Citizens' Views on Health Insurance in Croatia
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43(4):417-424,2002 PUBLIC HEALTH Citizens’ Views on Health Insurance in Croatia Miroslav Mastilica, Sanja Babiæ-Bosanac Andrija Štampar School of Public Health, Zagreb University School of Medicine, Zagreb, Croatia Aim. To examine the citizens’ attitudes toward health insurance and its reform in Croatia, and their views on private payments for health care services. Method. In 1999 and 2000, we surveyed 500 randomly selected adults from all regions of Croatia, aged 40 years and over. The questionnaire included questions on social health insurance, private payments for health care, and back- ground information. The net response was 393 (79%). The analysis of the data collected included univariate and multivariate analyses to test the differences in the attitudes among sociodemographic and socioeconomic groups. Results. Most interviewed Croatian citizens (83.2%) expressed the opinion that everybody should have access to health care services, irrespective of the health insurance contributions. However, 32.1% agreed that the utilization of services should depend on the payment of contribution; 39.1% believed that the money they contributed to health in- surance corresponded to health care services they received; 60.1% agreed that insurance rate should increase propor- tionally to income. When asked about reforms, more than half (53.4%) thought that the current health insurance cov- ered less benefits than 10 years earlier, whereas more than a third believed that changes offered more choice (36.9%) but less equity (37.7%), and 46% disagreed with the introduction of the basic package of health care benefits and sup- plementary insurance. About the same percentage of respondents thought that they had already been paying too much for health care out of their own pockets. Conclusion. Citizens in Croatia do not hold a positive opinion on health insurance reform. They fear the changes would bring about limitations in their social rights and increase their financial burden. Key words: Croatia; financing, government; health care reform; insurance, health; public opinion Over the last 10 years, social health insurance in 2000. In that situation, only 33% of the population Croatia has been continually changed, arousing fur- paid insurance contributions or, in other words, one ther public, professional, and political debates on the insured person contributing to insurance fund cov- need for a more radical approach. Eventually, a new ered the insurance for himself of herself and two other strategy for the reform of the health care system and persons who did not pay contributions. health insurance was adopted (1). In the last decade, the health care reform in The government decided to change the social Croatia, as elsewhere in Europe (3-5), was very much health insurance primarily because of the increasing a response to the issue of how to contain health care health care expenditure and constant lack of re- costs in a situation of scarce resources (6-9). A num- sources for financing health care services. Health care ber of measures aimed at cost containment were in- expenditure (expenditure of the national health insur- troduced in the Croatian health care system over the ance fund) increased from 5.6 billion Croatian Kunas last 10 years, such as rationing of services, limitation (HRK) or US$1.1 billion (US$1=HRK5.2) in 1994 to of services provided, penalties for excessive over-pre- HRK14.0 billion (or US$2.69 billion, calculated in scribing or referrals, limited positive drug list, reduc- 1994 US$) in 2000, or 2.5 times in five years (2). tions in health care budgets, and increase in co-pay- According to the Croatian Institute for Health In- ments. However, they had limited success and gained surance, the only national health insurance fund, the little acceptance from both providers and the public main reason for the current deficit are the insufficient (10-13). contributions to the Fund. The number of insured em- Macro financial goals of health care reform in ployees (those who pay contributions) is decreasing Croatia suppressed the issues of the quality of health and the number of those who do not contribute to in- care services and their response to the needs and ex- surance (dependants, retired, unemployed, and so- pectations of consumers. The reform measures were cially vulnerable) is increasing. In 1990, there were mostly directed to the supply side (providers), and the 38 retired per 100 employed, and in 1999 there were demand side measures were not much pronounced, 74 retired per 100 employed persons (2). Unemploy- although they were directly or indirectly affecting the ment rate increased to 22% of active population in consumers. Thus, the growing reduction of public www.cmj.hr 417 Mastilica and Babiæ-Bosanac: Citizens‘ Views on Health Insurance in Croatia Croat Med J 2002;43:417-424 health care resources under the reforming health care household (address) from the initial address by standard random