Development of family medicine in Kosovo

Quality Coordinators' Perspectives on Quality Improvement in Primary Healthcare in Kosovo: A Qualitative Study

AIMS

This qualitative descriptive study provides insights into the experiences of quality coordinators (QCs) in primary healthcare to inform policy and practice actions and empower QCs to enhance healthcare quality.

METHODS

We conducted focus group discussions with purposefully selected QCs to understand their motivations, job experiences, factors influencing healthcare quality, and suggestions for quality improvement. Content analysis and deductive coding were used to scrutinize the responses and answer the research questions.

RESULTS

The QCs thought highly about their job performance and were motivated by both extrinsic and intrinsic factors. Clinical audits, collegial reviews, and managerial support positively affected QCs' performance. In contrast, a lack of managerial support, limited working hours, and changes in organizing work caused the opposite. Empowerment and external support positively influenced healthcare quality, whereas lack of resources, managerial support, or training had a negative influence. Suggestions to improve quality include the role of QCs, external supervision, and centralization of the QCs' network.

CONCLUSION

Appointing QCs alone does not guarantee quality improvement. It is essential to ensure that QCs have the appropriate skills, tools, management support, and open communication channels. Further research is required to evaluate the effects of sex and age on QCs' performance.

Pioneering family physicians and the mechanisms for strengthening primary health care in India-A qualitative descriptive study

India has one of the most unequal healthcare systems globally, lagging behind its economic development. Improved primary care and primary health care play an integral role in overcoming health disparities. Family medicine is a subset of primary care-delivered by family physicians, characterized by comprehensive, continuous, coordinated, collaborative, personal, family and community-oriented services-and may be able to fill these gaps. This research aims to understand the potential mechanisms by which family physicians can strengthen primary health care. In this qualitative descriptive study, we interviewed twenty family physicians, identified by purposeful and snowball sampling, who are among the first family physicians in India who received accredited certification in FM and were identified as pioneers of family medicine. We used the Contribution of Family Medicine to Strengthening Primary Health Care Framework to understand the potential mechanisms by which family medicine strengthens primary health care. Iterative inductive techniques were used for analysis. This research identifies multiple ways family physicians can strengthen primary health care in India. They are skilled primary care providers and support mid and low-level health care providers' ongoing training and capacity building. They develop relationships with specialists, ensure appropriate referral systems are in place, and, when necessary, work with governments and organizations to access the essential resources needed to deliver care. They motivate the workforce and change how care is delivered by ensuring providers' skills match the needs of communities and engage communities as partners in healthcare delivery. These findings highlight multiple mechanisms by which family physicians strengthen primary health care. Investments in postgraduate training in family medicine and integrating family physicians into the primary care sector, particularly the public sector, could address health disparities.

Post-disaster recovery: a case study of human resource deployment in the health sector in post-conflict Kosovo

INTRODUCTION

A professional understanding of disasters, paired with the need for health service development, can provide opportunities for the recovery and improvement of the health sector. Investment in training capacity ranks among the top priorities of a recovering health sector. The recovery and development of primary healthcare delivery systems has been implemented by various international and local health players in the aftermath of conflicts around the world. However, human resource development in the post-conflict environment has not been evaluated and/or published appropriately in the medical literature.

OBJECTIVE

In this retrospective, descriptive study, the authors describe the strategy and evaluate the effectiveness of a field-based training program for primary healthcare doctors implemented by the US-based international non-governmental organization, the International Medical Corps, after the conflict in Kosovo in 1999.

METHODS

A six-month, comprehensive education and training program on primary healthcare issues was delivered to 134 Kosovar primary healthcare physicians in 10 Kosovo municipalities in 1999 and 2000. Qualitative and quantitative data were collected. The qualitative methods included open-ended, semi-structured, key informant interviews, structured focus groups, and unstructured participant observations. The quantitative method was multiple-choice knowledge tests.

