In the seven months that has elapsed since the withdrawal of the Serb forces, Kosovo’s health service has got back onto its feet, albeit somewhat shakily. Some reconstruction and rehabilitation has taken place, supported materially and financially by many NGOs and agencies, but many health facilities still struggle day to day with essential utilities. Drug supplies have been maintained but long term security is yet to be assured. More positively all hospitals and most health houses and ambulantas are now open and therapy of some kind is now available for most conditions. There have been no major outbreaks of infectious disease.
The vast majority of health staff are now Albanian, raising issues of access and integration for Serb and other minority groups. Another bone of contention has been the UN stipend payments, with erratic distribution and the perceived low levels causing unrest. Unconfirmed plans suggest the administration will attempt to introduce salaries in early spring.
The UN Mission in Kosovo (UNMIK) Department of Health and Social Services has been staffed with a small central secretariat and five field offices consisting of one or two health officers. Low technical and administrative staffing has limited UNMIK Health’s ability both to coordinate and effectively regulate the development of the health services. The structure of UNMIK health department has changed dramatically with the appointment of a Kosovar co-minister, Dr Pleurat Sejdiu (a representative of the Partia e Prosperitetit Demokratik të Kosovës or Democratic Prosperity Party of Kosovo, the political sucessor to the Ushtria Çlirimatare e Kosovës (UÇK) or Kosovo Liberation Army, and a number of Kosovar counterparts, in line with the central UNMIK development of the Joint Interim Administrative Council linking the three main Albanian political parties, and, it is hoped in future a Serb representative. The consequences of this change on regulating both the health service and the work of NGOs is as yet unclear.
However, some key questions with regard to the overall direction of the international effort in health in Kosovo do now need to be answered, including:
- What is to be the system of registration, reporting and accountability between UNMIK and the international community players who are working and investing in the health sector, and who is to implement it? This has important implications both for coordination of effort and for discovering essential information such as the gaps in service provision and the levels of ultimately unsustainable private funding currently supporting the health economy.
- Is there mutual or contractual agreement among all players - governmental, local professional, NGO, agency and others - on implementing UNMIK’s health policy guidelines (see below) which involves significant reform of the health system?
- Is UNMIK Health prepared, and empowered, to take the regulatory decisions required to implement this policy now, and to empower its own staff or other agents to enforce these policy decisions, or is it simply holding the reins until an elected government takes responsibility?
Although there are still emergency needs in health and other sectors, it is clear that Kosovo generally is no longer in an emergency state, but rather a transitional and development phase in which it will require no less, but differently focused, international support. It will be increasingly important, if this is to be professionally, effectively and efficiently provided, for the UN Administration and the new local counterparts to set up, or authorize others to set up, more authoritative coordination structures which will have the ability enforce policy and reduce overlap and well intentioned, but misdirected, effort.
Current UNHCR figures put the population at 1.8 million.
Some 22,000 Kosovar Albanian refugees transported under the Humanitarian Evacuation Programme currently remain overseas (Jan 2000). Over 820,000 people displaced during the NATO conflict have returned to Kosovo. Within Kosovo, 12% of the population was internally displaced in September 1999. 1 While proportion of these may have returned, substantial number remain displaced due to destroyed homes. There is also a large diaspora of Kosovar Albanians, who are either working as guest workers or were seeking asylum. Germany estimates its population of Kosovars at 180,000. Large numbers also reside in Switzerland and Austria.
Up to 300,000 Kosovar Serb and Roma are estimated to be living in Serbia, with some 30,000 more in Montenegro.
Over 50% of the population is under 20 years, 15% are over 50, 8% over 60. [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
Birth rate is high by European standards - 21.6/1000, but there is anecdotal evidence that this has decreased in recent years. Recent research also suggests that less than 10% of the population is under 5 years, less than some health planner have thought. [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
Death rate is estimated at 0.45 deaths/1000/month [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH] - a relatively low figure largely largely due to the youth of the population. However infants account for a full 40% of the deaths though they only make up 2% of the population.
