Kosovo Health Talks 25

NEWS UPDATE
HEALTH AND SOCIAL WELFARE

Co-payment instruction published

The people of Kosovo began paying for the use of health services on Monday, with fees ranging from two DM for a first visit to an ambulanta or health house to 30 DM for self-referral to Pristina/Prishtinë University hospital. The fees are set out in the Department of Health and Social Welfare administrative instruction on co-payments, published earlier this month, and will be displayed prominently in all health care institutions.

Children under six, pregnant mothers, people on emergency social welfare and patients with severe chronic diseases needing continuous care are exempt from payment. All preventive services, such as tuberculosis testing, family planning, ante- and postnatal care and immunization are free, as are repeat visits after the third visit for the same reason.

Health care institutions will be allowed to spend 60 per cent of the money collected, but only for three specific expenses: incentive payments for health workers in remote areas or working in hardship conditions; staff transport between home and a remote facility; payment for night and weekend duties.

Twenty per cent will be put into a regional solidarity fund to level inequalities between municipalities and communities and for emergency funding. The remaining 20 per cent will be held at central level and used for special needs such as control of epidemics and treatment abroad.

Apart from aiming to bring in extra revenue for the consolidated budget, the introduction of co-payments will promote a rational use of health services and encourage use of a referral system.

Co-director of the DHSW, Dr Hannu Vuori, said that apart from raising revenue for services, at local, regional and central level, the introduction of fees would teach people that "if they jump the queue they have to pay a penalty fee".

"Health services in Kosovo have been completely free so far, but most countries charge for them", he said.

To eliminate under-the-table charges, the list of fees carries a rider that the health care institution and staff are not allowed to make any other charges.

Budget cuts may be needed

Regional health officers have been told to prepare for two scenarios as budgets are refined for the remainder of the year. In the first case they should work to the full Health and Social Welfare allocation of 81.1m DM, but they should also be prepared for a 30 per cent reduction in the allocation.

Department of Health and Social Welfare co-director, Dr Hannu Vuori, told last week’s meeting of regional health officers that they should be ready for a possible shortfall. "We know estimates of generated income may not all materialize," he said. Revenue from Customs was coming in but revenue from other expected sources was behind schedule. The consolidated budget could therefore possibly be maintained only if donors make up the shortfall, "which is by no means certain", he said. "People will have to continue looking for funds in the health sector."

The meeting was told that the wages and salaries line would be kept intact as far as possible.

More data sought on workforce

Dr Attila Perczel, assistant co-director of human resources and member of the DHSW task force, set up to review issues relating to the medical workforce, told regional officers that the challenge would be to determine how many staff were needed in each location. The health services payroll contains 13,500 registered people. Of these 43 per cent work in hospitals and 55 per cent in health houses. The others are working at the Institute of Public Health and other institutions. There are just under 2,500 doctors and about 7,000 nurses, which places around 70 per cent of the staff in the professional category and 30 per cent as support staff.

The task force, led by Professor Bajram Nuraj, Dr Attila Perczel and Dr Naser Ramadani from the DHSW, also includes Stephen Briscoe, a human resource specialist from WHO, Dr Eva Hammershoy, a medical hospital director from Denmark and a representative from the Department of Education. First issues under discussion will be anaesthetics, obstetrics and gynaecology, paediatrics, surgery and priorities for specialist training.

The task force will begin by reviewing medical staff and specialisations, Dr Perczel said. But data was incomplete and needed to be improved; the date of birth of 10 per cent of doctors was missing, "making it impossible to do real planning", while about 900 doctors-in-residency had to specify what year of specialisation they were in.

He offered to meet the hospital and health house directors in each region to clarify the omissions and errors on the staff database.

PRIMARY CARE

First family doctors recruited

Recruitment for the first two cohorts of family doctors will be completed by tomorrow. The programme starts in July. Dr Robert Hedley, a Fellow at the Royal College of General Practitioners, GP Trainer and Kosovo family medicine programme coordinator in the WHO primary care unit, says "we have got a good bunch of doctors". Two Bosnians and one Turkish doctor are among the successful candidates.

The interview panel grouped together Dr Hedley, Dean Mazzlum Belegu, Dr Arben Cami, the family medicine unit doctors and external assessors. Dr Hedley, as one of the programme course writers has signed up for a year with the programme and he says "we shall be integrating all the six modules in June to ensure a consistency of approach and enable the first teaching methodology sessions to begin".

