WORLD BANK GROUP POLICY NOTE Tackling noncommunicable diseases in Kosovo to enhance human capital and economic growth May 2023 KEY MESSAGES 1. The health and economic burden of NCDs represents a significant toll on Kosovo. 2. Enhancing prevention and management of NCDs is essential to reduce the NCDs burden. 3. Proactively addressing NCDs will foster human capital and economic growth. Tackling noncommunicable diseases in Kosovo 01 Noncommunicable Kosovo is a young state that benefits from a young population which plays a key role diseases (NCDs) hamper in the country’s European progression. the development of human Economic growth has outperformed capital for current and future neighboring peers, leading to significant generations reductions in poverty. Yet, the country remains with a high unemployment rate that calls for major investments in building NCDs are chronic conditions that are often skills and creating quality jobs to boost untreatable and require close monitoring Kosovo’s human capital and economic to control the progression of the disease. growth. They account for 70 percent of all deaths worldwide and directly affect countries’ The threat NCDs pose to Kosovo’s progress economies, as every 10 percent increase in calls for a proactive approach to address mortality due to NCDs reduces economic them. Protecting Kosovars from NCDs growth by 0.5 percent.i NCDs have a will promote healthier lives, accelerate direct and indirect impact that threatens economic growth, and reduce the financial the human capital of current and future burden on the health system. generations (Figure 1). Source: Figure 1  Direct and indirect impact of NCDs on human capital Adapted from Nikoloski et al 2021 Direct and indirect impact of NCDs on Early retirement human capital Absenteeism Direct impact Productivity loss Presenteeism Educational attainment Noncommunicable diseases Intergenerational loss in education investment by Skill loss, loss in diverting resources the overall toward disease economic growth Indirect impact treatment Lower investment in human capital Loss of acquired by doing unpaid experience in the work caring world of work for the chronically ill 02 Tackling noncommunicable diseases in Kosovo Risk factors for NCDs damaging pollutant for health that affects human organs. Moreover, it is estimated that almost 400 premature annual deaths are Behavioral, metabolic, and environmental attributed to air pollution, which accounts factors influence the development of for up to 320 EUR million per year.iii NCDs. Behavioral factors are related to the individual’s behavior, for instance, smoking. Metabolic factors refer to The health and economic alterations in parameters such body-mass index. Lastly, environmental factors are burden of NCDs mainly attributed to air pollutants. NCDs pose a major challenge to Kosovo’s Smoking prevalence in Kosovo is at health system and the population’s similar levels compared with Western health. According to the Kosovo Agency Balkans peers, yet prevalence among men of Statistics, since 2015, the major NCDs is the second highest in the region (48.9 – circulatory system diseases, diabetes, percent), only behind North Macedonia cancers, and chronic respiratory diseases (57.9 percent). – account for over two-thirds of all deaths. Although mortality due to NCDs is higher Second-hand smoke is widely prevalent, among the elderly, around 25 percent of with around half of the population aged deaths in 2019 were attributed to these 13–15 years exposed to its harmful effects, conditions in the 20–29 age group. higher than most of Kosovo’s aspirational peers (Figure 2). Cancer cases have considerably increased over the last decade. From 2012 to 2019, there was a three- to fourfold increase in the cases of the most prevalent types Figure 2  Prevalence of second-hand of cancer (Figure 3). Women are mainly smoking at home affected by breast cancer while the main type of cancer in males is cancer of the 70% digestive organs. 60% 50% Figure 3  Trend of the five main types of 40% cancer per 100,000 population 30% 30 20% 25 Lithuania Slovenia Estonia Kosovo Croatia Latvia 10% 20 0% 15 Source: GYTS 2017 or latest available. 