It's thought over 95% of the population are ethnically Albanian with the majority of the remaining percentage ethnic Serbs. However reliable figures await a census. Other minority groups include Roma, Goran, Bosnians and Turks.
Unemployment is estimated at 50%, per capita income at around $470 per year.
Current estimates suggest an infant mortality rate of between 30 and 50 per 1000, compared to the European Union average of 5.6/1000. Most common causes are infections, prematurity and birth trauma.
Most common childhood illnesses are respiratory and diarrhoeal conditions
Communicable disease accounts for 12% of deaths, non-communicable diseases 53% and other neonatal conditions 30%.1 [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
Of Kosovars 5-years and older, 15.5% have at least one chronic disease; the top five in descending order are cardiovascular disease, chronic back pain and/or arthritis, renal disease, lung disease and ulcers. Only1.8% reported two or more chronic diseases. [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
Routine childhood immunization restarted in September 1999 and has so far achieved coverage by municipality of 44% to 92% in the first round and 50% to 91% in the second round (up from an estimated 40% during the recent years of conflict). Higher coverage was achieved in rural areas. [Institute of Public Health Report Dec 1999]
Nutritional surveys suggest 3% of children aged 6 months to five years are acutely malnourished (1% severely) while one in 10 are chronically malnourished. [Action Against Hunger Nutritional Anthropometric, Infant Feeding and Weaning Survey July 1999]
Breastfeeding rates are high: almost two thirds of mothers breast feed beyond six months. However, few start immediately after birth, which reduces the immune benefits, and exclusive breastfeeding is rare with most mothers introducing inappropriate foods very early in life. [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
There have been no outbreaks of serious epidemic disease, although rates of hepatitis A (transmitted via infected water sources and poor personal hygiene) continue to cause concern.
Tuberculosis incidence is high at 77 cases/100,000, three times that of the Federal Republic of Yugoslavia as a whole.
The majority of adult morbidity and mortality stems from heart and lung disease, diabetes, stroke and cancer.
Health policy and regulation
The UNMIK interim health policy guidelines, drafted by a UNMIK/WHO/local professional policy group and published in October, set out a blueprint for the reform of the health service in the territory, based on a move to a primary-care driven system. This process will require infrastructural, educational, financial and technical reforms over the next three to five years.
Health services are still free, but economic constraints both now and in the future mean policy makers are starting to consider options for contributory financing including health insurance and co-payments.
A survey in September 1999 found 55% of patients had spent money on health in the two weeks previous, including an average of 19 DM on drugs and 4.5DM on transportation. Extrapolating the data would see the population spending around 149m DM a year. [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
The introduction of the Joint Interim Administrative Council, due to become fully operative on 31 January, will alter the decision making structure in the health sector, since all new regulations and administrative instructions will need to be approved by the JIAC.
While some organizations (NGOs, UN agencies, local structures) are arranging their activities with attention to the reforms outlined in the ‘Blue Book’ (as the interim health policy guidelines are known), others are disregarding it. It will be important that UNMIK Health develops some form of enforceable authority to restrain projects that damage or set back the goals of the policy.
1. Primary Health Care
There are 29 health houses (polyclinics) and 234 ambulantas (small health centres) [UNMIK/WHO Health Personnel Database, Jan 2000] now functioning in Kosovo. Roughly a third did not sustain war damage, but most are suffering from varying levels of disrepair caused by long-term neglect. Due to problems with electricity supply, many health houses do not have access to mains electricity and, despite some sterling efforts at rehabilitation and reconstruction, there are still many ambulanta which do not have mains or generator electricity. Water supply and sanitation also continues to be poor in many facilities.
