Balkanalysis.com

By Christopher Deliso

On April 11, Macedonia’s medics went on strike. For a whole day, hospitals were deserted, and the workers’ syndicate threatened to picket the parliament building. The government quickly promised to seek their input in future reform negotiations. Yet even in a region infamous for walkouts and strikes, the grumbling from Skopje was significant.

Over the last few years, the Macedonian health reform drama has seen boycotts, protests and promises. It has also seen stage appearances by the Macedonian government, the World Bank, and Western consultants. The main headaches have been the issues of privatization, the state’s involvement, and Western influence over the reform process. For Balkan states in transition, these are common maladies indeed.

Unsurprisingly, everyone involved has strong and divergent opinions on the subject. According to the reformers, the problems are structural. The remedy for Macedonia’s ills, they claim, is gradual privatization. Naturally, most doctors would like to make more money working privately.

Yet some have doubts about the plan’s major component ˆšÂ¢Â¬Ã„” the changeover to the Western general practitioner (GP) model. This radical change in the primary health care system, doctors argue, will endanger the health of all Macedonians ˆšÂ¢Â¬Ã„” and especially women and children.

In public health care, Macedonia still follows the Yugoslav model. Clinics offer a wide variety of specialists. Children are sent directly to their assigned pediatrician, and women to their gynecologist. Under the proposed scheme, they will usually be referred only after seeing their GP. Citing huge over employment in the public health sector, the reformers maintain that this reform is cost-effective. They also argue that most ailments are relatively minor. A GP, reformers say, is oftentimes good enough.

Macedonian pediatricians disagree. They credit themselves for the sharp decline in Macedonia’s infant mortality rate ˆšÂ¢Â¬Ã„” from ten per hundred to one per hundred since the early 1960′s. Except in Albanian-majority areas, the birth rate has also plummeted. “Before there were pediatricians, people did not know how to treat their infants,” recalls one retired doctor in Skopje. “Especially in the rural areas, they were very ignorant ˆšÂ¢Â¬Ã„” they would even use cow’s milk to feed their babies!”

Pediatricians also point to one major success of the past thirty years: the eradication of gastro-intestinal bacterial diseases caused by poor hygiene. Like all of the developed countries, Macedonia’s “disease structure” is now centered on viral respiratory diseases. Doctors fear that by adopting the Western reforms ˆšÂ¢Â¬Ã„” which may include the end of mandatory, state-sponsored vaccinations for children ˆšÂ¢Â¬Ã„” Macedonia will slip below Western standards. “Why are they sending us back to the 19th century?” lamented one pediatrician. “We are already heading there anyway!”

One man who is not worried about the reforms is Dr. Aleksej Duma, president of the Macedonian Doctors’ Chamber. Duma supports controlled privatization, and suggests that the pediatricians are perhaps protesting too much. He also plays down the vaccination issue, forecasting that it will stay under government control after negotiations. But even he agrees that the reforms are coming too suddenly.

Although Macedonia started reforms in 1992, the country is still unprepared for change. By performing economic shock therapy, Western reformers may introduce more problems still. The West, say the doctors, has missed the point. Introducing the GP model is irrelevant, because the system’s inefficiencies do not derive fundamentally from the way primary health care is currently organized.

The main problem, according to Duma, is institutional weakness. After only ten years of independence, Macedonia is still politically immature. Health care funds are misappropriated with regularity, and political infighting means that top administrators are constantly being replaced. “Macedonia has had eight or ten health ministers in the last ten years,” quipped Dr. Duma. “We’re heading towards one minister per month.”

This high turnover rate has meant the constant appointment of bureaucrats who are both woefully unprepared and impatient for sweeping changes. Indeed, the doctors’ grievances are not without basis. The current Health Minister, Gjorgji Oruvchanec (from the ruling VMRO-DPMNE party) took office barely three months ago. He replaced Petre Milosevski, a member of the LDP party. Milosevski had been appointed in December, when his party came into the government. When LDP quit in February, he was gone too. And so it goes.

Yet the main objections have centered not on politics, but on the role of the West. The World Bank provided a total of $16.9 million for reforms, and the government also kicked in $2.5 million. The deadline for spending the money was successfully met on 31 March. Optimists cite the World Bank’s generous terms of repayment: a five-year grace period, followed by a 30-year biannual payment plan- all at a favorable rate of interest (0.7 percent per annum).

