The European Journal of Public Health Advance Access originally published online on January 9, 2007
The European Journal of Public Health 2007 17(5):430-436; doi:10.1093/eurpub/ckl270
Around the World |
Ethnic segregation in Kosovo's post-war health care system
J.D. Bloom1, I. Hoxha1, D. Sambunjak2 and E. Sondorp1
1 Conflict and Health Programme, Health Policy Unit, London School of Hygiene and Tropical Medicine, UK
2 Croatian Medical Journal, Zagreb University School of Medicine, Croatia
Correspondence: Dario Sambunjak, MD, Croatian Medical Journal, Zagreb University School of Medicine, Salata 3, 10000 Zagreb, Croatia, tel.: +385 1 4590 254, fax: +385 1 4590 222, e-mail: dario.sambunjak{at}mef.hr
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Abstract |
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Background: Seven years after the end of war in Kosovo, Final Status Negotiations have begun to determine the long-term political future of the province. This article provides an overview of the present situation regarding ethnic groups and their relations in Kosovo's health care system that might be helpful in preparing for the array of potential ramifications and repercussions that could arise at the conclusion of the negotiations. Methods: A review of the literature (including grey) was performed, and 16 interviews and two focus groups with key informants were conducted in Kosovo during October and November 2004. In addition, six informal discussions were held in-person or by telephone in London. Information collected in 2004 was re-confirmed and partially updated in October and November 2005, when three additional interviews were conducted in Kosovo. Results: Ongoing ethnic tensions in Kosovo, mainly between the Albanian and Serb populations, perpetuate a rigidly segregated health care system. Some other minority communities, such as the Roma, Ashkali and Egyptians, are afflicted by the double burden of getting caught up in the middle of these ethnic disputes and at the same time suffering from poverty and discrimination. Conclusion: While efforts have been put forward to promote peace-building within Kosovo's post-war health sector, very little progress has been achieved in fostering ethnic integration, reconciliation, cooperation or even co-existence. This failure reflects Kosovo's broader unresolved inter-ethnic problems. Final Status Negotiations are one of the last opportunities for the international community to address the problems of ethnic segregation in the province.
Keywords: conflict, delivery of health care, ethnic groups, Kosovo
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Introduction |
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War, ethnic conflict and political violence have a detrimental impact on health and health care systems.1 The restoration and development of health care systems in post-conflict situations are difficult tasks,2 and are not always successfully carried out.3
In Kosovo, officially still a province of Serbia and the scene of the 1999 armed conflict, there have been continuous efforts to reorient the health sector and provide equitable health care for all ethnic groups.3,4 However, the results of such endeavour are not certain.
Since June 1999, Kosovo has been under the temporary legal administration of the United Nations (UN). In July 2006, Final Status Negotiations were opened at the highest level to determine Kosovo's long-term political future. Although it is improbable that health issues will represent a major factor in these political talks, an overview of the present situation regarding ethnic groups and their relations in Kosovo's health care system might be helpful in preparing for the array of potential ramifications and repercussions that could arise at the conclusion of the negotiations.
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Methods |
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In order to provide such an overview, a review of the literature (including grey) was performed, and 16 interviews and two focus groups with key informants were conducted in Kosovo during October and November 2004. A semi-structured interview guide was used in these meetings. In addition, six informal discussions were held in-person or by telephone in London. Information collected in 2004 was re-confirmed and partially updated in October and November 2005, when three additional interviews were conducted in Kosovo.
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Results |
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Historical background
Ethnic relations between Kosovo's Albanian and Serb populations progressively worsened after Slobodan Milo
evi
became president of Serbia in 1989. Miloevi's Government declared a state of emergency in Kosovo and revoked the province's autonomy received under Yugoslavia's 1974 Constitution. As a result of stern measures under Miloevi, thousands of ethnic Albanian public employees were fired or left their jobs in protest during the first 2 years of the 1990s. Within the health sector, the Government dismissed approximately 2400–2500 employees and replaced them with health professionals imported from elsewhere in Yugoslavia as well as from other countries.2,5 While Kosovo's population was approximated as 82% ethnic Albanian and 10% ethnic Serb in 1991,6 after these radical policy shifts and mass layoffs, estimates suggested that ethnic Albanians accounted for < 5% of Kosovo's public health care workforce.7
The Kosovar Albanian community responded to these developments by forming their own parallel institutions and structures. In the health sector, ethnic Albanians opened private medical practices, 96 non-profit health facilities and a professional training network.8
During the late 1990s, the systematic oppression of Albanians by Serbian authorities escalated drastically9, which provoked Albanian factions to take on military resistance.
