ZAGREB, December 29, 2018 - The Clinical Hospital Centre in the southern coastal city of Split on Friday received the ten thousandth blood donation in the last ten years. The donor at the Split hospital was Mario Roguljić (27), who has donated his blood for the sixth time.

Mayor Andro Krstulović Opara thanked all the donors for the noble deed of saving human lives, while the head of the municipal Red Cross, Tomislav Gojo, emphasised the importance of raising awareness among young people as potential new blood donors.

With 10,000 doses of blood donated in the last decade, residents of Split have saved or helped over 30,000 people, given that one dose can be used for three patients.

More news on Croatia’s health system can be found in our Lifestyle section.

The St. Catherine Hospital, the official hospital of the Croatian national football team, and the Croatian Football Federation have begun, for the first time in Europe, a project of systematic screening of risk groups of football players to determine frequency of the most common genetic mutations that can lead to sudden cardiac death of athletes, announced the Croatian Football Federation on December 28, 2018.

The sudden cardiac death is a tragic event which occasionally happens at sports venue which opens up a series of questions among both the general public and professionals, such as "How can this happen to seemingly healthy and successful athletes" and "How to prevent such sudden events?"

The fact is that extremely intense physical activity can temporarily increase the risk of sudden cardiac death in predisposed athletes. Medical literature suggests that due to increased physical activity, athletes have a 2.8 times higher risk of sudden cardiac death compared to the general population which does not take part in sports activities. Particularly significant is the fact that genetically-based illnesses can cause such a dramatic event. Because of this, the medical professionals, in addition to introducing thorough clinical exams of athletes, have recently started recommending the introduction of targeted genetic testing, primarily because they can point to an existing genetic predisposition on time.

With the Cardio Screen "multi-gene panel testing" during the pilot project, 77 genes and related mutations that can lead to sudden cardiac death of athletes will be analysed simultaneously. These conditions include, among others, various disorders of the heart's electrical activity, including inherited disorders of the ionic heart canals (e.g., prolonged QT interval syndrome) or, on the other hand, structural changes in the heart, such as cardiomyopathy (most often hypertrophic cardiomyopathy), as well as many other conditions. When it comes to cardiomyopathies, sudden cardiac death unfortunately often occurs before any previous symptoms appear, so any diagnostic data that can reduce the frequency of such incidents is highly important.

The Croatian Society for Sports Medicine of the Croatian Medical Association, in connection with the systematic exams of athletes and in line with the views of the American Heart Association, the European Society of Cardiology and the International Olympic Committee, has issued guidelines for the scope of athletes’ examinations and have emphasised that "it is of particular concern that most athletes with undetected cardiac issues have no symptoms, and the only way to prevent sudden cardiac death is primary prevention involving an electrocardiogram. If there is any suspicion about heart disease, further examinations should be performed, including heart ultrasound, ergometry, 24h Holter monitoring, heart MRI etc.” It goes on to say that “today, genetic testing of deceased athletes is becoming more common so that we can get more information about these disorders in order to prevent sudden deaths in the future better.”

The goal of the St. Catherine Hospital and the Croatian Football Federation’s project is to use the genetic screening of athletes belonging to risk groups (athletes with a concerning personal or family medical history, athletes with specific findings after a clinical examination, athletes with previous episodes of weakness or excessive fatigue, athletes with unexplained loss of consciousness and chest pains, etc.) to find athletes with specific genotypes that contain typical mutations responsible for the emergence of these unexpected and tragic events. On the other hand, according to the guidelines of the Croatian Society of Human Genetics of the Croatian Medical Association, all persons who have been determined to be persons with higher risk will be provided with information as part of their genetic counselling process, in identifying the risk and after further examinations. This will provide the basis for optimal treatment and, if necessary, exclusion from the sports of under risk athletes all with the aim of reducing the incidence of sudden cardiac deaths.

“It is my pleasure to cooperate with our official hospital, the St. Catherine Hospital, the European centre of excellence, and to carry out for the first time in Europe a systematic genetic screening of football players. With this, we demonstrate that we can be leaders in a number of processes, like introducing new diagnostic tests, all with the aim of providing our athletes with the best possible health care,” said Davor Šuker, the president of the Croatian Football Federation.

