Medical Education in Kosova

Abstract

Background: Kosova, the poorest country in Europe, is an example of the challenges posed by higher education in the developing world. The last 10 years have represented a period of significant reform within both the health care and education systems in Kosova.

Aim: This article provides an overview of all levels of the higher medical education in Kosova, with particular emphasis on main issues and challenges.

Methods: This is a descriptive cross-sectional study. Data were collected through review of medical curriculum, student selection, licensure, continuing medical education (CME) and interviews with stakeholders in Medical School and Ministry of Health.

Results: Medical education in Kosova is categorised in three levels: undergraduate, postgraduate and CME. Kosova has a short tradition of medical education and has had a turbulent history in higher education during the last two decades. Starting in the academic year 2001/2002, the University of Prishtina adopted the Bologna system, although officially Kosova is not yet a member of Bologna Process.

Conclusion: Quality assurance and quality control measures are considered core elements in future modernisation of medical education in Kosova. Bologna Declaration provides an opportunity for improvement of current weaknesses in medical education system.

Introduction

Kosova is located in South East Europe with an estimated population of 2.1 million inhabitants and a land area of 10,908 km². With the youngest population in Europe (mean age of 26.5 years) and an unemployment rate of more than 50%, many challenges lie ahead for the future of Kosova. The estimated gross domestic product (GDP) per capita is 964 euro, with the average monthly salary being lowest in education (174€) and health care (167€). The World Bank poverty assessment report (World Bank 2007) indicates that 45% of Kosova's population lives below the poverty line, with another 15% living in extreme poverty. Life expectancy at birth is the lowest in the region, with 69 years of expected life. Albanians are the predominant ethnic group, constituting 92% of the population. Kosova has experienced a turbulent history in the last two decades and continues to face challenges common to all transitional and fragile states.

On 17 February 2008 the Kosovo Assembly declared independence from Serbia, which has been subsequently recognised by 71 United Nations member states.

Education and health care in Kosova has undergone some important reforms in the last decade, after lots of difficulties and obstacles. Like in many other European countries, medical education in Kosova is structured into three stages: (a) undergraduate medical education; (b) postgraduate education; and (c) CME and continuing professional development (CPD). The aim of this article is to provide an overview of the higher medical education in Kosova, as well as outline the difficulties and challenges ahead.

Table

Practice points

With the youngest population in Europe and highest unemployment rate many challenges lie ahead of Kosovo medical education system. Kosova has a short tradition of medical education (since 1969) with turbulent history during the last two decades. In medical education weaknesses are predominant at the undergraduate level. Kosova adopted Bologna system since 2001, although has not yet signed the Bologna Declaration. Postgraduate and continuing professional developmet have made important reforms and steps towards modernization. Research resources remain very low compared to disease burden in Kosova.

Short history of Kosova medical education

The University of Prishtina was founded in 1970 and is the main public university in Kosova, with its language of tuition being Albanian. There is also the University of Mitrovica, where the language of tuition is Serbian. In the academic year 2009/10, the University of Prishtina had 17 Faculties with 38,291 students and 1065 academic staff.

Table 1.  Data of medical education in Kosova

Kosova population	2.1 million
Public university medical schools	1
Total number of medical students	2659
Number of graduated students in all departments from 1969–2009	5915
Total first year students enrolment	320
Full professors	32
Associated professors	24
Assistant Professors	49
Teaching assistants	114
Hospital beds for undergraduate medical training	2100
Number of active general practitioners	845
Number of active medical specialist	2048
On residency	560

From a historical perspective, the Prishtina University has had similar experiences with other higher educational institutes within the Western Balkan area, and countries of the former Yugoslavia. Nevertheless, in the last few decades the University has also had some very unique experiences. During the 1990s, and as a result of the abolition of Kosova's autonomy, the Albanians in Kosova experienced 10 years of segregation under a Serbian Government; this had disastrous effects on education. In order to keep the spirit of education alive, the Albanian education system was forced to develop a 'parallel educational system', under very difficult circumstances, whilst for at least 10 years, having its higher education institutes excluded from any international cooperation and link programmes.

