Policy responses for North Macedonia - HSRM

North Macedonia

Policy responses for North Macedonia

1. Preventing transmission

The section on PREVENTING TRANSMISSION includes information on key public health measures that aim to prevent the further spread of the disease. It details how countries are advising the general public and people who (might) have the disease to prevent further spread, as well as measures in place to test and identify cases, trace contacts, and monitor the scale of the outbreak.

1.1 Health communication

1.2 Physical distancing

1.3 Isolation and quarantine

1.4 Monitoring and surveillance

1.5 Testing

The restriction of movement during the weekends was lifted from 9 May to allow more time outside. However, the Minister of Health appealed to citizens to refrain from gatherings and to abide by the government measures for physical distancing and hand hygiene.
The withdrawal of any restrictive measures was expected to lead to an increase in the number of new cases infected with coronavirus, which would then lead to adjustment and re-introduction of new measures. In May the Government developed plans for a gradual lifting of restrictive measures that reflected this, and which would be accompanied by continuous monitoring and evaluation. The plan highlighted the need to maintain measures for physical distancing overall. It was based on WHO guidance for the relaxation of restriction measures.

As of 12 May the government introduced a draft Transition Strategy which considered epidemiological measures, the national health system, and public health surveillance. The draft proposed a gradual lifting of restrictive measures, with continuous monitoring and evaluation of the situation after their withdrawal. It would be implemented in three phases according to the development of the epidemiological situation. Bars and restaurants were excluded from the first plan, with a separate plan proposed for their re-opening.
Starting on 13 May 2020, new work protocols were introduced in education and training centres, outdoor exercise of individual sports, betting houses and close shopping malls.
Selected Government officials will be allowed to take business trips abroad (although required to adhere to social distancing measures) and boards managing public companies can begin holding meetings. All businesses that include holding meetings and conferences can do so for at most six hours and will have to take mandatory breaks and have all participants wear masks and other protective equipment.
Guidance for managing issues relating to elections and election campaigning was also produced with a clear protocol for operations and voting procedures.

On 16 May 2020, the state of emergency was extended for an additional 14 days. However, curfew hours were adjusted for young people up to the age of 18 and people older than 67 years. All citizens, regardless of age, were allowed to move around outside between 05:00 and 19:00.

The Government implemented a temporary 48-hour lockdown over the holiday weekend 24-25 May, with curfew lasting from Sunday at 11:00 to Tuesday at 05:00. The reason for this was that that non-compliance with protection measures over the previous few days, primarily as a result of family gatherings, had resulted in an increase of cases.

As of 27 May 2020 the Government relaxed multiple restrictive measures, including the curfew. The measure exempting various categories from work were no longer in force, with the exception of those with chronic diseases and children up to pre-school age.
On 27 May the government published protocols for reopening and operating catering business objects and facilities, like restaurants and cafés, which were able to open on 28 May 2020. There were multiple requirements that needed to be followed such as room layout and ventilation, social distancing, and a limit on the number of people per table. Inspectors reportedly encountered significant problems when trying to control the work of restaurants and cafés under the new conditions and protocols, after they were reopened in May. These businesses had been closed for 66 days due to the governmental measures against spreading of the COVID-19.
On 30 May 2020, the Security Council extended the state of emergency for an additional 14 days.
By government decision, disinfection, observance of the minimum required distance while waiting in line, masks and gloves will be necessary while visiting shopping malls and other trade facilities for an additional 200 days after the end of the state of emergency.

On 2 June 2020 the Minister of Health stated that restriction measures could return to some areas (localized action) if epidemiological trends indicated that this was needed. A major concern was that citizens were not adhering to the recommended measures of wearing masks and keeping distance. He announced harsher controls for rule-breakers and requested higher involvement and sanctions.
Public transport returned but free public transport for retired people was canceled as of 2 June 2020. The maximum occupancy of the public transport must only be up to 50% of the capacity of the vehicles. With the new change, companies providing public transport services on the territory of Macedonia must limit the number of passengers in the vehicles to 50% of the total capacity. All passengers and drivers are obliged to wear protective equipment over their faces and all vehicles must be disinfected regularly.
All public administration employees returned to work on 2 June 2020. This excluded employees in education institutions like schools and kindergartens. All chronically ill people, as well as those with disabilities, pregnant women, single parents, those with children under 10 or children with disabilities remain relieved from work due to the coronavirus pandemic but are encouraged to work from home, if possible. New guidance on preventative measures for the workplace was produced by the government.
On 9 June 2020, the Government passed changes to the Decree on implementation of the law for the population’s protection from contagious diseases during a state of emergency.  According to the Decree, if a person refuses to accept a decision to self-isolate, provides false personal information or false data related to persons they had been in contact with in previous days, or fails to implement the measure of home self-isolation, they will be required to undergo 14-day strict isolation (quarantine) in facilities designated by the Government of North Macedonia, with the accommodation costs being covered by the person concerned.

On 12 June 2020, measures were extended to relieve from work the parents of children up to 10 years of age or in fourth grade, chronically ill and pregnant women, single parents, parents of children with disability who use the daycare center service, as well as persons who go to work accompanying completely blind people, people in wheelchairs and people with moderate and severe intellectual disabilities, with the possibility, if it is feasible, to perform their work assignments from home. The Government adopted additional protocols for camping sites.

On 15 June 2020, the President introduced a state of emergency for a period of 8 days (15-22 June 2020), upon a proposal submitted by the Government. This was done to enable the smooth preparation for the upcoming elections on 15 July, including the implementation of measures to protect public health during the election process.

The working hours of the malls returned to normal (10:00-22:00) as of 12 June 2020, except for Sunday which remains a non-working day.

The Government adopted protocols for the re-opening of hotels and other accommodation capacities around the country on 16 June 2020. These included new regulations on the number of occupants per room (2 maximum except for families where up to 4 was permitted), regular disinfection and masks to be worn.
On 19 June 2020, the Government adopted the Protocol for opening swimming pools to swimming clubs only (not for recreational purposes).
On 11 August 2020, the Government accepted changes in the protocols for intercity and international passenger transport, which instead of using up to 50% now allows for using up to 75% of the total capacity of the vehicles.