In 1999, the North Atlantic Treaty Organisation (NATO) came to the aid of the Kosovar Albanians.10 During the conflict, 1.5 million or 90% of Albanian population fled their homes and became internally displaced or refugees.11–13
Serbia succumbed to the NATO bombardment and agreed to both a ceasefire and the withdrawal of Yugoslavian security forces from Kosovo. With UN Security Council Resolution 1244 (1999),14 the UN authorized the formation of the UN Mission in Kosovo (UNMIK) to serve as the province's temporary administrator under a Special Representative of the UN Secretary-General (SRSG). After the war ended, ethnic Albanians poured back into Kosovo and reclaimed most of the official institutions and functions that were formerly controlled by Serbs during the 1990s. After Kosovo's 2001 elections, UNMIK devolved a number of governing responsibilities, including the management of the health sector, to Kosovar authorities within the Provisional Institutions of Self Government's (PISG).15 Ethnic Serbs, however, limited their participation within the PISG's new Ministry of Health (MoH). Rather, they developed parallel institutions, financially and administratively supported by the Serbian Government.
Security, health care and ethnic minorities in post-war Kosovo
The post-war period saw pervasive inter-ethnic and retaliatory violence despite the substantial presence of international military forces and civilian personnel from inter-governmental organizations (IGOs) and non-governmental organizations (NGOs). Serbs and some other minority communities such as Kosovo's Roma, Ashkali and Egyptian (RAE) populations were particularly at risk. While there has been a decrease in inter-ethnic violence in recent years, attacks and hostility, including major incidents, still occur and many minorities remain fearful of such dangers.16 As a consequence, many Serbs and other minorities left Kosovo after the war rather than languishing in a precarious situation. In total, approximately 230 000 Serbs, Roma and other minorities fled their homes, and most have never returned.17
Many ethnic Serb health professionals and patients initially stayed on at Kosovo's hospitals and health houses during the immediate aftermath of the war, while Albanian health workers and patients re-entered these institutions after their decade-long absence. Post-war violence directed towards Serbs at-large had repercussions on the health sector.18–20 As a result of threats, intimidation and incidents of violence, most Serbs felt unsafe remaining at the institutions that became administrated by ethnic Albanians. Some segments of RAE communities had similar experiences.21,22 This includes continued reports of abuse and harassment of RAEs at Albanian administrated health care institutions.23
Ethnic Albanians faced their share of problems in north Mitrovicë/Mitrovica (figure 1). Albanians found it dangerous to return to Mitrovicë/Mitrovica Hospital located in the Serb-dominated northern portion of the city.20,24 Fears of violence and maltreatment, mutual mistrust and a lack of inter-ethnic confidence in the quality of care provided by other communities contributed to the perpetuation of Serb aversions to predominantly Albanian facilities and Albanian aversions to Mitrovicë/Mitrovica Hospital.
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As a result, nearly all Serbs stay away from most of the health care facilities administrated by ethnic Albanians and it is equally rare for Albanians to receive treatment at the institutions supported by the Serbian MoH in Kosovo. Nevertheless, there are a limited number of locations where multi-ethnic health care still does exist and is openly and regularly accessed by both Albanians and Serbs, even though it is sometimes in different areas of the same building or in different shifts from one another. Services are to some extent mixed, for example, in Gjilan/Gnjilane, Kamenicë/Kamenica, Rahovec/Orahovac, the village of Drajkovc/Drajkovce in the Shtërpcë/
trpce Municipality and in parts of the Prizren area (e.g. in Zhupa/
upa and Reqan/Re
ane) (table 1).
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Beyond those locations, there are the rare and sparingly talked about instances where Serbs have gone to hospitals run by PISG's MoH, and Albanians have gone to Mitrovicë/Mitrovica Hospital without incident.25,26 Even during the outbreak of pervasive province-wide inter-ethnic violence in March 2004, there were isolated cases of Serbs receiving treatment at Albanians-run facilities. In an interview conducted for the purposes of this study, an international staff member at the PISG's MoH reported that he in fact knows of atypical cases in Llapje Sellë/Laplje Selo and Ulpiana/Gra
anica where Albanians quietly continue to see the Serb doctors who used to treat their families before the war. There are also a limited number of people from ethnically mixed families who regularly use or even work in the PISG institutions without problems. In addition, increasing numbers of Kosovar Albanian patients are seeking tertiary health care services in hospitals in Serbia.
