Albania Subnational

The Situation of Children and Young People at the Regional level in Albania

Prepared by Albania Country Statistical Team Co-ordinator: Milva Ekonomi Institute of Statistics, INSTAT, Tirana

MONEE Country Analytical Report November 2004

The project to monitor the impact of economic and social change on children in Eastern and Central Europe and the Commonwealth of Independent States (MONEE) was initiated at the UNICEF Innocenti Research Centre in 1992. The project seeks to monitor, analyse and disseminate information on economic and social trends affecting children’s rights and wellbeing in countries in the region. A key feature of the Project is a network of correspondents in the 27 National Statistical Offices (NSOs). On an annual basis these correspondents complete an extensive data template which in turn is used for calculating indicators, supporting research of the project and, in due course, being made publicly available as the TransMonee database and in tables and graphs of the Innocenti Social Monitor.

For a number of years, each participating NSO prepared a Country Analytical Report based on extensive outline from UNICEF IRC on a different theme on the situation of children every year. These analytical reports have provided valuable input into the research at UNICEF IRC and, as significantly, have also served as important national documents on monitoring aspects of child wellbeing in the countries. Some of these Country Analytical Reports have been issued by the NSOs (in the national language) as part of their publication programme.

UNICEF IRC attaches great value to these national assessments of the situation of children and is committed to promote the efforts, including through translating the reports into English (where the submitted report has been in Russian) and offering its website to make them accessible to a wider research audience. The Country Analytical Reports are owned and authored by the National Statistical Offices and are not the intellectual property of UNICEF (see below).

The opinions expressed are those of the authors and do not necessarily reflect the policies or view of UNICEF. The text has not been edited for official publication standards and UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers.

2 Situation of Children and Young people at the Regional level in Albania

Albania has not yet officialised the use of the NUTS nomenclature. All the regional statistics used right now are based at the territorial division of the country, approved by law No 8652, date 31.07.2000.

It is divided in two levels: at the first level are communes and municipalities, the second level is prefecture.

Commune represents a territorial administrative unit and a community of inhabitants, usually in rural area and occasionally in urban once. Subdivision of the communes are called village (country) and in occasional case city. Council of commune makes up the determination of the subdivisions territory.

Municipality represents a territorial administrative unit and a community of inhabitants, usually in urban area and in occasional case include the rural area. By law are determined territorial extension and name of municipality. Subdivisions of the municipality in urban zones are called neighbor. Neighbors are created by municipality council decision in territories with 15 000 inhabitants. When the rural zone is included in municipality, subdivision is called village. The village has to be created in a territory with 200 inhabitants. City is nominating a living center, which has an urban prospectus development plan, approved. Law makes proclamation of a city.

The region (prefectures) represents a territorial administrative unit composed of some communes and municipalities with geographical, traditions, economical, social links and common interests. The boundary of the region has the compatibility with the boundaries of communes and municipalities, which compound it. The center of the county decided at one of the municipalities, which are included in it. Law determines territorial extension, name and the centre of the county. Subdivision of the county is district. The region is the unit in which regional policies are carried out and harmonized with state policies. Albania is divided into 76 town municipalities including the 11 zones which form the municipality of Tirana, and 309 rural municipalities. This is the first level of local government. The town and rural municipalities are grouped into 12 regions, which represent the second level of local government.

Definitions of urban areas The classification on towns is not very clear. The government will review this classification in particular those towns with a relatively small population, and to find ways of adjusting the number (74) to correspondent to the number of town municipalities. As well the boundaries are town/village are not well defined because in Albania does not exist yet an official “yellow line” .

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4 Administrative division of the republic of Albania

Regions Districts Cities Regions Districts Cities Berat Berat 2 Korce Korce 2 Kucove 1 Devoll 1 Skrapar 2 Kolonje 2 Diber Diber 1 Pogradec 1 Mat 3 Kukes Kukes 1 Bulqize 2 Has 1 Durres Durres 4 Tropoje 3 Kruje 2 Lezhe Lezhe 2 Elbasan Elbasan 2 Kurbin 3 Peqin 1 Mirdite 4 Gramsh 1 Shkoder Shkoder 2 Librazhd 2 Malesi e Madhe 2 Fier Fier 3 Puke 2 Mallakster 1 Tirane Tirane 3 Lushnje 2 Kavaje 2 Gjirokaster Gjirokaster 2 Municipality of 1 Tirana Tepelene 2 Vlore Vlore 4 Permet 2 Sarande 2 Delvine 1

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Population and Demographic change.

The census in 2001 showed that the total population of Albania is 3,069,039 . The region of Tirana has 597,899 inhabitants followed by Fier ( 382,544), Elbasan (362,736) Korce (265,182). Albania’s population is younger (average age 28.6). In 2001 29.5% of the Albanians were children under the age of 15, and almost half (49 percent) under 25. These regions are as well with youngest population.

The rapid urbanization of the population is of growing concern. The ratio urban/rural has changed with the urban population of the ten major urban centers accounting for about 36 percent of the total population in 2001 compared to 20 percent in 1990. The Tirana region has seen a population increase of 30 percent due to internal migration mainly form places with poor economic opportunities, for instance rural areas in the mountainous north. The population is expected to fall slightly (-0.3) percent) in rural areas because of the migration to urban areas. During the past ten years, average annual growth has been 1.9 percent, but it is now declining.

Migration is perhaps the single most important political, social, and economic phenomena in post-communist Albania, and has been a dominating fact of everyday life in the last decade. Since 1990, approximately one-fifth of the total population of the country has left and is living abroad, and there have been large-scale movements of population from rural to urban areas .

External Migration . During the last decade Albania has undergone external migration flows along with large internal migration. The total number of population has been reduced by 113.000 inhabitants in the period between two censuses in 1989 and 2001. The main factor has been external migration, which probably exceeded 600.000 persons specially after 1995.

The vast majority of temporary migrants, mainly from rural areas in the Center and the North- East of the country, travel to Greece to seek short-term employment opportunities to complement the meager earnings from agricultural activities. Despite the higher transaction costs, in recent years the flow of temporary migrants to more distant destinations such as Italy and Germany has increased substantially. Evidence indicates that among the non-migrants, a large share has considered the option of migrating, and many have tried and failed.

Information from Greece and Italy, the two principal receiving countries, puts the number of legal residents in these countries as approximately 600,000 in 2000-2001, or one-sixth of the Albanian population. An astonishing 35 percent of children of household members currently live abroad. For children who left home in the 1990s, the share reaches exodus proportions, with one child in two currently living abroad. The poverty headcount for households with children abroad is significantly lower (12-18 percent, depending on the destination), as compared to households with children in Albania (31 percent).

6 Approximately 36 % of the households in the rural area of the Shkodra region( north of the country) have at least one of their family members in emigration. For these households that is the only way out for the males and in particular for the youngsters to find a job because in the village there is very little land available, while in the city there are no job opportunities.

Internal migration . In the past decade Albania has experienced a demographic transformation from rural to urban, and from the North Eastern Mountains to the districts of the Coast and Tirana. Tirana is by far the principal destination of internal migrants, a process that appears to have accelerated and become increasingly concentrated in the second half of the 1990s. According to the 2001 census, the migration between prefectures accounts for 252,700 persons(see tab) of whom nearly 58% migrated to urban areas. It shows that migration between prefectures is partially determined by the level of the economic situation of the prefecture of departure such as the prefecture of Diber and Kukes, where 37 % of the migrated population live in 1989. Both the regions are characterized by the economic poverty. Vlora, Tirana and Durres which are considered as the most developed prefectures had the lowest level of migration (8% of the total migrants) but at the other hand these are the main recipient prefectures, where the most important is Tirana. This uncontrolled migration in zones such Tirana and Durres have many negative consequences among which we can mention:

1. The process of the integration of immigrants is hard , almost impossible. These I integration can be possible only if immigration is regular and not at high levels. 2. An increase forced and uncontrolled of urbanization level ( housing, sewage canals, water pipelines, infrastructure) and a decrease in the level of urbanism. 3. Increase of unemployment and informal market.

7 Tab. Net migration and its proportion of the population in 1989 and 2001 by prefectures 1

Internal Internal Emigration Immigration immigrants emigrants in % of the in % of the Internal population population Population Population migration 1989 2001 Prefectures 1989 2001 balance

1989-2001 1989-2001

Berat 222901 193020 4260 25676 -21416 11.5 2.2 Diber 226324 189854 1682 49084 -47402 21.7 0.9 Durres 218530 245179 44859 7288 37571 3.3 18.3 Elbasan 357497 362736 6767 26645 -19878 7.5 1.9 Fier 379342 382544 21343 16536 4807 4.4 5.6 Gjirokaster 155998 112831 2686 17098 -14412 11 2.4 Korce 311448 265182 5874 23469 -17595 7.5 2.2 Kukes 146081 111393 1039 43178 -42139 29.6 0.9 Lezhe 165254 159182 10697 11945 -1248 7.2 6.7 Shkoder 285258 256473 3815 19408 -15593 6.8 1.5 Tirane 449228 597899 136576 6351 130225 1.4 22.8 Vlore 264556 192982 13137 6057 7080 2.3 6.8

Average household size in Albania is 4.3 members per household. In the north the average size is 5.7. Life expectancy at birth has reached an average of 75 years. In regions as Tirana, Durres, Elbasan actually predominate urban population which compose respectively 67%, 62% and 51% of total population compared to approximately 69 % in 1989. In the north the situation is different. Most of the population lives in the rural areas as in Shkodra 62.3%, compared to approximately 58% for the country level.

Deaths per 100.000 population in 1990 was 558, and in 2003 this figures is 575. The male death rate is higher that of woman. In 2002 the highest death rates were observed in Puke, Pogradec.

In parallel with the decrease in birth rate, infant mortality rates fall from 30.9 per 1000 live births in 1992 to 17.3 in 2002. The leading couse of infant mortality rate are acure respiratory infections, congenital anomalies, prenatal disorders. During 2002 the highest infant mortality rates were observed in Elbasan, Kukes. In 2002 infant mortality rate in Diber (north) was 3 times higher that the country average. The proportion of deaths in children under one year caused by acute respiratory infections fell from 32 per cent in 1999 to 19 per cent in 2002, and deaths from diarrhoeal diseases fell from 8 per cent to 3 per cent in the same period. Poor quality of basic services and limited access to

1 Population and migration in Albania, 2003

8 emergency obstetric care has stalled improvement in the maternal mortality rate. Surveys on pre-natal care show varying levels of access. According to a 2000 study of knowledge, attitudes, practices and behaviors, just 18 per cent of pregnant women have a first contact with the health care system during the first trimester. A 2001 needs assessment in four districts (Fier, Bulqize, M.Madhe, Pogradec) found 50 per cent of women have such access, and the 2003 reproductive health survey found 60 per cent. The health status of children and women is especially poor in the north and rural areas due to poverty and faltering health infrastructure. The maternal mortality rate in the northern town of Bulqiza is nine times higher than the national average, while infant mortality in the northern town of Diber was three times higher than the national average for 2002. Adolescent girls and women have poor pre-pregnancy health due to very low access to women clinics in health centres

Albania’s mortality rate is high …….. per 100000 live births in 2002. This rate seems to be higher in the northern regions. Lack of access to good health care in mountainous rural areas is the biggest contributing factor.

Regional Standard of Living

Average household size in Albania is 4.3 members per household. The average household size among is various from north to south. In the north predominate the large households type.

In a country level the active population makes up about 40 percent of the total population and is sensitively increased in the regions as Tirana, Durres, Elbasan due to the migration factors compared to 1989 and this increase is more evident to the population aged 35-55 years. In Shkodra region, the active population accounts about 42% of the total population of the region compared to 57% in 1989.

