Three periods of health system reforms in the Republic of Macedonia (1991-2011).

AIM To investigate, describe and classify main health policies and reform activities within the healthcare system undertaken over the past twenty years in R. Macedonia. METHODS Desk research was conducted on scientific literature and relevant documentation (in English and Macedonian) about healthcare reforms. Relevant documents available at the Ministry of Health, Health Insurance Fund, World Bank and World Health Organization were reviewed. Official data on demographic and health status indicators were collected from the Institute of Public Health and the State Statistical Office. A working hypothesis, that the health system reforms were not continuous, was generated following the shifts in decision-making power over allocation of resources and political influences. RESULTS Our study identified three periods of health system reforms in Macedonia: post-socialistic, pro-market and manifesto-driven. Throughout these periods poor maintenance, low efficiency and high operational costs increased out-of-pocket expenditures for health services and drugs and reflected on the deterioration of public hospital infrastructure. In parallel, liberal healthcare market regulation initiated commercialization of the healthcare services. Disappointed in the quality of healthcare services provided in the public health sector, many citizens opt to ask for services in private health care facilities, where social health insurance largely does not cover the costs. CONCLUSION The pace of the reforms is not continuous and the influence of politics is highly visible over the whole period of transition in the Republic of Macedonia. The main problems of the healthcare system in the Republic of Macedonia are politicization of the health sector, high centralization and government control, and poor efficiency of public health institutions. Evaluation framework should be developed to further assess the impact of the health reforms.