Will the transition ever end???

International organizations, experts of public health, health systems, global health, and governments of many countries have been talking a lot last year’s about universal health coverage, free medicaments, health as a human right, etc. Many countries are trying to promote health in all policies but in other countries these concepts look paradoxes if you compare with the situation that people face day to day. Albania is one of the countries that after 1991 started a big change in its history passing from a communist to a democratic country.

Prime Minister of Albania says: - Health system needs a radical change

 In that period of time people thought that this revolution was a miracle but soon the revolution became a slow evolution. A period of transition needed to be passed. This big change was also mirrored in the health system and health managers faced big difficulties to maintain the same health services with fewer resources. During 24 years, governments formed by different political parties implemented various strategies but still the health system is facing big problems. International transparency mentions that health sector is the second most corrupted sector in Albania after the justice one. 

https://www.youtube.com/watch?v=WreYT010rJA

Here you can find a chronic of an Spanish TV about the current situation of health system in Albania

One of the biggest problems Albanian Health systems is facing in the lack of medicaments in the hospitals and health centers. In many cases patients need to buy medicaments in the private pharmacies which can be easily located near the public hospitals. In Albania, the distribution of medicaments in the hospitals is done based in the needs of each hospital but the procedure of buying medicaments is undertaken by the Ministry of Health through a public tender. The procedures of this tender each year take a lot of time and occurs that half of the year patients have free access with hospital medicaments and half of the year not.  In April 2014, the government changed the procedures for the tender aiming to facilitate the process of buying the medicaments. In the same time the list of medicaments bought by the government was 525 compared with 327 types of medicaments bought by the public system in 2013.(1) This is a very good news but wasn’t it too late in April not to have medicaments still in the hospitals? Under this situation the procedure of Tender can start in December or November of each year in order medicaments can be in the hospitals in January of the next year. 

The government has increased the fund allocated to medicaments with 15% or 2 million of dollars. On the other side financing of all medicaments for hospital usage for a poor country as Albania is an expense that cannot be afforded. The real fact is that patients are contributing in financing the health system in Albania. The medicaments offered by the system are 525 as the minister mentions and the other type of medicaments or medical equipment need to be bought by the patients. Under this situation, wouldn’t it be fairer to accept the reality and introduce the concept of co-payment which is happening "de facto" but not "de jure"? The public system could buy all the needed equipments and then the patients could pay a bill in the end of their service in the hospital. Medicaments according to the list could be offered gratis for insured patients and the uninsured patients can pay the bill in the end of the service.

The population andhouse holding census of 2011 in Albania estimated that the population was 2.821.977. If we compare with other countries it is evident that Albania is a small country. In right proportion the needs for medicaments will be less than in other countries and the price of the same medicaments will be higher. Minister of Health gave the concrete example how the same medicament Bortezomib with the name trade Velcade for Albania cost 947 Euro and for Turkey 658 Euro which means 42% less. The same happened also for the medicament Trastuzumab.

The countries of the region have also small population as Macedonia (2,091,719) , Kosovo (1,859,203), Montenegro (650,036), Bosnia & Hercegovina (3,871,643) and Serbia (7,209,764). Wouldn’t it be of common interest to buy medicaments together in order to reduce the price of the medicament? The countries of the region can start a common agreement to buy the medicaments through joint procurement and to adapt their legislation according to international examples. The common fund that can be managed by an external agency or an international organization. There can be mentioned the example of PAHO Revolving Fund where 40 countries of middle America and Caribbean countries buy vaccines together. 

The question “Will the transition ever end?” is often asked among the population which sees the transition period the country is facing as the main “guilty” of the general situation. Managers of health system might find solutions like alternative forms of financing through co-payment, changing the period of times of the tenders or starting to work with other countries of the region in order to built a common fund. In the same time population should understand that every change needs to take its time. In order to have an universal health coverage in Spain took approximately 47 years (which changed in 2012 due to economical crisis). Albania has done a lot of positive change during these years and hopefully in the next years we will have a better health system.   

E. Tresa

My destiny or your responsibility???

The improvement of medicine would eventually prolong human life, but improvement of social conditions could achieve this result even more rapidly and successfully- Rudolf Virchow

The Roma community is the largest ethnic minority in Europe. According to Health World Organization in Europe live 12 to 15 million of Roma population(1)  which is characterized primarily by the situation of social exclusion and wide-ranging poverty experienced by a significant proportion of its members. Inadequate access to housing, education, employment and other needs, along with the existence of barriers to Roma access to health services and an ineffective use of these services due to their lack of adaptation and even to discrimination, all contribute to a range of avoidable injustices suffered by this community with regard to their health situation. (2)

UNDP survey data from 2004 and 2011 on Roma show that:

• One third of Roma respondents aged 35 to 54 reported health problems limiting their daily activities. (2011)     
• Approximately 20 per cent of Roma respondents were not covered by medical insurance or did not know if they were covered. (2011)
• 66 per cent of Roma said they could not afford prescription drugs compared to 29 per cent of the majority population. (2004)  
•  15 per cent of Roma children under the age of 14 are not vaccinated compared to four per cent of children from non-Roma households. (2004)(3)

In Albania the health situation of the Roma people is generally bad, due to the unhealthy environment where most of them live. Moreover, the Roma often do not have access to basic health services. High health service costs are the main obstacle towards the medical treatment of the Roma population. Only 25 percent of Roma earn enough income to buy medications. The government considers vaccination of children aged 1-14 years old as a priority measure, but in some cases, the vaccination of Roma children remains problematic particularly in the case of unregistered children or where families do not reside permanently in their place of residence. The Roma population has not enough information about the rights that the law guarantees in the field of health, including the vaccination system.(4)

This video was produced by ADRA 

But is this the destiny of Roma Community or it can be changed?

