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This paper is part of a series of columns on complex patients. The paper talks about complex patients in context of European health and social policies.

Volunteers have been present in palliative care since its inception. With the development of palliative care systems, their role and position are changing. Given growing long-term care needs and limited resources in health and social care, volunteers are becoming an important resource in meeting these needs. In Croatia, palliative care has been developing as an integrated care model since 2014. To assess the position and the role of volunteers, we analyzed legislative documents from healthcare and social care and conducted a focus group with volunteers in palliative care. We found that volunteers provide support from the social aspect of care, for the patient and the family. The formal palliative care system involves them as partners in the provision of care, even though this cooperation is informal. The main determinants of their activities are an individualized approach, flexibility, a community presence, and project funding. In conclusion, these determinants allow them to react quickly to identified needs, but with them come some uncertainties of their sustainability. Their activities could indicate what needs to be integrated between health and social care and in what areas. Volunteers both fill in gaps in the system and are ahead of the system, and by doing this they develop new processes around identified unmet needs.

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths.

In Croatia, palliative care has been developing as an integral part of the health care system since 2014. This development is in line with the integrated care concept emerging in many countries. However, there are a number of implementation problems. The aim of this article was to identify positive and negative determinants for the integration of palliative care in Croatia. We identified policy processes or organizational changes within three key domains: the development of new organizational structures, stakeholders' empowerment, and removing barriers to the provision of integrated palliative care. The progress visible in these domains shows the sustainability of the palliative care model used in Croatia. However, there are also barriers hindering the integration of palliative care. We conclude that patient-centred and process-based change in health care can have a positive effect on the integration of care. Staff education and regulation of business processes are key for the sustainability of reforms. Lastly, it seems easier to achieve the integration of care when it develops as a bottom-up model and reflects the need for new processes, than when it is imposed from above as a single regional or national model.

Aims and objectives: This paper investigates the feasibility and the perception of the nurse's role as the palliative care coordinator.Background:Integrated care is a global imperative in all healthcare improvement pro-cesses. Due to Andrija Štampar's success in the organisation of public health services, Croatia today has more than hundred years of experience in care integration. The pal-liative care system has been continuously developing since 2014 as an integrated care model, with nurses as care coordinators.Methods:The study used a mixed methodology based on pragmatic research prin-ciples, including an analysis of strategic and policy documents and reports, and the-matic analysis of focus group conducted with palliative care coordinators, following COREQ checklist.Results: Although a legal, professional and financial regulation of nurse coordinators has been achieved, a number of implementation challenges remain. These challenges arise as a result of long-term fragmentation of the health and social care, and can be found in both horizontal and vertical integration of care, that is in the dimensions of functional, clinical, cultural and social integration.Conclusions: Nurses play a central role in care coordination. Coordination and inte-gration promote professionalisation with clear roles and tasks. However, even with the legal, professional and financial implementation of the nurse coordinator model, it has to be further promoted as an equally important job in the healthcare system, with nurses as competent professionals in charge of care coordination.Relevance to clinical practice: Palliative care provides a range of individualised, coor-dinated services that meet the medical and non- medical needs of seriously ill patients. Described model of palliative care in Croatia is particularly important because it was developed as an integrated part of health care (and partly social welfare) system, indicating with the nurse's role as palliative care coordinator that coordination is a continuous process that requires a dedicated professional role.

Croatia is among the last countries in Europe to develop organized palliative care at the national level. Real changes in this area started after the parliamentary elections in 2011 and culminated in the 2013 adoption of the Strategic Plan for Palliative Care Development 2014–2016. The National Board for Palliative Care (NBPC), appointed by the Ministry of Health, was in charge of creating a scalable palliative care model and national guidelines. The Board drew on experiences from both neighbouring countries with similar societies and/or health care models (Bosnia and Herzegovina, Poland) and an international leader in palliative care (United Kingdom). It recognised that provision of palliative care in Croatia, thus far based on volunteering and isolated enthusiastic activities, needed to be improved through professionalization, regulation, and organized development. A variety of policy measures was used to implement these changes, including the introduction of professional guidelines and new payment models. The development of new palliative care structures and services significantly increased the number of patients who could access palliative care, from around 1–2% of patients needing such care in 2011 to 20–35% in 2014. It also ensured the provision of more appropriate services at each point of the palliative care pathway. The Strategy was extended for the 2017–2020 period.

