Nataša Todorović, Red Cross of Serbia, Gerontological Society of Serbia

Milutin Vračević, Red Cross of Serbia, Gerontological Society of Serbia

Long-term care services for older people in Serbia are fragmented between the systems of social welfare, healthcare and pension insurance. It can be argued that the long-term care system does not exist but that there are functioning, yet sub-optimally coordinated elements in three different systems. The rate of access and use of these services among the population over 65 is quite low: statistics provided by International Labour Organization, based on research in countries of Central and Eastern Europe estimated that, in 2013 [1], less than 10% of people over the age of 65 used some of the existing services of long-term care in Serbia. Total cost of long-term care services provided through the three systems was estimated to amount to 0.53% of Serbian GDP, which is notably lower than the European Union average (1.84% in 2010, ranging from 0.16% on Cyprus to 4.5% in Denmark). There are large numbers of trained care staff migrating to Western Europe, leading to shortages in care staff that are resulting in growing waiting lists for services. Family care is the main source of care, particularly in rural areas where formal long-term care services are rarely available.

There is no formal long-term care (LTC) system in the Republic of Serbia, in the sense of an integrated set of support services with a single entry point for users. Instead, the existing services and supports are fragmented into three different systems: the social protection system, the health care system, and the pension and disability insurance system. The social protection system in Serbia does not contain the term “long-term care” nor does it define the needs of users related to this type of care. The services that fall under the umbrella of LTC are therefore provided through the system of social welfare (services in the community and residential care services), healthcare system (through primary and secondary healthcare) as well as through the pension and disability insurance fund that provides financial transfers for LTC in accordance with the established criteria related to need for assistance in everyday activities.

Responsibility for citizens who need LTC is recognized in the regulatory framework by focusing on adult users whose well-being, safety and productive life in society are threatened by risks arising from age, disability, illness, family and other life circumstances. According to the Law on Social Protection, the responsibility for providing accommodation services is placed under the jurisdiction of the central government, while day care services and home-based services in the community fall under the mandate of local self-government units.

In line with the system’s governance, financing is similarly fragmented between different levels of government. For the services falling under the system of social welfare, there are multiple financing modes. In general, the services in the community are funded from the budgets of local administrations in each municipality and provided through employing or subcontracting private or third sector service providers. Such services can be also fully paid for by the clients. People who receive financial transfers for LTC services have to pay at least 20% of the cost of the service.

The residential care services managed by the public systems are funded from the national budget. The LTC services within the healthcare system are all funded from the national budget and are available to everyone covered by the public health insurance scheme, which includes everyone covered by the state pension.

The minimum standards for the provision of services in the Republic of Serbia are defined by the Rulebook on conditions and standards for the provision of social protection services, defining the minimum requirements that current and future service providers should fulfil. Social protection services for which there is a need and cannot be provided in the necessary scope by public social protection institutions, are procured from licensed providers of social protection services. The Ministry of Labour, Employment, Veteran and Social Affairs is responsible for accrediting providers and monitoring their work through inspections. The quality of social protection services is established through service provision standards that include the minimum structural and functional conditions that service providers must meet in order to obtain a work license. Compliance with the standards is monitored by the social protection inspection of the responsible Ministry. Licensing of professional workers who provide social protection services, which ensures the maintenance and continuous improvement of personnel capacities, also contributes to the quality of services. The appropriate level of quality is ensured by the accreditation of training programs in social protection.

Healthcare services falling under LTC are being provided through home and hospital or inpatient treatment. Home treatment is an activity at the primary level of health care and is primarily performed by health centres and institutes. Hospital treatment that contains an element of long-term care belongs to the secondary level of health care and is performed by different types of hospitals. Inpatient treatment can also be performed in institutes as a special type of primary health care institution. Palliative care is primarily provided as part of primary health care in the patient’s home.

There is an ongoing shift from residential care towards community-based services, however residential care services are still very much in demand and this sector is growing as well.

