HI 74a - Landmine victim assistance in Bosnia and Herzegovina Herzegovina

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L'assistance aux victimes des mines terrestres en Bosnie-Herzégovine: document de travail pour soutenir l'élaboration d'une stratégie à long terme pour l'assistance aux victimes des mines …

L'assistance aux victimes des mines terrestres en Bosnie-Herzégovine: document de travail pour soutenir l'élaboration d'une stratégie à long terme pour l'assistance aux victimes des mines terrestres

Auteur: Handicap International, l'UNICEF, du Centre international de réhabilitation (CIR), Share-SEE
Pays: Bosnie-Herzégovine
Date: 2003
Public: Spécialisé
Type: Ouvrage, Rapport
Lyon: Handicap International, 2003 .- 49 p.

Rapport sur l'Assistance aux Victimes de mines en Bosnie-Herzégovine, et Plus précisément sur la situation des personnes handicapées en matière de protection sociale, de législation et de réhabilitation.

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  • 1. LANDMINE VICTIM ASSISTANCE IN BOSNIA AND HERZEGOVINA Working paper to support the elaboration of a long-term strategy for landmine victim assistance December 2003
  • 2. Landmine victim assistance in BiH – Handicap International – December 2003 2 CONTENTS 1. Executive Summary................................................................................................................4 2. Introduction ............................................................................................................................6 3. BiH Legislation related to Landmine Victim Assistance .......................................................9 3.1. Assessment ....................................................................................................................11 3.1.1. Eligibility ................................................................................................................11 3.1.2. Impairment categories ............................................................................................12 3.1.3. Assessment process ................................................................................................13 3.2. Entitlements and benefits...............................................................................................13 3.2.1. Entitlements and benefits for Civilian Victims of War ..........................................13 3.2.1.1. Entitlements of Civilian Victims of War in the FBiH: ....................................13 3.2.1.2. Entitlements of Civilian Victims of War In RS...............................................16 3.2.2. Entitlements and benefits of Disabled Veterans.....................................................17 3.2.3. Examples of amounts of benefits............................................................................19 3.2.4. Specific case of the Brcko District .........................................................................19 3.3. Reforms .........................................................................................................................20 4. Medical and rehabilitation Care ...........................................................................................21 4.1. Overview of the Healthcare system in Bosnia and Herzegovina ..................................21 4.1.1. General Health overview of BiH's population........................................................21 4.1.2. Health care financing..............................................................................................22 4.1.3. Emergency care and hospital care ..........................................................................24 4.2. Rehabilitation care .........................................................................................................25 4.2.1. Physical rehabilitation ............................................................................................25 *(3 rehabilitation centres + 1 centre for paraplegics in Sarajevo Physiatric and Rehabilitation Institute). ............................................................................................................................25 4.2.2. Mental Health services ...........................................................................................30 4.2.3. Ortho-prosthetic services ........................................................................................30 4.2.3.1. Facilities...........................................................................................................30 4.2.3.2. Professionals ....................................................................................................33 4.2.3.3. Financing of ortho-prosthetic devices .............................................................34 4.2.3.4. Conclusion regarding ortho-prosthetic devices ...............................................36 5. specific programs for landmine victim assistance ................................................................37 5.1. Overview of the main existing landmine victim assistance programs ..........................37 5.2. Comprehensive analysis of landmine victim assistance................................................38 6. Information system ...............................................................................................................40 6.1. Objectives of a landmine victim assistance information system ...................................40 6.2. Overview of existing databases on landmine victims....................................................40 6.3. Analysis and recommendations .....................................................................................43 7. Conclusion ............................................................................................................................46 Annexe – List of the main BiH laws related to the field of landmine victim assistance..........48
  • 3. Landmine victim assistance in BiH – Handicap International – December 2003 3 The assessment presented in this report was the result of cooperation between Handicap International and UNICEF. It was undertaken from August to November 2003. The Centre for International Rehabilitation (CIR) collaborated to the assessment of ortho-prosthetic services. We would like to thank the BHMAC for its support to the organisation of a round table discussion on November 17th 2003 at which the main outcomes of the assessment were presented and discussed with stakeholders involved in landmine victim assistance in BiH. Our thanks also go to all the professionals working in rehabilitation institutions and centre for social work, assistant ministers and members of associations and organisations who agreed to provide us with information and documents needed for this assessment. The team who prepared and implemented this assessment was comprised of: Charlotte Axelsson Dejan Babalj Anne-Claire Colleville Alexandre Cote Vedran Fajkovic Pascal Granier Ivana Milincic Laure Van Ranst Enver Suljic Gradimir Zajic From Handicap International’s office for South Eastern Europe And Christian Schlierf, from the Centre for International Rehabilitation.
  • 4. Landmine victim assistance in BiH – Handicap International – December 2003 4 1. EXECUTIVE SUMMARY Bosnia and Herzegovina (BiH) is the most heavily mine affected country in South Eastern Europe. Since 1992, 4,824 landmine/UXO1 casualties have been registered. Assistance to landmine victims is a comprehensive process that includes medical, psychological, social and economic components. It aims at full socio-economical reintegration of landmine victims into society. As such, it is an integrated part of the overall system of assistance for persons with disabilities. Governments of both Entities are responsible for the provision of assistance to persons with disabilities including landmine victims, within the framework of their overall Social and Healthcare policies. Many improvements were achieved in those domains over the last 8 years, thanks to reconstruction programs and reform processes. But international assistance is still needed to fill the existing gaps and support the build-up of local capacities. With the aim of improving coordination among stakeholders involved in landmine victim assistance, the BiH Mine Action Centre (BHMAC), which is responsible for the development of a long-term strategy for Mine Action and Landmine Victim Assistance in BiH, has initiated regular landmine victims’ assistance meetings starting from September 2003. In that framework, Handicap International undertook, in collaboration with UNICEF, an analysis of the existing landmine victim assistance services in Bosnia and Herzegovina, with the objective of providing stakeholders with elements that allow further elaboration of a comprehensive long-term strategy for landmine victim assistance. The report reviews the legislation on social protection of Civilian Victims of War and Disabled Veterans. It also analyses the existing rehabilitation care system for persons with disabilities, and the existing specific landmine victim assistance programs. Finally, it reviews the main information sources available on landmine victims in BiH. Legislation: Four different schemes coexist in BiH that provide benefits for persons with disabilities: ! The Social Insurance system provides with pension and disability insurance workers who became unable to work because of a disability resulting from an injury or a disease; ! The Social Protection system provides social assistance for citizens in a state of social need, which includes persons with disabilities as a specific category; ! The Protection of Civilian Victims of War aims at compensating victims for injuries resulting from the war, and the families of those who died during the war; ! The War Veterans system notably provides compensation for the sacrifice made by military personnel who became disabled as a result of the war. Large discrepancies in the level of benefits exist depending on the status of beneficiaries (mentally or physically disabled person, Civilian War Victim, Disabled Veteran from either Army) and due to limited resources available to pay for benefits, with variability according to the geographic location. 1 Mine Victims Statistics BiH – November 2003, International Committee of the Red Cross (ICRC)
  • 5. Landmine victim assistance in BiH – Handicap International – December 2003 5 Rehabilitation care system: The report reviews the relevant legislation on healthcare and health insurance, and maps the main existing rehabilitation facilities (including 7 rehabilitation centres, 7 spas, 60 Community Based Rehabilitation centres, Physical Medicine and Rehabilitation departments in Clinical Centres and Hospitals, 24 ortho-prosthetic workshops) and the human resources available. There are significant discrepancies in the quality of existing rehabilitation services, due to the absence of professional standards and a lack of coordination. The access to rehabilitation care services is also very unequal, especially for ortho-prosthetic devices, due to the financial participation that patients have to pay, and to the lack of a harmonised and transparent approach to the setting of exemption criteria. Landmine victim assistance programs: The report provides an overview of these programs. The main shortcomings identified are their poor mutual coordination or with local institutions, and the fact that a number of them are still implemented in place of existing local stakeholders, which is not cost-effective and jeopardises the efforts made to build local capacities. Information system: The existing data about landmine victims in BiH is very fragmented, and provides insufficient information about their real socio-economical situation. This lack of reliable information on landmine victims allows neither a precise assessment of their needs nor monitoring of the impact of assistance programs. To conclude, the definition of a comprehensive and long-term strategy for landmine victim assistance should be underpinned by the principle of mainstreaming landmine victim assistance within the overall assistance to disabled persons in BiH. In that process, specific attention should be paid to: • Establishment a Landmine Victim Assistance Information and Research System, producing reliable and comprehensive information on the situation of landmine victims, in order to improve coordination and to allow proper allocation of resources and monitoring of the impact of assistance programs; • Improvement of coordination between international organizations working in the field of landmine victim assistance and local authorities and institutions; • Placing emphasis on strengthening of Bosnia and Herzegovina rehabilitation care system for people with disabilities, notably through promoting interdisciplinary and patient-centred approach, and developing quality standards for ortho-prosthetics and medical rehabilitation; • Harmonizing access to rehabilitation services, notably through the definition of a basic benefit package for this area; • Vocational training and promotion of employment.
  • 6. Landmine victim assistance in BiH – Handicap International – December 2003 6 2. INTRODUCTION Bosnia and Herzegovina (BiH) is the most heavily mine affected country in South Eastern Europe. With about 4 % of its territory’s area suspected to be contaminated by landmines/UXOs2 and with 4,824 landmine/UXO3 casualties, of a total population of 4,066,000 inhabitants4, registered since 1992, the country and its population has been deeply affected by landmines. Map 1: BHMAC, Mine Situation in BiH 2 Landmine Monitor Report 2003, ICBL. 3 Mine Victims Statistics BiH – November 2003, International Committee of the Red Cross (ICRC) 4 Selected indicators for BiH 2001, WHO (http://www3.who.int/whosis/country/indicators.cfm?Country=bih)
  • 7. Landmine victim assistance in BiH – Handicap International – December 2003 7 The political institutions of BiH are responsible for the provision of assistance to landmine victims, within their overall social protection and healthcare systems. However, because of the disruption to these systems caused by the war, and in the context of a slowly recovering economy, international assistance was and still is required to fill the gaps. Even though the number of landmine/UXO incidents shows a continuously decreasing trend since 1996 (632 incidents in 1996, 72 in 2002, and 53 from January to October 20035) largely thanks to Mine Action programs, assistance should be considered in a long-term context, as the needs of landmine victims for assistance are life-long. However, up until recently landmine victim assistance programs have been implemented within the framework of emergency support and as a substitute for what would normally be the state’s responsibility. One of the results is that at present there is no comprehensive and integrated strategy to plan and sustain this assistance, while the decline of international funds earmarked for landmine victim assistance in Bosnia and Herzegovina has already resulted in closing or scaling back of a number of these programs. From September 2003, the BiH Mine Action Centre (BHMAC), which is responsible for the development of a long-term strategy for Mine Action and Landmine Victim Assistance in BiH, has initiated regular landmine victims’ assistance meetings with the aim of improving coordination among stakeholders involved in landmine victim assistance. Meanwhile, Handicap International, in collaboration with UNICEF, undertook an analysis of the existing landmine victim assistance services in Bosnia and Herzegovina, mapping the resources and pointing out the gaps, with the objective to provide stakeholders with elements that allow further elaboration of a comprehensive long-term strategy for landmine victim assistance. The main outcomes of this assessment were presented at a round table conference on 17 November 2003. It was then decided to create a working group to prepare this landmine victim assistance strategy. This report presents a comprehensive description and analysis of existing landmine victim assistance services in BiH, to be used as a working document for the coming strategic work. Landmine victim assistance is a comprehensive process that should not be taken to be solely a medical and rehabilitation issue. The ultimate goal of landmine victim assistance is full social reintegration. It is comprised of the following components6: ! Pre-hospitalisation care (first aid and medical evacuation); ! Hospital care (surgery, medical care, pain management…); ! Rehabilitation (physiotherapy, prosthetic appliances, technical aids, psychological support); ! Social and economic reintegration (peer groups, professional re-education, vocational training, income-generating projects, leisure and recreational activities…) ! Laws and policies (development of inclusive legislation for persons with disabilities, education and public awareness campaigns, advocacy for the promotion of the rights of people with disabilities and landmine victims…); ! Information system and research in Health and Social Welfare; 5 Mine Victims Statistics BiH – November 2003, International Committee of the Red Cross (ICRC) 6 Landmine Victim Assistance – World Report 2002; Handicap International.
  • 8. Landmine victim assistance in BiH – Handicap International – December 2003 8 In fact, none of these components is specific to landmine victims. The overall landmine victim assistance process is similar to the assistance to persons with disabilities in general. And as such, the social and health services delivered to landmine victims cannot be dissociated from the overall Social Protection and Healthcare systems. Therefore, the situation of landmine victims cannot be studied separately from that of other persons with disabilities, but has to be tackled with a comprehensive approach to disability. The methodology used for the assessment was four-tiered: ! The legislation on social protection of Civilian Victims of War and Disabled Veterans was examined in both entities in the framework of the overall social protection system for disabled persons; ! An assessment of existing rehabilitation care system was undertaken, including a review of relevant legislation on healthcare and health insurance, a mapping of existing facilities, and gathering information directly from some of the rehabilitation institutions and ortho-prosthetic workshops; ! Interviews were held with organizations providing landmine victim assistance services and previous reports on landmine victim assistance services were reviewed; ! An analysis of the main information sources on landmine victims was done.
