Mental Health in Bosnia and Herzegovina: Situational Assessment and Policy Recommendations
A thesis submitted to the
Graduate School
of the University of Cincinnati
in partial fulfillment of the
requirements for the degree of
Master of Public Health
in the Department of Environmental Health
of the College of Medicine
by
Mohamed H. Elzarka
University of Cincinnati
28th March 2019
Committee:
Aimin Chen, MD, Ph.D., Chair
Jun Ying, Ph.D.
ABSTRACT
Background: The war that plagued Bosnia and Herzegovina in the mid-1990s has had far reaching effects on mental health within the nation, and its aftereffects have further exacerbated the challenges to mental wellbeing faced by the country’s citizens. Although the initial post-war support for mental health was robust, resources and investments into mental healthcare infrastructure in the country have diminished, and access to mental healthcare services is significantly lower than the incidence of mental health conditions would necessitate.
Objective: Identify and characterize the mental health challenges present in Bosnia and
Herzegovina and propose policy recommendations that can address the root causes of these obstacles to strong mental health in the country.
Methods: A comprehensive literature review was conducted to perform a situational assessment of the major mental health challenges experienced in Bosnia and Herzegovina today and the current mental healthcare infrastructure that has been set up to deal with them.
Results: Findings show that Bosnia’s key mental health challenges are rooted in larger challenges with post-war recovery, effective governance, sustaining a robust economy, educational integration, substance abuse, social inclusion for minority groups, and perceptions of mental health in civil society. These challenges are exacerbated by a healthcare system which has found some success in improving mental healthcare access and quality but which today is also overburdened, understaffed, and in need of serious streamlining. Ultimately, policy recommendations focusing on addressing these key challenges and shoring up infrastructure to better care for Bosnia’s mentally ill will be critical.
Conclusions: Important policy recommendations to be considered for facilitating improved mental health in Bosnia must look to address the societal, political, economic, educational, and
ii comorbid medical issues in the country. Particular focus should be paid to stigma reduction, health education, educational integration, governmental and economic reform, and coalition building and the consolidation of resources between the public and non-profit sectors.
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ACKNOWLEDGEMENTS
Mohamed Elzarka was supported by the Fulbright U.S. Student Program – a program of the
United States Department of State, Bureau of Educational and Cultural Affairs – with a
Study/Research Grant to Bosnia and Herzegovina for the 2017-18 academic year.
A very special thank you to the members of my committee for their time and effort, and to Prof.
Charles Doarn for his mentorship and support as the Global Health Concentration Director and the guidance that he has given which I hope will stay with me long into my career.
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Mental Health in Bosnia and Herzegovina: Situational Assessment and Policy Recommendations
TABLE OF CONTENTS
ABSTRACT ...... ii
ACKNOWLEDGEMENTS ...... v
LIST OF FIGURES AND TABLES ...... vii
BACKGROUND ...... 1
POST-TRAUMATIC STRESS AS A PRODUCT OF THE BOSNIAN WAR ...... 4 Comorbidity of Psychiatric Disorders ...... 8 Secondary Traumatic Stress ...... 11
ADDITIONAL KEY MENTAL HEALTH CHALLENGES ...... 13 Post-War Economic Struggles and Despondency ...... 13 Ethno-Religious Identity in the Classroom ...... 16 Substance Abuse ...... 20 Acceptance of LGBT Identity ...... 22
MENTAL HEALTHCARE INFRASTRUCTURE IN BOSNIA AND HERZEGOVINA .. 25 Post-War Reconstruction of Mental Health Services ...... 25 Current Mental Healthcare Infrastructure ...... 27
POLICY RECOMMENDATIONS ...... 30 Standardization of Mental Healthcare Policy and Integration of Partners ...... 31 Governmental Reform ...... 33 Educational Interventions ...... 34
SUMMARY ...... 35
BIBLIOGRAPHY ...... 37
APPENDIX A: FIGURES AND TABLES ...... 47
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LIST OF FIGURES AND TABLES
Figure 1: Map of the distribution of ethnic identity in Bosnia and Herzegovina based on data from the 1991 census Figure 2: Map of the separate federal entities of Bosnia and Herzegovina (A) and the distribution of Bosniak, Croat, and Serb ethnic groups in the country based on the 2013 Bosnian census (B,C, and D, respectively) Table 1: CIA World Factbook Data on GDP per capita for the sovereign nations of the Former Yugoslavia
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BACKGROUND
Bosnia and Herzegovina (hereinafter referred to as “Bosnia and Herzegovina” or simply
“Bosnia”) is a nation in southeastern Europe and a former constituent republic of the Socialist
Federal Republic of Yugoslavia. On March 3, 1992, the country declared its independence from
Yugoslavia as part of the larger dissolution of the Yugoslavian state over the course of the 1990s which eventually split the South Slavic republic into 7 sovereign nations today (Keil & Stahl,
2014). Yugoslavia (then known as the Kingdom of Serbs, Croats, and Slovenes) was a nation- state constructed after the end of the First World War that integrated the pre-war kingdoms of
Serbia and Montenegro with substantial territory from the former Austrian Empire. The majority of the resultant nation’s citizens shared a common South Slavic identity, as well as a common dialectical continuum (Langston & Peti-Stantić, 2014). Despite these shared characteristics, differentiation between people groups in Yugoslavia was common, based primarily upon ethnic and religious identity, as well as linguistic differences (Greenberg, 2001). These dissimilarities informed the creation of constituent republics within a socialist Yugoslavia after the end of the
Second World War.
To develop an understanding of the history of Bosnia and Herzegovina, three different ethnoreligious identities must be discussed: Bosniak, Croat, and Serb. These ethnic groups are primarily separated from one another on the basis of religion, since in the former Yugoslavia, religion was almost synonymous with ethnicity. Indeed, before the breakup of Yugoslavia, religion was not only a matter of private belief, but also a public identifier (Petrovich, 1967).
Previous censes underscore this point, by identifying the ethnic group which would later come to be known as “Bosniak” by the racial identifier of “ethnic Muslim” (Dyker, 1972). The ethnoreligious equivalences are such that Bosniaks are practitioners of Islam, while Croats are
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Roman Catholic and Serbs are adherents to the Serbian Orthodox Church. The affiliation between these identities of religion and ethnicity was so strong that a religious conversion was often thought to result in a simultaneous change of nationality from the perspective of other
Yugoslavs (Petrovich, 1967). This concordance between identities is both an interesting sociological phenomenon, and also a key factor in explaining the dissolution of Yugoslavia based upon ethnic nationalism.
Bosnia is, and was at the time of its independence declaration, a nation of diverse ethnic and religious identity (Figure 1). Surrounded on either side by the republics of Croatia and
Serbia, Bosnia contained large ethnic Serb and ethnic Croat populations in addition to its population of Bosniaks. As tensions grew in the early 1990s with increased calls for nationalism within Yugoslavia, these ethnic differences boiled over into outright violence. After the Bosnian independence referendum and declaration of 1992, conflict between ethnoreligious groups resulted in a three-year, often tripartite civil war that also saw numerous human rights abuses including ethnic cleansing and genocide. The war that took place in Bosnia was but one of several clashes in the region – which also saw armed struggles for independence from ethnic
Croats in Croatia and Kosovars Albanians in Kosovo – but even with the large amount of unrest regionally, Bosnia and Herzegovina served as a particular hotbed for violence for a number of reasons. Like its neighbor Croatia, the new Bosnian state was breaking away from a federal government centered in Belgrade, the then-Yugoslav and current Serbian capital. Doing so challenged the continued territorial integrity of the central Yugoslav government, and therefore incurred a military advance by the Yugoslav National Army to reclaim rebellious territories. At the same time, Bosnia and Herzegovina’s position between Croatia and the Serb-led Yugoslav government in Belgrade was a precarious one given that fighting had already broken out between
2 the two factions with the beginning of the Croatian War of Independence almost a year before
Bosnia’s secession.
