This chapter contextualises the current and pressing challenges of the long‑term care system in Croatia. It shows that the population is ageing fast and that long-term care needs are increasing. This chapter also discusses unmet needs.
Improving Long-Term Care in Croatia
OECD Health Policy Studies
1. Croatia has a fast ageing and vulnerable population
Abstract
This report uses data from SHARE Wave 6 (Börsch-Supan, 2020[1]) and 7 (Börsch-Supan, 2020[2]).1
In Croatia, the demand for long-term care (LTC) is set to increase, driven by population ageing. The household structure shows that most older people are living with, or close by, family members, reducing loneliness risks and indicating a potential supply of family carers. Older Croatians have one of the highest poverty rates among EU countries. Many do not have the income nor the wealth to pay for long-term care. In addition, the supply of health care received at home – which could help improve health in older ages and delay LTC needs – is already low and insufficient in Croatia, compared with most other EU countries.
Setting the scene: An ageing population and vulnerable population
The Croatian population is ageing quickly. The share of older people will continue to rise strongly in the next 30 years. By 2050, 31% and 11% of the population will be aged respectively over 65 years old and over 80 years old. The share of Croatians aged over 65 will be especially high compared with other European countries: it will rank in seventh position behind Greece, Portugal, Italy, Lithuania, Spain, and Latvia.
Health problems and disabilities are common at older ages. Croatia has made major progress in health in the last decades, achieving gains in life expectancy that places Croatia on par with many other EU countries, although below the EU average. The gender gap in life expectancy is persisting and stark, with women living six years longer than men. Not all additional years of life are lived in good health. After age 65, in Croatia, more than 70% (or 12.5 years) of years of life was lived with some health problems and disabilities, a share that was much higher than the EU average of 50% (or 10 years) in 2017 (OECD/European Observatory on Health Systems and Policies, 2019[3]).
Many Croatians would not have the income nor the wealth to pay for long-term care. A sizeable share of older people would be at considerable risk of poverty if they had to make out-of-pocket payments towards the costs of LTC. Almost 30% of older Croatians were below the poverty line in 2017, one of the highest shares among EU countries (Figure 1.1). Despite a high ownership rate, most of older people living alone cannot cash their house to pay for LTC services. In Croatia, about 65% of older people report owning their primary residence, but only 5% of older people living alone own their dwelling, based on the Survey of Health, Ageing and Retirement in Europe (SHARE).
Figure 1.1. The poverty rate among older Croatians is fifth highest in EU
Note: The indicator is defined as the share of persons with an equivalised disposable income below the poverty line, which is set at 60 % of the national median equivalised disposable income (after social transfers). The EU average is weighted.
Source: Eurostat Database (data refer to 2017).
Most older Croatians live with family members, but 30% live alone. Over half of older people live with a partner or with a partner and other relatives who can potentially provide family care. Almost 20% of older people live with other people than their partner – for example, their children. The remaining 30% of older people live alone in Croatia, a rate similar to the EU average.
Data suggests that families play a strong support role for older people in Croatia. About 17% of low-income older people lived in overcrowded dwelling in 2017. In comparison, it was 10% across EU countries, suggesting that many older Croatians live with children and other relatives for economic and long-term care reason. In 2017, 60% of widows lived alone, although this did not necessarily mean that they lived far away from family members. About one-third of widows living alone had at least one child that lived less than 5 kilometres from them.
When turning to the geographic distribution of older people, Zagreb and its surroundings counts the largest number of older people. In 2017, over 814 000 people were aged 65 years and over, of which slightly more than 200 000 people were aged 80 years and over. In Zagreb, the capital, there were almost 150 000 people aged over 65 in 2017 and in the surroundings of Zagreb, Zagrebacka, about 57 000 people. In the second biggest city’s province, Splitsko-dalmatinska, the number was about 85 000 people aged over 65. In contrast, in Licko-senjska, Pozesko-slavonska and Viroviticko-podravska, there were less than 15 000 people aged over 65.
However, the share of older people is slightly more concentrated in the southern coastal provinces: the share of older people is 25% in Licko-senjska and 24% in Sibensko-kninska. In comparison, the share of older people in Grad Zagreb is 19%. Overall, a sizeable share of older Croatians (38%) reported living in rural areas or villages.
