Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
1
ORIGINAL RESEARCH
Performance of the public health care sector in the Republic of Macedonia
Lolita Mitevska
1
, Manuela Sofia Stanculescu
2
, Elisaveta Stikova
3
1
National Institute of Transfusion Medicine-Skopje, R. Macedonia;
2
Research Institute for Quality of Life, Romanian Academy of Science, Romania;
3
University “Ss. Ciryl & Methodius”, Medical Faculty, Institute of Public Health, Skopje,
Republic of Macedonia.
Corresponding author: Prof. Elisaveta Stikova, University “Ss. Ciryl & Methodius”,
Medical Faculty, Institute of Public Health, Skopje, Republic of Macedonia;
Address: 50 Divizija No 6, 1000 Skopje, R of Macedonia;
Telephone: +38970230183; E-mail: estikova@ukim.edu.mk
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
2
Abstract
Aim: Healthcare authorities constantly search for new approaches of assessing the
performance of the health sector. Comparative studies help for improvements in healthcare
by learning from each-other. Our aim was to assess the performance of the public healthcare
system in the Republic of Macedonia, through the analysis of preparedness of institutions to
fulfill the population‟s healthcare needs and expectations.
Methods: This study had a regional character. The national research team interviewed 175
randomly selected participants from Macedonia. The research was performed in the period
March 2012 – March 2013. For the research purposes there were used especially designed
questionnaires for cancer, stroke, myocardial infarction, diabetes mellitus and injuries. For
assessment of the performances, the appropriate techniques were developed.
Results: Macedonians consider public healthcare system as being medium-good in all
aspects: accessibility, availability, quality of health care services and population‟s
confidence. The knowledgeable observers (N=125) believe that state-of-the-art treatment
exist all over the country (“yes”: 33.6% and “rather yes”: 44.8%). They believe that the
services are accessible to everybody, free of major charges (“yes”: 31.2% and “rather yes”:
45.6%). The individual witnesses (N=50) argued toward lack of pharmacies and proper
medicines in rural areas, with a gap between the availability and quality of services in rural
vs. urban areas.
Conclusion: The future goals for Macedonia include better public healthcare financing, cost
definition of health packages, improved disease prevention and effective human resources.
Keywords: assessment of services, availability, public healthcare system, quality of care.
Conflicts of interest: None.
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
3
Introduction
Health authorities are in constant search for systematic ways and new approaches of
assessing the performance of the health sector at national, or cross-national level. Main
arguments for the necessity of measurement include identification of the quality of healthcare
service delivery, support for design of the health sector reforms, improvement of healthcare
system and production of better outcomes for the patients and payers. The healthcare
performance can be followed and measured by different indicators, such are: life expectancy,
morbidity, or mortality. There are many determinants of health that have influence on the
health status of the population, but are not considered as direct indicators (1).
The performance assessment can be defined as comparing or measuring deviations of
observed clinical practice from recommended practice. This assessment may range from a
formal in-depth evaluation process to a much less elaborate simple review of practice. The
most common performance assessment methods are: (i) audits/audit groups, (ii) peer-review
groups, and (iii) practice visits (2,3).
Noncommunicable diseases (NCD), principally cardiovascular diseases (CVD), diabetes
mellitus (DM), cancer, and chronic respiratory diseases, are the most common diseases which
have caused million deaths worldwide. The scientists predict an increased number of deaths
from noncommunicable diseases that are projected to further 17% over the next 10 years (4).
Republic of Macedonia is not different in disease prevalence values compared with other
European or neighboring countries. According to the data from the National Public Health
Institute in the Republic of Macedonia, in the year 2011, the most frequent diseases for which
the patients had received treatments at out-patient services were: cardiovascular diseases
(23.6%), respiratory diseases (18.2%), diseases of the muscular-skeletal system (7.7%),
diseases of digestive system (7.2%), and diseases of the endocrine system (7.1%), out of
2695233 registered cases (5).
For the same year, the total number of hospitalized patients was 253906 (6), out of which for:
cancer 33836 (13.3%), endocrinology system diseases 6422 (2.5%) patients, musculoskeletal
system diseases 11150 (4.4%), cardio-vascular diseases 38133 (15.0%) and for injuries 12955
(5.1%).
The Republic of Macedonia has a compulsory health insurance system that provides universal
health coverage for the whole population. The goal of the health sector reform in Republic of
Macedonia is the creation of a system that is aligned to the needs of the population, which
can operate efficiently within the resources available.
The government and the Ministry of Health provide the legal framework for operation and
stewardship and the Health Insurance Fund (HIF) is responsible for the collection of
contributions, allocation of funds and the supervision and contracting of providers. In the
year 2002, the HIF has started contracting the private primary health care facilities (family
doctors or general practitioners-GPs), introducing a capitation-based payment system.
The medical examinations by the GPs are provided free of charge for all citizens. The
population participates in covering the health expenditures by paying some amount of money
which is calculated from HIF special scales and generally is 20% of the total costs of health
services.
This practice was changed and even improved in the year 2012, by introduction of a law for
health protection (7). Free-of-charge healthcare services receive all patients with monthly
salary lower than the average official salary for the previous year.
From co-payments are excluded blood donors, children with special needs, persons under
permanent social care, patients in mental institutions and mentally retired abandoned persons.
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
4
All citizens that do not have regular health insurance (for example: stateless persons and
social care recipients), are subsidized by the state budget (8).
In the year 2010, general government expenditure on health as a percentage of total
government expenditure was 12.9%. The total expenditure on health (PPP in US$) in the
same year was 791 $ per capita, which increased from 423 $ in the year 1995.
The healthcare system in the Republic of Macedonia is organized at three levels: primary,
secondary and tertiary level. Some of these services are part only of the public healthcare
sector, whereas some other services are provided in public and private healthcare facilities. In
the year 2011, there were 3375 at primary level and 386 at secondary level private healthcare
practices that had contracts with HIF. The total number of hospital beds in 2012 was 9076, or
4.4 beds per 1000 inhabitants (9). The hospital services are organized in: 14 general hospitals,
13 special hospitals, 30 university clinics and 19 other clinical hospitals, centers and units (9).
In this framework, the objective of this study was to assess the performance of the public
healthcare system in the Republic of Macedonia, through the analysis of the expected (state-
of-art treatment) and actual public health care of the patients.
Methods
The performance of the public health care system in the Republic of Macedonia was analyzed
trough assessment of the access of the population to health care services developed by
Wismar et al. (10), where “the state-of-the-art” of the healthcare system is defined as:
diagnosis, treatment and recovery, which are accessible to every citizen covered by a health
insurance, free of major additional charges. Accessibility of the health care system is defined
as “a measure of the proportion of the population that reaches appropriate health services”.
The assessment of the expected and actual performances of public health care system was
based on the data collected from 175 interviewed respondents: 125 knowledgeable observers
(family physicians and medical specialists in hospitals or emergency centers), and 50
individual witnesses (patients or their family members who were diagnosed during the period
between the 1
st
of January 2010 to the 31
st
of December 2011). The structured interviews
were performed for those two groups of the study participants, using ten different
questionnaires tailored according to the five selected health problems/diseases: cancer, stroke,
myocardial infarction, diabetes mellitus (type II) and injuries. The selection of these health
problems/diseases was due to the fact that they represent the major causes of death in the
country and require different approaches in the health care response (emergency versus long-
term monitoring and care). We combined two different sampling methods: selective expert
sampling for knowledgeable observers and non-probability convenience sampling method for
the individual witnesses. The field work was carried out in the period from March 2012 to
March 2013.
The data obtained through interviews with knowledgeable observers and individual
witnesses, for each of the five selected health problems, was organized and analyzed in
relation to an adjusted 6-access-steps model based on the following sequence of themes: the
extent to which the national benefit packages cover diagnostic, treatment, monitoring and
rehabilitation in the specific health problem; the extent to which payments, co-payments, and
out-of-pocket expenditure are involved and threaten equity of access; geographical access
and availability of services; availability of public and private health-care providers; waiting
lists and other aspects of system organization that can result in barriers to the health care
access; and groups with limited access and risk factors related to the specific health problems.
