Distribution of primary health care physicians in rural and urban areas of Albania during the period 2000-2012

Albana Adhami¹, Dritan Çela², Llukan Rrumbullaku³, Enver Roshi⁴

¹ Health Insurance Fund, Tirana, Albania;

² University Hospital Center of Traumatology, Tirana, Albania;

³ Faculty of Medicine, University of Medicine, Tirana, Albania.

⁴ Faculty of Public Health, University of Medicine, Tirana, Albania.

 

Corresponding author: Albana Adhami, MD

Address: Institute of Health Insurance, Rr. “Sami Frashëri”, L. 8, Tirana, Albania;

Telephone: +355692059202; E-mail: albana.adhami@gmail.com

 

Abstract

 

Aim: The aim of this study was to describe the distribution of primary health care (PHC) physicians in urban and rural areas of Albania in the past decade.

 

Methods: We reviewed the number of PHC physicians (per 10,000 population) in each of the 36 districts of Albania separately for urban areas and rural areas for the period 2000-2012. The information on the number of PHC physicians and the population size in each district for the period under study was collected from the files of the Health Insurance Fund. Mann-Kendall test was used to test for linear trend in the variation of the number of PHC physicians in both urban and rural areas of Albania.   

 

Results: In urban areas, there was evidence of an overall decrease in the number of PHC physicians (per 10,000 population) from 4.4 (in 2000) to 3.9 (in 2012) [linear trend: P=0.02]. Conversely, in rural areas, there was evidence of a slight increase from 3.5 (in 2000) to 3.7 (in 2012), with no evidence of a significant linear trend (P>0.05). In 2000, the excess number of PHC physicians in urban areas compared with the rural areas was 9 per 100,000 population, whereas in 2012 this difference was only 2 per 100,000 population.    

 

Conclusion: Regarding the distribution of PHC physicians in Albania, the current analysis indicates a significant decrease in urban areas, but only a slight non-significant increase in rural areas of the country. It would be interesting to assess in future analyses the link between the distribution of PHC personnel and health outcomes in urban areas compared to rural areas of transitional Albania.   

 

Keywords: family physicians, general practitioners, primary health care, rural areas, urban areas. 

 

Introduction

The quality of health care services has been convincingly linked to health outcomes in different studies reported in the international literature (1,2). This is particularly the case for primary health care (PHC) services which are considered as the most important level of health care in many developed countries (3). For this very reason, health care professionals operating at the PHC level are very cautious about PHC users’ demands, a process which is related to the need for continuous improvement of the quality of PHC services. In addition, the “gate-keeping” function of PHC services implicitly requires a reasonable degree of users’ satisfaction.    

 

There is a substantial amount of literature linking the number of PHC professionals (per 100,000 population) with the health outcomes of the served populations and their respective epidemiological profiles (4-6). However, other things being equal, the distribution of PHC professionals is also contingent on the demographic profile (age, sex and place of residence) and socioeconomic characteristics of the respective populations (4,7).

 

The issues related to PHC services are especially important and relevant for the former communist countries of the Western Balkans including Albania, a country which is currently undergoing profound reforms in the health sector moving from hospital-based system to the primary health care model (8). Nevertheless, as reported elsewhere, the current health care reforms in Albania face enormous challenges with regard to the effectiveness of the “gate-keeping” system (8).

 

We have recently reported on the number of PHC visits in the Albanian population for the period 2005-2012 (8). In this article we describe the distribution of PHC physicians in urban and rural areas of Albania in the past decade.  

 

Methods

In this analysis, we reviewed the number of PHC physicians (per 10,000 population) in each of the 36 districts of Albania separately for urban areas and rural areas for the period 2000-2012. The information on the number of PHC physicians and the population size in each district for the period under study was collected from the files of the Health Insurance Fund.

 

Mann-Kendall test was used to test for linear trend in the variation of the number of PHC physicians in both urban and rural areas of Albania for the period under investigation. Statistical Package for Social Sciences (SPSS, version, 19.0) was used for the data analysis.     

 

Results

It should be noted that there was no information available for the years 2001 and 2002. The number of PHC physicians per 10,000 population in urban areas and rural areas for each district of Albania is presented in Table 1 (for the year 2000) and in Table 2 (for the year 2012). At the start of the analysis (year 2000), the highest number of PHC physicians (per 10,000 population) in urban areas was evident in Durrës (5.5), Korça (5.4), Has and Tirana (5.2 for both). Conversely, the lowest number of PHC physicians in urban areas was in the districts of Kolonja (no physicians at all), Tropoja and Bulqiza (1.8 for both) followed by Delvina (2.2). As for the rural areas, the highest number of physicians was evident in Tirana and Durrës (5.1 in both), whereas the lowest number was in Delvina (1.3), Peqin (1.7) and Bulqiza (1.8).     

 

Table 1. Number of PHC physicians in urban areas and rural areas of Albania in 2000 by district 

Table 2. Number of PHC physicians in urban areas and rural areas of Albania in 2012 by district

 

 

 

On the other hand, at the end of the period under investigation (year 2012), the highest number of physicians (per 10,000 population) operating in urban areas was evident in Skrapar (4.6) followed by Berat (4.5), whereas the lowest number was in Delvina (1.5) and Bulqiza (2.4). In rural areas, the highest number of physicians was noted in Përmet (5.1) followed by Kolonja (5.0), whereas the lowest number was in Bulqiza (2.3) and in Peqin (2.4).

 

Figure 1 presents the overall distribution of PHC physicians in urban areas and rural areas of Albania for the period 2000-2012. In urban areas, there was evidence of an overall decrease in the number of PHC physicians (per 10,000 population) from 4.4 (in 2000) to 3.9 (in 2012) [linear trend: P=0.02]. Conversely, in rural areas, there was evidence of a slight increase from 3.5 (in 2000) to 3.7 (in 2012), with no significant linear trend (P>0.05).

 

Overall, in 2000, the excess number of PHC physicians in urban areas compared with the rural areas of Albania was 9 per 100,000 population, whereas in 2012 this difference was only 2 per 100,000 population.        

 

Figure 1. Overall number of PHC physicians (per 10,000 population) in urban areas and rural areas of Albania for the period 2000-2012

 

Discussion

Our analysis regarding the distribution of PHC physicians in Albania for the period 2000-2012 revealed a significant decrease in urban areas, but only a slight non-significant increase in the rural areas of the country. Essentially, there was a steady (albeit weak) decrease in urban areas in most of the districts of Albania, with no evidence of significant regional variations. In rural areas, the increase in the number of PHC physicians was quite small, with no significant regional variations for the period under investigation. However, the small increase in the number of PHC physicians in rural areas coupled with the decrease in the urban areas contributed to a steady reduction in the excess number of PHC physicians between urban areas (more privileged areas with a higher access to health care services) and rural areas (traditionally disadvantaged and underserved areas). Therefore, the current analysis supports the presence of a narrower gap in urban-rural disparities regarding the distribution of PHC personnel in Albania.        

 

Several studies have reported a positive association between patient satisfaction and the number of PHC personnel (9). The patient satisfaction with the quality of PHC services has also been more directly linked to health outcomes (10,11). Furthermore, different studies have reported a positive relationship between the number of PHC professionals (per 100,000 population) and morbidity outcomes of the populations (4-6). Nonetheless, as stated earlier, the distribution of PHC professionals, among other things, depends also on the demographic profile and socioeconomic characteristics of the respective populations (4,7).

 

From this point of view, it would be interesting to assess in future analyses the link between the distribution of PHC personnel and health outcomes in urban areas compared to rural areas of transitional Albania. Also, it is important to conduct a specific analysis by different demographic and socioeconomic characteristics of the Albanian population in both urban areas and rural areas. This would enable assessment of the putative link between the distribution of PHC physicians and demographic factors and socioeconomic characteristics of the served populations in different regions of Albania.  

 

Hence, a limitation of our analysis regards the lack of disaggregated data on the demographic and socioeconomic profile of urban areas and rural areas in each of the districts of Albania. From this perspective, future studies in Albania should explore in more depth the distribution of PHC professionals by specific demographic and socioeconomic characteristics of the population. Subsequently, the distribution of PHC physicians and other health personnel (nurses and midwives) should be linked to specific health outcomes of the population including a detailed list of mortality and morbidity indicators.

 

In conclusion, our analysis indicates a significant decrease in the number of PHC physicians in urban areas, but only a slight non-significant increase in the rural areas of Albania. Yet, the small increase in the number of PHC physicians in rural areas along with the decrease in the urban areas contributed to a steady reduction in the excess number of PHC physicians between urban and rural areas. From this point of view, our findings provide evidence of a narrower gap in urban-rural disparities regarding the distribution of PHC personnel in Albania.

 

References

1.        McElduff P, Lyratzopoulos G, Edwards R, Heller RF, Shekelle P, Roland M. Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK.  Qual Saf Health Care 2004; 13:191-197.

2.        Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83:457-502.

3.        Atun R. What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? Health Evidence Network report. Copenhagen, WHO Regional Office for Europe 2004. Available at:  http://www.euro.who.int/document/e82997.

4.        Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A, Wachter RM, Harris MJ. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PLoS One 2013; 8(6):e66699. doi: 10.1371/journal.pone.0066699.

5.        Agarwal S, Banerjee J, Baker R, Conroy S, Hsu R, Rashid A, Camosso-Stefinovic J, Sinfield P, Habiba M. Potentially avoidable emergency department attendance: interview study of patients’ reasons for attendance. Emerg Med J 2012; 29(12):e3. doi: 10.1136/emermed-2011-200585.

6.        Baker R, Bankart MJ, Rashid A, Banerjee J, Conroy S, Habiba M, Hsu R, Wilson A, Agarwal S, Camosso-Stefinovic J. Characteristics of general practices associated with emergency-department attendance rates: a cross-sectional study. BMJ Qual Saf 2011; 20:953-958. 

7.        Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc 1973; 51:95-124.

8.        Adhami A, Rrumbullaku L. Primary health care visits in the Albanian population during 2005-2012. Albanian Medical Journal 2013; 2:119-122.

9.        Heje HN, Vedsted P, Olesen F. General practitioners’ experience and benefits from patient evaluations. BMC Fam Pract 2011; 12:116.

10.     van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract 2010; 16:947-956.

11.     Hush JM, Cameron K, Mackey M. Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Phys Ther 2011; 91:25-36.