Crippled system
The government, however, balks at devoting more money to the system and opposes the idea of making the patients bear part of their healthcare expenses. While the two sides trade words, experts in the sector claim that the system needs reform, and fast, even if it means reaching into citizens' wallets
As the doctor's strike marched through its second straight week, Speaker of the Sejm Ludwik Dorn accused the representatives of the protesting physicians of trying to "press the government for the commercialization and privatization of the health sector." In response to this perceived pressure, Dorn proposed holding a national referendum on the issue.
The chairman of the Doctors' Trade Union of Poland (OZZL), Krzysztof Bukiel, dismissed the idea as "not serious," and suggested that it's "aimed at humiliating the doctors." An alternative interpretation is put forth by the Adam Smith Center's healthcare expert, Dr Wojciech Misiński, who thinks that the government would hold such a referendum with the aim of scaring ordinary people. "[The government] is telling the people that once the healthcare is private, they will have no access to it," he said.
Free-market freedom
But while the government is making a political bugbear out of health-sector privatization, experts claim that introducing some kind of free-market rules could save the public-healthcare system from collapsing. "If we had held a referendum about privatizing banks and enterprises at the beginning of the 1990s, we would still be stuck in communism," Misiński summed up.
Bogdan Zacharski, a Business Centre Club expert on healthcare issues, favors commercialization of the system. He explained that by "commercialization," he meant "accepting the rules and regulations which enterprises are subject to."
"Healthcare institutions need to start acting like normal enterprises, though they still must fulfill a mission not only maximise profits," Zacharski remarked.
Nowhere is the need to commercialize the sector more apparent than in the case of the independent public healthcare institutions (SPZOZs) which encompass most of the country's large hospitals and medium-sized clinics. As Zacharski explained, SPZOZs have founders but they do not have owners, and the founders do not fully face the consequences of bad management. This has led to massive indebtedness among the SPZOZs.
Zacharski thinks that setting up a clear ownership structure could help remedy the situation. "They would be 100 percent responsible for their own decisions," he said.
Private hopes, public fears
Misiński also thinks that hospitals should be transformed into entities subject to commercial law, but sees that as a first step. In fact, he would like to see the process extended to privatization. "But we have to keep in mind that the healthcare system has a mission to fulfill," he says. For this reason, he thinks that the system should be privatized by institutions rather than individuals - by banks, investment funds, pension funds and so on. "This would be a safer model," Misiński claims.
Tadeusz Cymański, a Law and Justice (PiS) deputy and member of the Sejm Health Committee, is afraid that wide-scale privatization of the healthcare sector could limit many people's access to medical services. "There are a number of people who are subsidized under the current system. Without [subsidies] - if everything was private - they wouldn't be able to afford to go to the doctor," Cymański said. "Those services would be available, but unaffordable," he concluded.
OZZL's plan to reform the healthcare system, apart from the commercialization of medical centers and hospitals, would introduce payments for medical services. Some services - including the most expensive, complicated and critical ones - would be available free of charge in a basket of guaranteed services. Others would be free for a certain standard of service and if the patient wanted any higher standard he would have to pay the difference either from his own pocket or through supplementary private health insurance.
"It's up to us to decide if we want the standard version or if we want to pay some additional money for a better standard," Misiński explains. OZZL's plan also stipulates that, in case of some services, the patient would also need to cover some expenses out of pocket if the amount of money in the system was insufficient.
The plan also wants to break the National Health Fund's (NFZ) monopoly and introduce other players to manage health premiums. Currently each hospital individually negotiates its budget with the NFZ, the size of which determines the number and kind of procedures and services it can offer. OZZL's plan looks to eliminate these limits, which today result in waiting periods of many months.
Government proposal
At the end of the month, Minister of Health Zbigniew Religa is to announce his own proposal to partially commercialize health services. This long-in-the-making proposal, however, has been much watered down from its original form and experts see the government's overcautious hand in it.
"The Ministry of Health needs to be very careful in order not to hurt many people," Cymański said. "To many it would be a tragedy if the guaranteed-services basket was limited," he explained.
