The 2014 primary health care reform in Poland : short-term fixes instead of a long-term strategy

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Health Policy

jo u r n al h om ep age :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

The 2014 primary health care reform in Poland: Short-term ﬁxes instead of a long-term strategy

^夽

Anna Mokrzycka

^a

, Iwona Kowalska-Bobko

^a,∗

, Anna Sagan

^b

, W. Cezary Włodarczyk

^a

aJagiellonianUniversityMedicalCollege,FacultyofHealthScience,InstituteofPublicHealth,Poland

bEuropeanObservatoryonHealthSystemsandPolicies,UnitedKingdom

a r t i c l e i n f o

Articlehistory:

Received16December2015 Receivedinrevisedform22June2016 Accepted15July2016

Keywords:

Primaryhealthcare Healthcarelegislation Healthcarereform Poland

Familymedicine Olderpatients Internists Paediatricians

a b s t r a c t

Attheendof2013,theMinisterofHealthstartedlegislativechangesdirectlyandindi- rectlyaffectingprimaryhealthcare(PHC). Thereformswerewidelycriticised among certaingroupsofmedicalprofessionals,includingfamilymedicinephysicians.Thelatter mainlycriticisedtheformalinclusionofspecialistsininternaldiseasesandpaediatrics intoPHCwithinthestatutoryhealthcaresystem,whichinpracticemeantthatthesetwo groupsofspecialistswerenolongerrequiredtospecializeinfamilymedicinefrom2017 inordertoenterintocontractswiththepublicpayerandwouldbeabletosetupsoloPHC practices—somethingoverwhichfamilymedicinephysiciansusedtohaveamonopoly.

Theyarguedthatpaediatriciansandinternistsdidnothavethenecessaryprofessional competenciestoworkasPHCphysiciansandthusassureprovisionofacomprehensiveand coordinatedPHC.Thegovernment’sstancewasthattheproposedmeasurewasnecessary toassurethefutureprovisionofPHC,giventheshortageofspecialistsinfamilymedicine.

Certaingroupsofmedicalprofessionalswerealsosupportiveoftheproposedchange.The keyargumentinfavourwasthatitcouldimproveaccesstoPHC,especiallyforchildren.

However,whilethiswasnotthesubjectofthecritiqueorevenapolicydebate,thepro- posalignoredtheincreasinghealthcareneedsofolderpatients—thekeyrecipientsofPHC services.ThepolicywaspassedintheParliamentinMarch–April2014withoutadialogue withthekeystakeholders,whichistypicalofhealthcare(andother)reformsinPoland.

Thestrongoppositionagainstthereformfromthefamilymedicinespecialists,represented bytwostrongorganisations,mayjeopardisethepolicyimplementationinthefuture.

1. Purposeandcontentofthepolicy

In2007,the2004ActonHealthCareServicesFinanced fromPublicSourceswasadaptedtotheprovisionsofDirec- tive2005/36/EC of theEuropeanParliament and of the

夽 OpenAccessforthisarticleismadepossiblebyacollaboration betweenHealthPolicyandTheEuropeanObservatoryonHealthSystems andPolicies.

∗ Correspondingauthor.Fax:+48124217447.

E-mailaddresses:iw.kowalska@uj.edu.pl,ikowalska72@gmail.com(I.

Kowalska-Bobko).

Councilontherecognitionofprofessionalqualiﬁcations.

AccordingtoArticle29ofthisDirective,whichregulates thepursuitofprofessionalactivitiesbygeneralpractition- ers(GPs),eachmemberstateshall,subjecttotheprovisions relatingtoacquiredrights,makethepursuitofsuchactivi- tiesintheframeworkofitsnationalsocialsecuritysystem contingentuponpossessionofevidenceofformalqualiﬁ- cationsreferredtoinAnnexVoftheDirective.InPoland, theevidenceofsuchformalqualiﬁcationsisthediploma infamilymedicine.TheadoptionoftheDirectivemadethe provisionofPHCserviceswithinthePolishsocialhealth insurancesystem,i.e.undercontractswiththeNational

http://dx.doi.org/10.1016/j.healthpol.2016.07.012

org/licenses/by-nc-nd/4.0/).