10 5 Around a third of children aged 2–7 are at risk of being overweight. The prevalence 0 of obesity among this age group is 2.3 2016 2019 2018 2015 2013 2014 2012 2017 percent, but higher among boys (2.7 percent) than girls (1.4 percent). The share Respiratory system Breast of overweight boys and girls is higher with 10.9 and 5.9 percent, respectively.ii Digestive organs Female reproductive system Annually, Kosovo’s two coal plants release over 7,500 tons of PM2.5 particles, the most Source: KAS. Tackling noncommunicable diseases in Kosovo 03 The prevalence of hypertension (28.4 Risk reduction and screening percent) and diabetes (4.3 percent) is lower than structural peers,1 however, most for NCDs cases remain undiagnosed, untreated, or Although Kosovo has conducted health uncontrolled. A World Health Organization promotion campaigns to reduce the risk (WHO) STEPS NCDs survey in 2019 found of NCDs, these campaigns are scattered that over half of the detected people with and mainly donor-driven initiatives. criteria for hypertension were previously Moreover, vaccination campaigns to undiagnosed. reduce the risk of cervical cancer are The country’s recent conflicts have left a missing despite the fact that the Human high mental health burden. It is estimated Papilloma Virus (HPV) vaccine reduces that of over 900,000 war survivors, more cervical cancer rates by almost 90 percent. than 60 percent experience post-traumatic Consequently, over 70 percent of women stress disorder or major depression. These have never heard of the HPV vaccine, and figures are expected to worsen due to the less than one percent have received it.iv impact the COVID-19 pandemic had on people’s mental health. Kosovo lacks systematic screening for NCDs. Less than 1 in 100 women has been tested for The direct and indirect costs of NCDs cervical cancer, and only 5 percent of eligible threaten the financial sustainability of women have been screened for breast Kosovo’s health system and economic cancer. The poor screening of NCDs has growth in general. A rapid cost-of-illness also led to over 90 percent of lung cancers analysis of six NCDs estimated that the being detected at late stages, where survival financial cost of these conditions will is poor and often requires more expensive 1 account for up to 714.89 million EUR in treatments, increasing the financial burden 2023. Indirect costs due to premature death on the health system. and absenteeism are the main contributors to the financial burden, representing 85 1  Structural peers are Albania, Armenia, Moldova, percent of costs (Table 1). North Macedonia, and Kyrgyz Republic. Table 1  Estimated economic burden of NCDs in 2023 (EUR millions), by disease Disease Health care Indirect costs Total % costs Hypertension 68.76 233.94 302.7 42.3% Diabetes 24.78 100.21 124.99 17.5% Breast cancer 5.28 86.54 91.83 12.8% Cervical cancer 1.79 27.12 28.92 4.0% Lung cancer 2.23 136.01 138.24 19.3% Colorectal cancer 1.96 26.25 28.21 3.9% Total 104.8 610.07 714.89 100% % 14.7% 85.3% 100.0% Source: Main report. 04 Tackling noncommunicable diseases in Kosovo Management of NCDs perform mammograms, representing 0.61 mammograms per 100,000 population, Kosovo’s health system is characterized by almost half the rate in North Macedonia low health expenditure and a high reliability (1.11 per 100,000 population). on out-of-pocket (OOP) payments. Total Similarly, diabetes care is limited as health expenditure in Kosovo as a share of evidenced by wide differences across GDP is the lowest among Western Balkans municipalities of patients receiving insulin (Figure 4). Consequently, OOP expenditure treatment. accounts for up to 60 percent of total health expenditure, exposing families to The constraints in the public health sector impoverishing health expenditures. motivate patients toward self-referral to specialized services to access care even for conditions treatable at the primary level. Additionally, the lack of defined clinical Figure 4  Total health expenditure as share pathways complicates adequate follow- (%) of GDP up of patients with NCDs, increasing the fragmentation of care and risking prognosis 10 9 and treatment. 8 7 6 5 Regulations and policies to 4 reduce the burden of NCDs 3 2 1 Kosovo has made important progress 0 in ensuring that the WHO Best Buysv 2015 2016 2017 2018 regulations are in place, but most are BiH Montenegro partially implemented (Table 2). The main reasons for the lack of fully implemented Serbia Albania regulations are lower taxes, lack of North Kosovo warning graphics, or lack of enforcement Macedonia and monitoring of existing regulations. Source: Like these products, sugar-sweetened Kosovo Health Insurance Fund Financing Plan 2022-2026 and WHO. beverages (SSBs) are partially regulated due to low excise taxes and inconsistent taxed products. Kosovo has one of the lowest supplies Air quality regulations adhere to the of healthcare staff in Europe due to the European Union standards, but human emigration of doctors and nurses to resource and financial constraints European countries. Moreover, personnel hamper actions to reduce air pollutants. staying in Kosovo engage in dual practice in The Law on Environmental Protection public and private facilities, compromising was implemented in 2009, and the Law the quality of care delivered. Guidelines on Air Protection for Pollution in 2010. for managing NCDs are also insufficient, However, lack of coordination among with only five diseases covered, leaving different government agencies and limited healthcare workers to make decisions from human and financial resources has led experience rather than evidence-based. to inadequate implementation of the Air Kosovo has constrained resources to Quality Action Plan since 2018. Therefore, screen and treat NCDs. For instance, Kosovars continue to be exposed to high only 11 centers have equipment to concentrations of air pollutants. Tackling noncommunicable diseases in Kosovo 05 Table 2  Status of the policies on tobacco products in Kosovo compared to WHO best-buys Regulation Status Rationale Reference Increase excise taxes and prices on Excise tax on tobacco products Law tobacco products. is applied but remains below No. 03/L-112 international standards. Implement plain/standardized Health warning remarks are present Law packaging and/or large graphic on tobacco products but remain No. 02/L-36 health warnings on all tobacco below international standards. packages. Enact and enforce comprehensive Advertizing, promoting, and Law bans on tobacco advertising, sponsorship of tobacco products No. 02/L-36 promotion, and sponsorship. are banned. Eliminate exposure to secondhand Smoking in public areas is Law tobacco smoke in all indoor prohibited; however, law No. 02/L-36 workplaces, public places, and enforcement remains compromised. public transport. Implement effective mass media Public and private media are obliged Law campaigns that educate the public to broadcast educational programs No. 02/L-36 about the harms of smoking/ on the harmful effects of tobacco. tobacco use and secondhand smoke. Increase excise taxes on alcoholic Excise taxes on alcoholic beverages Law beverages. are applied, but remain considerably No. 03/L-220 low for spirits. Enact and enforce bans or Advertising of alcoholic products is RR-110- comprehensive restrictions on banned from billboards, but there 2782-K.PR exposure to alcohol advertising is no evidence of bans from other (across multiple types of media). media types. Enact and enforce restrictions on No evidence of restrictions on N/A the physical availability of retailed the physical availability of retailed alcohol (via reduced hours of sale). alcohol. Note: = Present but partially implemented; = present and fully implemented; = not implemented. Source: Produced by the authors 06 Tackling noncommunicable diseases in Kosovo Reducing NCDs’ burden to Extend the national pilot screening program on breast and cervical cancer increase human capital and throughout the country. The current foster economic growth programs have increased the number of women screened for breast and cervical Kosovo has made appreciable efforts in cancer; however, the majority of eligible protecting its population from NCDs, women remain unscreened. Expanding yet the increasing health and economic the program throughout the country will burden due to NCDs calls for a proactive result in an increased share of eligible approach to tackle these conditions. As women benefiting from early detection of the country continues its journey towards cervical cancer and a better prognosis. enhancing health system performance and improving the population’s health, the Develop an integrated information system burden of NCDs can be further reduced by across healthcare institutions to improve addressing the following aspects. care coordination. For better disease management, NCDs will require the input Implement a rigorous national campaign of multiple professionals throughout on the prevention of smoking, particularly the progression of a disease. Ensuring among the youth. Learning from successful that healthcare professionals have campaigns from other countries can access to a patient’s record will increase provide the basis for a national campaign to care coordination and enhance health reduce smoking. Co-developing campaigns outcomes. with the targeted audience to ensure their perspectives are considered and adapted Develop standardized clinical protocols to the Kosovar context will increase the for the prevention and treatment of NCDs campaigns’ success. and build the infrastructure to provide evidence-based care. Kosovo has recently Develop condition-specific registries to produced a series of guidelines for only improve data quality and monitoring of five chronic conditions. Standardizing NCDs. The existing cancer registry has NCD care through developing clinical been implemented by law and satisfactorily guidelines for all of them will ensure that followed by healthcare staff at regional everyone benefits from the same care. hospitals and the National Institute of Equipping health facilities with resources Public Health. Adapting a similar process to implement standardized protocols for major NCDs, such as diabetes and is important to ensure adherence to hypertension, is necessary. standardized care. Hospital and primary care clinics continue to face shortages of Implement lists of patients at primary pharmaceuticals and medical equipment care facilities for better prevention and for everyday care. Clinical audits for control of NCDs. Assigning patients implementing the protocols should be to a specific healthcare facility will embedded as a regular oversight practice. improve the screening and management Empowerment and accountability of chronic conditions. Moreover, self- mechanisms for quality care coordinators referrals to specialized clinics will be across health facilities is also of high reduced, enhancing the health system’s importance. performance. Enhance the monitoring and enforcement Develop tailored prevention and screening of policies to reduce tobacco and alcohol services driven by a national strategy for consumption while increasing taxes NCDs. Access to prevention and screening on harmful products to international services remains limited. Developing a standards. Ensuring the current policies national strategy for NCDs will increase are adequately enforced while pairing the population’s access to and use of these them to international standards will reduce services. The strategy should consider the the impact of harmful products and bring rapidly escalating incidence rates of the economic and human capital development main types of cancer and the high numbers benefits. of undiagnosed cases of diabetes and hypertension. Tackling noncommunicable diseases in Kosovo 07 Develop strategic planning for human Advance health financing reforms to enable resources for health to improve attraction adequate resources for the prevention and and retention of healthcare workers. management of NCDs. Kosovo has one 23456 Emigration of healthcare workers has of the lowest health care expenditures resulted in limited availability of human and a high dependency on out-of-pocket resources for health in Kosovo, which payments. Advancing health financing compromises the quality of healthcare reforms, including strategic purchasing, delivery for patients with chronic will increase the availability of resources conditions. Developing a strategic plan that and infrastructure for the prevention, considers current and future population treatment, and control of NCDs. health needs, and addresses healthcare workers’ concerns for their professional practice will increase the attraction and retention of human resources for health. i  Jakab, Zsuzsanna. 2018. Health Systems Respond to Build service capacity and increase access Non-Communicable Diseases: Time for Ambition. European Journal of Public Health. Vol. 28. Copen- to mental health care. This is especially hagen: World Health Organization. Regional Office important for the most vulnerable for Europe. https://doi.org/10.1093/eurpub/cky069. populations and those with a higher risk of ii  Rysha, Agim, Tahire M. Gjergji, and Angelika Ploeger. 2017 “Nutritional status of preschool mental illness. The health system should children attending kindergartens in Kosovo.” also ensure that enough mental health Journal of Health, Population and Nutrition 36(1): professionals are available for meeting 1-8. https://jhpn.biomedcentral.com/counter/ pdf/10.1186/s41043-017-0105-1.pdf. future trends. iii  Netherlands Court of Audit, and Supreme Audit Office of Poland. 2019. “Joint Report Air Quality.” Accelerate the implementation of air https://english.rekenkamer.nl/publications/re- quality plans to reduce exposure to ports/2019/01/30/joint-report-air-quality iv  Raçi, Pranvera Zejnullahu, Fitim Raçi, and Teuta harmful concentrations of air pollutants. Hadri. 2021. “Kosovo Women’s Knowledge and Currently, air quality regulations adhere Awareness of Human Papillomavirus (HPV) Infec- to European standards but have not yet tion, HPV Vaccination, and Its Relation to Cervical Cancer.” BMC Women’s Health 21(1): 354. been fully implemented. Increasing the v  World Health Organization. 2017. “Tackling technical capacity and financial resources NCDs:’best Buys’ and Other Recommended to implement these plans will result in Interventions for the Prevention and Control of Noncommunicable Diseases.” https://www.who. cleaner air and healthier Kosovars. int/publications/i/item/WHO-NMH-NVI-17.9. This Policy Note is based on a report written by Ha Thi Hong Nguyen, Mrike Aliu, Alejandro Gonzalez-Aquines, and Ilir Hoxha “The State of Noncommunicable Diseases in Kosovo” (May 2023). The findings, interpretations, and conclusions expressed herein do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the Governments they represent. WORLD BANK GROUP Tackling noncommunicable diseases in Kosovo to enhance human capital and economic growth May 2023