Introduction: Existing Macedonian Legislature Regarding Human Rights in Healthcare
At its separation from the Socialist Federal Republic of Yugoslavia, Macedonia underwent a period of extensive legal reform, including the implementation of notable healthcare legislation . Thereafter, the government continued to affirm the right to health in its laws by including various protections for patient rights, health insurance, and mental health provisions. Articles 33 and 38 outline the responsibilities of health care institutions and health care workers, respectively, including both patient rights and mechanisms for protecting patient rights .
The primary focus of existing Macedonian healthcare legislation is patient rights, but these rights are encompassed by the broader and less defined category of human rights. Patient rights refer to clear, written policy that all personnel agree to by license or contract upon employment. These rights may include patient access to their health information or patient volition to refuse treatment. These procedures are central to care and can clearly be outlined, but peripheral solutions to peripheral issues are more difficult to implement and enforce. In other words, one of the barriers of advancing human rights in healthcare is the inability to clearly articulate where these rights are violated and how to combat these violations with legislation, if at all possible. Human rights are violated in more abstruse ways, such as in the quality of the care given, which can more easily be concealed due to its immeasurable nature.
Human rights are touched on through Macedonia’s adoption of international standards such as the “Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment” or “the International Convention on the Elimination of All Forms of Discrimination against Women” . Thus, human rights are beginning to be covered in Macedonian legislature through its overlap with patient rights and international standards, however, there are still human rights issues that have yet to be addressed.
Marginalization of Minorities and Defining Intersectionality
Historically, minorities tend to be marginalized in society and resultantly mistreated when receiving health care. Before explicating the concept of intersectionality, it is crucial to first recognize the ways that various minorities are marginalized. Groups can be oppressed based on being a minority of ethnicity, sexual orientation, gender identity, occupation, and more. For the sake of brevity, a few of the most prevalent minorities will be discussed.
Marginalization on the basis of ethnicity is a theme many societies, but in Macedonia, the neglect of Roma people is perhaps the most pertinent example. Roma suffer from marginalization in several respects, notably characterized by high rates of poverty and unemployment . These economic factors not only stem from social issues, but also cause social issues and enforce disparities. In other words, the lack of employment opportunities available to Roma people may be limited to due discrimination by employers, and an unemployed-status would make it more difficult for Roma to obtain health insurance, obtain pharmaceutical treatments or vaccinations, or purchase nutritious foods. These factors compound to yield numerous health concerns, demonstrated in the Roma populations’ higher infant mortality rates, shorter life expectancy, and low height, weight, and body mass index compared to their Macedonian counterparts .
Other traditionally marginalized groups are sexual and gender minorities (SGM) as well as transgender individuals. Similarly to Roma, SGM and transgender people can find it difficult to obtain employment due to prejudice . Thus, these groups are disproportionately involved in sex work, a field categorized by violence, disease, and mental health epidemics . SGM and transgender people are also uniquely exposed to health issues related to sexually transmitted diseases and various forms of cancer, such as cervical, vaginal, and penile . These issues are compounded by these patients’ tendency to conceal factors such as sexual history or profession from their physicians out of fear of discrimination or harsh treatment. Additionally, SGM people face the hurdle of not having same-sex marriage recognized in Macedonia, which means that same-sex couples do not receive the health insurance benefits that opposite-sex couples do.
A common theme among these minorities of ethnicity (Roma), gender and sexuality (gay, lesbian, bisexual, and transgender persons), and occupation (sex work) is their low socioeconomic status (SES). A low SES makes it exponentially more difficult to maintain optimal health due to a lack of health care, treatments, pharmaceuticals, nutritious foods, and more. Additionally, a low SES culminated with preexisting discrimination in health care yields worse health outcomes, creating inveterate health care disparities in the population.
Intersectionality is the concept of multiple identities intersecting to give each individual a unique experience engaging in society. Thus, the quality of each individual’s healthcare is dependent on their specific intersecting identities, and this can be problematic if a person has multiple identities that are traditionally prejudiced against in healthcare. Intersectionality amplifies the effects of marginalization and discrimination within healthcare institutions.
Various identities intertwine and have potential to put individuals under multiple layers of oppression. Consequently, the solution lies in the task of untangling the discrimination, seeing each facet clearly, and combatting it with antagonistic policies to keep healthcare institutions accountable.
The Effects of Intersectionality in Healthcare
As previously discussed, one effect of minority discrimination is the difficulty of finding employment. Resultantly, minorities are pushed into low-wage work, poverty, or occasionally high-risk work. There is a disproportionate rate of ethnic and sexual orientation minorities in sex work, a field that often entails sexual or physical violence, high risk of sexually transmitted disease contraction, and high stress levels . All of these health issues demand medical attention, yet ironically, these people are unable to obtain proper healthcare, if any healthcare at all, due to discrimination. The effects of discrimination appearing within patients may include their fear of obtaining care or fear of incarceration due to sharing relevant health information relating to sex work, an illegal form of work in Macedonia . The effects of discrimination appearing within healthcare staff may include the denial of a patient’s health insurance or harsh treatment by healthcare staff.
