The Croatian long-term care system is fragmented and public social support provides a lower coverage than in many other EU countries. Currently, Croatia does not have specific legislation on long-term care, nor a comprehensive system, but provides a range of social benefits and services for people with disability with different need assessments and eligibility criteria. These include two cash benefits (assistance and care allowance and personal disability allowance), as well as other in-kind services, namely home care services (home assistance allowance) and care in residential settings (nursing homes, family homes and foster families).
Overall, 5% of older people receive long-term care benefits at home, compared with 8% on average across 15 European countries with available data. At least 3% of older people lived in a residential care setting in Croatia in 2018, compared with an OECD average of around 4%. Even when considering LTC beds in hospitals, the overall rate of LTC beds remains lower than in most other EU countries. In contrast, about one-third of older people may have long-term care (LTC) needs, based on limitations in activity of daily living (ADL) and instrumental activities of daily living (IADL). This share is well above the EU average and there are large variations across the country.
The Croatian LTC system is underfunded. LTC expenditure is among the lowest in the EU as a share of GDP. In addition, benefits and services are based on strict eligibility criteria on income, limiting public support for home care and residential care. When those in need are entitled to public support, it covers only a fraction of the total costs, leaving individuals with high out-of-pocket expenditures, except in the case of institutional care. Those with moderate and severe needs at home are not sufficiently covered by public support and a large share of them risks living in poverty. Almost 30% of older Croatians are below the income poverty line, one of the highest rates among EU countries. Even though nearly two-thirds of older Croatians own their dwelling, options for selling assets to pay for long-term services are limited because only 5% of older people who live alone own their dwelling.
Family carers provide the bulk of care. According to a survey conducted by the OECD in Croatia in 2020, family carers are concentrated among women who provide support to their parents, in-laws, or spouses. Nearly 75% of carers are women and the mean age of carers is 62 years old. About 70% of carers do not work, of which close to 45% of carers are retired. An estimated half of carers live below the poverty line. Most carers provide help every day, and the rest mostly on a weekly basis: About 60% provide personal care, help with household chores and other types of (non-medical) care, amounting to a median of 45 hours of care per week. Caregiving takes a physical and mental toll on family carers. Family carers with care recipients who are not mobile or with advanced dementia have the heaviest burden.
Some avenues exist to strengthen LTC at home and in the community in Croatia:
Croatia should reform its social benefit framework to make it more coherent and less fragmented. To make the social benefit framework more coherent and less fragmented, Croatia should ensure a single entry-point for the provision of cash benefits and public services, based on one standardised need assessment. The current LTC provision generates inequalities across the country and leads to duplication. A gradation ladder of LTC needs with users of LTC placed on the ladder into tiers depending on the severity of their condition and receiving higher or lower benefits accordingly could be introduced. There is scope for more co-ordination and greater opportunities for more efficient use of resources. The Zaželi programme overlaps with home assistance (in-kind) benefits, especially in the remote areas in Slavonian counties and in the islands. Having a standard, nation-wide need assessment and clarifying eligibility criteria for this programme would help expand home care provision nationwide by co-ordinating entitlements across the different benefits. Similarly, Croatia has little control over how public LTC home spending is used, because cash benefits represent the bulk of home help. Additional requirements for the benefits could be considered, or, alternatively, the use of vouchers to ensure a broader coverage for long-term care.
Croatia should explore options to promote other care options and could leverage on wealth to finance LTC. To expand the offer and equity of the system, Croatia needs to incentivise the supply of services while looking at financing options. The need assessment and the gradation ladder would ensure that residential care capacity is used by people with the most severe LTC needs, provided Croatia expands public support to home LTC for people with moderate LTC needs. Foster care and family homes have the potential to be an alternative to LTC facilities for care recipients with moderate-to-severe LTC needs and could be further promoted. For the benefit, there could be stricter asset-testing and less stringent criteria on income, which could help expanding the coverage and the generosity of the provision. Croatia could also consider using the primary residence for asset-testing but, as cashing the value of primary residence is often difficult, deferred payment options through home equity programmes could be considered in parallel.
Croatia should revise the carer status for people with disability to cover people over 65 or introduce a new cash benefit to support further the family carers who provide LTC. The new cash benefit should compensate for the opportunity cost of family carers providing intense care, rather than offer a wage. In addition, the cash transfer should be combined with in-kind benefits (training and respite care). The amount of the cash benefit should be aligned with the current carer’s status for people with disability (which does not cover people over 65), the minimum wage, and the poverty line, to ensure decent living conditions and fairness with other carers.
