II. National Dynamics

Governance Architecture and Distributed Authority

Croatia’s mental health system operates within a three-tiered governance structure that both enables universal access and creates coordination barriers. The Croatian Health Insurance Fund serves as the primary financial and administrative mechanism, guaranteeing universal coverage while centralizing budgetary decision-making at the national level[1]. However, mental health service delivery is distributed across primary care (general practitioners and local psychological services) secondary care (specialized psychiatric centers and outpatient clinics), and tertiary care (university psychiatric hospitals and specialized institutes)[1]. This vertical separation of authority—where national policy frameworks set direction but
regional and municipal health authorities manage daily operations—creates what systems theorists call a “distributed accountability” problem. When the Strategic Framework for Mental Health 2030 mandates community-based care expansion, responsibility for implementation falls to fragmented local actors with competing resource constraints[2]. The framework itself acknowledges this tension: it emphasizes “intersectoral cooperation” as essential, yet provides limited enforcement mechanisms to compel coordination between health, social welfare, education, and labor sectors[2].

Historical Pivots: Crisis as Catalyst for Structural Change

Two catalytic events accelerated mental health system reform in Croatia. The 2020 earthquake and the COVID-19 pandemic exposed structural fragility—specifically, the
system’s over-reliance on hospital-based crisis response and its inability to serve dispersed populations[1][2]. Rather than treating these as isolated emergencies, policymakers diagnosed a systemic problem: institutions were the default setting because community infrastructure did not exist. This diagnosis triggered the adoption of the Strategic Framework for Mental Health 2022–2030, a policy document that represents more than incremental adjustment—it is a fundamental reorientation of the incentive structure underlying service delivery[2]. The framework shifted from asking “How do we treat more people in hospitals?” to “How do we
prevent crises by embedding care in communities?” This pivot is visible in concrete
mechanisms: the launch of telemedicine services, the creation of mobile multidisciplinary teams, and the initiation of the European Union–funded JA ImpleMENTAL project, which operationalized community-based interventions at scale[3].

Structural Complexity and Fragmentation Across Sectors

The most consequential feature of Croatia’s system is not its explicit architecture but its hidden fragmentation: mental health sits at the intersection of health, social welfare, education, and employment systems, yet none fully “owns” the outcome. A child experiencing depression might be counted in school attendance data, hospital admission statistics, and disability registries simultaneously—but no single authority aggregates this information into a coherent trajectory of care. This fragmentation is not accidental; it reflects deeper structural tensions. The health system
optimizes for acute episodes (hospitalizations, clinic visits), while social welfare focuses on disability support (housing, work assistance). Education prioritizes literacy and standardized test scores, not mental health literacy. Employment systems measure job retention but not the role of workplace stress in triggering mental health crises. Each system has its own incentive structure, and they rarely align. A concrete manifestation: Croatia’s hospitalization rate for depression has doubled in the last 20 years, yet the health system’s primary metric for success is often bed occupancy and treatment completion, not prevention or early intervention[2]. The system is trapped in a reinforcing feedback loop: more hospitalizations → higher costs → pressure to increase efficiency → reduced investment in prevention → more crises → more hospitalizations[2].

Policy Innovations: Mechanisms of Change

The introduction of mobile multidisciplinary psychiatric teams represents a deliberate attempt to break this loop. Rather than asking patients to navigate to hospitals, teams (comprising psychiatrists, nurses, case managers, social workers, and peer workers) deliver biopsychosocial interventions in patients’ homes[3]. The pilot project, launched in 2023 through the JA ImpleMENTAL initiative, worked with 15 patients and conducted 96 home visits by April 2024, achieving meaningful outcomes: improved recovery trajectories and reduced rehospitalization risk[3].
The success of this pilot triggered structural expansion: Croatia committed to establishing 30 mobile psychiatric teams and 24 psychological teams at the primary care level by 2027, embedded within the health system’s foundational layer[3]. This is significant because it represents a capability shift—the system is moving from treating crisis to building sustained community presence. Simultaneously, deinstitutionalization in the social welfare sector creates complementary infrastructure. The World Bank–supported initiative targets 907 individuals (children, youth, and adults with disabilities) transitioning from institutional care to community-based living with support by 2027[4]. This will include approximately 200 organized housing units and expanded services: daycare, psychosocial support, personal assistance, peer support, and employment assistance[4]. The structural significance is that this removes a major coordination failure point: individuals exiting mental health hospitals previously had nowhere to go except back to families or institutions.

