Reproductive Health for All

Reproductive Health in Albania

University Hospital of Tirana
Department of Obstetrics and Gynaecology

Dr. Dorina ISLAMI
Dr. Fjodor KALLAJXHI
Dr. Orion GLIOZHENI

in collaboration with the

Geneva WHO Collaborating Centre for Research in Human Reproduction

CONTENTS

1. INTRODUCTION

1.1 Implications of recent changes in political and economic life in Albania

2. BACKGROUND AND DEMOGRAPHIC DATA

2.1 Arguments to introduce Reproductive Health in Albania
2.2 Strategy for Reproductive Health
2.3 Structure of Reproductive Health
2.4 Definition of Reproductive Health periods
2.5 Components of Reproductive Health

2.5.1. Adolescent care
2.5.2. Family Planning
2.5.3. Mother care
2.5.4. Care for woman nourishment
2.5.5. Newborn care
2.5.6. Care for 0-5 years old children
2.5.7. Care for sexual health
2.5.8. Check up of genital and breast tumours
2.5.9. Care for post-reproductive health

3. COUNTRY STRATEGIES FOR ALBANIA

3.1 Governmental Policy

4. REPRODUCTIVE HEALTH SITUATON IN ALBANIA

4.1 Reproductive Health of Adolescents
4.2 Mother Health and Safe Pregnancy
4.3 Family Planning
4.4 New-born Care
4.5 Child Health and Development
4.6 Post-Reproductive Health
4.7 Genital Cancers Care

5. FAMILY PLANNING / REPRODUCTIVE HEALTH PROJECTS

5.1 Multilateral Organisation Assistance

5.1.1 UNITED NATIONS POPULATION FUND
5.1.2 OTHER MULTILATERAL AND BILATERAL AGENCIES
5.1.3 NGOs AND THE PRIVATE SECTOR

6. PERSPECTIVES FOR FUTURE PROJECTS IMPLEMENTATION

6.1 Objectives and Indicators of Reproductive Health till the year 2000
6.2 POPULATION DEVELOPMENT
6.3 HEALTH POLICY AND STRATEGY
6.4 APPROACH

6.4.1 Holistic approach of Reproductive Health
6.4.2 Client and Patient oriented
6.4.3 De-medicalisation of Reproductive Health and Family Planning
6.4.4 Information, education and communication

7. NECESSARY INPUTS FOR THE FUTURE

7.1 Personnel
7.2 Training
7.3 Material, facilities and contraceptives

8. OUTPUT MEASURES

9. PRIMARY EXPECTED EFFECTS AND OUTCOMES

LIST OF ANNEXES

ABBREVIATIONS / ACRONYMS

1. Introduction

1.1 Implications of recent changes in political and economic life in Albania

The transition from communism to a more plural form of government came later in Albania than in most other countries of central and Eastern Europe. The resignation of the last communist government in June 1992 plunged the country into political and economic chaos. Thereafter, following the election of a new government, attempts began to introduce comprehensive reform programmes. This process was interrupted in the early months of 1997 when the political and security situation became extremely volatile with the development of criminal activities, resulting in the evacuation of their staff by many of the donor organisations.

At the end of 1997, although the staff of the donor agencies has largely resumed their humanitarian activities, the security situation is still not entirely stabilised, and travel in certain areas presents a risk. There are very major infrastructure problems, giving rise to serious difficulties as regards water, electricity supplies and drainage. The arrangements for garbage collection have evidently broken down, and rotting rubbish in the streets would seem to pose a very real threat to public health. In these circumstances, the outbreak of epidemics, such as the cholera, which affected Albania in 1996, cannot be excluded.

Generally in Albania the roads are in bad condition, making transport very difficult even in urban areas, to say nothing of the more remote mountain regions which are almost impassable in winter. Postal services and telephones are unreliable. Assistance from the international community is critically needed in order to restart economic activity, but the fundamental changes which have marked the political and economic transition, combined with the uncertainty which characterises life in Albania, seem to have resulted in a certain level of inertia within the country.

2. Background and Demographic Data

After 45 years of Communist dictatorship it came to dramatic changes in Albania in the years 1991/92, which made possible first democratic elections, the introduction of first steps towards liberal market regulations and an opening of the society.

It is difficult to get a clear picture of the health situation in Albania. Data gathering is hampered by various factors, not least of which are the demographic movements and communications problems. In addition, the use of different definitions (for example, of infant, perinatal and neonatal mortality) and different methods of data gathering and recording, added to staffing problems and a lack of co-ordination results in a certain degree of inaccuracy in the field of Reproductive Health statistics.

In 1989 the total number of the Albanian resident population was reported to be 3.199.200 inhabitants (last official population census). The population was relatively young with about 33 per cent being younger than 15 years of age. The number of women in reproductive age (WRA: women 15-49 years of age) was about 800.000. It was estimated that 75 per cent of them were married. The gross reproduction rate was 1.46, the net reproduction rate 1.38 and the fertility rate 3.0 births per WRA (1990). With a female life expectancy at birth of 76.3 and male life expectancy at births of 70.0 years (1992), the rate of natural increase of the population was 1.9 in 1989 which predicted a population doubling time of about 40 years. In 1989 the Albanian population was in large majority a rural population. Only 36 per cent of the population (in absolute numbers 1.183.000) lived in an urban environment. Average population density was in 1993 : 110.2 inhabitants per square kilometre.

After the end of the Communist regime a huge wage of emigration flooded mainly to the neighbouring European countries (Greece and Italy). In 1992-93 during 1 1/2 years 165.000 people left the country (50 per 1.000 of the total population). During this time the emigration rate for the age group of 20-29 years old was even higher (20 per 1.000). In 1990 it was estimated that 300.000 people (or 90 per 1.000 of the population) and in 1994 nearly 400.000 people (120 per 1.000 of the population) had left the country.