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HealthFund(NHF),conditionalonthepossessionofsuch diploma. PHCphysicians whodo nothave adiploma in familymedicinebutwhohaveworkedasPHCphysicians foratleasttenyearspriortotheadoptionoftheDirective havebeenexemptedonthebasisoftheabovementioned provisions relatingtotheacquiredrights.AllotherPHC physicianswithoutsuchadiplomawhowishtocontinueto workasPHCphysicianswithinthesocialhealthinsurance systemwererequiredtoobtainaspecializationinfamily medicineuntil2017[3,26].

Giventhelownumberoffamilymedicinephysiciansin Poland(oneper3500people,comparedtooneper2500 recommended by theexperts[16]; seealso Fig.1) and theshorttimeleftforcompletingspecializationinfam- ilymedicine(until2017)itwasevidentthatashortageof familyphysicianswasloomingin2017,posingathreatto theprovisionofPHC.Facedwiththisthreatandalsotaking intoaccountthefactthatthedecliningdemandforpae- diatricianscausedbytheageingofthepopulationcould haveanunfavourableimpactontheemploymentopportu- nitiesforthisgroupofspecialistsinthefuture,attheend of2013,theMinisterofHealthproposedtolegallyallow allspecialistsininternaldiseasesandpaediatricstowork inthestatutoryhealthcaresystemasPHCphysiciansand tosetuptheirown(solo)PHCpractices.Apartfromavert- ingtheinevitableshortageofPHCdoctorsand ensuring employmentopportunitiesforpaediatricians,anothergoal ofthepolicywastoincreasethenumberofPHCdoctors– itwashopedthatthepolicywouldencourageprivately- practicingpaediatriciansandinterniststomovetopublic PHC–andtherebyimproveaccesstoPHCingeneral,and topaediatriccareforchildren.Thepolicywaspassedin March–April2014andcameintoforceinJuneofthesame year.

Previously, paediatricians and internists, with the exemption ofphysicians withat leasttenyears of PHC experiencepriortotheadoptionofDirective2005/36/EC, whilebeingallowedtoworkasPHCdoctorsundercon- tractswiththeNHF,werenotallowedtosetupsoloPHC practices(inbothpublicandprivatehealthcaresectors) andcouldonlyworkinPHCpracticesasemployees.More- over,from2017,youngpaediatriciansandinternists(with lessthantenyearsofexperienceinPHCatthetimeDirec- tive2005/36/ECwasadopted)wouldnolongerbeallowed toworkasPHCphysiciansundercontractswiththeNHF, unlesstheyspecializedinfamilymedicine.

ThepolicythatcameintoforceinJune2014included thefollowingmeasures:

(1) Thelegalrequirementonprimarycaredoctorswith lessthantenyearsofexperienceinPHCpriortothe adoptionofDirective2005/36/ECtospecializeinfamily medicineby2017wasexpunged;and

(2) Allpaediatriciansandinternists,notonlythose who hadat leasttenyearsof experiencein PHCpriorto theadoption ofDirective2005/36/EC,wereformally allowedtoworkasPHCdoctorswithinthestatutory healthcaresystemandtosetupsoloPHCpractices.

The policyplaced all paediatriciansand internistsat equal footing withfamily medicinespecialists, without

requiringfromthemanychangesinprofessionalcompe- tencies.Thismeans,forexample,thatpaediatriciansare allowedtoregisterandtreatadultsandcanreceivecapita- tionpaymentfromthePHCbudget,undercontractswith theNHF.