As of 26 June, gyms were allowed to open and shopping malls were able to stay open on Sundays.

On 29 June a protocol for organizing public events was announced. The protocol allowed public events; however, venues should only be filled to up to 50% of their capacity and there should be controlled entry at events. In addition, tickets must be sold online in advance, and wearing protective masks will be mandatory.

However, on the same day the Minister of Health confirmed that kindergartens will not be reopened any time soon because of a rising surge in new COVID-19 cases.

On June 30th, the Government decided to terminate the ban on sports competitions in collective sports provided there is a strict compliance to preventative measures and the lack of an audience.
On 7 July 2020, the Government adopted the protocol for operation of Day Care Centers for Children and Adults with Disabilities. They also announced that the regulation allowing citizens with children under the age of 10 to stay and work from home was officially annulled.

On 14 September 2020, the Government decided that, starting on 23 September 2020:

• Employees with chronic conditions who were released from work should go back to work. Exceptions to this decision are employees in which there is an exacerbation of the health condition and those with malignant conditions; these employees will need to provide a statement from their doctor.
• Employees on extended maternity leave should go back to work
• Taking into consideration that kindergartens have beenopen since 9 September 2020, the parents of children up to the age of 6 should go back to work.
• Parents of children up to the age of 10 attending school (either in person or online) should get back to work

On 14 September 2020, the Government decided outdoor events to be organized with 50% of the space capacity and a limited number of visitors up to a maximum of 1000 people, and indoors events with 30% of the site capacity and also maximum of 1000 people. However, several conditions remain in place for catering facilities including that live singers or music groups are not permitted in restaurant areas, only 4 people are permitted per table, and the maximum noise level is limited to 55 decibels.

On 28 October 2020, the Parliament adopted the amendments to the Law on Health Care. This included new regulations for the treatment of people with COVID-19. In addition to treatment in public health institutions, patients can now be treated and isolated in private health institutions, with prior consent from the Ministry of Health.

On 20 November 2020, the Government adopted a Decision for introducing state of emergency in the duration of 30 days on the entire territory to protect the public health and to contain the spread of SARS-CoV-2.

On 1 December 2020, the Government adopted the recommendation from the Committee for coordination and management of the system for crisis management to extend the state of emergency by 30 June 2021. They also adopted the decision of the Commission for Infectious Diseases that ski centres can be opened, including a Protocol for COVID-19 safety measures within the ski centres.

On the same day (1 December), the Government also adopted a Protocol for organizing events with media coverage during COVID-19 pandemic. This protocol regulates the presence of journalists on public events according to which the organizers of the event should ensure the safe and continuous work of journalists.

Additional restrictive measures were adopted for the period of 18 December 2020 to 20 January 2021:
• The hospitality services to be opened up until 18:00 instead of 21:00 The celebration on New Year’s Eve in open and closed spaces is prohibited
• Hotels are prohibited to organize celebrations of New Year’s Eve
• The renting of weekend houses and other tourist capacities is prohibited

On 20 January 2021, the Government annulled the decision for restaurants and other catering facilities to only work until 18:00. As of 21 January 2021, restaurants and other catering facilities can remain open until 21:00.

On 7 December 2020, the Government adopted amendments to the Immunization Program which confirmed the intention of the Ministry of Health to participate in the COVAX facility for procurement of 833,000 COVID-19 vaccines. Health workers, older people above 65 years and people with chronic cardiovascular and lung diseases will be the priority groups for vaccination.

On 15 December 2020, the Government released information regarding COVID-19 vaccinations, including with regard to the preparation of the system, the role of UNICEF as the coordinator of procurement under the COVAX mechanism, and the direct negotiations with the European Commission and EU member states.

On 26 January 2021, the Government adopted the National Plan for COVID-19 vaccination in North Macedonia. The vaccination will be implemented in three phases during which different population subgroups will be covered. The phases will be organized in line with the initial quantities of vaccines available and the risk priority vaccination groups. Three main groups will be prioritized in order to ensure the functioning of the health system, to protect those most at risk of disease, complication and death, and to maintain essential critical infrastructure services. The existing health infrastructure and professional staff who have previously been responsible for vaccinations in the country will be used for the implementation of the COVID-19 vaccination. The organization of the system will be adapted as needed by changing circumstances. Once a larger number of vaccines is available, vaccination will be implemented in a wider range with the possibility of involving more vaccination teams and opening points. The national plan also includes safe and secure logistical support for the reception, storage and distribution of vaccines to the points where the vaccination will take place.

On 10 February 2021, a website was launched allowing citizens to register their interest in COVID-19 vaccines (www.vakcinacija.mk). This platform is linked with national e-Health services. Based on the information from the platform, the family doctors will invite patients for vaccination according to the national plan for immunization. As of 19 February 2021, 91 000 citizens have expressed their interest in vaccination, of which 42,371 are people over 70 years old.

On 14 February 2021, 4680 vaccines donated from the Government of Republic of Serbia arrived in the country. Vaccination was initiated on 17 February 2021. Health workers in hospitals with high and very high risk of COVID-19 infection and transmission are a priority group in the first phase of the vaccination according to the national plan. As of 19 February 2021, 453 health workers have been vaccinated.

