Atonomus hospitals and health care organizationsPoland

Andrzej RysJagiellonian University, Krakow

Washington D.C., February 18-19th 2004 World Bank Conference

GOVERNANCE AND ACCOUNTABILITY INSOCIAL SECTOR DECENTRALIZATIONS

About

• Decentralization of the state

• Decentralization of the payer

• Autonomy of health care institution

• New actors

4 reforms 1999

State/public administration

Education

Social Insurance

Health care

Decentralization New State?

BEFORE Reform of the Administration (49 voivodship)

A NEW STATE FOR NEW CHALLENGES

STATE DECENTRALIZATION

StateAdministration:Central and on theRegional Level

Local GovermentPoviat and Gmina

Regional Government:Voivodship

IT ALL DEPENDS ...

DECENTRALIZATION NEW COMPETENCE

NEW FINANCING

DECENTRALIZATION vs. REGIONALIZATION

• Political Process - supported by local leaders (“fight” between 16 vs.12 regions followers)

• Culture, Tradition, Customs - additional factors

• ‘Competition” between regions • Disturbed (“unknown”) role of Voivod

and Marshal in practice

NEW ADMINISTRATIVE STRUCTURE

• VOIVODSHIP/Region - 16

• POVIAT/County - 376 (incl. 65 largest urban gminas with poviat status)

• GMINA/Communities - 2489

 

Owner Number of hospitals Number of beds Beds %

Voivodeships 223 75 364 38

Counties (powiat) 395 93 214 47

Communes 17 4 165 2,1

Ministries and medical universties ( from 2001)

59(42) 24 988 12,6

Privates 18 595 0,3

Total - Local governments 635 172 743 87,1

Total 712 198 327 100

Hospital’s ownership after 1999 reform

Is a role for local/regional governments? • Regional health plans (from 2003)• Strategic planning• Making a decisions (eg. privatization)• Activities coordination• Health programs • Working with local providers (local taxes, rents) • Services planning access • Finance investment • Using of resources (estate)• Personnel replacement programs• Supervision• Patients/clients satisfaction• New services planning

InsuranceFund

Local/RegionalGovernment

AutonomusPublic

Provider

Citizen/Consumer/Patient

Autonomus health care unit

• Free in : management, HR policy• Depend on the public owner in: planning,

investment, selling, renting, outsourcing, loans, taking next step to privatization• Negotiation: salary and personnel replacement

with trade unions

• In 2002- 2003 WB project: Decentralization of HC in Poland

Establishment of Autonomous Public Providers

• The General Health Insurance Act allowed for signing of contracts for providing health services only with entities with legal personality.

• Public HCEs that were budgetary units could acquire such personality by becoming autonomous.

• The 1991 Act on Health Care Establishments, and particularly its later amendments, defined the procedure of gaining autonomy by budgetary units. Gaining autonomy allowed the unit to conduct its own financial management, staff policy and to define a strategy conforming to the demands for services and the capacity of HCE.

MANAGEMENT PROCESS

• The polled managers acknowledged that autonomy is wider now as regards staff and financial management, whereas it was very limited before the entity became independent. Nevertheless, there are certain limitations as LGs assert undue influence in matters like hiring, investment decisions, and acquisition of fixed assets.

• The purview of manager’s decisions encompass matters like opening and closing of departments, purchase of equipment, staff policy, development of unit’s strategy, and most of the financial decisions. The autonomus unit require the consent of institutions like the Founding Body and Social Council in matters concerning changes in the organizational structure and statutes of the unit, disposing and acquiring fixed assets, and in making investment decisions

• The meetings of the Social Council are held at varied frequency, being linked to the subject of deliberation. Bi-monthly meetings are held to discuss current matters relating to finances and provision of health services .

