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WHO Kosovo Health Talks 17

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NEWS UPDATE
WOMEN’S HEALTH

Available from UNFPA and WHO: Health House maternity wards: assessment of infrastructure and equipment needs Mothers give birth in outside temperatures

Many women are giving birth in intolerable conditions according to an assessment of health house maternity wards carried out in late October and November.

Of 15 health houses with maternity facilities in Kosovo, all but two have no heating. Electricity in all is unreliable, food for mothers is available in only four out of the 15 facilities and hot water in the delivery room is an exception, available in only five units. Nearly all the health house maternity units lack bed sheets, diapers, baby clothes, basic equipment and drug supply, say investigators from UNFPA, WHO, Doctors of the World, CARE International, UNICEF and the UK’s Department for International Development. In some units women are sharing beds before and after delivery. Only eight units have a steriliser in working condition and improper practices like reuse.

Facts of birth

  • Births per year: 27,000 to 34,000
  • Infant mortality: up to 54/1000 (compared to 5.6/1000 average in European Union)
  • Maternal mortality ? 30 to 40/100,000
  • Death in pregnancy ? 25/100,000
  • Average stay in health house after delivery: 3 hours
  • Two out of 15 heath house maternity units with heating
  • Four out of 15 with food available for mothers
  • 10 out of 15 with no hot water

In Peja Hospital babies share blankets but they are better off than those in health houses of disposable instruments or simple dipping of instruments in antiseptic solutions are rife increasing the risk of post-birth infections. Transport is unreliable throughout and three-quarters of units have no specialist on call for emergencies.

“The situation is very worrying,” says Dr Olivier Brasseur, head of the United Nations Population Fund in Kosovo. “These 15 health house maternity units do not meet the basic reproductive rights standards acceptable by the international community. This situation must be urgently corrected because safe delivery is not possible in these places.”

Dr Hélène Lefévre-Cholay, WHO’s reproductive and child health adviser, stresses that it is unacceptable that women are left to give birth in such atrocious conditions and urges any agency or NGO able to help to come forward with immediate practical help. “Mothers are leaving the units just after the placenta removal is complete through cold and lack of simple services like food and hot water . Hypothermia weakens babies’ resistance to infection and, we think, could be increasing infant mortality by up to 50%. We cannot let this go on.”

CARE International estimates that complete rehabilitation of the health house maternity units would take US$960,000. Re-equiping and supplying the facilities which are run down from neglect in most cases rather than war damage is estimated at another US$580,000 But basic repairs and rehabilitation that would enable women to deliver in acceptable conditions could be done for around US$200,000, says Dr Brasseur. “And this must be done now – we have women delivering in outside temperatures and newborns dying of hypothermia.”

The UNMIK interim health policy guidelines recommend that only 10 of the 15 health houses should be allowed to maintain their maternity units in the long term, but Dr Brasseur stresses that these basic renovations are needed immediately and must not be delayed by longer term policy discussions, and he urges all NGOs who have promised help to make all efforts to carry out their activities immediately.

Blanket cover for babes and mothers

A blanket to cover you after giving birth may not seem much to ask for, but for new mothers and their babies in Kosovo, the delivery of over 4000 high quality comforters for adults and babes are a blessing.

Over 2000 adult size and 2000 infant-size blankets were delivered to hospital and health house maternity units across Kosovo over the past week in a collaborative initiative between the International Committee of the Red Cross and The World Health Organization. WHO sought ICRC’s help after investigations with UNFPA and others showed mothers were leaving maternity units immediately after birth through cold. Fortunately ICRC had the blankets already in Kosovo and rapidly arranged for them to be distributed in numbers according to a detailed list provided by WHO.

Mobile clinic reports STDS and malnutrition

CARE International’s new mobile gynaecological clinic team are reporting high levels of sexually transmitted diseases in women and high incidence of respiratory infections and malnutrition in children.
The team has been working in six villages in the Mitrovica region since October and saw over 300 gynaecological and 1,500 paediatric patients in the first month. The most common gynaecological condition seen in the first foru weeks, says public information officer Alix de Mauny, was the sexually transmitted disease (STD) trichomonas, with around 10% of patients
presenting with the condition. In children, poor diet and economic straits which prevent families supplementing children’s diets with fruits, vegetables and proteins are contributing to their poor health. “there is a high demand – a profound shortage – of children’s multivitamins,” she adds.

The mobile clinic is staffed by an all-woman team of Kosovar Albanians. Services include ultrasound, PAP tests, family planning advice and pre- and post-natal care, and basic pediatric services to children and adolescents up to age 18. It also provides education for women on hygiene, breast-feeding and child and maternal nutrition as well as the distribution of drugs, toys, clothes and baby hygienic packs.

UNMIK HEALTH

UNMIK moves to appoint health directors

Albanian representatives of UNMIK Health’s advisory body, the Joint Civil Commission (health), have agreed to moves by UNMIK to officially appoint directors and co directors of all healthcare institutions. According to Dr Hannu Vuori, JCC (h) chairman and director of the UNMIK health secretariat, one of the reasons for instituting the process is that, with the arrival of the administration’s budget, it is now important that managers are contractually accountable to UNMIK. Another reason, however, is the growing number of directors being appointed by the “Kosova Provisional Government” which is not recognised as an official body by the UN interim administration.

All current directors and managers of health institutions will be required to stand down and go through the appointment process. Candidates can be self nominated with the signed support of at least five colleagues, or nominated by colleagues. Hospital and Institute of Public Health representatives along with UNMIK health staff will be involved in selecting the final candidate for positions in health houses, while hospital department heads will be appointed in consultation with the hospital director and board.

It is hoped all positions will be finalised by 15 January and successful candidates will be entitled to hold their position until a Kosovo Government has been elected and formulated its own system of health service appointments.

For further information and terms of reference for these posts, please contact the UNMIK Health office, 4 th Floor, New Government Building, Pristina, or UNMIK Health regional offices

Spend, spend, spend

UNMIK regional and central health officers, with the help of WHO, are working overtime to try and commit the 25m DM allocated to the health services in the Kosovo budget before it evaporates on 31 December. Budget allocations for September through December were approved two weeks ago giving health staff just six weeks to spend the money
rationally, since UN procedures do not allow for funds to be carried over into the year 2000. Though there’s little question that the money is urgently needed, strict financial management including a bidding, authorisation and approval process makes the process of actually spending it more complex, especially since accounting system are being set up not only from scratch
but also in three languages. Meetings with hospital and health house directors are taking place throughout the regions this week to draw up priority purchase lists, while UNMIK health and WHO head quarters are working to set up central procurement for items from drugs and laboratory supplies to stationary and soap.

2000 budget includes PHC incentive

Draft plans suggest that not only has the year 2000 budget for health services increased from 79 million to 81.3 million DM but that the incentive for doctors working in primary care which had been refused previously has now been reinstated. The changes also include an increase in the number of hospital doctors allowed, although WHO hospital’s co-ordinator Dr Margareta Rubin points out that even this increase still places Kosovo below Macedonia – considered the lowest number acceptable in numbers of doctors per patient.

STIPENDS

Double payment before year end Health workers are to be paid two further stipends in the next few weeks. Unlike the previous payments, these will not be paid by cash envelopes handed out at the health facility, but using cash vouchers which employees will redeem at the local branch of the SDK bank or at the UNMIK administrative building where not SDK exists.
Last weekend WHO handed over more than 13,500 cash vouchers to UNMIK regional health officers who have been tasked to distribute the paperwork to hospital, health house and other health facility directors. These, in turn, will distribute the vouchers to individual health workers who have been entered on the WHO database and verified as eligible to receive the
stipend.

However, the process of payment has already been complicated by the fact that some health staff in the International Medical Corps area of responsibility have already received a single payment funded by the UK’s Department for International Development. Work is now underway to amend the voucher system to ensure health workers across Kosovo are treated equally.

Payments are due to start in some regional centres today (8 December) and should take 10-14 days to complete. Workers will receive two lots of 100, 200 or 300 DM depending on their position. This round takes the number of stipend paid to a total of three since the concept was raised in August. A fourth is planned for January.

COPAYMENTS

Will people pay for health services?

This is the key question to be asked in a new research project about to take place throughout Kosovo, under the auspices of the International Medical Corps and WHO Copayments are not new in Kosovo. For 10 years, Kosovars sustained an admirable parallel system of health care through unofficial taxes and voluntary donations. What investigators will be trying to find out is whether, given the changed circumstances, people are willing to continue to contribute, not this time because it’s the only way to make sure a health care service exists, but to improve its quality.

The research will be carried out through a series of nine focus groups involving eight to 10 participants each. Participants will be asked about issues such as what types of services they might be willing to pay for, what they currently spend on health care, who should support the 4 health care received by individuals, the concept of shared risk and who and where should manage the monies collected via any copayment system.

The research should take about six weeks and it is hoped results from the discussions will be available in late January to inform policy discussion.

