Iwona Kowalska-Bobko

Implementation of the 2011 Reimbursement Act in Poland: Desired and undesired effects of the changes in reimbursement policy

The Act of 12 May 2011 on the Reimbursement of Medicines, Foodstuffs Intended for Particular Nutritional Uses and Medical Devices constitutes a major change of the reimbursement policy in Poland. The main aims of this Act were to rationalize the reimbursement policy and to reduce spending on reimbursed drugs. The Act seems to have met these goals: reimbursement policy (including pricing of reimbursed drugs) was overhauled and the expenditure of the National Health Fund on reimbursed drugs saw a significant decrease in the year following the Acts introduction. The annual savings achieved since then (mainly due to the introduction of risk sharing schemes), have made it possible to include new drugs into the reimbursement list and improve access to innovative drugs. However, at the same time, the decrease in prices of reimbursed drugs, that the Act brought about, led to an uncontrolled outflow of some of these drugs abroad and shortages in Poland. This paper analyses the main changes introduced by the Reimbursement Act and their implications. Since the Act came into force relatively recently, its full impact on the reimbursement policy is not yet possible to assess.

Institutional analysis of health promotion for older people in Europe - concept and research tool

BackgroundEuropean societies are ageing rapidly and thus health promotion for older people (HP4OP) is becoming an increasingly relevant issue. Crucial here is not only the clinical aspect of health promotion but also its organisational and institutional dimension. The latter has been relatively neglected in research on HP4OP. This issue is addressed in this study, constituting a part of the EU project ProHealth65+, engaging ten member countries. This paper is based on two intertwining research goals: (1) exploring which institutions/organisations are performing HP4OP activities in selected European countries (including sectors involved, performed roles of these institutions, organisation of those activities); (2) developing an institutional approach to HP4OP. Thus, the paper provides a description of the analytical tools for further research in this area.MethodsThe mentioned aims were addressed through the mutual use of two complementary methods: (a) a literature review of scientific and grey literature; and (b) questionnaire survey with selected expert respondents from 10 European countries. The expert respondents, selected by the project’s collaborating partners, were asked to fill in a custom designed questionnaire concerning HP4OP institutional aspects.ResultsThe literature review provided an overview of the organisational arrangements in different HP4OP initiatives. It also enabled the development of functional institutional definitions of health promotion, health promotion activities and interventions, as well as an institutional definition adequate to the health promotion context. The distinctions between sectors were also clarified. The elaborated questionnaires provided in-depth information on countries specifically indicating the key sectors involved in HP4OP in those selected countries. These are: health care, regional/local authorities, NGO’s/voluntary institutions. The questionnaire and literature review both resulted in the indication of a significant level of cross-sectorial cooperation in HP4OP.ConclusionsThe inclusion of the institutional analysis within the study of HP4OP provides a valuable opportunity to analyse, in a systematic way, good practices in this respect, also in terms of institutional arrangements. A failure to address this aspect in policymaking might potentially cause organisational failure even in evidence-based programmes. This paper frames the perception of this problem.

Health promotion for older people in Portugal

In a country like Portugal where life expectancy is very high, Health Promotion for Older People (HP4OP) is a relevant issue and specific strategies are considered within priority health programmes defined at the national level by the Directorate-General of Health on behalf of the Ministry of Health. The National Health Plan 2016–2020 includes directives to facilitate health promotion and access to health and social services, as well as to reduce the burden of chronic diseases. HP4OP funds and resources derive mainly from the Ministry of Health and also from the Ministry of Labour, Solidarity and Social Security. Moreover, institutions can access European and other funds to develop projects in this field and some municipalities also finance projects and initiatives. Health plans, strategies and programmes outlined at the national level are adopted by Regional Health Administrations and the Groups of Health Centres guide implementation at the local level through dedicated units that work within the primary health care context. The integration of both social and health actions in terms of HP4OP depends on collaboration between the Ministry of Health; the Ministry of Labour, Solidarity and Social Security; municipalities; institutions in the cooperative and social sector and other stakeholders such as families, educational institutions, religious communities and health professionals. As a whole, health promotion policies for the older people in Portugal tackle the social determinants of health too. Nevertheless, a systematic approach and an integrated strategy to tackle HP4OP might constitute an important condition for the full implementation of such policies. Additionally, fragmentation of initiatives at the regional and local levels, together with other barriers to addressing health promotion activities among health professionals, might lead to the non-homogeneous implementation of interventions of HP4OP throughout the country. It is expected that many of these constraints will be overcome with the launch and implementation of the intersectoral National Strategy for the Promotion of Active Ageing from 2017.