“The sudden cardiac death is the leading cause of death in athletes, and every new diagnostic step is significant in preventing such unexpected and tragic events that leave a deep mark in every society. A large number of cardiovascular diseases that can lead to sudden cardiac death, such as hypertrophic cardiomyopathy or various heart electrical activity disorders, have a genetic basis. This naturally suggests the need for timely genetic screenings, especially with risky groups of athletes, which will lead, together with standard clinical treatments according to the guidelines of the European Society of Cardiology, to optimisation of treatment and providing recommendations related to further sports activities,” said Dragan Primorac, the president of the St. Catherine Hospital’s management council.

More news about the St. Catherine Hospital can be found in our Lifestyle section.

ZAGREB, December 17, 2018 - Cancer is the second leading cause of death in Croatia, accounting for nearly one in four deaths, as well as 26% of all deaths in 2017, it was said on Monday at the "Fight & Win" conference, aimed at raising awareness of the importance of preventing and fighting cancer. According to the International Agency for Research on Cancer, cancer kills 164 persons out of 100,000 in the United States and 262 in the European Union.

In 2016, 27 persons out of 100,000 died of breast cancer in the EU and 47 in Croatia, said Croatian member of the European Parliament Dubravka Šuica, also a member of the informal group of MEPs "Members Against Cancer".

"It's evident that in the US they invest more and do more than in the EU. This shows that it's necessary to invest more in research, development and innovation, which is a priority for the European Parliament. Croatia has to become more involved," said Šuica.

"Cancer is a topic that's often not visible enough, yet it's a big social phenomenon endangering families and radically changing their lives. The number of persons with malignancies is constantly on the rise both in Europe and the rest of the world," said Prime Minister Andrej Plenković.

The number of those ill is rising because people live longer and many people reach an age when malignancies appear more frequently because of daily stress, which is one of the psychological triggers contributing to the development of malignancies, and cause of the high number of smokers and obese persons, in which Croatia is near the top of European rankings, he said.

Participants in the conference agreed it is necessary to raise awareness of the fact that cancer does not choose its victims and of the importance of prevention, healthy living, and check-ups for early diagnosis and treatment.

"The turnout for screening programmes is poor," Health Minister Milan Kujundžić said, adding that next year, alongside the three existing national programmes for early diagnosis of breast, colon and cervical cancer, programmes would begin for the early diagnosis of lung and prostate cancer.

A national cancer plan is currently in public consultation and Plenković expects it to be adopted in the first half of next year.

"Funds have been ensured for future screenings as well as for priority lists, which primarily refers to patients suspected of having a malignancy who should undergo diagnosis within seven days. All other big investments we plan to finance from EU funds," said Kujundžić.

More health news can be found in our Lifestyle section.

ZAGREB, December 2, 2018 - The Croatian Health Insurance Fund (HZZO) reported recently that it was continuing to achieve good financial results this year and that in the first nine months of the year, it had generated a positive financial result of more than 668 million kuna.

These results are due to positive macroeconomic trends, and in particular due to the 5.4% increase in the average gross wage, HZZO stated.

The Croatian Health Insurance Fund's Jan - Sept revenue was 5.81% higher year-on-year and amounted to 18.5 billion kuna.

The higher contribution rate of 4.08% was conducive to this, as did a 20% increase in revenue from the budget which led to an additional 500 million kuna in contributions increasing from 2.5 kuna billion to 3 billion kuna.

This has resulted in a positive financial result in that period of about 668 million kuna, HZZO said.

The report further added that the average number of total insurees is decreasing, however, the number of active insurees is growing and as of 30 September there was an average of 1,563,452 registered employees, which is an nominal increase of 42,191 employees or 2.77% compared to the same period last year.

The rate of people on sick leave in the period from January to September increased slights and amounted to 3.41% y-on-y (3.22% in 2017) but has fallen compared to the first six months of this year when it amounted to 3.53%.

For more on Croatia’s health system, click here.

Although annually earning about 3 billion kuna in revenues, with investments in the next year to reach more than half a billion kuna and employing about 8,000 professionals, the private healthcare in Croatia still operates under unequal conditions in relation to the public healthcare system and other entrepreneurs. Namely, in addition to a number of law and regulations that need to be adapted to today's needs of the market and the patients, Croatia should also change its mentality which continues to stigmatize private capital in healthcare services, although in more developed European countries it serves as a powerful leverage for the strengthening of the public solidarity-based healthcare system, reports Poslovni.hr on November 27, 2018.