The family team is currently recruiting the translators, and sector teams for Gjilani/Gnjilane, Gjakovë/Djakovica and Prishtinë/Pristina. They are being assisted by the WHO logistics and personnel teams to ensure the learning facilities are fully equipped by mid-June.

Sue Woodward, WHO primary care coordinator is also working hard with a range of donors, the DHSW, the Department of Education and Science and the university, to develop a parallel programme for nursing in Kosovo alongside the family medicine programme for doctors. This includes the development of an action plan to nurture both the interim education needs and the longer term establishment of a recognised nursing programme in Kosovo.

Meanwhile the work completed by the WHO primary care group under the chairmanship of Sue Woodward is being converted into the administrative instruction for family health centres. The instruction sets out in detail the services to be provided, staff needed and material required by family health centres and their satellite centres.

A standard family health centre, serving a population of 10,000, will have a staff of 29, including five doctors and 10 nurses. There will also be a dentist and dental nurse, a social worker and a health promotion team, as well as administrative and support staff.

Doctors in Holland for training

Ten doctors recruited by the family medicine team and supported by Cordaid, the partners with the family medicine initiative in Gjakovë/Djakovica, is now in the Netherlands for a three-month fast-track training at Utrecht university. Utrecht is well away from the eastern Dutch city of Enschede where several people were killed in an explosion at the weekend. The doctors will join the first cohort of family medicine doctors on returning.

It is planned to enable the doctors to share their experience with the other members of the group and other staff who work at the three learning centres. They will also be a good support to clinical supervisors in the field. Cordaid in Gjakovë/Djakovica have done much to support the central programme for the benefit of all doctors in Kosovo. Sue Woodward says "this is exactly the type of support we need to ensure consistency of approach and benefit to the development of the family unit at the Prishtinë/Pristina university medical faculty. We have a good relationship with Cordaid and look forward to continuing the partnership throughout the programme. The ten doctors are Nexbedin Sadiku (Pristina), Valdet Hashani (Pristina), Sami UKa (Pristina), Elfete Kuttlovci (Pristina), Nazxane Hamza (Pristina), Ali Kuqi (Decane), Hektor Binishi (Gjakovë), Yllzim Dyla (Gjakovë), Burim Gojani (Gjakovë) and Flori Bakalli (Gjakovë).

PUBLIC HEALTH

New figures for communicable diseases

Latest figures for communicable diseases underline the urgent need to implement and extend the expanded programme on immunization (EPI) in Kosovo.

Data analysis shows a total of 2030 cases of mumps (epidemic parotitis), with 32% of all cases reported from Pristina/Prishtinë region (652), followed by Prizren region (559/27%) and Mitrovicë/Mitrovica region (397/19%). Most cases were in the five-49 age group. The high incidence is due in part to the non-availability of vaccines during the early 1990s and to mass population movements. The surveillance figures covered the first three months of the year. In January the Institute of Public Health and WHO introduced a new surveillance system for Kosovo with approval from the Department of Health and Social Welfare. Medical staff, at central and regional levels, have been receiving training in the new computer-based data gathering software.

A total of 1306 cases of Hepatitis A was reported during the first quarter, with 565 (42%) cases in Pristina/Prishtinë region followed by Gjilani/Gnjilane region with 306 (23%).

Among other communicable diseases, there was a month-long outbreak of influenza in the second week of January. More than 5000 doses of influenza vaccine were administered to those most at risk of developing complications.

Dr Nick Gent, who has just reviewed the cold chain arrangements for the EPI system in Kosovo and looked at issues in regard to training for EPI, says that "vaccines are not the problem. There has to be an organised programme of social mobilisation." And, as he reminds doctors on EPI courses, "vaccination is the easiest, the best, the cheapest and the most effective way to protect human beings from communicable diseases."

EMERGENCY MEDICAL SERVICES

Second assessment completed

The Action Plan for Emergency Medical Services (EMS) has been submitted to the Department of Health and Social Welfare for review.

Since last summer, WHO has been studying EMS in Kosovo, and this important area has received increased attention of late. The secondment of an emergency medicine specialist, Dr Kate O’Hanlon, to WHO from IMC (International Medical Corps) through DFID funding, and the increasing attention of UNMIK to emergency preparedness have been instrumental in focusing this attention. A second assessment of Kosovo EMS (the first was done in August 1999) took place in March 2000 to identify priorities for action. These include establishment of Kosovo administrative structures for EMS, selection of appropriate vehicles for a true emergency fleet, equipping of these vehicles, establishment of a rational communication system, and standardised training of personnel.

