19 MARTINDALE CENTER FOR THE STUDY OF PRIVATE ENTERPRISE nursing homes would have to spend about 94% of their income on care (OECD, 2023b). Instead, many are left to rely on unpaid family members. Confronting the obstacle of unaffordable facilities is essential because unmet health-care and social needs are 19 times greater among low-income groups compared to high-income groups (OECD, 2023a). Unmet needs range from activities of daily living, such as bathing, cooking, cleaning, and managing money, to handling medications and the ability to perform at-home treatments (OECD, 2023b). Although national statistics do not provide a direct breakdown by region, the concentration of poverty in rural areas suggests that gaps are likely most severe among older adults in remote communities. Without LTC services, health complications, mortality, and the burden on society all increase. Beyond expanding long-term geriatric care infrastructure, improving rural health-care access will require remedying the severe medical personnel deficit. The challenges of caring for a predominantly geriatric population in rural regions are intensified by emigration. Approximately 87% of Croatian citizens share a deeply rooted belief that children have a duty to care for aging parents (Gedeshi et al., 2020). Croatia ranks among the top EU countries where family-based care is the norm. The responsibilities of remembering doctor appointments, dispensing medications, and performing household duties fall mainly on family members or friends, as many older individuals cannot handle these tasks alone. Since Croatia’s admission to the EU in 2013, over 50,000 citizens have emigrated annually, reducing the availability of family and other informal caregivers who traditionally support the elderly. Prior to 2021, an estimated 7500–8000 nurses and more than 1000 physicians have emigrated from the country (Jurić, 2021). Contributing factors to their emigration are poor working conditions, low wages, and minimal professional support. Consequently, physicians increasingly take on social care responsibilities on top of clinical duties, intensifying pressure on an already understaffed system (E. Slapnicar, M.D., personal communication, September 29, 2025). With Croatia’s improved economic stability since gaining EU membership, costs of living have outpaced generally low salaries, making it common for both partners in a household to work, thereby reducing their ability to care for aging parents. Rising labor force participation among younger adults makes long-term home caregiving unsustainable. With fewer younger people available, one-third of caregivers are themselves 65 or older (OECD, 2023b). Additionally, caring for the chronically ill puts mental and physical burdens on caregivers who are not trained for those jobs. About half of caregivers report difficulties combining care tasks with their own daily activities and 38% report financial strain (OECD, 2023b). Given these factors, elderly care must shift from informal caregivers to professional health-care personnel, but this transition becomes problematic because of the simultaneous emigration of the general public, in particular healthcare personnel, from Croatia. Barriers to care In Croatia’s system, counties are responsible for establishing general and specialized hospitals, primary health-care centers, and elderly homes (Džakula et al., 2021). If rural areas do not have the funding and adequate numbers of medical personnel and management teams, the problem of access to LTC is difficult to solve. Medical personnel shortages In 2022, for every 10,000 individuals, Croatia had 39.6 total medical doctors and only 8.3 general physicians, the providers older adults rely on most for preventative care and chronic disease management (Eurostat, 2022). Although roughly 6000 students graduate from medical schools annually, this influx is insufficient to offset attrition through emigration and retirement (World Health Organization, 2022). Earlier estimates projected that by 2025 Croatia would have lost at least one-third of its physicians compared with 2021 levels (Jurić, 2021). The nursing workforce faces a similar decline. Nurse density fell from 7.4 per 1000 inhabitants in 2021 to 4.6 by 2025, far below the EU average of 9 (Croatian Perspective…, 2023). No data exist for doctors and nurses practicing specifically in rural communities, though research suggests an extremely uneven distribution of medical professionals outside urban areas. Without an adequate medical workforce, staffing more LTC facilities is a struggle. Remote regions face additional challenges recruiting recently graduated physicians and nurses. Croatia’s health-care system and medical schools are heavily concentrated in major cities. The top five hospitals are in Zagreb, Split, and Rijeka, providing many of the same services as each other. Currently, no policy initiatives address the imbalance between urban and rural facility distribution. Several factors may explain the relative scarcity of health facilities in rural areas. The clustering of hospitals could be partially attributable to the location of medical schools: Cro-
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