World Review of Entrepreneurship, Management and Sust. Development, Vol. 8, No.

2, 2012 221

The 4Cs of the Croatian public healthcare system:

social marketing challenges at the dawn of EU
accession

Nikola Draskovic*
Zagreb School of Economics and Management,
Jordanovac 110, HR1000 Zagreb, Croatia
E-mail: nikola.draskovic@kr.t-com.hr
*Corresponding author

Ana Valjak
Leeds Metropolitan University,
Civic Quarter, Leeds, LS1 3HE, UK
E-mail: a37_valjak@yahoo.com

Abstract: As a country nearing EU accession, Croatia faces many political,

legal and economical challenges. Harmonisation with EU laws within the
public sector is one of the most challenging steps in Croatia’s accession
process. Under the rubric of public sector services, public healthcare is one of
the most important as it supports the well being of individuals and society as a
whole. The primary aim of this paper is to provide limited insight into Croatian
public healthcare from the social marketing perspective. The exploration of the
implementation of the social marketing principles is conducted following
Lauterborn’s 4C marketing mix as the theoretical framework. Based on the
literature review and primary research finding, this study provides an overview
of the implementation of basic social marketing principles within the Croatian
public healthcare system. Finally, the authors propose necessary changes to
re-focus on user satisfaction and provide guidelines for further research.

Keywords: public healthcare; social marketing; healthcare services;

Lauterborn 4C; Croatia.

Reference to this paper should be made as follows: Draskovic, N. and

Valjak, A. (2012) ‘The 4Cs of the Croatian public healthcare system: social
marketing challenges at the dawn of EU accession’, World Review of
Entrepreneurship, Management and Sustainable Development, Vol. 8, No. 2,
pp.221–235.

Biographical notes: Nikola Draskovic received his PhD in Marketing from

Leeds Metropolitan University and two MSc degrees from University in
Zagreb. In addition to occasional guest lecturing, he works professionally in the
packaging industry. His main research interests focus on marketing aspects of
packaging, international aspects of marketing, advertising and social marketing.

Ana Valjak is a PhD candidate at Leeds Metropolitan University. Her current

research focus is on the public relations practice within public sector. She
received her BA in Media Communication from Webster University in Vienna
and is a Guest Lecturer at the Medical School in Zagreb.

Copyright © 2012 Inderscience Enterprises Ltd.

222 N. Draskovic and A. Valjak

1 Introduction

Due to the process of EU accession, structural changes and harmonisation with EU

legislation has been the Croatian modus operandi for the last five years. In such a
dynamic and challenging environment, the Croatian public healthcare system participates
in both mid- and long-term reforms, such as decentralisation. However, as Dzakula et al.
(2008) suggested, the process of decentralisation, if poorly managed, could negatively
impact the quality of healthcare, increase costs, delay development and structural
changes. Poorly managed reforms could also result with unintended damage. While the
reforms and decentralisation in the Croatian healthcare system are mainly focused on
cost-cutting, rationing services and encouraging the provision of private health services,
the level of satisfaction among users decreased because of increased inequality of access
to healthcare (Mastilica and Kusec, 2005). Unfortunately, in Croatia, like in other
Central and Eastern European countries, the quality of the healthcare system has rarely
been evaluated from the user’s perspective (Mastilica and Chen, 1998). However, the
implementation of marketing principles and focus on users could result in a more
effective healthcare system and increased satisfaction among both providers and users
(Dickinson, 1995; Evans, 2006). Therefore, the refusal to evaluate user satisfaction in
Croatia and make reforms based on that information seems unreasonable.
The primary aim of this article is to provide limited insight into the Croatian public
healthcare system from the social marketing perspective. In order to evaluate to what
degree marketing principles are implemented, the focus of this exploratory research study
is on the public healthcare providers and their understanding of marketing principles and
related everyday practice. Furthermore, this article also provides an overview of the
Croatian healthcare system from historical and political perspectives in order to establish
background information needed for a better understanding of the current marketing
related practice. Finally, based on empirical research findings and relevant body of
marketing literature, an objective of this article is to provide suggestions for better
implementation of marketing principles in the context of the Croatian public healthcare
system.

