Policy responses for Croatia - HSRM


Policy responses for Croatia

3. Providing health services effectively

The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.

3.1 Planning services

As of 4 February 2021, vaccines from Pfizer / BioNTech (mRNA vaccine) and Moderna (mRNA vaccine) are used in Croatia. The public health institutes organize the distribution / collection of vaccines at their place, if necessary with the help of the Civil Protection Headquarters.

Vaccine services and delivery

Croatia participates in the joint procurement of vaccines against COVID-19, carried out by the European Commission. Procurement has been contracted with several manufacturers, and procedures for negotiations and procurement of vaccines are still ongoing. The institution responsible for the management of the vaccine supply chain (procurement and distribution of vaccines) as well as for monitoring the expiry date of stock is the Croatian Institute of Public Health. After taking over the vaccine, the Croatian Institute of Public Health distributes it to the County Institutes of Public Health. The County Institutes of Public Health organize the distribution of vaccines in their field, if necessary with the help of the Civil Protection Headquarters.
When it comes to the logistics of conducting vaccination, Croatia has relied on the vaccination system for the usual seasonal vaccination, but strengthened this system, given the large number of citizens who should be included in this vaccination in a short time. The usual vaccination system is based on a network of county public health institutes (21 county institutes) with epidemiological services as coordinators of all doctors within their county. Vaccinators are family doctors, of which there are approximately 2,100, school doctors (about 155), and epidemiologists (slightly more than 100), as well as other doctors and health workers who, in accordance with the Act, can also vaccinate but under the supervision of an experienced senior doctor. Citizens receive all information about the vaccination procedure from their competent doctor.

The EMA and the national competent authorities (NCAs) in EU Member States have prepared a safety monitoring plan for COVID-19 vaccines. The plan outlines how relevant new information emerging after the authorisation and uptake of COVID-19 vaccines in the pandemic situation will be collected and promptly reviewed. Accordingly, the side effects of the vaccine in Croatia are monitored by Agency for Medicinal Products and Medical Devices (HALMED) in cooperation with the Croatian Institute of Public Health. HALMED receives reports of suspected adverse reactions from healthcare professionals and marketing authorization holders for medicinal products, as well as directly from patients. All applications received are considered as suspected adverse reactions on the vaccine and are used for continuous assessment of the safety profile of the vaccine, thus ensuring that only those drugs whose benefit-risk balance is positive are marketed.
Currently there is in preparation one project that will allow measuring/monitoring vaccine effectiveness in the population at the national level. This project will be used in the future for  conducting various research about COVID-19 cases.

Three safe and effective vaccines against COVID-19 are currently approved for use in Croatia: AstraZeneca / Oxford, Pfizer / BioNTech and Modern. The Johnson & Johnson / Janssen vaccine is also expected to be delivered. The logistics (i.e. storage and distribution of the vaccine), as well as the administration of vaccine are agreed directly with the manufacturer, given that the storage conditions and limits of the use of vaccine are different for each manufacturer. The cold vaccine chain (a vaccine transport protocol in which the vaccine must be at an appropriate temperature at any time during transport) in Croatia is organized by the National Institute of Public Health in cooperation with the County Institute of Public Health and, if necessary, with the help of the Civil Protection Headquarters. A cold chain is provided in accordance with the manufacturer's instructions on the use of each vaccine.

As for supplies to address adverse events due to vaccination, all doctors must have adrenaline during the vaccination procedure. If a certain reaction occurs, the doctor applies the adrenaline and calls an ambulance. People with a history of anaphylactic reaction are referred for vaccination under increased supervision.

There is no structured form of training that vaccinators have had to go through. Vaccinators received instructions from the Croatian Institute of Public Health with recommendations on the use of the vaccine.

The vaccination procedure is specifically defined for each priority group:
1. Vaccination of health care workers is planned at the workplace, through commissions for hospital infections, health care workers and, if necessary, outside assistance (epidemiologists, doctors in primary health care (PHC)), and additionally the Croatian Society of Occupational Medicine offered to participate in vaccination of work teams for which they are responsible.
2. Vaccination of users and employees of nursing homes (and other institutions in the social welfare system) is planned within homes for older people, and vaccination is carried out primarily by home doctors and nurses/technicians.
3. Vaccination of people older than 65 years and patients with chronic diseases is organized through family medicine in a way that every doctor vaccinates patients they have in their care. Another option is to organize clinics, the so-called. vaccination points in health centers, if this is more organizationally suitable for health center doctors. The organization of vaccination points is the responsibility of the territorial Health Center and the local Civil Protection Headquarters.

The vaccination in Croatia is conducted solely by the public sector.