The Institute of Public Health is responsible at the national level for epidemiological and laboratory surveillance and the response to all threats from communicable disease and to managing the implementation of the International Health Regulations (IHRs). All available surveillance systems for communicable disease are being used for detecting possible COVID-19 cases The Institute exercises its surveillance functions through: a) a syndromic surveillance and early warning system for outbreak identification or ALERT (EWARN) which it upgraded with WHO support to a real-time digitalized system (http://www.alert.mk); b) case-based surveillance of communicable disease as per the classic notification system of suspected and confirmed cases; c) Sentinel Surveillance of Influenza like illnesses (ILI), and Serious Acute Respiratory Infections (SARI). The Institute of Public Health prepares weekly and annual reports that are published on the Institute’s website (www.iph.mk). All confirmed COVID-19 cases and deaths are reported within 24 hours to WHO through IHR channels, according to the guidance provided by IHR procedures  
The regional surveillance network for communicable disease is composed of 10 Regional Centres for Public Health and 21 local Units of the Regional Public Health Centres, which are responsible for surveillance of communicable diseases, detection of clusters/outbreaks and response in their corresponding territory.
The country uses the WHO case definition of COVID-19.
Close contacts are defined as:
- Direct contact face-to-face, lasting more than 15 minutes in any environment with a confirmed case within a 24h period, or
- Sharing a confined space with a confirmed case over a prolonged period of time (e.g. longer than 2 hours), 24 hours prior to the onset of the symptoms in the confirmed case.
All contacts of confirmed COVID-19 cases are traced and interviewed by trained epidemiologists. 
WHO supported North Macedonia for Sero-epidemiological studies investigating the extent of infection in the general population, as determined by seropositivity. A standardized WHO master protocol was tailored to country needs in terms of public health, laboratory and clinical systems, capacity, availability of resources and cultural appropriateness. Using this standardized protocol allowed for comparability of data across different countries and helps to determine important epidemiological parameters (e.g. the proportion of the population that remains susceptible to infection, proportion of asymptomatic infections etc.) which inform public health action.
As laboratory capacity increased following the initial arrival of the pandemic, the Centre for Public Health and the Institute of Public Health developed a plan for screening people considered to be at high-risk (health professionals, employees in kindergartens and care homes, members of the police, public transport drivers, employees in public services and patients prior to hospitalization). The screening is to be done with PCR tests.

The Institute of Public Health and the Centre of Public Health in Skopje completed a plan for COVID-19 screening to start as of the week of 11 May for about 400-500 people of vulnerable groups, including health workers, kindergarten staff, and nursing/elderly homes in the first phase, and in a later phase members of the police, drivers, employees in public service, patients before hospitalization, and patients needing biological therapy. These are categories where it is essential to assess the risk and identify asymptomatic carriers.  Screening was to be done by PCR tests and with the help of primary care dentists and supported by the president of the Dental Association.  By 18 May 2020, 581 employees in kindergartens had been tested for SARS-CoV-2 over the previous three-days as part of the targeted screening following the registration of one COVID-19 case in Bitola. Between 14 and 19 May 2020, 908 screening tests were undertaken among employees in kindergartens in Bitola, Skopje and Veles and only one case has been detected.

Five coronavirus cases had been discovered in retirement homes in Skopje as of 3 June 2020. So far North Macedonia has been spared major outbreaks in these facilities which have claimed many lives in other countries. The cases were identified in privately owned homes managed by the same company in the north and the east of Skopje. In one case two female residents tested positive, and in the other, three employees.

As of 29 July, 62,979 citizens had downloaded the “StopKorona” app launched in April. The app notifies users if they have been in close proximity to potential coronavirus patients, thus help curb the spread of the infection. The aim of the app is to facilitate contact tracing by epidemiologists.

Representatives of the Football Federation of North Macedonia and members of the Commission for Infectious Diseases decided to test all athletes and all persons involved in training sessions ahead of the season restart. The Public Health Institute were to do the required testing.

As of 3 June 2020, 7 textile factories in Shtip were closed after employees tested COVID-19 positive. Three teams of epidemiologists carried out mass testing, a process which covered over 500 workers. 126 cases were confirmed, of which 24 people were hospitalized.

The Minister of Health urged infected citizens to cooperate fully with doctors when being asked about their contacts. It had been reported that many diagnosed patients refuse to cooperate with the mandatory surveys which prevents the full mapping of the new clusters. The Minister also noted that over 40 large clusters were registered in the past period on the entire territory of the country related to various family events where 50-150 people and in some cases 200 people were present.

WHO has worked closely with the Ministry of Health in refurbishing and equipping a dedicated space for real time epidemiological monitoring of outbreaks at the Institute of Public Health. This is part of the USAID emergency funds entrusted to WHO earlier in the outbreak for strengthening North Macedonia capacity in the COVID-19 response. This center is the first and so far only structure in a Ministry of Health among ministries in the Western Balkan countries.

As of 23 June 2020, over 60 000 citizens had downloaded the StopKorona app.

On 6 October 2020, based on a recommendation from the Commission for Infectious Diseases, the Government approved the algorithm for acting in schools in case of suspected or confirmed COVID-19 cases among students.

The first case of the British COVID-19 strain was reported on 27 January 2021.

Since the COVID-19 outbreak began in North Macedonia, the main messages have been for citizens to strictly adhere to government recommendations in order to stop the spread of the virus. On 29 March 2020, the Minister of Health sent a clear message: “the most difficult period is ahead, and cases will grow globally and in the country. Everyone must respect the instructions and the success of this fight will depend on each one of us.”
The Ministry of Health has run a vigorous risk communication campaign in social media, on TV and other channels of communication. There has been a positive public response to, compliance with and trust in the Government’s protective measures and instructions for social distancing. The Minister of Health is the single voice for government measures taken and for reporting cases officially for press releases, media and social media. Public health experts – either from the Institute of Public Health or other departments – also appear in the media providing recommendations to the public for protection and prevention.

A new Government webpage for all official COVID-19 related information was launched on 2 April. It is available in Macedonian and English: www.koronavirus.gov.mk. The Ministry of Health website also has a section entirely dedicated to COVID-19 (http://zdravstvo.gov.mk/korona-virus/) where all information, recommendations, questions and answers related to COVID-19 are posted. The Government’s main website also has a section on COVID-19 where the measures and recommendations for prevention and protection from COVID-19 are regularly updated, including decisions from the Government (https://vlada.mk/covid19).

The Ministry of Health initially posted on social media every day at 12:00 about any new cases registered in the past 24 hours, and the Minister of Health has at least one press conference in the afternoon to present the COVID-19 situation and developments, as well as any updates on government recommendations.
With support from the World Health Organization (WHO), the Institute of Public Health and the Ministry of Health have produced a number of self-explanatory videos based on WHO material, published on TV and social media in three different languages (Macedonian, English and Albanian). They have also published health advice notices (HANs), health declaration forms (HDFs), posters, leaflets and other materials.
As of March 12, 2020, the Ministry of Information Society and Administration initiated messages with recommendations for preventing COVID-19 transmission through mobile applications (text message, Viber message, etc.), which aimed in particular to reach the younger population. This was in collaboration with the Ministry of Health and telephone and national mobile operators. For travellers an SMS is sent automatically, as soon as mobile phones connect to the local telecom network, with helpline number and instructions on how to seek medical help in case of symptoms.

