Health System Reconstruction In Post-War Kosovo

In 1963, Kosovo became an autonomous province of Serbia in Yugoslavia under Josip Tito. Long before then, friction had existed between the ethnically Albanian and Serbian communities living inside and around Kosovo. These tensions escalated in the 1980s as ethnic Albanians pushed for greater autonomy for Kosovo and stronger connections to neighboring Albania, while Serbians wanted to maintain strong ties with Belgrade.

Since World War II, Yugoslavia’s (and therefore Kosovo’s) health system was based on the Semashko model common in other Communist states: centralized decision making, large institutions, and the domination of hospital, curative, and specialist care (Parmelee 1985; Shuey et al. 2003; Saric and Rodwin 1993). The Yugoslav government only paid lip service towards primary health care (e.g. wide scale access, focus on basic medical practitioners). While publically espousing the principles of primary care, the Yugoslav Ministry Of Health continued to focus on specialist care, in particular by changing the legal definition of primary care provider to include some specialists: obstetricians, pediatricians, gynecologists, and occupational health doctors (Saric and Rodwin 1993). Furthermore, under Yugoslavia, Kosovo had little local control of its health system. Kosovo worker councils and “health parliaments” did exist and formally had some power to influence health policy, however in reality these groups’ role was to give the proposals of government bureaucrats the veneer of local accountability (Himmelstein et al. 1984).

While the health system was centrally controlled, significant regional health disparities existed within Yugoslavia. Kosovo in particular lagged behind health improvements seen in other — particularly richer — regions. These health inequities increased throughout the 1980s. In 1950-1954, the difference in infant mortality rates between the best (Slovenia, Croatia, and Vojvodina) and worst regions (Kosovo and Macedonia) was 2.2, by 1986 it was 5.0 (Mastilica 1990). Around the same time while almost all pregnant women in other Yugoslav regions received prenatal care, only one third of Kosovar women did (Himmelstein et al. 1984).

Kosovo’s political structures underwent major changes in 1990. Slobodan Milošević, the President of Serbia elected the year before, revoked the autonomy of Kosovo and expanded the power of the Serbian government over Kosovo’s institutions, including the police, courts, educational institutions, and health system. The change devastated Kosovo’s health system. Almost two thousand ethnic Albanian health workers were dismissed including 263 doctors and 140 professors of medicine (Lynne 1993; Bloom et al. 2007). Many others quit after threats and intimidation (Dobrecu 1991). By 1991, while ethnic Albanians made up 82% of Kosovo’s population, they made up less than five percent of Kosovo’s public health workforce (Bloom et al. 2007). The remaining ethnic Albanian health workers were relegated to non-management positions (Buwa and Vuori 2007). New rules set down by the Belgrade demanded that Serbian be the official language used in Kosovo hospitals — a language unfamiliar to many ethnic Albanian health workers and patients (Lynne 1993; Percival and Sondorp 2010). Within a few years sixty-four percent of ethnic Albanian health workers had voluntarily or involuntarily left their jobs (Percival and Sondorp 2010). The Milošević government filled the vacancies with health workers brought in from other regions of Yugoslavia and from outside the country, many lacking the appropriate expertise (Bloom et al. 2007). The political interference in the health system undermined patient confidence. After the dismissal of over forty ethnic Albanian doctors, one obstetrics and gynecology department dropped from thirty deliveries per days to fewer than two because Albanian patients did not trust the Serbian health workers (Lynne 1993).

Medical education in Kosovo also suffered under Serbian rule. The new language rules demanded teaching be conducted in Serbian, effectively banning hundreds of medical and dental students from attending classes. Many other medical students were expelled entirely or quit after fearing for their personal safety (Campbell et al. 2003). They had good reason to be worried: multiple professors were detained and the dean of the University of Pristina’s medical school was beaten in front of his students (Dobreci 1991). Other ethnic Albanian professors quit in protest (Lynne 1993). By 1991, 44 percent of the professional and scientific staff at the University were dismissed and replaced by Serbians (Dobreci 1991).

