State of Health in the EU Croatia: Country Health Profile 2019

24 Pages·2019·2.963 MB·English

by  OECD, European Observatory on Health Systems and Policies

State of Health in the EU
Croatia HR
Country Health Profile 2019
The Country Health Profile series Contents
The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3
provide a concise and policy-relevant overview of 2. HEALTH IN CROATIA 4
health and health systems in the EU/European Economic
3. RISK FACTORS 7
Area. They emphasise the particular characteristics and
4. THE HEALTH SYSTEM 9
challenges in each country against a backdrop of cross-
country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 13
and influencers with a means for mutual learning and 5.1. Effectiveness 13
voluntary exchange.
5.2. Accessibility 16
The profiles are the joint work of the OECD and the 5.3. Resilience 19
European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22
in cooperation with the European Commission. The team
is grateful for the valuable comments and suggestions
provided by the Health Systems and Policy Monitor
network, the OECD Health Committee and the EU Expert
Group on Health Information.
Data and information sources The calculated EU averages are weighted averages of
the 28 Member States unless otherwise noted. These EU
The data and information in the Country Health Profiles averages do not include Iceland and Norway.
are based mainly on national official statistics provided
to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on
ensure the highest standards of data comparability. data available in July 2019.
The sources and methods underlying these data are
To download the Excel spreadsheet matching all the
available in the Eurostat Database and the OECD health
tables and graphs in this profile, just type the following
database. Some additional data also come from the
URL into your Internet browser: http://www.oecd.org/
Institute for Health Metrics and Evaluation (IHME), the
health/Country-Health-Profiles-2019-Croatia.xls
European Centre for Disease Prevention and Control
(ECDC), the Health Behaviour in School-Aged Children
(HBSC) surveys and the World Health Organization
(WHO), as well as other national sources.
Demographic and socioeconomic context in Croatia, 2017
Demographic factors Croatia EU
Population size (mid-year estimates) 4 130 000 511 876 000
Share of population over age 65 (%) 19.6 19.4
Fertility rate¹ 1.4 1.6
Socioeconomic factors
GDP per capita (EUR PPP²) 18 500 30 000
Relative poverty rate³ (%) 20.0 16.9
Unemployment rate (%) 11.0 7.6
1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the
purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 %
of median equivalised disposable income.
Source: Eurostat Database.
Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of
the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein
can in no way be taken to reflect the official opinion of the European Union.
This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation
of international frontiers and boundaries and to the name of any territory, city or area.
Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/
© OECD and World Health Organization (acting as the host organisation for, and secretariat of, the European Observatory on Health Systems and
Policies) 2019
2 State of Health in the EU · Croatia · Country Health Profile 2019
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1 Highlights T
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Life expectancy in Croatia is improving but continues to lag behind the EU average. Social inequalities in life
expectancy appear to be less pronounced in Croatia than in many other EU countries. A mandatory health
insurance system provides a broad range of benefits to the whole population, some of which are subject to
cost-sharing. Recent reform efforts have targeted both primary and secondary care, but with limited success so
far. The need to improve quality of care has been recognised, but requires a tangible policy response. Some of the
Croatia’s counties lack health workers, and migration abroad is another concern.
HR EU Health status
83
Life expectancy at birth in Croatia increased to 78 years in 2017, below the
80.9
81 EU average of 80.9 years. Ischaemic heart disease and stroke are the two
78.0
77.3
79 main causes of death. Lung cancer is the most frequent cause of death by
74.6
77 cancer and there has been no reduction in its mortality rate since 2000.
75 The death rate from diabetes has increased. Croatians aged 65 could
2000 2017 expect to live an additional 17.4 years, two years more than in 2000, albeit
Life expectancy at birth, years more than 12 of those years are spent with some chronic diseases.
Country
Ri%s0k1 fa%c0t1oErUs
HR EU
% of adults, 2014 There is much scope to address modifiable risk factors. In 2014, one in
Smoking 25 % four adults in Croatia smoked daily, which is above the EU average. While
19 binge drinking is below the EU average for adults, it is a problem among
Obesity 18 % adoleEUscents: a much higher proportion of teenagers report at least one
15 Country
episode of heavy alcohol drinking in the past month than in most other EU
Binge drinking 47 %
countries. Obesity rates are above the EU average and rising, particularly
38
% of 15-16 year olds, 2015 among children.
Health system
HR EU
Health expenditure per capita, at EUR 1 272, was among the lowest in the
EUR 3 000 EU in 2017, where the average was EUR 2 884. Croatia devotes 6.8 % of
EURS 2m 0o0k0ing 17 its GDP to health compared to an EU average of 9.8 %. Nevertheless, the
EUR 1 000 share of public expenditure, at 83 %, is above the EU average. The benefit
BEiUngRe 0 drinking 22 package is broad, but services require co-payments, for which many
2005 2011 2017 Croatians take out voluntary health insurance. Overall, out-of-pocket
Per capita spending (EUR PPP) payments, excluding voluntary health insurance, accounted for 10.5 % of
Obesity 21
health expenditure in 2017, below the EU average of 15.8 %.
Effectiveness Accessibility Resilience
Weak intersectoral policies to Self-reported access to health care The small pool
address key determinants of ill is good, with low unmet needs of social health
health contribute to high rates for medical care. However, there insurance
of deaths from preventable and is substantial variation between contributors,
treatable causes. The quality income groups and unmet needs combined with high hospital debt
of care is also an issue, which are high among older people. levels, raise concerns about the
a national strategy is trying to Geographical distance is also an financial sustainability of the
address. access barrier. health system. Strengthening
Country
EU governance and building support
Preventable 232 High income All Low income
mortality among stakeholders will be
HR
crucial to implementing reforms.
Treatable 140
EU
mortality HR EU
Age-standardised mortality rate 0% 3% 6%
per 100 000 population, 2016
% reporting unmet medical needs, 2017
State of Health in the EU · Croatia · Country Health Profile 2019 3
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T 2 Health in Croatia
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Life expectancy is below the EU average almost unchanged, amounting to 2.9 years (Figure 1).
The gender gap in life expectancy in Croatia is greater
Although life expectancy at birth in Croatia increased than for the EU overall, with women on average living
by 3.4 years between 2000 and 2017, from 74.6 to 6.1 years longer than men, compared to an EU average
78 years, the distance to the EU average remained of 5.2 years.
Figure 1. Life expectancy at birth is about three years below the EU average
Years 2017 2000
90 –
Gender gap:
4 Croatia: 6.1 years
85 – 83. 83.1 82.7 82.7 82.6 82.5 82.4 82.2 82.2 82.1 81.8 81.7 81.7 81.6 81.6 81.4 81.3 81.2 81.1 81.1 80.9 EU: 5.2 years
9.1 4
80 – 7 78. 78 77.8 7.3
7 8
76 75. 75.3 74.9 74.8
75 –
70 –
65 –
Spain ItalyFranceNorwaIycelanSdweden MaltaCyprusIrLeluaxnedmbNoeturhgerlandsAustriaFinlanBdelgiuPmortuganlitGreed ecKiengdoSlmoveniGaermanDyenmark EUCzechiaEstoniaCroatiaPolanSldovakiHaungaLrityhuaniRaomaniaLatviBaulgaria
U
Source: Eurostat Database.
Social inequalities in life expectancy obstructive pulmonary disease (COPD) have increased
differ greatly for men and women greatly since 2000. The rise in mortality from treatable
conditions – COPD, diabetes, breast and colorectal
Social inequalities in life expectancy appear to be cancer – is a cause for concern (Section 5.1).
less pronounced in Croatia than in many other EU
countries. Yet, men with low education live on average
Figure 2. The education gap in life expectancy at age
5.2 years less than those who completed tertiary 30 is more than five years for men
education (Figure 2). The gap for women (1.6 years) is
far below the EU average (4.1 years).
Mortality due to diabetes, chronic
obstructive pulmonary disease 53.1
and some cancers is growing y5e1a.5rs years 49.1
years
43.9
years
In 2016, ischaemic heart disease represented more
than one fifth of all deaths (Figure 3). In contrast to
most other EU countries, the mortality rate from this Lower Higher Lower Higher
disease decreased only slightly between 2000 and e ducated educated educated educated
women women men men
2016 (Figure 3). Despite a substantial reduction in the
Education gap in life expectancy at age 30:

mortality rate, stroke is still the second cause of death
Croatia: 1.6 years Croatia: 5.2 years
in the country. Lung cancer is the most frequent cause
EU21: 4.1 years EU21: 7.6 years
of death by cancer among Croatians and there has
been no reduction in its mortality rate since 2000. In
Note: Data refer to life expectancy at age 30. High education is defined as
fact, mortality rates from lung, breast and colorectal people who have completed a tertiary education (ISCED 5-8) whereas low
education is defined as people who have not completed their secondary
cancer in Croatia are among the highest in the EU.
education (ISCED 0-2).
Moreover, mortality rates from diabetes and chronic Source: Eurostat database (data refer to 2016).
4 State of Health in the EU · Croatia · Country Health Profile 2019
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Figure 3. Cardiovascular diseases are the main causes of deaths in Croatia TI
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% change 2000-16 (or nearest year)
R
100 C
Diabetes
Chronic obstructive pulmonary disease
Kidney disease
50
Colorectal cancer
Breast cancer Lung cancer
0
50 100 150 200 250 300
Liver disease Stroke Ischaemic heart disease
-50
-100
Age-standardised mortality rate per 100 000 population, 2016
Note: The size of the bubbles is proportional to the mortality rates in 2016.
Source: Eurostat Database.
The proportion of Croatians reporting Figure 4. Inequalities in self-reported health by
income level are substantial in Croatia
to be in good health is lower than
in most other EU countries
Low income Total population High income

