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The Challenges of Primary Health Care Sector in Federation of Bosnia and Herzegovina

BaşlıkThe Challenges of Primary Health Care Sector in Federation of Bosnia and Herzegovina
Publication TypeJournal Article
Year of Publication2015
AuthorsRidic, O
Secondary AuthorsBusatlic, S
Tertiary AuthorsDapo, E
Subsidiary AuthorsJukic, T, Sarajčić, S, Karamehic, J
JournalInquiry - Sarajevo Journal of Social Sciences
Volume1
Issue1
Start Page47
Pagination47-61
Date Published05/2015
Type of ArticleReview
Abstract

Abstract
In today’s modern society innovating in every organization becomes
a key of its competitive advantage and survival in the
highly competitive market. This rule, sooner or later will have to
be accepted by our primary sector health care organizations. All
institutions must strive that by constant innovating, using in the
best manner possible the limited and available resources, to, in
the long term, ensure continuing businessand better future. The
scope of innovating activities must be all segments of the health
care organizations. All employees must be involved in innovating
process, and not only the research and development departments
(R&D). The health care institutions, which constantly innovate,
enjoy the permanent advantage in the competition with
their competitors. They are able to produce products and services
that are cheaper and of better quality. The innovation type, which
the particular health care institution chooses, represents, in its essence,
the nature of the innovation. It also includes the influence
of change on the value chain participants, competence and firms’
inclination in tedious fields of innovation and innovative management.
The modern markets require from the health care organizations
to be more dynamic, and the environmental changes
demand comprehensive innovative orientations. The people who
kick start innovations in health care field are in principle leaders. 

The leadership variables become very important having in mind
that almost all organizations, to a certain extent are built based on
the hierarchical structure. As the result of this fact, the decision
making centers tend to be concentrated in the hands of the leading
individuals. The science has found the relationship between
leaders’ motivations and the frequencies of the innovations. The
health care in Federation of Bosnia and Herzegovina (F.B&H), and
its entry and Primary care sectorare faced with the serious challenges.
Thus, innovating in this sensitive service field becomes the
imperative for society. Innovating and at the same time, managing
these processes is necessary for more reasons. Financial resources
allocated for health care in B&H are limited, and are expected
to remain so in the future. The second part of the challenges
the health care sector is facing is represented in the aging of the
population. The people live longer, and as the consequence, for
the health maintenance of population over 65, more and more resources
are spent. By innovating, best practice checking and waste
reducing the immense savings can be achieved in the health care.
These actions, as well as the quality applications of best practices
will enable that health care outlays, (which exceed ten percent of
gross domestic product (GDP).

URLhttp://inquiry.ius.edu.ba/index.php/Inquiry/article/view/6
Full Text

Introduction
The health market is specific, sensitive and highly fragmented. This
fragmentation is especially emphasized in the F.B&H, as a consequence
of the constitutional arrangement by which the F.B&H is divided
into ten cantons. From all of this, naturally arises the logical
conclusion that the introduction of new technologies, especially information
technology and information media and through adequate
representation in their primary care systems is directly proportional
to the level of improving health care.Cantons in making laws and
decisions, including those in health care, enjoy high autonomy, so
that the federal institutions and ministries have largely advisory
role. This disunity often leads to irrational decisions, since each
canton has the autonomy to procure and spend funds independently.
It is not rare that, from modest and limited financial means, Cantonal
Ministries of Health purchase expensive equipment with which
on arrival there is no one to handle, because the necessary staff are
not trained, nor can be provided in sufficient numbers. These examples
and others, which have been burdening health care, require 

