Fundamentals of the health care system

Health care in Poland remains the responsibility of various sectors, but it is carried out principally by the social security system. Most aspects of the general health care framework were founded in 1997 by Article 68 of the Constitution which states that: (a) Everyone has a right to health care. (b) Citizens, regardless of their economic status, shall be provided with equal access to health care services financed from the public funds by the public authorities; the conditions and the scope of services are to be detailed in the appropriate laws. (c) Public authorities are obliged to provide special health care services to children, pregnant women, disabled persons, and the elderly. (d) Public authorities are obliged to counter epidemic diseases and prevent potentially health-threatening outcomes of environmental degradation.

Prior to 1989 the Polish health care system fell under a public integrated model, sometimes called the “Semashko” model, named for its Soviet ideologist, and changed gradually over time. In this system the government was both the principle insurer and the major provider of services, via health facilities owned and administered by regional representatives of the government (Voivods, “Governors”). The benefit basket in a given area was determined by the physical presence or absence of specialists and equipment. The country had begun to reform the health care system as early as the 1980s, albeit rather slowly. Until the end of the 1990s the reform process focused basically on redefining the role of the state and introducing quasimarket mechanisms, greater individual freedom, and decentralized responsibility and management. On 1 January 1999 the institutions of universal health insurance commenced their activity by virtue of the Law of Universal Health Insurance of 1997, with amendments from 1998. This established 16 Regional Health Insurance (Sickness) Funds along with the Health Insurance Fund for so-called “uniformed workers” (army workers, policemen, railway workers) and their families, which operated at interregional level. According to the Law of Universal Health Insurance, Health Funds sign contracts with health care institutions. Regional Health Funds covered particular voivodships (administrative regions) populated by 1–6 million inhabitants. After 2000 there were no legal barriers to the Health Funds extending their activities to other regions. Citizens were free to choose the Health Fund irrespective of their place of living. Health Funds had become autonomous organizational and property institutions, but they still remained public and managed funds collected through premiums under the supervision of a public “boards,” with the principle aim of providing insofar as their budget allowed the best health care to all insured persons in their region.

In reality, however, there was little competition between Health Funds for patients, except in some neighboring regions when certain Health Funds began absorbing persons in adjacent areas. Still however, they were focused rather on preserving quality and “proper relations” with providers in their own regions. In 2001 the Social-Democratic Government initiated a centralization of the system by merging all Health Funds into a unified universal National Health Fund (NHF) with 16 regional branches. The process of recentralization of the system lasted 2 years and was burdened with substantial technical problems and shortcomings. During the period from 2001 until 2005 there were six Ministers of Health, and the Health Insurance Act was completely re-written twice, one after the intervention of the Constitutional Tribunal. One of the reasons given by the Tribunal in declaring the law unconstitutional was the lack of definition concerning “conditions and scope of services” to which an insured person is entitled under the health insurance law.

Regulation of the benefit basket

There are various legal acts and documents defining the scope of services and conditions required for entitlement. In the hierarchy of regulations the most important and most general are those based upon the Constitution. More specific are the laws ratified by Parliament and the President, which regulate certain areas of social life and activities. The laws listed below include obligations of public organs and institutions, to provide and ensure health benefits to persons in need:

  • Health insurance law which regulates the universal and obligatory insurance scheme that covers some 99% of Polish citizens and a large proportion of noncitizens, residents, both short- and long-term (Ustawa, 27 August 2004, r. o świadczeniach opieki zdrowotnej finansowanych ze środków publicznych, Dz.U. Nr 210 z 2004 r. poz. 2135).

  • Labor code and occupational medicine law which regulates relations between employers and employees, including the health protection measures that employers are obliged to pay (Ustawa, 26 June 1974, r. Kodeks pracy-tekst jednolity, Dz.U. nr 21 z 1998 r. poz.94 z późn.zm; (Ustawa, 27 June 1997, o służbie medycyny pracy r., Dz.U. Nr 96 poz.593).

  • Laws which regulate the obligations of public authorities and individuals regarding protection against and coping with specific problematic health areas, such as infectious diseases (Ustawa z, 6 September 2001, r. o chorobach zakaźnych i zakażeniach, Dz.U. Nr 126 z 2001 r. poz.1384 z późn.zm), mental health (Ustawa, 19 August 1994, r. o ochronie zdrowia psychicznego, Dz. U. Nr 111, poz. 535, z późn. zm.), drug (Ustawa, 24 April 1997, r. o przeciwdziałaniu narkomanii, Dz. U. z 2003 r. Nr 24, poz. 198 i Nr 122, poz. 1143), and alcohol abuse (Ustawa, 26 October 1982, r. o wychowaniu w trzeźwości i przeciwdziałaniu alkoholizmowi, Dz. U. z 2002 r. Nr 147, poz. 1231, z późn. zm.10) problems-which.

