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

Health in Makarska

On Monday, May 25th, all of the students went to the city hall in Makarska to meet with the director of the legal department. She talked to us about the city’s development plan, tourism, and traditions. The government of Makarska is trying to encourage tourism and development of the area, while still maintaining the natural beauty of the city. To help maintain the water quality of the Adriatic Sea, Makarska has recently built a water treatment facility that treats all water before being released into the sea.

After our talk with the director of the legal department, we spoke with Mr. Josip Paunović, who works in the city manager’s office. Mr. Paunović covered a lot of health topics, including smoking, alcohol, substance abuse, and access to health care.

The government implemented the recent smoking ban to help reduce the health care costs related to smoking. The law initially started out as prohibiting smoking in workplaces, but instead of introducing new limitations gradually, the ban was extended to include all indoor public places. To enforce this law, there are inspections in bars and restaurants, and the fines can be at all levels: the individual that is smoking ($200, or a fifth of the average monthly salary), the server allowing the customer to smoke ($2500), or the bar/restaurant owner can all be fined ($20,000).

The smoking ban in Croatia is a very important first step to reducing the number of deaths from smoking and secondhand smoke, but more actions need to be taken. There needs to be a government-funded program to help Croatians stop smoking, whether it be counseling, behavioral therapy, or subsidies to purchase nicotine patches or gum.

About a year ago, DUI laws in Croatia were set to zero tolerance, but the legal limit was changed to a blood alcohol level of 0.05 after complaints from restaurant owners that the law had affected their business. DUIs do not go on a person’s record, but the driver does have to pay a fine. The most commonly abused drug in Croatia is marijuana.

Tourism has many impacts on Makarska. During the year, there are around 15,000 people in the city. In the summer, this number more than doubles to 35,000 due to the large amounts of tourists that come to Makarska. During the summer, there are lifeguards and beach patrol along the busy beaches.

Littering is another problem, especially at the beach. There are people from many different countries visiting the beaches of Makarska, bringing their own customs with them. Some people do not think it is necessary to throw away their trash, while others clean up after themselves. To help with the litter, crews are hired to clean the beaches every morning.

The main problem that comes with tourism is injuries. The ER in Makarska sees about 150 patients daily during the summer, but there is no actual hospital in the city. Any serious cases have to be taken to Split for more advanced care. This can be a problem due to the 2 hour drive from Makarska to Split, and the type of transportation. The ambulances are not actually ambulances, but more like a pick-up van that is not equipped with everything that could possibly needed in an emergency. There are 5 medic teams in the city, and 4 ambulances. The number of tourists in the city during the summer can strain these emergency medical services. Since severe cases from Makarska are sent to Split, this can strain the hospital system in Split. The health center in Makarska was actually designed as a hospital, but because of political reasons, the city has not yet been successful in converting this facility into a full-service hospital.


Following our meeting with Mr. Paunović, the Public Health students went to a local health center and met with the Director of School Health. School health is under the Public Health Department in Croatia. The school system in Makarska has 3,700 students, with less enrolling each year.

A child’s first visit with a school health doctor is usually around May during school enrollment. In the first meeting, the child’s school health record is compiled, consisting of prenatal and maternal health, family history, immunization records, vision, weight, height, etc. A team made up of a psychologist, pediatrician, school health doctor, and the child’s teacher meet to discuss the child’s health record and determine if the child would be best suited for a regular school program or a special education program. The child and his/her family can take the school medical record to their primary care physician and/or keep it with the school health doctor. Comprehensive health exams are conducted in grades 1, 5, 8, and 9. In 3rd grade, vision exams are conducted, and in 6th grade, the student’s motor skills are evaluated.

The school health department provides educational programs on prevention, injuries, hygiene, epidemics, and tourism and prevention programs that encourage early detection through breast self exam or mammograms.

Unlike in the U.S., obesity is not a major health problem in Croatia. The prevalence of overweight and obese students has increased, but only 6% of all children have weight problems, while about 12% of 8th grade students have a problem with their weight.

To help reduce the number of young people that smoke cigarettes, the school health department has anti-smoking programs, lectures, and school classes. As for sexual education in schools, there is no official program. There are two programs that are being debated: a more conservative program teaching abstinence only, and a program that would educate on abstinence and safe sex.

Teen pregnancy is not as big of a problem in Makarska as it is in the U.S. There are only three teen pregnancies per 1,000 population in Makarska. The director of school health informed us that many students that get pregnant during school end up completing their high school education.

