Warszawa 27 kwietnia 2011 r.

1. DEVELOPMENT OF PUBLIC HEALTH, HEALTH SERVICESAND PUBLIC HEALTH PROGRAMESIN POLAND AND IN MASOVIA VOIVODESHIP Krzysztof Romanowski M.D. Deputy Director Department of Health Office of the Marshal of the Mazovia Voivodeship 1 • Warszawa 27 kwietnia 2011 r.

2. Years 1948 - 1998After World War II a new centralized, budgetary, health care financing system has been introduced in Poland. The System of financing health care, based on soviet was called „Siemaszko's model”. A similar system was existing in all countries of Eastern bloc. The beginning of this system should be the date of 29 November 1948 - the date of enactment of parliament act of „the public health care units and planned economy in the health sector”. • In 1973 there has been a horizontal integration, the functional and managerial, based on medical facilities in the districts (powiat). The resulting, so-called Health Care Units, from the combined: district hospitals, outpatient specialty clinics, outpatient general clinics - municipal and rural communities, emergency services and social care centers.Today we would call these systems as "integrated care teams„. The assumptions of the budgetary system of financing health care: • financing of health services and health programes from the state budget, on the basis of central planning • stable budget of the health care units, based on the area, that is a place of residence of people entitled to using the system and the number of beds in hospital • national organization of health service • universal access no charge health service for all citizens • the marginal role of the private sector in health care 2 • Warszawa 27 kwietnia 2011

3. The good sides of the budgetary old system: • universal access to no charge health service for all citizens • low financial service cost for the system • integration of health services - hospital - outpatient specialist clinics - outpatient general care clinics. The bad sides of the budgetary old system: • lack of motivation, at management level and even the phenomenon anti-motivation to lift the level of services (better hospital - more patients - higher operating costs at the same pre-established level of funding), which in results to barriers of access to the hospital for patients • difficult access to health services for patients residing outside of the assigned region of hospital (e.g., for patients from another district) • difficult access to health services for patients, leading in corruption • arbitrarily determined by the Ministry of Health, level of salaries for the staff in state hospitals, which depends only on their position, and is completely independent of the effectiveness and productivity of labour, effecting a weak staff engagement to their work 3 • Warszawa 27 kwietnia 2011

4. Years 1989 – 1999 • REFORM • Parliamentary Act of 18 July 1998 on „universal health care insurance” (JL of 1998, No. 117 pos. 756) has introduced an insurance system of Sickness Funds.Budget funding system has been replaced by insurance system, which is a regional modification of the German insurance system in Polish health care.Functions of the organization and management have been separated from the system of financing.Assumptions the role of insurance funds: •   16 Regional Sickness Funds (for the regions) • One Sickness Fund for the uniformed services (police, army and others) • At the same time the parliament decentralized management of public health units, most of them giving to local governments at different levels, and social care were separated from the public health. 4 • Warszawa 27 kwietnia 2011

5. Each level of local government received the distinct tasks in the organization and management in public health and social care: Municipalities - basic health care, universal prevention programes, and some of the tasks in the field of social welfare.Districts - district hospitals (level I referentiality), outpatient specialist care and specialized health programes, and the remainder of the tasks of social welfare.Voivodship self-government - regional hospitals, (level II referentiality), in-patient psychiatric service, including hospitals, supervising for labour medicine, supervising the implementation of health programmes which are particularly important (combating drug abuse, combating alcoholism, HIV-AIDS prevention), as well as health education. 5 • Warszawa 27 kwietnia 2011

6. Health care financing by local governments Municipalities - for the public health spend only about 1% of theirbudget. These measures are mainly addressed for alcohol prevention programs at the elementary level. The funds for this purpose are derived from fees for the license to sell alcohol. In addition, municipalities supervise functioning of health care in general outpatient clinic, and financing investments in this sector. Districts - districts spend on the public health about 5% of their total budget. The district’s budget funds all district investments in hospitals and outpatient specialist clinics.In addition, districts finance health service for people having no obligation to insurance (the unemployed without entitlements to any benefits and homeless people). These are the tasks refunded by grants from national budget.Voivodships - on average, regions spend for the public health, approximately 7% of their budgets. The self-government’s budget mainly finance by region’s investment in regional hospitals, including: the purchase of medical equipment, building investments, as well as important health programes, and educational activities in the field of health promotion. 6 • Warszawa 27 kwietnia 2011

7. Units of health care subordinate to central government: • Clinical university hospitals (level III referentiality) and research institutes hospitals - subordinated to the Minister of Health • Military Hospitals and dispensaries - subordinated to the Minister of Defence • Hospitals and outpatient clinics for the police and security services - subordinated to the Minister of Internal Affairs and Administration • Hospitals and outpatient clinics in prisons - subordinated to the Minister of Justice 7 • Warszawa 27 kwietnia 2011

