Experience with corruption in the health sector in Poland
The origins of corruption in the health sector
After World War II health care was nationalized and became a responsibility of state
governments in all Soviet Bloc countries, including Poland. While salaries in state sector were
low, job security was absolute and citizens were given free access to basic services, including
education and health care. Doctors in the state sector were paid poorly, so patients felt obliged
to pay an extra gratuity to doctors for free services provided through the state health system.
Usually it was gratuity “in-kind” – like sweets or a bottle of a good liquor.
In the late 1970th the degeneration of the socialist command economic system
accelerated. Scarcity of financial resources led to a drop in the level and quality of medical
services provided by public hospitals and polyclinics. In this situation, the Communist Party
permitted doctors to establish private polyclinics named “doctors’ cooperatives”. Those who
had some money could buy simple medical treatments. Approximately and the same time as
the emergence of doctor cooperatives a practice of so called “hospital ward head’s private
beds” appeared. Patients who needed a surgery or expensive and complicated diagnostic
treatments and didn’t want to wait like others, visited a hospital ward head in a private
polyclinic and paid for consultations. In turn, the ward head would find a free bed in his/her
hospital.
In early 1990 the Government of Poland introduced a package of structural reforms
with the goal of transferring the centrally planned economic system into a free market
economy. Some reforms such as decentralization were introduced in the social service sector,
including in the health care system, although no significant changes took place until 1999. No
government was brave enough to tell citizens that totally free health care was an unrealistic
dream. On the contrary, the new Polish Constitution of 1997 declared free access to all levels
of education and health care services for all citizens.
In January 1999, the Government introduced a health care system reform. The core of
the reform was the introduction of a mandatory health insurance., Poland established regional
health funds, along the lines of the German health care system. Health finance was
decentralized and 16 regional health funds were empowered to decide who would be
reimbursed and for what kinds of treatments. The reform gave great power to the
administrations of regional health funds, but practically no control mechanisms were
instituted.. In theory, health fund money should follow the patient. The reality was different.
The health funds developed “limits”. Officials from health funds decided how many surgeries
and diagnostic treatments could be provided in a particular hospital or clinic and paid for
contracted services only. In small towns this system was justified, but in big cities and in large
hospitals it was not working. When monthly financial limits for contracted services were
exhausted, patients had to wait for medical treatments, while doctors had nothing to do and
medical equipment was not occupied. This became rather common. In some places a high
demand for certain medical services was created. This demand had to be satisfied and as a
result a lot of new private clinics and hospitals were established and a system of informal
payments became widespread.
After the elections the new government decided to introduce the second health sector
reform. This reform had two goals: to deliver more money to the health care system and to
centralize decision making. The Parliament increased the mandatory health care payroll tax
from 7,5% to 8% (in contradiction to the World Bank recommendations (including those
made in a 2001 report “Institutional Issues in Informal Health Payments in Poland” by Helen
Shahriari, Paolo Belli and Maureen Lewis) and the Government decided that health care
system had to be financed centrally. The centralized National Health Fund was established on
January 2003 in order to concentrate decision-making authority in the Ministry of Health.
Ministry officials are now responsible for decisions ranging from financial arrangements to
professional medicament certification procedures, from creation of the list of medicaments to
be reimbursed under the health insurance plan to the logistics of the refund process. This new
system, in fact, is just starting to function and it is not clear yet whether it will improve the
situation. During the last 19 months (January 2002 – May 2003) the country had three
Ministers of Health.
The extent and nature of corruption in the health care system
Starting in 2000, the Anti-Corruption Program of the Batory Foundation has prepared
annual reports on different aspects of corruption. The results of this research stated that Poles
regard public health care as the most or second most corrupt area of public life.
Areas where corruption is present (2001)
% indicated
- politicians – party activists, council members, MP’s
54
- health care
47
- Central administration
38
- courts and public prosecutor’s office
36
- police
30
- Sub-national and local administration
28
- state –owned enterprises
13
- private enterprises
13
- education and science
6
- banks
6
- difficult to say, refusal of answer
2
(The percentages do not add up to 100 because the respondents could give
multiple responses )
Corruption in the Polish health care system has different faces. The following are just a few
examples that show that corrupt practices occur practically at any interaction of two parties :
patient & doctor
patient & hospital
doctor & pharmacist
doctor & pharmaceutical firms
hospital & pharmaceutical firms
pharmaceutical firm & Ministry of Health departments
private clinics & health funds, now National Health Found
Corruption which occurs in contacts between patient & doctors
In the Fall of 2001 Anti-Corruption Program contracted one of the best Polish public opinion
research centres (CBOS) to conduct surveys: one, on a representative national sample of
households and the second one among 203 doctors countrywide. The results are presented in
the report “Doctors and patients on corruption in the public health care system”. The main
findings of the study are as follows.

61% of patients stated that during last 10 years they gave informal payments or gifts to
doctors and nurses, while only 11% of doctors admitted that money or gifts were
offered to them.

70% of bribes was given in cash.

Patients pay to ensure quality care (29%), to skip waiting list for surgical operations
(23%), to skip waiting list for complicated diagnostic treatments (13%), to guarantee
access to hospital treatments (12%), to get sick leave certification (6%).

Patients give bribes mainly to doctors who directly treated them (72%), to ward heads
(33%), rarely to nurses (21%) - (The percentages do not sum up to 100 because the
respondents could give multiple responses)

In doctors’ opinion those who accept bribes are ward heads (63%), professors and
doctors with long time practice (31%), hospitals’ and clinics’ directors (24%), nurses
(14%).

Among doctors the opinion is widespread that ward heads and professors of medical
faculties of universities are those who benefit from this pathological situation the
most, and are the main obstacle to provide real, deep reform of the health care system
in Poland.
Corruption which occurs in a contacts between patient & hospital
During the 1990s a phenomenon of “hospital development foundations” emerged and
then fully blossomed. People working in health care saw these foundations as a remedy for
lack of funding for hospitals and low doctors’ wages. Patients, especially in hospitals, were
pressed to make a donation or buy shares so-called “bricks” to support hospitals and clinics
financially. At that time, it was impossible to pay directly to a hospital, first of all because
hospitals were still a public property and free medical treatment was still a responsibility of
the state, but it was possible to support a hospital’s foundation.
Hospitals’ foundations usually also have managed private policlinics. Usually
foundations were using hospital’s space (property) and equipment, while the employees of
private policlinics were, in fact, hospital doctors. Those who wanted to bypass waiting lists
could receive needed services in the very same place and from the very same doctors in the
afternoon, but they had to pay.
Donations and a second job in private policlinics are legal and taxable activities. But
after an audit of several hospital’s foundations , the Polish Supreme Audit Chamber stated
that majority of them were founded on very unclear principles. Foundations paid very low
fees to the hospitals. The majority of foundations’ liabilities and operating costs were paid by
hospitals, while the majority of foundations’ income went to doctors.
Another illegal procedure used by health care workers is that of unwritten contracts
between funeral homes and health services personnel. When a death occurs in a family
relatives are usually shocked and desperate to find somebody who would help to arrange for a
funeral.
Funeral business can be very profitable if funeral directors have quick access to
information about whereabouts of newly deceased. Funeral homes pay health services
personnel for such an information. Last year journalists presented a series of the reports on
such cases. A prosecutors’ investigation is in progress. A number of doctors are being
investigated for not rendering medical assistance to dying persons in order to profit from
“selling” the deceased to a “friendly” funeral home .
Corruption which occurs in contacts between doctor & pharmacists
Currently reimbursement for medications (drugs) is organized in the following way.
For some of the medications patients have to pay 100% of the market prices, for other drugs
the refund can be 50% to 70% of the market price. Some groups of patients, e.g. combatants,
the chronically ill,. pay just a symbolic co-payment . As no system of registration of
prescription recipients was introduced, control of the amounts prescribed is practically
impossible. Cases were reported where doctors, patients and pharmacists created a structure
for fraudulent refunds.
Corruption which occurs in contacts between doctor & pharmaceutical firms
This type of corruption can have many forms. Here are only a few of the most frequent.

Pharmaceutical firms contact doctors directly and offer them extra pay during their
official government paid working time. In such cases doctors have to prescribe, or
even give for free, medications produced by that pharmaceutical firm and then observe
patients and prepare reports for the firm.

