Digital transformation of the healthcare system in Serbia: attitudes of eZdravlje and HIS users

Research and practice show that within the healthcare system (HCS) in Serbia, women?s passivity during childbirth is normalised. Both HCS staff and female patients hold this representation of women as inherently passive. The paper aims to present research findings on passivity normalisation during childbirth. This study aimed to investigate the factors related to HCS experiences contributing to this passivity normalisation. Participants (N=363, 252 with childbirth experience) completed scales measuring trust in medical staff, distrust in the HCS, reliance on the HCS, frequency of positive and negative experiences with the HCS, and normalisation of passivity during childbirth. The examined factors accounted for 25% of the variance in normalising passivity during childbirth. Specifically, participants who were more reliant on the HCS, had given birth and reported more positive or fewer negative experiences, were more likely to normalise passivity. Paradoxically, a positive relationship with the HCS led to adopting the passivity norm, while negative experiences were a protective factor. The HCS appears to teach women passivity, as positive experiences within the system reinforce the perception of passivity as appropriate.

Since the health information system (HIS) in public health care services in Serbia was introduced in 2009, it has gradually expanded. However, it is unclear how well the HIS components have developed and the whole system's stage of maturity. In June-September 2021, a maturity assessment of the Serbian HIS was conducted for the first time using the HIS Stages of Continuous Improvement (SOCI) toolkit. The toolkit measures HIS status across 5 HIS domains: leadership and governance, management and workforce, information and communication technology (ICT), standards and interoperability, and data quality and use. The domains were further divided into 13 components and 39 subcomponents whose maturity stage was assessed on a 5-point Likert scale, indicating the level of development: (1) emerging/ad hoc; (2) repeatable; (3) defined; (4) managed; and (5) optimized. The toolkit was applied in a working group of 32 professionals and experts who were engaged in developing the new national eHealth strategy and action plan. The overall maturity score of the Serbian HIS was 1.6, which indicates a low level. The highest baseline score (2) was given to the standards and interoperability domain, and the lowest (1.1) was given to ICT infrastructure. The remaining 3 domains (leadership and governance, Management and Workforce, and Data Quality and Use) were similarly rated (1.7, 1.7, and 1.6, respectively). A baseline assessment of the maturity level of Serbian HIS indicates that the majority of components are between the emerging/ad hoc stage and repeatable, which represent isolated, ad hoc efforts, with some basic processes in place and existing and accessible policies. This exercise provided an opportunity to address identified weaknesses in the upcoming national eHealth strategy.

Health institutions have the most complex organization and management among all institutions. Unlike traditional management in organizational systems characterized by analytical and interdisciplinary approach, health institution management is characterized by trans-disciplinary approach to solving business problems. Introduction of quality improvement is a challenge for health care managers due to their responsibility to create an environment that will lead to quality improvement and safety of health services. New Health care Act (2005) has created a legal framework for defining quality indicators, and setting up various committees and bodies in order to improve the quality of health care. As the planning, management and quality control are the most important parameters of the health system development, health manager must be a leader with exceptional communication skills and able to apply his knowledge and skills in the management of resources. Top managers, central type and lower level managers must be the driving force of their institutions creating the basis for activities related to quality. They should have a proper education as well. New concept of management emphasizes people and their specialized knowledge. Past practice in Serbia did not show significant improvements in the management process through the knowledge and skills of managers, especially in terms of strategic decision-making in the operation and development of the health system.