The Association of Private Polyclinics, Hospitals, Spas and Health Care Institutions of the Croatian Employers' Association has recently spoken about this issue. Jadranka Primorac, the president of the association and member of the Managing Council of the St. Catherine's Specialty Hospital, explains why patients would benefit from stronger private and public sector co-operation, and what needs to be changed to enhance this co-operation.

What are the laws and regulations that hinder the development of private healthcare in Croatia and better co-operation with the public sector?

To begin with, there are many contradictions between the Institutions Act and the Companies Act. Namely, private health institutions operate as companies, we pay the business tax on profits, but the 1996 Institutions Act prevents us from paying out the profits. It means that, if we generate any profit at the end of the year, we can only reinvest it into existing business, we cannot use it for any other purpose, any other investment, etc. The law was adopted in 1996 when private healthcare institutions did not exist in numbers like they exist now, and has not been changed since.

Why do you think the law has not been changed?

The law belongs to the government’s administration department, but it regulates institutions in many segments, healthcare, culture, education, social care, which concerns a wide range of ministries, and that is probably one of the reasons why this process is not proceeding faster. In April, we met with Administration Minister Lovro Kušević, and he promised us he would work on it, but no changes have been proposed.

What would be specific changes in the law if it were to be adapted to the private sector?

It should make it possible to pay out the profits and that would certainly provide a certain degree of investment momentum in private healthcare. There is a lot of talk about medical tourism and 300 million euro investments, but given this law, I am not sure that is realistic, because everyone who invests their capital expects that at the end they will be able to use the profits as they please since that is the key principle of entrepreneurship.

Private healthcare institutions also do not have the right to apply for EU funds?

Paradoxically, many public hospitals have been equipped in the 2014-2020 programme period with the help of grants from European funds. Each hospital asked for between 20 and 30 million kuna in grants. However, we still have to see if all those who asked for money have met all the necessary parameters for financing projects from EU funds since everything is being measured, so the question is what will eventually be paid to them if these parameters are not met. On the other hand, private healthcare institutions could not apply for these funds, we could not buy new equipment under the same conditions as public institutions, because private healthcare facilities were not put into operational programmes. We were looking for a way to have some funds allocated, but unsuccessfully. It should be said that this government is not responsible for it, but we are asking now to be included in the new 2021-2027 programming period. We have received promises that this will happen, but the question is how these negotiations will proceed, given the poor utilization of funds available to Croatia in this period. According to our information, the utilization is at just 22%, which is absolutely unsatisfactory and certainly not a positive for the future programming period.

The cooperation between private and public system is still very weak. How many services in the private sector are realized through the Croatian Health Insurance Institute (HZZO)?

It is still not a lot. On an annual basis, around 1.8 % of the funds are allocated by the HZZO to the private sector (about 400 million kuna of the 24 billion kuna HZZO budget). At the same time, we have a continuous increase of revenues in private institutions year after year, and this three billion kuna were paid by patients from their own pockets, while most of them simultaneously pay 15 percent of their salaries for the compulsory health insurance. So the patients are paying twice and do not have a lot of choices. It is not important to patients whether they go to a public or private institution if they receive a service that they do not have to pay from their own pockets. A good example is the Netherlands, where all insurance companies are private, and you have public and private hospitals working together. The healthcare in the Netherlands has been the best in Europe for many years. It is based on several principles; everyone has the right to healthcare, there is solidarity through health insurance which is compulsory for everyone and accessible to everyone, and they have good-quality and timely health services. The people in the Netherlands pay around 120 euro a month per person, which is comparable to Croatia, and during the year they pay additional 500 euro for treatments. Competition between providers of health services is promoted, and contracts are awarded to those who are the best and have the best outcomes of treatments, which is being monitored through patient registers. There are no waiting lists there. All this shows that our healthcare is extremely expensive and very ineffective, because the share of health spending which our politicians often speak about has little to do with the cost-effectiveness of the system.