Information for travellers and WHO leaflets in local languages and English were initially distributed at the airport and interviews and screening at points of entry was practiced assessing high-risk situations, in addition to thermal cameras. The International Federation of the Red Cross (IFRC) has also been active through the translation and distribution of WHO and IFRC’s educational materials for the prevention of COVID-19 into the Macedonian and Albanian languages. All UN agencies disseminated WHO educational and awareness material through their social media channels (e.g. Facebook and Twitter), websites and other means. 
On 5 April 2020, the Minister declared that the country had entered a new phase of the epidemic, although it was still a few weeks away from the peak of the outbreak. The number of cases and deaths was expected to rise markedly. On 6 April the Prime Minister declared that additional restrictive measures are part of the response to this critical phase of COVID-19 to protect the health of the people. The Minister of Health urged the citizens to adhere to the restrictions to be able to reduce the number of cases and to maintain the stability of the health system.
On 7 April 2020 the government adopted the regulation for the creation of the “StopKorona!” application for mobile telephones, which the citizens can use on a voluntary basis. The app can be downloaded here: https://stop.koronavirus.gov.mk/en. The goal is to assist the identification of close contacts of confirmed COVID-19 cases and thus to contribute to reducing the spread of the virus. More than 45,000 citizens had downloaded the StopKorona app by 23 April 2020, and the Ministry of Health advised family doctors to recommend the app to patients. The Government later expanded COVID-19-related information channels to include “Коронавирус МК Koronavirus” on Viber and urged citizens to use this channel for access to official and verified information related to the COVID-19 response from their phones.
In April, 16 applications were selected out of more than 500 sent to the CREATON public call to tackle COVID-19 challenges, issued by the Fund for Innovations and Technology Development. The public call was supported by the Embassy of Switzerland to North Macedonia, USAID, UNDP, UNICEF, and the Chamber of Commerce for Information and Communication Technologies (MASIT). Of those that made the cut, there are solutions involving medicine, digital tools as support to micro, small and medium-sized enterprises to weather the crisis, digital tools for education, and tools for culture and leisure. The total budget is 10 million denars and each proposal can receive up to EUR 10,000 in the local currency. The call is the first in a series of the Fund’s initiatives to tackle the COVID-19 consequences.
A Government Call Centre (02/324-8040) was set up to support businesses and citizens with information related to economic measures in response to COVID-19. The call centre is to be expanded to other institutions to strengthen the support for companies and citizens in providing COVID-19 related questions.
The University Clinic for Hematology published advice and recommendations for its patients during the COVID-19 crisis and established phone lines for doctors’ consultations.
In partnership with the National Institute of Public Health, WHO initiated a COVID-19 behavioral survey to gain an understanding of issues such as: trust in health authorities, recommendations and information; risk perceptions; acceptance of recommended behaviours; knowledge; barriers/drivers to recommended behaviours; misperceptions; and stigma.

The Government expanded the team working in the Contact Centre for the economic measures in response to COVID-19, with representatives from the Ministries for Labour and Social Policy, Economy, Finance, Information Society and Administration, the Public Revenue Office and the Employment Agency. The goal is to provide accurate and timely information to support citizens to obtain the assistance they need from the different institutions. 2,674 phone calls by citizens and companies were recorded in the Contact Centre during the last month.

On 19 May 2020, the Minister of Health highlighted that many of the new cases were related to gatherings or home celebrations and urged the citizens to refrain from engaging in such activities. The Minister of Health expressed concern that, despite the appeals of health institutions not to hold mass gatherings and to comply with measures for physical distancing and movement restrictions, this did not happen during Ramadan celebrations in the places of worship.

During World Mental Health Awareness Week (May 18-22), the University Clinic for Psychiatry emphasized the importance of promoting mental health, especially in the context of the Covid-19 pandemic. The University Clinic for Psychiatry opened more phone lines, intended for psychological support of adults in self-isolation, for mothers in pregnancy and childbirth, for parents of children of preschool and school age, for adolescents, for parents of children with disabilities, as well as a hotline for psychological support in Albanian.
On 15 June 2020, the Minister of Health urged parents to make sure that children and young people wear protective masks and are not gathering in groups, since they are typically asymptomatic but can still spread the infection.

The Health Minister urged all political actors to respect the preventative measures and protocols during the election process. He also urged all election-related activities to be tailored in line with the recommendations, expressing an expectation that all political parties agree on how to conduct the campaign and prioritize activities that will not endanger people’s health.

The Head of the Islamic Religious Community reminded believers that the coronavirus is still here, and that the virus is dangerous and spreading rapidly. He urged believers to respect the protection measures and recommendations of the experts.
A number of Official Statements were also released on 23 June 2020 to clarify the importance of maintaining risk communication and preventative behaviours. The World Health Organization's representative in North Macedonia also corrected a claim that the country had the highest mortality rate in the region as a result of the COVID-19 virus, reminding people that it is necessary to be careful when communicating about COVID-19 and making comparisons between countries.
According to a survey in June – conducted by BRIMA in 19 countries around the world – citizens in the country increasingly feared the risk of coronavirus infection, and the worsening situation with the epidemic had reduced citizens' support for the government in dealing with the crisis. During this period the number of people infected with the COVID-19 in North Macedonia rose to a three-digit number and reached its maximum since the beginning of the crisis, despite the fact that measures and restrictions were slowly easing. North Macedonia was among a minority of countries where fears of coronavirus infection are on the rise in comparison to March 2020.

By 30 September, WHO completed the results of two rounds of behavioural surveys to contribute to understanding behaviours of citizens and the communication messages needed for COVID-19 prevention and control. The results will help tailor risk communication and support better COVID-19 prevention at the national level. The project was conducted alongside the social medicine team from the Institute of Public Health.