Cilj: Opći cilj rada je ukazati na nedostatak postupaka za donošenje utemeljenih odluka u zdravstvu te prikazati negativan utjecaj koji medijske interpretacije mogu imati na odlučivanje. Metode: Prikaz i analiza medijskih objava o slučaju koji se analizira proveden je kvalitativnom metodom narativnog raspitivanja i tehnikom analize novinskih članaka. Predmet istraživanja je javni diskurs o organizaciji zdravstvene zaštite prikazan prizmom hitne medicinske službe, na primjeru specifi čnog slučaja smrti pacijenta u jednom od kliničkih bolničkih centara u Hrvatskoj. U analizu su uključene medijske objave na web portalima četiri velikih nacionalnih medija - Index.hr, Jutarnji list, Večernji list te Slobodna Dalmacija vezane za navedeni slučaj. Pretraživanje je provedeno prema ključnim riječima slučaja na samim web portalima navedenih medija. Rezultati: Metodologijom analize sadržaja pretražene su četiri dnevne nacionalne tiskovine. Pretraživanjem su obuhvaćeni članci objavljeni u razdoblju od 14. prosinca 2018. do 19. prosinca 2019. godine što ukupno iznosi 135 pregledanih i analiziranih novinskih članaka. Svi obuhvaćeni članci bili su usmjereni na pitanje tko je odgovoran odnosno kriv i zašto je došlo do smrtnog ishoda pacijenta. U javnosti i medijima je formiran prigodan analitički diskurs o organizaciji zdravstvene zaštite, u prvom redu hitne medicinske službe koji je započet zbog smrti pacijenta. Analizom članaka identifi cirane su četiri skupine aktera koje su sudjelovale u stvaranju diskursa – osobe nadležne za organizaciju i upravljanje sustavom zdravstvene zaštite, zdravstveni radnici, građani i novinari. Slučaj je analiziran sagledavajući perspektivu svih četiri aktera. Rasprava: Podatci o stanju u zdravstvenom sustavu vezanom za promatrani slučaj pokazuju da ne postoje odstupanja u elementima strukture sustava odnosno da su bili u skladu s regulativom koja propisuje minimalne uvjete u pogledu prostora, ljudi i opreme. Rezultati pokazuju da u svakoj kategoriji defi niranoj prema Antonacci postoje značajne razlike u razumijevanju situacije odnosno nastalog problema. Razlike postoje između pretpostavljenih organizacijskih rješenja u sustavu i načina kako ga prepoznaju i objašnjavaju građani odnosno zdravstveni radnici u prigodnom „medijski analitičkom“ diskursu. Rezultati analize ukazuju na nedostatak procesnog pristupa za upravljanje. Mapiranje i vrednovanje poslovnih procesa kao metoda nije provedena u pružanju skrbi za pacijenta. Samim time nisu identifi cirane jasne komponente sustava koje uključuju ne samo ljudske i materijalne resurse već i odnose i aktivnosti u procesu pružanja skrbi. Zaključak: Metoda mapiranja pomaže nam u prepoznavanju odstupanja u sustavu, identifi ciranjem procesa, njihovim analiziranjem, vrednovanjem i mapiranjem. Rekonstrukcijom slučaja uvidjeli smo kako pokazatelji strukture i ishoda rada nisu jedini čimbenici koji doprinose kvaliteti pružanja skrbi. Mapiranjem i vrednovanjem procesa mogao bi se pratiti „put“ pacijenta te prema njemu u bilo kojem trenutku analizirati kritična mjesta i pravovremeno provesti intervenciju unaprjeđenja., Aim: The general aim of this study was to point to the lack of procedures for evidence-based decision making in healthcare and to show the negative impact that media interpretations may have on decision-making. Methods: Review and analysis of media reports of the case was conducted with a qualitative method of narrative inquiry and a technique for analyzing newspaper articles. The subject of the research was public discourse on the organization of health care shown through the prism of emergency medical system, using the example of a specifi c case of death of the patient in one of the university hospital centers in Croatia. The analysis included media reports related to the mentioned case on the web portals of four major national media, i.e. Index.hr, Jutarnji list, Večernji list and Slobodna Dalmacija. The search was conducted using the keywords of the case on the web portals of the mentioned media. Results: Four daily national newspapers were searched using the content analysis methodology. The search included articles published between December 14, 2018 and December 19, 2019, in total 135 reviewed and analyzed newspaper articles. All included articles focused on the question of who was responsible or guilty and why the patient died. An analytical discourse was formed in the public and in the media about the organization of health care, primarily emergency medical services, which was initiated due to the death of the patient. Four groups of stakeholders who participated in the creation of the discourse were identifi ed using article analysis, i.e. people responsible for the organization and management of the health care system, healthcare professionals, citizens and journalists. The case was analyzed by looking at the perspective of all four stakeholders. Discussion: Data on the state of health related to the observed case showed that there were no deviations in the structural elements of the system and that they were consistent with the regulations that prescribe minimum conditions in terms of space, people and equipment. The results showed that there were signifi cant differences in the understanding of the situation or a problem in each of the fi ve categories defi ned according to Antonacci et al. Differences existed between the assumed organizational solutions in the system and the ways in which it was recognized and explained by citizens and healthcare professionals through appropriate ‘media analytical’ discourse. The results of the analysis indicated the lack of process approach to management. Mapping and evaluating processes as a method had not been conducted in the care of the patient. System components that include human and material resources, as well as the relationships and activities in the care process were not clearly identifi ed. Conclusion: The process mapping method helps identify system deviations by identifying, analyzing, evaluating and mapping processes. By reconstructing the case, we realized how indicators of work organizational structure and outcomes were not the only factors contributing to the quality of care. By mapping and evaluating the process, we could follow the patient’s ‘path’ and, at any time, analyze critical sites and conduct improvements in a timely manner.

This paper aims to: (1) provide a brief overview of hospital sector characteristics in 11 Central and Eastern European countries (Bulgaria, Czech Republic, Estonia, Croatia, Latvia, Lithuania, Hungary, Poland, Romania, Slovakia, Slovenia); (2) compare recent (2008 – 2019) hospital reforms in these countries; and (3) identify common trends, success factors and challenges for reforms. Methods applied involved five stages: (1) a theoretical framework of hospital sector reforms was developed; (2) basic quantitative data characterizing hospital sectors were compared; (3) a scoping review was performed to identify an initial list of reforms per country; (4) the list was sent to national researchers who described the top three reforms based on a standardized questionnaire; (5) received questionnaires were analysed and validated with available literature. Results indicate that the scope of conducted reforms is very broad. Yet, reforms related to hospital sector governance and changes in purchasing and payment systems are much more frequent than reforms concerning relations with other providers. Most governance reforms aimed at transforming hospital infrastructure, improving financial management and/or improving quality of care, while purchasing and payment reforms focused on limiting hospital activities and/or on incentivising a shift to ambulatory/day care. Three common challenges included the lack of a comprehensive approach; unclear outcomes; and political influence. Given similar reform areas across countries, there is considerable potential for shared learning.

