5. Provision of services
he provision of public health services is organized through a network of public health institutes, with one national institute and 21 county institutes. A number of national programmes are currently in place. The Mandatory Vaccination Programme, in place since 1948, is the most important and most successful preventive health programme in the country. The Early Cervical Cancer Detection Programme, launched in late 2012, is one of the most recent national public health programmes.
Primary care physicians (GPs, paediatricians and gynaecologists) are usually patients' first point of contact with the health system. Each insured citizen is required to register with a GP (adults) or a paediatrician (children), whom they can choose freely. Reflecting an EU recommendation, all practising GPs are required to specialize in family medicine by 2015. However, patients often skip the primary care level and seek health care services directly at hospitals and, so far, there have been no attempts to establish integrated care pathways. The share of specialized consultations among all CHIF-contracted ambulatory care consultations (i.e. primary and specialized care) was 23% in 2012, which may be an indication that some specialized care was used inappropriately. The introduction of “concessions” aimed at reforming the existing solution of rentals and privately contracted physicians seems to have weakened the continuity of care. There are not many group practices and interdisciplinary teams in primary health care. However, since 2013, GPs have been encouraged by the CHIF to create group practices (with financial incentives).
Before the reorganization of emergency care, which started in 2009, the provision of outpatient emergency medical services (EMS) was fragmented. The reform introduced a model of a country-wide network of County Institutes for Emergency Medicine. The next important reform step is the integration of all hospital emergency services into one emergency care hospital department. In about a third of general hospitals, emergency services are not yet integrated in one department; it is difficult to provide hospital EMS for patients with multiple symptoms and waiting times for patients are longer.
There is currently one pharmacy per 4000 inhabitants in Croatia, compared to one pharmacy per 3000 inhabitants in the EU on average. Pharmaceuticals are available free of charge for certain population groups and particular conditions; otherwise, co-payments are applied.
Rehabilitation services cover three types of care: orthopaedics, balneology and physical medicine. Although both the number of rehabilitation beds and physical and rehabilitation medicine specialists per 100 000 inhabitants is very high in Croatia compared to other EU Member States, the ratio of physiotherapists and other rehabilitation professionals is relatively low. There have also been shortcomings in education, which has been focused on rheumatology rather than rehabilitation, and in the quality and efficiency of rehabilitation medicine.
Long-term care (LTC) is mainly organized within the social welfare system. It is currently mostly provided in institutional settings. There is a considerable coverage gap regarding the estimated number of dependent people and those who have actually received some type of care, with shortages of formal services in the institutionalized context. Croatia is among the top three countries in Europe with the greatest scale of informal care, with the age cohort 50–64 bearing the greatest burden of caring for the elderly. Virtually no services are available for informal carers. Waiting lists for county nursing homes are long, while private providers are financially unaffordable to many. The 2013 Social Care Act includes provisions for generational solidarity, the objectives of which are to keep the elderly in their own homes and with their family; to promote their social inclusion; and to improve their quality of life by developing and expanding non-institutional services and volunteering. A new draft, currently under public debate, proposes, among other features, a guaranteed minimum income as a new form of social welfare compensation.
There is no adequate system of palliative care and only a few institutions provide some forms of palliative care. The Strategic Plan for Palliative Care in Croatia, adopted in July 2013, plans to increase the availability of palliative care resources in the country (both infrastructure and human resources).
Mental health services are mainly provided in institutions and the number of psychiatric beds has been increasing in recent years. Community mental health care (except for certain programmes such as addiction prevention) remains underdeveloped, and specific and well-organized programmes of mental health care in the community are lacking.
Croatia has no defined legal framework for complementary and alternative medicine (CAM). Only acupuncture is recognized as a medical treatment and may be reimbursed by the CHIF, but only under certain conditions.
5.1 Public health
The provision of public health services is organized through a network of public health institutes: one national institute (CNIPH), owned by the Ministry of Health, and 21 county institutes, owned by the counties. The activities of the county institutes are coordinated and supervised by the CNIPH.
The CNIPH is responsible for the collection, analysis and publication of public health statistics (e.g. information on disease incidence or mortality) and epidemiological data, and for health promotion and health education at the national level. It also maintains a number of public health registers, such as the Croatian Cancer Register, Croatian Register for Psychoses and Register of Suicides, Register of HIV/AIDS, Register of Health Care Workers and others. CNIPH’s Department of Epidemiology is the centre for disease control and prevention in Croatia. It maintains the central information system for reporting and monitoring the incidence of infectious diseases, and proposes and supervises the implementation of key preventive and anti-epidemic measures by various actors in the health care system, from family doctors to clinical hospitals, including specially trained and equipped epidemiology service units within the county institutes of public health. The Department also supervises compulsory immunizations and pest control; monitors environmental pollution and waste management; sets standards; and tests food and drinking water safety.
The county public health institutes provide services (for their respective populations) in the following areas: epidemiology and quarantine of communicable diseases; epidemiology of noncommunicable diseases; water, food and air safety services; immunizations (including overseeing the compulsory immunization programmes); mental health care (prevention and out-of-hospital treatment of addictions); sanitation; health statistics; and health promotion.
