ANALYSIS OF SURVEY RESULTS AND STATUS OF HEALTH IN ALBANIA Overall Descriptive Presentation

1. ANALYSIS OF SURVEY RESULTS AND STATUS OF HEALTH IN ALBANIA Overall Descriptive Presentation on the Obtained Data (HANS-MIS-Grid) of HANS (Health Adriatic Network Skills) Project Prof. Eduard Kakarriqi, MD, MSc, PhD Head, Department of Epidemiology and Health Policy Institute of Public Health Tirana, Albania (Ancona [Italy], July 29, 2008)

2. - Part I - Population Health Status into Demographic and Socio-Economic Context of the Country

3. Demographic features Albania’s current demographic profile is characterized by three main phenomena: large internal and external migratory waves, improving mortality rates and declining fertility rates. The population’s age structure has changed significantly over years 1990-2000’s onwards. The population below 15 years of age structure is now decreasing and the population over 65 years is growing faster than the rest of the adult population. Though population growth and fertility rates have been falling, Albania still has one of the highest fertility rates and the youngest population in Europe: the age groups 0-14 years represent 32% of its total population in 2001. The following map and tables aim at presenting detailed data of Albania’s population (based on the 2001 Population Census) according to Prefectures [or Regions or Qarks] (1st administrative level) and Districts [=Counties] (2nd administrative level), showing in the meantime the administrative structure (prefectures and districts) of the country.

4. ALBANIA: Administrative Structure (Prefectures [=Regions or Qarks] as 1st administrative level and their respective Districts as 2nd administrative level): 12 Regions and 36 Districts (each Region being composed by 2-4 Districts)

5. Population of Albania according to Prefectures [=Regions or Qarks] (INSTAT, Census 2001)

7. Educational level Albania achieved universal enrolment rate in basic education at the start of transition. Between 1990 and 2004, gross enrolment rates declined at all levels of education except for higher education. Concretely, between 1990 and 2004, gross enrolment rate declined from 103 percent to 99.6 percent for basic education, and – more drastically – from 78.5 percent to 43.6 percent in secondary education (mainly due to the closure of many secondary vocational training schools). During the same period, gross enrolment rates in higher education rose significantly from 6.6 percent to 17.1 percent mainly as a result of expansion in part-time enrolments. Unemployment Unemployment remains widespread (officially estimated at 14.4% in 2004) especially in urban areas despite marked declines in registered unemployment in the last decade, (between 1993 and 2003, registered unemployment fell by 46 percent). Economic growth continued to be supported by relatively high levels of aid and remittances from workers living abroad [EBRD, 2005].

8. Per capita income Poverty: more concentrated among specific population groups such as the Roma, unemployed, large households and those living in rural areas. Albania: 25% is the proportion of poor people; in addition, 5% of the population lives in extreme poverty. Considerable inequalities in access to health services are evident in Albania. The poor are more likely to face economic barriers to obtaining health care, which is to some extent due to the large proportion of uninsured people among the poor and their inability to afford health care. The access to health services is in reality not equitable. The widespread out-of-pocket expenditure is another impediment to equitable access to health services. The Living Standard Measurement Survey (LSMS) data suggest a divergence in health status between social groups, a disproportionate burden of poor health and chronic diseases in specific population groups such as the elderly and unemployed, and a high out-of-pocket expenditure on health, particularly in the hospital sector: 10% of the Albanian population is considered extremely poor after health expenditure is taken into account.

