21 MARTINDALE CENTER FOR THE STUDY OF PRIVATE ENTERPRISE provided the knowledge and skills to work in a rural area (Mrduljaš-Ðujić et al., 2025). Inadequate geriatric training Geriatric-specific training is limited in undergraduate medical programs and is only a subspecialty of internal medicine in Croatia. Physicians can pursue a subspecialization in geriatrics through 5-year programs approved by the Ministry of Health, after graduating medical school (Stuck & Masud, 2022). However, the country has fewer than 40 certified geriatricians nationwide, the majority clustered in Zagreb, Rijeka, and only a handful of regional centers (Croatian Medical Chamber, 2023). As a result, geriatric care relies mainly on internists, family physicians, rehabilitation specialists, and multidisciplinary teams, who often do not have advanced expertise in the complex care requirements of older adults (OECD, 2023b). Clearly, training in both rural medicine and geriatric care is inadequate, with a major obstacle in that medical schools do not adequately prepare students to practice in rural settings. Restricted medical care funding The limited availability of LTC facilities across Croatia is partly due to health-care funding priorities. Croatia allocates 8.1% of its GDP to health care, notably lower than the EU average of 11%. LTC accounts for only 2.5% of this spending, compared to 17.3% in the EU. Most funding is directed toward outpatient services, medications, and devices rather than long-term, geriatric, or community-based care. Another factor for the uneven distribution of medical facilities is that funding for major hospitals historically comes from the Croatian Health Insurance Fund (HZZO) (Džakula et al., 2021). As a large government organization, the HZZO tends to prioritize hospitals in the most densely populated areas, even if high-risk populations, such as the elderly, are left underserved. This challenge is particularly pressing because in 2019, 0.7% of Croatians reported unmet medical needs due to distance, compared to the EU average of 0.1% (Džakula et al., 2021). Considering the country’s aging demographic profile, this underinvestment is concerning. If the physician deficit were resolved, funding for LTC still must be increased to provide up-to-date medical equipment and facilities as well as sufficient salaries for healthcare professionals. Health-care reforms Croatia’s health-care system operates through mandatory social health insurance funded and administered by the HZZO—the only national body that collects insurance contributions; pays hospitals, clinics, doctors, and pharmacies; and covers all services included in the mandatory health insurance system. Tertiary care, delivered through university hospitals and general hospitals, falls under the jurisdiction of the Ministry of Health and the national government. Counties manage and coordinate primary and secondary care services, including health centers, public health facilities, pharmacies, and general or specialized hospitals (Džakula et al., 2021). Rural areas receiving limited funding from the Ministry of Health have difficulties navigating this system if they hope to establish large, specialized hospitals. The Government of the Republic of Croatia, along with the EU, has recognized the scarcity of clinicians and the inadequacy of geriatric support. After the COVID-19 pandemic, the EU Recovery and Resilience Facility (RRF) created the National Recovery and Resilience Plans in 2021. The RRF’s goal was to enable the construction and renovation of hundreds of care facilities across the member states while enhancing the training of social and health-care workers, nurses, and caregivers. Each member state then develops a Recovery and Resilience Plan detailing funding needs and how it will use the RRF’s resources. The funding came from the RRF’s €8.1 billion budget of total expenditures related to LTC across all EU member states, with €49.1 million allocated to Croatia in 2024 (European Commission, 2025). This modest allocation reflects the fact that less than 2% of member states’ spending is devoted to long-term care. More recently, in 2025, the EU RRF has allocated over €340 million to the Croatian health-care system to bolster efficiency and quality over the next few years but still not focusing on LTC specifically (International Trade Administration, 2025). As of 2024, it was estimated that 18 elder care centers with a total of 1795 beds should be built using €160 million from the RRF (Umirovljenci zajedno - Politička platforma, 2024). These initiatives are still in early stages, and their outcomes have not yet been fully evaluated. One of the main priorities of the EU Multiannual Financial Framework for 2021–2027 is the LTC system. To strengthen coordination between health and social care sectors and enhance accessibility, efficiency, sustainability, and affordability of services, Croatia introduced the National Health Development Plan in 2021 (Banadinović et al., 2025). As part of that plan, the Healthcare Act transferred ownership of general hospitals from county-level governments to the national Ministry of Health in January 2024. This reform aimed at restructuring the hospital
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