Health care issues in Croatian elections 2005-2009: series of public opinion surveys

Aim To compare the results of a series of public opinion surveys on experiences with the health care sector in Croatia conducted in the time of elections and to analyze whether political party affiliation had any influence on issues of priority ranking. Methods The surveys were conducted during 2005, 2007, and 2009. They were administered through a Computer Assisted Telephone Interviewing method to representative samples of Croatian population and were statistically weighted according to sex, age, level of education, and political party affiliation. The random sampling of the person within the household was done using the table of random numbers. Results Health and health care system was the most important issue (58%) during the 2007 parliamentary election and the second most important issue during the 2005 and 2009 elections (46% and 28%). In the 2007 election, health care was viewed as most important by women, respondents with lower education levels, and respondents with lower income. In 2005, the most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively), and in 2009 lack of funding and corruption (51% and 45%, respectively). Conclusion Health and health care system were consistently among the top two issues in all elections from 2005 to 2009. The top three most important health care sector issues were corruption, poor organization, and lack of funding. This indicates that political parties should include solutions to these issues in their health care policymaking.

There are various predictors of citizens' satisfaction with health care system, but there are two main political factors: patient participation and institutional influence of their representative organizations, and political party affiliations (1)(2)(3)(4).
Some authors concluded that socio-demographic characteristics were only a minor predictor of satisfaction with health care system, but older age appeared to be one of the most consistent positive determinants of health care satisfaction (5)(6)(7)(8)(9)(10)(11)(12)(13). Women were found to be less satisfied with care than men because they were more frequent users of care and had higher expectations (14,15).
Studies in post-communist states provide mixed evidence in this regard. In a 1991 cross-country survey study, most of the respondents believed that, while the market system was essential to economic development, policies that promoted social and economic egalitarianism were important (16). They also found that women, those with lower educational level, and those with lower income were more likely to be supportive of socialist principles. On the other hand, a study conducted in 1999 showed a change in value systems, with a majority of respondents from Poland and Hungary not favoring further redistribution of income, even at the expense of welfare (17). Furthermore, there was a positive correlation between education and positive attitude to health care competition. Still, in Hungary the older generations were predominantly against increases in health care competition.
Since the early 1990s, the public level of satisfaction with the health care system reforms in Croatia has not matched the apparent success of the reform goals. A 1994 consumer survey found that a vast majority of lower-and middleincome Croats was skeptical of health care reforms (18). They attributed this to the legacy of universal access to health care, the view of health care access as a universal right, negative consequences on the patients, and lack of public understanding of the reforms.
The same study (18) found the distribution of out-of-pocket payments and co-payment for health care to represent a regressive burden on those in the lower income group. Patient satisfaction was also low: 44% were dissatisfied with the quality of health facilities and 48% with the equipment (18). Similar face-to-face interviews found that citizens of Croatia did not hold a positive view of the health insurance reform (19). Their primary concern were limitations of their rights and the increase in the financial burden related to medical care. A 2005 survey found that during the presidential election campaign period health care was the second most important issue on the voters' minds, closely following economy (20).
Finally, a national survey on patients' satisfaction with hospital and primary health care in 2006 showed considerable concerns with relations between patients and medical professionals, hospital accommodation, communication between primary and secondary health care, and corruption (21,22).
In this study, we present and compare the results of a series of public opinions surveys conducted between 2005 and 2009. This is the first study that targeted public experiences and voters' opinion as an evaluation of the health care sector in Croatia.