The isolation of Kosova, together with the stagnation of all fields of cultural life, had tremendous effects on education. At the end of the war in Kosova (1999) the education system underwent important changes and reforms that presented new challenges for both academic staff and students (Pupovci et al. 2001). These reforms largely resulted from the presence and support of Governmental and Non-Governmental Organisations (NGOs) from around the world. The University of Prishtina operated through an interim statute drafted by international educational experts, which were part of the United Nations Mission in Kosova (UNMIK). The World University Service (WUS) from Austria was the main player in supporting the academic staff and students at the University of Prishtina during the first years after the war (Leutloff & Pichl 1999). Other important contributors were the European Council, the Organisation for Security and Cooperation in Europe and the SOROS Foundation. In many ways, the reforms (in teaching, curriculum, learning strategies and assessment) that have occurred in Kosovan education differ from what has occurred in other countries, since they were planned and run mainly by the international community instead of local experts, who had a relatively small input in the changes. Sommers & Buckland (2004) however, revealed that gaps existed in the communication channels between UNMIK and University professors in the implementation of the reforms. Reforms started from a zero point, because UNMIK wanted to put in place a brand new educational system: this approach created a tension between locals and internationals. The University professors remained as outsiders in the process of reforms despite the fact that they had contributed and sacrificed a lot in keeping the higher education ‘alive’ for previous decades.

Starting in the academic year 2001/2002, the University of Prishtina adopted the Bologna (3-5-8) system, based on three study cycles, which includes 3 years Bachelor, 2 years Master and 3 years PhD studies (Beqiri 2003). All courses are now being credited with the European Credit Transfer and Accumulation system (ECTS). The adoption of the Bologna Declaration was the first step taken by the University of Prishtina to integrate Kosovan higher education with the education systems of other European countries. It was realised, however, that this may be a long process reflecting the fact that Kosova is the poorest country in Europe. Poverty and limited resources affects the motivation and development of faculty, the infrastructure, access to library facilities, accommodation etc. The Republic of Kosovo is not an official member of the European Cultural Convention of the Council of Europe. Therefore, Kosovo is not a recognised member of the Bologna Process for the time being. The Kosovo Assembly however has now passed the Law on Higher Education, which was among the first law on higher education in Europe based on the Bologna Declaration.

Human resources are the greatest capital and saleable asset of Kosova, with many young people who have graduated from Western European and American universities; however, their potential has been poorly supported and exploited by the stakeholders from the Government and the University in the last decade. This has created a serious medical migration problem, resulting in the loss of very educated personnel needed for the development of the country.

Undergraduate medical education in Kosova

Medical education began with the establishment of the Faculty of Medicine in 1969 in the capital city, Prishtina, within the University of Prishtina. Today, the Faculty consists of five departments: General Medicine, Pharmacy, Dentistry, Physiotherapy and Nursery with Midwifery. Currently the Faculty has 322 academic staff and 2869 students. The number of General Practitioners (generalists) per 1000 inhabitants in Kosova is 0.94, with the number related to nursing being 2.61 and dentists 0.06.

Admission to undergraduate level requires success at the National admission examination, (related to the basic sciences of biology and chemistry, and set by the Government) and at a University admissions examination. Medicine usually attracts the best candidates from secondary school, although in recent years the popularity of medicine and nursing as a career has shown a decline. The admission numbers are fixed and set by the Government (Ministry of Education, Science and Technology). They are based on financial calculations, without any input from either the University or the Ministry of Health; nor are they based upon the market needs. Each year approximately 1500 prospective students apply to the Medical Faculty. After the entry examination, 320–400, depending on targets set by the Ministry of Education Science and Technology (MEST), enter in the undergraduate education. Higher medical education is financed by the Government and students pay only a token fee (150 euro per year) towards their study. However, it is expected that students should self-finance their living expenses, books and other learning material.

Medical undergraduate studies take 6 years to complete in General Medicine and Dentistry, 5 years in Pharmacy and 3 years in Physiotherapy and Nursery. The academic year starts on 1st October and ends on the 30th September of the following year, divided into winter and spring semesters. Learning time within each semester lasts a total of 15 weeks. The Faculty of Medicine's 6-year curriculum usually consists of 3 years of basic science, 2 years of clinical sciences and one year internship.

Clinical practice takes part in the clinical and preclinical Departments of the University Clinical Centre of Kosova (UCCK-the only tertiary care centre in Kosova), the National Institute of Public Health of Kosova (NIPHK) and also at the centres of Family Medicine from within the community.

The Faculty of Medicine has started to implement an integrated approach to its courses in the first 2 years of the curriculum. Although the University is free to design its own medical curriculum, select students and appoint teachers using their own criteria, the new curriculum, designed for academic year 2007/2008, has been modelled on recommendations from international experts and based on global standards for quality improvement in higher medical education.

With the new reforms, the courses in medicine are granted credits (ECTSC) with a total of 360 ECTS needed to obtain a Medical Doctoral (MD) degree. The majority of the undergraduate curriculum is compulsory for the students (80%) but the other 20% of the medical course is given over to elective subjects. The ratio between clinical courses and preclinical courses is 52:48, and is similar to the countries in the immediate Region (Šimunovic et al. 2004). At the end of undergraduate studies there is overall final written (not clinical) examination, with a failure rate of 10%. Traditional didactic teaching methods are dominant in Kosova, although there have been some initiatives to implement newer methods such as problem-based learning, skills-based teaching and a performance-based assessment.

Medical Schools are similar to other institutions of higher education in Kosova in that they require accreditation by the Kosova Agency of Accreditation, established by the Ministry of Education, Science and Technology (http://www.masht-gov.net/advCms/#id=1265). The accreditation process focuses on the following criteria: a mission statement, academic freedom (institution of higher education must be autonomous and ensure freedom in research and teaching), the academic programmes, student management, research, evidence of international cooperation, staff, organisation, planning and quality management.

An important input in improvement of quality in undergraduate higher education was created by the new found mobility of staff and students. Academic mobility and international cooperation is one of main priorities of the University of Prishtina and is focused on intensive participation in programs such as: Tempus, Erasmus Mundus, Erasmus, Socrates, Leonardo da Vinci, regional initiatives of South Eastern Europe and other collaborative projects, in which so far about 820 faculty and about 1500 students have been enrolled. The Prishtina University has so far signed 80 agreements with European and US Universities. The University of Prishtina is part of The Thematic Network on Medical Education in Europe through the MEDINE project (Cumming & Ross 2004).

Postgraduate medical education in Kosova

Kosova has a total number of 2.048 medical specialists, of which 557 belongs to tertiary health care at the UCCK, 552 work at the secondary health care institutions, within 6 regional hospitals and 975 in primary health care. Currently, over 560 physicians are in their residency programmes in different medical fields. For the year 2010, the Ministry has approved 225 new places for residency programmes in health care. Also, during this year, the Ministry has initiated sub-specialist training programmes that trainees can apply for. Bacteriology, parasitology, virology, mycology and infection control are such examples of sub-specialisation from the area of Medical Microbiology.

A Specialty Board, with specialty sub-committees within the Ministry of Health, is responsible for the residency programme. The Ministry mandated a 2-year orientation period in primary care after graduation as a precondition for future specialisation. After that, the designated generalists, known as General Practitioners, can apply for residency positions advertised by the Central Board for the training of Medical Specialists. A written test is used to rank General Practitioners for the purpose of selection to specialisation training. Residents are paid 249 euros per month by the Ministry of Health. Residencies in specialties other than Family Medicine last 4–5 years, depending on the specialty. Professional Medical Associations, the University Council of the Faculty of Medicine, UCCK, NIPHK nor any other scientific society had any input at all into postgraduate medical education until this year, when they now have input into the selection of candidates.

Training places for residents are fixed and allocated in the UCCK, NIPHK and the Centre for Development of Family Medicine. Trainees have to rotate between hospital departments depending on their specialty. Training is organised around clinical experience combined with teaching sessions. Daily case discussions, department meetings, publications and presentations in regional, national and international conferences are all part of the training. Trainees interested in research are enrolled into research projects. At the end of training all trainees have to sit for the specialty examination, which is conducted by the specific University Departments, and takes the form of both a practical and oral (or written) assessment.

The Ministry of Health has launched a postgraduate specialisation programme in Family Medicine, which is administered by the Centre for Development of Family Medicine- affiliated to the Royal College of General Practitioners, UK. This program lasts 3 years and has 11 very specific modules (Hedley 2005).

CME and CPD

It is accepted that all Doctors should continue to learn and update knowledge and skills throughout their lives: the need for CME in Kosova was officially recognised and established in 2002 through the CME Board, also managed by the Ministry of Health to support, evaluate and accredit scientific meetings, education and publications. In Kosova CME is compulsory for all doctors, dentists, pharmacists as well as for nurses. This area also underwent important reforms after the war (Buwa 2007). If the doctors fail to attend CME/CPD activities, their working licenses, which are reviewed every 5 years, are not extended by the Ministry of Health

During the year 2006, competencies for continuing education were transferred to the CPD Board. The Board has developed an indicative credit point system for health care professionals, in which 1 hour of educational activity equates to one credit. Doctors and pharmacists should acquire at least 100 credit points in every 5-year period. Educational activities are mainly courses, seminars, meetings, conferences and publication and the Licensing Board controls the content of these events.

CME is usually organised and delivered by the same institutions that offer postgraduate education. All University Departments organise scientific conferences, courses and meetings on a regular basis.

