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Serbia is the successor state of the former state union of Serbia and Montenegro which ceased to exist in 2006. The Republic of Serbia is a parliamentary democracy with a population of 7.35 million, excluding the population of Kosovo (according to  United Nations Security Council Resolution 1244 (1999)). The smallest administrative units in the country are municipalities which are the real carriers of local authority.

Serbia has experienced negative population growth rate since 1990. The country’s population, both domicile and refugees, is characterized by ageing, smaller families, and migration into cities. The proportion of population above 65 years of age, according to national mid-year estimates in 2008, was 17.8%

Serbia belongs to upper-middle-income countries, due to a steadily growing gross domestic product (GDP) which reached US$ 5458 in 2007. The poverty rate decreased between 2002 (10.6%) and 2008 (7.9%) but a large proportion of the population is in danger of falling into poverty. The impact of the economic crisis primarily affected employment and the official national unemployment rate was 26.5% in February 2010.

Health gains

Serbia made the biggest health gains in life expectancy, infant mortality, under-5 mortality. Maternal mortality, although rare, event showed variations over years, primarily due to differences in coding of causes of death.

Table 1. Selected statistics: Serbia

* Maternal mortality ratio in 2007 was 7.34

Despite these gains some population groups significantly lag behind the national averages. Estimated infant mortality and probability of dying before the age of 5 for Roma living in urban slums in 2006 was 3 times the national average.

Serbia defined “nationalized” Millennium development Goals (MDGs) for health of the Roma, to take targeted actions so that MDGs are achieved for all.

In addition, tuberculosis (TB) fell from 37 per 100 000 population to 24 per 100 000 population between 2003 and 2008.

Key public health problems and response

The highest burden of disease in Serbia is due to noncommunicable diseases (NCD): cardiovascular disease, responsible for 55% of mortality; and cancer, responsible for 20%. The ageing population and high burden of NCD mortality resulted in a continuously increasing crude death rate, which reached 13.97% in 2008.

The high burden of NCD is directly related to a high prevalence of risk-factors such as tobacco smoking (33% of adult population over 20 smoke) and growing obesity among adults and children. According to the national health survey 2006, 54.5% of adult population are overweight and 18% children aged 7–18 are moderately obese or obese. Only 23% of adult population reported taking daily physical activity, with 67% of adults being physically inactive.

Cancer is the second biggest killer of Serbian population, responsible for more than 20 000 deaths annually. The mortality for preventable cancer is of concern, especially for cervical cancer (incidence three times higher than the EU average), breast cancer (incidence higher than the European Union (EU) average) and growing lung cancer especially among women.

Injuries are a leading cause of death for young people aged 15–29 (standardized death rate (SDR) for all causes in 2008 was 65.9 per 100 000 and SDR for accidents was 21).

Public health measures

Serbia developed a number of strategies addressing NCDs and risk factors. Health promotion and intensive national campaigns against tobacco smoking and exposure to secondhand smoke have been under way since 2003 and resulted in a moderate but steady decrease of prevalence of smoking: on average by 1% annually. A national action plan on food and nutrition and action plan for increased physical activity are being developed.

Socioeconomic determinants of health

Serbia has identified inequities in health related to socioeconomic determinants, especially for the Roma population, as a key public health priority. The high incidence of cervical and breast cancer, the slow reduction of prevalence of smoking among women points to the need for targeted interventions. Serbia has launched the “Serbia against Cancer” programme in which organized screening for cervical cancer and breast cancer are under development, with strong support from WHO and the EU.

Health system

Serbian health system reforms started in 2003 and address structural and functional elements of the system, including human resources for health, organization of services and strengthening of primary health care. They aim to ensure that health professionals with the right skill mix are adequately distributed among levels of health care and geographic areas. Another objective is to restore the role of primary health care and increase the trust of population into primary health care while enhancing the primary health care workers’ capacity to deal with a high proportion of health problems.

Serbian health financing is based on mandatory health insurance with a high volume of rights defined by the law. The challenge is to achieve universal coverage for marginalized poor populations, including the Roma, internally displaced persons or persons returned through the re-admission process from EU countries. The key objective has been to ensure sustainability of health financing under difficult economic circumstances. Government expenditure per health per capita was US$ 475 (in purchasing power partiy – PPP), while total expenditure per health per was US$ 769 (in PPP) or (US$ 252 and US$ 408 in average exchange rate).

Total expenditure on health as percentage of GDP was 9.9 (2007), while general government expenditure on health as percentage of total expenditure on health was 61.8%. Nevertheless, the Government spent 13.7% on health from its overall expenditures.