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Base de datos de evaluación

Evaluation report

2000 ALB: Household Health Behaviour Attitudes Toward Paid Health Care and Health Care Expenditures

Author: Benes, O.; Seidova, A.

Executive summary


Household survey on “Health behavior, attitudes towards paid health care and expenditures on health” was carried out by UNICEF jointly with the Ministry of Health with an intention to elaborate the strategies for health intervention in one or two districts.  The survey was carried out in three districts, Elbasan, Pogradec and Vlora, which were selected as potential sites for primary health care project.

Purpose / Objective

The purpose of the survey was to obtain information from the households on current health care, specifically on their health-seeking behavior, attitudes towards changes and their expenditures on health and, based on the finding, elaborate the strategies for intervention in one of these districts.

Though several surveys have been carried out by the Ministry of Health and international organizations, most of them were looking at health care delivery from the provider side. This study was almost the first attempt to look at the health care situation in Albania from the consumer's perspective.


2,014 households were interviewed in three districts, which represented 9,778 individual family members, out of which 30.4% were children under 15 years of age (1% children under one [0.7-1.2], 6.6% [5.7-6.9] children of 1-under 5 years of age), which is close to the national average (33% under 15 in 1998, source - INSTAT). The survey was carried out in Elbasan, Pogradec and Vlora, with a total number of population at 535,630. The districts were suggested by the Ministry of Health and agreed with UNICEF.

Socio-economic questions and attitudes towards paid health care and participation were asked in all households, while the medical part was filled only for each sick member of the household who experienced a case of illness during the month prior to the interview. The delivery part was considered if there was a delivery in the household one year prior to the interview.

Key Findings and Conclusions

Socio-economic status
The average monthly declared income of households was 15,788 new leks. Salary contributes 33% to the household budget; mainly, the source of income comes from other than salary sources. Food accounts for less than half of the households' expenditures and, surprisingly, paying debts is the next biggest item of declared expenditures. In majority of cases, the declared income was less than expenditures.

Access to health care services
Overall, the accessibility of the population to health care is quite good and 87.5% of the population lives at a distance of less than 5 km to the nearest health facility. On the other hand, this is not always the case for the population of rural far areas where this proportion decreases to 55.6%. There is also good coverage of the population by a GP. The majority of households (78%) need less than one hour to find a GP, but this again differs from strata to strata. 47.5% of people from rural far areas need to travel for more than two hours to reach a GP.

Only 15.7% of households admitted that the price for treatment never prevented them from applying for health services. Though, in general, there are no formal charges for health services, the practice of informal payments (by cash or in kind) is widespread. The highest proportion of people for whom the price of health service was always an obstacle was in rural far area (61.1%). This was also the case for 61.2% of poor people with significant difference from other socio-economic groups (49.0% in medium and 33.6% in high groups). 43.4% had to borrow money to cover health expenses and this is more applicable to rural rather than urban areas.

Paid care
It is interesting to observe how the acceptability of paid health care changes from question to question. When the respondents were given only two options of whether they agree or do not agree to pay for health services, almost half of the respondents (49.2%) stated that in no way could they accept paying for health care (significantly lower in high socio-economic group than in medium and low groups). When they are given the opportunity to select the conditions under which they would pay, the proportion of people who refused to accept paying for care decreases to 27.7%, and this even goes further down to 24.4% when they are given a choice to select the item of payment.

Improvement of the performance of health personnel is the primary condition for the majority of people who agree to pay (33.6%). People are less concerned about availability of drugs in the nearest facility and this is the next preferred condition in rural areas (15%-18%).

In total sample, 27.8% of households prefer to pay only for drugs and 29.7% of households agree to pay for all items - drugs, doctor's consultation and examination and, here again, we can observe the differences in responses between areas and socio-economic groups. In rural areas, people are more prone to pay only for drugs, while in urban areas more people expressed their readiness to pay for everything. Similarly, in the high socio-economic group, more people agree to pay for everything, while in the low and medium groups the most preferred item is payment for drugs.

The interviewed households were ready to contribute monthly the average amount of 252 new leks though with significant difference in the amount of monthly contribution among strata and socio-economic groups (higher in urban and high socio-economic groups, and lower in rural and low-score groups).

Health insurance
72% of households preferred to pay once a month (as a kind of insurance) rather than to pay for health services when they are ill. At the same time, one third of interviewed households (33.7%) didn't know what health insurance is and this was found mainly in rural than in urban areas. 89% of people who are aware about health insurance considers that health insurance is helpful and 11% thinks that it is not. When asked why it is not helpful, the most frequently selected reason was that they have to pay for drugs anyway, and also that they do not know their rights and regulations.

Only 28.5% of households declared that they receive a salary and, consequently, make a contribution to the health insurance fund.

In general, 52.5% of people expressed their willingness to participate in the development of health care and, mainly, they want to take part in health education activities and assist in water and sanitation activities.

The study revealed a heavy reliance on hospitalization. Half of all patients were advised to be hospitalized and 24.2% of them actually stayed at hospital. 40.2% of those who should stay didn't; they could not do so because they could not afford it

Drugs availability
Only 1% of patients didn't need drugs. All others were either prescribed drugs or they bought without consultation with doctor. The accessibility to drugs is also very high and 95.7% of patients found all needed drugs in the pharmacy, with no difference by strata.

Expenditures on health
Only 2.9% of ill persons had no expenditures on health. The amount of expenditures did not depend on the socio-economic status and strata. If we look at the portion of health expenditures in the total budget of households (presented in the first part) who had the case/s of illness during previous month, we can see that it accounts for 20.5% of total household expenditures.

Expenditures on drugs account for the biggest proportion of expenditures (36.4%); personnel is the second biggest item of expenditures (21.2%). Expenditures on food and transport account for 18% and 14.6%, respectively. 6.3% from total expenditures were spent on medical examinations.

Because of the few number of cases (101 deliveries), it was difficult to make definite conclusions. 10 women (6.5%) delivered at home, and 60.4% of them (all from rural area) delivered at home because there was no facility providing maternal care close to their place of residence. 19.1% of women traveled more than two hours to reach the facility for delivery (37.2% in rural far area). There was only one case of unattended delivery but, speaking in proportional terms, this makes 9.7% from those who delivered at home. It is still difficult to make any conclusions but there is a clear indication that the problem of unattended deliveries exists.


Health insurance is going to play an important role in the health system of Albania. The introduction of user fees should be carefully examined. There is a still a big group of the population who think twice before applying for care because of price (though informal). In general, the population prefer monthly contributions rather than payments during illness.

There is also heavy reliance on hospitalization. This not only has a certain impact on the health system in general, but also puts an unnecessary financial burden on the population who uses an inappropriate level of care as their first provider.

More attention should be given for raising the participation of the community to the development of health care delivery. It is encouraging that the community is willing to participate and they especially like to be involved in health education and water and sanitation activities. Certain activities should be undertaken in order to transfer this readiness into reality. Local health authorities, jointly with the municipalities, should take a lead in this process.

At national level, UNICEF, not necessarily being involved in the major reorganization and restructuring of the health sector, should ensure that the rights of child, adolescent and woman to essential health services are preserved despite of the direction of the reform. To this end, a number of round table meetings, with the involvement of all major partners in the health sector reform, should be organized, where the potential impact (threats and benefits) of the current direction of the health reform process on the provision of basic health services (in terms of equity, accessibility, coverage and quality) is discussed.

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Health - Other

Ministry of Health


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