As in all other EU countries, most older people are women. About 60% and 68% of people aged over 65 and 80 were women, respectively. While the shares among people aged 65 years and over were even across counties, those among people aged 80 years were less so. In Krapinsko-zagorska and Medimurska, the shares were at almost 75%, while they were only around 65% in Licko-senjska and Zadarska. Compared with men, older women are more likely to be lower educated, poor, to live alone and to be widowed.
The demand for long-term care: A substantial share of older people has needs
While there is no single best measurement of LTC needs, nor an internationally consensus on “gold standard” to measure LTC needs, they are typically measured by assessing whether an individual requires help with basic activities of daily living (ADL), such as dressing or showering, and instrumental activities of daily living (IADL), such as preparing hot meals or managing money.
In Croatia, 18% of older people reported at least one limitation in ADL, 29% at least one IADL limitation and 32% at least one ADL or IADL limitation in 2017, according to the Survey of Health, Ageing and Retirement in Europe (SHARE). Overall, these rates are slightly higher than the EU average but are within the range of rates of Central and Eastern European countries.
The share of older people reporting limitations differs across counties, although small sample sizes limit interpretation. The share of older Croatians reporting at least one limitation ranged from under 20% to about 40% in 2017 (Figure 1.2). It was higher in the North-East of the country, while the rates were often lower in the West. Bjelovarsko-bilogorska, Brodsko-posavska and Splitsko-dalmatinska stood out as the counties with the most vulnerable older people among the 15 counties where data were available for the health, social and economic dimensions of LTC needs.
Figure 1.2. Share of older people with at least ADL or IADL limitations
Note: Small sample sizes – caution is required.
Source: Survey of Health, Ageing and Retirement in Europe (data refer to 2017).
In Croatia, LTC limitations increase with age and older women report limitations more often than men. Almost 40% of older women report at least one ADL or IADL limitation, compared with 23% for older men, and the gender gap is larger than the EU average of 10 percentage points. Limitations increase strongly with age especially for women. Two thirds of women aged over 80 years old reported at least one ADL or IADL limitation in the Croatian microdata sample, a share well above the EU average.
Differences in the prevalence of LTC limitations exist also between socio-economic groups, whether measured by education, income, home ownership and wealth. For instance, among the 20% poorest older Croatians the rate of LTC limitation is 40%, compared with 27% for the richest 20%, based on SHARE data on income and ALD/IADL. The social dimension also matters when looking at LTC limitations. Over 35% of older people living alone reported at least one ADL or IADL limitation, compared with 25% for those living with a spouse or a partner in 2017.
Because not all ADL and IADL limitations translate into LTC needs, cases of low, moderate, and severe limitations were defined to approximate the general level of severity of LTC needs. About 21% of older people with limitations in daily activities reported severe limitations, 33% reported moderate limitations and 46% reported low limitations in 2017.
Low access to home health care for older people does not help preventing or delaying LTC needs
As health care needs and LTC needs are partly interlinked, health care provided at home can help prevent or delay LTC needs. Data from the European Union Statistics on Income and Living Conditions (EU-SILC) survey2 indicate that the supply of health care received at home is already low and insufficient in Croatia, compared with most other EU countries.
In 2018, about 69 700 older Croatians received home assistance from nurses, technicians and physiotherapists, a rate of 86 per 1 000 older people. Older beneficiaries of home health care are frequently bed-ridden. About 44% of them are immobile, 31% suffer from severe mobility limitations and 5% are considered as near the end of life. The geographic variation is large, ranging from less than 20 per 1 000 older people in Dubrovačko-neretvanska, Virovitičko-podravska, Šibensko-kninska and Grad Zagreb to about two hundred or over in Ličko-senjska, Varaždinska, Istarska and Osječko-baranjska.
Compared with most other EU countries, access to home health care is low. Only 18% of households with an older person used formal home care in 2016 (Figure 1.3). This rate was well below the EU average of 34% and other countries such as Hungary (29%) and Slovenia (34%).
Figure 1.3. About 18% of households with older people used home health care in Croatia
Note: The EU average is weighted by sample weights.