Constrained by difficult economic situation, the health system in Serbia is facing a great challenge, and in order to overcome it and handle the gap between possibilities and expectations, it is necessary to implement economic reform of health care sector in Serbia, i.e. its decentralization, which implies improvements in providing health services while trying to find a model of financial sustainability of health care system in Serbia. One of the most essential impulses of society to its economic and general social development is the health of its population. In fact, in addition to being a social potential, health is to be considered as an economic potential of a country as well. The need to examine health from economic point of view, as well as in the sense of sustainable economic development, is gaining in presence in the newly made circumstances of an advancing economic crisis. There is an evident gap in the social community between the expectations of health care beneficiaries who are used to high-quality services with considerably subsidized health care and the new situation where health care institutions dispose of no funds to ensure the necessary prerequisites for providing health care, with an obvious weakening of social interlinkage and a fading trust in health care institutions. Any change in terms of scope, quality and prices of health care may and does runs into the wall of disapproval, even judgment; therefore, it is necessary to regulate and legally define health care quality standards in the health system of Serbia and thus precisely determine the quality of service provided and, at the same time, manner of payment, i.e. responsibility for the costs incurred. In order to reach a financially sustainable health care system in Serbia, it is necessary to analyze different models of funding, implement rationalization and reorganization of methods of funding and reexamine the health insurance models in Serbia. The priority concerning the health system financing is the selection of the most adequate method of raising sufficient funds. There are numerous factors which will determine our choice of a particular The address of the author: Ana Gavrilovic  anagavrilovic22@gmail.com Gavrilovic A. Health insurance system in Serbia MEST Journal Vol. 1 No. 2 pp. 114 – 126 Published: July 2013 MESTE | 115 model of health care system funding in Serbia, among which the following are most important: degree of socio-economic development of the country, fiscal capacity of the country, methods and efficiency of fund raising, support from the political system in its feasibility.

The Health Information System (HIS) in public healthcare services in Serbia was introduced in 2008, with the first comprehensive evaluation of its maturity conducted in 2021. Since then, several improvement initiatives have been implemented. This study aimed to assess the extent of HIS advancement between 2021 and 2024 and to identify both the desirable and realistic future maturity status. The maturity assessment of the Serbian HIS in 2024 was conducted using the same tool as in 2021: The Health Information Systems Stages of Continuous Improvement (SOCI), enabling direct comparison between the two periods. Progress was measured across five domains: Leadership and Governance, Management and Workforce, Information and Communication Technologies (ICT), Standards and Interoperability, and Data Quality and Use. These domains covered 13 components and 39 single subcomponents, with their maturity stages being assessed on a 5-point Likert scale on the basis of the opinions of key informants and documented through a desk review. Higher scores indicate a higher level of development. Along with a current assessment of maturity, key informants identified desired maturity levels for the future, using the same scale. Data were presented as comparisons in total scores per domain in 2024 versus 2021, for both current and projected statuses. Between 2021 and 2024, the overall maturity of the Serbian HIS improved by nearly 1 point (from 1.6/5 to 2.5/5). The same difference of 0.9 was observed between the current 2024 status and the future desired status (2.5 versus 3.4). The most notable improvements were observed in the HIS Strategic Plan under Leadership and Governance (2.5-point increase) and Business Continuity under ICT Infrastructure (2-point increase). The primary driver of progress over the past 3 years was the adoption of the national Program for Digitalization in the Health System of Serbia (eHealth Strategy) and its corresponding Action Plan, which served as a development blueprint. Substantial progress in HIS maturity was achieved between 2021 and 2024, driven by strong governmental commitment, international donor support, and the engagement of dedicated national professionals. If current momentum and resourcing are sustained, the projected maturity levels are likely to be attainable in the near future.

Introduction. The backbone of Serbian health system forms the public healthcare provider network with 355 institutions and around 112,000 employees, owned and controlled by the Ministry of Health and financed mainly by the Republican Health Insurance Fund. The law recognizes private practice that was not included, till recently, in the public funding scheme. New Health Insurance Law (2005) decreased the number of entitlements in the basic health service package. It abolished the right to dental health care for adults (exceptions are: children, older than 65, pregnant women and emergency cases) as well as the right to compensate travel expenses. The aim of this study was to evaluate the effects of health care system of the Republic of Serbia and indicate parameters that determine the state of health of the population, on the ground of data obtained by the Institute of Public Health of Serbia. Results. In the period 2004-2012, cardiovascular diseases represented the main cause of illness in Serbia (50%). In 2012 digestive system diseases were on the second place. Neoplasm and nervous system diseases were on the third place. From 2007 to 2012 there was slight decline in the birth rate and number of deaths, but the death rate increased from 13.9 to 14.2. Health care system in Serbia is funded through the combination of public finances and private contributions. Primary care is provided in 158 health care centres and health care stations, secondary and tertiary care services are offered in general hospitals, specialized hospitals, clinics, clinico-hospital centers and clinical centres. Conclusion. A significant but not satisfactory progress has been achieved in the field of health status indicators as the most important outcome of the final performance of the health system. The transition of public health care system in Serbia since the communist period to present and slow integration with European Union is unfinished process.

BackgroundThe government of Ethiopia has designed different initiatives for the Health Information Systems (HIS), including an Information Revolution (IR) transformation agenda by 2015. Various interventions and working documents have also been developed and implemented targeting the different aspects of the HIS program. However, there is no nationally designed accountability framework to govern HIS activities. Besides, how health institutions follow and monitor HIS activities is unknown. Therefore, this study aimed to assess the practice and barriers of HIS accountability framework at the selected public health institutions.MethodA descriptive qualitative study design was employed from June 05 to July 12, 2023. Purposively selected informants from public health institutions were recruited for key informant interviews. A prepared pilot-tested semi-structured interview guide was used. The conventional content approach was used to summarize and synthesize the information explored.FindingsThe study revealed that most respondents described the concept and advantages of the HIS accountability framework in different ways. The participants believed the HIS accountability framework would help to govern and manage behavioral-related HIS challenges. It was indicated that the framework will help to control the recurrence of HIS errors, enhance the commitment and adherence of health professionals, and improve data handover practice, data security and privacy, data quality, informed decision, and finality quality of care. Lack of national guidelines on the HIS accountability framework, the poor culture of accountability, multiple responsibilities and workload, high staff and leadership turnover, lack of motivation, and security problems were stated barriers to implementation of the HIS accountability framework. It was suggested to create a conducive work environment, engage health professionals and other actors during the intervention development, build the skills on HIS leadership, and have the national HIS accountability framework document to implement the intervention effectively.ConclusionsEven if there is a better understanding of the concept and advantages of the HIS accountability framework, its practice across the system is limited. It would be better to design the HIS accountability framework using a human-centered design/approach by engaging the key HIS actors and understanding their working environment.

Emergency psychiatric services in Serbia play a pivotal role in connecting patients who typically receive outpatient care with inpatient treatment options. The Serbian healthcare system provides 24-h emergency care through highly utilized, dedicated psychiatric emergency departments. This chapter presents the current landscape of the emergency mental health system in Serbia and describes the political and strategic undercurrents; this chapter also addresses education and training opportunities in the region for individuals who want to become emergency psychiatrists.

The foundational role of health information systems (HIS) in shaping decision-making dates back to the 19th century, driven by the pioneering efforts of John Snow and Florence Nightingale. In 1854, Snow meticulously mapped cholera cases in London, linking outbreaks to a contaminated water pump, which led to public health reforms and laid the foundation for modern epidemiology. During the Crimean War (1853–1856), Nightingale analyzed mortality data from field hospitals, using statistical methods and visualizations to present compelling evidence for sanitation reforms that drastically reduced death rates. These early examples underscore the transformative potential of systematically collected and aggregated data to drive health reforms and improve outcomes. In 2007, the World Health Organization (WHO) recognized health information system (HIS) as a critical building block for improving health systems. HIS serves as the backbone, supporting other essential components like service delivery, health workforce, access to essential medicines, health financing, and governance. In the Philippines, the promising benefits of electronic HIS began to take shape in the early 2000s with the implementation of the Department of Health’s (DOH) Rural Health Unit Information System (RHUMIS) and UP Manila’s Community Health Information Tracking System (CHITS). CHITS, in particular, has demonstrated the potential of electronic HIS—automating reports, improving data accuracy, and enabling public health facilities to track key indicators like vaccination rates and maternal health outcomes while integrating seamlessly into their workflows. In 2013, the establishment of the National eHealth Governance and the launch of the eHealth Strategic Framework and Plan marked a turning point, laying the groundwork for scaling electronic HIS nationwide. Progress was evident, with hundreds of PhilHealth-certified electronic medical record (EMR) providers now in place. Despite these advances, the promise of electronic HIS remains elusive, as resource constraints, uneven adoption, and technical gaps continue to hinder its full realization. The adoption of electronic HIS reflects a complex interplay of full digital transition, systemic barriers, and user engagement challenges. What Macabasag et al. describe as an “ambivalent transition” characterizes the shift from paperbased to electronic systems, where both coexist due to resource constraints, institutional pressures, and competing priorities. This partial implementation often relegates electronic HIS tasks to technologically adept workers or designated data encoders. PhilHealth compliance, while a key driver of electronic HIS adoption, primarily ties usage to mandatory reporting for claims reimbursement. However, inconsistencies in reimbursement processes limit the perceived benefits of integration, and broader systemic challenges such as limited infrastructure, workforce readiness, and interoperability further fragment efforts toward digitization. The COVID-19 pandemic exacerbated these systemic barriers while also emphasizing the need for digital health solutions. As Acacio-Claro et al. highlight, some facilities increased reliance on electronic HIS to manage operational demands, while others experienced reduced adoption as priorities shifted. Institutional gaps, such as the absence of strong governance frameworks and uneven technical infrastructure, combined with persistent interoperability challenges, have hindered the consistent use and utility of electronic HIS. User engagement, as De Mesa et al. emphasize, hinges on self-efficacy and user-oriented design. High intent-to-use among healthcare workers is more likely when electronic HIS is tailored to reduce workload and integrate seamlessly into existing workflows. Yet, barriers such as inadequate infrastructure, reliance on paper-based systems, and fragmented service delivery networks persist, particularly in resource-limited settings. These inefficiencies limit the potential for coordinated care and data sharing, and present significant challenges to achieving the full integration envisioned under the Universal Health Care (UHC) Law. Achieving an effective digital health ecosystem requires a concerted, multisectoral effort, as no single entity can address the inherent complexities of health systems alone. The Asia eHealth Information Network (AeHIN) introduced the Mind the GAPS (Governance, Architecture, Program Management, and Standards) Framework as key pillars for building integrated and interoperable systems. Marcelo emphasizes that through strategic governance, shared interoperability blueprints, and robust program management, governments can establish digital health infrastructures that meaningfully improve service delivery and public health outcomes. The DOH must take the lead in coordinating sectors such as Information Technology (IT), academe, finance, and development partners to ensure alignment and effectiveness. By harnessing the collective expertise of all sectors, the Philippines can turn the aspirations of the UHC Law into a reality—creating a digital health ecosystem that not only overcomes systemic barriers but also transforms healthcare delivery for generations to come.

The digital transformation of the healthcare system in Serbia brings numerous advantages, including more effective communication between patients and healthcare workers, better access to healthcare information and improvement of preventive and therapeutic services. However, the level of digital health literacy among primary healthcare users remains the key challenge. This paper highlighted the most important results of studies conducted in the Mačva District, which, after translation, cultural adaptation and validation of the eHealth Literacy Questionnaire (eHLQ), also examined the level of digital health literacy of users of primary health care services in the Mačva District. The results highlight the need for education of different demographic groups, especially senior and less educated users, as well as users from rural areas. Finally, recommendations are given for the improvement of digital health literacy so as to ensure equitable use of digital health services.

