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INTRODUCTION
‘Croatian Health Service Yearbook’ is based on the data
collected from the whole nation’s health system. The data
gives an insight into the Health Service’s organization and
human resource structure, operation and utilization of
health care facilities, as well as certain health status
indicators of the population. To present the health status
of Croatia’s population, we have selected some indicators
using both the WHO methodology, and comparable data on other
Central European countries. Since health care of the
population and its health do not solely depend on the
activity of the Health Service, they can not be considered
in isolation from demographic, economic and ecological
indicators, as well as population's educational structure.
Therefore, the present report also gives some demographic
and social characteristics of the country.
Demographic
and social characteristics
According to the Croatian Central Bureau of Statistics (CBS)
population estimate, for 2010 were 4,417,781 inhabitants.
Data of the first results of population census (published on
30 June 2011) show Croatia to have 4,465,096 people
recorded. Years of decline in the number of births, increase
in the mortality of younger age groups during the war and
negative migration trends of the last decade have influenced
the overall population trends. In 1991 Croatia entered a
depopulation stage. In 2010 Croatia had 43,361 births and
52,096 deaths, that is 8,735 more deaths than births.
Natality, mortality, and general fertility rates were
9.8/1,000, 11.8/1,000 and 42.2/1,000, respectively.
Croatia’s natural population increase rate was negative,
-2,0.
According to the Croatian Central Bureau of Statistics, life
expectancy at birth in Croatia in 2010 was 76.6 years for
both sexes, 79.6 years for women, 73.5 for men.
There were 192 infant deaths (4.4/1,000) in Croatia in 2010.
The most common causes of overall infant deaths were
pathologic conditions from perinatal period and congenital
malformations.
In total population, the leading causes of death in 2010
were circulatory diseases, due to which 25,631 people died
(580.18/100,000). They were followed by neoplasms,
responsible for 13,698 deaths (310,07/100,000). These two
disease groups accounted for three quarters of overall
causes of mortality. The remaining deaths were caused by
injuries and poisonings (67,18/100,000), diseases of the
digestive system (55.66/100,000), diseases of the
respiratory system (44.30/100,000) and other less common
causes.
In 2010, Croatia recorded 2,968 violent deaths. Among
accidents with a rate of 48.01/100,000, the leading were
deaths due to falls with a rate of 23.95/100,000. Suicides
had a rate of 17.59/100,000, murders 1.34/100,000. Violent
deaths were significantly less frequent in women (4%,
49.48/100,000) than men (7%, 86.17/100,000).
The principles
and organization of health care
The basic aim of health policy is not only extension of life
expectancy, but also the endeavor to improve the quality of
life. In addition to Health Service promotion and
development, this includes the promotion of healthier life
styles, reduction or elimination of preventable health
risks, and improvement of the quality of life of chronic and
disabled patients.
Facilities involved in health activities
are either state- or county-owned, or private. Teaching
hospitals, clinical hospital centers and state Institutes of
Public Health are state-owned. Health centers, polyclinics,
general and special hospitals, pharmacies, institutions for
emergency medical aid, home care institutions, and county
institutes of public health are county-owned.
During 2002 health centers began the process of merging due
to which their number was reduced from 120 in 2001 down to
49 in 2010. Out of 71 hospital institutions and sanitariums,
seven special hospitals and four sanitariums were privately
owned.
By the end of 2010, there were 6,223 private practice units
(doctors’ offices, laboratories, private pharmacies, private
physical therapy practices and home care services)
registered. Out of these, 2,561 were private doctors’
offices, 1,848 of which were rentals. There were 2,396
private dentists’ offices; out of these 948 were rentals.
Summary
By the end of 2010 Croatia’s health care had a permanent
work force of 72,207. Out of these, 54,873 were health
professionals and associates, 5,117 administrative and
12,217 technical staff. Structure wise, the most permanently
employed workers were of high school education (38.2%).
Administrative-tehnical staff had a 24.0% share, physicians
17.1% share in the work force.
As there were also additional 8,270 health professionals and
associates temporarily employed, 63,143 health professionals
and associates were employed in total on 31
December 2010 in health care in Croatia.
In 2010, by place of primary job, 9,178 out of the 12,341
permanently employed physicians worked in state health care
institutions, 606 in private health care institutions, and
2,557 in private doctors’ practices, out of which 1,884 in
rentals. Permanently employed medical doctors had a share of
60.1% women, and 66.9% specialists.
In addition to permanently employed physicians, by the end
of 2010, there were 945 additional part-time physicians.
By type of employing health institution, 57.5% of physicians
worked in hospitals, 10.0% in health centers, 15.3% in
rented doctors’ offices, 5.4% in private doctors’ practices,
and 4.6% in state health institutes. Other physicians worked
in private polyclinics as independent institutions and
health companies (4.9%) and emergency medical care stations
(1.5%).
Out of 3,121
dentists,
573 worked in state health institutions, 140 in private
health institutions, and 2,408 in private dentists’
practices. Out of the latter, 941 worked in rentals. 65.6%
of all dentists were women. 458 (14.7%) were specialists.
In addition to permanently employed, there were 210
additional part-time dentists.
By the end of 2010 there were 2,851 permanently employed
pharmacists, 1,115 of who worked in state institutions,
1,123 in private institutions, 613 in private pharmacies
(out of which 354 in rentals).
There were 35,223 health professionals with completed high
school or college employed in the health sector. Of these,
71% were nurses (25,000) including 1,553 midwives, which
meant there were 2.0 nurses per 1 permanently employed
physician.
Properly speaking, Croatian
Primary Health Care Service
consists of Pediatric Service and General/Family Medicine
Service. In the year 2010 Primary Health Care was conducted
in 2,540 teams seated on 2.544 locations (2.532 full-timers
and 12 part-timers). Out of all these, 1,505 were medical
specialists (1,072 specialists in general/family medicine,
255 specialists in pediatrics, 88 specialists in
occupational health, 71 school medicine specialists, and 19
specialists in other disciplines). As for the other health
professionals, there were 37 with college degree and 2,498
with high school education. Compared to 2009, the number of
teams and the number of medical specialists was higher in
2010. The number of different medical specialists in primary
health care increased by 0.7% in total (3.4% thereof refers
to family medicine specialists, but pediatricians,
occupational health, school medicine and other specialists
decreased by 0.4, 12%, 14% and 5% respectively. The number
of health professionals with college background was 24%
lower. The number of personnel with high school education
was 1% lower.
In 2010, Primary Health Care Service teams had 4,510,328
insurees in care. Out of these, 3,417,855 used health care
services (around 76% of total insurees count). The number of
insurees was higher and users lower than in 2009. In
family/general medicine 75.2% of insurees used health care
services in 2010, as did 82.3% in pediatric care (3% less
than in the previous year).
In 2010, there were 26,626,050 visits to doctors’ offices
(0.5% less than in 2009). Visits to other health
professionals in 2010 numbered 12,027,580 or 3% more than in
2009. The number of examinations at home in 2010 was 332,369
(2.5% more than in 2009).
In 2010, diseases and conditions diagnosed by
General/Family Medicine units numbered 10,217,165
(similar as in 2009).
Diseases of the respiratory system ranked first with
1,652,391 or 16% of total morbidity count. Cardiovascular
diseases still ranked second (1,273,119 or 12%). Diseases of
the musculoskeletal system and connective tissue ranked
third (1,111,466 or 11%). Other factors influencing health
status and contact with health service ranked fourth
(704,044 or 7%). Diseases of the urinary and reproductive
organs ranked fifth (627,857 or 6%), followed by mental and
behavioral disorders, skin and subcutaneous diseases,
endocrine, nutritional and metabolic diseases,symptoms,
signs and abnormal, clinical and laboratory findings, and
diseases of the digestive system.
In 2010 the Infant and Young Child Care Service
recorded 386,143 visits seeking preventive care. Out of
these, 175,208 were preventive visits by infants and 210,935
by preschool children. Of overall preventive visits by
infants, 173,039 related to systematic medical examinations
and pre-vaccination (4.0 per infant) and 2,169 to
counseling. Of 210,935 preventive visits by preschool
children, 198,253 related to preventive examinations and
12.682 to counseling.
According to the morbidity report in 2010, 1,019,164
diseases and conditions were registered in preschool
children and 270,851 in school children. The most frequent
diseases in preschool children were diseases of the
respiratory system (43,3%), infectious and parasitic
diseases (9.0%) and diseases of the ear (6.0%).The order of
the leading causes of morbidity in school age was:
respiratory diseases, 46.0%; infectious and parasitic
diseases, 8.9%;
symptoms, signs and abnormal clinical and laboratory
findings 7.4%.
General medical examinations of infants found undernutrition
in 1.7% and overnutrition in 3.6% of the examined cases. For
infants aged 0-2 months, the records show that 66.3% were
exclusively breast-fed (64.5% in 2009), 15.5% breast-fed
with formula (artificial diet) intake (16.3% in 2009),
whereas 13.3% were on the formula (13,4% in 2009). Feeding
method was unknown in 5.0% of the cases. After the first
three months, the share of infants fed exclusively with
mother’s milk fell to 45.9% in the group of infants under 6
months, and 15.9% at the age of 6-11 months. The use of
formula in combination with solid food increased
accordingly. In 81.6% of infants, general medical
examinations noted the administration of rickets
prophylaxis, in 11.1 % anemia prophylaxis. The signs of
rickets were evident in 0.1 % of infants. Most frequently
registered among the developmental disorders diagnosed at
general medical examinations of infants was retarded
psychomotoric development in 2.6% of the examined. Other
disorders were recorded in under 1% of the cases. General
medical examinations of preschool children showed
undernutrition in 1.4%, and overnutrition in 2.5% of the
examined. Caries (8.5%), dyslalia (3.4%), phymosis (2.3%),
musculoskeletal deformities of limbs (1.9 %) and strabism
(1.5%) were the most frequent patological conditions
diagnosed.
School doctors have been running preventive and specific
medical care of school children and youths as part of
public health institutes’ activity. In the school year
2010/11, this service had a work force of 177 teams, out of
them 141 were school medicine specialists, 19 school
medicine residents and 17 general practitioners.
According to systematic check-ups programme, in school year
2010/11 there were 44,039 pre‑enrollment medical
examinations, 41,699 in the fifth grade (94% coverage, in
the year before 90%). In the eighth grade of primary school
47,058 students were subjects to check-up and vocational
counseling (94% coverage). Systematic medical examination in
the first grade of secondary school covered 36,068 children
or 71% of the generation.
All children were covered by screening for vision and color
vision disorders in the third grade of primary school and
47.753 children in the sixth grade by screening for
developmental and structural deformities of the
musculoskeletal system.
In the school year 2010/11, there were 393,701 vaccinations
executed in primary and 41,591 in secondary schools (393,697
in primary and 41,597
in secondary schools in the previous year).
Special parts of preventive school health care are health
education and health counseling. Counseling centers for
children and adolescents are the places where children,
parents and teachers can seek for help in dealing with most
common health and growth problems. Number of visits to these
centers was growing consistently. The number of visits to
primary school counseling centers was 127,124 in the school
year 2010/11
(59.647 in the year 1998)
and 39,619 in secondary schools (18.196
in the year 1998).
In the school year 2010/11 257,222 primary school pupils and
77,407 secondary school students received health education
in some form. In addition, 75,431 parents and teachers in
primary schools and 10,122 in high schools took part in
health-related lectures, forums or workshops.
Occupational Health Service
had 173 full-time and 13 part-time teams employed in 2010,
with 179 occupational health specialists, 6 other
specialists, and 14 general medicine practitioners. In 2010
in Croatia there were 1,432,454 active insurees. Every team,
consequently, had, on average, 7,980 workers in their care.