Compulsory immunization programmes are carried out by primary care doctors (family doctors and primary care paediatricians) and the school medical service (affiliated with the county institutes of public health) for school-age children. Non-compulsory vaccination programmes are delivered through family doctors or county institutes of public health. Some of the non-compulsory vaccinations, recommended by the CNIPH for certain high-risk populations are free of charge for these populations (e.g. influenza vaccine for older people and patients with chronic diseases). Physicians may also offer opportunistic screening (e.g. cervical smear tests or mammograms) to patients attending for something else.
The Mandatory Vaccination Programme (also called the Childhood Vaccination Programme), which started in 1948, is the most important and most successful preventive health programme in the country. It covers the following vaccines: BCG (against tuberculosis) (administered with hepatitis B); DTaP/IPV/Hib (combination vaccine against diptheria, tetanus, pertussis, polio and Hib disease) (administered with hepatitis B); measles, mumps and rubella; diphtheria, tetanus and pertussis (combination vaccine); polio; and tetanus for people over 60 years old. Participation in this programme is obligatory for the target population, for doctors responsible for administering the vaccinations, and for the bodies responsible for its organization and funding (CHIF and CNIPH). The programme is improved every year on the basis of best practice evidence. The programme and other public health activities, such as surveillance and early response system, have been successful in keeping infectious diseases under control. Diseases preventable through vaccination have either totally disappeared (diphtheria, poliomyelitis) or their incidence has been drastically reduced.
Key public health programmes in Croatia are summarized in Table5.1. They are all national programmes and are developed and approved by the Ministry of Health.
The National Programme for the Early Detection of Breast Cancer, established in 2006, was the first national programme for the early detection of malignant diseases in Croatia. The programme encompasses a mammography examination every two years for all women aged 50–69. In addition, women aged 20–40 are recommended to undergo a clinical breast examination every three years, and women over 40 annually. The National Programme for the Early Detection of Colorectal Cancer was started in 2007 and includes an occult blood test for all persons over the age of 50. The Early Cervical Cancer Detection Programme was launched in December 2012 and will include a Pap smear every three years for women aged 25–64. A later phase of the programme foresees the introduction of new technologies, such as liquid-based cytology and human papilloma virus (HPV) testing. No evaluation of these programmes is yet available.
Occupational health services are provided through occupational medicine specialists, mainly working in private primary care practices or county health centres. Until 2011, all registered employers were required to register their companies and employees with the Croatian Institute for Health Insurance of Health Protection at Work, which was established at the end of 2007 and which directed them, on the basis of location, to occupational medicine specialists for periodic examinations (Lalić, 2008). In 2011, this Institute was annexed to the CHIF and no longer exists as an independent entity.
The National Centre for Addiction Prevention is part of the CNIPH and is responsible for the monitoring of addictions, and planning and evaluation of preventive measures. The National Register of Treated Psychoactive Drug Addicts was established in 1978 and is maintained by the National Centre for Addiction Prevention. Since 2003, county centres for addiction prevention form a part of the county institutes of public health. In 2010, the National Strategy against Disorders caused by Excessive Consumption of Alcohol for 2011–2016 was passed. It targets prevention of alcohol abuse, and treatment and rehabilitation of persons with alcohol-related problems, as well as promoting a socially engaged approach to the problems of excessive alcohol consumption. Operational plans for the Strategy are yet to be elaborated and adopted.
The Croatian Adult Health Survey (CAHS) was initiated in 2001 as part of a project for the prevention of cardiovascular diseases and was implemented jointly by the Croatian Ministry of Health, Statistics Canada, the Central Bureau of Statistics of Croatia and the Andrija Štampar School of Public Health (Vuletić et al., 2009). The survey was carried out in 2003. The aim was to provide comprehensive health data for the Croatian population, including health status, use of health services and health determinants (nutrition, smoking, alcohol consumption, physical activity, and body mass index (BMI) calculated from self-reported height and weight data). The Croatian Adult Health Cohort Study (CroHort) was carried out in 2008 as a follow-up study to the 2003 CAHS survey (and involved re-interviewing the respondents surveyed in 2003); another follow-up survey was planned for 2013 but was not carried out due to the lack of financial resources (Ivičević Uhernik et al., 2012).
There are currently no specific government measures for controlling tobacco consumption. The much debated Act on the Use of Tobacco Products was passed in 2008. It introduced a complete smoking ban in public places, with the intention of protecting non-smokers from tobacco smoke and changing the habits of smokers. The financial crisis that started in 2008 prompted a revision of this law in 2009 and, according to the new regulations, smoking is again allowed in bars.
The basic accessibility of public health services is good and is maintained through a well-developed network of public health institutions and professionals. However, accessibility is not equal for all citizens – access to public health services is more difficult in rural/underdeveloped areas and on the islands. The shortage of medical professionals in such areas, poorer socioeconomic characteristics of their populations and transport problems are the main root causes of inequities of access. Some populations are offered additional services; for example, free vaccinations are offered to high-risk groups and the National Programme for Roma (see Table5.1) aims to improve health care for the Roma population.