Inpatient Detoxification Procedure and Facilities: Financing Considerations from an Eastern European Perspective 

Eastern Europe and the Balkans region report high rates of alcohol abuse and addiction (OECD, 2009). Alcohol detoxification procedures in the countries of the European Union (EU) tend to be conducted at the primary care level or at specialized units associated with the psychiatric clinics. These facilities provide medical treatment to help achieve and maintain abstinence, often through initial 24-h psychiatric supervision. In the EU, these patients often already have an awareness of the reality of addiction and show a will to decisively tackle it (Hayashida, 1998). By visiting these facilities, they attempt and often succeed in preventing an abstinence crisis when they end a period of heavy drinking. Treatment protocols are intended to reduce and eliminate most symptoms of withdrawal (Beshai, 1990).

Serbian everyday experience, however, seems to be radically different from that of the EU. At first, we point out that we are observing a typical middle-income Eastern European transitional economy, in a society that is primarily Caucasian, secular, and with a low fertility rate, and is in many ways similar to Western European countries (OECD, 2009). Nevertheless, the Serbian economy has suffered from a high rate of unemployment and a declining standard of living since the onset of the current recession, both of which have proved to be significantly correlated with the country's rate of alcohol consumption (Ettner, 1997).

To take an example, The University Clinical Center Kragujevac is the oldest hospital in Serbia, located in the heart of the country. Intoxicated patients are brought to the psychiatric clinic either after being arrested by public security services on civil order violation charges, as suspected traffic accident perpetrators, or after being found in a state of severe alcoholic intoxication in a public place. Another possible scenario is of the patients to whom serious injuries have been ruled out but who are still conscious and are transported by emergency care vehicles. In cases where a mental disturbance with life-threatening symptoms is observed, the patient will be taken to the Emergency Medicine Clinic. It is important to emphasize that there is no voluntary treatment. In terms of International Classification of Disease (ICD-10) codes they are categorized as an F-10.0–F-10.4 diagnosis—acute drinking disorder—and most of them are considered to be at the ‘heavy drinker’ stage of dependency disorder evolution (World Health Organization, 2007). Cases like those described above are usually treated for no longer than 24 h based on their own legal expression of will to cease further hospitalization.

During 2009, at The Psychiatry Clinic of The University Clinical Center, Kragujevac, 379 people had been detoxified (349 males, 30 females) 952 times. After estimating detoxification-related costs, according to internationally recognized guidelines (Single et al., 2003), we concluded that the overall costs in a given year for these detoxification treatments amount to 11,681 € towards medical and 11,028 € towards law enforcement expenses. On the basis of these data and national statistics on the prevalence of heavy drinking with the greatest need for detoxification, we estimate that our country needs at least 9, 784, 011 € to cover only this part of the overall direct medical expenses intended for this particular purpose.

There is a question over who should finance this. In practice, these costs are never charged to the patient. That could be considered a relic of the so-called golden era of socialist public health insurance, which encompassed all citizens and covered all expenses that could accrue. While being an ideal ethical approach, this turns out  unsustainable in times of harsh ‘market reality’ with the economic changes of our time. To this day, neither psychiatric clinics nor our health-care system exhibits an efficient mechanism to charge for these services. Clinical bills are commonly not being delivered to the patients’ home address because it is still not the common practice in most eastern European countries.

There is also another obstacle. Many of the long-term admitted and treated cases are recipients of the so-called obligatory alcoholism treatment verdict. The typical social pattern thereof is that of a spouse accused of domestic violence, convicted and sentenced to a course of obligatory treatment. In these numerous cases, the Judicial Ministry of The Republic of Serbia does not consider itself responsible for the expenses of treatment. According to our Law, it instead falls within the purview of The Republic Health Insurance Fund by which most of the overall health-care sector is financed.

The proposed solution for resolving this issue would be to create a financial and infrastructural basis for the funding of specialized detoxification facilities associated with psychiatric hospitals in a manner similar to that already used in the EU. These facilities would be funded partially by detoxification charges paid by the patients, while the remainder of their costs would be covered by the republican health insurance fund's resources. More complicated cases, such as those with severe withdrawal symptoms such as convulsions, or significant co-morbidities, should be treated at appropriate clinics. The Ministry of Health would have 10,000,000 € to allocate towards these demanding areas of health care.

Funding

The authors would like to express their gratitude to the Ministry of Science and Technological Development of the Republic of Serbia for Grant N°175014, out of which the clinical trial that served as the basis for this Letter to the Editor was partially financed.