  • 9. Landmine victim assistance in BiH – Handicap International – December 2003 9 3. BIH LEGISLATION RELATED TO LANDMINE VICTIM ASSISTANCE Based on the Dayton agreement signed in December 1995, Bosnia and Herzegovina (BiH) is a State comprised of two entities, the Federation of Bosnia and Herzegovina (FBiH) and the Republika Srpska (RS)7, while the Brcko District is a single administrative unit of local self-government existing under the sovereignty of Bosnia and Herzegovina8. Besides the central government of Bosnia and Herzegovina, each entity has its own government with its own legislative and executive branch. These entity level governments are, amongst other issues, responsible for Social Welfare and Health and related legislation. Brcko District also has its own legislation. The RS has centralised political institutions, whereas the FBiH has decentralised political institutions, with 10 cantons that share responsibility with the Federal level, notably for Social Welfare, Health and public services. Each canton is responsible for enacting its own laws, which must be consistent with federal laws. Landmine victims are commonly defined as persons who sustain a fatal or non-fatal injury, caused by the explosion of a landmine or explosive ordnance. The category of Landmine Victims doesn’t exist in law, but those victims will be referred either to the Disabled Veterans’ system or to the Civilian Victims of War protection system depending on whether they were civilians or military personnel at the time of the accident. Victims’ rights differ from one system to the other. According to the ICRC database9, out of 4,824 registered landmine/UXO incidents since 1992, 56.1 % affected military personnel military personnel. Thus, four systems regulating benefits for persons with disabilities coexist in BiH, with distinct purposes: ! The Social Insurance system insures workers’ income source, and provides workers who became unable to work because of a disability resulting from an injury or a disease10with pension and disability insurance; ! The Social Protection system which provides social assistance for citizens in a state of social need, which includes persons with disabilities as a specific category; ! The Protection of Civilian Victims of War aims at compensating victims for injuries resulting from the war, and the families of those who died during the war; ! The War Veterans system, which notably provides compensation for the sacrifice made by military personnel who became disabled during the war. A list of the Laws that were reviewed for the purpose of this analysis is presented in the Annex, with complete references. 7 Constitution of Bosnia and Herzegovina, (Annex 4 of “The General Framework Agreement for Peace in Bosnia and Herzegovina”). 8 Statute of the Brcko District of Bosnia and Herzegovina, article 1 (“Official Gazette of Bosnia and Herzegovina”, no. 9/00; “Official Gazette of the RS”, no. 8/00) 9 Interview with Mr Mustafa Sarajlic, cooperation assistant, ICRC, on October 6th. 10 FBiH Law on Pension and Disability Insurance (“Official Gazette of FBiH” 29/98, 49/00, 32/01), RS Law on Pension and Disability Insurance (“Official Gazette of RS” no. 32/00, 40/00 and 37/01).
  • 10. Landmine victim assistance in BiH – Handicap International – December 2003 10 Table 1: Different systems regulating benefits for persons with disabilities in BiH. Social Civilian Victims Disabled Social Protection Insurance of War Veterans Aim Insures workers’ Provides assistance for Compensating victims Recognising the income source citizens in a state of social and/or their family sacrifice of military need members for fatal or personnel who died or non-fatal injuries where injured during the sustained during the war, and compensation war. of loss of earning capacity. Eligibility Workers who have Persons with disabilities in Civilians who were Military personnel who contributed to a situation of social need. injured because of the were injured because of Social Insurance war (during or after the the war (during or after and became war), with impairment the war), with unable to work due rate ≥ 60 %. impairment rate ≥ 20 %. to injury or disease Management By Pension and By Centres for Social - By Centres for Social By Ministries in charge Disability Fund, at Work: Work in FBiH, under for Disabled Veterans in Entity level. - At Cantonal level in Cantonal jurisdiction; either Entity. FBiH. - By Ministry of Labour - Centralised in the RS. and Veterans in RS. Benefits Disability pension. − Permanent financial allow. Refer to paragraph Refer to paragraph − Allow. 3rd person assist. 2.2.1. 2.2.2. − Placement into social institutions / foster families − CSW services. • Laws on protection of Civilian Victims of War: In the FBiH the same law regulates the Social Protection system and protection of Civilian Victims of War11, which lays down the basic rights. The system for Social Protection of Civilian Victims of War, as well as the overall Social Protection system, is under the jurisdiction of Cantons. Each Canton was obliged to enact its own law consistent with this FBiH law within 3 months. So far, 3 Cantons didn’t enact their law on Social Protection (Zenica-Doboj, Herceg-Bosna and Hercegovina-Neretva Cantons). Centres for Social Work administer assessments and benefits. In the RS, the Law on protection of Civilian Victims of War12 is distinct from the law on social protection13. The Ministry of Labour, Veterans and Victims of War administers the protection of Civilian Victims of War, through its regional offices. • Laws concerning Disabled Veterans: The laws on rights of Veterans, disabled Military Personnel and Families of Fallen Soldiers aim at recognizing the sacrifice made by veterans who were killed or became disabled; compensating the loss of earning capacity in case of disability resulting from the war or the loss of financial support for family members of soldiers killed during or because of the war; and covering basic needs of disabled veterans and families of killed soldiers. 11 FBiH Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children, article 11 (“Official Gazette of FBiH”, no. 36/99) 12 Law on Protection of Civil Victims of War (“Official Gazette of RS”, no. 25/93) 13 Law on Social Protection (“Official Gazette of RS”, no. 5/93 and 15/96)
  • 11. Landmine victim assistance in BiH – Handicap International – December 2003 11 Three sets of laws exist depending on the army in which veterans were enlisted: the Army of BiH14, the Croatian Defence Council Army (HVO)15, and the Army of RS16. Those programs are centralized and administered by Ministry of Veterans’ Affairs in the FBiH and Ministry of Labour, Veterans and War Victims in RS. 3.1. Assessment 3.1.1. Eligibility Definitions of disability in legislation are used to identify categories of individuals entitled to receive assistance, in accordance with the aim of each scheme. On the one hand eligibility criteria in BiH for the Social Protection Scheme are based on impairments and functional loss, regardless of their origin while on the other hand for Disabled Veterans and Civilian Victims of War schemes, the eligibility is based on the war origin of the impairment and on the level of impairment. The Law on Social Protection defines persons with disabilities: • In the FBiH as “children and adult persons who are blind or visually impaired, deaf or with hearing impairment, with speech or voice disorders, with physical disability and/or permanent problems in physical development, with difficulties in mental development (of mild, moderate, intense, and severe degree), with combined disabilities (multiple difficulties in development)17”, • In the RS for children as “an underage person with impaired sight and hearing, difficulties in speech and voice, physical disability, mental disability (of a light, moderate, severe and intense degree) or with combined disability”, and for adults as “an adult who due to physical or mental impairment is completely or partially incapable for work”.18 As for Civilian Victims of War: • FBiH legislation defines them as “person who suffered at least 60 % disability, due to injury or wound sustained in: 1. Abuse or deprivation of liberty due to war situation or direct war danger 2. War events (bombing, street fights, ordnance explosion, stray bullet) 3. From the explosion of ordnance after the war ended 4. Sabotage actions that endanger the security and order in FBiH. A Civilian Victim of War is also a person with at least 60 percent of physical disability due to illness sustained in circumstances described in the paragraph 1 of this Article. A civilian war victim is also a person who died, was killed or disappeared in circumstances described in the paragraph 1 of this Article.” 19 14 Law on the Basic Rights of Veterans and Families of Fallen Soldiers (“Official Gazette of the Republic of BiH”, no. 2/92 and 13/94) and The Law on Exceptional Financial Provisions for Disabled Veterans and Families of Fallen Soldiers (“Official Gazette of the Republic of BiH”, no. 33/95, 37/95 and 17/9) 15 Law on Protection of Disabled Veterans and Families of Fallen and Missing Soldiers (“Official Gazette of the Croatian Republic of Herzeg-Bosnia”, no. 36/94 and 24/95) 16 Law on Rights of Veterans, Military Disabled and Families of Killed Soldiers of RS (“Official Gazette of RS”, no. 35/99) 17 The FBiH Law on Basis of Social Protection, Protection of Civil Victims of War and Protection of Families with Children, article 14 (“Official Gazette of the FBiH” no. 36/99,) 18 The Law on Social Protection of RS (“Official Gazette of RS”, no. 5/93 and 15/96) 19 FBiH Law on Principles of Social Protection, Protection of Civil Victims of War and Protection of Families with Children, article 54 (“Official Gazette of the FBiH” no. 36/99)
  • 12. Landmine victim assistance in BiH – Handicap International – December 2003 12 • According to RS legislation, “A Civil victim of war is: 1. A person who has become disabled due to abuse, or mistreatment, i.e. capture (prison, concentration camp, forced works) or was injured while escaping and whose level of disability is at least 60%, and also a person who was killed, died or disappeared under the above mentioned circumstances. 2. A person who has become at least 60% disabled due to the injuries sustained in war operations (bombing, street fights, stray bullet or grenade) 3. A person who has become at least 60% disabled due to injuries sustained while handling remnants of military munitions or as a consequence of sabotage actions.”20 As described above, in both FbiH and RS the specific case of people becoming disabled as a result of landmine/UXO injuries is covered by legislation on the protection of Civilian Victims of War. The Definition of a Disabled Veteran is similar in the legislation of both Entities: • In FBiH “a person who was wounded, injured or became ill while performing military duties in war or peace.”21 • In RS “a person who was wounded, injured or became ill while performing military duties, which caused body impairment of at least 20%.”22 3.1.2. Impairment categories Based on the measurement of impairment, disabled persons are classified in categories that will determine the rates of the benefits they will receive. Measurement is based on the same “veteran rulebook” for both Civilian Victims of War and Disabled Veterans, but the Disabled Veterans scheme encompasses 10 categories while there are only 6 categories within the Civilian Victims of War scheme. Civilian Victims of War Disabled Veterans − I category - 100 % disability − I category - 100 % disability + care and assistance by a 3rd person + care and assistance by a 3rd person − II category - 100 % disability − II category - 100 % disability − III category - 90 % disability − III category - 90 % disability − IV category - 80 % disability − IV category - 80 % disability − V category - 70 % disability − V category - 70 % disability − VI category - 60 % disability − VI category - 60 % disability − VII category - 50 % disability − VIII category - 40 % disability − IX category - 30 % disability − X category - 20 % disability 20 The Law on Protection of Civil Victims of War , article 2 (“Official Gazette of RS”, no. 25/93) 21 The Law on the Basic Rights of Disabled Veterans and Families of Fallen Soldiers (“Official Gazette of the Republic of BiH”, no. 2/92 and 13/94) 22 The Law on the Rights of Veterans, Military Disabled and Families of Fallen Soldiers, article 4 (“Official Gazette of RS”, no. 35/99)
  • 13. Landmine victim assistance in BiH – Handicap International – December 2003 13 3.1.3. Assessment process Assessment of applicants is made for both Civilian Victims of War and Disabled Veterans in accordance with to the Veteran Rulebook23. It is based on impairment tables that indicate disability rate according to the types and levels of diseases or impairments. For instance limited mobility of all fingers of one hand corresponds to 20 % disability, below- knee amputation to 70 %, above-elbow amputation to 90 %, complete paraplegia to 100 %. Commissions conduct assessments based on their findings on medical documentation, which the applicant has to gather and present with his claim. In the FBiH, the application must be lodged at the Ministry of Veterans’ cantonal offices for Veterans Affairs and in Centres for Social Work for Civilian Victims of War. In RS, for both Civilian Victims of War and Disabled Veterans the application has to be lodged at regional offices of the Ministry of Veterans. The commissions responsible for conducting the assessments are usually special Veterans’ Assessment Commissions. In the FBiH some cantons have established specific Veteran Commissions, while others have contracts with Pension and Disability Fund Institutes. Those commissions conduct medical assessment for both Disabled Veterans and Civilian Victims of War. Members of the commission set the rating, and then for Civilian Victims of War the findings of the commission are sent to the Centre of Social Work that determines entitlements; while for Disabled Veterans the rating is sent to the Ministry , which then makes a decision on entitlements. In RS, 5 regional Veterans’ Assessment commissions assess both Disabled Veterans and Civilian Victims of War seeking entitlement. In all the cases, the commission uses guidelines from the Veterans’ Rulebook for the assessment, and agrees on the rating. Information is sent to Ministry of Labour, Veterans and War Victims, which has the final say in determining entitlements. Applicants who are not satisfied with the decisions have the option of appealing to second instance medical commissions. Two years after the final decision was issued, if there are some changes in physical disability that can affect entitlements, a person seeking entitlement as a Civilian Victim of War can apply for determination of a new degree of physical disability related to this change. 3.2. Entitlements and benefits 3.2.1. Entitlements and benefits for Civilian Victims of War 3.2.1.1. ENTITLEMENTS OF CIVILIAN VICTIMS OF WAR IN THE FBIH: The FBiH lays down some basic rights24. These are the minimum rights that Cantons must enact. The canton may also determine other rights and expand the scope of rights determined by the FBiH Law on the basis of its material capabilities and other needs of civil victims of war. As mentioned previously, only seven cantons have enacted their Law on Social Protection. In the other three, Cantonal Governments have enacted special decrees to regulate the social protection system. 23 List of percentages of Army Disability, (“Official Gazette of RS”, November 26th 1993). The List of Percentages of Veteran Disability used in the FBiH (reference not available) is identical. 24 FBiH Law on Principles of Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of the FBiH” no. 36/99)
  • 14. Landmine victim assistance in BiH – Handicap International – December 2003 14 A. Basic rights laid down by FBiH law a) Personal disability allowance Personal disability allowance is determined according to disability rate?, and the amount is set at 70% of the monthly allowance for disabled veterans of the corresponding category. b) Allowance for care and assistance by a third person Beneficiaries are disabled Civilian Victims of War from categories I to IV who cannot perform daily life activities without assistance from a third person. This monthly allowance is 70% of the monthly allowance for care and assistance by a third person for disabled veterans of the corresponding category. c) Orthopaedic allowance The right to orthopaedic allowance is given to Civilian Victims of War with the following types of physical disabilities: limb amputated or with severely restricted function, or total bilateral sight loss. The amount of this monthly orthopaedic allowance is 70% of the one for disabled veterans. d) Family disability allowance Following family members of Civilian Victims of War are entitled this allowance: 1. Widows, to the age of 55 and widowers to age 65, or even below this age limit if they are unable to work. 2. Children, adopted children and stepchildren to the age of 15 or up to the end of the prescribed duration of their education but limited to 27 years of age. e) Child allowance Beneficiaries of personal and family disability allowance are entitled to child allowance under the conditions and to the amount stipulated within provisions regulating child allowance, if they did not meet the requirements for recognition of this right on any other basis. B. Rights that can be added by Cantonal laws: f) Financial support to cover the costs of treatment and procurement of orthopaedic devices g) Vocational training (vocational rehabilitation, pre-qualification and additional qualifications) h) Priority in employment i) Right to Health Insurance for Civilian Victims of War not otherwise ensured. Centres for Social Work administer payment of allowances to civilian victims of war, except in Sarajevo Canton where protection of Civilian Victims of War and child and maternal protection are delegated to municipal departments. Centres for Social Work maintain the registry of executed payments, number and structure of beneficiaries, and other data, in accordance with cantonal legislation. The amounts of various allowances are regularly adjusted at the cantonal level to the corresponding level of allowances for Disabled Veterans, which are themselves based on the average monthly salary in the Canton. Funding is sourced from the Cantonal Government. Reportedly, amounts and regularity of payments vary significantly from one Canton to another.
