Macedonia Health Profile 2012

The former Yugoslav Republic of Macedonia, situated in the middle of the Balkan Peninsula, covers an area of 25 713 km2 and has a
population of 2 022 547 (2002), making it one of the relatively small
countries in Europe. In autumn 1991, after 45 years as part of the Socialist
Federal Republic of Yugoslavia, the country gained independence in a
peaceful secession and established the political system as a parliamentary
democracy. Peaceful and stable relations with the all neighbouring countries
and accession to the European Union (EU) and the collective security system
of the North Atlantic Treaty Organisation (NATO) are considered the foreign
policy priorities. Economic reforms have focused on fully establishing market
economy structures, including deregulation and the introduction of the necessary
privatization trends in the public sector, liberalization of international trade, etc.
Alongside facing a number of unforeseen obstacles owing to regional instability,
such as the NATO campaign in Kosovo and the country’s civil unrest in 2001,
reform implementation has been faced with frequent political changes. Since
independence The former Yugoslav Republic of Macedonia has seen five prime
ministers and 13 different compositions of government. During the same period
10 ministers of health have been appointed, which indicates the stewardship
challenges for continuous and consistent health policy.
Life expectancy at birth for both sexes in The former Yugoslav Republic of
Macedonia has increased slightly from 72.12 years in 1991 to 73.53 years in
2003. However, this figure is still much lower than in western Europe and was
five years below the EU average of 78.49 years in 2004.
The former Yugoslav Republic of Macedonia shares the disease prevalence
pattern of that of other European countries: cardiovascular diseases, cancer,
mental health problems, injuries and violence, and respiratory diseases represent
the most prominent causes of morbidity and mortality. Several public health and  health care indicators show that the country is outperforming those of central
and south-eastern Europe and its EU neighbours in some areas. For example,
owing to a number of policy interventions, there is evidence of a decreasing
trend in communicable diseases and in the period 2001–2004 infant mortality
was halved.
Following independence, The former Yugoslav Republic of Macedonia set
up an insurance-based health system with the Government and the Ministry of
Health providing the legal framework for operation and stewardship, and the
established Health Insurance Fund (HIF) being responsible for the collection
of contributions, allocation of funds and the supervision and contracting of
providers. The Ministry of Finance, with its role in setting the annual state
budget, including the funds for health, as well as sharing with the Ministry of
Health the chairmanship of the HIF, and the Ministry of Local Self-Government,
with its aim to strengthen the communities’ role in primary health care (PHC)
delivery, as well as prevention and health promotion activities, represent
additional important actors in the system. Doctors’, dentists’ and pharmacists’
chambers are responsible for licensing health professionals, and the medical
associations are responsible for drawing up clinical guidelines.
Health care is delivered through a system of health care institutions, covering
the country’s territory relatively evenly. The health facilities range from health
care stations and centres at PHC level and specialty-consultative and inpatient
departments at secondary level, to university clinics and institutes at tertiary
level, with the latter also carrying out research and educational activities.
Recently the medical centres at municipal level have been functionally and
legally divided into primary health care on the one hand and specialistconsultative
and hospital care on the other. Moreover, some tertiary-level
institutions also deliver secondary care, and the system has yet to implement
the necessary regulatory framework to ensure proper gatekeeping and referral
practices. Recent years have seen substantial growth of the private sector,
especially in the field of primary health care. Most dental offices have been
privatized, and pharmacies are in the process of privatization.
The country’s compulsory health insurance system provides universal
coverage, and the current benefits package is considered very comprehensive,
but also very costly.
The funds generated by the collection of contributions represent the main
source of financing for the health sector. In 2004 the contributions accounted
for more than 95% of the public resources available for health care delivery
and other health insurance-related benefits and activities. In view of the
necessary expenditure the revenue is insufficient. Moreover, premium collection
mechanisms are still considered unsatisfactory, and transfers from the central budget to finance prevention programmes, for example, remain outstanding.
In this way the HIF has accumulated a significant deficit.
According to WHO estimates, total health expenditure as a percentage of
gross domestic product (GDP) in The former Yugoslav Republic of Macedonia
amounted to 6.8% in 2002. This represents a significantly lower figure than
that of most of the other ex-Yugoslav countries and the EU. In the same year
the health care expenditure in US$ (with purchasing power parity) per capita
amounted to US$ 341, with 84.7% of health expenditure coming from public
sources. Data on private expenditure, especially out-of-pocket payments and the
financial burden they might constitute, are neither detailed nor precise, therefore
data analysis focuses on the expenditure of the HIF: in line with the trend over
the preceding decade, the major share in 2004 (over 90%) covered service
delivery costs, followed by pecuniary compensation of insured individuals
(6.5%) and the fund’s administrative costs (2.2%). Expenditure for investment
in the health sector (0.7%) continued to be insufficient.
Since independence, The former Yugoslav Republic of Macedonia has
embarked on a number of reform initiatives in the field of health care. All
reform initiatives are undertaken with the aim of sustaining access for the
whole population to a comprehensive health system, as well as improving the
quality of health services and enhancing financial sustainability. A number of
reforms have been very successful and have brought about positive changes
in the health sector. At present the system is facing a number of challenges,
however, including the need to overcome the legacies of the health system that
was in place until 1991. These challenges include: strengthening of human
resources planning and training, including the reduction of the oversupply
of staff, especially in the PHC sector; strengthening of continuing medical
education; and introducing admission quota to training facilities. Moreover,
the health care facilities need to be rationalized in order to redistribute limited
resources more effectively and thereby to improve the infrastructure of facilities,
as well as the quality especially of PHC services. The reorganization of medical
centres at primary care level, privatization trends and reforms regarding the
remuneration of providers – with the introduction of a capitation-based system
at primary care level and an annual global budget allocation for inpatient care
– represent important developments in this field. Furthermore, regulation of
the pharmaceutical sector will need to be strengthened, promoting improved
procurement procedures and rational drug prescription practices. Overall,
sustainable health financing will need to be secured, including adequate funding
for preventive programmes and capital investments. To this end the Ministry
of Health will need to strengthen its policy formulation, implementation and
monitoring capacities, while the HIF will need to enhance its budget planning,
monitoring and reporting instruments.

The health system of The former Yugoslav Republic of Macedonia
represents an interesting case study of a transition from highly
decentralized autonomous structures to recentralization and to
decentralization again (for details see Chapter 2 on the organization of the
health care system).
Since independence in 1991, the country has been facing various structural,
economic and political challenges, in light of which the preservation of the
publicly-funded health system is a success in itself. The coverage of the
established compulsory health insurance system is in effect universal and the
present benefits package comprehensive.
The former Yugoslav Republic of Macedonia shares the disease prevalence
pattern of that of other European countries: cardiovascular diseases, cancer,
mental health problems, injuries and violence, and respiratory diseases represent
the most prominent causes of morbidity and mortality. Some (infectious)
diseases such as HIV and TB are less prevalent, but nevertheless require
special attention. Significant achievements have been accomplished in the past
decade to advance the health of The former Yugoslav Republic of Macedonia’s
population. Several public health and health care indicators show that the
country is outperforming those of central and south-eastern Europe and its EU
neighbours in some areas, and these successes should be celebrated. As the
result of a number of policy interventions, there is evidence of a decreasing
trend in communicable diseases and in the period 1991–2004 infant mortality
was halved. However, efforts need to be maintained in this area, as the infant
mortality rate is still significantly higher than that of the EU (43).
The health system still faces a number of challenges: the system is continuing
to struggle to overcome the legacies of the structures in place until 1991, such as oversupply of human resources for health and little rationalization of health
care institutions. The health insurance system in The former Yugoslav Republic
of Macedonia has experienced sustained financial imbalances, exacerbated
in recent years by substantial expenditure growth, while the sector’s revenue
(almost exclusively based on contribution payments) has remained limited.
Against this background, the following reform priorities have been identified: the
strengthening of the sector’s financial sustainability, the further rationalization of
delivery structures as well as the enhancement of human resources planning.
Since independence, the health system has struggled to deal with a 40% cut
in public revenue for health. This has resulted in funding shortages for health
care services, pharmaceuticals and other consumables. Moreover, the supply
and renewal of equipment as well as capital investment have been neglected
and the HIF has accumulated substantial debts with suppliers and commercial
creditors.
Furthermore, the scope and cost of the basic benefits package will need to be
revised in order to match the revenue of the Health Insurance Fund. This may
include measures to reduce the scope of the package, to introduce additional
payments or to increase co-payments, to increase premiums and to decrease
the number of individuals exempt from payments.
Reforms regarding the remuneration of providers have been initiated, with
the introduction of a capitation-based system at primary care level and an
annual global budget allocation system for inpatient care. Furthermore, the
privatization of health facilities, especially at PHC level, is under way: an
increasing number of private PHC offices are entering the market, all dental
offices have already been privatized and pharmacies are currently in the process
of being privatized.
Regulation of the pharmaceutical sector will need to be strengthened
significantly, including the establishment of improved procedures for drug
procurement (initial efforts in the area have led to a substantial price reduction
for the drugs in question), as well as the promotion of rational prescribing of
drugs.
Health care delivery structures in The former Yugoslav Republic of
Macedonia need to be rationalized to tackle duplication and underutilization.
Priority will be given to improving the primary health care sector. To this end,
in the health centres, the functional split between services at primary care level
on the one hand and specialty-consultative care on the other has been recently
introduced. It is furthermore acknowledged that in an efficient hospital network
there will be only limited room for specialized hospitals and institutions.

It is generally agreed that service provision should follow efficient and
evidence-based guidelines. In this context, efforts in the area of human resource
planning and training need to be strengthened, including the introduction of
continuing medical education and the definition of quotas for admission to
training facilities, with the latter to be based on needs assessment.
At present the system’s actors have weak management capacities, especially
in the areas of financial planning, monitoring and auditing. This situation is
aggravated by the poor quality of the current information system and data flow.
Against this background, the overall management capacities of the Ministry of
Health and the HIF, and in particular the financial management methods of the
HCIs will need to be further strengthened.
For the time being the main priorities of the Government and the Ministry
of Health of The former Yugoslav Republic of Macedonia will continue to be
the achievement of improved health status of the population; the provision of
a more sustainable, affordable and efficient health care delivery system with
high-quality and more patient-focused service provision; increased emphasis
on health promotion and community-based health care; and, finally, greater
responsiveness of the health system to globalization, in preparation for accession
to the European Union.