Forty-ninth Regional Committee for Europe: Florence, 13 - 17 September 1999: the role of WHO in health and health care in Kosovo

WORLD HEALTH ORGANIZATION R e g io n a l O f f ic e f o r E u r o p e C o p e n h a g e n REGIONAL COMMITTEE FOR EUROPE Forty-ninth session, Florence, 13 — 17 September 1999 EUR/RC49/Inf.Doc./5 8 September 1999 12089 UNEDITED - ENGLISH ONLY T h e R o l e o f WHO in H e a l t h a n d H e a l t h C a r e in K o s o v o WHO has conducted humanitarian operations in the Federal Republic o f Yugoslavia since 1992. A humanitarian office in Pristina was opened in 1997. Activities there were discontinued during the recent hostilities. After the peace settlement, WHO returned with the first United Nations humanitarian convoy and has re-established substantial humanitarian operations focused on public health presence and surveillance, support to the local Institute of Public Health, hospital and primary health care management, and a range of public health programmes, together with health care policy, planning and financing. In addition, under the terms of United Nations Resolution 1244, a United Nations Mission in Kosovo (UNMIK) has been established to provide an interim government. WHO is acting as the health component of UNMIK’s civil administration component and a WHO staff member, Dr Hannu Vuori, has been appointed to the post of “Health Commissioner” . WHO is therefore taking a primary role in both the maintenance and promotion of the public health and the management of the existing health services in Kosovo, as well as in the planning and development of new structures. Currently WHO is deploying 25 international and 38 national staff in both the humanitarian and UNMIK dimensions of its work. To support this, work funds of around US $10 800 000 have been raised either in cash or as pledges from a number of generous donors. As a working assumption, and subject to resources remaining available, WHO anticipates continuing with its activities in Kosovo for 2 years. A detailed planning and budgeting exercise is currently underway to identify all the staffing and cash resources that will be needed for the next 12 months. EUR/RC49/Inf.Doc./5 page 1 B e f o r e t h e c r is is 1. WHO started humanitarian operations in the Federal Republic of Yugoslavia in October 1992, within the frame of the United Nations consolidated interagency appeal for humanitarian assistance in the former Yugoslavia. Humanitarian assistance programmes have continued to date, during and after the period of United Nations sanctions affecting that country. WHO’s aim has been to ensure that the most fragile and neediest people receive assistance throughout the country. Accordingly, WHO currently has humanitarian offices open in both Belgrade in Serbia and Podgorica in Montenegro. 2. WHO opened a humanitarian office in Kosovo in 1997, with international and local staff. Prior to the recent crisis, WHO’s humanitarian offices in Kosovo were managed by the Head of Office in Belgrade as a component of the overall programmes within the Federal Republic o f Yugoslavia. These programmes comprised: • assistance to local structures in health surveillance; • coordination of humanitarian assistance in the health sector; • the surveillance, prevention and control of communicable diseases, including substantial immunization activity; • assistance to sustain primary health care in the fields of drug policy and support to the pharmaceutical sector; • support to the development of appropriate health policies. T h e c r is is p e r io d 3. During the recent crisis, WHO international and local staff left Pristina. Similarly, after the start of the NATO bombing campaign, international staff left the Belgrade office. However, both the offices in Belgrade and Podgorica remained open throughout the campaign. Local staff continued to work in the fields of public health surveillance and the coordination of humanitarian assistance, within the operational limits imposed by the hostilities. 4. Specifically, the then Head of Office in Belgrade, Dr Stephane Vandam took part in the humanitarian assessment mission to the Federal Republic of Yugoslavia conducted during the hostilities by the Under-Secretary General for Humanitarian Affairs, Mr Viera Sergio de Mello. THE PEACE SETTLEMENT AND IMMEDIATELY THEREAFTER 5. WHO staff returned to Pristina with the first United Nations humanitarian convoy, and immediately re-established the humanitarian office. Since then the number of international and local staff has increased considerably. In addition, under the terms of the peace agreement for Kosovo set out in Security Council Resolution 1244, the United Nations Mission in Kosovo (UNMIK) was established to provide the civil administrative structures and functions of an interim government. UNMIK has mandated WHO to oversee the planning, regulation and supervision of the public health and health delivery systems in Kosovo. 6. Accordingly, the Regional Director wrote to the Special Representative o f the Secretary General (SRSG), Dr Bernard Kouchner nominating Dr Hannu Vuori as Health Commissioner. This nomination was accepted and Dr Vuori is now in post. EUR/RC49/Inf.Doc./5 page 2 T h e o r g a n iz a t io n a l s t r u c t u r e 7. A simplified organizational structure for all current WHO activities in Kosovo appears at Annex 1. T h e PRESENT SITUATION • Introduction 8. Health related activities in Kosovo currently consist o f three groups. In many technical areas, WHO has acted on behalf, or in support of, UNMIK. 9. Humanitarian assistance: WHO, the United Nations Children’s Fund (UNICEF), the Office o f the United Nations High Commissioner for Refugees (UNHCR), the International Committee o f the Red Cross (ICRC) and a great number of nongovernmental organizations (NGOs) have responded to the acute needs. The response has been mostly satisfactory. WHO has developed policy guidelines to ensure that the emergency activities support the future development needs. 10. Management o f existing health services: This has been primarily the responsibility o f the local “authorities” most health care institutions having a director either elected by the staff or appointed by one o f the political factions. WHO did, however, react to the initially chaotic hospital management situation by inviting, with UNMIK’s consent, international management teams to manage the hospital operations. WHO has also helped the Institutes o f Public Health to get going. Finally, many WHO activities related to health planning and policy development have influenced and guided the health care management in Kosovo. 11. Medium and long-term planning and health policy development. WHO has tried to anticipate the future development needs o f Kosovo’s health care system and support the work o f UNMIK/Health and Social Services by launching several policy activities. WHO’s policy guidelines have been widely discussed from the Joint Civil Commission on Health to regional health coordination meetings. They have already had an impact: all major donors expect the projects they fund to adhere to these guidelines. Several implementing agencies and NGOs have changed their plans to comply with WHO recommendations. 12. Re-establishment o f the health monitoring and surveillance has been one o f UNMIK’s and WHO’s priorities. All activities, be they humanitarian assistance or management o f development, should respond to the needs o f the people in Kosovo. • Health Status 13. Before the crisis, Kosovo’s health care statistics were among the poorest in Europe on virtually every health indicator. Kosovo was the political and epidemiological tinderbox o f Europe. Some statistics will illustrate the situation. • 50% of the population is under 20 years; 1.5% over 75. • The population growth rate is 1.7%; the fertility rate is high. • Infant mortality is 23.5/1000 - high for Europe; neonatal and early childhood mortality are also high. • Most common childhood illnesses are respiratory and diarrhoeal. • There is a low prevalence o f breastfeeding. • Adult morbidity and mortality are mostly from heart and lung disease, diabetes, stroke, and cancer. • Tuberculosis incidence is high at 60-70/100 000. • Due to Balkan endemic nephropathy, haemodialysis needs are high. • Environmental pollution (air, water and soil) is very significant. Water quality remains unpredictable because of extensive reliance on surface water, soil pollution and badly maintained and leaking water mains. • Hepatitis A epidemics are a recurring phenomenon. • No major outbreaks of other communicable diseases occurred during the recent crisis. • The prevalence of sexually transmitted infection (STI) level is suspected to be high, but information is scanty and STI treatment is not systematic. • Although no comprehensive figures are available, the incidence and prevalence of post-traumatic stress syndrome is assumed to be very high. • Nutrition surveys before the bombardment and in the refugee camps showed no significant problems. • Injuries due to landmines are at 10 per 100 000 during one month in June-July. This is an extremely high incidence. • Health care system Status • The system inherited from the Socialist Federal Republic of Yugoslavia was top-heavy relying heavily on hospitals, doctors and drugs. • Nursing services are poor and community services almost non-existent. • While health authorities in the Federal Republic of Yugoslavia had realized the need for health care reform, the normative and rigid health care planning tradition have rendered the efforts to modernize and streamline the system difficult. • There is little local competence in health care planning, policy development and health economics. • There is no local over-all plan for the development o f the health care system. • The collapse of the central health administration has forced each Kosovo health facility to provide services independently resulting in uncoordinated, even chaotic provision of services. • There are great expectations concerning the payment of salaries to the health personnel. Activities • WHO has produced guidelines for many aspects of the functioning of the health care system and health system recovery is beginning. • With WHO’s help, UNMIK/Health and Social Services prepared a costed proposal to UNMIK Civil Administration for payment of financial subsidies to all health workers. • With the support of WHO, international management teams, many NGOs and local health care institutions, UNMIK/Health and Social Services has compiled lists of health care workers currently active. • The payment of subsidies has begun. • At the request of UNMIK/Health and Social Services, WHO has produced the first draft of a Health Policy Paper proposing the way forward for the Kosovo health care system, along with a six-month action plan. A participatory consultation with the local and international community is ongoing. • WHO has issued guidelines on hospital and primary care rehabilitation and development for use by local and external providers have been issued. EUR/RC49/lnf.Doc./5 page 3 EUR/RC49/Inf.Doc./5 page 4 • WHO has established a system of health sector coordination meetings involving all stakeholders at central and regional level. • WHO has supported UNMIK/Health and Social Services in the recruitment of five Regional Health Managers. They will provide leadership and coordination for regional health care planning, budgeting and development. • UNHCR has developed a database of all agencies active in Kosovo and WHO is complementing this with additional information on health service providers/agencies and their inputs. H e a l t h S e r v ic e s Primary health care Status • The primary health care (PHC) system has been based on 26 health houses (health centres providing PHC and specialist services) and 308 ambulantas (small health centres staffed by a doctor and nurses, providing basic PHC). • The Mother Theresa Association (supported on a voluntary basis) developed in the last decade a parallel PHC service through 96 ambulantas spread in the most remote, rural areas of Kosovo. They have re-started PHC activities in 11 ambulanta. During the recent crisis, also some private ambulantas provided care. • During the recent crisis, the state ambulantas suffered little damage, though many were looted of equipment. 80% of the Mother Theresa ambulantas were severely damaged. The quality of buildings and equipment of many ambulantas was poor already before the crisis due to a lack of maintenance and repair or because they were makeshift facilities. • The health staff have been strongly affected and, like other population groups, became victims of the crisis that badly interrupted the provision of services. Most Albanian staff have returned to work but the great majority of Serb staff have left. Activities undertaken • Under WHO’s coordination, international NGOs are running 15 mobile PHC teams; emergency drug kits have been distributed through NGOs to the functioning PHC facilities. • WHO has helped to establish an interim epidemiological surveillance system based on reporting by the ambulantas and the NGOs. • Coordinated by UNMIK/Health and Social Services, WHO staff and many NGOs are carrying out a detailed mapping of population and health facilities in all regions. • Coordinated by UNMIK/Health and Social Services, an assessment o f the training needs of all health professionals working in PHC is going on. • Coordinated by UNMIK/Health and Social Services, the international hospital management teams are carrying out an assessment of the training needs of all health professionals working in hospitals. • In cooperation with UNMIK/Health and Social Services, WHO has developed and distributed policy guidelines for PHC. The guidelines stress: - family medicine; - larger catchment areas; better diagnostic facilities; greater role for nursing and community services; and the gatekeeping role for PHC. EUR/RC49/Inf.Doc./5 page 5 • A survey of all PHC facilities as regards infrastructure, equipment, epidemiological data reports, staff and priority needs is being designed with Centers for Disease Control (CDC)/Atlanta, International Rescue Committee and the Institute of Public Health. It will complement an initial assessment of the physical infrastructure by the EU Task Force. This will lead to a facility master plan and repair of those facilities included in the plan. • Hospitals Status 14. The main problems are redundant and poorly skilled staff, and poor quality institutions due to badly maintained facilities and outdated or rundown equipment. Nursing training has always been poor. Some Albanian doctors have not worked at all as doctors during the past years. Many specialist doctors had to work as GPs in the Mother Theresa ambulantas, thus losing their specialist skills. Other problems include: • an oversupply of staff; • a lack of some specialists (e.g. anaesthesiologists, surgeons) and some super-specialists (e.g. endocrinologists); • an irregular supply of drugs. While drugs on the essential drug list are mostly available, many expensive, less often used drugs (e.g. cytotoxic and immunosuppressive drugs) are lacking; • lack of spare parts; • lack of food for patients. The World Food Programme is expected to start a supply programme soon; • generally bad conditions due to lack of maintenance: water, waste disposal, kitchen hygiene, oxygen supply, etc; • lack of security; • lack of management skills (and sound management traditions); • access to hospitals is not equal; in Mitrovica, the Albanians are afraid of going to the hospitals; in most other hospitals, the Serbs fear for their safety; • no clear referral pattern. Many hospital patients are self-referred resulting in over- and inappropriate use of hospital services. 15. The following table shows the main hospitals in Kosovo and the current situation concerning international management teams: Hospital Bed number International m anagem ent team Pristina 2306 British (Department for International Development - DFID) Mitrovica 543 French (Action Humanitaire France) Gjilane 506 Finnish (Finnish Red Cross) Peja 541 Italian (Italian Cooperation) Prizren 605 Germany (Johanniter Order) Djakova 598 Swedish (SIDA, under negotiations) Stimje 303 Norwegian (ICRC) Activities • A q u ick assessm ent o f the m ost urgent unm et needs has begun. T he E U T ask F o rce is expected to carry out a detailed assessm ent. T he find ings w ill be used to develop a facility m aster plan. EUR/RC49/Inf.Doc./5 page 6 • At the request of UNMIK/Health and Social Services, WHO identified international management teams for most hospitals (see table above) to provide leadership and management and to introduce reform. • The international management teams are assessing the skills of the staff to enable a revalidation of their qualifications and to identify training needs. • The international management teams are in the process of twinning the hospitals where they work with health care facilities (mostly university teaching hospitals) in their home countries. This twinning will be an important mechanism in providing operational support for the hospitals and particularly in retraining the staff. • With the help of WHO, UNMIK/Health and Social Services has established hospital management boards in most hospitals working to common principles. • Public health Status • The closure of the Central Institute of Public Health in Pristina and the branch offices in the regional centres during the bombardment interrupted all environmental health and food control activities. • The surveillance system inherited from the past regime was relatively ineffective because of inappropriate case definitions, a too long list of reportable diseases and weak links to laboratory reporting systems. • The surveillance system run by the Institute of Public Health is not yet fully operational due to lack of forms in health facilities, and lack of fuel and transport. An interim surveillance system is in place with NGOs supporting primary health care facilities reporting. • Laboratory capacity for testing food, water and clinical specimens is insufficient. • Food control (particularly meat) is almost totally lacking. Activities undertaken • WHO has helped the institutions of public health to reopen and assisted the central institute to assess the situation in the branch offices. • - With the support of WHO, UNMIK/Health and Social Services has established an international director and management board in the Institute of Public Health. • WHO has produced and distributed guidelines for the management of outbreaks to health care facilities. • An outbreak control team has been established. • ICRC has distributed water testing field kits and laboratory equipment to the regional institutes of public health. • WHO has produced and distributed guidelines on food safety. The public is being educated through local media. Steps have been taken to urgently recruit food controllers and a local veterinarian for meat control. • Mental health Status • The psychiatric system is insufficient, with only 14 psychiatrists and 110 beds. It is very biologically and medically orientated, with no tradition of community services, no social workers, no clinical psychologists and no trained psychiatric nurses. • Treatment relies heavily on drugs. EUR/RC49/Inf.Doc./5 page 7 • There are no services for child psychiatry. • The only provision for mentally retarded people is the Stimje hospital, a rundown institute in great need of trained personnel and physical improvements. • Hospital psychiatric services are overwhelmed by demand and cannot provide an adequate service. NGOs are providing some input in the field but are not supporting the hospital. Activities undertaken • At the request of UNMIK/Health and Social Services, WHO has developed a project proposal for support to Stimje hospital, and has submitted this to all interested donors. • On behalf of UNMIK/Health and Social Services, the Norwegian Red Cross has established an international management team in the Stimje hospital. • WHO and DFID have appointed a Special Advisor in Psychiatry to develop a plan for future services in cooperation with the local professionals. • The Special Advisor is coordinating NGO activity in this field. • WHO has prepared a draft policy paper for future psychiatric services in Kosovo. • Reproductive health Status • Family planning services were disrupted during the emergency. • The majority of births takes place in hospitals under the care of nurses and doctors, but midwifery and obstetric services are poor. • There are very few trained midwives. Activities undertaken • Many NGOs provide contraceptives, essential drugs and equipment. • UNFPA is assessing reproductive health services and developing a reproductive health policy and plan as part of the overall health policy. • • WHO is reviewing nursing, midwifery and obstetric staffing and service. • A WHO consultant has reviewed the situation concerning violence against women. • Pharmaceuticals and drug supply Status • The supply of essential drugs to hospitals, primary health care facilities, and “state pharmacies” is currently assured for up to two months. • Private pharmacies are less regularly supplied but have their own channels. • There is a lack of specific emergency and potentially life saving items (including haemodialysis fluids, cytotoxic and immunosuppressive drugs). Activities undertaken • UNMIK/Health and Social Services has authorized Pharmaciens sans frontieres (PSF) to coordinate the distribution of humanitarian aid drugs. • All major donors, NGOs and local health “authorities” have accepted WHO’s essential drug list. • PSF and other agencies distributing drugs and pharmaceuticals, have currently placed orders to a value o f US $1.8 million. • On behalf of UNMIK, WHO will continue to coordinate drug policy development and supply of pharmaceuticals with the technical assistance and cooperation of existing pharmaceutical staff. • UNMDC/Health and Social Services has established a Task Force on Pharmaceuticals to carry out needs assessment, develop future drug policy and make proposals for the control of the quality of the drugs. • UNMIK/Health and Social Services has drafted an agreement to ensure the use of facilities of a previous central supply warehouse “FARMED”, as the central supply facility to be managed by PSF. • Immediate tasks Health service delivery issues 1. Establishment of UNMIK Regional Health Offices in Gjilane, Mitrovica, Peja and Prizren; recruitment of five regional public health specialists; 2. Payment of financial subsidies to all accredited health workers; 3. Definition of health service staff positions throughout Kosovo (numbers, levels, categories) 4. Health worker credentialling and appointment of appropriate staff to the defined health service posts; 5. Ensure hospitals are functioning with support from international management teams; 6. Ensure drug and equipment supplies at all service levels; 7. Review Medical Faculty plans and taken decision on staff appointments and student entry; initiate institutional link with European medical school; 8. Consider registration mechanism for health NGOs and the screening and approval of all international agency proposals. Establish “model” memorandum of understanding for NGOs. Policy planning and coordination tasks Policy 16. Target date for completion of consultation process on draft Health Strategy document: end-August. Planning Infrastructure • Primary care: • Secondary care: • Tertiary care: Equipment and supplies • standardized list for hospital and health centre equipment and supplies Human resources • planning size, composition and distribution of health workforce • management systems for health workers — validation of credentials, registration, recruitment and deployment — contracts; salary levels; mechanisms for payment — performance assessment; appeals procedure EUR/RC49/Inf.Doc./5 page 8 health fac ilities coverage p lan for am bu lan tas and health houses d istric t hosp ita l site and rehab ilita tion needs contro l o f p roposed new hospital facilities m on ito ring o f facilities at hospital rehab ilita tion o f specialized hospitals EUR/RC49/Inf.Doc./5 page 9 • development of health worker skills — pre-service education medical, nursing, midwifery and paramedical education — post-basic education identify priority areas for overseas training — in-service training; rapid skills up-grading in specific subjects Finances • payment of salaries and accounting for them — costing the plans: preparing the Kosovo health sector budget — financing the health sector - accessing donor funds - establishing cost recovery and/or health insurance systems Coordination • United Nations agencies • Health sector funders (donors) • Nongovernmental organizations • Staffing 17. There are currently 25 international and 38 national staff employed in WHO’s Kosovo operations, including its commitment to UNMIK. It is expected that these numbers will further increase. Numbers vary from day to day because of the significant numbers o f consultants employed. • Funds employed 18. Some US $10 800 000 in cash and pledges has been received to date to support WHO’s work in the Balkans. The donors are: Denmark, Italy, Japan, Luxembourg, Sweden, the United Kingdom, the United States and the European Commission Humanitarian Office (ECHO). WHO is extremely grateful for this assistance. 19. Sums of US $100 000 and US $50 000 have been made available from the Director-General and Regional Director’s Development Funds, respectively. 20. Work is proceeding now on the budgeting o f all WHO’s operations for the next 12 months: UNMIK; core humanitarian presence; institute of public health; hospitals and community care; pharmacy and supplies; and regional administrative operations. It is expected that this will exceed funds currently available, and that further resource mobilization will be required. • The future 21. The pace of political, social, economic and institutional development in Kosovo cannot now be known. Much will depend upon the success of the work of UNMIK in civil administration, civil society and democracy building, and reconstruction. Here also the timing and success of the free elections will be crucial. Further, the timetable for humanitarian assistance may be more limited. That for reconstruction, reform and development assistance will inevitably continue for some years. 22. Therefore, beyond the initial phase of humanitarian assistance, and the present phase of restitution of the existing health services, WHO’s task will be to institute policies and programmes that reflect the European mainstream and a commitment to HEALTH21. HFA policy development and master planning will therefore become a key future priority. To achieve these objectives, there will need to be significant and effective cooperation and coordination between the local offices and staff in Kosovo, and administrative and technical units both in Copenhagen and Geneva. A n n e x 1