Breathe Well Republic of North Macedonia

Project One: Does additional assessment & 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 team has completed recruitment of 1,366 participants from 32 GP practices. They have completed a process evaluation of the intervention. They will complete the 6 month follow-up assessments in May 2020. The trial results will be published by Dec 2020. 
The study protocol was developed and shared with 30 general practices.  Ethical approval for the study has been obtained and it has been registered on ISRTCN. Five GPs  participated in a pilot study who all participated in a training workshop. The team started recruitment in 2018.  



The Republic of North Macedonia has a population of 2.1 million.  Average life expectancy is 76 (WHO, 2015). The current health system 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 a 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 – being expected to refer patients to pulmonologists. With a lack of specialists in pulmonology, waiting lists can be long, and as 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.


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  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.



Principal Investigators