ZDRAVSTVENI KADROVI I REFORMA PRIMARNE ZDRAVSTVENE ZAŠTITE U CRNOJ GORI
Sažetak
Uvod: Reformske aktivnosti upravljanja univerzalnom zdravstvenom pokrivenošću u primarnoj zdravstvenoj zaštiti u Crnoj Gori sprovedene su u periodu između 2004. i 2012. godine, sa ciljem da se unapredi efikasnost zdravstvenog sistema kroz obezbeđivanje racionalnog korišćenja i dostupnosti resursa. Svrha ove studije je da opiše zdravstvene radnike tokom i nakon reformskih aktivnosti u Crnoj Gori.
Materijali i metode: Korišćen je prilagođeni četvorodimenzionalni okvir Svetske zdravstvene organizacije za ispitivanje dostupnosti, pristupačnosti, prihvatljivosti i kvaliteta zdravstvenog kadra u javnim ustanovama primarne zdravstvene zaštite u Crnoj Gori, u periodu reforme i nakon nje. Dostupnost, pristupačnost, prihvatljivost i kvalitet zdravstvenih radnika su ispitivani korišćenjem definisanog seta posrednih mera (engl. proxy). Pored toga, predstavljeni su najnoviji dostupni podaci o stopi obezbeđenosti doktorima medicine, stomatolozima, farmaceutima, izabranim doktorima i medicinskim sestrama, u javnim domovima primarne zdravstvene zaštite, kako bi se ispitala održivost sprovedenih reformi. Korišćeni su podaci informacionog sistema primarne zdravstvene zaštite, objavljeni podaci Instituta za javno zdravlje Crne Gore, kao i podaci iz niza zvaničnih i stručnih izveštaja relevantnih eksperata i institucija.
Rezultati: Tokom reforme, ukupan broj doktora zaposlenih u primarnoj zdravstvenoj zaštiti smanjen je za 5%, dok se broj medicinskih sestara smanjio za 35%. Istovremeno, povećao se broj doktora opšte prakse (izabranih doktora za odrasle) što je poboljšalo njihovu dostupnost (54,4 u 2015. godini u odnosu na 36,3 u 2004. godini, na 100.000). Ispitivanje pristupačnosti je pokazalo velike varijacije među opštinama. Korišćenje zdravstvenih usluga se, na nivou zemlje, povećalo za 25%, u službi za odrasle. Broj medicinskih sestara je smanjen i prilagođen normativima u službama za odrasle, žene i decu. Sa aspekta prihvatljivosti i kvaliteta, reformske aktivnosti su unapredile profesionalne kompetencije timova u primarnoj zdravstvenoj zaštiti.
Zaključak: Reforma primarne zdravstvene zaštite poboljšala je dostupnost i pristupačnost zdravstvenih kadrova, te sprovela aktivnosti koje su unapredile njihovu prihvatljivost i kvalitet. Preporučuje se uspostavljanje tela koje će kontinuirano pratiti promene u primarnoj zdravstvenoj zaštiti, kao i njeno funkcionisanje, kako bi se održali postignuti rezultati reforme i ostvario dalji napredak.
Reference
1. Figueras J, McKee M. editors. Health systems, health, wealth and societal well-being: assessing the case for investing in health systems. Maidenhead: Open University Press, 2012.
2. Saltman BR, Figueras J, Sakellarides C. Critical challenges for health care reform in Europe. Buckingham: Maidenhead, Open University Press, 1998
3. Saltman RB, Figueras J. Analyzing the evidence on European health care reforms. Health Aff (Millwood). 1998 Mar-Apr;17(2):85-108. doi: 10.1377/hlthaff.17.2.85.
4. Campbell J, Dussault G, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, et al. A universal truth: no health without a workforce. Forum Report, Third Global Forum on Human Resources for Health, Recife, Brazil. Geneva: Global Health Workforce Alliance and World Health Organization; 2013.
5. Dubey S, Vasa J, Zadey S. Do health policies address the availability, accessibility, acceptability, and quality of human resources for health? Analysis over three decades of National Health Policy of India. Hum Resour Health. 2021 Nov 13;19(1):139. doi: 10.1186/s12960-021-00681-1.
