Poland health system review.

Since the successful transition to a freely elected parliament and a market economy after 1989, Poland is now a stable democracy and is well represented within political and economic organizations in Europe and worldwide. The strongly centralized health system based on the Semashko model was replaced with a decentralized system of mandatory health insurance, complemented with financing from state and territorial self-government budgets. There is a clear separation of health care financing and provision: the National Health Fund (NFZ) the sole payer in the system is in charge of health care financing and contracts with public and non-public health care providers. The Ministry of Health is the key policy-maker and regulator in the system and is supported by a number of advisory bodies, some of them recently established. Health insurance contributions, borne entirely by employees, are collected by intermediary institutions and are pooled by the NFZ and distributed between the 16 regional NFZ branches. In 2009, Poland spent 7.4% of its gross domestic product (GDP) on health. Around 70% of health expenditure came from public sources and over 83.5% of this expenditure can be attributed to the (near) universal health insurance. The relatively high share of private expenditure is mostly represented by out-of-pocket (OOP) payments, mainly in the form of co-payments and informal payments. Voluntary health insurance (VHI) does not play an important role and is largely limited to medical subscription packages offered by employers. Compulsory health insurance covers 98% of the population and guarantees access to a broad range of health services. However, the limited financial resources of the NFZ mean that broad entitlements guaranteed on paper are not always available. Health care financing is overall at most proportional: while financing from health care contributions is proportional and budgetary subsidies to system funding are progressive, high OOP expenditures, particularly in areas such as pharmaceuticals, are highly regressive. The health status of the Polish population has improved substantially, with average life expectancy at birth reaching 80.2 years for women and 71.6 years for men in 2009. However, there is still a vast gap in life expectancy between Poland and the western European Union (EU) countries and between life expectancy overall and the expected number of years without illness or disability. Given its modest financial, human and material health care resources and the corresponding outcomes, the overall financial efficiency of the Polish system is satisfactory. Both allocative and technical efficiency leave room for improvement. Several measures, such as prioritizing primary care and adopting new payment mechanisms such as diagnosis-related groups (DRGs), have been introduced in recent years but need to be expanded to other areas and intensified. Additionally, numerous initiatives to enhance quality control and build the required expertise and evidence base for the system are also in place. These could improve general satisfaction with the system, which is not particularly high. Limited resources, a general aversion to cost-sharing stemming from a long experience with broad public coverage and shortages in health workforce need to be addressed before better outcomes can be achieved by the system. Increased cooperation between various bodies within the health and social care sectors would also contribute in this direction. The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services, and the role of the main actors in health systems; they describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis.

Poland: health system review

The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of policy initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.

[Hepatitis B in Poland in 1999]. / Wirusowe zapalenie watroby typu B w 1999 roku.

A total of 3,508 of hepatitis B cases (including 152 cases of mixed HBV and HCV infections) were reported in Poland in 1999. For the first time since 1979, when registration has began, the incidence decreased below 10.0 and was 9.1 per 100,000. The program of eradication of hepatitis B in Poland has been introduced in 1993 and since then the fourfold decrease in number of hepatitis B cases has been noticed. During the past 7 years there has been a steady decline in hepatitis B incidence. In 1997 the incidence decreased 23% as compared to 1996, followed by 16.8% decrease in 1998 and 13.9% in 1999; the marked differences in incidence in particular voivodeships have been observed. The overall rate of hospitalized hepatitis B cases in Poland reached 98.1%. A total of 25 cases of hepatitis B (rate 1.2 per 100,000) occurred among children under 4 years of age, who should be vaccinated. Among children aged 5-9 years, of which many could not be vaccinated, the incidence rate was 6 times higher, ranging from 4.9 per 100,000 in girls to 9.8 per 100,000 in boys. The increase of incidence from 5.3 to 9.2 was observed in young people (14-24 years old). Data from the study of serological markers of hepatitis B, conducted among 4,500 health care workers during 1998-2000, have indicated that about 22% of health care workers have been infected with HBV (in 21% of persons anti-HBc and in 1% anti-HBc together with HBsAg were detected).

[Hepatitis C in Poland 1999]. / Wirusowe zapalenie watroby typu C w 1999 roku.

In 1999, a total of 1,988 (5.1 per 100,000) acute and chronic hepatitis C cases were noted. HCV and HBV coinfections accounted for 7.6% reported cases. Incidence in urban areas (6.9 per 100,000) was 200% those in rural areas (2.3 per 100,000). Incidence among men (6.0 per 100,000) was 40% those among women (4.3 per 100,000). The most predominant groups were age 40-44 (235 cases, 11.8%) and 65-74 (229 cases, 11.5%). Presented data should be taken cautiously because of development of diagnosis and reporting.