Interaction Effects: How One Domain Affects Another

The deinstitutionalization initiative reveals how decisions in one domain cascade through others. When social welfare transforms residential institutions into community services, it simultaneously: Reduces hospital readmission pressure (people have stable housing); Changes workforce composition (demand for community support workers grows; demand for institutional custodial staff shrinks);
Redistributes costs (capital-intensive institutions become labor-intensive services, with different funding mechanisms); Alters accountability (individual outcomes become visible; institutional throughput becomes visible as institutional failure)
These are not separate effects; they form an emergent system behavior: as the service network becomes more community-facing, it becomes harder to ignore implementation failures, which creates pressure for further reform. Conversely, the workforce shortage in child and adolescent psychiatry creates a vicious cycle: understaffed clinics generate long waitlists, which shift demand toward crisis services and hospitalizations, which validates continued investment in emergency capacity over prevention[1].

Human-Scale Examples: Operationalizing Innovation

The mobile team model illustrates how abstract policy becomes practice. A patient discharged from psychiatric hospital encounters a multidisciplinary team at home, where a case manager coordinates services, peer workers (individuals with lived experience of mental illness) provide mentorship, and psychiatrists adjust medications in a natural environment rather than a clinic. This is not merely a service delivery change; it is a fundamental power redistribution: the patient controls the setting, the peer worker normalizes recovery, and the psychiatrist operates as a consultant within the patient’s life context, not the reverse[3]. The scale is currently limited—the 2023 pilot served 15 patients—but the planned 30 teams represent an investment in preventive capacity building. If each team serves 20–30 patients, the system moves from treating thousands of acute episodes annually to supporting hundreds of individuals in sustained recovery.

III. System Evaluation

Strengths: Universal Coverage and Emerging Network Integration

Croatia’s mental health system possesses a critical structural advantage: universal healthcare coverage administered through the Croatian Health Insurance Fund guarantees that mental health services are legally accessible to the entire population of 3.87 million[1]. This removes the gatekeeping mechanism (inability to pay) that plagues fragmented systems. This universality creates space for innovation. The Strategic Framework 2030 is not constrained by questions of who can afford services; instead, it focuses on where and how services should be delivered[2]. The framework mandates intersectoral cooperation—a policy approach that would be impossible without universal coverage, because cost-shifting between sectors becomes transparent and politically costly. The integration of peer workers into mobile teams exemplifies how the system is building legitimacy through participation. By employing individuals with lived experience of mental illness, the system accomplishes multiple functions simultaneously: it destigmatizes recovery (peer workers are visible as employed professionals), it incorporates user voice into service design (peers understand barriers firsthand), and it creates employment for people traditionally excluded from labor markets[3]. This is an emergent property of shifting from hospital-centric to community-centric organization: credibility comes from proximity and shared experience, not institutional authority. Telepsychiatry expansion, accelerated by pandemic-driven necessity, represents another structural asset[1][2]. For a Central European country with dispersed rural populations, digital mental health removes geographic barriers to specialist consultation. The system’s pivot toward telemedicine is not a temporary pandemic accommodation but a permanent capability upgrade.

