The development of primary health care in Poland from the 2 nd Republic to the Round Table Agreement ( )

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1 The development of primary health care in Poland from the 2 nd Republic to the Round Table Agreement ( ) Rozwój podstawowej opieki zdrowotnej w Polsce od II Rzeczypospolitej do Okrągłego Stołu ( ) Maciek Godycki-Ćwirko, Marek Oleszczyk, Adam Windak Key words: primary health care, history of medicine, public health, health policy, social insurance, Poland Słowa kluczowe: podstawowa opieka zdrowotna, historia medycyny, zdrowie publiczne, ubezpieczenie społeczne, Polska Department of Family and Community Medicine, Medical University of Lodz Maciek Godycki-Cwirko, MD, PhD Deputy Head of the Department Department of Family Medicine, Chair of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow Marek Oleszczyk, MD Assistant Adam Windak, MD, PhD Head of the Department CORRESPONDENCE ADDRESS: dr n. med. Maciek Godycki-Ćwirko Zakład Medycyny Rodzinnej i Medycyny Społeczności Lokalnych, Uniwersytet Medyczny w Łodzi ul. Kopcińskiego Łódź RECEIVED: ACCEPTED: Abstract: Backgroud. The article presents briefly the development of outpatient medical treatment and primary healthcare in Poland in the period , from the recovery of independence after the Great War until the fall of the communist regime. Methods. Review and analysis of data collected from the medical history journals, monographs, doctoral thesis, habilitation dissertations was performed. Results. It is possible to identify trends, giving a key role to primary healthcare in Poland. This may be seen in the multisectoral (public, congregational and private) structure, shaped by the 1920 Law on Mandatory Health Insurance. The system was consolidated in 1933 with the establishment of the Social Insurance Enterprise and, in 1935, with introduction of home physicians. In 1948, the multisectoral system was abolished and replaced with a uniform social health service, administered and financed by the state. Despite widening of access to healthcare, the quality of services and patient satisfaction fell. The Round Table Agreement of 1989 enabled political and social changes, including changes in the healthcare sector. Discussion and conclusion. Comparing the consecutive stages of development of the primary healthcare in Poland, one can see an increasing responsibility for healthcare taken by the state authorities, an increasing accessibility of health services, and the fluctuation of the role of primary care in the public system. There is an established tendency to finance healthcare from public funds. Streszczenie: Cel. Zwięzłe przedstawienie rozwoju lecznictwa pozaszpitalnego i podstawowej opieki zdrowotnej w Polsce w latach Materiał i metoda. Przegląd piśmiennictwa z zakresu historii medycyny, medycyny społecznej oraz organizacji ochrony zdrowia. Wyniki. Na podstawie przeglądu dostępnych publikacji książkowych, prac habilitacyjnych, prac doktorskich oraz artykułów opublikowanych w fachowej prasie medycznej sformułowano zarys historii podstawowej opieki zdrowotnej w Polsce w okresie od odzyskania niepodległości po I wojnie światowej do upadku systemu komunistycznego. Omówienie. Już od zakończenia pierwszej wojny światowej w Polsce obecne były tendencje i doświadczenia z przypisaniem podstawowej opiece zdrowotnej kluczowej roli w systemie opieki medycznej. Widać to w wielosektorowej strukturze lecznictwa, złożonej z sektora publicznego, kongregacyjnego i prywatnego. Taki system kreowała ustawa o obowiązkowym ubezpieczeniu na wypadek choroby z 1920 r. Ubezpieczenie to było powszechne i obowiązkowe, a Kasy Chorych korzystały z równolegle funkcjonujących ambulatoriów i prywatnych gabinetów lekarskich. Scalenie systemu nastąpiło w 1933 r. z wprowadzeniem Zakładu Ubezpieczeń Społecznych, Ubezpieczalni Społecznej, a w 1935 r. lekarzy domowych, udzielających świadczeń w ambulatoriach i w domach chorych w całym kraju. Wielosektorowość zlikwidowano w 1948 r. wprowadzając jednolitą społeczną służbę zdrowia, kierowaną i finansowaną przez państwo. Lekarze zobowiązani zostali do podjęcia pracy w zakładach społecznej służby zdrowia w miejscu zamieszkania z ustalonym w przepisach wynagrodzeniem. Mimo konsekwentnego poszerzania dostępu do bezpłatnych świadczeń zdrowotnych i prób modyfikacji systemu poprzez wprowadzanie kolejno: okręgowych ośrodków zdrowia, przychodni rejonowych, specjalizacji z medycyny ogólnej, trójpoziomowego modelu dla zapewnienia profilaktyki i lecznictwa pozaszpitalnego, rejonizacji działalności zdrowotnej, zespołów opieki zdrowotnej jakość świadczeń i zadowolenie pacjentów zmniejszało się. Wyniki obrad Okrągłego Stołu stanowiły zapowiedź przemian społeczno-politycznych, w tym także w sektorze opieki zdrowotnej. Wnioski. Porównując kolejne etapy rozwoju POZ w Polsce po pierwszej wojnie światowej, można zauważyć podjęcie przez państwo odpowiedzialności za zapewnienie opieki zdrowotnej; utrwalanie instytucjonalizacji opieki oraz profesjonalizacji kadry medycznej; upowszechnianie dostępności do opieki zdrowotnej; okresowo nasilające się i słabnące wykorzystywanie możliwości i roli podstawowej opieki zdrowotnej w syste- PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1 29

