Weekly Briefing, Vol. 17, No. 3 (ME), April 2019
Health in focus
Various publications regarding the health of the Montenegrin population emerged in April. In particular the data on fertility seems to be especially important, because these data are published parallely with the publication of the Statistical Office of Montenegro (MONSTAT) on the low fertility rate in the country. Also, the question is raised about the ability and capacity of the Montenegrin healthcare system to respond to the demands of many patients who have different illnesses.
The Montenegrin population is becoming less fertile
Recently, the Public Health Fund and the Public Health Institute of Montenegro have published worrying information regarding the number of users of in vitro fertilisation (IVF) treatment in order to solve the problem of infertility. This information may lead to the conclusion that fertility of the population is an increasing problem in Montenegro. The big problem is that there is still no register where the diagnosis of infertility would be reported, and consequently there are no reliable data. However, certain conclusions can be drawn from the existing statistics and opinions of the experts in this field.
The accurate data on how many people are really infertile in Montenegro does not exist, but the data of the National Committee of the European IVF monitoring program show that sterility in Europe is growing, and Montenegro obviously follows such a trend.
That the trend of growth in the number of implemented methods of in vitro fertilization is evident, show data for previous years. Thus, around 550 of IVF treatments are conducted in Montenegro in 2018. This number was lower during previous years: 511 in 2017, 474 in 2016, and 437 in 2015. Thus, the number of users of this medical treatment rose by 17.8% in just a few years. Also, this number is not final. The practice is that the IVF Commission sends patients to some of the five clinics (the most common and successful methods of infertility treatment are currently performed at the state hospital Danilo I in Cetinje and in four private clinics Life, Ars Medica and Codra in Podgorica and the Humana Reproduction Clinic in Budva ). So, in addition to almost 550 couples who went through the IVF procedure in Montenegro, many through this procedure went abroad. All those who were not eligible for treatment in Montenegro, whether they needed a different service or a preimplantation genetic diagnostic, went abroad. The estimate is that this number amounted between 100 and 150 annually, during last several years.
Therefore, it is evident that the number of IVF cycles is increasing each year and that there are more and more couples in Montenegro who are looking for medical help. However, the question is whether this is because this medical method is more accessible, or because sterility is growing. The answer to this question can be supported by the opinion of experts in this field in Montenegro (those who implement the IVF method in Montenegro and who are members of the international IVF monitoring program). In general, their impression is that there is essentially an increase in sterility. How much is sterility actually distributed? Although there is no accurate data, according to experts, sterility is widespread among the male population, so the ratio of infertile men and women in Montenegro is 60 to 40. The countries that definitely have detailed data are the Scandinavian countries because they have their own health registers on these issues. The introduction of such registries is what would significantly improve knowledge and policies aimed at increasing fertility in Montenegro.
What also needs to be pointed out is the economic side of this problem. It is known that IVF treatment is not cheap, regardless of success. According to the latest Health Insurance Fund data, in the last year, for IVF treatments in Montenegro were allocated almost one million EUR or nearly 2000 EUR per treatment. It is also unknown how much money has gone abroad for treatment, but it is certain that significant funds have gone for the IVF purpose.
Progress of the health system of Montenegro, but …
According to the latest rankings of the European Consumer Health Index (ECHI), of the 35 countries – Montenegro is ranked as 23rd, and has progressed in relation to the previous year for two positions.[1] These data from the Health Consumer Powerhouse Organization are proudly presented by Montenegrin officials[2]. However, the Montenegrin healthcare system should not be observed as a serious competitor to rich, modern health systems that have a long tradition of nurturing excellence in providing health services. This is shown in the previous example in the treatment of infertility because only certain methods can be implemented in Montenegro. And it’s not just about treating infertility, but also about many other diseases that do not have adequate treatment in Montenegro. As a confirmation of this, the analysis of the expenses of the Health Insurance Fund for treatment abroad on various bases could be used.
Medical treatment outside Montenegro amounted to EUR 4.3 million in 2018 or over 2% of total health expenditures. During the last year about 3200 patients were sent for treatment, control or diagnostics to health institutions outside of Montenegro. Although this figure is 23% lower than in 2017, the funds spent for this purpose are still very significant. Most patients (approximately 87.5% of all patients who received treatment abroad) were sent for treatment in health institutions in Serbia. Nevertheless, the data show that the number of Montenegrin insured persons who are being medically treated in this country is lower by almost a quarter compared to 2017. The majority of insured persons were referred for treatment due to disease from the cancer group (29% of the total sent abroad). Due to innate deformation and chromosomal abnormalities, 12% of total patients were sent abroad for treatment, while on third place are patients with mental disorders (9.8%). Also, patients were referred for treatment abroad because of numerous other diseases such as eye diseases, nervous system diseases, and the like. For treatment abroad, through the Commission for Treatment Abroad, 639 referrals were granted to fund insurers in 2018 (54% of them refer to health institutions in Turkey). Therefore, although some patients, especially those suffering from some serious diseases, have been provided with modern therapy in treatment in Montenegro, there are numerous patients who can still be treated only abroad.
All this indicates that the Montenegrin health system still suffers from numerous shortcomings. Progress is evident, but there seem to be a number of unresolved problems, which primarily relate to both technical and human capacities. Because, it seems that the “chronic illness” of the Montenegrin health system is exactly the outflow of medical personnel who leave Montenegro in search of better working and living conditions. According to the data of the Ministry of Health, 42 physicians left the Clinical Center of Montenegro in the last six years, but according to these data, these are migrations mostly within the health system. But, some other data do not correspond to the conclusion of Ministry of Health. Namely, the outflow of professional staff has been warned by the Trade Union of Doctors of Montenegro for a long time. According to the data of this trade union, in the last four years, 101 doctors abandoned the public health system of Montenegro and about fifty doctors found their jobs outside the Montenegrin borders. Why is it so? There are a number of reasons, but it seems that the bad situation within the overall health system over the last two decades have led to the accumulation of enormous dissatisfaction among doctors, among which there is a kind of silent rebellion in the form of an ever-increasing outflow of personnel. One of the many problems is also the fact that doctors are labeled as the most corrupted part of society.
Therefore, it is evident that the Montenegrin Government allocates significant funds for improving the health of people in Montenegro, as well as for the modernization of the overall health system. This primarily relates to the improvement of technical capacities and accessibility of various services, both administrative and professional. Nevertheless, the Montenegrin health system also requires a stronger human resources policy, bearing in mind the numerous departures of Montenegrin doctors abroad. It seems that the policy of engaging medical personnel from abroad is becoming more and more common, which is also not cheap at all. Continuous policy of keeping competent and qualified doctors from Montenegro is still absent. And, what technological improvements mean without competent people. Like many philosophers stated: technology will not save us…It is worthless without human capital.
[1] Four years ago, Montenegro was at the bottom of the ECHI list based on indicators, among which are the availability of health care for patients, outcomes of treatment, the extent and scope of services, and the prevention and use of pharmaceutical products.
[2] What this year recommended Montenegrin health care for progress in ranking is low infant mortality, the availability of modern malignant disease treatment, and the decision to introduce HPV vaccine for women in order to reduce the incidence of cervical cancer.