Primary Health Care Reform in Albania: Baseline Survey of Basic

180 Pages·2004·0.96 MB·English

Primary Health
Care Reform in
Albania: Baseline
Survey of Basic
Health Service
Utilization,
Expenditures,
and Quality

February 2004

Partners for Health Reformplus

(cid:0)
Abt Associates Inc. 4800 (cid:0)Montgomery Lane, S(cid:0)uite 600
Bethesda, Maryland 20814 Tel: [phone] Fax: [phone]

In collaboration with: (cid:0)
Develop(cid:0)ment Associates, Inc. Emory Univer(cid:0)sity Rollins School of Public
Health Philoxenia In(cid:0)ternational Travel, Inc. Program for Approp(cid:0)riate
Technology in Health S(cid:0)ocial Sectors Development Strategies, Inc.
Training Resource Group Tu(cid:0)lane University School of Public
Health and Tropical Medicine University Research Co., LLC.

Funded by:
U.S. Agency for International Development Order No. TE 038

Mission

Partners for Health Reformplus is USAID’s flagship project for health policy and health system
strengthening in developing and transitional countries. The five-year project (2000-2005) builds on the
predecessor Partnerships for Health Reform Project, continuing PHR’s focus on health policy, financing,
and organization, with new emphasis on community participation, infectious disease surveillance, and
information systems that support the management and delivery of appropriate health services. PHRplus
will focus on the following results:
(cid:0) Implementation of appropriate health system reform.
(cid:0) Generation of new financing for health care, as well as more effective use of existing funds.
(cid:0) Design and implementation of health information systems for disease surveillance.
(cid:0) Delivery of quality services by health workers.
(cid:0) Availability and appropriate use of health commodities.
This document was produced by PHRplus with funding from the US Agency for International Development
(USAID) under Project No. 936-5974.13, Contract No. HRN-C-00-95-00024 and is in the public domain. The
ideas and opinions on this document are the authors and do not necessarily reflect those of USAID or its
employees. Interested parties may use the report in part or whole, providing they maintain the integrity of
the report and do not misrepresent its findings or present the work as their own. This and other HFS, PHR,
and PHRplus documents can be viewed and downloaded on the project website, www.PHRplus.org.

February 2004
Recommended Citation

Partners for Health Reformplus (PHRplus). February 2004. Primary Health Care Reform in Albania: Baseline Survey of Basic Health Service Utilization,

Expenditures, and Quality. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc.
For additional copies of this report, contact the PHRplus Resource Center at [email protected] or visit
our website at www.PHRplus.org.

Contract/Project No.: HRN-C-00-00-00019-00

Submitted to: USAID/Albania

and: Karen Cavanaugh, CTO
Health Systems Division
Office of Health, Infectious Disease and Nutrition
Center for Population, Health and Nutrition
Bureau for Global Programs, Field Support and Research
United States Agency for International Development

Abstract
A number of problems are thought to affect the provision of primary health care services in
Albania, making their reform an important long-term objective. The Partners for Health Reformplus
(PHRplus) Project is currently providing assistance to Albanian counterparts to carry out a primary
health care pilot in two districts, whose results are expected to inform a proposed model for the
provision of primary health care across Albania and potentially move the country towards a more
efficient, higher quality health care system. In order to evaluate the impact of the pilot intervention,
the Albanian Institute of Statistics (INSTAT) collected baseline information on the availability and
utilization of selected primary health care services prior to pilot implementation in the two pilot
districts and in one control district. This information was gathered through facility/provider and
household surveys administered in fall 2002. The objective of this report is to describe the
information gathered through these baseline surveys, especially with respect to health care supply and
utilization patterns for key performance indicators. The facility/provider survey was conducted at 26
health care facilities and included interviews with 110 health care providers. Information was
collected on facilities’ infrastructure, availability and quality of services, provider training, and
management practices. The household survey is based on a sample of 2,000 urban and rural families
(8,142 individuals). Information was gathered on the sample’s demographic characteristics,
household assets, dwelling conditions, health problems, insurance status, preventive and curative
health care utilization, contraceptive use, health care expenditures, and perceptions of service quality.
As the pilot nears completion, the survey results will be used to investigate whether expected changes
in quality, financing, and health care service use occur. Key findings from the baseline survey include
the following: vulnerable groups (such as the poor and those living in rural areas) face barriers to
accessing appropriate care; the bypassing of lower level health facilities is extensive; the use of
modern contraceptive techniques among women of reproductive age is very low; and out-of-pocket
payments for many primary health care services are widespread.