In Croatia in 2010 there were 403,231 examinations done, out
of which 79.0% were preventive examinations of working
people. Preventive examinations rate was highest in the last
5 years (281.5/1,000). Periodic examination rate increased
from 88.9/1,000 in 2009 to 113.1/1,000 in 2010.
In the period from 1990 to 2010 2,973 occupational diseases
were reported. In 2010, 158 notifications of occupational
diseases were submitted. Total rate per 100,000 active
insurees in 2010 was 7.1 (2009: 7.4/100,000). By branch of
activity, the highest rate of occupational diseases was
recorded in manufacturing (22.2/100,000), followed by other
service activities (20.9/100,000), agriculture, forestry and
fishing (19.8/100,000), water supply, disposal of waste
water, waste management and environmental remediation
(9.0/100,000). The most common diagnoses reported in 2010
were asbestos dust-related lung disease
(47.5%),
skin diseases caused by substances confirmed to have an
allergic or irritating effect (12.9%) and diseases due to
the deleterious effects of vibration transmitted to the hand
(9.9%).
Croatian National Institute of Public Health (CNIPH)
recorded a total of 15,791 notifications of accidents at
work, which was 19.3% less than in 2009. The highest
share of all work accidents (75.8%), similarly as in the
previous years, happened at the workplace and 24.2% in
commuting. Croatia’s overall rate of work accidents in 2010
totaled 1,102.37 per 100,000 actively insured (2009 1,278.63
/100,000), whereas the rate of injuries at the workplace was
835.36/100,000 (2009: 974.82/100,000). By branch of
activity, the highest specific rates of injuries at the
workplace in 2010 were in water supply, disposal of waste
water, waste management and environmental remediation
(1,651.67/100.000), manufacturing industry
(1,450.31/100,000), and construction (1,160.99/ 100,000).
In 2010, 38 persons died due to work accidents. There were
35 persons (92.1%) fatally injured at the workplace and 3
(7.9%) in commuting. According to the fatal outcome of
injuries incurred at the workplace (including commuting
accidents), the average rate was 2.65/100,000 per 100,000
active insurees, more than in 2009 (2.46/100,000). According
to the fatal outcome of injuries incurred at the workplace
(excluding commuting accidents), the average rate was
2.44/100,000 per 100,000 active insurees, more than in 2009
(2.07/100,000), but significantly less than in 2008 and
2007 (3.81/100,000). The highest mortality (due to work
accident) was registered in construction; agriculture,
forestry&fishing; and manufacturing industry.
In 2010, in Women’s Health Care there were 1,534,621
women in the primary health care of gynecologists. Out of
the total women who selected their gynecologists in primary
health care, 631,660 or 41.1% used health services.
Full-time worked 219 teams and 21 teams worked part-time
under contract with the Croatian Institute for Health
Insurance (CIHI)) in 2010. Compared to 2009, the number of
full-time contracted teams and part-time teams decreased by
8. The numbers of non-contracted full-time and part-time
teams in private practices increased by 5.
In Women’s Health Care specially important are the care and
monitoring of pregnant women and women who gave birth. Every
pregnant woman was examined 8.5 times on average. The
numbers varied from county to county (from 5 to 12
examinations). Certain number of women, especially those
with high risk pregnancy or/and complications, received care
in specialist outpatient and hospital services. Compared
with the previous years, there was an increasing number of
pathologic pregnancies. In 2010 there were 57,975 such cases
(2009:26,404).
In 2010, were recorded 0.4% less visits for family planning
and/or prescribing contraceptives than in
2009.
The most common contraceptives prescribed were oral
contraceptives (75.5%) and intrauterine devices (12.9%).
In 2010 in Women’s Primary Care 486,581 preventive
examinations were reported (rate of 473,3. per 1,000 fertile
women), more than in 2009. (416.4 /1,000). There was a
decrease in the number of preventive breast examinations
(2010: 71.1/1,000; 2009:108.2/1,000 fertile women) probably
due to National breast screening programme. There was also a
decrease in the number of and Pap smears (2010:397.4/1,000;
2009:414.0 per 1,000 fertile women). The number of
pathologic test results was lower in preventive breast
examinations (2010:5.4%; 2009:6.0%), and in Pap smears
(8.0%) compared to 2009 (9.2%).
The most common groups of diseases and conditions causing
women to use primary health care in 2010 were the following:
diseases of the genitourinary system (48.4%), factors
influencing the health status and contact with health
services (26.6%), pregnancy, childbirth and the puerperium
(9.1%), infectious and parasitic diseases (8.0%), and
neoplasms (6.0%).
In 2010, Croatia’s Emergency Medical Service (EMS)
had 456 permanently employed physicians (increase by 4.6%
comparing to 2009). The EMS offices reported 1,025,980
interventions in 2010 (5.2% less than in 2009). They had
186,914 house calls (0.2% more than in the year before) and
68,914 field interventions (7.4% less than in the former
year). They carried out 542,461 medical transportations
(3.7% more than in 2009).
In 2010, Dental Care was conducted in the 1,748 teams
with 1,617 dental medicine teams, 52 preventive and
pediatric dentistry specialists teams and 79 other
specialists teams. In their care there were 3,890,514
insurees (1.4% more than in 2009), 1,363,217 of whom
actually used dental care (10% less than in 2009). In
addition, 658 teams without a contract with Croatian
Institute for Health Insurance provided the above mentioned
services as well: 596 dental medicine specialists, 13
specialists of preventive and pediatric dentistry and 49
other dentistry specialists.
During 2010, 4,122,185 visits to contractual (4.1% less than
in 2009) and 693,851 to non-contractual (10.3% more than in
2009) offices were recorded. Further, irrespectively to the
contracting status, 579,139 systematic examinations were
done (8.1% more than in 2009), 1,988,951 teeth were filled
(1.1% less than in 2009), 583,870 extracted (0.5% less than
in 2009), 251,772 dental prostheses were made (5.8% more
than in 2009) and 457,902 soft tissue treatments were
carried out (27.9% less than in 2009).
