2022

Croatia
Health system summary
 AUTHORS
Aleksandar Džakula, Dorja Vočanec, Maja Banadinović,
Maja Vajagić, Karmen Lončarek, Iva Lukačević Lovrenčić,
Dagmar Radin, Bernd Rechel
Anna Maresso (Series Editor)

CONTENTS
How is the health system organized?������������������������������������ 3
How much is spent on health services? ������������������������������ 4
What resources are available for the health system? ������ 8
How are health services delivered?������������������������������������ 11
What reforms are being pursued? �������������������������������������� 13
How is the health system performing?�������������������������������� 13
Summing up ���������������������������������������������������������������������������� 19

This Health System Summary is based on the Croatia: Health System Review (HiT) published in 2021
and relevant reform updates highlighted by the Health Systems and Policies Monitor (HSPM) (www.
hspm.org). For this edition, key data have been updated to those available in March 2022 to keep
information as current as possible. Health System Summaries use a concise format to communicate
central features of country health systems and analyse available evidence on the organization,
financing and delivery of health care. They also provide insights into key reforms and the varied
challenges testing the performance of the health system.

Main source: Džakula A, Vočanec D, Banadinović M, Vajagić M, Lončarek K, Lukačević Lovrenčić I, Radin D, Rechel B. Croatia: Health system
review. Health Systems in Transition, 2021; 23(2): pp. i–146.
Please cite this publication as: European Observatory on Health Systems and Policies (2022), Croatia: Health System Summary. WHO
Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, Copenhagen.
ISBN 9789289059060 (PDF)
 How is the health system organized?
The Croatian
ORGANIZATION health system is
centralized, with most
The Ministry of Health is responsible for health policy, (general and specialized health care providers
planning and evaluation, public health programmes hospitals). remaining under public
and the regulation of capital investments for publicly Croatia has a manda- ownership
owned health care providers. The Ministry of Health tory social health insurance
also regulates quality standards for public and private system which consolidates
health care providers. National authorities (the Ministry public financing under a single
of Health and the Government) are responsible for entity, the Croatian Health Insurance Fund (CHIF).
the provision of tertiary care, which includes university The CHIF is the single purchaser of health services
hospitals and university hospital centres. Counties provided under the mandatory health insurance scheme.
are responsible for the organization and manage- It also offers complementary voluntary insurance that
ment of public health services, primary care (health covers co-payments in the mandatory health insurance
centres and public pharmacies) and secondary care system.

PLANNING
All health reform proposals usually originate at the for the implementation of public policies in Croatia
Ministry of Health (see also Box 1). After consul- in the planning period. Aligned with the National
tation with the relevant stakeholders or an online Development Strategy until 2030, the National Health
public consultation, the proposal is being sent to the Care Development Plan for 2021–2027 was adopted in
Government for further development. For the period December 2021. The National Health Care Development
2020–2030, the National Development Strategy has Plan was developed by the Ministry of Health, as a
been developed at government level, including all medium-term planning tool that contains broad tasks
ministries, and was adopted in February 2021. The and goals for the health sector, sets out priority areas
strategy is the umbrella document determining the and identifies the health needs of population groups
context, vision, developmental directions, and priorities of special interest.

BOX 1 | INTERSECTORALITY IS SLIDING INTO FOCUS

IN THE CROATIAN NATIONAL HEALTH STRATEGY

The importance of intersectoral cooperation in the area of health is at the core of the latest National Health
Strategy, which is the Ministry of Health’s longer-term planning tool. Following the European strategy
“Health 2020”, set out by the WHO Regional Office for Europe, Croatia advocates “health in all policies”
and “whole-of-society” approaches. The Government has not yet developed any specific protocols for
intersectoral cooperation, except for major natural and technological disasters and accidents. However,
in response to the COVID-19 pandemic, a National Civil Protection Headquarters was established, together
with its local branches. The National Health Care Development Plan 2021–2027 addresses intersectorality
for health and social care.

HEALTH SYSTEM SUMMARY: 2022 3

 PROVIDERS
Most health care providers (especially of secondary and hospitals, general hospitals, medical institutes and health
tertiary care) remain under public ownership. However, centres cannot operate for profit. Furthermore, there
private providers have grown in number, notably in must be at least one publicly owned primary health
primary care, dental services and specialized clinics. care centre per county and at least three in the city
Most primary care practices have been privatized, with of Zagreb in order to make health care accessible for
the remaining ones in public ownership operating as the population. People can choose their primary care
health centres. University hospital centres, university provider and dentist.

How much is spent on Public spending on

health is high in Croatia

health services? and a comprehensive

benefits package covers
nearly the entire
population

FUNDING MECHANISMS
The key sources of the CHIF’s revenue are mandatory CHIF. CHIF also offers complementary voluntary
health insurance contributions. However, in 2020, due insurance that covers co-payments in the mandatory
to the COVID-19 pandemic and its impact on the health insurance system. Mandatory health insurance
economy, there were significant changes in the structure contribution rates stood at 16.5% of gross salary for
of the CHIF’s total revenues. The share of revenues employees (transferred by the employer), 7.5% of
from contributions decreased from 81.9% in 2019 to a proportion of the average salary for farmers and
74.2% in 2020, and the share of state budget revenues religious officials and 3% of the pension income
increased from 9.6% to 13.3% (CHIF, 2020). Revenue above the average net wage for pensioners. Funds
from mandatory health insurance contributions and are collected centrally and allocated to state-owned
the state budget is used to finance the provision of health facilities, with some funds transferred to the
health care, compensations and administration of the local level.

