North Macedonia conducted a rapid assessment and situation analysis of the impact of COVID-19 on EHS delivery. In June 2020, the Ministry of Health (MoH), in close cooperation with WHO Country Office and the RO, completed this activity with input from the country’s health institutions, the Health Insurance Fund and the Agency for Medicines and Medical Devices.

The analysis revealed that from the beginning of the COVID-19 pandemic, a range of EHS have been disrupted and/or suspended in North Macedonia.

• All non-urgent care and elective surgeries were postponed with the exception of life-threatening interventions and malignant surgeries.

• Specialist visits in outpatient and in-patient services were limited to urgent and acute cases.

• Partial disruption in diagnostics of cancer, asthma and COPD.

• Routine immunization was functioning with limited working hours.

• Full disruption of dental care services as well as of psychiatric group therapies.

Among the main causes for the disruption were:

• Closing of population level screening programs.

• Decrease in inpatient volume due to cancellation of elective care.

• Decrease in outpatient volume due to patients not presenting.

• Barriers in access to the health facilities for patients (e.g. restrictions in public transport) due to Government-ordered lockdowns and imposed curfews.

The gradual restoring of suspended services started in mid-May 2020, under strict protocols for health institutions to reduce and prevent the spread of SARS-CoV-2.

In response to the outbreak, immediate measures to maintain and restore EHS were taken in North Macedonia.

Spearheading the implementation of the four-step approach mentioned above, a technical working group was established at the MoH to develop an Action Plan on Maintaining EHS during the COVID-19 Outbreak for North Macedonia. This group identified a range of key goals and actions for maintaining EHS in the pandemic response:

• Strengthening the coordination and governance mechanisms for EHS.

• Appointing dedicated coordinators (“COVID coordinators”), tasked to organize the work of health care facilities with COVID-19 patients and to safeguard the overall provision of EHS.

• Strengthening capacities of health institutions, including erecting prefabricated modular hospitals that are intended primarily to supplement hospital capacities for COVID-19 patients, but may also serve as ambulances for non-COVID-19 patients, depending on the number of overall COVID-19 patients (please see more below).

• Using telemedicine to provide health services and to prevent disruption of EHS, e.g. e-ambulances, digital tools and platforms to facilitate the work of first line healthcare workers and to enable patient monitoring and exchange of information between care levels.

• Enhancing existing human capacities in healthcare, including raising the number of healthcare workers and their remuneration, as well as staff to conduct epidemiological surveys.

This Action Plan was shared with all key stakeholders for their comments, finalized based on their input, and submitted to the Government, where it was officially endorsed on 26.01.2021. It is currently in the process of being implemented.

The plan has been translated into action (reflecting step 3 of the approach) through a range of e-health interventions aiming at maintaining EHS, leveraging the e-health infrastructure built in North Macedonia in recent years.

These include to date:

• Telephone consultations for primary care and non-urgent activities.

• Telephone consultations for psychological support.

• E-prescriptions for patients with chronic diseases.

• Integrated telemedicine modules for provider-to-patient and provider-to-provider video consultations.

• E-module for immunization (evidence and monitoring of regular and COVID-19 immunization).

• Digital roster for healthcare workers and medical equipment.

• Register for patients tested positive for COVID-19 (including integration of lab results, scheduling of appointments for COVID-19 tests, follow-up of positive patients for home treatment).

• Ongoing content development for online trainings on www.obuki.zdravstvo.gov.mk (e.g. specific training modules about COVID – 19, mental health etc.).

A further intervention is the documentation, synthesizing and sharing of the work, experiences, challenges and learnings on the process of maintaining EHS in North Macedonia, through this Action Brief Deep Dive, and feeding into the Health Services Learning Hub.

Main outcomes of the rapid assessment and situation analysis were:

• Addressing needs for restoring and maintaining EHS.

• Identifying gaps on maintaining EHS.

• Developing priority areas and key tasks to follow with the aim of restoring and maintaining EHS.

• Developing the Action Plan, managed by the MoH in close cooperation with national and international partners. This includes establishing the abovementioned technical working group at the MoH.

Some principal outcomes of the e-health interventions are to date:

• Enabling clinicians to provide routine consultations via video and monitor clinical signs of certain conditions remotely (i.e. blood pressure), replacing in person consultations where possible.

• Minimizing contacts between GPs and patients, with referrals to doctors only when necessary, while enabling patients with chronic conditions to continue their existing therapy without physical presence at the specialists’ premises.

• Leading to fewer disruptions to patients’ care plans and treatment, while reducing the risk of SARS-CoV-2 transmission.

The e-health interventions have proven particularly beneficial for vulnerable patient groups, such as the mental health patients, elderly and those with comorbidities.

Despite the outcomes reported above, efforts on EHS are progressing slower than intended due to recurring waves of the ongoing pandemic, where the vast majority of the health system’s limited capacities are directed towards immediate emergency response activities.

• The Action Plan is likely to require increased financial resources. To secure these in the context of overall economic constraints, it is paramount to place the Action Plan on the national policy agenda and not to consider it as a technical undertaking only.

• The Action Plan is meant to be a “living document” that requires ongoing adaptation and refinements, based on the evolution of the pandemic in North Macedonia.

• The COVID-19 crisis has added challenges for the most vulnerable groups in the country (e.g. elderly, people with disabilities, refugees & migrants, people with pre-existing medical conditions), not only from health but also social and economic aspects. Every intervention to maintain EHS needs to consider this particularly.

• Effective and continuous engagement of local stakeholders throughout developing and implementing an Action Plan can promote country-ownership of all actions and can ensure their sustainability.

• It is pivotal that the Action Plan is fully endorsed by the MoH and Government. Political commitment and fully institutionalized activities are essential.

• Responsible governance is needed to develop and implement the Action Plan. Therefore, the nomination of a focal point for essential health services was of upmost importance for leading to a consensus on the crucial list of EHS in times of crises and emergencies. The lack of this list of EHS to be maintained while responding to COVID-19 and other emergencies has been one of the main challenges to ensure continuation of EHS in the country.

• Development and promotion of telemedicine is a way to expand delivery of acute, chronic, primary and specialty health care.

• Maintaining the trust of the population is related to the ability to meet their essential health needs, which includes to effectively control infection risk in health facilities, ensuring appropriate care-seeking behaviour and the provision of EHS.

• Responding to a pandemic and enabling the conditions for providing EHS is possible with a long-term operational plan for preparedness and response of the health system during crises and emergencies. Such a plan needs to be regularly updated, especially with regards to the provision of EHS.

The Rapid Assessment identified requirements for priority technical assistance in the areas of:

• Developing a draft of the national definition of the people-centered package of EHS for North Macedonia to be maintained during an emergency.

• Increasing the use of digital tools to improve contact tracing, real time evidence, care and to prevent disruption of EHS.

• Improving financing for the health system, including innovative approaches, international cooperation as well as actively seeking grant opportunities from international donor organizations.

• Considering new educational approaches for boosting and optimizing capacities at the health facilities and public health services; the use of digital technologies in form of distance learning and training needs to be developed based on international experiences.

• Enhancing use of international good practice examples.

• Scaling up capacities of health institutions.

Additionally, extra resources and knowledge will be needed to mitigate the consequences of COVID-19 on patients’ health and well-being.