How is public health expenditure hindering Albania from EU accession?

By Dovile Milisauskaite

Since the fall of its communist regime in 1990, the Balkan nation of Albania has worked toward a clear goal: European integration. The country, which was isolated economically and politically from the rest of the world just 20 years ago, has been an official candidate for accession to the European Union since 2014. Albania has successfully implemented policies aligned with the EU acquis, such as the Stabilisation and Association Agreement in 2006. This agreement approximated Albanian legislation to that of the EU and allowed for the country’s economy to integrate into the EU single market. It also ensured democracy and rights for all, at least by law (Panagiotou, 2011).However, as Albania nears its first Inter-governmental Conference, the European Commission has highlighted several areas of policy in need of reform. This essay serves toanalyseone of these areas: public health, with specific attention to its expenditure (European Commission, 2020).

Under the communist regime, Albania’s health system was centralisedand free-of-charge. This ensured healthcare to practically all citizens, regardless of age, sex and urban or rural dwelling. However, when the regime fell, the Albanian government started a process of decentralisationwhich, along with the shift to a market-based economy, resulted in the ‘breakdown of health services countrywide’ (Roshi, 2002, p. 504). The health sector was unable to accommodate population migration from rural to urban life. As a result of this demographic change, both primary care facilities and rural health centreswere underfunded, understaffed, and lacked necessary resources such as drugs and vaccines (Roshi, 2002). Moreover, public health professionals, whose pre-independence roles could be likened to that of epidemiologists or hygienists (e.g. food safety, air pollution management), were unable to fulfilthe duties of their new roles and provide substantial care to Albanians. In particular, citizens appointed to rural primary health facilities were often forced to commute to urban areas to receive necessary treatment (Colimbini, 2012).

This system has largely remained unchanged. In 1994, government health expenditure hovered at 2.8% of Albania’s annual GDP, in contrast to the EU’s 8.5% average (Nuri, 2002). This trend remains evident until the present day as the European Commission (2020) noted that Albania currently spends 2.9% of its GDP on its public health system annually. In contrast, the 27 EU member states total a collective average of around 10% (Eurostat, 2020). This underfunding has resulted in the prominence of informal payments, which run on a system of supply and demand. For example, a sum could be paid to skip a queue at the doctor’s office, or to receive better healthcare (Tomini, 2013). Conversely, public health workers could take informal payments as a supplement for low wages. Nevertheless, while out-of-pocket payments are beneficial to both citizens and healthcare professionals, ‘they prevent low-income people from obtaining services and pharmaceuticals’ (Nuri, 2002, p. 31). They also propagate the idea that it is necessary to tip to get proper treatment (Nuri, 2002). To circumvent this, the EC (2020) has suggested higher government spending on the health sector. Increased expenditure would allow Albania to fulfil this area of the EU membership criteria.

In particular, two sub-sectors of the Albanian public health system have been highlighted as areas in need of improvement: maternal and child health. Newborn (6 per 1,000 live births), infant (8 per 1,000 live births), and under 5 mortality (9 per 1,000 live births) rates remain high (European Commission, 2020). Abortion is legal and abortion care is guaranteed by law, however recent reform has seen the dissolution of polyclinics, leaving some settlements without a gynaecologist (Colimbini, 2012). Although the country has ratified the criteria for the Stabilisationand Association Agreement, marginalisedgroups, such as the Roma and Egyptian minorities, struggle to access state health services (European Commission, 2020; Colombini, 2012). The system is less accessible to them because general practitioners are largely unwilling to set up practices in minority settlements due to prejudice. Emergency services such as ambulances refuse to serve many Roma or Egyptian-majority areas because of the poor condition of roads in theseneighbourhoods. The minoritiesoften do not meet the criteria for obtaining health insurance, such as birth or citizenship documents, work permits, or personal identity cards. They are generally of lower socio-economic class, and thus they are less likely to be ‘health literate’, i.e. educated about contraception, infections, and entitlements to health services. Finally, there is a shortage of interpreters for those who do not speak the local tongue (Colimbini, 2012). However, while these problems persist, it is also important to acknowledge that the Albanian government has provided an increased amount of free health cards to the Roma and Egyptian minorities in the past few years. In addition, there has been an increase in the number of emergency services in informal settlements (European Commission, 2020).

In conclusion, with Albania now in accession negotiations, it is vital for the government to implement the recommendations made by the European Commission in regard to public health reform to comply with EU membership standards. The Albanian public health sector suffers from underfunding as the country spends less than 3% of their annual GDP on the sector. Thus, rural practiceslack the necessary drugs and vaccines, forcing citizens to commute to cities. Informal or out-of-pocket payments are common and are oftentimes necessary to receive better healthcare. In particular, the Commission emphasised maternal and child sub-sectors as newborn, infant, and under 5 mortality rates remain high. The Commission also highlighted that Roma and Egyptian minorities struggle to access services such as abortion care. This is not only due to their generally lower health literacy, but also because of prejudice (e.g. general practitioners unwilling to set up practices in minority settlements; lack of interpreters in care facilities). To circumvent these issues, the Commission has recommended increasing government health expenditure. This would allow for more resources to be allocated to child and maternal health, and it would also increase the number of interpreters available in care facilities. Subsequently, Albania’s public health infrastructure would be strengthened, and the country would comply to this area of membership standards, ostensibly presenting themselves as ‘EU ready’ in their first Inter-governmental Conference.


Colombini, M., Rechel, B. and Mayhew, S. (2012) ‘Access of Roma to sexual and reproductive health services: Qualitative findings from Albania, Bulgaria and

Macedonia’, Global Public Health, 7(5), pp. 522-534. Available at: 26 Oct 2020).

European Commission (2020) ‘Albania 2020 Report’. Available at: 23 Oct 2020).

Eurostat (2020) ‘Healthcare expenditure across the EU: 10% of GDP’. Available at:,9.9%25%20of%20GDP%20in%202017(Accessed 25 Oct 2020).

Nuri, B. in: Tragakes, E. (ed) (2002). ‘Heath care systems in transition: Albania’, European Observatory on Health Care Systems, 4(6). Available at: 25 Oct 2020).

Panagiotou, R. (2011) ‘Albania and the EU: from isolation to integration’, Journal of Balkan and Near Eastern Studies, 13(3), pp. 357-374. Available at: 22 Oct 2020).

Roshi, E. and Burazeri, G. (2002) ‘Public health training in Albania: long way toward a school of public health’.Croatian Medical Journal, 43(4), pp. 503-507. Available at: 25 Oct 2020).

Tomini, S. and Groot, W. (2013) ‘Paying informally for public health care in Albania: scarce resources or governance failure?’, Applied Economics, 45(36), pp. 5119-5130. Available at: 25 Oct 2020).


This blog post was written as part of the coursework for INRL20160 – Introduction to EU Politics.