The war in Bosnia was disastrous, and saw not only the largest genocide since the end of the Second World War, but also a siege of Bosnia’s capital city of Sarajevo that lasted for nearly four years. Brutal ethnic cleansing campaigns were carried out, including most famously that of
Srebrenica – a small town along the Bosnian-Serbian frontier in which more than 8,000 Bosniak men and boys were killed (Ryngaert & Schrijver, 2015). In Sarajevo, constant shelling and sniper fire from the mountains that surround the city trapped residents in a perpetual state of unease and anxiety, forcing many to go hungry and many more to remain sheltered in their homes. Overall, it is estimated that over 100,000 people – including more than 55,000 civilians – were killed as a result of the war (Hayden, 2007). A further 2.2 million people are thought to have been displaced (Conley-Zilkic, 2016), and 12,000 – 50,000 women are estimated to have been raped, most of whom were Bosniak (Crowe, 2014). This makes the war in Bosnia the most devastating conflict in Europe since World War II.
Fighting finally ceased with the Dayton Peace Accords signed in Dayton, Ohio, on
November 21, 1995 (U.S. Central Intelligence Agency, 2019). This agreement preserved the international boundaries of Bosnia and Herzegovina while granting the new nation its independence from Yugoslavia, but also created two governmental entities within the country that operate mostly independently to oversee most government functions. These two autonomous entities are the Bosniak and Bosnian Croat Federation of Bosnia and Herzegovina, and the primarily Bosnian Serb Republika Srpska (Figure 2). Since the end of the hostilities in 1995,
Bosnia and Herzegovina has remained peaceful and ethnically diverse, although still segregated by the borders of its two constituent entities, and still defined by political identification on the
3 basis of ethnoreligious identity (Kartsonaki, 2017). Today’s Bosnia has a population of 3.85 million that is 50.1% Bosniak, 30.8% Serb, and 15.4% Croat, and is currently moving towards greater integration with the rest of Europe as a potential candidate nation for the European Union
(Bieber, 2010).
POST-TRAUMATIC STRESS AS A PRODUCT OF THE BOSNIAN WAR
Despite the significant progress that Bosnia has made since the end of hostilities more than two decades ago, there are many aftereffects of the war that have made their mark on the fledgling nation. More than the pockmarks from shelling which still scar many of Sarajevo’s buildings, it is mental health which has been the most prominent of these lasting legacies of the conflict. In many ways, the aftereffects of the trauma caused by the war serve as a backdrop to most of the nation’s challenges, especially in the arena of mental health.
One the most significant of the mental health challenges faced by Bosnia is that of Post-
Traumatic Stress Disorder (PTSD). A difficult and ubiquitous challenge in post-conflict settings,
PTSD is a neuropsychiatric disorder that can occur in people who have experienced a traumatic event like a war, rape, or personal assault, and that results in intense and debilitating thoughts and feelings about this experience long after its conclusion (American Psychiatric Association,
2017). While it is common that those who have experienced a traumatic event experience fear, sadness, and other negative emotions, most individuals are able to recover from these feelings naturally. In instances of PTSD, however, affected individuals are unable to do so, and instead experience a defined series of symptoms for at least one month in order to meet the clinical qualifications for diagnosis. These symptoms include at least one re-experiencing symptom (e.g. a flashback in which an individual relives their trauma), at least one avoidance symptom (e.g.
4 staying away from places or objects that serve as reminders of the trauma), at least two arousal and reactivity symptoms (such as being easily startled or having difficulty sleeping), and at least two cognition and mood symptoms (such as difficulty remembering critical details about a traumatic experience or expressing apathy to previously enjoyable activities).
In recognition of the Bosnian War as an extensive mental health burden to Bosnians and of the potential for the trauma that the violence caused to induce significant post-traumatic stress, many efforts to support mental health were initiated during the course of and in the immediate aftermath of the war (Agger, 1995). Some of these programs were targeted at the direct treatment of PTSD – whether with the support of medication or psychotherapy – while others focused on preventative measures that targeted risk factors which would otherwise increase the likelihood of an individual who has undergone a traumatic experience to develop PTSD. In the European
Community Humanitarian Office report published in 1995 which outlined ongoing mental health programming in the region, these two methodologies for mental health intervention were widespread (Agger, 1995). Both domestic and international non-governmental organizations
(NGOs) provided psychological and psychiatric help to affected persons, including psychotherapy and pharmaceuticals which directly combatted PTSD. Similarly, NGOs worked to mitigate the influence of risk factors for PTSD such as a lack of social support or additional stressors after the traumatic event (National Institute of Mental Health, 2016). One Sarajevo- based French NGO, for example, designed a project which facilitated exchange with elderly persons living alone which facilitated the development of social support networks among this vulnerable population, while also providing food and hygiene products that would alleviate some of the additional stressors that could have negatively impacted responses to post-traumatic stress in the post-war period.
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The impetus for these initial efforts to combat post-traumatic stress were well-founded based on the immediate mental health challenges exhibited by Bosnians following the war. In
1996, the International Centre for Migration and Health and the Institute of Public Health in
Sarajevo conducted a multi-dimensional health and social data interview and medical examination for over 1500 families in five major Bosnian cities that included both internally displaced and non-displaced people. Significant mental health challenges were identified in both populations, but especially amongst those who had been displaced by the conflict (Caballo, et al.,
2004). Powerlessness was one such major theme of concern, and as a product of lost family, property, and sense of future purpose, 25% of displaced persons described feeling this sentiment.
Similarly, 16% of displaced Bosnians and 11% of non-displaced Bosnians reported a lack of self-confidence and the loss of a sense of personal worth. These challenges are directly relevant to Post-Traumatic Stress Disorder, insofar as feelings of helplessness are a risk factor for the disease (National Institute of Mental Health, 2016) and poor self-esteem has the capacity to contribute to other potential risk factors such as substance abuse (Alavi, 2011). Thus, based on the traumatic events experienced by Bosnians during the war and their initial post-war reported mental health, it is clear that support for mental health programming that prevented and treated post-traumatic stress disorder was incredibly relevant in the war’s initial aftermath.
Despite the great number of mental healthcare services which functioned to support those coping with post-traumatic stress after the war, long-term issues persist in Bosnia around this challenge. Indeed, because PTSD is a condition which can become chronic in some patients, it remains a concern for mental health providers more than 20 years after the events of the war took place. While there is no conclusive support for the relative importance of any particular type of stressful event or experience for contributing to this chronic state, data suggest that during the
6 wars in the Balkans, the number of human rights violations or other stressful events experienced by an individual can have a compounding effect on risk for PTSD prevalence more than 5 years after the war (Priebe, et al., 2010). Additionally, as might be predicted based on the risk factors for PTSD, postwar social stressors have also played a role in shaping the experience of those coping with chronic PTSD (Klaric, Klaric, Stevanovic, Grkovic, & Jonovska, 2007). War stressors are often associated with symptoms of postwar stress insofar as the number of traumatic war events experienced by women in Herzegovina, for example, correlates significantly with prevalence of experienced postwar social stressors. Even when isolated from wartime trauma, these postwar stressors contributed significantly to the average intensity of PTSD symptoms, if not to the prevalence of PTSD itself.
