International assistance and health care reform in Poland: barriers to project development and implementation.

The restoration of democracy in Poland initiated a major system transformation including reform of the health sector. The international community were quick to respond to the need for assistance. Polish proposals were supported by international experts and projects were developed together with international development agencies and donors. Donors had no experience of central and eastern Europe, these countries had never been beneficiaries of aid and neither side had experience working together. Progress and absorption of funds was slow. Comparative experience from developing countries was used to analyze the barriers encountered in project development and implementation in Poland. The conditions necessary for implementation were not satisfied. Insufficient attention was paid to the project process. Barriers originate on the side of both donors and recipients and additionally from programme characteristics. The most serious problems experience in Poland were lack of government commitment to health care reform leading to failure to provide counterpart funds and low capacity for absorption of aid. Rent seeking attitudes were important. Donor paternalistic attitudes, complex procedures and lack of innovative approach were also present. Poor coordination was a problem on both sides. Multi-lateral projects were too complex and it was not always possible to integrate project activities with routine ones. External consultants played an excessive role in project development and implementation, absorbing a large portion of funds. The barriers have been operationalised to create a checklist which requires validation elsewhere and may be useful for those working in this field.

Abortion law in Poland.

The Polish Senate has passed the Abortion Law without modification and by 1 vote. This means that indications for legal termination of pregnancy include threat to life and health of the mother, pregnancy resulting from criminal activity, and congenital disorder of the fetus. Social indications will no longer be consistent with the law. Concerning sex education and family planning, Article 2, point 2 of the law status that the local authorities according to their terms of references, defined elsewhere, are obliged to ensure unhindered access to method and articles used in informed parenthood. In Article 4 sex education, information concerning informed and responsible parenthood, family values, life in-utero, and methods of informed procreation will be introduced into the school curriculum. The responsibility for the details of the curriculum will rest with the Minister of Education. The Law requires the President's signature before its contents can be implemented.

Regional integration of health services in Poland--an ambitious pilot project.

A new and very important feature of the health care reform in Poland is a set of initiatives emerging locally and striving for decentralisation of the management structure. The most promising manifestation of this process consists in the ambition to set up regional systems of integrated health services, guaranteeing provision of comprehensive care and run efficiently by competent managers. The direction of reform has been strongly encouraged by the Ministry of Health and Social Welfare, but still faces many barriers, mainly because of the misuse of the concept of integration by former health politicians. In the seventies and eighties integration was implemented in a very formal way, neglecting both medical professional attitudes and managerial abilities of decision makers. A major mistake was the resignation of inclusion of the rich 'parallel systems' within the services available to the general public. In the new political circumstances regionalised services, or health consortia as they are called, are a deliberate response to the need for decentralisation and efficient use of scarce resources. Three regions which volunteered to start an extensive experiment were selected through a formal competitive process. They include more than six million inhabitants and almost one quarter of the territory of the country. New organisational arrangements, networks of contracts and agreements, channels of financing and quality control programmes will be monitored in pilot areas to make them applicable all over the country.

Impact of endoscopic duodenal biopsy on the detection of small intestinal villous atrophy.

Coeliac disease is underdiagnosed partly because of insufficient recognition of more subtle presentations and partly because of the relative difficulty of jejunal biopsy. We have compared new case detection of small intestinal villous atrophy in the 5 years following changing to endoscopic multiple biopsy with our preceding 9 year experience utilizing jejunal capsule suction biopsy. The detection rate for small intestinal disease doubled while the number of patients investigated by small bowel biopsy increased threefold. We recommend that endoscopic duodenal biopsy replace jejunal biopsy for routine diagnostic purposes.

Giant false aneurysm of the subclavian artery. An unusual complication of internal jugular venous cannulation.

A false aneurysm with a diameter of 15 cm developed in the wall of the subclavian artery after attempted internal jugular cannulation. This potentially lethal complication, its diagnosis and treatment are described.