The social determinants of health influence in the health status of each population but in any case most of the health problems related to social conditions can be prevented. Governments have undertaken concrete steps to integrate Roma Community and improve their health status but the strategies should not be built for Roma Community without Roma Community. It is not only needed to offer free health care to Roma people but also to inform them about the right to health access, vaccination, family planning program. There are needed programs that foster the Roma parents to register their children in order they can access free vaccination. As Virchow says we should have a look to social conditions in order to prolong human life. It is our responsibility, not their destiny. 

E. Tresa

Bibliography

1.  Newsletter. World Health Organization; [cited 2015 Mar 9]; Available from: http://www.euro.who.int/en/health-topics/health-determinants/roma-health/newsletter

2.      Rodriguez. NS, Derecho NR. HEALTH AND THE ROMA COMMUNITY, ANALYSIS OF THE SITUATION IN EUROPE. Bulgaria, Czech Republic, Greece, Portugal, Romania, Slovakia,  Spain [Internet]. Fundación Secretariado Gitano, editor. Madrid; 2009 p. 180. Available from: 

           http://ec.europa.eu/justice/discrimination/files/roma_health_en.pdf

3.     Roma Health Report. Health status of the Roma population Data collection in the Member States of the European Union [Internet]. 2014 p. 153. Available from: http://ec.europa.eu/health/social_determinants/docs/2014_roma_health_report_en.pdf

4.     Duka R. The decade of roma inclusion. National Action Plan 2010-2015 [Internet]. Tirana, Albania; 2015. Available from: 

      http://www.al.undp.org/content/dam/albania/docs/The Decade of Roma Inclusion - National Action Plan.pdf

The right Vs. The Access

Health started to be promoted as a human right in 1997 by the United Nations and later on in 2005 member countries of United Nations decided in unanimous to integrate human rights in their national policies. As well as World health organization World health organization also was recommending health as part of human rights. Local governments took also initiatives by offering universal health coverage (the example of Spain that later on in 2012 due to economic crisis restricted the offered services to a group of population), by laws that offered health care to people with social disadvantages and coming from marginalized groups of the society (minorities, disabled people, unemployed, etc). In Albania the law nr.8626 about “The status of paraplegic and tetraplegic people” approved by the parliament in 22/06/2000 mentions that physical disabled people have the right to have free access to health care and also free medicaments.

But why is needed free universal health care when it is not accessible???

World Health Organization estimates that a billion people, 15% of the word population have some form of disability. Also it is seen that people with disabilities have less access to health care services and therefore experience unmet health care needs. People with disabilities report seeking more health care than people without disabilities and have greater unmet needs. For example, a recent survey of people with serious mental disorders, showed that between 35% and 50% of people in developed countries, and between 76% and 85% in developing countries, received no treatment in the year prior to the study. Health promotion and prevention activities seldom target people with disabilities. For example women with disabilities receive less screening for breast and cervical cancer than women without disabilities. People with intellectual impairments and diabetes are less likely to have their weight checked. Adolescents and adults with disabilities are more likely to be excluded from sex education programs.

At the moment in Albania the total of people with disabilities is 75,044, but this number includes only those who are considered as subject of payment of allowances. The real number might be significantly higher. Albania has a disability legal frame, and all the disabled people have the same rights (education, employment, health) and freedom as others citizens (Article 25 of the Constitution of Albania), but there is still a lot do in terms of their implementing. Regarding the employment situation, the Labor Code prohibits any kind of discrimination and the working hours are reduced to 6 hours per day. Theoretically out of 25 employees, one should be a person with disabilities. Unfortunately this law had been poorly implemented. Regarding the education - many structures are inaccessible, thus teaching staff has no special education on disability.

In Albania, being a person with physical disability means a condition without hope associated with discrimination. Prejudices against disabled people are still strong and discriminating. Moreover, most of the disabled people are poor and have small access to health service. Disabled people face uneven access to buildings (hospitals, health centres), inaccessible medical equipment, poor signage, narrow doorways, internal steps, inadequate bathroom facilities, and inaccessible parking areas create barriers to health care facilities.


Why does a disabled person need free health care when he cannot get in the bus to go to the hospital? Why does a disabled person need free health care when he cannot enter in the health care center due to physical barriers?

https://www.youtube.com/watch?v=DIEbdoiQ2N0#

This video was made by 2 volunteers in Tirana, Albania

Even though health is promoted as a human right and international organisms are undertaking initiatives to integrate “Health in all policies” (lately WHO published Health in all policies manual http://apps.who.int/iris/bitstream/10665/151788/1/9789241507981_eng.pdf) some countries have basic barriers in accessing health services. It is not needed to have free health care but accessible health care. The objectives of health system managers should be orientated in making the services the offer accessible for all the population.

E. Tresa