Preliminary observations by UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Mr. Dainius Pūras at the Country visit to Croatia, 28 November to 6 December 2016

Croatia version

Zagreb, 6 December 2016

Members of the press, 
Ladies and gentlemen,

Good afternoon and thank you all for coming. Today, I finish an intensive nine-day visit to Croatia and I am here to present my preliminary observations. These will be further elaborated in a comprehensive report to be presented to the UN Human Rights Council in June 2017. You will find in this room a short document that explains my responsibilities as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health). As you will notice, I am an independent expert who reports to, and advises, the UN Human Rights Council and the UN General Assembly on the realisation of the right to health.

Before continuing further, I would like to sincerely thank the Government of Croatia for inviting me to visit the country and for the excellent collaboration extended in preparing for and during the visit. I highly appreciate the openness and frankness that prevailed in all meetings, in a genuine spirit of dialogue and cooperation.

I met with high-ranking Government officials, members of the judicial and legislative branches, and with representatives of international organizations and civil society. I visited the Clinical hospital Dubrava, primary health centres Zagreb-West and Zagreb-East, the University Hospital Centre in Osijek, where I also had the opportunity to deliver a lecture to medical students. I visited the Psychiatric hospital in Vrapče, the Centre for community-based services “I am just like you” in Osijek, and the Counselling Centre for the Prevention and Treatment of Addiction in Split.

I paid a moving visit to the hospital in Vukovar and heard first-hand about the painful experience they went through 25 years ago and about the commitment of medical staff in most challenging contexts. I further visited the 5th Gymnasium in Zagreb, the Reception Centre for Asylum Seekers in Porin and the Roma settlement Vrtni Put. I would like to take this opportunity to thank the United Nations in Croatia for their crucial support to my visit. 

After nine days in the country, I have gathered a wealth of information and testimony on my priorities for this visit, including the availability, accessibility, acceptability and quality of health services, goods and facilities, underlying determinants of health, primary healthcare, mental health, sexual and reproductive health rights and the special conditions of groups in situation of vulnerability including people on the move, children and older persons.

General context and achievements

With a relatively recent independence from Yugoslavia in 1991, Croatia successfully joined the European Union (EU) in July 2013. I learnt that this involved the revision and amendments of around 680 pieces of legislation, including a strengthened role of the Ombudsperson. Croatia has ratified almost all UN international human rights treaties and recently became a member of the Human Rights Council.

Croatia has made important efforts towards the progressive realization of the right to health.  Despite the difficulties stemming from the war, the transition of the health-care and other sectors in the 1990s, and the financial crisis of 2008-2009, the State has strengthened health-related policies and services in an attempt to make the healthcare system sustainable.

The authorities have taken steady measures to develop and strengthen primary and specialized healthcare, including through developing University Medical Centres in Zagreb, Split, Rijeka and Osijek. They also made good efforts to initiate needed reforms in the area of mental health.

Croatia should use this historic opportunity to further advance the right to health by investing in a human rights-based approach, in line with the Agenda 2030 and the Sustainable Development Goals (SDGs). Structural EU funds should be devoted to this aim and should be used in a transparent manner and in full compliance with universal human rights principles

Mental health

Mental health has taken priority at the international level as reflected by recent discussions at the Human Rights Council and the General Assembly. The World Health Organization (WHO) in recent years has also addressed mental health as a priority. In particular, the Convention of the Rights of People with Disabilities (CRPD) has brought forward new standards to fully protect the rights of persons with disabilities, in particular persons with intellectual and psychosocial disabilities.

Croatia was among the first countries in the world to ratify the CRPD, in August 2007, and to start investing in pilot community-based projects to end institutionalization. One such example is the experience developed at the Centre “I am just like you” in Osijek. I will recommend this practice for replication in Croatia and other countries. There, I could see how people with psychosocial disabilities are now fully included in society, living in regular apartments, in small groups and with minimal regular support from staff of the Center. This is an example of the way to invest throughout the country, as this transformation is beneficial for both the persons with psychosocial disabilities and society at large and shows that it is possible to end the sad legacy of institutional care if there is will.