Background: Many mental disorders require hospital care (HC) and long-term care (LTC), while in their stable presentation, they can be treated in outpatient care (OC) settings. In light of the Serbian system's transition towards community-based mental health care, this study aimed to determine the extent of the system's burden by schizophrenia, depression and psychoses, which require hospitalization and how LTC and to what extent OC services relieve them. Methods and Objectives: We used data on the number of patients, hospital days (HD) and the episodes of hospital treatment, aggregated based on the diagnostic groups (DGs): F23-29: Psychoses, F20-21: Schizophrenia and F32-33: Depression, according to the International Classification of Diseases, Tenth Revision, for 2021-2023 in Serbian hospitals. Results: In the 2021-2023 period, among patients with psychoses, an increasing number of LTC days spent and its share in the total HD for the specified DG [(2021, 2022, 2023: 21.1; 22.0; 23.2), %] was observed. Patients with schizophrenia spent the highest number of HDs in the LTC setting, with a growing share of the total time spent in LTC [(2021, 2022, 2023: 17.3; 18.7; 18,5), %]. Compared to psychoses and schizophrenia, patients with depression spent a higher proportion of days in OC settings, with an increase in the observed period [(2021, 2022, 2023: 16.1; 18.3; 18.6), %]. At the same time, patients with depression had a higher number of treatment episodes in the OC per person than other DGs, with an annual increase (p<0.05). Conclusions: To be able to more efficiently monitor and more clearly interpret the performance of the mental health care system in Serbia, more detailed analyses of individual data are necessary, as well as the implementation of new indicators that would monitor the relationship between interventions and health outcomes at the individual and population level.

This article presents results from a study on the use and appropriation of information and communication technologies (ICT) in Mozambique with a focus on the health sector. The three provinces of Gaza, Inhambane and Niassa were surveyed and two questionnaires addressing 1) computer users and their ability to manage ICT, and 2) health workers and their handling of health information, were used. Based on this study appropriate strategies for developing an ICT‐infrastructure with the needs of the health sector as points of departure are discussed. The study is born out of a program to strengthen and further develop the health information and management systems at district and provincial levels as part of a process to support decentralisation of the health system in Mozambique. The study shows that computers and Internet are rapidly being spread to the provincial capitals and major districts in Mozambique. A main problem identified is the lack of ICT‐skills and education and poorly developed infrastructure and networks of support. There are very few formal ICT companies providing hardware, and even less, software support. Maintenance and learning about ICT are to a large extent going on within informal networks of computer users in the provinces.A main finding in this study is that development of ICT capacity and information systems at district and provincial levels in Mozambique needs to be an integrated effort across sectors. A district health information system cannot be developed in a void.A general recommendation is to develop educational programmes ranging from training of ICT entrepreneurs and health workers and managers, to Masters and PhD programmes in ICT and health information systems. A specific recommendation related to health information systems development is to focus on the district level and to develop a strategy which encompasses and integrates all districts, both the advanced districts with computers and the majority of the districts where there are no computers.

Aim/Purpose: This study analyzes health professionals’ information security behavior (ISB) as health information system (HIS) users concerning associated information security controls and risks established in a public hospital. This work measures ISB using a complete measuring scale and explains the relevant influential factors from the perspectives of Protection Motivation Theory (PMT) and General Deterrence Theory (GDT) Background: Internal users are the primary source of security concerns in hospitals, with malware and social engineering becoming common attack vectors in the health industry. This study focuses on HIS user behavior in developing countries with limited information security policies and resources. Methodology: The research was carried out in three stages. First, a semi-structured interview was conducted with three hospital administrators in charge of HIS implementation to investigate information security controls and threats. Second, a survey of 144 HIS users to determine ISB based on hospital security risk. Third, a semi-structured interview was conducted with 11 HIS users to discuss the elements influencing behavior and current information security implementation. Contribution: This study contributes to ISB practices in hospitals. It discusses how HIS managers could build information security programs to enhance health professionals’ behavior by considering PMT and GDT elements. Findings: According to the findings of this study, the hospital has implemented particular information security management system (ISMS) controls based on international standards, but there is still room for improvement. Insiders are the most prevalent information security dangers discovered, with certain working practices requiring HIS users to disclose passwords with others. The top three most common ISBs HIS users practice include appropriately disposing of printouts, validating link sources, and using a password to unlock the device. Meanwhile, the top three least commonly seen ISBs include transferring sensitive information online, leaving a password in an unsupervised area, and revealing sensitive information via social media. Recommendations for Practitioners: Hospital managers should create work practices that align with information security requirements. HIS managers should provide incentives to improve workers’ perceptions of the benefit of robust information security measures. Recommendation for Researchers: This study suggests more research into the components that influence ISB utilizing diverse theoretical foundations such as Regulatory Focus Theory to compare preventive and promotion motivation to enhance ISB. Impact on Society: This study can potentially improve information security in the healthcare industry, which has substantial risks to human life but still lags behind other vital sector implementations. Future Research: Future research could look into the best content and format for an information security education and training program to promote the behaviors of healthcare professionals that need to be improved based on this ISB measurement and other influential factors.

