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

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

3. Miroslav Mastilica 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.'

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

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

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

7. Miroslav Mastilica 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

8. Miroslav Mastilica 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$

9. Miroslav Mastilica 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

10. Miroslav Mastilica 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

11. Miroslav Mastilica 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

12. Miroslav Mastilica 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

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

14. Miroslav Mastilica 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 198965.8% 199475.2% 2000 82.3% 2009 85,7%

15. Miroslav Mastilica Self-perceived general health status by socioeconomic group (Zagreb health inequalities study 1990, N=433, p<.01 ) Social groups/HealthVery Good GoodFairBad Executives17.242.931.72.8 Professionals25.040.037.13.3 Clerks17.738.830.612.9 Skilled workers21.223.834.615.9 Unskilled workers13.316,753.316.7 Farmers15.118.239.427.3 SOCIAL INEQUALITIES IN HEALTH IN CROATIA 1990

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

17. Miroslav Mastilica Table. Distribution of direct payments for health care by income quartiles Direct health care payments Income quartileProportion of incom e % Proportio n of copa ymen ts % Proportion of other direct paym ents % Proportion of total direct payments % Bottom11.337.730.332.1 2 nd 23.322.627.126.0 3 rd 24.318.915.516.3 Top41.120.827.225.6 % of total direct payments 24.775.3100 Gini0.226 Concentration-0.136-0.052-0.073 Kakwani-0.362-0.278-0.299

18. Miroslav Mastilica 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)

19. Miroslav Mastilica Table. Self-perceived health status by income 2003 Croatian AdultHealth Survey N=11138 % Health/INCOME low middlehigh Excellent13,8 2957,3% Very good11,9 2860,1 Good 25 33,841,2 Fair 32,7 35,731,6 Bad51,1 30,818,1 p<0.001

20. Miroslav Mastilica Table. Self-perceived health status by education 2003Croatian Adult Health Survey N=11138 % Health/Education low middle high Excellent2,4 9,9 12,0 Very good5,1 20,5 30,1 Good 28,4 30,3 30,3 Fair 35,9 28,6 21.6 Bad 28.210,8 6.1 p<0.001

21. Miroslav Mastilica Visits to specialists, by income groups when controled by health status 2003 Croatian Adult Health Survey N=11138 INCOME POOR HEALTH lowmiddlehigh Not visited 36,5 29,5 26,1 1-2 visits 26,3 22,9 26,1 3-4 visits 17,1 17,7 20,7 5-10 visits 12,7 16,3 13,0 10+ visits 7,4 13,5 14,1 p<0.001

22. Miroslav Mastilica Social inequalities in health in Croatia 2003 Croatian Adult Health Survey N=11138 SF36 Dimensions by education

23. Miroslav Mastilica Social inequalities in health in Croatia 2003 Croatian Adult Health Survey N=11138 SF36 Dimensions by gender

24. Miroslav Mastilica SF-36 Dimensions North Croatia Eastern Croatia South Croatia Western Croatia Middle Croatia City of Zagreb MMMMMM Physical Functioning (PF) 72,266,573,068,267,370,2 Role limitation due to Physical problems (RP) 65,157,867,169,958,260,4 Pain (P)66,263,268,172,662,361,9 General Health Perception (GH) 58,652,358,059,354,151,6 Energy/Vitality (EV) 54,751,955,857,552,752,0 Social Functioning (SF) 74,972,076,377,474,373,3 Role limitation due to Emotional problems (RE) 73,365,072,876,269,8668,3 Mental Health (MH) 64,760,264,965,663,161,7 Regional inequalities in health in Croatia 2003 Croatian Adult Health Survey N=11138

25. Miroslav Mastilica PRIVATE HEALTH CARE EXPENSES 2009 (N=525) Private payments for: Yes (f)%No% Suplemental insurance 52,247,8 Private insurance 203.896,2 Gratitude money 71,1 98,9 Gifts 101,998,1 Copayments 14026,773,3 Drugs otc 32561,938,1 Health care abroad 40,899,2 Sick leave 5510,589,5 Home care 142,797,3 Wellness 448,491,6 quickier access to services 448,491,6 Alternate healers 336,393,7 Private physician 5710,989,1

26. Miroslav Mastilica PRIVATE HEALTH CARE EXPENSES 2009 Private expenses( last 6 months) NoNo 6512,4 <500 HRK 24847,2 501-1000 hrk 11622,1 501-1000 hrk 6011,4 1001-2000 hrk 265,0 2001-3000 hrk 101,9 Total 525100,0

27. Miroslav Mastilica PRIVATE EXPENSES IN 2009 Disagree7915,0 Don’t know 7213,7 Agree 37471,2 Total 525100,0 Citizens pay too much from the pocket

28. Miroslav Mastilica PRIVATE EXPENSES IN 2009 Disagree234,4 Don’t know 6813,0 Agree 43482,7 Total 525100,0 Easier access to health care services if paid from the pocket: