Kosovo Health Talks 23

Report
from World Health Organization
Published on 22 Mar 2000
NEW UPATE
UNMIK HEALTH AND SOCIAL WELFARE

"People are our 'capital' too The Department of Health and Social Welfare's have submitted a capital investment request of almost 80 million DEM for the year 2000, including an budget line for training. Capital investment expenditure is usually limited to bricks, mortar and equipment, but co-head Dr Hannu Vuori told Kosovo Health Talks that the health department has bid for just over 14 million DM for "capacity building", particularly to fund training programmes in family medicine and management.

"There's no guarantee either that our whole request will be funded, but skilled health personnel and management could be considered to be the health service's most crucial 'equipment'," says Dr Vuori. There is no allocation in the Department's current running costs budget for training, though it is considered a pressing concern.

Another request is for funding to study the feasibility of building a new psychiatric hospital, since Stimlje has been firmly categorized as a social welfare rather than therapeutic institution. Donors have pledged some 1.8 billion DM for capital investment across all sectors in Kosovo. Departments are likely to learn of the outcome of their bids in early April.

HOSPITALS

Austria plans 7 million DEM hospital

An Austrian NGO has signed a contract with the municipality of Gjakovë/Djakovica to invest 7 million DEM in a new facility for mine injured children in the grounds of the town's hospital - to the surprise of the hospital board, the Department of Health and Social Welfare, the municipality's director of health, and agencies and NGOs who have the responsibility for handicapped care.


New directors - new accountability

Almost all Kosovar health institutions now have new, or at least newly

appointed, directors who are responsible directly to the Department of Health

and Social Welfare.

"It's going to make a big difference having people who are accountable to UNMIK

in each region, particularly in terms of budget and salary issues.," says deputy head Mr Bengt Ståhandske.

Hospital directors

Prishtinë/Pristina: Veton Hoxha

Prizren: Agim Hazrolli.

Gjakovë/Djakovica: Nexhat Rexha (dir.), Gëzim

Xharrra (deputy dir.)

Pejë/Pec: Isa Kaliqani

Gjilan/Gnjilane: Ukshin Ismaili

Health Houses directors

Prishtinë/Pristina: Sarlje Doko (dir.), Qemajl

Osmani (deputy dir.)

Gllogoc/Glogovac: Gani Halilaj

Obilic: Agron Kamberi

Podujevo Skender Murati

Lipljan: Naim Ardiu

Gjilan/Gnjilane: Hajriz Ibrahimi

Viti/Vitina: Hamdije Zuka

Ferizaj/Urosevac: Nase Flhmeti

Kaqanik: Nijazi Luma

Kamenicë/Kamenica: Risa Hoda

Dragash: Femi Sh. Bojaxhiu

Malishevë: Mursel Gashi

Suharekë/Suva Reka: Sali Rrustem Asllanaj

Rauhovec/Orahovac: Jusuf Korenica

Gjakovë/Djakovica: Bajram Kadrija

Pejë/Pec: Xhafer Dema

Istog/Istok: Rifat Dreshaj

Decan: Time Kadrijaj

Klinë/Klina: Haxhi Ibishi

Mitrovicë/Mitrovica: Drita Ibrahimi

Vushtrri/Vucitrn: Safet Idrizi

Skenderaj/Srbica: Man Dajaku

Still unconfirmed are executives at the Institute of

Public Health, state pharmacies, Mitrovicë/Mitrovica

Hospital Pejë/Pec Chest Hospital, Prizren and

Shtimë/Shtimlje Health House.



The development, which will cost the equivalent of almost 10% of the entire 2000 health budget for Kosovo, involves two buildings, one a living space for up to 35 mine injured children, the other containing a prosthetics workshop and physiotherapy and training facilities. A third building containing a bank, a delicatessen and flower shop will also be built. The 7 million DEM will also cover three years of running costs for the hospital which, it's understood, will be run by Catholic sisters.

The initiative comes from a branch of Caritas Austria, which was unable to be contacted for comment. It is understood to be eager to do it in Gjakovë because it is one of the most mine affected area in Kosovo. In addition, those aged under 19 make up almost a quarter of victims.

However, news of the development comes at time when the hospital board, together with international hospital director Eivor Akar, is in the middle of working out a master plan on how to rationalise the hospital's already extensive buildings and concentrate services to be more effective.

