IDEVELOPING THE NATIONAL HEALTH 2020 STRATEGY IN NORTH MACEDONIA A case study! II III Developing the National Health 2020 Strategy in North Macedonia A case study IV Abstract The WHO Regional Offi ce for Europe is systematizing evidence on developing and implementing national health policy to promote and facilitate the implementation of Health 2020. This case study, part of the series on the development and implementation of national health policy, pres- ents the experience of North Macedonia in developing its fi rst national health strategy, the Na- tional Health 2020 Strategy, enacted by its government in 2016. The study describes a series of factors and actions over three years that enabled a comprehensive national health strategy and operational plan to be enacted to guide further health developments to 2020 and represent the fi rst cornerstone of the country’s roadmap towards achieving the 2030 Agenda for Sustainable Development and the Sustainable Development Goals. It seeks to refl ect on what has worked, on the critical elements of the progress to date and the innovation and creativity used in the process. Keywords NATIONAL HEALTH POLICY HEALTH POLICY PROCESS HEALTH 2020 SUSTAINABLE DEVELOPMENT GOALS INTERSECTORAL APPROACH CASE STUDY SERIES Address requests about publicaƟ ons of the WHO Regional Offi ce for Europe to: PublicaƟ ons, WHO Regional Offi ce for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen O, Denmark. AlternaƟ vely, complete an online request form for documentaƟ on, health informaƟ on, or for permission to quote or translate, on the Regional Offi ce website (hƩ p://www.euro.who.int/ pubrequest). ISBN 978 92 890 5420 1 © World Health Organization 2019 Some rights reserved. This work is available under the CreaƟ ve Commons AƩ ribuƟ on- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; hƩ ps://creaƟ vecommons.org/licenses/by-nc-sa/3.0/igo). 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VContents Foreword ................................................................................................................................................................ vii Preface ................................................................................................................................................................... viii Acknowledgements .......................................................................................................................................... ix Executive summary .......................................................................................................................................... x Introduction ......................................................................................................................................................... 1 Sustainable Development Goals: an opportunity for new, transformative policies ........................ 1 Health 2020: framework for health and well-being through intersectoral action .......................... 1 Aligning the Sustainable Development Goals and Health 2020 in the WHO European Region 2 The process of developing national health planning in the global and regional contexts ............ 3 The country context ......................................................................................................................................... 5 Highlights of the country’s health status and outcomes ............................................................................ 5 The country’s status with Health 2020 indicators ......................................................................................... 7 Stronger equity and better governance for health through intersectoral action ...................... 8 Country-specifi c policy context .................................................................................................................. 9 European Union ........................................................................................................................................................ 10 South-eastern Europe Health Network (SEEHN) ...................................................................................... 10 WHO’s role: strong technical support for Health 2020 implementation and delivering on the 2030 Agenda........................................................................................................................................................... 11 Strategic and structured support .................................................................................................................... 11 Main features of the support .............................................................................................................................. 12 The case study of North Macedonia ..................................................................................................................... 13 Part 1. Developing the National Health 2020 Strategy in North Macedonia ......................... 14 History of health policy-making in North Macedonia .................................................................................. 14 Developing the National Health 2020 Strategy ............................................................................................. 15 Governance of the process .................................................................................................................................. 16 Multistakeholder consultation process ......................................................................................................... 17 Gathering evidence for policy ............................................................................................................................. 20 Establishing a roadmap for developing health policy .............................................................................. 21 Innovative approaches in developing the National Health 2020 Strategy ................................... 23 Innovative tools to support policy dialogue ................................................................................................. 23 Interactive e-platform as a policy tool ...................................................................................................... 23 E-library of evidence to inform experts and the general public ..................................................... 25 VI Providing a virtual meeting place for the stakeholders for health across government and society ............................................................................................................................................................. 26 Online public survey: Your opinion – What is the health I want by 2020? ................................ 27 Online tool for public contributions to policy dialogue: Your ideas! ............................................ 28 Operational planning .............................................................................................................................................. 29 Part 2. The National Health 2020 Strategy as an instrument for improving health through intersectoral action ........................................................................................................................ 32 Values and principles of the National Health 2020 Strategy .................................................................... 32 Creating resilient communities and supportive environments: the National Health 2020 Strategy in the community .................................................................................................................................. 34 Adding value through partnerships ................................................................................................................. 35 The content of the National Health 2020 Strategy refl ects its priority areas of work ................. 35 Priority area 1: public health and the life-course approach .................................................................. 36 Priority area 2: health and environment........................................................................................................ 39 Priority area 3: noncommunicable diseases and risk factors ............................................................... 40 Priority area 4: communicable diseases and emergency preparedness, surveillance and response ....................................................................................................................................................................... 42 Priority area 5: strengthening a people-centred health system and resources .......................... 44 Conclusion ............................................................................................................................................................. 46 References ............................................................................................................................................................ 48 Annex 1. Developing, implementing and evaluating national and subnational health policies drawing on the contribution of various sectors .................................................................. 52 Annex 2. List of national health and health-related strategies and plans (available in Macedonian or English or both) scoped for the National Health 2020 Strategy ................. 54 Annex 3. List of national strategies, policies and plans (available in Macedonian) scoped by the operational plan by priority area .................................................................................. 62 Annex 4. Key publications produced throughout the process ...................................................... 70 Annex 5. Strategic goals of the priority areas of the National Health 2020 Strategy ....... 72 Annex 6. Joint statement on intersectoral collaboration for health and well-being in the community .................................................................................................................................................... 75 Annex 7. List of institutions participating in the national health policy development, 2014–2015, by sector (in alphabetical order) ........................................................................................ 77 vi VII Foreword Health 2020, the European framework for health and well-being, has positively infl uenced policy-making in the WHO European Region since 2012. Studies show that Member States increasingly focus on outcome-oriented health policies, strategies and plans, using evidence in setting priorities and developing monitoring, evaluation and review frameworks. In ad- dition, policy dialogues more often involve stakeholders, who bring the benefi ts of timely reconciliation of diff erent interests, for realistic priority-setting and actual implementation of the policies enacted. The 2030 Agenda for Sustainable Development emphasized yet again Health 2020 guid- ance for providing policy coherence within the health sector, among the sectors in govern- ment and across diff erent levels of governance within countries. The imperative for achiev- ing the Sustainable Development Goals is breaking the silos and investing in intersectoral and all-inclusive policy dialogues that could enable policy-making that leaves nobody behind. Nevertheless, however appropriate the guidance provided by the international strategic papers is, the national context gives the policy-making for health and well-being real and specifi c content. The legitimacy of policy-making comes from the all-inclusive policy dia- logue underpinning the process of policy-making as a reiterative process that also scopes implementation, monitoring and evaluation, review and subsequent policy revisions. The countries in the WHO European Region are very diverse in their overall development, and especially the health situation and systems. Paying attention to the specifi cities of every country is key to sound policy-making. Demand is growing for national health policies to act as a mechanism for bringing about transformative change in accordance with the global and regional strategic papers and within specifi c national contexts. It is therefore of utmost importance to take stock of coun- tries’ experience in policy-making and share best practices to learn and use, as appropriate, the policy-making process and increase the likelihood of a favourable outcome. Piroska Östlin Director, Division of Policy and Governance for Health and Well-being WHO Regional Offi ce for Europe vii VIII Preface In accordance with WHO Regional Committee for Europe resolution EUR/RC62/R4: Health 2020 – the European policy framework for health and well-being, and in view of the continual updating of the evidence and knowledge base on national health policy de- velopment, the WHO Regional Offi ce for Europe is systematizing case studies on national health policy to promote and facilitate the implementation of Health 2020. The case stud- ies aim to synthesize relevant learning from countries’ experience of health policy that is developed, reviewed and updated taking account of the Health 2020 policy framework and the underlying evidence and WHO resolutions. The studies analyse the approaches used in the particular context, related to both the process of sound policy-making and the Health 2020 content, with a focus on innovative practices used throughout the process that have potential for being shared across the WHO European Region. The series of case studies is intended to explore and share relevant best practices in nation- al health policy-making in the current global and regional context, in terms of both process and content, with a view to: • recognizing health as a major societal resource and asset; • establishing a strong value base: reaching the highest attainable standard of health; • addressing social determinants of health, equity, gender and human rights; • presenting a social and economic case for improving health; • striving to achieve strategic objectives of Health 2020: better governance for health through intersectoral action; • contributing to the common Health 2020 policy priorities for health; • promoting a common purpose and shared responsibility; • adding value through partnerships; and • contributing to achieving the Sustainable Development Goals. viii IXix Acknowledgements This publication was led by Snezhana Chichevalieva, former Head, WHO Country Offi ce in North Macedonia and current Programme Manager for National Health Policies, WHO Re- gional Offi ce for Europe; Neda Milevska Kostova, Executive Director, Think-tank Studiorum; and Margarita Spasenovska, National Professional Offi cer, WHO Country Offi ce in North Macedonia. Aleksandar Manchevski, information technology expert at Studiorum, created and developed the illustrations. The WHO Country Offi ce in North Macedonia would like to thank everyone who gave valuable feedback on the publication, especially Piroska Östlin, Director, Division of Policy and Gover- nance for Health and Well-being, WHO Regional Offi ce for Europe; and Jovanka Kostovska, State Advisor, Ministry of Health, North Macedonia and National Technical Focal Point for collaboration with WHO. This publication and the achievements described in it would not have been possible without the active and constructive engagement of the national public health professional commu- nity and experts, and special thanks go to Jovanka Karadzinska Bislimovska, Golubinka Bo- shevska, Biljana Celevska, Dragan Gjorgjev, Mihail Kochubovski, Zharko Karadzoski, Elena Kjosevska, Vladimir Mikik, Brankica Mladenovik, Igor Spiroski, Fimka Tozija, Pavlina Vaskova, Elizabeta Zisovska and other experts, central and local government offi cials and civil society representatives from across the country. XExecuƟ ve summary In accordance with Health 2020, the European policy framework for health and well-being, the WHO Regional Offi ce for Europe is systematizing evidence on the development and implementation of national health policy to promote and facilitate the implementation of Health 2020. Through analysis of approaches used in specifi c country contexts, both the sound policy-making process and the Health 2020 content, the case study series strives to highlight innovative practices that have potential for being shared across the WHO Europe- an Region. The case study series draws on the Health 2020 implementation package (1,2), especially in applying the Health 2020 lens to country situation analysis, implementing whole-of-gov- ernment and whole-of-society approaches, addressing social determinants of health, eq- uity, gender and human rights and developing national and subnational health policies, strategies and plans aligned with Health 2020. In terms of content, Health 2020 and WHO Regional Committee for Europe resolutions guide the studies. These aim to contribute to implementing the Roadmap to implement the 2030 Agenda for Sustainable Development, build- ing on Health 2020, the European policy for health and well-being (3) adopted in resolution EUR/RC67/R3. In terms of process, the studies draw on the Universal Health Coverage Partnership’s national health policy tools and guidelines, where these are relevant to the country contexts in the WHO European Region (4). This case study presents the experience of North Macedonia in developing its fi rst national health strategy to 2020 (the National Health 2020 Strategy), enacted by its government in 2016. The study describes a series of factors and actions taken over three years that en- abled a comprehensive national health strategy and operational plan to be enacted to guide further health developments. It seeks to refl ect on what has worked, on the critical elements of the progress to date and the innovation and creativity used in the process. Key messages National health policies are increasingly tested on their capacity to fuel health development in the very complex national and international contexts. The policies should be seen as prod- ucts of a well designed, all-inclusive process and solid evidence. The National Health 2020 Strategy of North Macedonia was guided by and used Health 2020 evidence, in addition to both generating and using national evidence, to feed the policy dialogue process and iden- tify the challenges. It therefore presents a good example of Health 2020 providing useful guidance in national policy-making that aims to respond to both the health needs of the population within the country and the country’s international commitments. Eff ectively using evidence for health and well-being in the policy-making process requires appropriate mechanisms for all-inclusive dialogue and coordination. The National Health x XIxi 2020 Strategy process was carefully crafted to include everyone and make health every- body’s business. It was worth the investment: it legitimized the policy, it made the case for its enactment and it served as a guarantee for implementing the National Health 2020 Strategy. The National Health 2020 Strategy process was also a great capacity-building, learning and sharing exercise for the professional community in health and other sectors and for citizens. WHO played a strong role in the process of developing the National Health 2020 Strategy, providing integrated technical support to the Ministry of Health, through the WHO Country Offi ce’s intensive and proactive support for national eff orts. Political leaders need to maintain an outward-looking and outcome-oriented focus and make further investment so that the National Health 2020 Strategy delivers the outcomes as envisaged and feeds a continual policy cycle, with evidence to give priority to health and well-being beyond 2020 to achieve the Sustainable Development Goals. XIIxii Developing the National Health 2020 Strategy in North Macedonia 1 IntroducƟ on Sustainable Development Goals: an opportunity for new, transformaƟ ve policies The 2030 Agenda for Sustainable Development and its 17 Sustainable Development Goals, adopted in 2015 by the United Nations General Assembly, is a plan of action for people, plan- et, prosperity, peace and partnership, which all countries and stakeholders, acting in collab- orative partnership, will implement. The overarching goal of the 2030 Agenda, “to leave no one behind”, makes advancing equity, gender and human rights a key cross-cutting develop- ment need. Recognizing health as an indivisible part and also an achievement of sustainable development, the 2030 Agenda opens up new horizons for health policies to broaden the scope of health and opportunities for health policies to be devised for achieving national development agendas and commitments to the 2030 Agenda. Health 2020: framework for health and well-being through intersectoral acƟ on Health 2020 is a health policy framework for the WHO European Region designed to achieve the twin goals of improving health and well-being and reducing health inequities and of im- proving leadership and participatory governance for health. Its endorsement in 2012 by the 53 Member States of the WHO European Region created added value for the national health policy development process, by providing guidance on strengthening the health dimension beyond health systems and through the well-being and equity lens (Fig. 1). Fig. 1. Health 2020 strategic objectives and priority areas for health and well-being Strategic objectives of Health 2020: STRONGER EQUITY AND BETTER GOVERNANCE FOR HEALTH Improving health for all and reducing health inequalities Improving leadership and participatory governance for health Creating resilient communities and supportive environments Investing in health through a life-course approach and empowering people Tackling the Region's major health challenges of noncommunicable and communicable diseases Strengthening people-centred health systems, public health capacity and emergency preparedness, surveillance and responsepriority areas 2Health 2020 strives to achieve measurable impact on health in the Region. Member States agreed on the following regional goals. 1. Reduce premature mortality in the European Region by 2020. 2. Increase life expectancy in the European Region. 3. Reduce inequalities in health in the European Region. 4. Enhance the well-being of the European Region population. 5. Ensure universal coverage and the right to the highest attainable level of health. 