Table of Contents
Acronyms............................................................................................................................................xiii
Acknowledgments................................................................................................................................xv
Executive Summary...........................................................................................................................xvii
1. Introduction....................................................................................................................................1
1.1 Background on PHRplus.......................................................................................................1
1.2 Overview of Evaluation Study..............................................................................................2
1.3 Overview of Baseline Report................................................................................................2
2. Country Background......................................................................................................................5
2.1 Geographic Characteristics and Sociodemographic Profile..................................................5
2.2 Health Profile........................................................................................................................5
2.3 Economic and Political Profile..............................................................................................7
2.4 Health Care System in Albania.............................................................................................8
2.4.1 Policy.............................................................................................................................8
2.4.2 Organization and Infrastructure.....................................................................................9
2.4.3 Health Expenditure and Financing..............................................................................10
3. Health Reform and Primary Health Care.....................................................................................13
3.1 Problems with Primary Health Care Service Delivery........................................................13
3.2 PHRplus-Supported Pilot Strategy......................................................................................14
4. Albania Baseline Health Survey Design and Methodology.........................................................21
4.1 Study Design.......................................................................................................................21
4.2 Sample Selection.................................................................................................................22
4.2.1 Households..................................................................................................................22
4.2.2 Facilities......................................................................................................................23
4.2.3 Clients..........................................................................................................................23
4.3 Data Collection Instruments................................................................................................24
4.3.1 Household Questionnaire............................................................................................24
4.3.2 Facility Questionnaires................................................................................................25
4.4 Survey Procedures and Logistics........................................................................................25
4.4.1 Household Survey.......................................................................................................25
4.4.2 Facility Surveys...........................................................................................................26
4.5 Data Processing and Quality Assurance..............................................................................27
4.6 Methodology to Establish Wealth Quintiles.......................................................................27
4.6.1 Distribution of Wealth: PHRplus Data Compared to LSMS Data..............................28
Table of Contents vii
5. Results: Facility Inventory, Provider Survey, and Client Exit Interviews...................................31
5.1 Facility Inventory................................................................................................................31
5.1.1 Distance to Facilities...................................................................................................32
5.1.2 Facility Infrastructure..................................................................................................32
5.1.3 Services Provided........................................................................................................33
5.1.4 User Fees.....................................................................................................................35
5.1.5 Staff .............................................................................................................................36
5.2 Provider Survey...................................................................................................................36
5.2.1 Sample Characteristics by Age and Sex......................................................................37
5.2.2 Sample Qualifications.................................................................................................37
5.2.3 Sample Supervision.....................................................................................................38
5.2.4 Sample’s Views on Working Conditions....................................................................39
5.3 Client Exit Interviews.........................................................................................................39
6. Results: Household Survey..........................................................................................................41
6.1 Demographic Characteristics of the Survey Sample...........................................................41
6.2 Health Insurance..................................................................................................................43
6.3 Chronic Illness....................................................................................................................45
6.4 Acute Illness........................................................................................................................54
6.5 Preventive Health................................................................................................................68
6.6 Reproductive Health............................................................................................................72
7. Key Findings................................................................................................................................79
Annex 1: Household Survey Questionnaire.........................................................................................87
Annex 2: Facility Survey Questionnaire............................................................................................121
Annex 3: Provider Survey Questionnaire...........................................................................................133
Annex 4: Exit Interview Questionnaire..............................................................................................143
Annex 5: Information on Wealth Quintiles Methodology.................................................................153
Annex 6: Bibliography.......................................................................................................................155
List of Tables
Table 1: Basic Mortality, Maternal and Child Health, Lifestyle, and Health Care Resource Indicators
for Albania, Romania, Bulgaria, and CSEC, 2001.................................................................................7
Table 2: Number of Health Care Facilities, 1990 and 2000.................................................................10
Table 3: PHRplus Indicators for Albania Health Care Pilot Intervention............................................18
Table 4: Summary of the Total Number of Households in the Sampling Frame and the Number of
Households Surveyed, by Sample Area...............................................................................................23
viii Primary Health Care Reform in Albania
Table 5: Government Health Facilities by Type of Facility and by Study Group...............................23
Table 6: Average Distance to Facilities, by Facility Type and Urban/Rural Status.............................32
Table 7: Percentage of Facilities Reporting Availability of Electricity, Water Supply, Telephone, and
a Generator...........................................................................................................................................32
Table 8: Availability of Services, by Type of Facility and Urban/Rural Status...................................33
Table 9: Percentage of Facilities that Reported Charging User Fees, by Type of Service and by Type
of Facility.............................................................................................................................................35
Table 10: Average Number of Staff Available, by Type of Staff, Type of Facility, and Urban/Rural
Status....................................................................................................................................................36
Table 11: Providers by Age, Sex, and Type of Facility (Percent Distribution)...................................37
Table 12: Providers' Qualification by Type of Facility and Urban/Rural Status (Percent Distribution).
....................................................................................................................................................37
Table 13: Percentage of Providers Who Reported Being Supervised in the Last Month and Last Six
Months, by Type of Facility.................................................................................................................38
Table 14: Opinion on the Most Important Issues to Improve, by Type of Facility and Provider
Gender..................................................................................................................................................39
Table 15: Age Distribution of the Study Population, by Urban/Rural Status (Percent Distribution).41
Table 16: Educational Attainment Levels of the Study Population, by Urban/Rural Status* (Percent
Distribution).........................................................................................................................................42
Table 17: Insurance Status of the Study Population, by Urban/Rural Status, Asset Quintile, and Age
Group...................................................................................................................................................43
Table 18: Percentage of Individuals Reporting Chronic Illnesses or Disability, by Urban/Rural Status
and Age Group.....................................................................................................................................45
Table 19: Types of Chronic Symptoms Reported, by Urban/Rural Status and Age Group*
(Percentages)........................................................................................................................................46
Table 20: Type of Facility Used for Chronic Health Care*, by Urban/Rural Status and Age Group
(Percent Distribution)...........................................................................................................................50
Table 21: Type of Facility Used for Chronic Health Care*, by Health Insurance Status and Age Group
(Percent Distribution)...........................................................................................................................51
Table 22: Individuals Using Polyclinics or Hospitals Who Reported Having Another Facility Closer
to Their Place of Residence, and Reasons for Not Selecting that Facility (Percent Distribution).......52
Table 23: Percentage of Chronically Ill Outpatients Who Paid Anything for the Most Recently
Prescribed Medicines, by Asset Quintile and Health Insurance Status................................................53
Table of Contents ix
Table 24: Percentage of Individuals Reporting Acute Illness*, by Urban/Rural Status and Age Group.
....................................................................................................................................................54
Table 25: Types of Acute Conditions Reported, by Age Group (Percentages)...................................54
Table 26: Type of Facility Used for Acute Health Care*, by Urban/Rural Status and Age Group
(Percent Distribution)...........................................................................................................................58
Table 27: Type of Facility Used for Acute Health Care*, by Health Insurance Status and Age Group
(Percent Distribution)...........................................................................................................................60
Table 28: Type of Facility Used for Acute Illness for First Visit, by Reason for Selecting Facility
(Percent Distribution)...........................................................................................................................60
Table 29: Proportion of Acutely Ill Outpatients Who Used Health Care Services and Paid for
Consultation, Tests, Drugs, and Other Expenditures, by Asset Quintile.............................................65
Table 30: Proportion of Acutely Ill Outpatients Who Used Health Care Services and Paid for
Consultation, Tests, Drugs, and Other Expenditures, by Place Where Care Was Received................66
Table 31: Mean Levels and Shares of Total Payments for Formal Consultation, “Gifts and Other
Payments,” Tests, Drugs, and Other Expenditures by Acutely Ill Outpatients, by Asset Quintile......66
Table 32: Mean Levels and Shares of Total Payments for Formal Consultation, “Gifts and Other
Payments,” Tests, Drugs, and Other Expenditures by Acutely Ill Outpatients, by Place Where Care
Was Received.......................................................................................................................................67
Table 33: Mean Levels and Shares of Total Payments for Formal Consultation, “Gifts and Other
Payments,” Tests, Drugs, and Other Expenditures by the Acutely Ill Who Used PHCs, by Health
Insurance Status*.................................................................................................................................68
Table 34: Percentage of Individuals 15 Years of Age or Older Who Reported Having Had Physical
Examination or Check-up, by Urban/Rural Status and Age Group.....................................................69
Table 35: Percent of Women of Reproductive Age Who Have Been Asked or Advised about
Reproductive Health or Breast Self-Exam, by Urban/Rural Status and Age Group............................69
Table 36: Opinion of Quality of Facilities Where Children Were Taken for Immunizations, by
Dimension of Quality and Type of Facility (Percent Distribution)......................................................71
Table 37: Percentage of Women Who Gave Birth in the Past Two Years Who Reported Having Had
Prenatal Care, by Urban/Rural Status and Age Group.........................................................................72
Table 38: Percentage Distribution of Women of Reproductive Age Who Reported Having Prenatal
Care, by Type of Provider and Urban/Rural Status.............................................................................72
Table 39: Percentage Distribution of Women of Reproductive Age Who Reported Having Prenatal
Care, by Place of First Visit and Urban/Rural Status...........................................................................73
Table 40: Percentage Distribution of Women of Reproductive Age Who Reported Having Prenatal
Care, by When They Had Their First Visit, Urban/Rural Status, and Age Group...............................73
x Primary Health Care Reform in Albania