Rifat Latifi, MD, FACS, FKCS, FICS*

*Professor of Surgery,  the University of Arizona and University of Prishtina, Former Minister of Health, Republic of Kosova, Director of Kosova Center for Research, Simulation and Advanced Medical and Surgical Training at University of Prishtina, Founder and President Emeritus of  Kosova College of Surgeons, Editor-in Chief, Kosova Journal of Surgery,  and Editor-in-Chief, Surgical Technologies International, and Chairman of Surgical Consultant International, PLLC. E-mail: latifi@surgery.arizona.edu

Abstract: The part I of this article by Prof. Rifat Latifi, a trauma and general surgeon, is an update of  previously published article in Kosova Journal of Surgery,  on transforming healthcare systems in post conflict countries through detailed and multiprong strategy and  analysis assisted by medical diplomacy offers timely insights also for Bangladesh and other developing and/or post-conflict nations. By illustrating how strategic international partnerships, knowledge exchange, and targeted policy reforms can strengthen health infrastructure, workforce capacity, and access to essential services, the piece highlights a practical pathway for modernization that aligns with local needs. This framework focusing on creativity, collaboration, innovation, and sustainable investment on education and infrastructure, which holds broad applicability across third-world countries, especially those coming out of conflicts seeking to advance healthcare system. Establishing clinical centers of excellence, investing in human capacities will protect from the medical neocolonialism and subsequently create a resilient healthcare system. Upcoming part II will deal exclusively on Medical Diplomacy and Healthcare Transformation in Post-Conflict Countries.

From Chairman and Director of Surgery to the Minister of Health

Being the Minister of Health, of any country, is the greatest honor and privilege, but being the Minister of Health in Kosova, the newest country in Europe and where I grew up and was educated before I left for a better life, is was a very different honor, yet it was  the biggest responsibility that I could have. As a trauma, general and critical care surgeon, I have worked hard to prepare for any occasion and to treat any critical condition in my domain, and for this there are plenty of textbooks to show me how to do it. Some of these books I have written myself. It takes years to become a surgeon. Years of medical school, brutal surgical residency and fellowships training programs before you enter the arena of surgery. There is a general assumption and understanding  that it takes at least 10 years in practice to become a good surgeon. That I thought have achieved long ago, but one always learn new things.  When it comes to being a Minister, it was different, and I had many unresolved questions.

How does one prepare to be the Minister of Health? What training one needs to become a Minister of Health? What tools are required to help the Minister transform a healthcare system in disarray? How much money do you need to transform healthcare system that had suffered a great deal during the war or conflict? While admittedly, I am not very good with budget, it was very  clear to me that 263 million Euro will not cover healthcare services  for 1.8 million people.  How do you fight the corruption embedded in every layer of the healthcare system? Can you use medical diplomacy as a potential tool to deal with the problems of inequality and healthcare disparity?

To most of these questions, I had some answers, but none  was totally satisfactory  to me. The aim of this perspective is to discuss my short tenure as Minister of Health in Republic of Kosova and how, during that time, we created a model of healthcare transformation in Kosova, using every possible tool, all of which were designed to curb transfer of patients out of the country for advanced care.

November 2021, I took over the job as the Minister of Health in Kosova, as a non-political Minister. While it was something that never imagined doing in my career, I was not surprised by my own willingness to accept this position. A lifetime opportunity, I thought.  “Finally, I can help transform healthcare in Kosova”- kept saying to myself, like I was trying to convince myself that I am doing the right thing.

