The document provides an overview of the health care system for people with intellectual disabilities in Macedonia. It discusses the current situation, challenges, laws and policies related to health care for this population. It also outlines future directions, including establishing a central database on people with intellectual disabilities, ensuring health insurance covers rehabilitation costs, and developing education programs for health workers on caring for this group.

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University “St. Kiril and Metodij”
Faculty of Philosophy
Institute of Special Education and rehabilitation
HEALTH CARE SYSTEM FOR PEOPLE
WITH INTELLECTUAL DISABILITIES
IN MACEDONIA
Vladimir Trajkovski MD, PhD
Bristol, May 13, 2010

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INTRODUCTION (1)
Country profile
 Territory: 25 713 km2.
 Capital city: Skopje.
 Population: According to the 2002 census,
the country’s total population is 2 022 547 with
average population density of 78,7 per km2.
 Gender structure of the population:
• males 1 015 377,
• females 1 007 170,
• (1008 males : 1000 females ratio).

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Age structure:
0-14 years: 19.2%
males: 206,054
females: 191,354
15-64 years: 69.4%
males: 722,823
females: 710,830
65 years and over: 11.4%
males: 102,231
females: 133,426
Median age:
total: 35.1 years
males: 34.1 years
females: 36.2 years
Life Expectancy:
Total: 74.7
females: 77.4
males: 72.2
INTRODUCTION (2)
(Janicki, 2010)

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INTRODUCTION (3)
 Republic of Macedonia, with the independence
gained in 1991, inherited a large and well-
established health care system with good
geographical and financial accessibility, long
positive experience with health insurance covering
nearly the whole population, qualified staff, good
control of infectious diseases, and almost full
coverage of the population with the national
immunization programme.
 The health status of the population is similar as in
the other countries of South-Eastern Europe, but is
lagging behind the EU countries.

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INTRODUCTION (4)
 The health care sector is faced with several
challenges associated with the improvement of the
population’s health status, the provision of basic
benefits package, delivery of health services,
public health, planning, management and
development of human resources, quality
assurance, health financing, and provision of a
sustainable system of health care.

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Current situation in the health care system (1)
 The Law on Health Care has established the
organizational structure of the system with the
Ministry of Health (MoH) and the Government in
charge of health policy formulation and
implementation, the Health Insurance Fund
responsible for the collection and management of
funds, and the health care institutions responsible
for service delivery.

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Current situation in the health care system (2)
 Health care financing is organized around a social
insurance system managed by the Health
Insurance Fund (HIF). The HIF is primarily funded
through payroll contributions, while most of
remaining revenues come from the Pension Fund,
the Unemployment Fund and general revenues.
 The HIF is responsible for the allocation of 90% of
Government health expenditures.

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Current situation in the health care system (3)
 Health care in Macedonia is provided through an
extensive net of health care organizations. It is
organized on three levels: primary, secondary and
tertiary.
 Health care is delivered through a system of health
care institutions, covering the country’s territory
relatively evenly.
 This makes it possible for around 90% of the
population to get a health service in less than 30
minutes.

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Current situation in the health care system (4)
 The health facilities range from health care stations
and centers at PHC level and specialty-consultative
and inpatient departments at secondary level, to
university clinics and institutes at tertiary level,
with the latter also carrying out research and
educational activities.
 Smaller rural settlements are served with general
medicine services only.

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Parliament
Government
Ministry of
Health
Health Insurance Fund
Regional Institute for
Health Protection
Chamber of
Doctors
Chamber of
Pharmacists
Chamber of
Dentists
Speciality Hospitals
and institutes
University Clinics
and institutes
Specialists consultation
Services
General and
Specialists Hospital
Health Station
Private health
Organizations
Pharmacies Health centers
Republic Institute for
Health Protection
Organizational Chart of Health care System

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Health protection (1)
 The health protection of the people with intellectual
disability (PWID) is regulated with the Law for
health protection and Law for health insurance.
 Health protection is defined as: "sum of measures
and activities for compassion, protection, and
advancement of the health, inhibition, and
repression of diseases and wounds, early detection
of diseases, timely curing, and rehabilitation".
 Almost, none of the health institutions in
Macedonia is completely adjusted to the needs of
PWID.

