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Kosovo Health Talks 21

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NEWS UPDATE
PRIMARY CARE

Huge response to family doctors training

More than 430 doctors have expressed interest in taking part in the professional updating course in family medicine that will spearhead the revitalization of primary health care in Kosovo. Yet core funding for the programme has yet to be confirmed.

The extraordinary response results from personalized invitations sent out by Pristina University Medical Faculty three weeks ago to over 970 primary care doctors working in ambulantas and health houses around Kosovo, canvassing interest in the six-month, six-module programme that will combine theoretical training with on-the-job, peer supervised training.

Some 120 GPs, 104 specialists and 43 doctors on residency are included in the total, with the remainder of unknown specialty.

The next step, says WHO Primary Care Coordinator, Sue Woodward, is to analyze the responses in terms of experience, and draw up selection criteria. From these, application forms will be sent out and a selection board made up of faculty members and other experts set up to interview for the first intake of 50 who will start the course in June.

Worryingly, however, the profession's eager response to what is generally seen as an opportunity to rapidly improve the health of Kosovars, has not yet been matched by donor commitment, though agencies including the Swedish Development Agency, SIDA, the European Taskforce and ECHO have expressed interest in participating in a funding consortium.

Core funding of US$1 million is needed for the professional updating course, and a further US$6 million over three years to develop the Medical Faculty specialization that will firmly embed family medicine into the health system.

Pristina report finds plenty of work for donors

A WHO report which recommends where to focus effort in the development of family health centres in the Pristina region identifies over 30 health facilities in need of NGO support ranging from complete rehabilitation and equipping to minor repairs.

While some facilities in the region are being rehabilitated and equipped by organizations such as International Medical Corps, Médecins du Monde-France, Medicos Del Mundo-Spain and the Norwegian Aid Corporation, the report shows large numbers have garnered no donor or NGO interest despite their proximity to the international action in the capital.

Compiled over the past five weeks by WHO medical assistants, Dr Ismet Lecaj and Dr Sonja Bulaic, and Regional Public Health Adviser, Dr Nick Gent, the report provides up-to-date details of the services currently being carried out, and recommends which facilities have the potential to become family health centres and which should be developed as satellite surgeries to good comprehensive access.

Similar reports have been compiled by UNMIK regional health officers and WHO staff on the Pejë/Pec, Gjilan/Gnjilane and Prizren regions, and are being used by the UNMIK Department of Health and Social Welfare to aid its Kosovo-wide planning of the development of primary care.

For further information, please contact either WHO offices in Pristina or the regions, or UNMIK Department of Health and Social Welfare on +381 38 501 400/398/397/396, or hvvuori@hotmail.com

PUBLIC HEALTH

Britain funds practical goals but wants reform

The UK’s Department for International Development has paid £1 million into a project based in the Kosovo Institute of Public Health that will not only address key public health areas over the next year, but also start preparing the organization for a fundamental shift in its structure and role.

The three specific public health goals in the WHO-managed project were chosen in collaboration with the IPH and are:

  • improving immunization coverage via development of the most effective cold chain system and accurate monitoring systems, and eventually integration of the programme into primary care;
  • raising food and water quality control to European standards across Kosovo and implementing a cost effective model for the management of microbiological laboratories
  • developing appropriate modern guidelines and protocols on all areas of public health for professional training and public health promotion activities.

"We know there are many other things in public health that could be targeted, but these are our priorities," says IPH director Dr Skender Boshnjaku. "Our choice is based on the fields that we consider will be most successful in improving the health of the population."

Other key public health activities, such as epidemiological surveillance, are already being funded by other donors, while the crucial re-establishment of a health information system - estimated to cost some US$4 million - is currently the subject of WHO proposal to the European Union.

Underlying these specific public health goals, however, is a fourth objective without which, says DfID Health Adviser, Dr Rob Stevens, the agency would not have sealed funding. This is that there will be a programme of activities which will prepare the institute for a gradual but fundamental refocusing of its activities.

The aim is that instead of being an operational agency - physically carrying out programmes such as immunization and epidemiological investigation - the central IPH should become, over time, the technical and intellectual engine of public health policy, planning and standard-setting to the Government, while its current outposts form the technical backbone of, at present, hypothetical "regional health offices".

Practically, this will mean integrating many of the Institute's operational duties into primary and secondary health care. Progress over the year-long project will rely heavily on how quickly these are able to develop such capability.

It will also rely on the international team members convincing local colleagues of the health benefits and cost effectiveness of the new roles, which is why a series of feasibility studies have been written into the proposal, through which, it is hoped, the best models for each activity will be designed.

The problem says Dr Boshnjaku, is that "in our minds the role of the Institute of Public Health is very important because right now there is no other organization that can take on these duties.

If, over the next year, we achieve European standards in water, immunization, epi-demiological surveillance and response, health education and promotion, health planning and policy, air pollution - all the things that are the duty of a public health system. Then we can discuss the role of the IPH system with WHO and UNMIK."

Dr Ilir Begoli, IPH Head of Social Medicine, adds that while IPH specialists are open to the prospect of reform, they want the international community to explain their recommendations. "If people want to reorganize our health system in some way, it seems reasonable for them to justify their suggestions."

Dr Begoli also put in plea for "transparency": "People have come and gone so much and we have not known what is going on." The collaboration between DfID, IPH and WHO on this project, he adds, was unusual, and should be a model for proposals.

According to the newly arrived public health expert, Dr Reinhart Jung-Hecker, who will lead the project as WHO/IPH Coordinator for the next three months, the new programme "is a starting point for a comprehensive but step-by-step process of reform, which has to take local and international interests into consideration and which can only realised in an atmosphere of respect and confidence."

COMMUNICABLE DISEASES

TB commission backs action plan

After some five months of consultation and debate, the Kosovo Tuberculosis Commission has reached agreement and formally endorsed the TB Action Plan for the territory. The plan, which still needs official approval from the Department of Health and Social Welfare, introduces the WHO-recommended Directly Observed Treatment Short-course (DOTS) to Kosovo, the strategy which local and international experts anticipate will play a key role in halting the rising tide of TB cases in the province. Currently Kosovo is estimated to have a new case rate of 77 per 100,000 population, over three times the rate in the Federal Republic of Yugoslavia. Cases tripled between 1990 to 1996, largely due to abandoned treatment and are now estimated at around 1,800 and rising due to the larger pool of infected individuals and poor and confined living conditions.

Developing the plan involved much discussion and justification, particularly as Commission experts, which include local pulmonologists, microbiologists and TB specialists, plus representatives from WHO and the American NGO Doctors of the World, explored key issues such as the efficacy of the DOTS strategy and the number of tuberculosis centres that would be needed for effective coverage of the population.

The plan now endorses six TB diagnostic centres with strong services for patients and physicians, underpinned by a concerted programme of training for primary care doctors in both symptom identification and referral and management of therapy. The plan also calls for UNMIK to recruit a Kosovo programme manager who will plan the implementation process in detail and ensure close monitoring and evaluation of the system.

More details will be released following official approval.

Primary care, professionalism and pragmatism

After three weeks in post, Kosovar co-head of the Department of Health and Social Welfare, Dr Pleurat Sejdiu, talks about his priorities.

"The first change must be to establish a modern primary health care - this is the future of health care."

The Kosovo Liberation Army's "Jamie Shea" may have spent the past seven years persuading the world of the righteousness of Albanian Kosovars' cause in London, but one of Pleurat' Sejdiu's first campaigns on his return was to persuade his colleagues in the Partia e Prosperitetit Demokratik të Kosovës that health was a crucial department to control in the divvying up of governmental sectors that accompanied the introduction of the new Interim Administrative Structure.

"I was the main advocate of PPDK talking on health. Other people saw other departments as more influential but I convinced them that not only does the health system need great changes, but that since health is the first help to be felt by the Kosovar population and we are a social democratic party, we would show our skills best through the Department of Health," says Dr Sejdiu, who since his return has been the PPDK's Foreign Affairs Adviser. "It's also important because of the danger of privatization which could compromise access to health, and because of the needs of families affected by the war. It is our duty as a party to look after these people."

A medical doctor who trained in Romania after being expelled from Pristina University in 1981 for being a member of a Kosovan Marxist-Leninist youth organization, Sejdiu, also has personal reasons for backing health. "I started my specialization in orthopaedic surgery but never finished it. I can't get out of politics in just a minute but I hope soon I will be able to pursue my profession again."

The Minister is keeping his hand in by working night shifts and early morning hours in Pristina University Hospital, but to what, we asked, will he be giving most urgent priority in the department?

"The first change must be to establish a modern primary health care as it is in Western Europe. I am one of the militants pushing forward this idea because I used to live abroad and I know how it works. The health organizations who here been here over the past eight months have done a great job in preparing all the proposals and documents and convincing most of the doctors that this is the future of health care.

Now we have to make it work. Secondary health care needs a lot of change too because we still have the old system from the communist time, but the first target will be the primary health care."

This comment sounds like it comes straight out of the UNMIK's "Blue Book" strategy which recommended the health system be re-oriented around family medicine, but Sejdiu says the Blue Book can only show general direction. "It is probably the perfect way to do it, but it can't be done in this situation - there are many things that need to be adapted," he says promising a "realistic blue book" as soon as the department has its full staff. "Things must go slowly. I'm not for radicalism because I know what happened in Albania, Bulgaria, Romania. Let's try and transform the system from the old to the new as painlessly as we can."