WHO also collaborated with the office of the First Lady in launching a new media campaign led by the first lady of North Macedonia for proper wear and disposal of fabric and medical masks, to be followed by information on handwashing. The infographics and media spots are disseminated through social media and other audiovisual means and can be accessed on YouTube, Facebook and Instagram.

On 1 November 2020 the Ministry of Health began a communication campaign about wearing masks – using the hashtag #НосамМаскa (“IWearMask) – in order support the Law for Health Protection and to raise awareness about the importance of adhering to the measures and the recommendations of the Commissions for Infectious Diseases.

On 27 November 2020, the Government renewed the National Contact Center for Economic measures where the citizens can get informed about the mitigation measures.

The Institute of Public Health is in charge of COVID-19 testing through its virology and molecular diagnostics laboratory that was designated in 2019 by WHO as the national influenza laboratory after long years of preparations. The national reference laboratory for virology meets adequate biosafety standards to work with pathogens such in COVID-19. Although the national reference laboratory is adequately equipped with trained staff, there was initially a lack of testing kits, swabs for sampling and personal protective equipment (PPE). The reagents donated by WHO Europe ran out after increased testing activities due to a larger than expected number of suspected COVID-19 cases. The overall testing capacity was about 200 tests per day due to the limited number of trained technicians, but could be stretched to 300 tests a day with potential private sector involvement. The lab technicians worked non-stop in 3 shifts.

The testing was initially performed only in the laboratory of the National Public Health Institute. However, upon a Ministry of Health request, other national laboratories were assessed for inclusion and were gradually added. Two private laboratories offered testing funded by out-of-pocket payments by patients who wanted to be tested without referral, although the Ministry of Health required confirmation at the national virology lab. Significant increases were reported in the price of coronavirus test in at least one private clinic (Zan Mitrev), which the clinic blamed on supply shortages.
The Laboratory for Virology and Molecular Diagnosis at the Institute of Public Health  is the only reference laboratory for COVID-19 in the country. It operates in accordance with WHO laboratory testing protocols for COVID-19 with WHO-distributed tests. The national infectious diseases commission recommended not to extend testing capacity to other institutions in order to reduce the risk of spreading infection to health facilities.

On 18 March 2020, new COVID-19 testing guidelines were adopted whereby testing is performed only on persons who have symptoms of an acute respiratory infection, or who meet the WHO suspected case definition of COVID-19.  All contacts of a confirmed COVID-19 case are tested, regardless of whether they have symptoms or not.
Testing is supported by the Association of General Practitioners and nearly 1200 GPs are involved in the identification and early detection of cases, increasing access of citizens to diagnostics by referral to the screening outposts. GPs use the electronic health records platform “Moj Termin” to schedule appointments for testing at one of the 14 testing outlets that take swabs and send them to the national virology laboratory. Any citizen with or without symptoms can call their GP, be checked for symptoms and referred for testing if needed. Ministry of Health mobile teams have existed since the end of March but are designated primarily for older people

As of 12 April 2020, 8,000 tests had been done in the country, equivalent to about 4,000 tests per 1 million people. This was the highest testing coverage in the region. At that point, mass testing was not considered necessary, and only symptomatic COVID-19 cases were being tested, in line with WHO recommendations.
In April, the health authorities announced that 20-30% of the population in Debar, in the areas where the restrictive measures are in place, would be screened using COVID-19 antibody tests. The goal was to assess the immunity of the people in that region which would contribute to framing the expectations for the rest of the country for using antibody tests nationally.

In addition, army medical teams were enlisted to help with coronavirus testing due to the increased workload of the teams that take swabs for testing for coronavirus.

The President of the Doctor's Chamber of Macedonia (DCM) urged doctors who do not believe in coronavirus to put aside their personal beliefs and act upon the recommendations of WHO and the country's health authorities. The DCM had documented that some doctors did not believe in the existence of coronavirus and thus were not sending patients for SARS-CoV-2 testing. Some doctors had publicly announced on their social media profiles that COVID-19 does not exist.

As of 29 June 2020, the Ministry of Health had procured rapid tests that will be used prior to hospital admission of patients. Results were issued within 45 minutes to assist with patient triage. The tests were distributed to the laboratory of Institute of Public Health, Infectious Diseases Clinic and the Clinic for Gynecology and Obstetrics.  On 3 July 2020, the Health Minister and the Association of Journalists agreed to implement free COVID-19 screening among journalists and media workers. The goal wa to test 500 journalists and media workers in an initial 3-day phase and, depending on the outcomes, a second phase would be planned. 

As of 27 October 2020, in the Institute of Public Health a new COVID-19 testing admission point was opened with the aim to speed up the procedure for taking tests for Covid-19. The opening of the new testing point was intended to increase the number of tests performed in the National Public Health Institute to 1000 tests per day, about 150 tests more than before.  A plan to increase the testing capacities in other testing sites has also been presented, with an aim to achieve a daily number of up to 2000 COVID-19 tests in the public health institutions.

As of 2 November, rapid SARS-CoV-2 tests from the company “Abbott” are available in public health institutions. With these additional tests it is expected that the daily testing capacity in the public health facilities will exceed 2,000 tests per day.

As of 26 November, testing with rapid COVID-19 tests began in the General Hospitals in Kochani and Kavadarci, the PHC Centers in Veles, Kumanovo, Bitola and Delcevo. The tests are free of charge and testing can be scheduled only by the family doctor if the patient has had symptoms for no more than five days.
On 27 November 2020, Norway donated 13,500 rapid tests for COVID-19. On 27 November 2020, the Ministry of Health also initiated a procedure for the procurement of rapid tests for COVID-19.

