Professor at the Sts. Cyril and Methodius University Faculty of Medicine in Skopje Head of the Neurosurgery Department Clinical Center Skopje-Skopje Coordinator of the Team for Accreditation of Doctors in Macedonia (1999-2001)
The declaration of independent and sovereign Republic of Macedonia meant starting a long process of changes in society. The changes having resulted from the social transition started happening in the delicate political and global social relations in the region and beyond, in Europe.
While in Europe there is a pronounced trend for unification into a large social community, the European Union, the countries of Southeast Europe in the last decade of the past century were troubled by their own social turbulences. These events inevitably had an effect on the process of social transition in the Republic of Macedonia.
The changes began, but certain segments of society were marginalized. Thus, the health protection system remained hostage of the previous social system - health protection is of special social interest, but always serving the purpose of the countrys economic power. In the former community of the Yugoslav peoples this system was conceived by the Socialist principles of solidarity and represented a safety mechanism for protection of the citizens health no matter their social and economic position in society.
The system of funding health protection, as an important part of the development of this extremely significant segment of society, remained unchanged in the new circumstances of social turbulences. The funding goes through a public fund controlled by the state administration and operating by the principles of solidarity and formal responsibility for paying contributions, primarily by citizens making income.
Although there were attempts in the beginning at stimulating the private initiative in the health protection system too, in the first years of Macedonias independence, the country failed to make substantial efforts for fundamental changes in the health system, according to the models in the developed European and non-European societies.
WHY ARE HEALTH REFORMS NECESSARY?
It is clear that the changes in a given system, especially if it functions according to certain principles in a period of around half a century, are impossible without the consensus of the social community. In the case of the health protection system of the Republic of Macedonia, not only do all the relevant social factors agree that the health reforms are necessary, but also the Republic of Macedonia is faced with serious criticisms by the international factors directly involved with their financial assistance in changing the whole society. Namely, certain international institutions, through their representatives in Macedonia express openly their dissatisfaction with the sluggish health system reforms.
So there are objective conditions for changes in the health protection system. The changes cannot be isolated from the overall changes in the transition process, particularly if taking into consideration that Macedonia makes much effort to join the EU.
However, the need for changes, or, to be more exact, for reforms in the health system too, with the aim of completing the process of Euro-Atlantic integration, is being constantly underscored. Truly, there are standards in the health system as in all the areas of society, accepted by the EU member states. However, the overly pronounced will for European integration leaves little space for the arguments that the changes in the health system are necessary primarily for the citizens needs, no matter their social status, i.e. no matter if they pay contributions to the Health Insurance Fund from their personal income or are insured in another way.
Hence, we cannot and should not, and besides nobody is asking us to do that, to copy the rules of the health protection system of the EU member states. Instead we should make an analysis of the extant models of certain EU member states to develop a comparative study about the status of the health protection in Macedonia relative to its status in the countries to be used as reference points in the process of reforming the health system. In other words, the reforms of the health system are needed for the sake of the Macedonian citizens, and they should be carried out based on expert analyses and draw upon the experience of a number of models in organized and developed societies.
CONDITIONS IN WHICH HEALTH REFORMS BEGAN
It is fact that in the first few years of the independence of the Republic of Macedonia, the country was faced with massive, tectonic social movements in the region. The armed conflict caused a feeling of grave economic and social insecurity in the citizens of the Republic of Macedonia. Disturbance occurred in all the areas of life: even the supply of subsistence products became problematic. Macedonia faced a prominent shortage of medical supplies, including essential medicines. In such circumstances, initiating a process of reforming the health protection system, except for overcoming serious drawbacks in maintaining the health systems basic functions, was impossible for several years.
However, after a certain period, in the middle of the 1990s, circumstances were created, not only for stabilizing the conditions for normal functioning of the health system, of course in circumstances of global social transition, but also for preparing a ground for changing the health protection system in general.
