Kosovo: prehľad zdravotného systému

nedeľa, 03. november 2013, 12:00 a

Na akom princípe funguje zdravotníctvo v Kosove, ako je financované a aké zdroje využíva? Odpovede na tieto a mnoho iných otázok súvisiacich s touto chudobnou európskou krajinou prináša tento stručný prehľad zdravotného systému v Kosove. Zhrnutie najpodstatnejších ukazovateľov je v slovenskom jazyku. Podrobnejší popis kosovského zdravotníctva spracovala naša stážistka Arta Uka z Kosova v anglickom jazyku.


Zhrnutie

Kosovo - zástavaKosovo patrí medzi najchudobnejšie krajiny v Európe. Táto krajina má najväčšiu mieru chudoby a nezamestnanosti, ako aj najnižšie HDP na obyvateľa v Európe. HDP Kosova v roku 2012 bolo 4 916,4 mil. eur. Kosovo má najmladšiu populáciu v Európe s 50  % populácie pod 25 rokov. Množstvo Kosovčanov žije v chudobe, pričom až 34,5  % populuácie žije pod absolútnou hranicou chudoby a 12,1  % žije v extrémnej chudobe.

Zdravotný systém v Kosove, podobne ako inde vo východnej Európe, bol hlavne založený na Semaškovom modeli zdravotnej starostlivosti. Centrálna vláda tu funguje ako nákupca ako aj poskytovateľ zdravotných služieb. Samosprávne jednotky cez svoje zdravotné oddelenia sú zodpovedné za verejnú zdravotnú starostlivosť. Kosovské Ministerstvo zdravotníctva je zodpovedné za rozvoj zdravotnej politiky, strategické plánovanie, udeľovanie licencií, zaisťovanie kvality a tvorbu rozpočtu. Jeho primárna rola je monitorovať, dozerať a podporovať nemocnice aj primárnu zdravotnú starostlivosť.

Hlavným zdrojom príjmov zdravotného systému v Kosove sú dane z rozpočtu Kosova, rozpočtov samosprávnych jednotiek a priamych platieb. V roku 2006 boli celkové výdavky na zdravotníctvo vo výške 150,2 milióna. Vyjadrené ako podiel na HDP to predstavovalo 6,6  %, pričom na takejto úrovni sa pohybujú aj v súčasnosti. Príjmy z priamych platieb predstavujú 48  % celkových zdravotných výdavkov (3,2  % HDP).

Zdravotnícky personál v centrách primárnej starostlivosti poskytujú počiatočnú diagnostiku a liečebnú starostlivosť. Primárna starostlivosť zároveň slúži ako „gatekeeping“ pre sekundárnu zdravotnú starostlivosť.

Sekundárna zdravotná starostlivosť je poskytovaná šiestimi nemocnicami v Kosove, ktoré sú lokalizované v šiestich najdôležitejších mestách. Celkovo sa v Kosove nachádza 5 269 nemocničných lôžok. Všeobecne, podiel nemocničných lôžok v Kosove je 270 na 100 000 obyvateľov. Na 1 000 obyvateľov pripadá v Kosove 1,2 lekára, 3,5 zdravotných sestier a 0,2 zubára.

Očakávaná dĺžka života pri narodení je v Kosove v priemere 69 rokov. Celková miera pôrodnosti v Kosove je 2,5. To znamená, že kosovská populácia sa stále reprodukuje a mierne narastá. Napriek tomuto, z dlhodobého hľadiska bude aj kosovská populácia čeliť demografickým zmenám, ktorým väčšina európskych krajín čelí už dnes.

V indexe vnímania korupcie (CPI) sa Kosovo umiestnilo na 105. mieste zo 176, čo je o 8,1  % horšie ako je priemer celkovej korupcie za všetky krajiny. Za najviac skorumpované sa v Kosove považuje súdnictvo. Na konci roku 2011 bol počet nedokončených prípadov na úrovni 214 404, s najväčším počtom neuzavretých prípadov na súdoch na samosprávnej úrovni. Korupcia v zdravotníctve predstavuje takisto veľký problém. V Kosove v súčasnosti neexistujú politiky ani na centrálnej úrovni ani na úrovni manažmentu nemocníc, ktoré by sa týmto problémom zaoberali. 

