Thirteen years after the end of the war in Bosnia and Herzegovina, returning ref-ugees often find themselves barred from local health facilities because they have dropped out of the state-run health insurance. 

Bosnia's two autonomous regions have their own insurance systems (in one region this is further fragmented into ten cantonal funds) and contributors tend to have difficulty switching from one to another – for example, when they return to their pre-war homes in a different region.

Access is a key issue for patients in many European Union hopefuls in the south-east of Europe, and it is especially acute for vulnerable groups such as refugees

A number of international assistance projects over the years have helped improve specific aspects of policy-making and service delivery, but basic problems of under-investment and inequity remain.

Vulnerable groups

Bosnia is an extreme case – but access is a key issue for patients in many European Union hopefuls in the south-east of Europe, and it is especially acute for vulnerable groups such as refugees or Roma.

These countries – Albania, Turkey and most of the Yugoslav successor states – are lagging far behind the European average in economic and social development, although Croatia tends to do better on most counts.

In the latest human development ranking compiled by the United Nations Development Programme, Bosnia ranks last in the group of countries with high development, and Turkey tops the category of countries with medium human development.

In 2006, Turks had a life expectancy at birth of 71.6 years, which is close to Bulgaria's (72.9) but far behind that of most other EU member states.

Turkey also has the highest child mortality of any member of the Organisation for Economic Co-operation and Development.

But health outcomes are not only a reflection of social and economic conditions.

“The health status of Turkish citizens is poor compared with countries of similar economic and development situation,” a study commissioned by the European Parliament in 2006 found.

This is in part the result of systemic problems found across south-east Europe, especially in governance of the health sector.

Streamlined

Governments in the region are now trying to cut back the dominant role of the state in the provision of health services, focusing instead on policy, funding and standards, in the hope that this will lead to more streamlined and effective systems.

But policymaking at present is fragmented and implementation poor, which produces overbearing yet ineffective state intervention.

At the same time, where reforms are undertaken – with Turkey and Serbia at the forefront – major investments in physical infrastructure and education and training are also needed.

Twin challenges

As these countries emerge from decades of mismanagement and under-investment – compounded in the Balkans by the direct and indirect effects of war – they grapple with twin challenges: infectious diseases typical of transition countries (tuberculosis is still widespread, as are smoking and reckless driving), and at the same time, a growing incidence of diseases typical of middle-income countries, with conditions such as obesity presenting a serious threat to public health.

Awareness both among the public and policymakers is growing, however.

Dr Nata Menabde, deputy regional director for the World Health Organization/Europe in Copenhagen, said the Turkish government has undertaken “bold moves” in dealing with smoking as a public-health issue, despite pressure from the country's big tobacco industry.

More generally, Menabde sees the political will in most countries to deliver better results with limited funds, and a “substantial reform” in primary healthcare is under way.

Turkey, she said, now invests “substantial amounts” in its health sector. According to Menabde, this is not so much a reflection of inefficiencies as of the government's priorities.

“Turkey has put a lot of resources into making services available to the poor,” she said.

Such reforms have mostly been driven by political agendas, even by individual politicians, who recognise the electoral value of providing quality services to taxpayers.

Accession

But the process of EU accession has also boosted the reformers. Even though health is not a focus of the accession process – in the EU, the organisation of the health sector is a national prerogative, and the acquis communautaire does not prescribe a specific model – the cumulative requirements of good governance, transparency, prudent spending and non-discrimination provide powerful pressure in the direction of reform.