Pristina considers co-payments

Pristina University Hospital is considering introducing patient contributions for some treatments. Suggestions for fees range from 2 to 10 DM. The therapies that would become eligible for charges are still under consideration as is the system by which they may be administered, says hospital director Prof. Tony Redmond. But, he says, it is crucial that any system initiated is entirely transparent and accountable. “There would be a list of fees up on the wall in every clinic, patients would need to be given receipts and every transaction recorded and accounted for.”

It is also essential that the system allows for an evaluation of patients’ ability to pay and guarantees treatment for those who cannot contribute.

The money collected would most likely go into the Hospital Fund which, it is hoped, will soon be kick-started by a 300,000 DM injection from the Carabineri who are renting one of the hospital buildings (see Hospitals page 8) “My personal view is that the way forward for this hospital – and for the regional hospitals – is to operate like the charitable infirmaries that used to exist in Britain which received some state funds and some charitable donations and monies from elsewhere.”

This would also help donors, he added, who may not want to fund fuel for heating for example, but would happily donate a sum to the Hospital Fund.

A special meeting of the hospital board is being held this week to debate the possibilities and create a proposal for presentation to UNMIK Health.

ENVIRONMENTAL HEALTH

Paying for a cleaner Pristina

Paying a bill is rarely a cause for celebration, but according to the local organisations and UN agencies who became the first to pay a fee for commercial rubbish collection, this one was an exception.

“A clean environment is good for business and good for health,” Fexhr Hashani, told the press last Thursday as he handed over the fee for his business, the Bar Café Magic in Dardania. “I hope the new charges will improve the current waste management situation in the city, which is a disaster,” he added.

His enthusiasm was shared by the Grand Hotel, German government development agency GTZ, WHO, and the UNMIK Pristina regional administrator Enrique Aquilar, all of whom paid their fees on the first day.

The fees, which are backdated to 1 November are the first public rates to be legally authorised by UNMIK. They are calculated on floor area and the type of business so that larger waste producers pay more and will be collected by Hjgiena Teknika employees, the company now legally empowered to take charge of refuse disposal in Pristina. All fee payers will receive a certificate to demonstrate their commitment to a cleaner Pristina. Measures such as “naming and shaming” to penalize those who do not pay are under consideration.

The fee schedule is part of a wider agreement between GTZ and UNMIK co-ordinated by WHO through the Pristina Waste committee, and is the first official step toward building a sustainable waste management system, according to WHO Assistant Environmental Health Adviser, Sarah Gayton. “In discussions with the commercial sector, I’ve found many welcome the charges because they realise that poor waste 5 management is bad for business. Uncollected waste smells bad and creates vermin problems that no restaurant, hotel, food store or office really want to have linked to their name,” says Ms Gayton.

The money will be used to contribute to the company’s running and staff costs.

Street sweepers and new rubbish trucks

Fees are not the only new initiative on the waste front. This week will see 180 newly employed street sweepers take up their work around Pristina and the unveiling of the capital’s new waste collection equipment including six new waste trucks and 120 large skips. The equipment has been funded and brought into Kosovo by German Government donor GTZ which is spending 800,000 DM on cleaning up the city and setting in place a regular solid waste management system via the local refuse company Hjgiena Teknika. German waste management specialist Bernard Schenk has spent several weeks working with the company under the auspices of GTZ.

The project has been driven over the past two months by WHO’s environmental health advisers, Dr Philip Rushbrook and Sara Gayton, who are now handing over this role to UNMIK Pristina and shifting their focus to under-provided areas in the regions.

Attacking the healthcare waste crisis

With most waste disposal facilities destroyed or out of commission, most health facilities now have rapidly accumulating piles of healthcare waste, including sharps and infectious material, somewhere in their grounds.

Burial and burning offers some semblance of control, but the real need, says WHO environmental health coordinator Dr Philip Rushbrook, is to get waste treatment facilities into each region and organise for proper separation of waste inside hospitals and other facilities. WHO has been working with donors such as DANIDA, Cooperazione Italiana and GTZ for several months to gain funds and arrange a system whereby all healthcare waste in all Kosovo can be dealt with safely.

These talks are now starting to come to fruition and, says Dr Rushbrook, “barring last minute glitches, there are high hopes that clinical waste disposal will be back on a safer footing by early spring.”

Planning is underway to build a larger incinerator, capable of burning 300kg of health-care waste an hour for Pristina University Hospital and machinery should be in Kosovo by springtime. In fact, this installation could burn all the infectious waste produced in Kosovo, but transportation is not only difficult given the state of roads, but costly in fuel.