HEALTH EXPENDITURE
Croatia spends a smaller amount on health per capita Furthermore, the share of public spending as a pro-
than most other EU Member States (Fig. 1). In 2019, portion of current health expenditure is comparatively
the expenditure in Croatia was US$ 2168 (adjusted for high, amounting to 81.9% in 2019. This was higher
differences in purchasing power), placing it among the than the EU average of 76.3%, reflecting a tradition of
five lowest spenders in the EU (Fig. 2). However, when solidarity in health care financing and the continued
considering the proportion of GDP spent on health importance of health care on the Croatian policy agenda.
(6.9% in 2019), this share was higher than in eight other In 2019, 12.1% of the total state budget was allocated
EU Member States. to the health sector.

4 CROATIA
 2 500 9
FIG. 1  8

TRENDS IN 2 000
7

HEALTH EXPENDITURE, 6
1 500
2000–2019 5

US $ PPP

% GDP
4
(SELECTED YEARS) 1 000
3
Note: PPP: purchasing power parity. 2
500
Source: WHO (2022) Global Health 1
Expenditure Database, December 2022. 0 0
2000 2005 2010 2015 2016 2017 2018 2019

Current health expenditure per capita Current health expenditure as % of GDP

FIG. 2  Switzerland
Norway
CURRENT HEALTH Luxembourg
Germany
EXPENDITURE Netherlands
Sweden
(US$ PPP) PER Austria
Denmark
CAPITA IN WHO Ireland
Belgium
EUROPEAN Iceland
France
REGION United Kingdom
Finland
EU/EEA/UK average
COUNTRIES, 2019 Malta
Italy
Notes: CHE: current Spain
Slovenia
health expenditure; PPP: Portugal
purchasing power parity. Czech Republic
Cyprus
Data for Albania Lithuania
Estonia
are from 2018. Greece
Slovakia
Source: Global Health Poland
Expenditure Database, Croatia
Hungary
December 2021. Latvia
Romania
Bulgaria

San Marino
Andorra
Israel
WHO Euro average
Monaco
Montenegro
Russian Federation
Serbia
Armenia
Bosnia and Herzegovina
The Republic of North Macedonia
Belarus
Türkiye
Turkmenistan
Georgia
Ukraine
Republic of Moldova
Kazakhstan
Albania
Azerbaijan
Uzbekistan
Kyrgyzstan
Tajikistan
0 2 000 4 000 6 000 8 000 10 000
CHE in US$ PPP per capita

HEALTH SYSTEM SUMMARY: 2022 5

 OUT-OF-POCKET PAYMENTS
Croatia spends a higher share from public sources than (Fig. 3), which was below the EU average of 15.4%. The
the EU average for all areas of care, and co-payments voluntary health insurance market in Croatia started
do not seem to have affected affordability of health developing in the early 2000s, accounting for 6.6% of all
services. Out-of-pocket (OOP) spending on health as health expenditure in 2019. Complementary voluntary
a share of final household consumption was 1.1% in health insurance plans cover all patient co-payments in
2019, which was the lowest share of all EU countries the mandatory health insurance scheme.* The largest
and well below the EU average of 3.1%. OOP payments share of OOP spending is on pharmaceuticals, followed
stood at 11.5% of current health expenditure in 2019 by dental care (Fig. 3).

FIG. 3   COMPOSITION OF OUT-OF-POCKET PAYMENTS, 2019

Government/ VHI 6.6% OOP distribution

compulsory
schemes 81.9% Inpatient 0.8%

Outpatient medical care 2%

Pharmaceuticals 4.1%

OOP 11.5%

Dental care 3.1%

Others 1.5%

Note: OOP: out-of-pocket; VHI: voluntary health insurance.

Source: OECD Health Statistics; Eurostat Database, 2021 (data refer to 2019).

COVERAGE
Health insurance is mandatory in Croatia and covers of covered health services and medical goods. As
all residents, including foreign nationals residing in the main purchaser of health services, the CHIF, in
the country longer than three months (Box 2). No cooperation with medical associations, determines the
opting out of mandatory health insurance is possi- price list of all health services that are covered under
ble. Dependent family members are covered through the mandatory health insurance scheme. Decisions are
the contribution made by working family members, made with the approval of the Ministry of Health.
whereas the self-employed pay their own contributions Some services, such as services for children, pregnant
in full. Vulnerable groups are exempt from payments. women, people above 65 years of age and people
The Act on Mandatory Health Insurance gives the with disabilities, immunisations, palliative care etc.,
insured the right to health services and to financial are exempt from co-payments and covered by the
compensation. The Act also mentions broad categories CHIF in full.

