WESTERN BALKANS REGULAR ECONOMIC REPORT No.17 | Spring 2020 The Economic and Social Impact of COVID-19 HEALTH SYSTEMS “You and me” by Tanja Burzanovic (Montenegro) The RER No. 17 is a collection of notes on the Economic and Social Impact of COVID-19 that will be pub- lished in three parts. The first part was launched on April 29 and focused on the macroeconomic impact of COVID-19. This second part shows how the macroeconomic impact affects the people in the region. It discusses the social impact of COVID-19 in the Western Balkans in six separate RER notes on poverty and welfare, labor, health, education, air pollution, and social protection. The third part, to be launched in early June, will focus on specific economic policy response areas—fiscal, external, and financial sector—and the crisis impact on the private sector as reported by firms. THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 COVID-19’s Impact on Health Systems in the Western Balkans • Prior to the outbreak of COVID-19, health systems in the Western Balkans faced critical financing and service delivery challenges. Per capita spending on health systems is considerably lower than the EU average, and the way in which scarce funds are spent is not efficient or aligned with the region’s disease profile. This makes the region vulnerable to future public health outbreaks, particularly given that patients with non-communicable diseases are more vulnerable. • Going forward, Western Balkan governments will need to invest in critical pandemic preparedness gaps, which have been identified through international evaluations. They will also need to support healthcare workers with equipment and training for the treatment of infectious patients, as well as protect and strengthen supply chains for essential medicines, equipment and supplies. • Western Balkan governments will also need to secure funding for health systems to build resilience for future outbreaks. This will include managing multiple threats: the immediate pressure to cut funds for health due to the economic downturn; the contraction in hospital revenues from the deferral of elective care, which will challenge their financial sustainability; and, the contraction in financing sources for health arising from higher unemployment and lower remittances. It is critical that governments act promptly and decisively to safeguard revenues for health systems, given that future outbreaks are expected. • As they make investments in health systems it will be important for Western Balkan governments to identify opportunities to improve the quality of care and the efficiency and effectiveness of service delivery. Adaptive models, which draw on telemedicine and strengthen primary care, may hit a sweet spot of enabling health systems to remain resilient in response to COVID-19 while also bringing about longer-term benefits for health systems and the patients they support. Introduction international norms, and risk environment; in these areas the region performed well. The COVID-19 outbreak will exacerbate This has been seen in the ‘hammer’2 phase; long-standing challenges facing health system in the Western Balkans. Coronavirus 2 https://medium.com/@tomaspueyo/coronavirus-the-hammer- mortality and morbidity rates exist within the and-the-dance-be9337092b56. The ‘hammer and the dance’ concept refers to strategy to suppress COVID-19 outbreaks. In context of a healthcare system and a population. the ‘hammer’ phase governments act quickly and aggressively; they introduce lockdown measures and social distancing to bring At first glance, as reflected in international the outbreak under control so that the health system can manage rankings for pandemic preparedness, the severe cases. Given the value of time, this aggressive approach helps to curtail COVID-19 outbreaks. When this works, infection and Western Balkans fares well. The Global Health death rates fall quickly, and in theory the government is then in a better position to address the pandemic. The ‘dance’ phase is Security Index (GHSI) considers prevention, a longer-term effort to keep the virus contained until there is a detection, rapid response, compliance with vaccine, efficacious treatment, or achievement of herd immunity. Social distancing and lockdown measures can be looser in this phase, but overall, it is still necessary to: keep the reproduction 1 This note has been prepared by Naomi Rupasinghe, Federica Secci, number below one; continue to ban large gatherings; maintain the Predrag Djukic, Owen Smith, Ian Forde, Mrike Aliu and Jamele social distancing measures that have the highest cost-benefit ratio; Rigolini. It benefited from the comments of Tania Dmytraczenko, stay flexible to tighten up measures as needed; continue to educate Hope Volker, Edith Kikoni, Marc Schiffbauer, Jasmin Chakeri, the public on hygiene and social distancing; and, conduct contract Enrique Blanco Armas and Gallina Vincelette. tracing, quarantines, and isolation. Health Systems  |  1 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 COVID-19’S IMPACT ON HEALTH SYSTEMS IN THE WESTERN BALKANS governments have quickly