9. GDP Albania is performing better than other SEE countries: in 2004 its GDP exceeded the 1989 level by 36 percentage points. Despite GDP per capita reaching US$ 2,040 in 2004, the widespread poverty, high unemployment, and wide regional disparities remain daunting challenges. Life expectancy at birth (LEo) The Albanian population enjoys a reasonably long life expectancy, which seems paradoxical when one takes into consideration the country’s high infant mortality rate, low incomes, very limited health services and frequent outbreaks of infectious diseases. Evidence (2001 estimate by INSTAT) shows a life expectancy at birth of 75.4 years (72.1 years for men and 78.6 years for women)

10. Infant mortality The health of women and children continues to be a concern. According to Ministry of Health figures, infant mortality per 1,000 live births dropped from 28.3 in 1990 to 18.0 in 2001. Nevertheless, these rates are still among the highest in south-east Europe and in Europe in general. Meanwhile, there is a great variation of infant mortality rates between the 12 country regions (or prefectures or qarks): from the lowest figure of 5.5/1,000 (Gjirokaster region or prefecture) to the highest one of 25.5/1,000 (Diber region or prefecture) (the following graph)

11. Infant Mortality Rates (IMR) (infant deaths / 1,000 live births / year 2001) according to regions (or prefectures or qarks)

12. Population Mortality Rates (per 100,000) as general gender-specific, and cause specific gender-specific according to country regions (or prefectures or qarks):  Crude Mortality Rates  Age-Standardized Mortality Rates (standard population = Country population)  Age-Standardized Mortality Rates (standard population = World population)

13. Males show in a steadily way, higher general (=all causes) mortality ratescompared to females as both crude rates and age-standardized ones at each of 12 country regions; such a distinction results to be more evident in age-standardized rates with world population as a standard, (the following table and graph). There are slight differences between crude rates and age-standardized ones with country population as standard, whereas the age-standardized rates with world population as standard are evidently higher than the two first ones. Kukes and Shkoder regions show the lowestgeneral crude mortality rates, of 195.8 (males) and 128.9 (females) and 387.8 (males) and 237.2 (females) respectively. The general crude mortality ratesof other regions are higher, reaching the highest level at Korçe region (724.4 for males and 642.3 for females).

15. Gender–specific Mortality Rates (Crude and Age-Standardized) according to country regions (or prefectures or qarks)

16. At country level, the cause-specific mortality rates, by gender, both as crude and age-standardized (country and world populations as standard population) show: the diseases of circulatory system are ranked at the first place, with predominantly higher rates than the other cause-groups of deaths, being followed by neoplasms, cerebrovascular diseases, ischaemic heart disease, and injuries and poisoning, whereas the infectious diseases are ranked in the last order with the lowest mortality rates, (the following table and 3 graphs)

18. Cause-specific & Gender-specific Mortality Rates at country level: Crude Rates Males Females

19. Cause-specific & Gender-specific Mortality Rates at country level: Age-standardized Rates: Standard pop. = Country Population Males Females

20. Cause-specific & Gender-specific Mortality Rates at country level: Age-standardized Rates: Standard pop. = World Population Males Females

21. The same patterns of the cause-specific mortality rates, by gender, result to be at regions (prefectures) level as well, for each of 12 country regions. Vlore and Korçe regions show the highest mortality rates for diseases of circulatory system (387.2 and 381.3 for males and 318.8 and 328.0 for females respectively as crude rates), whereas the lowest rates result to be at Kukes and Shkoder regions, followed byTirana region. The following graphs demonstrate the respective obtained cause-specific mortality rates both as crude and age-standardized (with world population as standard population) ones.

22. Cause-specific & Gender-specific Mortality Rates at region level: Crude Rates

23. Cause-specific & Gender-specific Mortality Rates at region level: Age-standardized Rates: Standard pop. = World Population

24. Crude Mortality Rates (per 100,000), all causes and cause-specific, by gender, in Children/Adolescents [age <15 years] The general (=all causes) mortality rates, by gender, in children/adolescents [age <15 years], show more or less the same patterns of those of the general population (=all ages). Thus, the males demonstrate, in a steadily way, higher mortality rates compared to females in children/adolescents aged less than 15 years, both at country and region level. According to regions, Dibra region shows the highest crude mortality rates (126.9 for males and 96.1 for females), being followed by Elbasan region (104.1 for males and 76.5 for females). Meanwhile,Kukes, Shkoder, Vlore, and Gjirokaster regions show the lowest rates (30.8, 33.3, 40.9, and 52.8 for males respectively, and 31.7, 20.9, 23.6, and 26.8 for females respectively). The respective gender mortality rates figures of other regions oscillate in between these extremes. (the following table and graph)