There is a funnel of minority discrimination that leads to health care disparities, and it begins with discrimination that increases the number of individuals with a low SES. In addition to escalating health issues, low SES and marginalizing intersectionality put more individuals into poverty or high-risk work, leading them into a perpetual cycle of harm. They first face discrimination that then makes it difficult to obtain health insurance, and if they receive care after a dispute, their care has been delayed. A delay in obtaining care could potentially mean that a patient was neglected preventive care measures, leaving them with irreversible or chronic health conditions. The terminality of their conditions would cause healthcare providers to revert to palliative care methods as a desperate last attempt, enforcing the notion that these intersectional minorities are second-class civilians in society.
Intersectional minority status breeds a culmination of physical and mental health issues that contribute to a “double whammy” effect, where these health issues not only exist, but persist, given the current structure that creates inveterate health care disparities in healthcare institutions. For example, a transgender Roma sex worker would experience numerous difficulties in obtaining healthcare and could potentially face a new set of obstacles when finally stepping into a health care institution. Therefore, this individual’s intersectionality makes it extremely difficult to maintain their health and wellbeing and also serves to enforce health disparities in their respective identities.
Legislative Propositions for Advancing Human Rights in Macedonian Healthcare
The issue of intersectional marginalization and discrimination in healthcare is clearly complex and perplexing. Since this issue is multifaceted, policy makers can begin to point to legislative direction by first entangling the diverse ways patients are oppressed. However, solutions that come from different angles of the issue vary in practicality and difficulty.
Since the overarching issue of low SES is an agent of diminished health, policy makers can trace this phenomenon backwards to identify solutions. In the case of Roma or other ethnic minorities, obtaining health insurance is a focal issue. Many Roma lack healthcare due to their lack of identification documents and citizenship status. The first Citizenship Law in 1991 left many Roma without citizenship status, identification, and therefore health care . Administrative measures to help Roma obtain identification documents or citizenship could enable them to obtain health insurance and healthcare. Rather casting Roma out as a homogenous minority and worsening their marginalization, it would be more beneficial to work at the root of the problem, which is addressing Roma’s structural socioeconomic challenges .
A potential solution for similarly helping SGM obtain health insurance and health care is Macedonia’s recognition of same-sex marriage and adoption of family insurance policies. Sex workers may neglect to seek healthcare due to fear of incarceration since sex work and prostitution is illegal in Macedonia. Since all citizens have the right to health in the republic, a potential solution for granting sex workers health care is a pardon in appropriate or emergency circumstances. The right to a social worker or other guidance to explore options for employment may be a way to divert individuals from entering sex work.
Under the name of a republic and the Macedonian Constitution, all citizens have been granted the right to health regardless of identity or minority status . Thus, more specific policies in appropriate institutions need to be established to accomplish the goal of equality and health of the nation. To improve the overall population’s health, it is vital to avoid the “double whammy” of contracting health problems and then being discouraged from seeking care, which instills health disparities in the population.
The last and least concrete legislative proposition is policy to keep healthcare institutions accountable for discrimination and policy that encourages personnel to examine existing biases towards minorities. In these statutes, the authors should aim for specificity of discrimination and explicate the manifestations of discrimination.
Human rights issues grow and change as nations do, and a continuous aim to eliminate intersectional marginalization and discrimination is essential for creating a just and fair nation. To achieve the goal of all human beings having equal opportunities to achieve optimal wellbeing, the government must strive to understand marginalization and discrimination as it continues to develop.
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 Salioska, Nesime, Theodore T. Lee, Ryan Quinn. “Advancing human rights in patient care of Roma: access to health insurance in Macedonia”. Public Health Reviews, (2017). https://publichealthreviews.biomedcentral.com/track/pdf/10.1186/s40985-017-0064-5
 Law on the Protection of Patients’ Rights, Official Gazette of the Republic of Macedonia, No. 82/08 (2008).
 “Without Laws It’s All Worthless”, Subversive Front, (2017).
 Soohoo, Melissa, Magaly Blas, Gita Byraiah, Cesar Carcamo, Brandon Brown. “Cervical HPV Infection in Female Sex Workers: A Global Perspective”. The Open Aids Journal, (2013). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3915319/
 “Adult Sex Work”, National Sexual Rights Law and Policy Database. http://sexualrightsdatabase.org/static/country-456.html
 Constitution of the former Yugoslav Republic of Macedonia (1991).