But they allowed private health insurance companies to enter the system, while in Croatia they are still not integrated into the system and have the same status as private healthcare institutions.

The question of ownership is not important at all. There are rules that the state as regulator prescribes and controls with a series of parameters. Monopoly is not good in any business. When you have market competition, the quality is increased, performance and outcomes of treatments are being monitored, and you know who is who. If a hospital has excellent results in a particular department, then insurers, public or private, would negotiate more such procedure at that hospital. Nowadays, everything is measurable. Also, the HZZO needs to be transformed into a proper insurer that will then be subject to all the laws that other insurers are subjected to because the current situation is not fair market competition. That would make the HZZO finally turn towards patients who are financing it through their salary contributions, and not to the Ministry of Health, as is the case now. The primary role of the HZZO, as well as any health insurance, is to use the money it gives to hospitals to provide more “health” for the insured.

Does this mean that, without the private health insurance, private healthcare in Croatia will not further develop?

The healthcare system will not be maintained at this level with state monopoly and state health insurance unless a radical turnaround occurs. And there is no need to discover anything new here. We should just apply good solutions from well-regulated healthcare systems in the EU countries.

Would the strengthening of the role of private healthcare accelerate the reform of the public health system?

Yes, I believe that the public healthcare system cannot be reformed and I do not believe that it is possible to have full impact on cost-effectiveness as long as the state is the main and sole provider of both the insurance and the treatments.

Maybe the change is not in someone's interest?

The system as it has been set up is unsustainable. When we sum up everything, we have paid almost 30 billion kuna to cover the debts of the public healthcare system in the last 27 years. That is with no interest charged, which in the end makes this amount even larger. Thus, the way in which the Croatian health system is currently functioning is a "bottomless pit," and quality healthcare cannot survive in the long run unless processes and funds are managed rationally and unless there is competition, quality control and cost efficiency control, together with the accountability and professionalism in management.

If these legal changes were to be made and were to encourage foreign investment in healthcare, would anyone have an interest in buying a Croatian hospital that is currently operating with a loss?

No one will buy a public hospital, there is no fear, since that is not realistic, primarily because these are institutions that need large investments in facilities and equipment.

Despite these obstacles, what are the business results of the private healthcare in Croatia? It seems like you are doing pretty well.

The private healthcare in Croatia has an annual income growth of about ten percent; foreigners are coming, health tourism is getting stronger. However, in private healthcare institutions in Croatia, the profit is not as high as in some other sectors, since the price of services in Croatia is low compared to the Western countries and the cost of labour is high. So the return of investment is slow, but if the EU funds were to be opened, if we could acquire equipment through the funds, or if we could use the Investment Incentive Act, the return of investment would be much simpler and easier.

For more on the Croatian healthcare sector, click here.

Translated from Poslovni.hr (reported by Marija Crnjak).

ZAGREB, November 17, 2018 - After a pharmacist in Zagreb refused to issue contraceptive pills to a patient, citing conscientious objection, Health Minister Milan Kujundžić said on Friday that the pharmacist's behaviour was impermissible, while the Social Democratic Party (SDP) called for urgent regulations regarding conscientious objection so as to prevent recurrence of similar cases of denying someone medication or health protection.

There is nothing that a pharmacist has the right to deny a patient based on conscious objection, Kujundžić said after a government meeting when asked about the incident. "Every patient has the right to be issued with a prescribed medication in any pharmacy. The pharmacist has the right to freedom of conscience but not in the workplace, in the pharmacy," the minister explained.

In response to the incident the opposition SDP called on the Croatian Medical Chamber to finally present its official stance on the issue of the conscientious objection and said that that it expected the Health Ministry and Minister Kujundžić to regulate acts when conscientious objection can be cited.

SDP expects the authorities to draw up registers of pharmacists, physicians and other health personnel citing conscientious objection because citizens have the right to that information.

"We don't have to point out that actually (non)regulation of conscientious objection is usually at the expense of women in exercising their right to terminate pregnancy," SDP said in a press release.

In light of the fact that a month ago a very large number of women decided to break their silence and talk about violations of their rights regarding reproductive health, and also about the treatment in hospitals with gynaecological wards, we consider this to be yet another attack on women's rights in Croatia, SDP said.

For more on the position of women in Croatia and attempts to deny them their rights, click here.