  • Laws on the rescue system (Ustawa, 25 July 2001, r. o Państwowym Ratownictwie Medycznym, Dz. U. Nr 113, poz. 1207, z późn. zm.13) and services (Ustawa, 6 December 2002, r. o świadczeniu usług ratownictwa medycznego, Dz. U. Nr 241, poz. 2073 oraz z 2003 r. Nr 99, poz. 920) which regulate the functioning and financing of the national rescue system and care provided to persons in need.

  • Social security law which establishes rules for social security coverage for various population groups, both occupationally active and nonactive (Ustawa, 13 October 1998, o systemie ubezpieczeń społecznych, Dz. U. Nr 137, poz. 887 z późn. zm.).

  • Penal code which regulates the issues of crime and treatment of persons convicted of committing crimes (Ustawa, 6 January 1997, r.-Kodeks karny wykonawczy, Dz. U. Nr 90, poz. 557, z późn. zm.9).

  • Law on foreigners which regulates the rights and obligations of non-Polish residents who are under care of Polish authorities (Ustawa, 13 January 2003, r. o cudzoziemcach, Dz. U. Nr 128, poz. 1175 oraz z 2004 r. Nr 96, poz. 959 i Nr 179, poz. 1842).

  • Road traffic code which regulates the rights and obligations of public roads users (Ustawa, 20 January 1997, r. o ruchu drogowym, Dz.U. Nr 58 z 2003 r. poz.515 z późn.zm.).

Many of these laws contain so-called delegations to regulations/decrees regulating on a technical level both the scope and conditions of services available to individuals in Poland. The underlying logic of the legislative process in Poland provides that laws establish the fundamental principles and mechanisms while regulations/decrees govern their practical application. Both are by nature obligatory, and there are legal and administrative sanctions for noncompliance. In addition to legal acts, there are additional documents referring to the benefit basket which are not of legal nature. The most important of these and the only one discussed here is a catalogue of services (so-called “contracted products”) which are purchased by the NHF. The catalogues are appendices to the procurement documentation in the procedures of purchasing health services and goods within the universal health insurance system. The “products” included in the catalogues are then the subject of contracts between the NHF and the service providers, to be provided to the “beneficiaries.”

Table 1 presents a list of laws and decrees which determine the benefit basket in each of the existing subsystems. The level of detail in defining the scope of the benefits to which persons are entitled, differs in the Acts. It is worth noting that in each case the Act states who is entitled (covered) to a certain kind of protection and what protection it is, sometimes also defining the circumstances and conditions under which it is available. For present purposes we can differentiate three levels of explicitness of definitions in the benefit basket:

Table 1 List of documents determining the benefit basket and its level of explicitness
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  • Explicit: That which is understood as providing specific medical procedures and actions (e.g., immunization for hepatitis B), namely those mentioned in the law or regulation

  • Semiexplicit: That which outlines a certain area of health care to which beneficiaries have rights (e.g., primary care)

  • Implicit: That which mentions generally that health care is provided, sometimes with additional formulation as all necessary, efficient, etc.

In some of the Acts included in Table 1 some benefits are determined in more detail and some others in less detail, which means that the level of explicitness of defining the benefit basket ranges from implicit to explicit. As a rule, regulations (decrees) are more detailed in the benefits definition than laws, and the laws are more specific than the Constitution. However, in the case of the most prominent Act, the Universal Insurance Law, the Act encloses the benefits definition on all three levels of detail.

Obligations of the public authorities derived from the legal regulations are financed from public sources, which amount to 70% of the total health expenditure in Poland. Private expenditure (estimated as 30% of the total health expenditure) is mainly out-of-pocket payment with minor supplemental role of private insurance and quasi-insurance. As regards private expenditure, no benefit basket can be discussed; the only exception is occupational medicine, discussed below.

Roles of partners in defining the benefit basket

Parliament is the supreme legislative body in Poland. The central government, respecting (in theory) a subsidiary principle, regulates the activities of both individuals and institutions and, through its administration and agencies supervises their compliance with legal regulations. Local (regional) governments are responsible for public activities on their territories. Laws establish principles and mechanisms, while regulations/decrees establish their practical applications. Regulations/decrees cannot exceed the area determined by the specific law, and they are issued by each of the government ministries. With regards to the benefit basket, the National Assembly, i.e., a joint session of Sejm and Senate (lower and the upper chambers of Parliament), adopts the Constitution, among others, with its provisions dedicated to health protection. The Sejm drafts laws that must be approved by the Senate and signed by the President. The Government ministries define various parts of the “benefit basket” issuing regulations to existing legal provisions.

