A new WHO assessment on barriers to health in rural, remote and small urban areas in North Macedonia has revealed that accessing health services remains a significant challenge for many.
The Ministry of Health, WHO and Delegation of the European Union (EU) to the Republic of North Macedonia convened stakeholders from health and other sectors to discuss the initial findings from the assessment and identify strategies to ensure that people have better access to health services, irrespective of the conditions in which they were born, grow, live, work and age, as well as of their income.
“This assessment comes at the right time as the country is working on strengthening the health system and it underlines potential entry points for overcoming identified barriers through the primary health-care (PHC) reform, the forthcoming Health Workforce Strategy, and advancements in health financing,” said Dr Maja Manoleva, Deputy Minister of Health in North Macedonia.
Although the assessment report will officially be published in the coming months, initial findings enable preliminary understanding of the potential implications for informing public discourse and policy decisions.
“It is crucial to understand emerging evidence on the challenges in accessing health services faced by people living in remote areas. The findings will help us to identify effective solutions, such as promoting balanced territorial planning that reduces health inequities and tackles the underlying social determinants of health,” said Dr Anne Johansen, WHO Special Representative to North Macedonia and Head of Office ad interim.
As health care is inextricably connected to other sectors, overcoming the barriers to accessing health care can have a positive impact in other areas.
“Poor health in one sector of society is a threat to the public health of the whole society. To provide unequal care is untenable in a democratic society and carries with it an economic cost to society,” said Maria Kanelloppolou, Head of Operations at the EU Delegation. “The EU will work closely with the Government of North Macedonia and WHO to address the social determinants of health and achieve health equity.”
Availability, accessibility and acceptability of health services
The preliminary study findings are organized around the main principles from the Tanahashi Framework, according to which in order for a person to even obtain coverage, services must be available, accessible and acceptable.
The availability of health services in North Macedonia is being hindered by various challenges. The country’s essential medicines list, known as the Positive List, is not being updated regularly, which results in an insufficient number of medicines being available. Inadequate spatial distribution and supply chains, along with tender processes leading to shortages for some drugs, have further compounded the problem.
The situation is exacerbated by a persisting underprovision of modern medical technologies for diagnostic purposes, which are currently below EU levels.
In terms of the accessibility of health services, a perceived distance and lengthy travel time to reach services emerged as major barriers, particularly for people who are older, live in rural areas, do not have easy access to transport options, and for disadvantaged groups. Indirect costs, such as transportation and accommodation, as well as missed job opportunities, pose additional obstacles for these groups.
Organizational barriers, such as lengthy waiting times for appointments and limited service hours, also prevent many people from accessing health care. People with disabilities were particularly impacted, with over a quarter reporting inadequate access to services.
In addition, many people are deterred from seeking health care due to financial concerns and uncertainty about the costs involved. Fear of the financial burden associated with health care is a significant barrier for many people, limiting their access to essential services and medicines.
As regards the acceptability of health services, the issue of perceived discrimination in health-care settings has also been highlighted. People from certain ethnic backgrounds, occupations, education levels, socioeconomic backgrounds, and rural areas often experience discrimination from health-care providers. The assessment found that people with higher socioeconomic status are often perceived to receive better care, which further exacerbates inequalities in the health-care system.
Moving forward
The assessment demonstrates that investment in health systems and addressing health determinants needs to be at the heart of the socioeconomic development of the country. We look forward to being able to use the findings as a baseline for wider monitoring of health determinants across the health system,” said Dr Manoleva.
Building on the workshop for discussing the findings, a high-level health forum will take place in May 2023, launching the official report and promoting a more inclusive health-care approach in North Macedonia’s small urban and rural areas to reduce health inequities.
This initiative is an excellent example of collaboration across the 3 levels of WHO. Activities are being spearheaded by the WHO Country Office in North Macedonia alongside the Gender, Equity and Human Rights Team at WHO headquarters. This is supported by the WHO European Office for Investment for Health and Development, WHO European Centre for Primary Health Care, WHO Regional Office for Europe Health Workforce and Service Delivery Team and the Data and Digital Health Team, as well as the WHO Barcelona Office for Health Systems Financing.