CHALLENGING TIMES FOR GENERAL PRACTICE IN FORMER YUGOSLAVIA—COME AND GIVE YOUR SUPPORT
Wonca Rural Health Conference: Dubrovnik, 15–18 April 2015
I do not know how many readers remember when the roots of general practice emerged in the former Yugoslavia. This initiative was created with significant influence from one of the cofounders of the World Health Organization—Andrija Stampar, who was born, educated and has worked in Croatia.
Half a century after the first steps of general practice, the situation regarding development and organization of general practice is not very bright in countries of the former Yugoslavia. In Slovenia and Croatia, the situation is relatively good, whereas other countries still experience the consequences of decline in traditional public health care. The situation in Croatia has started to improve with Sinisa Varga assuming positions of director of Croatian Health Insurance Fund (CHIF) and current minister, but not fast enough or with sufficient quality.
During 1990, general practitioners were separated from primary care centres and became ‘private GPs.’ We have placed the word ‘private‘ in quotation marks on purpose, due to the fact that general practitioners of such type were under immense pressure from the CHIF. This control went so far (and it still does, although much less than before) that almost every GP received a financial fine, with some considering termination of their contract. These fines were not issued due to poor patient care, but because of practitioners ignoring CHIF guidelines for issuing drug prescriptions. Some of these guidelines were not aligned with European and global practice. This led to common misunderstandings, as specialists in hospitals issued prescriptions according to European and global guidelines, and which GPs were not allowed to prescribe as they did not fulfil health insurance fund prerequisites. If GPs issued such a prescription, they had to pay a fine, whereas the hospital doctor was clear of all responsibilities.
The second absurd situation involved sanctions against GPs who would prescribe a drug to patients who were treated during their stay in a hospital. Due to the very poor situation in health care, hospitals often demanded that patients bring in drugs prescribed by a GP. There were two possible scenarios: a GP would prescribe a drug without knowing the patient was in the hospital and would then have to pay for the drug's value, or enter into conflict with the patient's family because the GP would not prescribe the required drug. This situation has somewhat improved in Croatia, but in Bosnia and Herzegovina, and Serbia it is worse. In these countries the economic crisis has had the effect that a large number of drugs are not covered by the health insurance fund; e.g. our colleagues are unable to independently prescribe corticosteroids for asthma treatment, angiotensin II receptor antagonists, or insulin for treatment of diabetes mellitus type 2.
Verbal conflicts between doctor and patient often take place, and several colleagues in Bosnia and Herzegovina and Serbia have even experienced physical violence. The situation is even worse regarding recommendations for diagnostic tests, as a GP cannot send a patient for gastroscopy and colonoscopy without a gastroenterologist examining the patient.
All this adds up to difficulties with which GPs in the region have to deal, especially with patients who suffer the most, most of all those in rural areas, leading to a decline of reputation in society.
Therefore, we invite all our colleagues across Europe and the world to join our conference in Dubrovnik, 15–18 April 2015, to join their colleagues in the region to recover the knowledge, skills and reputation that they once had.