Albania experienced a most difficult transition of its economy, still lacking a mature market economy. The massive trade imbalance is largely due to a precipitous decline in exports. The relative progress of development was and still is possible only because of foreign aid (US$ 320 million, 1993) and the income received from Albanian emigrants working abroad and sending home money (US$ 400 million, 1993).

Before, health care was purely public, centrally organised and controlled. The population policy was pro-natalist, modern Family Planning (FP) unknown and it was taboo to speak about sexuality and contraception in the public. Constitutional guarantees existed also regarding the participation of women in political, economic, social and cultural life. Despite this, Albanian society remains relatively paternalistic, and status of women and their participation in public life have not improved over the last few years. According to the Albanian Development Report 1995, there are more young women than young men in secondary and higher education, possibly because of the greater difficulty they experience in finding posts within the private sector.

It is very difficult to draw a clear picture of the health status of the Albanian population. Especially, statistical data of the years 1991/92 are little reliable, incomplete or were based on different definitions. Even mortality data were somewhat uncertain. In 1989 overall perinatal mortality was 13.5/1.000. It was recognised that the official infant mortality rate (IMR) of 28.3/1.000 in 1990 was underestimated by one third. Instead of the under-5-mortality, the mortality of the under-4-years old children was reported. Estimating the under-5-mortality in 1991 by adding 10 per cent to the under-4-mortality, results in 43.9 per 1.000 live births. In 1989 the maternal mortality ratio (as obstetric risk) was: 49.5 per 100.000 live births. The maternal mortality rate (MMR) in 1989 was 4.8 per 100.000 WRA.

Till 1988 modern FP methods were forbidden, their application, effectiveness and safety virtually unknown and their use claimed to cause cancer or permanent sterility. Through the "Order of the Minister of Health concerning the performance of abortion" (April, 1991) and the "Decision of the Council of Ministers for the approval of activities of FP in Albania" (May, 1992) abortion became legalised and modern FP methods could be introduced in the public health services (Annex 5). In 1989, 300 abortions per 1.000 live births were performed. Premature birth rate was 6.55 per 100 live births (birth weight under 2.500 gr.). The life expectancy of women is increased through the years (Graph 11), while the total fertility rate (TFR) is decreased (Graph 12)

Of the sexually transmitted disease (STD), syphilis had been declared eradicated. AIDS or HIV-infections were unknown (the first HIV-infection was reported in May 1993).

2.1 Arguments to introduce Reproductive Health in Albania:

• Psychosocial aspects (rights of reproduction, economic situation, inclusion of social workers).
• Mothers and children’s health status is not yet satisfactory (reduce maternal and infant mortality).
• Health of adolescents is threatened (changing social and cultural environment).
• Burden through STD’s and other genital diseases may increase in the near future.
• Knowledge of the population in Reproductive Health is still not satisfactory.
• Health personnel are not yet sufficiently trained in Reproductive Health.
• Quality of the services related to Reproductive Health is not satisfactory.
• Health information system for Reproductive Health is weak and not satisfactory.
• Lack of co-ordination between the structure of primary and secondary health care.
• Integrated services have proved to be more cost-effective and more equitable.
• Reproductive and sexual health concerns of older women and men are inadequately addressed (Annex 8a, Annex 8b)

2.2 Strategy for Reproductive Health

• Human Rights, Ethics, Laws (in no case abortion should be promoted as a FP-method, rights of children to be protected against violence) and Regulations.
• RH in the context of socio-economic development of the country.
• Research in Reproductive Health (defavoured people, children; needs assessment for training, resources and infrastructure, etc.).
• Building institutional capacity (training, quality of service).
• RH will be introduced as a concept in all relevant services (facilities, resources, supervision, operational health management information system, IEC).
• Women-centred care (santé des femmes).
• IEC (multi-media approach).
• Introduction of the elements of RH at all levels of the concerning partners (training of health staff at different levels and with different specialisation, training of medical students, nurses, midwives and family doctors, job descriptions of Regional Inspectors of RH).
• Dialogue and coalition building (public/public and public/private mix, NGOs, international organisations).

2.3 Structure of Reproductive Health

• Reproductive Health is a concept and does not obligatoriously need an own structure (building, services, personnel). The concept must be introduced in several services and the concerned medical personnel trained to understand the concept and to perform the necessary services in an integrated manner.
• The type of vertical approaches to health problems has long been shown to be less cost-effective and less equitable than an integrated approach. Also the different elements of Reproductive Health are closely linked and patients are faced often to cumulating consequences of reproductive problems. Therefore, elements like STD/AIDS prevention, family planning, abortion, sterility, neonatal care, delivery and breast-feeding cannot been focused separately. Integration and an overall understanding of Reproductive Health are essential.
• Porte d’entrée (how to differentiate types of client enter the RH care? Central registration and orientation of client towards different parts of the service).

The services, which provide RH, are spread in the whole health institution network of the country. They involve:

1. First Level Care:

• Ambulances in rural zones

• Public run health centres in rural zones

• General Practitioner or Family Physician

• Mother and child consulting centres in districts

2. Second Level Care:

• District Maternities and Paediatric Hospitals

3. Third Level Care:

• University Hospital of OB/GYN

• University Hospital of Paediatrics

The second and third level centres are in the same time referral services for the whole country.

• Who is concerned with RH elements?

