Steering Macedonia towards Health

As healthcare systems go, Macedonia's is far from being the worst. By various criteria, Macedonia has attained more than all its neighbors and has even done better than the vastly richer countries of the EU or Israel. These accomplishments are rendered even more incredible if one considers the fact that, with an average monthly income of c. 250 euros, Macedonians are among the poorest nations in Europe. Macedonia's Health Insurance Fund has to cope with the same size of population (2 million) as does its Slovenian counterpart, but with 10 times fewer resources (300 million euros in contributions and other income vs. more than 3 billion euros).   Still, while, by objective measures, the system is reasonably successful, by subjective ones (customer satisfaction and trust) it is abysmally deficient. Patients consistently complain about a lack of resources, decrepit equipment, inordinately long waiting times, an all-pervading lack of responsiveness, corruption and informal payments, and other ills of the country's tottering healthcare institutions.   Enter the country's youthful (28) Minister of Health, Bujar Osmani, a medical doctor by profession. Having worked in the United Kingdom for a year, he speaks wistfully of its fabled National Health Service (NHS). This exposure to a model of healthcare delivery and provision that actually works may have been the impetus to the unusual events that took place in his Ministry in the last 4 months or so.   Osmani is soft-spoken, thoughtful, and pragmatic. He is well-educated, intellectually alert, and his English is impeccable. He, thus, reifies a new breed of Albanian politician in a country where Albanians are a much-maligned minority. In the government, he is in the demanding position of belonging to DUI, a party that is the political incarnation of Albanian insurgents and malcontents. In 2001, an armed conflict between the two major ethnic communities - Macedonians and Albanians - resulted in the Ohrid Framework Agreement which regulates their uneasy co-existence. Since then, DUI has twice joined coalition governments with various all-Macedonian parties.   Though naturally mindful of his public image, Osmani is far from vain. He was the one to reach out and initiate the first meeting between us. When I offered him the idea that was to become the Steering Committee for the Advancement of Healthcare in the Republic Macedonia, he unhesitatingly accepted it, an act of exceptional political courage. Attempts to reform the healthcare system - steeped as it is in special interests, political meddling, and resistance to change - have buried many a political career.   Osmani wants to leave a legacy of better health behind. He is a true reformer. But, after months of clashing with various constituencies while trying to implement even minor changes to the system, he understood that reform is not a command-and-control proposition. He had to bring aboard all the stakeholders in the process: doctors, patients, nurses, non-governmental organizations, consumer advocates, and the pharmaceutical industry. A varied group of experts - lawyers, economists, and healthcare advisors furnished by the World Health Organization (WHO) will help them along. The Steering Committee for the Advancement of Healthcare in the Republic Macedonia was launched on June 2, 2009.   Macedonia's long-suffering public has silently witnessed dozens of failed attempts at overhauling the creaking edifice of healthcare. A slew of committees has produced a midsize mountain of reports and recommendations that gather dust in drawers throughout the Ministry of Health. Not surprisingly, the new initiative met largely with skepticism and cynicism.  

But Osmani started a truly new process. Its novelty will undoubtedly sink in as it progresses. Regardless of whether this particular committee succeeds or not, it has established precedents that will be impossible to ignore.

Being an active member of this body, I will revert to first person:

For the first time we are attempting a sector-wide analysis with the intention of implementing changes across all institutions, not restricted to certain elements in healthcare delivery, provision, commissioning, and stewardship. Incremental, piecemeal reforms do not work. The entire system must be tackled simultaneously.

For the first time, all stakeholders in the health sector are involved directly in a Steering Committee that is not governmental. The government has a seat at the table (in the person of the Minister of Health), but no privileged status. Such wide participation guarantees "ownership" of the committee's work and of its recommendations. No one will be able to say: I have had no part in this process; these proposed changes are imposed on me against my better judgment and will.

For the first time, the public will be consulted directly, through townhall meetings and by constantly submitting ideas, opinions, and suggestions to the Committee.

For the first time, cutting edge, Web 2.0, social networking high-technologies are used to involve the entire public and all the stakeholders in the debate (Wiki, blogs, Facebook, Twitter, and an interactive Website - http://sc-healthreform.org.mk ).

For the first time, the members of the Committee are allowed to invite expert witnesses and seek information, insights, and advice from them.

For the first time, the process commences with the Committee’s recommendations rather than ends with them. Such recommendations will serve as the starting point and the basis for extensive public consultations.

For the first time, the Committee will produce draft laws, amendments to laws, and regulations rather than reports that are ignored and stashed away to be soon forgotten.

Ultimately, elected politicians will decide the fate of these "draft laws, amendments to laws, and regulations". This is how it should be in a democracy. Hopefully, constant exposure of the Committee's work to the public will prevent special, moneyed interests from thwarting true reforms in collusion with corrupt decision-makers and legislators. There's no guarantee of that, of course - just a slightly better chance than before.