 


Abstract

Kosovo belongs to the poorest countries in Europe, with highest poverty rates, unemployment rate, and lowest GDP per capita in Europe. Kosovo’s GDP in 2012 was 4,916.4 million Euros. It has the youngest population in Europe with 50 % of population being under the age of 25. Many Kosovo residents live in poverty; 34.5 % of the population of Kosovo lives below absolute poverty line and 12.1 % lives in extreme poverty. The health system in Kosovo was mainly based on the Semashko model of healthcare delivery. The central government functions as the purchaser as well as the provider of health care services. Main revenue sources of the health care system in Kosovo are taxes from the budget of Kosovo, taxes from municipal budgets and direct payments. In 2009 the total health expenditure in Kosovo was € 158.22 million. A large proportion of total health care spending in Kosovo, however, occurs outside of the budget, in the form of out-of-pocket payments by private individuals. On the Corruption Perception Index, Kosovo ranks 105 out of 176. Corruption in health care presents a big problem for the well functioning of health system. In Kosovo, there are still no policies that address this issue neither by the government nor by hospital management itself.

 


Introduction

Total land area: 10,908 km²
Resident population: 1,815,606
Total number of households: 297,090
% of people living in rural areas: 61 %
Average size of household: 5.85 persons
Population density (people per km2): 177.4
Real GDP growth (2012): 2.5 %
GDP per capita (PPP, international $, 2012): 7,400

 (Source: Kosovo Agency of Statistics – census 2011 and CIA Factbook)

 

Kosovo is located in the middle of Balkans in the southeastern Europe. Since June 1999 it has been administered by the United Nations (UNMIK)[1]. Prior to this, it was an autonomous province administered by the Federal Republic of Yugoslavia (FRY). On 17th of February 2008, Kosovo declared its independence from Serbia. Up till now, more than 100 countries recognized its independence. The capital of Kosovo is Prishtina. Official languages are Albanian and Serbian. According to the population census conducted in 2011 by Kosovo Agency of Statistics, there are 1.8 million residents, out of which are 92 % Albanian, 8 % Serbs, Bosnians, Turks, Roma, Gorani, Egyptian and Ashkali. It is estimated that 53 % of Kosovo’s land is agricultural, 41 % of Kosovo’s land is forest land, 1 % of the land of Kosovo is water surface and 5 % is other surface (traffic, urban, and other land).

Economy

During the time Kosovo was part of the Former Yugoslavia, it was among the poorest regions of the Federal Republic. The situation has continued to be quite difficult nowadays as well. It is among the poorest countries in Europe, with the highest poverty rates and unemployment rate and lowest GDP per capita in Europe. According to the National Statistical Office, Kosovo’s GDP grew from 2.911,8 million Euros in year 2004 to 3.940,3 million Euros in year 2008, while in 2012 it was reported to be 4,916.4 million Euro.

The euro is the official currency of Kosovo. Right after the 1999 conflict, alongside the Yugoslav dinar, other currencies – especially the deutschmark – were widely used in Kosovo. In September 1999, UNMIK generated a regulation accepting the use of other currencies, namely the deutschmark which was the most widely used currency, the US Dollar and the Swiss Franc which were also used. Kosovo substituted the deutschmark with euro on 1st of January 2002. The German Mark remained legal tender in Kosovo until 9 March 2002. This change was realized in cooperation with the European Central Bank, and a number of national banks in the Eurozone.

Kosovo is often classified as a lower-middle income country with a GDP per capita (in current prices) of 2.721 EUR in 2012. It has the youngest population in Europe with 50 % of population being under 25 years of age. Kosovo is facing multiple economic challenges. The youth unemployment rate of 55.3  % presents a difficult challenge considering that Kosovo has the youngest population in Europe (youth aged 15-24 comprise 31 % of the working age population). Lack of employment opportunities generates a situation in which many Kosovar residents live in poverty, defined as less than € 1.42/day and in extreme poverty, defined as € 0.92/day. The 2011 census reports that 34.5 % of the population of Kosovo lives below poverty line and 12.1 % lives in extreme poverty. UNICEF reports that 48.6 % of Kosovar children live in poverty, whereas 18.9 % of all children live in extreme poverty.

Health care

Health status

Although lots of progress has been made in recent years, the health information system in Kosovo is not yet been fully developed. So far, the quality of data in Kosovo sometimes should be treated carefully. For this article, mainly data from Kosovar official institutions has been used (Kosovo Agency of Statistics, Ministry of Health).

The following table shows the life expectancy at birth for both male and female. On average, a child born in Kosovo is expected to live up to 69 years of age.

