ZOZ Soviet Period Districts or Municipalities
TABLE OF CONTENTS
Executive Summary 5
1. Overview 7
2. THE DECENTRALIZATION PROCESS IN HEALTH CARE AND RE-CENTRALIZATION TRENDS 10
DECENTRALIZATION OF FINANCING SERVICES 10
Management Schemes 10
Financing Schemes 12
DECENTRALIZATION OF PROVIDING SERVICES 13
Management Schemes 13
Financing Schemes 14
ESTABLISHMENT OF THE NATIONAL HEALTH FUND- REVERSAL OF DECENTRALIZATION 14
3. EFFECT OF DECENTRALIZATION ON GOVERNANCE AND ACCOUNTABILITY OF PUBLIC FUNCTIONARIES 16
4. Analyzing the effects of decentralization in the context of governance and accountability 18
Basic Framework 18
Governance and Accountability in the Polish System of Health Care. 18
Conclusions Formulated within Examined Categories of Entities 20
General Conclusions 33
5. DISCUSSION 36
CONCLUDING REMARKS 42
Selected References 43
Text Box 1. Functions of a Sickness Fund Council 10
Text Box 2. Management Board of a Sickness Fund 11
Text Box 3. Designing Decentralization 16
Text Box 4. Research Methodology 18
Text Box 5. 1999 Reforms—The New Look Local Governments 24
Text Box 6. In-Focus Issues 29
Text Box 7. An Estimate of 1999 Reforms 38
Text Box 8. GHI Act—Falling Short 40
Figure 1. Barometer of Changes in Centralization and Decentralization Processes 6
Annex 3. Questionnaire with Responses: Local Governments
Annex 4. Questionnaire with Responses: Sickness Funds
This paper addresses the problem of decentralization of health care in Poland. Although the concept of decentralization includes many aspects of management actions, we have focused on two basic dimensions, i.e. financing and providing of health services. The focus of this study is on whether decentralization of health care has been successful in the country, highlighting the efficacy of mechanisms that have been adopted by the law on general health insurance and various health care entities.
As decentralization is essentially a political process involving distribution of power and resources, both among different levels of the state, and among different interests in their relationship to the ruling elite, the outcome depends on whether influential groups are being co-opted or challenged, and how much resources are available for the newly created units to function.
The beginning of 1999 marked a major step in the evolving reform of Poland’s health system, the culmination of a nine-year transformation process from the Soviet style Semasko system. The new law established a system of universal and compulsory health insurance for most of the population. The insurance is to be administered by regional sickness funds and by branch funds for selected groups based on their employment status. The regional sickness funds serve as institutions of contribution recipients.
The National Health Insurance Law was designed to separate financing from the provision of services. The government has created 17 public regional sickness funds that are responsible for inhabitants of the geographic voivodships and one country-wide branch fund. Services are provided by both public and private health care institutions and group or individual practices. The insurance funds enter into contracts with providers and may select either public or private providers.
The funds are financed by a contribution of 7.5 % of income of most employed and farmers. The contributions are taken out of the existing tax liabilities. These are paid to the Social Insurance Office, an agency which collects for all types of social insurance, and is then transferred to the sickness funds. Regional funds receive contributions from the population within their jurisdiction and there is an equalization fund to compensate for regional differences.
The law on general health insurance does not accurately define the scope of responsibility of local governments in health policy in the regions. There is an imprecise division of governance fields along with a vague notion and scope of accountability of the main actors in the health care. Ownership of the most valuable resources, i.e. inpatient care is ascribed to the voivodship and powiat self-governments. But this ownership lacks substance as the local governments are confronted with the strong position of sickness funds as monopolist remitters.
Two general observations can be made regarding this arrangement. One, the lack of precise division of obligations between voivodship and powiat self-governments viz a viz the sickness funds. Two, the matter of financial supply of the local governments, which determines the capacity of local governments to fulfill their health care tasks. There is an inadequate upward adjustment of the structure of income of local government in relation to the responsibilities defined for them.
Under the health insurance reform the position and role of the founding body and of the remitter is not clear. The functional links within the health care system among various entities (voivodship, powiat, gmina, health care establishments, sickness funds) and different levels of health care (primary care, inpatient care) are weak. As a result, there is no linkages of strategies of individual health care facilities with the strategy of voivodship and powiat self-governments. This constrains synchronization and coordination of effort and may result in duplication or absence of coverage.
Control and modification of the health care process is thus difficult to achieve. A control mechanism allows the flexibility of taking remedial measures in the event of undesirable developments. There is a clear need of sharply defining the relationship among ownership, management and financing in the health care system.
A pervasive problem is the political influence in the system. This is manifested through legal regulations and application of procedures making room for political appointments. For instance, appointment of management boards and councils of sickness funds, and health policy personnel in the local government tiers is the prerogative of the health minister.
Overall the experience with decentralization of health care in Poland is patchy. But there are grounds for optimism as there are bright spots. In emphasizing the unsatisfactory state of affairs, however, it must be said that gaining autonomy by the health care facilities (decentralization of management) has by and large brought positive results. Modern tools of human resource management like budgeting and expenditure management are now being more frequently used by the health care facilities.
In the case of decentralization of financing, it is more difficult to draw up a list of achievements. The portfolio of services has changed considerably since the introduction of reforms, but it is difficult to assess the accessibility of services. Although the number of provided services are increasing, there is no convincing evidence that it has resulted in better access to health care.
Some strategic options are identified in the text. The relationship of ownership, management and financing in the health care system needs to be sharply defined. In conclusion although decentralization has not universally benefited , its potential for improvement cannot be disputed. Much of course will depend on how some strategic options are resolved and implemented.