In Visiting Nurse Service in 2010 there were 838
nurses with college education (7.3% more than in 2009) and
123 nurses with high school education (9.6% less than in
2009). One nurse had an average of 4,693 insurees in care,
and in total, 1,414,578 visits were recorded in 2010 (7.3%
more than in 2009).
In Home Care Service in 2010 there were 107 nurses
with college education and 849 nurses with high school
education. One nurse had in average 4,718 insurees in care,
as well as 1,831 visits per year averagely (3.4% more than
in 2009).
During 2010, there were 7,747,116 specialist
examinations in outpatient services in Croatia, 1.5%
less than in 2009. Compared with 2000 when there was one
specialist examination per every 2.7 general medical
examinations, in 2005 the ratio worsened to one specialist
examination per 2.3 examinations, and in 2010 these trends
continued, as the ratio fell to one specialist examination
per 1.9 examinations in the general/family medical service.
CNIPH, according to legal regulations, collected data on
microbiological tests performed on human samples from
county Institutes of Public Health and other health
institutions (hospitals) in Croatia for 2010.
Croatian Committee for antibiotic resistance surveillance
of the Croatian Medical Sciences Academy, cooperating with
the Referral Center for Monitoring Bacterial Resistance to
Antibiotics at the Clinic for Infectious Diseases, regularly
monitors bacterial resistance to antibiotics in Croatia. In
2010, 37 laboratories collaborated in this monitoring
conducted in the time period from 1 October until
31 December, except for group-A streptococci (BHS-A),
anaerobial bacteria and schigellae that are monitored
continuously, given the low number of isolates.
Communicable diseases and immunization
Due to the importance that they have in every country, even
in the most developed ones, communicable diseases are one of
the health priorities. The same situation is in Croatia,
where monitoring, studying, prevention and control of
infectious diseases are regulated with various rules and
acts including: the Health Care Act, Act on the Protection
of the Population from Infectious Diseases, Ordinance on the
Reporting of Communicable Diseases, Mandatory Immunization,
Seroprophylaxis and Chemoprophylaxis Ordinance.
Prioritization of infectious diseases and their surveillance
was also emphasized in the newest EU legal acts (Croatia
being fully aligned), and even more accentuated by the
latest increased global threat of malicious use of
infectious agents including anthrax, smallpox etc., combined
with the appearance of new, or newly emerging diseases like
the recent new pandemic flu H1N12009pdm, or new arboviral
fevers transmitted by newly settled mosquitoes (Aedes
albopictus) owing to international traffic combined with
global warming, like chikungunya, dengue etc, which has
affected Croatia too in 2010.
In accordance to the above mentioned acts and ordinances,
the Service for Epidemiology of Communicable Diseases of the
CNIPH (which is the referral center for epidemiology of the
Ministry of Health as well, playing a role of the center for
diseases control and prevention (CDC)), acts as the central
information system for the reporting and monitoring of
infectious diseases and surveillance of the execution of the
most important preventive and antiepidemic measures
conducted by various health care system actors, from family
doctors to clinical hospitals, including specially skilled
and equipped Epidemiology (Hygiene-Epidemiology) Services
within Institutes of Public Health.
This publication contains the most important data and
indicators of the last year’s communicable diseases
situation in Croatia. These point to a favorable situation.
Among others, there can be marked a very low presence of
typhoid fever with only two imported cases registered in
2010, a very low prevalence of bacillary dysentery (40
cases), and hepatitis A (11 cases), all as a result of basic
hygiene and sanitary conditions improvements. There was a
relatively high level of salmonellosis morbidity but
decreasing in last ten years with the lowest figure in 2010
(2098) owing to complex preventive measures aimed to control
all possible sources in humans and animals (zoonosis).
Thanks to systematic vaccination, vaccine-preventable
diseases also showed a very satisfactory condition:
diphtheria – 0 cases, tetanus – 4, pertussis – 45, measles –
7, rubella – 1 (!), mumps – 40 and polio – 0 cases (same
state since 1989, eradication declared in 2002).
Tuberculosis incidence decreased further in 2010 being
lowest ever (768 cases or 17.3 o/oooo).
Venereal diseases: syphilis (18) gonorrhea (20) and AIDS
(19) exhibited a favorable, low, sporadic incidence. Owing
to systematic application of all preventive measures,
ranging from surveillance of human blood preparations to
health education since 1983, AIDS has been maintaining a low
level for 25 years (since the first appearance in 1986), one
of the lowest in Europe. Distribution of all AIDS patients
together (cumulative) by risk categories, showed the largest
proportion of homo/bisexual (males) and a relatively small
proportion of intravenous drug users. In the second largest
group (promiscuous heterosexuals) epidemiological history
indicated that over 90% of these patients were exposed to
infection outside Croatia, usually during a long-term stay
in some of the high HIV prevalence countries. Like in the
previous years, 2010 saw no new cases of hemophiliacs,
thanks to systematic safety control of blood preparations in
Croatia. The share of AIDS cases in the category “unknown”
remained rather low (3.4%) meaning that infection
transmission still remained within the known high-risk
groups, without “penetrating” into the general population.
This state can be maintained only if all scheduled
preventive measures are carried out, as well as additional
measures if necessary according to constant epidemiologic
analysis of this infection's movement.
The national program of mass immunization is one of the most
important and most successful preventive projects in the
country. Its fulfillment and implementation is obligatory
not only for citizens (vaccinees) but also for doctors
vaccinators, as well as for those responsible for funding
and organization. The Program is annually improved and
expanded on the basis of best practice experience. In 1999
hepatitis B vaccine for children aged 12 years was added, in
2002 Haemophilus influenzae type b vaccine for infants and
tetanus vaccine for 60-year-olds were introduced. In 2007
hepatitis B vaccine for infants was included.
The analysis of the vaccination coverage in 2010 showed that
it was very good. For all types of vaccinations, a legal
minimum coverage was fulfilled. However in case of tetanus (re)vaccination
of 60-year-olds, unsatisfying 60,3% coverage was achieved in
2010.Therefore, efforts are made to increase this coverage.
Vaccination coverage is monitored not only at national but
on county and sub-county levels, so gaps of low-vaccination
areas can be discovered and corrected. Such gaps could be a
dangerous prerequisite to potential outbreaks of currently
suppressed diseases.
It may be concluded that the communicable diseases situation
in Croatia has been fully equated with that of developed
countries of Europe and the world, this applying now also to
tuberculosis, showing decreasing trend but still asking for
a full implementation of all measures. The favorable
situation reached is, however, still unstable due to various
existing risk factors, thus depending on further systematic
work.
In 2010 bacteriological TB diagnostic was performed
in 14 laboratories, organized on three levels. Tested for
tuberculosis were 53,300 clinical samples and 4.3%
demonstrated mycobacteria. Among 2,712 isolated strains
M. tuberculosis remained dominant, with 2,283 (84,2%)
isolates. The share of nontuberculous mycobacteria (NTM)
among the isolated mycobacteria increased from 13.6 to
15.8%. And in 2010 no M. caprae or M.bovis
isolates were detected in clinical samples. Number of
patients with resistant tuberculosis has remained unchanged.
Of 2,283 isolated M. tuberculosis strains, 2,108
(92.3%) were sensitive, while 175 (7.7%) resistant to the
first-line antituberculotics. In 52.0% strains
monoresistance to first-line antituberculotics was detected.
The most common type of resistance registered was resistance
to isoniazid (H), with 28.6% isolates, and only in one
srtain (0.6%) resistance to rifampicin (R) was registered
with no resistance to ethambutol (E). In 30 patients
mycobacteriosis was verified. The most common causative
agents were
M. xenopi
and M. intracellulare, followed by M. chelonae,
M. fortuitum, M. avium, M. lentiflavum and
M. abscessus.
Inpatients
care
In 2010 there were 69 hospital institutions and treatment
centers in Croatia: 4 clinical hospital centers, 6 clinical
hospitals and clinics, 22 general hospitals, 26 special
hospitals and treatment centers,10 general wards and 1
out-of-hospital maternity ward.
In 2010, Croatian hospitals treated 745,692 people
(743,052 in 2009).
The care included hospital stays for childbirth, abortion,
and hospital rehabilitation.
According to individual reports on treated patients
(excluding childbirth, abortions and
rehabilitation), the number of patients
treated in Croatian hospitals in 2010 was 571,894 which was
less than in 2009
(611,368).
The number of beds
(expressed per 1,000 population)
in all hospital-type institutions in 2010 was 5.66
(in 2009 it was 5.40).
By bed structure per 1,000 inhabitants in 2010, there were
4.05 acute beds
(1.60 in general hospitals and 2.22
in teaching hospitals). For chronic patients,
1.62 beds per 1,000 inhabitants were available.
In Croatian hospitals, in 2010 there were 7,053,292 days of
hospital treatment. In other words, the average length of
treatment per stay was 9.46 days
(against the 1990 average length of
treatment of 15.37 days). Average length of
treatment in general hospitals has been reduced from 12.3
days in 1990 to 6.78 days in 2010. The average length of
stay in teaching hospital centers, teaching hospitals and
clinics was
reduced from 12.05 to 7.48 days and in special hospitals
from 34.83 to 25.54 days.
In 2010, general hospitals, hospital-type institutions and
out-of-hospital maternity wards had a turnover interval
(average number of days of bed
nonuse between two patients) of 2.23. In
teaching hospital centers, teaching hospitals and clinics
the interval was 2.26 days, in special hospitals 6.58 days.
The leading disease groups in inpatient care were diseases
of the circulatory system, neoplasms, diseases of the
digestive system, diseases of the respiratory system,
injury, poisoning and certain other consequences of external
causes and diseases of the genitourinary system.
Croatian hospitals generally admit more women than men
(1.04:1 ratio).
In female admissions in 2010, the most common diseases were
neoplasms, circulatory system diseases, genitourinary system
diseases, digestive system diseases and diseases of the
respiratory system.
In men treated in Croatian hospitals, the most common causes
of admission in 2010 were: circulatory system diseases,
neoplasms, digestive system diseases, mental and behavioral
disorders and diseases of the respiratory system.
There were 368,020 patients treated under the age of 64,
with the following most common reasons for admission:
neoplasms, mental and behavioral disorders, digestive system
diseases, respiratory system diseases and genitourinary
system diseases.
The number of patients aged 65 years and older treated in
Croatian hospitals
(excluding hospital rehabilitation)
in 2010 was 203,744
(35.6% of all treated patients).
The most common causes of hospitalization were:
cardiovascular diseases, neoplasms, digestive system
diseases, eye diseases and injury, poisoning and certain
other consequences of external causes.
Hospital day care and hospital
hemodialysis
According to individual reports on patients treated in the
day case units and outpatient hemodialysis units of
hospitals in 2010, there were 380,527 admissions recorded.
The leading disease groups in day case and outpatient
heamodialysis hospital care were diseases of genitourinary
system, neoplasms, diseases of the respiratory system,
mental and behavioral disorders and symptoms, signs and
abnormal clinical and laboratory findings.
Births and
abortions
In 2010, based on the individual childbirth reports,
Croatian maternity wards registered 42.694 deliveries with
43.419 total births. Out of these, 43.419 were liveborn, 210
stillborn. Out of the liveborn, 130 newborns died (113 in
the first 7 days of life).
Reflecting maternity wards, these figures differ from those
of the CBS. The latter, according to the UN and EUROSTAT
methodology, records children born by mothers residing in
Croatia and not having been absent from the country for more
than a year, as well as children born by mothers with no
permanent residence in Croatia, but present in Croatia for a
year or more. According to this source, in 2010 there were
43.361 live births in Croatia.
By age of mother, child deliveries were most common at the
age 25-29 (96,5 deliveries per 1,000 females of the same
age), followed by the age 30-34 (82,3 deliveries per 1,000
females of this age), and at the age 20-24 (54,9/1,000).
