Final version 2013 Overview of the integration and functioning of the Health Information System and the Civil Registration and Vital Statistics System, Republic of Macedonia Report of main findings External consultation1for WHO Regional Office for Europe and WHO Country Office in Skopje, Republic of Macedonia 3-7 December 2012 Skopje 1 Dr Fern Greenwell, International consultant, in collaboration with Professor Dr Elena Kjosevska, National Institute of Public Health 1 Final version 2013 Overview of the integration and functioning of the Health Information System and the Civil Registration and Vital Statistics System, Republic of Macedonia Report of main findings A well-functioning health information system (HIS) is the basis for effective, evidence-based policy- making and planning in the health sector. An important component of the HIS is access and use of high quality birth and death statistics generated by a continuous, universal, compulsory and permanent civil registration system (CRS) (WHO 2010). The World Health Organization (WHO) Regional Office for Europe and the WHO Country Office in Skopje have commissioned a review of the current functioning of national health information and civil registration systems in order to better understand the extent to which they are harmonized to produce quality, health-related data, with a focus on mortality data. The purpose of the mission to Skopje was to assess the quality and flow of health and demographic statistics in the Republic of Macedonia (hereafter, Macedonia), especially as regards the integration and use of birth, death, and cause of death information. The mission corresponds with one of the priorities in the WHO Biennial Collaborative Agreement between the Ministry of Health and the WHO Regional Office for Europe 2012/2013, ‘Health systems strengthening and public health’, and in particular, the ‘further development of an integrated health information platform with databases and analytical reports’2. The approach for carrying out the review was to become familiar with relevant national documents and laws, and to hold unstructured interviews with persons in key national and international institutions including the Ministry of Health, Ministry of Justice, State Statistical Office, Institute of Public Health, Centres for Public Health, Agency for Protection of Personal Data, UNFPA and UNICEF (see Annex 1 Mission agenda). Discussions with informants focused on the data collection mechanisms, quality control, and exchange of data, as well as their use in measuring health system performance. In addition, a WHO rapid assessment tool was completed to provide a standardized summary of the functioning of the national civil registration and vital statistics system. The WHO Country Office coordinated logistical and translation support during the mission, and all activities were conducted in Skopje, from 3-7 December 2012. This report reflects the main issues discussed with national specialists during the mission and proposes recommendations formulated together with WHO and national partners. Background The Republic of Macedonia became independent from the former Yugoslavia in 1991. It is located in the Balkan peninsula of Southeast Europe, and is the southern-most country among the former Yugoslavia countries. It is bordered by Albania to the west, Bulgaria to the east, and Greece to the south. Table 1 shows other countries in the neighborhood, and their comparative population sizes. 2Biennial collaborative agreement (BCA) 2012–2013, http://www.euro.who.int/en/where-we- work/memberstates/the-former-yugoslav-republic-of-macedonia/areas-of-work 2 Final version 2013 Table 1.Republic of Macedonia and surrounding countries Country (capital) Date of independence Population in 2010 (in millions) Slovenia (Ljubljana) 1991 2.0 Croatia (Zagreb) 1991 4.4 Bosnia Herzegovina (Sarajevo) 1992 3.8 Montenegro (Podgorica) 2006 0.6 Serbia (Belgrade) 2006 7.3 Kosovo (Pristina) 2008 from Serbia 1.7 Macedonia (Skopje) 1991 2.1 Source: WHO Regional Office for Europe, European health for all database (HFA-DB) In 2010 Macedonia had a population of about 2.1 million with about equal shares under 15 years (18%) and over 60 years (17%); the median age was 36 years. The natural increase of the population is slightly positive since the crude birth rate just exceeds the crude death rate (10.8 in 2010 and 10.1 in 2009, respectively) (WHO 2012). Although these parameters describe a slightly younger population than the average European population, population ageing and low fertility rates are nevertheless emerging demographic issues for the government3,4. Fifty-nine percent of the people live in urban areas. Since 2008 the World Bank classifies Macedonia among the upper-middle income group of countries. Comparing Macedonia’s Millennium Development Goal (MDG) indicators in 2010 with those for the European Region’s average for the same year, and with the average for other upper-middle income countries, the country as a whole does as well or better on most MDG indicators. Performance on other demographic and health workforce indicators