The vote of confidence on health minister Nikola Todorov was, as he put it himself, a great opportunity to compare results and figures on how much has been invested and what has been achieved during the endless reforms of the Macedonian health system
SDSM initiated a vote of no confidence on the health minister, citing a number of weaknesses in governmental health policies resulting in tragic consequences and jeopardising the lives of citizens and patients, including “systemic problems and the general chaos in public health safety” among the reasons. On December 21, 2015, the Assembly discussed and discarded the motion, as the minister received the support of the MPs from the parties in power.
In the interpellation request, the minister was blamed for showing complete disregard for the problems and the tragic events in hospitals throughout Macedonia, proving he had “no moral capacity”. The proposal and the discussion highlighted cases where young women died in labour (such as the Gevgelija case, where a woman was delivered by a gynaecologist and two drunk anaesthesiologists), as well as the deaths of other patients, like Tamara, the girl from Veles, and others whose plights did not receive the attention of the authorities. Critics cited insufficient equipment and medical material, performance-based salaries and their effect on worsening personal relations, and the significant increase in infant mortality (229 deaths in 2013, ranking Macedonia first in Europe, according to Eurostat).
Health expenditure per capita is among the lowest in Europe at $835, the lowest compared to ex-Yu republics, while public health debts reach into the tens of millions of euros, including debts by public health institutions and the health insurance fund.
The minister replied with an extended speech where he provided analyses on the hundreds of millions of euros invested in modern medical equipment and said that various programmes to improve public health infrastructure (renovating, reconstructing and building new hospitals in Macedonia) were underway, amounting to 150 million euro, that the use of his Methodology to determine a unified price for medical supplies saved 32 million euro since 2012, and so on.
Speaking on infant mortality, while generally recognizing the negative trend, the minister said that “the phenomenon of infant mortality can be precisely analysed only by looking at the falling (or rising) trends long term, not by simply comparing yearly data.”
Looking at the response, it is obvious the minister avoided issues of public health debt, brain drain and attendant causes, the lack of contrast material for x-ray imaging and the lack of other medical material, especially in surgical procedures, as well as the funds spent on annual advertising, with SDSM claiming that only the campaign to raise awareness against abortion cost 3 million euro a year.
A country’s public health system is a never-ending discussion topic. The vote of no confidence submitted by SDSM simply could not touch upon all segments of the system and the actual state of public healthcare, nor could the minister’s speech. Therefore, this analysis will address only three key segments: public health debt, the brain drain of highly trained medical staff, and the system to treat citizens abroad, perfectly embodied in the case of little Tamara.
WHAT IS THE TRUE STATE OF DEBT OWED BY HOSPITALS AND OTHER PHI?
In their motion, SDSM stated that the Mother Theresa Clinical Centre in Skopje alone, after its last re-organisation and two manager system, managed to reach debts of over 51 million euro and rising, while all other public health institutions (PHI) owe another 70 million euro. These numbers, they say, refer to the first half of 2015.
Vistinomer attempted to check the figures using publicly available information and managed to do so only for the first figure. A document from the Macedonian Health Insurance Fund (HIF) confirms that by the end of August, PHI owed 52.5 million euro (total debt for all PHI), a 7.5% increase from December.
Total PHI debt on August 31, 2015 was 3,234,124 thousand denar (52.5 million euro), an increase of 7.5% from December 2014 (3,008,866 thousand denar). The amounts are PHI totals, states the HIF period income-outcome report for August.
The PHI (113 institutions with HIF contracts) debt figures vary due to the increase in work volume surpassing the annual budget of the clinical institutions and other hospitals.
However, looking at HIF’s final annual report for 2014, there is no separate category for the operation of the 113 PHI which are part of the complete health care system paid for by the fund. The fund itself performed positively in 2014, with total incomes set at 370 million euro and expenditures at 367 million euro. We may conclude that HIF’s debts, which are generated per year, are likely covered by increasing fund revenues.
TREATMENT ABROAD REQUIRED BY FEWER PATIENTS
The Macedonian public is keenly aware of the case of Tamara Todevska, who died in February while waiting for the HIF to approve funds for an operation in Turkey costing about 30,000 euro. A series of protest were held in front of the Ministry of Health demanding Todorov’s resignation. While the minister did not, resignations were tendered by then HIF Director Maja Parnardzieva-Zmejkovska and her deputy. On the day of Tamara’s burial, her family received the signed decision approving the funds for her operation, only feeding a growing sense of absurdity.