Uvod: Cijepljenje je najučinkovitija preventivna mjera koja pored sprječavanja i/ili smanjenja obo-lijevanja od zaraznih bolesti kao dodanu vrijednost zdravstvenom sustavu donosi smanjenje troškova liječenja i boravka u bolnici. Cjeloživotno cijepljenje predstavlja cijepljenje u različitim uzrastima ti-jekom života i uključuje cijepljenje i docjepljivanje protiv bolesti kojima možemo biti izloženi u okruženju u kojem živimo i radimo ili kojima možemo biti izloženi na putovanjima u strane zemlje. Ka-da se govori o cijepljenju, uobičajeni fokus jest cijepljenje djece, dok se o važnosti cijepljenja u odraslih i starijih osoba, osobito onih s postojećim kroničnim stanjima još uvijek dovoljno ne govori. Cilj rada bio je prikazati dodanu vrijednost cjeloživotnog cijepljenja u obliku smanjenja troškova u zdravstvu uslijed liječenja i boravka u bolnici i smanjenja propisivanja antibiotika. Metode: Pregled i analiza publikacija i izvješća o cijepljenju Hrvatskog zavoda za javno zdravstvo i dostupne literature u bibliografskoj bazi PubMed. Pregled literature učinjen je prema ključnim riječima „vaccination“ i „costs“, a u analizu su uključeni radovi na engleskom jeziku publicirani u periodu od 2010. do 2019. godine. Za potrebe ovog rada analizirano je ukupno 10 publikacija. Rezultati i diskusija: Podaci iz literature pokazuju kako se cjeloživotno cijepljenje najčešće razmatra u kontekstu cijepljenja mladeži i odraslih protiv humanog papiloma virusa (HPV), kroničnih bolesnika (kao što su kardiovaskularne bolesti, kronična opstruktivna bolest pluća (KOPB), dijabetes) protiv gripe te cijepljenjem odraslih i starijih osoba protiv pneumokoka. Cijepljenje predškolske i školske djece pov-ezuje se najčešće s cijepljenjima u sklopu nacionalnih programa cijepljenja i postojećim preporukama. U Hrvatskoj se cijepljenjem predškolske i školske djece postižu zadovoljavajući cjepni obuhvati za obavezna cijepljenja. Kada se radi o cijepljenju odraslih osoba, osobito kroničnih bolesnika, dostupni su samo podatci o cjepnim obuhvatima protiv gripe i tetanusa. Cijepljenje protiv tetanusa se provodi u sklopu programa obaveznog cijepljenja i izvješće o cijepljenju za 2017. godini pokazuje cjepni obuhvat manji od 50%. Protiv gripe se prošle sezone u Hrvatskoj cijepilo manje od 10% populacije, među kojim je oko 30% starijih osoba što je značajno manje od preporuka Svjetske zdravstvene organizacije. Prema dostupnim objavljenim podacima o cijepljenju kroničnih bolesnika protiv gripe nije moguće odrediti o kojim kroničnim stanjima se radi. Podaci za zemlje koje imaju obuhvat za cijepljenje protiv gripe viši od 20%, kao što je Nizozemska i Ujedinjena Kraljevina pokazuju smanjenje hospitalizacija za više od 20%, dok se na primjeru Kanade cijepljenje protiv gripe može dovesti u vezu sa smanjenjem propisivanja antibiotika za gotovo od 50%. Istraživanje provedeno u najvećim europskim zemljama pokazalo je da se trošak cijepljenja pojedinca tijekom života kreće od 443€ za zdravu mušku osobu u Švedskoj (10 antigena) do 3 395€ za žensku osobu koja boluje od kronične bolesti u Ujedinjenom Kraljevstvu (15 antigena) što je i dalje ekonomski povoljnije od liječenja i zbrinjavanja mogućih posljedica bolesti. Zaključak: Unatoč postojećim dokazima o dobrobiti cijepljenja tijekom cijelog života i preporukama za cijepljenje odraslih i starijih osoba protiv gripe i pneumokoka, praksa cjeloživotnog cijepljenja u Hrvat-skoj još uvijek ne pokazuje rezultate vidljive na populacijskoj razini, a koji bi mogli ostvariti mjerljiv učinak na uštede u zdravstvenom sustavu. Kako bi se sagledao pravi potencijal cjeloživotnog cijepljenja kao strategije ne samo za prevenciju bolesti i komorbiditeta nego i u svrhu smanjenja troškova u zdravstvu ova tema mora zaživjeti izvan stručnih krugova, a na populacijskoj razini trebalo bi postići da pojedinci i zajednice razumiju vrijednost cjepiva i potražuju cijepljenje kao njihovo pravo i odgo-vornost., Introduction: Vaccination is the most effective preventative measure that, in addition to preventing and / or reducing infectious diseases, adds value to the health care system by reducing the costs of treatment and hospitalization. Lifelong vaccination is a vaccination at different ages through life and includes vaccination and revaccination against diseases that we may be exposed in the environment in which we live and work or when traveling abroad. When it comes to vaccination, the usual focus is on vaccination of children, while the importance of vaccination during adulthood and in older age, or es-pecially with pre-existing chronic conditions, is still insufficient. The aim of the paper is to present the added value of lifelong vaccination in the form of cost reduc-tions in healthcare resulting from treatment, hospitalizations and reduction of prescribing of antibiotics. Materials and methods: Review and analysis of publications and vaccination reports of the Croatian Institute of Public Health and available literature in the bibliographic database PubMed. The literature review was conducted according to the keywords „vaccination“ and „costs“. We have included in the analysis English-language papers published between 2010 and 2019. A total of 10 publications were analysed for the purposes of this paper. Results and discussion: Literature data showed that lifelong vaccination is most often considered in the context of vaccination of young people and adults against human papillomavirus (HPV), chronic patients (such as cardiovascular disease, chronic obstructive pulmonary disease, diabetes) against influ-enza, and vaccination of adults and the elderly person against pneumococcal disease. Vaccinations of preschool and school children are most commonly associated with vaccinations from the national vac-cination programs and with existing experts recommendations. In Croatia we are achieving satisfactory vaccination coverage for preschool and school children vaccinations from compulsory vaccination schedule. Tetanus vaccination is part of a compulsory vaccination program and the vaccination report for 2017 showed a vaccine coverage of less than 50%. Last year, less than 10% of the population was vaccinated against flu, including about 30% of the elderly, significantly less than the World Health Organization's recommendations. According to the available published data on the vaccination of chronic flu patients, it is not possible to determine what chronic conditions were involved. Data for countries with an influenza vaccination coverage of more than 20%, such as the Netherlands and the United Kingdom, showed a reduction in hospitalizations of more than 20%, while in Canada, for example, influenza vaccination may be reduced by almost 50%. A study conducted in the largest European countries found that the cost of a lifetime vaccination for an individual ranges from € 443 for a healthy male in Sweden (10 antigens) to € 3 395 for a female patient with chronic illness in the United Kingdom (15 antigens), which is still more economically viable than treating the disease and the possible consequences of the disease. Conclusions: Despite existing evidence of lifelong vaccination benefits and recommendations for vac-cination of adults and the elderly against influenza and pneumococcus, lifelong vaccination practices in Croatia do not yet show results visible at the population level that could have a measurable effect on savings in the health care system. To see the true potential of lifelong vaccination as a strategy not only for the prevention of disease and comorbidity, but also for the purpose of reducing health care costs, this theme should go beyond profession, and at the population level, individuals and communities should recognize the value of vaccines and seek for vaccination as a their right and responsibility.

