ZAGREB, May 9, 2019 - Health tourism is a great opportunity for Croatia to extend the tourist season, increase its off-season services and attract higher-profile tourists, it was said on Thursday at the formal opening of the annual meeting of the European Spas Association (ESPA), the umbrella organisation that promotes health tourism, which is taking place in the north-western spa town of Tuhelj until May 10.

The conference has brought together representatives of 21 European countries who will be discussing the latest trends and innovation in health tourism. The event was co-organised by the Croatian Chamber of Commerce (HGK) in partnership with the Croatian National Tourism Board (HTZ).

It was said that health tourism was the fastest growing segment of the tourism industry, growing at an annual rate of between 15 and 20 percent.

HTZ director Kristjan Staničić said he was confident that health tourism would grow considerably in the years ahead and that Croatia could definitely be competitive in this sector. He said that health tourism did not depend on the sun and sea and could help extend the tourist season, both along the Adriatic coast and in continental Croatia.

Citing the TOMAS Summer 2017 survey, Staničić said that seven percent of tourists visiting Croatia did so for health reasons and eight percent to visit spas.

Dragan Kovačević, the HGK vice-president for agriculture and tourism, said that health tourism was a great opportunity for Croatia to increase its tourist services in the off-season, adding that a mild climate and the high quality of health services were the country's advantages in that regard.

Assistant tourism minister Olivera Šarić that 15 percent of all tourist travels were motivated by health reasons. She said that the potential for the development of health tourism as a year-round business was extraordinary and that health tourism was included in the Croatian Tourism Development Strategy until 2020, noting health tourists spent between 20 and 30 percent more than the average.

The ESPA conference is taking place under the motto "Secrets of life balance - A life full of well-being". It will discuss new trends and innovations through presentations of best practice and new market niches in spa and wellness tourism. ESPA Innovation Awards will be presented for innovation and excellence in providing medical spa services.

More health tourism news can be found in the Travel section.

CLEVELAND, April 4, 2019 – The Association of Croatian American Professionals (ACAP) hosted medical professionals from the United States and Croatia at a business meeting to advance the agenda of the ACAP Medical Task Force at a gathering on Saturday, March 30, 2019.  

This event marks the third in-person meeting for the ACAP Medical Tourism Task Force. The initiative was launched in 2016 to identify opportunities for businesses and professionals to create relationships and open dialogue with organizations and entities in Croatia involved in the growing healthcare sector of medical tourism. 

“It’s amazing to see the talent and excellence of the diaspora and Croatia come together with a goal to positively impact Croatian healthcare. That exemplifies not only their dedication to, but love for, their homeland,” says Pjer Šimunović, Ambassador of the Republic of Croatia to the United States. 

Ambassador Šimunović was accompanied by Mirna Vlašić Feketija, Minister Counselor, and Nikica Kopačević, Counselor, also members of Croatia’s diplomatic mission to the U.S.

“Our task force allows our members to bring forth their creative vision and expertise to help Croatian businesses in the health sector understand how we, as Croatian-American professionals, can help leverage and make the region more attractive for patients and travelers looking for quality medical tourism experiences,” says Steven Pavletić, MD, ACAP vice president and chair of ACAP Medical Task Force. Dr. Pavletić serves as a senior clinician at the Center for Cancer Research for the National Cancer Institute in Bethesda, Maryland.

The outcome of this meeting was the creation of a formal process to implement four key initiatives including:

• Croatia Connected Health Hub: a centralized medical health tourism agency for patients
  
• Croatia Cancer Center: high-quality, comprehensive cancer center in Croatia
  
• Integrated Medical and Wellness Program: new partnerships at destinations in Croatia   
  
• Education: a program that enables Croatian medical and other health care students to spend clinical preceptorship time at hospitals in the U.S.  
  

"The collective enthusiasm and brainpower of Croatian professionals, coupled with a laser focus on creating a pragmatic solution, resulted in an innovative educational, marketing and logistics plan to boost Croatia to the forefront of the cross-border health movement,” says Mirena Bagur, MBA, president, CONTeXO Group, a consultancy for health tech entrepreneurs. 

Forty professional leaders participated in the discussions including: Ognjen Bagatin, MBA, CEO, Bagatin Clinic, Croatia; Anto Bagic, MD, UPMC Pittsburgh; Marijo Bilusic, MD, National Cancer Institute, Bethesda, Maryland; Miljenko Bura, MD, Medical Group, Zagreb; Mate Car, PhD, Assistant Deputy Minister of Health, Croatia; Mladen Golubić, MD, Cleveland Clinic; Kerry Laufer, director, onsite global consulting, Tuck School of Business at Dartmouth College; Biljana Lovrinovic, CEO, Equus Group/Galop Digital; Mario Skugor, MD, Cleveland Clinic; Drew Stoken, MD, Harrisburg, PA; and Josie Tomljenovic, RN, Cleveland Clinic. 

