POLAND NATIONAL SOCIAL REPORT 2012

Transcription

1 POLAND NATIONAL SOCIAL REPORT

2 Table of Contents Introduction Assessment of the main objectives of the "social" open method of coordination Reducing poverty and social exclusion Adequacy of benefits and sustainability of pension systems... 4 Financial stability of the system... 4 Adequacy of benefits... 5 Pensions for farmers (Agricultural Social Insurance Fund - KRUS)... 6 Adjusting the system to meet the demographic challenge Availability of quality health care and long-term care and stability of systems for the provision of such care... 7 Availability of services... 7 Quality of services... 9 Financial stability of the system of benefits

3 Introduction EPSCO Council of 17 June 2011 endorsed the opinion of the Social Protection Committee (SPC) of 23 May 2011 on "Reinvigorating the social open method of coordination in the context of the Europe 2010 Strategy" [10405/11]. Doing so, EPSCO agreed on the relevance of the regular, annual strategic reporting of the Member States on their strategies and progress achieved in social protection and social inclusion area. The reporting starts as from 2012 and takes the form of the National Social Reports (NSR). The aim of NSRs is to complement the National Reform Programme (NRP) with the three paths of social open method of coordination : social inclusion, pensions, health and long-term care. Both documents (NRP and NSR) will contribute to better reflect the social dimension of the EU 2020 Strategy. NSR is submitted to the President of the SPC and the Director General of DG EMPL. 1. Assessment of the main objectives of the "social" open method of coordination The economic and social situation of Poland in the coming years, as in the year 2011, will be shaped under the influence of economic conditions in the EU, under the pace and structure of fiscal consolidation and demographic trends in the country and in particular - the decrease of working-age population and changes in work activity of the Poles. Measures taken by the Government to considerably reduce the early retirement possibilities and to raise the retirement age should (assuming an increase in professional activity) reduce the negative effects of demographic change on the labour market. We even expect some The increase in labour supply by 2015 is even expected. Thus, with the increase of the work/professional activity, the unemployment rate in 2015 should fall to 10.0% (from 12.4% in June of 2012). In 2011, the first time in recent years, the decline of public consumption was recorded. This was the result of fiscal consolidation of national and local government sector. In subsequent years, the public consumption will be dependent on the consolidation of public finances announced in the Convergence Programme. After the decrease of 1.3% in 2011, the public consumption in will grow at about half slower than the expected GDP growth. The government is taking steps to ensure the financial stability of the pension system and the adequacy of pension benefits. They consist in reforming the pension system and strengthening the professional activation systems, including, as labour market policy measure, the support for employment of young and older people. By increasing the labour supply, the pension reform will contribute to the increase of the GDP in the long-term. GDP growth, growth of the wages and longer working lives will be factors of the increase the pension capital, i.e. the amount of future pensions. The government is also taking actions aimed to ease the access to regulated professions, trying to facilitate the entry into the labour market of young people and to encourage professional mobility of those already employed. 3

4 Programme activities and organizational preparations in order to increase the availability and quality of geriatric and long-term care are also carried on. In the context of ageing populations, raising the retirement age and actions undertaken to stay longer in the labor market it is crucial not only to lengthen the average life expectancy, but also to provide more Healthy Life Years and therefore enabling longer professional activity. The fact that the number of Healthy Life Years is declining in Poland could represent a serious threat in the implementation of actions to stay longer in the labor market. It seems therefore necessary to emphasize, as development priorities, the importance of providing adequate health care infrastructure, an adequate number of competent medical personnel and to conduct actions to improve the state of health of the population. 2. Reducing poverty and social exclusion Poland aims to reduce by 1.5 million the number of people at risk of poverty and/or material deprivation and/or living in households with no workers or with low-intensity work. Implementation status for that national objective is presented in the National Reform Plan It describes the tasks in the field of Professional activity for inclusive growth, implemented in 2011 and planned to be implemented in , in sub-areas "modern labour market" and "social inclusion". 3. Adequacy of benefits and sustainability of pension systems Financial stability of the system In order guarantee the stability of public finances and, by that, the stability of the general, compulsory pension system, whose part are II funded pillar - open pension funds (OFE), the changes in the amount of pension contribution to be transferred to OFE were introduced in As from 1 May 2011, OFEs receive 2.3% of the base pension premiums, instead of 7.3%, as it was before. The remaining 5% is placed in The Social Insurance Institution (ZUS) on a special individual sub-account. These funds are indexed by the rate of economic growth over the past 5 years, and the rate of inflation. The balance between the funds transferred to the sub-account in the ZUS and the funds transferred to open pension funds will change in subsequent years, until 2017, when they will reach 3.8% and 3.5% respectively. The capital accumulated in the sub-account in ZUS can be inherited. 1 1 Act of 25 March 2011 on the amendment of certain Acts relating to the functioning of the social security system (Dz. U. No. 75, item 398). 4