6. Set national goals and targets related to health in Member States. Health 2020 recognizes that achieving these regional goals is conceivable through national health policy and thus provides guidance to Member States on developing, implementing and evaluating health policies at the national and subnational levels (Annex 1). Health 2020 also recognizes that successful governments can achieve real improvements in health if they work across government to fulfi l two linked objectives: improving health for all and reducing health inequalities; and improving leadership and participatory gover- nance for health. Health 2020 proposes that new forms of governance for health are need- ed in today’s diverse and horizontally networked, information-based societies, requiring multisectoral and multifaceted policy responses and interventions. Increasingly, the terms whole-of-government and whole-of-society in policy development refl ect this reality, and these concepts are at the heart of Health 2020 (1). Leadership from health ministers and public health agencies will remain vitally import- ant to address the disease burden across the European Region. It needs to be strength- ened. The health sector is responsible for: developing and implemenƟ ng naƟ onal and subnaƟ onal health strategies; seƫ ng health goals and targets for improving health; assessing how the policies of other sectors aff ect health; delivering high-quality and eff ecƟ ve health care services; and ensuring core public health funcƟ ons. It also has to consider how its health policy decisions aff ect other sectors and stakeholders. Aligning the Sustainable Development Goals and Health 2020 in the WHO European Region The WHO Regional Offi ce for Europe developed a roadmap to assist Member States in im- plementing the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well-being (3). The Member States adopted the roadmap at the 67th session of the WHO Regional Committee for Europe in September 2017 in resolu- tion EUR/RC67/R3. The roadmap (Fig. 2) aims to strengthen the capacities of countries to achieve better, more equitable and sustainable health and well-being for all at all ages in the WHO European Region. Achieving the Sustainable Development Goals requires working in a transforma- tive way to implement a set of coherent, evidence-informed policies that address health, well-being and all their determinants throughout the life-course and across all sectors of government and society. Revitalized global and regional partnerships are essential and will provide the necessary support and momentum for this joint societal and global eff ort. 3Developing the National Health 2020 Strategy in North Macedonia Fig. 2. Roadmap to implement the 2030 Agenda for Sustainable Development: strategic directions and enabling measures Advancing governance and leadership for health and well-being Leaving no one behind Preventing disease and addressing determinants of health by promoting multi- and intersectoral policies throughout the life-course Establishing healthy places and settings and resilient communities Strengthening health systems for universal coverage Roadmap to implement the 2030 Agenda for Sustainable Development Investment for health Health literacy, research and innovation Monitoring and evaluation Multi-partner cooperation The WHO Regional Offi ce for Europe provides assistance to countries and promotes the progressive alignment of health and development policies or plans; the achievement of di- rectly and indirectly health-related Sustainable Development Goals and their targets; the use of existing networks and platforms to ensure dialogue between organizations, sectors and countries; and the monitoring and evaluation of the implementation of the Sustainable Development Goals. In addition, the United Nations Development Group has adopted the Mainstreaming, Accel- eration and Policy Support (MAPS) approach (5) as the common approach to implementing the 2030 Agenda at the country level, as an instrument for landing the Sustainable Devel- opment Goals into national, subnational and local plans for development, shaping budget allocations (mainstreaming), targeting resources at priority areas, paying attention to syn- ergy and trade-off s, bot tlenecks, partnerships, measurements (acceleration) and ensuring that the skills and expertise of the United Nations Development System are available in an effi cient and timely way, including joined-up approaches to ensure coherence and inte- gration (policy support). This presents an opportunity for consistency in development and health planning and work for health across the sectors. The global, regional and subregional contexts inevitably infl uence and play an active role in national health agenda-setting and policy development processes, as described below. The process of developing naƟ onal health planning in the global and regional contexts Although national health planning is often viewed as linear or cyclical in nature, in reality it is a complicated, diffi cult, challenging process (6) that seeks to address context-specifi c di- verse needs and interests with limited resources (Fig. 3). Thus, best practices in the national health policy development process are worth sharing to bring to the wider audience what works and what the best buys are and how these can be adapted to the specifi c country context. Well designed national health policy processes can help policy-makers in engaging the pro- fessional and general public in identifying priority concerns, needs and areas for strategic action. Continued involvement of the public can help ensure that policy-makers adhere to the specifi c tasks laid out and, importantly, reduce potential resistance to the changes that reform may introduce. Further, public empowerment and the sense of control achieved through democratic policy-making processes have been associated with enhanced social 4capital and health (7). Health policy is usually developed through diverse approaches and levels and with diff ering aims. Mechanistic approaches are not suffi cient and have been found wanting in any case. More fl exible and integrative approaches are required that can respond rapidly to changing circumstances and to sound evidence of what works well and not so well. The comprehensive development of health strategy is inherently a highly polit- ical process, and this must be acknowledged at every stage (1). In addition, processes must always be customized to country-specifi c conditions. Fig. 3. Elements and dynamics of a sound national health policy development process Situation analysis Population consultation Priority setting Operational planning Budgeting Monitoring and evaluation Strategic planning Costing Source: Schmets et al. (6). Policy-making is not a straightforward exercise, much less a linear one. It is a reiterative pro- cess of diff erent steps involving defi ning a problem, considering it through policy analysis, enacting a policy to address it, implementing the policy and following up. The national health policy planning cycle could be visualized as shown in Fig. 4. Fig. 4. Policy process cycle Problem definition Policy analysis Policy enactment Strategy and policy development Policy implementation Monitoring and evaluation Source: adapted from CDC policy process (8). 5Developing the National Health 2020 Strategy in North Macedonia Defi ning the problem: policies are developed in response to a perceived problem or opportu- nity. Policies are developed and implemented in a wider context, and it is therefore import- ant in this stage to clarify and frame the problem or opportunity in terms of the eff ect on, for example, the health or well-being of the population. Policy analysis means establishing the goals of the policy and various options to address the problem or opportunity. Strategy and policy development defi nes the strategy to get the policy adopted, such as engaging stakeholders, drafting necessary regulations or laws, setting up procedures, defi ning pro- grammes and projects and managing them and monitoring and evaluation frameworks. Pol- icy enactment means that procedures need to be followed to get policy enacted (for exam- ple, taking administrative actions and enacting regulations). Policy implementation: fi nally, the enacted policy will be translated into outcome-oriented actions, such as implementing programmes and projects. Policy evaluation, defi ned as “... an assessment, as systematic and impartial as possible, of an activity, project, programme, strategy, policy, topic, theme, sector, operational area, institutional performance and so forth” (9,10), is an important part of policy development. The national health policy tools and guidelines of the Universal Health Coverage Partnership (4) describe the process “as a comprehensive endeavour that ideally includes: (a) population and stakeholder consultation, (b) situational analyses, (c) priority setting, (d) strategic plan- ning, (e) operational planning, (f) costing, (g) budgeting and (h) monitoring and evaluation”. Strategizing - that is, designing plans and policies to achieve a specifi c goal related to the health of a country – is absolutely critical in the 21st century. This is not only a recommen- dation but also a necessity for all countries in all settings. Achieving this requires perma- nent, well structured and dynamic policy-making processes, with a true consensus between governments, service providers and the population (6). This case study elaborates the evi- dence-informed policy dialogue and its outcome of national health policy endorsement. The country context The country embarked on the process of developing a national health strategy and opera- tional plan on 27 May 2014, through an open stakeholder and nationwide consultative pro- cess, which resulted in the adoption of the National Health 2020 Strategy on 26 December 2016. The positive results of past and current experiences of the country in developing in- tersectoral actions and participatory processes for health and well-being off ered a good starting-point for developing the National Health 2020 Strategy. The process, with all its reiterative steps, commenced with identifying the current challenges for health and oppor- tunities for improving it. Highlights of the country’s health status and outcomes The country is facing a trend of ageing population, which will also potentially aff ect the health system. The fertility rate of 1.5 births per woman is below the European Union av- erage (1.58) and far below the replacement level. Life expectancy increased from 71.1 years in 1991 to 75.1 years in 2010, but this is still considerably lower than the European Union average of 80.2 years in 2010. The death rates from the three major causes (cardiovascular diseases, selected smoking-re- lated causes and cerebrovascular diseases) have strongly declined since 2005 (Fig. 5). How- 6ever, death rates for diseases of the circulatory system and selected smoking-related causes were nearly twice as high as the respective European Union averages. This is mostly related to unhealthy lifestyle habits and behaviour, with smoking being the leading cause (40–50% of the population older that 15 years are regular smokers) (Fig. 6). Further, the prevalence of hepatitis B is especially high in the country, with incidence being 6.5 times higher than the European Union average. Although the country is still struggling with avoidable mortality, disease prevention and health promotion, it has made considerable progress in reducing child and maternal mortality in recent decades (11). Fig. 5. Main causes of death as a percentage of the total number of deaths, 2016 100% 4% 19% 5% 17%53% Cardiovascular (I00-I99) Resp irato ry (J 00-J 99) End ocrin e (E0 0-E9 0) OtherNeoplasms (C00-D48) Source: authors’ compilation from Makstat database [online database] (12). Fig. 6. Percentage of smokers among boys and girls 13−15 years old, 2008 and 2016 Overall Boys Girls 9.7 9.0 9.8 6.1 9.8 7.6 2008 2016 Sources: 2008 Global Youth Tobacco Survey. The Republic of Macedonia report (13) and 2016 Global Youth Tobacco Survey. The Republic of Macedonia report (14). 7Developing the National Health 2020 Strategy in North Macedonia The country’s status with Health 2020 indicators Most recent analyses of WHO data on how countries are performing in terms of Health 2020 indicators1 showed that, compared with other countries (grouped by countries of the Com- monwealth of Independent States,2 Nordic countries, South-eastern Europe Health Network, European Union before May 2004 and European Union after May 2004) between 2005 and 2015, the country experienced large improvements regarding alcohol use (35%), infant mor- tality (40%), unemployment (25%) and life satisfaction (13%). Smaller improvements were observed for premature mortality (5%), mortality from external causes (5%), life expectancy (2%), sanitation (1%) and out-of-pocket health expenditure (8%). The indicators overweight (–3%) and measles and polio vaccination (–3% and –2%, respectively) declined slightly. Fi- nally, the performance on school enrolment (–11%) and health expenditure (–18%) showed great declines between 2005 and 2015, of similar size to the European Union before 2004 and after 2004, respectively. No change between 2005 and 2015 could be identifi ed for the Gini index, because data are only available for 2015. Regarding key indicators of health and well-being, the country has similar outcomes to other countries in south-eastern Europe, which altogether show the same trends of population ageing (Fig. 7). Fig. 7. Key indicators of health and well-being compared with selected countries in the WHO European Region, 1970–2014 Source: European Health for All database [online database] (16). 1 Data sources: WHO databases. Data for all quantitative indicators were retrieved from the Health 2020 database (15), except for indicators 12 (Health for All database (16)) and 13 (World Happiness Report (17)). Performance for the 16 quantitative indicators was assessed from the years 2005, 2010 and 2015 or another year in a three-year range if data were not available. The three-year ranges used were 20042006 for 2005; 20092011 for 2010; and 20132015 for 2015. 2 The Commonwealth of Independent States is a country group for statistical purposes that includes Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. 8Stronger equity and beƩ er governance for health through intersectoral acƟ on Inequalities are high and growing. Box 1 shows that North Macedonia is worse off than the other countries in the European Region and compared with the European Union average. This aff ects population health status and adds urgency to addressing health inequities. A national report on social determinants of health was commissioned in 2017 to reveal bot- tlenecks in addressing inequalities and to strengthen governance for health through inter- sectoral action. Box 1. Evidence of impact of social determinants on health According to the World Bank classifi cation, the country belongs to the upper-middle-income group with gross national income of US$ 4980 per capita in 2016 (18). However, according to the Gini index, inequality of the income distribution among individuals and households in the econ- omy is cause for concern, with a tendency towards deterioration: the Gini index increased from 39.1 in 2005 to 43.6 in 2012. Further, there is evident inequality of income distribution between diff erent parts of the country; the regional analysis of this index shows that income inequali- ty is highest in the North-eastern Region (46.6) and lowest in the Pelagonia Region (33.7). The analysis of material deprivation, poverty and social inclusion identifi ed that 31% of all surveyed households are materially deprived, and half the population cannot aff ord unexpected expenses (50%) (19). The unemployment rate is very high; despite recent reductions compared with 2005, when this rate was at its highest (37.3% of the labour force), the unemployment rate is still the highest in south-eastern Europe and ranks among the highest worldwide (20). This largely aff ects health, as shown by how mothers’ educational attainment is associated with infant mortality (Fig. 8). Fig. 8. Association between mothers’ educational attainment and infant mortality per 1000 live births compared with several countries in the WHO European Region, 2012−2014 Albania MKD – primary school MKD – total Romania Bulgaria European Region Serbia Croatia MKD – higher education Poland United Kingdom France Germany Italy Portugal Greece Spain Norway Estonia Sweden Iceland 13 9.4 8.6 8.3 7.3 6.6 5.7 5.3 5.1 4.2 3.9 3.4 3.2 3.2 2.9 2.9 2.9 2.4 2.4 2.2 1.8 0 2 4 6 8 10 12 14 MKD: North Macedonia. Source: Ministry of Health working document, 2018. 9Developing the National Health 2020 Strategy in North Macedonia In terms of country progress, measured through the Health 2020 targets and indicators (Fig. 9), the most striking results are for alcohol use in absolute terms (indicator 3), which is very low and even declining compared with the fi ve clusters. The country is performing very well on the prevalence of overweight (indicator 4). Interestingly, its performance on mortality from external causes (indicator 6) is very good, both in 2005 and 2010; the coun- try is doing even better than the Nordic countries or the European Union before May 2004. The unemployment rate (indicator 10) is about three times higher than other countries and clusters. People from North Macedonia are not very satisfi ed with their lives (indicator 13), although a 13% improvement was observed between 2010 and 2015. This may in part result from the continuing high out-of-pocket health expenditure, with more than one third of the health expenditure (indicator 16) being paid out of pocket, despite the increase in health expenditure (indicator 17). Fig. 9. Health 2020: percentage of relative change of indicators, 2005−2015 With the above in mind, the country has recognized the need for developing a comprehen- sive health policy to address not only the health but also the well-being of the population. This is refl ected in the National Health 2020 Strategy, endorsed in 2016. Country-specifi c policy context Context is of prime importance in national planning and policy dialogue (6). The internation- al context that shaped the development of the National Health 2020 Strategy derives from country membership in global organizations: the United Nations, WHO, the Organization for Security and Co-operation in Europe and the Council of Europe. In developing the National Health 2020 Strategy, special importance was given to the international instruments for hu- man rights: the WHO Framework Convention on Tobacco Control, the International Health Regulations (2005), United Nations and WHO resolutions and especially to Health 2020, the 2030 Agenda and the Sustainable Development Goals, including the Sendai framework for disaster risk reduction 2015-2030 (21) and South east Europe 2020. Jobs and prosperity in a European perspective (SEE 2020) (22). 10 European Union In addition, North Macedonia was granted candidate status for European Union member- ship in 2005. This has signifi cantly infl uenced health policy development in the country ever since and still plays a signifi cant role in policy development, through the European Union acquis communautaire and transposition of European Union regulations into the national legislation, pertaining to political criteria of democracy and rule of law, economic criteria for fi nancial sustainability, functional market economy and competitiveness and social criteria, including social protection, health and well-being. The country has a strong commitment to follow the roadmap towards European Union membership, through a consistent and con- tinuing process of national policy development aligned with the European Union, of which the process of development of the National Health 2020 Strategy was a part. Since acquiring its candidate status in 2005, the process of alignment with European Union membership requirements has progressed in multiple political and social spheres, includ- ing democratization, rule of law and respect for human rights, free trade and movement of goods and people, agricultural development and food safety, consumer and health protec- tion and others, and the country remains on the pathway towards achieving the required standards for European Union accession. South-eastern Europe Health Network (SEEHN) At the subregional level in south-eastern Europe, the country is a member of the Regional Cooperation Council, which serves regional cooperation and European and Euro-Atlantic in- tegration of south-eastern Europe to spark development in the region to benefi t its people. The Regional Cooperation Council has been leading the western Balkan economies in de- veloping the SEE 2020, inspired by the European Union’s Europe 2020 Strategy, using a similar approach and addressing related issues towards expediting progress through better cooperation in areas that are of common interest. Five south-eastern European countries adopted the SEE 2020 in November 2013 in Sarajevo, Bosnia and Herzegovina: Albania, Bosnia and Herzegovina, Montenegro, Serbia and North Macedonia (23). The country is a founding member of SEEHN, which emerged from the Stability Pact initia- tive and further developed under the Regional Cooperation Council umbrella. SEEHN is the only initiative of many that had emerged under the Stability Pact to develop into an interna- tional, intergovernmental organization with the seat of its Secretariat in Skopje, the capital of the country. SEEHN is a partnership of member countries and other European countries and organiza- tions. The country has hosted the SEEHN Secretariat since 2010 and continually invests in and contributes to SEEHN activities. The second SEEHN Forum of Ministers of Health, held in Skopje in 2005, was a milestone event, gathering together for the fi rst time the ministers of health and fi nance in the region alongside all major organizations and institutions work- ing on health and development. On that occasion, the case was made for health as an invest- ment in development, through ministers’ commitment to further investments in health and 11 Developing the National Health 2020 Strategy in North Macedonia well-being, refl ected also in the award-winning publication Health and economic development in South-eastern Europe (24).3 The 2017 SEEHN Ministerial Forum, held in Chisinau, Republic of Moldova (Fig. 10), refl ect- ed on 15 years of regional collaboration in public health and endorsed the Chisinau Pledge, which presents the SEEHN framework for action towards 2020. It emphasized the complex and signifi cant contribution of SEEHN to health and well-being, which has had a positive im- pact on peace, stability and economic development in the region and continues to play a key role in its further economic prosperity and societal advancement. The Forum highlighted the active role of SEEHN in both infl uencing public health developments in south-eastern Europe and in the rest of Europe and in supporting its member countries in their response to the international and regional commitments. Fig. 10. Participants at the Fourth South-eastern Europe Health Ministerial Forum, 3-4 April 2017, Chisinau, Republic of Moldova ©SEEHN WHO’s role: strong technical support for Health 2020 implementaƟ on and delivering on the 2030 Agenda Strategic and structured support WHO was instrumental in the policy developments described in this case study. During the three years from 2015 to 2017, it oriented, jointly with the Ministry of Health, collaboration to provide coherent and continual policy development for health and well-being throughout two strategically oriented biennial cooperation agreements (2014−2015 and 2016−2017). Eff orts have been made to integrate all the priority areas of technical work under the um- brella of the national health strategy and its priorities. WHO technical expertise has been 3 The publication was commended in the 2007 British Medical Association Medical Book Competition, public health category. Health is increasingly seen as a robust predictor of economic growth. This report examined the contribution of health to economic develop- ment in south-eastern Europe, where the dynamics of health cooperation gained momentum following the Second Ministerial Health Forum, co-organized by the WHO Regional Offi ce for Europe, the Council of Europe Development Bank, the Council of Europe and with the special participation of fi nance ministers. The report presented the socioeconomic context and the evolution of the health sector. It examined the trends and patterns in the burden of disease and socioeconomic inequalities in health, the development of health sys- tems and policies and how they should evolve to meet future health challenges. The report demonstrated the economic importance of health for the countries of south-eastern Europe. Health, as an ingredient in human capital, is especially relevant for sustained economic development and social cohesion. These two political objectives fi gure prominently in the European Union’s agenda and play a central role in its Lisbon agenda. 