Following graduation from Medical Faculty of University of Prishtina and two years of residency in orthopedics, I moved to the USA in 1985. Since then, I was lucky to train and worked in some of the best major medical institutions in the USA ( Texas Medical Center, Houston, Texas, Pennsylvania Hospital Philadelphia, Pennsylvania, Cleveland Clinic, Ohio, Yale University Hospital, New Haven, Connecticut, Virginia Commonwealth Hospital, Richmond, Virginia, Tucson, University of Arizona, Arizona, Westchester Medical Center Valhalla, New York) and abroad (Hamad Medical Center, Doha, Qatar), Tagbilaran, Bohol, Philippines  (as surgeon volunteer one week a year for 13 years). In addition. I led a major academic department of one of the oldest university hospitals and medical schools in the USA. Valhalla, NY. I have written and edited 21 books, including one entitled “The Modern Hospital. Patient Centered, Disease Based, Research Oriented, Technology Driven”. In addition, I have published more than 500 peer-reviewed articles and book chapters. I was familiar with the healthcare system in Kosova and have been a loud critic of how healthcare in Kosova was being managed during the last 3 decades. As the founding president of Kosova College of Surgeons (KCS), I led the creation of daily operations and content, as well as the growth strategy of KCS, which is helping transform surgery. Should all this have prepared me for a job as the Minister? My answer was yes. It made perfect sense to me, then and now, to leave my position as Chairman of Surgery at New York Medical College  and Director at Westchester Medical Center, a network of 10 hospitals in Valhalla, NY, and go back to Kosova to help rebuild the healthcare system. So, I said yes to the invitation by Prime Minister Kurti. The news went viral. Many were surprised, many were supportive, and many others thought -it was flat out a bad idea.

New Minister of Health in the Middle of Covid-19

I came during the COVID-19 pandemic, while I was re-creating the cabinet and learning an administrative maze. The state of healthcare was dismal. Everyone intubated with Covid-19  and the University Clinical Center died. Old and young. The initial “honeymoon” of excitement and hope that healthcare system may be changed (92% believed that we can transform healthcare system), with my coming,  did not last long. I was “welcomed” by the protests of residents, that were asking for pay for night calls, not for advanced education. The nursing staff were demonstrating as well in front of my office at the Ministry of Health (previously an old tuberculosis hospital where I rotated as a medical student in pulmonology), for higher wages. Media outlets had a lot to say about my cowboy boots and bow tie. Only few  were interested in my vision to transform the healthcare system. That did not bother me, but I must admit, I did not read social media, I was too busy working. My team insisted that we publish everything that we were planning but I disagreed. Did not want to sound like another politician. “The news should be announced only when something is completed”, I told them.

Endless Meetings and No Time To Work

As the new Minister, I met many people, ambassadors of many countries, many representatives of various governmental and non-governmental organizations and partners of the Ministry of Health, both national and international. There was palpable excitement about my arrival from the internationals. I must admit, I liked it to be able to present the new platform and strategy. The donors were coming out of the woods. We had a clear plan. I did not need any more hospital beds, or vaccines that will expire in couple of months. There  were times, we accepted vaccines (that we did not need them) under “political pressure”, not to upset our friendly countries. I did not think they were trying to help us.

But there were some great things as well being a Minister.  As a non-politician,  I particularly enjoyed parliamentarian meetings, not so much parliamentarian committees’ hearing. These were too political. But the parliament was a different matter.  Having members of parliament express themselves freely, criticizing ministers and the Prime Minister, which  was not allowed just 25 years ago, it was refreshing and liberating. Now, Kosova is a democratic nation with our own parliament. I love democracy and could not ask for anything else. My answers with MPs were short, to the point, and I was not engaging in political games, for the MPs only to be seen live on TV and to show off to their base.

My calendar was busy, but I enjoyed it. I woke up at 5 AM and was usually emailing my team by 5:15. There were way too many useless emails (most FYI type)  in my inbox, and when I replied, I was told that I was the only minister that replies to or sends emails. There were to many of meetings too, courtesy dinners, lunches, and other useless gathering. When does the Minister work, I kept asking. Five to eight AM- I would answer to myself.

I lived alone in my apartment (first few months) in the most famous, muddy, and always under construction, “Muharrem Fejza” street. Often there was  no electricity and had to walk to the 8th floor to get to my apartment. I did not mind the walk at all. The apartment was small (compared to my house on the hill in Katonah), and the winter was brutal. My apartment was cold too, and I do not like the cold. My life became a mess, but I loved my new mission. Days were passing and I remained very busy, but I could not see as much satisfactory progress as I expected. As a surgeon, you see progress immediately. Not as the Minister. That bothered me a lot.