The expected performance of the health care system was assessed by measurement of four
dimensions of the health care system: accessibility, availability, quality of health-care
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
5
services and the population‟s confidence in the public health system, based on the opinion of
the knowledgeable observers. Assessment for each dimension was made using the Likert
scale from 1 („very poor‟) to 5 („very good‟). Results were presented as the average of the
scored values for each dimension.
For measurement of the general assessment of the health system, the opinions on the four
dimensions were aggregated into a dominant opinion index, using the method basically
developed by Hofstede in 1980 (11) and the formula: (P-N) * (T-NR)*100/T*T, where P –
positive answers („very good‟ or „good‟), N – negative („very poor‟ or „poor‟), NR – neutral
or non-response, and T – total number of variables. This type of index varies between -100
(generalized negative attitude) and 100 (generalized positive attitude toward the issue).
For assessment of the actual performance of the public health care system, the analysis of the
opinions/experience of the individual witnesses and knowledgeable experts was made with a
focus on the history of the health problem. The main focus was on the factors hampering the
access to the health care system, as essential elements for the assessment of the actual
performance of the public health care system.
Results
Health status of the population in Macedonia shows many different characteristics and
tendency, caused by economic, political, socio-demographic changes, as well as health care
reforms which have been in process in the past 20 years. Figure 1 presents the standardized
death rate (SDR) of five health problems: malignant, cerebrovascular and ischemic heart
diseases, diabetes and injuries in the period 1990-2010 (12).
SDR of malignant neoplasms shows higher rate and increasing trends in the Republic of
Macedonia, compared with the EU and the European region countries. Hence, the SDRs of
cerebrovascular diseases and diabetes are 3.5 times higher in Macedonia than in the EU
countries and much higher than in the countries of the European region. SDR of
cerebrovascular diseases follows the similar trend as in the other European countries, but the
SDR of injuries is two times lower than in the European countries.
In the current research, all respondents were divided into two groups: individual witnesses
(n=50) and knowledgeable observer (n=125). Their distribution is presented in Map 1.
The demographic characteristics of the individual witnesses that have participated in the
study are presented in Table 1.
The dominant characteristics of the respondents from the group of the individual witnesses
included: patients (64%) that live in a large urban residency (48%), pensioners (34%), with
high school level of education (54%) and middle income (38%).
The characteristics of the knowledgeable observers are presented in Table 2.
According to demographic data, the dominant group of respondents from knowledgeable
observers consisted of doctors (34.4% GPs and 31.2% specialists), males (58.4%) that live in
a large urban residency (66.4%), with a mean age of 43.3 years.
The results of the assessment of the performance of public health care system in the country
are presented in Table 3.
Knowledgeable observers consider the health system as being medium/good in all four
dimensions: accessibility, availability, quality of healthcare service and the population‟s
confidence in the public health system, with an average score of 3.5. The scores vary from
3.4 points for the population confidence to 3.7 points for the availability of the services.
The biggest part of respondents from the group of the knowledgeable observers believes that
state-of-the-art treatment exists all over the country (“yes”: 33.6% and “rather yes”: 44.8%)
and that they are accessible to everyone free of major charges (“yes”: 31.2% and “rather yes”:
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
6
45.6%). Yet, health professionals from rural areas tend to assess the system performance with
lower remarks.
At the level of the overall sample, the dominant opinion index about the health care services
showed an average value of 34 points in a scale from -100 to +100. This index had very little
variations from 38 for diabetes mellitus, 37 for injuries, 35 for stroke and myocardial
infarction, but it was significantly lowest for cancer, with only 23 points. These findings are
shown in Figure 2.
