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.