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Health protection (2)
 Most of the health institutions are not accessible
for the PWID, and there where is partial
adjustment, the accessible are only entrance and
exist of the institution.
 As a result of the inadequate ramps, they do not
full fill even minimal standards and the result is
they are not even used by PWID.
 The situation is less satisfactory in adapting to the
internal infrastructure for the needs of PWD.
 There is low adaptation of the toilets, bathrooms,
rooms, as well as ambulances.
 It is necessary to note that the beds at certain
hospitals are quite old or in bad condition, which
are lead to patients developing decubitus wounds.

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Health protection (3)
 There is a lack of multidisciplinary team, which will
give psychosocial support to the families of PWID
in the health institution and will give information
for the responsible institutions and organizations
for PWID.
 It is necessary to implement further education of
the teams in the development counseling centers
and the members of their families.
 There are no programs for overcoming the
consequences of cancerous diseases to the mental
health of women.

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Health protection (4)
 There are no legal obstacles in the process of
implementation of the rights for services for sexual
and reproductive health for the man and woman
with disability, but in the practice there is quite
small number of accessible health institutions
where they can achieve their rights.
 In Macedonia, there is no gynecological dispensary
for woman with disability.
 Additional problems are created with the
prejudices in line with the marriage and sexuality
of man and woman with disability.

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Health protection (5)
Laws that regulate this field:
 Law for health protection,
 Law for health insurance.
Policy in this field:
 Advancement of the health of PWID and their
families through development of over all universal
system for health care of the primary, secondary,
and tertiary level, sensitive to the general and
specific needs for health care of PWID.

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Health care (1)
 The right for health and health care is one of the
rights guaranteed by the Constitution in
Macedonia.
 Real life practices show that the factual situation is
different, i.e. not all citizens have equal health
rights or equal access to health services or health
information.
 Health care does not cover all rural and small town
areas, which turns out to be a problem all over
Macedonia. There are not enough possibilities for
primary and secondary health care and there are
not enough services for house visits and patronage
services.
 Another major problem is that certain groups of

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Health care (2)
 There is a constant shortage of medicaments from
the positive list of the Macedonian Fund for Health
Insurance which forces citizens to buy them and pay
the full price.
 Beside these general health problems, certain groups
are facing many specific ones:
 Absence of continuous health care of children in pre-
school which is due to abolishment of pediatric
services within these institutions, become a major
problem referring to children all over Macedonia.
 There is no continuity in prevention and follow up of
children’s health in pre-school which causes
multidimensional problems.

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Health care (3)
 Consequences can be short term – such as epidemic
among children or long term such as serious
consequences on children’s growth and development
in future.
 Reasons for not having total coverage of children are:
• poverty,
• distance from their homes,
• insufficient number of institutions for primary health
care especially in mountain villages and rural areas,
• privatization of primary health care,
• superficial health education,
• legal regulations etc.
• mostly because of parents’ unawareness of their right
for health insurance.

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Health care (4)
 Health care is a very important segment in the lives
of elder people.
 They face many problems when trying to achieve
their right for medical care.
 There are no special programs within the primary
health care for old-age diseases, nor suitable
patronage nursing system for senior citizens, which is
a reason why elder people do not get detailed
explanation of the nature, treatment and
consequences of certain diseases.
 They are not well informed about diseases they suffer
from, which frequently causes further disturbance of
their health condition.

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Health care (5)
 Home medical care in rural areas is not well
organized, with additional cost for the doctor’s trip to
the old person’s home since these health centers do
not have vehicles.
 Elder people have to participate financially for the
services they get in the secondary and tertiary health
care centers, as well as to buy medicaments not
present on Health Insurance Fund positive list. This
deteriorates both their health and their financial
condition.