12 invested in all the technical areas of work under the National Health 2020 Strategy. It re- quired the active involvement of all divisions of the WHO Regional Offi ce for Europe, led by the Division for Policy and Governance for Health and Well-being and the Regional Direc- tor’s Offi ce – Unit for Strategic Collaboration with Countries (Fig. 11). Fig. 11. Structural involvement of the WHO Regional Offi ce for Europe in technical support for developing the National Health 2020 Strategy Regional Director Strategic relations with countries WHO Country Office Policy and Governance for Health and Well-being National Health 2020 Strategy main and enabling pillars and WHO Regional Office for Europe divisions and centres involved Information, Evidence, Research and Innovation Health Systems and Public Health Environment and Health Noncommunicable Diseases and Promoting Health Through the Life-course Health Emergencies and Communicable Diseases Main features of the support WHO supported the process of developing the National Health 2020 Strategy through technical assistance with policy dialogues (Box 2), capacity-building, strategic guidance, in- dividualized consultancy, strengthening national capacity in identifying appropriate mech- anisms for developing health policy relevant to the country needs and circumstances and advocacy and advice to enhance the leadership skills of the health ministry in working with multiple stakeholders for developing health policy using various entry points and shared governance approaches. Box 2. Policy dialogue for policy change In the policy dialogue initiated in 2014 and continuing throughout the development and adop- tion of the national health policy, more than 300 representatives from more than 100 institu- tions participated, contributing to developing several key strategic documents, including: • the National Health 2020 Strategy; • the operational plan of the National Health 2020 Strategy; • action plans developed as part of the National Health 2020 Strategy: o action plan for public health 2020 o action plan for health and environment 2030 o action plan for noncommunicable diseases and risk factors 2025 o action plan for food and nutrition 2025 o action plan for healthy ageing 2020 o emergency preparedness and response action plan o strategy for prevention and control of antimicrobial resistance 2021 o national HIV/AIDS strategy 2021. 13 Developing the National Health 2020 Strategy in North Macedonia The case study of North Macedonia The case study comprises two parts. Part 1 gives an overview of the process of developing national health policy in the country. Beginning with the background to health policy-making, it goes on to describe the steps taken, applying the whole-of-government and whole-of-so- ciety approaches. It describes the innovative approaches and tools used throughout this process, with intersectoral collaboration at its core, including face-to-face and virtual meet- ings, and new media facilities to ensure the involvement of all relevant institutions and in- terested stakeholders. Both the development of the policy and its operational planning were key within this process towards achieving the strategic priorities and objectives. Part 2 focuses on the outcomes of this process. It describes the content and features of the National Health 2020 Strategy as an instrument for better health through intersectoral action. It gives an overview of the evidence used to feed the content of the strategy and provides arguments for structuring the fi ve main pillars for action. It also describes part- nerships in health – at the national, subregional and regional levels – and their pivotal role in the process. Although the case study presents vast evidence, the annexes provide additional useful in- formation. 14 Part 1. Developing the NaƟ onal Health 2020 Strategy in North Macedonia History of health policy-making in North Macedonia The process of formulating health policy has evolved through several stages over the years. During the 1990s, major driving forces for new health policies were international agencies such as the International Monetary Fund and the World Bank, compensating for the lack of knowledge and skills inherited from the centralized policy and decision-making process in the former Yugoslav system. The loans provided by these institutions were conditional and linked to specifi c regulatory changes in the health-care system. Similar to many post-so- cialist countries, the emphasis was on improving the effi ciency of service delivery and eff ec- tiveness of resource utilization. The World Bank Health Sector Transition Project in 2006, with WHO support, did not end up in a national health strategy enacted by the authorities. With time, public administration built up its capacity to develop health policies, aligning them with international and European frameworks that were especially relevant for the European Union and North Atlantic Treaty Organization (NATO) integration processes. In the 2000s, the top-down process of overall policy formulation started with the adoption of a government programme, in which the government set the goals and objectives for all sectors, with the Ministry of Health undertaking action to transform these goals and ob- jectives into policies and actions. This approach of policy formulation replaced the previous donor-driven legislative changes, expressing the capability of the country to take a lead role in achieving its strategic development goals. A mechanism of obligatory publishing of draft laws on the website of the unique national electronic registry of regulations (ENER) (25) was developed, with the possibility for any interested organization or individual to comment on draft documents. The few independent analyses and evaluations of policies and legislation for reforms continue to have a limited impact in the overall formulation of the policy agenda. In 2009, the Ministry of Health initiated an open consultation process with numerous stake- holders to propose solutions for better health care for all. The process was governed by the Committee for Advancement of the Healthcare System, consisting of fi ve subcommittees in various areas of interest (health-care system governance, administering health care, health- care funding, pharmaceuticals and protecting patients’ rights) (26). Through an open web platform, any interested party (citizen or legal entity) could submit an identifi ed problem or proposed solution, which would be deliberated in sessions of the particular subcommit- tee. Each of the fi ve subcommittees prepared a report based on the analysed contributions and discussions, resulting in a compilation of contributions – the Green Book on health, an 800-page-long book on the committee’s work. A concluding chapter contained the opinions of many stakeholders about diff erent issues in the area of public health. This process was seen by many as a good example of participatory democracy in health and an opportunity to engage the public in decision-making. However, the White Book on Health was used to 15 Developing the National Health 2020 Strategy in North Macedonia reinforce the further development of top-down, vertical strategies and plans in the health sector, thus failing to respond to the increasing call for providing policy coherence among vertical strategies and plans and across diff erent levels of governance. Although civil soci- ety engagement gained momentum in the process, other sectors stayed out of the process. However, the design of the process and lessons learned served as a template for other pro- cesses of reform that require a broad participatory approach for understanding, addressing and negotiating the various interests of stakeholders (11). The thematic approach of the government to planning policy was a regular practice in the following years. Developing a health account for HIV and AIDS in 2015 was an eff ort to insti- tutionalize and set up a harmonized, intersectoral, integrated platform for annual and timely collection of data on health expenditure. The health account provided the intersectoral fund- ing and spending in the area. It was, thus, a valuable learning tool for policy-makers to invest in intersectoral work as a necessity in policy-making. The reports of international organizations increasingly called for an intersectoral approach to policy-making. As an example, the review of the HIV and AIDS programme in October 2015 (27) recommended that the government “clarify roles, responsibilities and information fl ow between stakeholders and strengthen the collaborative structure of the national HIV response, including strong leadership”. The most recent analyses (28,29) performed in developing the National Health 2020 Strat- egy demonstrated more than 200 policies and legal documents, including strategies, plans and regulations to shape national health policy, with a strong vertical thematic approach. The expert teams involved in the process decided that integrating these under one coher- ent policy framework is essential to the policy reform for health and well-being. Developing the NaƟ onal Health 2020 Strategy The Health 2020 Strategy of the Republic of Macedonia tells us what maƩ ers most for the health of our naƟ on. It also highlights the fact that health services are just one of many factors that can keep us healthy, help us recover from ill health or make it easier for us to live with chronic illness. If we really want to make a posiƟ ve diff erence to health, we will need to coordinate acƟ on across diff erent areas of government and address a broad range of social, economic, environmental and lifestyle issues adopt- ing new modaliƟ es of good governance. (30) The country embarked on the process of developing a national health strategy and opera- tional plan on 27 May 2014. A high-level technical gathering of health and other sectors con- fi rmed the need for an integrative policy framework that would work at both the horizontal and vertical levels of governance and across the sectors to bring the whole of society togeth- er in joint action for health and well-being. National experts concluded that Health 2020 pro- vides much-needed guidance on how to provide for the coherence of eff orts in all the areas of health that had been developed since the country became independent. The transparency of the process and providing opportunities for all stakeholders to participate was made a prerogative. Approaches that are innovative for the country have thus been developed to support the process and address its complexities. 16 Governance of the process The process developed under the umbrella of the Government Committee for Health and Environment (Fig. 12). Fig. 12. Governance structure of the Government Committee for Health and Environment Government Prime Minister (CHAIR) Committee for Health and Environment National health strategy process Secretariat: Ministry of Health Ministry of Health Ministry of Environment and Physical Planning Ministry of Economy Ministry of Education and Science Ministry of Finance Ministry of Labour and Social Policy Ministry of Local Self- government Other The steering role of the Committee as an intersectoral body was pivotal for the process of preparing and enacting the National Health 2020 Strategy. Chaired by the Prime Minister and co-chaired by the Minister of Health, it represented a stable, active and goal-oriented political structure established at the highest political level and an excellent example of the whole-of-government approach to health. Key drivers of the process were the Ministry of Health and the professional public health community. It scoped all the stakeholders at the national and local levels. The overall pro- cess was supported by the existing structures of the Ministry of Health –its departments – and the focal points for collaboration with WHO at both the political and technical levels that constituted the Secretariat to the process (Fig. 13). WHO off ered extensive technical support. 17 Developing the National Health 2020 Strategy in North Macedonia Fig. 13. Governance of the process for developing the National Health 2020 Strategy Governance of the process for developing the National Health 2020 Strategy: Government Committee for Health and Environment Technical support St ra te gi c co op er at io n w ith c ou nt rie s (O ffi ce o f t he R eg io na l D ire ct or ) D iv is io n of P ol ic y an d G ov er na nc e fo r H ea lth a nd W el l-b ei ng Division of Health Emergencies and Communicable Diseases Division of Noncommunicable Diseases and Promoting Health through the Life-course Division of Health Systems and Public Health Division of Information, Evidence, Research and Innovation Other departments of the Ministry of Health Other sectors Academia Civil society Municipalities - Mayor - Municipality Departments - Local units of central authorities (all sectors) - Civil society Head of the Department for Preventive Health Care, national technical counterpart for collaboration with WHO National focal points for collaboration with WHO Chief of Cabinet of the minister of Health, national (overall) counterpart for collaboration with WHO N at io na l a nd lo ca l l ev el M in is tr y of H ea lth W H O C ou nt ry O ffi ce Professional (public health) community Key drivers for the process MulƟ stakeholder consultaƟ on process Involving diverse stakeholders in policy-making is pivotal to creating sustainability and sup- porting ownership. A public consultation process was guided by the advice of the expert team from the European Centre for Disease Prevention and Control (ECDC) (31). The following points addressed key issues regarding the values and principles of involve- ment. • Those involved must see the bigger picture and know why this is being done, stating clear objectives. • There must be openness and honesty, with clear expectations. • The process must be inclusive, connecting people and their ideas in a transparent and democratic process. • The process must be fl exible and responsive to diff erent needs and preferences. • There should be respect for divergent views and values. • The system must be willing to take up and build on people’s ideas. Box 3 sets out the methods and outcomes used in the public consultation process. Ten steps for public consultation were implemented. 18 Box 3. Methods and outcomes used in public consultation for health policy development 1. Methods for public consultation: 10 steps for public consultation (32) To ensure the proper involvement of all relevant stakeholders, the public consultation process was based on the following 10 steps: 1. Taking action - overcoming obstacles to action 2. Selecting your issue - identifying issues where public involvement will enhance the ef- fectiveness of interventions 3. Understanding your political context - identifying the key groups and people that need to be engaged 4. Engaging citizens - researching the issue and mapping the potential roles of relevant groups and people 5. Selecting the level of public involvement - informing, listening, consulting, engaging and partnering 6. Elaborating on strategic plans - designing a process and selecting a public engagement approach related to the selected level 7. Synthesizing results - analysing input and drafting results 8. Ongoing dialogue with participants 9. Evaluating - reporting on activities and training and disseminating fi ndings 10. Building sustainable capacity throughout the process 2. Outcomes for public consultation: SWOT analysis of the consultation process Among other things, SWOT (strengths, weakness, opportunities and threats) analysis of the con- sultation process was performed, yielding the following outcome (Fig. 14). Fig. 14. SWOT analysis of the consultation process Strengths t4JHOJöDBOUBOEBDUJWFFOHBHFNFOUPGBCSPBEHSPVQPGTUBLFIPMEFST t.JOJTUSZPG)FBMUIJOWPMWFECVUKVTUPOFPGNBOZ t5SBOTQBSFOU PQFO JOEFQFOEFOUQSPDFTT UIFNJOVUFTPGNFFUJOHTBOE PUIFSSFMFWBOUEPDVNFOUTBSFQPTUFEPOBXFCTJUF t"DPNNPODPNNJUNFOUUPJNQSPWJOHIFBMUI t7PMVOUBSZFòPSUT t4IBSFEPXOFSTIJQ t&YQFSUTBTTJHOFEUPFBDIPGUIFöWFUIFNBUJDHSPVQT t5IFTUSVDUVSFPGUIFXFCTJUFNBLFTQBSUJDJQBUJPOFBTZ t"OFX GSFTIBOEFYDJUJOHQSPDFTT t(PPETVQQPSUGSPNJOUFSOBUJPOBMBHFODJFT Weaknesses t4UJMMMJNJUFESFTQPOTFGSPN/(0T DJUJ[FOTBOEPUIFSTFDUPSTUIBO IFBMUI t.JTUSVTUBOETDFQUJDJTNBNPOHNBOZ BOEFTQFDJBMMZUIFNFEJB t4IPSUUJNFBMMPUUFEUPUIFQSPDFTT POFZFBSJTOPUFOPVHIUJNF GPSUIJTMBSHFUBTL t5IFIFBMUIDBSFTFDUPSoFTQFDJBMMZEPDUPSToEPFTOPUIBWFB USBEJUJPOPGMJTUFOJOHUPQBUJFOUTBOEJTIBSEUPFOHBHF t5IFIVNBOBOEöOBODJBMSFTPVSDFTPGUIF.JOJTUSZPG)FBMUIBSF UPPTNBMMGPSUIFKPC Opportunities t.PSFBDUJWFQSPNPUJPOPGUIFQSPDFTTJOUIFNFEJB DPVMEMFBEUPCSPBEFSQVCMJDQBSUJDJQBUJPO t*OWPMWFNFOUPGQVCMJDöHVSFT QPMJUJDJBOT DFMFCSJUJFT FUDDPVMEFOIBODFQFSDFJWFEDSFEJCJMJUZ t8FCBDUJWJUJFTOFFEFEUPCFQSPNPUFECFUUFS Threats t-BDLPGGVOETBOEIVNBOSFTPVSDFT t1PMJUJDBMEJTDPSEBOEPXOFSTIJQ t1BZNFOUTUPQBSUJDJQBOUTDPVMEDSFBUFDPOøJDUTPGJOUFSFTU t.FEJBTDFQUJDT SWOT 19 Developing the National Health 2020 Strategy in North Macedonia During the development of the National Health 2020 Strategy, nearly 100 contributions were collected in thematic areas of the health system, public health, environment and health, noncommunicable diseases, communicable diseases and emergency preparedness, social determinants of health and others. Proposed ideas were related to various aspects of the policy, including governance, mechanisms for implementation, desired outcomes and indi- cators to measure them and others. Beyond the endorsement of the National Health 2020 Strategy, the online tool for contributions continued to gather ideas, thus ensuring sustained dialogue with the expert community and other stakeholders for the health and well-being of citizens (Fig. 15). Fig. 15. Agents and actors in developing the National Health 2020 Strategy t Ministry of Health t Institute for Public Health t Centres for public health t State Rescue Directorate t Crisis Management Centre t Border police t Hospitals t Civil society t Ministry of Health t Institute for Public Health t Centres for public health t University clinics t General hospitals t Health centres t State Sanitary and Health Inspectorate t Ministry of Health t Ministry of Environment and Physical Planning t Institute for Public Health t Centres for public health t Civil society Agents and actors t Ministry of Health t Ministry of Education and Science t Institute for Public Health t Centres for Public Health t State Sanitary and Health Inspectorate t State Labour Inspectorate t Service Employment Agency t State Statistical Office t Medical, pharmaceutical and dental faculties t Civil society Health system and resources t Ministry of Health t Ministry of Labour and Social Policy t Ministry of Economy t Institute for Public Health t Centres for public health t State Sanitary and Health Inspectorate t State Statistical Office t Civil society Noncommunicable diseases Health and environment Communicable diseases Emergency preparedness and response Public health and the life-course approach t Ministry of Health t Institute for Public Health t Centres for public health t Civil society t State Sanitary and Health Inspectorate t State Labour Inspectorate t State Statistical Office National Health 2020 Strategy The professional public health community played an instrumental and multifaceted role in the National Health 2020 Strategy process. It drove the process and acted individually or as part of the institutions involved in the process (Fig. 15). Public health professionals served as policy entrepreneurs, supporting innovative approaches and engaging, among other things, in the following: • leading and working in technical working groups; • communicating public health information provided by surveillance and health infor- mation systems to policy-makers, health-care providers, the administrative agen- cies and others involved in the process; 20 • performing policy analysis; • supporting partnerships for public health and intersectoral action; and • promoting evidence-informed interventions and outcome-oriented policy. Gathering evidence for policy The book of evidence for the National Health 2020 Strategy was developed, serving as an evidence base for a comprehensive and meaningful policy (Fig. 16). In addition to the data and information that derived from the regular information system of the country and in- ternational sources, specifi c to the process described here were the submissions received through the Health 2020 e-platform features for sharing (“Your Ideas”) and the online sur- vey “What is the health I want in 2020?”. Fig. 16. Book of evidence, structure and content Interaction: key conclusions and recommendations for National Health 2020 Strategy Book of evidence Aims and methods Overview of process National Health 2020 Strategy Overview of context of National Health 2020 Strategy Public health and the life-course approac Communicable diseases Emergency preparedness and response Non- communicable diseases Health system and resources Environment and health Matrix of proposed policy formulation steps towards National Health 2020 Strategy Matrix of policy links, activities and outcome indicators Matrix of monitoring and evaluation measures, outcomes and indicators Avenues of action The country joined the Evidence-informed Policy Network (EVIPnet) in 2015, by establishing a core team that initiated the development of more than 20 policy briefs to inform the Na- tional Health 2020 Strategy. The policy briefs were also published in the form of a compen- dium to inform research and policy processes in health and other areas. 21 Developing the National Health 2020 Strategy in North Macedonia Establishing a roadmap for developing health policy The process of development of the Health 2020 Strategy of the Republic of Macedonia encompasses various modaliƟ es selected to generate debate and reach consensus on the vision, mission, objecƟ ves and prioriƟ es for health. The process gives us the oppor- tunity to determine what health and well-being we would like to have by 2020, while taking into account the social, economic, environmental and cultural circumstances; the iniƟ al health status of each populaƟ on group; as well as the possibiliƟ es for reduc- ing health inequaliƟ es in the parƟ cular context. The Health 2020 Strategy of the Republic of Macedonia considers the public’s shared opinions, aƫ tudes and experƟ se regarding the quality of health that ciƟ zens would like to have for themselves and for the others by 2020. (30) At the very start of the policy dialogue, the stakeholders decided to adopt a phased approach to the National Health 2020 Strategy, as shown in Fig. 17. The process had seven phases: the preparatory phase, in which stakeholder analyses, governing structures, tools and instru- ments in support of the process and the work plan were developed; fact fi nding, the result of which was the book of evidence; the consultative process, which scoped clarifying and framing the problems within the context and options to address the problems identifi ed; presentation of results, when stakeholders were informed of the results from the consulta- tive process; and drafting, in which the National Health 2020 Strategy and its implementing instruments were drafted. The process ended with endorsement in December 2016. The country is currently in the implementation phase. The Ministry of Health, as the lead agency of the Government Committee for Health and Environment, started the process in the second quarter of 2014. The preparatory phase resulted in establishing the governing structure of the process and a roadmap (Fig. 17). A promotion and communication strategy was developed to serve policy dialogue and public hearings. 