Most childbirths recorded were first births (49.2%), second
births accounted for 33.3%, third for 11.9%, and fourth or
higher 5.7%. Approx. 83% women had no previous abortions,
13.1% had one earlier abortion, and 4 % women had more than
one.
Of 42.694 deliveries, 42.001 were single-child births
(98.4%). In 663 births twins were delivered (1.6%). There
were 28 (0.07%) births of triplets and 2 delivey with
quadruplets. During pregnancy, labor or puerperium died four
women. Total maternal mortality rate (including direct and
indirect obstetric causes) was 9,22/100.000 liveborn.
Each pregnancy that does not end in childbirth is considered
an abortion and, as required by law, a notification
on a duly completed form is to be sent to the CNIPH.
Counted as pregnancies terminated by abortion are extra
uterine pregnancies, hydatidic mole, other abnormal products
of conception, spontaneous and medically induced abortions.
During 2010, notifications came in 10,150 abortions, which
constitutes a slight decrease compared to the previous
years. Among them, 4.043 (39,8%) were medically induced
abortions.
The count of spontaneous abortions was 1,413 (14.0%). Other
abortions (O00 extra uterine pregnancy, O01 hydatid mole,
O02 other abnormal conception products, O05 other abortions,
O06 unspecified abortions) counted 4,694 (46,2%). Within the
structure, these abortions registered a gradual increase.
Most of the women having had an medically induced abortion
were 30-39 years old. Among the women who demanded an
abortion, most had already had children (2.283 or 56,5% ),
and were in the 30-39 age group. This confirms the fact that
abortion is continually used as a contraceptive.
Chronic
diseases Registries
Croatian National Cancer Registry
was established in 1959 in the aim of collecting, managing
and analyzing cancer incidence data. Since 1994, the
Croatian National Cancer Registry has been a full member of
the International Association of Cancer Registries (IACR)
with the head office in Lyon, France, and is also a member
of the European Network of Cancer Registries (ENCR).
In 2009, 21,199 new cancer cases (11,483 males and 9,716
females) were diagnosed (invasive cancers excluding skin
cancer). The incidence rate was 477.7/100,000; 537.6/100,000
for men, and 422.1/100,000 for women.
Age-standardised incidence rates were highest in Međimurska
for men and in Zadarska County for women.
Ten most common cancer sites in males, making up 73% of
total incidence, were the trachea, bronchi and lungs (19%),
prostate (16%), colon (8%), urinary bladder (6%), rectum and
sigmoid (6%), stomach (5%), kidney (4%), pancreas (3%),
larynx (3%) and melanoma (3%).
In females, the 10 most common cancer sites were the breast
(25%), colon (8%), trachea, bronchi and lungs (7%), uterine
body (6%), rectum and sigmoid (5%), ovary, fallopian tube
and adnexa (5%), thyroid gland (4%), stomach (4%), uterine
cervix (4%), and pancreas (3%). These ten sites accounted
for 71% of total cancer incidence in females. Presented
jointly, colorectal cancer ranked third in men and second in
women, with proportions of 15% male and 13% female cancer
incidence.
Back in 1961, Croatian National Psychoses Registry
was established in the CNIPH. On the scale of causes of
hospitalization in Croatia in 2010, with a proportion of
7.2%, the mental disease and disorder group ranked seventh.
However, by number of hospital treatment days used, it was
the first, with a 23.6% share in total hospital treatment
days. In practical terms, it means that nearly every fourth
day of hospital treatment in Croatia was used to treat
mental diseases and disorders.
With 31.4%, schizophrenia ranked first in the mental disease
and disorder group, according to total hospital treatment
days.
In 1962 the highest number of the first time
hospital-treated schizophrenic patients was registered.
Although a portion of these had been hospitalized earlier,
they had not been registered until the establishment of the
Registry. In the subsequent period the age-standardized rate
of hospital incidence of schizophrenia did not exhibit any
major change, accounting on average for 0.26/1,000
inhabitants over 15. Evident was an increase in admitted and
discharged schizophrenic patients, as well as in the number
of admissions and discharges. The ratio of admissions to
admitted patients, and discharges to discharged patients
grew accordingly. Hospitalizations were more frequent, but
mainly shorter, with shorter total time spent in the
hospital. Also the decline in the number of yearlong treated
patients was observed.
This situation was the result of an improved treatment and
psychiatric care of schizophrenics by using higher-intensity
therapeutic programs, rehabilitation programs, outpatient
monitoring and treatment, which at the same time constitutes
an improvement in the patient's quality of life.
The number of committed suicides has been
oscillating over the years, as did rates per 100,000
population, with a declining trend started in 1999. In last
decade the lowest number of suicides was registered in 1995
(930 suicides, rate of 19.4/100,000), and in the period
2000-2010 (926 suicides, rate of 20.9 in 2000; 777 suicides,
rate of 17.5 in 2010). The ratio between the sexes ranged
between 2.2 and 3.6:1 for men.
CNIPH has collected all information in the health system on
individuals treated for psychoactive drug use since 1978 in
the form of the Registry of Treated Psychoactive Drug
Addicts. In 2010, Croatian health institutions
registered 7,550 persons treated for psychoactive drug
dependency. Of these, nearly every tenth person (507 or
6.7%) was under 20. Most of the treated (2,038 persons,
27.0%) belonged to the 30-34 age group. With 81.8% (6,175
persons treated), opiate addiction was the predominant
addiction. This high proportion of drug addicts treated for
opiates was partly due to methadone maintenance and
buprenorfin as a method of treatment. During 2010, marijuana
(cannabis) was the leading drug in 11.4% of the cases. The
mean age of first consumption of cannabinoids was 16.3
years. The rates of treated persons per 100,000 inhabitants
aged 15-64 by county demonstrated that the drug abuse
problem was still most prominent in Istria County, followed
by Zadar County, Sibensko-kninska County,
Dubrovačko-neretvanska, the City of Zagreb,
Splitsko-dalmatinska County and Primorsko-goranska County.