Ireland
In Croatia, the share of people (61 %) reporting in 2017
Cyprus
to be in good health was below the EU average (70 %). Norway
Italy1
Additionally, disparities in self-rated health between Sweden
people in different income groups are comparatively Netherlands
Iceland
large (Figure 4). Three quarters of those in the highest Malta
United Kingdom
income quintile considered themselves to be in good Belgium

health compared to less than half (44 %) of those in GrSepeacien1
the lowest income quintile. Denmark
Luxembourg
Romania1
More than 70 % of life after 65 is lived Austria

Finland
with health issues and disabilities EU
France
Slovakia
In 2017, Croatians aged 65 could expect to live an
Bulgaria
additional 17.4 years, 2 years more than in 2000. Germany
Slovenia
However, more than 12 years of life of this period is Czechia
Croatia
spent with disabilities (Figure 5). The gender gap in Hungary
life expectancy at age 65 is about 3.5 years in favour Poland
Estonia
of women (18.9 years compared to 15.5 for men). Portugal

Latvia
However, there is no gender difference in the number Lithuania
of healthy life years1 because women tend to live 0 20 40 60 80 100

a greater proportion of their lives after age 65 with % of adults who report being in good health
health issues and disabilities.
Note: 1. The shares for the total population and the population on low
Three in five (60 %) Croatians aged 65 and over report
incomes are roughly the same.
having at least one chronic condition, which is higher Source: Eurostat Database, based on EU-SILC (data refer to 2017).
than the average across the EU. Most people are able
to continue to live independently in old age, but one in
five people report some limitations in basic activities
of daily living (ADL; such as bathing, dressing or
getting out of bed) that may require long-term care.
This proportion is similar to the EU average.
1: ‘Healthy life years’ measure the number of years that people can expect to live free of disability at different ages.
State of Health in the EU · Croatia · Country Health Profile 2019 5
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TI Figure 5. Three in five people aged 65 and over report having at least one chronic disease
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R Life expectancy at age 65
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Croatia EU
4.9
17.4 19.9
10 9.9
years years
12.5
Years without Years with
disability disability
% of people aged 65+ reporting chronic diseases1 % of people aged 65+ reporting limitations
in activities of daily living (ADL)2
Croatia EU25 Croatia EU25
25% 20% 20% 18%
40%
46%
35% 34% 80% 82%
No chronic One chronic At least two No limitation At least one
disease disease chronic diseases in ADL limitation in ADL
Notes: 1. Chronic diseases include heart attack, stroke, diabetes, Parkinson’s disease, Alzheimer’s disease and rheumatoid arthritis or osteoarthritis.
2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet.
Sources: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refer to 2017).
6 State of Health in the EU · Croatia · Country Health Profile 2019
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3 Risk factors T
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Behavioural risk factors account for can be attributed to dietary risks (including low fruit
more than half of all deaths and vegetable consumption, and high sugar and
salt consumption). Tobacco consumption (including
Slightly more than half of all deaths in Croatia direct and second-hand smoking) is the second major
can be attributed to behavioural risk factors, behavioural risk factor to health, being responsible for
including dietary factors, tobacco smoking, alcohol an estimated one fifth of deaths. About 7 % of deaths
consumption and low physical activity, exceeding can be attributed to alcohol consumption, and 3 % of
the EU average in particular for dietary risks and deaths are related to low physical activity.
tobacco (Figure 6). One-quarter of all deaths in 2017
Figure 6. Dietary risks and tobacco are major contributors to mortality
Dietary risks Tobacco Alcohol
Croatia: 26% Croatia: 20% Croatia: 7%
EU: 18% EU: 17% EU: 6%
Low physical activity
Croatia: 3%
EU: 3%
Note: The overall number of deaths related to these risk factors (24 281) is lower than the sum of each one taken individually (28 899) because the same
death can be attributed to more than one risk factor. Dietary risks include 14 components such as low fruit and vegetable consumption and high sugar-
sweetened beverage consumption.
Source: IHME (2018), Global Health Data Exchange (estimates refer to 2017).
Croatia has the third highest rate While overall alcohol consumption has declined,
of teenage smoking in the EU half of adolescents engage in binge drinking
Tobacco consumption represents a serious In 2015, more than half (51 %) of 15- to 16-year-old
public health issue in Croatia among both adults boys reported at least one episode of binge drinking2
and children. Little progress has been made in during the past month (42 % among girls). These
reducing smoking rates because of generally weak proportions are much greater than their respective
anti-smoking policies (Section 5.1). Some 25 % of EU averages. Among adults, 1 in 10 reported at least 1
Croatian adults reported to be daily smokers in episode of binge drinking per month, which is clearly
2014, which was above the EU average (19 %). One below the EU average (10.9 % compared to 19.9 %).
in five women reported smoking daily in 2014, the However, as is the case with many other risk factors,
third highest rate in the EU after Austria and Greece. the difference between men and women is very
Regular tobacco consumption in teenagers is also marked (19 % for men compared to 4 % for women).
a concern. In 2015, one third of 15- to 16-year-old Alcohol consumption per capita in Croatia declined
boys and girls reported that they smoked in the past from 14 litres in 2000 to 10 litres in 2016, close to the
month, the third highest rate in the EU (Figure 7). EU average (9.9 litres per capita).
2: Binge drinking is defined as consuming six or more alcoholic drinks on a single occasion for adults, and five or more alcoholic drinks for children.
State of Health in the EU · Croatia · Country Health Profile 2019 7
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TI Figure 7. Many risk factors to health are greater in Croatia than in most EU countries
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R Smoking (children)
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Vegetable consumption (adults) 6 Smoking (adults)
Fruit consumption (adults) Binge drinking (children)
Physical activity (adults) Binge drinking (adults)
Physical activity (children) Overweight and obesity (children)