and organization of health care (OZZ) to successfully operate in
a market, they must improve their organizational performance by
improving the management of innovation. Innovation in the health
care organizations becomes not only a factor of competitiveness,
but increasingly a factor of survival (Joksimovic & Vujovic, 2005)
(Masic, Novo & Toromanovic, 2009) (Jones & George, 2009).
Processes of innovation began in F.B&H immediately after the war,
in 1996, but its implementation was not sufficiently diffused, it was
narrowly focused and limited to a small number of primary health
care entities. Innovation is an activity that is far more complex than
it looks. Compared with developed countries, the process of innovation
in healthcare in F.B&H began relatively late. In a country,
where the war destroyed a significant number of production
and infrastructure, no health facilities or personnel were spared.
Although, the significant resources in the reconstruction of medical
facilities and equipment were expended, a significant number of
them was worse off as compared before the war. Implementing the
reform of the health system aims to strengthen primary health care
(PHC). Within the PHC teams the implementation of the family
medicine (TOM) is one of its highest goals. At this level,the rehabilitation
centers in the community have also being introduced.
As part of the reforms the issues of financing health carehave also
been addressed. On the basis of the contributions, health insurance
contribution is calculated on the gross salary of the employees at
the rate of 16.5% (12.5% at the expense of employees and 4% at
the expense of employers). Funding for health purposes are collected
and distributed at cantonal levels(Katz & Green, 1997), (Masic,
Novo & Toromanovic, 2009).
Exploring innovation in primary health care sector in F.B&H is just
in the beginning. The reason for this is serious resistance to the
introduction of changes and its monitoring. Analysis of recent research
shows that innovation deals with only a very small number
of primary health care institutions, that this process is not planned
and organized broadly, that radical innovations are more the exception
than the rule and that they were practiced in only a small number
of health care institutions. As pioneers in innovation, we can
mention the Agency for Quality and Accreditation in Health Care
(AKAZ) F.B&H, Clinic for Heart at clinical centers in Sarajevo and
Tuzla, Institute of Radiology at the University Clinical Centre in 

Sarajevo (KCUS), some private clinics and clinics, etc . (Narayan,
2001), (Valjevac-AKAZ, 2009).
As an interesting example of innovation we note the Department of
Radiology KCUS, who was among the first began with the introduction
of electronic medical records (EMR). Electronic card designed
to replace existing paper medical records. It has several important
advantages, such as the absence of errors, cost savings, the ability
to exchange medical information in a short period of time, easier
diagnosis, reducing administrative costs and more. Unfortunately,
the card shows its full advantage only if it is adopted by all health
institutions and if all institutions are bound into a single information
system. Cards that introduce individual institutions can not
fully show its effects. Private healthcare facilities make significant
results in innovation. Results are reflected mainly in the approach
to the patient, speed of service and different environment, which
resembles a small hospital in which reluctant to plunge, and less in
top medical results (outcomes). Private clinics, in general, does not
constitute a significant percentage compared to the total percentage
of healthcare services (Lighter & Fair, 2000), (Levi-Jaksic, 2008).
Discussion:
Historical overview of health care development and challenges
The health care system in B&H is rooted in the 1995 Dayton Peace
Agreement, after which the B&H was composed of two entities;
Federation of Bosnia and Herzegovina (F.B&H), Serbian Republic
(RS) and Brcko District. According to the B&H Constitution,
health care is the responsibility of the two entities and one (Brcko)
District. F.B&H has a decentralized health care system, which was
organized at the cantonal level. F.B&H has ten cantons, each canton
has its own Ministry of Health, which is responsible for the organization
of health care at the primary (health centers - health centers
with general practitioners and family health units), secondary (cantonal
hospitals and clinics) and tertiary level (general hospitals,
special hospitals and university-university clinical centers). Each
entity has its own district and the Law on Health Care and Health
Insurance Act. Unlike F.B&H, RS has a centralized health care system.
Changes in the health system began in 1996, immediately after
the signing of the Dayton Peace Agreement, with a view to reform
the Primary Health Care (PHC), the inclusion of family medicine.
This concept was aimed at rationalizing health care based on the 

strengthening of primary health care. With the help of the Canadian
Association (CIDA) and Queens University, the Canadian federal
government of Ontario, introduced family medicine teams. At the
PHC level, at the level of municipalities and communities, municipalities,
and because of the large number of injured and disabled
persons, as a result of the war in 1992-1995, the medical centers
and mental care centers for physical rehabilitation were introduced.
Strengthening of PHC was monitored by rationalizing the hospital
care with the help of the Australian Health Insurance Commission,
and the World Bank’s loan. Hospital capacity was reduced in accordance
with the federal program of reconstruction of the healthcare
system, established in 1996 (Masic, Novo, Pilaf, Jokic, Toromanović,
2006) (Masic, 2007), (Masic, Novo, Toromanović, 2009).
The use of hospital capacity showed a slight increase, and it is still
below the acceptable level of occupancy. At the level of F.B&H
the cantonal authorities are seeking ways to improve the uniformity,
effectiveness, efficiency, speed and quality of service. In 2005,
most cantons established a strategy for health care reform to be
implemented by 2015.
The main objectives of this strategy are: equal access to health care
services, efficient delivery of health care through adequate health
financing through adequate structure of human resources, effective
monitoring of demographic changes, as well as improving the limited
and fragmented institutional capacity. The strategic objectives
are: to improve the health of the population and the creation of
satisfaction with services through the delivery of affordable, effective,
high-quality, cost-effective programs and interventions in the
care, health promotion and disease prevention. The new practice
of health care would be based on the concept of family medicine,
enabling patients’ registration and free choice of doctor. This would
create a basis for the entire health care organization. Health care
organizations (OZZ) must be restructured and health centers must
begin using a common and acceptable practice adopted by other
organizational units, which can provide services to the widest strata
of the population. Within family medicine teams, except family
doctors, a major role has to have general and visiting nurses for active
control and health promotion. All consulting services should be
provided for consultation with family doctors and specialists (with
the possibility of electronic and tele-consultation) Mihajlovic &
Kostic, 2005) (Masic, Novo &Toromanović, 2009) (WHO, 2013). 

Reform of primary health care should be based on a solid financial
basis with the aim to protect the population from the high costs, ensure
redistribution and guaranteeing access to those who need basic
services. For this reform, cantonal ministries and fund health care
reform law must prepare and regulation in the style of movement
of financial resources, including methods of payment services and
payment of staff and institutions. HCO in F. B&H continue to work
with the organizational structure that existed before the war in Bosnia
and Herzegovina (1992).. The new legislation, which is based
on the Dayton Peace Accords (1995). The former socialist-centralized
system, became increasingly decentralized with a tendency
to become completely fragmented at the local level. Currently in
F.B&H there is the ongoing process of reconstruction of PHC. Accordingly,
the Ministry of Health of F.B&H, in cooperation with
international institutions, has prepared a document for the reform
of the primary health care system, with the aim to increase: effectiveness,
efficiency and rationalization of health care. At the same
time, structural changes in the system OZZ occur in the RS (Masic,
Novo, Pilav, Jokic, Toromanović, 2006), (Miljkovic, 2006), (Masic,
Novo &Toromanović, 2009).
The innovative approach to the development of primary health
care in the Federation of Bosnia and Herzegovina
The dynamics of the key development trends and characteristics
of health care in the Federation of Bosnia and Herzegovina
Health care is acomplex and open macro system of special social
significance. The health care system is made up of large number of
its sub-systems (microsystems). These are primarily:
- Organization of the human population and community (i.e. social-
medical diagnostics and health indicators),
- Health Ecology,
- Scientific research,
- Medical Education,
- Medical staff,
- A network of health care institutions,
- Pharmaceutical and sanitation production and supply,
- The role of government in health care-the Ministry of Health and
- Health economics (health care financing)
(North & Bradshaw, 1997), (Porter, 1998), (Masic, Novo& Toromanović, 2009). 

Each of these subsystems has its own line of microsystems, such as:
health facilities (health centers with health centers, and a network
of outpatient clinics, laboratories, etc.). The value and quality of
any social system is estimated degree of mutual harmonious functioning
of its subsystems, individually and all together. Unfortunately,
today, in many countries, including the entity F.B&H, we
have a very low and uncoordinated degree of complementarity and
harmony health system (Porter & Teisberg, 2006).
Illustrations for this situation are:
- A large number of dissatisfied customers (citizens) in health care
facilities,
- A large number of unemployed educated health professionals,
- Uncontrolled spending in health care,
- Inadequate and insufficient production of necessary medicines,
- Lack of quality control (i.e. insufficient scientific solutions to better
organization system)
(Porter & O’Grady, 2007).
F.B&H is divided into 10 cantons, each canton has practically its
own government. The cantons are composed of municipalities that
have the property of socio-political communities. Health jurisdiction
in F.B&H are divided between the federal and cantonal authorities,
which has decentralized health. Federal level usually has a coordinating
function. Health services by health institutions founded
by the Federation, cantons and municipalities, in accordance with
the law on health care F.BiH. Reforming health care is started immediately
after the war (1996). Reform commitments are focused
primarily on strengthening primary health care to the principles of
family medicine, the rationalization of higher levels of secondary
and tertiary health care, and more uniform distribution in the health
facility and staff. Health care reform was agreed that the highest
percentage of requests and needs of the population in the area of
health care addresses the primary care level, through family medicine
and specialist consultation service, which existed in the area
of the primary health care. The reform also foresees that a small
portion (15%) requests and needs of the population solves the secondary
and tertiary levels of care. In this manner would be rationalized
spatial and human capacities at secondary and tertiary levels
of health care, and rationalize the overall cost of health care (Masic,
Novo & Toromanovic, 2009), (Federal Ministry ofHealth, 2012). 

In accordance with the socio-political and socio-economic changes
in society, the actual process of privatization in health care is
modified, too. The privatization process will open the competition
between the state (canton) and private hospitals. Because of legal
restrictions that process still runs very slow. Some private hospitals
already have an enviable reputation, while the rest are just trying
to achieve the reputable results. One of the objections to private
hospitals and those that are open are the individuals whose medical
experience is rather questionable and that there is no transparency
in their work. According to the Law on health protection
at the municipal level, the following health entities are formed: a
regional community health clinics, pharmacies and general hospitals.
At cantonal level are formed: Ministry of Health, cantonal
hospitals, special hospitals, Institute of Transfusion Medicine, Institute
of Public Health and Institute of Insurance. At the federal
level are formed: Ministry of Health, Clinical Centers, Institute of
Transfusion Medicine, Institute of Public Health, Bureau of Drug
Control and the National Institute for Insurance and Reinsurance.
The objective of health system reform F.BiH the strengthening of
primary health care (PHC), which monitors the rationalization of
higher levels of protection. Within the PHC will deploy teams of
family medicine (TOM). At this level are introduced and rehabilitation
centers in the communitycare (Masic, Novo & Toromanovic,
2009), (Federalno Ministarstvo Zdravstva, 2012).
The reform included the financing of health care. Allocations for
health amounted to 16.5%, of which 12.5% are allocations of gross
personal income workers, and 4% of the allocations by employers.
The funds are collected and distributed at the cantonal level. “The
package of health rights” for federal, cantonal and municipal level
came into force on 1 April 2009th Unfortunately, the Charter of
Patients’ Rights was adopted even in F.BiH, neither the Serbian
Republic (Initiative and Civil Action, 2009), (Masic , Novo& Toromanović
2009) (Federal Ministry ofHealth, 2010).
Despite all the efforts that were done, there is no universal approach
to health care(HC) in the entire territory of Bosnia and Herzegovina,
as required by the European Social Charter and other international
documents. The estimated inequality in access to HC, both
in geographical and in financial terms, depending on the canton in
which this patient lives. HC benefits are unfortunatelly not enjoyed
equally by all citizens, because the current way of providing protec-

