Health Coverage

To help you better understand the health care system in Croatia, here is some information on their public health insurance plan. Thanks to Mr. Josip Paunovic for the info during our lecture at the Makarska City Hall.

Health insurance in Croatia is provided through the government, with about 80% of the funding from taxes and 20% from the federal budget. This health plan covers 97% of the population (the other 3% is not covered due to reasons like working or living outside of Croatia). Private providers and insurance options are also available, but the system is mostly public. In the U.S., there is currently no national health insurance program to cover all citizens. The only public programs in the U.S. are Medicaid, Medicare, and the Children’s Health Insurance Program. (The pictures are from the Public Health Insurance Buildings in Osijek).

According to the Croatian Ministry of Health, in 2003 total spending on health was estimated at 8.9% of GDP, in 2004 at 9.7% of GDP and in 2005 at 8.7% of GDP. In the U.S. in 2005, national health expenditures totaled 16$ of GDP, with this number increasing every year.

There are three types of care: primary, through small clinics; secondary, through hospitals; and tertiary, through institutional hospitals, typically more advanced procedures. This plan covers dental, hospitalizations, vision, and care at primary and secondary health centers. Pharmaceuticals are also included, and those that are covered are listed in a national database. One half the cost of tertiary services are covered under this plan. Cosmetic surgeries are not covered.

Patients are required to pay for certain publicly provided health services through co-payments or to buy supplemental health insurance. Certain groups are exempt from paying co-pays, including: the unemployed, disabled, people under 18, students, the military, war veterans with disabilities, and people that voluntarily donate blood more than once.

The Croatian health insurance program also includes services such as prenatal and maternity care, school health services, and care for the elderly and subsidizes costs of health care in remote regions. The government pays for public health, environmental protection, and health education, and provides paid maternity leave. The Public Health students were surprised to learn about this during our presentation at the Psychodermatology clinic in Zagreb. The psychologist giving the presentation came in during her maternity leave and told us a little about maternity leave in Croatia. Every woman has a child in Croatia has the choice of maternity leave up to one year from the child’s birth, with an additional 45 days of leave. After the first three month’s of the mother’s leave, the father can opt to take paternity leave if the mother chooses to go back to work. In the U.S., women do not have the right to maternity leave, and maternity leave policies differ from company to company.

During our time in Croatia, we discovered many things we liked about the country’s policies, like paid maternity leave, free education through college, and free health insurance for those under 18.

Also, we would like to say thank you to our wonderful professors, all of our guest speakers, program planners, tour guides, and to Mr. and Mrs. Phillips for allowing so many students the opportunity to visit and learn about such a wonderful country!

- Elizabeth

Brac

We visited the island of Brac for one night and I think it is safe to say we all wish we had more time at this particular hotel (The BlueSun)!! May 31st marked our last hike of the trip. We hiked to a Monastery in what seemed like the middle of nowhere. No, scratch that- it was in the dead center of nowhere. The only way to get to the Monastery is by foot- up, down, and around a canyon surrounding the Monastery. We learned that the the villages were built deep into canyons because pirates would come and plunder the villages if they were close to the sea. The "church" was built in 1757 and was considered to be the cultural, spiritual, and educational center of the island.

The school portion was designated for four basic grades of education for children. After this level of schooling, kids of the area went to other villages on the island for more education. The school in the Monastery was operative until 1962, with a class size of 15 students. Everyday the students would bring a log for the fire, that was used for heat and cooking.

While touring the Monastery, we saw various sizes of original weights in the hall that were used by the monks.

We also saw the original kitchen of the Monastery, which is over 400 years old. The kitchen was a central place of the monk's lives.

The monks utilized the land to their benefit by producing goods for bartering. There was never any money exchanged for goods, just a barter system of different goods from foods to wool to furniture. Wheat and corn were ground to produce flour; if a person ground all day, they could produce 10 kilos of flour. There were 3000 olive trees available to the Monastery and this would produce 60,000 gallons of olive oil per year. We also saw a schematic of a beehive layout of the island. Three tons of honey were produced each year from the 237 beehives.

