1 JOURNAL JOURNAL OF OF PUBLIC OF PUBLIC HEALTH, HEALTH, NURSING NURSING AND AND AND MEDICAL MEDICAL RESCUE RESCUE No.4/2014 2/2014 (4-8) 4 Health promotion in Polish legislation ( Promocja zdrowia w polskim ustawodawstwie ) M Bażydło A, B, C, D, I Radlińska C, E, B Karakiewicz F Abstract Introduction. Law has a variety of functions concerning public health and health promotion; among others, it forbids selected anti-health attitudes, supports selected healthoriented attitudes, determines the powers of health care units, regulates the practice of medical professions and determines the requirements concerning the quality of health care. The aim of the research. The research aims at the analysis of legal regulations on the statutory level concerning health promotion. Materials and Methods. The material for the research comprises legal acts on the statutory level (as on 15 March 2014). The adopted method was document analysis. The acts regulating the issues concerning health promotion were analysed. Results. The Constitution of the Republic of Poland indicates that everyone has the right for health protection. Legal definition of health promotion is included in the Act on Medical Activity. The act indicates that medical activity can involve realisation of tasks concerning health promotion. The Act on the Professions of Doctor and Dentist as well as the Act on the Profession of Nurse and Midwife mention health promotion in respect of the practice of these professions. Furthermore, the Act on Public Benefit and Volunteer Work defines health promotion as one of the spheres of public benefit activity. The so-called self-government acts (the Act on Commune Selfgovernment, the Act on District Self-government, the Act on Province Self-government) indicate that a commune, a district and a province are competent for realisation of tasks concerning health promotion. Among the state administration authorities concerned with public health, there is State Sanitary Inspectorate. Conclusions. 1. There is no legal act which would comprehensively regulate the issue of health promotion. 2. The tasks in this respect rest mainly with the units of local selfgovernment, with communes and State Sanitary Inspectorate in particular. 3. Polish legislation puts emphasis on the role of public benefit organisations in shaping health-oriented attitudes. Key words - health promotion, legislation, medical law. Streszczenie Wstęp. Prawo pełni różnorodne funkcje w zakresie zdrowia publicznego oraz promocji zdrowia, między innymi: zakazuje wybranych zachowań antyzdrowotnych, wspiera wybrane zachowania prozdrowotne, określa uprawnienia jednostek w opiece zdrowotnej reguluje kwestię wykonywania zawodów medycznych, określa wymagania w zakresie jakości opieki zdrowotnej. Cel pracy. Celem pracy jest analiza regulacji prawnych na poziomie ustawowym w zakresie promocji zdrowia. Materiał i metoda. Materiał stanowiły akty prawne na poziomie ustawowym (stan na dzień r.). Wybraną metodą była metoda analizy dokumentów. Analizie poddano ustawy regulujące kwestie związane z promocją zdrowia. Wyniki. Konstytucja wskazuje, że każdy ma prawo do ochrony zdrowia. Definicja legalna promocji zdrowia znajduje się w ustawie o działalności leczniczej. Ustawa ta wskazuje, że działalność lecznicza może polegać na realizacji zadań z zakresu promocji zdrowia. Ustawa o zawodach lekarza i lekarza dentysty, a także ustawa o zawodzie pielęgniarki i położnej wymieniają promocję zdrowia w kontekście wykonywania wyżej wymienionych zawodów. Z kolei ustawa o działalności pożytku publicznego i o wolontariacie określa promocję zdrowia jako jedną ze sfer działalności pożytku publicznego. Tzw. ustawy samorządowe (ustawa o samorządzie gminnym, ustawa o samorządzie powiatowym, ustawa o samorządzie województwa) wskazują, że kompetentne do wykonywania zadań z zakresu promocji zdrowia są gmina, powiat, województwo. Wśród organów administracji państwowej zajmującej cię zdrowotnością publiczną znajduje się Państwowa Inspekcja Sanitarna. Wnioski. 1. Nie ma aktu prawnego kompleksowo regulującego kwestię promocji zdrowia. 2. Zadania z tego zakresu spoczywają głównie na jednostkach samorządu terytorialnego, w szczególności na gminach oraz na Państwowej Inspekcji Sanitarnej. 3. Ustawodawstwo polskie podkreśla rolę organizacji pożytku publicznego w kształtowaniu postaw prozdrowotnych. Słowa kluczowe - promocja zdrowia, legislacja, prawo medyczne. Author Affiliations: Chair and Department of Public Health, Pomeranian Medical University in Szczecin Authors contributions to the article: A. The idea and the planning of the study B. Gathering and listing data C. The data analysis and interpretation D. Writing the article E. Critical review of the article
2 5 F. Final approval of the article Correspondence to: Marta Bażydło, Department of Public Health, Pomeranian Medical University in Szczecin, Zabużańska 35a Str., Pl Szczecin, Poland, Accepted for publication: November 15, A I. INTRODUCTION ccording to the Ottawa Charter of 1986, Health promotion is the process of enabling people to increase control over (...) their health in terms of improvement and maintenance thereof . Therefore, health promotion aims at the change of behaviour of individuals and, consequently, of the whole society. Behaviour changes of individuals and social groups are achieved through two types of mechanisms: the first mechanism involves influences of psycho-sociological nature. The second one involves legal instruments . The functions of law concerning public health and health promotion include, among others, forbidding actions and attitudes which are harmful for health of an individual and a community, determining the right of an individual and social groups as far as health care services are concerned as well as regulating the rules of producing health care resources . For health promotion, the creation of mechanisms enabling an individual to increase their influence on their own health seems to be the most significant issue. Interestingly, legal norms which protect health can be found in all bodies of law. According to civil law, health is a personal, non-proprietary right. The infringement thereof results in civil liability, which may take