Since 2015, Health for All has played a critical role in reforming Primary Health Care in targeted regions across Albania. This initiative, led by the Swiss Agency for Development and Cooperation and implemented by the Swiss Tropical and Public Health Institute and HAP Centre in Albania, has had a significant impact, particularly on the Fier and Dibër regions – the project's longest-standing intervention areas.
HAP’s contribution to Dibër and Fier has been multifaceted. The Project helped shape important national health strategies and policies (such as the PHC Strategy 2020-2025), defined PHC job profiles (strengthening the role of nurses), developed and implemented new models of care (such as home-based care), standardized health service by updating and implementing manuals and protocols (such as those for NCDs, elderly care, and mental health disorders), supported the capacity building of PHC staff (through continuing education and Peer Group activities), and invested in the improvement of HC infrastructure (reconstructing 28 health facilities).
This article explores the outcomes of the Health for All Project (HAP) on these regions, carefully selected based on their socioeconomic development indicators, as they have made significant progress in the prevention, treatment, and management of Non-Communicable Diseases (NCDs). The article draws on the results of important baseline and endline Quality of Care Evaluations, which were conducted in 2015, 2018, and 2022, to measure the effectiveness of the Project’s key interventions.
Methodology
Utilizing internationally recognized methodologies for evaluating Quality of Care (QoC), HAP assessed three key pillars: (1) doctor-patient interaction/consultation, including adherence to clinical guidelines for managing chronic conditions, (2) health centre infrastructure, and (3) patient satisfaction upon service completion.
The evaluations were conducted in 38 selected health centres. Table 1 shows an overview of the survey samples.
Table 1: Survey Samples: Dibër and Fier| | 2015 | 2018 | 2022 |
| Health Centres | 38 | 38 | 38 |
Observerd Consulations
| 625 | 842 | 415 |
Patients interviewed
| 706 | 776 | 445 |
Results
The findings show a notable improvement in the Quality of Care from 2015 to 2022 across the three dimensions (doctor-patient interactions, HC infrastructure, and patient satisfaction). The visible decrease in QoC scores following 2018 is mainly attributed to the impact of Covid-19 on the health system which seriously affected the access, quality, and availability of health services.
Figure 1: Mean overall scores reached in each measurement by year and regions. 
The quality of doctor-patient interactions saw a significant improvement from 2015 (mean score: 53.9) to 2018 (mean score: 69.5). However, in 2022, there was a slight decline in the quality of this interaction (mean score: 58.8), although it remained higher than the 2015 levels. In 2022, over 60% of doctors in both regions achieved a score of over 80 (out of 100 points), indicating their adherence to all principles of clinical practice. Furthermore, more than 90% of family doctors scored above 60 (out of 100), which is an overall positive outcome. It should be noted that doctor-patient interactions were assessed not only for diabetic and hypertensive patients, but also for all other chronic diseases not specified in the survey.
Noteworthy is that patient satisfaction consistently outperformed both the doctor-patient observation and infrastructure scores across all years and regions. Patient satisfaction increased marginally from 84.6 score points in 2015 to 89.9 score points in 2018 and maintained a high level at 89.0 points in 2022. It is worth highlighting that patient satisfaction has consistently been high in Albania PHC for reasons that we will explore further on.
The infrastructure score showed substantial improvement between 2015 and 2018, attributed in part to HAP investments in infrastructure, such as the rehabilitation of the 12 healthcare facilities indicated in the sample. Although the infrastructure score remained relatively stable in 2022 at a mean score of 61.6 out of 100, indicating only a slight decrease since 2018, the positive trend from previous years is evident.
Monitoring doctor-patient interaction during diabetic and hypertensive consultations
As the most prevalent chronic diseases, we are drawing on the diabetes and hypertension care and the comprehensive assessment of their doctor-patient interactions encompassing as many as 37 and 36 indicators respectively covering medical history, health management advice, and further examinations relevant to the condition.
Diabetic Consultation: Scores showed slight improvements in the receipt of medical history and the advice provided to diabetic patients. However, examination scores for these patients remained consistently low across three surveys.
In Dibër, 60% of family doctors in 2022 achieved a score of >60 out of 100, and an impressive 88% attained a score of >40 for adherence to principles of clinical practice in diabetic consultations. This indicates that more doctors in Dibër were successful in making patients feel at ease, asking questions about their well-being, ensuring privacy during consultations, addressing patient concerns, allowing time for patients to explain their health situations.
Meanwhile, in Fier, diabetic consultations have been improving slowly but steadily over the years. In 2022, 68% of family doctors scored >40, compared to 35% in 2018 and 15% in 2015. This positive trend suggests that diabetic patients in Fier are experiencing better anamnesis from family doctors and receiving improved advice on managing their health. However, there is a concerning aspect as patients in Fier are still less likely to undergo further examinations for potential harms or risks associated with diabetes.
Despite patients in both regions being more informed, comfortable, and engaged in discussing their health situations, there is a notable gap in the examination practices (i.e. examination of legs, eyes, and other critical areas) and in having and using the patient’s medical record. This underscores the need for a comprehensive approach to diabetic consultations that addresses not only communication and advice but also ensures thorough and consistent physical examinations for the holistic well-being of diabetic patients.
