Healthcare in Macedonia

How does the healthcare system work in Macedonia?

On paper, Macedonia is a welfare state. By law, every employer pays health insurance for their employees. The employee receives a number of blue paper coupons each month. The coupons are used to "pay" for a doctors appointment or prescription drugs.

In real life, the social insurance law is not implemented everywhere. In a country with almost 40 % unemployment, most jobseekers will accept uninsured work without reporting it, and many employers are happy to exploit their situation.

However, every insured citizen has their "personal" general practitioner who coordinates treatment and transfers them to specialists or public hospitals, if needed. Free choice is not intended in the system. If a patient sees another specialist than his general practitioner recommended, or turns to a private practice or hopsital, insurance will not cover for it.

But even in public institutions, a blue coupon grants the patient free treatment only in theory. Doctors will frequently require bribes before treating or admitting a patient to a hospital, coupon or not. Even after admittance to a hospital, families contínue to bribe the staff so the patient will actually receive treatment. This was confirmed in last year´s UNODC Corruption Survey of the Western Balkans, where doctors and nurses are found to be by far the most corrupt professions.

Comments on healthcare´s efficiency cannot be made since there are no statistics. No public hospital has a quality management system implemented. My impression is transparency is not intended for good reasons. In Macedonia, there´s no family that hasn´t lost a loved one to obvious and horrifying malpractice.

What are the main differences between public and private sectors?

As in any low income country, private healthcare institutions offer better basic hygiene, food and overall service quality. The more ambitious healthcare professionals tend to seek employment in the more progressive and dynamic private sector.

In Macedonia, the public and private sector are strictly separated. The private sector is excluded from the state´s healthcare system. If a patient seeks treatment in a private practice or hospital, he has to pay for himself even if he has health insurance. The legitimacy of this has been publicly disputed many times because it condemnes the poor who depend on healthcare insurance to the miserable and corrupt public healthcare, while the wealthy have access to decent private treatment. The system also protects the dysfunctional public sector from competition with the quite functional private sector, so there´s no pressure for progress.

There´s one exception to the above: cardiosurgery. Since no public hospital has a functioning cardiosurgery department, the two private hospitals Filip Vtori and Sistina have contracts with the healthcare fund providing free operations for the patients and reimbursement for the hospitals.

For you as a foreigner, public healthcare institutions are an absolute no-go. Even though your embassy probably lists the state hospital on Vodnjanska on their website as a recommendation - seriously, don´t.
But even though there are decent private hospitals in Skopje, for a more complex or rare pathology you should still seek treatment in a Western country.

Here´s why: Keep in mind that there´s a learning curve in medicine. The higher the case numbers of a certain pathology, the better the quality of treatment. Macedonia´s poplulation is small - it equals cities like Hamburg or Vienna - and academic exchange with developed countries is limited. Even if Macedonian healthcare professionals were trained at the best medical faculty in the world - which they´re not - for certain diseases they simply don´t have enough patients to ever climb up the learning curve. You´ll probably be fine to have your appendix or your gall bladder removed at Remedika, but to treat, say, a phaeochromocytoma, Macedonia is the wrong place.

Is it recommended to purchase private health insurance in Macedonia?

Unfortunately, there is no such thing as private health insurance in Macedonia.
Get a good private expat insurance and make sure Medivac´s included as well as coverage for medical care in your home country. This is even more important than coverage in Macedonia, where medical care is overall incredibly inexpensive. As a fact, certain diseases or injuries CANNOT BE TREATED in Macedonia (there is no brain surgery, no spinal surgery, no traumatologist who´s fit to operate on complex fractures in the country, to name a few).

What should you do?

My law-abiding employer provided me with health insurance and the monthly blue coupons which I never used. Given how inexpensive private practice is, it never seemed worth the hassle to see a general practitioner first each time I wanted to see my, say, dermatologist. You can always ask for a bill in English, your expat health insurance will cover private practice. But mostly my fees were less than 10 €, so I didn´t even bother. The most expensive procedure I had in Skopje was an MRI of my knee which cost merely 150 €. Just to give you an idea of the price range.

Good physicians and dentists can be found reliably by word of mouth in the expat community which is tightly knit in Skopje. Macedonians are sometimes reluctant to give recommendations, you´re the foreigner and they´re insecure their recommendation will meet your expectations.

I agree with much of the comments mentioned by the previous poster in term of private care being so low in price it seems largely pointless to worry about going to a GP. However, that is because I feel I am a guest here and I expect to pay my way. I personally know some very good doctors here and i would have no problem entrusting my care or those of my family to them but I chose not too on the basis I mention.

There seems to be a real lack of leadership here generally, particularly when it comes to middle tier management.  Unfortunately, when it comes to people that can actually do the job (as I have found when hiring) the CV is meaningless. So you have 30 somethings that have spent virtually all their lives training and building a CV rather than actually demonstrably doing the job. In a health care scenario, I can only imagine how chaotic things must get. The key to survival here is to build a good CV so no one can question why you got hired.  There is far less emphasis on real world experience and achievement and far more on auto qualification by paper. So many competent people languish under utilized and under developed while others quickly get responsibility they are ill suited for. It is often baffling if you try to think about how some people got into very key roles in many authorities. Health service managers that are allergic to patients and civil servants that clearly detest the public arriving at their offices.

In terms of medical care, thing are improving a great deal and having seen the changes for myself when it came time for my wife to have a baby we decided to do it here.  There are various reasons for that but the new maternity wards are very good and the care was excellent.  A Macedonian speaking partner or advocate is always essential if you live here.  Like many things in Macedonia, you are completely stranded if you do not have a local to communicate and advocate for you.

There is very little accountability to the public here for services provided to the public. No ombudsman, no properly managed complaints procedure or accountability.  Unfortunately, there seems to be a few bad apples in every public agency here these give an impression that the entire infrastructure lacks competence which unfairly undermines the good work many people do. 

I would suggest a hybrid method to make sure your medical needs are met.  Utilise private care here for general illness and medical issues but if your from a country with a good health care system, don't stop your payments.

If countries with exponentially more tax paying citizens cant get it right most of the time, how can a country with exponentially less resources?

Hi,

In order to help expats and soon-to-be expats, we would like to invite you to share your experience on this topic, with updated info on the healthcare system.

Thank you in advance,

Julie
Expat.com Team

If you are an expat, anyway you should have additional insurance.

I was lucky enough not to have any need for any kind of medical care. Once, my daughter was ill and we went to private health care institution Acibadema Sestina. This proved to be good decision.

So, if you want proper health care than go to private care, if possible discuss this (which hospital you can use) prior to contracting private insurance.

The public sector is OK, private however much better.

There are two big private clinics (as far as I know), Sistina and Remedika. I prefer Remedika, since in my experience, Sistina just tries to squeeze money out of you every step of the way. I did not have that feeling in Remedika, you pay a fair price for very good service.