title: Multimodal assessment of the primary healthcare system of Serbia: a model for evaluating post-conflict health systems.
abstract: BACKGROUND
  Conflicts, social unrest, and disasters can significantly affect the ability of a healthcare system to provide for the needs of its citizens. The collapse of the primary healthcare system in Serbia is a model of the effects that civil unrest can have on the health of a population. However, with improving social and political conditions, focus now can be turned towards the greatly needed development and reorganization of the primary healthcare system in Serbia. Due to the complexity of health-system reform in the post-conflict/post-disaster setting, attempts to restructure health services are fraught with pitfalls that often are unanticipated because of inadequate preliminary assessments. A multimodal assessment involving quantitative and qualitative methodologies may provide a more robust mechanism to identify key programmatic priorities and critical barriers for appropriate and sustainable health-system interventions. The purpose of this study is to describe a multimodal assessment using primary healthcare in post-conflict Serbia as a model.
  
  
  METHODS
  Integrated quantitative and qualitative methodologies--system characterization and observation, focus group discussions, free-response questionnaires, and Q-methodology--were used to identify needs, problems, and potential barriers to primary healthcare development in Serbia. Participants included primary healthcare providers and administrators from 13 institutions throughout Belgrade.
  
  
  RESULTS
  Demographic data indicate a well-established infrastructure of primary health centers and stations. However, focus group discussions and free-response questionnaires reveal significant impediments to delivery of care: (1) Inadequate equipment, supplies, and medications; (2) Poor financial investment; (3) Discouraging worker salaries; (4) Few opportunities for professional development; and (5) Little emphasis on or respect for primary healthcare. Q-methodology of provider perceptions and opinions supports these concerns, shows remarkable consensus among participants, and provides further insights toward system development by grouping respondents into distinctive types.
  
  
  CONCLUSIONS
  This study identified the critical needs and barriers to development of primary healthcare in Serbia. This combined methodology may serve as a model for future health system assessments in the post-conflict and post-disaster settings.
authors.affiliation: The Center for International Emergency, Disaster and Refugee Studies, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA. bnelson@jhsph.edu
authors.forename: Brett D
authors.initials: BD
authors.lastname: Nelson
authors.forename: Snezana
authors.initials: S
authors.lastname: Simic
authors.forename: Lauren
authors.initials: L
authors.lastname: Beste
authors.forename: Dejana
authors.initials: D
authors.lastname: Vukovic
authors.forename: Vesna
authors.initials: V
authors.lastname: Bjegovic
authors.forename: Michael J
authors.initials: MJ
authors.lastname: VanRooyen
mesh_terms: D003695:Delivery of Health Care / Q000592:standards / Q000639:trends; D005260:Female; D017144:Focus Groups; D018166:Health Care Reform; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D020380:Needs Assessment; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care / Q000592:standards* / Q000639:trends; D014857:Warfare; D015022:Yugoslavia