and aggressively spending on health in the Western Balkans; implemented public health measures and throughout the region, it is considerably lower lockdowns. However, the GHSI also noted than the European Union (EU) average of that health system capacity was limited—this $3,127.3 Across the region, the lack of funds was the area with the lowest scores. This finding for health systems is often borne by private reflects long-standing structural weaknesses in households, whose out-of-pocket (OOP) financing, service delivery, governance, and expenditure is high. For example, across the workforce management, making health systems region it ranges from 37 percent in Serbia in the region vulnerable to adverse events. and Montenegro to 50 percent in Albania, compared with 14.9 percent in the EU4. These As governments in the region now move financing challenges are also exacerbated by toward the ‘dance’ phase, managing and inefficient service delivery models, which supporting health systems is critical. Given heavily weight cases towards hospital provision, the GHSI findings on health system capacity, which is expensive and not well aligned with it is even more important that attention is a high non-communicable disease profile. paid to building up their capacity. With smart This not only leads to arrears and debt policy actions and investments in five crucial accumulation, but also means there is under- areas (stopping future transmission, managing investment in primary healthcare, prevention budgets, protecting vulnerable patients, and public health, which make health systems ensuring service delivery, and recovery to a new more vulnerable to pandemics and which offer normal), health systems can emerge from the efficient ways of securing health and well-being 2019-20 outbreak stronger, and better able to in normal circumstances. protect the health and well-being of citizens. This report first considers the extent to which Workforce migration and shortages also health systems were prepared for COVID-19 make health systems vulnerable during a and the immediate impact of the disease. It pandemic.5 For several decades health worker then explores options for governments and emigration has been a creeping challenge.6 health system leaders to consider as they seek On average, each year, the Serbian Medical to manage the outbreak until a vaccine or Chamber issues over 700 certificates that allow efficacious treatment options are available. Serbian doctors to work overseas. In 2016, Bosnia and Herzegovina’s (BiH) National Medical Workers Association reported that Preparedness Western Balkan health systems were 3 https://gateway.euro.who.int/en/indicators/hfa_571-6722- public-expenditure-on-health-ppp-per-capita-who-estimates/ already facing serious challenges before the visualizations/#id=19666&tab=table EU refers to the EU15 COVID-19 outbreak. members before 2004. 4 https://gateway.euro.who.int/en/indicators/hfa_584-6860- Securing enough funding for health and private-households-out-of-pocket-payments-on-health-as-of-total- health-expenditure/visualizations/#id=19679&tab=table EU refers modernizing service delivery to deliver care to the EU15 members before 2004. 5 Two case studies, led by the World Bank, on health workforce efficiently and effectively have been long- migration and how it affects the healthcare system in Serbia and standing challenges throughout the region. North Macedonia are forthcoming. 6 https://balkaninsight.com/2020/01/13/time-for-policy-change- Table 1 outlines national per capita public on-western-balkans-emigration/ 2  |  Health Systems THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 Table 1. Key health sector indicators and COVID-19 cases and deaths Albania Bosnia and Kosovo* Montenegro North Macedonia Serbia Herzegovina Per capita public spending 307 681 - 508 539 812 on health ($, 2014)a Out-of-pocket expenditure** 50 28 - 43 37 37 (percent, 2014) Confirmed 949 2,321 985 325 1,839 10,733 Cases*** Deaths*** 31 134 29 9 106 234 Percent population 13.75 (2018) 16.47 (2018) 6.77 (2015) 14.97 (2018) 13.63 (2018) 18.68 (2019) over 65 Global Health Rank: 39/195 Rank: 79/195 Rank: - Rank: 68/195 Rank: 90/195 Rank: 41/195 Security Indexb Country Score: 52.9 Country Score: 42.8 Country Score: - Country Score: 43.7 Country Score: 39.1 Country Score: 52.3 Prevent: 43.8 Prevent: 36.7 Prevent: - Prevent: 37.6 Prevent: 37.0 Prevent 48.8 Detect: 74.3 Detect: 41.7 Detect: - Detect: 77.3 Detect: 41.7 Detect 46.2 Respond: 52.0 Respond: 51.8 Respond: - Respond: 37.8 Respond 33.1 Respond 55.1 Health system: 35.9 Health System: 38.3 Health System: - Health System: 30.8 Health systems: 25.4 Health systems: 56.5 Norms: 53.0 Norms: 37.8 Norms: - Norms: 52.6 Norms: 44.8 Norms: 49.7 Risk: 55.7 Risk: 50.8 Risk: - Risk: 60.8 Risk 57.7 Risk 59.2 * Kosovo was not assessed in the 2019 Global Health Security Index. ** Private household out-of-pocket expenditure as a percentage of total health expenditure, standardized to US$. *** Data as of May 20, 2020 based on WHO situation reports and John Hopkins University. a Public health expenditure, PPP$ per capita, WHO estimates. https://gateway.euro.who.int/en/ b https://www.ghsindex.org/ For the overall ranking out of 195 countries, the higher the ranking the better e.g. Albania scores higher than North Macedonia. For the prevent, detect, respond, health system, norms and risk scores, scores are normalized from 0 to 100, where 100 is the most favorable. about 3007 highly qualified doctors left the health system robustness and capacity to country—a snapshot of the region-wide issue: treat the sick and protect health workers the brain drain of qualified workers to Western were consistently identified as weak areas. health systems, which offer more professional The GHSI measures prevention, detection, development opportunities as well as higher rapid response, compliance with international incomes. In 2013, Albania had 128 physicians norms, risk environment, health system per 100,000 people; in 2014, Montenegro had capabilities (Table 1). In Albania, detection 234 per 100,000 and North Macedonia 280. was identified as being particularly strong The 2014 European Union average was 369 per and contributed to the region’s highest 100,000. As health systems struggle to engage ranking, 39 out of 195 countries. The 20168 in effective case detection and treat COVID-19 Joint External Evaluation (JEE) for Albania patients, the long-standing shortages of health echoed this assessment, noting the tiered workers is a serious problem. national laboratory network, clinical guidance, protocols, and laboratory diagnostics as areas Even though the five countries measured in of strength. Both the JEE and the GHSI the 2019 GHSI all placed in the top half, identified Serbia as strong in infection control and ability to secure personal protective 7 Adisa Imamović, “Zastrašujući podaci: Stotine ljekara otišlo iz equipment (PPE). For all five countries, the FBiH 2016”, TVN1, 16 January 2017, http://ba.n1info.com/ a132717/Vijesti/Vijesti/Zastrasujuci-podaci-Stotine-ljekara-otislo- 8 https://apps.who.int/iris/bitstream/handle/10665/254886/WHO- iz-FBiH-2016.html. WHE-CPI-2017.18-eng.pdf?sequence=1. Health Systems  |  3 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 COVID-19’S IMPACT ON HEALTH SYSTEMS IN THE WESTERN BALKANS lowest GHSI scores were for health system Moreover, in Serbia, BiH, North Macedonia and capacity, which considers factors such as: health Montenegro, more than 8 of the top 10 causes capacity in clinics, hospitals, and community of premature death14 are comorbidities for care centers; medical countermeasures and COVID-19. Typical causes are cancer and heart personnel deployment; access to health care; disease—, reflecting an epidemiological profile communications between health care workers that is particularly vulnerable to COVID-19.15 in a public health emergency; and infection control practices and equipment availability. For example, North Macedonia had the Impact lowest health system preparedness score: 25.4. Similarly, the 2019 JEE9 for North Macedonia COVID-19 has upended life across the identified vulnerabilities in terms of emergency region and raised financing, service delivery, and stewardship issues for health system response financing, health workforce readiness leaders. and risk communication. These results underscore the limitations of Western Balkan The lockdowns necessary to contain the health systems. epidemic and protect health and health systems have had significant impact in the Globally, COVID-19 has disproportionately ‘hammer’ phase. As of May 20th, 17,152 affected the elderly, and with its heavy confirmed cases and 543 deaths had been burden of non-communicable diseases, the reported in the region. However, case detection Western Balkans is particularly vulnerable. and testing problems16 suggest that the numbers It is generally recognized that the disease is could be higher. Across the region, governments more likely to cause severe respiratory distress, have introduced states of emergency and necessitating intensive care and hospitalization, lockdown measures17 that have helped ease the for elderly patients and those with underlying immediate burden on health systems. Attempts health conditions. On average 14 percent of the to ease lockdown measures quickly are likely population in the Western Balkans, are over 65. to see a resurgence in infections and a second High-risk groups10 are those who are immune wave of the outbreak (see Figure 1)—health suppressed, suffer from respiratory diseases, systems will need to prepare for both short- and are over 70, and have specific cancers, severe medium-term responses. respiratory conditions, or metabolic disorders; are pregnant, have a serious congenital heart disease. Smoking is most prevalent in Montenegro and Serbia11. In North Macedonia, Tobacco-control-fact-sheet-Serbia.pdf?ua=1 35 percent of men and 27 percent of women 14 http://www.healthdata.org/serbia. 