The rate for the whole of Croatia was 206.7.
The system of outpatient treatment of drug addicts in
Croatia is organized through services for addiction
prevention and outpatient treatment based at county public
health institutes. Consequently, a high quality network has
been achieved to cover well the entire territory of Croatia,
providing psychoactive drug addicts, consumers and
experimenters with high quality services. In the previous
year all Croatian services for addiction prevention and
outpatient treatment had a total of 74,801 visits (74,060 in
2009), which averaged 6,233 visits per service (6.171 in
2009). Most visits were registered in the City of Zagreb
with 19,841 visits
(18.209 in 2009.),
Istria County numbering 7.564 visits
(7.513 in 2009),
Primorje-Gorski Kotar with
7.177
visits
(5.968 in 2009.) and
Splitsko-dalmatinska County with 7.087 visits (9.064 in 2009.).
On a monthly basis, a total of
6.095
persons
(5.950 persons in 2009.)
required help from one of the services. Most of these 6.095
visits took place – an average of 508 persons monthly (496
in 2009.). The City of Zagreb is leading with
1,391 persons
and Split-Dalmatia County (1.037), Istria County (826),
Primorsko-goranska County (615) and Zadar County with 554
persons.
Croatian Disabilities Registry
was established in 2002. Access to reliable data about
disability is a postulate for the planning of adequate
health measures and programs for disabled persons. Having
recognized the problem, Croatia passed the National
Disabilities Registry Act (OG 64/01), that regulates the
manner of collection, analysis and confidentiality of the
data. The Registry is managed by the CNIPH.
For the purposes of the Registry the data are collected
from:
·
Health care system
·
Social welfare system
·
Educational system
·
Ministry of Family, Veterans’ Affairs and Intergenerational
Solidarity
·
Croatian Pension Insurance Institute
·
Ministry of Health and Social Welfare
By 30 September 2011, the Disabilities Registry collected
978,818 individual reports for 525,312 disabled persons.
Croatian National Diabetes Registry was established in 2000 with the aim of improving health care of
persons with diabetes mellitus, assessing the prevalence and
incidence of diabetes mellitus and its acute and chronic
complications, monitoring morbidity, mortality and other
clinical care quality indicators on a national level. Since
2004, registration has been mandatory for all general
practitioners and hospital physicians treating persons with
diabetes mellitus. The overall number of patients registered
in the CroDiab registry is 110,804, while in 2010
registrations were collected for 35,643 patients.There were
6.17% of patients with type 1 diabetes, 91.93% with type 2
and 0.95% of those with other specific types of diabetes
mellitus. With oral antidiabetic agents 52.99% patients were
treated, 17,95% with oral antidiabetics and insulin, 27.20%
with insulin alone, while 1.94% of patients were treated
only with diet and physical activity. Glycemic regulation
was good (HbA1c<6.5%) in 26.59% of cases, intermediate (6.5
%< HbA1c<7.5%) in 33.80% and poor (HbA1c>7.5%) in 39.61% of
patients with average value (mean±standard deviation) of
HbA1c being 7.38±1.42, fasting glucose 9.51±3.14, and
postprandial glucose 12.06±4.25.
Morbidity and causes of death in the elderly population
Like most European countries, Croatia belongs among the
countries with an exceedingly aged population. According to
a population estimate made by the Central Bureau of
Statistics (CBS), in mid 2010 Croatia had 762,290
inhabitants aged 65 or older (17.3%).
According to primary health care reports from 2010, the
established number of diseases and conditions registered in
general/family medicine was 3,245,287 or 31.8%. Most common
groups of registered diseases and conditions in the elderly
proved to be the same as in 2009: diseases of the
circulatory system (with a share of 21.9%), musculoskeletal
system and connective tissue (12.1%) and diseases of the
respiratory system (7.9%).
The share of hospitalizations at the age of 65+ in 2010
(excluding hospital rehabilitation) was 35.6% of overall
treatment cases in Croatian hospitals (34.9% in 2009). The
number of 203,744 hospitalization cases involving persons
aged 65+ (rate of 267.3/1,000) totaled 2,311,020 days of
hospital treatment. An average duration of treatment per
stay was 11.3 as in 2009. The leading disease groups as
cause of hospitalization in the elderly were: diseases of
the circulatory system (67.4/1,000), neoplasms (44.2/1,000),
diseases of the digestive system (23.5/1,000), diseases of
the eye and adnexa (23.3/1,000), respiratory diseases
(16.8/1,000) and injuries, poisonings and other sequelae of
external causes (17.6/1,000).
Day hospitals and hospital hemodialyses in 2010 saw 151,446
persons aged 65+ (100.708 in 2009), whereof 75,688 men and
75,758 women. According to individual patient reports, the
most common causes of hospitalization were: diseases of the
genitourinary system (137.93/1,000), neoplasms
(28.87/1,000), diseases of the circulatory (7.15/1,000) and
respiratory systems (5.90/1,000), as well as symptoms, signs
and abnormal clinical and laboratory test results not
elsewhere classified (4.44/1,000).
According to the CBS death statistics, in 2010 a total of
41,670 persons aged 65+ died, with a mortality rate of
54.7/1,000. At the age of 65+, most people died of
circulatory diseases, evidenced by the rate of 29.9/1,000
(33.3/1,000 in 2009). Ranking second on the cause of death
list were neoplasms with a rate of 12.6/1,000 (12.5/1,000 in
2009), followed by respiratory diseases with a rate of
2.3/1,000 (2.6/1,000 in 2009), diseases of the digestive
system at 2.1/1,000 (2.1/1000 in 2009) and, finally,
injuries, poisonings and other sequelae of external causes
at 2.1/1,000 (2/1,000 in 2009).
In year 2010, a total of 1,603 violent deaths were
documented at the age of 65+ (rate of 2.1/1,000), whereof
1,276 were caused by accident (1.7/1,000), 284 suicide
(0.4/1,000), 14 murder and 29 by other causes. Over one half
of all fatalities caused by accident in 2010 were a result
of a fall – namely, 931 persons (1.2/1,000).
