Financing occupational health services in Poland

Int Arch Occup Environ Health (2002) 75 (Suppl): S10–S13 DOI 10.1007/s00420-002-0352-2 Izabela Rydlewska-Liszkowska Financing occupational health services in Poland Published online: 4 July 2002
Springer-Verlag 2002 Abstract Objectives: Financing occupational health services (OHS) at the regional and basic level is an important issue in view of the transformation process going on in OHS in Poland. The Occupational Health Services Act from 1997, The Public Finance Act from 1999 and The Labour Code Act with amendment have been regulated by the new principles of financing. The organizational structures and the financial system have been changed since 1 January 1998. The process is still being continued. The gaps between information systems of past and present financial data enforced the examination of the current situation in regard to the structure of financing and internal allocation of financial means. Material and method: The studies of OHS funding were carried out by the Nofer Institute of Occupational Medicine in Lodz. The data were collected and analysed for the period 1998–2000. They included full accessible statistics on OHS funding in Poland. The information on the financing system was collected by a questionnaire mailed to directors of OHS centres, and was supplemented by direct contact with directors. Results and conclusions: Sources of OHS financing in Poland are as follows: local government, state budget, companies, social health insurance institutions (since 1 January 1999 a social health insurance system has been implemented), OHS providers (as primary units), other sources. Analyses of their structures in a given period were conducted. The role of companies and social health insurance institutions in financing Regional Occupational Health Services Centres (ROHSCs) was considered in relation to the existing law regulation. Work presented at the 29th Congress on Occupational and Environmental Health in the Chemical Industry (Medichem 2001), 3–6 September 2001, Prague, Czech Republic I. Rydlewska-Liszkowska Nofer Institute of Occupational Medicine, Department of Health Care Organization, 8 Teresy Street, Lodz 90-950. Poland E-mail: iza_ez@imp.lodz.pl Fax: +48-42-6556102 Keywords Occupational health services Æ Funding sources Æ Information system Introduction and objectives The structure of the Occupational Health Service (OHS) in Poland consists of primary units (authorized doctors, approximately 10,000 units) and Regional Occupational Health Services Centres (ROHSCs) – 24 organizations. ROHSCs are responsible for control, education, consultation, supervision and diagnosis of occupational diseases. The present state of OHS financing results from legal regulation, namely The Occupational Health Services Act (1997) with amendments; The Public Finance Act (1999); The Labour Code (1991) with amendments; The Health Care Organizations Act (1991) and numerous executive law acts to the mentioned above. According to the Acts there are two different levels of OHS financing in Poland: regional (ROHSCs) and primary level (OHS primary units). Moreover, OHS is not thought to be responsible for curative services, but it is possible for individual units to provide curative services depending on the contracts with companies and/or health insurers. The sources of funding were changed in 1999 [3]. Before 1999, ROHSCs were financed from regional budgets, by companies, individuals, primary OHS units and from other sources (for example, financial means coming from the hire of property). The health insurance institutions have participated in financing OHS institutions (providers) since 1999. The gaps between past and present information systems on OHS financing enforced the examination of the current situation in regard to the structure of funding and internal allocation of financial means [2]. OHS financial analysis on the regional level was undertaken as a Nofer Institute of Occupational Medicine grant. The formulated objectives of the project, among others, were as follows: precisely to identify and characterize the sources of financial means received by ROHSCs; to analyse the structure of funding from different S11 sources; to define relations between the financial sources and the actual activities of the OHSC. The main questions which had been expected, arose: Is the present mechanism of financing sufficient to provide financial means in adequate quantity to the obligatory OHS tasks and responsibilities? Is there the right relationship between structure of funding and OHS functions? What is the internal allocation of financial means? Are there implemented economic instruments which give the sufficient bases for costing, pricing, financial planning? Moreover, the system of OHS is accepted as a component of National Health Accounts. It is necessary to create a suitable system of OHS data reporting. The main purposes of the National Health Accounts (NHA) [4] with reference to OHS include: to provide a set of internationally comparable accounts; to distinguish core OHS functions from work-related and health-related functions and to show