As both an initial postwar and now long-term concern, PTSD and the non-clinical post- traumatic stress experienced by many Bosnians continue to occupy a central role in the discussion of mental health in the country. As a condition modulated in its severity by important risk factors like social integration, a perceived loss of locus of control, and subsequent stressors in the postwar period, PTSD and post-traumatic stress are inherently tied in their prevalence and severity to many of the other socioeconomic and psychosocial concerns present in Bosnia today to be discussed further. Moving forward, it is also clear that PTSD will continue to present a significant burden on the country, in part because of the intricate ties that PTSD has to other psychiatric difficulties as a comorbid condition, and because of the continued challenge of secondary post-traumatic stress.
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Comorbidity of Psychiatric Disorders
In addition to the direct negative mental health consequences that arise from Post-
Traumatic Stress Disorder, there are many other poor mental health outcomes that have experienced extensive comorbidity with PTSD in Bosnia and Herzegovina. To begin, it is critical to reflect on the interconnected nature of psychiatric diseases, and even more broadly, that of mental and physical health. Because, for example, many of the risk factors for PTSD are themselves negative mental health outcomes, it becomes clear that facing one particular mental health burden is often accompanied by a wide array of additional, related challenges to mental wellness. Alternatively, mental health conditions like PTSD can manifest on physical health by affecting physical impairment and contributing to disability. Among Bosnian refugees living in neighboring Croatia after the war, for example, disability levels were markedly increased among those Bosnians comorbid with symptoms of PTSD and depression, independent of poor physical health (Mollica, et al., 1999). This suggests that PTSD can have a compounding effect on other physical and mental health conditions, and that in tandem, these comorbid diagnoses can exacerbate challenges faced by those affected.
The mental health diagnosis most commonly seen with a diagnosis of Post-Traumatic
Stress Disorder is that of Major Depressive Disorder. Indeed, because traumatic experiences can serve as a catalyst for both conditions, PTSD and depression often have a shared etiology – especially among victims of war or conflict – to the level that some psychiatrists studying
Bosnian refugee populations have expressed interest in recognizing the comorbid pattern of
PTSD and depression in refugees and victims of violent conflict as a separate, core posttraumatic affective disorder (Momartin, Silove, Manicavasagar, & Steel, 2004). In Bosnia, wartime trauma has been significantly linked to both PTSD and depression. As first responders to different
8 wartime events, healthcare providers have been a population of particular interest for further investigation of this relationship. During the course of the war, doctors, medical students, and nurses faced a combination of emergency hospital environments and potential personal traumatic experiences outside of the workplace, exposing them to a great number of direct and indirect traumatic stressors. In Sarajevo in particular, daily bombardment and sniper fire directed at civilians during the course of the siege of the city caused hospitals to face regular inundation with war-related injury. This high volume of patients was further complicated by the targeting of medical facilities, ambulances, and medical personnel. From 1992 to 1993, over 400 doctors and medical personnel were killed in Bosnia, and over 70 in Sarajevo (Barber, 1993). Among these are those who died in ambulances that were targeted by gunfire and in hospitals targeted by shelling. By May 1993, this targeting of medical personnel meant that seventy percent of all war victims in Sarajevo were transported to hospitals in private vehicles (Pretto, Begovic, & Begovic,
1994). These significant challenges faced by medical professionals seeking to provide care to war victims while simultaneously being affected by the war contributed to a significant burden on mental wellness for this population. This is supported by data assessing doctors serving during the war, who experienced a PTSD prevalence of 10% and a depression prevalence of
30%, with 87.5% of those physicians with PTSD also suffering from depression (Hasanovic &
Herenda, 2008).
In a non-conflict setting, this comorbid relationship between PTSD and depression has been shown to correlate significantly with more severe reported depression and increased suicidal ideation as compared to cases of depression alone. This implicates the compounding role of PTSD in shaping response and recovery to depression, and highlights the impact that PTSD can have when operant as comorbid condition (Campbell, Felker, Liu, & Yano, 2007).
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Another mental health diagnosis which has been associated with PTSD in victims of the
Bosnian War is Persistent Complex Bereavement Disorder (PCBD). A new addition to the
Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American
Psychiatric Association, PCBD describes a debilitating clinical condition following bereavement and has been previously referenced as “complicated grief” and “prolonged grief disorder” in the literature before efforts of standardization made in the 5th edition of the DSM released in 2013
(Cozza, et al., 2016). In particular, individuals with PCBD differ from those undergoing the traditional grieving process primarily by exhibiting reactive distress to death that may result in social environment or personal identity disruption and clinically significant distress or impairment in functionality that is outside of sociocultural norms. In an investigation into the relationship between PCBD and PTSD in bereaved Bosnian adolescents, researchers underscored not only that there is a high level of correlation in symptomology for these two conditions within this population, but that based on the current clinical definitions for the two conditions, there is a direct overlap in their alignment (Claycomb, et al., 2016). In particular, the symptoms of intrusive memories and avoidant behaviors are incredibly important to qualifying and understanding both diagnoses – especially in cases where traumatic stress responsible for inciting
PTSD involves the death of a friend or family member. Functionally, this means that there is an increasingly better-developed understanding of the interplay between trauma and grief and the process of coping with these often-associated but distinct processes. For Bosnia, the particular relevance of the connection of these comorbid conditions is for victims of the war who experienced either personal traumatic events that directly involved death (such as witnessing a family member shot by sniper fire) or that experienced war-related trauma and death separately
(including death directly unrelated to the war but within the same time period).
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In addition to comorbidity with other mental illnesses, Post-Traumatic Stress Disorder has also been strongly linked to somatic diseases in Bosnia and Herzegovina. An often neglected relationship, the connection between exposure to traumatic events and physical health has special relevancy to the aftermath of the war. For patients diagnosed with PTSD in the third largest
Bosnian city of Tuzla, for example, chronic somatic disease was comorbid in nearly 85% of cases, with hypertension, chest and back pain, degenerative bone diseases, cerebrovascular complications and diabetes presenting as the most common comorbid conditions (Avdibegovic,
Delic, Hadzibeganovic, & Selimbasic, 2010). Additionally, findings from research conducted with this patient population suggest that nearly 40% of patients diagnosed with PTSD suffered from at least three chronic somatic diseases. This information serves to highlight the incredibly important connection between mind and body wellness, and highlights the full extent of potential downstream negative health outcomes for patients experiencing PTSD.
Secondary Traumatic Stress
Unfortunately, the direct and indirect challenges that Bosnia is facing because of post- traumatic stress are likely to persist into the future, largely due to the phenomenon of secondary traumatic stress. Often associated with caregivers like nurses, social workers, or family members of those suffering from PTSD, secondary traumatic stress can occur when individuals not exposed directly to traumatic events become exposed instead through their interaction with traumatized individuals or populations. For nurses and social workers, secondary traumatic stress is increasingly being seen as an occupational hazard for those providing services to traumatized populations, and the medical literature suggests that many social workers are likely to experience
11 at least some symptoms of secondary traumatic stress with a significant minority even meeting the diagnostic criteria for PTSD (Bride, 2007).
In Bosnia, these caregiver populations are at risk for secondary traumatic stress, but because of the cemented place that the war still occupies in the collective Bosnian consciousness today, are not the only vulnerable groups. Instead, for many Bosnians who may not have had direct experience with traumatic events, secondary exposure to trauma happens by familial connection. Bosnian wives of wartime veterans suffering from PTSD, for example, have significantly poorer mental health outcomes than their counterparts whose veteran husbands do not experience PTSD. A significantly larger number of the former group report higher rates of current and past episodes of depression, generalized anxiety disorder, and suicidality (Klaric, et al., 2012). More tellingly, these wives of veterans with chronic PTSD also experience significantly higher scores of PTSD symptoms themselves, supporting the explanation that the wives of veterans suffering from PTSD are exposed to secondary traumatic stress because of their husbands.