The employment structure has changed during last 10 years and this is the direct consequence of transition. Until 1990 about 85% of the labor force in the urban areas were employed in the industrial sector. Actually in Albania 56% of the active population work in agricultural sector and 23% in private non agriculture. Shkodra has an employment structure very different from the national situation where 65% of the employment population works in agriculture. Since its peak in 1993, when more than 22 percent of the labor force in Albania was out of work, the unemployment rate has fallen to the mid-teens and in the 2001, the last year for which official data is available, the unemployment rate was 14.5 percent. Unemployment in Albania has been historically higher for women than men. The data for 1993-2001 indicate that more men register as unemployed than women. In the year 2001, there were just two percent of individuals with higher education among the registered unemployment, suggesting that university education is most likely to help escape unemployment. Primary or secondary education, on the other hand, does not guarantee such opportunity. In 1993- 2001, the share of 35 year olds and over among the unemployed increased by 10 percent, while the share of 15 to 19 year olds decreased from 15 to 7 percent. In the year 2001, 93 percent of the unemployed were in primary working age.

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Tab. Youth population and young active population in Albania

Population Economically active Decline in % Year 15-19 years 20-24 15-19 years 20-24 Young Economically. years years population active

1989 321,007 302,219 138,364 211,816 100 100

1998 287,155 303,845 127,982 144,339 - 5 -22

2001 295,161 232,013 154,883 160,420 -15 -10

The data of 2003 shows that the unemployment rate is about twice higher in the regions in the north as Kukes, Shkoder, Lezhe ( 34.3%, 26.0%, 28.3%) compared to the rest of the country when the country unemployment rate is 15%.

The indicators of unemployment have features which reflect not only rhythms of change, but also traditions characteristics and opportunities for development in the various regions. Thus for the period 1998 –2001 Laci, Librazhdi, Shkodra, Kukes were considers enclaves of unemployment 2.

Tab. Employment and unemployment in some main districts

District Unemployed jobseekers, end 2003 Employed in 2003 Total In % Tirana 18071 3456 19 Shkodra 17790 841 4.7 Elbasan 13003 964 7.4 Fier 8509 1182 14 Korca 8108 1470 18 Vlora 6700 1723 25 Berat 6183 929 15 Country 163561 21405 13

The unemployed belonging to population 15-24 years old is various from 15-30 % from region to region, except Shkodra where this rate is about 60%.

2 Based on a study made by Ministry of Labour in 2002

10 Rural areas have around 50% more poor than urban areas and this rises to 66% for Tirana. The poorest areas are the North-East region, mountainous areas, and any area distant from infrastructure and urban centers. Around half of the population in these areas lives in absolute poverty and 20% of them live in extreme poverty. The level of poverty in Kukes, Has, Tropoje, Diber, Malesi Madhe, Bulqize, Librazhd, and Gramsh is 46%. This represents 80% of those receiving aid for the whole country. The poor live in big and young families. Around 40% of the poor live in households with 7 or more people. The incidence of poverty in youth is higher than average for the country. More than 50% of the poor in the country are under 21 years of age.

Mountain region in the north and northeast of the country fare worst in terms of poverty (Table ) Almost half of resident of this area are poor, and more than a fifth in this group live in extreme poverty. Also, the depth of poverty in this area is much more pronounced than in any of the other regions, with a poverty gap index of over 11 percent. Average consumption in those mountainous regions is two-thirds of consumption levels in Tirana, and about 20-30 percent lower than the rest of the country. Poverty rates and depth in all other regions are around or below the national averages. Agricultural jobs are considered as the main source of revenues, but the incomes coming from it are very low so a large part of the agricultural land is either abandoned or refused. Inequality levels are moderate and stable across regions and the Gini coefficient in the regions is between 0.28 and 0.29, with the exception of Tirana, where inequality is higher.

