First published in ITIJ 138, July 2012
Roger St Pierre reveals how a devastated nation has turned its back on the past and once more become a major tourism draw, complete with a growing assistance industry and established health system
These are tough times for tourism globally, but Croatia has been one of very few bright spots. Recently announced government figures reveal that just a fraction under 10 million foreign tourists visited the Adriatic country last year, an eight-per-cent rise over the 2010 figure. Even domestic tourism was in growth mode, with a four-per-cent rise in numbers.
It’s reassuring to visitors that the country has a modern healthcare system, with visitors assured of equal treatment rights to those available to Croat citizens.
At the end of World War I, the notorious Versailles Treaty rang the death knell of Austro-Hungarian domination of the region and Croatia was lumped together with Serbia, its dominating neighbour, and Slovenia to form the new country of the Kingdom of Yugoslavia. Set in the Balkans, just across the Adriatic from Italy, the new nation shared language and ethnic background but was deeply divided by three religions – Eastern Orthodoxy, Roman Catholic and Islam. It was an uneasy alliance that all but shattered during the dark days of the Second World War. It took the strong leadership of wartime partisan leader Josip Broz Tito, who held power as president from 1945 to his death in May 1980, to pull things back together.
To maintain its independence from Moscow, Yugoslavia desperately needed foreign exchange and Tito, himself a Croat in a nation dominated by Serbs, wisely saw tourism as the
key to a rich treasure chest, with Croatia’s coast as the most powerful lure for those who would otherwise most likely holiday in the Italian Riviera or on the Spanish Costas. It worked well and through the 60s, 70s and 80s, Croatia’s resorts, with their good weather, great beaches and highly competitive pricing, attracted ever larger hordes of Western European package holidaymakers, with a particularly strong appeal to young families. Such success proved a double-edged sword.
Increasingly through the 1980s, Croats came to resent domination by the larger, more powerful Serb interests, who they believed were creaming off the benefits of Yugoslavia’s steadily improving economic status. Slovenia and the territories of Bosnia-Herzegovina, Montenegro and Macedonia were also experiencing the stirrings of nationalism whilst
Kosovo was changing its ethnic mix with a growing influx of immigrants from next-door Albania. Only the iron-strong personality of Marshall Tito held it together and in the decade following his death it all quickly unravelled, leading to the tragic and savage fighting that ripped Yugoslavia apart between 1991 and 1995 and during follow-up fighting as the various now disunited territories sought to establish their frontiers. The devastation – of infrastructure, property, the economy and lives – was cataclysmic.
"unexploded land mines still turn up in some remote areas, so it is important to stick to well-trodden footpaths"
Most observers, not least the peoples themselves, believed it would take many decades to bring life back to a semblance of normality, let alone to recapture the economic growth of earlier times.
But Croatia showed amazing resilience and whilst shell holes still peppered the ancient walls of Dubrovnik – ‘The Jewel of the Adriatic’ – the infrastructure was rapidly repaired and the visitors started flocking back. Anxious to maintain Croatia’s tourism momentum, the country’s new prime minister, Zoran Milanovic, who heads a four-party centre-left coalition, used his first TV interview, back in December, to announce plans for a reduction of VAT on tourism – slashing the rate from 23 per cent to 10 per cent.
Given its good climate, Croatia is a healthy place to live – as long as you take care on the roads. According to Department of Transport figures, in 2010, the latest year for which figures are available, there were 426 road deaths in Croatia. This equates to 9.6 traffic fatalities per 100,000 population – compared to a figure of 3.1 in the UK the same year.
There’s another particular hazard too: in the aftermath of war, unexploded land mines still turn up in some remote areas, so it is important to stick to well-trodden footpaths.
Croatia’s present universal healthcare system dates right back to the Hungarian-Croatian Parliament Act of 1891, which introduced mandatory health insurance for all factory workers and craftspeople. In 2010, the last year for which figures were available as we closed for press, some 6.9 per cent of national GDP was spent on healthcare, an eight-per-cent
decline over 2008, when 84 per cent of healthcare funding came from public sources. A reassuringly high standard of healthcare is available in Croatia however – with public sector provision still dominant as in other former Communist countries. Some 79 well-equipped hospitals and clinics, with a total 23,967 beds, deal with more than 700,000 patients annually.
These institutions can easily be found in cities and towns across the country – with 24-hour emergency treatment readily available – while GPs, first aid clinics and pharmacies are located even in relatively remote areas.
