Kosovo is the only country in the Western Balkans whose citizens do not have access to public health insurance. At present, only individuals who can afford private insurance have any health coverage. Others must rely on the public health system, which is widely criticized for its poor quality, or spend large sums to receive care either in the private sector or abroad.

Critics have constantly accused successive governments of neglecting the health sector. The University Clinical Center of Kosovo still follows an administrative guideline approved in 2007, when Kosovo was under UNMIK administration, which sets the prices for health services. Prices vary depending on the type of service, ranging from as low as 1 euro and reaching up to 350 euros for certain invasive surgeries, such as heart catheterization, coronary angiography and other treatments.

In addition to paying for services, patients often encounter a lack of appropriate equipment, as most infrastructure has not received investment for years. Basic supplies, like syringes and materials for CT scans, are often missing and patients must cover the costs themselves. They also pay for their own medications.

Long waiting times for services like CT scans or MRIs push citizens to opt for private health care over public options. In more complex cases, they seek treatment abroad. Over the last decade, the health sector has also struggled with a shortage of staff, as highly qualified employees have migrated to European countries in search of better wages and working conditions.

Ensuring all citizens have health insurance is seen as a way to make medical services accessible to everyone while also improving the quality of care in public health institutions.

Health insurance has been a recurring promise in electoral campaigns and government programs, including that of Vetëvendosje, the ruling party since 2021 that is seeking a second term in the upcoming elections in February 2025. The health insurance bill has been on the government’s legislative agenda since 2022 but was not approved until August 29, 2024.

The government’s approval of the bill is just one step toward implementing health insurance, as its history shows. Kosovo already has a law on health insurance. In April 2014, the Assembly of Kosovo approved the Law on Health Insurance, and the Ministry of Health, under the Democratic Party of Kosovo, planned to start collecting contributions in January 2017 to begin establishing the Health Insurance Fund.

At that time, the government of Kosovo allocated 17 million euros for implementing the law, but later redirected these funds to pay war veterans’ pensions. Budgetary constraints were one of the reasons health insurance was sidelined over the years, and the 2014 law was never implemented. From 2017 to 2024, despite four changes in government and repeated promises, no concrete steps were taken to implement health insurance.

Despite the clear advantages of a comprehensive health insurance system, critics have raised concerns about the program’s sustainability over the years. They have pointed out the lack of readiness among state institutions to manage the program, the poor state of public health institutions and the possibility that implementing the health insurance program might push citizens to seek care at private health clinics.

With the bill still far from becoming a fully operational program, K2.0 reviewed the version passed by the government and broke down its key implications.

Who is required to have health insurance?

The program will ensure that health services are comprehensively extended to the entire population, providing equal access to health services even for the poorest citizens. The only difference lies in who pays: the employee and employer, or the state.

According to the draft law, there will be two types of health insurance: active and inactive. Active insurance will be required for employees over 18, the self-employed, individuals receiving pension payments accumulated during their work and all other residents who are at least 18 years old and do not benefit from other schemes.

Inactive insurance will cover dependent family members, such as children under 18. It will also apply to unemployed individuals, those receiving a basic pension, those aged 18 to 28 who are studying or undergoing training and individuals participating in state-funded social schemes.

Who will pay for health insurance?

The gross salary of employed citizens over 18 years old who do not belong to any social schemes will be taxed at 7%. Of this, 3.5% will be paid by the employer and 3.5% by the employee.

For example, if your monthly gross salary is 500 euros, 35 euros will be deducted from your salary, with 17.5 euros paid by the employer and 17.5 euros paid by the employee. This means that, on an annual basis, a citizen with a gross salary of 500 euros will contribute 210 euros to health insurance.

If both parents work and the children are under 18 or are studying until age 28, the children will be co-insured through the insurance of the parent with the highest gross salary.

The government will cover the contributions for categories that cannot make this payment themselves, as detailed in the following table.

Critics have highlighted the budgetary implications of implementing this program. These implications have been used to justify the delay in health insurance implementation. In addition to covering contributions for all exempt groups, the state budget will also cover 3.5% of the gross salary for about 85,000 public sector workers.

While there is no analysis of the total cost of health insurance for these categories, in 2021, payments for the social scheme cost 400 million euros, or 16.6% of the state budget. In 2024, about 24% of the state budget went to public sector salaries. 

What happens if you don’t pay for health insurance? 

Citizens not registered in the insurance scheme will pay for health services according to a price list approved by the Ministry of Health. However, regardless of their insurance status, all citizens will still have free access to essential health services in public institutions. These services will be outlined in a list before the health insurance program is fully operational.

Will health insurance cover all health services?

Yes and no. Health insurance will cover a package of services either fully or partially. Citizens will need to make additional payments for services that are only partially covered. If they receive services not included in the package but deemed necessary, they will be reimbursed.

Will treatment abroad be covered?

Health insurance can cover the expenses for treatment abroad if such treatment proves to be necessary for the insured’s health and cannot be performed by health institutions in the country.

What is the package of services and benefits?

The fund will design a package of health services available for free or with partial payment under health insurance, while the specifics of the service package can vary and the draft law outlines what it might include. Here’s what may be part of a typical health insurance package:

The package also offers access to a network of medical service providers, including doctors, specialists, hospitals and clinics, which you are encouraged to consult, visit and use.

Who will manage health insurance?

The approved bill establishes a Mandatory Health Insurance Fund to manage health insurance. This fund will oversee the implementation of health service policies and enforce the health insurance law. The fund will propose the levels or amounts of contributions, co-payments, additional payments and other financial resources necessary for compulsory health insurance.

The fund negotiates and establishes contractual relations with health institutions and pharmacies in Kosovo for the services and products included in the benefit package.

However, a Compulsory Health Insurance Fund already exists. It is unclear whether a new institution will be created or if the existing fund will be used. The article on the establishment of the fund might have been carried over from the 2014 law that served as the basis for the draft law.

Established in 2018, the fund has managed the treatment of patients abroad, with these treatments subsidized by the state budget. In 2022, KOHA reported on abuses in the fund, including issuing referrals for treatment abroad without proper criteria, negotiating invoices for clinics in Turkey through outside agencies and paying amounts that differ significantly from the invoices issued. KOHA also reported that the fund owed tens of millions of euros to Turkish hospitals. This year, the State Prosecutor’s Office began investigating the mismanagement of the fund’s budget for treatment abroad. Some hospitals abroad have rejected bills submitted by patients to the Health Insurance Fund. These invoices, suspected to be fraudulent, appear to have been issued by hospitals in various countries, including China.

When can it be done?

Although the government’s approval of the draft law on mandatory health insurance was met with enthusiasm, critics argue that it will take over five years to fully implement the health insurance system in Kosovo. Once the government approves the draft law, it will go to the Kosovo Assembly. It must first pass a reading, address comments and then be approved in a second reading before it can be finalized and come into effect.

One of the key systems needed to make health insurance functional in Kosovo is the Health Information System (HIS), which has not been implemented.

HIS is an electronic system and database for tracking medical care for every citizen in Kosovo. It would collect health data, including visits, diagnoses and medications received. It would allow medical history to be accessed at any health institution without requiring citizens to keep numerous documents and reports on their health status. Public and private health institutions would enter new data into the system, ensuring that the information is constantly updated.

In April 2024, Health Minister Arben Vitia stated that implementing HIS would take at least two years, while implementing health insurance would require four years. He mentioned that the Ministry of Health had completed the feasibility study for HIS and the action plan for its installation. To facilitate this, the ministry requested a loan from the World Bank, which was in the final stages of negotiation in April 2024.

Will contributions be paid before the insurance becomes operational?

The approved version of the draft law does not address this issue. However, an earlier version of the draft law stated that contributions could only begin once certain preconditions were met. First, the package of health service benefits must be approved. Second, the list of services provided free of charge must be defined and financed.

Another requirement was to set fees for each health care service and product. Before collecting premiums, the draft law stipulated that contractual agreements with health institutions and pharmacies must be established and co-payments and other levels of co-financing must be defined. These prerequisites have been removed from the approved version of the draft law.

Approving the health insurance draft law is just one step in fully implementing health insurance in the country. After the Assembly of Kosovo passes the bill and HIS becomes operational, the list and price of services will still need to be determined.

Given that national elections will be held in six months — on February 9, 2025 — and the party or parties in government may change, it remains uncertain when all Kosovars will have access to health insurance.

Feature image: K2.0

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