5 Adopted changes provide for a new way of financing funded pensions (second pillar), both from the funds collected by the insured in their accounts in the OFEs and from those registered on an individual subaccount in ZUS. The latter is financed by the Social Insurance Fund revenues, which, in addition to contributions, also include grants from the state budget. In addition, OFEs investment limits will be gradually increased. The previous limit of 40% of investments of assets in shares will be gradually raised to 62% in 2020 (up to 90% in 2034) 2. Some incentives were also introduced for additional retirement savings in the third pillar. In addition to existing Employee Pension Programs (PPE) and Individual Retirement Accounts (IKE), from 1 January 2012 it is possible to set up Individual Retirement Provision Accounts (IKZE). They can be set up in banks (as a savings account), in investments funds, in institutions operating in brokerage, in insurance institutions and in voluntary pension funds. The funds collected on IKZE can be paid to the holder of the account, once he reaches 65 years, respectively: as a lifetime pension in instalments over a minimum of 10 years or as a lump sum. IKZE holders benefit from a special relief on individual tax revenue. Adequacy of benefits In 2012, the government has taken actions for the progressive increase and equalisation of the retirement age for women and men. This is to ensure the adequacy of retirement benefits and to balance public finances in the long-term. Those measures follow the spirit of recommendations of the Annual Growth Survey 2012 of the Commission and of the Council Recommendations for Poland of 12 July 2011 (2011/C 217/02). The law adopted in May 2012 provides for 3 : gradual increase of the retirement age for men and women to the same level of 67 years, harmonisation of the length of insurance period for men and women entitling to the lowest pension, adaptation to the increased retirement age - the principles on which the so-called hypothetical insurance period are taken into account for the calculation of the amount of disability pension reduction of the basis of pension calculation by the gross amount of previously paid pensions ( i.e. granted prior to the retirement age.) 4 At present, the retirement age is 60 years for women and 65 for men. The Act provides for raising the retirement age from 1 January 2013 by 1 month every four months.the increase of the retirement age up to 67 years will be achieved in 2020 for men and in 2040 for women. The new regulations will apply to women born after 31 December 1952 and to men born after 31 December Regulation of the Council of Ministers of 26 April 2011 on determining the maximum part of the assets of an open pension funds, which can be invested in different investment categories (Dz. U. No. 90, item 516) 3 Act of 11 May 2012 amending the Act on pensions from the Social Insurance Fund and certain other acts (Dz. U. of 2012, No. 107, item 637). 4 It will be possible to receive so-called partial pension for women aged 62 years (with 35 years of contribution periods) and for men aged 65 years (with 40 years of contribution periods) in the amount of 50% of the earned retirement. Collecting a partial pension will be financed with accumulated capital; therefore reducing the target retirement pension. 5