By the 1990s, 50 percent of ethnic Albanians did not have the social insurance card required to access the government health care system. In response ethnic Albanians organized a “parallel” health care system including private practices in their houses and a network of clinics called the Mother Theresa Society. The Mother Theresa Society ran 96 clinics around Kosovo and was supported by volunteers and a parallel tax system (Percival and Sondorp 2010). The ethnic Albanian medical professors and staff fired from University of Pristina even founded a parallel medical school. Instruction was conducted in Albanian and provided students with strong medical knowledge but, due to their lack of access to health facilities, weak clinical skills (Lynne 1993). During the 1990s this underground medical school graduated 600 doctors and 1,200 nurses (Percival and Sondorp 2010).

The loss of political autonomy and the discrimination against ethnic Albanians increased tensions between ethnic Albanians Kosovars and Serbians throughout the early 1990s. While there had been organized passive resistance to Serbian rule for decades, the political watershed came in 1996 when the previously unknown separatist group, the Kosovo Liberation Army (KLA), launched a campaign of attacks and bombings against Serbian security forces, officials, and loyalists. In March of 1998 the conflict escalated into a civil war when Belgrade turned to the Yugoslav National Army to put down the separatists. Intense fighting been Serbian controlled forces and the KLA throughout Kosovo over the next year killed and displaced thousands. The following March, after months of failed negotiations, western governments under the North American Treaty Organization (NATO) launched an air campaign against Serbian and Yugoslavian forces. A NATO spokesman tactfully summarized the goal of the operation: “Serbs out, peacekeepers in, refugees back” (Houghton 2011, 16). On June 10th, the Kosovo War ended when Serbian and Yugoslavian governments signed the Kumanovo Treaty that, combined with Security Council Resolution 1244, gave administrative control of the province of Kosovo (including its health system) to the United Nations.

When the United Nations Interim Administration Mission in Kosovo (UNMIK), the organization created to govern Kosovo, took charge of the embattled province, it inherited a health system at the brink of collapse from neglect and conflict. Responsibility for financing, managing, regulating, and rebuilding Kosovo’s health system fell on UNMIK’s newly established Department Of Health. Before the war, Kosovo’s official health system consisted of 300 “ambulantas” providing primary care, 30 “health houses” offering secondary care, five district hospitals (one in each major urban area), a central hospital and medical school in Pristina (Buwa and Vuori 2007; Davies 2000). The health houses were the most common destinations for patients, constituting 35 percent of all health usage (The Interim Health Policy Guidelines For Kosovo 2000). Following the Semashko model, each hospital was dominated by a set of largely independent clinics providing specialized secondary or tertiary care, often with their own laboratories, intensive care facilities, and surgical suites (Kirkup and Hoyle 2002; Davies 2000; The Interim Health Policy Guidelines For Kosovo 2000). University of Pristina’s central hospital was by far the largest, with 2200 of the Kosovar health system’s 5300 total hospital beds (Davies 2000). Kosovo’s total bed capacity amounted to 450 hospital beds per 100,000 people, comparable to the European Union average (Report On Kosovo Hospitals 1999). However, the strength of the health system on paper was in stark contrast to its true state.

Most of the health system was not directly targeted by either side (Shuey et al. 2003). However, the Yugoslav Army did attack rural health posts and the parallel health network, with 90 percent of the Mother Theresa clinics looted or destroyed (O’Connor 1998; Shuey et al. 2003). To a large extent, the destruction of Kosovo’s health system was indirect. One of the greatest sources of physical destruction was looting, which caused the loss of much of the health system’s supplies and equipment (Shuey et al. 2003; Kirkup and Hoyle 2002; O’Hanlon and Budosan 2011). In addition to looting, the health system suffered from a host of other problems at the end of the war. Many of the facilities lacked basic maintenance and used low quality or outdated equipment (Buwa and Vuori 2007). Many of the hospitals lacked 24-hour access to electricity, water, food and basic sanitation (Ashford and Gottstein 2000). One hospital even had to bring in all its water by truck (Report On Kosovo Hospitals 1999). A United Kingdom team visiting the Pristina Hospital ten days after the war ended described the state of the facility:

On arrival, the hospital presented an extensive complex of mostly dilapidated buildings. Although these were fitting out with much high technology equipment, they were used mainly for straightforward procedures. The informal economy had already taken told, and departing Serbian Army (and some health professionals) had taken opportunities for gratuitous acts of theft and vandalism within the hospital. Damaged and missing materials ranged from small items such as cleaning and sterilizing equipment through to hospital boilers. […] The main utility services were in very poor condition, and the general standard of the hospital’s infrastructure was appalling, with no evidence of any effective maintenance or modernization since 1990 (Kirkup and Hoyle 2002, 220).

Another major problem was the ethnic tensions inside the health workforce. Before the war, many ethnic Albanian health professionals had been forcibly replaced by Serbians workers. After the war ended (and with it de facto Serbian control over Kosovo’s health system) a massive turnover in the health workforce occurred in a few short months. Fearing reprisals by ethnic Albanians, almost all Serbian health workers working in Kosovo’s health system fled (Ashford and Gottstein 2000). Those fears were well founded, as the few Serbian health workers that stayed on faced threats, intimidation, and incidents of violence (Bloom et al. 2007). One of the few exceptions was the hospital in the Serb dominated city of Mitrovica, where many Serbian health workers and patients flocked (Ashford and Gottstein 2000). The flight of Serbian health workers cost the health system significant amounts of managerial experience and institutional knowledge (Buwa and Vuori 2007). Positions formerly held by Serbians were rapidly and haphazardly replaced by returning ethnic Albanian health workers. These health workers varied widely in education and knowledge: from veteran physicians that had been expelled by the Serbian government in the early 1990s to new doctors trained in the parallel medical education system with limited clinical experience (Ashford and Gottstein 2000).

More than simply attempting to rebuild the pre-war institution, which many considered fundamentally broken, the United Nations civil administrators in Kosovo believed the end of the war presented a window of opportunity to leapfrog Kosovo’s institutions into those of a modern European state (Percival and Sondorp 2010). In the health sector, this belief led to the development of dramatic and sweeping health reforms. Incorporating major health reforms into a post-conflict reconstruction effort was considered desirable for four reasons (Shuey et al. 2003; Analysing Disrupted Health Sectors 2009). First, many health systems in peaceful states had already undergone similar health reforms. Second, the pre-war health system was considered outdated and unsustainable and many thought the reforms were inevitable. Third, modernizing the health system would build stronger connections between the eventual independent state of Kosovo and Europe. Finally, the weakness of the Kosovo political structures and the lack of interest groups in post-war Kosovo were thought to present an opportunity to make sweeping changes with little domestic political constraints.

Spurred by the window to make major changes and with limited local political structures to contend with, Kosovar’s international administrators — led by the World Health Organization — developed an ambitious health reform plan that would act as the normative framework for the reconstruction process. The plan, outlined in the WHO’s Interim Health Policy Guidelines, set forth a series of points which were to define Kosovo’s new health system. Three of these points were particularly significant. First, the reform plan called for a shift away from the Semashko model: health care delivery would be more decentralized with more power given to the district and local level. Second, under the plan primary health care was to take precedence over secondary and tertiary care (Bower 1999; Burkle 2010). This move was a major change in a system where primary health care had historically been given little importance. Third, private clinics commonly used by many Kosovars would stilled allowed to operate, but would be well regulated (Shuey et al. 2003). When the internationally governed reconstruction effort — guided by the health reform plan — began, it was hoped to be a model for future post-conflict reconstruction efforts. However, the reality would fall far short of the hopes. Kosovo faced a number of challenges that hampered efforts to reconstruct, and reform, its health system.