* Complementary voluntary insurance, covering user charges in the mandatory health insurance scheme is called “supplementary insurance”
in Croatia. The other type of VHI, which covers higher standards of care is called “additional insurance”.

6 CROATIA
 BOX 2 | WHAT ARE THE KEY GAPS IN COVERAGE?

Population coverage under the mandatory health insurance system is nearly universal, as all citizens and
residents have the right to health care through the mandatory health insurance scheme. The scope of cover-
age is also broad, with most health services and medical goods publicly covered. The main gaps in coverage
relate to the depth of the benefits package, as patients must contribute to the costs of many goods and
services through co-payments. There are, however, exemptions from co-payments for vulnerable population
groups. Certain population groups (e.g. people with disabilities) have the right to free complementary health
insurance membership in the CHIF and their respective contributions are financed from the state budget.

PAYING PROVIDERS
Providers contracted by the CHIF are paid on the basis Outpatient services are paid according to fee-for-
of different payment mechanisms (Fig. 4). Primary service, while hospitals that belong to the National
care providers are paid using a combination of cap- Health Care Network are largely paid according to global
itation, fee-for-service and pay-for-performance. In budgets, with 90% of revenues fixed and 10% depend-
April 2013 a new payment model for general prac- ing on provided services (invoices by cases based on a
titioners (GPs) was put in place. The goals were to diagnosis-related groups (DRG) system). Since 2020,
incentivize health care providers to further increase 100% of hospital income has been paid in advance (up
the provision of certain types of care (e.g. preventive from 90% in 2019) and the hospitals provide invoices
care) and to improve quality of care and patient sat- based on episodes of care. Furthermore, the CHIF intro-
isfaction. In addition, GPs may receive bonus pay- duced in 2015 a new price list for hospital outpatient
ments, depending on their performance and quality services, offering higher reimbursement for same-day
indicators. surgery procedures.

FIG. 4 | PROVIDER PAYMENT MECHANISMS IN CROATIA

Hospital
Acute
GPs Specialists Outpatient Dentists Pharmacies
Hospitals
services

Contact Contact
Global budget Case based
capitation capitation
+ diagnosis- (diagnostic-
+ fee-for- Fee-for- + fee-for- Fee-for-
related therapeutic
service + service service + service
groups, procedures,
pay-for- pay-for-
DRGs) DTPs)
performance performance

HEALTH SYSTEM SUMMARY: 2022 7

 What resources are available
for the health system?
HEALTH PROFESSIONALS
Human resources in Croatia’s health system are on a However, the geographical distribution of health care
similar level to the EU overall. The number of practis- infrastructure and human resources varies considerably.
ing physicians per 100 000 inhabitants (352 in 2019) Central Croatia (mainly Zagreb county and the city of
in Croatia was below the EU average (395), but had Zagreb) has the largest number of facilities and health
increased steadily from 237 in 2000, despite fears of out- workers, while there are fewer facilities and health per-
migration following EU accession in 2013. (Fig. 5a) sonnel (in particular primary care practitioners) in
The number of nurses per 100 000 population more remote areas, such as the islands off the
in Croatia has increased over the years and Adriatic coast and rural areas in central and
reached 685 in 2019 (Fig. 5b). Nurses There are sufficient eastern Croatia. More people in Croatia
are the most numerous professional physical resources and (0.7% in 2019, compared to an EU aver-
group within health care, and account the number of physicians age of 0.1%) report unmet medical needs
for 43.5% (31 555) of the total number has increased, but due to distance than in any other EU
of health professionals employed in geographical imbalances Member State, indicating challenges in
the health sector (Croatian Institute of remain the geographical distribution of health
Public Health, 2020). facilities.

FIG 5A  
NUMBER OF PHYSICIANS PER 100 000 POPULATION IN CROATIA AND SELECTED
COUNTRIES, 2000–2019
400

350 Croatia
Physicians per 100 000 inhabitants

Hungary

Romania
300
Slovenia

European Union - 27
250

200

150
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019

Source: Eurostat, 2021.

8 CROATIA
FIG. 5B  
NUMBER OF NURSES PER 100 000 POPULATION IN CROATIA AND SELECTED
COUNTRIES, 2000–2019

1 000
Nurses per 100 000 inhabitants

Croatia

Hungary

800 Romania

Slovenia

European Union - 27

600

400
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Source: Eurostat, 2021.

HEALTH INFRASTRUCTURE
Despite its low levels of health expenditure per capita, been substantially modified in recent decades to match
physical resources in Croatia’s health system are on a migration patterns, the changing demographic struc-
par with many other European countries. The number ture of the population or advancements in medicine
of curative care beds in hospitals declined from 389 per that enable care provision on an outpatient or day care
100 000 population in 2012 to 354 in 2019, which was basis rather than in inpatient facilities. The geographical
below the EU average of 387 in 2019 (Fig. 6). However, distribution of health care infrastructure and human
a large share of hospital beds in Croatia are long-term resources for health varies considerably. The number of
care beds and the number of curative hospital beds magnetic resonance imaging (MRI) units in hospitals
per population is lower than in comparator countries. and providers of ambulatory health care in Croatia in
Most hospitals are located in central Croatia, including 2019 was 1.3 per 100 000 inhabitants, and the number
in the city of Zagreb. The network of hospitals has not of computed tomography (CT) scanners was 2.0 (Fig. 7).

