Health Care in Eastern & Central European Countries with special ref. to Poland

---------------------------------------------------------
    This document has been made available in electronic format
         by the International Co-operative Alliance ICA 
    ----------------------------------------------------------
                         July, 1996

Source : Review of International Co-operation Vol.89, No
1/1996, 82-85.


          Health Care In Eastern and Central European
          Countries with special reference to Poland
                    by Alina Pawlowska*
          *******************************************


Introduction
------------
The organisation of health services in communist countries
varied from one country to another with one constant: there
were provided and owned by the state through several
ministries and financed out of general tax revenues. The
private sector with few exception was virtually nonexistent. 

The structural sophistication of the care systems is
comparable to that of the most advanced Western countries. The
infrastructural network is closely knit and access to basic
health services can be regarded as easy. When measured in %
share of the GDP the health care is not cheap. Total health
care expenditure in Eastern and Central European Countries
relative to GDP is in low range of expenditure reported by the
OECD - around 5%. In absolute values it is much lower than
that observed in most Western countries.

All countries are now reorganising the health sector,
transferring services to the business sector, community
organisations and NGO's. This process should lead to the
optimization and rationalization of resources into which the
co-ops could be integrated as yet another option in the
market. 

Health Status
-------------
Available statistics show that the health status of the
Eastern European region is worse that those of the Western
part. Relative comparisons between the Eastern and Central
European countries (ECEC) and the rest of the Region also show
that the gaps have widened in all respects between 1981 and
1989/1990. Infant mortality rates are 2-3 higher than in the
rest of the Region. Communicable diseases are persisting,
implicating problems with vaccine production and quality. The
mortality from cardiovascular diseases indicates unhealthy
life-styles, low-quality hypertension screening, lack of
proper follow-up and medication and poor emergency care for
coronary disease. Mortality from liver disease and cirrhosis
and that from chronic pulmonary disease are also higher in the
ECEC. This difference is associated with greater alcohol and
tobacco consumption, poor nutrition and living conditions. 

Nonetheless, there is evidence of quality deficiencies in the
system due to the shortage of crucial inputs such as drugs. A
demotivated low-paid task force is an equally important
problem. There are reports of inefficiencies due to
misallocation of resources between different categories of
providers.

Characteristics of the Polish  System
--------------------------------------
Any discussion of the changes needed and support for the
reform process must start with the analysis of the health
system. 

Comprehensive health care is provided by the Ministry of
Health through three tiers of a highly structured network of
services. The cornerstone of the system is the Local Health
Centre (LHC). Rural localities have usually one LHC, when in
large cities several may operate. An average LHC has a general
practitioner, a dentist, a paediatrician and a gynaecologist.
As a rule there is no free choice of doctor. The general
practitioners provide basic care, patients may then be
referred to polyclinics at the secondary level and to regional
or specialized clinics at the tertiary level. There is no fee
charged for consultations or analysis, but informal payments
are widespread. 

Fragmentation of Health Care
----------------------------
A characteristic feature of the Polish health care system is
the existence of parallel health systems managed by the
ministries of Defence, Justice, Transport, Industry and the
Interior. The Ministry of Education shares responsibility for
medical education and implementing school health programmes.
Large schools have medical and dentist cabinets with doctors
and nurses employed either full or part time. Some large
public enterprises run their own medical facilities. The
Ministries of Environment, of Food and of Agriculture are
jointly responsible for monitoring public health. 

These parallel health systems mirror the structure of the
public sector. The basic unit is the health centre which is
followed by the polyclinic and regional hospital. The salaries
of medical staff and drugs expenditures are financed from a
central budget while other costs are covered by respective
authorities. In the public's opinion the parallel systems are
more efficient and better equipped than local health centres.
Since the use of these facilities is limited to only one
category of patients, e.g.  railway personnel or army staff
and their families - they tend to be less overcrowded. Care
units are managed centrally by the relevant ministries with no
coordination at local level, therefore overlapping or
under-utilisation of services occurs frequently. The services
provided are free of charge and are perceived as a part of the
salary benefits. 

