Miroslav Mastilica

CROATIAN HEALTHCARE REFORM FROM THE PERSPECTIVE OF USERS 1990-2009

Miroslav Mastilica

CROATIAN HEALTHCARE REFORM

• Alice's Adventures in Wonderland

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.'

Miroslav Mastilica

CROATIAN HEALTH CARE REFORM 1990-2009:

• PRIVATISATION

• RATIONING

• MARKETISATION

Miroslav Mastilica

CROATIAN HEALTH CARE REFORM - ACTERS

• GOVERMENT- MINISTRY OF HEALTH !!!!

• HEALTHCARE PROVIDERS !!

• (((CITIZENS – CONSUMERS-PATIENTS)))????

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1. PHASE - PROVIDERS ORIENTED-1990-1993

• Centralization of financing ("Croatian Institute for Health Insurance ")

• Control of provision of services

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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

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

amenitiesOTC medicamentsalternative medicine

CONSUMERSGDP per capita 10.678 US$ (2008) Average income 5178 HRK 950 US$HCE per capita 400 US$

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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

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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

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

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

Miroslav Mastilica

HEALTH CARE REFORM IN CROATIA

transformation of health services

from SOCIAL GOODS to COMMODITIES

from PUBLIC to MARKET

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

1989 65.8%1994 75.2%2000 82.3%2009 85,7%

Miroslav Mastilica

Self-perceived general health status by socioeconomic group (Zagreb health inequalities study

1990, N=433, p<.01 )

Social groups/Health Very Good

Good Fair Bad

Executives 17.2 42.9 31.7 2.8

Professionals 25.0 40.0 37.1 3.3

Clerks 17.7 38.8 30.6 12.9

Skilled workers 21.2 23.8 34.6 15.9

Unskilled workers 13.3 16,7 53.3 16.7Farmers 15.1 18.2 39.4 27.3

SOCIAL INEQUALITIES IN HEALTH IN CROATIA 1990

Miroslav Mastilica

SES INEQUALITIES IN HEALTH IN CROATIA- 1994

11,3

23,3 24,3

41,146,03

31,75

12,79,52

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4

Quartiles of income

Sha

re in

per

cent

% income % poor and very poor health

Miroslav Mastilica

Table. Distribution of direct payments for health care by income quartiles

•

Direct health care payments

Income quartile Proportion of

income

%

Proportion of copaymen

ts%

Proportion of

other direct payments

%

Proportion of total direct payments %

Bottom 11.3 37.7 30.3 32.1

2nd 23.3 22.6 27.1 26.0

3rd 24.3 18.9 15.5 16.3

Top 41.1 20.8 27.2 25.6

% of total direct payments

24.7 75.3 100

Gini 0.226

Concentration -0.136 -0.052 -0.073

Kakwani -0.362 -0.278 -0.299

Miroslav Mastilica

Inequaities in Health care financing in Croatia (Mastilica, Božikov. 1999)

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100% of population

% o

f inc

ome

and

paym

ents

g-inc g-pay

Lorenz curve for income (triangles) and the concentration curve of out-of-pocket payments (squares)

Miroslav Mastilica

Table. Self-perceived health status by income 2003 Croatian AdultHealth Survey N=11138

%

Health/INCOME low middle high

Excellent 13,8 29 57,3%

Very good 11,9 28 60,1

Good 25 33,8 41,2

Fair 32,7 35,7 31,6

Bad 51,1 30,8 18,1

p<0.001

Miroslav Mastilica

Table. Self-perceived health status by education 2003Croatian Adult Health Survey N=11138

%

Health/Education low middle high

Excellent 2,4 9,9 12,0

Very good 5,1 20,5 30,1

Good 28,4 30,3 30,3

Fair 35,9 28,6 21.6

Bad 28.2 10,8 6.1

p<0.001

Miroslav Mastilica

Visits to specialists, by income groups when controled by health status 2003 Croatian Adult

Health Survey N=11138

INCOME

POOR HEALTH

low middle high

Not visited 36,5 29,5 26,1

1-2 visits 26,3 22,9 26,13-4 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

Miroslav Mastilica

Social inequalities in health in Croatia2003 Croatian Adult Health Survey N=11138

SF36 Dimensions by education

20

30

40

50

60

70

80

90

100 Low Middle High

Miroslav Mastilica

Social inequalities in health in Croatia2003 Croatian Adult Health Survey N=11138

SF36 Dimensions by gender

20

30

40

50

60

70

80

90

100

Male Female

Miroslav Mastilica

SF-36 Dimensions North Croatia

Eastern Croatia

South Croatia

WesternCroatia

Middle Croatia

City of Zagreb

M M M M M M

Physical Functioning(PF)

72,2 66,5 73,0 68,2 67,3 70,2

Role limitation due to Physical problems (RP)

65,1 57,8 67,1 69,9 58,2 60,4

Pain (P) 66,2 63,2 68,1 72,6 62,3 61,9

General Health Perception(GH)

58,6 52,3 58,0 59,3 54,1 51,6

Energy/Vitality(EV)

54,7 51,9 55,8 57,5 52,7 52,0

Social Functioning(SF)

74,9 72,0 76,3 77,4 74,3 73,3

Role limitation due to Emotional problems(RE)

73,3 65,0 72,8 76,2 69,86 68,3

Mental Health(MH)

64,7 60,2 64,9 65,6 63,1 61,7

Regional inequalities in health in Croatia2003 Croatian Adult Health Survey N=11138

Miroslav Mastilica

PRIVATE HEALTH CARE EXPENSES 2009(N=525)

Private payments for: Yes (f) % No%

Suplemental insurance

52,2 47,8

Private insurance 20 3.8 96,2

Gratitude money

7 1,1 98,9

Gifts 10 1,9 98,1

Copayments 140 26,7 73,3

Drugs otc 325 61,9 38,1

Health care abroad 4 0,8 99,2

Sick leave 55 10,5 89,5

Home care 14 2,7 97,3

Wellness 44 8,4 91,6

quickier access to services

44 8,4 91,6

Alternate healers 33 6,3 93,7

Private physician 57 10,9 89,1

Miroslav Mastilica

PRIVATE HEALTH CARE EXPENSES 2009

Private expenses( last 6 months)

  No 65 12,4<500 HRK 248 47,2501-1000 hrk 116 22,1501-1000 hrk 60 11,41001-2000 hrk 26 5,02001-3000 hrk 10 1,9Total 525 100,0

Miroslav Mastilica

PRIVATE EXPENSES IN 2009

Disagree 79 15,0Don’t know 72 13,7Agree 374 71,2Total 525 100,0

Citizens pay too much from the pocket

Miroslav Mastilica

PRIVATE EXPENSES IN 2009

Disagree 23 4,4Don’t know 68 13,0Agree 434 82,7Total 525 100,0

Easier access to health care services if paid from the pocket: