The organisation of mental health services in post-war Bosnia and Herzegovina.

Bosnia and Herzegovina (BH) is located on the western part of the Balkan Peninsula. It has an area of 51 210 km2 and a population of 3 972 000. According to the Dayton Agreement of November 1995, which ended the 1992-95 war, BH comprises two 'entities' - the Federation of Bosnia and Herzegovina (FBH) and the Republic of Srpska (RS) - and the District of Brcko. The administrative arrangements for the management and financing of mental health services reflect this. The FBH, with 2 325 018 residents, is a federation of 10 cantons, which have equal rights and responsibilities. The RS has 1 487 785 residents and, in contrast, a centralised administration. Brcko District has just under 80 000 residents.

Mental health policy and legislation

Healthcare systems in BH are regulated basically by the entities’ different laws on healthcare and on health insurance. Each entity and Brcko District is responsible for the financing, management, organisation and provision of healthcare. The health administration is centralised in RS, through the Ministry of Health and Social Welfare, but in FBH is decentralised – each of the 10 cantonal administrations has responsibility for healthcare through its own ministries. The central Ministry of Health of the FBH, located in Sarajevo, coordinates cantonal health administrations at a federal level. The District of Brcko provides primary and secondary care to its citizens. The mental health policies and national programmes for mental health were created in 1999 and adopted in 2005. A law on the protection of persons with mental disorders was adopted in 2001 and 2002 in FBH (Official Gazette of BH, Nos 37/01 and 40/02), and in 2004 in RS (Official Gazette of RS, No. 46/04). These laws define the rights of people and regulates the procedure for voluntary or involuntary admission to a psychiatric hospital.

Mental health service delivery

There are no private mental health institutions. Psychiatric services are available for all citizens, paid from a special national fund for healthcare, financed by mandatory health insurance. The reform of mental health services began in 1995. The focus has been on care in the community, limiting the use of psychiatric hospital beds, establishing a network of community mental health centres (CMHCs), and developing other services in the community, a multidisciplinary approach and teamwork, as well as cooperation between sectors. Each CMHC is responsible for general mental health in a catchment area of 50 000–80 000 inhabitants; each has 10 psychiatric beds, intended for the acute admission of patients (these beds are in fact on neuropsychiatric wards of regional general hospitals). The CMHCs have many different functions, including the promotion of mental health, early detection of mental disorders, and the provision of multidisciplinary care (Ceric et al, 2001).

Psychiatric services are provided throughout BH through the network of 55 CMHCs and family medicine services at primary care level. Secondary and tertiary mental health services are provided in three psychiatric clinics, one department of a university clinical centre, two general psychiatry hospitals, two institutions for the treatment, rehabilitation and social care of patients who are chronically mentally ill, and neuropsychiatric wards in general hospitals in major cities. In the reform of the mental health services, mentioned above, new out-patient services were established, the existing primary care services were adapted to mental healthcare and, in addition to the CMHCs, sheltered housing services for patients with a chronic mental illness were established.

The reform of mental health services had a direct impact on the development of users’ initiatives in BH: there are now several user associations, which are provided with professional support and education from CMHCs and psychiatry clinics.

There are only two wards and two specialists for child and adolescent psychiatry within the psychiatry clinics. There are four institutions for the care of adults and children with special needs and chronic mental disorders, mainly financed from social welfare. Persons with drug addiction are treated in a specialist institute and two other centres for addiction; methadone is the predominant form of treatment.

There are no specific programmes for the mental healthcare of minorities and the elderly in BH. There are programmes for refugees and war victims of torture, through a network of non-governmental organisations developed during the war.

The provision of forensic psychiatry services is insufficient. Individuals with mental health problems who commit criminal acts are treated in one forensic ward of a general psychiatry department of a prison psychiatry hospital.

According to the Regional Office of the Mental Health Project for South Eastern Europe (2004), in 2002 in FBH there were 159 neuropsychiatrists, in RS 67 and in Brcko District 6. The number of psychiatric beds in FBH was 632, in RS 640 and in Brcko District 30. These data differ from those in Table 1, from the World Health Organization (2005) and based on data collected from 2001 to 2004.

