Health reforms in Croatia unlikely to address glaring gaps in coverage, staff shortage

Health workers have warned that the latest reforms proposed by Croatian minister Vili Beroš will do nothing to reduce the workforce shortage and burnout, or increase access to care

March 19, 2023 by Ana Vračar
Doctors protesting in Zagreb on March 18. Photo: Photo Maja Sever/Trade Union of Croatian Journalists;

The latest round of health legislation reforms proposed by Croatian minister Vili Beroš has been widely criticized with health workers warning that they will do nothing to reduce the workforce shortage and burnout among workers, or increase access to care.

The ministry has proposed to transfer ownership of general hospitals from the local to the state authorities, increase the level of centralization in primary health care, and reorganize the emergency services, among other things.

It seems likely that the proposals will be another in a very long line of so-called health system reforms dating from the early 1990s, which shifted the system towards a financialized and commercialized vision. In the early phases of this process, patients retained access to a basic level of care thanks to the remains of the Yugoslav health infrastructure. However, the cracks caused by decades of underfunding and mismanagement began to widen over the previous years, leading to gross infringements on people’s right to health.

After the death of journalist Vladimir Matijanić in the summer of 2022, the Croatian Journalists’ Association and the Trade Union of Croatian Journalists held a series of protests warning about the state of the health system. Then, in February this year, attorney Lina Budak, known for her work on lawsuits against infringements on freedom of the press, came out with her own experience with breast cancer. Budak was misinformed about her diagnosis for seven months, which jeopardized her chances of treatment and recovery. 

Read | What the death of a journalist from COVID-19 says about Croatia’s health system

Both Matijanić’s death and Budak’s case are strongly linked to the overall weakness of the health system. Their experiences have resonated because of them being public figures, but it is certain that there are currently hundreds of people in the same situation, without the access to resources to fight for themselves and missing out on life-saving therapy.

Not a reform

The changes announced by Beroš are unlikely to improve the situation. While the minister insists on presenting the plan as a way towards a stronger health system, in practice, it is only an attempt to mask problems which have persisted for years: an above average allocation of funds for purchasing of pharmaceuticals, long waiting lists, and inefficient public health programs among others. The ministry’s plans also do not give more significant signals about increases to the health budget, or even the reallocation of available financial resources to strengthen primary health care and preventive services.

Another serious problem with the minister’s plans is that they do not concretely address the acute health workforce crisis in Croatia. During the lead up to the parliamentary presentation on health legislation, MPs from the green party Možemo! and their coalition partner Nova ljevica warned that as many as 36%t of physicians in the primary health care system will reach retirement age in the next five years. Because of this, the system will face almost 800 vacancies among family physicians alone – and only 290 doctors are currently specializing in this branch of health care.

Even now, access to primary health care is extremely limited in some regions, especially on islands and in remote areas. As the organization of this level of care is formally decentralized, economically disadvantaged areas mostly cannot offer adequate measures, like early education services or public housing, to keep young health workers in their health centers. 

Salaries of health workers in primary health care, especially in the publicly administered community health centers, are also low in comparison to real costs of living. In the area of Rijeka, one section of primary health care nurses with approximately 30 years of experience are paid a net salary under 950 euros (1.010 USD). This is lower than the overall 2022 net average of 1.025 euros (1.090 USD), and not even close to the 1.370 euros (1.455 USD) income trade unions calculated as necessary for achieving a decent life standard in 2021.

Crisis spreads to doctors

While health workers’ income in the public health system has generally been lower than it should be, doctors were said to enjoy a somewhat better position compared to others. Yet, recently even some of the largest hospitals in the country have struggled with physicians leaving for other jobs. The University Hospital Center Zagreb, the biggest hospital center in the country, has reportedly faced somewhat of an internal exodus of mid-career experts, starting with radiologists and internal medicine specialists. The doctors left either to work in the private sector, with less overtime and presumably better pay, or to work from home as contractors for health institutions in other countries in the EU.

This caused additional issues in the treatment of patients and implementation of procedures, as trade unions and professional associations had been warning about for years. Apparently reaching their breaking point, several doctors’ associations recently ramped up action in an attempt to shape better working conditions. The doctors took to the streets on March 18, asking for a separate collective agreement for their profession and a reform of the specialization system, among other things. 

Thousands of people took part in the protest, with a particularly large number coming from the lines of junior doctors and medical students. Marin Smilović, the representative of junior doctors in the protest organization committee, said during his speech: “Junior doctors remained silent for too long. We dealt with all the extra work, all the overtime, all the added responsibilities. Now the time has come to say enough.”

According to Laura Mayer, a medical student who took part in the protest, most students in Croatia were eager to join the protest because they are worried about the health system in which they are going to work in a couple of years. “The current system is not organized in a way that works for patients or health workers. We need a stronger primary health care system and better working conditions to stop so many people leaving right after university”, she told People’s Health Dispatch.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and subscription to People’s Health Dispatch, click here