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Kosovo Health Talks 22

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NEWS UPDATE
UNMIK HEALTH AND SOCIAL WELFARE

Sorrow and dismay at doctor's death

The Department of Health and Social Welfare (DHSW) co-heads have strongly condemned the murder of Dr Josifa Vasic, a member of the Serb church council in Gjilan/Gnjilane and a doctor at the hospital, and the attempted murder of a WHO microbiologist employed at Gjilan hospital.

"This was the cold-blooded murder of a health worker who was carrying out his humanitarian duties as a doctor," said department co-heads Drs Pleurat Sejdiu and Hannu Vuori in a letter to Mr Marcel Cintalan, regional administrator of Gjilan/Gnjilane. "And it is unacceptable."

Department spells out investment needs

The Department of Health and Social Welfare is working to produce a capital budget, which will reflect the health service's requirements in terms of bricks and mortar and large-scale equipment for the year 2000.

Donors have pledged roughly DEM 1.8 billion for capital investment projects across all sectors of activity in Kosovo. Currently, around a third of this is destined for housing reconstruction with large figures also tentatively allocated to transport and private sector revival.

Around DEM 51 million has been sketched in for the health sector, but, says Dr Hannu Vuori, DHSW co-head, nothing is "set in concrete" and good justifications and detailed plans could see this increased, especially as it's thought the housing sector is likely to need much less money due to the strenuous efforts of NGOs and their donors.

WHO advisers, along with UNMIK regional health officers and key health organizations, are currently collating information on facility repair and large equipment needs and the DHSW will present its proposal for funding by 15 March.

Women call for a violence-free Kosovo

Kosovar women groups are urging local women to take to the streets for International Women's Day today to demonstrate their concern in three areas: violence against women, the division of Mitrovica, and the continued detention of people taken during the conflict. Student and women's organizations coordinating the day are hoping for a mass march of women in every centre between 11am and noon, with men offering support from the side lines.

In Pristina, the International Women's Day will be marked with the launch of an exhibition of children's drawings illustrating a "Violence Free Kosovo" and a show of images by local and international women photographers on women's experiences in Kosovo. The exhbition is a collaboration between the International Medical Corps, WHO, OSCE, UNHCR, UNICEF, EU and UNMIK and will tour Kosovo during April.

PAY AND CONDITIONS

Salary payments kick off in Pristina...

UNMIK paymasters distributed salaries for January and February to health workers in Pristina Health House last week and will start paying other public workers, including all other health employees, on 13 March.

WHO, which is continuing to maintain the health service pay and human resource database until the 1 April hand-over to a new UNMIK system, has provided over 13,000 salary vouchers for health workers over the past fortnight.

It is understood March salaries will be paid in early April when the new system, expected to be run by the British organization Crown Agents, should be fully operational.

... but Gjilan workers protest unfair treatment

Over 150 employees at Gjilan/Gnjilane Hospital joined a demonstration last week to protest the differing number of stipends that were paid to health workers around Kosovo prior to salaries. Actions also took place in Gjakovë/Djakovica.

Delivering a letter of complaint to the Department of Health and Social Welfare, Dr Binaze, unofficial director of health for Gjilan/Gnjilane municipality, told Kosovo Health Talks that the employees are upset that Pristina University Hospital received seven monthly stipend payments while they, and other health workers around the province, received four.

But the UK Department for International Development management team of Pristina Hospital (PUH) says the problem is not that they paid more, but that UNMIK was able to pay fewer stipends that it originally intended. "There have no 'extra' payments to Pristina hospital staff," says operations director Arthur Pittman,

"The payments were in lieu of payments promised by UNMIK, and UNMIK continues to ask the UNK Department for International Development (DfID) to support hospital salaries, despite the fact that it also contributes to the overall salary pot for health workers."

DHSW budget, finance and personnel officer, Anthony Gabriel says the DHSW itself is committed to equal payment across Kosovo. "I can only say that this is an independent action by DfID with no input from the health department."

Few take up retirement deal

Only one person took up Pristina University Hospital's offer of a DEM 1000 'golden handshake' to pave the way to retirement - unsurprisingly given the lack of pension provision in Kosovo.

Pension funds were looted and left completely empty after the crisis. But it is not only the money that makes many people reluctant to retire, or that is encouraging management to suggest they should. A key problem is that younger doctors are loath to take senior positions that older doctors feel should rightfully be theirs.

At PUH, international director Professor Tony Redmond has floated the idea that over-age doctors - which number about 80 on his site - could be asked to become 'Emeritus' - that is an honorary unpaid senior - as they are in other parts of Europe. This means the health service could retain their expertise while still allowing space for younger doctors to move up.

"It's a very emotional issue," says Professor Redmond. "Many doctors who are now of retirement age were not of that age when they were expelled. They came back triumphant to their jobs only, as they see it, to be expelled again. We've also got to make space for the young doctors, but we've also got to allow these older doctors their return."

However, the question of surviving without a state pension - emeritus or not - remains unresolved..

Carabinieri money benefits staff and children

Rent paid to Pristina University Clinical Centre by the Italian police for the use of the former defectology clinic building will be used to build a staff restaurant and crèche, according to international director Professor Tony Redmond.

"We need to do things for patient care in the hospital, but we also have to do things for staff - especially as they are not paid their worth. We have to look after their health and needs. If the staff are healthy and happy, patients get better treatment."

On-duty staff will get free meals at the restaurant at least until salary levels improve, at which time the facility itself could become income generating, said Professor Redmond, while the crèche will be particularly important in opening up hospital work to women. "Not having a crèche prejudices against women," says Professor Redmond.

Asked whether such 'perks' might stir up trouble at other facilities. Professor Redmond noted that the café and the crèche are both funded from an initiative by the hospital, not from the UN budget. "I would hope that it might encourage others to develop their own initiatives."

The Carabinieri deposited back rent to the tune of DEM 375,000 in the hospital trust fund at the turn of the year and continue to pay DEM 75,000 a month. Both café and crèche are hoped to be open in two to three months.

CO-PAYMENTS

Co-payments advised but who should pay?