Physical distancing, evening curfew and further movement restrictions were introduced gradually, beginning with the closure of educational institutions and progressing to curfew hours during the day and evenings, on weekends. There were also mobility hours separating younger and older people to minimise risk. Official decisions on more stringent movement restrictions were taken after the President declared a national month-long state of emergency. 
Lockdown was imposed in cities with significant community transmission. On 13 March 2020, the municipalities Debar and Centar Zhupa declared a state of emergency and entered total lockdown.  On 26 March, Kumanovo was also isolated. All public transportation to and within these cities stopped and all shops except food stores and supermarkets closed. The Government recommended manufacturers and trade markets on the territory of Kumanovo which had large production and sales capacities to adjust their operations in order to abide by distancing restrictions in the cities, or alternatively to completely shut down. 
On 13 March 2020, all public and private gatherings were banned nationally, regardless of the number of participants. All stores, shopping malls, restaurants, and other public gathering places were closed, except for food stores, supermarkets and pharmacies – business online is encouraged. All cafes, bars, clubs, casinos and betting agencies were completely closed. All cinemas, theatre shows, sports events and concerts were cancelled. All kindergartens, schools and universities also shut on 13 March 2020. In order to support families, the Government made a decision that one parent of children under the age of 10 (or enrolled in the 4th grade) was allowed to stay at home for childcare during the time when the schools are closed. This measure was not applicable to people working in health facilities, army, fire department and police workforce. On 13 March 2020 a temporary stay at home was also announced for all employees with chronic illnesses and for pregnant women.  Diplomats were not exempted.
On 15 March 2020, the Government recommended all employers in North Macedonia to allow employees to work from home, depending on the type of work and without interrupting the regular functioning of the institution. The Ministry of Health recommended to the textile industry to organize the work process applying preventive measures, such as an appropriate distance between employees.

On 18 March 2020, the office of the Skopje Orthodox Diocese, in addition to the recomendations by the Macedonian Orthodox Church – Ohrid Archbishopric for the territory of Skopje’s Orthodox Diocese – adopted the following measures:
• All religious practices of parish priests prior to and during the Easter holidays should be stopped or postponed. Those that cannot be postponed should to be conducted in small numbers.
• Funerals and memorials should be performed only with the closest family members in the open or at graveyards.
• The use of church halls and clerical offices for meetings, religious lessons, board meetings and other irregular activities is prohibited.
• During worship services, attendees are advised to keep the recommended distance between each other.
• The monastaries should not allow in worshippers, unless there is a specific need.
• Sunday’s and festive holy liturgies should be held outdoors.
On 20 March 2020, the Government decided to ban for a period of 14 days access of persons and vehicles to the Forest Park "Vodno" after 18:00, as well as gatherings of more than five people in parks and other public places, and classes, training and exams at driver training schools. The Government obliged the Ministry of the Interior to intensify controls on private houses and villas that organize parties and gatherings (in the municipality of Sopishte and in the village of Sonje) in order to take measures to prevent such gatherings. Both the owner of the building and the persons present in the premises would be subjected to appropriate legal measures for disregarding the recommendations of the Government.
On 22 March 2020, the Government began implementing restrictions on the movement of all citizens (curfew). People have initially been forbidden to move around outside between 21:00 and 06:00 every day. On the 24 March 2020, the curfew was revised to end at 05:00 am to reduce crowding on public transport during commuting hours. Public transport across the country was discontinued between 21:00 and 05:00.

As of 25 March 2020, the movement of citizens older than 67 years was allowed only between 05:00 and 11:00 and for citizens up to 18 years between 12:00 and 21:00.
On 26 March 2020, a ban on the movement of all citizens during the weekend (Saturday and Sunday) was introduced for the time between 16:00 and 05:00. On 30 March 2020, the Government adjusted the curfew hours during the weekend– movement is allowed for pet owners and their pets between 20:00-20:30 up to 100m from the place of residence.

The authorities also adopted a measure that all markets, pharmacies, banks and post offices should have entry barriers to regulate the distance between people inside the premises, which should be at least 2 metres, and guards to regulate the number of people entering each place.
On 23 March 2020, the Government adopted a decision regarding teaching and the assessment of primary, secondary and higher education. The Government ordered schools and faculties to find ways to teach, test and evaluate pupils and students online. A national platform for e-learning was operational from the 27 March 2020. As of 8 April 2020, the Ministry of Education is considering the possibility to cancel the state graduation examination for all high school students throughout the country.

North Macedonia has a large textile industry constituting a considerable economic sector for the country. On 23 March 2020, the Government adopted a recommendation for the organization of work in factories in shifts for all companies in the country, issuing several directives:
• The number of employees in a certain facility should be limited so that there is a distance of at least 1.5 metres between each of them
• Employees should be provided with protective and disinfection equipment
• Working premises should be disinfected at least once a week
• Employees from different departments should avoid physical contact with each other as much as possible
• All meetings should be conducted via telephone, video-link or e-mail
• If any employees have been in contact with a person who has tested positive for COVID-19, they must be put in 14-day isolation at once.
On 25 March, the government banned the movement of citizens during weekends in the following days: Saturdays and Sundays from 16.00 to 05.00 am the following day with an increased presence of the police in order to prevent the clustering of individuals in groups of more than 5 persons. All previous measures remained in force. 
On 26 March, people who have pets were advised to leave home up to 200 m from their address for 30 minutes within 16:00-21:00 on weekends.
On 31 March 2020, the Government called upon all public institutions and bodies and recommended to the private sector to exempt from work all people who may need assistance – completely blind people, people with wheelchairs and people with moderate and severe intellectual disability due to the higher risk of COVID-19 complications.

On 3 April 2020, movement restriction hours were extended in Kumanovo, with a curfew during the weekend (21:00 on Friday to 05:00 on Monday) and on workdays (from 16:00 to 05:00). These new restrictions were not applicable to the police, the army or health professionals (in the public and private health sector and including family doctors). The pharmacies will also be operational. For agricultural activities, movement within the territory of the villages is permitted exclusively for working purposes.
On 6 April 2020, the Government announced that new decisions restricting the movement of all people on the entire territory of the country would enter into force on Wednesday, 8 April 2020 at 16:00. The conditions were:
- The movement of people on the entire territory of the country was to be prohibited between 16:00 and 05:00 from Monday to Friday. Only people in need of emergency medical care, with life-threatening conditions or dialysis patients, accompanied by up to two persons, will be excluded.
- During the weekends, movement was prohibited from Friday 16:00 until Monday 05:00 for all citizens.
- Citizens above 67 years of age could only move around outside between 10:00 and 12:00 from Monday to Friday.
- Young persons under 18 years old could only move around outside between 13:00 and 15:00 from Monday to Friday.
- Citizens were not allowed to move in public places in groups of more than two people – a parent can be in a greater group with their children who are under the age of 14.
- Farmers could move only within the territory of their village, exclusively for working purposes, e.g. agriculture activities.
- The police, the army, health workers, and markets and restaurants that deliver products were excluded from the ban.
- Pet owners and their pets could move between 20:00-20:30 from Monday to Sunday and between 08:00-08:30 and 15:00-15:30 during the weekend, up to 100m from the place of their residence.