tion concentrated in cities, and access to care is difficult especially
for the rural population. Persons insured in different cantons have
different rights and different access to services ZZ, especially tertiary
HC.Modern hospitals should answer the many demands and
challenges posed by increasingly complex medical conditions and
diseases, and more demanding patients on the one hand and limited
material and financial resources on the othe (OECD, 1991),(Mihajlovic
& Kostic, 2005), (OECD, 2012).
A similar situation is with the health insurance system in F.B&H. I
still have health insurance funds of state institutions, or the entity
and cantonal. The transition from one state to another system, that
is, from a planned economy to a market economy, requires a reform
of the health insurance system in F.B&H.Reform orientation development
of family medicine was introduced as a fundamental objective.
The privatization process has been made some progress, but
not yet defined key trends. There is no country in the world today
that meets all the health needs of its population, since the demandis
greater than the available funds to meet all your health needs.
Therefore, in order to make the optimal choice, we need to define
priorities. This is an exceptional and difficult task, and therefore
the planning of health services with its wide range of activities belonging
scientific disciplines (Stosic, 2007), (Orszag-CBO, 2009),
(Prester, 2009).
The problems of even larger, and in most instances, non-transparent
cost-inflation consequences can be seen even in the most developed
industrialized countries in the world. The usual culprit is the
liberalization of for –profit insurance market, which, through its
lobbying power can strongly influence the power of the insurance
factor (which can even exceed the power of patients and providers), as seen in Figures 1. and 2. 

Table No.1 represents the ultimate criteria of performance in the
health sector. The picture shows that financing, payment, organization,
regulation, and social marketing are determined intermediate
performance criteria in the health sector, and they affect the
efficiency, effectiveness and quality of ZZ. Intermediate criteria
affect the ultimate criteria, namely protection against financial
risks, health status of patients and their satisfaction with services
(Gavrankapetanović, 2010).
Figure 2. International Comparison of Spending on Health 1980 to 2009
Source: (Commonwealth Fund National Scorecard on U.S. Health System Performances, 2011)
The ultimate performance criteria in the health sector
1. Protection/Insurance from Financial Risks/Loss/Bankruptcy
2. Health Status of the Population and
3. Patients’ Satisfaction
are influenced by
Intermediary performance criteria in the health sector:
1. Effectiveness
2. Efficiency and
3. Quality
1. Financing, 2. Payment, 3. Organization, 4. Legislation-Regulation &5. Social
Marketing
Table 1: The ultimate performance criteria in Health Care Sector

Analyzing human resources in health care of F.B&H compared to
the European population at 100,000, we can conclude the following:
- The total number of doctors in F.B&H is 165, and the European
average is 358,
- The number of general practitioner in F.B&H is 22, and the European
average is 102,
- The number of dentists in F.B&H is 20, and the European average
is 166,
- The number of pharmacists is 11, and the European average is 82
and
- The number of nurses / technicians in F.B&H is 498, and the European
average is 818
(Federal Ministry of Health, 2012)
These data suggest that in F.B&H human resources in the health
sector are significantly lower than is the case with the European
average. The same applies to the capacity of hospitals. At 100,000
residents of hospitals in F.BiH is 1, and the European average is
3.4. The number of hospital beds in F.B&H is 350, and the European
average is 611. Number of annual reception for 100 residents
in F.B&H is 9.6, while the European average is 18. Residents
of F.B&H in average lay in hospital 9.2 days, while the European
average is 10 days. Every fifth inhabitant of F.B&H visits the
dentist,which represents an unsatisfactory statistic. The number of
dental visits was 3.6, while the EU average of 7.8 visits per capita
per year. On average, as employment status ZZ most used pensioners.
The largest number of medical doctors present in the Canton
of Sarajevo (87 per 100,000) and lowest in the Una-Sana Canton
(35 per 100,000). Despite all efforts to develop PHC is disrupted,
the proportionality general practitioner and specialist doctors at the
expense of general practitioner. In order to reach European levels
of quality in health care, F.BiH must necessarily strengthen their
human and other medical facilities. This is not a short-term or easy
task. In its implementation must include all the relevant stakeholders:
Ministries, federal and cantonal authorities, health organizations
and university institutions that educate medical staff (Masic,
Novo& Toromanović, 2009).
The World Health Organization (WHO) defines primary care as
“part of health care that is affordable comprehensive individual or 

