There are currently about 1,800 patients on the waiting list for organ transplants in Serbia. For each of them, this waiting is an uncertainty that lasts for months, and often years, as they hope to get a new chance at life. Although the Human Organ Transplantation Act of 2018 provides for a presumptive consent model, according to which all adult citizens are considered potential donors unless they have explicitly objected to it, in practice this model is not based on clear, operational procedures.

Serbia still does not have a functioning register in which citizens can 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 declaration. That is why the decision to make a donation is often made in circumstances that are burdened with doubts and uncertainty. Medical staff do not have access to the necessary information, and families often face the issue of donation for the first time in moments of personal trauma, without a 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.

Organ Transplantation Law: How the Transplantation System Remained on Hold

The Human Organ Transplantation Act, which was adopted in Serbia in 2018, introduces the principle of presumed consent, which means that every adult citizen is considered a potential donor, unless he or she has explicitly declared that is against it during his or her lifetime. However, in 2021, the Constitutional Court of Serbia challenged a key provision of the law that stipulated that organs from a deceased person could be taken for transplantation if the adult donor did not object orally or in writing before death, and if a family member did not explicitly object at the time of death. The Constitutional Court assessed that such a provision is not in accordance with the Constitution of the Republic of Serbia, because it does not clearly prescribe the role of the family in the process of giving or denying consent, nor does it provide sufficient guarantees that the will of citizens will be respected and applied in practice.

Despite this verdict, so far no amendments to the law have been adopted to resolve the controversial points, which is why there is no precise and applicable legal framework regulating the transplant process in Serbia at the moment.

Ivana Jović from the Patients' Association "Donation is Heroism" said to the weekly "Vreme" that the citizens of Serbia still do not have the opportunity to formally declare whether they want to be organ donors. As she points out, the draft amendments to the Law already exist and were prepared in cooperation with experts in medical law and human rights - Professor Jelena Simić from the Faculty of Law of Union University, Marta Sjeničić, PhD 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 refuse to do so - through eGovernment, a doctor or a notary public. In the absence of such a statement, 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 independently decide whether his organs can be used for the treatment of other people after his death," adds Jović.

The expert team that worked on the proposal is also part of the task force of the Ministry of Health, and the text of the draft was presented to the Ministry. Although Minister Zlatibor Lončar expressed support for the initiative last year and stated that transplantation is one of the priorities, after the formation of the new Government, the task force has not yet continued its work.

Jović points out that the proposals are also based on a survey conducted by IPSOS for the association, according to which as many as 80% of Serbian citizens support organ donation, while half would enroll in the Registry if it existed. As a key reason for refusing to donate, citizens cite a lack of trust in the health care system. Also, the bill includes the expansion of the right to transplantation from living donors, because now the law allows donation only between the closest relatives, which, as he says, forces many patients to go abroad and pay for the transplant from their own budget.

It is important to mention that Serbia has previously tried to establish cooperation with Italy in the field of organ transplantation, but that the agreement has not been implemented, and one of the main reasons is the lack of a functional system and register of donors in Serbia, which has made it difficult to establish trust and standardized cooperation with Italian partners. Due to long waiting lists and a lack of donors in Serbia, an increasing number of patients decide to seek salvation abroad, where Belarus has stood out in recent years. As "Vreme" previously wrote, in 2024, 12 patients from Serbia performed kidney transplants 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 disadvantaged position among neighboring countries. Unlike Republika Srpska and Montenegro, which finance transplants in Belarus for their citizens, Serbia does not provide such support.

"A few 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 stabilizes. We never received an official answer, but it was verbally explained to us that the support of the state is impossible due to the sanctions imposed on Belarus," she said.

She 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 drives. "Our patients have to provide and pay for everything themselves - from transportation to preparations and the surgery itself. Minsk is 1,500 kilometers away, and this dream of a new life is financed exclusively by good people who donate funds," says Jović.

Efficient models in practice

While patients in Serbia continue to face dysfunctional transplant system and are increasingly forced to seek salvation 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 stated during his or her lifetime that he or she does not wish to do so. Such statements are recorded in the Register of Non-Donors kept by the Ministry of Health, and the system is digitized and functional.

A significant contribution to the success of this model has also come from the social sphere, primarily through the support of the Catholic Church, which has a strong influence in Croatian public life. In the early 2000s, the Croatian Bishops' Conference clearly stated that organ donation is a morally acceptable act and an expression of Christian love for close people, which eliminated one of the most common ethical and religious dilemmas among citizens.

