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European Observatory on Health Systems and Policies

Croatia


Health Systems in Transition (HiT) profile of Croatia

4.2 Human resources

4.2.1 Health workforce trends

At the end of 2012, Croatia’s health care system had a permanent workforce of 74 241. Of these, 56 598 (77%) were health professionals and associates, and the remainder worked as technical (12 470 or 17%) or administrative (5173 or 7%) staff. There were also 7149 part-time employed health workers, of which 830 were physicians (out of a total of 13 640 physicians) (CNIPH, 2012).

Physicians

In 2012, full-time physicians accounted for 12 810 or 17.3% of the permanent workforce in the health sector or 22.6% of the number of permanent health professionals and associates. The majority of permanently employed physicians (75.8% of the total number of 12 810 physicians) worked in public health care institutions; 5.1% in private health care institutions; and 19.1% in private doctors’ practices. The majority of doctors working in private doctors’ practices (73.5%) worked in rented facilities (i.e. concessions). Most doctors working in (public and private) health care institutions other than private practice worked in hospitals (58.7% of all permanently employed physicians), followed by health centres (8.9%), state health institutes (4.5%) and emergency medical care stations (3.4%). Other physicians worked in independent (i.e. not contracted by the CHIF) private polyclinics and health care companies (5.1%) (CNIPH, 2013).

The majority of permanently employed medical doctors (61%) were female, and 70.6% of permanently employed doctors had a specialization. About 14.7% of specialists specialized in internal medicine, 6.6% in paediatrics and 6.1% in psychiatry. Only 2.8% specialized in family medicine and 0.3% specialized in public health (CNIPH, 2013).

The number of physicians per 100 000 inhabitants increased from around 212 in 1990 to 299.4 in 2011 but is still substantially lower than the EU27 average of 346 (Fig4.5). There is a perceived shortage of physicians, especially in family medicine. Shortages are also observed in rural areas and on the islands.

According to a study on the regional distribution of physicians in Croatia conducted in 2006, there were significant differences in the number of physicians per 100 000 inhabitants between the counties. For example, the number of GPs per 100 000 inhabitants ranged from 47.1 in Pozeško-Slavonska County to 61.8 in Primorsko-Goranska County (the national average was 54.2). There were also significant differences in the number of specialists per 100 000 inhabitants between the counties (Drakulić, Bagat & Golem, 2009).

Nurses and midwives

The number of nurses in Croatia has been rising continuously over recent years, from 506 per 100 000 in 1990 to 579 per 100 000 in 2011. The number of nurses per 100 000 inhabitants in Croatia in 2011 was well below the EU average of 836 (Fig4.6 and Fig4.7) and the ratio of nurses to physicians, at approximately 2:1 in Croatia, was lower than the same ratio in the EU15 countries (2.3:1) (Fig4.7). Nevertheless, unemployment was recorded among this category of medical professionals.

The majority of nurses and medical technicians (71%) have at least college and high school qualifications; the remaining 29% are mostly health care engineers and technicians. According to data from the Croatian Chamber of Nurses, in 2010 there were 6147 nurses/medical technicians with a university degree in nursing (Government of the Republic of Croatia, 2012). Most nurses and technicians work in clinical hospital centres, clinical hospitals and clinics, and general hospitals.

In 2012, there were 38 midwives per 100 000 inhabitants in Croatia, which is slightly more than the EU27 average of 33 (CNIPH, 2013). However, according to data from the Croatian Chamber of Midwives, about a third of all registered midwives do not work in their profession but are employed as nurses, laboratory technicians and dental assistants (Croatian Chamber of Midwives, 2011).

Dentists

The number of dentists in Croatia has risen substantially over the years, from 47 per 100 000 in 1990 to 72 per 100 000 in 2011 – above the EU27 average of 67 (Fig4.8). In 2012, out of the total of 3185 dentists, 698 worked in State health institutions, 189 in private health institutions, and 2298 in private dentists’ practices. About 14.7% of dentists (467) had a specialization (CNIPH, 2013).

Pharmacists

The number of pharmacists in Croatia rose substantially from 39 per 100 000 in 1990 to 70 per 100 000 in 2012. This is much less than the EU15 average of 76 (Fig4.9) and there is currently a shortage of pharmacists in Croatia. One of the reasons for this shortage is the fact that foreign pharmaceutical companies that open offices in Croatia offer well-paid jobs to pharmacists, particularly in the marketing of finished products.

4.2.2 Professional mobility of health workers

There is no systematic surveillance or reporting of migration trends in the health sector. The key destination countries of health workers trained in Croatia are Slovenia, Italy (particularly nurses), other western European countries and the United States. Some doctors that are residents of other countries (especially of Bosnia and Herzegovina or Serbia) but have Croatian citizenship immigrate to Croatia, but data on such flows are scarce. It is expected that the number of foreign students coming to Croatia to study will increase (following Croatia’s EU accession), especially from countries with less developed medical education. There is no migration strategy on the national level but efforts have been made to harmonize Croatian policies on professional mobility with the EU policies (in the area of recognition of diplomas and licences) (amendment to the Health Care Act of 28 June 2013).