Environmental Health
Service
As a part of monitoring the Croatian population’s
nutritional status and quality of diet, an analyses of
nutritional status of school children aged between 7 and 14
years in the period 2005 -2010 was performed. The data
obtained from systematic medical examinations consisted of
proportion of children with body weight/body height ratio
over 90. centile (BW/BH>90c) and below 10. centile (BW/BH<10c)
of the distribution. A trend of increase in proportion of
children with BW/BH>90c was observed, with significant
differences between counties. Such trend of increase in the
proportion of the examined boys and girls with BW/BH>90c
during the five-year period is particularly notable in
Vukovar-Srijem County. In 2005/2006. proportion of boys with
BW/BH>90c in Vukovar –Srijem County was lower than the
Croatian average (9.2% compared to 11.7%), whereas in
2009/2010. the percentage raised to 22.3%, which is
considerably higher than Croatian average (14%) in the same
period. A similar trend is noted in girls, where at the
beginning of the period 10.7% of grils had BW/BH>90
(Croatian average 11%), whereas in the last year
(2009/2010) of observed period it reached 19.4% (Croatian
average 12.3%). Counties following such unfavorable trend of
increasing share of overweight children are
Bjelovar-Bilogora (19.6% boys, 18.1% girls), Varaždin (16.5%
boys, 14.9% grils), Osijek-Baranja (16.4% boys, 16% girls)
and Požega–Slavonija County (15.8% boys, 15,1% girls). In
Brod-Posavina County there were 14% of examined girls with
BW/BH>90c (Croatian average 12.3%). Counties in which the
proportion of examined children (boys and girls) with BW/BH>90c
is less than 10% are Lika-Senj (9.2% boys, 9.8% girls),
Zadar (9.8% boys, 8.1% girls), Šibenik-Knin (9.9% boys, 9.5%
girls) and Koprivnica-Križevci County (4.7% boys, 5.2%
girls).
Counties in western and southeren Croatia have mostly lower
proportion of children with BW/BH>90c compared to Croatian
average. The exception is the Dubrovnik-Neretva County,
where it is higher than the Croatian average (15.4% and
14.1% compared to 14% and 12.3%).The share of boys with BW/BH>90c
in Split-Dalmacija County corresponds to the Croatian
average (14%), while the proportion of girls is slightly
lower (10.7% compared to 12.3%).
The data about the quality of diet of
fifth-to-seventh-graders in monitored primary schools,
showed the satisfactory intake of energy, proteins, fats and
carbohydrates, as well as the share of these nutrients in
the overall energy content for both surveyed periods.
Average data for the period 2005-2010 compared to the data
from the previos five year period show an increased intake
of vitamin A, C and vitamin B2, calcium and iron. It could
be explained by improving children’s diet due to increased
consumption of fruit, vegetables, milk and milk products in
school meals.
The health safety monitoring system for foods and objects
of common use is based on the obligation of laboratories
authorized for examining their health safety to submit
quarterly reports to the CNIPH. These have to specify the
number and type of samples covered and final analytical
results.
Among food samples examined microbiologically in the
authorized laboratories which submitted their reports for
2010, 31,875 samples were of domestic origin. Among them
2,369 or 7.43% (7.23% in 2009) were found microbiologically
unsafe. Out of the 2,498 analyzed imported samples, 24 or
0.96% (2.16% in 2009) were unsafe. Out of the institutes’
total microbiologically examined samples in 2010 (34,373),
there were 2,393 ( 6.96%) unsafe samples (6.81% in 2009).
The most common cause of microbiological incompliance in
terms of hygienic unsafety was finding of increased total
counts of aerobic mesophilic bacteria, enterobacteria,
Escerichia coli, yeasts and molds higher than their
respective values recommended by Guide on microbiological
criteria for food (Ministry of Agriculture, Fisheries and
Rural Development, 2011). Detection of Salmonella spp.
and Listeria monocytogenes in analyzed food samples
was the cause of microbiological food unsafety according the
provisions of Regulation on microbiological criteria for
food (OG 74/08, 156/08, 89/10).
All authorized laboratories that submitted their reports in
2009 had jointly chemically examined 14,669 food samples of
domestic origin, whereof 522 (3,56%) were unsafe. At the
same time, 5,993 imported samples were examined, out of
which 282 (4,71%) were rejected. This adds up to 20,662
examined samples, whereof 804 (3,89%) were unsafe.
As to chemical parameters, the most common causes of
unsafety were incorrect labeling, inappropriate sensory
properties due to chemical changes, levels of artificial
sweeteners and other additives (preservatives, organic
colourings and others), pesticides, heavy metals and
mycotoxins above allowed limits, and iodine in salt below
allowed limits. Furthermore, a proportion of analyzed food
samples was not in compliance with the legal provisions
regulating genetically modified organisms and products.
In 2010, all authorized institutions examined
microbiologically a total of 1,442 samples of objects of
common use (989 domestic and 453 imported). Of these, 34
(2.36%) were unsafe (2.02% domestic samples and 3.09%
imported samples). A total of 6,085 samples (2,741 domestic
and 3,344 imported) of objects of common use were assayed
chemically, with 396 or 6.51% (6.2% domestic and 6.76%
imported) declared unsafe.
The data for the period 1990-2010 reveal considerable annual
variation in the number of food and object of common use
samples assayed. A decrease in the number of
microbiologically and chemically analyzed food samples as
well as decrease in the number of microbiologically and
chemically examined samples of objects of common was
registered in 2010 in reference to previous year.
Public water supply systems accounted for about 80% of the
national supply with drinking water. The County of
Bjelovar-Bilogora reported the lowest (ca. 34%) and
Primorje-Gorski Kotar County the highest percentage (ca.
97%) of water supply.
Physical properties of water, presence of nitrogen salts,
iron or manganese, and increased levels of total organic
matter in terms of KMnO4 consumption were found
to be the main causes of chemical unsafety of drinking water
in 2010. |
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