7.4 Healthy lifestyles and healthy nutrition
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There is no separate strategy related to nutrition and healthy lifestyles, but some issues are incorporated in Health Strategy 2021-2030. The strategy defines special attention to be paid to the health education for school children, to contribute to better health for young people considered as especially important for the adoption of healthy lifestyles, such as proper nutrition, sufficient physical exercise, prevention of addiction to tobacco, alcohol and psychoactive substances, and prevention of sexually transmitted diseases including HIV/AIDS and mental health problems.
In 2016, an Action Plan on Food and Nutrition in the Republic of Macedonia (2016-2025) (Акциски план за храна и исхрана во Република Македонија 2016-2025) was adopted. The plan envisions action to encourage healthy eating for children, adolescents and young people to be strengthened and become sustainable by promoting a healthy diet throughout their lives.
Based on previous research and behavioral studies, the Ministry of Health initiated preparation of the National Strategy on Sexual and Reproductive Health (Стратегија за сексуалното и репродуктивното здравје во Република Македонија до 2020, со Акциониот план до 2013 година) that was enacted in 2009 for the period 2010–2020. With financial support from the United Nations Children’s Emergency Fund and United Nations Population Fund, the Strategy was developed by an interdisciplinary team of representatives of the Ministry of Health and civil society organizations, and with contribution from other line ministries and agencies, including Ministry of Labor and Social Policy, Ministry of Education and Science, Ministry of Local Self-Government, Agency for Youth and Sports, and the Health Insurance Fund. With regard to the low prevalence of HIV/AIDS in the country, the Ministry of Health initiated a process of building a coordinated national response to prevent a major HIV/AIDS epidemic in 2003. Through multi stakeholder cooperation, the country received funding through the Global Fund to fight AIDS, Malaria and Tuberculosis, amounting to nearly US$ 21 million since 2003. This funding has been used to successfully contain any major outbreak of HIV/AIDS epidemics.
After this National Strategy, for period after 2020 there is no prepared and published National Strategy on Sexual and Reproductive Health.
The National Drugs Strategy of the Republic of Macedonia 2021-2025 (Национална стратегија за дрога на Република Македонија 2021-2025) is also with the coverage of all the citizens of the Republic of North Macedonia, but a special emphasis is placed on young people knowing their vulnerability to the mentioned issues. The Strategy was adopted in cooperation with the Agency of Youth and Sport and it foresees improvement of access to early intervention programs (measures), especially for young people with experimental use of psychoactive substances.
National Youth Strategy 2016-2025 also covers healthy life-style. Thus, Objective 3 emphasizes the importance of establishing healthy eating habits among young people aged between 15 and 19. To achieve this, the Strategy foreseen following measures:
1. Regular general medical examinations for monitoring child development.
2. Developing personal programs for every child in secondary school.
3. Promoting healthy life-styles.
4. Introducing continuous medical education on topics in this area.
5. Involving health workers in training for the prevention of obesity, anorexia and bulimia.
 National Youth Strategy 2016-2025, Agency of Youth and Sports of Republic of Macedonia, (Skopje, 2016), p. 33-34 http://ams.gov.mk/wp-content/uploads/2021/07/National_Youth_Strategy_2016-2025_mkd.pdf (Accessed March 03, 2021)
The Public Health Institute is the bearer of the activities to implement the Children's Initiative for Children's Obesity in Europe (COSI). The World Health Organization's research is conducted in most countries in Europe to explore the trends in weight gain and obesity among school children. The initiative is implemented in accordance with the adopted protocol, every 3 years. The Republic of North Macedonia has participated since 2010, and the activities for implementing the initiative are financed by the National Annual Public Health Program of the Ministry of Health.
According to the Initiative for monitoring obesity in children (Иницијатива за следење на дебелината кај децата), school diets and conditions for physical activity can be improved in order to reduce the high rates of obesity among children in the Republic of North Macedonia. A plan for better nutrition and greater physical activity in schools could be used as a helpful tool in the conduct of such activities, which will be agreed with all stakeholders. Government policies are currently not being implemented in this field.
In 2014, the Government of Republic of North Macedonia launched a campaign for using healthy food and keeping a healthy lifestyle under the slogan “Health is the Choice! Healthy food and a healthy lifestyle mean a long life!” (“Кампања за користење здрава храна и водење здрав начин на живот”) The campaign was aimed at the entire population in North Macedonia, including young people, and aimed at raising awareness among citizens about the importance and the need to use healthy food and a healthy lifestyle as well as increased physical activity. There is no measurable outcome about the success of the campaign.
In the past there were also some campaigns for preschool pupils, but the promotion of healthy eating among young people (15-29) is not high on the list of government policies.
Nevertheless, it seems that there is still awareness among young people about the need for healthy lifestyles, and in May 2018, semi-graduates from a primary school organized a campaign for healthy eating. They delivered lectures and presentations about the importance of nutrition to the health of the organism before students from other departments.
In line with the Laws for primary, secondary and higher education, health promotion is carried out in each educational institution, within close collaboration among the Ministry of Education and Science and Ministry of Health. Health promotion is included in the teaching curricula, but there is no separate National Strategy for health promoting schools. National Bureau for Educational Development (BDE) is an entity under MES and is responsible for designing the school education curricula, monitoring and evaluation.