When the Kosovo War ended, the Serbian and Yugoslavian military withdrew, a major victory for the KLA. However, political negotiations that resulted in the Kumanovo Treaty did not culminate in the immediate establishment of an ethnic Albanian government with sovereign rights over Kosovo – that would only happen in 2008 with the internationally recognized independence. Instead, the political agreement that ended the Kosovo War, as previously discussed, gave control of the territory to the United Nations. The result of this agreement was that Kosovo’s population, who had the greatest stake in the health reforms and would eventually inherit the health system, lacked both the legitimacy and ability to shape the reconstruction process until the establishment of a Kosovar administrative institution in 2001.

Between 1999 and 2001 (and indeed to a large extent afterwards), the administration and reconstruction of Kosovo’s health system was dominated by international and non-governmental organizations. These international actors had control over billions in reconstruction funds and the authority to use them without consulting local political leaders. However, the power of the internationals was not absolute. Despite the Kumanovo Treaty, Kosovo’s IGO administrators were not Kosovo’s government and lacked the clear authority and legitimacy awarded to states. Unlike with state governments, the rules concerning the United Nations civil administrators in Kosovo were complex, ambiguous, and fluid. While the lower levels of the health system were being reformed, the upper tiers were effectively being built from scratch. There was uncertainty as to what role UNMIK’s Department Of Health would play in relation to the World Health Organization (WHO) and local actors, undermining the ability of any group involved in the reconstruction effort to act decisively. Resolution 1244 only recognized the United Nations (and therefore UNMIK) as the legitimate power, however on the ground there was a wide array of actors — some local, some international — who had to be death with (Shuey et al. 2003). Furthermore, WHO and later UNMIK lacked a national government’s ability to force other actors to follow its guidelines. Adherence to the health reform policy was voluntary — particularly in the early months of the reconstruction effort (Shuey et al. 2003). The repeated transfer of the responsibility of Kosovo’s health system only complicated the problem. Initially the WHO was in charge of the reconstruction effort, however, later the health system was handed off to UNMIK with the WHO acting as a technical advisor (Shuey et al. 2003). Later the health system was transferred a third time to a Kosovar political administration.

While Kosovo’s international administrators were hampered by complex organizational structures and unclear rules of authority, pre-2001 Kosovar political institutions often lacked the capacity to influence the governance of the territory they would one day inherit. In the immediate aftermath of the conflict only a shadow Ministry Of Health existed, which UNMIK could not officially recognize since Kosovo was legally still part of Serbia (Percival and Sondorp 2010). Therefore the initial health reconstruction efforts after the war reflected international, not Kosovar, preferences (Campbell et al. 2003). The WHO and UNMIK did make some effort to work with local ethnic Albanian health officials, however it was unclear what authority and legitimacy these officials held, especially since many had only returned to the health system weeks prior (Shuey et al. 2003).

In late 2001, a local administrative agency was created, called the Provisional Institutions Of Self-Government (PISG). With the PISG came a new Kosovar run Ministry Of Health mandated to manage the health system. International actors, previously in control of the health system, became advisors to the MOH. However, in the first year of its existence the MOH was wracked by a series of political scandals, including the dismissal of the first Minister Of Health. During this time the institution paid little attention to continuing the reforms started by WHO and UNMIK (Percival and Sondorp 2010). After the war the reconstruction of Kosovo’s health system also suffered from widespread ethnic tensions. Officially the reformed health system was meant to be ethnically neutral, both in terms of hiring and patient care (The Interim Health Policy Guidelines For Kosovo 2000). However, in practice there was widespread distrust between ethnic Albanians and Serbs. Tensions amongst the Serbian health workers and newly returning Albanians were high as both attempted to secure their position in the health system (Access To Health Care In Kosovo’s Minority Areas 2001). Intimidation and reprisals led many Serbian health workers to abandon their posts in the health system (Kirkup and Hoyle 2002). In June 1999, a majority of Pristina Hospital’s staff was Serbian, however by August it was almost entirely ethnic Albanian (Percival and Sondorp 2010). Most of the Serbian health workers left Kosovo or fled to the hospital in the Serbian enclave of Mitrovica (Access To Health Care In Kosovo’s Minority Areas 2001).

