Public health in Kosovo: five difficult years after independence Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 1 REVIEW ARTICLE Public health in Kosovo after five difficult years of independence Naim Jerliu1,2, Naser Ramadani2, Iris Mone3, Helmut Brand1 1 Department of International Health, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands; 2 National Institute of Public Health, Prishtina, Kosovo; 3 Faculty of Medicine, Tirana Medical University, Tirana, Albania. Corresponding author: Naim Jerliu, MD, MPH National Institute of Public Health, Prishtina, Kosovo; Telephone: +38138550585; E-mail: naim.jerliu@maastrichtuniversity.nl Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 2 Abstract Kosovo is undergoing a rapid process of transformation to an independent state, which was formally proclaimed in 2008, after almost a decade under United Nations administration. Regarding the health status, five years after independence, compared with other European countries, post-war transitional Kosovo is still characterized by higher mortality rates including traditional public health problems pertinent to infant mortality and maternal deaths. In parallel, however, Kosovo is undergoing a rapid process of epidemiological transition characterized by an aging trend which is inevitably coupled with high cardiovascular and cancer mortality and morbidity along with an excess mortality in external causes of death and injuries among the adult population. Adoption of the new Health Law in December 2012 by the Kosovo Assembly aims the transition from centralized health care system established under emergency conditions of the post-war period towards a contemporary modern health care system with a clear purchaser-provider split based on a high transparency and accountability of the health care providers and their contractors. The health care reform, leading eventually to significant changes within the health sector in Kosovo, consists of two main pillars: (i) structural and functional reorganization of the health care system through establishment of Kosovo Health Service (an autonomous and non-for-profit public enterprise at central level of the health care sector), and; (ii) establishment for the first time of the public health insurance system with a Health Insurance Fund as its main body. Nevertheless, five years after declaration of independence, Kosovo, the newest state in Europe consisting of the youngest population, is currently facing a particularly difficult socioeconomic and political transition and is additionally struggling and mainstreaming all energies and efforts in order to get full international recognition. Keywords: independence, Kosovo, public health, transitional countries, Western Balkans. Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 3 Introduction After the war and the liberation from the Serbian regime in 1999 and almost a decade under United Nations administration, Kosovo is undergoing a rapid process of transformation to an independent state, which was formally proclaimed in 2008. Kosovo, currently recognized by 105 countries (but not yet a member of the World Health Organization), is the newest country in Europe. Notwithstanding the fact that Kosovo is not an European Union (EU) member state, this new country is nevertheless at a very early stage on its way to EU integration and has to cope already with the EU standards and policy reforms in both social and health care sectors. Demographic and socioeconomic indicators Kosovo consists of the youngest European population, with an average age of about 27 years (50% of the population is under 25 years) (Table 1). Notwithstanding its young population, Kosovo is inevitably affected by the global aging trend characterized by a substantial reduction of population increase from 27% in 1981 to 9% in 2007 (1). This is reflected in a steady increase in the proportion of older people over the years. Thus, official data indicate that from 2003 to 2009 the proportion of people aged ≤15 years decreased by five percent (from 33% to 28%), along with an increase (albeit less evident) in the proportion of individuals aged ≥65 years from 4.5 % (in 1981) to 6.7% (in 2011) (Table 1). The ageing trend could be attributed to the lowering levels of fertility rates, a higher life-expectancy and emigration of working- age adults (2). According to a recent World Bank report, Kosovo is among the poorest countries in Europe, with 34% of the population living below the national poverty line and 12% living in extreme poverty (3). Furthermore, poverty in Kosovo may be of particular concern for the older segments of the population as suggested from a recent report of the International Labour Organization (1). As a matter of fact, a fairly recent population-based study involving a large sample of older people (individuals aged ≥65 years), reported a high level of self-perceived poverty, especially among older women (52% vs. 41% in men) (4). Another remarkable finding from this population- based study of older men and women in Kosovo was the low educational attainment, especially among women (4). Thus, about 48% of the women had no formal education at all compared to 17% of men (4). In addition, in multivariable-adjusted analyses controlling simultaneously for all the demographic and socioeconomic characteristics, self-perceived poverty rates were higher among older women, the low- educated individuals, urban residents, and older people living alone (4). Health profile Life expectancy in Kosovo was 67 years for males and 71 years for females in 2008 (2), whereas in 2011 the overall life expectancy was 70.0 years (Table 1). Currently, life expectancy in post-war Kosovo is considerably lower than in the EU member states for both males and females (Figure 1) (5). Notwithstanding the higher infant mortality rate (17.1 per 100 live births in 2011 – Table 1), the higher child mortality rate, as well as the higher maternal mortality rate (7.2 per 100.000 in 2011 – Table 1), the excess mortality in Kosovo is also due to the higher death rates from injuries and other external causes of death and, to a lesser Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 4 degree, from cardiovascular diseases and cancer (Table 1). On the other hand, stroke mortality constitutes an exception: notwithstanding the absence of official reports, death rate from stroke in Kosovo is considerably higher than in the EU member states – a situation which is similar to many countries in the Western Balkans. Table 1. Selected socioeconomic and health indicators in Kosovo Indicator Year Estimate Source Life expectancy at birth 2011 70.0 years Kosovo Human Development Report 2012. Average age of the population 2012 27.1 years CIA, World Fact-book. Population aged ≥65 years 2011 6.7% Kosovo Population and Housing Census 2011. Percentage of urban population 2011 38.0% Kosovo Population and Housing Census 2011. GDP per capita 2012 2650 Euro Agency of Statistics, Kosovo, 2012. Human Development Index 2011 0.713 Kosovo Human Development Report 2012. Percentage of poor 2009 34.0% World Bank, 2011. Percentage of extremely poor 2009 12.0% World Bank, 2011. Illiteracy rate (population aged ≥10 years) 2011 3.85% Kosovo Population and Housing Census 2011. Infant mortality rate (per 1000 live births) 2011 17.1 Ministry of Health, Kosovo, 2012. Maternal mortality rate (per 100.000) 2011 7.2 Ministry of Health, Kosovo, 2012. CVD mortality rate (per 100.000 population) 2011 157.0 Agency of Statistics, Kosovo, 2012. Cancer mortality rate (per 100.000 population) 2011 34.2 Agency of Statistics, Kosovo, 2012. Infectious diseases mortality rate (per 100.000 population) 2011 1.36 Agency of Statistics, Kosovo, 2012. External causes of death (per 100.000 population) 2011 7.7 Agency of Statistics, Kosovo, 2012. Proportional mortality from CVD 2011 59.3% Agency of Statistics, Kosovo, 2012. Proportional mortality from cancer 2011 15.0% Agency of Statistics, Kosovo, 2012. Proportional mortality from infectious diseases 2011 0.55% Agency of Statistics, Kosovo, 2012. No. physicians per 100.000 population 2011 146 Institute of Public Health, Kosovo, 2011. No. nurses per 100.000 population 2011 412 Institute of Public Health, Kosovo, 2011. No. health visits per person per year 2010 2.8 World Bank, 2010. Public spending on health (in % of GDP) 2009 2.3 Ministry of Health, Kosovo, 2010. Public spending on health (in % of total government expenditure) 2009 7.6 Ministry of Health, Kosovo, 2010. Percentage of smokers in the population 15- 64 years 2011 28.4 % NIPH Survey, Kosovo, 2011. Alcohol consumption 2011 25.0% ESPAD, Kosovo, 2011. As of a recent study involving a population-representative sample of older individuals in Kosovo (N=1890), 83% of the elderly people reported at least one chronic condition (63% cardiovascular diseases), and 45% had at least two chronic diseases (6). In multivariable-adjusted analyses, factors associated with the presence of chronic conditions and/or multimorbidity were female sex, older age, self-perceived poverty and the inability to access medical care (6). Hence, limited access to medical care was a significant and consistent predictor of chronic morbidity and chronic multimorbidity among older people in Kosovo (6). The overwhelming majority of Kosovo older Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 5 individuals who couldn’t access medical care (almost 90%) indicated the economic barriers as the main reason for this. The unfavorable health outcomes in the adult population including older people is noticeably a reflection of the difficult socioeconomic situation in Kosovo vis-à-vis the ongoing reforms in the health sector (7). Figure 1. Life expectancy in Kosovo vis-à-vis the European Union in 2011 and in 2007 (just before the independence) Lifestyle factors In Kosovo, age and lifestyle related non-communicable diseases are increasing, especially cancer, cardiovascular diseases and diabetes (6) – diseases which are commonly related to a high consumption of tobacco, alcohol, and saturated fat. The prevalence of smoking in Kosovo (overall: 28.4%, Table 1) is lower than in the other countries of the Western Balkans including the neighboring Albania (8). Similarly, excessive alcohol consumption and binge drinking are considerably lower than in Albania, reflecting a higher degree of traditionalism and religious observance in Kosovo. On the other hand, unhealthy dietary habits including low intake of fresh fruits and vegetables are considered to be more prevalent in the Kosovo population compared with the somehow Mediterranean diet of Albania. Along with the unhealthy dietary patterns and the low levels of physical activity, unfavorable socioeconomic and psychosocial conditions are considered as the main drivers of the excess morbidity and mortality from chronic diseases in Kosovo including diabetes, cardiovascular diseases and other chronic conditions. Nevertheless, in Kosovo, which is characterized by a traditional society, changes in lifestyle/behavioral patterns may have differentially affected different segments of the population, particularly the vulnerable and the marginalized individuals who suffer enormously the consequences of the rapid transition and are unable to cope with the dramatic changes (4,9). Health care reforms Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 6 The analysis provided in the Health Sector Strategy (HSS) of the Ministry of Health indicates that the Republic of Kosovo has a network of health institutions staffed with committed health professionals, who provide regional comparable basic health care services including also a high immunization coverage. The HSS, but also more recent analyses, highlights that Kosovo, as one of the poorest countries in Europe, needs to tackle a number of fundamental challenges before the health sector becomes a comprehensive system of preventive, diagnostic and treatment services attuned to the needs of the population and supporting the citizens in obtaining a health status comparable to the EU populations (10). With the youngest population in Europe, Kosovo’s health care system needs to respond to a high demand for reproductive health and family planning services. Although infant mortality has fallen since 2000, the current level is high and places Kosovo at the very bottom compared to the EU member states. Furthermore, the existing high rate of maternal deaths points to the need and the requirements for establishing a system of services able to support all women (and men) with family planning, quality antenatal care and to ensure that hospitals, both at secondary and tertiary level, are prepared to assist in the case of complications (10). Therefore, the current action plan of the Ministry of Health gives special attention to improving mother and child health to a European Union comparable level, and hereby to achieve the Millennium Development Goals (10). In Kosovo, basic diagnostics and treatment services are currently provided by the public health care system and yet, comprehensive tertiary care services such as oncology and cardio-surgery are not fully available. Therefore, the action plan of the Ministry of Health focuses on improving these services. Further, the action plan addresses the development of preventive measures with a significant impact on the incidence and the survival rates of these diseases (10). Conversely, Kosovo is in urgent need of deep reforms as the armed conflict left the country with a very inefficient health system characterized by a lack of trained personnel, disparities in health force distribution leading to variations in access to primary care, corruption and informal payments, as well as deteriorated child and adult health indicators. In this context, the continuous reforming of the health sector has brought up a complex configuration of the stakeholders operating in the health system. Under these conditions, little attention is paid to the growing community of vulnerable and marginalized individuals in Kosovo which, combined with the inadequacy of financial resources, the economic insecurity and the unclear and unstable development of the health sector, pose a serious barrier for these population subgroups to access medical care (4,6). The inability of certain disadvantaged segments of the population to adapt to the new political and economic system inevitably leads to change in the position of individuals in the society, enhanced social mobility and increased inequalities, with some groups thriving and others falling behind, as it was previously demonstrated in the adult population of the neighboring Albania (9). Health care financing Adoption of the new Health Law in December 2012 by the Kosovo Assembly aims the transition from a centralized health care system established under emergency conditions of the post-war period towards a contemporary modern health care system Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 7 with a clear purchaser-provider split based on a high transparency and accountability of the health care providers and their contractors. The main objective is a steady improvement of the quality of healthcare of the population in Kosovo. This reform, leading eventually to significant changes within the health sector in Kosovo, consists of two main pillars: (i) structural and functional reorganization of the health care system through establishment of Kosovo Health Service (an autonomous and non-for-profit public enterprise at central level of the health care sector), and; (ii) establishment of the public health insurance system with the Health Insurance Fund as its main body. In any case, the basic principles of the current health care reform in Kosovo include the following principles: universal coverage, equity, transparency, sustainability, equity, accountability, inclusiveness, solidarity, reciprocity and participation. Structural and functional reorganization of the overall health care system represents a rather challenging and complex process that includes a simultaneous process of purchaser-provider split through internal reorganization of the system. As a first step, the Ministry of Health is planning to establish the Health Financing Agency (which, by law, represents the precursor of the Health Insurance Fund) and further establishment of a contemporary system of service delivery. This step, in turn, foresees the establishment and proper functioning of the University Clinical and Hospital Service of Kosovo as a unique and integrated healthcare institution at the secondary and tertiary level, closely coordinated with healthcare institutions in the primary healthcare level through a system of performance-based payments from the Health Financing Agency. In any case, the main step of the reform will consist of adoption of the already elaborated draft on Health Insurance Law in the Government of Kosovo and establishment for the first time of the public health insurance system with the Health Insurance Fund as its main body. The main objective of the Health Insurance Law is to ensure optimal and sustainable healthcare financing. Conclusion Kosovo is undergoing a rapid transition involving major political, social and economic changes which are associated with deleterious health effects in the adult population, particularly among older people. Nonetheless, current evidence about the exact magnitude of both acute and chronic morbidity and distribution of risk factors in the population of Kosovo is scarce due to limited vigorous research work aiming at exploring the health effects of transition and the variations in health outcomes of the adult population. From this point of view, similar to the other countries in the Western Balkans region, there is an obvious need to promote research funding and especially to develop and strengthen research capacities in Kosovo. In conclusion, five years after the Declaration of Independence, Kosovo is currently facing a particularly difficult socioeconomic and political transition and is additionally struggling and mainstreaming all energies and efforts in order to get full international recognition. References 1. International Labour Organization. Profile of the social security system in Kosovo (within the meaning of UNSC Resolution 1244 [1999]). 2010. Jerliu N, Ramadani N, Mone I, Brand H. Public health in Kosovo after five difficult years of independence (Review article). SEEJPH 2013, posted: 31 October 2013. DOI 10.12908/SEEJPH- 2013-02. 8 Available from: http://www.ilo.org/wcmsp5/groups/public/---europe/---ro- geneva/---sro-budapest/documents/publication/wcms_168770.pdf (accessed: October 05, 2013). 2. Statistical Office of Kosovo. Demographic, Social and Reproductive Health Survey in Kosovo, November 2009. Pristina, Kosovo; 2011. 3. The World Bank. Europe and Central Asia Region. Poverty Reduction and Economic Management Unit. Statistical Office of Kosovo. Consumption Poverty in the Republic of Kosovo, in 2009. Western Balkans Programmatic Poverty Assessment. 2011. 4. Jerliu N, Toçi E, Burazeri G, Ramadani N, Brand H. Socioeconomic conditions of elderly people in Kosovo: a cross-sectional study. BMC Public Health 2012;12:512. 5. World Health Organization, Regional Office for Europe. European health for all database. Copenhagen, Denmark, 2013. 6. Jerliu N, Toçi E, Burazeri G, Ramadani N, Brand H. Prevalence and socioeconomic correlates of chronic morbidity among elderly people in Kosovo: a population-based survey. BMC Geriatr 2013;13:22. 7. Percival V, Sondorp E. A case study of health sector reform in Kosovo. Conflict and Health 2010;4:7. 8. Institute of Statistics, Institute of Public Health [Albania] and IFC Macro. Albania Demographic and Health Survey 2008-09. Tirana, Albania, 2010. 9. Burazeri G, Goda A, Sulo G, Stefa J, Roshi E, Kark JD. Conventional risk factors and acute coronary syndrome during a period of socioeconomic transition: population-based case-control study in Tirana, Albania. Croat Med J 2007;48:225-33. 10. Ministry of Health, Kosovo. Action plan 2011-2014. Pristina, Kosovo, 2011. ___________________________________________________________ © 2013 Jerliu et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=Jerliu%20N%5BAuthor%5D&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=To%C3%A7i%20E%5BAuthor%5D&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=Burazeri%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=Ramadani%20N%5BAuthor%5D&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=Brand%20H%5BAuthor%5D&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed/22776197 http://www.ncbi.nlm.nih.gov/pubmed/22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=Jerliu%20N%5BAuthor%5D&cauthor=true&cauthor_uid=23452830 http://www.ncbi.nlm.nih.gov/pubmed?term=To%C3%A7i%20E%5BAuthor%5D&cauthor=true&cauthor_uid=23452830 http://www.ncbi.nlm.nih.gov/pubmed?term=Burazeri%20G%5BAuthor%5D&cauthor=true&cauthor_uid=23452830 http://www.ncbi.nlm.nih.gov/pubmed?term=Ramadani%20N%5BAuthor%5D&cauthor=true&cauthor_uid=23452830 http://www.ncbi.nlm.nih.gov/pubmed?term=Brand%20H%5BAuthor%5D&cauthor=true&cauthor_uid=23452830 http://www.ncbi.nlm.nih.gov/pubmed/23452830 http://www.ncbi.nlm.nih.gov/pubmed?term=Burazeri%20G%5BAuthor%5D&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=Goda%20A%5BAuthor%5D&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=Sulo%20G%5BAuthor%5D&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=Stefa%20J%5BAuthor%5D&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=Roshi%20E%5BAuthor%5D&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=Kark%20JD%5BAuthor%5D&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed/17436387 http://www.ncbi.nlm.nih.gov/pubmed/17436387