RESULTS

The education and training program proved to be culturally appropriate and well-accepted by local communities. The program met its overall objective to refresh the knowledge of primary care doctors on various primary healthcare issues and set the stage for further strengthening and development of primary health services and their required human resources in Kosovo.

CONCLUSIONS

The comprehensive education and training of primary healthcare doctors in Kosovo was a feasible, much appreciated, and effective intervention implemented in a difficult post-conflict environment. This training was one of the early steps in the modernization of primary healthcare services in Kosovo. Later, primary health care was strengthened by the introduction of a Department of Family Medicine at the university, which includes a residency program. The intervention described in this study has the potential to be reproduced in other post-disaster environments, especially in resource-poor settings with long-time troubled health sectors in developing countries.

Introducing family medicine in a pluralistic health care system: how patients and doctors see it

BACKGROUND

The health care systems in many countries are focused on specialist care. In those countries that have recently changed to a primary care-based system, some doctors and patients were dissatisfied with the change.

OBJECTIVE

To explore the opinions of the general public and the doctors on the change to a family medicine (FM)-based health care system.

METHODS

Qualitative study with focus groups of doctors working in different practice settings. Quantitative study with questionnaires sent to all doctors registered in Hong Kong and a telephone survey targeting the general public aged ≥18.

RESULTS

Doctors in the focus groups generally supported a FM-based health care system. They were concerned that there were not enough family doctors for such a system and the patients' current free choice of any doctor for primary care would impede its success. Thousand six hundred and forty-seven adults took part in the telephone survey (response rate 67.6%) and 2310 doctors (22.8%) responded to the questionnaire. Nearly 95% of the general public respondents agreed to the FM system though only 66.3% of them had ever heard of the term family doctor. About 65% of the doctors supported this system but only 33% agreed that the system would work. The specialist-doctors were less supportive of mandatory referral than the non-specialists, while the public was equally divided on this issue.

CONCLUSIONS

The public accepts the FM-based system but needs education on the benefits of primary health care. Direct access to the specialist would be the greatest barrier. Government involvements are essential for the reform.

Post-conflict transition and sustainability in Kosovo: establishing primary healthcare-based antenatal care

INTRODUCTION

Kosovo is a post-conflict nation with an extensively damaged infrastructure, a weak primary care base, and poor maternal-child health outcomes. The Kosovo-Dartmouth Alliance for Healthy Newborns (the Alliance) sought to improve maternal and neonatal health in Kosovo by providing family medicine-based antenatal care (ANC).

METHODS

The ANC Program used a modification of the World Health Organization's four-visit, prenatal care model. The program is based in family medicine and requires minimal medical equipment, such as a blood pressure cuff, fetal doppler, measuring tape, urine dipstick, and charting materials. Patient education and counseling are stressed. Women are taught about danger signs in pregnancy and establishing an emergency plan, so that they can respond promptly if complications occur. Antenatal care doctors and nurses are trained to refer women to obstetricians for deviations from normal pregnancy. The providers are taught using a "Training of Trainers" approach, building on an existing system of family medicine trainers. In order to address challenges in implementation and sustainability, microsystems methodology is used to focus on implementing change and assuring quality improvement through shared decision-making and the study of outcomes.

RESULTS

Based on chart reviews and direct observation, ANC providers showed mastery of the components of ANC, including physical examination, recognition and referral of high-risk pregnancies, and patient education. After an initial pilot project, Kosovo's Ministry of Health recommended this program for dissemination throughout the country. During the next year, ANC was implemented at 27 Family Medicine Centers in nine municipalities; 1,671 women were seen for a total of 3,399 visits. Currently, the Alliance's model of ANC is offered in 30% of Kosovo's municipalities.

DISCUSSION

International aid projects often lack attention to long-term sustainability. Microsystems training gives participants the tools and framework to implement and sustain change, even after international support is withdrawn.