The  Bureaucratic Barriers and the State of Neocolonialism of Healthcare in Kosova

It did not take me long to understand the bureaucratic  attempts to stop any progress  were everywhere.  Creating a committee or a working group for everything was mandatory. This is how we do things here, was reminded often. I despised that. It did not take me long to conclude that the healthcare sector in Kosova,  was run by the corrupt administration leadership,  and this part of the Ministry itself, was a very complex enterprise: a maze or web of entanglement of incomprehensible designed rules, regulations, and policies in which many (mostly invisible) actors had major stakes. The public healthcare in Kosova was ignored for decades, if not outrightly neglected, poorly managed, segmented into ridiculous segments and clinics for special interests. Some departments of University Clinical Center had more doctors than beds; clinics with no professors, but each surgical section for example had its own director.  Each surgical unit had its own committee  (chaired by the director) to send patients out of the country.  There was no accountability. The number of questions kept increasing.  Why was Kosova’s public healthcare sector in this state? A state of disarray. Why did the public healthcare system continue to be underfunded year after year, government after government, and so badly managed? Why did Kosova have the lowest GDP for healthcare in the Western Balkan countries and amongst the lowest in the world? Why, even when something was invested, was mismanaged? Why were so many public hospitals started but were never finished? A hospital donated  was inaugurated, but had no patients and no services being provided?  When we eventually opened the children’s hospital, I refused to have another inauguration, as I did not want to embarrass  those who cut the ribbon 9 months earlier.

The hospital infrastructure was old, or of low quality, and for many years, there have been a number of hospital buildings (such as emergency and trauma hospital building in Prishtina, the Ferizaj regional hospital building, the pediatrics department at Mitrovica hospital and a few other projects) that have started but remained unfinished or not completed for various reasons; they look like ghost buildings that have disintegrated year after year. The central pharmacy of UCCK was placed in a malodourous and poorly secured basement of Gynecology and Obstetrics clinic. Why did private “hospitals”, private clinics, and pharmacies grow like mushrooms right in the backyard of the University Clinical Center of Kosova? Who owned them? It was difficult to understand the web of manipulation and outright abuse of the public trust and healthcare system, the very same healthcare system that should care for all of us, rich and poor. There were many questions that I could not get answers, but this one was clear: There was a state of medical neo-colonialism, installed by many countries over the entire healthcare system, from the  so-called friends of Kosova.

Due to low wages, most physicians, nurses, laboratory technicians, and others healthcare workers are forced to work 3–4 jobs, often to the detriment of public hospitals. All doctors work without malpractice insurance, even though court cases often get dragged out for years in courts, fueled by the media with unverified information. Doctors often were dragged hand-cuffed from their offices in case of comlications. Clinical faculty of the University Clinical Center were divided into those who taught medical students at the Medical Faculty of University of Prishtina and those who “cannot” teach medical students. For both groups (although many are Doctors of Science or have master’s degrees), the scientific contribution and peer-reviewed publications are very low. Why for example, there was not a single full professor of surgery in the Medical Faculty? Nepotism was everywhere present.

Answers to all these questions were not easy to find but comes back to the state of neo-colonialism. That is how it is here in Kosova, everyone was telling me. Matter fact and almost hopelessly without flinching. God help you! I could not understand, and it was impossible to justify this state of the healthcare system. How does an ordinary mind understand this bizarre state of healthcare system, when everywhere else Kosova has made great progress? In asking this question, I found solace in working  day and night on a new complex and ambitious transformation plan.

Please Not Another Feasibility Study

Study after study of many donors and partners came to the same conclusions: Kosova has too many hospital beds but an occupancy rate at about 50%, too many doctors (most of them in Prishtina), too many nurses, no efficiency, and a major mismanagement of resources. How can 15 surgeons  of a major department perform only 1,500 operations per year or, even worse, 13 surgeons perform only 600 operations per year, and, in both cases, most procedures were not major surgeries by any standard? I could not help but remember that my first 3 months as a trauma and general surgeon in Arizona in 2003, I performed 361 major operations.

