Primary health care
Applicants are entitled to health care. However, the LITP prescribes that health care includes emergency care and necessary treatment of illnesses and serious mental disorders.
In 2020, an Ordinance on health care standards for applicants for international protection and foreigners under temporary protection entered into force regulating, amongst other, initial and supplementary medical examinations and the scope of health care for applicants of international protection. Additionally, the Ordinance lists the different vulnerable groups entitled to health care as follows: persons deprived of legal capacity, children, unaccompanied children, elderly and infirm persons, seriously ill persons, persons with disabilities, pregnant women, single parents with a minor children, people with mental disabilities and victims of human trafficking, victims of torture, rape or other psychological, physical and sexual violence, such as victims of female genital mutilation. These categories of persons have a right to psychosocial support and assistance in appropriate institutions A pregnant woman or a parturient woman who requires monitoring of pregnancy and childbirth is entitled to health care to the same extent as insured person from compulsory health insurance. Children up to the age of 18 are guaranteed the entire right to health care in accordance with the legislation governing the right to health care from compulsory health insurance.
Medical assistance is available in the Reception Centres for Applicants for International Protection in Zagreb and Kutina. While no information is available for the full year 2019, nor for 2020, at the beginning of 2019, the Ministry of Interior reported that health care is also provided by the health care institutions in Zagreb and Kutina designated by the Ministry of Health. In the Health Centre, a competent ambulance (family medicine) has been designated for the provision of health care from the primary health care level for chronic and life-threatening illnesses. A specialist ambulance for vulnerable groups has been appointed by the Ministry of Health and Local Health Centres. This includes: paediatric ambulance, gynaecological ambulance, school medicine ambulance, neuropsychiatric ambulance at the Hospital of Kutina, ambulance for addiction treatment; dental ambulances and Psychiatric Hospital in Zagreb.
In addition, applicants are referred to local hospitals i.e. in Sisak for those accommodated in Kutina, and the Hospital of Zagreb. The competent pharmacies, one in Zagreb and one in Kutina, have also been determined. Vaccination is performed by doctors in health centres or by specialists of school medicine.
A medical team of MdM was present at the Reception Centre in Zagreb every working day and in Reception Centre in Kutina depending on the needs.
Due to outbreak of COVID 19 in 2020, applicants for international protection were placed in a two-week quarantine and tested for COVID-19 based on medical assessments after being accommodated in Reception Centres for Applicants of International Protection. At the beginning of the COVID-19 pandemic, the Croatian Institute for Public Health issued Protocol related to testing for COVID-19 / SARS-CoV-2. The protocol states that, among others, applicants for international protection and refugees belongs to priority groups for testing.
Information posters and/or leaflets on COVID 19 and hygiene were prepared by the Croatian Institute for Public Health and Ministry of the Interior, Médecins du Monde (MdM), and the Croatian Red Cross.
The Institute of Ethnology and Folklore Research reported that foreigners without appropriate identification documents could order a free PCR test at the Teaching Institute of Public Health Andrija Štampar without difficulty soon after the outbreak of the epidemic, but stressed that the application of the City of Zagreb launched in November 2020 for rapid antigen tests required the entry of a health insurance number, which is why the app could not be used by applicants for international protection and persons granted international protection.
Complementary services by NGOs
In 2020, the MDM-Belgique team consisted of a medical doctor, a nurse and interpreters for Arabic and Farsi (3 to 5 people during 2020).  The team conducted daily health consultations at the level of primary health care in the Reception Centre for Applicants for International Protection in Zagreb (working with patients for 6 hours every working day) and in Kutina (depending on needs), and conducted official initial medical examinations of newly arrived applicants for international protection. In order to provide comprehensive support and care to patients, the community worker / social worker and interpreters provided practical support to applicants for international protection in terms of interpretation, provision of information and counselling, transport of patients to health care facilities for specialist consultation and diagnostic examinations, by transporting samples, medications, and medical records as needed. MDM-Belgique arranged the dates of examinations in health care institutions, and organised the transport schedule and patient transportation (including the transport schedule for the Croatian Red Cross).
Regular vaccination of children was carried out continuously in 2020 through the cooperation of the Ministry of Interior, Health Center, Andrija Stampar Teaching Institute of Public Health and the Croatian Institute of Public Health and MDM-BELGIQUE.
In accordance with the instructions of the Ministry of Health from 27 January 2020, the medical team of MDM-Belgique performed only initial medical examinations / emergency medical examinations and medical interventions, while referring other patients to the Ambulance for Applicants for International Protection at the Health Centre – Dugave. In this new organisational setting, MDM – Belgique also provided support to the general practitioner of the Health Centre with the division of prescribed therapy (on the recommendation of the general practitioner of the Health Centre) and through the organisation, coordination, making appointments and transportation of applicants to health facilities for specialist consultations and diagnostic examinations.