Vaccination against COVID-19 is carried out in accordance with the Plan for the introduction, implementation and monitoring of vaccination against COVID-19 defined by the Croatian Institute of Public Health.
1. The first vaccination phase: vaccination of employees and users of homes for older people (and other institutions for the provision of accommodation in the social welfare system) as well as health professionals.
2. The second vaccination phase: people over 65 years of age and people with chronic diseases.
3. The third vaccination phase: general population.

The start of the vaccination of people from certain priority groups depends on the availability of vaccines, the response to vaccination, but also the number of people belonging to these priority groups.
Once all healthcare professionals, users, and employees of nursing homes have been vaccinated, the next doses to arrive will be given to older people who are not in nursing homes and all chronic patients (over 16 years of age).
In the third phase when vaccination will be offered to everyone, it will be firstly offered in work organizations through occupational medicine specialists, the Institute of Public Health and in primary health care. The organization and implementation of vaccination in PHC (at vaccination points or in family doctor's offices) is the responsibility of the Health Center. Also, if an agreement will be reached with the Pharmacy Chamber, vaccination will also be provided through pharmacies, as it was with flu vaccination.

There are no specific efforts for prioritising deprived areas and high-risk social groups. Vaccination is carried out according to defined priority groups in accordance with the National Vaccination Plan against COVID-19. The focus is on health professionals who are in direct contact with COVID patients as well as vulnerable groups defined by age group and health status specifically the individuals at increased risk of developing a more severe clinical picture.

According to the initial plan, Croatia ordered a significantly greater amount of vaccines, however, due to high demand, much less was delivered. Therefore, a certain degree of reorganization of the vaccine has been carried out in some vaccination phases.
The opening of public hearings on the effectiveness of the vaccine for different age groups and its indications has contributed to the hesitation of citizens from priority groups to apply for vaccination in a timely manner. This had direct effects on the overall slowdown in vaccination.
Also, there were several local specifics that affected vaccine distribution. Due to the earthquake that occurred in Sisak-Moslavina County on December 29, 2020, it was impossible to adhere to the epidemiological measures, which led to a significant increase in the number of coronavirus cases. As a result, there has been a reorganization and redistribution of vaccines at the national level. Sisak-Moslavina County has become a priority for vaccination of the general population.

In some counties vaccination points have been organized in order to accelerate the vaccination procedure.

On March 1, 2021, a new digital platform was launched as a system that allows citizens to apply for vaccination. Citizens can apply for vaccination with their family doctor, but also via  cijepise.zdravlje.hr or by calling the toll-free number 0800 0011. Upon receipt of the application, citizens will receive a notification about the place and date of vaccination either to their e-mail addresses, by text message or by phone, depending on their choice when registering. People aged 65 and over have an advantage over people of a younger age. Also, each county institute for public health opened specific telephone lines where employees of the institute can fill in the application form for citizens. This is also the contact for all foreign citizens who want to get vaccinated in the Republic of Croatia.

An information and education campaign was also established under the slogan "Misli na druge-cijepi se! (Think of others - get vaccinated)!" The campaign builds on a joint campaign of the European Union under the slogan "Together through the crisis." The aim of the Croatian national campaign is to provide citizens with as much information as possible about the vaccine, its properties and effects, possible side effects after vaccination and contraindications for vaccination, as well as the organization and implementation of vaccination programs for all citizens who decide to vaccinate.
The campaign has two main determinants:
• Information and education
• Social appeal
Vaccine coverage & access

Vaccination against COVID-19 is free of charge in the Republic of Croatia, regardless of the type of health insurance. If the person does not have a family doctor, he/she can contact the county public health institute in their place of residence.

Access to vaccines is generally universal leaving no-one behind. Due to the high demand on the market, a significantly smaller amount of vaccine was delivered in Croatia than expected. Due to this situation, the planned vaccination process was slowed down.

No specific organizational difficulties were noted in the country that affected the availability of the vaccine. Given that the delivery of vaccines to Croatia was delayed, the planned start of vaccination was postponed, which means that all citizens in the Republic of Croatia are waiting slightly longer for their vaccine.

The Ministry of Health started preparations for a response to COVID-19 weeks before the first case appeared in Croatia. Every hospital in the Republic of Croatia had to reorganize its work due to the COVID-19 outbreak.

The main isolation centre is the University Hospital for Infectious Diseases “Dr. Fran Mihaljevic”. However, since the cases of the infection spread to all Croatian regions, many county general hospitals had to reorganize one hospital ward into an isolation unit for the infected. Croatia has also prepared several checkpoints such as military tents in front of the Clinical Hospital Dubrava, as well as the Arena Zagreb as places that will serve for the reception of infected patients.

Some hospitals are providing telephone counseling. Another example is the Centre for Paediatric Medicine Helena, a private polyclinic, that provides consultations in the fields of paediatrics, paediatric nephrology, gastroenterology and nutrition. As for public sector hospitals, citizens were instructed not to go to a family physician but to call by phone.