When I would question these dismal performances, the explanations  were all kind and very colorful:  we do not available operating rooms (OR), we do not have anesthesiologists, we do not have OR nurses, and other managerial issues. The University Clinical Center had 37 operative rooms. Most are dedicated ORs for special clinical disciplines. I could not help but remember that Westchester Medical Center where I was a director of surgery we had only 21 ORs (7 of which were ambulatory ORs), where we did everything including heart, liver and kidney transplants and everything else in between, in all clinical disciplines, including serving two Level I trauma centers for adult and children. When  I needed an OR, the one that was not busy became the  OR to be used.

Over the span of 23 years since the war ended, despite the lowest GDP share, large amounts of funding from international donors and various NGOs have been donated to the healthcare system. Several Ministers, governments, and directors of hospitals and clinics have come and gone, but the situation has not changed. Even when highly expensive medical equipment was purchased, they did not function.  Another mystery to me.

Visiting the various departments and clinics reminded me of days when I was a medical student here: four patients in one room and no bathroom. Even in the renovated parts of the hospitals that have been finished in the last few years, there are three beds in one room (for the most part); the offices of staff occupy large portions of hospital wings, with one exception, the new pediatrics wing of surgery.

In summary, the public healthcare system in Kosova has remained in disarray and, overall, can be realistically characterized it was unsafe, unregulated, low quality clinical services with a lack of clinical faculty ability and skills, modern hospital infrastructure, and, above all, lack of managerial skills at all levels. Most patients with complex diagnoses were being sent out of the country or private institutions for treatment, at an astronomical cost.

How Do We Transform the Healthcare In Kosova?  ⁠A Trauma Surgeon’s View

Can healthcare Kosova be transformed? I asked myself every day while I was a Minister and still do. Rightly, people of Kosova asked the same question. Yes, it can, was my unequivocal answer, but it will require support for the vision and new investments, determination, and time. But how do you transform this state of healthcare and deal with each of these parts and segments of this very complex and distorted mosaic and healthcare disparity under medical neocolonialism? The ugly truth of the healthcare system is that those who have the financial means go to boutique private hospitals and clinics in the country or outside. Most rich people used Germany, Turkey, Austria, Switzerland and other countries for routine examinations. Most politicians go to private hospitals or outside the country even for routine procedures. When my appendix ruptured, I went to the public hospital, not private. If I have chosen to go to private hospital, first I would resigned and then go.  Those who do not have the financial means or do not have any one in the hospitals to vouch for them were faced with long wait times to see a doctor, with even longer wait times for a radiologic test or procedures or even an operation unless it is an emergency. These wait lists are often super-inflated and are created by some doctors to have patients go to private institutions to see the same doctors. Not all doctors are like this, but a majority are. It should not be like this. But it was there, and I had to  deal with it.

Let me try to simplify the answer to can we transform healthcare in Kosova, using the analogy of a trauma surgeon. As trauma surgeons, we save many lives by stopping the bleeding, securing the airway (intubate the patient early), always expecting the worse, performing laparotomies or emergency thoracotomies or whatever it takes, and working system by system, organ by organ, and simultaneously using lots of blood and blood products.

In rebuilding the healthcare system, we must use the same approach. Stop the bleeding (stop the flow of patients out of the country). This can be done by creating local expertise and modernizing the hospital infrastructure. Secure the airway (bring oxygen for the healthcare system) by adding resources to provide high-quality healthcare services and curbing treatment abroad, and finally, transfuse blood (transfuse knowledge and reform training ) to increase the ability to make the provision of high-quality services possible.

In summary, to achieve this, however, there are a few (essential) requirements:

1) Attract well-trained and prepared medical students, residents and fellows, faculty, nurses, and healthcare managers-eliminate nepotism; 2) Modernize the hospital infrastructure, put in place an advanced internationally- accredited healthcare system with health insurance and a health information system, and finally, 3) Ensure  professionalism and dedication at all levels by everyone  in healthcare system. People of our small but beautiful country of Kosova deserved that, and still do. They fought for this; they expected this from us, and we have failed them. The question remains, how do we do all this and was there an appetite for change? There was no appetite for change. Neocolonialists do not want change.

Data Driven Strategy as Tools of Transformation

During the first few months I was in the office, my team and I performed an analysis of the healthcare system, using the following methodology: 1) Interviews and written survey with all clinical leaders (directors of each clinical discipline); 2) A review of all patients treated outside of the public healthcare system, including diagnosis, reasons for treatment abroad (2019-August 2022); 3) Review of all reports of costly feasibility studies from consultants on hospital infrastructure and other opinions and materials available to the Ministry of Health in Kosova (MHK) on infrastructure, hospital bed occupancy, human capacities, and healthcare efficiency.
 Due to frequent changes of leadership of hospitals, not even board members of the hospitals did not read them, did not know about these studies, but at the insistence of many foreign governmental and non-governmental agencies, new  feasibility studies were being performed constantly. I thought it was madness, but it was the one of themmany cruxes of the problem.

The main outcome of this analysis was the lack of clinical expertise, hospital infrastructure (equipment or technology), lack of system in place ( trauma and emergency system) or other factors (lack of legislation for example for transplant). Often, even there was a clinical expertise, some directors would tell their young staff willing to do the procedure “remember if you have a complication” . which lead that great number patients with even trivial problems (need for biopsy) to be sent out of the country for treatment. The cost for each organized and highly structured enterprise was tremendous, and the amount for each patient that Kosova paid or owe to many countries, with the majority (84%) owed to Turkish private (not public)  hospitals was incredible.

Seven pillars of transformation and two-prong approach to transformation

Based on this analysis and reports from leadership of each clinic and feasibility  studies carefully reviewed,  we designed a seven pillars platform from which the entire strategy of transformation was derived (Table 1). Subsequently a two-prong strategy was created,

This can be simplified in two-prong process with multiple elements:1) Increasing capability of human healthcare capacities by 1) creating 12 clinical centers of excellence (CCE) and clinical programs of excellence (CPE) (Table 2; 2) creating  22 advanced clinical training fellowships (ACTF) (Table 3) for physicians and surgeons and train them initially  at best international centers of excellence, and 3) simultaneously reforming residency training programs and 4) building human research capacity and infrastructure. The second prong was 1) building and modernizing the hospital infrastructure, and improving the quality of healthcare services, and management skills, working through local and international collaboration- a well-known form of medical diplomacy.

Everyone  thought this was an ambitious plan, as one must agree, but these measures were the only way to transform the healthcare system and reduce patient flow outside of the country and public healthcare institutions. I knew that transformation would not happen quickly. It would take time, but we needed to start with a comprehensive plan and vision.

Summary

The main objectives and goals of transformation of healthcare of many post-conflict countries  are to advance their clinical medicine and surgery, increasing human capacities and expertise, reduce the number of patients flowing outside of the country or to the poorly regulated private sector to zero, and strengthen the relationships between the country in need with true partner countries. Unfortunately, many developed countries see an opportunity for a new form of neo-colonialism. Instead of helping these countries rebuild the infrastructure, and human capacities, they “help” by taking the patients for treatment, and of course this is too expensive and worse, does not allow development of capacities, so the dependency is perpetual. This is medical neocolonialism, as it has been thus far, for the most part.

It should be a true partnership built through medical diplomacy and friendship, aiming for post conflict countries to become part of the global medical village and to independently run its medical affairs. This totally can be done, post conflict countries need to lead the process, not those who benefit greatly from our medical incompetence. Finally, the next leaders of healthcare in Kosova will need to have the expertise and knowledge of how to do it but mostly free hands to transform and lead the change.

