The private dental sector in Montenegro or the state sector in Serbia and Bosnia and Herzegovina - it seems that the problems are similar, and they concern the unavailability and quality of the service, but also the poor oral health of the population.
Thus, in Serbia, for example, only every sixth resident has their own teeth, and in Montenegro there has been no analysis and data on the oral health of the population for about fifteen years. Since 2009, when dentists moved to the private sector through the reform, there is no record of the number of dental services provided to the youngest citizens.
Representatives of the profession and competent institutions agree that preventive health in dentistry is at an unacceptably low level in Montenegro, and the promised reform according to which school dentists should be returned to schools and health centers has been delayed for several years.
According to the Law on Compulsory Health Insurance, only certain categories of the population have dental health care at the primary level of health care at the expense of the state. This protection includes promotion through advisory work, prevention through preventive examinations of children up to the age of 18, diagnosis and treatment of persons under the age of 18, pupils, students and children without parental care, up to the age of 26 at the latest. At the state's expense, in dental practices that have concluded a contract with the Health Insurance Fund, persons older than 67 years of age, women during pregnancy and one year after childbirth, persons with disabilities who have muscle damage and neuromuscular diseases, plegic syndrome, damage hearing, vision and speech with more than 70 percent physical damage, intellectual disability with IQ 69 and below, autism, psychoses, epilepsy.
Mobile orthodontic appliances are available for minor patients, and fixed orthodontic appliances for children up to 18 years of age who have an intellectual disability with an IQ of 69 or less, autism, epilepsy and impairments that limit mouth opening.
The return of dentists to schools and health centers, as the beginning of a new reform in this area, is announced from the middle of 2021, and the opening of clinics is first planned for 2022, then for the beginning of the school year in September 2023, and then for January 2024. It is certain that even in the next school year, the children will not have a school dentist. At the end of last year, the tender for the reconstruction of buildings in 59 primary and secondary schools was canceled because there were no interested bidders for this work. New tender for school clinics in schools in Andrijevica, Bar, Berane, Bijelo Polje, Budva, Cetinje, Danilovgrad, Gusinje, Herceg Novi, Kolašin, Kotor, Mojkovac, Nikšić, Petnjica, Plav, Pljevlja, Plužine, Podgorica, Rožaj, Šavnik, Tivat, Tuzim and Ulcinj were announced again in February, but the contractor has not yet been selected.
The planned reform of dental health care, which would initially return outpatient clinics to only 59 out of 300 schools, was not acceptable to the Dental Chamber, and the members of the Association of Preventive and Pediatric Dentists did not agree with the proposed model either.
Five months ago, the Dental Chamber said that they support the idea of returning dentists to health centers in order to improve preventive dental health care, but that without an assessment of the state of oral health, which is the basis for planning the development and improvement of that area, the fear remains that just another experiment with that activity in Montenegro.
The state is forcing patients to private hospitals
The statistics are inexorable: in Serbia, only 16,5 percent of the population have their own teeth, and as many as 700.000 of them do not have any teeth. These are the latest data from the Institute for Public Health "Dr. Milan Jovanović Batut", after 18 years since only children, students, pregnant women, over 65 and the socially disadvantaged can go to the dentist with a card, and not others.
A logical question arises whether the "narrowed service" of state dentists has "driven" citizens to private dentists and whether all of them are able to pay to be treated in private practice?
Drasko Karađinović, a dentist from the NGO Doctors Against Corruption, tells "Danas" without any doubt:
"Of course, the system forces citizens to work with so-called private individuals who are often in the state service, in a health center or at one of the dental faculties, since the Health Care Act has a corrupt article on supplementary work that allows a state doctor to work privately. The less service is provided in the morning in a state institution, the fuller the private surgery is in the afternoon".
On the other hand, that "Batut's" research, according to the published information, shows that dental health has significantly deteriorated.
"Unproductive state dentistry still exists and continues in Serbia. About 1.700 dentists annually cost the RFZO close to 60 million euros, with a deplorable daily performance of 1,4 fillings per day and 20 mobile prostheses per year, in addition to 3.200 private practices whose services are used by the vast majority of citizens and who again pay out of pocket even though they have paid the health contribution of 10,3 percent of the gross salary. The annual consumption for dentistry is 350 million euros," claims Karađinović.
According to him, in Europe, less than five percent of dentists are employed in the public sector, the rest are private individuals, that is, employed in dental networks of voluntary health insurance institutions.
Montenegrin model
True, at the end of last year, the former Minister of Health Danica Grujicic announced that citizens with a certified health card will be able to use free dental services in health centers, such as tooth extraction or repair, cleaning of tartar, however, it is not yet known when this will be.
Karađinović therefore, as he told "Danas", the old/new Minister of Health Zlatibor Lončar recommends that he should consult about the reform of dentistry with dr Vuk Kadić, director of the Health Insurance Fund of Montenegro, regarding the agenda and modality of changes in dentistry.
"Until recently, that country had the same service model as Serbia. In short, in brotherly Montenegro they took over the model of dental services from other more advanced transitional states, for example, Slovakia, Hungary... There is no state dentistry, and every private practice can sign a contract with the Fund and be paid for the treatment of certain categories of the population, children , young people, pregnant women, over 65 years old", explains the interlocutor of "Danasa".
"Such a reform move would require Minister Lončar to dismantle the existing corrupt links in dentistry and thus provide a wide range of citizens with better access to dental services and at the same time stop expensive wastage while stopping the further deterioration of the nation's oral health," Karađinović points out.
A contribution is paid, but so are Private Services
Commenting on the state of the nation's oral health, he says there are several reasons for this, the first of which is financial in nature:
"Dental services are easily available, but only in the private sector where the patient pays for them again out of his own pocket, despite the already paid mandatory health contribution of 10,3 percent of the gross salary."
