North Macedonia country snapshot: public health agencies and services in the response to COVID-19

Florian Tille, Jihane Tawilah, Arta Kuli, Margarita Spasenovska, Goran Kocinski, Sara Kajevikj

Introduction

This snapshot explores the role of public health agencies and services in North Macedonia in responding to the COVID-19 pandemic. It uses a sub-set of public health functions to serve as ‘tracers’ of how far public health was engaged in different aspects of the response to the pandemic. The snapshot covers the role of public health agencies and services in the following areas: pandemic planning, overall governance of the pandemic response, guidance on non-pharmaceutical interventions, communication, testing and tracing, and vaccination. The report draws on a review of published evidence, as well as expert interviews.

Pandemic planning and response

The COVID-19 pandemic has been a global emergency since early 2020.  In North Macedonia, public health bodies have consistently been involved in both the planning and management of the national outbreak response.

As soon as information about a new pathogen was announced, the country immediately scaled up its capacity to detect, trace, prevent, treat and reduce virus transmission. The country mobilized a pan-government response to fight COVID-19, scaling up emergency response mechanisms across all sectors. The government activated a national crisis management unit, consisting of ministers and headed by the President of the Republic, to ensure that the response to COVID-19 was based on a multi-sectoral approach.  A formal declaration of emergency was issued on 18 March 2020, and remained in place until December 2021.

Overall planning is led by the Ministry of Health (MoH), through both existing health agencies and new ones established by the MoH during the pandemic. These include the National Institute of Public Health (IPH), the National Commission for Infectious Diseases (CID), the Coordinator of Human Resources in the Hospital Sector, the National Technical Working Group on Covid-19 Vaccination (NTWG) and the National Vaccination Commission (NITAG).

On the ground, regional Centres for Public Health (CPH) have been responsible for the surveillance of COVID-19 cases and for performing contact tracing, with direct support and coordination from the IPH. The IPH has been collecting and processing these surveillance data, preparing reports and disseminating them to the relevant audiences, including the MoH and the general public. Much of the information is available on its website (https://www.iph.mk/en/).

The country’s public health laboratories have been managing the laboratory diagnostics. At the beginning of the pandemic, only the IPH was permitted to perform laboratory diagnostics for SARS-CoV-2. To cope with demand, laboratory capacities were later expanded to include 11 other laboratories, located in CPHs, hospitals and medical faculties. Private laboratories have also now been included to increase the health system’s testing capacity. At the end of 2021, there were 26 laboratories that provided laboratory diagnostic services.

For the management of COVID-19 cases, initially COVID-19 patients were treated only in infectious disease wards of selected public health facilities. However, currently the majority of public hospital facilities provide treatment for COVID-19 patients, as well as two private hospitals. One major achievement in the public health response was setting up 19 modular, pre-fabricated hospital units across the country. These helped to repurpose health facilities that previously did not treat patients with infectious diseases into centres for COVID-19 patients during peak periods of high patient numbers and hospitalizations.

In terms of staff capacity, the country has met the challenges of the pandemic with an effective response. Fundamental to this has been a focus on deployment of health care workers (HCW) across the country. Staff are rotated between health facilities, including COVID-19 centers, and all medical staff have supported epidemiological services, including public health care workers. Additional contact tracers were trained, mostly university medical and nursing students and Red Cross volunteers.

There were shortcomings in the public health response, especially at the start of the pandemic.  Repurposing health services and facilities was initially a challenge , and during this period capacity for routine health services diminished with appointments cancelled or delayed.  Access to basic and preventative health services has remained variable during the pandemic, and there have been  disparities between certain types of clinical conditions and regions. The overall number of referrals and referral rates decreased in 2020 by 36.7% and 25.2% respectively when compared to 2019. Paradoxically, this meant that primary care appeared to be more responsive, reaching levels of referrals close to advanced primary care systems.

Governance and key entities

COVID-19 is not the last health emergency that North Macedonia will face. Prevention, preparedness, readiness, response and recovery lie on a continuum, and to be effective, this continuum needs a stronger public health system. In recognition of this lessson from the pandemic, North Macedonia is adopting plans to strengthen its overall capacity for health security in the country, to support recovery from COVID-19 and improve responses to future threats.

That said, it must also be recognized that COVID-19 has highlighted some positive attributes about the country’s health capacity. These include:

• Transparent decision-making during a crisis;
• Trust in WHO and international partners to provide or facilitate support;
• Willingness to engage in national, local and international partnerships;
• Strong coordination across the many different sectors affected by the pandemic.

