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Statistical Office in Krakow Centre for Health Statistics Health care sector in Poland: the history of financing and organization.

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Presentation on theme: "Statistical Office in Krakow Centre for Health Statistics Health care sector in Poland: the history of financing and organization."— Presentation transcript:

1 Statistical Office in Krakow Centre for Health Statistics Health care sector in Poland: the history of financing and organization

2 Health care system prior to 1989 SIEMASZKO MODEL Public health service model typical for eastern communistic countries - members of the Union of Soviet Socialists Republics (ZSRR) Public health service model typical for eastern communistic countries - members of the Union of Soviet Socialists Republics (ZSRR) Centralized health care – all decisions made on the state level by Communistic Party leaders Centralized health care – all decisions made on the state level by Communistic Party leaders State-owned health care facilities State-owned health care facilities Financing from general taxation Financing from general taxation

3 Consequences Chronic overstaffing Chronic overstaffing Low level of motivation / decline in moral standards Low level of motivation / decline in moral standards Declining efficiency Declining efficiency Insufficient salaries for health care professionals (corruption) Insufficient salaries for health care professionals (corruption)

4 Quasi market of health care services between 1990 – 1998 (a period of transition) Introducing the universal coverage with a comprehensive program of health care Introducing the universal coverage with a comprehensive program of health care Distributing services through facilities owned and run by the state Distributing services through facilities owned and run by the state Financing from general taxation (the Ministry of Health) Financing from general taxation (the Ministry of Health) Initial steps to decentralization of ownership and private ambulatory medical services Initial steps to decentralization of ownership and private ambulatory medical services Implementation of family doctor scheme Implementation of family doctor scheme

5 Consequences Over centralization Over centralization Over specialization Over specialization Regional inequalities Regional inequalities Regional rationing and misallocation of resources Regional rationing and misallocation of resources Problem of informal payments to public health care providers Problem of informal payments to public health care providers Lack of costs awareness Lack of costs awareness

6 AIM of the reforms: highly developed health care financing system meet the health care needs of population by providing health care services of high quality meet the health care needs of population by providing health care services of high quality

7 Legislations Acts 1989 Act on the Establishment of a Medical Chamber 1989 Act on the Establishment of a Medical Chamber 1990 Local Government Act 1990 Local Government Act 1991 Health Care Institutions Act 1991 Health Care Institutions Act 1991 Nurses and Midwives Self Government Act 1991 Nurses and Midwives Self Government Act 1991 Act on Payment for Drugs and Medical Materials 1991 Act on Payment for Drugs and Medical Materials 1993 Law on Abortion 1993 Law on Abortion 1994 Law on Nurse and Midwives Professions 1994 Law on Nurse and Midwives Professions 1995 Regulations on transfer of budgets to self- managing institutions 1995 Regulations on transfer of budgets to self- managing institutions 1997 Law on Physicians Profession 1997 Law on Physicians Profession 1997 Law on Universal Health Insurance 1997 Law on Universal Health Insurance 1997 General Health Care Act 1997 General Health Care Act 1998 Law on Universal Health Insurance – Amendments 1998 Law on Universal Health Insurance – Amendments

8 1997 General Health Care Act Universal participation Universal participation Mandatory principle Mandatory principle Social solidarity Social solidarity Autonomous and self-governing scheme Autonomous and self-governing scheme The state guarantees the security of the insurance scheme The state guarantees the security of the insurance scheme

9 Reform of the administration system in Poland 49 voivodships 16 voivodships

10 Health care system after reform 1 st of January 1999 (1) National health insurance program based on Bismarcks social health insurance model National health insurance program based on Bismarcks social health insurance model Compulsory health insurance scheme (for all citizens) Compulsory health insurance scheme (for all citizens) Decentralization – transfer of decision rights from the state level to regional and local levels Decentralization – transfer of decision rights from the state level to regional and local levels Sickness Fund as a third player - payer (16 insurance founds Sickness Fund as a third player - payer (16 insurance founds + 17 th found for different groups of proffesionals) + 17 th found for different groups of proffesionals) Introduction of the primary health care institution (POZ) – general practitioners play a role of gate keepers Introduction of the primary health care institution (POZ) – general practitioners play a role of gate keepers

