konzistentan i osmišljen način. I opet, zbog boljeg poznavanja
lokalne situacije i posedovanja odgovarajućih informacija,
lokalni menadžeri svesniji finansijskih ograničenja mogu
delotvornije usklađivati troškove u odnosu na prihode nego
što to čine centralne vlasti.
Finansijska odgovornost lokalnih vlasti je decentraliza-
6
Regretfully, numerous arguments from developed federal
systems indicate quite contrary conclusions. Without
good mechanisms for redistribution of resources among local
authorities, richer communities try to take more than poorer
communities, and often manage to do so. In addition, there is
proof that local communities are not sufficiently equipped for
redistribution of resources from the richer to the poorer.
With more credibility, it is stated that local managers
can make more efficient decisions
than bureaucratic central authorities.
And once again, it is said that they
have more knowledge and data on local
conditions, and are therefore in a better
position to make decisions which can
improve the efficiency of their actions.
In many corporations, delegation
of responsibility to lower levels of
management, together with adequate
incentives and the development of skills,
can result in significant improvement
of efficiency and productivity. Still, here
again there is a basis for reinvestigating
these arguments. Local managers are
often exposed to more pressure to
preserve inefficient capacities or surplus
workforce, whereas central authorities
solve such issues more easily.
Table 1. Reinvestigation of goals of decentralization
The quality of health care services, especially such issues
that beneficiaries easily notice, such as cleanliness of rooms,
availability of drugs, basic equipment, or attentiveness of the
staff, and which are connected to patient satisfaction, are
frequently something for which local authorities can be held
responsible. If requests for quality at the local level are clearly
articulated to local decision makers, decentralization can
provide mechanisms to upgrade quality. However, it is not
clear if beneficiaries can also notice other, key clinical aspects
of quality, nor is it clear if they can convey their requests to
local authorities in a consistent and carefully thought out way.
And again, due to better knowledge of the local situation and
to the availability of adequate information, local managers
who are more aware of financial limitations, can balance
costs vs income more efficiently than central authorities.

cijom povećana. Međutim, i u ovoj situaciji ima puno dokaza
da lokalna vlast trpi značajne pritiske za prekomernim trošenjem
i prebacivanjem budžetskih deficita na više administrativne
nivoe.
Decentralizacijom se promovišu lokalni izbori i prioriteti.
Time se ističe ono što ljudi stvarno žele, a ne šta udaljene
birokrate misle da je za njih najbolje. Ovaj argument obično
pretpostavlja postojanje vitalnog demokratskog sistema gde
su lokalni zvaničnici odgovorni za zadovoljavanje prioritetnih
potreba stanovništva. Na primer, bolja lokalna kontrola može
rezultirati i većom odgovornošću prema lokalnim potrebama,
poboljšanim upravljanjem logistikom i većom motivacijom za
lokalne službenike koji na taj način mogu da ubrzaju izvođenje
reforme. Ipak, i ovde se postavlja pitanje ko je sposoban da
donosi odluke na lokalnom nivou. Ako se lokalnom politikom
daje moć privilegovanoj eliti, tada je njen izbor, a ne lokalne
zajednice, šta su prioriteti. Takođe se postavlja pitanje, kako
zadržati prioritete na nekim jasnim javnozdravstvenim
potrebama kao što je primarna zdravstvena zaštita, umesto na
izraženim zahtevima za skupim bolnicama ili sofisticiranom
opremom, često prisutnim na nivou lokalne zajednice.
Tipovi decentralizacije
Najpoznatija tipologija različitih oblika decentralizacije
jeste ona koja polazi sa pozicija
javne administracije i razlikuje
dekoncentraciju, devoluciju, delegiranje
i privatizaciju.
U svakom od ovih oblika
decentralizacije značajan deo vlasti i
odgovornosti ostaje na centralnom nivou.
U nekim slučajevima ovo pomeranje
redefiniše funkcionalnu odgovornost tako da centri zadržavaju
ulogu u formulisanju politike, u koordinaciji i praćenju, dok
lokalni nivo dobija operativnu odgovornost za dnevne
odluke. U drugim slučajevima, odnos između centra
i periferije se redefiniše u smislu ugovora, tako da se oni
međusobno dogovaraju koja se izvršenja za svakog od njih
očekuju.
Kako decentralizacija predstavlja prenošenje vlasti
i odgovornosti za javne funkcije sa centralnog nivoa na
subordinirane ili kvazi-nezavisne nivoe i/ili na privatni sektor,
osnovni zadatak pristupa javne administracije je da definiše
odgovarajući nivo za decentralizaciju funkcija odgovornosti
i ovlašćenja. Osnovni administrativni nivoi na koje se
decentralizuju funkcije su: regioni, okruzi i opštine - lokalne
zajednice.
Tabela 2: Tipologija decentralizacije
Decentralizacija u sistemu zdravstvene zaštite
Decentralizacija je atraktivna alternativa centralizovanoj
administraciji kojoj je teško da bude dovoljno blizu
korisnicima usluga i da brzo i adekvatno odgovori
Finanancial responsibility of local authorties is
increased by decentralization. However, again in this
situation, there is abundant evidence that local authorities are
exposed to substantial pressure to overspend and to transfer the
budget deficit to higher administrative levels.
Decentralization promotes local choices and priorities.
It emphasizes what the people really want, not what distant
bureaucrats think is best for them. This argument usually
presumes the existance of a vital democratic system, in
which local officials are responsible for fulfilling priority
needs of the population. For example, better local control can
result in hightened responsibility for local needs, improved
management of logistics, and better motivation of local staff,
who can thus speed up reforms. However, here again the
question arises of who is capable of making decisions at the
local level. If local policy gives power to the privileged elite,
then the elite chooses priorities, and not the local comunity. In
additon there is the question of how to maintain the priority
of certain clear public health requirements, such as primary
health care, instead of the requests expressed for expensive
hospitals or sophisticated equipment that frequently exist at the
level of the local community.
Table 2. Typology of decentralization
Types of decentralization
The best known typology of decentralization is the one
originating from the position of public administration, which
recognizes deconcentration, devolution, delegation, and
privatization.
In each of these forms of decentralization, a significant
share of power and responsibility remains at the central level. In
some cases this shift redefines functional responsibility, so that
centers reserve a role in formulating policies, in coordination
and monitoring, while the local level is assigned operative
responsibility for day to day decisions. In other cases,
the relationship between the center and the periphery is
redefined in the sense of an agreement, so that they mutually
agree in relation to what actions are expected of either of
them.
Since decentralization represents the transfer of
authority and responsibility for public
functions from the central level to
subordinated or quasi-independat
levels and/or to the private sector, the
basic task of the public administration
approach is to define the adequate
level of decentralization of functions
of responsibility and authorization. The
basic levels of administration to which
functions are decentralized are: regions,
districts, and municipalities - local communities.
Decentralizacation of the health care system
Decentralization is an attractive alternative to centralized
administration which finds it difficult to be sufficiently close
7

na njihove potrebe i očekivanja. Razočaranja velikim
centralizovanim sistemima u bivšim socijalističkim zemljama
i često isticane primedbe na njihovu malu efikasnost, sporo
uvođenje promena i inovacija, i nedostatak odgovornosti za
odrednice zdravlja ljudi kao što su životna sredina, ponašanje
i nasleđe, uslovili su popularnost ove ideje u zemljama
Centralne i Istočne Evrope. Podložnost centralizovanih
sistema političkim manipulacijama je takođe često isticana,
mada bi trebalo istaći da decentralizacija nije automatski
rešenje za te probleme.
Decentralizacija predstavlja jedan od najvažnijih aspekata
reforme sistema zdravstvene zaštite u većini evropskih zemalja.
Ona se smatra delotvornim načinom za:
• Poboljšanja u obezbeđivanju zdravstvene zaštite
stanovništva;
• Bolju raspodelu sredstava prema potrebama;
• Uključivanje zajednice u donošenje odluka o prioritetima
u sistemu zdravstvene zaštite,
• Smanjivanja nejednakosti u zdravlju.
Iako se opšti argumenti za decentralizaciju u sistemu
zdravstvene zaštite manifestuju u njenom potencijalu za
poboljšanje kvaliteta usluga, finansijskoj odgovornosti i
boljem obuhvatu stanovništva zdravstvenom zaštitom, još
uvek su aktuelna pitanja koja su prisutna u svakoj sredini,
kako koristi od nje na najbolji način realizovati, a zatim, i
problem kontroverzne prirode nekih zdravstvenih usluga, kao
što je planiranje porodice, formalna edukacija zdravstvenih
radnika ili integrisanost nekih zdravstvenih mera i aktivnosti.
To sve čini decentralizaciju u sistemu zdravstvene zaštite vrlo
kompleksnim poduhvatom i potencijalno težim nego u drugim
sektorima (društvenim podsistemima). Pošto je decentralizacija
u sistemu zdravstvene zaštite često politički indukovana,
teoretska razmatranja često dobijaju veću težinu nego
konkretne činjenice o iskustvima drugih zemalja od kojih se
može mnogo toga naučiti.
Bez odgovarajućeg planiranja i prihvatanja pouka iz
iskustava sa decentralizacijom sistema zdravstvene zaštite
drugih zemalja, može doći do mnogih razočarenja i
usporavanja ili ugrožavanja celog procesa decentralizacije.
Iskustvena zapažanja i studije slučajeva za pojedine
zemlje potvrđuju da loše osmišljena i nedovoljno pažljivo
implementirana, ili brzo i bez dovoljno priprema primenjena
decentralizacija, može imati ozbiljne konsekvence na
obezbeđivanje zdravstvenih usluga stanovništvu.
Osmišljena decentralizacija u sistemu zdravstvene zaštite
podrazumeva posebnu pažnju usmerenu na procenu potreba za
zdravstvenim uslugama i uspostavljanju prioriteta u tome koje
funkcije i programi se mogu prebaciti na lokalni nivo, a koje
zahtevaju centralnu kontrolu. Ako je program ili funkcija od
suštinske važnosti za dostizanje ciljeva na nacionalnom nivou,
a njegova održivost se ne može garantovati na lokalnom nivou,
ne bi ga trebalo decentralizovati. Stoga se ističe da postoji
nekoliko aspekata sistema zdravstvene zaštite koji se ne mogu
decentralizovati i koji čine odgovornost nacionalnog nivoa:
• Formulisanje osnovnog okvira zdravstvene politike sa
ciljevima i podciljevima koje bi trebalo dostići u razumnim
rokovima;
• Praćenje, procena i analiza zdravstvenog stanja
stanovništva i obezbeđenosti stanovništva zdravstvenom
zaštitom;
• strateške odluke o razvoju resursa (posebno humanih), u
sistemu zdravstvene zaštite; i
• regulativa koja se odnosi na javnu sigurnost uključujući
akreditaciju programa i aktivnosti i licenciranje zdravstvenih
8
to the users of services and to quickly and adequately
respond to their needs and expectations. The disillusionment
with large centralized systems in former socialist countries, and
the often repeated comments pertaining to their low level of
efficiency, slow introduction of changes and innovations, and
lack of responsibility for determinants of human health, such
as the environment, behavior, and heredity, has prompted the
popularity of this idea in countries of Central and Eastern
Europe. The susceptibility of centralized systems to political
manipulations was also frequently emphasized, even though
it should be stressed that decentralization is not automatically
the solution to such problems.
Decentralization represents one of the most important
aspects of reform of the health care system in most European
countries. It is considered to be an efficient way to:
• Improve the delivery of health care to the population;
• Achieve better distribution of funds according to
requirements;
• Include communities in making decisions on priorities for
the health care system,
• Reduce inequality in health care.
Even though general arguments for decentralization of the
health care system are manifested in its potential for upgrading
the quality of services, financial responsibility and better
coverage of the population by health care, there are still
pending questions in every community of how to best realize
its benefits, as well as pertaining to the controversial nature of
certain health care services, such as family planning, formal
education of health care professionals, or the integration
of certain health care measures and activities. This all makes
decentralization of the health care system a very complex
undertaking, potentially more difficult than in other sectors
(social subsystems). Since the decentralization of a health care
system is often induced by politics, theoretical deliberations are
frequently attributed a higher importance than concrete facts
about experiences of other countries from which much can be
learned.
Without adequate planning, and accepting experiences
in decentralization of the health care system in other
countries, many disapointments and decelerations, even
the endangering of the entire process of decentralization are
possible. Observations based on experience and case studies
for individual countries confirm that, if badly designed, and
insufficiently carefully implemented, or rapid and without
sufficient preparation, decentralization can have serious
consequences on the provision of health services to the
population.
A justified decentralization of the health care system implies
special attention to the assessment of needs for health services,
and for the establishing of priorities pertaining to which
functions and programs can be transferred to the local level,
and which require central control. If a program or a function are
of crucial importance for achieving goals at the national level,
and their sustainability can not be guaranteed at the local level,
they should not be decentralized. Therefore it is emphasized
that there are several aspects of the health care system that can
not be decentralized, and that fall within the responsibility of the
national level:
• Formulating of the basic framework of health care
policy with goals and subgoals that should be achieved
within reasonable deadlines;
• Monitoring, evaluation and analyzing the status of the
population and the level of provision of health protection to
the population;

adnika.
Imajući ovo u vidu, napravljen je opšti okvir za
prebacivanje odgovornosti sa centralnog na lokalni nivo.
Već je istaknuto da bi o nekim aspektima decentralizacije
trebalo posebno povesti računa. Tako na primer, sloboda
lokalnih vlasti da se prilagode lokalnim uslovima bi trebalo da
bude pažljivo izbalansirana sa zajedničkom vizijom i ciljevima
sistema zdravstvene zaštite. Stoga bi politika decentralizacije
trebalo da uključi mehanizme koordinacije, pošto jačanje
lokalnih političkih interesa raste kako se prenosi više
odgovornosti na taj nivo.
Tabela 3: Opšti okvir za opravdanost prebacivanja
odgovornosti sa centralnog na lokalni nivo
Iako je prednost decentralizacije porast odgovornosti
na lokalnom nivou, trebalo bi povesti računa o nekim
ograničenjima ovog procesa. Prvo, lokalni političari često se
menjaju, te mogu biti nedovoljno informisani o osnovnim
ciljevima nacionalne zdravstvene politike, i drugo, lokalne
grupe mogu biti oponenti nacionalnoj
zdravstvenoj politici (tako se dogodilo da
je jedan lokalni guverner na Filipinima
ukinuo projekat planiranja porodice koji
su finansirali donatori). Zdravstvene
usluge od nacionalne važnosti trebalo
bi ustanoviti, regulisati i finansirati od
strane centralne vlade.
Adekvatno finansiranje i jasno
razgraničavanje finansijskih tokova
je od suštinske važnosti u procesima
decentralizacije. Raskorak između
finansijskih mogućnosti i onoga što
se očekuje ili čak obezbeđuje, može
kompromitovati mogućnost zdravstvene
službe da obezbedi pravične, efikasne i
kvalitetne usluge u decentralizovanim sistemima. Na osnovu
prethodnog iskustva sa decentralizacijom finansiranja može se
izvući nekoliko preporuka:
• Alokacija prihoda mora da obuhvati i odgovornost za
postojeće lokalne troškove i sopstvene resurse zajednice. U
mnogim zemljama se koristi fiksna nacionalna formula za
alokaciju prihoda, ali se vodi računa da ona uzme u obzir
i postojeći nivo razvijenosti zdravstvene službe, jer ako se
lokalnoj vlasti prenese odgovornost za skupu tehnologiju ili
skup segment sistema (bolnice) ona neće moći da održi nivo
usluga koji je prethodno postojao.
• Lokalne slobode za alokaciju fondova trebalo bi
• Strategic decisions on the development of resources
(especially human resources), in the health care system; and
• Regulations pertaining to public safety, including
accreditation of programs and activities, and licensing of health
care professionals.
With this in mind, a general framework for transferring
responsibility from the central to the local level was
prepared.
It has already been stated that certain aspects of
decentralization merit special attention. For example, the
liberty of local authorties not to adapt to local conditions
should be carefully balanced against a common vision and the
goals of the health care system. For this reason, the policy of
decentralization should include mechanisms of coordination,
since the local political interests grow
as more responsibilities are transferred
to that level.
Even though an advantage of
decentralization is the increase of
responsibility at the local level,
care should be taken about certain
limitations of this process. First, local
politicians are frequently replaced, and
may be insufficiently informed about
the basic goals of the national health
care policy, and second, local groups
may oppose the national health care
policy (for example, a local governor
in the Philippines discontinued a family
planning project which was financed
by donors). Health care services of national importance
should be established, regulated, and financed by the central
Government.
Table 3: The general framework for justification of
transfer of responsibility from central to local level
Adequate financing and clear delineation of financial flows
is of the essence in processes of decentralization. The clash
between financial potentials and expectations, or even what is
provided, can compromise the potential of the health service
to provide fair, efficient, and quality services in decentralized
systems. Based on previous experiences with decentralization
of financing, several recommendations can be made:
• The allocation of income must also encompass
responsibility for existing local expenses and own resources of
the community. In many countries a fixed national formula
is used to allocate income, but care is taken for it to also
take into consideration the existing level of development
9

ograničiti minimalnim skupom zahteva postavljenim na
nacionalnom nivou.
• Svaka nacionalna politika mora da razmotri lokalne
uslove i kapacitete. Ograničenja u kapacitetima na
centralnom i l i lokalnom nivou ne smeju se ignorisati i
potrebno je obezbediti obuku kadrova za njihove nove uloge
u procesu decentralizacije. Pošto su to uglavnom zahtevi sa
menadžerskim veštinama i znanjima na lokalnom nivou,
posebno bi trebalo obučiti kadrove za donošenje odluka,
planiranje, kontrolu i liderstvo u sistemu zdravstvene
zaštite.
• Decentralizacija menja i ulogu ministarstva zdravlja od
neposrednog upravljanja i odlučivanja prema formulisanju
zdravstvene politike, tehničkim savetima i pomoći, kao i
praćenju i evaluaciji programa i aktivnosti. Zato je potrebna
sistematska obuka i preorijentacija osoblja u ministarstvu
zdravlja koja se često prenebregava pa ih decentralizacija
zatiče nespremne za nove uloge.
U zaključku se može reći da decentralizacija stvara
velike izazove u obezbeđivanju zdravstvenih usluga. Aktivno
uključivanje menadžera u zdravstvu u procese decentralizacije
podrazumeva stvaranje nacionalnih standarda za alokaciju
resursa i norme zdravstvenih usluga. Takođe je potrebno
stvoriti novi sistem za praćenje izvršenja i evaluaciju
programa i aktivnost, kao i praćenje pravednosti u
obezbeđivanju usluga, unapređenju efikasnosti i kvaliteta rada.
Decentralizacija u sistemu zdravstvene zaštite Republike
Srbije do donošenja novog Zakona o zdravstvenoj zaštiti
(Službeni glasnik Republike Srbije br. 107/05) 2005. godine
Sistem zdravstvene zaštite u Republici Srbiji je bio izrazito
centralizovan na republičkom nivou. Zakonom o zdravstvenoj
zaštiti (Službeni glasnik RS br. 17/92,
26/92, 52/93, 67/93. 48/94, 25/96 i
18/02) u članu 15. predviđeno je da
sve zdravstvene ustanove čijom se
delatnošću obezbeđuje ostvarivanje
prava građana utvrđenih Zakonom,
osniva Vlada Republike Srbije, u
skladu sa planom mreže zdravstvenih
ustanova. Vlada i Ministarstvo
zdravlja postavljaju direktore
zdravstvenih ustanova i praktično
upravljaju zdravstvenim ustanovama.
Posle oktobarskih promena 2000.
godine, decentralizacija i jačanje
lokalne zajednice se postavljaju
kao jedan od nacionalnih zadataka,
te se počinje sa pripremom zakonske
regulative u ovom domenu.
Strateška opredeljenja Ministarstva
zdravlja u domenu decentralizacije
Vlada Republike Srbije je početkom februara meseca
2002. godine usvojila dokument Zdravstvene politike sa
sedam ciljeva, među kojima četvrti cilj predviđa postizanje
»Održivog sistema zdravstvene zaštite uz transparentnost i
selektivnu decentralizaciju u oblasti upravljanja resursima i
širenje spektra izvora i načina finansiranja«. U Viziji sistema
zdravstvene zaštite u Srbiji koja je donesena na radnom
sastanku o strateškim opcijama septembra meseca 2002.
godine, vodeći princip broj pet (od devet navedenih) se
odnosi posredno na decentralizaciju: povećaće se učešće
privatnog, profitnog i neprofitnog sektora u pružanju
zdravstvene zaštite finansirane od strane Republičkog zavoda
10
of health care services, since if responsibility for expensive
technology or an expensive segment of the system (hospitals)
is transferred to a local authority, it will not be able to maintain
the level of services that had previously existed.
• Local freedom to allocate funds should be limited by a
minumum set of requirements set at the national level.
• Every national policy must review local conditions
and capacities. Limitations of capacities at the central or
the local level must not be ignored, and it is necessary
to provide training of human resources for their new
roles in the process of decentralization. Since it is mostly
management skills and knowledge that are required at the
local level, human resources should especially be trained for
decision making, planning, control, and leadership in the
health care system.
• Decentralization also shifts the role of the Ministry of
Health, from direct management and decision making toward
formulating health care policies, technical counceling
and assistance, as well as monitoring and evaluation of
programs and activities. Therefore, systematic training and
reorientation of human resources in the Ministry are required,
which is frequently neglected and leaves them unprepared for
their new roles imposed by decentralization.
In conclusion, it can be said that decentralization creates huge
challenges in the providing of health care services. The active
inclusion of health managers in processes od decentralization
implies the forming of national standards for allocation of
resources, and norms for health services. In addition, a new
system of monitoring must be formed to monitor fulfillment
and to evaluate programs and activities, as well as to
monitor fairness in the provision of services, the upgrading
of efficiency, and the quality of work.
Decentralization of the health care system
of the Republic of Serbia until the passing of
the new Law on Health Care in 2005 (Official
Gazette RoS No. 107/05)
The health care system in the Republic
of Serbia was exceptionally centralized at
the republic level. The Law on Health Care
(Official Gazette RoS Nos. 17/92, 26/92, 52/93,
67/93, 48/94, 25/96 and 18/02), in Article 15,
envisages that all health care institution active
in providing the rights of citizens established
by the Law, are founded by the Government of
the Republic of Serbia, in accordance with the
plan of the network of healthcate institutions.
The Government and the Ministry of Health
nominate directors of health care institutions,
and practically manage health care institutions.
After the changes in October 2000,
decentralization and strengthening of local
communities are postulated as on of the national tasks, and
the preparation of legislation in this domain is initiated.
Strategic objectives of the Ministry of Health in the domain
of decentralization
At the beginning of February 2002, the Government of
the Republic of Serbia adopted a Health Care Policy
document containing seven goals, with the fourth goal
envisaging the achieving of a “Sustainable health care system
with transparency and selective decentralization in the field of
resources mangement, the broadening of the spectrum of sources
and manners of financing”. In the Outline of the health care
system in Serbia, which was adopted at a meeting on strategic

za zdravstveno osiguranje.
Zakonom o lokalnoj samoupravi (Službeni glasnik RS,
broj 9/2002) u članu 18, tačka 14 predviđena je odgovornost
opštine za osnivanje ustanova i organizaciju službi u oblasti
osnovnog obrazovanja, kulture, primarne zdravstvene
zaštite, fizičke kulture, sporta, dečje i socijalne zaštite i
turizma, kao i praćenje njihovog funkcionisanja. Navedenim
Zakonom je takođe predviđeno da skupština opštine vrši
nadzor nad radom ustanova čiji je osnivač, postavlja i
razrešava direktore i daje saglasnost za njihove statute u
skladu sa zakonom. Na taj način ovim Zakonom je predviđena
decentralizacija odgovornosti za menadžment primarnom
zdravstvenom zaštitom sa centralnog na nivo opštine u našem
sistemu zdravstvene zaštite.
Kako postojeći Zakon o zdravstvenoj zaštiti na drugačiji
način reguliše pitanje osnivanja zdravstvenih ustanova u
odnosu na predviđena rešenja Zakona o lokalnoj samoupravi,
smatralo se da se do izmene i dopune, odnosno do donošenja
novog Zakona o zdravstvenoj zaštiti, kao i do donošenja nove
Uredbe o planu mreže zdravstvenih ustanova, odredbe Zakona
o lokalnoj samoupravi ne mogu primenjivati. Ovakav stav
vezan za tumačenje Zakona o lokalnoj samoupravi podržalo
je i Ministarstvo za državnu upravu i lokalnu samoupravu.
Zakonom o utvrđivanju nadležnosti autonomne pokrajine
(Službeni glasnik RS, broj 6/2002) u članu 20. predviđeno je da
autonomna pokrajina preko svojih organa, u skladu sa zakonom
kojim se uređuje oblast zdravstvene zaštite:
• osniva zdravstvene ustanove koje pružaju bolničku,
specijalističku i visokospecijalizovanu zdravstvenu zaštitu u
skladu sa planom mreže zdravstvenih ustanova koje donosi
Vlada Republike Srbije;
• predlaže plan mreže zdravstvenih ustanova za teritoriju
autonomne pokrajine;
• donosi posebne programe zdravstvene zaštite za pojedine
kategorije stanovništva, odnosno vrste bolesti koje su specifične
za autonomnu pokrajinu, u skladu sa zakonom;
• daje mišljenje na predlog za dobijanje zvanja primarijusa,
u skladu sa Zakonom;
• utvrđuje cene pojedinačnih usluga, odnosno programa
zdravstvene zaštite za koje se sredstva obezbeđuju u budžetu
autonomne pokrajine.
Odredbama navedenog Zakona u članu 21. predviđeno
je da autonomna pokrajina, preko svojih organa, u skladu sa
Zakonom kojim se uređuje oblast sanitarnog nadzora, vrši
poslove sanitarnog nadzora. Ove poslove autonomna pokrajina
vrši kao poverene poslove. Odredbama člana 22. istog Zakona,
regulisana je oblast zdravstvenog osiguranja, odnosno
predviđeno je osnivanje Pokrajinskog zavoda za zdravstveno
osiguranje, kao organizacione jedinice Republičkog zavoda
za zdravstvenog osiguranje. Na taj način je predviđena
decentralizacija finansiranja i osnivanja zdravstvenih ustanova,
kao i obezbeđivanja zdravstvenih usluga sa republičkog na
nivo autonomne pokrajine. Međutim, i odredbe ovog Zakona
se u sistemu zdravstvene zaštite još uvek ne primenjuju zbog
neusklađenosti sa sistemskim zakonima.
Zakon o zdravstvenoj zaštiti (2005)
Iako je donekle rano govoriti o efektima novog Zakona
o zdravstvenoj zaštiti vredno je pomena da Zakon predviđa
decentralizaciju osnivačkih prava zdravstvenih ustanova.
Zdravstvene ustanove u državnoj svojini, u zavisnosti od vrste,
osnivaju Republika, autonomna pokrajina, grad i opština,
u skladu sa ovim Zakonom i planom mreže zdravstvenih
ustanova.
Zakon o zdravstvenoj zaštiti takođe predviđa i
options in September 2002, guiding principle number five
(of the listed nine) pertains indirectly to decentralization:
the participation of the private, profit, and nonprofit sectors
will be increased in providing health care financed by the
Republic Health Insurance Administration.
Article 18, Paragraph 14, of the Law on Local Self-
Government (Official Gazette RoS, No. 9/2002), envisages
the responsibility of the municipality to create institutions
and to organize services for elementary education, culture,
primary health care, physical education, sport, children’s
and social protection, and tourism, as well as to monitor
their functioning. The mentioned Law also stipulates that the
municipal Assembly shall monitor activities of institutions
that it had founded, nominate and depose directors, and
approve their bylaws in accordance with the law. Therefore, this
Law envisages decentralization of responsibilities for managing
primary health care in our health care system, from the central
level to the level of the municipality.
Since the existing Law on Health Care differently regulates
the issue of founding health care institutions compared to the
solutions planned by the Law on Local Self-Government, it
was deemed that before amendment and supplementation, i.e.
until the passing of the new Law on Health Care, as well as the
New Regulation on the Plan of the Network of Health Care
Institutions, it is not possible to apply the provisions of the
Law on Local Self-Government. This view in connection
with the interpretation of the Law on Local Self-Government
was supported by the Ministry for State Administration and
Local Self-Government.
Article 20 of the Law on Establishing Competences of
the Autonomous Region (Official Gazette RoS, No. 6/2002),
envisages that the autonomous region, via its organs, in
accordance with the Law governing the field of health care,
shall:
• Found health care institutions that will offer hospital,
specialist, and highly specialist health care in accordance with
the Plan of the network of health care institutions adopted by
the Government of the Republic of Serbia;
• Suggest a Plan of the network of health care institutions
for the territory of the autonomous region;
• Adopt special programs of health care for specific
categories of the population, i.e. for types of diseases specific
for the autonomous region, in accordance with the law;
• Offer opinions regarding suggestions for obtaining the
title of Primarius, in accordance with the law;
• Establish prices for individual services, i.e. programs
of health care, for which funds are provided in the Budget of the
autonomous region.
Provisions of Article 21 of the mentioned Law, stipulate that
the autonomous region shall, via its organs, in accordance with
the Law regulating the field of sanitary surveillance, perform
activities of sanitary surveillance. The autonomous region
performs these tasks as entrusted tasks. Provisions of Article 22
of the same Law, regulate health insurance, i.e. envisage the
formation of the Regional Health Insurance Administration,
as an organizational unit of the Republic Health Insurance
Administration. This enables decentralization from the
republic to the level of the autonomous region, of financing
and the founding of health care institutions, as well as of the
providing of health care services. However, provisions of this
Law are still not applied due to lack of harmonization with
systemic laws.
The Law on Health Care (2005)
Even though it is still rather early to speak about the effects
11

decentralizaciju u obezbeđivanju i sprovođenju zdravstvene
zaštite od opšteg interesa i precizirano je šta opšti interes
obuhvata na nivou Republike, a šta čini interes na nivou
autonomne pokrajine, grada, odnosno opštine. Sredstva za
ostvarivanje opšteg interesa na nivou Republike se obezbeđuju
iz budžeta republike, dok se sredstva za ostvarivanje interesa,
odnosno zdravstvene zaštite koja se odnosi na praćenje
zdravstvenog stanja stanovništva, očuvanje i unapređenje
zdravlja, sprečavanje i suzbijanje bolesti, otkrivanje
i suzbijanje faktora rizika kao prioritetima primarne
zdravstvene zaštite, obezbeđuju u budžetu autonomne
pokrajine, odnosno grada, odnosno opštine, kao i drugih izvora
u skladu sa zakonom. Takođe je predviđeno da opština,
grad i autonomna pokrajina mogu donositi svoje programe
zdravstvene zaštite stanovništva.
Član 13. Zakona jasno sumira očekivanja u pogledu uloge
nižih nivoa vlasti u pogledu društvene brige za zdravlje:
Društvena briga za zdravlje na nivou autonomne pokrajine,
opštine, odnosno grada, obuhvata mere za obezbeđivanje i
sprovođenje zdravstvene zaštite od interesa za građane na
teritoriji autonomne pokrajine, opštine, odnosno grada, i to:
1) praćenje zdravstvenog stanja stanovništva i rada
zdravstvene službe na svojoj teritoriji, kao i staranje o
sprovođenju utvrđenih prioriteta u zdravstvenoj zaštiti;
2) stvaranje uslova za pristupačnost i ujednačenost
korišćenja primarne zdravstvene zaštite na svojoj teritoriji;
3) koordiniranje, podsticanje, organizaciju i usmeravanje
sprovođenja zdravstvene zaštite koja se ostvaruje delatnošću
organa jedinica lokalne samouprave, građana, preduzeća,
socijalnih, obrazovnih i drugih ustanova i drugih organizacija;
4) planiranje i ostvarivanje sopstvenog programa za
očuvanje i zaštitu zdravlja od zagađene životne sredine što je
prouzrokovano štetnim i opasnim materijama u vazduhu, vodi
i zemljištu, odlaganjem otpadnih materija, opasnih hemikalija,
izvorima jonizujućih i nejonizujućih zračenja, bukom i
vibracijama na svojoj teritoriji, kao i vršenjem sistematskih
ispitivanja životnih namirnica, predmeta opšte upotrebe,
mineralnih voda za piće, vode za piće i drugih voda koje služe za
proizvodnju i preradu životnih namirnica i sanitarno-higijenske
i rekreativne potrebe, radi utvrđivanja njihove zdravstvene i
higijenske ispravnosti i propisanog kvaliteta;
5) obezbeđivanje sredstava za vršenje osnivačkih prava nad
zdravstvenim ustanovama čiji je osnivač u skladu sa zakonom
i Planom mreže zdravstvenih ustanova, a koje obuhvata
izgradnju, održavanje i opremanje zdravstvenih ustanova,
odnosno investiciono ulaganje, investiciono-tekuće održavanje
prostorija, medicinske i nemedicinske opreme i prevoznih
sredstava, opreme u oblasti integrisanog zdravstvenog
informacionog sistema, kao i za druge obaveze određene
zakonom i aktom o osnivanju;
6) saradnja sa humanitarnim i stručnim organizacijama,
savezima i udruženjima, na poslovima razvoja zdravstvene
zaštite.
Opština, odnosno grad obezbeđuje rad mrtvozorske službe
na svojoj teritoriji.
Autonomna pokrajina, opština, odnosno grad obezbeđuje
sredstva za ostvarivanje društvene brige za zdravlje iz stava 1.
ovog člana u budžetu autonomne pokrajine, opštine, odnosno
grada, u skladu sa zakonom.
Autonomna pokrajina, opština, odnosno grad mogu doneti
posebne programe zdravstvene zaštite za pojedine kategorije
stanovništva, odnosno vrste bolesti koje su specifične za
autonomnu pokrajinu, opštinu, odnosno grad, a za koje nije
donet poseban program zdravstvene zaštite na republičkom
12
of the new Law on Health Care, it is worth mentioning that the
Law envisages decentralization of the foundation of health care
institutions. State owned health care institutions, depending on
their type, are founded by the Republic, the autonomous region,
a city, a municipality, in accordance with this law, and with the
Plan of the Network of Health Care Institutions.
The Law on Health Care also envisages decentralization of
the provision and implementation of health care of common
interest, and details what such common interest encompasses
at the level of the Republic, and what at the level of the
autonomous region, a city, or a municipality. Funds for
fulfillment of a common interest at the level of the Republic
are provided from the Budget of the Republic, while funds
for fulfillment of the interest, i.e. of health care pertaining to
monitoring the health status of the population, maintaining and
upgrading health, prevention and suppression of diseases,
discovering and suppression of risk factors, as priorities of
primary health care, are provided from the Budget of the
autonomous region, the city, or the municipality, as well as
from other sources, in accordance with the law. In addition,
it is also envisaged that the municipality, the city, and the
autonomous region may adopt their own programs of health
care for the population.
Article 13 of the Law clearly summarizes expectations
pertaining to the role of lower levels of authority in the field of
social care for health:
Social care for health at the level of the autonomous
region, the minicipality, i.e. the city, encompasses measures for
providing and implementing health care of interest for citizens
on the territory of the autonomous region, the minicipality, i.e.
the city, as follows:
1) Monitoring the health status of the population, and of the
work of health care services on own territory, as well as care for
the implementation of established health care priorities ;
2) Forming conditions for accessibility and equal distribution
of use of primary health care on own territory;
3) Coordination, promotion, organization, and channeling of
the implementation of health care achieved by activities of the
organs of units of local self-government, of citizens, companies,
social, educational, and other institutions, and organizations;
4) Planning and realization of own program for preserving
and protection of health from environmental polution caused by
harmful and dangerous materials in the air, water, and soil, by
storage of waste materials, of dangerous chemicals, by sources
of ionizing and nonionizing radiation, by noise and vibrations,
on own territory, as well as by conducting systematic research
of food, general purpose objects, mineral drinking waters,
drinking waters, and other waters used for production and
processing of food, and for sanitary-hygienic and recreational
needs, in order to establish their health hygienic properties and
prescribed quality;
5) Provision of funds for implementation of founding rights
pertaining to health care institutions in which they are founders,
in accordance with the law and with the Plan of the Network
of Health Care Institutions, which encompass construction,
maintenance, and equipping of health care institutions, i.e.
investments, investment and current maintenance of areas,
medical and nonmedical equipment, and vehicles, and of
equipment belonging to the integrated health care information
system, as well as other obligations determined by the law and
the Act of Foundation;
6) cooperation with humanitaroan and expert organizations,
unions and associations, on tasks of developing health care.
The municipality, i.e. the city provides funerary services on