Background: The connection between socio-economic status and health is documented, yet not fully understood. The goal of this research was to analyze the relationship between socio-economic status, lifestyle and health status, availability of health-care, social capital, and satisfaction with life. Subjects and methods: Subjects were 1117 women aged 25-65 years divided in two groups. Group 1 consisted of women who receive public assistance (N1=591), while Group 2 consisted of women who do not (N2=526). The sample was stratified by random choice into multiple stages based on six regions of Croatia, residential area size, and the age of respondents. Visiting nurses surveyed the deprived population, while in Group 2 self-interviewing was conducted. A questionnaire entitled “Inequalities in health” was used. The respondents participated in this research voluntarily and anonymously. Results: Socially deprived women consume spirits and wine more often (p

The aim of this study was to assess the value of the “Health-Plan for It” Program for the capacity of Croatian counties to plan health and implement services based on locally recognized health needs. From 2002 to 2008, the county health teams formed in twenty Croatian counties passed the first set of training modules. First assessment was conducted in 2006. Based on assessment results, in 2008-2009 a new set of training modules was organized and attended by six counties. In second assessment conducted in 2012, three instruments were applied: Local Public Health Practice Performance Measures Instrument and Procedure Chart as self-reporting instruments, and tutorial notes assembled/analyzed by the Faculty. All 13 county health teams that participated in second assessment showed an increase in the 2012 score compared to 0-point. The score change showed statistical significance on both the overall core public health functions and on any of its components (assessment, policy development, assurance). All counties showed improvement in assessment and policy development functions. The assurance function was improved in counties that attended the second set of training modules. The Procedure Charts showed that all counties had developed their own health profiles and health plans, with prioritized health needs and identified actions to address them. Like the first evaluation workshop in 2006, results of the second evaluation workshops in 2012 showed that the Program increased the counties’ public health capacity. Two of the counties that had enrolled late in the Program (2007/2008) achieved much better results than ‘older’ counties, showing that the time spent in the Program was not a key factor contributing to local project success. Different levels of achievement due to ‘institutional or personal capacity to change’, reported by other authors, are in line with our findings that individual county success in the Program depended on the team composition and the level of (regional) political stability. In conclusion, the program showed improvement of all core public health functions in all counties. Assurance function showed generally a higher change in counties that had passed both sets of modules. The counties’ capacity for change differed and the Program was not equally efficient in all of them. The differences in county achievements could be explained by stability of political support at the county level, team composition, and commitment of the team leader., Cilj ovoga istraživanja bio je ocijeniti vrijednost učinaka programa “Rukovođenje i upravljanje za zdravlje” na sposobnost hrvatskih županija da planiraju za zdravlje te implementiraju programe temeljene na lokalno prepoznatim zdravstvenim potrebama u podizanju javnozdravstvene i upravne kompetencije hrvatskih županija dvanaest godina nakon pokretanja toga Programa. U razdoblju od 2002. do 2008. godine svih dvadeset županijskih timova za zdravlje provedeno je kroz prvi set edukacijskih modula. Prva evaluacija Programa napravljena je 2006. godine. Temeljem rezultata evaluacije izrađen je drugi set edukacijskih modula kroz koji je, u razdoblju od 2008. do 2009. godine provedeno šest županijskih timova. U drugoj evaluaciji Programa održanoj 2012. godine primijenjena su tri evaluacijska instrumenta: Matrica temeljnih funkcija javnog zdravstva (Local Public Health Practice Performance Measures Instrument) i hodogram aktivnosti županijskih timova (Procedure Chart) kao instrumenti za samoprocjenu te zabilješke/zapažanja mentora sa Škole narodnog zdravlja “Andrija Štampar”. Rezultati timova za zdravlje trinaest županijskih timova, sudionika u drugom krugu evaluacije u 2012. godini bolji su u usporedbi s njihovim početnim stanjem (0-point). Promjene u rezultatima pokazuju statistički značajnu razliku kako u ukupnom zbroju (sve tri temeljne funkcije zajedno) tako i za svaku funkciju pojedinačno (procjena stanja, oblikovanje zdravstvene politike, osiguravanje resursa). Sve su županije pokazale napredak u funkciji procjene stanja i oblikovanja zdravstvene politike. Funkcija osiguravanja sredstava bila je unaprijeđena kod županija sudionica u drugom setu edukacijskih modula. Hodogrami aktivnosti županijskih timova pokazali su da su sve županije (sudionice u evaluaciji) izradile Županijske slike zdravlja i Planove za zdravlje s jasno definiranim prioritetima i aktivnostima kojima ih namjeravaju riješiti. Rezultati evaluacije provedene 2012. godine, kao i rezultati evaluacije iz 2006. pokazuju da su Programom unaprijeđene javnozdravstvene kompetencije županija. Dvije županije uključene u Program tek 2007./2008. godine postigle su bolje rezultate od „starih“ (ranije uključenih) županija te time pokazale da vrijeme provedeno u programu nije ključni čimbenik uspješnosti projekta lokalno. Razlika u postignućima može se pripisati „institucionalnom ili osobnom kapacitetu za promjenu“ o kojem izvještavaju i drugi autori. Ovdje prikazani rezultati ukazuju na to da je razlika u postignućima u Programu među županijskim timovima bila uvjetovana sastavom tima i političkom stabilnosti lokalno. Programom su unaprijeđene sve temeljne javnozdravstvene funkcije u županijama sudionicama Programa. Funkciju osiguravanja sredstava najviše su unaprijedile županije uključene u oba seta edukacijskih modula. Županije imaju različit kapacitet za uvođenje promjene pa sudjelovanje u Programu nije kod svih polučilo jednako dobre rezultate. Razlike u razini postignuća između županija moguće je objasniti postojanjem (ili odsustvom) kontinuirane političke potpore na županijskoj razini, sastavom tima i predanošću njegovog voditelja.

