Jan Hartman
Lessons of Shared Responsibility: People Learning in the Process
of Health Care Reform in Poland
 
In recent three years, Polish health service has been undergoing revolutionary transformations. Naturally, various interests conflicts have surfaced, sometimes publicly perceived as destruction and chaos. The new structure of health care, and the changed social status of this service, have been developing through complex processes, which can be planned or controlled but partially. The essential precondition for success of these significant and profound changes consists in the deconstruction of existing structures and transitory system deregulation. This precisely is the current stage of health service reform in Poland. Despite some promising changes, yet visible, the public opinion has been convinced that the reform resulted so far in partial decay of health service organizations, their anarchization, corruption and politicization. Considering the occasional frightful anomalies, often very drastically presented to public opinion and increasing the feeling of dissatisfaction, the widely held views seem to have good reasons to be as they are. Yet, the evident limitations of state’s involvement in guaranteed medical service, relying on compulsory health insurance tax, and the clear inefficiency of the system of budget outlays to health protection, and refunding of medical services by public agencies managing the health tax (“Sickness Funds”), have resulted in significant change of average Pole’s attitude to his health condition. This has been a side-effect of the social dissatisfaction with health service. For the first time for many decades, the average Pole feels essentially responsible for his/her own physiological condition, as well as the health of his/her family. Poles have understood that their various life decisions and restraints influence essentialy the length and quality of their lives. Such decisions include the life style and alimentation mode, knowledge of certain medical advice and prophilaxis recomendations, as well as the decisions concerning a selection among insurance agencies, the family doctor and personal expenditures on health protection. What is more, in effect of intensified interest in personal health and the condition of public medical services, the citizens naturally learn to fulfil public acts, which seem usual for the inhabitants of law-abiding and democratic West. Polish citizens are now forced to search for information, develop their own opinions, voice their views in certain political and social issues (such as the strikes of nurse in 2001) and finally they express their experience, views and interests in elections. In effect the health service reform, which is now in the culminating phase of system deregulation accompanied by weakness and instability of new structures (a quasi-anarchic phase) has become for the Polish society a school of responsibility and democracy.
From the viewpoint of a “common man,” which is by definition the most common and influential in the process of community opinion formation, the emergence of the economic dimension of health service has been noticed as a critical systems change in relation to communist times. Previously, the society was by and large unconscious of any costs that might be generated by medical services. Indeed medical aid and treatment were not considered a ‘service’ at all. “Care” was the term generally applied, and it was sufficient for all practical uses. Such “care” was provided by omnipotent state, which could not incur any costs, since it was “buying” products exclusively from itself. A “service” could be understood only as a “favour” (in Polish both words are very similar) rendered by the physician in exchange for a bribe. Such “favour” consisted in extending to “common man” the type of medical treatment which was essentially reserved for communist nomenklatura and doctors’ families. Graft was not the rule in communist health service, but neither was it evaluated negatively in general. Instead, it was seen as a relatively fair deal: the physician was selling his risk in solidarity with common patient, facing the grim power of the state and its cronyism. In result, the bribe provided the patient with a shortcut, and indeed only chance, to obtain good and fast treatment. 
Yet, new times have come and inflicted severe shock to this cosy world. It appeared that medical treatment was related to costs. This new concept of costs was not connected any more to graft expenses assuring fast access to unlimited resources of the national health service. It seemed that the very generation of such resources was costly. The society was shocked to learn that the state hospital was no longer an integral part of omnipotent state, wielding unlimited assets. The hospital needed money to operate! What is more (and that was beyond the understanding level of anyone) the hospital could be indebted in relation to its very owner-the state. In these very new circumstances, the status of physician has suffered. Previously, doctors were the very well placed intermediaries between the patient and state bureaucracy, often having the power of deciding about life and death. At present, the position of medical doctor has become an awkward combination of two roles. On the one hand, the doctor has remained an elevated authority, as depository of obscure medical knowledge and “wielder of hope,” and, on the other hand he/she has fallen to the status of common man: someone who must make his living somehow, and must demand payment. The dilemma is: how can we revere someone, who is also as common as to demand money for his/her service. The moral situation, which has developed in effect of the fragmentary introduction of market mechanism to health service, has proved awkward both for patients and physicians. Many patients are not willing to meet any additional cost of medical care, on top of the health insurance. Yet, they need to respect the doctors. On the other hand, the doctors would much prefer to obtain adequate regular incomes, and to avoid the dubious moral standards of under-the-table remuneration, which deprives them of social respect. Recent years have witnessed the uncontrolled spread of informal financial flows (including both shear bribes and half-legal patients’ “donations” to the hospital acknowledged with “contributory receipts”). Parallelly, an ambigious discourse of moral legitimisation has been emerging (“I do not take bribes, but I do accept tokens of patients’ gratitude”). Fortunately, we have just entered the formation period of lawful citizens’ consciousness, where doctors and patients are linked by relations of mutual solidarity having positive nature: i. e. the acceptance of mutual relations as honest. This is in contrast to the “ancien regime” negative solidarity-in common opposition to the arch enemy defined as “The State” or “The System.” I do not claim that graft has been terminated. To the contrary, bribing medical doctors is still-like in recent years-an everyday fact. Though, in most cases it is caused by inertia of social imagination or indeed magical thinking. “Common man” remains persuaded that “bribe offering” has a magical sense, and “redeems” you from the realm of evil powers. In practical terms, the link between graft and better treatment of patients has been on the decline. Indeed, the patients have by and large ceased to expect such correlation. 