• The scope of the operational management powers of the managers of the autonomous units is evaluated as adequate. Limitations do occur in investment and asset management decisions. It is observed that the Polish model of management of autonomous units is imperfect as it does not in itself lead to efficiently functioning institutions supporting operating management (such as management boards) or institutions that provide opinions

• New quality programs (including hospital accreditation and ISO)

HUMAN RESOURCE MANAGEMENT• The employment decisions are made by the manager/director in each case. But the

autonomy has not resulted in the introduction of new procedures in the field of staff management.

• Although formally there are no external employment limits, the respondents point to indirect constraints stemming from the value of the contract with the payer or with the minimum norms of employment as regulated by the Labor Code or the MOH. Such norms regulate the number of duty hours, time of work of x-ray technicians etc.

• The managers emphasized that the scope of freedom in employment is greater than it was before the reform. The remunerations are decided by the managers, who have greater freedom in modeling wages, as there is no upper limit.

• The procedure for dismissing workers is in accordance with the provisions of the Labor Code and the Act on Trade Unions. There are no changes from the pre-reform period. The managers make the final decision on dismissal from the service. The Labor Code and the Act on Trade Unions define the circumstances when dismissal decisions must be consulted with the trade unions.

• The scope of freedom of managers in staff policy has increased. The still encountered limitations are budgetary and not systemic, i.e. they result from legislative regulation. The little use of modern tools of human resource management is striking since the role of professionals (mainly medical personnel) in contributing to the success of the unit may suggest that staff policy would be accorded a priority

• Contracts with the medical professionals• Outsourcing of some services and transfer some workforces to private companies

MANAGEMENT OF FINANCES AND SUPPLY

• Significant changes in the practice of preparing the budget, including the method of making the budget and method of recording costs (currently the memorial method). New elements, like income from additional and financial activity, fixed assets as a value on the assets side, or cash flows have been added.

• Monitor execution of the budget with monthly analyses or continuous controls. An account of costs is maintained and one facility uses the system of budgeting of individual organizational units.

• Could plan for external financing sources including loans, credits, and leasing. The same number gave a negative reply. Banks often classify autonomous hospitals as a fourth risk group making it difficult to obtain a loan

• Prepare annual financial statements in accordance with the provisions of the Accounting Act.

• Could now transfer and utilize a financial surplus • Debts belong to the facility itself or to the LG (after closing)• Investment plans • Decisions concerning supply of goods and service

STRATEGIC PLANNING

• Strategic plan was required to became autonomous units• The management prepared the plan in the remaining

entities or in the small groups• I many cases was had not been modified since

becoming autonomous.• The mere existence of strategic plans may be interpreted

with great caution as their usefulness is limited and there is no linkage of the strategies of the individual units with those of the voivodship and powiat governments.

ENSURING PATIENT RIGHTS AND IMPROVING ACCESS

• Regular meetings are held with the representatives of the community, patients and members of associations. There was no such practice before reforms.) maintained that their strategic plan takes into account the needs of the community in which they operate

• Managers claimed that the portfolio of services offered by them has changed. Existing services have either been expanded or new ones introduced

• Special cells to deal with complaints of the patients • After the 1999 reforms, patients have more avenues to lodge

complaints regarding the operation of the health care system. • Insurance against malpractice. Such insurance did not exist before

autonomy was gained • Monitoring the waiting time and patient satisfaction. • The changes in the health care system have strengthened the position of

the patient by better serving his rights. The patients are more aware of their interests and are more vocal in protecting them

Payer and Provider

HEALTH INSURANCE FUND

PROVIDER

CONTRACT

buyer seller

What does the CONTRACT mean?

?

RESULTS OF PAYER DECENTRALIZATION

• 17 antonomous and independent units...from everyone

• Over 23.000 contracts in the year 2001

• Various payment methods

• Disturbance in the information flow

• Permanent lack of information at the all decision makers level

INNOVATION or ANARCHY ?

INNOVATION or ANARCHY?