In Pejë/Pec, where two month’s worth of healthcare waste is currently sitting in a container and growing everyday, the Cooperazione Italiana has offered a large incinerator that will service all the surrounding area. Mitrovica Hospital too has funds for an incinerator, while Gjakovë/Djakovica should have a small brick-built facility built with GTZ funds fired up and ready to go by late January.

Inside the hospitals, only Pejë/Pec is currently using the standard WHO “three bin” (black bag for general waste, yellow bag for infectious materials and boxes for sharps) method of separating healthcare waste. But over the first few months of next year, says Dr Rushbrook, each hospital will receive a starter pack containing the equipment to put this into place courtesy of a 200,000 DM donation from GTZ.

“The idea is that WHO will work with the hospital management to train workers in waste separation as soon as the waste disposal systems are in place. The starter packs should last one to two months after which the hospital budget from UNMIK should cover the materials needed to continue the system. Once the hospital waste is being treated in reasonable satisfactory way, we’ll move onto the health houses and ambulanta.”

Water enforcement standards passed

The Joint Civil Commission (Health) have approved the regulatory administrative instructions drafted by WHO to put into place water sampling, testing and quality enforcement. The central Kosovo Institute of Public Health will be the water testing authority and will be able to charge for water testing as soon as water companies start collecting consumption fees, possibly in early spring.

Inspectors will be recruited from among current Institute of Public Health central and regional staff and trained, and laboratories equipped to carry out testing. It’s hoped the inspectors will be out and about after the New Year, though practically this depends on the availability of transport. Though they will be empowered to enforce and fine those failing to meet standards in due course, again the reality is that for the time being the inspectors will concentrate on tracing the source of deficient samples and correcting the problems through consensus wherever possible.

Holistic ways will improve wells

Well cleaning has been going on all over Kosovo since the return of the population in summer.

undreds have been cleaned in the past five months but, says Dr Philip Rushbrook, WHO environmental health coordinator, much good work is going to waste because contamination sources are not being dealt with at the same time. “Many of the cleaned wells risk becoming recontaminated because sewage channels need to be redirected or collected elsewhere. What’s needed is a more holistic approach – not just looking at cleaning the well, but at the surroundings and how they can be adjusted to improve the well’s environment”

The WHO team is currently investigating the possibility of getting septic tanks manufactured locally and in the New Year hopes to create a ‘Healthy Village’ campaign incorporating a number of environmental issues.

MENTAL HEALTH

Mental health conference draws wide crowd

Over 80 people attended last weekend’s “Perspectives on community-based mental health in Kosovo” conference organised by the neuropsychiatric section of the Kosova Medical Association in association with WHO and UNICEF.

The two day conference focussed on community mental health services and the resources in the Albanian culture and professional available to develop a more dynamic connection between primary and secondary health care. It also addressed the practical issues that arise when large numbers of international organisations start working in a sensitive area.

One outcome of working groups' discussions, said Ms. Melissa Brynner, was that many NGOs had made false promises and brought about disappointment and distress largely due to their lack of co-operation with local professionals.

Summing up Dr. Ferid Agani, associate professor at the neuropsychiatric clinic of Pristina University Hospital, said one crucial and unanimous conclusion was on the need for some sort of body to be created between local and international professionals to ensure that all groups who run training courses or who offer therapy are appropriately supervised.

Other key issues were how to remedy the lack of trained psychiatric and psychology staff in Kosovo and how to strengthen the role of the family practitioner, particularly in early awareness of deteriorating mental health.

A full report of the conference will be available from the WHO office later this month.

Repairing Shtime

Shtime Special Institution brought the world’s press running – mentally-ill patients abandoned and locked in dark and terrible conditions. Make no mistake Shtime is still no palace, but these days lights burn into the evening, windows not only close but exist, patients are dressed and on 20 November, just in time the central heating repairs by the German Red Cross produced the goods – heat.

The Institution, which currently has 316 patients, is managed by the Norwegian Red Cross but, says administrator Beate Fasting, many other agencies and NGOs are providing crucial support. Food is no longer a problem thanks to Catholic Relief Services, War Child and the French food NGO ACTED. Lighting has come from Danish Red Cross, German Red Cross has repaired water and sanitation and installed heaters, while the International Committee of the Red Cross delivered over 28,00 litres of oil and the patients’ favourite gift 100 hand-driven radios.