Weaknesses: The Implementation-Outcomes Gap and Root Causes

Despite policy innovation, measurable population-level outcomes remain troubling.
Hospitalization rates for depression have doubled in two decades; average length of hospital stay exceeds EU norms; suicide rates surpass European averages[2]. These are not indicators of a system succeeding at prevention—they are evidence of a system still oriented toward acute response, despite policy frameworks mandating otherwise. The root cause is structural underfunding relative to the scope of reform. The Strategic Framework 2030 mandates a comprehensive network of community services, but the system’s budget allocation mechanism has not fundamentally changed. Hospital psychiatry remains the largest budget category because historically institutionalized staff and infrastructure represent sunk costs. Shifting resources from hospitals to community services requires simultaneously: Maintaining hospital capacity (bed-based care does not disappear; vulnerable populations still need inpatient facilities for acute crises) Building new community capacity (staff hiring, training, outreach) Managing a transition period in which both systems operate below optimal efficiency. This creates what economists call a transition cost trap: the system appears to afford neither adequate hospitals nor adequate community services. Evidence suggests Croatia is experiencing this trap: the universality of coverage is not translating to adequate depth of service across all sectors. Workforce shortages, particularly in child and adolescent psychiatry, represent a structural constraint with deep causes[1]. Medical education in Croatia trains psychiatrists, but the profession faces competitive disadvantages: wages lag other specialties, rural recruitment is difficult, and burnout from high caseloads drives attrition. The shortage is not incidental; it reflects systemic incentive failures: if the system values hospitals over community care, it funds hospital positions; if hospitals offer better pay or scheduling, psychiatrists concentrate there; if young people experience insufficient mentorship in child psychiatry, fewer enter the specialty. This creates a reinforcing cycle that underfunds prevention and child mental health development. The primary care recognition problem is structural rather than individual. General practitioners, who constitute the first contact point for most patients, receive limited mental health training and low reimbursement for mental health consultations[2]. This creates a perverse incentive: a GP can see more patients if each appointment is shorter and simpler. Mental health assessment requires time, ongoing relationship, and coordination with specialists—activities that are administratively costly and poorly compensated. The result: many people with treatable mental disorders go unrecognized at primary care, instead appearing downstream as crisis hospitalizations[2]. Stigma, while often presented as a cultural problem, is better understood as a structural output of the system’s historical organization. When mental health is delivered by isolated specialists in hospitals, mental illness becomes “exceptional”—something that happens to other people in other places. Community-based care, by contrast, normalizes mental health
as part of ordinary life. Croatia is investing in stigma reduction through school-based mental health literacy programs, but structural destigmatization requires the visible presence of mental health services in ordinary community spaces (primary care clinics, schools, workplaces)—a transition still underway[2].

Structural Tensions: Universality vs. Sustainability

A deeper tension underlies these immediate challenges: how does a middle-income Central European country sustain a universal mental health system in the face of rising demand (driven by aging, urbanization, workplace stress, and migration), competing fiscal pressures (healthcare infrastructure, pensions, defense), and workforce constraints? Croatia’s suicide rate and depression hospitalization trends suggest the system is responding to demand with crisis management rather than prevention, not because of ineptitude but because prevention requires sustained investment in services that prevent crises—and the budget mechanism does not reliably protect those investments when fiscal pressure emerges. Deinstitutionalization initiatives depend on EU funding; mobile teams are piloted through external projects (JA ImpleMENTAL); telepsychiatry expansion is state-funded but uneven across regions. The system lacks a **self-sustaining financial architecture** that prioritizes prevention at scale.

III. Future Outlook

Digital Transformation and Infrastructure Investment

Croatia’s mental health system is positioned to leverage digital tools more systematically than it currently does. Telemedicine services are operational but not yet standardized across regions; the next phase should involve electronic health records (EHRs) that enable shared information across primary, secondary, and tertiary care—reducing duplication and improving coordination[1][2]. The 2025 Digital Decade Country Report indicates Croatia has made progress in digital infrastructure, and health system digitalization is a priority[8]. The emerging frontier is predictive analytics and risk stratification. If EHRs integrate mental health data across primary care, emergency departments, and hospitals, machine learning algorithms could identify high-risk individuals (those with depression symptoms, prior crisis episodes, social isolation markers) and trigger proactive outreach before crises occur. This would reverse the current reactive orientation. However, implementation requires
data governance infrastructure and clinical workforce training—both areas where Croatia faces capacity constraints.

Workforce Trends and Capacity Planning

The planned expansion to 30 mobile teams and 24 psychological primary care teams requires recruiting and training approximately 150–200 additional mental health professionals[3]. This is a significant but achievable target if policy creates incentives: competitive salaries, loan forgiveness for rural practitioners, and career pathways from peer worker to clinical roles (recognizing lived experience as a form of expertise). A structural opportunity is task-shifting: training graduate nurses and social workers to deliver evidence-based psychological interventions (problem solving therapy, behavioral activation, motivational interviewing) that currently require psychiatrist or psychologist delivery. This extends specialist capacity without proportional cost increases. The mobile team model already employs this principle psychiatrists provide medication management; nurses and case managers provide ongoing psychosocial support[3]. Child and adolescent psychiatry remains a critical gap. The shortage is partly driven by low specialist prestige and poor compensation, but partly structural: training positions are limited, and mentoring is weak. The national program for improving mental health literacy among educational staff suggests secondary prevention is being prioritized[2]—if successful, school-based early intervention will eventually reduce demand for specialist crisis services, allowing the system to equilibrate. However, this benefit emerges over years, not months.