The Government instructed public institutions and bodies to adjust working hours to meet the curfew starting at 16:00 on workdays (Monday-Friday). The Government instructed the Municipal Crisis Headquarters to designate economic operations (grocery stores) to provide essential groceries during the curfew.

Some municipalities were particularly concerned about the Orthodox Easter holidays period, due to fears that there would be travel between municipalities.  
North Macedonia was placed in total lock-down from Friday, 17 April at 16:00 to Tuesday, 21 April at 05:00. Movement in all picnic places, parks and forests was prohibited from Thursday, 16 April, at 16:00 to Tuesday, 21 April, at 05:00.
The period of crisis in the municipalities Debar and Center Zhupa was discontinued as of 12 April 2020. The Government concluded that this measure yielded the expected health results, and no new COVID-19 cases had occurred in Debar in the preceding 7 days.
People in Prilep, Kumanovo and Tetovo were asked to wear masks, scarfs, shawls or similar pieces of clothing to cover the mouth and nose from the 22 April 2020. Organized transport of passengers, namely entry and exit from Tetovo and the surrounding municipalities, was banned as of 21 April 2020. Air, rail and road traffic between Greece and North Macedonia was suspended until 15 May 2020.
On 20 April 2020, all institutions, agencies and local offices in Kumanovo were instructed to reduce their capacities and enforce specific protective measures for the purpose of isolating as many people as possible during this period. The Government recommends that all citizens of North Macedonia, especially those living in Kumanovo, Prilep and Tetovo, reduce outings from their homes, as well as designate one family member responsible for buying groceries and medicines.
The Prime Minister announced that the process for life to return to normal would begin after Labour Day (1 May) but cautioned that the process would be gradual and implemented in several stages.

The Government adopted a Decree with Legal force for the application of the Law on Trade during the emergency for establishing order and discipline at the entrance and inside the facilities where trade is conducted, such as retail or grocery stores, markets and bakeries, during the state of emergency. Every trader was obliged to provide security at the entrance and inside the facility, and to place appropriate markings indicating the direction of movement and observance of the minimum required distance.  Markings had to be placed at the distance of two metres in front of each cash register and in front of the entrance of the facility. Retail business owners were asked to regulate the circulation of people in their establishments, depending on the establishment’s size, i.e. to let inside one person for each 20 m2 of indoor space.

A Decree with legal force was also adopted for mandatory self-isolation during coronavirus testing. All domestic and foreign nationals, symptomatic and asymptomatic who had been tested for coronavirus, should be self-isolated from the moment of taking the test material until issuing the result. The self-isolation should last until a negative test result is obtained.
From the 23 April 2020, the Government adopted a set of changes in the duration of the curfew and the use of protective equipment by citizens:
- All movement was prohibited between 19:00 and 05:00 during weekdays across the entire territory of the country. However, during weekends, movement was prohibited from 15:00 on Saturday until 05:00 on Monday.
- During the weekdays, older people above 67 years old could move between 05:00-12:00 and young people up to age 18 can move between 13:00 to 19:00. On Saturday, older people could move between 05:00-11:00 and young people between 12:00-15:00.
- Mask or protective face coverings were mandatory outside the home, with a few specific exceptions.
The ban of gatherings and groups of people and other restrictive measures regarding physical distancing on public spaces and parks remained the same.
To support these measures, on 27 April 2020 the Commission for Infectious Diseases proposed that the Government implement sanctions for failing to abide by the mandatory protective equipment measures in public. Officials have put forward this proposal after an abundance of photographic evidence showing people not abiding to the mandatory protective equipment measure surfaced on social media.
The Government temporarily adjusted the curfew during the Labour Day (1 May) holiday weekend to tighten restrictions and prevent the risk of transmission during holiday celebrations.
The Constitutional Court eventually decided to annul the restriction of movement of young people up to the age of 18 and older people above 67 years old. The curfew was subsequently updated to cover all citizens equally, regardless of age.

On the 30 May the President declared an extension to the state of emergency by another 14 days to June 13 due to a recent increase in coronavirus cases in the country. A curfew was introduced for all Skopje municipalities, Kumanovo, Lipkovo, Stip, Tetovo, Bogovinje, Brvenica, Tearce, Zelino, and Jegunovce lasting from 21:00 on Thursday to 05:00 on Monday. In all other cities, the curfew will last from 21:00 on Thursday to 05:00 on Friday, as well as from 16:00 to 05:00 on Friday, Saturday, and Sunday. Friday was declared a non-working day for all citizens. Work in textile and leather factories in Shtip was also temporarily prohibited during an extended holiday weekend from 5-7 June.
On 9 June 2020, the Government introduced intensified controls and monitoring in targeted areas of the city of Skopje and the municipalities of Arachinovo, Studenicani, Ilinden, Petrovec and Zelenikovo, as well as the municipalities of Kumanovo, Lipkovo, Shtip and Karbinici, and Tetovo municipalities Bogovinje, Brvenica, Tarce, Zelino and Zelistrano – areas in which a larger number of new cases were registered.
After a period of gradually lifting restrictions over the summer (see Transition measures: Physical distancing), several restrictions were reintroduced due to ongoing concerns about the virus.
On the 20 Oct, the Government of North Macedonia adopted the recommendations from the Commission for Infectious Diseases at the Ministry of Health with the following new restrictive measures:
• to limit the working hours of all catering facilities to 23:00hrs, except those delivering.
• to limit the capacity of passengers on public transport to max 50% of the total number of passenger capacity in one vehicle.
• the entire state and public administration, municipalities and courts, in accordance with the principle and organization of work process of the institutions, to organize their working process in shifts, online from home or reduced by a system of rotations.
• to maintain the ban on attendance at sports competitions organized by the Handball Federation and other sports federations.
Protective masks, scarfs or other covers for the mouth and nose continue to be obligatory in all enclosed areas, such as markets, pharmacies and banks, as well as outdoors in places where there is big crowding and 2m distance can’t be easily maintained. Parliament is set to adopt the amended Law for communicable diseases and enforce a new set of recommendations including wearing a protective face mask outdoors, prohibiting the gathering of more than four people outdoors and limiting the number of visitors at homes.
On 28 October 2020, the Parliament adopted the amendments to the Law on Health Care which stipulated the following:
• Mandatory wearing of personal protection (such as a respiratory mask, disposable surgical mask, reusable textile mask, silk scarf or shawl, cotton scarf or shawl, bandana or similar) when leaving home or when moving around in public places (open and closed areas), on markets, in public transport and when entering indoor spaces with several people gathered, even if for business purposes. Failure to wear a mask outside the home is punishable by a fine of 20 euros.
• Clear regulation on self-isolation, stating that self-isolation is mandatory when testing for COVID-19 - from scheduling of the test or the testing itself, until obtaining the result. Self-isolating must also continue if the result is positive.
• Prohibition of gatherings in public space (parks, public areas or any outdoor area) in certain periods of the day and other measures determined by law.
These measures are due to last for as long as there is a danger of the COVID-19 epidemic continuing.
At the government session on 10 November various new measures were adopted to prevent the spread of the COVID-19 virus, including restrictions on working hours for catering facilities, a ban on the gathering of more than 4 people in public space after 21:00, and limits on hotel working hours. Citizens in the territory of the country were also asked not to move in public spaces after 21:00 except for urgent needs.