The plan also appears to duplicate many of the activities of Handicap International which has been mandated by UNMIK to deliver and co-ordinate physical development programmes, including the rebuilding of the National Orthoprosthetic Workshop in Pristina which reopened in August 1999, and of local disabled organization Handikos which, with support from the International Canadian Agency for Community Based Rehabilitation, has developed 10 community centres for rehabilitation. All three organizations, says HI head of mission Driton Ukmata, are also working to strengthen the professional capacities of physiotherapists in the community.

The project has been greeted with dismay by the hospital and the health authorities. Department of Health and Social Welfare co-head Dr Pleurat Sejdiu told Kosovo Health Talks the development was simply "wrong". "We cannot support this, now or in the future. The staff won't be paid by us. We don't have the budget." Eivor Akar who, with the board, only found out about the project from a newspaper report, adds "We would be very happy to have those 7 million DM to do something else with "there's certainly plenty to do."

Health house forges University link

Ferizaj/Urosevac "Hospital" - or surgical unit as the Department of Health and Social Welfare prefers to call it since it is adamant it will not support the development of any new general hospitals - became a professional branch of Pristina University Hospital earlier this month. While the facility remains financially independent with its own budget and administration, professionals working in the unit will benefit from the professional supervision and advice of the teaching hospital.

Call for uniform radiology departments

WHO is calling on UNMIK and donors to support a project that would give all regional hospitals in Kosovo a uniform 'package' of radiology equipment. While in most areas of investment hospital directors should be left to make their own investment decisions, centrally coordinating and supervising investment in radiology, which involves high levels of technical maintenance and calibration, will reap more benefit than individual activities, says WHO hospital's co-ordinator, Francois Cremieux.

"The project aims at providing hospitals with new, identical, equipment certified to European X-ray protection regulations, which would enable them to benefit from coherent radiological policy with economies of scale in maintenance, training, spare parts and consumables," says Cremieux, who has developed specifications for a basic radiology department package costing just over US$320,000 each, including training, roughly US$1.6 million for the five hospitals.

The equipment list focuses on developing capability in traumatology, diagnosis of abdominal and rheumatological disease and screening and diagnosis of pulmonary disease. It includes two tables, one remote and fixed bone table, a chest stand, and necessary film development equipment. The machines should not be digital at this stage but able to be upgraded in the future. All could be installed in existing radiological departments with little construction, but X-ray protection standards mut be upgraded. Any existing safe, reusable and maintainable equipment could be relocated to larger family health centres, adds Cremieux,

For further information, please contact Dr Arta Ibrani, medical assistant, hospitals at the WHO office, or artaibrani@hotmail.com.

Dozen days is average stay in Pristina

Bed utilisation statistics from Pristina University Hospital show average stay is a lengthy 11.62 days. The TB and neuropsychiatric wards have the highest rates - 36 and 21 days respectively - while ENT, internal medicine, orthopaedics, and paediatrics all keep patients for an average of 16 to 17 days. Dermatology averages 14 days.

The statistics also show that only a quarter of the hospital's patients come from Prishtinë/Pristina. Almost 20% of patients come from Podujevo and Ferizaj/Urosevac combined, closely followed by Mitrovicë/Mitrovica and Vushtrri/Vucitrn who ake about 5% of the facility's capacity each.

Intensive care funded by Britain

Pristina University Hospital celebrated the opening of its sophisticated centralised intensive care unit recently - a development funded by the UK's Department for International Development not, as reported in Kosovo HealthTalks 22, by Mediciens du Monde France.

DfID has invested over £1 million in building and equipping the unit which has 10 intensive care and four coronary care beds. The UK also funded MDM France to supply and intensive care specialist nurse who, with DfID-sponsored director of nursing Jo Greenfield, has been training and working alongside local staff.

CO-EXISTENCE

Surgical unit opens to serve Serb communities Special Representative to the Secretary General, Dr Bernard Kouchner opened the new surgical clinic at Gracanica on Saturday (18 March).

The unit, which has been built and equipped by Medécins du Monde Greece with funding from the Greek Government and UNMIK, has 15 in-patient beds, four intensive care beds and emergency, delivery, laboratory and X-ray faciltities. It will serve around 35,000 ethnic Serbs and other minorities, including some 5000 in the town of Gracanica itself. However, medical co-ordinator for MDM-Greece Dr Zouheir Dabbour, stresses that the facility will offer care without discrimination to patients of all ethnicities.

