Awareness, knowledge and attitude toward secondary health care system: survey of physicians in Kosovo

Objective: To assess knowledge, awareness and attitude among hospital physicians from Kosovo toward current situation of Health Care System (HCS) especially Secondary Health Care (SHC) in Kosovo. 
Methods: In this cross-sectional study, anonymous questionnaire were delivered to three regional hospitals in Kosovo. The main outcome measures were physician’s awareness of the management of secondary health care institutions, awareness and use of new technology for improving health care in second level and their suggestions for further improvement. 
Results: Results are divided into three main categories: I. Relevant information on the knowledge of the health care system, were respondents had valuable information and insight; II. Relevant information on suggested improvements, in which respondents gave their proposals regarding workplace and inter managerial relations and III. Relevant information on continues education possibilities for medical staff. 
Conclusions: In conclusion there is a need to prioritize proper cooperation between primary, secondary, and third level of health institutions, in terms of entire health management in order to increase the quality of health services delivery, in line with western standards. 
Bangladesh Journal of Medical Science Vol.18(2) 2019 p.288-293


Introduction
The health system includes all activities, which main purpose has the promotion, recovery and protection of health [1][2] .Consequently, the health system is a complex of interconnected elements that contribute to health in homes, educational institutions, workplaces, public places, and communities and in health sectors.Health system infrastructure includes facilities, institutions, organizations and all those who deal in providing various health programs 3 .A country`s particular of economic production, distribution and consumption, as well as its patterns of ownership, economic control and the distribution of resources and wealth, directly affect the healthcare organizations and traditions in the healthcare system 4 .The role of health policy is to determine the preferences of the society and to develop institutions that can efficiently meet those preferences.This may mean defining the ground rules under which insurers and providers compete 5 .There are several types of settings or places in which patients can receive treatments: inpatients (or individuals who have been formally admitted to healthcare facility, are treated in acute care (hospitals)) and long term care facilities and outpatients care who have not been formally admitted to healthcare and usually have stays of 24 hours or less (ambulatory) 6 .Aim of health system is providing good health care to population to increase their wellbeing and life expectancy and in Kosovo average life expectancy is 79.4 years for female and 74.1 years for male 7 ; although in the EU as a whole, average life expectancy for men is 82.4,while for female it is 85.9 8 .Health care which consists of combined measures: promotional, protective, preventive, diagnostic and rehabilitation is offered to individuals, families and communities.Health resources include all the tools available to the health system in its operation, including workforce, buildings, equipment, supplies, funds, knowledge and technology 6 .There are five main types of health management systems across Europe with respect to the role played by local and regional actors and two of the most important ones are: • Type 1 (decentralized systems) includes 'regional health management systems' or management systems whose regulation, operation and also co-funding are delegated to regional authorities (example in Italy and Spain) or are delegated to the States (example: Austria) 9 ; • Type 2 includes those health management systems where local and regional governments are responsible for several planning and implementation functions, besides co-funding 9 .In Kosovo, healthcare system is organized in three levels: primary health care (PHC), secondary health care (SHC) and tertiary health care (THC) [1][2][3][4][5][6][7][8][9][10] .The World Health Organization (WHO) defines Primary Health Care (PHC) as essential health care to which people has universal access in the community, in ways acceptable to them, through full participation and at a cost that can be covered by community and state 11 .One of the main rights of the people, is regarded as well the equality in access to health services, and its assurance should be the primary objective of the healthcare system 12 .In Kosovo, all municipalities have PHC institutions, respectively Main Family Medicine Centres (MFMC).Secondary Health Care (SHC) is provided through Regional Hospitals.Within the SHC is also organized Professional Service of Mental Health through the institutions of Mental Health Centers in Communities, organized in major centres of Kosovo, Homes for Integration Community and the Center for Integration and rehabilitation of chronic psychiatric patients in Shtime 2 .SHC includes: outside hospital health care (diagnostic, therapeutic and rehabilitative), hospital health care for 24 hours: diagnostic, therapeutic and rehabilitative, health education of the patients and professional support for primary health care level.Tertiary health care level covered by the Kosovo University Clinical Center (UCC) within which operate many clinics and institutes and University Dental Clinical Center of Kosova (UDCCK).Tertiary health care level includes several important national institutions such as National Center for Blood Transfusion (NBTC) which manages the center of the blood collection, the National Institute of Occupational Medicine (IKMP) covering health care for employees, the Center medical Sports and Recreation (QMSR) and National Institute of Public health (NIPH) which offers programs for maintaining and improving health, reducing environmental risks, early detection and monitoring of diseases, conditions and problems and represents the main source for the collection and analysis of medical data [3][4][5][6][7][8][9][10][11][12][13] .Regarding the motive of the research, since SHC presents a bridge between two health care levels, PHC and THC, it adds as an additional motivation for the research.The other important motive is the number of Kosovar practitioners leaving the country for work in EU 1 .This could be interlinked to many European countries lacking of general practitioners or specialized ones: based on 2010 data, Greece had the highest number of doctors with 6.1 doctors per 1,000 people, followed by Austria with 4.8 doctors per 1000 inhabitants compared to the average of the EU countries 3.4 doctors 14 .In the region, the lowest number of doctors per capita was in Montenegro 2.1 and Turkey 1.7 7 .Due to reduction in number of doctors, some hospitals changed their managerial policies by: increasing the number of specialization, changes in employment practice-improved efficiency, quality and volume, safety and quality 15 .Health financing policy encompasses a range of functions: collection of funds for health care, pooling funds (and therefore risks) across time and across the population, and purchasing health services 16 .All Member States use a range of contribution mechanisms to finance health care, including public (tax and social insurance contributions) and private (private health insurance, medical savings accounts (MSAs) 2 and out-of-pocket (OOP) payments in the form of direct payments for services not covered by the statutory benefits package, cost sharing (user charges) for services covered by the benefits package, and informal payments) 17 .Since in Kosovo the number of doctors is decreasing, and while they are still leaving, we thought it would be good to research and find their satisfaction in regards to healthcare system in Kosovo, their payments and conditions and possible future educational advancement.Therefore, we have conducted the survey, which is basically divided into three parts: their knowledge on the system itself, their satisfaction and educational improvements.