6 The proposed way the of increasing the retirement age is not linked directly with the average life expectancy buta similar effect has been achieved a result of undertaken actions. In 2010, the average life expectancy at retirement age was years for women and years for men. After equalizing the retirement age of women and men the average life expectancy used in determining the pension will be 17,64 years. It should be also emphasized that the longer life expectancy is already included in the pension formula calculation. The amount of pension benefits depends in direct proportion on the amount of contributions paid and inversely proportional to the average life expectancy. Insured persons are therefore financially motivated to work longer. A significant increase in the level of retirement benefits paid in the future from the Social Insurance Fund should be expected as a result of increasing the retirement age to 67 years,. People earning an average salary and whose working life increase from 40 to 47 years - for women and from 45 years to 47 years for men, would have their pension raised by 72.4% for women, and by 20.4% for men. The measure to be introduced consisting of the coverage by the State budget the pension contributions for the period of parental leave also for the self employed who will suspend activities for the duration of that leave (till now, the pension contributions are only covered for persons employed under an employment contract) will be an important change. In this way, another group of insured persons will not be exposed to the negative effects of the reduction of future pensions, resulting from their decisions to have children. Pensions for farmers (Agricultural Social Insurance Fund - KRUS) The Act of 11 May 2012 amending the Act on pensions from the Social Insurance Fund and certain other acts, increasing and equalising the retirement age for men and women, also applies to persons insured in KRUS. 5 The increase of the retirement age for farmers will only have a minimal effect on the amount of their future pension benefits, as the pension system for farmers is based on the defined benefit and not on the defined contribution principle, as is the case in the general pension scheme. The above-mentioned Act introduces a new benefit - the partial pension for those who are insured in social insurance of farmers and are in pre-retirement age ( women over 62 and men over the age of 65 ) at the level of 50% of "regular" agricultural pension. The partial agricultural pension is paid until retirement age, and its payment is not related to the condition of quitting agricultural activities (e.g. handing over the farm), nor will it affect the reduction of agricultural pension after reaching the retirement age. The partial pension can be awarded for those with longer insurance period in KRUS: women - 35 years, men - 40 years (the required insurance period to benefit from agricultural pension in normal retirement age is only 25 years ). In addition, farmers continue to have the right to retire "earlier" on the basis of existing provisions until the end of Currently, the legislative works are conducted on the governmental draft law amending the law on social insurance and introducing pro-family elements to the social insurance system and the social insurance for farmers. The 3 years period of care for children under the age of 4 years and, if child is disabled, the period of 6 years care until it reaches 18 years, will be considered as insurance period. The social insurance contribution for old age and invalidity 5 Act of 20 December 1990 on social insurance of farmers (Dz. U. of 2008, No. 50, item 291, as amended). 6

7 pension for farmers and household members providing personal care over those children will be paid by KRUS from the State budget subvention. During this time, health insurance contributions for these people will also be paid by KRUS from the State budget subvention. The reform of social insurance for farmers was announced by the Prime Minister in the Sejm exposé of November 11, 2011, presenting the government's intentions. The reform is conditioned by the introduction of a system of taxation of agricultural activity. Works in this area already started. Adjusting the system to meet the demographic challenge The decision to raise and equalise the retirement age anticipates the demographic changes, to be faced by Polish society. It is expected that the introduced changes will result in the employment rate of 61.5% in 2060 among those aged 15-74, i.e. similar to the current rate (60.2% in 2011), despite changes in the age structure of society. Decrease in the number of people of working age will be significant enough to take necessary proactive measures to mitigate the effects of this phenomenon in the future (e.g. labour market policy). 4. Availability of quality health care and long-term care and stability of systems for the provision of such care Availability of services Universal health insurance covers 98% of legal residents with the right to work (2007). People who are not subject to compulsory health insurance can be insured under the general scheme voluntarily. Uninsured individuals remaining in the difficult financial situation, may be temporarily eligible for free medical care financed from public funds. Free access to medical services financed from public funds is provided also to: all children under 18 years of age, not covered by public health insurance, all uninsured women during pregnancy and childbirth, those treated in conjunction with addiction to drugs or alcohol, people with certain mental illnesses and communicable diseases. Health care system is based on the principle of equal access to benefits financed from public funds. Actual availability of benefits is rationalized by the requirement of referral to specialist treatment by the so-called "general practitioners" and by the system of waiting queues. The system of waiting queues serves the equal access to benefits. The sequence in the provision of benefits depends on the time of visiting the doctor and entering the patient on the waiting list and on the medical indications. Based on evaluation of the condition the patient is considered to be an urgent or stable case. First, the benefits are directed to urgent cases. The waiting time for most medical procedures is not too long, and in urgent cases the benefits are provided immediately for the most part. However, for some procedures, waiting time can be 7

