The 1995 Constitution of Bosnia and Herzegovina, The Resolution on Politics of Health for all Citizens of Bosnia and Herzegovina,[i] and the Gender Equality Law in Bosnia and Herzegovina all set standards and offer guidelines for organization of a healthcare system that will provide adequate help and protection to all citizens, aiming to improve the standard and quality of health and life, for everyone equally. Reproductive health, as defined by the World Health Organization (WHO), is a state of physical, mental and social wellbeing in relation to all aspects of the reproductive system, throughout one’s life. The Strategy on Reproductive Health published by the WHO in 2004 defines 5 main focus areas in reproductive health: improvement of health in pregnancy, childbirth and health of newborns; offering high-quality family planning services, including the services of treating infertility; eliminating unsafe abortions; tackling sexually transmitted infections, and promoting sexual health.[ii]
Treating Infertility and Assisted reproductive technology
The estimates are that in Europe more than 15% of couples of reproductive age are infertile, or experience difficulties in conceiving. It is evident that the increase in infertility is causing negative demographic trends in Europe. In warning of the importance of treating infertility the European Parliament in cooperation with the European Society for Humane Reproduction and Embryology (ESHRE) gave, in 2008, the key guidelines for the tackling this problem by creating conditions in which diagnosis and treatment of infertility (including the assisted reproductive technology) are widely available and of good quality. [iii] Since the right to family life is a human right,[iv] it is recommended that assisted reproductive technologies (ART) be incorporated in population policies of all European states.
The official statistics show a worrying trend that in Bosnia and Herzegovina only 83 babies are born for every 10,000 inhabitants and that Bosnia and Herzegovina has the lowest birthrate in the region.[v] According to the data from the Agency for Statistics BiH 21,141 newborns were registered in the first nine months of 2015, which shows a 2.16% decrease in the birthrate from the 2014’s 21,607 live births. This alarming information demonstrates that the birthrate is declining in Bosnia and Herzegovina and it is becoming clear that without specific, medical, social and political steps this problem will worsen.[vi]
The biggest issue is that there is no Law on Treatment of Infertility by Assisted Reproductive Technology on state-level, and so this is regulated differently in FBiH, RS and Brčko District. In RS according to the Law on Assisted Reproductive Technology the Health Insurance fund covers two ART treatments for women up to the age of 40 and for women aged 41-42 the Fund covers 50% of the expenses. The health insurance refunds women who are older than 42 years only if they give birth through ART. In the first eight months of 2015 a total of 270 requests for ART were approved.[vii]
Assisted Reproductive Technology/IVF were included in the Brčko District’s Financial Plan of the Health Insurance for 2015. The Fund covers at most two attempts for each married couple, as well as cohabitating couples. The Fund covers the IVF costs of up to 4,000 KM for the first attempt, and up to 3,000 KM for the second attempt, for women of up to 42 years of age.[viii]
There is no law regulating Assisted Reproductive Technology in FBiH. By a decision on the basic right to healthcare in FBiH it was determined that Cantonal Health Insurance Institutes can fund up to two attempts of ART, for women aged up to 37 years of age.[ix] However, the implementation of this decision is not uniform in all cantons and depends on the available financial means in each canton. For an example, in accordance with the Financial Plan of the Health Insurance Institute of Tuzla Canton for 2015, funding was secured for married couples, and cohabitating couples for at most two IVF treatments.[x] In Zeničko-Dobojski Canton co-financing of IVF of up to 2,000 KM was approved, for each married couple. In Canton Sarajevo the patients have the possibility of buying the medications that are on the list of essential medications at half-price.[xi] The Health Insurance Institute of Unsko-Sanski Canton co-financed 20 couples for up to 3,000 KM. With the necessary medical documentation the key criteria are two years of marriage and the woman has to be younger than 42 years of age. It is important to note that couples are not limited as to where they can do the medical procedure itself.[xii]
On Federal level couples with disabilities have the right to one free procedure and the funds are secured from the Solidarity Fund FBiH within the program Humane Reproduction of Persons with Disabilities.
In accordance with the Strategy for advancement of sexual and reproductive health and rights in FBiH 2010-2019,6 the Federal government wrote the Draft Law on Treating Infertility through Technologically Assisted Reproduction,[xiii] and in June 2014 submitted it to the Parliament through the emergency procedure. The House of Representatives of Parliament FBiH did not support its passage and it never made it to the House of Peoples FBiH.
