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Croatia - Country report |
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Demographic data. The total number of inhabitants of the Republic of Croatia in 2001 was 4.437.460. In 2002 year 50.569 persons died. The leading cause of death were circulatory diseases (26.698), malignant diseases (12.1579) the rest being various incidents: suicides (875), traffic accidents (639) and other diseases. Only 21,7% of the inhabitants completed primary education, and 7,85% completed higher education. The registered unemployment rate in 2002 was 22,3%. The number of retired people in 2003 was 1.014.381, their average income being 1.610,74 kn. (220,65 Euro) per month. Old attitudes in oncology and primary care institutions. Introducing palliative care was attempted already in the 1970's at the Institute for Oncology in Zagreb and repeated attempts occurred in the 1980's at the Medical Faculty in Zagreb. There were no successful results because of the general attitude «we are doing all that is recommended and we do not need any further improvement». Organising the hospice movement in Croatia In 1994 the First Symposium on Hospice and Palliative Care was organized in Zagreb and as a result the Croatian Society for Hospice/Palliative Care was founded as part of the Croatian Medical Association. The initiator and organizer of both events, Anica Jušic, was elected president of the society. Different symposia, conferences and various training courses were organised with the participation of guest speakers from England, Poland, Germany, Italy, Hungary, USA, Canada with the valuable financial help received from the Open Society Institute (OSI) in New York. The members of the newly founded "Society" went abroad for training courses and professional meetings to England, Poland, USA, Canada, mostly with the help and generous support of the OSI – Kathleen Foley and Mary Callaway. In 1999 practical activities were started by interdisciplinary teams. The Croatian Association of Hospice Friends was founded by Anica Jušic as the logistic support for the Croatian Society for Hospice/Palliative Care (CMA) as an independent legal unit with its own bank account. Training courses for hospice volunteers were organised, and the first interdisciplinary hospice visits were effectuated in December 1999. The visits to «Centar», the home for the retired and the sick, started as home care visits and spread its activities even to the children's hospital. At the beginning the private flat of the president in Zagreb was the centre of activities, weekly supervisions and deposit for aids and medicine. In 2002 the City health government rented a 90m2 office space (the former laundry of the Public Health Center in Maksimir) for the Society. The Regional Hospice Centre in Zagreb was founded in 2002 with the support of the Ministry of Health. A 90m2 was rented, the former laundry room of the Public Health Center in Maksimir, to host the Hospice Home Care Services Centre and provide a place for supervision, professional meetings and further trainings. The main activities have been: providing home care services, consulting, and supplying necessary aids. The first home visits have been effectuated mostly by two members of the team – a physician and a nurse/social worker who assessed the needs of the patient and his/her family. The additional members of the interdisciplinary team or voluntary medical consultants have been involved depending on the actual situation and arising problems. Necessary aids have been supplied as well: electronically directed beds, oxygenator, patient controlled subcutenous infusions etc. The only full time employees are the administrator and the social worker who coordinate the volunteers. They organize the team transfer according to the availability of volunteers engaged in a full-time job elsewhere beside performing family duties. Volunteers need to take a day off in order to participate at training courses on palliative care, and/or must make up for the missed hours at their full-time job. Participants have to work twice as much at their return from the training course instead of elaborating their newly acquired knowledge. In 2000 we provided care for 45 patients and their families. In 2004 this number reached a turn-up of 291 patients. During the last five years we cared for a total of 725 patients and their families with the help of our team consisting of 3-4 physicians, 2-3 nurses, 1 social worker, 1 physiotherapist, 2 psychologists and about 25 non-health-professional volunteers. We have started bereavement services and an outpatient department for pain and palliative care treatment. Hospice/palliative care department The old problem is recurring: the need for a hospice department – a unit with beds for those who cannot be treated at home, a unit that allows practical education in palliative care for different health professionals. The first realistic initiative for founding the hospice department was made in 1997 by prof. Valentin Pozaic and the German order "Allexianerbruder", dealing with problems of marginalised people, who wanted to invest in the Croatian hospice. The main drawback was the unfavourable law that discouraged foreign investments. Another difficulty was that no one was willing to go to Germany for 2-3 years in order to study the management of such an institution. In 2001 the city mayor promised to provide us a ground-plot and all the necessary permissions for building a hospice department. We made the investment plan, and a Canadian construction company promised to invest in our project as a kind of economic propaganda. The ground-plot has not been provided, and as the investment laws did not change in time the company lost interest in our project. Trial of integration into the existing health system Committee for Palliative Care at the Ministry of Health In 2001, during the visit of Kathleen Foley (the chair of the International Association for Hospice and Palliative Care) in Zagreb, the Committee for Palliative Care at the Ministry of Health was established with 18 representatives from the different fields of interest in Croatia. Additionally, nine palliative world experts from the US, the UK, and Sweden acted as committee members, receiving the English version of the minutes taken at each committee session and commenting on them. Their comments were very useful, especially those of Jan Stjernsward and David Oliver. The work of the committee proved successful, the main result being the integration of palliative care into the new Health protection law in 2003. This opened up new opportunities for setting up an independent institution for palliative care consisting of a Centre for Hospice Home Care Services, an Outpatient department for palliative care and pain treatment, and Daily hospice care. Programs for primary care were developed as well as homes for the retired and the sick. Undergraduate studies