2 Background: an overview of the Croatian public healthcare sector

In this section, a brief background, which includes a historical and political context, is
provided. Since changes and reforms to Croatian public healthcare are closely related to
changes in the political environment (Dzakula et al., 2008), it is necessary to also
approach the topic of research from the historical perspective.

2.1 Brief historical and political background

Once an independent kingdom, in the period between 1102 and 1991, Croatia was
incorporated into several unions and sustained varying degrees of political and cultural
independence (Horvat, 1990). From the 16th century until the end of the First World
War, Croatia formed part of the Austro-Hungarian Empire. Between the two world wars,
Croatia was a part of the Kingdom of Serbs, Croats and Slovenes, which, in 1929, was
renamed the Kingdom of Yugoslavia. In 1941, after the Axis powers seized Yugoslavia,
most of the territory that today comprises Croatia was under the fascist regime of
 The 4Cs of the Croatian public healthcare system 223

Ante Pavelic who, supported by Germany and Italy, formed a puppet state.
Simultaneously, the resistance against the regime and the axis powers was organised by
communist partisans and their leader Josip Broz Tito.
After the Second World War, Croatia became one of the six federal units in social
(communist) Yugoslavia. However, due to Tito’s policy of independence from the
Soviet Union, unlike other communist countries of that time, Yugoslavia had introduced
a unique type of socialism/communism (i.e., a self-governing socialism), which gave
certain managerial rights to the workers and limited possibilities for the private
entrepreneurship (Horvat et al., 1975; Horvat, 1982). Furthermore, due to the freedom to
travel, Croatian consumers and their behaviour was significantly influenced by the
surrounding Western countries (i.e., Austria, Italy) (Ozretic-Dosen, 2005).
Unlike the majority of other transitional ex-communist European countries, recent
Croatian history consists of many dramatic events. War followed secession from the
former Yugoslav federation in 1990s. In the following decade, Croatia embarked on the
path to EU accession. In 2001, Croatia signed the Stabilisation and Association
Agreement, in 2003 officially applied for the EU membership and the European
Commission confirmed Croatia as a candidate country in 2004. After five years of
negotiation, the closing of the few remaining negotiation chapters is expected in the first
half of 2011 (Delegation of the European Union to the Republic of Croatia, 2011).

2.2 Development of the public healthcare system in Croatia

The origins of today’s public healthcare system in Croatia could be tracked back to 1923
when the Epidemiological Institute was founded in Zagreb, as a successor to several
institutes which were active in healthcare activities since 1893 (HZJZ, 2011). The
greatest contributor to the institutionalisation and development of public healthcare
efforts in Croatia was Andrija Stampar, one of the founders of the World Health
Organization, and his vision of public health, with the basic role of prevention of diseases
and promotion of health (Cvjetanovic, 1990).
Table 1 Decentralisations and centralisations of Croatian public healthcare

Period Development
1980s Decentralisation (self-governing socialism)
1990–1993 Centralisation (war, economic crisis, transition)
1993–2000 Re-decentralisation (reform of the system)
2000 Further decentralisation, legal harmonisation with EU
Source: Adapted from Dzakula et al. (2008)
The Croatian public healthcare system went through many transitions and structural
changes in the last forty years (Table 1). Despite some western stereotypes, during the
socialist era, the Yugoslav health system was considered innovative and committed to
primary healthcare (Saric and Rodwin, 1993). Geographical, political and administrative
circumstances prompted Croatia to decentralise its healthcare during the era of
self-governing socialism (Dzakula et al., 2008). Due to the outbreak of war and economic
crisis in early 1990s, the decentralised public healthcare system based on the concept of
permanent development and total social safety proved unsustainable (Hebrang, 1994).
During the war, Croatia also provided assistance to Bosnia and Herzegovina in terms of
224 N. Draskovic and A. Valjak