Tab. Poverty and inequality indices by PREFECTURE (%) 3

Head Gini- Prefecture FGT(1) FGT(2) Gini Sen GE(0) GE(1) Con count poor 1: BERAT 26.42 5.81 1.89 25.64 11.00 4.29 10.65 10.85 7,233.45 2.16 0.67 0.27 0.52 0.44 0.59 0.46 0.47 193.63 2: DIBËR 42.77 11.88 4.65 28.31 13.95 10.36 13.09 13.39 6,125.03 2.04 0.84 0.41 0.57 0.38 0.91 0.55 0.60 153.13 3: DURRËS 24.77 6.07 2.18 31.23 12.49 4.42 15.99 16.46 8,412.58 1.38 0.48 0.22 0.96 0.40 0.42 1.00 1.14 259.03 4: ELBASAN 31.84 7.54 2.61 26.60 11.89 5.91 11.48 11.74 6,852.57 1.74 0.57 0.24 0.42 0.32 0.55 0.37 0.38 147.41 5: FIER 29.71 7.05 2.46 28.83 11.99 5.43 13.49 14.03 7,365.17 2.51 0.82 0.34 0.98 0.42 0.77 0.91 1.05 201.87 6: GJIROKASTËR 19.38 4.11 1.31 27.43 10.68 2.79 12.26 12.62 8,393.35 1.90 0.54 0.21 0.64 0.48 0.43 0.61 0.70 284.64 7: KORÇË 26.95 6.09 2.03 27.03 11.27 4.52 11.82 12.09 7,405.28 2.67 0.84 0.34 0.57 0.49 0.76 0.52 0.53 239.50 8: KUKËS 39.98 10.59 3.99 27.53 13.27 8.99 12.32 12.53 6,282.05

3 WB, Albania Poverty Assessment, 2002

11 1.90 0.76 0.37 0.61 0.43 0.81 0.56 0.57 150.55 9: LEZHË 36.68 9.83 3.76 30.74 13.54 8.11 15.59 17.24 6,898.25 2.17 0.85 0.40 1.07 0.44 0.86 1.26 2.67 203.69 10: SHKODËR 32.77 8.43 3.14 28.60 13.06 6.72 13.38 13.59 7,025.02 3.26 1.14 0.50 0.60 0.57 1.10 0.61 0.61 308.93 11: TIRANË 23.44 5.51 1.92 29.48 12.00 3.96 14.22 14.66 8,201.84 1.19 0.39 0.17 0.46 0.31 0.33 0.46 0.52 134.69 12: VLORË 18.26 4.14 1.42 33.52 11.72 2.82 18.63 20.93 9,817.49 1.58 0.47 0.19 2.12 0.45 0.37 2.55 4.42 502.02

Table reports the poverty and inequality measures calculated at the Prefecture level. The Prefecture of Vlore has the highest per capita consumption and the lowest percentage of poor people (16.57%), whereas according to the Gini coefficient consumption is very concentrated (33.61%). On the other hand, the Prefecture of Diber is the worst off, with per capita consumption of only 6,211 Leks per month, and the highest percentage of poor individuals (42.1%).

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Poverty and Social Assistance. The extend of poverty is also reflected clearly in the number of families receiving social assistance ( Ndihma Ekonomike). According to the law the state provides social assistance to those HH that do not have any, or insufficient incomes and living means Over the years the prefectures of Kukes and Diber show high share of families that receive social assistance: respectively 40% and 30% in 2001, while the average for the whole country is 12%. In the prefectures of Shkodra about 32% and in the prefecture of Lezha about 24%. The number of families officially living under the poverty line also varies considerably within the region. In the rural areas in the north ( Shkodra )about 30% percent of the households are entitled to benefit the social assistance payment, and the average amount they get from this important source of living is Lek 544 per month per person. In particular in some communes in the extreme north over 80% of HH receive social assistance payment. But also in the prefecture of Korca in 8 rural municipalities, 40 to 95% of the population lived at or under official poverty line.

