Social Participation for Health and Health Care Workers' Self-Management: Lessons from Socialist Yugoslavia for Contemporary Health Systems-A Systematic Review.

BACKGROUND/

objectivesContemporary health systems continue to face persistent challenges in financing, equity, and governance, particularly under conditions of limited resources, workforce shortages, and demographic pressures. While the World Health Organization calls for strengthening social participation to achieve universal health coverage, evidence suggests that such participation often remains largely symbolic. Existing global examples of social participation in health are limited either by their short duration of implementation or by their limited scope. In contrast, the experience of former Yugoslavia (1945-1991) represents a distinctive case. In the early post-war period, health reforms were directed towards the development of a decentralised, self-managed health system that emphasised universal coverage, participatory governance, social solidarity, and local autonomy. The trajectory of these reforms was further shaped by global economic and political pressures, including neoliberal trends, international debt, and the oil crises, which constrained resources and exposed systemic vulnerabilities. The so-called Yugoslav Experiment may offer an alternative to existing market-oriented and, at times, inefficient health systems. This review aims to synthesise evidence on the governance, financing, organisation, and outcomes of Yugoslavia's self-managed health system and to evaluate its relevance to contemporary debates on health system resilience, decentralisation, participatory governance, equity, and sustainability. It examines power relations, stakeholder interests, and resource allocation, and assesses the lessons that the Yugoslav experience offers for contemporary debates on participatory governance and the sustainability of healthcare systems, while identifying areas of convergence, debate, and gaps in the existing scholarship.

methodsWe conducted a systematic narrative review of peer-reviewed articles, book chapters, conference papers, and commentaries published in English or Bosnian-Croatian-Montenegrin-Serbian that covered the period 1945-1991. Scopus, PubMed, and EBSCOhost (including CINAHL Plus with full text, Medline and PsychInfo) were searched on 19 January 2026. Studies were included if they addressed health system reform, self-management, governance, financing, or institutional continuity. Contextual studies of selected services-primary care, mental health, reproductive health, and vaccination-were included only if they illuminated reform trajectories. Data synthesis focused on reform phases, institutional transformations, financing arrangements, governance mechanisms, and power relations, with particular attention to continuity, path dependence, and critical junctures. Given the heterogeneous and predominantly historical, analytical, and policy-oriented nature of the literature, we did not apply conventional study-design-specific risk-of-bias tools. Instead, we used an overarching framework to classify and contextualise the included evidence according to five dimensions: source type, nature of contribution, evidentiary role, temporal context, and health-system domain. The protocol was not registered. The study was financed by the Provincial Secretariat for Higher Education and Scientific Research, Autonomous Province of Vojvodina, Republic of Serbia.

resultsThe database searches yielded 265 records, of which 193 were selected for title and abstract screening after removing 72 duplicates. At this stage, 133 publications were excluded because they did not meet the eligibility criteria and 60 publications were selected for full-text review. Application of the predefined inclusion and exclusion criteria resulted in 22 eligible publications. An additional 18 studies were identified through citation chaining and targeted Google Scholar searches. Twenty-two publications were coded as primary studies, directly examining health system reform, governance, or self-management, while 18 were classified as contextual studies addressing specialty areas. The analysis identified key reforms that followed the social participation, i.e., 'self-management', approach, which expanded primary care, preventive services, and local participation. It revealed institutional changes, as well as the role of power and health financing in health reforms aimed at strengthening social participation. Nonetheless, challenges-including bureaucratic and managerial elitism, unequal professional authority, resource scarcity, and tensions between market-oriented policies and social solidarity-were amplified by global economic forces and neoliberal trends, ultimately contributing to the system's collapse by the late 1980s. This review was limited by its search strategy, the exclusion of grey literature, the potential omission or inaccessibility of relevant studies, and its focus on selected aspects of health reform, namely post-war recovery and self-management.

conclusionsThe Yugoslav experience illustrates both the promise and the fragility of socially oriented, participatory health systems, demonstrating how international political alignments and global economic pressures can profoundly shape domestic health reform trajectories. Lessons from this case remain relevant to contemporary efforts to strengthen social participation for universal health coverage through designing sustainable, resilient, equitable, and socially accountable health systems under complex global conditions.