  • 15. Landmine victim assistance in BiH – Handicap International – December 2003 15 Table 2: Civilian Victims of War entitlements in each Canton. Allow. Priorit Famil Right Pers. Third Ortho for Vocat. y in y Child to Disab. Person p medic. trainin emplo Disab. Allow. health Allow. Allow. allow. trtmen g y- Allow. care t ment FbiH Yes Yes Yes Yes Yes Law 1 Una-Sana Yes Yes Yes Yes Yes Yes Yes Yes Yes 2 Posavina Yes Yes Yes Yes Yes Yes 3 Tuzla Yes Yes Yes Yes Yes Yes Yes Yes 4 Zenica- Doboj 5 Bosnia Yes Yes Yes Yes Yes Yes Yes Yes Yes Podrinje 6 Central Yes Yes Yes Yes Yes Yes Yes Yes Bosnia 7 Herzegov ina Neretva 8 West Herzegov Yes Yes Yes Yes Yes Yes ina 9 Sarajevo Yes Yes Yes Yes Yes Yes Yes Yes Yes 1 Herzeg 0 Bosnia Entitlements are indicated only for the 7 cantons that enacted their law. Map 2: Civilian Victims of War entitlements in BiH Canton 2 BD Canton 1 RS Canton 3 Canton 4 Canton 6 Canton 10 Canton 9 Canton 5 Canton 7 Canton 8 RS Legend: all 9 entitl. 8 entitl. 6 entitl. No entitlements
  • 16. Landmine victim assistance in BiH – Handicap International – December 2003 16 3.2.1.2. ENTITLEMENTS OF CIVILIAN VICTIMS OF WAR IN RS Entitlements of Civilian Victims of War are laid down by the Law on Protection of Civil Victims of War25. Municipalities may extend the scope of the rights or determine easier conditions for achievement of the rights. In that case Municipalities must ensure the necessary financial means to cover the extended rights. a) Civil disability allowance Monthly amount is a percentage of the average salary in RS, depending on the category. I – 100% disability + need for assistance by a third person 90% II – 100% disability 70% III – 90% disability 50% IV – 80 % disability 40% V – 70% disability 35% VI – 60% disability 30% b) Family disability allowance For family members of a person who died or disappeared in war circumstances the amount is 40% of the group I civil disability allowance. For family members of a deceased person who had Civilian War Victim status the amount is 20% of the group I civil disability allowance. c) Allowance for care and assistance by a third person Civilian Victims of War in category I are entitled to receive this allowance. The amount is 80% of the civil disability allowance for category I. d) Allowance for family member incapable for work This allowance is provided to persons who are family members of Civilian Victims of War and are incapable to work (disabled persons, child up to 15 years, female over 55 years or with a child younger than 7 years, male over 65 years). e) Additional financial assistance Civilian Victims of War from categories I to V, category VI if they are incapable to work, and family members incapable to work, are entitled to this additional financial allowance if they are unemployed, don’t receive any pension and have a household income per family member below 10 % of the average salary. The amount is 20% of the civil disability allowance. f) Allowance for single beneficiary Beneficiaries of additional financial assistance who do not have any family member to support them can receive this allowance. The amount is 50% of additional financial assistance. g) Health care Civilian Victims of War and family members incapable to work are entitled to Health Care Assistance. h) Vocational rehabilitation Civilian Victims of War are entitled to benefit from vocational rehabilitation. These benefits are covered by the RS budget. The Ministry of Labour, Veterans and War Victims determines the amounts of allowances. Reportedly, payments are made regularly, but amounts may vary depending on available funds. 25 The Law on Protection of Civil Victims of War (“Official Gazette of RS”, no. 25/93)
  • 17. Landmine victim assistance in BiH – Handicap International – December 2003 17 3.2.2. Entitlements and benefits of Disabled Veterans Various laws, depending on which army is under consideration, regulate entitlements in the FBiH: For members of the BiH Army: • The “Law on the Basic Rights of Disabled Veterans and Families of Fallen Soldiers” regulates Veterans’ basic rights in the FBiH. This regulation is adopted from the Socialist Federal Republic of Yugoslavia law of 1986.26 A new law is in preparation. • The “Law on Exceptional Financial Provisions for Disabled Veterans and Families of Fallen Soldiers” regulates the right to personal exceptional financial provision, family exceptional financial provision and exceptional financial provision to the recipient of medals called “Golden Lily” and “Silver Shield” 27for disabled veterans and families of fallen soldiers. The rights of veterans who were members of the HVO (Croatian Council Defence Army) are determined by the Law on Protection of Disabled Veterans and Families of Fallen and Missing Soldiers.28 Disabled Veterans from both armies in FBiH have the same entitlements, which are managed by the FBiH Ministry of Veterans’ issues. In the RS, Veteran’s rights are laid out in the Law on the Rights of Veterans, Military Disabled and Families of Fallen Soldiers.29 The legislation of each Entity allows for identical list of entitlements, as they are both based on the former law of the Republic of BiH. The monthly average net salary is the basis for determining the monthly amounts of allowances. Amounts of entitlements can therefore vary between the 3 schemes. a) Personal disability allowance The amount is a percentage of monthly average salary determined from the category: I category - 100% disability + needs for assistance by a third person 100% II category – 100% disability 73% III category – 90% disability 55% IV category – 80% disability 41% V category – 70% disability 29% VI category – 60% disability 18% VII category – 50% disability 13% VIII category – 40% disability 8% IX category – 30% disability 7% X category – 20% disability 6% b) Allowance for care and assistance by a third person Category I Disabled Veterans are entitled to receive this allowance. Amounts vary between 46 and 86 % of the average net salary depending on the level of disability. 26 “Official Gazette of the Republic of BiH”, no. 2/92 and 13/94 27 “Official Gazette of the Republic of BiH”, no. 33/95, 37/95 and 17/96 28 “Official Gazette of the Croatian Republic of Herzeg-Bosnia”, no. 36/94 and 24/95 29 The Law on Rights of Veterans, Military Disabled and Families of Killed Soldiers of RS (“Official Gazette of RS”, no. 35/99)
  • 18. Landmine victim assistance in BiH – Handicap International – December 2003 18 c) Orthopaedic allowance Veterans from categories I to VI receive this allowance that ranges from 7 to 29 % of the average net salary. d) Health care assistance Disabled veterans are entitled to free healthcare services, without financial participation. This includes the right to orthopaedic and ortho-prosthetic devices, and to rehabilitation treatment in spas or rehabilitation centres following medical treatment. The First Instance medical commission makes this decision. Ministries of Veterans have signed an agreement with a number of health institutions. e) Free and privileged transport Disabled veterans who receive allowances for care and assistance by a third person or an allowance for orthopaedic devices have the right to use free intercity transport by train or bus three times a year, and free transportation within the city. Disabled veterans from category II to VI, who are not entitled either to allowance for care and assistance by a third person or to orthopaedic allowance, have the right to free one- time use of intercity transport and half-price monthly tickets for city transport. f) Right to import a motor vehicle Disabled veterans from category I who import a motor vehicle are exemp from customs duty. For Category II the customs duty is reduced by 50%. g) Priority in employment This right is actually not enforced, as there are neither incentive measures nor fines for non-compliance, in place for employers. h) Other rights Disabled Veterans are also entitled to priority in solving housing problems, tax exemptions, compensation in food and accommodation, vocational training, and participation in the privatization process (they have the right to free of charge participation in the privatization process). All these entitlements are administered by the Ministry of Veterans Affairs in the FBiH through Cantonal offices. The database on war veterans is centralized in Sarajevo within the Ministry and financial benefits are paid through postal cheques to the individual regularly and without delays. is the procedure is the same regardless of which canton you live in. The Ministry pays around 23 million KM per month for financial benefits30. Disabled Veterans from HVO might get additional benefits from the Republic of Croatia, but there is no data available on that issue. In RS, the Ministry of Labour, Veterans and War Victims pays benefits to both Disabled Veterans and Civilian Victims of War through regional and municipal offices. Payments are made regularly and without delays. Amounts of allowances for Disabled Veterans (and Civilian Victims of War) have been frozen since 2000 due to budget shortfalls. The Ministry of Labour, Veterans and War Victims is also trying to lobby for employment rights and the removal of architectural barriers, which they consider should apply equally regardless of the cause of the disability31. 30 Meeting with Halil Plimac, Deputy Minister, FBosnia and Herzegovina Ministry of War Veterans, Sarajevo, November 12th 2003. 31 Meeting with Radomir Graonic, Assistant to RS Minister of Labour and War Veterans, Banja Luka, November 13th 2003.
  • 19. Landmine victim assistance in BiH – Handicap International – December 2003 19 Municipalities in both Entities and Cantons may also provide some support to Disabled Veterans such as a reduction in electricity bills, or housing aid but this differs by municipality depending on its’ economic situation. Veterans associations can provide additional support. In some places they get funds from Cantons or Municipalities. 3.2.3. Examples of amounts of benefits Table 3: Amounts (in KM) of Personal Disability Allowance and Allowance for Care and Assistance by a third person in RS and in 3 municipalities in FBiH. Republika Srpska Sarajevo Bihac Zenica Personal Third Personal Third Personal Third Personal Third Disab. Person Disab. Person Disab. Person Disab. Person Allow. Allow. Allow. Allow. Allow. Allow. Allow. Allow. Pers. with Disab (Soc Protection) 40 60 164 171 29.5 29.5 56 30-70 Civilian Victims of War Cat. I 233 186 149 149 149 - - - Cat. VI 78 NE - NE 35 NE - NE Disabled Veterans Cat. I 316 145- 272 734 367-734 734 367-734 734 367-734 Cat. VI 57 E 132 NE 132 NE 132 NE Cat X 19 NE 37 NE 37 NE 37 NE “NE”: Non entitled. When no figure was available, the cell is empty ( - ). The figures indicated in the table for Disabled Veterans were provided by the Ministry of Veterans’ Issues in FBiH and by the Ministry of Labour, Veterans and War Invalids in RS. For other Categories, they were collected from Centres for Social Work in municipalities. 3.2.4. Specific case of the Brcko District The situation in Brcko is quite complex, due to the District’s special status. Brcko has its own legislation for Social Protection32, but did not issue any legislation regulating the rights of Civilian Victims of War and Disabled Veterans. Laws on Disabled Veterans from either Entity cover disabled Veterans, depending on the Army they are enlisted in. An Internal Agreement of the Department for Social Affairs of Brcko District regulates the rights of civil victims of war. 32 Law on Social Protection (“Official Gazette of BiH Brcko” no. 1/03)
  • 20. Landmine victim assistance in BiH – Handicap International – December 2003 20 3.3. Reforms As previously described, assistance that BiH citizens with disabilities can receive in terms of in-kind and financial support varies sharply according to their status (social assistance for physically or mentally disabled persons; compensations for Civilian Victims of War and Disabled Veterans with different schemes) and to their place of residence, with inter- Entity and inter-Cantonal discrepancies. Generally speaking, Disabled Veterans face fewer difficulties than other categories. They receive higher allowance amounts, which are paid regularly, and are administered at the federal level in FBiH and are thus equal for all beneficiaries. They also benefit from a number of additional allowances and in-kind support, from Entity, Cantonal and municipal levels. Civilian Victims of War allowance amounts are significantly lower with slight inter-Cantonal discrepancies, but payments are not always regular. And persons with disabilities in general receive much lower amounts, and discrepancies are significant depending on the availability of funds at the municipal or cantonal level. Amounts allocated to Disabled Veterans’ assistance make up an important part of the limited budgets of both Entities. In the FBiH, the budget for Ministry of War Veterans in 2003 was 275 millions KM, or 22 % of the total FBiH budget, for 97,976 beneficiaries33. In the RS, the 2003 budget for military and civilian victims of war was 112 million KM, with support provided to 64,556 individuals and families of those killed34. The World Bank is currently promoting reforms of the Veterans’ assistance system. In FBiH a reform process has started. One of the aims is to reconsider amounts received by persons who are categorized into the lower levels of disability and who are able to work, in order to be able to prioritise allocations of resources to persons unable to work35. In RS reforms are also under consideration. One of the issues, for example is to coordinate Disabled Veterans’ benefits with social policy schemes. For instance, a Disabled Veteran can now also receive benefits from pension and disability funds if he has been working for a minimum of 30 years prior to the onset of the disability. This will probably be regulated in the reformed legislation so that the person will not be paid twice from the same budget36. 33 Landmine Victim Assistance in South East Europe, Final study report, Shirley Bailey, Handicap International Belgium, September 2003. 34 Ibid. 35 Meeting with Halil Plimac, Deputy Minister, FBosnia and Herzegovina Ministry of War Veterans, Sarajevo, November 12th 2003. 36 Meeting with Radomir Graonic, Assistant to RS Minister of Labour and War Veterans, Banja Luka, November 13th 2003.
