The Minister Rama Is Looking For

Albatros Rexhaj

When I asked Edi Rama why Klodiana Spahiu, the answer came in three words: humble, professional, loyal.

The more I think about that answer, the less those three qualities look accidental. They read like a description of the minister Rama is looking for at this stage of his government. And healthcare is perhaps the best place to see whether he has found her.

Spahiu comes with an advantage no seminar can buy. She knows the hospital from the inside. She has been a doctor on the ward, she ran the Durrës hospital for a period, and she knows what happens between a decision taken at the ministry and the patient waiting in the corridor.

That distance is one of the old diseases of our health system. On paper you have a doctor; in the hospital you cannot find one. In the inventory you have the equipment; when you need it, they tell you it is broken and send you across the street to the private clinic. The budget has paid for the medicine; the patient leaves the hospital with a prescription in hand to buy it outside. Investment, contract, reform, statistic – everything exists, only the service is missing. A Health Minister is not measured by what the state says it has built. She is measured by what a citizen finds when something hurts.

So “humble” here is not a decoration of character. For that word I did not settle for the prime minister’s assessment; I asked around among people who know her from the hospital and from Parliament, and the answer was almost everywhere the same: yes, she is a woman with her feet on the ground. In healthcare, that quality is a way of working. A humble minister does not believe the system works because the report that landed on her desk says it works. She goes, sits in the hospital, talks to the doctor, the nurse and the patient, and asks why there is a queue, why the machine sits idle, why the medicine is missing, why someone from Kukës or Gjirokastra has to come to Tirana for something they should get near home. Not for the photograph.

Professionalism has just as practical a meaning. Spahiu is a physician. Nobody needs to explain to her what a delayed examination means, or a missing specialist, or a department that exists only on the staffing chart. She has seen the other side of the counter, and that makes her harder for the system to fool.

But the word that interests me most is the third.

Not that I want to philosophise about political loyalty. Rama has the right to choose ministers he trusts; every prime minister does. The question is what that trust produces.

Rama is trying to bring into government an idea he has called BESA and a way of working he has called Prania Besnike, the Loyal Presence. At its core it is simple: the citizen should not face a state that talks to itself, but someone who listens, someone who answers and someone who does not let go of the problem until it is solved.

I believe Rama when he says that this time he means it. Not out of any special faith in the word of prime ministers. He simply does not need this manoeuvre. He has the power. There is no opposition capable of taking it away. He does not need BESA to survive a single month in office. That does not prove his sincerity; a leader with secure power can do communication and legacy at once. But it is the main reason I am inclined to believe him, and why I think the initiative comes from a different question: now that he has power again, what will he do with it? Not how to win the next election, but how to make the administration he runs behave differently toward the citizen.

If that is so, Klodiana Spahiu is not simply the new Health Minister. She is one of the first tests of whether that reflection can become a way of governing. And in healthcare the test is brutally concrete, because the patient is not asking for a building permit or an administrative reply. The patient is afraid, in pain, perhaps with a sick child beside them, and the organigram is no use to them.

Prania Besnike in healthcare is not Spahiu turning up at a hospital every week. It is the hospital that works while she is in Tirana: the doctor on shift, the laboratory with reagents, the machine that works instead of sending you to the private clinic the moment you need it, the medicine in stock where the state says it has already paid for it, and a director who answers when something fails. That is her test: how much of the gap between healthcare on paper and the healthcare the patient finds she manages to close.

It will not be easy. Health care is a minefield, and the mines have owners. I do not know this only from reports. I have been in and out of hospitals for years, waited in corridors, listened to people and watched how the system works when there are no cameras. From those corridors I formed a conviction long ago: the pharmaceutical trade runs as a parallel budget, with financial relationships that reach all the way to the doctor; import prices are inflated because the wholesalers make the market; public money is paid for services the patient does not receive; and private owners have more influence over a public appointment than a private interest should have over a public system.

Albania needs pharmaceutical companies, needs private hospitals, needs the private sector. But the public health system has only one reason to exist, the patient, and when someone else’s interest starts to determine what service the patient receives, the minister must know how to say no.

This is where we will learn whether Rama has read Spahiu right. He did not choose an outsider who has to learn where the doors are. He chose a physician who knows the hospital, a politician with standing of her own and a person he himself says he trusts. Now it is her turn. She will need humility to hear the things subordinates would rather not tell a minister. She will need her profession to know when she is being given an explanation and when she is being sold an excuse. The rest is simpler: a problem that has merely been forwarded is not a problem solved.

The great condition remains. BESA and Prania Besnike cannot become one of those Albanian wonders that last three days. The first enthusiasm is the easy part: ministers go into the field, MPs listen, phones are answered, cameras roll. The test begins when this is no longer news. After six months, after a year, when the director has understood that the wave is not passing, when the minister knows it is not enough to say “I forwarded it”, when the citizen starts demanding answers not because the prime minister has just announced an initiative but because that is how the state works.

If Rama means it, and I believe he does, he must defend this standard even against his own people. Especially against his own people. Not by sacking a minister every time a machine breaks or a director blunders; that would be theatre. But when a minister abandons the spirit, when the office again becomes more important than the field and the report more important than reality, when the citizen goes back to being a nuisance rather than the reason for the work, there is nothing left to discuss. Whoever deviates from this standard goes. No political negotiation, no months of excuses, no automatic protection that power extends to its own.

Klodiana Spahiu should know this, and so should every other minister. Only then does “loyal” acquire weight: not to the chair, not to the minister, not even to the prime minister, but to what the government has undertaken to deliver to the citizen.

The citizen does not care how many meetings the minister has held, how many reforms she has presented or how many kilometres she has covered. The citizen wants to know whether, when something hurts, the state is there. If Klodiana Spahiu achieves that, Rama has found the minister he is looking for. If the obstacle is the system, Rama must give her the power to break it. If the obstacle becomes the minister herself, he must look for another.

BESA and Prania Besnike will not be judged by how they began. They will be judged by something much simpler: whether, this time, they last longer than three days.