The work, results, and thoughts of Andrija Štampar are recognized globally as a public health heritage (1). They encompass the vision of health as a state of overall well-being, society as the key responsible health care provider, and a set of values and guiding principles underlining the importance of optimal health. The reasons behind their adoption worldwide lie in the success of public health projects in Croatia (former Yugoslavia) in 1920s promoted by Zagreb School of Public Health (SPH) (later SPH A. Štampar), established in 1927. The key mission of the SPH was to develop further the public health practice and promote Štampar’s public health principles (2). Andrija Štampar’s principles (Box 1) advocate universal and widely understood values in different social contexts. Apart from their widely understood meaning, the principles also serve as a guideline for policy makers and governments to promote a just and fair society, equality, and equity (3). Whereas these principles illustrate the general determinants of health system organization in some societies, in Croatia they have been acclaimed and accepted in general as a comprehensive and best public health practice. In some way, we have kept the inherited Štampar principles and practice as a professional “dogma” and unquestionable public health business model.

There are various predictors of citizens’ satisfaction with health care system, but there are two main political factors: patient participation and institutional influence of their representative organizations, and political party affiliations (1-4). Some authors concluded that socio-demographic characteristics were only a minor predictor of satisfaction with health care system, but older age appeared to be one of the most consistent positive determinants of health care satisfaction (5-13). Women were found to be less satisfied with care than men because they were more frequent users of care and had higher expectations (14,15). Studies in post-communist states provide mixed evidence in this regard. In a 1991 cross-country survey study, most of the respondents believed that, while the market system was essential to economic development, policies that promoted social and economic egalitarianism were important (16). They also found that women, those with lower educational level, and those with lower income were more likely to be supportive of socialist principles. On the other hand, a study conducted in 1999 showed a change in value systems, with a majority of respondents from Poland and Hungary not favoring further redistribution of income, even at the expense of welfare (17). Furthermore, there was a positive correlation between education and positive attitude to health care competition. Still, in Hungary the older generations were predominantly against increases in health care competition. Since the early 1990s, the public level of satisfaction with the health care system reforms in Croatia has not matched the apparent success of the reform goals. A 1994 consumer survey found that a vast majority of lower- and middle-income Croats was skeptical of health care reforms (18). They attributed this to the legacy of universal access to health care, the view of health care access as a universal right, negative consequences on the patients, and lack of public understanding of the reforms. The same study (18) found the distribution of out-of-pocket payments and co-payment for health care to represent a regressive burden on those in the lower income group. Patient satisfaction was also low: 44% were dissatisfied with the quality of health facilities and 48% with the equipment (18). Similar face-to-face interviews found that citizens of Croatia did not hold a positive view of the health insurance reform (19). Their primary concern were limitations of their rights and the increase in the financial burden related to medical care. A 2005 survey found that during the presidential election campaign period health care was the second most important issue on the voters’ minds, closely following economy (20). Finally, a national survey on patients’ satisfaction with hospital and primary health care in 2006 showed considerable concerns with relations between patients and medical professionals, hospital accommodation, communication between primary and secondary health care, and corruption (21,22). In this study, we present and compare the results of a series of public opinions surveys conducted between 2005 and 2009. This is the first study that targeted public experiences and voters’ opinion as an evaluation of the health care sector in Croatia.

Objective To determine the progress in the development and implementation of health policies on a county level resulting from the learning-by-doing training provided through the County Public Health Capacity Building Program started in 2001 in Croatia. Methods Modular training using management tools, public health theory and practice, and SMDP's Healthy Plan-it™ tool, followed by the self-evaluation of the progress made by county teams in health needs assessment and health policy development, implementation, and assurance. Fifteen county teams consisting of politicians, executive officers, public health professionals, and community members. Results Twelve of 15 county teams completed the program. The teams made progress in the evaluated areas, although to a different extent, which did not depend on the amount of time they had or the governance experience. The differences in improvement depended on the differences in the strength of political, executive, and professional components of the teams. Teams with a strong political and/or executive component, but weak public health professional and community components made major improvements in policy development and/or assurance function, but performed less well in the health needs assessment and constituency building. The reversed was also true. Conclusion Learning-by-doing training program improved public health practices on a county level in Croatia.

Our study reviewed policies in 8 high-income countries (Australia, Canada, United States, Italy, Spain, United Kingdom, Croatia and Estonia) in Europe, Australasia and North America with regard to hospitals in rural or remote areas. We explored whether any specific policies on hospitals in rural or remote areas are in place, and, if not, how countries made sure that the population in remote or rural areas has access to acute inpatient services. We found that only one of the eight countries (Italy) had drawn up a national policy on hospitals in rural or remote areas. In the United States, although there is no singular comprehensive national plan or vision, federal levers have been used to promote access in rural or remote areas and provide context for state and local policy decisions. In Australia and Canada, intermittent policies have been developed at the sub-national level of states and provinces respectively. In those countries where access to hospital services in rural or remote areas is a concern, common challenges can be identified, including the financial sustainability of services, the importance of medical education and telemedicine and the provision of quick transport to more specialized services.