A number of temporary health stations/ambulantas have been organized to improve access to minority group. Mobile clinics also serve some areas (see Access and Integration below). However a survey in September 1999 suggested only 2% of the population used mobile clinics and suggested NGOs might wish to redirect their resources. [Kosovar Albanian health Survey Report, Sept 1999. CDC, IRC, WHO, IPH]
Rehabilitation: the most recent assessment - October 1999 - showed rehabilitation was in progress with NGO support in 24%, of health houses with plans for a further 38%. Among ambulanta 6% had been renovated, 14% were in progress, and rehabilitation was being planned in a further 36%. [WHO Primary Care Facility Database, November 1999]
Equipment: at October 199, re-equipment was in progress in 28% of health houses and planned in 30%. Re-equipment was complete in 2% of ambulantas, in progress in 8% and planned in 49%. [UNMIK/WHO Health Personnel Database, Jan 2000] Many facilities still lack basic, essential equipment: see UNMIK/WHO guidelines of equipment donation.
UNMIK’s health policy outlines a re-orientation towards a primary-care focused service, based on concepts of family medicine delivered by family health teams to specific catchment populations. This will require the development of larger family health centres serving a defined population. It will also enable the development of preventative health care, health education and health promotion, and permit secondary care to concentrate on developing more targeted modern care. Pursing the policy effectively will require strong regulation to ensure that efforts are focused according to the policy.
There is a need to define the package of services to be delivered at each level of primary care
Sites for family health centres are being identified and requests are being made to NGOs and donors to focus rehabilitative efforts on these.
Medical Faculty training courses to update family medicine doctors will start in June. Similar courses are being planned for nurses, as well as activities to develop team working in primary care. A full curricula for training young undergraduates to specialise in family medicine is being developed in parallel with the updating courses to ensure consistency
One tertiary/teaching hospital (Pristina University Hospital) and five regional hospitals (Prizren, Gjakovë/Djakovica, Pejë/Pec, Gjilan/Gnjilane and Mitrovica*) are functioning in Kosovo. All have several buildings and ‘clinics’ which, in the past, have operated independently of each other (eg. Many have their own laboratory, emergency room etc), a situation which continues to exert extreme pressure on equipment and expertise.
*As of end December 1999, Mitrovica Hospital has been taken under entirely Serb management, staffed only by Serb personnel who have refused to allow entry to Albanian staff. A strategy to create new structures to provide Albanian patients with hospital care is underway.
Each hospital also has an international management team which is taking varying levels of responsibility for implementing UNMIK policy.
None of the hospitals suffered war damage; their condition is a consequence of 10 to 15 years of poor maintenance and investment. International management teams (present in all hospitals) and donors have facilitated essential repairs (broken windows, replacement roofs, getting rudimentary kitchens and laundries functioning etc.) in all hospitals. However heating, water, sanitation are an ongoing problem due to the antiquity of the systems.
There are 4 769 beds in acute care hospitals - equivalent to an average of 264/100 000 population. In Europe, only Turkey and the UK have a lower ratio. [WHO Fact Sheets on Hospitals Dec 1999]
Average stay in hospital is 12.5 days, in part reflecting the relative under-performance of primary care.
Most common hospital treatments/specialty consultations are available in Kosovo. There is limited service in plastic surgery, more advanced eye surgery, neuro, and orthopaedic surgery. Missing completely are cancer services, both in treatment and investigation, heart surgery and transplant surgery. [Conclusions and Recommendations after 6 months in Kosovo, Margareta Rubin, WHO hospitals co-ordinator 1999]
Many hospitals still lack basic, essential equipment: see UNMIK/WHO guidelines of equipment donation.
Emergency care is delivered by urgjences (emergency centres) attached to hospitals or health houses and by KFOR medical services. All emergency centres have at least one ambulance adequate for emergency transport though most are not capable pre-hospital care. NGOs are carrying out training for emergency care staff and Work is ongoing in staff training, developing communications and providing equipment. Pristina University Hospital now has a state of the art emergency centre, funded and equipped by the UK’s Department for International Development.