MethoDs
The The probabilistic sample was stratified in two stages with the following characteristics: six traditional regions -City of Zagreb region, Northern, Southern, Central, Western, and Eastern region, defined through existing counties (to achieve sorting election units based on principle of exclusiveness and exhaustiveness), and according to settlement size. Unit allocations over strata were performed proportionally to strata size (number of adult examinees in stratum). The urbanization level was distributed in 4 population size categories (up to 2000 residents, 2001-10 000, 10 001-100 000, and more than 100 000 residents). Randomization of the sample was computer-based according to stratum definition, but the sample was additionally weighted to obtain a fully representative sample of the Croatian voting body.
Random sampling of persons within households was done using the table of random numbers. Studies have shown that this type of statistical adjusting of data obtained through CATI was appropriate taking into account that the survey was conducted during a short period (21)(22)(23)(24). The questionnaires were divided into three question groups. The first question group consisted of general questions on household size, location, and region. The second group of questions was related to the respondent's age, sex, employment status, and income. The third question group consisted of questions related to the elections, presidential and parliamentary role in the interior and foreign policy, health care issues, and health priorities related to the president's/parliament`s work. Questions were made on the basis of topics recognized in the press as the most important in the period of two months before the election (20).
While the raw data for presidential election included individual candidates and their party affiliation, we were interested in how public opinion may be affected by differences between the two major political options. Thus, we created a new variable that grouped the central-right (C-R) parties/party coalitions vs central-left (C-L) parties/ party coalitions. Candidates' ideological standings were assessed by a qualitative analysis of party platforms (if candidates were affiliated) or public campaign statements (independent candidates). The information was gathered from the respective party/candidate internet homepages (25,26) as well as from the Comparative Manifesto Project Database (27).

statistical analysis
Bivariate analysis was performed with χ 2 test. Multivariable model, controlling for respondent's age, sex, and place of residence was used to determine the difference between left-and right-wing voters' opinions and was expressed as odds ratio with 95% confidence interval. The analysis was performed by SPSS, version 12.0 and 16.0 (SPSS Inc., Chicago, IL, USA), with statistical significance level set at P < 0.05.

Results
The results presented in this section are not exhaustive of all the questions asked in the individual public opinion surveys. The purpose of this study was to compare the answers to the same question asked across all surveys and analyze specific determinants relevant for public opinion during election. Thus, we divided the results into sections: general election comparison, socioeconomic factors, and party affiliations.

General election comparison
Health and health care system were placed near the top of the list of important issues in Croatian elections since 2005 (Table 1). In the 2005 and 2009 presidential election, health care was the second most important issue (46% and 28%, respectively) and in the 2007 parliamentary election the most important issue (58%), closely followed by economy (57%). When asked about the most important problems in the health care sector, the most highly ranked were corruption, lack of funding, and poor organization.
In 2005, the two most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively) and in 2009 lack of funding and corruption (51% and 45%, respectively).
Regarding the order of priority in which the newly elected government should address the existing issues, health care ranked very low (fifth both in 2007 and 2009), with corruption, unemployment, and economy ranking higher.

socio-economic determinants
We also determined which socio-economic factors affected individuals' view of health care as the most important issue. For this analysis, we selected the 2007 election because then health care was recognized as the top priority by the majority of the respondents. A total of 65.3% of female respondents viewed health care as the most important issue. Respondents with primary and secondary education and those who were part-time employed or unemployed also viewed health care as the most important issue. Respondents in the low and low-middle income group and C-R voters preferred private care and viewed poor organization, lack of funding, poor performance, and insufficient equipment as most problematic in the health care system. They were also more likely to choose health care as the most important issue (Table 2).

Party affiliations
In 2005, significantly more C-R respondents than their C-L counterparts viewed health care as most important (26.  ered suboptimal physician performance as most important (6.4% vs 4.5%) and more C-R respondents considered lack of funding (31.0% vs 20.5%). In 2007, more C-R respondents considered insufficient equipment as most important (33.1% vs 43.6%), while more C-L respondents considered poor organization (51.2% vs 45.9%). In 2009, both C-L and C-R respondents considered lack of funding as most important (47.8% and 56.4%) ( Table 3).

Ranking health care priorities -2009 presidential election and party affiliation
As two most important health care problems in Croatia, respondents identified corruption (about 44.8%) and lack of funding (50.5%), similar to the findings in 2005 and 2007. With regard to poor organization and insufficient equipment, more C-L respondents than their C-R counterparts considered both issues most important (45.1% vs 41.3% for poor organization and 38.9% vs 38.6% for insufficient equipment). More C-R than C-L respondents considered lack of funding and suboptimal physician`s performance most important (56.4% vs 47.8% and 7.8% vs 7.4%, respectively) ( Table 4).
When asked about experiences with a health care problem in the previous year, C-L respondents selected poor organization (22.3%), lack of funding (7.3%), and health care corruption (8.9%). C-R respondents also reported experience with these three issues, but in different order -17.4% expe-  (20). †F test was performed to assess the differences in probabilities. significance level is at P > 0.05. ‡significance level is at P > 0.001. §this response option was not included in the 2007 questionnaire. IIthis response option was not included in the 2005 questionnaire.
rienced poor organization, 8.4% corruption, and 6.9% lack of funding. As a priority after election, C-L voters predominantly chose corruption and poor organization, while C-R voters chose corruption and lack of funding. Looking at the number of visits to the private practice, nearly 60% of respondents who visited a private practice did so only once, while almost 11% visited it five or more times. More C-L respondents visited private practice once (39.1% vs 20.3). The primary reasons for visiting a private practice were long waiting lines in the public sector and better quality of care provided.

