The WHO Regional Office for Europe Situation analysis on the prevention of child maltreatment in Albania: The World Health Organization (WHO) the way forward is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Situation analysis on the prevention Member States Albania of child maltreatment in Albania: Andorra Armenia Austria the way forward Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization, Regional Office for Europe Original: English UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00. Fax: +45 45 33 70 01. E-mail: [email protected]. Web site: www.euro.who.int Situation analysis on the prevention of child maltreatment in Albania: the way forward ABSTRACT This situation analysis report on prevention of child maltreatment in Albania has been prepared with the cooperation of many stakeholders from different ministries, such as Social Welfare and Youth, Education, Justice, the police as well as nongovernmental organizations. Studies conducted in Albania suggest that many children needlessly suffer from child maltreatment. As in other countries, most maltreatment occurs in the community and may not come to the attention of child protection agencies. It is nevertheless a grave public health and societal problem with far-reaching consequences for the mental, physical and reproductive health of children, and for societal development. Health systems have a key role to play, not only in providing high-quality services for children who experience violence, but also in detecting and supporting families at risk. They should also implement prevention programmes such as home visitation and parenting support, and hospital-based interventions to support parents, along with programmes against abusive head trauma. Collaborative actions are required between all partners in order to tackle this public health and societal problem. One way of ensuring this is to develop a national policy on the prevention of child maltreatment. Keywords Child abuse – prevention and control Violence – prevention and control Health policy National health programmes Albania Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2016 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. CONTENTS Acknowledgements iv Acronyms v Preface vi Executive summary vii 1. Intoduction 1 2. Scope of the document 1 3. Key facts and figures on children in Albania 2 4. The extent of child maltreatment in Albania 3 4.1 Background 3 4.2 Studies of child maltreatment in Albania 4 5. Policy and legal frameworks to protect children from abuse and neglect in Albania 7 5.1 Policy framework 7 5.2 Legal framework in Albania 8 6. Services and systems for the prevention of child maltreatment 10 6.1 Social protection sector 10 6.2 Health-care sector 11 6.3 Education sector 12 6.4 Police sector 13 6.5 Justice sector 13 6.6 Nongovernmental organizations 13 6.7 Assessment of existing interpersonal prevention programmes in Albania 14 7. Conclusions and recommendations 16 7.1 Conclusions 16 7.2 Recommendations 16 8. References 18 ANNEX 1. List of the relevant stakeholders: assessment mission on prevention of child maltreatment 22 ANNEX 2. Summary report of the national policy dialogue on prevention of child maltreatment 24 ANNEX 3. International and national legislations 26 ANNEX 4. Types of services and support provided by NGOs 28 iii ACKNOWLEDGEMENTS This report on Situation analysis on the prevention of child maltreatment in Albania: the way forward was developed within the framework of the WHO Country Office in Albania/WHO Regional Office for Europe Biennial Collaborative Agreement 2014–2015 with the Ministry of Health in Albania. This report has been written by Ms Dimitrinka Jordanova Peshevska, WHO Consultant in Violence Prevention; Dr Gentiana Qirjako, Institute of Public Health, Medical Faculty Tirana; Dr Dinesh Sethi, Programme Manager, Violence and Injury Prevention, WHO Regional Office for Europe; and Dr Ledia Lazeri, Head of the WHO Country Office in Albania. Exceptional thanks to the key stakeholders who kindly contributed to the document by participating in the semi- structured interviews and sharing their knowledge, experience and commitment in the area of prevention of child maltreatment (see Annex 1). Special thanks to Ms Tamara Jordanova, psychologist, for her contribution to this report and provision of valuable comments. iv ACRONYMS ACE adverse childhood experience ADHS Albanian Demographic and Health Survey ANCH ALO 116 – Child Help Line BECAN Balkan Epidemiological study on Child Abuse and Neglect CM child maltreatment COMBI communication for behavioural impact CPU Child Protection Unit CRC Convention on the Rights of the Child CRCA Children’s Human Rights Centre of Albania CRU Children’s Rights Unit CSA child sexual abuse CSO civil society organization GP general practitioner IECD Institutions for Executing Criminal Decisions INSTAT National Institute of Statistics of Albania MICS Multiple Indicator Cluster Survey NSDI National Strategy for Development and Integration NGO nongovernmental organization SAPCR State Agency for the Protection of Child Rights UNESCO United Nations Economic, Scientific and Cultural Organization UNFPA Unied Nations Population Fund UNICEF United Nations Children’s Fund UNDP United Nations Development Programme WHO World Health Organization v PREFACE Child maltreatment has long been regarded as a criminal justice and social issue, and has only recently been seen in a public health perspective. This approach supports the view that child maltreatment is not inevitable and argues that prevention is more cost−effective than dealing with the consequences. Evidence gathered elsewhere such as in the European report on preventing child maltreatment indicates that organized responses by society can prevent child maltreatment. Child abuse and neglect are a product of social, cultural, economic and biological factors, and occur in all societies and countries in the World Health Organization (WHO) European Region. They are a leading cause of health inequality and social injustice, with the socioeconomically disadvantaged more at risk. Studies conducted in Albania suggest that many children needlessly suffer from child abuse and neglect. These studies have shown that, as in other countries, most child abuse and neglect occurs in the community and may not come to the attention of child protection agencies. They are nevertheless grave public health and societal problems with far-reaching consequences for the mental, physical and reproductive health of children, and for societal development. Maltreatment is also closely linked to other adverse childhood experiences. The consequences of such adversity may affect people throughout the life-course, with high societal costs. This situation analysis report on prevention of child maltreatment in Albania has been prepared with the cooperation of many stakeholders from different ministries, such as Social Welfare and Youth, Education, Justice, the police as well as nongovernmental organizations. The documents and studies that have been examined show that the scale of the problem in Albania is large, and that many victims of maltreatment do not come to the attention of the health and child protection services. Health systems have a key role to play, not only in providing high-quality services for children who experience violence, but also in detecting and supporting families at risk. They should also implement prevention programmes such as home visitation and parenting support, and hospital-based interventions to support parents, along with programmes against abusive head trauma. The health sector is also best placed to advocate for preventive approaches within an evaluative framework. The development of the Situation analysis of the prevention of child maltreatment in Albania was initiated and supported by WHO as part of the WHO Biannual Collaborative Agreement between the Ministry of Health, Albania and the WHO Regional Office for Europe. This report was presented in draft form at a policy dialogue with stakeholders from different ministries and sectors, civil society and international organizations. Many of the comments that were made have been incorporated in the report. I am grateful for the political commitment and leadership of my colleagues, especially those from the Ministry of Social Welfare and Youth, and Ministry of Education. Collaborative actions are required between all partners in order to tackle this public health and societal problem. One way of ensuring this is to develop a national policy on the prevention of child maltreatment. Dr Milva Ekonomi Deputy Minister Ministry of Health, Albania vi EXECUTIVE SUMMARY Child abuse and neglect are increasingly recognized and Discrimination, and Law on the People’s Advocate of serious threats to the nation’s children. This report is an Albania. Within the amendments of the Law on People’s initial attempt to describe and analyse the actual system, Advocate of Albania, there is a special section for the service provision, policy and legislation with the aim of protection and promotion of children’s rights. The current better preventing child maltreatment in Albania. policy and legal framework of the country enables a suitable platform for the prevention of child maltreatment, The consequences of child abuse, both immediate and but there is a need for stronger policy and legal long term, and exposure to different adverse childhood reinforcement and monitoring. experiences (ACEs) in childhood have a serious impact on physical and emotional well-being, as well as the health Several relevant sectors work in the area of prevention and and development of children. protection of child maltreatment: social, health, education, police, justice and others. Some nongovernmental Several studies in Albania have found an unjustifiably high organizations also provide services for children. At the prevalence of abuse and neglect in children. The results central level, there is the National Council for Protection of from the ACE study in Albania showed that the most Child Rights, and at the state level, the State Agency for frequently reported forms of abuse and neglect were the Protection of Child Rights (SAPCR). At the local level physical (40%), psychological (50%), sexual (6%), and (Regional Council) is the Unit for the Rights of the Child, witnessing the mother being treated violently (around and the Children’s Protection Unit at the municipality level 30%). The highest rates were found in Albania compared to work with non-profit organizations in line with rules to the eight other countries that conducted the ACE determined by the Council of Ministers. Health services for survey. Even higher rates of child abuse were presented in violence against children are part of the basic package of the Balkan Epidemiological study on Child Abuse and primary health-care services, which is provided in both Neglect (BECAN) study in Albania. The prevalence of urban and rural areas. Furthermore, these services are an physical abuse was 59%, psychological abuse 69%, sexual integral part of reproductive health. Existing services are harassment 11%, and sexual abuse 4.9%. The prevalence mainly focused on the detection and protection of victims, of neglect was 26%. Results obtained from studies on the and further efforts are needed to develop preventive attitudes toward child discipline showed that 28.6% of programmes and evidence-based practices tailored to the participants thought that children should be slapped for country context. the mistakes they make, while 7.7% said that they beat their children with a belt or hard object. In line with the European report on preventing child maltreatment, Investing in children: the European child As part of the response, the Government of Albania has maltreatment prevention action plan 2015–2020 and the prepared several policy documents targeting protection of country context, the following recommendations are child victims of abuse and neglect. These include the proposed: Action Plan for Children, 2012–2015; National Strategy for Development and Integration, 2007–2013 (NSDI); the • Develop a national policy. Although a child National Strategy on Gender Equality and Domestic protection strategy is being developed in 2016, there Violence, 2007–2010; the Strategic Document on is a need for a comprehensive action plan for the Reproductive Health, 2009–2015; and the Public Health prevention of child maltreatment, which would and Health Promotion Strategy – Towards a Healthy coordinate the actions of the different sectors. Such Country with Healthy People. a plan should specify who does what, to whom, when and where – this could be stand alone or In Albania, children’s rights and their best interests are incorporated into the strategy. protected by several laws. These are the Law on the Protection of the Rights of the Child, Family Law, Law for • Enforce the law on corporal punishment more the Pre-University Educational System, Law on Measures thoroughly. The State should promote and against Domestic Violence, Law on Protection from encourage non-violent forms of discipline as vii alternatives to corporal punishment through social • Improve data collection for monitoring, marketing campaigns, thereby changing the evaluation and research. The differences between traditional norm of violent discipline. the recorded cases of abused and neglected children and research data indicate the requirement for • Implement evidence-based preventive improving the system for data collection. The health programmes. The majority of services provided by and social protection system also needs institutions in the country are focused on detecting strengthening in order to adopt standardized abuse and protecting children from further approaches and collect valid data on mortality, maltreatment. More emphasis should be placed on morbidity, socioeconomic status and risk factors. implementing evidence-based prevention programmes such as home visits, positive parenting, • Address equity in prevention of child preventing abusive head trauma, teaching children to maltreatment. The relevant data suggest that the recognize signs of sexual abuse, and pre-school and development of national and local action plans and school preventive programmes. programmes should take into account socioeconomic inequalities such as by rural/urban areas and region. • Strengthen the systemic response for prevention, multisectoral collaboration and capacity building. The heath, social, police, education and justice sectors should adopt a coordinated approach to delivering quality services for recording, detecting, treating, preventing and protecting children. viii 1. INTRODUCTION Child maltreatment (CM) is a significant public health Involvement of different disciplines or a “health-in-all- problem that has a serious impact on the health and well- polices” approach to preventing violence is of crucial being of children. Globally, millions of children suffer from importance, and is in line with Health 2020: the European some form of violence. At the WHO Consultation meeting policy framework on health and well-being, and the on child abuse prevention in 1999, CM was defined as “all Sustainable Development Goals (6).1 The European report forms of physical and/or emotional ill-treatment, sexual on preventing child maltreatment provides policy-makers abuse, neglect or negligent treatment or commercial or with evidence-based preventive practices to tackle CM (7). other exploitation, resulting in actual or potential harm to The WHO Regional Committee resolution, EUR/RC64/R6: the child’s health, survival, development or dignity in the Investing in children: the European child and adolescent context of a relationship of responsibility, trust or power”(1). health strategy 2015–2020 and Investing in children: the Four types of CM are recognized: physical, sexual and European child maltreatment prevention action plan emotional (psychological) abuse, and neglect (1). 2015–2020 puts emphasis on improving the health and well-being of children, and reducing the burden of World Health Assembly resolution WHA 56.24 put maltreatment and other adverse childhood experiences violence on the international agenda, highlighting the (ACE) (8). importance of this major public health problem (2). Later in 2005, the Regional Committee resolution, EUR/RC55/ In Albania, the problem of CM has been addressed by R9 on the prevention of injuries in the WHO European numerous stakeholders, including the Government, Region, gave high priority to the prevention of violence ministries, public institutions and nongovernmental and unintentional injury (3). The United Nations Secretary- organizations (NGOs). The country has made impressive General’s study on violence against children brought gains in improving the policy and legal framework, but renewed policy attention to end violence against children additional efforts are required. This includes developing (4). The United Nations Convention on the Rights of the protocols, guidelines and tools for child protection. In Child (CRC) has been an influential instrument for particular, there is a need for greater coordination of the protecting children and preventing violence, supporting intersectoral response to prevent CM (7). the best interests of the child (5). 1 Sustainable Development Goals (http://www.un.org/sustainabledevelopment/). 2. SCOPE OF THE DOCUMENT This document was presented at a national policy dialogue Investing in children: the European child maltreatment on prevention of child maltreatment in Albania on 2 prevention action plan 2015–2020 (8) was used as the December 2015. Feedback was obtained on the next steps basis. (Annex 2). Its intended target audience is policy–makers and practitioners. Semi-structured interviews were conducted with key stakeholders in Albania in October 2015, focusing on four This document reports on a policy analysis to assess the main pillars: policy framework, legal framework, current situation of CM in Albania, and makes suggestions programmes and sources of information on the burden. on how to better prevent it. The aim is to identify gaps This was supplemented by an Internet search for key and further actions that stakeholders can take to improve documents from projects, organizations, agencies (World the CM prevention policy and evidence-based Health Organization [WHO], United Nations Children’s programming. The framework and evidence base in the Fund [UNICEF], United Nations Economic, Scientific and European report on preventing child maltreatment and Cultural Organization [UNESCO], and Council of Europe) 1