A Medevac committee has been set up and a weekly commission reviews patients. There is a waiting list of 238 patients (Jan 2000). Most common reasons for medical evacuation are complex injuries, congenital disease (mainly cardiac), and cancer.
There is considerable excess of beds in specialties which modern practices suggest require less or no in-patient care (eg. ENT, dermatology, ophthalmology and infectious diseases) and under-provision in other areas. Re-organization of bed use will be needed to achieve more effective care within the financial constraints.
Most patients currently self refer to hospitals due to the collapse of the official referral system during the crises. Re-establishing referral systems and guidelines for referral will be required alongside the redevelopment of primary care.
Real development of managerial skills and decision-making are required if changes are to be made hospital care
UNMIK is carrying out a process of appointing local directors of hospitals, health houses and other institutions to ensure accountability. Until now these posts have been filled by a mixture of locally popular, self appointed or political appointees, with no contractual duty to the administration.
WHO is developing a business plan for the hospital sector including recommendations for step-wise changes to improve the effective use of secondary care resources including bed ratio, staffing, building rationalization
There are currently 13, 610 people on the UNMIK/WHO data health personnel database including approximately 2100 physicians, 6,200 nurses and medical technicians, 360 dentists, 50 pharmacists and 290 'midwives'. [UNMIK/WHO Health Personnel Database, Jan 2000] A further 800 Serb staff are thought to be attached to Mitrovica Hospital. The Kosovo budget allows for payment of 10,550. How this is to be achieved while maintaining acceptable standards of care remains unclear. WHO has recommended that staffing ratios should be maintained at a level equivalent to Macedonia. This would mean raising the number of doctors from 139/100 000 to approximately 200/100 000. [WHO briefing paper Oct 1999.]
In secondary care the most urgent shortages of staff are in anaesthesiology and radiology; in primary care fully updated family health care doctors and nurses. [WHO Primary Care Facility Database, November 1999]
Most health care positions are now filled by Albanian workers, except in Mitrovica where the health system is effectively segregated. Many Serb health workers have congregated in Mitrovica hospital because they fear at best that their work environment will not be acceptable, at worst that their safety may be at risk, in facilities elsewhere. Albanian hospitals staff, on the other hand, have been prevented from entering the hospital since September 1999. These workers attempt to serve their patients through the polyclinic on the south (Albanian) side of town, or other sites.
A handful of Serbs are employed in Pristina University Hospital and similar low numbers in the regional hospitals.
A human resources strategy must be developed, taking into account issues of standards of care as well as the impact on the Kosovo economy and population.
Health workers remuneration continues (in Jan 2000) to be by irregular UN stipend, paid out at three levels: physician/nurse/support worker. There are suggestions that salaries - incorporating more detailed occupation categorization - may be introduced by February. It is unlikely that salary levels will reach local expectations. Unrest regarding salaries has been stoked by the additional payments made to Pristina University Hospital staff by the UK’s Department for International Development, the hospital’s chief supporter. These payments also work against the thrust of the health policy by signaling that the best place to be to be well paid is in a hospital, rather than in primary care. It is crucial, if the re-orientation of the health services towards family medicine is to succeed, that some sort of incentive, financial or other, is introduced for primary care.
The issue of accreditation and validation of qualifications is important, but also sensitive, not least because of the parallel system of education and the fact that many health workers had papers destroyed during the conflict. Discussion is continuing between all counterparts as to the best way to resolve these issues.
Access and integration
UNMIK has now chosen to pursue a policy of ‘co-existence’ rather ‘multi-ethnicity’ when it comes to essential services like health and education. This means a ‘parallel’ facilities can be set up if relationships between ethnic communities are such that one group would have no access to health care.
WHO has been instrumental in encouraging Serb doctors to return to serve Serb villages. As a result many minority enclaves now have access to primary health care services provided by staff of their own ethnicity either in small health stations. Where this is not possible humanitarian organizations are serving patients via mobile clinics. However, secure transportation for those living in more isolated settings, or to transport patients between enclaves and regional hospitals, is more problematic. UNHCR have set up KFOR protected bus services in some districts; in others there are local arrangements with KFOR.