nivou, u skladu sa svojim mogućnostima, i utvrditi cene tih
pojedinačnih usluga, odnosno programa.
Iz javne rasprave koja je o Strategiji reforme i predlozima
sistemskih zakona vođena u Republici Srbiji pre njihovog
usvajanja, stiče se utisak da još nema spremnosti za
decentralizaciju u sistemu zdravstvene zaštite, nešto zbog
nerazumevanja samog koncepta, potom zbog zakonskih
ograničenja za menadžere na lokalnim nivoima, a isto tako
i zbog nepoznavanja menadžerskih veština za preuzimanje
odgovornosti za izvođenje programa i aktivnosti na nivou
lokalne zajednice. To se ogleda i u zalaganju za selektivnu
decentralizaciju na konsenzus konferencijama na kojima se
raspravljalo o reformskim promenama. ■
own territory.
The autonomous region, municipality, i.e. city, provides funds
for implementing social care of health from Paragraph 1 of this
Article, in the Budget of the autonomous region, municipality,
i.e. city, in accordance with the law.
The autonomous region, municipality, i.e. city may adopt
own programs of health care for specific categories of the
population, i.e types of diseases specific for the autonomous
region, municipality, i.e. city, and for which no special program
of health care has been adopted at the level of the republic,
according to their potentials, and may establish prices of such
individual services, i.e. programs.
The public debate on the Strategy for the reform, and the
draft systemic laws, which took place in the Republic of Serbia
before they were adopted, give the impression that there is still
no readiness for the decentralization of the health care system,
partially due to the lack of understanding of the concept, as well
as due to legal limitations for managers at local levels, but also
due to the lack of knowledge of managerial skills required
to take over responsibility for programs and activities at the
level of the local community. This is reflected in the promoting
of the concept of selective decentralization at consentient
conferences at which reforms were discussed. ■
13

Sistem finansiranja
zdravstva RS
Republički zavod za zdravstveno osiguranje
između želja i mogućnosti
System of Financing
Health Care in Serbia
Republic Health Insurance Administration
between wishes and possibilities
Svetlana Vukajlović
Sistem finansiranja zdravstva RS, može se posmatrati sa dva
aspekta:
1. sa aspekta mesta i uloge Republičkog zavoda za
zdravstveno osiguranje (RZZO) u sistemu finansiranja
zdravstvene zaštite stanovništva
2. sa aspekta načina sprovođenja finansiranja i
funkcionisanja sistema zdravstva.
I jedan i drugi aspekt podrazumevaju niz problema i
kontradiktornosti, te ukazuju na nužnost temeljne reforme
sistema finansiranja zdravstva Srbije.
1. Mesto i uloga RZZO u sistemu
finansiranja zdravstvene zaštite
stanovništva
U članu 95. Zakona o zdravstvenom
osiguranju propisano je da je Zavod pravno
lice sa statusom organizacije za obavezno
socijalno osiguranje u kojem se ostvaruju
prava iz zdravstvenog osiguranja i obezbeđuju
sredstva za ove namene. Članom 5. stav
1. navedenog Zakona utvrđeno je da se
sredstva za ostvarivanje prava po osnovu
obaveznog zdravstvenog osiguranja za
osigurana lica (nosioce osiguranja i članove
njihovih porodica) obezbeđuju doprinosom za
zdravstveno osiguranje i iz drugih izvora, u
skladu sa zakonom.
U članu 6. Odluke o obimu i sadržini
zdravstvene zaštite propisano je da “Sadržina
i obim prava na zdravstvenu zaštitu koja su utvrđena ovom
odlukom i sredstva za finansiranje tih prava, moraju biti
međusobno usklađena”.
Šta čini obim i sadržaj zdravstvene zaštite 1 , propisano je
članom 18. i 19. Zakona o zdravstvenom osiguranju.
U članu 7. stav 5. i 6. Zakona o zdravstvenoj zaštiti propisano
je da se sredstva za obezbeđenje zdravstvene zaštite lica koja
nisu obuhvaćena obaveznim zdravstvenim osiguranjem, a
koja su izložena povećanom riziku obolevanja 2 , obezbeđuju iz
budžeta Republike i prenose Zavodu.
Zakonom o zdravstvenom osiguranju, u članu 108.dž,
utvrđeno je da je Republika garant za obaveze Zavoda u
ostvarivanju prava po osnovu obaveznog zdravstvenog
osiguranja (državna garancija).
Dakle preko Zavoda se obezbeđuje finansiranje zdravstvene
zaštite i drugih prava iz zdravstvenog osiguranja za oko 7,7
miliona lica:
- 6,5 miliona, koje čine osiguranici i članovi njihovih
porodica po Zakonu o zdravstvenom osiguranju,
- 1,2 miliona koje čine tzv. neosigurana lica po Zakonu o
zdravstvenoj zaštiti, kao i za izbeglice, prognana lica i
privremeno raseljena lica sa Kosova i Metohije.
14
Svetlana Vukajlović
The system of financing of health care in the Republic of
Serbia, can be regarded from two aspects:
1. From the aspect of the place and role of the Republic
Health Insurance Administration in the system of
financing of health care for the population
2. From the aspect of the implementation of financing and
the functioning of the health care system
Both aspects imply a series of problema and contradictions,
indicating the need for an in depth reform of the system of
financing of healthcare in Serbia.
1. The place and role of the Republic
Health Insurance Administration in the
system of financing of health care for the
population
Article 95 of the Law on Health Insurance
prescribes that the Administration is a legal
person with the status of an organization for
obligatory social insurance realizing rights
from health insurance, providing funds for this
purpose. Article 5, Paragraph 1 of the mentioned
law establishes that funds for realization of
rights based on obligatory health insurance
for insured persons (holders of insurance, and
members of their families) are provided from
contributions for health insurance, and from
other sources, in accordance with the law.
Article 6 of the Decision on the Scope
and Content of Health Care prescribes that
the Scope and content of rights to health care established by
this Decision, and the funds for financing those rights, must be
mutually harmonized.
Scope and content of health care 1 are prescribed by Articles
18 and 19 of the Law on Health Insurance.
Article 7, Paragraphs 5 and 6, of the Law on Health
Insurance prescribes that funds for providing health care for
persons not covered by obligatory health insurance, and exposed
to increased risk of disease 2 , are provided from the budget of the
Republic, and transferred to the Administration.
The Law on Health Insurance, Article 108 dz, establishes that
the Republic is the guarantor of obligations of the Administration
for realization of rights based on obligatory health insurance
(state guarantee)
Therefore, the Administration provides financing of health
care and other rights of health care insurance for some 7.7
million people:
– 6.5 million are insured persons and members of their
families, in accordance with the Law on Health Care
Insurance,
– 1.2 million are so-called uninsured persons in accordance
with the Law on Health Care Insurance, such as refugees,
exiled persons, temporarily displaced persons from

S toga svako neispunjenje ili delimično ispunjenje utvrđenih
finansijskih obaveza prema ovom Zavodu od strane države,
pravnih ili fizičkih lica, ima za posledicu otežano ispunjenje
obaveza Zavoda u pogledu obezbeđenja obima i sadržaja
zdravstvene zaštite garantovane državljanima Srbije i ostalim
navedenim licima.
S obzirom da su pravo na zdravstvenu zaštitu, kao i obim
i sadržina iste, Zakonom garantovane državljanima Srbije, to
je Vlada dužna da planira sredstva za ostvarivanje ovih prava
u Budžetu Republike shodno realnim potrebama, kao i da
sprovodi druge mere iz njene nadležnosti kako bi se u Zavodu
obezbedila dovoljna količina sredstava, što Vlada godinama
unazad ne čini.
U 2004 g. Vlada je iz budžeta izdvojila svega 2, 6 milijardi
din. za finansiranje navedenog broja neosiguranih, izbeglih i
prognanih lica, što je svega 2.170,00 din. po jednom licu, dok
su osigurana lica na ime doprinosa izdvojila 80 milijardi dinara,
odnosno 12.300,00 din. po jednom licu. S obzirom na to da i
jedna i druga kategorija lica ima isti obim prava na zdravstvenu
zaštitu, to je očigledno da uprkos zakonskim propisima
zdravstvenu zaštitu neosiguranih, izbeglih i prognanih lica
finansiraju osigurana lica, kroz prelivanje doprinosa
Godinama unazad Vlada sprovodi mere koje ne samo da
pogoršavaju materijalni položaj Zavoda, pa time i ukupnog
zdravstvenog sistema, već i ozbiljno dovode u pitanje
funkcionisanje Zavoda kao organizacije za zdravstveno
osiguranje, kroz uvođenje zakonskih rešenja koja su primerenija
sistemu budžetskog finansiranja zdravstva nego sistemu
osiguranja:
- Kontinuirano smanjenje stope doprinosa za zdravstveno
osiguranje, uprkos rastućim potrebama
1994-1996 20,2 % (PIO 20,2%)
1996-1998 16,2 %
1999-2001 19,4 %
2001-2004 11,9 %
2004 12,3% (PIO 20,2%)
- Donošenje Zakona o budžetu, kojim se budžetski način
finansiranja primenjuje i na Zavod, suprotno odredbama
Zakona o zdravstvenom osiguranju i samoj suštini
osiguranja.
- Donošenje zakona o jedinstvenoj stopi doprinosa, kojim
se sve ingerencije prenose sa Upravnog odbora Zavoda
na Ministarstvo finansija, smanjuju osnovice za obračun
doprinosa, predviđaju razna oslobađanja od obaveze
plaćanja doprinosa.
- Donošenje Zakona o poreskom postupku i poreskoj
administraciji, kojim su sve ingerencije oko naplate
i kontrole naplate doprinosa prešle sa Zavoda na
Ministarstvo finansija-poresku upravu.
- Neadekvatna naplata i kontrola naplate doprinosa
od strane poreske uprave (trenutno nenaplaćeni
doprinosi samo od obveznika samostalnih zanimanja i
zemljoradnika iznose blizu 10 milijardi dinara).
- Donošenje Odluke o odlaganju plaćanja dela dospelih
obaveza po osnovu javnih prihoda, koju je donela Vlada
13. 2. 2004., a kojom je, suprotno odredbi člana 108p
stav 3. Zakona o zdravstvenom osiguranju utvrđen
otpis 50% doprinosa za zdravstveno osiguranje (koji
je definisan kao sporedno poresko davanje) utvrđenog
na dan 31. 12. 2003. godine, preduzećima koja se
nalaze u procesu restruktuiranja (62); na tenderu (14);
aukciji (39); koja su sa većinskim državnim paketom
akcija (6) i iz nadležnosti Akcijskog fonda (5), što čini
ukupno 125 privrednih subjekata. Pri tome po navedenoj
Kosovo and Metohia.
For this reason, any failure to fulfill, or partial fulfillment
of established financial obligations to the Administration by the
state, by legal or natural persons, results in a difficulty to fulfill
the obligation of the Administration pertaining to the scope and
content of health care guaranteed to citizens of Serbia and other
listed persons.
Since the right to health care, as well as its scope and content
are guaranteed to citizens of Serbia by the Law, the Government
is obliged to plan funds for the realization of these rights in the
Budget of the Republic in accordance with actual needs, as well
as to implement other measures within its scope of competences,
in order to provide to the Administration sufficient funds, which
is something the Government has not done for years.
In 2004, the Government set aside in the Budget only 2.6
billion dinars for financing the above mentioned number of
uninsured persons, while insured persons contributed 80 billion
dinars, i.e. 12,300.00 dinars per person. Since both categories
have the same scope of rights to health care, it is apparent that,
regardless pf legal regulatives, the health care of uninsured
persons, refugees, and exiled persons is financed by insured
persons, by transfer of contributions.
For years, the Government has undertaken measures that not
only worsen the financial position of the Administration, and
thus of the entire health care system, but also seriously threaten
the functioning of the Administration as the organization for
health insurance, by introducing legal solutions more adapted
to a system of budget financing of health care than to a system
of insurance:
- Continuous decrease of the level of contributions for
health care insurance, regardless of growing needs
1994-1996 - 20.2% (Pension and Invalidity Insurance 20.2%)
1996-1998 - 16.2%
1999-2001 - 19.4%
2001-2004 - 11.9%
2004 - 12.3% (Pension and Invalidity Insurance 20.2%)
- The passing of the Law on the Budget, which applies
budget financing also to the Administration, contrary to
provisions of the Law on Health Insurance, and to the
very essence of insurance.
- The passing of the Law on Unified Level of
Contributions, which transfers all competences from
the Management Board of the Administration to the
Ministry of Finance, decreases the base for calculation
of contributions, envisages various exemptions from
payment of contributions.
- The passing of the Law on Taxation Procedure and
Tax Administration, which transfers all competences
pertaining to collection and control of collection of
contributions from the Administration to the Ministry of
Finance – Tax Administration.
- Inadequate collection and control of collection of
contributions by the Tax Administration (presently,
uncollected contributions, only from payers engaged in
individual activities and farmers amount to almost 10
billion dinars).
- The passing of the Decision to postpone payment of part
of obligations in arrears from public income, passed by the
Government on 13 February 2004, establishing, contrary
to the provision of Article 108p, Paragraph 3 of the Law
on Health Insurance, a write-off of 50% of contributions
for health insurance (which are defined as an auxiliary
tax) established on 31 December 2003, for companies in
the process of restructuring (62); in tender procedure (14);
15

odluci, nisu u istom položaju sve organizacije socijalnog
osiguranja. U mnogo povoljnijem položaju je Fond PIO
jer se navedenom odlukom obaveze ovih preduzeća za
plaćanje PIO doprinosa ne otpisuju. Takođe je u periodu
do 2004. god. otpisano 4,7 milijardi dospelih doprinosa
za zdravstveno osiguranje.
- Obezbeđivanje iz Budžeta svega 1/3 potrebnih sredstava
za pokriće troškova zdravstvene zaštite neosiguranih
lica, kao i izbeglih i prognanih lica (za zdravstvenu
zaštitu izbeglih i prognanih lica nepokriveni troškovi sa
31.12.2003 iznose 2,3 milijardi dinara).
- Uvođenje PDV na lekove sa liste lekova i pomagala koja
se izdaju na teret sredstava Zavoda, čime će se preko
1,8 milijardi dinara preliti iz sredstava doprinosa za
zdravstveno osiguranje u sredstva budžeta.
- Donošenje Uredbe o povećanju koeficijenata za zarade
zaposlenih u zdravstvu i druge mere socijalne politike,
suprotno finansijskim mogućnostima i interesima
osiguranika Zavoda.
Kada se ovome doda i činjenica da je stopa nezaposlenosti
visoka, a prosečna primanja, kao osnovica za obračun doprinosa,
niska, odnosno da manje od dva miliona građana izdvaja
doprinose za zdravstveno osiguranje, te da Zavod raspolaže
sa svega 140 evra po glavi korisnika zdravstvene zaštite (za
razliku od Slovenije koja raspolaže sa 1.200 evra), očigledno
je da je Zavod ustanova koja se bori sa teškom finansijskom
situacijom, i da je hitno potrebno preduzeti odgovarajuće mere
ka uspostavljanju održivog sistema finansiranja.
Posledice ovakvog funkcionisanja sistema finansiranja
zdravstva su:
- Preko 10 milijardi dinara duga zdravstvenih ustanova
zatečenih sa 31. 12. 2003. godine i svakodnevni problemi
u održavanju dnevne likvidnosti zdravstvenog sistema
- Loša zdravstvena zaštita i nemogućnost njenog
poboljšanja
- Nezadovoljstvo građana zbog nemogućnosti da ostvare
zakonom garantovana prava
- Dalje zaduživanje zdravstvenih ustanova kod dobavljača
lekova i drugog materijala, komunalnih i drugih javnih
preduzeća, u svrhu pružanja zdravstvene zaštite, a
usled nedovoljne količine prenetih sredstava od strane
Zavoda)
- Primena budžetskog sistema finansiranja na Zavod
dovodi do sledećih kontradiktornosti:
- Po Zakonu o Budžetu, prihodi i rashodi moraju biti
usklađeni, odnosno planiranje rashoda određuju
očekivani prihodi, a što u sistemu zdravstva
nije moguće usled gore iznetih činjenica. U
sistemu zdravstva visinu rashoda određuju prava
i potrebe korisnika zdravstvene zaštite, te se i
prihodi moraju ostvariti shodno rashodima (što
trenutno nije moguće). Ovo se posebno odnosi na
obavezu Vlade da iz budžeta obezbedi sredstva za
zdravstvenu zaštitu neosiguranih lica u stvarnom
iznosu, a ne prema procenjenim mogućnostima.
U sistemu zdravstva nije moguće smanjiti potrošnju
smanjenjem izvora finansiranja, već isključivo
smanjenjem obima i sadržine zdravstvene zaštite.
- Zavod i ustanove se ne mogu zaduživati kod
Banaka i drugih finansijskih organizacija, ali
se ustanove realno zadužuju kod dobavljača
medicinskih sredstava i pružalaca usluga u okviru
zdravstvenog sistema, s tim što se ovi dugovi ne
16
auction procedure (39); with majority package of shares
in state ownership (6), and within the competence of the
Shares Fund (5), amounting to a total of 125 economic
entities. At the same time, the mentioned Decision does
not place all organizations of social insurance in the same
position. The Fund for Pension and Invalidity Insurance
is in a much better portion since contributions of above
mentioned companies for this fund have not been
reduced. In addition, in the period before 2004, a sum of
due contributions for health insurance of 4.7 billion was
also written off.
– The providing from the Budget of only 1/3 of the sum
required for costs of health care for uninsured persons,
as well as refugees and exiled persons (unsettled costs
for health care for refugees and exiled persons as of 31
December 2003, amount to 2.3 billion dinars).
– The introduction of VAT for medicines on the list of
medicines and devices funded by the Administration,
which will result in the transferring of over 1.8 billion
dinars of funds from contributions for health care to the
Budget.
– Passing of the Decree on increasing the coefficients for
salaries of health care staff, and other measures of social
policy, contrary to financial potentials and interests of
citizens insured by the Administration.
When all this is supplemented by the high rate of
unemployment, and the fact that the average salary, as the
basis for calculating contributions is low, i.e. that less than two
million citizens pay contributions for health care insurance, as
well as that the Administration has only 140 EUR per capita for
beneficiaries of health care (as opposed to Slovenia with 1,200
EUR), it is apparent that the Administration is an institution in a
difficult financial situation, and that urgent measures need to be
undertaken to establish a sustainable system of financing.
The consequences of such functioning of the system for
financing health care are:
– A debt of health care institutions of over 10 billion, as on
31 December 2003, and daily problems to maintain daily
liquidity of the health care system
– Bad health care without the possibility to make
improvements
– Dissatisfaction among citizens because of not being able
to realize rights guaranteed by the law
– New debts of health care institutions to suppliers
of medicines and other materials, and to communal
enterprises, in order to provide health care (as a
consequence of insufficient funds transferred from the
Administration)
– The application of a budget system of financing of the
Administration leads to following contradictions:
– According to the Law on the Budget, income
and expenditures must be harmonized, i.e.
expenditures are planned based on expected
income, which is not possible in the health care
system, as a consequence of above mentioned
facts. In the health care system, expenditures are
determined by the rights and needs of beneficiaries
of health care, which requires realization of
income in accordance with expenditures (which is
presently impossible). This is especially true for
the obligation of the Government to provide from
the Budget the realistic level of funds for health
care for uninsured persons, not funds according to

prikazuju u bilansu Zavoda.
- Sredstva namenjena za tekuće finansiranje, koriste
se za pokriće dugova iz prethodnog perioda. Često
se na osnovu starih dugova utužuju ustanove
i izvršenjem presuda vrši blokada sredstava
opredeljenih za druge namene (a nije redak
slučaj da ustanove budu utužene od strane javnih
preduzeća i to onih kojima je Vlada u prethodnom
periodu otpisala ili reprogramirala dugove po
osnovu doprinosa za zdravstveno osiguranje).
- U bilansu Zavoda, sačinjenom u skladu sa
pravilima koje nalaže budžetsko knjigovodstvo,
prihodi i rashodi su uravnoteženi. U ovom bilansu
ne može se iskazati deficit Zavoda, koji je u
2004. godini iznosio preko 7 milijardi, ne mogu
se iskazati dugovi zdravstvenih ustanova, nastali
usled nedovoljnog obima finansiranja, a koji su
se u 2004. uvećali za 3 milijarde dinara, takođe
se ne mogu iskazati potraživanja Zavoda od
Budžeta u iznosu od preko 7 milijardi dinara, kao
ni potraživanja za dospele a neuplaćene doprinose
za zdravstveno osiguranje od preko 17 milijardi
dinara.
2. Način sprovođenja finansiranja i funkcionisanje
sistema zdravstva
Zavod sprovodi finansiranje zdravstva po sistemu finansiranja
( zatečenih) kapaciteta.
To znači da Zavod obezbeđuje sredstva za finansiranje
zarada za 127.000 zaposlenih u zdravstvu u 350 zdravstvenih
ustanova, troškove prevoza, utrošene energije i ostalih troškova
funkcionisanja zdravstvenih ustanova, zatim za troškove lekova,
sanitetskog i ugradnog materijala, ishrane i drugih potreba
osiguranika.
Ovakav sistem finansiranja ne obezbeđuje potreban
kvalitet pružene zdravstvene usluge
niti zainteresovanost ustanova za
pružanjem većeg broja usluga, odnosno
racionalnijim odnosom u korišćenju
prenetih sredstava.
S druge strane Zavod je prinuđen
da finansira višak kapaciteta, čime
se neracionalno i suprotno interesu
osiguranika troše sredstva osiguranja.
S obzirom na sve navedeno može se
zaključiti da je neophodno reformisati
sistem finansiranja zdravstvene zaštite,
kako u pogledu načina sprovođenja
osiguranja, odnosno prelaska na sistem
finansiranja usluge umesto finansiranja
kapaciteta, tako i u pogledu vraćanja
Zavodu funkcije osiguranja.
U protivnom, Zavod će se i dalje
nalaziti između želja Ministarstva
zdravlja, u čijoj je ingerenciji
definisanje obima prava osiguranika,
i finansijskih mogućnosti, diktiranih
merama Ministarstva finansija,
bez realnih mogućnosti da utiče na
održivost finansiranja. ■
assessed possibilities.
In the health care system it is not possible to reduce
spending as a consequence of reduced sources of
financing, but only by reducing the scope and content of
health care.
– The Administration and the institutions can not
procure loans from banks and other financial
organizations, however institutions in fact incur
debts to suppliers of medicines and medicinal
devices, and providers of services within the
health care system, without these debts appearing
in the balance sheet of the Administration.
– Funds for current financing are used to settle debts
from the previous period. Institutions are often
subject to legal actions, and the implementing
of the verdict, traps funds designated for other
causes (with instances when institutions are
subject to proceedings as a consequence of
actions initiated by public enterprises – the very
enterprises for whom the Government had written
off or reprogrammed debts based on contributions
for health care).
– In the balance sheet of the Administration,
prepared in accordance with regulations pertaining
to budget accounting, income and expenditures are
balanced. This balance can not present the deficit
of the Administration, which was over 7 billion
dinars in 2004, it can not present debts of health
care intuitions incurred as a consequence of the
insufficient level of financing, which have grown
by 3 billion dinars in 2004, it can not present
accounts receivable of the Administration from
the Budget amounting to over 7 billion dinars,
nor can it present claims for due, but uncollected
contributions for health insurance of over 17
billion dinars.
2. The manner of implementation of
financing and the functioning of the
health care system
The Administration finances health
care based on a system of financing
(existing) capacities.
This means that the Administration
provides funds for financing salaries for
127,000 employees in health care, in 350
health care institutions, for traveling costs,
energy, and for other costs of functioning
of health care institutions, as well as for
costs for medicines, sanitary and other
materials, nutrition, and other needs of
beneficiaries.
Such a system of financing does not
provide the required quality of health care
services nor does it ensure the interest of
institutions to offer more services, i.e. to
use transferred funds more rationally.
On the other hand, the Administration
is forced to finance surplus capacities,
thus using insurance funds unreasonably, and contrary to the
best interests of insurance beneficiaries.
In view of all of the above, it can be concluded that a
reform of the system of financing of health care is inevitable,
17

1
Obaveznim zdravstvenim osiguranjem se obezbeđuje zdravstvena
zaštita koja obuhvata: 1) medicinske mere i postupke za unapređivanje
zdravstvenog stanja odnosno sprečavanja, suzbijanja i ranog otkrivanja
oblasti i drugih poremećaja zdravlja (član 18. stav 1. tačka 1. Zakona);
2) lekarski pregled i druge vrste medicinske pomoći u cilju utvrđivanja,
praćenja i proveravanja zdravstvenog stanja (član 18. stav 1. tačka 2.
Zakona); 3) lečenje obolelih i povređenih i druge vrste medicinske pomoći
(član 18. stav 1. tačka 3. Zakona); 4) prevencija i lečenje bolesti usta i
zuba (član 18. stav 1. tačka 4. Zakona); 5) medicinska rehabilitacija u
ambulantno-polikliničkim i stacionarnim uslovima (član 18. stav 1. tačka
5. Zakona); 6) lekovi, pomoćni materijal koji služi za primenu lekova i
sanitetski materijal potreban za lečenje (član 18. stav 1. tačka 6. Zakona);
7) proteze, ortopedska i druga pomagala, pomoćne i sanitarne sprave,
stomatoprotetska pomoć i stomatološki materijali (član 18. stav 1. tačka
7.).
both pertaining to the manner of implementing insurance, i.e.
by transferring to a system of financing services instead of
financing capacities, and by returning the function of insurance
to the Administration.
If this is not done, the Administration will remain in a gap
between the wishes of the Ministry of Health – the institution
competent to define the scope of rights of insured persons, and
the financial potentials, dictated by the measures of the Ministry
of Finance, without any realistic possibility to influence the
sustainability of financing. ■
2
Zdravstvenom zaštitom grupacija stanovništva izloženih povećanom
riziku obuhvataju se: 1) deca do navršenih 15 godina života, školska deca
i studenti do kraja propisanog redovnog školovanja; 2) žene u vezi sa
planiranjem porodice, trudnoćom, porođajem i materinstvom; 3) lica starija
od 65 godina života; 4) hendikepirana i invalidna lica, nezaposlena lica
prijavljena organizaciji za zapošljavanje, materijalno neobezbeđena lica
koja primaju materijalno obezbeđenje po propisima o socijalnoj zaštiti i
zaštiti boraca, korisnici stalnih novčanih pomoći za smeštaj u ustanove
socijalne zaštite.
1
Mandatory health insurance provides health
care encompassing: 1) medical measures
and procedures for improving the health
status, i.e. for preventing, curbing, and
early detection of diseases and other health
disorders (Article 18, Paragraph 1, Dot
1 of the Law); 2) medical checkups, and
other forms of medical aid with the goal
of establishing, monitoring and checking
the health status (Article 18, Paragraph 1,
Dot 2 of the Law); 3) treatment of the ill,
and the injured, and other types of medical
assistance (Article 18, Paragraph 1, Dot 3 of
the Law); 4) prevention and treatment of oral
and dental diseases (Article 18, Paragraph 1,
Dot 4 of the Law); 5) medical rehabilitation
in OPDs and polyclinics, and in hospitals
(Article 18, Paragraph 1, Dot 5 of the Law);
6) medicines, auxiliary material for the
administration of medicines, and sanitary
materials required for treatment (Article 18,
Paragraph 1, Dot 6 of the Law); 7) prostheses, orthopedic and other devices,
auxiliary and sanitary devices, dental prostheses and dental materials
(Article 18, Paragraph 1, Dot 7 of the Law).
2
Population groups with higher risk covered by health care are:
1) children under 15 years of age, school children, and students until the
end of prescribed regular schooling; 2) women, in connection with family
planning, pregnancy, parturition, and maternity; 3) persons over 65 years of
age; 4) handicapped persons and invalids, unemployed persons registered
with the employment administration, persons without material support
who receive material support according to provisions on social protection,
and the protection of veterans, beneficiaries of permanent monetary aid for
placement in institutions for social protection.
18

2.
Ozdravimo
zdravstvo!
Korupcija i transparentnost u
zdravstvenom sektoru
Let us cure
the Health Care!
Corruption and transparency
in health services
PALGO centar i Republički zavod za zdravstveno
osiguranje Srbije su u okviru kampanje „Ozdravimo
zdravstvo” organizovali okrugli sto na temu “Korupcija
i transparentnost u zdravstvenom sektoru”. Okrugli sto je
održan 20. maja 2005. u hotelu Palas u Beogradu. Okrugli
sto je finansijski podržao Institut za otvoreno društvo iz
Budimpešte.
O problemima korupcije u zdravstvu i merama
koje mogu doprineti da se rad Republičkog zavoda za
zdravstveno osiguranje i ostalih zdravstvenih ustanova
učini transparentnijim govorili su Tomica Milosavljević
(ministar zdravlja), Svetlana Vukajlović (direktorka
Republičkog zavoda za zdravstveno osiguranje), Srbobran
Branković (direktor Agencije za ispitivanje javnog
mnjenja Medijum Galup), Verica Barać (predsednica
Saveta za borbu protiv korupcije) i Nemanja Nenadić
(Transparentnost Srbija).
U diskusiji je pokrenuto pitanje internacionalizacije
problema korupcije i ostvarivanja ljudskih prava u oblasti
socijalnih prava u Srbiji, zatim pitanje srazmerno malog
broja osude slučajeva korupcije, pitanje budžetskog
planiranja i prioriteta finansiranja u zdravstvenom sektoru.
Čula su se različita mišljenja o Zakonu o komorama i
Zakonu o zdravstvenoj zaštiti, visokom obrazovanju
zdravstvenih radnika i specijalizaciji, institutu zaštitnika
prava pacijenata, odnosu privatnog i društvenog sektora
i sukobu interesa, pilot projektu osnovnih zdravstvenih
usluga u zdravstvenom sistemu Srbije (zdravstveni centar
Studenica u Kraljevu). ■
PALGO Centre and the Republic Health Insurance
Administration organized a round table on the topic
“Corruption and Transparency in Health Sector”, as
part of the “Cure the Health Care” campaign. The panel
discussion was held on May 20, 2005, in the Hotel Palace
in Belgrade. The round table was funded by the Open
Society Institute from Budapest.
The problem of corruption in health care, and the
measures that can make the work of the Republic
Health Insurance Administration and other health care
institutions more transparent, were discussed by Tomica
Milosavljević (minister of health), Svetlana Vukajlović
(director of the Republic Health Insurance Administation),
Srbobran Branković (director of the Public Opinion Poll
Agency Medium Gallup), Verica Barać (president of
the Anti-Corruption Council), and Nemanja Nenadić
(Transparency, Serbia).
The question of internationalizing the corruption issue,
and of realizing human rights in the sphere of social rights
in Serbia, was touched upon in the course of discussion,
and the matters concerning a relatively small number
of convicted cases of corruption, as well as the budget
planning and priority financing in the health sector.
Various opinions were stated on the Law on Chambers and
the Law on Health Care, on higher education for health
workers and advanced trainings, on the institution called
the protection of patient’s rights, the relation between the
private and public sectors and collision of their interests, on
the pilot project of basic health services in the health care
system of Serbia (the
health centre Studenica
in Kraljevo).■
19

3.
Šta građani
dobijaju novim
Zakonom o
zdravstvenoj
zaštiti?
What do the
Citizens get with
the New Law on
Health Care?
U okviru serije okruglih stolova o
reformi zdravstvenog sektora u Srbiji,
PALGO centar je, pod pokroviteljstvom
Instituta za otvoreno društvo iz
Budimpešte, 23. juna 2005. u hotelu
Palas u Beogradu organizovao javnu
raspravu na temu „Šta građani dobijaju
novim Zakonom o zdravstvenoj zaštiti?”.
U raspravi o Predlogu zakona o
zdravstvenoj zaštiti, učestvovali su: u ime
Ministarstva zdravlja, (koje je pripremilo
Predlog zakona o zdravstvenoj zaštiti),
Nevena Karanović (zamenica ministra
zdravlja), Snežana Simić (pomoćnica
ministra zdravlja u sektoru zdravstvene
politike i planiranja) i Zorica Dinić
(savetnica ministra zdravlja u oblasti
razvoja i unapređenja privatne prakse);
Hajrija Mujović-Zornić (generalni
sekretar Udruženja za medicinsko pravo);
Zoran Stamatović (predsednik Udruženja
privatnih doktora stomatologije); i
Višeslav Hadži-Tanović (predsednik
Privatne lekarske komore Srbije). ■
As part of a series of round tables
on the reform of the health sector in
Serbia, PALGO Centre organized, under
the sponsorship of the Open Society
Institute from Budapest, on June 23,
2005, in Hotel Palace in Belgrade, a
public discussion entitled “What Do
the Citizens Get With the New Law on
Health Care?”
The following took part in the
discussion on the Bill of the Law on
Health Care: on behalf of the Ministry
of Health (where the Bill of the Law
on Health Care was prepared) Nevena
Karanović (deputy minister of health),
Snežana Simić (assistant to the minister
of health for health policy and planning),
and Zorica Dinić (counsellor to the
minister of health for development and
improvement of private practice); Hajrija
Mujović-Zornić (Medical Law Society,
secretary general); Zoran Stamatović
(Private Dentists Association, president);
and Višeslav Hadži-Tanović (Private
Medical Chamber of Serbia, president).
■
20

Šta donose novi zakoni
u zdravstvu?
What will the New Laws on
Health Care bring?
Hajrija Mujović-Zornić
U današnje vreme pravo na zdravstvenu zaštitu, u većem
ili manjem obimu, proklamovano je i zagarantovano u svim
zemljama sveta. Zaštita i unapređenje zdravlja predviđeni su
međunarodnim deklaracijama i ugovorima. U Statutu Svetske
zdravstvene organizacije (WHO) navodi se kao trajni zadatak
dostizanje najviših standarda zdravlja svih naroda.
Prvi put se u tom međunarodnom dokumentu
zdravlje proglašava za jedno od osnovnih i
neotuđivih prava svakog čoveka, bez obzira na
rasu, religiju, politička ubeđenja, ekonomski ili
društveni položaj. U njemu je još istaknuto da
vlade država snose odgovornost za zdravlje svojih
naroda i da ta odgovornost iziskuje donošenje
odgovarajućih zakona i mera socijalnog karaktera
u oblasti zdravstvene zaštite. U Evropi je na
planu zaštite zdravlja i obavljanja medicinskih
delatnosti usvojen značajan broj dokumenata,
od kojih su na planu ljudskih prava u oblasti
zdravlja najvažniji: Deklaracija o promovisanju
prava pacijenata (1994), Konvencija o ljudskim
pravima i biomedicini (1997), kao i Povelja o
pravima pacijenata (2002).
Zdravstvo razvijenih zemalja fokusira se
na subjekte zdravstvenog sistema i podizanje
standarda kvaliteta pružanja usluga, gde je od suštinske važnosti
briga o korisniku usluga tj. pacijentu, njegovom zdravlju i
njegovim pravima, što predstavlja svrhu ustrojstva sistema
uopšte. S druge strane, svest o tzv. pacijentovim pravima
kao “novoj” kategoriji prava prati opšta obligacija sigurnosti
koja stoji na teret društva, da obezbedi valjanu, sigurnu,
kvalitetnu i efikasnu zdravstvenu zaštitu. U tom pravcu je išao i
zakonodavac u Srbiji usvajajući novembra 2005. godine tri opšta
zakona koja uređuju oblast zdravstvene zaštite, zdravstvenog
osiguranja i komora u zdravstvu kao staleških organizacija.
Svaki od ovih propisa je uslov sprovođenja reformskih promena
u funkcionisanju zdravstvenih službu i poštovanju i zaštiti
prava u vezi sa tim. Inače, u Srbiji je pravo na zaštitu zdravlja
proklamovano i zagarantovano kako Ustavom, tako i zakonima
o zdravstvenoj zaštiti i zdravstvenom osiguranju. Prava iz oblasti
zdravlja dalje se razrađuju kroz odgovarajuća podzakonska akta,
kao što su uredbe, pravilnici, odluke i uputstva.
Donošenje novih zakona odnosi se na obavljanje medicinske
delatnosti sa posebnim težištem na zakonitost rada i poštovanje
ljudskih prava po osnovu zaštite zdravlja. Stručnom vrednovanju
ovih zakonskih tekstova može se prići sa više strana, ali se težište
uvek stavlja na celovitost, koherentnost i pravnu tehniku takvih
sistemskih zakona sa aspekta ljudskih prava i zdravlja, a ne na
ekonomski, organizacioni ili funkcionalni aspekt obavljanja
zdravstvenih delatnosti, koji bi u nekoj neravnoteži mogli
značiti manja prava. Kao i svaki drugi pravni propis, ovi zakoni
imaju takođe sopstvenu razvojnu dimenziju, odnosno oni su u
oblasti medicine često podložni promenama i novim rešenjima.
To potvrđuje uporednopravna praksa drugih zemalja u težnji da
rešenja pravno relevantnih pitanja budu što više progresivna i
primerena. Zakon se ceni prema tome da li je u duhu savremenih
pravnih rešenja u oblasti medicinskog, tj. zdravstvenog prava,
Hajrija Mujović-Zornić
Today, the right to health care is, to a greater or lesser
extent, proclamed and guaranteed in all countries in the
world. The protection and upgrading of health is envisaged in
international declarations and agreements. The Statute of the
World Health Organization is cited as the permanent task of
achieving the highest standards of health for
all nations. For the first time, this international
document proclaims health as one of the basic
and unalianable rights of every man, regardless
of race, religion, political convictions, economic,
or social status. It also emphasizes that state
governments bear the responsibility for the health
of their population, and that this responsibility
requires the passing of adequate laws and social
measures in the field of health care. In the field
of health protection and performimg of medical
activities, a considerable number of documents
were adopted in Europe, of which pertaining to
human rights in health care, the following are the
most important: Declaration on the Promotion of
Patients’ Rights in Europe (1994), Convention
on Human Rights and Biomedicine (1997), as
well as the European Charter on Patients’ Rights
(2002).
Health care in developed countries is focused on entities in
the system of health care, and on raising the standard of quality
of health care services, with the crucial importance of care about
the beneficiary i.e. the patient, his health, and his rights, which
represents the reason for establishing the system in general. On
the other hand, the awareness about the so-called patient’s rights
as a “new” category of rights is accompanied by the general
obligation of security, as the obligation of the society to provide
good, certain, quality, and efficient health care. This was also
the direction taken by Serbian legislators, when in November
2005, three general laws that regulate the field of health care,
health insurance, and chambers in health care as professional
organizations were adopted. Each of these regulatives is a
precondition for implementing reforms in the functioning of
health care services and for respecting and protecting the rights
in this field. In Serbia, the right to health care is proclaimed and
guaranteed both by the Constitution, and by laws on health care
and health insurance. Rights in the field of health are further
detailed via adequate bylaws, such as regulations, rule books,
decisions, and instructions.
The passing of these laws pertains to the performace of medical
activities, with special emphasis on legality and respect of human
rights in health care. Expert valuation of these legal texts can be
approached from various aspects, however, the focus is always
placed on completeness, coherence, and the legal technique of
such systemic laws from the aspect of human rights and health,
and not on the economic, organizational, or functional aspect of
performing health care activities, which could, in case of lack
of balance, imply fewer rights. Like any other legal regulation,
these laws also have their own development dimension, i.e. in
the field of medicine they are frequently subject to changes and
new solutions. This is confirmed by comparative legal practice
21

kako se shvata u širem smislu. Napori zakonodavaca razvijenih
zemalja usmereni su u tom pravcu. U tome se prepoznaje i
odgovor na pitanje da li u Srbiji ima dovoljno svesti i saznanja
o tome da se prihvate trendovi tzv. juridizacije medicine, pravne
kontrole u vršenju medicinske delatnosti, poimanja uloge prava
kao garanta vršenja “dobre” medicine a čoveka kao “pravnog
subjekta” u medicini.
Novi Zakon o zdravstvenoj zaštiti izvesno je bolji u
mnogim segmentima, naročito kada su u pitanju pacijentova
prava, od do sada važećeg zakona s kojim se poredi kao svojom
polaznom referencom. Može se prigovoriti načinu donošenja
ovog zakona gde je nedovoljno korišćeno pravničko znanje.
Iako se može posmatrati iz više uglova, ovaj Zakon, inače
obiman po broju članova, je pre svega pravni akt najvišeg ranga
pa je po tome njegov pravni aspekt najvažniji u odnosu na druge.
Napredak je u tom smislu vidljiv. Čitava dva nova odeljka
zakona posvećena su načelima zdravstvene zaštite i ljudskim
pravima. Doduše, još postoji neujednačena terminologija (u
prvom delu govori se o građaninu a u drugom o pacijentu, a
to treba povezati) i mehanički pristup u razumevanju pojedinih
pravnih instituta, kao na primer kod dužnosti pacijenata gde se
mešaju pojmovi odgovornog ponašanja, dužnosti u sopstvenom
interesu, i obaveze, a veštački se pravi simetrija između položaja
lekara i položaja pacijenta (čl.43 ZZZ). Nedovoljno je i dalje
istaknut aspekt pomoći pacijentima u ostvarivanju njihovih
prava, imajući u vidu loše strane koje su se pokazale u praksi
zaštitnika prava pacijenata u delu autonomnosti njihovog rada.
Zakon sadrži određene odredbe koje nisu dobro uobličene i u
tome bi sigurno mogao biti bolji. Pojedine preuzete odredbe
starog zakona, pojašnjene su i poboljšane, ali ponekad ne
i u dovoljnoj meri. Na primer, to se može videti na pitanju
obdukcije gde je bolje zacrtana obaveznost obdukcije (čl.222
ZZZ), ali je i dalje ostala nedovoljno razjašnjena uloga bliskih
lica preminulog, koji bi mogli ne samo zahtevati obdukciju,
nego se njoj i protiviti.
Zakon o komorama zdravstvenih radnika je zakon
koji se po prvi put donosi za Srbiju, budući da ga decenijama
unazad nije bilo, ne računajući vreme kraljevine Jugoslavije i
ondašnjeg Zakona o lekarima (1931). Zakon pokriva ključna
pitanja obavljanja zdravstvenih profesija: kodeks etike, licence,
kontrola kvaliteta medicinskih usluga, zaštita članova komore i
posredovanje u sporovima sa pacijentima. Njegova rešenja su
načelno u skladu sa savremenim rešenjima u uporednom pravu.
Komora je staleška organizacija trajnog karaktera, obavezna je
za one koji obavljaju delatnosti za koju se osniva i na nju nema
uticaja sastav članova niti njihova vlasnička struktura. Ona je
zakonski predstavnik i zastupnik interesa svojih članova. Po
22
of other countries in the effort to make legally relevant issues
as progressive and as relevant as possible. A Law is assessed
from the aspect of its adherence to modern legal solutions in
the field of medical, i.e. health law, in the broader sense. Efforts
of lawmakers in developed countries are channeled in this
direction. This also offers the answer to the question if in Serbia
there is sufficient awareness and knowledge to accept trends of
the so-called juridisation of medicine, the legal control over the
performing of medical activities, the comprehension of the role
of law as the garantor of
“good” medicine, and of the
man as the “legal subject” in
medicine.
The new Law on Health
Care is certainly better in
several segments, especially
when it comes to rights of
the patient, than the law
which preceeded it, with
which it is compared as
its initial reference. The
manner of passing this law
may be criticized, due to
insufficient application
of legal knowledge. Even
thought it may be regarded
from several angles, this Law, composed of numerous articles,
is above all a legal document of the highest order, which
makes its legal aspect more important than its other aspects.
An improvement in this respect is apparent. Two new chapters
of the Law are entirely devoted to principles of health care
and to human rights. There still in fact remains unharmonized
terminology (in the first part the Law speaks of the citizen, and
in the second of the patient, which should be connected), and
the mechanical approach to the understanding of certain legal
institutes, such as for example when it comes to obligations
of the patient, where there is a confusion between responsible
behavior, obligations in ones own interest, and obligations, with
an artificial symmetry between the position of the doctor and
the position of the patient (Article 43 of the Law). The aspect
of assisting patients to realize their rights is still not sufficiently
stressed, in view of the negative aspects that have become
evident in the practice of the patient ombudsman from the aspect
of autonomy of activities. The Law contains certain provisions
that are not well formulated, which is another aspect where it
could be better. Certain provisions that were taken over from the
old Law have been clarified and improved, however, not always
to a sufficient degree. For example, this is apparent pertaining to
post mortem examination, where the obligation to perform such
examination is better defined (Article 222 of the Law), however
the role of persons close to the deceased, who could not only
demand post mortem examination, but also oppose it, remains
insufficiently clear.
The Law on Chambers of Health Care Professionals is a
law which is adopted in Serbia for the first time, since it did not
exist for decades, if the period of the Kingdom of Yugoslavia
and its Law on Physicians (1931) is excluded. This Law governs
key issues of the health care profession: code of ethics, licenses,
quality control of medical services, protection for members of
the Chamber, and mediation in disputes with patients. Solutions
from the Law are generally in agreement with modern solutions
of comparative law. The Chamber is a permanent professional
organization, it is obligatory for those who are active in the
field of work for which it is founded, and it is not influenced