1. Public Health Institutions:

• PHC-directorate:

  • sector of reproductive health

  • sector of hygiene and epidemiology

• Hospital care directorate

  • gynaecological and obstetrical services

  • paediatric services (peri- and neonatal care)

• Institute of Public Health

  • STD/AIDS prevention and control programme

2. Public Education Institutions:

• Ministry of Education

• Medical Faculty of the University of Tirana, Department of OB/GYN

3. Private Sector:

• gynaecologists

• paediatricians

• family physicians

• druggists

• different NGOs

2.4 Definition of Reproductive Health periods

There are three main periods of Reproductive Health:

• Period of pre-Reproductive Health, which corresponds to adolescent age

• Period of Reproductive Health, which includes

• Maternal period: prenatal, delivery, post-natal, post-partum and breast-feeding period

• Intervals between deliveries

• Period of post-Reproductive Health, which corresponds to menopause and andropause time

2.5 Components of Reproductive Health

2.5.1. Adolescent care

• Improvement of RH education in school

• Increased knowledge of STD and contraception

• Prevention of pregnancies in early age

• Prevention of STD

• Prevention of inadequate sexual behaviours

• Safe abortion

2.5.2. Family Planning

• Pre-conception counselling

• Prevention of abortion

• Post-partum and post-abortion counselling

• Safe abortion

• Information, application and counselling on different contraceptive methods

• Follow-up of contraceptive side-effects and complications

• Providing of modern contraceptive methods

• Sexuality

• Infertility

2.5.3. Mother care

• Pre-conception

• Prenatal care

• Reduction of pre-term and hypotrophic deliveries

• Adequate vaccination of pregnant women

• Labour care

• Postnatal care

• Promotion of breast-feeding

• Reduction of perinatal mortality

• Reduction of maternal mortality

• Reduction of obstetrical and neonatal complications

2.5.4. Care for woman nourishment

• Improving the knowledge and education on nourishment

• Reduction of anaemia during pregnancy

• Promotion of breast-feeding

2.5.5. New-born care

• Reduction of neonatal mortality and morbidity

• Reduction of neonatal infections after delivery

• Improvement of early neonatal intensive care

• Incitement of exclusive breast-feeding

• Incitement of rooming-in in the maternities all over the country

2.5.6. Care for 0-5 years old children

• Check up of psycho-motor development

• Adequate vaccination

• Improvement of education and knowledge on child feeding

• Reduction of mortality and morbidity

2.5.7. Care for sexual health

• Prevention, treatment and counselling on STD/AIDS

• Reduction of other genital infections

• Reduction of gynaecological disease complications

2.5.8. Check up of genital and breast tumours

• Early screening of breast, cervical and prostate cancer

• Counselling and referring

• Reduction of HPV prevalence (human papilloma virus)

2.5.9. Care for post-reproductive health

• Prevention and treatment of menopause disorders

3. Country Strategies for Albania

3.1 Governmental Policy

Within the framework of the national health policy, the government has defined a set of primary health care priorities. These include: maternal and infant mortality, antenatal and post-natal care, access to RH/FP/SH care and prevention of sexually transmitted diseases.

The Governing Council asked for $3 million from UNFPA for a five-year programme starting in 1991. The programme aimed to strengthen Government capacity in the area of maternal and child health, by providing training and equipment; reduce maternal mortality and promote child spacing; increase the knowledge base in demographic statistics, analysis and research to help integrate population factors into development planning and further develop population policies; and improve the status of women and their participation in population and development.

With external technical assistance and in co-operation with the Phare Health Programme of the European Commission, the MoH developed a policy of Primary Health Care (PHC). In this policy it was stated that MCH will be a future priority for the public health services. Reproductive health (RH) was mentioned for the first time. It was further stated that equity and equality are important elements of the PHC-policy to allow the same access to health care services to every Albanian citizen.

A number of laws, Presidential decrees and orders of the Minister of Health related to FP and RH-issues have passed the Parliament or were published (Annex 5).

Amidst the current climate, it is hardly surprising that the advancement of Reproductive Health/Family Planning and Sexual Health rests always one among many on the list of priorities currently facing the Ministry of Health and Environment. Not least of these are the impending across-board budgetary cuts of 15% and staff cuts of 10% which are to be introduced as part of the structural adjustment conditions attached to the World Bank loan of US$ 204 million in which 100 primary health care centres and 2 regional hospitals will be rehabilitated and equipped, health management improved and health personnel trained, drugs procurement and distribution improved, and health financing reviewed and reorganised.

4. Reproductive Health Situation in Albania

4.1 Reproductive Health of Adolescents

According to one study made in 1994 on the abortion situation, 3.6% of abortions were performed in girls of 13-19 years old, mostly living in the cities. 45.3% of adolescents undergoing an abortion had followed just the low school, and 48.2% the high school. Only 2.9% of them were students.

Another study on sexual education found that information provided by mass media and different sources was often inadequate and not professional. 92% of adolescents of 13-19 years old had at least once tried a sexual experience.

Sexual education in school is still in the first steps and thus, its level is quite low. Even teachers are not yet liberated from the ancient mentality and hardly speak freely or naturally on sex problems. To improve the quality of teaching skills, a number of seminars and workshops are organised in different cities by the Ministry of Health and the Ministry of Education in collaboration with UNFPA and diverse NGOs.

4.2 Mother Health and Safe Pregnancy

From 1991 to 1996 maternal mortality decreased by 25 per cent and reached the level of under 30 per 100.000 live births (28.5 in 1995, Annex 1, Graph 1a). The main causes of maternal mortality in recent years have been defined, as: 1) haemorrhage during and post-partum; 2) different previous pathologies; 3) pregnancy-induced hypertension.

It has been assumed, that the decrease of maternal mortality was primarily due to the legalisation and liberalisation of abortion in 1991. Abortions became more safe, but there is still no clear sign for a decrease of the abortion rate (Annex 2, Graph 2a). In Albania abortion was and still is one of the most important methods to reduce the number of births. Maternal deaths from abortion are considerably reduced, mainly occurring above 12 weeks of pregnancy, a fact that is also related to the old abortion techniques still in use. 28% of abortions are performed in 30-34 age group and 22.9% in 25-29 age group, thus in the most reproductive period. Regarding the parity, 23.7% of abortions come after two other pregnancies, while 17.1% of them are performed at the very first pregnancy. Data related to abortion complications are still missing, but several studies are undergoing for their evidence.