The introduction of travel restrictions started gradually, with the closing of some border crossings on 13 March 2020, and the closing of all border crossings to North Macedonia for foreign nationals, passengers and vehicles (except freight vehicles, diplomatic corps representatives and other persons with special permit) as of 16 March 2020. Initially, the Ministry of Health issued an order asking people to self-isolate for 2 weeks if they entered the country recently and came from countries with a high or medium risk, according to the WHO’s list which was revised on a daily basis.
Ohrid is a highly frequented tourist area, but its airport was the first to close. Later, as of 00:00 a.m on 19 March 2020, Skopje International airport was closed except for state, military medical and emergency flights.

The Ministry of Foreign Affairs set up a system of registration for Macedonian citizens stranded abroad and organized their return to North Macedonia with humanitarian flights. On arrival they were quarantined for 2 weeks in designated venues guarded by local security. People self-isolating were mostly citizens who were abroad when the coronavirus was spreading throughout Europe and elsewhere and returned home. By 30 March 2020, more than 9,000 people in the country of 2.1 million were in quarantine or in self-isolation. A number of fines had also been issued to people breaking quarantine.

On 22 March 2020, the Government urged hotels with more than 50 beds to allow them to be used for state quarantine, with up to EUR 10 a day provided per bed as compensation. Hotels that made their capacities available also needed to provide three meals a day for each person using a bed, as well as ensuring the maintenance of hygiene in the hotel. As of 24 March 2020, 8 hotels had offered capacity to serve as COVID-19 quarantine accommodation.

All suspected cases or contacts of a confirmed COVID-19 case are asked to self-isolate for 14 days in their homes.
As of 3 April 2020, the Government reaffirmed that inspectors would continue with intensive field surveillance in order to ensure full compliance with government measures and recommendations related to COVID-19. A total of 5 213 inspections were carried out and the general conclusion was that most entities were respecting the Government’s measures for prevention of coronavirus. That said, by the 4 April 1322 individuals had violated the curfew.

As of 9 April 2020, a decision was made to extend the 14-day state quarantine for people to be returned from Italy via humanitarian flight to be at least 21 days. Citizens returning to North Macedonia from countries with a high risk of COVID-19 also had to spend 21 days in quarantine. As of 12 April 2020, the mandatory state quarantine was expanded to include citizens arriving in the country via land convoys, in addition to humanitarian flights. As of 15 April, 152 citizens had been repatriated from Italy, and over 3,000 Macedonian nationals stranded abroad had been repatriated in total.
For quick and easy contact with the teams who help vulnerable people in home isolation a mobile phone app (www.pomagame.mk) is being used.
A citizen association called “Youth Can” created a digital platform “Time Bank” to allow citizens to share different options for activities they could do during isolation in their homes. The platform allowed users to convert the time spent in their own homes doing activities suggested by the platform into credits they can later use for purchasing products and services from different businesses.

There were several small outbreaks which were kept under control. For example, as of 23 May 103 police officers had been put in isolation in Skopje, Tetovo, and several other cities throughout the country, 14 of which have tested positive for COVID-19. Six COVID-19 cases had also been registered among textile workers in Shtip.
Health protection protocols have been poorly respected by the public especially in the popular tourist areas of Strumica, Prilep, Veles and Ohrid. Temporary bans have been introduced in several night clubs and pools because measures for protection against COVID-19 were not being respected. Regular inspections are carried out and there is a decision that if irregularities are identified, the immediate temporary closure of restaurants or other spaces will follow, and criminal charges may be brought against the owners. A social media movement has started whereby citizens post information about events and places that are breaking protective rules.

Specific periods of time were especially challenging for enforcement. During one holiday period – a long weekend in early June – the Interior Ministry registered 5,397 curfew violations, most of which were in Skopje (340), between 21:00 on Thursday (June 4) and 05:00 on Monday (June 8). 1,777 people were caught without appropriate protective equipment, i.e. face masks, with the majority of such offences registered in Strumica (417) and Ohrid (356). During that period, 8,701 police controls were conducted to check whether people were abiding by temporary stay-at-home orders.

In June it was decided that the names of people refusing to accept self-isolation orders were to be made public, involving some 450 self-isolation orders.

Eight mosques were temporarily closed in Kichevo on 3 July 2020 due to COVID-19, as the imam of one of the town’s mosques tested positive.

On 18 August 2020, the Government adopted a new protocol for isolation. According to the new protocol the isolation period for asymptomatic people is 10 days after the test, 20 days for symptomatic people and for the close contacts of a confirmed case the period is 14 days after the last contact with the confirmed case.