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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. INTRODUCTION (1). Country profile

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Health care system for people with intellectual disabilities in macedonia

University “St. Kiril and Metodij”Faculty of PhilosophyInstitute of Special Education and Rehabilitation


Vladimir Trajkovski MD, PhD

Bristol, May 13, 2010

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).

Health care system for people with intellectual disabilities in macedonia


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

(Janicki, 2010)

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.

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.

Current situation in the health care system 1
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.

Current situation in the health care system 2
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.

Current situation in the health care system 3
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.

Current situation in the health care system 4
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.

Health protection 1
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.

Health protection 2
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 exit 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.

Health protection 3
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.

Health protection 4
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.

Health protection 5
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.

Health care 1
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 citizens do not have health insurance.

Health care 2
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.

Health care 3
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.

Health care 4
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.

Health care 5
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.

Health care 6
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.

Some data available 1
Some data available (1)

Do you think that health institution in your Municipality

provides you with satisfactory health services?

UNDP final report: Trajkovski V, 2008

Some data available 2
Some data available (2)

What has to be done to improve the

health services in the Municipality?

UNDP final report: Trajkovski V, 2008

Some data available 3
Some data available (3)

Professionals graduaded in Mental health –

rate per 100.000 population

WHO-AIMS report, 2009

Some data available 4
Some data available (4)

Beds in Mental Health Facilities and

other residential facilities

WHO-AIMS report, 2009

Future directions 1
Future directions(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;

  • To ensure protocols for compulsory cooperation and exchange of data between central data base and other sectors responsible for gathering data about PWID;

  • To ensure constant up date of the central data base in the field of health protection of PWID;

  • To plan evidence of PWID on the next population census;

Future directions 2
Future directions(2)

  • 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;

  • To adopt program for development of qualitative relations between beneficiary (PWID) and health workers;

  • 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;

Future directions 3
Future directions(3)

  • To ensure receiving adequate assistive means free of charge in dependence of their diagnose;

  • To establish special department for protection of rights and interests of PWID in the Ministry for labor and social policy;

  • 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;

Future directions 4
Future directions(4)

  • 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;

  • Neonatal screening for the intellectual impairments that are occurring often as a possibility for tertiary prevention.

Future directions 5
Future directions (5)

  • To introduce participation dispensation in healthcare right realization for the intellectually disabled persons without age restrictions;

  • To prepare and introduce National program for disabled persons rehabilitation;

  • To promote the existing legal health care framework related to health care insurance in order to provide medications from the positive list;

Future directions 6
Future directions (6)

  • 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;

  • To bring separate Act which would establish 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.


  • 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.

Thank you


Prof. Vladimir Trajkovski, MD, PhD

Phone: +389-2-3148-834

Fax: +389-2-3118-143


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