World Bank Analytical Paper
Poland Health Decentralization
1
ACCRONYMS
GHI
HCE
HM
LG
NHF
PLN
RSF
SF
UNUZ
SEJM
ZUS
ZOZ
General Health Insurance
Health Care Establishments
Health Ministry
Local Government
National Health Fund
Zloty Polish currency
Regional Sickness Fund
Sickness Fund
Health Insurance Supervision
National Assembly
Social Insurance Institution
Soviet Period Districts or Municipalities
2
TABLE OF CONTENTS
Executive Summary
5
1.
7
Overview
2. THE DECENTRALIZATION PROCESS IN HEALTH CARE AND RECENTRALIZATION 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
Findings......................................................................................................................... 19
Conclusions Formulated within Examined Categories of Entities ........................... 20
General Conclusions ..................................................................................................... 34
5.
DISCUSSION
36
CONCLUDING REMARKS ........................................................................................ 42
Selected References ...................................................................................................... 43
TEXT BOXES
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
3
FIGURES
Figure 1. Barometer of Changes in Centralization and Decentralization Processes .........................6
ANNEXES
Annex 1. Model of General Health Insurance ..................................................................................
Annex 2. Questionnaire with Responses: Managers
Annex 3. Questionnaire with Responses: Local Governments
Annex 4. Questionnaire with Responses: Sickness Funds................................................................
4
EXECUTIVE SUMMARY
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 coopted 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
5
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.
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1. OVERVIEW
1.
The existing constitutional and political framework of a country determines the shape of
its health care system. In most of the country settings, the health care systems exhibit varying
degrees of a spectrum that move between the extremes of a totally centralized and a fully
decentralized method of organization. The different systems, in turn, have their own respective
governance and accountability components.
2.
The centralized systems are largely geared toward serving the aims of their organizational
structures. The provision of health services is linked with ensuring the operation of outpatient
centers, hospitals, and other health care facilities, which dispense complimentary or subsidized
specialized procedures. In centralized budgetary systems, where the state is the employer and
the base (beds and people) is financed, there are no incentives for adjusting the employment level
to the actual requirements. There is a lack of incentives for efficient and effective use of funds,
and certainly it is not in the interest of an establishment to decrease the number of beds.
3.
In many developing countries the compulsion of cost containment and the ensuing need
for change has turned the attention of decision-makers to decentralization. This is because it is
widely assumed that decentralization of the decision-making process in the provision of social
services leads to improved efficiency in the operation of central institutions (for example,
through the decrease in the number of cases and problems to be solved.)
4.
At the same time, decentralization increases the role of local governments, importantly in
matters confronting their own regions. Moreover, as the decentralized systems act as the most
direct interface with the people they serve, they may be better placed in providing higher quality
and lower cost services.
5.
The bipolarity in defining centralized and decentralized systems is not, however, so vivid
or rigid in the real world. In a centralized health care system of the kind that exists in France,
many legal regulations allow for autonomous and independent pursuit of health policy in the
regions.
6.
On the other hand, the situation that occurred in Poland in 1990s is an example of
decentralization of the system combined with numerous central government interventions. These
were attempts to chip off powers of local governments, or impose central schemes on
autonomous entities.
7.
Decentralization is a process of shifting authority from the central level to lower local
levels. The shifting of authority is meant to facilitate the response of the local institutions to the
diverse needs of the community. Decentralization is a broad concept that encompasses many
facets of public life and refers to various institutional levels. Several types of decentralization
can be defined of which two are more important in our context.
7
8.
Geographic or territorial decentralization consists of the State delegating strictly defined
accountability and authority to institutions operating within a specified territory. Whereas,
functional decentralization is shifting of accountability and authority in the field of specific
actions to specialized entities operating locally, and without defining the territorial boundaries of
operation of these entities.
9.
Besides, the literature review of decentralization distinguishes several other kinds of
decentralization, such as political, administrative, financial, or market based. These types
virtually do not occur independently. There are varying shades that combine proportions of
individual types, depending on the sector-specific decentralization strategy.
10.
There are many instances, where despite defined criteria of accountability and scope of
authority, decentralization could not achieve the desired outcomes by not being fully responsive
to the local needs. An example that illustrates this is the fate of school hygiene that was
introduced in Poland as part of sickness funds in 1999. The absence of provisions on
transferring accountability for this area of care led to its practical elimination from the pool of
public services.
11.
Similar effects may occur with the transfer of identical powers to more than one entity,
with the idea of initiating a competitive mechanism among the entities. An illustration of this is
from early 1999, when the powers of the founding bodies with regard to hospitals located in one
city were turned over to the Voivodship1 Assembly and Powiat2 Councils. In many towns and
cities throughout the country, like in Pruszków for instance, the hospitals have not been merged
to date, and the provided services are not standardized.
12.
The above instances show de-fragmentation in the health care sector, instead of the
intended decentralization. The first example concerns the functions, and the other the structure
of the system.
13.
In cases where the structural (hierarchical) and functional (cooperation) links between
existing and emerging entities is not properly defined, it leads to a situation where units occupy
the positions that are most convenient for them. In the absence of a comprehensive model of the
desired system, the detailed specifications concerning the shifted power and accountability alone
would not suffice. This coupled with the leverage to form discretionary alliances characterizes
the disintegration process.
14.
This is borne out by the conduct of the self-governing and autonomous sickness funds,
which led to the appearance of 17 different systems of financing health services, resulting in 17
different health care systems. Another distortion in the system is the price difference in the
contracts for the services of the same kind.
15.
If we think of decentralization as a process that delegates centralized powers to the lower
organizational tiers, which in turn are accountable not only to the center, but also to the people
on behalf of whom they operate, this would be a progressive step towards the liberalization of
the system. The delegation of powers, tasks and responsibilities requires definition of the target
1
Voivodships are the Polish equivalent of states or provinces in other countries
2
Powiat is the Polish equivalent of county
8
model, along with coordination of implementation and monitoring of the whole process. The
model should incorporate functional links among the involved entities.
16.
The non-fulfillment of these requirements leads to distortion and fragmentation of the
intended system. The ideal premise of a decentralized system is greater flexibility and
adjustment of the entities to the changing external conditions and demands. The ultimate
expression of decentralization is privatization.
17.
On the other hand, a centralized system requires definition of the structural and
hierarchical links and their close supervision. A centralized system has high internal stability of
organizations, but also greater inertia as regards change. The lack of motivation of individual
entities is counter balanced by a large number of central executive directives, regulating most
aspects of entity operations.
18.
The rigid red tape and regimented hierarchy may invoke the resistance of units that wish
to retain their autonomy, thereby leading to their breaking away from the system resulting in
anarchy. The consequence of strong centralization of the system is nationalization.
Figure 1. Barometer of Changes in Centralization and Decentralization Processes
centralization
anarchy
decentralization
chaos
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2. THE DECENTRALIZATION PROCESS IN HEALTH CARE
AND RE-CENTRALIZATION TRENDS
19.
The welfare-state model prevailing in Europe imposes certain limitations on
decentralization of health care systems. In the European Union countries, health care has
become the top most public value. Consequently, the manner of organizing health services has
become a key element of political play. In late 1990s, the government of France was brought
down as a result of attempted unpopular reforms in the health care system. In 2002, the electoral
victory of the Social Democratic party in Sweden was in part due to their main electoral slogan
guaranteeing all citizens full access to medical services.
20.
More radical changes are taking place in the countries of the former Eastern Bloc. This
arises from the necessity of introducing changes concerning the entire social system. In these
countries decentralization process in health sector mainly consist of the manner of financing
health services and of paying contributions.
21.
The new financing method is mainly through health insurance, which introduces
independent institutions for contribution collection. Through the manner of contracting services,
the insurance companies affect the changes on the side of the contribution payers. The resultant
negative effect on equity and coverage of the health cover often prompts East European
governments to withdraw the earlier delegated powers.
22.
In Poland, there have been many attempts at introducing re-centralizing regulations since
the inception of general health insurance in 1999. These endeavors seek to eliminate existing
anomalies in the system, rather than devising a strategic plan to improve the working of the new
system. For instance, the general health insurance law imposes on employers the necessity of
paying rises in the amount of PLN (Polish Zloty) 203. The implementation of this act became
the subject of the verdict of the Constitutional Tribunal in December 2002, hence the financial
effects for the health care system are still difficult to estimate.
DECENTRALIZATION OF FINANCING SERVICES
Management Schemes
23.
Establishment of Regional Sickness Funds. The 1997 Act on General Health
Insurance (GHI)3 called for the establishment of Regional Sickness Funds (RSF)– institutions of
contribution recipients. In the time of vacatio legis this Act was greatly amended. However, its
basic premise i.e. to make the contribution recipient independent and to separate the health care
budget remained intact. In 1998, office of the government plenipotentiary for implementation of
GHI was established, which reported directly to the prime minister.
3
Act of 6 February 1997 on General Health Insurance Dz.U.No. 28, item 153 with subsequent amendments
10
24.
As the Act on GHI called for the setting up of RSF, (within at least one voivodship),
the government body appointed regional plenipotentiaries, whose responsibility was to establish
RSFs. The regional plenipotentiaries had the powers of directors of the Sickness Funds (SF),
and the government plenipotentiary performed supervision of their activity. This is an example
of geographic administrative decentralization.
25.
RSFs are the basic organizational units of GHI. Institutionally they represent the insured
and have legal personality functioning on the basis of self-governance, geared at economic
efficiency and rational operation. RSFs became operative at the same time as GHI, i.e. January
1, 1999. The SFs do not operate for profit, which in practice means that any surpluses may only
be used for statutory purposes of the fund.
26.
Responsibilities of Sickness Funds. The SFs have the statutory obligation of performing
all functions concerning health insurance. These include in particular:




Maintaining records of persons covered by health insurance
Approving and confirming the right of an insured person to services
Analysis of the execution of the obligation of GHI
Management of financial resources of the fund
27.
The operation of SFs has made possible regional decentralization in acquiring
contributions. The GHI Act allowed the operation of a SF outside the borders of the voivodship,
i.e. to acquire insured persons residing and working in other voivodships. This would have, in
effect, given rise to a market competition among SFs. However, in practice, the funds did not go
for active recruitment of insured persons residing in neighboring voivodships, with the only
exception of persons living near the borders. The SFs left implementation of the first three
responsibilities largely on the service providers.
28.
Governing Body Rules and Powers. The governing body of a SF comprises the council
and management board. From 1999 to 2002, the voivodship assembly appointed the council
members from among persons insured in the given fund,. This arrangement ensured that the
authorities of the self-governing voivodship had some influence on the operation of the SFs. In
May 2002, there was an important change in the structure of the councils, when the Health
Minister (HM) acquired powers to appoint the majority of members.
Text Box 1. Functions of a Sickness Fund Council
The responsibilities of a SF council include supervisory functions, of which the following are especially
important:










Passing statutes
Appointing and recalling the Director
Appointing and recalling members of the committee for complaints and motions
Passing the financial plan and accepting and approving quarterly and annual financial reports
Approving the plan of work and considering and accepting quarterly and annual execution reports
Considering periodical reports on the operation of the Management Board and the committee for
complaints and motions
Passing the bye-laws of the Council and Management Board
Deliberation on resolutions concerning assets of the SFs, investments exceeding statutory powers,
acquisitions, and disposing of immovable property
11

Selecting representatives to the National Union of Funds
Source: Act of 6 February 1997 on General Health Insurance Dz.U.No. 28, item 153 with subsequent
amendments
29.
The responsibilities shown in Text Box 1, are of key importance for the operation of the
SFs, but were taken up by the councils as late as the end of 1999. At that time the voivodship
assemblies appointed their members to the SF councils. This procedure of appointments led to
the first two years of general contracting of medical services in Poland, without any social
surveillance.
Text Box 2. Management Board of a Sickness Fund
The Management Board of a SF is composed of the director and 2-5 members. It leads the operations of
the fund and decides all matters outside the competence of the fund council. The following are the important
responsibilities:







Execution of resolutions of the SF Council
Preparation of a draft plan of work and financial plan of the SF and their execution
Management of financial resources and assets of the fund
Investing the reserve resources
Drawing up reports on operations and compiling financial reports
Negotiation of contracts with service providers, conclusion and settlement of contracts, and control of their
execution
Source: Act of 6 February 1997 on General Health Insurance Dz.U.No. 28, item 153 with subsequent amendments
30.
The implementation and fulfillment of statutory responsibilities proceeded differently in
various funds. On the one hand this was the result of the diverse financial situation of the
individual funds (external factor), and on the other, of the manner of management and internal
policy pursued in a given SF (internal factor).
Financing Schemes
31.
Budget Creation and Financial Resources of Funds. The budget of the SFs is derived
from the contribution of persons covered by the mandatory GHI. The contribution is 7.5%
levied as part of the tax in the case of income tax payers. The state budget provides payments for
individual farmers, unemployed and homeless persons.
32.
Health insurance contributions are paid to the Social Insurance Institution (ZUS). ZUS is
responsible for identification of insured persons, levying contributions and transferring them to
the Office for Health Insurance Supervision (UNUZ). The latter apportions the financial
resources to the RSFs and to the branch fund.
33.
In the division of resources, the index of the number of insured persons in a SF and a
mechanism for financial equalization are used. It is calculated by taking into account the
differences in income of insured persons and the number of people over the age of 60 in a given
12
SF. The application of the equalization mechanism has led to Mazowiecka, Śląska and Branch
sickness funds to lose over 10% of their revenue.4
34.
Additional financial resources for SFs may be provided by income from investment
deposits and securities, carrying out tasks commissioned by the Health Ministry (HM) and
financed from the State budget. The SFs settle accounts for health services among themselves.
35.
Rules of Financing Services. The SFs buy health services under contracts concluded
with Health Care Establishments (HCE) or individual service providers. The contracts define the
scope of provided services, the organization of work of the service provider, the persons eligible
for services, the price for a unit service and the rules of settlement among the parties to the
contract. The signing of a contract is preceded by competitive offers and negotiation of its terms.
The contract types correspond to the categories of division of resources in the financial plan of a
SF.
36.
In all SFs the form of the contracts underwent changes in the course of execution. The
reasons for this were three fold: technical - resulting from an authentic need to increase the
number of services, economic - related to the efforts of service providers to increase
remuneration, and political - causing increased financing of facilities run by persons from the
same political group.5
DECENTRALIZATION OF PROVIDING SERVICES
Management Schemes
37.
Establishment of Autonomous Public and Private Service Providers. The GHI Act
allowed for signing of contracts for providing health services only with entities with legal
personality. Public HCEs that were budgetary units could acquire such personality by becoming
autonomous. The 1991 Act on Health Care Establishments, and particularly its later
amendments, defined the procedure of gaining autonomy by budgetary units.6 Gaining
autonomy allowed the unit to conduct its own financial management, staff policy and to define a
strategy conforming to the demands for services and the capacity of HCE. The idea of gaining
autonomy was to meet the needs of functional decentralization.
38.
Under the GHI the private service providers could use financial resources apportioned for
health care on equal rights. Indeed, after the introduction of general contracting of medical
services there was a rapid growth in the number of private HCEs. This mainly involved
outpatient and primary care.
39.
Role and Responsibilities of Local Governments in Providing Health Services. The Act
on the new administrative division of the country saddled all three levels of Local Government
(LG) in Poland, i.e. Gmina, Powiat and Voivodship, with various health care functions. Each of
the three tiers is responsible for prevention of disease and health promotion of its citizens. In
4
Sowada Ch. 2001. “Financial Equalization between Sickness Funds. Social Policy” (Wyrównanie
Finansowe Między Kasami Chorych. Polityka Społeczna),no. 10, Warsaw
Golinowska S. Et al. 2002. “Health Care in Poland after the Reform” (Opieka zdrowotna w Polsce po
Reformie). Center for Social and Economic Research. Report 53, Warsaw.
5
6
Act of 30 August 1991 of Health Care Establishments Dz. U. 91.91.408 with subsequent amendments
13
general, it can be said that Gminas supervise HCEs that provide primary health services, Powiats
cater for specialist outpatient and inpatient services within the primary medical disciplines, and
Voivodships are responsible for specialist treatment at all levels.
40.
In the area of prevention and promotion it appears that relatively major financial capacity
and resources are with the gminas, due to their tax base, whereas the voivodships enjoy the best
organizational capacity. Due to the population size, powiat may have the biggest health care
demand. Because there are no established principles of hierarchy of individual LG levels, it is
difficult to prepare a standard plan of preventive actions that would link and make use of the
potential of all LG units.
Financing Schemes
41.
LGs finance the health care system in a two-track way. As founding bodies, they are
obliged to repay the debt of HCEs that are going bankrupt. They may also apportion a targeted
subsidy for them, for example for renovation or renewal of equipment. This is provided in the
Act on HCEs.
42.
The second track is apportioning part of their own budgets in the area of health
promotion and disease prevention. This task results from the Act on the Powers of Self
Government. We have, however, estimated that though sizeable funds are allocated for this
purpose, they are not efficiently used. In most cases fund utilization is not properly planned, and
the service provider selection procedure does not assure execution of the task.
ESTABLISHMENT OF THE NATIONAL HEALTH FUND- REVERSAL OF
DECENTRALIZATION
43.
Recently, there has been an upsurge in legislative efforts for creation of National Health
Fund (NHF). The Sejm accepted this Act in December 2002 and forwarded it for deliberation to
the Senate, where it is still pending. The roots of this proposed legislation can be traced to a
document titled “National Health Care: Strategic Actions of the Health Ministry”, which came to
light in 2002-03. This document, amended several times, contains a very general description of
the system of health care recommending closing down the SFs, and an outline of the procedure
for introducing changes.
44.
This Strategy document raised many controversies. The main concern was evoked by the
proposed setting up of NHF to supersede SFs. The opponents focused on the centralist trends of
the proposed changes. The Health Minister would be the in charge of NHF according to the
provisions of the Strategy and in the proposed Act on General Insurance in the National Health
Fund.7.
45.
The Strategy also proposes a plan for the creation of a national network of hospitals
reporting to the health minister. This is intended to serve as a guarantee for obtaining from NHF
7
Act of 17 December 2002 on General Insurance in the National Health Fund – website of the Sejm of
Poland
14
an appropriate amount of resources to maintain a ready base for providing services. This can
also be seen as a step towards re-centralization. 8
46.
The plan for securing services in accordance with the provisions of the Act on Insurance
in the NHF is the ground for buying a specific number of services by the Fund. The procedure of
creating the plan, described in detail in the Act, designates the Health Minister as the authorized
person to approve the drafts of the plan.
47.
On the basis of the documents prepared by the staff of the HM, it is not easy to explicitly
define the extent of reversal of the decentralization process by the induction of NHF. However,
the examples given point to the establishment of a strong central institution, under the direct
control of Health Minister. The extent of advancement of centralization can be determined only
after analyzing the first year of operation of the NHF.
Sidorowicz W. 2002. “National Health Care of the Health Ministry – is this the right path? “(Narodowa
Ochrona Zdrowia” Ministerstwa Zdrowia – czy tędy Droga?) Zdrowie i Zarządzanie volume IV, no. 3-4
8
15
3. EFFECT OF DECENTRALIZATION ON GOVERNANCE AND
ACCOUNTABILITY OF PUBLIC FUNCTIONARIES
48.
The issues of the impact of decentralization on governance and on the accountability of
public authorities have already been elaborated in a separate paper9 and will not be examined in
greater detail in this document.
49.
Just to recap, the impact of decentralization on governance can be examined in the
following categories.