"Painless" change is, however, likely to be as much a tautology in Kosovo as anywhere, and Sejdiu now faces the difficult task of managing public and professional expectations, expectations which he says have been unfairly raised by the international community. "People are expecting much more than we will have power to offer - which is just basic care. UNMIK promised a whole lot from the beginning, I have been involved with 200 international companies who came here promising big things and everybody thought they will build factories, hospitals in 20 minutes. That was a wrong message. I won't make promises - what I can achieve is just zero plus. I know we will need to make some unpopular decisions soon that will bring the whole pot to boiling point - on issues like staffing numbers - but I am asking people to be patient."

One imminent challenge to patience will be the introduction of salaries. Here, Sejdiu asks health workers to, for the time being, maintain the spirit they showed during the times of conflict. "I totally disagree with the sums for salaries. I am afraid that they will be an open door to corruption... but health workers must understand that the budget we have now has been donated and we have to deal with it."

Another immediate challenge are accusations that political pressure is distorting appointments to key health service posts. But Sejdiu says: "I want to make clear that our policy is that the professionals should take over. For me, it is not enough to be PPDK to lead a hospital. I want success for my party but that means having professionals. I encourage anyone who has been put under any pressure to approach the department."

And it's not only local 'rigging' he rejects. "The international community have to realise their role is changing too. It is a very important role, but my message is to listen more to the needs and the proposals Kosovars. We have to centralize the help being offered and see who is best to do what - and at the same time bring Kosovars back onto the scene so that they can very soon take over the whole system."

Outbreak of epidemic preparedness

Around 30 Kosovar epidemiologists, microbiologists and infectious disease clinicians will descend on Pejë/Pec tomorrow for the second in a series of International Rescue Committee/Institute of Public Health/WHO-sponsored training workshops for those involved in controlling communicable disease.

The four-day course includes lectures and workshops in planning and implementing outbreak investigations, maintaining preparedness in terms of protocols, supply stockpiles and team availability, outbreak response and control, and communicating outbreak information both professionally and via the media, and will allow regional response teams to develop and improve their skills. A previous event, held in Prizren in December, offered training in disease surveillance and methodology.

Polio campaign planned for spring

UNICEF statistics which suggest an almost 30% drop in the number of children who turned up for their second polio dose compared to the first, have caused alarm, especially since this is the year the World Health Organization hoped to certify the whole European region as polio-free.

Although there have been no confirmed cases of polio since the end of the conflict, falling immunization rates bode ill for the future. Consequently Dr Hannu Vuori, Co-Head of the Department of Health and Social Welfare, has asked UNICEF, WHO and the Institute of Public Health to investigate methods of increasing immunization coverage. The best way to achieve this is to add a polio campaign onto the routine immunization schedules. UNICEF already have vaccines in-country and funds to cover such a campaign, says the Agency's Health Coordinator, Dr Monica Paslaru.

However, such a campaign has to tackle key reasons for the low rates in the first place such as parental education and motivation.

No spread of meningitis from solder victims

One fatal case of meningoccal septicaemia and another of suspected meningitis among German KFOR troops put medics on alert earlier this month, but no further spread has resulted.

With the evacuation of the second case to Germany, military doctors instigated preventative drug therapy in close and secondary contacts, and offered vaccination against meningitis A and C to soldiers who felt at risk. Surveillance was also stepped up. Since the incubation period for the condition is five to 14 days, further linked cases are now unlikely.

Water warning

Studies into the levels of detectable chlorine in water supplies in the capital show the lowest rates are occurring in the supply to Pristina University Hospital, followed by supplies to Sunny Hill. Institute of Public Health water scientists are following up the cause of this poor chlorine protection.

UNMIK HEALTH AND SOCIAL WELFARE

Health budget on drip feed

UNMIK Health has received their first allocation of money from the 2000 budget, but uncertainty about future tranches is complicating planning.

The first tranche makes up 11% of the 81 million DEM promised to health for the year, but so far there is no information on when the next payment will come through. Given the donors' disappointing performance on last year's pledges - health got half the 24.9 million it was promised - health managers are worried that instead of having to last just over a month, they may have to stretch their allocation over several months.

Purchasing is also complicated by the drip-drip approach, meaning, for example, that long-term, more cost-effective ordering of drugs cannot be done. Instead the arduous process of tendering and delivery has to be repeated every few weeks.

On top of this is the uneasy possibility that last year's poor performance on delivering actual cash could be repeated this year, especially as Kosovo is increasingly replaced in the headlines by other emergencies. A repeat would see health workers struggling to provide a service for 1.8 million people on just 40 million DEM - a situation that would almost inevitably mark the end of a comprehensive state service and a move to a private system.

According to Dr Nick Gent, Regional Public Health Adviser for WHO, both UNMIK Health and its international and local agency partners must start acting as real advocates for the health service.

"We are not playing our legitimate part if we don't loudly point out to the highest levels the problems that these uncertain - and decreasing - budgets are putting on the health care system. We can sit here and hope that the money arrives, or a magic solution turns up, but we are in for real trouble in the second part of this year if we don't have a clearer idea of what money is coming in."

In fact, estimations of the total Kosovo 2000 budget have increased in recent weeks from 350 million DEM to 542 million DEM with 70% projected to come from international donors with the remainder generated within Kosovo from activities such as customs, licensing and taxes.

But whether the allocation for health will increase proportionately, and whether donors will stay loyal to their pledges, remains to be seen.

UNMIK wants to start salaries next week.

UNMIK's salaries unit is aiming to make the first payments to health workers by the end of February. The programme is likely to be a rolling one, with payments starting in Pristina next week then moving into the regions. Regardless of the start date, the paymasters have confirmed salaries will be back-dated to 1 January.

Smooth transition to salaries will rely on the prompt return of nominal rolls by health facility directors who have been asked to check the lists for correct categorization, full or part-time work and other information that might affect final salary levels. UNMIK health officers have also been asked to compile lists of workers who they believe are incorrectly classified, such as technicians who are heads of departments.

Interviews underway for new directors

Department of Health and Social Welfare Co-Heads, Dr Hannu Vuori and Dr Pleurat Sejdiu, will be out in the regions this week interviewing candidates for the posts of hospital and health house directors. Candidate numbers per post range from one to six, and the department hopes to have signed contracts as soon as possible so that progress can be made on key planning issues.

CALL FOR INFORMATION

Health Talks is a forum for health information from all sources, agencies and organizations. If you wish to disseminate or request information on any health-related subject, please contact:

Hilary Bower,
WHO Information Officer,
at the WHO office, Pristina
Office phones: + 381 38 549 216/218,
Office mobile: +381 63 406 895.
Personal mobile: + 41 79 244 6008
Email: hbower26@hotmail.com

Please provide information, by email if possible, by the weekend before the General Health Coordination meeting (held fortnightly 11am, 3 rd floor Dean's Building, Pristina University Medical Faculty.

Don't export patients: UNMIK won't pay

UNMIK Health is reiterating its warning that it cannot pay for the treatment of patients transported outside Kosovo. Reports have surfaced of patients being sent to Tirana and Skopje outside the official Medevac programme, but Co-Head of the Department of Health and Social Welfare, Dr Hannu Vuori, says UNMIK will not pay when the bills arrive.

"In the past, a patient could be referred anywhere in 'Yugoslavia' and no bill would be submitted. Health insurance paid. It's estimated this cost around US$10 million a year but there is no provision in the UNMIK budget for this at all."

A recent example involved a child patient who was said to require surgery not available in Kosovo to allow haemodialysis treatment to begin But Professor Tony Redmond, International Director of Pristina University Hospital, said the patient could have be treated with techniques available Pristina. "The capacity of the hospital is there - some people may want their operation or dialysis outside of Kosovo but that is their preference."

INTEGRATION

MSF maintains house calls to minorities

Mediciens sans Frontières - Belgium have replaced nationals in their mobile medical teams with internationals to enable them to continue serving the 8,000-odd people living in single-ethnic enclaves in the Mitrovica region.

The service, which has run since October in two enclaves Skenderaj/Srbica, six in Vushtrri/Vucitrn and nine small communities in and around Mitrovica town, involves one or two doctors, two nurses and a psychologist. Mostly they offer basic primary health care, says MSF - Belgium medical coordinator, Dr Bart Janssens, and work in some cases from consulting rooms often organized by the Mother Teresa Society; in others, patients know when they will come and the team goes door-to-door.

"Most of the time we are taking care of chronic patients. We find diabetics not being taken care of, chronic wounds that haven’t been cared for. But it is also presence through medical activities, showing that people still care," says Dr Janssens. The clientele served are 50:50 Albanian and Serb, he adds.

FOCUS ON CO-EXISTENCE

The imminent opening of secondary care units in the ethnically Serb town of Gracanica six kilometres from Pristina University Hospital, and measures being taken in divided Mitrovica to provide services to the Albanian community, have brought the issue of 'co-existence' into sharp focus for health agencies. But might such parallel services actually set back progress to integration?

The debate turns on whether the wellbeing of isolated and threatened communities are better served by the development of 'parallel' health facilities or by strongly enforcing access to and undiscriminating care in normal health services.

