Autor: Martin Siebert

Poland’s public health care system’s reputation—already frayed after years of protests, strikes and bad press—has suffered fresh blows. The recently published results of a Supreme Control Chamber (NIK) audit carried out at 48 public hospitals paint a grim picture of healthcare infrastructure.

The list of transgressions is long and includes a deficit of basic safety equipment (such as fire extinguishers, hydrants and alarms), blocked emergency exits and architecture that is distinctly unfriendly to the disabled. Even more devastating was the audit’s conclusion that two-thirds of the inspected hospitals were in such poor technical and infrastructural condition that they posed a threat to patient safety.

In a second report, following an audit of medical equipment, the NIK stated that some items used in hospitals such as faulty X-ray scanners could pose a danger to patients and staff. A stunning 46 hospitals out of 53 inspected, or 88 percent, were chastised for this problem. Equally upsetting is that every third hospital under audit was found to have brand new equipment sitting, unused, in storage because of a lack of properly trained personnel.

Little comfort can be drawn from the fact that at least the sanitary conditions in these hospitals were described as “satisfactory.”

But the problems of Poland’s hospitals extend far beyond matters of infrastructure and equipment. Things have obviously changed since the end of communism, but doctors and nurses remain overworked and bedside manners are in short supply.

The cure for many of the system’s ills is straightforward, but not painless: professional, independent management.

That’s easier said than done. Many local authorities will not even consider restructuring or closing unprofitable hospitals for fear that this would cost them the next election.

National politics, as usual, have complicated the matter. Back in late 2008 the ruling Civic Platform (PO) pushed a health care reform package through Parliament despite opposition, but President Lech Kaczyński then vetoed it.

“Health is not a product,” he said at the time, arguing against privatization of the industry.

Law and Justice (PiS), the party led by the president’s twin, Jarosław Kaczyński, has consistently opposed the government’s reform plans. A new Constitution proposed by the party even postulates that “All citizens have access to health care benefits funded by the state and it is the state that maintains and develops the public health care reform system.”

Meanwhile, several individual attempts at hospital commercialization have been blocked by medical staff. In January, for example, employees at a hospital in Starachowice went on a hunger strike to protest against impending privatization. As a result, that privatization has been postponed indefinitely.

There have been a number of examples of successful privatizations, however, proving that it is possible to mix water with fire. Wrocław-based EMC Instytut Medyczny, a Warsaw Stock Exchange (WSE)-listed health care network operator, has been doing just that. Its network has grown through the acquisition of public hospitals, mainly in Lower Silesia.



Public-private partnership, of a sort

The key to EMC IM’s growth has been in turning neglected hospitals with strong potential for efficiency into profitable institutions. These hospitals remain in private hands, but thanks to contracts with the National Health Fund (NFZ), which finances medical services with public health care premiums, they are able to offer free services like any public hospital.

According to Piotr Gerber, CEO of EMC IM, convincing patients that a private hospital can offer free health care is one major challenge. Bringing the medical staff around is another. “They have to switch from the old public model into a completely new business environment,” he said.

As an example, Gerber offered a county hospital in Ząbkowice Śląskie, Lower Silesia, which his firm considered crucial for its development strategy.

“Renovation of the pre-war building had to be consulted with the Heritage Protection Department. But it was all worth it. Today we have a prosperous hospital with an emergency room and a helipad,” Gerber said. And commercial services account for only 12 percent of all services rendered; the remainder are financed by the NFZ.

EMC IM is no exception. Although private hospitals remain a minority on the Polish health care map, many have been open for years.

Enel-Med Medical Center opened a hospital in Warsaw in 1996, for example. Despite being a private facility, it is also part of the public health care system; 70 percent of the surgeries performed at the hospital last year were financed by the NFZ.

Meanwhile, private health care network Medicover opened its own hospital last year in the Wilanów district of Warsaw. Other companies are planning to follow suit.

“We plan to open an outpatient surgery hospital in Warsaw’s Ursynów district this summer,” said Anna Rulkiewicz-Kaczyńska, CEO of Lux Med Group. The company had planned on developing its own general hospital, but came to the conclusion that demand in the private market for such a facility might not be great enough.

Enel-Med CEO Adam Rozwadowski listed two obstacles to the development of new private hospitals. The first is that building a hospital from scratch is expensive and time-consuming. It is much easier to take part in a privatization, to invest in an already operating hospital and restructure it.

“This is a very convenient solution from the investor’s point of view because these hospitals have NFZ contracts. Without these, profitability in managing a hospital would be very doubtful,” Rozwadowski explained.

The other problem is that private health care providers have to endure a measure of unfair competition. They have to invest in infrastructure and personnel on their own—while turning a profit—whereas unprofitable public hospitals are subsidized by the state.

Despite these shortcomings, both independent experts and Health Ministry officials tend to agree that the commercialization of Polish hospitals is inevitable. The public hospital system has suffered from terminal inefficiency for too long, while private hospitals are generally in good health.

The success enjoyed by the private sector seems to be slowly changing the minds of some opponents of privatization. Recently the Pomorskie voivodship health care workers’ chapter of the Solidarity labor union came to a deal with the voivodship authorities on the possible privatizations of hospitals in the region. In such cases, the voivodship marshal (the regional executive) will help them negotiate benefits packages and 5 percent stakes in privatized companies.

Physician, humble thyself

Accepting professional, private management in a hospital—along with the accompanying need to maintain fiscal discipline—requires a big change in thinking for employees of the Polish health care system. But it is not the only such change needed.

In a recent interview, Health Minister Ewa Kopacz noted that voivodship and county authorities, the formal owners of public hospitals, should be guided first and foremost by the good of patient.

“Doctors and hospital directors have to understand that the NFZ or ministry is not their employer—the patient is. As long as doctors don’t treat patients that way, nothing will change,” she told Dziennik Gazeta Prawna.

This too would require a huge shift in mentality, and it wouldn’t fix all the system’s problems. But it would make a nice start.

This is an edited version of a story published by Warsaw Business Journal.