Challenges for health care development in Croatia [Izazovi razvoja zdravstvenog sustava Republike Hrvatske]

The main aim of the research done in this paper was to establish key challenges and perspectives for health care development in the Republic of Croatia in the next two decades. Empirical research was conducted in the form of semi-structured interviews involving 49 subjects, representatives of health care professionals from both, public and private sectors, health insurance companies, pharmaceutical companies, drug wholesalers, and non-governmental organisations (patient associations). The results have shown that key challenges and problems of Croatian health care can be divided into three groups: functioning of health care systems, health care personnel, and external factors. Research has shown that key challenges related to the functioning of health care are inefficiency, financial unviability, inadequate infrastructure, and the lack of system transparency. Poor governance is another limiting factor. With regard to health care personnel, they face the problems of low salaries, which then lead to migration challenges and a potential shortage of health care personnel. The following external factors are deemed to be among the most significant challenges: ageing population, bad living habits, and an increase in the number of chronic diseases. However, problems caused by the global financial crisis and consequential macroeconomic situation must not be neglected. Guidelines for responding to challenges identified in this research are the backbone for developing a strategy for health care development in the Republic of Croatia. Long-term vision, strategy, policies, and a regulatory framework are all necessary preconditions for an efficient health care system and more quality health services

Health and Health Care Systems: from Millennium Development Goals to Sustainable Development Goals

Potpuno ostvarivanje prava na zdravlje ključno je za ostvarivanje drugih ljudskih prava i osnova za više dimenzija održivog razvoja. Ujedno, zdravlje je posljedica, ali i preduvjet razvoja te je ključno za blagostanje ljudi. Ulaganje u zdravlje, posebno u prevenciju bolesti, potiče ekonomski rast i razvoj zemlje učincima na obrazovna postignuća i stjecanje vještina, produktivnost i zaposlenost, povećanu štednju i investicije, demografsku tranziciju i utjecaje na zemljin ekosustav. U radu se razmatraju važnost zdravlja i učinkovitih zdravstvenih sustava za održivi razvoj te njihova uloga u Milenijskim ciljevima razvoja i Ciljevima održivog razvoja. U 21. stoljeću prioritet je uz održiv razvoj maksimalizirati zdravstveno blagostanje u svakoj životnoj dobi uz opću pokrivenost zdravstvenom zaštitom i prozdravstvenim politikama u svim sektorima. Stvaranje održivih zdravstvenih sustava budućnosti zahtijeva preoblikovanje potražnje za zdravstvenim uslugama smanjujući teret oboljenja, pomažući ljudima da ostanu zdravi i osnažujući ih da upravljaju svojim zdravljem.Full enjoyment of the right to health is crucial for the enjoyment of other human rights, and has a central role in many other dimensions of sustainable development. In addition, human health is a consequence, but also a precondition of development, and is crucial to human welfare. Investment in health, especially prevention, fosters the economic output of a country through its effects on education achievements and skills acquirement, labour productivity and employment, increased savings and investments, demographic transition and the earth\u27s ecosystem. This paper analyses the importance of health and efficient health systems in terms of sustainable development, and their role in Millennium Development Goals and Sustainable Development Goals. Through sustainable development in the 21st century, the priority is to maximize health welfare for all age-groups, through universal health protection and pro-health policies in all sectors. Creating sustainable health care systems for the future demands reshaping the demand for health care services, diminishing the burden of illness, helping people to stay healthy, and empowering them to manage their own health

