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Table 1 Progress in Meeting Health-Reform Goals

From: A case study of health sector reform in Kosovo

  Reform Objectives Reform Progress
Primary Care Location and services offered by family-medicine centres would be based on population.
Family doctors would have patient lists, and be responsible for diagnoses and curative care, reproductive, maternal and child health, and emergency care and stabilisation. Family doctors would be responsible for coordinating specialist and tertiary-care services.
Private practice would be allowed, and physicians would be allowed to practise in both the public and private sectors, but institutions must be approved and regulated.
The WHO established a facility master plan based on capitation, which guided rehabilitation and staffing. In minority areas, some facilities were opened that were not included on the master plan.
Family-medicine training established.
Serious impediments exist: patient registration is not universal, gate-keeping role of primary care underdeveloped, and specialists resist primary care role.
Ministry lacks the capacity to regulate the private sector, and there are accounts of physicians redirecting patients from the public sector to their private clinics.
Secondary and Tertiary Care Patients would receive specialist care and hospitalisation upon referral only, except in emergencies.
Hospital Master Plans will establish a vision for increasing the efficiency of hospitals.
Patients often bypass the primary care level to receive direct treatment by specialists. Hospitals were overburdened and under-resourced.
While Hospital Master Plans were developed, the Ministry lacked the resources to implement these plans.
Public Health The Institute of Public Health would focus on communicable disease control, health promotion, and water safety.
The institute would operate as the technical arm of the Department of Health, providing it with information on public-health issues.
Oversight of public health transferred to municipalities, public-health inspectors operate at the municipal level. Immunisation transferred to primary care.
Health information system established, but the ability of the Institute of Public Health to provide timely and accurate analysis to the Ministry of Health questioned.
Healthcare Financing No commitment was made to any financing system, but a pledge was made to study the merits of various alternatives. Some form of pre-payment system would be established through compulsory or voluntary insurance. Co-payments would be maintained. Equity marred by significant private expenditures (including under-the-table payments)
System funded out of the Kosovo Consolidated Budget.
Precursor to a social-insurance system, the Health Care Commissioning Agency (HCCA), established. Establishment of the HCCA and performance-based contracting has been undermined by the absence of accurate data, and information and management systems.
The failure to establish a transparent accounting system prior to the HCCA slowed efforts to implement health-financing.
Organisation and Governance The Ministry of Health would be responsible for policy, strategic planning, and regulation and standard setting.
Responsibility for primary care would be decentralized to municipal level.
The Ministry initially undermined by political turmoil, including changes of Minister and controversy surrounding the appointment of senior civil servants. Turmoil undermined its capacity to implement reforms.
Oversight for primary care became the responsibility of the municipalities in 2001. Municipalities slow to establish oversight structures, and capacity of municipalities varies.