BACKGROUND: Macedonia has universal public health care coverage. Acute and emergency patient care is provided in different care environments based on the medical complaint and resource proximity. While emergency medicine and well organized emergency departments (EDs) are an essential component of any developed health care system, emergency medicine as a specialty is relatively non-existent in Macedonia. DATA RESOURCES: A system assessment regarding presence, availability and capacity of EDs was completed from 2013–2015, based upon assessments of 21 institutions providing emergency care and information provided by the Ministry of Health. This assessment establishes a benchmark from which to strategically identify, plan and implement the future of emergency medicine in Macedonia. RESULTS: In general, emergency departments – defined by offering acute care 24 hours per day, 7 days per week – were available at all general and university hospitals. However, care resources, emergency and acute care training, and patient care capacity vary greatly within the country. There is limited uniformity in acute care approach and methodology. Hospital EDs are not organized as separate divisions run by a head medical doctor, nor are they staffed by specialists trained in emergency medicine. The diagnostic and treatment capacities are insufficient or outdated by current international emergency medicine standards and frequently require patient transfer or admission prior to initiation. CONCLUSION: Most of the surveyed hospitals are capable of providing essential diagnostic tests, but very few are able to do so at the point or time of presentation. While emergency medical services (EMS) have improved system-wide, emergent care interventions by EMS and within al hospitals remain limited. Further system-wide acute and emergency care improvements are forthcoming.