6. Correia T, Gomes I, Nunes P, Dussault G. Health workforce monitoring in Portugal: Does it support strategic planning and policy-making? Health Policy. 2020 Mar;124(3):303-310. doi: 10.1016/j.healthpol.2019.12.014.
7. Homer CSE, Castro Lopes S, Nove A, Michel-Schuldt M, McConville F, Moyo NT, et al. Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: addressing the post-2015 agenda. BMC Pregnancy Childbirth. 2018 Feb 20;18(1):55. doi: 10.1186/s12884-018-1686-4.
8. Fleming P, Thomas S, Williams D, Kennedy J, Burke S. Implications for health system reform, workforce recovery and rebuilding in the context of the Great Recession and COVID-19: a case study of workforce trends in Ireland 2008-2021. Hum Resour Health. 2022 May 26;20(1):48. doi: 10.1186/s12960-022-00747-8.
9. Burke S, Parker S, Fleming P, Barry S, Thomas S. Building health system resilience through policy development in response to COVID-19 in Ireland: From shock to reform. Lancet Reg Health Eur. 2021 Oct;9:100223. doi: 10.1016/j.lanepe.2021.100223.
10. Thomas S, Sagan A, Larkin J, Cylus J, Figueras J, Karanikolos M. Strengthening health systems resilience: Key concepts and strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2020.
11. WHO European Framework for Action and Integrated Health Service Delivery. Montenegro - WHO European Primary Health Care Impact, Performance and Capacity Tool (PHC-IMPACT) Copenhagen: World Health Organization 2020. [Internet]. Dostupno: https://www.who.int/europe/publications/m/item/montenegro---who-european-primary-health-care-impact--performance-and-capacity-tool-(phc-impact)-(2020).
12. World Bank. The Montenegro health system improvement project. Project ID: P082223. [Internet]. [Pristupljeno: 7. 3. 2020.]. Dostupno: http://web.worldbank.org/.
13. Ministry of Health of the Republic of Montenegro, Government of the Republic of Montenegro, Master plan 2005-2010.
14. Ministry of Health of the Republic of Montenegro, Government of the Republic of Montenegro, Law on Health care (Official Gazette Republic of Montenegro No. 39/04 from April 9, 2004, 14/10 from March 17, 2010).
15. World Bank. Population, total; annual change; urban population – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.].
16. World Bank. Fertility rate, total (births per woman) – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?end=2015&locations=ME&start=1960
17. World Bank. Life expectancy at birth, Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2015&locations=ME&start=1960
18. World Bank. Mortality rate, neonatal (per 1,000 live births). [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SH.DYN.NMRT?locations=ME
19. World Bank. Mortality rate, infant (per 1,000 live births). [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=ME
20. World Bank. Mortality rate, under-5 (per 1,000 live births) – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SH.DYN.MORT?locations=ME
21. World Bank. Maternal mortality ratio (modeled estimate, per 100,000 live births) – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SH.STA.MMRT?locations=ME
22. World Bank. GNI per capita, PPP (current international $) – Montenegro; Current health expenditure (% of GDP). [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD?locations=ME
23. UNECE. Population living on below $1 (PPP) per day – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://w3.unece.org/PXWeb/en/Charts?IndicatorCode=200
24. WHO Regional Office for Europe. “Total health expenditure as percentage of GDP in 2004,2015(Montenegro); Government spending as percentage of health expenditure in 2004,2015 (Montenegro), WHO estimates” European Health for All explorer. [Internet]. [Pristupljeno: 15. 1. 2020.].
25. OECD (2022), Health spending (indicator) 2019. [Internet]. [Pristupljeno: 3. 9. 2022.]. doi: 10.1787/8643de7e-en.
26. WHO Global health expenditure database. External health expenditure as percentage of current health expenditure (indicator). [Internet]. [Pristupljeno: 3. 9. 2022.].