In BiH ART is done at several private clinics: one in RS (Banja Luka) and six in FBiH (three in Sarajevo, two in Tuzla and one in Mostar). Many couples who are facing some form of infertility have to set aside vast amounts of money for IVF treatments. According to some estimates one IVF treatment costs between 4,000 and 8,000 KM, depending on the medication used to stimulate the ovaries.
At the initiative of the Commission for Gender Equality of the Parliamentary Assembly BiH, a group of experts created a draft of the state Framework Law on Treating Infertility by Assisted Reproductive Technology. The first discussion of this framework law was held in Sarajevo on 19 October 2015. The aim of this law was to enable offspring and family planning for married and cohabitating couples and women who are infertile through Technologically Assisted Reproduction while ensuring quality and safety in all procedures in line with the achievements of biomedical science, and in accordance with EU regulations.[xiv] This question will continue to be debated and it will be decided in 2016 whether the Commission for Gender Equality will be proposing this law. It has also been unofficially stated that one of the opposition parties will put a similar law in procedure in FBiH Parliament in 2016.
Access to healthcare
Decentralization of health insurance and healthcare in BiH, as well as variations in economic power of entities and cantons make the availability of healthcare unequal, in terms of both primary healthcare (rural/urban areas, differences between entities and cantons) and the more specialist health services.
The problems in the use of healthcare faced by the population of rural areas are: distance from healthcare providers, cost of transportation, time necessary to see a physician, the cost of appointments and interventions in private clinics and the price of medicine. The majority of the population in rural areas has to travel to cities for specialist appointments, dentists’ appointments and to buy medication.
On 12 February 2015 the Department of Humanitarian Aid and Civil Protection of European Commission (ECHO) donated two mobile gynecological clinics to UKC Tuzla and JZU Dom Zdravlja Doboj as a part of the UN Flood Recovery Programme “Today for us.” The mobile clinics are equipped with a gynecological chair, mobile ultrasound and other necessary apparatus that will enable the provision of essential reproductive health services to women in rural and remote areas of Tuzla and Doboj regions.[xv]
Persons with disabilities are facing particular difficulties in using healthcare services in BiH. In the majority of cases the healthcare providers are not accessible to this population. Women with disabilities are particularly discriminated. Although they have the same health, reproductive and sexual needs, as well as rights and freedoms as women without disabilities, they are still facing physical and psychological obstacles in realizing their rights. Healthcare providers are still not sufficiently accessible to women with disabilities. Inaccessibility, which is based on building design, includes the unadjusted access to buildings, lack of elevators, accessible changing rooms and toilets. Written information, like admission forms and educational materials for patients are not available in alternative formats (e.g. in Brail, audio tapes, enlarged print). One of the key obstacles is also the lack of adequate equipment, such as tables for gynecological checkups and delivery for women with disabilities and mammograms that do not require the patients to stand. According to the available information, a very small number of public healthcare providers in BiH have the adequate equipment for checkups and delivery aimed at women with disabilities. It has also been documented that medical staff shows a lack of sensitivity towards women with disabilities.[xvi]
With the aim of improving the state of health services when it comes to their use by persons with disabilities the Agency for Quality and Accreditation of Healthcare FBiH (AKAZ) included persons with disabilities in the review of the Standards for the general practitioners and centers for mental health. Swedish non-governmental organization My Right signed a Memorandum of Understanding with the Agency for Certification, Accreditation and Improvement of quality of healthcare services in RS (ASKVA) and they are hoping to achieve similar results as soon as the revision of the RS standards begins.[xvii]
An informal croup of citizens DRIP conducted research on women’s experiences of deliveries in RS, in February 2015. Out of the 539 women who gave birth in one of the 13 public and one private delivery ward, 59% of interviewees responded that if they could choose they would not give birth again in the same ward. Around 60% of women stated that the atmosphere in the delivery rooms was not confortable and 85% expressed dissatisfaction over the lack of privacy during the delivery. Almost 80% of women stated that they did not participate in the medical decision-making regarding the way in which they delivered.[xviii]
The fact that the majority of Roma women and girls still do not have access to adequate healthcare is alarming, as is the fact that funds aimed at rectifying this have been decreasing, rather than increasing in recent years.