HEALTH SYSTEM SUMMARY: 2022 9

 FIG. 6  
BEDS IN ACUTE HOSPITALS PER 100 000 POPULATION IN CROATIA AND SELECTED
COUNTRIES, 2000–2019
800

700 Croatia

Hungary
Beds per 100 000 population

Romania
600
Slovenia

Slovakia
500 European Union - 27

400

300
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Source: Eurostat, 2021.

FIG. 7   NUMBER OF PUBLIC HOSPITALS, MRI UNITS AND CT SCANNERS IN CROATIA, 2019

MRI scanners CT scanners

Public Acute
per 100 000 per 100 000
Hospitals Notes: CT: computed
population population
tomography; MRI: magnetic
resonance imaging.
48 1.3 2.0 Source: CHIF, 2022;
Eurostat, 2021.

DISTRIBUTION OF HEALTH RESOURCES

The uneven geographic distribution of health workers overtime shifts and the employment of retired staff.
and the difficulties in recruiting and retaining them The main reasons why health workers leave rural areas
in certain regions is an important policy issue in are family commitments (associated with the poor
Croatia. The density of health workers is consistently employment and education opportunities there and
greater in urban regions, reflecting the concentration a lack of free time) and lack of professional support.
of specialized services. The main concern is short- Furthermore, the distribution of pharmacies is also
ages of primary care practitioners in rural areas and uneven, with pharmacies mainly located in urban
on the islands. Furthermore, hospitals are struggling settings and a poorly developed pharmacy network
to provide a functioning service, resulting in many in rural areas.

10 CROATIA
 How are health services GPs can be
delivered? chosen freely and
independently of the
place of residence

PRIMARY AND AMBULATORY CARE

Primary care services are provided by a network of hospital outpatient departments. Other settings include
first-contact doctors and nurses contracted by the CHIF. specialized ambulatory care units in public polyclinics
Every insured citizen is required to register with a family and county health centres (usually linked to general
physician (in the case of adults) or a paediatrician (in and clinical hospitals) or private facilities. Provision
the case of pre-school children), whom they can choose of publicly paid services is subject to a contract with
freely. Primary care physicians can be changed at any the CHIF. Patients need a referral from a primary care
time, free of charge. They serve as gatekeepers to second- physician to access specialized ambulatory care.
ary and tertiary levels of care. Upon referral, patients are There are difficulties in organizing continuous
free to go to a hospital of their choice. A wide range of and comprehensive care for people with complex
services is available at the primary care level, including needs, especially in remote areas (rural areas and
general practice/family medicine, health services for the country’s islands). The strategic policy documents
pre-school children, maternal health services, home care for the forthcoming period emphasize the impor-
and nursing care (Box 3). tance of horizontal and vertical integration within
Specialized outpatient care, such as consultations pro- the health system and between the health and social
vided by secondary care specialists, is mostly delivered in care systems (Box 4).

BOX 3 | WHAT ARE THE KEY STRENGTHS AND WEAKNESSES OF PRIMARY CARE?

One of the key strengths of primary care in Croatia is organization according to underlying principles (with
the entire population being covered by mandatory health insurance, receiving continuous care throughout
their lifespan, the availability of primary care in all parts of the country, and primary care following a holistic
approach), ensured through the implementation of integrated measures for health promotion and disease
prevention, treatment, rehabilitation and palliative care.
Among the weaknesses is low availability of primary care, especially in rural areas. Privatization is believed
to weaken the role of health centres as key stakeholders in organizing aligned health services at the local
level. Patients tend to have lower trust in primary care physicians and rely more on specialist care, leading
to a larger number of referrals to secondary care than would be clinically indicated.

BOX 4 | ARE EFFORTS TO IMPROVE INTEGRATION OF CARE WORKING?

Functional integration is one of the core principles of health care in Croatia, according to the 2019 Health
Care Act. However, so far, no official report on its implementation has been published. Palliative care is
a service developed as an integrated care model, coordinating all levels of health care as well as social
care through palliative care coordinators, and there are visible results in this regard in the last 10 years
(Vočanec et al., 2022).

HEALTH SYSTEM SUMMARY: 2022 11

 HOSPITAL CARE
Inpatient secondary care facilities include general counties. Specialist hospitals are organized around
hospitals and specialized hospitals. All general and specific acute diseases, chronic illnesses or population
the majority of specialized hospitals are owned by the groups. Tertiary care is provided in state-owned univer-
counties. While general hospitals primarily serve the sity hospitals and university hospital centres. In order to
population of their respective counties, specialist hos- access secondary or tertiary hospital care contracted by
pitals serve the entire population. All general hospitals the CHIF, patients need a referral from their primary
must have the following departments: obstetrics and care doctor, except for medical emergencies. Waiting
gynaecology, internal medicine, surgery and inpatient times for certain diagnostic and treatment procedures
paediatric care. Other departments are optional and are long in some hospitals (e.g. more than 12 months
depend on the needs of the county population and the for hip and knee replacements), with major differences
availability of hospitals or polyclinics in neighbouring between hospitals.