Some Serb patients still travel to Serbia for hospital care because they believe they will not get good care from Albanian staff. There is little evidence of mal-treatment of Serb patients in Albanian-dominated facilities.
Some key public health functions, such as epidemiological surveillance and immunization, have been re-established. Others, such as water and food testing, have been delayed by slow progress in re-establishing appropriate legislation, while still others such as health information systems and improving laboratory analysis have been hampered by complexities of donor support.
There have been no major outbreaks of infectious disease, although high levels of hepatitis A continue to cause concern. Several samples of suspected polio (acute flaccid paralysis) have been confirmed negative in international reference laboratories.
Basic microbiological tests can be done but work is needed, and planned, to improve standards to modern European levels.
The communicable disease of major concern is TB, which currently has an incidence three times the rate of the Federal Republic of Yugoslavia. A new TB treatment and prevention, incorporating the WHO-recommended DOTS strategy of treatment is being developed.
Routine collection of communicable disease surveillance information has been reintroduced after six months of using an emergency system instigated by WHO and using NGO information. The new system - KO-SURV - will allow for more detailed and accurate analysis of public health risks in Kosovo itself.
Regulations to allow routine water sampling, testing and quality enforcement and the recruitment of inspectors have just been approved by UNMIK. Similar regulations are awaited on food hygiene.
WHO has shepherded the process of re-empowering local contractors to charge fees to collect municipal waste. This has kick-started the process of municipal rubbish collection in Pristina, together with injections of donor-funded equipment and personnel. Several community campaigns have taken place to involve the public in managing rubbish. However, illegal dumps and some overflowing skips and still remain, particularly in the capital.
WHO is working with the Institute of Public Health to gradually integrate public health functions in primary or secondary care, allowing the institute itself to become the engine of public health policy, training and supervision for the Ministry of Health.
Revitalization of the microbiology, food safety and environmental laboratories is planned including equipment, and training.
A Kosovo-wide health information system project - which would see every health facility computer networked and staff trained in data collection - has been presented for donor support.
A strategy for the integration of routine childhood immunization into primary care is being developed, as is a plan to move the microbiology laboratories currently placed in the Institute of Public Health into the hospitals.
Health education and health promotion skills are being developed.
Pharmaceuticals and Drug Supply
Drugs are currently being supplied free of charge from hospitals and primary health care facilities and privately from pharmacies.
Primary care supplies: Pharmaciens sans Frontiers (PSF) are WHO and UNMIK's major partner in drug supply. As the emergency situation subsides, dispensing of most drugs will be through Kooperativa Farmaceutike e Kosoves(KFK) - a co-operative of the former state pharmacies which is being supported by WHO and UNMIK in the transition from PSF to a Kosovo -owned system.
The transition from humanitarian aid to government procurement has begun, with UNMIK placing orders for drugs with its first budgetary allocation.
A drug regulatory office is being established by UNMIK to ensure drugs are of required quality and sold from appropriate outlets, however the regulations are await approval.
A Kosovo essential drugs list has been developed and adopted on which primary care procurement is based
A Kosovo essential drugs list for hospitals will be available mid-February
There is continued uncertainty regarding ongoing supplies. There is an urgent need for UNMIK health to clarify and assign responsibility for procurement and distribution if continuous supplies are to be assured through spring time.
A centralised procurement office is to be established, together with strengthened drug management and development of common tools. Pharmacists from WHO, PSF and Medicins sans Frontiers (MSF) are supporting this activity initially in Pristina and Prizren.
Reproductive and Child Health
Accurate figures for maternal and infant mortality are not available as yet, but estimates - 30-50/1000 infant mortality, 30-40,000 maternal mortality - suggest this is the most acute area of health concern currently.
