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Introduction:

When deeply divided societies that have experienced or are experiencing periods of war

and mistrust between different ethnic groups, it is expected that a nation-state will experience a

new dilemma in the practice of state building. The main challenge for state builders in such

societies like Cyprus, Palestine, and the seven republics of what was once Yugoslavia is to

design and enhance civil society in relations to public perception and the ability to have

sustainable public institutions. In the context of the Republic of Kosovo, this is particularly

difficult to manage due to the de-centralized nature of the Kosovar government model, in which

most institutions are under municipal jurisdiction because the level of ethnic polarization

between ethnic groups. According to the Constitution of the Republic of Kosovo, the municipal

governments are responsible for maintaining and creating civil or public institutions that range

from schools, the protection of religious-cultural buildings, and public health institutions (i.e.

hospitals).1,2 One of the greatest concerns facing Kosovo’s post conflict society regards the issue

of minority integration of civil institutions particularly that of health care. The ethnic divisions

between Kosovar Albanians(K-Albanians) and Kosovar Serbs (K-Serbs) has posed a great post-

conflict structural challenge in relation to creating an effective a healthcare model that is

efficient and integrates the peoples of Kosovo. However, both current demographic realities and

historical precedent has posed great structural-hierarchal challenges for the Kosovar health care

system. Under the present circumstances the current health care system in Kosovo has proved to

be insufficient, despite the guidance provided by the Ahtisaari Plan for the creation and

accessibility of public health services in the Republic of Kosovo.3,4,5 The aim of this policy

1 Spiegel 20002 Ministry of Health 20133 Trans-Conflict 20134 McKee 20135 Rechel 2003

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analysis is to discuss and analyze the numerous structural complexities that inhibit the current

health care system in Kosovo, as well as what recommendations would help to alleviate some of

the current inhibitions.

Context:

The main factors that have prevented the Republic of Kosovo’s healthcare system from gaining

stronger ground revolve around the following dilemmas: distrust in governmental institutions,

de-centralization, and resource shortages. Such concerns are reminiscent of the previous system

that had been in place when Kosovo was an autonomous region of what was once the number of

incarnations of the former Yugoslavia. Based on a health system developed by the former USSR,

the Semashko Model was a centralized decision-making model that called for areas of

specialization for services in polypclinics (several services).1,6,7,8,9These services were located in

densely populated areas and the central government (Belgrade) in turn acted as the purchaser of

the services rather than the patient. However, under the Yugoslav leadership of Tito, this model

was revised to make a self-sufficient version of the Semashko Model where municipalities

managed their own polyclinics and general health care services.1,6,7,8,9 This system was noted to be

extremely effective and there was a dramatic improvement in mortality rates (from 46 per 1,000

in 1956 to 29 per 1,000 in 1990). Unfortunately, this period of success was to end in 1989 when

Belgrade renounced the 1974 Yugoslav Constitution that had granted Kosovo an autonomous

status within the Serbian province. When this occurred, the issue of health care access became

the center of contention because of the ethnic politics that divided the region. By the early

1990’s, Belgrade took over the health sector by closing Pristina University’s medical school,

6 Percival Egbert 20137 Roberts M 20048 Hsiao W, Berman 20049 Reich M 2004

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which created a cascade of mass firings, smear campaigns, and harassment of ethnic Albanian

professionals (estimates are believed to be around 2,400 health professionals). Four hundred and

forty of these medical professionals that were dismissed were specialist physicians.1,6,10 The

hardest hit medical field was Gynecology and maternity polyclinics due to the dismissals and the

newly imposed Cyrillic language requirement of medical professionals.1,7,8,9.

These impositions were targeted at the Albanian community and resulted in the creation

of parallel primary health care systems that were aided by Non-Governmental Organizations

(NGOs). Of the health service NGOs present, the predominate provider was the Mother Theresa

Society, who operated 96 polyclinics throughout the Kosovo region, especially in remote areas.

Health care workers consisted of volunteers that ranged from financial aid for supplies, to

doctors, and business management groups that formed a parallel tax system specifically for the

Kosovar-Albanian minority.6,8,9,10,11 Other Kosovar-Albanians and Albanians established their

own practice in addition to creating a parallel system of medical training. This system trained

and graduated about 600 doctors and 1,200 nurses from this parallel system.6,10 While this system

provided students with a high degree of theoretical knowledge, clinical training was still

problematic because of the limited access to medical facilities that were formed in order to

conduct practicums. Due to such situations, it left these “para-medical professionals” with an

uncertain future that was made even more dubious when violence broke out between the KLA

and the Yugoslav Army in 1998.1

In the fall of 1998, UNHCR estimated that 200,000 Kosovar-Albanians were displaced,

in which most of the Albanian minority civilian population fled to the Republic of Albania and

Republic of Macedonia to escape the violence. Those who stayed in the Kosovo region saw the

10 Tolaj 199911 Paris 2004

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mortality rate double due the violence that claimed over 12,000 civilians. This violence helped to

spark the North Atlantic Treaty Organization’s (NATO) entrance into the conflict.10 Then in June

of 1999, the United Nations Security Council attempted to bring the humanitarian crisis in

Kosovo under control by passing Resolution 1244. This resolution was adopted to provide the

legal foundation for United Nations control over the former Yugoslav province, which was also

known as the United Nations Interim Administrative Mission in Kosovo (UNMIK). The UNMIK

had been charged with the responsibility to govern the province until Kosovo was able to

become a self-sufficient governmental entity. On February 17, 2008, Kosovo declared

independence from the Republic of Serbia, but the small republic still heavily relies on UNMIK

aid, as well as other IGOs and NGOs for policy recommendations and financial assistance.12,13

Works Cited:

Websites:

European Center for Minority Rights. “Minority Healthcrae in Kosovo.” Last modified April r 10, 2013. http://www.ecmikosovo.org/

12 UNMIK 200113 UN Security Council 2007

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International Crisis Group, "Setting Kosovo Free: Remaining Challenges." Last modified September 10, 2012. http://www.crisisgroup.org/en/regions/europe/balkans/kosovo/218-setting-kosovo-free-remaining-challenges.aspx.

Ministry of Health: Kosovo, "Ministry of Health: Current Issues." Last modified May 02, 2013. http://www.msh-ks.org/?lang=en.

TransConflict, "TransConflict: The Ahtisaari Plan and North Kosovo." Last modified April 04, 2013. Accessed April 30, 2013. http://www.transconflict.com/approach/think/policy/ahtisaari-plan-north-kosovo/

Valerie, Percival, and Sondorp Egbert. Conflict and Health, "A case study of health sector reform in Kosovo." Last modified April 16, 2010. http://www.conflictandhealth.com/content/4/1/7

United Nations Office Special Envoy to Kosovo (UNOSEK), "The Comprehensive proposal for Kosovo Status Settlement." Last modified April 01, 2013. Accessed April 2, 2013. http://www.unosek.org/unosek/en/statusproposal.html.

Government Reports:

"Combating Corruption in Kosovo:A Citizens' Perceptions Survey in Support of the Kosovo Anti-Corruption Strategy." Advisory Office on Good Governance, Human Rights, Equal Opportunities and Gender Issues, Office of the Prime Minister (PISG). : 1-32; 2012

"Comprehensive Proposal for the Kosovo Settlement." United Nations Security Council. (March 26, 2007): 1-73.

UNMIK: Kosovo Consolidated Budget. Pristina: United Nations Interim Administrative Mission in Kosovo; 2000. 

WHO: Interim Health Policy Guidelines for Kosovo and Six Month Action Plan. Copenhagen, World Health Organisation; 1999. 

Academic Journals/Articles:

Bloom, JD, D Hoxha, and E Sondrop. "Ethnic segregation in Kosovo's post-war health care system. "European Journal of Public Health. no. 05 (2007): 430-436.. doi: 10.1093/eurpub/ckl270

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Figueras J, McKee M, Cain J, Less of S: Health Systems in Transition: Learning from Experience. Copenhagen, European Observatory on Health Systems and Policies; 2004. Gloeb J: Perinatal Health Care Situation in Kosovo: Past, Present, and Future. Pristina: UNFPA; 2001. 

"Kosovo Health Financing Reform Study." Human Development Sector Unit Europe and Central Asia. (May 6, 2008): 1-131. Report No. 43183-XK.

Kosovo Ministry of Health: Kosovo Health Strategy. Pristina: Kosovo Ministry of Health; 2005. 

UNMIK Department of Health: Health Policy for Kosovo. Pristina: United Nations Interim Administrative Mission in Kosovo; 2001. 

Paris R: At War's End: Building Peace after Civil Conflict. Cambridge: Cambridge University Press; 2004. 

Rechel B, McKee M: Healing the Crisis: A Prescription for Public Health Action in South Eastern Europe. London: London School of Hygiene and Tropical Medicine; 2003.

Roberts M, Hsiao W, Berman P, Reich M: Getting Health Reform Right: A Guide to Improving Performance and Equity. Oxford: Oxford University Press; 2004. 

Setting Kosovo Free: Remaining Challenges Report Europe Report N°218." International Crisis Group.” (September 10, 2012): 1-35.

Simpson D: Kosovo Health Profile. London: DFID; 2003. 

Spiegel P, Salama P: War and Mortality in Kosovo, 1998-99: An Epidemiological Testimony. The Lancet 2000, 355:2204-2209

Tolaj I: Health and Human Rights in Kosova: A Kosova Doctor's Story. Student BMJ 1999. (7)

Appendices:

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Figure 1: Current budget spending on Healthcare

Figure 1.2: GDP

Figure 2: Corruption Index

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Figure 3: Minority Demographics

Figure 4.1: Amount of inpatient out patient care

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Figure 4.2: Hospital Beds

Figure 4.3: Occupancy Rate

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Figure 4.4.: Hospital admission rate

Figure 5: Current Level of Communicable Diseases and Birth Rates

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Figure 6.1: Human Development Model:

Figure 6.2: Human Development Model System

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