Health and social inequities in Yugoslavia

Social determinants of health inequalities in Bosnia and Herzegovina

OBJECTIVE

To examine the social determinants of inequalities in health in Bosnia and Herzegovina in the post-conflict period, and to test if the relative effects vary across the two entities of the Federation of Bosnia and Herzegovina and the Republika Srpska.

STUDY DESIGN

Cross-sectional data come from the first wave of the Bosnia and Herzegovina Household Panel Study conducted in 2001, which collected data from 7482 respondents aged 17 years and older based on over 3000 households.

METHODS

Distributions and odds ratios for physical limitations and poor mental well-being were calculated over a number of known social determinants. Multivariate logistic regression and t-tests were used to compare risks across entities within the state of Bosnia and Herzegovina.

RESULTS

The prevalence of poor mental well-being and physical limitations was significantly higher in the Republika Srpska. Significant differences in poor mental well-being and physical limitations were observed across most determinants within each entity, but only a few of these relative effects differed between entities.

CONCLUSIONS

Efforts to tackle absolute differences in poor health between the entities within Bosnia and Herzegovina should be pursued, along with reducing social inequalities.

Croatian healthcare system in transition, from the perspective of users

Reform of the Croatian healthcare system focused mainly on centralising financing, rationing services, and encouraging the provision of private health services with incentives. Although these changes may have contained costs, they have increased inequality of access to health care and proved highly unpopular with users

Public health capacity building in southeastern Europe: a partnership between the Open Society Institute and the US Centers for Disease Control and Prevention

The political disintegration of former Yugoslavia inaugurated in 1991 resulted in the decentralization of health systems in the federation's successor nation-states. Efforts by the Open Society Institute improved public health planning and management needs consequent to health sector changes. Beginning in Croatia in 2001, the Institute developed ongoing collaborations between Andrija Stampar School of Public Health and the US Centers for Disease Control and Prevention. In 2003 and 2004, it expanded its project to include the republics of Macedonia and of Serbia and Montenegro.

The making and breaking of Yugoslavia and its impact on health

The creation of nation-states in Europe has generally been assumed to be intrinsic to modernization and to be irreversible. The disintegration of Czechoslovakia, the Soviet Union, and Yugoslavia demonstrates that the process is not irreversible. I argue that in the case of Yugoslavia, (1) disintegration was caused by the interaction between domestic policies with regard to nationalities and integration into the global economy and (2) the impact of the disintegration of the federation on health care and public health systems has been profound. Improving and converging measures of mortality before the collapse gave way to increasing disparities afterward. The lesson is that processes of individual and social modernization do not result in improvements in health and well-being that are necessarily irreversible or shared equally.

Market reforms and public incentives: finding a balance in the Republic of Macedonia

The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians-over 40% of all physicians-will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies.

Variation in survival in coastal and continental regions of Croatia--results of a longitudinal study

After 25 years of follow-up, regional variations in survival were analysed on a sample of 3343 participants (1780 female, 1563 male) from three urban and three rural municipalities in Croatia. Age of participants was in the range 35-54 years at the beginning of the study (1969). Cox regression for general mortality singled out one continental rural municipality (Virovitica) with the lowest survival in both genders. The relationship between the risk of death and age at the beginning of the study was approximately linear throughout its range for men, and after the age of 45 for women. Men showed a trend of better survival in the coastal region, which was consistent with findings of a similar concurrent study of rural Croatian population.

Health care reform in Croatia: for better or for worse?

Along with the rest of Central and Eastern Europe, Croatia has begun to dismantle its long-standing socialist health care system and to replace it with a market-based approach. Marketization's advocates maintain that the market will bring efficiency and quality to the Croatian health care system. Nevertheless, data from consumer surveys and official statistics reflect the reform's hidden costs: limited access to care, heightened costs, growing inequality, and the deemphasis of preventive and proactive care in favor of costly therapeutic medicine.