ZAGREB, November 16, 2018 - The government on Friday accepted a draft framework agreement on cooperation with the City of Zagreb in the preparation of a project for the construction of a national children's hospital within the compounds of what was supposed to be a hospital in Zagreb's Blato suburb.

"This is a historic opportunity for this government to do something that this nation and state badly need. We can now, in partnership with the City of Zagreb, build a new university hospital with its first stage being a children's hospital, instead of just adapting and refurbishing the existing hospitals," Health Minister Milan Kujundžić said.

On 13 September, the Zagreb City Assembly adopted a decision on the conclusion of the framework agreement regulating cooperation in the preparation of the project to build a national children's hospital as the first stage of the establishment of a national university hospital within the compounds of the Blato hospital, whose construction was never completed.

The cooperation refers to the elaboration of a feasibility study and other documents as the basis for applying for project funding from the EU, the minister said.

The 2012-2020 national public healthcare development strategy envisages changes in the organisation and activities of hospitals and the establishment of a national university hospital as an umbrella healthcare institution offering medical services of the highest quality to citizens of Croatia, reads the government decision on endorsing the draft framework agreement.

For more on hospitals in Croatia, click here.

A pharmacy in the Jordanovac neighbourhood in Zagreb has recently refused to issue a women contraceptive pills, invoking the right to conscientious objection, reports Faktograf.hr on November 16, 2018.

“The pharmacist has refused to issue a gynaecologically prescribed contraceptive pill that I use because of a menstrual bleeding issue, as well as a method of contraception. She invoked the conscientious objection principle because she does ‘not support the use of contraceptive pills as a contraceptive method.’ She was the only one working at the pharmacy and there was no one else who could issue me the pills. The employee said I should come in the morning when she is not there. How can she decide this? First, it was the gynaecologists, now the pharmacists, where it will all end?” asked the woman.

Sandra Čelina, the owner of the pharmacy, confirmed that the controversial incident had occurred. “Of course I know about this, I am the head of the pharmacy. It happened because the other employee was sick, but I do not have to answer anything to you,” said Čelina, adding that she had sent her statement to the Croatian Chamber of Pharmacists.

The Chamber said they had received two complaints this month. These two are the only complaints this year. “In the period from January 1 to November 12, one complaint was received concerning an invocation of the conscientious objection by a pharmacist. We are currently in the process of resolving the case before the competent Ethics and Deontology Commission. In addition, we have received a query which does not make it clear whether the drug was not issued due to the conscientious objection or for some other reason in line with the rules (expert opinion that the medicine could endanger the patient’s health, improper medical records, threat or violent behaviour of a patient),” said the Croatian Chamber of Pharmacists.

The conscientious objection by pharmacy employees is defined by the Code of Pharmacy Ethics and Deontology. According to the third paragraph of Article 12, “pharmacists have the right to the conscientious objection only if it does not endanger the health and life of the patient.”

Višnja Ljubičić, the Gender Equality Ombudsperson, noted that the right to conscientious objection was individual. In cases where a worker or a pharmacist in a pharmacy invoke conscientious objection, pharmacies are “obliged to organize their operations in such a way that the use of the right to conscientious objection does not interfere with the work of the health institution or the pharmacy as a whole, which would prevent the provision of specific services.”

Since in the last week’s case the pharmacy in question did not reorganise its work, the gender equality ombudsperson says that the code of pharmacy ethics and deontology has been violated.

“In this particular case, if a pharmacy as an institution as a whole is unable to issue a medicine due to the conscientious objection of its employees, I consider this to be a threat to the user’s health,” concluded Ljubičić.

For more on the conservative movement in Croatia, click here.

Translated from Faktograf.hr (reported by Ana Brakus).

ZAGREB, November 14, 2018 - Diabetes has become the fourth most frequent cause of death in Croatia, moving up in the ranking from fifth position last year, and the main reason for this is chronic complications arising from late detection of the disease, the Croatian Federation of Diabetes Associations said at a press conference in Zagreb on Wednesday, marking World Diabetes Day.

