What are the problems of the local legal framework when it comes to the transplantation process? What would the changes in the law bring? Why are the citizens of Serbia in the most unfavorable position in the region when it comes to going abroad for transplants? What can we learn from the more than successful examples of Croatia and Spain
On the waiting list for organ transplantation there are currently around 1800 in Serbia patients. Each of them lives in constant uncertainty as to whether and when they will get a new chance at life. Although the Law on Transplantation of Human Organs from 2018 foresees a model of presumed consent - which means that all adult citizens are considered potential donors, unless they have expressly opposed it - in practice there are no well-founded and clear operational procedures for this.
Serbia still does not have a functional registry where citizens could officially express their position - whether they want to be donors or not. The registry of non-donors is not digitized, it is not available to hospitals in real time and there is no simple mechanism for electronic reporting. Therefore, the decision to donate is often made in demanding and difficult circumstances. Medical personnel do not have access to the necessary information, and families often face this issue for the first time in moments of personal trauma, without reliable insight into the will of the deceased person. In such a system, potential donations are lost, and the opportunity to save someone's life remains untapped.
And when it comes to the mentioned principle of presumed consent, in 2021 the Constitutional Court of Serbia challenged a key provision of the law which provided that organs from a deceased person can be taken for transplantation if the adult donor did not object to it verbally or in writing before death, and if a family member did not expressly object to it at the time of death. The Constitutional Court judged that this provision is not in accordance with the Constitution of the Republic of Serbia, because the role of the family in the process of giving or withholding consent is not clearly prescribed, nor does it provide sufficient guarantees that the will of the citizens will be respected and applied in practice. Despite that verdict, to date no amendments to the law have been adopted that would resolve the disputed points, which is why at this moment in Serbia there is actually no precise and applicable legal framework that regulates the transplantation process.
PENDING CHANGES
Ivana Jović from the Patient Association "Donation is heroism" tells "Vreme" that Serbian citizens still do not have the opportunity to formally declare whether they want to be organ donors. As he points out, the draft amendment to the Law already exists and was prepared in cooperation with experts in medical law and human rights - Professor Jelena Simić from the Law Faculty of Union University, Dr. Marta Sjeničić from the Institute of Social Sciences and Vladica Ilić from the Belgrade Center for Human Rights. The proposal envisages that citizens can clearly and simply express their will - whether they want their organs to be donated or explicitly reject it - through e-Administration, at a doctor's or notary's office. In the event that such a statement does not exist, the decision would be made by the family, and this approach would be in accordance with the decision of the Constitutional Court, as well as with international and European standards.
"Just as every adult has the right to decide who will inherit his property, he must also have the right to decide independently whether after his death his organs can be used to treat other people," adds Jović.
The expert team that worked on the proposal is part of the working group of the Ministry of Health, and the text of the draft was presented to the Ministry. Although Minister Zlatibor Lončar expressed his support for the initiative last year and stated that transplantation is one of the priorities, after the formation of the new Government the Working Group still did not continue its work.
Jović points out that the proposals are also based on research conducted by IPSOS for the association, according to which as many as 80 percent of Serbian citizens support organ donation, while half would register in the Registry if it existed. Citizens cite mistrust in the health system as the key reason for refusing the donation. Also, the draft law includes the extension of the right to transplant from living donors, because now the law allows donation only between the closest relatives, which, he says, forces many patients to go abroad and pay for the transplant from their own budget.
TRANSPLANTS ABROAD
It is important to mention that Serbia previously tried to establish cooperation with Italy in the field of organ transplantation, but the agreement was not implemented. One of the main reasons is the lack of a functional system and registry of donors in Serbia, which made it difficult to establish trust and standardized cooperation with Italian partners. Due to the long waiting lists and the lack of donors in Serbia, an increasing number of patients decide to seek salvation abroad, where in recent years Belarus stands out. As "Vreme" previously wrote, in 2024, 12 patients from Serbia underwent a kidney transplant in Minsk, at their own expense, while in the same year only 17 kidney transplants were performed in Serbia.
Speaking about the departure of patients from Serbia for transplants abroad, Jović points out that the citizens of Serbia are in the most unfavorable position in the region. Unlike Republika Srpska and Montenegro, which finance their citizens' transplants in Belarus, Serbia does not provide such support.
"Several years ago, our association submitted an initiative to the Ministry of Health to enable the reimbursement of transplant costs in Belarus, at least until the domestic system is stabilized. We never received an official answer, but we were verbally explained that state support is impossible due to the sanctions imposed on Belarus," she says.
He adds that it remains unclear how other countries in the region have successfully overcome these obstacles, while patients from Serbia still depend exclusively on humanitarian actions. "Our patients have to provide and pay for everything themselves - from transportation, to preparations and the operation itself. Minsk is 1500 kilometers away, and that dream of a new life is financed exclusively by good people who donate funds," says Jović.
CROATIAN AND SPANISH MODEL
While patients in Serbia still face a dysfunctional transplant system and are increasingly forced to seek help abroad, some countries have managed to develop sustainable models that enable timely, organized and transparent transplantation. Such examples exist in the immediate environment, but also in countries that have had stable and successful systems for decades.
Croatia stands out as one of the European countries with the most efficient transplant system, and its model is often used as an example of good practice. The national law on organ transplantation is based on the principle of presumed consent, according to which every citizen is treated as a potential donor, unless he has explicitly declared during his lifetime that he does not want to do so. Such statements are recorded in the Registry of Non-Providers maintained by the Ministry of Health, and the system is digitized and functional.
