The politics of health care

One hundred and forty-four days a year, Fehim Huskić gets up at 3 a.m. to save his life by making the trip to Bihać from his home in Sanski Most. Huskić’s kidneys are failing to clean his blood of impurities and therefore a dialysis machine in Bihać must do the work his body cannot.

But Huskić, 67, said the cure he depends on three times a week has also become a threat to his life. His doctors tell him the four-hour round trip to Bihać, added to the five hours on the dialysis table, is not good for his health. Huskić must bring a pillow to cover the seat springs in the 10-year-old government van that makes the four-hour round trip over a bad road.

What makes it even harder to bear is that Huskić knows that his Bihać trips are a needless result of the regional conflicts in Bosnia-Herzegovina’s dysfunctional health care systems.

Thirty kilometers from Sanski Most, the van with Huskić and nine other kidney patients passes through Prijedor, in the Republika Srpska (RS), where the same dialysis treatment is available at the local hospital. But the Federation of BiH (FBiH) and RS health insurance funds do not recognize each other. Huskić would have to pay cash in Prijedor, which, in effect, with his FBiH insurance, would mean paying twice for his treatment.

The grueling journey makes Huskić’s already difficult life even more gloomy.

‘Coming back from dialysis I pray to God to take my life away’ Huskić said in an interview.

A health care system that can make its patients pray to die is caused by the same regional and political conflicts that affect so much of life in Bosnia-Herzegovina, according to health officials. But the surprisingly low priority that public officials give health care system reform may have the most devastating effects on everyday life.

Not only is the system forcing patients like Huskić to drive by nearby facilities, students and other patients cannot get any treatment at all if they are out of their entity. They are forced to pay cash for emergency treatment despite having already paid for insurance in their home entity, and then wait for months for repayment from the government.

Meanwhile, duplicated facilities bloat administrative and medical costs in a system that health officials claim does not have a big enough budget.

Perhaps the most stunning fact is that millions of KM are being sent to Croatia and Serbia-Montenegro to treat Bosnian patients who could be treated in BiH, according to health officials. Foreign treatment cost the combined FBiH and RS systems close to 102 million KM from 2001 to 2003.

The irrational divisions in the health system are ‘a real madness, a chaos which threatens to collapse the entire health system’ according to Dr. Aida Čemerlić, deputy director of the FBiH Public Health Institute, which analyzes statistical data on the health system.

Patient care is suffering from the lack of coordination between 10 cantonal insurance funds that cover the health care of 2.5 million insured FBiH citizens, Čemerlić said. The system spent 712 million KM in 2003. The Federation also has a separate entity-level Solidarity Fund for special costs, such as sending children abroad for treatment and paying for patients from poorer cantons.

The RS has a centralized fund administered through six districts, which together spent 235 million KM last year. In the same period the budget of the Brčko District spent 40 million KM.

Huskić counted out the costs to the FBiH fund for his trips: the van gasoline, the travel costs for the driver and the money for his waiting time while Huskić spends five hours hooked to the machine that cleans his blood.

‘Prijedor is only 30 km away, but due to politics, for me it is like another country’ Huskić said bitterly.

The hassle, said Huskić, takes away what he has left of life. He shook his head and added that the money that could be saved by going to Prijedor could probably buy another dialysis machine and save other peoples’ lives.

He is angry at all those responsible but he doesn’t really know who to blame.

Older patients and those facing serious illness, like Huskić, are not the only ones caught between the jurisdictional conflicts.

Lejla Rešić, a student from Prijedor who studies in Sarajevo, cannot get treatment in Sarajevo unless she pays for it. Then she has to wait for the RS fund to repay her. The last time it took two and a half months to get 30 KM back. Most of the time she doesn’t have the money to loan to the insurance fund and she must go to East Sarajevo, or for serious illness, to Foča or Banja Luka.

‘This is pure discrimination, and I feel like a foreigner in my own country’ Rešić said.

Like Huskić, Rešić is angry at the situation but she doesn’t know whom to blame.

‘Who was crazy enough to come (up) with a health system like this one?’ she said.

There are no agreements between the two entities to solve Huskić’s or Rešić’s problems. And there is little hope for the future based on the only attempt made so far to coordinate health service between the entities.

In 2001, they agreed that war refugee returnees would get medical care in the entity they were returning to, which would be paid for by the entity from which they were resettled.

But when put into practice, the entities did not honor the agreement by paying each other.

Tomislav Lučić said that the current health care system doesn’t
function.

Suspicion rules again when it comes to trying to coordinate the two systems so that Rešić would not have to pay in advance for her care in Sarajevo. The BiH fund does not want to experiment with taking care of RS patients because there is no common price list for procedures, according to FBiH Health Minister Tomislav Lučić.

‘The funds are cautious because this agreement might raise the costs out of control’ Lučić said. ‘We have two separate funds whether we like it or not.’

The entities might be able to pay their bills if they were not spending so much avoiding each other by duplicating facilities, according to Federation public health institute’s Čemerlić and others.

The FBiH is wasting millions by duplicating health centers, especially in Srednja Bosna Canton, Čemerlić said.

Plans have been made to merge the facilities, but the plans never seem to be carried out.

In Novi Travnik, there are two health centers within 500 meters of each other and two hospitals two kilometers apart. One set of facilities serves Croats and the other is for Bosniaks.

There is simply no medical need for both sets, according to Josip Fišić, director of one of the health centers, which primarily treats Croats.

Duplicated facilities also exist in Jajce, Bugojno, Mostar and Sarajevo, health minister Lučić said.

‘Politics has its finger in the pie like in any other (issue)’ said health center director Fišić. ‘This situation is inherited from war times, and it is still in force today.’

His counterpart at the second clinic in Novi Travnik, Dr. Vahida Smreka, agrees that the legacy of the war is to blame for the situation.