Croatia is a small central European country on the Balkan peninsula, with a population of approximately 4.3 million and a gross domestic product (GDP) of 62% of the European Union (EU) average (expressed in purchasing power parity; PPP) in 2012. On 1 July 2013, Croatia became the 28th Member State of the EU. Life expectancy at birth has been increasing steadily in Croatia (with a small decline in the years following the 1991 to 1995 War of Independence) but is still lower than the EU average. Prevalence of overweight and obesity in the population has increased during recent years and trends in physical inactivity are alarming. The Croatian Health Insurance Fund (CHIF), established in 1993, is the sole insurer in the mandatory health insurance (MHI) system that provides universal health coverage to the whole population. The ownership of secondary health care facilities is distributed between the State and the counties. The financial position of public hospitals is weak and recent reforms were aimed at improving this. The introduction of concessions in 2009 (public private partnerships whereby county governments organize tenders for the provision of specific primary health care services) allowed the counties to play a more active role in the organization, coordination and management of primary health care; most primary care practices have been privatized. The proportion of GDP spent on health by the Croatian government remains relatively low compared to western Europe, as does the per capita health expenditure. Although the share of public expenditure as a proportion of total health expenditure (THE) has been decreasing, at around 82% it is still relatively high, even by European standards. The main source of the CHIFs revenue is compulsory health insurance contributions, accounting for 76% of the total revenues of the CHIF, although only about a third of the population (active workers) is liable to pay full health care contributions. Although the breadth and scope of the MHI scheme are broad, patients must pay towards the costs of many goods and services, and the right to free health care services has been systematically reduced since 2003, although with exemptions for vulnerable population groups. Configuration of capital and human resources in the health care sector could be improved: for example, homes for the elderly and infirm persons operate close to maximum capacity; psychiatric care in the community is not well developed; and there are shortages of certain categories of medical professionals, including geographical imbalances. Little research is available on the policy process of health care reforms in Croatia. However, it seems that reforms often lack strategic foundations and or projections that could be analysed and scrutinized by the public, and evaluation of reform outcomes is lacking. The overall performance of the health care system seems to be good, given the amount of resources available. However, there is a lack of data to assess it properly.

U ruralnim područjima živi 47,6 % ukupnog stanovništva Hrvatske. Procjenjuje se da ima 1.485.647 članova poljoprivrednih kućanstava u koje ubrajamo pored radno aktivnih muškaraca i žena, djecu te starije i invalidne osobe. Na članove poljoprivrednih kućanstava ne primjenjuju se mjere i pravila sigurnosti za osiguranje njihove zaštite zdravlja, ni nadzor nad njihovom primjenom temeljem postojećih zakona jer nije zasnovan radni odnos. Broj ozljeda i profesionalnih bolesti se ne može utvrditi jer ne postoji obveza prijavljivanja. Cilj rada je utvrditi postojeće stanje zaštite zdravlja i sigurnosti članova poljoprivrednih kućanstava na području Požeško-slavonske županije, opasnosti i štetnosti koje se javljaju prilikom obavljanja poljoprivrednih poslova zbog uređivanja i donošenja specifičnih mjera i minimalnih uvjeta za zaštitu zdravlja i sigurnost kojima se mogu otkloniti i smanjiti ozljede te profesionalne bolesti. Upitnikom su prikupljeni podaci o članovima poljoprivrednih kućanstava, najčešćim ozljedama, profesionalnim bolestima, nošenju zaštitne opreme te uporabi pesticida. Istraživanje je provedeno na području Požeško-slavonske županije u razdoblju od veljače do travnja 2011. godine, a obuhvatilo je 164 ispitanika, od toga 104 žene (dobi od 18 do 83) i 60 muškaraca (od 18 do 93 godina). Ozljede prilikom obavljanja poljoprivrednih poslova zadobilo je 32 (19,5 %) ispitanika. Utvrđene ozljede klasificirane su kao lakše i teže, a otrovanje pesticidima zabilježeno je u 6 ispitanika (3,6 %). Zaštitnu opremu, uglavnom rukavice, nose njih 84 (51,2 %). Od ukupno 91 djeteta, njih 58 (63,7 %) obavlja poljoprivredne poslove u kućanstvima. Prikazani podaci o stanju zaštite zdravlja i sigurnosti upućuju na potrebu proširivanja istraživanja ruralnih područja RH te pristupanja uređivanju i donošenju mjera i pravila kojima bi se svim članovima poljoprivrednih kućanstava osigurali bolji uvjeti rada i zaštite zdravlja., In Croatia, 47.6% of the population lives in rural areas. It is estimated that the number of persons working in farm households is around 1,485,647 which includes labour-active male and female population, children, the elderly and disabled persons. Occupational safety measures and regulations are not enforced in the case of the farm households and their implementation cannot be controlled as the people are not officially employed. The exact number of injuries and professional diseases cannot be determined since there is no obligation of reporting. This research aims to describe the current status of health protection and safety in farm households as found in Požeško-slavonska County. The gathered information can be used to introduce specific minimum health protection and safety measures in agriculture intended to remove causes of injuries and occupational diseases. Using the HELS questionnaire data was collected regarding participants' health status, behaviour and perception of typical factors related to agriculture and rural life, most frequent injuries and occupational diseases, usage of protective equipment and methods of pesticides application. The research was conducted from February to April 2011 in Požeško-slavonska County. The research sample consisted of 164 participants, 104 women (aged 18 to 83) and 60 men (aged 18 to 93). Injuries were reported in 32 (19,5%) participants and categorised from minor to severe. Pesticide intoxication was reported in 6 (3,6%) participants. The questionnaire shows that protective equipment, mostly work gloves, is used by 84 (51,2%). Out of 91 children in families that participated in this research, 58 (63,7%) worked in agriculture. Presented results suggest the need for further research in rural areas of Croatia regarding health protection and safety of farm households and a need for securing the implementation of equal or at least minimum health and safety measures for all members of farm households.

Background and Purpose: The aimof this study is to evaluate the use of EriscssonMobileHealth (EMH) system for rural, distant, older, chronically ill patient monitoring in SisakMoslavina County in the region of ASSC. The aim is to evaluate quality, patient satisfaction, health care provider satisfaction with EMH system as well as possible obstacles and points for possible cost savings. Materials and Methods: The solution we tested is Ericsson Mobile Health (EMH), a mobile medical device of class IIa, composed of several components that include package for patient, server and applications. Package for patient includes several sensors depending on type of monitoring, communication device and expendable material. Package for patient consists of sensors for Pulse Oximetry (SaO2), Electro Cardio Graph (ECG), Peak Expiratory Flow (PEF) and Forced Expiratory Volume in 1 Second (FEV1), Blood Pressure (BP) and Blood Glucose Level. Communication device is central part of patient package. It collects sensor measurements available via Bluetooth interface and it sends themtowards server available viamobile network.Doctor access to server and browse through patient data using application for doctors. As amethod for evaluationwe used interviews with open-ended questions for both patients and medical personnel. Data were analyzed using qualitative conventional content analysis. Results: Common denominator in all interviews with patients was feeling of security and possibility of quick intervention if needed. Also, they felt they can substantially save on transportation. Medical personnel observed mainly technical objections regarding devices. As for benefits they recognized continuity of care, easy access to primary care, responsiveness to specific patients needs, in one visit field nurse can cover group of patients, and accurate data for decision making. Conclusion: EMHis adaptable and secure systemthat can reduce costs of health care in distant rural areas both for population and health care system. Direct link with primary health care provider contributes to the patient’s feeling of security.

