Primer on Bosnia and Herzegovina
Bosnia and Herzegovina (BiH)1 is a state of two entities, plus a self-governing unit, a federation of sorts, dominated by three ethnic communities.2 Geographically speaking, BiH is located in south-eastern Europe, west of the Balkan Peninsula.3 With a landmass of 51,197 square kilometers, BiH is comparable in size to the State of West Virginia in the United States (62,758 square kilometers), Croatia (56,594 square kilometers), and Slovakia (49,035 square kilometers).4 The country is bordered by Croatia to the north, Serbia and Montenegro to the east, and the Adriatic Sea to the south, with a total boundary length of 1389 kilometers.5
BiH has a population of 3.5 million people.6 The figure is 1 million people less than 4.5 million persons from the prewar census in 1991.7 The significant drop in population is due to various factors, including a negative perception of their socioeconomic futures by many Bosnians and a fertility rate below replacement numbers.8 Bosnia is a post-socialist state with a service-based economy.9 It is one of six components of former Socialist Federal Republic of Yugoslavia (SFRY).10 SFRY existed from 1945 to 1992, although its roots date back to the Kingdom of Serbs, Croats, and Slovens, formed in December of 1918.11 Bosniansâ self-awareness of their separate statehood goes back in time to the tenth century.12 One recent expression of this self-image was in 1943 when BiHâs present boundaries were determined as part of a boundary-making exercise for the whole of Yugoslavia.13
Healthcare in Bosniaâs Reform Agenda
In September of 2015, fourteen governments which make up Bosnia and Herzegovina drew up a set of proposals for reform in several fields of national development that included healthcare.14 The fourteen governments were the Council of Ministers of Bosnia and Herzegovina, the Government of the Federation of Bosnia and Herzegovina (FBiH),15 the Government of Republika Srpska (RS), the Government of BrÄko District, and the governments of the ten Cantons in FBiHâUna-Sana, Posavina, Tuzla, Zenica-Doboj, Bosnia-Podrinje, Central Bosnia, Herzegovina-Neretva, West Herzegovina, Sarajevo, and Canton 10 (West Bosnia Canton).16 The fourteen governmental units, minus the Council of Ministers of Bosnia and Herzegovina, constitute the BiH healthcare system, itself alternatively organized around two entities, plus a self-governing unitâFBiH and its ten Cantons, RS, and BrÄko District.17
Broadly, the fourteen governments ârecognize[d] an urgent need to initiate a process of rehabilitating and modernizing the economy with a view toâ realizing certain cherished values, such as âfostering sustainable, efficient, socially[-]just and steady economic growth; [and] creating new jobs[.]â18 With specific reference to healthcare, the fourteen governments pledged to curtail âthe burden on labor needsâ âby reducing contributions for health insurance, coupled at the same time with the need to ensure additional revenues for extra-budgetary funds to cover the losses generated as a result of the reduced contribution rate.â19 The team of fourteen governments also pledged to âseek financial and technical assistance [from] the World Bank to implementâ several aspects of healthcare reform, âinclud[ing] a solution for outstanding debts,â and defining ânew models and sources of funding, with a more precise regulation of the network of health care institutions.â20 Finally, the fourteen governments proposed to âsupport an increase in excise duties on tobacco and alcohol which will be the direct income of the health insurance fund of the RS and health insurance funds in the FBiH, Cantons[,] and BrÄko District by the end of 2015.â21 These pledges of healthcare reform culminated âan increased demand from many sectors for improved and comprehensive information on the workings and quality of the health care system in Bosnia and Herzegovina,â the Office of the United Nations High Commissioner for Refugees (UNHCR) in Sarajevo commented upon in a study that the office published in 2001.22
Argument
This book contributes to the long-standing debate on healthcare reforms that reached a high point in the Reform Agenda for BiH discussed in the previous section. Bosnia is a nation forged in war.23 Twenty-five years after the bloody fighting, Bosnians have yet to recover fully from the war that shook the country to its very foundation on the verge of its nationhood.24 The contribution to the debate on healthcare reforms this book embodies revolves around the concept of preventive medicineâquality medical attention short of complex examination and treatment, that is actuated by the need to remove the causes of ill-health.25 The book portrays preventive medicine as a function of progress in genetic counseling,26 plus alcohol and tobacco controls.27 More elaborately, the bookâs argument is that twenty-five years after the ethnic war that shook Bosnia and Herzegovina to its foundations at the dawn of its independent nationhood, healthcare reforms in the land is a function of preventive medicine, defined as genetic counseling, backed by alcohol and tobacco controls.28
BiH maintains an abiding commitment to socioeconomic human rights, including healthcare, that dates back to its socialist incarnation in Yugoslavia.29 However, enjoyment of these rights by citizens, particularly the healthcare rights at the focus of this book, lacks depth.30 This is due to multiple forces which individually and collectively took a decided toll on these guarantees. Predictions are hazardous and this book takes no cause-and-effect position on the matter, but a foundational factor was the destruction of health and other infrastructure by the internecine war from 1992 to 1995 that convulsed BiH.31 About 200,000 people died during the war with another 240,000 wounded, many of them seriously, some to the point of permanent disability.32 Many of these were healthcare workers.33 The war also devastated much of the countryâs already-modest healthcare infrastructure.34 Problems after the war with negative ramifications for healthcare, including genetic testing and counseling at the heart of this study, revolved around deficiencies in the various hallmarks of a good healthcare system,35 that this book pulls together in Chap. 4.
In the light of the foregoing, it may be argued that the quantity and quality of healthcare services produced today in BiH fall below âthe facilities available in Western Europeâ and the level achieved before the war.36 First, the level of healthcare services provided to insured persons falls below the level guaranteed by law.37 Second, despite the promise of an unalienable right to healthcare, a large number of the populace lack acc...