Liberalisation and reform of the health service in Albania.
As is clear, the health care system in Albania remains essentially public and centralised. The majority of health care services, including those in prevention, health promotion and diagnostics, as well as in providing cure, are provided by the state. Private health services reappeared in Albania at the beginning of the 1990s following the collapse of the communist regime, while new legislation and the reform of the health sector have paved the way for the development of various types of private services and facilities.
Today, the private sector provides the following important health services:
• Drug distribution. Most of the drug distribution system in Albania is privately owned. A dozen wholesale companies import most of the drugs, biological products and diagnostic equipment in the country. A network of more than 700 private pharmacies and pharmaceutical agencies ensures a good distribution of drugs all around the country, including in rural areas. The establishment of a health insurance scheme and the subsidising of essential drugs have strengthened the development of the private drug distribution network;
• Dentistry. Dental care is private, with the exception of an emergency dental service and services provided in school to children from the first to the twelfth grade. Both these public services are provided free.
• Medical care. Private medical care has been developing rapidly, despite the country’s difficult economic situation. Most private services are provided in diagnostic centres and specialised out-patient clinics located in large urban areas, particularly in Tirana.
Most private sector facilities are well-equipped and well-organised; some of them are financed and materially established by private agencies or religious bodies such as the Roman Catholic church or the Christian Orthodox church. However, there are no mechanisms in place to monitor the quality of the services offered by private facilities.
In addition, there is no exchange of information between private and public facilities. Most developed countries have a mixture of both public and private sector financing and provision of medical care. For example, in the UK most medical care is provided by state-owned medical institutions and financed from public sources – primarily from central budgets.
The major distinction is that in Albania, as in several countries of the former soviet bloc, the bulk of primary care is provided by the stateowned institutions, which employ both primary care providers (district physicians responsible for serving a specified area) and specialists.
In the UK and most other western countries, primary care is separated from secondary care (financially and operationally), the latter provided by private free-standing practitioners who contract to health authorities to supply a specified volume of care to a registered population. This is an example of public finance and private provision.
An example of public finance for private provision that has begun to be implemented in several regional hospitals in Albania relates to hospital support services, for example laundry, cleaning, security, canteens, etc. By using competitive tendering and contracts for specific services, hospitals may be able to make cost savings and obtain a better quality of service than if they used in-house services.
The health sector in Albania has to solve several problems in connection with increasing public spending on health as a percentage of GDP:
• recurrent spending should increase from 2.1 per cent of GDP in 2001 to 2.4 per cent of GDP in 2004
• investment spending should remain at 0.8-0.9 per cent of GDP (source: Ministry of Finance – Medium-term expenditure framework 2002-2004).
But, regardless of the associated action that must be undertaken, the state of national health care in Albania dramatically reflects the important changes which have occurred in the past ten years all over the country and which, at the present time, appears to be significantly inadequate to respond to the health care needs of the population.
Several indicators that are linked with life expectancy, infant and maternal mortality, etc. demonstrate that health conditions in Albania are not good. Such a situation is also reflected in hospitals that are not adequate because the number of hospital beds is low compared to the population while, even so, their occupancy rates remain really rather poor. Such a situation requires the formulation and development of policies and plans for the Albanian health sector and, above all, for the liberalisation of health services.
However, basic questions of the reform of health care, as well as of the liberalisation of health services, are linked to health expenditure and how the burden of funding of the health care system can be distributed. The level of financing of health care in Albania remains very low; the system is funded through a mixture of taxation and statutory insurance but, while the bulk of funding still comes from the state budget, the tax
base is problematic due to low incomes, the large informal economy and problems with the collection of taxes.
In 1999, health care was financed as follows: 59 per cent from the state budget; 29 per cent from household payments; 4 per cent from employer health insurance contributions; and 8 per cent from foreign donors. Such a situation requires the liberalisation of health services as well as their privatisation.