The Public Health Program of the Soros Foundation started in 1993. The gradual degeneration of the communist system, culminated in the eighties which recorded the total inability of the state to provide the basic public services. In particular, this period marked the almost total collapse of the public health system. The fall of the communist system, found the Albanian system in a bankrupt situation. In addition, the recurrent crisis made it even more difficult for the transition governments to pay due attention to the sector. The health system in Albanian was faced with an additional and even bitterer challenge, i.e. the one coming from the appearance of “new’ diseases, while the traditional ones were radically changing typology and the chronic conditions were being increased and re-enforced. It is in this background that the Soros Foundation started its Public Health Program. The projects under this program over the years made a significant contribution to the Albanian medicine, the medical personnel, the civil society organizations dedicated to improvements in this field and especially to the individuals who had the most of the needs and the least of opportunities. From the first project funded in 1993 and the last one in 2005, the Public health program has supported above 100 large and small scale initiatives in both prevention and treatment of diseases. In addition, the Foundation supported a great number of training events and participation in international and national conferences and exchanges. Given the lack of national resources, the PHP became a great supporter in the field of upgrading the capacities of a great many Albanian doctors. Special mention should be made of the Salzburg Seminars which offered high level courses in the various fields of medicine. The Soros funded projects contributed to the improvement of the capacities of family doctors especially as related to the diagnostic, treatment and prevention aspects which has led to the curbing and prevention of serious diseases threatening the life of the population. A great help toward the improvement of professional capacity was given by the conferences and events organized by medical associations. Another great contribution by the Soros Foundation is that it underlined the need for specialized doctors and capable managers and administrators of the health system, consequently leading to further improvements in the sector as a result of exchanges with foreign counterpart institutions. To maximize the value of its intervention, the PHP of the Soros Foundation promoted the engagement of other donors, strengthened the civil society organizations involved in the health field and supported the public institutions in overcoming the difficulties. Of the multitude of projects supported by the Soros Foundation, mention can be made:
Models of health facilities for vulnerable people
Palliative care programs
The Albanian School of Public Health
Models of services to prevent AIDS and Drug use
Strengthening medical capacity: Salzburg Seminars
Improving the quality of medical services
Models of health facilities for people at risk
Apart from freedom and hope, the Albanian transition has been filled with crisis. Lack of stability and crisis weakened social cohesion. At a time when some segments of the society were making profits, other communities and individuals, for biological and/or social reasons remained underprivileged and became increasingly vulnerable. Health services for these people were either minimal or inexistent. This situation promoted the Soros Foundation to support the provision of basic health services in areas where they were missing or for those members of communities who could not afford them. The elderly, women, children and the seriously ill were the target groups most benefitting from the new initiatives and practices supported by the Soros PHP which in many cases became models to be followed.
a) Child Development Center (CDC)
The CDC was created in the form of a model facility to provide services to children with special development needs. Child development problems tend to affect the entire family, which when left without support, tend to slide into marginalization and therefore become vulnerable and at risk.
The Center carried out the assessment of about 1335 children from the age of 0-18 from all over the country. The CDC has established a genuine database of more than 1000 children who came to be diagnosed and treated here. The children displayed various problems related to disorders which were previously untreated:
psycho somatic disorders,
psycho motor problems,
mental development problems,
emotional and relational disorders,
speech and communication problems,
A commendable aspect in the work of the CDC was the cooperation and interaction with other health institutions in the country especially with mother and child facilities in the maternities, the health clinics in the town and villages, with family doctors, with day care and residential centers. In addition, the CDC did a good job in collaborating with the Ministry of Education, the educational directorates in the regions, the relevant authorities responsible for nursery and kindergartens and other structures. The purpose of these efforts was to promote the integration of children with disabilities into the mainstream pre-school and school institutions.
b) Model facilities for elderly care
Demographic changes have made the elderly a real concern for the Albanian society. Health facilities before the nineties were not structured to address specifically the needs of the third generation. It is widely recognized that the majority of people above 65 years are afflicted by at least one chronic disease and most of them have more than one chronic ailment. In addition, the elderly are afflicted by diseases limiting their movement and affecting their mental faculties. Poverty prevents them from acquiring help from a system dominated by informal payments. The Soros Foundation supported a number of projects addressing the health needs and problems of this population group. Such projects are represented by the day care centers for the elderly in Saranda and Korca and the prevention center in Kruja as well as other projects which made a great contribution to the improvement of health conditions the elderly.