The negative psychological effects of this secondary traumatic exposure are not limited to the wives of wartime veterans, but can also affect their children. Children of Bosnian war veterans suffering from PTSD have, for example, been identified to have significantly more developmental, behavioral, and emotional problems that their peers (Klaric, et al., 2008). This information paints a worrying picture of mental health in Bosnia moving forward by highlighting the extent to which the effects of the traumatic events of the Bosnian War may have long-lasting consequences on mental health beyond the immediate scope of persons who lived through these experiences. Indeed, further study of systemic traumatology – or the study of groups, institutions, and other human systems that exhibit a form of stress response caused directly by a traumatic
12 event or series of events – has shown that PTSD may be potentially transferrable to subsequent generations following the war in Bosnia, interfering with the psychological development of children, and presenting a continued burden of mental illness on the country (Klaric, Kvesic,
Mandic, Petrov, & Franciskovic, 2013).
ADDITIONAL KEY MENTAL HEALTH CHALLENGES
While a significant and ongoing obstacle to more robust mental wellness in Bosnia, post- traumatic stress is not the only major hurdle to overcome in the arena of mental healthcare. In the time since the end of the war, political, social, cultural, and economic struggles have contributed to new challenges for the country, and have directly contributed to issues of mental health. Better understanding these emerging challenges and the multifocal, multidisciplinary influences that have shaped them is critical to developing an effective assessment of the current landscape of mental health in Bosnia and Herzegovina. As such, several key themes driving mental illness in the country today are discussed.
Post-War Economic Struggles and Despondency
One of the most challenging struggles for an independent Bosnia has been creating a robust economy that can ensure for the welfare of all of its citizens. The 2017 GDP per capita for the country was $12,800, which ranks second to last among all Former Yugoslav republics, and is only roughly 1/3 of the highest GDP per capita of $34,500 seen in Slovenia (Table 1).
Bosnia’s economy is heavily reliant on resource exportation in the areas of metals, energy, and textiles, and both remittances sent into the country from Bosnian expatriates and foreign aid contribute sizably to the Bosnian economy. Limited market reforms and a highly decentralized
13 central government have contributed to discouraging foreign investment and making Bosnia’s economy one of the least competitive in the region (U.S. Central Intelligence Agency, 2019). In comparison to the tourism powerhouse that is neighboring Croatia with its many beaches along the Adriatic, Bosnia’s tourism sector is threadbare. Much of the economic activity in the country remains unofficial and unrecorded, in part because of public perception of government corruption and the misuse of taxpayer money. Furthermore, the Bosnian national unemployment rate is over 20% by 2017 estimates, and 16.9% of all Bosnians live below the poverty line. While stepwise integration into trade agreements such as the central European Free Trade Agreement in
September 2007 has helped to improve national-level statistics over time, critical aspects of
Bosnia’s economy continue to keep it off balance and in many ways inequitable.
In particular, Bosnia suffers from a disproportionately large public sector that has not been reformed in a major way since the socialist era and which has contributed to aforementioned public perceptions of corruption. Indeed, public expenditures account for half of the GDP in the country, and state-owned enterprises and corruption may push this figure as high as 70% (Goldstein, Davies, & Fengler, 2015). Even this high level of spending, however, is not sufficient to protect the nation’s poor from economic shocks, as the wealthy within the country benefit almost as much from social spending as the poor and taxes are not progressive enough to limit the burden on low-paid workers while also incentivizing work. Additionally, Bosnia suffers from a significant export-import imbalance, with only 30 percent of the nation’s GDP accounted for by exports. With a poor business climate disincentivizing foreign investment and rated among the nations with the worst transportation infrastructure in Europe, Bosnia is exporting only a third of the products that it did while a constituent republic of Yugoslavia. Coupled with a consumption-based economy which has seen consumption levels of over 100 percent of GDP,
14 this lack of exports has led to a prolonged economic downturn which has left many Bosnians without work.
Young people have been hit especially hard by these economic challenges, with the unemployment rate of Bosnians from 15-24 years of age reaching 63.1 percent in 2012
(International Labor Office, 2013). This has led to a massive exodus from the country to neighboring nations and economic powerhouses in Northern and Western Europe. Between 1996 and 2002, around 100,000 left the country – causing a significant “brain drain” that has hampered further economic growth. This trend does not seem to be slowing down either, as from
2008 to 2010, 10,000 young Bosnians emigrated from their home country, and in 2006, 73% of young people were ready to leave Bosnia and Herzegovina “either in pursuit of education or temporary employment, marriage or permanent settlement in a foreign country” (International
Labor Office, 2013). This pattern of emigration based on broader economic instability is indicative of the relative lack of opportunity for young Bosnians. Moreover, it reflects overall negative perceptions of the Bosnian economy, especially among the traditionally disenfranchised
– with young, educated, and low-family income Bosnians reporting the highest intentions to emigrate (Efendic, 2016).
The perceived lack of economic opportunity among young people in Bosnia has in turn directly affected mental wellbeing in the country. Researchers from the Tuzla University School of Medicine have found that those adolescents who are unsatisfied with their families’ financial situation show progressive symptoms of unhappiness and expressed discontent with their health condition, and even self-hate in comparison with peers who are satisfied with their financial situation (Pranjic, Brkovic, & Beganlic, 2007). Significant statistical correlation was also found for symptoms of depression, sadness, moroseness, struggles in the classroom, and suicidal
15 attempts among economically dissatisfied young people, with satisfaction with their financial situation serving as a major factor predicting depression for young Bosnians.
Even without taking the influence of the perception of economic opportunity into account, socioeconomic status plays a significant role in shaping mental health. Parental socioeconomic status, for example, serves as a strong predictor of physical and mental health outcomes for Bosnian children. Indeed, parental income, employment status, and level of education directly affect all aspects of a child’s life, health outcomes, education, and social inclusion, and therefore play a highly influential role in determining children’s academic achievements, physical abilities, cognitive function, and fundamental neurobiology and brain development (Vukojevic, et al., 2017). Similarly, in the working age population, unemployment in particular has been shown to impair mental health. Unemployed Bosnians have been shown to have significantly poorer mental health than their employed counterparts, and for this reason, job loss has been a predictor of impaired mental health in the country (Batic-Mujanovic, Poric,
Ramic, Alibasic, & Karic, 2017). Functionally, the strong predictive power of economic dissatisfaction, socioeconomic status, and unemployment on mental health means that continued economic stagnation in the country will serve to hamper advancements in mental health moving forward, and that even for those Bosnians who have no memory of the violent struggle which marked the birth of their country and are not affected by secondary traumatic stress, mental health presents a serious challenges because of a struggling economy.
Ethno-Religious Identity in the Classroom
Yet another challenge for young people in Bosnia is the fact that some of the sentiments around ethnic separatism and nationalism from war-time have permeated into the structure of
16 many of the young nation’s institutions. In particular, ethnic divides have been perpetuated in the school systems of Bosnia’s 10 cantons and 1 autonomous region. Within the Serb-dominated
Republika Srpska – which operates autonomously, and in many ways, as a de facto independent state in the northeast of the country – schools are taught in Serbian and pro-Serbian educational materials paint a history that is distinctively supportive of Serbian ethnoreligious identity.