Transparency of practices and corruption
Participation of citizens
Improvement in social services
Improving access and equity
Ensuring efficiency
50.
The impact of decentralization on governance does not lead to the formulation of
explicit conclusions in practice as they do in theory. In theory, transparency and corruption are
counter concepts, i.e. with increased transparency, corruption declines and the other way round.
Decentralization leads to greater participation of citizens in public life, but this positive
development can easily be marred when different social groups with higher potential for
organization and articulation of their interest, may acquire and strengthen their privileged
position (e.g. doctors, hospitals, and insurance companies).
51.
One of the effects of decentralization can be the improvement of providing social
services in areas such as education, health, infrastructure or the natural environment.
Decentralization may lead to leveling out of differences through public expenditures, tax policy
and cash transfers. At the same time, intense competition in the form of a totally privatized
system also does not lead to improved efficiency of the system of health care in the
macroeconomic sense. This is borne out by the British and American experience.
52.
On examining the influence of decentralization on accountability, one can distinguish
two basic variables: mobility and the election mechanism. These two variables may (in theory)
enforce the desired code of conduct on entities in the performance of their duties. However, in
practice there are important prerequisites that need to be fulfilled for these variables to work.
For instance the desire to participate in political life and elections, and availability of appropriate
information. In practice, standard procedures of control are also applied in a decentralized
setting (financial, budgetary and administrative accountability).
“Governance and Accountability in a Decentralized Setting. An Examination of Selected Issues”,
December 5, 2002 - mimeo
9
16
Text Box 3. Designing Decentralization
Decentralization is not a panacea for improved quality and access of service delivery. The process does not
absolve the central government from all responsibilities. What it means is that the nature of this responsibility has
changed from delivering services directly to regulating and monitoring the efficiency and equity of services
delivered by others.
Decentralization requires a strong central entity to regulate, to provide an overall framework to manage the
re-allocation of responsibilities and resources in a predictable and transparent way, and to assist local governments
build capacity in the early stages. For instance, there is compelling evidence that some of the best progress against
HIV/AIDS is in countries with strong central governments like in Thailand.
The solution to pitfalls of decentralization is empowerment of people through broader local participation,
transparent governmental procedures, and protection of minority rights. It is important to answer the following
questions in affirmative to realize the benefits of decentralization. Does decentralization provide for ordinary people
to express their views and see them translated into future policy? Does it enable citizens to participate in policy
formulation or only ratify pre-selected choices? The citizens should not be remote from these debates.
Accountability is paramount for the success of any decentralized system. Locally empowered actors should be
downwardly accountable to their constituents. The citizens should be able to challenge the decisions of governing
bodies. They can only do so if they receive accurate and timely information and are able to use this information in
making their assessments.
17
4. ANALYZING THE EFFECTS OF DECENTRALIZATION IN
THE CONTEXT OF GOVERNANCE AND ACCOUNTABILITY
BASIC FRAMEWORK
53.
The basic premise of decentralization of the health care system rests on the twin pillars of
governance and financing. This may be evaluated according to a number of criteria. This paper
examines decentralization in the context of governance and accountability focusing on three
selected entities of the health care system: autonomous Health Care Establishments (HCEs),
Local Governments (LGs), and Sickness Funds (SFs).
54.
In this paper governance is defined broadly, denoting phenomena relating to planning,
managing and controlling health services provided within the framework of general health
insurance and relating to the devolved responsibilities for implementation of public programs by
the above three entities.
55.
Decentralization processes are examined viz a viz their effectiveness in delivery of public
programs, overall transparency of operations and general conformance to internationally
accepted good business practices. Governance is described by taking into account such quality
indicators as: (i) nature, type and scope of regulations referring to SFs and HCEs; (ii) implicit
and explicit policies and actions related to informal payments in the health sector, particularly in
public HCEs and (iii) nature and the level of economic and financial management of SFs and
HCEs.
56.
For the purposes of this paper, accountability is defined in qualitative terms by such
indicators as: (i) application of such policy and strategy instruments to ensure that health services
are generated and supplied to carry out the basic objective of improvement in the state of health
of the people; (ii) financing and organizing health services in a way to ensure universal access
for all, and (iii) adoption of such governance practices which are universally acknowledged to be
acceptable in management of public funds.
Governance and Accountability in the Polish System of Health Care.
57.
In Poland, the following are the important entities in health care governance: the Health
Ministry, local government bodies, sickness funds and health care establishments. Each of these
entities has a different scope of powers given to it by law. By the specific nature of the Polish
model in governance the most important role is played by: SFs, LGs and HCEs.
58.
As has been mentioned, the legislation does not adequately define the types and areas of
decisions remaining within the competence of the individual entities. This is particularly true for
the LGs at the voivodship and the powiat levels. The decentralization model is therefore open to
criticism. There is an imprecise division of governance fields along with a vague notion and
scope of accountability of the main actors, which are entrusted with the implementation of the
18
basic objectives of health care.
59.
Text Box 4 outlines the research methods that have been employed in the pilot study to
analyze the impact of decentralization on governance and accountability in the health care
system. The following four areas of dependencies are selected to formulate general conclusions.
60.
Decentralization of Management of Health Care in the Context of Governance
Procedures. In this category the analysis includes the following: implementation of statutes and
regulations that define the scope of governing powers of the main entities of the health care
system, the governance procedures applied by them, with particular attention to the management
of finances and resources and the practice of making informal payments by patients.
61.
Decentralization of Management of Health Care in the Context of Accountability. It
analyzes the scope and type of health services offered to eligible persons, expressed in a dynamic
way. It is important here to examine how the portfolio of services has changed and whether the
changes were necessitated by an actual demand for health services.
62.
Besides, it is also significant to examine the extent to which the LGs and SFs are carrying
out their functions as organizers of health care in the voivodships and powiats. This means
ensuring access to services and openness of procedures.
63.
Decentralization of Financing of Health Care in the Context of Governance
Procedures. Within this topic an analysis is carried out on the governance procedures for
resources apportioned for health, both at the central level (UNUZ), and for the RSFs and HCEs.
This includes procedures for acquiring and transferring contributions, making budgets of RSFs,
equalizing mechanism, and control of expenditures of SFs and HCEs.
64.
Decentralization of Financing of Health Care in the Context of Accountability. In a
situation where the dispenser of financial resources is a RSF, assuming monopolist proportions,
an extremely important matter is to define the scope of its responsibilities for working out the
appropriate portfolio of services and ensuring accessibility to them.
Text Box 4. Research Methodology
Research Objectives and Scope: The purpose of the research is to define the consequences of
decentralization in the health care system in the field of management and financing, with particular attention to
governance and accountability, as applied in autonomous health care establishments, local governments and sickness
funds. These phenomena will be examined at the time of the implementation of the 1999 social insurance reform
and later.
Research Sample: The pilot study covers six managers/directors administering health care establishments,
nine local governments and two sickness funds.
Research Tools: The study was carried out with questionnaires, adjusted to each of the three types of
respondents (Annex 2-4). The annex also includes tables with the answers provided during the survey by the
respondents.
FINDINGS
65.
The conclusions from the survey can be presented in two arrangements, i.e. within each
19
surveyed category, and as general inferences.
Conclusions Formulated within Examined Categories of Entities
66.
Managers of Autonomous Public Health Care Establishments. The managers of public
HCEs were asked questions regarding issues covering human resource and financial
management.
67.
MANAGEMENT PROCESS. The polled managers acknowledged that autonomy is
wider now as regards staff and financial management, whereas it was very limited before the
entity became independent. Nevertheless, there are certain limitations as LGs assert undue
influence in matters like hiring, investment decisions, and acquisition of fixed assets.
68.
The purview of manager’s decisions encompass matters like opening and closing of
departments, purchase of equipment, staff policy, development of unit’s strategy, and most of the
financial decisions. The HCEs require the consent of institutions like the Founding Body and
Social Council in matters concerning changes in the organizational structure and statutes of the
unit, disposing and acquiring fixed assets, and in making investment decisions.
69.
Eighty percent of the respondents criticized the Social Council due to the protracted time
it takes in arriving at a decision and the suspect competence of the persons that are appointed.
They reflected that neither the 1999 administrative reforms nor the HCE autonomy has caused
any changes in the structure or composition of the Social Council.
70.
The meetings of the Social Council are held at varied frequency, being linked to the
subject of deliberation. Bi-monthly meetings are held to discuss current matters relating to
finances and provision of health services. When the Social Council is to prepare opinions on
financial and restructuring plans and directions of development, the meetings take place twice a
year. If required, the managers have no difficulty in convening extraordinary meetings.
71.
The survey could not determine the existence of a management board. 10 The respondents
were of the opinion that the 1999 reforms did not affect the structure of the management board
and management itself in autonomous facilities.
72.
The scope of the operational management powers of the managers of the autonomous
HCEs is evaluated as adequate. Limitations do occur in investment and asset management
decisions. It is observed that the Polish model of management of autonomous HCEs is imperfect
as it does not in itself lead to efficiently functioning institutions supporting operating
management (such as management boards) or institutions that provide opinions, (such as social
councils).
73.
HUMAN RESOURCE MANAGEMENT. The employment decisions are made by the
manager/director in each case. But the autonomy has not resulted in the introduction of new
procedures in the field of staff management. Due to the situation in the labor market greater
10
This may be termed as a deficiency in the translation of the questionnaire into Polish as the term
“management board” is not found in the dictionary. Perhaps because of the imprecise translation none of the
respondents answered questions containing this term (cf. Tab. II and Tab. III in Annex). The Polish version of
management board should be: “zarząd”
20
attention is focused on checking the qualifications and on direct contact with the candidates for
work.
74.
Although formally there are no external employment limits, the respondents point to
indirect constraints stemming from the value of the contract with the SF or with the minimum
norms of employment as regulated by the Labor Code or the MOH. Such norms regulate the
number of duty hours, time of work of x-ray technicians etc.
75.
The managers emphasized that the scope of freedom in employment is greater than it was
before the reform. The remunerations are decided by the managers, who have greater freedom in
modeling wages, as there is no upper limit.
76.
The procedure for dismissing workers is in accordance with the provisions of the Labor
Code and the Act on Trade Unions. There are no changes from the pre-reform period. The
managers make the final decision on dismissal from the service. The Labor Code and the Act on
Trade Unions define the circumstances when dismissal decisions must be consulted with the
trade unions. The respondents felt that in half of the cases public opinion plays a certain role in
arriving at the decision on dismissal.
77.
The questionnaire responses show that the scope of freedom of managers in staff policy
has increased. The still encountered limitations are budgetary and not systemic, i.e. they result
from legislative regulation. The little use of modern tools of human resource management is
striking since the role of professionals (mainly medical personnel) in contributing to the success
of the unit may suggest that staff policy would be accorded a priority.
78.
MANAGEMENT OF FINANCES AND SUPPLY. The HCEs report significant changes
in the practice of preparing the budget, including the method of making the budget (one
respondent stated that it was initiated from the bottom), and method of recording costs (currently
the memorial method). New elements, like income from additional and financial activity, fixed
assets as a value on the assets side, or cash flows have been added.
79.
The HCEs monitor execution of the budget with monthly analyses or continuous controls.
An account of costs is maintained and one facility uses the system of budgeting of individual
organizational units.
80.
In the event of exceeding expenditure limits (two respondents emphasized that they do
not allow for such situations), remedial actions are taken. Only one respondent pointed to
specific actions taken in such cases, naming diversification of revenue sources, loans for
operations and cost reductions.
81.
Three entities indicated that they could plan for external financing sources including
loans, credits, and leasing. The same number gave a negative reply. One respondent pointed out
that banks classify autonomous HCEs as a fourth risk group making it difficult to obtain a loan.
All respondents confirmed that prior to reforms they were not able to plan external financing.
82.
In efforts to obtain a loan, half of the respondents said that a guarantee from the founding
body is used. One manager also mentioned assets of SPZOZs (Autonomous Public HCEs) and
bills.
21
83.
The HCEs prepare annual financial statements in accordance with the provisions of the
Accounting Act. Two of the entities also mentioned monthly and quarterly statements prepared
for the founding body. Surprisingly the respondents did not make any distinction between the
pre and post reform period.
84.
The social council (two cases), founding body (three cases) and the manager (one case)
approved the statements. In a couple of cases a chartered accountant carried out the audit. Three
respondents said that the accounts are audited once a year. Only one respondent stated that there
was no audit in pre-autonomy days, and if carried out, it was done by the voivodship office. One
respondent was of the opinion that the nature of the audit has not changed after autonomy.
Another respondent emphasized the high transaction costs of this type of control and its limited
value due to the peculiar nature of the health sector.
85.
All respondents agreed that they could now transfer and utilize a financial surplus. One
observed that it is better to show a loss or a zero surplus to avoid the cumbersome procedure of
utilizing it after involving the social council and trade unions. The SPZOZ decided by itself on
the manner of utilizing a surplus (according to four respondents), whereas one maintained that
consent from the outside is needed without specifying the kind of consent. Before reforms, the
HCEs were unable to keep and invest surpluses.
86.
It is interesting that regarding responsibility for debts of an autonomous HCE, three
responses pointed to the founding body, whereas two singled the facility itself.11 Previously the
voivod was responsible for debts.
87.
The decisions on allocation of resources and procedures of spending are made by the
manager, and in one case by the voivodship. Only the manger makes the decisions concerning
supply of goods and services. All of the surveyed establishments planned supplies and stocks,
which did not exist previously. The respondents showed little understanding of the question on
who makes decisions on supplying fixed assets. In one case the voivod was indicated, in another
the establishment itself.
88.
All HCEs had investment plans. The decisions on the suitability of these investments are
made after identifying the needs and after consulting the managers of cells (two responses) as
well as the founding body (two responses). Majority of responses indicated that the grounds for
investment decisions are different from the pre-reform days.
89.
The surveyed establishments reported significant changes in the manner of making
budgets. More attention is now paid to factors and parameters recognized as appropriate for
efficient management of resources. There is a limited scope of pursuing an active financial
policy by the HCEs. The question of managing a financial surplus is only academic as majority
of entities are running losses. The nature of an audit has not changed essentially, and the
transaction costs in carrying it out are considered excessive. The investment requirements are
high but are not fulfilled.
90.
STRATEGIC PLANNING. One out of six HCEs did not have a strategic plan. The
management prepared the plan in the remaining entities, (in one case a single person formulated
11
This may be explained by lack of clarity in the question; the founding body is ultimately responsible for
the debts of the establishment, but operationally – the establishment itself bears responsibility.
22
it). Although a strategic plan was not required prior to reforms, in three (out of five) cases it was
nevertheless prepared. A striking observation by a respondent was that the strategic plan had not
been modified since becoming autonomous.
91.
All establishments implement a strategic plan.12 In only three cases adequate examples
of target goals from the strategic plan are given, and in one case the strategic goal is also defined.
92.
The mere existence of strategic plans in the HCEs may be interpreted with great caution
as their usefulness is limited and there is no linkage of the strategies of the individual units with
those of the voivodship and powiat governments.
93.
ENSURING PATIENT RIGHTS AND IMPROVING ACCESS. In five HCEs regular
meetings are held with the representatives of the community, patients and members of
associations. There was no such practice before reforms. The HCEs (with one exception)
maintained that their strategic plan takes into account the needs of the community in which they
operate.
94.
All managers claimed that the portfolio of services offered by them has changed.
Existing services have either been expanded or new ones introduced. However, only two gave
specific examples of new services which are angiosurgery, neurosurgery, and video colonoscopy.
95.
All HCEs, barring one, had a cell to deal with complaints of the patients. One-half of
HCEs had this cell before reforms. The number of complaints over the past year ranged from 0
to 10. The number was equal (in two cases) or smaller than before autonomy (two cases). A
respondent cited an increase in patient awareness as a reason for increased number of
complaints.
96.
The managers enumerated the courts, prosecutor, MOH, SFs, physicians’ chambers and
the founding body, as appellate authorities in patient complaints. They were of opinion that after
the 1999 reforms, patients have more avenues to lodge complaints regarding the operation of the
health care system. In one case a patient had complained against the establishment before the
reforms, whereas no such complaint was registered afterwards.
97.
In four cases (out of five) the HCEs were insured against malpractice. Such insurance
did not exist before autonomy was gained.13
98.
Three managers observed that the waiting time has become shorter. Four (out of six)
respondents conceded that they were aware of the existence of informal payments in their units,
though there was no material evidence for this. A manager explicitly denied any such practice.
In two instances the management took action on these complaints, by dismissing an employee
and issuing a warning to the other.
12
One respondent gave an affirmative answer to the question on implementation of the strategic plan, even
though in an earlier question he had denied the existence of a strategic plan in his unit.
This is another example of Polish translation blues. The word “malpractice” was translated as “etyka
zawodowa” [English “professional ethics”]. Probably for this reason one respondent did not understand the question.
13
23
99.
A manager claimed a decrease in the practice of informal payments, which was
widespread before. Another suggested possibilities of “legalizing” such practices, for example,
in the shape of private doctors’ offices outside the unit.
100. The responses to the questionnaire show that in the opinion of managers, the changes in
the health care system have strengthened the position of the patient by better serving his rights.
The patients are more aware of their interests and are more vocal in protecting them. Although
the portfolio and number of provided services are changing, there is no convincing evidence that
it has resulted in better access to health care. The existence of informal or “envelope” payments
in HCEs is not questioned, and there is no attempt to introduce measures to eliminate them.
101. PROPOSAL FOR REFORM OF HEALTH CARE. There was a mixed response on the
potential effect of the proposed NHF on operations of the HCEs. A manager evaluated the
directions of these changes as definitely negative, whereas another construed it as a positive
effect on his unit. Other respondents underscored the absence of detailed information on the
form of introduced changes, to be able to form an informed opinion. Similarly, lack of adequate
information on unification of the rules of contracting evoked a mixed response.
102. Local Governments. The LGs are involved in the health care sector as the founding
bodies – owners of assets securing the relevant network of health care centers and carrying out
public health responsibilities. Their responses are presented below.
103. MANAGEMENT PROCESS. The LG responsibilities include health promotion and
protection, informing people of the rules of operation of the health care system, and plan for
securing outpatient health services. Before the 1999 administrative reforms in Poland, the LGs
in some cases were the actual organizers of health services, for instance, in Sosnowiec for
outpatient care, and in Chorzów for inpatient services. Some LG entities ran public health care
facilities where changes were introduced (creation of family doctor practices), in other cases the
entire inpatient system was run by budgetary units controlled by the voivod.
104. Specialist care and rehabilitation, with occupational medicine and school hygiene, was
financed from resources of the HM, while inpatient care was financed by the voivod in the case
of Gdańsk, Poznań, Sosnowiec. There were also instances when the city was the founding body
for hospitals, as in Chorzów. There were no powiats.
105.
LGs have the following health care responsibilities:







As a founding body establishing, transforming and closing down of HCEs
Monitoring health care problems
Analyzing health needs and access to primary health care
Drawing up plans for securing outpatient services
Implementing prevention programs
Running schools that promote health
Rehabilitating alcohol-dependent persons
106. In the structure of the town LG, the municipal council is the resolution-making body and
the commission for health is the advisory and opinion-giving body. There is a health care
department in the municipal office. In a powiat, the powiat council formulates local legislation
24
on health care, ratifies financial resources, and enforces rules governing opening and closing of
health units. The Health Commission provides opinions on draft resolutions of the powiat
council. The Powiat Board manages assets of the powiat, executes its budget, and supervises
personnel and financing policies of HCEs. The social council oversees responsibilities
emanating from the Act on Health Care Establishments.
107. In cases where this was applicable (i.e. aside from powiats, which did not exist before
1999, and Świnoujście), the LGs were the organizers of health services (e.g. in Wrocław,
Gdańsk, Poznań, Chorzów). In the surveyed LGs the meetings of the Health Commission are
held at least once a month (6 responses), twice a month (2 responses) and once a week (1
response). The frequency of meetings is maintained from the pre-reform days.
108.
Among decisions recently made by LG authorities, the respondents listed:





Revamping LG health care, consisting of transferring health services to nonpublic entities (Gdańsk, Poznań)
Separation of primary health care from SPZOZ structures (Mielec)
Restructuring of HCEs (e.g. creation of new departments in hospitals,
transformation of general hospital into hospital for the chronically ill, closing
down of public health units - Chorzów)
Increasing the number of schools promoting health
Providing consent for transformation of several institutions into employee
companies (Wroclaw)
109. Six respondents indicated that before 1999, the scale of deficit of resources for outpatient
treatment was smaller, and therefore the LGs decided on the organizational and functional
structure of outpatient care (Poznań).
110. The LGs carry out comprehensive health care units monitoring at least once a year
(Wrocław, Nowy Targ, Świnoujście, Mielec), once every two years (Sosnowiec), and once every
quarter (Chorzów). Gdańsk LG felt that after privatization of outpatient care there were no legal
grounds for such controls. The frequency of monitoring and evaluation carried out by the LGs
before 1999 was the same. Most respondents felt that no significant changes have taken place in
the manner of monitoring of entities even after the introduction of health insurance.
Text Box 5. 1999 Reforms—The New Look Local Governments
The respondents have indicated the following priorities adopted by the LGs after the 1999
reforms:









Cardiac disease prevention program for the population between 40-50 year
Financing the program for correcting posture defects
Launching cancer prevention programs
Rent reductions for family doctors and employee companies (Wrocław)
Creation of the National Medical Rescue system
Promotional programs in the field of social diseases and addictions
Modernization of 24 hour outpatient centers
Lowered rents for non-public entities who have taken over health services from autonomous
P Act on General Health Insurance (GHI ublic HCEs (Gdańsk)
25




Modernization and expansion of powiat hospital (Mielec)
Vaccinations for virus hepatitis B for children born before 1995
Vaccinations for epidemic parotitis (mumps) for children aged 4
Mammography screening (Poznań)
Source: From the Laws of Poland’s Public Administration Reform
111. The respondents listed the following decisions related to health priorities that were taken
before 1999,




Implementation of cancer prevention, cardiac related, and alcoholism treatment
programs (Wrocław)
Decision to build a new pediatric hospital building (Sosnowiec)
Network of healthy cities (Poznań)
Prevention of caries in children and young people (Poznań)
112. Most of the respondents (eight out of ten) think that LG does not decide in what health
priorities to invest. For example, Sosnowiec stated that the LG has no influence on decisions in
the field of rehabilitation medicine.
113. After the introduction of health insurance, the LGs no longer formulate health policy or
organize health services. Although in many cases they currently serve as the founding body for
HCEs, the change of the rules of financing health services has atrophied their significance.
They, nonetheless, endeavor to actively influence health policies within their competence mainly
through prevention and health promotion programs. LGs are also striving to steer the HCEs in
their jurisdictions in the direction of privatization by creating competition in the market for
outpatient services.
114. HEALT CARE MANAGEMENT AND STRATEGIC PLANNING. Of the 9 surveyed
LGs, 8 have a strategic plan for the health sector. One respondent pointed out that despite the
powiat and voivod controlling some of the hospitals, in practice they can draw up and carry out
strategies only for outpatient treatment. With the exception of Sosnowiec, the LGs had worked
out such strategic plans before 1999 also.
115. Four LGs felt that they had only a minimal role in the operation of HCEs, their role being
limited to supervision and indirect control. Before 1999, this role consisted of responsibility for
access to services (Wrocław), supervision and consultation of management decisions
(Sosnowiec), and organizing and financing services (Gdańsk, Poznań). Four respondents opined
that especially in the case of entities where health insurance was introduced, the role of the LG
was sharply reduced. From a leader in health care policy decisions, the LG turned into an entity
passively functioning in the system (Sosnowiec).
116. To the question on the preparation of plans for supplying medical services to the
primary, specialist and hospital levels, three respondents gave an affirmative answer, two pointed
merely to participation in the preparation of such plans, and one reported that such plans were
envisaged only by the voivod and updated once a year. Only two respondents stated that the LG
had prepared a plan for supplying services in primary and specialist health care prior to the 1999
26
reform.
117. Eight respondents were positive that LGs affected the structure of the budget of HCEs.
This may be in the form of financing health-oriented programs, giving subsidies for the purchase
of equipment, and assisting in efforts to increase resources from the RSF. The LG had a greater
influence on shaping the structure of the budget in the pre-reform era.
118. The LGs require the following reports from HCEs: financial statements on revenues and
expenditures every month (6 respondents), and statements on execution of contracts once every
quarter (3 respondents). According to two respondents, HCE reports to the LG are limited in
scope (Wrocław), or there is no such procedure (Gdańsk). Before the reform, the LG had
comprehensive, as in Wrocław, insight into the structure of services, their costs, and constraints
etc.
119. Structural reforms have led to a decrease in the role and significance of LGs in the health
care system. This has made the system inefficient in some ways. The placing of health care
resources under various entities is counter-productive for coordination of health policy in the
regions and in building cohesive strategies. The LGs, in performing ownership functions, make
use of the standard tools for monitoring the actions of HCEs under their control.
120. ENSURING PATIENT RIGHTS AND IMPROVING ACCESS. The respondents rated
the role of LG in the protection of patient rights as limited (the LG is unable to establish the
number and type of contracted services). The most important activity in this respect was in
performing efficient supervision and comparison of the results with the standards specified in the
contracts. In Gdańsk the LG model for protection of patient rights was not worked out.
121. With the exception of Świnoujście, all respondents replied in affirmative to the existence
of a cell dealing with queries and complaints of patients. Such institutions had also existed
before the 1999 reform. The respondents reported that the number of patient complaints in the
last year ranged from 28 (Wrocław) to 1 (Poznań).
122. The respondents suggested that the number of complaints before 1999 did not differ
significantly from the present. Figures were available only for Poznań, where the number of
complaints was 16 in 1994 and 9 in 1998. Due to this the question on the reasons for the
difference in the number of complaints addressed to the LG remained unanswered.
123. In the opinion of the respondents, patients whose complaints had not been acknowledged
could address them to the SFs (7 responses), physicians’ chambers (3 responses), common courts
(3 responses), the prosecutor, and the bodies especially created for this purpose, e.g. the
Pomeranian Association for Patient Rights (Gdańsk). In the pre-1999 era, patients could appeal
to the voivod, the city president, occupational self-governments, and the court.
124. To the question on awareness of the existence of informal payments in HCEs in their
jurisdiction, the respondents said that either this was marginal (Wrocław), or non-existent
(Gdańsk). Three respondents accepted such occurrences in their units, and two conceded that
they had information that such payments are prevalent.
125. To the question on actions taken in the event of information about informal payments,
either no answer was given (2 cases), or no notifications were reported (5 responses). Only one
27
respondent mentioned a talk with the director of the unit. A mixed response was obtained to the
question gauging a possible change in the informal payments scenario before and after the 1999
reform. One respondent suggested that the dimensions of this phenomenon have not changed,
and another opined that competition among the service providers discouraged this practice.
126. After losing the capability to influence the provision and type of health services, the LGs
also became less significant as institutions protecting patient rights. The LGs, like the managers,
are usually aware of the existence of informal payments in the units working under their
supervision, but the problem is not addressed. There is no reliable information on the prevalence
of this phenomenon and there are no laid down procedures to counteract this practice.
127. IMPROVING STATUS OF HEALTH OF THE POPULATION. The average budgetary
share of expenditures for health promotion ranged from 0.00011% (innovative) to 22.5%
(Gdańsk). Compared with the situation before 1999, two respondents felt that the share of
expenditures is growing (Wrocław, Sosnowiec), whereas others described this ratio as similar.
128. The number of LGs on-going health promotion programs financed from their own budget
is much higher than before 1999. The respondents listed the following new programs:










Mammography tests for women over 45
Stand up straight program
Health Education in School program
Health Promotion Program consisting of a number of undertakings
Community programs
Preventive-treatment program for cardiovascular diseases
Cancer prevention and treatment program
Diabetes early detection program
Educational program “Prevention of Cancer by Reducing Tobacco Smoking”
Addiction prevention programs carried out in schools. The examples of these are:
“Aggression and how to control It”, “Good Life”, “Cheerful Class”, “Basics 2,
“Program of 7 steps”, “Drugs or Life”, “Learn to say No”, and “Taming
Aggression”.
129. Six respondents were positive on LG influence on the scope and type of services
provided within its territory. One respondent described this influence as small, and one thought
that the SFs have taken over the major functions. Two respondents felt that such an influence is
expressed through the programs carried out by the LGs. For example, cytological tests for
women, preventive tests for prostate for men, and preventive tests for cardiovascular diseases are
carried out in Gdańsk. In Świnoujście, part of the costs of services is covered, in Chorzów there
is a plan of ambulatory security, and in Mielec, LGs support service providers in exploring new
areas of care.
130. Before the 1999 reform, the LG had a much greater influence on the scope and type of
services (Wrocław, Sosnowiec, Poznań).
131.
New services have been incorporated keeping in view the specific needs of the
28
communities. The following are the examples of such services:






Self-examination of breasts (breast cancer prevention) with financing of full
oncological diagnosis for women taking part in the program (Wrocław)
Program to correct faulty posture of children (Wrocław)
Medical rescue system in mountains (innovative)
Prevention of cancer and cardiovascular diseases (Gdańsk)
School hygiene (Gdańsk)
Prevention of epidemic parotitis (Poznań)
132. Before the 1999 reforms, the LGs also incorporated services that were important for the
needs of the local community into their plans, but answers from surveyed LGs suggest that the
scope of this activity was small. Some respondents stated upfront that they did not carry out
such programs (Gdańsk), others pointed to the particular needs of the local communities in the
past (e.g. Sosnowiec: industrial medicine, Poznań: high incidence of virus hepatitis B among
children under 4, dental caries).
133. The 1999 reforms stripped the LGs of many policy making and implementing tools to
contribute to the state of health of the populations within their areas of operation.
Notwithstanding, the surveyed LGs are considerably increasing their activity in conducting and
financing preventive and health program within the powers still vested in them.
134. PROPOSALS FOR HEALTH CARE REFORM. The respondents did not formulate
clear assessments of the impact of the NHF on the operations of health units working under their
control. Four respondents indicated that they are unfamiliar with the details of the planned
changes. Two others estimated that any influence would not be too strong or direct. Most of the
respondents refrained from comprehensive evaluations of the proposed changes.
135. Poznań rated positively measures to standardize services throughout the country, whereas
the creation of a network of hospitals, the issue of defining the financing sources for investments,
regulations of the powers of LGs and reduction of resources for financing services of the NHF
are rated negatively.
136. Sickness Funds. The SFs are the third and the last category to be surveyed. The
questions covered similar aspects as in the last two categories, like governance, strategic
planning and improving access to health.
137. MANAGEMENT PROCESS. According to the respondents, administrative matters in a
SF were the responsibility of a member of the management board and the director of the
organizational division. In matters concerning contracts, contracting services and refunds, the
management board makes the decision.
138. The scope of real accountability of the management board and council of a SF comes out
in somewhat different ways in the surveyed units. In one SF, the council exercises actual power,
whereas accountability rests supra on the management board. This is because the new councils
have replaced the old ones on the recommendations of the health minister. Another respondent
estimated that the council as well as the management board have full powers and carry out the
29
responsibilities prescribed for them in the Act on General Health Insurance (GHI).
Text Box 6. In Focus Issues
The issues that are frequently encountered during the meetings of the management board and the council of
a sickness fund are:
Management board of SF:






Conclusion and renegotiation of contracts
Conditions of contracting services (with draft contracts)
Motions regarding contracting services (e.g. new medical procedures)
Current financial condition of the SF
In special cases individual motions to refund costs of treatment
Trends in refunding drugs
Council of a SF:







Financial plan
Plan for restoring financial equilibrium
Settlements with service providers (especially inpatient care)
Drug refunding
Periodical reports
Organizational structure of the SF
Appeals against decisions of management board
Source: Act of 6 February 1997 on General Health Insurance Dz.U.No. 28, item 153 with subsequent
amendments
139. Consent of the council of a SF is required, for instance, in making and amending a
financial plan, restoring equilibrium plan, disposing of or acquiring immovable property, making
major investments, and granting authorization to the management board.
140. Consent of the management board is required in: cessation of payment due to
irregularities in settlement of medical services, changes in the financial conditions of contracts
(renegotiations), announcement of a competition of offers, individual consent for providing
services for insured persons, increasing outlays for medical services in case of exceeding
financial limits, and taking over of services by newly established entities.
141. The respondents acknowledged that the role of UNUZ in the current operations of the
SFs is overwhelming. This can be seen in its influence on the organizational structure, its
capacity to issue instructions concerning contracting of specific services, expression of consent
for refunding of certain medical services, the capacity to lodge objections to the financial plan of
a SF. Besides, UNUZ often makes interpretations of the provisions of the Act on GHI.
142. The respondents assessed the role of UNUZ in a similar way when the SF makes strategic
decisions. An incident was cited of UNUZ recommendations in terminating contracts with
service providers (due to the new rules of contracting services in effect from 2003), and then
30
counter-instructions to withdraw terminations.
143. The UNUZ calculation of the amounts of financial leveling out among the SFs has a great
impact on the budgets of these funds. The consent of UNUZ is necessary to adopt a financial
plan or to make amendments, and the plan for restoring equilibrium, and to approve the statutes
of a SF.
144. The analysis and evaluation of management in the SFs – on the eve of their elimination –
has merely a cognitive value. The statements of the respondents only confirm the strong political
influences in the SFs, shown by the changes in the composition of the fund councils and their
subordination to the decisions of the Health Minister. An issue which is still unclear is the
position of UNUZ and the health minister in the new configuration, e.g. in the matter of
contracting, contracting specific services, and lodging objections to financial plans etc.
145. STRATEGIC PLANNING. In both the examined cases the SF had a strategic plan for
the health care sector. Notably, one respondent assessed the interest of the voivodship selfgovernment in such a plan as none. The respondents conceded that the SFs indirectly influenced
the current operations of HCEs. This takes place e.g. through speeding up of payments,
definition of the conditions of providing services, and modeling the standards of the services and
their structure.
146. The respondents opined that a SF also influences the structure of the budget of the HCEs
(financial resources apportioned for providing services cannot be used for investment purposes).
147. The SFs expect to receive detailed reports on provided services from the service
providers, delivered in electronic form in accordance with the standard defined by the fund
(Pomorska RSF) and any changes in the manner of providing services (Opolska RSF).
Moreover, declarations on the number of patients covered by primary health care are required, as
well as information on the quantity of services provided to members outside SFs. Usually these
are monthly reports. Data are also gathered in quarterly periods on the subject of the performed
services according to disease units covered by treatment (ICD-9 classification), and according to
school hygiene services (ICD-10 classification).
148. The Pomorska RSF does not require that service providers submit regular reports to
outside institutions, but the Opolska RSF requires that service providers submit reports to the
Opole Center for Public Health (information on hospital statistics), to sanitation-epidemiological
field stations (information on epidemiological matters) and to the Voivodship Oncological
Hospital (information on oncological matters).
149. Although the legal regulations do not have relevant provisions defining the role and
position of the SFs in building health care strategy in the voivodship, in practice the SFs affect
not only the form of the strategy, but also influence the current operations of HCEs.
150. ENSURING PATIENT RIGHTS AND IMPROVING ACCESS. The respondents
maintained that monitoring quality control and access to health services is done in a multi-track
form, through surveys of patient satisfaction, comparing offers of service providers with the
actual results, and direct control of execution of services. However, there was no clear indication
on the frequency of such controls, mentioning only that patient satisfaction surveys are carried
out once a year. Technical reports on the number of performed services, their types, procedures,
31
patient age etc. are furnished by the service providers every month.14
151. Examples of actions taken: The patients of one outpatient center of primary health care
complained about the behavior of a physician, the time of his work and unwillingness to make
house calls. Following a direct inspection and confirmation of the charges, the contract was
terminated. Similar situations occurred in dental offices and some specialist outpatient centers
(Pomorska RSF). Additional competition of offers have also been announced in specialties
where there was deficiency of services and constrained access to medical services (Opolska
RSF).
152. The respondents maintained that SFs ensured quality of services, though one claimed that
it was inadequate due to the minute share of specialist supervision. One respondent required that
service providers carry out assessments of the quality of services (Opolska RSF), another
encouraged service providers to do this through propagation of good practices.
153. The respondents claimed that regular meetings are held with local leaders, representatives
of patients and members of local communities. In the Opolska RSF there are frequent meetings
with organizations of service providers, especially preceding a competition of offers.
154. Both respondents conceded that the strategic plan of the SF reflected the need of the
given population for health services. One added that there were also difficulties in carrying out
such a plan.
155. Both respondents confirmed that the funds were financing expansion and changes in the
type of services provided. Examples: Pomorska RSF introduced botulinum therapy for children
with cerebral palsy, specific immunotherapy for insect bites, and new oncological drugs.
Opolska RSF introduced specialist procedures not financed by the MOH like, coronary surgery
(bypasses), and anti-virus drugs for hepatitis B and C.
156. Both SFs contained units and individuals to deal with queries and complaints of patients.
Last year Pomorska RSF received 655 complaints, and Opolska RSF 103 complaints. In case the
complaints are not heeded by the funds, the patients had the option of going to the physicians’
chamber, court of labor and social insurance.
157. The respondents conceded that they were aware of the existence of informal payments.
One pointed to a peculiar inability to complete proceedings and formulate charges against a
physician even when it was widely known in the medical circles and was given a broad press
coverage. The respondents could not come up with examples of actions taken in the event of
having information on the acceptance of an informal payment.
158. In the presence of institutions like commissioner for patient rights, such rights are
protected. The SFs assures quality control of provided services. However, the budget constraint
imposes a limit to certain services and may also lead to infringement of patient rights. As in the
case of managers and LGs, the SFs are aware of the existence of informal payments, but this
phenomenon is not investigated or registered, nor any concerted action taken to reduce it.
14
The data acquired by the sickness funds in this way does not allow for investigation of the actual
accessibility of services.
32
159. IMPROVEMENT IN HEALTH STATUS OF THE POPULATION. To the question on
how the SFs made use of the health care programs prepared by the LGs, the respondents stated
that the plans for securing outpatient care were analyzed and evaluated according to the financial
capacity of the fund. These programs were started in the cities of Gdynia and Słupsk in
Pomorska RSF. Opolska RSF made use of programs prepared by the voivod (“Minimum plan
for securing outpatient health care for treatment of the Opolskie Voivodship” and “Plan for
securing medical rescue actions”) and the voivodship self-government (“Opole Regional Plan for
Health Protection”).
160. To the question on giving examples when the SF did not take into account the
recommendations of the voivodship and instead financed other services, Pomorska RSF
maintained that Pomorskie Voivodship did not have any such program. Opolska RSF, on the
other hand, claimed that there was no significant difference between the actions of the fund and
the programs of the LGs. If such a difference existed, it was merely caused by the limited
budgets of the funds and was only quantitative rather than qualitative in character.
161. The respondents also admitted that the SFs influenced the scope and type of services
provided within their area. Beside influencing the contracts, the suggestions of the funds are
binding too. In Opolskie Voivodship, for example, on the recommendation of the SF, two
children departments were transformed into daytime departments, and outlays for inpatient care
(internal diseases) were decreased through a change in the profile of four departments.
162. Only Opolska RSF gave examples of financing services that were of special significance
to the inhabitants. Among other things RSF financed:





New cardiac procedures (Carto ablation)
Home rehabilitation
Introduction of new forms of chemotherapy for rheumatoid arthritis and
malignant lymphoma
Drug protection in intervention cardiology
Vaccinations for hepatitis for 6-year olds
163. The SFs are aware of their influence on the scope and type of health services provided
within their area. They cited examples of expansion of health services financed from their
budget.
164. PROPOSALS FOR HEALTH CARE REFORM. The respondents made selective
evaluations of the proposed changes like setting up of NHF and establishing a network of
hospitals. The unification of contracting rules is considered a positive step. The lack of
flexibility in the adjustment of contracting of services to the local needs and capacity, and
absence of any criterion for apportioning financial resources among voivodships are rated as
negative influences.
33
GENERAL CONCLUSIONS
165. The character and scope of the research rules out incisive conclusions. However, on the
basis of the obtained findings, one can attempt to point out phenomena that are more general in
character and may serve to inspire towards further, more profound research.
Decentralization of Management of Health Care in the context of Governance Procedures.
166. The process of decentralization of management of the health care system in Poland
before 1999 was without any clearly articulated strategy. Rather, it was a result of the initiative
of a group of LG activists that belonged mostly to big cities. The actions of this group were not
closely coordinated. This lack of coordination contributed to a multitude of schemes and
procedures that were adopted in different regions.
167. HCEs, which acquired the status of autonomous facilities after 1995, were motivated to
revise the existing management procedures and build new ones, to adapt to the changing
conditions of operation. Most of these procedures (e.g. preparation of budgets and their control,
creation of an account of costs, collective creation of strategic plans and staff policy) passed the
test of time successfully, as the surveyed establishments were using them in 2002.
168. The LGs, in pursuance of the functions as organizers of health care in the region of their
operation until 1999, worked out a number of management procedures to carry out these tasks.
The preparation of health care plans was one such task.
Decentralization of Management of Health Care in the context of Accountability
169. The information on accountability acquired in the survey, though treating it with due
caution, entitles us to say that decentralization of health care management has resulted in a
change of both the scope of services and their quality. We are dealing here with considerable,
and in some cases significant changes in the portfolio of services offered by HCEs. It is more
difficult to precisely pinpoint the factor that led to the restructuring of the offer of services, as
there is no convincing evidence to show that the factor generating change was the actual demand
for health services existing in the given region.
170. Even less explicit is the matter of assessment of accessibility of health services. Here
there are both positive developments (better access to a first-contact physician) as well as
negative ones (reduction in the number of admissions to hospital wards because of small
contracts with the RSF). But the effects of decentralization are apparent as far as improved
access to information and transparency of the applied business practices are concerned.
Decentralization of Financing of Health Care System in the context of Governance
Procedures
171. Decentralization of financing of the health care system brought a number of changes in
the governance procedures both with regard to the payment remitter (SFs) as well as the service
providers (HCEs). First of all, new institutions appeared (SFs) with their governing bodies
(management board, council). Then new quality procedures were adopted (e.g. preparation of
34
budgets of the SFs, the mechanism of leveling out differences, and negotiation of contracts).
172. Some procedures like, making budgets of HCEs, introduction of account of costs, and
control of budget execution, were changed significantly. After carefully evaluating the
organizational working of the SFs and operation of autonomous HCEs, one may observe that the
four years experience with the SFs has not culminated in the formation of mature and efficient
management procedures. This remark applies first of all to control functions. It may also be
noted that the mangers of HCEs were constrained to operate in conditions of incessant financial
crunch, which affected the nature of employment and investment policies pursued by them.
Decentralization of Financing of Health Care System in the context of Accountability
173. Decentralization of financing of the health care system has left its impression on the
scope of accountability of the main players. It is universally observed that through the
contracting system the SFs decided on the scope of health services offered to the populations.
This remains in a certain inconsistency with the legal regulations, which ascribe accountability
for health care mainly to the LGs.
174. The existing procedures of supervision of the SFs provided the voivodship selfgovernments with the legislative ability to influence their policy in contracting services. But due
to rigid budgetary limitations, the shape of the health policy in the regions was defined by the
financial capacity of the SF. By merely financing preventive and health promotion programs, the
LGs are able to influence the portfolio of services only to a limited extent.
35
5. DISCUSSION
175. In this part of the paper, the conclusions from the pilot survey are synthesized with the
findings of other relevant studies concerning health care reform in Poland.
176. In Poland the method that has been adopted for decentralizing health care system
delegates authority to the voivodship, powiat and gmina levels. In this respect, no model was
developed that could have been the theme of prior in-depth public or political discussion, nor a
plan of implementation was chalked out for schemes that were adopted ultimately.
177. As has been emphasized in previous sections, decentralization is the implementation of a
certain political ideal, in accordance with which local communities get an opportunity to
participate and decide about themselves. Decentralization is accompanied by strengthening of
accountability of local politicians towards the communities they represent. 15 But this is
dependent on the existing political model of organization of authority, especially if we appreciate
that the actual model is neither rigidly centralized nor strictly decentralized.
178. In a given national model of health care we can thus find elements of a centralized as
well as decentralized system. For example, in a centralized model of health care such as in
Sweden, there are elements of the decentralized system (e.g. dental care). In a decentralized
model, such as in Germany, there are arrangements typical for the centralized system (e.g. the
sector of preventive public health).16
179. There was no model of health care during the two-tier administrative division in
voivodships and gminas in the country. The same situation persisted after the introduction of the
1999 general administrative reforms when a three-tier administrative division was implemented
in Poland.
180. The scholarly debates on reforms aiming at decentralization of state authority point out to
the necessity of taking up a parallel research effort in public finances, political science and
organization theory.17 While moving in the direction of decentralization the fulfillment of
several social and cultural conditions is also a prerequisite:



Appropriate administrative and management potential
Strong (ideological) belief in the fulfilled tasks
Readiness to accept a multitude of views and interpretations of the same problem
15
D.J.Hunter et al. 1998. “Optimal balance of centralized and decentralized management”, in:
R.B.Saltman et al, (eds.), “Critical Challenges for Health Care Reform in Europe,” Open University Press, s.309
16
ibidem, s.310
S.J.Burki, G.E.Perry, W.R.Dillinger. 1999. “Beyond the Center: Decentralizing the State”, The World
Bank, Washington, , p. 17
17
36

Appropriate change of institutions.18
181. The preparation of the draft on General Health Insurance in Poland did not fulfill the
above analyses or conditions for decentralization.
182. An enabling environment of liberal orientation, consisting of regional and local leaders,
who act as agents of change, spur the decentralization process. It is interesting to note that the
first attempts at decentralization of health care management were made in Poznań and Łódź
much before the political-economic transformation of 1989.19 These actions were intensified
after 1990, at the passing of the Local Government Act20 and the Competence Act21 (the pilot
program launched in 1993 aiming at taking over running of HCEs within “commissioned”
responsibilities).22
183. The 1990 restoration of the institution of territorial self-government (local government) at
the gmina level, with simultaneous weakening of administration of the voivodship level led to a
dichotomous division of public administration into local (gmina) and central administration.23
This created an interesting topic for discussion on the lack of cohesion in the schemes and
outlined model.
184. The passing of Act on Cities24 in 1995 was another important step in the progress of
decentralization in the management of the health care system. Even though the agents of change
cooperated and collaborated with each other and received technical support from western
institutions and grant donors,25 there was a lack of vision for a decentralized system of
management. As a result, the actions could not be synchronized leading to considerable
variation in the adopted schemes. The research carried out in Bielsko-Biała, Chorzów, Koszalin,
Kraków, Olsztyn, Poznań, Wrocław, Szczecin and in the Sądecka Zone of Public Services
illustrates this in a convincing way.26
185. The experience of health care units (which were autonomous before 1999) in
management practices showed that the managers of these units had begun to implement tools and
D.J.Hunter et al. 1998. “Optimal balance of centralized and decentralized management”, op.cit, p. 316.
These are also the conclusions of the paper: “ Governance and Accountability in a Decentralized Setting. An
Examination of Selected Issues”, December 5, 2002, mimeo
18
19
A.Kozierkiewicz, M.Kulis. 1999. “Health protection in local government”(in Polish), Kraków, p. 21-
20
Act of 8 March 1990 on Local Self-Government, Dz.U. No. 16, item 95 with subsequent amendments
22.
21
Act of 17 May 1990 on division of responsibilities and powers between Bodies of the Gmina and Bodies
of Central Government Administration, Dz.U. No. 34, item 198 with subsequent amendments
22
Please note that the original titles of all Polish footnotes are given in the “Selected References.”
23
J. Brożek. “Finances of local government – the first year of operation”(in Polish), op.cit.
24
Act of 24 November 1995 on Changing the Scope of Operation of Certain Cities and on Municipal Zones
of Public Services, Dz.U. No. 141, item 692
25
Here mention must be made of the initiatives of the Harvard-Jagiellonian Consortium for Health, which
operated in the years 1996-1999 and was sponsored by USAID/DAI.
26
A. Kozierkiewicz, M. Kulis. 1999. “Health protection in the local government”, op.cit.
37
practices that can be described as Best Business Practices.27 Unfortunately, in a situation where
these units had only de jure guaranteed autonomy and had to function in a system that was not
restructured or reformed, it was difficult to achieve spectacular economic and financial success. 28
This was compounded by the fact that along the way issues kept on cropping up that constantly
needed explicit interpretations or statutory resolution (e.g. services guaranteed by the state,
primary care, the list of patients and the manner of creating it, financing services in social
assistance homes and small-child homes, reference levels of hospitals etc.).29
186. A striking feature of the implemented reform on GHI was the lack of a well thought out
and coordinated effort. A typical example is the HCEs that gained autonomy. The arrangement
was bereft of a mechanism that could motivate towards changes. The short and stormy history of
management contracts in health care30 can be an example of compromising an essentially good
tool through its improper use.
187. The negative fall out with the fragmentary reform effort of pre-1999, was not fully
rectified when the four reforms, including the health insurance reform, were introduced in 1999.
The charges against the newly introduced reforms may be arranged in two groups:
188. Manner of preparing and introducing changes. This had many weak areas. The manner
of informing and introducing changes was not all-inclusive. The functional links among the four
reforms could not be discerned. The mechanism dealing with control and modification of
changes was not transparent. Above all, there was excessive political influence in the system.
189. Health insurance reform. The position and role of the founding body and of the remitter
was not clear. The functional links within the health care system among various entities
(voivodship, powiat, gmina, HCEs, SFs) and different levels of health care (primary care,
J. Klich. 1996. “Building a strategic plan for health care units”, (in Polish), in: J. Skalik (ed.) “Current
problems of health care management”, Research paper No. 719, Academy of Economics.
Wrocław, M. et al. 1996. Planning processes in health care units”(in Polish), Research report, No. 11-12.
“Current practice of planning and control in the health care system: outpatient and inpatient care :Report on execution
of task D.1”(in Polish.), “Development of local initiatives for health care reform.”(in Polish), Conference material
P.Campbell et al. 1997. “Process of planning in units of the health care sector in Poland”,(in Polish),
Przegląd Organizacji 1997, No. 1
27
J. Klich, M. Chawla. 1999. “Operation of autonomous public health care establishments”(in Polish),
Gospodarka Narodowa, , No. 1-2,
M. Kautsch, J. Klich, M. Chawla, M. Kulis, B. Bulanowska, P. Campbell. 1999. “Autonomous public health
care establishment: recommendations”(in Polish), Zdrowie i Zarządzanie, , No. 2, Volume I
28
Z. Król. 1999. “Further Transformations of Autonomous Public Health Care Establishments” (in
Polish), Zdrowie i Zarządzanie, Vol. I, No. 5
29
A.Kozierkiewicz, J.Klich. 1999. ”Agreement – management contract”(in Polish), Zdrowie i Zarządzanie, ,
No. 1, Vol. I,
J.Klich. 1999. Management contracts in conditions of market and systemic limitations” (in Polish) , Zdrowie i
Zarządzanie, No. 4, Vol. I,
M.Kautsch, J.Klich. 2002. Management contracts in health care” (in Polish), Gospodarka Narodowa, No. 4
30
38
inpatient care) were weak. Control and modification of the health care process was thus difficult
to achieve.
Text Box 7. An Estimate of 1999 reforms
A.Wojtyna in commenting on the degree of conceptual preparation, the manner of introduction and the first
experiences of the four reforms, points out that:
The individual reforms had different degrees of preparation that went into the making of draft resolutions.
Only in the case of the pension reform a model was worked out that served as a point of reference in evaluating the
variant that would be most appropriate for Poland. A cohesive document was thus prepared that not only served the
propaganda and information purposes, but was also analytical containing cost/benefit calculation. Such a model was
conspicuous by its absence in other reform areas.
The reforms were accumulated in time without any reasoning presented to support such procedure.
The external conditions of introducing reforms were not properly taken into account.
Source: A.Wojtyna, “Decentralization of public finances”, Gospodarka Narodowa, 2000, No. 7-8, p.13-14
190. The health insurance reform has been criticized because of the manner of introducing
changes. There were discrepancies between the compulsions of organization and management
theory and the practice of preparation and introducing the reform.31
191. Setting aside for a moment such issues as cohesion and internal logic of the schemes
adopted, several features in reform implementation were striking. A prominent feature in public
presentation was the lopsidedness of the assumptions and anticipated effects of reform. It was
heralded as a panacea for all maladies of the health care system, which was supposed to fulfill
the expectations and interests of all entities. This not only heightened the expectations of the
public, but also of the managers of HCEs.
192. The introduced reform had no built-in control mechanisms. Such a mechanism would
have allowed remedial measures to be taken in the event of undesirable developments. A
pervasive problem was the political influence in the system. This was manifested through legal
regulations and application of procedures making room for political appointments. For instance,
appointment of management boards and councils of SFs, and health policy personnel in the LGs
was the prerogative of the health minister.
193. Before taking up the main elements of criticism of the schemes adopted in GHI (which
we can call a model created ex post), let us focus on two issues that should have been vetted
prior to the adoption of concrete statutory provisions. Both concern systemic solutions, with the
first having a more general significance, being linked with definition of the relation between
ownership, management and financing in the health care system, and the other with definition of
the fields that should not be included in decentralization.
31
J.Klich. 1996. “Reform of health insurance – its draft and amendments” (in Polish), Polityka Społeczna, ,
No. 4
39
194. In a regulated market, like that of health services, separating financing of services from
ownership leads to sub-optimal results. Ownership of the most valuable resources, i.e. inpatient
care, is ascribed to the voivodship and powiat self-governments. However, these entities are
unable to fully exercise their powers, comprising the “positive” side of ownership, defined in law
as(i) the right to use a thing, i.e. to its ownership, use, drawing benefits, and effecting actual
disposal (utilization, processing, destruction), and (ii) rights to dispose of a thing(disposing of a
right and burdening it with limited real rights).32
195. In the context of the political choices adopted in Poland and the reform of GHI, the LGs
rights to use things are in practice limited (i.e. rights to draw benefits and make actual
dispositions). This along with the ill-suited financing schemes of LGs and ownership divisions
of inpatient care (i.e. either voivodship, powiat or municipal property), leads to significant
disturbances in the fulfillment of corporate governance. It creates disturbances in the precise
definition and execution of responsibilities for health services.
196. Holding the view that Act on GHI has not been the best of legislations, we may point out
the areas that should not be included in decentralization. The experience of the European states
is instrumental in indicating that the following should be excluded from decentralization: (i) the
main assumptions of the health policy, (ii) the resources used in the health sector: skilled
personnel(education, accreditation, registration), costly medical equipment, research and
development, (iii) specific schemes concerning regulation and (iv) monitoring, assessment and
analysis of the health of the population and performance of services.33
197. Unfortunately, in Poland when adopting successive schemes, the scope of responsibility
of the health ministry was not defined very accurately, as regards items (i) and (iii), while
leaving incoherent provisions as regards (ii) and (iv) above.
198. The shortcomings are also apparent in the detailed solutions that were adopted in the
reform. The LGs being limited to exercising ownership functions, were confronted with the
strong position of the SFs as monopolist remitters.
199. The provisions of the Act on GHI did not accurately define the scope of responsibility of
LGs in health policy in the regions. It can be gauged by two observations. One, the lack of
precise division of obligations between voivodship and powiat self-governments34 on one side
and the SFs on the other.35 Two, the matter of financial supply of the LGs,36 which determines
the capacity of LGs to fulfill these tasks. J.Brożek (2002) succinctly describes the situation by
32
U.Kalina-Prasznic (ed.). 1999. “Encyclopedia of Law” (in Polish), Wydawnictwo C.H.Beck, Warsaw,
33
D.J.Hunter,et al. Optimal balance of centralized and decentralized management”, op.cit, p. 316
p.850
.J.Klich. 2001. “Building health protection programs in the voivodship” (in Polish), Zdrowie i
Zarządzanie,Volume III, No. 1., cf. K.Czarniecka, A.Huk. 2001. “Program of health care restructuring”
34
S.Golinowska et al. 2002. Health care in Poland after the reform”(in Polish) Reports of CASE - Center
for Social and Economic Research, No. 53/2002, Warsaw 2002, p.116
35
,J.Brożek. 2000. “Finances of local government – the first year of operation” (in Polish), in Report on
the financial status of the State in 1999, Institute for Finance of the University of Insurance and Banking in Warsaw,
Warsaw, p.85
36
40
saying that: “local government reform, although carried out from the political point of view, is
legislative fiction in the economic aspect.”
Text Box. 8. GHI Act—Falling Short
The provisions of the Act on GHI did not accurately define the scope of the responsibilities of Local
Governments in health policy.
An example here can be the procedures for creating plans for health protection in the region. The
preparation of plans in the area of primary health care is the responsibility of the powiat self-governments. It
remains unclear, however, who is responsible for the creation of plans for comprehensive securing of health
services. Regional restructuring programs created within the ministerial plan in 2000 were the first forum where
representatives of all those interested met to initiate the formation of a partnership for health in the region.
The sickness funds not only carried out the functions ascribed to them, but others were also taken over by
the SFs due to the existence of a ‘competence vacuum’ or lack of adequate motivation on the part of the appropriate
entities in the system.
Source: J.Brozek. 2000. Finances of local government—the first year
200. There was an inadequate upward adjustment of the structure of income of LGs in relation
to the responsibilities defined for them. As pointed out by Swianiewicz,37 the structure of tax
income of LGs in Poland shows several visible weaknesses. Despite the proclamation made in
Article 168 of the Constitution of Poland that “to the extent established by the state, units of local
self-government shall have the right to set the level of local taxes and charges,” neither the
powiats, nor the voivodships have a broad tax base that could increase their low incomes.
201. As compared to 2000, the structure of income of LGs in 2001 shows the predominant
share of the general subvention for powiat and voivodship self-governments, which was 46.3%
and 34.4% respectively. The targeted subsidies for the two levels of self-governments was 45%
and 51.1% respectively for the year 2001.
202. Although the share of own income is relatively largest in gmina self-governments, as
compared to powiat and voivodship self-governments, a declining trend is still discernable. It is
shown by a drop of the share of own income, from 40.1% in 1995 to 33% in 2001. The pattern
of gmina income is extremely fragmented.
203. Another disturbing development in the implementation of the reform was the relatively
low quality of management in HCEs, SFs, and founding bodies. Although great efforts were
made (with the use of foreign assistance) in training the staff of HCEs, SFs and LGs, 38 the need
in this area is still substantial. This is borne out by the findings of research on the quality of
management in HCEs.39
P.Swianiewicz. 2002. “Local taxes in the system of financing of tasks of local governments – theoretical
topics and practice of schemes in Poland and in European countries” (in Polish), Samorząd Terytorialny, No. 12
37
38
e.g. the programs of the World Bank and Project HOPE in this respect
M.Kautsch, J.Klich. 2002. “Quality of management in health care establishments of the Małopolskie
Voivodship. Results of pilot research” (in Polish), Kraków (article submitted for printing in periodical Organizacja
i Kierowanie)
39
41
204. Many practices have been observed that have a negative effect on the performance of the
system. An example is the practice of shifting of part of the administrative costs onto the service
providers by the SFs, or shifting part of the costs of primary care to outpatient specialist services
and inpatient care.
205. SFs require that service providers send reports in electronic form, which in practice
means that the task of maintaining records of persons covered by health insurance, determining