English is now understood by the majority of the population and virtually everyone working in healthcare speaks the international language well – a factor which, along with the sheer volume of foreign patients, has allowed international standards to be attained.
Croatian healthcare today accounts for around seven per cent of gross domestic product, close to 80 per cent of it coming from public sources. The state system employs 5,205 medical doctors, including 3,929 specialists. Altogether, some 41,271 people work across the healthcare sector, including those employed by the 6,379 private practice offices. Sixty-three emergency medical service units respond to more than a million calls annually.
While the facilities and the treatment the public hospitals provide are good, there are now severe budgetary constraints in place and some medicines are currently in short supply. Tourists will, in the vast majority of cases, be treated within the public health system. “It’s only a small minority of people, be they tourists or locals, who feel the need to go private
when it comes to healthcare, and that is usually for elective surgery, for such things as artroscopies, cholectstectomias and hernia repair,” comments Boris Hreckovski, president of the Croatian Urgent Medicine & Surgery Association, chairman of the ESTES Education Section and a general surgery and trauma care specialist at the Slavonski Brod general
hospital. “We are used to dealing with international insurers and assistance companies like ADAC and Europ Assistance and I don’t know of any major problems in the relationship, apart from the occasional hiccup,” he says, adding: “It generally runs smoothly though, of course, you can always improve things when it comes to making the process more efficient.”
Thanks to treaty arrangements, on production of a valid passport – European Health Insurance Cards not being valid in Croatia – European Union (EU) visitors are not billed for initial medical treatment. However, such patients will be charged 20 per cent of the costs for follow-up treatment, as are locals, though such charges will normally be recoverable under the patient’s own travel insurance policy. Others should expect to pay around 200HRK (€26) – in cash – for a routine medical visit. The major hospitals operated by the Croatian health
ministry are classified in five categories – there are three large clinical hospitals, all in Zagreb; five major medical centres, two of them in Zagreb; two large clinics, both in Zagreb; 22 smaller general hospitals serving communities across the country and 27 specialised hospitals, also dotted around the country. Renowned for its trauma care is the Zadar General
Hospital. Also notable are the Zagreb, Split, Osijek and Rijeka university hospitals, which have level one trauma centres, with systemisation currently being put in place, and the level two trauma centres at the general hospitals in Dubrovnik, Slavonski Brod, Varazdin and Zadar.
"smaller public hospitals ... still deem the assistance business as an intrusion on their usual practice"
Among the other better-known public sector facilities are Zagreb’s KB Merkur, which has 300 beds and employs 1,200 medical and support staff, and KB Sveti Duh, also in the capital, in the Cernomeric district, which has more than 600 beds. Private doctors, hospitals and clinics will usually require payment to be made up-front, in cash, with credit cards not accepted. Any charges accrued by public sector patients are charged at the end of treatment.
Air ambulance provision is comprehensive in Croatia. There is a contract between the Ministry of Defence and the Ministry of Health through which military helicopters are made available to provide a helicopter emergency medical service for the evacuation of civilian casualties. Islands, many of them occupied, are dotted all along the coast, attracting many tourists. They are well served with ambulances but have no hospitals so patients have to be transported to the mainland – by helicopter in the more serious cases. During the tourist season, additional ground ambulances are stationed on a 24-hour basis at major points along the highways while police personnel from Hungary, the Czech Republic and other neighbouring countries are seconded to help the local emergency services cope with higher volumes of traffic accidents. For patient repatriation out of the country and similar
air ambulance services, local service providers are joined by internationally known operators.
Hill walking holidays are increasingly popular in Croatia: “Unfortunately, that creates major problems, especially with Czech visitors, who have a very bad record because they tend to wander off into remote areas without proper preparation and equipment," comments Boris Hreckovski, adding, “Fortunately, the country has a very efficient and active mountain
rescue service.” Besides representative offices of major international assistance companies, Croatia has its own operators. During its 15 years of operations, Maribor-based
TBS Team 24 has amassed a premium selection of more than 1,300 technical and medical providers with which it works, while AP Companies, which has been providing medical assistance in Russia, the CIS and the Balkans since 1997, now operates worldwide.
Now a stable, thoroughly modernised country, set to become the 28th member of the European Union, Croatia seems set fair for a bright future, even in these tough times. Tourism and healthcare are both set to play a major role.