To improve the Government's response to problems and delivery of products, the Office of the Prime Minister of Croatia introduced Agile methodology and Agile teams, which mimicked startups in using iterations and learning to inform their next move. All governments have policy challenges that seem too complex to be solved. These challenges span across several departments, have some areas where jurisdiction of departments is unclear, and any intervention would have serious impact on all citizens.
In 2014 Croatia initiated two digital health sector innovations, E-Results and E-Referrals. The systems were intended to digitize the process of referral to hospitals and medical results, including hospital discharge letters. The innovations would have changed the hospital experience for an average citizen had they been implemented in full. Unfortunately, disappointing levels of innovations uptake and use by health practitioners have limited their impact.
In 2019 the Office of the Prime Minister of Croatia started looking into these limited successes. The team was convinced that the innovations were of critical importance for the citizens, and wondered, if the low uptake and low use were a result of limited user engagement in system design and, equally, a result of limited user engagement upon system implementation. They were interested in experimenting with agile methodology to see if it could unlock a way forward out of this situation. The team proceeded to organize a three-day workshop on agile and an associated method, problem driven iterative adaptation (PDIA), in Zagreb in 2019. Many of the workshop participants expressed a high level of enthusiasm about wanting to work in these new ways on their challenges. They were, however, weary about how successful the methods would prove to be within the country. No one had tried using agile methodology in the public sector in Croatia.
Undeterred and bolstered by the Prime Minister’s support, the team went on to grow the idea and created two teams to pilot the new method. One team would work on a digital governance issue related to healthcare, while the second team would work on improving the user experience relating to Government digital services.
These were the questions that teams needed to answer:
Agile Health team: 'Can the Health system shift to only use the electronic referrals to hospitals (without relying on the paper print-outs)?'
Public Administration (PA) team: 'What can we do to improve how the Government delivers its services and information?'
Learning through activities has been the greatest challenge for the teams, as quick solutions kept on creeping up. Insistence was made on the fact that the teams discuss the learning and refrain from providing ready-made solutions. Iterative approach uncovered the need to analyse problems from a user perspective rather than the institutional perspective while support of the Prime Minister's Office meant they could do it.
Team Health shadowed health practitioners in the different hospital departments during which they could understand business processes and software protocols but also see the user experience first hand. When they paired this hands on experience with prior data analysis and interviews with professional Chambers and patient associations they were confident when the team suggested to the Minister of Health to abolish the paper version of the e-referral. In 2020, citizens did not have to make a trip to their family doctor anymore to pick up the paper e-referral just to bring it to the hospital desk.
The PA Agile team had a profound impact on the development of the e-Citizens portal in Croatia. The team delivered a new portal that replaced four different websites and two different registries. It introduced user perspective and delivered a document "Standards for the development of public services" that was adopted by the Government session in April 2021. This document formalized the approach and introduced agile teams as a mechanism of developing new digital services.
The new e-Citizens portal was launched in May 2021, as a system that caters to all life roles (parent, business owner, guardian etc.) our citizens might hold. All in one place for all life roles and situations. The number of e-Citizen users grew 30% since. The teams are proud of their work. The Agile approach allowed them to break down institutional silos. It provided the teams with ways to communicate across departments and organizations, to learn from users, to rapidly identify practical and accessible ideas to try and resolve long-standing problems, and to gain support for an exciting new experimental approach to testing these ideas out.
This kind of work is not common in the Croatian public service context, and the work of this team shows that significant progress can take place in a matter of months towards solving problems that are complex and seem overly challenging to handle. Agile methodology and agile teams have now been recognized as drivers of positive change in the field of digital transformation and play a central role in plans for the next phase of digital transformation in Croatia.
What Makes Your Project Innovative?
This was the first time that agile methodology was applied in Croatian Government. We already knew examples of other Governments using agile methods to deliver e-products but we were not aware of any example where it was used to unlock a reform agenda as in the example of our Agile Health team. Strong focus on the learning, has made PDIA methodology particularly good because it has allowed us to bypass the usual instant and/or partial solutions. Agile approach kept our focus on the user, which in turn helped steer the immense amount of data and analysis that the team delivered through their activities toward conclusions.
