Key points: ● North Macedonia’s health system provides a relatively comprehensive basic benefits package, with more than 90% of the population covered under the social health insurance scheme. ● Public spending on health increased in response to the COVID-19 pandemic, but remains comparatively low. There is a continued strong reliance on out-of-pocket (OOP) payments which accounted for 41.7% of health spending in 2021, one of the highest shares in south-eastern Europe. ● Most primary care services are free at the point of delivery but certain health services, in particular outpatient specialist visits, prescribed outpatient medicines and inpatient care, require user charges. ● Catastrophic health spending remains a problem, particularly for poorer households, and is largely driven by OOP payments for outpatient medicines. ● Unmet needs for medical care due to financial reasons have declined over the last decade but remain relatively high among people on low incomes. ● The information system Moj Termin (My Appointment) has greatly improved scheduling and waiting times for clinical appointments and diagnostic tests. Its effectiveness could be further expanded in primary care by using it for scheduling appointments and allowing primary care nurses access. ● The COVID-19 pandemic has severely impacted life expectancy in North Macedonia, which in 2021 fell back almost to its 2000 level. ● Childhood immunization rates were falling even prior to the COVID-19 pandemic and declined further in 2020 and 2021. ● Maternal and infant health improved markedly in recent years, but the quality of prenatal and perinatal health service delivery remains a concern. ● The country faces a high burden of noncommunicable diseases (NCDs), but mortality from stroke and ischaemic heart disease has decreased in recent years. ● The population is at risk from high blood pressure, unhealthy diets (including high salt intake), smoking, high blood sugar and, to a lesser extent, alcohol consumption. North Macedonia has one of the highest smoking rates worldwide. Increasing overweight and obesity among adults and adolescents, as well as respiratory ill-health and death due to air pollution, are other major public health concerns. ● The health workforce has increased in the last decade, but faces pressures of outmigration and ageing.