Quality of Care Study 2018

Primary Health Care in Kosovo

National Report

Contacts

Swiss Tropical and Public Health Institute Socinstrasse 57 4002 Basel, Switzerland www.swisstph.ch

Debra Stevenson Manfred Zahorka Team Leader Project Director Accessible Quality Healthcare Project (AQH) Accessibly Quality Healthcare Project (AQH) [email protected] Swiss Centre for International Health http://www.aqhproject.org/ [email protected] Consortium partner:

Save the Children Schweiz Sihlquai 253 8005 Zürich, Switzerland www.savethechildren.ch

Acknowledgements

We are very thankful to Ms. Debra Stevenson, Dr. Qamile Ramadani and Dr. Merita Shehu and all the AQH staff for providing overall support to the study. We warmly thank our local study coordinator Dr. Pranvera Krasniqi and Dr. Myvedete Tershnjaku from the National Institute of Public Health Kosovo for their commitment and support in the implementation and quality assurance of the study. We would also like to thank Ms. Fetije Huruglica, Ms. Fekrije Hasani and Mr. Srdjan Simonović who supported in collecting the data relevant for the sampling of the study. Further, we are grateful to Applicable Research Solutions and its staff for ensuring a smooth implementation of data collection and field supervision. Specifically we would like to highlight the excellent work from our data collectors. Lastly we would like to express our gratitude to all participants in our survey including facility managers, doctors and patients.

Suggested citation:

Kiefer S, Gerold J, Ramadani Q, Shehu M, Stevenson D, National Quality of Care Study Kosovo. Accessible Quality Healthcare Project, Basel: Swiss Centre for International Health, 2019

Quality of Care Study 2018 Contacts

Table of Contents

Executive Summary 5 1 Background & Objectives 7

2 Methodology 8 2.1 Study design 8

Swiss Tropical and Public Health Institute 2.2 Study area & target population 8 Socinstrasse 57 4002 Basel, Switzerland 2.3 Sample size and sampling strategy 8 www.swisstph.ch 2.4 Data collection and analysis 9

Debra Stevenson Manfred Zahorka 2.5 Limitations 11 Team Leader Project Director Accessible Quality Healthcare Project (AQH) Accessibly Quality Healthcare Project (AQH) 2.6 Ethical considerations 11 [email protected] Swiss Centre for International Health http://www.aqhproject.org/ [email protected] 3 Results 12 Consortium partner: 3.1 Overall assessment of municipalities 12

3.1.1 Infrastructure 13 3.1.2 Clinical Observations 25

Save the Children Schweiz 3.1.3 Exit Interviews 33 Sihlquai 253 8005 Zürich, Switzerland 4 Key Findings and Recommendations 35 www.savethechildren.ch 5 References 38 Appendix A: Abbreviations 39 Appendix B: Questionnaires 40

Acknowledgements

Suggested citation:

Kiefer S, Gerold J, Ramadani Q, Shehu M, Stevenson D, National Quality of Care Study Kosovo. Accessible Quality Healthcare Project, Basel: Swiss Centre for International Health, 2019

Primary Health Care in Kosovo

Tables and figures

Table 1 Overview rank of all municipalities in Kosovo, 2018 ...... 12 Table 2 Services offered ...... 16 Table 3 Facility infrastructure and overall cleanliness and maintenance ...... 17 Table 4 Hygiene ...... 18 Table 5 Public accountability items* ...... 19 Table 6 Availability of guidelines and information materials ...... 19 Table 7 Availability of functional general medical equipment* ...... 20 Table 8 Availability of functional advanced equipment* ...... 21 Table 9 Availability of functional equipment to assess and monitor child growth* ...... 22 Table 10 Availability of medical products ...... 23 Table 11 National findings on clinical practice ...... 26 Table 12 Adherence to principles of history and physical examination ...... 26 Table 13 Infection prevention and control ...... 26 Table 14 Patients with diabetes ...... 27 Table 15 Patients with hypertension ...... 29 Table 16 Patients consulting for other reasons than diabetes or hypertension ...... 31 Table 17 Patients consulting for referrals ...... 32 Table 18 Overall satisfaction with health services - exit interviews ...... 34 Table 19 Satisfaction with different aspects of health service - exit interviews ...... 34 Table 20 Payment for health service – exit interviews ...... 34

Figure 1 Overview infrastructure rank of all municipalities (MFMCs and FMCs) ...... 13 Figure 2 Overview infrastructure rank of MFMCs only ...... 14 Figure 3. Overview infrastructure rank of FMCs only ...... 15 Figure 4 Overview clinical rank of all municipalities (MFMCs and FMCs) ...... 25 Figure 5 Overview patient satisfaction rank of all municipalities (MFMCs and FMCs) .. 33

Quality of Care Study 2018

Tables and figures Executive Summary Table 1 Overview rank of all municipalities in Kosovo, 2018 ...... 12

Table 2 Services offered ...... 16 The Quality of Care (QoC) study is designed to consider key aspects of Primary Health Care (PHC) services, primarily from the perspective of the patient who is receiving the service rather Table 3 Facility infrastructure and overall cleanliness and maintenance ...... 17 than the perspective of the health professional who is providing the service. Table 4 Hygiene ...... 18 Table 5 Public accountability items* ...... 19 The QoC study captures the overall quality of the facility infrastructure, the quality of provider- patient interaction and patient satisfaction after the consultation. It does not aim to assess all Table 6 Availability of guidelines and information materials ...... 19 aspects of PHC. Table 7 Availability of functional general medical equipment* ...... 20 The study was originally designed for the Accessible Quality Healthcare (AQH) project with a Table 8 Availability of functional advanced equipment* ...... 21 focus on Non-Communicable Diseases (NCDs), and more specifically on diabetes and Table 9 Availability of functional equipment to assess and monitor child growth* ...... 22 hypertension as these are key areas of interest for the project. When the study was first conducted in the 12 project municipalities in 2016 the findings provided those municipalities Table 10 Availability of medical products ...... 23 with evidence about the current status of their PHC services. Table 11 National findings on clinical practice ...... 26 In 2018, at the request of the Minster of Health, the same study was undertaken in all 38 Table 12 Adherence to principles of history and physical examination ...... 26 municipalities and municipality-specific data has been produced for each municipality. This Table 13 Infection prevention and control ...... 26 provides research-based data to support PHC managers and service providers in making evidence-based decisions in their municipalities. Table 14 Patients with diabetes ...... 27 Table 15 Patients with hypertension ...... 29 This report provides consolidated data that illustrates the current status of PHC from the national perspective. The data indicates a number of areas where things work well but also Table 16 Patients consulting for other reasons than diabetes or hypertension ...... 31 other areas where further improvements are needed. Findings on the quality of infrastructure Table 17 Patients consulting for referrals ...... 32 and the quality of provider patient interaction that raise concern include:

Table 18 Overall satisfaction with health services - exit interviews ...... 34 On the quality of the facility infrastructure: Table 19 Satisfaction with different aspects of health service - exit interviews ...... 34  Some PHC facilities do not have constant access to utilities including electricity, hot and Table 20 Payment for health service – exit interviews ...... 34 cold water, or heating.  Availability of functioning basic PHC equipment was variable across all facilities and no Figure 1 Overview infrastructure rank of all municipalities (MFMCs and FMCs) ...... 13 facilities fully meet the requirements Administrative Instruction (AI) (Health) No. 08/2017 Figure 2 Overview infrastructure rank of MFMCs only ...... 14 ‘Organising, Structure, Determining the Services and Activities of PHC Institutions’ in respect of the listed items. Figure 3. Overview infrastructure rank of FMCs only ...... 15  Basic equipment needed for care of obstetric patients, infants and toddlers was commonly Figure 4 Overview clinical rank of all municipalities (MFMCs and FMCs) ...... 25 absent.  No facilities fully met the hygiene requirements of AI 08/2017. Basic items such as soap Figure 5 Overview patient satisfaction rank of all municipalities (MFMCs and FMCs) .. 33 and cleaning solutions were often not available.  Only 80% of all MFMCs and FMCs have a patient record system in place, and only 22% of clinical consultations were conducted with the patients’ medical record available to the doctor.  None of the basic drugs or medical consumables, generally considered to be essential for the delivery of PHC services, were available in all facilities, and some items were only

available in very few facilities.  Contraceptives were only available in 3 out of 98 facilities included in the study.  Functioning gynaecology equipment was mostly absent at the FMCs and Pap smear materials were available at only one third of MFMCs.  Clinical waste management mechanisms were found to be weak and basic items such as antiseptics and disinfectants were often missing. On the quality of provider patient interaction:  There was a very low adherence to available treatment guidelines, and counselling on lifestyle factors such as smoking, alcohol consumption, physical activity is often not provided for patients where it is highly relevant.

5 Primary Health Care in Kosovo

 Overall, infection and prevention procedures (for example, hand washing before and after seeing the patient) were very poorly implemented.  Regarding referral mechanism, feedback mechanism between the family doctor and the specialist are often not in place and are not known to the patient.  Overall, questioning patients about current medication and advising on prescribed medication could be improved.

Important note:

Whilst the national ranking of all 38 municipalities presented within the report provides a useful illustration of the data, they should be interpreted with caution and should be seen within the wider context. Aspects that should be considered for interpretation are: the number of assessed facilities per municipality; the number of provider-patient observations per municipality; the number of doctors observed per municipality.

The number of facilities selected per municipalities varied because a) several municipalities only had one facility (typically the MFMC) and b) the sampling of facilities within municipalities was done proportional-to-size based on the reported number of visits in June 2018.

As a result, those municipalities where only the MFMC was visited were likely to score higher, specifically in infrastructure, than other municipalities where the rank was calculated based on the diversity of all facilities visited.

6 Quality of Care Study 2018

 Overall, infection and prevention procedures (for example, hand washing before and after seeing the patient) were very poorly implemented. 1 Background & Objectives  Regarding referral mechanism, feedback mechanism between the family doctor and the specialist are often not in place and are not known to the patient. The AQH project in Kosovo is funded by the Swiss Agency for Development and Cooperation  Overall, questioning patients about current medication and advising on prescribed (SDC) and implemented by a Consortium comprising Swiss Tropical and Public Health Institute medication could be improved. (Swiss TPH) and Save the Children. The overall goal of the AQH project is to ensure that the health of the population of Kosovo has improved, with strengthened healthcare providers and managers able to meet the needs of the patients (especially vulnerable groups), who are more aware of their rights and needs. Important note: At the request of the Ministry of Health, the AQH project conducted the first national facility- based QoC study from August to October 2018. Whilst the national ranking of all 38 municipalities presented within the report provides a useful illustration of the data, they should be interpreted with caution and should be seen within the wider The objective of the study was to measure the quality of care related to structural and context. Aspects that should be considered for interpretation are: the number of assessed facilities procedural aspects, as well as selected outcomes, in PHC in all 38 municipalities in Kosovo. per municipality; the number of provider-patient observations per municipality; the number of doctors The specific objectives of this study were to provide PHC service providers with information to: observed per municipality.  Assess the quality of health services provided in several PHC centres in each The number of facilities selected per municipalities varied because a) several municipalities only had municipality, including specific structural and procedural aspects. one facility (typically the MFMC) and b) the sampling of facilities within municipalities was done  Allow comparison of different aspects of quality of care between all municipalities. proportional-to-size based on the reported number of visits in June 2018.  Determine to what degree health providers have infrastructure and consumables

As a result, those municipalities where only the MFMC was visited were likely to score higher, available as outlined in the national PHC norms or, where these are unavailable, those specifically in infrastructure, than other municipalities where the rank was calculated based on the outlined in WHO standards. diversity of all facilities visited.  Assess patient satisfaction with the services provided at PHC centres. For this study we considered an operational definition of the quality of health services based on the concept of quality of care presented by Donabedian (1988, 1990), which has frequently been used in similar studies (Boller and Wyss et al., 2003; Matthys, 2013; Kiefer and Kadesha, 2015; Lechthaler, 2015; AQH, 2016). This is characterized by three dimensions:

1) Structural attributes - relate to the setting where health care is provided. These attributes mostly refer to the organizational structure, human and financial resources, as well as availability of technical resources such as clinical protocols and guidelines.

2) Process attributes - relate to the provider-client interaction, for example professional conduct and technical competence, as well as interpersonal relations/client satisfaction. 3) Outcome attributes - relate to the effect of care delivery on the health status of populations. Outcomes result from the structural and process attributes, for example, survival and recovery of patients or, more indirectly, patient satisfaction. This operational definition is based on the assumption that the three dimensions are connected to each other and ultimately to service quality: good structure increases the likelihood of good processes and good process increases the likelihood of good outcomes, although outcomes are a consequence rather than a component of the quality of services.

7 Primary Health Care in Kosovo

2 Methodology

2.1 Study design The QoC study is designed as a facility-based cross sectional survey to measure aspects of the quality of care of PHC service. It captures the overall quality of the facility infrastructure (structural aspects), the quality of provider-patient interactions (process aspects) and patient satisfaction after consultation (outcome). The study assesses quality of care provided to all patient groups but particularly focuses on patients with diabetes and hypertension. The modules for the QoC survey are based on a mix of indicators from the WHO Service Availability and Readiness Assessment (SARA) and the “Tool to Improve Quality of Health Care” within the “ACCESS” program supported by the Novartis Foundation for Sustainable Development (2014), as relevant. The modules were adapted to the Kosovo local context thereby taking into consideration the national PHC norms or, where these are unavailable, the WHO norms established in the Package of Essential NCDs Interventions.

2.2 Study area & target population The survey was implemented in all municipalities. The QoC survey targets PHC facilities in both rural and urban areas. During the survey data was collected at three different levels: 1) the health facility, 2) the health provider and 3) the patients.

Inclusion criteria for the baseline assessment Inclusion criteria for the health facilities were as follows:  Main Family Medicine Centre (MFMC) or Family Medicine Centre (FMC)  At least one medical doctor assigned to the facility for at least one day per week

Inclusion criteria for health providers of the selected facilities for provider-patient observations were:  Doctors providing PHC services  Patients (18 years or older, or children accompanied by a legal representative) accessing the facility and receiving a consultation from a health provider  Oral informed consent provided by the provider  Oral informed consent provided by the patient or his/her legal representative (mother/father/caretaker)

Inclusion criteria for patients accessing the selected facilities and receiving consultation were:  Patients (18 years or older, or children accompanied by a legal representative) accessing the facility and receiving a consultation from a health provider  Oral informed consent provided by the patient or his/her legal representative (mother/father/caretaker)  Accessing the facility to receive services either for themselves or their accompanying minors.

2.3 Sample size and sampling strategy Sampling of health facilities We applied a random proportional-to-size sampling procedure for each of the domains assuming that the facilities will be allocated to urban and rural areas proportional to the size of urban and rural populations in the region. The number of daily visits in June 2018 is considered a proxy of daily attendances.

