Comparison of 2019 and 2018 data on the services provided by the National Emergency Centre 127 revealed a notable increase, reflecting the broader awareness and utilization of this service by the Albanian population. It's worth noting that Centre 127 was implemented throughout the Albanian national territory in 2018. In 2019, as compared to 2018, the following changes were observed:
-
Calls to 127 increased by + 99%;
-
Missions ending with emergency department admission rose by + 209%;
-
Missions concluding on-site increased by + 66%;
-
Medical consultations experienced a + 71% growth.
This surge in activity demonstrated the growing recognition of the quality and effectiveness of the services offered by Centre 127 among the Albanian population. It is anticipated that, without considering potential health emergencies such as the COVID-19 pandemic, the numbers related to the National Emergency Centre 127's activities will gradually stabilize as the entire Albanian population becomes more aware of the service's excellence. This trend is already noticeable in the 2020–2022 period, excluding COVID-19 services (see Table 1).
In 2019, the number of admissions to Albanian emergency departments increased by an average of + 28% compared to 2018. Admissions saw a + 13% increase in district and regional hospitals and a significant + 112% rise in university hospitals.
Despite the implementation of pre-hospital services contributing to the consolidation of in-hospital EMSs, the percentages of admissions to emergency departments facilitated by medical transports from Centre 127 remained limited, around 4%.
Looking ahead, it is expected that there will be a natural increase in admissions mediated by the National Emergency Centre 127, driven by the enhancement of its capacity to address acute health needs across the entire country (refer to Table 2).
Table 1
Data about activity of National Emergency Centre 127
Years
|
Calls to 127
|
Missions ended with
emergency department admission
|
Missions
ended on site
|
Medical
consultations
|
No COVID-19
|
COVID-19
|
No COVID-19
|
COVID-19
|
No COVID-19
|
COVID-19
|
No COVID-19
|
COVID-19
|
|
2018
|
202.349
|
-
|
19.998
|
-
|
24.464
|
-
|
22.302
|
-
|
|
2019
|
402.107
|
-
|
61.711
|
-
|
40.684
|
-
|
38.210
|
-
|
|
2020
|
557.239
|
190.984
|
61.164
|
7.414
|
59.057
|
8.403
|
82.732
|
92.744
|
|
2021
|
556.948
|
68.159
|
58.892
|
10.502
|
58.381
|
12.394
|
37.334
|
34.154
|
|
Table 2 Data about admissions to hospitals’ emergency departments
|
2019
|
2020
|
2021
|
|
N° admissions
|
Unit costs
|
N° admissions
|
Unit costs
|
N° admissions
|
Unit costs
|
District hospitals
|
407.673
|
1568
|
331.712
|
2182
|
380.301
|
2203
|
Regional hospitals
|
729.040
|
981
|
493.618
|
1309
|
633.280
|
1574
|
University hospitals
|
364.295
|
1826
|
303.825
|
4324
|
351.866
|
2390
|
Albania was the first country in the Western Balkans to enforce a lockdown on 9th March 2020.
Since 11th March 2020, the government has progressively put in place stringent and timely measures to curb the spread and citizens’ respect of confinement orders.
The government has made COVID-19 related care available to all residents and waived out-of-pocket payments for such treatments. For these reasons, Albanian government put in place numerous measures to support the Albanian economy, including the health sector, with both internal funding (amounting to 4% of GDP) and external emergency financing support from international entities such as the International Monetary Fund, European Union, and other donors [World Bank, 2021].
During the COVID-19 pandemic, the ability to build resilience depended on the strength and capacity of institutions to timely design and implement strategic measures. In Albania, when the COVID-19 pandemic impacted the healthcare system, the National Emergency Centre 127 was identified by the Ministry of Health as the reference service for the population to request information and receive an initial response. In cases requiring hospitalization, all COVID-19 positive cases were assisted in the infectious disease departments of university hospitals, where infectious disease wards nationwide and the majority of intensive care units are located. This approach reflected Albania's first choice for a hospital-centred response to the COVID-19 pandemic, as confirmed by all interviewees (Fig. 1).
