Part XI – The Agreement Identifying the Method and Procedure Pursuant to which the Insurants, Registered as Such in the the Territory of Bosnia and Herzegovina, May Exercise their Rights to Healthcare outside the Territory of the Entity or the Brcko District as appropriate with which they are affiliated, signed on 5 December 2001.
For the purpose of settling the differences in the legislative arrangements of the health insurance systems in Bosnia and Herzegovina, but adhering to the general principles of the Constitution of Bosnia and Herzegovina, and also in order to ensure equal treatment for all insured persons with different health insurance institutions and for the sake of ensuring the use of health care on equal footing, the Health Insurance Fund of the Republika Srpska, the Brcko District Government – the Department for Health and Other Services to the Citizens, and the Health Insurance and Reinsurance Institute of the Federation of Bosnia and Herzegovina, concluded the said Agreement on 5 December 2001.
Under this Agreement, the Health Insurance Fund of the Republika Srpska, the Health Insurance Fund of the Federation of Bosnia and Herzegovina and the Government of Brcko District havecommitted themselves to undertake all measures that are required towards ensuring the use of health care services in the event that a person insured with an institution in one Entity, or Brcko District, needs to use health care services in the territory of the other Entity.
An insured person changing his or her residence outside the territory of one Entity shall be entitled to health care subject to a condition that the legal person under the obligation to calculate and pay the contribution should make the payment of such contribution for the person concerned in the way and in accordance with the Law on Health Insurance applicable in the Entity of the new place of residence.
With a view to ensuring the health care for the persons who are beneficiaries of pensions, so as to enable their exercising of the right to health care, the retired persons shall be provided with health care, even in the event that the relevant Entity pension and disability insurance institution, which is the under obligation to calculate and pay the contribution, fails to calculate and pay the contribution for the respective person.
Responsible entity-level pension and disability institutions shall have the obligation under the law to settle their financial liabilities towards the health care institutions, on the grounds of the compulsory health care contribution.
The persons that are insured under this agreement shall be entitled to the type and scope of health care, in the way and under the procedure provided by the law, by-laws and general acts that are applicable for the persons insured with the health insurance institution of their new place of permanent residence
For the purpose of the said Agreement, the healthcare shall be enjoyed by the insured persons:
- during their temporary residence in the territory of another Entity for the purpose of education, studying and additional training,
- in the event that they are referred for purposes of medical treatment to a medical institution situated within the other Entity on the basis of a document issued by the health care institution responsible for the person concerned.
Either party to the Agreement has undertaken to enable smooth access to health care services by the person on the basis of the valid medical documents, during the education and in the event of the person’s referral to the territory where the health care jurisdiction is exercised by the other entity.
In the cases where emergency medical aid is required and threats to life and health exist, the medical care services shall be provided even without immediate presentation of any documents, but such documents shall be presented subsequently within the period of three days.
Medical services provided in accordance with this Agreement shall be calculated at the prices set by a pricelist or tariff rates of medical services of the competent health insurance institution.
Thus the entities have secured the free movement of persons, goods and services, which nevertheless encounters certain implementation problems in practice. Namely, the invoices unpaid by the insurance funds for the services provided outside the territory of the entity as provided by the Agreement, as well as the required paperwork which is necessary in order to implement the Agreement, have both lead to the lack of implementation and to frequent obstructions of this highly important, useful and indispensable Agreement in regard of most of its sections. Still, one section of the Agreement that remains unquestionable and applicable is related to the health care provided to returnees and retired population, who receive their pension from the entity which, due to the insurant’s place of temporary residence, does not seem to correspond to the territory covered by his or her own native Health Insurance Fund.
Part XII – Executive Summary
There are four laws in Bosnia and Herzegovina that regulate the matter of health insurance. Thus the health insurance is of local character and is strictly divided across the regions, which prevents free movement of patients from one entity to another, just as it does from one canton to another and Brcko District alike.
Health insurance in the Federation of Bosnia and Herzegovina is divided into ten cantonal health insurance institutes and ten health insurance funds, just as there is a single Federation Health Insurance and Reinsurance Fund and a single Federation Solidarity Fund. This kind of division across the health insurance regions is making the health care enforcement additionally difficult and has the identical effect in regard to service providing in the larger specialized clinics that are situated in the cantons or the entities where the insurant is not covered by the health insurance in question.
Only one canton – i.e. the Central Bosnia Canton, has enacted its own health insurance law. The Health Insurance Law of the Central Bosnia Canton is quite similar to the Federation Health Insurance Law.