Infrastructure Investments and Specific Examples

Deinstitutionalization will deliver approximately 200 organized housing units by 2027, representing a significant investment in community infrastructure[4].

⚠️ Data Gap: The search results do not specify total budget allocation for the deinstitutionalization initiative or the mental health reforms more broadly. This is a critical gap for assessing financial sustainability.

The University of Zagreb’s School of Medicine is hosting a mental health exchange program (October 2025–ongoing) to disseminate new prevention, early intervention, and reintegration approaches across European systems[5]. This indicates Croatia sees itself as a site of innovation worth exporting—a sign of system confidence despite remaining challenges.

Structural Challenges: Translation of Policy to Outcomes

The most consequential challenge is neither technical nor financial but organizational: translating policy frameworks into consistent, measurable improvements in population mental health. Croatia’s Strategic Framework 2030 articulates the vision; the JA ImpleMENTAL project and World Bank deinstitutionalization initiative are building operational capacity. However, the system still lacks:

Unified outcome measurement: Different sectors track different metrics (hospital admissions, disability rolls, school attendance, employment rates). No integrated monitoring system aggregates these into a coherent picture of individual trajectories or population health trends.

Accountability for implementation: The Framework mandates action, but responsibility is distributed across health, welfare, education, and employment ministries. When outcomes fail to improve, it is unclear which authority is accountable and which is responsible for course correction[4].

Feedback mechanisms linking outcomes to budgeting: If hospitalization rates remain high despite community service expansion, does the system reallocate resources from hospitals to community? Or does it continue parallel funding? The current structure suggests the latter—institutional persistence in budgeting creates path dependency.

Implementation science capacity: The research base for what works in the Croatian
context is thin. Mobile teams show promise in pilots, but scaling from 15 patients to
thousands requires rigorous monitoring of fidelity, outcomes, and cost-effectiveness. The system lacks dedicated epidemiologic and health services research capacity to guide these questions.

The broader pattern is characteristic of health systems in the reform phase: ambitious policy, emergent innovation, uneven implementation, and slow measurement-to-learning-to-adjustment cycles. Croatia’s advantage is that its universal coverage and EU integration provide fiscal and technical support unavailable to many peer countries. Its constraint is that structural change is slow the doubled hospitalization rate for depression did not emerge overnight, and it will not resolve through policy pronouncement alone.

V. Sources

[1] Rojnic Kuzman, M., & Medved, S. (2025). Mental health services in Croatia: Current
perspectives and future challenges. International Review of Psychiatry, 37(3–4), 221–228.
https://doi.org/10.1080/09540261.2024.2434576
[2] European Public Health Association. (2024). Reform of the mental health care system in
the Republic of Croatia. European Journal of Public Health, 32(Supplement 3),
ckac129.611.
https://academic.oup.com/eurpub/article/32/Supplement_3/ckac129.611/6765679
[3] Kalinic, M. (2024). Community mental health care in Croatia: Mobile team for
community-based interventions. European Journal of Public Health, 34(Supplement 3),
ckae144.657.
https://academic.oup.com/eurpub/article/34/Supplement_3/ckae144.657/7844877
[4] World Bank. (2025, February 5). Deinstitutionalization in Croatia: Social welfare institutions shift to community-based care [Press release].
https://www.worldbank.org/en/news/press-release/2025/02/05/deinstitutionalization-in-croatia
-social-welfare-institutions-shift-to-community-based-care
[5] EU-PROMENS. (2025). Mental Health Exchange Programme—Croatia, 2nd wave
(October–November 2025). https://eu-promens.eu/exchange-visit-croatia2
[6] World Health Organization. (n.d.). Croatia: Health and employment.
https://www.who.int/croatia/home/9789289054034