  • 21. Landmine victim assistance in BiH – Handicap International – December 2003 21 4. MEDICAL AND REHABILITATION CARE Rehabilitation services including ortho-prosthetic fitting are provided within the overall BiH healthcare system. Rehabilitation facilities have been targeted by a number of capacity- building programs since 1992. This chapter will firstly describe the overall healthcare system context, and then present an assessment of existing human resources and facilities for rehabilitation and ortho-prosthetics. 4.1. Overview of the Healthcare system in Bosnia and Herzegovina A recently published report from European Observatory on Health Care Systems provides a very comprehensive and accurate description of BiH healthcare system37. When not otherwise specified, information on this paragraph is based on this report. The healthcare system in Bosnia and Herzegovina was heavily affected by the war. According to government statistics, around 30% of health facilities were destroyed or severely damaged, and the country lost about 30% of its health professionals. In the aftermath of the conflict, based on the Dayton Agreement, Bosnia and Herzegovina’s health system fell under the sole jurisdiction of the Entity Level. Each Entity had to issue legislation on healthcare and health insurance38. In RS the health care system is centralized, whereas in the FBiH it is decentralized, with the responsibility for health care administration and financing being shared between the FBiH and each of the ten cantons. In addition, since its creation in March 2000, the Brcko District is also responsible for organizing and financing its own health care system. This division of the health care system into 13 distinct administrative and financing units (the RS, 10 cantons in the FBiH, and the Brcko District) resulted in a very complex legal, administrative and financial organization, with an increased management cost. It also created an uneven territorial distribution of health facilities, which hinders equitable access to health services. A list of legislation on healthcare and health insurance reviewed during the assessment is presented in the Annex. 4.1.1. General Health overview of BiH's population − Total population: 4,066,000 inhabitants − Annual population growth rate from 1991 to 2001: - 0.2 % − Life expectancy at birth (years): 69.3 (males) / 76.4 (females) − Healthy life expectancy at birth (years): 60.0 (males) / 64.9 (females) − Child Mortality (probability of dying under age 5)(per 1000): 19 (males) / 15 (females) − Adult Mortality (probability of dying 15-69) (per 1000): 194 (males) / 91 (females) 39 37 Health Care Systems in Transition: Bosnia and Herzegovina – Cain J. and Jakubowski E., Copenhagen, European Observatory on Health Care Systems, 4(7) (2002) 38 FBiH Law on Health Care (“FBiH Official Gazette” no. 29/97); FBiH Law on Health Insurance (“FBiH Official Gazette” no. 30/97); RS Law on Health Care and RS Law on Health Insurance (“RS Official Gazette” no. 18/99). 39 Selected health indicators 2001-WHO (http://www3.who.int/whosis/country/indicators.cfm?country=bih).
  • 22. Landmine victim assistance in BiH – Handicap International – December 2003 22 The leading causes of death in Bosnia and Herzegovina in 2001 were cardiovascular diseases (54.1 % in FBiH40 and 53.6 % in RS41), malign neoplasm (18.3 % in FBiH and 16.8 % in RS), injuries and poisoning (2.1 % in FBiH and 5 % in RS), diseases of the digestive tract (2.9 % in FBiH and 2.5 % in RS). No figure is available on the leading causes of disability. There is no accurate data regarding prevalence of various types of disabilities, but one estimates that persons with disabilities make up 10 % of the total population of Bosnia and Herzegovina.42 In 2002, 6,119 children with disabilities and 14,636 adults with disabilities were recorded into Social Welfare Statistics43 in the FBiH registered. In the RS in year 2001, 1805 children with disabilities and 5,861 adults with disabilities were recorded in Social Welfare statistics44 It has been estimated that every 173rd citizen of Bosnia and Herzegovina has been disabled due to war related injury. The most frequently registered injuries were amputations (5000 cases), spinal cord injuries (750 cases), lesions of peripheral nerves (3000 cases) traumatic brain injuries (2180 cases), fractures (10150 cases).45 A total of 2280 cases of amputation related to landmine accidents were registered in the ICRC database between 1992 and October 2003. Those figures illustrate that the specific case of landmine victims doesn’t represent a public health priority. It suggests that medical needs of landmine victims have to be considered within the overall framework of healthcare services delivered to persons with disabilities. 4.1.2. Health care financing Health Insurance Funds collect financial contributions and provide coverage for insured people and their family members. Whereas there is a single Health Insurance Fund in RS (with 8 regional offices), the FBiH has one Federal Health Insurance Fund, which controls, supervises and provides reinsurance to 10 cantonal health insurance funds. Each cantonal authority is responsible for the adoption of specific legislation defining the contribution rates and the extent of healthcare coverage for its health insurance fund. The FBiH Ministry of Health is responsible for setting legal standards and norms for the health insurance schemes. All BiH residents receiving regular income must pay contributions, and are thus covered by this compulsory health insurance scheme. This means that officially employed persons, pensioners, registered unemployed persons and social welfare recipients should all be insured46. Contributions are directly deducted from gross income payments, and paid partly by the employer and partly by the employee. For unemployed persons and pensioners, contributions are paid by the unemployment office and pension fund. The amount represents an average of 18 % of the gross income payment in the FBiH, and 15 % in the RS, with variations from one canton to another and for different groups of employees. 40 Statistical yearbook 2002, FBiH Federal Office of statistics, Sarajevo, 2002. 41 Demographic Statistics - Bulletin 2003; RS Institute of Statistics. 42 Bosnia and Herzegovina Human development report 2003 – UNDP. 43 Social Welfare in 2002, Statistical bulletin from Federal Office of Statistics, Sarajevo, May 2003. 44 Social Welfare Statistics - Bulletin 2003, report from the RS Institute of Statistics. 45 Bosnia and Herzegovina human development report 1998 – UNDP. 46 According to UNDP in 2001 78 % of the total population was insured (“BiH Human development report 2003” – p 129).
  • 23. Landmine victim assistance in BiH – Handicap International – December 2003 23 This compulsory health insurance scheme theoretically provides insured persons with entitlements to health care assistance, paid sick leave and reimbursement for healthcare related travel costs.47 Constitutions of both Entities guarantee the right to health care for all citizens. All insured persons are entitled to health care services, and the Law defines a wide scope of primary, secondary and tertiary health care levels. Medical Rehabilitation, prosthesis fitting and provision of orthopaedic devices are, among other services, covered by the health insurance schemes in both entities. Insured persons are nevertheless required to contribute directly to health services costs, by contributing a small, fixed percentage of the total cost of their treatment (participation). Participation amounts are set by the Cantons in the FBiH, and by the RS Health Insurance Fund.48 Some categories are exempt from participation, for instance Disabled Veterans throughout Bosnia and Herzegovina, and Civilian Victims of War with disability over 60 % only in some Cantons in the FBiH, (like Sarajevo, Una Sana and Zenica- Doboj cantons), but not in the RS. In absence of insurance coverage, patients are obliged to pay the full cost of medical services. In both Entities’ legislation there is a special provision stipulating that in case of medical emergency, assistance must be provided regardless of the ability to pay. Even though a vast majority of BiH residents are covered by these compulsory health insurance schemes, and despite of specific legal provisions aiming at providing health insurance coverage to vulnerable groups such as refugees, returnees, and persons in social need, many of them face difficulties to access health care services49. This inequity in access to health care services is determined by several factors50: ! Due to the slow economic recovery of the country and the difficulties in collecting contributions, health insurance funds’ budgets cannot cover the whole costs from the legislated entitlements.51 ! Implicit rationing, under-the-table payments, and the development of a large private health sector with neither an accreditation system or pricing guidelines stem from this lack of financial resources. ! Low inter-Entity / inter-Cantonal cooperation: the insurance coverage is valid only in the geographical area of the health insurance fund where the person is insured, and does not follow him / her when he moves to another entity / canton. This person will thus be considered as «uninsured». 47 FBiH Law on Health Insurance (“FBiH Official Gazette” no. 30/97). RS Law on Health Insurance (“RS Official Gazette no. 18/99”). 48 Health Care in BiH in the context of the return of refugees and displaced persons – July 2001, Geneva UNHCR. 49 Health Care in BiH: a pauper in princes’ clothing; a report on the inequity of health care for citizens of BiH – Jen Tracy, July 2002, UNDP & WHO. 50 Health Care in BiH in the context of the return of refugees and displaced persons – July 2001, Geneva UNHCR. 51 According to a rough estimation reported in “BiH Human development report 2003 (UNDP)”, 31.85 millions KM would be needed for Bosnia and Herzegovina in order to reach a minimal insure level for all citizens, in addition to the 589.7 millions total yearly cumulated budget of both Health Insurance Funds.
  • 24. Landmine victim assistance in BiH – Handicap International – December 2003 24 In order to tackle these problems, several reforms have been undertaken: ! A Federal Solidarity Fund was established in January 2002, which should enable movements of insured persons from one canton to another, and establish an inter- canton risk-pooling. It receives 8 % of the resources collected by each cantonal health insurance fund, to be matched by the federal government budget. ! An inter-entity and inter-cantonal agreement was signed in December 2001, which aims at guaranteeing healthcare where the person lives, regardless of the contribution source. ! In December 2000, the RS Health Insurance Fund laid down the Basic Benefit Package, defining public funded and universally covered health care services. Implementation commenced after its validation in May 2001, but full population coverage is still to be reached. Ortho-Prosthetic devices and physical rehabilitation services are part of this basic benefit package, and community based rehabilitation services have recently been included as well, which should be effective from January 200452. The FBiH Health Care legislation states that every insured person has the right to Basic Health Care Assistance, but there is a need to quantify those services and entitlements, and thus to establish a FBiH-wide package with schemes to ensure equal access to this package among the Cantons. ! The Social Insurance Technical Assistance Credit Project currently initiated by the World Bank, notably aims at strengthening the effectiveness and efficiency of the Health Insurance system in both Entities, through technical support and training on definition of health strategies, rationalisation of the provider network, development of inter-Entity and inter-Cantonal coordination and risk-pooling mechanisms, and development of options to expand the population covered53. The case of the Brcko District needs to be considered separately. The Brcko District is responsible to provide primary and secondary care to its citizens. It has its own “Department of Health, Public Security and other Services”, which is responsible for health care administration and financing in the district. Special legal provisions stipulate that each entity is obliged to pay healthcare contributions for persons not insured in the Brcko District54. 4.1.3. Emergency care and hospital care First aid and emergency medicine are provided, in the first instance by the so-called “Hitna Pomoc”. Those first aid centres are usually located in the “Dom Zdravlja” facilities (health centres set up in each main village of a municipality, providing a set of general and specialised medical services, together with basic medical imagery and laboratory examinations). “Hitna Pomoc” is open 24 hours a day, can be called by phone, and provides first aid and emergency care and medical transportation. Staffing and ambulance equipment vary from one place to another. The “Hitna Pomoc” net is well organized, and provides a good geographical coverage. But the lack of resources and sufficient equipment, especially in 52 Interview with Dr Latinovic, RS Deputy Minister of Health, and Dr Radulovic, RS Health Insurance fund, on October 24th 2003. 53 BiH – Social Insurance Technical Assistance Credit, project information document, World Bank, May 2003. 54 Agreement on the Implementation of the Entity Obligations from the Final Arbitrage Award for Brcko on Health Care and Health Insurance dated 24 October 2000.
  • 25. Landmine victim assistance in BiH – Handicap International – December 2003 25 rural areas (with less than 1 vehicle for 100,000 inhabitants) hinders its efficiency, and it can take up to 3 hours following a call, for an ambulance to arrive on-site55. Despite the above-mentioned legal provisions that allow emergency treatment to be covered, regardless of a patient’s ability to pay, the lack of resources often leads to a restrictive approach to such emergency treatment56. 4.2. Rehabilitation care The assessment of Bosnia and Herzegovina’s rehabilitation care system was undertaken via interviews with Ministries of Health in both Entities57, visits to most of the rehabilitation facilities, the compilation of relevant statistics from Public Health Institutes and Statistical Institutes in both Entities58, and the study of legislation on entitlements to health care assistance concerning rehabilitation. The analysis pointed out some discrepancies between different information sources, especially regarding rehabilitation centres and spas, where public-funded medical rehabilitation services and self-paying courses of treatment at a spa co- exist within the same infrastructure, most of the time, without clear distinctions in either standards or human and physical resources. This paragraph gives a comprehensive analysis of existing rehabilitation facilities, rehabilitation professionals, and financing of rehabilitation services. 4.2.1. Physical rehabilitation Table 4: Number of rehabilitation facilities in FBiH and RS. Total Number Financing capacity FBiH 4* 818 beds Free for Disabled veterans, pensioners Rehabilitation below 170 KM pension, children < 15. centres RS 3 335 beds Others: participation 20% - 25%. FBiH 2 ≈ 250 beds Self financed facilities mostly. Spas / Banja Self-payment, except war invalids. RS 5 ≈ 800 beds Free for Disabled veterans, Civilian FBiH 38 ≈ 30/day/centre Victims of War with disability > 60%, CBR centres pensioners below 170 KM pension, RS 22 ≈ 30/day/centre children < 15. Others: participation 20% (1–3 KM) *(3 rehabilitation centres + 1 centre for paraplegics in Sarajevo Physical and Rehabilitation Institute). 55 Health Care in BiH in the context of the return of refugees and displaced persons – July 2001, Geneva UNHCR. 56 Ibid. 57 Interviews with Dr Latinovic, RS Deputy Minister of Health, on October 24th 2003, and with Dr Goran Cerkes, deputy Minister of Health in the FBiH, on October 23rd 2003. 58 Network, capacities and functions of Health System in the FBiH in 1999, Public Health Institute of the FBiH; interview with Mrs Aida Pilav, Head of health statistics department in FBiH Institute for Public Health, on November 12th 2003; “Social Welfare Statistics – Bulletin 2003”, RS Institute of Statistics.