50,000 -60,000 deliveries take place annual and 51% take place at home. [UNFPA/IOM demographic and reproductive health survey, in press]
Immediate practical efforts are focused on improving basic conditions in maternity units in health houses and hospitals - ensuring especially heating, hot water, blankets and baby clothes are in place. Half way through winter, however, many of these remained elusive. A working group including the special adviser to SRSG, WHO, UNFPA, UNICEF and KFOR is been working to resolve these issues by end January.
Projects which will have longer term impact on infant statistics include the introduction of the WHO/UNICEF gold standard approach to infant care, the Integrated Management of Childhood Illness programme. This is currently being adapted for Kosovar circumstances for planned training. An international course in Essential Newborn Care has also taken place with similar goals.
The vast majority of women have less than one antenatal visit during their pregnancy, contributing to a high rate of prematurity and birth complications. Developing ante-natal services is an important element in the training of new family health teams.
Contraceptive awareness has been boosted by the presence of NGO-supported mobile and static gynaecological clinics. UNFPA has distributed contraceptive supplies, though stocks are now low. However, abortion is still the most common form of contraception. Much work remains to be done in raising awareness about methods of controlling fertility and the rights associated with planning a family among both medical professionals and the general population.
Several as yet unpublished surveys suggest there may be a high use of ultra-sound to sex the foetus; boys are a more popular sex.
Up-to-date statistics for HIV/AIDS infection are not yet available. The only figures to hand show 24 cases reported since 1986. The Institute of Public Health, WHO and the UK’s Department for International Development are exploring a collaborative project which would encompasses developing laboratory facilities for HIV testing, counseling and health promotion activities.
International organizations wishing to offer help with post conflict trauma have poured into Kosovo. In some cases these good intentions have come unstuck due to lack of sensitivity to local culture and language. The most successful projects are those which empower and train local counselors or offer financial and material support to local NGOs and public services.
The system of psychiatric services in Kosovo is highly centralized and hospital-focused with almost total lack of community services, other than those associated with conflict trauma. Patients are mostly treated pharmaceutically. However, awareness of alternative systems both in terms of treatment sites and types has risen over the past seven months and a strategy for the gradual reform of the system - including increased primary care and community services - is being drawn up.
Shtime/Shtimlje mental institution has undergone substantial repair and rehabilitation under the international management of the Norwegian Red Cross, who have also recruited international staff to work alongside local staff.
There continues to be a lack of psychiatrists, psychologists, nurses and social workers, as well as support services for children and adolescents.
Initiatives to start informing and re-orientating professionals towards a community approach to mental health are underway, and includes workshops and the development of a relationship with the WHO Community Mental Health Collaborating Centre in Trieste.
Violence and injury prevention
Local organizations estimate between 10,000 and 20,000 women were raped between February 1998 and June 1999. Though accurate statistics do not exist, it is thought that the majority of women who became pregnancy from rape aborted their children. A number of children have, however, been born, and a number have been placed with foster families.
Mines have been cleared from all schools and from most public areas, but many remain in rural or countryside areas.
Most recent statistics show 405 people became victims of mines and UXO in Kosovo between June and November 1999. Seventy nine people died and 326 people were injured, with males making up the vast majority in both cases. Numbers fell substantially in November, with only two victims in the month compared to 60 in September and a peak of 156 in July.
Mine awareness groups continue to run mine awareness courses for adults and projects using child-to-child techniques in various areas throughout Kosovo. UNMACC have set up a database which does what?
WHO is concerned that there has been no assessment of what local people who have been exposed to violence believe they lacking in terms of health and social services and support. To remedy this a series of focus groups are being held in January to provide information to workshop aimed at finding ways to fill the service gaps.
WHO documents are available on many of the areas detailed in this report.
For further information, please contact:
Hilary Bower, Information Officer
Ph: + 381 38 549 216/218
Mobile: + 41 79 244 6008