Table 1. Life expectance at birth

Life expectancy at birth, total  2011 est. 69.0 years
   Life expectancy at birth, male population 2011 est. 67.0 years
   Life expectancy at birth, female population 2011 est. 71.0 years

Source: Worldstat info, Kosovo Agency of Statistics

The table below shows some statistics on population growth rate, birth rates, fertility and mortality rates. The increase of Kosovo’s population in 2011 was estimated at 0.6 % which is lower than the projected number in 2004 (it was estimated at 1.8 %), but higher than other countries in the region, which mainly have negative values (see: Pocketbook on Candidate Countries and Western Balkans, European Commission).

Table 2. Kosovo’s population statistics

Population growth rate 

2011 est.

0.6

 % per year

Birth rate 

2011 est.

9.70

births/1,000 population

  Birth rate, boys

2011 est.

5.05

births/1000 population

  Birth rate, girls

2011 est.

4.65

births/1000 population

Death rate 

2011 est.

3.2

deaths/1,000 population

Net migration rate 

2011 est.

-0.3

migrants/1000 population

Total fertility rate 

2011 est.

2.50

children born/woman

Infant mortality rate 

2011 est.

33.52

deaths/1000 live births

  Infant mortality rate, boys

2011 est.

36.56

deaths/1000 live births

  Infant mortality rate, girls

2011 est.

30.25

deaths/1000 live births

Source: Worldstat info, Kosovo Agency of Statistics

Organization and provision of services

The health system in Kosovo, as elsewhere in Eastern Europe, was mainly based on the Semashko’s model of healthcare delivery. The central government functioned as the purchaser as well as the provider of health care services, which is still the present model in Kosovo, with a few minor changes (municipalities through their health departments are responsible for public health care). Public health was made a municipal responsibility, and municipal public-health inspectors were hired. Responsibility for immunisation was transferred to primary care facilities. The inheritance of a typical socialist health system and infrastructure, which was largely mistreated in the 1990s and then disrupted and damaged by the 1999 conflict, has notably affected health services in Kosovo.

The Kosovo Ministry of Health (MoH) was established in February 2002; together with its National Institute of Public Health, it has the responsibility for policy development, strategic planning, licensing, quality assurance, and budgeting. Its primary role is to monitor, supervise and support both the hospitals and primary health care. The MoH includes the following organisations:

  • Kosovo Drug Regulatory Agency (KDRA)
  • Kosovo Food Safety Agency
  • Prishtina University Hospital
  • National Institute of Public Health
  • Kosovo Health Care Commissioning Agency
  • District health authorities that aim to improve coordination at the district level between secondary and primary health care.

Health care is provided by health care workers in Health Care Institutions. Health care activity is subject to professional and legal supervision provided by the Ministry of Health. The Act on Health stipulates that financial support insures combined modality between Kosovo budget, municipal budgets, contributions of the citizens and employers to the Health Insurance Fund and other insurance agencies based on the principle of reciprocity and solidarity, as well as direct payments of the citizens during utilization of health care services. However, due to financial instability, this Health Insurance Fund is still under the process of establishment, and by 2015 it is expected to be operational.

Emergency care – The activity and the financing of the Medical Emergency Service in Kosovo are regulated by Law No. 02/L-50. Financing of emergency care is defined by the Kosovo Law on Health under a separate budgetary line, within the budget of the respective institutions. Both inpatient and outpatient (through ambulance services) forms of emergency services are implemented in Kosovo. Medical Emergency Service is organized and implemented on primary and secondary levels, as well as at referral centers.

Primary care – Medical staff in primary care centres provides initial diagnoses and curative care, with the objective of treating 80 to 90  % of present problems and at the same time serving as gatekeepers to secondary healthcare. The location of health clinics is determined on the basis of population: in most cases, facilities have catchment populations of approximately 10,000 individuals. Larger communities have more extensive primary care facilities known as ‘family medicine centers,’ while smaller communities have small clinics. Family medicine centers are responsible for diagnosis and curative care, including minor surgery and drug management; emergency care and stabilization of emergency patients; maternal and child healthcare; and reproductive health services, including antenatal and post-natal care, as well as family planning and treatment of sexually transmitted diseases.

Secondary care – Secondary care is a system whereby patients receive specialist care and hospitalization upon referral only, except in emergencies. Specialists who are not working in family medicine are hospital-based. Outpatient specialty care is provided at hospitals and selected family medicine centers on referral. Six hospitals at six major cities provide secondary care, and tertiary care is provided at Prishtina University Hospital only.

