Consultant- primary health care Project Specialist Specialist Team Leader.
Poland’s health outcomes are below those of other EU countries. Despite significant improvement since 1990, life expectancy in Poland remains one of the lowest among OECD countries. In particular, its male adult population suffers from an excessively high rate of mortality, which is mostly caused by behavioral and preventable factors such as tobacco and alcohol abuse, road accidents and suicides.
Inadequate access to and quality of care are contributing factors to the below average health outcomes. The Polish healthcare system is one of the least accessible systems among EU28 countries. According to an OECD study in 2012, one in seven people in Poland (14.2%) reported unmet medical care needs due to high costs, long waiting times, and long travel distances to health facilities. This does not fare well with the EU average (6.4%), and only Latvia scored lower than Poland. Poland also has the longest waiting times for health care with an average of 300 days for a cataract surgery and a knee replacement, and 200 days for a hip replacement. A 2013 survey showed that the population rated the overall performance of the health care system only at 2.8 out of 10 (Puchta 2014). Consequently, access to quality healthcare is the number one priority for Polish citizens, as shown in a 2010 survey.
Health financing is insufficient, which makes it difficult for the country to tackle the access and quality challenges in the health care system. The OECD data shows that total health spending accounted for 6.8% of GDP in Poland in 2012, lower than the OECD average of 9.3%. In terms of % of GDP or spending per capita, it remains one of the lowest in the OECD. Out-of-pocket (OOP) expenditures account for 24% of total health expenditures, above 20% for the EU average (Chart 4). The lack of resources also affects the compensation abilities of the National Health Fund (NFZ) –the main purchaser of health services—only providing a reduced coverage of health services and key inputs particularly drugs, which increases the OOPs.
In addition to insufficient resources, inefficient use of existing resources has exacerbated the situation, calling for further reforms. Poland’s health spending is heavily skewed toward expensive hospital care. In contrast with its low overall health spending, Poland’s number of acute care beds is surprisingly higher than the EU average (4.3 beds in Poland versus 3.5 in the EU) based on OECD data, pointing towards an excessively hospital-centric health system. The share of inpatient care within health expenditures steadily increased over the years, jumping from 27% in 2004 to 36% in 2012. Between 2011 and 30 April 2014, the number of hospitals went up from 984 to 10781.Moreover, many of the public hospitals are in debt. In 2012, the total hospital debt and arrears reached at 10.6 billion Zlotys (0.7% of GDP). On the other hand, despite its aging population and increasing burdens of Non-Communicable Diseases (NCDs), very low public resources are allocated to long term care - only 0.7% of GDP compared to the EU average of 1.8% - and public health (2% of total health expenditures). Thus, there is a lack of strategic investing in cost-effective Primary Health Care (PHC) and public health interventions like prevention and health promotion to reduce the risk factors such as tobacco and alcohol use, lack of physical exercise, and inadequate diet.
One important source of inefficiencies is the fragmentation of the service delivery system. Since 1999, the decentralized levels of government (Voivoidships, Powiat and Gmina) operate their own facilities, but have no direct control over the resources required to finance the facilities, as funding is provided by NFZ.). No institution is in a position to carry out long-term strategic planning which spans the entire system. As a result, health services at different levels have not been able to form a coordinated and patient-centric network to completely serve citizens’ medical needs. The 2008 reform of the provider payment system (e.g., the introduction of Diagnosis-related Groups) has created some incentives for improving performance at the individual level. However, a large scale of efficiency can only be achieved through integrating different levels and types of care in order to create a patient-centered pathway throughout the services. Experience from other countries clearly shows that a more integrated care approach can achieve a higher level of efficiency and quality of care.
To address the fragmentation of service delivery and improve efficiency and productivity of the health system, the Ministry of Health (MoH) and the National Health Fund (NFZ) launched an integrated care discussion in Poland in 2013.
The envisaged integrated delivery systems (IDS) will focus on two key areas: (i) reform on contractual arrangements between NFZ and service providers to encourage service integration and coordination, (ii) The reform on provider contractual arrangements is coupled with reform on service organization solutions and structures to explore Integrated Care Organization (ICO) options
Objectives of Consulting Services
The objective of the work is to manage, coordinate, conduct and technically support the work of the Project Specialist Team.
The World Bank work will be divided into three components.
Component A will be dedicated to a short analyses of the polish health care system conducted both based on the available literature but also on the ground by the meetings and interviews with most of the relevant health stakeholders. Second part of the component A will be in depth analyses and desk review of the relevant international examples of the integrated care.
