HEALTHCARE A BALANCE BETWEEN STATE & LOCAL JURISDICTION, PUBLIC & PRIVATE SECTOR Ass.of private hc employers Zagreb, Croatia Ante Gabrilo B.Sc.E.

Croatian healthcare y (facts & figures)(1) Population 2007.: 4,357 Mio Active workers paying benefits:1,547 Mio State fund income 2,475 Bln € Budget transfers 165 Mio € State fund expenses 2,539 Bln € Debt (paid) 101 Mio €

Croatian healthcare - hc expenditures(2) Primary healthcare 401 Mio € Secondary hc - hospitals 1,008 Bln € Secondary hc - polyclinics 83 Mio € Medications481 Mio € Sickness leave175 Mio € Maternity leave 94 Mio € Others297 Mio € TOTALexpenses 2,539 Bln € Debts(medications & hospitals)542 Mio €

Healthcare funding (y 2006) Macro level imbalance between High % of State fund/Low % of State budget High % patients out of pocket/Low % private hc insurances

Healthcare expenses (y 2006) Low% of primary hc/High% of hospitals, Sickness & Maternity leave

Problems Primary healthcare funding dropped from 35% in 90*s to 16% of total hc budget in 2007 Capitation system in primary hc (fixed income for every patient) encourages MDs to send patients to secondary hc, not to cure themselves (as the result only 50% of diagnosis cured in primary hc/EU-15 75%) There are no funds for new equipment in primary hc, just for secondary hc provided by the state Healthcare costs account for only 2,3% of average household expenses Benefits for hc paid by employers among the highest in Europe at 15,50% on gross sallary

Problems (2) Maternity,sickness and invalidity account for 14% of total hc expenses No participation in hc funding from municipalities Doctors & nurses in secondary level paid by their education and status, not by achievement ( as the result 1 doctor in a hospital was absent 281 days/year attending various seminars, congresses etc.paid by pharmaceutical companies as stated in Evening post) Only 50% of diagnostic ˛laboratory analysis are referred to family doctor

Solutions Increase state budget transfers for hc to % as in the EU-10 Increase private insurance funding to min. 5% of total hc funds Change from capitation system in primary hc to services for price system Include depreciation of assets, resources for new equipment etc. in the calculation of price

Solutions (2) To increase participation from local municipalities in hc funding Change of sallaries in secondary level from fixed to variable method according to individual achievement Increase primary hc funding to 25-30% of total hc funding in order to be able to cure up to 75% of all diagnosis as in EU-15 Division of work between general hospitals and clinical hospitals Participation of patients for better control of hc expenses

Solutions (3) Regionalization of hospitals with 1 hospital in the 50 km radius (today we have 3 hospitals within 30 km range - Vinkovci,Vukovar,Osijek with the total of 1760 beds - this is a higher standard that should be covered by the municipality if they can afford to) Standardization of hospitals according to the number of beds, should have 300 to 500 beds to be cost effective (today Clinical hospital Zagreb has 1673 beds,Hospital Pakrac 115, Gospić 94, Đakovo 19 beds etc.) Hospitals as profit centers,as the 1.st step towards privatization or private public partnership

Primary healthcare Private family practices:1297 MD´s Private specialist practices:1280 Med. Specialists Private dentist practices:1952 (1/1986 persons) Average family practice has 1700 insured persons and receives cca €/year from State fund, family specialist an extra 1850 €/year Patient check ups in ,279 Mio; referrals to specialist 7,408 Mio (28% of total visits)

Secondary outpatient healthcare Polyclinics 314, Pharmacy instituitions 177, Nursing care instituitions 153, Health companies 46 (y 2006) Medical examinations total in instituitions who have contract with the State fund Owned by private persons/companies or by municipalities who are obligated to invest in their equipment, resources etc., but they lack to do so

Secondary inpatient healthcare Number of hospital beds (5,46 beds/1000 persons) Number of doctors ( 1/5,1 beds) Nr.of patients discharged Average length of treatment 9,94 days Bed utilization 84,55% Hospital hc expenses are 1,008 Bln € or 40% of total hc expenses Owned by municipalities and state (only 2 private hospitals)

Municipalities Should invest in the equipment of instituitions they own, organize primary hc themselves with the resources available Should form a group of counties so they have 1 hospital in the 50 km range instead of several Should pay for higher standard of hc service if they want a doctor in very low inhabited areas Should plan more resources for healthcare in their budgets (City of Zagreb planned for their hc instituitions in ,45 Mio € and for sports clubs 30 Mio €)

Conclusion Primary hc which is privately owned is by far most cost effective level of hc with 16% of total hc expenses, while secondary hc with 40% created additional cca 390 mio € of debts Neither state budget, nor municipalities budgets participate enough in hc funding (state 3%, municipalities less than 1% of total hc funding) Municipalities have many obligations to organize hc in their region, but they lack to do so for reasons like shortage of funds or other activities priority