The capacity of PISG was also undermined by political infighting between ethnic Albanian factions. At the end of the war the KLA filled leadership positions in hospitals and primary clinics. However, many of the KLA appointments were later replaced on orders of their political rivals, the Democratic League of Kosovo (Percival and Sondorp 2010). In another incident, the Prime Minister dismissed the first Minister Of Health less than a year after the appointment during a time of political jostling between ethnic Albanian factions. At the same time, the Permanent Secretary of the Ministry Of Health, the most senior civil-servant in the health system, was suspended by UNMIK until the dispute over the Minister Of Health could be resolved (Campbell et al. 2003). These and other internal political disputes hampered the reconstruction efforts by depriving the health system of stable, effective leadership during its crucial first few years (Percival and Sondorp 2010).

Aside from its political problems, Kosovo’s Ministry Of Health also did not have the administrative capacity to implement the reform and reconstruction efforts. The health system lacked experienced administrators and managers able to develop and execute Ministry policy (Homan et al. 2010). After the war, hundreds of NGOs arrived to provide assistance, including 160 working in the health sector (Davies 2000). The Ministry Of Health was only marginally effective at coordinating the efforts of these NGOs into a national reconstruction strategy. Without a strong political leviathan which NGOs had to follow, many operating independently with only partial and voluntary coordination with the government health institutions. The proliferation of independently operating NGOs in Kosovo undermined the Ministry Of Health. The NGOs’ favored short-term projects with quantifiable results, which they could report back to their donors. However while these projects strengthened the health system on paper, they did not build the capacity of the Ministry Of Health and its civil servants to provide health in the long term (Percival and Sondorp 2010).

The reconstruction effort was also hampered by an unstable financial situation. After the war Kosovo was flooded with billions in international donor funding (Percival and Sondorp 2010). However, many health workers and administrators complained that they had little information as to how much funding they would receive from UNMIK, and thus how they should budget their resources (Agovino 1999). More importantly, this injection of international funding was short-lived. As international sources of funding dried up, the health system quickly started to have to rely on tax revenue, which was inadequate to fund the ambitious reconstruction and reform projects. Despite the surge of international funding — including €80 million of international spending on the health system alone — immediately after the war, by 2005 Kosovo’s health system’s budget was €22 per person; in comparison Croatia’s was €320 per person (Percival and Sondorp 2010).

Despite the massive scale of the reconstruction effort, the results have been marginal. Kosovars often saw the health reconstruction efforts of UNMIK as imposed upon them by the international community with little local input into the design and implementation of the plan (Shuey et al. 2003). There was much truth to this complaint, the UN health reform program was to a large extent designed and implemented by the preferences of international actors, with only token efforts to include local Kosovar stakeholders in the process (Percival and Sondorp 2010). Furthermore, the model of health care provision introduced by the UN and other international agencies was unfamiliar to both local patients and health care providers in Kosovo. The outcome was predictable: within a few years of the reforms health care providers and their patients began reverting to the old ways of health care delivery (Burkle 2010).

Today, more than ten years since the end of the war and the start of the ambitious U.N. health reconstruction and reform program, the health system remains problematic. The much-promoted primary health care introduced by the WHO and UNMIK never fully took hold, with many Kosovars considering it a “stopping point on the road to specialist care, not as a place to receive treatment” (Percival and Sondorp 2010, 15). In turn, primary health care doctors are leaving for clinical specialties and then to the booming private health clinic industry, where they can earn far more than they can in the primary health care system (Buwa and Vuori 2007). Health facilities continue to be burdened by lack of maintenance and limited access to pharmaceuticals (Tërdevci 2009). Health workers continue to perpetuate the pre-war models of health care, including nurses asking for side payments, doctors referring patients to private clinics they own, understaffing of primary health care providers, overstaffing of specialists (Tërdevci 2009). The result of these problems has been a lack of progress in improving health in the region: Kosovo’s health level infant mortality rate is the highest in Europe, twice as high as nearby countries and maternal mortality remains high, 12 to 23 deaths per 100,000 live births (United Nations Kosovo Team 2010).

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