11 Health care system after reform 1 st of January 1999 (2) Financing: Financing: - health insurance contribution – 7,5% of income – monthly deducted by employer and paid directly to the insurance found - unemployed and retired – contribution covered by the state - out-of-pocket payments Introduction of a hospital accreditation system Introduction of a hospital accreditation system Patients right to choose health care provider Patients right to choose health care provider Contracting health care services as a new tool of planning and control Contracting health care services as a new tool of planning and control Market competition between providers Market competition between providers

12 Diversity of responsibility on governmental levels (2) Voivodship (Regional level): secondary care in voivodship hospital secondary care in voivodship hospital providing acute care providing acute care planning health care services, organizing the structure of health institutions planning health care services, organizing the structure of health institutions allocating founds allocating founds Powiat (District, local level): the owners of health care organizations within their territory the owners of health care organizations within their territory district hospitals district hospitals Gmina (Municipality): primary care primary care

13 Consequences Misuse of market mechanism in terms of high autonomy among Sickness Founds Misuse of market mechanism in terms of high autonomy among Sickness Founds Increase of public expenditures on inpatient care and drugs reimbursement Increase of public expenditures on inpatient care and drugs reimbursement Wrong allocation of resources Wrong allocation of resources Inequalities between Sickness Founds located in different voivodships Inequalities between Sickness Founds located in different voivodships Growth of out-of-pocket expenditures + informal co- payments Growth of out-of-pocket expenditures + informal co- payments Increase of public expenditures due to high rate of unemployment Increase of public expenditures due to high rate of unemployment

14 Health care system after reform 23 rd of January 2003 (1) Sickness Funds were replaced by the National Health Fund (NFZ) with 16 regional branches + 1 central Sickness Funds were replaced by the National Health Fund (NFZ) with 16 regional branches + 1 central NFZ located out of the public budgetary finance construction NFZ located out of the public budgetary finance construction Centralization of responsibility for financial and human capital service plan realization Centralization of responsibility for financial and human capital service plan realization The Insurance Law - insurance contribution will increase from 8.25% in 2004 to 9% in 2007 The Insurance Law - insurance contribution will increase from 8.25% in 2004 to 9% in 2007 Many providers combine a private practice with part- time employment in the public sector Many providers combine a private practice with part- time employment in the public sector

15 Health care system after reform 23 rd of January 2003 (2) Creation of a Polish Health Technology Assessment Agency Creation of a Polish Health Technology Assessment Agency Introducing a system of waiting lists but not for emergency services Introducing a system of waiting lists but not for emergency services Introducing the National Drug Policy (transferring the market share from branded to generic drugs) Introducing the National Drug Policy (transferring the market share from branded to generic drugs) Introducing the basic package of health care services Introducing the basic package of health care services Hospital networks Hospital networks

16 Dimensions of the analysis of health care sector financing in Poland Financing of the health care services Production of the health care services Functions of the health care services Insurance contribution Taxes Employers expenditures Households disposable incomes Financing sources Financing agents The National Health Fund State budget Households Territorial self- government units Employers Private insurers Independent health care units (SPZOZ) Dependent health care units (NZOZ) Offices of physicians and dentists Medical care centres (ZOL) Nursing centres (ZPO) Kind of cost Providers Salaries Pharmaceuticals and medical equipment Non-medical costs of treatment Administration Upkeep of infrastructure Outsourcing Functioning of the system Pharmacies Investments Prevention and public health Long-term care Curative and rehabilitative care Ancillary services to health care Health administration and health insurance Provision of health care services