  • 26. Landmine victim assistance in BiH – Handicap International – December 2003 26 In the FBiH, 38 Community-Based Rehabilitation (CBR) centres and Community Mental Health services were established in the period 1996 – 1999. The World Bank and the Canadian Government funded the project at a total cost of $13 million (including $1.3 millions from Canadian Government) for refurbishment of facilities, equipment, and training on physiotherapy, occupational therapy and psycho-social support. This CBR project was part of a broader $30 millions war victim’s rehabilitation project59. CBR is part of the Federal primary health care system, and the centres are located in the “Dom Zdravlja”. Each CBR centre covers a population of 50,000 to 80,000 inhabitants. Each CBR centre is staffed with a minimum of one physiatrist, a physiotherapist, an occupational therapist, a nurse and a psychologist. All professionals from those 38 CBR centres were educated through CBR training implemented by Queen’s University. Various types of physiotherapy treatment are provided within the centres60. The CBR system has significantly improved access to rehabilitation services at the community level. Civilian Victims of War and Disabled Veterans are treated free of charge. The system was initially envisioned to function on a community based approach, visiting patients at home and building an interdisciplinary referral system with other health services and with community stakeholders from various sectors. This has been achieved with various levels of success, from one place to another, as establishing such new approaches requires time, and practical transportation problems often prevent professionals from making home visits. In 2002 RS initiated the development of a network of 22 Community Based Rehabilitation centres and Community Based Mental Health centres integrated into the “Dom Zdravlje” facilities61. The Japanese International Cooperation Agency is funding the refurbishment and equipment for 17 of these CBR centres for a total amount of $8 million, including the provision of one wheelchair accessible van per centre and the setting up of a database system. The refurbishment and provision of equipment was completed in September 2003. Queen’s University / ICACBR is currently implementing a CBR clinical education program for 100 professionals, a CBR policy course for 30 persons, and a peer program. These educational programs are funded by the Canadian International Development Agency, at an approximate cost of $955,000. Each CBR team is comprised of one physiatrist, one high-level physiotherapist, one nurse and 2 physiotherapy technicians. CBR services will be included in the Basic Benefit Package of the RS Health Insurance Fund from January 2004. Civilian Victims of War and Disabled Veterans will be treated free of charge62. Within secondary and tertiary health care systems, there are a number of Rehabilitation Centres and Spas / “Banjas”. The difference between those two types of facilities is not always evident. In BiH there is a long tradition and history of water therapy, with many spas providing such water cures and various types of physical therapies (parafangotherapy, paraffin, electrotherapy…), together with massages and physiotherapy treatment. The main difference actually is that some of these facilities provide rehabilitation services covered by the Health Insurance Funds (this is what we chose to call “Rehabilitation Centres” in this report), while patients have to pay the full cost of the services provided by the others, listed as “Spas / Banjas” in the current report, even though some of them are not historically classed as Spas. 59 “War Victims Rehabilitation Project” World Bank Reconstruction and Development Program in Bosnia and Herzegovina, Progress Update, May 2001, p. 41. 60 Interview with Dr Goran Cerkes, deputy Minister of Health in the FBiH, on October 23rd 2003. 61 “Amendment to the Health Care Law”, enacted on September 12th 2002; and “Decision on amendment of the plan for network of health institutions” enacted on December 20th 2002. 62 Interviews with Dr Latinovic, Republika Srpska Deputy Minister of Health, Dr Radulovic, Republika Srpska Health Insurance fund, and Dr Natasa Tomic, Queen’s University Project Manager, on October 24th 2003.
  • 27. Landmine victim assistance in BiH – Handicap International – December 2003 27 Most of the Rehabilitation Centres however, provide complete physical rehabilitation services and water cures. The Health Insurance Fund contracts them for a number of beds, and in addition they have a number of beds for which patients have to pay for the services they receive. Most of the time, there is no clear distinction between the two types of services, which are provided by the same structure, without defined standards, and without difference in terms of allocation of material and human resources. To be covered by Health Insurance Fund, a specialist must prescribe rehabilitation care. The patients must participate in the costs of the treatment, usually contributing 20 % or 25 % of the total cost, which is between 50 and 89 KM a day depending on the location and the type of treatment. Disabled Veterans and Families of fallen soldiers are exempted of participation, as are pregnant women, mothers and pensioners with low income (less than 170 KM per month). Civilian Victims of War have to pay this participation fee most of the time (except in few Cantons like Sarajevo, Zenica-Doboj or Una-Sana Cantons) as well as other persons with disabilities. Most of the Spas / “Banjas” provide not only water cure and fitness treatment, but also physical rehabilitation. As previously mentioned, in most of the cases patients have to pay the total price for services (usually 35 up to 40 KM a day), except Disabled Veterans who are treated free of charge in most of the places. In addition, some Spas / “Banja” mentioned having a specific contract for a small number of patients from specific health care structures. This is for instance the case of the Centre Vilina Vlas, in Visegrad, where patients referred by Srpsko Sarajevo and Foca / Srbinje Clinical Centres just pay a fixed price of 35 KM. This absence of clear distinction between the two types of services / structures; the fact that they sometimes coexist within the same health care institutions without any differentiation in the allocation of resources; the absence of a definition of priority pathologies that should benefit from rehabilitation services; and the absence of standards for physical rehabilitation services; contribute to create a situation where there is a significant discrepancy in the quality of rehabilitation services provided, and in the patients’ access to rehabilitation services. Reportedly many patients, and notably Civilian Victims of War, cannot afford the rehabilitation services they would need. In the FBiH, 3 Rehabilitation Centres are financed by Health Insurance Funds. Those are the Rehabilitation Centre in Fojnica, the Centre for Physical Medicine and Rehabilitation in Gradacac, and the Rehabilitation Centre “Gata” close to Bihac. The Centre for Paraplegics in Sarajevo is also a public health care structure (where patients are reportedly treated free of charge). In addition, there are 2 spas / “Banja” where patients are reportedly treated free of charge. In the RS, there are 3 Rehabilitation Centres established as part of public health care institutions.63 The Institute for Physical Medicine and Rehabilitation “Dr Miroslav Zotovic” in Banja Luka is the tertiary level referral institution, providing all types of specialised rehabilitation services. The two others are the Institute for Medical Rehabilitation, Physical Medicine and Balneoclimatology Mljecanica, and the Rehabilitation Centre Kasindo in Srpsko Sarajevo. There are also 5 Spas / “Banja”. 63 “Amendment to the Health Care Law”, enacted on September 12th 2002; and “Decision on amendment of the plan for network of health institutions” enacted on December 20th 2002.
  • 28. Landmine victim assistance in BiH – Handicap International – December 2003 28 Map 3: Rehabilitation Centres in BiH ! Mljecenica ! ! Bihac Banja Luka ! Gradacac Fojnica ! Sarajevo ! !Kasindo In addition to the above mentioned Rehabilitation Centres and Spas / “Banja”, most General Hospitals (secondary health care level facilities, with a total figure of 14 General Hospitals in total in the FBiH, 9 in RS, and 1 in the Brcko District) and Clinical Centres (tertiary health care level facilities, situated in Sarajevo, Mostar, Tuzla, Banja Luka and Foca / Srbinje) also have Physical Medicine and Rehabilitation (PMR) capacities. Some smaller district hospitals in the FBiH may also have some Physical Medicine and Rehabilitation capacities. From one hospital to another, those capacities may vary from few rehabilitation nurses whom provide basic physical therapy to inpatients in the different medical and surgical departments of a general hospital; to a distinct Physical Medicine and Rehabilitation department staffed by physiatrists, high level physiotherapists and physiotherapy technicians, that in addition provides outpatient rehabilitation care, and in some few places even a small inpatient ward. Outpatients Physical Medicine and Rehabilitation services are usually covered by compulsory insurance schemes, with a participation fee (1 to 3 KM per session). Exemptions exist upon the same conditions as in rehabilitation centres.
  • 29. Landmine victim assistance in BiH – Handicap International – December 2003 29 In the FBiH, we visited 6 of those Physical Medicine and Rehabilitation (PMR) departments (Clinical Centre in Tuzla, Cantonal Hospital in Zenica, Bihac, Travnik, Gorazde and district hospital in Konjic). In the RS we visited 3 hospitals with a specific PMR department: the Clinical Centre in Foca / Srbinje, the General Hospital in Prijedor, and the General Hospital in Doboj. Brcko General Hospital has a Physical Medicine and Rehabilitation department receiving an average of 100 outpatients a day, which is the sole public rehabilitation facility of the Brcko District. Table 5: Number of rehabilitation professionals employed in each entity. FBiH* RS** Brcko Bosnia and Herzegovina Ratio inhabitants / Number Number Number Number professionals High level 90 102 3 195 1 / 2,0851 physiotherapists (PT) Physiotherapy 305 250 4 559 1 / 7,274 technicians (PTT) PT + PTT 395 352 7 754 1 / 5,393 Physiatrists 125 83 1 209 1 / 19,455 Nurses in 212 220 7 439 1 / 9,262 rehabilitation * The Public Health Institute provided figures for the FBiH; ** Figures for RS were calculated adding those collected from each facility; Even though these figures are likely to underestimate the actual number of rehabilitation professionals to some extent (those working solely privately have not been registered), the figures collected for the present survey show a shortfall of rehabilitation professionals. According to WHO standards, an average of 1 physiotherapy worker for 2,000 inhabitants is required to answer the needs of a population. Adding here high-level physiotherapists and physiotherapy technicians, it gives a figure of 1 physiotherapy worker for 5,443 inhabitants, which is less than half what would be needed. The education system for physiotherapy workers in Bosnia and Herzegovina is two- tiered: medical secondary schools provide a 4 year education program for various future health technicians (such as physiotherapy technicians, nurse technicians, lab technicians, pharmacy technicians…etc). Those medical secondary schools are located in the main municipalities. Students are enrolled after finishing primary school, usually at age 14. In most municipalities a new generation of physiotherapy technician students is enrolled only once every second or third year. After completing medical secondary school with last year specialization in physiotherapy, graduates are entitled to work as physiotherapy technicians. Their role in rehabilitation facilities is to provide hydrotherapy, massage, electrotherapy, and basic physical therapy treatment.
  • 30. Landmine victim assistance in BiH – Handicap International – December 2003 30 Physiotherapy technicians can also continue with post-secondary education at Physiotherapy College, which is an additional 2 years study. Such Colleges exist in Sarajevo, Tuzla, Mostar, Bihac, Banja Luka, Foca/Srbinje. Programs vary between schools and range from 2 to 4 years degree program. In Sarajevo for instance, physiotherapy post- secondary program had lasted 3 years and was recently changed to 4 years Bachelor degree program at High Health School, University of Sarajevo. High-level physiotherapists then work as a rehabilitation team members, and provide patients with physiotherapy treatment. There is currently no individualized occupational therapy education in Bosnia and Herzegovina. Physiatrists are medical doctors who completed their medical studies (6 years) and an additional 3 years specialization in physical medicine and rehabilitation. They are responsible for the coordination of the rehabilitation team, and liaison with other specialists. In many facilities the rehabilitation process is broken up into a set of specialized services performed by various health professionals, rather than having comprehensive, patient-centred and interdisciplinary approach. 4.2.2. Mental Health services As previously mentioned, Community Based Mental Health (CBMH) services were developed together with CBR centres in the FBiH, and will be established in RS as well. The CBMH teams include a psychiatrist, 1 psychologist, 1 social worker, and nurses. 3 psychiatric hospitals exist in Bosnia and Herzegovina, 2 in RS (in Sokolac and Modrica, with together a total number of 550 beds), and 1 in the FBiH (Jagomir Psychiatric Hospital in Sarajevo, 70 beds). Hospitalization is free of charge. 4.2.3. Ortho-prosthetic services 4.2.3.1. FACILITIES The assessment allowed us to identify 27 ortho-prosthetic workshops in Bosnia and Herzegovina. The table below shows their geographical distribution.
  • 31. Landmine victim assistance in BiH – Handicap International – December 2003 31 Table 6:List of ortho-prosthetic workshops in BiH. Cantons Workshops Status Regions Ortho-prosthetic centre in Cazin Public Una-Sana Filial of Medicus Matea Centre in Bihac. Private Posavina Tuzla Centre for Prosthetics and Rehabilitation in Tuzla Hospital Public Department for Rehabilitation of Amputees in Zenica Hospital Public Zenica-Doboj “Ortoze” Centre in Zenica Private Bosnia Podrinje Ortopedia Lasva in Travnik Public Central Bosnia Orthopaedic workshop “Orto-Pro” in Vitez Private FBiH Reumal Centre in Fojnica Public Herzegovina Ortho-prosthetic centre in Mostar Clinical Centre Public Neretva Orthopaedic workshop Sjeverni Logor in Mostar Public West Herzegovina Orthpaedic Centre Neretva in Sarajevo Public Medicus Matea Centre in Sarajevo Private Sarajevo Otto-Bock Centre in Sarajevo Private Orto Sar in Sarajevo Private Herzeg-Bosnia Ortho-prosthetic centre in Livno Public Miroslav Zotovic rehabilitation centre Public Ortho-prosthetic centre – Slatinska in Banja Luka Private Nova Ortopedija in Banja Luka Private Banja Luka Orthopaedics Astra in Banja Luka Private region Med/Reha workshop in Banja Luka Private Prosthetic Centre Izvor in Banja Luka Private Ortho-prosthetic centre in Prijedor Public RS Doboj region Prosthetic Workshop in Bjeljina Public Bjeljina region Filial of Bjeljina Prosthetic workshop in Zvornik Public Sarajevsko- Romanjiska RUDO ortho-prosthetic centre in Trebinje Private Trebinje Region Ortho-prosthetic Centre in Foca/Srbinje Clinical Centre Private Brcko Brcko Filial of Bjeljina Prosthetic workshop Public District In the FBiH 8 public and 7 private ortho-prosthetic workshops were identified. They are quite unevenly distributed, with 4 workshops in Sarajevo for instance, while 3 cantons (Posavina, Bosnia-Podrinje, and West-Herzegovina Cantons) do not have any ortho-prosthetic facility. In those four cantons, Health Insurance Funds usually have a contract with ortho- prosthetic workshops in other cantons, in order to allow insured persons to have access to ortho-prosthetic devices. In addition to geographical distances, political parameters can also hinder the access to ortho-prosthetic services. In Velika Kladusa area for instance, much anecdotal evidence were reported showing that some patients have to travel to Banja Luka to obtain prostheses, while they should normally be entitled to be fitted in Cazin ortho-prosthetic workshop, which is around 40 km away. Similarly, many patients from the eastern part of
  • 32. Landmine victim assistance in BiH – Handicap International – December 2003 32 Mostar have to obtain ortho-prosthetic devices in Sarajevo rather than in the workshop located in the western part of the city. In the RS, we identified 4 public and 7 private ortho-prosthetic workshops. They are mainly concentrated in Banja Luka, with 6 of them located in this city. The RS Health Insurance Fund has a contract with a total number of 15 ortho-prosthetic facilities, but this figure includes some centres that only sell ready products and some that produce only orthopaedic shoes. There is one public ortho-prosthetic workshop in Brcko District, which is affiliated to the “Prosteticka Radiona” in Bjeljina. Map 4: Ortho-prosthetic workshops in BiH Cazin " " Prijedor Bihac " ! Banja Luka Brcko ! " " Bijeljina " Tuzla " Zvornik Travnik " "Zenica ! ! Vitez Fojnica " Sarajevo Livno ! " " ! Foca " Mostar Trebinje !