22 Fig. 17. A roadmap of the National Health 2020 Strategy development process No nc om m un ica bl e di se as es H ea lth a nd en vi ro nm en t Co m m un ic ab le di se as es a nd em er ge nc ie s Ph as e 1 PR EP A RA TO RY P H A SE Ph as e 2 FA CT F IN D IN G Ph as e 3 CO N SU LT AT IV E PR O CE SS Ph as e 5 D RA FT IN G Ph as e 6 EN D O RS EM EN T Ph as e 7 IM PL EM EN TA TI O N Pu bl ic h ea lt h » Pu bl ic h ea lth s el f-a ss es sm en t c om pl et ed u si ng W H O e ss en tia l p ub lic h ea lth o pe ra tio ns to ol » Se lf- as se ss m en t e -t oo l a da pt ed fo r t he c ou nt ry » Ac tio n pl an fo r p ub lic h ea lth to w ar ds 2 02 0 de ve lo pe d in c on su lta tiv e in te rs ec to ra l p ro ce ss H ea lt h an d en vi ro nm en t » Ac tio n pl an fo r e nv iro nm en t a nd h ea lth to w ar ds 2 02 0 de ve lo pe d in c on su lta tiv e in te rs ec to ra l p ro ce ss » D ra ft m on ito rin g an d ev al ua tio n fr am ew or k in iti at ed »E nv iro nm en t a nd h ea lth e -p la tf or m la un ch ed H ea lt h sy st em » In iti al d at a ga th er ed » H ea lth in fo rm at io n sy st em a ss es sm en t co nd uc te d w ith W H O R eg io na l O ffi ce te ch ni ca l s up po rt Co m m un ic ab le d is ea se s an d em er ge nc ie s » Em er ge nc y pr ep ar ed ne ss a nd re sp on se ex er ci se s co nd uc te d » A nt ib io tic c on su m pt io n su rv ey ed a t t he ho sp ita l l ev el » Aw ar en es s ca m pa ig ns o n H IV a nd A ID S, an tim ic ro bi al re si st an ce a nd im m un iz at io n co nd uc te d N on co m m un ic ab le d is ea se s » H ea lth s ys te m s tr en gt he ne d fr om a n on co m m un ic ab le d is ea se p er sp ec tiv e » In iti al d ra ft a ct io n pl an fo r n on co m m u n ic ab le d is ea se s H ea lth sy st em s Pu bl ic he al th Em ba rk in g on th e p ro ce ss To ol s a nd in st ru m en ts (e -p lat fo rm , o n- lin e s ur ve y) Co nt in ua l pr om ot io n of H ea lth 20 20 Ev id en ce b as e of H ea lth 20 20 Co nt in ua l pr om ot io n of H ea lth 20 20 La un ch in g th e Na tio na l H ea lth 20 20 St ra te gy Co nt in ua l pr om ot io n of H ea lth 20 20 H E A L T H 2 0 2 0 P R O M O T I O N M I L E S T O N E S Ph as e 4 PR ES EN TA TI O N O F RE SU LT S 23 Developing the National Health 2020 Strategy in North Macedonia InnovaƟ ve approaches in developing the NaƟ onal Health 2020 Strategy A technical structure was established to respond to the decision made by the stakehold- ers to focus on fi ve main areas of work in developing the National Health 2020 Strategy. For each of these fi ve priority areas of work, an expert-facilitated process was established, involving representatives of the health sector and other line ministries and agencies, prac- titioners and experts, civil society and academia. The core expert teams, consisting of a co- ordinator and technical experts, were established and involved in all stages of the process as advisory and drafting teams (Fig. 18). This was an innovative approach for the country: gathering together experts across sectors to work for health. Fig. 1 8. Organization of the technical work of the national health policy development process Coordinator Technical team Public health and the life-course approach Health and environment Noncommunicable diseases Communicable diseases and emergency preparedness and response Health system and resources InnovaƟ ve tools to support policy dialogue InteracƟ ve e-plaƞ orm as a policy tool The National Health 2020 Strategy process was an all-inclusive, participatory process and entailed the involvement of both experts and the general public. As part of the whole-of-society approach, the Ministry of Health, with technical support from the WHO Regional Offi ce for Europe and the WHO Country Offi ce playing an active role, established a wide array of communication and exchange channels for broadening in- formation and involving all stakeholders at the national and local levels and across sectors in the policy dialogue. This action was inspired by the vision for advancing national deci- sion-making and health planning support systems. The action was based on the belief that securing broad public consultation can give decision-makers a stronger basis to make bet- ter decisions that are representative and more equitable when arising from pluralistic and democratic processes. It also derived from a pragmatic need to bring timely information to the broader audience and was based on the evidence for Internet use by Macedonians: 73% of households have access to the Internet at home, and nearly 70% of the population 24 15−74 years old uses the Internet every day. Some 82% of the population access the Inter- net through mobile phones or smartphones, of which 91% are people 18−24 years old (33). The National Health 2020 Strategy platform is a publicly accessible, web-based platform (34), designed as a policy tool to support policy-makers in developing the National Health 2020 Strategy and its implementing package. It was developed to help public users to access, dis- seminate and integrate information related to the National Health 2020 Strategy. The e-platform facilitated the development of the National Health 2020 Strategy and proved to be a useful policy tool for the following policy development and implementation elements. • Public outreach, data collection and information sharing: the National Health 2020 Strategy e-platform is an interactive, web-based e-platform that brings the policy process to the professional and wider public, which enabled the continual exchange of information during the process of developing the National Health 2020 Strategy. It applies and builds on existing evidence that enhanced links can improve policy de- velopment and outcomes. It hosts an e-library of useful documents and information from health and other sectors and serves as a data collection tool from sectors other than health. It also displays the evidence for the National Health 2020 Strategy and facilitates outreach action, regularly publishing information related to the priority areas of the National Health 2020 Strategy and instruments for its implementation, such as action plans on public health, health and environment, noncommunicable diseases, communicable diseases, emergency preparedness and response and oth- ers. As such, it represents a useful instrument for developing and implementing the National Health 2020 Strategy and monitoring the outcomes. • Managing and facilitating policy dialogue: since policy dialogue is key to success- fully developing and implementing policy, the e-platform is intended also to serve the purpose of managing and facilitating policy dialogue between diverse stake- holders, potentially becoming a virtual meeting place and evidence-gathering space to promote the continuity and consistency of the process of developing and imple- menting the National Health 2020 Strategy. • Enabling citizens’ direct contribution to policy dialogue: through various forms and survey questionnaires, it provides citizens with the opportunity to raise issues in given areas related to health and well-being and off er their opinions, suggestions and ideas and thus contribute to developing the National Health 2020 Strategy in general. It allowed informal public contributions to the offi cial National Health 2020 Strategy development process and facilitated robust public participation in the pol- icy-making process. • Facilitating intersectoral contribution to developing the National Health 2020 Strategy: given the intersectorality of health and well-being and aiming at ad- dressing the challenge of silo approach usually taken by governments, the National Health 2020 Strategy e-platform was also created to facilitate the intersectoral contribution to developing the National Health 2020 Strategy. Through compo- nents such as the e-library and listing all stakeholders for health, the Health 2020 e-platform acknowledges the infl uence of health on other sectors and vice versa – the contribution of other sectors to health and well-being - and provides a space for developing and sustaining intersectoral action across government and society. • Coordinating stakeholders and networking for implementing the National Health 2020 Strategy: in addition to the above, the e-platform serves as a co- 25 Developing the National Health 2020 Strategy in North Macedonia ordination and networking tool among health and other sectors and disciplines that can contribute to the online evidence base, e-library or to the policy dialogue, providing for improving understanding of the roles and responsibilities of other sectors, institutions and organizations and enabling them to communicate to cre- ate and implement joint overall and specifi c actions. The Ministry of Health continues to host and manage the Health 2020 e-platform (34). Its main features are presented below. E-library of evidence to inform experts and the general public The national health strategy began its development in a context of vertical and thematic na- tional planning, often not explicitly related to other sectors’ policies that might aff ect health. The myriad policies, plans and actions (Annexes 2 and 3) were not always consistently de- veloped or implemented. In addition, the overall national agenda for development, to which health is increasingly shown to be an exceptional contributor, had already been developed. It was thus of paramount importance to consider this policy context and to invest eff orts into providing policy consistency as a step towards improving effi ciency and eff ectiveness in using resources for achieving strategic goals and objectives for health and well-being. A comprehensive online inventory (library) of evidence and of strategy papers and policies was created with the aim of informing the process of developing the National Health 2020 Strategy. Using the Health 2020 approach, this inventory has provided better and more comprehensive insight into the overall country context relevant to the health and well-be- ing of everyone included in the process. It provided more consistent understanding of health and investments for health and well-being by all sectors and levels of governance (Fig. 19). Fig. 19. Diversity of resources for the e-library for national health policy development National Health 2020 Strategy Social determinants of health Agriculture Finance Media and communication Judiciary Labour and employment Social protection Transport HealthEquity and human rights Education Housing Development and growth Cross-sectoral Economy WHO assessment reports enriched the inventory of evidence for health and contributed to documenting the process of developing the National Health 2020 Strategy (Annex 4). The publication process also promoted policy dialogue in specifi c areas of developing national health policy. Collaborative publications aimed at opening up and maintaining communication channels between the public sector, academia and experts were used for discussing contex- 26 tualized evidence and possible solutions for specifi c issues identifi ed in the process of devel- oping national health policy. These were also published as compendiums of policy briefs, as special editions of Evrodijalog – Journal for European Issues, published since 2002 by Studiorum. Providing a virtual meeƟ ng place for the stakeholders for health across government and society Governance for health is defi ned as the attempts of governments or other actors to steer the process and involve actors in the pursuit of health as integral to well-being through both whole-of-government and whole-of-society approaches (33). Governance for health promotes joint action of health and non-health sectors, of public and private actors and of citizens for the common interest of creating successful societies in economic terms while considering human rights and equity dimensions. It requires creating synergy of policies, many of which are within the authority of sectors other than health and with stakeholders outside government, and thus calls for establishing an enabling environment of structures that support collaboration. It gives strong legitimacy to health ministers and ministries and to public health agencies, to help them reach out and perform new roles to shape policies to promote health and well-being (35). Under the motto “All for health”, the e-platform provided a mapping of all institutions across all sectors of central and local government, the international community and civil society (Fig. 20), with the following objectives: • to share the vision of health as everybody’s business; • to provide information on other sectors’ policies that aff ect health; and • to provide an opportunity to update and share health-related information across the sectors and levels of governance and contribute to the National Health 2020 Strategy process. All sectors and institutions were responsible for updating the inventory of their poli- cies, tools and information, which contributed to the e-platform becoming a tool to en- hance shared responsibility for health, including the process for developing the National Health 2020 Strategy. F ig. 20. All for health: mapping stakeholders in the national health policy process Public sector (central level) Public sector (local level) Civil society International community Academic and research institutions Private sector Other institutions and organizations 27 Developing the National Health 2020 Strategy in North Macedonia Online public survey: Your opinion – What is the health I want by 2020? Public opinion matters, since it contributes to shaping policies that lead to desired out- comes and increases ownership in implementation. The survey What is the health I want in 2020? (Fig. 21) was disseminated through the Health 2020 e-platform for the public to share their opinion, not only on how they perceive their health but also on what they value most for health and well-being, thus contributing to defi ning the vision, mission, scope and strategic objectives of the National Health 2020 Strategy. The input from citizens and their considerations of what constitutes good health for them were considered in developing the policy (Fig. 22 and 23). Fi g. 21. Your opinion − What is the health I want by 2020? How is my health today? What do others think about my health? How is my health system doing? What is the health system I want in 2020? What do I think about others' health? What is the health I want in 2020? What do I think of my environment today? What is the environment I want in 2020? Fig. 22. Perceived and actual participation in care of one’s own health in the 2016 survey: What is the health I want in 2020? Excellent Very well Well Not so well I don't know 14% 38.5% 40.5% 3.5% 3.5% 100% 100% Once a day 3–5 times a day 3–5 times a week Once a month Rarely or never 9% 1.7% 9.5% 26.4% 53.4% How well do I take care of my health? How often do I measure my blood pressure? Source: authors’ compilation of the results of the 2016 survey What is the health I want in 2020? 28 Fig. 23. Citizens’ expectations from implementing the National Health 2020 Strategy from the 2016 survey: What is the health I want in 2020? Less stress at workplace Healthier environment 100% 100% 81.5% 7.3% 1.6% 9.6% 89.9% 4.5% 1.1%4.5% Yes Partly No I don't know More services for healthy ageing Cleaner air 100% 100% 74.7% 7.9% 6.2% 11.2% 89.3% 5.1% 1.7%3.9% Source: authors’ compilation of results of the 2016 survey What is the health I want in 2020? Online tool for public contribuƟ ons to policy dialogue: Your ideas! Adding possibilities for honest contribution to the policy-making process, the online tool for public contribution to policy dialogue was developed and published on the e-platform under the title Your ideas! (Fig. 24). Fig. 24. Your ideas! Public and expert contributions to policy dialogue Communicable diseases and emergency preparedness and response Public health and promoting health through the life-course Noncommunicable diseases Health and environment Monitoring and evaluation Governance Management Services Financing Intersectoral cooperation Monitoring and evaluation Contribution areas Thematic areas 29 Developing the National Health 2020 Strategy in North Macedonia Contributions were collected throughout the process of developing health policy, using both face-to-face and e-mail communication to invite experts and stakeholders to contribute their ideas on how to defi ne the strategic objectives and also how those could be better addressed through specifi c actions, drawing from experience and practice. The process gathered more than 100 contributions on all aspects of the policy process and referring to all fi ve main pillars of the strategy. The contributions were supported by evidence from international and national sources, enabling an evidence-informed approach in developing national health policy. OperaƟ onal planning An operational plan was developed using the same inclusive participatory process. It equipped the National Health 2020 Strategy with strong management, responsibility and monitoring and evaluation frameworks and had local Sustainable Development Goals (Fig. 25). Fig. 25. Strategic framework and operational planning O rg an iz in g so ci et al e ffo rt s fo r h ea lth DEVELOPMENT AND HEALTH National Development Strategy ONE INTERSECTORAL OVERARCHING NATIONAL HEALTH POLICY FRAMEWORK National Health 2020 Strategy ONE NATIONAL HEALTH OPERATIONAL PLAN National Health 2020 Strategy has devolved the Sustainable Development Goals One framework for: t Responsibility t Management t Monitoring and evaluation t ReportingLOCAL HEALTH PLANS: Building resilient communities Local public health councils revitalizing existing structures The operational plan was developed after the National Health 2020 Strategy was endorsed. Integration and providing cohesion were two main objectives of the operational plan of the National Health 2020 Strategy, which has gathered more than 200 existing national health strategies, plans and other strategic documents under one umbrella (Annex 2). The operational plan was developed to meet the following objectives related to implement- ing the National Health 2020 Strategy: • to provide for consistency among the strategic, operational, legal and other documents at different levels and of different sectors comprising the National Health 2020 Strategy; • to establish a clear framework of responsibility for all the stakeholders involved for, among other things, the quality, scope, type, timeliness, consistency, effi cacy and bud- geting of the activities within their respective mandate and of their health outcome; 30 • to establish responsibility, management, monitoring, evaluation and reporting frameworks; • to facilitate coordination and collaboration among diff erent entities and sectors at diff erent levels of governance; • to facilitate creativity and innovation to obtain competence, effi cacy and eff ective- ness; and • to provide for transparency of all the activities, their implementation and their out- comes. The same principles of transparency and accountability are also envisaged in the implemen- tation phase, which is to be monitored through the joint monitoring and evaluation frame- work of the National Health 2020 Strategy and its constituent action plans, developed with technical and expert guidance from WHO and aligned with the monitoring frameworks of the Sustainable Development Goals, Health 2020 and Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (Fig. 26 and 27). Fig. 26 . Structure and content of the operational plan of the National Health 2020 Strategy Operational plan Establishing appropriate mecha- nisms for managing the opera- tional plan High level of responsibility for the ultimate impact of the con- tained measures and activities on the health of the population Coordination and communica- tion of the entities responsible for its implementation Transparency and continuity of information and information, monitoring and evaluation and use of the available funds OVERALL GOAL Establish coherence between the adopted strategic, operational, legal and other docu- ments at different levels and different entities Establish a clear framework of responsibility for all responsible entities for the results of the implementation of the defined activities Encourage coordination and cooperation between different entities and sectors and at different levels of governance (central-local) Encourage creativity and innovation in specific activities to achieve a high level of expertise, cost-efficiency and effectiveness Achieve transparency and publicity of the activities, their realization and the effects of their implementation Establish systems for: a) accountability b) management c) monitoring and reporting d) assessment Sp ec ifi c ob je ct iv es M at rix o f a ct iv iti es Activity Responding to Sustainable Development Goals Primary implementer Central-local collaboration Instrument for verification Aim and scope Time frame Intersectoral collaboration Indicator Budget To provide comparability to the European Union and the countries in the WHO European Region while eff ectively measuring the progress of action taken to improve the health and well-being of the country and specifi c population groups, the indicators for the National Health 2020 Strategy have been drawn from three sets of indicators: the Health 2020 tar- gets and indicators of the WHO Regional Offi ce for Europe (36), the European Core Health Indicators (37) and WHO’s 100 core health indicators (38). 31 Developing the National Health 2020 Strategy in North Macedonia Fig. 27 . Monitoring and evaluation framework of the National Health 2020 Strategy Funds spent per outcome unit (output) Monitoring of implementation: REPORTING Cost–effectiveness of the activities implemented Qualitative reporting Quantitative reporting Indexing activities implemented Narrative report Level of programme implementation Level of financial implementation Quantitative outcome of activities implemented (number of preventive examinations, trees planted, filters installed, etc.) Planned activities Funds used Planned funds Despite the important number of fi ndings and studies on the cost-eff ectiveness of public health measures, both the selection of the best interventions and how successful they are often depend on the national – and sometimes the local – context. In addition to regular reporting on the progress of implementation (Fig. 28), the National Health 2020 Strategy envisages monitoring the cost-eff ectiveness of selected population-oriented interventions, using an online, interactive monitoring database, in which responsible ministries and agen- cies would be required to provide input for matrix-based correlative monitoring of progress. Fig. 28. Reporting on implementation of the National Health 2020 Strategy Process of reporting on operational plan implementation Government Permanent Steering Committee Ministry of Health Primary implementers Contracted parties Contracted parties This is enabled through the broad scope of National Health 2020 Strategy activities based on the whole-of-government and whole-of-society approaches, also enabling analysis of how social determinants aff ect the health of specifi c population groups and how the Na- tional Health 2020 Strategy reduces health inequalities. 32 Part 2. The NaƟ onal Health 2020 Strategy as an instrument for improving health through intersectoral acƟ on The National Health 2020 Strategy is the most comprehensive policy framework developed so far in the country for organizing and facilitating inclusive, dynamic and results-orient- ed action with common objectives and clear priorities towards improving the health and well-being of the population by 2020. The National Health 2020 Strategy implicitly aims to reduce the negative health eff ects of social determinants, specifi cally focusing on the most severely aff ected vulnerable groups. In addition, it puts intersectoral action at the very heart of each strategic area of action. Part 2 of this case study describes the content and features of the National Health 2020 Strategy, which was developed in an open consultative process (as described previously), resulting in a strategic framework of national signifi cance and wide stakeholder ownership, preconditions to its ability to be implemented and the sustainability of results achieved. Values and principles of the NaƟ onal Health 2020 Strategy The National Health 2020 Strategy refl ects the political will for the strategic development of health by 2020. Its structure and components clearly indicate the multisectoral approach needed for coordinated action among various sectors (both systematically and socially) and the hierarchy of cooperation necessary at diff erent levels within the health system. Introducing unique values based on evidence and experience, the National Health 2020 Strategy could be considered a platform for partnership and collaboration for health. The engagement of society is a central aspect of National Health 2020 Strategy planning, de- velopment, implementation and monitoring of both its implementation and its success in realizing the defi ned aims at all levels. Further, it provides the basis for empowering each individual, citizens, consumers and patients and health workers and other experts, crucial factors for improving health outcomes. This is not intended to undermine the crucial role of government and its responsibility for providing better, more effi cient, eff ective and sustain- able governance for health, public health protection and services and individual health care but rather to complement it in this endeavour. The box 4 describes the vision and core values of the National Health 2020 Strategy. 