Patently, the political decision has been to chose the former. On 13 December 1999, SRSG Dr Bernard Kouchner launched the "Agenda for Co-existence" one aim of which is to provide safe access by minorities to essential public services. "Facilities will be established at the community level to guarantee access to public services such as health and education," he told journalists.

While many NGOs have worked hard over the past eight months using mobile clinics to ensure that vulnerable enclaves have access to primary care, and UN organizations such as WHO have worked to re-establish Serb and minority staff in primary care surgeries with legitimate catchment populations, the new units at Gracanica, supported by Médecins du Monde-Greece and the French Red Cross, will be the first concrete parallel structures to open.

The 20-bed unit with emergency, delivery, laboratory and X-ray services intends to serve roughly 35,000 ethnic Serbs and other minorities, some 5000 in the town of Gracanica itself and the remainder from the surrounding mixed-ethnic areas - all of whom would, in normal circumstances, attend Pristina University Hospital for these services. On Dr Kouchner's orders, running costs and staff will be paid from the UNMIK health budget.

According to MDM-Greece Medical Coordinator, Zouheir Dabbour, there is no doubt that this service is vital for the health of the population. "If you think this facility is not needed, please go into the field and try and find a place to transfer a five year old with a fever in the night. It's true there should not be a parallel system but patients cannot wait for integration to happen to get help, and it is against all international laws to send a patient to a place they don't want to go or health care."

However, although the emphasis is always that these measures are temporary - Dr Dabbour says as soon as there is integration the unit will be closed - many believe such parallel developments not only undermine the feasibility of Kosovo's health service with its already limited financial resources, but may set back the process of integration. What chance, for example, is there of encouraging a community - now or in the future - to go to a hospital some kilometres away, when they have been given a tailor-made facility, most likely of higher quality, on their doorstep? What chance is there of changing perceptions of the care available in mainstream hospitals and primary care.

Then there are the blunt cash term. "How,.says UMMIK Health deputy head, Bengt Stålhandske, "are we going to pay for it? If it is a political decision that these activities should occur, will they be paid for out of a political budget?"

In Mitrovica, the parallel developments can be seen in different light since it is already a regional hospital centre and equipment supplied could easily be transferred should the hospital reintegrate, but in Gracanica, this is much less likely.

Arthur Pittman, international operations director at Pristina Hospital agrees patients cannot be forced to go where they fear to go, but believes the problem lies now not in discriminatory treatment, but failure in the rule of law.

"I have never seen any mistreatment of patients in Pristina Hospital, and have heard no allegations of mistreatment for months, but getting there and back, and changing people's perceptions is a different matter. I have seen patients waiting for hours to return home (to Serb areas). I have tried to pay taxis to take them there, but they won't. I've had people in critical care who insist on being taken to lesser facilities because they feel unsafe. Until there is some rule of law that assures access and reassures people, things are not going to change."

It could be argued that boat rocks less when UNMIK supports the building of parallel health structures than when it tries to get KFOR to maintain secure access to hospitals and health houses. After the war, says Dr Sinan Prekazi, spokesman for Mitrovica's Albanian hospital workers, Albanian and Serb doctors worked together for three months with patients from both sides. They were eventually stopped by the daily gauntlet of stoning on the route to work. "If we can solve the problem of security of movement, the other issues can be easily solved,"

As one American doctor, who preferred remain nameless, told Kosovo Health Talks "UNMIK should look to history - other places where "separate but equal" development has been tried have been a disaster. It took America 100 years to decide that black and white kids should go to the same schools but then it took soldiers to do it - and if there's one thing UNMIK has in abundance, it's soldiers."

HOSPITALS

Board stays but deputy director post reopens

Pristina University Hospital's new board of directors will keep their posts for the period of their six month contracts, despite the displeasure of the new co-head of the Department of Health and Social Welfare over the way they were appointed.

But the post of deputy director, originally offered to Dr Ilir Tolaj, head of the hospital's infectious diseases clinic, is to become a full time position at the request of UNMIK Health, rather than an additional role for one of the existing board members.

Candidates for the new post were given just five days to apply and fresh interviews will be carried out this time by the Department heads who say they want to take into account the views of the staff body as well as board members.

"We have to listen to the people about who are the best, who is acceptable to them," says Dr Pleurat Sejdiu. "People have been working for nine months with little or no payment, at least they can give their opinion.

Members of the hospital's board strongly objected to the Department's opinion that it should appoint the deputy director not the board, but were eventually forced to concede. "This is our house," says Dr Sejdiu, "The department is the owner so it is our prerogative to put in the director."

Days numbered for health care waste

Two brick-built, De Montford-style incinerators are being test fired in Gjakovë/Djakovica this week and should be fully operational by the end of the month. The machines are the first of six to be built. Two are now under construction in Gjilan/Gnjilane Hospital, and the foundations are being laid for two more in Prizren Hospital.

"These incinerators are small but effective and fast to build, and they treat waste to a high standard," says WHO's assistant environmental health coordinator, Sarah Gayton, who has been coordinating the project. "They will also allow the hospitals to start doing proper waste management. Before waste was openly burnt in the hospital grounds."

The machines, which have been funded by German aid agency GTZ, take just a week to build, cost around 6,000 DEM each and burn around 15kg of health care waste an hour.

Similar machines are planned for Pejë/Pec and Mitrovica hospital and health house to fill the gap until larger machines planned by the Cooperazione Italiana and, for Mitrovica, using a UN rapid impact fund grant, can be constructed.

GTZ is also supplying each hospital with a starter pack including black and yellow bags (to separate normal and potentially infectious health care waste) and sharps containers which should last until the Department of Health and Social Welfare's supplies arrive around May.

In Gjakovë, the hospital's newly constituted hygiene committee is taking advantage of the testing time to develop its waste management plan and carry out training based on WHO guidelines for Central and Eastern Europe. They are also planning a big party to clean up the hospital grounds.

Anaesthetists alert...

Pristina University Hospital's biggest clinical problem at present is a dire shortage of anaesthetists, according to Operations Director Mr Arthur Pittman, who says surgery cases are backed up for weeks in some departments as a result. The hospital is looking to recruit at least four Kosovar practitioners but, in the meantime, says Pittman, "It would be extremely helpful if we could locate an international team of anaesthetists and anaesthesiologists willing to come to the hospital to remove the backlog of cases."

For further information, please contact Mr Pittman on arthurp1@hotmail.com

Health promoting hospital expert arrives

Waste management trainer Dr Sian Fisher from Preston Hospital in England, a member of WHO's Health Promoting Hospital Network arrives later this week. Funded by GTZ, she will work with hospital hygiene workers to develop waste management and waste minimization strategies over a two week period.

Further information from Sarah Gayton, WHO deputy environmental health adviser.

HEALTH TALKS ON THE NET

Kosovo Health Talks is also published fortnightly on the WHO/EURO website - http://par.who.dk, click contents, then enter Kosovo Health Talks in the search field for back issues - and on Relief Web: www.reliefweb.int.

Emergency room for split Mitrovica

Experts from French NGO Premier Urgence are currently assessing the possibility of setting up an emergency room in Mitrovica's health house to improve service to the Albanian population who are cut off from the town's hospital.

The initiative comes hard on the heels of the continuing development of diagnostic facilities on the south side of the divided town.

Echocardiographs have already been installed and it is hoped donor support for X-ray equipment will soon be confirmed.

MILITARY

NGO criticises medical manoeuvres

Leading medical NGO, Médecins sans Frontières-Belgium, has questioned the value of military medical activities in Kosovo.

Speaking to NGOs and donors at the General Health Coordination meeting earlier this month, Dr Bart Janssens, MSF-B Medical Coordinator said KFOR's heavy logistic support for health care was invaluable but in many cases its medical activities were uncoordinated with the mainstream of the international and local efforts and are often "isolated, irrational and duplicative".

"For example, there are 'wild' mobile clinics in Skenderaj/Srbica and Vushtrri/Vucitrn where KFOR medical battalions go into 'empty' ambulantas and offer medical services often just after a local or MSF team have been doing the same thing. Yet high in the mountains where there is no service, where they could usefully go, they don’t seem to want to go."

In other areas, such as Vushtrri/Vucitrn, where United Arab Emirates KFOR has been keen to take over the health house, and Mitrovica where Moroccan KFOR has been providing secondary care services, KFOR is in danger of setting up a completely parallel service. Although there is clear need for immediate support in both cases, Dr Janssens questions the effects of these activities which involve virtually no local staff.

"There is an important risk of devaluation of local staff at both clinical and managerial level... There is also the question of how these structures will integrate into the system in the medium and long term - particularly the risk that the role of the health house as the central organizing point of the primary care system in the municipality will be neglected.

"There is the issue of sustainability. It is not at all clear what can be KFOR's delivery over the long term."

The trouble, he added, is that medical activity has become part of military strategy. "Troops need proximity to the population and medical services are seen as the most sexy, most friendly way of doing it. The question is since these activities are not military and are 100% towards the population, should they not be coordinated by UNMIK Health?"

REPRODUCTIVE HEALTH

Healthy family committee sets big agenda

In a two day-long workshop last week, the UNFPA-supported National Committee for Healthy Families identified a total of 16 key areas and over 80 potential activities that could improve the lives of women and children in Kosovo in terms of mental, physical and reproductive health, their place in society and socio-economic development.

Among the recommendations which the group intend to present to the Co-Heads of the Department of Health and Social Welfare for consideration are the development of reproductive health and premarital counseling skills, the sensitization of political, religious and NGO groups to health family issues, development of laws against domestic violence, and public campaigns to address among other things child spacing, the status of women and children and school drop-out rates.

The group, which is chaired by Director of the Institute of Public Health, Dr Skender Boshnjaku, brought together public health workers from around Kosovo, journalists and representatives from Pristina Health House and the Centre for the Protection of Women and Children as well as members from UNFPA, UNHCR, UNICEF and WHO.

MOTHER AND CHILD HEALTH

Essential newborn care moves to Gllogoc

The second five-day course in Essential Newborn Care and Breast Feeding to take place in Kosovo starts in Gllogoc/Glogovac on Monday, 28 February.

Facilitated by WHO and Pristina Hospital neonatologist, Dr Drita Rizvanolli, the leader of the Kosovar Doctors Action Committee against Infant Death which was created on the wave of enthusiam raised from the first course, the course focuses on ways of making delivery safer and maximizing care of babies in the first few hours of life. It investigates issues such as the 'warm chain', resuscitation, 'rooming in', and maternal referrals and is open to obstetricians, gynaecologists, neonatologists, paediatricians and nurses.

In another initiative Dr Rizvanolli and her committee colleagues are to run single day updating course in infant resuscitation techniques for doctors and nurses, prompted by the realization during the first ENC course that the lack of skilled resuscitators available 24 hours a day was one factors in Kosovo's high rate of infant mortality.

For more information please contact Dr Suzanna Hadzialjevic at the WHO office, or Dr Rizvanolli at Pristina University Hospital.

Hot beds for Pristina

WHO has donated four 'hot' mattresses for premature babies to Pristina University Hospital's neonatal ward. The mattresses, which can be simply placed on a bed, act like a warm nest and can be used for fast rewarming of babies which have lost heat for some reason after delivery. They are also ideal for transporting newborn babies within and outside the hospital in cold temperatures and to allow "in between" babies - those who are small or slightly premature and don't really require the full resources of intensive care - to stay with the mother during their first days after birth.

Though electric-powered, they are filled with water, the temperature of which drops very slowly when power is disconnected.

PHARMACEUTICALS

UNMIK promises emergency purchase

UNMIK Health has guaranteed to complete an emergency purchase of roughly one month's worth of hospital drugs by the end of this week to ensure there is no gap in supply. The emergency procurement has become necessary because of the drawn-out nature of new UN procurement procedures. To speed the process of securing longer term hospital supply, WHO is bringing in a pharmaceutical expert to work with UNMIK procurement for a week on the technical evaluation of tenders.

Lack of knowledge causes pain

Many ill Kosovars are suffering pain unnecessarily due to combination of inexperience and fear regarding the use of morphine as a painkiller, according to Dr. David Moorsom, a UK specialist in palliative medicine sponsored by Child Advocacy International.

After four weeks assessing the management of patients with life-threatening diseases and terminal illness in Pristina University Hospital and the community, Dr Moorsom says: "There is a very limited choice of analgesics, and the two most commonly used for severe pain (metamizide and tramadol) are not suitable for severe chronic pain, particularly cancer pain.

"Injectable morphine is available but is almost exclusively used in the intensive care unit. Many patients are suffering unnecessarily with uncontrolled pain because of the lack of morphine, particularly patients in the community."

Cancer patients are particularly affected, adds Dr Moorsom. "Morphine is the gold standard around the world for cancer pain control. Since advanced cancer treatment, including radiotherapy is not available in Kosovo, it is imperative patients receive excellent pain and symptom control to enhance quality of life."

One factor in the low level of pain control is that many doctors have little or no experience in the use of morphine for the management of chronic pain.

"And there are still many fears around the use of morphine that need to be dispelled," he adds In addition, oral morphine is still unavailable, though immediate release tablets are on the essential drug list.

To improve the situation, Dr Moorsom has started treating patients with injectable morphine in collaboration with their attending doctors. "This is allowing doctors to witness the benefits of morphine and to begin learning how to prescribe it."

He has also arranged for a starter supply of oral morphine to arrive in Kosovo this week.

"A secure supply of morphine is needed in Kosovo as well as a plan to ensure physicians and nurses are skilled and comfortable with its use," says Dr Moorsom, adding that there is also and urgent need for a coordinated training program in pain and symptom control and other principles of palliative care.

