A journey through the corridors of power, and how they determine the corridors of your local hospital.
Imagine a dedicated physician, trained for years to heal the sick, now caught in a web of political appointments, shifting regulations, and systemic pressures that have little to do with patient care. This is not a hypothetical scenario in Croatia's healthcare system—it's daily reality. Since the country's independence, health institutions have become a battleground where political ideologies, corruption scandals, and reform efforts collide, directly impacting the quality of care received by millions of citizens 2 4 .
The story of Croatian healthcare is one of complex transformation—from a communist-era model to a hybrid system grappling with the challenges of transition, war, and European integration. Political decisions made in parliamentary chambers often reverberate through hospital wards, determining everything from waiting times to whether your doctor might encourage you to visit their private practice after hours 2 5 .
As we explore this intricate relationship between politics and healthcare, we uncover how the treatment of a system can be as critical as the treatment of patients.
Political decisions affect every citizen's healthcare experience
Hybrid healthcare model with inherent tensions
Daily challenges for medical professionals
The roots of today's healthcare challenges trace back to the early 1990s, when Croatia emerged as an independent nation and began dismantling its communist-era healthcare model. During the Yugoslav era, Croatia operated under a unique Bismarckian-inspired system characterized by formal decentralization, social ownership, and self-managing interest communities that gave workers a voice in managing their enterprises, including healthcare institutions 4 .
Štampar model organized around distinctly Yugoslav communist values of self-management.
Political transition triggered an "anti-communist backlash"—a fundamental rejection of previous policies that created an opportunity for sweeping reforms 4 .
Three powerful mechanisms drove this transformation:
"The state is obligated to provide health care services for all its citizens, and guarantee maximum freedom on the private health market"—objectives that often work at cross-purposes in practice 2 .
The outcome was a hybrid healthcare system combining Bismarckian (social health insurance), Beveridgean (state-funded), and neoliberal (market-oriented) principles 4 . Rather than adopting a pure version of any single international model, Croatia created a peculiar blend—centralizing the insurance system under the Croatian Health Insurance Fund while allowing private practice and introducing out-of-pocket payments.
Social health insurance model
State-funded healthcare
Market-oriented elements
Corruption represents one of the most persistent political pathogens affecting Croatian healthcare. Surveys conducted before and during the COVID-19 pandemic revealed that corruption salience (the general perception of corruption) consistently undermines public trust in healthcare institutions 5 .
Research indicates that while corruption generally decreases public trust, during crises like the COVID-19 pandemic, corrupt practices become more tolerated by the public even as recognition of corruption increases 5 .
The phenomenon of "dual practice"—physicians working in both public and private sectors—represents a particularly contentious political football. Initially allowed only to university medical teachers in 1994, the practice expanded following political pressure and physician strikes 2 .
"If you allow public physicians to work in their private practices in the afternoon... you get the effect of 'patients relocation' to the private sector, which is more profitable for the physician" 2 .
Despite multiple governments acknowledging this problem, meaningful resolution has proven politically challenging due to physician lobbying and the system's reliance on this arrangement to supplement incomes.
A recurring theme across political administrations has been opacity in financial management. As one critic bluntly states:
"Since the Croatian Institute for Healthcare Insurance in years has not issued an annual financial report on health institutions, we are left to see how... experts will reduce health care contributions when they see the real financial situation in the sector" 2 .
This lack of transparency enables political manipulation of healthcare resources and prevents evidence-based policymaking.
In 2025, researchers conducted a comprehensive study to measure the ethical climate at the University Hospital of Split, one of Croatia's largest medical centers .
This cross-sectional survey utilized a validated Croatian translation of the 36-item Ethical Climate Questionnaire (ECQ), distributed to hospital employees across all departments and positions.
The research team collected 401 complete questionnaires, primarily from doctors (43.6%) and nursing staff (32.7%), creating a robust snapshot of the moral atmosphere within the institution.
