7.1 General context
Bosnia and Herzegovina (BiH) is classified as an upper middle-income country. As a former republic of the Socialist Federal Republic of Yugoslavia, BiH inherited a fully articulated modern system of education, healthcare, social insurance and welfare. Although the basic structures of the system remain in place today, the consecutive impact of the conflict of the 1990s, economic transition, external economic shock, austerity policies, low growth and rising inequality have left many parts of the system unable to provide the quality of care and equality of access required by citizens.
The existing social assistance system creates inequality among its clients based on both their place of residence (territorial inequality) and the social category to which the user belongs (status-based inequality).
Overall, the social assistance system in BiH fails to reach many of the most vulnerable and to keep them from descending into poverty.
At 9.2 per cent of GDP, healthcare expenditure in BiH is the highest in the region yet has lower health outcomes, less medical staff and number of hospital beds in comparison with the neighbouring countries. This is in part a result of the devolved administration that entails substantial duplication and hinders coordination.
When it comes to lifestyle of young people in BiH, it seems worth mentioning that in 2014 the Canton of Sarajevo Ministry of Education, Science and Youth, acting in cooperation with the XY Association issued a syllabus called Healthy Lifestyles, targeting pupils at elementary schools, which should help youth to have more quality life and to learn what quality life is. According to Association XY survey conducted before the syllabus creation, young people in BiH enjoy shopping (33.9 percent of them say they go shopping at least once a week, although half of them have never done any shopping online), and 39 percent of young people believe that wearing branded clothes is important or very important. Healthy eating is important or very important to 84.5 percent of young people, while only 1.2 percent of them says it is not important at all. Of the only 16.7 percent of young people who say that they have more money for personal needs in comparison to other youth in BiH, it is questionable how much they can afford healthy food and branded clothes. Yet 81 percent of respondents say that looking good is important or very important to them (48.5 percent of them say they are satisfied with the way they look, and 27.2 percent are very satisfied).
51 percent of youth say they never drink any alcohol and 96 percent never used any soft drugs. Also, 66.6 percent of youth say they do not smoke cigarettes and never have. On the other hand, 20.3 percent of them smokes cigarettes every day.
When it comes to sexual and reproductive health, the most common age for the first sexual intercourse is 17 – 18, with 42 percent of young people saying they use birth control methods as a rule. However, 15.5 percent of young people were uncomfortable about discussing this issue.
71.6 percent of respondents rate their health as very good or excellent. In general, one can say that young people are aware of the importance of healthy lifestyles and try to base their lives on these foundations as much as possible.
In this context, 66.3 percent of young people say that engaging in sports is important or very important, although 49 percent of youth do sports rarely or never. Since engaging in sports has a significant commercial aspect (it requires specific equipment, membership fees at sports clubs or for using sports facilities), one can say that young people would like to do sports and consider this to be quite important but cannot afford it. 40.8 percent of them say that they are concerned about poverty in society, allowing one to identify this as an issue that affects their lives. Of course, there are some sports activities that do not require significant financial investments by youth, but most sports clubs are commercial ones.
BiH inherited a system of social insurance (healthcare, old age pension insurance, unemployment and disability insurance, and child protection in RS) in which entitlement is linked to employment and based on paid contributions. Coverage is straightforward for anyone who is formally employed along with his or her dependents. The employer deducts the employee’s health insurance contribution as a constant percentage of base pay that cannot be low-er than the minimum wage, with no minimum or maximum levels, from his or her wage and pays it directly into the respective insurance fund in the employee’s place of residence.
Given that citizens of BiH can live in one entity and work in another, the interrelationship between place of residence, payment and treatment are important. The health insurance contributions employers deduct from their employees’ wages flow into the fund in the employee’s place of residence and are not transferable. Citizens in FBiH are expected to receive planned care through the entity or the canton of their residence, while by law emergency medical treatment is provided at the nearest appropriate facility regardless of insurance coverage. Patients can be referred elsewhere for specialist treatment, with the payments being transferred between the respective funds and care institutions.
Each registered individual receives a health booklet and must ensure that it is stamped regularly (monthly or quarterly) to show that the contributions have been paid by them or on their behalf. The paper booklets are gradually being replaced by smart cards, but the principle remains the same.
While the underlying principle of an insurance based healthcare system is that care is provided to those who have insurance coverage, the Constitution of BiH follows the European Convention on Human Rights. In 2008, by ratifying the European Social Charter, BiH accepted the obligation to provide the uninsured with access to necessary healthcare. Under the Charter parties are required, "to ensure that any person who is without adequate resources and who is unable to secure such resources either by his own efforts or from other sources, in particular by benefits under a social security scheme, be granted adequate assistance and, in case of sickness, the care necessitated by his condition." In practice, however, many people lack adequate coverage. Current estimates suggest that only 78 per cent of the population of RS and 86 per cent of the population of FBiH are covered by health insurance. This estimate ranges from a low of 64 per cent in Canton 10 to a high of 96 per cent in the Sarajevo and the West Herzegovina cantons. In addition to the variation in the levels of coverage across the entities, the level of average per capita expenditure varies widely across the cantons of the Federation of BiH. The rate in Sarajevo Canton, for example, is nearly double that of the Central Bosnia Canton. Aside from those employed by enterprises that are in financial difficulty (including many state-owned companies and hospitals) and fail to pay the health insurance contributions required under law, the lack of coverage most frequently affects individuals outside the formal economy who are vulnerable according to one or more dimensions.
Although individuals without health insurance have the right to medical treatment, they and their dependent family members are less likely to seek preventive care and to delay addressing health problems until they become more acute and thus more difficult as well as expensive to treat. While emergency care is provided for those without insurance, despite the absence of the 'adequate assistance' guarantee, vulnerable individuals may not be aware of their right to receive care and may find it difficult or impossible to obtain care.