The international community started analyzing in 1996 the overall situation in Macedonia, including its health system as part of the social system. The first analyses and estimates of the structure of this system, which carried the legacy of the previous system, which was being abandoned as recommendations for changes came, were made.
It was necessary then to define the need for creation of a National Strategy for health system reforms, which required consensus of the countrys political factors. Based on a previously created strategy for reforms, establishing a system of changes in this significant social segment could have been expected. In other words, it was necessary to pass appropriate legal norms underlying Macedonias health system.
(The state administration, i.e. the Ministry of Health, initiated this, but failed to make genuine effort to develop such a document and make it binding for the institutions acting within the health protection system. A group of experts, including representatives of professional associations of health workers within the framework of the Macedonian Academy of Sciences and Arts, worked for a while on this document, but a strategy has not yet been formally adopted by the Ministry of Health).
At the end of the last decade, i.e. in 1999, conditions were created under the auspices of the World Bank for reaching an agreement among the Ministry of Health, the Chamber of Medics and the Faculty of Medicine of Skopje for starting concrete activities for improving the health protection system, which expert teams (also under the auspices of this financial institution) assessed as inefficient and with inappropriate performances. At the end of 1999, the document "Memorandum of Consent for Developing Standards in the Primary Health Protection" was signed, according to which these four factors in the health system should take concrete steps to transform the health system into a modern concept, yet in keeping with our social conditions.
Previously, in a 2-year period, the project for continuous medical education of doctors practitioners, primarily in the segment of the primary health protection, was carried out, because according to the foreign consultants, the changes of the health system should focus and start in this segment, given that almost 70 per cent of the health services in Macedonia are thought to be rendered on this level. This matches the scope of health services in the European countries, or at least the EU member states. Despite the initial resistance from certain groups of public sector doctors rendering services on this level of health protection, the results of the project were evaluated as satisfactory.
INITIAL RESULTS OF HEALTH REFORMS
The effect of the used funds provided from the credit of the World Bank in the amount of around US$17 million is very frequently discussed. There are some benevolent remarks, and much more criticisms by the political parties, which, due to their ignorance, try to prove that the credit has been irrationally used. There are documents precisely showing the effects of the used funds. Namely, investments have been made in supplying and standardizing health stations in the country, largely those from whose health organizations primary health protection doctors were sent to educational courses within the aforementioned project of Continuous Medical Education (CME), and also in constructing and supplying four centers to this end in Prilep, Veles, Gostivar and Strumica, as well as in the initial courses of the CME project in Ohrid, and later in Skopje. Unfortunately, these centers seemed to have one-time use because upon completing the first stage of CME, which encompassed over 600 doctors from the whole country from the primary health protection sector, this process did not join the system of health education of doctors.
In parallel with the initiation of the education activities within the framework of the CME Project, based on the provisions of the Memorandum of 1999, a working group was established, which in the course of 2001, after a one-month stay in relevant institutions in London and the Netherlands, and cooperating intensively for nine months with experts from these European countries, developed a Strategy for Accreditation of Doctors in the Republic of Macedonia. This document became the cornerstone for quality changes in the Amendments to the Health Protection Law of Macedonia. The document was reviewed and positively evaluated by experts authorized by the World Bank. The Strategy foresees that all the doctors, no mater what level of health protection they are on, should be accredited for their professional activities. In addition, the health institutions in Macedonia should receive accreditation for conducting practical medical training, also known as post-graduate internship.
According to this strategy, through the process of accreditation, the knowledge, skills and professional approach (stands) will be verified, based on which licenses for professional activities will be issued to individuals and institutions.
The accreditation will be conducive to objective evaluation and monitoring of the performance, the ultimate goal of which is meeting the required professional standards. Such imperatives are already employed in a number of countries of the European Union.
In this way, the accreditation will contribute to improving the quality of health protection, protecting patients from incompetent doctors, and improving the status of doctors showing top quality professionalism.
