Kosovar Albanian Health Survey Report September 1999

1

Kosovar Albanian Health Survey page -

Kosovar Albanian Health Survey Report September 1999

International Rescue Committee

Institute for Public Health, Kosova

World Health Organization

Centers for Disease Control

Prepared by Paul Spiegel and Peter Salama

International Emergencies and Refugee Health Branch,

Centers for Disease Control and Prevention

Map 1

Map too big to email

Acknowledgments

This project was supported financially by the International Rescue Committee (IRC) and additional support was provided by the World Health Organization (WHO) and the Institute for Public Health (IPH) in Pristina.

The authors would like to thank the people of Albania who supported this project by giving their time and hospitality so generously despite the recent traumatic events. We would also like to thank a number of individuals who provided key support during this undertaking. Special thanks to Dr Idriz Gerqari and Ms Marci Van Dyke from IRC and Dr Mike Ryan of WHO. Also from IRC, Dr Rick Brennan, Dr K Raj, Dr Bill Mackenzie, Dr Melihate Mustafa, Mr. Roy Brennan and Mr. Richard Jacquot. From WHO, Dr Maire Connolly, Dr Ardiana Gjini and Dr Kees Reinveldt. From IPH, Dr Skender Boshnjaku, Professor Yusef Dedushaj, Dr Luljeta Gashi and Dr Ariana Kalaveshi. From UNHCR, Ms Annalies Borrel. We would also like to thank Dr Brent Burkholder, Dr Brad Woodruff, Dr Carol Gotway-Crawford, Dr Barbara Cardozo, and Dr Alfredo Vergara of the Centers for Disease Control (CDC). Finally many thanks to the survey teams, data entry staff and drivers (appendix 1).

Group Photo of Surveyors, Pristina, Kosovo, September 1999

Survey Staff: Ibrahim Haziri, Shqipe Bytyqi, Fikrije Ramadani, Anita Krasniqi, Nora Tafarshiku, Bardhyl Reqica, Mimoza Myha, Regjep Reqica, Abdullah Bajraktari, Rahim Beqiri, Rustem Bekteshi, Ganimete Qadraku, Bekim Syla, Aferdita Sadiku, Naim Bilalli, Zana Ismaili, Shpend Hajdari, Hydajete Ademi, Naim Gashi, Lindita Regjepi, Munir Ahmeti, Hyremete Hoxha.

Data Entry Staff: Myrvete Bilalli, Burim Gashi, Valeza Oruqi, Fatmir Belallari, Valbona Kozmaqi.

Abbreviations

AAH: Action Against Hunger

ARI: Acute Respiratory Tract Infection

CDC: Centers for Disease Control and Prevention

CMR: Crude Mortality Rate

DM: Deutsche Mark

DOW: Doctors of the World

DPT: Diptheria, Pertussis, Tetanus

FRY: Federal Republic of Yugoslavia

IMC: International Medical Corps

IPD: Inpatient Department

IPH: Institute of Public Health (Pristina)

IRC: International Rescue Committee

MCH: Maternal-Child Health

MDM: Medecins du Monde

MMR: Measles, Mumps, Rubella

MSF: Medecins Sans Frontieres

NATO: North Atlantic Treaty Organization

NGO: Non-government organization

OPD: Outpatient Department

OPV: Oral Polio Vaccine

PHC: Primary Health Care

RD:Rural Destroyed

RND:Rural Non-Destroyed

TB: Tuberculosis

U5 MR: Under 5 Mortality Rate

UD:Urban Destroyed

UND:Urban Non-Destroyed

UN: United Nations

UNFPA: United Nations Population Fund

UNHCR: United Nations High Commissioner for Refugees

UNICEF:United Nations Children’s Fund

UNMIK: United Nations Mission in Kosovo

USD: United States Dollar

WHO: World Health Organization

Table of Contents

page #

1. Tables and Figures 6
2. Executive Summary, Summary of Key Results and Recommendations 7
3. Introduction 14
4. Background 15
5. Survey Objectives 16
6. Methodology 16
7. Results, Discussion, and Recommendations for each section

1. Demographics 18
2. Displacement 21
3. Mortality 23
4. Child Health 29
5. Adult Health 34
6. Health Decision Making37
7. Health Facilities and Utilization 40
8. Health Costs 44
9. Water and Sanitation 46
10. Sources of Income50

1. General Recommendations 52
2. Appendices
3. Appendix 1:Persons Met 53
4. Appendix 2:Map of Kosovo 54

iii.Appendix 3:Agenda for the Training of the Survey Teams 55

1. Appendix 4:Interviewer Manual 56
2. Appendix 5:Survey Questionnaire in English 58
3. Appendix 6:Survey Questionnaire in Albanian 63
4. Appendix 7: Methodology 68
5. Appendix 8: Sampling frame of clusters chosen for Kosovar 70
6. Appendix 9: WHO classification of diseases 71
7. Appendix 10: Taking Care of Children with Simple Cough or Cold

- or with Simple Diarrhea 72

1. Appendix 11: Member of household usually making the decision

concerning taking a child with diarrhea to the doctor 73

1. Appendix 12: Distance from dwelling to functioning health facility _____ 73
2. Appendix 13: Type of health facility used since end of war (June ’99) ___ 74
3. Appendix 14: Percentage of Kosovar Albanian persons who sought

health care in the 2 weeks before the survey 74

1. Appendix 15: Total numbers and percentages of Kosovar Albanians

seeking health care by type of facility 75

1. Appendix 16: Breakdown of Health Care Expenditures and Related

Costs in 2 weeks prior to interview 76

1. Appendix 17: Water and Sanitation 77
2. Appendix 18: Methods of waste disposal by household in Kosovo______78
3. Appendix 19: Current sources of household income: primary

and secondary79

10. References 80

1. Tables and Figures

Table 1: Demographics of Kosovar Albanian survey population, including age, sex,

and household characteristics 19

Table 2: CURRENT displacement of Kosovar Albanian households as of

September 1999 21

Table 3: Displacement of household at ANY TIME of Kosovar Albanians since

February 1998 21

Table 4: Hospital Deaths in Kosovo by Hospital from August 22 to September 18 1999 24

Table 5: Proportionate Hospital Mortality in Kosovo: August 22 to September 18 199924

Table 6: Disease classification of Hospital Mortality in Kosovo: August 22 to

September 18, 1999 25

Table 7: Hospital Deaths in Kosovar Albanian population by Age Group: Aug 22 to

Sept 18, 1999 25

Table 8: Proportion (%) Mothers Breastfeeding and Formula Feeding Children by

Age and by Rural/Urban Status 29

Table 9: Immunization Coverage (%) in Children Under 5 by Type of Verification

Table 10: BCG Coverage (%) by Age and Rural/Urban Status 30

Table 11: MMR/OPV/DPT Coverage (%) By Age and Rural/Urban Status 30

Table 12: Prevalence Estimate for Chronic Disease by Age Group for Kosovar

Albanian Population, September 1999 31

Table 13: Age breakdown of population who sought health care in the 2 weeks before the

survey + relative risk of each age group as compared to rest of population 34

Table 14: Mean amount in Deutche Marks (DM) spent per household, per person,

and total, on health care by category 40

Table 15: Current major source of drinking water, action before drinking water, system

of defecation in household44

Figure 1: Monthly Mortality Rates of Kosovar Albanians due to Natural Causes

from January 1998 to September 1999 23

Figure 2: Immunization Coverage by Age 31

Figure 3: Proportion of chronic diseases by type in population 5 years and over, Sept 1999 35

Figure 4 : Percentage breakdown by category of treatment dispensed at home

for a simple cough /cold 37

Figure 5 : Percentage breakdown by category of treatment dispensed at home

for simple diarrhea 37

Figure 6: Percentage breakdown by type of caregiver, of those making decisions

concerning when to take child with diarrhea to doctor38

Figure 7 a-c: Health care utilization in past 2 weeks by type of facility used 41

Figure 8: Proportion of money spent by category, on health care and related costs in

previous 2 weeks 44

Figure 9: Histogram showing methods of household waste disposal 48

Figure 10: Primary Sources of household income at present (September 1999) 50

Figure 11: Secondary Sources of household income at present (September 1999) 50

2. Executive Summary

This report summarizes the findings of a province-wide health survey conducted throughout Kosovo in September 1999 by the International Rescue Committee (IRC), the Institute of Public Health, Pristina (IPH), the Centers For Disease Control and Prevention (CDC), and the World Health Organization (WHO). The survey was financed by IRC and received in kind support from WHO and the IPH.

The primary objectives of the survey were to provide baseline information on the current health status and health seeking behaviors of the Kosovar Albanian population after a ten year gap in comprehensive information collection. The areas chosen were deemed to be of importance to local and international health policy makers currently in the process of re-orienting the health system. Areas such as nutrition and food security, hospital facility assessment, psychological health and reproductive health that were or will be the subject of other surveys were not included. The second objective was to develop capacity within the IPH to design, conduct and analyze surveys of this nature.

The survey covered 25 of the 29 municipalities in the province. The 4 municipalities with a majority Serbian population, at the time of the survey were excluded from the sampling frame because of practical considerations. We undertook a separate survey in selected Serbian enclaves in October 1999 which will be the subject of a forthcoming report. A two stage cluster survey with clusters chosen proportional to population size, and separate strata for 4 areas defined as rural destroyed, rural non-destroyed, urban destroyed and urban non-destroyed was implemented. Fourteen survey teams interviewed a total of 1197 households between September 7 - 17, 1999. A 28-day hospital mortality survey was also undertaken to gain a better understanding of the current major causes of death as well as to triangulate the findings of the population-based survey. A population census, which will provide necessary information for all sectors should be implemented as soon as feasible.

The overall epidemiological profile for Kosovo is that of a developed country with low mortality rates and a high prevalence of non-communicable diseases, representing the major burden of disease in terms of morbidity and mortality. From the population-based survey, it appears that the conflict increased the rate of death due to natural causes and this was more pronounced in the elderly. The hospital mortality study showed high levels of mortality in the neonatal and infant periods, which needs further investigation. Poor antenatal care and infant weaning practices may be partially responsible for these deaths. Self-reported chronic disease prevalence rates are high and represent a major burden on the health services. This burden will most likely increase as the population ages. The rate of seeking health services for children under 5 and the elderly is higher than that of other groups.

Overall the public health system seems acceptable to the Albanian population. The ambulanta and health houses provide the majority of consultations. The current high rate of health care utilization may relate to the special circumstances of the recent past and will most likely normalize in the future. The utilization rate will need to be monitored. Health houses appear to be used as primary care centers for the population, and this usage should be shifted to the ambulanta level. Pristina central hospital receives a disproportionate amount of admissions as compared to the regional hospitals, and more services should be decentralized to the regional hospitals where possible. Households spend a significant amount of their disposable income for health care. The largest expenditure is for medications, followed by transportation to facilities. In order to address this issue, the regulation of prescription drugs together with strict clinical guidelines and generic drug lists should be implemented as soon as possible.

In the short term, households without adequate shelter, particularly in the rural destroyed areas, households with more than one family per dwelling, and those households which are currently displaced should continue to be targeted for assistance. It is clear that preventive measures such as public health education and immunization services have suffered during the chronic conflict. Immunization coverage is poor as is maternal knowledge of the correct management of diarrhea. Immunization programs, especially for measles, should be made a priority for all children without vaccination cards, regardless of their previous immunization status, and a standardized recording system should be implemented. In the medium to long term, training for Albanian physicians should stress primary health care, especially maternal-child health care, and outpatient clinic management of the major chronic diseases outlined in this report, including psychological disease. The care of the elderly who have a higher prevalence of chronic disease should be stressed. The development of a home-based public health/community health nursing system to address this problem as well as to help with education and care of post-partum mothers and infants should be considered.

