Prezentacja programu PowerPoint

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Atonomus hospitals and health care
organizations Poland Andrzej
Rys Jagiellonian University, Krakow Washington
D.C., February 18-19th 2004 World Bank
Conference GOVERNANCE AND ACCOUNTABILITY
IN SOCIAL SECTOR DECENTRALIZATIONS
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About

• Decentralization of the state
• Decentralization of the payer
• Autonomy of health care institution
• New actors

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4 reforms 1999
Social Insurance
State/public administration
New State?
Decentralization
Education
Health care
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BEFORE Reform of the Administration (49
voivodship)
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A NEW STATE FOR NEW CHALLENGES
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STATE DECENTRALIZATION
State Administration Central and on the Regional
Level
Regional Government Voivodship
Local Goverment Poviat and Gmina
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IT ALL DEPENDS ...

• DECENTRALIZATION
  NEW COMPETENCE
• NEW FINANCING

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DECENTRALIZATION vs. REGIONALIZATION

• Political Process - supported by local leaders
  (fight between 16 vs.12 regions followers)
• Culture, Tradition, Customs - additional factors
• Competition between regions
• Disturbed (unknown) role of Voivod and Marshal
  in practice

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NEW ADMINISTRATIVE STRUCTURE

• VOIVODSHIP/Region - 16
• POVIAT/County - 376 (incl. 65 largest urban
  gminas with poviat status)
• GMINA/Communities - 2489

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Hospitals ownership after 1999 reform
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Is a role for local/regional governments?

• Regional health plans (from 2003)
• Strategic planning
• Making a decisions (eg. privatization)
• Activities coordination
• Health programs
• Working with local providers (local taxes, rents)
  
• Services planning access
• Finance investment
• Using of resources (estate)
• Personnel replacement programs
• Supervision
• Patients/clients satisfaction
• New services planning

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Insurance Fund
Local/Regional Government
Citizen/Consumer/Patient
Autonomus Public Provider
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Autonomus health care unit

• Free in management, HR policy
• Depend on the public owner in planning,
  investment, selling, renting, outsourcing,
• loans, taking next step to privatization
• Negotiation salary and personnel replacement
  with trade unions
• In 2002- 2003 WB project Decentralization of HC
  in Poland

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Establishment of Autonomous Public Providers

• The General Health Insurance Act allowed for
  signing of contracts for providing health
  services only with entities with legal
  personality.
• Public HCEs that were budgetary units could
  acquire such personality by becoming autonomous.
  
• The 1991 Act on Health Care Establishments, and
  particularly its later amendments, defined the
  procedure of gaining autonomy by budgetary units.
  Gaining autonomy allowed the unit to conduct
  its own financial management, staff policy and to
  define a strategy conforming to the demands for
  services and the capacity of HCE.

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MANAGEMENT PROCESS

• The polled managers acknowledged that autonomy is
  wider now as regards staff and financial
  management, whereas it was very limited before
  the entity became independent. Nevertheless,
  there are certain limitations as LGs assert undue
  influence in matters like hiring, investment
  decisions, and acquisition of fixed assets.
• The purview of managers decisions encompass
  matters like opening and closing of departments,
  purchase of equipment, staff policy, development
  of units strategy, and most of the financial
  decisions. The autonomus unit require the
  consent of institutions like the Founding Body
  and Social Council in matters concerning changes
  in the organizational structure and statutes of
  the unit, disposing and acquiring fixed assets,
  and in making investment decisions
• The meetings of the Social Council are held at
  varied frequency, being linked to the subject of
  deliberation. Bi-monthly meetings are held to
  discuss current matters relating to finances and
  provision of health services .
• The scope of the operational management powers of
  the managers of the autonomous units is evaluated
  as adequate. Limitations do occur in investment
  and asset management decisions. It is observed
  that the Polish model of management of autonomous
  units is imperfect as it does not in itself lead
  to efficiently functioning institutions
  supporting operating management (such as
  management boards) or institutions that provide
  opinions
• New quality programs (including hospital
  accreditation and ISO)

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HUMAN RESOURCE MANAGEMENT

• The employment decisions are made by the
  manager/director in each case. But the autonomy
  has not resulted in the introduction of new
  procedures in the field of staff management.
• Although formally there are no external
  employment limits, the respondents point to
  indirect constraints stemming from the value of
  the contract with the payer or with the minimum
  norms of employment as regulated by the Labor
  Code or the MOH. Such norms regulate the number
  of duty hours, time of work of x-ray technicians
  etc.
• The managers emphasized that the scope of freedom
  in employment is greater than it was before the
  reform. The remunerations are decided by the
  managers, who have greater freedom in modeling
  wages, as there is no upper limit.
• The procedure for dismissing workers is in
  accordance with the provisions of the Labor Code
  and the Act on Trade Unions. There are no
  changes from the pre-reform period. The managers
  make the final decision on dismissal from the
  service. The Labor Code and the Act on Trade
  Unions define the circumstances when dismissal
  decisions must be consulted with the trade
  unions.
• The scope of freedom of managers in staff policy
  has increased. The still encountered limitations
  are budgetary and not systemic, i.e. they result
  from legislative regulation. The little use of
  modern tools of human resource management is
  striking since the role of professionals (mainly
  medical personnel) in contributing to the success
  of the unit may suggest that staff policy would
  be accorded a priority
• Contracts with the medical professionals
• Outsourcing of some services and transfer some
  workforces to private companies

