It’s 4 weeks since I arrived in Krakow, Poland, on a 5-week
field trip that represents the culmination of year 1 on the MSc Global Health
programme.
Having been offered the opportunity to travel to either
Tanzania or to Poland, I elected to come here to Krakow. The decision, in
hindsight, wasn’t that difficult. In 2010/11 I spent some time working in
Gambia and Kenya, I loved living both and am sure I will return at some point
in the near future. So there is
perhaps a sense of irony - with Poland being less than 2 hours flight from
Copenhagen – that I felt this may be one of my only opportunities to come and
explore and work in a Central European country.
During the 5 weeks I’m based at Jagiellonian University, one
of the oldest Universities in Europe with a rich and proud heritage, I was even
fortunate enough to be here for their 650th
anniversary. My main academic interest on arriving here was to delve into
the world of a post communist health care system and discover the journey that
Polish health care has been on over the past 23 years.
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| Collegium Novum Kraków |
Brief history of Polish health care
Up until the late 1980s the polish health care system was largely based on
the Semashko model, a heavily centralised system driven by the value ‘free
health care for all’. While in principle it’s difficult for anybody to argue
against that value, the system during the communist era was vastly underfunded
with under the table payments common place for those wishing to access
services. At this time, emphasis was placed on in-patient hospital care, little
attention was paid to primary or secondary prevention, which further compounded
the issues of under funding. A
further issue with the system was the vertical nature of programmes, with limited
integration of services. For example children’s,
adults and women’s health were organised within separate clinics, and
co-morbidities were often not treated in conjunction.
With the fall of communism the Polish health care system
underwent major transformation and restructuring. Service delivery was largely
decentralised, with the administration of services moving from a national level
to regional levels. The financing mechanism until around 1999 was largely the central
budget, while after this date mandatory insurance contribution linked to the
labour market took over. These contributions currently stand at 9%, however,
they were originally intended to reach 12%, and thus there is clearly a large
gap in the intended and actual income. At present there is only one
administrator of funds, the National Health Fund (NHF) that collates
contributions from all 16 regions (voivodeships) and then reallocates this back
to regional NHF offices. There is are currently political murmurings about the
need to decentralise the NHF allowing more autonomy at the regional level, Which could result
in a system that looks similar to the clinical commission groups used in the
NHS in England. Although at present it seems like this is some way off.
Moving forward; challenges and opportunities
A number of key things have stuck me during my time in
Poland.
We haven’t ended a single lecture or visit without the issue
of waiting times being mentioned in some context. It seems like this is an
issue that cut across the whole of the health care sector. The government has
been talking about cutting waiting times, particularly for oncology. In March
of this year the Minister of Health outlined some initial ideas, such as
cancelling limits on the number of oncological procedures and the introduction
of a cap on the time from a patient visiting their primary health care
physician to beginning treatment, this is currently proposed at 9-weeks.
However, the real dilemma is that no additional funds have been identified for
such activities. Which begs the question; where is the money coming from? The
simple (and most likely) answer seems to be, other clinical departments
budgets. Perhaps there is a suggestion that these reforms will bring efficient
savings that can cover the additional costs. Undoubtedly there are efficiency
saving to be made across the board, but this would likely take major
restructuring, and of course time. The current worry is that if oncology
becomes the key focus of the Polish government – and a flagship for the health
systems success – will this have negative consequences for other departments?
The second thing to make me sit up and think was a visit to
the Agency
for Health Technology Assessment in Poland (AHTAPol). The agency was only
launched in 2005, and now plays a critical role in the health system of Poland.
One of the main responsibilities is to make informed recommendations to the
Ministry of Health on what pharmaceuticals should be placed in the ‘guaranteed
basket’ of services. When services
are included in this basket patients should have free point of access care
which the service provider can then have reimbursed from the NHF. It wasn’t necessarily the agencies
current role or performance that got me thinking, but more the question; who
was doing this before? As far as could understand the simple answer was,
nobody. With pharmaceuticals such
an expensive element of any health acre system, having a regulatory body that
can decide what should be provided based on cost to benefit, in an impartial,
equitable and safe manner is essential. The role of agencies such as AHTAPol will be essential
in the coming years as the Polish health care system looks to control costs
while improving access and quality of services. Visiting the AHTAPol made me realise that certain core
elements of the current health care system are still relatively nascent, while
it also gave me a sense of positivity for the future with things are moving in
the right direction.
Final remarks
The factors I have mentioned here may in fact not be
particularly novel, the issues of financing and equity in access and quality of
care can be applied to all heath systems around the globe. As a health care system that has
undergone some major transformation over the past decades the Polish system is
one that perhaps needs some level of stability. Political commitment to
reducing waiting times is commendable, but only if it results in concrete
policies that ensure equitable utilisation, access and quality of care across
the board, which will inevitably need to be accompanied by the appropriate
funding mechanisms.
It has been an interesting and enlightening time in Poland. Krakow
has been a great city to spend time in and one that I can recommend to all!
Hope you enjoyed the read
Henry.
Reference:
The background for this piece came from lectures provided at
Jagiellonian University, Krakow and from visits to agencies and institutions
during the field trip. A general reference below can give more insights into
the Polish health system for those interested.
Paulina Pieprzyk. The polish health care system’s endless
journey to
Perfection – a never ending story ‘‘Social Transformations
in Contemporary Society’’, 2013 (1) ISSN
2345-0126 (online)
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