8 Quality of Care Study 2018

2 Methodology Sampling of providers for provider-client observations 2.1 Study design All provider-patient consultations, for which informed consent could be obtained from the patient or their legal representative, were observed in each health facility “Provider” hereby The QoC study is designed as a facility-based cross sectional survey to measure aspects of only refers to medical doctors (see inclusion criteria). A healthcare provider could but did not the quality of care of PHC service. It captures the overall quality of the facility infrastructure have to be observed repeatedly. (structural aspects), the quality of provider-patient interactions (process aspects) and patient satisfaction after consultation (outcome). The study assesses quality of care provided to all Sampling of patients for exit interviews patient groups but particularly focuses on patients with diabetes and hypertension. For the exit interviews, all patients that received care for themselves, or for a child in their care, 1 The modules for the QoC survey are based on a mix of indicators from the WHO Service at the facility were interviewed for the exit interview, provided they gave consent . The patients Availability and Readiness Assessment (SARA) and the “Tool to Improve Quality of Health included for exit interviews did not necessarily need to be the same as for the provider-patient Care” within the “ACCESS” program supported by the Novartis Foundation for Sustainable observation (see inclusion criteria). Development (2014), as relevant. The modules were adapted to the Kosovo local context thereby taking into consideration the national PHC norms or, where these are unavailable, the WHO norms established in the Package of Essential NCDs Interventions. 2.4 Data collection and analysis Data collection Before data collection, relevant authorities, specifically Directors for Health and Social Welfare 2.2 Study area & target population (DHSW), mayors as well as managers of all selected facilities in all surveyed Municipalities The survey was implemented in all municipalities. The QoC survey targets PHC facilities in were informed about the study, its purpose and its schedule at a meeting hosted by the Ministry th both rural and urban areas. During the survey data was collected at three different levels: 1) of Health on 5 July 2018. the health facility, 2) the health provider and 3) the patients. The data collection team consisted of 23 data collectors, divided into 10 sub-teams. Most data Inclusion criteria for the baseline assessment collectors had a background in medical training and public health and previous survey experience. Each data collection team was assigned to a set of designated facilities where Inclusion criteria for the health facilities were as follows: they conducted the assessments. The data collection teams were closely monitored by the  Main Family Medicine Centre (MFMC) or Family Medicine Centre (FMC) local study coordinator and supervisors. Data collection in the field took place from 10  At least one medical doctor assigned to the facility for at least one day per week September 2018 until 05 October 2018.

Inclusion criteria for health providers of the selected facilities for provider-patient observations The following procedures were followed at each facility: were: 1) Introduction of purpose and procedures of the survey to the targeted service providers.  Doctors providing PHC services 2) Data collection  Patients (18 years or older, or children accompanied by a legal representative) o Starting with provider-patient observations and exit interviews with patients accessing the facility and receiving a consultation from a health provider conducted at the facility.  Oral informed consent provided by the provider o Exit interviews with clients were conducted in an appropriate location ensuring  Oral informed consent provided by the patient or his/her legal representative privacy and confidentiality. (mother/father/caretaker) o Structural attributes related to infrastructure and management were assessed after the consultation hours in the afternoon. Inclusion criteria for patients accessing the selected facilities and receiving consultation were: Data collection was performed electronically using the Open Data Kit (ODK)2 software on  Patients (18 years or older, or children accompanied by a legal representative) tablets. During and after each day of data collection, the local study coordinator and the accessing the facility and receiving a consultation from a health provider supervisors conducted quality assurance.  Oral informed consent provided by the patient or his/her legal representative

(mother/father/caretaker)  Accessing the facility to receive services either for themselves or their accompanying Data analysis minors. During the analysis of the obtained data, full confidentiality of respondents was assured. Data was analysed using Stata Statistical Software/SE v15.0. 2.3 Sample size and sampling strategy Additive index: The overall scores were calculated as additive indices to indicate the achieved Sampling of health facilities percentage score. For a certain set of questions, e.g. infection prevention and control measures the additive index counts the answers/criteria which were fulfilled or not fulfilled. We applied a random proportional-to-size sampling procedure for each of the domains Questions/criteria which are not applicable were not considered. The number of positive assuming that the facilities will be allocated to urban and rural areas proportional to the size of urban and rural populations in the region. The number of daily visits in June 2018 is considered a proxy of daily attendances. 1 Depending on the capacity of the data collectors. 2 Open Data Kit (ODK) is a free and open-source set of tools for mobile data collection solutions. https://opendatakit.org/

9 Primary Health Care in Kosovo answers is then divided by the total of valid answers (ratio). This way a percentage score is obtained for each patient. Example: For infection prevention and control measures we measured five different aspects. For the first patient none of the aspects we measured was relevant, e.g. no examinations were done. For the second patient only two of the five aspects were relevant: hand washing before and after the examination. Both actions were not observed. Hence this person had two valid answers but did not achieve any score. So the percentage score achieved for this person was 0. For the third patient all five actions related to infection prevention and control measures were relevant. However, none of the five actions were observed. So the percentage score is yet once more 0. The fourth patient was examined and instruments were used. Thus three aspects were relevant, but only one aspect (disinfection of instruments) observed. Hence 1 out of 3 were achieved, translating to a percentage score of 33%. For the fifth patient all five aspects were considered relevant and all were also adhered to by the doctor. Hence for this person a percentage score of 100% was achieved. The average index for the facility for infection and prevention measures would be calculated as 133/4=33%

Patient Washed Washed Disinfected Used Used Number Number Ratio hands hands instruments gloves mask of valid of (positive/valid before after as as answers positive answers) required required answers 1 n/a n/a n/a n/a n/a n/a n/a n/a

2 no no n/a n/a n/a 2 0 0

3 no no no no no 5 0 0

4 no no yes n/a n/a 3 1 33

5 yes yes yes yes yes 5 5 100

Facility Score 133/4=33 Yes/no: as observed; n/a: action was not needed, e.g. no examination conducted

95% - CI: A 95% confidence interval (CI) is used to analyse the data presented in Tables 15 - 20 whereby the average is a range with an upper and lower number calculated from a sample. Because the true population average is unknown, this range describes possible values that the mean could be. If multiple samples were drawn from the same population and a 95% CI calculated for each sample, we would expect the population mean to be found within 95% of these CIs. CIs are sensitive to variability in the population (spread of values) and sample size. We could say: we are confident that the real value lies somewhere within this value range. A confidence interval cannot be estimated if there is only one observation or if there is no variation of values. n: number of observations in the sample Rank: The rank provides an indication on the position of the municipality related to certain aspects. In other words: how does the municipality perform in comparison to the other 37 municipalities. In case of ties (=municipalities achieving the same score) the average rank is calculated and assigned, e.g. achievement scores are for two facilities 90, then their potential ranks 8 and 9 and are taken together and divided by 2. This results in the rank 8.5. Hence there is no rank 8 or 9 assigned and the next municipality would be assigned the rank 10.

10 Quality of Care Study 2018 answers is then divided by the total of valid answers (ratio). This way a percentage score is Case of Pristina obtained for each patient. Sampling of facilities was done proportional to size with the exception of Pristina, which was Example: For infection prevention and control measures we measured five different aspects. sampled disproportional to its size. Hence for data analysis, the national average is calculated For the first patient none of the aspects we measured was relevant, e.g. no examinations were as a weighted score according to the number of clusters and observations by municipality, done. excluding Pristina. For the second patient only two of the five aspects were relevant: hand washing before and after the examination. Both actions were not observed. Hence this person had two valid 2.5 Limitations answers but did not achieve any score. So the percentage score achieved for this person was Sample size 0. The study was designed as a nationwide survey. Hence, in comparison to a census, only For the third patient all five actions related to infection prevention and control measures were randomly selected facilities were included in the study. Due to the different sizes of the relevant. However, none of the five actions were observed. So the percentage score is yet municipalities, but also the different utilization patterns in the different municipalities, some once more 0. municipalities had more facilities included than others. Some of the municipalities had only the The fourth patient was examined and instruments were used. Thus three aspects were MFMC and 1 FMC included. This limits our ability to show possible wider variations in these relevant, but only one aspect (disinfection of instruments) observed. Hence 1 out of 3 were municipalities. achieved, translating to a percentage score of 33%. In addition some facilities had only a few visits from patients on the day(s) of the survey. Thus For the fifth patient all five aspects were considered relevant and all were also adhered to by the numbers of observations or exit interviews varies substantially between the facilities. the doctor. Hence for this person a percentage score of 100% was achieved. The average index for the facility for infection and prevention measures would be calculated Interviewer bias as 133/4=33% Interviewers were trained and received clear instructions on the data collection, nevertheless Patient Washed Washed Disinfected Used Used Number Number Ratio variations between interviewers cannot be completely ruled-out. hands hands instruments gloves mask of valid of (positive/valid before after as as answers positive answers) required required answers Clinical observations 1 n/a n/a n/a n/a n/a n/a n/a n/a The observations protocols for diabetic and hypertensive patients were very detailed in comparison to other illnesses. Hence, this might partially explain achievement differences 2 no no n/a n/a n/a 2 0 0 between those illnesses and all other. 3 no no no no no 5 0 0 4 no no yes n/a n/a 3 1 33 2.6 Ethical considerations 5 yes yes yes yes yes 5 5 100 Before the interviews and observations, participants were given an information leaflet and Facility Score 133/4=33 asked for their consent. For this, participants were informed that a) their participation is voluntary, b) they can withdraw from participation at any time without any consequences, c) Yes/no: as observed; n/a: action was not needed, e.g. no examination conducted non-participation will not have any negative effects. Participants were also informed how the data will be used and that confidentiality is ensured as no names or other identifying aspects will be collected. 95% - CI: A 95% confidence interval (CI) is used to analyse the data presented in Tables 15 - 20 whereby the average is a range with an upper and lower number calculated from a sample. Ethical clearance was obtained from the Kosovo Medical Chamber on 3rd of August, 2018 Because the true population average is unknown, this range describes possible values that (Reference Number: 04/2018). the mean could be. If multiple samples were drawn from the same population and a 95% CI calculated for each sample, we would expect the population mean to be found within 95% of these CIs. CIs are sensitive to variability in the population (spread of values) and sample size. We could say: we are confident that the real value lies somewhere within this value range. A confidence interval cannot be estimated if there is only one observation or if there is no variation of values. n: number of observations in the sample Rank: The rank provides an indication on the position of the municipality related to certain aspects. In other words: how does the municipality perform in comparison to the other 37 municipalities. In case of ties (=municipalities achieving the same score) the average rank is calculated and assigned, e.g. achievement scores are for two facilities 90, then their potential ranks 8 and 9 and are taken together and divided by 2. This results in the rank 8.5. Hence there is no rank 8 or 9 assigned and the next municipality would be assigned the rank 10.

11 Primary Health Care in Kosovo

3 Results

3.1 Overall assessment of municipalities Table 1 Overview rank of all municipalities in Kosovo, 2018

Infrastructure Clinical Consultation Exit Interview Number of Infrastruct Clinical Clinical Exit Exit Municipaliti Infrastruc facilities in ure Score Consultation Consultatio Interview Interview es ture Rank this study (%) Score (%) n rank Score (%) rank Partes/Pasj 1 85 1 84 1 97 1.5 ane Mitrovica 1 80 2 68 20 77 34.5 North Zvecan 1 78 3 54 34 73 38 Prishtinë 5 77 4 59 30.5 88 21 Strpce 1 76 5 78 8.5 94 5 Zubin Potok 1 73 6 67 22 79 32.5 Mamusha 1 68 7.5 77 10 89 18 Leposavic 1 68.1 7.5 61 29 75 36 Istog 2 65 10 78 8.5 97 1.5 Kaçanik 2 65 10 75 12 92 10 Gracanica 3 65 10 55 33 79 32.5 Prizren 8 64 13 83 2.5 91 14 Mitrovicë 6 64 13 81 4 87 23 Fushë 3 64 13 70 18.5 84 28.5 Kosovë Obiliq 2 63 15.5 83 2.5 85 26.5 Viti 2 63 15.5 67 22 88 21 Dardanë 2 62 19 79 6.5 93 7.5 Peja 3 62 19 72 17 94 5 Hani I Elezit 1 62 19 67 22 91 14 Rahovec 3 62 19 52 35 93 7.5 Gjakovë 5 62 19 46 36 89 18 Junik 1 61 22 42 37 88 21 Ranilug 1 60 24 75 12 86 24.5 Novo Brdo 2 60 24 75 12 77 34.5 Shtime 2 60 24 74 14.5 89 18 Ferizaj 4 59 26.5 74 14.5 85 26.5 Gjilan 5 59 26.5 64 25 82 30 Dragash 2 58 28 73 16 91 14 Skenderaj 3 57 29.5 80 5 94 5 Therandë 3 57 29.5 65 24 80 31 Klinë 2 56 31 79 6.5 92 10 Drenas 3 55 32.5 63 27 91 14 Vushtrri 3 55 32.5 59 30.5 74 37 Malishevë 3 53 34 63 27 91 14 Podujevë 2 51 35 56 32 84 28.5 Lipjan 5 49 36.5 70 18.5 86 24.5 Deçan 2 49 36.5 41 38 95 3 Klokot 1 44 38 63 27 92 10

12 Quality of Care Study 2018

3 Results

3.1 Overall assessment of municipalities Table 1 Overview rank of all municipalities in Kosovo, 2018

Mamusha 1 68 7.5 77 10 89 18 8,

Leposavic 1 68.1 7.5 61 29 75 36 n= Istog 2 65 10 78 8.5 97 1.5 Kaçanik 2 65 10 75 12 92 10 Gracanica 3 65 10 55 33 79 32.5 Prizren 8 64 13 83 2.5 91 14 Mitrovicë 6 64 13 81 4 87 23 Fushë 3 64 13 70 18.5 84 28.5 Kosovë ) Obiliq 2 63 15.5 83 2.5 85 26.5 FMCs

Viti 2 63 15.5 67 22 88 21 Dardanë 2 62 19 79 6.5 93 7.5 and Peja 3 62 19 72 17 94 5

Hani I Elezit 1 62 19 67 22 91 14 Rahovec 3 62 19 52 35 93 7.5 Gjakovë 5 62 19 46 36 89 18 Junik 1 61 22 42 37 88 21 Ranilug 1 60 24 75 12 86 24.5 Novo Brdo 2 60 24 75 12 77 34.5 Shtime 2 60 24 74 14.5 89 18 Ferizaj 4 59 26.5 74 14.5 85 26.5 Gjilan 5 59 26.5 64 25 82 30 Dragash 2 58 28 73 16 91 14

Skenderaj 3 57 29.5 80 5 94 5 and n=1 between varying municipalities, each in visited were ities Therandë 3 57 29.5 65 24 80 31 Klinë 2 56 31 79 6.5 92 10

Drenas 3 55 32.5 63 27 91 14 (MFMCs municipalities all of rank rastructure Vushtrri 3 55 32.5 59 30.5 74 37 Malishevë 3 53 34 63 27 91 14 Podujevë 2 51 35 56 32 84 28.5 Lipjan 5 49 36.5 70 18.5 86 24.5 Overview inf Overview Deçan 2 49 36.5 41 38 95 3 Infrastructure Klokot 1 44 38 63 27 92 10 3.1.1 1 Figure of facil Note: numbers Different methodology 2: chapter see information more For municipality.

13 Primary Health Care in Kosovo

only

MFMCs

Overview infrastructure rank of rank infrastructure Overview

Figure 2 Figure

14 Quality of Care Study 2018

, depending on the service utilization per utilization the service on , depending 8

only

MFMCs

tion see chapter 2: methodology methodology 2: see tion chapter

Overview infrastructure rank of rank infrastructure Overview . Overview infrastructure rank of FMCs of rank infrastructure Overview .

Figure 2 Figure 3 Figure n= and n=1 between varying municipalities, each in visited were facilities of numbers Note: Different informa more For municipality.

15 Primary Health Care in Kosovo

Table 2 Services offered

MFMCs (n=36) FMCs (n=62) Family planning 81% (29) 47% (29) Antenatal care 72% (26) 37% (23) Obstetric and newborn care 61% (22) 23% (14)

Immunization 100% (36) 77% (48) Child care 92% (33) 58% (36)

Adolescent health 86% (31) 65% (40) STI services 64% (23) 32% (20) Tuberculosis services 36% (13) 19% (12)

NCD services 89% (32) 90% (56) Minor surgery 44% (16) 23% (14) Outreach activities (mother, newborn and child health) 97% (35) 66% (41) Lab services 97% (35) 42% (26) X-ray 72% (26) 5% (3)

Doctor present 5 or more days per week 100% (36) 90% (56)

 Overall, there is no clear division between FMC and MFMC on what services are offered. It seems that each municipality offers their own portfolio, based on the mix of service between the levels of facilities.  According to AI (Health) No. 08/2017 Organising, structure, determining the services and activities of PHC institutions, all of the above services (with the exclusion of STI services) should be offered in PHC. However, the AI does not specify which services should be offered at MFMC, FMC or Ambulanta levels.  Although STI services are not specifically mentioned in the AI, it would be normal practice for these to be available somewhere within each municipality.  The AI does not specify how many days per week a doctor should be present in the facility.  Both MFMCs and FMCs scored highly for NCD services offered and for a doctor being present.  All MFMC facilities provided immunization services, while this service was only available at 77% of the FMCs.  X-ray services were mostly unavailable in the FMCs and only available at two thirds of the MFMCs.  Family planning, antenatal care, child care and adolescent health had variable availability in the MFMCs although outreach programs for mother, newborn and child health were mostly available. These services were more limited in FMCs.  Laboratory services were available in most MFMCs but less than half of the FMCs provided these services.  Minor surgery, STI services and TB services were largely absent from both MFMCs and FMCs.

16 Quality of Care Study 2018

Table 2 Services offered Table 3 Facility infrastructure and overall cleanliness and maintenance

MFMCs (n=36) FMCs (n=62) Facility MFMCs (n=36) FMCs (n=62) Family planning 81% (29) 47% (29) The facility and immediate surroundings (facility yard, waiting area outside) are free from long grass, paper 94% (34) 92% (57) Antenatal care 72% (26) 37% (23) debris and solid waste.^ Obstetric and newborn care 61% (22) 23% (14) The facility has a rubbish bin which is properly used 92% (33) 85% (53) and not overflowing.^ Immunization 100% (36) 77% (48) There is a designated waiting room for patients*. 89% (32) 79% (49) Child care 92% (33) 58% (36) The waiting area is mopped, free of dust, trash; dirt, Adolescent health 86% (31) 65% (40) 92% (33) 85% (53) spider webs, and generally tidy^. STI services 64% (23) 32% (20) There is at least one designated consulting room for 67% (24) 21% (13) Tuberculosis services 36% (13) 19% (12) women.* There is at least one designated consulting room for NCD services 89% (32) 90% (56) 69% (25) 21% (13) children^. Minor surgery 44% (16) 23% (14) All examination room(s) ensure(s) 97% (35) 94% (58) Outreach activities (mother, newborn and child health) 97% (35) 66% (41) privacy/confidentiality (door, window blind, curtain)^

Lab services 97% (35) 42% (26) All examination rooms are mopped, free of dust, trash; 94% (34) 85% (53) dirt, spider webs, and the rooms are generally tidy. X-ray 72% (26) 5% (3) All examination rooms are well illuminated*. 100% (36) 92% (57) Doctor present 5 or more days per week 100% (36) 90% (56) The facility has electricity^ 100% (36) 98% (61)  Overall, there is no clear division between FMC and MFMC on what services are During the past 7 working days, did you have any 36% (13) 62% (38) offered. It seems that each municipality offers their own portfolio, based on the mix of power cuts of more than 1 hour during opening hours^ service between the levels of facilities. Is there routinely a time of year when this facility has a 36% (13) 61% (37)  According to AI (Health) No. 08/2017 Organising, structure, determining the services severe shortage or lack of power?^ and activities of PHC institutions, all of the above services (with the exclusion of STI The facility has a functional generator.^ 89% (32) 45% (28) services) should be offered in PHC. However, the AI does not specify which services should be offered at MFMC, FMC or Ambulanta levels. The facility has a functional heating system.^ 100% (36) 73% (45)  Although STI services are not specifically mentioned in the AI, it would be normal Has the facility a functional communication equipment practice for these to be available somewhere within each municipality. (functional landline telephone or cell phone) available 94% (34) 56% (35)  The AI does not specify how many days per week a doctor should be present in the (either private phone or facility phone)?* facility. The facility has functional computer.* 94% (34) 50% (31)  Both MFMCs and FMCs scored highly for NCD services offered and for a doctor being present. The facility has a functional printer.* 92% (33) 40% (25)  All MFMC facilities provided immunization services, while this service was only The facility has internet access.^ 83% (30) 45% (28) available at 77% of the FMCs. The administration shelf is filed and in order*. 92% (33) 87% (54)  X-ray services were mostly unavailable in the FMCs and only available at two thirds of the MFMCs. Does the facility have a patient record system?* 81% (29) 81% (50)  Family planning, antenatal care, child care and adolescent health had variable Are there sufficient empty patient record cards 79% (23) 80% (40) availability in the MFMCs although outreach programs for mother, newborn and child available?* health were mostly available. These services were more limited in FMCs. *Specified in AI 08/2017  Laboratory services were available in most MFMCs but less than half of the FMCs ^Not specified in AI 08/2017 but considered to be minimum standard for PHC services provided these services.  Minor surgery, STI services and TB services were largely absent from both MFMCs  Overall, structural issues vary between MFMC and FMCs and no facilities fully meet and FMCs. the requirements of AI 08/2017.  Only 80% of all MFMCs and FMCs have a patient record system, indicating that a number of patients are being seen without any medical record. Sufficient empty patient records cards are available in those facilities which have a patient record system.  Both MFMCs and FMCs generally scored well for cleanliness of both consulting rooms and waiting areas with a few exceptions.  Designated consulting rooms for women and children were limited across all facilities, being present in only two thirds of MFMCs and one fifth of FMCs.  Examination rooms were mostly private, clean and well illuminated.

17 Primary Health Care in Kosovo

 Although AI 08/2017 does not specify that electricity should be available at all times this is a fundamental requirement for the delivery of patient services.  With the exception of one FMC, all facilities had electricity, however approximately one third of MFMCs and two thirds of FMCs had experienced power cuts in the previous 7 days. Most MFMCs had a functional generator while this was only available at half of the FMCs.  All MFMCs had a functional heating system compared to only two thirds of FMCs.  While most MFMCs had functional communication equipment, computers and printers this was very limited in the FMCs.  Just over 80% of the MFMCs had internet access while this was available in less than half of the FMCS. Of the facilities that had internet access most had access at least 1 hour per day in the previous 7 days.

Table 4 Hygiene

MFMCs (n=36) FMCs (n=62) There is running water in the facility (out of the tap).* 94% (34) 94% (58) There is warm water available (out of the tap).* 65% (22) 57% (33) Is there routinely a time of year when this facility has 29% (10) 47% (27) a severe shortage or lack of water (out of the tap)?^ Functional washing points exist in examination rooms and/or entrance hall, and soap or hand disinfectants 92% (33) 90% (56) and water are available.* Labelled containers for medical waste disposal are available in all required areas (e.g. examination 86% (31) 87% (54) rooms).* The facility has adequate and safe disposal of sharps 81% (29) 76% (47) (sharps box/container).* The facility has adequate and safe disposal of 72% (26) 60% (37) infectious waste.* Infectious waste is temporary stored at a protected 83% (30) 77% (48) place.* Sharps waste is temporary stored at a protected 83% (30) 77% (48) place.* There is regular and appropriate collection for 83% (30) 76% (47) infectious waste.* There is regular and appropriate collection for sharps 86% (31) 84% (52) waste.* The facility has essential disinfectants and 81% (29) 61% (38) antiseptics*. The facility has chlorine solution or other disinfectants to disinfect contaminated instruments in all required 81% (29) 53% (33) areas (e.g. in examination rooms).* The facility has at least one accessible and functional 97% (35) 87% (54) toilet for patients.* The facility has at least one accessible and functional 100% (36) 85% (53) toilet for staff.*

The toilet(s) or latrine is clean^. 56% (20) 71% (44) A washing point is available near the toilet or latrine.* 92% (33) 90% (56) Soap and water are available at the washing point 47% (17) 66% (41) near toilet or latrine.^ *Specified in AI 08/2017 ^Not specified in AI 08/2017 but generally considered to be minimum standard for PHC services

18 Quality of Care Study 2018

 Although AI 08/2017 does not specify that electricity should be available at all times this is a fundamental requirement for the delivery of patient services.  No facilities fully meet the requirements of AI 08/2017.  With the exception of one FMC, all facilities had electricity, however approximately one  Tap water was for the most part available in both MFMCs and FMCs. However hot third of MFMCs and two thirds of FMCs had experienced power cuts in the previous 7 water was limited and both facility types reported routine water shortages. days. Most MFMCs had a functional generator while this was only available at half of  Waste storage and collection was an issue across all facilities. the FMCs.  Antiseptics and disinfectants were often missing in both facility types.  All MFMCs had a functional heating system compared to only two thirds of FMCs.  Toilets were mostly available for both staff and patients in the MFMCs, but were more  While most MFMCs had functional communication equipment, computers and printers limited in the FMCs. this was very limited in the FMCs.  Cleanliness of toilets was generally a common issue, and more prominent at the  Just over 80% of the MFMCs had internet access while this was available in less than MFMCs. half of the FMCS. Of the facilities that had internet access most had access at least 1  Soap and water near the toilet was missing at around half of the facilities. hour per day in the previous 7 days. Table 5 Public accountability items* Table 4 Hygiene MFMCs (n=36) FMCs (n=62) MFMCs (n=36) FMCs (n=62) Facility location visibly displayed 94% (34) 84% (52) There is running water in the facility (out of the tap).* 94% (34) 94% (58) Opening hours visible 94% (34) 85% (53) There is warm water available (out of the tap).* 65% (22) 57% (33) Phone number displayed 75% (27) 55% (34) Is there routinely a time of year when this facility has 29% (10) 47% (27) Tariffs displayed 81% (29) 77% (48) a severe shortage or lack of water (out of the tap)?^ Ministry of Health (MoH) complaints number displayed 83% (30) 73% (45) Functional washing points exist in examination rooms and/or entrance hall, and soap or hand disinfectants 92% (33) 90% (56) Flyer about MoH complaints number available 75% (27) 71% (44) and water are available.* Tobacco laws displayed 100% (36) 90% (56) Labelled containers for medical waste disposal are available in all required areas (e.g. examination 86% (31) 87% (54) Patient's rights and responsibilities displayed 89% (32) 81% (50) rooms).* Logos of pharmaceutical industries showing 19% (7) 19% (12) The facility has adequate and safe disposal of sharps 81% (29) 76% (47) (sharps box/container).* Mechanisms to give public opinion on the service* 89% (32) 81% (50) The facility has adequate and safe disposal of Mechanisms for referrals available* 89% (32) 37% (23) 72% (26) 60% (37) infectious waste.* *Specified in AI 08/2017

Infectious waste is temporary stored at a protected 83% (30) 77% (48) place.*  AI 08/2017 states that naming and information boards should be available in all PHC facilities, but does not specify what information should be provided. Mechanisms for Sharps waste is temporary stored at a protected 83% (30) 77% (48) obtaining opinion of service users, and referrals, are both required by the AI. place.*  Overall, public accountability items were displayed with room for improvement, There is regular and appropriate collection for 83% (30) 76% (47) especially at FMCs. infectious waste.*  Tobacco laws were generally on display in both facility types. There is regular and appropriate collection for sharps  86% (31) 84% (52) Many other public accountability items were often missing, particularly in the FMCs. waste.*  In the FMCs mechanisms for referrals were most often absent. The facility has essential disinfectants and 81% (29) 61% (38) antiseptics*. Table 6 Availability of guidelines and information materials

The facility has chlorine solution or other disinfectants MFMCs (n=36) FMCs (n=62) to disinfect contaminated instruments in all required 81% (29) 53% (33) areas (e.g. in examination rooms).* Therapeutic standard guideline for PHC 72% (26) 56% (35) The facility has at least one accessible and functional List of essential drugs* 83% (30) 77% (48) 97% (35) 87% (54) toilet for patients.* Calendar for health promotion 53% (19) 42% (26) The facility has at least one accessible and functional 100% (36) 85% (53) toilet for staff.* Vaccination calendar 89% (32) 65% (40) Are awareness materials based on standard package The toilet(s) or latrine is clean^. 56% (20) 71% (44) 72% (26) 55% (34) info A washing point is available near the toilet or latrine.* 92% (33) 90% (56) *Specified in AI 08/2017 Soap and water are available at the washing point 47% (17) 66% (41) near toilet or latrine.^  Overall, availability of guidelines and information materials was limited across all *Specified in AI 08/2017 facilities, such as therapeutic standard guidelines for PHC, list of essential drugs; ^Not specified in AI 08/2017 but generally considered to be minimum standard for PHC services calendar for health promotion, vaccination calendar among others.

19 Primary Health Care in Kosovo

Table 7 Availability of functional general medical equipment* ^Not specified in AI 08/2017 but considered to be minimum standard for PHC services

 Availability of functional medical equipment was variable across all facilities and no facilities fully meet the requirements of AI 08/2017 in respect of the listed items.

MFMCs (n=36) FMCs (n=62)

Microsurgery 47% (17) 37% (23) Nebulizer 97% (35) 90% (56) Ambu mask 92% (33) 69% (43) Strong source of light in good condition (portable) 86% (31) 71% (44)

Nasal speculum 44% (16) 21% (13) Otoscope 69% (25) 76% (47)

Ophthalmoscope 56% (20) 66% (41) Doppler 25% (9) 13% (8) Glucometer 81% (29) 61% (38) Peak flow meter 39% (14) 18% (11) Tape measure 83% (30) 90% (56) Pen light 86% (31) 53% (33) Head light 39% (14) 11% (7)

Neurological hammer 56% (20) 61% (38) Weight scale for adults 83% (30) 92% (57)

Weight scale for children (over 2 years old) 86% (31) 71% (44) Weight scale for infants and toddlers (up to 2 years old) 92% (33) 84% (52) Sphygmomanometer for children 42% (15) 29% (18) Sphygmomanometer for adults 78% (28) 89% (55) Stethoscope for children 31% (11) 42% (26)

Stethoscope for adults 97% (35) 95% (59) Obstetrical stethoscope/Fetoscope 28% (10) 15% (9) Pelvimeter 28% (10) 6% (4)

Sterilization equipment and anti-septical protocol 83% (30) 74% (46) Pulse oximeter^ 78% (28) 73% (45) Refrigerator 86% (31) 74% (46) Vaccine refrigerator/portable 89% (32) 76% (47) Height meter board for children (up to two years old) 72% (26) 68% (42) Meter for height measuring (children over two years of 89% (32) 81% (50) age) Thermometer 92% (33) 92% (57) Tuning fork 19% (7) 3% (2) Table for vision testing 72% (26) 58% (36)

Ear syringe 58% (21) 34% (21) Scissors 86% (31) 95% (59)

20 Quality of Care Study 2018

Table 7 Availability of functional general medical equipment* Timer 53% (19) 37% (23)

^Not specified in AI 08/2017 but considered to be minimum standard for PHC services Snellen eye chart 64% (23) 58% (36)

 Availability of functional medical equipment was variable across all facilities and no Children growth chart 50% (18) 35% (22) facilities fully meet the requirements of AI 08/2017 in respect of the listed items. Tongue depressor 100% (36) 92% (57)

MFMCs (n=36) FMCs (n=62)  Functional equipment specific for obstetrics, infants and toddlers was commonly Microsurgery 47% (17) 37% (23) absent. Nebulizer 97% (35) 90% (56)  Functional equipment for eye and ear testing were also often missing.

Ambu mask 92% (33) 69% (43) Table 8 Availability of functional gynaecology equipment Strong source of light in good condition (portable) 86% (31) 71% (44) MFMCs (n=36) FMCs (n=62) Nasal speculum 44% (16) 21% (13) Gynaecological bed 69% (25) 8% (5)

Otoscope 69% (25) 76% (47) Gynaecological instruments 69% (25) 6% (4) Ophthalmoscope 56% (20) 66% (41) Oxygen tank (tube) 92% (33) 74% (46) Doppler 25% (9) 13% (8) Vaginal speculum, small size 61% (22) 6% (4) Glucometer 81% (29) 61% (38) Vaginal speculum, medium size 67% (24) 6% (4) Peak flow meter 39% (14) 18% (11) Vaginal speculum, large size 61% (22) 8% (5) Tape measure 83% (30) 90% (56) Pap smear materials: (brush, spatula, holder) 28% (10) 3% (2) Pen light 86% (31) 53% (33) Gloves (latex) 89% (32) 90% (56)

Head light 39% (14) 11% (7) Masks for doctors 72% (26) 66% (13) Neurological hammer 56% (20) 61% (38) Weight scale for adults 83% (30) 92% (57)  Functional equipment for gynaecological services was generally available at two thirds of MFMCs, and mostly absent at the FMCs. Weight scale for children (over 2 years old) 86% (31) 71% (44)  Pap smear materials were available at only one third of MFMCs. Weight scale for infants and toddlers (up to 2 years old) 92% (33) 84% (52) Sphygmomanometer for children 42% (15) 29% (18) Table 8 Availability of functional advanced equipment* Sphygmomanometer for adults 78% (28) 89% (55) MFMCs (n=36) FMCs (n=62) Stethoscope for children 31% (11) 42% (26) EKG machine 92% (33) 48% (30)

Stethoscope for adults 97% (35) 95% (59) Sterilizer/Autoclave 92% (33) 77% (48) Obstetrical stethoscope/Fetoscope 28% (10) 15% (9) Photometer 36% (13) 23% (14) Pelvimeter 28% (10) 6% (4) Centrifuge 86% (31) 37% (23)

Sterilization equipment and anti-septical protocol 83% (30) 74% (46) X-ray 25% (9) 6% (4) Pulse oximeter^ 78% (28) 73% (45) Defibrillator 69% (25) 18% (11) Refrigerator 86% (31) 74% (46) Ultrasound machine 72% (26) 15% (9) Vaccine refrigerator/portable 89% (32) 76% (47) Microscope 86% (31) 44% (27) Height meter board for children (up to two years old) 72% (26) 68% (42)  The above items are all included in AI 08/2017. The AI seems to suggest that these Meter for height measuring (children over two years of 89% (32) 81% (50) items should be available in both MFMCs and FMCs. age)  Availability of advanced equipment was variable across the MFMCs and largely absent Thermometer 92% (33) 92% (57) in the FMCs. Tuning fork 19% (7) 3% (2)  Photometer and X-ray equipment especially were often unavailable across all facilities. Table for vision testing 72% (26) 58% (36)

Ear syringe 58% (21) 34% (21) Scissors 86% (31) 95% (59) 

21 Primary Health Care in Kosovo

Table 9 Availability of functional equipment to assess and monitor child growth*

MFMCs (n=36) FMCs (n=62) Box of blocks in different colours 11% (4) 2% (1)

Rattle, small red ball hung in a piece of thread 11% (4) 2% (1) Book with simple illustrations or some sheets of colour paper with illustrations, i.e. a flower, a girl, a car, a cat, etc. 22% (8) 0% (0) Large and thin pencils, sheets of paper for drawings 8% (3) 3% (2)

Doll 25% (9) 6% (4) Hairbrush 11% (4) 0% (0)

Small plate and spoon 6% (2) 0% (0) Cups 11% (4) 2% (1) Simple puzzles with 2-3 pieces 6% (2) 0% (0) Sheet with stripes and shapes 8% (3) 2% (1)

 Very few MFMCs had functional equipment to assess and monitor child growth.  The equipment to assess and monitor child growth was generally missing in all FMCs.

22 Quality of Care Study 2018

Table 9 Availability of functional equipment to assess and monitor child growth* Table 10 Availability of medical products

MFMCs (n=36) FMCs (n=62) *Specified in AI 08/2017

Box of blocks in different colours 11% (4) 2% (1)  Overall, the availability of medical products was very variable across all facilities. Rattle, small red ball hung in a piece of thread 11% (4) 2% (1)

Book with simple illustrations or some sheets of colour Facility MFMCs (n=36) FMCs (n=62) paper with illustrations, i.e. a flower, a girl, a car, a cat, etc. 22% (8) 0% (0) Vaccines 92% (33) 76% (47) Large and thin pencils, sheets of paper for drawings 8% (3) 3% (2) Water for injections 92% (33) 94% (58)

Doll 25% (9) 6% (4) Atropine sulphate 36% (13) 13% (8) Hairbrush 11% (4) 0% (0) Dextrose solution 89% (32) 81% (50)

Small plate and spoon 6% (2) 0% (0) Manitol solution 19% (7) 6% (4) Cups 11% (4) 2% (1) Diazepam 97% (35) 94% (58) Simple puzzles with 2-3 pieces 6% (2) 0% (0) Adrenaline / epinephrine 97% (35) 98% (61) Sheet with stripes and shapes 8% (3) 2% (1) Furosemid 100% (36) 98% (61) Natrium chloride solution 92% (33) 94% (58)  Very few MFMCs had functional equipment to assess and monitor child growth. Glyceryl trinitrate/nitroglycerin 56% (20) 34% (21)  The equipment to assess and monitor child growth was generally missing in all FMCs. Dexamethason 86% (31) 79% (49) Antitetanus serum 44% (16) 11% (7) Antivenom imunoglobulin/antivipera serum 28% (10) 2% (1)

Oral rehydration salt/tresol (o.r.s) 36% (13) 37% (23) Benzylpenicillin/ bipenicillin 67% (24) 42% (26) Metoclopramide/ methochopramid 89% (32) 81% (50) Paracetamol/acetaminophen 78% (28) 71% (44) Morphine sulphate 47% (17) 13% (8)

Diclofenac 97% (35) 98% (61) Salbutamol (nebulizer) 69% (25) 60% (37)

Hydrocortisone 28% (10) 16% (10) Contraceptives: oral (COC, POP), Injectables, DIU, 6% (2) 2% (1) Condoms Emergency conceptive pill/levonorgestrel 3% (1) 2% (1) Plastic syringes 100% (36) 94% (58) Needles for syringes 89% (32) 89% (55) Povidon jod/iodine solution 97% (35) 100% (62) Surgical gloves 100% (36) 89% (55) Amoxicillin/erythromycin 81% (29) 68% (42) Chloropiramine/chlorfeniramin (oral antihistamine) 36% (13) 34% (21) Acid acetylsalicylic/aspirin 67% (24) 50% (31) Atenolol/metoprolol 44% (16) 13% (8) Sol. glucose 97% (35) 94% (58)

Hyoscine butylbromide/buscopan 58% (21) 60% (37) Folic acid 8% (3) 0% (0)

23 Primary Health Care in Kosovo

Oxygen* 75% (27) 73% (45)

Bandages 89% (32) 89% (55) Gauze 89% (32) 85% (53) Hydrogen peroxide 69% (25) 42% (26) Hydrophilic cotton 83% (30) 95% (59) Plastic perfusion system 94% (34) 79% (49)

Spiritus aethylicus 70% (alcohol) 86% (31) 98% (61) Ranitidine 92% (33) 94% (58)

Magnesium sulphate 6% (2) 5% (3) Suture/thread for stitching wounds* 31% (11) 13% (8)

Kalium (potassium) iodine 8% (3) 11% (7) Test strips for Glucometer* 56% (20) 38% (24)

Urine protein test strips* 61% (22) 23% (14) Urine ketones test strips* 53% (19) 19% (12) Urine microalbuminuria test strips* 42% (15) 16% (10) Fluorescein strips 17% (6) 3% (2) Blood cholesterol assay* 92% (33) 23% (14) Lipid profile* 72% (26) 15% (9) Serum creatinine assay* 83% (30) 23% (14)  The national Essential Drug List and Essential List of Expenditure Materials (both 2013) includes all the above items, however the lists do not differentiate between items that should be available in primary, secondary or tertiary care.  The above items are generally considered as minimal standard for PHC.  None of the listed items were available in all facilities and some items were only available in very few facilities.  Contraceptives were only available in 3 out of 98 facilities.  Atropine solution, mannitol solution, antitetanus serum, antivenom, atenol/metonrolol, folic acid, magnesium sulphate and potassium iodine were commonly missing.  Blood glucose and urine test kits were also largely unavailable.

24 Quality of Care Study 2018

Oxygen* 75% (27) 73% (45)

Bandages 89% (32) 89% (55) Gauze 89% (32) 85% (53) Hydrogen peroxide 69% (25) 42% (26) Hydrophilic cotton 83% (30) 95% (59) Plastic perfusion system 94% (34) 79% (49)

Spiritus aethylicus 70% (alcohol) 86% (31) 98% (61) per ce utilization Ranitidine 92% (33) 94% (58)

Magnesium sulphate 6% (2) 5% (3) Suture/thread for stitching wounds* 31% (11) 13% (8)

Kalium (potassium) iodine 8% (3) 11% (7) Test strips for Glucometer* 56% (20) 38% (24)

Urine protein test strips* 61% (22) 23% (14) , depending the servi on , depending

Urine ketones test strips* 53% (19) 19% (12) 8 Urine microalbuminuria test strips* 42% (15) 16% (10) Fluorescein strips 17% (6) 3% (2) Blood cholesterol assay* 92% (33) 23% (14) Lipid profile* 72% (26) 15% (9) Serum creatinine assay* 83% (30) 23% (14)  The national Essential Drug List and Essential List of Expenditure Materials (both 2013) includes all the above items, however the lists do not differentiate between items that should be available in primary, secondary or tertiary care.

 The above items are generally considered as minimal standard for PHC. n= and n=1 between , varying  None of the listed items were available in all facilities and some items were only available in very few facilities.

 Contraceptives were only available in 3 out of 98 facilities. FMCs) and FMCs)  Atropine solution, mannitol solution, antitetanus serum, antivenom, atenol/metonrolol, folic acid, magnesium sulphate and potassium iodine were commonly missing. municipalities  Blood glucose and urine test kits were also largely unavailable.

all municipalities (MFMCs

cilities were visited in each in visited were cilities rank of

of fa . For more information see chapter 2: methodology methodology 2: chapter see information more . For Overview clinical Overview Clinical Observations

municipality 3.1.2 4 Figure Note: Different numbers numbers Note: Different

25 Primary Health Care in Kosovo

Table 11 National findings on clinical practice

Asks questions Conducts Advises, explains National average examination Hypertension 52% 35% 52% 48% (n=210) Diabetes 56% 32% 58% 51% (n=64)

Referral 72% 53% 51% 59% (n=391)

Other 89% 81% 68% 76% (n=1357)

 Overall, clinical practice scores were low for treating patients with diabetes and hypertension, particularly for conducting examinations.  When patients presented for referral, low scores were achieved for conducting examinations and providing advice and explanations, suggesting that patients were often referred by the doctor without any examination or advice to determine whether or not the referral was necessary. This indicates that PHC doctors are not entirely fulfilling the role of gatekeepers, in line with the Family Medicine concept.  Better scores were achieved for asking questions and conducting examinations of patients treated for other illnesses.

Table 12 Adherence to principles of history and physical examination

National (n=2022)

The medical doctor adheres to principles of history and physical examination, i.e. …

Greets the client 97%

Sees the client in privacy/confidentiality 84%

Makes the client comfortable (e.g. seat offered) 93%

Asks the client about concerns, allows client to explain his/her health issue 96%

Has the patient record 22%

Uses the patient record during consultation (if applicable, n=554)* 62%

Documents consultation in patient record (of all who have the patient record, n=554)* 93%

Closed politely the consultation 99%

 Overall, principles of history and physical examination were generally adhered to well.  Improvements could be made to ensure patient privacy and confidentially.  The doctor only had the patient record in approximately 20% of the cases.

Table 13 Infection prevention and control

National (n=2022)

The medical doctor pays attention to infection prevention and control, i.e. ...

Washes hands before the procedure (if applicable; n=1055) 7%

Washes hands after procedure (if applicable; n=1095) 11%

Applied proper decontamination procedures (if applicable; n=589) 10%

26 Quality of Care Study 2018

Table 11 National findings on clinical practice Puts on gloves where required (if applicable; n=341) 11%

Asks questions Conducts Advises, explains National average Puts on a mask where required (if applicable; n=294) 4% examination

Hypertension 52% 35% 52% 48%  Whilst Table 4 Hygiene shows that items for infection prevention and control are (n=210) missing in many facilities, this Table suggests that even when items are available they Diabetes 56% 32% 58% 51% are not being used sufficiently. (n=64)  Overall, infection prevention and control procedures were very poorly followed. Referral 72% 53% 51% 59%  Hand washing before and after seeing a patient for example was only followed by 10% (n=391) of the doctors.

Other 89% 81% 68% 76% (n=1357) Table 14 Patients with diabetes

Diabetes National (n=64)  Overall, clinical practice scores were low for treating patients with diabetes and hypertension, particularly for conducting examinations. The medical doctor asks questions, about …  When patients presented for referral, low scores were achieved for conducting Any specific health complaints 83% examinations and providing advice and explanations, suggesting that patients were often referred by the doctor without any examination or advice to determine whether or General weakness 78% not the referral was necessary. This indicates that PHC doctors are not entirely fulfilling Urine discharge 63% the role of gatekeepers, in line with the Family Medicine concept.  Better scores were achieved for asking questions and conducting examinations of Vulvovaginitis or pruritus (if applicable; n=34) 10% patients treated for other illnesses. Appetite 62%

Table 12 Adherence to principles of history and physical examination Eye-sight 29% Visit to ophthalmologist 17% National (n=2022) Alcohol 19% The medical doctor adheres to principles of history and physical examination, i.e. … Smoking 55% Greets the client 97% Using other medicine 92%

Sees the client in privacy/confidentiality 84% Sedentary way of life 52%

Adherence with diabetes treatment (if applicable; n=58) Makes the client comfortable (e.g. seat offered) 93% 91% The medical doctor conducts examinations, i.e. … Asks the client about concerns, allows client to explain his/her health issue 96% Checks blood pressure 68% Has the patient record 22% Weight measurement / calculation of body-mass index 4%

Uses the patient record during consultation (if applicable, n=554)* 62% Of skin, mucus membranes, nodes of lymph, ears, nose, thyroid glands 34%

Documents consultation in patient record (of all who have the patient record, n=554)* 93% Of eyes 15% Of chest, auscultation of lungs 32% Closed politely the consultation 99% Auscultation of heart 45%

 Overall, principles of history and physical examination were generally adhered to well. Of abdomen, palpation of liver and signs of percussion 9%  Improvements could be made to ensure patient privacy and confidentially. Perfusion of legs (veins and feeling of legs) 15%  The doctor only had the patient record in approximately 20% of the cases.

Table 13 Infection prevention and control

National (n=2022)

The medical doctor pays attention to infection prevention and control, i.e. ...

Washes hands before the procedure (if applicable; n=1055) 7%

Washes hands after procedure (if applicable; n=1095) 11%

Applied proper decontamination procedures (if applicable; n=589) 10%

27 Primary Health Care in Kosovo

Diabetes National (n=64)

Gives clear explanations to the client concerning the purpose of tests and procedures. 69%

The medical doctor advices, explains and instructs, about …

Results of examinations 83%

The situation and diagnosis 87%

The prognosis 49%

About needed examinations 75%

Nutrition, i.e. Food intake and weight decrease 76%

On the prevention and treatment of hypoglycaemia and other acute and chronic 45% complications of diabetes

On self-monitoring - glycaemia control and prevention of hypoglycaemia 46%

About alcohol 18%

About smoking 48%

About physical exercise 35%

Right ways of care of legs 16%

Potential complication of the illness 40%

Potential risks if illness is not treated 54%

Importance of adherence to treatment 79%

About follow-up visit 73%

About the referral (if applicable; n=29) 69%

On prescribed medicines/treatment (if applicable; n=54) 94%

 Blood pressure was taken in approximately 2/3 of patients however other assessments were performed in less than half of the patients, with weight/Body Mass Index (BMI) being measured in only 4% of cases.  To better align with best practice3, improvements could be made to questioning patients with diabetes about lifestyle factors.  Diabetes patients are generally well advised on their condition, importance to treatment adherence, prescribed medications and nutrition. However, counselling patients with diabetes on specific issues such as smoking, alcohol consumption, physical activity and leg care is often overlooked.

3 As illustrated in WHO Package of Essential Noncommunicable (PEN) Disease Interventions for PHC 2010

28 Quality of Care Study 2018 Table 15 Patients with hypertension

Diabetes National (n=64) Hypertension National (n=210)

Gives clear explanations to the client concerning the purpose of tests and procedures. 69% The medical doctor asks questions, about….

The medical doctor advices, explains and instructs, about … Any specific health complaints 90%

Results of examinations 83% Headache 71%

The situation and diagnosis 87% The use of medicine other than for hypertension 85%

The prognosis 49% The use of contraceptives (if applicable; n=124) 8%

About needed examinations 75% Eye-sight 18%

Nutrition, i.e. Food intake and weight decrease 76% Visit to ophthalmologist 8%

On the prevention and treatment of hypoglycaemia and other acute and chronic Alcohol 21% 45% complications of diabetes Smoking 41% On self-monitoring - glycaemia control and prevention of hypoglycaemia 46% Sedentary way of life 44% About alcohol 18% High blood pressure (if applicable; n=204) 90% About smoking 48% Adherence with hypertension treatment (if applicable; n=195) 82% About physical exercise 35% The medical doctor conducts examinations, i.e. … Right ways of care of legs 16% Checks blood pressure 98% Potential complication of the illness 40% Weight measurement / calculation of body-mass index 7% Potential risks if illness is not treated 54% Of skin, mucus membranes, nodes of lymph, ears, nose, thyroid glands 37% Importance of adherence to treatment 79% Of eyes 15% About follow-up visit 73% Of chest, auscultation of lungs 40% About the referral (if applicable; n=29) 69% Auscultation of heart 43% On prescribed medicines/treatment (if applicable; n=54) 94% Of abdomen, palpation of liver and signs of percussion, palpation of kidneys 7%

 Blood pressure was taken in approximately 2/3 of patients however other assessments Perfusion of legs (pulse and perfusion of legs) 10% were performed in less than half of the patients, with weight/Body Mass Index (BMI) And gives clear explanations to the client concerning the purpose of tests and 60% being measured in only 4% of cases. procedures. Checks blood pressure  To better align with best practice3, improvements could be made to questioning patients with diabetes about lifestyle factors. The medical doctor advices, explains and instructs, about …  Diabetes patients are generally well advised on their condition, importance to treatment Results of examinations 82% adherence, prescribed medications and nutrition. However, counselling patients with diabetes on specific issues such as smoking, alcohol consumption, physical activity The situation and diagnosis 86% and leg care is often overlooked. The prognosis 57%

About needed examinations 67% About signs of extreme hypertension 39%

About what to do when signs of extreme hypertension occur 33%

Nutrition, i.e. food intake 57%

About alcohol 22%

About smoking 38%

About physical exercise 34%

About oral contraceptives (if applicable, n=124) 5%

Potential complication of the illness 36%

Potential risks if illness is not treated 49% 3 As illustrated in WHO Package of Essential Noncommunicable (PEN) Disease Interventions for PHC 2010

29 Primary Health Care in Kosovo

Hypertension National (n=210)

Importance of adherence to treatment 66%

About follow-up visit 73%

About the referral (if applicable, n=116) 48%

On prescribed medicines/treatment (if applicable, n=185) 78%

 Blood pressure measurement was taken in almost all patients; however other assessments were performed in less than half of the patients.  To better align with best practice4, improvements could be made to questioning patients with hypertension about lifestyle factors.  Hypertension patients were generally advised on their condition and prescribed medications and treatment. However, counselling patients on smoking, alcohol consumption and physical activity was generally not provided.

Table 16 Patients consulting for other reasons than diabetes or hypertension

Other diseases National (n=1357)

The medical doctor asks questions, about….

Takes patient history (general history, specific to disease) 91%

Asks open ended questions during history taking 91%

Asks about any prescriptions the client is currently taking. 77%

Listens to the client and responds to client questions 97%

The medical doctor conducts examinations, i.e. …

Performs medical examinations and other investigations as individually required. (if 89% applicable; n=1210) Gives clear explanations to the patient concerning the purpose of medical 80% examinations and other investigations. (if applicable; n=968)

The medical doctor advices, explains and instructs, about …

Results of examinations (if applicable; n=1067) 90%

The situation and diagnosis 83%

The prognosis 42%

About needed examinations 71%

About follow-up visit 64%

About the referral (if applicable; n=689) 43%

On prescribed medicines/treatment (if applicable; n=1189) 85%

On risks factors/health education (if applicable; n=1163) 61%

 Patients attending for illnesses other than diabetes and hypertension were generally well questioned and examined, although improvements could be made to questioning about current medication.  Patients were well advised on the results of their examinations and diagnosis as well as prescribed treatments and medications.  Regarding referral mechanism, feedback mechanisms between the family doctor and the specialist are often not in place and are not known to the patient.

4 As illustrated in WHO Package of Essential Noncommunicable (PEN) Disease Interventions for PHC 2010

30 Quality of Care Study 2018

Hypertension National (n=210) Table 17 Patients consulting for referrals Importance of adherence to treatment 66% Referrals National (n=391) About follow-up visit 73% The medical doctor asks questions, about About the referral (if applicable, n=116) 48% Takes patient history (general history, specific to disease) 80% On prescribed medicines/treatment (if applicable, n=185) 78% Asks open ended questions during history taking 72%  Blood pressure measurement was taken in almost all patients; however other Asks about any prescriptions the client is currently taking. 51% assessments were performed in less than half of the patients.  To better align with best practice4, improvements could be made to questioning patients Listens to the client and responds to client questions 85% with hypertension about lifestyle factors. The medical doctor conducts examinations, i.e. …  Hypertension patients were generally advised on their condition and prescribed Performs medical examinations and other investigations as individually required. (if 57% medications and treatment. However, counselling patients on smoking, alcohol applicable; n=198) consumption and physical activity was generally not provided. Gives clear explanations to the patient concerning the purpose of medical 88% Table 16 Patients consulting for other reasons than diabetes or hypertension examinations and other investigations. (if applicable; n=102) The medical doctor advices, explains and instructs, about … Other diseases National (n=1357) Results of examinations (if applicable; n=109) 82% The medical doctor asks questions, about…. The situation and diagnosis 48% Takes patient history (general history, specific to disease) 91% The prognosis 34% Asks open ended questions during history taking 91% About needed examinations 57% Asks about any prescriptions the client is currently taking. 77% About follow-up visit 41% Listens to the client and responds to client questions 97% About the referral (if applicable; n=343) 92% The medical doctor conducts examinations, i.e. … On prescribed medicines/treatment (if applicable; n=163) 47% Performs medical examinations and other investigations as individually required. (if 89% applicable; n=1210) On risks factors/health education (if applicable; n=250) 42% Gives clear explanations to the patient concerning the purpose of medical 80% examinations and other investigations. (if applicable; n=968)  Questioning patients about current medication and advising on prescribed medication could be improved. The medical doctor advices, explains and instructs, about …  Only around half of patients attending for referral were examined. Results of examinations (if applicable; n=1067) 90%  Those patients who were examined, were generally well advised on their examination The situation and diagnosis 83% results. However, any further advice was often lacking.

The prognosis 42%

About needed examinations 71%

About follow-up visit 64%

About the referral (if applicable; n=689) 43%

On prescribed medicines/treatment (if applicable; n=1189) 85%

On risks factors/health education (if applicable; n=1163) 61%

4 As illustrated in WHO Package of Essential Noncommunicable (PEN) Disease Interventions for PHC 2010

31 Primary Health Care in Kosovo

, depending on the service utilization per utilization the service on , depending 8 FMCs) and FMCs)

of all municipalities (MFMCs

ities were visited in each municipalities, varying between n=1 n= and n=1 between varying municipalities, each in visited were ities Overview patient satisfaction rank satisfaction patient Overview Exit Interviews

3.1.3 5 Figure of facil Note: numbers Different methodology 2: chapter see information more For municipality.

32 Quality of Care Study 2018

Table 18 Overall satisfaction with health services - exit interviews

National (n=1310) Overall: How satisfied were you with the services you received today

Very unsatisfied 3% Unsatisfied 8%

Satisfied 49% Very satisfied 40%

 Overall, patients were mostly satisfied or very satisfied with the health services.  It is surprising to see such high levels of patient satisfaction when the data presented elsewhere in this report describes many areas where PHC services are deficient.  Similar high levels of satisfaction with health services has been seen in other patient surveys in recent years. However, this does not seem to be an accurate reflection of findings from other feedback mechanisms for example media reports, focus group discussions, anecdotal evidence etc. This likely reflects a low level of expectation about , depending on the service utilization per utilization the service on , depending the quality of services provided.

Table 19 Satisfaction with different aspects of health service - exit interviews

National (n=1312) Patient was given the opportunity to explain the health problem 98% Patients privacy was ensured 85%

Doctor explained the questioning and physical examinations and the health problem (if 92% applicable; n=1084) Doctor explained the intake of prescribed medicine (if applicable; n=1098) 87% FMCs) and FMCs) Doctor asked if patient currently takes prescriptions 72% Patient was given chance to ask questions about the investigation, health problem and 89% treatment

Doctor listened carefully to patients concerns and questions and gave satisfactory 92% answers Patient got advice on health problem 76% Medical doctor was polite during consultation 98%

 Most patients felt they had to opportunity to discuss their health problems and the of all municipalities (MFMCs doctor politely answered their concerns.  Improvements could be made in the area of asking about current medication the patients were taking and providing health advice.

Table 20 Payment for health service – exit interviews ities were visited in each municipalities, varying between n=1 n=8and n=1 between varying municipalities, each in visited were ities

National (n=448) Did you get a receipt for your payment? (if applicable) 96%

 Of those patients who paid for their medical services, 96% received a receipt.

Overview patient satisfaction rank satisfaction patient Overview Exit Interviews municipality. For more information see chapter 2: methodology methodology 2: chapter see information more For municipality. Note: Different numbers of facil Note: numbers Different 3.1.3 5 Figure

33 Primary Health Care in Kosovo

4 Key Findings and Recommendations

Key findings needing improvement Recommendations

Infrastructure

1. PHC services

 Other than laboratory testing AI 08/2017 does not  Administrative Instruction (AI) (Health) No. 08/2017 differentiate which services should be provided at should be revised to specify which services are to be MFMC and FMC facilities, with each municipality offered at MFMC, FMC and Ambulanta facilities. offering their own portfolio of services at each level.

2. Facility infrastructure

3. Equipment and guidelines

 Variation in the range of equipment available at  Develop minimum specifications for PHC equipment facilities. listed in AI 08/2017, defining which items should be  Basic equipment not available in some facilities. available in MFMCs, FMCs and Ambulantas.  Lack of standards for some categories of  Ensure availability of at least one complete set of equipment (e.g. gynaecological equipment). PHC equipment in each facility, as per the above  Equipment specific for obstetrics, infants and specification, as a minimum standard. toddlers was commonly absent.  Develop Planned Preventive Maintenance (PPM)  Equipment for gynaecological services was only schedules for PHC equipment. available at two thirds of the MFMCs and largely  Ensure distribution and implementation of national absent from the FMCs. Clinical Protocols and Guidelines. Where these are  Lack of equipment to assess and monitor child not available, other best practice guidelines should growth. be adapted, e.g. WHO PEN Protocols.  Guidelines and information materials were lacking  To improve drugs management, the national in both facility types but more often limited in the Essential Drug List and Essential List of Expendable MFMCs. Materials need to differentiate between items that  None of the basic PHC drugs and materials listed should be available in primary, secondary or tertiary were available in all facilities, and some items care. were only available in very few facilities.  It is critical that drug supply systems at national and  Contraceptives were only available in 3 out of 98 local levels are improved to ensure availability of facilities. basic drugs and consumables at PHC facilities.  The availability of contraceptives in PHC facilities requires urgent review.

34 Quality of Care Study 2018

4 Key Findings and Recommendations 4. Hygiene and clinical waste

Key findings needing improvement Recommendations  Disinfectant for instruments often not available in  Ensure implementation of hygiene standards the necessary places. specified in AI 08/2017, e.g.: Infrastructure  Washing points/soap not available near all toilets. o Functional washing points must be close to  Cleanliness of toilets was low. toilets 1. PHC services  Storage and collection of infectious waste not o Functional washing points must be in the sufficient. consultation rooms  Other than laboratory testing AI 08/2017 does not  Administrative Instruction (AI) (Health) No. 08/2017  Inadequate waste disposal procedures for sharps o Water and soap are constantly available at all differentiate which services should be provided at should be revised to specify which services are to be and infectious materials in both levels of health washing points MFMC and FMC facilities, with each municipality offered at MFMC, FMC and Ambulanta facilities. facilities. With FMCs being more limited, reporting o Ensure that chlorine solutions or other offering their own portfolio of services at each only 60% having adequate disposal of infectious disinfectants for instruments are available. level. waste.  Develop/update clinical waste management protocols/guidelines and ensure implementation in each facility.  Head Nurses to implement and monitor regular 2. Facility infrastructure cleaning schedules in each facility.

 Frequent power-cuts and only half of the  Ensure the availability of basic utilities in all PHC surveyed facilities had a generator. facilities (power, water, heating) as a minimal Clinical observation  Functional heating systems unavailable in 1/3 of standard. the FMC facilities.  Where there is insufficient space to identify a  Limited availability of tap water, particularly in consulting room specifically for women/children, 5. Patient records FMCs with half of the facilities reporting routine ensure at least one consulting room in each facility is shortages. ‘child-friendly’. The doctor only had the patient record in  Each facility should have a functioning patient  Designated consulting room for women and  Communication equipment, computers and printers approximately 20% of the cases records system that includes standard operating children often unavailable and very rare for the and internet access should be made available in all procedures for retrieving individual patient records FMCs. FMCs to improve communication, referrals and prior to clinical consultation  While most MFMCs had functional reporting etc. between MFMCs and FMCs. communication equipment, computers and  Every facility should be required to ensure that a printers this was very limited in the FMCs. functioning patient record system in place. Internet access is available in less than half of the FMCS. 6. Infection prevention and control  Only 80% of all MFMCs and FMCs have a patient record system indicating that some patients are   being seen without a medical record. Very low adherence to infection prevention and Develop infection prevention and control standards  In the FMCs mechanisms for referrals were most control measures during consultations. for PHC and monitor implementation often absent.  Provide refresher training for clinical staff on infection prevention and control as part of CPD

3. Equipment and guidelines 7. Management of diabetes and hypertension  Variation in the range of equipment available at  Develop minimum specifications for PHC equipment facilities. listed in AI 08/2017, defining which items should be  Very low adherence to general diabetes  Implement national CPGs on diabetes and  Basic equipment not available in some facilities. available in MFMCs, FMCs and Ambulantas. treatment guidelines hypertension, including:   Ensure availability of at least one complete set of Lack of standards for some categories of  Very low adherence to general hypertension Distribution of CPGs to the health facilities equipment (e.g. gynaecological equipment). PHC equipment in each facility, as per the above o treatment guidelines Training health professionals on CPGs  Equipment specific for obstetrics, infants and specification, as a minimum standard. o  Variable adherence to principles of good clinical Monitoring and evaluation of implementation toddlers was commonly absent.  Develop Planned Preventive Maintenance (PPM) o practice and physical examination  Counselling on lifestyle factors should be integrated  Equipment for gynaecological services was only schedules for PHC equipment.  into all clinical consultations, by including health available at two thirds of the MFMCs and largely  Ensure distribution and implementation of national Counselling on smoking, alcohol consumption, absent from the FMCs. Clinical Protocols and Guidelines. Where these are physical activity is often not provided for patients education counselling skills in CPGs, CPD and the medical education curriculum.  Lack of equipment to assess and monitor child not available, other best practice guidelines should with diabetes or hypertension. growth. be adapted, e.g. WHO PEN Protocols.  Guidelines and information materials were lacking  To improve drugs management, the national in both facility types but more often limited in the Essential Drug List and Essential List of Expendable Other observations MFMCs. Materials need to differentiate between items that  None of the basic PHC drugs and materials listed should be available in primary, secondary or tertiary  Feedback mechanism missing in 11% of MFMCs  Ensure each facility implements at least one were available in all facilities, and some items care. and 19% of FMC facilities. patient/provider feedback mechanism were only available in very few facilities.  It is critical that drug supply systems at national and  Contraceptives were only available in 3 out of 98 local levels are improved to ensure availability of facilities. basic drugs and consumables at PHC facilities.  Referral mechanisms could be improved.  Develop and implement either national or local  The availability of contraceptives in PHC facilities referral mechanisms to ensure standards set in AI requires urgent review. 08/2017 are met

35 Primary Health Care in Kosovo

5 References

Accessible Quality Healthcare (AQH) (2016). “Quality of Care Study 2016 – Technical Report of the Baseline Study.” Swiss Tropical and Public Health Institute, Basel.

Boller, C., Wyss, K., et al. (2003). “Quality and comparison of antenatal care in public and private providers in the United Republic of Tanzania.” Bull World Health Organization 81(2): 116-122.

Donabedian, A. (1988). "The quality of care. How can it be assessed?" JAMA 260(12): 1743- 1748.

Donabedian, A. (1990). "The seven pillars of quality." Archives of pathology & laboratory medicine 114 (November): 1115-1118.

Foundation for Sustainable Development (2014). Quality as the missing link between access to healthcare and improved patient outcomes. Express Newsletter 3/14, URL: http://www.novartisfoundation.org/_file/205/newsletter-3-14.pdf (Access: 11 February 2015).

Kiefer, S. and Kadesha, B. (2015). Report on the Assessment of Quality of Care in Primary Health Care Facilities in the two Pilot Regions, Health for All project, Albania. Study report. Basel: Swiss TPH.

Lechthaler, F. (2015). Study Protocol on the Quality of Care Study in Chad. Unpublished.

Matthys, B. (2013). Assessment of quality of care in primary health care facilities in two pilot rayons of project Sino. Study report. Basel: Swiss TPH.

World Health Organization (2010). Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings. Geneva: WHO.

World Health Organization (2015). Service Availability and Readiness Survey (SARA). An annual monitoring system for service delivery. Version 2.2. Geneva: WHO.

36 Quality of Care Study 2018

5 References Appendix A: Abbreviations

Accessible Quality Healthcare (AQH) (2016). “Quality of Care Study 2016 – Technical Report AI Administrative Instruction of the Baseline Study.” Swiss Tropical and Public Health Institute, Basel. AQH Accessible Quality Healthcare CI Confidence interval Boller, C., Wyss, K., et al. (2003). “Quality and comparison of antenatal care in public and CPD Continuing Professional Development private providers in the United Republic of Tanzania.” Bull World Health Organization 81(2): CPG Clinical Protocol and Guideline 116-122. DHSW Directors of Health and Social Welfare FM Family Medicine Donabedian, A. (1988). "The quality of care. How can it be assessed?" JAMA 260(12): 1743- FMC Family Medicine Centre 1748. MFMC Main Family Medicine Centre Donabedian, A. (1990). "The seven pillars of quality." Archives of pathology & laboratory MoH Ministry of Health medicine 114 (November): 1115-1118. NCD Non Communicable Disease ODK Open Data Kit Foundation for Sustainable Development (2014). Quality as the missing link between access to healthcare and improved patient outcomes. Express Newsletter 3/14, URL: PHC Primary Health Care http://www.novartisfoundation.org/_file/205/newsletter-3-14.pdf (Access: 11 February 2015). QoC Quality of Care SARA Service Availability and Readiness Assessment (SARA) Kiefer, S. and Kadesha, B. (2015). Report on the Assessment of Quality of Care in Primary SDC Swiss Agency for Development and Cooperation Health Care Facilities in the two Pilot Regions, Health for All project, Albania. Study report. STI Sexually Transmitted Infection Basel: Swiss TPH. Swiss TPH Swiss Tropical and Public Health Institute Lechthaler, F. (2015). Study Protocol on the Quality of Care Study in Chad. Unpublished. WHO World Health Organisation

Matthys, B. (2013). Assessment of quality of care in primary health care facilities in two pilot rayons of project Sino. Study report. Basel: Swiss TPH.

World Health Organization (2010). Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings. Geneva: WHO.

World Health Organization (2015). Service Availability and Readiness Survey (SARA). An annual monitoring system for service delivery. Version 2.2. Geneva: WHO.

37 Primary Health Care in Kosovo

Appendix B: Questionnaires

Quality of Care Assessment - Infrastructure Assessment Answers

Interviewer_ID

IMEI (International Mobile Equipment Identity)

Date of interview

Start time of interview

Name of municipality

Name of facility

Oral consent given by interviewee yes no

Which services do you provide at this facility?

Family planning yes no

Antenatal care yes no

Obstetric and newborn care yes no

Immunization yes no

Child preventative and curative care yes no

Adolescent health yes no

Sexually transmitted infections yes no

Tuberculosis yes no

Non-communicable diseases yes no

Surgery yes no

Do you provide any outreach activities? yes no

If yes, SPECIFY

Do you have laboratory services? yes no

Do you have X-ray facilities? yes no

1-2 days per week

38 Quality of Care Study 2018

How many days of the working week is at least one doctor present to provide general 3-4 days per week Appendix B: Questionnaires primary health care services? 5 or more days per Quality of Care Assessment - Infrastructure Assessment Answers week

Facility infrastructure and overall cleanliness and maintenance Interviewer_ID

IMEI (International Mobile Equipment Identity) The facility and immediate surroundings (facility yard, waiting area outside) are free yes from long grass, paper debris and solid waste. no

Date of interview

Start time of interview The facility has a rubbish bin which is properly used and not overflowing. yes Name of municipality no

Name of facility There is a designated waiting room for patients. yes Oral consent given by interviewee yes no no

Which services do you provide at this facility? The current waiting area is mopped, free of dust, trash; dirt, spider webs, and generally yes tidy. no

Family planning yes no There is at least one designated consulting room for women. yes no Antenatal care yes no There is at least one designated consulting room for children. yes no Obstetric and newborn care yes no All examination room(s) ensure(s) privacy/confidentiality (door, window blind, curtain). yes no Immunization yes no All examination rooms are mopped, free of dust, trash; dirt, spider webs, and the rooms yes Child preventative and curative care yes are generally tidy. no no

Adolescent health yes no All examination rooms are well illuminated. yes no Sexually transmitted infections yes no The facility has electricity yes no Tuberculosis yes no During the past 7 working days, did you have any power cuts of more than 1 hour during yes opening hours. no Non-communicable diseases yes no Is there routinely a time of year when this facility has a severe shortage or lack of power? yes Surgery yes no no

Do you provide any outreach activities? yes no If yes, SPECIFY: The facility has a functional generator yes If yes, SPECIFY no Do you have laboratory services? yes no If the health facility has a functional generator: is fuel available today for the generator? yes no Do you have X-ray facilities? yes no The facility has a functional heating system. yes 1-2 days per week no

39 Primary Health Care in Kosovo

If yes, SPECIFY:

Has the facility a functional communication equipment (functional landline telephone or yes cell phone) available (either private phone or facility phone)? no

What type of phone do you have available? private cell phone of staff

cell phone of facility

landline of facility

The facility has functional computer. yes no

The facility has a functional printer. yes no

The facility has internet access. yes no

During the past 7 working days did you have internet for at least 1 hour every day? yes no

The administration shelf is filed and in order. yes no

Does the facility have a patient record system? yes no

In which year was the patient record system introduced?

Are there sufficient empty patient record cards available? yes no

Are minimum hygiene and safety standards in the facility ensured?

There is running water in the facility (out of the tap). yes no

There is warm water available (out of the tap). yes no

Is there routinely a time of year when this facility has a severe shortage or lack of water yes (out of the tap)? no

If yes: In case there is a severe shortage or lack of water (out of the tap), where do you well (protected) fetch water? bottled water

water tank/storage

other

If other, please SPECIFY:

40 Quality of Care Study 2018

If yes, SPECIFY: Functional washing points exist in examination rooms and/or entrance hall, and soap or yes hand disinfectants and water are available. no Has the facility a functional communication equipment (functional landline telephone or yes cell phone) available (either private phone or facility phone)? no

Labelled containers for medical waste disposal are available in all required areas (e.g. yes examination rooms). no

What type of phone do you have available? private cell phone of staff The facility has adequate and safe disposal of sharps (sharps box/container). yes cell phone of facility no landline of facility

The facility has functional computer. yes The facility has adequate and safe disposal of infectious waste. yes no no

The facility has a functional printer. yes Infectious waste is temporary stored at a protected place. yes no no

The facility has internet access. yes Sharps waste is temporary stored at a protected place. yes no no

During the past 7 working days did you have internet for at least 1 hour every day? yes There is regular and appropriate collection for infectious waste. yes no no

There is regular and appropriate collection for sharps waste. yes The administration shelf is filed and in order. yes no no The facility has essential disinfectants and antiseptics. yes Does the facility have a patient record system? yes no no

In which year was the patient record system introduced? The facility has chlorine solution or other disinfectants to disinfect contaminated yes instruments in all required areas (e.g. in examination rooms). no

Are there sufficient empty patient record cards available? yes The facility has at least one accessible and functional toilet for patients. yes no no

Are minimum hygiene and safety standards in the facility ensured? The facility has at least one accessible and functional toilet for staff. yes no

The toilet(s) or latrine is clean. yes There is running water in the facility (out of the tap). yes no no A washing point is available near the toilet or latrine. yes There is warm water available (out of the tap). yes no no Soap and water are available at the washing point near toilet or latrine. yes Is there routinely a time of year when this facility has a severe shortage or lack of water yes no (out of the tap)? no Public accountability

Is the facility location visible displayed in public? yes no If yes: In case there is a severe shortage or lack of water (out of the tap), where do you well (protected) fetch water? bottled water Are the facility opening hours visibly displayed to the public? yes no water tank/storage other Is a contact phone number visibly displayed to the public? yes no If other, please SPECIFY:

41 Primary Health Care in Kosovo

Are the tariffs visibly displayed to the public/patients? yes no

Are the contact details of the Ministry of Health helpline for citizen complaints publicly yes displayed? no

Are information leaflets about the Ministry of Health helpline for citizens complaints yes available at the heath facility? no

Is information on the violation of the Kosovo law against tobacco displayed to the yes public? no

Is the Charter of Patient’s Rights and Responsibilities visibly displayed in the waiting yes area? no

Do any of the leaflets/posters at the facility have a logo/trademark from a yes pharmaceutical company? no

Does the facility have a box/book to get public opinion on the quality of services? yes no

Does the facility have mechanisms to facilitate referral of emergency patients to the yes next level? no

When was the last quality inspection by the health inspectors from the Ministry of Health?

Is there a document or copy available of the following essential treatment / management guidelines for different common conditions treated in your health facility?

Is the booklet on Therapeutic standard guideline for PHC available at the facility? yes no

Is the list of essential drugs available at the facility? yes no

Are the following IEC materials visibly displayed to patients?

The Calendar of health promotion developed by MOH or IPH yes no

The Calendar of Vaccination/Immunization yes no

Awareness materials (posters, leaflets) (when counseling) based on standard package yes info (children, adults, women and reproductive health, seniors, mental health) no

Does the facility have the following basic/essential medical equipment and supplies and are they functional?

42 Quality of Care Study 2018

Are the tariffs visibly displayed to the public/patients? yes General medical equipment no Microsurgery available, functional Are the contact details of the Ministry of Health helpline for citizen complaints publicly yes displayed? no available, NOT functional not available

Are information leaflets about the Ministry of Health helpline for citizens complaints yes Nebulizer available, functional available at the heath facility? no available, NOT functional not available Is information on the violation of the Kosovo law against tobacco displayed to the yes public? no Ambu mask available, functional

available, NOT functional Is the Charter of Patient’s Rights and Responsibilities visibly displayed in the waiting yes area? no not available

Strong source of light in good condition (portable) available, functional Do any of the leaflets/posters at the facility have a logo/trademark from a yes available, NOT pharmaceutical company? no functional not available Does the facility have a box/book to get public opinion on the quality of services? yes no Nasal speculum available, functional

available, NOT functional Does the facility have mechanisms to facilitate referral of emergency patients to the yes next level? no not available

Otoscope available, functional

available, NOT When was the last quality inspection by the health inspectors from the Ministry of functional Health? not available Is there a document or copy available of the following essential treatment / management guidelines for different common conditions treated in your health Ophtalmoscope available, functional facility? available, NOT Is the booklet on Therapeutic standard guideline for PHC available at the facility? yes functional no not available

Doppler available, functional Is the list of essential drugs available at the facility? yes no available, NOT functional Are the following IEC materials visibly displayed to patients? not available

The Calendar of health promotion developed by MOH or IPH yes Glucometer available, functional no available, NOT functional The Calendar of Vaccination/Immunization yes no not available

Awareness materials (posters, leaflets) (when counseling) based on standard package yes Peak flow meter available, functional info (children, adults, women and reproductive health, seniors, mental health) no available, NOT functional Does the facility have the following basic/essential medical equipment and not available supplies and are they functional?

43 Primary Health Care in Kosovo

Tape measure available, functional

available, NOT functional not available

Pen light available, functional

available, NOT functional not available

Head light available, functional

available, NOT functional not available

Neurological hammer available, functional

available, NOT functional not available

Weight scale for adults available, functional

available, NOT functional not available

Weight scale for children (over 2 years old) available, functional

available, NOT functional not available

Weight scale for infants and toddlers (up to 2 yers old) available, functional

available, NOT functional not available

Sphygmomanometer for children available, functional

available, NOT functional not available

Sphygmomanometer for adults available, functional

available, NOT functional not available

Stethoscope for children available, functional

available, NOT functional not available

Stethoscope for adults available, functional

44 Quality of Care Study 2018

Tape measure available, functional available, NOT functional available, NOT functional not available not available Obstetrical stethoscope/Fetoscope available, functional

Pen light available, functional available, NOT functional available, NOT functional not available not available Pelvimeter available, functional

Head light available, functional available, NOT functional available, NOT functional not available not available Sterilization equipment and anti-septical protocol available, functional

Neurological hammer available, functional available, NOT functional available, NOT functional not available not available Pulse oximeter available, functional

Weight scale for adults available, functional available, NOT functional available, NOT functional not available not available Refrigerator available, functional

Weight scale for children (over 2 years old) available, functional available, NOT functional available, NOT functional not available not available Vaccine refrigerator/portable available, functional

Weight scale for infants and toddlers (up to 2 yers old) available, functional available, NOT functional available, NOT functional not available not available Hight meter board for children (up to two years old) available, functional

Sphygmomanometer for children available, functional available, NOT functional available, NOT functional not available not available Meter for height measuring ( children over two years of age) available, functional

Sphygmomanometer for adults available, functional available, NOT functional available, NOT functional not available not available Thermometer available, functional

Stethoscope for children available, functional available, NOT functional available, NOT functional not available not available Tuning fork available, functional

Stethoscope for adults available, functional available, NOT functional

45 Primary Health Care in Kosovo

not available

Table for vision testing available, functional

available, NOT functional not available

Ear syringe available, functional

available, NOT functional not available

Scissors available, functional

available, NOT functional not available

Timer available, functional

available, NOT functional not available

Snellen eye chart available

not available

Children growth chart available

not available

Tongue depressor available

not available

Gynacological service equipment

Gynecological bed available, functional

available, NOT functional not available

Gynecological instruments available, functional

available, NOT functional not available

Oxygen tank (tube) available, functional

available, NOT functional not available

Vaginal speculum, small size available

not available

Vaginal speculum, medium size available

not available

46 Quality of Care Study 2018 not available Vaginal speculum, large size available

Table for vision testing available, functional not available available, NOT Pap smear materials: (brush, spatula, holder) available functional not available not available Gloves (latex) available Ear syringe available, functional not available available, NOT functional Masks for doctors available not available not available Scissors available, functional Delivery set: available? yes no available, NOT not applicable functional not available Delivery set: sterile yes no Timer available, functional Does the delivery set contain… available, NOT functional Haemostatic pincette available, functional not available available, NOT Snellen eye chart available functional not available not available Obstetrical forceps available, functional Children growth chart available available, NOT not available functional Tongue depressor available not available not available Scissors available, functional

Gynacological service equipment available, NOT functional Gynecological bed available, functional not available available, NOT functional Sterile cat gut available, functional not available available, NOT functional Gynecological instruments available, functional not available available, NOT functional Sterile gauze available, functional not available available, NOT functional Oxygen tank (tube) available, functional not available available, NOT functional Umbilical cordon clip available not available not available

Vaginal speculum, small size available Needles and needle bearer available not available not available

Vaginal speculum, medium size available Anatomic pincette available not available

47 Primary Health Care in Kosovo

not available

Sterile surgical gloves (two pairs) available

not available

Surgical coat available

not available

Oxytocin ampoule (one) + metergine ampoule (one) available

not available

Syringes available

not available

Plastic aspiration tubes for newborns available

not available

Lydocain (One vial) available

not available

Betadine solution (vials) available

not available

Oxytocin (vials) available

not available

Advanced equipment

EKG machine available, functional

available, NOT functional not available

Sterilizer/Autoclave available, functional

available, NOT functional not available

Photometer available, functional

available, NOT functional not available

Centrifuge available, functional

available, NOT functional not available

X-ray available, functional

available, NOT functional not available

48 Quality of Care Study 2018 not available Defibrillator available, functional

Sterile surgical gloves (two pairs) available available, NOT functional not available not available Surgical coat available Ultrasound machine available, functional not available available, NOT Oxytocin ampoule (one) + metergine ampoule (one) available functional not available not available Microsope available, functional Syringes available available, NOT not available functional Plastic aspiration tubes for newborns available not available not available Necessary tools/materials to assess and monitor child growth

Lydocain (One vial) available Box of blocks in different colors yes not available no Betadine solution (vials) available Rattle, small red ball hung in a piece of thread yes not available no

Oxytocin (vials) available Book with simple illustrations or some sheets of color paper with illustrations, i.e. a yes flower, a girl, a car, a cat, etc. no not available

Advanced equipment Large and thin pencils, sheets of paper for drawings yes no EKG machine available, functional available, NOT Doll yes functional no not available Hairbrush yes no Sterilizer/Autoclave available, functional Small plate and spoon yes available, NOT no functional not available Cups yes no Photometer available, functional Simple puzzles with 2-3 pieces yes available, NOT no functional not available Sheet with stripes and shapes yes no Centrifuge available, functional Were the following products available the day of the visit? available, NOT functional not available Do you have all vaccines available today as foreseen by the calendar of vaccinations? yes no X-ray available, functional Water for injections yes available, NOT no functional not available Atropin sulphat yes no

49 Primary Health Care in Kosovo

Dextrose solution yes no

Manitol solution yes no

Diazepam yes no

ADRENALINE / Epinephrine yes no

Furosemid yes no

Natrium chloride solution yes no

GLYCERYL TRINITRATE/Nitroglycerin yes no

Dexamethason yes no

Antitetanus serum yes no

ANTIVENOM IMUNOGLOBULIN/Antivipera serum yes no

ORAL REHIDRATATION SALT/Tresol (O.R.S) yes no

BENZYLPENICILLIN/ Bipenicillin yes no

METOCLOPRAMIDE/ Methochopramid yes no

PARACETAMOL/Acetaminophen yes no

Morphin sulphate yes no

Diclofenac yes no

Salbutamol (nebulizer) yes no

Hydrocortison yes no

Contraceptives: oral (COC, POP), Injectables, DIU, Condoms yes no

Emergency conceptive pill / LEVONORGESTREL yes no

Plastic syringes yes no

50 Quality of Care Study 2018

Dextrose solution yes Needles for syringes yes no no

Manitol solution yes POVIDON JOD/Iodine solution yes no no

Diazepam yes Surgical gloves yes no no

ADRENALINE / Epinephrine yes Amoxicillin/erythromycin yes no no

Furosemid yes CHLOROPIRAMINE/Chlorfeniramin (oral antihistaminic) yes no no

Natrium chloride solution yes ACID ACETYLSALICYLIC/Aspirin yes no no

GLYCERYL TRINITRATE/Nitroglycerin yes Atenolol/metoprolol yes no no

Dexamethason yes Sol.Glucose yes no no

Antitetanus serum yes HYOSCINE BUTYLBROMIDE/Buscopan yes no no

ANTIVENOM IMUNOGLOBULIN/Antivipera serum yes Folic acid yes no no

ORAL REHIDRATATION SALT/Tresol (O.R.S) yes Oxygen yes no no

BENZYLPENICILLIN/ Bipenicillin yes Bandages yes no no

METOCLOPRAMIDE/ Methochopramid yes Gauze yes no no

PARACETAMOL/Acetaminophen yes Hydrogen peroxide yes no no

Morphin sulphate yes Hydrophilic cotton yes no no

Diclofenac yes Plastic perfusion system yes no no

Salbutamol (nebulizer) yes Spiritus aethylicus 70% ( alcohol) yes no no

Hydrocortison yes Ranitidin yes no no

Contraceptives: oral (COC, POP), Injectables, DIU, Condoms yes Magnesium Sulphate yes no no

Emergency conceptive pill / LEVONORGESTREL yes SUTURE/Thread for stitching wounds yes no no

Plastic syringes yes Kalium (potassium) iodine yes no no

51 Primary Health Care in Kosovo

Test strips for Glucometer yes no

Urine protein test strips yes no

Urine ketones test strips yes no

Urine microalbuminuria test strips yes no

Fluorescein strips yes no

Blood cholesterol assay yes no

Lipid profile yes no

Serum creatinine assay yes no

Thank you very much for the interview.

Interviewer comments

Do you have any indication of cigarette smoke within the premises of the health facility? yes no

End time of interview

52 Quality of Care Study 2018

Test strips for Glucometer yes Quality of Care Assessment - Clinical observation Answers no

Urine protein test strips yes Interviewer_ID no IMEI (International Mobile Equipment Identity)

Urine ketones test strips yes Date of interview no Start time of interview Urine microalbuminuria test strips yes no Name of municipality

Fluorescein strips yes Name of facility no Good morning! My name is [NAME]. We are here on behalf of the Accessible Quality Healthcare Project funded Blood cholesterol assay yes by the Swiss Development Cooperation to conduct a survey of selected health facilities of the project. The no objective of this study is to assess the quality of health care services provided in health facilities. The Ministry of Health and ethical review board has approved this study. Lipid profile yes no Your experiences are very important to improve aspects related to quality of care. Information collected from this interview/questionnaire will be used by the Accessible Quality Healthcare Project. Summaries of findings might also be shared with municipal or national authorities. Serum creatinine assay yes no The information collected from you will be kept confidential within the research team. Instead of using your name, we will give a non-personal identification number which cannot be traced individually. We are not interested in Thank you very much for the interview. your disease or disease history but want to observe some aspects on the care that the doctor provides to you. You are free to decide whether or not you participate in this study. If you decide not to do it, there will be no Interviewer comments negative effect.

Do you have any indication of cigarette smoke within the premises of the health facility? yes no Do I have your agreement to observe your consultation? yes no

End time of interview Is the patient during the consultation present? yes no

Patient profile

Patients' gender female

male

Patients' year of birth

Mother/father/caretaker with child (child is patient) yes no

Profile of health staff

Staff name

Doctors' gender female

male Doctors' year of birth

Type of doctor that is observed family doctor

general doctor

specialist

Please specify:

53 Primary Health Care in Kosovo

Adherence of medical doctor to principles of clinical history and physical examination

The medical doctor yes no

… greets the client. yes no

… sees the client in privacy/confidentiality. yes no

… makes the client comfortable (e.g. seat offered) yes no

… asks the client about concerns, allows client to explain his/her health issue. yes no

… has the patient medical record yes no

… uses the patient card for anamnesis yes no

For which illness is the patient seen? arterial hypertension

diabetes

referral

other

Assessment of an adult diabetes mellitus patient - Does the medical doctor follow the clinical assessment procedures, investigations and treatment guidelines?

Asks questions on the illness about yes no … any specific health complaints yes no

... general weakness yes no

... urine discharge yes no

… vulvovaginitis or pruritus yes no

… appetite yes no

... eye-sight yes no

… visit to opthalmalogist yes no

... alcohol yes no

54 Quality of Care Study 2018

Adherence of medical doctor to principles of clinical history and ... smoking yes physical examination no ... using other medicine yes The medical doctor yes no no

… greets the client. yes … sedentary way of life Yes no no

… sees the client in privacy/confidentiality. yes … adherence with diabetes treatment yes no no

… makes the client comfortable (e.g. seat offered) yes Conducts examination… yes no no not applicable … asks the client about concerns, allows client to explain his/her health issue. yes … checks blood pressure yes no no … has the patient medical record yes no … weight measurement / calculation of body-mass index yes no … uses the patient card for anamnesis yes no … of skin, mucus membranes, nodes of lymph, ears, nose, thyroid glands yes no For which illness is the patient seen? arterial hypertension ... of eyes yes no diabetes ... of chest, auscultation of lungs yes referral no other … auscultation of heart yes no Assessment of an adult diabetes mellitus patient - Does the medical doctor follow the clinical assessment procedures, investigations and ... of abdomen, palpation of liver and signs of percussion yes treatment guidelines? no

Asks questions on the illness about yes ... perfusion of legs (veines and feeling of legs) yes no no … any specific health complaints yes no … and gives clear explanations to the client concerning the purpose of tests yes and procedures. no ... general weakness yes no Advices, explains, instructs yes no ... urine discharge yes no … results of examinations yes no … vulvovaginitis or pruritus yes no ... the situation and diagnosis yes no … appetite yes no ... the prognosis yes no ... eye-sight yes no … about needed examinations yes no … visit to opthalmalogist yes no … nutrition, i.e. food intake and weight decrease yes no ... alcohol yes no … on the prevention and treatment of hypoglycemia and other acute and yes chronic complications of diabetes no

55 Primary Health Care in Kosovo

… on selfmonitoring - glycemia control and prevention of hypoglycaemia yes no

… about alcohol yes no

… about smoking yes no

… about physical exercise yes no

... right ways of care of legs yes no

… potential complication of the illness yesno

… potential risks if illness is not treated yes no

… importance of adherence to treatment yes no

... about follow-up visit yes no

Advices, explains, instructs yes no not applicable

… about the referral yes no not applicable

… on prescribed medicines/treatment yes no not applicable

Assessment of an adult patient with arterial hypertension - Does the medical doctor follow the assessment procedures, investigations and treatment guidelines?

Asks questions on the illness about yes no

… any specific health complaints yes no

… headache yes no

… the use of medicine other than for hypertension yes no

... the use of contraceptives yes no

... eye-sight yes no

… visit to opthalmalogist yes no

56 Quality of Care Study 2018

… on selfmonitoring - glycemia control and prevention of hypoglycaemia yes ... alcohol yes no no

… about alcohol yes ... smoking yes no no

… about smoking yes … sedentary way of life yes no no

… about physical exercise yes Asks questions on the illness about yes no no not applicable ... right ways of care of legs yes no … high blood pressure yes no … potential complication of the illness yesno not applicable … adherence with hypertension treatment yes no … potential risks if illness is not treated yes not applicable no Conducts examination… yes … importance of adherence to treatment yes no no … checks blood pressure yes ... about follow-up visit yes no no … weight measurement / calculation of body-mass index yes Advices, explains, instructs yes no no not applicable … of skin, mucus membranes, nodes of lymph, ears, nose, thyroid glands yes no … about the referral yes no not applicable ... of eyes yes no … on prescribed medicines/treatment yes no ... of chest, auscultation of lungs yes not applicable no

Assessment of an adult patient with arterial hypertension - Does the … auscultation of heart yes medical doctor follow the assessment procedures, investigations and no treatment guidelines? ... of abdomen, palpation of liver and signs of percussion, palpation of kidneys yes no Asks questions on the illness about yes no ... perfusion of legs (pulse and perfusion of legs) yes no … any specific health complaints yes no … and gives clear explanations to the client concerning the purpose of tests yes and procedures. no … headache yes no Advices, explains, instructs yes no … the use of medicine other than for hypertension yes no … results of examinations yes no ... the use of contraceptives yes no ... the situation and diagnosis yes no ... eye-sight yes no ... the prognosis yes no … visit to opthalmalogist yes no

57 Primary Health Care in Kosovo

… about needed examinations yes no

… about signs of extreme hypertension yes no

… about what to do when signs of extreme hypertension occur yes no

… nutrition, i.e. food intake yes no

… about alcohol yes no

… about smoking yes no

… about physical exercise yes no

… about oral contraceptives yes no

… potential complication of the illness yes no

… potential risks if illness is not treated yes no

… importance of adherence to treatment yes no

... about follow-up visit yes no

Advices, explains, instructs Yes no not applicable

… about the referral yes no not applicable

… on prescribed medicines/treatment yes no not applicable

Assessment of a patient with other condition than diabetes or arterial hypertension.

Asks questions on the illness about yes no

… takes patient history (general history, specific to disease) yes no

… asks open ended questions during history taking yes no

… asks about any prescriptions the client is currently taking. yes no

… listens to the client and responds to client questions. yes no

58 Quality of Care Study 2018

… about needed examinations yes Conducts examination… yes no no not applicable … about signs of extreme hypertension yes … performs medical examinations and other investigations as individually yes no required. no not applicable … about what to do when signs of extreme hypertension occur yes no … gives clear explanations to the patient concerning the purpose of medical yes examinations and other investigations. no … nutrition, i.e. food intake yes not applicable no Advices, explains, instructs yes … about alcohol yes no no … results of examinations yes … about smoking yes no no ... the situation and diagnosis yes … about physical exercise yes no no ... the prognosis yes … about oral contraceptives yes no no … about needed examinations yes … potential complication of the illness yes no no … about follow-up visit yes … potential risks if illness is not treated yes no no Advices, explains, instructs yes … importance of adherence to treatment yes no no not applicable

... about follow-up visit yes … about the referral yes no no not applicable Advices, explains, instructs Yes no … on prescribed medicines/treatment yes not applicable no not applicable … about the referral yes no … on risks factors/health education yes not applicable no not applicable … on prescribed medicines/treatment yes no Did the medical doctor apply infection prevention and control not applicable measures? Assessment of a patient with other condition than diabetes or arterial hypertension. The doctor... Asks questions on the illness about yes no … washed hands before the procedure (including use of soap). yes … takes patient history (general history, specific to disease) yes no no not applicable … asks open ended questions during history taking yes no … washed hands after the procedure (including use of soap). yes no not applicable … asks about any prescriptions the client is currently taking. yes no … applied proper decontamination procedures (e.g. soaking contaminated yes instruments into a bucket with chlorine or any other disinfectant) no … listens to the client and responds to client questions. yes not applicable no

59 Primary Health Care in Kosovo

… put on gloves where required. yes no not applicable

… put on a mask where required. yes no not applicable

… closed the consultation politely. yes no not applicable

Does the doctor document the consultation in the patient card? yes no

Thank you very much for the interview.

Interviewer comments

End time of interview

60 Quality of Care Study 2018

… put on gloves where required. yes no not applicable Quality of Care Assessment - Exit Interview Answers

… put on a mask where required. yes Interviewer_ID no not applicable IMEI (International Mobile Equipment Identity) Date of interview … closed the consultation politely. yes Start time of interview no Name of municipality not applicable Name of facility Does the doctor document the consultation in the patient card? yes Good morning! My name is [NAME]. We are here on behalf of the Accessible Quality Healthcare Project funded by the Swiss no Development Cooperation to conduct a survey of health facilities in our project area. The objective of this study is to assess the quality of health care services provided in health facilities. The Ministry of Health and the ethical review board has approved this Thank you very much for the interview. study.

We would like to interview people who have today consulted the medical doctor for their own health issues or for a child. Interviewer comments Your experiences are very important to improve aspects related to quality of care. Information collected from this interview/questionnaire will be used by Accessible Quality Healthcare Project. Summaries of findings might also be shared with End time of interview regional or national authorities.

The information collected from you will be kept confidential within the research team. Instead of using your name, we will give a non-personal identification number which cannot be traced individually. You are free to decide whether or not you participate in this study. If you decide not to do it, there will be no negative effect. However, we hope you will answer the questions, which will benefit the people of Kosovo.

yes Do I have your consent to proceed? no

Have you been here today for issues related to your own health or the one of a child (child yes must be with the person)? no Socio-demographic information female Patients' gender male Year of birth yes Mother/father/caretaker older 18 with child (child is patient) no Satisfaction with health service very unsatisfied unsatisfied Overall: How satisfied were you with the services you received today? satisfied very satisfied Received services did not access this HC in the past 3 months Excluding today: How often did you over the past 3 month access this HC? 1-3 times more than 3 times chronic condition antenatal care What was the reason for your consultation today? child health immunisation other conduct an examination

write you a prescription

Did the medical doctor… Other

61 Primary Health Care in Kosovo

Aspects of todays consultation At the beginning of the consultation, were you given the opportunity to explain your health yes problem? no yes During your visit today, did the medical doctor ensure your privacy? no Did the medical doctor explain the questioning and physical examinations and your health yes problem? no yes Did the medical doctor clearly explain the intake of prescribed medicines to you? no yes Did the medical doctor ask if you are currently taking any (other) prescriptions? no

During consultation were you given a chance to ask questions about the investigations and yes your health problem and treatment? no

Did the medical doctor listen carefully to your concerns and questions and did he/she give yes satisfactory answers? no yes During consultation, did you get any advice on your health problem? no yes Was the medical doctor polite in general during consultation? no

We would now also like to ask you a few questions on your knowledge and opinion on health. yes Are you willing to continue the interview with me for some more questions? no

Knowledge, Attitude and Practice cough difficult or fast breathing fever chest in drawing chest pain especially when breathing deeply blue lips and nail beds (cyanosis) seizures In your opinion, what are symptoms that children with Acute Respiratory Infections (ARI) inability to swallow have? inability to drink or breastfeed vomiting after each drinking or breastfeeding irritation dehydration comorbidities/polyorganic deficiency blood streaked sputum don't know other PLEASE SPECIFY air droplets fomites In your opinion, how do people get infected with ARI? dirty hands other don't know PLEASE SPECIFY every day How often do people smoke in the same room where your child is present? several days a week several days a month

62 Quality of Care Study 2018

once a month or less Aspects of todays consultation never At the beginning of the consultation, were you given the opportunity to explain your health yes don't know problem? no strongly agree yes During your visit today, did the medical doctor ensure your privacy? no agree Knowing the symptoms and warning signs of ARI will help to visit the doctor in time. neither agree, nor disagree Did the medical doctor explain the questioning and physical examinations and your health yes problem? no disagree strongly disagree yes Did the medical doctor clearly explain the intake of prescribed medicines to you? no strongly agree agree yes Smoky surroundings (due to tobacco smoking, fires, etc) have no effect on whether a baby Did the medical doctor ask if you are currently taking any (other) prescriptions? neither agree, nor disagree no catches pneumonia. disagree During consultation were you given a chance to ask questions about the investigations and yes strongly disagree your health problem and treatment? no drinking dirty water Did the medical doctor listen carefully to your concerns and questions and did he/she give yes eating contaminated food by satisfactory answers? no unwashed hands after defecation yes What do you think are causes of diarrhea? eating contaminated food During consultation, did you get any advice on your health problem? no food allergies yes other Was the medical doctor polite in general during consultation? no don't know PLEASE SPECIFY We would now also like to ask you a few questions on your knowledge and opinion on health. yes drinking clean water Are you willing to continue the interview with me for some more questions? no protect drinking water from contamination Knowledge, Attitude and Practice washing hands before preparing and How can you prevent diarrhea? eating food cough safe disposal feces by using safe difficult or fast breathing latrine fever other chest in drawing don't know chest pain especially when breathing PLEASE SPECIFY deeply visited doctor/family medicine center blue lips and nail beds (cyanosis) tried applying traditional therapy at seizures home In your opinion, what are symptoms that children with Acute Respiratory Infections (ARI) inability to swallow What did you do when your child last had diarrhea? nothing specific have? inability to drink or breastfeed other vomiting after each drinking or don't know breastfeeding PLEASE SPECIFY irritation yes dehydration Do you give liquids to your child when he or she has diarrhea? no comorbidities/polyorganic deficiency medical prescription blood streaked sputum your own decision don't know How do you get the medication to treat diarrhea? pharmacist recommendation other other PLEASE SPECIFY PLEASE SPECIFY air droplets Any infant formula (baby food) fomites [CERELAC, HIPP, NAN, VINNY, In your opinion, how do people get infected with ARI? dirty hands NESTOGENE] other Any bread, rice, noodles, biscuits, cookies, or any other foods made Child’s food diversity during the last 24 hours: Did you child eat any of the following food don't know from grains? items within the last 24 hours? PLEASE SPECIFY Any dark green, leafy vegetables like every day parsley, spinach, or coriander? Any vegetables/ cucumbers, How often do people smoke in the same room where your child is present? several days a week eggplant, onion, tomato, pumpkins, several days a month carrots, potatoes?

63 Primary Health Care in Kosovo

Any fruits/ apricot, apples, strawberry, bananas? Any meat/ beef, pork, lamb, chicken, fish? Any eggs? Any foods made from beans, peas, or lentils? Any cheese, yogurt or cottage cheese? Any food made with oil, fat, or butter? Any other food? PLEASE SPECIFY strongly agree agree How much do you agree with the following statement: Unsafe water, poor sanitation and neither agree, nor disagree hygiene can cause the diarrhea but not ARI disagree strongly disagree Non-communicable diseases diabetes high blood pressure obesity smoking/tobacco use (Nos) high cholesterol/high blood fat unhealthy diet Which risk factors for cardiovascular disease do you know? physical inactivity family history/genetics age stress other don't know none left-sided chest pain headache Which of the following is a typical symptom of a heart attack? feeling thirsty pain in the legs don't know frequent need to urinate lower back pain Which of the following is not a typical symptom caused by diabetes? tiredness unexplained weight loss don't know strongly agree agree How much do you agree with the following statement: Overweight people are healthier. neither agree, nor disagree disagree strongly disagree strongly agree agree How much do you agree with the following statement: Smoking does not effect the health. neither agree, nor disagree disagree strongly disagree strongly agree How much do you agree with the following statement: Changing my lifestyle today will not agree affect my health later. neither agree, nor disagree

64 Quality of Care Study 2018

Any fruits/ apricot, apples, disagree strawberry, bananas? strongly disagree Any meat/ beef, pork, lamb, chicken, strongly agree fish? agree Any eggs? How much do you agree with the following statement: I cannot influence my health because neither agree, nor disagree Any foods made from beans, peas, it depends on the doctors. or lentils? disagree Any cheese, yogurt or cottage strongly disagree cheese? no, not at the moment Any food made with oil, fat, or butter? I am trying from time to time Any other food? Are you currently taking measures to have a healthy lifestyle? yes, sometimes PLEASE SPECIFY yes frequently strongly agree not motivated agree How much do you agree with the following statement: Unsafe water, poor sanitation and rather not motivated neither agree, nor disagree How motivated are you to change your lifestlye? hygiene can cause the diarrhea but not ARI rather motivated disagree motivated strongly disagree do more physical exercise Non-communicable diseases lose weight diabetes eat less fat high blood pressure eat less sugar obesity What have you already changed in your life to decrease your risk of getting cardiovascular eat more fruits and vegetables smoking/tobacco use (Nos) disease? (do not read responses) stop smoking /stop using Nos high cholesterol/high blood fat control my diabetes more actively (if unhealthy diet applicable) Which risk factors for cardiovascular disease do you know? physical inactivity control my high blood pressure more actively (if applicable) family history/genetics I have never tried age Now a few last questions…. stress Basic information other yes don't know Did you pay today for your health consultation? no none benefitting from any economic or left-sided chest pain social aid scheme headache If no, why not? health insurance Which of the following is a typical symptom of a heart attack? feeling thirsty other pain in the legs Please, SPECIFY don't know yes Did you get a receipt for your payment? frequent need to urinate no lower back pain yes Are you benefitting from any economic or social aid scheme? Which of the following is not a typical symptom caused by diabetes? tiredness no unexplained weight loss don't know This following questions concern the person who answered strongly agree never attended school agree completed lower primary school How much do you agree with the following statement: Overweight people are healthier. neither agree, nor disagree (max 5 years) disagree What school level did you complete? completed primary school (9 years) strongly disagree completed high school (12 years) strongly agree completed college/university agree other How much do you agree with the following statement: Smoking does not effect the health. neither agree, nor disagree PLEASE SPECIFY disagree farmer strongly disagree employed What is your current occupation? strongly agree self-employed business How much do you agree with the following statement: Changing my lifestyle today will not agree affect my health later. housewife neither agree, nor disagree

65 Primary Health Care in Kosovo

governmental employee, teacher, administrative / professional, unemployed pensioner Other PLEASE SPECIFY Thank you very much for the interview. Interviewer comments End time of interview

66 Quality of Care Study 2018 governmental employee, teacher, administrative / professional, unemployed pensioner Other PLEASE SPECIFY Thank you very much for the interview. Interviewer comments End time of interview

67 Primary Health Care in Kosovo