Challenge
Because of the war (1992-1995) and post-conflict needs of reconstruction and institutional development, BiH lagged behind many other countries in Central and South Eastern Europe in addressing the challenges faced by the health system. First, the burden of disease was high, largely attributable to non-communicable diseases – 50 percent of deaths were attributed to cardio-vascular disorders and about 20 percent to cancers. Second, the health system was unsustainable (in 2000, total expenditures on health accounted for about 6.9 percent of GDP) and inequitable (with more than half of health expenditures spent by households for health as direct out-of-pocket payments). Finally, the health system was inefficient, with poor quality of services and lack of coordination resulting in more cases being referred to and health care being delivered in hospitals than necessary (a referral rate from medical offices to hospitals of more than 50 percent, whereas, in Europe, the typical referral rate is around 20 percent).
Approach
Starting in 2000, the Bank supported the development of consistent primary health care (PHC) system restructuring strategies by the two BiH governing entities (the Federation and Republika Srpska) with the assistance of other development partners in order to strengthen the point through which most people access the health system and are potentially referred to higher and more expensive levels of care and receive prescriptions since unnecessary referrals and treatment cost the public system and the households.
The delivery of PHC services through Family Medicine (FM) teams – with its focus on the health of an entire family, prevention of disease, as well as curative services and coordination of care with other providers – was initially piloted and evaluated. It was found that the FM teams (particularly, those led by FM Specialists and those who were accredited) did indeed provide for better quality and coordination of care, and required fewer referrals to higher levels of care. A pilot evaluation determined that 35 percent fewer cases were referred. The Health Sector Enhancement Project (HSEP) supports the scaling up of the Family Medicine Model from the initial pilot to national implementation.
Results
The Project focuses on restructuring of the PHC systems of BiH through the expansion and enhancement of Family Medicine. Specifically, the following results have been achieved between 2005 and 2010:
- Primary health care restructuring strategies were developed and approved by both BiH entities so as to be consistent in approach across the country.
- The pilot enrolled and provided services to about 216,000 people, or about 5 percent of the BiH population, by 2005. By the end of 2010, HSEP had scaled-up the project to reach about 2.2 million people, or 58 percent of the population.
- By the end of the academic year in 2010, nearly 575 doctors had completed a three-year specialization program in Family Medicine that did not exist at the start of the reform.
- The Project has supported a one-year intensive knowledge and skills development program for nearly 1,100 doctors and 2,500 nurses to address the existing health professionals working in primary health care and to establish a team relationship between the primary health care doctors and nurses.
- The buildings of Primary Health Care Centers in 135 communities have been constructed or renovated and equipped to support the operation of more than 625 Family Medicine offices.
- The investments in the education, training and physical capacity of the FM offices provide the prior conditions for the FM team to meet the accreditation standards. A study from the Republika Srpska provides evidence that the quality of care and the continuity of care is significantly higher in those teams having been accredited (Quality of Care Index is 0.8440 in accredited FM teams and 0.5738 in non-accredited FM Teams).
Bank Contribution
The Bank and other development partners provided technical support to the BiH authorities in the development of their primary health care restructuring strategies, reforms of the social insurance system, and other key areas through other operational and analytical instruments. The Bank, through HSEP, has provided IDA financing of US$17 million towards the overall Project objectives and has approved additional IDA financing of US$10 million on March 22, 2011, to further scale up the Project until 2014. The Bank contributes about 40 percent of the total costs of the Project, which is co-financed by the BiH authorities and the Council of Europe Development Bank.
Partners
The Bank has worked with a number of key development partners – the Council of Europe Development Bank (CEDB), the Canadian International Development Association, the Swiss Agency for Development and Cooperation, the World Health Organization, and the EU – to support the BiH authorities to develop and implement its reform strategies. In particular, HSEP has helped BiH authorities receive and execute US$14 million in co-financing from the CEDB for investment in the primary health care infrastructure and technology. Since the Bank has approved an extension and scaling up of HSEP, the BiH authorities and CEDB are in discussions concerning a further US$10 million loan to support the implementation of HSEP.
Toward the Future
Bank support is mainly about a transition to a new system based on Family Medicine. Continued support will be achieved through BiH financing of the medical education of FM specialists, and the social health insurance financing of the primary health care services. Based on the path followed by its neighboring countries, the next stage of development in the health sector will be towards determining how other funds that may become available through the process of integrating with the EU can be used to address other health investment and restructuring needs to benefit the health and financial protection of the population.
Beneficiaries
Zoran lives with his extended family of ten people in Banja Luka of the Republika Srpska of BiH. “A family doctor is a doctor who approaches the whole family, from the youngest members to the oldest one. Now we have fast and good quality health care. This means we can make an appointment with our family doctor, which has not been the case in the past. The family doctor provides continuous care for our health, and personally provides adequate treatment to each member of my family. All this time, our family doctor monitors us, and is now in a position to remind us to, for example, come and pick up our prescription. Or the doctor may say: ‘Zoran, I think your wife did not get her referral to a specialist. Here it is. I have prepared it for you.’ This is something I am delighted with.”
RSS