These measures were part of the general effort to improvethefunctioningof PHCbyimprovingtheavail- ability of primary care doctors, shifting patientsto the lowestpossiblelevelofcare,shorteningwaitingtimesfor diagnosisandfurthertreatment,andintroducingnewcare pathwaysforcertaintypesofpatients(mainlyoncological patients).Otherkeymeasureswithintheseeffortsincluded the“waitinglists”andthe“oncology”reformpackagespro- posedinMarch2014andpassedintheParliamentinJuly ofthesameyear[9,8].

2. Politicalandeconomicbackground

Poland,likemanyotherformereasternbloccountries, inheriteda poorlyarrangedPHCsystem,withtoomuch focusontreatmentofcommonconditionsandrelatively lowimportancegiventoprophylacticactivities.Afterthe collapseofthecommunistregime,effortshadbeenmade toimprovetheroleandqualityofPHCthatatthattimewas atrendvisibleinmanyothercentralandeasternEuropean countries[10].In1993specialisationinfamilymedicine wasintroducedand, aroundthis time, severalattempts weremadetoelaborateapolicydocumentdescribingthe desireddevelopmentofPHC,includingaproposaltomake it the main driver of health sector transformation. The attemptstoworkoutacomprehensivestrategydocument hadbeenunsuccessfulduetofrequentchangesofgovern- mentand,todate,thereisnocleargovernmentalstrategy forPHC[26].ThisappliestomanyaspectsofPHCservices, includinghealthpromotion asoneof themainareasof PHCactivities(emphasisedassuchintheAlmaAtaand OttawaDeclarations)andtoolderpatientsasoneofthe keyrecipientsofPHCservices(seebelow).

Familymedicineis not a very popularspecialization amongmedicalstudentsinPoland[21].Thereasonsbehind this include: broad scopeof required knowledge; rela- tivelypoorworkingconditions, wages,and professional statuscomparedtoothermedicalspecializations;andlim- itedcareeroptions,withbetterprofessionaldevelopment opportunitiesavailableinhospitalsettings(seeforexam- pleRef.[7]).Accordingtothemostrecent international data,in2013PolandhadthelowestnumberofGPsper 100000peopleintheEU(21comparedtotheaverageof79 intheEUmemberstates),whilethenumberofspecialists per100000washigherthattheEUaverage(100inPoland comparedto97intheEU)(Fig.1).Thisisreﬂectedinthe ratioofGPstospecialists,whichinPolandisthesecond lowest(afterGreece)amongEUmemberstates.In2013, thisratiowas0.2forPolandcomparedto0.8forEUcoun- tries.Whenpaediatriciansareincludedintothenumberof primarycaredoctors(nodataonthenumberofinternists wasavailable),theratiogoesupto0.3,whichisstillvery lowbyEuropeanstandards(itis1.0forEUmemberstates onaverage).

The2004ActonHealth CareServicesFinanced from Public Sources amended in 2007 deﬁnes PHC as pro-

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21 13 100

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00

0 50 100 150 200 250 300

Greece Poland Czech Republic EU13 Bulgaria Croaa Portugal Lithuania Italy Romania Germany Austria Slovenia Estonia EU Netherlands EU15 Luxembourg Ireland Spain Malta United Kingdom Belgium France

GPs per 100000 Paediatricians per 100000 Specialists* per 100000 GPs to specialists*

Fig.1.NumberofGPs,paediatriciansandothermedicalspecialists*inEUmemberstates,2013.

Notes:*Excludingsurgery,gynaecologyandobstetrics,paediatrics,psychiatryandgeneralpractice;i.e.GPs=familymedicinespecialistsinPoland.EU15=EU memberstatesbeforeMay2004;EU13=EUmemberstatessinceMay2004.NodataforCyprus,Denmark,Hungary,SlovakiaandSweden;nodataonthe numberofGPsforFinlandandLatvia.CountriesweresortedfromlowesttohighestratioofGPstospecialists.