medical supplies and securing the most basic level of healthcare for the parts of the
country not occupied by Serbian forces and for the refugees stationed in Croatia (Rados
et al., 2000). To tackle the emerging challenges and demands, public healthcare was
reorganised and centralised in early 1990s, but the basic principles of universal coverage
and mandatory health insurance were preserved (Kovacic and Sosic, 1998).
Despite the war, new reforms to the healthcare system were initiated in 1993. The
reforms allowed patients to chose providers, expanded the privatisation of primary
healthcare, organised financing the system through the Health Insurance Institute and
transferred the ownership of hospitals and primary healthcare from state to local
authorities (Hebrang et al., 1993). The reforms introduced a level of decentralisation but
also raised some concerns, especially from an ethical perspective. For example, reforms
enabled the establishment of private specialised policlinics in which staff employed in the
public sector could work part-time (Kovacic and Sosic, 1998). With inefficient structure
and waiting lists in the public sector, users were simply forced to use expensive services
in the private sector. Further attempts at decentralisation were made in 2000, but the
process was introduced slowly and sporadically, due to the issue of competence and
accountability on the part of local authorities and health providers (Dzakula et al., 2005).
However, reforms were not well accepted by the public due to decreased coverage of the
health insurance (Mastilica and Babic-Bosanac, 2002). With the start of the EU accession
process, the Croatian public healthcare system went through the process of legal
harmonisation with the EU. While this process went smoothly, the public healthcare
system suffers from increasing issues with funding due to high expenditures, inadequate
financial resources, continuous deficits of the state insurance fund, lack of transparency
in funding, aging population, etc. (Voncina et al., 2007).
During the last 20 years the Croatian public healthcare system went through a series
of changes due to a number of initiated reforms. While the goal of these reforms is almost
always related to reducing the system’s costs, the users’ perspective seems to be
neglected. Consequently, the level of satisfaction with the healthcare system among both
participants and users has been in constant decline (Mastilica and Babic-Bosanac, 2002;
Mastilica and Kusec, 2005).

3 Theoretical framework: marketing perspectives of public healthcare

In this section, a theoretical framework for the empirical research is established.

Following the concept of social marketing, a basic link between marketing principles and
public healthcare is explained.

3.1 An overview of the social marketing approach within the public healthcare
system
The social marketing approach was first introduced in early 1970s by Kotler and Zaltman
(1971) in their pioneering article on social marketing published in the Journal of
Marketing and titled ‘Social marketing: an approach to planned social change’. In the
article, the authors defined social marketing as:
“The design, implementation, and control of programs calculated to influence
the acceptability of social ideas and involving considerations of product
planning, pricing, communication, distribution, and market research [...] it is
 The 4Cs of the Croatian public healthcare system 225

the explicit use of marketing skills to help translate social action efforts into
more effectively designed and communicated programs that elicit desired
audience response.” (ibid, p.6).

According to a more recent definition, social marketing “is the use of marketing
principles and techniques to influence a target audience to voluntarily accept, reject,
modify, or abandon behaviour for the benefit of individuals, groups, or society as a
whole” [Kotler et al., (2002), p.5].
Social marketing covers a broad area of marketing implications for non-commercial
purposes. Following this idea, academic researchers largely grounded their theoretical
considerations of social marketing on the theoretical foundations of commercial
marketing (Grier and Bryant, 2005). In other words, social marketing utilises tools,
techniques and concepts derived from commercial marketing in the pursuit of social goals
(Andreasen, 1995). However, an overemphasis on the direct translation of commercial
marketing principles and practices into social context could cause practical problems and
confusion regarding the theoretical basis of social marketing (Peattie and Peattie, 2003).
As Willcocks (2008) noted, the application of marketing to healthcare has been the
subject of some scepticism from various sources, not least healthcare employees, due to
the following reasons:

• marketing is more about commercial as opposed to healthcare objectives

• the competition upon which marketing is based will bring about the pursuit of profit
and not quality of care

• healthcare is different from other services/products, and is less amenable to the

techniques and approaches of marketing

• healthcare is, to a large extent, an intangible service, while marketing primarily deals
with tangible products

• healthcare is a unique service because of the individual freedom of clinicians

• healthcare operates with unpredictable demand

• it is ambiguous in terms of being unable to offer a precise definition of the

‘customer’.

