Kosovo - on the gateway to Europe

Kosovo came to the world's attention during the Balkan War in the 1990's. More than a decade has passed since TV monitors worldwide showed villages in flames and a population in the midst of a deep ethnic conflict.

Dr. Luan Gola watches while podiatrist Ms Vjolca Kola treats a patient's foot at the podiatry centre in Gjakova. The patient, aged 84, has suffered from diabetes the last 20 years with chronic complications (photo: Karoline Kragelund Nielsen).

Kosovo has declared its independence even as the international community remains divided on the issue of international recognition of the new country. With a population of close to 2 million people and an economy at the very bottom of the list of the developing nations, Kosovo is a very poor country at the gateway to Europe. In fact, Kosovo's GDP per capita is 2,500 USD (1), similar to the levels of Pakistan and Yemen. With 44% of the population living in poverty and 14% in extreme poverty, the country remains heavily dependent on foreign assistance and remittances from compatriots living abroad.

First in Europe

Amidst all this, life continues with dreams and ambitions. In 2008, Dr. Luan Gola took the initiative to start a diabetes project in his home town, Gjakova, Kosovo's second largest city. "I had stayed in Gjakova all through the war, and I was very motivated to change the state in health care for people with diabetes. I was part of a small group of health professionals who had managed to present a national diabetes plan to the Ministry of Health back in 2005. For several years, however, no activities took place due to the lack of financial support. Because we knew the Foundation was a leading organisation in improving diabetes care in developing settings, we prepared a project application hoping to be able to begin activities to change the situation in our own country," says Dr Gola.

The application resulted in the project named "Improvement of health care for patients with diabetes" which is the first project funded by the Foundation in Europe and the only one in Kosovo to date. The project is rooted with the Diabetes Association of Gjakova; it was initiated in November 2008 and will run until May this year.

Care to 5,000 people

More than two years into the project, important improvements in access to and quality of diabetes care have been made. As a first step, a multi-disciplinary working group developed national protocols for treatment based on existing guidelines - adjusted to a Kosovar context. The protocols were developed in English and Albanian and have been disseminated to health facilities and used as the basis for developing diabetes training modules.

Secondly, the project team has established centres of diabetes education, information and treatment at main, public, family medicine centres in four regions of Kosovo (Gjilan, Peja, Ferizaj and Prizren). Similar centres have been established at tertiary level health facilities in Gjakova and Pristina. The centres offer new laboratory standards, such as testing for HbA1C and microalbuminuria, which are being applied for the first time in the health system in Kosovo. So far, the six centres have provided care to more than 5,000 people with diabetes.

Sustainability and social impact

According to Dr. Gola, the sustainability of the centres after the project ends has been ensured through a memorandum of understanding with the municipalities where the centres were established. Another indicator for sustainability is the social roots which have been planted with the foundation of five diabetes patient associations. They do lobby work and educational activities such as celebrations during World Diabetes Day. Last year, more than 2,000 people in six regions of Kosovo participated in these activities. In a near future, these associations are expected to create the basis for an organisation at the national level which will be of great importance in terms of improving the diabetes health care.

Ensuring the diabetic foot component

Improving diabetes foot care is also part of the project objectives. Given the general lack of diabetes care, many patients have had a very poorly controlled course of disease with complications such as diabetic foot as a consequence. Widespread poverty and poor quality housing does not alleviate the situation which is well exemplified by a 65-year old patient at the diabetes centre in Gjakova. Before being referred to the diabetes centre, he had seen several doctors who were not trained in diabetes and they had given him inept advice on treatment. In the end, he was affected by neuropathy and came to the diabetes centre with a burn from a hot water container he used to keep warm in the cold winter nights. The wound would not heal, but at the centre in Gjakova he was able to get treatment for his wound at the podiatry centre established as part of the project to ensure integrated diabetes care.

Kosovo-Eindhoven round trip

The podiatry centre in Gjakova is run by the only trained podiatrist in Kosovo, Ms. Vjollca Kola. Her story is a curious one involving a number of coincidences which turned out to benefit the current project and the health care system in Kosovo today. In the early 1990s Ms. Kola left Kosovo and travelled to the Netherlands where she and her husband had relatives. At that time she was a trained nurse. In the Netherlands she initially began working as a housekeeper for Margreet van Putten, who was a teacher at the School of Podiatry at Fonty's University in Eindhoven. The two ladies became friends and Ms. Kola subsequently enrolled at the school and trained to become a podiatrist.

After working in the Dutch health care system for a number of years Ms Kola and her family decided to return to Kosovo five years ago. In Kosovo, she teamed up with Dr Gola and the Diabetes Association of Gjakova to implement this project. Due to this history and the personal connection the podiatry centre in Gjakova now has a close collaboration with Fonty's University and materials for diabetes foot care are shipped to the centre from there. However, one podiatrist alone is not enough for the project, and as a consequence, 12 doctors and 30 nurses have been trained on diabetes foot prevention and education. More training is planned on actual wound care. In addition to the podiatry centre in Gjakova the project has opened another centre in Prizren.

The need is beyond discussion

Programme Coordinator at the World Diabetes Foundation, Ms. Karoline Kragelund Nielsen visited the project in Kosovo in January. Her assessment was swift and clear: "The need for prevention and advocacy in Kosovo is definitely present. Although data on risk factors are sparse, there are indications that they are prevalent and on the rise: tobacco smoking is widespread and fast food is becoming increasingly available. When this is coupled with the facts that the population of Kosovo has been exposed to tremendously stressful events before, during and after the conflict and many are living in poverty the justification for comprehensive health promotion is really beyond discussion," she says.

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