Reproductive health, sexual well-being, mental health: these are the most critical aspects of the Polish healthcare system. Universalist and very versatile, the NFZ (Narodowy Fundusz Zdrowia, as the national health system is called in Polish) is currently not very attentive to the most fragile people (women, the elderly, transgender and intersex people) and has difficulty determining reimbursement circles.
TrendSanità interviewed Maria Boratyńska, lecturer in medical law, secretary of the Committee on Bioethics of the Polish Academy of Sciences.
A researcher at the University of Warsaw and editor of the quarterly Przegląd Prawa Medycznego (Medical Law Review), she is an active supporter of dialogue between lawyers, doctors and philosophers to create interdisciplinary syntheses. Takes up the most difficult topics that require comprehensive analyzes: collisions of people’s good and duties in medicine, end-of-life medicine, reproductive rights, gender dysphoria, medical decisions for the needs of children.
Healthcare system in Poland
In Poland, the healthcare system stands on the pillars of statutory universal health insurance, ensuring that citizens have access to medical care. The system is primarily funded through contributions deducted as a percentage of salaries from employment contracts. Those without such contracts can opt to pay their own health insurance contributions, while certain groups like students are exempt from these payments.
Dr. Maria Boratyńska tells: «Contributions and subsidies from public funds are administered by the National Health Fund (NFZ). The National Health Fund administers contributions and subsidies from public funds by concluding contracts with individual medical institutions for the provision of health care services in the interests of the insured».
The NFZ is a government organisation with legal personality. It manages the financial resources derived from health insurance contributions and, for this purpose, acts on behalf of the insured and other eligible individuals. Its activities include assessing the quality and accessibility of services, as well as analyzing healthcare costs, necessary for concluding contracts for the provision of healthcare services. It also handles organizing tender procedures, negotiating and concluding contracts for healthcare services, as well as monitoring and settling their implementation.
Dr. Boratyńska says: «The Fund is the only entity that organises health care services, as it is the only entity entrusted by the legislator with the right to manage the financial resources transferred for this purpose, as well as the right to conclude agreements with health care providers in order to secure health care services. The NFZ is obliged to ensure equal treatment of all service providers applying for a contract for the provision of health services and to conduct the procedure in such a way that fair competition is maintained, but in practice this is not always the case. Alongside the NFZ, other key actors in the healthcare arena include public health institutions, which may operate as independent entities with their own assets and budgets. These institutions, often funded by the State Treasury or local governments, aim to sustain themselves through contracts with the NFZ. However, many still rely on government subsidies for financial stability. Some have even transformed into limited liability companies to enhance management efficiency».
The strongest point of the health insurance system is its versatility
Independent public health institutions are generally not financially self-sufficient and still depend on subsidies from the state or local government. There are also non-public, i.e. private, institutions, including private hospitals. These provide services mainly to commercial patients with private insurance. They also provide services on behalf of the NFZ that can no longer be provided by public institutions, such as cholecystectomies or cataract operations. Dr. Boratyńska explains: «Demand for certain types of treatment is so high that patients would have to wait too long. Therefore, to relieve the public hospitals, the NFZ entrust a certain number of procedures to private facilities and signs additional contracts with them. Priority is always given to contracting in public facilities».
Boratyńska sheds light on the intricacies and challenges facing the country’s healthcare system, asserting: «The strongest point of the health insurance system is its versatility. Every citizen with a contract of employment has health insurance by law and certain groups of potential patients – e.g. children, students – are included in the system in such a way that the cost of their contributions is covered by the state. In addition, reimbursement is provided for very expensive care – for example, for children born extremely prematurely».
The weaknesses are glaring, Boratyńska acknowledges adding: «As universal health insurance fails to extend coverage to individuals without employment contracts. In addition, the administration of contributions is not very cost-effective and, in practice, day-to-day access to health care is difficult. Waiting times to see a specialist are usually so long that many people opt out and seek specialist care on a fee-for-service basis. There are also long queues for scheduled (as in, arranged) surgical procedures. In addition, there is a shortage of doctors and nurses in Poland, especially at the beginning of their careers, as result, many doctors go abroad».
