A cure for healthcare

The new Minister for Health has come up with a plan to cure the ailing health system that will see the creation of several new funds to rival the beleaguered NFZ. Critics say the new prescription will simply increase bureaucracy by creating more institutions, but the Minister insists it will increase efficiency through competition. Meanwhile, the private sector is waiting in the wings to roll out a range of private healthcare services that it hopes will replace the state system altogether.

He may have been on the losing side in the general elections, but Professor Zbigniew Religa has still managed to end up at the government top table.

Not only has he shed his party allegiances, he also wants voters to forget his pre-election promises now that he is firmly ensconced at the Health Ministry's helm. "Earlier, different things were said [and] that already belongs to the past. Now, we have a more important task to do - we want to create a good health system," he said.

If Minister Religa manages to reform the creaking health system, few will begrudge him a bit of amnesia. However, his reforms will be slow and steady, taking place over the next six or seven years, and whether Poles will have the patience for this remains to be seen.

Gradual approach

Under Religa's softly, softly approach, the National Health Fund (NFZ) will continue to operate for the next couple of years and will then be replaced by two or three independent funds.

Religa claims the NFZ is merely a substitute for true health insurance, as it only collects contributions for the health service, and suffers from poor organization and political dependence. Although these new funds will also be state-funded, Religa promises that they will be strong and competitive.

"It is similar to the competition between the Institute of Cardiology in Warsaw and the Silesian Center for Heart Diseases in Zabrze," the Minister says. "We want to do better, each manager wants to be better, so with the same money, with the same contributions, they want to offer better services." 

Supervisors needed

The president of the NFZ, Jerzy Miller, whom Religa considers a professional manager, has a similar opinion. He claims that the monopolistic position of the NFZ can only lead to inefficiency.

The healthcare service has an extremely complicated structure and in order to enhance its effectiveness and good management it needs proper instruments for information and analysis.

One example comes in the form of a suggestion from Marek Balicki - a former Health Minister - for the introduction of a medical technology assessment agency. A constant stream of new products, pharmaceuticals and equipment is flowing into the market, and there is no independent organization that examines which is the most effective and efficient. This assessment agency could tackle medical procurement and save the NFZ billions in the process.

"Such supervision would help the NFZ to operate well," says Professor Stanisława Golinowska from the Institute of Public Health Collegium Medicum at Jagiellonian University and a member of the Center for Social and Economic Research. However, she is less enthusiastic about Religa's new funds. "I can see no way two public funds can compete. [Will they have] different contributions and [offer] different quality of services?" 

Triple the price

Marcin Halicki, the president of the board at LuxMed and president of the Private Health Service Employers' Association, is also skeptical about competition between the new public funds. "National and public funds do not cause any changes except for additional costs. Instead of one president there will be three and the number of workers will be tripled. Each of them will have to contract the same services," he says. "The situation would be similar if we decided to divide the Social Security Institution (ZUS) into three institutions. I don't know why it would be better."

Miller says that at the moment the NFZ is able to manage itself. However, it enjoys the comfort of a monopoly. Miller is open to any solution that would enable equal access to medical services and will alter the current situation, but he would not comment on whether or not private funds should be allowed onto the market.

One of the main problems identified by Religa is that ZUS contributions are not effectively collected. "We need to base our health system on the contributions paid by each individual. [and ensure] everyone has access to the same services," he says. "If the economy grows, and unemployment decreases then the amount of money coming from the contributions will be bigger. If we only had a subsidy from the budget, it would be constant throughout the year."

Dr Katarzyna Tymowska, from the Faculty of Economic Sciences at Warsaw University, questions the constitutionality of Religa's proposed new public funds. Article 68 of the Constitution says that citizens regardless of their economic situation shall be provided with equal access to health services financed from public resources. The contributions paid for the healthcare service is tax-like and cannot differ between patients. According to Tymowska, this means that competition between the new public funds will therefore be impossible because they must operate under the same conditions and none of them will ever lose because the weaker fund will always receive financial support from the budget. 

Prevention is better than cure

For the moment, Religa claims that contributions paid by citizens will remain and during the next two years the Ministry will create a packet of guaranteed services. On the one hand, this would ensure that the state's obligations are met and, on the other, room would be made for other systems, including private schemes. "The procedure of creating the packet is difficult on account of politics and lobbying," says Golinowska, "but it is much easier if the Ministry has well-developed instruments for information and analysis," such as the previously mentioned medical technology assessment agency.

According to a recent survey conducted by the National Trade Union of Doctors, patients would be willing to pay extra for this packet of services, but it must include all possible and effective methods of treatment and services. At the same time, Golinowska would like to see the health service nip most problems in the bud, and the government should fund frequent check-ups for the population and campaigns that promote a healthy lifestyle. This 'prevention is better than cure' approach could free up a lot of healthcare services and resources.

Once the packet of guaranteed services has been created, supposedly within four years, Religa intends to allow new voluntary and alternative health insurance firms onto the market to stimulate competition.

Krzysztof Bukiel, the president of the National Trade Union of Doctors, supports the decentralization of the health service. However, he is concerned that private funds and insurance companies may favor young patients who are less likely to take advantage of health services.

Religa rejects this, and says it will not be possible for an insurance company to favor younger people. Each person, regardless of age, will have the right to buy insurance. "Whether such conditions are acceptable for the insurance companies, I don't know," he adds.

Corrupt practices

Corruption is endemic in the healthcare system, and patients are often willing to grease the wheels of bureaucracy with cold, hard cash, rather than wait weeks or months for an appointment with a specialist or an operation. According to the last Green Book of Finances, which is a survey of healthcare conditions in Poland conducted by the Ministry of Health, the average Polish family spent zł.6.63 per month on bribes for healthcare in 2003. That makes almost 15 percent of their total expenditure on healthcare for the same year. Additional private insurance is one way to re-direct the money spent on healthcare in a legal way.

However, not all healthcare providers are waiting for the government to point them in the right direction. Last week Signal Iduna announced that it would introduce a new form of health insurance that will cover the cost of ambulance services and hospital treatment (see News, page three).

In the private sector it is the survival of the fittest that counts. Minster Religa will be hoping the same is true of his new healthcare funds.