The assessment of pregnancy is mostly done in specialised centres, which means mother counselling centres and maternities. The number of hospital beds for ob/gyn service in 1994, was 60 for 100.000 inhabitants. The average number for prenatal control of a pregnant woman is 5.4, and about 72% of pregnancies are covered by a medical service (1995).

In 1990, about 2.370 general practitioners, 2.090 medical specialists (all together: 1 physician per 730 inhabitants) and 14.780 nurses/midwives (1 para-medic per 220 inhabitants) were employed by the MoH. At PHC-level were working: 1.500 general practitioners (GP), 240 medical specialists (mostly gynaecologists and paediatricians) and 4.250 nurses/midwives. On average 2-3 GPs and 4 nurses/midwives worked in one health centre (1993).

One of the main problems of maternal morbidity is ferriprive anaemia of pregnancy, which varies from 40 to 56% of all pregnant women.

4.3 Family Planning

Information about and availability of modern FP methods were introduced for the first time in Albania by 1992. Many gynaecologists, paediatricians and midwives participated in the fellowship programmes abroad and in training courses in Albania. But there was no ex-ante evaluation of knowledge, attitude and practice of the health staff, to quantify the changes after training and to measure the impact of the training activities.

In 1995, the first National Conference of Population and Development was organised by the MoH, the Academy of Science and UNFPA, as follow-up of the Cairo Programme of Action. This was a first opportunity to discuss in public and within a wider auditorium, population issues and FP. The conference documentation was published in August 1996.

FP facilities

First (PHC) level:

At PHC-level, there are about 1.973 ambulances operating at village level, staffed by a midwife-nurse. There are currently 731 functioning, publicly run health centres in Albania, 129 in cities and 602 in rural areas. 137 of the health centres (19 percent) have a mother and child consulting centre and provide FP services. At district level, 11 regional FP centres (4 of them are so called pilot FP centres) provide FP services.

Second level (District Maternity Hospitals):

28 district maternity hospitals offer FP services and provide contraceptives. These FP facilities at maternity hospital level do not play a reference role for the PHC-facilities but offer FP-services to the hospital patients (pre- and post-abortion counselling, post-partum counselling, counselling for FP, prescription and application of FP methods).

Third level (Maternity Hospital of the University, Tirana):

The Maternity Hospital in Tirana has two compounds at different places in town and is part of the University Hospital. Recently it was decided that both facilities (in former times separated in maternity and gynaecological hospital) shall have the same gynaeco-obstetrical services and function. In the Maternity Hospital l, AFPA/IPPF has installed its main centre offering counselling (pre- and post-abortion, post-partum), contraceptives and abortion. Next door to the AFPA-centre and the maternity's abortion ward, a social service of the "pro life" initiative (Bethany Hospital) is offering counselling and help to pregnant women. In the Maternity Hospital 2, a UNFPA supported FP-centre is offering counselling and modern methods of contraception.

The main modern FP-methods have been made available all over Albania. In general, there were no major or longer interruptions in the availability of contraceptives at central level. Till the year 1995 the contraceptives were distributed to and sold through public pharmacies. When pharmacies became privatised in 1995, access to contraceptives decreased through higher retailer prices. By order of the Minister of Health, contraceptives were distributed free of charge through the FP-facilities themselves, starting in January 1996 (Annex 5). This had a positive influence on the utilisation of the FP-facilities and the access to modern contraceptives. On the other side, the distribution of contraceptives free of charge would limit the sustainability of the FP-services, especially when it came to future finance of FP activities and contraceptives. Gratis contraceptives provided through the public services decreased their valorisation through the users.

Data about the use of contraceptives are available since the beginning of 1996, assuming that contraceptives given to the acceptors are used. The estimated contraceptive prevalence rate of the first six months of 1996 (data from 28 of 36 districts), indicates that the use of contraceptives may not exceed 5 per cent. An additional difficulty in calculating the CPR was the unclear number of the target population per district or covered by FP-facility. In the years 1993 to 1995 the CPR was calculated out of the couple years of protection (CYP) and distribution of contraceptives to the district. A coverage of contraceptives of 4.96 per cent of WRA in 1993 was reported, 8.27 per cent WRA in 1994 and 10.9 per cent of WRA in 1995. Reasons for the differences are the uncertainty of both calculations, based on unclear numbers of target population, incomplete data about the number of acceptors and the number of distributed contraceptives.

An increase of OC and injectable method use in years 1995-1996 has been observed, while IUD-s were not any longer the most preferred method. The age group of 30-34 years old counts for 35% of total contraceptive users, followed by the age group of 25-29 with 24.9%, while the adolescents of 15-19 years old represent only 2% of contraceptive users.

From mid-1992 to 1995 contraceptives (except condoms) were imported nearly exclusively through UNFPA and IPPF, with UNFPA importing the main part of more than 95 per cent (Annex 6, Graph 6a, Graph 6b)

In the public FP-facilities the contraceptives are given free of charge to the client. The clients sign the register of the free reception of the contraceptives. There was and still is no effective monitoring or control system for storage, consumption, needs and demand of contraceptives, neither in the different districts nor at central level.

4.4 Newborn Care

The perinatal mortality rate has significantly increased during the period from 1991 to 1995, early postnatal mortality from 4.8%o to 8.0%o and late postnatal mortality from 8.6%o to 11.3%o. Neonatal mortality accounted for 27.6% of infant mortality in 1991, and this was increased in 1997 to 46.5%. The actual rate of 13.2 per 1.000 live births is still above the target set of 12 per 1.000 live births. Data on perinatal mortality, especially for 1992/93, may not be reliable (Annex 3). It is important to note the fact that early postnatal mortality (0-6 days) in 1997 counted for 33.4% of infant mortality and late postnatal mortality (7-27 days) for 13.1% of it.