Survey Instrument
We used self-administered questionnaire from which physicians were asked about the knowledge on health system organization, suggested improvements on health system and continues education.The questionnaire was distributed to 140 physicians together with a short letter explaining the aim of the study and stating that participation in the study was voluntary and anonymous.Methods This is a cross-sectional survey of physicians working in secondary health care institutions in Kosovo.Kosovo has a population of 1.739.825 7and it has 7 public SHC institutions in (Prizren, Gjilan, Ferizaj, Gjakova, Mitrovica, Peja, Vushtrri).Ethical Clearance: The study was conducted in the SHCs and was approved by the Ethics Committee of each hospital.

Results
Out of 200 questionnaires, 140 of them were completed, making the total response rate of 70%.The responses are presented in three separate tables.Table 1 presents results regarding questions related to the knowledge of the system.It is an interesting fact that 16.4% of the respondents didn't respond correctly to the question of what institutions belong to SHC system, which could be represented as a lack of knowledge regarding the Health Care System in general in Kosovo.Moreover, in the question of development of SHC, 17.2% of the respondents claim that it is not being developed at all.Furthermore, around 6.4 % of the respondents were not aware of working protocols and guidelines in their institution.Interestingly, 20% of the respondents do not see as a good cooperation between SHC and other levels of health care, while 27.8% of the respondents stated that they do not have any knowledge regarding the health information system implementation.In the last table, Table 3, we have provided responses regarding continues education.The first question is regarding the help that the staff gets from management in order to pursue professional education, where 10.7% suggested that they do not get any help.That could be related as well to the performance evaluation, where 35% responded that it is not conducted in their institution.Even though internet penetration in Kosovo is very well compared to other regional countries, two most common databases for medical literature PubMed and Scopus are not so much used (22.1% and 8.5%) compared to other resources 69.2%.But, that could be connected to the next question, where 33.5% of respondents responded that their institution doesn't conduct research or they do not know about it (32.8%).Related to that, the next question on support from senior management to exchange medical experience with other countries, only 22.1% of the respondents think that the support is enough.

Discussion and recommendation
In accordance with the questionnaire, several recommendations can be suggested.Regarding the knowledge of the system, recommendations are as follows: To prioritize proper cooperation between primary, secondary, and third level health institutions; in terms of entire management in order to increase the quality of health services delivery, in line with Western standards.
• Unification and implementation of protocols in secondary health care institutions.While regarding continues education the recommendation is: • Supporting health professionals in relation to ongoing health education, enabling their development in addition to modernizing medicine and medical procedures.As for the final and more general recommendation for the Kosovo Institutions is the need for organization and reorganization of secondary healthcare facilities as well as the opening of new secondary health care institutions in other regions.

is the level of your cooperation with other levels of health institutions?
In Table2, we have presented findings regarding suggested improvements from the medical staff.The first improvement proposal was to increase the number of staff, where 69.3% of the respondents were unhappy regarding the existing number of staff.Moreover, 70.7% propose improvements on the workplace, to make it suitable for providing health care.95.7% of respondents think that the health insurance would improve the health institutions status in Kosovo.Regarding the support from management structures for exchanging medical experiences, 38.5 % of respondents suggested that they have no support at all, versus 22.1% that have stated that they have "enough" support.