2. Atonomus hospitals and health care organizations Poland Andrzej Rys Jagiellonian University, Krakow Washington D.C., February 18-19th 2004 World Bank Conference GOVERNANCE AND ACCOUNTABILITY IN SOCIAL SECTOR DECENTRALIZATIONS

3. About Decentralization of the state Decentralization of the payer Autonomy of health care institution New actors

4. 4 reforms 1999 State/public administration Education Social Insurance Health care Decentralization New State?

5. BEFORE Reform of the Administration (49 voivodship)

6. A NEW STATE FOR NEW CHALLENGES

7. STATE DECENTRALIZATION State Administration: Central and on the Regional Level Local Goverment Poviat and Gmina Regional Government: Voivodship

8. IT ALL DEPENDS... DECENTRALIZATION NEW COMPETENCE NEW FINANCING

9. DECENTRALIZATION vs. REGIONALIZATION Political Process - supported by local leaders (“fight” between 16 vs.12 regions followers) Culture, Tradition, Customs - additional factors ‘Competition” between regions Disturbed (“unknown”) role of Voivod and Marshal in practice

10. NEW ADMINISTRATIVE STRUCTURE VOIVODSHIP/Region - 16 POVIAT/County - 376 (incl. 65 largest urban gminas with poviat status) GMINA/Communities - 2489

11. OwnerNumber of hospitalsNumber of bedsBeds % Voivodeships 22375 36438 Counties (powiat) 39593 21447 Communes 174 1652,1 Ministries and medical universties ( from 2001) 59(42)24 98812,6 Privates 185950,3 Total - Local governments 635172 74387,1 Total 712198 327100 Hospital’s ownership after 1999 reform

12. Is a role for local/regional governments? Regional health plans (from 2003) Strategic planning Making a decisions (eg. privatization) Activities coordination Health programs Working with local providers (local taxes, rents) Services planning access Financeinvestment Using of resources (estate) Personnel replacement programs Supervision Patients/clients satisfaction New services planning

13. Insurance Fund Local/Regional Government Autonomus Public Provider Citizen/Consumer/Patient

14. Autonomus health care unit Free in : management, HR policy Depend on the public owner in: planning, investment, selling, renting, outsourcing, loans, taking next step to privatization Negotiation: salary and personnel replacement with trade unions In 2002- 2003 WB project: Decentralization of HC in Poland

15. Establishment of Autonomous Public Providers The General Health Insurance Act allowed for signing of contracts for providing health services only with entities with legal personality. Public HCEs that were budgetary units could acquire such personality by becoming autonomous. The 1991 Act on Health Care Establishments, and particularly its later amendments, defined the procedure of gaining autonomy by budgetary units. Gaining autonomy allowed the unit to conduct its own financial management, staff policy and to define a strategy conforming to the demands for services and the capacity of HCE.

16. MANAGEMENT PROCESS The polled managers acknowledged that autonomy is wider now as regards staff and financial management, whereas it was very limited before the entity became independent. Nevertheless, there are certain limitations as LGs assert undue influence in matters like hiring, investment decisions, and acquisition of fixed assets. The purview of manager’s decisions encompass matters like opening and closing of departments, purchase of equipment, staff policy, development of unit’s strategy, and most of the financial decisions. The autonomus unit require the consent of institutions like the Founding Body and Social Council in matters concerning changes in the organizational structure and statutes of the unit, disposing and acquiring fixed assets, and in making investment decisions The meetings of the Social Council are held at varied frequency, being linked to the subject of deliberation. Bi-monthly meetings are held to discuss current matters relating to finances and provision of health services. The scope of the operational management powers of the managers of the autonomous units is evaluated as adequate. Limitations do occur in investment and asset management decisions. It is observed that the Polish model of management of autonomous units is imperfect as it does not in itself lead to efficiently functioning institutions supporting operating management (such as management boards) or institutions that provide opinions New quality programs (including hospital accreditation and ISO)

17. HUMAN RESOURCE MANAGEMENT The employment decisions are made by the manager/director in each case. But the autonomy has not resulted in the introduction of new procedures in the field of staff management. Although formally there are no external employment limits, the respondents point to indirect constraints stemming from the value of the contract with the payer or with the minimum norms of employment as regulated by the Labor Code or the MOH. Such norms regulate the number of duty hours, time of work of x-ray technicians etc. The managers emphasized that the scope of freedom in employment is greater than it was before the reform. The remunerations are decided by the managers, who have greater freedom in modeling wages, as there is no upper limit. The procedure for dismissing workers is in accordance with the provisions of the Labor Code and the Act on Trade Unions. There are no changes from the pre- reform period. The managers make the final decision on dismissal from the service. The Labor Code and the Act on Trade Unions define the circumstances when dismissal decisions must be consulted with the trade unions. The scope of freedom of managers in staff policy has increased. The still encountered limitations are budgetary and not systemic, i.e. they result from legislative regulation. The little use of modern tools of human resource management is striking since the role of professionals (mainly medical personnel) in contributing to the success of the unit may suggest that staff policy would be accorded a priority Contracts with the medical professionals Outsourcing of some services and transfer some workforces to private companies

