Abstract
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Abstract
Objectives.
The principal objectives of this research is to investigate and evaluate the health system reforms that occurred in the R. Macedonia since independence of the country in 1991 to present days.
Methodology.
We conducted desk research of all available scientific literature in English and Macedonian languages on the health sector reforms, review of health legislations, and relevant documents available at the Ministry of health and Health insurance fund. Official data on demographic and health status indicators were collected from the Institute of Public Health, State Statistical Office, and were doubled checked with available international data sets. In addition, we conducted interviews with number of stakeholders working in the health care system to assess their perceptions on the impact of the health system reforms.
Results.
The Republic of Macedonia has inherited from former Yugoslavia health system with widespread and easy accessible health infrastructure, big hospitals, regional network of institutes of public health responsible for preventive activities, as well as notion of social ownership of health facilities. Since independence in 1991, the health system was reestablished to protect and promote the values of solidarity, equity and participation. Health system is predominantly financed by compulsory social health contributions of 7.3% from the gross salary of employees. Over the past two decades monopoly position of the Health Insurance Fund as single purchaser of health care services limited fragmentation of scarce health resources. However, more recently financing of the HIF is put into jeopardy due to increased number of insures, smaller transfer of funds from the central budget and generous basic benefic package. We recognized three waves of health system reforms in Macedonia: post-socialistic, pro-market, and manifesto driven period. These periods are selected on the basis developed and implemented reforms over specific period and political developments in the country. Over the years, poor maintenance, low efficiency and high operational costs has increased out of pocket expenditures for health, and reflected on the deterioration of public hospital infrastructure. This has reduced the quality in provision of health services in the public facilities. In parallel to these processes, liberal health care market regulation led towards trend in commercialization of the health care services, and investment in new private for-profit hospital services. Long transition and ineffective reforms in the public health sector forced huge number of health personnel, to move to the private sector. Many citizens disappointed in the quality of services provided in the public health sector, decide to opt for the services in private health care facilities, even without available health insurance.
Conclusions.
Despite many reforms and initiatives, political promises and actions, health sector reforms in the R of Macedonia are rather fragmented and overall does not present success story. The key problems are poor efficiency and quality of the services provided in the public health facilities; distortion of the social health insurance system and politicization of health sector system. This paper argues that in order to protect the system, public health facilities should be made more autonomous, efficient and more independent from direct influence of politics. To maintain the values of solidarity and equity, health system financing should be supported with additional funds from the central budget to cover the expenses for the previously uninsured.
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