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Primary Health Care in

Poland

Slawomir Chlabicz

Department of Family Medicine

and Community Nursing

Medical University of Bialystok

Basic facts

• The largest country in central and eastern Europe

• Population - 38.2 million

• Area - 312 685 square kilometres

Poland – basic facts

Poland – short history

• 1569-1795 Polish-Lithuanian

Commonwealth

• 1795-1918 Partitions

• 1918-1939 Independence

• 1945-1989 Part of Soviet bloc

• Healthcare largely financed from government

resources

• No market economy

• Healthcare workers – salaried employees

Poland

Previous healthcare model

Based on Soviet system

Polyclinic with

Paediatrician

Internist

Gynaecologist

Dentist

• The concept of a family physician or general practitioner did

not exist

• Primary care undervalued

• Narrow specialties dominated the system

• Primary care not an academic discipline

Primary health care before 1991

• The introduction of compulsory health insurance

(9% of gross income)

• Development of the private sector in ambulatory

and primary health care

• The strengthening of primary care

Health care reform 1997-1999

• 9.0% of the base (almost all the income of an insured

person)

• contributions calculated, collected and transferred by payers

(by employers or institutions responsible for providing

benefits)

• all social groups practically covered

• unemployed contributions covered from budget

Mandatory health insurance

Workforce

Pediatrician Internist Gynaecologist

Family physician

How do you become a FP in

Poland

• Residency training (4 years)

• Retraining (previously for 6 months for

established prinmary care physicians)

• Medical specialist training -“residency”

financed from the state budget via the

Minister of Health

• Training 4 years

• 2 months – family medicine

• 24 months hospital and specialist

outpatient

• 22 months – family medicine

• 44 days of courses

Training of family physicians

• Broad curriculum

Rotate through internal medicine,

obstetrics, gynecology, surgery,

emergency medicine, critical care, and

psychiatry as well as other medical and

surgical subspecialties

• Includes training in both hospital and

primary care

How to become FP

Training in Family Medicine

Types of doctors in PHC in

Poland

1. Residency trained FP (certified)

2. Retrained Paediatricians and Internists (certified)

3. Pediatricians and Internists without FM

certificates

Some competent in care of children and adults

Some competent only in children or adults

Some competent mostly in one age group but ready

to see adults/children if necessary

Gynaecology part of FM residency training but not

practiced by FP

• 1994 – first exam for specialization in

family medicine held

• MCQ-Warsaw

• Oral exams in regional centers

Exams

Number of residents in FM

• 200 graduates in Medical University of

Bialystok

• Around 12 (6%) start FM residency every

year

• Target for UK – 50%

• Primary care mostly based on private

medical practices and private health care

institutions (contract with NHF)

• Usually practices run by a group of 1-3

doctors

• They may employ other doctors (not

partners)

• Everybody is entitled to open a practice

and apply for a contract

Primary care ownership

Family practice team

• Family physician

• Family nurse (capitation fee)

• Community midwife (capitation fee)

• Departments of Family Medicine in all

Medical Universities in Poland

• Family medicine obligatory in

undregraduate curriculum (105 teaching

hours)

Changes in education

Activities

Books

Journals

Guidelines

Congresses

CME

3 organizations

Financing

Mandatory health insurance - the major source

of financing

Complementary sources

• Private medicine (not financed by NHF) large part of

healtcare services

• (pay as you go, or prepaid monthly schemes individually ot by

employer)

Financing Health reform 1997-1999

• health insurance contributions directly linked to personal

income tax

• can be regarded as a “quasi-tax”

• lack of a defined upper limit

• no relation between health risk and the insurance

contribution

• you get the same irrespectively what you pay

Insurance or tax?

• The National Health Fund (NHF) with its regional branches

administers the health insurance scheme

• The NHF has the responsibility for planning and

purchasing public financed health services

Organization

• Contracts for health services can be made only with service

providers who meet the requirements laid down in the law along

with specific requirements defined by the National Health Fund.

