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The Pharmaceutical Journal Vol 264 No 7081 p190-191
January 29, 2000 Articles

Pharmacy in Macedonia

Pamela Mason reports on health care provision in Macedonia

Macedonia is a small country in the middle of the Balkan peninsula, which, following the disintegration of Federal Republic of Yugoslavia, became an independent state in 1991. Few people knew much about the country until the spring of 1999 when the conflict in its northern neighbour Kosovo produced a huge flood of refugees. Nearly a quarter a million people - mostly ethnic Albanians, but some Serbs - came to Macedonia, swelling the country's population of just under two million by about 12 per cent. In British terms, this was like having to absorb the population of London twice over.
Although Macedonia has been fortunate enough to avoid directly the conflicts that have plagued the Balkans in the past decade, the stress of these conflicts - economic, social and psychological - has taken its toll. Moreover, Macedonia is not without its own ethnic tensions: Macedonians constitute 66 per cent of the population, Albanians 23 per cent, Turks 4 per cent, gypsies 2 per cent and Serbs 2 per cent. Its fledgling democracy has a lot of work to do to create a stable environment for the future. In addition, more than 50 per cent of the population is currently unemployed, an increase of 15 per cent from a year ago, due partly to loss of industry and partly to sanctions from Serbia.

Prilep old town
Prilep old town

Health care

When Macedonia became independent, health care shifted from a decentralised to a centralised system, and a health insurance fund was established by the ministry of health. Health care is delivered at three levels - primary, secondary and tertiary.
Primary care is provided by both general practitioners and specialist doctors through a network of organisations, known as ambulantas, health houses and polyclinical centres. This structure varies slightly between rural and urban areas and with the size of the town. In rural areas, one primary care physician provides care for every individual in the population allocated to him or her. In urban areas, however, a primary care physician takes care of individuals from one population group, including infants and young children up to the age of six, schoolchildren, women and employees. A general physician takes care of everyone else. This means that primary care physicians tend to take care of one individual in a family and not the whole family.
Secondary care is provided by hospitals and tertiary care (highly specialised care) at the large hospital in the capital city of Skopje.
In common with many countries in the former eastern European communist bloc, Macedonia produces a huge number of doctors per head of population (one for every 410 people), and the hospitals are particularly overstaffed. And although the need to emphasise primary care and preventive services instead of secondary care and curative services is recognised, there is a great deal of work required to make this a reality. This will include educating and shifting the attitudes of both health care workers and patients.
Money is also a problem. Even before the refugee crisis, the health insurance fund was unable to cover the health care needs of the population, mainly because of the difficult economic situation. In primary care, many institutions do not have such basic equipment as sphygmomanometers, glucometers, peak flow meters and ophthalmoscopes.

Prilep hospital
Prilep hospital

Pharmacy

Lack of funds has also created a shortage of drugs in the state system. Medicines are reimbursed by the health insurance fund, although patients (with some exemptions) pay 20 per cent of the cost. There is a list of reimbursable drugs, and for each drug, the ministry of health asks suppliers both inside and outside Macedonia to quote a price. The ministry then selects a supplier. In Macedonia itself, the pharmaceutical market is small and there is little competition with drug prices being about four times as high as the European Union average, but the ministry's tendering system for drug supplies should eventually help to bring national prices down.
To obtain reimbursable medicines, patients normally go to a so-called state pharmacy. In operation during the time when Macedonia was part of the Federal Republic of Yugoslavia, these pharmacies tend to be large and run with a high degree of professionalism, and there are about 100 of them. I visited one in Prilep, a town with a catchment area of approximately 72,000 inhabitants, and, like all of the state pharmacies in Macedonia, this one was supplying both medicines reimbursed by the state and medicines paid for entirely by the patient (ie, a mixture of public and private business).
Moreover, there was a clear division between the two parts of the pharmacy and a clear distinction in terms of stock levels. In the "state" part, I took an inventory of the entire stock - just 50 different items - in about 20 minutes, whereas in the private part, the shelves were reasonably stocked with about four to five times the variety. Given that this was a large pharmacy, the shelves of reimbursable medicines were pretty empty. However, a delivery was expected within a few days and the pharmacy manager explained that patients tended to know when the drugs were coming and brought their prescriptions on the first couple of days, thus making the situation look worse than it was.
The pharmacy manager also explained that, like all state pharmacies, he had a drug budget and he could order only up to this amount, which covered about 70 per cent of the prescription items brought into the pharmacy. The World Health Organisation, which is working in Macedonia, has funds for drug purchase for vulnerable groups in primary health care and at the time I visited was currently thinking about how to target these funds. As one of the poorer parts of the country, the area in which Prilep is situated was being considered, and it could be that state pharmacy shortfalls could be remedied at least for a short period to provide breathing space for the economic situation to improve.
Medicines are also available through private pharmacies, of which there are about 400. In the main, patients visiting these pharmacies have to pay the entire costs of the medicines, although the ministry of health has made an agreement with about 60 private pharmacies to deliver reimbursable drugs in places where there are no state pharmacies. Any private pharmacy can enter such an agreement, but few want to do so, because it is currently taking so long to get paid. Although a new drug law was passed during 1998, it is by no means enforced yet. There is, therefore, little control on drug supply to the public, and pharmacies tend to sell all types of medicines without prescription.