8 significant. For example, the actual waiting time for highly specialist procedures was in days and by the cases of urgent and stable nature (as of 31 December 2011) in relation to: hip replacement, 215 and 388; knee replacement, 281 and 450; angioplasty -18 and 47 6 Average waiting time for care and welfare benefits under the long-term care in days and by the cases of urgent and stable nature in 2011 was: long-term care 0 and 0; long-term nursing care - 0 and 0; Unit/ward of nursing and care - 0 and 60; Unit/ward of nursing and treatment - 0 and 40; 7 Medical procedures and forms of medical care presented as examples above tend to be especially provided to elderly patients. The availability of treatment may be affected by the costs borne by patients themselves (e.g. the costs of certain drugs in the treatment of outpatients). They can surpass the financial capacity of the patient, causing resignation from buying needed medicines. Despite the actions taken so far, the solutions concerning the waiting queues, waiting time management and protection from excessive financial risk are not working satisfactorily at the moment, and therefore further work is needed to improve the situation in this regard. 8 As for the subjective assessment of the availability of medical care, according to the overall assessment of 62% of patients, the quality of care has not changed in 2010, according to 21% it worsened, and according to 5% it improved. Opinion on the availability of medical care at home is distributed symmetrically; 34% of respondents felt that access to this form of care is rather difficult or rather easy, and according to 16% it is very easy, but almost as many felt that it is very difficult. Respondents presented similar positions regarding the availability of nursing care at home. According to 95% of patients, one had to wait no longer than a week to visit a primary care physician. According to over 16% of patients, one has to wait 3-6 months for an appointment with a specialist. 9 The availability of medical services in Poland is analyzed in two studies prepared in by the Ministry of Health in cooperation with the World Health Organization (WHO): Social Inequalities in Health in Poland and Analysis of health and socio-economic characteristics of district level populations in Poland. 10 The Operational Programmes prepared under the Norwegian Financial Mechanism and the EEA Financial Mechanism : Reducing social inequalities in health and Development and better adaptation of health care to demographic and epidemiological trends, take account inter alia of the better adaptation of health care in order to meet needs of the fast-growing population of persons chronically-ill and dependent as well as the elderly. 6 Information of the president of the National Health Fund of , No. NFZ/CF/DSS/2012/073/0008/W/07277/JGP, the actual average waiting time for highly specialist procedures by medical categories, Annex 1, Table 3. 7 Information of the president of the National Health Fund of , No. NFZ/CF/DSS/2012/073/0008/W/07277/JGP, average waiting time for organizational units providing benefits under the type of nursing and care benefits in the long-term care by medical categories, Annex 1, Table 1D. 8 "Organization and functioning of the universal health insurance in Poland", Ministry of Health, Warsaw, March 2012, p "Health and health care in 2010", Central Statistical Office, Warsaw 2012, p The study is used, among others, to prepare medium-term strategies covering health topics. 8

9 Quality of services Quality of health care and patient s safety is ensured in Poland by (a) mandatory standards, which are, inter alia, the registration rules, standards of construction law, technical and sanitary requirements for the conduct of certain types of medical entities and medical practices, and (b) mandatory requirements for recipients set by Minister of Health and payer for the organization of care, the number and qualifications of medical staff, provision of equipment and medical apparatus to medical service providers. Units which provide services of high quality can apply for accreditation of the Minister of Health. Moreover, there are guidelines and standards in some areas, e.g. in the field of perinatal care, anaesthesia and intensive care, as well as others guidelines and standards created by science societies. Preventive health care includes the following groups of benefits: promotion of healthy behaviour, in particular by encouraging individual responsibility for one's own health; early, multispecialist and comprehensive care over children at risk of disability or with disabilities; medical examinations for early diagnosis of diseases, particularly cardiovascular disease and cancer. Under the National Programme for Equal Accessibility Prevention and Treatment of cardiovascular disease for POLKARD and the Cancer Fighting National Programme; activities under the National Mental Health Programme; routine checkups for pregnant women, including prenatal tests recommended in risk groups and in women over 35 years of age and dental prophylaxis; health promotion and prevention, including preventive dental care involving children and young people until they are 19 years old; preventive health care for children and youth in a learning and education environment; performance of immunization; examinations in the field of sports medicine, including children and young people until they are 21 years old, practicing amateur sport and the athletes between 21 and 23 years of age; 11 balance testing; occupational health examination; enrichment of food. Geriatric care. Team of experts in gerontology, established in July 2007 at the Ministry of Health, prepared a draft regulation on modern forms of health care for the elderly and the standard comprehensive geriatric care. As a result they prepared the Comprehensive Geriatric Assessment (CGA) as a medical procedure. CGA is a multidimensional and standardized assessment of vital functions, essential to the planning of treatment and care stages. It arranges diagnosis and eligibility to certain medical procedures and services, thus allowing proper adjustment of the treatment and care to the patient's condition at old age. It leads to more effective treatment of patients: reduces their mortality, eliminating the taking of unnecessary medicines, and eliminates unnecessary services (mainly the number of 11 Act on health services financed from public funds (Dz. U. 2008, No. 164, item 1027, as amended), Art. 27 (1). 9