Other cantons tend to apply the Federation Health Insurance Law.
Health insurance in the Republika Srpska is centralized, which ensures a much more functional principle of realization in regards to health insurance and ipso facto of health care as well. Therefore such decentralized health insurance schemes that are applicable in Republika Srpsak reduce the possibilities of discrimination and facilitate a much easier and simpler access to health insurance for its insurants.
The unemployed persons registered with the employment bureau have the possibility of filing their applications with the Bureau without any time limits set in that regard.
Brcko District has its own legislation in the area of health insurance, which differs from entity-level health insurance legislation.
The range and type of health care-related rights covered from various health insurance funds tend to vary among the entities, the Brcko District and the cantons.
The prices of services may vary considerably which makes the rendering of health care services additionally difficult to insurants who come from different entities and cantons.
In short, there is no universal approach to health care in Bosnia and Herzegovina, per requirements of the European Social Charter and other international documents.
Health care benefits are not enjoyed equally by all citizens without discrimination. The provision of health care is concentrated in major towns and cities, and access to health care is made extremely difficult for the rural populations who reside in rural areas that are not adequately connected with towns by public transport. Therefore such access is made particularly difficult in regard to tertiary health care, which is a result of differing amounts of revenues collected through health insurance funds.
The range of rights arising out of the basic health care or the paid and unpaid health care services vary among the cantons, the Federation, the Republika Srpska and Brcko District. This makes medical treatments and the provision of long-term health care services particularly difficult for persons that are registered and receive health insurance benefits in one entity, while being stationed in the medical institutions of the other entity. (For example persons with with mental disorders and retarded persons may reside in locations or institutions outside of the geographic coverage area of their affiliated Insurance Fund and this poses problems of reimbursements, given the different rates established by the separate entity Insurance Funds.)
The amount and the base rate for calculation of salary compensations for temporary absence from work also vary among some cantons and the entities, which creates discrimination among the persons covered by health insurance.
The population groups that are not covered by health insurance are also different in the entities.
In both entities, among those who are not covered by health insurance are the employees for whom the employers do not pay health insurance contributions. In addition, in Federation that there are some other categories individuals not covered by health insurance, and this group is comprised of: workers whose employment has been terminated and who have failed to report themselves within the required timeframe; secondary school pupils and higher education students who have completed their education but failed to comply with the deadline of 30 days for reporting with the employment bureau; and self-employed workers who do not pay health insurance contributions for themselves (street vendors, greenmarket vendors).
Failure to pay health insurance contributions in the Federation and in the Republika Srpska alike, places into a difficult situation not only the employee but also his or her entire family. For example, a child that is younger than 15 years of age and that is entitled to the compulsory health insurance cannot be covered by health insurance on the grounds of the child’s years of age, since his or her parent is maintained in the employment records as an employed person for whom the employer has to pay health insurance contribution without exception on account of his or her employment status. Such child is treated as though he or she is covered by insurance on another ground. The fact that the employer is not paying the contribution for the parent and that the insurant is unable to force the employer to pay such contributions leads to a stalemate situation for both the insurant and members of his or her family.
Unemployed persons with a severe permanent disability also fail to exercise the rights in the health care and health insurance domains.
A large group of population belonging to Roma national minority is not insured due to the lack of documentation and information about their health insurance rights.
In order to rectify these health insurance inequalities, by using the possibilities provided in theLaw on Ministries and Other Bodies of Administration of Bosnia and Herzegovina, it would be necessary to enact a state-level Framework Law on Health Insurance of Bosnia and Herzegovina that would guarantee the same range of health insurance rights. That Law could arrange and regulate the required minimum of health insurance standards equal for all insurants, it could provide for the same basic package of health services, ensure a simple and transparent system of reimbursement for inter-entity insurance, and strike the balance among all essential elements of health insurance.
Another requirement would be to strengthen the Health Department within the Ministry of Civil Affairs of Bosnia and Herzegovina and to establish an independent state-level Health Insurance Agency, which would be responsible for prescribing uniform health insurance criteria and monitoring the State and entity level health insurance legislation, but which would also reconcile all differences in the levels of economic development and income-related discrepancies in Bosnia and Herzegovina. This Agency could contribute to coping with the decentralized Health Insurance Funds more effectively.
Finally, there is a pressing need for urgent harmonization of the entity-level laws and incorporation of the grounds and main principles of health insurance in an equitable and nondiscriminatory way, which is also a requirement contained in all international documents of relevance for the health insurance matters.