suštini to je oblik decentralizovane posredne uprave u stvarima
koje se tiču medicinskih delatnosti i njenih pripadnika. Država
na komoru prenosi deo svojih javnih ovlašćenja i komora tako
postaje oblik samokontrole. Ipak, zbog opštih interesa društva
aktivnost komore takođe mora da podleže državnom nadzoru
nad zakonitošću, ali ne i svrsishodnošću rada, pri čemu odnos
komore i državnih organa nije samo odnos podređenosti i
nadređenosti, nego i odnos saradnje.
Zakon o zdravstvenom osiguranju stvara bolje uslove
za zdravstvenu zaštitu i uvodi određene promene u pravima
po osnovu osiguranja građana. Pored obaveznog predviđa se,
po prvi put, i dobrovoljno zdravstveno osiguranje. Zakon,
kao i ranije, prvenstveno definiše osigurana lica i posebno
zaštićene kategorije, a u pogledu medicinskih usluga pravi
razliku između standardnih i vanstandardnih usluga. Jasno
se nabrajaju prava iz obaveznog zdravstvenog osiguranja i
izuzeci u smislu zdravstvene zaštite koja se ne obezbeđuje
obaveznim zdravstvenim osiguranjem, u kom domenu su
neka prava smanjena na račun uvođenja novih ili proširenja
već postojećih prava. Ipak, problemi i dalje postoje u pogledu
tretmana zdravstveno neosiguranih lica, a čija zaštita pada na
teret sredstava iz budžeta, i redukovanja nekih prava po osnovu
bolovanja.
Zakonsko uređenje koje se tiče obavljanja zdravstvenih
delatnosti, prava davaoca usluga i prava pacijenata kao
korisnika treba da bude zaokruženo i usklađeno, čemu teže i
najnovija zakonska rešenja u Srbiji. Pri tome, i zakonodavna
aktivnost predstavlja uvek kontinuirani proces, kako zbog toga
što “život” ide uvek ispred prava, tako i činjenice da neka od
usvojenih rešenja zahtevaju potvrdu ili proveru u svakodnevnoj
medicinskoj praksi. U okviru korpusa pravnih propisa uvek
se ima u vidu: normativni aspekt (državni i staleški propisi;
odnos medicinske etike i prava); aspekt primene propisa (sa
stanovišta zdravstvenog radnika poštovanje pravila struke i
pažnje; poštovanje tuđih prava); aspekt odgovornost (krivična,
građanska, staleška; osiguranje od odgovornosti).
Reforma zdravstvenog sistema u Srbiji na samom je početku.
Nesporno je da ona treba da bude celovita i da uvažava potrebu
promena i u sferi zdravstvenog zakonodavstva, pre svega
unifikacije i harmonizacije domaćih propisa sa evropskim
propisima koji su brojni u ovoj materiji. Jedan broj pravnih
pitanja koja ulaze u domen tzv. medicinskog (zdravstvenog)
prava je od ranije regulisan, ali i ove propise treba ponovo
razmotriti, osavremeniti ih i dati im nov smisao. Postoje još
uvek neka pitanja koja su ostala potpuno neregulisana, naročito
u pogledu posebnih medicinskih postupaka i mehanizama zaštite
i osnaživanja pacijentovih prava gde se nije daleko odmaklo. ■
by the composition of members or their ownership structure. It
is the legal exponent and the representative of interests of its
members. In essence, this is a form of decentralized indirect
management pertaining to issues in connection with medical
activities, and its members. The state delegates to the Chamber
a part of its public competences, and thus the Chamber becomes
a form of selfcontrol. However, due to the general interest of the
society, the legality of the Chamber, but not the justification of
its activities, must also be subject to surveillance by the state,
with relations between the Chamber and the state organs being
not only in the domain of senitority, but also in the domain of
cooperation.
The Law on Health Insurance forms better conditions for
health care and introduces certain changes of rights based on
insurance of citizens. In additon to mandatory, for the first time
voluntary health insurance is also envisaged. Like before, the
Law primarily defines insured persons and special protected
categories, and in the domain of medical services, it makes a
difference between standard and out of standard services. Rights
belonging to mandatory health insurance are clearly listed, as
well as exemptions pertaining to health protection not provided
within mandatory health insurance, wherein certain rights have
been reduced in order to introduce new or to expand alredy
existing rights. Still, problems remain pertaining to treatment of
persons without health insurance, which falls on budget funds,
and in the reduction of certain rights pertaining to sick leave.
The legal regulation for performing of health care activities,
the rights of providers of services, and rights of patients as
beneficiaries, should be rounded off and harmonized, as is also
the trend of the latest legal regulations in Serbia. In this respect,
legislative activity is always a continuous process, both because
“life” always preeceds the law, and because of the fact that
certain adopted solutions require confirmation or verification
during daily medicial practice. The body of legislation at
all times bears in mind: the normative aspect (state and
professional regulations; relationship between medical ethics
and the law); the aspect of implementation of regulations
(from the aspect of the health care professional this is the
respect of professional rules and care; the respect for rights of
others); the aspect of responsibility (penal, civic, professional;
insurance from liability).
The reform of the health care system in Serbia is just
beginning. It is without a doubt that it must be comprehensive,
and must respect the need for change of health care legislation,
above all unification and harmonization between domestic
regulations and European regulations, which are numerous in
this field. A certain number of issues belonging to the domain
of the so-called medical (health care) law have already been
regulated, but these regulations also need to be reevaluated,
updated, and endowed with a new meaning. There still remain
issues that are completely unregulated, especially pertaining to
special medical procedures and mechanisms of protection and
strengthening the rights of patients, where not much progress
has been made. ■
23

4.
Javno zdravstvo u Srbiji i
Dekada inkluzije Roma
U godini početka Dekade inkluzije Roma 2005-2015.
PALGO centar je uz podršku Fonda za otvoreno društvo
(Beograd) i Instituta za otvoreno društvo (Budimpešta)
organizovao konferenciju pod nazivom „Javno zdravstvo
u Srbiji i Dekada inkluzije Roma”.
Cilj konferencije, održane 21. decembra 2005. u
Sava Centru, bio je da okupi predstavnike relevantnih
institucija centralne i lokalnih vlasti, romske lidere, kao i
predstavnike međunarodnih i nevladinih organizacija koje
se bave pitanjima od značaja za javno zdravstvo u Srbiji i
zdravstvenu zaštitu romske nacionalne manjine.
Glavne konferencijske teme formulisane su na sledeći
način:
• Šta donosi Zakon o zdravstvenoj zaštiti kada je u
pitanju zdravstvena zaštita Roma?
• Uloga i planovi jedinica lokalne samouprave u
ostvarivanju ciljeva Dekade inkluzije Roma.
• Da li su Zakonom o budžetu Republike Srbije
predviđena odgovarajuća sredstva za sprovođenje
akcionog plana u oblasti zdravstva?
Među osnovnim problemima u pristupu zdravstvenoj
zaštiti Roma istaknuti su: nemogućnost ostvarivanja
zdravstvene zaštite bez prijave prebivališta, nedostatak
ličnih dokumenata, predrasude, novčana participacija
i nedovoljno odgovoran stav Roma prema sopstvenom
zdravlju.
Na konferenciji je zatraženo od predstavnika
Ministarstva zdravlja i Ministarstva za ljudska i manjinska
prava da, u cilju veće transparentnosti, objave na svojim
Internet prezentacijama plan raspolaganja budžetskim
sredstvima rezervisanim za sprovođenje akcionog plana u
oblasti zdravstva. ■
Public Health in Serbia
and Decade of Roma
Inclusion
In the initial year of the Decade of Roma Inclusion
2005-2015, PALGO Center organized a conference “Public
Health in Serbia and Decade of Inclusion of Roma”,
supported by the Fund for an Open Society (Belgrade) and
the Open Society Institute (Budapest).
The Conference, held on December 21, 2005 in Sava
Center, Belgrade, was aimed at gathering representatives
of the relevant institutions of central and local authorities,
Roma leaders, and members of international and nongovernmental
organizations dealing in matters of
importance for the public health sector in Serbia, and also
the health care of Roma national minority.
The chief topics at the Conference were formulated
thus:
• What to expect of the Law on Health Care in relation
to health care of Roma?
• Role and plans of local community self-rule units in
realizing the goals of the Decade of Roma Inclusion.
• Does the Law on the Budget of the Republic of Serbia
foresees adequate funds for the realization of the Action
Plan in the field of health care?
The following was emphasized as some of the crucial
problems in approaching the health care of Roma people:
impossibility of realizing one’s health care rights without
the registered place of residence, missing personal
documents, prejudices, financial participation, and
irresponsible attitudes of Roma themselves toward their
own health status.
The conference pleaded with the representatives of
the Ministry of Health and the Ministry for Human and
Minority Rights, to publish
at their web presentations,
for the purpose of greater
transparency, the allocation
plan for the budget funds
reserved for the realization of
the Action Plan in the sphere of
health care. ■
24

Zdravlje Romkinja
Potrebe i problemi
Health of Roma Women
Needs and Problems
Đurđica Zorić
Na početku priče o mogućnosti praktikovanja ljudskih
prava imamo jedan opšti stav da su ženska ljudska prava sva
prava koja ženama pripadaju jednostavnom činjenicom da su
pripadnice ljudskog roda. Ali i konstataciju da su svi oblici
ponašanja i nasilja kojima su žene izložene samo zato što su žene,
ustvari oblici kršenja ženskih ljudskih
prava. Stvari se dodatno komplikuju
kad se postojeća situacija primeni na
romsku ženu, pripadnicu manjinske,
marginalizovane grupe društva.
Poziciju Romkinje u porodici i užoj
i široj društvenoj okolini najčešće
karakterišu situacije koje su pretnja
njenim ljudskim, manjinskim i
naposletku ženskim pravima. Ove
situacije, bez obzira da li se deo njenog
porodičnog života ili se događaju
izvan njene zajednice, dakle, na ulici,
kod lekara ili u školi, gotovo bez
izuzetka mogu se opisati kao primeri
diskriminatorne prakse. Ženska prava
Romkinja su od strane društvene
zajednice u potpunosti nepriznata, te
se aktivistički rad na ovom pitanju
nameće kao imperativ. Razmišljanja o karakteristikama pozicije
Romkinje dovode nas, na samom početku, do praktikovanja
prava na adekvatnu zdravstvenu zaštitu. Skup ovog materijala
moramo da razdvojimo na probleme i potrebe Romkinja
u domenu zdravlja. Najpre, problemi, nalazimo ih svuda:
neposedovanje zdravstvene knjižice, rana udaja, uslovi života,
česta pojava fenomena „bolesnog zdravlja”, nasilje nad ženom i
na kraju, ali ne manje važna, učestala pojava diskriminacije nad
Romkinjama.
Zdravstvena dokumentacija
Dobro poznati problem koji svoj koren ima u problemu
stanovanja u nelegalizovanim naseljima, nehigijenskim
slamovima, koji nemaju mogućnost prijave stanovanja ili prijave
Na konferenciji su učestvovali: Jelena Marković (pomoćnica
ministra za ljudska i manjinska prava, nacionalni koordinator
Dekade inkluzije Roma), Osman Balić (YUROM centar),
Petar Antić (Centar za prava manjina), Ðorde StojiljkoviÐorde
Stojiljkovi (Ministarstvo zdravlja, Sektor za razvoj i reformu),
Ðurdica ZoriÐurdica Zori (Romski ženski centar “Bibija”),
Marjan Muratović (Jugoslovenska asocijacija za kulturu i
asocijaciju Roma), Anne-Maria Ćurković (Sekretarijat za
Romsku nacionalnu strategiju), Jadranka Stojanović (Fond za
otvoreno društvo), Borka Jeremić (UNDP), Vesna Jovanović
(CARE International), Barbara Davis (CARE International),
Davor Rako (UNHCR), Ljubinka Smiljanić (UNHCR), Mirko
Vučinić (UNHCR), Darko Mišić (član opštinskog veća opštine
Novi Beograd), Predrag S. Šalinger (Zdravstveni centar
Leskovac), Vanja Ilić (Okružni koordinator promocije zdravlja,
Leskovac), Silvia Koso (CIDA), Anđelka Miljević (Dečji romski
centar), Mijat Damjanović (PALGO centar), Dejan Pavlović
(PALGO centar).
Đurđica Zorić
At the source of issues of implementing human rights there
is a common view that human rights of women are all the rights
belonging to women by the very fact that they are members
of the human race, but also the conclusion that the types of
behavior and violence that women are subjected to just because
they are women, are in fact forms of violating the
human rights of women. Matters are additionally
complicated when this last premise is applied to
a Roma woman, who is a member of a minority,
marginalized group within the society.
The position of a Roma woman within the
family, and in the narrower and broader social
millieu is most frequently characterized by
situations which threaten her human, her minority,
and finally her woman’s rights. These situations,
regardless if they are part of her family life, or
take place outside this community, i.e. in the
street, at a doctor, or in school, can virtually
without exception be described as examples of
discriminatory practices. Women’s rights of Roma
women are completely unrecognized by the social
community, making activist work in this field
imperative. Deliberations on the characteristics of
the position of the Roma woman, bring us at the
very onset to the issue of exercising the right to adequate health
care. This set of issues must be subdivided into problems and
needs of Roma women in the domain of health. First, problems,
which exist everywhere: not having a health card, early
marriage, living conditions, the frequent phemonenon of „ill
health”, violence against women, and last but not least, frequent
discrimination of Roma women.
Health documentation
This is a well known problem, rooted in life in illegal
settlements, unhygienic slums, without the possibility to register
address or residence. Without this document, it is not possible
to obtain an ID card, which is a prerequisite to obtain a health
care card. Therefore, this is a cycle of problems stemming
from decades of problems, which could be broken by offering
provisional legalization or virtual addresses. This is envisaged in
the Draft Action Plan for personal documents in the framework
of the Decade of Roma Inclusion – which was, regretfully, not
adopted by the Government of the Republic of Serbia, and can
therefore not be implemented. However, our law envisages
privileges for vulnerable groups of citizens, such as children
under 15 years of age, and pregnant women, regardless of
nationality or ethnic group. And this is exactly where there are
instances of primarily violations of the law, also accompanied
by disrespect for basic human rights. There is a series of cases
when pregnant women, and not only those from the group of
internally displaced persons, were denied health care, without
anyone suffering any consequences.
Another very vulnerable category within the Roma population
are the elderly, above all, elderly women, who are also illiterate
in 80% of cases, as well as young mothers, single mothers, and
of course children. Consequences of this state of affairs are
many: neglect of own health, inadequate treatment, “ill health”,
25

oravka. Bez ovog dokumenta ne može se izvaditi lična karta a
bez ove ni zdravstvena knjižica. Dakle, jedan krug problema koji
ima svoje decenijsko nasleđe, a može biti prekinut davanjem
privremene legalizacije ili virtulenih adresa. Ovo predviđa
nacrt akcionog plana za pristup ličnim dokumentima u okviru
Dekade Roma – koji, nažalost, nije usvojen od strane Vlade
Republike Srbije, pa ne može ni da se primenjuje. Međutim,
naš zakon predviđa povlastice kad su u pitanju osetljive grupe
građana kao što su deca do 15 godina i trudnice, bez obzira kojoj
nacionalnoj ili etničkoj grupi pripadaju. Upravo ovde se grade
slučajevi nepoštovanja zakona, pre svega, a potom i kršenja
osnovnih ljudskih prava. Niz je slučajeva trudnica, i to ne samo
IRL, kojima je uskraćena zdravstvena nega, a da niko nije snosio
odgovornost za to. Jedna od najugroženijih kategorija u okviru
romske zajednice su i stara lica, pre svega, stare žene koje su
u 80% slučajeva nepismene, zatim mlade majke, samohrane
majke i naravno deca. Posledice ovog i ovakvog stanja
višestruke su: zanemarivanje sopstvenog zdravlja, neadekvatno
lečenje, »bolesno zdravlje«, pribegavanje korišćenju tuđih
zdravstvenih knjižica, porođaji u kući gde ne postoje uslovi a
ni stručna pomoć, povećani rizici smrtnosti. Ovde je značajno
skrenuti pažnju na probleme pristupa zdravstvenoj i socijalnoj
zaštiti sa kojima se susreću porodice deportovane po ugovorima
o readmisiji. Nacrt akcionog plana u okviru Dekade Roma koji
reguliše ova pitanja takođe, postoji, i takođe nije usvojen od
strane Vlade RS, pa nam onemogućava delovanje na osnovu
ovog dokumenta.
Reproduktivno zdravlje žena
Ako krenemo od porodičnog okruženja Romkinje, dakle,
susrećemo jednu patrijarhalnu zajednicu čije žene vrlo rano
ulaze u proces biološke reprodukcije, gotovo još kao devojčice.
Njima pada u obavezu celokupno staranje oko brojne dece i
porodice, uključujući i stare članove, pri čemu se podrazumeva
da su one istovremeno angažovane i u ekonomskoj sferi
domaćinstva i porodice.
Kad je reč o planiranju porodice Romkinja nema gotovo
nikakvog udela, dakle u 95% slučajeva muž je taj koji odlučuje.
Kontracepciju koristi njih vrlo malo, najviše 30%. Svaku
neželjenu trudnoću romske žene rešavaju nasilnim prekidom
trudnoće. Broj ovakvih intervencija je vrlo visok, kreće se oko 8-
14 kiretaža po ženi. Razlog ovome je nedovoljan broj informacija
koje stižu do Romkinje, ali u većini slučajeva i diskriminacija od
strane lekarskog osoblja u ustanovi, zatim nedostatak novčanih
sredstava ili jednostavno nepristanak muža. Smrtnost Roma, a
posebno romske žene alarmantna je. Podsetimo se da su Romi
najmlađa populacija na svetu, prosek životne dobi je 45 godina,
što je bar 20-30 godina manje od ostalih.
Iskustvo rada na terenu Romskog Ženskog Centra BIBIJE, a
teren je jedna od osnovnih naših aktivnosti, pokazuje da romska
žena relativno trpeljivo podnosi ovakav položaj
u porodici. Čini se bliskim objašnjenje da je u
pitanju svojevrsna »socijalizacija« žene ili bolje
rečeno pripremanje kćerke u primarnoj porodici
za ulogu koja joj je namenjena. Konkretnije
rečeno, Romkinja se udaje vrlo rano, iako se
starosna granica u novije vreme pomera, sa
13 na 15 ili 16 godina. Ova socijalizacija ili
naprosto priprema odvija se u okviru primarnog
porodičnog okruženja u kome vladaju strogi
patrijarhalni zakoni. Jedan od njih je dobro
poznati kult nevinosti koji ima duboku tradiciju
i neguje se u romskoj zajednici. Budući da
zna svoje dužnosti (vrlo retko i prava) mlada
žena, uistinu još devojčica (12,13 godina stara)
26
use of health care cards belonging to other people, births in the
home without required conditions or expert assistance, higher
mortality risks. An issue that needs to be emphasized here, are
problems of access to health care and social protection facing
families deported according to agreements on readmission. The
Draft Action Plan in the framework of the Decade of Roma
which regulates these issues also exists, and once again, it
was not adopted by the Government of the Republic of Serbia,
making it impossible for us to act based on this document.
Reproductive health of women
Starting with the family environment of Roma woman, we
are faced with a patriarchal community, within which women
enter the process of biological reproduction very early, virtually
as young girls. They have the complete responsibility of caring
for numerous children, and for the family, including also elderly
members, while it is selfexplanatory that they are also engaged
in the economic aspects of the household and of the family.
A Roma woman plays virtually no part in the domain of
family planning, namely in 95% of cases the husband is the
one who makes the decision. Contraceptives are rarely used,
i.e. in no more that 30% of cases. Roma women resolve all
undesired pregnancies by induced abortions. The incidence
of such interventions is very high, with 8-14 abortions per
woman. Reasons lie in insufficient information that reaches
Roma women, but in most cases also in discrimination by health
care staff in institutions, in lack of funds, or in a simple lack of
consent of the husband. Mortality of Roma, and especially Roma
women is alarming. Here, we wish to remind that the Roma are
the youngest population in the world, with an average life span
of 45 years, which is 20-30 years less than other populations.
Experiences from field work of the Roma Women’s Center
BIBIJA, which is one of our main activities, indicate that Roma
women endure such a position within the family relatively
passively. A plausible explanation can be found in the specific
“socialization” of the woman, i.e. the preparing of daughters
in the primary family for their destined role. More concretely,
Roma women marry very early, even though lately the age is
shifting from 13 to 15 or 16 years. This socialization, or simply
preparation, takes place within the primary family environment
with strict patriarchal rules. One such rule is the well known
virginity cult, with a very deep tradition still nurtured in the
Roma community. Knowing her obligations (very rarely her
rights), a young woman, acctualy still a girl (at 12-13 years
of age), accepts obligations, of which bearing children is the
most important. However, being a good housewife, servility,
obedience, proving ones worth – are all virtues expected from the
bride from the moment when she gets married, until she herself
becomes a mother in law, and even beyond that – so that the time
to prove ones various virtues practically never ends. Regardless
Conference attendees: Jelena Marković (assistant to the minister for human
and minority rights, national coordinator of the Decade of Roma Inclusion),
Osman Balić (YUROM Center), Petar Antić (Center for Minority Rights), Đorđe
Stojiljković (Ministry of Health, Development and Reform Sector), Đurđica Zorić
(Roma Women Center “Bibija”), Marjan Muratović (Yugoslav Association for
Culture and Association of Roma People), Anne-Maria Ćurković (Secretariat
for Roma National Strategy), Jadranka Stojanović (Fund for an Open Society,
Serbia), Borka Jeremić (UNDP), Vesna Jovanović (Care International), Davor
Rako (UNHCR), Ljubinka Smiljanić (UNHCR), Mirko Vučinić (UNHCR), Darko
Mišić (member of the municipal council, Novi Beograd), Predrag S. Šalinger
(Health Center Leskovac), Vanja Ilić (County coordinator for health promotion,
Leskovac), Silvija Koso (CIDA), Anđelka Miljević (Roma Children Center), Mijat
Damjanović (PALGO Center), Dejan Pavlović (PALGO Center).