  • 33. Landmine victim assistance in BiH – Handicap International – December 2003 33 Individual situations of these workshops in terms of equipment, staff, range and quality of appliances produced, and volume of production dramatically varies from one place to another. On the one hand some of them are poorly equipped, with limited staff, and produce or sell only few types of devices, as in the case of the Reumal ortho-prosthetic workshop in Fojnica, and of the “Ortopedska Radionica Sjeverni Logor” workshop in Mostar. On the other hand, there are a number of bigger facilities, which fit most of the amputees, received equipment and training from various international organizations, and have a multidisciplinary team of ortho-prosthetic technicians, physiotherapists and physiatrists. For instance 6 ortho- prosthetic workshops (Neretva centre in Sarajevo, Tuzla, Cazin, Mostar, Zenica and Banja Luka) were included in the World Bank funded “war victims’ rehabilitation project”, to the tune of $6.2 million.64 The project comprised civil works, equipment, ortho-prosthetic materials and training. From this assessment, it appears that 6 ortho-prosthetic workshops in the FBiH and 2 in the RS can be considered as very well equipped and staffed with basic skilled professionals. In the RS the ortho-prosthetic workshops located in the rehabilitation centre “Miroslav Zotovic” fits the majority of amputees (the public ortho-prosthetic workshop Miroslav Zotovic was recently split into two workshops, one being public and the other private). A detailed survey would be needed to provide evidences about the quality of ortho- prosthetic appliances produced in each place, but it is obvious from the data of the current assessment that not all of the 27 existing facilities have the human or material resources needed to provide quality services. The absence of established quality standards also supports this statement. 4.2.3.2. PROFESSIONALS In the 11 ortho-prosthetic workshops that we interviewed or visited, we numbered 35 ortho-prosthetic technicians in Bosnia and Herzegovina. We estimate that the total number of ortho-prosthetic technicians is likely to be between 60 and 70. Two of them have a high-level ortho-prosthetic technician (engineer) diploma (one completed his degree in Belgrade, the other recently graduated in Ljubljana). Both of them work in the private ortho- prosthetic workshop situated in the Miroslav Zotovic Centre in Banja Luka. If one refers to WHO and International Society for Orthotics and Prosthetics (ISPO), the number of persons needing ortho-prosthetic appliances is estimated to be between 0.5 and 0.8 % of the total population. The optimal number of qualified professionals to meet those needs should be one professional per 500 to 1000 persons needing ortho-prosthetic devices. According to these recommendations, BiH would need between 22 and 71 ortho-prosthetic technicians to answer the ortho-prosthetic needs of its population. If one reads these figures, BiH should be considered as having sufficient number of ortho-prosthetic professionals. But the problem is that among the existing professionals, only 2 received a complete professional education. For the others, their background varies from medical secondary school (medical technicians) to various handcraft professional experiences. Each of them has received some short-term ortho-prosthetic training, the most frequent type being in-service training provided during the emergency phase by some international organizations such as the Finnish Red Cross, Jesuit Refugee Services, World Bank war victims’ rehabilitation project, Handicap International or International Rescue Committee, with training lasting from 1 to 10 64 “War Victims Rehabilitation Project” World Bank Reconstruction and Development Program in Bosnia and Herzegovina, Project Document, April 1996, p. 41.
  • 34. Landmine victim assistance in BiH – Handicap International – December 2003 34 months. Recently, Otto Bock (which is the leading ortho-prosthetic components producer in Europe) took the lead in such short-term education, offering 1-4 week courses for staff of workshops purchasing OttoBock equipment and components, at its regional centre OttoBock Adria located in Samobor in Croatia. According to ISPO standards, the education program for high-level ortho-prosthetic technicians requires a minimum of 3 years. Such a level of Education is not available in BiH. In addition, there is no official recognition by governments, of the ortho-prosthetic profession itself. Two initiatives can be mentioned that aim at filling this gap. The International Trust Fund is financing the studies of 4 technicians from BiH in the University College for Medical Studies in Ljubljana. One of them already graduated, 3 others are still in training. The Centre for International Rehabilitation (CIR) has established an upgrading educational program in Bosnia and Herzegovina. The curriculum is designed in a modular way, and based on international standards. The theoretical part is made by distance learning, through the CIR website. The practical part and examinations are held in Tuzla. 23 students from 12 different workshops are enrolled and have already completed the first module on Trans-Tibial Prosthetics on September 2003. 4.2.3.3. FINANCING OF ORTHO-PROSTHETIC DEVICES As previously mentioned in paragraph 3.1., ortho-prosthetic appliances are part of Health Care Assistance covered by Health Insurance Funds. But with limited financial resources available, the high cost of artificial limbs is a major problem that hinders patients’ access to these appliances. For example, according to RS Health Insurance Funds pricelists, below-knee prosthesis cost 2,018 KM65, above-knee prosthesis costs 3,803 KM, and upper limb above-elbow functional prosthesis costs 2,696 KM. Those prices correspond to prosthetic devices made according to European standards, using contact laminated sockets and endoskeletal modular components. The most commonly used components in BiH are from OttoBock. In some ortho-prosthetic workshops patients also have the possibility to get more expensive components such as silicon socks or sophisticated knee joints, but must pay for it. In the FBiH, the extent to which insured persons are required to participate in the costs of certain types of care provision, and the list of persons who are exempted, is dependent on Cantonal regulation. In Una-Sana Canton, for instance, the participation fee is 15 % of the total price for prosthesis and for lower limb orthoses, 20 % for corsets, 50 % for eye devices and prosthesis, 40 % for orthopaedic shoes, and 10 % for mechanical wheelchairs66. In Zenica-Doboj Canton, the participation fee is 15 % for prosthesis, 100 % for corsets, 50 % for hearing and eye devices, 70 % for orthopaedic shoes, and 10 % for mechanical wheelchairs67. But actually, in most of the Cantons the Health Insurance Fund sets the price it will pay for each type of appliance according to their prices and to availability of funds. And then the participation fee is the difference between the price paid by Health Insurance Fund and the price asked by the ortho-prosthetic workshop. For example Health Insurance Fund in Sarajevo Canton pays 1,500 KM for below-knee prosthesis, and 2,500 for above-knee 65 Figure from RS Health Insurance Fund price list. 66 Una-Sana Cantonal Assembly Decision on participation of insured persons in healthcare expenses. 67 Decision on direct participation of insured persons in health care expenses on the territory of Zenica-Doboj Canton, enacted on January 2002 by the Assembly of Zenica-Doboj Canton.
  • 35. Landmine victim assistance in BiH – Handicap International – December 2003 35 prosthesis68. In Tuzla Canton, in year 2002 the participation fee was set at 15 % of the total cost of a prosthetic device, and 7.5 % for pensioners. But the Health Insurance Fund had to revise participation fees on April 2003. The fund pays now 1,500 KM for below-knee prosthesis (which costs 1,600 KM in Tuzla workshop), 2,000 KM for above-knee prosthesis (which total cost is 2,800 KM) and for hip-desarticulation prosthesis (which costs 3,150 KM). Some workshops in other Cantons have reported the actual financial participation of the patients to be close to 50 or even 60 %, like in Mostar General Hospital or in “Ortopedija Lasva” in Travnik. In all Cantons Disabled Veterans are normally entitled to receive prosthetic devices free of any participation. When it is not the case, most of the time they can get financial support from associations of war invalids or from the Cantonal office for Veterans Affairs. Civilian Victims of War have to participate in the costs of their ortho-prosthetic devices as other patients do in most of the Cantons, but there are some exceptions like in Sarajevo Canton and in Una-Sana Canton. Nevertheless, there are a number of international organisations like LSN or JRS that can still provide Civilian Victims of War with financial support. The period after which prosthesis can be renewed varies between 36 and 48 months for adults depending on the type of prosthesis and the Canton. In most Cantons this period for renewal is the same for children, while a new prosthesis would be needed in average each year to adapt to the child’s growth. For orthopaedic shoes in most of the Cantons adults can get a new pair each year, while it is every 6 months (or 8 months) for children. Regarding orthotic devices this delay varies a lot from Canton to Canton and depends on the type of device. According to the RS Law on Health Insurance69 and to related decisions70, the participation fee that patients have to pay for ortho-prosthetic devices and technical aids is a percentage of the total price, and it is set to be 10 % for orthotic and prosthetic devices for upper and lower limbs, 30 % for corsets, 10 % for hearing devices, 20 % for ocular prosthesis, 10 % for mechanic wheelchairs, and 30 % for orthopaedic shoes. War Veterans and families of fallen soldiers are exempted from this participation fee. This is also the case for children below 15 years, elderly people above 65 years, persons with certain types of disabilities (progressive muscular dystrophy, cerebral palsy, multiple sclerosis, paraplegia and quadriplegia) or with severe chronicle disease.71 Amputees are entitled to get a new lower- limb prosthesis every 30 months, which refers to both adults and children.72 Regarding orthopaedic shoes, this delay is 6 months for children below 7 years, 8 months from 7 to 18 years, and 12 months for adults. The existence of a participation fee is for many patients is a major obstacle for getting ortho-prosthetic devices. Even when the participation fee is “low” (10 or 15 %), it can represent up to 1,000 KM for above-knee prosthesis, which some persons cannot afford. But in some cantons where this participation makes up to 50 % of the total cost of the appliance, 68 Decree on the Scope of Rights of Insured Persons to Use Orthopedic and Other Devices, Endoprosthesis, Dental-Prosthesis Assistance (“Canton Sarajevo Official Gazette” no. 7/00 issued on the basis of FBiH Law on Health Insurance, Art. 33). 69 RS Law on Health Insurance (“RS Official Gazette” no. 18/99). 70 RS Decision on personal participation of insured persons for health care expenses, June 20th 2001 71 Ibid. 72 Add Reference
  • 36. Landmine victim assistance in BiH – Handicap International – December 2003 36 or when Health Insurance Funds shortfalls in some regions or cantons lead to implicit rationing, ortho-prosthetic devices really become unaffordable. Disabled Veterans can get ortho-prosthetic devices free of charge most of the time, but in the RS and in most of the Cantons Civilian Victims of War have to pay their participation fee. Some initiatives have been undertaken to try to decrease the production cost of artificial limbs, and at the same time to stick to European quality standards. Elegant Design and Solution (an independent design consultancy) has conducted an assessment on landmine victim assistance for Adopt-A-Minefield (an US based non governmental organization) in 200173, and concluded that “outside Sarajevo artificial limbs were too often of poor quality, limited function, and too expensive for limb fitting clinics to apply sustainably”. They are currently working on a program to design a European certified high activity low cost limb system, based on European quality74. Centre for International Rehabilitation is currently testing a “dilatency system”, which enables to cast patient’s stump much faster and simpler than traditional plaster technique. The system is currently being tested for below-knee prosthesis in several countries, including BiH. Such initiatives are interesting, but local professionals, health institutions, health insurance funds and decision makers should be involved in that process to give more chances to such technologies to be distributed in the future. 4.2.3.4. CONCLUSION REGARDING ORTHO-PROSTHETIC DEVICES Big investments have been made in the ortho-prosthetics field in Bosnia and Herzegovina over the last 10 years, in terms of equipment and training. Even though the number of facilities and staff would theoretically be enough to meet the needs, two major concerns contradict this global achievement. Firstly the quality of ortho-prosthetic appliances is very unequal from one place to another, and this is mainly due to the absence of professional standards and to discrepancies in human and material means among the centres. Secondly a majority of patients are facing financial difficulties to get ortho-prosthetic devices, due to the lack of financial resources in Health Insurance Funds to pay for the high costs of these products. Elaboration of quality standards and recognition of high-level ortho-prosthetic technician profession, together with development of upgrading educational programs based on ISPO standards in Bosnia and Herzegovina or in collaboration with foreign countries, would allow harmonizing and improving the quality of appliances produced. Guarantying equal access to prosthetic devices is also a real challenge, which should be tackled through a comprehensive and multi-faceted program involving Health Insurance Funds, professionals, Ministries of Health, associations, international and local experts, and taking into consideration epidemiological, economical and technological aspects. A comprehensive plan should comprise the work on the technologies and materials used in order to decrease the costs of appliances, prioritization of the needs with a detailed and realistic estimation of the costs according to available resources, and efforts to improve transparency and harmonization in procedures for Health Care Assistance provision. 73 Final Report on the MOPS Research Phase, EDaS, October 2001. 74 Information provided by EDaS through mails and phone interviews.