Patient contributions to health services should be introduced as soon as possible not only to add to finances, but also to 'steer' patients into primary health care and discourage the development of under-the-table payments, say German experts from the Griesfeld School for Economics and Health Management. But key questions, including who will pay, how much, for what, and where the extra money will be spent, still need to be decided by UNMIK Health.

Presenting their work to a seminar of governmental and non-governmental local and international parties last week, Jurgen Wasem and Florian Buchner, who were commissioned by WHO to study the issue for the Department of Health and Social Welfare, recommended a uniform co-payment scheme based on a fee per visit in primary care (DEM 1-2) and a single admission fee in secondary care (DEM 15-45), with exemptions for children under 5 and pregnant women, and a maximum annual fee to protect the chronically ill. They also suggested a larger fee - DEM 50 or more - for patients who self-refer to hospitals. However, their recommendations would bring an income far lower than the 30% anticipated in the Kosovo budget calculations.

As well as providing income, establishing co-payments quickly could prevent the development of local schemes that could see patients moving from one region or service to another in search of free treatments, and deter private requests for payment, say Wasem and Buchner.

During the debate, the majority of participants backed exempting primary care consultations from any future fee system, partly to ensure access to basic health care for everyone, but also to prevent fees steering people away from family practice which should act as a gatekeeper to referrals and drugs. However, this exemption would also significantly reduce income, or mean loading fees in other areas.

Which patients should be exempted also brought a wide range of views. There was, however, clear unanimity that the revenue from co-payments should remain at local level, though the issue of using the funds to make extra payments to health staff raised concerns about equity.

The ball is now back in the Department of Health and Social Welfare's court, which will need to make some quick decisions if it is to pre-empt the development of a rash of different payment schemes throughout Kosovo,

For a full copy of the report, please contact Dr Fatime Arenliu-Qosaj at the WHO office

Willing to pay but worried about ability

Kosovars would happily take a share of health care costs if their income allowed, according to the preliminary report of focus groups carried out in the Pejë/Pec/Klina area by International Medical Corps (IMC) and WHO.

But participants were concerned that this will not be the case for some time. One man put it plainly: "We are not going to be able to pay (for health services) for some time because we have nothing. I had a house, a store and a car, too. I lost them all. How am I going to pay?"

However, while this may be individually true, this view contradicts other information which shows people are already paying significant amounts for consultations, drugs and transport. The Kosovar Albanian Health Survey, carried out by the US Centers for Disease Control and Prevention last September, found average expenditure per person per week on health care was DEM 70 on drugs, DEM 17 on transport, DEM 3 on outpatient care and just over DEM 1 on in-patient care a week.

"If these expenses can somehow be redirected to direct health care delivery then cost-sharing by health care consumers may be feasible as long as there are no further challenges to the economic state of household," write authors Jose Ravano and Diana Diaz Granados of IMC and Dr Fatime Arenliu-Qosaj of WHO The focus groups also showed that people overwhelming perceived `health services' as drugs and injections and were unsatisfied if they did not receive one or both. In rural areas, the service interviewees were most willing to contribute to was the doctor's salary in order to keep them in the area.

A full report will be available by 20 March.

DONORS

Emergency? What emergency?

NGOs running mobile clinics to ensure access to healthcare to embattled groups are facing increasing demands for their services just as funders of such operations are starting to pull back. According to Barbara Pearcy, medical co-ordinator for IMC, one of the key NGOs providing mobile care, requests for their teams to visit enclaves increased dramatically with UNMIK's decision to move from a policy of integration to one of 'co-existence'.

"We are being asked to do more clinics in more places. In Mitrovica, for example, we now go house to house. A month or two ago, it was thought there was no more need for mobile teams but with co-existence, it's become clear that people are not going to integrate. The trouble is that the emergency donors are pulling out and development donors don't have money for mobile clinics which they see as an emergency response."

So far IMC's mobile teams, which were originally intended to fill gaps in services while the 74 ambulantas were rebuilt and renovated, have been supported by the US Office of Foreign Disaster Aid. But this will finish on 31 March.

"We are trying to get more money since it's clear that whatever other people think, mobile clinics are still vital for certain populations," says Robyn Ziebert, IMC head of mission.

New name but support remains

The European Union Agency for Reconstruction of Kosovo, which took over from the European Union Taskforce for Kosovo in February, will launch its health sector on 15 March. Task manager will be Dr Rob Stevens, currently health adviser for the UNK’s Department for International Development in Pristina which is due to reduce its presence in springtime. EU Agency funding is likely to be available from June.

The European Community Humanitarian Office, which has poured some DEM 22 million into primary health care since June last year, will remain a separate entity with separate funding geared to emergency-orientated projects, particularly in primary health care, says ECHO health adviser Dr Skender Kutlovci. In recent months, it has supported primary health care drug supplies and distribution through its partner Pharmaciens sans Frontières, the re-establishment of routine childhood immunization through UNICEF, disabled needs though Handicap International, and mental health and rehabilitation projects via Medécins du Monde organizations.

PHARMACEUTICALS

Stop gap hospital supply on its way

A shipment of some 42 tonnes of essential hospital drugs - funded by UNMIK - will arrive in Kosovo by the end of March. Planning for its distribution - the first to be organized by UNMIK Health rather than humanitarian agencies - is well advanced, according to department budget, finance and personnel officer, Anthony Gabriel. One of the key issues to be resolved is achieving space in Farmed warehouse, which UNMIK maintains is state property but management and workers are claiming they own via a share syndicate.

State pharmacists plan future

All 300 employees of the ex-state pharmacies of Kosovo are to meet this Saturday (11 March) to formally approve the concept of the Kooperata e Farmaceutike e Kosovës (KFK) and the ways in which it will work. The meeting will also elect a management board and discuss future strategies developed by KFK, WHO, UNMIK and PSF/ECHO.

KFK have recently acquired a small office at the Vetfarm warehouse, courtesy of the Saudi Joint Relief Committee and equipped by the WHO pharmaceuticals project.

Further information can be obtained from Bedri Abdullahu, KFK interim president, either in person or via the WHO office until phones are connected. See also [below] for Focus on Drug Supply

Kosovo Health Sector Rehabilitation and Reconstruction Interest Group
First meeting
Thursday 9 March, 2pm

Why?
  • To share information between donors and providers concerning current and future UNMIK plans, commitments and intentions of donors and providers and gaps in provision.
  • To provide UNMIK with up-to-date information.
  • To match bids and offers in order to meet immediate and medium term needs.

Who?

Groups involved in letting and managing contracts, including donors, representatives of interested UN agencies and reconstruction managers from NGOs and consultancy firms.

Building contractors should not attend the first meeting, although if there is a demand for such a group, its creation will be considered.

Please bring any survey reports or other documents you wish to share.

Where?

UK Department for International Development offices,
1 st road left over the railway, Dragodan

Further information: Dr Robert Stevens,
Health Adviser, DFID Pristina,
ph: (+38 381) 549 724 or 549 725
E-mail: rob_stevens@talk21.com

Drug supply manager to join department

The Department of Health and Social Welfare has welcomed an offer by WHO and the European Agency to fund the post of a drug supply system manager in the department.

Over the next six months, around 35 million DM of essential drugs will be bought and distributed by UNMIK health, fully warranting a dedicated drug manager who will not only deal with tender, procurement and distribution procedures and work to ensure a coordinated development of the pharmaceutical supply system but also work with hospitals to develop the online systems currently being put in place by WHO and Pharmaciens sans Frontieres.

FOCUS ON DRUG SUPPLY

Confidence in any health service is intimately connected with the availability of safe and affordable drugs.

In Macedonian where drugs are unregulated, prices are five times more than international costs.

There may be no electricity or no heating in the surgery, but trusted doctors and a supply of drugs means a cure is at hand to most patients.

While this is almost certainly a simplistic confidence, ensuring that Kosovo has access to essential drugs over the past nine months has been a priority activity among international health agencies.

Since the last year's crisis, health facilities have relied on humanitarian organizations to maintain their supply. But with the arrival of defined monies for drugs within the Department of Health and Social Welfare budget, these organizations, most of whom do not have mandate from their donors to function beyond the emergency stage of the crisis, are beginning to phase out.

To prepare for this the UNMIK/WHO Taskforce on Drugs and Medical Supplies has been working since September last year with local pharmacists and international humanitarian organizations to develop a Kosovo-wide system of drug supply that will guarantee all patients - not just those who can pay - good quality, low cost drugs, as well as assuring pharmacists of a reasonable living.

The overriding aim is to prevent the development of an effectively uncontrolled private drug supply system which has occurred in many countries of Eastern Europe, and which pushes up the cost of drugs dramatically. Macedonian drugs, for example, cost five times more than international prices.

The supply system proposed by WHO and its local and international partners involves close co-operation with the newly established co-operative of state pharmacists - Kooperata e Farmaceutike e Kosovës (KFK) - which, it's suggested, should work side by side with international humanitarian pharmaceutical organization Pharmaciens sans Frontieres in a phased hand over of purchase, stock keeping and distribution of primary care drugs over the next six months. This gradual process is supported by ECHO, which has confirmed it will pay for PSF and KFK to procure, store and distribute the needed drugs, while for its part UNMIK has verbally guaranteed that a defined percentage of the health budget will be given to PSF/KFK to buy drugs.

While this is happening, WHO has recommended that the management of hospital supplies should be contracted out to an experienced humanitarian supply agencies to give KFK or other organizations time to develop expertise in evaluating tenders, price negotiation and the sheer logistics of distributing tonnes of temperature and time sensitive products to Kosovo's six hospitals.

The ultimate goal is to have a centralised procurement unit which will buy for both primary and secondary care, since this will provide the cheapest possible way of buying drugs. But this, says WHO's pharmaceutical adviser, Martin Auton, requires time to develop.

When it comes to getting prescriptions filled, patients will initially go to the network of state pharmacists licensed recently. But with time, the private sector will also have opportunity to be involved in distributing public sector drugs.

All these plans do still have to be confirmed however by the Department of Health and Social Welfare. Department co-head Dr Pleurat Sejdiu would, for example, like to see KFK in control of both primary and secondary care supplies rapidly, while others in the department are keen to see free market competition which, they believe, will reduce prices. Other organizations, including some members of KFK, are reluctant to push KFK to run before they can walk, not least because any failure could leave the door wide open for private vendors, while a free market in Kosovo's current entirely unregulated environment (the legislation for an authority to regulate the import and quality of drugs has been sitting in UNMIK's legal department since October) would be playing with fire, not to mention people's lives, Martin Auton believes.

Whichever route is taken, key decisions about drug supply must be made very soon. The emergency procurement of drugs which will arrive in the next two to three weeks should bring breathing space, but only for a month or so.

PRIMARY CARE

Talking about family medicine

Primary care doctors and nurses around Kosovo have come together twice in the past two weeks in seminars organized by the new Association of General Practitioners of Kosovo (AMPK) which aim to clarify ideas on family medicine and address some of the key issues that face Kosovo in rebuilding a strong system of primary care

The two-day seminars in Pristina and Prizren were the first in a series of six which have been funded by WHO to the tune of 20,000 DM. Each drew around 40 GPs from all over Kosovo, and were opened by Department of Health and Social Welfare co-head Dr Hannu Vuori, WHO's primary care coordinator Sue Woodward in Pristina, and regional public health adviser, Dr Erik Schouten in Prizren.

The agenda ranged from conceptual debate to very practical discussions on how different components of patient care and preventative medicine should be divided between family practitioners, specialists and nurses in the primary health care team.

"I was orientated to family medicine before the workshop," Dr Abdullah Hoti, a participant and head of general medicine at Pristina Health House told Kosovo Health Talks, "but after the workshop things were more clear."

For example, he says, there was keen discussion about how current health house specialists should fit into the scheme of things and the relationship between doctors and nurses in family medicine teams. "We heard that nurses should be more competent in future and more rationally involved with diagnosis and treatment. though it is more problematic for specialists," he adds.