15 The negative impact of air pollution on respiratory infections, are smokers12. In Serbia, 37.9 percent of men such as SAR’02 and MERS’05, has been discussed in other RER notes, and this connection could be relevant for the management and 31.6 percent of women are smokers13. of COVID-19. While subject to further studies documenting an association between COVID-19 and air pollution, it is reasonable 9 https://apps.who.int/iris/bitstream/handle/10665/325320/WHO- to assume that air pollution problems in the Western Balkans WHE-CPI-2019.59-eng.pdf?sequence=1. worsen the region’s vulnerability to COVID-19. 10 https://digital.nhs.uk/coronavirus/shielded-patient-list. 16 https://balkaninsight.com/2020/04/08/the-torture-of-a- 11 https://apps.who.int/gho/data/node.sdg.3-a-viz?lang=en coronavirus-test-in-serbia/. 12 http://www.euro.who.int/__data/assets/pdf_file/0010/312589/ 17 States of emergency were declared in Kosovo, Montenegro, Serbia Tobacco-control-fact-sheet-Albania.pdf?ua=1 (all March 15), BiH (March 17), North Macedonia (March 18), 13 http://www.euro.who.int/__data/assets/pdf_file/0008/312596/ Albania (March 25). 4  |  Health Systems THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 Figure 1. Expecting a Resurgence Cases being reported Timing and width of peak uncertain due to: • Stochasticity in early dynamics • Heterogeneities in contact patterns • Spatial variation • Uncertainty in key epidemiological parameters Social distancing flattens curve Risk of resurgence following lifting of interventions Epidemic growth, doubling time 4–7 days 0 1 2 3 4 5 6 7 8 9 10 11 12 Months since transmission established  igure: Illustrative simulations of a transmission model of COVID-19 F  A baseline simulation with case isolation only (red); a simulation with social distancing in place throughout the epidemic, flattening the curve (green), and a simulation with more effective social distancing in place for a limited period only, typically followed by a resurgent epidemic when social distancing is halted (blue). These are not quantitative predictions but robust qualitative illustrations for a range of model choices. Source: Anderson, Lancet 2020 (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30567-5/fulltext.) The immediate demands of case management, Health systems are struggling to secure communication, surveillance, and essential equipment in a rapidly changing repurposing facilities are confronting health social, economic, and political environment. system leaders with numerous operational, One immediate issue is price increases. In logistical, organizational tasks. Prior to normal circumstances, the cost of an intensive COVID-19 the National Academy of Medicine care bed is about US$30,000. However, as estimated the global cost of preparedness at global demand has surged and prices have shot $4.5 billion a year.18 Moreover, with global up, securing supplies has become a furious markets distorted and the unprecedented race. Countries within the region have turned nature of COVID-19, the immediate financial to international diplomacy to secure supplies, demands of the COVID-19 outbreak on the through bilateral and multilateral relationships. Western Balkans are severe. In the first few The European Commission announced weeks of the outbreak, it became essential to a package of €38 million in immediate scale up case detection, contact-tracing, and support, primarily for medical equipment reporting. Now that health systems leaders and protection.20 North Macedonia, like must manage community transmission, the other countries, moved swiftly to address range of tasks they must undertake, at once, is equipment needs; and its Infectious Disease daunting. This includes: training and equipping Commission standardized PPE specifications front-line health workers; repurposing facilities; communication, securing essential supplies, and reorganizing the refurbishing intensive care units and inpatient health system. For example, in North Macedonia, the Ministry of Health has started a vigorous risk communication campaign facilities; and, communications on public on social media, TV, and other media, with strong support health risks, to allay fears and keep citizens from international agencies, including the WHO. The Albanian government has increased the number of medical personnel at all appropriately informed.19 ports of entry to examine suspected cases. The Serbian Ministry of Health, with UNICEF support, has partnered with the Association of Roma Health Mediators to provide Roma communities with 18 https://www.ncbi.nlm.nih.gov/books/NBK368391/ . information about preventing COVID-19. 