While the authors endorse the proposed re-orientation of the health service towards primary health care, the documented heavy reliance on international aid in households as a primary and secondary income source will affect the ability of the Albanian population to contribute to any proposed cost-sharing mechanisms in the health sector. A study should be undertaken to estimate current household and disposable incomes as well as willingness to pay for health care. Furthermore, many findings of this survey point to an overall lack of a functioning public health infrastructure. Efforts have already been made to establish a communicable disease surveillance system in Kosovo. Other surveillance modules including mortality, chronic disease and health utilization need to be established and integrated into the overall surveillance system. Health education strategies including the promotion of breast feeding, the management of diarrhea, better weaning practices and the hygienic disposal of waste should be undertaken as soon as possible. The primary responsibility for the establishment of a modern public health system in Kosovo resides with the IPH. Resources from the international community will be required in order for the IPH to meet this primary objective.

1

Kosovar Albanian Health Survey page -

Summary of Key Results and Recommendations

rural / urban / Total
Total Survey Pop’n / 6177 (75.6%) / 1998 (24.4%) / 8175 (100%)
Mean age (yrs) / 25.8 [25.1,26.4] / 28.4 [27.2, 30.0] / 26.4
Sex ratio (f:m) / 1.08: 1.00 / 1.15:1.00 / 1.10:1.00
# hholds/dwelling / 1.17 / 1.09 / 1.15
# people/dwelling / 10.0 [9.3, 10.7] / 7.0 [6.2, 7.8] / 9.2
# people/hhold / 6177/837
(7.4) / 1998/360
(5.6) / 8175/1197
(6.8) / Rural Non-
Destroyed / Rural
Destroyed / Urban Non-
Destroyed / Urban
Destroyed
hholds displaced / 80 (9.6%)
[6.1, 13.0] / 64 (17.8%)
[12.7, 22.9] / 144 (12.0%) / 17 (4.7%)
[1.4, 8.1] / 63 (13.2%)
[8.2, 18.2] / 35 (16.3%)
[9.8, 22.8] / 29 (20.0%) [11.3,28.7]
CMR ‘natural’ deaths/1000/month / N/A / N/A / 0.26 [0.18, 0.34] / N/A / N/A / N/A / N/A
Elderly (50+ yrs) CMR ‘natural’
deaths/1000/month / N/A / N/A / 1.20 [0.70, 1.70] / N/A / N/A / N/A / N/A
Distance from health facility (km) / 4.1 [2.4,5.8] / 1.0 [0.8, 1.3] / 3.2 / 5.1 [1.9, 8.3] / 3.4 [1.7, 51] / 1.2 [0.8,1.5] / 0.8 [0.4, 1.2]
seeking care in past 2 wks / 742/6177
(12.0%) / 305/1998
(15.3%) / 1047/8175 (12.8%) / 353/2765
(12.8%) / 389/3412
(11.4%) / 168/1174
(14.3%) / 137/824
(16.7%)
adults with chronic disease / 698/5543
(12.6%) / 301/1824
(16.5%) / 999/7367
(13.6%) / 330/2482
(13.3%) / 368/3041
(12.1%) / 185/1074
(17.2%) / 116/750
(15.5%)

N/A – not applicable because of low incidence of event

Immunization coverage by age

1

Kosovar Albanian Health Survey page -

Recommendations:

1. Short-term

1. A population census, which will provide necessary information for all sectors, should be undertaken as soon as possible.

1. The increased number of deaths of men as compared to women in hospitals at nearly all ages should be investigated, especially regarding access to hospital care

1. Over reliance upon the central hospital of Pristina should be discouraged. Hospital care should be decentralized by equipping the regional hospitals with appropriate materials and personnel.

1. The loss of documentation not withstanding, immunization coverage is very low and programs need to target rural areas. Measles vaccination should be an immediate priority.

1. A new uniform system of documenting vaccination status needs to be implemented across Kosovo.

1. There was a clear deterioration in immunization coverage over recent years and education programs need to be implemented to rebuild people’s confidence in the public health system.

1. Anecdotal evidence suggests that tuberculosis may be a significant and expanding problem, and prevalence and incidence rates should be documented as well as antimicrobial sensitivity patterns.

1. Over-reliance on hospital outpatient visits as well as in-patient visits should be discouraged.

1. NGOs should examine the need for mobile clinics in the locations where they are working, and consider transferring their resources to stationary clinics, if they find their mobile clinics being under-utilized.

1. Given the high rate of neonatal mortality documented in hospitals, these institutions need to be prepared for high risk pregnancies among the approximately 36,000 births/year.