Obesity (adults)
Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is
room for progress in all countries in all areas.
Sources: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013–14 for children indicators; and EU-SILC 2017, EHIS 2014 and OECD Health
Statistics 2019 for adults indicators.
Select dots + Effect > Transform scale 130%
One fifth of adults are obese and childhood Socioeconomic inequality impacts
obesity rates are rapidly increasing adversely on health risks
In 2017, nearly one in five adults in Croatia were As in many other EU countries, there are large
obese, a proportion higher than the EU average (18 % disparities in obesity rates between people with the
compared to 15 %). Obesity is also a growing issue lowest and highest levels of education or income.
in children. While the overweight and obesity rate People with only a low level of secondary education
among 15-year-olds is comparable to the EU average, are almost twice as likely to be obese than those with
it reached 16.5 % in 2013-14, a substantial increase a university education (22.5 % compared to 12 % in
since 2001–02. Nutrition in Croatia can be improved 2017). Similarly, smoking prevalence in the lowest
in multiple ways, including by reducing salt and fat income quintile (30.1 %) in 2014 was much higher
(and in particular trans-fat) food consumption, and than in the highest income quintile (21.5 %). Several
increasing fruit and vegetables intake. More than half national health policy documents have acknowledged
of the adult population (54 %) do not eat fruit daily health inequalities, but so far these have been
and vegetable consumption is very low as well, since followed up with few specific measures.
around 45 % of adults do not eat vegetables every day
(Figure 7).
8 State of Health in the EU · Croatia · Country Health Profile 2019
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4 The health system T
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Mandatory public insurance is complemented
by voluntary health insurance Box 1. Reforms have targeted both primary and
secondary care
The Ministry of Health holds the stewardship role in
the health system and is the main regulatory body, Croatia’s reform attempts have been guided by the
responsible for an array of functions, including health National Health Care Strategy 2012–2020, which
policy development, planning and evaluation, public identified strategic problems and reform priorities
health programmes, regulatory standards and the in the health sector. In addition, national reform
training of health professionals. The Croatian Health programmes (the most recent adopted in April
Insurance Fund (CHIF) is the sole insurer and main 2019) enlist concrete actions that the government
purchaser in the mandatory health insurance system. plans to take on an annual basis. The 2012-2020
It plays a key role in contracting health services. Strategy anticipated developing and implementing
Complementary health insurance, mainly to cover a hospital master plan to rationalise and
co-payments for services in the benefit package, is modernise hospital services, but implementation
voluntary and purchased individually from either the has lagged behind and health reform initiatives
CHIF (the main provider) or a private insurer: over have been poorly coordinated (Section 5.3). In
60 % of the population has this additional insurance. primary care, the newest initiative (in 2018) further
Several health reforms have been initiated in recent regulates private practices in primary care and
years but implementation is often stalled (Box 1). states that up to 75 % of practices in any region
can be run privately.
Population coverage is universal and the
benefit package is relatively broad
The CHIF provides health insurance coverage to the
whole population and it is not possible to opt out of
the system. Dependent family members are covered
through the contributions made by working family
members, while those who are not economically
active (such as pensioners and the unemployed), as
well as vulnerable groups (people with disabilities,
those on low incomes) are exempt from contributions
and are covered through state budget transfers.
The benefit package is broad, covering most types
of health services. While co-payments have been
introduced in recent years, exemptions for vulnerable
groups ensure a good degree of financial protection
(Section 5.2).
State of Health in the EU · Croatia · Country Health Profile 2019 9
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C
Over the last few years, Croatia has seen large expenditure (Section 5.2). Overall, out-of-pocket (OOP)
fluctuations in health expenditure per capita. In payments accounted for 10.5 % of health spending in
2017, it was among the three lowest spenders in the 2017 (clearly below the EU average of 15.8 %), while
EU, reaching EUR 1 272 (adjusted for differences in the voluntary health insurance component of health
purchasing power). Expenditure as a percentage of expenditure accounted for a much larger share than
GDP was 6.8 % in 2017, below the EU average of 9.8 %, is usual for EU countries (6.5 % in 2017).
Figure 8. Croatia spends less than half the EU average on health per capita
Government & compulsory insurance Voluntary schemes & household out-of-pocket payments Share of GDP
EUR PPP per capita % of GDP
5 000 12.5
4 000 10.0
3 000 7.5
2 000 5.0
1 000 2.5
0 0.0
NorwaGyermanyAustriSawNeedtehnerlanDdsenmarkFLruaxnecembourBgelgiumIrelanIdcelaUnndiFitenlda nKidngdom EU Malta ItalySpainCzechiSlaoveniPaortugalCyprusGreecSleovakLiitahuaniaEstoniaPolanHdungarByulgariaCroatiaLatviRaomania
Source: OECD Health Statistics 2019 (data refer to 2017).
Health expenditure is skewed
towards pharmaceuticals
Over one third (38.8 %) of total health expenditure
in Croatia is spent on outpatient (or ambulatory)
services (consisting of primary care and specialist
outpatient care mostly provided by hospital
outpatient departments). However, the country
spends a much larger share of its health expenditure
on pharmaceuticals and medical devices than many
other EU countries, although in absolute terms (EUR
296 per person) it is below the EU average (Figure 9;
see Section 5.2). Such spending amounted to 23.3 %
of health expenditure in 2017 (compared to an EU
average of 18.1 %). In contrast, funds for long-term
care only made up 3.1 % of health expenditure in
Croatia, much lower than the EU average of 16.3 %,
reflecting the fact that formal long-term care is still
underdeveloped and mostly provided in institutional
settings. On a per capita basis, spending on prevention
is less than half the EU average, but this translates to
3.1 % of expenditure, equal to the EU average.
10 State of Health in the EU · Croatia · Country Health Profile 2019