intersectoral aspects of health as a concern of social and economic policy; to present bases for the analysis of flows of financing in OHS together with funding arrangements; to provide a framework of data aggregates relevant to research into micro-, meso- and macro-structure; to provide a framework for reporting on OHS over time for monitoring economic consequences of OHS policy, and a framework for analysing OHS from an economic point of view. Methods All ROHSCs in Poland were invited to participate in the study. The special questionnaires were prepared and sent to ROHSCs in 1999 (data for 1998) and in 2001 (data for years 1999, 2000). The information was collected and analysed separately. The sources of information were official financial reports and other statistics created for ROHSCs internal use only. In case of need additional information was received from ROHSCs on request. All conditions referring to the confidentiality of data were fulfilled. The data were also analysed from the point of view of NHA interests. Results and discussion Fourteen ROHSCs responded in 1999, presenting data for 1998. All 24 ROHSCs responded in 2001. The data Table 1. The structure of funding ROHSCs in 1998 (%) delivered from regional units were almost complete, and only few amendments were needed during direct discussions with ROHSC managers. The structure for funding ROHSCs in 1998 is shown in Table 1. It is evident that the uniformity of ROHSC financing was not achieved. According to the legal regulations the main source of funding for ROHSC should be regional budget, and the other sources should be used only additionally. The data obtained indicated that there was a discrepancy between the ideal (budgetary) funding and the real incomes of different ROHSCs in 1998. The participation of companies in funding ROHSCs was present in all units studied, and it was significant for a remarkable portion of ROHSCs. It indicated that the budgetary funding was not sufficient. Moreover, the ROHSC system is obliged by law to control and supervise all primary units in the region. Primary units are funded mainly by the companies for prophylactic services. If ROHSCs are also contracting prophylactic health care to companies, it becomes a supervisor and competitor in one. It is a serious legal and ethical problem to be described in detail and analysed in the future. The implementation of a health insurance system in 1999 also influenced the funding of ROHSCs. The detailed data are presented in Table 2. The process that was noted in 1998 (looking for additional funding sources by ROHSCs) was intensified during the next 2 years. Local government budgets were almost sufficient only in two ROHSCs. The rest of the organizations were looking for contracts with health insurance, and in one case the ROHSC’s funding depended almost exclusively on health insurance. The budgetary funding of ROHSCs was 0% to 99% of the organization’s income. The phenomenon observed in 1998 was more pronounced in the next years. The consequences of these changes are essential for OHS functioning in the country. Diversification of funding also influences the responsibilities of the ROHSCs as consultants, supervisors or training centres for primary units. The presented data suggest that the unified concept of a two-level OHS in Poland should be carefully analysed and reviewed. At first sight it is clear ROHSC Regional budgets Companies Individuals OHS primary units Others 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 94.76 41.09 77.31 93.02 89.58 53.39 72.00 65.16 74.10 81.78 94.43 99.84 83.93 89.36 5.07 48.36 22.50 6.93 8.29 43.80 27.00 31.78 23.68 17.66 2.81 0.16 16.07 9.19 0.17 2.84 0.19 0.05 1.71 2.81 1.00 3.06 2.22 0.01 1.83 – – 1.02 – 2.17 – – – – – – – – 0.93 – – – – 5.54 – – 0.42 – – – – 0.55 – – – 0.43 S12 Table 2. The structure of funding ROHSCs in 1999 and 2000 (%) ROHSC Local government 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Health insurance institutions Companies Subsidies Donations Others 1999 2000 1999 2000 1999 2000 1999 2000 1999 2000 1999 2000 40.0 22.0 61.76 – 11.0 69.44 92.25 54.0 92.0 54.7 24.0 92.0 44.50 40.0 20.31 57.0 66.3 52.3 58.60 6.50 76.0 69.0 49.59 74.2 40.5 26.0 73.36 – 11.0 54.52 94.70 56.0 97.0 53.0 22.0 96.4 34.48 30.0 14.82 54.0 68.0 41.4 57.50 7.43 78.0 68.0 46.37 50.5 16.25 11.0 – 97.0 49.0 – – – – – 27.0 – 3.62 4.0 13.86 – 23.0 – 29.34 50.0 – – 4.65 – – 8.0 – 95.0 49.0 – – – – – 32.0 – 13.16 35.0 21.43 – 22.0 – 31.00 52.0 – – 8.75 – 27.0 52.0 38.24 3.0 40.0 – – 32.0 4.0 3.8 9.0 1.8 15.17 20.0 41.42 42.0 10.0 14.2 9.49 17.6 24.0 31.0 43.73 – 44.0 56.0 26.64 5.0 40.0 – – 40.0 3.0 3.9 18.0 3.2 11.28 35.0 38.04 45.0 9.0 12.7 10.95 19.1 22.0 32.0 41.84 – 5.75 – – – – 30.56 – – – 38 40.0 5.0 33.37 – 23.32 – – 16.4 – 21.2 – – 0.73 16.9 14.5 – – – – 45.48 – – – 40.1 28.0 – 37.61 – 24.91 – – 27.6 – 15.52 – – – 32.3 1.3 – – – – – – – – – – – – – – – 0.2 0.4 0.21 – – – – – 1.0 – – – – – – – – – – – – – – – – 0.2 – – – – – – 9.7 15.0 – – – – 7.75 14.0 4.0 3.5 – 1.2 3.34 – 2.2 1.0 0.5 16.7 2.36 4.7 – – 1.30 8.9 – 10.0 – – – – 5.30 4.0 – 3.0 – 0.4 3.47 – 1.6 1.0 1.0 18.1 0.55 5.95 – – 3.04 7.2 why companies play such important role in financing ROHSCs if preventive examinations are the basic activity of primary units. ROHSCs provide, partly, the same activities as primary units do, although some ROHSCs are better equipped and provide a broad scope of services including curative medicine and rehabilitation. There are numerous patients who choose a ROHSC as the outpatient clinic, laboratory and consultant centre or rehabilitation facility. It is a side effect of free-market economy applied to the public (national) health care. When the budgetary funding is not sufficient the OHS providers, referring to their institutional independence, combine their statutory functions with other activities beyond the first (e.g. curative medicine), contracting them to the health insurance institutions. Generally, all the ROHSCs have been transformed from so called budgetary units into independent health care units. The result of this is the specific interpretation of existing law by OHS managers in order to collect more income. On the other hand, it is why the specialists have suspected that it may reduce the quality of the statutory OHS functions. Practically, we do not have the aggregated information on the structure of financial means (and their sources) in the primary OHS units. There are public and private units in Poland, but there are no official aggregated statistics on their financing. These data are available only from individual financial reports at unit level, gathered by the National Statistical Office. This study was the first attempt in Poland to clarify the situation of OHS and also from the NHA point of view. The main purposes of the NHA with reference to OHS are: • To provide a set of internationally comparable accounts. • To distinguish core-OHS functions from work-related and health-related functions and to show inter-sectoral aspects of health as a concern of social and economic policy. • To present bases for the analysis of flows of financing in OHS together with funding arrangements. • To provide a framework of data aggregates relevant to research into micro-, meso- and macro-structure. • To provide a framework for reporting on OHS over time. • To monitor economic consequences of OHS policy. • To provide a framework for analysing OHS from an economic point of view. The interest in OHS sources and structure of funding results not only from political and managerial reasons but also from international trends in NHA (demand for improved OHS accounts) [1, 4, 5]. According to the international standards, the position of OHS in NHA should be the sum of expenditures incurred by corporations, central and local government, and other institutions on the provision of occupational health care. At this time the expenditures incurred in OHS can only be approximately estimated on the basis of the costs. Policy makers and others engaged in the managerial process have raised the question of the adequacy of current accounting practices and the ability of existing health accounts to monitor OHS changes, among others. It is assumed that NHA in Poland will take the form of three-dimensional tables S13 cross-classifying expenditures by OHS providers, functions and by sources of finance. • The need for further debate on an OHS financing system with special attention on the role of health insurance institutions (if any) in OHS financing in the view of different existing laws. Conclusions The results of the project indicate that OHS should be an important subject in the economics research area. Further studies should be concentrated on the following problems: • Management OHS finance in order to assure the relevant use of the resources and quality of care. • Creation of an information system on OHS as a component of the NHA according to OECD standards; it is assumed that inclusion of OHS as a component of NHA will allow the implementation of a powerful statistical instrument providing framework for monitoring, analysing and assessing the economic consequences of OHS policy. • Creation of the official statistics on OHS primary-unit financing; these data are available from individual financial reports only. • The need for implementation of the economic appraisal of OHS activities as a tool of priority setting and resource allocation. Acknowledgement The study was conducted at the Nofer Institute of Occupational Medicine in Lodz, Poland and was financially supported by a Nofer Institute of Occupational Medicine grant, project IMP 8.3. References 1. Getzen TE (2000) Health Economics. PWN, Warsaw 2. Rydlewska-Liszkowska I, Jugo B (2001) Problemy ustalania kosztów zadan wojewódzkich osrodków medycyny pracy (The problems of cost calculation in Regional Occupational Health Services Centres ), Med Pr 52:197-201 3. Rydlewska-Liszkowska I, Jugo B, Durasiewicz Z (1999) Zadania wojewódzkich osrodków medycyny pracy a zródla ich finansowania. (Responsibilities of voivodeship centres of occupational medicine and sources of their funding) Med Pr 50:237–244 4. Polish National Health Accounts 1,0. IRBD grant 35466-POL (in press) 5. Zweifel P, Breyer F (1997) Health Economics, Oxford University Press