Serbs
Segregation remained a prevailing feature of Kosovo's post-war health care system like it had been during the 1990s.8 However, the balance of power shifted predominantly in favour of the ethnic Albanian majority, disadvantaging the remaining Serb minority. In the areas where non-displaced Serbs remained, the health care structures in existence from before the war received support from Serbian Government (table 1). This support was provided to sustain pre-existing pre-war level of health care. In essence, many services that the Serbian Government provided in Kosovo were not interrupted by the advent of the UNMIK administration. Most Kosovar Serb health professionals maintained their ties with the Serbian health care system. Many of these individuals and parallel institutions would not recognize UNMIK's authority.
The parallel system was widely perceived as a necessity by Serbs due to fears related to their security, safety and freedom of movement. These factors limited Serb access to secondary or tertiary health care facilities.27 Most Serbs continue to feel as though they effectively cannot access nearly all health care facilities that serve ethnic Albanians. They therefore only use Serb-controlled facilities (in Kosovo and in Serbia) or they turn to health care provided by the NATO-led Kosovo peacekeeping force (KFOR).
In a late 2000 interview with Médecins du Monde, a Serb woman from Pristina said:
I myself have never been in an Albanian hospital. I have never heard of anyone who has tried to go to one. I’d never go myself because I’m afraid. And I think that the others would never go either because they are afraid.28
In the past, several international NGOs provided services directly to Serbs. Nearly all of these NGO initiatives have been phased out as many of these organizations have scaled back their operations or have withdrawn completely from Kosovo.
Reaching Serb providers in areas where none are available locally poses problems for several enclaves. In the past, KFOR troops as well as Kosovo police often supplied ambulance services and escorts for enclave residents so they could reach Serb health care facilities within Kosovo or hospitals within Serbia proper.29,30 As the years passed, the security situation began to improve marginally and by late 2003 the routine provision of medical escorts was phased out. They temporarily restarted following the March 2004 riots but were subsequently phased out again. The PISG's MoH has introduced mobile units to offer medical care to isolated communities, including Serb and other minority enclaves, around Prizren, Gjilan/Gnjilane and Kamenicë/Kamenica and in some other areas.
The restricted freedom of movement, fear and lack of trust among Serbs in Albanian health care providers can have negative health impacts. Some ethnic Serbs and members of other minority communities in isolated locations limit their travel to secondary and tertiary health centres to only times when they deem it absolutely necessary due to fears about travelling within Kosovo. Such delays can worsen prognoses, sometimes until points when treatments are no longer viable.
The Serb Assistant Director of the Preluje Dispensary shared his experience in an interview with Médecins du Monde shortly after the war ended:
All our patients say they want to go to the Mitrovica hospital. I myself had two urgent cases, cases of life or death. The Norwegian KFOR wanted to take them to Pristina. The patients were afraid, they said, ‘for us it's the same thing, to die a natural death or to go to the Pristina hospital.28
Much like their patients, ethnic Serb health professionals also have had anxiety about travelling within Kosovo. This too has had some negative health consequences. For example, Doctors of the World USA documented how these fears detrimentally impacted the provision of health care to ethnic Serb tuberculosis patients.31
Roma, Ashkali and Egyptians (RAE)
Throughout Europe, RAE communities remain significantly marginalized both economically and socially.32 In Kosovo some of these communities face unique difficulties. An international staff member at the PISG's MoH explained:
Given the years of Serb dominance, some Roma communities in particular locations, are thought to have collaborated with the Serbs. This seems understandable perhaps since the Serbs had the authority at the time; it was only reasonable to ally with the authorities.