A state pharmacy in Prilep
A state pharmacy in Prilep

Prescribing

How many prescriptions are really needed is, of course, open to question, and there is, for example, high use of antibiotics and sedatives. However, a continuing medical education project at Prilep medical centre, funded by the World Bank, is helping to tackle irrational prescribing. An enthusiastic team of Macedonian doctors from a variety of backgrounds has put together a certificate programme to train primary care physicians in the locality. Sixty doctors have been trained on the pilot programme, which consists of 18 days of workshops, including clinical skills, problem solving skills and group work, all of which is nothing short of revolutionary in this country. Not surprisingly, participants have gained as much from meeting together - and for them this was the first time - as they had from the training itself.
Much of the clinical input is based on 15 or so treatment guidelines - again developed by the project team - on therapeutic areas common in general practice, such as hypertension, heart failure, asthma, osteoporosis and so on. One of the problems with the guidelines, however, is that not all the drugs recommended, such as hydrochlorthiazide as a first-line treatment for hypertension and beclomethasone for asthma uncontrolled with salbutamol, are reimbursable by the health insurance fund, although this is likely to change in the near future.
Initial assessment of the pilot project seems to indicate that prescribing is changing with cost savings of 40 per cent on injections already achieved. If this figure proves to be correct, and prescribing similarly altered on a country-wide basis, significant savings to the health care budget could be achieved. Macedonia, like most of its neighbours, has a strong "injection culture": patients believe in the value of a medical intervention that they can see, and injections are therefore commonly prescribed.

Refugees

The acute phase of the crisis that brought refugees from Kosovo to Macedonia is now over, although refugees who were and continue to be hosted by families in Macedonia are putting additional strain on a health care system that is already desperately short of money. In addition, many of the refugees in host families (approximately 150,000 during the peak period) lived in the north west of Macedonia which is one of the poorest parts of the country.
Eight camps had another 80,000 refugees and the last of the camps closed in November, 1999, because of the coming of winter. The health care needs of the refugees were met largely by non-governmental organisations, although refugees were entitled to health care through the state system if they needed it.
Pharmaciens Sans Frontieres (PSF), which is funded by the European Community Humanitarian Organisation provided most of the pharmaceutical needs.
Ms Martine Poitou (PSF pharmacist) told me that diarrhoea and upper respiratory tract infections had been the most common illnesses, but there had been no typhoid and no cholera. Although health care services in Kosovo had been neglected during the past 10 years, the refugees were relatively well nourished, compared with those in other crises in developing countries.
Scabies and lice had been endemic, however, necessitating the ordering of huge quantities of shampoo and lotion. Thirteen thousand people had been treated for lice in five months. In Kosovo, itself, three babies had died as a result of people smearing their bodies with organophosphates and the PSF pharmacist in Kosovo had developed a poster campaign to help prevent this happening in the future. In the height of the summer, sunburn had been a particular problem in the camps, Ms Poitou said, something that you do not tend to think about in a crisis of this nature. However, the refugees were living outside in camps with almost no shade available and 45,000 tubes of sun cream were provided.

Conclusion

In 1999, much effort went into the health care needs of the refugees, most of whom have now returned to Kosovo, and Macedonia must now return to strengthening its health care system. As finances allow, genuine drug shortages need to be tackled, but rational prescribing must be encouraged to cut down excessive drug use in some areas. The drug law needs to be enforced to protect the public from being able to obtain prescription medicines over the counter. All pharmacies will probably be privatised during the next few years, and Macedonia should take advantage of the experience of other eastern European countries that have recently done this to avoid some of the chaos that privatisation has often caused.

ACKNOWLEDGMENTS I would like to thank Mr Martin Auton (pharmacist consultant on the WHO pharmaceuticals programme in Skopje) for organising the visits to pharmacies, and Dr Marija Gulija (general practitioner and assistant on the WHO pharmaceuticals programme) for acting as translator.

Pamela Mason is a pharmacist and freelance writer from South London