Meanwhile, in the Federation of Bosnia and Herzegovina, which occupies the rest of the country and is comprised of mainly Bosniaks and Bosnian Croats with a sizeable Bosnian Serb minority, the language of instruction shifts from school to school and often between morning and afternoon classes to focus on different ethnolinguistic identities. This dichotomy is due in part to the fact that the Constitution of Bosnia and Herzegovina only assigns legislative power to the central government in a few areas, leaving most others like education within the purview of the respective entities within the country (Busch & Schick, 2007). This allows for the entities which were constructed around ethnic identity to further entrench this identity through education of the next generation of Bosnians.
Indeed, because of a lack of standardization and centralization in education across the country, the capacity for the manipulation of education for political and ideological purposes is profound. Curricula and textbooks tailored to the three major ethnic groups in the country often provide students with different interpretations of the same facts (Pasalic-Kreso, 1999). For example, one text may present the start of the war as aggression and occupation, while another characterizes it as a fight for liberation and national emancipation. Similarly, one curriculum might describe genocide and ethnic cleansing in some parts of the country during wartime, while another curriculum would not mention genocide at all, and instead qualify the actions taken by certain actors during the war as self-defense. These different explanations of history for different
17 ethnic groups provide competing visions for the nature of the nation and its people, and present a key challenge to peacebuilding and interethnic cooperation moving forward.
While all schools in the country are mandated to serve students from all ethnic backgrounds, in practice, education is often the product of segregation in Bosnia. Characterized as “educational protectionism”, segregation within Bosnian schools is widespread, and targeted to reinforce nationalistic values among respective ethnic groups that link these groups to particular territories within the country (Bozic, 2006). Often this segregation along the lines of ethnic identity can be attributed to the existence of ethnic enclaves and homogeneity within certain communities regionally. Even in ethnically heterogeneous areas, however, students are frequently separated based on their ethnicity, language and religion into different classrooms teaching divergent curricula (Pasalic-Kreso, 1999). For students who do not attend schools which are overtly segregated in this manner, the vast majority still study only with others from their same ethnonational group and learn from a mono-ethnic curriculum tailored not to foster understanding or tolerance between peoples, but shaped by political interests and crafted to breed suspicion and mistrust (Swimelar, 2012).
While intending to secure rights and build security for their group through this process of segregation, leaders of the different ethnic groups in Bosnia who advocate for this method of educational instruction end up actually hampering the development of the country as a whole. It is true that for these political leaders, reinforcing ethnic identity serves as a powerful tool for galvanizing support and therefore amassing political power. At the same time, though, isolating the ethnic groups in Bosnia from one another and teaching them with curricula espousing nationalist ideologies actually jeopardizes every group’s security by calling into question the stability of the Bosnian state itself and the potential for further violent conflict (Swimelar, 2012).
18
This policy of educational segregation therefore has relevancy to issues of mental health insofar as it functions to increase the likelihood of future violence that would further increase the number of Bosnians affected by post-traumatic stress and other mental health challenges. The impacts of such an educational model, though, extend beyond the hopefully avoidable potential for future violence. This kind of educational system in Bosnia which keeps young people divided also helps to fuel prejudice and stereotypes (Clark, 2010). These prejudices can serve as critical impediments to reconciliation and also contribute to the prevalence of bullying based on ethnic identity, as ethnic identity is a target of verbal bullying behavior in Bosnia (Dracic, 2009).
Bullying, in turn, has been shown to have significant effects on psychological development in
Bosnia. Those students exposed to bullying in childhood and adolescence, for example, have been found to have significantly higher levels of anxiety, depression, sleeping problems, and dissociative and traumatic symptoms when compared to those not exposed to bullying (Sesar,
Barisic, Pandza, & Dodaj, 2012). This is corroborated by additional research which has shown that Bosnian children who have been the victims of bullying exhibit an increased prevalence of depression (29.0% vs. 8.8%) and suicidal ideation (16.15 vs. 3.5%) as compared to their peers who were not bullied (Pranjic & Bajraktarevic, 2010).
The segregated educational system in Bosnia and Herzegovina, then, contributes significantly to the burden of mental illness in the country. First, by excacerbating interethnic tensions, this system jeopardizes the ongoing reconciliatory process and threatens the possibility that nationalistic rhetoric – this time espoused in schools – will once again throw the country into violence and expose it to the significant associated mental health challenges. Secondly, by serving as a catalyst for the development of stereotypes and prejudices, segregrated schools indirectly support bullying and the long-term negative mental health outcomes tied to it.
19
Substance Abuse
In response to the many challenges that have plagued the country in the time since the
Bosnian War, substance abuse has featured as a significant challenge in Bosnia and Herzegovina.
While no comprehensive national general population survey on drug abuse in adults has been conducted in Bosnia, local data and national figures for particular drugs of interest provide insight as to challenges with substance abuse currently facing the country. Alcohol consumption, for example, is widespread in Bosnia, despite a substantial Muslim population, but at 5.19% of the population, Bosnia’s rate of alcohol abuse disorder in men does not differ significantly from the rest of Europe (World Health Organization, 2012). At the same time, however, alcoholism and problematic drinking are a worrying trend in adolescents and young people, and have been seen in student populations at both the high school and university level in urban centers (Skobic,
Sinanovic, Skobic-Bovan, Ivankovic, & Pejanovic-Skobic, 2010). The literature suggests that
15.55% of adolescents aged 12-17 have abused alcohol, with 62.4% of those reporting previous abuse coming from urban environments (Licanin & Rezic, 2005). Additionally, risk factors for problematic drinking in Bosnia have been identified to include truancy, low success at school, suicidal thoughts, delinquency, and destructive behavior.
When it comes to the consumption of tobacco, Bosnia does experience a high prevalence of tobacco smoking, with an estimated 47.2% of the male population aged 15 years and older currently smoking tobacco. This high rate places Bosnia as the 22nd highest on the ranking of all countries’ prevalence of tobacco smoking, and 8th highest among European countries (World
Health Organization, 2016). Among adolescents, the smoking of tobacco is also fairly common.
42.8% of adolescent respondents in one study had ever smoked, with 30.3% smoking only 1 cigarette a week and 17.9% smoking at least one cigarette every day. Alarmingly, 50% of all
20 adolescents who do smoke started smoking at or before the age of 13 (Domic, Tahirovic, &
Sajko, 2016). The smoking of marijuana, by contrast, is much less common in Bosnia with only
2.8% of the population identifying as smokers of marijuana (United Nations Office on Drugs and
Crime, 2011). In the adolescent population, this figure is estimated to be slightly higher at
3.34%. Marijuana use among adolescents is a largely urban phenomenon, with 70% of all users coming from urban environments (Licanin & Rezic, 2005).
Polydrug abuse – or the abuse of more than one psychoactive substance – is also a common occurrence in Bosnia. For example, 75% of adolescents that abuse cannabis also smoke cigarettes, while 80% of young people who have tried cannabis also consume alcohol (Redzic,
Licanin, & Krosnjar, 2002). Additionally, substance abuse has well-researched and robust connections to a variety of mental illnesses, and data from Bosnia support these established links.
From among adolescents in the Sarajevo and Tuzla areas, for example, cannabis abusers and alcohol abusers were found to have significantly higher prevalence of suicidal ideation than their peers who did not use these drugs (Licanin, et al., 2003). Critically, this does not suggest that substance abuse causes suicidal ideation, but the strong correlation between the two highlights that these problems are often comorbid.