Calls to 127 grew by + 86% in 2020 compared to the previous year (2019). The growth would have been only + 39% net of calls for COVID-19 (+ 47%). Regarding the characteristic activity of Centre 127, missions ending with admission in the emergency department grew by + 12% for COVID-19, while they would have remained essentially stable (-1%) otherwise. Instead, missions that ended on-site increased by + 45% for COVID-19 negative patients and by another + 21% for COVID-19 positive patients. Medical consultations experienced a significant total growth of + 317%, + 117% for the public and + 243% for COVID-19 positives (see Table 1 and graphics from 1 to 4).
In 2020, COVID-19-related calls accounted for 34% of the total calls to Centre 127. Among these, 4% ended with admission to the emergency department, 4% concluded on-site, 49% involved medical consultations, and the remaining 43% were categorized as other. On the other side, access to hospital emergency departments, on average, contracted by -25% in 2020 compared to 2019. District hospitals reported a reduction in access by -19%, regional hospitals by -32%, and university hospitals by -17% (see Table 2 and Graphic 5).
In alignment with global health strategies against the COVID-19 pandemic [WHO, 2020] but without specific guidance from the Albanian government, EMSs managed low and middle healthcare for COVID-19 negative patients and pauci-symptomatic and asymptomatic COVID-19 positive patients at home. This was evident in the increased related calls to 127, and, above all, missions ending on-site and medical consultations.
Focusing on these last two services, the increase of missions ending on-site and medical consultations demonstrated specially how the implementation of pre-hospitals EMSs enlarged the response capacity of the Albania healthcare system and ensured the provision of appropriate and of quality EMSs to very low and low health problems at local level. It allowed to limit accesses to hospitals emergency departments, avoiding unnecessarily crowding.
Accesses to emergency medical services of district hospitals must be considered as part of primary assistance. District hospitals supported the weak Albanian primary healthcare system in managing low-middle health needs, predominantly at home, for both positive (pauci-symptomatic and asymptomatic) and negative COVID-19 patients [WHO, 2020].
Regarding symptomatic COVID-19-positive patients in critical condition requiring hospitalization, all such patients were directed to university hospitals, where infectious disease wards were located. Centre 127 traced all COVID-19 transports provided for these patients. Consequently, the reduction in accesses to district and university hospitals was more moderate than in regional hospitals. In terms of the total number of admissions to emergency departments each year, the percentage of admissions in emergency departments in district hospitals (+ 2%) and university hospitals (+ 3%) increased, while those in regional hospitals decreased (-5%) in 2020 compared to 2019.
In line with the described health strategy, there was no reorganization in regional hospitals to provide essential services to manage the COVID-19 pandemic, and thus, no compensatory effect for the decrease in admissions was observed. Nevertheless, regional hospitals still accounted for 44% of the total admissions to emergency departments, district hospitals 27%, and university hospitals 24% in 2020 (see Table 2 and graphic 5).
In 2020, the national average cost for patient admissions to emergency departments substantially increased (77%) due to the widespread adoption of more expensive safety protocols (e.g., patient isolation, use of personal protective equipment, disinfection, surveillance) and to the efforts limit contagion during the provision of Emergency Medical Services (EMSs). Additionally, unit costs experienced a significant increase, particularly in university hospitals (137%), where COVID-19 positive patients were treated. The growth of unit costs in district and in regional hospitals was also notable with an increase of 39% and 34%, respectively (see Table 2 and graphic 6). The increase of the costs was fully confirmed by the interviewees (Fig. 1).
Thanks to the health strategies adopted to struggle against the first wave of COVID-19 in 2020 by the Albanian government and the intrinsic resilience of the Albanian health sector, primarily in territorial primary cares, the Albanian EMSs systems resisted and offered a good quality response, although more expansive.
The concentration of complex patients, both positives and negatives, in university hospitals permitted the accumulation of experience in managing this new disease, researching, and implementing innovative treatments by practitioners who possessed the necessary knowledge and know-how. On the other side, the enforcement of territorial health assistance for non-complex patients allowed avoiding the spread of contagion by maintaining these persons separated through domiciliary assistance [Migone, 2020].
In 2021, during the second wave, new health emergency strategies were implemented learning from the first impact of the COVID-19 pandemic. Increased comprehension of the disease course led to better treatments [WHO, 2021], while the arrival of the COVID-19 vaccine [WHO, 2023], and the observed resilience shown by Albanian primary care assistance during the first wave of the COVID-19 pandemic favoured territorial health assistance for all positive COVID-19 patients. The hospitalization of COVID-19 positives was no longer in university but in regional hospitals. It permitted the resumption of elective and outpatient activities in hospitals.