19 Among these tasks are working with development partners, 20 https://ec.europa.eu/neighbourhood-enlargement/sites/near/files/ coordinating construction of new facilities, fielding coronavirus_support_wb.pdf. Health Systems  |  5 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 COVID-19’S IMPACT ON HEALTH SYSTEMS IN THE WESTERN BALKANS to align with WHO recommendations in all through OOP, raising equity and access health care facilities country wide. In April, challenges for populations in need of health North Macedonia received donations and services. support from multiple donors, for example, the WHO provided 5,000 COVID tests and Even with aggressive social distancing the Czech Republic donated 1 million masks. measures, health systems have been forced Montenegro’s request for PPE and medical to prepare for a surge in cases. Modelling supplies was supported by NATO bringing in February for North Macedonia illustrates 7,000 kilos from Beijing to Podgorica. The the nature of this surge. Its first COVID-19 Croatian government has also provided case was confirmed on February 26, 2020. supplies to Montenegro, Albania, and BiH. By April 12, confirmed cases had reached These examples are a snapshot of the wider 828, an increase of 68 over the previous day exchanges between countries, governments, (8.9 percent); 34 people had died; and 41 companies and international organization in people had recovered. Of the confirmed cases, pursuit of much-needed medical equipment, 117 (14.1 percent) were health workers. The medication and supplies. potential impact of 3 scenarios of population transmission (25, 50 and 80 percent) were Beyond the immediate impact on equipment modelled to estimate the impact on intensive prices and demand, medium-term health care units (ICUs). Even if only 25 percent of financing challenges are building as hospital the population becomes infected and a range revenues fall and sources of financing for of social distancing measures in place, the ICU the publicly funded health system contract. capacity needed to treat severe cases would Hospitals across the region have had to suspend exceed reported capacity eight-fold. or limit elective procedures, a critical revenue stream. Detailed analysis of the impact in the Short- and medium- term equipment region is yet to come21 but it is likely that shortages translate into additional demands this revenue loss will worsen arrears and debt and risk for physicians and health workers, issues for many healthcare providers. Moreover, who are at high risk of becoming COVID-19 given the economic contraction and the rise patients. For health workers, with inadequate in unemployment, sources of financing are access to PPE, everyday tasks have become and will be narrowed by the lower tax base much more complex, and more risky and and lower contributions from employers complexity. Entela Kolovani22, an infectious and employees. This is pertinent for the disease physician in Tirana who has been Western Balkans, given the reliance on OOP treating patients since March 9th, explains the expenditure. The downturn in the region and stresses on facing health workers: “Treating elsewhere in Europe will reduce wage income patients with COVID-19 is very hard, each one and remittances, severely impacting the ability with their own unique needs. We are dealing of households to finance health expenditure not only with the virus, but also with the psychological impact it has on patients. They 21 https://www.nytimes.com/2020/05/15/us/hospitals-revenue- are totally isolated from their families and we coronavirus.html?searchResultPosition=2. The types of revenue losses documented in hospital systems in the United States are 22 https://www.unwomen.org/en/news/stories/2020/4/feature- expected to be replicated in the Western Balkans. nurses-in-albania-on-front-line-of-covid-19-response. 6  |  Health Systems THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 Figure 2. Protecting Stopping Managing Ensuring service Recovery to a vulnerable transmission budgets delivery new normal patients need to stay as close as possible to them.” She What Next? also notes the burden of seeing colleagues and friends become ill with COVID-19, because To manage the future impact of COVID-19 of their exposure to infected patients. Beyond on health systems, five policy areas need special attention. the physical and psychological demands on healthcare workers, for the government the In the aftermath of COVID-19 governments, crisis has raised the issue of health worker health-system leaders, and policy makers pay. For example, the Serbian government has must deal with complex problems introduced a 10 percent salary increase, effective particularly in five areas(Figure 2). This April 1st. in recognition of the demands being section looks at strategic issues and suggests placed on health workers; as a sign of support, priorities for decision makers tasked with it is likely to be permanent. ensuring the continuity and financial sustainability of health services, and the general For many patients, too—particularly for health and well-being of populations in the pregnant women, cancer patients, and aftermath of an unprecedent health crisis. those in at-risk groups—accessing care has Actions are prioritized based on their potential become much more complex. In Serbia and to affect lives and health system resilience. Montenegro,23 as elsewhere, routine and non- urgent procedures have become lower priorities as the system struggles to limit transmission Invest in pandemic preparedness and between hospitalized patients. COVID-19 is public health systems to stop transmission. also a barrier to patients accessing important preventive care services throughout the region. High priority: Review GHSI and JEE Deferral of such care is expected to lead to a country-specific