Public health and social measures

The planning and coordination of all non-pharmaceutical interventions – also known as public health and social measures (PHSM) – sits under the jurisdiction of the Commission for Infectious Diseases. In terms of communication, messages have focused on encouraging citizens to strictly adhere to Government recommendations in order to prevent the spread of the virus. Implementation of all PHSMs has been supported by the 10 regional and 21 local units of the Centres for Public Health at the municipality level, together with the Institute of Public Health.

Physical distancing, evening curfews and other movement restrictions were introduced during various waves of the pandemic in North Macedonia. Restrictions began with the closure of educational institutions, and progressed to curfew hours during the day and evenings. There were also restrictions on mobility hours separating younger and older people to minimise the risk of transmission, which received some international criticism. More stringent movement restrictions were introduced after the President declared the first national state of emergency in March 2020. To support these measures, the Government implemented sanctions for anyone failing to comply with regulations, and enforcement was supported by police and state inspectorate.

Later in 2020, a new set of PHSM were introduced. These included:

• Wearing face coverings (masks);
• Promoting remote working for public organizations;
• Limiting operating hours for restaurants, public services and courts;
• Capping participant numbers at sporting events;
• Assorted physical distancing measures, including banning gatherings in public spaces at certain times, and reduced public transport capacity.

All of these measures were continually monitored and readjusted according to the epidemiological situation, whilst carefully balancing economic and social considerations. They were all developed in line with WHO recommendations.  

There was also room for innovation. In April 2020, the government launched the “StopKorona!” app, which alerted users if they had been in contact with someone who tested positive for COVID-19. Unfortunately, the application was not widely used (15-20% uptake by 2021) by the population, undermining its effectiveness as a public health tool.

PHSMs only work when properly enforced or when there is high public compliance. Initially, the public demonstrated a positive response and good compliance with the new measures, indicating strong trust in government decisions. However, by the summer of 2020 there was a growing public fatigue, aggravated by the economic impact of the measures. Against a declining number of cases, some of the measures were lifted, unfortunately resulting in a rapid resurgence of cases. 

Data available from behavioral insight studies on the public uptake of PHSM in North Macedonia (in June 2021) indicate that about one third of people did follow social distancing recommendations. Non-compliant individuals tended to have lower levels of education or literacy than those following the recommendations. They usually held beliefs that getting infected would not have severe consequences, or they voiced low trust in official institutions and the national government. Of the various PHSM, wearing a mask in public received the highest level of support among citizens, with 7 out of 10 respondents supporting this measure. On the other hand, imposing restrictions on restaurants or celebratory gatherings such as weddings were only supported by around 5 out of 10 respondents.

Public information, risk communication and community engagement

In any public health crisis, it is critical to monitor public perceptions of risk, public behaviours, and levels of public trust. It is also important to monitor where citizens are sourcing their health information, in order to enable health authorities to understand perceptions of key measures and tailor suitable responses to any challenges.

Since the beginning of the pandemic, the MoH and its agencies have engaged in regular, proactive and transparent communication with the general public. As the COVID-19 situation evolved and messages changed, significant support was needed from a robust network of stakeholders to address a number of communication challenges and to highlight the importance of the public’s compliance with PHSM.

Communication strategy

The MoH has been the official voice for the Government, announcing all measures and reporting the number of cases. It has liaised with the press daily through regular press conferences, press releases, media appearances and social media. Early on in the pandemic, the Ministry ran an extensive communication campaign on social media, television and other channels, to inform the public about the national response to COVID-19. Subsequent campaigns have specifically focused on reducing COVID-19 vaccine hesitancy. 

Initial information-sharing was designed to tackle swiftly and consistently the need to access life-saving information and essential services from trusted sources and to fight misinformation.  Public health experts and society leaders have regularly appeared in the media, providing recommendations and explaining them to the public. In addition, community engagement in North Macedonia has been a promising feature in the fight against COVID-19. It should be further promoted by ensuring health decisions and messaging are adapted according to community feedback, concerns and priorities.

Sources of information

The MoH has established a central website dedicated to all official COVID-19-related information. Official information published there daily includes:

• Number of newly infected cases
• Total number of infections
• Number of deaths
• Number of recoveries
• Updates on hospital capacity (total available beds etc.)

As the vaccination campaign has got underway, the Ministry of Health has also begun reporting statistics relevant to this, such as number of vaccine registrations, vaccine administrations (single and double dose), percentage of population vaccinated, and vaccination demographics.

On its main website, the Government has also dedicated a section to COVID-19 where information on the pandemic and associated measures is updated regularly. The Ministry of Education and Science has established a daily monitoring tool that gathers data on the number of active and new cases of COVID-19 in schools (both among students and staff), as well as staff absences, total number of students attending school, and issues with remote learning.