Hepatitis C

Infekcija hepatitis C-virusom (HCV) vodeći je javnozdravstveni problem diljem svijeta. Nažalost, nakon akutne, do progresije u perzistentnu HCV-infekciju dolazi u velike većine zaraženih osoba (80%). Klinički je tijek HCV-infekcije podmukao i asimptomatski te se dijagnoza kroničnog C-hepatitisa najčešće postavi slučajno tijekom pregleda krvi kod rutinskih sistematskih pregleda. Inače, klinička defi nicija kroničnog hepatitisa odnosi se na upalu jetre koja, bez bitnog poboljšanja, traje dulje od 6 mjeseci. Dugoročne komplikacije HCV-infekcije su ciroza jetre i hepatocelularni karcinom. Upravo stoga su, danas, kronične bolesti jetre uzrokovane HCV-om najčešća i vodeća indikacija za transplantaciju jetre. Osnovni ciljevi liječenja hepatitisa C su eradikacija virusne infekcije i sprječavanje progresije bolesti. Današnji zlatni standard antivirusne terapije je kombinacija pegiliranog interferona i ribavirina, čija učinkovitost iznosi od 45 do 80% zavisno od inicijalnih obilježja bolesti. Samo poboljšanje terapije donijelo je povećanje neposrednih troškova liječenja virusnog hepatitisa, no uz dugoročne uštede u smanjenju troškova liječenja dekompenzirane jetrene bolesti uključujući transplantaciju jetre.Infection with hepatitis C virus (HCV) is a major global public health problem. Unfortunately, once established, the HCV infection persists in the vast majority of patients (80%). The clinical course of the disease is asymptomatic, with infection often identifi ed only on routine biochemical screening. Chronic hepatitis implies viral infection and secondary infl ammation that, without any signifi cant improvement, persist for more than six months following the initial exposure. The long-term complications of chronic hepatitis C are cirrhosis and hepatocellular carcinoma. Therefore, the end-stage liver disease associated with HCV infection is the most common indication for liver transplantation around the world. The main goals in the treatment of chronic hepatitis C are the eradication of the viral infection and prevention of progression to the end-stage liver disease. The current gold standard treatment is a combination of pegylated interferon and ribavirin, which achieve a sustained viral response in 45% to 80% of treated patients depending on patient characteristics. Improvements in therapy caused the increase in the costs of treatment of viral hepatitis, but with signifi cant long-term savings in the treatment of advanced liver disease, including liver transplantation

Health and Health Care Systems: from Millennium Development Goals to Sustainable Development Goals

Potpuno ostvarivanje prava na zdravlje ključno je za ostvarivanje drugih ljudskih prava i osnova za više dimenzija održivog razvoja. Ujedno, zdravlje je posljedica, ali i preduvjet razvoja te je ključno za blagostanje ljudi. Ulaganje u zdravlje, posebno u prevenciju bolesti, potiče ekonomski rast i razvoj zemlje učincima na obrazovna postignuća i stjecanje vještina, produktivnost i zaposlenost, povećanu štednju i investicije, demografsku tranziciju i utjecaje na zemljin ekosustav. U radu se razmatraju važnost zdravlja i učinkovitih zdravstvenih sustava za održivi razvoj te njihova uloga u Milenijskim ciljevima razvoja i Ciljevima održivog razvoja. U 21. stoljeću prioritet je uz održiv razvoj maksimalizirati zdravstveno blagostanje u svakoj životnoj dobi uz opću pokrivenost zdravstvenom zaštitom i prozdravstvenim politikama u svim sektorima. Stvaranje održivih zdravstvenih sustava budućnosti zahtijeva preoblikovanje potražnje za zdravstvenim uslugama smanjujući teret oboljenja, pomažući ljudima da ostanu zdravi i osnažujući ih da upravljaju svojim zdravljem.Full enjoyment of the right to health is crucial for the enjoyment of other human rights, and has a central role in many other dimensions of sustainable development. In addition, human health is a consequence, but also a precondition of development, and is crucial to human welfare. Investment in health, especially prevention, fosters the economic output of a country through its effects on education achievements and skills acquirement, labour productivity and employment, increased savings and investments, demographic transition and the earth\u27s ecosystem. This paper analyses the importance of health and efficient health systems in terms of sustainable development, and their role in Millennium Development Goals and Sustainable Development Goals. Through sustainable development in the 21st century, the priority is to maximize health welfare for all age-groups, through universal health protection and pro-health policies in all sectors. Creating sustainable health care systems for the future demands reshaping the demand for health care services, diminishing the burden of illness, helping people to stay healthy, and empowering them to manage their own health