UNMIK Department of Civil Security and Emergency Preparedness (CS&EP) has been facilitating meetings of those responsible for emergency services in Kosovo. Representatives from the Police, Fire/Rescue, Kosovo Protection Corps, KFOR, WHO EMS, UNMIK Health, PTT, and involved NGOs are currently developing a communications net linking all services.

There is general recognition that the medical services branch of the emergency services lacks adequate organisation and planning.

EMS projects continuing in the field include:

• Prizren Region cooperative effort between the emergency services branches to establish an emergency services system. The system will be tested with a mock disaster on June 21st organized by CS&EP
• Proposal by Malteser, Johanniter, and Arbeiter Samaritaner Bund for ongoing EMS training and coordination in all municipalities of the Prizren region
• IMC training in Pristina at the First Aid Facility and Hospital Emergency Centre
• Samaritan’s Purse emergency medicine development at the Gjakova Hospital

Administrative and training issues in EMS require ongoing attention; WHO will work to establish appropriate Kosovar bodies to take the lead in these areas.

The Kosovo EMS Assessment of March 2000 is available at WHO main office in three languages. Accompanying tabulated data for the Assessment and a distinct Health Services Vehicle Survey are available by special request.

PHARMACEUTICALS

Drug control regulations

As we reported briefly in our last issue, the Kosovo Drug Regulatory Agency (KDRA) is now operating at the Department of Health and Social Welfare (DHSW). KDRA’s role is to regulate, monitor and enforce regulations concerning the quality of medication on the Kosovo market as well as on the places and people importing, wholesaling and retailing the medications.

DHSW has published an interim administrative instruction covering the requirement to seek approval from KDRA of all medications to be imported into Kosovo by all organisations and companies. (Administrative Instruction [Health] 14/2000: "Import Licenses for Pharmaceuticals"). Procedures and application forms to support the implementation of this administrative instruction will be implemented this week. The interim regulations are a stepping stone to a more comprehensive control that will come into effect during the summer period.

The aim of the import approval regulations is to ensure that only pharmaceuticals of proven quality are on the market and that drugs known to be dangerous are excluded. The target is to introduce mandatory import approval before despatch from the supplier. Approval will take a couple of days and the requests must be made prior to arrival at the border.

There are two steps in the procedures:

1. Companies and organisations (including NGOs and IOs) must register with KDRA as a pharmaceutical importer

2. Registered organisations may then apply for approval of each shipment. Details of all drugs to be imported will be required.

The approval will be in the form of a license to import a shipment of pharmaceuticals, a copy of which should be with the customs documentation with the shipment and another copy will be faxed to the customs authorities for verification. Unlicensed shipments will not be permitted to enter Kosovo.

Humanitarian assistance drug donations will have to comply fully with the WHO/Interagency "Guidelines for Drug Donations". The two most important criteria are that the drugs must be on the Kosovo primary care or model hospital essential drugs lists and that there must be at least one year remaining shelf life within the expiry date.

Copies of a more detailed explanation, the Interim Administrative Instruction, the Drug Donation Guidelines and the various application forms are available from the Kosovo Drug Regulatory Agency at the Department of Health and Social Welfare in the EximKos Building on Mother Theresa Street, Pristina/Prishtinë.

Disposal of unwanted pharmaceuticals

A large quantity of unwanted pharmaceuticals has entered Kosovo over the past months - either drugs that were expired (or expired shortly after arrival) or were not useful items. Many institutions are filling up with unwanted pharmaceuticals and are hindered by overcrowding. WHO is working to eliminate this backlog of waste drugs, and the licensing procedures outlined above should reduce the flow.

The pharmaceuticals project has adapted the global WHO/Interagency "Guidelines for Disposal of Unwanted Pharmaceuticals" for the situation in Kosovo, to be able to offer advice on how to safely dispose of unwanted pharmaceuticals at the lowest cost.

The guidelines explain how to sort the pharmaceuticals into various categories for disposal:

• those that need incineration
• those that can be safely put into the sewerage system
• those that have to be stored as there are not safe disposal methods readily available

This means that institutions can begin to reduce the total volume of unwanted pharmaceuticals and separate items that need incineration.

WHO is working to identify incineration locations within Kosovo suitable for disposal of these unwanted drugs. A pilot project tried by International Medical Corps, WHO and ElectroKosovo to incinerate drugs at the Kosovo power stations was technically successful, but proved too expensive in terms of the large amount of time taken for sorting and de-packing.

