COMMENTS FROM LORAINE HAWKINS ON: FLAGSHIP COUNTRY REPORT FOR MACEDONIA (prepared by Drs Tozija and Dimovska and Mmes Bacanovich and Gjozeva)

1. Thank you for the opportunity to comment on this report. For Rajna Cemerska, myself and for the four authors of the report, this is a very valuable step in our ongoing dialogue about health reform in Macedonia. The report demonstrates that the authors’ detailed knowledge of a wide range of reform initiatives in Macedonia – not only the problem of how to reduce infant mortality. The report recognizes that it is not possible to tackle problems with mother and child health services unless some more generic health system improvements take place, including:

• More effective revenue collection by the HIF;
• Improved resource allocation methods by the HIF and the State budget;
• Financial incentives for health professionals;
• Management capacity and training;
• Reform of the medical curriculum and institutionalizing regular CME and CPD;
• Development of clinical audit;
• Development of accreditation and re-certification of health professionals and healthcare institutions;
• Development of national data bases and information systems, with internationally standard definitions and systems.

2. I would add two additional items to this list of generic health system improvements which are needed:

• Strengthening of the capacity of the MOH and HIF for policy, planning, monitoring and evaluation.
• Systems for monitoring and enforcing contracts with providers and regulations.

3. The report is systematic in its approach to listing the factors that are likely to contribute to the problem of high infant mortality. The report also acknowledges that there is a lack of data, and a lack of data which is internationally comparable. An important area for future work is to gather data which will make it possible to make a more specific diagnosis of the causes of Macedonia’s relatively high infant mortality, compared to other CEE and EU countries. For example, it could be useful to identify the extent to which high risk of perinatal or post-neonatal infant death is associated in Macedonia with: maternal age, educational status, ethnicity/nationality, socioeconomic circumstances. It could also be useful to gather data to compare the performance of different healthcare institutions in terms of the health outcomes they achieve for mothers and babies. This kind of information would make it possible to develop a more specific and targeted strategy for reducing infant mortality.

4. One additional factor which makes it difficult to address the problem of maternal and child health in Macedonia, is the fragmentation of primary health care delivery. It is likely that a different doctor (or two doctors) would be responsible for the health of the pregnant woman from the doctor who will be responsible for the baby after birth. The patronage nursing service and the immunization service are also organized separately. This fragmentation makes it very complicated to implement new protocols for mother and child health, and complicated to ensure continuous care and good systems of patient information and health data.

5. The report presents a series of complementary measures for improving infant mortality – financing sources, a changed payment method for PHC, changes to regulations, organization and persuasion. These measures are not alternative options – they are all part of one program of measures to address the problem.

6. For the financing "control knobs", however, there are some alternative options which the authors or the GOM could consider – different ways of achieving the same objective. For example, there is at present a vertical program, partly financed from the State Budget, which covers preventive aspects of mother and child health services. The report proposes that the State budget should fully finance this program by reallocating funds from the Ministries of Education and Labor and Social Welfare. There are some alternative options which could be considered, including:

• Replacing the vertical approach to preventive care for mothers and babies with an integrated, horizontal program, as part of PHC reform. Under this option, PHC services would be integrated to include patronage nursing, primary-level obygyn services for normal childbirth, and care of well babies, and community/local health education. The BBP for PHC, and the contract and payments for PHC would include the activities in the Preventive Program for mother and child listed in the report. The source of finance would be the HIF – through integrated payments for PHC. The report could consider the advantages and disadvantages of a vertical program compared to an integrated program.
• Keeping the budget-financed vertical program for preventive care for M&C, but reallocate funds to finance the program from low priority areas of government expenditure (such as savings from the IMF program reducing the number of Government agencies, cutting the public sector payroll, eliminating or privatizing inessential services). This may be politically more realistic than reallocating funds from Education and Social Welfare (which are high priority areas for government expenditure, and can help reduce some risks that contribute to high infant mortality).

5. The report recognizes that changes are needed in the payment mechanism and in regulations, as well as additional finance for the M&C program. The payment mechanism needs to be consistent with the financing mechanism. I see two options for this, consistent with the two options for financing:

(i) If the M&C program is a separate vertical program financed from the State Budget, it will be important to have a separate payment stream to providers for these services. The budget-financed vertical programs are not part of the BBP covered by the HIF – they are a separate service provided to the whole population by the MOH regardless of whether they are insured or uninsured. The MOH will need to contract with health care providers to specify the M&C services to be provided, in return for the M&C payments. (For practical reasons, the MOH could contract the HIF to administer these contracts and payments on its behalf – but the monitoring and reporting by the HIF should account for M&C program separately from the other PHC services which the HIF pays for.)

(ii) If the M&C program is an horizontal program, integrated with PHC and financed by the HIF, then the payment stream for PHC providers will cover all PHC services in a single payment stream – covering all PHC services. The BBP and the contract with PHC providers would specify the M&C services which are the responsibility of PHC (as listed in the report). Some of the target performance indicators in the contract which earned doctors up to 30% of their income would relate to the M&C program – but there would also be target performance indicators for other PHC services.

6. In addition to the measures listed in the report, based on the problem diagnosis I would suggest considering some additional interventions:

• Reforms to the system for selecting and appointing managers of clinics and departments, so that the best trained, qualified and experienced people are in charge, and are less likely to be replaced.
• Development of better information collection and better analysis of data on risks and clinical outcomes for mothers and babies.
• Organizational change in PHC to reduce the fragmentation between different types of doctors, and nurses working in different organizations.

7. One area for further investigation would be to see if there is any international evidence on whether it is more cost-effective to use mass media for changing behavior of pregnant women, or whether it is more cost-effective to use targeted education campaigns for women at higher risk (eg in rural or poor urban communities) or women who are already pregnant.

8. It could be interesting to carry out a political analysis for the alternative options suggested in paragraph 6 above, to see which option is likely to attract the greatest stakeholder support and minimize opposition of key stakeholders.

9. Because the report presents such a broad strategy for reform – going much wider than just the area of M&C services – it would be too large and complex a task to develop a comprehensive implementation plan within the timeframe of the Flagship Program. If the authors develop want to develop a more detailed implementation plan, it could be useful to focus specifically on their proposal for developing a collaborative approach to M&C education/preventive activities with Ministries of Education and Labor and Social Protection. In developing the plan, it would be good to identify who would be responsible for each task, and what resources would be required for implementation. It would also be good to try to think of some outcome-oriented indicators, and some intermediate indicators (which could provide evidence of progress more quickly and for smaller numbers of births than the IMR itself).

I would be happy to discuss these comments with the authors next time I am in Skopje, and share ideas for how to make progress on some of the create new ideas in this report.