Hypertensive Consultation: Over the surveyed years, there have been consistently fewer and fewer consultations receiving scores below 40, indicating a positive trend in the quality of care. In Dibër, in 2022, 89% of family doctors achieved a score of >40, a notable increase from 78% in 2018 and 53% in 2015. Similarly, in Fier, 55% of family doctors scored >40 in 2022, compared to 46% in 2018 and 30% in 2015. This marks a significant improvement, with more hypertensive patients benefiting from better advice on managing their health and from a better anamnesis related to their medical history.
However, despite these advancements, examination scores for hypertensive consultations remain a concern. Only 11% of family doctors in Dibër and 13% in Fier achieved scores >40, indicating a need for increased attention to this aspect of care. While Dibër has seen a slight decrease from 38% in 2018, there has been significant progress compared to the 5% in 2015. It is evident that enhancing examination practices remains a critical focus in both regions.
The overall trend indicates that more family doctors are aligning with clinical guidelines and protocols developed and implemented in Primary Care, resulting in improved health outcomes for diabetic and hypertensive patients. However, these slight improvements indicate the need for more consistent efforts for more sustainable outcomes.
Assessing Patient Satisfaction through Patient Exit Interviews
Patient satisfaction emerged as the highest-scoring metric consistently outperforming doctor-patient observation and infrastructure scores across all years and regions. The gradual rise in patient satisfaction is evident, increasing from 84.6 score points in 2015 to 89.9 in 2018 and maintaining a high level at 89.0 points in 2022. Notably, satisfaction scores from chronic patients were slightly higher compared to overall consultations in all three surveys.
In Dibër, there is a subtle decrease in patient satisfaction in 2022, with 88% of patients scoring >80, compared to 92% in 2018 and 90% in 2015. Conversely, Fier demonstrates a clearly increasing trend, with satisfaction scores increasing from 62% in 2015 to 80% in 2018 and reaching an impressive 89% in 2022.
The noteworthy satisfaction with Primary Healthcare (PHC) services in Albania can be attributed to several factors. First, there is a low awareness among users about their rights and what they can demand from PHC services. Second, there are generally low expectations for PHC. Third, satisfaction is often associated with direct referrals to specialists or prescriptions of medicines by doctors. Additionally, in remote areas, especially in parts of Dibër where access to services is challenging, patients tend to express satisfaction with whatever is made available to them.
The influence of the Covid-19 pandemic is apparent in patient satisfaction. The perception of increased services, including home-based care and telephone consultations, coupled with a perceived improvement in staff friendliness during the pandemic, likely contributed to the overall satisfaction levels.
Assessing Quality of HC infrastructure
The assessment of healthcare infrastructure reveals a marked improvement between 2015 and 2018, attributed in part to the strategic investments of the Health for All Project (HAP), including the rehabilitation of the 12 healthcare centers in the sample. While the infrastructure score remained relatively stable in 2022 at a mean score of 61.6 points, indicating only a slight decrease since 2018, it shows the importance of continued investments to sustain and enhance the quality of care.
Health centres, on the whole, exhibit the recommended standards in cleanliness and appropriate management of medical and hazardous waste in various areas, including surroundings, waiting areas, and examination rooms. Notably, HAP-rehabilitated HCs in 2022 demonstrated superior cleanliness scores and more effective waste management practices compared to non-rehabilitated HCs. This emphasizes the correlation between targeted investments and improved infrastructure quality and, consequently, quality of care.
Steady improvements have been observed in the water and sanitation situation within HCs over the surveyed years in both regions. Additionally, a majority of HCs scored high (80-100) in the display and visibility of HC information, including working hours, emergency numbers, and green numbers to denounce corruption) and health information materials (educational leaflets and posters, anti-tobacco posters, etc), which were prominently available.
While there has been an increase in the availability of physical copies of guidelines in HCs between 2018 and 2022, with more HCs falling into the >60 score category in both Fier and Diber, it is crucial to note that possessing a guideline does not necessarily indicate its active use in daily healthcare practices.
These findings collectively emphasize the intricate interplay between clinical practices, patient experiences, and infrastructural elements, calling for sustained efforts and investments to ensure a holistic and enduring enhancement of healthcare quality in both regions.
It is, however, essential to acknowledge that changing clinical practices according to newly approved Non-Communicable Diseases (NCDs) Protocols and Guidelines for Primary Health Care requires time, ongoing supervision, continuing medical education, and investments. Implementing these changes is a complex process, extending beyond physical infrastructure improvements, and necessitates a concerted effort towards education and support for healthcare professionals and the system in which they operate.
References:
- Study Rreport “Assessment of Quality of Care in Primary Health Care in Diber and Fier Regions of Albania”, 2022 (Available upon request).
- Saric, J., et al., Assessing the Quality of Care at Primary Health Care Level in Two Pilot Regions of Albania. Front Public Health, 2021. 9: p. 747689.
- Donabedian, A., The quality of care. How can it be assessed? JAMA, 1988. 260(12): p. 1743-8. Donabedian, A., The seven pillars of quality. Arch Pathol Lab Med, 1990. 114(11): p. 1115-8.
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