The ECQ measures nine climate types across two dimensions:
This sophisticated framework allows researchers to identify not just whether the climate is "good" or "bad," but the specific character of ethical reasoning that guides behavior in the organization .
The findings revealed a complex ethical landscape dominated by "Company rules" and "Laws and professional codes"—suggesting that compliance with regulations and professional standards guides much of the ethical decision-making .
| Professional Group | Highest Scoring Climate Types | Lowest Scoring Climate Types |
|---|---|---|
| Doctors of Medicine/Dental Medicine | Personal morality, Laws and professional codes | Team interest, Social responsibility |
| Nursing Staff | Social responsibility, Efficiency, Team interest | Self-interest, Company profit |
| Non-ICU Staff | Social responsibility | Self-interest |
| ICU Staff | No dominant climate type identified | Self-interest |
Source: Ethical Climate Study at University Hospital of Split
These divergences matter because they reveal potential ethical fault lines within healthcare teams. When doctors prioritize personal morality while nurses emphasize social responsibility and team interests, the stage is set for ethical conflicts in patient care decisions.
The number of years spent working in the hospital positively predicted the "Self-interest" climate score . This suggests a potential erosion of ethical commitment among longer-serving staff.
Understanding how politics infiltrates healthcare requires specialized conceptual tools. Here are key instruments for analyzing this phenomenon:
| Conceptual Tool | Function | Research Application |
|---|---|---|
| Ethical Climate Questionnaire | Measures organizational ethical perceptions | Identifies how political pressures translate to workplace ethics |
| Policy Transfer Analysis | Traces cross-border movement of policies | Reveals how international models get adapted for domestic political needs 4 |
| Corruption Salience Measurement | Quantifies perceived corruption levels | Tracks how corruption perceptions affect public trust in healthcare 5 |
| Hybridization Index | Maps blending of healthcare system types | Analyzes political compromises in system design 4 |
| Dual Practice Metrics | Measures public-private sector overlap | Evaluates conflict of interest regulations and implementation 2 |
The combination of these tools allows researchers to move beyond superficial analysis and understand the deep structural relationships between political decisions and healthcare outcomes in Croatia.
Despite these challenges, evidence suggests potential pathways for healing the system. Multiple analysts point to essential reforms that could mitigate political damage:
Making healthcare spending completely public and requiring regular financial reporting from the Croatian Institute for Health Insurance 2 .
Systematically analyzing and regulating consequences of dual practice, physician-pharmaceutical industry relationships, and public procurement processes 2 .
Establishing clear rules for the private health market and its relationship with the public sector 2 .
Replacing political committees with independent institutions like an ombudsman to protect patient rights 2 .
Creating funds for patients affected by unwanted treatment outcomes or physician mistakes 2 .
The antifragility demonstrated during crises like the COVID-19 pandemic and earthquakes suggests that beneath the political surface, Croatia's healthcare system possesses underlying resilience 3 . This capacity to benefit from stressors provides hope that with proper reforms, the system could transform political challenges into sources of strength.
The diagnosis is clear: political influence constitutes a chronic condition in Croatia's healthcare system, requiring ongoing management rather than expecting a one-time cure. From the anti-communist backlash that created a hybrid financing model to the persistent corruption and dual practice issues that challenge daily operations, politics has become intertwined with healthcare delivery at every level.
Yet the ethical climate study at Split University Hospital also reveals that even within politically constrained systems, professional values persist . The dominance of "Laws and professional codes" as an ethical guidepost suggests that medical professionalism provides some buffer against political pressures.
The path forward requires recognizing that healthcare systems are not just medical creations but political ones. Healing Croatian healthcare demands not just better medicines or technologies, but better governance practices, transparency, and accountability mechanisms.
The relationship between politics and healthcare resembles the practice of medicine itself: it requires accurate diagnosis, evidence-based treatments, constant monitoring, and the wisdom to know that some conditions require lifelong management rather than hoping for miracle cures.
The patient—Croatia's healthcare system—remains in need of careful, sustained political commitment to truly heal.