Teleconferencing is regularly used in CPD. The Telemedicine Centre of Kosova (TCK) is a state-of-the-art telemedicine centre, among the best in south-eastern Europe. This Centre is now providing a basic foundation for educational medical programmes in Kosova, and helping to create human capacity that will lead and implement telemedicine programmes in nine regional telemedicine centres.

Research and academic education in Kosova

Research resources for addressing health problems of Kosova remain disproportionately low compared with the tremendous disease burden. Ten years after the war, Kosovo has not set up a fully fledged scientific research system yet. The national economy remains too weak to support research and development, as it is not able to absorb the products of research and benefit from them. Research activities in medicine remain sporadic and marginal, based mainly on individual initiatives in the university sector and with almost no support from the Government, which remains focused on the teaching component of higher education. Public expenditures for research and innovation in Kosova remain at the low level of 0.1% of the GDP, indicating minimum conditions for any scientific and research work. This funding is mostly used to cover operational costs of the existing research institutions (Raka & Pupovci 2009).

The Faculty of Medicine started to implement PhD studies for about 60 doctors in 2009. From the years 1992–2009 a total of 127 PhD theses were defended at the Faculty. From previous theses defended during the last 8 years, the publication output has not been satisfactory, with only 8.1% of PhD theses resulting in articles published in journals indexed in PubMed, indicating a poor renewal capability of the health research community. Publications in peer-reviewed journals are considered essential requirements for appointments in higher education and health system. They are important drivers for professional development of doctors and career progression.

Training in Medical Education is presently recognised as a subspecialty within the Public Health and Social Medicine at the Ministry of Health.

Issues and challenges

Higher education in Kosova is facing many challenges at all three levels of medical education, with quality improvement as a cornerstone for the future (Tahirsylaj 2008). Ten years of isolation harmed the educational system in Kosova and higher education had to struggle for survival, often existing within private houses in a very isolated fashion, and not capable of change. The reform process is now underway, but it will take a long time to deliver skilful and competitive students for the global market.

Currently, the University of Prishtina is far from being able to compete with universities in developed countries. It still concentrates primarily on academic learning with teacher-centred methods and full-time compulsory courses. Lack of funds has resulted in a poorly developed research infrastructure, lack of space and equipment. From the 42 Departments within the Faculty, only 15 of them hold at least one post of an ordinary/regular Professor (according to the Statute of the University of Prishtina, to become a Professor the applicant must fulfil the following qualifications: hold a Doctorate or equivalent; demonstrate a high level of academic competence and scientific experience in the subject, have established proof of high educational and pedagogic skills through reasonable practice; show convincing evidence of academic leadership and proven mentorship for postgraduate and doctoral studies).

For 10 years after the war, the development plan of the faculty was not in place. As a result there were no clear directions regarding the faculty, the infrastructure and future research. This year (2010) has brought only conditional accreditation status by the Kosova Agency of Accreditation. The number of international students in the Faculty is lower today than 30 years ago, whilst its financial system is centralised and controlled within the Rectorate and there are many debates about academic freedom at all levels of higher education.

During the last 3 years the number of unemployed General Practitioners in Kosova has increased. Low salaries, demands to work in urban areas and lack of opportunities to make a successful career in private practice has decreased the interest of students and candidates to study general medicine. There is also an increased tendency for doctors to work mainly in the capital city Prishtina at the tertiary care facilities, rather than in the regional and rural areas, where care is needed, and which remain without good health care coverage.

In the field of postgraduate training, the coordination between the Ministry of Health, representing the health care system, and the Ministry of Education, representing the medical education system, is not satisfactory and needs to be improved in the future. Sub-specialisation is still at an infancy level and there are still many problems with legislation dealing with the private health care sector.

An increasing number of specialists, with experience in clinical practice and education are leaving the University because they do not have opportunities to finish their PhD studies. They are replaced by young academic staff with little or no experience in real clinical settings. The present situation is also creating a significant medical migration of doctors from Kosova to other western European countries that offer more opportunities for postgraduate training and employment.

Research is still considered a luxury by stakeholders. So far, research activities are not supported by any research grant from Government, University or industry. Only this year has the Government approved the national program for science, in which health research is among the top five of the country's priorities.

Conclusion

Medical education in Kosova compared to other European countries has a short and turbulent history. A strong commitment of all players in our society involved in higher education is needed to achieve the goal of attaining European and North American standards. The Bologna Declaration provides many opportunities for improving current weaknesses in the Kosova medical education system and to implement the reforms through collaboration, and communication with universities in higher education, from within Europe, North America and the rest of the world; it is now time to convert the opportunities into effective action.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.