Source: EU-SILC (data refer to 2016).
The rates of home care use suggest there may be gaps in the availability of home care use for those in need in Croatia. Home care use ranges from 15% among households with a respondent aged between 65 to 79 years old to 23% among households with a respondent aged over 80 years old (Figure 1.4). However, this increase of home care use is small in comparison to the strong association between LTC needs and ageing. In comparison, 19 other EU countries have a larger difference of home care use between the two age groups.
Figure 1.4. The increase of the rate of home health care use as people age is small in Croatia
Note: The EU average is weighted by sample weights.
Source: EU-SILC (data refer to 2016).
Data on the rate of home care use by widowhood status seem to corroborate this suggestion. Being widowed is strongly associated with reporting LTC needs. Yet, the rate is only 16% for households with a married respondent and 18% for households with a widowed respondent in Croatia. In comparison, the average rates in the EU are respectively 25% and 40%. The gap in Croatia is smaller than in most other EU countries, suggesting again that the volume of home care use is lower across the board in Croatia.
Unmet medical needs among older people who report some or severe limitations in their daily activities is high. According to EU-SILC, about 7.3% of Croatians aged 65 years and over reported unmet medical needs in 2017, a level 1.6 times higher than for those aged 15 years old and over (3.1%) and much higher than the EU average of 3.6%. Unmet medical needs could have a knock-on effect on LTC needs, as chronic conditions are strongly associated with LTC needs. At 11%, the rate of unmet medical needs is even higher among those who report severe limitations in daily activities (Figure 1.5). The rate is similar in Slovenia, Hungary, and on par with the EU average.
Figure 1.5. Eleven percent of older Croatians with severe limitations in activities report unmet medical needs
Note: The EU average is weighted by sample weights.
Source: EU-SILC (data refer to 2017).
Distance to health care services and financial barriers are the main reasons for unmet medical needs among older people in Croatia. Among people reporting limitations, 50% of unmet medical needs are due to distance and over 20% are due to financial barriers in Croatia, although caution is needed because of small sample sizes. In comparison, most unmet medical needs across EU countries are first mainly due to financial barriers followed by waiting times.
Notes
← 1. This report uses data from SHARE Waves 6 and 7: 10.6103/SHARE.w1.710 (http://dx.doi.org/10.6103/SHARE.w1.710), 10.6103/SHARE.w2.710 (http://dx.doi.org/10.6103/SHARE.w2.710), 10.6103/SHARE.w3.710 (http://dx.doi.org/10.6103/SHARE.w3.710), 10.6103/SHARE.w4.710 (http://dx.doi.org/10.6103/SHARE.w4.710), 10.6103/SHARE.w5.710 (http://dx.doi.org/10.6103/SHARE.w5.710), 10.6103/SHARE.w6.710 (http://dx.doi.org/10.6103/SHARE.w6.710), 10.6103/SHARE.w7.711 (http://dx.doi.org/10.6103/SHARE.w7.711), 10.6103/SHARE.w8cabeta.001 (http://dx.doi.org/10.6103/SHARE.w8cabeta.001), see (Börsch-Supan et al., 2013[32]) for methodological details. The SHARE data collection has been funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812), FP7 (SHARE-PREP: GA N°211909, SHARE-LEAP: GA N°227822, SHARE M4: GA N°261982, DASISH: GA N°283646) and Horizon 2020 (SHARE-DEV3: GA N°676536, SHARE-COHESION: GA N°870628, SERISS: GA N°654221, SSHOC: GA N°823782) and by DG Employment, Social Affairs & Inclusion. Additional funding from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, the U.S. National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, OGHA_04-064, HHSN271201300071C) and from various national funding sources is gratefully acknowledged (see www.share-project.org).
← 2. The European Union Statistics on Income and Living Conditions (EU-SILC) is a survey carried out every year since 2005 across all EU countries and other European countries (Iceland, Norway, Switzerland and candidate countries to the EU), under the coordination of Eurostat. Every year, an ad-hoc module complements the main questionnaire to provide a more in-depth picture of one dimension (for example, well-being, housing conditions, material deprivation, children’s health, etc). The 2016 ad-hoc module focused on the access to various services, including health care services and formal home care.