The causes of increased neonatal mortality

1. Increased medicalisation of deliveries.

2. The inadequate low technical level of medical personnel in rural maternities and of their equipment.

3. Lacking of prenatal assessment, especially in rural areas.

In 1991, 7.5% of deliveries took place at home, while in 1991 this rate was 9.1% and 0.3% of all deliveries were not medically assisted. Currently, 89% of all deliveries take place in maternity hospitals.

The premature birth rate has not obviously changed: 3.5 per 100 live births in 1995. But different definitions were used (birth weight under 2.500 gr. versus number of gestation weeks at birth) which makes interpretation difficult (Annex 4).

Breast-feeding

In Albania several programmes are already written for the training of personnel and mothers on breast-feeding. The initiative of a "baby friendly hospital" is also progressing fast. UNICEF and different NGOs have collaborated in preparing these programmes.

New-borns fed by breast-feeding, according to their monthly age

4.5 Child Health and Development

Infant mortality is high in Albania, thus presenting one of the main health problems of the country. In 1990 this index was 45 for 1.000 live births, in 1997 it decreased to 22.5 for 1.000 live births and it is 4% higher in rural areas. 39% of infant (0 - 1 year old) deaths happen at home and in 1997 42.2% of them died before 28 days of life (Annex 3).

At the first level in 1997, 1.986 child-care units functioned in rural areas and 181 in towns and cities. At the second and third levels, 49 paediatric wards provide service in the whole country. The number of paediatric beds in 1994 was 55.7 for 100.000 inhabitants.

The childcare is improving in the following ways:

• priority of primary care

• integration of service

• training of medical personnel

To achieve better results, projects of UNICEF in collaboration with MoH have started since July 1993. These projects involve:

• Check up and prevention of ARI

• Immunisation

• Nutrition

• Check up for diarrhoeic diseases

• Safe Motherhood

• Breast-feeding and rooming-in

4.6 Post-Reproductive Health

So far, the control of women in menopause has been almost spontaneous and not co-ordinated and the gynaecological services are provided at the first and second levels of the health care system.

4.7 Genital Cancers Care

The services that provide screening of genital cancers are placed in specialised polyclinics of some cities of the country, in gynaecological hospitals and in services of gynaecological oncology. The service for the prevention of genital cancers is not yet organised by first, second or third level services.

5. Family Planning / Reproductive Health Projects

5.1 Multilateral Organisation Assistance

5.1.1 United Nations Population Fund

As far as external assistance is concerned, co-operation between UNFPA and the Government of Albania started in 1983 and until 1990 was focused mainly on maternal and child health, family planning and data collection. The first Country Programme (1991 - 1995), which was extended into 1996, concentrated essentially on the training of medical personnel in all aspects of MCH/FP, on equipment and other structures of RH. The project aimed to decrease maternal and infant mortality and the incidence of premature birth, and to increase modern contraceptive prevalence.

5.1.1.1 Goals and objectives

The objectives of the project (signed on 28 July, 1992 by the MoH, WHO and UNFPA) were the following:

• the reduction of maternal and perinatal mortality rates by adequate birth spacing and prevention of induced abortion

• the upgrading of services at the central level and in 26 districts by training of personnel (physicians and midwives) and upgrading of equipment

• modern contraception was to be made available in 26 maternity hospitals by the end of 1992/3 and in all 137 women's consulting centres by the end of 1995

The following immediate objectives are specified in the project document:

• to decrease maternal mortality by at least 50 per cent to 30 per 100.000 at the end of the project

• to reduce perinatal mortality by 30 per cent at the end of the project to reach 12 per 1.000 live births

• to reduce the number of premature births by 20 per cent from 8 per 100 to 6 per 100 live births at the end of the project (1995)

• to improve contraceptive coverage to at least 10 per cent of WRA through the implementation of FP-activities in all district maternity's, 137 women's consulting centres and 400 pharmacies

5.1.1.2 Strategy and approach

In 1992, the main focus of the project on gynaecologists for training and performance of project activities was justified. Women were used to visit the gynaecologist for specific health reasons and the former reference system had foreseen this "entrance point" to the public health system. The gynaecologists were the first medical profession who had learned about FP and its scientific background. Furthermore, the project focus was not a pure FP project but included MCH as an equally important part. Whereas the MCH-component concentrated on fellowships and provision of some medical equipment, the FP-component focused on the installation of services, local training and provision of contraceptives.

It was therefore logic that at the start of the project, FP-services were delivered only by gynaecologists and project's activities (training, fellowships) focused on them. During project implementation it turned out that gynaecologists were more interested in performing "real medical interventions" such as performance of abortions or application of IUDs. The clinical-, service- and doctor-orientation approach of the project neglected somewhat the needs of the clients.

5.1.1.3 Outputs

Taking into account the very difficult political, economic and social circumstances in Albania during at least three years of implementation, the project can be considered to have been a success in certain areas. Within less than four years the political and health understanding changed tremendously. A centrally planned health care system became liberalised, legal preconditions for FP and abortion were created, knowledge of health personnel improved and modern FP was no longer banned. The presence of the project alone influenced positively these changes. FP and information structures have been built up and supply structures established. Even if these systems are still not fully operational, a dynamic process could be initiated which showed increasing commitment of the MoH.

5.1.1.4 Conformity to project design

The contraceptive needs (unmet and met needs) were estimated in May 1996. Assuming a 5 per cent coverage with contraception of married women in reproductive age in 1995, the unmet needs were calculated to be on average 40 per cent or about 250.000 women in reproductive age (Annex 7a, Annex 7b).