c) Support to improving women health
Reports by United Nations and other international organizations consider women to be the population group most exposed to risks in Albania. It is a fact of life that women encounter difficulties in their efforts to be equal beneficiaries from the social and economic developments in the country. Women have limited access in policy and decision making and are dependent on men economically. In addition, the specific health needs of the women as mothers and females place them at risk. In the past, for purposes related to demographic increases, health services in Albania were designed to pay attention to mother and child health. Partially this tradition was carried into the transition years, but a number of newly emerging phenomena affected its effectives, i.e., lack of financial resources, great inequalities related to access and the increase of such new practices such as abortion and family planning. The Soros supported projects aimed at addressing some of these issues. Mention can be made of the manual suction abortion experimented by the Albanian Perinatalogy Association which later received national institutionalization, building awareness and knowledge of the pregnant women, implemented by the University Hospital Center, the rehabilitation of paralyzed women by the Counseling Center in Shkoder, building awareness about gender health including domestic violence implemented in Tropoja with the participation of communities and health authorities, etc.
Palliative care programs
Palliative care focuses the terminally ill especially patients afflicted by cancer, AIDS, neurological diagnosis and the elderly with chronic diseases. Ryder Albania (RA) was created at a time when the curb of cancer diseases was going up. More than 70 per cent of people with cancerous diseases, due to late detection and inadequate treatment became terminal patients and therefore, subjects for palliative care. Over the years, RA has been forced to cope with a number of problems and hardships originating from social, economic and health situations which the country was experiencing. However, it was the existence of these problems in the first place which prompted the creation of RA. Problems with the poor road infrastructure in Albania were the main difficulties facing RA in its efforts to reach the terminally ill in the remote and rural areas. However, despite these difficulties RA has been able to carry out a large volume of work. In the year 1994, RA could assist 42 patients, in 2003 417 patients and so on. The total number of patients helped from November 1993 to December 2003 is 2115 (of which 1187 in Tirana and 930 in Durres). The training of personnel and other persons who are available to offer palliative care, a total number of 414 have benefited, of whom 225 doctors and nurses, 88 social workers and psychologies and 108 relatives of the patients. As part of the project a practical manual called “Palliative care” was published and two publications by the WHO were adapted in Albanian “Control of Symptoms in Palliative care” and “Relieving cancer pain.” An additional book was produced called “Practical advice to the relatives of the patients” and 4 leaflets with information about the activity of the center. RA made efforts and succeeded in introducing certain topics on palliative care in the curricula of the Medical Faculty an those of the Natural Sciences Faculty. RA was the promoter and cofounder of the Albanian Association on Palliative Care.
The Albanian School of Public Health
Discussions on the creation of the Albanian Public Health School had started a longtime ago, but until the year 2000 there was no significant progress. A serious obstacle was the lack of qualified personnel and the unresolved institutional rifts. The Albanian health system followed the Russian model. The changes that followed, brought to the fore the need to reform the system. However, in other countries in Europe, training in the field of public health was undergoing reformation. Health reform was taking place in the context of all-round reform in the higher education which culminated with the Bologna process. The public health sphere had all the more reason to reform and approximate programs. ASPHER, the European organization of public health schools, was the driving force behind the reformation process. In other former socialist countries, cooperation between Soros foundations and ASPHER had yielded important results. In Albania, this cooperation made possible the resources and expertise towards this reformation. The project laid important ground in three important directions:
the creation of an enabling environment for the younger generation of professionals, both administrators and academics of public health;
promoting of research both in laboratory and real life conditions;
providing leadership and counseling models for the actors with political and decision making authority in the field of public health.
In order to implement this long term endeavor, emphasis was placed on the improvement of theoretical knowledge, methodological and practical skills in accordance with international standards. The foundations for a genuine school of public health in Albania were laid with the creation of the Masters Program in Public Health. The establishment of the Master’s Program went through three main phases:
• Institutional and legal arrangements and training of the trainers;
• Preparation of the curricula and design of the modules;
• The launching of the one year Master’s Program in Public Health with the support of the Ministry of Education and the Ministry of Health.