From a legal perspective, use-related offences are regulated at the level of the entities of
Bosnia and Herzegovina, whereas supply-related offences may also be punished by law at the state level if they involve transportation of illicit substances across international borders
(European Monitoring Centre for Drugs and Drug Addiction, 2017). In the Federation of Bosnia and Herzegovina, personal possession of illegal drugs is punishable by up to one year of imprisonment, while in the Republika Srpska and the Brcko District, narcotic drug possession is a minor offense punishable by a fine of roughly €250 - €750. In 2015, the total number of
21 criminal offenses related to drugs numbered 1,325 across the country involving 1,470 people, with the majority involving use and possession as opposed to unauthorized production and trafficking. While a decentralized governmental approach to drug policy does present a potential obstacle to effective standardization, continued collaboration between governmental groups through the national-level Law on the Prevention and Combat of the Abuse of Narcotics has meant that substance abuse challenges can be addressed with national-level interventions
(Skipina, et al., 2015).
Acceptance of LGBT Identity
While same-sex sexual activity has been legal in the Federation of Bosnia and
Herzegovina since 1996 and in the Republika Srpska since 1998, common sentiment toward members of the Lesbian, Gay, Bisexual, and Transgender (LGBT) community has led to discrimination, ostracizing, verbal abuse, and even harassment and physical violence in Bosnia and Herzegovina. Activism for the LGBT movement began in Bosnia and Herzegovina in 2004, making it the youngest such movement in the Balkans (Gavric, et al., 2017). Despite some early indicators of progress, LGBT identity still faces significant challenges in the country. Public opinion polls have shown that alongside people of Romani descent, LGBT-identifying Bosnians are the least-accepted minority group. The vast majority of citizens continue to support the criminalization of homosexuality and punishment of LGBT people, and the Family Laws of
Bosnia and Herzegovina do not currently recognize same sex marriage, therein disqualifying same-sex partners from health benefits, tax relief, and other associated benefits that heterosexual partners may enjoy (Quinn, 2006). Moreover, the vast majority of families would refuse to accept an LGBT family member, and because of stigma and discrimination, the vast majority of
22
LGBT people do not mention their sexual orientation or gender identity in the workplace. While on the decrease, hate speech against LGBT people remains widespread in the Bosnian media, often perpetrated by senior government officials and religious leaders (Gavric, et al., 2017).
Public perception has also been mirrored by outward violence to LGBT persons and those advocating for them. Attacks on LGBT people take place regularly in Bosnia and Herzegovina, and between January and September 2017, the LGBT rights organization Sarajevo Open Centre documented 39 cases of hate speech and 23 cases of hate crimes toward LGBT people (Human
Rights Watch, 2018). Of particular note is that among the cases of hate crimes were five cases of homophobic and transphobic violence in schools (three of which were committed against children). Another very prominent anti-LGBT hate crime occurred in 2014, when activists at the
Merlinka Festival LGBT cultural event were attacked by a dozen masked people shouting homophobic slurs (Human Rights Watch, 2014).
Especially as Bosnia and Herzegovina moves toward integration into the European
Union, however, some advancements are slowly being made to better protect LGBT-identifying
Bosnians and grant them equal rights under the law. Adoption of amendments to the national- level Law on Prohibition of Discrimination, for example, have created a strong legal basis for combatting anti-LGBT violence and discrimination (Gavric, et al., 2017). Even so, reports of human rights violation of LGBT people under this framework remain low while abuses recorded by independent groups like the Sarajevo Open Centre continue – indicating that the effectiveness of this law in working to challenge discriminatory anti-LGBT behaviors is not robust. More recently, in October of 2018, the government of the Federation of Bosnia and Herzegovina adopted a request for the legalization of same-sex marriages that will enable the entity-level government to form an inter-ministerial working group to analyze how to amend existing laws to
23 enable same-sex couples to realize their rights as outlined by the European Human Rights
Convention (N1 Sarajevo, 2018). This move, which Federation of Bosnia and Herzegovina
Prime Minister Fadil Novalic characterized as being a step along the path toward admittance into the European Union, is expected to propose regulatory changes that will allow for domestic partnerships or civil unions between same-sex couples to be codified into law.
Despite these more recent positive developments, LGBT identity still faces significant pushback in daily life, including in the realm of healthcare. The health system does not recognize the specific needs of LGBT people, and many doctors ignore or even actively discriminate against LGBT-identifying patients (Gavric, et al., 2017). Most health institutions, for example, claim a lack of significant LGBT patient populations as a reason for not offering special services
(Quinn, 2006). Additionally, Bosnians undergoing sexual reassignment treatment are not allowed specialist treatment in the country, and health funds from the country’s social medicine system cannot cover the costs of such procedures abroad (Gavric, et al., 2017). Medical professionals in
Bosnia are prohibited from asking private questions of patients which are not necessary for diagnosis or treatment, presenting a major challenge to effective disbursement of medical care for issues like HIV/AIDS and Hepatitis B and C infections which face significant burden in the
LGBT community (Quinn, 2006). Same-sex partners, by way of the lack of legal recognition in
Bosnia, are also barred from the right of attorney for their partner in health-related decisions, the right to their partner’s health insurance in cases of unemployment, and the right to paid family leave in cases of sickness or death of their partner without the potential for losing their job
(Sarajevo Open Centre, 2018).
While no official data is collected in Bosnia on discrimination, bullying, and violence in schools based upon sexual orientation or gender identity, evidence from systematic analysis in
24 other nations including the United States and the United Kingdom shows that LGBT students suffer disproportionately from bullying and that they are at an increased risk for mental health problems (Burgic Radmanovic & Burgic, 2017). Individual cases of bullying and violence targeting LGBT students in Bosnia also highlight the problems that exist in the country when biases and prejudices inform discrimination. In 2016, for example, a 14-year old boy in Sarajevo died of suicide following homophobic harassment, abuse, and sexual violence by his peers over an extended period of time (Gavric, et al., 2017). Additionally, aforementioned restrictions on physicians to ask patients private questions means that mental healthcare concerns specific to
LGBT youth such as those relevant to bullying and violence in school face significant obstacles to treatment with effective mental healthcare.
Thus, while improvements are slowly being realized at the governmental level in a bid to comply with European Union norms, significant challenges persist for LGBT-identifying
Bosnians. Discrimination, hate speech, violence in schools, and a lack of legal protections for
LGBT persons in Bosnia are compounded in their effects by ongoing negative perceptions among the general public. Functionally, these challenges directly reflect on healthcare access and thereby on the effective treatment of mental health concerns for this vulnerable group.
MENTAL HEALTHCARE INFRASTRUCTURE IN BOSNIA AND HERZEGOVINA
Post-War Reconstruction of Mental Health Services
The mental healthcare system in Bosnia and Herzegovina while the country was a part of the state of Yugoslavia was one of the best organized among the former nation’s constituent republics (Cerić, et al., 2001). At this time, the psychiatric care system was primarily focused on psychiatric hospitals and small neuropsychiatric wards within general hospitals, with a secondary
25 focus on psychiatric services in health centers. With the onset of the war, though, much of the functionality of these services was disrupted, and numerous institutions were either destroyed or closed. Indeed, as previously discussed in the context of post-traumatic stress and depression among wartime physicians, medical facilities were a specific target during the Bosnian War. This focus on attacking healthcare facilities caused experts during the time of the war in Bosnia to characterize it as a “war against public health” (Mann, Drucker, Tarantola, & McCabe, 1994).
