Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 1 ORIGINAL RESEARCH Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania Herion Muja1,2, Genc Burazeri1,2, Peter Schröder-Bäck1, Helmut Brand1 1Department of International Health, School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands; 2 Institute of Public Health, Tirana, Albania. Corresponding author: Herion Muja, MD; Address: Rr. “Aleksander Moisiu”, No. 88, Tirana, Albania; Telephone: +355672315056; Email: herionmuja@gmail.com http://doi.org/10.4119/UNIBI/SEEJPH-2017-143 Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 2 Abstract To inform policymakers well, there is a need to promote different types of health examination surveys as additional sources of valuable information which, otherwise, would not be available through routine/administrative statistics. This is especially important for former communist countries of South Eastern Europe including Albania, where the existing health information system (HIS) is weak. Among many efforts to strengthen the HIS in Albania, there is currently a commitment to undertake a second round of a nationwide Demographic and Health Survey (DHS). This survey will involve a nationwide representative sample of about 17,000 private households, where all women aged 15-59 years and their respective partners will be interviewed and examined. Externally, the upcoming Albanian DHS will contribute to the European Union accession requirements regarding provision of standardized and valid health information. Furthermore, the DHS will considerably enhance the core functions of the Albanian health system in line with the WHO recommendations. Internally, the DHS will promote societal participation and responsibility in transitional Albania. Importantly, the forthcoming survey will promote good governance including transparency, accountability and health system responsiveness. Also, the DHS will allow for collection of internationally valid and standardized baseline socio- demographic and health information for: assessment of future national trends; monitoring and evaluation of health programs and interventions; evidencing health disparities and inequities; and cross-national comparisons between Albania and different countries of the European Region. Ultimately, findings of the DHS will enable rational decision-making and evidence- based policy formulation in Albania including appropriate planning, prioritization and sound resource allocation. However, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post-communist countries of South Eastern Europe including Albania. Keywords: Albania, Demographic and Health Survey (DHS), health examination survey, health information system, health interview survey, health system governance. Conflicts of interest: None. http://doi.org/10.4119/UNIBI/SEEJPH-2017-143 Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 3 The need to strengthen health information systems A “health information system” (HIS) is conventionally defined as a system which collects, stores, processes, conducts analysis, disseminates and communicates all the information related to the health status of the population and the activities and performance of health institutions and other health-related organizations (1). From this point of view, a suitable and well-designed HIS incorporates data generated from routine information systems, disease surveillance systems, but also laboratory information systems, hospital and primary care administration systems, as well as human resource management information systems (1,2). The ultimate goal of a well-functioning HIS is a continuous and synchronized endeavor to gather, process, report and use health information and the knowledge generated for the good governance of health systems; in other words: influence policy and decision-making, design activities and programs which eventually improve the health outcomes of the population, but also contribute to more efficient use of (often limited) resources (1,3,4). At the same time, the evidence generated from HIS may suggest the need for further research in certain areas (1,5). Nevertheless, a major prerequisite for a good health system governance consists of a wide array of valid and reliable data, which are not often available from a traditional (routine) or administrative HIS (2,6).Therefore, there is a clear need to promote different types of health examination surveys and health interview surveys as valuable sources for generation of additional health information which, otherwise, would not be available based on routine/administrative statistics. This is important in any health care system, where reforms are underway constantly (7). Health examination surveys and health interview surveys Issues related to the quality of life of individuals, patient satisfaction of health care delivery, knowledge, attitudes, perceptions, or beliefs of individuals, as well as health literacy levels in general are all important components which should be measured at a population level in order to design and tailor health strategies and policies accordingly (1,3). From this perspective, health examination surveys are a powerful tool which enrich a certain HIS and provide useful clues about the health status of populations, quality of life, as well as access, utilization and satisfaction with health care services. In this framework, the European Health Examination Surveys (EHES: http://www.ehes.info/) and the European Health Interview Surveys (EHIS: http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey) constitute two major exercises which are carried out in most countries of the European Union (EU). Indeed, health examination surveys and health interview surveys are conducted periodically in most of the EU countries generating important evidence about the magnitude and distribution of selected ill-health conditions and health determinants at a population level. Based on the unique value of health examination surveys and health interview surveys, there is a clear call for undertaking a similar exercise also in transitional former communist countries of South Eastern Europe including Albania. Country profile: Albania After the collapse of the communist regime in early 1990s, Albania has undergone significant political, social and economic changes striving towards a market-oriented economy (8). Nevertheless, the particularly rapid transition from state-enforced collectivism towards a capitalistic system was associated with poverty, high unemployment rates, financial loss and social mobility, and massive emigration (9). At the same time, however, the transition period in Albania was associated with increased personal and religious freedom in a predominantly Muslim secular society (8,10). All these features continue to spot Albania as a distinctive http://doi.org/10.4119/UNIBI/SEEJPH-2017-143 Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 4 country in Europe, notwithstanding the similarities in many characteristics with other transitional countries in the Western Balkans and beyond. The health care sector has suffered substantially during the transition period and there has been a significant change in the epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (NCDs) (11,12). Indeed, there is a tremendous increase in the total burden of NCDs in Albania including heart disease, cancer, lung and liver diseases, and diabetes (11,12). Against this background, there is an urgent need for an integrated approach for both prevention and improvement of health care in order to face the high burden of NCDs in transitional Albania (12). In any case, the existing HIS in Albania has insufficient routine health data for a valid and reliable analysis of disease trends and the associated risk factors. The first round of a nationwide Demographic and Health Survey (DHS) in Albania was conducted in 2008-2009 (13). Almost ten years later, there is currently an urgent need to carry out a second DHS round which would generate valuable information regarding selected key socio-demographic characteristics and health data of the Albanian population, which are otherwise not available based on routine/administrative statistics. Not only that with new data new needs for priorities in the health system governance can be identified, but the changes and potential effects of health policy decision-making of the last years can be measured too. The Albanian Demographic and Health Survey (DHS) 2017-2018 Among many efforts to strengthen the HIS in Albania, there is currently a commitment to undertake a second round of a nationwide DHS. The upcoming round of DHS in Albania will be implemented by the National Institute of Public Health and the Institute of Statistics with technical support from the US-based company ICF International (https://www.icf.com/). Funding has been already provided by the Swiss Cooperation and the United Nation agencies operating in Albania. The DHS will involve a nationwide representative sample of about 17,000 private households. All women aged 15-59 years and their respective husbands/partners living permanently in the selected households or present in the household on the night before the survey visit will be eligible to be interviewed in the DHS. The specific objectives of the DHS will be to: i) collect data at a national, regional and local level which will allow the calculation of key demographic rates; ii) analyze the direct and indirect factors which determine the level and trends of fertility and abortion in Albania; iii) measure the level of contraceptive knowledge and practice of Albanian men and women; iv) collect data on family health including immunization coverage among children, prevalence of most common diseases among children under five and maternity care indicators; v) collect data on infant and child mortality and maternal mortality; vi) obtain data on child feeding practices including breastfeeding, collect anthropometric measures to use in assessing the nutritional status of children including anemia testing; vii) measure the knowledge and attitudes of women and men about sexually transmitted diseases and HIV/AIDS; viii) assess key conventional risk factors for NCDs in Albanian men and women aged 15-59 years including dietary patterns and nutritional habits, smoking status, alcohol consumption, physical activity, systolic and diastolic blood pressure, and measurement of anthropometric indices (height and weight, as well as waist and hip circumferences). The data collected will be scientifically analyzed and scientific reports and policy briefs will be subsequently written and disseminated for a wide audience including health professionals, social workers, policymakers and decision-makers, as well as the general public. In addition, http://doi.org/10.4119/UNIBI/SEEJPH-2017-143 Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 5 the open data source approach will enable secondary (in-depth) analysis to all interested researchers and scientists all over the world. Contribution of the Demographic and Health Survey (DHS) to health system governance in Albania Table 1 presents the potential contribution of the upcoming Albanian DHS at different levels (international, national, regional, and local level), recognizing that different actors of health system governance which are located at different levels, yet, interact with each-other (14,15). Selected potential contributing characteristics (features) include different dimensions pertinent to both, the international environment and cooperation, as well as the internal (national) situation/circumstances. Table 1. International relevance and contribution of the “Albanian Demographic and Health Survey 2017-18” to governance processes at national, regional and local levels INTERNATIONAL RELEVANCE Characteristic Description European Union Fulfillment of accession requirements, and contribution to the “Europeanization” process of Albania World Health Organization (WHO) Strengthening of the core functions of the health system (in line with the WHO recommendations) NATIONAL (CENTRAL) GOVERNMENT Characteristic Description Democracy A good exercise for strengthening societal participation and responsibility Governance Enhancing good governance: transparency, accountability and responsiveness Informing policy Prioritization, evidence-based planning and allocation of resources Research Strengthening research capacities at a national level National data Collection of (good quality) nationwide representative health data National disparities Evidencing overall (national) disparities in terms of place of residence (urban vs. rural areas), ethnicity, minorities, vulnerable subgroups, socioeconomic categories, as well as sex- and-age group differences Baseline national data Useful baseline data for assessing national trends over time, as well as monitoring and evaluation of nationwide health programs and interventions Cross-country comparisons Use of internationally valid/standardized instruments will eventually enable cross-national comparisons with the neighboring countries and beyond REGIONAL LEVEL: INTERFACE BETWEEN THE CENTRAL AND THE LOCAL GOVERNMENT Characteristic Description Research Strengthening research capacities at a regional level Regional data Collection of sub-national data Regional disparities Evidencing sub-national (regional) health disparities and inequities Baseline regional data Baseline data for assessing regional trends, as well as monitoring and evaluation of regional health initiatives, programs and interventions LOCAL GOVERNMENT Characteristic Description Research Strengthening research capacities at a local level Local data Collection of health data at a local level Local disparities Evidencing local health disparities and inequities Individual-based data Potential for intervention (treatment and counseling of people in need) Baseline local data Baseline data for assessing local trends, as well as monitoring and evaluation of interventions implemented at a local level http://doi.org/10.4119/UNIBI/SEEJPH-2017-143 Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 6 Regarding the international environment, the upcoming Albanian DHS will significantly contribute in terms of fulfillment of accession requirements to the EU related to provision of standardized and valid health information/data. On the other hand, the DHS will also contribute considerably to the enhancement of the core functions of the Albanian health system in line with the WHO recommendations (16). According to WHO, four vital functions of health systems include provision of health care services, resource generation, financing, and stewardship (16).The upcoming survey will support most of these core functions in the context of a particularly rapid process of transformation and reform of the Albanian health system. As for the internal environment, at a central (national) level, the DHS will be an important exercise for strengthening societal participation and responsibility, which is fundamental given the low participation rates and societal contribution in post-communist countries such as Albania. From a governmental point of view (4), the forthcoming survey is expected to promote good governance in terms of transparency, accountability and health system responsiveness. Conversely, the DHS exercise will considerably strengthen national research capacities in Albania. The survey will be conducted in close collaboration with the University of Medicine, Tirana, and other scientific and research institutions in Albania which will help to further strengthen the epidemiological and the overall capacities of the Albanian research community. Furthermore, the DHS will allow for collection of nationwide high-quality information including a wide array of demographic and socioeconomic characteristics and valuable health data. Such data will provide useful baseline information for assessment of national trends in the future, as well as monitoring and evaluation of nationwide health programs and health interventions. In addition, this baseline information will evidence national disparities and inequities regarding the place of residence (urban vs. rural areas), ethnicity groups and minorities, vulnerable/marginalized segments, socioeconomic disadvantaged categories, as well as sex- and-age group health differences. At the same time, employment of standardized and internationally valid instruments for data collection will allow for cross-national comparisons between Albania and different countries of the European Region. Ultimately, at a central (national) level, findings of the DHS will enable rational decision-making and evidence-based policy formulation in Albania including appropriate planning, prioritization and sound resource allocation. At a lower level, the DHS exercise will help to strengthen research capacities and collaboration at a regional level. This will be an important added value given the new administrative/territorial reform which was fairly recently implemented in Albania. In addition, availability of health data at a regional level will help to tailor regional policies in accordance with the epidemiological profile and health problems of the respective population groups, as well as monitoring and evaluation of different interventions and programs implemented at a regional level. At the lowest (i.e., local) level, the DHS will similarly but even more specifically contribute to evidence-based policy formulation and rational decision-making at a local/community level. Likewise, the survey will contribute to the enhancement of research capacities at a local level, which will be particularly valuable for many under-resourced communities in Albania characterized by limited and not properly trained research personnel. It should be noted that, for the first time ever, the upcoming DHS round will be a unique opportunity to collect representative data at the lowest administrative level in Albania. Also, importantly, the survey will offer a unique opportunity for intervention regarding potential treatment and especially counseling of individuals in need, particularly those who, for different reasons, have limited access to health care services, such as the case of Roma community (17). http://doi.org/10.4119/UNIBI/SEEJPH-2017-143 https://en.wikipedia.org/wiki/Health_care_provider Muja H, Burazeri G, Schröder-Bäck P, Brand H. Enhancing health system’s governance through demographic and health surveys in transitional European countries: The example of Albania (Original research). SEEJPH 2017, posted: 15 August 2017. DOI 10.4119/UNIBI/SEEJPH-2017-148 7 Conclusion The upcoming DHS round will be a unique opportunity for Albania for strengthening research capacities at a national and local level. In addition, the DHS will provide valuable baseline evidence highlighting regional disparities and subgroup inequities which are assumed to have been rapidly increasing given the rapid political and socioeconomic transition of Albania in the past three decades. Furthermore, this survey will offer an opportunity for evidence-based policy formulation in Albania. Overall, the DHS exercise will be an important tool for strengthening the core functions of the Albanian health system contributing also to the Europeanization process and accession to the EU. 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