it is not easy to define a  good  health care system and  good  health care services . in these definitions , there is a complexity of elements or components , which contribute separately , but influence in a harmonized manner the perceptions towards a given health care system ( 1 , 2 ) . the health care system in albania has undergone several periods in which the health care concept has evolved significantly ( 3,4 ) . currently , the health care system in albania consists of three main pillars : primary , secondary and tertiary health care services ( 3 ) . the quality of health care is the consequence of strong links between service providers and users of the health care services at all levels ( 5 ) . perceived quality is one of the principal determinants of utilization and non - utilization of health care services ( 6 , 7 ) , a major issue in developing and transitional countries including albania , a former communist country in the western balkans which has undergone tremendous political and socioeconomic changes in the past two decades associated with significant health consequences ( 8 , 9 ) . in addition , the rapid process of transition in albania over the past two decades has been associated with an intensive process of internal migration ( from rural areas to urban areas of the country , especially in tirana , the albanian capital city ) and external migration ( mainly to the neighboring countries including greece and italy ) ( 9 ) . migration is linked to an increased aging which , in turn , enhances the general and already existing aging effect on healthcare utilization ( that is the relative care needs of the albanian population ) . to date , however , the available information regarding the quality of primary health care services in albania is scarce . in this framework , the aim of our study was to assess the quality of the primary health care services in albania with a main focus on family physicians perceptions towards the quality of health care services provided to the general population . a cross - sectional study was conducted in january - march 2013 including a representative sample of 132 physicians providing primary health care services in several polyclinics ( health centers ) of tirana . initially , a simple random sample of 150 physicians operating at primary health care level in tirana was targeted for recruitment . of these , 18 physicians could not be contacted ( n=7 ) , or refused to participate ( n=11 ) . the final study population consisted of 132 physicians ( 59 men aged 41.36.9 years and 73 women aged 43.74.8 years ; overall response rate : 132/150=88% ) . a structured self - administered and anonymous questionnaire was applied to all male and female primary health care physicians who agreed to participate in this survey . the questionnaire consisted of self - assessment of the following key dimensions / components of primary health care services : physical conditions at the workplace ( measurement scale : good [ score : 2 ] , average [ score : 1 ] , bad [ score : 0 ] ) ; availability and quality of working devices and equipment for proper diagnostic and treatment services ( measurement scale : not available [ score : 0 ] , available but not good [ score ; 1 ] , available and good [ score : 2 ] ) ; sources of scientific information available at the workplace ( not available [ score : 0 ] , available but outdated [ score : 1 ] , available and updated [ score ; 2 ] ) ; level of autonomy in decision - making ( no autonomy [ score : 0 ] , partial autonomy [ score : 1 ] , sufficient autonomy [ score : 2 ] ) . a summary score ( ranging from 0 to 8) was calculated for each physician based on these four dimensions of the quality of health care services which was dichotomized into inadequate quality ( overall score : 0 - 4 ) vs. adequate quality of health care services ( summary score : 5 - 8 ) . in addition , demographic data ( age and sex of physicians ) , information on working experience , number of population served , working place ( polyclinic , or health center ) , type of specialization received and involvement in teaching / training activities were collected for all physicians included in the study . median values ( and their respective interquartile ranges ) were used to describe the distribution of age , duration of work experience and the number of population served by the physicians included in this cross - sectional study . conversely , frequency distributions ( absolute numbers and their respective percentages ) were used to describe the distribution of sex , working place , specialization , involvement in teaching and training activities of the primary health care physicians . similarly , absolute numbers and their respective percentages were used to describe the distribution of the key dimensions / components of primary health care services according to physicians perceptions ( physical conditions at the workplace , devices and equipment , sources of information and level of autonomy ) . binary logistic regression was used to assess the association between the self - assessed overall quality of primary health care services ( adequate vs. inadequate ) with baseline characteristics of primary health care physicians . odds ratios ( ors ) , 95% confidence intervals ( 95%ci ) and their respective p - values were calculated . spss ( statistical package for social sciences , version 15.0 ) , was used for all the statistical analyses . demographic characteristics , working experience , specialization received , teaching involvement and population coverage of primary health care physicians included in this survey are presented in table 1 . median age of study participants was 44 years ( interquartile range : 38 - 51 years ) . median working experience was 14 years ( interquartile range : 4.5 - 23.5 years ) . median number of population served was 2500 inhabitants ( interquartile range : 2000 - 4000 ) . about 37% of the physicians were specialized in family medicine , 42% were general practitioners , whereas 21% had received other types of specializations including cardiology , pediatrics , rheumatology , or allergology . only 29.5% of primary health care physicians included in this study were involved in teaching and training activities ( table 1 ) . baseline characteristics of a representative sample of primary health care physicians in tirana in 2013 ( n=132 ) . * median values and interquartile ranges ( in parentheses ) .  