The issue of private practice was also raised which, Dr Hoti says, could have a crucial role in keeping doctors in the public system. "If a family doctor has the training that makes him equal to a specialist, he can also start private practice - this will relieve the state health budget and enable him to keep working for less money in the public system."

AMPK vice president Dr Genc Halili says while many of the uncertainties about family medicine were worked through at the meeting, the discussion brought up key areas of concern which need to be addressed by policy makers, such as what level of service society will be able to be provided, and whether patients will make financial contributions to their care (see [above] for further discussion of this issue).

But, Dr Hoti noted, while much progress would depend on the economy, " we have to use our heads and start even in a small way."

Twenty years ago, he said, GPs did all the things that are now required of family practitioners. "We took care of the new-borns, pregnant women, the old, we stitched people up, we kept patient records, we knew our patients personally. But the system degraded us and now we're used as administrators. We have to start to increase the position of the GP because it is the cheapest way of helping the health of the population."

Further workshops are scheduled for Gjilan/Gnjilane (11-12 March), Mitrovica (25-26 March), Pejë/Pec (1-2 April) and Pristina again (15-16 April). For information please contact Dr Arben Cami or Dr Genc Halili on 038 24 837.

Who will kick off family medicine in Kosovo?

Pristina University Medical Faculty Primary Health Care Unit this week started sifting through the details of the over 600 doctors who want to take the six month updating module on family medicine.

Three new recruits to the unit, Dr Paul Silverman, a paediatrican from New York who has worked in Kosovo for two years, and Drs Genc Buçinca and Dr Selvie Gashi, both GPs from Pristina, will make the initial cut according to criteria developed by WHO primary care coordinator Sue Woodward and medical faculty Dean Professor Mazllum Belegu. Doctors shortlisted for the first intake will then be interviewed by an expert panel.

But although WHO has given core-funding for the faculty unit and staff and there have been several inquiries from various donors, the actual training programme due to start in June still has no confirmed funding. And there can be no help from UNMIK either: despite family medicine's crucial position in its adopted strategy for health, the Department of Health and Social Welfare has been allowed no allocation for training and education of any kind in its 2000 budget.

Unit prepares family medicine outline

An outline of what services family medicine centres are expected to offer and what buildings and equipment they will need has been prepared by the Medical Faculty's primary care unit and is currently under consideration by the Department of Health and Social Welfare. It is anticipated that the material will be ready for release by mid-March.

For further details, please contact Sue Woodward, WHO primary care coordinator at the WHO office or the faculty after 12 March.

Pristina's call for help is heard

Donors and NGOs have responded rapidly to the call for help in rehabilitating health facilities in the Pristina region (Kosovo Health Talks 21).

One shining example is the Lipljan health house, which will now be renovated by CARE with C$1.3 million donated by the Canadian Government. CARE is also looking at supporting one health stations in the Pristina city.

According to WHO regional public health adviser Dr Ismet Lecaj, almost all ambulantas in Pristina municipality which required help have now received commitments from international agencies, but donors are still needed to support other parts of the region, particularly the health stations in Pristina city.

NURSING

LEMON role play refreshes

"I learnt many new things but also I refreshed my mind about many things that I learnt in nursing school years ago, but had little chance to use. The role play especially was very interesting for many participants because it allowed us to assess nursing behaviour."

That's the verdict of Fetije Huruglica, a nurse of 24 years experience, on the first Learning Materials on Nursing (LEMON) workshop which was held in Pristina last week.

The workshop was attended by 25 hospital and community nurses, including two from Shtime/Shtimlje Mental Institution, and facilitated by WHO, which has led the development of the participatory education materials specifically designed to be adapted in individual countries.

One key outcome of the workshop was that LEMON group for Kosovo has now been established.

This event was funded by the UK’s Department for International Development while future courses, scheduled for April/May, plus translation of material will be finanaced by the Norwegian Aid Committee (NORWAC) which is contributing 120,000 DM to the project.

Mrs Huruglica, who is currently working with the International Medical Corps mobile maternal and child health team, says in the past nurses had many skills but expectations of their role diminished after 1985.

The advantage of the LEMON process, she says, is that it allows nurses to start appreciating new philosophical and new practical concepts in nursing. "Now students often see nursing as not a responsible job. LEMON gives them the knowledge to change that perception.", says Mrs Huruglica,

For further information regarding the LEMON group or workshops, please contact Fetije Huruglica though the International Medical Corps office, ph 038 549 001/027/028/029.

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 Co-ordination meeting (held fortnightly 11am, 3 rd floor Dean's Building, Pristina University Medical Faculty.

PUBLIC HEALTH

Communicable disease resource for primary care

Five hundred, folder-bound copies of the "Guidelines for the Management of Communicable Diseases" in Albanian language are now being distributed to ambulantas and health houses throughout Kosovo.

Launched in January, the collection is a collaborative effort by the Institute of Public Health, the Medical Faculty of Pristina University, the International Rescue Committee, the International Medical Corps and WHO, with publication funding from the US Office of Foreign Disaster Assistance.

IRC information officer Tamra Madenwald says the guidelines should provide Kosovar clinicians with "a foundation on which to develop a comprehensive resource on communicable diseases."

The publication is in binder format, so information can be easily updated. The current edition focuses on preventing and treating diseases with epidemic potential, such as acute diarrhea, pneumonia, cholera, bacillary dysentery, hepatitis A and B, haemorrhagic fever syndrome, measles, influenza, meningitis, epidemic typhus, tetanus and neonatal tetanus. Diseases being considered for future inclusion are tuberculosis, brucellosis, and rabies.

Also included are recommendations on the proper measures public health authorities can take.

For more information, please contact IRC, 038 549 033, tamramadenwald@hotmail.com or WHO national professional officer Dr Ardiana Gjini, 038 549 218/216, agjini@hotmail.com.

Cold chain and cars for immunization teams

The childhood immunization programme is now - literally - mobilised. Last week 30 cars were delivered to the Institute of Public Health last week courtesy of UNICEF. Donated on a lease arrangement these vehicles will be dedicated to out-reach immunization activities and sited throughout Kosovo to improve equal access to vaccination to all children regardless of ethnicity.