Serb leader Bishop Artemije told the audience the opening was full of "deep symbolism". "This is the first ray of hope for months for the Serbs in this region" It is a symbol of hope for Serbs throughout Kosovo," he said.

The clinic is part of Dr Kouchner's Agenda for Co-existence and will remain open, says UNMIK, while there continues to be a security risk for Serbs living in the areas to reach the more normal source of secondary care, Pristina University Hospital. Plans for a similar 20-bed unit for internal medicine on the same site, funded by the French Red Cross, are on the drawing board.

PUBLIC HEALTH

Polio First for eight municipalities The Institute of Public Health, UNICEF and WHO are to target eight municipalities with worryingly low levels of polio vaccination with the new 'Polio First" strategy.

It was originally thought that a Kosovo-wide campaign would be needed to combat what appeared to be astonishingly low levels of polio vaccination across the province. However, review of the results of the three catch-up rounds of routine childhood immunization from 1999 revealed eight black spots where immunization has dropped below 60%. These are Prishtinë/Pristina, Podujevo, Pejë/Pec, Rauhovec/Orahovac, Prizren, Shtime/Shtimlje, Gjilan/Gnjilane and Mitrovicë/Mitrovica.

International Regional Health Advisers wanted

The World Health Organization is looking to recruit several international regionally-based public health advisers to work with regional teams of Kosovar professionals. Candidates should preferably be qualified in public health, or have strong, long term experience in the field of public health.

Interested applicants should provide their CV and references to the Personnel Department, WHO Office, Momcilo Popovic 1, 38000 Pristina, Kosovo. Fax +381 38 549 217 or email: haganr@who.int.

For further information, please contact Chief of Mission, Robert Hagan on +381 38 549 216/218 or Dr Erik Schouten, regional public health adviser for Prizren and Pejë/Pec on +377 44 120 361

The Polio First strategy means strengthening the regular schedule of immunization with the accent on polio. "In these eight municipalities every child in the target age-group of 0 to five years regardless of whether they have immunization cards, are resident, internally displaced - everyone should be immunized, "says Dr Ramez Zemokhol, WHO communicable disease epidemiologist.

The Kosovo Polio First Steering Committee has been set up to design the programme, which will be carried out by Institute of Public Health and a group of polio management teams under strict WHO/UNICEF observation, together with NGOs and KFOR in the target areas. The group will also devise the best messages for mass social mobilisation in each area. Vaccination will start in April and be complete by mid May. WHO is hoping to be able to declare Europe polio-free by the end of 2000.

Well designed wells would boost health

A survey of personal, domestic and environmental hygiene knowledge and practices carried out by Mediciens sans Frontieres Belgium among the rural population of Vushtrri/Vucitrn and Skenderaj/Srbica concludes that improving population skills in well and latrine design and maintenance could have a significant impact on health.

Researcher Nicola Main found that illnesses from water-borne diseases are not a major concern, with the exception of hepatitis A, head lice and scabies (though statistics on these are hard to verify due to over-reporting and stigma respectively). People were also generally well aware of preventative measures such as hand washing with soap. However, many of those questioned had a weak understanding of the ways in which well water could be contaminated and the design techniques that can reduce the possibility, says Dr Main.

"It is surprising the few number of cases of hygiene-related disease given the current lack of proper containment and disposal of excreta necessary to ensure its safe composition."

Dr Main noted that none of the participants in the 98 households in 18 villages surveyed, which are in a particularly destroyed area of the Kosovo, mentioned health or hygiene as one of their main priorities, placing shelter, blankets and heating as key priorities right now.

"[But with] many Kosovoars planning to rebuild their homes in the coming spring, linking both the need and interest in rebuilding homes with rebuilding and redesigning of wells and latrines would maximize the number of participants and beneficiaries. The extra effort and materials necessary would be minimal, yet its impact on health could be significant."

For further information, please contact MSF-Belgium on +381 38 501 030/ 549 615/ 25 691

HEALTH EDUCATION

Kosovo marks World TB Day in school

A campaign to raise the awareness of school children about the signs and symptoms of tuberculosis began this week in Prishtinë/Pristina, Pejë/Pec and Ferizaj/Urosevac to mark World TB Day on Friday 24 March. Organized by the Institute of Public Health Health Promotion Commission and supported by Doctors of the World, World Vision, International Medical Corps and International Rescue Committee, the week-long programme includes distribution of various materials.

For further information, please contact Dr Ilir Begoli, Institute of Public Health.

