Croatia has grown into a thriving nation imbued with a rich cultural background and history. With its famous cities, stunning beaches, islands and extraordinary national parks, this country will undoubtedly captivate every tourist who visits, especially nature lovers.
There are a wealth of historic sites across Croatia, ranging from Ancient Roman ruins to twelfth-century churches, fifteenth-century palaces. Croatia is also home to historic towns reflective of the country’s communist era and the devastating Balkan Wars.
When combining all of this with Croatia’s unique culture and traditions, as well as its wine, seafood and famous Pag cheese, it becomes apparent why this country has become a favourite with tourists from across the world.
The population of Croatia
While a relatively small country, Croatia boasts a unique and diverse geography. As seen on the map above, the upper arm of Croatia’s crescent shape borders Slovenia and Hungary in the north and Serbia in the east. The coastal strip along the Adriatic Sea is bordered by Bosnia and Herzegovina in the East, creating the hollow part of the crescent, and Montenegro in the south.
Croatia has constantly been on the border between competing forces, from the two halves of the Roman Empire to the Austro-Hungarian Empire and the Ottoman Empire, and the split between the Eastern and Western churches.
All of these various political, cultural and religious movements have had a lasting impact on Croatia’s culture and history and continue to shape its development to this day.
Croatia’s history begins with the arrival and settlement of Slavs in the Western Balkans, in what would eventually become an independent Croatian state in the 9th century. This kingdom retained independence until 1102, at which point it was ruled by the Hungarian dynasty. But this was only the first of many changes.
From the loss of part of its territories to the Venetians and Ottomans in the 15th and 16th centuries and the election of the Austrian Habsburgs to the throne in 1527, Croatia changed significantly over the centuries.
The loss of independence and the pressure created by various conflicts throughout the years eventually steered the Croats towards Nationalism in the 19th century.
Eventually, Croatia broke apart from Austria-Hungary only to become a part of Yugoslavia for most of the 20th century. Finally, in 1991 Croatia regained its independence, although it continued to be plagued by instability due to The Yugoslav Wars, which ended in 1995.
Today, Croatia is a flourishing nation and in 2013 joined the European Union.
Geographic and demographic information
Summary statistics
- Land area: 2020 estimate: 55.960 sq. km
- Gross domestic product (GDP):
- Total: 2021 estimate: 67.84 billion USD
- Per capita: 2021 estimate: 17,398.8 USD
Population statistics
- Population size: 2021 estimate: 3.899.000
- Birth rate: 2020 estimate: 8.9 per 1000 people
- Death rate: 2020 estimate: 14.1 per 1000 people
- Infant mortality rate: 2020 estimate: 3.9 per 1000 live births
- Average Life expectancy: 2020 estimate: 77.7 years
- Male estimate: 2020 estimate: 74.7 years
- Female estimate: 2020 estimate: 80.9 years
- Ethnicities: 2021 estimate: 91.6% Croat, 3.2% Serb and less than 6% of other ethnicities
Healthcare system
Croatia’s healthcare system was significantly modified during the 20th century. It was during the 1920s, immediately after the First World War, that the state started to focus on creating a public healthcare system that could help provide a better standard of care for all Croats.
This led to the creation of a revolutionary system marked by mandatory health insurance that covered almost every citizen in Croatia. Over time, more changes were made, culminating in the 1993 Health Care Act, whereby financing and governance became centralized under the Croatian Health Insurance Fund (CHIF).
Today, the CHIF covers most preventative and curative health services for nearly all citizens and residents in Croatia. Through this system, patients still have to contribute to the costs of several services and goods through co-payments, with exception of vulnerable groups.
However, out-of-pocket spending on health as a share of household consumption is the lowest across all European Union countries. In Croatia, this equates to 1.3%, while the EU average is 3.3%, as per 2018 statistics. Overall, Croatia’s policies of co-payment exemptions and cost-sharing caps have led to great results, with only 0.3% of medical needs remaining unmet in 2019.
Even so, Croatia’s healthcare system, like any other, still faces several challenges.
According to the WHO’s 2021 review of Croatia’s health system, one of the major issues within the system is the uneven geographical distribution of resources. They found that there was a shortage of human resources in rural areas and the country’s islands, especially in comparison with urban regions.
Another significant problem in Croatia’s healthcare system is the lack of a complete and suitable long-term care system. While cash benefits and services are available, such as assistance and care allowance, personal disability allowance, home assistance allowance and organized housing, there are coordination issues across the structures responsible for providing these. This has led to a fragmented and dysfunctional system that fails to provide the basic services necessary and isn’t available to all groups of people.
Finally, areas such as mental health care and public health campaigns are also severely lacking. In the next section, we’ll see how these are contributing to some of Croatia’s major health concerns.
Health priorities
In comparison to the average among EU countries, Croatia has a significantly lower life expectancy. Understanding the causes behind this discrepancy is vital to implement targeted measures that effectively help Croatia achieve (or even surpass) the EU average.
When we look at this problem in depth, we find that Croatia has multiple mortality rates amongst the highest in the EU, which is a clear contributing factor to a lower life expectancy. Amongst these are mortality from cancer, air pollution, and preventable causes such as road traffic deaths.