on palliative care were stimulated. In the meantime David Oliver and Kathleen Foley were elected guest professors of the Zagreb Medical School. The Recommendation of the Committee of Ministers to member states on the organisation of palliative care (2003) issued by the Council of Europe was translated, edited and distributed. This was the seventh translated material among palliative care core books beside the five year long regularly issued Bulletin (BILTEN) for palliative medicine/care, the official journal of Croatian Society for Hospice/Palliative care (CMA). A hospice website was also designed (www.hospicij-hrvatska.hr), and specific leaflets were issued occasionally as attachments of the most popular Croatian medical journal. Following the parliamentary elections in Croatia in November 2003 the government was changed, and along the radical personal and structural transformations most committees were dissolved. The financed project on Croatian health reform with acceptable design for palliative care was also discarded. Eight months later the Committee for Palliative Care was reestablished with the same president, but with a reduced number of members from Croatia and with no foreign counselors. Its existence became only formal, despite the minister's written declaration of support. Collaboration between the University of Kent at Canterbury and the University of Zagreb, Medical School The collaboration between the University of Kent at Canterbury and the University of Zagreb, Medical School is an ongoing source of optimism for us. This cooperation was initiated by Dr. David Oliver, director of the Wisdom Hospice in Rochester, and the Honorary Senior Lecturer of the Kent Institute of Medicine and Health Sciences (KIMHS). He has regularly visited the University of Zagreb Medical School as guest lecturer since the First Conference on Neurological Palliative Care in Zagreb in 2001. He and his team organised three training courses in Zagreb, and several other palliative care courses in other cities in Croatia. Dr. Oliver together with his team and some of our lecturers are actually preparing an undergraduate course for the Medical Studies in English in Zagreb to be held in June 2006. In 2004 Dr. Oliver had already given an introductory lecture that had been well received by the medical students. Furthermore, two students, and interdisciplinary team members for years, are now proceeding with their MSc courses at the University of Kent at Canterbury. At the High school for nurses there are lectures on palliative care in the first three years, which are optional in the 4th year. Palliative care is also taught at specialized secondary schools for nurses. Preparations have already started for the Fifth Croatian Nurses' Conference on Palliative Care that will take place in Zagreb in June 2006. The Vice-President's Support Our new hope is in the Vice-President of the government, Jadranka Kosor, who acts also as Minister of family and inter-generations solidarity. Ms Kosor declared that she should be considered our volunteer. She asked the Ministry of Health and Social Welfare to report to the government on what had been done for palliative care in Croatia. Ms Kosor acted as patron of the Fifth Symposium on Hospice and Palliative Care in 2005, and we have asked her to accept patronage for our First Congress on Palliative Care to be held as celebration of World Hospice and Palliative Care Day in 2006.Strategic Strategic plans for future All health care workers in Croatia should have some education in palliative care. The less complicated patients should be treated by primary care or the appropriate medical specialists. The hospice/palliative care interdisciplinary team should be involved in more complicated cases, because they have more expertise and more time left for solving complex medical and psychosocial issues. The Regional Hospice Centre should develop into the First Institution for Palliative Care implementing the health protection law passed in 2003, that is to operate the Home Care Hospice Service Centre, the Outpatient department for palliative care and pain treatment, and the Daily hospice care. It should be the beacon to all Croatian cities. Medical schools in different cities in the country should have practical education units involved in undergraduate and postgraduate studies. They should all be connected by an elaborate and widespread network. The financial basis should be provided first of all by the Croatian Institute for Health Insurance (CIHI). The payment for the core team working full-time should be supported by the CIHI, while the payment for part-time employees, respectively transportation, administration, and research should be covered by projects. At the moment the projects and donations are the only financial source. The full-time jobs and contract with CIHI can be realised only after founding the Institute for Palliative Care. The main criterion for setting up this institution is to have proper headquarters instead of the 90m2 office space developed from an old laundry. We are struggling with finding an appropriate flat at discount price (at least a 200m2 space is needed), that can serve as headquarters for the future Institute for Palliative Care. As we often say – hope dies last…plans for future Any health worker in Croatia should have some education in palliative care. The noncomplicated patients should be treated by primary care or correspondent specialist of different medical specialties. In complicated cases the hospice/palliative care interdisciplinary team should be involved, because having more expertise and more time left for solving complex medical and psychosocial issues. The Regional Hospice Centre should develop into the First Institution for Palliative Care (according the health protection law from 2003) implementing Home care hospice visits centre, Outpatient department for palliative care and pain treatment and Daily hospice. It should be beacon – model for all the croatian cities At the cities with Medical schools they should be the practical education units during the undergraduate and post graduate studies. They all should be connected by elaborated and widespread network. The financial basis should be covered first of all by Croatian Institute for Health Insurance (CIHI). It should pay for a core of fulltime team workers. The part times workers, transportation, administration, research should be covered by projects. For the moment the projects/donations are the only financial resource. The fulltime jobs and contract with CIHI can be approached only after foundation of Institute for Palliative Care. The condition for its foundation is to get another space/room instead of our 90m2 of old laundry, actually used by Regional Hospice Centre. We are strugglling hard to get chiep flat of at least 200 m2. As we often say – hope dies last… dr Anica Jušic, President of the Croatian Society for Hospice/Palliative Care (CMA) |