All interviewees underlined how territorial health assistance was promoted as a better response to population health needs than a hospital-centred one, remodulating the health emergency strategies in this sense.
The pressure on Albanian EMSs due to the COVID-19 pandemic was relieved with a significant reduction in Centre 127 activity in 2021 compared to 2020. In fact, calls to 127 decreased by -64% due to fewer calls related to the COVID-19 pandemic. Missions ending with admission of COVID-19 positive patients to emergency departments decreased by -42%, while those ending on-site for COVID-19 positive patients were reduced by 32% due to the slowdown of the COVID-19 missions. In fact, missions were almost constant (-1% for those ending with admission to emergency departments and − 4% for those ending on-site), excluding calls due to COVID-19. Medical consultations decreased by 130%, -75% for those related to COVID-19 and − 55% for other health needs. In 2021, COVID-19 calls were only 12% of the total calls to 127 (15% missions ending with emergency department admission, 18% missions ending on-site, 50% medical consultation, 17% other). The decrease in the use of Centre 127 for COVID-19 was the recognition of Centre 127 as a reference institution in case of acute health needs or in case of health emergency by the Albanian population, even with the progressive overcoming of the COVID-19 pandemic emergency. This was demonstrated by constant levels of ordinary pre-hospital EMSs provided (see Table 1 and graphics from 1 to 4).
Accesses to hospital emergency departments, on the contrary, increased on average by + 21% in 2021 compared to 2020. Emergency departments of district hospitals reported an increase in access by + 15%, those of regional hospitals by + 28%, and those of university hospitals by + 16% (see Table 2 and graphic 5).
The increase in accesses to emergency departments was especially driven by the recovery of admissions to regional hospitals due to the changing organization of Albanian in-hospital EMSs for the management of the COVID-19 pandemic. This rising trend was, in fact, justified by the resumption of elective activities and the implementation of a new health strategy to fight the COVID-19 pandemic.
As reported in interviews, Albanian government promoted the management of all COVID-19 positive people at the local level, designating regional hospitals as reference health facilities for the treatment of symptomatic COVID-19 positives that needed hospitalization due to their severe health conditions during the pandemic second wave. On the other side, at the same time, university hospitals were invited to return mainly to the treatment of ordinary health emergencies. It allowed a substantial reduction in the national average cost of each patient by -18%.
The shift of COVID-19 positive patients' treatment from university to regional hospitals led to an increase in unit costs in these hospitals (20%), but it was strongly compensated by a substantial reduction in unit costs for patients assisted in university hospitals (-45%) (see Table 2 and graphic 6). This change in strategy for the management of the outbreak obviously made possible by setting up infectious disease wards at regional hospitals and equipping them with added intensive and sub-intensive care units, as confirmed by the same interviewees working here.
Based on the available management and economic data, along with insights gathered from interviews, the Albanian emergency health system successfully adapted its health emergency strategies to manage the COVID-19 pandemic between 2020 and 2021. It demonstrated the ability to provide optimal responses to the health needs of the entire population, not solely limited to COVID-19 positive patients, all while ensuring the economic and financial sustainability of the system. This accomplishment was facilitated by the implementation of a common strategy and plan, allowing each organization to utilize its economic, organizational, and professional resources. In this context, Albanian pre-hospital and in-hospital EMSs system collaborated to address patients, providing the best possible healthcare response based on the organizational configuration at the time [Ma et al, 2020; Bartlett et al, 2023], similar to practices in high-income countries [WHO, 2022; Bong et al, 2020; Bollyky et al, 2022]. This collaboration occurred despite the lack of full operational integration and the absence of a communicative channel.
While the complete suspension of routine care posed challenges for patients with other diseases alongside COVID-19, Albania effectively met the health needs of these patients through the reorganization of the EMSs system in 2021. Notably, more personalized treatment was provided at the local level. Additionally, there was success in strengthening the role of Centre 127 as an information and first aid point of reference for health emergencies, aligning with the achievement of the goals set by the Sustainable Development Goals (SDGs) [Martín-Blanco et al, 2022].