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Back to People's Health in Croatia – Generating New Forms of Collective Agency

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Back to People's Health in Croatia – Generating New Forms of Collective Agency ORIGINAL RESEARCH Back to People's Health in Croatia – Generating new forms of collective agency Snježana Ivčić, PhD; Lecturer Aleksandar Džakula, MD; Damir Martinović, MD; Valerija Žapčić, Abstract frequently focused on a single-disease approach and collaboration with the pharmaceutical This paper concerns new forms of industry. Such practices produced limited results; collective agency in the area of healthcare in hence improved forms of activism emerged. Croatia from 2015 until 2018. These new forms In this research, we illustrate their developed in the midst of the growing development using the example of three case privatization and commodification of health care studies of collective agency. The first case study is and the simultaneous decrease in the accessibility looking at the policy analysis and the activist to healthcare. group started by the Organization for Workers' Privatization has taken place slowly, but Initiative and Democratization (OWID); the continuously over the last 29 years. The traditional second one focuses on the informal group of civil society organizations in the field of medical students called U3 formed at the Andrija healthcare used to be characterized by a narrow set Štampar School of Public Health with the aim of of activities, with vertical structures, and were developing critical thinking; and the third case study considers the Karika Association, started as an attempt to rethink healthcare in the community. Snježana Ivčić, PhD, The main research methods employed Croatian Academy of Sciences and Arts, snjezana. included process tracing analysis and research data Email: [email protected] comparison aimed at showing the differences between the traditional and the new forms of Lecturer Aleksandar Džakula, MD, Škola narodnog zdravlja Andrija Štampar “/ healthcare activism, in addition to the secondary School of Public Health „Andrija Štampar “, sources of information such as scientific and Email: [email protected] professional literature. The results show that the new forms of collective agency in the healthcare Damir Martinović, MD, area include various groups of citizens not Odjel za radiologiju, Opća bolnica Zabok i bolnica necessarily connected with a specific disease, that hrvatskih veterana / they have a horizontal structure and are focused on Department of radiology, General Hospital Zabok and the healthcare system in general. In conclusion, Hospital of Croatian Veterans , they represent the beginning of a paradigmatic Email: [email protected] shift in activism from a single-disease approach Valerija Žapčić, towards comprehensive health care that has the Nurse Educator, Udruga Karika / potential to deal with the growing issue of Karika Association, commercialization, commodification and Email: [email protected] inequalities in today's healthcare systems .Key words: Croatia, public health, Received: December 3, 2020. comprehensive health care, collective agency, Accepted: March 18, 2021. Conflict of interest: none. active. Social Medicine (www.socialmedicine.info) - 96 - Volume 14, Number 2, May - August 2021. Introduction many ways complementary to the healthcare system in Yugoslavia at the time (8), which saw This paper is focused on a paradigmatic the health of the population as a concept made up shift in the approach to the access to health care in of biological, social and economic components Croatia. Historically speaking, there were three (1,9,10). shifts. The first one occurred at the beginning of The second paradigmatic change occurred the 20th century, when Doctor Andrija Štampar in the 1980s, its first sign being the 1973 oil introduced comprehensive health care in the then crisis. In fact, these changes started back in the Yugoslavia invoking a transition from capitalism 1980s, when neoliberal politics dominated also to social medicine. health policies, especially in the south-eastern Andrija Štampar, doctor and founder of European countries (11), and Croatia was no the public healthcare system in this area, pointed exception (8, 12). In Croatia, however, out in his 1919 text O zdravstvenoj politici [On privatization started to emerge in the 1980s (13). Health Policy] (1) the negative influence of the Formally speaking, the second shift took capitalist economy on human health: "the whole place in Croatia at the beginning of the 1990s, national economy is managed and flourishes to the with privatization in the healthcare system and the detriment of the people’s health and our overall consequent replacement of the social economy by health budget is in substantial deficit". Štampar the free market economy over the next 29 years. warned against another very important fact, that The second change of paradigms in Croatia was capitalism comes down to purely physical/corporal introduced by a programme written by Andrija strength, where sale is considered goods and Hebrang in 1994 (14). He was not the first one to people's health has no value, but is simply a announce privatization, as it had already started at consumable good: "In a capitalist economy the the end of the 1980s but he wrote a programme for man provides some economic value, although he it, advocating firmly the privatization of primary has no economic value himself; if he does not use health care in Croatia. Subsequently, ministers of his working power or loses it, he is like air and health and health experts continued along the same water." (1) path, resulting however in today’s deterioration of In his 1934 paper 10 godina the healthcare system. unapređivanja narodnog zdravlja [Ten Years of The third shift, which is the object of this Improving Public Health], Andrija Štampar, wrote research, started taking place very recently, only a that the State was responsible for the citizens' few years ago. This new transition from the free health "…only the state-controlled health service market and commercialization and can, in certain circumstances, provide adequate commodification of the healthcare system to health care to the people” (2, p. 105). In addition, universal/social and comprehensive healthcare is he was convinced that “Everybody should be very interesting from several aspects. While a equally committed to the issue of public health, strong personality (A. Štampar) and the social affecting not only the health but also the progress state played a big role in the first transition, and in of every individual. This is the only way that it can the second transition, international institutions become an object of public concern.” (2, p. 109). (e.g., the International Monetary Fund and the Štampar’s principles and approach to World Bank) exercised a great influence in the health care were implemented into the health newly formed state, the third, most recent policy of former Yugoslavia (1945-1991). The transition began as a bottom-up shift to which civil Yugoslavian healthcare system was based on society made a great contribution. solidarity and the principles of Andrija Štampar The third paradigmatic change was also (3). Furthermore, it is worth noticing that health marked by the global situation which contributed was defined by the Health Protection and Health to the rethinking of the Croatian healthcare system Insurance Act (1980) (4) and treated as a public and had influence on collective agency. Three good (although this was not explicitly stated). concepts1 need to be taken into consideration: The outcomes of the Lalonde report (1974) (5), the Alma Ata Charter (WHO, 1978) (6) 1There are some differences between the PHC and UHC and the Ottawa Charter (WHO, 1986) (7) were in approach. The PHC implies “primary healthcare Social Medicine (www.socialmedicine.info) - 97 - Volume 14, Number 2, May - August 2021. refocusing on the primary health care (PHC) as Association, started as an attempt to rethink defined in the Alma Ata Chapter, global request healthcare in the community. for the universal health coverage (UHC) and promotion of the value-based health care (VBHC) Methods defined by Michael Porter in 2010. This wave The main research methods employed in affected the OWID’s group for health, the U3 this study included process tracing analysis 2 and group and the Karika Association. research data comparison aimed at showing the This paper will try to answer the following changes of paradigms and the differences between research question: What factors led to the the traditional and the new forms of collective emergence of the third paradigmatic shift in the agency in the field of healthcare, in addition to the civil society area dealing with healthcare, and, secondary sources of information such as scientific more particularly, to a transition from a single- and professional literature. disease approach towards comprehensive health Process tracing is the appropriate method care in Croatia over the last decade. Furthermore, for case studies based on qualitative data (18, p. this paper focuses on the difference between 823), as was the case in this research. For the traditional civil society organizations and the new purpose of this research, Collier's definition of forms of collective agency in the healthcare area process tracing was used (18, p. 824): “Process as shown in three case studies. tracing is an analytical tool for drawing descriptive The first case study is looking at the policy and causal inference from diagnostic piece of analysis and the activist group started by the evidence often understood as part of a temporal Organization for Workers' Initiative and sequence of events or phenomena.”
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