lags behind the European average but is more favorable compared to the average for upper-middle income countries (Table 2). Table 2. Selected indicators for Macedonia FYR, the World Health Organization European Region (average), and the World Bank Upper-middle-income group of countries (average), 2010 Macedonia FYR WHO European WB Upper-middle Region (average) income countriesa (average) Millennium Development Goals MDG 1 Percentage of children 1.8 0.5 na under five underweight (2005-2011) MDG 4 Infant mortality (per 1000 7.6d 12 16 live births) 2010 MDG 4 Under-five mortality (per 8.3d 13 19 1 000 live births) 2010 MDG 4 Measles vaccination 97 94 96 coverage among 1-years olds (%) 2010 MDG 5 MMR (per 100 000 live 10b 20 14 births) 2010 [3-31] [18-24] [12-16] MDG 5 Antenatal care coverage (at 94 97 80 least one visit, 2005-2011) 3http://en.worldstat.info/Europe/Macedonia 4 Country Factsheet, http://eeca.unfpa.org/webdav/site/eeca/shared/documents/Macedonia%20factsheet.pdf; Addressing Low Fertility in a World of 7 Billion: Macedonians Try Financial Incentives (13 October 2011) http://www.unfpa.org/public/home/news/pid/8591 3 Final version 2013 Macedonia FYR WHO European WB Upper-middle Region (average) income countriesa (average) MDG 5 Births attended by skilled 100 98 96 personnel (%, 2005-2011) MDG 6 Prevalence of tuberculosis 24 63 108 (per 100 000 population) 2010 MDG 6 TB case detection rate (%) 89 78 81 MDG 6 TB treatment success rate 90 63 86 (% in 2009) MDG 7 Population using improved 100 98 93 drinking water source (% in 2010) Demographic and health workforce Life expectancy at birth (both sexes) 74 75 68 2009 Total fertility rate 2010 1.4 1.6 1.8 Physicians per 10 000 population 27c 33 17 (2010) Nurses per 10 000 population 42c 75 26 (2010) Hospital beds per 10 000 population 45 62 39 (2005-2011) Source: World Health Statistics 2012 (WHO 2012), unless otherwise noted.http://www.who.int/gho/publications/world_health_statistics/2012/en/ aUpper-middle-income economies ($4 036 to $12 475 in 2011) http://data.worldbank.org/about/country- classifications/country-and-lending-groups b WHO, UNICEF, UNFPA, and The World Bank estimates (2012). Trends in maternal mortality: 1990 to 2010. WHO: Geneva. www.who.int/reproductivehealth/publications/monitoring/9789241503631 c European health for all database (HFA-DB), World Health Organization Regional Office for Europe (July 2012) http://data.euro.who.int/hfadb/ dOfficial national estimates, Janeva 2012 Macedonia has defined its administrative areas according to the European Union classification of Nomenclature of Territorial Units for Statistics (NUTS). The NUTS-1 and NUTS-2 comprise the whole territory and NUTS-3 comprises eight statistical regions (Annex 2). There are furthermore 84 municipalities and 1776 settlements. In addition to the legal statistical regions, there are 30 health regions that do not correspond with NUTS. Institutional and legal framework National institutions The institutions introduced below represent the main ones involved with the collection and/or dissemination of health-related statistics. Ministry of Health (MOH) http://moh.gov.mk/eng/. The MOH was established in 1991 with the adoption of the Law on Health Care. The core functions of MOH are to formulate and implement policy, set priorities, and monitor health system performance (Gjorgjev et al. 2006). The Sector for EU Integration participates in negotiations for EU accession, monitors and evaluates implemented measures, and cooperates with international partners. The Sector for Modernization Management in Health and IT is actively building upon the ‘Strategy for the Development of Macedonian Integrated Health Information System’ (2006) to monitor quality of health care services, financial activity and 4 Final version 2013 patient satisfaction. This Sector also plans to undertake research and analysis, health care promotion, and monitoring and evaluation. National Institute of Public Health (IPH) http://www.iph.mk/and regional Centers of Public Health (CPH).The National Institute of Public Health is the national reference centre for health statistics that is responsible for surveillance, research and health promotion(MOH 2007, p30). It provides annual indicators to the WHO Health for All (HFA) database as well as other international indicator repositories e.g., Transmonee, Eurostat. The IPH Department of Social Medicine is responsible for routine public health information collected from public and private health facilities by its 10 regional Centers for Public Health (CPH). The CPH regularly submit to IPH monthly forms with aggregated data and quarterly individual case reports from out-patient clinics and hospital discharges. The IPH processes these data to monitor the utilization of health services, in-patient and out-patient, as well as to maintain various individual-level patient registries. IPH provides regular information to MOH and the public through disseminating annual publications- several of which are also translated into English- which help to inform policy decisions at national, regional and local levels.