Coronavirus, Budget Cuts, and Labour Migration

“I have dismissed Milan Kujundžić from the post of Minister of Health because he wasn’t focused enough on the novel coronavirus”, Croatian Prime Minister Andrej Plenković announced in late January this year. At the time, the PM’s statement was sneered at: it was common knowledge that Kujundžić’s deposition had more to do with the scandals he was involved in than with what was then still largely considered to be an overblown public health issue.

From when he took office in 2016 until his dismissal, Kujundžić showed a blunt disregard for anything that could be considered evidence-based health policy. Yet it should be noted that he was only part of a long list of ministers of health who will not be remembered for their positive contribution to the local health system. In fact, for the last 30 or so years, Croatia has faced a steady downwards trend when it comes to access to care. This can be linked to the absence of a coherent health policy framework, but also to the commercialization and privatization of health care.

Although most of the population is formally covered by a quasi-universal national insurance scheme, in practice there are notable inequalities in quality of care among different regions. Additionally, some population groups, such as migrants and refugees, continue to face obstacles to accessing health care, despite being entitled to it. Finally, corruption and nepotism run rampant, as has been exposed over and over again by the few investigative journalists who still work on healthcare issues.

Needless to say, all these things have undermined much of the population’s trust in health practitioners and the system. Expectations were thus low to negative when the name of the new Minister of Health was announced on 29 January 2020. Yet soon after, something almost fairy-tale-like happened: once it turned out that the new coronavirus (COVID-19) pandemic was anything but overblown, Vili Beroš, the newly appointed minister, seemed to hold his ground. The civil protection authority staff put in charge of the response was made of public health professionals, rather than politicians; information was communicated to both media and the public in due time; at the end of February, when the first cases of COVID-19 were diagnosed in Zagreb, the local hospital for infectious diseases was ready to host them. Learning from the experience of other EU countries, stay-at-home measures were implemented well before a notable spike in cases occurred. And although testing capacities lagged at first, they seem to have picked up the pace as well.

By now the minister has come to be perceived as a real-life superhero, with school children drawing him in Superman’s clothes. From the numbers reported over the last few days, it appears Croatia may be on its way to flattening the curve, as opposed to countries with better-ranked health systems like Italy and France. Recent public opinion polls suggest unprecedented trust in the government: as far as most people are concerned, things are looking good.

There is a parallel narrative to this. It is illustrated by endless examples of health institutions being destroyed by privatization, and reflections on how the implementation of austerity measures has exploited most health workers and pushed many more to emigrate. The Croatian Medical Chamber has conducted several surveys on attitudes towards migration among its membership. In 2016, its survey focused on physicians below 40 years of age, and showed that 60 percent of those participating (898 doctors of a total of 1,496 participants) contemplated emigrating, mostly due to poor working conditions in the Croatian health care system. Data on health worker migration in Croatia is still lacking, but anecdotal accounts from both physicians and nurses indicate a strong trend towards emigration, particularly to Germany and Austria, along with other EU countries.

A specific outcome of the shortage of health workers on the European level can also be seen in the growing interest in health-related high school programmes: some medical high schools have enrolled additional classes of teenagers who see a career in pharmacy or physical therapy as one of the easiest ways of leaving the country. This narrative exposes the more fragile health system most people experience when they need to see a doctor, one which still depends on buildings and policies built in socialist Yugoslavia (in the best of cases), and left to their own devices to navigate the transition to a new, market-oriented health landscape.

A month into the epidemic, on 22 March, Zagreb and the surrounding area were hit by the strongest earthquake in over 100 years: in addition to scaring people out of their homes and self-isolation, it also rattled hospitals and community health centres. Among the most poignant photographs of the earthquake was one of an evacuated maternity ward (built in 1914), where women assembled in the front parking lot with their new-borns, unsure of what would happen next. They were then transferred to other health facilities thanks to the help of volunteers. This unfortunate episode had a more or less happy ending, but we can hardly say it conveyed the image of a strong health system.

Other episodes ended worse. The Institute of Immunology, for example, used to produce interferon-based medical products not unlike the ones currently made by Cuba, which have been included by WHO on the list of products tested as treatment for COVID-19. Established in 1893, the Institute constitute an important asset for the local health system as it was able to supply enough high-quality vaccines to satisfy local need. By 1930 Croatia had no need for vaccine imports, meaning that more funds could be allocated to strengthening the health system and training of health workers.

Local production continued in socialist Yugoslavia as part of the health system, but at the end of the 1980s the first signs of trouble appeared. From this period onwards, the Institute of Immunology, like other health institutions, was heavily influenced by guidelines imposed by international financial institutions and general commodification trends. The Institute has since been completely ruined through various attempts at privatization, executed through a well-known blueprint: first, the Institute’s existing production capacities were reduced to minimum and ignored, causing the Institute to lose many of the WHO certificates it used to have. Once Croatia joined the EU, even more restrictions on production were implemented by the Agency for Medicinal Products and Medical Devices (HALMED). In 2012 the management of the Institute fired around 100 workers and sold shares in the Institute, which sparked reactions from trade unions and the public. Although efforts to protect the Institute of Immunology and its production stretched over a long time and included different approaches—from establishing a citizens-oriented limited partnership called Visia Croatica to advocating that the Institute should remain in public hands—they only resulted in a stalemate, with basically all relevant production halted. And although the building still stands, production capacities are reduced to minimum, meaning that Croatia is dependent on big pharma when it comes to the import of medicines and vaccines.

The COVID-19 epidemic has been a particularly strong reminder of the importance of having an independent production capacity in the health sector, and several public health officials have publicly stated that a fully operational Institute of Immunology would probably do wonders in terms of response. Instead, the Institute is currently involved only in the production of smear substrates.  The downfall of the Institute of Immunology is often quoted as key evidence of the lack of responsibility of local health officials, who were quick to forego health resources when pressed by the private sector.

The lack of planning and dedication to the right to health is also reflected in the current state of the health workforce. Around the world, workers in the health sector—not only nurses and doctors, but paramedics and ambulance drivers, midwives, cleaning staff, cooks, laboratory technicians, etc.—are bearing the brunt of the response to the pandemic. In Croatia, although these efforts are nominally recognized, health workers still have to deal with lousy working conditions (strongly linked to a general shortage of health workers) and problems in allocation of personal protective equipment. Even in so-called “peace time”, excessive overtime and bullying are the order of the day.

In the intensive care unit of the general hospital in the city of Sisak, seven nurses reported that one of the physicians from the unit continuously mistreated them, making the workplace unbearable and leaving them in a state of extreme emotional, psychological, and physical stress. Although the nurses addressed hospital management several times in an effort to mitigate the negative effects of this particular experience, and the media covered the case quite extensively, no concrete result was achieved. Instead, the nurses—who all had significant experience in intensive care—were either transferred to other departments or left the hospital entirely, some to work in other parts of the health care system and others to emigrate.

ICUs are something we are likely to need during the COVID-19 pandemic, and thus should it not be at least a bit embarrassing for health officials to count on those workers to go the extra mile now, when they are otherwise not willing to put any effort in ensuring safe and decent workplaces for them? Apparently not. These tiny, insignificant, systemic details are left unaddressed when individual responsibility is invoked: as far as government officials are concerned, it will be the people’s fault if the health system grows overburdened and collapses. Given their approach, it is safe to say that if Croatia makes it through this pandemic relatively unscathed, the experience will say a lot about the solidarity that arose in communities and health workers’ dedication. It will say next to nothing about the strength of the Croatian healthcare system.