Bosnia’s once well-developed healthcare system saw crippling attacks that limited its capability to provide even the most basic healthcare services. Despite the attacks on and deaths of healthcare personnel during the war (Barber, 1993), healthcare personnel were largely available for the duration of the conflict, in part because of an influx of international health providers from humanitarian organizations. Rather, the main public health challenges of wartime were focused on devastated infrastructure and extremely scarce supplies (Mann, Drucker, Tarantola, &
McCabe, 1994). A lack of food, energy, and supplies meant that many hospitals during the war lacked heat, lights, medical equipment, and even the basic tools needed to ensure that proper hygienic procedures could be followed. In these kinds of conditions, it was not uncommon for surgeons, for example, to have to operate under candlelight without anesthesia, having not been able to completely maintain sterile techniques, and with freezing hands in a hospital that was unable to provide heat in the middle of the Bosnian winter.
Mental health services in particular were vulnerable to destruction during the war.
Sarajevo’s Kosevo Hospital, for example, was home to one of the major psychiatry departments in the former Yugoslavia, but after bombing in 1992, the psychiatry department was forced to close, and important mental health services including alcohol and drug rehabilitation units were lost. Anecdotally, reports also suggest that institutions serving the developmentally disabled and
26 mentally ill were among the first healthcare facilities to lose access to fuel and other supplies
(Mann, Drucker, Tarantola, & McCabe, 1994). These closures and losses played a major role in reducing access to mental healthcare services during the war, with only about one-third of all people suffering from mental health problems able to receive professional assistance (Medecins
Sans Frontieres, 2015).
Even as the war raged on, though, the reconstruction and reorganization of mental health services was taken on, and this process only grew in scope once the war had ended. While attacks on psychiatric hospitals and other providers of mental health services did serve to damage much of Bosnia’s mental healthcare infrastructure, this also left Bosnia with the opportunity to completely redesign its approach to mental health. To cope with the immense amounts of post- war trauma and mental health challenges, Bosnian public health leaders designed a new system that focused on targeting mental health at the community level instead of restricting it to the regional psychiatric hospital hubs (Cerić, et al., 2001). This was done in order to allow comprehensive primary healthcare to incorporate more readily the integration of mental healthcare, and envisioned family practitioners and medical health professionals working in communities near the patients they served. Thus, remaining large psychiatric institutions were closed or had their capacities reduced, and community-based mental health centers became the new model of practice with the goal of focusing on the prevention and treatment of psychiatric disorders as well as the preservation of mental wellbeing.
Current Mental Healthcare Infrastructure
More than 20 years after the development of this plan for revitalizing the Bosnian mental healthcare system was finalized, Bosnia has continued to focus efforts in supporting mental
27 health at the community level. Today, 74 community-based mental health centers spread across the country operate to provide mental health services. Increasingly, these centers employ multi- disciplinary teams that comprise psychiatrists and psychologists, but also social workers and medical nurses, and in some centers even occupational and speech therapists and specialists in child psychiatry (Asocijacija XY, 2017). This multidisciplinary approach to service provision is rooted in the aim of shifting the focus of mental health services from psychiatric bed occupancy to prevention, social integration, and adaptive services which tailor to service-users’ needs. In the
Federation of Bosnia and Herzegovina, 45 such community mental health centers (CMHCs) operate with the support of 10 allocated beds per CMHC available in the psychiatric wards of nearby general hospitals for acute cases. Teaching hospitals in the Federation’s three largest cities of Sarajevo, Tuzla, and Mostar also provide secondary and tertiary healthcare services for more intricate cases. Despite the fact that the number of CMHCs has grown from 55 in 2009
(Sinanovic, et al., 2009) and 39 in 2005 (Kucukalic, et al., 2005), demand has outpaced supply, and there still remain significant challenges with supporting all patients in need. In 2009, for example, over 1,000 psychiatric patients were placed in welfare institutions designed for persons with special needs because they could not be accommodated in the adequate facilities
(Asocijacija XY, 2017).
In the Republika Srpska, 28 CMHCs fulfill a similar role as in the Federation – providing service-users with multi-disciplinary teams that aim to support mental wellness in a comprehensive way. In this entity, secondary and tertiary services are provided in the capital of
Banja Luka, and in regional centers in Sokolac and Modrica. Because the healthcare systems of
Bosnia and Herzegovina are regulated primarily by the different entities’ laws, each entity is responsible for financing, managing, organizing, and providing adequate healthcare to its
28 constituents. Much like for education, healthcare in the Republika Srpska is centralized out of
Banja Luka, but in the Federation, each of 10 administrative divisions (cantons) has separate ministries of health and each the responsibility to provide care for its residents (Sinanovic, et al.,
2009). For this reason, the central Ministry of Health for the Federation of Bosnia and
Herzegovina fulfills a role mainly focused on coordinating between the cantonal administrations.
In some ways, the community mental health center model of care has proven to be effective in protecting mental wellness in Bosnia and Herzegovina. The community-based approach offered by CMHCs, for example, has functioned to provide localized access to mental healthcare services across the country instead of targeting services to regional psychiatric hospitals. Additionally, a multidisciplinary approach in these CMHCs has allowed for more comprehensive means of addressing patients’ mental health from a variety of perspectives, including the psychological, legal, social, cultural, and educational perspectives. The positive effects of the reform in mental healthcare services from a more centralized focus to a more dispersed one are visible primarily through improved access to and multidimensional quality of treatment, as well as shorter lengths and frequencies of hospitalization and increased staffing levels in mental health care (Asocijacija XY, 2017). In addition, research suggests that Bosnian
CMHCs have been fairly cost effective in their provision of services to patients as compared to similar centers in the neighboring countries of Croatia and Serbia (Priebe, et al., 2010).
At the same time, however, there are still numerous significant challenges which are target areas for improvement moving forward. For example, as previously mentioned, the burden of mental illness in Bosnia is still very large, and the current infrastructure does not have the capacity to address completely the demand for mental health services (Asocijacija XY, 2017).
Existing resources in the mental health system are often unable to cover the demands of
29 appropriate care, especially for poor patients with chronic mental health challenges.
Additionally, while well-motivated and effective when implemented successfully, multidisciplinary teams at Bosnian CMHCs are often incomplete, with the majority of the teams at CMHCs across the country not being able to include all of the different positions that would make services provided the most comprehensive (International Organization for Migration,
2014). As a complex and often overburdened system, the network of CMHCs in Bosnia and
Herzegovina also require improvements in administrative and legal frameworks so as to ensure efficient operation and the streamlining of processes in a way that could help to maximize the positive impact that these centers are already having. The intricate system of referrals, cooperation and responsibilities between departments at different levels of mental healthcare services and between the different sectors involved are not always clearly defined, resulting in a lack of continuity and quality of service. Increased crosstalk with the non-governmental sector in particular is a continuing challenge and potential avenue for improvement. Finally, ongoing stigmatization and discrimination of people with mental disorders among the general population and in the media is a widespread phenomenon, and addressing the social stigma surrounding mental illness has been a challenge.
POLICY RECOMMENDATIONS
In the aftermath of war, genocide, and ethnic cleansing, the nation of Bosnia and
Herzegovina has faced difficult and long-lasting political, social, and economic challenges which have all contributed to enduring struggles with supporting strong mental wellness in the country.
While often at the forefront of any discussion of mental health in Bosnia, post-traumatic stress is but one of many issue areas in mental healthcare that merit attention. Challenges with economic
30 stagnation, educational segregation, substance abuse, and LGBT identity also weigh heavily in the discussion of key themes to be addressed moving forward. Additionally, while a redesign of the Bosnian mental healthcare system focused more on community engagement has been successful in addressing mental health concerns, significant challenges have meant that this system is also in need of improvements and additional support. In order to address the central themes identified in this situational assessment of the mental health in Bosnia and Herzegovina today, a series of potential policy recommendations are outlined below.
