For the area of essential health services (EHS), WHO EURO IMST’s Clinical & Health Interventions Pillar developed a systematic four-step approach, including:

• Rapid assessment of the impact of COVID-19 on EHS and situation analysis.

• Development of an Action Plan on restoring and maintaining continuity of EHS.

• Implementation of the Action Plan.

• Monitoring and evaluation as well as continuous amendment of the Action Plan.

Following this approach, the Ministry of Health (MoH) of Kosovo undertook a Rapid Assessment and Situation Analysis of the Impact of COVID-19 on EHS delivery and analysis of health system functions in June 2020. This assessment found that from March until May 2020, all non-acute health services were suspended in Kosovo, with their gradual re-opening afterwards. Some of the priority areas that have been subject to disruption include:

• Elective surgery

• Antenatal care

• Routine immunization services in health facilities, except for BCG and Hepatitis B for new-borns.

• Routine outreach immunization services and home visits.

• Outbreak detection and control for non-COVID-19 diseases.

• Diagnosis and treatment of major non-communicable diseases (e.g. hypertension, diabetes, asthma, COPD, coronary artery disease).

• Dental, rehabilitation and palliative care services.

Pharmacies remained open without any disruptions. The restrictive measures introduced to mitigate the COVID-19 outbreak, paired with the repurposing of health services and health workforce capacities to COVID-19 treatment canters, have negatively impacted (essential) health services in Kosovo, including access to and utilization of these. The observed decline in outpatient volume was also attributed to a decrease in the demand of services by patients across Kosovo.

The analysis also showed that:

• No identified list of EHS or specific EHS package was in place before the COVID-19 pandemic.

• No plan for maintaining the continuity of EHS during the COVID-19 pandemic existed.

• There was no system to monitor EHS delivery in place.

• No generic protocol or mechanism to govern EHS existed.

• No specific or additional funding to maintain the availability of EHS during the pandemic was made available.

On this background, a set of key interventions to maintain and restore essential health services (EHS) were implemented in Kosovo. Reflecting step two of EURO’s approach mentioned above, an Action Plan on Maintaining EHS during the COVID-19 Outbreak was developed by the MoH in Kosovo, supported by WHO EURO and Liaison Office in Pristina. The following priority areas and key tasks were identified:

• Task 1: Nominate a focal point for essential health services.

• Task 2: Reach consensus on a definition of the list of context-specific essential health services to be maintained during emergencies for Kosovo.

• Task 3: Investigate and get to the root cause of disruption and/or cancellation of essential health services.

• Task 4: Develop a plan for restoring essential health services.

• Task 5: Monitor essential health services delivery.

• Task 6: Share experiences and best practices across Kosovo and the region.

• Task 7: Develop telemedicine strategies.

Throughout the development of the Action Plan, partners such as UNFPA and UNICEF were continuously consulted, and their inputs incorporated. Subsequently, the process of developing a list of EHS was started as a key intervention for maintaining EHS, implementing the Action Plan: On 20 January 2021, the MoH’s Acting General Secretary issued a directive (Prot.nr. 05-460) to establish a Working Group with the aim of ensuring the continuity of EHS in the context of COVID-19. This included:

• Assigning a dedicated coordinator from the MoH for the group.

• Engaging stakeholders across all sectors.

• Distributing a draft list of EHS among these stakeholders with a request for review.

• Getting the list approved within the legislative process.

It is further aiming at establishing a unit on EHS at the MoH for general oversight of EHS.

The Working Group has been meeting weekly since January 2021 and, led by the MoH, includes representatives from the three levels of the health delivery system, as well as the Health Insurance Fund and partners (WHO, United Nations Population Fund (UNFPA).

Another key intervention, implementing Tasks 3 and 5 of the Action Plan, is the development of a Household Pulse Survey, prioritizing the monitoring of EHS delivery across Kosovo and to be fielded starting in March 2021.

The objectives of the survey are three-fold: 1) to track the impact of disruption caused by the COVID-19 pandemic on health needs of the population as reported by households, while 2) feeding this input into the Action Plan and 3) monitoring the implementation of the Action Plan over the long term. The Household survey is based on protocol from WHO EURO and has been developed in close collaboration with the MoH and UNFPA.

Complementing the three rounds of Behavioural Insights Studies conducted in Kosovo until February 2021, this survey explicitly addresses the needs of disadvantaged and marginalized groups, including ethnic minority groups, people living in homelessness of all ages and other vulnerable groups. To ensure inclusiveness, add-on pulse surveys and focus group sessions specifically targeting these groups will be conducted.

Another intervention, and relating to Task 6 of the Action Plan, is the documentation and sharing of the work, experiences, challenges and learnings on the process of maintaining EHS in Kosovo through this Action Brief Deep Dive at hand, feeding into WHO’s Global Health Services Learning Hub.

Main outcomes of the Rapid Assessment were:

• The identification of gaps on maintaining EHS.

• Addressing needs for restoring and maintaining EHS.

• Developing priority areas and key tasks to follow with the aim of restoring and maintaining EHS, and translating these into an Action Plan, managed by the MoH in close cooperation with partners.

The main outcomes of the Working Group on EHS include the ongoing processes of:

• Assigning a coordinator for EHS at the MoH.

• Drafting the list of EHS for all levels of care to be maintained during the ongoing health emergency.

• Drafting an EHS monitoring framework/plan, all to be approved by the MoH.

Additional long-term functions of the Working Group include:

• Continuously updating the Action Plan to ensure maintaining EHS in the COVID-19 context.

• Determining the status of continuity of EHS in the COVID-19 context through reviewing existing and/or new pulse surveys and health facility assessments.

• Advising on appropriate delivery EHS platforms.

• Monitoring the implementation of plans on the continuity of EHS beyond the pandemic.

The main outcomes of the Household Survey will be:

• Conducting rapid assessments on where the greatest challenges and needs are regarding maintaining EHS in Kosovo, thereby informing policy dialogue and supporting decision-makers at all levels.

• Providing input into guidance resources and investments throughout the course of the pandemic and beyond,

• Continuously monitoring and evaluating trends in EHS continuity as well as the impact of the implemented actions.

All of this recent work on EHS in Kosovo must be considered in the context of the majority of the scarce resources for health being dedicated to the immediate COVID-19 response. All the steps on EHS needed and will have to seize the right “window of opportunity” for strategizing and acting (e. g. towards the end of the single major waves of the outbreak), in order to receive the necessary engagement and resources from all stakeholders.

Throughout this process of working towards restoring and maintaining EHS in Kosovo, while responding to a public health emergency over the different waves, further key challenges have been:

• General low levels of health financing in Kosovo, with the Health Insurance Fund not fully functioning.

• Weak monitoring capacities of the health system’s performance during the pandemic, with silo-thinking across the health system.

• Lack of data analysis capacities, with the Health Information System not functioning optimally.

• Lack of awareness and understanding of the concept of EHS.

These challenges were overcome mainly by:

• Targeted, direct consultations accompanied by effective and continuous collaboration with relevant stakeholders across the health and other sectors.

• Continuous awareness raising, including clearly explaining the benefits of all actions.

• Participatory engagement efforts.

• Continuous technical assistance from EURO, WHE Balkan Hub and WHO HQ, and reference to WHO guidance documents and different country experiences.

Some of the important lessons learned throughout this process in Kosovo until now include:

• An official package of EHS is an indisputable precondition for continuing the provision of health care services during emergencies.

• It is paramount to coordinate and base all efforts on equal partnerships with public health authorities and UN agencies, in order to avoid duplication of efforts and redundancies.

• Reassure to public health authorities that they will receive the necessary support throughout the entire process of a project and program (and not exclusively for kick-starting it); this will increase the likelihood of initiating, continuing and successfully finalizing projects.

• Plan for and ensure reliable transition of projects and programs to public health authorities, including commitment from them to continue with projects once partners step back, to ensure sustainability.

• Continuously adapt to needs and capacities of public health authorities and organizations, as failing to do so will result in projects solid in theory but not carried out successfully in practice.

• Communication cannot be overstressed: Being very clear, concise and consistent in messaging with all partners is indispensable.

• The shortage of staff in public health authorities and partner organizations (incl. WHO) has been resulting in overlapping areas of engagement of the different actors throughout the work described above, sometimes leading to inefficient actioning.

• Establishing a unit on EHS at the MoH would secure institutionalized oversight for coordinating, monitoring, updating and adjusting these services; the list of EHS, approved by the MoH and legislative process, will be at the core of it.

• The technical support continuously received from the WHE Balkan Hub as well as WHO’s office for the European region has been essential for the work on EHS in Kosovo, and will remain to be so.

All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999).