The U3 Public Health Initiative in Croatia

RTBC_U3.jpg

Andrija Štampar’s legacy 100 years later

"Parrhesia is a verbal activity in which a speaker expresses his personal relationship to truth, and … recognizes truth-telling as a duty to improve or help other people (as well as himself). In parrhesia, the speaker uses his freedom and chooses frankness instead of persuasion, truth instead of falsehood or silence ... criticism instead of flattery, and moral duty instead of self-interest and moral apathy."  -Michel Foucault, Fearless Speech

Governed by these principles on a more or less conscious level, a colourful band found itself gathered in an old but cosy library in Zagreb, Croatia on a Tuesday afternoon in the autumn of 2015.

The band consisted of a dozen students of medicine, pharmacy, nursing, sociology, political sciences, anthropology and the arts, young (and not-so-young) public health professionals, medical professors with Harvard affiliations and retired professors. They met each Tuesday (utorak in Croatian) at 3pm in the library of Andrija Štampar School of Public Health. That’s U3, and it has been going on weekly since January 2015.

We are an informal initiative of a group of people whose diverse professional and private backgrounds and experiences are, in one way or another, connected by the topics of health, healthcare and public health. But most importantly, our discussions have shown that we all share a desire to be cheerful in our little society—so we had no choice but to try and find ways in which we could make that happen.

But before we go into the work of the U3 group, let’s introduce the eponymous character here—Andrija Štampar. And what’s with the incredibly cool moustache and glasses combo?

  Photo courtesy of Proleksis Enciklopedija.

Photo courtesy of Proleksis Enciklopedija.

Štampar was the first President of the World Health Assembly and one of the founders of the World Health Organisation in 1948. He was one of the most charismatic and beloved figures in 20th century public health. In 1920, Štampar published his “10 Principles of Public Health and Social Medicine”.

10 principles.jpg

How should we interpret this 98 years later? Besides the Croatian connection, what does this public health globetrotter from a century ago have to do with what we do in 2018?

A year before publishing his 10 principles, Andrija Štampar wrote:

"All our efforts made so far toward the promotion of public health have been considered as charity, as acts of humanity, and that is why the budget allotted for these efforts has been so small, for the understanding of charity can be found only among the few… a turning point will occur only when health policy is looked upon as the most important part of national economy….

Physicians will not be allowed to remain in their hospitals, consulting rooms, and sterile offices— they will have to step into public life and fight for achieving an ideal— an appropriate health policy—and considering this policy as the most important part of general national political life."

Politics—such a dirty word!
So, what did we at U3 do? Conclude that health policy is too political and too top-down to be dealt with from an activist-academics perspective? On the contrary, we decided to act as parrhesiastes (ones who speak truth to power) and deal with the topic during the 2015 parliamentary elections, and, unexpectedly again in 2016.

Croatian political parties’ interest in health care policy is a relatively recent affair. Both national and local pre-election campaigns have traditionally been devoid of health policy programs, as have their party manifestos, even though health care has often been a top issue in the public eye. One explanation for this is the fact that health care is a complex issue, requiring in-depth knowledge both by parties offering solutions, and the public who are evaluating them and their proposed solutions.

In the past couple of years, however, we have seen increased conversations both in the media, as well as on public forums, about the detrimental state of the healthcare system. Based on the prosperity index, Croatia has the fifth worst health pillar score in the EU.  Healthcare has been pushed to the top of the political agenda, and political parties have begun forming official party platforms concerning health. More specifically, parties focused on healthcare, in terms of functioning and financing of the system, rather than health—addressing the drivers of ill-population health in general.

Nonetheless, the years since the 2011 parliamentary elections have been characterized by a discrepancy between rhetoric and actions in the health policy arena. Additionally, because of the inconsistency and the diversity of the health platforms presented, it was often difficult for voters to assess what the parties promised and what they realized in the post-election period.

  Photo courtesy of U3.

Photo courtesy of U3.

In an effort to understand the health platforms of the running parties, the U3 group analysed and compared health policies contained in the party platforms preceding the 2015 regular, and 2016 snap parliamentary election. The reason we focused on the period of parliamentary elections is that it is during this period that political parties are trying to appeal to the voters and put the most effort into communicating their plans for policy change and reforms.  

The results of our analyses showed that the parties’ pre-election programmes were mostly focused on the topics of accessibility and financing of health care (especially hospitals) while prevention and financial resources needed for the implementation of the health policies were rarely discussed. We also discovered there was a lack of interest among parties to include policies targeting the prevention of major public health problems in Croatia such as obesity, cancer, tobacco and alcohol use in their programmes. These four made up for 59% of risk factor attributable deaths in Croatia in 2013.

Our efforts were not only academic! We started a blog, a Facebook page and designed a number of infographics promoting our reasoning, methodology, findings and recommendations. We wrote “How to vote on healthcare topics” manual for the voters and “10 things to consider when preparing your health policy” for political parties. None of these drew much attention, but we had fun and learned a lot in the process.

Then in 2016, when snap elections were announced after a year of very unstable government, it happened. Our publications started receiving unexpected attention. Newspapers started calling in for interviews, parties asked for assistance in writing their health policies for the upcoming elections… and we decided to repeat the analysis. The results were still not satisfying, but just a little bit better this time. We imagine(d) U3 might have something to do with it.

Since 2016, the U3 team has changed. Some of us moved to Atlanta and Vienna, some are moving to Amsterdam, some are still in Zagreb. Despite this, we continue to act as watchdogs even if those scattered all over the planet are planning to return to Croatia eventually. Until the next elections!

To paraphrase Kurt Vonnegut—if this is not a reason to be cheerful, what is?

Epilogue:

In this article, we did not—on purpose—mention other U3 interventions and actions like promoting public health concepts to the general population, organising a “health fair” or helping to fix curtains in a local palliative care hospital. These actions help, but we are also aware of the limited temporal and spatial effect. We also wanted to present a different, activist-scientist-politician approach to working on local and national health issues.

Following the work of the U3" initiative, the Andrija Štampar School of Public Health is currently establishing the “Best practice in health and healthcare” centre in Zagreb. The centre is an institution which aims to improve the effectiveness and efficiency of the Croatian healthcare system, and will surely be a cause for celebration and all around cheerfulness.

Damir, Senad, Juraj and Rafaela, on behalf of the U3 bunch.


Damir Ivanković is a Public Health Resident at the Croatian Institute of Public Health and, soon to be, a PhD Researcher at the Academic Medical Center in Amsterdam.

Senad Handanagic is a medical doctor, public health practitioner and external associate at WHO Collaborating Centre for HIV Strategic Information at Andrija Stampar School of Public Health.

Juraj Kreso-Lovric is an undergraduate student at the University in Zagreb, with a keen interest in a future public health career.

Rafaela Tripalo is an anthropologist, also trained in public health, and currently working for a health policy research and implementation forum in Vienna, Austria.