Dr Moorsom would like to hear from anyone interested in pain control and palliative care and can be reached on ph: 381 38 21 931 or e-mail: dmoorsom@hotmail.com

Emergency haemodialysis supplies arrive

UNMIK Health's emergency procurement of one months supply of fluids and consumables for haemodialysis arrived last week and was distributed to Pristina University Hospital and the regional hospitals. This is the first purchase of drugs from the health budget, says UNMIK Financial Officer, Anthony Gabriel.

Drugs survey looks for hard evidence

No one changes their routines without good reason, and doctors are no different in their prescribing habits, says Dr Evdokia Dardarmissis, UK specialist registrar in public health currently on assignment with WHO, who began a survey of drug use throughout Kosovo on Monday.

"The aim of the survey is to identify current prescribing tends so that we can plan a rational prescribing policy. For example, we know anecdotal that people use a lot of injectable antibiotics for minor illnesses that are often viral. That's not good for patients but you need hard evidence to get people to change."

Over the next two weeks, Dr Dardarmissis and her pharmaceutical colleague Dardane Arifaj will visit 20 health care facilities, including a health house and an ambulanta in each region, and examine medical records from February 2000 for details of presenting conditions and drug treatment provided.

"What we'll get is a representative snapshot of what's being done," says Dr Dardamissis, who notes they'll also be gathering information on how facilities deal with their clinical waste like needles and unused pills.

Results from the study should be available by the end of April and will be used to develop a Kosovo prescribing policy that can form the basis of a professional and public campaign for rational prescribing.

Strong control of hospital drugs instigated

The first Kosovo-wide hospital pharmacy meeting, organized by WHO, Pharmaciens sans Frontières and the pharmacy department of Pristina hospital, took place last week in the rooms of the new hospital central pharmacy.

Strong hospital pharmacies are essential in order to, among other things, ensure rational management of the large proportion of the health budget that is spent on drugs in the secondary care, and high on the agenda for the local managers, pharmacists and international NGOs attending was discussion of development plans for the strengthening of hospital pharmacy services.

The group also explored progress in establishing Drug and Therapeutic Committees, the role of hospital drug lists, drug management tools, computer stock management software and re-distribution of excesses of short-dated drugs.

"Many examples of recent progress at Pristina hospital were shared with those attending the meeting so that each hospital did not have to start from scratch," adds WHO Pharmaceutical Adviser, Martin Auton.

The meeting report including copies of management tools developed so far are available from the WHO pharmaceutical adviser. Next meeting Wednesday, 15 March, at 11:00.

Essential drugs for Kosovo hospitals

WHO has launched the Kosovo model hospital essential drugs list, a document which details the most important drugs recommended for use in the hospitals of Kosovo. It is intended to be the starting point for each hospital to develop their own list through their Drugs and Therapeutics Committee, which can then used as the basis for prioritizing during procurement.

Electronic and hard copies have been distributed to each hospital and further copies are available from WHO, Pristina and will soon be available in the Regional WHO and UNMIK Health Offices.

WHO in Kosovo

Head Office
M. Popovic 1, 38 000 Prishtina
Ph: + 381 38 549 216 /218
Fx: + 381 38 549 217
Office mobile: 063 406 895
Chief of Mission: Mr Robert Hagan
e-mail: haganr@who.int

Pristina region
C/O WHO Head Office
Emails:nick_gent@hotmail.com,
ismet_l@hotmail.com
Regional Public Health Adviser: Dr Nick Gent
Medical Assistant: Dr Ismet Lecaj

Pejë - Gjakovë:
UNMIK Building
Sat. ph: +871 761 669 030
Sat. fx: + 871 761 669 031
e-mail: who_peja_gjakova@hotmail.com
Regional Public Health Adviser: Dr Erik
Schouten, Medical Assistant: Dr Xhevdet
Xhemajli

Gjilan:
c/o UNMIK Health Office
Ph: 038 501 400 Ext. 7600
e-mail: selezi@hotmail.com
Regional Public Health Adviser: Dr Shpend Elezi

Mitrovica:
UNMIK Building
Sat. ph: +873 761 602 155
Sat. fx: +873 761 602 156
e-mails:nick_gent@hotmail.com,
mcpaty@hotmail.com
Regional Public Health Adviser: Dr Nick Gent,
Medical Co-ordinator: Dr Marie Claire Paty
Medical assistant: Dr Qamille Ramadani

Prizren:
New Bankos Building- UNMIK
Ph: + 381 (0)29 41 430 Ext. 8043
Sat. ph: +873 76 1668 660
Sat. fx: +873 761 668 661
e-mail: who_prizren@hotmail.com
Regional Public Health Adviser: Dr Erik
Schouten. Medical assistant: Dr Osman Zhuri

Please note the opinions expressed in this publication do not necessarily reflect the official views or policies of WHO