Overall, according to data from 2018, the leading cause of death in Croatia is ischaemic heart disease, followed by stroke, accounting for nearly 20% and 12% of total mortality respectively.
It’s important to note that several of these mortality rates have been decreasing over the past few years, but more progress is needed as these are still above the EU average.
Improving these factors requires not only enhancing access for all to diagnosis and treatment, but also to preventative care and public health campaigns.
Statistics show that Croatia has higher rates associated with a series of risk factors than the EU average, including smoking, low levels of physical activity, obesity, and low consumption of fruit and vegetables. Between 2015 and 2017, for example, 35% of 8-year-old children in Croatia were overweight or obese, in comparison to 29.2% on average in the EU.
Further, risk factors including smoking, alcohol consumption, low physical activity, and poor dietary habits caused 44% of all deaths in Croatia in 2019.
Of these factors, dietary risks are one of the most concerning given that these were responsible for 22% of all deaths in the same year. After this, the largest behavioural risk factor contributing to mortality is smoking, followed by alcohol consumption and low physical activity.
Factors such as low income and low levels of education also need to be carefully considered when creating strategies targeting these issues, given that large socioeconomic disparities have been found in obesity and smoking rates.
In order to tackle the current health concerns in Croatia, the government has developed several action plans to be implemented over the next decade. Amongst these are the National Strategic Framework against Cancer until 2030, and the Action Plan for Prevention and Control of Chronic Non-Communicable Diseases for 2020–2026.
Genomic medicine capabilities
Research in the field of genetics and its clinical application began to be developed in Croatia in the middle of the 20th century. As such, prenatal diagnosis of genetic conditions started relatively early in this country. An example of this is the screening for Down Syndrome, which was introduced in 1996. Nowadays, prenatal diagnosis is commonplace during high-risk pregnancies, either due to a family history of a given hereditary disease, or a higher risk of chromosomal abnormalities.
Conversely, preimplantation genetic diagnosis isn’t available in Croatia for people that opt to have children through assisted reproduction.
Newborn screening, which aims to diagnose and prompt early treatment of newborns affected by certain disorders, is mandatory in Croatia. First implemented in 1978 to detect phenylketonuria (PKU), the newborn screening program now includes eight screened diseases.
These include CH (congenital hypothyroidism), CUD (carnitine uptake defect), GAI (glutaric acidaemia type I), IVA (isovaleric acidaemia / 2-methylbutyrylglycinuria), VLCADD (very long-chain acyl-CoA dehydrogenase deficiency), LCHADD (long-chain L-3-hydroxy acyl-CoA dehydrogenase deficiency/trifunctional protein deficiency), MCADD (medium-chain acyl-CoA dehydrogenase deficiency), and PKU.
Similarly to prenatal diagnosis, newborn screening is also funded by the Croatian Health Insurance Fund (CHIF). The results of this program are clear – in 2019, 99.9% of newborns were screened.
Genetic testing for several monogenic and multifactorial disorders has been available since the 1990s when genetic assays for multiple conditions were developed in the Zagreb University Hospital Center.
Currently, genetic testing is available in Croatia for several neurological and psychiatric disorders, including Huntington’s disease, as well as tumours like hereditary nonpolyposis colorectal cancer. The primary objective of these tests is to diagnose patients before they start experiencing symptoms and hopefully prevent or treat these conditions as early as possible.
There are multiple laboratories in Croatia that carry out genetic testing for rare diseases; however, there is a lack of coordination concerning the standards for these tests which is yet to be effectively addressed.
The genetic tests available are funded by CHIF and, if a specific test can’t be performed within Croatia, there is a possibility for medical recommendation of testing abroad.
The most significant issue arises after genetic testing is carried out. While genetic counselling units have existed in Croatia since 1964, appropriate genetic counselling following genetic testing is still severely lacking.
It’s essential to ensure that genetic test results are appropriately interpreted and that the patients receive correct and comprehensive information about the disease being tested. However, not only is there still a deficiency in access to this service but there is also a lack of regulation.
Notable projects
Beyond 1 Million Genomes (B1MG) project: The B1MG project builds on the European Union’s 1+ Million Genomes (1+MG) Initiative by creating a framework and legal guidance for access to genomic and clinical data across Europe. The aim is to facilitate the sharing of genomic data across European countries, promoting better scientific research and health policymaking. Croatia is part of the project’s Governing Board given its participation in the 1+MG initiative and, as such, is involved in making decisions (for example, regarding the inclusion of new countries in the project) and laying out strategic guidance.
European Genomic Data Infrastructure (GDI) project: Building on thework of the 1+MG Initiative working groups and the outputs of the B1MG project, the GDI project was created to establish a sustainable and secure infrastructure to access genomic data. The main focus of this project is long-term sustainability, by creating a governance model and financial plan that can work in the long term, ensuring the longevity of the infrastructure created. Representing Croatia in this project is the Ruđer Bošković Institute.
10,001 Dalmatians – Croatian National Biobank – this project was created to provide comprehensive resources for the study of the genetic, environmental and social factors associated with health and disease. As part of the program, researchers are able to conduct genome-wide association studies using data from the “10 001 Dalmatians” study of Croatian island isolates and the hospital-based DNA bank.