CONCLUSIONS

The Alliance's model of family medicine-based ANC is simple to teach and emphasizes sustainability. It may be modified for use in different cultures and healthcare systems and offers the opportunity to improve maternal and infant health by providing low cost antenatal care, available in a woman's own community.

Medical education in Kosova

BACKGROUND

Kosova, the poorest country in Europe, is an example of the challenges posed by higher education in the developing world. The last 10 years have represented a period of significant reform within both the health care and education systems in Kosova.

AIM

This article provides an overview of all levels of the higher medical education in Kosova, with particular emphasis on main issues and challenges.

METHODS

This is a descriptive cross-sectional study. Data were collected through review of medical curriculum, student selection, licensure, continuing medical education (CME) and interviews with stakeholders in Medical School and Ministry of Health.

RESULTS

Medical education in Kosova is categorised in three levels: undergraduate, postgraduate and CME. Kosova has a short tradition of medical education and has had a turbulent history in higher education during the last two decades. Starting in the academic year 2001/2002, the University of Prishtina adopted the Bologna system, although officially Kosova is not yet a member of Bologna Process.

CONCLUSION

Quality assurance and quality control measures are considered core elements in future modernisation of medical education in Kosova. Bologna Declaration provides an opportunity for improvement of current weaknesses in medical education system.

Survivors of the war in the Northern Kosovo: violence exposure, risk factors and public health effects of an ethnic conflict

BACKGROUND

The aim of this population-based study was to assess the long-lasting effects of ethnic conflict on health and well-being (with a focus on injury and persistent pain) at family and community level. We have also investigated possible risk factors for victimisation during the conflict and factors contributing to healing.

METHODS

We conducted a district-level cross-sectional cluster survey of 1,115 households with a population of 6,845. Interviews were carried out in Mitrovicë district in Northern Kosovo from September to October 2008, using standardised questionnaire to collect lifetime violence exposure, lifestyle factors and health information on individual and household.

RESULTS

Ethnic Albanians made up 95% of the sample population. Crude mortality and under-five mortality rate was not high in 2008. Over 90% of families had been exposed to at least two categories of violence and human rights violations, and 493 individuals from 341 families reported torture experiences. During the two weeks before the survey, 20% of individuals had suffered physical or mental pain. There were differences in pain complaints according to gender and age, and whether people had been injured within 12 months, had lifetime exposure to violence-related injury, or had been tortured. Patterns of social and political participation in a family could affect the proportion of family members complaining of pain. The proportion of family members with pain complaints was related to a decline in the household income (coef = 9.31, 95% CI = 6.16-12.46, P < 0.001) and the fact of borrowing money (coef = 6.11, 95% CI = 2.91-9.30, P < 0.001) because of an injured person in the household. Families that were affiliated with the Kosovo Liberation Army, or had participated in a protest before or during the war, were likely to be targeted by Serbian paramilitary and law enforcement agencies.

CONCLUSIONS

Mitrovicë district is currently characterised by a low level of violence, but the effects of ethnic conflict on health and well-being have not gone. The level of lifetime exposure to violence, the proportion of family members reporting pain and lifetime violence-related injury, and family's financial burden were found to be inter-correlated. The sample confined to one ethnic group in one district limits the generalizability of the findings.

A case study of health sector reform in Kosovo

The impact of conflict on population health and health infrastructure has been well documented; however the efforts of the international community to rebuild health systems in post-conflict periods have not been systematically examined. Based on a review of relevant literature, this paper develops a framework for analyzing health reform in post-conflict settings, and applies this framework to the case study of health system reform in post-conflict Kosovo. The paper examines two questions: first, the selection of health reform measures; and second, the outcome of the reform process. It measures the success of reforms by the extent to which reform achieved its objectives. Through an examination of primary documents and interviews with key stakeholders, the paper demonstrates that the external nature of the reform process, the compressed time period for reform, and weak state capacity undermined the ability of the success of the reform program.