Standardization of Mental Healthcare Policy and Integration of Partners
Community mental health centers (CMHCs) have proven to be effective in expanding access to mental health services across Bosnia and Herzegovina and in supporting the different dimensions of mental health that can be addressed by professionals in multidisciplinary teams.
Indeed, these centers have been instrumental in coping with the significant mental health challenges posed by Post-Traumatic Stress Disorder and associated mental illnesses. This system, however, is also overburdened, and often unable to provide adequate care for vulnerable populations like poor patients with chronic mental health challenges. Rapid growth and extensive expansion in the number of centers made operational around Bosnia have also meant that the
CMHC system has become increasingly complex, especially because of differential mental health policy in Bosnia’s two constituent entities, and because of the significant collaboration that exists between CMHCs and other partners in the mental health sphere like user-service organizations, secondary- and tertiary-level medical institutions, and non-governmental organizations. Because of these significant challenges, it is clear that the system needs to be examined critically in much the same way that the Bosnian mental healthcare system was
31 scrutinized toward the end of the war, and amended and improved so as to better standardize the systems of mental health service provision throughout the country and integrate different partners into defined roles that can complement and support one another.
Working, for example, to develop universal standards and models of care across the country, and then integrating these into administrative and legal frameworks will support increased efficiency in the mental healthcare system, allowing for a maximization of positive impact. A key part of this process will involve developing workforce training and retention programs that will allow for the adequate recruitment of a wide variety of relevant personnel in
CMHCs so as to take full advantage of a collaborative interdisciplinary model of care. Ensuring that wherever patients are seen, they will always have access to, for example, a social worker, occupational therapist, and legal counsel, will enable the aforementioned universal standards to be applied practically rather than simply a proposed ideal.
In addition to creating stability within the CMHC system, it will be important moving forward to form strong partnerships and connections with other actors in the mental healthcare arena like service-user organizations and non-governmental organizations. At the local level, many partnerships already exist between individual CMHCs and mental health services users’ associations (Sinanovic, et al., 2009), and this is because these groups realize that their collective impact through collaboration is greater than any which might be achieved operating alone. If these kinds of productive relationships can be brought forward to the national or at least entity- wide level, the impact of positive and production collaboration could be expanded greatly. This is especially true if new frameworks were developed to codify set opportunities for dialogue between these groups, such as a national council with regional representation of both CMHCs and users’ associations. An initiative like this would help to amplify the collective voice of
32 service-users given that these patient advocacy groups play a diminished role in the formulation and implementation of mental health policy in Bosnia (World Health Organization, 2011). At the same time, this would provide CMHCs with insight and feedback that could inform the development of best practices, while also establishing a partner that would be extremely useful in pursuing goals in the wider community like campaigns to reduce stigma around mental health.
Governmental Reform
More broadly, widespread governmental reform is also a priority in Bosnia and
Herzegovina. A large portion of the reason for economic stagnation in the country can be attributed to an ineffective and fractured governmental system that has not taken the steps needed to open up the country to entrepreneurship and development. If the country’s economy is to be revitalized and its citizens thereby reinvigorated with a strong sense of self-efficacy, governmental reform is the first area for intervention. To begin, the long-standing relationship between the two entities represented within the nation of Bosnia and Herzegovina is due for a critical analysis. Since the Dayton Peace Accords which brought peace to Bosnia and set out the current subdivisions within the country, no formal constitution has been adopted at the national level (Bieber, 2010) and leading political parties are still more focused on ethnic identities than collaboration across the aisle to develop commonsense solutions to Bosnia’s many problems
(Belloni, 2006). As Bosnia and Herzegovina moves toward integration into the European Union, the divided nature of the country has already been a cause for concern.
So, too, has the overly-complex and inflated public sector. A total population of 3.8 million across the country means that Bosnia has a population smaller than that of Los Angeles, and yet unlike the city and its single mayor, the head of state for Bosnia and Herzegovina is a
33 three-member presidency. Perhaps even more tellingly, 12 ministerial cabinets operate out of the country, with both entities and also each of the ten cantons of the Federation of Bosnia and
Herzegovina having their own ministers of health, education, etc. (Divjak & Pugh, 2008). While undoubtedly a difficult undertaking, working to reduce this redundancy in the government and to make the public sector efficient will help Bosnia to move past the post-socialist era and catch up to its neighboring ex-Yugoslav states.
Educational Interventions
To address several other key challenges in the country, variations of educational programming will be a strong tool to bring about societal change and increase health literacy.
Anti-bullying campaigns in schools, for example, have been shown as an effective way to open up dialogue between students about their previously held biases, and can work to mitigate the level of bullying experienced by minority students. Given that such anti-bullying campaigns have already been introduced into public schools in Bosnia (Fondacija Krila Nade, 2018), continuing this programming can aid with some of the key challenges posed by educational segregation and the formation of prejudices and stereotypes, as well as reduce the bullying directed to LGBT-identifying students in the school system.
Different educational interventions in the form of health educational outreach will also be a key method by which themes like substance abuse can be addressed. The capacity for change here is significant if addressed early, given that alcohol abuse is primarily a problem for adolescents and that at least 50% of adolescent smokers began smoking at the age of 13 or younger. Increased investment into health education for adolescents at school allows for this
34 captive audience to improve their health literacy about substance abuse and the negative consequences that accompany the abuse of drugs.
Finally, and perhaps most importantly for the future of the country, educational intervention will need to be taken to reintegrate schools in Bosnia and Herzegovina, and provide standardized, national curricula that provide one neutral narrative of Bosnian history which can serve to unite the different ethnic groups that call Bosnia home. From the perspective of students, reintegration has widespread support. Local demonstrations, student walkouts, and even national-level conferences have shown that students are willing to take a stand to make reintegration happen (Sito-Sucic, 2017). If this persists and political leaders take notice and take action, effective reintegration will ensure additional stability to the country while further opening up the door to political reintegration down the road.
SUMMARY
In the nearly 25 years that the nation of Bosnia and Herzegovina has operated as a sovereign nation, consequences of the devastating war that followed the country’s initial independence declaration have had profound lasting effects, and new challenges have come to the fore as the fledgling nation finds its feet. One of the most widespread and difficult issues that
Bosnia has had to face in this time has been the challenge of providing adequate mental healthcare to those who suffered through the traumatic events of the war, and more recently, to other Bosnians experiencing mental illness. Post-traumatic stress has been a major focal point in this process, but as new challenges emerge due to Bosnia’s political, economic, social, and cultural situation, other mental illnesses and stressors have taken on new importance. By way of a revitalized mental healthcare system designed to replace infrastructure damaged in the war,
35
Bosnia has been highly successful in increasing access to mental healthcare services and improving the quality of these services through multidisciplinary teams. Persistent challenges exist, however, in meeting the still significant mental illness burden in the country. Moving forward, potential policy recommendations suggested here provide means by which to strengthen this system of mental healthcare while also addressing some of the root causes underlying mental health challenges.
36
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APPENDIX A: FIGURES AND TABLES
Figure 1:
Figure 2:
47
Table 1:
GDP per capita in the Former Yugoslavia (2017) Nation GDP per capita (US dollars) Slovenia $ 34,500 Croatia $ 24,700 Montenegro $ 17,800 Serbia $ 15,100 North Macedonia $ 14,900 Bosnia and Herzegovina $ 12,800 Kosovo $ 10,900
48