5. Provision of services
- The adoption of the Act on Public Health in 2015 has enhanced the status of public health in Poland. The Act has pulled together regulations pertaining to public health in one piece of legislation; it also changed the focus of the National Health Programme to fighting risk factors and, for the first time, allocated separate funding for its implementation.
- Numerous programmes of coordinated care have been implemented since 2015, including for cancer patients, pregnant women and children, improving integration of primary and secondary care. Since late 2017, coordination of care has also been piloted within primary care – care for patients with selected chronic diseases will be coordinated by teams consisting of a physician, nurse and midwife. Integration of health and social care remains poor.
- Pharmaceutical pricing and reimbursement policy has been reformed: reimbursement rules have been made more transparent and a number of cost-saving measures have been introduced, including a cap on the NFZ’s pharmaceutical spending and risk sharing instruments.
- Provision of rehabilitation and LTC remains inadequate to the population needs and waiting times are long. The burden of caring for dependent persons remains largely borne by their family members. The quality of palliative care is good; however, only about 50% of palliative care needs are met.
- Mental health care is mainly provided in outpatient mental health care institutions and renewed efforts are being made to shift care into the community. To that end, work on piloting Mental Health Centres has begun since mid-2018.
- The scope of publicly financed dental health services is very narrow and most dental care financing comes from private sources. Incidence of dental caries in children is very high. In 2017, the Minister of Health purchased 16 mobile dental clinics (“dentobuses”) to improve access to dental health for children.
5.1 Public health
National policy in the area of public health is set out in the NPZs. The first NPZ was developed in 1990 as a response to the Global Strategy for Health for All by the year 2000. It was the first attempt to coordinate efforts of different units of government administration, NGOs and local communities in order to protect, maintain and improve the health of the population. The fourth edition of the NPZ covered the 2007–2015 period (see section 2.5 in Sagan et al., 2011) and the current version is in place for the years 2016–2020. Its goals are described in Box5.1.
Until the adoption of the Act on Public Health in 2015, there was no single legislative act comprehensively regulating public health services in Poland. Regulation was scattered over a number of acts regulating specific public health issues, such as control of alcohol and drug consumption, control and prevention of infectious diseases, control of hygiene and sanitary conditions, and acts setting out the tasks of public health institutions. The Act on Public Health aims to increase the recognition of the importance of public health, which has been traditionally low, and to contribute to a systematic and multidisciplinary approach to public policy in this field. The Act changed the strategic focus of the NPZ from disease prevention to fighting risk factors and allocated (for the first time) separate funding for its implementation. From 2017 onwards the NFZ has been obliged to spend 1.5% of its overall budget on preventive services. To put this in context, spending on prevention accounted for 0.2% of the NFZ’s total budget in 2016 (see Table3.4). The Minister of Health, supported by the Public Health Department of the Ministry, is responsible for managing public health services and coordinating public health activities. The Act gives the Minister the right to establish a plenipotentiary for these tasks. The Act also established a Public Health Council as a consultative and advisory body to the Minister of Health. The Council is tasked with ensuring that public policies follow a Health in All Policies approach and fostering intersectoral cooperation.
Key national institutions with responsibilities over public health include the National Institute of Public Health – National Institute of Hygiene (NIZP-PZH), the Chief Sanitary Inspector and the State Pharmaceutical Inspectorate (see Table2.1). Other national level actors with responsibilities in certain areas of public health include specialized research institutes (the Nofer Institute of Occupational Medicine, the Institute of Occupational Medicine and Environmental Health, the Institute of Agricultural Medicine, and the National Food and Nutrition Institute) and state agencies (the AOTMiT, which evaluates publicly financed health policy programmes; the CSIOZ; the National Bureau for Drug Prevention; the State Agency for the Prevention of Alcohol-Related Problems; and the National AIDS Centre).
Local authorities finance local health policy programmes and can independently decide on how to spend their budgets, depending on the local needs. Local health policy programmes are usually carried out by health care providers owned by the local authorities. The main exceptions are the programmes to control consumption of alcohol and illicit drugs which are implemented by the entities of the local self-governments. In 2017, alcohol control measures accounted for the largest part (68.3%) of health care expenditure of the municipalities and the second largest part (25.6%) of health care expenditure of cities with the county status (GUS, 2019). In terms of the number of local health policy programmes, the majority (e.g. in 2018, 108 out of 352 programmes as of November 2018) were related to vaccinations (AOTMiT, 2018b).
Box5.2 provides an assessment of the effectiveness of public health interventions that address risk factors.
5.1.1 Prevention and screening
The Polish immunization programme includes the mandatory immunization programme for children and youth, mandatory immunization programme for risk groups (e.g. vaccination against hepatitis B for medical personnel at risk, vaccination against chickenpox for people with immunodeficiency – mainly children in nurseries), post-exposure immunization (e.g. rabies vaccination) and the programme of recommended immunizations for children and adults. (See Fig5.1 for the incidence of infectious diseases in Poland in 2012–2017). Vaccinations included in the mandatory immunization schedule for children are compulsory to all children residing in Poland for at least 3 months and are available free of charge. The current immunization schedule (2018) includes 11 mandatory vaccines (see Table5.1). Parents who refuse to vaccinate their children must pay a monetary fine (Fig5.2 shows the number of children who did not receive mandatory immunizations in 2012–2017). The recommended immunization schedule includes additional vaccines that are recommended but not publicly financed, e.g. a rotavirus vaccine or meningococcal vaccine (NIZP-PZH, 2017b).
National screening programmes currently in place include:
- breast cancer prevention programme offering mammography to women aged 50–69;
- cervical cancer prevention programme offering cytology to women aged 25–59;
- colorectal cancer prevention programme offering free colonoscopy and personal (one-off) invitations for colonoscopy for persons aged 55–64;
- tuberculosis prophylaxis programme addressed to people over 18 years old with no previously diagnosed tuberculosis;
- prenatal testing programme for pregnant women who meet at least one of the following criteria: (a) are aged 35+; (b) experienced the occurrence of fetal or child chromosomal abnormalities in a previous pregnancy; (c) are themselves affected (or their partner is affected) by structural chromosomal aberrations; (d) have a significantly increased risk of giving birth to a child afflicted with a monogenetically or multifactorial disease; (e) whose pregnancy has a confirmed (via an ultrasound or biochemical tests) increased risk of a chromosomal aberration or fetal defects;
- cardiovascular disease prophylaxis programme for people aged 35, 40, 45, 50 or 55 years old; and
- programme for the prevention of tobacco-related diseases (including COPD).
According to a recent audit by the NIK (NIK, 2017c), participation in cancer prevention programmes is not very high, which indicates that educational campaigns related to these programmes are not very effective. For example, approximately 16% of the target group participate in the colorectal cancer prevention programme; just over 20% in the cervical cancer prevention and about 40% in the breast cancer prevention programme. The outreach of the cardiovascular disease prophylaxis programme was also low: in 2012–2015, screening reached less than 5% of the target population (NIK, 2017c).
5.1.2 Occupational health services
Occupational health services are provided by local occupational health practices and medical centres. Their scope is limited to individual periodic health exams and fitness checks. Focus on working conditions and work environment is weak and workplace health promotion activities are restricted to individual projects. There are no system-wide activities in this area.