The Concept of Family Medicine in Kosovo

Implementation and development

Dugagjin Lleshi EMBA student

Cohort 24a
Table of Contents
Executive Summary 1
Introduction 3
Description of current situation 4
Possible solutions 14
Proposal of a new procedure or change 16
Description of a new situation 18

Justification of change 18

Conclusions and recommendation 18

 1.

I.EXECUTIVE SUMMARY

Family Medicine is also called family practice or general practice, is field of medicine that is
very much applied in primary health care, regardless of the age or sex of the patient, with
special emphasis on the family unit.

Family medicine is recognized officially since year 1969, but it developed from older models of
a patient’s health care needs are covered by a single doctor.

Medicine or Medical Practice is concerned with the maintenance of health and the
prevention, diagnostics and cure of disease. In recent time another duty of medical practice is
prevention and treatment of elderly.

The World Health Organization(WHO) at is International Conference in Alma- Ata in Soviet

Union defined health as a state of complete physical, mental and social wellbeing, and not
merely the absence of disease or infirmity.

According to the documents of this conference which is described in all textbooks of Public
Health Medicine: is a fundamental human right and the attainment of the highest possible level
of health is a most important world-wide social goal whose realization requires the action of
many other social and economic sectors in addition to the health sector.

The Family Medicine Concept is initiated, founded and implemented in all countries of our
region: Bulgaria, Romania, Serbia, Montenegro, Kosovo, Albania etc. This model has been taken
from developed European Countries such as Great Britain, Germany, France, Italy, Scandinavian
Countries, and Czech Republic etc.

In these countries this model is implemented and developed many years before.

In Kosovo, this field of medicine started its implementation in year 2000.

This concept was implemented in all primary health care centers of our country and it was
under surveillance of Department of Health and Social Welfare of Kosovo. In first years of its
function, Family Medicine practice was assessed by many foreign organizations and institutions
that worked in our country and with collaboration with Department of Health and Social
Welfare and it was effectuated by high number of medical experts from European Union
Member States and United States of America.
 2.

They helped the implementation of this concept by holding numerous professional trainings for
Kosovo health care workers and with sending them in trainings abroad in European and US
Health Care Centers. They worked also in restoring and supplying with medicaments and
medical equipment our premises.

The main reason to initiate the Family Medicine Concept is to redirect the patients to primary
health care level for resolving their health needs and not to send a high number of patients to
secondary health care level (hospital) for problems that can be solved in primary health.

The model for the introduction and development of Family Medicine in Kosovo was British
Family Medicine model and Royal General Practitioner Association.

The results were immense in comparison with the years before war and the years of
occupation. The health care situation and health care quality has increased and become
comparable with other countries of region.
 3.

II.INTRODUCTION

The Institution chosen for this description is Family Medicine Center in town of Gjakova-
Kosovo. This Health Care center is founded in year 1955 on was situated in an old aristocratic
house in the center of the city. Later, in year 1966 was build the existing object which is still
functional with all services.

This center is functioning as primary health center for the entire population of Gjakova and its
rural areas.

As a specialty, family practice incorporates portions of other medical specialties, including

internal medicine, pediatrics, obstetrics and gynecology, surgery and psychiatry.

The family medicine doctors of this center must a series of comprehensive tests of medical
skill and knowledge to demonstrate their familiarity with the rapidly changing body of medical
knowledge in these areas.

Recertification for the specialists in family medicine is required every five years. The changing
of the working system was done in year 2000. Before the Kosovo War this center was named
Health Center ”ISA GREZDA” and had general medicine clinics and ambulatories and dental care
policlinic in urban and rural areas of the town.

In year 2000 was implemented by the Ministry of Health of Kosovo and its International
partners the Project of Family Medicine of Kosovo.

The description of these operations are made based on long personal working experience of
the author of this work in operational management in general practice and also as a project
manager in many health project of this institution. The present work is also based on many
years of independent research and the large number of consulted literature and academic
journals of health care management.

Operations carried out was made was made by management board of the center in
coordination with the department of primary health of Ministry of Health.
 4.

III.DESCRIPTION OF CURRENT SITUATION

The introduction of Family Medicine Concept was made with the help of Project of Family
Medicine which is elaborated by the group of eminent health care experts and the professional
board of Ministry of Health.

Before we can start to describe the current situation in Family Medicine Center in Gjakova-
Kosovo, we need to introduce a few basic notions of Operational Management.