Source:WHORegionalOfﬁceforEurope[27].

phylactic health services, diagnostics, treatment, and rehabilitationandnursingservicesintheareaofgeneral medicine,familymedicineand paediatricsthatare pro- vided withinambulatory care settings by specialists in family medicine (including physicians undergoing such specialisation)and (secondgrade)specialists in general medicine. The Executive Regulation of the Minister of Healthof20October2005onthescopeoftasksofdoc- tors,nursesandmidwivesworkinginPHC(JournalofLaws, 2005,No2014,item1816)setsoutactivitiesinthearea ofhealthpromotionandprophylaxisthataretobeper- formedwithinPHCwithinthestatutoryhealthcaresystem butwithnoindicationonwho,i.e.typeofprovider,isto providetheparticularservices.ThisRegulationexplicitly listsanumberofhealthpromotionandprophylacticser- vicesthataretobeprovidedwithinPHC;theseinclude:

indicationanddiagnosisofhealthrisk,healtheducation, provisionofmentoringin healthylifestyle,educationin hygienicnursingofnew-borns, educationin prevention ofgynaecologicaldiseases.Despitetheexistenceofthese veryclearlegalobligations,preventiveactivitiesareoften neglectedandmedicaltreatmentofdiseasesisprioritized.

Thisspeciﬁcallyconcernsactivitiessuchashealtheduca- tionandmentoringinhealthylifestyleandismainlycaused bythelackofresourcesandtheresultingneedtoprioritize tasks[19].Thelistofhealthpromotionservicesthatare

includedintheguaranteedbeneﬁtswithinthestatutory healthcaresystemintheareaofPHCisshowninTable1.

Deficiencies in the provision of health promotion services within PHC are particularly visible for older patients. Olderpatients often represent the mostcom- plexcasesthatPHChastodealwith,astheyoftensuffer fromco-morbidities.Theymayalsohavelong-established unhealthy habits and behaviours that may be difficult to correct and the health effects of these habits and behavioursmaybedifficulttoreversebyhealthpromotion activities.Giventheabove,preventionofhealthrisksand promotionofhealthylifestylesinthispopulationgroupis oftenneglectedbyhealthcareprofessionals.Theresultsof apilotresearchprojectcarriedoutwithintheframework oftheEuropeanProjectPROHEALTH65+,whichincluded in-depthinterviewswithPHCexperts,showedthatthere isnotenoughemphasisonhealthpromotionservicesat thelevelofPHCinPolandandthis ismorepronounced forolderpatients(thisresearchfindingisincludedinan unpublished reportof a pilotstudy undertaken aspart ofPROHEALTH65+projectfundedwithintheframework ofEU’sHealthProgramme2008–2013;seeAcknowledge- ments).Accordingtotheinterviews,lackoftimeisthemain reasonwhydoctorsarenotabletodeliverproperhealth promotionservicestothispopulationgroup.APHCphysi- cianmustseeallpatientswhocometoseetheminagiven dayandthereisnolegallyproscribedminimumtimethat

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Table1

TypesofprimarycareservicesprovidedbydifferenttypesofPHCproviders.

Primarycaremedicaldoctor Primarycarenurse Primarycaremidwife Nurseschoolhygienist - Medicaladvice(preventiveand

curative)

- Preventivehealthservices(e.g.

cardiovascularprevention programme)

- Periodichealthassessment - Vaccinations

- Diagnostictests

- Referralstothehigherlevelof healthcare

- Medicaladviceatnightandduring holidays

- Nursevisit - Patronagevisit

- TBpreventivehealthvisit(e.g.

healtheducation,collectionof samplesforpreventive diagnostics)

- Screeningtests

- Servicesprovidedatnightand duringholidays,includinginmedical emergencies

- Midwifevisit - Patronagevisit

- Preventivehealthvisit(e.g.

healtheducation,adviceon nutrition)

- Planningthescreeningprocess - Conductingscreeningtestsand

interpretingresults

- Activeguidanceforpupilswith healthproblems

- Paramedicalservices(inaspeciﬁed cases)

- Guidancefortheschooldirectorin commonhealthproblems - Educationinoralhealth - Participationinplanning,

realizationandevaluationof healtheducation

Source:ExecutiveRegulationoftheMinisterofHealthof24September2013ontheguaranteedbeneﬁtsintheareaofprimarycare(JournalofLaws,2013, item1248).

