Poland is changing its health system from a Communist-era, government-run bureaucracy to a decentralized, competitive service oriented to consumers. To help with this task, the Polish government has enlisted experts from the Harvard School of Public Health.

The School, supported by a $3 million grant from the U.S. Agency for International Development, formed a consortium with Jagiellonian University in Krakow. The two began working together in 1995 to solve the many problems that arise from trying to adapt an obsolete health system to a modern market economy.

Since the fall of communism in 1989, the Polish people have been quick to establish private businesses. For example, consumers now enjoy a variety of fast foods at restaurants like McDonald’s without having to wait on long lines. They want the same kind of service from public health care providers.

But costs, efficiencies, and organization present problems. Strikes have occurred among doctors and nurses trying to raise their salaries from levels once below those of factory workers.

In the old regime, patients queued up in front of small windows in solid walls, behind which sat seemingly unresponsive bureaucrats. When the government literally knocked down the walls separating health workers and patients, one receptionist sued her bosses to restore the hole-in-the-wall situation.

"Things are happening very slowly, but they’ve been happening," says Paul Campbell, deputy director of the School of Public Health’s International Health Systems Group.

The Polish government approved private health care beginning in 1989, but that made things easier for only a relatively small number of people – those who can afford the best care. To begin reform of the public system, the national government in Warsaw transferred authority for outpatient services to Poland’s 46 largest cities.

Decentralization continued in January of this year when Warsaw divided the country into 16 regions and established separate health insurance funds in each. Payroll taxes support these funds, and decisions on spending are made by new regional boards.

Previously, all tax money went to the central government. The Communist party, then later a Parliament, debated how to spend these funds and notified clinics and hospitals accordingly. With the new system, regional boards make decisions for their region, and managers of individual facilities have authority over such things as buying medical equipment or hiring new people.

One of the School of Public Health’s major roles involves training managers to make the right decisions. "They need to be able to hold costs down while increasing the quality of care," Campbell says.

In 1994, Poland was spending $148 per person per year on health services. Women in that country could expect to live 76.1 years, men 67.5 years, and infants died at a rate of 15 deaths for every 1,000 live births. In the United States, life expectancy had reached 79 years for females, 72.4 years for males, and eight infants died per 1,000 live births. However, the U.S. was spending $3,628 per capita, or more than 20 times as much as Poland was.

So the Poles had a good start, but pressures for higher salaries, better technology, and improved health care have been building. "The Poles cannot spend too much on health care because it would drag down the rest of their economy," Campbell notes.

He and his colleagues advise the Poles not to do some of the things that make the U.S. health care system less than ideal. One is the purchase of high- cost, low-payoff technology, such as an overabundance of CAT-scan and magnetic resonance imaging (MRI) equipment. Such machines cost $1 million or more and every hospital wants the latest models. "There are more MRI machines in Los Angeles than in all of Canada," Campbell points out. "Such capital investments should be regulated even in a market economy."

"Poland lacks a private insurance industry," Campbell adds. "The country remains relatively free of the entrenched corporate interests that we must deal with in the U.S. when we try to improve the equity or efficiency of the health system. We have advised the Polish to develop regulations to prevent the mistakes and inequities that exist in this country."

With all the problems to deal with, progress is measured in short steps. In 1998, one network of public clinics in Krakow began offering 24-hour access for the first time.

Campbell’s team measured patient satisfaction with health care in Krakow in 1997 then again in 1998. "We found a significant increase in patient satisfaction," he reports, "and what was learned in this one city can be applied to others. Of course, the new initiatives have not been working long enough for us to see any improvement in rates of sickness and death."

Such gains could come with changes in lifestyle. "Poland has no tradition of regular exercise, diets are not tuned to reducing the risk of heart disease, and many people like to smoke and drink alcohol," Campbell points out. "Public health programs are needed to help people take charge of their lifestyles. In the past, all health directives came from the outside; now individuals must look inside and be accountable for their own health behaviors."

The Agency for International Development has extended the School of Public Health’s grant until June 30, 2000. At that time, the Agency will close its Warsaw office because the U.S. views the changes made in Poland’s health, education, and economy as a success story, according to Campbell. His group, however, plans to continue its cooperative efforts with Jagiellonian University.

Looking back on four years of experience, Campbell says, "all we’ve done is advise local and national officials about changes in the system. It’s the managers and consumers who ultimately determine the success of these changes."