|Status of health care units - Project of Law|
|Implemented in this survey?|
After wide discussions and debates on the situation in the Polish health care sector, the law on health care units, prepared by the parliamentary health commission together with MoH, was passed on October 2008. The proposed law was changed during the legislation process due to the lack of an agreement between the government and the parliamentary opposition. Finally the President vetoed the law. The presidential veto completely blocked the law implementation process.
On October 21st, a package of 5 health bills was passed by the Polish parliament. The package included the law on health care units; the law on patient rights, the law on national and regional consultants in health care; the law on accreditation in health care and the law on health care professionals particular rights. The main purpose of the proposed package of laws was to replace the old version of the health care units law from 1991 and to introduce new legal frames (ie. a new legal status) for the operation of health care units.
The major changes introduced to the policy concerning health care units during the parliamentary process are as follows:
The final draft of the law project was under the strongest influence of the parliamentary grouping SLD (Social Democrats) that on the one hand is part of the parliamentary opposition, but on the other hand constitutes the only potential supporter for the government in case of presidential vetos. The Polish political system requires a qualified majority of 3/5 votes (307/460) in order for laws vetoed by the president to be passed again.
The attitude of President Lech Kaczynski was also an important aspect in the political context. Lech Kaczynski announced his veto already at a very early stage of the legislation process. During the discussions concerning the health care units' formal status, he often used the argument that the proposed law would in fact be a legislation on hospital privatisation and he expressed his strong opposition against it. He also argued that such a process and its consequences would not be acceptable for most of the Polish population.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The proposed policy concerning the legal status of health care units is innovative for the Polish health system. It is also controversial because of the possibility of transforming SPZOZ (or liquidation if they don't change their legal status). Although this form of transformation is likely to give rise to opposition within the local community (including the personnel of SPZOZ) it still remains the only way to enable a fundamental change of the employment structure of the institutions. Infringement of this principle may cause a substantial risk: the newly established body (after the SPZOZ transformation) will continue to generate further losses and fall quickly into new debt, as a result it may have no financial liquidity. Unfortunately if the new companies do not find any private investors and will depend on the local authority, they could still have financial problems. The benefit of this transformation of SPZOZ into limited liability companies is that the local government has the right in the case of new debts to close hospitals operating as new companies. All this could subsequently lead to the implementation of another set of changes.
The impact on the system will in any case be fundamental (the implementation depends on systemic law and other important regulations).
The public visibility of the proposed changes is much higher now than at the stage of policy planning as a result of wide discussion on the subject initiated by the President and by the media.
|Implemented in this survey?|
During the whole legislation process there were many new stakeholders involved in the discussions and consultation on the law on health care units. The most important role in this stage of the policy had President Lech Kaczyñski who announced the presidential veto to the proposed law at the very first moment and promoted a national discussion on the issue of privatization of public health care units (spzoz - hospitals). He opted for a national referendum that would ask for the people's opinion on the reconstruction of public hospitals.
In such circumstances the patients' position has changed. According to media reports the common public perception is that the process would aim at a change that will lead to "payment for services necessity". This particular opinion was intensified by political forces (PiS and President), which stressed that privatisation of hospitals would immediately result in the establishment of an unequal system in which only rich people would be able to afford hospital's services.
The role of the parliamentary opposition was also very important at this stage of policy. The strongest influence on the final draft of the law proposal had the parliamentary grouping SLD (Social Democrats). SLD belongs on the one hand to the parliamentary opposition but they are also the only potential group of supporters for the government position in case of presidential vetos (the Polish political systemic rule is that in case of a law vetoed by the President, it can only be passed again with a qualified majority of 3/5 votes (307/ 460)).
The MoH was the main actor initiating and strongly supporting the described law. At the legislation level of this policy, the position of the Minister of Health in the government was much more stable. She became the deputy chair of the governmental party (PO) and the decisions were not controlled by the Prime Minister to such an extent as it was before.
Unfortunately the interest, position and influence of the scientific community, especially lawyers and public health professionals, has decreased. Lawyers in their expert opinions noticed many legal errors and doubts concerning the legal instruments and warned of unexpected legal effects of the proposed changes. A very differentiated set of opinions of experts can be observed at the moment.
|MoH||very supportive||strongly opposed|
|Prime Minister||very supportive||strongly opposed|
|MoF||very supportive||strongly opposed|
|Parliamentary Health Commission||very supportive||strongly opposed|
|Citizens' Platform (government)||very supportive||strongly opposed|
|Social Democrats (opposition)||very supportive||strongly opposed|
|Right and Justice (opposition)||very supportive||strongly opposed|
|Health care unit managers||very supportive||strongly opposed|
|Medical professionals||very supportive||strongly opposed|
|Other personnel (e.g. administrative staff)||very supportive||strongly opposed|
|NHF||very supportive||strongly opposed|
|Patients||very supportive||strongly opposed|
|Public health professionals||very supportive||strongly opposed|
|Health economics specialists||very supportive||strongly opposed|
|Lawyers||very supportive||strongly opposed|
|National media||very supportive||strongly opposed|
|Local media||very supportive||strongly opposed|
|Regional authorities (voivodship level)||very supportive||strongly opposed|
|Local authorities (powiat level)||very supportive||strongly opposed|
The original proposal of the health care units law has been fundamentally changed. In the draft law prepared by the MoH and given to Parliament three crucial elements were indicated:
In the law on health care units the governmental Party (PO-Citizens Platform) backed out from the above described proposals and decided that:
The Social Democrats (SLD) claimed that those provisions that represented a compromise had been removed from the law during the legislation process and, as a result, there is no possibility to vote upon the law.
Nevertheless some of the amendments raised by SLD have been accepted by the parliamentary majority e.g.:
Parliament unanimously decided to obey the rules on the minimal standards for the employment of nurses.
The second chamber of the Polish parliament specified the provisions concerning the decisions to be undertaken by the general meeting of the shareholders in cases where a sale of company shares would result in the loss of public ownership. It also supported the possibility to have a local referendum in the described cases.
In the final version of the law provisions concerning aspects of health care services advertisement, the management of public hospitals operating in the new legal form and on health care professionals were cancelled.
Rejection of bill
|Prime Minister||very strong||none|
|Parliamentary Health Commission||very strong||none|
|Citizens' Platform (government)||very strong||none|
|Social Democrats (opposition)||very strong||none|
|Right and Justice (opposition)||very strong||none|
|Health care unit managers||very strong||none|
|Medical professionals||very strong||none|
|Other personnel (e.g. administrative staff)||very strong||none|
|Public health professionals||very strong||none|
|Health economics specialists||very strong||none|
|National media||very strong||none|
|Local media||very strong||none|
|Regional authorities (voivodship level)||very strong||none|
|Local authorities (powiat level)||very strong||none|
The government showed strong determination to implement the new policy on health care units transformations. For this reason the MoH started to work on "plan B" of the policy implementation. The same goals (excluding only the controversial question of obligatory transformation of the legal status of health care units) will be presented and implemented pursuant to a new governmental resolution.
At this stage no monitoring and evaluation instruments have been foreseen.
It seems that the scale of the problems related to SPZOZ (ie. debts and mismanagement) as well as the experience of a number of restructuring cases have reached the point that does not allow to avoid radical changes. The organisational forms of public health care centres (SPZOZ), and in particular hospitals, have to be transformed on the basis of legislation. The problem is the scope and means of such a change, the identification of the desired direction and pace for a change. Financial and administrative support are necessary for the transformation process to work and are the main tasks of the authorities, specifically for the central Government and MoH itself. Significant and serious opposition to unavoidable changes is not likely to take place at this point of time, although political battles and conflicts of interest will probably arise. The public seems to be tired of this issue and probably not interested at the moment, but the media can influence the situation and bring interest back.
Based on the findings from the previous HPM report, the changes described in this report and having in mind also the different expert opinions, the overall assessment of the policy could be limited to the following recommendation:
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The planned changes in the new law on health care units are based on the assumption that the process will result in quality improvements. At the current stage the impact on equity and cost-efficiency cannot be judged unambiguously.
|Status of health care units - Project of Law|
Process Stages: Policy Paper
Dr Iwona Kowalska, lecturer in the Institute of Public Health, Medical College, Jagiellonian University. She graduated in Political Science at the Faculty of Law and Administration, Jagiellonian University. Her main areas of research are: health and social policy, European health policy and health care systems.