Social Exclusion and Poverty

Some of the most vulnerable groups in Albania are: Children at risk (0-14 years) include orphans, abandoned children, children of solo-parent families, beggars, child workers, children not at school and make up 5.72% of all children. Youth at risk (14-25 years) include unemployed, narcotic and alcohol abusers, criminal behavior and make up 22.8% of all youth.

Health

The health care sector in Albania is mostly publicly owned, and the Ministry of Health (MOH) is the major provider of services. The private sector is limited mostly to the distribution and commercialization of pharmaceuticals and to dental care services, though the last decade has seen a surge of private outpatient practices and diagnostic centers in urban areas, especially Tirana. Lack of funding has led to widespread deterioration of health infrastructure and equipment. Medicines, consumables and equipment are lacking, treatment regimens are often obsolete, and it is very difficult to provide high quality care. UNICEF reported that more than 40% of health facilities in five districts of Albania visited in 1999 had no running water. They also reported in 2000 that the low availability of such basics as gloves and antibiotics could be linked to high infant morality.

Primary Health Care (PHC) is provided by health care centers and health posts in rural areas; in addition to health centers, PHC in urban areas is also provided by large polyclinics offering specialized outpatient care. In 1997, the government developed a PHC policy that aims at securing one health post per village and a health care center per commune, and to create PHC teams led by family physicians. The health care centers are usually staffed by three primary care doctors and by nursing staff.

13 Table. Health care personnel per 1000 habitants across districts 4

District Specialist/1000 Gen.Phys/ 1000 Nurses/ 1000 Dentist/ 1000 Pharmacist/ 1000 Berati 0.68 0.47 4.37 0.11 0.04 Elbasan 0.55 0.41 3.74 0.11 0.04 Gjirokaster 1.14 0.66 6.19 0.19 0.07 Korce 0.89 0.60 4.53 0.15 0.05 Shkoder 0.68 0.45 4.34 0.11 0.05 Durres 0.75 0.55 3.18 0.16 0.04 Fier 0.52 0.43 2.85 0.10 0.03 Lezhe 0.56 0.43 4.05 0.16 0.04 Vlore 1.00 0.60 4.62 0.16 0.06 Diber 0.56 0.33 4.96 0.07 0.05 Kukes 0.80 0.45 5.85 0.12 0.07 Tirane 1.69 0.57 4.09 0.15 0.11 Total 0.90 0.50 4.11 0.13 0.06

Mother and child health care is based on the analysis of maternal and child mortality incidence and on the access level to basic health care. In the analyses made for the whole country it comes out that in the north part 2/3 of villages where live around 50% of the rural population do not have out patient clinics; access to pharmaceutical services is very low and specialized doctors very hard to find.

Since 1990, indicators pertinent to maternal and child health have improved, but there is evidence of decline in access and quality of services in certain geographic areas, such as the north-eastern part of the country and the outskirts of Tirana and Durres. Maternal mortality rate in 2000 was 50% lower than in 1990. In regions as Kukes is much higher than the country average The main couses0f maternal deaths are abortions, hemorragjite and infections. The exact determinations of death causes are not available because the Albanian system of death reports contain only two categories of maternal deaths : during birth delivery and abortions. This indicator reflect the risk of mothers during the pregnancy and after child births. There is also an increase of unwanted pregnancy among young girls and the result is the increase of the number of abortions from 1989 to 1998 among young girls 15-24 years of age.

Infant mortality in Diber was three times higher that the national average in 2002, while maternal mortality rate in Bulqiza was (in the same year) nine times higher than the national average. Important causes of infant deaths are newborn diseases which are gradually increasing and next, respiratory infections and diarrhea, both of which are nevertheless in decline. According to INSTAT, a substantial proportion of infant deaths are due to the early neonatal period, indicating that maternity services for newborn babies are scarce. In general, as mortality rates fall, the proportion of deaths in neonatal period will increase, and this should logically lead to a special

4 Living standard Measurement Survey 2002

14 emphasis in antenatal care and adequate essential newborn care to improve pregnancy outcomes and prevent deaths in newborns.