Now, however, Ms Fasting says major construction work being carried out by the Norwegian Red Cross team is demanding a lot of flexibility from both patients and staff. Dr Liliana Urbina, WHO’s mental health adviser adds that ‘humanization’ of life in the institution, and identification of its population is the first step in the more complex task of shifting this work of this institution into the community and replacing it with alternative structures.

Teachers train in psychosocial care

Teachers participating in CARE International’s psychosocial training and support programme compelted their second module focussing on trauma in adults especially women’s experiences during the conflict – last week.

Begun in October, the programme comprises four modules of three days each and is an extension of the psychosocial projects that were run by CARE in Cegrane Camp in Macedonia. It is being run in close cooperation with the Ferizaj
Institute of Pedagogy.

Over 100 primary school teachers from 22 schools in the Ferizaj/Urosevac region are participating in the course which focuses on how to recognize signs of trauma, learning disabilities and behavioral problems in children, and how to address them. The project aims to empower teachers through giving them additional knowledge and tools with which to help create
better atmospheres in the classroom.

For further information please contact Alix de Mauny, public Information Officer on mobile: ++ 389 70 267 043, landline ++ 381 760 38 549 130. Or email: a_de_mauny@hotmail.com

Tirana experts help in trama workshop

The Tirana-based Women’s Centre which specializes in providing psychosocial advice and 7 support for Kosovar women, is facilitating a two-day women’s trauma counseling workshop taking place today (8 December) under the auspices of CARE International. Participants include CARE’s mobile gynaecological teams who are currently working in the Mitrovica region. “Women are so traumatized. It is a huge problem, because they are unable to take care of their children, who are also traumatized. In both cases, they need special care. We encourage them to forget what has happened in their past and to start a new life, but I think we need to find ways of giving them more support,” says CARE public information officer Aliz de
Mauny.

Feeding minds as well as brains

Apples, leeks and big fat donuts commandeered from US KFOR’s weekly co-ordination meeting in Viti make for a strange diet, but people are used to Doreen Huddart’s eclectic approach. Psychosocial director of Feed the Children and community psychiatric nurse and trainer in Britain, Huddart interprets the term ‘psychosocial’ broadly. During the day I spend with her, she runs a seminar on the signs and symptoms of trauma in children where 20 male teachers in the freshly blue and pink-painted village classroom high above the fog-line talk about a child who is afraid to speak and another who is convinced he is very ill.

In another village she promises to relay the villagers feelings about KFOR’s night-time searches of houses which terrify children and adults alike, helps a single mother who lost her husband in the conflict fill in the forms to meet UNMIK’s deadline for emergency financial assistance, and transports a woman who gave birth alone in a tent seven days ago, and her five other children, to the ambulanta in Pozeranje for the infant’s new born check. On the way boxes of pampers, cereals, baby hygiene packs are left here, the apples and leeks there while, stopped on the hoof, she gives advice to the parents of neurologically sick child on where to find expert help.

Working from the town of Viti and in the surrounding villages, Doreen and colleague Mel Barton have delivered warehouses-full of everything from soup to fertiliser over the recent months. Now they’re looking to the future, working with the UK’s Department for International Development and local agriculturalists to rebuild several football field’s worth of glass houses and, on Doreen’s part, to set up a pilot community mental health project linking specialists from Gjilan/Gnjilane hospital, a drop-in centre and a team of community psychiatric nurses. “I came initially to try and get an idea of how much trauma there is among children but I quickly realised that the teachers and adults had to deal with their own before they
could start helping the children.” Her regular visits to the villages bring up problems from the horrific to the mundane – the traditional territory of a community nurse in other countries, she adds. Just how Kosovar health services and personnel can develop these kind of services is a one of the key focuses of the international mental health community.

Psychosocial students start university course

Fifty people from all over Kosovo started lectures on the International Organisation of Migration’s year long inter-faculty Psychosocial and Trauma Response training course this Monday (6 December). Arranged in association with Faculty of Medicine and the Faculty of Philosophy and Sociology, the course includes seven weeks of theory work, seven week of field
work and a total of 300 hour clinical work. At the end of the academic year, the students will be in a position to provide “professional, qualified and timely” psychosocial support and care in the “new reality of Kosovo, says an IOM spokesperson.

VIOLENCE PREVENTION

Preventing violence against all is priority

Gunilla Bachman, WHO consultant on violence against women arrived in Kosovo last week for an initial three month mission which will involve in-depth research into the specific situation in Kosovo and the development of suitable and effective interventions, both in supporting those subjected to violence and developing means of violence prevention.

