Emergency rescue

The ruling Civic Platform (PO) and Polish Peasants' Party (PSL) coalition has riled the opposition and launched a heated public debate with its attempt to reform the public healthcare sector. The coalition's reform package, a set of six acts, was passed by both the Sejm and Senate late last month.

"[This is] anti-reform," Zbigniew Religa, a renowned cardiologist, former health minister and Law and Justice (PiS) MP, said before the Sejm.

The government, however, has described the reforms as the best solution possible. "I don't know any alternative for saving Polish hospitals," Prime Minister Donald Tusk told reporters during his visit to Beijing at the end of October. 

A sector in poor health

The public healthcare sector in Poland has been a source of worry for every government since 1989. Several decades of communist command economy left Poland's healthcare sector under-financed and under-equipped. Various attempts at reform have been made over the last two decades, but the system still falls short of Western European standards in a number of areas.

News of strikes or protests by underpaid and overworked medical staff makes headlines every few months and many hospitals are struggling to cope with crippling debts, the sum total of which amounted to about zł.2.6 billion in June this year, according to Ministry of Health data. Also, the Supreme Chamber of Control revealed in September that an inspection of 34 state hospitals had found that inefficient use of funds and misappropriation were widespread.

The Polish health service is considered among the least patient-friendly in Europe. It ranked 27th out of 29 countries in the Euro Health Consumer Index 2007 published by Health Consumer Powerhouse. The organization declined to comment on its 2008 index, which should be released in mid-November. A representative said, however, that it would be surprising to see any dramatic change regarding Poland's position.

Tomasz Teluk, the president of the Foundation Globalisation Institute (IG), agreed. "Poland's health service is still at the poor end in Europe," he said.

A corporate approach

The government claims that its reforms will finally improve the situation in the public healthcare system. "The draft reform is a breakthrough," Jakub Szulc, a secretary of state in the Ministry of Health, told Rzeczpospolita daily.

One of the central and most contentious parts of the reform effort obliges all public hospitals and healthcare units in Poland to incorporate, with local governments becoming the owners of these new companies. Furthermore, hospitals will become responsible for their own financial health, and if they suffer losses the local authorities may declare them insolvent.

Meanwhile, care will continue to be funded by the state-owned insurer, the National Health Fund (NFZ). The Democratic Left Alliance party also added an amendment to the reform package which keeps ownership of hospital land and buildings in the state's hands.

The new law will force hospitals to monitor their own economic well-being and guard against falling into uncontrolled debt, the government predicts. Another advantage is that local governments will have more decision making powers on the shape and functioning of the health care system in the area.

Not enough free market?

PO portrays itself as a free-market-oriented party, but its healthcare reforms have been criticized by advocates of economic liberalism. Wojciech Misiński, a doctor and expert on health services at the AdamSmithResearchCenter, calls the project a "quasi-free-market" solution. The greatest danger of the reform is that it allows commercialization and privatization but leaves the financing to the state-run NFZ, he said.

"The hospital becomes a company, but the manager has no influence over financial income, only on spending. It's like making someone swim with their legs tied," Misiński said. Allowing other insurers into the healthcare system, apart from the NFZ, would enable coverage of even more costly and time-consuming treatments, he added.

IG's Teluk was of a similar opinion. "We should allow private insurers to enter," he said, pointing to the healthcare system in neighboring Slovakia as an example. "Their system has several private insurers and works very well," he said. 

He said that hospitals should be managed by professionals who understand and are responsible for their finances. "What sort of management takes multi-million złoty loans without needing to pay them back?" he asked.

Too much free market?

At the same time, forced commercialization and the need for hospitals to focus on profit has raised strong objections from opposition parties on both sides of the political spectrum. Some fear that the search for profit will push hospitals to concentrate on areas that generate secure revenues from the NFZ, such as cardiology.

The more costly and time-consuming treatments will be neglected, according to PiS MP Czesław Hoc, a member of the Sejm Health Commission and a doctor with 30 years of experience. "Rather than increase access to care, the reforms will lead to cases of under-treatment in some areas of medicine, and cases of over-treatment in others," he told WBJ.

"The result of the reforms can be compared to the present condition of dentistry, where the NFZ pays for very few treatments and the rest must be covered by the patients themselves," Hoc said.

Both PiS and the Sejm's Left faction want commercialization to be voluntary. "Almost 55 percent of public healthcare units are doing well and there is no reason why they should be commercialized," Hoc said.

Opposition parties also warn that the reform package imposes financial demands on hospitals, but leaves them with limited financing. Many hospitals are bound to suffer losses and go bankrupt as a result, according to Social Democracy of Poland - New Left MP Marek Balicki, and this could lead to uncontrolled privatization of the system.

"Hospitals in debt will be sold like hot cakes to those seeking to buy them for a low price," PiS MP Przemysław Gosiewski told the press in October. "We will not allow the robbery of the national assets and the division of sick people into better and worse depending on the thickness of their wallets," he said.

Hoc listed other dangers allegedly posed by the reform package, including the fact that it allows a hospital to limit services to patients if the hospital is operating at a loss. The package even enables hospitals to suspend medical activities for up to three months, he said.

He also said the new law did not ban hospitals from conducting commercial activities unrelated to the treatment of patients, although such a restriction is included in the present law. These activities, Hoc said, could even have the potential to be harmful for patients.

"This means that hospitals would be allowed to run a hotel or a restaurant - anything they want," Hoc said, adding that the reform would violate medical code of ethics and the Polish Constitution if enacted.

In response to similar protests, Minister of Health Ewa Kopacz replied, "Some people suspect everything and everyone."

Public hospitals still necessary

Hoc stressed that private hospitals were welcome to begin operating, but the public health service should remain the dominant system in Poland. He said,  "Private hospitals do function well, but most of them are small and only provide treatments that guarantee profits from the NFZ. For more advanced or less profitable treatments, there is always a huge state-owned hospital nearby." He added that the state remained the primary health provider in the majority of EU countries.

The healthcare system does not have to be either totally public or totally private, according to Konstanty Radziwiłł, the president of the Polish Chamber of Physicians and Dentists. "Healthcare units which are doing well should be left alone," he told the press.

According to Hoc, reform is necessary, but it should involve evolution, not revolution. "I advise making the system more insulated and increase the state's spending," he said, adding that this method had seen zł.4 billion saved on overdue hospital debts when his party was in power during the 2005-2007 period.

The debate over reform has brought into question of the role of the medical profession. According to PiS' Religa, if a hospital's mission is to cure patients, then finance and profit should not be the top priority. "Healthcare is an extremely complex issue and it is not enough to act politically," he said during a Sejm debate in October.

IG's Tomasz Teluk disagreed, however. "I see no reason why the health service should be free from free market mechanisms. Eating is an even more basic need for human life, and if we imposed central planning [in the food industry] we would face starvation," he said.

The battle continues

The fight over the reform is far from over as President Lech Kaczyński has declared his intention to veto the legislation. The government will then try to overturn the veto and, to this end, it is making an effort to persuade the parties on the political left to support the reform. Meanwhile, PiS intends to offer its own reform proposal in January.

IG's Teluk stressed that well-planned healthcare reform was necessary and warned that a wake-up call would eventually come when the EU freed the market for health services throughout Europe.

"We may face a situation when a Polish citizen will be treated abroad by a Polish doctor for money paid by the NFZ," he said.