There are 313 licensed service providers for community-based care, 261 of whom have been active in 2022. 38.6% are public organisations and 61.4% are private or civil society organisations. [2]

Home care is the most frequently provided service in the community, with 130 licensed providers in 129 municipalities in Serbia (80%) providing services for more than 13,000 beneficiaries in 2021. These are private and civil sector organisations and companies contracted by municipal self-governments.[2]

Day care exists and is predominantly provided to younger beneficiaries with a disability. In 2021 it had only 4 beneficiaries over 65. This service was provided by 60 private and civil society providers to younger persons with disabilities in 57 municipalities [2].

Personal assistant is another service aimed predominantly at persons with disabilities and in 2021 it was provided in 28 municipalities in Serbia by licensed civil sector or private organisations [2].

Respite care exists but in 2021 was provided by only one provider, a public organisation established by a municipal self-government [2].

Foster care for adults is a type of service that the normative framework recognizes and recommends, but this type of accommodation for the older persons has still not received its deserved place in practice due to lack of minimum conditions and standards. However, in the last few years, the number of users of this service was around a thousand, of which close to a third were over 65 [2].

Patronage nurse visits: Regular visits are made to persons over 65 years of age, persons with disabilities and mental health conditions, as well as persons suffering from diseases of greater public health importance. In 2017, 4% of the total number of adult patients were covered by regular visits. During that year, visiting nurses visited 3,893 people with disabilities. A total of 232,541 regular visits were made to persons over 65 years of age [3].

Residential care accommodation is a social protection service that includes a wide range of users and is not exclusively aimed at LTC. The purpose of residential accommodation for adults and older persons is to maintain or improve their quality of life, their independence, or prepare them for a sustainable independent life. Residential care services are provided to persons over 65 who, due to limited abilities, have difficulty living independently, without round-the-clock support, care or supervision. As of 31 December 2022, 16,151 beneficiaries were using this service, of which 14,374 (89%) were over 65. Women make up the majority of users (65% compared to 35% of men). As of end 2022, there were 297 registered care homes in Serbia, out of which 40 were public while the rest were private run.

Palliative care is primarily provided as part of primary health care in the patient’s home. However, there is a need for hospital-based health care services for patients with severe symptoms that cannot be adequately cared for at home. This type of health care is provided through prolonged hospital treatment and care at the secondary and tertiary level of health care. As a rule, palliative care in hospital conditions is organized by establishing special organizational units in inpatient health care institutions.

The Republic of Serbia is a signatory of the Convention on the Rights of Persons with Disabilities and is working on creating a more inclusive, enabling environment for persons with disabilities through policies that regulate the rights to social protection and access to adequate healthcare, as well as to education, work and employment. In addition to legislation regulating access to services of healthcare and social welfare, as well as financial transfers, there are efforts to ensure enabling and accessible environments, for example through the Law on Planning and Construction that mandates accessibility of all new buildings for persons with disabilities, or the Law on the Movement with the Help of a Guide Dog. The traffic laws also make special provisions for persons with disabilities.

The public Pension and Disability Fund provides financial subsidies for purchase of medical/ assistive aids for persons that have been prescribed these aids by a physician. The Rulebook on Medical-Technical Aids stipulates the maximum subsidised amount that can be claimed for each type of aids and if the prices of the specific aid selected by the user exceeds this amount, the user is required to pay the difference from their own pocket. There is a wide array of aids available in the Rulebook catalogue including prosthetics, orthotics, orthopaedic aids, oxygen concentrators, insulin pumps, as well as aids related to sensory functions (hearing and vision) and speech impediments.

The workforce providing formal services includes both medical staff and care staff without medical training. The healthcare system provides its services through work of trained doctors and nurses, who also work in the residential care services that are under the responsibility of the system of social welfare. The same facilities also hire care staff without medical training as caregivers, as well as psychologists and physiotherapists. The services in the community rely on the work of gerontocarers who are non-medically trained care staff who are licensed but usually have only had a week of training. Further information on workforce can be found below in the Resilience section.

Community-based services: All providers of these services in the social welfare area had 8,239 staff in 2022 [4].

Residential care: in 2022 there were 6,699 professional workers in residential care services, 80% of them women and 48% of them directly providing care to beneficiaries [4].