This case raised the issue of the system for required treatment abroad. This is especially pertinent after PM Nikola Gruevski, via a Government spokesperson, boasted that citizens requiring such treatment would only pay a consideration of 200 euro, the state bearing the rest of the brunt. He also boasted that the state had increased the budget for this item in 2015. What does this mean?
HIF’s 2014 annual report shows that the number of citizens sent for treatment abroad is in decline. 400 requests were submitted in 2011, 296 in 2014, while 2012 saw a record low of 243. HIF’s double control mechanism, employing a first and second instance commission, approved 274 requests in 2011, and only 123 in 2014. This shows the number of treatments abroad has been falling while the budget has increased.
A very indicative figure is the number of processed complaints on the basis of unsanctioned treatment or funds requested on other grounds for treatment abroad. In 2011, HIF received 33 complaints and approved 26, a rate of 79 percent. In 2014, however, a total of 106 complaints were received, 25 of which were approved, a rate of only 24 percent.
However, the most indicative figure is yet to come. According to the same 2014 report, all treatments abroad brought about expenditures of 2.6 million euro, less than 1 percent of the total expenditures amounting to 367 million euro! Why the amount is so small and why so many patients are denied, regardless of a general policy of the Government to treat citizens domestically, are questions that await answers. The manipulation is blatant if you claim free treatment abroad for anyone in need (at a cost of only 200 euro) and produce the appropriate sound bites, while the number of such requests is declining and there is an increase in claims denied. One of the causes is certainly the increased adoption of new methods and medical procedures, such as paediatric heart surgery, but another is the increased difficulty in dealing with the requisite bureaucratic procedure: medical panel opinion, first and second instance HIF commissions, and finally the signature of the Fund directors.
REFORMS SO FAR HAVE NOT PREVENTED MEDICAL BRAIN DRAIN
The brain drain of general MDs, senior specialists and sub-specialist has been a journalistic topic for years. The state has never revealed a specific number, either because the figure is unknown or is being withheld. The state published the public census of doctors and medical specialists, dentists and pharmacologists only in 2009 and 2011, through publications of the Public Health Institute of the Republic of Macedonia.
The main drain of public health doctors takes two courses – towards private healthcare or abroad. Private healthcare also has its migration processes – a minute percentage returns to the public healthcare system and a portion goes abroad.
If the state will not determine the exact number, we can find an approximate figure. Among the chief indicators are the requests for membership, recommendation or licencing from the Medical Chamber of the Republic of Macedonia.
The international research project Healthgrouper published a research on several Balkan countries in July 2015. The research claims that around 2,000 doctors left Albania, Kosovo, Macedonia and Serbia and headed abroad. How many of those left Macedonia?
We cannot provide a precise figure, as doctors have no obligation to register their departure, but indirect indicators estimate the number to be at least 500, said Vladimir Lazarevik MD, Healthgrouper CEO and health management specialist.
An older piece of research done by now defunct weekly Gragjanski which was never refuted indicated that some 500 highly trained doctors, i.e. specialists and sub-specialists, left the public healthcare system in the period 2006-2012. Some found work in private healthcare, others abroad.
Medical brain drain can be ascertained from the 2014 HIF report (p. 4), although limited to general practitioners. This report renders visible the yearly decline in the number of general practitioners in private health institutions. Their number was 1692 in 2012, 1500 in 2013, and 1471 in 2014. In two years, the number of doctors decreased by 221.
The Healthgrouper research divides problems and causes for migration in 5 key categories: economic, professional, political, personal and social factors influencing medical staff to leave their countries. The primary factors behind doctors migrating are the desire for professional development and higher income. Some 80% of those surveyed in Macedonia indicate these two factors influence their considerations to go abroad, the report states.
A key cause of migration for all countries which participated in the study is the political situation. Confirmation for this comes from those surveyed, both potential migrants and doctors who have already left. More than 80% indicate that the Macedonian political situation is a key factor in their considerations to go abroad.
Employment gained by direct political ties is among the factors stimulating young doctors to consider leaving Macedonia, but this is also true for the other countries, the survey of over 1,600 doctors finds.
The conditions are alarming in certain regions, such as the south-east, where the remaining two anaesthesiologists were suspended due to intoxication and the death of a patient. Aspiring specialists (about 1000 currently in training, with 400 receiving state aid) must invest at least 10 years specialising and interning to be considered fully trained doctors. One may deduce that of the numerous healthcare reforms, medical brain drain has had the biggest effect. Todorov and Gruevski may decide to invest another 300 million euro in medical equipment, but it will be in vain if there is no-one to use it, said a doctor we spoke to.