Fišić and Smreka also agree that reason and efficiency demand that the two health centers become one. But, in a possible indication of why facility merger plans never seem to happen, each director speaks in favor of keeping his or her center, and closing the other one.

The situation is just as conflicting with the two hospitals, in Travnik and Nova Bila. The one in Travnik has many years of experience, while the one in Nova Bila is new and with up-to-date equipment. Politics had its say here also, said Dr. Mirsad Granov, director of Travnik Hospital.

‘The process of joining existing double facilities is ongoing for two years without results. It is all up to the politics’ Granov said.

The oversupply of facilities gives the canton 5.6 hospital beds per 1,000 inhabitants, according to Dr. Faris Gavrankapetanović, the director of University Clinical Center of Sarajevo. The ratio in western European hospitals is only 3.2 beds per 1,000, he added.

The fact that 22 health centers and five hospitals can be found in Srednja Bosna Canton does not seem to bother anyone, said Travnik Hospital’s Granov.

It doesn’t appear that the situation in the canton will be changing soon.

For two years the canton’s city councils have not been able to reach an agreement on how to come together, according to Lučić, the Federation health minister.

Apparently, there will be no further progress while the canton waits until late next year for international help to lead the way.

A World Bank-sponsored program to reform medical care is due to be finished next year. Lučić said the problem of duplicated facilities can wait until then.

‘We are not tearing down anything until the SITAP project is done’ Lučić said.

SITAP, the Social Insurance Technical Assistance Project, will produce a plan for giving duplicated facilities different functions rather than closing them, said Mirjana Karahasanović, SITAP project manager.

The project will also investigate redistributing primary care patients to health facilities based on capacity rather than for other arbitrary reasons, she said.

But SITAP does not anticipate formulating a similar efficiency plan for hospitals and clinics, according to the World Bank’s project description.

Also, the European Union is making an assessment of management problems in all BiH health funds, which will be ready at the same time, Lučić said.

Despite the overbuilding of facilities in BiH, the entity health funds are also shipping BiH patients and their insurance money to other countries, entity health officials said.

Millions of marks are spent on patients’ trips to Croatia and Serbia-Montenegro. But the FBiH government does not know exactly how much is spent on foreign medical care, according to the FBiH Health Insurance Office, because the specific regulations for sending patients out of the country have never been written.

The authority regarding the transfer of patients abroad for treatment rests in the hands of the FBiH-level insurance fund. Payment comes from the Solidarity Fund, a special account maintained by an 8 percent tax on the cantonal funds, which amounted to 70 million KM last year, according to health fund officials.

Cantons with Croat majorities for years have been sending their patients to health institutions in Croatia. This has resulted in millions of marks in debts owed to Croatia by the FBiH. Although no one knows exactly the total amount, Croatia estimates it to be 50 to 60 million KM, according to the assistant director of the Republic of Croatia’s Health Insurance Office.

The outcome of the accumulated debt is the rejection of patients from the FBiH in some clinics and health institutions in Croatia, said assistant director Jasenka Pap.

Meanwhile, the RS Health Insurance Fund paid 42 million KM between 2001 and 2003 for the treatment of their patients in Serbia-Montenegro.

The majority of these patients could be treated in the RS at one-third the cost, according to the director of the RS Health Insurance Fund.

For example, director Luka Kosanović added, it would be much less expensive to send patients from the Trebinje region to Sarajevo, Mostar, Tuzla or Banja Luka for a treatment rather than to send them to Serbia-Montenegro.

‘It is crazy to throw money into someone else’s bag, when ours is empty’ Kosanović said, adding that the insured persons are the ones hurt the most when money is spent without control by sending them abroad.

The greater part of this money could be used to equip hospitals, health centers, but also to improve health services, Kosanović said.

‘Don’t ask me why patients do not trust doctors and health institutions, not only in the Federation of BiH, but also for the most part in the Republic of Srpska as well’ said a frustrated Kosanović. ‘Ask the BiH Presidency who is to blame for this situation.’

Political and regional conflicts are present in the health system, although they should not be, said RS Health Minister Marin Kvaternik.

According to Kvaternik, the problem is larger in the FBiH, where there are 11 health insurance funds, than in the RS, which has just one health fund administered in eight branch offices.

‘I believe the real problem to be in the Federation of BiH. The administration alone in this entity spends a lot and represents a big cost for the insured’ Kvaternik said, and then he ended the discussion. ‘I would not like to discuss other peoples’ problems.’

Although Kvaternik and his counterpart Lučić, the FBiH health minister, are pointing fingers at each other’s entities as the problem, others see the only solution to the financial and administrative problems in finally burying the legacy of the war.

‘There is a solution’ said Kosanović, the Trebinje insurance office director. ‘Health insurance should be at the state level.’

A state-level organization including all the funds in both entities with local administration, would put an end to the ‘nationalistic herd mentality’ that Kosanović said is ultimately responsible for the regional conflicts and the waste of millions of KM.

‘I think the BiH Presidency should solve this problem’ Kosanović said.

Kosanović’s boss, the director of the RS Health Insurance Fund Nebojša Zgonjanin, disagreed. The solution, Zgonjanin said, is in the status quo.

‘I do not believe this (a state-level entity) to be the right solution’ Zgonjanin said. ‘The solution should be sought within existing agreements and contracts.’

A state-level ministry of health, like everything else in the current system, may have to wait.

The BiH government is talking to the international community, not the entities, about the possibility of a state ministry of health, said BiH Civil Affairs Minister Safet Halilović.

‘What we will have for sure in the near future is the introduction of an electronic heath card for all who have mandatory health insurance’ Halilović said. ‘It was the first deputy of the High Representative, Donald Hays himself, who proposed establishing of the …system.’