17 Financing sources – health insurance contributions Health insurance contributions - the biggest financing source In Poland, the universal health insurance system has been in effect since 1 January 1999, when the health care contribution was introduced In Poland, the universal health insurance system has been in effect since 1 January 1999, when the health care contribution was introduced Contributions are transferred to the payer - National Health Fund (NFZ) from the Social Insurance Institution (91% of the total, the real growth of financial means acquired from this source in the period of 2000- 2007 amounted to 48%) as well as from the Agricultural Social Insurance Fund. The total growth of revenues higher than the GNP one. Contributions are transferred to the payer - National Health Fund (NFZ) from the Social Insurance Institution (91% of the total, the real growth of financial means acquired from this source in the period of 2000- 2007 amounted to 48%) as well as from the Agricultural Social Insurance Fund. The total growth of revenues higher than the GNP one. The majority of Poles are subject to obligatory health insurance. The majority of Poles are subject to obligatory health insurance. Persons who are mentioned in Art. 66 item 1 of the Law on health benefits financed from public means are subject to obligatory health insurance, whereas persons mentioned in Art. 68 of the Law are subject to voluntary health insurance Persons who are mentioned in Art. 66 item 1 of the Law on health benefits financed from public means are subject to obligatory health insurance, whereas persons mentioned in Art. 68 of the Law are subject to voluntary health insurance the health insurance contributions rate has risen from 7,5% of the base in 1999 to 9,0% in 2007 From the moment, when system was introduced, the general revenues from contributions expressed in current prices has risen by 19 bilions of zl (around 80%) - the health insurance contributions rate has risen from 7,5% of the base in 1999 to 9,0% in 2007

18 Financing sources (2) - taxes For some insured persons the health insurance contributions are financed directly from the budgetary revenues : farmers, unemployed without the benefit, persons receiving child- care benefits and war pensions, soldiers Expenditure on health care, which comes from the state budget, is spent by: the Ministry of Health, the Ministry of Interior and Administration, the Ministry of National Defence, the Ministry of Justice as well as the Ministry of Labour and Social Policy Level of financing; stable for 2004-2006 (around 4 bln zl), some growth since 2007 – financing emergency service. The flow of funds mainly in form of the purposeful subsidies The stable level of budgetary financing is predicted in the future

19 Financing sources (3) - Financing sources (3) - employers expenditures Law on Occupational Medicine Service: employers (corporations) are obliged to finance occupational medicine services (preliminary, periodic and control medical examinations, as well as preventive care related to working conditions) for their employees Financing of medical services including diagnostics, often combined with preventive medical examinations, within medical subscription packages purchased by employers at health care institutions Expenditure on preventive medical examinations is employers costs of obtaining income A rapid growth of financial means : from 545 mln zl in 2002 to 1,3 bln zl in 2007

20 Financing sources (4) – Financing sources (4) – Households disposable incomes Estimation: based on household budgets survey, household notes its expenditure and incomes in a special budgetary book Net income = combination of funds in household disposition – (prepayment for income tax from natural persons + contributions for social and health insurances) + savings Net income = Net income = disposable income + savings The average monthly expenditure on health care per capita incurred by households amounted to 36.57 zl in 2006 The total amount of direct health care expenditure incured by households in 2006 amounted to: 16,8 bln zl* * stands for minimal direct health care (out-of-pocket) expenditure beard by households, since it may not include the informal payments for health care services.

21 Production of the health care services – costs in the health care system in Poland The total costs of the health care system has been rising steadly: from 41,6 bln (1999) to 70,4 bln (2007) – 70% Main causes of rapid growth: results of requirements regulated in the ustawa 203 – results of requirements regulated in the ustawa 203 – independent health care units (SPZOZ) had to incur debts in order to finanse the increasing value of personel salaries, Additional costs for SPZOZ: preparation of restructurization plans. Law on Pubic Aid and restructurization of the independent health care units of 15 April 2007 was established to solve this problem. Additional costs for SPZOZ: preparation of restructurization plans.

22 Costs in the health care system – main trends Significant increase in salaries-related costs and costs of drugs: a growth by 12,2% in 2006 and nearly 8% in 2007 respectively. Rapid growth also for other kind of costs: medical materials, orthopaedic equipment, electricity, out-sourcing, upkeep of infrastructure, non- medical costs of treatment. The biggest part = personel salaries + cost of drugs A recent domination: before 1999 – salaries, 2000-2006 – costs of drugs Drugs: 37% of the total in 2003, latter improvement – 31% in 2007 !!! The most dynamic trend - financial liabilities in form of tax charges and debts repayment; a growth by 728% for 1999-2007. Noticable improvement: a decrease by 16% for 2004-2007 – enormous hospital debt is decreasing.

23 Total health care expenditure – OECD comparison Where we are??? Comparison with selected OECD countries Conclusion: level of total expenditure on health care in Poland, Mexico and Turkey belongs to the lowest among the OECD countries


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