1. Drugs represent a major household health expenditure and need careful regulation and strict clinical protocols accompanied by generic drug lists.

1. WHO should reconsider the budgetary allocation for drugs in their proposed health budget.

1. A study should be undertaken to estimate current total household incomes, disposable income as well as willingness to pay for health care.

1. Employment opportunities and income generating projects need to be targeted towards the rural communities, who rely more upon food aid as their primary source of income and do not have the same opportunity as people in the urban areas to be more independent by relying upon income from business ventures.

1. Although income from employment by international organizations remains a small source of households’ primary income, these organizations should attempt to base more of their offices and operations in rural areas.

1. Surveillance modules for mortality, chronic non-communicable diseases of particular importance, and certain chronic communicable diseases such as TB and HIV need to be integrated into the IPH/WHO communicable disease surveillance system as soon as feasible.

1. Recent events in Kosovo underscore the fact that the health and well-being of ethnic minority communities represents a key public health issue for the present and for the future. Surveillance and public health programs need to be implemented as soon as possible.

1. Long-term

1. Public health professionals should be made aware that CMRs in Kosovo may increase in the future, and that this increase may be a result of the changing demographic characteristics of the population, and not necessarily due to other causes, such as poor health care services.

1. The high proportion of hospital neonatal and infant deaths needs further investigation. Probable factors for the former include poor antenatal care and low birthweight. The high infant mortality may be related to weaning practices. If nurses were given appropriate training, the home-based public health nursing system proposed above, could also be used to educate mothers and monitor breastfeeding and weaning practices.

1. Maternal-child health needs to be a high priority within the health system; increased training of health care personnel, with an emphasis on public health is needed.

1. Breastfeeding rates are within an acceptable range but mothers in urban areas need health education and promotion programs.

1. Weaning practices, particularly the early introduction of cow’s milk and formula, need further study and recommendations must be put into practice soon in order to decrease infant mortality.
2. Chronic diseases are common in this population. Health personnel need to be trained appropriately in order to help prevent and treat these diseases.

1. Public health education needs to be directed at preventing these chronic diseases; since cardiovascular and lung diseases are prevalent, smoking and diet should be addressed.

1. Psychosocial problems account for a significant proportion of chronic disease and need to be systematically addressed for both children and adults.

1. The management of diarrhea is poor in terms of both breastfeeding practices and rehydration techniques. This area needs targeted health education and health promotion programs. These messages should target mothers throughout Kosovo, and potentially grandmothers and fathers in rural areas.

1. Health care decision makers should be educated regarding when to bring in their children to be seen by a health professional. Decreasing the automatic reflex to bring in a child for any minor ailment will decrease the demand on the health care system.

1. If the UNMIK/WHO health care strategy is to be implemented, both health care providers and the public need to be educated in PHC, and rules which require that ambulantas are to be the first stop for care and act as gatekeepers for the rest of the system must be enforced.

1. The current high rates of health care service utilization should be monitored closely.

1. Transportation costs related to health care expenses is a significant household expense, especially in the rural areas, and should be considered by health planners as a factor regarding health care accessibility.

1. Health education messages should concentrate upon the need for the public to cease dumping garbage in open areas and flowing water in the rural areas.

1. A large amount of households in all strata rely upon food aid for the majority of their income/food. Before leaving Kosovo, humanitarian and UN agencies should ensure that basic food supply and food security exists.

1. The primary responsibility for the establishment of a modern public health system in Kosovo resides with the IPH. In order to fulfill this responsibility, the capacity of the IPH in Pristina and at the regional levels, should be strengthened.

1. Introduction

Kosovo is the southernmost province of the Federal Republic of Yugoslavia (FRY- see map in appendix 2) and is considered to be its most under-developed region with an average per capita income of $470 dollars in 1991 and up to 50% unemployment. It covers an area of 10,887 square kilometers and prior to the recent conflict had approximately 2 million inhabitants. The population density of 200 persons per sq. km was one of the highest in Europe. Trends in the early nineties showed a declining infant mortality rate, crude mortality rate and birth rate. Some 52.7% of the population were reported to be under 20 years of age1.