Mone I, Kraja B, Roshi E, Burazeri G. Overview on health status of the Albanian population (Review article). SEEJPH 2022, posted: 02 October 2022. DOI: 10.11576/seejph-5913 P a g e 1 | 6 REVIEW ARTICLE Overview on health status of the Albanian population Iris Mone1, Bledar Kraja1, Enver Roshi1, Genc Burazeri1,2 1 Faculty of Medicine, University of Medicine, Tirana, Albania; 2 Department of International Health, School CAPHRI (Care and Public Health Research Institute), Maastricht University, Maastricht, The Netherlands. Corresponding author: Iris Mone, University of Medicine, Tirana; Address: Rr. “Dibres”, No. 371, Tirana, Albania; Telephone: 00355692149301; Email: iris_mone@yahoo.com Mone I, Kraja B, Roshi E, Burazeri G. Overview on health status of the Albanian population (Review article). SEEJPH 2022, posted: 02 October 2022. DOI: 10.11576/seejph-5913 P a g e 2 | 6 Abstract The Albanian population is rapidly aging (in 2020, almost 15% of the population was ≥65 years) as a result of a steady increase in life expectancy (74.4 years in men and 78.7 years in women in in 2021), a gradual decrease in fertility rate (1.6 children per woman of childbearing age in 2020), and emigration of particularly young adults. This demographic transition experienced in the past three decades has inevitably led to a significant change in the epidemiological profile of the Albanian population, characterized by a remarkable shift towards non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD), cancer, chronic respiratory diseases, and diabetes. The main risk factors in the Albanian population consist of high blood pressure (top risk factor, accounting for about 34% of the overall mortality), nutritional-related risks (second, constituting about 25% of the overall mortality), and smoking (third risk factor, accounting for about 20% of the overall mortality). The national “Health Strategy, Albania 2021-2030” is a political document of the Albanian government that aims to define and achieve the objectives of the program for the protection and improvement of the health of the Albanian population. Following the national “Health Strategy, Albania 2021-2030”, two new action plans were recently developed: the “Action Plan on NCDs, Albania 2021-2030” and the “Action Plan on Health Promotion, Albania 2022-2030”. Keywords: Albania, demographic transition, epidemiological transition, health profile, Western Balkans. Mone I, Kraja B, Roshi E, Burazeri G. Overview on health status of the Albanian population (Review article). SEEJPH 2022, posted: 02 October 2022. DOI: 10.11576/seejph-5913 P a g e 3 | 6 Demographic characteristics of the Albanian population As of January 2022, the population of Albania consists of about 2.8 million inhabitants (1), displaying a gradual decrease in the past decade due to a decrease in fertility rate and emigration. As a matter of fact, fertility rate in Albania has decreased steadily in the past few decades, exhibiting a level of 1.6 children per woman of childbearing age in 2020 (2), which is only slightly higher than the average in the European Union countries (1.5 live births per woman in 2020) (3). According to the official figures provided by the national Institute of Statistics, in 2021, life expectancy in Albania was 74.4 years in men and 78.7 years in women (4), representing a significant decrease compared with the pre-COVID-19 pandemic (in 2019, life expectancy in men was 77.6 years, whereas in women it was 80.6 years). Seemingly, there is evidence of a considerable excess death due to COVID-19, especially among adult men in Albania during the period 2020-2021. Nevertheless, COVID-19 aside, there is evidence of a steady increase in life expectancy in Albania in the past three decades (4). In the past three decades following the breakdown of the communist regime, Albania has experienced an unprecedented level of emigration, which continuous unabated. The net migration rate in Albania is estimated to be between -5% to -10%, which involves a loss of more than 300,000 people only due to emigration in the past two decades (5). Only during 2019-2020, the net migration rate in Albania was about -40 thousand individuals (5). As a consequence of a gradual increase in life expectancy in the past few decades, the decrease in fertility rate, and the massive emigration of especially young adults, there is evidence of a significant demographic transition of the Albanian population, with a substantial increase in the proportion of older individuals (≥65 years): from about 4% in 1990 to almost 15% in 2020 (4). Mortality indicators of the Albanian population In the past two decades, the age-standardized mortality rates in Albania have declined more rapidly than in most of the other countries of the European Region including especially the neighbouring countries of the Western Balkans (6). The overall mortality rate (number of deaths per 100,000 population) in Albania in 2021 was 1,085, with cardiovascular diseases comprising about 53% of proportional mortality (7). According to the Global Burden of Disease (GBD) estimates, the age-standardized overall mortality in Albania in 2019 was about 575 (95%CI=460-714) deaths per 100,000 population, whereas in 1990 it was 830 (95%CI=813-849) deaths per 100,000 population (6). Consistent with the overall increase in life expectancy in Albania, infant mortality and child mortality, on the whole, have both decreased in the past three decades, a trend which was nevertheless interrupted in the past few years (2019-2021). In 2021, infant mortality rate was 8.4 deaths per 1,000 live births, whereas under-5 mortality rate was 9.2 deaths per 1,000 live births (4). The plateau or even worsening of child indicators in the past few years should be a cause of concern to policymakers and decision- makers in Albania, pointing to lack of sufficient attention in strategies and interventions targeting traditional mother and child health care programs and probably budget shifts toward other healthcare services. Conversely, maternal mortality ratio in Albania in 2020 was 3.6 deaths per 100,000 livebirths, indicating a decrease in the past decade (in 2012, it was 5.6 deaths per 100,000 livebirths) (4). Of note, there has been a significant change in the Mone I, Kraja B, Roshi E, Burazeri G. Overview on health status of the Albanian population (Review article). SEEJPH 2022, posted: 02 October 2022. DOI: 10.11576/seejph-5913 P a g e 4 | 6 epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (NCDs), characterized by an increase of cardiovascular diseases (CVD), cancer, chronic respiratory diseases, and diabetes (8). The age-standardized mortality rate from all NCDs in 2019 was estimated at 520 (95%CI=413-649) deaths per 100,000 population, whereas in 1990 it was estimated at 673 (95%CI=657-705) deaths per 100,000 population (6). In 2019, about 93% (95%CI=92%-94%) of all deaths in Albania (all ages) were caused by NCDs, as opposed to only about 71% (95%CI=69%-76%) in 1990 (6). CVD mortality in 2019 was estimated at 474 (95%CI=374-596) deaths per 100,000 population, constituting 57% (95%CI=52%- 60%) of the overall mortality in the Albanian population (6). Furthermore, mortality from neoplasms in 2019 was estimated at 173 (95%CI=131-223) deaths per 100,000 population, accounting for 21% (95%CI=19%-23%) of the overall mortality (6). In addition, mortality rate from chronic respiratory diseases in 2019 was 30 (95%CI=22-39) deaths per 100,000 population, comprising 3.6% (95%CI=3.1%- 4.2%) of the overall mortality (6). Mortality rate from diabetes mellitus in 2019 was 6.4 (95%CI=4.8-8.5) deaths per 100,000 population, comprising 0.8% (95%CI=0.7%- 0.9%) of all-cause mortality (6). On the other hand, in 2019, mortality rate from communicable diseases, maternal, neonatal and nutritional disorders altogether was estimated at 27 (95%CI=22-33) deaths per 100,000 population, comprising 3.2% (95%CI=2.8%-3.8%) of all-cause mortality (6). In turn, mortality rate from injuries in 2019 was 31 (95%CI=24-39) deaths per 100,000 population, comprising 3.7% (95%CI=3.5%- 3.9%) of all-cause mortality (6). Based on this rapid epidemiologic transition (from infectious diseases toward NCDs), there is a pressing need for an effective strategy for control and prevention of NCDs, which has been a core component of the health sector reform in Albania, culminating with the fairly recent development of the “National Plan on NCDs, Albania 2021- 2030” (document pending official endorsement by the Albanian Ministry of Health and Social Protection). Disease burden and the main risk factors in the Albanian population Regarding the burden of disease (mortality and disability combined), in 2019, NCDs accounted for 82% (95%CI=81%-84%) of all disability-adjusted life years (DALYs) (6). CVDs only constituted 29% (95%CI=25%- 33%) of the overall disease burden in the Albanian population (6). Conversely, neoplasms, chronic respiratory