Despite a great deal of difficulties at each step from the moment I took over my tenure as Minister of Health in Kosova, we have made significant progress. We have a clear picture what is missing. Moreover, we have defined the platform and the path to transformation by using the new seven pillars of transformation, establishing 12 centers of excellence (one of which now I lead), and 22 advance clinical fellowships and reforming the residency training program. All these steps will improve human capacities and the hospital infrastructure, and this will stop or significantly reduce treatment abroad. Above all, it will increase security of the Republic of Kosova and other countries that implement such strategy.  There is no security without modern healthcare system.

PS: On a personal note, this has been one of the most remarkable segments and truly enriching experiences of my life. It has been an awesome opportunity to attempt to give back all I know and have learned in the USA and around the world, as well to attempt to integrate that global experience into our vision and mission of healthcare transformation in Kosova. We cannot accomplish this major transformation without partnering with countries around the world and without using medical diplomacy as a platform.  Using all these tools mentioned in this article, now we are building on of the centers mentioned in the Table I. (#3): The Kosova Center for Research, Simulation and Advanced Medical and Surgical Training at University of Prishtina. It does takes times, but we cannot hesitate to persevere.

 Tables

Table 1. Seven Pillars of Transformation

Seven pillars of transformation

1. Digitalization of healthcare services, including health insurance.

2. Brain return (gain) and reducing brain drain, creating policies for including the experts from diaspora in clinical, managerial, and leadership positions throughout the healthcare system.

3. Advancing clinical programs and centers of excellence through the specially designed and data-based analysis of programs for treatment outside the country and private hospitals and institutions.

4. Reforming residency and training programs and adding fellowships and international accreditation.

5. Decentralization of the hospital system and reorganization of UCCK, with empowering regional and local health systems.

6. Advancing research capacities and embedding research personnel, research residents, and medical students into most of the major clinical disciplines.

7. Modernization of hospital infrastructure and other healthcare institutions and increase quality of healthcare services including international accreditation of hospitals and other institutions.

Table 2. Proposed Centers and Clinical Programs of Excellence

1. The Emergency, Trauma, and Burn Center

2. Clinical Oncology Center of Kosova (COCK) or Cancer Center with ten departments and eleven clinical programs

3. Kosova Center for Research, Simulation and Advanced Medical and Surgical Training at University of Prishtina

4. Center for Children and Adults with Disabilities (Autism, Down Syndrome, and Other Rare Diseases)

5. Addiction Rehabilitation Center

6. Regional Center for Training and Emergency Disaster and Trauma Management

7. Expansion of the Telemedicine program from all Regional Hospitals of the Country to Main Centers of Family Medicine

8. Consolidation of the Advanced Center for Neurosciences

9. Consolidation of the Heart Center

10.⁠ ⁠Minimally Invasive Laparoscopic Surgery Program in General Surgery, Urology, Gynecology, Pediatrics, and Thoracic Surgery

11.⁠ ⁠Endovascular Surgery Program

12.⁠ ⁠Kidney and tissue transplant program

Table 3. Advanced Clinical Fellowships

Type of fellowships

1. Trauma and Surgical Intensive Care

2. Critical Intensive Care Medicine

3. Acute Burn and Wound Care

4. Breast Surgery and Breast Health

5. Surgical Oncology

6. Colorectal Surgery

7. Pediatric Cardiothoracic Surgery

8. Minimally Invasive Surgery

9. Geriatric Medicine

10.⁠ ⁠Palliative Medicine

11.⁠ ⁠Intra-abdominal Organ Transplant

12.⁠ ⁠Neonatology

13.⁠ ⁠Neurosurgery

14.⁠ ⁠Orthopedy

15.⁠ ⁠Psychiatry

16.⁠ ⁠Endovascular Surgery

17.⁠ ⁠Hematology

18.⁠ ⁠Pediatric Hematology-Oncology

19.⁠ ⁠Inner Ear Surgery

20.⁠ ⁠Obstetrics & Gynecology

21.⁠ ⁠Thoracic Surgery

22.⁠ ⁠Maxillofacial Surgery