Highlights
12 July 2023
Health-care system transformation in North Macedonia: towards health equity, cohesion and resilience
During the Third National Health Forum held on 31 May 2023 in Skopje, North Macedonia, WHO, the Ministry of Health (MoH) and the Delegation of the European Union (EU) to North Macedonia convened stakeholders from health and other relevant sectors to inform, agree on the vision for strengthening the health system and improving access to health services, and explore how those stakeholders can work together more effectively at national level, supporting the implementation of strategic directions for improving access to health services.
Strengthening the health system has been a top national priority for North Macedonia in recent years. A series of systemwide interventions and reforms have been initiated to improve health and social protection and quality of care, but accessing health services remains a significant challenge for many.
According to the latest Health Systems in Action Insights, public spending on health in North Macedonia has declined in recent years and is among the lowest in south-eastern Europe. There is strong reliance on out-of-pocket payments, which represented 40.4% of the total health spending in 2019 – one of the highest shares in south-eastern Europe. Consequently, catastrophic health spending remains a problem, particularly for poorer households, and is largely driven by out-of-pocket payments for outpatient medicines.
The Minister and Deputy Minister of Health, together with key professionals in the area, gathered at the Forum to establish concrete steps towards a transformation of the health system.
“A couple of months ago, when I first saw the results of the 2 studies presented this morning, I thought the picture they painted was very bleak. I had concerns about holding an event to launch the accompanying reports, lest we continue past practices of discussing assessments revealing how many challenges we face, and once again mapping out strategies to address them without following up to ensure that these strategies were actually implemented,” adds Dr Fatmir Mexhiti, Minister of Health.
Building on the findings of the “Assessment of barriers to health services in rural and remote areas and small urban settlements of North Macedonia” and the “Health Systems in Action Insights” (2022), and as part of the Regional Director’s initiative “Building state capability in North Macedonia: Strengthening the MoH governance and stewardship functions”, in the past few months WHO supported the MoH in developing strategic directions for addressing the key challenges currently contributing to poor health outcomes, inadequate financial protection, and dissatisfaction with the health system among both the public and the health workforce. The Minister of Health presented the strategic directions for strengthening the health-care system and reaffirmed the Government’s commitment to improving access to health services for all in the country. WHO and the MoH concluded that success in this process depends on joint coordinated action of all stakeholders.
“We all have a shared purpose and we are moving in the same direction. Even if the goal may be far in the future, we are taking steps towards it. It is a journey and I hope that we all continue on it together. Even though I am no longer in my previous role, I am always available to support North Macedonia,” says Dr Anne Johansen, Head of the WHO Country Office in Skopje.
Limited availability of some health services in many municipalities throughout the country (such as services of mental health professionals, gynaecologists or paediatricians) and transport-related barriers represent major obstacles in accessing health services for the people of North Macedonia. Data from the Assessment of barriers to health services show that 68% of the respondents reported that the number of paediatricians in their community was not sufficient, 49% of the respondents with a chronic health condition stated that travel time was a barrier to accessing a specialist, 58% indicated that appointment wait times were a major barrier to accessing health care, and for 71% of respondents the lack of appointments for specialists was a major barrier to health services.
Geographical disparities are noted both in the provision of outpatient consultation and specialist health services and for hospital health services. While access to these services is limited for residents of smaller towns, this is true also for some of the larger towns, including Kumanovo, Tetovo and Strumica. All tertiary health-care services are provided solely in the capital city of Skopje. Moreover, the distribution of hospitals in North Macedonia is unequal, with more than half of all hospitals located in Skopje. The rural population is underserved in many aspects, compared to people living in urban areas. The quality of physical and social infrastructure in rural areas has worsened over the past decades due to underinvestment in development and maintenance.
WHO’s valued partner, the EU, also recognizes the importance of the initiative taking place in North Macedonia. Says Maria Kanellopoulou, representative of the Delegation of the EU in Skopje, “Addressing the social determinants of health and reducing health inequalities has long been at the heart of the European idea. We have common objectives, and we need to pool resources and overcome our shared challenges, aiming indeed to address health inequalities present in daily life. Health for all had been the guiding vision of WHO for several decades. As EU we support this, and through the instrument of pre-accession assistance, the EU has invested over €20 million in the health sector so far and more than €10 million is in the pipeline.”
The lively panel discussion at the Forum, moderated by Dr Fabio Scano, emphasized the steps towards a successful transformation of the health-care system, as well as the issue of training and retaining health-care workforce in North Macedonia.
Dr Zlate Mehmedovic, one of the panelists and WHO focal point for primary health care at the MoH, said, “In our patient-centric system, protocols in primary health care existed before, but we now have these upgraded protocols with many more components, such as clinical pathways and quality indicators. This is what makes them a bit different than the system previously used in our country. It will allow us to precisely define the competencies, responsibilities and skills of health-care providers – both doctors and nurses – at primary level.”
At the closing of the Forum, the Minister of Health said, “I am confident that with a concerted effort, North Macedonia can look forward to a future with a healthier population, better and safer treatment, and more equitable access to health care, where no one faces financial hardship when falling ill or being afflicted with a disabling condition. To reach that goal, we must make primary health care the cornerstone of our health system, capable of meeting 80% of our health needs, as envisioned by the 2018 Astana Declaration.”
Event notice
31 May 2023
Purpose
The purpose of the National Health Forum is to inform and agree on the National Task Force’s vision for strengthening the Macedonian health system and improving access to health services. The Forum will also explore in a multistakeholder setting how key stakeholders in the health sector can work together more effectively at national level.
Objectives
- present the Ministry of Health’s strategic directions for strengthening the health system and improving access to health services;
- present the expected changes in the system;
- share findings of the “Assessment of barriers to health services in rural and remote areas and small urban settlements of North Macedonia”, “Health Systems in Action: North Macedonia (2021)”, and the “Health Labour Market Assessment” built into the strategic policy directions paper;
- enhance collaborative work and engagement of national and local authorities to contribute jointly to overcoming barriers to health services; and
- outline final steps needed to translate the Ministry of Health’s strategic directions into implementation actions.
Participants
Ministry of Health, Ministry of Labour and Social Policy, Ministry of Finance, Ministry of Information Society and Administration, Ministry of Local Self-Government, Ministry of Economy, and Ministry of Education, representatives of hospitals/health centres from the capital and the regions, select municipalities, mayors, members of the Parliamentary committee on health care, civil society organizations, youth organizations, patient organizations, academic institutions, Health Insurance Fund, Macedonian Agency for Medicines and Medical Equipment, Agency for Quality and Accreditation of Health-care Institutions, Institute of Public Health, Centres for Public Health, e-Health Directorate, State Sanitary and Health Inspectorate, United Nations partners, donors, ambassadors and the media.