This study examined individual and combined influence of smoking, physical inactivity, alcohol drinking, and unhealthy diet on total mortality. Relationship between individual and combined poor health behaviours and total mortality were examined using Cox proportional hazards regression. Out of 7490 individuals included in the study, during 5 years follow up 808 died. Adjusted hazard ratios (HRs), and 95% confidence intervals (95% CIs) for men with health behaviour scores 1, 2, 3, and 4 compared with those with score 0 were 1.67 (1.24-2.24), 2.28 (1.64-3.18), 2.24 (1.32-3.84), and 2.86 (0.77-11.70), respectively (p value for trend < 0.001). Adjusted HRs (95% CIs) for women with health behaviour scores 1, 2, and 3 compared with those with score 0 were 1.17 (0.97-1.42), 1.37 (1.02-1.86), and 1.20 (0.37-3.61), respectively (p value for trend = 0.04). A unit of the health behaviour score increased mortality risk equivalent to being 5.9 and 2.9 years older, for man and woman respectively.

The aim of this study is to identify factors that influence the success of the implementation of the primary and secondary prevention programs in Croatia by the visiting/community services. Two main sources of information were used: reports about regular visiting nurse services in Croatia and research about visiting nurse participation in the Croatian Adult Health Cohort Study (CroHort) 2008. Out of the total number 9, 070 respondents who participated in CAHS 2003 survey, during CroHort 2008 program 3, 229 (35.6%) participants were re-interviewed. The qualitative analysis was done with a sample of 34 visiting nurses, which participated in the CroHort 2008. Results show that there are three key problems which limit preventive programs: inability of the health care system to recognize the importance of the primary prevention ; visiting nurses’ lack capacity to implement prevention and populations’ lack of motivation and education.

Although decentralization is based on the simple idea that smaller organizations, properly structured and steered, are inherently more agile and accountable than larger organizations, in the health system this idea requires much more exploration (Saltman et al. 2007). Health systems are large and composed of several subsystems, including health care providers, health financing, and public administration. All of them have their own organizational patterns and values. Furthermore, inside each of them are further divisions, sometimes with almost opposite approaches: health promotion, disease prevention, clinical medicine, or palliative care. All of these subsystems and divisions could recognize decentralization as an opportunity or a threat.

Croatia has a long tradition of non-communicable disease prevention, but also obstacles to the implementation of preventive programs related to the general attenuation of public health and primary health care sector. The aim of this study was to determine trends in behavioral and biomedical risk factors and evaluate primary non-communicable disease and cardiovascular prevention. Physical inactivity was a leading risk factor with increasing trend and prevalence of 33.9% and 38.9% in men and women in 2008. In 2008, obesity was present in 26.1% and 34.1%, and hypertension in 65.8% and 59.7% of men and women. During the follow-up only smoking and alcohol consumption in men decreased significantly, while alcohol consumption and obesity in women, and hypertension in both sexes significantly increased. In the present situation, with the existing trends and environment it will not be possible to stop negative trends. Revitalization of public health activities and primary health care is essential.

Over the past decade, public opinion surveys have shown that Croats are deeply dissatisfied with their health care system and asses it to be one of the most important issues. However, health care hardly makes it into any political discourse in Croatia. This study analyzes the results of a public opinion survey conducted before the 2007 parliamentary elections to find out what the public sentiment on health care performance in Croatia is and to analyze the reasons why health care is not addressed by political actors. Evidence suggests that while health care is the most salient issue today, the public often understands it poorly. Thus, in a political environment of competing issues, and given the complexity of tacking health care in the policy arena, politicians strategically avoid discussing the issue.

The aim of this article was to identify parameters that determinate PCS and MCS values, and analyze 5-year changes in those values according to the age, sex and geographic region. Cohort of 3229 participants was obtained from the CAHS 2003-2008. Results revealed no statistically significant differences between same age group, sex, and different region regarding PCS and MCS. When chronic conditions were in the model difference was present, PCS being more influenced by all conditions but bronchial asthma. The strongest influence comes from musculoskeletal conditions; followed by weak heart. Values for PSC and MSC decreased in 2008 compared with 2003, but only in few cases decrease was statistically significant. Values of PCS and MCS are higher in men in all regions, but they show higher variability than woman. Our results support the findings that data obtained through SF-36 could be the useful for public health interventions regarding chronic diseases.

Nutritional habits between urban and rural population differ as much as life style and socioeconomic standards of these populations. In Croatia, rural populations are mostly live stock producers. Their nutrition frequently depends on their own production, which includes high quantity of cured meat products, eggs and dairy products. Data were obtained from longitudinal the Croatian Adult health Survey and pilot cross-sectional survey in three villages in Sisa~ko-moslava~ka county. Our findings show that there is no great difference between urban and rural population regarding salt intake. The difference is in the type of food and food preparation, as well as life style. We propose combination of more culturally and socially sensitive questionnaires along with analytical methods that include biological matrix, such as 24-hour urine collection.

Cardiovascular diseases are the leading cause of death in Croatia, with significant regional differences. Despite high mortality rates, high prevalence of various cardiovascular risk factors and well organized public health network, comprehensive system for cardiovascular disease monitoring and interventions does not exist. In this study we analyzed legislation framework and responsibilities of stakeholders relevant for cardiovascular disease surveillance and prevention. According to the international experiences we analyzed characteristics of cardiovascular disease prevention in Croatia and causes of the problems appeared in the preventive programs in Croatia. Analysis showed that primary problem is not inefficiency, but the existence of barriers in preventive activities definition, responsibilities distribution and task implementation. Main cause for such situation is incompatibility of the existing practices in clinical medicine and public health with recommendations from other countries. For the successful prevention of cardiovascular disease in Croatia at least three changes need to be made – define new terms and contents of prevention, define new responsibilities distribution and provide equity in health as basic criterion for successful preventive programs.

