1. HEALTH CARE IN CROATIA – MARKET OR SOCIAL VALUES? Aleksandar Džakula Jadranka Mustajbegović Universitiy of Zagreb, Medical School Andrija Stampar School of Public Health The XIV th International Conference- Health Policy in Europe: Contemporary Dilemmas and Challenges Thessaloniki, 25-29 May 2005

2. AIM:To analyse policy changes as relation between social and market values in health care system in Croatia. We analysed health care reforms and health policy between 1980 and 2005

3. Cycles of policy changes in health care system in Croatia between 1980 and 2005  1980-1990 Socialism, self-governing  1990-1993 Democratic changes, transition, state independence, centralization  1993-2002 Reforms in health care: governing and financing  2002-2005 Launching of complementary health insurance  2005 - ? Complementary health insurance will be stopped?

4. 1980-1990 socialism, self-governing Circumstances:  socialism,  workers – central power of the society,  economical crisis,  beginning of transition.

5. 1980-1990 socialism, self-governing Motto:  workers are main stones of development and progress. Characteristics:  Target group: workers,  Managing: workers through self - governing,  High level of autonomy for local authorities,  Health workers and users participated in decision– making.

6. Organizational structure of the Self- managing communities Source: Letica S. Zdravstvena politika u doba krize. Naprijed, Zagreb 1989. p.208

8. 1980-1990 socialism, self-governing Problems:  Lack of control over the system,  Financial problems (in society and in health system).

9. 1990-1993 Democratic changes, transition, state independence, centralization Circumstances:  transition,  independence and organizing of the state,  War!

10. Motto:  Independent state whose citizents democraticaly decide on all matters including health care. Characteristics:  Target group: citizents, particulary war victims,  Managing: centralization of health care,  Lack of co-operation and control,  Severe financial difficulties. 1990-1993 Democratic changes, transition, state independence, centralization

12. Problems:  Orientation related to war circumstances,  Health care system strongly dependent on the state governement,  Absence of healt care market. 1990-1993 Democratic changes, transition, state independence, centralization

13. 1993-2002 Reforms in health care: governing and financing Circumstances:  War,  Economical crisis,  Negative relationship: persons non genereting income/employed ;  Central administration kept very tight control.

14. Inhabitants of the Republic of Croatia who do not generate income (1994)  Displaced persons247185  Refugees 272383  Unemployed245634  Retirement beneficiaries731922  Social welfare beneficiaries300000 TOTAL1797124 (displaced + refugees)/population = 10.84 % (persons non generating income)/employed=1.76

15. Motto:  State assures circumstances in which citizents, health care services and health insurances are able to create quality health care market. 1993-2002 Reforms in health care: governing and financing

16. Characteristics:  Target group: citizents-users,  Managing: several elements of decentralization (health institutions owened by local authorities, privatization in primary health care…),  Central administration kept very tight control over health care through finances and by-laws:  the system remaind highly centralized. 1993-2002 Reforms in health care: governing and financing

18. Problems:  Participation of health care expences in GDP increased,  Underdeveloped health care market,  Remain only one Health insurance as a national system,  Clients paying participation (equity?). 1993-2002 Reforms in health care: governing and financing

19. Income of health providers in 1999 Income from the Croatian Health Insurance Institute 84.9% Services to other health providers 0.44% Other users 9.44% Patient co-payment 0.76% Other income 3.1% Additional income1.36% TOTAL100%

20. Expenditure of health providers in 1999 Pharmaceuticals and consumables13.77% Other material expenditure13.90% Nonmaterial expenditure12.62% Payroll44.37% Financing costs 0.47% Capital investment 1.32% Additional costs 0.30% Other costs 0.71% Purchase price of sold goods2.54% TOTAL 100%

21. 2002-2005 Launching of complementary health insurance Circumstances:  S ocial issues or political dimension of health care?  Economical movement,  Increase in standard,  Issue of decentralization was raised again.

22. GDP=7,800

23. Motto:  State ensures health care market circumstances; and chages are recognized as patient friendly (spec. for voulnerable groups: unemployed, retired,..). 2002-2005 Launching of complementary health insurance

24. Characteristics:  Target group: social sensitive groups: unenployed, retired,…  Complementary insurance was introduced for participating fees,  Many sensitive groups become free of any participation, even complementary insurance. 2002-2005 Launching of complementary health insurance

25. Problems:  Complementary insurance introduced growth of consumption in basic, primary insurance and costs in general, espetially pharmaceuticals (23% higher 2003/04). 2002-2005 Launching of complementary health insurance

26. 2005 - ? Complementary health insurance will be stopped?? The last announced reforms stress:  Need to cut costs,  Introduce higher participation fees,  More market values in health care.

27. GDP=7,800

28. CONCLUSION: Croatia has heath care system that :  recognized many social issues and sensitive groups,  long lasting financial crisis,  partially reformed system and  permanent increase of health care expenditures…

29. every few years:  face decision makers with  need to make changes in health policy.  Any idea? Thank you!