“To effectively understand and deal with the issue of violence, it is necessary to first clearly define the problem,” says Ms Bachman who spent two and half years in Bosnia in a similar role. “So my first priority is to travel throughout Kosovo, and meet as many people as possible, particularly local organisations, working in all sectors concerned. For me this means health, social, educational, legal and media sectors as well as policy makers and NGOs.”

Ms Bachman hopes to conduct a series of focus groups to pin down priorities which will then feed into workshops on violence prevention and care in early February 2000. She can be contacted at the WHO office.

HOSPITALS

Gaps in services

Given the lack of equipment and the isolation of recent years, obstetric staff in Kosovo are “pretty competent” according to a WHO consultant. “Some of the practices are inappropriate or outdated but they are not major problems. In fact, few British doctors and certainly no US doctors could provide the level of care these doctors do with the equipment they’ve got,” says
Dr Mary Hepburn, consultant obstetrician and gynaecologist and senior lecturer in women’s reproductive health at the University of Glasgow who has spent the past two week’s examining the skills and training needs of O&G specialists.

The biggest gaps, she says, are in provision of services such as ante- and post-natal care, family planning and preventative gynaecology. “Obstetric patients are only seen when they need something – like going into labour and gynaecological patients are only seen when they’ve got major problems. It’s crisis prevention with very little preventative care – which is quite
normal in countries where there is under-investment in the health services.”

Dr Hepburn says the first step is to set up a body with representation from the university and O&G specialists which will draw up training for their own specialty. “This is where local doctors may appreciate external facilitation. Once the specialists have devised their own updating then they can look at the curriculum for junior staff and also for undergraduates.”

Italian police pledge to pay rent bill

After four months of procrastination, the Carabinieri have promised to deposit the 300,000 DM owed to Pristina University Hospital for the rental of the property they now occupy in the hospital grounds in UNMIK hands this week.

The unit has been resident for reasons of space not security in what was the Serb administration building for the hospital since July, but despite numerous promises to pay in cash and kind, until now nothing has materialised. This situation has caused tension not only for normal landlord-tenant reasons but also because, prior to 1990, the building had housed
the ‘defectology’ or learning-disabled wards. Staff were keen to resurrect this but in the light of the greater good six months’ rent would bring to the hospital, had been persuaded to wait six months, says international director Prof Tony Redmond.

However, with the Italians’ non-payment, the situation became more fraught.The money has now been paid into the new “Hospital Fund” and will be used, among other things to equip a modern learning disabled centre which will most likely share the re-occupied building with a rehabilitation unit in due course.

Nikol comes home

One of the first patients to be evacuated from Kosovo for medical reasons after the conflict – six-year-old Nikol Dodaj – returned home from Italy last week after multiple operations to save his sight.

The victim of a grenade attack in May, Nikol lost the sight in one eye due to wood slivers lodged in it in the blast, and was in danger of losing the other. He was brought to the attention of WHO’s then head of mission Dr Luigi Migliorini and public health adviser Dr Cristina Profili who
personally arranged for visas from the Italian embassy in Skopje to enable Nikol, his 16 year old sister Violeta, who has suffered a spinal defect from childhood, and his mother Hane to be evacuated to Italy. The papers of all three had been recently destroyed so WHO acted as guarantor. The group flew to Rome with the World Food Programme flight and were taken under the wing of Don Doriano, a priest and the director of the Confraternita della Misericordia di Siena which has supported the three for the past four months. Nikol’s treatment at the Hospita of Sienna – Le Scotte was paid for by the Italian
government. Violeta, who remains in Italy has been given life-long treatment in Italy free of charge. She is currently attending the University Hospital of Siena and the Hospital Bambini Gesu in Rome for assessment on the possibility of a surgical operation.

Now returned to Klina and her four other children, Hane Dodaj says everything that has happened in the past four months seems like a dream. “Everything we needed, shelter, food, medicine, has been taken care of – it’s impossible to thank everyone enough.” Medical evacuation is now organised by the Medevac Selection Committee. Please contact
Dr Andrea Capusan at IOM, or Dr Margareta Rubin or Dr Arta Ibrani at WHO.

EDUCATION AND TRAINING

NGOs should facilitate not train

NGOs should not be providing specialist training, but helping local institutions to examine their own needs and devise their own courses, says Dr Mary Hepburn, WHO obstetric consultant. Dr Hepburn, who has spent two weeks assessing the skills and training needs of local obstetricians and gynaecologists, says when it comes to updating specialists in Kosovo, NGOs
and agencies should focus on providing access to training materials and strategies, to resources such as the Internet and evidence-based practices and only offer actual training when specifically invited by local doctors.