However, these pilot projects have not yet been enough to make a difference in the national system. So far, around 4,200 people with mental disabilities still live in institutional care, deprived of their liberty and not able to fully enjoy their rights in an equal manner with other members of the society. While the social welfare system is making attempts towards de-institutionalization, the health-care system is not contributing enough to these attempts and it continues to be reliant on biomedical interventions and psychiatric hospitals. In general, with regards to funding and decision-making, the mental healthcare system remains dominated by large inpatient and residential psychiatric facilities.

I would like to recall that already in its World health report 2001, the WHO highlighted that in order to have rights-compliant and cost-effective mental health care systems mental health services should be integrated in community-based health and social services. Segregated institutions aimed at the long-term care of persons with psychosocial disabilities, as well as large psychiatric hospitals should no longer be supported and expanded as models for mental health policies and services.

However, in Croatia, this shift in policy and practice is yet to happen, and I hope it will happen in the nearest future. Croatia has an incredible opportunity to replicate throughout the country the good experiences that have already proven to be rights compliant and effective. De-institutionalization should be the final goal, and I believe that each county should develop a plan to implement the transformation towards community-based mental health services, so that there is no longer a need to rely on large psychiatric institutions.

I was happy to learn about the new legal framework and measures aimed at addressing many of the recommendations issued in 2015 by the Committee on the Right of People with Disabilities. At the same time, I also learnt and observed that, when it comes to persons with psychosocial and intellectual disabilities, there are important challenges in terms of coordination. Some good efforts by the social welfare system are directed at reducing reliance on institutional care, stigma and discrimination to ultimately reduce the number of people living in institutional care. However, the healthcare system, largely based on treatment in psychiatric hospitals with mainly biomedical interventions, is “feeding” the institutional care system, keeping its clients hostages of these institutions.

For example, the number of children with disabilities in institutional care has increased and there is a lack of adequate treatment and quality care for children in these institutions, as well as lack of services in the community. Both UN-supported and other researches have shown that the placement in long-term institutions deprives children of their right to live in supportive family environments and also often deprives them of appropriate development support, including the enjoyment their right to education.

In addition, there does not seem to be enough efforts to enable non-violent environments for children and adolescents, including efforts aimed at preventing bullying in schools, protecting children from any form of violence in families and developing a network of community-based mental health services for children and adolescents at the county level.

Sexual and reproductive health rights

I was encouraged to learn about the announcement by the Prime Minister, shortly before my visit, regarding Croatia’s intention to ratify the Council of Europe Convention on preventing and combating violence against women and domestic violence, which it had signed in January 2013. I hope that this ratification will become a reality soon.

However, I was discouraged to hear that some policy makers are being influenced in their decisions by a growing number of church-affiliated organizations who continue to oppose well-established instruments and mechanisms for the promotion and protection of women’s sexual and reproductive health rights.

Not only last year’s recommendations of the Committee on the Elimination of Discrimination against Women on the issue are still valid today, but further attempts to implement retrogressive measures seem to be under way, including a recent redefinition of marriage in the Constitution, and a pending revision of the Law of Abortion of 1978, before the Constitutional Court. The implementation of this Law was already facing some challenges, such as hospitals’ denial of abortion on the ground of conscientious objection. In addition, the use, availability and accessibility of modern contraception and reproductive services continue to be low and excluded from the services that are covered by the Croatian Health Insurance Fund.

I also learnt about remaining challenges regarding shelters and counselling centres for victims of domestic violence, including their lack of consistent and adequate funding. Legal reforms are necessary to effectively protect women from domestic violence, and to address arguable gaps in the implementation of the hate crime provisions of the Criminal Code, regarding violence against LGBT people.

On the other hand, while sexuality education was introduced in schools, not enough hours per year are allocated to this important topic and the delivery of the relevant module actually depends on each teacher, who often refuse to do it on the basis on misleading arguments that prevent children and adolescents from making informed decisions about their sexuality and adopt healthy sexual behaviours.