prihvata dužnosti od kojih je najvažnije rađanje, ali i dobro
vođenje domaćinstva, pokornost, poslušnost, dokazivanje
– sve su to vrline koje se očekuju od mlade od vremena kad se
uda pa sve dok sama ne postane svekrva, pa i dalje – to vreme
dokazivanja raznih vrlina ustvari ne prestaje. Bez obzira što će
rađanje biti mnogobrojno i često ne planirano od nje same, što
će je u određenom, na primer zdravstvenom smislu, naročito
opteretiti, Romkinja se neće pobuniti, naročito ne javno, kao
što se to može sresti kod većine drugih etničkih zajednica.
Ako je njen život ispunjen samo rađanjem dece i vođenjem
domaćinstva, ona će decu voleti, a hranioca dece poštovati.
Poštovanje muža, pokornost i neprikosnovenost njegovog
autoriteta izraz je zahvalnosti za obezbeđenu egzistenciju deci.
Zdravlje mladih
Tradicija i vaspitanje ovde igraju vrlo važnu ulogu.
Istraživanje koje je RŽC BIBIJA vodila a ticalo se pitanja
kulta nevinosti u romskoj porodici, pokazuje visok procenat
roditelja, pre svega očeva, koji očekuju, zahtevaju od svojih
kćerki da budu nevine kad se budu udavale. Ovo je jedan od
razloga tako rane udaje koja definitivno utiče na zdravlje mladih
devojaka. Još jedan od razloga rane udaje jeste činjenica da ta
devojka postaje besplatna radna snaga u svojoj novoj porodici.
I pored toga što je i u svojoj primarnoj porodici radila mnogo, u
muževljevoj se mora i dokazati i svakako raditi još teže poslove
što opet loše utiče na zdravlje ove devojke, ponekad ustvari još
devojčice.
Uslovi života
Sledeći problem, iako po važnosti verovatno treba da je
na prvom mestu, su teški uslovi u kojima živi a koji svakako
ostavljaju dubok trag na život Romkinje. Svi smo, makar jednom,
prošli pored nekog romskog naselja i na prvi pogled videli da
ono nema struju, vodu, kanalizaciju, grejanje. Domaćinstvo se
vodi na šporetu na čvrsta goriva, što podrazumeva sakupljanje
i cepanje drva i slično, a to je gotovo redovno posao domaćice.
U naselju Deponije, koje je praktično u centru Beograda, ne
postoji voda u kući, već žene uzimaju vodu iz ogromne cevi
koja je pukla i iz koje neprestano otiče voda koja je usred
naselja stvorila udubljenje u kome se zadržava. Ovde se pere
veš, tepisi, uzima voda za domaćinstvo leti i zimi. I na plus 40
i na minus 20 možete videti žene koje peru do kolena u hladnoj
vodi, bose, jer nemaju drugog izbora. Konkretno, u Deponiji, od
146 porodica, ne postoji ni jedna žena koja nije imala ozbiljnijih
ginekoloških problema, od redovnih upala jajnika i bešike, do
ozbiljnijih bolesti. Zanimljivo je pomenuti da se upravo u ovom
naselju dogodilo nekoliko nemilih događaja, kao što su smrti
beba bez objašnjenja, iako su vođena kod lekara. Pomenuću
rasprostranjeni stereotip da žene iz romske zajednice rađaju
mnogo dece, što je svakako tačno. Međutim, Deponija je naselje
u kome je zabeležen i znatan broj žena nerotkinja i onih koje su
imale problema u trudnoći, prilikom začeća. Ovo se lako može
povezati sa teškim uslovima u kojima žive, a koji definitivno
ugrožavaju žensko zdravlje.
Bolesno zdravlje
Fenomen «bolesnog zdravlja« žena čest je kod Romkinja.
Razlozi su mnogobrojni: nedostatak vremena, novca,
tradicionalan stav da žena mora da je uvek na nogama, da je
sramota ići kod lekara. Naravno, da su nedostatak potrebne
dokumentacije i ponekad diskriminatorni stav zdravstvenih
radnika, prva i glavna prepreka. Nažalost, sve pomenute
činjenice često se »čitaju« kao nebriga za sopstveno zdravlje,
niska svest o važnosti zdravlja i sl. Razbijanje ove predrasude
ili mišljenja je moja misija. Sve što naizgled liči na nebrigu i
nedostatak svesti, ustvari je naučena uloga žene koja se žrtvuje
of the fact that births will be numerous and frequently without
her own planning, thus resulting in various, for example health
burdens, a Roma woman will not rebel, especially not publicly,
as would be the case in most other ethnic groups. If her life is
filled only with bearing children and managing the household,
she wil love the chidren, and respect the breadwinner. Respect
for the husband, obedience, and his unquestionable authority are
an expression of gratitide for providing the means of existance
for the children.
The health of young people
Tradition and upbringing play a very important role. Research
done by Roma Women’s Center BIBIJA pertaining to the cilt of
virginity in the Roma family, has indicated a high percentage
of parents, primarily fathers, who expect, rather demand, from
their daughters to marry as virgins. This is one of the reasons for
early marriage, which definitely influence the health of young
girls. Another reason for early marriage is the fact that the girl
becomes a source of free labor for her new family. Even though
she worked very hard in her primary family, in her husband’s
family she must additionaly prove herself, and must take on
even harder tasks, which again influences the health of the
young woman, in some cases in fact still a young girl.
Living conditions
The next problem, which should probably be placed first for
its importance, are the difficult living conditions, which leave
their mark on the life of the Roma woman. We have all, at one
time or another, passed by a Roma settlement, and seen that
there is no electricity, no running water, no sewerage, or heating.
The household relies on a stove burning solid fuel, which
means gathering and preparing wood, etc., which is almost
always the task of the housewife. In the settlement “Deponija”,
virtually in the center of Belgrade, there is no water in houses,
so women take water from a huge pipe, which has cracked and
is constantly letting out water that has formed a recess in the
middle of the settlement and remains there. This is used to
wash laundry and carpets, and to take water for the household,
both in summer and in winter. At +40 o C, as well as at -20 o C,
women can be seen doing the laundry, knee deep in water and
barefoot, because thay have no other choice. More precisely, in
the “Deponija” settlement, there are 146 families, but there is not
a singe woman who has not had serious gynecological problems,
from regular inflammations of ovaries and the bladder, to very
serious diseases. It is interesting to mention that it was in this
settlement that several unpleasant instances have ocurred, such
as unexplained deaths among infants who had been taken to
doctors. I will mention the general sterotype that Roma women
bear many children, which is no doubt true. However, the
“Deponija” settlement is also a place with a significant number
of infertile women, and women who experienced problems
during pregnancy, or to concieve. This can easily be linked to
diffucult living conditions, which definitelly threaten the health
of women.
Ill health
The phenomenon of “ill health” is frequent in Roma women.
Reasons are numerous: lack of time and money, the traditional
view that a woman must be up and about at all times, that it
is a disgrace to visit a doctor. Naturally, the lack of required
documents, and sometimes the discriminatory attitide of health
care staff, are the first and the main obstacle. Unfortunately, all
mentioned facts are often “interpreted” as lack of care for own
health, as a low level of awareness of the importance of health,
etc. My mission is to shatter this prejudice or opinion. All that
resembles lack of care or lack of awareness, is in fact the learned
27

za porodicu, koja je stub i oslonac svima, jedan model ponašanja
izrastao na osnovama patrijarhalnog društva, a koji nije nepoznat
na ovim prostorima. U čemu se ogleda bolesno zdravlje
Romkinja: u svakodnevnim rečima »nije mi ništa«, »samo mala
prehlada«, »proći će«, »lekari ionako ništa ne znaju«, »biće mi
bolje«. Rezultat ovoga su hronične upale pluća koje su nastale iz
nepreležanih prehlada, hronične upale jajnika, pojačane migrene
– i sve to ove žene leče na nogama.
Zdravstvene posledice nasilja
Nasilje u porodici je tek od nedavno postalo predmet
krivičnog zakona sa dosta neujednačenom praksom za sada.
Iako prestaje da bude zabranjena tema ili nešto što se događa
nekom drugom a ne nama, reakcije institucija, ali i okoline
na nasilje nanesu više štete nego koristi. Pokrenuti krivični
postupci dugo traju, stambena i ekonomska zavisnost žena od
nasilnika, nepostojanje sigurne kuće koja ima dovoljno mesta za
majke i decu samo su neki od delova opšte ženske priče kad je
reč o nasilju. Zapažanja aktivistkinja RŽC BIBIJA govore da je
svaka DRUGA Romkinja pretrpela neki oblik nasilja u porodici,
da tek 2% Romkinja prijavi slučaj nasilja policiji, a da policija
reaguje na svaki PETI poziv iz romskog naselja.
Diskriminacija
Ovaj široki pojam
obuhvata zdravstveni
sektor u dva smera:
direktni i indirektni.
Direktna diskriminacija
ispoljava se u situaciji
kada zdravstveni radnik
odbija da pruži pomoć
Romu. Ovde ubrajamo
i verbalno nasilje,
degradirajući tretman,
odvajanje od drugih
pacijenata. Ne postoje
relevantni podaci kojima bi mogla da se izmeri zastupljenost
ove pojave. Rad na terenu RŽC “BIBIJI” doneo je ove podatke:
od 40 romskih naselja u Beogradu u kojima smo radile najmanje
65% Romkinja izjavilo je da se susreće da diskriminatornim
tretmanom od strane zdravstvenih radnika. Prenebregavanje
specifičnih potreba romskog stanovništva, nedostatak
informacija na njihovom jeziku, nepoznavanje državnih
institucija generalno, a zdravstvenih posebno, nedostatak kadra
dovoljno senzitivnog na romsku kulturu i verovanja, nedostatak
zdravstvenih radnika romskog porekla - su sve vidovi i razlozi
indirektne diskriminacije.
Za kraj o zdravlju
Na kraju potrebno je istaći i moguća rešenja ovog krajnje
nezavidnog položaja koji ima tendenciju pogoršavanja. Pre
svega, treba stvoriti čvrste mehanizme koji će omogućiti lakšu
dostupnost primarne zdravstvene zaštite i specijalističkih službi,
zatim važna je primena postojećih zakona i/ili njihova dopuna,
kao i podizanje dostupnosti informacija od značaja za zdravlje na
daleko viši nivo od trenutnog. Uspostavljanje uloge medijatorke
– kao spone između romske zajednice i zdravstvene institucije,
predstavlja takođe mogućnost prevazilaženja vekovnog jaza
koji je stvoren između ove dve strane. I na kraju, jedna od vidnih
potreba svih zainteresovanih strana je ustanovljenje validne baze
podataka o ženskom zdravlju koja bi doprinela potpunijoj slici
o zdravstvenom stanju žena iz marginalizovane populacije, ali i
bila dobar temelj za građenje jedne sveobuhvatne strategije za
konačnu eliminaciju ovakvog stanja. ■
role of the woman, who sacrifices herself for the family, who
is a pillar of support for all, as a model of behavior rooted in a
patriarchal society, and by no means new in this region. What
are the indicators of ill health in Roma women? They are in
daily statements such as: “I am all right”, “it’ just a mild cold”,
“it’ll pass”, “doctors are ignorant anyway”, “I will feel better”.
Results of all this are chronic lung inflammations resulting
from untreated colds, chronic inflammations of ovaries, strong
migranes – all of which these women take on their feet.
Health consequences of violence
Family violence has only recently become subject to
penal legislation, accompanied by a rather varying approach
in practice to date. Although it is no longer a taboo topic, or
something that happens to others, never to us, the reactions of
institutions, but also of the milleu to violence bring more harm
than good. Initiated criminal proceedings take a long time, and
the housing and economic dependence of women on the violator,
the nonexistance of a safe house which would have sufficient
space for mothers and children, are only parts of the universal
tale about women and violence. Activists of Roma Women’s
Center BIBIJA have noted that ONE OUT OF TWO Roma
women have suffered some form of family violence, that only
2% of Roma women report cases of violence to
the police, and that the police reacts only to ONE
FIFTH of calls from Roma settlements.
Discrimination
This broad concept encopasses the health
care sector from two aspects: direct and indirect.
Direct discrimination is expressed in a situation
when a health care worker denies assistance to
a Roma. This also encompasses verbal violence,
degrading treatment, segregation from other
patients. There are no relevant data that would
permit measuring the level of this phenomenon.
Field work by Roma Women’s Center BIBIJA
rendered following data: in the 40 Roma settlements in Belgrade
in which we worked, at least 65% Roma women stated that they
are faced with discriminatory tretment by health care workers.
The oversight of specific needs of the Roma population, the
lack of information in their language, the lack of knowledge
about state institutions in general, and health care institutions
speciafically, the lack of staff sufficiently sensitive to Roma
culture and beliefs, the lack of health care workers who are Roma
– all represent types of and reasons for indirect discrimination.
In conclusion – about health
In conclusion, one must indicate also the potential solutions
for this extremely unfavorable position with a worsening trend.
First of all, strong mechanisms need to be created that will
enable easier access to primary healthcare and to specialist
services. The implementation of existing laws and/or their
supplementation is also required, as well as raising the level
of access to information important for health to a much higher
level than it is presently. The establishing of the role of a female
mediator – as a link between the Roma community and the
health care institution, also represents a possibility to overcome
the centuries long gap between the two sides. And finally, one of
the visible requirements of all interested parties is to establish a
valid database on women’s health, which would contribute to a
more complete picture about the health of women belonging to
a marginalized population, but would also form a good basis for
creating a comprehensive strategy for the final elimination of
this state of affairs. ■
28

5.
Zdravlje žena u
zdravstvenoj politici
Srbije
Women’s Health in
the Health Care Policy
in Serbia
U okviru serije okruglih stolova posvećenih
ključnim pitanjima zdravstvene politike Srbije,
PALGO centar je, u Sava Centru, 20. juna 2006.
godine, u saradnji sa Fondom za
otvoreno društvo iz Beograda,
organizovao okrugli sto na temu
„Zdravlje žena u zdravstvenoj
politici Srbije”.
Cilj skupa bio je da
okupi relevantne stručnjake,
odnosno organizacije, vladine
i nevladine, kako bi se otvorila
važna pitanja iz ove, donekle
zapostavljene, problematike.
Uvodna izlaganja su imale
Snežana Simić (pomoćnica
ministra zdravlja), Hajrija
Mujović-Zornić (Institut
društvenih nauka) i Đurđica
Zorić (nevladina organizacija
“Bibija”). ■
As part of a series of round tables dedicated
to the key problems of health care in Serbia,
PALGO Center organized, in co-operation with
the Fund for an Open Society from Belgrade, on
June 20, 2006, in Sava Centre, a round table on
the topic of “Women’s Health in the Health Care
Policy in Serbia”.
The goal of the meeting was to gather relevant
experts, governmental and non-governmental
organizations, in order to open up discussion
on pertinent issues related to those somewhat
neglected problems.
Introductory speeches were delivered by
Snežana Simić (assistant to the minister of
health), Hajrija Mujović-Zornić (Institute of
Social Sciences), and Đurđica Zorić (“Bibija”
NGO). ■
29

