Doctor with 40 years experience at the National Institute for Public Health Care discusses Kosovo’s health system.
In 1925, Kosovo established the National Institute for Public Health (IKShP). Since then, the Institute has been responsible for compiling and implementing strategies for public health care. Some of IKShP’s activities include implementing hygienic and sanitary measures, trying to prevent epidemics, promoting health care, analysing water, food and air quality, and conducting scientific research studies. The Institute has branches in all of the country’s biggest urban centers.
Ilir Begolli, in his role as a doctor that specializes in public health issues, was part of the Institute from 1978 up until he retired in March 2018. During this period, he was part of two health care systems: the former Yugoslavia’s, in which he worked for two decades, and Kosovo’s, in which he has worked for almost as long.
A professor at the Faculty of Medicine of the University of Prishtina, Begolli expresses criticism for both systems. He is surprised at the nostalgia for the former health care system, as for Begolli, the Yugoslav system was even more difficult.
However, Begolli doesn’t speak kindly about the contemporary health care system either, saying that the health of patients is not the focus. He feels that the last 18 years have not been utilized enough in terms of reforming the healthcare system and for this, he blames all of the responsible political and health care institutions.
K2.0 spoke to Begolli about whether the health care system has a clear model which it needs to follow, about applied policies and strategies, issues relating to medical staff, the role of international foundations, and public perceptions of the Kosovar health care system.
Photo: Atdhe Mulla / K2.0.
K2.0: You have been engaged at the National Institute for Public Health Care (IKShP) for quite some time. You also led this institution for a few months. The objective of the institution is to organize, develop, oversee and implement public health care policies in Kosovo. Does Kosovo’s health care system have a clear basis or model of policies that it has followed over the last 18 years?
Ilir Begolli: In the last 18 years we have witnessed a mixture of policies and strategies, as a result of many foreign institutions that have come to Kosovo to facilitate health care.
However, since ’99 we have also witnessed reforms in some branches, especially the primary health care sector. This sector offers services to the overwhelming majority of people. We have also witnessed changes in other services, based on strategies compiled after ’99. But not every one of these policies were welcomed by staff, institutions and the people.
The reason behind this is that maybe we were not sufficiently prepared to intervene in the health care system, which is very big and as such cannot experience quick changes. Preparation of medical staff and citizens is required if we want to achieve successful change.
"Primary health care training has not been in harmony with the demands of citizens."
It’s not easy to adapt to new regulations. To take one example: One policy was to eliminate specializations from primary health care — so to not include, for example, pediatrics and gynecology at this level — but now they are necessary because we have not managed to provide these services at other levels.
Primary health care training has not been in harmony with the demands of citizens, because parents trust pediatricians more than they trust general practitioners, and women find it easier to visit gynecologists than general practitioners, because they have more trust in the former.
What role did experts have in compiling health care policies? Did they take into account the parameters of Kosovar society?
The policies are well-written, but just like in every other sphere, implementation is being impeded. This is because not everyone was prepared to take on their foreseen responsibilities. The lack of implementation of policies was also influenced by the individual capacities of people who were supposed to implement these strategies. There were many beneficial positions [foreseen in strategies] but the people that occupied these positions were incompetent. Policymakers should take into account these parameters as well.
However, on the other hand we had people who were educated for management in the health care sector, but never found jobs in it. Maybe they did not fulfil political criteria. It seems that was more important than professional preparation. This stalls the process. We need to identify qualified people for key positions.
Photo: Atdhe Mulla / K2.0.
Many governments have come and gone in recent years. Based on your experience, are policies followed by successive governments built on the previous one, or does the approach change with every new government?
This might be one of the key issues: the sustainability of every policy or law. Usually, when new governments come to power, they come with new approaches to health care. However, they have also changed priorities, something which was not necessarily foreseen in past policies and strategies.
Up until now we have compiled five or six five-year strategies, which means that in a very short period of time we have changed strategies many times. There is no sustainability in our policies. Strategies should have longer implementation periods, because you can’t change things overnight. You cannot prepare specialists within one week. This takes five years.
If we have decided that we need new specialists, and we need five years to train them, and at some point some new minister says that we don’t need new specialists — what happens then? There is no analyses about the need for specialists. In the future we could experience a brain drain, because we are educating people, but failing to find jobs for them.
IKShP also deals with health care economy and management. Many have continuously highlighted that the health care budget has been low. Do you think the budget has been well-managed?
Unfortunately, no-one knows what is happening with the health care budget. This is because we do not have access to most of the data regarding the budget. Let’s make it clear: health care spending is not only the funds allocated by the state. A big part of it is also the money spent by individuals [on health issues]. I doubt that anyone knows that amount. We might spend 170 million euros [allocated for health care from the state budget], but maybe citizens give just as much from their own pockets. We don’t know how much health care costs in Kosovo.
Photo: Atdhe Mulla / K2.0.
The Oncology Institute is facing a shortage of medicine and medical equipment for treating patients. On the other hand, we have the Program for Medical Treatment Outside of the Public Health Service, which since 2002 has had a budget of millions of euros. Some say that this money should be invested in public healthcare institutions, arguing that the level of professional preparation of doctors is good, and that we only need to invest in equipment, apparatus and other infrastructure. How do you feel about this?
It is good to have a fund which enables people to seek treatment abroad for illnesses they cannot cure in Kosovo. On the other hand, if we secure medication, infrastructure and medical apparatus… our medical staff is quite prepared professionally. All this requires good management, starting from the Ministry of Health, all the way down to health care institutions which work with the ministry.
If we see all these as sequences, as a puzzle… when we put them together we will get an ugly Frankenstein. So it is necessary for treatment to have a beginning and an end, and for all of it to be protocoled.
You mean that if we want to have a good health care system, we need to have a clear model and to follow it, because ad hoc actions are not efficient?
There are a lot of ‘holes’ and problems that we need to patch up. Let’s take the example of insulin shortages for diabetics. Insulin can be secured — because it is produced in the world after all — but the order of events, from securing the request for it, to having it brought to the patient for treatment, it all takes time.
Most diabetics can’t afford to wait that long, because they need their medicine straight away. This procedure [of securing insulin] should be investigated, so that we know whether or not it is adequate. In health care, everything is urgent.
"Facts show that certain social groups could suffer consequences due to their limited access to health care services. It is not that we have been very successful in our fight against prejudices."
IKShP is also obliged to “evaluate the medical condition of the population, especially its most vulnerable groups.” Does the institute have a list of vulnerable groups? If it does, which are the groups, how are they treated, and what needs to be done in the future?
Our laws do not discriminate against anyone. But, in practice, there might be failures in this regard. We have conducted research, especially for the Roma, Ashkali and Egyptian communities, and have found that they are not discriminated based on their ethnicity.
However, facts show that certain social groups could suffer consequences due to their limited access to health care services. It is not that we have been very successful in our fight against prejudices. This is the case in all spheres, not just health care.
Photo: Atdhe Mulla / K2.0.
Is health insurance one of the solutions, especially for marginalized groups?
Health insurance is for everyone. As long as we don’t have insurance, everyone is discriminated against. When we get sick, we have no one to support us. I am a doctor and I don’t have health insurance. Even animals have ID numbers and veterinary health insurance. Why don’t we have health insurance? Because we did not work on this intensively. A draft law is pending, and it is expected to be concluded within the next few weeks.
Some say that with health insurance the health care system will flourish, but we — as with every other country — will continue to face problems. This is especially true in countries in which there are limited collected funds. We don’t have many employed people, but we have many people who need medical treatment.
Public opinion seems to mistrust Kosovo’s health care system. Is this a fair perception? What steps need to be taken to change this situation?
There is a negative perception of the healthcare system. One of the reasons behind it is that within the system there are irresponsible people who have abused patient funds. Very often, professional ethics have deviated, because even the people who are supposed to oversee such issues did not control the situation. No measures were taken against abusers. How do we eliminate such phenomena? We need cooperation between medical personnel, citizens, media and institutions. It is not a deficiency of one party, but of the whole system.
Photo: Atdhe Mulla / K2.0.
What role does an honorable doctor have in denouncing these cases?
They have to judge actions. We must do it without hesitation. There are cases in which doctors themselves have denounced actions which are not based on professional ethics.
I am not only talking about ethics. There were also cases of corruption and other violations…
It is difficult for medical personnel to do this job. We have other bodies which are supposed to deal with such issues. In these circumstances, patients must raise their voice through mechanisms which have been established to protect patients’ rights. Cases must be reported to the police, because if we stay silent, then we will have more such cases and the situation will be exacerbated.
"Patients are financial objects. This is especially true in the private sector."
What role has the private sector played in Kosovar health care?
It seems that it did not achieve the objective which it was created to achieve: to foster healthy competition between the public sector and the private sector. I believe that the private sector — which is built on staff that also work in the public sector -— has degenerated the approach towards patients. It has created a situation in which only people who have money can be cured.
It has exacerbated the situation in the public sector, it has made patients more sceptical by accusing the public sector of not offering proper services. The private sector has opportunities because it has better conditions. But let’s not forget that a great number of medical staff who work in the public sector also work in the private sector.
Photo: Atdhe Mulla / K2.0.
Is patients’ health at the core of these two sectors?
It should be, but I’m not so sure that it is. Patients are financial objects. This is especially true in the private sector. The situation has been stated in many reports, which have highlighted that there is potential for further deviation and exacerbation. Patients are leaking from the public to the private sector, with doctors recommending those with money to go private.
Patients’ health is not in focus. There is room for improvement, especially in the approach towards vulnerable groups: children, the elderly, people suffering from chronic illnesses, disabled people, poverty-stricken people.
What role have international foundations played in defining Kosovar health care?
All spheres have faced the consequences of the diverse mixture of foreign institutions and interest groups which have participated in increasing capacities in the Kosovar health care sector. For example, primary health care has been influenced more so by the British and their model, namely the model of [national] health insurance, which we don’t have. Americans were focused on the hospital health care system. Whoever helped, implemented their policies. So we have a mixture of everything and are trying to achieve something.
If we are unhappy with the health care system in general, then we can come to the conclusion that none of the above-mentioned models have been successful. So we must transform these small creations into our own bigger creation, so that the pictures in the gallery can create unified policies.
If they remain separated then it will not facilitate a functioning and integrated health care system. We cannot have them be separate. If someone is injured, we can’t tell them that the only treatment they will get is primary health care. Maybe they need secondary or tertiary care. If we do not manage to connect them, we will surely have failures and disappointments.
Photo: Atdhe Mulla / K2.0.
Shouldn’t this connection have been made by institutions, the institute, the faculty and experts?
The institute had the capacity to do it, but often foundations imposed themselves with their money. When they gave us money, we were obliged to do their work, unaware of the damage caused to long-term policy. Maybe improvements were made, but mostly to the facade. Inside, it was chaos. Now, with our powers, we need to orientate our healthcare system.
After the end of the war, around 700 doctors were needed in the primary health care system. The Ministry of Health offered specializations which might not have served the system. Investments have been made that do not translate into benefits in practice. So I believe this is our general failure, and again I cannot say that there is only one culprit. Is it because we didn’t raise our voice, because our voice wasn’t heard, or because we lacked professionalism?K
This conversation has been edited for length and clarity. The interview was conducted in Albanian.
Feature image: Atdhe Mulla / K2.0.
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