[Influenza in Poland in 1999]. / Grypa w 1999 roku.

A total of 2,344,773 cases of influenza were reported in Poland in 1999, corresponding to 6066.1 cases per 100,000 population and was 2.8 times higher as compared with 1998. The highest influenza incidence rate (10,770.9 per 100,000) was reported in Malopolskie voivodeship. Children up to 14 years old accounted for 34.9% (818,629; incidence 10,616.2 per 100,000) of all reported influenza cases. A total of 3,925 persons required hospitalization, eight times more as compared with 1998. The number of deaths due to influenza amounted to 402. Compared with 1998, in 1999 reported influenza deaths increased 6.4 times. During the second two weeks of January 1999 four influenza strains of type B were isolated from patients aged 13, 16, 31, and 38. During the first part of February 1999 another two strains of influenza virus type B were obtained from persons aged 35 and 45. All six isolates were related antigenically to the vaccine strain B/Beijing/184/93 and were confirmed by the WHO Collaborating Center for Influenza Reference and Research, London.

[Influenza in 1998]. / Grypa w 1998 roku.

In Poland in 1998 total number of 825,345 cases of influenza were noted. It meant decrease in half (47.7%) of the number of cases registered in 1997. Cumulative incidence was 2134.5 per 100,000. It was 449,592 cases in children up to 14 years old. 489 persons were hospitalized which was 0.06% of reported cases. Percentage of hospitalizations decreased almost in half. Number of case fatalities due to influenza was 63. In January 1998 there were isolated four variants of Influenza virus of subtype A(H3N2). They were related to the variant included in the influenza vaccine used in epidemic season 1997/1998 (results of antigenic analysis was confirmed by WHO Collaborating Centre for Influenza Reference and Research, London).

[Hepatitis B in 1998]. / Wirusowe zapalenie watroby typu B w 1998 roku.

In 1998 in Poland 4074 new cases of viral hepatitis B were noted (including 149 mixed infections with HBV and HCV). Incidence was 10.5 per 100,000 and it was 2.2 lower than year ago. In 1997 the infection with HBV was observed in 4896 persons, including 66 mixed infections (incidence rate 12.7/100,000). Constant decrease in number of new cases and incidence was observed in both sexes gender and all age groups after introduction of the intensive program of prevention and control of hepatitis B in 1993. It lead to almost 4 fold decrease of the number of new cases. There are still significant differences in incidence between particular voivodeships. For example between voivodeships Lodz and Warsaw the difference is twofold (20.6 and 10.2). The incidence of hepatitis B is still higher in cities (11.8) then in rural areas (8.6). It is dependent on gender and age. The lowest incidence is among children 0-4 years old 2.8/100,000 (61 cases). Twofold increase of incidence (from 4.6 to 9.8) is observed between ages 14 and 24; it is mainly due to higher incidence among young men especially those living in cities.

[Hepatitis C in 1998]. / Wirusowe zapalenie watroby typu C w 1998 roku.

In 1998, 1,710 cases of viral hepatitis type C were reported (incidence 4.4 per 100,000). There were 149 (8.7%) mixed infections: HCV + BBV. Both acute cases and newly diagnosed chronic cases were registered. Highest incidence was found in people 55-59 years old (7.49) and 60-64 years old (7.05). Cumulative incidence was higher in men (5.2), than in women (3.7). In particular in age groups of 15-34 incidence in men was even 2-3 times higher that in women. Incidence in cities (5.9) was 3 times higher then in rural areas (2.0). Among reported cases at least 113 (6.6%) employees of health system were found. Data presented above should be taken cautiously because separate registration of hepatitis C was introduced in Poland as late as in 1997.

The epidemiology and history of influenza.

Disease caused by influenza virus has been known from ancient times. However, in spite of the progress in pharmacology and vaccinology, this pathogen still affects morbidity and mortality in all age groups all over the world. This article gives some essential information on the history of influenza, its pandemics and main features of influenza viruses. Data on the epidemiologic situation of influenza in Poland in the period 1946-1999 are presented. Influenza surveillance issues and particularly prevention of influenza by vaccinations are discussed.

[Influenza in 1997]. / Grypa w roku 1997.