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MANAGEMENT OF FINANCES AND SUPPLY

• Significant changes in the practice of preparing
  the budget, including the method of making the
  budget and method of recording costs (currently
  the memorial method). New elements, like income
  from additional and financial activity, fixed
  assets as a value on the assets side, or cash
  flows have been added.
• Monitor execution of the budget with monthly
  analyses or continuous controls. An account of
  costs is maintained and one facility uses the
  system of budgeting of individual organizational
  units.
• Could plan for external financing sources
  including loans, credits, and leasing. The same
  number gave a negative reply. Banks often
  classify autonomous hospitals as a fourth risk
  group making it difficult to obtain a loan
• Prepare annual financial statements in accordance
  with the provisions of the Accounting Act.
• Could now transfer and utilize a financial
  surplus
• Debts belong to the facility itself or to the LG
  (after closing)
• Investment plans
• Decisions concerning supply of goods and service

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STRATEGIC PLANNING

• Strategic plan was required to became autonomous
  units
• The management prepared the plan in the remaining
  entities or in the small groups
• I many cases was had not been modified since
  becoming autonomous.
• The mere existence of strategic plans may be
  interpreted with great caution as their
  usefulness is limited and there is no linkage of
  the strategies of the individual units with those
  of the voivodship and powiat governments.

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ENSURING PATIENT RIGHTS AND IMPROVING ACCESS

• Regular meetings are held with the
  representatives of the community, patients and
  members of associations. There was no such
  practice before reforms.) maintained that their
  strategic plan takes into account the needs of
  the community in which they operate
• Managers claimed that the portfolio of services
  offered by them has changed. Existing services
  have either been expanded or new ones introduced
• Special cells to deal with complaints of the
  patients
• After the 1999 reforms, patients have more
  avenues to lodge complaints regarding the
  operation of the health care system.
• Insurance against malpractice. Such insurance
  did not exist before autonomy was gained
• Monitoring the waiting time and patient
  satisfaction.
• The changes in the health care system have
  strengthened the position of the patient by
  better serving his rights. The patients are more
  aware of their interests and are more vocal in
  protecting them

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Payer and Provider
seller
buyer
CONTRACT
PROVIDER
HEALTH INSURANCE FUND
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What does the CONTRACT mean?
?
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RESULTS OF PAYER DECENTRALIZATION

• 17 antonomous and independent units...from
  everyone
• Over 23.000 contracts in the year 2001
• Various payment methods
• Disturbance in the information flow
• Permanent lack of information at the all decision
  makers level

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INNOVATION or ANARCHY ?
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INNOVATION or ANARCHY?

• Problems with innovation in such a short term
• A lot of changes in short term
• Unprepared - providers, professionals, patients,
  media
• LACK OF estimation of innovations and its
  implementation process
• LACK OF education about prepared, implemented and
  present innovations
• LACK OF analyses - MOVING TARGET

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Changes done...to reduce anarchy

• Legal changes(2000, 2001, 2002)
• Changes in a board 21 to 7 (in three steps),
  quality of a members, MOH control
• Changes of CEOs
• More clear responsibility for different level of
  health services
• More transparency in contracting
• Seek funds could be merged
• More information for patients

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Citizens evaluation of the new health care
system (2000)

• Health care situation is worsening (67 )
• disorder in the system (40 )
• increasing costs of care and medication (24 )
• problems obtaining referrals to specialists
• (23 )
• long waiting time (15 )
• uncertainty about rules, entitlements (10 )

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Citizens evaluation of new health system(2000)

• Health care situation is improving (19 )
• good quality of patient care (26 )
• free choice of doctors, health care facilities
  (18)
• competition enhances quality (18 )
• good relations doctor - patient (15 )
• privatisation (10 )

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New Actors in Health Care Reform

• Government
• Minister of Health
• Voivod
• 3 Levels of Local Governments
• Regions
• Poviats
• Gminas
• Chamber of Nurses, Chamber of Physicians, etc.
• New Trade Unions and Employers associations
• NGOs

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Partners creating Regional Restructuring Programs
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Program implementation

• decentralisation and regionalisation were
  introduced
• social communication techniques were applied
• procedures of applying to the Program together
  with the assessment criteria of regional programs
  were clearly identified,
• the final distribution of funds depended on the
  program quality
• all parties interested in the problem were
  involved by initiating to build a regional
  partnership for health.

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Outcomes of the program

• the reduction of beds by over 12,000,
• better utilisation of resources (e.g. bed
  occupancy, length of patients stay),
• establishing of long-term health care
  institutions - 218
• purchases and investments for over 1000
  integrated health care institutions,
• adaptations, modernisations and general repairs,
  
• rationalisation of employment, which meant plans
  of dismissing about 100,000 employees within 3
  years (only the 1999 and 2000 plans were
  implemented, i.e. dismissal of about 70,000
  employees, out of which over 50 found employment
  in non-public health care institutions)
• extensive educational program both for managers
  and local health politicians
• mass privatisation of primary care and specialist
  outpatient medical services, i.e. generation of
  competition

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Staff reduction 1999-2001
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Next steps 2002-2004

• Centralization
• Commercialization of the hospitals?
• New legal frame after decision of the
  Constitutional Court, 7th January 2004