The "Adapted Guidelines for the Safe Disposal of Unwanted Pharmaceuticals in Kosovo" are available from Lirim Azizi at the pharmaceuticals project, WHO Pristina. Information on incineration facilities will be published when it is available.

ENVIRONMENTAL HEALTH

Infectious waste goes up in smoke

Some hospitals are able at last to begin safely destroying accumulated piles of dangerous waste, including infectious waste and sharps. A large incinerator at Pristina hospital, built with funds from Britain’s Department for International Development (DFID), is due to be fired up this month and will soon be burning through bagged up waste from the gynaecology-obstetrics, pathology and surgical departments. Three more departments will join the system each week, as health staff are trained to separate waste into black or yellow bags, until all departments have joined the system, probably by the end of June or early July.

The incinerator has a capacity of 200 kg per hour of healthcare waste.

Meanwhile eight small incinerators are now in operation in other parts of Kosovo, and there are plans for several more. Pairs of the brick built incinerators, designed and developed by De Montfort University in the UK, have been set up at Prizren, Gjakovë/Djakovica, Pejë/Pec and Gjilani/Gnjilane hospitals. The German Technical Aid agency GTZ funded the construction of these, as well as a further five. Sites are being sought for two of these in northern Mitrovicë/Mitrovica for the Serbian community, two in southern Mitrovicë and a single unit in another Serbian community elsewhere.

Disposal of healthcare wastes is a problem in Kosovo. Potentially infectious waste has been mixed with general waste and either thrown into open dumps or burnt openly.

The De Montfort incinerators, which can burn at temperatures between 850º and 1000ºC, are made from local materials for about 6,000DM and run on small amounts of diesel fuel.

Pristina landfill needs attention

The WHO’s European regional adviser for waste, Philip Rushbrook, has been working with UNMIK to seek ways to improve Pristina’s landfill while the administration looks at proposals for alternative sites. The existing site needs rehabilitation if it is to be usable for the next 18 months to two years. This is a realistic "worst case" assessment of the time needed to get a new landfill ready.

At the moment the landfill is "an operational disaster with an obvious and adverse environmental impact", says Dr Rushbrook. "It will never be perfect because it is in the wrong place and run the wrong way. However, much could be improved with modest additional resources and sustained willpower."

The recent tularemia outbreak helped to focus attention on the dire sanitation and waste problems throughout Kosovo, especially in periurban and rural communities, UNMIK and KFOR have set up a task force with interested agencies to confront the crisis.

Progress on water quality control

Water quality is high on the agenda of environmental health as the government and health services start to implement water quality legislation. This aims to enforce minimum standards through water sampling for testing, while in rural areas the focus remains on the need for new well construction, cleaning and chlorination. The danger of waterborne disease has increased with the change of seasons and hotter weather. The recent tularemia outbreak drew attention to the need to address the clean water problem in Kosovo with vigour, although rodents and contaminated food are now known to have been main vectors in spreading the disease.

Municipalities in Kosovo have now received the administrative instruction (Health 2/1999) setting out the minimum standards of drinking water quality and listing the way standards will be tested and enforced.

Dr Selvete Krasniqi, WATSAN coordinator of the Institute of Public Health and the "enforcer" of water quality standards, is now supervising the situation in 26 municipalities. Daily tests are carried out at 11 points in the Pristina/Prishtinë network.

"We are concerned about water disinfection," Dr Krasniqi says. "Thirteen municipalities have no residual chlorination and the other 13 are low on residual chlorination. If a water company fails a sampling test we will send the results to the sanitation inspectors. We are now the water police."

HIV/AIDS

UNAIDS seeks information

Dr Stuart Kingma, specialist on HIV/AIDS prevention for UNAIDS, has completed a 10-day preliminary assessment trip to Kosovo. There is thought to be a relatively low number of people with HIV in the province, but the absence of reporting and testing means there is a lack of published data. "A true estimate is impossible to guess", says Dr Kingma, but the risk from sexually transmitted diseases, including HIV, is high in conflict and post-conflict situations.

"Everyone agrees that the time is ripe for some programme to be started among all population groups, whether they are internationals deployed with KFOR, the UN and NGOs or Kosovars of any community and particularly those who have returned from abroad", he says. Dr Kingma, who is director of the Civil-Military Alliance to Combat HIV and AIDS, will be making recommendations to the Department of Health and Social Welfare, WHO and UNAIDS to lay the ground for an HIV prevention programme.