TREATMENT OF NON-1 GENOTYPE CHRONIC HEPATITIS C PATIENTS

U Republici Hrvatskoj infekcija ne-1 genotipom registrirana je u 41,2 % bolesnika s kroničnim hepatitisom C. Od posljednjih smjernica za liječenje ove skupine bolesnika iz 2009. godine malo je novosti. Aktualnom terapijom trajni virološki odgovor postiže se u 43-85 % ne-1 KHC bolesnika. Najniži postotak postiže se u bolesnika s infekcijom genotipovima 3 i 4. Posljedično tome preporuča se prilagođavanje dužine liječenja, ali i doze RBV odnosno individualizacija terapije ovisno o pojedinim parametrima. Najvjerodostojniji prediktivni faktori trajnog virološkog odgovora jesu: brzi virološki odgovor, bazalna viremija, indeks tjelesne mase, inzulinska rezistencija, metabolički sindrom, stadij fibroze/ciroza i životna dob. Nedavno objavljeni rezultati studije PROPHESYS potvrđuju da određivanje brzog virološkog odgovora ima pozitivnu prediktivnu vrijednost za procjenu učinka liječenja i u ne-1 KHC bolesnika. Potencijalnu korist od skraćivanja liječenja (24 tjedna) nisu jednoznačni i eventualno se može razmišljati u bolesnika s nepovoljnim bazalnim parametrima koji su postigli odgođeni virološki odgovor i koji su CC homozigoti za IL28B. S obzirom na nezadovoljavajući učinak aktualnog protokola liječenja za bolesnike s ne-1 genotip kroničnim hepatitisom C očekujemo na tom području intenzivnija istraživanja.Infection with non-1 genotype in Croatia is detected in 41.2% of patients with chronic hepatitis C. Since the last treatment guidelines for hepatitis C patients, little has been changed. With today’s standard of care, sustained viral response can be achieved in 43% to 85% of non-1 CHC patients, which is not satisfactory at all. The lowest cure rate is usually found among patients with genotype 3 and 4 infection. The grouping of genotype 2 and genotype 3 patients to “easy to treat” genotypes was an unfortunate consequence of their underrepresentation in previous large registration clinical trials. Careful re-examination of the data obtained shows clearly enough that patients with genotype 3 infection respond less to treatment than genotype 2 patients. They sometimes behave more like patients with genotype 1 infection. Small progress is found in treatment approach and viral kinetics might be a useful tool for tailoring therapy to improve efficacy. Rapid virologic response is the best parameter to predict success of therapy. For patients who achieve a rapid viral response, consideration of shortened therapy (24 weeks) in patients who do not achieve a rapid viral response would be beneficial, particularly in patients with genotype 3 infection and poor prognostic factors, but formal recommendation should be confirmed in prospective trails. New data suggest a prognostic role for IL28B polymorphisms mostly in genotype 3 patients not achieving a rapid viral response and these could also be considered for improved tailoring of therapy. In conclusion, new treatments are urgently needed for non-1 genotype chronic hepatitis C patients. So far, telaprevir and boceprevir have failed to show a satisfactory activity in these genotypes. Evaluation of many promising molecules such as second generation of protease inhibitors or NS5B nucleos(t)ide inhibitors, NS5A inhibitors, cyclophilin inhibitors or their combinations with or without pegylated interferon or ribavirin is still in progress