A significant contribution to the success of this model also came from the social sphere, primarily through the support of the Catholic Church, which has a strong influence in Croatian public life. At the beginning of the 2000s, the Croatian Bishops' Conference clearly announced that organ donation is a morally acceptable act and an expression of Christian love for one's neighbor, thus removing one of the most common ethical and religious doubts among citizens.
At the organizational level, a central role is played by the Coordination for Transplantation at the Ministry of Health, which manages all applications of potential donors, manages waiting lists and ensures operational connection with international partners. Since 2007, Croatia has been a full member of the Eurotransplant network, which allows its patients faster and fairer access to organs based on medical compatibility, not just national capacities.
Comparing data from the region, Jović points to facts that indicate the need to improve the system in Serbia. "Until August of last year, in Croatia, which has a much smaller population, 90 consents for organ donation were requested. In Serbia, in the same period, only 30", he states. He adds that behind those numbers are hidden missed opportunities for a significant number of people waiting for a transplant, including thirty children on a chronic dialysis program.
The result of the organized system in Croatia is an extremely high number of donors, which ranks it among the leading European countries in the field of transplantation, right next to Spain, which has been considered a global leader for decades.
According to the latest data from the Spanish National Organization for Transplantation (ONT), in 2024, 6464 organ transplants were performed in Spain, which represents an increase of 10 percent compared to the previous year. Such results are not only the result of the legal framework, but consistent institutional practice, continuous investment in professional staff and systematically built trust between citizens and health institutions. There, too, the presumed consent model is at work, and the National Transplantation Organization has a central role in the planning, supervision and operational coordination of the entire system of organ donation and transplantation. One of the key elements of the success of that model is the presence of specialized hospital donation coordinators, mostly doctors with experience in intensive care, who are located in almost all major hospitals. They are in charge of identifying potential donors, conducting discussions with the family, logistics, as well as the entire flow of the donation process, with careful attention to the medical and emotional aspects of the situation.
It is interesting that Spain, despite one of the highest donation rates in the world, does not maintain a centralized register of citizens who wish to be donors. The interpretation of the law goes in the direction that the existence of such a register would contradict the logic of presumed consent. Instead, the system clearly allows every citizen to express their disagreement with the donation, and such will is always and without exception respected.
This approach is often described as the "Spanish model", whose success lies not solely in the legislative framework, but in its consistent and carefully organized implementation. Through continuous education, institutional connection and highly professional staff, Spain has developed a system that works in practice, not just on paper. The trust of citizens, the presence of trained teams and clearly defined protocols proved to be crucial factors in the development of one of the most efficient transplant systems in the world.
And while in Spain the strength of the system is reflected in the internal structure and professional culture, and in Croatia in efficient integration with domestic legislation and social support, the additional quality of the countries in Europe is the connection with the wider European framework. One of the key elements of success, both in the region and in the wider European space, is international connection in the field of transplantation, primarily through membership in the Eurotransplant organization, which enables a faster and fairer distribution of organs among countries that share common medical protocols and databases.
SERBIA AND EUROTRANSPLANT
Eurotransplant is a European organization that connects eight countries in a common system for the distribution of donated organs, with the aim of more efficient and fair transplantation. Members exchange organs on the basis of medical indications, urgency and compatibility, without taking into account administrative borders. Among them are two countries from the region, Croatia and Slovenia, which record significantly better results thanks to their membership in this network.
In 2017, Serbia received an invitation for associate membership, which was then assessed as an important step forward. However, the invitation was conditional on meeting precise criteria - from establishing a reliable and up-to-date waiting list, through defining a clear legislative framework, to increasing the number of donors and developing technical infrastructure aligned with the organization's standards.
Despite the initial enthusiasm, the demands were not met within the stipulated time, and further negotiations with Eurotransplant were not continued. Instead of joining the European organ exchange system, Serbia remained outside the network, relying solely on its own, limited capacities. This lost the chance to provide patients with wider access to potential donors and a shorter waiting time.
Almost a decade later, Serbia is still not a member of Eurotransplant. Without an organized register of donors and non-donors, with uneven practice and a low number of transplants, the health system still does not meet the requirements for membership. Meanwhile, a large number of patients remain on waiting lists, while the experiences of countries in the region show how much membership in such an organization can contribute to greater availability and efficiency of transplants.
The establishment of a transparent and functional registry of organ donors and non-donors in Serbia is crucial for restoring citizens' trust in the transplantation system, but also for meeting constitutional and international standards. The solution requires not only technical implementation, but also institutional responsibility, a clear legal basis and continuous communication with the public.
The law on human organ transplantation must contain precisely defined provisions on how citizens can express their will, whether they want to be donors or refuse to do so. That will must have legal force and be binding for all participants in the transplantation procedure. The registry should be easily accessible and connected to already existing government platforms like eGovernment, and unlike the current practice, where information is not available to doctors at the time of decision-making, the registry must be linked with hospitals and transplant centers, with clear protocols on accessing and updating data.
Although the legislative framework exists, the organ donation system in Serbia is still not sufficiently developed to respond to the needs of those waiting for a transplant. Obstacles, from imprecise regulations to technical dysfunctionality, continue to have very concrete consequences for people's lives. The experiences of other countries show that with clear rules, stable institutions and the trust of citizens, such a system can be effective and sustainable. In the context of transplant waiting lists, this is an issue that requires concrete steps, because for many patients it is not an administrative issue, but a question of survival.
The text was created in cooperation with the Hemofarm Foundation
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The lack of public education and the absence of a clear strategy for normalizing the conversation about donation make it difficult to change attitudes about organ transplantation. In many cases, families simply do not know what their deceased member's attitude would have been, because they never discussed it. Death is still quite taboo, death is not discussed. This is precisely why most people do not express their views on donation during their lifetime, which makes the decision even more difficult for families when they are faced with a loss.
