title: Croatia: health system review.
abstract: Croatia is a small central European country on the Balkan peninsula, with a population of approximately 4.3 million and a gross domestic product (GDP) of 62% of the European Union (EU) average (expressed in purchasing power parity; PPP) in 2012. On 1 July 2013, Croatia became the 28th Member State of the EU. Life expectancy at birth has been increasing steadily in Croatia (with a small decline in the years following the 1991 to 1995 War of Independence) but is still lower than the EU average. Prevalence of overweight and obesity in the population has increased during recent years and trends in physical inactivity are alarming. The Croatian Health Insurance Fund (CHIF), established in 1993, is the sole insurer in the mandatory health insurance (MHI) system that provides universal health coverage to the whole population. The ownership of secondary health care facilities is distributed between the State and the counties. The financial position of public hospitals is weak and recent reforms were aimed at improving this. The introduction of concessions in 2009 (public private partnerships whereby county governments organize tenders for the provision of specific primary health care services) allowed the counties to play a more active role in the organization, coordination and management of primary health care; most primary care practices have been privatized. The proportion of GDP spent on health by the Croatian government remains relatively low compared to western Europe, as does the per capita health expenditure. Although the share of public expenditure as a proportion of total health expenditure (THE) has been decreasing, at around 82% it is still relatively high, even by European standards. The main source of the CHIFs revenue is compulsory health insurance contributions, accounting for 76% of the total revenues of the CHIF, although only about a third of the population (active workers) is liable to pay full health care contributions. Although the breadth and scope of the MHI scheme are broad, patients must pay towards the costs of many goods and services, and the right to free health care services has been systematically reduced since 2003, although with exemptions for vulnerable population groups. Configuration of capital and human resources in the health care sector could be improved: for example, homes for the elderly and infirm persons operate close to maximum capacity; psychiatric care in the community is not well developed; and there are shortages of certain categories of medical professionals, including geographical imbalances. Little research is available on the policy process of health care reforms in Croatia. However, it seems that reforms often lack strategic foundations and or projections that could be analysed and scrutinized by the public, and evaluation of reform outcomes is lacking. The overall performance of the health care system seems to be good, given the amount of resources available. However, there is a lack of data to assess it properly.
authors.affiliation: Andrija Stampar School of Public Health.
authors.forename: Aleksandar
authors.initials: A
authors.lastname: Džakula
authors.affiliation: European Observatory on Health Systems and Policies,LSE Health.
authors.forename: Anna
authors.initials: A
authors.lastname: Sagan
authors.affiliation: Croatian Health Insurance Fund.
authors.forename: Nika
authors.initials: N
authors.lastname: Pavić
authors.affiliation: University Hospital of Rijeka.
authors.forename: Karmen
authors.initials: K
authors.lastname: Lonćčarek
authors.affiliation: Croatian Medical Chamber.
authors.forename: Katarina
authors.initials: K
authors.lastname: Sekelj-Kauzlarić
mesh_terms: D017523:Croatia; D003657:Decision Making; D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration*; D018166:Health Care Reform / Q000458:organization & administration; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D057766:Policy; D011057:Politics; D015980:Public Health Practice; D011787:Quality of Health Care / Q000458:organization & administration; D012959:Socioeconomic Factors; D013222:State Medicine / Q000191:economics / Q000458:organization & administration*; D019472:Universal Health Insurance