In 2020, the MdM’s medical team carried out 1,690 medical consultations with applicants for international protection out of which 483 initial medical examinations. Out of the 1,690 medical consultations: 38.05% were performed with women and 35.44% with children The average age of patients was 24 years and the two most represented nationalities were Afghans (29.86%) and Iraqis (28.12%). In addition, a total of 537 transports of applicants for international protection to health care facilities for the necessary specialist and diagnostic treatment were performed (including 67 transports for children to paediatricians / vaccinations / school medicine specialists).
Two MdM’s psychologists conducted individual psychological counselling sessions every working day for 6 hours in Zagreb and when necessary in Kutina. An external associate- psychiatrist visited the Reception Centre in Zagreb three times a month.
The MdM team provided 424 individual psychological counselling sessions and 117 specialist psychiatric examinations in the course of 2020.
All children who stayed in the Reception Centre upon arrival and for whom it was possible to obtain an appointment for specialist examination, were examined and vaccinated if necessary by a paediatrician at the Health Center Zagreb – Center or „Andrija Stampar“ Teaching Institute of Public Health. MDM-Belgique provided transportation of children to relevant health institutions and hospitals and other health centers with paediatric clinics.
Pregnant women who stayed upon arrival in the Reception Centre were examined by a gynaecologist at the Health Center and at the hospital. The MDM – Belgique team coordinated the transport of pregnant women for examinations, as well as visits of the nurse after childbirth. During summer 2020, a large number of pregnant women were accommodated in the Reception Centre.
However, MdM reported that one of challenge for the MdM team was the lack of available appointments for gynaecologists and paediatrics.
During the initial medical examination, applicants for international protection with a possible problem of addiction to psychoactive substances were referred to an MDM’s psychiatrist (subspecialist in addiction) or to „Andrija Stampar“ Teaching Institute of Public Health and MDM – Belgique team ensured transportation as well as the subsequent supervision and issuance of prescribed pharmacotherapy in cooperation with the doctor of Health Center on a daily basis.
Applicants for international protection were informed about hygiene, health care and protection primarily during medical consultations and health examinations (especially during the initial medical examinations of newly arrived applicants) as well as during information workshops. A total of 8 workshops were held in 2020 i.e. 2 preventive psychoeducational workshops, 2 workshops on contagious disease, 3 workshops on hygiene in general, 1 workshop on sexually transmitted diseases and family planning.
MdM noted that the proportion of women, children, families, patients with chronic or serious illnesses, as well as people with disabilities, has increased in 2020 among applicants. An additional challenge was the physical and psychological exhaustion of applicants who came from Bosnia and Herzegovina where they had stayed in the temporary reception centres with poor living conditions.
Since March 2020, the MDM-Belgique team was also in charge of health protection and prevention of spread of COVID-19 disease among applicants for international protection accommodated in the Reception Centre in Zagreb. From March 2020 onwards, the MDM-Belgique team implemented a number of preventive measures and recommendations i.e. ensured hand disinfection in several places in the Reception Centre, carried out daily temperature measurement of all applicants, distributed protective masks, disseminated and translated info-preventive material and established telephone and e-mail communications of applicants who were isolated with psychologists and a psychiatry specialist as needed. Specific info-materials were also produced and distributed to applicants in self-isolation. MDM-Belgique developed a Protocol on the treatment and testing strategy when there is suspicion of COVID infection, which has proved necessary in coordinating the work of all services and organisations working within the Reception Centre. The Protocol is regularly updated in accordance with official instructions.
Since the beginning of September 2020, the staff of MDM-Belgique operated in two teams, which rotated every 14 days due to the increase in the number of COVID -19 patients in Croatia, and in accordance with the instructions of the Ministry of Interior. Given the need for a doctor to be present in each team, another part-time doctor was hired.During 2020, a continuous increase in the number of applicants in quarantine was noted, starting with a daily number of 10-15 people in May, up to 115 people daily at the end of June and a daily number of 210 people at the end of November 2020. The total number of persons in quarantine reached 1,390 from May 2020 to the end of December 2020 (out of which 76 persons were twice in quarantine and 5 persons three times). In the self-isolation premises, the health of the applicants was monitored daily and the measurement of the body temperature was carried out. Applicants that showed symptoms were immediately referred for coronavirus testing. In situations of suspicion of COVID 19, MDM-Belgique has fully taken over the organisation of testing in cooperation with „Andrija Stampar“ Teaching Institute of Public Health. Out of the total number of persons in quarantine (1,390), 240 persons (17.26%) were tested during the year.
