"Hospital autonomy", the debate about health services returns

2024-02-25 20:13:09, Aktualitet CNA

"Hospital autonomy", the debate about health services returns

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 increases even further 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 is going to go to Germany, to get us bad" .

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.

"This is a propaganda measure, with no real basis, that corrupts and overloads the hospital system. Disorganization will definitely be created, internal misunderstandings will be created, the impossibility of separation where the public and private service begins, the same assets will be used. What did we win? Nothing. If we refer to concessions. Does an autonomous hospital have room to decide on a service that the ministry decides? This happens for labs and other elements. Is this autonomy?" - said Petrit Vasili, former Minister of Health.

But the manager of the memorial hospital of Fier, where several elements of the management card of hospital autonomy were piloted a year ago, says that the activity of this hospital increased by 70%, and as a result, the access of citizens.

"The double practice does this, reduces the waiting list, manages it well, and gives the citizen the right to choose the right place where the best and highest quality service is available. At the same time, a new relationship of trust is created between the patient and the doctor" - argued Rudina Degjoni, Director of Fier Memorial Hospital.

Many citizens ask the question whether hospital autonomy avoids corruption in the ranks of white shirts. Some of them see the reform positively in this regard and think that its success will depend on the teams that will implement it.

"Management teams must be at the height of the reform. If we do not establish leading authorities and a management team with control and audit mechanisms, we risk having problems related to the lack of transparency, the promotion of favoritism of certain colleagues, and it can be a moment that can put us in a vicious circle the health system" - said Qamil Dika, lecturer at the UMT Faculty of Medicine.

Another element of hospital autonomy reform is competitiveness. Officials think that public hospitals will be increasingly competitive with private ones.

"The citizen who receives an even better quality service will definitely bring a healthy competition not only between public hospitals but also with private ones" - continued Deputy Minister of Health Entela Ramosaçaj.

But public health expert Ilir Alimehmeti no longer agrees with this argument.

"Why would anyone want to work overtime? It means that that first job is not enough. The principle should be decent pay for a decent job. If we go beyond the schedule, it means that we did not guarantee anything during the schedule. You are in competition with the private hospital system. We are in totally unequal positions. And in this competition, the private sector will win because whether the conditions, the methods, the contracts which are continuously improved are in their favor?" - continued Ilir Alimehmeti, public health expert.

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 system./ VOA

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