family in the community, in a manner that is acceptable to them,
through full participation and the cost that the community and
country can not bear.” PHC will be more effective if it is able to
reduce the number of patients who are unnecessarily sent to secondary
and tertiary levels. To meet the basic health care needs of
the population, a wide range of health services must be made at the
local level. If the family is actively involved in the protection of
their own health and works closely with the health system, it will
be economically highly cost effective manner, with the least effort,
health care comprise the largest segment of the population. Health
services, family oriented, also provide an opportunity to share responsibility
for the health of the public, using the promotion of
a healthy lifestyle. Reform Programme OZZ F.BiH in the future
should be practiced conception, according to which the family doctor
served as the starting point for the overall coordination of care.
He played the role of “gatekeepers” whose goal is materially more
efficient, coordinated and effective protection (Roberts, Hsiao, Reich
& Berman, 1999). (Masic, New & Toromanović, 2009).
The patient should, when this first contact, got advice from your
family doctor as the best and most effective can provide adequate
protection. With this model, the implementation of PHC will be
able to efficiently solve at least 80% of claims for medical services
at this level. The reform program meets with significant problems.
For complete coverage of all 2.4 million inhabitants in the territory
F.B&H is necessary to equip the 1200 family medicine teams. Currently,
this number is slightly less than 50%.
(Masic, Novo& Toromanović, 2009).
In terms of supply of medical equipment, medical institutions have
so far been recorded and the following failures:
- Standardization and unification of medical equipment is not performed;
- Equipping of health facilities has flowed spontaneously, because
they had not been consulted health institutions, nor are respected
norms;
- Servicing and maintenance of equipment was not provided and
- Decreased amortization value of medical equipment, where her
life grew shorter.
The new law on health care given the opportunity to organize private
practice. Doctors are allowed to be contracted his services to
the funds of health care through a “capitation system.” By law, 

every insured person is entitled to a basic package of health services,
regardless of the resources available in the county-Canton
(Masic, Toromanović & Smajkić, 2009).
Conclusion:
Rationalization and continuing education, lower cost, competition,
new technologies, better diagnosys and continuous improvement
through the implementation of effective and efficient innovation
policies give the PHC sector of F.B&H a reasons for hope. Reform
of primary health care should be based on a solid financial basis
with the aim to protect the population from the high costs, ensure
redistribution and guaranteeing access to those who need basic services
ZZ. For this reform, cantonal ministries and fund health care
reform law must prepare and regulation in the style of movement
of financial resources, including methods of payment services and
payment of staff and institutions.Despite all the efforts that were
undertaken, there is no universal approach to HC in the entire territory
of Bosnia and Herzegovina, as required by the European Social
Charter and other international documents. The estimated inequality
in access to HC, both in geographical and in financial terms,
depending on the canton in which this patient lives. HC benefits
are not enjoyed equally by all citizens, because the current way of
providing protection is concentrated in cities, and access to care is
difficult, especially for the rural population. Persons insured in different
cantons have different rights and different access to HC services,
especially tertiary HC.Modern hospitals should answer the
many demands and challenges posed by increasingly complex medical
conditions and diseases, and more demanding patients on the
one hand and limited material and financial resources on the oth er.
Reform orientation development of family medicine was introduced
as a fundamental objective. The privatization process has
been made some progress, but not yet defined key trends. There is
no country in the world today that meets all the health needs of its
population, since the demandis greater than the available funds to
meet all your health needs. Therefore, in order to make the optimal
choice, we need to define priorities. This is an exceptional and difficult
task, and therefore the planning of health services with its wide
range of activities belonging to scientific disciplines.Despite all efforts
to develop PHC, undermined the equivalence general practitioner
and specialist doctors at the expense of general practitioner.
For optimal number of family medicine teams should be ensured 

and associated equipment and space. It is estimated that over 90%
of medical equipment is deemed obsolete
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http://www.zjztk.ba/ . Ministry of Public Health Tuzla Canton.
http://www.javnozdravstvo. 

Ministry of Public HealthZenica-Doboj Canton.
http://www.who.org