33 Developing the National Health 2020 Strategy in North Macedonia Box 4. Establishing a strong value base: vision and core values of the National Health 2020 Strategy Vision statement Our goal is that, by 2020, the health and well-being of the population will be signifi cantly im- proved, public health strengthened and there will be a patient-centred health system that is sustainable. Core values Health is a fundamental human right The right to health was fi rst proclaimed in 1948 in the preamble to the WHO Constitution and later the same year in Article 25 of the Universal Declaration of Human Rights. In 1976, the International Covenant on Economic, Social and Cultural Rights entered into force, reaffi rming in its Article 12 the enjoyment of the highest attainable state of health as a human right under international law. Health is the greatest wealth Health contributes signifi cantly to economic growth and socioeconomic development. The Tal- linn Charter: Health Systems for Health and Wealth aimed to build on that common core set of values in 2008 and focused on the shared values of solidarity, equity and participation. It em- phasized the importance of investing in health systems that off er more than health care alone and that are committed to preventing disease, promoting health and making eff orts to infl uence other sectors to address health concerns in their policies. In addition, health ministries should promote the inclusion of health interests and goals in all societal policies. Intersectoral approach to health We accept that this new concept of governance for health brings together and extends the prior notions of intersectoral action and healthy public policy within the more comprehensive and linked notions of whole-of-society, whole-of-government and health in all polices responsibility for health, strengthening the policy dialogue on health and its determinants and building ac- countability for health outcomes. Sustainable development We will work to meet the needs of the present without compromising the ability of future gen- erations to meet their own needs. To achieve sustainable development, we will establish new forms of responsibility, solidarity and accountability at national level and across generations. In addition, we will stay active in pursuing the same goal at the regional and global levels. Source: Health 2020 Strategy of the Republic of Macedonia (30). 34 CreaƟ ng resilient communiƟ es and supporƟ ve environments: the NaƟ onal Health 2020 Strategy in the community The National Health 2020 Strategy clearly recognizes the interdependence of sectors, gov- ernance levels and actors at the global, regional, national and local levels and the need to address today’s health challenges through highly coordinated action. In this process, com- munities and local-level action are key to sustaining the momentum on health action and achieving wider (national, regional and global) health goals. Building resilience is a key factor in protecting and promoting health and well-being at both the individual and community levels. People’s health prospects are closely linked to the conditions in which they are born, grow, work and age. Systematically assessing the health eff ects of a rapidly changing en- vironment, especially related to technology, work, energy production and urbanization, is essential and must be followed by action to ensure positive benefi ts for health. Resilient communities respond proactively to new or adverse situations, prepare for economic, social and environmental change and deal better with crisis and hardship (1). The 80 local governments in the country and the capital city of Skopje are mandated by law to ensure decent living conditions, a safe environment and economic well-being, through their capacity in all sectors, including education, employment, transport, environment, social protection and others. Their mandate also includes establishing councils for public health aimed at supporting and creating community resilience through intersectoral action for public health. Local governance structures and other local community actors in the country, alongside civil society active at the community level, were invited and contributed signifi - cantly to the process regarding local priorities and needs. The devolving of the National Health 2020 Strategy to the local level commenced in 2016 through policy dialogues at the local level for community diagnosis and community involvement (Fig. 29). These involved stakeholders from 50 municipalities, representing health, education, environment, social protection, city planning, employment and other sectors, as well as other local actors, such as local civil society organizations and other formal and informal citizen movements. Their commitment to improving the health and well-being of citizens was expressed by endorsing the joint statement to strengthen intersectoral action for health and well-being at the local level (Annex 6), as an initial step to creating local health plans to contribute to achieving the vision and objectives of the National Health 2020 Strategy. Fig. 29. Intersectoral work for health and well-being at the local level: meetings of diverse stakeholders 35 Developing the National Health 2020 Strategy in North Macedonia The country has a good legislative base for local health and well-being action. Local health councils, as community-based structures for health and well-being, were established under the Public Health Act in 2010, although not funded or used to fulfi l their tasks. They have great potential to guide the intersectoral policy planning and implementation at the local level. The operational plan of the National Health 2020 Strategy focuses on revising lo- cal health council structures and developing incentives to support their work as agents for bringing about consistent policy planning and focused implementation, based on develop- ing local (community) intersectoral health plans (Fig. 30). Fig. 30. Health in the community: mapping public health councils at the local level Municipality Public health council Date of establishment - President and members - Contact details Adding value through partnerships The National Health 2020 Strategy recognizes the need for and enables creative partner- ships for health to be initiated and established for specifi c activities to realize its vision and goals. The Ministry of Health plays a key role and holds decision-making power and mandate in participating in, supporting and coordinating these partnerships for operationally effi - cient, timely, harmonized and coordinated implementation of activities and achieving the vision and goals of the National Health 2020 Strategy. The content of the NaƟ onal Health 2020 Strategy refl ects its priority areas of work Health is a complex category as well as a public good that all sectors not only con- tribute to through their acƟ ons but also benefi t from. It is, therefore, understandable that a single document cannot comprise nor refl ect all aspects of health including all determinants that aff ect health, or describe and integrate all relaƟ onships, respon- sibiliƟ es and possibiliƟ es for intersectoral collaboraƟ on and coordinated acƟ on for beƩ er health and well-being. (30) 36 The National Health 2020 Strategy represents a framework for development and action di- rected at health challenges across the life-course in relation to both communicable and non- communicable diseases. It is designed to connect clinical interventions with activities aimed at achieving equity and equality and related to the social, economic and environmental de- terminants of health and with the necessary inputs into the health system, such as human resources, high-quality medicines and funding, including improving governance for health. The country focused on fi ve main pillars in the National Health 2020 Strategy: (1) public health, (2) health and environment, (3) noncommunicable diseases, (4) communicable diseas- es and emergency preparedness and response and (5) health system and resources (Fig. 31). Strategic goals were set up separately for each priority area (Annex 5). Based on the National Health 2020 Strategy, specifi c action plans have been developed for all the content areas, except the health system and resources. The operational plan of the National Health 2020 Strategy has brought together the national health strategy management, responsibility and monitoring and evaluation frameworks of National Health 2020 Strategy specifi c action plans and other vertical strategies and programmes under one umbrella, for coherence of policy implementation. The Sustainable Development Goals were devolved to the local level across all the areas of work of the National Health 2020 Strategy (Fig. 31). The respective monitoring and evaluation frameworks are designed to respond to the national framework for priorities for delivering on the 2030 Agenda and Sustainable Development Goals. Fi g. 31. National Health 2020 Strategy content and priority areas H ea lth p ol ic y m on ito rin g an d ev al ua tio n Health 2020 – key indicators Devolving Sustainable Goal 3 and other Sustainable Development Goals related to health Thematic areas National Health 2020 Strategy Health system and resources Public health and the life-course approach Health and environment Non- communicable diseases Communicable diseases and emergency preparedness Monitoring and evaluation The National Health 2020 Strategy envisages implementing Health 2020 at the national level and delivering on commitments to the 2030 Agenda. The Sustainable Development Goals have been devolved into the National Health 2020 Strategy regarding delivery on the indicators and targets of specifi c Sustainable Development Goals, and subsequently trans- ferred into the action plans of the priority areas. Priority area 1: public health and the life-course approach Public health was defi ned as one of the most important areas of health promotion and dis- ease prevention for the population throughout the life-course. Following robust multistake- holder situation analysis, performed in the form of self-assessment using the WHO essen- 37 Developing the National Health 2020 Strategy in North Macedonia tial public health operations tool in 2015 (Box 5), the government developed and endorsed the public health action plan in 2016. Its vision of “better health and well-being through the established quality of health services, strengthening a patient-centred health-care system and improved public health oriented towards the community” underlines the importance of this pillar within the National Health 2020 Strategy, scoping the government’s health and well-being commitments. Fig. 32 shows the main priority areas of the public health action plan. Fig. 32. Priority area 1: public health and the life-course approach Priority area: Public health and the life-course approach VISION Better health and well-being through established quality of health services, strengthening a patient-centred health-care system and improved public health oriented towards the community. Advocacy and communication EPHO 9 Health promotion EPHO 4 Health protection EPHO 3 Disease prevention EPHO 5 Research, evidence base and evaluation EPHO 10 Workforce EPHO 7 Structure and resources EPHO 8 Public health information and assessment EPHO 1 & 2 Planning and public health law EPHO 6 EPHO: essential public health operation 38 Box 5. Building policies on evidence - public health self-assessment as the basis for the public health action plan 2020 The public health self-assessment process was initiated as part of the biennial collaborative agreement between the Ministry of Health and WHO for 2014–2015, in a workshop held in Ohrid on 25−27 August 2014. The workshop served to open dialogue on the current situation and pros- pects of public health in the country in accordance with Health 2020 and the development of a new vision and strategy for public health in the country as part of the National Health 2020 Strategy. The assessment was based on the WHO essential public health operations tool for self-assess- ment and involved policy-makers, experts and practitioners from health and other sectors, who assessed the current situation through specifi c essential public health operations and provided recommendations for improvement (Fig. 33). Overall, the assessment showed that the health system is still very much oriented towards clinical services, and only to some extent towards primary prevention; further focus and attention was identifi ed as needed in primary, secondary and tertiary prevention. Regarding data, although da- tabases exist, they are not interconnected, and more eff ort needs to be put into harmonizing data and establishing registries. Further, the self-assessment found that governance and funding can sometimes be an issue and that more eff ort is needed in public health information and research. The country has developed an e-tool for assessing essential public health operations, translated and adapted to the national context, the fi rst of its kind in the WHO European Region. Fig. 33. Results of the self-assessment of essential public health operations, 2014 EPHO 1 4.6 EPHO 2 4.9 EPHO 3 5.6 EPHO 4 4.5 EPHO 5 5.4 EPHO 6 4.7 EPHO 7 3.3 EPHO 8 3 EPHO 9 1.9 EPHO 10 2.7 0 1 2 3 4 5 6 EPHO: essential public health operation Source: Report on the self-assessment of essential public health operations (EPHOs) on national level (39). 39 Developing the National Health 2020 Strategy in North Macedonia Priority area 2: health and environment The government has recognized environmental determinants of health, and its high-level political support is embodied in the Government Committee for Health and Environment, whose membership comprises health and all key ministers, including environment, fi nance, economy, education, social protection and others. With this support and the active engage- ment of the expert community, based on a comprehensive situation analysis and discus- sions, an action plan for health and environment was developed, with the strategic objective of improving health through action at all levels of the health system and beyond, including assessing and managing health and environmental risks and acting on them through inter- sectoral action to improve and protect the health of the population by creating and main- taining a healthy environment. The strategic goals of the action plan envisage, among other things, strengthening the intersectoral approach in health and environment, establishing an effi cient model for identifying and addressing environmental risks and adverse eff ects on health and well-being, bearing in mind cost-effi ciency and cost-utility, across all sectors and at all levels. The action plan is broadly based, covering a wide range of topics related to environment and health (Fig. 34 and Box 6). Fig. 34. Vision and strategic goals of priority area 2: health and environment Priority area: Health and environment VISION ...our strategic objective is to improve health through action at all levels of the health-care system and far beyond it, including assessing and managing health and environmental risks using an orga- nized, strategic and intersectoral approach with specified activities and measures from the wide area of environ- ment and health to 2020 to improve and protect the health of the population by creating and maintaining a healthy environment. GOALS 1. Strengthening the capacities for creating and conducting policies in the fields of environment and health, with an emphasized intersectoral approach 2. Introducing an efficient model of identifying the environmen- tal pressures and preventing and/or reducing their adverse effects on the health and well-being of the population in general, particularly on certain vulnerable groups 3. Defining and conducting cost-efficient intersectoral actions aimed at all levels of the environmental and health pressures of the population Thematic areas Air and indoor air quality Water, water supply and sanitation Safe food and nutrition Waste Soil, chemicals and industrial hot-spots Climate change Other important chemical and physical hazards (asbestos, noise) 40 Box 6. Data on health and environment triggering the development of the action plan for health and environment According to WHO estimates, the environmental burden of disease in the country is 3370 annual deaths attributable to environmental causes, or 166 per 100 000 population (40). In 2010, in the capital city of Skopje alone, an estimated 110 deaths (of 4602 total, excluding violent deaths) directly resulted from increased concentrations of particulate matter (PM10: particulate matter with an aerodynamic diameter of less than 10 μm). In the same year, of 8630 people hospitalized for respiratory disease, 420 suff ered illness resulting from increased air pollution by PM10 (1). A recent study in Skopje found that an increase in PM10 by 10 μg/m 3 above the daily maximum permitted level (50 μg/m3) was associated with a 12% increase in the incidence of cardiovascular diseases. In 2011, particulate matter air pollution cost the economy €253 million (3.2% of gross domestic product (GDP)) in lost earnings from premature mortality and lost productivity at work or absenteeism. Complying with the European Union standards (by implementing the air-related en- vironmental acquis communautaire) and reducing PM10 and PM2.5 to the European Union limit would avoid more than 800 deaths and thousands of days in lost productivity and result in €151 million in health savings per year. Even a 1 μg/m3 decrease in the ambient concentration of PM10 and PM2.5 would result in potential health savings of €34 million (0.4% of GDP) annually. The cost of the in- terventions required for European Union compliance could be justifi ed through these savings (41). Such alarming data triggered the process of developing the action plan as part of the Nation- al Health 2020 Strategy. This development directly evolved from the country’s active role in WHO’s European Environment and Health Process. As a result, the national environment and health process has progressed strongly, with the expert community at its centre driving it for- ward, pushing for changes, bridging sectors and informing the public of the evidence and related action to remedy the situation. Source: [Strategic framework and action plan for health and the environment by 2030] (42). Priority area 3: noncommunicable diseases and risk factors Although the country avoided the mortality crisis many central and eastern European coun- tries experienced in the early 1990s, the overall picture remains of improvements achieved but still much to do. This especially pertains to noncommunicable diseases and the associat- ed risk factors, which were recognized as a key pillar of the National Health 2020 Strategy. The vision of the action plan for noncommunicable diseases towards 2025 (“reduce the bur- den of noncommunicable diseases to reduce their negative infl uence on socioeconomic de- velopment in the country, and the population in North Macedonia will achieve higher stan- dards of health and productivity at any age”) shows the commitment of the government and professional community to upstream action to tackle the burden of noncommunicable diseases and, through such action, to contribute to the social and economic development of the country. This vision will be achieved through four areas of work: (1) managing non- communicable diseases by building partnerships and networks and encouraging citizen in- volvement; (2) promoting health and preventing disease; (3) transforming health services in preventing and controlling chronic diseases; and (4) strengthening surveillance, monitoring and evaluation and research activities (Fig. 35 and Box 7). Alongside the action plan for noncommunicable diseases towards 2025, an action plan for food and nutrition towards 2025 was developed, widening the scope and outreach of action related to some of the risk factors associated with noncommunicable diseases. 41 Developing the National Health 2020 Strategy in North Macedonia Fig. 35. Vision and strategic goals of priority area 3: noncommunicable diseases and risk factors Priority area: Noncommunicable diseases Managing noncommunicable diseases through building partnerships and networks and encouraging citizen involvement Transforming health services to prevent and control chronic diseases Strengthening surveillance, monitoring and evaluation and research activities Promoting health and preventing disease Reduce the burden of noncommunicable diseases to reduce their negative influence on the socioeconomic development in the country, and the population in the country will achieve higher standards of health and productivity at any age. VISION Box 7. Assessment of the health system to respond to noncommunicable diseases as basis for developing the national action plan for noncommunicable diseases towards 2025 The leading causes of death in the country are cardiovascular diseases and cancer, which in 2014 together accounted for 76% of all causes of death, a large increase compared with 1991 (65%). The standardized mortality rate from cardiovascular diseases has increased from 360 per 100 000 population in 1991 to 546 per 100 000 in 2014. Although premature mortality is decreasing with the increase in life expectancy, regional variation exists and is very high (Fig. 36). Slightly more than 50% of deaths in the worst-performing region are premature versus 8% in the best-performing region. The variation within Skopje is also striking: from 50% to 18%. The highest percentage of premature mortality is registered in the municipality that is home to people with the lowest socio- economic status, a very low educational level and poor access to health-care services. Based on these fi gures and the commitment of the country to address the overall burden of dis- ease associated with increased health expenditure and aff ecting economic development, in 2015 the Ministry of Health requested technical assistance from WHO to assess the health system’s response to major noncommunicable diseases (43). Following the assessment, with technical support from WHO, the policy dialogue for developing an action plan for noncommunicable diseases and their risk factors was initiated. By the end of 2016, the draft action plan had been developed, together with an associated action plan for food and nutrition to 2025. Both documents are in the process of being adopted. Fig. 36. Percentage of premature deaths (<65 years old) by region, 2012 Source: Better noncommunicable disease outcomes: challenges and opportunities for health systems. The former Yugoslav Republic of Macedonia country assessment (43). 