However, as a concept, marketing could provide certain benefits to healthcare

practitioners and the public. Advocating the marketing approach in public healthcare,
Lotenberg and Siegel (2008, pp.621–623) suggested:
“The discipline of marketing offers public health organizations a variety of
concepts and strategies for understanding and motivating behaviour change in
specific populations of interest. Public health organizations use these
techniques not only to influence individual health behaviour, but also to build
public support for core public health policies and institutions. Using a
marketing approach can therefore enable organizations to improve the
effectiveness of specific health interventions and to strengthen the institutional
capacity of the public health system as a whole. [...] The appropriate use of
marketing can help public health practitioners be more effective in today’s
environment.”
226 N. Draskovic and A. Valjak

Table 2 The role of communication in performing the essential public healthcare services

1 Monitor health status and solve community 6 Enforce laws and regulations that protect
health problems. and ensure safety.
Communication role: Deliver relevant Communication role: Share information
health status information to communities, with the regulated community to facilitate
particularly changes in rates that suggest the the adherence to proper licensing and
need for intervention; provide an safety standards; ensure easy access
opportunity for communities to voice (e.g., website availability) to the required
concerns about perceived health problems. forms and rules relating to licensing and
regulation.
2 Diagnose and investigate health problems 7 Link people to needed personals health
and health hazards in the community. services and ensure the provision of
healthcare when otherwise unavailable.
Communication role: Notify individuals Communication role: Inform medically
and communities of potential health hazards underserved population about
(e.g., issue traveller’s advisories in areas opportunities for healthcare and the need
with known vector-borne disease for preventive services.
transmission).
3 Inform, educate, and empower people about 8 Ensure a competent public health and
health issues. personal healthcare workforce.
Communication role: Use multiple levels of Communication role: Inform public health
communication, including social marketing practitioners and healthcare providers
and community education, to bring about about training opportunities, such as
healthy lifestyles. satellite video-conferences.
4 Mobilise community partnerships and 9 Evaluate effectiveness accessibility and
action to identify and solve health quality of personal and population-based
problems. health services.
Communication role: Assist in the Communication role: Inform policy
development of coalitions and partnerships makers about the efficacy of
that will lead to collaborative action. population-based health services.
5 Develop policies and plans that support 10 Research for new insights and innovative
individual and community health efforts. solutions to health problems.
Communication role: Inform the public Communication role: Publish results of
about new laws that affect health; share applied research in peer-reviewed journals
draft planning documents with stakeholders so that other agencies can translate
as a means to receive input and generate findings into more effective public health
investment and outcomes. practice.
Source: Harrell et al. (1994)
Medical care focuses on disease management and the act of curing while public
healthcare efforts focus on health promotion and disease prevention (Nies and McEwen,
2011). As Evans (2006, p.1208) stated, “social marketing messages can aim to prevent
risky behaviour through education or the promotion of behavioural alternatives”.
Therefore, communication plays an important role in the context of public healthcare,
especially for performing essential public healthcare services (Table 2). The organisation
and management of such a vast number of communications with public and stakeholders
definitely calls for a marketing approach. Some scholars consider social marketing solely
a set of communicational activities (Hill, 2001). However, it should not be so limited.
Social marketing is grounded in commercial marketing’s conceptual framework and
includes exchange theory, market research, target audience segmentation, competition,
 The 4Cs of the Croatian public healthcare system 227