Very frequently pharmaceutical firms organize so-called “seminars” in very attractive
tourist places, which take at least a week. Professional presentations and discussion
usually take one day, rest of the time is spend on social activities. Pharmaceutical firm
covers all costs for such ‘seminars”. When doctors were asked whether they saw any
ethical problem in accepting such gifts, the answer was that they did not feel obliged
to promote the products of the seminar sponsors.
Corruption which occurs in contacts between pharmaceutical firms & ministry of health
departments
All medications (drugs) have to be certified. Certification is a time consuming process.
Also a lot of documents and professional opinions are needed.
There is also a list of the medications (drugs) the cost of which, if prescribed, are
refunded by the health insurance fund. Obviously, medications that are on that list are
prescribed much more often than others. The processes of certification and inclusion in the
“refund list” are completely non-transparent. All these decisions are in the hands of few
officials nominated by Ministry of Health. Very recently the media accused one such official
of asking an international pharmaceutical firm to pay $1 500 000 for the placement of their
drugs on the refund list, with an additional $ 1 500 000 to be paid annually.
Corruption which occurs in contacts between private clinics & health funds, now National
Health Found
Each year the health funds and now the National Health Fund are signing contracts for
medical services that will be paid for from the Fund’s sources. There are many more
providers of such services than money to contract them. There were cases reported where
health funds contracted a private clinic that had business relationships with members of the
contracting committee.
The experience of the Anti-corruption Program
Corruption in health care system was not a priority of the Batory Foundation early on,
although we were aware how complicated that problem is. After first half a year of Program
operations a number of doctors approached the program and declared that they wanted to
change the situation but did not have enough power to do this individually. A working group
on ethical issues in health care system was established. The group organized a series of
internal and then public discussions. A year later the Group, based on the results of the
discussions, came to the conclusion that to combat corruption in health care system a
comprehensive program of structural changes is needed, and that a group of citizens and nongovernmental organization is not able to do this. This is a task of the Government. But such a
group is able to change the situation in limited, focused areas. One of the areas for such
focused intervention the Group has selected is corruption in marinating? waiting lists – some
patients wanted to bypass long waiting times for medical treatments. The practice of bypassing is possible when there are no clear transparent rules or criteria for assigning people to
waiting lists, and when there is no existing sys tem of public monitoring of waiting lists.
The Group started by studying models of waiting lists and oversight existing in other
countries and with the recommendations of the Council of Europe. Then a survey of
cardiological treatments was sent to 116 cardiological clinics in order to research patterns of
supply and demand. Almost 40% of clinics approached responded to the survey. About 70%
of those who answered stated that they maintain official waiting lists. A majority of them
(68%) stated that lists are based on clear medical criteria, but only a minority (23%) said that
those criteria are public and available for patients.
The next step was to prepare a proposal in order to change the Health Care Institutions
Act. The proposal suggested that the Act should specify clear and transparent criteria in
developing waiting lists, as well as public access to that information.
When these documents were ready the Group decided that they were ready to start a
campaign in order to persuade politicians that the proposed changes are necessary and to
inform patients what is the problem and that they have rights to be better served by health care
institutions. The Group have found journalists who offered their support. Last month a public
conference presenting all aspects of the problem was organized. A number of well known
doctors and politicians from Parliament and the Ministry of Health were in attendance. After
the conference the media took the lead on the promotion of the changes. .
Efforts to address the problems
The latter are small steps that have been taken by a non-governmental organization. As was
mentioned, the fundamental, real reform has to be done by the Government – the problem is
very complex and politically sensitive - first, the resistance of a very influential group of
medical professionals and ward heads has to be broken. In parallel, a risky political decision
has to be made to tell Poles that the state can not guarantee completely free health care to
everybody.
A basket of guaranteed medical services has to be defined. Politicians have to say openly
what kind of medical treatments can be paid from the insurance fund managed by the state
and what kind of medical treatments the fund cannot pay for. In consequence of that decision,
the voluntary health insurance system has to be further developed. And last but not least,
effective control of financial procedures in the public health system has to be introduced.