|Law on Health Benefit Basket|
|Implemented in this survey?|
Following the concept of the guaranteed health services basket, implemented by the amendment to the law, the MoH introduced a decree on Primary Health Care (PHC) services. A shortened time of access ? overnights and on weekends ? was approved as a rule for contracts between the payer and providers, together with a narrowed scope of competences attributed to PHC, increasing demand for specialist care. Advantages for one side, the PHC-providers, may prove to be rather dissatisfying for the other.
The recent decision concerning the decree on Primary Health Care (PHC) resulted from two lines of developments.
Firstly, it originated from the Government's and the MoH's efforts to improve the performance of health care. Coming to power in late 2007, the government developed many ideas for health care reform. The initiatives led to many bills - a package of laws - which were submitted to the parliament in early 2008, underwent the parliamentary procedure, were passed by two houses, but vetoed by the president. To keep the momentum of the reform, the MoH prepared a law on amending the Law on Health Care Services Financed from Public Sources - it was the idea of the health services basket. The MoH managed to get support from all authorities and the law went into force.
Secondly, it came from an evolving concept of PHC. Originally, PHC - and especially family medicine - was presented as an universal remedy ready to solve almost all problems the system was facing in the past. Unfortunately, under pressure of many circumstances, the concept degenerated and the damaged figure was petrified in the decree (see below).
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
In previous reports, the problem of PHC has not been raised so no evaluation has been expressed.
It should be emphasised that one of the essential problems - the role of PHC - was not solved by the law passed by the parliament, but by ministerial decree. Usually parliamentary debates are published that open the insight for the general public. Undoubtedly, patients are very much concerned with the rules regulating access to PHC and range of services provided at this level of the system.
|Implemented in this survey?|
Very first suggestions to enhance the role of PHC were voiced as early as in the beginnings of the eighties, together with first reports presented by the social movement "Solidarnosc". They were developed afterwards, being one of the prevailing topics during the Round Table talks. After a political breakthrough in 1989, in early phases of reform, PHC was believed to be a leading force of improvements and family doctors were propagated as potential leaders of progress. Due to their involvement, it was to be possible to run the system in a more rational way seeking savings in reduction of unnecessary ambulance services and emergency care provided overnight and on weekends.
Later on, it turned out that the co-operation between the payer (National Health Fund - NFZ) and PHC providers was difficult. A conflict referred mostly to questions of 24 hours availability of services and availability on Saturday mornings: providers intended to eliminate these obligations, NFZ tried to impose them. In a response, providers decided to set up an alliance (Porozumienie Zielonogorskie - PZ) to represent their common interests. The alliance has become an association of medical providers, active especially in primary health care, and family physicians. After months of fierce negotiations - that began in 2004 - the NFZ gave up and the PZ could announce the victory. It added a lot of prestige to the alliance, which has continued to fight in defense of its member's vested interests. Because of the position adopted by the PZ - and weaknesses of the NFZ - many potential benefits promised at commencements of the reform have found themselves in danger. Apparently, the agreement once achieved had a primordial impact on the decree finally adopted.
|MoH||very supportive||strongly opposed|
|MoF||very supportive||strongly opposed|
|Health Commission||very supportive||strongly opposed|
|Family doctors||very supportive||strongly opposed|
|PZ members||very supportive||strongly opposed|
|Other providers||very supportive||strongly opposed|
|NFZ (National Health Fund)||very supportive||strongly opposed|
|Private insurers||very supportive||strongly opposed|
|Local governments (large)||very supportive||strongly opposed|
|Local governments (small)||very supportive||strongly opposed|
|PHC patients||very supportive||strongly opposed|
|Other patients||very supportive||strongly opposed|
|Private Sector or Industry|
|Most of family physicians||very supportive||strongly opposed|
|Specialists||very supportive||strongly opposed|
|The President||very supportive||strongly opposed|
|PO (Civic Platform)||very supportive||strongly opposed|
|PiS (Justice & Right)||very supportive||strongly opposed|
|PSL (Agriculture Party)||very supportive||strongly opposed|
|SLD (Social Democrats)||very supportive||strongly opposed|
The solution concerning PHC was an element of much broader issue - the basket of services guaranteed services to be financed by public sources. The Government raised this concept after having failed implementating a large "package of laws" containing many different mechanisms. Facing political opposition, it picked up the issue of the basket hoping to attract public attention. The concept passed a long way. First proposals to implement a basket were conceived as early as in the beginnings of the nineties. The basket was on the agenda of the former government, many huge documents were worked out but due to political barriers - disintegration of the coalition - the efforts failed. The efforts were renewed by the new government. When the parliament paved the way, the MoH was obliged to work out all necessary executive regulations. It fulfilled the task and published as many as 13 decrees - the one on Primary Health Care among the others. It should be emphasised that a change which had a very important significance for the patients was introduced by a decree, a rule of rather minor position among legal regulations.
|Health Commission||very strong||none|
|Family doctors||very strong||none|
|PZ members||very strong||none|
|Other providers||very strong||none|
|NFZ (National Health Fund)||very strong||none|
|Private insurers||very strong||none|
|Local governments (large)||very strong||none|
|Local governments (small)||very strong||none|
|PHC patients||very strong||none|
|Other patients||very strong||none|
|Private Sector or Industry|
|Most of family physicians||very strong||none|
|The President||very strong||none|
|PO (Civic Platform)||very strong||none|
|PiS (Justice & Right)||very strong||none|
|PSL (Agriculture Party)||very strong||none|
|SLD (Social Democrats)||very strong||none|
When the result of the decree was issued in autumn 2009, there were two occurrences.
Firstly, the concept of the health benefit basket was explicitly introduced into the Polish system, even if the practice of limiting scope of the services rendered to the people had been applied - by time consuming formal requirements and waiting time - nevertheless, for the first time it was officially proclaimed.
Secondly, the limited range of services rendered by PHC providers was maintained. The decree petrified gains previously acquired by PZ: the time of services was indicated between 8 a.m. till 6 p.m., five days per week (Monday- Friday). Other decrees made in the same time reduced competences attributed to PHC physicians, and many medical actions are now reserved for specialists.
New regulations petrified the situation already existing. As the outcome of earlier concessions to providers their duties had been substantially reduced. The payer - NFZ - proved to be short sighted as it gave up, causing losses for patients whose access is hampered now. The decree damaged many chances bonded in the past with the strengthened role played by PHC.
The regulations consolidated a situation that is advantageous for one side only - PHC providers. Because of that it was welcomed by them and implementation proved to be easy. However, it was disadvantageous for patients whose access is more difficult now than it used to be. The patients - who generally are rather dissatisfied with quality and performance of health care - will likely realise that soon. If so - a new wave of criticism will appear.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The outcome of the new regulation is unavoidably limiting access and increasing patients' dependency on specialists. It was against all efforts to make the system more rationally arranged.
1. Law on change of the Law on Health Care Services Financed from Public Sources and the Law on Prices, dated 25 June 2009, Journal of Laws No. 118, item 989.
2. Decree of the Minister of Health dated 29 August 2009 regarding guaranteed PHC services, Journal of Laws No, 140, item 1138.
|Law on Health Benefit Basket|
Process Stages: Implementation, Legislation