the marketing mix, consumer orientation, and continuous monitoring (Grier and Bryant,
2005).
The application of social marketing requires certain changes in approach to the
target audience. Public healthcare, according to its definition, consists of organised
health efforts directed to communities rather than to individuals, relying on a
combination of science and social approaches (Novick and Morrow, 2008). On the
other hand, commercial marketing focuses more on individuals, since it is considered
“the art and science of choosing target markets and getting, keeping, and growing
customers through creating, delivering, and communicating superior customer value”
[Kotler and Keller, (2008), p.6]. However, social marketing calls for a shift
from targeting everybody to targeting different segments or subgroups of the population
who share needs, wants, lifestyles, behaviour and values that make them likely to respond
in a similar manner to certain public healthcare marketing activities (Grier and Bryant,
2005).

3.2 4Cs as an alternative view of the classic 4P marketing mix

One of the long-standing fundamentals of marketing science is the classic 4P marketing
mix. According to McCarthy (1964), the elements of the 4Ps are: product, price,
promotion and place (distribution). Over time, the 4P approach received criticism and
suggestions were made to expand the concept. One criticism of the 4P approach is that is
does not focus on people (i.e., employees), even though people are important, especially
in the context of personal selling in the business-to-business (B2B) market. Therefore,
Judd (1987) suggested people as the fifth P. As Zineldin and Philipson (2007) echoed, the
role of people as the fifth P gains additional importance in the context of relationship
marketing and customer relationship management (CRM). On the other hand, Kotler and
Keller (2008, p.392), reflect practitioners’ view with the suggestion of packaging as the
fifth P. Packaging is commonly included as part of the product-P, but this approach
ignores the communicative aspects of packaging and its role as a part of a brand
(e.g., Löfgren et al., 2008; Underwood, 2003, Underwood et al., 2001). Therefore, the
expansion of the classic 4P to include packaging is reasonable.
In addition to the 5P suggestions, there are also a few suggestions for a 6P marketing
mix. Kotler (1999, p.95) suggests, for example, politics and public opinion as the two
additional Ps. Knillans (2008) suggests people and planning, while Smith (2010) suggests
people and performance as the extension of the 4Ps.
In the context of the service sector, Booms and Bitner (1981) suggest a 7Ps marketing
mix, which represents the classic 4Ps extended to include process (of service delivery),
physical evidence (of delivered service) and participants (involved in the service
delivery). However, this approach should not be limited to services, but also take
products into consideration, as Rafiq and Ahmed (1995) argue. There are also proposals
to expand the 7Ps. For example, Goldsmith (1999) suggests personalisation (of product or
service to the specific consumer preferences), while Melewar and Saunders (2000)
include publications (e.g., corporative publications as part of the corporate PR) as the
eighth P.
Constant criticism of the classic 4Ps and changes in business practice, led Lauterborn
(1990) to offer a different perspective through the proposition of an alternative marketing
mix consisting of 4Cs:
228 N. Draskovic and A. Valjak

• Consumer wants and needs, instead of product – consumers are educated and aware
of various options available on the market. It is essential to understand their specific
wants and needs towards products and services, because companies “can only sell
what someone specifically wants to buy”.

• Consumer’s cost to satisfy that want or need, instead of price – consumer perceives
the total cost of acquiring a product or a service. Besides price, the total cost could
include the cost of time, travel expenses, etc.

• Convenience to buy, instead of place – due to changes in consumption behaviour and

emerge of e-commerce, the focus should be on providing convenience to consumers
through constant change and adaptation, rather than setting-up traditional and rigid
distribution channels.

• Communication, instead of promotion – while classic promotion mainly relays on

one-way communication, the focus should be on dialogue with the consumer.

Instead of adding new elements, Lauterborn’s 4Cs model provides a different,

contemporary view of the classic 4Ps marketing mix. Fundamentally, the 4Cs emphasises
the importance of consumer focus with the approach to the marketing mix from the
perspective of a modern and well-informed consumer faced with a vast choice of
products and services in oversaturated markets.