In addition, and particularly to support those without internet access, national helplines were quickly set up. These were intended to support all groups of society, but especially vulnerable populations, women and children, and parents. They offered psychological support and guidance for stress, mental health issues, parenting and for reporting domestic violence.

Based on guidance from WHO, UNICEF and others, the MoH and the Institute of Public Health have also produced a number of simple videos for the general public, urging adherence to protective behaviours such as wearing masks, washing hands, social distancing, and avoiding crowds. These videos were published widely on TV and social media in three different languages: Albanian, English and Macedonian. Health advice notices, health declaration forms, posters, leaflets and other materials were later added.

The media has played a major role in keeping the public informed throughout the pandemic, as well as helping fight fake news and disinformation. A positive example is the website StopDezinformacii.mk which is part of the News and Digital Literacy Project – Where Fake News Fails.[1] In addition, a disinformation toolkit has been made available.

Finally, the private sector has been active in promoting messages about safety measures and health protocols. Some private companies have stepped up in digitalizing services and creating new digital platforms to help people access information.

Public engagement

To ensure campaigns respond to audience needs, WHO has implemented several rounds of behavioural insight studies. The purpose of these has been to provide rapid assessments of public opinion on COVID-related issues, in particular vaccine hesitancy. Data collected from these has been incorporated into the design of campaigns, especially in terms of harmonizing messaging and highlighting any specific needs for key vaccine target groups such as health care workers.

Media monitoring and social listening have also been key sources of data for public opinion on the national response to COVID-19 and associated measures. Closely monitoring online and offline media, as well as community conversations where appropriate, has enabled health authorities and their partners to track misinformation and combat it in a timely and effective manner. Another source of support has been the chatbot HealthBuddy+, launched in North Macedonia in 2020 with the help of WHO and UNICEF. It is a multilingual interactive digital tool designed to debunk false claims about the virus and support the dissemination of truthful information on COVID-19. HealthBuddy+ also provides access to insights on chatbot use, topics of interests, reported rumour and data from polls which can be used to inform national health authorities and decision makers.

Impact

Overall messaging to the general public has been consistent and delivered by trusted stakeholders. Messages have been delivered in all local languages, and have been updated according to the evolving epidemiological situation, new scientific findings, and the efficacy of protective measures.

It has also been recognized that people’s engagement with and response to public health information and messaging is significantly affected by economic, sociocultural and psychological factors. These factors have also had an impact on vaccine uptake during the initial COVID-19 vaccination roll-out, and have therefore also affected communication campaigns and messaging. By using behavioural data, media monitoring and social listening, health authorities have been able to adjust their communication approaches and better target their efforts.

In the future – for both COVID-19 and non-COVID information campaigns – North Macedonia should reinforce its community engagement, creating ways and means for local community representatives to be partners in developing tailored delivery strategies and information campaigns in health. This will ensure that their knowledge and experiences are included in the planning process, and that resulting services and engagement strategies meet local needs.

Early SARS-CoV-2 detection, testing, tracing and isolation

Starting with the outbreak of COVID-19 in North Macedonia, the Institute of Public Health activated services to deliver laboratory virology and molecular testing on an unprecedented scale. It has acted as lead agency for contact tracing and risk assessment, epidemiological analysis and surveillance, and providing evidence-based information to the Government and the public. These essential public health functions have been delivered in collaboration with 10 regional Centres for Public Health and 21 municipal units.

The Laboratory for Virology and Molecular Diagnosis, at the Institute of Public Health, is the only reference laboratory for COVID-19 in the country. Designated in 2019 by WHO as the national influenza laboratory, meaning it met adequate biosafety standards to work with pathogens, it immediately started operating in accordance with WHO laboratory testing protocols for COVID-19 and with WHO-distributed tests. While the laboratory had been adequately equipped with trained staff, there was initially a lack of testing kits, swabs for sampling and personal protective equipment (PPE). Nevertheless, overall testing capacity has increased continuously across the country from an initial 200 tests per day to more than 8,000 PCR tests daily. Most of these are performed by the IPH Viral lab, with support from the regional public health labs and a number of private institutions.   WHO has helped expand national SARS-CoV-2 detection capacities by supporting the large-scale procurement of equipment and supplies, as well as continuing weekly training on testing, reporting, biosafety and biosecurity.  Virus testing in the public health labs remain easily available and free of charge for all citizens.