  • 37. Landmine victim assistance in BiH – Handicap International – December 2003 37 5. SPECIFIC PROGRAMS FOR LANDMINE VICTIM ASSISTANCE The previous paragraphs aimed at describing and analyzing the overall BiH Social Protection system for persons with disabilities, Civilian Victims of War and Disabled Veterans, and the Medical Rehabilitation Care system. This is the general framework for landmine victim assistance in Bosnia and Herzegovina, and on the long run this is the system that will remain to answer the life-lasting needs of landmine victims. In that framework, specific programs were set up, with the aim to provide those who suffered injuries from landmine accidents with assistance for care, rehabilitation, and social and economic reintegration. The aim of this report is not to make a detailed review of all existing programs. This has recently been done in a very comprehensive way by Handicap International Belgium, which published a report on landmine victim assistance in South Eastern Europe in September 2003 that presented the results of a study commissioned by the International Trust Fund for Demining and Mine Victim Assistance (ITF) and undertaken in collaboration with the Landmine Monitor country research network.75 We will hereafter focus more on the interactions between these specific landmine victim assistance programs and the existing services for persons with disabilities, trying to analyze in which extent those programs are filling the gaps and strengthening local capacities. The amount of international funds earmarked for landmine victim assistance in BiH has been continuously decreasing since 1999. Consequently, a number of landmine victim assistance programs have been closed, and most of the others had to reduce their activities. 5.1. Overview of the main existing landmine victim assistance programs In most cases, landmine victim assistance programs operate complementary with existing services, filling the gaps in the BiH assistance services. The main components of these programs are referral and financial support to receive prosthetic devices and rehabilitation, material support (notably house repairs and food aid), psychosocial support, socio-economic reintegration, advocacy and promotion of rights. Landmine Survivors Network (LSN) is working in BiH since 1997. It has developed a network of 12 outreach workers spread throughout BiH (in Sarajevo, Banja Luka, Tuzla, Mostar, Bihac, Gorazde, Velika Kladusa, Trebinje, Bijeljina, Doboj, Doboj-Istok and Bugojno). Outreach workers identify and visit landmine survivors on a peer-counselling approach (they are themselves amputees). They assess the needs of amputees and provide them with psychosocial support and education on limb loss. They refer them to existing services, and follow-up the overall rehabilitation and reintegration process. LSN has created a database of all assistance services available (in rehabilitation, vocational training, recreation and sports services…). Financial support can be provided according to the needs to support the cost for prosthesis, for emergency home repair or other needs. LSN also support group activities, organization of tournaments, and vocational training. A number of 1400 amputees have been identified through its network, among which 90 % are landmine victims. 830 of them still need regular visits. LSN is also active on lobbying for the rights of persons with disabilities in BiH76. 75 Landmine Victim Assistance in South East Europe, Final study report, Shirley Bailey, Handicap International Belgium, September 2003. If not otherwise specified, references are from this report. 76 Interview with Plamenko Priganica, Director, and Amira Kavgic, executive assistant, on September 26th and November 3rd.
  • 38. Landmine victim assistance in BiH – Handicap International – December 2003 38 Jesuit Refugee Services (JRS) has identified 330 children victims of landmine injuries and other war accidents, and is continuously providing assistance to 188 of them. This assistance is comprised of medical assistance (in some cases children are referred to BiH facilities and JRS covers expenditures not covered by Health Insurance Funds, in some other cases children can be sent to be fitted in Croatia), financial support for education, material assistance and psychosocial support77. The International Trust Fund for Demining and Mine Victim Assistance (ITF) has financed the prosthetic fitting and rehabilitation of 646 landmine victims with amputation since 1998. 127 of them have been fitted in 3 centres in Fojnica, Mostar and Banja Luka. 519 others were sent to the Slovenian Institute for Rehabilitation78. Hope 87 provides medical and psychosocial support for about 200 victims of war, notably through its outpatient clinic in Sarajevo. It has established a database of 1150 amputees. This organization is also proposing vocational training in computer skills and languages, and employment projects. The NGO Adopt-A-Minefield is currently implementing an income-generating project for 10 landmine victims in RS who are trained and provided with equipment to become beekeepers. It is also planning to develop a project to link services for landmine survivors to the new CBR program in the RS. There are some examples of landmine victim assistance projects that have allowed building up local capacities or establishing local services that will benefit to all persons with disabilities. For example, the above-mentioned CBR project and peer-support projects implemented by the Canadian organization ICACBR / Queen’s University as a part of the World Bank funded “war victims’ rehabilitation project” in the FBiH or in collaboration with Japanese International Cooperation Agency in the RS. Those projects were targeting primarily landmine survivors, but were open for other disabled participants. A number of professionals from BiH have benefited from trainings provided by various international organizations. ITF has notably enabled 268 specialists to attend training seminars, and is supporting the education of 4 ortho-prosthetic technicians in Slovenia. 5.2. Comprehensive analysis of landmine victim assistance The main gaps that we have identified in the landmine victim assistance services are the following: ! There are still some cases of programs partially duplicating services that are already provided in Bosnia and Herzegovina. Sending amputees to receive prosthetic fitting abroad should not be needed anymore considering the resources available locally. It appears to be absolutely non cost-effective, to hinder the comprehensive follow-up of the rehabilitation process, and to jeopardize the efforts to strengthen local facilities notably by channelling abroad resources. ! There is a need to improve coordination and referral among existing services, and to develop collaboration between local professionals, local governments and international organizations. 77 Meeting in JRS office in Sarajevo on September 24th 2003. 78 Phone interview with Mr Roman Tursic, Head of ITF office in Sarajevo, on October 21st 2003.
  • 39. Landmine victim assistance in BiH – Handicap International – December 2003 39 ! Socio-economical re-integration of landmine victims remains very difficult in the poor economic conditions still prevailing in BiH (according to BiH poverty profile, in December 2002 the unemployment rate was 41.1 % of active population)79. In that context, theoretical priority in employment laid down in legislation for protection of Disabled Veterans and Civilian Victims of War is far from being enforced. According to a needs assessment survey undertaken by LSN in 2002, 30 % of landmine victims interviewed consider economic self-reliance as their major need, which appears to be the first priority. Medical needs rank third, with 17 %. ! According to EdAS, little has been done for adult blind persons’ assistance, including those from landmine accident origin80. In the future, collaboration between international organizations acting in the field of landmine victim assistance and governments should be improved, with particular attention drawn to put more emphasis on building up local capacities and improving coordination and networking. A cross-sectoral approach is needed to tackle socio-economic reintegration. The initiation in September 2003 by the BHMAC of regular landmine victim assistance coordination meetings can be seen as an encouraging step in that direction, but a lot remains to be done. 79 The second draft of the Poverty Reduction Strategic Paper for BiH, Sarajevo, 2003. 80 Final Report of the MOPS research phase, Elegant Design and Solution, October 2001.
  • 40. Landmine victim assistance in BiH – Handicap International – December 2003 40 6. INFORMATION SYSTEM 6.1. Objectives of a landmine victim assistance information system Production of comprehensive, reliable and up-to-date information on landmine victims should be considered bedrock for both mine action and landmine victim assistance. As about landmine victim assistance, this information must meet the following objectives: ! Assessing landmines’ impact in terms of morbidity and mortality; ! Providing a comprehensive and precise picture of landmine victims’ needs in terms of medical treatment, rehabilitation including ortho-prosthetic fitting, social and economic reintegration; ! Estimate the capacity of BiH political, social or medical institutions and of local associations to answer the needs of persons with disabilities; and identify the gaps that need to be bridged and services that need to be established or strengthened; ! Estimate the cost of landmine victim assistance, and provide tools to prioritize the needs and support accurate funds’ allocation for assistance and capacity building; ! Monitor the impact of landmine victim assistance programs on landmine victims’ situation. 6.2. Overview of existing databases on landmine victims In BiH a number of databases exist, developed by local authorities or international organizations working in that field. The International Committee of the Red Cross (ICRC) continuously collects data about landmine/UXO casualties in BiH since 1996, and maintains the most complete database on landmine and UXO incidents. Incidents are reported through local Red Cross network from hospitals, police stations, local authorities and organizations working in mine action areas. Victims and their relatives are visited and a questionnaire is fulfilled for each case. Monthly updated statistics are provided to mine action / mine assistance main stakeholders. Table 7: number of landmine/UXO casualties over the period 1992 – 30 November 200381 Age categories Total Injured Killed Children 18-39 40-59 Over 60 1992 - 1995 - - - - 3,346 2,821 525 1996 151 254 158 40 632 522 110 1997 55 118 84 20 290 202 88 1998 22 56 44 17 149 89 60 1999 19 39 25 10 95 57 38 2000 29 40 24 7 100 65 35 2001 12 36 23 7 87 55 32 2002 19 26 22 5 72 46 26 2003 (to 30 Nov) 9 23 14 7 53 31 22 After the war 316 592 394 113 1,478 1,067 411 Total - - - - 4,824 3,888 936 81 Mine Victim Statistics BiH, November 2003, ICRC, Sarajevo.
  • 41. Landmine victim assistance in BiH – Handicap International – December 2003 41 For the period 1992-October 31st 2003, a total of 4,824 landmine/UXO incidents were reported into the ICRC database. 1478 of these incidents occurred after the war, while 3,346 occurred during the period 1992-1995 (data during the war period was collected retrospectively and is likely to be incomplete). Annual number of casualties has regularly decreased since 1996 (632 in 1996, 53 from January to October 2003), but the percentage of fatal injuries tends to increase (21 % in 1996, 65 % in 2003). A total number of 936 persons (19.4 %) died from those incidents. Children make up 21.4 % of incidents. Analysis of the type of non fatal injuries shows 635 cases of foot amputations, 1,002 below-knee amputations, 290 above-knee amputations, 350 upper limb amputations, 411 eye injuries, 1,293 fragmentation injuries to the upper body and arms, and 1,417 cases of fragmentation injuries to the lower body and legs (the total figure is higher than the number on non-fatal incidents because a victim can sustain multiple types of injury)82. Out of the 4,824 victims, 2,706 were reported to be military personnel (2,558 of them were injured or killed during the war), others were civilians. Other existing databases were developed by governments, public institutions, international organizations or associations in order to identify beneficiaries, plan and monitor their activities and evaluate their impact. The BiH Mine Action Centre (BHMAC) has its database that registers incidents, with the aim to monitor impact of mine action programs. It has commissioned a Landmine Impact Survey (LIS) in 2002, designed by the Survey Action Centre and implemented by Handicap International. The aim of the survey is to provide quantifiable and standardized socio- economic indicators about landmines/UXO's impact on communities. Results were presented on December 9th 2003. The survey was conducted in 3,247 communities out of 6,146 in total in BiH. There were 1366 communities reported to be impacted by landmines/UXOs. It included specific data on landmine victims. The tables below are extracted from the LIS report, with BHMAC authorisation. Table 8: Mine victim survey from LIS83 Victims Period Communities involved Killed Injured All Recent victims 71 62 67 129 Victims of less recent data 565 788 1,383 2,171 All victims 583 850 1,450 2,300 Had no victims 783 - - - In the communities surveyed, a total of 2,300 landmine victims were reported. There were 129 recent casualties were reported over the period January 2001-mid 2003. 82 Those figures are from ICRC database, for the period 1992 – August 15th 2003, and were extracted and analysed in the above mentioned “Landmine Victim Assistance in South East Europe, Final study report, Shirley Bailey, Handicap International Belgium”, September 2003. 83 In municipalities Gradačac, Gračanica and Sapna, total number of earlier victims reported by the communities was distortional compared to other municipalities (confusion was made with war victims). As it was not possible to verify at the time of analyzing data, LIS team decided arbitrarily to reduce the number to 2 for each suspected community.
  • 42. Landmine victim assistance in BiH – Handicap International – December 2003 42 Table 9: Mine Accident and Fatalities by Gender from LIS. Accident fatal Female Male Total No 10 57 67 Yes 7 55 62 Total 17 112 129 Fatality Rate 41% 49% 48% Out of those 129 casualties, 62 persons died. For the 67 survivors, the types of injuries sustained were amputation in 16 cases, sight loss in 3 cases, and other types (mostly fragmentation wounds, eye injuries and hear loss) in 48 cases. Information collected on assistance received could not be used due to insufficient number of valid answers. Table 10: Recent victim in affected municipalities, communities and populations (LIS) Impacted Recent Canton / Region Affected Affected Communities Victims municipalities population Srednjebosanski 12 188 174,729 14 10.9% Hercegovacko- Neretvanski 12 117 51,229 3 2.3% Una-Sana 8 123 175,646 3 2.3% Tuzlanski 13 166 368,127 23 17.8% Sarajevo 13 127 16,577 4 3.1% Zenicko-Dobojski 12 131 200,145 18 14.0% Doboj 11 109 111,905 19 14.7% Sarajevski 8 85 143,939 4 3.1% Hercegbosanski 6 80 14,322 3 2.3% Bjeljina 10 77 23,682 12 9.3% Brcko District 1 28 27,791 6 4.7% Bosansko-Podrinjski 3 56 3,796 1 0.8% Trebinje 5 37 27,387 5 3.9% Posavski 3 17 24,726 13 10.1% Banja Luka 10 24 11,798 1 0.8% Zapadno- Hercegovacki 1 1 8 0 0.0% Total 128 1366 1,375,807 129 100% Ministry of Labour and Social Policy in the FBiH, and Ministry of Health and Social Welfare in RS have collected through Centres for Social Work data on Social Services’ beneficiaries. Those data are published by Institutes of Statistics in both entities. Those publications indicate for instance that in 2002 in the FBiH, a total of 20,755 persons with physical and/or mental disabilities (including 6,119 children under the age of 18) were receiving social assistance, and 3,720 Civilian Victims of War (including 530 children). An additional figure of 5,228 Civilian Victims of War’ family members were also benefiting from social services84. 84 “Social Welfare in 2002”, Statistical bulletin from Federal Office of Statistics, Sarajevo, May 2003.