CHRONIC LIVER DISEASES IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Funkcionalni integritet jetre od vitalne je važnosti za zdravlje svakog pojedinca pa tako i kroničnih bubrežnih bolesnika. Pri evaluaciji bolesti jetre rutinski se određuju aminotransferaze. Njihova serumska koncentracija u kroničnih bubrežnih bolesnika često je na donjoj granici normale te normalne vrijednosti aminotransferaza ne znače nužno i odsustvo bolesti. Prema nekim autorima u praksu je potrebno uvesti „niže“ gornje vrijednosti normale za kronične bubrežne bolesnike. Stadij kronične bolesti jetre izražava se stupnjem fibroze (Ishak ili METAVIR). Kronični virusni hepatitis B i C najznačajniji su komorbiditet u bolesnika s bubrežnom bolesti. Prema preporukama Hrvatske konsenzus konferencije o virusnom hepatitisu terapija se preporuča u kroničnih bubrežnih bolesnika posebno ako su na listi čekanja za transplantaciju bubrega. Odluku o načinu liječenja treba temeljiti na procjeni dobrobiti, ali i rizika terapije. Nealkoholna masna bolest jetre rastući je javnozdravstveni problem a prema novijim saznanjima povezana je i s povećanjem prevalencije i incidencije kroničnog zatajenja bubrega. Ciroza jetre je terminalni stadij bolesti jetre kada reverzibilnost oštećenja više nije moguća. Preživljenje bolesnika s cirozom jetre ovisno je o Child-Turcotte-Pugh stadiju i najlošije je za bolesnike sa stadijem C što je potrebno imati na umu pri evaluaciji za liječenje transplantacijom bubrega.The morphological and functional integrity of the liver is vital to human health in general as well as to patients with renal disease. Any chronic liver disease will eventually lead to liver insufficiency. Liver enzymes are routinely measured to assess liver function in patients with or without renal failure. The use of standard reference values of aminotransferases to help detect liver disease is less useful in patients on chronic dialysis therapy. Some investigators have suggested that, to increase the sensitivity of liver function tests among dialysis patients, lower “normal” values of aminotransferases should be adopted. Liver biopsy may be helpful for assessing the activity and severity of liver disease, especially in chronic viral liver diseases. The most widely used scores are Ishak (6-point scale) and METAVIR (4-point scale). The most important chronic liver diseases associated with chronic renal disease are hepatitis B and C. Several types of renal disease have been recognized: mixed cryoglobulinemia, membranoproliferative glomerulonephritis, membranous nephropathy and polyarteritis nodosa. In any patient first ever diagnosed with any of the mentioned features, serologic and molecular tests for hepatitis B and/or C should be done. There is limited information on the treatment of HBV-associated renal diseases. Nonrandomized studies suggest that antiviral therapy may be beneficial in patients with glomerular disease or vasculitis due to HBV. According to Croatian National Guidelines for Hepatitis B and C, treatment with antiviral drug is recommended for patients with chronic renal disease, especially those on the waiting list for kidney transplantation. Decision on the type and duration of treatment is based on the level of viremia and biochemical and histological activity of liver disease. Several antiviral drugs are currently used for hepatitis B: pegylated interferon alpha-2a and nucleot(z)id analogues. The choice of analogues is based on their genetic barrier and resistance. The probability to develop resistance is much higher in prolonged treatment, more than 1 year. To avoid it, regular check-ups are mandatory. First check-up is recommended after 12 weeks of treatment to detect the possible primary resistance to treatment. Similar approach is used in patients with hepatitis C. Today’s standard of care is treatment with a combination of pegylated interferon alpha and ribavirin. Serum concentration of both drugs rises in patients with impaired renal function. The dosage should be corrected according to the glomerular filtration rate. Treatment with pegylated interferon alpha is not recommended in patients with glomerular filtration rate less than 15 mL/min and ribavirin less than 50 mL/min. Recent evidence suggest that nonalcoholic fatty liver disease is associated with an increased prevalence and incidence of chronic renal disease. Current treatment recommendations for nonalcoholic fatty liver disease are limited to weight reduction and treatment of any component of the metabolic syndrome. Liver cirrhosis is the terminal stage of any chronic liver disease. Mortality differs according to the stage of cirrhosis evaluated with Child-Turcotte-Pugh score. The worst prognosis have patients with grade C cirrhosis, which should be borne in mind when evaluating patients with terminal renal disease for treatment with kidney transplantation

Public access to the “Restart a Heart – Save a Life” early defibrillation programme in Croatia