PHARMACEUTICAL CARE
Croatia spends a larger share of its health expenditure specialized retail shops, subject to special permission
on pharmaceuticals and medical devices (20.2% of cur- from the Agency for Medicinal Products and Medical
rent health expenditure) than the EU average (13.9%). Devices (HALMED). HALMED oversees and mon-
Pharmaceuticals are sold to the public in pharmacies itors consumption of medicinal products and promotes
contracted by the CHIF. The sale of prescription drugs their rational use. In 2019, the total turnover of med-
is restricted to pharmacies and dispensing can only be icines in Croatia, according to data from community
done by a pharmacist. Over-the-counter medicines are and hospital pharmacies and specialized drug stores,
dispensed mainly through pharmacies (dispensing can amounted to HRK 7.7 billion, or 15.5% more than in
also be done by a pharmaceutical technician), but some 2018. This was equivalent to approximately €255 per
over-the-counter pharmaceuticals can also be sold in capita (HALMED, 2021)

LONG-TERM AND PALLIATIVE CARE

Croatia’s long-term care system is underdeveloped, with The establishment of palliative care was one of
little or no coordination between the social welfare, the priorities of the National Health Care Strategy
health and war veterans’ systems; between national, 2012–2020. Two strategic plans for palliative care
county and municipal/city levels; or between public were adopted subsequently that helped to establish
and private (not-for-profit and for-profit) providers. a model of integrated palliative care that was imple-
Only about 3% of older people received a form of public mented nationally.
residential long-term care in 2018.

DENTAL CARE
The basic package of dental services covered by the services and is responsible for monitoring the quality
CHIF ensures almost all basic dental procedures of dental care.
(restorative, endodontic, basic periodontal, oral surgery, Dental services are delivered through a network of
oral diseases, specified orthodontics up to 18 years dental offices, with teams consisting of a dentist and a
of age, and some prosthodontics) and emergency dental assistant. In 2019 the Dental and Oral Health
dental care. The CHIF manages the content and Service included 1940 teams. Geographical accessibility
price of each service provided within the mandatory of dental services is good, although with some variation
health insurance scheme and actively checks billing across the country. As for most other health services,
to ensure that bills reflect the amount of work done. access is more limited in rural and underdeveloped areas
The Croatian Dental Chamber sets standards for and on the islands.

12 CROATIA
 What reforms are being Principal health
pursued? reforms in Croatia aim
to make health financing
more sustainable
In recent years Croatia has undertaken reforms in a which includes areas of focus
range of areas, including health financing, primary care, in the health sector, is anticipated
hospital care, public health, pharmaceutical policies and to be a key strategic document to
palliative care (Box 5). The reforms aimed to make health direct future efforts, partly because it is anticipated
financing more sustainable, strengthen primary care, to be the basis for planning the budget and pro-
reduce hospital capacity and improve access to palliative gramming of financial resources from EU funds and
care and expensive pharmaceuticals. However, progress other international sources. Other important strategic
in implementation varied, with implementation still at documents are the National Plan Against Cancer for
an early stage in the areas of hospital reform, primary 2020–2030 and the Action Plan for Prevention and
care and human resources management and planning. Control of Chronic Non-Communicable Diseases
The National Development Strategy for 2020–2030, for 2020–2026.

BOX 5 | KEY HEALTH SYSTEM REFORMS OVER THE LAST 10 YEARS

• 2013: New financing model for primary health care

• 2014: Palliative care reform
• 2015: Croatian Health Insurance Fund separates from the State Treasury
New financing model for hospitals (partially implemented)
Strategic Plan for Human Resources in the health sector
• 2017: Hospital restructuring (functional integration model) (partially implemented)
Hospital priority waiting lists
• 2019: Increase of health insurance contribution rate to raise CHIF revenue
Abolition of concessions and further privatization of primary care practices (implementation
ongoing)
Introduction of the Central Management System (implementation ongoing)
Rationalization of public health and health quality agencies

How is the health system

performing?
Health services
HEALTH SYSTEM PERFORMANCE MONITORING AND are accessible and
INFORMATION SYSTEMS affordable, but mortality
from preventable and
Improving health care quality is an explicit policy aim, mortality rates are among the
amenable causes
but so far, a comprehensive quality improvement strategy highest in the EU, including
remains high
with an action plan that defines priorities, performance mortality from cancer, pre-
indicators and roles/responsibilities is missing. Several ventable causes (including lung

HEALTH SYSTEM SUMMARY: 2022 13

 cancer, alcohol-related causes and road traffic deaths) Registry of Committed Suicides and the Registry of
and air pollution. However, the Croatian health system Psychoses. There are also registries collecting information
has developed networks for collection and processing of on health care resources. Based on previously uncon-
health information: examples of registries include the nected and non-harmonized registries, the National
Cancer Registry, the Registry of People with Disabilities, Public Health Information System was developed as a
the Registry of Treated Psychoactive Drug Addicts, the common platform.

ACCESSIBILITY AND FINANCIAL PROTECTION

Accessibility of services is generally high, given the 8). Unmet medical need due to cost is relatively low and
country’s near universal population coverage (covering has been on the decline over the past few years, decreas-
over 99% of the population), with a wide range of ser- ing from 2.2% in 2011 to 0.3% in 2020. However, the
vices covered by mandatory health insurance and low poorest are more affected. There are also geographical
out-of-pocket payments. Eurostat data for 2020 show barriers (in rural, poorly populated and remote areas, and
that 1.5% of respondents expressed an unmet need for islands), as well as long waiting times, which are likely to
medical care due to cost, distance or waiting list (Fig. have increased as a result of the COVID-19 pandemic.

HEALTH CARE QUALITY

Croatia has been developing a quality monitoring and Key indicators on the quality of primary care,
analysis system for more than 15 years, but there is still such as avoidable hospital admissions for chronic
no comprehensive quality improvement strategy (World conditions including chronic obstructive pulmonary
Bank, 2020). One of the strategic goals of the National disease (COPD), congestive heart failure, diabetes
Health Development Plan for the period 2021–2027 is and asthma, which are available for other EU coun-
the improvement of the health system, with one of its tries, are still lacking for Croatia. With regard to
priority measures to establish a comprehensive national the quality of hospital care, the standardized 30-day
health quality and safety system, including through hospital mortality rate for acute myocardial infarc-
clinical guidelines, accreditation, payment related to tion (AMI) is much higher than in most other EU
quality and outcomes, health technology assessment countries (Fig. 9).
(see also Box 6).

BOX 6 | WHAT DO PATIENTS THINK OF THE CARE THEY RECEIVE?

In 2017 the Croatian Health Insurance Fund (CHIF) conducted a nationally representative survey exploring
the views of 1000 respondents on the health system and the work of health institutions. On a scale of 1 to 5,
the average satisfaction with the quality of services and the work of health institutions was 3.2. Respondents
identified as the greatest strengths of the health system the performance of medical staff (42.4%), the work
of the emergency medical service (40.8%), the attitudes of health professionals towards patients (39.3%)
and the availability of health services (37.5%). The waiting lists for diagnostic tests and specialist exami-
nations were identified as the biggest problem in the health system. Respondents were generally satisfied
with the primary care system.

14 CROATIA
FIG. 8  
UNMET NEEDS FOR A MEDICAL EXAMINATION (DUE TO COST, WAITING TIME, OR
TRAVEL DISTANCE), BY INCOME QUINTILE, EU/EEA COUNTRIES, 2020

Estonia
Greece
Finland
Latvia
Romania
United Kingdom
Iceland
Slovakia
Slovenia
France
Ireland
Poland
EU27
Italy
Denmark
Lithuania
Portugal
Belgium
Croatia
Sweden Total
Bulgaria
First quintile
Norway
Hungary Fifth quintile

Switzerland
Czechia
Spain
Cyprus
Netherlands
Germany
Luxembourg
Austria
Malta

0 5 10 15 20

% of population

Notes: EEA: European Economic Area; EU: European Union. Data refer to 2020 except for Italy (2019), Iceland (2018) and United Kingdom (2018).
Source: Eurostat (2021), based on EU-SILC.

HEALTH SYSTEM SUMMARY: 2022 15

 FIG. 9  
IN-HOSPITAL MORTALITY RATES (DEATHS WITHIN 30 DAYS OF ADMISSION) FOR
ADMISSIONS FOLLOWING ACUTE MYOCARDIAL INFARCTION, CROATIA AND SELECTED
COUNTRIES

Lavia
Croatia
Estonia
Lithuania
Germany
Luxembourg
Finland
Malta
Portugal
United Kingdom
EU-23
Spain
Belgium
Austria
Czechia
Slovakia
France
Italy
Ireland
Slovenia
Poland
Sweden
Netherlands
Norway
Denmark
Iceland

0 3 6 9 12 15
Rate per 100 patients
Notes: Figure is based on admission data and has been age–sex standardized to the
2010 OECD population aged 45+ admitted to hospital for AMI.
Source: OECD Health Statistics, 2019 (data refer to 2017 or nearest year).

HEALTH SYSTEM OUTCOMES

Croatia’s mortality rates from amenable* causes accounting for almost 40% of deaths that could be
are very high and well above the EU average (141 avoided through timely and appropriate treatment.
compared to 111 per 100 000 population), but have Colorectal and breast cancer also contribute substantially,
declined since 2011 (Fig. 10). As with mortality making up a further 26% of deaths from amenable
from preventable causes, cardiovascular diseases and causes. Croatia has also been severely affected by the
ischaemic heart disease in particular play a big role, COVID-19 pandemic.

* Amenable mortality refers to causes of death that can be mainly avoided through timely and effective health care interventions, including
secondary prevention and treatment (i.e. after the onset of diseases, to reduce case fatality).