Health System Reform
--------------------
Today the parallel health systems are under severe criticism.
The rarefaction of public money boosts the demand for
rationalisation of expenditure. In order to increase the
efficiency and cost-effectiveness some restricted services
need to be incorporated into the public sector while others
ought to be privatised. The privatisation of state enterprises
has also influenced the discussion on the real costs of health
care. The Polish government is actively seeking  ways to
introduce more competition and to diversify service providers,
however, the development of the co-operative sector has not
been under consideration as an option.

Co-operative Sector in Poland
-----------------------------
Health co-ops in Poland started in 1945 and are included in
the workers' sector as professional service provider co-ops.
Their members are medical doctors with a first degree
specialisation, already employed in public health system.
Although the private sector has a long history, carefully
edited laws prevent its development as an alternative to
public health service. 

The Medical Co-operatives operate on a fee-for-service basis.
Since there is no private health insurance, doctor's fees are
not reimbursed, which considerably limits the number of
patients. However, the fees are still less expensive that
those of a private practice. The most appreciated advantage of
the co-operative is the free choice of practitioner. 

The Medical Co-ops supplement Local Health Centres principally
in the field of special care. As a rule they have better
equipment, therefore the consultations are made under better
conditions, with shorter waiting lists and by specialized
physicians. They provide ambulatory treatment which they are
allowed to offer, but this does not include surgical
interventions when a clinic is needed. They also run
`wellness' centres which have became more and more polyvalent,
providing medical services to a limited extent.

Additionally, certain medical co-ops conduct prophylactic
consultations for employees as well as the medical assessment
of the work environment of co-ops for the disabled. Most of
the patients are insured. 

The Association of Medical Work Co-ops had 27 members by the
end of eighties out of total 31 health care co-ops and 9
multipurpose work co-ops running medical and dentistry
cabinets. The number of centres was 325 with 9.262 employees
including 3.532 doctors and 1.100 dentists. Recent statistics
are lacking because the co-operative system is undergoing a
transformation with many societies dissolving or changing
legal status. This is because the tax system is unfavourable
to co-ops, forcing several doctors to quit co-operatives in
order to open private cabinets.

Most of the Medical Co-ops used to rent premises from housing
co-ops. These co-ops have doubled and even tripled rents over
the past few years with the result that almost all societies
have to reduce their work space. In consequence the medical
equipment which has been assembled over the years had to be
put into storage and, therefore, deteriorated. 

However there is still room to develop medical co-ops. In 
future the co-ops will focus their activities on providing
services which are not yet available elsewhere. Current
research challenges the assumptions of theorists that the
health co-ops are only appropriate for lower-income classes.

Priorities 
----------
Within the framework of the systemic reform, the co-operatives
have a multiple role to play. First, as users' co-ops they
protect members in case of disease. Secondly, as insurance
societies they form a social security net for the aged and
thirdly, as provider's co-ops they allow doctors to reduce the
operating cost of clinics and share professional insurance
fees.   The Report of the ILO Director-General to the Fifth
European Regional Conference in Warsaw in September 1995
discusses the actual situation within the sector and sets out
priorities in the reconstruction of the Eastern European
health care systems.  

There is an obvious need to decentralize the planning and
management of the health delivery systems in order to improve
the adequacy of health services at the community level. In its
1993 World Development Report, the World Bank stresses the
need for greater involvement by nongovernmental and other
private organisations in the provision of health services. The
Report underlines the significant role of health and education
for economic and social development. It invites the
governments to devote more attention to family health,
particularly by improving access to schools for girls and by
promoting women's employment. Privatisation - including
setting up of co-operatives - is widely regarded as a way to
contain public spending and to ameliorate the efficiency of 
service. 

----------
* Ms Pawlowska is the Documentation Officer for ICA, Geneva.