Healthy ageing – happy ageing: Health Promotion for Older People in Italy

Health Promotion for Older People (HP4OP) is a relevant issue in Italy, one of the countries where people live the longest. Strategies, programmes and projects are set and planned at the national level, mainly by the Ministry of Health within the National Health Service, but strong competencies, funds and resources derive also from the Government, the Ministry of Labour and Social Policies and the Ministry of Internal Affairs. Moreover, European funds contribute to programmes and projects in this field. After strategic implementation at the regional level, programmes and projects are carried out at the local level under the National Health Service, mainly by the Local Health Authorities in conjunction with municipalities and other relevant stakeholders such as NGOs, the voluntary sector, families and educational and religious entities, etc. Even though Italy has been engaged in HP4OP to improve active life expectancy since 1992, a lack of planning and resources for HP4OP, policy diversification at the regional level and a prevailing interest in care-assistance rather than health promotion and prevention have prevented consistent implementation of HP4OP throughout the country.

The 2014 primary health care reform in Poland: Short-term fixes instead of a long-term strategy

At the end of 2013, the Minister of Health started legislative changes directly and indirectly affecting primary health care (PHC). The reforms were widely criticised among certain groups of medical professionals, including family medicine physicians. The latter mainly criticised the formal inclusion of specialists in internal diseases and paediatrics into PHC within the statutory health care system, which in practice meant that these two groups of specialists were no longer required to specialize in family medicine from 2017 in order to enter into contracts with the public payer and would be able to set up solo PHC practices-something over which family medicine physicians used to have a monopoly. They argued that paediatricians and internists did not have the necessary professional competencies to work as PHC physicians and thus assure provision of a comprehensive and coordinated PHC. The governments stance was that the proposed measure was necessary to assure the future provision of PHC, given the shortage of specialists in family medicine. Certain groups of medical professionals were also supportive of the proposed change. The key argument in favour was that it could improve access to PHC, especially for children. However, while this was not the subject of the critique or even a policy debate, the proposal ignored the increasing health care needs of older patients-the key recipients of PHC services. The policy was passed in the Parliament in March-April 2014 without a dialogue with the key stakeholders, which is typical of health care (and other) reforms in Poland. The strong opposition against the reform from the family medicine specialists, represented by two strong organisations, may jeopardise the policy implementation in the future.

The 2015 emergency care reform in Poland: some improvements, some unmet demands and some looming conflicts

Between 2006 and 2015, the Act on the State Emergency Medical System was the key act governing the organization, financing and provision of emergency care in Poland. From the moment it entered into force, it had been heavily criticized. The critique focused, among others, on the lack of provisions allowing for emergency medical services (EMS) to be performed outside the EMS units, the lack of a separate Act regulating the profession of a medical rescuer and the lack of a separate professional organization representing medical rescuers. As early as 2008 a team of specialists was set up to work on amending the Act and these works resulted in the draft Act on the State Emergency Medical System that was submitted to public consultations on 19 August, 2014. This draft was further reworked in 2015 and was signed by the President on 25 September of the same year. The Act addressed some of the shortcomings of the EMS legislation that was previously in place. However, the new Act did not meet the key demands of medical rescuers; namely, it did not introduce a separate legal act regulating this profession nor established a professional organisation representing their interests. An analysis of the vested interests of various groups of medical professionals indicates that these interests are likely to have influenced the final legislative outcome. The Act, as well as its implementing executive regulation from April 2016, may reduce support of certain medical professional groups during the Acts implementation as well as create tensions between these groups, especially between medical rescuers and nurses.

