This study explores the key drivers of North Macedonia's fiscal deterioration, marked by persistent budget deficits and a sharp rise in public debt to a historic high of 62.4% of GDP by 2024—an increase of 39.4%, or 2.7 times its 2008 level. It offers a critical assessment of the credibility of the projected medium-term debt trajectory that is premised on expectations of robust economic growth and optimistic fiscal projections, which may fail to materialize amid heightened global trade-related uncertainty and rising geopolitical tensions. Structural weaknesses—such as stagnant productivity, a shrinking working-age population, and high youth emigration—combined with low statutory direct tax rates, widespread tax expenditures, growing spending pressures, and significant budget rigidity—further undermine the fiscal consolidation outlook. A realistic reassessment of the medium-term fiscal strategy, underpinned by evidence-based tax policy and structural expenditure reform, constitutes a prerequisite for formulating a more credible and accelerated fiscal consolidation path. Institutionalizing the “value-for-money” framework and embedding spending reviews into the regular budget process may support the consolidation process, by helping enhance the effectiveness and the technical, allocative, and functional efficiency of public spending.