Zdravlje žena
Women’s Health
Hajrija Mujović-Zornić
Položaj žena sa aspekta zaštite njihovog zdravlja nije u
dovoljnoj meri bio predmet interesovanja u Srbiji. Promovisanje,
unapređenje i zaštita zdravlja žena zacrtani su još od ranije
kao značajni ciljevi zdravstvene politike prema ženama, ali
svakodnevna medicinska praksa i pozitivna zakonska rešenja iz
ove oblasti svedoče o određenim
manjkavostima. Naročito se
pokazuje potreba preispitivanja i
redefinisanja zdravstvene politike
imajući u vidu širi kontekst gde
postoje aktuelna “granična”
pitanja zdravlja, kakva su
pitanja povezana sa odnosima
u porodici, socijalnim statusom
žene, radno-ekonomskim
aktivnostima, kao i rodno (po
polu) uočene razlike u pristupu
zdravstvenoj zaštiti žena. Samim
tim zdravstvena politika bi dobila
mogućnost mnogo realističnijeg i
životnijeg pristupa u oblikovanju
i sprovođenju svojih ciljeva.
Otvaranje značajnih
pitanja o zdravstvenoj politici
prema zdravlju žena, međutim,
znači i više od toga. Naime, time
se dolazi bliže odgovoru kakva je
stvarna i efektivna zdravstvena zaštita žena u Srbiji danas, koje
su njene dobre a koje loše strane, kako je žena tu pozicionirana,
odnosno kakav je pravni položaj žene kao subjekta zdravstvene
zaštite u jednom takvom sistemu. Osnovni pokazatelji tog
položaja svakako jesu: stanje zdravlja ženske populacije,
rad zdravstvenih službi i stepen uređenosti i poštovanja
prava iz oblasti zdravlja. Kroz ove odrednice sagledava se i
implementacija ciljeva zdravstvene politike u svakodnevnoj
medicinskoj praksi.
Iako žene čine 51,4% ukupne populacije Srbije, a istovremeno
većinu zaposlenih u zdravstvu čine žene, zdravstvena zaštita
žena nije uvek adekvatna u pogledu organizacije, metoda rada
i pristupa službama. Zaštita je više orijentisana na lečenje a
zanemareni su prevencija oboljenja i stanja i promocija zdravlja.
Postoji nedostatak rodno senzitivnih istraživanja za praćenje
zdravlja, ali i nedostatak vođenja istih takvih statističkih
podataka, posebno podataka iz rutinske zdravstvene statistike za
evidenciju korišćenja usluga zdravstvenih službi. Kada je reč o
stanju zdravlja žena, značajni faktori uticaja su: - demografski,
gde se posebno posmatra starenje žena, stopa smrtnosti i
broj živorođenih po polu; - promene u porodičnom životu; -
obrazovanje žena; - opterećenje faktorima rizika oboljevanja;
- nasilje nad ženama. Posebni problemi se javljaju kod žena
Romkinja i socijalno ugroženih žena kako u pogledu pristupa
zdravstvenoj zaštiti, tako i sagledavanju njihovih zdravstvenih
potreba.
U prošlosti zdravstvena zaštita žena se tradicionalno vezivala
samo za reproduktivnu medicinu. Danas je pristup mnogo širi
a veliki uticaj ima rodni pristup, koji uvažava polne razlike i
ravnopravnost. Svetska zdravstvena organizacija (SZO) je
kroz svoje analize zauzela takođe određene stavove: - bolesti
Hajrija Mujović-Zornić
The position of women from the aspect of health protection
is not attributed sufficient interest in Serbia. Promotion and
protection of women’s health have been previously postulated
as important goals of health care policies for women,
however, daily medical practice and legal solutions in this field
demonstrate certain shortcomings. There is
a very evident requirement to review and
redefine the health care policy in view of the
broader context when current “borderline”
health issues exist that are connected to
family relationships, the social status of
women, their work-economic activties,
as well as to gender differences in the
approach to health care for women. This
would result in a much more realistic and a
closer to life approach to the designing and
implementation of health care goals.
The initiating of important issues of
health care policy pertaining to women’s
health, however, means more than this.
Namely, it brings us closer to the answer
of what is in fact the acctual and effective
health protection for women in Serbia today,
what are its good and its bad sides, how the
woman is positioned within this concept, i.e.
what is the real position of the woman as a
subject of healt care within such a system.
Basic indicators of this position are by all means: the health
status of the female population, activities of health care services,
and the level of regulation and respect of rights to health care.
These parameters offer an insight into the implementation of
goals of health care policies in daily medical practice.
Even though 51.4% of the population of Serbia are women,
who are also the majority of employeees in health care,
women’s health care is not always adequate from the aspect
of organization, methods of work, and accessibility of services.
Protection is more channeled toward treatment, while prevention
of diseases and various states, and promotion of health are
neglected. There is a lack of gender sensitive research to monitor
health, as well as lack of registration of such statistical data,
especially data from routine health statistics pertaining to use of
health care services. Factors important for women’s health are:
- demographic, with special emphasis on the aging of women,
mortality, and number of liveborn infants by sex; - changes
pertaining to family life; - education of women; - burden of
disease risk factors; - violence against women. Special problems
appear in Roma women, and in women who are socially
vulnerable, both when it comes to access to healthcare and to the
assessment of their health care needs.
In the past, health care for women was traditionally connected
only to reproductive medicine. Today, the approach is much
broader, with a significant influence of the gender approach,
which takes into consideration gender differences and gender
equality. In its analyses, the World Health Organization (WHO)
has also adopted certain views: - diseases are not manifested
in the same manner in women and in men; - certain diseases
are exclusive to women; - diseases in women often demand
a different approach to diagnosis and treatment than in men;
30

se ne ispoljavaju na isti način kod žena i kod muškaraca; - neke
bolesti su isključivo vezane za ženski pol; - bolesti kod žena
često zahtevaju drugačiji pristup dijagnostici i lečenju nego
kod muškaraca; - faktori rizika po zdravlje nisu isti za oba pola,
pogotovo u pogledu nasilja na ženama; - dobra preventivna
zaštita može dovesti do smanjenja obolevanja i produženja
životnog veka žena. U razvijenim zemljama to je dovelo do
veće pažnje društva i stvaranja svojevrsnih pokreta za zdravlje
žena. Naročito su važni pravci razvoja i preporuke SZO u
pogledu otklanjanja nejednakosti među polovima, smanjenja
stope smrtnosti i invalidnosti porodilja, bezbednog abortusa,
smanjenja nasilja nad ženama i programa zdravstvene zaštite
žena na svim nivoima.
Stanje ljudskih prava žena u oblasti zaštite zdravlja je deo
šireg konteksta. Život i zdravlje svakog čoveka predstavljaju
pravom zaštićena lična dobra, a iz toga proizilazi niz bazičnih
i izvedenih prava iz korpusa tzv. pacijentovih prava. U osnovi
većine od tih prava jeste pravo na samoodređenje i kontrolu
vlastitog tela. Kod ženske populacije, u zavisnosti od konkretnih
okolnosti i životnog veka, ova pitanja se tipično aktuelizuju
kod: preventivne zaštite zdravlja žena, planiranja i kontrole
rađanja u pozitivnom i negativnom pravcu, trudnoće, porođaja i
materinstva, seksualne aktivnosti i rizika od prenosivih bolesti,
prelaznog doba i starosti.
Zaštita žena kroz zdravstveno zakonodavstvo Srbije danas
je praktično redukovana na reproduktivnu ulogu žene. Većinom
su to opšte odredbe o pojačanoj zaštiti žena, gde od posebnih
zakona koji bi obuhvatnije posmatrali celokupnu oblast medicine
rađanja, postoji samo Zakon o postupku prekida trudnoće u
zdravstvenoj ustanovi (1995). Inače ovaj zakon je restriktivniji
u propisivanju uslova za pobačaj po odobrenju u odnosu na
prethodno važeći istoimeni zakon, zbog čega predstavlja
korak unazad u pogledu slobode žene da odlučuje o pobačaju.
Kod zaštite reproduktivnog zdravlja od suštinske je važnosti
razumevanje tesne veze između ove zaštite i reproduktivnih
prava, čije se ostvarivanje uvek treba omogućiti i respektovati
od strane zdravstvenih službi, bez uticaja i pritisaka na slobodnu
volju žene. To dolazi u prvi plan naročito kod sledećih pitanja:
pravo na rađanje i mere potpomognutog oplođenja, pravo na
kontrolu rađanja u pogledu željenog i zdravog potomstva, pravo
na pobačaj uz specifičnosti ranog i kasnog pobačaja, pravo
na sterilizaciju, prava trudnice kao pacijenta uz specifičnosti
HiV-pozitivne trudnoće, prava porodilja, i prava vezana za
ginekološko-hirurške intervencije.
Potrebno je oblikovati koncept reprodukcije koji objašnjava
i potvrđuje ideju o pravu na reprodukciju kao bazičnom
ljudskom pravu. U većini liberalnih zapadnih demokratija
smatra se da ljudi moralno i legalno uživaju prokreativnu
slobodu ili prokreativnu autonomiju. Ona uključuje kako pravo
na reprodukciju, tako i pravo da se spreči reprodukcija. Tako
definisano pravo povlači za sobom niz spornih pitanja koja traže
svoje razrešenje. Na primer, ko ima pravo na reprodukciju; da
li njega uživaju samo venčani parovi ili i pojedinci; da li je ovo
pravo ograničeno na heteroseksualne parove; da li je limitirano
starosnom granicom titulara; da li mogu maloletne osobe ili
starije žene u postmenopauzi imati pravo na reprodukciju;
da li ovo pravo pripada samo fertilnim osobama koja mogu
da rađaju prirodno, via coitus, ili i sterilne osobe imaju pravo
na reprodukciju. Na ova pitanja ne može se dati odgovor bez
koherentne koncepcije prava na reprodukciju u kontekstu zaštite
reproduktivnog zdravlja. ■
- health risk factors are not the same for both sexes, especially
when it comes to violence against women; - good prevention can
lead to decrease of diseases and to a longer life span of women.
In developed countries, this has lead to greater attention of the
society, and to the formation of specific movements for women’s
health. Directions of development and WHO recommendations
are especially important when it comes to eliminating gender
inequality, reducing the level of mortality, and morbidity of new
mothers, safe abortion, decrease of violence against women, and
programs of health care for women at all levels.
The status of women’s rights in health care is part of a
broader context. The life and health of each individual are
personal assets protected by the law, forming a basis for a series
of basic and deduced rights belonging to the body of so called
rights of patients. The basis of most such rights is formed by the
right to self determination and to control over ones own body. In
the famale population, depending on concrete circumstances and
life span, such issues become typically current from the aspect
of: preventive protection of women’s health, planning and
control of reproduction in the positive or the negative direction,
pregnancy, parturition and maternity, sexual activity, and risk
from communicable diseases, menopause, and old age.
Today, health protection of women in the health care
legislation of Serbia is practically reduced to her reproductive
role. There are mostly general provisions on the intensified
protection for women, with only one specific law encompasing
in more detail the entire area of reproductive medicine, the
Law on Procedure for Termination of Pregnancy in a Health
Care Institution (1995). When prescribing conditions for
approved termination, this Law is in fact more restrictive than
the previous Law under the same name, thus representing a
retrograde step when it comes to the right of a woman to decide
about an abortion. From the aspect of protection of reproductive
health, it is very important to understand the close connection
between this type of protection and the right of reproduction,
which should always be enabled and respected by health care
services, without any influence or pressure against the free will
of the woman. This takes center stage especially in connection
with the following issues: the right to give birth, and to measures
of assisted ferilization, the right to birth control in the sense of
desired and healthy offspring, the right to an abortion with the
specificity of early and late abortion, the right to sterilization,
the rights of pregnant women as patients belonging to the
group of specific HIV-positivne pregnancies, the right of new
mothers, and rights in connection with gynecological surgical
interventions.
There is the need to shape a concept of reproduction which
explains and confirms the idea of the right to reproduction
as a basic human right. In most liberal western democracies
there is the view that people are morally and legally entitled
to the freedom to procreate or the autonomy to procreate.
This includes both the right to reproduce, and the right to
prevent reproduction. The right thus defined implies a series
of disputable issues demanding to be resolved. For example,
who has the right to reproduce; is this the right only of married
couples, or also of single individuals; is this right limited to
heterosexual couples; is it limited by the age of the individual;
can minors or older women during postmenopause have the
right to reproduce; is this the right only of fertile individuals
who can give birth naturally, via coitus, or do sterile persons also
have the right to reproduce. These questions can not be answered
without a coherent view of the right to reproduce in the context
of protection of reproductive health. ■
31

Zaključci konferencije
Conference Communiqué
Zdravstvena politika prema ženama u Srbiji treba
da polazi od faktičkog stanja zdravlja i položaja žena,
uzimajući u obzir sve ono što determiniše, a naročito
ugrožava i ostavlja posledice na zdravlje žena.
Zdravstvena politika u vidu holističkog pristupa treba da
ima u vidu kontinuitet brige o zdravlju žena od perioda
začeća do kraja životnog veka, počev od zabrane selekcije
ženskog embriona do rađanja i tokom čitavog životnog
veka do smrti.
Da bi imala svoje efekte zdravstvena politika
prema ženama treba da bude pretočena u konkretne
ciljeve i zakonske i druge propise, naročito u pogledu
reproduktivnog zdravlja. Potrebno je dopuniti i revidirati
postojeću regulativu, a u pojedinim segmentima i doneti
nove propise. Naime, ranjivost ženske populacije u ovom
trenutku izražena je kroz zakonsku regulativu samo
u odnosu na reproduktivnu ulogu žene, a trebalo bi je
proširiti posebno na probleme žena invalida, žena žrtava
nasilja i, uopšte gde je to prepoznatljivo, žena u posebnim
životnim i radnim uslovima, budući da su sve pobrojane
situacije one koje u bitnoj meri utiču na fizičko i mentalno
zdravlje žena.
Prava žene u domenu zdravstvene zaštite treba
sagledati u širem kontekstu, kao deo pacijentovih prava
koja pripadaju svakom pojedincu i kao deo sveukupnog
položaja žena u Srbiji koji se odražava na konkretne
situacije (porodica, socijalno okruženje, ekonomski i
radnopravni status).
Bitna odrednica zaštite reproduktivnog zdravlja jesu
reproduktivna prava, a zaštita zdravlja u tom domenu se
adekvatno može promovisati i vršiti jedino pri njihovom
punom poštovanju.
Nužno je veće učešće žena u odlučivanju o pitanjima
zdravlja, što bi doprinelo boljem prepoznavanju od
strane kreatora zdravstvene politike i zdravstvenih službi
potreba i problema žena vezanih za zdravlje. Učešće
žena u kreiranju i sprovođenju zdravstvene politike treba
obezbediti kroz učešće u nadležnim predstavničkim
telima. ■
The policy of health care for women in Serbia
should be based on the acctual health status and the
position of women, taking into consideration all that
which determines, and especially that threatens and has
consequences in connection with the health of the woman.
The healt care policy, based on a holistic approach should
encompass a continuity of care for the health of women,
from the period of conception, until the end of their lives,
starting with the prohibition of selection female embryos,
to the birth, and during her entire life, until death.
In order to be effective, the policy for women’s
health care should be transformed into concrete goals
and legal and other regulations, especially in connection
with reproductive health. Existing regulations need to be
supplemented and revised, and in some segments new
regulations should be adopted. Namely, the vulnerability
of the female population at this point in time is reflected
in legal regulations that are in connection only with
the reproductive role of the woman, which should be
broadened, especially to cover problems of women
invalids, women victims of violence, and generally where
this is recognized, to women under specific conditions of
life or work, since all listed situations to a significant degree
influence the physical and mental health of women.
Women’s rights in the domain of health care should be
regarded in a broader context, as a part of patient’s rights,
which exist for all individuals, as well as a part of the
overall position of women in Serbia, reflected in concrete
situations (the family, social environment, economic, and
labor and legal status).
An important determinant in the protection of
reproductive health are reproductive rights, while the
protection of health in this domain can be adequately
promoted and implemented only if they are fully
respected.
More pronounced participation of women is required
in decision making pertaining to health, which would
contribute to better recognition of the health needs and
problems of women by the creators of health care policies
and by health care services. The
participation of women in creating
and implementing health care
policies should be ensured via
their particpation in competent
representative bodies. ■
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