Before the war, health care in Bosnia and Herzegowina was very much intervention oriented and hospital based. There was a strong bias towards high-tech medical approaches and solutions. Primary health care did not receive much attention and preventive measures and health promotion were neglected. Rising costs were outstripping the available resources. The government reduced funds for the health care system, but extended at the same time free access to all forms of health care. The health system was centralized and private practice was extremely rare. However, on the positive side, health protection was available across the country.
A psychotherapeutic approach did not exist in spite of the high level of neuropsychiatry in the country, because the attention was directed to the psychopathology and the treatment of psychiatric disorders, while the so called healthy population did not have easy access to counselling – and did not even seek this type of assistance. Counselling services were only available within the structure of the social protection system, but for obvious reasons no-one in Ex-Yugoslavia wanted to be a «social case».
Already two years before the war started, it became more difficult to obtain drugs and people had to contribute to their health care expenditure. The beginning of the war led then to a total breakdown of the system. In the aftermath of the war, humanitarian organizations arrived in Bosnia and Herzegovina and drugs became available again so that medication continued to be the common approach.
Establishing of the «Vive žene» Therapeutic Centre
Based on the initiative of a group of local women and with the support of the international community, the NGO «Vive žene» was established in 1994. For Bosnia Herzegovina the emergence of civil society organizations was a new phenomenon and it took quite some discussion for the Tuzla municipality to approve the centre’s working program. At that time Tuzla had been overcrowded by hundreds of thousands of refugees from various areas who were accommodated in facilities like dormitories, kindergartens, schools etc.
The structure of our organization and of our centre relied on professional staff that consisted of psychotherapists, pedagogues, social workers, a physiotherapist, a general practitioner and a nurse. Work focused initially on in-patient psychotherapy giving help in form of group and individual therapies, groups with social workers and medical help. The centre’s capacity was a maximum of 40 patients. Compared to the general difficulties, working conditions were exceptionally good: we had water, electricity and a sufficient working space. This facilitated the development of a new approach in a community which at that time was only familiar with medical treatment of psychosocial problems.
For example in the beginning traumatized women thought that entering the centre would bring them the stigma of being a ”crazy person” and it was therefore not easy for them to seek help in our centre. The staff of «Vive žene» did its best to consider each traumatized person as an individual and give him or her the feeling to be understood and respected. Patients got a feeling of safety and that someone cared for their chance of regaining their lost identity and their self-esteem. As «Vive žene» did not only concentrate on in-patient care, but also provided psychosocial and medical support to refugee settlements in the canton.
Consequence of war
Poverty and war had significant negative consequences for public health in Bosnia and Herzegovina. Migration, disability and new environmental factors have led to worsening social and economic conditions and unhealthy life styles and finally resulted in more chronic illnesses. The devastation of health care facilities, the emigration of trained health care professionals have made it difficult for the health sector to cope with these problems. In addition, an increasing number of private clinics attract with their higher salaries the well skilled staff of the state institutions, but are not willing to offer affordable services for the people.
As a direct consequence of the war, the incidence of mental illness increased considerably, especially among displaced, refugees, orphans, elderly and demobilized soldiers. 15% of the population are estimated to have suffered psychological trauma, in particular post-traumatic stress disorder. The most common diseases are neurotic disorders associated with stress (61%) and affective mood disorders (14%). There are certain indications that there has been an increase of violence as a result of mental problems.
In the immediate post-war period «Vive žene’s» work focus remained on the refugee population in the refugee settlements. Seriously traumatized women were offered in-patient treatment. As a result of the treatment successes the confidence in the therapeutic treatment has grown considerably. In 2001 the offer for psychotherapy and counselling was extended to victims of domestic violence, and an increasing number of local people of the Tuzla canton are now using the centre. Almost 400 clients per year in our out-patient clinic highlight the big need for this unique type of service.
Building partnerships
As the only organization in the Tuzla canton offering in-patient psychotherapeutic treatment, «Vive žene» has become an important referral point for other NGOs working in the area. Clients in need of in-patient therapy are frequently referred to the centre. The cooperation with other NGOs provides ample synergistic opportunities, for example in the field of continuous education. To strengthen the collaboration and synergies 49 NGOs formed in 1996 a network, which is called ”Reference Group”. All organizations of the Reference Group are recognised by the governmental institutions as important service providers and actors in and for the community.
In the last years, cooperation between «Vive žene» and the public institutions has improved in terms of quantity and quality. Referrals of clients from the public psychiatric clinic to the centre of «Vive žene» or vice versa have become common. Influenced by the new approaches used by «Vive žene», also the public psychiatric clinic introduced some changes in its working concept and started also to provide psychotherapeutic and out-patient psychiatric care. This cooperation and the sensitization work of «Vive žene» and the Reference Group led to positive changes in the health system and it is now widely accepted that a good collaboration between the public and the NGO sector is vital for the development of the health system.
The Reference Group has a very important role in the future of «Vive Žene», as a part of the NGO sector being established in Bosnian society. Through the activities of the Reference Group we can influence the governmental institutions and the government itself. We are invited to work on the family law, the law for the NGO sector and we jointly organize public campaigns about human rights, democracy, domestic violence etc.
The general situation in the country – very low and slow economic development, high unemployment - is causing young people to leave the country. In order to make it attractive for them to stay, investments in infrastructure to induce development, a prerequisite for modernization, are crucial. However, as we can see in our work at the Therapeutic Centre, it is also important to invest in the training of professional staff.
«Vive žene» uses a multidisciplinary approach in working with clients at the community, out- and in-patient level. The development of the out-patient therapy and the counselling service is receiving particular attention.
Because of a lack of personal capacities in the public sector the centre was also requested to provide psychosocial services for the general population. However, the centre is still lacking the official recognition of the government. It is therefore the aim of «Vive žene» to become one of the officially approved mental health centres of the canton. This process is on good track and will open the possibility to obtain in the future public funding.
The work of «Vive žene» is now widely recognized, and fruitful working relationships and cooperation projects have been established - not only with the psychiatric clinic, but also with the Police, the Center for social work, the Federal Ministry for health and the Federal Ministry for Work and Social Politics. The sustainability of «Vive žene» is closely linked to building partnership relations with governmental organisations and to fit into the system of psychosocial care of Bosnia and Herzegowina.
*Since 1997, Vive žene has been supported by IAMANEH Switzerland and co-financed by DDC/AZO, Glückskette, the Canton Aargau and the Communities of Jona and Meilen. Contact and information: info@iamaneh.ch.