system, privatization and marketization of services, procedure. In each household, the respondent was drawn at ran- dom. The selected adults were face-to-face interviewed in their and increased cost sharing have been shifting a pro- homes by trained interviewers (medical students). The interviews portion of health care costs on to the health care us- took 15 minutes on average to be completed. The net response ers, with a significantly negative impact on low in- rate was 79%. Major reasons for non-response were absence come patients (14,15). from home and refusal to be interviewed due to lack of time. The new changes in the health insurance system The final sample consisted of 393 respondents, 39.2% men and 60.8% women, with the mean age of 51 years (±9.8 SD). in Croatia, primarily those aimed to restrict patients’ Most respondents (81.8%) were younger than 60 years, and rights and benefits and to increase private payments, 18.2% were aged 60 years and over. Majority were married are showing serious impact on the users of health care (76.5%), with a family of four persons on average. The average services. For that reason, it is important to analyze the education level of the respondents was secondary school. The views of the public on health insurance, to see how education distribution showed that 54.7% of the respondents had elementary or secondary education, and 45.3% higher educa- the new reform measures correspond to the needs tion. Most were employed (66.2%), and 25.2% were retired. The and expectations of the citizens. occupational status distribution showed that 30.2% were agricul- Our aim was to examine the citizens’ attitudes tural workers (farmers), unskilled, and skilled workers; 39.2% were routine non-manual employees in administration and com- toward reforms in health care and health insurance in merce; and 30.5% were professionals. The average family in- Croatia. Specifically, we wanted to assess the public come of the respondents was HRK4,000 (or US$500). To analyze opinion on health insurance contributions, changes the income group differences, the sample was divided into two in the health insurance, and the out-of-pocket pay- income groups. The low-income group comprised those with ments for health care services. We assumed that the family income of HRK5,000 (US$625) or less (49.6% of the re- spondents), and the medium-income group had income of people in Croatia, having enjoyed high and unlimited HRK5,001 or higher (50.4% of the respondents). Most respon- benefits of social health insurance for a long time and dents lived in urban areas (57.3%), 23.4% lived in semi-urban, having traditionally a strong perception of health care and 19.3% in rural areas. as a social good, “something you get for free”, did not The results on the citizens’ views on health insurance con- have positive attitudes towards the ongoing reforms, tributions, reforms, and out-of-pocket payments for health care which reduce public financing and health care bene- were analyzed by sex, age, education, income, occupation, and place of residence. To determine the statistical significance of the fits and significantly increase private payments for differences in the sociodemographic and socioeconomic categor- health care services and pharmaceuticals. We also ical groups, a chi-square test was used. analyzed views of different demographic and socio- To analyze the latent dimensions in the citizens’ views, the economic groups on health insurance contributions, principal component model of factor analysis with a VARIMAX health insurance reforms, and private payments for rotation was used. For this purpose, only the respondents who health care, assuming that differences in their opin- expressed positive opinion (“completely agree” or “mostly ions would be significant. agree”) or negative opinion (“mostly disagree” or “completely disagree”) to the given statements were included in the analysis. The answers to the statements included in the factor analysis Subjects and Methods ranged from “complete agreement” to “complete disagreement”. Differences between sex, age, education, income, occupation, Data were collected through a sample survey carried out in and place of residence were analyzed by comparing the mean 1999 and 2000 in all regions of Croatia. The questionnaire ap- values of the factor scores, using t-tests or analysis of variance plied in the study included originally constructed questions about (ANOVA). The statistical analysis was performed with the citizens’ views on compulsory health insurance and its reform. STATISTICA data analysis software system (Version 6; StatSoft Inc., It also included questions on direct payments for health care ser- Tulsa, OK, USA). vices and socio-demographic characteristics of the person surveyed. The respondents were asked to express their agreement or disagree- Results ment with the list of statements. The answers were based on a four- degree scale: “completely agree”, “mostly agree”, “mostly dis- Opinions on Contributions for Health Insurance agree”, and “completely disagree”.