The following article was originally published by the Serbo-Croatian online platform, Bilten. It is republished here with that site’s kind permission.
During the electoral campaign of 2013, the Socialist Party of Albania, then in opposition, made a stunning promise for a Third-Way party. Its chairman Edi Rama stressed that once in power the Socialists would implement universal public health care coverage, modeled after the British NHS. No more health care insurances, which left the unemployed or illegal workers without care, but a state-sponsored central agency, which was going to cover free health care for everybody. A neoliberal ideological uproar countered that proposal, but more intelligent commentators were skeptical as to whether the promise was ever intended to be realized, or was simply conceived as a propaganda tool during the campaign.
Once in power, the Socialist government has been held publicly accountable several times for not following up on its promise of universal health care reform. For a while, the government justified itself by responding that the promise was never meant to be implemented immediately. Nonetheless in 2015, it showed what it had really meant by the health care reform, and what its understanding of universal health care coverage was.
Firstly, it didn’t touch the actual insurance system, which left those without health care insurance without coverage. In a peripheral country like Albania, where predatory capitalism has pushed many workers to the informal sector – without working contracts and insurance payments – this means that a lot of people are practically without any health care coverage.
Secondly, instead of universal coverage provided by public institutions, the government has begun creating public-private-partnerships (PPPs) that are supposed to offer universal coverage of some basic health care services. The range of these services is never meant to extend to anything resembling comprehensive health care. In this spirit, the government established a public-private partnership in what is called a general free health check-up for people between 40 and 65 years old. Another PPP is currently providing free hemodialysis procedure to several hundred patients. As part of these PPPs, private firms are contracted to implement the infrastructure inside public hospitals or open health care centers.
The government has tried to legitimate the PPPs by stressing budgetary constraints for the state to buy the necessary medical apparatuses (actually only 3% of the GDP is invested in health care in Albania), the supposed smaller costs and efficiency of PPP, and the larger geographic coverage of the population that the PPP would provide.
In order to understand the relative ease with which the government is overcoming the meek public resistance to the PPP, one has to take into consideration the evolution of the health care system in Albania in the last quarter of a century.
Until 1991, the bureaucratic socialist system had built an enormous health care system, which penetrated even the remotest rural areas in Albania. The mortality rate was decreased substantially and the general health care of the population was improved significantly compared not only to the pre-socialist era, but also to some developed countries. Naturally, there has always been a lack of highly modern medical equipment, which the socialist state couldn’t afford, but on the other hand medical professionalism had improved a lot and the Hippocratic ethics of the medical personnel was rather high.
After 1991, due to the general withdrawal of the state from the economy and the provision of public services, the health care system entered in a multidimensional crisis. Lack of investments, partial infrastructural degradation and the new ethics of institutional personalization had led to the feudalization of public hospitals. The state provided nominally free or affordable health care for all, but practically every patient had to pay covertly the doctor or the nurse for any kind of medical treatment. Hospital administrators held medicaments from the patients and ushered them to buy even the basic pills in the nearby private drugstores. Stories about people left without medical treatment, even to die, if they didn’t pay the doctors beforehand were widespread and revolting.
As a result, one by one, due to the public hospitals’ deterioration and corruption, numerous private hospitals began to thrive. Some of them, in corrupted deals with the central government, even managed to rent or buy public facilities for symbolic sums of money. The patient was basically faced between two forms of payments for health care: either pay illegally the doctors in public hospitals, or pay something more legally in private hospitals. Basically a choice between a feudal and capitalist forms of accumulation by dispossession.
In order to prepare the ground for the PPP, the government started an anti-corruption campaign against the medical staff, which immediately gained public support. That campaign didn’t last long, but it made it possible to push through the PPP. People were supposed to pay the same rate, or even get free health care in some basic aspects, using the more modern medical infrastructure of private hospitals.
However, the real picture began to take form after a while. According to independent journalistic investigations, the three major PPPs in health care (the general check up, the hemodialysis procedure and the sterilization of medical equipments), for which the government has pledged to pay more than 300 million USD to private firms and hospitals, have been granted to ghost companies, without prior experience in the health sector, with direct or indirect connections to high governmental officials. The current Minister of Health Care, Ilir Beqaj, is currently being investigated by the Attorney General’s office.
On the other hand, public discontent about the patient’s treatment in the private hospitals that have been contracted in PPPs with the government, is growing. Many patients who undergo treatment in these hospitals complain about the lack of care, not being provided sufficiently with food or sleeping materials etc. In July, a tragic incident occurred in one of the largest private hospitals – The American Hospital – where one patient set another on fire and three people died. Report TV, the television station which made the news public, reported that administration of The American Hospital put pressure on journalists not to mention the name of the hospital in the reporting. Otherwise, the hospital threatened, they wouldn’t buy commercial time from them. Other media outlets have remained silent about the incident or have under-reported it.
Nevertheless the government hasn’t shown signs of retreat. Prime Minister Rama strongly advocates PPPs as a successful model, and pledges to extend their application in every sector of the public services. Meanwhile, governmental officials have announced that a new financial and management scheme is being concocted for the public hospitals. Taking as a model the neoliberal reform in higher education, where private universities are made eligible to compete with public universities for state funds, the government is thinking of extending this logic to health care institutions. So either private hospitals will be eligible to compete for state funds or health insurances could be used to pay for services one gets in private hospitals.
Unfortunately, the public resistance that met the neoliberal reforms of higher education have not yet been matched with regard to the same reforms in the health care system. This is largely because of the highly corrupted and feudal status quo of today’s public hospitals, which few will go out on the streets to defend.
Arlind Qori works as a lecturer of political philosophy in the University of Tirana, Albania. He is also an activist at the radical leftist organisation Organizata Politike