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The Republic of North Macedonia has a population of 2.1 million.  Average life expectancy is 76. (WHO, 2015). 

The current health system in the Republic of North Macedonia developed out of the one put in place by the previous Yugoslavian government. When the Republic of North Macedonia gained independence in 1991 efforts were made to retain the universal coverage and strong public health institutions. However, the system was plagued by old infrastructure, overdependence on large hospitals and a low trust, causing patients to turn to the private market. This led to an increase in out of pocket expenditure, widening health inequalities and workforce migration from the public to the private sector.

Efforts were taken to improve system efficiency, cutting hospital beds and staff and promoting the private sector to complement the public provision. As part of these efforts primary care provision was privatised in 2007, and in 2012 the government began to integrate public and private care. FYR Macedonia has experienced a strong improvement in health parameters since gaining independence, with marked reduction in communicable disease burden and general mortality. Still, mortality remains among the highest in Europe, possibly explained by a combination of lifestyle factors, poor health promotion and inadequate non-communicable-disease treatment. (1)

COPD burden and management 

COPD prevalence is 3.5 per 100,000 and mortality from COPD is around 1.6% (2) The majority is attributed to smoking which is causing about two thirds of all COPD morbidity, highest among the compared countries. There is a lack of published studies on the current situation, but unpublished sources suggest that COPD management in the Republic of North Macedonia is underdeveloped and inadequate. GPs have insufficient familiarity with diagnosing, treating and preventing COPD, and are generally not authorised to do so, but are expected to refer patients to pulmonologists. Due to a lack of specialists in pulmonology, waiting lists can be long, and since COPD care is not available at local care centres, geographical accessibility can be an issue. This also makes long-term follow up complicated. Furthermore, COPD medications are expensive resulting in high OOP, causing poor long-term compliance to treatment with associated risks of disease progression and exacerbations.

  1.  Kostova N, Chichevalieva S, Ponce NA, van Ginneken E, Winkelmann J. The former Yugoslav Republic of Macedonia: Health system review. Health Systems in Transition, 2017; 19(3):1–160.
  2. Global Burden of Disease Study 2016. Available at:

Principal Investigators:  Katarina Stavrikj and Radmila Ristovska

Breathe Well study

Summary research question

Does additional assessment and communication of lung age/feedback on exhaled CO levels among smokers in primary care increase likelihood of quitting smoking compared to giving very brief smoking cessation advice (VBA) alone?

Study Design

Phase III randomised controlled effectiveness trial with process and cost effectiveness analysis

Progress update

The study protocol has been developed and shared with 30 general practices.  Ethical approval for the study has been obtained and it has been registered on ISRTCN. The contract with the University of Birmingham has been signed and the equipment needed has been distributed.  Five GPs have been selected to  participate in the pilot study. They have all participated in a training workshop. The team started recruitment in 2018.  By the end of March 2019, 492 patients have been radomised for inclusion  in the trial.

This research was commissioned by the National Institute for Health Research (NIHR) NIHR Global Health Research Group on Global COPD in Primary Care using UK aid from the UK Government. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.