Prof. Aneta Boskovic, MD, MSc, PhD, FESC, internist and cardiologist
National CVD Prevention Coordinator for Montenegro and President of Montenegro Society of Cardiology
This report was prepared by Professor Boskovic with the kind assistance (on the CR chapter) of Marina Delic, MD, specialist in physical medicine and rehabilitation.
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Baseline information about Montenegro
Montenegro is a Mediterranean country in Southeast Europe. It's proclaimed its new constitution on 22 October 2007. The President of Montenegro is the head of state, elected for a period of five years through direct elections. The government is headed by the Prime Minister, and consists of the deputy prime ministers as well as ministers. The Parliament of Montenegro is a unicameral legislative body. Its main and largest city is Podgorica, and Cetinje was declared Old Royal Capital.
Read more about Montenegro and its biodiversity.
The health care system in Montenegro is publicly financed by the National Health Insurance Fund and health service is accessible to all inhabitants. Montenegro is divided into 3 health care regions: the biggest is central region, Podgorica with primary, secondary and tertiary level of health care. All municipalities have primary health care centres with family doctors, paediatricians and gynaecologists. Some of primary health care centres can provide additional services.
There is one university hospital in Montenegro, in the capital Podgorica providing tertiary level of health care for the whole country. There are a few private hospitals, much more out-patients private institutions. The government is aware that cardiovascular diseases (CVD) are the leading cause of morbidity and mortality but CVD prevention is still not a priority for the government.
In 2014, chronic non-communicable diseases accounted for more than 90% of all causes of death in Montenegro. CVD accounted for more than half of all deaths, 61%. There is one percutaneous coronary intervention (PCI) centre (1.61/million inhabitants) in the country, and it is 24/7 available for primary PCI in ST-Elevation Myocardial Infarction (STEMI).
In 2008, one third of the adult population smoked in Montenegro. About 20% of the high school population consumes tobacco. Among adults 41.7% had hypertension, 40.0% had hypercholesterolemia, 52.7% had hypertriglyceridemia, 15.1% of adults were obese and 40.0% were overweight. Only a small percentage, 11.5% regularly performed physical activity.
A study shows that among the adult population there is insufficient consumption of fresh vegetables and fruits: 47.4% of adults consume fresh vegetables daily and 39.4% of fresh fruit. A similar situation exists among young people: 41.5% consume daily fresh vegetables and 33.4% fresh fruit.In contrast, the daily consumption of sweets and sweet soft drinks is markedly high.
Family doctors and cardiologists are the basis of the Montenegrin CVD preventive strategies. They are all involved in prevention programmes in everyday practice. Family doctors should be more actively involved, but they also need better education about prevention and treatment of cardiovascular risk factors and morbidities. They should even be offered more time dedicated to prevention in daily practice.
There are some initiatives of the Ministry of Health and the National Public Health Institute in CVD prevention. Even the Montenegro Society of Cardiology carries out activities and campaigns to prevent CVD such as education for family doctors, the promotion of healthy lifestyle with the help of media for the general population and the campaign for the World Heart Day. National guidelines in CVD prevention were published in 2012, but as they have not been updated, clinicians tend to use the European Guidelines on CVD Prevention in Clinical Pracitice.
The Government of Montenegro adopted a Strategy for the prevention and control of chronic non-communicable diseases in 2008. The Health Care Improvement Project in Montenegro, funded by the World Bank, includes the component of improving the quality of health care, as well as the development and implementation of clinical guidelines and protocols in Montenegro.
The tobacco control law was amended to ensure compliance with the EU standards on health warning labels on packaging. However, the law on the use of tobacco in public places, although adopted, is not fully respected. Smoking is prohibited in work areas, while in most restaurants there is a part where smoking is allowed.
The Montenegro Society of Cardiology carries out the promotion of healthy lifestyles and participates in various campaigns. There were several national projects in the area of prevention of cardiovascular diseases approved by the Ministry of Science and the Ministry of Health of Montenegro. Cardiovascular prevention is part of student education in internal medicine and family medicine and in post-graduate training in family medicine at the Medical Faculty of the National University in Podgorica.
The Health Insurance Fund of Montenegro approves in-patient cardiac rehabilitation for patients after acute myocardial infarction, coronary artery bypass surgery (CABG), valvular surgery and after graft aorta interposition. For all of the above mentioned conditions, the 3-week rehabilitation is approved within 6 months after hospital treatment.
There are two highly specialised institutions for in-patient cardiac rehabilitation: the Institute “Dr Simo Milosevic” in Igalo, as a tertiary rehabilitation institution annually through the Health Insurance Fund, receives about 700 patients on cardiac rehabilitation from all regions of Montenegro. The other institution is the private Hospital Meljine.
The costs of three weeks rehabilitation are completely covered by Health Insurance Fund for patients with acute myocardial infarction, for patients older than 65 years, for those who are unemployed and for those who are recipients of social assistance. For the remaining patients 40% of the costs has to be paid out of the pocket.
Cardiac rehabilitation is carried out in three stages:
- The first phase is carried out during the hospital stay where all patients are involved.
- In the second phase which follows immediately or a few weeks after the first phase the patient is referred to the institution for stationary (in-patient) cardiac rehabilitation. This multidisciplinary rehabilitation phase lasts three weeks and enrols about 70% of the eligible patients.
- The best results are achieved if the third phase, a long-term programme, is commenced directly after stationary rehabilitation. The quality of cardiac rehabilitation in Montenegro is considered to be quite high.
Aims for the future
Health promotion and prevention of CVD still has a middle priority. More complete data from acute coronary syndrome and cerebrovascular disease registers are expected in the near future, as well as indicators that will be generated based on these registers.
Possibilities for success depend on a broad national awareness of cardiovascular preventative programs and people’s health education which should be significantly improved. For this, it needs help and support from the entire community.
On the population level strict compliance with the law on prohibiting of smoking in public places is needed.
In 2017, the Government established the National Council for the Coordination and Prevention of Chronic Non-communicable Diseases and this highlighted the need to increase taxes on tobacco and sweet soft drinks, which could contribute to reduced smoking and obesity.
With the increasing contribution of obesity and diabetes mellitus to the national risk factor burden the Montenegro Society of Cardiology aims to continue promoting a healthy lifestyle, especially regarding physical activity and healthy food habits.
Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.