UDK: 336.58:614.2(497-15)
www.doi.org/10.67214/66y5t474
Vasilevska H.1, Stojchevska M.2, Tozija F.2
1Public Health Center, Bitola, Republic of North Macedonia
2Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia
Abstract
Objective: Reforms introduced in the 1990s aimed at sustainability amidst high out-of-pocket costs and low public funding. Over the past three decades, the Western Balkans (WB) countries have undergone profound transformations. The aspiration to join the European Union (EU) strongly shapes health financing policies in the Western Balkans, encouraging reforms focused on equity, efficiency, and financial sustainability. The aim of this paper is to analyze and compare health expenditure levels and financing structures across Western Balkan countries.
Materials and Methods: The analysis is based on data from the World Health Organization HFA-DB and the World Bank, supplemented by Health in Action reports for the selected countries. Public health approach has been applied.
Results: In 2023, health expenditure ranged from 7% of GDP in Albania to 9.7% in Montenegro. Despite this growth, per capita spending remains substantially below EU levels (US$4,153), with Albania reporting the lowest (US$590) and Montenegro the highest (US$1,147). A common regional challenge is the high reliance on out-of-pocket (OOP) payments, exceeding 30% in most countries and reaching over 40% in Albania and North Macedonia, well above the EU average (14,8%).
Conclusion: Health financing systems in the Western Balkans show increasing expenditure but continue to face limited financial protection and persistent inequities. High reliance on out-of-pocket payments and unmet healthcare needs continue to expose populations to financial risk, particularly among lower-income groups. Strengthening public financing, improving risk pooling, and enhancing system efficiency are essential to accelerate progress toward universal health coverage in the region.
Keywords: efficiency; health financing systems; Western Balkans.
References:
- Tozija F. Function 2: Financing of the health system. In Editors: Spasovski M, Tozija F, Kjosevska E. Introduction to medicine. Skopje: Faculty of Medicine; 2022.
- Cylus J, Sallaku J, Jowett M. Health system performance assessment: a framework for policy analysis. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK590186/ - Jevtic M. Health policy considerations in the Western Balkans. Western Balkans Info Hub; 2025. Available from:
https://westernbalkans-infohub.eu/wp-content/uploads/2025/07/Policy-Report_Health-Policies_Western-Balkans_final.pdf - Organisation for Economic Co-operation and Development. Government at a glance: Western Balkans. Paris: OECD; 2020. Available from:
https://doi.org/10.1787/a8c72f1b-en - Tomini SM, Groot W, Pavlova M. Paying out-of-pocket and informally for health care in Albania: the impoverishing effect on households. Front Public Health.2015;3:207. Available from: https://doi.org/10.3389/fpubh.2015.00207
- Bredenkamp C, Gragnolati M. Sustainability of healthcare financing in the Western Balkans: an overview of progress and challenges. Washington (DC): World Bank; 2007. Available from: http://hdl.handle.net/10986/7377
- World Health Organization Regional Office for Europe. Roadmap for health and well-being in the Western Balkans (2021–2025): European Programme of Work (2020–2025) – United Action for Better Health. Copenhagen: WHO Regional Office for Europe; 2021. Available from:
https://www.who.int/europe/publications/i/item/WHO-EURO-2021-3435-43194-60508 - International Trade Administration. Healthcare resource guide: Albania. Washington (DC): U.S. Department of Commerce; 2021. Available from:
https://www.trade.gov/healthcare-resource-guide-albania - World Bank. Current health expenditure (% of GDP). World Development Indicators. Available from:
https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS - World Bank. Current health expenditure per capita (current US$). World Development Indicators. Available from:
https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD - World Bank. Out-of-pocket expenditure (% of current health expenditure). World Development Indicators. Available from:
https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS - European Observatory on Health Systems and Policies, WHO Regional Office for Europe. Health systems in action: Bosnia and Herzegovina 2024. Available from:
https://eurohealthobservatory.who.int/publications/i/health-systems-in-action-bosnia-and-herzegovina - European Observatory on Health Systems and Policies, WHO Regional Office for Europe. Health systems in action: Montenegro 2024. Available from:
https://eurohealthobservatory.who.int/docs/librariesprovider3/publicationsnew/montenegro—hsia-one-pager.pdf - European Observatory on Health Systems and Policies, WHO Regional Office for Europe. Health systems in action: North Macedonia 2024. Available from:
https://eurohealthobservatory.who.int/docs/librariesprovider3/publicationsnew/north-macedonia—hsia-one-pager.pdf - European Observatory on Health Systems and Policies, WHO Regional Office for Europe. Health systems in action: Serbia 2024. Available from:
https://eurohealthobservatory.who.int/docs/librariesprovider3/publicationsnew/serbia—hsia-one-pager.pdf - Rancic N, Kovacevic A, Dragojevic-Simic V. Long-term health expenditure changes in selected Balkan countries. Front Public Health.2015;3:152. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4450573/
- Thomson S, Cylus J, Evetovits T. Can people afford to pay for health care? New evidence on financial protection in Europe. Health Policy Plan [Internet]. 2010 [cited 2026 Apr 27];25(6):430–437. Available from:
https://doi.org/10.1093/heapol/czq070 - World Health Organization. From evidence to action: improving affordable access to medicines in the Western Balkans. Available from:
https://www.who.int/europe/news-room/feature-stories/item/from-evidence-to-action–improving-affordable-access-to-medicines-in-the-western-balkans - Saksena P, Xu K, Durairaj V. The drivers of catastrophic expenditure: outpatient services, hospitalization or medicines? World Health Report Background Paper. Geneva: World Health Organization; 2010;21. Available from:
https://cdn.who.int/media/docs/default-source/health-financing/technical-briefs-background-papers/21whr-bp.pdf - Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ.
2013;91(8):602–611. Available from: https://doi.org/10.2471/BLT.12.113985