3.3 Introducing the 4Cs in the context of social marketing

Since the corner stone of public healthcare is to address and satisfy public (and
individual) needs related to (personal) health, the 4Cs seems to be an appropriate
theoretical framework for the investigation of the marketing dimension of the public
healthcare system. However, due to the specifics of social marketing, it is necessary to
make certain adjustments. Adopting the suggestions by Peattie and Peattie (2003),
Willcocks (2008) and partially by Rothschild (2010), the following modification to the
interpretation of the Lauterbourns’s 4Cs in the context of social marketing could be
suggested:

• Consumer/user wants and needs – in the context of public healthcare, the user is
often not aware of his/hers needs for better and healthier living and his/hers wants
are usually not related with that. Therefore, it is the goal of social marketing to, from
time to time, define those needs and to act in order to change a specific type of
behaviour and to achieve desired behaviour.

• Consumer’s/user’s cost – relates to the cost of behaviour change. However, this cost
is mostly not related with the financial cost, but it mostly reflects time and effort
spent by a person in the process of behaviour change. In this context, the goal of the
marketer in social marketing is to minimise the cost of involvement for the user
(Bloom and Novelli, 1981).

• Convenience – refers to the accessibility of locations related to the process of

behaviour consideration or interventions aimed at changing it.
 The 4Cs of the Croatian public healthcare system 229

• Communication – consists of various types of marketing communications activities

used to promote certain ideas and practice in the context of social marketing. Instead
of a one-way dissemination of information, the focus of social marketing is on
two-way communication through a multimodal transaction model of communication
(Evans, 2006).
Bearing in mind these proposed modifications to the interpretation of the elements of the
4Cs, this alternative marketing mix could be used as a model for the assessment of the
level of acceptance of social marketing within the public healthcare system. Furthermore,
this approach should also provide aid to detect public healthcare efforts mislabelled as
‘marketing’ or ‘social marketing’ due to the neglect of many core marketing concepts.

4 Empirical research: in-depth interviews with experts

4.1 Methodology
Due to the explorative nature of this research study, a qualitative approach to the primary
research was selected. Within the range of qualitative research methods, an in-depth or
intensive interview has been selected. As Hesse-Biber and Leavy (2006, p.119) outlined,
“in-depth interview uses individuals as the point of departure for the research process and
assumes that individuals have unique and important knowledge about the social world
that is ascertainable through verbal communication”. The goal of the in-depth interview
is to yield information and to thoroughly explore a respondent’s point of view and
perspective (Guion, 2001).
The in-depth interviews were conducted from a convenient sample of nine employees
of the Croatian public healthcare institutions. Respondents were recruited among senior
staff with a minimum of ten years experience in Croatian public healthcare. The in-depth
interviews were unstructured in order to achieve a wider understanding of the
implementation of marketing principles within the public healthcare system, without
imposing any a priori categorisation, which might limit the field of inquiry (Punch,
2005). The in-depth interviews’ agenda was structured around the modified interpretation
of the 4Cs marketing mix, as proposed in the previous section.
The data collected through the in-depth interviews was interpreted by content
analysis. As Shapiro and Markoff (1997, p.14) suggest, content analysis refers to ‘any
systematic reduction of a flow of text (or other symbols representing the presence, the
intensity, or the frequency of some characteristics relevant to social science’. Since the
in-depth interview is based on the open-ended questions and its overall approach could be
characterised as explorative, the qualitative conventional content analysis was selected
for data interpretation. Hsieh and Shannon (2005, p.1278) define qualitative content
analysis as “a research method for the subjective interpretation of the content of text data
through the systematic classification process of coding and identifying themes”.