26. Crude Mortality Rates (per 100,000), general (=all causes), by gender, in Children/Adolescents [age <15 years] at region level

27. The picture slightly differs as regardsthe cause-specific mortality ratesin children/adolescents aged less than 15 years compared to the respective figures of the general population (=all ages).The differences concern the ranked order of the death cause-groups and/or the ranked gender-order within the same cause-group of deaths. In general, the diseases of the circulatory system, the diseases of the respiratory system, and the injuries and poisoning show to be the first cause-groups of deaths among the age-groups of less than 15 years old. They are followed byinfectious diseases, which, on the contrary, are ranked at the last order as cause of death among the general population (= all ages). Meanwhile, there are differences, sometimes notableones between country regions concerning the afore-mentioned order of cause-groups of deaths in these age groups and/or between gender-order within the same cause-group of deaths. (The following graph summarizes the overall obtained picture on the matter, thus avoiding a detailed table with the exact figures.)

28. Crude Mortality Rates (per 100,000), cause-specific, by gender, in Children/Adolescents [age <15 years] at region level

29. Population Hospital Morbidity Rates (per 10,000) as general gender-specific, and cause-specific gender-specific according to country regions (or prefectures or qarks):  Crude Hospital Morbidity Rates  Age-Standardized Hospital Morbidity Rates (standard population = Country population)

30. The hospital morbidity discharge data as regards the causality (=cause-specific hospital morbidity rates) show that: -       the diseases of the digestive system are ranked at the 1st order: 176.6/10,000 for males and 133.4/10,000 for females as hospital morbidity rates, or 24.3% and 13.2% of the total hospital morbidity rates (discharges) for males and females respectively; -        the diseases of the respiratory system, (though a large part of them, especially of acute ones, are essentially infections, and/or in the context, that is, usual complications of infectious diseases), are ranked at the 2nd order: 153.0/10,000 for males and 115.9/10,000 for females as hospital morbidity rates, or 21.1% and 11.5% of the total hospital morbidity rates (discharges) for males and females respectively; -        the diseases of the circulatory system are ranked at the 3d order: 68.2/10,000 for males and 58.3/10,000 for females as hospital morbidity rates, or 9.4% and 5.8% of the total hospital morbidity rates (discharges) for males and females respectively; -        infectious diseases and the diseases of the genitourinary system, (though a large part of them being essentially infections), are ranked at the 4th-5th order: infectious diseaseswith 64.8/10,000 for males and 49.7/10,000 for females as hospital morbidity rates represent only 8.9% and 4.9% of the total hospital morbidity rates (discharges) for males and females respectively.

31. But, meanwhile there is something very important to be emphasized, which is related to the question if this were the real picture of the current morbidity patterns of Albania. The answer would be a negative one. The reason consists on the fact that the hospital morbidity discharge data concerning the infectious diseases represent at maximum 10% of the total infectious diseases morbidity, around 90% of them being reported (in the context of the existing statutory integrated surveillance system of infectious diseases in Albania) from the primary health care sources. Therefore, despite of the aforementioned obtained hospital morbidity data, we might claim that, while the infectious diseases are ranked at all but the last order as regards the cause-specific mortality rates, they still occupy one important place in the cause-specific morbidity rates in Albania. Something must however be emphasized: a specificity within cause-specific morbidity as regards infectious diseases. The still high frequency occurrence of infectious diseases is due mainly to those of environmental determinants risks/hazards (water-borne infectious diseases first of all), and zoonotic and parasitic infectious diseases as well, while the EPI (Expanded Immunization Programme) infectious diseases constantly have shown and still show quite insignificant (even …zero) incidence rates, (that is, the same patterns of the Western European Countries).