Cultural and religious factors inhibited sexual libertarianism in Kosovo in the past, Dr Kingma told Health Talks, but the aftermath of conflict, high unemployment, rural-to-urban migration and the presence of a high number of expatriates has "created a situation where the risks spread to the local population."

During his visit Dr Kingma presented a training of trainers (TOT) programme to a large number of international and local organisations and agencies, including the Kosovo Protection Corps medical unit.

MENTAL HEALTH

Conference in Montenegro

WHO Kosovo mental health officer Liliana Urbina has returned from a short training visit to Montenegro, where she took part in a conference on community health organised by the ministry of health and WHO office in Podgorica. The conference was attended by public healthcare workers, psychiatrists, psychologists, social workers and nurses. The process of downsizing large psychiatric institutions in Montenegro is moving ahead despite some problems.

Meeting set for Stimlje/Shtime

A two-day workshop on mental health is to open in Pristina on 25 May followed by a one-day conference on community mental health to be held in Stimlje/Shtime.

The Stimlje/Shtime meeting, which will group mental health professionals, social workers and the staff of Stimlje/Shtime institution, is the second community mental health conference organised by WHO in collaboration with Norcross. One of the aims is to draw attention to the poor conditions of residents in the institution.

VIOLENCE AND INJURY PREVENTION

New report released

WHO has published an executive summary of work carried out in Kosovo between December 1999 and April 2000 on violence prevention. A workshop, "Violence Prevention and Care: a multisectoral public health approach", was held 6-8 April. The workshop involved multiple stakeholders, including police, health, legal, social and educational NGOs and associations, local and international. The broad objective of the workshop was to develop a coordinated strategy on violence prevention. Participants identified the need for rapid and sustainable multi-disciplinary action to prevent violence and provide support for victims of violence. The report is available from WHO main office, Pristina.

Meanwhile the domestic violence sub-group is preparing concrete recommendations for discussion with the government. The sub-group, which meets on alternate Thursdays at WHO main office, has identified many gaps in policy on domestic violence in Kosovo. They include lack of education among police, healthcare workers and teachers, absence of services including safe havens, lack of hotlines and a need for human rights education in the school curriculum.

For further information, contact Luiz Vieira, MCI, email: Vieira_luiz@hotmail.com

NGO ACTIVITIES

MDM records high rate of hypothermia

There was a 15 per cent incidence of hypothermia among newborn babies in Gjakovë/Djakovica hospital in 1999, according to a report published by Medecins du Monde-Belgium. The report, which covers MDM-B’s six-month training and technical support project for the hospital’s gynecology and obstetrics department, mentioned 217 cases of hypothermia from 1442 live births in 1999. Of these, 190 cases (87.6 per cent) mainly occurred between September and December.

One explanation for this high rate was the habit of nursing staff to wash the newborn baby under running tap water. The baby often became blue with cold, the report said, and the midwife usually wore gloves, which made it difficult to test the water temperature. Babies were placed uncovered on scales, without thermal protection, and during the harsh Kosovo winter the delivery ward was sometimes heated poorly.

The report, written by Dr Ngoc Lessire-Nguyen thi, noted 26 neonatal deaths during the same period, often due to premature delivery or respiratory distress syndrome.

MDM said that while a high number of babies was abandoned in Pristina hospital in the months after last year’s war, only three or four babies were abandoned in Gjakovë/Djakovica, and one of these was subsequently adopted.

IRC equips IPH microbiology

The International Rescue Committee (IRC) began its largest distribution of laboratory equipment to Institute of Public Health (IPH) microbiology facilities this week. The distributions are part of a $400,000 programme to equip and upgrade such laboratories across Kosovo.

IRC Microbiologist, Mark Grey, and his team distributed microscopes, biohazard safety cabinets, incubators, centrifuges, refrigerators, freezers and other essential equipment to the IPH Pristina/Prishtinë, where a primary reference microbiology lab supports regional facilities in Prizren, Pec/Peje, Mitrovica/Mitrovica, and Gnjil-ane/Gjilan.

Microbiologists from different parts of Kosovo will attend a 10-day training in clinical microbiology organised by WHO and IRC at the central reference laboratory at IPH.

Dr. Ram Dessau, a consultant, Amy Kravitz of WHO and Mark Grey, IRC Microbiologist, will train participants in the use of the new laboratory equipment. Training will also focus on updating diagnostic techniques, establishing protocols to ensure the quality of laboratory results, and improve the mechanisms by which specimens are tracked through the lab.

IPH microbiologists will also learn media preparation and staining and sample collection techniques.