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Law on health care units

Country: 
Poland
Partner Institute: 
Institute of Public Health, Jagiellonian University Medical College, Krakow
Survey no: 
(13) 2009
Author(s): 
Kowalska, Iwona
Health Policy Issues: 
System Organisation/ Integration, Political Context, Funding / Pooling, Quality Improvement, Benefit Basket, Access, Remuneration / Payment
Reform formerly reported in: 
Status of health care units - Project of Law
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Abstract

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.

Recent developments

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:

  • According to the new legislation on health care units, the transformation of state-owned health care units (spzoz) into companies governed by the provisions of economic law (limited liability companies or joint-stock companies) is obligatory. All state-owned units which are not going to transform their legal status until the 1st of February 2011 will be liquidated;
  • According to the draft law on health care units prepared by the MoH, buildings and the land were to be handed over to the new companies. As a result of strong criticism to this idea during the parliamentary discussions and consultations, the parliament finally decided to change this regulation. Now the land can only be handed over in the form of leases.
  • The law on health care units still meets controversies. The main argument against it points out the many inadequate or even wrong concepts and legal solutions, e.g. the fact that responsibilities (liabilities) of interested stakeholders e.g. health care professionals are not defined precisely enough (eg. there is a lack of information about specific work conditions, about organizational structures, medical doctors working times etc.)
  • According to the new law, the proportion between the share of the State Treasury and other owners in the transformed health care units should aim at a minimum level of  51% of shares for the State (in case of clinical hospitals - 75% minimum).

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.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent strongly system-dependent system-neutral
current current   previous previous

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. 

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Initiators of idea/main actors

  • Government: The Minister of Health is extremely active concerning the planned changes in the healthcare sector: She initiates many discussions and consultations with different bodies and groups.
  • Parliament: The parliamentary health commission initiated the legislation process. The parliamentary grouping SLD (Social Democrats) had the strongest influence on the law.
  • Providers: Providers are still recognized as a unified group. However the positions within this group may differ depending on the legal status of the different health care units, on the specific financial situation and on the professional staff members within the group: managers, doctors, nurses and others.
  • Payers: All hospitals owned by companies or run by local governments have contracts with the NHF and they provide a very similar scope of services compared to the services offered by the previous SPZOZs (due to the similar scope of NHF contracts).
  • Patients, Consumers: The public perception, intensified by some political forces, could be described as the strong opinion that a change of legal status, from SPZOZ to non-public, automatically results in the unavoidable neccessity for out-of-pocket payments for services.
  • Scientific Community: The opinion of experts differs: some point out that there will be more difficulties resulting from the legal, political and fiscal consequences of the law implementation, some underline the neccessity of a radical change taking into account other important changes in health care in Poland like: benefit basket, additional health insurance etc.
  • Media: The media express great interest and often support for the changes proposed by the law.
  • Others: The poviat (local authorities) and voivodship (regional authorities) positions are still not clear. The law on health care units aims to avoid a situation in which changes initiated by healthcare units lacking any debt would be blocked by the political opposition at the local level.

Stakeholder positions

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.

Actors and positions

Description of actors and their positions
Government
MoHvery supportivevery supportive strongly opposed
Prime Ministervery supportivevery supportive strongly opposed
MoFvery supportiveneutral strongly opposed
Parliament
Parliamentary Health Commissionvery supportivevery supportive strongly opposed
Citizens' Platform (government)very supportivevery supportive strongly opposed
Social Democrats (opposition)very supportiveopposed strongly opposed
Right and Justice (opposition)very supportiveopposed strongly opposed
Providers
Health care unit managersvery supportivesupportive strongly opposed
Medical professionalsvery supportiveneutral strongly opposed
Other personnel (e.g. administrative staff)very supportiveneutral strongly opposed
Payers
NHFvery supportivesupportive strongly opposed
Patients, Consumers
Patientsvery supportiveopposed strongly opposed
Scientific Community
Public health professionalsvery supportivesupportive strongly opposed
Health economics specialistsvery supportivevery supportive strongly opposed
Lawyersvery supportiveneutral strongly opposed
Media
National mediavery supportivesupportive strongly opposed
Local mediavery supportivesupportive strongly opposed
Local authority
Regional authorities (voivodship level)very supportivesupportive strongly opposed
Local authorities (powiat level)very supportivesupportive strongly opposed
current current   previous previous

Influences in policy making and legislation

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:

  • voluntary transformation of the state owned units (spzoz) into limited liability companies or into joint-stock companies;
  • only local authorities or the State Treasury (in the case of clinical hospitals)  can hold the majority of shares (51%);
  • the newly established health care units should act as non-profit institutions. 