8. REFORM AGAIN Parliamentary Act of 23 January 2003 for general insurance in the National Health Fund (JL 2003, No. 45, item. 391) - health care financing reform.16 Regional of Sickness Funds and Sickness Found for the uniformed services were converted into in a one National Health Fund with 16 provincial branches.The main source of financing for medical services in Poland are the resources recived from the health premium, collected by ZUS (Social Insurance Institution) and KRUS (Agricultural Social Insurance Fund) and transferred to the National Health Fund.Farmers pay a premium for health care, in proportion to the area of farms (by half the current price of the 100 kg of rye from one conversion hectare).All other citizens, pay percentage premium. The actual amount of health premium is 8.75% of gross salary, of which 7.5% is reduced from income tax. 8 • Warszawa 27 kwietnia 2011

9. Financed of health care programmes: • from the state budget – by Minister of Health – strategic programmes, • from the National Health Fund – comon programmes, e.g.: prophylactic vactinations for children, anti-smoking programmes, combating with hiprtension disease programmes, oncologic programmes (brest cancer, cervix cancer) • from self-governments budget – local health care programes. - voivodships, - districts, - municipalites. Financed of pro-health education: • from the state budget – by Minister of Education – as a part of sylabus • from the voivodships self-governments budget – as a local programmes 9 • Warszawa 27 kwietnia 2011

10. In accordance with article 68 of the Polish Constitution, everyone has the right to health care. Citizens, regardless of their financial situation, public authorities shall be ensure equal access to health care services, financed from public funds. The conditions and scope of benefits are specified by law.Objectives:• improve the health status of population and promotion of social welfare• ensure equality of in access to health care• ensure micro-and macro-economic efficiency of the resources used• take care at the clinical effectiveness of the care distributed• improve the quality of health care and patient satisfaction• ensure long-term financial stability of the system 10 • Warszawa 27 kwietnia 2011

11. Priority action undertaken to improve the health state of Mazovia voivodship residents (according to voivodship strategy) accomplishment of investments in the stationary health care – development and modernisation of stationary health care units; including reequipment of operating theatres, new wards in hospitals as well as buying modern equipment and medical apparatus. restructuring short-term health care and creating daily stay pattern enabling quick diagnostic and perform minor surgeries in hospitals. creating new forms of health care resulting from medical needs of aging population, especially long-term health care, e.g. out-patient clinics, long term care and nursing clinics with rehabilitation wards. expansion of emergency assistance, including cardiac, post – accident and medical emergency. New emergency departments were opened. development of the system of prevention and treatment of addictions – detox organisation. 11 • Warszawa 5 luty 2011

12. Expansion of the highly specialised cardiology wards, coronary care units and intensive care units in self-government hospitals ( example of accomplishment of medical policy strategy. Cardiology and immediate cardiology intervention • 10 hospitals have cardiology wards with the total number of 506 beds, including 66 intensive cardiological care positions • 7 hospitals ,which have cardiology wards, opened hemodyamics labs. They were provided with proffessional angiographs and medical equipment • self-government hospitals attend 24 hour service of acute coronary syndrome treatment. Neurology and coronary care units. • New intensive neurological care positions and coronary care units have been opened • For the time being there are 8 hospitals which posses 295 beds in neurology wards, including 111 for the patients after stoke and 12 intensive neurological care positions. Intensive care units • Expansion and complete modernisation of wards and intensive therepeutic care positions (extension by 33 positions) • For the time being there are 132 intensive care positions, including 18 for children, in 15 hospitals. Warszawa 5 maja 2011

13. Extension of hospitals, modernisation of wards – improvement of treatment . Adjusting rooms to EU standards, anti-fire , sanitary, epidemiology and other requirements Thermomodernisation of buildings, modernisation of energy infrastructure , water and sewage supplies, additional sources of energy and water, vertical communication and improvement of patient safety. Modernisation and extension of operating theatres, intensive care units, renewing their functions both, besides modernisation and building new sterilisation rooms, points of preparing beds. Building emergency departments in multi – profile hospitals, extension of cardiology wards with hemodynamics wards, neurosurgery, rehabilitation wards and the others Expansion of long-term health care clinics for chronically ill patients by adopting empty rooms and building up new ones. Purchase of proffessional computer tomographs, resonances, angigraphs, Ultrasounds apparatuses, respirators and many others cruicial to diagnostic and medical treatment. Purchase of modern emergency ambulances Equiping hospitals in IT tools. Despite incuring expenses for investments of approximtely 910 milion PLN (227 milion Euros) from 1999 to 2009, the needs of health care units of voivodeship’s self – government have not been fullfilled entirelly. Main directions of investments 13 • Warszawa 5 maja 2011

14. Examples of accomplishment of medical strategy . New voivodship’s hospital in Plock with an extension of 90 beds New hemodynamics lab in Ciechanow New ambulances of Warsaw’s Emergency Department. New expansion of Air Emergency Services in Plock. Long term care and nursing clinics in Rasztow 14 • Warszawa 5 maja 2011

15. Thank you for your attention 15 • Warszawa 27 kwietnia 2011