10 hospitalizations and admissions to stationary care facilities). It improves the quality of life of elderly people without increasing the cost of care. Team of experts in gerontology also prepared the Strategy for development of geriatric care system and solutions to improve the quality of care for the elderly in the health care system. It proposes, among others, the development of gerontological education, creating a network of geriatric clinics, wards, and geriatric consultants in hospitals units and in long-term care. The strategy suggests the priority of geriatrics for a period of 10 years in health policy and NHF preferential contracts with geriatric centres, accredited under the geriatric standards. A draft standard in geriatric healthcare has been prepared, as well as a bill regulating the matters concerning the application of standards for proceedings in the field of geriatrics in healthcare institutions. The Human Capital Operational Programme launched a project titled "Support for the system of continuing education of medical staff in the field of geriatric care". Long-term care, such as specialized institutional care for the chronically ill and dependent, is carried out in Poland under health care and social assistance systems. Long-term care in health care is directed to people severely and chronically ill who do not require hospitalization, with significant deficits in self-care and who require round the clock, professional, intensive care and continuing care and treatment. The aim of care is also to prepare the patient and family for self-care at home. Long-term care includes medical and social needs. In Poland there are two types of long-term care facilities, i.e. care lasting more than 6 months: medical care and nursing care facilities. Care in the above institutions is exercised by a therapeutic team, which includes a doctor, nurse, physiotherapist, occupational therapist, psychologist and social worker. In the case of ill health, preventing the care of the patient at home, there are several possibilities to place an older person in long-term care facilities organized within the framework of health care or social assistance system. Institutional long-term specialist care ensures the continuity of the diagnosis, treatment, rehabilitation and health education. Depending on the patient's health status, benefits are provided in stationary or household conditions. 12 In 2010, there were a total of 467 long-term care facilities, 3% (14) more than in 2009 and 67 hospices, 13.6% (8) more than in They had a total of 26.1 thousand beds (8% more than in 2009) and provided inpatient care to 68.2 thousand people (an increase of 6.1% over 2009). Home care was provided to 4.4 thousand people (as in 2009), mainly in hospices (two thousand people) and by home care teams (2.2 thousand people) operating at long-term care facilities. 79% of patients in long-term care facilities were people aged over 60 years, 56% persons aged 75 and over. 13 In 2009, long-term nursing care services covered 5.1% of total expenditure on health care Conditions for performance of services are established in the ordinance of the Ministry of Health of 30 August 2009 on the guaranteed benefits in nursing and care benefits in the long-term care (Dz. U. No. 140, item 1147, as amended). 13 "Health and health care in 2010", Central Statistical Office, Warsaw 2012, pp "Health and health care in 2010", Central Statistical Office, Warsaw 2012, p