In the law on health care units the governmental Party (PO-Citizens Platform) backed out from the above described proposals and decided that:

  • the transformation of public hospitals (spzoz) into companies would be obligatory;
  • local authorities receive 100% of the health care unit capital and have the right to sell even 100% of shares.   

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.:

  • any public hospital acting in the form of e.l. company cannot refuse help in case of emergency;
  • the liquidation of hospitals acting in the new legal form or the decision on the sale of the majority of shares is valid only under the condition that the founding body (local authority) supports the change by a majority of 3/5 votes. There should also be the possibility of a local referendum in that case. 

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.

Legislative outcome

Rejection of bill

Actors and influence

Description of actors and their influence

Government
MoHvery strongvery strong none
Prime Ministervery strongvery strong none
MoFvery strongvery strong none
Parliament
Parliamentary Health Commissionvery strongvery strong none
Citizens' Platform (government)very strongvery strong none
Social Democrats (opposition)very strongneutral none
Right and Justice (opposition)very strongstrong none
Providers
Health care unit managersvery strongstrong none
Medical professionalsvery strongstrong none
Other personnel (e.g. administrative staff)very strongweak none
Payers
NHFvery strongneutral none
Patients, Consumers
Patientsvery strongnone none
Scientific Community
Public health professionalsvery strongneutral none
Health economics specialistsvery strongstrong none
Lawyersvery strongstrong none
Media
National mediavery strongstrong none
Local mediavery strongstrong none
Local authority
Regional authorities (voivodship level)very strongneutral none
Local authorities (powiat level)very strongneutral none
current current   previous previous
Health economics specialistsMoH, Prime Minister, Parliamentary Health Commission, Citizens' Platform (government)NHF, Public health professionals, Regional authorities (voivodship level), Local authorities (powiat level)Health care unit managers, National media, Local mediaOther personnel (e.g. administrative staff)Medical professionals, LawyersMoFPatientsSocial Democrats (opposition)Right and Justice (opposition)

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

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.

Monitoring and evaluation

At this stage no monitoring and evaluation instruments have been foreseen.

Expected outcome

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: 

  1. a fundamental recommendation would be to introduce a clause saying that transformations of SPOZs into commercial companies is voluntary
  2. the ownership of health care unit (hospital) property should be separated from the newly established company (ie. local authorities should stay the owners of the property).
  3. the SPZOZ liquidation process is the preferred method of organisational and legal transformation.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system less equitable system more equitable
Cost Efficiency very low neutral very high
current current   previous previous

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.

References

Sources of Information

  • The project of the law on Health Care Units from 27th of March 2008.  www.mz.gov.pl
  • Presentation of Jacek Klich, PhD, on the management disfunctions in health care units in the context of the project. Institute of Public Health, Jagiellonian Univerisity, Kraków, 2nd of April 2008.
  • Press, TV and radio comments on the "White Summit"
  • The Disscusion Forum on the project of the Law on Health Care Units from 27th of March 2008.
  • The law on health care units from 21st of October 2008.
  • The Study and Analysis Office. Opinion on health care units law project changes. Sejm, form nr 284, July 14, 2008.
  • Parliamentary Health Commission. Stenograms from the parliamentary discussion on the health care units project. 2008.

Reform formerly reported in

Status of health care units - Project of Law
Process Stages: Policy Paper

Author/s and/or contributors to this survey

Kowalska, Iwona

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.

Suggested citation for this online article

Kowalska, Iwona. "Law on health care units". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/pl/a13/4