The Medical Tourism Task Force meeting was held at the Four Points by Sheraton Hotel in Eastlake, Ohio. 

The Association of Croatian American Professionals is a non-profit organization bringing together professionals, business leaders, academics, students and community organizers. Its mission is to foster leadership, collaboration and to promote the advancement of issues relevant to the Croatian-American community. ACAP currently has 11 chapters in the United States and Croatia with 750 members — and is growing — worldwide. 

For more information, please visit croampro.com; follow us on Twitter (@CroAmPro) and Facebook.

ACAP is hosting its fourth national conference in Cleveland, Ohio from Sept. 19 through 22, 2019. The conference aims to bring together more than 500 professionals from all facets of the U.S. and international professional community, including a delegation from Croatia’s Chamber of Commerce.   

Additional Quotes 

“By assembling a diverse group of Croatian professionals from the U.S. and Croatia, we started to develop a Croatia Connected Health Hub as a one-stop-shop healthcare platform that will position Croatia as a synonym for health in Europe and the world. When enthusiasm, knowledge, experience and love for Croatia are placed on one team, everything is possible. This was one of the best ACAP meetings yet, thank you for this experience.”

Ognjen Bagatin, CEO, Bagatin Clinic (Split and Zagreb, Croatia) 

"Planning and implementation of the second phase of the integrated medical wellness program highlighted the meeting. The task force focused on identifying potential partnerships in the U.S. and Croatia, legal and business needs, and implementation of pilot programs by 2020." 

Jeana Havidich, MD, Dartmouth-Hitchcock Medical Center (Lebanon, New Hampshire)

“The confluence of broad vision, strategic planning, and tactical execution emanating from the conference served to demonstrate the critical importance of having diversity of thought at the table. Perspectives from clinicians, marketers, risk managers, IT experts, bankers and finance professionals -- representing large and small companies, for-profit and non-profit organizations, from Croatia and the US -is crucial to fostering and accelerating success in cross-border investments.” 

Paula Poskon, President, STOV Advisory Services (Reston, VA)

"The Croatia Connected Health Hub working group has certainly been adopted and well received within the ACAP medical tourism task force. We find it extremely important to have one central place for information in which international patients can have easy access and make it a one-stop-shop for the best Croatian healthcare practices. A large part of this will be telemedicine which involves clinical, technology and process improvement experts who we are fortunate to have as ACAP members." 

Biljana Lovrinovic, CEO, Equus Group (Cleveland, Ohio)/Galop Digital (Travnik, Bosnia and Herzegovina), President, ACAP—Cleveland

The global growth of medical and health tourism industry is estimated at 15 to 20% per year, and by 2025, according to estimates by Business Insider, it should amount to over 120 billion dollars, writes Jadranka Primorac for Slobodna Dalmacija on December 8, 2018.

The growth in the demand for medical and health tourism services in the world is mostly generated by the crisis in healthcare systems of developed countries, the high cost of health services, long waiting lists, and the general trend of population aging. The European Commission's most recent estimates show that in Europe by the year 2040, people older than 65 will represent 26% of the total population, so the growth in healthcare services being provided abroad will be even more critical.

The question is whether Croatia as a state is ready to respond to the future challenges to redirect at least part of this revenue to the Croatian healthcare institutions since many countries have already realized a significant economic development potential of this branch.

However, while Croatia keeps discussing its potential, governments around the world are launching various initiatives to encourage and develop the health and medical tourism market in their countries. Turkey, for example, not only invests immense financial resources in promotion and marketing but has also introduced so-called "medical visas" and special low-cost flights to Turkey.

Also, it has exempted from paying the VAT all international patients receiving medical care in the area of preventive medicine, various diagnostic services, dentistry, care and rehabilitation in all medical institutions accredited by the Ministry of Health. Also, the government has signed contracts with international social security and insurance institutions to attract seniors to come to Turkey for care and treatments.

The Health Tourism Department of the Ministry of Health has a phone contact service for international patients which provides around-the-clock translation services in four languages: English, German, Russian and Arabic, and the official goal of the Turkish government is to earn 20 billion dollars annually by 2023 from health and medical tourism.

Another good example is Hungary, which was visited by about 2.5 million medical and wellness tourists in 2017, according to the information provided by the Hungarian Statistical Office. The most sought-after services are dentistry, ophthalmology, aesthetic surgery, and medical assisted fertilization (IVF), in addition to the well-developed spa centers. Hungarian dentists, who aim to attract foreign patients, have also received substantial grants from EU funds, while on the other hand they also have the right to state funding, as part of a plan that supports the development of dental tourism in Hungary.