Tomorrow (9 March) will also see the donation of seven vehicles by the Saudi Joint Relief Committee for Kosovo which will be based at regional IPHs and dedicated to EPI - the Expanded Programme for Immunization.

UNICEF field teams also spent last week distributing cold chain equipment including fridges and generators to immunization sites around the territory, says UNICEF information officer Gordon Weiss. Total distribution should be complete by this week. The agency has also been asked to provide cold chain equipment for five continuous immunization stations, ID cards for registrars, bags and stationary for nurses and registrars, per diems to cover food and transport, and public information materials to encourage parents to have their children vaccinated.

Routine childhood immunization was re-established in Kosovo last September. At present the programme is managed and largely operated by the Central Institute of Public Health in Pristina, resourced by UNICEF and NGO partners, and technically supported by World Health Organization. It is hoped, over time, actual immunization will become the job of family medicine doctors and nurses, working with the technical support and guidance of the Institute of Public Health.

Cubans leave big contribution to public health

The 11-strong delegation of Cuban specialists in environmental health, food safety, occupational health, health information system, public health, health policy and microbiology leaves Kosovo on 20 March after six months working within UNMIK Department of Health and Social Welfare, WHO, the Central Institute of Public Health and regional institutes in Prizren, Pejë/Pec and Gjilan/Gnjilane.

"The work we have performed has covered a wide spectrum including field work, identification of problems and methodologies in the area of environmental health, development of the health information system and strengthening the laboratory capacity of Institute of Public Health" say senior delegation members Drs Emilio Morales and Leticia Fernandez.

According to Department of Health and Social Welfare co-head Dr Hannu Vuori, the delegation has made a valuable and significant contribution towards improving the health systems available to the people of Kosovo. "We thank the delegation, and their Government for sending them, and wish them well."

Among the work completed by the delegation are proposals to the European Union for development of the health information system, and to the UK’s Department for International Development for development of the Institute of Public Health now approved, also documents on demographic and health statistics analysis, oral health policy, food safety programmes and legislation. Members of the delegation have also helped co-ordinate and carry out environmental health activities in Gjilan, Prizren and Peje, train central IPH staff in microbiological laboratory work and in the use of computers, and have carried out an assessment and programme proposal for occupational health.

Finally, the team has developed a software package for health information at ambulantas together with a proposal for outpatient information systems. (see [below] for detail)

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.

VIOLENCE AND INJURY PREVENTION

New freedoms but old problems haunt

First impressions of series of focus groups, aimed at discovering the gaps in health and social services available to help people cope with violence resulting both from conflict and in the home, reveal a people delighted to be free but still suffering violence in different forms.

The focus groups, which were organized by WHO with local NGO and health professional facilitators trained by Mercy Corps International, took women and men separately through a series of questions that drew out their perceptions of societal change, gender roles, definitions of health particularly mental and reproductive health, forms of violence and the coping methods and services available.

Though the compete report, drawing conclusions from over 40 hours of tapes, is not yet ready, some clear impressions stand out, says WHO adviser on violence and injury prevention Gunilla Backman. "Many people described a situation where they had to be strong to survive the war but now they are free and they have survived, poor conditions in Kosovo without the overriding need to survive is causing bad physical and mental health."

This is also resulting in more hidden violence, says Backman. "Many participants said that violence does not exist now in their communities, but as the discussion continues accurate scenes of domestic violence are described. Violence against children is a concern expressed due to the mental health of parents as a consequence of the war."

Groups also perceived other deprivations - such as strict parenting through fear, lack of electricity, or lack of education - as forms of violence.

Regarding health and social services needed, counseling and the need for women to have supportive social spaces come across strongly says Backman. But she cautions that the full report, due for completion in early April and scheduled to be the basis of a multi-sectoral workshop on violence prevention, is likely to add more specific details to these general concepts.

HEALTH INFORMATION

Study pilots rebirth of information system

The Institute of Public Health and WHO hopes to begin a two week pilot of a new health information record system in Pristina later this month which will lay foundations for the re-establishment of vital health data gathering throughout Kosovo.

The study, designed by WHO/UNMIK experts Drs Leticia Fernandez and Ileana Castaneda in collaboration with Prof. Enver Baraku, chief of social medicine at the Institute of Public Health and health information system and surveys commission, aims to test a computerized and a manual data collection system that will move information on patient consultations from ambulanta level, through the municipality, to regiona level, and then to the central IPH for analysis.

When a complete system is in place, the analysis will allow the Department of Health to provide more targeted health services. It will also allow feedback to be given to doctors in primary care allowing them to plan preventative and health education interventions for their own catchment population.

Computers for the study have been supplied by the International Rescue Committee and ECHO which has also supported the printing of forms. The software programme for entering and analysing the data was developed from a package originally created by the International Medical Corps.

As well as piloting the system, the team hope to be able to get a useful snapshot of the most frequent causes of morbidity, drug use and the workload of doctors and health facilities.

Putting the whole system in place will cost around US$1 million according to Dr Fernandez.

HOSPITALS

WHO launches new report on hospital needs

A report from WHO launched this week offers a detailed evaluation of the current status of equipment in all five regional hospitals of Kosovo, and identifies gaps in provision crying out for donor intervention.

While much equipment has been promised and some has arrived in the 10 months since the return of the population - particularly to Prizrren, Gjakovë/Djakovica and Mitrovica - most hospitals have also suffered from the humanitarian disease of premature promises, say report authors WHO medical assistant Dr Arta Ibrani and hospitals coordinator Francois Cremiuex.

"The habit of carrying out assessments and giving promises before any money is available leads to situations where a particular medical ward may wrongly believe that its needs will be met... Coordinating investments in medical equipment is necessary, both to guarantee the best possible allocation of resources and to provide all of Kosovo with a sustainable, and coherent medical equipment policy," says Dr Ibrani.

All hospitals, the report finds, have some disciplines where equipment still needs upgrading to basic levels set by WHO in its equipment guidelines, while basic reusable equipment such as stethoscopes, reflex hammers, thermometers, peak flow metres and other tools for everyday work are also missing.