What is the current status of your innovation?
We are in the process of drafting the Digital Croatia Strategy 2022-2032. In this strategy, we rely heavily on restructuring the way we manage digital transformation in Croatia and how the results are delivered operationally. Agile teams are now embedded, not only in the Standards for the development of e-services but also in delivery of our digital policy through an improved project management model. Finally, it will be interesting to see whether teams will continue to approach their work with such ambition and success once they are formalized.
Collaborations & Partnerships
- Agile Health team involved: Office of the PM, Ministry of Health, Croatian Health Insurance Fund, Croatian Institute for Public Health, University Hospital Center Zagreb, Croatian Medical Association, Croatian Association of Patients, all companies that produce software for hospitals.
- Agile Public Administration team: Office of the PM, Ministry of Justice and Administration, Central State Office for Digital, Student of IT, citizens, representatives of employers, etc.
Users, Stakeholders & Beneficiaries
In both agile teams, the primary beneficiaries were citizens. Secondary beneficiaries were civil servants, health workers, owners of companies, parents of minor children, companies, etc.
Results, Outcomes & Impacts
Results: The Agile team provided evidence that the Government should stop generating 13 million paper referrals/year. All of the paper referrals had to be archived in paper form which meant 65 million referrals in the past 5 years. All Croatian hospitals proved ready to transfer to e-referrals only. This had a positive impact on citizens and their access to hospital care. It also had a positive impact on the nurses who did not have to deal with two systems (both electronic and paper system).
The PA Agile team delivered e/Citizens portal that replaced four different websites and two registries. It became a central place for both citizens and business entities. The new e-authorization system allowed for services to be offered for all life situations. For example, parents of minor children are automatically offered to use e-services on behalf of their minor children, business owners are automatically offered to use business e-services, etc.
Challenges and Failures
There have been numerous challenges in agile methodology implementation in a system that is not designed to support or understand such an iterative approach. After several months of work, when we compiled and analysed a lot of data, the teams realized the magnitude of work and two members quit. It has become difficult to juggle agile work alongside our usual work and this has taken a toll on the entire team. We have gone through these challenges together, sharing more about our deadlines and obligations and started to rely on each other for support.
Conditions for Success
There needs to be a sense of urgency. A feeling that a problem has not been resolved for a while and that it has become a problem. Then there needs to be a champion of change that has the right values, motivation and skill set to see the proposed experimentation from the beginning to the end. Personal values and motivation of individual members of the team is of great importance because when the motivation is low, personal motivation will provide the fuel. The experiment has to have the political support from the top so that when unconventional approach is recommended it can be implemented. Finally, the experiment has to bring an added value to the community of practitioners and to the leadership in order to continue receiving support for further development.
Yes, it has been replicated within Croatian Government again to develop new e-services and functionalities for the e-Citizens portal.
Team’s key findings led to the team writing a proposal for five rapid interventions to improve system use by practitioners in the country’s largest hospital, KBC Zagreb. These interventions were developed in a faster period than is typical to Croatian policy making, at lower cost than is normal, and enjoyed more ownership and acceptance than is common (in the various entities represented on the agile team and in their user collaborators). The ideas were directly targeted at solving users’ problems, and slated to be introduced through an iterative, adaptive process centered on garnering and then adapting to user feedback (where ideas would be activated quickly with the involvement of users, users would then be asked if the action solves their problem, the idea would then be adapted based on user feedback, and a newly adapted idea activated in a repeated iteration—until the user expresses satisfaction that the ‘problem is solved’).
Part of this material is an excerpt from the case study written by prof. Matt Andrews for the purposes of teaching it in the "Implementing Public Policy" course, Harvard Executive Education Program.
- Diffusing Lessons - using what was learnt to inform other projects and understanding how the innovation can be applied in other ways
27 November 2023