and confirming the right of an insured person to services and analysis of the execution of the
obligation of GHI has been transferred from the SFs into the hands of the service providers.
Because of the poor control in the implementation of the reform, these practices have not been
eliminated.
CONCLUDING REMARKS
206. The foregoing discussion and evaluation show that there have been significant lapses in
all stages of health insurance reform, starting from its conceptual assumptions and planning
procedures to its implementation.
207. In emphasizing the unsatisfactory state of affairs, however, it must be said that gaining
autonomy by the establishments (decentralization of management) has by and large brought
positive results. Autonomy combined with the introduction of Programs for Restructuring and
Safety Shields in health care carried out since 1999 have made it possible to attain notable results
in e.g. restructuring of the number of beds,40 creation of facilities and beds for long-term care,
better use of resources, employment rationalization, and the emergence of an outsourcing
market.41
208. The quality of the staff at the local level impacts the quality of policy advice and policy
development on the one hand, and the quality of policy implementation and service delivery on
the other. In this backdrop there is still scope for better incorporation and utilization of modern
tools of human resource management like budgeting and expenditure management. A more
concerted effort may be launched in training the staff of HCEs, SFs and LGs. This would
improve the quality of management and free up resources for improved service delivery.
209. In the case of decentralization of financing, it is more difficult to draw up a list of
achievements. 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.
210. Long term service delivery may be enhanced by enhancing capacities like improving
planning, risk appraisal and financial management. There is a clear need of sharply defining the
relationship among ownership, management and financing in the health care system. Besides,
there is a need to strengthen control functions so that there is transparent accountability for the
responsibilities entrusted to the entities.
K. Czarniecka. 2002. “Effects of implementation of the Program of Restructuring of the Health Care
System in Poland in the Years 1999-2001” (in Polish), Zdrowie i Zarządzanie, Vol. IV, No. 3-4, p.21
40
K. Czarniecka. 2002. “Complementary to publications related to NIK [Supreme Chamber of Control]
report on the program of restructuring in health care” (in Polish), Zdrowie i Zarządzanie, Vol. IV, No. 3-4, p.23
41
42
SELECTED REFERENCES
J. Brożek, Finanse. 2000. “Finances of Local Government – the First Year of Operation”
(Samorządu Terytorialnego.– Pierwszy rok Funkcjonowania in Raport o Stanie Finansowym
Państwa w 1999 roku), “Report on the financial status of the State in 1999”, Institute for
Finance, the University of Insurance and Banking in Warsaw.
S. J. Burki, G. E. Perry, W. R. Dillinger. 1999. “Beyond the Center: Decentralizing the State”
The World Bank, Washington.
P. Campbell, J. Klich. 1997. “The process of planning in units of the health care sector” (Proces
Planowania w Jednostkach Sektora Opieki Zdrowotnej w Polsce”, Przegląd Organizacji), No. 1.
K. Czarniecka. 2002. “Effects of implementation of the Program for Restructuring of the Health
Care System in Poland in the Years 1999-2001”(Efekty Realizacji Programu Restrukturyzacji
Systemu Ochrony Zdrowia w Polsce w Latach 1999—2001), Zdrowie i Zarządzanie, Volume
IV, No. 3-4.
K. Czarniecka. 2002. “Complementary to publications related to NIK [Supreme Chamber of
Control] report on the program of restructuring in health care” (Uzupełnienie do Publikacji
Związanych z Raportem NIK –u o Programie Restrukturyzacji w Ochronie Zdrowia), Zdrowie i
Zarządzanie, Volume IV, No. 3-4.
K. Czarniecka, A. Huk. 2001. “Program of Health Care Restructuring” (Program Restrukturyzacji
Opieki Zdrowotnej), Zdrowie i Zarządzanie, , Volume III, No. 1.
S. Golinowska, Z. Czepulis-Rutkowska, M. Sitek, A. Sowa, Ch. Sowada, C. Włodarczyk. 2002.
“Health care in Poland After the Reform, CASE Reports” (Opieka Zdrowotna w Polsce Po
reformie, Raporty) CASE No. 53/2002, Warsaw.
“Governance and Accountability in a Decentralized Setting. An Examination of Selected
Issues,” December 5, 2002 - mimeo
D. J. Hunter, M. Vienonen, W. C. Włodarczyk. 1998. “Optimal Balance of Centralized and
Decentralized Management,” R. B. Saltman, J. Figueras, C. Sakellarides (eds.), Critical
Challenges for Health Care Reform in Europe, Open University Press.
U. Kalina-Prasznic (ed.) 1999. “Encyclopedia of Law” (Encyklopedia Prawa), Wydawnictwo
C. H. Beck, Warsaw.
M.Kautsch, J.Klich. 2002. “Quality of Management in Health Care Establishments of the
Małopolskie Voivodship. Results of Pilot Research” (Jakość Zarządzania w Zakładach Opieki
Zdrowotnej Województwa Małopolskiego. Wyniki badań Pilotażowych), Kraków (article
submitted for printing in periodical Organizacja i Kierowanie).
43
M. Kautsch, J. Klich, M. Chawla, M. Kulis, B. Bulanowska, P. Campbell. 1999. “An Autonomous
Public Health Care Establishment: Recommendations”) (Samodzielny Publiczny Zakład Opieki
Zdrowotnej: Rekomendacje) Zdrowie i Zarządzanie, , Volume I, No. 2.
M. Kautsch, J. Klich, A. Mazur. 1996. “Processes of Planning in Health Care Units. Report on
Research” (Procesy Planowania w Jednostkach Opieki Zdrowotnej. Raport z badań), Antidotum, ,
No. 11-12.
J. Klich. 1996. “Current Practice of Planning and Control in the Health Care System: Outpatient
and Inpatient Care. Report on Execution of Task D.1. “Development of Local Initiatives for Health
Care Reform.” Conference material. (Aktualna Praktyka Planowania i Kontroli w Systemie Opieki
Zdrowotnej: Lecznictwo Otwarte i Zamknięte. Raport Wykonania Zadania D.1, „Rozwój Inicjatyw
Lokalnych na Rzecz w Służbie Zdrowia”. Materiały konferencyjne), Antidotum , , No. 11-12.
J. Klich. 2001. “Building Health Protection Programs in the Voivodship” (Budowanie
Programów Ochrony Zdrowia w Województwie), Zdrowie i Zarządzanie, Volume III, No. 1.
J. Klich. 1996. “Building a Strategic Plan for Health Care Units” (Budowanie Planu
Strategicznego dla Jednostek Opieki Zdrowotnej), in: J.Skalik (ed.), “Current Problems in Health
Care Management” (Aktualne Problemy Zarządzania Ochroną Zdrowia), Prace naukowe no. 719,
Academy of Economics, Wrocław.
J. Klich. 1999. “Management Contracts in Conditions of Market and Systemic Limitations’
(Kontrakty Menedżerskie w Warunkach Ograniczeń Rynkowych i Systemowych), Zdrowie i
Zarządzanie, , Tom I, Nr 4.
J. Klich. 1996. “Reform of Health Insurance – its Plan and Amendments” (Reforma Ubezpieczeń
Zdrowotnych - Jej projekt i Zmiany), Polityka Społeczna, , No. 4.
J. Klich, M. Chawla, M. Kautsch. 1999. “Operation of Autonomous Public Health Care
Establishments” (Funkcjonowanie Samodzielnych Publicznych Zakładów Opieki Zdrowotnej),
Gospodarka Narodowa, , No. 1-2.
A. Kozierkiewicz, M. Kulis. 1999. “Health Care in Local Government” (Ochrona Zdrowia w
Samorządzie Lokalnym), University Medical Publishers “Vesalius”, Kraków.
A. Kozierkiewicz, J. Klich. 1999. “Agreement – Management Contract” (Umowa - Kontrakt
Menedżerski), Zdrowie i Zarządzanie, , Volume I, No. 1.
Z. Król. 1999. “Further Transformations of Autonomous Health Care Establishments” (Dalsze
Przekształcenia Samodzielnych Publicznych Zakładów Opieki Zdrowotnej, Zdrowie i
Zarządzanie), , Volume I, No. 5.
P. Swianiewicz. 2002. “Local Taxes in the System of Financing of Tasks of Local Governments
– Theoretical Topics and Practice of Schemes in Poland and in European countries” (Podatki
Lokalne w Systemie Finansowania Zadań Samorządów – Zagadnienia Teoretyczne i Praktyka
Rozwiązań w Polsce oraz w Krajach Europejskich), Samorząd Terytorialny, , no. 12.
A. Wojtyna.
2000.
“Decentralization of Public Finance” (Decentralizacja Finansów
44
Publicznych), Gospodarka Narodowa, , No. 7-8
45
Annex 1
MODEL OF GENERAL HEALTH INSURANCE
no model
Preparation of
changes
draft laws
Reform
Of general
health
insurance
- property
- management
- financing
Position o
as
a
CHANGE
Implementation
of change
MODEL
(EX POST)
Role of p
Links bet
care syste
Control a
process
46
Annex 2
QUESTIONNAIRE WITH RESPONSES: MANAGERS
Questionnaire for Managers of Health Care Facilities
Introduction:
Dear Mr/Ms Manager,
We are conducting the study of decentralization in Polish health care. This study will
describe, assess and evaluate the impact of decentralization in the health sector –
particularly insofar as it relates to governance and accountability.
We define governance as the manner in which governments discharge their
responsibilities, particularly insofar as it relates to effectiveness in delivery of public
programs, overall transparency of operations, and general conformance with
internationally accepted good business practices. Governance will be measured in terms
of such qualitative indicators as: (i) the nature, type and level of regulation of the health
insurance funds and health facilities; (ii) implicit and explicit policies and actions related
to informal payments in the health sector, particularly in public facilities and involving
public health personnel; and (iii) nature and level of economic and financial management
and guidance for health insurance funds and health facilities. Similarly, we define
accountability for the purposes of this study is defined in qualitative terms by such
indicators as (i) adoption of such policy instruments and strategies as ensure that health
services are produced and delivered so as to meet the ultimate objective of improving the
health status of the people; (ii) financing and organizing health services in such a way so
as to ensure universal access to health services for all; and (iii) adoption of such business
practices as are deemed acceptable in the utilization of public funds.
In this study we want to capture the changes that occurred in Poland in the last few years
following the enactment of major Acts and Regulations, such as: health facilities act from
1991, big cities reform from 1995, public administration reform from 1999, health
insurance reform from 1999 and their impact on your health care facility.
Questions:
When did your institution become independent?
If in year 1999, please respond to the following questions. If before 1999, we would
request you to make a distinction on how the independence that happened before 1999
influenced your institution along the following dimensions and what was the impact of
administrative and health insurance reforms on your institution as far as these areas are
concerned.
Governance
47
1. How would you describe the nature and extent of autonomy that you have in
managing your institution? In responding to the above, could you please refer to
autonomy with respect to personnel and financial management, procurement of
goods and services and day-to-day governance?
2. What was the nature of the autonomy before the “official” independence?
3. Could you please give some examples of the decisions that you are presently
making yourself or within your institution?
4. Could you please give some examples of the decisions for which you need
clearances from outside the institution?
5. From where do you need to get these clearances?
6. What is de jure and de facto role of the advisory board?
7. Who are the members of the advisory board?
8. Who performed these functions before your facility became independent?
9. Did the 1999 administrative reforms have any influence on the role of advisory
board?
10. How often does the advisory board meet?
11. What issues are typically discussed during the advisory board meetings?
12. Can you request for an advisory board meeting if there are any urgent matters to
be discussed?
13. In your opinion, what are the benefits and pitfalls of this kind of the advisory
body?
14. Besides the advisory board, your facility also has a management board. In your
opinion, what is the role of the management board?
15. What is the structure of the management board?
16. Are the members of the management board salaried or on managerial contracts?
17. Before independence, what was the structure of the managing body?
18. What was the influence of the 1999 administrative reforms on the structure of
your institution management?
Human Resources Management
The next few questions relate to Human Resource Management in your institution.
19. As you know, before independence, the number of FTE employed in health care
institutions was predefined. Has this changed after independence, de jure and/or
de facto?
20. What procedures are currently followed in personnel hiring? How has this
changed since independence?
21. Who makes the decision to hire particular individuals? How has this changed
since independence?
22. Are there any externally imposed limits in number of staff and the structure of the
personnel? Did these limits exist before independence?
23. If yes, what are these?
24. And who sets them?
25. What are the procedures of firing the personnel? How has this changed since
independence?
26. Who makes the decision to fire particular individual? How has this changed since
independence?
48
27. Do you have to consult these decisions with trade unions? Has this practice
changed since independence?
28. Is there any role for the public in defining who would be employed in or fired
from your institution? For example, would you consider patient satisfaction
surveys or any other tools examining public opinion in your decisions regarding
the personnel?
29. Who decides salary and payment levels? Who decided them before
independence?
Financial Management and Procurement
Let me know shift to questions related to financial management and inputs management/
procurement in your institution. As you know there are a number of financial instruments
that support management decisions. I would like to ask you about the practice of financial
management in your institution.
30. As you know, the basis for the proper financial management is a well-prepared
budget. Does your facility currently prepare a budget? Did it prepare a budget
before independence?
31. Does your budget need to be approved by someone? If yes, by whom?
32. How has the practice of making the budget changed after independence?
33. What are the new elements of the budget now compared to before independence?
34. How do you monitor implementation of the budget?
35. What actions do you take if actual expenditures vary significantly from the
budget?
36. Can you plan for external sources of financing such as: loans, credits and leasing?
Does your facility plan for these?
37. Could you plan for these sources of financing before independence?
38. Is there any guarantee required from the owner or other party? If yes, from
whom?
39. What kind of financial statements do you prepare on regular basis (monthly, semiannually, annually)? What statements were prepared before independence?
40. Who approves them? Who approved them before independence?
41. Are these statements audited? If yes, how often?
42. Were these audited before independence?
43. In your opinion, has the nature of audits changed since independence?
44. If you have an end-year surplus, can you reallocate it in any manner?
45. If so, do you need any external clearances?
46. Prior to independence, could you retain and allocate surpluses, if any, in any
manner?
47. Following independence, who is responsible for facility debts?
48. Who was responsible before independence?
49. Who makes decisions on allocating resources across services and expendituretype? Who made these decisions before independence?
50. Who makes decisions regarding procurement of goods and services? Who made
these decisions before independence?
51. Do you plan for supplies and stocks in your institution?
49
52. Did you plan for them before independence? Was that planning any different? If
so, in what respect?
53. Who makes decisions regarding procurement of fixed assets? Who made these
decisions before independence?
54. Do you have any investment plans?
55. How are these investment decisions made?
56. Is the basis for investment decisions different from before the independence?
Strategic planning
57. As you know one of the requirements of independence for the health facility is the
preparation of the strategic plan. Does your institution have a strategic plan?
58. Who prepared it?
59. Was a strategic plan required before independence?
60. If not, did your facility have one nevertheless?
61. Since independence, did you modify your strategic plan?
62. Does your institution follow this plan?
63. Could you please give examples of few goals set by the strategic plan that you are
currently implementing?
Ensuring patient rights and improving access to health care
64. Do you currently have frequent meetings with community leaders, patient
representatives, society members etc.? Did you have these meetings before
independence?
65. Does your strategic plan reflect the health services requirements of the people in
the community that you serve?
66. Has this in any way changed the service mix that your facility provides? If yes,
could you please give a few examples of this change?
67. Does your institution currently have a unit or person dealing with patient
questions and complaints?
68. Did such an arrangement exist before independence?
69. How many complaints did you receive last year?
70. How many complaints did this facility receive in the year before it became
independent?
71. If there is a significant difference, what do you think is the reason?
72. What other recourse does the patient currently have if you did not deal with
his/her complaint satisfactorily?
73. What recourse did the patient have prior to independence?
74. Has your facility ever been sued by the patient/family before independence? After
independence??
75. Is the facility insured against malpractice? Did this insurance exist before
independence?
76. Since independence, has there been a change in the time that a patient has to wait
before getting health services? If so, what is the nature and extent of this change?
77. There is evidence of widespread informal payments in Poland. Are you aware of
incidents of informal payments within your institution and to any health personnel
working in your facility?
50
78. Can you give examples of actions that you have taken when you have been
informed about informal payments being accepted by any of your staff?
79. In your opinion, has the prevalence of informal payments changed since
independence? If so, what has been the nature and extent of this change?
Proposed health care reforms
80. As you know the current Government has just announced the strategy for health
care reforms that includes the consolidation of Sickness Funds into one Health
Fund, unification of the contracting rules and provider payment methods, and
creation of the public hospital network. Do you think these changes will have any
impact on your institution? If yes, what?
51
Annex 3
QUESTIONNAIRE WITH RESPONSES: LOCAL GOVERNMENTS
Questionnaire for Local Governments
Introduction:
Dear Mr/Ms Director,
We are conducting the study of decentralization in Polish health care. This study will
describe, assess and evaluate the impact of decentralization in the health sector –
particularly insofar as it relates to governance and accountability.
We define governance as the manner in which governments discharge their
responsibilities, particularly insofar as it relates to effectiveness in delivery of public
programs, overall transparency of operations, and general conformance with
internationally accepted good business practices. Governance will be measured in terms
of such qualitative indicators as: (i) the nature, type and level of regulation of the health
insurance funds and health facilities; (ii) implicit and explicit policies and actions related
to informal payments in the health sector, particularly in public facilities and involving
public health personnel; and (iii) nature and level of economic and financial management
and guidance for health insurance funds and health facilities. Similarly, we define
accountability for the purposes of this study is defined in qualitative terms by such
indicators as (i) adoption of such policy instruments and strategies as ensure that health
services are produced and delivered so as to meet the ultimate objective of improving the
health status of the people; (ii) financing and organizing health services in such a way so
as to ensure universal access to health services for all; and (iii) adoption of such business
practices as are deemed acceptable in the utilization of public funds.
In this study we want to capture the changes that occurred in Poland in the last few years
following the enactment of major Acts and Regulations, such as: health facilities act from
1991, big cities reform from 1995, 1999 Public Administration Reform, health insurance
reform from 1999 and their impact on your health care facility.
Questions:
When did you take a responsibility for health care? If before 1999, we would request you
to make a distinction on how did you perform you responsibilities before 1999 and after
the 1999 Public Administration Reform.
Governance
1. What is the nature of your involvement in health care sector?
52
2. What was it before 1999 Public Administration Reform (and Big Cities Act where
applicable)?
3. Could you please give some examples of your tasks as a local regulator of the health
care now?
4. Could you please give some examples of similar tasks from before 1999
administrative reforms (and Big Cities Act where applicable)?
5. What is the structure and responsibilities of health care authorities within the local
government?
6. What was it before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
7. If there is any, how often does the Health Care committee meet?
8. What was it before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
9. By the law, local governments are responsible for local health policies. Could you
please give few examples from your government of recent policy decisions that you
have taken?
10. What was the situation before 1999 Public Administration Reform (and Big Cities
Act where applicable)?
11. Local government as the founder and owner of the health care facilities has rights to
monitor and control the health care facilities performance. How often do you monitor
health care facilities performance?
12. How often did you monitor these facilities before the 1999 Public Administration
Reform (and Big Cities Act where applicable)?
13. Did introduction of the health insurance cause any change in your monitoring
practices?
14. Could you give any examples of your decisions related to health priorities setting in
the recent years (after 1999)?
15. Could you give any examples of your decisions related to health priorities setting
before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
16. Does the Local government decide what health priorities to invest in?
Health care management and strategic planning
17. Does your local government have a strategic plan for the health care sector?
18. Did you have such a plan before 1999 Public Administration Reform (and Big Cities
Act where applicable)?
19. What is the role, if any, that the local government has in day-to-day operations
performed by health facilities?
20. What role did it have before the 1999 Public Administration Reform (and Big Cities
Act where applicable)?
21. Did introduction of the health insurance cause any change in your involvement in
day-to-day operations performed by health facilities?
22. As you know, the law requires that the local government prepare plan for primary
care/specialist care/hospital services delivery. Do you prepare the plans?
23. How often do you update the plans?
53
24. Have you prepared them before the 1999 Public Administration Reform (and Big
Cities Act where applicable)?
25. Does the local government determine the structure of the health institutions budget?
26. How was it before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
27. Do you require regular reports from the health care facilities? If yes, how often and
what is their nature?
28. How was it before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
Ensuring patient rights and improving access to health care
29. What is the role, if any, that the local government has in protecting patient rights, and
responding to patient needs?
30. How was it before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
31. Does your government currently have a unit or person dealing with patient questions
and complaints?
32. Did such an arrangement exist before the 1999 Public Administration Reform (and
Big Cities Act where applicable)?
33. How many complaints did you receive last year?
34. How many complaints did this government receive in the year before the 1999 Public
Administration Reform (and Big Cities Act where applicable)?
35. If there is a significant difference, what do you think is the reason?
36. What other recourse does the patient currently have if you did not deal with his/her
complaint satisfactorily?
37. What recourse did the patient have prior to the 1999 Public Administration Reform
(and Big Cities Act where applicable)?
38. There is evidence of widespread informal payments in Poland. Are you aware of
incidents of informal payments within your local government operations?
39. Can you give examples of actions that you have taken when you have been informed
about informal payments being accepted in any of the institutions reporting to you?
40. In your opinion, has the prevalence of informal payments changed since 1999 Public
Administration Reform (and Big Cities Act where applicable)? If so, what has been
the nature and extent of this change?
Improving health status of the population
41. As you know one of the main roles of the local government in the area of health care
is to support development and implementation of the health promotion programs. On
average what percent of your budget for health care do you spend on health
promotion?
42. What was the situation before the 1999 Public Administration Reform (and Big Cities
Act where applicable)?
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43. Can you give examples of the health promotion programs financed from your budget
now and before the 1999 Public Administration Reform (and Big Cities Act where
applicable)?
44. Does your local government determine the services mix- scope and type of services
provided in your area?
45. What was the situation before the 1999 Public Administration Reform (and Big Cities
Act where applicable)?
46. Could you please give examples of the services that you included in your plans for
health services delivery, that are of an important nature to your area residents?
47. Could you also give examples of such services before the 1999 Public Administration
Reform (and Big Cities Act where applicable)?
Proposed health care reforms
48. As you know the current Government has just announced the strategy for health care
reforms that includes the consolidation of Sickness Funds into one Health Fund,
unification of the contracting rules and provider payment methods, and creation of the
public hospital network. Do you think these changes will have any impact on your
institution? If yes, what?
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Annex 4
QUESTIONNAIRE WITH RESPONSES: SICKNESS FUNDS
Questionnaire for Sickness Funds
Introduction:
Dear Mr/Ms Director,
We are conducting the study of decentralization in Polish health care. This study will
describe, assess and evaluate the impact of decentralization in the health sector –
particularly insofar as it relates to governance and accountability.
We define governance as the manner in which governments discharge their
responsibilities, particularly insofar as it relates to effectiveness in delivery of public
programs, overall transparency of operations, and general conformance with
internationally accepted good business practices. Governance will be measured in terms
of such qualitative indicators as: (i) the nature, type and level of regulation of the health
insurance funds and health facilities; (ii) implicit and explicit policies and actions related
to informal payments in the health sector, particularly in public facilities and involving
public health personnel; and (iii) nature and level of economic and financial management
and guidance for health insurance funds and health facilities. Similarly, we define
accountability for the purposes of this study is defined in qualitative terms by such
indicators as (i) adoption of such policy instruments and strategies as ensure that health
services are produced and delivered so as to meet the ultimate objective of improving the
health status of the people; (ii) financing and organizing health services in such a way so
as to ensure universal access to health services for all; and (iii) adoption of such business
practices as are deemed acceptable in the utilization of public funds.
In this study we want to capture the changes that occurred in Poland in the last few years
following the enactment of major Acts and Regulations, such as: health facilities act from
1991, big cities reform from 1995, 1999 Public Administration Reform, health insurance
reform from 1999 and their impact on your health care facility.
Questions:
Governance
1. Who is responsible for day-to-day administration in your Sickness Fund?
2. Who takes strategic decisions on such issues as contracting, services
contracted, reimbursement, etc.?
3. We believe that all Sickness Funds have a Management Board and Sickness
Fund Councils. The roles of both these are defined in the Health Insurance
Act. In your Sickness Fund and in your opinion, what are the real
responsibilities and power of the Management Board and the SF Council?
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4. What issues are typically discussed during meetings of the Management
Board and Sickness Funds Council? Could you please give a few examples of
these?
5. For what issues do you have to take prior clearance from the Sickness Funds
Council? Could you please give a few examples of these?
6. For what issues do you have to take prior clearance from the Management
Board? Could you please give a few examples of these?
7. Can you request for Sickness Funds Council meeting if there are any urgent
matters to be discussed?
8. What is the de facto and de jure role of UNUZ in the day-to-day
administration of the Sickness Fund?
9. What is the de facto and de jure role of UNUZ in strategic decision-making of
the Sickness Fund?
10. For what issues do you have to take prior clearance from UNUZ? Could you
please give a few examples of these?
Strategic planning
11. Does your Sickness Fund have a strategic plan for the health care sector?
12. What is the role, if any, that the Sickness Fund has in day-to-day operations
performed by health facilities?
13. Does the Sickness Fund determine the structure of the health institutions
budget de jure and de facto?
14. Do you require regular reports from the health care facilities? If yes, how
often and what is their nature?
15. Are you required to submit regular reports to any external agency? If so, what
kinds of reports and to whom?
Ensuring patient rights and improving access to health care
16. Sickness Fund as a financier of the health care services has rights to monitor
and control the health care services quality and access to health care services.
How often do you monitor it?
17. Could you please give few examples of the actions that you have taken
recently when the results of the monitoring of patients’ access to health
services were not satisfactory to you?
18. In your opinion, how does your Sickness Fund ensure quality of health
service?
19. Do you encourage or demand any quality assurance assessments and patients’
satisfaction surveys?
20. Do you have frequent meetings with community leaders, patient
representatives, society members etc.?
21. Does your strategic plan reflect the health services requirements of the people
in the community that you serve?
22. Has this in any way changed the service mix that your Sickness Fund
finances? If yes, could you please give a few examples of this change?
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23. Does your institution currently have a unit or person dealing with patient
questions and complaints?
24. How many complaints did you receive last year?
25. What other recourse does the patient currently have if you did not deal with
his/her complaint satisfactorily?
26. Do you have any regulations that you impose upon the provider related to the
time that a patient has to wait before getting health services?
27. There is evidence of widespread informal payments in Poland. Are you aware
of incidents of informal payments within providers that you finance?
28. Can you give examples of actions that you have taken when you have been
informed about informal payments being accepted by any of those providers?
Improving health status of the population
29. As you know one of the main roles of the local government/voivod in the area
of health care is to support development and implementation of the health care
programs. To what extent do you use those programs in your decision on
financing health services?
30. Could you give few examples of situation when you did not use the
recommendation of the voivod health program and financed other services?
31. Do you determine the services mix- scope and type of services provided in
your area?
32. Could you please give examples of the services that you financed last year,
that are of an important nature to your area residents?
Proposed health care reforms
33. As you know the current Government has just announced the strategy for
health care reforms that includes the consolidation of Sickness Funds into one
Health Fund, unification of the contracting rules and provider payment
methods, and creation of the public hospital network. Do you think these
changes will have any impact on your institution? If yes, what?
58