Component A will be conducted mostly by the international team of the Bank. The international examples of the IDS could be prepared with the cooperation with the international research health institutions.
It is expected that about 20% of the consultant time will be dedicated to the component A of the project.
Component B will be dedicated to elaboration and the design of the IDS pilots, which includes (i) finalizing the pilot design strategy based on the review and consultations conducted in Component A; (ii) proposing the pilot intervention packages (e.g., different type of bundled service contract options and organizational modalities); (iii) suggesting the generic statistical features for the pilot (sampling, matching etc.); (iv) designing the pilot instruments/questionnaires; and (v) drafting the pilot manual for each pilot site.
It is expected that about 40 % of the consultant time will be dedicated to the component B of the project. The work in the component B will be conducted threw out the work of the working groups with some amount of the individual work of the Consultant.
Once of the main tasks of the component C will be creation and conduction of the Project Specialist Teams (one for primary health care, one for ambulatory health care and one for hospital health care). The groups will be created by the NFZ. The role of the consultant, with the support from WB experts will be to organize and manage the work of the Project Specialist Team- working group.
The National Health Fund has envisaged the design phase of the IDS program is also a learning phase for the health stakeholders (starting from the NFZ and MoH teams, threw the service providers ending with the NGOs) During the course of the PSTs meetings, it is planned to adopts an actively participatory approach to make the models design a joint process and learn more about the integrated care.
NFZ will nominate the national technical experts to join the PSTs.
It is envisaged that there will be around 20 meetings of each of the PSTs over the course of the project. Some work of the specialist teams will be conducted with the cooperation with the others and some meetings of the PSTs could be conducted jointly
It is expected that about 40 % of the consultant time will be dedicated to the component C of the project.
Scope of work.
The National Health Fund will establish Project Specialist Teams (PST). They aim is to work with the WB experts on the defined technical issues. The PST setup is also designed for capacity building as the PST members are expected to play a key role during the implementation phase of the IDS program.
Each PST will be co-chaired by a Bank expert - consultant and the NFZ representative.
The consultant will be responsible for setting up the agenda and technical topics and presenting project findings and receiving feedback for further discussion with the Bank’s team and the NFZ. Each PST will have about 20 meetings over the course of the project.
The PST meetings will be synchronized with the systematic reviews and pilot design process, which will provide real time inputs to the Bank team.
The consultant supported by the Bank team will play a technically leading role in the PST meetings. The Bank consultant in primary health care will be co- chareing and leading the meetings of the primary health care PST. The work will also include preparation of the technical content of the meetings, facilitating the discussion, drawing conclusions from the meetings, drafting meeting minutes, and reflecting the conclusions in the review reports and pilot design.
The Consultant will also contribute to on-going team’s operations and missions when required.
In particular the consultant will:
Prepare the agenda for the PSTs meetings
Discuss and adjust the agenda when needed with the Bank’s team and the client
Prepare, be present and lead the meetings of the PST
Coordinate the work of the primary health care PST with the other teams
Be in the constant dialog with the other two experts leading the ambulatory and hospitals PSTs
Prepare the minutes and main conclusions from the PST meetings (no later than 5 working days from the PST meeting).
Actively participate in the workshops and conferences related to the integrated care project when required ( no more then 4 times a year).
Collect of relevant data related to the integrated care project.
Cooperate with other PST members in order to obtain the additional data and information needed in order to facilitate the process of report preparation
Conduct evaluation of the data, analyses and information obtained from the other PST members.
Contribute in writing or prepare briefs, reports, facts-sheers, et. in relation to the work of the PST and prepared by the Bank report.
Monitor the overall implementation, writing progress reports of the PST work and informing the team of progress/problems at regular intervals, make all relevant suggestions to improve effectiveness and when needed, in cooperation with the team propose and implement remedial actions.
Assist the Bank team in the formulation of proposals which meet the need of the client under the integrated care project. This might include providing technical inputs, collecting additional information and documents, critical analyses of the material collected, further discussions with counterparts, elaboration of budgets etc.
Support to the review of the national integrated care initiatives.
Some in country and international travels could be required
Ability to establish priorities; plan, coordinate and monitor work;
Ability to operate effectively in a team across organizational boundaries;
Ability to establish and maintain effective partnerships and harmonious working relations in a multi-cultural, multi-ethnic environment with sensitivity and respect for diversity and gender;
The contract will run for a total of 30 working days from February 1 till June 30 2016. Possible extension for another fiscal year (July 2016- June 2017) of total 80 is envisaged. The final estimation of the daily fee will be conducted by the HR of the WB but should not go above 1100 PLN per day (netto).