Bosnia’s weak health system is the cause of the highest mortality rate in West Balkans

Bosnia and Herzegovina has registered the highest Covid-19 mortality rate in the West Balkans, as a health system weakened by budget cuts could not respond to the pressure. This difficult situation has only been made worse by limited access to vaccines.

July 29, 2021 by Ana Vračar
Banners outside a health center in the town of Odžak in Bosnia and Herzegovina where workers went on strike in June.

During June 2021, health workers in government-run institutions in different cantons of Bosnia and Herzegovina (BiH) went on strike to protest the deteriorating working conditions in the sector. Health workers in Sarajevo Canton, one of the country’s ten administrative units, have spent the last 22 months agitating for better pay and working conditions, without much response from the government. Finally, they launched a strike on June 14.

At the same time, workers in a community health center in the town of Odžak, Posavina Canton, went on strike after they were not paid salaries for May. The workers highlighted the overall conditions in which the center has been forced to operate. One of the doctors, Mirza Omerbašić, told the media that the situation had become untenable after the local government failed to allocate funds for the center’s work earlier this year. Although both actions referred to the Covid-19 pandemic as the cause of deterioration of working conditions, the roots of the problems can be traced back to the long-term weakening of the health system in Bosnia.

Healthcare dismantled

Since the 1990s, regional differences in access to healthcare in Bosnia have grown, mostly due to an uncoordinated atomization of responsibilities for healthcare delivery between the cantons.  Today, the bulk of the responsibility for ensuring access to healthcare falls upon the governments of the autonomous entities – the Federation of Bosnia and Herzegovina, Republika Srpska (RS), and the District of Brčko – while the federal government has limited say on any decisions of importance.

Mario Kikaš, a regional analyst from the portal Bilten, says that complications are created by the fact that there are no links between the healthcare systems in the Federation and RS. “There is no state ministry of health nor clear protocols between health institutions in the different parts of the country. This was particularly pronounced during the pandemic, as there was a constant gap in epidemiological measures between the entities.”

The lack of coordination renders public health services completely dysfunctional, he says.  “This is particularly true for the Federation, where public health is completely under the jurisdiction of the cantons. This means that not only is the infrastructure unequally distributed among the cantons, but also that there are 10 different institutions in charge of health insurance,” he adds. “For example, if a person from Konjic in the Herzegovina-Neretva Canton who works in Sarajevo is insured through her employer, she will not have access to primary health care at home.”

The haphazard distribution of responsibilities, along with extremely limited funds for public healthcare, has opened the doors for private healthcare providers. “Compared to other countries in the region, privatization of healthcare in BiH has gone the furthest. For most diagnostics, people are forced to use private services,” explains Kikaš.

No signs of solidarity

Although many key health institutions are formally still government-owned, their capacities have been weakened by the lack of funding. The extent to which the healthcare system was undermined in this manner was illustrated by Bosnia’s pandemic response and vaccination efforts. As of July 28, BiH had the most Covid-19 related deaths in the West Balkans. It is also the third highest ranking country in the world when it comes to Covid-19 related deaths per million inhabitants, preceded only by Peru and Hungary.

BiH still struggles to obtain vaccine doses through direct procurement because of complicated bureaucratic processes and steep pricing. Instead, like in North Macedonia and Albania, the vaccine rollout is strongly related to the dynamics of COVAX dispatches and humanitarian donations.

The first batch of the COVAX doses was expected to reach early this year, but it turned out that BiH did not fulfill the technical conditions for the storage of the Pfizer vaccine and hence, they arrived only in March. Kikaš points out, “Inertia and delayed reaction had a big role in shaping the country’s Covid-19 vaccine rollout. The complete failure of the COVAX mechanism didn’t help, of course.”

Approximately 940,000 vaccine doses were administered in BiH, which was not even enough for priority groups, including health workers. In comparison to other countries of the region which too depend on COVAX and donations, with the exception of Kosovo, BiH has the lowest vaccination rate: only 7% of the population has received both doses of the vaccine, and less than 12% of them have received at least one. In comparison, the percentage of people with at least one dose of the vaccine in both Albania and North Macedonia is now at around 23%.

Just a car drive away, in Serbia and Croatia, 42% and 39% of the population respectively have received at least one dose of the vaccine. Although the proximity of the two countries enabled a certain percentage of the population of BiH to access the vaccine sooner than at home, there was no sign of a solidarity-based approach to vaccine sharing between the neighbors.

Instead, the advantage of having more vaccine doses available is being used by the surrounding countries to show their pandemic responses as far more advanced than the one in Bosnia, and as a way to exert political influence in the region. Croatia and Serbia opened their vaccination programs to BiH citizens only after it became clear that the local drive was slower than expected. “Sure, if you set the bar low enough, Bosnia did get some doses through neighbors and donations. But their actions should be analyzed keeping in mind the specific geopolitical and regional public health context Bosnia is part of,” Kikaš concludes.

Although it is situated right outside of the borders of the EU, it seems that Bosnia has very little in common with its richer neighbors. Unless there are drastic changes to how rich countries are approaching global vaccine distribution and public health systems in general, this is unlikely to change.

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