Guidelines for Action
- The responsible institutions need to conduct campaigns for raising awareness of the wider public on the importance of reproductive health in all stages of life, and these questions need to be included in primary and secondary education;
- It is necessary to pass the Framework Law on Treating Infertility by Assisted Reproductive Technology at state level, in order to finally establish a legal framework for implementation of the guidelines with the aim of ensuring quality and safety in all IVF treatments in line with EU regulation and ensuring equality in access to funding for IVF treatments for all citizens of BiH;
- Increase access to preventive healthcare and promote health in remote and rural areas;
- Enhance healthcare provision and improve access to services for persons, and especially women, with disabilities, who live in rural areas;
- Implement the solutions set out in the document Politics in the Area of Disability in BiH and which address family and private life.
You can find The Orange Report 2016 – Annual Report on the State of Women’s Rights in BiH following this link.
[i] Resolution on the politics of health for all citizens of BiH adopted in 2002: (Službeni glasnik BiH, No. 20 12/2002)
[ii] WHO Assembly (WHO, 57 Session, 2004) passed the Global Strategy for reproductive health with the aim of speeding up the progress towards achieving Millennium Development Goals, especially in terms of improved sexual and reproductive health.
[iii] Ziebe S, Devroy P. Assisted reproductive technologies are an integrated part of national strategies addressing demographic and reproductive challenges. Hum Reprod Update 2008;14: 583–92.
[v] News: bh.novinska agencija Patria, 19.08.2015, available at: http://nap.ba/new/vijest.php?id=15208
[vi] News: Večernji list BiH, 30.12.2015, available at: http://www.vecernji.ba/rodeno-500-djece-manje-nego-u-2014-1048331
[vii] News: BiH: Vantjelesna oplodnja preskupa, Mondo – izdanje BiH, 31.10.2015, available at: http://mondo.ba/a609484/Info/Drustvo/Tretmani-vantjelesne-oplodnje-preskupi-BiH-nema-uskladjene-odredbe-u-finansiranju-tih-pokusaja.html
[viii] News: www.drbalic.ba/index.php/o-nama/novosti-iz-centra/218-refundacija
[ix] Decision on the elementary rights to health FBiH: („Službene novine Federacije BiH“, broj 21/09)
[xi] News: BiH jedina u regiji koja nema zakon o vantjelesnoj oplodnji: pravo na roditeljstvo ne smije biti privilegija bogatih, 05.12.2015, available at: faktor.ba/stav-bih-jedina-u-regiji-koja-nema-zakon-o-vantjelesnoj-oplod
[xii] News: Biscani.net: ZZO USK sufinansira vantjelesnu oplodnju, 12.11.2015, available at: http://www.biscani.net/zzo-usk-sufinansira-vantjelesnu-oplodnju/
[xiii] Government of the FBiH: Proposal of the Law on ART, March 2014, available at: http://predstavnickidom-pfbih.gov.ba/upload/file/sjednice/30_sjednica_bs/7.pdf
[xiv] News: Slobodna Bosna, 01. 11. 2015: Pogledajte novi prijedlog Zakona o biomedicinski potpomognutoj oplodnji, available at: http://www.slobodna-bosna.ba/vijest/24665/sb_objavljuje_pogledajte_novi_prijedlog_zakona_o_biomedicinski_potpomognutoj_oplodnji.html
[xv] News: UN: Tuzli i Doboju dodijeljene dvije mobilne klinike za zdravlje žena, 13.02.2015, available at: http://ba.one.un.org/content/unct/bosnia_and_herzegovina/bs/home/presscenter/tuzli-i-doboju-dodijeljene-dvije-mobilne-klinike-za-zdravlje-ena.html
[xvi] Laura Hershey: Women with Disability: Health, Reproduction, and Sexuality, available at: http://www.cripcommentary.com/women.html
[xvii] News: Blijesak.info: Zdravstvene ustanove nisu prilagođene invalidima: Žene ne mogu kod ginekologa, djeca kod zubara, 17.06.2015, available at: http://bljesak.info/rubrika/sci-tech/clanak/zdravstvene-ustanove-nisu-prilagodene-invalidima-zene-ne-mogu-kod-ginekologa-djeca-kod-zubara/122967
[xviii] News: Gordana Katana: Reproduktivna prava osoba sa invaliditetom: I mi želimo biti majke, Oslobođenje 26.03.2015, available at: http://www.oslobodjenje.ba/vijesti/bih/reproduktivna-prava-osoba-sa-invaliditetom-i-mi-zelimo-biti-majke