Table 1

Numbers of psychiatric beds and staff

	Federation of Bosnia and Herzegovina	Republic of Srpska	Brcko District
Total number of psychiatric beds per 10 000 residents	3.6	3.93	3.5
in psychiatry hospitals	2.4	0.91
in general hospitals	1	0.68	3.5
in other institutions	0.2	2.33
Numbers of professionals per 100 000 residents
psychiatristsa	–	2.3	–
neuropsychiatristsa	1.8	1.2	7.0
nurses in psychiatry	10	19.4	21.8
psychologists	0.5	0.86	1.8
social workers	0.03	0.66	1.8

In Bosnia and Herzegovina until 1992 there was education in ‘neuropsychiatry’ only; during the war (1992–95), medical doctors from the Republic of Srpska were trained in Belgrade (Serbia), where they could gain a qualification in ‘psychiatry’.

Source: World Health Organization (2005).

Treatment of traumatised persons

At the beginning of the war (1992) knowledge about the psychological consequences of war and therapeutic approaches to post-traumatic stress disorder (PTSD) in BH was rather poor. The therapeutic approach was based on the experience of psychiatrists and their receptiveness to the ideas suggested by the foreign literature and the many foreign workers (Jensen & Ceric, 1994; Hasanovic et al, 2006). At the end of the war, various psychosocial programmes were organised by the government and international non-governmental organisations (de Jong & Stickers, 2003; Nelson, 2003). The psychosocial approach to trauma aimed to reduce not only the risk of serious mental disorders but also stigma, through mass education about the psychological consequences of trauma. Working with traumatised people during the war, we perceived that religious people coped more successfully with difficulties than those who were not religious. In selected cases, spirituality and religion are therefore used in the process of healing, and so they found their place in educational programmes and psychotherapeutic treatment. In hospitals, adequate rooms for the spiritual and religious needs of patients were allocated (Pajevic et al, 2005).

Psychiatric training

There are five medical faculties, two in RS and three in FBH, with different education programmes, all lasting 6 years. At four medical faculties, the undergraduate courses include only two semesters of psychiatry, while at one medical faculty the undergraduate course has only a neuropsychiatry element. Medical schools are associated with psychiatric clinics. After graduation from the medical faculty and a 1-year internship, specialisation in neuropsychiatry/psychiatry is available, authorised by the entity’s Ministry of Health.

Specialist training is different in the two entities. In FBH there is specialisation in neuropsychiatry, which takes 4 years, with 20 months of psychiatry, while in RS there is a programme of education in psychiatry only, which also lasts 4 years. There is no unified national programme of psychiatric education for residents.

Psychiatric sub-specialties and allied professions

The educational programme for the specialisation in neuropsychiatry/psychiatry does not include psychotherapy. Residents from neuropsychiatry/psychiatry are familiar with the theoretical basis of psychotherapy mainly from their undergraduate education. There are no institutions for education in psychotherapy in BH, and there is no regulation of psychotherapy licences. Education in psychotherapy is organised from psychiatry clinics and by psychologists’ associations, in cooperation with psychotherapist educators from other European countries.

The only recognised sub-specialisations are in social psychiatry and alcoholism and drug addiction, each taking 1 year. There is undergraduate education in psychology, but no specialisation in clinical psychology. Furthermore, there is no specialist training for psychiatric nurses. Additional psychiatric education for nurses is provided through special education programmes organised at the psychiatric hospitals.

Main areas of research

Psychiatric research in BH is insufficiently developed. There is no professional psychiatry journal, nor a particular institute for research in psychiatry. Existing research projects are undertaken at the psychiatric hospitals and medical faculties. The main areas of research are currently related to the psychosocial consequences of war trauma. Lack of a uniform database and insufficient development of entity and cantonal public health services represents big problem for research, particularly epidemiological studies.