Testing and contact tracing was initially largely supported by the Association of General Practitioners (GPs), and nearly 1200 GPs became involved in the identification and early detection of cases. Citizen access to diagnostics was increased by referral to temporary screening outposts. A digital record was created within the health information system, and was used to schedule testing by GPs and monitor the outcome of persons with positive results. Volunteers from the Red Cross and NGOs have been also mobilized to support the process. Nevertheless, the public health capacity for contact tracing and isolation enforcement quickly became a major problem. Public understanding and compliance with tracing and isolation measures was quickly highlighted as essential to reinforce these behaviours.

The establishment of an Epidemic Intelligence and Emergency Operating Centre (EOC) built on an existing early-warning system to rapidly report and detect diseases. The EOC increased national capacity for strategic emergency management and monitoring. It also strengthened communications and cross-sectoral coordination, as well as enabling capacity-building for required skills such as contact tracing and epidemiological investigation. The experiences of the pandemic have emphasised the future need to establish a coherent network of national and subnational health entities, to allow a more coordinated response to health emergency operations.   

On a positive note, North Macedonia’s response to COVID-19 has shown how sustainable public health emergency capacity depends largely on the availability of well-trained and responsive field epidemiologists. An initial shortage in epidemiologists was a critical health system gap in the country, and low capacity to deploy epidemiological staff to meet surges negatively affected overall health system performance and specific needs such as contact tracing. As a result of these experiences, the MoH has been exploring possibilities of quickly training field epidemiologists to create rapid response teams. There is currently no robust training programme that combines both the theoretical and the applied part of epidemiology, and COVID-19 has shown that this is an omission. This situation had already been noted prior to the COVID-19 pandemic, in a report by the International Health Regulations Joint External Evaluation mission in 2019.

COVID-19 vaccination

North Macedonia has decades of experience running national vaccination campaigns for large parts of its population. It worked quickly to develop a National Vaccine Deployment Plan (NVDP) for COVID-19, which was adopted on 26 January 2021 by the national Government. This detailed operational plan covered all aspects of COVID-19 vaccination, including number of vaccination points and their location, and the recruitment and training of staff.

Before the vaccination roll-out began, the Technical Working Group for COVID-19 Vaccination developed a plan on how vaccines could be imported, transported, and stored according to the manufacturers’ requirements. They began securing ultra-cold chain facilities and training health workers involved in storage, management and distribution.  Volunteers and the health workforce were then trained to administer vaccines in order to join the immunization campaign. The MoH issued special authorizations to Health Centres to grant them permissions for administering vaccines outside the regular immunization calendar. A digital vaccine registration platform was created for vaccine-eligible citizens, and many of the health institutions adapted their work to support COVID-19 vaccination.

Limited availability of vaccine doses at the start of the vaccination campaign imposed the need to prioritize high-risk groups. Under the initial NVDP, priority groups included older people, health workers, and the immune-compromised. However, by the summer of 2021 vaccines were available to all age groups above 12 years old, and at all vaccination points.

Vaccine procurement in North Macedonia is coordinated by the MoH, together with the national Government. Initially, the Government had signed a COVAX agreement for covering vulnerable groups, estimated at 20% of its population. It also arranged to receive vaccines from the EU Solidarity Fund, and negotiated directly with manufacturers. By the end of 2021, the national team was able to update and submit their COVID-19 response and vaccination budget needs to the Partners Platform, where potential donors can access information on available and requested resources.

Despite the country’s extensive experience with vaccination campaigns, COVID-19 vaccination is complex. It involves targeting a wide range of different age groups, and continuous efforts to ensure workforce readiness, vaccine management, community engagement and reducing hesitancy towards the new vaccines.  

The COVID-19 national vaccination strategy initially aimed at 50% vaccine uptake in 2021 (1,042,000 people). Vaccination started in March 2021, and, by the beginning of 2022, almost 40% of the population had been fully vaccinated. 

Overall, demand for vaccination has increased after the Government imposed more restrictive measures for non-vaccinated people.  However, vaccination rates for health care workers and older people have not reached the levels expected. North Macedonia remains vulnerable to COVID-19 fatalities and severe disease, partly because of low vaccine coverage of high-risk groups. This is due to an initially low availability of vaccines, and then to rising rates of vaccine hesitancy. There are also some access issues which need further examination.

Given the growing understanding of specific vaccine attributes and the risk of severe COVID-19 for key population groups, such as pregnant women and younger people, the NVDP is currently being adjusted to align with the latest WHO SAGE guidance. This includes a new target of 70% vaccination coverage. The new national vaccination guidelines also address vaccination for secondary school and university students, booster doses for older people and the immunocompromised, and issues such as vaccine hesitancy. That said, North Macedonia continues to have a rather limited daily vaccination capacity, and this may cause problems for the new strategy. It will remain necessary for the MoH and partners to proactively look at ways to absorb bottlenecks and expand immunization capacity. The National COVID-19 Vaccination Working Group will continue to provide guidance on issues such as vaccine prioritization, planning, resource requirements and capacity building.  