Ibrani and Cremieux have also identified two key investment 'black spots" - X-ray equipment and haemodialysis - where donor attention is now an urgent priority.

More positively, they say, donors have recently shown a great interest in gynaecology and maternity ward, putting them now among the better equipped departments. Laboratories in Gjakovë/Djakovica, Prizren and Mitrovica have also received new equipment.

The report, which is available electronically and in hard copy from both the WHO office and the Department of Health and Social Welfare, contains a detailed department-by-department analysis of equipment currently in place, including age and repair.

It also spells equipment requirements as of February 2000. However, potential donors are asked to liaise with the Department of Health and Social Welfare and WHO before making commitments to avoid duplication.

For further information, please contact Dr Arta Ibrani, at the WHO office, or email: artaibrani@hotmail.com.

Deputy director confirmed for Pristina

Professor Veton Hoxha has been appointed the full time deputy director of Pristine University Clinical Centre. Now head of the hospital's department of dentistry, Prof. Hoxha spent many years teaching in Turkey and managed a large private dental clinic there.

Appointments to the post of deputy director, and of the hospital board have been controversial not only due to allegations of political manoeuvring but because UNMIK contracts were delivered to those chosen just as the new Joint Interim Administrative Structure, with its introduction of the local co-head structure, was coming into being, leaving a shadow over their validity. Department co-head Dr Pleurat Sejdiu also raised concerns about how the appointment process should be run, and the part-time nature of the deputy director's post. The latter particularly affected Dr Ilir Tolaj who, in the earlier appointments was charged with combining his role as head of the infectious diseases clinic with that of deputy director.

It is understood that Dr Tolaj, who remains a strong member of the hospital board, did not apply for the new post, and is in discussion with UNMIK Health over the contractual issues.

Mitrovica looks to secure blood supply

With hospital and its transfusion department off limits in the north of Mitrovica, medics on the south side have been looking with growing concern on the lack of blood supply for the Albanian population, especially in the light of the tense political situation.

Meetings last week between Albanian doctors representatives, UNMIK, WHO, Moroccan KFOR who are carrying out civilian surgical activities, Pristina University Hospital, and the International Committee of the Red Cross which monitors blood products, brought agreements that will both assure supply in an emergency situation and set in motion blood collection in the town.

According to ICRC's Dr Per Oermer, it is advisable to maintain Pristina Hospital as the centre for division of blood products in order to maintain quality standards. As such, the centre has agreed to supply a blood store in Moroccan KFOR.

However, very few people currently give blood, so address this, the displaced Albanian head of transfusion is to work with the Pristina team to identify a site for donation and initiate collection in the south side of the town.

In the North, hospital director Dr Milan Ivanovic has assured ICRC that both blood and reagents are being made available by other sources and no help is needed, but, says WHO medical coordinator Dr Marie Claire Paty, an assessment of the capability needs to be done to ensure blood is available when required.

Emergency services planning back on track

How to organize emergency services including ambulances, urgjenca (emergency health stations), medical staff, equipment and communications both within the health service and between the other emergency services has been up in the air since a working group last year failed to agree on policy. In the meantime, donated ambulances have been arriving regularly - including seven last week dontated by the Turkish goernment - NGOs such as International Medical Corps and Spanish Red Cross have run emergency skills training courses in various parts of Kosovo, and the emergency telephone number 94 still tries to ring in some health houses.

Now, IMC emergency physican Dr Kate O'Hanlon has been seconded to WHO to pull together all the diverse elements and create coherent recommendations for a Kosovo-wide service. Dr O'Hanlon is currently touring the territory to make contacts with all involved in providing emergency services or planning to supply equipment, ambulances or training. She plans to make initial recommendations by April.

Intensive care for all specialties opens

This Friday (10 March) sees the launch of Pristina hospital's new intensive care unit. Not only is the 10 intensive care, four coronary care-bed unit equipped with state of the art machinery, it is also one of the first centralised ITU facilities in Kosovo which has traditionally had such units attached to each clinic. Generally speaking, this has kept intensive care services at a lower level than would usually be expected in Europe.

The intensive care unit has been funded by Mediciens du Monde France which has also trained staff on the equipment and recruited an international intensive care nurse who will work alongside local staff for three months.

CONFLICT

New refugee influx from Serbia feared

With tension rising in the border towns of Presevo, Medvedja and Budjanovac, authorities and NGOs in Gjilan/Gnjilane met last week to discuss action needed if the worst case scenario - a flood of up to 60,000 displaced Albanians into the region - becomes a reality.

Situated just inside southern Serbia, these predominantly Albanian towns have become increasingly tense over the past two month after a series of clashes between Serbian police and a newly-formed Albanian rebel group, the UCPMB (Liberation Army of Presevo, Medvedja and Bujanovac).

International Rescue Committee representative Bekim Dauti estimates some 1,300 people have fled to Gjilan/Gnjilane in the past two months, but admits the true number could be much higher since people who stay with relatives often do not register with aid agencies.

UNMIK regional health officer for Gjilan/Gnjilane, Dr Christoph Hepp says consideration has to be given to the pressure on health and social services if the situation worsens.

SURGERY

Keyhole surgery proves beneficial

Over 90 laproscopic operations, commonly known as keyhole surgery, have taken place with no major complications in Pristina University Hospital's new laproscopy suite since it opened in late November. All but two operations were for cholecystectomy - removal of the gallbladder due to gallstones - in patients with chronic gallbladder disease.

While normal surgery achieves the same result and keyhole surgery equipment is expensive, says Dr Vic Davis, interim international director of surgery, "the benefit is that patients can be discharged on the day after the operation and have much less pain and almost no scar compared to the 'open' method which is more painful, involves a 6 to 8 cm incision, and four to seven days hospitalization."

The laproscopy suite was initiated and equipped by Saudi Joint Relief, whose director in Pristina Dr Faris, a surgeon himself, is training four local surgeons in the technique, and will train four more after the first cohort is competent.

Currently the unit has about 80 patients waiting for keyhole operations.

