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Politike

"The debate about health services returns", VOA analysis of 'Hospital Autonomy': Experts show an increase in costs from citizens' pockets

"The debate about health services returns", VOA analysis of

In Albania, the official authorities are introducing some elements of hospital autonomy, which envisages the gradual delegation of financial and administrative decision-making from general government structures to hospitals. Public hospitals that meet certain criteria are being provided with the managerial autonomy card, which is based on what is called dual practice, according to which citizens will have the opportunity to choose the doctors they want to receive service outside official hours, against payment. Officials say that this reform will bring an increase in services and quality, while experts in the health field think that, conceived in this way, it will further increase the costs from the citizens' pockets.

"Not only double practice, but also the internal increase in the remuneration of doctors, based on merit, will make the interest to work in public hospitals always higher, the competition always stronger and then who will go to Germany, to take our evil".

This is what Prime Minister Edi Rama said a while ago, during the presentation of hospital autonomy, just one day after the Constitutional Court decided to give the right to medical students who requested the repeal of a legal definition that forced them to work after completing their studies in the country for a period of 2, 3 and 5 years, before the diploma was handed to them. With the conviction that the reform will manage to prevent the departure of doctors from the country, the authorities argue that it gives independence to hospitals, that through the boards that will be elected, manage financial and human resources, or conclude contracts with third parties. Officials are convinced that this practice will increase quality, services for citizens, and secondary income of hospital institutions.

At the end of January of this year, 5 hospitals, 4 regional and the Mother Teresa University in Tirana, received the management card of hospital autonomy (in the country there are 41 public hospitals, 6 tertiary level, 11 regional level and 24 municipal hospitals). Some elements of the card have been experimented for a year in Fier Memorial Hospital.

Today, citizens receive health services in public hospitals through the referral system, free of charge. What is being discussed the most in the context of autonomy is related to what is called double practice, according to which doctors who are requested by citizens outside of working hours, have the opportunity to use the hospital premises, initially only for consultations and in a the next stage is the equipment, to offer an extra paid service, where 70% of the payment is taken by the doctor and 30% by the hospital, provided that the doctor's payment does not exceed 30% of his monthly salary. This happens when citizens do not want to wait for the queue provided by the referral system from the family doctor and the specialist. But public health experts think that the model of hospital autonomy offered by the government will increase the out-of-pocket costs of citizens for health.

"When I hear the expression 70% is taken by the doctor and 30% by the hospital, the first question that comes to mind is - who pays this money?" Citizens pay. So what are we doing, we are asking people for money to increase out of pocket expenses. Let's not forget an important element. It is not only the doctor in health. It's a team. There are doctors, there are nurses, assistants, laboratory technicians, imagers, imaging technicians, administration, there is no explanation for this and no discussion," said Ilir Alimehmeti, public health expert, for the Voice of America.

Deputy The Minister of Health Entela Ramosaçaj, for the Voice of America, opposed these arguments and said that the double practice reduces the waiting list within the referral system, increases the quality and services but not the costs for the citizens.

"Definitely not. The service at public hospitals will continue to be offered free of charge. And for patients who want to receive this service during working hours, within the referral system there will be no cost to the citizens' pockets. The cost will be zero" - said Entela Ramosaçaj, Deputy Minister of Health.

On the other hand, the former Minister of Health, Petrit Vasili, told the Voice of America, that some steps of hospital autonomy related to the management of the drug fund by the hospital institutions themselves, investments or staff recruitment were taken over a decade ago and that the following needed to be improved. He takes as an example the pilot project of Hospital Autonomy in the hospital of Durrës, which operated for a long time. Mr. Vasili is critical of the elements of hospital autonomy that are offered today by the government while bringing to attention the concessions in the health system as a centralizing practice.

“Kjo është masë propagandistike, pa bazë reale që e shthur dhe e mbingarkon sistemin spitalor. Do të krijohet patjetër dhe çorganizim, do krijohen keqkuptime të brendshme, pamundësi të ndarjes ku fillon shërbimi publik dhe ai privat do përdoren të njëjtat asete. Çfarë fituam. Asgjë. Nëse i referohemi konçensioneve. A ka hapësirë një spital autonom të vendosë për një shërbim që e vendos ministria? Kjo gjë ndodh, për laboratorët dhe elementë të tjerë. Ky është autonomia?”- u shpreh Petrit Vasili, ish Ministër i Shëndetësisë.

Por drejtuesja e Spitalit memorial të Fierit, ku prej një viti u pilotuan disa elementë të kartës menaxheriale të autonomisë spitalore thotë se aktiviteti i këtij spitali u rrit me 70%, dhe për pasojë dhe aksesi i qytetarëve.

“Praktika e dyfishtë këtë bën, ul listën e pritjes, e mirmenaxhon atë, dhe i jep qytetarit të drejtë të përzgjedhë vendin e duhur aty ku është shërbimi më i mirë dhe më cilësor. Njëkohësisht krijohet dhe një marrëdhënie e re besimi mes pacientit dhe mjekut”- argumentoi Rudina Degjoni, Drejtore e Spitalit Memorial të Fierit.

Mjaft qytetarë shtrojnë pyetjen nëse e shmang korrupsionin në radhët e bluzave të bardha utonomia spitalore. Disa prej tyre e shohin pozitivisht reformën në këtë drejtim dhe mendojnë se suksesi i saj do të varet ekipet që do ta zbatojnë.

“Ekipet menaxheriale duhet të jenë në lartësinë e reformës. Nëse ne nuk vendosim autoritete drejtuese dhe një ekip menaxherial me mekanizma kontrolli dhe audituese rrezikojmë të kemi probleme që lidhen me mungesën e transparencës, me nxitjen e favorizmit të kolegëve të caktuar, dhe mund të jetë një moment që mund të na fusë në një rreth vicioz sistemin shëndetësor”- u shpreh Qamil Dika pedagog në Fakultetin e mjekësisë UMT.

Një tjetër element i reformës së autonomisë spitalore është konkurueshmëria. Zyrtarët mendojnë se spitalet publike do jenë gjithnjë e më konkuruese me ato private.

“Qytetari i cili merr një shërbim edhe më cilësor patjetër që do të sjellë një konkurencë të shëndetshme jo vetëm mes spitaleve publike por dhe me ato private”- vijoi Zv.Ministrja e Shëndetësisë Entela Ramosaçaj.

Por eksperti i shëndetit publik Ilir Alimehmeti, nuk pajtohet më këtë argument.

“Përse dikush dëshiron të punojë jashtë orarit? Do të thotë që ajo punë e parë nuk i mjafton. Parimi duhet të jetë pagë e denjë për një punë të denjë. Nëse ne dalim përtej orarit, do të thotë që ne gjatë orarit nuk garantuam asgjë. Je në konkurencë me sistemin spitalor privat. Jemi në pozita totalisht të pabarabarta. Dhe në këtë garë do fitojnë privatët sepse qofshin kushtet, metodat, kontratat të cilat përmirësohen në vijimësi janë në favor të tyre?- vijoi Ilir Alimehmeti ekspert i shëndetit publik.

Public hospitals in Albania are entering the competition for autonomy, in a not very favorable climate regarding the financing of the health system. Although the budget for this sector has grown significantly in the last decade by over 80%, in relation to GDP it is about 3%, significantly below the average of 8% of the EU countries. On the other hand, the number of doctors per inhabitant is also low, 188 per 100 thousand inhabitants, when in the EU countries it is 374. Although salaries in health have increased in recent years, the departure of doctors from the country is giving a continuous blow the system.