27. World Bank (indicator). Births attended by skilled health personnel (%), Montenegro. [Internet]. [Pristupljeno: 3. 9. 2022.]. Dostupno: https://data.worldbank.org/indicator/SH.STA.BRTC.ZS?locations=ME
28. Institute for Health Metrics and Evaluation. GBD Profile Montenegro. [Internet]. Dostupno: http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_montenegro.pdf
29. Institute of Public Health of Montenegro. “Hospital morbidity in Montenegro in the period 2010-2015”. [Internet]. [Pristupljeno: 21. 1. 2020.]. Dostupno: https://s3.eu-central-1.amazonaws.com/web.repository/ijzcg-media/files/1574195600-analiza-bolnickog-morbiditeta-u-crnoj-gori-2010-2015.pdf
30. Klančar D, Svab I. Primary care principles and community health centers in the countries of former Yugoslavia Health Policy Health Policy. 2014 Nov;118(2):166-72.
31. Ministry of Health of the Republic of Montenegro, Government of the Republic of Montenegro, Health Development Strategy of Montenegro, 2003.
32. Drecun M. “Specialization of Family Medicine – implementation project”, Ministry of Health and Social Wellfare of Montenegro, 2009. In print.
33. World Bank. The Montenegro health system improvement project. Project ID: P082223. [Internet]. [Pristupljeno: 7. 3. 2020.]. Dostupno: http://web.worldbank.org/.
34. Šter MP, Kezunović LC, Cojić M, Petek D, Švab I. Specialty Training in Family Medicine in Montenegro – an Evaluation of The Programme by the First Generation of Trainees. Zdr Varst. 2018 Apr 6;57(2):96-105.
35. Cvejanov Kezunović L, Drecun M, Švab I. Primary care reform in Montenegro Zdr Var 2013; 52: 247-254.
36. Medical faculty Podgorica, Basic information. [Internet]. [Pristupljeno: 23. 1. 2020.]. Dostupno: https://www.ucg.ac.me/objava/org/18/poz/info
37. Ministry of education of Montenegro. Public announcement for enrolment in high schools in Montenegro. [Internet]. [Pristupljeno: 23. 1. 2020.]. Dostupno: http://www.mps.gov.me/vijesti/185873/KONKURS-ZA-UPIS-UcENIKA-U-I-RAZRED-SREDNJIH-sKOLA-U-CRNOJ-GORI-ZA-sKOLSKU-2018-2019-GODINU.html
38. Law on Health Care. Off Gazette CG 003- corr. 2016; 039, 2016; 002, 2017.
39. Law on University Education. Off Gazette CG 2014, 044, 052- corr. 2014; 047, 2015; 040, 2016; 042, 2017; 071, 2017; 055, 2018; 003, 19; 017,19.
40. Institute of Health Metrics. Global Burden of disease 2019 data. [Internet]. Dostupno: https://www.healthdata.org/gbd/2019
41. Health at a Glance: Europe 2014 – OECD. Dostupno: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2014_health_glance_eur-2014-en
42. Rule book on detailed conditions regarding standards and methods of achieving primary health care through the chosen doctor team or chosen doctor. [Internet]. [Pristupljeno: 18. 5. 2020.]. Dostupno: http://www.mzdravlja.gov.me/ResourceManager/FileDownload.aspx?rid=222998&rType=2&file=Pravilnik%20o%20bli%C5%BEim%20uslovima%20u%20pogledu%20standarda,%20normativa%20i%20na%C4%8Dina%20ostvarivanja%20primarne%20zdr.za%C5%A1tite%20preko%20ITD%20ili%20ID.pdf
43. Eurostat database. Physicians by medical specialty data 2015. [Internet]. Dostupno: https://ec.europa.eu/eurostat/web/health/data/database
44. Statistical Office of Montenegro. Release Internal Migration in Montenegro in 2015. [Internet]. Dostupno: https://www.monstat.org/userfiles/file/migracije/Migracije%20unutar%20Crne%20Gore%20u%202015_%20godini%20-%20eng_n.pdf
45. Santric Milicevic M, Vasic M, Edwards M. Mapping the governance of human resources for health in Serbia. Health Policy (2015). [Internet]. [Pristupljeno: 30. 8. 2022.]. Dostupno: http://dx.doi.org/10.1016/j.healthpol.2015.08.016
46. Burke S, Thomas S, Barry S, Keegan C. Indicators of health system coverage and activity in Ireland during the economic crisis 2008–2014—from ‘more with less’ to ‘less with less.’ Health Policy. 2014;117(3):275–8.
