Overview

This analysis of North Macedonia’s health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance.

The centralized health system uses mandatory social health insurance as the main source of public funding

The Ministry of Health is responsible for health policy, planning and evaluation, public health programmes and the regulation of capital investments for publicly owned health care providers. The main strategic planning is articulated in the National Health Strategy, renewed in 2020 for the period 2021–2030.

North Macedonia has a mandatory social health insurance system which consolidates public financing under a single entity, the Health Insurance Fund (HIF), which is the single purchaser of health services provided under the social health insurance scheme.

All primary care practices have been privatized

Although most health care providers (especially of secondary and tertiary care) remain under public ownership, private providers have grown in number, notably in primary care, specialist and inpatient care, dental services and pharmaceuticals. All primary care practices have been privatized and operate under contracts with the HIF.

The share of public spending is low and private spending is substantial

The share of public spending as a proportion of current health expenditure is comparatively low and stood at 54.5% in 2021. Consequently, out-of-pocket (OOP) spending as a share of current health expenditure remains high (41.7% in 2021), far exceeding the EU average of 15.0% in 2021. Affordability is particularly an issue for pharmaceuticals, which consumed up to half of OOP payments in 2021.

There are sufficient physical resources but migration poses challenges

To ensure equitable geographical access to health services, the Health Network of certified health care providers was introduced in 2012. As regards human resources, North Macedonia struggles with overall shortages, emigration and internal migration. The Ministry of Health has initiated a process for assessing human resources in health, with the aim of gathering data to enable long-term planning of the demand and supply of health workers and of the necessary skills and competencies.

Improving the quality of care is an explicit policy aim, but premature mortality rates remain high

North Macedonia faces high rates of premature mortality and a disease burden that could be improved if public health policies were strengthened and health care provided more effectively in a timely manner, particularly in the treatment of noncommunicable diseases. Improving health care quality is an explicit policy aim of the National Health Strategy 2021–2030, but so far a comprehensive quality improvement strategy with an action plan that defines priorities, performance indicators and roles/responsibilities has not been developed.