Tab. Number of mothers and children’s consultancies by regions, year 2003

Regions (Prefectures) Mothers Consultancy Children’s Consultancy

Berat 185 187 Diber 62 62 Durres 103 100 Elbasan 231 240 Fier 116 117 Gjirokater 102 110 Korce 261 263 Kukes 60 43 Lezhe 103 103 Shkoder 77 81 Tirane 180 184 Vlore 131 148 Total 1,611 1,638

For both, maternal and child health, there are notable disparities, with a lower utilization of health facilities in rural areas. The distance from health care centers is an important factor to take into consideration in regards to equitable access to health care. Poor roads lead to poor access to antenatal services for women living in remote and mountainous areas. In addition, according to the Albanian Public Health Strategy, there is an imbalance in the distribution of health care staff across the country, with variations in the ratio medical staff/population up to 50% between some districts. Doctors in rural areas are expected to cover several villages without an adequate transport infrastructure. Therefore, infant mortality shows an important gradient from rural to urban areas. Poor sanitary conditions and lack of facilities at the health centers of rural areas are likely to be influencing high infant mortality rates. Furthermore, the lack of health insurance coverage of many internal migrants - as well as their dependants staying in Albania - is an issue of concern. This issue involves mainly the areas most affected by migration movements (Northern and Southern regions).

Children Immunization . Albanian Government has made numerous efforts to maintain and improve the children vaccination coverage in the whole country. An extended immunization programme has been established especially during these last years which enhanced the management of vaccination coverage structures. Albania already has an obligatory vaccination scheme against the main diseases such as: Measles, Diphtheria, Tetanus, Perthussis, Tuberculosis, Poliomyelitis, B Hepatitis and Rubella which is introduced recently in the scheme. These efforts have resulted with a high level of children immunization in Albania (more than 90%), which reduced considerably the infant mortality from infection diseases.

15 Public Expenditures on Health. Public expenditure on health amounted to 18,022 million Leks on health care in the year 2002. 5 This amount represents about 3% of total GDP, one of the lowest shares in the Balkans, and about one-half of the CEE average. 6 Public expenditure on health is not only low when compared to other countries in the region, it is also low when compared to Albania’s expenditure a decade ago. As share of total government expenditure, public expenditure on health was 9.8% in 2002, slightly up from 8.8% in 2000. In contrast, Croatia and Slovenia spent 13.7 and 15.6 percent of total government expenditure on health while the EU average was about 13 percent (1998).

Table 5.10: Public Expenditure on Health 1991 2000 2001 2002 Total public spending/GDP 62.2 25.9 27.5 27.9 Public spending on health/GDP 4.8* 2.3 2 2.7 Spending on health as % of total public spending 8.8 7.4 9.8 Source: Albania Ministry of Finance; * WHO/Europe, HFA Database, June 2002

This limited public spending on health care has implied an increased participation of the private sector in financing health care. Health care services are increasingly being paid out-of-pocket for both formal “co-payments” and informal payments.

Education

Access to primary education are in general satisfactory. The opportunities for a good access in education are higher for the lower cycle of the primary education due to the existence of the subsidiary schools. However this indicator vary from region to region. The very mountain terrain and the problematic status of the road infrastructure are very serious impediments for the children which lives in the north and east part on some villages on to physically reach school. In these zones a large part of the road segments that connect the villages with centers of the commune or the villages with each other are seasonal roads.

5 Source: Ministry of Finance, Medium Term Expenditure Framework (MTEF). 6 In line with its commitment to improve access and quality of health care services, the Albanian authorities have started to increase expenditure on health care. The Government of Albania 2003-2005 MTEF has projected an increase in public resources earmarked for health from 2.7% to 3.1% of GDP by 2005.