Apart from the outward migration, there are several other migratory pathways in Croatia. These trends are not systematically measured (Babić-Bosanac & Džakula, 2006) but, according to anecdotal evidence, some (especially unemployed) health care workers leave the medical profession to work in other professions, for example, as sales representatives for pharmaceutical companies or in medical trade companies. Regional migration occurs within the country, with health care workers moving from less developed rural areas to city centres (which results in medical staff shortages in the rural areas). Doctors undergoing internships also prefer to work in the City of Zagreb rather than move to other Croatian regions. The main reasons why health workers leave rural areas are family commitments and lack of technical support in the rural areas.

An increase in migration of Croatia’s health workforce to other EU countries was expected after Croatia’s EU entry. This related especially to nurses, due to the lack of employment opportunities in Croatia. At the time of writing, no information on the actual trends was available (however, the number of medical doctors collecting documents from the Medical Chamber allowing them to seek employment in the EU appears to be increasing). Long-term measures to increase the number of health workers are: increased enrolment quotas and encouraging young people to study medicine, primarily through financial incentives and the improvement of physicians’ living standards (mainly through salary increments) (Drakulić, Bagat and Golem, 2009).

4.2.3 Training of health workers

Five types of medical professionals (medical doctors, nurses, dentists, pharmacists and midwives) fall within the system of coordination of minimum training conditions according to Directive 2005/36/EC on the recognition of professional qualifications. Croatia meets these minimum training conditions for all five categories of medical professionals. However, according to the National Health Care Strategy 2012–2020, the field of nursing education is insufficiently regulated, and there are discrepancies in the educational standards of several types of health worker (see Section 2.8.3).

Medical doctors

Four universities offer medical education in Croatia (in Zagreb, Osijek, Rijeka and Split). It takes six years to complete the medical degree for doctors (Doctor of Medicine). After completing the degree, students must complete a one-year supervised (and paid) internship programme at the hospital of their choice and pass the State examination, the Croatian Medical Licensing Exam, organized by a special commission at the Ministry of Health. Doctors who pass the examination must apply for a licence with the Croatian Medical Chamber in order to be able to practise. All medical doctors practising medicine in the Republic of Croatia must register with the Chamber.

The internship and the state examination are not obligatory for medical doctors who are nationals of EU Member States. Since the EU accession, EU rules on the recognition of medical education also apply in Croatia.

Specialization programmes are offered in 46 areas. These are competency based and doctors undergoing specialization training maintain log books detailing completed interventions and procedures. Doctors obtain generic competences (skillful communicator, collaborator, scholar, manager, health advocate and professional) and specific competences that comprise medical skills, knowledge and attitudes particular to each area of specialization. All specialties with a common trunk (e.g. internal medicine and surgery) have the same competences for the common trunk segment. The National Commission for the Specialist Training of Physicians is responsible for defining the generic and specific competences, and for evaluating, assessing and improving the quality of specialist training of physicians. Each specialty training programme defines the specific criteria required for a health care institution (hospital) to be accredited as a training institution. The Ministry of Health grants accreditations and supervises specialization programmes.

The duration and content of each specialization programme must meet the minimum requirements set by EU Directive 2005/36/EC. In addition to training at accredited specialty training institutions, a resident trainee attends a full-time three-month postgraduate specialty course at a medical school. Training ends with a specialist medical examination and those who pass this obtain a specialist diploma and are registered by the Chamber as a specialist.

Compulsory relicensing of all medical doctors was introduced in 1996. In order to be relicensed, a medical doctor must collect 120 credit points (through CME, publications, etc.) over a period of six years and apply for a renewal of their licence with the Chamber. If the applicant fails to earn a sufficient number of points, he or she will have to take a re-assessment examination in front of the Chamber Examination Commission.

A medical doctor’s licence may be temporarily or permanently revoked subject to a Decision of the Chamber Court. The Chamber Court may also temporarily or permanently restrict the licence with respect to the scope and type of medical treatment and services the doctor is allowed to provide.

Nurses

Nurses complete either a course at a vocational high school for nurses or a Bachelor’s degree in nursing at a university, followed by a compulsory internship and a State examination. Those who pass the examination are eligible to apply for a licence with the Croatian Nursing Council and are subsequently entered into the register. After passing the State examination, nurses can attend one of the two postgraduate specialist programmes, in public health or management. A number of specializations are also available in psychiatry, paediatrics, internal medicine, intensive care, surgery and emergency medicine.

Nurses are required to participate in continuing education and collect 90 points during a six-year period (a minimum of 15 points a year). If a nurse fails to earn a sufficient number of points, he or she will have to take a re-assessment examination in front of the Croatian Nursing Council.