BackgroundHealth information systems (HIS) are meant to support decision‐making at all levels of the system, including frontline health workers. In field studies in Côte d’Ivoire, Mozambique and Nigeria, we observed health workers' interactions with the HIS and identified twelve decision‐making components of HIS. The objective of this framework synthesis is to portray these components in HIS research, in order to inform the ideation of a paper‐based HIS intervention (PHISICC).MethodsWe searched studies in the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Epistemonikos, Medline, in‐Process on the Ovid platform, OpenGrey, PDQ Evidence (“pretty darnd quick” Evidence), the World Health Organization (WHO) Global Health Library and included studies focussing on HIS interventions, data quality, information support tools and data use for decision‐making in the context of the governmental health care sector. We assessed the methodological quality of studies using the Critical Appraisal Skills Programme tool. We synthesised the findings based on the decision‐making components of HIS and thematic areas.ResultsThe search identified 6784 studies; 50 were included. Most of the 50 studies had quality concerns. All studies included at least one of the decision‐making components: the most prominent were the technical aspects of ‘recording’ and ‘reporting’. Data use for decision‐making was much less represented.ConclusionHIS research focuses on the more technical aspects of HIS. Further research on HIS, given the strong push towards HIS digitalisation, should consider putting at the centre the human experience of decision‐making and data use, in order to make HIS relevant for quality of care.

Globally, health information system (HIS) development projects face challenges regarding technology infrastructure, financing, user resistance, and interoperability. While these challenges are well-described in literature, most studies on HIS digitalization focus on the development of national and hospital HISs, with little focus on HISs in primary care. We described the HISs of two primary care clinics in Manila, Philippines in terms of data management procedures, governance, training and equipment, information culture, and health worker data skills, and investigated health workers' experiences during digitalization.This convergent mixed-methods descriptive study included two clinics: a nongovernmental organization (NGO)-operated clinic and a government-operated public health center (PHC). We surveyed eight health workers in the NGO clinic and six in PHC using the Performance of Routine Information System Management (PRISM) Community HIS evaluation tools from the World Health Organization and MEASURE Evaluation and conducted in-depth interviews among the same participants to explore their HIS experiences.Respondents in both clinics provided low scores on governance, indicating deficiencies in HIS strategy and documentation. PHC scored higher on data management, training, and equipment compared with the NGO clinic, whereas information culture scores were similar. Survey results reflected differences in IT infrastructure and services, stemming from PHC's larger size and funding. Interviews corroborated the survey results, highlighting barriers such as inadequate training and resources and the critical roles of internal communication and joint data stewardship, as described by the Filipino term "damayan," which means working together in times of adversity. Additionally, interviews revealed expected benefits from digitalization, negative impact on workflow, and limited communication with external organizations.The findings highlight critical areas for enhancing HIS implementation and digitalization in primary care clinics in the Philippines. Addressing governance gaps, resource deficiencies, and communication barriers can improve HIS performance and help build digital resilience.