Figure 1. SDR for selected diseases in the Republic of Macedonia during 1990-2010
130
140
150
160
170
180
190
200
210
1990 2000 2010
MKD*
European Region
EU
SDR, malignant neoplasms, all ages, per 100 000
0
50
100
150
200
250
1990 2000 2010
MKD*
European Region
EU
SDR, cerebrovascular diseases, all
ages, per 100 000
10
15
20
25
30
35
40
1990 2000 2010
MKD*
European Region
EU
SDR, diabetes, all ages, per 100 000
20
30
40
50
60
70
80
90
100
1990 2000 2010
MKD*
European Region
EU
SDR, external causes of injury and
poisoning, all ages, per 100 000
10
20
30
40
50
60
70
1990 2000 2010
MKD*
European Region
EU
SDR, ischaemic heart disease, 0–64, per 100 000
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
7
Map 1. Distribution of respondents
Table 1. Demographic characteristic of individual witnesses
VARIABLE CATEGORY NUMBER PERCENT
Type of respondent
Patients 32 64
Family member 18 36
Residence
Large urban 24 48
Small urban 14 28
Rural 12 24
Ethnicity
Macedonian 37 74
Albanian 11 22
Other (Roma, Serbian) 2 4
Age (average)
Cancer 54.9 ?
Stroke 65.3 ?
AIM 53.8 ?
Injuries 43 ?
DM 61.6 ?
Employment status
Manager 1 2
Clerical staff 6 12
Non-manual worker 5 10
Manual worker 11 22
Pensioner 17 34
Student 3 6
Housewife or inactive 7 14
Level of education
None 3 6
Elementary 10 20
High school 27 54
College or more 10 20
Income
Low 10 20
Middle low 13 26
Middle 19 38
Middle high 6 12
High 2 4
X Knowledgeable observers
Individual witnesses
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
8
Table 2. Demographic characteristic of knowledgeable observers
VARIABLE CATEGORY NUMBER PERCENT
Type of respondent
General practitioners 43 34.4
Specialist doctors 39 31.2
Representatives of regional or national
directions of public health
7 5.6
Hospital representatives 11 8.8
Emergency centers representatives, 3 2.4
Representatives of NGOs active in the field 2 1.6
Representatives of patient organizations 3 2.4
Other 17 13.6
Residency
Large urban 83 66.4
Small urban 32 25.6
Rural 10 8
Age (average)
43.3
(min=24;
max=67)
Gender
Male 73 58.4
Female 52 41.6
Figure 2. The value of the Dominant Opinion Index
-150
-100
-50
0
50
100
150
Dominant Opinion Index
Min
Max
Average
Diabetes
Injuries
Infarction
Stroke
Cancer
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
9
Table 3. Assessment of the performance of public health care system in the Republic of
Macedonia
ASSESSMENT OF PUBLIC
HEALTH PERFORMANCE
CATEGORY NUMBER PERCENT
SCORE
(1-5)
Availability of health care services
Very poor 0
Poor 11 8.8
Medium 43 34.4
Good 48 38.4
Very good 23 18.4
Average Score 3.7
Quality of health-care services
Very poor 1 0.8
Poor 11 8.8
Medium 52 41.6
Good 44 35.2
Very good 17 13.6
Average Score 3.5
Population’s confidence in the
public health-care system
Very poor 3 2.4
Poor 14 11.2
Medium 52 41.6
Good 40 32
Very good 16 12.8
Average Score 3.4
Health-care services are accessible
to any person who needs them,
regardless their economic situation
Very poor 8 6.4
Poor 16 12.8
Medium 32 25.6
Good 37 29.6
Very good 32 25.6
Average Score 3.5
State-of-art treatment (of the
respective health problem) is
available?
Yes 42 33.6
Rather yes 56 44.8
no 6 4.8
Rather no 21 16.8
Is the state-of-the-art treatment
(including diagnostics, monitoring
etc.) accessible to everybody, which
means free of major charges?
Yes 39 31.2
Rather yes 57 45.6
No 6 4.8
Rather no 23 18.4
Dominant opinion index (overall) 34
When analyzing which group of knowledgeable observers are most satisfied, it is remarkable
to note that physicians (general practitioners and specialists) are the most satisfied observers,
with a score on the dominant opinion index of 40 points, despite the NGO and representatives
of the patients‟ organizations who are the least satisfied observers (approaching to the 0 point
on the scale). However, it should be emphasized that the simple size and the profile of the
observers influenced on the observed results of this research work.
Regarding the assessment of the actual performance of the public health care system, Table 4
provides descriptions about the main barriers of access to services in Macedonia.