I would like to underline that sexual and reproductive health rights are human rights. Retrogressive measures preventing access to safe abortion and contraceptives, and hindering access to age-appropriate comprehensive sexuality education, may amount to human rights violations. Sexual and reproductive health rights also indicate that primacy should be given to women’s and children’s rights and not to the family unit.  

I urge all stakeholders in Croatia to critically address the attacks on universal human rights principles based on “conspiracy” theories which are detrimental to the enjoyment of all rights, including the right to health, in particular of women and children. I urge the Croatian authorities to follow universal and regional human rights principles and standards which, if applied in a consistent manner, constitute the basis for the realisation of the right to health and other rights.

People on the move

Asylum-seekers in Croatia are entitled to health care, but with the last amendments to the Law on Asylum, health care was restricted to emergency care. This has prevented effective access to health care, particularly by children and pregnant women who are both asylum-seekers and migrants.

Many children arriving in Croatia have not been vaccinated against preventable diseases. Urgent efforts are needed to vaccinate all children without relevant health records that arrive or are born in Croatia and to provide all pregnant women with regular medical care, irrespective of her nationality or legal status. Another important gap refers to the suspension of mandatory initial medical check-ups upon arrival, which should immediately be reinstated.  

I learnt that, in recent months, the provision of services has improved in the Reception Centre of Porin through the regular attendance of a General Practitioner and support of the non-governmental organization Médecins du Monde; however the work that is now undertaken by the latter should be promptly taken over by national authorities to ensure continuity, ownership and compliance with Croatia’s international obligations. There are additional gaps related to this situation which I will address in my report.

On the other hand, I was encouraged to hear about the work done by humanitarian organizations vis-à-vis the refugee emergency response. These organisations should have access to all migrants in need irrespective of their legal status. Migrants should always be treated in a way that respects their dignity and upholds their fundamental rights.

Roma and other groups in situation of vulnerability

During my visit to a Roma settlement, I noted that environmental conditions may be a threat to the health of the Roma people. I also learnt that their diet is nutritionally deficient which is particularly affecting children and has a direct impact on school drop-out rates. Deficient diets also largely contribute to worsen adult’s chronic diseases.

Available data indicates that one-fifth of Roma children in Croatia may not have access to health care and that infant mortality rates of Roma children are significantly above the national average.  In addition, Roma women face various constraints to access healthcare. In meetings with the Government’s Office of Human Rights and National Minorities, I learnt about ongoing and upcoming measures specifically targeting the Roma population which may need to be further supported and strengthened.

During my 9-day visit, I also had the chance to hear about local measures addressing older persons with community-based approaches. I further examined issues pertaining to the health of children that will be later developed in my report. 

National health system

While the proportion of the Gross Domestic Product allocated to the health sector and the per capita health expenditure remains relatively low compared to high-income European countries, the share of public expenditure devoted to the health sector in Croatia is still relatively high by European standards.

Overall, life expectancy at birth in the country has been increasing progressively, but new public health concerns have appeared in recent years, including a prevalence of overweight and obesity and worrisome trends regarding physical inactivity.

In various meetings, I have consistently stressed the importance of primary health care which should be strengthened so as to, inter alia, detect and treat mild forms of illnesses at early stages before they reach a level of that needs specialized medical attention. Having solid primary health care services which are trusted by the people is crucial to rationalize the resources allocated to specialized medicine.

Members of the press,
Ladies and gentlemen,

Croatia has walked a long way since the war and now as member of the EU and newly appointed member of the Human Rights Council. The country cannot afford to go back or stagnate when it comes to the promotion and protection of human rights.  Human rights are not only a matter of acquired obligations of the State, but a matter of ensuring the full realization of the rights and well-being of all people in Croatia as human beings.

Croatia is to be commended for its efforts in setting up a framework for the enjoyment of the right to health. The country should continue to move forward without sliding back or implementing retrogressive measures. Remaining gaps need to be addressed, and the political will seems to be there.

Croatia has today a good opportunity to become a real inclusive society but it must avoid a selective approach that discriminate against certain groups while favouring others.

I would like to thank once again the Government for inviting me to visit the country and I hope that my recommendations will assist Croatia to continue moving forward.

Thank you.