Mend the Gap – This project was created to “mend the gaps” in the research capacity in Croatia in areas such as archaeology and genetics. The aim was to enhance research conducted in Croatia, by joining a consortium of Croatian researchers with scientists from the University of Cambridge and the University of Pisa.
Notable organisations and companies
Croatian Society for Human Genetics (HDHG): Founded in 1972, the HDHG is a component of the Croatian Medical Association that joins more than 250 experts in genetics. From doctors who diagnose and treat genetic disorders regularly, to scientists in fields like molecular biology, cytogenetics, and anthropology, the HDHG aims to bring them together and promote the development of medical genetics.
Division of Molecular Medicine at the Ruđer Bošković Institute (RBI): The RBI is the largest multidisciplinary scientific research centre in Croatia, conducting research across the natural, biomedical, and engineering sciences. In particular, the Division of Molecular Medicine focuses on research into the nature of diseases (including genetic conditions) and potential strategies for their diagnosis, treatment, and prevention.
Department for Functional Genomics at the Center for Translational and Clinical Research: Established in 2009, the Center for Translational and Clinical Research aims to help translate scientific discoveries into clinical applications to enhance health care, as well as to help transfer clinical data into research. The Department for Functional Genomics is currently the most advanced institution of its type in South-Eastern Europe, focusing on research that connects basic and clinical research efforts using genomic approaches.
Institute for Anthropological Research: Founded in 1992, The Institute for Anthropological Research is a public research institute that focuses on research and education in the field of anthropology. Within the institute, there are four sophisticated laboratories, equipped with state-of-the-art equipment for the study of molecular and evolutionary anthropology, human growth and development, ageing, and personalised medicine, amongst other areas.
Notable individuals
Prof. Dragan Primorac: Croatia’s Minister of Science, Education and Sports until 2009, Prof. Primorac is a paediatrician, forensic expert and geneticist. Today, he serves as the Chair of the International Affairs Committee of the American Academy of Forensic Sciences, is a Professor at Universities in Croatia, the United States, India, and China, and presides over several societies, including the Croatian Society for Human Genetics.
Some of his most significant work to date includes pioneering DNA identification of human remains found in mass graves, an EU FP7 project entitled “Multi-dimensional OMICS approach to stratification of patients with low back pain” and his pioneering work in the application of personalized medicine in clinical practice.
Dr Sanja Kapitanović: Dr Sanja Kapitanović works as the Head of the Laboratory for Personalized Medicine at the Ruđer Bošković Institute in Croatia. Dr Kapitanović’s work focuses on the study of the molecular and genetic mechanisms responsible for the development and progression of colorectal cancer, one of the most common types of cancer in Croatia.
Dr Oliver Vugrek: Dr Oliver Vugrek is the Head of the Laboratory for Advanced Genomics at the Ruđer Bošković Institute in Croatia, as well as the Coordinator of the InnoMol Project, which aims to facilitate scientific research and develop innovative approaches for the diagnostic, prevention, and treatment of the major diseases today. Within the RBI, Dr Vugrek’s work focuses on the study of methylation and its connection with various diseases.
Prof. Vlatka Zoldoš: Prof. Vlatka Zoldoš is not only a professor at the Division of Molecular Biology of the University of Zagreb but also the group leader of a laboratory for epigenetics in that department. Her work focuses on protein glycosylation and its role in human diseases and the use of CRISPR/Cas9-based molecular tools for epigenetic editing. So far, Prof. Vlatka Zoldoš has published various prominent papers, such as the first demonstration of epigenetic regulation of plasma protein and IgG glycosylation.
The future genomics landscape
As we’ve highlighted, there are a number of scientists in Croatia actively contributing to the development of the field of genomics and its application into practice, particularly in clinical settings.
Some of the most significant research topics within this field that are being investigated in Croatia include the genetic basis of various monogenic and multifactorial disorders, the diagnosis and treatment of hereditary disorders, the development of targeted therapies against cancer and viral disease, the application of genetic editing tools, and precision medicine.
Pharmacogenetics, which concerns the impact of genetics on drug metabolism and action, is also a very promising field of research in Croatia. This is particularly due to the work carried out in the Clinical Laboratory of Pharmacogenomics and Individualized Therapy of the Zagreb University Hospital Center.
Hopefully, this research will lead to major breakthroughs with clinical applications that help address some of the most significant health concerns in Croatia and the world.
Nevertheless, some changes are already underway, particularly in regard to newborn screening. Further expansion of the newborn screening program is already being planned and, according to a report from 2021, will likely start including testing for PA/MMA (propionic/methylmalonic aciduria), HCY (homocystinuria), and SMA (spinal muscular atrophy).
The same report also indicated that Croatia plans to introduce next-generation sequencing (NGS) as a second-tier method for screening.
Finally, an article published in August of 2022 reported the opening of a new genetic counselling office in the University Hospital Centre in Split focused specifically on testing for hereditary cancers. Perhaps this is the first step in enhancing access to this service across Croatia.
References
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