The death of a 3-year-old following a dental procedure at a private clinic in Tirana exposed the lack of standards and assurances from these institutions. Normally, data regarding the legality or legitimacy of the clinic should be publicly available, serving as basic criteria for the accreditation process. This unsuccessful process, echoing previous promises that licenses would be revoked from healthcare institutions lacking accreditation, highlights the deficiencies. However, the system works ‘backwards’; the clinic in question was unlicensed to perform the activity and was only issued a license one month after the incident resulting in the death of the 3-year-old.
Esmeralda Keta
‘After obtaining the license, all private activities will undergo the accreditation process and comply with basic standards. In case of non-compliance, their license will be revoked,’ – declared Former Minister of Health, Ogerta Manastirliu, during the Parliamentary Health Commission in 2019, as she presented amendments to the healthcare law.
On the official page of ASCSG (Health and Social Care Quality Assurance Agency), the importance of accreditation is explained:
‘Accreditation’ entails the direct verification of the fulfillment of specific standards by healthcare institutions through on-site visits and external assessment concerning what is performed in that institution: products, processes, systems, personnel or teams, including a formal demonstration of the institution’s competence to carry out specific tasks. In this sense, the term ‘accredit’ is linked to this process of examining, assessment, or external evaluation.
“Screenshot of the explanatory video on the ASCSG page promoting the accreditation of healthcare institutions
The case of the 3-year-old revealed the failure of the accreditation process
Despite the Health Ministry’s pressure on license revocation, private healthcare institutions appear uninterested in the accreditation process, even though accreditation certificates would help assess the quality of healthcare services provided in the country.
The death of the 3-year-old in October 2023 following a dental procedure with anesthesia at the ‘Splendent’ clinic owned by Dr. Ina Xhaxho in Tirana raised questions about the monitoring of the quality of hospital care provided in private hospitals or clinics.
The clinic lacked a license, a compulsory requirement for conducting operations, at the time the child visited this facility in early October 2023. The State Health Inspectorate confirmed this to Faktoje through an official response, explaining that immediately after the incident, it conducted an inspection and clinic audit to verify compliance with healthcare service provision standards at the ‘Splendent’ clinic. ‘The State Health Inspectorate determined that the entity lacked a license for providing medical and/or dental services, category II.6 A.3 dental clinic,’ stated SHI, which imposed a fine of 500,000 Lekë on the entity in question.
In a WhatsApp communication, Dr. Ina Xhaxho herself provided the following explanation to Faktoje:
‘….I just wanted to clarify, as for more thorough information, you can ask a legal expert. The latter will explain that, as a legal entity, I can provide dental services. This is because I am not only registered with the Albanian Dental Association, but I have also been regularly registered with the National Business Center from a fiscal standpoint. As for the type of licensing, the latter is a formal administrative procedure that does not impede my professional practice. Merely reading the legal provisions on licensing is adequate. However, I would like to inform you that the decision has been legally contested because, in my view, it is unlawful. Currently, the matter is under consideration by the Administrative Court of First Instance in Tirana.’
On the other hand, the Ministry of Health specifies that the institution’s license should not be confused with the professional license of the doctor.
‘The license issued by the Dental Association is valid for practicing the profession, not for conducting business activities, for which the entity must apply through the National Licensing Centre, in accordance with the provisions of the law,’ – explains the Ministry of Health. According to the National Register of Permits and Licenses, it appears that this clinic currently holds two licenses. However, the licensing for conducting activities was obtained almost a month after the fatal incident, specifically on October 31st. In January 2024, the dental clinic was granted a second license, without any expiration date.
The failure of the accreditation process under expert scrutiny
Regardless of promises and deadlines, Albania has been failing for decades to accredit healthcare institutions, both public and private.
‘The state discovers the problem after it occurs,’ – comments Ilir Alimehmeti, the Vice Dean of the Faculty of Medicine, on the institutions’ incapacity to monitor the situation.
‘The principle is simple: a license grants you the right to engage in the activity. Without a license, you are operating unlawfully,’ he further explains.
‘Unlike accreditation, licensing is a mandatory process. Without a license, there is no healthcare service,’ – says Erion Dasho, taken aback by the situation.
Klodiana Spahiu, Vice Chair of the Health Commission, acknowledges that she is not aware of the specific deficiencies of the clinic where the incident of the child’s death occurred following the procedure. However, she emphasizes that licensing is the cornerstone of healthcare activities.
‘I am not aware of the dental aspect; fundamentally, any dental center surely cannot function without a license,’ she comments.
Viewing it holistically rather than as an isolated problem of one entity, experts consider it a failure that a healthcare institution has escaped the scrutiny of the system.
‘The question is, how much damage has been incurred here?’ How do I, as a patient, protect myself when the state monitors everything an individual does, but a clinic ‘slips through the cracks’?’ – Alimehmeti expresses his concern.
According to him, responsible institutions should establish a database where licenses are publicly accessible. ‘Why aren’t licenses made public, so people know who has them and who doesn’t? Clinics, hospitals, laboratories— you assume they’re licensed, and patients enter and seek services, believing they’re legitimate,” insists Alimehmeti.
Only 17 private institutions are accredited, which is 203 times fewer than the total
Unlike licensing, accreditation remains a voluntary process. The goal of accreditation is to assess compliance with standards and protocols, aiming to enhance the quality and safety of patient care.
While public institutions have advanced more rapidly, private ones have shown almost no interest in participating in the accreditation process.
According to the list of accredited institutions provided by ASCK, only 17 private healthcare facilities (including hospitals, medical and dental clinics, or laboratories) are involved in the accreditation process. Three other institutions had their accreditation completed several years ago.
This number of accredited institutions is utterly insignificant, considering that in the private system, there are 9 hospitals, 122 private clinics, 408 laboratories, 1416 dental clinics, and around 1300 pharmacies. Altogether, it is calculated that the number of unaccredited private institutions is over 203 times greater than those that are accredited.
In mid-2022, the National Accreditation Center, which had been involved in accrediting hospitals for nearly 20 years, was reformed, and the Albanian Quality Assurance Agency was created. Former Minister Ogerta Manastirliu also attended the event reiterating:
‘We will not tolerate any public or private entity evading such a vital process as the self-assessment and accreditation of the institution. This is a battle for quality’. Despite these ‘warnings’, figures show an indifference toward this process. Throughout 2023, the State Health Inspectorate conducted 62 inspections and re-inspections to ensure compliance with quality, safety, and accreditation standards in healthcare institutions.
The debate is that accreditation, being a complex process, cannot operate without autonomy
Klodiana Spahiu views accreditation as closely related to hospital autonomy.
‘This process, even though it’s not mandatory, forces you to do it eventually. Accreditation is a step that leads you towards autonomy. It’s becoming mandatory for the hospital sector because if you aim for hospital autonomy, you cannot attain it without accreditation’ – she explains.
Spahiu states that if there’s a mandatory ongoing education process for the staff, then institutions will also move towards this path.
Erion Dasho also believes that accreditation should align with autonomy, but he envisions it within the framework of complete autonomy.
‘When you look at a checklist and fail to meet certain criteria, such as lacking staff and autonomy, then you don’t have independence,’ – Dasho argues.
The numerous decisions regarding the accreditation process have resulted in confusion in the final regulation of this process.
‘The accreditation process is an extension of the obligation to meet the basic quality standards for accreditation. Only when an institution meets these basic standards can it proceed with the accreditation process. The Ministry of Health clarifies, according to DCM No. 865, dated 24.12.2019, ‘On the conduct of the accreditation process of healthcare institutions and the determination of tariffs and timeframes.’
Even the experts themselves are not completely clear about this process; in fact, they express skepticism about how it was left unresolved. Erion Dasho, one of the pioneering specialists who collaborated with Professor Isuf Kalo in the early 2000s to implement the accreditation process for healthcare institutions, states that any initiative that begins but remains incomplete creates another deficiency in the system.
‘;Albania suffers from measures taken in a non-strategic manner; they are initiated and abandoned halfway,’ – Dasho insists.
In his view, accreditation is a process that healthcare institutions opt for individually to demonstrate credibility and uphold a specific quality. According to him, in developed countries, ‘accreditation obligation’ is addressed by health insurance.
‘In some countries, it has become indirectly mandatory as insurance companies choose to collaborate only with accredited institutions. If you’re not accredited, no insurance company chooses to work with you’ – he explains.
For Ilir Alimehmeti, accreditation is a process that has only increased bureaucracy.
‘What are licensed hospitals missing today, as the fulfillment of criteria is the basis of licensing, and accreditation adds to this process? To simplify: if a university is accredited, what does it have more of? Does it have more recognized diplomas, more mobility? So, what does the accreditation process add to make institutions interested?’ – he says skeptically, adding that bureaucracies do not incentivize doctors, quite the opposite.
However, Erion Dasho argues for the necessity of the accreditation process, which, according to him, promotes the accountability of healthcare institutions in ensuring service standards:
‘In a country like Albania, where licensing procedures have been deficient, accreditation serves as a complement, placing the health institution in front of the responsibility to enhance safety and quality’.
The Ministry of Health has established a set of basic criteria that are prerequisites for obtaining a license to practice healthcare, along with a set of optimal criteria that must be met for accreditation. Full accreditation has a 5-year term and means that the healthcare institution meets at least 85% of the optimal standards. What is noticeable in the list of accredited institutions, which the Health and Social Care Quality Assurance Agency (ASCK) has sent to ‘Faktoje’, is that a significant number of institutions have received partial accreditation, meaning from 1-3 years, indicating that they have met 70% of the optimal standards.
Conclusion
The accreditation process for healthcare institutions, especially private ones where citizens choose to seek more specialized and less bureaucratic services, has failed despite the government’s commitments. The case of the clinic where the 3-year-old underwent dental surgery is an illustration of how the state’s oversight radar failed to identify the illegal activity of a clinic in the heart of Tirana. Based on the verification conducted and consultation with experts, former Minister of Health Manastirliu’s commitment to accrediting healthcare institutions will be categorized as Unfulfilled.
