«100 80 60 40 20 0 FBIH MINISTARSTVO BOSNA I HERCEGOVINA BRČKO DISTRIKT RADA I SOCIJALNE POLITIKE FEDERACIJA BOSNE I HERCEGOVINE FEDERALNO ...»
Analysis of Social Welfare and Health
Needs of Families and Children
in the Federation of Bosnia and Herzegovina
and Brčko District
FBIH MINISTARSTVO BOSNA I HERCEGOVINA BRČKO DISTRIKT
RADA I SOCIJALNE POLITIKE FEDERACIJA BOSNE I HERCEGOVINE
FEDERALNO MINISTARSTVO ZDRAVSTVA
BOSNA I HERCEGOVINA
FEDERACIJA BOSNE I HERCEGOVINE
FEDERALNO MINISTARSTVO ZDRAVSTVA
RADA I SOCIJALNE POLITIKE
BRČKO DISTRIKTProject is funded by the European Union This publication has been produced with the assistance of the European Union.
The contents of this publication are the sole responsibility ofCustom Concept and can in no way be taken to re ect the views of the European Union.
Table of Contents
I. EXECUTIVE SUMMARY 6II. INTRODUCTION 9 III. DETAILED RESULTS 17
ANALYSIS OF SOCIAL WELFARE NEEDS OF FAMILIES AND CHILDREN 17
IN THE FEDERATION OF BIH AND BDLegislation/Policies 17 Budget 18 Management and Coordination 21 Availability of Basic Resources to Enable Service Delivery/Capacity of CSWs 28 Access to Information, Facilities and Services 33 Financial Access/Direct and Indirect Costs 49 Quality
I. Executive Summary
This Analysis of Social Welfare and Health Needs of Families and Children in the Federation of BiH and BD (the Analysis) was conducted for the purposes of the SPIS Program. The primary goal of this Program is to enhance the social protection and inclusion system at all levels of governance, through strengthening the policy framework for the social protection and inclusion system and building national capacities for cross-sectoral approaches to child protection and inclusion. The Analysis aims to provide an overview of the currently available statistical data in the relevant areas; to conduct a qualitative and quantitative study to better understand the needs of children and families in terms of available social welfare and health care services; and to support the ongoing social welfare and social inclusion reform in the Federation of BiH and BD.
This report presents a comprehensive analysis of the data obtained through both parts of the study and from all stakeholders, including representatives of different levels of authorities responsible for social welfare, health care and education, as well as service providers and social welfare beneficiaries themselves. In this way, by shedding light on the needs of children and families, the report paints a comprehensive picture of the situation in social welfare and health care and allows for identification of barriers and bottlenecks and, most importantly, recommendations for ways to overcome them.
The analysis has shown that the ongoing reform of the social protection and inclusion system is very important and necessary in both geographical areas covered by the study. More specifically, the legal framework that governs social welfare in these areas and the vagueness and poor implementation of some of these laws, combined with differences in amounts, planning and allocation of Cantonal and municipal budgets, have led to significant differences in the types, amounts and quality of social assistance provided to beneficiaries in different Municipalities and Cantons in the Federation of BiH and BD. The presence of these differences leads the beneficiaries to doubt the system and feel discriminated, encouraging an impression that the funds intended to help individuals and families in social need are manipulated and misused.
Vertical cooperation between institutions is generally functional, but advisory and supervisory roles of higher levels are not sufficiently expressed. In addition, there are some examples of instructions and “unofficial” guidance received by lower levels that are not in line with applicable legal provisions, which place service providers in a difficult position and prevent beneficiaries from accessing their statutory rights. Horizontal cooperation is also functional, but it rarely functions at a level that provides a swift, effective and full response to beneficiary needs. Furthermore, the absence of a mixed social welfare system (in which social services can be provided, in addition to governmental institutions, by individuals and legal entities, including associations and foundations) limits options for establishing and providing certain services and for registering and addressing the specific needs of beneficiaries.
The next barrier interfering with the functioning of the social welfare system and the addressing of needs of children and families is insufficient (technical, material, human and financial) capacity of most of the Centers for Social Work (CSWs). This lack of capacity, in combination with other factors, contributes to lower levels of preventive, counseling and field work; prevents continuous monitoring and analysis of the status and needs of (potential) beneficiaries; and prevents effective action to address these needs. For beneficiaries, this is further evidence of a lack of interest for socially vulnerable groups on the part of the government, which increases feelings of marginalization and undermines their faith in an effective social welfare system. Beneficiaries have difficulties accessing social welfare facilities because CSW offices are often located on the second, third or higher floors, and few Centers operate in facilities adapted for access by disabled persons. Access to information among beneficiaries is better than that of the general population (potential beneficiaries). For the general population, the main sources of information about social welfare benefits are acquaintances, relatives and friends, who quite often have incomplete and inaccurate information and this information does not reach potential beneficiaries on time. In contrast, most of the current beneficiaries have had immediate access to all the necessary information about a benefit when they filed their most recent application for 6 Analysis of Social Welfare and Health Needs of Families and Children in the Federation of Bosnia and Herzegovina and Brčko District such benefit, and the accuracy, clarity and completeness of this information was, in principle, highly rated. However, beneficiaries also have much less information about (other) social benefits that are available, which arouses suspicion of this information being deliberately kept inaccessible. In combination with other instances of non-transparency, this contributes to the perception of corruption in the social welfare sector.
