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Title page 1

Contents 6

Foreword 4

Acknowledgements 5

Executive summary 9

1. Disability policy and people with disability in Croatia 11

In Brief 12

1.1. Social and labour market inclusion of people with disability 13

1.2. Disability policy changes in recent years 20

References 21

2. Disability and work capacity assessment in Croatia 22

In Brief 23

2.1. Governance and methodology of disability assessments 24

2.2. Challenges with the current disability assessment process 30

2.2.1. The assessment procedure is too long threatening the return to the labour market 30

2.2.2. The assessments have an outdated medical approach 34

2.2.3. Current assessments do not seem to take mental health sufficiently into account 35

2.2.4. Use of different definitions of work capacity across institutions 37

References 39

Note 39

3. Disability assessment in other OECD countries 40

In Brief 41

3.1. Bringing functioning into disability assessment 42

3.2. The consensus framing of DA&D 42

3.3. Observations from case examples 43

3.4. European Union countries 48

3.4.1. Latvia 48

3.4.2. Lithuania 53

3.4.3. Estonia 57

3.4.4. Belgium 62

3.5. Non-European Union case studies 67

3.5.1. Moldova 67

3.5.2. Uzbekistan 69

3.5.3. United States: including functioning into the assessment system for veterans 71

3.6. Lessons learned 75

References 76

Notes 80

4. A new methodology to assess functioning for disability in Croatia 81

In Brief 82

4.1. The World Health Organization WHODAS Questionnaire 83

4.2. WHODAS and disability assessment 85

4.2.1. Performance-based disability assessment tools 85

4.3. How can WHODAS be used for disability assessment? 86

4.4. Preparing WHODAS for country-specific applications 87

4.5. Lessons learnt from pilot studies 97

4.6. WHODAS in practice: Linear metric scales and disability cut-offs 98

4.7. Using WHODAS-generated functioning information for disability determination 99

4.8. Using WHODAS for disability assessment in Croatia 100

References 102

5. Going beyond disability assessment 104

In Brief 105

5.1. Supporting workers through long-term sickness 106

5.2. Supporting the (long-term) unemployed 111

5.2.1. The key role of the Croatian Employment Service 111

5.2.2. Initiatives to support finding employment for people with disability 112

5.3. Professional rehabilitation 113

5.3.1. Croatia has a strong and comprehensive professional rehabilitation system 113

5.3.2. Professional rehabilitation outcomes could be further improved 115

5.4. Developing an evidence base and strengthening monitoring and evaluation 117

References 119

Tables 7

Table 3.1. Latvia - health disorders assessment table for adults 50

Table 3.2. Latvia - an excerpt from the "Functioning ability evaluation table" 51

Table 3.3. An excerpt from the criteria to assess an individual's basic participation level 55

Table 3.4. Belgium assessment of functional impairment for invalidity pension 64

Table 3.5. Invalidity pension - combining medical and functional assessments 64

Table 3.6. Income Replacement Allowance - Combining medical and functional assessment 65

Table 3.7. General Rating Formula for Mental Disorders in the US system for veterans 72

Table 3.8. The examiner compares WHODAS results with VA's mental health rating schedule 72

Table 3.9. Anchoring WHODAS and impairment levels 73

Table 4.1. The questions of the 12-item and 36-item WHODAS questionnaire, by domain 84

Table 4.2. Key features and parameters of the WHODAS pilot testing implemented in 10 countries 2018-2024 89

Table 4.3. WHODAS pilots: Sample demographic and medical characteristics and some key findings from the data analyses 92

Table 4.4. Potential use of WHODAS for disability and work capacity assessments in Croatia 101

Table 5.1. Most people come to professional rehabilitation through employer referral or self-referral 115

Figures 7

Figure 1.1. Poverty rates in Croatia are high for people with disability and have been increasing continuously in the past decade 14

Figure 1.2. Persistently low employment rates of people with disability in Croatia are the key cause of the observed high and increasing level of poverty 15

Figure 1.3. Employment rates in Croatia are also low for people receiving a disability benefit 16

Figure 1.4. Contrary to other European countries, in Croatia the share of people with disability who achieve at least upper secondary education has not changed 17

Figure 1.5. The employment gap between people with and without disability is large in Croatia 18

Figure 1.6. After adjusting for levels of disability prevalence, Croatia continues to stand out as a country with a large employment disadvantage caused by disability 19

Figure 2.1. The number of HZSR and overall assessments has sharply increased since 2022 29

Figure 2.2. Today, almost 60% of all disability assessments are requested by the HZSR 29

Figure 2.3. The backlog of unresolved applications for an assessment continues to increase 30

Figure 2.4. More and more people must wait for an assessment decision for several months 31

Figure 2.5. Waiting times have increased most for requests for a disability pension from HZMO 31

Figure 2.6. The Croatian assessment body (ZOSI) struggles to hire sufficient assessors 33

Figure 2.7. The caseload and thus the actual workload of assessors is constantly increasing 33

Figure 2.8. The large share of reassessments further adds to the considerable workload of ZOSI 34

Figure 2.9. Mental health conditions are one of the most common conditions for assessments 36

Figure 2.10. A high share of young disability benefit applicants reports mental health conditions 37

Figure 2.11. Differences in work capacity definitions may explain differences in assessment outcomes, at least in part 38

Figure 4.1. WHODAS 0-100 score distributions in nine WHODAS pilot test countries 88

Figure 4.2. Latvia WHODAS-score density line by determined disability status groups 96

Figure 4.3. Azerbaijan WHODAS-score density line by medically established disability severity 96

Figure 5.1. Longer sickness spells reduce the likelihood to return to work and increase the likelihood to transition to disability benefits 107

Figure 5.2. Sick leave in Croatia could be reduced by a stronger return-to-work focus 110

Boxes 24

Box 2.1. The difference between disability assessment and work capacity assessment 24

Box 2.2. Three different registers for people with disability in Croatia 28

Box 3.1. A cautionary tale for other countries: Armenia's instrument to assess functioning 46

Box 3.2. A unique example: Chinese Taipei's disability assessment system in a nutshell 47

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