recommendations and huge backlog in the health system, creating invest in bridging critical pandemic more complexity and difficulty in treating preparedness gaps. Globally, pandemic patients. When opportunity arises it will be preparedness has been a neglected dimension important to assess the indirect impact of of global security24 and in the Western Balkans, delays on preventive care, but down the road even though external evaluations have identified it is likely to heighten morbidity and mortality vulnerabilities. Still critical, too, are core across the region. public health functions of surveillance, testing, contact tracing, and isolation that are crucial for stopping transmission. The ‘dance’ between retaining measures to prevent COVID-19 resurgence and facilitating economic revival 23 https://bdkadvokati.com/covid-19-update-17-serbia-montenegro- bosnia-and-herzegovina/. 24 https://www.nejm.org/doi/full/10.1056/NEJMsr1600236. Health Systems  |  7 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 COVID-19’S IMPACT ON HEALTH SYSTEMS IN THE WESTERN BALKANS Table 2. Health System Analysis, 2019 Global Health Security Index Bosnia and North Albania Montenegro Serbia Herzegovina Macedonia Health capacity in clinics, 10.8 15.1 23.1 42.2 19.4 hospitals and community care centers Medical countermeasures and 33.3 0 33.3 0 33.3 personnel deployment Healthcare access 30 47.7 31.9 47.6 45.9 Communications with healthcare 100 50 0 0 50 workers during a public health emergency Infection control practices and 0 50 50 0 100 availability of equipment Capacity to test and approve new 50 75 50 75 100 medical countermeasures Note: Scoring is 0 to 100, with 100 being more favorable. Pink blocks indicate each country’s three lowest scores, which should be considered highest priorities. will depend not only on treatment but also to promote citizen knowledge, attitudes, and on the effectiveness of core public health practice, with supporting behavior change functions. Deciding how and where to invest communications. will be critical. Although each country must take stock of its successes and struggles, the JEE Medium priority: Combine a thorough and GHSI ratings are a useful starting point for testing and surveillance strategy with setting spending priorities (Table 2). effective strategies to ease lockdowns. Based on the JEE and GHSI recommendations, Medium priority: Establish and reinforce governments can review their surveillance and communication and information contact-tracing capabilities so they can target mechanisms within and between investments to ensure they can rapidly contain government agencies and with the public. any second waves of COVID-19 of any other As COVID-19 has required cross-sectoral infectious diseases. If an effective antibody test coordination across government, it is essential becomes available, governments may need a to identify efficient ways to use existing cross- testing strategy to determine who can safely ministry mechanisms for communication interact with others so that economic activity and information sharing. Clear and concise can resume. However, such a strategy must be messaging from government to constituents based on clear scientific guidance for safe and will be important to retain public confidence effective testing. and understand how to proceed. As lockdown measures are eased, messaging will become High priority: Equip healthcare workers more nuanced and complex so it will be even with PPE and train them in treating infected more important for government to speak with and thus infectious patients. Recognizing a single clear and coherent voice. Governments global shortages, it will still be important to can Recommended actions include designing procure vital equipment and supplies, and to and implementing information campaigns reinforce protocols, training, and infrastructure 8  |  Health Systems THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 to support health care workers. The rush to ensuring the continuity of health care services buy complex equipment like ventilators must will be critical to avoid more severe consequences be accompanied with training and support later. As a high priority, governments must so that health workers can use equipment safeguard and increase spending on primary appropriately to treat patients. health care, public health, and emergency care. It may also be prudent to review inter- governmental transfers to ensure that regions Recognize and manage the impact of with significant health or social inequities deep recessions on budgets and have sufficient access to care to avoid future the fiscal space for health. outbreaks and health vulnerabilities. Given arrears and debt accumulation, governments High priority: Brace for and plan for the will need dedicated strategies to deal with economic impact of lockdown measures the financial sustainability issues arising from and the COVID-19 outbreak and the COVID-19. They must make critical choices severe pressure on government at the very because fiscal space for health will be severely moment that funds for health systems are limited. It