numbers and column percentages ( in parentheses ) . table 2 presents the distribution of selected key dimensions / components of primary health care services according to physicians perceptions . overall , 31% of the physicians considered  good  the physical conditions at their workplace , whereas 24% deemed them about 24% of the physicians perceived that there were no devices and equipment for a proper diagnosis and treatment of their patients , as opposed to 40% of the physicians who considered the equipment and devices available and appropriate . about 48% of the physicians stated that there were no sources of scientific information available at their workplace , compared with 20% of physicians who reported availability of updated sources of scientific information at their workplace . about 67% of the physicians perceived a complete lack of autonomy in decision - making , whereas 10% of physicians perceived sufficient autonomy in decision - making in their current ( routine ) health care practice ( table 2 ) . distribution of selected key dimensions of primary health care services according to physicians perceptions table 3 presents the association of the self - assessed quality of services with characteristics of primary health care physicians included in this survey . age of physicians was positively related to the self - perceived level of quality of health care services . hence , younger physicians reported a lower quality of health care services compared with their older counterparts , a finding which was borderline statistically significant ( or=0.79 , 95%ci=0.61 - 1.04 ) . the odds of perception of adequate health care services were lower in men compared to women , a finding which was statistically significant ( or=0.68 , 95%ci=0.42 - 0.91 ) . physicians with less than ten years of working experience had significantly lower odds of perceiving the services as  adequate  ( or=0.77 , 95%ci=0.51 - 0.94 ) . the number of population served was a borderline  predictor  of the quality of primary health care services ( p=0.09 ) . physicians specialized in family medicine had significantly higher odds of perception of services as  adequate  compared with the rest of physicians who were not trained in family medicine ( or=1.56 , 95%ci=1.13 - 1.97 ) . on the other hand , involvement in teaching or training activities was not significantly related to the self - perceived quality of primary health care services ( table 3 ) . association of quality of services with characteristics of primary health care physicians ; odds ratios ( adequate vs. inadequate quality ) from binary logistic regression main findings of this survey relate to a positive association of an adequate quality of primary health care services with female gender , older age , working experience and training in family medicine of physicians operating at primary health care level in tirana , the albanian capital . these are generally in line with previous reports from the international literature ( 5 - 7 ) . albanian doctors working at the primary health care sector face many difficulties in their professional practice . hence , albanian physicians are currently expected to provide not only high - quality services , but they should also apply competencies related to leadership , management , and community support at large . from this point of view , our findings suggest that older doctors and those with more years of working experience tend to report a higher quality of primary health care services  reflecting a more favorable attitude which may be presumably linked to a higher level of professional skills and competencies . the population coverage was only a borderline predictor of the self - reported quality of services in the sample of primary health care physicians included in this study . this is an intuitive finding , in line with the expected direction , as the level of physicians competencies is related to the experience gained in the course of their health care practice ( 6 ) . our study was based on doctors perceptions about their working conditions and working environment and this can imply a subjective evaluation that can bear the possibility of information biases in the assessment of the current situation in terms of the quality of primary health care services in albania . therefore , health authorities in albania should develop and implement suitable instruments to measure the quality of health care services at all levels . furthermore , there is also a need to place in the public domain tool kits that can be used by physicians , administrators , and patient groups to assess and improve the quality of care . similar to many countries , albania should develop a national quality report , based on standardized comprehensive and scientifically valid measures , which should describe the country s progress in improving quality of care ( 10,11 ) . measurement and ranking of the quality of health care services should also involve patients perspective , in line with experiences and practices from other countries ( 10,11 ) . the current survey was an attempt to provide evidence about the perceptions of primary health care physicians regarding different aspects of their profession . our findings indicate that albanian doctors face several difficulties in performing their everyday tasks and , therefore , health authorities must undertake measures to improve their performance through provision of better working environment , availability and improvement of the instruments and diagnostic devices for diagnostic and treatment services . our findings provide useful evidence on the self - perceived quality of health care services from primary health care physicians perspective in transitional albania .
aim : to date , the available information regarding the quality of primary health care services in albania is scarce . the aim of our study was to assess the quality of primary health care services in albania based on physicians perceptions towards the quality of the services provided to the general population.methods:a cross - sectional study was conducted in january - march 2013 including a representative sample of 132 physicians ( 59 men aged 41.36.9 years and 73 women aged 43.74.8 years ; overall response rate : 132/150=88% ) providing primary health care services in several polyclinics ( health centers ) of tirana , the albanian capital city . 
 a structured self - administered and anonymous questionnaire was applied including physicians perceptions regarding different dimensions of the quality of primary health care . 
 binary logistic regression was used to assess the association of self - perceived quality of health care services with baseline characteristics of physicians.results:self-perceived adequate quality of health care services was positively related to the age of physicians , their working experience , female gender , a lower population served , and specialization in family medicine.conclusion:our findings provide useful evidence on the self - perceived quality of health services from primary health care physicians perspective in transitional albania . 
 health authorities in albania should implement suitable instruments to measure the quality of health care services at all levels .