1. Centre for Health Statistics
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)
Centralized health care – all decisions made on the state level by Communistic Party leaders
State-owned health care facilities
Financing from general taxation

3. Consequences Chronic overstaffing
Low level of motivation / decline in moral standards
Declining efficiency
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
Distributing services through facilities owned and run by the state
Financing from general taxation (the Ministry of Health)
Initial steps to decentralization of ownership and private ambulatory medical services
Implementation of “family doctor scheme”
Gmina has became responsible for primary care and voivodship for many other services
A new model for the general practitioner role for delivery of primary cost reduction care

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

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

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

8. 1997 General Health Care Act
Universal participation
Mandatory principle
Social solidarity
Autonomous and self-governing scheme
The state guarantees the security of the insurance scheme
entire population will be covered by insurance under the same conditions and no population group will be excluded
everyone will be required to pay income tax-based insurance
the costs of health insurance are borne by all insured persons; there will be equal access for insured persons; insured people will be covered despite the extent of their risk; and contributions will be re-distributive

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

10. Health care system after reform 1st of January 1999 (1)
National health insurance program based on Bismarck’s social health insurance model
Compulsory health insurance scheme (for all citizens)
Decentralization – transfer of decision rights from the state level to regional and local levels
Sickness Fund as a third player - payer (16 insurance founds
+ 17th found for different groups of proffesionals)
Introduction of the primary health care institution (POZ) – general practitioners play a role of gate keepers
Financing- public fraction in healthcare spending (health insurance contributions through a payroll tax and expenditures of state, regional and local government budgets) and private fraction in healthcare spending (household expenditures)

11. Health care system after reform 1st of January 1999 (2)
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
Patients’ right to choose health care provider
Contracting health care services as a new tool of planning and control
Market competition between providers

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

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

14. Health care system after reform 23rd of January 2003 (1)
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
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
Many providers combine a private practice with part-time employment in the public sector

15. Health care system after reform 23rd of January 2003 (2)
Creation of a Polish Health Technology Assessment Agency
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 basic package of health care services
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
Kind of cost
Financing sources
Financing agents
Curative and rehabilitative care
Providers
The National Health Fund
Salaries
Independent
health care units
(SPZOZ)
Long-term care
Insurance contribution
Pharmaceuticals and medical equipment
Provision of health care services
Dependent
health care units
(NZOZ)
State budget
Taxes
Health administration and health insurance
Non-medical costs of treatment
Territorial self-government units
Offices of
physicians
and dentists
Employer’s expenditures
Administration
Ancillary services to health care
Medical care
centres (ZOL)
Households
Upkeep of infrastructure
Household’s disposable incomes
Prevention and public health
Nursing centres
(ZPO)
Outsourcing
Employers
Functioning of the system
Private insurers
Investments
Pharmacies

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
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 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.
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
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 contribution’s 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
The stable level of budgetary financing is predicted in the future
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 (around 4 bln zl), some growth since 2007 – financing emergency service. The flow of funds mainly in form of the purposeful subsidies

19. Financing sources (3) - employer’s 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 employer’s 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) – 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 = disposable income + savings
The average monthly expenditure on health care per capita incurred by households amounted to 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” – independent health care units (SPZOZ) had to incur debts in order to finanse the increasing value of personel salaries,
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, – 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
Noticable improvement: a decrease by 16% for – 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