will be essential to protect funds for essential; appropriate funding for health front-line services, and to quickly identify and services will be critical. Ministries of health act on opportunities to make service delivery and health insurance agencies may be asked more cost-effective and sustainable. to cut spending, but if cuts continue, systems will be so undermined that they cannot deal Medium priority: Review options for with the current pandemic and become even improving service delivery, so that direct more vulnerable to future outbreaks. Among transfers to health systems do not bypass the range of decisions government must make, opportunities to consolidate much needed Box 1. Invest in Primary Health Care Systems for Non-communicable Diseases C  itizens of the Western Balkans are increasingly likely to have non-communicable diseases, such as heart disease, lung cancer, and diabetes that make them more vulnerable to pandemics and influenza. By the time these patients are hospitalized, it can be more expensive, painful, and difficult to provide treatment. By building primary care capacity, health systems can offer better care earlier and at lower cost. In preparation of a recurrence of COVID-19 and another influenza-like pandemic, primary care reduces the need for intensive care and surge capacity. Strong primary care systems can also ensure continuity of essential services, even during a crisis, which prevents erosion of previous health gains. We know from the Ebola epidemics that lack of access to essential services due to service delivery disruptions has had dramatic negative consequences for non-Ebola patients. The Primary Healthcare Performance Initiativea supports countries conducting systematic assessments of their primary care systems, with a view to formulating strategies to better guide investments. The recent such assessment in North Macedonia has helped inform the dialogue on drafting a primary care strategy. This type of analysis can be critical to identify how and where to invest for long-term benefits and strategic pandemic preparedness. a Founded in 2015 by the Bill & Melinda Gates Foundation, WHO. and the World Bank Group, in collaboration with Ariadne Labs, Results for Development, and UNICEF (www.improvingphc.org). Health Systems  |  9 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 COVID-19’S IMPACT ON HEALTH SYSTEMS IN THE WESTERN BALKANS Box 2. Using Telemedicine for Innovative Service Delivery  elemedicine can be defined as using information technology—tablets, phones, and computers—to T provide health care services in situations where the health professional and patient are not in the same locationa COVID-19 has seen telemedicine expand in many countries and may serve as a catalyst for accelerating its use. In the medium term it allows for continuity of medical care for suitable COVID-19 patients at lower risk for patients and health workers. Long-term, it also offers a more cost-effective model that could be readily adapted to the epidemiological profile of the Western Balkans. Telemedicine is a sustainable investment that can be optimized through government attention to the following areas: • Information: informing patients about how to use and access telemedicine; • Data security: ensuring that medical data, images, text, and sound are secure; • Accessibility and equality: analyzing how best to engage and support patients and health workers who might be less comfortable using technology; and • Appropriate use: identifying services where telemedicine is valuable and effective, and those where it is not suitable for a patient’s needs or profile. a https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4987488/. reforms across the region. It will be important Minimize financial risk to patients in need for governments to improve the efficiency of of care to protect vulnerable patients their health system investments, particularly Medium priority: Recognize that lost income given the legacy of arrears and debts facing and government budget cutbacks will expose health systems across the region. For example, many people seeking care to financial risk by investing in primary health care and and actions may be required to ensure that telemedicine (Boxes 1 and 2) to manage mild those most at need can access health care. COVID-19 patients and routine care, waiting Given out-of-pocket payments for healthcare times can be minimized and service delivery are notable (Table 1), protecting patients adapted to more efficient models. Savings might from financial risk protection is an important also be also achieved by using generic rather than goal. Addressing financial barriers to care will branded drugs and centralized procurement of ensure that patients seek care early, which not certain commodities. Governments may also only improves their experience and outcomes want to explore additional revenue options, but often is also because more cost-effective. such as sin taxes for tobacco consumption Options for doing this include: universalizing and sugar-sweetened beverages—all options to coverage of COVID-19 care; adjusting expand the fiscal space for health ought to be eligibility for targeted health programs; considered. avoiding blanket application of demand management measures (e.g., co-pays); carefully targeting cash transfers and in-kind assistance (e.g., for mitigation) to high-risk populations; revising health conditionalities of cash transfer programs; and, introducing or expanding sick leave benefits. 