11 Responding to the growing demand for care services, we set up a new profession - medical caregiver. 15 In September 2007, we began training in the profession (in effect 1600 medical caregivers were educated by 2009). They are part of the medical staff. The development of the long-term care seeks in particular to compensate for lost efficiency. There are also measures to improve the quality and effectiveness of care for an elderly person. Polish health priorities are in line with the long-term health programs adopted by the European Union and with the objectives of the National Health Programme for , adopted by the Council of Ministers on 15 May 2007, and with the Health Development Strategy , adopted by the Council Ministers on 29 November Planned activities: The existing system of long-term care does not meet the needs of the aging the population; dependence generated as a result of diseases, injuries or old age, becomes a social problem. Currently in Poland there are about 800 thousand dependent people, and in 10 years there could be more than 2 million. Therefore there are plans to better incorporate the needs of older people in health policy strategies. The aim will be to: improve access to health services on equal terms to all older people, better coordinate provision of care, ensure the comprehensiveness of care through better integration of services responding to specific health, nursing, care and rehabilitation needs of geriatric patients, chronically and terminally ill and the disabled; ensure the quality of care through the use of standards developed in geriatrics, long-term care, palliative care and rehabilitation and to improve the financing of health care for the elderly. The detailed priorities are: 1. Geriatric care. Following the implementation of the Comprehensive Geriatric Assessment, the most important issue is the implementation of standards in geriatric care. The Ministry of Health finalizes preparation for the draft regulation in this respect. The Gerontology Team at the Ministry of Health monitors the implementation of recommendations of the strategy for the development of geriatric care and solutions to improve the quality of care for the elderly in the health care system. In addition, the team evaluates, assesses and programs all activities to improve care of geriatric patients. 2. Long-term care. The Ministry of Health conducts intensive systemic activities designed to improve the functioning of long-term care in Poland. In August 2011 the Minister of Health established the Team for long-term care, which by the end of the first quarter of 2013 is to prepare a draft National Programme for Long-Term Care. It will identify, among others, the principles of availability of services and coordination of care for the chronically ill patients. The Ministry of Health also carries out the work on developing standards for long-term care (rehabilitation, nursing and treatment), and organization of structures for long-term care, and to improve the financing of that care. 3. Care for dependent persons. The main improvement in access to nursing and care services is dependent on the introduction of nursing-care insurance. The Senate is working on the assumptions of the law on dependency, completely covering the aid for dependent persons. They provide for the appointment of the State Security Welfare Fund. Representatives of the 15 At the request of the minister of health this profession was added to the ordinance of the Minister of National Education of 26 June 2007 on vocational education (Dz. U. No. 124, item 860). 11

12 Minister of Labour and Social Affairs and the Minister of Health also participate in these works. Long-term care under the social assistance system includes 16 : care services and specialist care services provided at the place of residence, daily services provided at support centres, round-the-clock services provided at family-based assistance homes, round-the-clock services provided at residential care homes, round-the-clock services provided at centres that assure round-the-clock care for the disabled, chronically ill or the elderly, operated as a business or statutory entity. Care services and specialized care services, are provided for the benefit of a single person, who, due to age, illness or disability, requires assistance. They may also be provided to a person in the family, if family is not able to provide the necessary assistance. Help is provided by gmina social assistance centres. These services can be provided free of charge or for partial payment, depending on the income of a person or a difficult situation. Payments are regulated by gminas. Care services cover: satisfying daily necessities of life (cleaning, laundry, shopping, preparing meals), hygienic care, nursing as recommended by a doctor, ensuring contacts with the environment. Specialist nursing services are services are tailored to the specific needs of the particular disease or disability, and are provided by persons with specialized professional preparation. A family care home is a special form of support and care services provided by a person at home (under business activities) or by a non-profit organizations for not less than three and not more than 8 elderly or disabled, requiring such support. Placement in a nursing home is made on the request or with the consent of the person or his or her legal guardian. Support centre is a daily form of institutional aid, under which are different services are provided, tailored to the specific needs of people using this form of assistance, including food services. Support centres may provide full-time lodging for temporary stay. These centres support families in exercising care for the disabled family members, avoiding placing them in permanent care institutions. They also support single persons by preventing their exclusions from social life. Such centres are managed by gminas or poviats. In 2010, there were 1530 support centres, they provided services to more than 130 thousand people. 17 Support centres for persons with mental disorders, including community self-help centres provide services to persons with mental disorders (mentally ill persons, including autism and Alzheimer's disease, and persons with mental disabilities). Several such centres in Poland provide daily services to persons suffering from the Alzheimer's disease. Creation and funding of such units is the task assigned to gminas and poviats. Nursing homes are institutions providing round-the-clock services of housing, care, support and education according to the standards specified for the type of home. Persons needing such 16 Act of 12 March 2004 on social assistance (Dz. U. of 2009 No. 175, item 1362, as amended). 17 MLSP-03 reports for period January - December