• The NHF contracts for the delivery of

health services are concluded through a competition for public

funds

Market in healthcare

• Financing per capita on the basis of patient lists

(capitation fee)

• A basic rate is adopted and differentiated by age for three

age groups (0–6 years, 7–19, 20-39, 40-64 years, 65

years and older)

20-39 – 140 PLN/year

0-6 x2

7-19 x1,2

20-39 x1

40-65 x1,1

>65 x2

Primary care financing

Capitation fee

0-6 years – 11,7 zł x 2 = 23,4 zł;

7-19 years – 11,7 zł x 1,2 = 14,4

20-39 11,7 zl x 1 11,7

40-65 years – 11,7 zł x 1,1 12,9 zł

Over 65 – 11,7 x 2= 23,4 zł

• Rent for the premises

• Salaries of employees (receptionist,

cleaner)

• Cost of tests (laboratory, microbiology, x-

ray, ultrasound)

• Accounatancy

• Cost of equipment

• TAX

• Physician’s income

Capitation fee

In a family physician’s practice there are

1750 persons,

• 250 children up to 6 years,

• 300 people 7–19 years,

• 200 people 20-39 years,

• 600 people 20–65 years,

• 400 persons over 65 years

Example

Money

0-6 yrs– 250 x 23,4 zł = 5850 zł

7-19 yrs– 300 x 14,4 zł = 4320 zł

20-39 yrs– 200 x 11,7 zł = 2340 zł

40-64 yrs 600 x 12,9 zł = 7740 zł

Over 65 yrs– 400 x 23,4 zł = 9360 zł

29610 zł – 7400 EURO

INCOME- 5000 EURO?

• The level of the basic rate is a problem

• In 2004 the rate remained at the 2003 level, whereas

physicians were required to provide, additionally, 24-hour

health care services

• mass protest of primary health care physicians

2015 again

Many Poles left without medical care as health

minister clashes with protesting doctors

January 7, 2015

Organization of work and

scope of services

Exclusions

Very low threshhold for referral

• STD

• Obst and Gyn

• Psychiatrist

• HIV

• Oncology

• Tbc

Family physician as a gate-keper

Family physician

Patient’s expectations Free choice of physician

Capitation

Family physician

• Active list –each patient has to choose his

primary care physician and sign the

Decalaration of Choice

• Free choice

• Max. number of patients 2500/physician

• FP work with list of patients

• Patient records obligatory by law

Patients’ list

• Care of the newborn

• Care of children

• Screening (children, adults)

• Immunizations

• Chronic and acute diseases

Scope of services

• Open 8 am-6 pm on weekdays

• Office visits and house-calls doctor, nurse,

midwife)

• Appointements personally and by phone

Organization

Chronic diseases

• Ability to diagnose and follow-up common

chronic conditions

Chronic diseases

Tests (+) Tests (-)

Thyroid

TSH,ft4,ft3, ultrasound Antibodies

Diabetes

Glucose, eGFR, oral glucose

test, HBa1C

Microalbuminuria,

Albumin/creatinin ratio

Prostate

PSA, prostate ultrosound

COPD/Asthma

Spirometry IgE. Skin tests

Chronic diseases

Tests (+) Tests (-)

Osteoporosis

- Densitometry

Gastrointestinal

Gastroscopy, colonoscopy Tests for coeliac disease

Cardiology

ECG, BP Holter RR, Holter,

Echocardiography, BNP,

exercise test

Haematology

FBC, Fe, TIBC B12, folic acid

Chronic diseases

Tests (+) Tests (-)

Angiology

D-dimers, Doppler

ultrasound

Allergy

FBC Total IgE, Skinprick tests

Oncology

CXR, endoscopy, ultrasound,

FBC, FOB

No tumour markers

Rheumathology

Rheumatic factor, CRP, x-

rays

autoantibodies, anti-CCP

Cooperation with other healthcare

providers

• Generally poor

• Some referrals answered by specialists

but low quality

• Many pts instead of being consulted

overtaken by specialist care

• Waiting lists for outpatient specialist

services!!!

• The Ministry of Health attempts to address

those problems with rather poor outcomes

For physicians

• Family medicine – academic discipline

• Training of family physicians designed for primary care

needs

• Private ownership of practices

• Freedom (you are your own boss)

• better income

For Patients

• Free choice of physician

• Open and easy access to primary care

• Much better premises

Achievements

• For the NHF (the payer)

• Rigid budget for primary care (no risk of

increased costs)

• Free choice illusional in small towns

• The system encourages to refer to other

sectors even simple cases

• Waiting lists!!!

• AandE overburden

• No data on quality of care of individual

doctors

Disadvantages

• Nurse of long term home care

• Home hospice

New developments – home care

(paid by NHF)

• only one payer in the system – NHF –

monopolist position

• No co-payment on the patient side

(unlimited demand for health care

services)

• Many consult unecessarily

• Incentives not to investigate at primary

care level

Problems with the current system