Dentists

Dentists complete a six-year university programme in dental medicine, followed by a compulsory internship and a State examination. Those who pass the examination may apply for a licence with the Croatian Dental Chamber and can be subsequently entered into the register of doctors of dental medicine. Dentists may then choose one of eight specializations.

Dentists are required to participate in continuing education (a minimum of 10 points a year) in order to have their licence renewed.

In 2009, the Chamber recognized two categories of auxiliary dental staff: dental technicians (working independently) and dental assistants (working under the direction and supervision of a doctor of dental medicine). Dental technicians and dental assistants complete a degree (four years) in vocational schools and are registered by the Chamber (registration gives them the right to practise).

Pharmacists

Pharmacists complete a university degree in pharmacy (five years), followed by a compulsory internship and State examination. Those who pass the examination are eligible to apply for a licence with the Croatian Chamber of Pharmacists, and will subsequently be entered into the register of pharmacists. The licence has to be renewed every six years and to achieve this they need to collect a minimum of 5 points a year.

4.2.4 Doctors’ career paths

After passing the State examination, doctors can choose either to pursue a career in academia or to work as a clinician and seek promotion to different managerial grades within the hospitals. A doctor choosing the academic path will begin as a research assistant and may then be promoted to the level of assistant, assistant professor and, eventually, full professor. Doctors choosing clinical careers will first undergo specialist training (as resident doctors). After passing the specialization examination, they can be promoted to the position of chief of department or chief of staff and ultimately to that of hospital director. These decisions are taken internally at the hospital level and are based on merit.

4.2.5 Other health workers’ career paths

Nurses can advance professionally in hospitals to become head of department nurses and, eventually, hospital head nurses. According to the Health Care Act, nurses are members of the governing bodies in hospitals and participate in the decision-making.

On 27 September 2019 the Ministry of Health signed Appendix II of the Collective Agreement on Health Care and Health Insurance, agreeing with the trade unions to increase salary supplements from 1 September onwards, amounting to an increase of HRK 400 million per year. The Collective Agreement entails an increase of 3% in the allowance for special working conditions, as well as a 4% increase in the allowance for exceptional responsibility for life and human health. There will also be an allowance for on-call work and associated transportation costs. Appendix 2 of the Collective Agreement will be implemented by 31 December 2022.

For more information (in Croatian) see:
https://zdravlje.gov.hr/vijesti/potpisan-dodatak-ii-kolektivnog-ugovora/4747
https://zdravlje.gov.hr/UserDocsImages/2019%20Vijesti/Dodatak%20II.%20Kolektivnom%20ugovoru%20za%20djealatnost%20zdravstva%20i%20zdravstvenog%20osiguranja.pdf

In September 2019, the Croatian Medical Chamber (HLK), the Croatian Medical Union (HLS), and the Croatian Medical Association (HLZ) adopted the September Declaration on Medical Practice and the Health System. The document is an appeal to the Government to address the “unsustainable state” of the country’s medical profession and health system. It requests to set up a task force to draft a Law on Physicians' Salaries or a Collective Agreement for Physicians by the end of 2019, that will regulate the work, status and position of physicians.

For more information (in Croatian) see:
https://www.hlk.hr/hlk-hls-i-hlz-vrijeme-necinjenja-u-hrvatskom-zdravstvu-je-isteklo.aspx
https://www.hlk.hr/EasyEdit/UserFiles/priop%C4%87enja/rujanska-izjavaweb.pdf

In December 2017, REGIOMED Clinics (Bavarian hospital group and one of the largest hospital groups in Germany) and the Medical Faculty of the Split University in Croatia entered into partnership to provide medical education. The initiative was supported by the Bavarian Ministry of Health and the Minister of Health of the Republic of Croatia.

As part of this collaboration, up to 30-40 Bavarian students per year can enroll in preclinical lectures at the Medical Faculty of Split University. Clinical part of the medical degree can be completed in clinical hospitals in Split and Coburg. Specialist doctors from REGIOMED Clinics will also be able to attend doctoral studies at Split University - 20 are currently enrolled. Moreover, professors from Split University will be able to attend lectures at the REGIOMED Clinic in Coburg.

https://zdravlje.gov.hr/vijesti/suradnja-medicinskog-fakulteta-u-splitu-s-bavarskom-regiomed-kliniken/3048

In May 2015 the government adopted the Strategic Plan for Human Resources in Healthcare, 2015-2020. The Plan recognizes that one of the fundamental problems in the area of human resources development in the Croatian health system is the lack of a human resources management system. There is a need for the development of a comprehensive system of monitoring of human recourses in the health system in order to improve the projections of human resources supply and estimation of human resources needs in the health sector (both the number and structure). The goals of the Plan are to develop a system of organization and active management of human resources in the health sector with the aim of achieving a sufficient and adequate staff structure.