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20 March 2023 | Policy Analysis
The new Health Care Act
2.2. Organization
The legal framework for the Croatian health system is largely set out by the 2018 Health Care Act. The steward of the health system is the Ministry of Health, responsible for health policy, planning and evaluation, public health programmes and the regulation of capital investments for publicly owned health care providers. Publicly financed health services are based on the principles of comprehensiveness (covering all segments from health promotion to palliative care), continuity, accessibility and universality (covering the whole population) in primary care and referral-based secondary and hospital care. Accessibility is regulated with the aim of ensuring that every person has equitable access to health services, such as through an appropriate distribution of health care institutions and health workers. The principle of comprehensiveness in primary health care is addressed by measures aimed at improving health, preventing disease and providing treatment, rehabilitation and palliative care.
Generally, counties, as regional authorities, are accountable for the organization, coordination and management of primary health care (health centres, public health services and public pharmacies) and secondary health care (general and specialized hospitals). Most primary care practices have been privatized, and the remaining ones are in public ownership as health centres. National authorities (the Ministry of Health and the Government) are responsible for tertiary care.
Fig2.1 provides an overview of the Croatian health system.
Fig2.1
On 17 March 2023, the Croatian Parliament accepted Amendments to the Health Care Act as part of the ongoing health reform.
The amended Health Care Act introduces new concepts such as:
- Integration of care (across levels of health care, as well as between health and social care), which will later be specified in a rulebook on integration.
- The complex patient, understood as a patient who suffers from mutually aggravating conditions. Patient complexity is seen as consisting of medical, socioeconomic, and/or psychological factors specific to the person that interfere with the provision of usual care and decision-making regarding a patient’s condition.
- A 24/7/365 care model, referring to the provision of comprehensive, continuous and coordinated care in different settings and from different care providers for the entire duration of the health need taking into account social needs as well.
- A hospital without walls concept that includes care provision, management, and monitoring, regardless of the health care setting and including hospitals, nursing homes, and home care.
Moreover, the new Health Care Act aim to strengthen primary health care by:
- establishing one health centre per county and strengthening its role as the fundamental provider of primary health care;
- strengthening the coordination and integration of long-term care activities within the health centre and with other stakeholders in health care, social care, as well as patients and their caregivers; and
- strengthening specialized secondary-level care outside of hospitals and within health centres.
This aims to provide easier access to health services, reduce the burden on the hospital system, and shorten waiting times.
Third, the amendments aim to strengthen the hospital system and improve their management by transferring ownership of general hospitals from counties to the state. This change aims to achieve financial sustainability by strengthening business control mechanisms at the national and regional level, and increasing skill requirements for the management teams of health institutions.
For more information on the Health Care Act (in Croatian) see:
2.2.1. Ministry of Health
At the central level, the Ministry of Health is responsible for:
- health policy, planning and evaluation, drafting of legislation, regulation of standards for health services, and training of health workers;
- public health programmes, including monitoring and surveillance; and
- regulation of capital investments of publicly owned health care providers.
In particular, it draws up legislation for consideration by the Parliament, produces health-related strategic documents, monitors population health status and health care needs, regulates standards in health facilities, and supervises professional activities such as specialist training. The Ministry of Health also manages public health activities, including sanitary inspections, supervision of food and pharmaceutical quality, and health promotion activities. It also nominates the chairs of the governing councils and appoints the majority of the board members in state-owned health care facilities.
2.2.2. Ministry of Finance
The Ministry of Finance is responsible for the planning and management of the government budget, including the approval of central budget transfers to the CHIF and the Ministry of Health. Therefore, the Ministry of Finance plays a key role in determining the overall level of public spending on health.
2.2.3. Ministry of Labour, Pension System, Family and Social Policy
The Ministry of Labour, Pension System, Family and Social Policy was set up in 2020, when the Ministry of Demography, Family, Youth and Social Policy was merged with the Ministry of Labour and Pensions. The Ministry oversees the network of social care entities and monitors the social welfare system. Since June 2017 the previous Ministry of Labour and Pensions has developed the Zaželi programme, which offers unemployed, lower-educated women home assistance jobs targeting older people and people with disabilities in local communities, especially those in remote areas (rural areas and islands).
2.2.4. Croatian Health Insurance Fund (CHIF)
Established in 1993, the CHIF is the single purchaser of health services provided under the mandatory health insurance scheme. It may also offer complementary (called “supplementary” in Croatia) voluntary health insurance to persons insured under the mandatory health insurance scheme. The Ministry of Health defines the basic benefits covered under the statutory insurance scheme, while the CHIF plays a key role in the establishment of performance standards and price-setting for services covered under the mandatory health insurance scheme. The CHIF is also responsible for the distribution of sick leave compensation, maternity benefits and other allowances as regulated by the Mandatory Health Insurance Act. In 2002 the CHIF was consolidated under the Treasury account but it has operated separately since 1 January 2015.
2.2.5. Croatian Institute of Public Health (CIPH)
The Croatian Institute of Public Health (CIPH) was established in 1923. Its main activities include:
- statistical research on health and health services;
- maintaining public health registers;
- monitoring and analysing the epidemiological situation;
- provision, organization and conduct of preventive and counter-epidemic measures;
- planning and control of disinfection and pest control measures;
- planning, control and evaluation of mandatory immunizations;
- microbiological activities; and
- testing and control of the safety of drinking-water, wastewater and food.
2.2.6. Counties and the city of Zagreb
Local governments own and operate most of the public primary and secondary health care facilities, including general and specialized hospitals, county health centres, public health institutes and community health institutions (home care and emergency care units). While these facilities receive operating expenditure through their contracts with the CHIF, local authorities are responsible for financing infrastructure maintenance and, increasingly, capital investments. They are also responsible for any losses these health care facilities accrue.
2.2.7. Professional chambers
Croatia has statutory professional chambers for a number of medical professions. The chambers are responsible for the registration of professionals and the maintenance of professional standards. Membership of health care workers in their respective professional chamber is mandatory. The chambers also provide opinions on a variety of issues, as well as advice on the licensing of private practices and the opening or closing of health institutions.
2.2.8. The private sector
Although most health care providers remain under public ownership, private providers have grown in number, notably in primary care, dental services and specialized clinics. A small but growing private insurance market has also developed, offering complementary (covering cost-sharing in the mandatory health insurance system) and supplementary (covering health services not included in the mandatory health insurance system) insurance coverage.