Help is Around the Corner:
CBR in Bosnia


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Community-based rehabilitation (CBR) allows Bosnians to receive rehabilitation services within their own community, offering many advantages to Bosnians and Bosnia.


A nurse applies ice therapy in a Sarajevo CBR center.
by JJ Scott, MAIC

Community-Based Rehabilitation

The idea behind CBR is really quite simple: instead of restricting health care facilities to a few large regional centers, CBR spreads clinics and hospitals among as many communities as possible. This makes it easier for people to receive health care by reducing their travel time and allowing them to remain in comfortable surroundings. In crisis situations, CBR at the least provides needed health services to desperate people who are sometimes immobilized and often fearful of venturing too far from their homes, even for medical care. But it can do much more for scarred post-conflict populations. CBR relies on a sense of community to function—everything from the buildings to the doctors to the programs should be built, trained or developed locally—and its successful implementation reinforces those communities. According to the experts, CBR helps rebuild communities by diminishing perceived barriers between formerly competing groups, helping those groups find solutions to the complex management and organizational problems facing their rebuilding society, and demonstrating opportunities for health, social and economic reform in a peaceful, constructive context.1

CBR in Bosnia-Herzegovina

CBR sounds great, but how does it work in the often-chaotic, devastated communities created by an all-out war? In Sarajevo, “many communities, they were closed during the war. [People] didn’t want to walk around too much because they were at risk of being shot or killed, and many times they couldn’t leave their area even if they wanted to,” Dr. Goran Cerkez of the Bosnian Ministry of Health remembers. Under these perilous conditions, no one could risk the walk to the local hospital, which might be many blocks away—and was probably destroyed anyway. Outside of Sarajevo, worse conditions existed: people relied on medical centers that could be dozens of miles away—not bad for a non-emergency during peacetime, but an impossible journey for a critically injured civilian trying to negotiate mined roads as shells burst all around him. Dr. Cerkez explained how civilians discerned the opportunity from the disarray, taking care of their medical needs “using local capacity and local people to set up [health care] services.” The fog of war shrouded the birth of a new Bosnian rehabilitation system: community-based rehabilitation.

Since the war ended in 1995, Dr. Cerkez has helped guide the development of the Bosnian CBR system from its ad-hoc beginnings to its current incarnation as a network of 38 standardized clinics spread throughout the country, each providing a surrounding population of about 60,000 people with local, completely integrated rehabilitative care. Bosnia did not set out to develop a CBR system; their rehabilitation systems simply evolved into what we call CBR as the Bosnians sought a way to treat an incredible number of amputees as cheaply as possible while maintaining quality and comfort. National pride played no small role either—Bosnians wanted the ability to not only treat their wounded immediately, but to care for them over the long term. CBR was the answer.

Each of the 38 clinics offers basic rehabilitation services free of charge for any person injured during the war and for all landmine victims, regardless of when their injuries occurred (landmines still cause 80–90 annual casualties in Bosnia). An estimated 684,000 patients filter through Bosnia’s clinics each year, receiving hot, cold, electro- or kinesiotherapy according to their needs. Trained professionals also provide psychosocial rehabilitation in every clinic, so patients who require both physical and mental assistance need not venture all over town. These clinics can’t solve all of a patient’s rehabilitation problems—they have no anesthesia, for example, so doctors do not conduct surgeries of any type. CBR clinics aren’t meant for major operations, but “if you need continuous, daily treatment, you can do this in your community—and that’s an advantage,” for both patients and nations, claims Dr. Cerkez.
For major undertakings, such as surgery or fitting a prosthesis, Bosnia built six regional prosthetic centers. They too are spread throughout the country, located within major cities. The regional centers offer the “best possible level of care,” and “are outfitted with all the latest technologies,” says Dr. Cerkez. Their function is quite different from the local clinics, but no less necessary. They fit into the CBR model perfectly: for low-level, regular rehabilitation, patients can go to their local clinics; for specialized, more sporadic procedures, patients venture a few hours away to one of the regional clinics.

(Top) The site of a new prosthetic center in Sarajevo.
(Bottom) A fully-equipped CBR clinic in Sarajevo.

A few numbers express the economic advantages of CBR quite clearly. The 38 standardized centers take up just 150 square meters each, and the whole project cost a bit over $5 million (U.S.)—a pittance in the healthcare realm. Dr. Cerkez states, “If you compare it to the cost of one big center, it’s about the same amount of money. It’s clear that [CBR] is the better investment.” CBR makes economic sense for patients, too. Travel costs quickly become prohibitive if patients must travel daily, or even weekly, to a distant rehabilitation center. CBR eliminates such voyages, allowing the patient to remain closer to home, within his or her own familiar community. Mountains of anecdotal evidence point to the rehabilitation benefits that regular contact with family and friends—in other words, a patient’s community—can bring. When people are comfortable, they are happier, and that leads to higher attendance at therapy sessions—quite necessary for an effective rehabilitation program. Numbers can’t adequately show the psychological advantages of CBR, though they may be most significant of all.

Still, some patients seek rehabilitation services outside of Bosnia. They go to Slovenia or Croatia, always looking for better care. They (or the government) have to pay for a plane, for accommodation and for the services themselves. “They think that in other places they can be treated better than here,” Dr. Cerkez laments, though “in our analysis, less than 10 percent of our patients are not satisfied with their prosthesis.” The grass is always greener on the other side, especially in Bosnia. Only a very few, extremely complex cases must receive help outside of the country, and that will not change for several years. But the majority could easily find needed help within Bosnia. Dr. Cerkez would prefer that money spent to transport such patients instead be invested in developing Bosnia’s internal capacity.

But there are others he’d be more willing to send abroad: young surgeons, technicians and other medical personnel. Like many other professionals in Bosnia, the current crop of doctors has a great deal of hands-on experience but little formal training. “We need to exchange people and knowledge” to build up Bosnia’s internal abilities. That way, “we can support ourselves after international support is gone.”

*Photos courtesy of the author.  

References

  1. Peat, Malcom; Edmonds, Lorna Jean; Boyce, Will; Ballantyne, Sandra; Smith, Jennifer; Koros, Michael J. “Community Based Rehabilitation: A Peace Building Opportunity.” Copyright ICACBR, Queen’s University at Kingston.
  2. Interview with Dr. Goran Cerkez in Sarajevo, in July of 2002. Many thanks for his generosity and patience. Any misquotes, mischaracterization or misinformation is my fault alone.

Contact Information

JJ Scott
MAIC
E-mail: scottjj@jmu.edu

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