OZZL's Bukiel doubts that the proposal will be effective, especially considering the government's aversion to payments from the patients' side. "The basket will be a list of what is potentially, but not actually available," according to a polemic Bukiel authored on OZZL's website.
Prime Minister Jarosław Kaczyński is an ardent opponent of the idea that patients should bear some costs of medical services. "This is an idea aimed at reaching for the pocket of ordinary citizens," he has stated, adding that the retired and young families with children would find the costs particularly painful.
Misiński has some reservations as to whether Religa's proposal will be coherent. He points out that in order for the basket of guaranteed services to work, the methodology of medical standards as well as the standard costs need to be set. That would tell the patient what standard of services was available for free as well as the cost and details of higher standards of care. "This [methodology and cost-setting] hasn't been done," Misiński claims, based on his knowledge of the proposal's development. "Without this the basket has no logical sense," he adds.
The money factor
The root of the problem - from which the idea of patient co-financing stems - is the simple lack of money in the NFZ. Cymański says that the system's limited funds are a problem which affects both doctors' wages as well as the availability of medical services. "Our premiums are low even in comparison to neighboring countries," Cymański said. But he acknowledges that this is a delicate and controversial issue. "There would be an uproar of discontent if an increase in healthcare premiums was announced," he predicts.
On the other hand, Misiński claims that there are a number of people who "overuse" the system, going to the doctor frequently and not always when necessary. "Those people would think twice about going again if they had to pay for it," he argues.
While the politicians are telling people that they will not make them pay for medical services, the experts point out that people are in fact already paying for healthcare. Zacharski notes that while government healthcare-related expenses amounted to zł.37 billion in 2004, household expenses for the same purpose reached zł.16 billion - almost 50 percent of the public expenditures. "They are paying," says Misiński, "but right now they are doing so under the table."
Mass exodus
Another issue troubling the system is the fact that many doctors are leaving the country and emigrating westwards. A second, large group of doctors is finding employment in the dynamically growing private-healthcare sector.
Misiński believes this could become a serious problem. "The result could be that, instead of a few months, we could wait a few years for an appointment," he said. Moreover, he points out that this could lead to a situation where Poles would simply go abroad to undergo medical treatment in the common EU market and the NFZ would have to pay for it. That could mean that Poland's chance to make use of its cheaper healthcare services would be wasted. "Instead of curing Europe, Europe would be curing us," Misiński sums up.
Private popularity
Patients as well as doctors are avoiding public-health facilities and the strike could further contribute to the growing popularity of private healthcare. According to a survey by insurance firm PZU Życie, in the last 12 months around 30 percent of Poles used a private healthcare facility. Furthermore, the company's data shows that around 25 percent of Poles are considering the purchase of private-healthcare insurance policies. The result is that many Poles support the state system with their premiums, but hardly ever use it due to queues and long-waiting periods, thus spending additional money in the private sector.
Misiński notes that a similar situation existed in the UK. Those who could afford it had private healthcare insurance and, despite their tax contributions to the public system, only used the private sector. "The difference is that the middle class in the UK is much bigger, so more people could afford to go to the doctor privately than in Poland," he said.
Public-private partnership?
The government also wants to benefit from the growing interest in private-healthcare services. It is planning to make cash registers obligatory in private practices, thus increasing revenue from income taxes. Patients using the private system could benefit from tax allowances.
"We want to relieve the public-healthcare service and encourage people to use private offers," stated Deputy Prime Minister Przemysław Gosiewski. PiS deputy Cymański claims that introducing cash registers at doctors' offices would help regulate and control the market. He also stated that this could help increase the amount of money in the healthcare system. "This should help young doctors [whose situation is particularly hard], as it is the experienced, older specialists who benefit from private visits," he said.
But while the private sector of the healthcare industry is thriving, Zacharski suggests that it will not fully replace the public sphere, not even in the case of affluent citizens. "When someone is to undergo a serious operation, they will choose a good public hospital," Zacharski claims, adding that - besides ambulatory procedures - the private sector nowadays specializes in some well defined procedures such as childbirth, dialysis, plastic surgery and so-called "one-day surgeries."
Still, Misiński is sure that OZZL's reform proposal will be implemented. "The question is when," he avers. "Will we adopt it [voluntarily] or will life force us to do it?"
