Vivian Mancellari
People with mental health disorders in our country face difficult living conditions, insufficient capacities and a lack of human resources. The problems that accompany this category are systemic and the economic burden that falls on them and their families is unimaginable.
Capacities and official data in figures
In our country, there are 4 hospitals that provide psychiatric Services with beds, which have a total capacity of 635 beds. In specialized mental health Services with beds, in the last 5 years, about 15000 hospitalizations have been carried out, according to a referral system of family doctor - Community Mental Health Center (CMHC) - Psychiatric Hospital or from the emergency room of Regional hospitals, to the Psychiatric Hospital.
The Psychiatric Service at the “Mother Teresa” University Hospital Center has a capacity of 90 beds. The reconstruction of this hospital has begun for several months and the service has been transferred to temporary facilities until the works are completed. For this reason and the conditions in which it is operating, the capacity of beds has been reduced to 55 in the transitional facilities, prioritizing cases. The Psychiatric Service currently has 52 patients hospitalized.
The "Sadik Dinçi" Psychiatric Hospital in Elbasan has a capacity of 310 beds and there are currently 302 people hospitalized in this hospital.
The bed capacity of the “Ali Mihali” Psychiatric Hospital in Vlora is 200. This figure includes the bed capacities of the two Sheltered Homes near this service, where chronically ill men with a capacity of 61 beds and 43 currently hospitalized patients and women with a capacity of 60 beds with 58 hospitalized patients stay. Currently, a total of 150 patients are hospitalized at this hospital, while in August of this year, 434 patients were reported.
The Shkodra Mental Health Service has a capacity of 35 beds and currently has 28 people hospitalized.
At the national level, a total of 10 Community Mental Health Centers operate, which provide multidisciplinary Services to the community in the field of mental health.
These centers are distributed in 4 regions and cover the respective areas as follows:
- Tirana Region – 4 centers: QKSHM No. 1 Tirana, QKSHM No. 2 Tirana, QKSHM No. 3 Tirana and QKSHM Kavaja;
- Elbasan region – 4 centers: QKSHM Elbasan, QKSHM Gramsh, QKSHM Berat and QKSHM Korça;
- Shkodra Region – 1 center: QKSHM Shkodra;
- Vlora region – 1 center: QKSHM Vlora.
In the period 2022 and January–September 2023 alone, over 108,000 visits were reported to all centers together.
Problems reported over the years
Our country is reported to have the lowest number of psychiatrists per 100000 inhabitants in Europe. In the Basic Register of the Order of Physicians of Albania, there are 57 registered doctors who are licensed and specialized in psychiatry. With a slight increase compared to a few years ago, Albania now has 2.4 psychiatrists/100000 inhabitants, compared to the EU average of around 18 psychiatrists/100000 inhabitants.
According to professionals, the low number of human resources, not only psychiatrists, but also psychologists, social workers, and nurses trained to work in mental health Services, reduces the quality of Services provided to citizens.
For psychiatrist Neli Demi, the problem is not only the quantity, but also the quality of the Services that this limited number of professionals provide.
"I think the way these specialists are trained is important, which in my opinion has room for improvement," says Demi.
According to information received from hospitals, there is sufficient training available for psychiatric staff, while mandatory training is mostly financed by the individuals themselves.
The Ombudsman considers it an urgent need to add psychiatrists, "caregiver/task force" nurses, security staff, sanitation workers, and barbers to the hospital staff, in order to provide a service appropriate to the specifics of this in-patient mental health service.
Through a communication with the Ombudsman's office, we are informed that: "The Ombudsman continues to assess that it is necessary to immediately increase the quotas for Psychiatry specialists in the coming years; reformulate the employment criteria for the clinical functions "caregiver" and "task force", with nursing education and in-depth knowledge in hospital psychiatric rehabilitation, as well as with age and physical abilities appropriate for managing agitation and high risk, as well as training current employees."
"Many social workers attached to the service are needed, due to the complex social problems that patients have when they are preparing to leave the hospital," says a response from the QSUT, regarding the shortcomings of the service.
Meanwhile, according to the "Ali Mihali" Psychiatric Hospital, Vlora, there is a need for an increase in the number of healthcare staff; Nurses and Caregivers at this service.
The Ombudsman has raised concerns over the years that the living conditions in which patients with mental health disorders are accommodated in Albania continue to be severe and unacceptable.
The National Mechanism for the Prevention of Torture has inspected mental health institutions such as the Vlora Psychiatric Hospital, the Shkodër Psychiatric Hospital, the Elbasan Psychiatric Hospital and the “Xhavit Gjata” Psychiatric Hospital in Tirana.