Polish medical science and services have two different faces. One of them shows the everyday misery: long queues of patients awaiting surgeries, low level of hygiene in hospitals, the necessity of regular “donations” expected from patients to support the elementary medical tests and procedures, administrative competence chaos and excess of bureaucratic activities, resulting of the assumption that all users of the system try to cheat the system and other users. The other image relates to world-scale achievements of some Polish medical scientists, high level of certain clinical centres, and a good system of medical education (though festered with corruption). The conflicting co-existence of both these worlds can be illustrated by the case of a cardio-surgery clinic which runs the most complex and expensive open-heart surgeries, and yet the patients’ families are expected to finance food and buy syringes in hospital chemists’ shop. All these petty economies are expected to finance the costs of perhaps one more essential surgery. Such solidarity in face of common cause-saving the lives of patients-sometimes assumes the form of military discipline, and can be upheld due to the absolute authority of doctors. In these specific conditions, the rule is that “money is not essential,” while the desease and the “real conditions of the System” are the common enemy of both officers-physicians and privates-patients and their families.
However, also in those circumstances where the elevated atmosphere of life-saving is somewhat deficient, i. e. in “common hospitals” where money does play important role, and where “The System” is regularly criticised, there are good reasons for growing solidarity between the patients and doctors. The sustained atmosphere of financial deficit and threat of stopped financing unites the patients and physicians in a “community of complaint.” At the same time, it leads to hostile confrontation of both groups, since the doctors cannot advise patients about all used economy methods applied at the expense of selected patients, or the strategies of transferring the patients in the direction of private medical services sector, where the physicians essentially work and realise their incomes. In these circumstances, the patient is forced to embark on intellectual effort consisting in the assessment of his/her own situation and the financial position of the hospital and employed physicians. Such complex analysis would require the understanding of social security system. For the first time in post-war Polish history, we do face the situation when the society is expected to feel the correlation between its own health security and a certain political involvement, conceived as comprehension of an important element of State institutional infrastructure. 
Naturally, the first, and the most direct impulse of defensive social reaction was suspicion and criticism. Except for the social organisation trying to protect the rights of patients-victims of medical malpractice, the community’s reaction focused essentially on the activities of “Sickness Funds” i. e. the state organs purchasing medical services from most efficient providers. As could be expected, these organisations presiding over sustained structural deficit, have been neither cheap in administration costs nor free of graft. To make matters worse, the boards of “Kasy Chorych” have been overtly dominated by party interests. Both patients and doctors have reasons to be critical about the activities of these organisations. In effect a sort of negative alliance of both groups has developed. However, the reformed system has given rise also to affirmative attitudes. An impartial observer must see that essentially the new system of health service is by far more honest and humanitarian. In consequence, the Polish citizen: both in the role of patient and doctor, while criticising the inefficiency of national health service, corruption, penury, hospital infections, and the proverbial carelessness of surgeons leaving cotton wool tampons in the bodies of unfortunate surgery patients, has the grounds to believe that at least “they” (the State)-and indirectly ourselves (“us”) have developed institutions which are basically correct. The new system both relies on the rule that “everyone pays for themselves insofar they able to,” and the principle of social solidarity or mutual insurance; the rights of patient and doctor are protected. Thus the desired social order and justice do prevail. This has been an important practical lesson of democracy. The society has learnt that the elected authorities can effect major systems changes in a short time. The success or failure of desired changes depends essentially on the social agents affected by new laws. Possibly, even more important is the fact that citizens have understood finally their own responsibility for their health condition. The “ancien regime” magic faith that the Omnipotent State will take care of you in case of need has partly evaporated. This amendment of political awareness, resultant of law system changes, has led to very favourable effects in the field of contagious diseases control. The raised social health awareness, partially caused by the reduced magical confidence in state’s power in the domain of health, resulted in the fact that Polish citizens (urban population most clearly ) have been observing much more rational dietary rules, and undergoing much more frequent preventive medical tests.