At the organizational level, the central role is played by the Transplant Coordination at the Ministry of Health, which manages all applications from potential donors, maintains waiting lists and ensures operational links with international partners. Croatia has been a full member of the Eurotransplant network since 2007, which allows its patients faster and fairer access to organs based on medical compatibility, not just national capacities.

Comparing the data from the region, Jović points to facts that indicate the need to improve the system in Serbia. "By August last year, in Croatia, which has a much smaller population, 90 consents for organ donation had been requested. In Serbia, in the same period, only 30," he says. He added that a missed opportunity for a significant number of people waiting for a transplant lies behind these numbers, including 30 children on chronic dialysis programs.

The result of the regulated 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 Spain's National Transplant Organization (ONT), 6,464 organ transplants were performed in Spain in 2024, an increase of 10% compared to the previous year. Such results are not only the result of the legal framework, but of consistent institutional practice, continuous investment in professional staff and systematically built trust between citizens and health institutions.

The system is based on a model of presumed consent, which stipulates that every citizen of Spain is a potential organ donor, unless he explicitly declares against it, which he can do by submitting an official statement.

The National Transplant Organization plays 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 model's success 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 conversations with the family, logistics, as well as the entire course of the donation process, with a careful attitude towards the medical and emotional aspects of the situation.

Interestingly, Spain, despite having one of the highest donation rates in the world, does not keep a centralized register of citizens who want to be donors. The interpretation of the law goes in the direction that the existence of such a register would be contrary to the logic of presumed consent. Instead, the system clearly allows every citizen to express their disagreement with the donation, and such a will is always and without exception respected.

This approach is often described as the "Spanish model", the success of which lies not solely in the legislative framework, but in its consistent and carefully organized implementation. Through continuous education, institutional connections and highly professional staff, Spain has developed a system that works in practice, not just on paper. Citizens' trust, the presence of trained teams and clearly defined protocols have proven to be crucial factors in the development of one of the most effective transplant systems in the world.

While in Spain the strength of the system is reflected in the internal structure and professional culture, and in Croatia in effective 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 area, is international integration in the field of transplantation, primarily through membership in the Eurotransplant organization, which enables faster and fairer distribution of organs among countries that share common medical protocols and databases.

Serbia and Eurotransplant: An Opportunity for International Cooperation

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 equitable transplantation. Members shall exchange organs on the basis of medical indications, urgency and matching, disregarding the administrative boundaries. Among them are two countries from the region, Croatia and Slovenia, which have recorded significantly better results thanks to their membership in this network.

In 2017, Serbia received an invitation for associate membership, which was assessed as an important step forward at the time. However, the call was conditional on the fulfilment of precise criteria - from the establishment of a reliable and up-to-date waiting list, through the definition of a clear legislative framework, to increasing the number of donors and developing technical infrastructure in line with the organization's standards.

Despite the initial enthusiasm, the demands were not met within the stipulated deadline, and further negotiations with Eurotransplant were not continued. Instead of joining the European organ exchange system, Serbia has remained outside network, relying solely on its own, limited capacities. Thus the opportunity was lost to provide patients with wider access to potential donors and shorter waiting times.

Almost a decade later, Serbia is still not a member of Eurotransplant. Without a regulated registry of donors and non-donors, with unequal practices 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 experience of countries in the region shows 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 transplant system, but also for meeting constitutional and international standards. The solution requires not only technical implementation, but also institutional accountability, a clear legal basis and continuous communication with the public.

The law on transplantation of human organs must contain precisely defined provisions on how citizens can express their will, whether they want to be donors or refuse to do so. This will must have legal force and be binding on all participants in the transplant procedure. The registry should be easily accessible and connected to already existing state platforms such as eGovernment, and unlike the current practice, where information is not available to doctors at the time of decision-making, the registry must be linked to hospitals and transplant centers, with clear protocols on access and updating of data.

Although there is legislative framework, the organ donation system in Serbia is still not sufficiently developed to respond to the needs of those waiting for transplantation. Barriers, from imprecise regulations to technical non-functionality, continue to have very concrete consequences for people's lives. The experience of other countries shows 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.

Author: Jovana Đurđić, journalist of the weekly ‘Vreme’