4.2 Research findings

The first section of the in-depth interviews focused on consumers/users and their needs
and wants. Overall, the interviews revealed a lack of market segmentation in the context
of social marketing activities within the Croatian public healthcare sector. All
230 N. Draskovic and A. Valjak

respondents agreed that the general public is the focus, rather than on particular
segments. Therefore, individual needs and wants are not properly addressed. As an
exemption, two respondents mentioned the breast cancer awareness and the prevention of
cardiac diseases campaigns:
“The campaign targeted women in their 40s. During the campaign, I think
women that didn’t even care about breast cancer got tested […] I think we
saved some lives. And not just that, I think women started thinking more about
routine check-ups and prevention all together.”[Respondent 3]
“The campaign was intended for the population of certain age, gender neutral.
And although everybody could have problems with heart, the most critical
consumer group is over 45 years of age.” [Respondent 5]

One respondent also mentioned activities addressing the increasingly problematic issues
associated with overweight and obesity. The activities are aimed at the general public,
with occasional segmentation:
“Amongst others, children are one of the target groups. The plan is to provide
better diet options to schools and kindergartens so that children would get used
to healthier types of food, rather than fast food and candies. This way, they will
develop their preferences towards healthier options at the early stage. [...] The
idea came from England, where Jamie Oliver, a famous cook, tried to remove
vending machines from schools and introduce a healthier diet to children.”
[Respondent 2]

Respondents had difficulty understanding the context of consumer/user cost. Respondents

focused their discussion mostly on the financial aspects. For example, the cost of primary
healthcare is no longer fully covered by personal insurance, which was case in past.
Furthermore, they noticed a decrease in the overall quality of the healthcare system,
which provides fewer benefits to the users. Consequently, the increased financial cost of
medical services did not result with an increase in the quality of services. The concept of
the non-financial user cost is not that well recognised among respondents. Most of them
find the cost of behaviour change as something that should be considered solely by users.
In other words, users should be aware of the benefits which the change of behaviour will
result with. Furthermore, some respondents suggested that users should not consider their
effort as a cost since “all they do, they do for themselves”. However, a minority of
respondents acknowledged the need for the healthcare system to communicate benefits
of, for example, behaviour change in relation with the level of involvement and needed
effort. For example, one respondent recognised the need for taking into account the user
cost within the context of blood donation:
“A couple of years ago we had a very successful campaign where we promoted
blood donation. First of all, we needed blood because, since the war, the blood
banks needed [...] and the second reason was that we wanted to educate people
from the age of 18 that donating blood is a normal and noble thing. Our goal
was to move the focus from needles. ” [Respondent 7]

Care about consumer/user convenience in the context of the Croatian public healthcare
system also seems to be neglected. The majority of respondents consider the geographical
dispersion of the primary healthcare institutions to be appropriate. However, they
acknowledged the inequality of service among some institutions, which has a negative
 The 4Cs of the Croatian public healthcare system 231

impact on the overall user convenience. A minority of respondents tried to minimise the
importance of convenience. According to them, users should show more initiative in, for
example, finding relevant information about the healthcare system reforms and
supplemental health insurance coverage:
“There was no need for providing more information to users on recent changes
or to provide better access to information. All the needed information was
published on the HZZO (Croatian Institute for Health Insurance) web page.”
[Respondent 1]

Respondents perceived communication as the most important aspect of social marketing

or, in some cases, as the only marketing tool that is needed within the healthcare system.
However, the majority of respondents described only one-way communication, with no
clear idea about the benefits of two-way communication with users. Respondents also
identified one of the structural problems within communication and the entire concept of
social marketing within the Croatian public healthcare system – the lack of social
marketing experts within the system. The majority of communication is managed and
executed by staff with medical background and no formal education in marketing. Just a
few, larger communication campaigns were handled by advertising agencies, like the
anti-smoking campaign. Furthermore, management of communication activities is mostly
treated as a side-job. As respondents noted, the Croatian public healthcare system’s
primary channel of communication is internet, namely the official websites of various
healthcare institutions. Due to limited funds, other types of media are used scarcely and
mostly in cases of emergencies (e.g., epidemic outbreaks). However, all respondents
recognised the need for better management of communication activities and the
introduction of marketing experts within the healthcare system. Poorly managed
communication could result in a serious crisis:
“One relatively recent example of poorly managed PR activities is the case
of Rijeka hospital and the Maskarin incident. Miroslav Maskarin was a
20-year-old man who came to the hospital in Rijeka for a routine
appendectomy. During the operation he nearly died. Additionally, his leg was
amputated due to complications during the surgery. The hospital’s PR was
managed and executed poorly. Although the doctors were exonerated by the
Croatian Medical Association, the hospital took a hard blow when it came to its
image and is now being sued by Maskarin. That is just one example of [what
happens] when PR is not managed by experts [...] Doctors and the hospital
board gave statements and communicated with the reporters themselves…And
they are just not educated for something like that.” [Respondent 8]