DIsCussIoN
Our study showed that voters in Croatian elections viewed health and health care as important issues.
Health care consistently ranked among the top issues in Croatian elections, with the exception of the last election when the economic and financial consequences of the world crises overshadowed it. The top three health care issues in all of the elections were corruption, poor organization, and lack of funding. The persistence of the same issues in the health care sector over the years indicates that they remain ineffectively addressed by the government.
The results presented here were obtained in a telephone survey, and therefore are prone to certain levels of selection bias. Furthermore, the comparison across elections was not as extensive as wanted given the limited number of comparable questions and their diversity.
Despite the reforms that have been implemented in Croatia over the years, and most notably the sweeping changes aimed at cost-cutting in the last year, not much has been done to alleviate public concerns. As an example, while one of the aims of the 2009 reforms was to shorten waiting lines, the most often cited reason for using private health providers in that same year was the long waiting lines in the public health care system (28-30).
We kept observing a counterintuitive finding that while the public perceived health care as one of the most problem-ridden sectors, it did not view it as a post-election priority. One possible explanation is that the issue of reforming a health care system is a complex one, which requires detailed information and specialized knowledge (31). In fact, there is no clear blueprint for reforming a health care system successfully compared to a blueprint followed for enacting macroeconomic reforms in the 1990s. Another explanation is that there have been other issues of equal importance (unemployment, the sluggish economy) in Croatia since the transition.
In the 2009 presidential election, health care lost priority as Croatia was facing the consequences of the international financial and economic crises. Considering long term structural problems in the Croatian economy unresolved since the beginning of the economic transition of the early 1990s, it is not surprising that we found that the state of the economy was of pressing concern to most citizens.
Overall there were no significant differences between C-L and C-R voters when it came to identifying health care or particular health care problems as an important issue. However, in 2009 some differences were pronounced, such as the identification of health care problems, experience with problems, and priority that should be given *t test was performed to assess the differences in probabilities; significance level is at P < 0.001. †t test was performed to assess the differences in probabilities; significance level is at P < 0.05.
to particular health care problems. Some findings are, therefore, in accordance with the trends in other consolidated democracies, where left oriented voters are more supportive of, and concerned with, social welfare policies, including health care (1,2). This also signals to Croatian parties that they can focus on health care issues in order to achieve electoral gain. Our study showed that women, respondents with lower education levels, and respondents with lower income viewed health care as the most important issue in the 2007 election. A 2007 study found that only sex was a significant predictor of attitudes toward selecting health care as the most important issue (32). This confirms that the most socially and economically vulnerable groups in Croatian society are the ones that have the greatest concern for health care, which brings up the issue of health inequalities. In the 2009 presidential election, many of these differences disappeared as the government, public, and media focus shifted toward problems in the domestic economy brought on or accentuated by the global economic and financial crises.
Finally, health care corruption is a persistent problem in Croatian health care, which is not only a product of public perception, but is supported by public experiences with corruption.
We demonstrated that health care was an issue that cut across party lines. However, until recently, only two Croatian parties had a clearly stated mandate that included health care sector performance and reforms. This discrepancy between public opinion and party mandates indicates a greater need for the political parties to compete on the basis of clearly articulated issue-based programs, and include public concerns in their health care policymaking.
Funding None.
ethical approval Not required.
Declaration of authorship DR wrote the main text of the manuscript and developed the idea for the paper. ADž is the project coordinator for the Health Care and Elections in Croatia developed by "PIN for Health, " Zagreb, Croatia, an outcome of which is this study. He developed basic research framework, organized the survey, and participated in all phases of the manuscript development. VB was involved in data acquisition, analysis and interpretation, critical revision for important intellectual content, and final version revision.