For years, Marko Malzarkov worked long days as a delivery driver in Skopje, North Macedonia, while navigating the difficult trade-offs of a limited household budget. Each month brought the same calculations: rent, utilities, food – and the recurring question of whether he would be able to afford his medicines.
The arithmetic was simple: the monthly out-of-pocket cost for medicines was too high for him.
Aged just 35, Marko has had high blood pressure since his late twenties and, more recently, elevated blood lipids – a pattern, he says, that runs in his family. His family doctor had long recommended new medicines to stabilize his condition, but they were not included in the national benefits package, and he could not afford to pay for them.
“That’s why I stayed on older therapy – it helped to some extent, but it wasn’t ideal,” Marko explained. “I had days when my blood pressure was unstable, and I felt tired and unfocused.”
Everything changed in 2024.
The Government of North Macedonia added several essential medicines to the benefits package, including new medicines to control blood pressure and lipid levels.
“Now I still pay something, but it’s fair. I can afford it. And most importantly, I’m finally on medication that really suits me. That makes a big difference.”
A policy shift driven by evidence
Dr Akeem Ali, WHO Representative to North Macedonia, said the WHO findings, published in the country’s first comprehensive analysis of affordable access to health care in 2021, played a decisive role in shaping the reform. “Regular monitoring of financial protection provides countries with the evidence they need to act, as reflected in North Macedonia’s review of covered medicines,” Dr Ali said.
“We expanded the positive list of medicines for the first time in 10 years, adding 9 generic designations encompassing over 70 registered brands,” said Sasho Klekovski, Director of North Macedonia’s Health Insurance Fund. “The budget for the positive list was also increased by around €5 million a year.”
The North Macedonian analysis revealed significant gaps in the coverage of outpatient medicines – the main driver of catastrophic out-of-pocket payments – with a disproportionately large impact on households with low incomes and older people. People who face catastrophic health spending may struggle to afford other basic needs like food, housing and heating.
“Medicines are still the largest driver of catastrophic out-of-pocket payments, but the addition of new medicines to the positive list is a promising change that will reduce financial hardship,” said Vladimir Dimkovski, the lead author of a new report, “Can people afford to pay for health care? New evidence on affordable access to health care in North Macedonia 2025”.
At their clinics, health-care providers are already noticing the difference. With more essential medicines covered, they say patients are better able to start – and stay – on the treatment recommended for them.
“Patients fail to adhere to treatment if medicines are financially inaccessible. They always ask whether a medication is on the positive list. Expanding the list even further would result in better patient health and improved primary health-care services,” said Dr Marta Tundzheva, specialist in family medicine at the primary care provider “Dr Kiril Atanasov”.
“The addition of new medicines to the positive list means we can offer our patients more up-to-date treatment,” added Dr Marija Mihajlova, specialist in family medicine at the primary care provider “Semed”.
Generating new evidence on affordable access to health care
The evidence on financial protection in North Macedonia is part of a broader project to strengthen health financing policy in the Western Balkans led by the WHO Barcelona Office for Health Systems Financing and funded by the European Commission’s Directorate-General for Enlargement and the Eastern Neighbourhood (DG ENEST).
“This project has provided policy-makers with the data and analysis they need to make progress towards universal health coverage and ensure that everyone can access quality health care without facing financial hardship,” said Marco Chiapusio, Programme Manager at DG ENEST.
Between 2021 and 2025, the WHO Barcelona Office generated new evidence on financial protection in Albania, Bosnia and Herzegovina, Montenegro, North Macedonia, Serbia and Kosovo*, working closely with local and international experts. Based on country-level data, WHO’s analysis finds that a heavy reliance on out-of-pocket payments to finance health care leads to financial hardship and unmet need for many households in the Western Balkans. Financial hardship is largely driven by spending on outpatient medicines and mainly affects people with low incomes and older people.
“In recent years, policy-makers across the Western Balkans have taken steps to improve affordable access to outpatient medicines. North Macedonia is a good example. But more remains to be done, particularly for people with low incomes,” said Dr Natasha Azzopardi-Muscat, Director of the Division of Health Systems at WHO/Europe.
WHO has identified a range of policy options to address persistent gaps in coverage.
- Ensure the publicly financed benefits package covers a wide range of cost-effective treatment and is aligned with population health needs and national clinical guidelines.
- Improve efficiency and equity in the use of medicines by working with health-care providers and pharmacies to ensure appropriate prescribing and dispensing and encourage greater use of generic medicines; expand and enforce the use of International Nonproprietary Names and electronic prescribing; make generic substitution in pharmacies mandatory; strengthen regulation to limit the influence of pharmaceutical companies on prescribing and dispensing; and make covered medicines available in all pharmacies.
- Re-design co-payment policy to minimize financial barriers to access by replacing percentage-based co-payments with low, fixed co-payments; exempt people with low incomes and older people from co-payments; introduce a cap on all co-payments and link it to income, so that it is more protective for people with low incomes and softens the impact on the health budget; and use digital tools to automate exemptions and caps and remove administrative barriers that prevent people from accessing their entitlements.
- Change the basis for entitlement to health insurance fund (HIF) benefits from the payment of mandatory health insurance contributions to residence, so that all residents are permanently covered and non-payment of mandatory contributions is treated in the same way as non-payment of other taxes (e.g. using fines, when relevant, rather than denying people access to health care).
- Broaden the public revenue base for the health system to reduce reliance on employment, so that public revenue for health does not shrink as the population ages.
- Support these efforts by increasing the priority given to health in allocating the government budget and use any additional public funds to reduce unmet need and financial hardship for people with low incomes.
Developing capacity and fostering policy dialogue
During the project, findings from country and comparative analysis were widely used in events to enable cross-country learning and collaboration, facilitate networking and translate evidence into action.
The WHO Barcelona Office trained around 100 experts and policy-makers from the Western Balkans through 3 editions of the annual WHO Barcelona course on health financing for universal health coverage, a special edition of the course exclusively for the Western Balkans, the WHO Barcelona Forum on Financial Protection and a subregional workshop on out-of-pocket payments in Skopje, North Macedonia. In addition, more than 200 experts and policy-makers took part in national or subregional policy dialogue events.
By generating new evidence, building capacity and engaging in policy dialogue, the WHO Barcelona Office supports governments in making a real difference to many people such as Marko Malzarkov.
About WHO/Europe’s work on financial protection
WHO/Europe monitors affordable access to health care through the WHO Barcelona Office for Health Systems Financing using regional indicators that are sensitive to equity. Financial protection is central to universal health coverage and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals, part of the European Pillar of Social Rights and at the heart of the Second European Programme of Work 2026–2030, WHO/Europe’s strategic framework.
As part of the project, affordable access to health-care evidence from Albania, Bosnia and Herzegovina, Montenegro, North Macedonia, Serbia and Kosovo* is now featured on UHC Watch (an online platform tracking progress on affordable access to health care in Europe and Central Asia), enabling both country-level and comparative analysis.
The reports and UHC Watch benefited from financial assistance from the European Union through DG ENEST.
*All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999).