42 Priority area 4: communicable diseases and emergency preparedness, surveillance and response Although the largest share of the burden of ill health is attributable to noncommunicable diseases, communicable diseases continue to play a role in modern societies, especially with the intensive societal and economic movement of goods and people and emerging and re-emerging threats to health. Together with preparedness and response, communicable diseases are considered an important pillar of the National Health 2020 Strategy (Fig. 37 and Boxes 8 and 9). Fig. 37. Strategic goals and pillars of priority area 4: communicable diseases and preparedness Priority area: Communicable diseases and preparedness and response Immunization and vaccine-preventable diseases International Health Regulations (2005) Emergency preparedness and response Antimicrobial resistance Improve levels of immunization and reduce the occurrence of vaccine-preventable diseases Reduce the burden of waterborne HIV and sexually infectious diseases Strengthen the monitoring, control and response system for hospital- acquired infections and antimicrobial resistance Maintain low prevalence of HIV, sexually transmitted infections Reduce the burden of zoonoses and vector-borne infections Maintain surveillance of emerging and re-emerging communicable diseases Prepare the health system for rapid response in emergencies STRATEGIC GOALS 43 Developing the National Health 2020 Strategy in North Macedonia Box 8. Action-oriented approach in communicable diseases and emergency preparedness and response In conditions of global environmental change, an increase in the number of disasters caused by weather conditions, such as fl oods, storms and extreme temperatures (Fig. 38) and an increase in the threat of pandemic infl uenza and other communicable diseases have highlighted the need for developing and adopting a preparedness and response action plan for the health system for emergencies, crisis situations and disasters. The plan should enable rapid, timely and complete action of the health system and all other entities according to the emergency, crisis situation and/or disaster. Fig. 28. Number of people aff ected by disasters in the country in 2001-2015, by type of disaster Sources: [Action plan for the health system’s preparedness and response to emergency, crisis and disas- ter situations] (44) and Making things happen 2014−2015. Implementing the European policy framework for health and well-being Health 2020 in the former Yugoslav Republic of Macedonia (45). Preparedness of the health system to respond to emergencies is seen as vital to an organized and well defi ned approach to health threats and challenges. With WHO technical support, sever- al technical group meetings and workshops were held and three emergency exercises organized. Based on the outcomes, the action plan for the health system’s preparedness and response in emergencies was developed in 2016 and adopted in February 2017. 44 Box 9. Long-term partnership on antimicrobial resistance and rational use of antibiotics Resistance to antibiotics is a growing global problem for public health. In the WHO European Re- gion, the resistance of some pathogens now exceeds 50% in some countries, and new resistance mechanisms are emerging and spreading rapidly. Measures including good hygiene, rational use of antibiotics, surveillance and vaccination and awareness-raising are currently among the most eff ective ways to prevent infections associated with health care. At the national level, joint ef- forts have been in place since 2008, with the establishment of the European Antibiotic Aware- ness Day and the World Antibiotic Awareness Week. National campaigns and education events for professionals, students and the general public have been organized jointly by the Ministry of Health, the Institute of Public Health, the Medical Faculty in Skopje and Studiorum with WHO technical support (Fig. 39). Fig. 39. Awareness-raising activities on antimicrobial resistance and rational antibiotic use, annual average, 2008–2014 Promotional materials distributed (pieces) Professionals targeted (number) Media coverage (articles) Media coverage (hits) Anticipated population reached (number) Number 0 1000 2000 3000 Guidelines distributed (pieces) Source: Making things happen 2014–2015. Implementing the European policy framework for health and well-being Health 2020 in the former Yugoslav Republic of Macedonia (45). Priority area 5: strengthening a people-centred health system and resources The health system is based on values of solidarity, equity and the participation of all citi- zens in the country. However, similar to other countries, issues of access, equity and quality remain challenges. Recognized as one of the most important pillars, the health system and resources is a comprehensive area that scopes activities related to other pillars, especially human resources, infrastructure and equipment (Fig. 40 and Box 10). 45 Developing the National Health 2020 Strategy in North Macedonia Box 10. Health system and resources The Ministry of Health’s 2011 initiative, My Appointment, includes e-health records for all visiting patients, and its objective is to incorporate all health data, including national registries of diseas- es. My Appointment is opening the pathway to a better integrated and coherent health infor- mation system (Fig. 41). WHO provided technical support to assess the situation and technical guidance to fully integrate the national health information system, ensuring the sustainability, comprehensiveness and comparability of the initiative, while bearing in mind the usefulness of the data at both the individual and population levels. Looking forward, the focus is on developing evidence-informed policies to improve health system planning and management as well as dis- ease prevention, early detection and health promotion. Fig. 41. New media used in real-time monitoring of health system performance: structure and operation of the electronic health platform My Appointment Patient Online booking portal Diagnostic radiology referral General practitioner Specialist referral Hospital stay Treatment plan Diagnostic instruments Prescriptions Specialist Specialist gfindin s Radiology report and images Treatment completed Electronic record management Source: Milevska Kostova et al. (11). 46 Fig. 40. Strategic goals and elements of priority area 5: health system and resources Priority area: Health system and resources Strengthening capacities for gover- nance and management of the health system Introducing and promoting compre- hensive health information system at all levels of health care Establishing a sustainable financial system Improving the capacities of the health system (space, equipment and staff) through ensuring equity of access based on diverse regional needs Ensuring that effective and high-quali- ty health services are available to every citizen Creating and maintaining necessary human resources for health with the right skills and capacity at the right place at the right time STRATEGIC GOALS Governance Organization and management Human resources Service delivery Access to medicines Patients' rights Conclusion Strategizing and designing plans and policies to achieve a particular goal related to the health of a country are absolutely critical in the 21st century. The National Health 2020 Strategy of North Macedonia exemplifi es how national poli- cy-making could eff ectively respond to both the health needs of the population in the coun- try and the country’s international commitments. It was guided by and used Health 2020 evidence, in addition to both generating and using national evidence, to feed the policy dia- logue process and identify the challenges. The National Health 2020 Strategy as an overar- ching health policy has served as a tool to provide coherence among health and health-re- lated policies, strategies and plans at diff erent levels of governance and across sectors. Eff ectively generating and using knowledge on health and well-being in the policy-making process requires appropriate mechanisms for dialogue and coordination within and across levels of government and across the public and private spheres. The National Health 2020 Strategy policy process was carefully crafted to include everyone and make health every- body’s business, and it was worth the investment: it legitimized the policy, it made the case for its enactment and it serves as the best guarantee of its implementation. The National Health 2020 Strategy process was a great capacity-building, learning and sharing exercise for the professional community in health and other sectors and for the citizens and their local communities. Its innovative features supported democracy for health, health literacy, health promotion and activities to build community resilience. 47 Developing the National Health 2020 Strategy in North Macedonia The public health professional community played an instrumental and multifaceted role, being the driving force of the process. Public health professionals acted as policy entre- preneurs, supporting innovative approaches, engaging in policy analysis and promoting evi- dence-informed and outcome-oriented interventions. The equity dimension was considered throughout the process, through gender and human rights perspectives, considering the necessity of intersectoral collaboration to address this societal goal. The Sustainable Development Goals were devolved across all the National Health 2020 Strategy areas of work. The respective monitoring and evaluation frameworks were de- signed to respond to the national priority-setting framework for delivering on commitments to Health 2020 and the 2030 Agenda with its Sustainable Development Goals. WHO had an essential role in supporting the development of the national health policy. It used various avenues of action: strategic planning and deliberate implementation of the ac- tion at the country level, convening stakeholders, maintaining continual intersectoral policy dialogue, capacity-building, generating and sharing evidence and promoting outcome-ori- ented health policies. The WHO Country Offi ce acted as a change agent in society through its proactive support to the national eff orts while bringing aboard international technical experience and expertise. Implementation of the National Health 2020 Strategy remains a challenge in many ways. Further eff orts should be invested in providing consistency of policy planning at the central and local levels and maintaining and improving governance mechanisms to maintain inte- gration and coherence across levels and sectors. 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Developing, implemenƟ ng and evaluaƟ ng naƟ onal and subnaƟ onal health policies drawing on the contribuƟ on of various sectors Health policies focus on the pursuit of specifi c and measurable health gain, especially the increase of healthy life-years and the ability to live independently with chronic disease. Con- cern about health is a key policy priority at all levels of governance, requiring an eff ective and integrated health system serving public health needs and focusing on primary health care. Achieving these goals involves preparing a comprehensive plan for developing health and well-being, including developing and strengthening health services. Related to this is the aim of strengthening intersectoral approaches. Such planning instruments must transcend delivering only health care and address the broad agenda of improving health and the social determinants of health, as well as the in- teraction between the health sector and other sectors of society. A national health strategy – which can take many diff erent forms – can provide an inspirational overarching or “um- brella” policy, involving a comprehensive range of stakeholders and sectors and focusing on improving population health. Such a strategy can support shared values, foster synergy and promote transparency and accountability. For low- and medium-income countries, the process of developing health policies, strategies and plans can also assist donors in health planning work and contribute to eff ective donor coordination. The process should be in- formed by a comprehensive health needs assessment that is sensitive to age, gender, social position and condition. Research and other intelligence shows that many policies and services, despite having an established evidence base (such as reducing salt and saturated fat in diets, increasing tax- es on tobacco, detecting and managing hypertension, managing stroke by multidisciplinary teams, and actively managing the third stage of labour), do not reach populations in need. There are many reasons for a failure to apply evidence to policy and practice. Some are tech- nical and arise from the type and nature of the evidence collected; some are organizational and occur when partnerships or cross-sector working is weak; others are political and arise because what the evidence says is not welcomed by those charged with setting priorities and making investment decisions. Response to interventions also depends upon individuals being empowered to sustain the potential benefi ts. Of course, evidence is rarely the only or even the principal factor governing how decisions are made. Values and other infl uences are also important. Nevertheless, there remains scope to scale up the delivery of core cost-eff ective services and free up resources, but this means ef- forts must be made to expand evidence-informed interventions aimed at those with greater needs and reduce the delivery of inappropriate care or public health interventions of limited utility. For such an approach to succeed, researchers, policy-makers and practitioners need to work in new and diff erent ways, centred on the co-production of knowledge and evidence that truly meets their respective needs. In addition to necessary, and often new, funds, a commitment to address the ineffi cient use of resources in the health sector is vital to secure popular and political support for more 53 Developing the National Health 2020 Strategy in North Macedonia spending. Effi ciency gains need to be a central part of health plans and strategies rath- er than a short-term response to budget cuts, because the transition to a new, lower-cost delivery system needs to be carefully managed and may require investment in the short term. The goal is to achieve sustainable effi ciency gains, such as improving energy effi cien- cy, shifting more care to outpatient settings, allocating more resources to primary health care and cost-eff ective public health programmes, cutting the least cost-eff ective services, and improving the rational use of medicines. The performance of often fragmented health systems may be mismatched with the rising expectations of societies and citizens. People expect greater participation, empowerment, fairness and respect for human rights in health system delivery. The expectation is for in- creased domestic expenditure on health, but resources are always limited. Strengthening health systems and health system governance are crucial for meeting these expectations. Health ministers and health ministries, and other national authorities, need help and support in improving health system performance and in increasing accountability and transparency. Health policy is usually developed through diverse approaches and levels and with diff ering aims. Mechanistic approaches are not suffi cient and in any case have been found wanting. More fl exible and integrative approaches are required, which are able to respond rapidly to changing circumstances and to sound evidence of what works well and not so well. Compre- hensive development of health strategy is inherently a highly political process, and this has to be acknowledged at every stage. Political and legal commitments are of crucial importance for ensuring long-term sustain- ability. Flexibility is needed to adapt to unexpected developments in the political, economic and health environment. The value largely lies in the process. Such strategies are more likely to be implemented if they are made and “owned” by the people who will implement them and if they are aligned with capacity, resources and constraints. The instruments must chart realistic ways of developing capacity and resources by mobilizing partners and stakeholders, who may have competing interests. Source: Health 2020: a European policy framework and strategy for the 21st century (1). 54 Annex 2. List of naƟ onal health and health-related strategies and plans (available in Macedonian or English or both) scoped for the NaƟ onal Health 2020 Strategy Title Period Sector 1 Strategy for demographic development 2008−2015 Development and growth 2 Action plan on prevention and dealing with sexual abuse of children and paedophilia 2009−2012 Social protection 3 Cooperation protocol between competent authorities in cases of sexual abuse of children and paedophilia NA Social protection 4 Action plan on street children 2013−2015 Cross-sectoral (vulnerable groups) 5 Multidisciplinary treatment protocol of street children February 2010 Cross-sectoral (vulnerable groups) 6 National programme for social protection development 2011−2021 Social protection 7 National strategy for deinstitutionalization of the social protection system 2008−2018 Social protection 8 National strategy for prevention and protection from domestic violence 2012−2015 Social protection 9 Programme for addressing social exclusion issues 2004 Cross-sectoral (vulnerable groups) 10 National strategy for equal rights of people with disabilities (revised) 2010−2018 Cross-sectoral (vulnerable groups) 11 National strategy for reduction of poverty and social exclusion (revised) 2010−2020 Social protection 12 Strategy for integration of refugees and foreigners 2008−2015 Cross-sectoral (vulnerable groups) 13 National strategy for older people 2010−2020 Cross-sectoral (vulnerable groups) 14 National security programme NA Security 15 National strategy for waters 2011−2041 Environment 16 National platform for disaster risk reduction (third revised edition) 2015 Environment 17 National strategy for rescue and protection 2009−2013 Cross-sectoral 18 General plan for crisis management in the area of food safety and animal food safety 2013−2018 Agriculture (food and nutrition) 19 National transport strategy 2007−2017 Transport 20 Housing strategy 2007−2012 Housing 21 National strategy for promotion of road safety 2009−2014 Transport 55 Developing the National Health 2020 Strategy in North Macedonia Title Period Sector 22 Cold-health action plan for prevention of health consequences for the population 2012 Health 23 Heat-health action plan for prevention of health consequences for the population 2011 Health 24 Action plan 2013–2014 for implementation of the strategy on safety and health at work (2011-2015) 2013−2014 Health 25 National strategy for prevention of oral diseases in children from 0 to 14 years 2008−2018 Health 26 National HIV/AIDS strategy 2012−2016 Health 27 Adaptation strategy of health sector to climate change with action plan 2011−2015 Health 28 Strategy for safety and health at work (2011-2015) with action plan 2011-2012 2011−2015 Health 29 Immunization strategy 2012-2020 with action plan 2012-2015 2012−2020 Health 30 Safe motherhood strategy with action plan 2010−2015 Health 31 Action plan for the safe motherhood strategy 2010−2013 Health 32 Action plan on reduction of maternal, perinatal and infant mortality 2013−2014 Health 33 National strategy for prevention and control of noncommunicable diseases 2009 Health 34 Sexual and reproductive health strategy with action plan 2020 Health 35 Tuberculosis control strategy with action plan 2013−2017 Health 36 Action plan on tuberculosis 2013−2017 Health 37 National strategy for antimicrobial resistance control 2012−2016 Health 38 Second action plan for food and nutrition 2009−2014 Agriculture 39 Communication strategy and action plan on climate change 2013 Environment 40 National action plan for strategic management of chemicals 2020 Environment 41 National strategy for sustainable development 2009−2030 Development and growth 42 Draft national strategy for sustainable development Part II: Strategy basis and analysis 2009−2030 Development and growth 43 2014 environmental investments programme 2014 Environment 44 National strategy for environmental investments 2009−2013 Environment 45 Draft strategy for waste management 2008−2020 Environment 46 Strategy for environmental data management (technical report) NA Environment 47 Environmental monitoring strategy (technical report) NA Environment 48 National strategy for agriculture and rural development 2007−2013 Agriculture 56 Title Period Sector 49 Strategy for regional development 2009−2019 Development and growth 50 Work programme of the government 2011−2015 Governance 51 Health care law 2013 Health 52 Development strategy 2013 Development and growth 53 Strategy for Roma integration 2004 Cross-sectoral (vulnerable groups/minorities) 54 The former Yugoslav Republic of Macedonia - European Commission 2013 progress report 2013 Human rights 55 National health strategy 2020 - safe, effi cient and just health-care system 2007 Health 56 Offi cial development assistance for health (country profi le) 2001−2011 Health 57 Fact sheet on reproductive health at national level 2012 Health 58 Health equity and fi nancial protection datasheet for national level 2012 Health 59 National drugs strategy 2006−2012 Health 60 Health care programme for people with addictions in the country in 2013 2013 Health 61 Country overview: health 2013 Health 62 Harm reduction at national level – report NA Health 63 Macedonia HIV/AIDS national strategy 2007−2011 Health 64 Law on narcotic drugs and psychotropic substances 2008 Health 65 Local drug strategy of the city of Skopje 2008−2013 Health 66 National background report on health for North Macedonia 2009 Health 67 Gender equality strategy 2013−2020 Cross-sectoral 68 Strategic framework for promoting energy effi ciency by 2020 2012 Economy 69 Strategy for energy development by 2030 2008−2020 Economy 70 Strategy for the use of renewable energy sources by 2020 2020 Economy 71 National strategy for development of electronic communications and information technologies 2007−2010 Communications 72 Interim strategy for universal service 2006 Communications 73 Strategy for the development of postal services 2007−2010 Communications 74 National strategy for cultural development 2013−2017 Culture 75 National strategy for integration of the country into NATO 2004 EU integration 76 Defence strategy 2015 Defence 77 Strategy for geological research, sustainable use and exploitation of mineral resources for the period 2010-2030 2010−2030 Economy 57 Developing the National Health 2020 Strategy in North Macedonia Title Period Sector 78 Draft strategy on phytosanitary policy 2016−2020 Agriculture 79 Law on medicinal products and medical devices 2007 Health 80 Law on changing and amending the law on medicinal products and medical devices 2010 Health 81 Law on amendments and modifi cations to the law on medicines and medical devices (1) 2011 Health 82 Law on amendments and modifi cations to the law on medicines and medical devices (2) 2011 Health 83 Law on amendments to the law on medicines and medical devices 2011 Health 84 Law on amendments and modifi cations to the law on medicines and medical devices 2012 Health 85 Law on amendments and modifi cations to the law on medicines and medical devices (1) 2013 Health 86 Law on amendments and modifi cations to the law on medicines and medical devices (2) 2013 Health 87 Law on amendments and modifi cations to the law on medicines and medical devices (1) 2014 Health 88 Law on amendments and modifi cations to the law on medicines and medical devices (2) 2014 Health 89 Ordinance declaring the law on precursors 2004 Health 90 Ordinance declaring the law on amendments and modifi cations to the law on precursors 2007 Health 91 Ordinance declaring the law on amendments to the law on precursors 2011 Health 92 Law on amendments to the law on narcotic drugs and psychotropic substances 2010 Health 93 Law on modifi cations to the law on narcotic drugs and psychotropic substances 2013 Health 94 Plan of activities for implementing the national drugs strategy 2014−2020 Health 95 The former Yugoslav Republic of Macedonia - European Commission 2014 progress report 2014 Human rights 96 Operational programme for regional development 2007−2009 Development and growth 97 Programme for social protection 2014 Social protection 98 Programme for child protection 2014 Social protection 99 National strategy to reduce poverty and social exclusion 2010-2020 2010−2020 Social protection 100 Conditional allowance programme for secondary education for the academic year 2014/2015 2014 Social protection 101 Subsidies programme for energy consumption for 2014 2014 Social protection 102 Application for energy consumption subvention 2014 Social protection 103 On the road to the European Union: the contribution of civil society to creating a social inclusion policy NA Social protection 58 Title Period Sector 104 The SEE 2020 strategy 2013 Economy 105 Strategy for the industrial policy 2009 Economy 106 Programme for consumer protection for the period 2013-2014 2013−2014 Economy 107 Programme for development of entrepreneurship, competitiveness and