A project is a set of people and other resources temporarily assembled to reach a specified
objective, normally with fixed budget and with a fixed time period. Projects are generally
associated with products or procedures that are being done for the first time or with known
procedures that are being altered.

The project is a unique venture with beginning and an end, conducted by people to meet
established goals within parameters of cost, schedule and quality.

A temporary endeavor undertaken to create a unique product or service.

Project management is the planning, scheduling and controlling of project activities to meet
project objectives.

Another more interesting definition:

Project management includes planning, organizing, directing and controlling activities in

addition to motivating what is usually the most expensive resource on the project-people.
 5.

The Family Medicine Project enters in category of Management Projects. There also exits
many research projects in the framework of family medicine.

Health care consists on measures, activities and attitudes related to maintenance and
advancement of health and working and living environment which is effectuated by citizens,
health institutions, business organizations, socio-political associations, municipality institutions,
funds of health care and health care assurance and other organizations and institutions.

Primary health care consists on:

-health education of population in all actual problems and methods for their elimination and
control,

-advancement of food production and healthy food production,

-adequate providing of drinking water and other hygiene materials,

-health protection of mother and child and family planning,

-immunization,

-prevention and control of local endemic disease,

-treatment of common disease and traumatic conditions,

-providing with essential medicaments

The role of primary health care:

-advancing the health,

-prevention of disease,

-early diagnostics of disease,

 6.

-quick and efficient treatment,

-rehabilitation.

Beside the health care sector, all sectors of local and national development have an active
role on the health of population. These sectors are:

-protection of environment and working and living spaces,

-agriculture production, farming and food production,

-industry, education and culture,

-living spaces,

-public works and employment,

-communication and other sectors which influence the quality of living.

The Family Medicine Center in Gjakova is a part of primary health care. In continuation of this
work we will describe the most important functions of this center in related to the importance
of Operational Management for the good functioning of below presented services.

This health center is responsible for the next health care services:

a)service of General Practice and Family Medicine with service of urgency,

b) Hygiene and epidemiology service,

c) Dispensary services:

-dispensary for women,

-dispensary for children,

-school dispensary,
 7.

-dispensary for anti TBC protection,

-dispensary for noninfectious chronically disease,

d)service for dental health with all units for dental care of children and adult,

e) Home care unit,

f) Medicament unit,

g)Biochemical clinical laboratory,

h) Radiology service,

i) Specialist services,

-Internal Medicine cabinet,

-Ophthalmology cabinet,

-ORL cabinet.

All these units are functioning in the proper way thanks to the effective Management in
Family Practice clinics and the Operative Management of the health center. The services are
covered by general medicine doctors and Family Medicine specialists. The specialist cabinets
are covered by specialists in respective fields.

As a case study we would like to introduce the founding of Mammography cabinet.

Mammography is a special diagnostic investigation which is used for the screening of the
Breast Cancer in woman. The equipment and technics for this diagnostic investigation is
provided by Rotary Organization of Great Britain part of which is also Gjakova Rotary Club. This
unit is situated in special cabinet in an Family Medicine Ambulatory in other dart of town.

The Family Medicine Center of Gjakova has her own network of family medicine units in
urban areas and in all villages of municipality which are covered by medical and nursing staff.
 8.

The Family Medicine Center works in health protection, diagnostics and elimination of
infectious disease and other acute and chronically disease, wounding and other health
disorders especially in public health problems.

-in family planning and in developing human and responsible relations between genders,

-medical examinations of persons before starting to work and doing systematic control
examinations of workers, following and studding the appearance professional disease, working
on discovery of disease and wounding of workers, studding and taking measures for their
elimination, evaluating and controlling working ability of workers and temporary disabilities of
the workers for specific working places and doing other works which are important for the
health care of workers.

The Family Medicine functioning in health care in these domains of medicine:

-health education,

-general medicine/family practice,

- health care of woman,

-health care of children,

-home care,

-dental health care,

-laboratory diagnostics,

-radiology diagnostics,

-urgency

In continuation we will present some important statistics regarding the functioning of Family
Medicine in European Countries.
 9.

Table nr.1

Number of persons visited by Family Medicine doctors in some European Countries

State approximate number of persons/FD

Belgium 725

Italy 880

France 1150

Norway 1500

Finland 1730

Denmark 1750

Austria 1800

Great Britain 1950

Germany 2030

Nederland 2400

Sweden 2900

Source: Medicina Moderna

 10.

The payment of Family Medicine doctors is made by scheme of Ministry of Finance and
Ministry of Health of Kosovo. Here we will represent some modalities of payment in European
Countries.