16 CROATIA
 Mortality from preventable causes (deaths which policies in Croatia are still weak, with a lack of smoke-
could have been avoided by public health interventions, free places (indoor smoking is allowed in some bars)
including lung cancer, alcohol-related causes and road and underdeveloped media campaigns against tobacco
traffic deaths) in Croatia was the third highest in the EU use. There is anti-tobacco legislation (such as the 2017
in 2017 and well above the EU average (79 compared Act on Restrictions on the Use of Tobacco and Related
to 55 per 100 000) (Fig. 10). This high rate points to Products), but evaluations or outcome data of national
underdeveloped intersectoral policies to address key strategies or interventions are not available. Deaths
determinants of ill-health, such as smoking, alcohol con- from alcohol-related causes and transport accidents also
sumption and road traffic deaths (Box 7). Anti-smoking exceed the EU average.

AMENABLE MORTALITY PREVENTABLE MORTALITY

FIG. 10  AMENABLE
Romania Hungary
AND PREVENTABLE
Latvia Romania
MORTALITY PER
Bulgaria Croatia
100 000 POPULATION
Lithuania Poland
IN CROATIA
Hungary Slovakia
AND OTHER EU
Slovakia Bulgaria
COUNTRIES,
Estonia Latvia
2000 AND 2019
Croatia Lithuania

Poland Estonia

Notes: EEA: European Czech Republic Czech Republic

Economic Area. EU27 Slovenia
Age-standardized death rates
Greece EU27
for all persons calculated by
European Observatory for Portugal Belgium

Health Systems and Policies. Ireland Greece

Source: Mortality and Germany France
population data from
Malta Germany
WHO detailed mortality
files (released June 2021); Finland Austria

amenable causes as per Cyprus Denmark

list by Nolte and McKee Slovenia Finland
(2004); preventable causes:
Denmark Spain
lung cancer, chronic liver
disease, road traffic. Austria Netherlands

Belgium Luxembourg

Italy Portugal

Luxembourg Ireland

Spain Italy

Sweden Cyprus

Netherlands Malta

France Sweden
0 50 100 150 200 250 300 350 400 0 50 100 150 200

2000 2019 (or latest)

HEALTH SYSTEM SUMMARY: 2022 17

 BOX 7 | ARE PUBLIC HEALTH INTERVENTIONS MAKING A DIFFERENCE?

Approximately 44% of all deaths in Croatia can be attributed to behavioural risk factors, including dietary
factors, tobacco smoking, alcohol consumption and low physical activity. Intersectoral policies to address
key determinants of ill-health, such as smoking and poor nutrition, are underdeveloped. Anti-smoking pol-
icies are weak, with a lack of smoke-free places and underdeveloped media campaigns against tobacco
use. The prevalence of obesity is high and growing. A Centre for Healthy Eating and Physical Activity was
opened in 2014 and a National Plan for the Reduction of Salt Intake for the period 2015–2019 was adopted
in 2014, but there is much more scope for stepping up preventive programmes. Deaths from alcohol-re-
lated causes and transport accidents exceed the EU average. Alcohol control policies have been adopted,
including a minimum age of 18 years for sales on or off the premises, but there is scope for implementing
further restrictions.

HEALTH SYSTEM EFFICIENCY

Health system efficiency is not monitored systemat- efficiency. In 2019 Croatia spent 29.5% of its expenditure
ically in the Croatian health system. There are some on inpatient curative and rehabilitative care, which was
limited studies, but their results need to be treated slightly above the EU27 average of 29.1%. Expenditure
with caution due to the limited availability and qual- on outpatient care (consisting of primary care and spe-
ity of data. Some examples are the low efficiency in cialist outpatient care mostly provided by hospital out-
the implementation of programmes for the prevention patient departments) accounted for 37.9%, which was
and treatment of cancer, the high rates of amenable above the EU27 average of 29.5%. Policies are also being
mortality and large regional disparities in the use of pursued to improve expenditures on pharmaceuticals
emergency medicine, all indicating that there may be (Box 8).
more efficient ways of using existing resources (Voncina, Technical inefficiencies (a poor level of outputs
Dzakula & Mastilica, 2007; Jafarov & Gunnarsson, given the quantity of inputs) exist in both hospital
2008; Šiško & Šiško, 2017). At a very macro level, and primary care. The hospital payment system has
considering levels of amenable mortality in relation been reformed in recent years, but hospitals remain
to health expenditure per capita (Fig. 11), Croatia is prone to the accumulation of arrears, as spending limits
doing reasonably well, with several countries having are not sufficiently aligned with types and amounts of
higher levels of amenable mortality despite similar or services. The average length of stay in hospitals has
higher levels of expenditure. been gradually decreasing, from 9.5 days in 2010 to
The breakdown of health expenditure by health 8.2 days in 2018, but remains above the EU13 and
care functions indicates scope for improved allocative EU15 averages.

BOX 8 | IS THERE WASTE IN PHARMACEUTICAL SPENDING?