two forms: tort liability, which is the result of committing a tort, and contractual liability, which is the result of nonfulfilment of a contractual obligation . In respect of criminal law, it should be noted that violating another person's health as well as acts or negligence which are threatening to public health result in criminal liability . Administrative law, in turn, comprises numerous norms that protect health, e.g. in the provisions concerning health administration, in public welfare law or environmental protection law . The norms concerning health promotion are present in legal acts of every level, from the Constitution to local law. For the purpose of this research, the authors have limited themselves to legal acts on the statutory level. The research aims at the analysis of legal regulations on the statutory level concerning health promotion. II. MATERIALS AND METHODS The material for the research comprises legal acts on the statutory level (as on 15 March 2014). The acts were selected with the use of Lex Legal Information System (System Informacji Prawnej Lex) and Internet System of Legal Acts (Internetowy System Aktów Prawnych). The adopted method was document analysis. The acts regulating the issues concerning health promotion were analysed. III. RESULTS In order to commence the analysis of legal status concerning health promotion on statutory level, the Constitution of the Republic of Poland of 2 April 1997 should be taken into consideration in the first place. In Poland, the right to health protection is regulated by Article 68, Section 1 of the Constitution, which provides that Everyone shall have the right to have his health protected. The importance of the right to health protection is emphasised by including it in the Constitution as well as by the place it occupies therein, i.e. in Chapter II, among economic, cultural and social freedoms and rights. Neither the Constitution nor ordinary acts define the concept of health protection. There is no legal definition of health, either. Health protection, as well as health itself, should be understood in a multi-faceted way and there is rather no doubt that the concept of health promotion is included in the concept of health protection . Despite of the lack of legal definitions of health and health protection, Polish law comprises the definition of health promotion, which is stated in the Act on Medical Activity of April 15, According to this act, health promotion is an activity enabling individual persons and a community to increase control over factors determining one's health status and consequently to improve it; it is also the promotion of healthy lifestyle as well as of environmental and individual factors beneficial to health. The act also indicates that medical activity involves providing health services; it may also involve health promotion and the realisation of educational and
3 6 research tasks in relation to the provision of health services and health promotion . A notice should also be taken of the Act on the Professions of Doctor and Dentist of December 5, 1996, which states that the practice of the profession of doctor (and dentist) can involve conducting research in the field of health promotion . In turn, the Act on Professions of Nurse and Midwife of July 15, 2011 states overtly that the practice of the profession of nurse (and midwife) can involve health promotion and health education . Particular activities of health promotion are described in the Act on Mental Health Protection of August 19, 1994, which provides that the tasks of mental health protection include the promotion of mental health . The legislator's attitude towards the realisation of health promotion tasks by non-governmental organisations is also an important issue. Thus, it is worthwhile to cite the Act on Foundations of April 6, 1984 and the Act on Public Benefit and Volunteer Work of April 24, According to the Act on Foundations, a foundation can be established in order to realise goals in the area of health protection, i.e. also goals related to health promotion. The Act on Public Benefit and Volunteer Work, in turn, lists health promotion as one of the spheres of public benefit activity [11, 12]. It appears, however, that tasks concerning health promotion rest mainly with the units of local selfgovernment. According to the Act on Commune Self-government of March 8, 1990, commune's own tasks include tasks in the areas of health protection, physical culture, tourism and commune's green areas. In line with the principle of the presumption of competences in favour of a commune, the scope of activity of a commune includes all public matters of local importance which are not restricted by legislative acts to other bodies. A commune can also commission its duties to non-governmental organisations. A contractor must be chosen through an open tender. However, legal doctrine points out that, first of all, the catalogue of commune's tasks itself does not order a commune to undertake the tasks listed therein (a separate act is required) and, secondly, it constitutes no legal basis for undertaking actions. In the case when there is no specific thematic act on actions undertaken by a commune, a commune can undertake actions, but only those which are not of binding nature - i.e. they do not result in rights and obligations of third parties [13, 14]. By virtue of the Act on District Self-government of June 8, 1998, a district performs public tasks as provided by acts. Contrary to the catalogue of commune's tasks, the catalogue of district's (as well as of province's) tasks is exhaustive and it includes tasks in the areas of health promotion and protection as well as the areas of physical culture and tourism . Similarly, the Act on Province of June 5, 1998, states that a province self-government performs tasks of a province range as provided by acts. Among the listed tasks, there are health protection and promotion as well as physical culture and tourism, like in the case of a district . The regulations referring to the tasks of a commune and district concerning health promotion are included in the Act on Publicly Funded Healthcare Benefits of August 27, The act provides that commune's own tasks include the development, implementation and evaluation of effects of health programmes arising from recognised health needs and health status of the residents of the commune; providing the district with information on health programmes in realisation; initiating and participating in setting directions for local initiatives which aim at acquainting the residents with factors that are harmful for one's health and with their effects; undertaking other actions arising from recognised health needs and health status of the residents of the commune. The act provides for district's own tasks in the way analogous to the tasks of a commune, with the addition of the task of inciting actions that encourage individual and group responsibility for health and actions that encourage health protection . Among the state administration authorities concerned with public health, there is the State Sanitary Inspectorate. According to the Act on State Sanitary Inspectorate of March 14, 1985, the State Sanitary Inspectorate, along with its main supervisory activity, initiates, organises, conducts, coordinates and supervises educational activity concerning health, which aims at developing proper health-oriented attitudes and behaviour in society . For this reason, in the province units of the State Sanitary Inspectorate, departments of healthoriented education and health promotion are established. The State Sanitary Inspectorate is known of its numerous actions promoting health-oriented attitudes, like, for example, the organisation of the World Health Day in Poland (7th April), World Tobacco-Free Day (18th November) or, on more local scale: Safe winter holidays, Safe summer holidays. In the case of the
4 7 State Sanitary Inspectorate, there are also no reservations about its evaluation of health education activity of entities like: schools and other educational facilities, institutions of higher education, mass media, health care entities and other entities, institutions and organisations. However, it seems that regulations do not enable the State Sanitary Inspectorate to fully develop its activity concerning the coordination of actions of various authorities and institutions in the area of health promotion so that these actions would complement and support one another. It is a pity, since the Inspectorate could undertake such tasks, given its nationwide administrative system and the strong position of the Chief Sanitary Inspector as a central authority of state administration. IV. DISCUSSION A similar scope of statutory regulations concerning health promotion was described already in the 1990s by Górska-Marciniak. The author indicates that the legal situation as of that time also featured a definition of health promotion and of various obligations related to health promotion realised by government and selfgovernment administration, medical personnel, employers, entities providing health services. It is nonetheless difficult to agree with a definite statement that the above listed entities, in the past as well as present legal situation, have been subject to the obligation of health promotion (except for the Management of Health and Safety at Work regulations). It should also be noted that the attitude of Polish legislation to health promotion has not changed since the 1990s. Słońska points out that a cross-sectoral cooperation should ensure the success of health promotion . However, it is difficult to speak about a cross-sectoral cooperation in a situation when the legislator regulates the issues concerning health promotion in a chaotic way. It is the legislative deficiencies that are identified by Słońska as the reason for the lack of cooperation at the cross-sectoral level in the first place, only then followed by financial limitations. At the same time Słońska points to commune as a unit that is most suitable for the realisation of tasks in the area of health promotion. It is impossible not to agree with the author's opinion that at present there are no mechanisms which would guarantee the realisation of tasks in the area of health promotion . Krajewski and Kaczmarek notice that the division of tasks among a commune, a district and a province is unclear. The authors point out, however, that such a situation could open a possibility for interested entities to undertake actions. They also notice that local selfgovernment units are burdened with numerous tasks and they would not want to undertake actions in the area of health promotion due to the lack of financial resources. Contrary to the opinion presented by Słońska, Krajewski and Kaczmarek express a position that communes do not possess resources appropriate for the realisation of health promotion projects . The research carried out by the Public Opinion Research Center (Centrum Badania Opinii Społęcznej CBOS) demonstrates that communes do not consider health protection and promotion as belonging to their tasks, they are not priority tasks and there are more important needs in communes. Another reason for the fact that communes do not realise tasks in the area of health promotion is the lack of sufficient financial resources . A question arises, whether tasks in the area of health promotion should be realised by district. The research conducted by Nosko and Marcinkiewicz in 2008 discloses that out of all Polish districts only 57% included provisions concerning preventive health care and health promotion in the organisational regulations of District Starosties and Town Offices of towns with district right . It appears that, given the lack of coordination and the lack of entities unequivocally responsible for the realisation of tasks in the area of health promotion, it would be reasonable to implement the solutions put forward in the bill on Public Health [24-26], which provide for systemic solutions. V. CONCLUSIONS 1. There is no legal act which would comprehensively regulate the issue of health promotion. 2. The tasks in this respect rest mainly with the units of local self-government, with communes in particular. 3. Polish legislation puts emphasis on the role of public benefit organisations in shaping healthoriented attitudes.
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