innovation of small- to medium-sized enterprises in 2012 2012 Economy 108 Programme for competitiveness, innovations and entrepreneurship for 2014 2014 Economy 109 Programme for competitiveness, innovations and entrepreneurship for 2013 2013 Economy 110 Strategic plan of the Health Insurance Fund for the period 2010-2015 2010−2015 Finance 111 Working programme of the Health Insurance Fund for 2014 2014 Finance 112 Strategic plan of the Ministry of Justice for the period 2014-2016 2013 Judiciary 113 National strategy for information society development with an action plan 2005 Communications 114 National action plan for the strategy for integration of refugees and foreigners, part 1 2009 Cross-sectoral 115 National action plan for the strategy for integration of refugees and foreigners, part 2 2009 Cross-sectoral 116 National action plan for gender equality 2013−2016 Cross-sectoral 117 Operational implementation plan for the gender equality strategy 2013 Cross-sectoral 118 National action plan for gender equality 2007 Cross-sectoral 119 Operational implementation plan of the national plan for gender equity 2012 Cross-sectoral 120 National strategy for equality and non-discrimination 2012−2015 Cross-sectoral 121 Operational implementation plan of the national strategy for equality and non-discrimination 2013 Cross-sectoral 122 National strategy and action plan to combat human traffi cking 2013−2016 Cross-sectoral 123 National action plan for the implementation of United Nations Security Council Resolution 1325 2012 Cross-sectoral 124 Operational plan of the national action plan for the implementation of United Nations Security Council Resolution 1325 2013 Cross-sectoral 125 Action plan for United Nations Security Council Resolution 1325: strategic objective 1 2013−2015 Cross-sectoral 126 Action plan for United Nations Security Council Resolution 1325: strategic objective 2 2013−2015 Cross-sectoral 127 Action plan for United Nations Security Council Resolution 1325: strategic objective 3 2013−2015 Cross-sectoral 59 Developing the National Health 2020 Strategy in North Macedonia Title Period Sector 128 Strategy for introducing gender-responsive budgeting 2012 Cross-sectoral 129 Methodology for gender-responsive budgeting for the state administrative organs at central level 2014 Cross-sectoral 130 Concept of vocational education 2010 Education 131 Concept of vocational training 2010 Education 132 Concept of post-secondary education 2010 Education 133 National education development programme 2005 Education 134 Strategy for adult education 2010 Education 135 Strategy for youth 2005 Education 136 National strategy for development of aviation for the period 2013-2018 2013−2018 Transport 137 National action plan for employment 2014−2015 Labour and employment 138 National employment strategy 2015 Labour and employment 139 Action plan for youth employment 2015 Labour and employment 140 Action plan for youth employment - progress review 2015 Labour and employment 141 Operational plan for active programmes and measures for employment for 2014 2014 Labour and employment 142 Operational plan for amending and modifying the operational plan for active programmes and measures for employment for 2014 (July 2014) 2014 Labour and employment 143 Operational plan for amending and modifying the Operational plan for active programmes and measures for employment for 2014 (June 2014) 2014 Labour and employment 144 Guidelines for transparency of the implementation of the Operational plan for active programmes and measures for employment for 2012-2013 2012−2013 Labour and employment 145 Calendar of active policies and measures for employment for 2014 2014 Labour and employment 146 Operational guidelines for the community service programme for 2014 2014 Labour and employment 147 Subvention programme for unemployed persons and social security benefi ciaries 2013 Labour and employment 148 Strategy for volunteerism promotion and development with an action plan 2010−2015 Labour and employment 149 Action plan to reduce the informal economy for 2014 2014 Labour and employment 150 Law on the protection of patients’ rights 2008 Health 151 Brochure with information and tips for new parents 2014 Health 152 Environment statistics 2013 Environment 153 Environment statistics 2011 Environment 154 Environment statistics 2009 Environment 60 Title Period Sector 155 Environment statistics 2007 Environment 156 5th national report to the Convention on biological Diversity 2014 Environment 157 Annual report on environmental quality data 2013 Environment 158 Annual report on environmental quality data 2012 Environment 159 Annual report on environmental quality data 2011 Environment 160 Annual report on environmental quality data 2010 Environment 161 Annual report on environmental quality data 2009 Environment 162 Annual report on environmental quality data 2008 Environment 163 Annual report on environmental quality data 2007 Environment 164 Annual report on environmental quality data 2006 Environment 165 Annual report on environmental quality data 2005 Environment 166 Annual report on environmental quality data 2004 Environment 167 Annual report on environmental quality data 2003 Environment 168 Fourth and fi fth periodic report of the country to the United Nations Convention on the Elimination of All Forms of Discrimination against Women 2011 Cross-sectoral 169 Initial and second periodic report of the country to the United Nations Convention on the elimination of all forms of discrimination against women 2003 Cross-sectoral 170 Analysis and evaluation of budget process and budget policy reforms in terms of gender equality 2013 Cross-sectoral 171 Analysis of juvenile delinquency situation in 2013 2014 Cross-sectoral 172 Analysis of relevant regulation to overcome unequal treatment and access of Roma women to the services of national institutions 2009 Cross-sectoral 173 Analysis of capacities and conditions of nongovernmental organizations working against human traffi cking 2007 Cross-sectoral 174 Analysis of the current situation and reduction of dropouts of Roma children from the educational process 2010 Cross-sectoral 175 Gender analysis in primary and secondary education 2009 Cross-sectoral 176 Report on the situation and activities undertaken regarding domestic violence in the fi rst half of 2009 2009 Cross-sectoral 177 Manual for protection against discrimination 2010 Cross-sectoral 178 Manual for gender budgeting in the public administration 2013 Cross-sectoral 179 Annual report on the implementation of the law on free legal aid 2014 Judiciary 180 GRECO (Group of States against Corruption) compliance report - fi rst round 2004 Judiciary 61 Developing the National Health 2020 Strategy in North Macedonia Title Period Sector 181 GRECO compliance report - second round 2007 Judiciary 182 Second GRECO compliance report - third round of evaluation 2014 Judiciary 183 Annex to the GRECO compliance report - fi rst round 2002 Judiciary 184 GRECO evaluation report - fi rst round 2010 Judiciary 185 GRECO evaluation report - second round 2007 Judiciary 186 GRECO evaluation report - third round 2010 Judiciary 187 GRECO evaluation report - fourth round 2014 Judiciary 188 GRECO compliance report - incriminations and transparency of party funding 2012 Judiciary 189 GRECO compliance report - incriminations 2010 Judiciary 190 Report on the work of the Ministry of Transport and Communications in 2013 2014 Transport 191 Report on the work of the Ministry of Transport and Communications in 2012 2013 Transport 192 Report on the work of the Ministry of Transport and Communications in 2011 2012 Transport 193 Report on the work of the Ministry of Transport and Communications in the period 2007-2010 2010 Transport 194 National plan for protection of ambient air quality in the period 2013-2018 2012 Environment 195 National programme for emission reduction 2012 Environment 196 Management plan for waste electrical and electronic equipment in the period 2013-2020 2011 Environment 197 Draft plan for waste management (2009-2015) 2008 Environment 198 Third national plan on climate change 2013 Environment 62 Annex 3. List of naƟ onal strategies, policies and plans (available in Macedonian) scoped by the operaƟ onal plan by priority area Public health 1. Law on health records (Offi cial Gazette no. 20/09, 53/11, 164/13) 2. Law on public health (Offi cial Gazette no. 22/10, 136/11, 164/13) 3. Law on protection of patients’ rights (Offi cial Gazette no. 82/08, 12/09, 53/11, 150/15) 4. Public health programme (annual programme) 5. Strategic assessment of the policy, quality and access to contraception and abor- tion at the national level in 2008 6. Second national road safety strategy 2015−2020 7. National transport strategy 2007−2017 8. Law on road traffi c safety (Offi cial Gazette no. 54/07, 86/08, 98/08, 64/09, 161/09, 36/11, 51/11, 27/14, 169/15) 9. Law on prevention and protection from domestic violence (Offi cial Gazette no. 138/14, 33/15) 10. National strategy for prevention and protection from domestic violence 2012−2015 11. Law on termination of pregnancy (Offi cial Gazette no. 87/13, 164/13, 144/14, 149/15) 12. Law on sanitary and health inspection (Offi cial Gazette no. 71/06, 139/08, 88/10, 53/11, 164/13, 43/14, 144/14, 51/15, 150/15) 13. Programme for compulsory immunization of the population (annual programme) 14. Proactive protection of mothers and children (annual programme) 15. Programme to protect the population from HIV/AIDS (annual programme) 16. Programme for systematic examination of students (annual programme) 17. Programme Health for All (annual programme) 18. Strategy for safe motherhood action plan 2010−2015 19. Action plan for reducing maternal, perinatal and infant mortality (2013−2014) 20. National strategy for HIV/AIDS 2007−2011 21. National strategy on HIV/AIDS 2012−2016 and action plan 22. Strategy on sexual and reproductive health 2020 with action plan to 2013 23. Brochure with information and advice for new parents (2014) 24. Strategy for immunization 2012−2020 with action plan 2012−2015 25. Strategy for safety and health at work (2011−2015) with action plan 2011−2012; action plan 2013−2015; and action plan 2015 63 Developing the National Health 2020 Strategy in North Macedonia 26. Strategy for safety and health at work with action plan to 2020 (in the fi nal phase - a new strategy) 27. Strategy on sexual and reproductive health by 2020, with action plan 2018−2020 (draft) 28. National strategy for demographic development 2015−2024 29. Action plan for the national youth strategy 2016−2017 30. Standard operating procedures for responding to nutrition for infants and young children in crisis situations (in transit migrant centres) 2017 31. Action plan for public health to 2020 32. Campaign for European Immunization Week 33. World Breastfeeding Week Campaign 34. Gender equality strategy 2013−2020 Health and environment 1. Strategic framework and action plan for health and environment to 2030 2. Strategy for occupational safety and health with action plan to 2020 3. Action plan for public health to 2020 4. National strategy for sustainable development 2009−2030 5. Strategy for regional development 2009−2019 6. National strategy for agriculture and rural development 2014−2020 7. Waste management strategy 2008−2020 8. Strategy for innovation 2012−2020 9. Strategic plan 2016−2018, Ministry of Environment and Physical Planning 1O. Strategic plan of the Ministry of Health for 2016−2018 11. Strategy for implementation of the Protocol on Pollutant Release and Transfer Registers (PRTR) 2016−2020 12. Strategy for utilization of renewable energy sources to 2020 13. Strategy for energy development to 2030 14. National water strategy (2012−2042) 15. Strategy for utilization of renewable energy sources to 2020 16. Strategy and action plan for protection of biological diversity (2004) (draft strategy on na- ture protection and the draft biodiversity strategy in the process of adoption) 17. Communication strategy and action plan on climate change 2013 18. Strategic plan of the Food and Veterinary Agency for the period 2017−2019 19. Strategy for improving and monitoring the quality of milk 2013−2020 20. Strategic environmental assessment for the third national plan to the United Nations Framework Convention on Climate Change 2014 21. Action plan for implementation of the programme for sustainable local development and decentralization 2015−2020, for the period 2015−2017 64 22. National environmental action plan 2 (2006−2011) 23. Local action plans for the environment 24. National action plan for the ratifi cation and implementation of the Protocol on Heavy Met- als, Protocol on Persistent Organic Pollutants (POPs) and Gothenburg Protocol to the Con- vention on Long-range Transboundary Air Pollution (2010) 25. National plan for air protection 2012−2017 26. Third national climate change plan (2013) 27. Third update of the national transport strategy 2007−2017 28. Plan for waste management of electrical and electronic equipment with feasibility study 2013−2020 29. National organic production plan 2013−2020 30. Third national climate change plan, 2014 31. Health care law (consolidated text Offi cial Gazette no. 61/15, 154/15, 192/15) 32. Law on health insurance (Offi cial Gazette no. 25/00, 34/00, 96/00, 50/01, 11/02, 31/03, 84/05, 37/06, 18/07, 36/07, 82/08, 98/08, 6/09, 67/09, 50/10, 156/10, 53/11, 26/12, 16/13, 91/13, 187/13, 43/14, 44/14, 97/14, 113/14, 120/14, 188/14, 20/15, 61/15, 98/15, 129/15, 154/15, 155/15, 192/15) and law on voluntary health insurance (Offi cial Gazette no. 145/12, 7/13, 192/15) 33. Law on public health (Offi cial Gazette no. 22/10, 136/11, 144/14, 149/15) 34. Law on records in the fi eld of health (Offi cial Gazette no. 20/09, 53/11, 164/13) 35. Law on protection of the population against infectious diseases (Offi cial Gazette no. 66/04, 139/08, 99/09, 149/14, 150/15) 36. Law on sanitary and health inspection (Offi cial Gazette no. 71/06, 139/08, 88/10, 18/11, 53/11, 164/13, 42/14, 144/14, 51/15, 150/15) 37. Law on environment (Offi cial Gazette no. 53/05, 81/05, 24/07, 159/08, 83/09, 48/10, 124/10, 51/11, 123/12, 93/13, 187/13, 42/14) 38. Law on chemicals (Offi cial Gazette no. 145/10, 53/11, 164/13, 116/15, 149/15) 39. Law on waste management (Offi cial Gazette no. 68/04, 71/04, 107/07, 102/08, 134/08, 09/11, 63/16, 156/15, 163/13, 147/13, 123/12) 40. Law on management of packaging and packaging waste (Offi cial Gazette no. 163/13, 6/12, 136/11, 47/11, 17/11, 161/09) 41. Law on management of electrical and electronic equipment and waste electrical and elec- tronic equipment (Offi cial Gazette no. 163/13, 6/12) 42. Law on ambient air quality with the by-laws (Offi cial Gazette no. 67/04, revised text no. 100/12) 43. Law on ratifi cation of the Protocol to the Convention on Long-Range Transboundary Air Pollution (control of the discharge of nitrogen oxides, sulfur, volatile organic pollutants, ground ozone, acidifying substances, etc.) (Offi cial Gazette no. 24/10) 44. Law on ratifi cation of the Protocol to the Convention on Long-Range Transboundary Air Pollution for Heavy Metals since 1979 (Offi cial Gazette no. 24/10) 45. Law on spatial and urban planning (Offi cial Gazette no. 199/14, 44/15, 193/15, 31/16) 46. Law on implementation of the spatial plan (Offi cial Gazette no. 39/04) 47. Law assessment (Offi cial Gazette no. 115/10, 158/11, 185/11, 64/12) 65 Developing the National Health 2020 Strategy in North Macedonia 48. Law on energy (Offi cial Gazette no. 16/11, 136/11, 79/13, 164/13, 41/14, 154/14, 33/15, 192/15, 215/15, 6/16, 63/16, 189/16) 49. Law on industrial green zones (Offi cial Gazette no. 119/13) 50. Law on agriculture and rural development (Offi cial Gazette no. 49/10, 53/11, 126/12, 15/13, 69/13) 51. Water Act (Offi cial Gazette no. 87/08, 6/09, 161/09, 83/10, 51/11, 44/12, 23/13, 163/13) 52. Law on nature protection (Offi cial Gazette no. 67/04, 14/06, 84/07, 35/10, 47/11, 148/11, 59/12, 13/13) 53. Law on batteries and accumulators and waste batteries and accumulators (Offi cial Gazette no. 140/10, 47/11, 148/11, 39/12, 163/13) 54. Law on packaging and packaging waste (Offi cial Gazette no. 161/09, 17/11, 47/11, 136/11, 6/12, 39/12, 163/13) 55. Law on management of electrical and electronic equipment (Offi cial Gazette no. 6/12, 163/13) 56. Law on fertilizers (Offi cial Gazette no. 110/07, 20/09, 17/11, 148/11) 57. Law on water communities (Offi cial Gazette no. 51/03, 95/05, 113/07, 136/11) 58. Water economy law (Offi cial Gazette no. 85/03, 95/05, 103/08, 1/12, 95/12) 59. Law on products for plant protection (Offi cial Gazette no. 110/07, 20/09, 17/11, 53/11, 69/13, 10/15) 60. Law on supply of drinking-water and disposal of urban wastewater (Offi cial Gazette no. 68/04, 28/06, 103/08) 61. Law on food safety (Offi cial Gazette no. 157/10, revised text 123/15) 62. Law on genetically modifi ed organisms (Offi cial Gazette no. 35/08, 163/13) 63. Law on quality of agricultural products (Offi cial Gazette no. 140/10, 53/11, 55/12, 106/13, 116/15) 64. Law on State Inspectorate of Agriculture (Offi cial Gazette no. 20/09, 53/11) 65. Law on livestock (Offi cial Gazette no. 07/08, 116/10, 23/13, 149/15) 66. Law on veterinary health (Offi cial Gazette no. 113/07, 24/11, 136/11, 123/12, 154/15) 67. Law on mineral resources (Offi cial Gazette no. 136/12, 25/13, 93/13, 132/13) 68. Law on product safety (Offi cial Gazette no. 33/06, 63/07, 24/11, 51/11, 148/11, 164/13, 152/15, 53/16) 69. Decree on determining the activities for installations for which an integrated environmental permit is issued, and adjustment permit with adjustment plan (Offi cial Gazette no. 89/05) 70. Law on protection against noise in the environment (Offi cial Gazette no. 79/07, 63/13) 71. National annual programme for public health (annual programme) 72. National programme for agriculture and rural development 2013-2017 73. Programme for fi nancial support of rural development 2017 74. Programme for fi nancial support of agriculture for 2017 75. National programme for the elimination of diseases caused by asbestos: submitted to Min- istry of Health, October 2015 76. Health for All (annual programme) 66 Noncommunicable diseases and risk factors 1. Strategic framework and action plan for prevention and control of noncommunicable dis- eases to 2025 2. Action plan on food and nutrition 2016−2025 (developed, awaiting adoption) 3. Guidelines for nutrition of the population (2014) 4. R ulebook on nutrition standards and meals in primary school (Act No. 11-5668/1 of 3 April 2014, Ministry of Education and Science) 5. Rules on standards and norms for the activity of institutions for children (Offi cial Gazette no. 28/14, 40/14, 136/14) 6. Rulebook on food standards and meals of students accommodated in student dormitories (acts 20-46/91 from 26 February 2011, Ministry of Education and Science) 7. Health care law consolidated text (Offi cial Gazette no. 61/15, 154/15, 192/15) 8. A programme for providing insulin, glucagon, insulin needles, sugar measuring tape and education for the treatment and control of diabetes (annual programme) 9. Strategy for prevention and control of the harmful consequences of the use and abuse of alcohol on the health of the population with action plan (2017−2027) (ready, waiting for adoption) 10. Health care programme for people with addictions (annual programme) 11. Health care programme for people with mental disorders (annual programme) 12. National strategy for fi ght against drugs 2014−2020 13. Law on health insurance (Offi cial Gazette no. 25/00, 34/00, 96/00, 50/01, 11/02, 31/03, 84/05, 37/06, 18/07, 36/07, 82/08, 98/08, 6/09, 67/09, 50/10, 156/10, 53/11, 26/12, 16/13, 91/13, 187/13, 43/14, 44/14, 97/14, 113/14, 120/14, 188/14, 20/15, 61/15, 98/15, 129/15, 154/15, 155/15, 192/15) 14. Law on records in the fi eld of health (Offi cial Gazette no. 20/09, 53/11, 164/13) 15. Law on protection of patients’ rights (Offi cial Gazette no. 82/08, 12/09, 53/11, 150/15) 16. Law on sports (Offi cial Gazette no. 29/02, 66/04, 81/08, 18/11, 51/11, 64/12, 148/13, 187/13, 42/14, 138/14, 177/14, 72/15, 153/15) 17. National youth strategy 2016−2025 with an operational plan 18. National health strategy 2020 19. Strategy on sexual and reproductive health 2010−2020 20. Programme for prevention of cardiovascular diseases (annual programme) 21. Programme for early detection of cancer (breast, cervix, colon, prostate) (annual pro- gramme) 22. National annual programme for public health (annual programme) 23. Programme Health for All (annual programme) 24. Programme for systematic examinations of students and youth (annual programme) 25. Programme for feeding preschool and school children 26. National strategy for reduction of poverty and social exclusion 2010−2020 with operational plan 27. Strategy for sustainable development to 2020 67 Developing the National Health 2020 Strategy in North Macedonia 28. Health Insurance Fund annual work programme 29. Law on primary education (Offi cial Gazette no. 103/08) 30. Law on secondary education (Offi cial Gazette no. 44/95, 24/96, 34/96, 35/97, 82/99, 29/02, 40/03, 42/03, 67/04, 55/05, 113/05, 35/06, 30/07, 49/07, 81/08, 92/08, 33/10, 116/10, 156/10, 18/11, 42/11, 51/11, 6/12, 24/13, 100/12) 31. Law on higher education (Offi cial Gazette no. 35/08, 103/08, 26/09, 83/09, 99/09, 115/10, 17/11, 51/11, 123/12, 15/13, 24/13, 11/14, 116/14, 130/14, 10/15) 32. Law on medical studies and continuing professional development of doctors of medicine (Offi cial Gazette no. 16/13, 32/14, 144/14, 150/15) 33. Continuing medical education (CME) programme 34. Law on tobacco and tobacco products (Offi cial Gazette no. 24/06, 88/08, 31/10, 36/11, 53/11, 93/13, 99/13, 164/13, 151/14) 35. Law on protection against smoking (Offi cial Gazette no. 36/95, 70/03, 29/04, 37/05, 103/08, 140/08, 35/10, 100/11, 157/13) 36. National strategy for tobacco control 2010−2015 37. National strategy for prevention of alcohol use with action plan 2010−2015 (expired, new strategy is developed, awaiting adoption) 38. Report from the Health Behaviour in School-aged Children study (March 2016) 39. European School Survey Project on Alcohol and Other Drugs (ESPAD) study report (2015) 40. Report of Global Youth Tobacco Survey (GYTS) at the national level (July 2016) 41. Report from the study on nutrition (2015) Communicable diseases and crisis preparedness and response 1. Law on health care (Offi cial Gazette no. 43/12, 145/12, 87/13, 164/13, 39/14, 43/14, 132/14, 184/14, 10/15, 61/15, 154/15, 192/15, 17/16, 37/16) 2. Law on public health (Offi cial Gazette no. 22/10, 136/11, 144/14, 149/15) 3. Law on sanitary and health inspection (Offi cial Gazette no. 124/15) 4. Law on health-care records (Offi cial Gazette no. 20/09, 53/11, 164/13) 5. Law on the protection of population from infectious diseases (Offi cial Gazette no. 66/04, 99/08, 86/11, 149/14) 6. Law on safety and health at work (Offi cial Gazette no. 53/13, 137/13, 164/13, 158/14, 15/15, 192/15, 30/16) 7. Law on food safety (Offi cial Gazette no. 123/15, 129/15, 39/16) 8. Law on waters (Offi cial Gazette no. 87/08, 6/09, 161/09, 83/10, 51/11, 44/12, 23/13, 163/13) 9. Law on veterinary health (Offi cial Gazette no. 113/07, 24/11, 136/11, 123/12, 154/15) 10. Law on crisis management (Offi cial Gazette no. 29/05, 41/14, 104/15, 39/16) 11. Law on protection and rescue (Offi cial Gazette no. 93/12, 41/14, 129/15, 71/16, 106/16) 12. National HIV/AIDS strategy 2012−2016 13. Strategy for tuberculosis control 2013−2017 14. Strategy for adaptation of the health sector to climate change with action plan (2011) 68 15. Strategy on sexual and reproductive health 2020 with action plan for 2013 16. National strategy and action plan for the control of antimicrobial resistance 2012−2016 17. Action plan for prevention of adverse eff ects and the eff ects of heat-waves on health of the population (2011) 18. Action plan for prevention of adverse eff ects and the eff ects of cold-waves on health of the population (2012) 19. Plan for preparedness and response of the health-care system in dealing with emergencies, crisis situations and disasters (2017) 20. National annual programme for public health (annual programme) 21. Programme for