Note:Preventivehealthservicesaremarkedinbold.

aprimarycaredoctorshouldspendwitheachpatient.Also thelackofﬁnancialincentives inthecontracting model withtheNHFcontributestotheunder-provisionofsuch services.

3. Stakeholders’positions

Thepositionsofthekeystakeholdersduringthepol- icyprocessdifferedandreﬂectedtheirparticularinterests (Fig.2).Ithastobenotedthatpatientslackedavoiceinthe decisionmakingprocess.Thismaybebecausetheywere eithernotawareofthepolicychangetakingplaceorthere wasnoinﬂuentialorganisationthatwouldrepresentthem (bothoftheseargumentsoftenapplytoolderpatients), eveniftheiropinionswerewelcomed.Forexample,the InstituteforPatientRightsandHealthEducation,whichis usuallyveryactive,withnoexplanationandunderstand- ablereason,didnotgetinvolvedinthepolicyprocess.

Thepolicywaspassedwithnoconsultationswiththe majorstakeholders,i.e. familymedicinespecialists.This is typicalofthelegislativeprocess inPoland andis not restrictedtothehealthcaresector.

3.1. Mainopponents

Familyphysicianswerethekeyopponentsofthepro- posedpolicy.Thisstakeholdergroupwasrepresentedby twostrongorganisations:theCollegeofFamilyPhysicians and theHealthCareEmployer’sFederation. TheCollege of Family Physicians made a very emotional appeal to theMembersoftheParliamentarguingthattheproposed changeswouldleadtoafragmentationofPHCservices,pro- longwaitingtimes,limitaccesstocomprehensivemedical care,increaseinequalitiesinaccesstocareand increase healthcarecosts[3].Theyassertedthatpaediatriciansand internistsdidnothavethenecessaryprofessionalprepara- tiontoguaranteecomprehensiveandcoordinatedPHCto thepatients.Theyalsostatedthatthismeasurecouldlead tomorereferralstospecialistcaresincepaediatriciansand internistsaretrainedinanarrowrangeofservicesanddo

nothavecompetenciesinareassuchaswomen’shealth, mentalhealth,orminorsurgery(postgraduatetrainingof paediatriciansandinternistsdoesnotinclude anyprac- ticeinaPHCsetting).Thiscouldnegativelyaffectwaiting timesfortreatmentandqualityandaccessibilityofPHC, especiallyforolderpatients,whooftensufferfromchronic conditionsandarehighlydependentonPHC—theneeds ofthispopulationgroupwerenottakenintoaccountby thelegislator.Whilethisnotfeatureintheofﬁcialdebate, oppositionoffamilyphysicianswasprobablyalsodriven by their ﬁnancial interests. Shifting paediatricians and internistsintoPHCwoulddiminishthebargainingpower offamilyphysiciansandincreasedcompetitionofNHF’s contractscouldalsoaffecttheirremuneration.

The Health Care Employers’ Federation, known for beingconfrontationalintheirresponsestopolicychanges (theyhavepreviouslyinitiatedprotestsandstrikes),was alsostronglyopposedtotheproposal[5].TheFederation stressedtheimportanceofprovidingPHCbyphysicians trained in family medicine: unlike paediatricians and internists,familymedicinedoctorscanlookafterallmem- bersofahouseholdinacomprehensivewayandallowing paediatriciansand internistsinto PHCwould inevitably narrowthescopeofPHCservices.NeithertheCollegeof FamilyPhysiciansnortheHealthCareEmployer’sFeder- ationproposedasolutiontotheloomingshortageofPHC physicians.