While there has been a relatively positive public response to protective measures and instructions for PHSM, public opinion on vaccination has virtually divided the country in half. This has resulted in two main challenges: 1) managing expectations for those who are eager to get vaccinated, and 2) reassuring and encouraging those who are hesitant about or actively opposed to the vaccine. Vaccine hesitancy has been a core component of public communication campaigns (see the above Section on public information, risk communication and community engagement).

Lessons Learned

A huge amount has been learnt during the pandemic. However, several key lessons can be identified in North Macedonia:

1. An effective pandemic response requires a combination of good leadership, a strong public health system, and good community engagement. When systems and organizations work well together, restrictions are more effective and can be lifted sooner.

2. In a pandemic as complex as COVID-19, the health system and public health structures must be flexible. Whilst national strategies are needed, they must allow for rapid transformation and repurposing of resources and tasks depending on the needs of diagnostics, treatment, prevention and vaccination. This is especially important in allowing the movement and reallocation of human resources.
   

3.  Responding to a public health crisis is not the business of the health sector alone. It requires a whole-of-government and whole-of-society approach. It also requires preventative planning to ensure that response systems are functional before emergencies strike.

4.  COVID-19 is an information crisis as well as a health crisis. Disinformation and misinformation have been some of the biggest challenges to a successful pandemic response. Clear and consistent messaging from public health authorities and all other stakeholders is vital, but must also be tailored to the health literacy of the population. Good risk communication and community engagement helps prevent “infodemics”, builds trust in the national response, and increases the probability that health advice will be followed. Behavioral insight studies can help assess perceptions of risk among different community groups and contribute to controlling the spread of the virus.

5. More investment is needed in health system human resources and community readiness. While responding to the immediate health emergency and mitigating its effect, public health should also look at how capacity issues faced during the COVID-19 response can be mitigated in the future.  There is currently an opportunity to leverage public health investments for longer-term health system strengthening, both to support the ongoing COVID-19 response, and to build better health system resilience in the future.
   

6.  Addressing vulnerability means using evidence-based analysis that incorporates the realities of social, political and economic influences. Many valuable adaptations in governance and delivery processes, evidence generation, and competency building, have helped increase COVID-19 vaccine demand by understanding and targeting specific groups. This has potentially paved the way for their use in improving service reach and uptake by vulnerable groups for other health issues, such as routine vaccination, maternal and child health, and others.

7. A good public health workforce is the most valuable ingredient in the response to any health crisis.  Success in reducing the deaths and long-term implications of COVID-19 requires a well-organized, well-trained medical and public health staff. All personnel must be equipped with adequate personal protective equipment, and have received training on up-to-date and fit-for-purpose skills. Public health staff should receive continuous support and preparation ahead of any emergency in order to be capable of managing surges in patient demand or support for specific public health interventions such as vaccination. Ensuring a safe environment for the health workforce during COVID-19, with adequate protection and psychological support, remains one of the most important elements of an effective outbreak response.
   

References

1. Health System Response Monitor [https://eurohealthobservatory.who.int/monitors/hsrm/analyses]
2. Institute of Public Health [https://www.iph.mk/en/]
3. Draft UN Common Country Assessment (in process of development)
4. Winkelmann, Tille, Litvinova and Rechel: Health Systems In Action Insight For North Macedonia, World Health Organization 2021
5. Health Services Learning Hub, 2021, COVID-19: Action Brief On North Macedonia
6. RCCE Strategy (in final draft form)
7. North Macedonia, COVID – 19 Response Framework, July 2020 [https://northmacedonia.un.org/sites/default/files/2020-10/MKD-COVID_19-Response-Framework-20200730_costed.pdf]
8. Report, WHO Mission to North Macedonia, June 2020 [https://apps.who.int/iris/handle/10665/336267]
9. COVID-19 websites of the Government of North Macedonia [http://zdravstvo.gov.mk/korona-virus/] [https://vlada.mk/covid19] [https://koronavirus.gov.mk
10. [https://vlada.mk/protokoli-koronavirus] [https://kovid19vakcinacija.mk/]
11. WHO (2019). Joint external evaluation of IHR core capacities. Republic of North Macedonia: mission report: 11–15 March 2019. World Health Organization [https://apps.who.int/iris/handle/10665/325320].
12. The National Plan for Covid-19 Vaccination in the Republic of North Macedonia version 2.1