Table nr.2

Modalities of payment of Family Medicine doctors in European Countries.

Payment per capita

a)Undifferentiated payment

Denmark-Copenhagen

Nederland (for patients with public assurance)

b)Differentiated payment in function of age

Italy, Great Britain (plus fixed allocations and payment for some services)

Payment for service

Belgium

France

Germany

Nederland (for patients with private assurance)

 11.

Norway (for FM from private sector plus payment of fixed allocations)

Mixt system (payment per capita, payment for services)

Denmark (exception Copenhagen until years 1987 and whole country after year 1987)

Austria

SALARY

Finland

Sweden

Norway

Source: Medicina Moderna. Bucuresti Romania

Family Medicine in Kosovo

Family Medicine was introduced in year 2000 as the cornerstone of health care in Kosovo,
country in the Balkans region of south-eastern Europe. After the war in Kosovo, it was soon
discovered that an entirely new primary health care system was needed, while we also began
to rebuild our society.

An analysis by the World Health Organization (WHO) regional office for Europe showed that in
reformation of the health care system in Kosovo there were many NGO-s (non-governmental
 12.

Agencies) involved in the health sector, each providing ideas about the directions that should
be taken. Initially efforts made by the WHO highlighted the importance for strengthening the
role of general practitioners and reorganizing primary health care. Family Medicine was chosen
to be foundation of the primary health system that was yet to be build (I. Miftari, R. Calgan
2007).

For this purpose the training of 100 general practitioners begun. Fifty of these general
practitioners were trained at the same time to become trainers who will ultimately be
responsible for training next generation of family physicians. Medicine, Child Health,
Reproductive Health, Mental Health, Common Illness and common emergencies. The
establishment of this program was recognized by the Ministry of Health of Kosovo as an
important specialization program in Family Medicine. Because of the importance of this effort,
it was given a fast-track toward implementation.

The program has been accredited by the Royal College of General Practicioners in the United
Kingdom (I.Miftari, R. Colgan 2007).

In the development of Family Medical Center in Gjakova-Kosovo were involved also a

group of experts from Dartmouth University from United States of America. They held
many training courses for nurses and they made a lot of investments in this health center.

Family Medicine in Kosovo

A recently formed Association of Family Physicians of Kosovo, with established

department and clear goals and objectives for the future.

New approach toward prevention, patient consultation, scientific research and team
work.
 13.

Challenges

Finalizing the implementation of Family Medicine in Kosovo and raising the quality of
health services to widely accepted international standards is our main goal. A review of Family
Practitioner salaries, along with further development of human resources and the
infrastructure of health facilities is another important aspect for successful completion of this
process. Creating a legal infrastructure for both public and private health sector is of crucial
importance for improving the quality of health services. Intensifying scientific research in
primary health care on further development of Family Medicine based on the results of our
own research is one of the biggest challenges for Family Medicine in Kosovo
(www.clinicalmicrosystems.org).
 14.

IV. POSSIBLE SOLUTIONS

I the entire territory of Republic of Kosovo, there are more than 400 specialists of Family
Medicine and almost the same number of general practice doctors. The most important factor
for reformation of primary health care system is made for increasing the quality of health care
for our population and increasing the quality of their living.

The situation now, in comparison with the postwar period is much more favorable but there is
still place for improvements.

The Family Medicine clinics and ambulatories now are at high level and they are comparable
with European standards. There is also a training center for raining of doctors and nurses which
provides high quality training for the medical and nursing staff.

The pharmacy of the center is supplied only with some medicaments from the list of essential
medicaments. This pharmacy is under supervision of Pharmaceutical Division of Ministry of
Health. There is lack of essential medicaments for the ambulatory and chronically ill patients.
There even missing Penicillin medicaments which are very important medicaments in treating

the common infections. The patients must pay from their own money all medicaments and
many diagnostic tests. There is a low quantity of Insulin for home treatment of diabetic
patients. The analgesic drugs which are used for treatment of patients with cancer also are not
available. All these medicaments must be paid by patients. The Ministry of Health says that
situation is present because of low budget of state of Kosovo.

As a solution for this issue we will recommend the strengthening of Operational Management
Board of the center and a intensification of collaboration with the Directory of Health Care in
municipality level which is responsible for the primary health care at local level.

For the improving the medicament supply of the health center we will suggest the improving
of supply chain of Pharmaceutical Division of Ministry for facing this situation.

