In general

Croatia is European country in transition with a population of about 4 300 000. It is located in central Europe, covering an area of 56 542 km2 and with 5835 km of coastline. Croatia’s political system is a parliamentary democracy. Regional and local government is organized on two levels: 20 counties plus the city of Zagreb, and 426 municipalities.

Organisation and financing of health care

Croatia’s health care system is based on principles of inclusivity, continuity and accesibility. The network of health care providers is organized in a way that makes it accessible to all citizens.

Croatia’s health care system  is based on the principles of social health insurance. Provision and funding of services are largely public, although private providers and insurers also operate in the market. The health care system is dominated by a single public health insurance fund: National Health Insurance Institute (NHII) which is financially part of State Treasury. To ensure quality of access to all citizens, NHII-contracted health care providers operate within the framework of the national health care network. The network determines allocation of public financial resources between the 20 counties according to morbidity, mortality, demographic characteristics etc. The central government continues to play a dual role as the purchaser and provider of health care through its influence on the NHII funding, on the one hand, and as the largest owner of hospitals and public health institutions, on the other. Ownership of secondary and tertiary health care facilities (buildings) was distributed among the State, counties and cities. Tertiary health care facilities, comprising clinical hospitals, clinical hospital centers and national institutes of health, remained state-owned. Secondary health care facilities ( general and special hospitals ) and county institutes of public health became county-owned.

Funds for social health insurance are collected mainly from payroll taxes paid by employees, the self-employed and farmer’s contributions. Social health insurance for certain vulnerable categories of the population is partly cross-subsized from payroll contributions and additionaly funded by transfers from the central government budget and from county budgets. These categories include the unemployed, disabled, elderly, people under 18, students, war veterans and the military. Patients are required to pay for acess to certain publicly provided health services through co-payments or to buy complementary health insurance. Certain groups are exempt from paying co-payments. These include the unemployed, disabled, people under 18, students, the military, war invalids and multiple voluntary blood donors.

Position of GP/FM

According to the Croatian Health care Law, the two main roles to be fulfilled by primary health care are: being the foundation of the health care system, and gatekeeping. Primary health care is organized as a network of first-contact doctors. Each insured citizen is required to sign up with a specific GP. Primary health care is delivered through a network of individual offices, larger units comprising several offices ( some including small laboratories ), and health centers that provide general medicine consultations, primary care gynecology services, care for pre-school children, school medicine ( preventive medicine and vaccinations of school children ), occupational health services and dental care. Most of primary health care is provided through private practices comprising a team of doctor and a nurse, financed by capitation and some additional payments .

General practice/family medicine treats patients of all ages. GP/FPs are required to treat patients in their offices, provide home visits and provide preventive check-ups. Doctor and nurse teams are independent entrepreneurs owned by the doctor and contracted by the NHII. Each GP is expected to carry an average of 1700 people per year on the roster ( with huge differences, from more than 2000 at eastern part of Croatia to rural and island practices with 400 patients ).

The total number of licenced doctors in Croatia is about 18000 and according to the data from NHII in April 2012 there were 2340 GP/FPs. 47% of them are specialists, and only 23% are men. Most of the GPs/FPs , 85%, work as self-employees with contracts to NIHI (official  data from Croatian Medical Chamber, 11.01.2012). 15% of GPs/FPs work as public employees at Medical Health Centers.

There is a shortage of all kinds of doctors in Croatia especially GP/FPs, so there is an urgent need to create the way to keep young doctors in family medicine. Young doctors do not want to go to mostly isolated family practices where they must take the responsibility for managing practice from medicine to administrative work, taxes, finding replacement for themselves and nurse in case of absence. Vocational training for FPs is also demanding so there is a great fall in interest for family medicine.

Education and training for GP/FM

There are four undergraduate medical schools in Croatia. They are situated in Zagreb and the regional centers Osijek, Rijeka and Split. Medical school is completed over six years. Prior to practicing, graduates must take a one-year internship and pass the state exam. Further specialization takes place after the internship.

Medical training for GP/FM according to the new law lasts 4 years. It consists of theoretical part with final exam ( 6 months ), period of visiting hospital departments and period with teacher (“mentor”) in family practice ( 6 months – 1 year ). At the end of training there is specialist exam with written part of exam, practical part ( OSCI ) and oral exam with cases from GP/FPs practice.

CME and relicensing

GP/FM gets the license for work by Croatian Medical Chamber (CMC) and CMC is National Authority for CME. The condition for relicensing is collecting of 120 points during 6 years. It can be done through few ways – CME courses, participating on local or international professional medical meetings or conferences, publishing the papers in magazines or books, participating in different kinds of lecturing in community. In case of not collecting the needing points GP/FM needs to pass the exam after period of 6 years.

Pharmaceutical supply

Patients in Croatia are supplied with medicines by public and private pharmacies. Pharmacies have largely been privatized, mostly by renting existing pharmacy premises to private pharmacists. Privatization has largely been successful in improving the supply of, and access to, drugs, but the undesirable consequence has been that pharmaceutical expenditure has increased.

Patients who are insured and additionally insured pay nothing for medicines from the main list and some amount for the additional list of medicines. Some of the medicines require additional paying by patients. The NHII controls drug prices and has been imposing price cuts.

To curb the volume of prescriptions, the NHII has imposed annual limits of the number of prescriptions per beneficiary and limited the number of drugs per prescription. Exceptions are permitted for special cases. Overspending by individual GP/FPs is subject to financial punishments.

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