Systemowe reformy zdrowotne w Stanach Zjednoczonych. Obamacare versus Trumpcare

The purpose of the article is to present the complexity of the US health insurance system and the changes it brings in Obamacare against the background of reform proposals pushed forward and run by the new US presidential administration (Trumpcare). An attempt will be made to compare the two reform proposals for the health care – Obamacare versus Trumpcare in the light of the assessment of the changes implemented by Barack Obama since 2013 as well as the political implications of the new proposals put forward by current President Trump. The US health care system stakeholders environment is very divided in Obamacare’s and President Trump’s new proposals assessment. The new change is backed by insurance corporations. Meanwhile, the largest American medical association, the American Medical Association, has sent to the leaders of both parties in the Senate a statement stating that it supported Obamacare because it was a significant improvement over its previous status quo. At this stage, presenting the whole formula of a new change is difficult due to unfinished legislative process.

The activities of older people when healthy ageing policy and funding is limited. The institutional and financial dimensions of health promotion for older people in Poland

The presented country profile, based on several national reports, legal acts, international databases, scientific articles and pilot research performed with the use of health care sector templates, outlines the major institutional, organisational and financing challenges for health promotion in Poland, and specifically, health promotion for older adults. Despite the numerous legislative and organisational changes in the health care sector since 1989 and the strengthening of the public health institutions in Poland, the country lacks a long-term, sustainable policy perspective in the public health area. The traditionally higher priority attached to curative care than to public health actions is one of the major reasons for the shortcomings of public health policy and the insufficient resources for health promotion and primary prevention in general, and health promotion for older adults specifically. However, there are also many weaknesses at the organisational level. One of the most important is the weak cooperation between the different levels of territorial self-government, the central government and other institutions when undertaking health promotion actions, which results in the development of both under- and overprovision of health promotion interventions for different population groups and at different geographical locations. Few self-government associations try to improve the cooperation and experience exchange in this field. However there is a need for a greater coordination and information exchange concerning plans and financial possibilities as well as for more competent health educators with better communication skills, less bureaucratic burdens, and better financial conditions.

Health promotion for older people in Lithuania: Between bureaucratic and financial constraints

The health system in Lithuania has a strong focus on hospital treatment. Overall, there is a lack of sufficient funds explicitly devoted to public health. This country report draws upon several national reports focused on the Lithuanian health system and other country-specific sources in order to outline the major institutional and financing challenges for health promotion in Lithuania, specifically for older adults. As suggested in our review, the key problems in public health services in Lithuania, including health promotion for older persons, are the bureaucratic and financial constraints, a lack of intersectoral cooperation, staff shortages and capacity problems. The implementations of public health initiatives greatly depend on the political will and the government’s ability to implement policies, which are still weak in Lithuania. Moreover, the public health legislation lacks clarity and fails to provide an adequate base for local-level evidence-based interventions. Concrete action plans, as those recently developed in the area of healthy aging and health inequalities, are needed to provide guidance for health promotion among older adults.

Health promotion for older people in Hungary: The need for more action

The health status of the Hungarian population is relatively poor, compared to other countries of similar socio-economic development. Unhealthy diet, smoking, alcohol consumption and low physical activity are important risk factors leading to cardiovascular system diseases – the main cause of death in the general population and among people 65+ in Hungary. Yet, the OECD health statistics indicate that Hungary belongs to a group of countries with the lowest per capita expenditure on prevention and public health and that the level of this expenditure is decreasing. In Hungary, there is no legislation specifically dedicated to public health (Public Health Act) and the matters of public health and health promotion are regulated by various legal documents. The directions for public health policy are set in National Public Health Programmes. To address the problem of the ageing population, in 2009 a National Ageing Strategy (2009–2034) was adopted. The Strategy stresses the need to develop programmes for prevention, rehabilitation and health promotion for older people. The main actor in public health policy is the central government, namely its agency the National Public Health and Medical Officer Service. Also, territorial governments play an important role, though they have limited financial capacity to spend on health promotion and they need to rely on external unstable sources of funds when implementing health programmes for older people. NGOs might be important partners for health promotion along with public authorities. However, they require more financial and infrastructural support to be able to perform more activities in the field of health promotion for older people.