Campaign for smoke-free health services

Municipality leaders in Prizren region have kicked off the first post-conflict anti-smoking campaign in Kosovo with a call to the new hospital and health houses directors to ban smoking in their facilities.

At the request of WHO, UNICEF and the Institute of Public Health, members of the Prizren Municipalities Board have written to health facility directors making it clear that smoking is not conducive either to good health or good health care. And they are strongly urging the new directors to make banning smoking from all areas of health houses and hospitals one of their first managerial decisions.

The move is the first of several actions planned by WHO, UNICEF, UNMIK and the municipalities board to combat Kosovars' increasing addiction to tobacco. A schools campaign is being discussed, as are stickers and posters based on the famous Marlboro advertisement.

For further information, please contact WHO regional public health adviser Dr Erik Schouten or Dr Osman Zhuri at the WHO office in Prizren

New health educators learn to reach people

Budding health educators spent last week learning the techniques of participatory adult learning courtesy of the International Medical Corps.

The course was based on the philosophy that adults learn best firstly when they are interested, and secondly when the situations that trigger their interest reflect the cultural values and resources available in the community, and it took participants through techniques such as role play, story-telling and using pictures to bring health information to the attention of community gatherings.

"These are teaching methods that pose a problem rather than giving answers. It's a long way from the old authoritarian health worker image," says Aryn Faur, editor of the Hesperian Foundation's Women's Health Exchange magazine who came to Kosovo to lead the course.

For participant Venera Muçolli, the most interesting technique is role playing. "People can feel freer. The play can pose questions without people knowing who is asking, so everyone feels free to answer. Story-telling also lets people understand that there are other people who have the same experience, that they are not alone."

Most of the participants were field-based health workers, newly recruited by IMC who will themselves now recruit and train a network of community health educators throughout IMC's area of responsibility which includes Podujevo Ferizaj/Urosevac, Klina Gjilan/Gnjilane and Mitrovicë/Mitrovica.

"Community health education is more sustainable than social marketing, because you don't need resources like mass media and booklets," says IMC health education coordinator Susan Ashmore.

The course focused on the essential techniques of getting across acceptable messages. The new team will now spend the next five weeks developing the content for the first campaigns which are planned to focus on the benefits of ante-natal care and child health based on the UNICEF/WHO Facts For Life programme.

For further information please contact Susan Ashmore at IMC on +381 38 549 001/027/028 or at darjan@eunet.yu.

WHO estimates there are at least 2000 active cases in Kosovo, making TB the most dangerous infectious disease threat to the health of the population. After long months of debate, the Tuberculosis Commission is this week launching the Action Plan for TB control in Kosovo - in time for World TB Day 24 March setting the territory on track to develop a comprehensive WHO gold-standard DOTS - Directly Observed Treatment Strategy = programme by the year 2100.

Rising death rates from TB after nearly 40 years of steady decline, plus the increase of multi-drug resistant TB led WHO to declare tuberculosis a global emergency in 1993.

In Kosovo the situation is no less serious, since the conflict has caused both interruptions to treatment and an increase in the poor living conditions that help TB to thrive. Interruption of treatment is the worst thing that can happen to a TB patient, because it can mean having to repeat six to eight months of treatment. In addition, almost all community treatment facilities were destroyed or looted during the war.

WHO estimates there are currently at least 2000 active cases in Kosovo - five times as many cases now as in 1990, giving an incidence three times that of the Federal Republic of Yugoslavia. This makes TB the most severe dangerous infectious disease threat to the health of the population, says Dr Ramez Zemokhol, WHO communicable disease epidemiologist,

The Kosovo 2000 Tuberculosis Action Plan is the culmination of almost six months work by the Tuberculosis Commission which includes experts from hospital lung diseases' departments, WHO and NGO Doctors of the World. Its two key goals are to reduce rates of illness and death from TB so that it no longer constitutes a threat to public health, and to limit the emergence of drug-resistant strains of TB, which can be 100 times more expensive and take up to four times longer to treat.

The Plan is designed to fit in with the Department of Health and Social Welfare's overall strategy for health care in Kosovo which involves integrating the majority of patient care into primary care. For tuberculosis patients, this is particularly important because, with modern treatment protocols, less hospitalization is required and patients can return earlier to their communities where they can lead a normal life, while taking their medications at home.

