In 2008, immediately after the election and es ta blish ment of the Croatian Government, at the very beginning of his mandate, the Minister of Health and Social Welfare initiated and supported the model of structural innovative reform. In so doing, the ‘’rereform’’ idea was dismissed (that is to say ‘’reverting to the old but maintaining positive solutions’’), and the new reform model, was created based on science and knowledge, experience and positive solutions from developed healthcare systems worldwide. The fundamental reason for initiating this reform was the aggregation of debt in healthcare with the constant increase of costs that did not result in adequate quality of protection and work improvement, nor indicators on increased life expectancy and quality of life for citizens/insured persons.
Modified Modus of Collecting Money for Health
Given that money for the healthcare system in Croatia is collected exclusively from contributions from employed persons, with an insignificant amount coming from the budget, one of the most important chapters of the reform was finding new sources of funding through the broad introduction of supplementary health insurance, special contribution from tobacco products, contributions for unemployed, pension fund contributions, charging treatment costs in traffic accidents from insurance companies instead of healthcare funds, charging and introducing participation, and increasing the share of personal consumption for healthcare.
Rationalisation of Consumption – Modified Payment System
Instead of a payment system that consisted of paying hospital capacities and capitation system for primary healthcare, the payment system for provided services, that is, the system of paying delivered health, through DTS (DRG - Diagnose Related Groups) for payment of hospital was introduced as was a performance payment system for payment in primary healthcare, and new mechanisms of intensive treatment payment (SAPS II score) . In the field of consumption of medications, an array of measures is being introduced, a “Pay-back” system, utilisation of electronic guidelines in prescribing medications for most frequent illnesses, international competition for procurement of especially expensive medications, public procurement for vaccines and so on. Also contracted was the delivery of an integral healthcare information system, which, inter alia, should enable the monitoring of healthcare consumption and implementing reform.
Other Reform Interventions
Reduction of sick-leave rate, unification of procurement for expensive equipment, establishment of national waiting lists, standardisation of orthopaedic aids (introduction of ISO 9999) etc… Proposals of structural changes penetrate into all forms of work organisation and present replacement of many current solutions for work organisations with new contents and economic and organisational solutions.
What Has Been Achieved so Far
Reduction of sick-leave rate from 4,2 to 3,69 in first four months, reduction of physical volume of drug consumption by 7%, reduction of number of references for consultative - specialist healthcare. Prescribing permanent prescription for chronic patients, simplified manner of prescribing orthopaedic aids were introduced, and consultative examination in the same institution was provided to specialists in secondary and tertiary level. Competition for the informatisation of primary healthcare system project and for equipment procurement was finished, new sources of financing were ensured, transferring to new evaluation systems and work payment for hospitals, D.T.S. system, etc.
In order to have a real, inventive reform and not a bureaucratic, and formal one, essential changes in management and organisation must be followed, and not only for standards, norms, rules and obligations. The basic aims of the healthcare reform: reduction of (irrational) consumption of medicines, hospital and specialist- consultative healthcare, reduction of inequalities, upgrading preventive activities, improving patients’ and medical doctors’ satisfaction level, improving the quality of protection and overall effect on health, etc, are achievable and likely to be maintained only through changes to the overall attitude of all participants in the healthcare system.
Healthcare system reform is a process which takes several years of changes, and welldesigned and implemented reform in the healthcare system represents a great opportunity for insured persons to receive improved and wider care, for doctors to receive improved evaluation of their work and for it to be recognised by the community, and for the healthcare system to achieve better results in healthcare for the population with equal resources. Accepting the aforementioned principles already applied in business and redesigning work worldwide is one of the fundaments on which the Croatian healthcare system reform is based.
Dražen Jurkovic, M.D.,
Republic of Croatia,
Ministry of Health and Social Welfare
e-mail: [email protected]