Outside in the courtyard of the Monastery, we learned of the bathroom mechanisms and burial methods for the Monastery. The bathroom was a pretty ingenious idea: there was what was like an outhouse to the side of the courtyard that utilized gravity for flushing. There are no pipes and no running water and the waste is naturally pulled down and away from the "bathroom".

The ancient burial processes for this island are much different from what we think of as burial processes. The dead were buried in a vertical position to make room for others in such a small and confined place. The bodies were wrapped in sheets, then placed in the ground. Once the bodies deteriorated, the bones would fall together in a pile and allow for more room in the burial pit. We learned that where we were standing former priests and residents were buried, totaling about 70 people buried in the courtyard.

Water is a major issue on an island. We learned that the monks would use cisterns to collect rain water and store it in jugs and pots for later use. The island of Brac is used to having many, many sunny days in the year, so rain was very precious. The water to the Monastery and the rest of the island now comes from pipes from the mainland.

There are five things to consider about water: quality (free of sediments, algae, parasites, and clean); cost (has to be affordable); proximity (must be within 1km of person); quantity (minimum amount needed for hygiene and cooking/drinking; 5L/person/day); and reliability (water must be available and there when one needs it). Water should be considered a basic human right, because an individual can only live without water for about a week. Water that is contaminated must be boiled to kill anything harmful (this is one of the reasons the students had to bring logs to school, to ensure a way to boil the water to clean it for drinking and cooking). Storage of the water is a part of proximity and reliability. The mechanisms used to store the water must not contain any cracks and must be easily transported. Storage of the water must also be close enough for the people to access if they are going to cook or clean. We learned that people who have reliable water sources have improved health.

We were also informed about trash being an important issue to consider on an island. There is already limited space on the island, so the trash produced by humans must either be incinerated or transported to a landfill, as to not waste space of the island. We learned that trash from Brac was picked up by barges on a regular basis and transported to a landfill on the mainland.

Mental health is the last issue we learned about that is important to island life. Recent data shows that Croats living on the islands scored higher in better physical conditions compared to those not living on an island. These people did score as having feelings of isolation, but it should be noted that they want an isolated life. This is the reason why they moved away to the island. They feel more vital and not restrained as they do on the mainland. Generally those who are sick or have underlying health problems do not stay on the island because of the limited access to health care. Island people are more likely to endure pain than their non island counterparts. There was also a significant decrease in gastric/pancreatic cancers of the Croatian island people compared to non-islanders.

This last hike was by far one of the hardest, but really interesting to participate in.
-Rachel

Last night in Croatia

We have come to the conclusion of an amazing three weeks in the country of Croatia. Our time here has been filled with academics, culture, explorations, and new friendships. The blog will be complete on Sunday, so please check back then to read our last posts and see some other pictures. We have thoroughly enjoyed our time studying abroad and hope our blog has given you some insight in international health.
- Thanks for following our trip
- Ben, Elizabeth, and Rachel

Dubrovnik

May 29
Friday morning we started the morning very early and loaded the bus on the way to Dubrovnik. Dubrovnik is a city situated along the coast about 3 hours away from Makarska and we had to go through Bosnia to get there. We were given a brief history of the city. Dubrovnik was founded by refugees, but has a much more interesting history than that. To maintain peace in their city, they paid off other countries to leave them alone. The city is noted for heavy promotion of freedom and liberty. Dubrovnik was more interested in trade than territorial conquest and is also noted for progressive ideas for systems of governance.