However, MdM reported that the coronavirus pandemic posed a challenge for their team and required flexibility in line with recommended preventive epidemiological measures.Nevertheless, the long-term exposure of MdM staff to the significantly increased workload in the Reception Centre that is not sufficiently equipped and does not have enough staff to organize and maintain an efficient and safe quarantine space has caused high levels of stress and a sense of disproportionate responsibility among their employees.
A guide called “I want to be healthy” with general guidelines and preventive measures for physical and mental health was created in Arabic, English, Farsi, French and Croatian in October 2019, and a poster of the same name in November 2019.
In 2020, MdM has produced the publication “Everyone has the right to healthcare: A model of healthcare mediation/support intended for asylum seekers in Croatia – outline, challenges & recommendations”. The publication describes various components of the health care model, as well as the results in terms of facilitating access to health care for applicants of international protection in Croatia. The publication was published in Croatian and English.
In July 2020, the Directorate for European Affairs, International Relations and European Union Funds issued a decision on the allocation of financial resources for the implementation of the project to be implemented by MDM. The aim of the project is to protect the health and prevent disease among applicants of international protection through improved access to first examinations and medical consultations in Reception Centres for applicants for international protection
Since 1 August 2020, the possibility of continuous, individualised, language-adapted and culturally aware monitoring of health and health care has been ensured within the Reception Centre for Applicants for International Protection through a new project implemented by MdM,.
The devastating earthquake which hit central Croatia at the end of 2020 was also significantly felt in Zagreb. All staff working in the Reception Centre as well as applicants accommodated both in the quarantine as well as in open part of the Centre were evacuated immediately. Although, no one was physically injured, a significant number of applicants showed signs of an acute stress response or re-traumatization, especially applicants accommodated in the quarantine section of the Reception Centre. In order to assess the condition of applicants and the need for additional interventions, prevention of long-term symptoms and stabilization of emotional responses to a crisis event, applicants were provided with psychological support by MDM-Belgique team. Due to the facts that tremors have continued, additional psychological support is planned.
Psychological counselling and support was provided by MdM during 2020. Two MdM’s psychologists conducted individual psychological counselling sessions every working day for 6 hours in Zagreb and when necessary in Kutina. An external associate- psychiatrist visited the Reception Centre in Zagreb three times a month. MdM team provided 424 individual psychological counselling sessions and 117 specialist psychiatric examinations in the course of 2020.
Additional issues related to trauma and mental health of applicants for international protection are further described in Screening of vulnerability.
Special health needs
Applicants who need special reception and/or procedural guarantees, especially victims of torture, rape or other serious forms of psychological, physical or sexual violence, shall be provided with the appropriate health care related to their specific condition or the consequences resulting from the mentioned acts. However, this type of specialised health care has been lacking for years in practice. According to the Law on Mandatory Health Insurance and Health Care for Foreigners in the Republic of Croatia, an ordinance which defines the scope of the right to health care for applicants who has been subject to torture, rape or other serious forms of violence and as well as for those with special health care needs, should have been adopted in previous years, however the Ordinance on health care standards for applicants for international protection and foreigners under temporary protection was finally adopted in 2020 and entered into force in March 2020 (see Primary health care for more information).
According to national legislation, the procedure of recognising the personal circumstances of applicants shall be conducted continuously by specially trained police officers, employees of the Ministry of Interior and other competent bodies, from the moment of the expression of the intention to apply for international protection until the delivery of the decision on the application. However, according to CLC’s knowledge there is still no further detailed guidance available in the law, nor an early identification mechanism in the form of internal guidance. According to the Croatian Law Centre’s insights, less evident vulnerabilities such as those relating to victims of torture are much less likely to be identified in current practice (see Identification).
However, in 2020, as part of the project implemented by MDM-Belgique entitled: “Empowering Women and Children in the migrant population to take ACTion against sexual and gender-based violence (We ACT)”, Guidelines for dealing with cases of sexual violence against women and children were prepared. The content of guidelines was incorporated in the Standard Operational Procedure in Cases of Sexual and Gender-Based Violence in the Reception Centres for Applicants of International Protection”.
 Article 57(1) LITP.
 Article 9 (1) (4) Ordinance on health care standards for applicants for international protection and foreigners under temporary protection
 Information provided by the Ministry of Interior, 28 January 2019.
 Information provided by MdM, 17 January 2021.
 Information provided by the Institute of Ethnology and Folklore Research, 11 January 2021.
 Information provided by MdM, 17 January 2021.
 MdM, Everyone has the right to healthcare: A model of healthcare mediation/support intended for asylum seekers in Croatia – outline, challenges & recommendations, 2020, available at: https://bit.ly/3sEwEIH.
 Information provided by MdM, 17 January 2021.
 Article 57(2) LITP.
 Information provided by MdM, 17 January 2021.