Bosnia and Herzegovina (Federation of Bosnia and Herzegovina) way the social assistance system is structured – that is, so long as the father is covered, women and children are not obligated to pay for insurance. Other frequently noted issues were the need for Roma to attend medical schools, the role of unhealthy housing in health, and the need for greater employment (and thus health coverage) among the Roma. The importance of birth certifi cates (and that Roma disproportionately do not have these) was also noted.
Some meeting attendees called for specifi c programmes that target Roma drug users, women and children. Activities proposed to improve health included locating health services in Roma communities. Also, many stressed the importance of raising the awareness of Roma and the general population about the work on the action plan.
In the Roma health action plan, activities to improve Roma health are broken down into several categories (Decade of Roma Inclusion 2005–2015, 2008c). The following objectives and measures are refl ected in three key areas: (a) ensuring the right of Roma national minority members to health care; (b) raising awareness in the health care fi eld; and (c) providing and implementing preventive measures aimed at improving Roma health.
Measures in the action plan to ensure the right of Roma national minority members to health care are:
• registering newborn children and other Roma who are not registered in birth records, in compliance with the law;
• developing a database of insured Roma health care benefi ciaries, disaggregated by gender and age;
• aligning legislation to ensure Roma rights to health care are exercised uniformly in all of Bosnia and Herzegovina; and
• obliging governments at all levels of authority in Bosnia and Herzegovina to provide funds to ensure the right to health care for all Roma who are not insured on some other grounds.
Action plan activities for awareness in the health care fi eld are:
• providing health professionals with additional training in fi ghting prejudice and preventing stereotypes about Roma;
• providing additional training in specifi c health risks faced by this population and specifi c health care programmes;
• having information campaigns on the right to health care and working on raising the awareness of the Roma national minority about the importance of health care (and prevention of diseases);
• educating Roma trainers within local communities in preventive health care measures, as proposed by the Bosnia and Herzegovina Roma Council;
• implementing health and educational activities on prevention of illness, through local trainers; and
• ensuring governmental and nongovernmental organizations fi nancial support for education and training of Roma medical staff.
Preventive measures aimed at improving Roma health covered in the action plan are:
• conducting priority preventive health care programmes;
• ensuring proper health care provision for Roma, including immunization and complete medical check-ups for high-risk groups at the primary health care level; and
• ensuring integration of health-promoting measures, from strategies in other fi elds, into Roma programmes.
Funds for implementing all action plans will be provided by two main sources. First, they will be provided from the budgets of the authorities – those at the state, entity and Brčkо District levels, and canton and municipal levels – in the amount of 70% of the total sum necessary and planned for implementation. Second, they will be provided through aid from various international organizations and institutions, in the amount of 30% of the total funds planned. The estimated total budget of the Roma health action plan is KM 347 million, until the end of 2015 (Decade of Roma Inclusion 2005–2015, 2008a). Funds for implementing the health action plan now come from different sources, generally through the Ministry of Human Rights and Refugees, in partnership with the Swedish International Development Agency (for action plans on housing), while the EC and World Vision fi nanced health and employment action plans. Other agencies, such as CE, OSCE, the Spanish Development Agency, UNHCR and UNICEF, also supported the development of action plans.
While also facing challenges, the implementation of the Roma Strategy of Bosnia and Herzegovina and sectoral action plans has resulted in successes. The greatest success of the Strategy thus far has been the gathering of professionals to discuss the same topic:
the inclusion of the Roma population. This process has resulted in increased awareness of Roma health issues, as well as the social and living conditions that affect their health. The most signifi cant challenges in implementing the Strategy relate to organization/
coordination and a lack of consensus among stakeholders on the best way to proceed to include the Roma minority.
Interviews by the author of the present case study with stakeholders involved in the process have revealed opportunities to address these challenges: by more clearly defi ning the roles of the different stakeholders involved in implementation; by ensuring suffi cient human resources for coordination – for example, to facilitate participatory preparation and follow-up to coordination meetings; and by including measures to ensure that actors representing or working directly with the Roma population are included. To facilitate coordination and execution, specifi c operational documents with targets and indicators for competent authorities – also for branch ministries at the entity and cantonal levels – may help. Furthermore, to address the lack of human resources for coordination, a Coordination Board has been established by the Council of Ministers (Decade of Roma Inclusion 2005–2015, 2008d).
As stated above, the involvement of several different sectors (such as social, health insurance, NGOs, different ministries and international organizations) in this process has been positive. They have developed connections, reinforced each others’
capacity and shared viewpoints. Much of the impetus for dealing with Roma exclusion came from international organizations.
As a result of the ongoing discussions about the status of Roma, Roma have been identifi ed as a distinct vulnerable group, which has resulted in NGOs undertaking special programmes that deal more broadly with social and health issues. For example, recent Global Fund Programme to Prevent HIV/AIDS activities included as an objective the introduction of HIV prevention in Roma communities and among formerly displaced persons.
Health providers and governmental representatives are reticent to focus on the right to health for just one national/ethnic category, especially in a country where there are 17 minority groups. Some professionals feel that programmes aimed at a particular group of people could create a backlash among providers and health service users in a country where many people are poor and vulnerable. Thus, despite the good intentions of Roma-specifi c programmes, there are fears that these activities could lead to even deeper discrimination. It would be opportune to raise the awareness of service providers of the increasing recognition at the European level of the need to address the specifi c needs of Roma populations through targeted measures within universal social service provision, measures that aim to reduce social and health inequities and ensure the inclusion of all vulnerable groups (EC, 2008).