There was (and still is) a fountain in the middle of the walled portion of the city and anyone was allowed to come and get clean water. A statue also stands inside the city walls that has a very important role for those not of nobility or wealth. The statue is a man, but that is not the interesting part. On the bottom of the statue, on one side only, there is a line carved in the stone. This line looks like it is part of the statue, so it is very easy to miss. The significance of the line is that it was used for people to measure their bought goods. People who were members of the peasant class were often short-changed on their cloth purchases because they didn’t know how much a specific measurement was supposed to be. The line was etched in the statue to allow these peasant people to come and measure their purchased goods and contest with the seller that they were indeed short changed.

Dubrovnik was heavily attacked in the Homeland War like Vukovar. They were attacked from the sea and because the attacks were so intense, this is actually the place that put Croatia on the worldwide map. There was a public outcry about the city being destroyed because of the cease-fire from 1992-1995 in the rest of the country, but there were bombings still occurring in Dubrovnik. Many of the old historical buildings and relics of the town were destroyed. There was terror among the people because random bombings still occurred during this time and made it unsafe for the citizens.

Dubrovnik was one of the first cities to recognize the United States independence and supported the country in their efforts to promote freedom and liberty.

As far as public health goes, Dubrovnik was well ahead of others concerning infectious diseases. Dubrovnik initialized the first systematic quarantine in 1337 because of the plague. They were realizing how the disease was being spread from ships coming into the ports bringing in vermin and fleas and separated out potential exposures as well as complete cases of the plague. Quarantine is when people are kept separate from the general population that have been exposed to the infection until they present with symptoms. This was utilized at the sea ports. Isolation is separating out people who have specific diseases from the general population, such as the plague or lepers. The public health office looked at data from registries of ships in 1337 and realized that more people equaled more diseases. Caravans and travelers came through Dubrovnik and had to swear that they had not been in an area exposed to the plague for two months. The place where people were traveling from determined the length of their quarantine, lasting from days up until months for some areas. This initialization of quarantine stopped the plague from being endemic in the area. The model was utilized in other parts of Europe because of how effective it was at controlling the spread of disease. The program was based on real data and it still heavily utilized in times today, such as the recent scare of the H1N1 Flu.

During our time in Dubrovnik, we toured a small museum of the “Defenders of Dubrovnik” from the Homeland war and visited the City Hall to meet with a local city planner. The speaker talked to us about urban planning for the city of Dubrovnik. The designer of the city wanted everything in a block and this model was utilized in other parts of the world after Dubrovnik was designed. The designer for Washington D.C. visited Dubrovnik to see how a city could be put in grids on a sloping land. We also discussed Manhattan and Philadelphia’s city layout, and Dubrovnik had small roles in their implementation as well.

The rest of the time we were in Dubrovnik we had free time to explore. Many students walked the outside city walls and saw how the city was during ancient times, as well as how life is there today. The city wall provided the students with amazing landscape photos.
-Rachel

Biokovo

On Thursday, we visited the Biokovo Nature Park in Makarska. We started with a presentation by Ivana Gabric at one of the education centers in the park. In 1981 the park was designated as one of the 11 nature parks in Croatia, and in 1998 it was designated as a public institution. At the park, visitors can sightsee, hike, go on tours, and explore the caves. The park’s mission is to protect and safeguard nature, ensure undisturbed natural processes, and maintain sustainable use of natural resources. The financing comes from the national, county, and municipality budget; entrance fees; revenue from reimbursement; donations; and grant funding for projects. The park has 12 employees: the director, conservation manager, park rangers, technical and expert services, and a governing board with 5 members.

The park is located in part of the Dinaric Alps, covering about 19,550 hectares (48,309 acres), with heights ranging from 200-1762 meters (656-5780 feet). The highest peak at Biokovo is St. Jure. The park has a variety of wild plant and animal species, including rare and protected species. There are 120 cave organisms, 221 species of butterflies, 7 protected amphibian species, 21 protected reptile species, 13 endangered bat species, and more. Also located in the park is the Biokovo Botanical Garden Kotisina (16.5 hectares, or about 40 acres).