The liaison between the Ministry, the Doctors’ Chamber and the World Bank is the IPU (International Project Unit), headed by Dr. Dragan Gjorgjev. The IPU’s difficult job is threefold: to sell the project, carry out the administrative work, and implement it. Despite vague allegations of government corruption, Gjorgjev stresses that the project has been “very transparent” throughout. “Each single activity must be approved by the World Bank,” declares Gjorgjev, pointing to the extensive paperwork that documents the project’s spending. In any case, the money is kept in a Washington credit account, and released incrementally.

Indeed, the $16.9 million was spent entirely legally. How it was spent, however, offers fascinating insight into the methodology and psychology of the Westerners whose handouts Macedonia is obliged to take.

The World Bank’s first stipulation was to find “appropriate conditions.” Four centers- in Gostivar, Prilep, Veles and Strumica ˆšÂ¢Â¬Ã„” were built to train the doctors. Skopje, home to over half of Macedonia’s population, was not chosen. The IPU feared that the politicized air of the capital would jeopardize their activities.

Such a concern attests to the important role public relations have played in the project’s development. Directed by a World Bank PR expert, the IPU conducted a massive campaign of selling its reform package. This consisted of television, billboard and newspaper advertisements. The powerful local media was also targeted. In January, the IPU hosted 18 journalists for two days of “training.” Holed up in the resort town of Ochrid, the journalists were educated as to the reformers’ true goals. Later, the IPU paid for the same journalists to travel to Estonia, where similar reforms have been enacted.

All in all, 75 percent of the World Bank credit was spent on medical upgrades and goods, and 25 percent on consultants. According to the IPU staff, hiring consultants was a lengthy ˆšÂ¢Â¬Ã„” and expensive ˆšÂ¢Â¬Ã„” process. Most of the $4 million spent on consultants went to experts from abroad. Naturally, these cost more than the locally-recruited consultants.

After the centers were ready, the IPU sent out the invitations. Doctors were asked to take a two-week CME (Continuing Medical Education) course. While some did not want to attend, 800 doctors did cooperate. The purpose of the course was to churn out general practitioners for the new system. Doctors were trained in how to use such challenging equipment as a stethoscope, orthoscope, peak-flow-meter, mouthpiece, and reflex hammer. Afterwards, they were allowed to take home their grab bags of new gear. In total, these supplies cost approximately $1 million. Although there are Macedonian companies, which manufacture such equipment, all contracts were decided by international competitive bidding. Unsurprisingly, the winners were industry giants like Speidel & Keller, Roche, Welch Allyn, and Kirchner & Wilhelm.

The 800 successful graduates then received their certificates. According to the IPU, these will help them to practice medicine in the West. There are fears that this incentive will only intensify the “brain drain” phenomenon ˆšÂ¢Â¬Ã„” and leave Macedonia bereft of qualified doctors.

Other serious issues have been raised. The frank appraisal of some course participants begs the following question: have the Western reformers empowered the doctors, or merely sought to buy their allegiance with a grocery bag of gimmicks?

One Skopje doctor who took the CME course said, “it was fun, but the training was not really necessary. We knew most of the things already. The supplies we received were important, but they did not really need to pay for constructing the centers. The course could have been just one or two days long, instead of two weeks.”

Of course, the reformers protest that CME remains vital. The IPU stresses the “continuing” nature of the education, and hopes that such courses will help the doctors keep from remaining ossified in outdated training and practices. Those opposed to the reforms, allege the IPU, are merely change-resistant curmudgeons who fear having to learn something new.

In the big picture, the reformers’ vision is for a Macedonia with 80 percent GP’s and 20 percent specialists. The IPU also suggests limiting medical school enrollment, maintaining that the country’s small population requires fewer doctors than it currently has.

While this prognosis may or may not be accurate, it is clear that the process has left many Macedonian health care workers feeling slighted. As in other countries in transition, the Macedonians feel patronized by know-it-all foreigners. Wisecracked one doctor, “they act is if they are coming to some exotic place, to teach the savages.” A well-trained gynaecologist ridiculed how the CME class was given a plastic doll to show how to perform childbirth. Another doctor resented being “advised” by an American who had no medical training.

Hurt feelings aside, one crucial question remains: what will happen if the reforms fail? Pointing to the rejection of similar programs by Croatia and Slovenia, and their failure in Bulgaria, doctors prophesy dark days ahead. Here the usually outspoken reformers offer no answers. If the reforms go sour, however, it is unlikely that they will be held accountable. After all, in Macedonia the government changes with the seasons ˆšÂ¢Â¬Ã„” and the consultants and experts will have long packed up and left. In the end, Macedonians may end up with only a pile of debt and wistful memories. While there is always room for optimism, one painful Balkan truth remains: when it comes to programs of reform, it is far easier to get in than get out.

This article was originally published on 24 May 2002 by UPI.