However, the institutional reform for the establishment of the Public Health School would require a higher organizational decision making. The widely accepted formula was the one which required the drafting of a Decision by the Council of Ministers which had to be defended with the Ministry of Health, the Ministry of Education and the Prime Ministers Office. The School of Public Health will operate as a post graduate school at the Faculty of Medicine. The relations between the Institute of Public health and the School would follow the established pattern of relations between the Faculty of Medicine and the University Hospital Center. The School and the Institute of Public Health will be led by the Dean and the Director respectively and their relations will be governed by the regulations endorsed by the Rector’s Office and the Minister of Health. The school will have five departments, Epidemiology & Biostatistics, Health Education, Health Management & Planning, Environmental Health and Control of Infectious Diseases. The school’s professors will engage in research and operational activity at the Institute of Public Health, while the heads of school departments will be eligible for heading the departments of the Institute of Public Health. In any case, they will implement and abide by instructions and ordes issues by the Ministry of Health.
Models of service delivery towards the prevention of AIDS and drug abuse
The sexually transmitted diseases (STD) and drug abuse, although they have different clinical symptoms in different individuals, still have many common characteristics. Like in other countries, developed, developing or under-developed without distinction, STD and drug use have caused serious health problems. Due to the extreme isolation before the year 1990, Albania was one of the rare countries with no incidence of such diseases. New diseases such as the STD-s and those caused by drug use had not made their way into the country, whereas the so called “old” STD-s had been eradicated a long time ago. The opening of the country and the adoption of more liberal lifestyles created possibilities for the incidence of STD-s and drug related diseases. The health system was not prepared to handle the emerging pathologies. In these circumstances, civil society organizations took the lead. Mention should be made of Aksion Plus which was created in 1992 by a team of doctors, artists and students. The mission of Aksion Plus was to prevent the spread of AIDS and drug use through education, awareness, instruction, and training of trainers, peer education, publications and a whole range of other civil society activities.
Strengthening medical capacity in the country – the Salzburg Seminars
The Salzburg Seminars dedicated to medical training have for many years now enabled the establishment of relations among medical doctors from some of the best medical schools in North America with the doctors of Central and Eastern Europe, Central Asia and former Soviet countries. Albania is among the beneficiary countries. The seminars are organized according to four large medical disciplines: adult medicine, pediatry, neonatology and public health. American Austrian Foundation (AAF) is the organizer of the Seminars. Together with the Soros Foundations in different countries, AAF funds the training of doctors from a number of countries. The Salzburg Seminars came into being in 1993. The aim of these seminars is to improve health care quality through the improvement of doctors’ knowledge and skills. This objective has been attained through knowledge transfer and exchange of experiences. An additional aim of the Seminars is to contribute to networking among doctors. Towards this objective, the seminars enable continuous contacts among the participants, their professional growth and access to medical authorities in medical practice and academia. A global medical school empowered by internet and on line resources, the Salzburg Seminars offer access to the most advanced medical thought and advice. About 100 Albanian doctors have participated in the Salzburg Seminars, of whom 16 were interns for one months and the rest were fellows in one week courses. With OSI as one of the main funders of the Salzburg Seminars, the Public Health program had a coordinating role, while also promoting the seminars and helping out with the selection of the candidates. In 2002, OSFA started to transfer responsibility in relation to the Salzburg seminars to a local entity that would continue to function independently from OSFA to the benefit of program participants and the network of Salzburg fellows.
Improving the quality of health services
For over one decade now, the Albanian health is being reformed and transformed. However, progress has been uneven and relations between supply and demand in the system remain deformed, at best. Patients receive medical care at high costs, both in moral and financial terms. Patients’ rights often are ignored and trampled upon. Albania has signed all international treaties on patients’ rights, but a hoard of factors impede their implementation in real life. OSFA placed patients’ rights on top of its long term priorities in the public health program. The main efforts by the Foundation over the years concentrated on spreading knowledge and building awareness about patients’ rights and the various international perspectives and standards in this respect. The OSFA Public Health Program supported projects by civil society organizations to promote these standards with the Albanian health system. The OSFA PHP also contributed to the strengthening of the various patient organizations which were newly created in the transition years. Mention should be made of a project to encourage the participation of patients in the assessment of health care quality. The initiative was implemented by the Institute of Assessing Public Opinion. Up to that point, assessments were carried out by the Regional Health Authorities as part of internal assessments in the systems. This project for the first time ever encouraged the participation of users and patients in the system assessment. Based on information collected by focus groups and questionnaires, a report was prepared with detailed information. It was submitted to health authorities and was discussed with various stakeholders, interest groups and civil society organizations engaged in public health. The report was widely distributed among the hospital and health centers in the country.