There are also present many corruption cases in our health care system. The only solution for
this problem is increasing the incomes of Family Medicine Center by using the participation of
patients for the health care that provide and also increasing the increasing the funds that come
 15.

from Ministry of Health for supplying the primary health care with medicaments and diagnostic
agents.

For resolving the problem of corruption practices, we will suggest the more intense
collaboration with Division of Sanitary Inspection and with Division of Health Policy of Ministry
of Health.
 16.

V.PROPOSAL OF A NEW PROCEDURE OR CHANGE

Strengthen primary health care services through family medicine approach.

Primary health care in Kosovo before the war was undeveloped and seriously neglected. The
health system of Kosovo was based heavily on secondary health care. After the war, many
efforts were invested to develop and update primary health care services. WHO initiated the
family medicine specialization program and after two years of implementation continued by
Ministry of Health. The Concept of Family Medicine continues to be the cornerstone of
development of primary health care services in Kosovo.

Measures: design of detailed plan for development of primary health care based on the

Health need in municipalities

-develop human resources in primary health care,

-develop infrastructure and equipment,

-develop necessary legislation,

-develop financial system and sustainable payments through capitation in primary health care,

-improve nursing service,

-develop necessary organizational system for implementation of the Family Medicine concept,

-develop the set of functional and general public health, diagnostic and curative services,

-enable local communities to actively participate in planning and decision-making processes

regarding provision of primary health care,

-develop the detailed plan of emergency services in primary health care level in order to
improve provision of these services.
 17.

One of the most important factors for improvement in quality of health care in Family Medicine
is the education of doctors and nurses in this area.

For the education in Family Medicine is important to have specific textbooks and manuals
that are written specially for using in family medicine practice because of working conditions in
which Family Medicine operates. The standard clinical medicine textbooks are published for
using of doctors who operate in hospital conditions and therefore are not practical for doctors
in General Practice/Family Medicine.

Unfortunately there is a lack of medical literature in General Practice/Family Medicine in

Albanian language in Kosovo region. Some textbooks are now published in Albania and there
are present in Kosovo book market. For this presentation I would like to introduce one of the
finest textbook in this field: Robert Rakel. Family Practice (2015).

The profession of General Practice/Family Medicine continues to be one of the most romantic
medical professions and is described even by classical writers such as H. Balzac ”The country
doctor”, A. Cronin “The citadel”, B. Pasternak “Doctor Zivago”etc.
 18.

VI. DESCRIPTION OF NEW SITUATION

Improving management of drugs and medical supplies

During the previous years there were noticed there were noticed many shortages and
dissatisfactions in supplying the population with essential drugs. Therefore the priority of
Ministry is to improve this issue with available resources. Improvement in this field aims
ensuring sustainable, safe and efficient resources and approach to essential drugs and other
medical and logistics supplies. It will develop a harmonized, sustainable and efficient
procurement and supplies management system. Also it will develop a plan for development of
pharmaceutical policy as well as quality control. This is one of most important issues in
managing the Family Medicine care in our country.

The education of general practice/family medicine physicians for their work

The evaluation and the role of some parts of the health service starts from volume and
structure of the health requests that are being solved rationality, efficiently and with extreme
quality. Family Medicine solves independently more than 80% of the health requests.
Rationality of its activity reflects in the results achieved with minimal expenses. Efficiency is one
of comparable advantages and its referring to technical activities in prevention, diagnostics,
treatment and rehabilitation. The quality of work observed through components: structure,
process and results shows that we have done some advancing but we are still insufficient in
physicians and nurses that elaboration of criteria for evaluation of quality of work is late, and
the measuring of results, other than examination of the satisfaction of patients is waiting for a
research project.
 19.

VII.JUSTIFICATION OF CHANGE

In order to respect the word limit of this report, we can only ad that justification is
multifactorial for this topic.

VIII.IMPLEMENTATION PLAN

The implementation of Family Medicine Project was described in previous chapters.

IX.CONCLLUSION AND RECOMMENDATION

Operations Management refers to the administration of business practices to create the

highest level of efficiency possible within an organization.

It is concerned with connecting materials and labor into goods and services as efficiently as
possible to maximize the profit of an organization.

In our case the most important profit is to increase the quality of health care for our
population.

Family Medicine is separate medical discipline and its doctrine is made of following
components:

-task in the health care,

-characteristic of Family Practice Medicine,

-competence for solvation of task efficiently, with quality and rationality. Recc.=strengthening.
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