Dr. Victoria Hewitt
Palliative Care in North Macedonia: Teamwork underpinned a new service framework
For the past 18 months, I have been working with a team of experts on a European Union-funded project to implement the national health action plan in the Republic of North Macedonia. My task was to design and develop a comprehensive service framework for integrated palliative care services—from home to hospital—in line with best European practices.
North Macedonia is a small, landlocked country in the Western Balkans region of Southeast Europe. Like most other countries, it faces the challenge of an ageing population and increasing demand on health care services. Globally, the majority of people who need palliative care are over the age of 60, so explicitly including palliative care in efforts to strengthen health systems is wise. Simultaneously, North Macedonia is experiencing a decline in the 20-64 age group, which comprises the majority of the health care workforce and social health insurance contributors, putting further strain on the health care system.
The North Macedonia team (L-R): Natasha Zdraveska, Dr. Salija Ljatif Petrushovska, Director of Geriatrics Dr. Lidija Pavlovska, Dr. Victoria Hewitt, and Dr. Lidija Veterovska Miljkovic. Photo used with permission.
One goal: develop strategies with stakeholders
North Macedonia has an established model of integrated palliative and geriatric care at the tertiary level. However, with seven specialist palliative care adult services (0.4 per 100,000 people) and none at all for children, there is insufficient capacity to meet current and projected demand. My role was to understand the national context and work with stakeholders to develop strategies to implement best practice.
My task was made easier and more enjoyable by the amazing people working tirelessly to make palliative care more accessible to everybody in North Macedonia, as part of universal health coverage. Dr. Lidija Veterovska Miljkovic heads both the Sue Ryder Hospice in Skopje and the Macedonian Association for Palliative Care. Natasha Zdraveska, clinical pharmacist at the Specialized Hospital for Geriatrics and Palliative Care, has a passion for equitable access to medicines. Dr. Salija Ljatif Petrushovska, director of that same institution throughout most of the project, introduced me to key stakeholders in the wider health care context beyond palliative care.
Group effort resulted in a database & symposium
These incredible women were my rock and my inspiration. With their guidance, I developed a rich understanding of palliative care’s place in the complex and dynamic health system. Together, we developed a prototype palliative care database and delivered a national palliative care symposium.
Throughout the project, I had the honor of collaborating with stakeholders involved in other, complementary health-related projects. On my first mission, I learned of a recent project to establish a geriatric-palliative care subspecialty program and through this, I connected with Dr. Goran Stevanovski, a World Health Organization (WHO) country office consultant, and Dr. Time Gaul, project director for Medical Education International. Both provided invaluable insight, indispensable support, and enduring wise counsel.
Credible costing models produced
Similarly, I advocated for the inclusion of palliative care into projects supported by the World Bank on primary health care and long-term care. This involved dipping my toe into health economics, to produce credible costing models; fortunately, I received guidance from fellow project experts Lasse Nielsen and George Boulton.
A life-changing experience
Being part of this project has been life-changing for me. The tangible outcome is a service framework for comprehensive palliative care, integrated into a complex health system and aligned to the WHO conceptual model of palliative care development.
I started with as much knowledge and data as I could find, but this was merely the platform upon which I have built some incredible relationships. Sometimes the sense of common purpose was immediate and the bonds we formed have remained strong. Sometimes it took time to understand the various motivations and barriers, but this has served me well because with it came an appreciation of the reality of the challenges ahead. I have learned to modulate my message to different audiences and to mold it into different projects, while keeping true to the principle that universal health coverage cannot be achieved until everyone has access to the palliative care they need.
Geriatrics and Palliative Care Symposium panel (L-R): Dr. Lidija Veterovska Miljkovic, Dr. Ali Hamandi (senior economist at the World Bank), Dejan Nestorovic (palliative care nurse in Serbia), Dr. Victoria Hewitt, and Natasha Zdraveska . Photo used with permission.
Read Dr. Hewitt's bio.