Thestrongoppositiontotheproposedchangesofthe representatives of family medicine physicians has also beenvisiblesincethesechangeshavebeenpassedinthe Parliamentandmayjeopardisetheirimplementationinthe future.TheCollegeofFamilyPhysicianshasclaimedthat theimplementedchangesareincompatiblewithDirective 2005/36/EC[20],whichmakesprovisionofstatutoryPHC servicescontingentupon possessionof evidenceof for- malqualiﬁcationsingeneralmedicalpractice(i.e.family medicineaccordingtotheterminology usedin Poland).

TheCollegehasclaimedthatallowingpaediatriciansand internistsintoPHCwould reduce thenumber offamily physicians in Poland. This is because medical students

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The Ministry of Health

Family medicine physicians represented by the College of Family Physicians and the Health Care Employers’ Federations

Pediatricians and internists represented by the Polish Pediatric Society and the Polish Society of Internal Medicine

The Chief Medical Chamber and the National Trade Union of Physicians The Children Rights Ombudsman 1

2 3 4 5

POSITION

INFLUENCE

very supportive

strongly opposed

g n o r t s e

n o n

1 2

3

4 5

Fig.2.Positionsofthekeystakeholdersandtheirinﬂuence.

Source:Authors.

arelikelytospecializeinpaediatricsorinternalmedicine ratherthanfamilymedicine,becausewhenchoosingthe latterspecialization,theycanonlyworkinPHC,whilewhen choosingtheformer,theycanworkinbothPHCandinpa- tientandanyoutpatient settings—notonly PHC[11].In early2015,manyPHCunitswereinaccessibleduetostrikes offamilyphysicians.Thesituationimprovedtowardsthe endoftheyear,partlythankstoaslightincreaseinthe PHCcapitationratesandpartlythankstotheshiftingof thefocusofpublicattentiontotheparliamentaryelections thattookplaceattheendofOctoberofthatyear.

3.2. Mainproponents

Themainproponentofthepolicythroughouttheentire policy process was its initiator—the Ministry of Health [24,23,12].AccordingtotheMinistryofHealth,inclusionof paediatriciansandinternistsinPHCwouldnotonlyassure theprovisionofPHC(giventheloomingshortageoffamily medicinespecialists)andimproveaccesstoPHCservicesto thepopulationbutalsoimproveaccesstopaediatriccare forchildren¹[24]:assumingthat15%ofpaediatricianswho currentlyworkoutsidepublicPHCmovetopublicPHC,the ratioofpaediatricianstochildrenwouldincreasefromone paediatricianper1150children toonepaediatricianper 980children[24].Withregardstotheclaimsmadebythe CollegeofFamilyPhysiciansonthepotentialincompati- bilityofthepolicywithDirective2005/36/ECtheMinistry formallyconfirmedthatthepolicywascompatiblewith EUlaw[22]. Thisofficialstancewasbasedonthelegal opinionoftheOfficeofParliamentaryAnalyses.TheMin- istryclarifiedthattheorganisationofnationalhealthcare

1 AccesstopaediatriciansworkingoutsidePHCwithinthestatutory system(i.e.intheprivatesector)canberegardedasmoredifﬁcultbecause oneneedstopayoutofpockettoseeaprivatepaediatrician.

systems,includingthePHCsystem,lieswithinthecompe- tencesofthememberstates.Itclaimedthattheinclusion ofphysiciansotherthanfamilyphysiciansinPHC,namely paediatriciansandinternists,waspossible,aslongasthe latter providedhealth care serviceswithinthescopeof theirprofessionalqualiﬁcations,i.e.paediatricsandinter- nalmedicine.Thisinterpretationhasbeenconﬁrmedbythe MinistryofForeignAffairs[22].Thismeansthatpaediatri- ciansandinternistswillnotobtainthesamecompetencies asfamilyphysiciansandwillonlybeabletoprovidePHC serviceswithinthescopeoftheirspecializations.