mandatory immunization and immunization for epidemiological indications of the population (annual programme) 22. Programme of preventive measures to prevent tuberculosis among the population (annual programme) 23. Programme for examining the emergence, prevention and eradication of brucellosis in the population 24. Programme to protect the population from HIV/AIDS in 2017 (annual programme) 25. Rulebook on the manner of application and the form and content of the forms for reporting contagious diseases and microbiologically proven causes (Offi cial Gazette no. 46/09) 26. Rulebook on minimum requirements for safety and health at work of employees from risks related to exposure to biological agents (Offi cial Gazette no. 170/10) 27. Rulebook on the special requirements for the safety of natural mineral water (Offi cial Ga- zette no. 32/06, 127/12) 28. Rulebook on the manner and measures for bathing water management, the technical crite- ria and the objectives of the bathing water quality, as well as the manner and procedure for informing the public about the results of the bathing water monitoring (Offi cial Gazette no. 129/16) 29. Rulebook on the general requirements for food safety in relation to the maximum levels of certain contaminants (Offi cial Gazette no. 102/13) 30. Rulebook on special requirements concerning microbiological criteria for food (Offi cial Ga- zette no. 100/13) 31. Rules on the manner and handling medical waste, as well as the packaging and labelling of medical waste (Offi cial Gazette no. 146/07) 32. Rulebook on the criteria for prevention and treatment of intra-hospital infections (Offi cial Gazette no. 25/08) 33. Rules on the manner of execution, the content of the examinations, types of examinations and the timing for the obligatory health - hygienic examinations of employees (Offi cial Ga- zette no. 152/07) 34. Regulation on measures against entry and eradication of cholera, plague, viral haemorrhag- ic fever, yellow fever and malaria (Offi cial Gazette no. 76/03) 35. Rules for immunoprophylaxis, chemoprophylaxis, people subject to these measures, the manner of execution and record-keeping and documentation (Offi cial Gazette no. 177/15) 69 Developing the National Health 2020 Strategy in North Macedonia Health system and resources 1. National Health 2020 Strategy 2. Action plan for public health 3. Strategy for demographic development 2015−2024 4. Health care law consolidated text (Offi cial Gazette no. 61/15, 154/15, 192/15) 5. Decree on the network of health institutions (Offi cial Gazette no. 81/12, 169/13, 21/14, 90/14, 161/14, 2/16, 144/16) 6. Law on health insurance (Offi cial Gazette no. 25/00, 34/00, 96/00, 50/01, 11/02, 31/03, 84/05, 37/06, 18/07, 36/07, 82/08, 98/08, 6/09, 67/09, 50/10, 156/10, 53/11, 26/12, 16/13, 91/13, 187/13, 43/14, 44/14, 97/14, 113/14, 120/14, 188/14, 20/15, 61/15, 98/15, 129/15, 154/15, 155/15, 192/15) 7. Law on medicines and medical devices (Offi cial Gazette no. 106/07, 88/10, 36/11, 53/11, 136/11, 11/12, 147/13, 164/13, 27/14, 43/14) 8. Law on medical studies, the continuous improvement physicians (Offi cial Gazette number no. 16/13, 38/14) 9. Programme for mandatory health insurance of citizens with Macedonian citizenship not insured under mandatory insurance (annual programme) 10. Programme for providing funds for hospital treatment for covering co-payments for pen- sioners (annual programme) 11. Programme for education of doctors and health-care personnel and co-fi nancing of spe- cialization and subspecialization for health providers and health associates employed in private health institutions and other legal entities and unemployed health profession- als (annual programme) 12. Programme for the needs of specialist and subspecialist personnel in accordance with the network of health care institutions (2015−2018) 13. Project on introduction of 100 new methodical interventions in order to use the equipment and the provision of additional quality services 14. Construction of a new clinical centre in Skopje and Shtip 15. Rehabilitation of public health-care facilities 16. Building clinics in rural areas 17. Procurement of medical equipment for public health institutions 18. Rural doctor project 19. Home visit project 20. Roma health mediators project 21. Strategy for immunization 2012−2015 and action plan 2012−2015 22. Safe motherhood strategy 2010−2020 23. National strategy for older people 2010−2020 24. National plan for preparedness and response to health system in crisis 2017 70 Annex 4. Key publicaƟ ons produced throughout the process Milevska Kostova N, Chichevalieva S, Ponce NA, van Ginneken E, Winkelmann J. The former Yugo- slav Republic of Macedonia: health system review. Health Syst Transition. 2017;19:1–160 After a decade since the previous overview of the health system in the country, the Health Systems in Transition analysis came at the right time to inform the policies related to the health system’s governance, organization, fi nancing, service delivery and reforms and future action to contribute to better health and well-being. Assessment of human resources for health (2017, Ministry of Health working document)4 First of its kind, the human resources for health profi le provided an overarching and comprehensive overview of current and future human resources, including proper distribution, existing and new pro- fi les, professional upgrade and valuation, as indispensable elements in the health of the population. Healthy ageing assessment (2016, Ministry of Health working document)5 The country’s rising trend of population ageing will have potential eff ects not only on the health sys- tem but also on economic and social prosperity. Understanding the determinants of healthy ageing is pivotal in addressing the resulting issues, and also in transforming challenges into opportunities for an engaged older population and creating resilient communities. The assessment of the deter- minants of healthy ageing was a precursor to the action plan for healthy ageing, which was drafted and submitted for adoption in 2017. Central Asian and eastern European surveillance of antimicrobial resistance. Annual report 2014. Copenhagen: WHO Regional Offi ce for Europe; 2015 (http://www.euro.who.int/en/publications/ abstracts/central-asian-and-eastern-european-surveillance-of-antimicrobial-resistance.-annu- al-report-2014, accessed 14 December 2018) The long-term commitment of the country to tackling antimicrobial resistance, since 2008, was en- riched with expanded activities for addressing antibiotic consumption in inpatient facilities. To this end, current prescribing levels and practices were assessed to inform future policies on antimicrobial stewardship aimed at contributing to the global fi ght against antimicrobial resistance. Report on the self-assessment of essential public health operations (EPHOs) on national level. Skopje: Studiorum; 2014 (http://zdravje2020.mk/index_en.php?page=e-lib1, accessed 14 De- cember 2018) The country was among the fi rst countries in the WHO European Region to undergo a process of self-assessment of public health based on the essential public health operations, using the latest available version of the WHO Regional Offi ce for Europe’s self-assessment tool (18 July 2014). Using the tool, the current situation was analysed and used as a baseline study for developing the public health action plan as an integral part of the National Health 2020 Strategy. The government adopt- ed the action plan in 2016, which aimed at strengthening the health system and the essential public health operations provided by national and subnational institutions. 4 See http://www.euro.who.int/en/health-topics/Health-systems/health-workforce/news/news/2017/07/the-former-yugoslav-re- public-of-macedonia-develops-profi le-of-human-resources-for-health (accessed 22 December 2017). 5 See http://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/news/news/2017/03/who-supports-the-former-yu- goslav-republic-of-macedonia-in-the-development-of-its-national-action-plan-on-healthy-ageing-20172025 (accessed 22 Decem- ber 2017). 71 Developing the National Health 2020 Strategy in North Macedonia Desk review: the evidence base of National Health 2020 Strategy. Skopje: Ministry of Health, North Macedonia; 2015 Desk review of documents in support to the preparation of operational plan for the National Health 2020 Strategy. Skopje: Ministry of Health, North Macedonia; 2017 Both desk reviews were indispensable in creating evidence-informed policy, linked to the current situ- ation and needs, while considering policies, strategies and plans in other sectors. Admirable eff ort was put into this to achieve policy coherence and putting intersectoral work into action: 214 papers were analysed across the main pillars and objectives of the National Health 2020 Strategy, of which 33 focused on public health; 80 health and environment; 42 noncommunicable diseases and risk factors; 35 communicable diseases and preparedness and response; and 24 the health system and resources. Compendium of policy briefs for health and well-being. Evrodijalog J Eur Issues. 2015;20 (http:// studiorum.org.mk/evrodijalog/20/index_eng.html, accessed 14 December 2018) This issue of Evrodijalog contained 22 policy briefs in diff erent thematic areas pertaining to the na- tional health policy development process, and in accordance with the commitments to Health 2020 at the national level: international commitments and national policies for health; public health and health through the life-course; health and environment; noncommunicable diseases and risk factors; communicable diseases and emergency preparedness and response; and knowledge and evidence informing policies for health. These policy briefs informed the process of developing the National Health 2020 Strategy, which was endorsed in 2016. Compendium of policy briefs on health and the Sustainable Development Goals. Evrodijalog J Eur Issues. 2016;22 (http://studiorum.org.mk/evrodijalog/22/index_eng.html, accessed 14 Decem- ber 2018) Following the national commitments to the global health and development agendas, this issue com- prised professional views, opinions and analyses related to the implementation of the 2030 Agenda and the Sustainable Development Goals through national health and other sector policies. Compendium of policy briefs on health in the local community. Evrodijalog J Eur Issues. 2017;23 (http://studiorum.org.mk/evrodijalog/23/index_eng.html, accessed 14 December 2018) Following endorsement of National Health 2020 Strategy, and the government’s vision for its imple- mentation at all levels of governance, this issue includes diverse practices and policy proposals for devolving the national health priorities to the community level, with special focus on intersectoral eff orts to: promote resilient communities; provide healthy choices and reduce risks to health; and identify facets of intersectoral action for health and well-being involving environment, social, educa- tion, economy, employment and other sectors at the community level. 72 Annex 5. Strategic goals of the priority areas of the NaƟ onal Health 2020 Strategy To realize the strategic vision by 2020, the National Health 2020 Strategy envisages under- taking activities within the fi ve priority areas through specifi c action plans whose strategic goals complement the implementation of the 2030 Agenda for Sustainable Development and the achievement of the national sustainable development priorities. Public health Strategic goals • Improving population health and welfare across the life-course • Reducing the negative health eff ects of social determinants with a specifi c focus on the most severely aff ected vulnerable groups • Enabling each individual, community and sector to actively participate and assume respon- sibility for citizens’ health promotion • Promoting and strengthening public health capacity and services within the national health system and within all sectors at all levels of society to ensure the delivery of essential public health operations and a basic package of available, high-quality, effi cient and eff ective pub- lic health services at the individual, community and population levels Expected contribuƟ on to the naƟ onal sustainable development prioriƟ es • Towards Sustainable Development Goal 3, ensuring a healthy start in life and reducing ma- ternal and child mortality and reducing the negative eff ects of the social determinants of health and of the burden of noncommunicable and communicable diseases • Towards the remaining Sustainable Development Goals, especially intersectoral collabo- ration for better health; that is, Sustainable Development Goal 1: reduce poverty through action on the social determinants of health; Sustainable Development Goal 4: ensure edu- cation for all; Sustainable Development Goal 6: ensure access to safe drinking-water; Sus- tainable Development Goal 10: ensure social and health equity; and Sustainable Develop- ment Goal 17: provide better health through intersectoral collaboration and partnerships. Health and environment Strategic goals • Including all health-related factors in environmental policies • Health and welfare protection from environmental risks arising from climate change, air, water, soil, chemicals, asbestos, etc. • Reducing all kinds of environment-related health inequalities Expected contribuƟ on to the naƟ onal sustainable development prioriƟ es • Towards Sustainable Development Goal 3, ensuring a healthy living environment for all and reducing morbidity and mortality from diseases caused by the environmental determinants of health and reducing negative environmental infl uences. 73 Developing the National Health 2020 Strategy in North Macedonia • Towards the remaining Sustainable Development Goals, especially the living environment and its health impact; that is, Sustainable Development Goal 1: reducing poverty through action on the social determinants of health; Sustainable Development Goal 6: ensure ac- cess to safe drinking-water and sanitation; Sustainable Development Goal 10: ensure social and health equity; Sustainable Development Goal 11: creating safe, resilient and sustain- able cities and human settlements; Sustainable Development Goal 12: ensure sustainable consumption and production patterns; Sustainable Development Goal 13: address climate change and its impact; and Sustainable Development Goal 17: provide better health through intersectoral collaboration and partnerships. Noncommunicable diseases and risk factors Strategic goals • Reducing morbidity and mortality caused by diseases of the circulatory system (cardiovas- cular diseases and cerebrovascular diseases), cancer, chronic respiratory diseases, diabetes and mental disorders • Preventing disease through modifi able risk factors (smoking, improper nutrition, over- weight and obesity, physical inactivity, alcohol and hypertension) and from premature on- set of noncommunicable diseases • Strengthening the health system to deal with noncommunicable diseases • Involving all structures of society in reducing the burden of noncommunicable diseases Expected contribuƟ on to the naƟ onal sustainable development prioriƟ es • Towards Sustainable Development Goal 3, ensuring a healthy start in life and opportunities for making healthy lifestyle choices and reducing the negative eff ects of the social deter- minants of health and of the burden of noncommunicable diseases. • Towards the remaining Sustainable Development Goals, especially noncommunicable dis- eases and the risk factors that cause them; that is, Sustainable Development Goal 1: reduc- ing poverty through action on the social determinants of health; Sustainable Development Goal 2: ensure access to nutritious and safe food and nutrition for all; Sustainable Develop- ment Goal 4: ensure education for all; and Sustainable Development Goal 17: provide better health through intersectoral collaboration and partnerships. Communicable diseases and emergency preparedness Strategic goals • Improving the status of both immunization and vaccine-preventable diseases • Reducing the burden of food- and waterborne communicable diseases • Strengthening the surveillance, control and response system for hospital-acquired infec- tions and antimicrobial resistance • Maintaining low prevalence of HIV, sexually transmitted and bloodborne infections • Reducing the burden of zoonotic and vector-borne diseases • Reducing the burden of infl uenza and infl uenza-like diseases • Maintaining and further reducing the burden of tuberculosis 74 • Implementing a surveillance and response system for new reoccurring communicable dis- eases • Preparing the health system for quick emergency response Expected contribuƟ on to the naƟ onal sustainable development prioriƟ es • Towards Sustainable Development Goal 3: provide security from communicable diseases by immunizing against vaccine-preventable diseases, eliminating the epidemics of HIV, tuberculosis and other transmissible infections and reducing the burden of transmissible infections • Towards the remaining Sustainable Development Goals, especially addressing the burden and the risks of communicable diseases and the preparedness for quick emergency re- sponse; that is, Sustainable Development Goal 6: ensure access to safe drinking-water and sanitation; Sustainable Development Goal 10: ensure social and health equity; Sustainable Development Goal 11: create safe, resilient and sustainable cities and human settlements; Sustainable Development Goal 13: address climate change and its impact; and Sustain- able Development Goal 17: provide better health through intersectoral collaboration and partnerships. Health system and resources Strategic goals • Strengthening the capacity for health system governance and management • Introducing and promoting comprehensive health information system at all levels of health care • Introducing a sustainable fi nancial system • Improving health system capacity to the furthest extent (space, equipment and personnel) through equitable distribution within the health system and in accordance with the needs of diff erent regions • Introducing eff ective and high-quality health-care services available to every citizen • Working to create the necessary human resources for health, with the right skills and ca- pacity, in the right places at the right times Expected contribuƟ on to the naƟ onal sustainable development prioriƟ es • Towards Sustainable Development Goals 3, especially ensuring access to timely and quality health care for all, in terms of disease prevention, treatment and providing the highest at- tainable quality of life for people with specifi c health conditions • Towards the remaining Sustainable Development Goals, especially the action of the health sector towards providing the highest attainable standard of health and of quality of life, es- pecially towards Sustainable Development Goal 16: promote access to eff ective, account- able and inclusive institutions at all levels; and Sustainable Development Goal 17: provide better health through intersectoral collaboration and partnerships. 75 Developing the National Health 2020 Strategy in North Macedonia Annex 6. Joint statement on intersectoral collaboraƟ on for health and well-being in the community 76 77 Developing the National Health 2020 Strategy in North Macedonia Annex 7. List of insƟ tuƟ ons parƟ cipaƟ ng in the naƟ onal health policy development, 2014−2015, by sector (in alphabeƟ cal order) Central government institutions and bodies 1. Agency for Quality and Accreditation of Health Facilities 2. Cabinet of the Prime Minister 3. Centre for Public Health, Skopje 4. Centre for Public Health, Bitola 5. Centre for Public Health, Kumanovo 6. Centre for Public Health, Prilep 7. Centre for Public Health, Kochani 8. Centre for Public Health, Gevgelija 9. Centre for Public Health, Ohrid 10. Centre for Public Health, Tetovo 11. Centre for Public Health, Veles 12. Crisis Management Centre 13. Customs Administration 14. Employment Service Agency 15. Food and Veterinary Agency 16. Health Insurance Fund 17. Health Centre, Skopje 18. Health Centre, Bitola 19. Health Centre, Kumanovo 20. Health Centre, Prilep 21. Health Centre, Kochani 22. Health Centre, Gevgelija 23. Health Centre, Strumica 24. Health Centre, Tetovo 25. Health Centre, Ohrid 26. Health Centre, Berovo 27. Health Centre, Kavadarci 28. Health Centre, Veles 29. Institute of Public Health 30. Ministry of Agriculture, Forestry and Water Economy 31. Ministry of Culture 32. Ministry of Defence 33. Ministry of Economy 34. Ministry of Education and Science 35. Ministry of Environment and Physical Planning 36. Ministry of Finance 37. Ministry of Foreign Aff airs 38. Ministry of Health 39. Ministry of Internal Aff airs 40. Ministry of Justice 41. Ministry of Labour and Social Policy 42. Ministry of Local Self-Government 43. Pension and Disability Insurance Fund 44. Protection and Rescue Directorate 45. Public Revenue Offi ce 46. Secretariat for European Aff airs 47. State Sanitary and Health Inspectorate 48. State Statistical Offi ce 49. Youth and Sports Agency 78 Local self-government units and institutions at the local level 1. Association of Local Self-Govern- ment Units (ZELS) 2. Local Self-government Unit (LSGU) of Aerodrom 3. LSGU of Arachinovo 4. LSGU of Berovo 5. LSGU of Bitola 6. LSGU of Bogdanci 7. LSGU of Bogovinje 8. LSGU of Bosilovo 9. LSGU of Brvenica 10. LSGU of Butel 11. LSGU of Centar 12. LSGU of Centar Zhupa 13. LSGU of Chair 14. LSGU of Chashka 15. LSGU of Cheshinovo-Obleshevo 16. LSGU of Chucher Sandevo 17. LSGU of Debar 18. LSGU of Debarca 19. LSGU of Delchevo 20. LSGU of Demir Hisar 21. LSGU of Demir Kapija 22. LSGU of Dojran 23. LSGU of Dolneni 24. LSGU of Gazi Baba 25. LSGU of Gevgelija 26. LSGU of Gjorche Petrov 27. LSGU of Gostivar 28. LSGU of Gradsko 29. LSGU of Ilinden 30. LSGU of Jegunovce 31. LSGU of Karbinci 32. LSGU of Karposh 33. LSGU of Kavadarci 34. LSGU of Kichevo 35. LSGU of Kisela Voda 36. LSGU of Kochani 37. LSGU of Konche 38. LSGU of Kratovo 39. LSGU of Kriva Palanka 40. LSGU of Krivogashtani 41. LSGU of Krushevo 42. LSGU of Kumanovo 43. LSGU of Lipkovo 44. LSGU of Lozovo 45. LSGU of Makedonska Kamenica 46. LSGU of Makedonski Brod 47. LSGU of Mavrovo-Rostushe 48. LSGU of Mogila 49. LSGU of Negotino 50. LSGU of Novaci 51. LSGU of Novo Selo 52. LSGU of Ohrid 53. LSGU of Pehchevo 54. LSGU of Petrovec 55. LSGU of Plasnica 56. LSGU of Prilep 57. LSGU of Probishtip 58. LSGU of Radovish 59. LSGU of Rankovce 60. LSGU of Resen 61. LSGU of Rosoman 62. LSGU of Saraj 63. LSGU of Shtip 64. LSGU of Shuto Orizari 65. LSGU of Sopishte 66. LSGU of Staro Nagorichane 67. LSGU of Struga 79 Developing the National Health 2020 Strategy in North Macedonia 68. LSGU of Strumica 69. LSGU of Studenichani 70. LSGU of Sveti Nikole 71. LSGU of Tearce 72. LSGU of Tetovo 73. LSGU of the City of Skopje 74. LSGU of Valandovo 75. LSGU of Vasilevo 76. LSGU of Veles 77. LSGU of Vevchani 78. LSGU of Vinica 79. LSGU of Vrapchishte 80. LSGU of Zelenikovo 81. LSGU of Zhelino 82. LSGU of Zrnovci Civil society organizations 1. Confederation of Free Trade Unions 2. Consumer’s Organization OPM 3. Dijabet, Union of Associations of People with Diabetes 4. HERA (Association for Health Education and Research) 5. Habitat – Macedonia 6. Macedonian Red Cross 7. Macedonian Centre for International Cooperation 8. Nefron, Association of People with Kidney Disease 9. Studiorum, Centre for Regional Policy Research and Cooperation 10. Sveti Nikole (women’s organization) International partners 1. World Health Organization (WHO) 2. United Nations Children’s Fund (UNICEF) 3. United Nations Population Fund (UNFPA) 4. United Nations Development Programme (UNDP) (Footnotes) 1 National report on social determinants of health 2017, due to be published in 2018. 80 81 Developing the National Health 2020 Strategy in North Macedonia 82 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway North Macedonia Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan tŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ ZĞŐŝŽŶĂůKĸĐĞĨŽƌ ƵƌŽƉĞ UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int
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