Health promotion and health education are the main priorities within the Ministry of Health policy, as one of the important subjects in the frame of the National Health Strategy 2021-2030. National Institute for Public Health (IPH) with 10 Centers for Public Health (CPH) are the main institutions involved in planning, implementation, coordination and monitoring of health prevention programs for the whole population, including children and young people, in collaboration with the BDE’s regional offices and with the municipalities and schools.
School programs include variety of activities, such as:
- “Life skills” as a new subject, introduced in the primary schools with lectures for healthy lifestyle, prevention of HIV, STIs and drug addiction, reproductive health/pregnancy, smoking prevention, physical activity and healthy diet, violence in schools, oral health and hygiene etc.;
- Increased number of classes for the subject “Physical education”;
- Comprehensive health promotion materials distributed regularly among students;
- Active involvement of students in preparation of projects for health and
- Organization of workshops for teachers in terms of better promotion of health and health behavior;
- Training courses for teachers for implementation of the new educational curricula prepared in collaboration with Cambridge International Examinations
- Involvement of schools in governmental and international projects and campaigns for improvement of the relationship among pupils from different ethnical groups, etc.
- Improvement of the physical capacities of schools (new and renovated schools with new gyms, new equipment, new laboratories, ecological school yards, etc.)
Main challenges for the nearest future are development of “Strategy for health promoting schools” with WHO and SHE support, increase of public financing for healthy lifestyle programs for adolescents and youth and development of a manual for the implementation of the whole school approach as it is developed in the Netherlands (for example).
Sexual and reproductive health and rights are taboo both at home and at school. According to CSO HERA, in our formal education only 13% of students learned about condoms, and barely 2% about oral contraception. The most common reason for poor health among young people is lack of information, especially about their sexual and reproductive health. School is crucial for the development and information of young people, and thus the right place where they should learn how to take care of their health. Lack of adequate information is one of the main reasons for discrimination, violence, hatred and bullying in the school environment. That is why since 2009 HERA advocates comprehensive sex education (VSE) to be part of the curriculum in primary and secondary schools.
In 2018, a working group was formed in the Bureau for Development of Education to prepare models for piloting VSE in formal education.
Finally, in 2020 the pilot program for comprehensive sex education (VSE) started in 4 schools as part of the educational system. On December 4th was held first training for teachers about comprehensive sex education (VSE).
Positive example for peer-to-peer education is the one mentioned above. In May 2018, semi-graduates from a primary school “Goce Delcev” from municipality of Gostivar organized a campaign for healthy eating. The motto of the campaign was ‘No for fast food and carbonated drinks. Yes for more fruits and vegetables and developing healthy habits.’
They delivered lectures and presentations about the importance of nutrition to the health of the organism before students from other departments. The students decided for such a campaign because of the knowledge that their classmates often eat chips, burgers, and drink carbonated juices. Due to the fact that their classmates do not have healthy habits, they decided to inform them about the harmful effects of such a food and to present what kind of food they should have on the daily menu.
Peer-to-peer education is not the usual method used in education and is mainly implemented by CSOs when establishing activities at school. One example is NGO HERA who has trained a network of educators in sexual and reproductive health that now serve as peer educators in school. Peer education was also promoted by the HIV/AIDS prevention project funded by Global Fund to Fight HIV/AIDS, TB and Malaria with 20 peer educators trained in prevention, but there is no system for regular monitoring of activities beyond project closure.
Funding of such activities is largely donor based, making their monitoring and long-term evaluation almost impossible when the project ends.
The Health Strategy of the Republic of North Macedonia 2021 - 2030 stipulates that the pursuit of better health determinants for all will be achieved through the partnership of individuals, groups and organizations from the public and private sectors and civil society.
Also, in the National Youth Strategy 2016 - 2025, in the area of cooperation and partnership it is stated that the challenges facing the young are complex, and involve many sectors of society and the economy. That is why the only model that can enable these challenges to overcome is through cross-sectoral cooperation with the complementarities of the efforts in implementing the proposed solutions. It is necessary to build partnerships between institutions and civil society organizations and organizations working with young people in order to ensure active participation of young people and appropriate representation of their opinions in solving problems.
There is no available information whether such a partnership is created.
 Health Strategy of the Republic of Macedonia 2020 Reliable, Efficient and Fair Health System, Ministry of Health of the Republic of North Macedonia, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=http%3A%2F%2Fzdravstvo.gov.mk%2Fwp-content%2Fuploads%2F2021%2F12%2F19.11.-SZ-posledna-Konechna-Natsrt-Strategija-MKD.pdf&clen=1352330&chunk=true (Accessed March 3, 2021)
 National Youth Strategy 2016-2025 of the Republic of Macedonia, Agency of Youth and Sports (Skopje, 2016), p. 12 http://ams.gov.mk/wp-content/uploads/2021/07/National_Youth_Strategy_2016-2025_mkd.pdf (Accessed March 3, 2021)
Raising awareness on healthy lifestyles and on factors affecting the health and well-being of young people
In the absence of a National health promotion strategy, there is no systematic way of counseling and information campaigns related to raising awareness on healthy lifestyles and factors affecting the health and well-being of young people.
Awareness raising campaigns are organized usually on the designated day, mainly by CSO sector, in collaboration with line ministries (World Food Day, World AIDS day, etc.). Funding for such events comes from international donors mainly and organization largely depends on availability of funds that defines the scope and timeframe.
An example of CSO campaign is the one for the Comprehensive sexual education. 
 http://seksualnoobrazovanie.hera.org.mk/ (Accessed March 3, 2021)