Marija Novkovic, UNDP in Montenegro
Have you ever been in a position where medical services have been refused or delayed because an under-the-counter payment was necessary? Were you given the cold shoulder by your doctor? Has there been a shortage of hospital beds, or scarcity of information about your condition?
There may still be lingering disputes over the legal definition of corruption, but one thing’s for sure: corruption is painfully easy to define once it becomes personal.
Back in 2011, the Ministry of Health in Montenegro requested assistance from UNDP and the World Health Organization to assess the integrity of the country’s health care system (pdf). The research was intended to generate data on effectiveness of the health care reform thus far.
While 80 percent of patients were satisfied with the course of the primary health care (centres) reform, the reform at the secondary and tertiary levels (hospitals) hadn’t fared so well. It seems that doctors at primary level of care forged better relationships with their patients, due to a more thorough insight into personal histories and medical records.
However, there was one particularly delicate additional ingredient: the survey unearthed information on causes and patterns of informal payments. The health care system in Montenegro is suffering from a high rate of informal payments; they occur in 55.7 percent of cases and the average amount given to the medical staff is 60 euros. When analyzed against the average gross monthly salary, it transpired that the ‘informal’ contribution of Montenegrin citizens to health care equals their regular contribution through insurance.
Why is it that health care comes with such a steep price? The research revealed that the primary motive for informal payments is a sense of gratitude; money most commonly exchanges hands when a baby is delivered. Some might even say that this is part and parcel of the Montenegrin mentality. If so, then the prospects for amelioration are quite low.
Others might claim that the patients are not sufficiently informed about their rights and that they are unaware of the avenues to enforce them. One thing’s for sure, the relationship between a doctor and a patient is asymmetrical, resulting in high vulnerability of patients.
The Ministry of Health has been working towards improved patient rights for some time now. In 2011, the Law on Patient Rights was enacted and Health Sector Ombudspersons appointed in all health facilities throughout Montenegro.
During the past twelve months, patients lodged 396 complaints to ombudspersons, mostly because they were unhappy with long waiting lists, actions of the medical staff or the quality of service. By contrast, the NGO “Montenegrin Association for Patients’ Rights Protection” received some 800 complaints, over the course of two years, through their network of volunteers.
Therefore, 30 health sector ombudspersons from all health care facilities in Montenegro gathered in December to discuss the quality of health care. The discussion was very open and revealed some of the deficiencies of the system.
Firstly, ombudspersons find themselves in a conflict of interest as they are employees of the hospitals where they are supposed to enforce patient rights. Secondly, there are no uniform procedures to be followed in dealing with complaints and, in most cases, the legal deadline of three days is insufficient to resolve the matter and inform the grieved patient.
Being all about equality and predictability, health care is as basic as it gets: it’s so vital for the quality of our lives and is essential to everyone, regardless of social status, monthly income, religion or ethnicity. And informal payments increase the costs and make the poor and vulnerable absurdly ‘ineligible’ for medical services.
This was a humble attempt to bring to the fore some of the burning issues when it comes to fair and equitable access to basic services. There are many factors in play, and the old chicken and egg riddle can be summoned: did the patient offer a bribe? Or did a medical worker request it?
If efforts are invested to help patients understand their rights, and the avenues for enforcing them, would it improve the situation? Or should priority be given to enhancing civil society oversight of health sector ombudspersons? How important are legislative amendments? How can we best ensure transparency and accountability of everyone involved in the provision of medical care?