The five most important contraceptives were available at central level most of the duration of the project. Only brief shortages could be noticed, but never resulted in a longer absence of contraceptives in the pharmacies or FP services.

Some supplementary activities have been performed by the project, which were not foreseen in the project document: for the training of trainer and the training of the gynaecologists/midwives, a training module was elaborated and distributed to the participants. These modules were very well accepted by the trainees and are still in use and preferred to the later published FP book.

When contraceptives were distributed, receptively sold, in the time from 1992 to 1995 through the firstly public and later private pharmacies, it became evident, that better knowledge of the pharmacists was desirable. Therefore, in 1993, 248 pharmacists were trained to improve the quality of distribution of contraceptives.

Till now about 150 GPs were trained in FP and 4 GPs are now working in the pilot FP centres where they also have training obligations.

The newly established RH sector has elaborated a draft for the implementation of the RH-concept, an analysis of problems in the RH-sector and the definition of priorities.

(Annex 8a, Annex 8b)

5.1.1.5 Outcomes

The crude birth rates decreased slightly over the last years from 24.7 in 1989 to 22.7 live births per 1.000 population in 1995. The rate of natural increase of the population was in 1989: 1.9 per cent and in 1995: 1.74 per cent. Also the total fertility rate decreased from 1980 : 3.6 births per women to 2.3 births per women in 1995, independently from pro-natalist Government policies. But in the same time the abortion rates increased and contributed most to the decrease of the total fertility rates. The achieved contraceptive prevalence rate was still too low to have significant impact on the reduction of fertility. The decrease of the maternal mortality is an important health gain, which was due to the reduction of clandestine and self - induced abortion and its liberalisation.

Indeed, maternal mortality as an indirect measure of the health status decreased by 25 per cent, but in the same period perinatal mortality did not decrease and infant mortality increased slightly. However, influences on mortality are manifold, especially when dramatic changes characterised the transition period.

5.1.2 Other Multilateral and Bilateral Agencies

Although UNFPA is the only donor organisation present in Albania which has an overall Reproductive Health strategy, a number of other multilateral and bilateral organisations are also active within this field.

Among the international organisations, there are: UNDP, UNICEF, WHO, World Bank, the European Union and the International Red Cross. A WHO Programme which aimed the strengthening of Maternal and Child Health/Family Planning Services, was implemented in 1995, with a funding of $ 114.464.

5.1.2.1 Bilateral Agency Assistance

The main bilateral donor agencies in Reproductive Health are: United States Agency for International Development (USAID) and Kreditanstalt für Wiederaufbau (KfW). The Italian and Swiss Governments, Population Services International and Marie Stopes International have been involved in rehabilitating and upgrading health facilities, supplying equipment, providing training and supporting social-marketing.

The Project of German Federal Ministry for Economic Co-operation and Development aimed to rehabilitate and construct 60 MCH centres in six districts in the southern and northeastern region and would also include a contraceptive social marketing component. Executing agency was the Ministry of Health and the duration of Project was 1996-1998. The German contribution is DM 8 (5 + 3) million.

5.1.3 NGOs and the Private Sector

The following national and international NGOs are working in the field of FP/RH: AFPA, MSI, PSI, SEATS.

AFPA is actually running three FP centres in Albania (Tirana/maternity 1, Durres and Lezha / maternity hospital). The FP centre in Tirana offers the full range of FP services, including abortion while the centres in Durres and Lezha do not perform abortions. AFPA receives their funds from IPPF and provide services with own contraceptives. IPPF was asked to extend their activities to Shkodra. There are plans to install, together with the UNFPA-project, a joint youth counselling centre for reproductive and sexual health in Tirana. IPPF requested funding from UNFPA to install a computer based "client management information system" (CMIS).

MSI is most likely to implement the social marketing project, financed through a DM 3 million soft loans of the Kreditanstalt für Wiederaufbau (KfW, German Development Bank). The project started at the end of 1996 and includes the social marketing of 3 to 5 contraceptives. This project is executed by the MoH and is complementary to the UNFPA activities.

PSI has started the execution of a social marketing project for their own brand of condoms. They performed focus group discussions and some analysis for the marketing of their product. PSI imported 500.000 condoms in 1996.

USAID has performed focus groups discussions and training of personnel working in FP in the districts of Tirana and Durres. They held a first training course in FP in October 1996, with special focus on counselling and IEC. Seminars and training activities have often been co-ordinated by the MoH and UNFPA. A 3-year project (1995 - 1997) is already implemented on RH of US$ 800.000, and the same funding is planned to be available for another 3 other years (1998 - 2000).

Currently, there are at least 3 wholesalers and about 630 private pharmacists operating in Albania (April 1996) who stock some contraceptives. Prices vary widely with a cycle of OC costing from US$ 1.5 to US$ 5 (and up to US$ 10 in some cases). Since contraceptives are distributed free of charge through the public sector, most private pharmacies have only limited stocks and varieties of contraceptives available and often refer clients to the public FP-facilities. It was estimated by PO3 that in 1996 about 10 per cent of the contraceptives are provided by the private sector. Wholesalers with exclusive sales and distribution rights for specific brand products (e.g. MicrogynonÒ from Schering) have sometimes problems with illegally imported (mostly from Greece) or falsifications of their brand drug.

Private health care services are not yet widely spread. Approximately 10 per cent of physicians have shown interest in working privately. Till now the social security as a civil servant is preferred, the possibilities to earn money "under the table" and second jobs in the afternoon are compensating low public salaries. However, it is expected that the private sector will increasingly provide contraceptives. Social marketing projects and IEC will contribute to the increase of the private share of the public-private mix of supply of contraceptive and FP services in the next 5 to 10 years. Projections suggest that in the year 2005 about 65 per cent of contraceptives shall be provided by the private sector (Annex 10).