Informal care: There is no reliable public data on informal forms of care in Serbia available, but it is common knowledge, confirmed by research [5], that family members take care of their relatives who need support for the activities of daily life. Family-based informal care comes in particular to the fore in remote and rural communities where the formal long-term care system is all but absent. Although there is a need to support and regulate informal care, currently there are no measures or services that directly support informal caregivers.

The data on LTC is separated between systems and currently there are no existing provisions for it to be shared between different sectors and systems.

“Addressing and preventing care needs through innovative community care centres (I-CCC)” [6] is a project implemented by the Red Cross of Serbia in two pilot communities, Sombor and Pirot. Through two community care centres persons in need of long-term care have access to a variety of services, including day care and home-based assistance alongside remote consultation on a number of relevant topics related to care plans etc. The work of the two centres supports both older beneficiaries and their family carers, recognising the essential role of informal care in the LTC system. The project also has a strong focus on persons with diagnosed dementia and their families, with an innovative programme of cognitive exercises, using tablet computers, for persons with dementia, aimed at slowing the onset of symptoms and providing them with opportunities for socialising.

The coverage of the LTC services is insufficient if compared to the need: more than 30% of persons over 65 with expressed need and no support received from any other source are currently not covered by any of the needed formal LTC services [7].

The unevenly developed services also mean that rural and remote areas have less in the way of services available.

The standards of care services are defined through appropriate legislation and the licensed providers must meet these standards in order to acquire and extend their licenses. The Ministry of Labour, Employment, veteran and Social Affairs is responsible for monitoring quality, and this is done through the work of commissions and monitoring departments. The same is true for the healthcare services where the standards are defined through appropriate rulebooks for different services and their quality is monitored through the work of commissions and inspections.

Regarding effectiveness and resilience, the small number of accredited services on offer is an ongoing problem, with home-based care and residential facility-based care being the prevalent two services. Other services do exist in the LTC system but they are underutilised and underdeveloped.

The generally overworked and underpaid care staff continues migrating to Western Europe in search of better wages [8],[9],[10],[11], and it becomes increasingly challenging to replace trained professionals, especially nurses and the trained carers who work in residential care institutions. Public residential care institutions have faced shortages of trained care staff for several years already [12], but this is an issue with home-based services as well, with long waiting lists, significant burden on the shoulders of informal caregivers and a grey market of unlicensed service providers that are additionally prohibitively expensive for the majority of potential clients.

In Serbia the pandemic response included a very strict prohibition of movement for persons over 65, putting the whole older population of countries in detention at their homes for weeks on end, with very small exceptions [13]. Coupled with the uncertainties about supply chains and the safe way to get supplies, especially for those older persons living on their own or in elderly households, this put large portions of the older population in Serbia in a difficult position with psychological stress caused by isolation and separation from their friends, families and neighbours coupled with the real fear of being unable to meet their needs related to food, medication and other essential supplies. On top of that, lack of protocols for emergencies and protective equipment, as well as frequent curfews, significantly impacted the delivery of services in the community especially in the first phase of the pandemic. The services were reduced to just delivery of supplies in the first weeks until protective equipment was provided and some protective measures were established [13].

Additionally, the residents and staff of residential care centres were under significant pressure due to epidemiological measures that prevented visits and residents leaving the premises and also required the staff to stay in their workplace for two-week shifts. Separation from their families for both residents and staff added to the other dimensions of psychological pressure that increased the risk of mental health issues [13].

The Strategy for De-institutionalization and Development of Social Protection Services in the Community for the Period 2022-2026 was adopted in 2022 and it aims to enable the development of social protection services in the community. It focuses on users of the social protection system who need more intensive support with a view to supporting them by meeting most of their needs in their natural environment. The main goal of the Strategy is to realize the right to life in the community of social protection beneficiaries through the processes of de-institutionalization and social inclusion

The government of Serbia is also participating in a project funded through Instrument for Pre-Accession (IPA) of the European Union which aims to work on developing additional services in the long-term care system, such as foster care for adult and older persons – which exists but is very underutilised – in order to reduce the pressure on the system of residential care institutions.