The NHF defines catalogues of services (so-called “products”) which are purchased by the health insurance institution that implements universal mandatory health insurance. The process of defining the list of products was not formalized until recently, although in 2005 a formalized process of setting general conditions of contracting was established, which take places under the NHF protectorate and with participation of providers associations representing more the 10,000 professionals. The catalogues are published as appendices to the procurement documentation in the process of purchasing health services and goods within the universal health insurance system. The “products” from catalogues are later placed in contracts between the NHF and the providers of the services.

Definitions of the benefit basket in certain areas of health care

Health care is a wide area, and sometimes it is difficult to define which actions belong to it and which, for example, to social security. For the present study, the OECD functional classification (International Classification for Health Accounts–Health Functions) was used to define boundaries of the health care system. Table 2 presents areas/subsystems of health care in Poland with their respective regulations regarding the benefit basket and their characteristics; the individual Acts presented in Table 1 are aggregated here into following areas:

Table 2 Benefit basket and an explicitness of its description in distinguished areas (L law, R regulation, A nonlegal document,1 least precise, 3 most precise)
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  • Social health insurance system, regulated by health insurance law and related decrees. Procurement documentation belongs to this system, which is not a legal act but is discussed here because of its role in the system.

  • Social insurance system, which is a wider concept than social health insurance, but here it contains functions regulated by social insurance law and farmers’ social insurance law (Ustawa z dnia 20 grudnia 1990 o ubezpieczeniu społecznym rolników i ich rodzin, Dz.U. z 1998r. Nr 7 poz.25 z późn.zm.) and related decrees.

  • Occupational medicine, which is a privately funded system, according to OECD definitions, often in the form of prepaid arrangements of employers, covering prevention services and often some forms of outpatient health care.

  • Rescue system, comprising benefits resulting from regulations on national rescue system and rescue services.

  • Mental health and substance abuse, comprising benefits for persons suffering from mental disorders and substance abuse problems.

  • Infectious diseases, covering prevention and treatment services, partly provided on a mandatory basis.

  • Prisoners and foreigners residing in closed centers, covering all necessary medical interventions for persons with limited freedom.

Table 2 describes the kind of document that regulates the benefit basket in each subsystem and the level of precision in determining the basket, which refers to the distinctions mentioned above (1 the least precise, 3 the most precise).

Social health insurance system

Most health services and goods are delivered within the social health insurance system, which we therefore discuss in more detail. After lengthy debate and two major changes in the law in 1997 and 2003 and the Law of 27/08/2004 on health care services funded from public resources was adopted in 2004 to replace existing health insurance laws (Letter of Issue no. 210, 2004, pos. 2135). Under the new law the beneficiaries, i.e., EU citizens with insurance rights, gained the right to access the entire range of available health care services. Publicly funded services are divided into 22 different categories, for example, diagnostic tests including medical laboratory diagnostic, services aimed at health protection, prevention of diseases and injuries, early detection of diseases, including compulsory vaccinations, primary health care, outpatient specialist services, and inpatient care. The Minister of Health has several legal obligations for issuing the regulations partially forming the benefit basket. These are specified in Table 1.

According to Article 16 of the Act on health care services financed from public funds, the benefit basket does not cover some services, such as reimbursement of the cost of certificates required for a driving license and other medical statements or forensic expertise obtained at the request of the court or prosecutor, which are covered by separate public funds. Patients residing at nursing homes must cover the cost of food and accommodation themselves. There is a negative list of services excluded from the guaranteed public health service basket, such as vaccinations not included in the compulsory vaccination package, plastic and cosmetic surgery when it is not necessary treatment for malformation, injury, illness, and gender change operations but also treatment of epilepsy with stimulation of nervus vagus, diagnostics and treatment of the taste disorders, hyperbaric chamber in SM treatment. A full list of these services was appended to the law, which means that it must be ratified by Parliament. Moreover, according to Article 25 of the Act, the NHF does not reimburse the costs of treatment or diagnostics of an insured person that are incurred abroad unless these services were provided in accordance with Regulation 1408/71/EC. On the basis of these regulations and previously presented legal provisions the NHF defines the so-called “contracted products” that are purchased in the scheme. The catalogue of health care products includes a number of parts/chapters, as presented in Table 3.

Table 3 Categories of “contracted products” purchased by National Health Fund with classification by SHA categories and short description, valid for 2005
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The catalogue of services is not published in a uniformed way but rather as a set of appendices to various models of contracts with various groups of providers. It is published in electronic form usually in October of the year preceding the year of contracting. Table 3 was developed on a basis of an official publication of the NHF and presents an aggregate of a product list from a variety of NHF internal documents. The logic of products nomenclature reflects the way in which it is used for payment and monitoring purposes. Some parts of the catalogue are published in the form of legal acts and appendices and are rewritten into contractual conditions, for example, dentistry, spas, and medical products (including orthopedic) while others are developed fully by the NHF experts.

Other schemes

A number of laws regulate the other schemes providing services and goods to Polish inhabitants (see Table 1). General characteristics of the remaining schemes are that they usually rely on public funds and implement social and public policy in delivering services and goods to various population groups. Some of the schemes obligatorily engage private funds, for example, occupational medicine which obliges employers to provide certain kind of services to employees. The special regulations often focus on underprivileged populations, such as the mentally ill and alcohol and drugs addicts, to make available necessary services to persons who would otherwise not receive them. It is interesting to note that many of the functions specified in these special regulations oblige the NHF to finance it, as in the case of infectious diseases.

Discussion

This study presents the legal and administrative regulations regarding health benefits to which various groups in Poland are entitled. The range of available benefits is clearly quite wide, and the justifications for respective entitlements are also varied. However, in both public and professional opinion there is no such a thing as the “benefit basket” in Poland [1]. This is also frequently the reason adduced to explain why the health system works so poorly. There is no systematic research in this area, but the different parties in the system appeal for the provision of a benefit basket clearly for different reasons: patients who feel lost in the system see in the envisioned benefit basket a way to secure their rights, and professionals have claimed that the lack of explicit listing of benefits make patients demand more then necessary, which places physicians under strong pressure to prescribe and perform many services that are not eventually covered by the payer. On the other hand, explicit formulation of “products” purchased in the insurance system creates substantial controversies and criticism because some medical procedures are omitted.

In 1999–2000 the Ministry of Health and Social Welfare publicly expressed its commitment to the development of a defined basic benefit basket. This proposal was hotly disputed at the time, with a number of groups opposing the concept because it was often seen as a way of limiting available health care and thus saving money. The debate prompted the Ministry to seek outside assistance in the form of consultants’ advice. The consultation project was aimed at “verifying and arranging the range of services purchased by the Health Funds” regarding determination of the range of guaranteed services, the so-called basic benefit basket, with specification and terms of their provision [2]. The formulated range and description of services were expected to serve as the basis for the Health Funds in drafting contracts with service providers. It was also intended to serve as a tool for performance assessment of particular Sickness Funds, made by the Health Insurance Supervisory Office and the Ministry of Health.

In January 2004 the Polish Constitutional Tribunal announced its finding (Trybunał Konstytucyjny orzeczenie, 7 January 2004, r. (Sygn. Akt K 14/03) that the existing health insurance law was unconstitutional because it failed to define with sufficient precision the scope of services that beneficiaries may expect from the national health system as mentioned in the Constitution (“Conditions and scope of services will be detailed in the appropriate law,” Paragraph 62). The Government was given approx. 1 year to prepare a new law to fulfill this requirement.

In formulating the new law many different possibilities were considered. One suggestion was that the law should contain a list of medical procedures which are performed in the system. This idea was considered unrealistic, however, especially because of the short period available for drafting the law. There were strong voices to the effect that some one must distinguish clearly between those services that are provided fully free of charge within the system and those that must be paid for either partially or in full by the patients. This differentiation was made by a group of experts assembled by the Minister of Health [3]. The concept also considered the establishment of a special institution, which would make technology assessments of medical interventions and participate in the decision-making process on inclusion and exclusion of the interventions in the benefit basket for universal health insurance. Finally, because there was no prevailing opinion as to the final role of the technology assessment institution, it was not established. However, the Minister of Health was required by stipulations in the last paragraph of the insurance law to “undertake efforts to establish an organizational structure, whose task would be to make health technology assessment of medical procedures, with special regard to procedures, which were subject to purchasing by the Fund.” Certain changes in insurance law, namely attachment of a list of excluded procedures, together with a promise to establish an institution of health technology assessment, solved the legal controversy between Parliament and Constitutional Tribunal.