“We should act as facilitators and support local health care providers to work through the issues, but when it comes to arranging and carrying out courses, we should be letting local doctors and institutions do it themselves,” she says. “I'm not
opposed to NGOs providing training, but I am opposed to it being done uninvited and without consultation with local clinicians which is happening here. It’s also important for NGOs not to attempt to provide training to health care workers according to their own perception of need.

Dr Hepburn’s views are echoed by the Dean of the Medical Faculty Prof Mazllum Belegu. “NGOs and agencies can help greatly by bringing literature, by creating seminar venues and materials, by bringing an expert professor from overseas but not by offering training themselves. We are a medical faculty and we have standards that must be maintained. We cannot accredit just any training,” he says. There are practical problems with ad hoc courses too. A request for graduates of an
internationally-arranged neurology course to be awarded credits for their work via the medical faculty had to be refused recently, says Prof Belegu, because the faculty had no input into the course, or oversight of the standards attained.

Dr Hepburn says ‘self-directed’ learning is well established as the most effective method in the rest of Europe and internationals have a crucial role in facilitating this in Kosovo.

“It may take a little longer since people need to work out the issues themselves but it will be much more effective. If we don’t allow local doctors to take control, it will delay things even more because when we go, they will have to begin the process of examining their own practice, months after they could have done.”

The place for international-led courses like training of trainers, she adds, is in areas where there is no local expertise or culture such as family medicine or antenatal care.

HEALTH INFORMATION

Wanted: numbers to crunch

How many people have diabetes, how many die of coronary heart disease, how many smoke, who drinks well water, how many are overweight – statistics like these are taken for granted in most health services, but in Kosovo, they are 10 like a scarce commodity. A heavily centralised reporting system based in Belgrade plus the parallel system put paid to any semblance of accurate figures and over the past 10 years most data collected has been a combination of guesswork and leg work.

Remedying this situation will not be a quick fix but it is a crucial one for health planning, according to WHO’s health policy team, which is seeking a donor for an ambitious plan to provide Kosovo with a computerised health information system by the year 2001.

The essentials of the project are equipping all facilities with a computer and training staff in data processing, but it is also vital, says Dr Emilio Morales, a Cuban health information systems expert seconded to WHO, that local health managers become skilled in analysis so that the data can be immediately useful in municipalities for planning health services.

The project will cost in the region of $US4 million.

PRIMARY CARE

First steps to family health care outlined

A WHO working group has drawn up a plan of the steps now needed to develop family medicine and family health care teams in Kosovo. Among the priorities are defining the relationships, obligations and expectations each loevel of health provider will have in the new system and fleshing out the characteristics of the workforce and infrastructure needed to deliver
these contributions.

The plan also outlines the guiding principles for family medicine, including the aim that in future family health centres and teams will provide the total health care needed for the vast majority – 90% – of the health problems of a clearly defined catchment population, and take their care beyond the curative and into health promotion and disease prevention services.

To do this, these teams will need clearly defined access to specialist services with a properly regulated referral system, says Dr Pekka Kuosamen, WHO’s primary care adviser. Another ‘first step’, now almost complete, is the identification of whichh of the current ambulantas and health houses will become the new family health centres.

The full report will be available from the WHO office next week.

Mitrovica looks to 2000

Health house directors, personnel from the Institute of Public Health, local hospital staff and all interested NGOs, donors and agencies are invited to a meeting which aims to plan the provision of health care services within the Mitrovica region for the coming year. Postponed from the end of November due to Flag Day disturbances, the event will be held on Friday 10
December at Mitrovica UNMIK headquarters between 10am and 3pm.

“The main focus of the meeting will be the development of family health services and I hope as many as people as possible will be able to attend,” says Dr Nick Gent, WHO public health adviser who is chairing the meeting. The meeting will be a mix of presentations, workshops and round table discussions, covering issues such as:

  • type, scale and distribution of existing services
  • future role for family medicine services
  • developing a vision for the future type and distribution of services
  • the role of the hospital in providing support to family medicine services
  • maternal and child health services
  • support to enclaves
  • the future for mobile clinic services and other transitional service issues
  • Access to social support.