The article investigates availability and quality of drinking water along with possibilities of rainwater harvesting, as an element of sustainable development on four Croatian islands. Investigated islands, represent two main regions: northern and southern Adriatic coast. This division corresponds with gravity to two main macro regional centers on the coast and it is common in demographic, economic and sociological research. Data on local water resources, conditions and type of water supply, quality of water, prices, consumption of water, number and condition of cisterns and demographic records are collected and analyzed. Also, meteorological data on annual rainfall in past 26 years are collected and analyzed. Drinking water quality corresponds with Croatian law regarding physical and chemical parameters, while most of microbiological parameters are unacceptable. The results point out modest possibility of developing public water supply on islands. Average annual rainfall indicates that harvesting of rainwater should be integrated as additional water source on investigated islands which would save great quantities of the drinking water that are used as technical water and for the other purposes such as agriculture or forest fires. Also that would lower the household expenses for the water and diminish water crisis during the tourist season months. Natural water resources on Croatian islands are scarce and it is our ethical obligation to preserve them in favor of existing eco systems and long term exploitation.

Aim To explore the association between the social role and objective and subjective health measures and use of health care services in the population of women older than 65 years in Croatia. Methods We used the data from the 2003 Croatian Adult Health Survey (Short Form 36 Health Survey). Two sub-populations, retired women and housewives aged over 65 years, were analyzed and compared according to anthropometric measures, health self-assessment, utilization of health care services, and socioeconomic status. Results The final sample consisted of 791 housewives and 1151 retired women. Housewives had larger waist circumference (98.44 ± ; ; 13.9 vs 96.49 ± ; ; 13.5, P = 0.002, t test) and higher systolic blood pressure (152.88 ± ; ; 25.2 vs 147.79 ± ; ; 22.8, P

Aim: To investigate the importance of issues related to health care provision in the 2005 Presidential elections in Croatia. Methods: A computer randomized, two-stage stratified telephone survey of a 1000 respondents sample of the Croatian voting population was surveyed in December 2004, 5 days prior to Presidential elections. Respondents were asked to rank priority areas in politics and specific priority areas in health care. Only responses from those voters who identified the two most likely candidates were used in analysis: candidates Stipe Mesić and Jadranka Kosor (center left and center right political options). Results were analyzed with chi-square test and binary logistic regression. Results: Citizens ranked health care issues as their second most important priority in politics, preceded only by economic issues. Top three priority areas recognized in health care were organization (24.7%), financing (23.2%) and corruption (24.3%). Ranking of priority areas in health care varied insignificantly between left and right wing candidate voters. However, right wing oriented voters were more likely to identify lack of finances as the top health priority in the multivariable model (Odds ratios 2.21, 95% CI 1.25 - 3.89). There were no other differences between the two candidate groups. Conclusion: Health and health care ranked as the second most important issue in the list of general priorities in Croatia. The study recorded a strikingly high level of homogeneity between specific health care priority areas in the two groups of voters. The phenomenon might be attributed to the magnitude and importance of issues that burden the basic functioning of the health care system: poor organization, inadequate financing and corruption. Public opinion on health care priorities might be a useful tool in determining priorities for policymaking, especially in transitional health care systems undergoing reforms.

Udio osoba starije životne dobi u populaciji Republike Hrvatske u kontinuiranomu je porastu. Otprije poznate poteškoće razvijenih zemalja Zapada poput nedostatka zdravstvenih radnika u sustavu te njihove nedovoljne edukacije iz gerontologije i gerijatrije vode u nepripremljenost za specifi čne potrebe starijih, koje postaju značajan problem i u Hrvatskoj. Suočeni smo također i s nestankom obiteljskih zajednica koje su tradicionalno nosile velik dio tereta skrbi za starije. Primjena Programa utvrđivanja, praćenja i proučavanja zdravstvenih potreba i funkcionalne sposobnosti starijih osoba koji se provodi putem centara za gerontologiju županijskih zavoda za javno zdravstvo nužno je razvijati te unapređivati. Planiranje zdravstvene skrbi za osobe starije životne dobi treba biti dovoljno fl eksibilno da prepoznaje ključna društvena kretanja i razvojne procese te da im se prilagođava kako bi moglo adekvatno udovoljiti zdravstvenim potrebama starijih i u budućnosti. Moguća rješenja treba tražiti u već postojećim primjerima suradnje profesionalih skupina, javnoga i nevladinog sektora te na primjerima dobre prakse iz inozemstva. Rješenja treba temeljiti na “bottom up” pristupu, dovoljno osjetljivom da prepoznaje regionalne geografske, populacijske i gospodarske razlike kako bi se svima osigurala kvaliteta i pravednost u osiguranju zdravstvene skrbi. Preduvjeti uspješnog planiranja zdravstvene skrbi za starije uključuju kontinuirano praćenje pokazatelja, rad sa zajednicom te proaktivan pristup javnog sektora, prije svega zdravstvenoga i socijalnog, ali i gospodarstvenoga te mirovinskog i izobrazbenog sustava., The share of the elderly in the overall population of the Republic of Croatia has been continuously growing. The already known diffi culties that western countries have had to face, such as the insuffi cient number of health care providers and the inadequate education in gerontology and geriatrics, have led to the unpreparedness for special needs of elderly patients and have become a major problem in Croatia as well. We are also facing the disappearance of traditional families that were engaged in the care for the elderly to a large extent. The Programme for Defi nition, Monitoring and Studying of Health Needs and Functional Abilities of the Elderly, which is implemented by Centres for Gerontology of County Institutes of Public Health, should be developed and upgraded. The planning of geriatric health care should be suffi ciently fl exible to identify key social trends and development processes, adjust to them and thus be able to adequately meet the health requirements of the elderly in the future. Cooperation of professional associations, public sector and NGOs, as well as best practices applied abroad, should provide a good example. The solutions should be based on a bottom up approach, which is suffi ciently thorough to identify regional, geographical, demographic and economic differences and thus ensure quality and fair health care for everybody. The prerequisites for a successful planning of geriatric health care include the continuous monitoring of indicators, work in the community and the proactive approach of the public sector, primarily health care, social, economic, pension and education systems.