The hospital board and SJR are also putting into action plans which will expand the suite. Within three months, says Dr Davis, there will be another room for laparoscopic operations plus one for urologic endoscopy. There is also to be an area devoted to upper and lower intestinal endoscopy and for the very complex operation to remove stones from the pancreas known as ERCP (endoscopic retrograde cholangio-pancreatography)

SOCIAL WELFARE

Health authorities set up disability panels

UNMIK regional health officers are to set up local panels to assess the extent and permanence of disability among applicants for social benefits. The panels will include experts on specific disabilities as well a lay and medical representatives.

For more information, please contact the Department of Health and Social Welfare.

REPRODUCTIVE HEALTH

Midwife team grasps modern methods

Midwives are not well regarded by the medical fraternity in Kosovo, but in Istog/Istok Health House a team of nine, with the help of Mercy Corps International, have taken on board one of midwifery's most important, yet least high-tech, modern tools - the partograph.

Little used anywhere in Kosovo, the partograph is a paper chart which allows pregnancy practitioners to clearly chart the stages of labour and delivery, allowing them to act on early warnings of complications for both mother and baby. Learning to use it, says MCI's Michele Heymann, a certified nurse midwife and family nurse practitioner from Phoenix, Arizona who has spent the past four months working with the Istog midwives, is a significant advance, especially in this small, spotless maternity ward where unlike any other health house in Kosovo, there is no resident obstetrician or gynaecologist.

"In the time we worked together, I've seen the midwives develop a vastly different approach to problem solving," says Heymann, who has now returned to the US. "The approach we used was very participatory - case studies, review sessions, audio visuals, model - but also we worked together. I'm not interested in just 'exposing' someone to new ideas on a course, I want them to go away with new skills."

Heymann's work is part of a four-strand MCI reproductive health programme in the Istog and Klina region. Another strand is the development of a Women's Health Centre in Klina, sited next to what is anticipated to become Klina's new family medicine centre (currently being used as a home for displaced people) and which will house women's health specialists, as well as offering space for seminars and counseling. MCI is also involved in training of patronage nurses, and doing community outreach in reporductive health. The package is funded by UNHCR (US$ 450,000) and the Jewish Joint Distribution Committee (US$100,000), while Liechtenstein Refugee Aid and Caritas Vorarlberg provided the two-storey linked wooden cabins for the women's centre.

For more information, please contact Lou Cooney, Mercy Corps International, Istog/Klina, sat ph. +871 762 053 327, or +873 762 134 183, email: mcikosovo8@worldnet.att.net

FOCUS ON COMMUNITY MENTAL HEALTH

"We saw psychiatric hospitals that had 900 beds totally empty. We saw psychiatrically ill patients who we would have had in our wards for months, even years, living in nice looking apartments supported by nurses in places that looked like home. It was really shocking for some of us,"

The voice is Dr Ferid Agani's, assistant professor in neuropsychiatry at the Pristina University medical faculty, consultant neuropsychiatrists and one of a group of eight Kosovar specialists who, sponsored by WHO, recently visited the WHO Community Mental Health Collaborating Centre in Trieste, Italy.

"You see, community mental health was something we thought we knew all about - we'd read it in books. This was the first time that we really practically saw that community mental health is a system designed for the good of the patient. Not for society to resolve their problems with mental illness. Not for psychiatrists to make their life easy or to do research, but to provide dignity, integrity and autonomy to people with mental health problems. It was the most important discovery."

Young, dynamic and now evangelically convinced of the benefits of developing community-oriented care for Kosovo's mentally ill, Dr Agani is far from blind to the challenges to achieving this state.

While experts have for years accepted that allowing people with mental health problems to integrate as much as possible into society through carefully tailored support is not only the best and most humane but also the most cost-effective approach, development of such programmes have caused controversy and taken years in every country that has started on the path.

But, says Dr Agani, Kosovo has some unique advantages, even over other Balkan countries which have started from the same clinical traditions

"Croatia is in the forefront of mental health reform in the Balkans. It has lots of beds - 4500 - and many professionals. It's got a very strong institutional infrastructure to change. Bosnia too has lots of professionals and lots of beds, though many were destroyed by the war. But Kosovo is completely different: we have very few large institutions, so mentally ill people have not been divided from society as much. It's true we also have a very low number of professionals but we are in a unique situation and I think Kosovar society will accept mental health care in the community much more easily than other places."

One of the reason why there are so few large institutions is the strength of the Kosovar family, though this has both positive and negative effects for the chronically mentally ill, says Dr Agani. Though the mental ill are less likely to be institutionalised, the family, whether out of instincts of shame or protection, can form a sort of mini-institution in which the mental ill are hidden. "They are in better conditions than an institution but still stigmatised." Dr Agani notes.

The essence of community mental health care is to offer the kind of treatment, rehabilitation and support that will allow the mentally ill to lead as normal a life as possible..

But, says Dr Agani, while this sounds relatively logical, even easy, from a theoretical point of view, his experiences and the experiences and reactions of his colleagues during their week in Trieste gave him foresight into just how difficult it may be.

"The most difficult part is changing mentality, particularly of psychiatrists but also of the public, and of the patient's family. The family is strong resource in Kosovo, but we need to get it working on the side of the patient."

Another trip to Trieste is planned in order to expose more specialists to the realities of community mental health, says WHO mental health adviser Dr Liliana Urbina. But equally importantly, says Dr Agani, is a public campaign that will help people understand why care in the community is a must.

In the meantime too, Agani and his colleagues are working with WHO and UNICEF on how to make community mental health are a reality both in terms of services for patients and skills training for professionals.

Please contact WHO for more information

Far East finds funds for mental wellbeing

The Japanese government has just agreed to channel US$1.2 milllion into a WHO-managed project which will kick start the re-orientation of mental health services into the community in Kosovo.

WHO mental health adviser Dr Liliana Urbina says the funds will be extremely helpful in supporting actions needed to move services towards the community.

"We are very keen to ensure there is a close connection between policy and people working in mental health. Many countries have wonderful 'programmes' but nothing happening at ground level. The funds will help us develop policy, but also support some very concrete demonstration pilot experiences in the community - which will really help to change activities and attitudes," she says.