The park is a very valuable resource to the surrounding community. In the park, visitors can see the traditional architecture, pastoral housings, Illyrian heaps (tombs), churches and chapels, and traditional agriculture and farming techniques. The park offers educational programs, ecological workshops, presentations, discussions, and informational centers. The park also encourages stewardship in the community. People can come to the park to learn about nature and their environment, and what they can do to help protect it. Biokovo is also important to the Makarskan community identity. Having this resource available to the area helps strengthen the community and provides many opportunities to improve overall health through many facets.

The Biokovo Park also supports social bonding. Many school groups, tour groups, and families come to the park. It is a great opportunity to get out and get physical activity. Coming to the park to hike or ride bikes can help many chronic diseases, like cardiovascular disease, high blood pressure, and osteoporosis. There are many marked trails throughout the park so that people can hike on their own. We saw several people hiking and riding bicycles throughout the park. Our group took vans part of the way up and hiked to one peak. We hiked back down and had lunch, then took vans to St. Jure, the second highest peak in Croatia.

The park is a great place for individuals to come to relieve stress through exercise and meditation. The park can also serve as a place for people to improve their spiritual health. Visiting the park can help improve mental health problems such as depression, anxiety, self-esteem, and phobias.

Many residents of Makarska and the surrounding areas have farms in the mountains. They typically grow potatoes and other vegetables, and many of them have cattle and horses in the park. These farmers have improved health from farming, clearing the fields of rocks, herding their cattle or other livestock, and hiking to their farms.

The weather was perfect for our hike, and the storm from the night before gave us a clear view of the islands off the coast of Makarska. The view from the peaks is absolutely amazing. One of our professors, Dr. Tir, pointed out all of the familiar parts of Makarska, like the street our apartments are on. We had a great time hiking and visiting the Biokovo Park and recommend this to anyone who is in Makarska.

- Elizabeth

Bosnia

Stepping off the bus in Mostar, Bosnia, there was a clear difference between the previous stops along our journey in Croatia. From the masses of dilapidated buildings to the trash cluttering the city streets to the many gypsy beggars, it appears to me that the wounds from the Homeland War are not as well healed as in most of Croatia. In most cities we have visited in Croatia, the memories and pain of the war are still vivid, but much of the external damage has long been repaired, yet for some reason there is a sad, sobering feeling that comes over as you walk the streets of Mostar. While in the U.S. I am accustomed to the sight of beggars; seeing the gypsy mothers holding young children and begging for money was far more difficult to see in Mostar.

Visiting the University of Mostar, we learned a little bit more about the current political atmosphere in Bosnia and about the University itself. Bosnia is a very complicated country, being comprised of three main ethnic groups: Muslims, Serbians, and Croatians. Bosnia was home to some of the most brutal atrocities committed during the homeland war of the 1990’s. While all groups were involved, most of the acts were committed by the Bosnian Serbs to the Muslims. Even though the fighting has ceased for a number of years now, a very complicated political structure remains in Bosnia. The three main ethnic groups each alternate the presidency and it is very difficult to get anything accomplished with the current political system. While it does not seem to be very high on the list of priorities for such a war-torn nation, the political structure makes the health care system very complicated for the people of Bosnia. Health care is governed by the different cantons in Bosnia, or city-like structures with no real national health care plan. The lecture was not focused on health care in Bosnia, but it seems reasonable to assume that heath care governed at the city level leaves the Bosnian people with differing quality of and access to health care. Talking with some students at the University of Mostar, it seems that this structure only allows you to access health care services in your canton of residence. Thus if you were in another part of Bosnia and needed medical services, the health care plan would not pay for these services. I can only imagine that this system would leave the more urban cantons with better access and quality health care services than other rural cantons.

From the lecture, we learned that due to political disagreements there has not been a census in Bosnia since 1991, long before the end of the war. With no census data in nearly 20 years, it would be very difficult to have any accurate health statistics at a population level. If the political system is so dysfunctional that it cannot even agree on a census, I have little faith that good epidemiological work is going on at the government level in Bosnia.