To kick start the process, the document picks out key activities to be undertaken over the next 12 months. The first, the appointment of a Kosovo Tuberculosis programme manager funded by WHO, Dr Bahri Tigani, took place this week. Other key elements are:

1. Establish a Kosovo-wide TB diagnosis and treatment programme, based on the WHO DOTS strategy by January 2001. Directly Observed Treatment short course (DOTS) is considered the most cost-effective TB management system. It includes diagnosis, treatment, follow-up, recording and reporting, patient education, management of TB clinic, community education, and finally monitoring and evaluation.

2. Refurbish and re-equip six diagnostic centres in Prishtinë/ Pristina Pejë/Pec, Gjilan/Gnjilane, Gjakovë/Djakovica, Prizren, and Mitrovicë/ Mitrovica by July 2000. These will be specialized TB Diagnostic and Therapeutic Centres, fully equipped with new sophisticated equipment, with staff trained in the best ways to manage tuberculosis.

3. Organize a reliable continuous supply of essential anti-tuberculosis drugs and materials required for diagnosis. This requires long term commitment by the local and international authorities to the DOTS TB control policy.

4. Arrange training programmes to update all professionals involved in TB. The plan is to help the existing pulmonary specialists develop updated skills and knowledge, but it also includes the training of the family doctors to look for, identify, suspect and refer TB patients.

5. Deliver a public education programmethat enhances understanding of TB, encourages people to seek early diagnosis and treatment, and reduces stigma associated with TB.

6. Develop an information systemthat allows the effectiveness of TB treatment to be evaluated, drug resistance to be monitored and doctors to start proactively seeking out those who may have been in contact with an infectious person.

Total anticipated costs for the one-year programme, including drug supply, are just over US$1 million.

For further information, please contact: Kosovo Tuberculosis Programme Manager Dr Bahri Tigani, via the WHO office.

PHARMACEUTICALS

Workers endorse pharmacy co-operative

After a day of hot debate, over 200 workers from the ex-state pharmacies threw their weight behind the Kooperata e Farmaceutike e Kosovës (KFK) - the co-operative of state pharmacies - as the best option for the workers and the good for the patient. The aim of the co-operative is to ensure the development of a distribution network of public-health orientated pharmacies.

The meeting, held on 11 March also elected a management board with regional representatives, whose will be responsible for preparing, together with WHO, Pharmaciens sans Frontières, the European Agency for Reconstruction of Kosovo, European Community Humanitarian Office and UNMIK, the cooperative's statutes and business development plan.

Primary care drugs assured to mid 2000

The Department of Health and Social Welfare and the international humananitarian pharmaceuticals organization, Pharmaciens sans Frontieres, signed a contract last week that will ensure continuity of drug supplies to primary care until June or July this year.

PSF, funded by ECHO and the UK's Department for International Development, have been the lead agency in primary care drug supply, channelling some 6 million EUROs into maintaining the supply of essential drugs to primary care ambulantas and health houses since the return of the population last year.

In addition to continuing to procure and distribute drugs, PSF will also work with the Kooperata e Farmaceutike e Kosovës to build its capacity to take over management of drug supply for the territory. Continued reliability of supply after June/July will depend on the Department of Health's funding allocation, which in turn depends on the generosity of donors to the Kosovo Consolidated Budget.

Using antibiotics in surgery

The correct use of antibiotics for patients undergoing surgery is the subject of the Pristina University Clinical Centre's March Drugs and Therapeutic Bulletin.

"In surgery antibiotics are used prophylactically to diminish wound infections after operations," says WHO hospital pharmacist Theo Ferguson. "The problem is that presently different surgeons all have their own protocols and many of them are using antibiotics as a preventative for too long. It is important to choose antibiotics for prophylaxis that are not currently used for therapy in the hospital to prevent the emergence of resistance."

In the new protocol, which has been developed on the evidence of current research, the main antibiotic recommended is cephazolin, a cheap first generation cephalosporin. The aim is to standardize treatment throughout the hospital.

For copies of the Drugs and Therapeutics Bulletin, please contact Theo Ferguson at the WHO Office or fergusontheo@hotmail.com, or Pristina University Hospital Pharmacy.

February's issue, which is still available, covered a new protocol for pain control.

PRIMARY CARE

Spring brings renewed building efforts

With spring on the way, and the Department of Health and Social Welfare due to bring out its 'facilities master plan' spelling out the shape of family medicine development, NGOs involved in reconstruction work are getting back onto the job.

The pictures above show International Medical Corps' work in rebuilding Gllobocice ambulanta in Kacanik mu