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
10
Table 4. Main access barriers in public health care of the five selected health problems
ACCESS BARRIERS
1 2 3 4 5
IW KO IW KO IW KO IW KO IW KO
Delayed first contact with a doctor x X X X X
Poor knowledge and low level of
prevention and information of
population
X X X X X
Doctor or medical services are not
available in some areas
X X X X X X
Diseases‟ related services are available
only in some areas
X X X
Rehabilitation units/ services are not
available/enough in some areas
X X
Pharmacies are not available in some
areas
X X X
Emergency services are not available in
some areas or are underdeveloped
X X
X
X X
Transport services are underdeveloped
or too costly
X
The waiting time for being received by
a specialist is very long
X
X X
The waiting time for getting medication
is very long
X X
The waiting time for rehabilitation
services is very long
X X
Lack of trust in doctors, nurses or
medical staff
X X X
Lack of interest or unprofessionalism of
the doctor or medical staff
X X X
Lack of humanness of the staff x X
Lack of money to pay the doctor x X
Lack of money to pay the needed tests
Lack of money for out-of-pocket
payments
X
Low quality and effectiveness of
medical services
X X X X X X X X
High costs of medication X X X X X X X
Poor equipment of public
clinics/hospitals
X X X X X X
Lack of accessibility and continuity of
care
X X
Specialists of certain subspecialties are
missing or insufficient
Legend: 1 = infarction; 2 = stroke; 3 = cancer; 4 = injuries; 5 = diabetes
IW = individual witnesses; KO = knowledgeable observers
There are four major aspects of the health care system that are major barriers in accessing
state-of-the-art treatment, for all the selected health problems:
low quality and effectiveness of medical services;
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
11
high cost of medication;
poor equipment of public health care clinics/hospitals, and;
availability of doctors and medical services.
Additionally, the respondents gave high priority to the poor knowledge and the low level of
information and the lack of preventive health-related behavior; availability of emergency
services and lack of trust in medical staff and their unprofessionalism as possible barriers
hampering state-of-the-art treatment of the patients.
The respondents in this study confirmed a delayed first contact with a doctor in four of the
analyzed diseases (myocardial infarction and stroke from knowledgeable observers, cancer
and diabetes from individual witnesses), as well as unavailability of healthcare services in
some areas (for stroke and cancer) and long waiting time for specialized care (myocardial
infarction and cancer).
More than 70% of participants in the study referred to a low quality of medical services, high
cost of medication and poor equipment of public clinics and hospitals. Despite these remarks,
Macedonian citizens showed a high level of trust in doctors. The trust in medical doctors or
nurses in this study was pointed out for cancer (knowledgeable observers) and injuries
(individual witnesses and knowledgeable observers).
Discussion
Considering the health challenges that are facing all countries in the Southeastern European
(SEE) region, a comparative qualitative study about assessment of the performance of the
public health care system was performed in 2013, with participation of eight countries. This
paper is focused on the research results obtained in the Republic of Macedonia. The main
idea was to compare the actual level of health care delivery in comparison with the highest,
“state-of-the-art” diagnosis, treatment and recovery, related to five deadliest health problems
in the country: myocardial infarctions, stroke, cancer, diabetes mellitus type 2 and injuries.
The results of the study showed that health professionals consider the Macedonian health care
system as being “medium/good” with no significant variations in the accessibility,
availability, quality of health care service and the population‟s confidence. The overall
performance of the health care system was similarly assessed as “good” with no significant
differences for different health care problems/diseases. Regarding the opinions of study
participants, low quality and effectiveness of medical services, high cost of medication and
uncommon preventive health related behavior were pointed out as the main barriers in
delivery of the state-of-the-art health care treatment.
There is a lot of information about the risk factors for non-communicable diseases and
preventive measures in the country, but apparently they do not reach the needs and
expectation of the citizens, even though the GPs are obliged to make regular preventive
examinations among the population, according to the national preventive programs.
The strategic objective to the Ministry of Health (2010-2014) aimed to provide healthcare
services for the population with good quality, improved availability and accessibility, as well
as better primary health care services for the population (13). There are a lot activities that are
conducted to meet this goal (including provision of new equipment, education of medical
staff, preventive programs and the like). In 2011, the Ministry of Health started a project for
public procurement of new equipment. With a budget of 70 million Euros, there were
provided over 609 new sophisticated medical devices.