At present Croatia spends around €100 million on the procurement of medicines for the treatment of cancer.
Due to increases in the price of medicines and the number of patients, this amount is increasing on aver-
age by €20 million annually. The Ministry of Health aims to achieve savings through joint public procure-
ment with other EU Member States, better control over the consumption of expensive medicines, and an
increase in the use of generic drugs. Croatia is taking part in cross-border cooperation to jointly negotiate
with the pharmaceutical industry on drug pricing through the Valletta Group (with Cyprus, Greece, Ireland,
Italy, Malta, Portugal, Romania, Slovenia and Spain). CHIF’s basic list comprises generic drugs whenever
available. The use of expensive medicines is coordinated between the CHIF and the hospital commission.

18 CROATIA
 FIG. 11  
AMENABLE MORTALITY PER 100 000 POPULATION VERSUS HEALTH EXPENDITURE
PER CAPITA, CROATIA AND SELECTED COUNTRIES, 2019

300

Romania
250
Amenable mortality per 100 00

Bulgaria Latvia
200
Hungary
Slovakia

150

Poland
Croatia
100

50

0 2 000 4 000 6 000 8 000 10 000

Health expenditure US $ PPP per capita

Note: PPP: purchasing power parity.

Source: WHO Global health expenditure database and WHO mortality data, December 2021.

Summing up Improvements
in the accessibility
Prior to the onset of the COVID-19 pandemic in on quality of care suggests that and quality of care are
2020, the Croatian health system had made important there is much scope for improve- among key strategic
progress towards improving the health of the popu- ment. The standardized 30-day goals for the health
lation. Almost the entire population has access to a hospital mortality rate for acute system
broad range of publicly paid services. Private out-of- myocardial infarction (AMI) is much
pocket payments are relatively low and the country has higher than in most other EU countries.
achieved high levels of financial protection. However, The National Development Strategy for 2020–2030
there are geographical barriers, as well as long waiting that was adopted in February 2021 has the strategic
times, impeding the accessibility of health services, goals of improving the health of citizens throughout
which are likely to have increased as a result of the their lifecourse, and improving access to and quality of
COVID-19 pandemic. health services and creating an efficient health system.
In addition to COVID-19 infections, the health This strategy might provide the required framework
system is faced with high levels of mortality from pre- for accelerating reforms of hospital and primary care
ventable and amenable causes. Available information and improving quality of care.

HEALTH SYSTEM SUMMARY: 2022 19

 POPULATION HEALTH CONTEXT
KEY MORTALITY AND HEALTH INDICATORS

LIFE EXPECTANCY (YEARS)

Life expectancy at birth, total 77.8

Life expectancy at birth, male 74.7
Life expectancy at birth, female 80.9

MORTALITY (SDR PER 100 000 POPULATION)

All causes* 1331

Circulatory diseases* 609
Malignant neoplasms* 324
Communicable diseases* 12
External causes* 76
Infant mortality rate (per 1 000 live births) 4.2
Maternal mortality rate per 100 000 live births (modelled estimate) 8

Notes: SDR: standardized death rate.

*Age-adjusted rates with the European standard population 2010.
Life expectancy data is for 2020. Mortality data is for 2018. Infant
mortality data is from 2019. Maternal mortality data is for 2017.
Source: Eurostat, 2022; World Bank, 2022 for maternal mortality.

REFERENCES

Croatian Institute of Public Health (2020) Croatian Health Statistics OECD (2022). OECD Statistics. Paris: Organisation for Economic
Yearbook 2019. Co-operation and Development.

CHIF (2021) CHIF Business Report for 2020, Zagreb: Croatian Health Šiško I, Šiško N (2017). Preventivni programi za rano otkrivanje raka
Insurance Fund. dojke u Republici Hrvatskoj [Prevention programmes for early detection
of breast cancer in Croatia]. Sestrinski glasnik, 22(2):107–10.
CHIF (2022) Contracted contents of health care in the Republic of Croatia.
Zagreb: Croatian Health Insurance Fund. Vočanec, D., Džakula, A., Lončarek, K., Sović, S., & Rechel, B. (2022).
Integration processes within the Croatian palliative care model in
Eurostat (2021). Eurostat database. Luxembourg: European Commission.
2014 – 2020. Health Policy, 126(4), 207–215.
HALMED (2021) Report on drug consumption in the Republic of Croatia
Vončina L, Dzakula A, Mastilica M (2007). Health care funding reforms
in 2020. Zagreb: Agency for Medicinal Products and Medical Devices
in Croatia: a case of mistaken priorities. Health Policy, 80(1):144–57.
(HALMED).
WHO (2021). Global Health Expenditure Database. Geneva: World Health
Jafarov E, Gunnarsson V (2008). Government spending on health care
Organization. Available at: https://apps.who.int/nha/database/ViewData/
and education in Croatia: efficiency and reform options. IMF Working
Indicators/en (accessed 18 May 2022).
Paper No. 08/136. Washington: International Monetary Fund.
World Bank (2020). World Development Indicators database. Washington
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Zagreb: Ministry of Health.
Keywords:
DELIVERY OF HEALTH CARE
EVALUATION STUDIES
FINANCING, HEALTH
HEALTH CARE REFORM
HEALTH SYSTEM PLANS – organization and administration
CROATIA

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