For further information, please contact WHO Mitrovica, UNMIK Building

COMMUNICABLE DISEASES

Hep A ‘epidemic’ is red herring

High reporting of hepatitis A infection may be more due to inaccurate diagnosis than true occurrence, according to Dr. Michael Rolfe, specialist in internal medicine with the international team at Pristina University Hospital “I have no doubt that some cases of hepatitis A are occurring, but I believe the large numbers currently being reported are grossly exaggerated,” says Dr Rolfe, who notes that the standard test for hepatitis A (the IgM antibody test) is not available in Kosovo. “Standard
practice here is to test patients with jaundice hepatitis B and hepatitis C, and diagnose the patient with hepatitis A if both are negative. However, whenever I have been to the infectious diseases ward and asked to see some patients, only few are in fact jaundiced. In August and September the figure was 1 in 18 and today it was three out of nine. And perusal of the notes
usually fails to show any convincing biochemical evidence of deranged liver function.”

Diagnosis by exclusion is not only an ineffective method of identifying hepatitis A, says Dr Rolfe, it also consumes a huge amount of laboratory resources which the hospital can ill afford. Only when the specific test becomes available, will the true figures for hepatitis A be known, he adds. In the meantime patients should only be categorised as probably cases of hepatitis A where strong clinical evidence is found.

Young people talk safe sex

A Kosovar “Young Ecologist” offers condoms to passers-by for World AIDS Day World AIDS Day was marked with exuberance and gifts never given before in the main street of Pristina. Dress in silken pink, blue and purple ‘condom’ suits, members of the Kosovo Young Ecologists gave out condoms and chanted safe sex slogans up and down Pristina’s main
thoroughfare, Mother Theresa Street followed closely by the cameras of Reuters and Radio TV Kosovo. Supported financially and in spirit by WHO and UNICEF, the local youth group designed posters and gave interviews in a perfect campaign for the World AIDS day them of raising awareness among children and young people. Elsewhere CARE International and World Vision supported stands of public awareness materials run by the Institute of Public Health and showed the UNAIDS video “Staying Alive” which was launched on MTV on 1 December and features recording artist
George Michael introducing a series of experiences from young people living in a world with HIV/AIDS.

Copies of the video are available from the WHO office

PHARMACEUTICALS

Budget funds essential drugs

Sixty per cent of the 1999 UNMIK health budget will be used to buy pharmaceuticals from the essential drugs list for primary care in Kosovo This list was released last month and is available from all WHO offices.

The remaining 40 per cent of the UNMIK health drugs budget will be spent on pharmaceuticals for hospitals and haemodialysis supplies.

UNMIK Taskforce’s Working Group On Selection and Rational Drug Use is currently developing a list for Kosovo hospitals which is intended to indicate the core medications which will be essential for the provision of the basic services of secondary health care. Although not finalised, this list will be used as the basis for the above purchase of drugs.

Seasons Greetings!

WHO staff send good wishes to all Kosovars and internationals in Kosovo for the holy month of Ramadan, and Christmas and for the Millennium celebrations.

WHO offices throughout Kosovo will be officially closed from Wednesday 22 December to Tuesday 4 January 2000, though some technical staff will be available over the holiday period.

We welcome you to the next General Health Co-ordination Meeting on Wednesday 12 January in the Dean’s Building of the Medical Faculty (3 rd Floor).

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 written information, by email if possible, by midday on the Monday before the General Health Co-ordination meeting.

HEALTH TALKS ON THE NET

Kosovo Health Talks is also published fortnightly on the WHO/EURO website. Please visit http://par.who.dk, click contents,
then enter Kosovo Health Talks in the search field for back issues.

WHO in Kosovo
Pristina
M. Popovic 1, 38 000 Prishtina
Ph: + 381 38 549 216
+ 381 38 549 218
Fx: + 381 38 549 217
Office mobile: 063 406 895
e-mail: pristina@who.dk

Head of Mission: Mr Bob Hagan
haganr@who.int

Head of Office: Dr Kees Rietveld
headpristina@who.dk
Pejë – Gjakovë : UNMIK Building
Sat. ph: +871 761 669 030
Sat. fx: + 871 761 669 031
e-mail: c/o peja_jane@hotmail.com

Regional Public Health Adviser: Dr Jane Hoffmeyer
Gjilan: - c/o UNMIK Health Office
Ph: 038 501 400 Ext. 7600
e-mails: nick_gent@hotmail.com, selezi@hotmail.com

Regional Public Health Advisers: Dr Nick Gent, Dr
Shpend Elezi
Mitrovica: UNMIK Building
Sat. ph: +873 761 602 155
Sat. fx: +873 761 602 156
e-mail: nick_gent@hotmail.com
Regional Public Health Adviser: Dr Nick Gent

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