2 mie publicznym. Po odrodzeniu się państwowości Polski, trwale obecna jest tendencja utrzymywania publicznego finansowania opieki zdrowotnej dla całego społeczeństwa, ze zróżnicowanym wykorzystaniem POZ. (Probl Med Rodz 2010;1(30):29 36) Background Since the 1978 Alma Ata Conference, WHO Member States have given primary healthcare (PHC) a leading role in their respective healthcare systems. 1 In Poland, this was influenced by trends and experiences from the end of the Great War onwards. With a lack of monographic studies available on the history of outpatient treatment and on the roots of Polish PHC, this paper attempts to concisely present the establishment and development of PHC in Poland after The aim of the study was to present the development of outpatient medical treatment and primary healthcare in Poland in the period , from the recovery of independence after the Great War until the fall of the communist regime. Methods Review and analysis of data collected from the medical history journals, monographs, doctoral thesis, habilitation dissertations was performed. Results The multisectoral system In February 1917, as part of a programme of reconstructing Polish government institutions, the Temporary Council of State established a sanitary unit in the Ministry of Home Affairs, which started to train poviat (powiat the secondlevel unit of territorial division in Poland) physicians. As early as May 1917, a Draft Public Health Law was drawn up. 2 5 The document was based on the idea of a multisectoral healthcare system with the public sector (state, municipal and insurance) being dominant over the private sector, an idea promoted by the Polish Society of Social Medicine (PTSM), the Warsaw Society of Hygiene, and contemporary medical societies. 6 In July 1917, the Medical Council of the Kingdom of Poland was restored. The Council prepared detailed professional instructions for poviat physicians. On 4 th April 1918, the Regency Council of the Kingdom of Poland established the Ministry of Public Health, Social Welfare and Occupational Safety. This became, on 13th December 1918, by decree of the Chief of State (the official title of the head of state in Poland, ), the Ministry of Public Health. One of the actions of the Ministry was a proposal to introduce into the Treaty of Versailles, presented to the League of Nations in Geneva in 1922, 7,8 a right to health. The multisectoral structure clearly defined the role of the public sector, in which the state health service (structures directly subordinated to poviat physicians) established local government health service facilities (mainly hospitals and health centres) and self governed Sick Funds for employees. The congregational sector consisted of charities, religious communities, the Polish Red Cross and the like; and the private outpatient healthcare sector consisted of autonomous private physicians, who provided 80% of outpatient treatment. All of the above institutions, as well as private practice, were monitored by poviat physicians directly subordinated to the head of their respective poviat. 3,9 Employee Sick Funds The most important legal act relating to healthcare after the recovery of independence was the Mandatory Insurance in Case of Illness Law of 19 th May 1920, which established a system of treatment service provision to working people, and laid down conditions for the employment of health care personnel (in particular physicians) in inpatient and outpatient units. Insurance was universal and obligatory, and services were provided by licensed physicians contracted by the Sick Funds. With no executory provisions to the above Law, local rural and poviat Sick Funds made use of various structures remaining after the Prussian and Austrian partitions, which resulted in the parallel functioning of systems of outpatient clinics and private surgeries. The Law did not extend to Upper Silesia where, on the strength of the Treaty of Versailles and decisions of the Silesian Parliament, German insurance law applied until The Ministry of Public Health survived until January 1924, when its responsibilities were taken over by the General Directorate for Health Service in the Ministry of Home Affairs, transformed in 1928 into the Department of Health of the Ministry of Social Welfare, which dealt partially with health issues, in parallel with other Departments. 7 In 1928, a law on treatment enterprises was adopted, in which a distinction was made between general outpatient clinics (for all patients, irrespective of the nature of their disease) and specialist outpatient clinics. In the majority of Sick Funds, specialist outpatient clinics predominated. General outpatient clinics covered areas of 5,000 19,000 insured persons. Such clinics were staffed mainly by internists and, subject to the availability of funds in a given Sick Fund, other specialist physicians. Since access to specialist was unlimited, waiting times for appointments were often very long. 30 PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1

3 ORIGINAL PAPERS Private surgeries were most numerous in the Poznan, Pomerania and Upper Silesia regions. In that system, patients were free to choose both their general practitioners and specialists; the exception being Upper Silesia, in which the insured could only choose one from two or three physicians working in a particular area. Silesian physicians had contracts and received monthly salaries dependent on the number of appointments. Operating costs were covered by physicians. The system required a great deal of flexibility, but earnings were significantly higher than in other Sick Funds, salaries reaching four times those of a civil servant. Most Sick Funds determined hourly fees for physicians, dependent on, among other things, length of professional experience and particular field of specialty, and offered bonuses for minor operations, home visits and night visits. Physicians were also allowed to run their own private practices. Functioning as they did at that time, