Gaining health : analysis of policy development in European ...

doctors are not trained in general practice. A typical health
post is staffed by a nurse or midwife and provides maternity
care, child health care services and immunizations. Rural
health services have ceased to function in some areas owing
to a shortage of equipment and staff resignations.
In urban areas, large polyclinics provide specialized outpatient
care, but are now also used by people as their first
point of contact with the health care system. Previously,
patients had to be referred for specialist care by their
general practitioner (GP), even though GPs were not highly
respected as health professionals. This referral system is no
longer used. The Ministry of Health has introduced fees for
those who bypass their GPs but, so far, this disincentive has
had little effect.
Local authorities now own PHC facilities in rural areas,
whereas in urban areas health care facilities are still owned
by the Ministry of Health. This division in the country’s decentralization
of health services has led to underfunded rural
health services and better funded urban health services.
Reform of the PHC system began in 1992, guided by the
EU’s PHARE programme (Assistance for Economic Restructuring
in the Countries of Central and Eastern Europe),
the World Bank and WHO. PHC facilities remain publicly
owned, with the exception of licensed private pharmacies
and dental clinics. The PHC policy, which was developed
in 1997 with EU support, states that there should be at
least one health care centre in each commune and one
health post in each village. Health centres are supposed to
be physically separate from polyclinics, medical centres and
hospitals. Many health centres were renovated and reequipped
during 1999/2000, and the Ministry of Health is
rebuilding others with financial assistance from the European
Commission’s Humanitarian Aid Office (ECHO), the
World Bank and the German Government. The policy proposes
that primary care teams have to be led by GPs. The
planning guideline is one GP per 2000 inhabitants in urban
areas and one per 1700 inhabitants in rural areas.
The Ministry of Health, with assistance from donors, has
started integrating separate health services into PHC teams.
As part of this process, tuberculosis prevention services,
which are part of a national programme administered
through the districts, will also become part of the PHC
system. Public health and preventive services such as school
health and health education will also be included, along with
maternal and child health and family planning services. Recently,
mental health services have been tested at the level
of primary care, with the support of the Swedish Government
and WHO. A pilot integration project has been set
up in the Tirana Prefecture in connection with the development
of its regional health authority. The World Bank
is supporting this effort. At present, PHC teams have very
limited actual involvement in NCD prevention (3).
2. Albania’s approach to developing policies
to tackle NCD
2.1. How things started
In 2003, Albania developed a document on health promotion
and disease prevention. In fact the process was initiated
by the World Bank as a condition for a loan. The relevant
Albanian authorities were quite open to the idea but were
not very motivated or convinced of the rationale of such
a policy measure. Consultants from the London Development
Agency drafted the text in cooperation with a small
group of internationally trained Albanian experts.
The first draft was considered by the Albanian partners to
be too theoretical and not specific enough for Albania. The
drafting team was requested to prepare a more balanced
and action-oriented document with specific priorities reflecting
the Albanian situation.
Chapter 4
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Case studies: policy development in countries for tackling noncommunicable diseases