The reimbursement chaos
The reimbursement system in the Polish healthcare sector is characterised by inefficiency, disorganisation and inadequacy: «Serious weaknesses can also be found in the reimbursement system, which is inconsistent, irrational and incoherent. On closer inspection, it is impossible to determine the criteria for reimbursement of medicines or certain medical devices. For example, only large ostomy bags are reimbursed, whereas smaller bags are much more convenient and appreciated by patients because they can be used more discreetly. Smaller bags should be cheaper. Another example is cataract surgery reimbursed by the National Health Fund, where only a very lowquality lens is reimbursed. The patient who wants to pay for a better lens – one that corrects severe nearsightedness, for example – is not covered at all and is forced to pay for the entire procedure in a private practice».
It is impossible to determine the criteria for reimbursement of medicines or certain medical devices
Moreover, the problems highlighted in the healthcare reimbursement system are intertwined with the challenges in access to healthcare, as pointed out by Dr. Boratynska, highlighting several critical issues that require urgent corrective action: «Among adults, those who “drop out” of the insurance system are those who work under conditions other than an employment contract. Such contracts are known in Poland as ‘junk contracts’ and such workers have to pay for their own health care costs in full, no matter how high they may be. Furthermore, difficulties in access to healthcare for older people are due to the fact that very few doctors choose to specialise in geriatrics. As a result, there is a shortage of geriatricians and the elderly usually suffer from multiple co-morbidities. What is needed is geriatric care that takes this into account, rather than queuing up to see several different specialists».
Gynaecology and sexual well-being
Speaking with Dr. Boratynska, a fairly critical picture emerges regarding gynaecological and sexual health and there are numerous obstacles women face in seeking appropriate medical care. In this regard, Boratyńska states: «It is unfair that all pharmacological contraceptives are available only on prescription and this has been enshrined in law to make it difficult to change this situation. Post-coital contraception is also only available on prescription».
Reproductive health is really difficult to ensure in Poland, in fact the situation is further complicated in the context of abortion and assisted reproduction methods, where legal restrictions significantly limit women’s autonomy and access to reproductive services. In this regard, Boratyńska explains: «It is now virtually impossible to legally terminate a pregnancy, since the politically serving Constitutional Court ruled in 2020 that one of the preconditions for abortion is unconstitutional: to be precise, the suspicion of severe fetal defects. Doctors are now afraid to terminate pregnancies for other reasons provided for in the law. As a result, there have been several high-profile deaths of women with complicated pregnancies who did not receive appropriate medical care. Out of fear, doctors wait until the foetus dies, putting the patient at serious risk. One of the reasons for this is the criminalisation of abortion by a doctor in contravention of the law. The campaign organised by church circles against gynaecologists and the accompanying over-zealousness of prosecutors has led, among other things, to accusations of infanticide against women who have had miscarriages or who have terminated their pregnancies themselves, even though it is not a crime in Poland for a woman to terminate a pregnancy herself».
It is now virtually impossible to legally terminate a pregnancy
The difficulties also extend to prenatal examinations, where there is not only a lack of adequate information, but also a limitation of truly free access – that is, on request, despite being theoretically guaranteed by the Family Planning Act. «There are also cases of doctors refusing to refer for invasive or more advanced prenatal diagnosis on the grounds of conscience (so called conscience clause). There have also been cases of unfavourable results of such tests being concealed or hushed up. Access to assisted reproduction methods, including IVF, is closed to people other than heterosexual couples – i.e. singles, homosexual couples, non-binary couples, transgender people. Surrogacy is not prohibited, but there are laws that effectively exclude surrogacy through assisted reproduction. Non-partner donation of gametes and embryos is only allowed for the benefit of an ‘anonymous recipient’. This also excludes any open donation».
Dr. Boratyńska on the subject wishes to emphasise the impact of the declining birth rate, coupled with concerns over reproductive rights, which have led to the closure of maternity wards in several regions. In fact, she states «Notably, regions like Małopolska and Podkarpacie face ideological barriers, limiting access to prenatal testing, abortion and contraception. Addressing equitable access to healthcare necessitates systemic changes».