The following otherstakeholders werealsosupport- iveoftheproposedchanges:thePolishSocietyofInternal Medicine,thePolishPaediatricSociety,thePolishChamber of Physicians, and the National Trade Union of Physi- cians.Paediatriciansandinternists(andtheorganisations representing theirinterests) werein favour of the policy. Theproposed changes improvedtheir employment perspectives,especiallygiventhelowerdemandforpaedi- atriciansduetopopulationageing,andformallyallowing themintoPHCwithoutimposingadditionalrequirements withregardstotheirprofessionalqualificationsandper- formed tasks. Moving to PHC may also be financially attractivetomanypaediatriciansandinternists:forpae- diatriciansandinternistsworkingintheprivatesectorthis isbecausemovingtothepublicsystemmeansreceiving capitationpayments undercontracts withtheNHF and forpaediatriciansandinternistsworkinginthestatutory sector—becausesalariestheyreceiveinhospitalsarerela- tivelylow.Inthedocumentsignedbytherepresentatives ofthePolishSocietyofInternalMedicine,thePolishPae- diatricSocietyandthePolishChamberofPhysiciansbefore theMinistryinitiatedthepolicy,thethreeorganisations actuallyarguedthatPHCwouldbenefitfromthespecific competencies ofpaediatriciansand internists[18].Sim- ilarargumentsweremadeduringthelegislativeprocess in2013[17].TheChiefMedicalChamber,whilstbeingin

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favourofformallyincludingpaediatriciansandinternists into PHC,recognised that the proposal didnot address the many problems faced by PHC, such as underfund- ing, ﬁnancing model (exclusively based on capitation), lack of incentives to undertake specialisation in family medicineandaverynarrowcatalogueofdiagnosticser- vicesprovidedwithinPHC[1].TheNationalTradeUnion ofPhysicians,whichwassupportiveofallowingpaedia- triciansandinterniststopracticeasPHCphysicians,also recognised some of the shortcomings of the proposed changes: thechanges were not sufﬁcient to strengthen theroleofPHCinthesystemandreducetheburdenon specialistambulatorycare.AccordingtotheTradeUnion, PHCdoctorsshouldbeallowedtoperformservicesthat liewithinthescopeoftheirprofessionalcompetencesand withinthe(narrower)scopedeterminedbytheadminis- trativerules[14].

Whilethepositionsadoptedbythephysiciansaffected bytheproposedchanges,familymedicinephysicians,paediatriciansandinternists,wereratherself-evident,itwas less obvious why the Chief Medical Chamber and the NationalTradeUnionofPhysiciansweresupportiveofthe policy.Onepossibleexplanationis thatit wasa signof concernabouttheaccessibilityofPHCservicestothepop- ulation,bothforchildren(apositionsharedbytheChildren RightsOmbudsman[2];andadults.Theproposedchanges mayalsohavebeenregardedasanopportunitytoimprove employmentopportunitiesforphysiciansingeneral(with- outfocusingonanyspeciﬁcgroupofspecialists).

4. Discussion

Somepolicyanalystshavearguedthatthenewpolicy meansa defacto return tothe pre-1990s (i.e.commu- nist)arrangements,underwhichothermedicalspecialties, includingpaediatriciansandinternists,wereallowedinto PHC,anditwassuggestedthatthedescribedpolicywasnot basedonevidence[25].However,whileitisunlikelythat thereformisbasedonanyrigorousanalyses,paediatricians andinternists(andothermedicalspecialists)areinvolved intheprovisionofPHCinmanyEuropeancountries(seefor exampleRefs.[10,15])andmanyofthesecountriesscore highintheareaofPHCdelivery(intermsofitsaccessibility, continuityandcoordination)(seeRef.[10]).Also,paediatri- ciansandinternistswereformallyincludedintheprovision ofPHCnotonlyinthecommunisttimesbutaslateasuntil 2007,whichiswhentheamendmentofthe2004Acton HealthCareServicesFinancedfromPublicSourcesrequired thattheyobtainadiplomainfamilymedicineuntil2017.