Regarding nutrition, the schools serve a snack between the start of the school day and lunch, and then lunch in the afternoon. Some schools have extended programs that also serve breakfast. There are many unhealthy snack and drink machines around the schools. A recent pilot program to introduce healthier snacks was not successful.

- Elizabeth

Croatia Health Statistics

As we traveled to Plitvice Lakes, the Public Health students were informed of the health statistics of Croatia by our teacher. Croatia has a population of 4 ½ million people, with about a 50/50 ratio of men to women. The life expectancy is 75 years for Croatians. Women generally live longer than the men with an average of 79 years, while men live to about 72. The GDP spent on healthcare is 7% and the average income is $14,000.
The leading causes of death in Croatia are cardiovascular disease and cancers. The #1 killer of Croatians is also the #1 killer of Americans. Stroke affects 1 out of 3 Croatians. The leading types of cancers in Croatia are tracheal, lung, and bronchial cancers. The large prevalence of smoking contributes to these cancers, but also the exposure to dust from working in industrial settings (which is the #1 source of employment in Croatia). Colon/Rectal cancers are the next leading causes of death for Croats. This can be attributed to sedentary lifestyles and the gluten-sensitivity that is a genetic trait of the Croatians. The next leading cause of death is cirrhosis of the liver. Croats consume considerably more alcohol than Americans. Cancers appear again on the list for the 3rd time with stomach and breast cancers contributing to deaths in Croatia. The list rounds out with injuries that are either self-inflicted, brought on from the war, or external poisonings and hypertension. Hypertension affects 55% of the Croatian population.
These top ten leading causes of death demonstrate that the country is in the process of becoming a more developed and industrialized nation, experiencing higher rates of chronic diseases more than infectious diseases. -Rachel

Public Health in Zagreb

May 13th the Public Health students visited many schools and universities in Zagreb to learn about Public Health and Medical Schools in Zagreb. We visited the Academy of Science and Arts first to learn of Croatian Medical History, Andrija Stampar, and current issues in Croatia today. Public Health has many many roots in Croatia. X-rays, pharmecuticals, hygiene, prescriptions, sewage, and quarentine all have grassroot beginings here. For Croatia to be such a small country, they really have made important contributions to the field of medicine and Public Health.

Stampar, who was a man well ahead of his time, should be considered the Father of Health Education. His ideology and philosophy are all around preventative strategies and having the doctors come to the patients, rather than the patients having to search for healthcare. He held many notable positions during his time:

• Graduated from Vienna Medical School
  
• The Health Advisor of Croatian Commission for Social Welfare


• Head of Department of Public Health


• Founding member of Public Health School in Zagreb


• Dean of the Medical School in Zagreb


• Engaged in creation of the World Health Organization
  
• Chairman of Hygiene/ Social Medicine


• President of Yugoslav Academy of Sciences and Arts


• Director of the School of Public Health

He was a reformer promoting public health and hygiene, while at the same time, had an input on international health. His view of Social Medicine consisted of 10 points:

1. Inform rather than conform laws


2. Understand the health problem (most importantly)


3. Improve health by working together


4. The physicial should be regarded as a social worker


5. Money should not be the issue in care; care of the patient should be the concern


6. There is no difference between rich and poor and having access to health care


7. The doctor should seek out the patient, not the other way around


8. Doctors should be the people's teacher


9. Health is of economic importance, not humanitarian- meaning that healthy people benefit a society more in terms of economics


10. Location of the doctor's activity should be in the community- people's homes, not in an office or lab

Stampar had a message that was clear and simple "health for all." This is where the name of our blog came from. We agree that health and healthy opportunities should be made available to all people, regardless of race, ethnicity, socioeconomic status, standing in the community, or location of the people. Stampar recieved much criticism from many people around the world, especially in the United States. He visited many notable schools from one side of the county to the other and was not highly favored. Stampar accessed many Medical schools around the world and stated "They learn how to examine a body in detail, why don't they learn how to study a community?" Here is where the foundations of health education were laid. Prevention strategies and health promotion take root in Stampar's teachings.

Stampar's teachings still have an impact on Croatia today. Students studying medicine in Croatia will all have a Public Health background upon graduation. Students spend 6 years in med school, 1 year in an internship, 1 year in residency, and potentially 3-5 years in specialty training. Students can enroll in med school after high school graduation with no undergraduate degree required. The first 2-3 years are pre-clinical classes and the last 3 are clinical classes.

The University of Zagreb provides many different disciplines for medical students. There is a post graduate program for those wanting their PhD and continuing education classes offered as well.

This is one example of Public Health going on while we were on one of the tours. It is a free blood pressure screening set up in the city square.

- Rachel