Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: 17 April 2021. DOI: 10.11576/seejph-4352 P a g e 1 | 10 ORIGINAL RESEARCH Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt Alban Ylli1,2, Arnoldas Jurgutis3, Genc Burazeri1, Gazmend Bejtja4, Nazira Artykova4, Tetine Sentell5 1 Faculty of Medicine, University of Medicine, Tirana, Albania; 2 Institute of Public Health, Tirana, Albania; 3 World Health Organization, European Centre for Primary Health Care, Almaty, Kazakhstan; 4 World Health Organization, Office in Albania, Tirana, Albania. 5 University of Hawai‘i at Mānoa, USA. Corresponding author: Alban Ylli, MD, PhD; Address: Faculty of Medicine, Rr. “Dibres”, No. 371, Tirana, Albania; Telephone: 355672052674; Email: albanylli@yahoo.co.uk mailto:albanylli@yahoo.co.uk Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 2 | 10 Abstract Non-communicable Diseases (NCDs) in Albania are increasing, yet the country has a low number of outpatient visits per inhabitant per year. A primary health care (PHC) based programme of medical check-ups, with a focus on prevention, was set up in the country in 2015 aiming to address this issue, among others. This manuscript describes the development and status of the programme at key time points after its implementation, and considers some of its outcomes. The current analysis was based on data gathered from the check-up programme information system and the registry of diseases at PHC centres, and guided by the European Framework for Action on Integrated Health Services Delivery. Based on PHC registered cases, a 13% and 34% increase in the prevalence of elevated blood pres- sure and diabetes were observed in 2015 respectively, following the introduction of the check-up programme compared to the previous year. Three years after implementation, about 60% of the population aged 35–70 years old had used the programme at least once, with 61% of the total 954 667 visits provided to women. Overall, the check-up programme in Albania has identified a substantial number of new cases of NCD as well as their associated risk factors in its population. The early detection of NCDs is expected to contribute to the prevention of complications, premature mortality and their associated costs. Albanian politicians and decision-makers should regularly revise and introduce appropriate changes to the check-up programme in the future. In particular, the issue of sustainability and long- term resource mobilization is of particular concern and warrants careful consideration. Keywords: Albania, check-up programme, prevention, primary health care. Conflict of interests: None declared. Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 3 | 10 Background In Albania, non-communicable diseases (NCDs) are estimated to account for 89% of all deaths, with cardiovascular diseases ac- counting for 57%, cancer 20%, chronic res- piratory diseases 3%, diabetes 1% and other NCDs 12% (1). The probability of dying be- tween the age of 30 and 70 years old from a NCD in Albania is 17% (1), and NCDs as a percentage of total disability-adjusted life- years (DALYs) increased considerably from 67% in 2000 to 80% in 2012 (2). Further- more, lifestyle factors account for more than 70% of the total disease burden in Albania. During the past two decades, the total mortal- ity rate related to being overweight or obese has more than doubled, and the death rate from ischaemic heart disease and diabetes have more than doubled and tripled respec- tively (3). Despite the increases in NCDs in Albania, the country was reported as having the fewest outpatient visits per inhabitant per year out of the eight countries in south-east- ern Europe in 2013, at 2.5 per inhabitant per year, with the average in the WHO European Region at 7.5 (2). This low attendance rate, and consequent delays in addressing health problems, were assumed to be a result of the lack of state funded health care, low popula- tion coverage of health insurance and high out-of-pocket payments, which comprised 55% of the total Albanian national expendi- ture on health in 2014 (4,5). In response to these issues, the government of Albania, in addition to introducing national intersectoral policies targeting the determinants of NCDs, developed and implemented a national medi- cal check-up programme in 2015, aiming to improve the early detection and management of NCDs, and to increase access to and trust in the primary health care (PHC) sector (6-8). The objective of this study was to describe the development and status of the programme at key time points after its implementation, and to quantify some of its outcomes. Methods and approach Each of the following factors were initially assessed: the scope/selection of services for the check up programme; the system’s deliv- ery capacities; design of patient pathways; organization of providers at the PHC centres; screening management; and the mechanisms in place to ensure performance