THE BASE FOR DEVELOPING ACCREDITATION STRATEGY
The analyses conducted by the foreign consultants and the other home participants in the project showed that a system for monitoring the professional activities of the participants in the health protection system had not been established. There are too many medics, a great number of unemployed physicians and also a great deal of students of medicine at the Faculty of Medicine in Skopje and the other universities in the neighboring countries. On the other hand, the need for medics is limited, although undoubtedly quality professionals are always necessary. It was said that a moratorium for admission of new students of medicine should be declared for a given period of time and then establish the principle of numerus claussus, or "closed", fixed number of newly admitted students at the Faculty. The Facultys curriculum should undergo changes in terms of introducing more practical training and mentor system of studying, objective evaluation of knowledge in a transparent way and including experts from universities of other countries of the region and the European Union.
The EU member states, as well as the countries striving to receive that status, are developing a system of safe and quality health protection. The frequently used phrase GOOD MEDICAL PRACTICE stands for the standards required from all the medics and their professional practice. This term indicates professional competence, keeping high standards of professional performance, joining a process of continuous medical education, professional conduct in accordance with the ethical standards of the medical profession and prevention against doing harm to the patients health.
In this way, the EU member states set up strict and defined standards of medical practice and health protection.
On the other hand, the basis for accepting the young doctors of medicine (no matter where they completed their university education) is the period of PRACTICAL MEDICAL TRAINING. Whether this training takes six months or a year, the practical training needs quality changes. This period should represent a process during which the graduates of medicine should transform into doctors afforded the opportunity to supplement their theoretical knowledge with practical skills and to develop the right attitude to patients and their profession in general.
Upon completing this obligatory period, the young doctors take the Exam for Obtaining the Basic License granting them the right to join the health protection system. As the practical training, the exam is likewise structured to be fully objective and transparent, in contrast to the previous state exam. It will be conducted by the Chamber of Medics of Macedonia rather than the Faculty of Medicine, as has been the case so far, due to the evident conflict of interests: those being educated cannot at the same time be supervisors of their own product!
The practical medical training will be conducted in all the health institutions accredited by the Chamber of Medics, not exclusively at the Clinics of the Faculty of Medicine, capable of providing conditions and resources for post-graduate education of doctors of medicine.
The practical medical training will be conducted by accredited educators and mentors having the required qualities and motivation to educate, particularly in terms of practical education of young graduates of medicine.
Practicing the medical profession will be possible on completing the professional education in a period of three to five years, after which the closing, professional exam (specialist exam) is taken, granting the right to the Operating License in the health protection system.
It is clear that this concept of establishing a system of accreditation and licensing secures quality health protection, while professional and trade associations of doctors are attributed great responsibility to ensure quality health protection, which is all the more so considering that after a given period of professional activity there should be re-accreditation, or re-licensing of individuals and institutions accredited for conducting practical medical training.
CHALLENGES WE FACE
The ongoing changes inspire insecurity in the medical profession. But not only are certain groups of professionals concerned about their professional future. It is uncertain if the state too is ready to deal with all the challenges that medical professionals and health insurees face.
It is clear that in Europes developed countries private health institutions or individuals are responsible for the primary health protection. Only the services in the domain of the secondary or tertiary health protection (regional hospitals or university clinics) are state-owned, i.e. part of the public sector.
However, according to the Constitution of the Republic of Macedonia too, the ownership - public or private - does not determine the level i.e. the quality of health protection. Hence, the health insurance of citizens should guarantee for quality health protection regardless of whether the protection is provided by public or private health institutions or individuals.
The quality of the rendered services is the chief criterion for accreditation of individuals or institutions for rendering health protection to citizens.
