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CROATIAN HEALTHCARE REFORM FROM THE PERSPECTIVE OF USERS 1990-2009. CROATIAN HEALTHCARE REFORM. Alice's Adventures in Wonderland. 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. - PowerPoint PPT Presentation
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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)))????
Miroslav Mastilica
1. PHASE - PROVIDERS ORIENTED-1990-1993
• Centralization of financing ("Croatian Institute for Health Insurance ")
• Control of provision of services
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
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$HCE per capita 400 US$
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
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
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: