People in North Macedonia can increasingly access publicly financed health care, but catastrophic health spending remains a challenge, reveals a new WHO/Europe report.
The report, “Can people afford to pay for health care? New evidence on financial protection in North Macedonia” assesses the extent to which citizens experience financial hardship when they use health services. It is part of a series of country-based reviews monitoring financial protection in health systems across the WHO European Region.
The report shows that catastrophic health spending, or out-of-pocket payments that are large in relation to a household’s capacity to pay for health care, affects poorer people and older households the most and is mainly driven by out-of-pocket payments for medicines.
“For the first time, we have comprehensive, robust data and an opportunity to take stock of the progress on financial protection that North Macedonia has made in recent years,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe, at an event launching the report. “Stronger primary care, shorter waiting times and extended health insurance coverage have improved financial protection in the country. Now is the time to build on this success to ensure everyone has access to the health services they need.”
“This report comes at the right time, as we are facing acute needs for rapid response to the COVID-19 pandemic and transitioning to a more sustainable and resilient health system, where no one is left behind,” noted the country’s Minister of Health, Dr Venko Filipče. He added that the Ministry of Health would commit to taking forward the recommendations of the report, aiming to reduce financial hardship for citizens using health services, as the country makes further progress towards universal health coverage and builds back better from the pandemic.
Reducing financial hardship
Financial hardship caused by formal and informal out-of-pocket payments reflects persistent gaps in health coverage: some of the population is uninsured; coverage of medicines is limited; and protection from user charges (co-payments) is insufficient. In addition, public spending on health has been falling as a share of gross domestic product (GDP).
The new report sets out a series of policy recommendations to improve access and financial protection in North Macedonia:
- cover the whole population by breaking the link between entitlement to health care and payment of health insurance contributions, so that access to health care no longer depends on health insurance status;
- make outpatient medicines more affordable for people through strategic purchasing, regular updating of the list of covered outpatient and inpatient medicines, exempting more low-income people from user charges (co-payments) and extending the annual co-payment cap to all co-payments;
- address the root causes of informal payments, starting with better monitoring of their role and magnitude.
These changes will need to be supported by additional public spending on health, the report concludes, and careful use of new resources to meet equity and efficiency goals.
Addressing health inequalities
“In recent years, the European Commission has repeatedly underlined the need for investments in equipment and facilities in the health sector in North Macedonia, as well as measures designed to staunch the flow of medical staff from the national health system. The WHO analysis of financial protection in North Macedonia’s health system confirms this assessment and provides an insight into the financing of health-care services in the country,” explained European Union (EU) Ambassador David Geer.
“North Macedonia needs to develop organizational and management structures, as well as key functions and skills to ensure effective governance, planning and management of its public health-care system. In particular, measures are needed to address health inequalities, including through the strengthening of the national health insurance system,” he continued, adding that EU support for the development of the 2021–2030 health strategy will contribute to an improved health environment for all.
Moving towards universal health coverage
Universal health coverage is at the heart of the European Programme of Work 2020–2025, WHO/Europe’s strategic framework. Through the WHO Barcelona Office for Health Systems Financing, WHO/Europe carries out context-specific monitoring of financial protection in over 35 countries, including North Macedonia. The WHO Barcelona Office also provides tailored technical assistance to countries to reduce unmet need and financial hardship by identifying and addressing gaps in coverage.
“It is good to see that access and financial protection were improving before the pandemic began. The report’s findings indicate, however, that these issues deserve more attention as North Macedonia works to build back better,” said Dr Jihane Tawilah, WHO Representative in North Macedonia.
The report on North Macedonia is partly funded by the European Commission, Directorate-General for Neighbourhood and Enlargement Negotiations (DG NEAR) under the project “Strengthening health systems resilience in the Western Balkans”. This 3-year project will contribute to mitigating the impact of COVID-19 in the western Balkan region and to supporting the region to move towards universal health coverage.