Primary health care helps extend sexual and reproductive health services in North Macedonia

Dr Gilgor Tofoski

A major part of WHO’s work in the coming years will be supporting countries in moving towards universal health coverage, as part of an ambitious plan designed to help achieve the Sustainable Development Goals. Such efforts will not be complete without ensuring that people everywhere have access to sexual and reproductive health information and services. In North Macedonia, where patients have faced challenges in getting access to modern contraception, primary health care has been used as an important vehicle to extend the benefits of sexual and reproductive health.

An assessment conducted in 2013, with help from WHO and the United Nations Population Fund (UNFPA), set out to determine the level of knowledge about family planning among doctors in North Macedonia and the prevalence of modern contraception use. The assessment showed both low knowledge and low use of modern contraception methods. It further revealed that people in North Macedonia had negative experiences when trying to access prescriptions for modern contraception. They were frequently referred by family doctors to gynaecologists, who were often reluctant to promote the use of modern contraception.

Family planning education for family doctors

To help meet the needs revealed by the assessment, the Government of North Macedonia launched an initiative to better educate family doctors in family planning. According to Dr Gligor Tofoski, Assistant Professor at University Clinic of Gynaecology and Obstetrics in Skopje and National Coordinator for Sexual and Reproductive Health, the first approach considered was to educate gynaecologists about the value and importance of contraception. “But we soon realized that this group that was reluctant to prescribe was actually primarily made up of older doctors who would be retiring soon,” says Dr Tofoski. “So we shifted our strategy and instead planned to focus on educating family physicians and new medical residents about family planning.” The aim was to educate a whole cohort of doctors to prescribe contraception, as well as training the next generation of doctors. For the latter, this meant expanding the medical curriculum devoted to family planning. Prior to the initiative, only 1–2 class periods in the whole curriculum covered the field of family planning.

For those already practising medicine, a series of trainings were developed, using international experts to equip family doctors with modern concepts on family planning, and sexual and reproductive health. These initial trainees then went on to become trainers of their colleagues, delivering a series of workshops. Since 2016, more than 200 family doctors have been trained through these workshops. WHO’s Four Cornerstones of Family Planning have been translated into the local languages, Macedonian and/or Albanian, and all workshop participants receive these materials.

Dr Tofoski says that doctors’ attitudes towards family planning methods have changed significantly since the workshops were introduced. He says initial feedback shows that people now find the process of accessing family planning methods much easier. Family doctors, for their part, are grateful for the education they have received and report a need for more in-depth training on family planning to become more competent in this area.

“Family doctors are absolutely critical to delivering sexual and reproductive health services in North Macedonia,” says Dr Tofoski. However, he cautions that it is not possible to rely on family doctors alone – it is vital to train other health workers too. Using primary health care as a key starting point has helped the country expand access to family planning services and move further along the path to achieving universal health coverage.