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5. There are many constraints on making these changes that need to be dealt with at the
government level. The working arrangements and structure of the Ministry has evolved in
response to issues such as:
Current governance and accountability framework for the hospitals and other agencies
that are not creating sufficient incentives for performance.
Method of setting pay levels which provide incentives to create divisions, centres, and
agencies.
Incentives for doctors and other technically skilled staff to be managers to get into the
higher paid management positions. This reduces breadth of other skills at senior levels.
There is insufficient recognition in the civil service classifications and pay scales of the
value of technicians in the public sector compared to managers. The draft Civil Service
Law and the proposed Law on Salaries continue these problems.
Government-wide administrative instructions that require a legal department, an
information department, and other government requirements such as the European
Integration Office and the Gender, Human Rights and Quality office. These instructions
specify positions and staffing but a “one size fits all” approach is not suitable for all
ministries.
Frequent changes of senior leaders. There have been four ministers and six PSs since
2002, with three changes in PSs in the past year. The current PS is acting in the role.
Some key departments have acting directors.
Funding decisions by the government. In some areas there has been insufficient
investment to support critical changes and improvements.
Rigidities in the allocation and management of finances that make it difficult for health
institutions to manage effectively (see World Bank report’s comments on hospitals in
Appendix D). 1
6. Changes need to be sequenced in a way that will build on current capabilities without
putting the organisation at risk of failing at its key roles during the changes. The
organisational arrangements and structure are the way they are in response to the
environment. If changes are forced without dealing with the barriers mentioned earlier, there
will be unintended consequences, such as losing key people. Best practice ideas could be
bad practice if the constraints affecting the MOH are not addressed. The reforms must be
designed to deal with the unique conditions in Kosovo and not simply transport models from
other countries. While there are many valuable lessons from other countries, the best
design will be the one that fully taps into the potential for rapid development, given the
situation in Kosovo.
Recommendations for the short term- next three months
1. Develop a process to consider the reform options for MOH functions, structure,
systems, processes, staffing and culture with a timeline for analysis and decision
making, resulting in the production of the Institutional Development Plan. As part of this
process, consider the options and variations presented in this report alongside others that
may emerge from the internal work on the reform options. If possible, conclude this plan
within three months and start implementing it as soon as possible.
2. Contribute to the policy and preparation of the changes to the laws on civil service,
labour and pay to address the potential problems emerging in these draft laws, including
the civil service job classifications; the pay mechanism; and the implications for workers in
the wider health sector who will not be civil servants. Consider if there are opportunities to
influence the law and policies impeding good design for the MOH relating to the form of
1 World Bank, “Kosovo Health Financing Reform Study”, page 11.
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