CROATIAN HEALTHCARE REFORM FROM THE PERSPECTIVE OF USERS 1990-2009

1. CROATIAN HEALTHCARE REFORM FROM THE PERSPECTIVE OF USERS 1990-2009 Miroslav Mastilica

2. CROATIAN HEALTHCARE REFORM • Alice's Adventures in Wonderland Miroslav Mastilica

3. Would you tell me, please, which way I ought to go from here?' `That depends a good deal on where you want to get to,' said the Cat. `I don't much care where--' said Alice. `Then it doesn't matter which way you go,' said the Cat. `--so long as I get SOMEWHERE,' Alice added as an explanation. `Oh, you're sure to do that,' said the Cat, `if you only walk long enough.' Miroslav Mastilica

4. CROATIAN HEALTH CARE REFORM 1990-2009: • PRIVATISATION • RATIONING • MARKETISATION Miroslav Mastilica

5. CROATIAN HEALTH CARE REFORM - ACTERS • GOVERMENT- MINISTRY OF HEALTH !!!! • HEALTHCARE PROVIDERS !! • (((CITIZENS – CONSUMERS-PATIENTS)))???? Miroslav Mastilica

6. 1. PHASE - PROVIDERS ORIENTED-1990-1993 • Centralization of financing ("Croatian Institute for Health Insurance ") • Control of provision of services Miroslav Mastilica

7. 2. PHASE - CONSUMERS ORIENTED-1993-2002 • Voluntary health insurance • supplementary insurance • private insurance • Co-payments • Private practice • a) full private • - with or without contract with • insurance fund • b) in PHC in rented offices / contracted Miroslav Mastilica

8. DEVELOPMENT OF MARKET • PROVIDERS • public (still dominant-69%-2004) • private (growing- 31%) • SERVICES OFFERED • public providers - services covered by compulsory health insurance (all what is available) private providers – services covered by supplemental insurance • amenities • OTC medicaments • alternative medicine • CONSUMERS • GDP per capita 10.678 US$ (2008) • Average income 5178 HRK 950 US$ • HCE per capita 400 US$ Miroslav Mastilica

9. THIRD PHASE – 2003+ • COMPULSORY BASIC HEALTH INSURANCE • covers 85% - 25% of total price of services or drugs • co-payments from the insured 15% - 75% of the cost for most health care services or drugs Miroslav Mastilica

10. VOLUNTARY HEALTH INSURANCE • 50% of the population • SUPPLEMENTARY HEALTH INSURANCE • covers the difference between the basic insurance and the total service or drug cost • greater scope of rights or standard for contracted health services • amenities PRIVATE HEALTH INSURANCE • full coverage of contracted health care services Miroslav Mastilica

11. CURRENT SITUATION • reductions in the right to health care within the mandatory health insurance system • introduction of market mechanisms into the health care and health insurance system • citizens as patients are paying a growing share of health services transforming them into consumers Miroslav Mastilica

12. INCREASE OF DIRECT PAYMENTS • reduced access / utilization of services and medicaments • PRIVATISATION AND MARKETISATION • two-tiered system for necessary health services • new inequalities / inequities in access / utilization / quality of services • low income persons in disadvantaged position in access to quality services Miroslav Mastilica

13. HEALTH CARE REFORM IN CROATIA transformation of health services from SOCIAL GOODS to COMMODITIES from PUBLIC to MARKET Miroslav Mastilica

14. Do you agree with the statement that: • ‘some people in this country have easier access to healthcare services and receive better quality of care than others’? • YES • 1989 65.8% • 1994 75.2% • 82.3% • 2009 85,7% Miroslav Mastilica

15. Self-perceived general health status by socioeconomic group (Zagreb health inequalities study 1990, N=433, p<.01) SOCIAL INEQUALITIES IN HEALTH IN CROATIA 1990 Miroslav Mastilica

16. SES INEQUALITIES IN HEALTH IN CROATIA- 1994 Miroslav Mastilica

17. Table. Distribution of direct payments for health care by income quartiles Miroslav Mastilica

18. Inequaities in Health care financing in Croatia(Mastilica, Božikov. 1999) Lorenz curve for income (triangles) and the concentration curve of out-of-pocket payments (squares) Miroslav Mastilica

19. Table. Self-perceived health status by income 2003 Croatian AdultHealth Survey N=11138 % Health/INCOME lowmiddlehigh Excellent 13,8 29 57,3% Very good 11,9 28 60,1 Good25 33,8 41,2 Fair32,7 35,7 31,6 Bad 51,1 30,8 18,1 p<0.001 Miroslav Mastilica

20. Table. Self-perceived health status by education 2003Croatian Adult Health Survey N=11138 % Health/Education lowmiddlehigh Excellent 2,4 9,9 12,0 Very good 5,1 20,5 30,1 Good28,4 30,3 30,3 Fair 35,928,6 21.6 Bad 28.2 10,8 6.1 p<0.001 Miroslav Mastilica

21. Visits to specialists, by income groups when controled by health status 2003 Croatian Adult Health Survey N=11138 p<0.001 Miroslav Mastilica

22. Social inequalities in health in Croatia2003 Croatian Adult Health Survey N=11138SF36 Dimensions by education Miroslav Mastilica

23. Social inequalities in health in Croatia2003 Croatian Adult Health Survey N=11138SF36 Dimensions by gender Miroslav Mastilica

24. Regional inequalities in health in Croatia 2003 Croatian Adult Health Survey N=11138 Miroslav Mastilica

25. PRIVATE HEALTH CARE EXPENSES 2009(N=525) Miroslav Mastilica

26. PRIVATE HEALTH CARE EXPENSES 2009 Private expenses( last 6 months) Miroslav Mastilica

27. PRIVATE EXPENSES IN 2009 Citizens pay too much from the pocket Miroslav Mastilica

28. PRIVATE EXPENSES IN 2009 Easier access to health care services if paid from the pocket: Miroslav Mastilica