The citizens of the Republic of Macedonia may expect appropriate health protection in line with the funds they pay to the health insurance funds. Apart from the public fund for mandatory health insurance, whose funds are of the citizens and of the state too because of the obligatory services it provides (contagious diseases, prevention from diseases, obligatory health protection of a certain category of insurees, etc), it is necessary to establish funds for private and additional insurance, which should also be mandatory for all the insurees, with different participation though, according to their own needs, but with a previously defined minimum amount of additional insurance.
Considering that most of the funds paid to the Health Insurance Fund are funds of insured citizens, the Fund and its bodies should not be operated only by government officials, possibly joined by representatives of the political opposition, but only and exclusively by those paying contributions including representatives of the government, participating in the funding of the health protection in agreement with its powers.
The Fund, or Funds for Health Insurance are primarily financial institutions and they should operate by economic principles, which means that the Fund should be managed by economic or financial experts rather than politicians.
PROBLEMS IN SECONDARY AND TERTIARY HEALTH PROTECTION
In Macedonia there are three levels of health protection. On the first level, citizens mainly receive elementary health protection. However, for slightly bigger health problems, patients are referred to the Medical Centers where they receive specialist help. However, they are referred ever more frequently to the Clinics of the Medical Faculty in Skopje, i.e. the Clinical Center (the third, top level) where many services, which should fall under the second level of health protection, are rendered. On the other hand, the supplies of the Clinics lag behind the equipment, which, according to international standards, is indispensable for this level of health protection. The reason is largely economic. This equipment is expensive, but on the other hand, the apparatuses are overused and depreciate quickly because of the mounting number of examined patients in a short period of time. Instead of diverting the amortized equipment to the Medical Centers where it can still be used for a little while, while procuring new modern apparatuses and instruments for the purposes of the Clinical Center, a certain number of patients are still being referred to medical treatment abroad (Greece, Slovenia, etc) for shortage of adequate equipment, which is all covered by the impoverished Health Insurance Fund. Many hospital departments in Macedonia do not have the required staff, are troubled by a shortage of medical apparatuses or are mistrusted by patients, and the irrational use of resources is paid for by the public Fund, irrespective of the size and quality of the performed job. Thus, there is a surplus of personnel and hospital departments, which use funds from the Health Insurance Fund, without producing results though. Therefore the Clinical Center operates under constant pressure of patients who can be given the adequate health protection on lower levels.
Not even the professional staff at the Clinical Center are stimulated to work on their personal professional advancement because they should do that with their own funds. The health workers in the health institutions of lower ranks do not even think of the need for continuous professional advancement.
Therefore, the obligation for the health institutions, rather than the individuals alone, to become part of the system of continuous professional advancement, including the continuous medical education, will be a very important challenge. Without establishing such a system, re-accreditation, i.e. renewal of the operating licenses of individuals is impossible. Thus, the health organizations rendering health protection, whether public or private, should obligatorily set aside funds for continuous professional advancement of their professionals. The Health Insurance Fund, or Funds, too will be interested in the continuous professional advancement because that will be conducive to providing quality health protection according to international professional standards and norms.
In this way, the interest of the future university students will be diverted from the medical profession to other professions because not only will the time of medical education, indispensable for starting independent professional activity, be prolonged considerably, but also the conditions for acquiring authorization will be raised to a level set according to the norms in the developed countries, primarily the EU member states.
The number of practicing doctors will decline, but the quality of their professional activity will be raised to a higher level, and their achievements too will be evaluated more appropriately.
In this way working and making profit in an unprofessional way will surely decline and perhaps disappear.
In the course of making these changes, the role of the Chamber of Medics and the Macedonian Association of Medics, as professional organizations of doctors in Macedonia increases considerably. But their responsibility will greatly exceed their rights, particularly because of the fact that the authorizations granted by the state can be suspended if these organizations fail to do their job.
These principles, some of which already implemented in the modifications to the Health Protection Law (February 2004), are a solid base for drafting the indispensable National Strategy for Health Promotion, which should be the prerequisite for true reforms in the health system of the Republic of Macedonia, especially now that the country decided with a consensus to join the European Union.