16 Total number of children registeren in kindergarden, rural-urban

140 120 100 80 60 40 20 0 ’90-91 ’91-92 ’92-93 ’93-94 ’94-95 ’95-96 ’96-97 ’97-98 ’98-99 ’99-00

Total children in kinder- garden Urban Rural

During the last decade the number of children’s enrolled in schools is decreased. During 1990, in Undergraduate Education 55% of children 3-5 years old attend preschool education, 96-98% of children attend compulsory eight year (elementary) education, 70% of pupils completing the elementary education attend high education. In the course of the transition period, the number of pupils attending preschool and high school education decreased sharply. The drop uout rate in elementary education also increased. In academic year 2000-2001 attend the school 19% less pupils compared to the 1989-1990. The registration for school attendance were the following: Preschool education 36% of 3-5 years of age; elementary education 543,967 pupils and secondary education 102,971 pupils 7. Meanwhile in the regions where the migration level is high, specially among young generations, we can notice an increase of illiteracy.

Enrolment rates in upper secondary schools are low, and have dropped during the transition years to about half of the 1990 levels. Enrolment rates in secondary school also vary largely across income and region of residence, and the net enrolment in secondary education of poor children is less than half that of the non-poor. Across regions, while almost 70 percent of the children of the relevant age group are enrolled in Tirana, and close to 60 percent in other urban areas, only a quarter of the children in secondary school age in the rural areas are enrolled. Reasons for not enrolling in secondary school tend to be economic, and many students leave to work after completing basic education.

In the north part ( region of Shkodra, Figure 7 Enrolment in different levels of educa tion Kukes, does exist a large number of Percentage of enrolment problems in the education system which 98% affect the children living in these zones 100% 68% described as follows: 80% 46% 60% 40% * ¼ of the pupils in the villages attend 20% 0% the lesons in combined classes. Pre school Mandatory High School

7 National Strategy for Children source INSTAT 2003

17 * The enrollment rate in secondary education is particularly low whilst the hidden drop-out rate is high. * The physical conditions of schools are poor

Of the 1401 rural secondary schools around 90% have ‘ dependant’ schools. In these schools classrooms often contain children from different years (mixed classes). This is even more of a problem with rural primary schools (classes 1-4). Even with improvements in the quality of the teaching process at primary schools 13 % of the teachers remain without appropriate education. At the secondary level this rises to 18.2% (the main lack of education being in mathematics, biology, history The number of teachers with an insufficient level of education rose from 24.2% in ’92-93 to 26% 2 in 1999, also the average rate of children per teacher in Albanian is very low, 17,1 3 per cent for primary education.

Table 1 Enrolment level in mandatory education (classes 1-8), year 2002

Mandatory Number of Number of Number of Number of Education schools students teachers students/teacher Primary Education 255.628 11.792 22 classes 1-4 Secondary education 1838 260.154 16.028 16 classes 5-8

Education Public Expenditure. Equity in education can also be considered from the point of public expenditure on education. The transition period in Albania effected negatively in the budget expenditure for education. Budget expenditure for education decreased from 10 per cent of the budget expenditure in 1995 to 10% of the budget expenditure in 2000.So Albania spent 3.7 per cent of gross domestic product (GDP) in 1995 before declining again to 3,4 per cent of GDP in 2000. Tab. Public expenditure for education

1991 2000 2001 2002 Total public spending/GDP 62.2 25.9 27.5 27.9 Spending on Education as % of GDP 5 3.2 3.3 3.4 Education as % of total public spending 8.1 12.3 12 12.1

2 Albanian National Women Report -1999

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16 14 12 10 In % of GDP 8 In % of total government 6 expenditures 4 2 0 ‘90 ‘92 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00

Private Expenditure The reduction in public spending on education has been balanced by increase in private expenditures, which on average represents about 1.4% of the total household monthly per capita expenditure (almost 2.5% for households with students). Households in the upper quintiles of the income distribution pay on average about 2.5 times more than those in the poorest quintile. However, as a percentage of total monthly expenditure, poorer households pay a similar or even a higher percentage (the difference, however, is not statistically significant) of their total household expenditure. Among households with students, expenditure on education can be a considerable share of their total expenditure, representing 2.2% of the total monthly expenditure among the poorest households and 3.5% among the richest. 8

8 WB, Albania Poverty Assessment, 2002

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