Financing

Main revenue sources of the health care system in Kosovo are taxes from the budget of Kosovo, taxes from municipal budgets and direct payments. The budget of the Ministry of Health is subject to budget division that takes place in the government every year; therefore the ministry of Health has to compete with other ministries for its share of the budget. The level of government spending on health is the lowest in the region. Estimations of total health expenditures in Kosovo in 2009 were 158.22 mil EUR, out of which 62.01 are private out-of pocket expenditures. Expresed as a share of GDP it was 6.6  %. Out-of-pocket payments are believed to account for nearly forty percent of total health spending in 2008. Much of this amount is most likely spent on informal payments to health staff working in the public sector and for the purchase of drugs and supplies. Some is also spent on care in private facilities and abroad.

The biggest amount of public revenues is used to finance health expenditures at the central level, while only 24 % of revenues coming from the budget is used to finance municipality levels. The table below shows trends in health expenditure in Kosovo during 2005-2009.

Table 3. Trends in Health Expenditures in Kosovo

 

2005

2006

2007

2008

2009

Total health expenditures (€, mil.)

107.80

115.05

121.21

136.15

158.22

          Public spending

71.40

71.80

67.43

78.39

89.28

          Private Out-of-Pocket

30.80

42.81

52.81

56.64

62.01

Public spending on health

 

 

 

 

 

          In  % of GDP

2.9

2.3

2.0

2.0

2.3

          In  % of total GE    

9.7

10.0

10.2

8.3

7.6

Sources: Treasury data; Kosovo household budget survey; Ministry of Health; GE = government expenditures

In Kosovo, state plays the role of the purchaser and the provider at the same time. Besides state budget and direct payments, a small amount of revenues in Kosovo comes from international aid. Organizations such as WHO, the World Bank, ILO etc, are actively engaged in enhancing human and capital capacities in Kosovo. Another revenue source comes from the private voluntary health insurance, which are agreedon voluntary bases, and are insignificant in the amount.

Out-of-pocket payments in Kosovo are applied for many services such as medical check-ups, ECHO, diagnostic tests, many pharmaceutical products etc. The out-of-pocket payments, particularly the informal payments, have a negative impact on low-income household’s well-being. The highest impact is seen at the lowest quintiles of the population, by pushing people deeper into poverty and those vulnerable who are above or just at the poverty line, into poverty.

High out-of-pocket payments raise many concerns about equality and equity of access to health care services, particularly for the vulnerable groups in a country like Kosovo, where poverty is widespread. Out-of-pocket payments in Kosovo are higher in urban than in rural areas. Households spend approximately the same amount on health care across the income distribution; however the poor are the most harshly hit in terms of share of the overall consumption. Some studies show that expenses for health care at the lowest quintile represent 13 % of total consumption, in comparison to only 4 % for the highest income quintile. An estimation of the World Bank reveals that the impact of health spending increases the poverty rate by 3 and 4 percentage points for total and hospital expenses respectively. The highest share of out-of-pocket payments in Kosovo goes to pharmaceutical products and private sector health care. Drugs are often overprescribed by medical staff, particularly those drugs not included in the list of drugs that are provided free of charges. It happens very often that essential drugs are not available; hence people are obliged to buy them in private pharmacies.

Resources

Secondary health care is delivered by six hospitals in Kosovo located in the 6 main cities. Most have departments of Internal Medicine, General Surgery, Orthopaedic Surgery, Nephrology, Obstetrics and Gynaecology, Infectious Diseases, Dermatology, Neuropsychiatry/logy and Paediatric. Prishtina University Hospital (PUH) also delivers tertiary health care and with a few exceptions (i.e., Organs Transplants and some Heart Surgery), all specialties are present. Regional hospitals (all excluding PUH) have in between 500 to 650 beds. PUH has around 2,500 beds. In total, there are 5,269 hospital beds in Kosovo. Some Health Houses, PHC institutions, throughout Kosovo have Maternity Services accounting 173 maternity beds. In general, the rate of hospital beds is 270 per 100,000 inhabitants and the rate of maternity beds in PHC is 8.8 beds per 100,000 inhabitants.

The table below shows the human resources in the Kosovo health sector by the category and number in public and private sector.