10  |  Health Systems THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 Ensure continuity of service delivery, is safe, cherry-picking is avoided, and patients and explore opportunities for are not put at risk of catastrophic OOP health sustainable innovation. expenditures. High priority: Maintain safe (non-COVID) emergency care in the face of the pandemic, Finally, it is important to consider how to protect and redeploy health recover to a new normal. care workers and protect and strengthen supply chains. The service delivery agenda Medium priority: As countries and their will entail both expansion and reorganization health systems progress in combatting the of care to simultaneously manage COVID-19 pandemic, and as economies emerge from cases and ensure continuity of essential non- recession, policy makers can look into COVID services. Globally, many countries have creating a post-COVID-19 health system. had to postpone elective care and the backlog From a strategic perspective, this implies taking of patient needs is rising by the day. Chronic stock of strengths and weaknesses and where care management, procedures to investigate and how health systems were resilient and able pressing health conditions, and important and to function well. The immediate demands of life-saving procedures have been postponed. the pandemic allow little time for reflection, Western Balkan governments will need to draw but ultimately it will be important for health up triage strategies and protocols to support workers, health system leaders, and policy those most at risk. Health workers will need to makers to reflect and fine-tune accordingly. be protected and effective procedures will need Short-term measures responding to emergency to be put in place to allow for redeployment circumstances need to be rolled back so to meet demand surges in a range of chronic attention can turn to planning for the long disease areas over the next year. Adaptive service term. Systems will also need to remain agile delivery models may also be critical to sustain to respond promptly to similar outbreaks; it the health system, with help from telemedicine will be important that lessons and successes are (Box 2). easily replicated should that become necessary. Governments may wish to reinstate public Medium priority: Consider how best to financial management controls or private sector use private sector capabilities, recognizing regulations that had been relaxed and plan the regulatory and costing difficulties. It for how to unwind temporary suspensions of has become prudent for governments to look benefit coverage. For future pandemic readiness, into how to expand engagement with actors it may also be prudent to think about optimal in the private sector and non-governmental supply chains and service delivery mechanisms. organizations to deliver care, especially in surges. However, careful regulation and oversight will be necessary so that private service delivery does not compromise long- term financial sustainability and the quality of care for the population at large. Efforts should be made to ensure that private sector provision Health Systems  |  11 Western Balkans Regular Economic Report No.17 | Spring 2020 Health Systems View this report online: www.worldbank.org/eca/wbrer You and me by Tanja Burzanovic (Montenegro) Dr. Tatjana Burzanovic has a wide experience in the fields of graphic design, graphics in architecture, interior design. She has worked as an art editor, interior designer and graphic designer at various levels. Many of her art exhibitions have taken place at different places. She has received many awards for her arts and literary works. She has published a book with a title The Interrelation between Art Worlds, with the support from the Embassy of India for Austria and Montenegro in Vienna. Her artistic philosophy includes displaying of interrelationship between art worlds (spatial and temporal arts). The artist thus meditates between nature and the sprits and yet stems from the absolute idea and serves the goal of realization of absolute sprit. ‘Grasping the meaning through the form’ is a task of the art set by a contemporary thinker to demonstrate that building forms and creating sense are two simultaneous, intertwined, and absolutely inseparable processes in Arts. Without that recognition it is not possible to take any further step in investigating the nature of art and literature. She believes that art is a way to search the truth. Art is inseparable from searching the truth. People forge ideas, people mold dreams, and people create art. To connect local artists to a broader audience, the cover of this report and following editions will feature art from the Western Balkan countries.