Overall, all respondents agreed that the Croatian public healthcare system lacks a social
marketing approach. First, there are almost no marketing experts employed within the
system. More or less, all marketing labelled activities are handled by medical doctors,
which respondents consider as a weakness. Second, marketing formally does not exist
within the system. Second, the system is going through reforms initiated during the EU
accession process. However, these reforms are aimed at the financial side of the system.
As one of the respondents pointed, “the system is not focused on users, but on itself”.
Finally, there is a huge impact of politics on the system. As some of the respondents
mentioned, it is always about maintaining a balance between political demands and
taking care about the users.
232 N. Draskovic and A. Valjak

5 Conclusions

The Croatian public healthcare system went through a series of reforms during the last
twenty years. As both the literature review and primary research revealed, these reforms
were mostly focused on cutting costs, which resulted in a lower quality of the healthcare
from the user’s perspective. Ironically, the overall quality of the Croatian healthcare
system was much better before all of these reforms and decentralisation efforts (Dzakula
et al., 2005). While the Croatian public healthcare system’s current focus on financial
matters and budgetary issues could be partially justified from the perspective of the
demands from the EU accession process and the need for cuts in public spending, there is
an obvious need for the system to re-focus on user satisfaction.
As the primary research revealed, members of the Croatian public healthcare system
do not understand the concept of social marketing. Similar to the reported discrepancy
between the awareness of service marketing among Croatian surgeons and its application
to medical care (Ozretic-Dosen and Bilic, 2009), members of the healthcare system
mislabel certain communication activities as the marketing activities, while neglecting
other important elements of the marketing mix in the context of social marketing, like
focus on user satisfaction, user convenience, etc. Furthermore, there is a lack of social
marketing experts within the healthcare system. Medical staff, with limited or no
marketing education, manages social marketing activities, which is mostly limited to
communication.
The Croatian public healthcare system will have to re-focus its efforts on user
satisfaction in order to improve the quality of service. Implementation of the social
marketing principles could provide an appropriate framework for further development
and improvement. However, there is a need for specific adjustments before the new
approach could be enacted. First, social marketing should be officially recognised by the
system and implemented within the organisational structure. It is important to include the
social marketing concept within development strategies and plans of the Croatian
healthcare system to provide the critical mass needed for re-focusing on user satisfaction.
Furthermore, the system should employ social marketing experts. Second, internal
educational programmes should be designed for staff in charge for the social marketing
activities and management. Since the implementation of the social marketing concept
should result in the overall change of how the system treats users, a broader
understanding of social marketing principles among healthcare staff is essential. Finally,
the Croatian healthcare system needs to allocate sufficient funds for the implementation
of social marketing principles, employment of social marketing experts and staff
education. The implementation of the social marketing principles within the system is not
possible without spending, but this should be considered as an investment into a better
healthcare system and satisfied users.
This explorative study provides limited insight into the structural deficiency of the
Croatian healthcare system and adaptation of social marketing principles. Some
problematic issues and the lack of comprehension of the social marketing concept were
revealed. Therefore, there is potential for further research in the field of the social
marketing education for the healthcare staff. Furthermore, research focused on the user
perspective should also be intensified, not only to measure the satisfaction level with
healthcare services, but also to provide information needed for the development and
execution of social marketing activities.
 The 4Cs of the Croatian public healthcare system 233

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