13 care are directed to the appropriate type of nursing home by the gminas that participate in the cost of maintenance. Homes allow and organize assistance in using health services and cover charges for such services to the extent provided in regulations on general health insurance. The homes are run by local governments and by the Catholic Church, other churches, religious associations, social organisations, foundations, associations, natural persons and other legal persons. At the end of 2010, there were 792 residential care homes with 77,092 residents. Centres operated as part of a business or statutory activity providing a round-the-clock care to persons with disabilities, chronically ill persons or the elderly Such establishments provide nursing services on a commercial basis. They are not social welfare institutions. Stay in such centres is not the provision of social assistance; social assistance does not co-finance the stay of persons in these facilities. The Act on social assistance specifies, among other things, the standards for the operation of such businesses. Running this type of facilities requires a permit of the voivode. Those measures help to ensure an adequate level of service and to protect the rights of people living in them. The voivode has the right to monitor compliance with permit conditions. Financial stability of the system of benefits The National Health Account (NHA), conducted in accordance with the System of Health Accounts (SHA) of the OECD indicates that in 2010 the total expenditure on health amounted to nearly PLN 99 billion, i.e. 7.4 % of GDP, and together with the expenses associated with health PLN billion, i.e. 10.2% of GDP. 70% are public expenditure, 30% are private. In the years current and capital expenditure for health care grew steadily. Total expenditures on health care in 2009 were 88% greater than in Expenditure on medical services related to aging population, especially on health care of older people are not kept separate in the NHA. These people use, like all entitled persons, medical services, medical products for outpatients, rehabilitation services from long-term nursing care and preventive medicine. However, in groups of services that particularly benefit the elderly, spending for the period was also steadily rising. In the case of long-term nursing care, from PLN 2.5 billion in 2003 to PLN 5 billion in 2009, and in the case of rehabilitation services, from PLN 0.9 billion in 2003 to PLN 3 billion in As for the composition of public expenditure on health care in 2010, 84% was financed by the National Health Fund (NHF), 10% by the state budget, and 6% by local government units. In 2010, state budget expenditures on health care amounted to approximately PLN 6.9 billion, i.e. 2.3% of expenditures, and local governments spending - ca. PLN 4 billion, i.e. 2.2% of their spending. State budget expenditures were directed inter alia to emergency medical services (30.6%), health insurance contributions for persons not covered with compulsory insurance (22.7%), health policy programs (11.7%) and the functioning of hospitals (8.4%). 19 In addition, state budget expenditures were directed also to fund internships and specialized training of physicians, dentists, nurses and midwives. The National Health Fund (NFZ) is the main payer in the health care system. Self-financing is one of the principles of operation of the NFZ. It provides the financial stability of operation of the system, since the NFZ can contract medical services and reimburse medicines only within 18 "Health and health care in 2010", Central Statistical Office, Warsaw 2012, pp "Health and health care in 2010", Central Statistical Office, Warsaw 2012, pp

14 the limits of available resources. In this system there are also mechanisms of regulating the benefits, such as waiting lists for procedures and specialist services, the primary care physician acting as a "gatekeeper" deciding on access to specialized services, or the NFZ controlling the grounds justifying the provision of medical services - with the possibility of the refusal to cover bills in case of irregularities. 20 Nursing and specialist services provided under the social assistance system are financed from the budgets of gminas. Specialist nursing services for people with mental disorders are financed from the state budget. In 2010, spending on care services for people with mental disorders amounted to more than PLN 378 million. 21 Nursing homes operated by municipalities are financed from their budgets; homes run by poviats or on their behalf are co-financed from the state budget, regional homes can be financed as own tasks or co financed from the state budget. The charges for staying in nursing homes of people sent there after 1 January 2004 are covered partially by gminas. The stay or residents in nursing homes before 1 January 2004 is co-financed by the state. In 2010, expenditures of gminas in respect of payment for the stay of persons in nursing homes amounted to more than PLN 526 million. 22 In the same year the state budget spent over PLN 1 billion for the maintenance of nursing homes (co-financing for stay of residents and grants for the implementation of recovery plans to raise the standard). 20 "Organization and functioning of the universal health insurance in Poland", Ministry of Health, Warsaw, March 2012, pp. 5-6, 8, 9, MLSP-03 reports for period January - December MLSP-03 reports for period January - December