In addition we learned from our lecture prior to arriving in Bosnia that human trafficking is a growing problem for Bosnia. In fact, in 1995, 25% of women working in night clubs were trafficked, and there are approximately 2,500 trafficked women working in brothels within Bosnia. These numbers are shocking because Bosnia is a relatively small country and because of the extremely cruel nature of trafficking. Many of the young women from poorer countries are tricked into this trade with promises of a better life, offers to be a nanny for a rich family and to learn trades to make a future for themselves. In reality they are often smuggled across country lines and forced to work in the sex trade, factories, and generally treated as less than human. A country such as Bosnia, ripe with political struggles, is a likely place for trafficking to occur. With no truly effective government to provide true oversight, corruption can run rampant and often times police play key roles in allowing trafficking to occur. For example the police may be paid to keep quite or paid to alert offenders of raids, or may even be night club owners and directly involved with trafficking of women.

While I have only seen one city in Bosnia, my first impression of this country based on our visit to Mostar is mixed. Bosnia seems to have a great deal of work ahead if they are to truly recover from the Homeland war and to perhaps one day reach their goal of getting into the European Union. With such a defunct government, the people of Bosnia are left with little in the way of leadership and are struggling because of this. While some problems obviously exist because of the political problems, we don’t even know the full extent of the public health situation in Bosnia and thus little can be done to improve it. Yet with all the sadness, I also witnessed great enthusiasm and hope from several young people from the University of Mostar. I can see that this younger generation has grown tired to the status quo and is ready to bring about change and produce a brighter future for the people of Bosnia. While it seems recovery has been slow, I remind myself that Bosnia is less than 10 years removed from a brutal war that many in the U.S. can likely not even imagine and full recovery may take many years Hopefully the Obama administration will make a substantial effort to help the people of Bosnia finally recover and lead the lives they truly deserve.
-Ben

Split

Today we visited Split, a city with a rich Roman history including its most famous attraction, Diocletian’s palace. Diocletian was an emperor of the Roman Empire and upon being one of the only emperors in history to step down from office, he built his palace which remains today in Split. Being my first time traveling to Europe, I am amazed by how many historic structures remain, and by how well preserved they are. Along with our previous stops in Istria, including the amphitheater in Pula, Split reminds me of the significant influence that Romans had in many areas of Croatia. This is significant to public health because the Romans were innovators in many areas of public health, realizing the link between exposure and resulting disease. This is an example of how early public health efforts were conducted, using trial and error and simple observations. These observations lead the Romans to develop aqueducts for providing clean water, sewer systems to remove contact with waste and to create public baths for cleanliness. Ancient Romans believed that the main goals of life were health, beauty, and happiness, and baths became a central part of the Roman life. These baths, many of them public, were places for more than just bathing. They often included attached gymnasiums and were central social meeting spots. These baths were precursors to the health and wellness spas that are found throughout Europe today.

Some of these innovations can be seen today inside Diocletian’s palace, including in the basement where remains of the plumbing infrastructure are on display. The ancient Romans used aqueducts to pull water into the city, not using the common lead pipes of the day, because they realized from trial and error that lead made them sick. Walking through the basement of Diocletian’s palace, I couldn’t help but wonder if .there may be health implications from breathing the air. While an interesting sight, there was a lot of moisture and mold growing on many of the walls. I tried to discover if regular air quality checks were conducted to see if it was safe for the many tourist, while unable to find an exact answer I have doubts. This mold combined with possible radon from the stone and rocks of the basement could have significant respiratory health implications if at high enough levels.

After an afternoon of touring the palace and surrounding areas, we finished the day in Split with a visit to the former home and museum of renowned artist Ivan Mestrovic. One of the best known artists in the region, the works of Mestrovic can be seen throughout Croatia, including the statue of Nikola Tesla in downtown Zagreb. Nikola Tesla is an important Croatian figure and is known as the discoverer of AC electrical current and radio waves.
-Ben