6. Perspectives for Future Projects Implementation

6.1 Objectives and Indicators of Reproductive Health till the year 2000

Goals:

• To offer good quality of Reproductive Health service in the relevant services to the Albanian population. Quality means to ensure good quality of information, of the services provided, availability of clinical and referral services, good quality of training and the application of different approaches for single women, female and male adolescents and men.

• To improve the health status of women during their reproductive age, especially during child bearing and delivery.

• To improve the health status of the foetus, newborn children, infants and children till 5 years of age.

• To improve the sexual health of adolescents and adults.

• To enable individuals and couples to make informed choices when and how many children they want to have. This will be achieved through adequate timing, spacing or limiting of pregnancies, the use of a wide range of methods, high quality counselling, IEC and efficient logistics of high quality contraceptives.

• To contribute to the development of Reproductive Rights, which promote gender equality, contraception, voluntary sterilisation and abortion as reproductive right, family planning as a human right and women’s right to health.

Objectives (Indicators):

1. To reduce infant mortality (to under 25 per 1.000 live births).

2. To increase the vaccination coverage (to over 95%: with effective vaccines of a good working cold chain, complete and respected vaccination scheme, correct application, to eradicate neonatal tetanus, to eradicate new poliomyelitis infections).

3. To reduce the mortality of children under 5 years of age from diarrhoea (by 50% and to reduce incidence of diarrhoea infections (by 25%).

4. To reduce maternal mortality (to 25 per 100.000 live births).

5. To reduce the risks in fertility regulation (e. g. mortality of abortion).

6. To increase the coverage of antenatal care by medical professionals (to 90%).

7. To increase the percentage of deliveries through qualified medical personnel (to 95%).

8. To reduce the incidence of high-risk pregnancies (to reduce pregnancy anaemia, defined as Haemoglobin < 10 mg%).

9. To increase the contraceptive prevalence rate (from 10% to 20%).

10. To reduce the prevalence and incidence of STDs through IEC, early detection and early treatment and herewith reduce the risk for the foetus for STD infections (basic data should be required through studies).

11. To reduce mortality through ARI of children under 5 years of age (by 30%).

12. To reduce under- and malnutrition of children under 5 years of age, to reduce the severe and moderate dystrophy in children under 5 years of age (by or to 50%, to eliminate the disorder caused by Vitamin A deficiency).

6.2 Population Development

Future project planning and implementation has to consider changes in demographic and epidemiological transition: projections of population growth (medium population growth: overall life expectancy at birth will increase over the next 15 years from 71.4 to 74.5 years and infant mortality rates are assumed to decrease from 43.2 to 26.8 per 1.000 live births) predict populations of 3.350.000 in the year 2000, of 3.550.000 in 2005 and of 3.750.000 inhabitants in 2010. The present demographic transition will not only change the distribution of urban and rural population, but the population will grow older in the next ten years. Epidemiological transition may appear especially in the rural areas, whereas in cities prevalence rates of infectious diseases will remain high.

6.3 Health Policy and Strategy

Increasingly, elements of decentralisation and privatisation will affect the public health system and also be introduced at the PHC-level. RH as a concept has to find ways to enable intra- and inter-sectoral co-operation between ministries and the different services of ministries which are still vertically organised. NGOs will be increasingly active in RH activities, especially women's groups and non-for-profit organisations, in order to reach special target groups (students, young women, "community women", minorities, etc.). The co-ordination and supervision of NGOs should be a major task of the MoH both, at central and district level.

At central level:

• Knowing of legislation on human reproduction rights and ethics, necessary improvement. (Women and children rights on RH).

• RH and its role on socio-economic development of the country. (Identification of problems and co-ordination with different organisations involved in these issues).

• Research on RH ( unfavourable population, need for training and for infrastructure).

• Increasing the capacity of services (formation, quality of service).

• Integration of RH services.

• Focusing on woman health.

• Improving of IEC (using mass media, as well).

• Collaboration between institutions (public/public, public/private, NGO, international organisations).

At district level:

• Knowing the concepts and components of RH in general, and especially for respective districts.

• Creating a professional team, supervised by the second level care Director, which will provide the adequate information in different districts, regarding the:

• re-evaluation of situation

• the priorities

• the level of IEC

• necessary materials and equipment

• Creating a specialised team, supervised by the first level care Director, which will aim at improving the quality of life of families in the rural areas:

• family planning, related to mother health care

• adequate conditions for delivery

• vaccination, breast-feeding and adequate child nourishment

• spacing between deliveries

• preventing very early marriages and pregnancies

6.4 Approach

Albania is a low FP-prevalence country and STD/AIDS-prevalence is still low. Therefore, the major orientations should be the introduction of innovative services, information education communication and operations research on consumers/clients, to influence the health-policy, and to improve the training of personnel.

6.4.1 Holistic approach of Reproductive Health

The exclusive focus on MCH and FP has to be widened in the future towards a holistic approach of RH as an integrated part of PHC. In order to orient RH/FP towards PHC, GPs, family physicians, midwives and nurses should be in the centre of training and delivery of services at first level. In the future special attention should be paid to improve the quality of training and refresher courses. To that end, separate training will be provided for those who work at maternity, at the primary health care level, in abortion services and in the regional centres.

MoH will be encouraged to create some form of recognition for its principal trainers and this should be evident in their title, status or by alternative incentive of the MoH. The appointment of future trainers should be by open competition within the profession and will be decided by an authoritative panel on which the MoH, the IPH, the MoE and the Faculty of Medicine and the School of Midwifery are represented. Trainers need to be made accountable after providing their training to this authority and their recommendations need to be considered in the ongoing development, review and emergence of the Reproductive Health/Family Planning and Sexual Health profession.

6.4.2 Client and Patient oriented

People should be put in the centre of concern. Therefore RH and FP-services should be more client/patient oriented (i.e. based on unmet needs of the client/patient, acceptance or rejection of contraception, etc.). RH should be concerned with women as women, with women's needs before, during and after the age of reproduction and not just as mothers. RH should respond to sexual and RH needs of women, of men and of adolescents and it should respond especially to the needs of the rural population, who still represents the majority of the population of Albania.

At present, men are hardly participating in any discussion concerning FP or RH. It seems that actually FP is a women's issue. Most FP-services are offered close to MCH-services and may therefore limit the accessibility for men. At present it may be difficult to involve men in RH and FP, but first measures should be taken to address men and to facilitate their access to condoms. For planning and evaluation purposes, needs assessments related to the population and health personnel are important to describe the baseline situation in RH. In order to be more client oriented, knowledge, attitude, practice surveys are needed to find out the position of women and men with regard to FP, contraception and other RH-issues.

6.4.3 De-medicalisation of Reproductive Health and Family Planning

In order to de-medicalise RH-services and to improve accessibility and availability of contraceptives, it should be considered to give trained midwives and nurses the right to distribute some of the contraceptives without the approval of a medical doctor. This should contribute to improve the information level of the population, especially of the rural population, to enable them to make free and informed choices in FP. RH and FP should be de-medicalised by introducing IEC, social marketing and improving counselling.

6.4.4 Information, education and communication

A wide range of leaflets covering a variety of key subject areas have been produced. However, in rural areas the services are poor and maternal and child morbidity is also the highest. Print runs have only been small and quantities are insufficient to meet need and guarantee distribution throughout the country. Distribution of existing materials has been confined mostly to the capital and main urban towns.

IEC should be one of the main components of the future programmes. The high rate of literate persons, the high number of TVs and radios will facilitate the transmission of FP/RH-messages. There will be heavy emphasis on the collaboration of the television and radio through regular spots and documentary broadcasting. Improved communication with the client during counselling and follow up of the client are urgently needed. IEC with service delivery at the same time should be considered as a standard quality of service.

Through public media and medical personnel the clients should be informed better about contraceptives, their use, effectiveness, their side-effects and their price (or free distribution). Especially the consequences of abortion, the risk of too early pregnancies, too frequent pregnancies and too late pregnancies are important information. The main concern of women not using modern contraceptives should be widely discussed. The Albanian women and even the medical specialists are not yet aware that OC contribute to reduce the risk for endometrial or ovarian cancer. Other main focuses of information and education should be the nutrition during pregnancy, RTI/STD and general education about human reproduction.

Special emphasis will also be placed on assisting the Ministry of Education to elaborate a multi-sector (Government and NGO) policy document on introducing and providing sex education into school, both using formal and informal teaching opportunities. NGO experience, especially among the young people, will be exploited in the informal learning aspects, while sociology and biology teachers will increase their comfort and skill in providing sex education to secondary school age children through formal learning.

Community, religious leaders and opinion leaders should be motivated to promote a positive public image of and esteem about FP and RH.

7. Necessary Inputs for the Future

7.1 Personnel

The MoH has expressed the need for technical support concerning the execution of the project and past experience has demonstrated that a short-term technical assistance is less efficient. Therefore the possibilities of a long-term technical assistance in project management for the RH-Sector should be considered, especially if baseline and consumer oriented research will be planned and co-ordination of different NGOs will become essential. Long term local staff for the implementation and supervision of activities should be contracted, to assist the MoH and the personally weak RH-Sector, especially in improving the inter- and intra-sectoral co-operation.

7.2 Training

Human resources development is needed at the MoH, at both the central and district level. Training in clinical as well as in management issues is still necessary. Training courses in Albania should be promoted and especially directed towards the para-medical personnel, especially of the level of ambulances. The quality of the training through the national and regional training teams should be evaluated and improved. Training in information and research techniques (use of data, concentrate on the important) and training in supervision techniques (more training than control and inspection) should be considered in the curriculum.

7.3 Material, facilities and contraceptives

Basic medical equipment should be provided to the mother consulting centres which have not yet been supplied and which are not included in other projects (e.g. partial rehabilitation of 60 health centres through KfW loans). Equipment, such as adequate midwife-kits should be provided to the midwife-nurses at the level of ambulances and to midwives and nurses at health centres.

An evaluation should be made to identify the necessary material resources to realise the holistic approach of RH at PHC level, for instance, the needs of basic laboratory equipment. The MoH needs to be supported in the purchase of contraceptives. Quantities and method mix should be planned in close co-ordination with the NGOs providing contraceptives, including condoms. Contraceptive supply should be planned on the base of the needs assessment and the expected changes of different variables such as population growths, unmet needs, increasing demand and contraceptive use, changes of the method mix, increasing involvement of the private sector, etc. Preliminary needs in contraceptives have been calculated by the project till the year 2005, based on different assumptions (Annex 10, Graph 10a)

8. Output Measures

To measure at least the outputs and some quality indicators of the RH-services (e.g. accessibility, availability, continuation rate) a newly designed health information system should be introduced and adapted to the overall health management information system. The new HMlS should include data which allow to calculate the contraceptive prevalence rate based on new acceptors and repeated cases. Simple methods to evaluate the needs and satisfaction of clients should be introduced to increase follow-up and communication between the service provider and client.

9. Primary Expected Effects and Outcomes

To evaluate changes in primary expected effects, the awareness of special population groups concerning RH should be evaluated as well as the acceptance of different contraceptives and the acceptance of condoms by men, the motives of different population groups to practice or to reject different FP methods, including natural methods.

Behaviour change, FP practice, the continuation in contraceptive use and consumer satisfaction should be evaluated at the beginning of the project and monitored throughout its implementation to allow the evaluation of the effectiveness, efficiency, relevance and sustainability of the interventions in RH. (Graph 9a, Graph 9b)

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Edited by Aldo Campana,