As a result, thousands of RAEs fled their homes after the war and continue to live as refugees or internally displaced persons.33 Some RAE communities have faced freedom of movement concerns, harassment, violence, discrimination, environmentally dangerous living conditions (including exposure to dangerous levels of lead in the Mitrovicë/Mitrovica area) and poor access to secondary and tertiary health care.34 Like other disadvantaged enclaves, several RAE communities have required KFOR protection and escorts.31
Discrimination at ethnic Albanian administered health care facilities throughout all regions of Kosovo continues to be reported by members of RAE communities.23 As a result of fears of ill-treatment, some RAE communities prefer to receive medical treatment from ethnic Serb providers rather than ethnic Albanian providers. An official from the Organization for Security and Cooperation in Europe (OSCE) gave the example of a Roma community in Gjilan/Gnjilane:
They are about 150 meters from the (ethnic Albanian) hospital which is in the town but they prefer to go 6 km to one of the Serbian enclaves for their health care. So again in the case of emergencies it can be very complicated. They are afraid to go to this hospital and they prefer to go to the Serbian enclave.
The overall assessment by RAE respondents in a 2003 OSCE survey categorised health care services as somewhere between poor and average.23 An ethnic Albanian doctor who works with RAE communities provided a gloomy depiction of the position of large segments of these minorities groups within the Kosovo's health care system:
... they have no where to go because Serbs do not want them and Albanians do not care about them, they don't think about them ...
Bosniaks, Turks, Croats and Goranis
The other main minority communities have integrated more fully into Kosovo's post-war society and within the PISG health care system. Bosniaks, Turks, Croats and to a lesser degree Goranis participate in and do not have problems accessing health care provided by the PISG's MoH.31 However, in a survey conducted by OSCE in 2003, the average assessment by Bosniak, Turk and Croat respondents of health care services was at the lower end of poor to average; Gorani respondents assessed health care services as even lower, on average at the higher end of between very poor and poor.23
Due to a UNMIK-compelled political requirement, the Minister of Health post is set aside for a member of a non-Serb minority community. Consequently, Numan Bali, a Bosniak, became the first Minister of Health in 2002.15 The Prime Minister replaced Bali with Resmije Mumgjiu, an ethnic Turk, in 2003. Sadik Idrizi, an ethnic Gorani, became Minister of Health after the formation of a new Government following Kosovo's 2004 elections.
Ethnic Albanian enclaves in north Mitrovicë/Mitrovica and in other Serb dominant areas
Small Kosovar Albanian communities that remained in predominantly Serb north Mitrovicë/Mitrovica became vulnerable to violence and intimidation.35 Several ethnic Albanian enclaves in other Serb dominant areas of north Kosovo face similar hazards. Like ethnic Serbs in Albanian dominant areas, these isolated ethnic Albanian communities often live with restricted freedom of movement and decreased access to secondary and tertiary health care.27,30 KFOR troops provided many of these ethnic Albanian enclaves’ protection and escorts much like they did for minority communities.30
Mitrovicë/Mitrovica's only hospital is located in the northern portion of the city and is run by Serbs. Following an inter-ethnic incident on 23 September 1999,36 relationships between Albanians and Serbs at the hospital spiralled further downhill, and soon after all ethnic Albanian staff were gone from the hospital and ethnic Albanians stopped using the facility as Serbs effectively denied Albanians access to it.27 The scope of the problem was well described by a MoH official:
We still have a big problem in the Mitrovica region because the regional hospital in Mitrovica is on the other side of the bridge. More than 200 000 inhabitants cannot access (it), so we are improvising by making available part of the primary health setting for the hospital care.
However, there are some reports that a very small number of ethnic Albanians quietly and discretely continued to be treated at Mitrovicë/Mitrovica's hospital on occasion.25
Minorities overall
Kosovo continues to be an insecure place for many of its minority inhabitants. In June 2006, UNHCR concluded that the province is still vulnerable for inter-ethnic violence and civil unrest.37 UNHCR therefore recommended that the return of displaced Kosovar Serbs, Roma and Albanians in Serb dominant areas should only occur on a voluntary basis as these groups remain at risk of persecution. In light of positive security developments for Kosovar Ashkali and Egyptians between 2004 and 2006, the organization withdrew the call for international protection for these minorities, but suggested the return of displaced members of these communities occur in a phased manner.37 UNHCR does not consider Kosovo's other minorities to be at particular risk.
