Talk to any Pole in Warsaw today and you quickly realize that there are 2 eras in recent Polish history: "before market economy" and "after market economy." In the decade since this country of 38.7 million people, squeezed between Germany, Russia and the Ukraine, threw off Soviet control, it has moved at warp speed toward embracing capitalism and integrating with the West. When I visited Poland last June I was struck by the way everybody I spoke to - students, writers, cab drivers, government officials and physicians - repeated the same phrases and appeared committed to free-market principles. The sense of optimism and energy was almost palpable, a sign that Poland is doing far better than any of the other former Soviet republics and is expected to enjoy stellar economic growth of more than 4% this year. (Figure)
However, the journey from free-market principles to practice has been bumpy, particularly in the health care sector. Health care reform is part of a massive restructuring of services that the current government introduced this year; pensions, local government and education are also in the throes of wrenching change. The changes have led to confusion, anxiety and political turmoil. The physician who, as health minister, introduced the health service reforms in January was forced to resign in March. While I was in Warsaw, nurses were demonstrating for pay increases and anesthetists were threatening to walk out.
Dr. Krystyna Pliszkiewicz, a Warsaw ophthalmologist, offered a perspective that might have been offered by a Canadian physician during this country's current restructuring of its own health care system. "Everything is going too fast, before the details are clear," she said. "Even the doctors don't understand what is supposed to happen. My colleagues and I are all unhappy - only the administrators are happy."
Yet the government is plowing ahead with its plans. And what is most surprising to a Canadian observer is that in its enthusiasm for market principles, Poland is embracing not only more choice within its public health services but also the establishment of a private health sector, a move choreographed by large, for-profit Western European health insurance companies. "This does not worry us," says Helena Luczywo, publisher of Poland's largest-circulation newspaper, Gazetta Wyborcza, which started life in the 1980s as an underground broadsheet supporting the Solidarity movement. "It can only improve the state system."
The most important change for patients is that family practitioners have become "gatekeepers." Patients are no longer permitted to go straight to a specialist. They must first register with a family practitioner, who will assess the need for additional services. Reformers point out that the element of choice is increased today, since patients can choose their own family physician and the hospital or clinic where they receive additional treatment. However, many Poles find that it takes days before they can see their own doctor. "I had to wait 3 days for my daughter to have an appointment with our GP," recalls Dr. Aldona Sito, a pediatrician who works at the National Research Institute of Mother and Child. "Eventually I couldn't wait any longer, so we took her to the emergency department of the local hospital."
Giving patients more "choice" is part of a larger initiative to decentralize health services. Before the collapse of communism, Poland's health system was centrally controlled from Warsaw. It had no dedicated funding and there was little incentive for clinics and hospitals to be efficient or measure their own productivity. The per-unit cost of services and procedures, or the size of administrative overhead, was unknown and impossible to calculate.
One fresh chicken, please
And corruption was widespread. Everybody knew that an envelope of cash or even a fresh chicken would improve your chances of getting the attention you needed. The quality of medical care was excellent, but the standard of hygiene and patient care in hospitals was appalling. "I remember when my daughter was born in the mid-'80s," says Helena Luczywo. "The floor of the hospital was blood-spattered and the bathrooms were filthy. The sheets were never changed. I couldn't wait to get out."
Today, 7.5% of gross wages are deducted from each Pole's earnings and pooled in "patients' funds." Poland is now divided into 16 provinces, each of which has its own patients' fund that is administered independently of the local government. All health care costs dispensed by physicians and institutions, both private and publicly owned, are covered by these funds. Although patients can visit the general practitioners and hospitals of their choice, they must choose doctors and institutions within their own province. This should strengthen the facilities throughout the country. Before the market economy took over, Poles always preferred to use facilities in Warsaw, which reinforced a tendency for provincial facilities to be second rate.
The stress on this new system is beginning to mount as health care workers realize the implications of financial limits and a competitive market place. The flow of patients to specialists is smaller because they now need referrals, and specialists' incomes are dropping. Ambulance drivers see their jobs disappearing, as patients and doctors learn to be more sparing in making emergency calls. Badly run hospitals with poor reputations are losing money as patients opt for better hospitals within their provinces.
Physicians such as anesthetists who have little choice but to remain within the state system are protesting their fee scales. Health care workers' unions and the medical establishment are demanding that the deduction from gross wages should rise to 11% from the current 7.5%. And like their counterparts in Canada, Polish nurses are feeling particularly incensed because they think they are paying for health care reform out of their own pockets. Their wages have hardly moved in the past decade, but their workload has doubled.
It doesn't help when these public-sector employees see the growing affluence around them. They can barely afford to use public transport, where fares have increased from a few cents per journey to the equivalent of a couple of dollars. Meanwhile, in the streets of cities like Warsaw and Poznan, ancient Ladas are outnumbered by BMWs, Renaults and Nissans.
However, many specialists are thriving in the "after-market-economy" era. Pliszkiewicz, who did much of her training in ophthalmology in Switzerland, began moving into private medicine as soon as the post-1989 government permitted. At that stage she worked 4 days a week in the public sector and 2 days in private practice, and paid a flat tax on the hours worked in private practice. "Originally I had to keep one foot in the public sector to ensure insurance coverage," explains Pliszkiewicz, who speaks Polish, French, German and a smattering of English. Today she works full time in the private sector and pays a tax on her gross earnings rather than hours worked. "I have to spend far more time on my accounts," she grimaces.
So many successful specialists moved into the private sector in the early 1990s that, when a Communist government was elected in 1995, it initially tried to throttle back the exodus from the state system by squeezing the private sector out of existence. It said that its goal was state medicine for every Pole. "But the private system was already too well established," says Pliszkiewicz. "The government soon realized that it could not discourage it."
Private health insurance corporations from Germany and Holland had already begun negotiations to buy or administer some of the private clinics that had been founded. And the new government quickly discovered that, despite its electoral success, Poles wanted new-style Communism, not a return to a Soviet-style system. For a country that, since 1939, has suffered 2 occupations by totalitarian regimes committed to centralized control, private medicine represents a guarantee against government oppression.
Nobody I spoke to mentioned the downsides of private medicine, which include spiralling costs and two-tier care, probably because the shortcomings of the "before-market-economy" system were too fresh in the collective memory.
Has health care improved for the average Pole today? "Definitely," says Pliszkiewicz. The new regime has forced physicians to upgrade their education and health care institutions to upgrade their services. And the massive changes that have taken place in this country have had health spinoffs. "In the past 10 years the media have devoted far more space to health topics. People are encouraged to think about their own health and to ensure they have the right immunizations and regular checkups."
Before 1989, health care was as much of a sham as many other services under the Soviet regime. Several people I met told me about "white Sundays," days when a handful of doctors in white coats would arrive in a village to stage a well-publicized public health clinic. Once they had been duly photographed, they would climb back into their cars and disappear for another few months.
Pliszkiewicz recalls how difficult it was to provide patients with any kind of health information: "It was hard to photocopy anything and everything had to be passed by the censor." Today there are leaflets on every condition imaginable. In addition, Poles have free access to the Internet. "Poles are finally learning to take responsibility for their own health," Pliszkiewicz notes with pride.