Last year, 2,331 Croatians died from the disease, and it is estimated that 40 percent of people with diabetes are not even aware of it. As a result, costs of diabetes treatment have increased by 2 billion kuna over the last ten years to 4.6 billion kuna annually. This is 19.8 percent of the Croatian Health Insurance Fund's budget and 88 percent of the amount goes towards the treatment of complications, mostly those of a cardiovascular nature.

Both patients and specialists believe that urgent changes are necessary within the healthcare system to ensure better prevention, faster detection and treatment, and better treatment outcomes.

About 300,000 diabetes patients are currently registered in Croatia, but their actual number is believed to be about 500,000.

All medicines for diabetes treatment are available in Croatia, and new treatment guidelines should also improve the quality of treatment. The biggest problem is the late detection of the disease, because by the time of diagnosis most patients have already developed certain complications, the most frequent being a stroke and a heart attack.

"The number of these patients in Croatia is growing steadily. Right now more than nine percent of the adult population have diabetes, compared to six percent ten years ago. The fact that the death rate is growing shows that we are unsuccessful in treatment," general practitioner Tereza Šarić said.

She presented the results of a survey conducted among diabetes patients, according to which 62 percent of patients had undergone only one or no examinations at all in the past year, and half of them had not taken any of the basic tests. A third did not receive any information about the disease and a fifth said they knew nothing about cardiovascular complications, although half of the patients had such complications.

For more on Croatia’s healthcare sector, click here.

ZAGREB, November 10, 2018 - The Health Ministry issued a statement on Friday saying that an analysis of complaints submitted by the parents association "Roda" in a campaign called "End the silence" regarding the unprofessional treatment of women by medical staff showed that most of the 401 complaints refer to female patients' dissatisfaction with the administration of anaesthesia during medical procedures, lack of communication or inappropriate communication and the unprofessional conduct of medical staff.

The ministry notes that the number of 401 complaints over a period of more than 15 years (the oldest complaint dates back to 1983) is a relatively small number but that it considers even one complaint to be too many.

It notes that since 400 of the complaints were anonymous and many did not contain information on the time when the events in question occurred or the name of the medical institution concerned, inspections could not be carried out in those cases.

A ministry task force entrusted with analysing the complaints nonetheless analysed all individual complaints and conducted inspections in seven hospitals. The inspections, focusing on gynaecologists, were carried out to check the lawfulness of medical procedures and the professionalism of medical staff, with emphasis on the availability of various types of anaesthesia at childbirth and invasive procedures in gynaecology and obstetrics, the ministry said.

A preliminary analysis established certain differences in the organisation of anaesthesiology health services and anaesthesia administration procedures, with the task force concluding that each patient has the right to adequate anaesthesia in line with medical indications.

Commenting on the recent case of Member of Parliament Ivana Ninčević Lesandrić, who publicly spoke of her negative hospital experience following a miscarriage, and whom the ministry identified only by her initials, the ministry described the procedure applied at the Split Clinical Hospital's emergency service in cases of miscarriage, noting that inadequate communication may be the reason why patients do not understand medical procedures and the types of anaesthesia applied.

As for reports of inappropriate communication or unprofessional conduct, collected in the "End the silence" campaign, the ministry says that it could not establish facts in those cases because the complaints were anonymous. "However, even if there were such cases, the Health Ministry considers them unacceptable, condemns them and expresses regret at them," the ministry says calling on all women patients who have complaints about the quality of healthcare to report their experience immediately to the relevant medical institutions' administration and cite as many relevant data as possible.

It says that based on its analysis, the Health Ministry task force has defined a set of measures to improve healthcare for women.

"Doctor-patient communication is to be improved at all levels of healthcare for women. Medical institutions have the obligation to ensure formal theoretical and practical education in communication skills for employees at all levels, and their obligation is to undergo such training.

"Every woman has the right to adequate analgesia and anaesthesia. Medical staff have the duty to explain to every woman the possibilities of various types of analgesia and anaesthesia as well as indications and counter-indications for their use, with all advantages and risks," the ministry says, noting that rules for the application of different types of analgesia and anaesthesia for specific procedures should be defined by the Croatian Medical Chamber.

The ministry task force also proposes zero tolerance to inappropriate and/or unprofessional conduct and advises patients who encounter such conduct to report it immediately to the relevant medical institutions so that legally defined procedures could be launched.

For more on Croatia’s healthcare sector, click here.