From these inspections, the main problems identified are:
- Lack of appropriate structural conditions for the treatment and recovery of patients at the “Sadik Dinçi” Psychiatric Hospital in Elbasan, the “Xhavit Gjata” Psychiatric Hospital in Tirana and the Hospital with beds in Shkodra;
- Infrastructure conditions in the wards, heating, showers and toilets in order to provide the most dignified service possible to persons treated in psychiatric hospitals, as well as ensuring the necessary material base for psychosocial staff;
- Lack of new beds and mattresses for all rooms in the Shkodra Inpatient Mental Health Service;
- Lack of recovery activities or occupational skills development facilities at the “Xhavit Gjata” Psychiatric Hospital in Tirana, the “Sadik Dinçi” Psychiatric Hospital in Elbasan and the Hospital with beds in Shkodra;
- Lack of medications and receiving the full supply of medications provided by Psychiatric Hospitals according to needs;
- Lack of clinical bio-chemical laboratories, as well as the provision of equipment for dental offices.
To address the need to improve infrastructural conditions and Services provided within hospitals, work has begun on the reconstruction of Psychiatric Hospitals and psychiatric inpatient Services.
However, from the long list of recommendations issued by the Ombudsman's office, the insufficient number of capacities to accommodate people in the recovery phase remains a concern.
According to a report According to the Supreme State Audit Office, published in 2024, 60% of beds in health institutions where specialized inpatient Services are provided are used by chronic resident patients, who have been living and being treated at these facilities for years. 58.6% of chronic resident patients have more than 10 years of stay in the hospital service.
This phenomenon is most pronounced in the psychiatric hospitals of Elbasan and Vlora where chronic resident patients are sheltered by these structures in the absence of alternative accommodation for them. According to this report, 37.5% of chronic resident patients are abandoned by their families.
Such a problem is also confirmed by psychiatric hospitals themselves. According to information received from the Vlora Psychiatric Hospital, rehabilitation is not impossible for people who have been in the hospital for several years, but they are abandoned people or people without a family nucleus.
For the inpatient mental health service in Shkodra, the main problem is where the patient goes after leaving the hospital, due to the numerous cases of abandonment by the family.
Another issue is their reintegration through regaining self-care skills and work capacity.
According to the Healthcare Services Operator, Community Mental Health Centers consider the lack of social residences for lonely and abandoned people as the main problem.
The ALSHI report highlights another problem regarding the process of physical restraint at specialized health Services with beds in our country, which is carried out in the absence of conditions and means that guarantee the protection of patients' rights.
More specifically, the field audit team observed that the rooms that should be dedicated for this purpose do not meet the criteria and best practices in this field to ensure that the patient is not harmed and traumatized by this process. Other means of restraint, such as straitjackets, mobilization beds and carts, etc., are also missing.
"In this regard, the Ministry of Health and Social Protection has not approved a unified protocol for carrying out this process, but has only approved the Protocol for the Management of Agitated Patients through relevant medications. Meanwhile, the specialized health structures themselves with beds have not systematically and accurately documented data on cases of physical restraint, leaving it unclear how this intervention is practically carried out in cases when it is necessary.", the SAI report further states.
During the inspections carried out by the Ombudsman, deficiencies were found in the training of support staff for the use of physical means in accordance with the standards provided for in the package of Sub-Legal Acts of Law No. 44/2012 "On Mental Health", as well as the need to improve the current conditions for the isolation of patients with acute crises. According to information from psychiatric hospitals, the Psychiatric Service at the QSUT needs to increase the number of nursing and task force staff trained in the management and intervention of extremely aggressive and violent cases. The psychiatric hospital in Elbasan and the Mental Health Service with beds in Shkodra lack isolation rooms, but they are foreseen in the reconstruction of the hospitals.
Unimplemented Action Plans
Until 2022, mental health issues are based on the Action Plan for the Development of Mental Health Services 2013 - 2022, which is accompanied by the drafting of the Action Plan for Mental Health 2023 - 2026 with the aim of promoting mental health care and the well-being of every citizen in the Republic of Albania.
The realization of this goal is based on the fulfillment of two major strategic objectives, the decentralization of mental health Services through the expansion and enrichment of the existing network with Services closer to the community, and deinstitutionalization, through the reduction of the number of psychiatric beds and the establishment and strengthening of community mental health Services.
According to the mental health action plans, the establishment of psychiatric wards in all regional hospitals in the country was foreseen, aiming to create around 325 psychiatric beds in these structures by 2022. This objective has not been achieved, causing the specialized health service to be overloaded with beds.
Regarding the centralization of psychiatric Services with beds, psychiatrist Neli Demi estimates that there is a need for a reformatting of capacities.