improvement. Subsequently, the outcomes and impact of the programme were analysed by focusing on indicators such as the early detection of health conditions/metabolic risk factors and changes in the registered prevalence of NCDs as a result of the programme. Two main data sources were used in our analysis: The check- up programme documentation and infor- mation system and the registry of diseases at PHC centres. The check-up programme in- formation system, managed by the Ministry of Health and Social Protection (MHSP), is a fully computerized case-based registry, which employs a state-of-the-art BI (business intelligence) system and provides timely in- formation about the result of each patient visit. The registry of diseases, which was set up twelve years ago, contains all prevalent cases of disease diagnosed by a general prac- titioner (GP) and confirmed by a specialist, within a PHC centre’s catchment area. Each PHC centre reports the data periodically to the Compulsory Health Insurance Fund (CHIF) and the aggregated database is shared with the Institute of Public Health. Along with the check-up information system, these registries are considered reliable sources of information as they have frequently (i.e., every three months updated core documenta- tion and are also periodically checked by CHIF supervisors. The current analysis and presentation of findings were guided by the principles put forward by the European Framework for Action on Integrated Health Services Delivery and its approach to trans- forming the delivery of health services (9). It Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 4 | 10 includes among others the people-centred ap- proach, which recognizes that before people become patients, they need to be informed and empowered in promoting and protecting their own health. Results and Discussion Scope of the check-up programme Based on the changing health needs of the population resulting from the increasing bur- den of NCDs, the Albanian government put forward a national health programme with the primary goal of increasing life expec- tancy by preventing premature deaths. Fol- lowing international evidence on the role of PHC in addressing NCD-related health needs, the government put priority on im- proving PHC performance. During 2013/2014 the government conducted de- tailed preparatory work before launching a primarily preventive programme in 2015 of- ficially named the Essential Medical Evalua- tion, but announced under the logo ‘How are you?’ for all Albanian citizens aged 40–65 years. This was initially set to run over three years, but has subsequently been expanded until 2024. In addition, the target age group was expanded to cover all citizens between 35–70 years at the end of 2016. The size of the initial target group in 2015 was around 1 160 000 inhabitants, which constituted 41% of the total resident population in Alba- nia. The programme, considered by the gov- ernment as a major step towards universal health coverage, targeted all Albanian resi- dents regardless of their insurance status. The scope of the programme was to assess health status of eligible individuals on a yearly basis in six priority areas highlighted as high prior- ity by the Albanian Institute of Public Health (10) and included several tests (such as blood sugar level and lipid profile, as well as assess- ment of other key cardiovascular risk factors) to be performed throughout the target popu- lation (Table 1). Table 1. Tests provided in six priority areas of the check-up programme (Source: reference number 10) AREAS TESTS Risk factors Tobacco use Harmful use of alcohol Unhealthy diet Physical Inactivity Hypertension Blood pressure measurement Diabetes Fasting plasma glucose test Glucose tolerance test (2-hour plasma glucose) Cardiovascular risk SCORE (systematic coronary risk evaluation) Family history ECG Mental health and depression Patient health questionnaire Key laboratory tests Complete blood count Complete urine analysis Faecal occult blood test Liver enzymes: aspartate aminotransferase and alanine aminotransferase Blood lipid analysis Creatinine and urea (since 2016) Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 5 | 10 The included screening tests were more com- prehensive than those previously available in PHC services in Albania (notably the inclu- sion of laboratory tests) (11), and went be- yond evidence-informed recommendations to include areas of priority to the government, including liver enzymes tests, electrocardio- gram (ECG) etc. (10,12,13). Furthermore, at the end of 2016, in addition to expanding the age group eligible for screening, the govern- ment increased the scope of the check-up pro- gramme by increasing the number of labora- tory tests, (creatinine and urea tests were added). As of yet, there have been no at- tempts to reduce the frequency of some of the current tests, despite evidence to do so, but there is a willingness to consider the inclu- sion of cervical and breast cancer screening as recommended by WHO (12), although this has yet to be implemented. Capacity for implementing the check-up programme The MHSP and CHIF implemented the pro- gramme through a contract with an external company, which was responsible for pur- chasing and maintaining equipment and the information technology system in all 380 Al- banian PHC centres, training the staff in- volved in the screening, transporting sam- ples, organizing mobile units to provide screening in remote areas and carrying out all laboratory tests. The government-funded PHC centres were themselves obliged to pro- vide: (i) suitable premises for receiving peo- ple coming for a check-up; (ii) a list of the people eligible for screening in their desig- nated catchment area; (iii) a computer for registering and transferring data; (iv) main- taining equipment provided by the contrac- tor; and (v) nurses responsible for check-ups. Larger PHC centres appointed nurses solely responsible for the check-ups, whereas smaller PHC centres usually just expanded the role of the family nurse. This was re- flected in higher attendance rates in larger PHC centres due to their larger capacity, whereas smaller centres encountered several challenges in conducting the programme tasks. All PHC doctors and nurses responsi- ble for check-up processes were trained for the task and equipped with an accompanying manual (14) and clinical algorithms, both of which provided guidance on when further in- vestigations and referrals were recom- mended. Preventive check-up procedures, referrals and follow-ups The MHSP clearly defined the processes for the check-ups. All necessary steps involved, as well as the responsibilities of the contrac- tor, PHC centre and secondary health care consultants were clearly stated in a written manual. The check-up appointment itself consisted of an initial briefing on the pro- gramme by the nurse, followed by the com- pletion of questionnaires on behavioural risk factors, body mass index calculations based on measured weight and height, an ECG, and the taking of blood samples. Laboratory tests were collected by the contractor on a daily basis. If behavioural risk factors were identi- fied, the patient received a brief intervention consisting of advice and guidance by the nurse. In addition to the 380 PHC centres, mobile units visited 35 remote villages with limited health services, twice a year. The con- tractor provided the laboratory tests results to each PHC centre and, in case of abnormali- ties, the stationed GP provided health advice and suitable prescriptions, or referred the pa- tient to a secondary health care clinic, follow- ing the well-defined clinical pathways. A check-up programme referral guaranteed free and easy access to secondary health care re- gardless of the patient’s insurance status, with short waiting times to see a consulting Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 6 | 10 specialist and for any necessary further clini- cal investigations, as confirmed elsewhere (15). The check-up process was deemed com- pleted after the GP sent the contractor a report with the results of the check-up describing any identified or suspected clinical condi- tions. These reports were filed before any feedback from subsequent specialists and therefore rarely included a final clinical diag- nosis. If the person did not require a referral to a GP, the report was filed by the nurse. Identification of new cases and changes in registered morbidity The analysis of check-up programme data de- termined the extent to which check-ups iden- tified new cases of NCDs, and risk factors as- sociated with NCDs, but also the number of referrals to a specialist. In 2016, of the 329 576 people that underwent a check-up in Albania, 36% had elevated blood pressure (systolic at 140 mmHg or higher and/or dias- tolic at 95 mmHg or higher); 21% were sus- pected of having depression; 15% had blood glucose levels higher than 5.5 mmol/L; 9% higher than 7.0 mmol/L; and 1% had a posi- tive faecal occult blood test (Table 2). Table 2. Distribution of selected medical conditions among 329,576 individuals undergoing a medical check-up in Albania in 2016 Condition Number Percentage Percentage not previously aware of their condition Depression 69211 21% 76% High blood pressure 118647 36% 49% High blood glucose 49436 15% 42% Positive occult blood in faeces 2637 0.8% 99% In 2016, there were 39 213 referrals to spe- cialists as a result of the check-ups, although there is no data regarding follow-ups and fi- nal diagnoses. A large proportion of people identified as having a medical problem as a result of the check-up had not previously been aware of their condition, with 49% una- ware of their high blood pressure status and 42% unaware of their diabetic status in 2016. According to the PHC registries, there was a marked increase in the prevalence of diabetes mellitus, depression and arterial hypertension (34%, 30% and 13% respectively) following the introduction of the check-up programme in 2015 compared to the previous year (Fig. 1). Previous annual increases had only been at around 1% for diabetes, hypertension and depression. Despite the observed increase in the prevalence of PHC registered hyperten- sion, the overall prevalence actually re- mained low compared to the expected popu- lation levels based on WHO NCD country profiles in 2014, where more than 36% of the population (over 25 years old) had hyperten- sion (3,9). Almost three years after the intro- duction of the check-up programme, at the end of 2017, the prevalence of PHC regis- tered arterial hypertension was only 15%. Similarly, the registered prevalence of diabe- tes mellitus was lower than expected at 3.8%. It seems that program has yet to diagnose and register all cases of hypertension and diabetes in community. Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 7 | 10 Figure 1. Number of cases of hypertension, diabetes and depression in NCD registries of PHC centres, from 2011-2017 F Outcomes and impact Up until February 2018, 54% of all 954 667 check-up visits were carried out in rural ar- eas, which was a strong point of the pro- gramme, as one of its objectives was to tackle geographical differences in accessing PHC. It is also worth noting the gender difference in the programme participation, with 61.3% of the check-ups provided to women, in line with the fact that programme compliance was lowest among younger middle-aged men (aged 35–44 years), an issue that deserves fu- ture attention. Beyond informing and man- aging patients suspected of having a NCD, the check-up programme also brought about a number of key changes in the Albanian health sector: (i) It changed traditional atti- tudes that health services should only be used for perceived and disturbing health problems, with healthy people now attending check-ups aimed at the prevention and early detection of severe health problems, as described else- where (16); (ii) it increased trust and utiliza- tion of PHC services; and (iii) it increased the accessibility of health services for socially disadvantaged population groups, although more data are needed to confirm the extent of this (17). The perception among health pro- fessionals was that Albanian population place a higher value on objective measurements of health, such as laboratory and diagnostic tests, over questionnaires for assessment of behaviour risk factors (16). Therefore, in or- der to make the intervention more attractive and to increase participation, more laboratory tests were included in the check-up pro- gramme in 2016. Overall, the check-up pro- gramme raised the awareness of the popula- tion for the need of preventive check-ups, with 60% of the people eligible for the check- ups attending at least once in the period March 2015–March 2018. About half of the people screened in 2015 attended a second check-up in 2016. Data on check-ups from the first quarter of 2017 indicated that about one third of the eligible population partici- pated in the check-up programme for the first time, one third for the second time and one 229.519 231.396 233.71 236.047 267.28 269.077 281.857 45.606 48.05 48.53 48.966 65.55 71.414 72.926 7.614 7.489 7.564 7.64 9.905 10.154 10.448 0 50 100 150 200 250 300 2011 2012 2013 2014 2015 2016 2017 N um be r o f c as es (t ho us nd s) Year HBP Diabetes Depression Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 8 | 10 third of them for the third time. The PHC cen- tres were encouraged to invite eligible indi- viduals through all channels they considered appropriate. This included both advertising campaigns and individual letters sent out to each subject, but some barriers still remain both in communication logistics between PHC centres and their communities, and in the low awareness of the importance of the check-up programme in certain population groups, especially young males in the cities. Only 8% of the young middle age (35–44 years) urban male population responded to the invitation. This low level of attendance may reflect different priorities in this popula- tion than preventive health, a concern in men’s health (18). It may also reflect chal- lenges in accepting a shift from the more tra- ditional role of the Albanian PHC services, which focused on illness and maternal and child health. Hence, the programme still needs to be adapted to the needs and prefer- ences of the male population, especially given that a higher prevalence of several NCDs and their risk factors are expected among men. At the end of 2016, the govern- ment extended the check-up programme and from the beginning of 2017 free PHC visits for the entire population, covering all health conditions, were introduced, along with easy access to specialized services, targeting this overall aim of providing universal health coverage. Conclusions The check-up programme has been an im- portant intervention in strengthening the PHC service in Albania. It has helped improve ac- cess to, and build more awareness about pre- ventive care among the Albanian population. There is a general consensus among profes- sionals that the program has created the basis for better service attendance and improved health seeking behaviour in Albanian adults, as well as restoring trust and communication between health professionals and communi- ties (16). Yet, there are areas to be addressed within the programme in the future. Notably, the programme needs to focus on encourag- ing men to also attend check-ups, and needs to assess potential differences in participation rates between different socioeconomic popu- lation subgroups. This information is cur- rently not available. Overall, the check-up programme in Albania has identified a sub- stantial number of new cases of NCDs and risk factors associated with chronic disease. The early detection of a NCD is expected to reduce the development of related complica- tions, as well as premature mortality rates, which in turn should reduce the associated costs. However, policy makers need to con- tinue to support and shift more resources to PHC services to cover the increase in work- load for PHC GPs and nurses. To ensure the effectiveness of the check-up programme and improvements in the overall health status of the population, however, it is not sufficient to have a well-funded check-up programme if it is based in the framework of low-resource PHC facilities, with a limited capacity for the follow-up and management of patients with NCDs. The check-up programme needs to be accompanied by a more advanced primary health care model that would include NCD management by well-trained family doctors and PHC nurses, supported by other members of a multidisciplinary team (for example psy- chologists, health educators, public health specialists), as required. In addition, the pro- gramme should be further optimized by re- vising the scope of tests, the targeted age groups, and the frequency of the tests accord- ing to age and health status. For example, a number of tests including in the check-up programme, including ECG, liver enzyme tests and complete urine analysis, among oth- ers, have not been shown to be effective in population based screening (19), and should therefore only be used for opportunistic Ylli A, Jurgutis A, Burazeri G, Bejtja G, Artykova N, Sentell T. Preventive check-up programme for strengthening people-centred primary health care services in Albania: Case study and lessons learnt (Original research). SEEJPH 2021, posted: XX April 2021. DOI: P a g e 9 | 10 screening of patients at risk for a particular disease. This would optimize resources within the programme potentially allowing for the introduction of other evidence-based tests, including the screening of some can- cers, as well as the better follow up of de- tected cases. Overall, a better financial opti- mization is required to encompass both the costs of further investigation and specialist consultations, which are currently covered by health insurance, in addition to the cost of the check-ups. The check-up programme has also helped raise the professional profile of PHC nurses, by transferring to them some es- sential tasks previously carried out by physi- cians. The check-up programme could grad- ually introduce PHC nurses responsible for a particular district, so that every individual would receive a more comprehensive service from their own nurse, including check-ups, behaviour change counselling, and follow- ups for patients with NCDs. Such a model should be supported by clear clinical guide- lines and should include some form of both performance measurement and accountabil- ity for health personnel – along with support- ing incentives (for example the revision of re- muneration schemes) – with patients reaping the benefits. User-friendly and culturally- sensitive information campaigns aimed at all levels of society each at an individual, family, and community-based level will be important for the future of the programme. In addition, measures to enhance the responsibility of cit- izens themselves to participate in the check- up programme should be gradually intro- duced, and incentives towards this aim need to be considered. In conclusion, the current case study is an example of how a country in the WHO European Region with limited re- sources was able to make prompt resource mobilization and to strengthen the role of PHC in NCD control. However, Albanian politicians and decision-makers need to be able to regularly revise and introduce appro- priate changes to the check-up programme in the future. In particular, the issue of sustaina- bility and long-term resource mobilization is of particular concern and deserves careful consideration. References 1. World Health Organization. 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