Table 4. Human Resources in Public Health Sector 2013

Human Resources Category

Number in Public Sector

Number per 1,000 inhabitants in Public Sector

Number in Private Sector

Number per 1,000 inhabitants total

Doctors

2,003
(19.0  %)

1.15

1,806

1.2

Nurses

6,043
(57.2 %)

3.48

 1,666 

3.5

Non-medical co-workers

1,996
(18.9  %)

0.15

/

0.8

Dentists

321
(3.0  %)

0.19

/

0.2

  Source: Kosovo Ministry of Health, 2013

Corruption

According to the Transparency International Global Corruption Barometer 2007, 67 % of respondents in Kosovo paid bribery to obtain services (not just health services). On the Corruption Perception Index (CPI), Kosovo ranks 105 out of 176 countries (least corrupt is 1 out of 176). The CPI score in 2012 was 3,4 from 10 (where 0 means that a country is perceived as highly corrupt and 10 means it is perceived as very clean). The judiciary is perceived to be the most corrupt institution in Kosovo, according to Transparency International’s Global Corruption Barometer 2010/2011.

According to Freedom House 2011, the judiciary in Kosovo had a large backlog of cases. At the end of 2011 the figure stood at 214,404 cases uncompleted, with the largest backlog in the municipal courts. However, Freedom House 2012 reports that the judiciary has made considerable improvements since, such as implementing reform measures, increasing judges’ and prosecutors’ wages to promote independence, as well as decreasing backlogged cases by 26 %. Despite these commendable achievements, the judicial system is nevertheless under political influence and intimidation, and enforcement of legal verdicts is still weak, according to the report. 

Corruption in health care – Corruption in health care presents a big problem for the well functioning of health system due to many reasons. First, it may have catastrophic effects on low income families by pushing them further into poverty. Second, these payments are made directly to health care workers and therefore do not contribute to improving health care infrastructure, increasing medical supplies or other necessities. Third, these payments are not recorded; hence, taxes are not collected, which could be used to improve public services such as the health system itself. Fourth, informal payments seriously harm equity in health care delivery. Patients that are not able to pay informally are usually treated with less attention, or at least, not as good as those who are able to pay. The socio-cultural theories explain informal payments by traditions or the habit of tipping while the legal-ethical theories explain it by breach of professional moral principles and lack of a proper system of legislation. Economic approaches give emphasis on common insufficiency of financial resources in a healthcare system as the main grounds of the problem. Health sector is particularly vulnerable to corruption, as people buy care even if it costs them their long-term livelihood. In Kosovo, there are still no policies that address this issue neither by the government nor by hospital management itself, therefore a lot remains to be done in order to improve the current situation.


References:

  1. Arben Cami, Kosova Health System, Kosovo Ministry of Health
  2. Business Anti-Corruption Portal, retrieved from http://www.business-anti-corruption.com/country-profiles/europe-central-asia/kosovo/corruption-levels/judicial-system.aspx on 15 October 2013
  3. IOM Country Fact Sheet Kosovo, June 2011, retrieved from http://www.bamf.de/SharedDocs/MILo-DB/DE/Rueckkehrfoerderung/Laenderinformationen/Informationsblaetter/cfs-kosovo-download-englisch.pdf?__blob=publicationFile on 15 October 2013
  4. Kosovo Agency of Statistics http://esk.rks-gov.net/eng/ 15 October 2013
  5. Kosovo Ministry of Health. Kosovo Health Strategy. Pristina: Kosovo Ministry of Health; 2005.
  6. Law on Public Health No 02/L-78, Kosovo Assembly
  7. Law on the Medical Emergency Service in Kosovo No 02/L-50, Kosovo Assembly
  8. Pocketbook on Candidate Countries and Western Balkans, European Commission, EUROSTAT 2006, retrieved from http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-70-05-899/EN/KS-70-05-899-EN.PDF on 15 October 2013
  9. UNMIK. Kosovo Health Law No 2004/4. Pristina, United Nations Interim Administrative Mission in Kosovo; 2004
  10. UNICEF Child Poverty in Kosovo – Policy Options Paper & Synthesis Report May 2010, retrieved from http://www.unicef.org/kosovo/Child_Poverty_ENG(2).pdf on 15 October 2013
  11. Transparency International, retrieved from http://www.transparency.org/country#KOS on 15 October 2013
  12. Valerie Percival and Egbert Sondorp. Confl Health.  2010 April 16 MCID: PMC2864221
  13. WHO. Interim Health Policy Guidelines for Kosovo and Six Month Action Plan. 1999.
  14. WHO. Kosovo Public Expenditure Review. Report No. 53709-XK. June 2010.
  15. WHO. Hospital Statistical Indicators August – December 1999. March 2000. Kosovo

[1] The United Nations Interim Administration Mission in Kosovo ( the officially mandated mission of the United Nations in Kosovo)

 

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