The comprehensive primary health care approach infl uences determinants of health that arise in sectors other than health. It also permits health systems to be more responsive to the needs of people, including those facing adverse conditions, through delivery points located in their communities. Better coordination among sectors for improving Roma health and that of other disadvantaged groups could best be achieved through primary health care. As the country is currently pursuing health reform, the Ministry of Health has opportunities to start more collaborative efforts with other actors at the primary health care level, not just for the Roma population. Community-oriented mental and physical rehabilitation at the primary health care level are good models for such cooperation.
Opportunities for improved health may arise from health sector providers receiving further training (and capacity building) about Roma inclusion and addressing health inequities. They may also arise through further engagement of the Roma themselves. Training on Roma inclusion issues was conducted for members of the Health Working Group and the Monitoring and Evaluation Working Group in parallel with drafting the action plan. If the training had been conducted prior to the start of the drafting process, its effect could have been optimized. This is an important lesson to consider when producing further operational plans. Also, mechanisms to ensure participation should be built into the specifi c implementation plans of each component of the health action plan.
Lessons learned
A coordinating body for monitoring the implementation of (all) action plans was established in October 2008 (Albert Pančić, programme manager, World Vision, and Samir Šlaku, associate, Ministry of Human Rights and Refugees, personal communications, November 2008).
Bosnia and Herzegovina (Federation of Bosnia and Herzegovina)
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Acknowledgements
For the input they provided, thanks go to: Mr Raif Alimanovic, of the NGO Roma and Friends; Mrs Sanela Bešić, coordinator of the Roma Council; Mrs Maja Grujić, of World Vision; Mr Rašid Milkunić, of the Municipality of Tuzla; Mr Albert Pančić, programme manager of World Vision; Mr Dervo Sejdić, OSCE monitor, of the Roma Council; and Mr Samir Šlaku, of the Ministry of Human Rights and Refugees.
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3. Bosnia and Herzegovina (Republika Srpska): poverty and protecting children from family violence
Anka Seranic and Jasminka Vuckovic Ministry of Health and Social Welfare of Republika Srpska
The postwar years have seen growth, increased macroeconomic stability, and strengthened central monetary institutions in Bosnia and Herzegovina (Republika Srpska). Yet, much remains to be done to reduce economic insecurity. Growth in inequality and the worsening of the material well-being of some groups are exemplifi ed in data provided by the 2005 revision of the Bosnia and Herzegovina Medium-term Development Strategy (DEPBiH).
Research consistently suggests that people with lower socioeconomic status are at greater risk of exposure to violence.
Numerous studies of many countries have shown a strong association between poverty and child maltreatment. Communities with higher levels of unemployment, concentrated poverty, population turnover, less social capital, deteriorating physical and social infrastructures, and overcrowded housing have higher rates of child abuse. In Republika Srpska, domestic violence affects children disproportionately. Many factors lead to the rise in domestic violence and violence against children, and these include poverty, unemployment, social insecurity and changes in societal/cultural values.
The activities of institutions that protect children from violence in Republika Srpska are aimed at effective and cross-cutting systemic solutions. In recent years, a number of important legislative acts and regulations (by-laws), as well as policies, strategies and guidelines, have been developed and adopted with the aim of reducing domestic violence signifi cantly, especially violence against children. Republika Srpska is also advancing policies and strategies that promote social equity and foster social capital.
Reforms in the health care system in Republika Srpska address the problem of unequal access to health care by: (a) reducing the number of people without health insurance; (b) ensuring better availability of health care through technical and allocation effi ciency (including the primary health care level); and (c) enhancing the availability of health care to vulnerable groups. The introduction of the family medicine model has promoted continuous monitoring of the health status of all family members through early detection of risk factors, promotion of healthy lifestyles, treatment of disease and rehabilitation. The need to provide a more comprehensive service package to the benefi ciaries, particularly to the more vulnerable groups, requires changes in the composition of the family medicine team and how it functions. To meet the additional responsibilities of family medicine, the Ministry of Health and Social Welfare of Republika Srpska decided to incorporate existing community nurses into the family medicine network.
Protecting children from domestic violence involves forming a network that aims to accomplish that goal. This network includes NGOs, schools and kindergartens, medical institutions, counselling centres and social institutions, the police, public prosecutors, and the courts. In this network, the Centres for Social Work have a primary role in detecting, evaluating
Summary
Socioeconomic and policy context
Bosnia and Herzegovina was recognized by the international community in 1992 as a newly independent country. A war followed from 1992 to 1995 and was ended by the Dayton Peace Accords. Today, Bosnia and Herzegovina is comprised of two entities: Republika Srpska and the Federation of Bosnia and Herzegovina, as well as Brčko District – which is independently administered and over which neither Republika Srpska nor the Federation of Bosnia and Herzegovina have jurisdiction. This case study focuses on Republika Srpska, which comprises 49% of the total territory of Bosnia and Herzegovina. Republika Srpska’s current population is estimated to be 1 487 800 people (Republika Srpska Institute of Statistics, 2007a).