DATA COLLECTION SURVEY ON HEALTH SECTOR IN KOSOVO AND ALBANIA FINAL REPORT July, 2014 JAPAN INTERNATIONAL COOPERATION AGENCY FUJITA PLANNING CO., LTD. 7R CR(3) 14−014 SUMMARY 1. The Republic of Kosovo 1.1. Background and Outline of the Study The Japanese government has supported for strengthening Kosovo’s emergency medical services through human resource development by conducting trainings in Japan and providing ambulances through a grassroots’ grant scheme for the purpose of improving the governmental administrative capacity, which is a priority area of assistance of the Japanese government for Kosovo. In addition, the introduction of “Japanese-Style” ODA assistance which has been currently promoted by Government of Japan (GOJ) in terms of health system is also expected to be addressed based on the strategy diplomacy in Japan. In order to develop more effective and efficient supports in the future, it will be useful for Japan to update the comprehensive and latest information of the health sector in Kosovo. The field survey was conducted from April 1st to 17th, 2014 at the capital Pristina, Mitrovice, Prizren, Peje (Gjakove) in Kosovo. In the field study, past achievements of projects in which Kosovo Ministry of Health was involved, the future needs and plans, and a support trend of international donor countries were also investigated, in addition to the basic information of the health sector of Kosovo. A Study Team had also exchanged opinions with stakeholders of the Ministry of Health about Japanese interest fields of assistance and its adaptation schemes. 1.2. Country overview and the Health Sector in Kosovo Kosovo is a country of 10,887 sq. km area, and located almost at the center of the Balkan peninsula with 1.8 million inhabitants. Kosovo declared its independence from Serbia in February 2008, and has continued its stable economic growth since then. However, its gross national income (GNI) per capita is USD 3, 890 in 2013 (World Bank), meaning that it is one of the poorest countries in Balkan region. In the “Program of the Government of Kosovo 2011-2014”, four major development agendas are listed: (1. Sustained economic growth, 2. Improvement of governance and rule of law, 3. Human resources development, 4. Social welfare being currently underway. In the health sector, with the aim to provide high quality medical services to the general public by the health sector reform, the development of medical-related laws and regulations, and the policy with an emphasis on the improvement and expansion of health facilities from the primary to tertiary levels, have been promoted under “Health Sector Strategy 2010-2014”. i Up to now, since the declaration of independence, although there is the momentum that many related laws and regulations are discussed and certified by the National Assembly in the health sector, the sufficient capital investments and development have not been done for securing of healthcare resources, securing and training of medical personnel, updating of medical equipment and medical infrastructure, and appropriate procurement and distribution of drugs. In order to solve these issues, Kosovo Ministry of Health has been promoting wide ranging health sector reform , by strengthening the governance, increasing financial resources by introducing the medical insurance system, strengthening of drug management system, and introducing medical information management system (HMIS), with supports of donor countries and organizations. In addition, the government has been promoting expansion of the function of University Clinical Center of Kosovo (hereinafter referred to as "UCCK") as a development project of secondary and tertiary medical care facilities. Trends of donor assistance in the health sector is as follows; with regard to the development of the health insurance system and laws and health care regulations, which forms the basis of health sector reform in Kosovo, strengthening of governance and the legislation development have been implemented with the support of technical assistance by the Luxembourg government and a soft loan from the World Bank (Approximately USD 25 million, subject to authorization of the Kosovo Parliament and the World Bank, five-year planned from the end of 2014.). For the development of secondary and tertiary medical care facilities and equipment, the maintenance of equipment associated with construction of a cardiac surgery still under negotiation in UCCK, and construction of the Emergency Medical Care Center and its equipment maintenance are to be supported by soft loans of the Austria government (4.6 one million euros) and the Islamic Development Bank (about 30 million). ii 1.3. Challenges and Suggestion for Project Formulation on the Health Sector in Kosovo 1.3.1 Challenges on the Health Sector in Kosovo 1) Changes in the Disease Structure Disease of the circulatory system was almost two thirds of the cause of death in Kosovo. Lifestyle diseases, including cancer and stroke, and heart disease are on the rise nowadays. Furthermore, the external causes to a seventh leading cause of death of men include suicide and traffic accidents, and it has been increasing sharply 4 times from 2006 to 2011. Thus, it is required high medical care service for disease which can worsen rapidly, advanced medical technologies for early diagnosis and treatment, and introduction of campaign and public relations activities to disseminate preventive measures to encourage the transformation of diet and lifestyle. 2) Patient Concentralization at the Tertiary Health Care Facility (UCCK) Patients tend to concentrate at UCCK, the only tertiary health care facility in the country. Such phenomenon occurs based on the patients’ notion that more advanced facilities and equipment as well as higher competent doctors are available at UCCK. As a result, the patients believe that they will be able to receive higher level of treatment, and prefer to visit the tertiary health care facility from the first contact (without knowing the actual necessity of having advanced treatments). Challenges involved centralization of patients into tertiary health care facility is as follows: i) Vulnerability of Function of Secondary Health Facilities It is necessary to develop infrastructures and equipment of secondary health care facilities (10 regional hospitals) which are located throughout the country. Lifestyle-related diseases, such as tumor, cerebrovascular and heart disease, and severe trauma due to traffic accidents have been increasing recently and both require early diagnosis and treatment. Therefore, the development of medical facilities and equipment, strengthening of the transport system of patients, and capacity building of medical personnel who are working at the secondary health care facilities are all necessary for patients to receive proper treatments at the level of secondary health care facilities, without visiting a tertiary health care facility. ii) Vulnerability of Function of Primary Health Facilities and Lack of Prevention Activities In order to expand the activities to reduce the mortality and morbidity of the lifestyle-related diseases, such as a tumor or cardiovascular disease, which are accounts for significant mortality factors, the functions of Main Family Medicine Center (MFMC) and Family Health Centers (FMC) also need to be improved. Upgrading of existing aging equipment in primary health care facilities is required in combination with the introduction of campaigns and activities of public iii relations to disseminate preventive measures to encourage the transformation of diet and lifestyle, and the capacity building of health care workers responsible for the public health of local residents. The “Health Sector Strategy 2010-2014”, its aim is at upgrading nearly half of existing medical facilities within the year of 2014, but the progress of this attempt has been delayed. Majority of existing equipment of primary and secondary medical care facilities, which was introduced at the end of the conflict in early 2000, is aging and need to be updated now. iii) Aging Medical Equipment and inadequate Medical Equipment for Advanced Medical Care in Tertiary Health Care Facilities In the UCCK, responsible for tertiary health services, there are several developments which cannot provide required medical services due to the lack of adequate medical equipment, although health care workers with sufficient competency are working there. Particularly, at the pediatric surgery department, the orthopedic surgery department, gastroenterology department (endoscope), and the medical services department using diagnostic imaging tests, activities of equipment maintenance are insufficient. Therefore, although the number is slight low, some patients who are in need of further medical services have been transferred to private hospitals or neighboring countries, including Macedonia. 1.3.2 Suggestion for Future Assistances on Health Sector in Kosovo 1) Upgrading and Renewal of Medical Equipment Although the developments of facility infrastructure for UCCK, , and for some regional hospitals, have been conducted as high-priority projects, equipment of the majority ofregional hospitals and MFMCs have remained intact. According to the results of sampling survey of regional hospitals and MFMCs, and interviews with the Ministry of Health, it was identified that the highest priority is to upgrade existing aging equipment in the secondary health care facilities, followed by primary medical facilities. Although the priority would be lower