In collaboration with the Croatian Institute of Emergency Medicine and the Croatian Institute of Public Health, the Ministry of Health launched the National Public Access to Early Defibrillation Programme entitled “Restart a Heart – Save a Life” in 2013. The main implementing activities are public health education about early defibrillation in the case of sudden cardiac arrest, enlarging the accessibility of the automated external defibrillator (AED) and training laymen to perform cardiopulmonary resuscitation and defibrillation by use of AED. Forty-one training courses were organised and 422 lay people trained in 2013. In addition, 197 AEDs were obtained and fitted in settings where people are expected to assemble permanently or occasionally. The “Restart a Heart – Save a Life” programme ensures a broad platform for joint action of public administration authorities, governmental and nongovernmental agencies, and all organisations and individuals interested in reaching the goal of increasing the rate of survival of people suffering from a sudden cardiac arrest

MONITORING OF PATIENTS WITH CHRONIC HEPATITIS DURING AND AFTER THERAPY

Unatoč razvoju učinkovitih lijekova koji umanjuju nepovoljni ishod akutnih i kroničnih bolesti izazvanih infekcijom virusima hepatitisa B i C te su bolesti i nadalje globalni zdravstveni i socijalno društveni medicinski problem. Danas su na raspolaganju osjetljivi i specifični testovi za HCV i HBV kojima se ne testira opća populacija nego samo rizične skupine. Kod sumnje na infekciju C hepatitisom određuju se antiHCV antitijela, potom HCV RNK kvantitativno i uvodi terapija prema nalazu genotipa, viremiji i prihvaćenim kriterijima. Težina oštećenja jetre i fibroza određuju se biopsijom jetre ili danas češće sveopće prihvaćenim neinvazivnim metodama: uglavnom elastografijom ili serološkim biljezima za fibrozu. Neliječeni HCV bolesnici također se prate do mogućnosti liječenja. Bolesnici s HCV cirozom jetre prate se u smislu detekcije hepatocelularnog karcinoma (HCC), odnosno najčešća su indikacija za ortotopnu transplantaciju jetre. Sva se novorođenčad cijepi protiv virusa hepatitisa B, a rizične se skupine testiraju na HBsAg, antiHBc i antiHBs protutijela. Bolesnicima s pozitivnim HBsAg, HBeAg ili antiHBe, te HBV DNK kvantitativno se određuje HBAg i HBV DNK, jer su vrijednosti prediktori uspješnog liječenja. Utvrđuje se težina jetrene bolesti i uvodi liječenje interferonom ili analozima nukleoz(t)ida. Terapija peroralnim antivirusnim lijekovima je pretežno doživotna. Bolesnici s HBV cirozom i inaktivni HBsAg nosioci doživotno se prate zbog rane detekcije HCC-a odnosno liječe se prema indikaciji transplantacijom jetre.Different effective treatments, which are today available for chronic virus hepatitis C and B, reduce the rate of adverse outcomes but HCV and HBV infections are still one of the major health and public medical problems. Screening for HCV and HBV is performed only in high-risk groups with diagnostic tests with high sensitivity and specificity. In HCV antibody positive patients, serum HCV RNA has to be determined by quantitative assay and virus genotype identified. Liver fibrosis is determined by liver biopsy or widely accepted elastography and different serum fibrosis markers. In patients with HCV cirrhosis, HCC has to be detected by expert ultrasound performer or MSCT, MR, and liver transplantation performed according to indications. The current hepatitis B vaccination policy is universal neonatal vaccination. The risk population undergo screening for HBsAg, antiHBc and antiHBs antibodies. The HBsAg, HBeAg and antiHBe positive individuals undergo quantitative testing for HBsAg and HBV DNA. According to the stage of their liver disease, patients are treated with interferon or nucleos(t)ide analogues. The optimal treatment with oral antivirals are entecavir and tenofovir, but the duration of treatment with nucleos(t)ide analogues is generally life-long. In HBV cirrhosis and HBsAg inactive carriers, detection of HCC is essential, and liver transplantation is successfully performed in these patients