The number of cases of influenza and influenza-like illness registered in Poland in 1997 amounted to 1,578,494. This number of cases is 41.8% lower when compared with the previous year 1996. The incidence of influenza amounted to 4,084 per 100,000 inhabitants. The number of influenza cases registered in children aged up to 14 years was 557,033. This is 35.6% of total number of cases. The incidence of influenza in this group amounted to 6,828.7 per 100,000 and was 67% higher than total incidence. In the beginning of January 1997 six strains of A (H3N2) influenza virus were isolated in the National Influenza Center WHO, Dept. of Virology, National Institute of Hygiene. These isolates were similar to A/Wuhan/359/95 and A/Johannesburg/33/94 strains and were obtained from patients aged 5, 6, 45, 50, 75 and 85 living in Warsaw. In February 1997 next six strains A (H3N2) similar to A/Wuhan/359/95 were isolated. Four of them were obtained from patients aged 9, 10, 11 and 14 living in Lublin. One strain was isolated from patient aged 14 living in Kielce and the last one was obtained from patient aged 70 from Warsaw. In general, ten strains isolated in 1997 were similar to the vaccine strain A/Wuhan/359/95 recommended for the epidemic season 1996/97, while two isolates were antigenically similar to the strain included in the vaccine in the previous epidemic season, i.e. 1995/96.

[Hepatitis B and C in 1997]. / Wirusowe zapalenie watroby typu B oraz typu C w roku 1997.

In 1997, 4,896 cases of hepatitis B were notified in Poland, including 66 mixed infections with B and C virus. The number of cases notified was 1,539 less than in 1996. The incidence rate was 12.7/100,000, which was lower by 4.0 than in the proceeding year (16.7), what means a decline in the incidence rate of hepatitis B by 24%. 1997 was the fifth consecutive year when a decline in incidence rate hepatitis B was observed, since the intensive program of hepatitis B prevention was introduced in 1993 Hepatitis B incidence rate was greater in urban areas (14.1/100,000) than in villages (10.4/100,000). In urban area, the incidence rate was proportional to the number of habitants (fig. 1). The immunisation programme is the main reason of falling incidence among children aged 0-3. In 1997, 36 cases were notified in children aged 0-3 while in 1990 129 cases were registered. The incidence rate has fallen from 9.5/100,000 to 2.5/100,000 in this age group, which means a drop of 74%. The analysis of notified cases shows that the program of hepatitis B prevention is effective. Positive trends from previous years were maintained in 1997 although the declining trend has been slightly sloved. In 1997 hepatitis C has become a statuatory notificable disease in Poland. 1,064 cases were notified, with an overall incidence of 2.75/100,000.

[Epidemiologic situation of diphtheria in the European region of the World Health Organization in 1992 and during the first half of 1993]. / Sytuacja epidemiologiczna blonicy w Europejskim Regionie Swiatowej Organizacji Zdrowia w 1992 i w pier wszej polowie 1993 roku.

In sixties and seventies small number of diphtheria cases was registered in European countries and diphtheria seems to go to be eliminated. Between 1982 and 1985 the first wave of diphtheria epidemic, and since 1990 the second wave were observes. Majority of cases during the first epidemic was registered in Soviet Union, but also in Germany, Italy, Portugal, Turkey and Sweden. Since 1990 increasing numbers of cases were registered in Russia and Ukraine. Some imported cases from these countries were observed in Bielorussia, Lithuania, Latvia, Estonia, Poland, Finland, Norway. Prophylactic measures undertaken in Russia and Ukraine were not sufficient. Shortage of vaccines were the most important reason of this situation. In 1992 one case and in first six months of 1993 five cases of diphtheria were imported in Poland. Production of Td vaccine started in Poland in 1991 and vaccination of adolescents in 19 as well as vaccination of some risk groups were introduced especially in the east port of country.

[Evaluation of immunologic response in individuals of various ages to Td vaccine]. / Ocena odpowiedzi immunologicznej osób w róznym wieku na szczepionke Td.

Forty adults volunteers 25-65 years received 10 BU tetanus and 2 Lf diphtheria adsorbed vaccine (Td). The tolerance was very good, it was not depended on the age antitoxin level. Eleven persons have not diphtheria immunity before the vaccination. The serological response was determined by the passive hemagglutination in sera collected in 4 week after the vaccination. Only in one serum the level of diphtheria antitoxin was below 0.1 IU/ml. It is recommended than two doses of Td vaccine are necessary for anyone whose last dose of diphtheria anatoxin was given more than 10 years ago especially to persons travelling to other countries at risk for diphtheria.

[Evaluation of vaccination reactions and serologic responses after Td vaccine in pilot studies]. / Ocena odczynów poszczepiennych i odpowiedzi serologicznej po szczepionce Td w badaniu pilotowym.

Fifty six young adults volunteers received 10 BU tetanus and 2 Lf Diphtheria adsorbed vaccine (Td). Reactogenicity was noted in the special formulas, the serological response was determined by the passive hemagglutination in sera collected before and in 4 week after the vaccination. Twelve persons were not immunity for diphtheria before booster. The results confirmed the safety and efficacy of the polish Td vaccine.