“I think it is a high number for an institution with beds, as I think psychiatric beds should also be distributed to regional hospitals,” says Demi, who further adds that “a certain number of beds in general hospitals would enable quick and convenient access to these bed needs throughout Albania.”
The path towards deinstitutionalization and the reduction of the number of psychiatric beds would be accompanied by the establishment and strengthening of community Services, such as Community Mental Health Centers.
Despite this commitment to establish and strengthen health Services at all levels, in practice it has resulted that, out of 25 Community Mental Health Centers that should have been established to provide outpatient care to patients with mental health disorders, only 10 have been established, in non-implementation of the Mental Health Action Plan 2013 - 2022.
"Available resources are concentrated in 4 regions: Tirana, Vlora, Shkodra and Elbasan. Being mainly concentrated in 4 or 5 districts, access for the population in general is reduced," says psychiatrist Neli Demi.
Low health budgeting and the consequences for the mental health sector
"Together for Life" is an organization that carries out its activities at the national level for the promotion and protection of human rights in general, and vulnerable social categories in particular.
According to the public expenditure monitoring report for the health sector, conducted by TFL, Albania is among the countries with the lowest funding for health in the Region and the EU, increasing the financial burden on citizens and jeopardizing access to Services for those in need.
Although the budget for health and social protection has seemingly increased nominally in recent years, it turns out that the percentage of Gross Domestic Product (GDP) and General Public Expenditure (GPE) has decreased significantly.
"In the European Union, the average expenditure to GDP is 10.4%, while Albania stands at the bottom of the list with only 2.8% for 2024. Albania also has the highest level of out-of-pocket payments in the region, with 51.3% of total health expenditure covered directly by citizens," says Alma Lahe, an expert at Together for Life.
The National Health Strategy 2021-2030 predicts that the health budget by 2024 would reach 4% of GDP, while starting from 2021 onwards, the percentage has been decreasing.
"Unfortunately, the forecasts in the 2026-2028 medium-term budget itself expect a decrease again," says Lahe, who further emphasizes that "the reduction in the health budget is worrying because it has a direct impact on reducing access to quality health Services, especially for vulnerable groups and those coming from low-income families."
As of September 2024, the Mental Health Action Plan 2023–2026 has had partial and limited implementation, mainly due to a lack of adequate funding and institutional prioritization.
"Financial resources have not adapted to the increase in real needs," explains Lahe.
According to the ALSHI report, for 2023 the weight that the treatment of mental health patients in psychiatric hospitals has taken is 2,5% of the budget used in the country's hospitals: "There has been a small budget for these patients, this has led to the lack of full satisfaction of the needs of these patients with mental health problems."
Financial burden on citizens
Many citizens with mental health disorders are in the care of their families, whether due to a lack of capacity or their own choice to care for their loved ones. The financial cost to these families is extraordinary.
Due to the distribution of community and inpatient Services, they often have to travel to Services and in cases of long distances from their homes, patients' families have to spend money on accommodation near the Services.
"If we calculate the cost of lost work days, and the expenses that people make, and sometimes are forced to take on debt, these are certainly hidden costs that unfortunately never come to the surface," says psychiatrist Neli Demi.
Family members who care for these people are often counted as a missing financial income in Albanian homes, as they have become dedicated caregivers and are not employed.
Another cost for this category of citizens is the purchase of medications they need for various emotional and mental disorders. A good portion of them are reimbursable, but this does not avoid abusive market practices.
"Due to some dynamics that in my opinion I could call criminal, monopolizing the pharmaceutical market, from day to day a widely used medication disappears and patients are forced to seek it abroad, and doctors are then forced to find alternatives to that medication or the quality of the medications that unfortunately, in my opinion, is not rigorously controlled," says psychiatrist Demi.
The KLSH report found that the failure to build capacity in the country's regional hospitals has caused an overload of medical staff, as the psychiatrists of these structures, especially in Elbasan, Vlora and Shkodra, not only cover the problems of the hospitals where they currently provide Services, but they also support regional hospitals.
More specifically, in the case of psychiatrists at the hospitals of Elbasan and Vlora, as well as the specialized health service with beds in Shkodra, despite the fact that the service is also provided to regional hospitals, psychiatrists are not paid additionally for this purpose. According to this report, this situation has occurred because the Council of Ministers No. 555, dated 11.08.2011, did not include the emergency Services provided by psychiatrists at the psychiatric hospitals of Elbasan, Vlora and the specialized health service with beds in Shkodra, who do not receive the necessary payment for this service.
The problems that accompany this health sector and this vulnerable category of citizens are complex. From all the data analyzed above, experts assess that there is a need for a redesign, reformatting of Services and a need for increased budgeting in health, especially for mental health.