32. The following tables and graph give a detailed picture of the crude and age-standardized (country population as standard population) hospital morbidity rates, by gender, general and cause-specific, at region level

34. Hospital Morbidity Rates (per 10,000), general (=all causes), by gender, as Crude Rates and Age-standardized Rates (population Standard = Country population) at region level

35. Crude Hospital Morbidity Rates (per 10,000), cause-specific & gender-specific at country level

36. Crude Hospital Morbidity Rates (per 10,000), cause-specific & gender-specific at region level

37. Crude Hospital Morbidity Rates (per 100,000), general (=all causes) and cause-specific, by gender, in Children/Adolescents [age <15 years] The general (=all causes) hospital morbidity rates, by gender, in children/adolescents [age <15 years], do not show the same gender-specific patterns of those of the general population (=all ages). Thus, there are males which demonstrate, in a steadily way, higher hospital morbidityrates compared to females in children/adolescents aged less than 15 years, both at country and regions level. According to regions, Berat and Vlore regions show the highest crude hospital morbidity rates (13,563.4 for males and 11,660.5 for females, and 13,412.9 for males and 10,834.1 for females respectively). Meanwhile, Durres region shows the lowest hospital morbidity rates due to all groups of causes. The respective gender hospital morbidity rates figures of other country regions oscillate in between these extremes. (the following table and graphs)

39. Crude Hospital Morbidity Rates (per 100,000), general (=all causes), by gender, in Children/Adolescents [age <15 years] at region level

40. As regards the causality, the Crude Cause-specific Hospital Morbidity Rates patterns in Children/Adolescents [age <15 years] are slightly different compared to the Crude Hospital Morbidity Rates in the General Population both at country and region level: the diseases of the respiratory systemare ranked at the 1st order, being followed by the diseases of the digestive system (which are at the 1st place in the Hospital Morbidity Rates of the General Population); while the diseases of the circulatory system are ranked at the 3d order in the Crude Hospital Morbidity Rates of the General Population, they occupy all but the last place in the Crude Cause-specific Hospital Morbidity Rates patterns in Children/Adolescents [age <15 years]; (the following table and graph)

42. Crude Hospital Morbidity Rates (per 100,000), cause-specific, by gender, in Children/Adolescents [age <15 years] at region level

43. Tuberculosis and HIV/AIDS (incidence rates per 100,000), both genders Though in a framework of interrelationship between tuberculosis and HIV infection:  Albania show in a steadily way over years a moderate incidence rate of Tuberculosis – TB, but with remarkable differences according to country regions.  Albania is still (year 2007) a country with a low frequency occurrence of HIV/AIDS, though a steadily increasing incidence rate over years; (the first HIV case has been detected in 1993). The following tables and graphs on the matter aim at giving an overall picture of TB and HIV/AIDS incidence rates in the year 2001.

45. Tuberculosis: Incidence rates (per 100,000), both genders

47. HIV/AIDS: Incidence rates (per 100,000), both genders

48. Important to emphasize: The above-presented data on the Population Health Status in Albania are obtained in a one certain year, specifically year 2001. Therefore, they are not able to label any“problematic areas”. There are distinctions between country regions concerning mortality and/or morbidity rates (general and cause-specific ones), but presenting one year rather a trend over years. The data over years only, that is, the respective trends over time, would be able to indicate which country regions might be labelled as “problematic” ones concerning the population health status.

49. - Part II - Environmental, Occupational, and Individual Lifestyle Risk Determinants of Health/Disease

50. Smoking The data on Smoking in Albania (year 2004), being obtained by different sources, are not at all able to give the required figures at each country region/district level. On the basis of the existing data we can give the required figures for Tirana city and Albania only. Prevalence of smoking in adults in Albania (2004): Total 39.0%, Males 60.0%, Females 18.0%. Prevalence of smoking in adults and young people in Tirana city (2002): 41.0% of the study population (61% males and 24% females) were current or ex-smokers, 28% were current smokers (37.6% of males and 19.3% of females), and 13.0% were ex-smokers (23.4% of males and 4.7% of females). Age-standardized (to the European standard population) prevalence of smoking for the adult population of Tirana was 31.2% (42.8% in males and 21.2% in females).