The targeted funding by an economic development programme, through the National Agency for Development and the Hungarian Central Operational Programme, has been received by 136 dental clinics, thus achieving a 19% increase in revenue. It is important to note that most Hungarian cities are well-connected and have several direct daily flights to almost all European cities.

Poland also has excellent results in medical tourism, particularly in the UK market, but also in the Scandinavian countries. Dental services and aesthetic surgery are still the most popular services for medical tourists, but orthopedics, neurosurgery, medical assisted fertilization treatments and oncology are also on the rise. In Poland, there is also a high level of availability of low-cost flights, inexpensive accommodation options and an attractive tourist offer, which all brings in medical tourists.

An increasing number of clinics and hospitals offer packages that include transportation to and from the airport, as well as accommodation in apartments or hotels, sightseeing of cultural sites, and gastronomic offer. The cost of treatment in Poland is up to 40% lower than in Germany or the UK. A unique feature of health and medical tourism, which makes it a real economic activity, is its multiplying effect, since it develops many different sectors, with medical tourists spending up to 30% more than regular tourists.

As far as medical and health tourism is concerned, Croatia is still trying to wake up, although it has great potential, primarily because it has a high level of medical excellence, great doctors, including some internationally renowned, as well as safety and security, which is crucial. There is a whole market of tourists who adore Croatia, but who probably do not even think they could find a solution to their health problems in Croatia. In their heads, there is no link between Croatia as a summer destination and Croatia as an accessible solution for obtaining quality healthcare. It is absurd that, of the 19 million foreign tourists who visited Croatia this year, the number of those who came for medical treatment is at the level of a rounding error.

Creating an attractive and sustainable destination for medical and health tourism requires a long-term strategy. The strength of the tourist brand which Croatia has should be exploited for further positioning on the health-tourism market. Foreign tourists do not have a generally developed trust in the Croatian health system but base it on individual experiences, and this is not nearly enough for the arrival of foreign patients.

All of us who "live" the medical tourism often find ourselves in situations in which patients coming from countries in which the perception of Croatia is not great are shocked when they discover they can get better service here than at home, often at a price which is two to three times lower than in their countries. They can also enjoy other attractions, from natural phenomena, cultural heritage to gastronomy. If we look at the surrounding states, I am sure that with a good marketing strategy we can redirect to Croatia 30% of patients coming to neighboring Hungary or Poland.

Let us not forget that Croatia has excellent potential in health tourism. For example, Slovenia and Hungary have long ago privatized or put into public-private function all their spa facilities and completely renovated them with grants from EU funds, which was the European Commission's recommendation, since it is firmly committed to a public-private partnership, because it believes that the sluggish public sector cannot be activated without the support of a more efficient private sector, nor can it finish projects.

To make a new step forward and develop health tourism, in addition to individual activities and efforts by individual healthcare institutions, stronger state support is needed, primarily through defining and implementing clear rules which apply equally to all businesses in Croatia.

For example, the use of financial resources from European funds allocated to health should be allowed, in addition to public institutions, to private healthcare institutions as well, as it is the case in other well-regulated EU countries. Also, to make healthcare a desirable investment segment, it must be possible to use the benefits of the Investment Promotion Act, which is not the case now. Furthermore, the Croatian Tourist Board and the Ministry of Tourism already have well-developed promotion and sales channels, which need to be modernized and adapted to add new content and services that the health sector can help develop.

Nothing will happen by itself, but only because of innovative and creative individuals and companies which listen to what the medical tourism market is looking for and try to improve their offer by creating high-quality content. Global changes in this type of tourism are taking place exceptionally quickly, and we must not give over to chaos, but we have to get involved and know how to deal with them, which demands a much greater involvement from the state authorities, but also from all other stakeholders than it has been the case until now.

Given that Croatia is becoming an increasingly desirable and popular tourist destination, this moment should be used to give it added value because the effects of tourism should not be limited just to hotels, marinas or camps, i.e., “sun and sea,” but they should be much more extensive. The impact on Croatia's reputation of this synergy between health and tourism is invaluable, and it represents an entirely different positioning of Croatia in the world, not only regarding its natural beauty but also concerning knowledge-based added value.

The author is a member of the Management Board of the St. Catherine's Speciality Hospital responsible for financial and strategic issues. She is also the president of the Association of Private Polyclinics, Hospitals, Spas and Healthcare Institutions at the Croatian Employers' Association.

For more on medical tourism in Croatia, 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).

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The session for the Council of Community Health Tourism at HGK concluded that there must be a stronger promotion for medical tourism within Croatian borders, expressing the need to put Croatia in the medical world map, reports HRTurizam.