Thismeansthatsomeofthemmayhavealongstanding experienceofworkinginPHCsettingsandshouldbeable toprovidequalityPHCtopatients.Inaddition,theformal inclusionofpaediatriciansintoPHCislikelytoimprovethe qualityofsuchcareforchildrenandadolescents:ifthere aremorepaediatriciansinPHC,thenitmaybemorelikely thatachildaccessingPHCisseenbyoneandthequality ofcareforthispatientgroupmayimprove.However,since pediatriciansand internistsareonlyallowedtoperform healthcareserviceswithinthescopeoftheirrespective specializations(seethepositionoftheMinistryofHealthin

Section3),theirinclusionintoPHCwillnotimproveaccess tofamilymedicineingeneral.

Thesuccessofthereformremainsuncertain.Becauseof thelackofrelevantdata,itisstillnotclearhowmanypae- diatriciansandinternistsdecidedtomovetopublicPHC.

ThePolishPaediatricSocietyhassignalledthatthereisan outflowofpaediatriciansfrompaediatrichospitalwardsto PHC,duetolowsalariesinhospitalsettings[6];however, thereisnoofficialdataallowingtoquantifythis‘outflow’.

Thereis alsonodataonwhetherthechangeledtoany efﬁciencylossesor gains(e.g.anincreaseinhealth care costspredictedbytheCollegeofFamilyPhysicians;see Stakeholders’positions).Aspecialstudywouldneedtobe undertakentoobtainsuchdata.However,itmaystillbe tooearlyforanysigniﬁcantchangestobedetected.Italso remainstobeseenwhetherthecompatibiliyofthereform withDirective2005/36/ECwillnotbequestionedbythe EuropeanCommissioninthefuture.

5. Conclusions

While this reform wasnecessarytoassureaccess to PHCforthepopulationasawholebyavertingtheshort- ageofPHCphysiciansloomingin2017,asallrecenthealth carereformsintheareaofPHCtheimplementedmeasure wasanotherad-hocsolutionandalong-termstrategyis stillmissing,especiallyonethatwouldtakeintoaccount thechangingdemographictrends.Populationforecastsfor Polandshowthatby2035thenumberofpeopleaged85 andover willincreasebyover 158% comparedto2007.

Polandalsohasoneofthelowestfertilityratesamongthe EUMemberStatesandtheeffectiveoldagedependency ratio(forpeopleaged65+)isprojected topeak in2060 [4].Thiswouldconstituteadramaticchangeinthestruc- tureofhealthcare needsofthepopulationsas awhole andahugestrainonhealthcareﬁnancing(demographic changesaloneareprojectedtoincreasepublichealthcare speedingby0.9%ofGDPbetween2005and2050andby 1.3%of GDPbetween2007and 2060[4]. It alsomeans thatthestructure ofhumanresources,especially atthe levelofPHC,shouldbeadaptedtothesechanginghealth care needs: more emphasis should be put onthe pre- ventionof geriatric problems and provision of LTCand communitynursing.TheHealthNeedsMapsthatarecur- rentlyunderpreparationbythepublicadministrationat thevoievodship(region)level[13]areboundtoﬂagupthe problemsdescribedabove.Theattempttoshiftpaediatri- cianstoPHC,whileassuringemploymentforthisgroupof medicalspecialists,doesnotaddresshealthcareneedsof thekey recipientsof suchcare—olderpatients.Thefun- damental questiononhow PHCshouldbeorganised to meetthechangingpatientneedsremainsopen.Thenew governmentelectedattheendofOctober2015hasyetto presentitsvisionforPHCandthehealthcaresystemasa whole.

Acknowledgements

The article is partly based on the work conducted within the research grant PROHEALTH65+ which has receivedfundingfromtheEuropeanUnion,intheframe-

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work of the Health Programme (2008–2013) (focusing ontheelderlypopulationandhealthpromotion)andthe grantfromthePolishNationalScienceCentre(NCN)no UMO-2011/01/D/HS5/03399 (quality assessment of the legislationprocess).

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