If they manage to have all the necessary information and successfully complete the application process (including associated costs, which make this process barely accessible to some beneficiaries), and finally submit an application for a particular service, most of the beneficiaries receive a relatively simple, efficient and quick response to their application and can access the appropriate service. However, in Cantons which experience difficulties in securing the necessary resources in their budgets, the number of applications that remain unanswered within the statutory period is significantly higher, as is the number of instances of late payments or even discontinued payments of benefits.
There are also cases of inefficiencies in the work of CSW staff and major delays in notifying beneficiaries, with some cases where the inability to pay certain benefits has had extreme consequences. Under these circumstances, some Cantons have decided to reduce individual amounts of transfers to ensure their regular payment. However, since the amount of cash assistance is generally low and insufficient to meet the needs of beneficiaries, these reduced amounts cannot cover even the basic needs of beneficiary families, and are often even degrading.
When it comes to addressing beneficiary needs by providing intangible services, the excessive administrative workload of CSW professionals and the general lack of capacity limit the number, diversity and quality of these services, and encourage perceptions among beneficiaries that the CSW staff does not have enough time and patience to “deal with beneficiaries” and provide them with all the necessary support. This is particularly important because the beneficiaries’ assessment of the staff’s attitude toward them is generally guided by home visits (which is the lowest rated element of CSW performance) and the time the staff spends with them. Beneficiaries expect the staff to take time to hear them, to visit them, and to show appreciation and a desire to help them. They often interpret the (perceived) absence of such attention as a lack of recognition on the part of the staff, concluding that the staff and the rest of the environment view them as “less important” and “welfare cases.” At the same time, CSW employees feel misunderstood and insufficiently recognized by other professionals they cooperate with in the course of their work. Furthermore, their perception that the role of CSWs is not appreciated enough by the community in general and that their social and financial status is lower than they deserve leads to resentment. This resentment is then transferred to beneficiaries and causes a “vicious circle” that is hard to break. Nonetheless, general levels of satisfaction with CSWs show that, in spite of everything, beneficiaries truly appreciate the support they receive and are able to recognize the efforts made by the majority of CSW staff in the performance of their duties. Specifically, three-quarters of beneficiaries made a positive assessment of CSWs’ work in principle. On the other hand, this also means that one in four beneficiaries were not satisfied, or even one in two beneficiaries in some Cantons.
Compared to the general population, social welfare beneficiaries enjoy higher levels of health coverage, but there are still 7.5% adults and 5.5% children in beneficiary families who do not have health insurance. These are mostly adults who have not registered or have failed to report regularly to Employment Bureaus; persons whose employment status remains unresolved and whose employers do not pay insurance contributions; persons over 65 years of age in BD who used to be self-employed farmers; children who failed to register with the Employment Bureau after they completed or left school; children insured through parents whose employers do not pay insurance contributions; and children not registered in Birth Registers. However, this lack of coverage is partly due to the lack of information among beneficiary families that uninsured pre-school children and children under 26 who are in full-time education, persons with disabilities, pregnant and childbearing women, and persons over 65 years of age, who are not insured on any other grounds, are able to enjoy health insurance through CSWs and Cantonal Ministries of Education.
Beneficiary needs for health care also remain unmet in cases when beneficiaries with health insurance must pay an annual premium or stamp to avoid co-pays or to pay lower co-pays for medical examinations, tests and purchase of medications listed on the positive drug list. Further cases of unmet need for health care involve instances when purchases of medications, orthopedic aids and sanitation devices constitute most of the household budget or greatly exceed the budget. In addition, some beneficiaries cannot access therapies administered outside their place of residence, with travel costs being an insurmountable obstacle. Lack of cooperation and coordination between CSWs and Health Insurance Institute of the Federation of BiH and the BD Department for Health and Social Affairs further limits accessibility of health care to beneficiary families. For the time being, CSWs try to help by providing one-off cash 7 Analysis of Social Welfare and Health Needs of Families and Children in the Federation of Bosnia and Herzegovina and Brčko District assistance (which may be received one to four times per year, depending on the Canton, in amounts that are low and paid with delays of several months in some Cantons) or extraordinary cash assistance (paid once per year in principle), which is nowhere near enough to meet these beneficiary needs. (At the same time, this redirection of the majority of one-off cash transfers to cover health-care-related needs leaves no room to address other beneficiary needs.) The end result is that beneficiaries do not visit a physician every time they think they should/when they have symptoms of a disease, and some of them do not even take their children to see a physician when they are suspected of being ill. (However, beneficiaries are generally satisfied with pediatricians and have comments on their work only in towns with insufficient number of pediatricians, resulting in limited time devoted to each beneficiary.) In addition, beneficiary families who use psychologist, speech therapist and special educator services outside of their place of residence find these services costly and time-consuming, which impedes and at times prevents continuous access to these services. This in turn has a negative impact on the quality of health care received by their children.