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Health care (6)
 Senior citizens are a category of people
mostly in need of help and care from others.
Absence of care services, absence of
patronage nursing system for elder people,
and insufficient sensitivity for their needs by
local communities, deteriorates elder people
health and social condition.

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Some data available (1)
30%
51%
19%
Yes
No
I don’t know
Do you think that health institution in your Municipality
provides you with satisfactory health services?
UNDP final report: Trajkovski V, 2008

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Some data available (2)
UNDP final report: Trajkovski V, 2008
45
13
21
3
0 5 10 15 20 25 30 35 40 45
Not paying
participation
Help and care from
other person
Improving services
more specialist
doctors
What has to be done to improve the
health services in the Municipality?

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Some data available (3)
WHO-AIMS report, 2009
Professionals graduaded in Mental health –
rate per 100.000 population

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Some data available (4)
WHO-AIMS report, 2009
Beds in Mental Health Facilities and
other residential facilities

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Future directions (1)
1. To prepare unique central data base with data
about PWID in Macedonia which will be at the
Ministry for health or Ministry for labor and
social policy;
2. To ensure protocols for compulsory
cooperation and exchange of data between
central data base and other sectors
responsible for gathering data about PWID;
3. To ensure constant up date of the central data
base in the field of health protection of PWID;
4. To plan evidence of PWID on the next
population census;

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Future directions (2)
5. To amend the legislation regulation so the health
insurance will cover 100% of the cost for all of the
services for rehabilitation in the health institution
and to ensure health protection without
participation for all categories of PWID, no matter
of the level or type of impairment;
6. To adopt program for development of qualitative
relations between beneficiary (PWID) and health
workers;
7. To develop program for activities in the field of
prevention with aim to enlarge the number of
preventive examinations and inhabit existing of
disability and severe impairment of the human
body;

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Future directions (3)
8. To ensure receiving adequate assistive means free
of charge in dependence of their diagnose;
9. To establish special department for protection of
rights and interests of PWID in the Ministry for
labor and social policy;
10. To create a network of development counseling
centers this will ensure provision of services in a
modern way. The counseling centers will function
as multidisciplinary teams and will provide
assistance to the children with development
impairments and to their families as well as to the
other existing social services;

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Future directions (4)
11. To create programs for education of the health
workers at the level of primary health protection
for education of the specific diseases and
conditions in relation to the PWID and to plan
then as one of the conditions for gaining licenses
for work in this field;
12. Neonatal screening for the intellectual impairments
that are occurring often as a possibility for tertiary
prevention.

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Future directions (5)
13. To introduce participation dispensation in healthcare
right realization for the intellectually disabled persons
without age restrictions;
14. To prepare and introduce National program for
disabled persons rehabilitation;
15. To promote the existing legal health care framework
related to health care insurance in order to provide
medications from the positive list;

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Future directions (6)
16. To establish the right to accompanying person during
intellectual disabled person hospitalization depending
on the disablement degree and on the disabled
capacity with physician recommendation to realize
the right for accompanying person without age
restrictions;
17. To bring separate Act which would establish which
healthcare services that are not included in the
compulsory healthcare insurance, but are necessary
for improvement and sanation of the health care
condition of the disabled persons and will be treated
as basic healthcare services.

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Conclusions
 Right to life have priority in the application of the
medical assistance and health protection;
 Right to prevention and rehabilitation and then
care;
 Right to qualitative medical service;
 Forbid discrimination and equal accessibility to
the medical services and appropriate medical
treatment no matter of the nature and
severeness of the disease;
 Establishment of the rehabilitation programs for
the individual needs of PWID as well as the
principles for complete participation and equality.

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THANK YOU
Prof. Vladimir Trajkovski, MD, PhD
Phone: +389-2-3148-834
Fax: +389-2-3118-143
E-mail: vladotra@fzf.ukim.edu.mk
Web blog: http://vladotra.blog.mk