Todorović N. and Vračević M. (2024) Long-term care system profile: Serbia. Global Observatory of Long-Term Care, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/serbia

“Long‐term care”: an overview of LTC in Serbia published by MONS (Monitoring Social Situation in Serbia) magazine in 2018: https://mons.rs/long-term-care

“Long-term care of older persons and persons with disabilities in the Western Balkans” is a study done by the Red Cross of Serbia and SeConS Development Initiative Group in 2023 and includes data for Serbia as well: https://www.redcross.org.rs/media/9019/long-term-care-of-older-persons-and-persons-with-disabilities-in-the-western-balkans.pdf

Serbian Language:

“Access to long-term care services in Serbia” is a study done by the Red Cross of Serbia and SeConS Development Initiative Group in 2022: https://www.redcross.org.rs/media/8802/pristup-uslugama-dugotrajne-nege-u-srbiji-studija-za-web.pdf

“Mental health of informal caregivers” is a study done by the Red Cross of Serbia in 2020: https://www.redcross.org.rs/media/6994/ment-zdravlje-neformalnih-negovatelja-web.pdf

“Social protection in old age: Long-term care and Social Pensions” is a report of two research studies supported by the Social Inclusion and Poverty Reduction Unit of the Government of Serbia, published in 2014:

https://socijalnoukljucivanje.gov.rs/wp-content/uploads/2014/06/sipru_DTNSC_web_jan.pdf

“Qualitative research – long-term care of older persons in Serbia” is a research report supported by the Social Inclusion and Poverty Reduction Unit of the Government of Serbia, published in 2013: https://socijalnoukljucivanje.gov.rs/wp-content/uploads/2014/05/istrazivanje_dugotrajne_nege_starih.pdf

“Long-term care of older persons in Serbia – Situation, Policies and Dilemmas” is a scientific paper published in 2012: https://www.scribd.com/doc/216757281/Dugotrajna-Nega-Starih-u-Srbiji

[1] Kenichi Hirosea, Czepulis-Rutkowska(2016), Challenges in Long-term Care of the Elderly in Central and Eastern Europe str. 6

[2] Report on the Work of Centres for Social Welfare  for 2022. Republic Institute for Social Protection, Belgrade, Serbia, 2023

[3] Analysis of the work of outpatient health care institutions and the use of primary health care in the Republic of Serbia in 2017. Institute for Public Health of Serbia “Milan Jovanović Batut, 2018. p.35;

[4] Report on the Work of Centres for Social Welfare  for 2022. Republic Institute for Social Protection, Belgrade, Serbia, 2023

[5] Being a Caregiver. Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/caregiving/being-a-caregiver

[6] https://communitycarecenter.eu/

[7] European Health Interview Survey, Serbia 2019: https://publikacije.stat.gov.rs/G2021/pdf/G20216003.pdf

[8] Migration to Germany: skilled workers instead of refugees: https://www.dw.com/sr/migracija-u-nema%C4%8Dku-kvalifikovani-radnici-umesto-izbeglica/a-67978541

[9] Caritas: “Every year, Serbia loses a medium-sized city”: https://www.dw.com/sr/karitas-svake-godine-srbija-gubi-grad-srednje-veli%C4%8Dine/a-65762797

[10] Care workers and intermediaries from the Balkans: the precarity of female work fosters a lack of solidarity: https://www.masina.rs/eng/care-workers-and-intermediaries-from-the-balkans-the-precarity-of-female-work-fosters-a-lack-of-solidarity/

[11] Germany and Serbia: What immigration law reforms mean for Serbian workers: https://www.bbc.com/serbian/lat/srbija-64034800

[12] Social Security Workers Union: Protest on December 6, followed by a warning strike: https://www.021.rs/story/Info/Srbija/360316/Sindikat-zaposlenih-u-socijalnoj-zastiti-Protest-6-decembra-a-zatim-strajk-upozorenja.html

[13] Older Persons in the Republic of Serbia and COVID-19 Pandemic. UNFPA, 2020: https://serbia.unfpa.org/sites/default/files/pub-pdf/older-persons-and-covid-19-01-12.pdf

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