18. MANAGEMENT OF FINANCES AND SUPPLY Significant changes in the practice of preparing the budget, including the method of making the budget and method of recording costs (currently the memorial method). New elements, like income from additional and financial activity, fixed assets as a value on the assets side, or cash flows have been added. Monitor execution of the budget with monthly analyses or continuous controls. An account of costs is maintained and one facility uses the system of budgeting of individual organizational units. Could plan for external financing sources including loans, credits, and leasing. The same number gave a negative reply. Banks often classify autonomous hospitals as a fourth risk group making it difficult to obtain a loan Prepare annual financial statements in accordance with the provisions of the Accounting Act. Could now transfer and utilize a financial surplus Debts belong to the facility itself or to the LG (after closing) Investment plans Decisions concerning supply of goods and service

19. STRATEGIC PLANNING Strategic plan was required to became autonomous units The management prepared the plan in the remaining entities or in the small groups I many cases was had not been modified since becoming autonomous. The mere existence of strategic plans may be interpreted with great caution as their usefulness is limited and there is no linkage of the strategies of the individual units with those of the voivodship and powiat governments.

20. ENSURING PATIENT RIGHTS AND IMPROVING ACCESS Regular meetings are held with the representatives of the community, patients and members of associations. There was no such practice before reforms.) maintained that their strategic plan takes into account the needs of the community in which they operate Managers claimed that the portfolio of services offered by them has changed. Existing services have either been expanded or new ones introduced Special cells to deal with complaints of the patients After the 1999 reforms, patients have more avenues to lodge complaints regarding the operation of the health care system. Insurance against malpractice. Such insurance did not exist before autonomy was gained Monitoring the waiting time and patient satisfaction. The changes in the health care system have strengthened the position of the patient by better serving his rights. The patients are more aware of their interests and are more vocal in protecting them

22. Payer and Provider HEALTH INSURANCE FUND PROVIDER CONTRACT buyer seller

23. What does the CONTRACT mean? ?

24. RESULTS OF PAYER DECENTRALIZATION 17 antonomous and independent units...from everyone Over 23.000 contracts in the year 2001 Various payment methods Disturbance in the information flow Permanent lack of information at the all decision makers level

25. INNOVATION or ANARCHY ?

26. Problems with innovation in such a short term A lot of changes in short term Unprepared - providers, professionals, patients, media LACK OF estimation of innovations and its implementation process LACK OF education about prepared, implemented and present innovations LACK OF analyses - “MOVING TARGET”

27. Changes done...to reduce anarchy Legal changes:(2000, 2001, 2002) Changes in a board: 21 to 7 (in three steps), quality of a members, MOH control Changes of CEOs More clear responsibility for different level of health services More transparency in contracting Seek funds could be merged More information for patients

28. Citizen’s evaluation of the new health care system (2000) Health care situation is worsening (67 %) disorder in the system (40 %) increasing costs of care and medication (24 %) problems obtaining referrals to specialists (23 %) long waiting time (15 %) uncertainty about rules, entitlements (10 %)

29. Citizen’s evaluation of new health system(2000) Health care situation is improving (19 %) good quality of patient care (26 %) free choice of doctors, health care facilities (18%) competition enhances quality (18 %) good relations doctor - patient (15 %) privatisation (10 %)

31. New Actors in Health Care Reform Government Minister of Health Voivod 3 Levels of Local Governments Regions Poviats Gminas Chamber of Nurses, Chamber of Physicians, etc. New Trade Unions and Employers associations NGOs

32. Partners creating Regional Restructuring Programs

33. Program implementation decentralisation and regionalisation were introduced social communication techniques were applied procedures of applying to the Program together with the assessment criteria of regional programs were clearly identified, the final distribution of funds depended on the program quality all parties interested in the problem were involved by initiating to build a regional partnership for health.

34. Outcomes of the program the reduction of beds by over 12,000, better utilisation of resources (e.g. bed occupancy, length of patient’s stay), establishing of long-term health care institutions - 218 purchases and investments for over 1000 integrated health care institutions, adaptations, modernisations and general repairs, rationalisation of employment, which meant plans of dismissing about 100,000 employees within 3 years (only the 1999 and 2000 plans were implemented, i.e. dismissal of about 70,000 employees, out of which over 50% found employment in non-public health care institutions) extensive educational program both for managers and local health politicians mass privatisation of primary care and specialist outpatient medical services, i.e. generation of competition

35. Staff reduction 1999-2001

36. Next steps 2002-2004 Centralization Commercialization of the hospitals? New legal frame after decision of the Constitutional Court, 7th January 2004