The “Integrity assessment of the health system in Montenegro” research to help in stamping out corruption

In order to assess the health system integrity and to analyse citizens’ satisfaction with the reform of the primary health care, the study “Integrity Assessment of the Health System in Montenegro” was conducted by the CEED Consulting of Podgorica for the needs of the Ministry of Health, the United Nations Development Programme (UNDP) and the World Health Organization in Montenegro. Special focus was dedicated to informal payments as a form of corruption in the health system.

The research reveals that informal payments and gifts are common – 55.7% out of 3.000 respondents stated that they made informal payments or gave gifts, which makes around 8% of the gross average salary (or 12,5% of the net average salary) in 2010 in Montenegro. These payments were made in addition to regular contributions amounting to 8.5% of the gross average salary, which each employed Montenegrin citizen is already paying to the health care system. Among health care workers, 49% confirmed that they received informal payments from their patients. In the majority of cases, patients or their family members who gave gifts/money were hospitalized to give birth (36,8%) or to undergo a surgery (31,7%). In particular, payments and gifts are frequently made to doctors who treat the patient (26%), surgeons (24%) nurses (21%) and midwives (21%) and in 1% to anesthesiologists.

The most common reason given by patients for the informal payments was a feeling of gratitude (43%) and when asked to specify what they expected in return after they gave gifts/money, majority of the respondents stated that it was their will to give (42,2%)  and that they did not expect anything in return. However, it is notable that those respondents who did expect something in return specified the following: more attention and information from their doctors, as well as prompter clinical service. Yet even so, every fifth patient complained about the lack of motivation among doctors, and 12% had doubts about the doctor’s adequate qualifications and training, and 14% complained about the queues and waiting time for medical check-ups, while 12% complained about the lack of medicines in pharmacies.

Those who most often gave gifts were inhabitants of the central part of the country,women, entrepreneurs, people with secondary and higher education degrees, and those with monthly income higher than €500. The research also reveals that 7% of patients feel negative impacts due to the neglect and mistakes of health workers – most often this referred to wrong diagnoses, wrong therapy and long waiting for medical check-up due to which their health condition deteriorated. As defects of the health system reform, they most often reported inaccessibility of doctors for scheduling check-ups. One of the respondents said: “Every Monday I schedule a meeting with my doctor because I do not know when I will get ill.” Additionally, they are not pleased with the heavy workload of doctors and hindered access to specialists, while as advantages they reported less time spent on waiting in queues, better monitoring of patients and scheduling in advance. Patients who most often decide to go for treatments in private practice are the ones who identified the following shortcomings of the health system reform: availability of different levels of the health care requires more direct expense/payments, rapid and routinely performed check-ups, more difficult access to specialists and the way of selecting doctors. The most common reason that patients listed for giving additional payments for the mentioned services that influence reduction of the monthly income was – receiving the service when they needed it (30%). Almost half of the employees in the health system admitted that they received gifts or money from patients, stating that doctors expect presents in envelopes, while some of them send signals by their behavior that they should be given a gift. Furthermore, among health workers, 76% believe that some sort of compensation is acceptable because “patients give it as a present” or because “patients get insulted if you refuse some small thing as a present”. Health workers believe their income level is the biggest problem in their sector, but they also quote insufficiently equipped institutions and lack of motivation of staff as reasons.

At the media conference, Minister of Health in the Government of Montenegro Dr. Miodrag Radunović said he was satisfied with the results of the research. “Unlike all previously conducted researches in this area, this one provides us with a comprehensive assessment of the degree of corruption. This will help us better define and undertake measures and activities aimed at stamping out the corruption, with maximum involvement of all stakeholders in the health system,” Minister Radunović pointed out. He explained that everything that a patient leaves in a health institution – money, presents, a bottle of spirits, juice, fruit, coffee… falls under the term ‘informal payments’. “A precondition for efficient elimination of corruption in the health system is upgrading of the whole system and reaching the next level of development. That is one of the reasons we were conducting a reform of the health system over the past several years. We are well aware that that is a long and demanding job, but as a final result we will certainly have a system that will be more resistant to all forms of corruption,” said Minister Radunović.

Alexander Avanessov, UN Resident Coordinator/UNDP Resident Representative to Montenegro said that with this Integrity Assessment the Ministry was now furnished with baseline data on various aspects of the health care system functioning and occurrence and amounts of informal payments, which would help further support the efforts of the Ministry of Health and other relevant institutions in Montenegro to elaborate and implement effective counter-measures. “However, we must not remain complacent; the momentum of the health reform needs to be sustained in order to address the deficiencies underscored in the Integrity Assessment. The recommendations that this research produced offer a sound basis for stepping up the efforts in this area. Hence, it is with great eagerness that we await future activities in the field where it’s often a question of life and death, where corruption, if present, can have a corrosive impact on the system, denying equal access to the basic services of the health care system,” Mr. Avanessov emphasized.

Head of the WHO in Montenegro, Ms. Mina Brajović said that corruption was a challenge for that sector because it jeopardized health care. “Corruption in the health system exists on all levels – starting from construction works in the institutions, procurement of equipment, relations with the pharmaceutical industry up to the provision of health services. Informal payments in this sector jeopardize reform processes and endanger the trust in the institutions. Informal payments occur if the funds acquired for financing health care and protection are not sufficient. But, we also have to have in mind a very important social and cultural factor – i.e. our predominant tradition of expressing gratitude by treating,” Ms. Brajović concluded.

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The aim of the “Integrity Assessment of the Health System in Montenegro” was to analyze the functioning of the system as a whole, as well as to analyze citizens’ satisfaction with the reform of the primary health care. Special focus was dedicated to informal payments for health care, as one of the forms of corruption in health system. Informal payments jeopardize equal access to quality health care, which is one of the basic postulates in organization and functioning of a modern health system.

With an aim to get a more detailed insight and understanding of the respondents’ attitudes and opinions ‘face-to-face’ research was conducted using a sample of 3000 respondents among hospital patients, 1159 patients in primary health care and 301 health workers. Anonymity was guaranteed which certainly contributed to acquiring more sincere and correct data processed in this Report.

The research was conducted within the framework of the UNDP Programme for the fight against corruption that aims to contribute to the efficient implementation of anti-corruption initiatives, and in that way to improve the democratic governance in Montenegro. Within this Programme UNDP has, in cooperation with the Directorate for Anti-corruption Initiative, conducted three capacity and integrity researches – in domains of judiciary, local governance and public administration.


The “Integrity Assessment of the Health System in Montenegro” Research (coming soon)
Istraživanje „Ocjena integriteta zdravstvenog sistema u Crnoj Gori“
Prezentacija glavnih nalaza istraživanja „Ocjena integriteta zdravstvenog sistema u Crnoj Gori“