Health Systems in Action (HSiA) Insights - Bosnia and Herzegovina

Key points ● Bosnia and Herzegovina consists of two entities – the Federation of Bosnia and Herzegovina, and the Republika Srpska – and the Brčko District of Bosnia and Herzegovina. The Federation of Bosnia and Herzegovina is further divided into 10 cantons, each governed independently by cantonal governments. The resulting complex structure includes 13 health insurance funds and 14 ministries in charge of health. ● Health policy decisions are centralized in the Republika Srpska and decentralized to the canton levels in the Federation of Bosnia and Herzegovina, complicating reform and consensus-building efforts. ● Although social health insurance schemes are mandatory in both entities, population coverage is not universal and varies across the entities of Bosnia and Herzegovina and the cantons within the Federation of Bosnia and Herzegovina, leaving significant portions of the population with very limited access to publicly financed health care. ● In the case of the Federation of Bosnia and Herzegovina, resource pooling occurs at the cantonal level, which hinders equitable distribution and accessibility of services, particularly in secondary and tertiary care, and results in limited patient choice. In the Republika Srpska and the Brčko District of Bosnia and Herzegovina pooling takes place at the entity/district level. ● Health care provision remains largely hospitalbased, although efforts are under way to strengthen primary health care (PHC). Other reforms aim to improve prevention programmes for noncommunicable diseases (NCDs) and immunization, as well as initiatives to digitalize health records and introduce e-health to improve accessibility and efficiency of care. ● Public spending on health as a share of gross domestic product (GDP) declined in the years before the COVID-19 pandemic. Out-of-pocket (OOP) spending is high (amounting to 31% of health spending in 2021), which results in a relatively high degree of financial hardship, affecting over 8% of households in the Federation of Bosnia and Herzegovina and almost 10% in the Republika Srpska. ● Despite increased bed capacity in response to the COVID-19 pandemic, Bosnia and Herzegovina still has a comparatively low ratio of hospital beds per population. Occupancy rates vary significantly between entities, indicating disparities in health care demand and/or resource utilization. ● The numbers of physicians and nurses per population in Bosnia and Herzegovina have increased markedly. However, the country lacks a strategic approach to health workforce development in the face of an ageing health workforce and increasing emigration to other countries. ● Bosnia and Herzegovina experienced substantial excess mortality during the COVID-19 pandemic. Nevertheless, the pandemic did not undo gains in maternal and infant mortality rates, with both reaching historic lows in 2021. ● Prior to the COVID-19 pandemic, mortality rates in the country declined, including premature mortality. Cardiovascular disease remains the leading cause of death and disability. Premature mortality among adults aged 30 to 69 years is mainly due to cancer. ● Behavioural risks such as smoking and unhealthy diets, as well as hypertension and high fasting blood sugar, are major contributors to ill health. Ongoing efforts are aimed at promoting healthy lifestyles, including the implementation of stricter tobacco policies and the provision of smoking cessation services by family doctors.