diseases, and diabetes accounted respectively for 15%, 2.6% and 2.1% of the overall burden of disease in the Albanian population (6). The NCD burden in Albania is caused by a wide range of health determinants, but, particularly, due to a high prevalence of high blood pressure (top risk factor for the Albanian population according to the most recent GBD estimates, accounting for about 34% of the overall mortality); nutritional related risks (second, constituting slightly more than 25% of the overall mortality); smoking (third risk factor, accounting for about 20% of the overall mortality), as well as overweight and obesity, high plasma sugar level and physical inactivity (6). Regarding the trends in the main conventional risk factors, the prevalence of smoking has slightly decreased in Albanian men in the past few years, whereas in women it remains low (as a matter of fact, the lowest Mone I, Kraja B, Roshi E, Burazeri G. Overview on health status of the Albanian population (Review article). SEEJPH 2022, posted: 02 October 2022. DOI: 10.11576/seejph-5913 P a g e 5 | 6 in the region) (9). In 2019, mortality attributed to smoking comprised about 50% of chronic respiratory diseases deaths, 31% of deaths from neoplasms, and 17% of CVD deaths (6). On the other hand, the average alcohol consumption has increased by half a litter (per capita) in the past few years. In 2019, mortality attributed to alcohol consumption comprised about 5% of deaths from neoplasms, and 1.7% of CVD deaths (6). As for the high blood pressure, which is the main risk factor in the Albanian population, its attributable mortality in 2019 accounted for more than 57% of CVD deaths (6). Of note, there is evidence of a considerable increase in the prevalence of obesity in both men and women in Albania in the past decade (overall, 28% increase) (9). In 2019, mortality attributed to high body mass index constituted about 43% of deaths from diabetes mellitus, more than 19% of CVD deaths, and about 5% of deaths from neoplasms (6). Current strategies and policies to address disease burden in the Albanian population The national “Health Strategy, Albania 2021- 2030” is a political document of the Albanian government that aims to define and achieve the objectives of the program for the protection and improvement of the health of the Albanian population (10). This policy document defines the main objectives for improving health and healthcare for the period 2021-2030, although the vision presented in the strategy will also be suitable for the period after the official implementation of this strategy (10). The drafting of the national “Health Strategy, Albania 2021-2030” was led by the Ministry of Health and Social Protection through an Inter-Institutional Technical Working Group, which was established by a special order of the Minister of Health and Social Protection and was supported with technical assistance of local and international experts (10). Following the national “Health Strategy, Albania 2021-2030”, two new action plans were recently developed: the “Action Plan on NCDs, Albania 2021-2030” and the “Action Plan on Health Promotion, Albania 2022- 2030”. Both documents are still pending official approval by the Albanian Ministry of Health and Social Protection. Nonetheless, the new Action Plans are based on positive developments and progress of Albania in general and reforms in the health sector in particular. The documents take into consideration the updated legislation and the regulatory framework adopted in Albania during the last decade, in close cooperation and with the technical assistance of various partner organizations and international agencies. Also, both Action Plans address the actual public health challenges and the priorities defined by the Albanian government, focusing especially on major non- communicable diseases, such as cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases. References 1. Institute of Statistics, Albania. Key data, 2022. http://www.instat.gov.al/al/statistika/ t%C3%AB-dh%C3%ABna- ky%C3%A7e/ (accessed: September 26, 2022). 2. The World Bank. Fertility rate, Albania. https://data.worldbank.org/indicator/ SP.DYN.TFRT.IN?locations=XK.- AL&name_desc=false (accessed: September 26, 2022). 3. EUROSTAT. Fertility Statistics. https://ec.europa.eu/eurostat/statistics - explained/index.php?title=Fertility_s tatistics#:~:text=The%20total%20fer https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=XK.-AL&name_desc=false https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=XK.-AL&name_desc=false https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=XK.-AL&name_desc=false https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Fertility_statistics#:%7E:text=The%20total%20fertility%20rate%20is,in%202019%20%2D%20Figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Fertility_statistics#:%7E:text=The%20total%20fertility%20rate%20is,in%202019%20%2D%20Figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Fertility_statistics#:%7E:text=The%20total%20fertility%20rate%20is,in%202019%20%2D%20Figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Fertility_statistics#:%7E:text=The%20total%20fertility%20rate%20is,in%202019%20%2D%20Figure%202 Mone I, Kraja B, Roshi E, Burazeri G. Overview on health status of the Albanian population (Review article). SEEJPH 2022, posted: 02 October 2022. DOI: 10.11576/seejph-5913 P a g e 6 | 6 tility%20rate%20is,in%202019%20 %2D%20Figure%202) (accessed: September 26, 2022). 4. Institute of Statistics, Albania. Population data, 2022. http://www.instat.gov.al/al/temat/tre guesit-demografik%C3%AB-dhe- social%C3%AB/popullsia/#tab2 (accessed: September 26, 2022). 5. Institute of Statistics, Albania. Migration and integration of migrants. http://www.instat.gov.al/al/temat/tre guesit-demografik%C3%AB-dhe- social%C3%AB/migracioni-dhe- integrimi-i- migrant%C3%ABve/#tab2 (accessed: September 26, 2022). 6. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease estimates. https://vizhub.healthdata.org/gbd- results/ (accessed: September 26, 2022). 7. Institute of Statistics, Albania. Causes of death in Albania, 2021. http://www.instat.gov.al/al/temat/kus htet- sociale/sh%C3%ABndet%C3%ABsi a/publikim et/2022/shkaqet-e- vdekjeve-2021/(accessed: September 26, 2022). 8. Institute of Public Health, Albania. Health status of the Albanian population. Tirana, 2014. http://seehn.org/web/wp- content/uploads/2015/02/Albanian- Health-Report_download.pdf (accessed: September 26, 2022). 9. Institute of Statistics, Institute of Public Health and ICF. Albania Demographic and Health Survey; 2018. https://www.ishp.gov.al/wp- content/uploads/2015/04/ADHS- 2017-18-Complete-PDF-FINAL- ilovepdf-compressed-1.pdf (accessed: September 26, 2022). 10. Government of Albania, Ministry of Health and Social Protection. Health Strategy, Albania 2021-2030. Tirana, 2022. https://konsultimipublik.gov.al/Kons ultime/Detaje/434 (accessed: September 26, 2022). _____________________________________________________________________________________________ © 2022 Mone 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. https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Fertility_statistics#:%7E:text=The%20total%20fertility%20rate%20is,in%202019%20%2D%20Figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Fertility_statistics#:%7E:text=The%20total%20fertility%20rate%20is,in%202019%20%2D%20Figure%202 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/migracioni-dhe-integrimi-i-migrant%C3%ABve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/migracioni-dhe-integrimi-i-migrant%C3%ABve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/migracioni-dhe-integrimi-i-migrant%C3%ABve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/migracioni-dhe-integrimi-i-migrant%C3%ABve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%C3%AB-dhe-social%C3%AB/migracioni-dhe-integrimi-i-migrant%C3%ABve/#tab2 http://www.instat.gov.al/al/temat/kushtet-sociale/sh%C3%ABndet%C3%ABsia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%C3%ABndet%C3%ABsia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%C3%ABndet%C3%ABsia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%C3%ABndet%C3%ABsia/publikim http://seehn.org/web/wp-content/uploads/2015/02/Albanian-Health-Report_download.pdf http://seehn.org/web/wp-content/uploads/2015/02/Albanian-Health-Report_download.pdf http://seehn.org/web/wp-content/uploads/2015/02/Albanian-Health-Report_download.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/ADHS-2017-18-Complete-PDF-FINAL-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/ADHS-2017-18-Complete-PDF-FINAL-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/ADHS-2017-18-Complete-PDF-FINAL-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/ADHS-2017-18-Complete-PDF-FINAL-ilovepdf-compressed-1.pdf https://konsultimipublik.gov.al/Konsultime/Detaje/434 https://konsultimipublik.gov.al/Konsultime/Detaje/434