The war in Bosnia caused widespread devastation. Over half of the population was displaced and 10 per cent was killed or wounded. 30% of the hospitals were destroyed or severely damaged, and almost a third of health-care professionals were lost due to death or emigration. Until now, health-care reform has been slow. However, the health-care system is now moving away from city-based hospital treatment. Outreach clinics, known as ambulantas, have been refurbished using finances from the World Bank’s country assistance strategy (CAS), with the aim of treating 80 per cent of all patients.
Health in Bosnia and Herzegovina
The state of health among the population of Bosnia and Herzegovina has been deteriorating steadily since the war. The reasons include socio-economic circumstances, unemployment, migration, large-scale displacement, lack of health insurance and unhealthy lifestyles. In Bosnia and Herzegovina, 22 per cent of the population aged over 17 report constraints on their daily activities as a result of health problems; 24 per cent have chronic ailments and 4 per cent suffer from serious ailments.
Even before the war, the health system was poorly placed to treat normal health needs. While it provided almost universal access to a wide range of services, it was oriented towards high-cost curative treatment by specialists in hospitals, and was poorly focused. There was a severe lack of more cost-effective health promotion and disease prevention approaches that are capable of dealing with most of the health risks faced by the population. As a result, the system was unsustainable and costly.
The system, therefore, was intervention-oriented and hospital-based with a high-tech emphasis. Primary health care was understated. Preventative measures and health education did not receive enough attention.
Health Care Reform
“Although the war brought destruction, death and devastation, and horrible things to the sector, to the country, to the people of Bosnia and Herzegovina, it did create opportunity for change, to help the country build a new, more efficient system with much more equity.”
Dr Nedim Jaganjac
The strategy of health-care reform aims at organising health care within the cantons (regional sub-districts), while maintaining coordination at the hands of the Federation government. This allows for a decentralised health system, in line with the experience of developed health systems in other parts of the world.
This creates the opportunity to build an economic and efficient health care sector by devolving part of the responsibility for health to individuals, families and local communities, who can mobilise the resources that have not been tapped so far. The maintenance of coordination by the Federation prevents the fragmentation that would be likely if responsibility was held by the cantons independently.
By reforming and decentralising health-care provision in this way, the process aims to address to following limitations of the existing structure:
- Inequalities and inequities in the health-care system The concept of health reform promotes the principles of equality and equity. This requires equal access to an equal quality of health care by all citizens.
- Insufficient health insurance coverage and monitoring of contribution collection Currently, 26 per cent of the population are not covered by health insurance. Universal health insurance coverage is needed to ensure equal access to health care.
- Weaknesses in links between cantonal systems Improving the links between health-care systems in different cantons will aid the free movement of people across boundaries, as well as leading to increased equality and equity of health-care provision.
- Inadequate allocative efficiency The efficient allocation of health-care resources is vital because it determines how the collected funds will be distributed both by geographic regions and levels of health care.
- Inefficient organisation of the system and service provision Primary health care could be made more efficient if the proportion of patients unnecessarily referred to the secondary and tertiary level could be reduced. Trained family medicine teams will be able to satisfy most requests for health care (80 per cent). The family doctor should take over control as the ‘gatekeeper’ to the higher levels of the health-care system.
- Corruption Corruption serves as a significant burden for the poorer social groups when they are forced to pay for health-care services in the public sector.
The main focus of the Basic Health Project has been to support the development of a viable basic system of primary health care, public health and disease control. Specifically, its objective have been to:
- Establish a primary health-care system based on cost-effective interventions in pilot areas;
- Improve local and national capacity for management of health-care systems;
- Reduce losses in productivity due to preventable illness, disability and premature deaths.
Developing Family Medicine
The focus of the Basic Health Project has been to design and implement a new approach for delivering primary health care based on Family Medicine (FM) teams. Training, equipment and incentives are used to produce services that are better managed, more cost-effective, higher quality, and better focused on the health needs of the population. This approach was developed through the coordination of the World Bank with the Ministry of Health (MoH), the Canadian International Development Agency (CIDA) and Queens University. While the pilot FM teams were expected to cover 10 per cent of the population, the project has actually achieved coverage of 31 per cent.
The Canadian International Development Agency carried out a mid-term evaluation of the project for additional training in March 2004. The evaluation reports positive developments in the teaching skills and enthusiasm of the Bosnian trainee teachers. Canadian teachers continue to teach some parts of the classes, but as teaching assistants gain in confidence they become more willing to take on greater responsibility. Duties are therefore increasingly being handed over to Bosnian teachers, with guidance when needed and resources provided where required.
The project supports the staffing and operation of FM teams, and the design and implementation of professional training programmes for these teams. The programmes are also integrated into university medical school teaching. There is support for health management training and the testing of new payment mechanisms for the FM teams. This ensures that their incentives are aligned with their role in the system. The project has small, but important, components to strengthen public health services and to establish accreditation and quality assurance capacities in each entity as an initial step in a longer-term strategy to improve quality at all levels.
Commitment to the Family Medicine concept has expanded beyond the pilot sites to the national level. As of June 2004, 31 per cent of the country’s FM team requirements had been met, which is well above the expected results. Bosnia and Herzegovina has a population of about 2.4 million. In order to meet the requirements of the total population, about 1200 teams need to be trained. Based on the family medicine departments’ capacity regarding the number of residents, the transition to FM should be completed within 10 to 15 years. However, with adoption occurring more rapidly than expected, it is hoped that completion may be sooner.
The project is set to expand with support from the proposed Bank-financed Health Scale-Up Project, scheduled for initiation in 2005. Local governments are committed to the expansion of FM and are investing their own funds in various sites. There has also been a high level of commitment by FM teams and local health authorities.
Such commitment has played a vital role in improving the quality of services, thereby boosting patient satisfaction. This is an important outcome of the project that should not be underestimated. Poor-quality services were one of the key elements in low take-up of health-care service in rural areas.
Each health centre and field clinic in the project has been equipped with a pharmacy and spacious waiting rooms, where appointments are scheduled to allow doctors more time with their patients.
‘The patients are very satisfied because they can find doctors who can understand their needs and can understand how they suffered.’
Prof. Dr Muharem Zildzic
A Healing Process
The Basic Health Project, and its emphasis on primary health care through family medicine, has brightened the prospects for future health care in Bosnia and Herzegovina. Offering a type of health care that is sensitive to the needs of each patient, FM may prove to be the way forward in similarly war-stricken countries. Decentralising primary health-care systems in this way reduces the burden upon central health-care facilities. It also helps extend health care to the many displaced individuals of a society still reeling from the effects of conflict.
‘The war in post-conflict brought a lot of psychological trauma and the model of family medicine that is implemented through the project actually helps patients establish a better relationship with their family doctors, and express themselves and therefore help the healing process.’
Dr Nedim Jaganjac
ITDG would like to thank Betty Hanan of the World Bank for providing information and helping in this case study.
The case study draws on articles written by the World Bank and the UN.
Government of Federation of Bosnia and Herzegovina (2004). Mid-Term Development Strategy for Bosnia and Herzegovina (PRSP) 2004-2007.
United Nations Development Programme (2002). Human Development Report 2002: Bosnia and Herzegovina. Sarajevo: Economics Institute.
Government of the Federation of Bosnia and Herzegovina: Ministry of Health www.fbihvlada.gov.ba/english/ministarstva/zdravstvo.php
United Nations Development Programme www.undp.org
World Bank www.worldbank.org
ITDG Technical Briefs answers.practicalaction.org