Twenty-five years on: revisiting Bosnia and Herzegovina after implementation of a family medicine development program

BACKGROUND: The wars that ravaged the former Socialist Federal Republic of Yugoslavia in the 1990’s resulted in the near destruction of the healthcare system, including education of medical students and the training of specialist physicians. In the latter stages of the war, inspired by Family Medicine programs in countries such as Canada, plans to rebuild a new system founded on a strong primary care model emerged. Over the next fifteen years, the Queen’s University Family Medicine Development Program in Bosnia and Herzegovina played an instrumental role in rebuilding the primary care system through educational initiatives at the undergraduate, residency, Masters, PhD, and continuing professional development levels. Changes were supported by new laws and regulations to insure sustainability. This study revisited Bosnia and Herzegovina (B-H) 8-years after the end of the program to explore the impact of initiatives through understanding the perspectives and experiences of individuals at all levels of the primary care system from students, deans of medical schools, Family Medicine residents, practicing physicians, Health Center Directors and Association Leaders. METHODS: Qualitative exploratory design using purposeful sampling. Semi-structured interviews and focus groups with key informants were conducted in English or with an interpreter as needed and audiotaped. Transcripts and field notes were analyzed using an interpretative phenomenological approach to identify major themes and subthemes. RESULTS: Overall, 118 participants were interviewed. Three major themes and 9 subthemes were identified including (1) The Development of Family Medicine Education, (subthemes: establishment of departments of family medicine, undergraduate medical curriculum change), (2) Family Medicine as a Discipline (Family Medicine specialization, academic development, and Family Medicine Associations), and (3) Health Care System Issues (continuity of care, comprehensiveness of care, practice organization and health human resources). CONCLUSIONS: Despite the impact of years of war and the challenges of a complex and unstable postwar environment, initiatives introduced by the Queen’s Program succeeded in establishing sustainable changes, allowing Family Medicine in B-H to continue to adapt without abandoning its strong foundations. Despite the success of the program, the undervaluing of Primary Care from a human resource and health finance perspective presents ongoing threats to the system.