Gender Reconciliation
A crucial aspect of health and well-being that requires special attention is the challenges faced by vulnerable groups due to their specific health needs. Dr. Boratyńska raises the issue of gender reconciliation for people wishing to undergo gender reassignment surgery.
In Poland, such procedures are not covered, creating serious impediments to accessing health services for this community, Dr. Boratyńska says: «There is also a lack of organised care for those who declare a need for gender affirmation. The organisation of everyday health care does not consider the specific needs of gender reconcilitation procedures. When a person is admitted to hospital, there is a problem of accommodation, as multi-bed wards are either for women or men only. Only 24% of citizens are in favour of gender reconciliation procedures reimbursement. This is due to the low level of public awareness of the issue, but also to the fact that public attitudes towards transgender people have deteriorated considerably over the last 8 years due to the overtly negative attitude of the authority. But the truth is that when the authorities tolerate something, the average of citizens concludes that this is the way it should be and many of them join in the denigration. The same applies to homosexuals and issues such as same-sex unions or the joint adoption of children».
Mental health
In the complex landscape of the Polish health care system, several significant challenges and gaps emerge that affect access to and quality of health care, e.g. Boratyńska, on mental health interventions, states: «Children and young people generally have access to a relatively good level of health care. The exception is psychiatric care, as there are too few hospitals and psychiatrists for children and adolescents. The pandemic has made access even worse, with a significant increase in the number of patients. Chronic underinvestment in mental health care results in psychiatric hospitals that are severely overcrowded and have intolerable living conditions. The mental health system is geared towards inpatient care».
There could be solutions as the creation of open regional psychiatric care facilities. Queues to see a National Health Service psychiatrist are record-breaking: «To get a place in a psychiatric hospital, you have to wait a long time or look for one far from your home, possibly across the country. Those who can use private care, which is fully paid for, do so. Psychiatric drugs are reimbursed and relatively cheap, but you have to wait for a prescription».
Looking to the future
Dr. Boratyńska outlines a complex landscape concerning access to healthcare, equity and sustainability in Poland, addressing a number of crucial issues ranging from geographical disparities to legislative reforms and the broader European context.
Firstly, Boratyńska focuses on improving working conditions for doctors as a strategy to counteract the brain drain, emphasising the importance of boosting specialisation in psychiatry and geriatrics to meet growing healthcare needs. However, despite these efforts, financial sustainability remains a significant challenge, with Boratyńska criticising the lack of coherent strategies and denouncing instances of mismanagement, such as the over-distribution of medical supplies during the COVID-19 pandemic.
Looking to the future, Dr Boratyńska emphasises that in Poland it is a priority «a legislative reform, including revising laws on reproductive rights and assisted reproduction, limiting the scope of the conscience clause and institutionalizing patient autonomy through health proxies and living wills. Moreover, there’s a call for legal frameworks to address end-of-life care and support transgender and intersex individuals».
Financial sustainability remains a significant challenge that needs appropriate strategies
At the European level, Dr. Boratyńska highlights the importance of complete reproductive autonomy, the legalisation of euthanasia and the need for organised health care for the elderly. In addition, she calls for consistent guidelines on terminal medicine and a re-evaluation of the Oviedo Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine to adapt it to advances in assisted reproductive methods.
By addressing access disparities, ensuring financial sustainability and advocating for legislative reforms, Poland can pave the way for a more equitable and patient-centered healthcare future, both domestically and within the broader European context. Boratyńska in conclusion states: «I suspect that in no country are citizens satisfied with the public health service. Certainly, there are abuses everywhere, but perhaps the most irritating are the mismanagement and waste and the blatant discrimination against certain groups in society. As a lawyer, I look at it in terms of injustices in the laws themselves, or where those laws are not in place when they should have been for a long time. However, the adoption of appropriate solutions at European level is likely to pave the way for the adoption of appropriate national solutions».