Teachers learn psychosocial skills

The International Rescue Committee launched a 16-week psychosocial training program for secondary school teachers in Prizren and Gjilan/Gnjilane on Monday (6 March).

Funded by the Bureau for Population, Refugees and Migration, the programme aims to address the post conflict needs of Kosovar adolescents by offering psychosocial support training for teachers and other youth service professionals.

IRC psychosocial programme manager, Dr Harriet Epstein, says: "This training recognizes the need to provide students with more than stability and normalcy. Teachers also need the skills to address problems brought on by the conflict, like trauma and stress. And they need help incorporating new and evolving civil structures into their curriculum."

The training will provide secondary school teachers with leadership-building skills and establish a resource and information network. It should also establish a model for future locally-initiated teacher training programs throughout Kosovo.

IRC hopes to replicate the program in Pejë/Pec and Prishtinë/Pristina.

For further information, please contact IRC information officer, Tamra Madenwald, 038 549 033/034, email: amramadenwald@hotmail.com

CHILD HEALTH

Most Kosovar kids are well nourished

The most recent research into child nourishment in Kosovo suggests levels of chronic malnourishment have fallen to below levels seen prior to the flight of the population, while acute malnourishment has risen slightly but remains at a low level.

The survey, carried out by Action Against Hunger in January 2000, is a follow-up study to research by the group in June and July 1999 and December 1998.

The latest study, which involved 900 children aged 6 to 59 months selected at random from different communities, showed 7.5% were chronically malnourished (that is short for age) with 1.9% severely stunted - a drop of around quarter and a third respectively on 1999 and 1998 rates.

The number of acutely malnourished - 'light for height' - children rose in January to 4.7%, with 1.1% severely malnourished compared to the July figures of 3.1% and 1% respectively. The January 2000 figures are also more than double the rates seen in December 1998.

AAH nutritionist Laura Phelps notes that there may well also be pockets of malnutrition among minority groups, adding that in families where there is moderate malnutrition, there is often a social reason for it, outside the presence of food aid or lack of access. "This may be poverty, destruction of housing, history of psychiatric illness, domestic illness or alcoholism, " she says.

As a result of the study, AAH say it's important to continue the active search for malnourished children using both height for age and weight for age criteria, and to develop the skills of health staff to detect malnutrition so that there is an early warning system of changes in nutritional status with capacity for rapid reaction. Both of - these elements feature in the WHO/UNICEF integrated management of childhood illnesses modules.

Continuing to encourage exclusive breastfeeding and educating mothers on appropriate weaning foods is also important, particularly to address anaemia, says Phelps, while on a socio-economic level, agricultural activities which help vulnerable families gain self sufficiency need to be maintained.

"June-July will be a crucial time since it's likely food aid will start to phase out, but the main harvest and collection of main vegetable crop won't have come through."

For the population at large however, notes Phelps, a more problematic issue for the future may well be the rate of overweight and obesity in the elderly, which was also studied in the research project. Over a third of the 224 people over 65 assessed were overweight and 16% were obese.

For further information and a full copy of the report, please contact Action Against Hunger, 038 21 291

Youth centres draw hundred of members

A new youth centre in Ferizaj/Urosevac opened by the International Medical Corps on February 16 welcomed over 2000 different people though its doors in the first two weeks, according to IMC youth development coordinator Diane Diaz Granados.

The centre is one of three to be opened by the NGO in the past three months - the other two are in Mitrovica (south side) and Kaçanik/Kaçaniku. And all are getting 500 to 800 visits a day by their target community - young people aged between 15 and 24.

Developed in municipal properties to help with sustainability, the centres offer recreational activities such as music and drama and sports but also health education on issues such as puberty, contraception and sexually transmitted diseases, and counseling. Various courses such as computing and languages are also being set up depending on the skills of the team and the interests of the centre members. The Mitrovica centre, for example, is led by a Kosovar actor, who has runs highly popular music and drama classes, while at the weekend the space is used by budding rap and rock artists. In Ferizaj/Urosevac and Kacanik/ Kaçaniku, the Vietnam Veterans of American Association are working with centre members on mine awareness.

"Ninety percent of the programme," says Diane Diaz Granados, " is about having a space young people can call their own. But each month we also focus on one topic - such as poetry, or drama, or a health issue."

The centres, which have been renovated from scratch, are funded by the US Bureau of Population, Refugees and Migration and run by four to five person-strong local management teams, supported by international IMC staff. Two more are planned for Klina and Podujeva.

For further information, please contact IMC on 038 549 027 or darjan@eunet.yu.

Equipment improves mother and baby care

Over £1.2 million-worth of high tech equipment for Pristina University Hospital's gynaecology, obstetric and neonatal department should arrive this weekend (11 March), according to director Professor Tony Redmond. The shipment, funded by the UK’s Department for International Development includes surgical equipment, incubators and other essential modern items.

Rehabilitation of the delivery suite and the paediatric out-patients department is also part of the same initiative.

DENTISTRY

Policy framework develops for oral health

A policy group, convened by WHO and the Pristina University School of Dentistry and including local and international dentists and organizations, has drawn up an oral health policy for Kosovo which will be finalized by 15 March and presented to the Department of Health and Social Welfare.

The document details four options for future development which address community dental health care, public-private provision, emergency dental care, secondary orthodontic interventions and oral health education.

WHO is recommending pursuit of an option which would largely integrate emergency dental care, oral health promotion and prevention into family medicine centres, with referrals though to a central public dental clinic at regional level, and tertiary care at Pristina University Hospital.

Other key elements recommended are cost sharing of dental services at all levels, 24 hour emergency services, provision of cheap fluoridated toothpaste and salt, development of an information system to aid planning of services, and the development of oral health education.

Copies of the draft policy are available from the WHO office

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:ismet_l@hotmail.com,
sonja_bu@hotmail.com
Medical Assistants: Dr Ismet Lecaj, Dr Sonja Bulaic

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
who_mitrovica@hotmail.com,
mcpaty@hotmail.com
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