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Kosovo's post-war health sector development process, led by UNMIK, the WHO, the PISG's MoH and other international actors and local counterparts, aimed to improve the poor health status in the province by establishing equal access to health care and more cost-effective delivery of health care services.15 Peace-building objectives such as inclusiveness, non-discrimination, ethics and human/patients’ rights were also stressed.38 However, major social rifts still persist and segregation remains a prominent feature of Kosovo's health care system. Deeply rooted divisions in the health care system proved very difficult to overcome, which is similar to the experience of South Africa after its transition to democracy and the post-war experiences of other countries affected by inter-ethnic conflict.39–41
Serbs, Albanians and the international community all share accountability for the peace-building failures within Kosovo's health care system. In general, Serbs were reluctant to participate in Kosovo's official post-war structures. On the other hand, it can be argued that the local institutions led by ethnic Albanians could have done more to create a safer, more welcoming and inclusive environment. It has also been suggested that these local institutions could have done more to ensure and promote equality and non-discrimination.30,42 UNMIK can be faulted for hastily devolving the health care system's management authority from international to local administrators despite persistent inter-ethnic problems.
Lessons could have been learned from the other Balkan conflicts of the 1990s about the complexities of attempting to reconcile ethnic divisions in post-war health care systems. The reintegration processes in Croatia's Eastern Slavonia region since 1995 have demonstrated that even a 2-year mandate of an international authority is not enough to achieve the complete transition to an ethnically integrated health care system.40 Despite intensive efforts by the WHO to develop inter-ethnic cooperation in Bosnia-Herzegovina after the end of the 1992–95 war,41 no unified health systems strategy or lasting significant collaboration occurred between the Ministries of Health of the country's two entities, the Federation of Bosnia and Herzegovina (Federacija Bosna i Hercegovina) and the Republika Srpska, as well as the independently administered district of Brcko.43 In the case of Kosovo, UN can still use its authority to mandate certain structural and political changes prior to turning over of power to the local actors entirely.
The international community and local institutions should find better ways to foster positive peace, meaning not merely the absence of direct and structural violence, but also the presence of collaborative and supportive relationships between Kosovo's majority and minority populations.44 The mistrust between the ethnic groups is a major problem with broad societal consequences, including the existing rift in the health care system. In view of the weighty history of interethnic relationships in Kosovo, there might be a need for establishing a body similar to the Truth and Reconciliation Commission in South Africa, with the task of investigating and exposing the violations of human rights that took place in Kosovo's health care system in the last several decades.45 First steps towards dealing with the past in ex-Yugoslavia have already been made,46 and such efforts should be strongly supported.
Economic revitalization must be an integral part of the peace efforts, since economic hardships and disparities are themselves great destabilizers not only in the province, but also in the whole region. In an environment of economic uncertainty and widespread unemployment, public sector jobs such as those within the health care system, are highly coveted and easily become a source of friction.40
Many aspects of joint life of ethnic groups in Kosovo, including health care, need to be resolved at the political level. PISG should have a clear plan for forging an inclusive and multi-ethnic state identity for Kosovo, as a tool to engage minority communities.47 Finally, political pressures from the international community may be needed in order to overcome ethnic divisions and some of its consequences.
In conclusion, Kosovo's divided health sector exemplifies the overall context of segregation and failures of peace-building in the province. Despite poor progress in inter-ethnic relations, Kosovo's Final Status Negotiations were opened in July 2006. While these talks are meant to lay the groundwork for a final resolution to Kosovo's conflict, the talks themselves and their outcome could become a major source of further inter-ethnic tension.48 At the same time, the Final Status Negotiations revive opportunities for dialogue and concessions by representatives of Kosovo's various ethnic blocs. International pressure should be brought to bear and all efforts should be made to unify all ethnically divided aspects of Kosovo's government and social services, such as its health care system, prior to the conclusion of these talks. If left unresolved, the international community and the local parties to the talks will miss out on one of the last remaining windows of opportunity to rectify the de facto ethnic segregation that is a major underlying source of conflict and instability within the region.
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For personal reasons, a Kosovar Serb colleague of ours who made a significant contribution to our research and to this article, asked to remain anonymous. Had it not been for this request, this individual would have been included as a co-author of this article. We would like to express our appreciation to all of the interviewees and informants who also contributed to this project and to the reviewers who provided us with feedback.
This study is a sub-component of a larger body of research conducted by the Conflict and Health Programme at the London School of Hygiene and Tropical Medicine and the Centre for Health and International Relations at the University of Wales, Aberystwyth under the overarching title of ‘Global Health, Security and Foreign Policy’. That project was made possible through grants from the New Security Challenges Programme of the UK's Economic and Social Research Council and the Nuffield Trust's Global Health Programme.
Dr Sambunjak was supported in part by a grant from the Croatian Ministry of Science, Education and Sports (No. 0108182).
Key points
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