The research that was performed in Macedonia (in May, 2012) with 531 respondents, showed
that citizens expect better behavior of the medical staff, shorter waiting time for medical
examination or diagnostic procedures and better hygiene (14).
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
12
In comparison with the results from the other seven countries included in the research
comparative study, Macedonia shares the same situation as the other SEE countries, where
poverty, financial and geographical barriers are major factors that lead to a lack of access. In
most of the countries (especially in Moldova, Bulgaria and Kosovo), out-of-pocket payments
constitute more than 40% of the total payments for health care services, in contrast with the
responses from participants in Macedonia, where out-of-pocket payments as a barrier is
mentioned only for cancer.
However, the performance of the public health care system in Macedonia has differences
compared with other SEE countries, from the point of view of knowledgeable observers,
because the knowledgeable observers from Croatia, Montenegro and Serbia tend to assess
their health systems in positive terms. On the other side, representatives of Romania,
Moldova and Kosovo are rather critical in evaluating their health systems. Bulgarians and
Macedonians consider their health systems as being “medium-good” in all respects.
Macedonian citizens showed a high level of trust in doctors, similar to the results from the
whole study, where from a total number of 845 respondents, 70.8% reported trust in doctors,
21.4 % did not, and the remaining 7.8% were neutral (15).
The future reforms in health policies in the Republic of Macedonia, as well as in other SEE
countries should be oriented toward six major goals (15,16):
- The need to better define, and evaluate the costs of benefit packages:
All eight countries provide, by national laws, comprehensive packages of health-care
services. None of the studied health systems has the capacity to ensure the universal
provision of such services.
- The need to develop prevention services:
The community nursing system, considered to be the most powerful “equalizer” in the health
system is still largely unutilized in most of SEE countries. Despite efforts to develop primary
care, access to adequate and holistic community, health care remains a challenge for certain
segments of the population (low-income groups, residents of rural areas and small towns,
Rom, and the like).
- The need to develop rehabilitation, palliative and long-term care services:
Palliative, long-term and rehabilitation care are not sufficiently developed as parts of the
healthcare systems in the region. Most long-term care is provided in the family, and there are
few resources available for informal cares.
- The need to improve the financing of the public health care systems:
Public health-care systems in the region are under-financed, primarily as a result of fiscal
constraints. Hence, political will is a major factor for improving the performance of public
health care systems.
- The need for an effective human resource policy in health:
In nearly all countries included in this survey, the availability of all types of medical
professionals is far below the European average. Shortages of some specialties and skills are
also reported in the studied countries such as Croatia, Macedonia, Kosovo and Moldova, and
are not necessarily related to health professional mobility.
- The need to address informal payments in the public health care system:
The study showed that informal payments still represent an access barrier to state-of-the-art
treatment, in particular in relation to chronic diseases. Informal payments primarily represent
a response to the poor capacity of the public health-care system to provide adequate access to
basic services.
In conclusion, over the last ten years, many efforts have been undertaken to establish a
common conceptual framework for health system performance assessment which is defined
Mitevska L, Stanculescu MS, Stikova E. Performance of the public health care sector in the Republic of
Macedonia (Original research). SEEJPH 2016, posted: 15 April 2016. DOI 10.4119/UNIBI/SEEJPH-2016-104
13
as the way how the individuals/patients are treated encompassing the notion of the patients‟
experience. Measuring of the health care performances is a key tool in aiding decision makers
to describe, analyze, compare and improve the delivery and outcomes achieved by health care
systems (17). This study applied the method of measuring qualitative parameters received by
structured interview to quantitative indicators. The results from the first research study
performed in the country show that Macedonians consider their health systems as being
“medium-good” in all respects. The research methodology used in this paper has the potential
to extend the applied methods to the large population taking into consideration other socio-
economic characteristics (income, education, cultural influences and the like). It would help
to obtain stronger scientific evidence on health care system performances and to foster the
development of measuring tools of its components.
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