• Problems with innovation in such a short term• A lot of changes in short term • Unprepared - providers, professionals, patients,

media• LACK OF estimation of innovations and its

implementation process• LACK OF education about prepared, implemented

and present innovations• LACK OF analyses - “MOVING TARGET”

Changes done...to reduce anarchy

Legal changes:(2000, 2001, 2002)• Changes in a board: 21 to 7 (in three steps),

quality of a members, MOH control• Changes of CEOs• More clear responsibility for different level of

health services • More transparency in contracting • Seek funds could be merged • More information for patients

Citizen’s evaluation of the new health care system (2000)

Health care situation is worsening (67 %)

• disorder in the system (40 %)• increasing costs of care and medication (24 %)• problems obtaining referrals to specialists (23 %)• long waiting time (15 %)• uncertainty about rules, entitlements (10 %)

Citizen’s evaluation of new health system(2000)

Health care situation is improving (19 %)

• good quality of patient care (26 %)• free choice of doctors, health care facilities

(18%)• competition enhances quality (18 %)• good relations doctor - patient (15 %)• privatisation (10 %)

New Actors in Health Care Reform• Government• Minister of Health• Voivod• 3 Levels of Local Governments• Regions• Poviats• Gminas• Chamber of Nurses, Chamber of Physicians, etc.• New Trade Unions and Employers associations

• NGOs

Partners creating Regional Restructuring Programs

Health careorganization em-

ployees

RegionalSupport Group Governor

Ministryof Health

SP ZOZ Or-ganizations

RegionalRestructuring

Program

Commune,county, andvoivodeshipgovernments

RegionalSteering

Committee

Sickness Funds

ExpertGroup

NationalSteering

Committee

Program implementation

• decentralisation and regionalisation were introduced • social communication techniques were applied • procedures of applying to the Program together

with the assessment criteria of regional programs were clearly identified,

• the final distribution of funds depended on the program quality

• all parties interested in the problem were involved by initiating to build a regional partnership for health.

Outcomes of the program

• the reduction of beds by over 12,000,• better utilisation of resources (e.g. bed occupancy, length of patient’s

stay), • establishing of long-term health care institutions - 218 • purchases and investments for over 1000 integrated health care

institutions, • adaptations, modernisations and general repairs, • rationalisation of employment, which meant plans of dismissing about

100,000 employees within 3 years (only the 1999 and 2000 plans were implemented, i.e. dismissal of about 70,000 employees, out of which over 50% found employment in non-public health care institutions)

• extensive educational program both for managers and local health politicians

• mass privatisation of primary care and specialist outpatient medical services, i.e. generation of competition

Staff reduction 1999-2001Voiewodship

Number of people

reducing in 1999

Number of people

reducing in 2000

Number of people

reducing in 2001

Number of people

reducing in 1999-2001

1. Dolnośląskie 3 105 3 870 922 7 897

2. Kujawsko - Pomorskie 1 588 3 744 1 131 6 463

3. Lubelskie 1 815 2 185 776 4 776

4. Lubuskie 3 446 1 515 875 5 836

5. Łódzkie 2 744 3 689 515 6 948

6. Małopolskie 3 439 2 847 1 050 7 336

7. Mazowieckie 3 538 5 506 373 9 417

8. Opolskie 522 1 314 32 1 868

9. Podkarpackie 1 757 1 520 598 3 875

10. Podlaskie 1 280 1 809 1 216 4 305

11. Pomorskie 1 838 2 627 221 4 686

12. Śląskie 3 021 2 391 51 5 463

13. Świętokrzyskie 542 451 124 1 117

14.Warmińsko- Mazurskie 2 352 1 418 680 4 450

15. Wielkopolskie 3 141 3 457 158 6 756

16. Zachodniopomorskie 2 621 2 211 992 5 824

Razem 36 749 40 554 9 715 87 018

Next steps 2002-2004

• Centralization

• Commercialization of the hospitals?

• New legal frame after decision of the Constitutional Court, 7th January 2004