When asked why the problem is not being solved, he answers that "working groups in and around health care have tailored health laws according to their interests and thus block the reform."
"The legalized supplementary private work of a state doctor/dentist is a typical example of a legalized conflict of interest that prevents any reform. This manifests itself drastically in state dentistry: a dentist performs 1,4 fillings per day, less than 20 mobile prostheses per year... A state dentist with this productivity earns more than a Swiss dentist, I can say that from my own experience. When will the vast majority of citizens over the age of 65, who have lost their teeth, exercise the right to dentures if the state dentist does 20 a year? And the loss of teeth is a type of disability that strongly affects the overall health of a person," the dentist points out.
Dean of the Faculty of Dentistry in Belgrade Aleksa Marković he recently told the media that nowhere in the world, not even in the region, is it like here, and that Serbia needs the return of state dentistry.
He reminded that in 2006 a law was passed that health insurance covers dental services up to the age of 25 and after the age of 65.
"At that time, a large number of our colleagues were fired from the health centers and a great injustice was done to them. Today, you have about 5.600 private dentists in Serbia and about 2.400 dentists who work in the state service. That's not enough. Certainly, dentistry should be returned to health centers", he stated.
For a month in a state institution, or immediately with a private person
The public health system in Bosnia and Herzegovina needs to provide much more to its citizens and be more accessible to them, which also applies to dental practice. The law says one thing, but the practice says something completely different. Dissatisfied citizens say that they wait a month for appointments in public institutions, and that they often cannot meet them, so they still decide to repair their teeth privately. The service is significantly more expensive, but that's why those who need some of the dental services agree on appointments when they want.
Oral medicine and periodontology specialist dr Miroslav Prvulović from JU Dom zdravlja Canton Sarajevo in an interview with "Oslobođenje" explains that dental practice is regulated by the Law on Health Care and the Law on Dental Activity. The basic principle of dental care, such as the accessibility of continuity, the comprehensiveness of a specialized approach, and the improvement of quality and efficiency, are ideas that define the quality of dental services in addition to knowledge and skills.
"These are guidelines that are imperative in practice. We, on behalf of the Union of Doctors of Medicine and Dentistry, are intensively advocating and achieving better working conditions, thereby enabling greater motivation of dentists to provide even better service. Conditions are not ideal after years of neglect of public health. This was warned about and now results in a general lack of staff in public institutions", emphasized Dr. Prvulović.
Dental services in KS health centers, he adds, are comprehensive and completely free for insured users. Only mobile prosthetic works are paid for, minus a part of the money borne by the Institute of Health Insurance. For example, the price of a total prosthesis costs 133 KM (about 67 euros), while a partial one is 11,5 KM, mobile orthodontics is also free. For uninsured persons, the price list from 2001 applies, so the prices are more than competitive.
"The waits, when there are any, are minimal, they are usually conditioned by an additional diagnostic procedure. In cases where the specialist staff of a certain specialty is in short supply, and the need for the service is more intense in municipalities with a larger number of insured persons, there is a waiting period of seven to 14 days, such as, for example, the case with prosthetics", explains Dr. Prvulović.
Lack of staff
Our interlocutor points to a major public health problem, the lack of medical personnel. It is, Dr. Prvulović warns, a direct consequence of attempts to collapse public health and the long-term absence of planning and care from the authorities. The source of the problem with the lack of materials lies in the legal procedures of public procurement, which are known to be extended for a longer period due to the lawsuits of bidders who have not passed the tender procedure, Dr. Prvulović points out.
For patients who need certain dental services in public dental institutions in the Republic of Srpska, the Health Insurance Fund covers basic dental services, i.e. primary dental care, total dentures for patients over 65 years of age and mobile orthodontic appliances for children up to 15 years of age.
The Specialist Center for Dentistry is a teaching base for students at the Faculty of Medicine in Foča. 30 doctors, professors and teachers from all areas of dentistry are employed here, where patients are provided with complete dental health care. Patients can come with a referral, the service is paid for by the Health Insurance Fund of the RS, children up to 15 pay nothing, and adult patients pay 50 percent of the cost of the Health Insurance Fund of the RS. For all services performed (repairs, treatments, tooth extractions, oral surgery operations), patients pay only a co-payment.
For example, the price prescribed by the FZO RS, Prof. explains in an interview for Oslobođenje. Ph.D Nikola Stojanovic, assistant dean for dentistry at the Faculty of Medicine in Foča, is not large, the fund's prices are lower than in private clinics, and patients over 65 pay nothing because the costs are borne by the Fund.
"We don't have a long wait. If you came for repair or tooth extraction, you will be admitted during that week, if it is urgent, you will be admitted immediately. When it comes to making prostheses for patients over 65 years old, there is a certain waiting list, but for the sake of example, if you applied today, it is two to three months," says Dr. Stojanović, adding that there is a waiting list for the production of mobile orthodontic appliances for children. months, but they are free.
Details and prices of commercial dentistry services: metal-free ceramics, zirconium crowns in this specialist center cost from 280 to 305 KM per tooth. If metal ceramics are made commercially, it is about 140 KM. The installation of the implant is 770 KM, and the prosthetics that come on the implant are also charged, so in the end everything costs about 1.000 KM. Orthodontic appliances cost 1050 KM, and if the patient has two appliances, there is a discount of five or 10 percent.
In private dental offices, the services are much faster, but you need to allocate much more money for them, so tooth extraction with anesthesia alone costs 50 KM, while more complicated tooth extraction procedures cost up to 100 KM. The price of dental implants ranges between 1.200 and 1.500 KM. Tooth repair costs between 40 and 60 KM, and tooth extension costs 50 KM. Installation of metal-ceramic crowns costs about 250 KM per tooth.
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