  • 43. Landmine victim assistance in BiH – Handicap International – December 2003 43 In the RS in 2001, a total of 7,666 persons with physical and/or mental disabilities (including 1,805 children under the age of 18) were receiving social assistance, and 717 Civilian Victims of War (including 118 children). An additional figure of 714 Civilian Victims of War’ family members were also benefiting from social services85. RS Ministry of Labour, Veterans and War Victims mentioned for 2003 a figure of 2,035 Civilian Victims of War and 1,778 Civilian Victims of War’ family members receiving support.86 Disabled Veterans benefit from separate assistance scheme, and are therefore registered separately. Ministries of Veterans issues in the FBiH, and Ministry of Labour, Veterans and War Victims in the RS have updated lists of Disabled Veterans. According to FBiH Ministry of veterans’ issues 45,327 Disabled Veterans from categories I to X were receiving personal disability allowance in 200387 Public Health Institutes in both Entities collect data on mortality and morbidity causes and treatments provided. It seems that there is no individualized data available on medical treatment for patients who sustained injuries from landmine/UXO incident. Health Information System in BiH is reportedly impeded by insufficient budget allocation and lack of accurate information technology. In addition, absence of uniforms standards for indicators is a problem in the FBiH. But significant improvements have been achieved over the last years88. Japanese International Cooperation Agency is currently providing RS with equipment and technical support for the development of an information system within the CBR project. LSN has developed a database to follow-up rehabilitation and socio-economic reintegration of amputees, and to monitor the impact of its program. It contains information about needs, medical situation, ortho-prosthetic treatment and rehabilitation, housing conditions, economical situation and psychosocial aspects. Jesuit Refugee Services also has a database about 330 children and young adults victims of war. 6.3. Analysis and recommendations Even though information on landmine victims exists in BiH, this information is partial and fragmented. Most of the existing databases provide mainly information regarding landmine incidents, identification of the victim (age and sex), and medical data on the type of injury sustained. Very little information is available about the actual situation of landmine victims in BiH, about the kind of obstacles that prevent them from participating into the society on a daily basis, about the way they can access or not to rehabilitation services and general services (such as other medical services, education, social services, leisure…etc). Existing information on their needs is biased by the fact that those databases assess mainly medical needs, and that most of them are service-provider oriented (i.e. designed according to the services offered by the institution or organisation) rather than demand-oriented. 85 “Social Welfare in 2002”, Statistical bulletin from Federal Office of Statistics, Sarajevo, May 2003. 86 Interview with Mr Radomir Graomic, Assistant Minister for Veterans, RS Ministry of Labour, Veterans and Civilian Victims of War, November 13th 2003. 87 Interview with Halil Plimac, Deputy Minister, FBosnia and Herzegovina Ministry of War Veterans, Sarajevo, November 12th 2003. 88 Health Care Systems in Transition: Bosnia and Herzegovina – Cain J. and Jakubowski E., Copenhagen, European Observatory on Health Care Systems, 4(7) (2002).
  • 44. Landmine victim assistance in BiH – Handicap International – December 2003 44 There is no coordination between different existing databases, which results sometimes in contradictory information. This doesn’t allow comparing different information available and completing them with each other. For those various reasons, it is impossible to have a comprehensive and documented picture of the impact of landmine victim assistance programs implemented so far. It is worth noting that the global assessment of Social Protection System for persons with disabilities in BiH that Handicap International conducted simultaneously with this assessment of landmine victim assistance, led to similar conclusions regarding information system for persons with disabilities, but to a much more dramatic extent. A number of persons with disabilities are not registered anywhere. The existing information is partial, and doesn’t give a comprehensive assessment of persons with disabilities’ needs and living conditions. And there is no tool in place to measure the impact of social assistance. This analysis reveals that there is a need to develop a Landmine Victim Assistance Information and Research System that would be responsible for gathering existing information on landmine victims and developing research activities, with the objectives to: ! Produce comprehensive and reliable information on the situation of landmine victims and their demands; ! Provide objective elements for prioritizing the needs and orienting the allocation of resources; ! Develop tools for improving services for persons with disabilities in an inclusive and comprehensive way and for evaluating them; ! Monitor landmine victim assistance programs; ! Have a learning value for the needed overall improvement of disability information system. Activities developed by such Landmine Victim Assistance Information and Research System could be: ! Establishing coordination mechanisms between existing databases; ! Publishing yearly reports on situation of landmine victims in BiH and landmine victim assistance services; ! Conducting surveys on the situation of landmine victims in BiH, using comprehensive tools such as Measurement of the Quality of the Environment, Measurement of Life Habits. The above-mentioned tools are based on the model of the Disability Creation Process89. The Disability Creation Process is an explanatory model of the causes and consequences of disease, trauma and other disruptions to a person’s integrity and development. It is based on an anthropological model of human development that applies to every human being. It allows the distinction between personal factors and environmental factors in the creation of “Disability”. 89 The Quebec Classification: Disability Creation Process, Patrick Fougeyrollas, René Cloutier, Hélène Bergeron, Jacques Côté, Ginette St Michel, INDCP / CSICIDH 1998.
  • 45. Landmine victim assistance in BiH – Handicap International – December 2003 45 “Handicap” in this model is considered as a disturbance in a person’s life habits as a result of personal factors (impairments or disabilities) and/or environmental factors (obstacles). It is therefore a relative “situation” that varies according to the context and to the environment, but which can also be modified by reducing impairment (medical care) and developing capacities (rehabilitation) as well as adapting the environment (policies, removal of physical obstacles). This approach is consistent with human rights and equal opportunity approach to disability. A number of tools were designed according to the Disability Creation Process model. They allow comprehensive assessment of the situation of persons with disabilities and of their needs, with the advantage of taking their opinion into consideration. Some tools also exist for comprehensive assessment, individualised intervention plan, and interdisciplinary follow up of rehabilitation process. Risk Factors Handicap Creation Process Cause (Canadian Society on ICIDH, 1996) Personal Factors Environmental Factors Organic Capabilities Systems Integrity Impairment Ability Disability Facilitator Obstacle Interaction Life habits Social Participation Handicap Situation
  • 46. Landmine victim assistance in BiH – Handicap International – December 2003 46 7. CONCLUSION The assessment undertaken provides a comprehensive overview of BiH landmine victim assistance system, with focus on analysis of legislation and rehabilitation care system. The analysis of this system highlights the existing resources and the main gaps, with the aim to contribute to the process of definition of a long-term strategy for landmine victim assistance in BiH. This process was initiated by the BHMAC, which established regular landmine victim assistance coordination meetings from September 2003. A decision was recently taken to create a strategic working group under the BHMAC, comprised of representatives from governments of both Entities, BHMAC and some associations and international organisations. This working group will start from February 2004 to work on the definition of the strategy, using this paper as a working document. Assistance to landmine victims is a comprehensive process that includes medical, psychological, social and economical components. It aims at full socio-economical reintegration of landmine victims into the society. As such, it is an integrated part of the overall system of assistance for persons with disabilities. Governments of both Entities are responsible to provide assistance to persons with disabilities including landmine victims, in the frame of their overall Social and Healthcare policies. Many improvements were achieved in those domains over the last 8 years, thanks to reconstruction programs and reform processes. Still, many gaps have to be mentioned: • In the fields of Social Assistance to disabled persons and compensation for Civilian Victims of War and Disabled Veterans, big discrepancies exist according to beneficiaries’ status (mentally or physically disabled person, Civilian War Victim, Disabled Veteran from either Armies) and due to limited resources available to pay for benefits, with variability according to the geographic location. • In the field of rehabilitation care, there are significant discrepancies in the quality of existing rehabilitation services, due to the absence of professional standards and a lack of coordination. The access to rehabilitation care services is also very unequal, especially for ortho-prosthetic devices, due to the financial participations that patients have to pay for, and to the lack of harmonised and transparent approach to set exemption criteria. • Socio-economic insertion opportunities remain weak in the current economical context. Therefore international assistance is still needed to fill the existing gaps and support the building-up of local capacities. But the funds earmarked for landmine victim assistance are now following a decreasing trend. And existing international assistance programs have their own shortcomings, which are mainly their poor coordination among themselves or with local institutions and the fact that a number of them are still implemented in substitution to existing local stakeholders, which is not cost-effective and jeopardises the efforts made to build local capacities. International assistance for landmine victims should also be used as an opportunity to improve overall services for persons with disabilities. The existing data about landmine victims in BiH is very fragmented, and provides insufficient information about their real socio-economical situation. This lack of reliable information on landmine victims allows neither to precisely assess their needs nor to monitor the impact of assistance programs.
  • 47. Landmine victim assistance in BiH – Handicap International – December 2003 47 Those gaps shall be tackled within the definition of a comprehensive and long-term strategy for landmine victim assistance. The principle of mainstreaming landmine victim assistance within the overall assistance to disabled persons in BiH should underlie this strategy. In that process, specific attention should be drawn to: • Establish a Landmine Victim Assistance Information and Research System, producing reliable and comprehensive information on the situation of landmine victims, in order to improve coordination and to allow proper allocation of resources and monitoring of the impact of assistance programs; • Improve coordination between international organizations working in the field of landmine victim assistance and local authorities and institutions; • Put the emphasis on strengthening of Bosnia and Herzegovina rehabilitation care system for people with disabilities, notably through promoting interdisciplinary and patient-centred approach, and developing quality standards for ortho-prosthetics and medical rehabilitation; • Harmonize the access to rehabilitation services, notably through the definition of a basic benefit package for this area; • Vocational training and promotion of employment; A long-term strategy for landmine victim assistance that would tackle these key points could be considered as a real opportunity to improve overall assistance to persons with disability in Bosnia and Herzegovina.
  • 48. Landmine victim assistance in BiH – Handicap International – December 2003 48 ANNEXE – LIST OF THE MAIN BIH LAWS RELATED TO THE FIELD OF LANDMINE VICTIM ASSISTANCE Legislation studied for this report belongs to the fields of Social Protection, Protection of Civilian Victims of War, protection of Disabled Veterans, Health Care and Health Insurance. FEDERATION OF BOSNIA AND HERZEGOVINA 1. The Law on Principles of Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of FBiH”, no. 36/99) 2. The Law on Pension and Disability Insurance (“Official Gazette of FBiH”, no. 29/98) 3. The Law on Health Insurance (“Official Gazette of FBiH”, no. 30/97) 4. The Law on the Basic Rights of Disabled Veterans and Families of Killed Soldiers (“Official Gazette of the Republic of BiH”, no. 2/92 and 13/94) 5. The Law on Exceptional Financial Provisions for Disabled Veterans and Families of Killed Soldiers (“Official Gazette of the Republic of BiH”, no. 33/95, 37/95 and 17/96) UNA-SANA CANTON 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of Una-Sana Canton”, no. 05/00) 2. Decision on Rights to use Orthopaedic and other Devices Ensured Through the Health Insurance Fund of Una-Sana Canton (“Official Gazette of Una-Sana Canton”, no. 6/99) 3. Decision on Direct Participation of Insured Persons in the Health Care Expenses on the Territory of Una-Sana Canton (“Official Gazette of Una-Sana Canton”, no. 6/99) POSAVINA CANTON 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children of Posavina Canton TUZLA CANTON 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of Tuzla Canton”, no. 12/00) ZENICA-DOBOJ CANTON 1. Decision on Right to Financial Allowance for Care and Assistance by a Third Person (Decision was enacted on 26th June 2002, and amended by the Government of Zenica-Doboj Canton, on 28th May 2003) 2. Decision on Direct Participation of Insured Persons in the Health Care Expenses on the Territory of Zenica-Doboj Canton (Decision was enacted in January 2002, by the Assembly of Zenica-Doboj Canton) BOSNIA-PODRINJE CANTON (GORAZDE) 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of Bosnia-Podrinje Canton Gorazde”, no 10/00)
  • 49. Landmine victim assistance in BiH – Handicap International – December 2003 49 CENTRAL BOSNIA 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children of Central Bosnia Canton, enacted in 2002 WEST HERZEGOVINA CANTON 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of West Herzegovina Canton”, no. 16/01) SARAJEVO CANTON 1. The Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children (“Official Gazette of Sarajevo Canton”, no. 16/02) 2. Decree on the Scope of Rights of Insured Persons to use Orthopedic and Other Devices, Endoprosthesis and Dental Prosthesis Assistance (“Official Gazette of Sarajevo Canton”, no 7/00) 3. Decision on Individual Participation of Insured Persons in the Health Care Costs (“Official Gazette of Sarajevo Canton”, no 11/00) 4. Regulation on the Amounts of Entitlements According to the Law on Social Protection, Protection of Civil Victims of War and Protection of Families with Children (Enacted in May 2003, by the Ministry of Labor, Social Affairs, Displaced Persons and Refugees of Sarajevo Canton) 5. The Rule Book on Procedure and Way of Work of the Medical Expertise Organ for Achievement of Rights from Social Protection and Protection of Civil Victims of War (Enacted in December 2002, by the Ministry of Labor, Social Affairs, Displaced Persons and Refugees of Sarajevo Canton) REPUBLIKA SRPSKA 1. The Law on Social Protection (“Official Gazette of Republika Srpska”, no. 5/93 and 15/96) 2. The Law on Protection of Civil Victims of War (“Official Gazette of Republika Srpska”, no. 25/93) 3. The Law on the Rights of Veterans, Military Disabled and Families of Killed Soldiers (“Official Gazette of Republika Srpska”, no. 35/99) 4. The Law on Pension and Disability Insurance (“Official Gazette of Republika Srpska”, no. 32/00) 5. List of percentages of Army Disability, “Official Gazette of RS”, November 26th 1993. 6. The Law on Health care and the law on Health Insurance, “Official Gazette of RS” no. 18/99. BRCKO DISTRICT 1. The Statute of the Brcko District of Bosnia and Herzegovina (“Official Gazette of Bosnia and Herzegovina”, no. 9/00; “Official Gazette of the Republika Srpska”, no. 8/00) 2. The Law on Social Protection (“Official Gazette of BiH Brcko District”, no. 1/03) 3. The Law on Health Insurance (“Offical Gazette of BiH Brcko District”, no. 1/02)