Although the Covid-19 experience brought significant investments in hospital logistics and the National Emergency, geographical inequality and chronic underfunding remain serious obstacles to coping with new pandemics of the magnitude of Covid-19. The critical shortage of doctors, driven by emigration, as well as the dependence of laboratories on imports risk bringing delayed responses to crises. Experts call for the creation of emergency reserves and the strengthening of regional hospital hubs

Blerina Hoxha | Monitor

The world we live in today has made it easier for infectious diseases to spread from one continent to another more quickly than ever before. Free movement has encouraged travel, while the modernization of transportation has made it easier for both people and viruses to move.

It's been six years since the Covid-19 pandemic paralyzed the world in 2020, with the still-fresh trauma recently fueled by Hantavirus, Ebola. The infectious diseases now ravaging Africa and Asia scare us more than ever, but is Albania ready to face another pandemic of the size of Covid-19, without experiencing the drama of 2020?

Health experts and doctors claim that the system is undoubtedly more tested and coordinated than in 2020, but challenges related to the lack of infrastructure in primary care and human resources throughout the health infrastructure chain still remain.

Albania ranked fourth in the world for the level of actual deaths from Covid-19 in relation to the population, after Azerbaijan, Bosnia and Herzegovina and Bulgaria, according to data from "Health Data", an American institute for health assessment.

According to the report, Albania had a total of 529 deaths per 100 inhabitants, for the period March 2020 to May 2021, ranking fourth among the 20 countries with the highest actual deaths from Covid-19.

Plan 2030, how health capacities for pandemics are being strengthened

The public health system in Albania has made significant progress, with the consolidation of the National Emergency and the complete digitalization of surveillance systems for infectious agents undoubtedly representing two of our strongest points, said Alban Ylli, a public health policy expert.

Mr. Ylli said that, in this decade, the attention of health policies is focused on several vital directions. First, the increase in laboratory capacities will take a new impetus next year with the start of work of the new National Reference Center.

Secondly, priority is being invested in the training of experts, doctors, epidemiologists, nurses and support staff, to guarantee epidemiological investigation and risk communication during health crises.

He said that the Ministry of Health is working on a capillary system, through the "Solidar" program. "We have started work on preparing primary care structures with intersectoral plans and mechanisms to react in times of emergency.

"This entire architecture will function as a single body by integrating and standardizing the exchange of clinical, laboratory and environmental data across all our digital platforms," ​​he said.

How prepared is Albania?

If a new pandemic were to strike today, Albania would not be caught by surprise as it was in March 2020, as emergency response mechanisms have been created and tested.

However, the long-term sustainability of the system will depend largely on the speed of the virus' spread and the ability to retain and motivate existing medical staff, said pulmonologist Luan Dyrmishi, who worked on the front lines of the Covid-19 pandemic.

The Covid-19 experience served as a precedent for the Albanian healthcare system, forcing it to build almost from scratch a logistical and management structure for major emergencies.

If another crisis were to occur, Albania would rely on some of the concrete assets and experiences that were created during that period. In operational terms, this would be easier, but the country still needs investments in capacity and logistics, such as in doctors, hospital facilities and surveillance, said Dr. Dyrmishi.

Problem of lack of medical staff

The lack of medical staff in Albania is a major problem for providing dignified services in normal times, but in the event of a pandemic this is a major problem for saving lives, said Gazment Koduzi, a physician and experienced health policy expert.

According to World Bank data, Albania had 1.9 doctors per 1000 inhabitants during the pandemic, while the European Union average is over 3.5 doctors per 1000 inhabitants.

The World Health Organization sets the minimum health workforce threshold at around 2.3 - 2.5 doctors for basic health system function in normal times, but this level is not sufficient for a pandemic.

The Covid-19 experience showed that countries that managed to better manage the pressure on hospitals typically had a higher density of doctors, often above 3.5 to 5 doctors per 1000 inhabitants, accompanied by an even higher number of nurses and strong intensive care capacities.

These countries did not avoid the pandemic, but they managed to dominate the collapse of the system. Our country continues to suffer from high emigration of doctors, while services are centralized in Tirana and there are major shortages in the districts.

"For two years in a row, during the 2020-2021 pandemic, it was worse than a war front. It was exhausting, with only two or three hours of sleep. While we were working in Covid hospitals at super intensity, hundreds of messages, graphs and scans came to the phone.

"Many patients who were recovering at home were seeking advice. It was simply impossible to provide it for everyone," said P. Malaj, a pulmonologist who was on the front lines of disease management during the pandemic.

Mr. Koduzi claims that doctors are currently overworked. With the aging population and the spread of non-communicable diseases, the workload is increasing, while almost half of the doctors graduated in our country have emigrated abroad.

Laboratory and diagnostic capacities

Public health infrastructure for prevention and timely case detection (testing) is another weakness that the health system needs to improve, said Mr. Koduzi.

The Covid-19 pandemic clearly demonstrated the importance of rapid and widespread testing, but also Albania's structural limitations in this regard. According to data from the Institute of Public Health, testing capacities increased significantly during 2020–2021, but remained mainly concentrated in Tirana.

A World Bank analysis of Western Balkan countries highlights that laboratory systems in the region are fragmented and highly dependent on imported reagents.

This dependency became apparent when global supply chains were disrupted, causing delays in testing. In Albania, transporting samples from rural areas to laboratory centers created many delays, reducing the effectiveness of case tracking.

In a new pandemic, this means that the system risks reacting too late, allowing the virus to spread before it is systematically identified, said expert Koduzi, according to whom diagnostics remains a link that still does not guarantee the necessary speed and coverage with current capacities.

Weak and uneven infrastructure

The hospital infrastructure in Albania is characterized by a strong concentration in the capital and a lack of medical equipment according to WHO standards. The majority of specialized services are provided in Tirana, especially in the QSUT. Meanwhile, regional hospitals have fewer intensive care capacities and advanced equipment.

Mr. Koduzi said that the inefficient distribution of resources is one of the main challenges of health systems in Albania and also the lack of medical equipment remains a major problem even now in normal times.

Last year's data showed that the "Mother Teresa" Hospital Center handled almost half of the flow of hospital services throughout the country.

During Covid-19, this was reflected in the high pressure on hospitals in Tirana. In a new pandemic, the lack of flexible structures for isolation and treatment could lead to spread within hospitals and a decrease in the quality of service.

Currently, major hospitals have technological equipment from diagnostic imaging with scanners, magnetic resonance imaging, digital radiography and new generation ultrasound, but the country still does not have a PetScanner in the public system. However, the system's challenges are related to their management and maintenance.

According to audit reports by the Supreme State Audit Office, one of the main problems is the large concentration of high technology in Tirana, which creates geographical inequality and forces patients from different districts to travel to the capital for specialized examinations.

This situation is further aggravated by the lack of regular and prompt service contracts. Equipment remains out of service for months due to delays in obtaining spare parts, forcing citizens to turn to the private sector and increasing their direct costs.

Underfunded healthcare

Health financing in Albania remains among the lowest in Europe, said Mr. Koduzi, who considered it the major source of the problems in Albanian health. Data from INSTAT show that health spending is around 3% of GDP, while the EU average is over 8%.

Also, per capita spending is several times lower than in European countries. This level of funding does not allow for the creation of reserve capacities, which are vital in emergencies.

The system operates mainly to cover basic needs, with no room for major investments in modernization and expansion. In a pandemic, this lack of financial flexibility becomes a serious obstacle, as the demand for resources increases significantly in a very short time. Underfunding, in this sense, is the problem that feeds all the others, making the system less resilient to major shocks.

Mr. Koduzi said that due to a lack of funding, lower salaries and less competitive working conditions encourage the departure of doctors and nurses, creating chronic staff shortages and increasing the burden on those who remain.

Another direct consequence of the lack of funding is the degradation of medical infrastructure and technology. If demand suddenly increases, hospitals quickly become overwhelmed, intensive care beds become insufficient, and staff are forced to work beyond their capacity.

Under these conditions, even diseases that would normally be manageable become more dangerous due to delays in treatment and lack of resources.

Data and information gaps

During the discussion with Dr. Dyrmishi on the management of pandemic situations and the challenges of the healthcare system, it was emphasized that one of the main difficulties during such periods has been the lack of experience of doctors in dealing with cases of this level of complexity, as well as the frequent change of information on treatment methods.

A fundamental problem has been the lack of a unified and official treatment protocol according to the stages of the disease.

Instead of clear and standardized guidance, the situation has often been managed in a decentralized manner, relying on individual decision-making by doctors and the overall experience of the health system, which has been considered insufficient for a crisis of this level, the doctor said.

Additionally, patient treatment was provided at all levels of healthcare without a clear division according to the stages of the disease, directly affecting the effectiveness of treatment and clinical outcomes. This uniform approach, without differentiation of cases according to their severity, was assessed as one of the factors that influenced the progress and survival of patients during the crisis period.

Expert Koduzi said that information is fragmented and not always accessible in real time for decision-making. In a pandemic, this limits the ability to track the spread and take rapid measures.

Furthermore, the lack of predictive analytics makes the system more reactive than proactive. In a health crisis, data and protocols are the basis of every decision, and any gaps in this regard translate into delayed and less effective response.

What should we prepare?

Doctors said that according to the analysis, during the pandemic, many Albanian families faced high costs for home treatment, spending on private tests and expensive medicines. This situation has contributed to their impoverishment and the overloading of hospitals.

Doctor Malaj proposes the creation of an "Emergency Pharmaceutical Package" with immediate reimbursement of drugs, stricter protocols to avoid abuse of medical prescriptions, and the provision of free basic tests in public laboratories.

Expert Koduzi recommends strengthening regional health poles in Shkodër, Fier, Vlorë, Elbasan and Korçë, with full intensive care capacities and specialized wards. He also suggests developing telemedicine for real-time consultations between regional hospitals and specialists in Tirana.

He said that the Covid-19 pandemic has shown the lack of a national stock of medical supplies, making Albania dependent on imports and donations. He said that special biosecurity warehouses with protective equipment, medicines and testing kits should be created, as well as a stock rotation system to avoid expirations.

Experts claim that preparing for future pandemics cannot be done during a crisis, but through long-term reforms in peacetime, requiring political will and a deep overhaul of the healthcare system.

The Covid-19 pandemic, in addition to being a global health crisis, was a real stress test for every public system. In Albania, the pandemic exposed old gaps, but also built new mechanisms that forever changed the way emergencies are managed.

One of the strongest lessons of the pandemic is related to hospital infrastructure. Before 2020, Albania had only about 4–5 intensive care beds per 100,000 inhabitants, among the lowest in Europe. This limitation became the most dangerous point of the system during the first waves of the virus.

Through investments in Covid hospitals and the regional network, the number of intensive care beds was expanded by over 300%, creating a reserve that did not previously exist.

From about 60–70 functional ventilators at the beginning of the crisis, the country reached hundreds within two years, distributed across regional hospitals. For the first time, cities outside Tirana became an active part of the treatment of critical cases.

Hospitals that previously relied on mobile cylinders were equipped with central lines and liquid oxygen plants in over 15 public institutions. This reduced logistical dependency and increased safety in the treatment of critically ill patients.

Tracking systems were also renovated and improved, and now today's generation of doctors has a strong experience in responding to a similar case.

/ Monitor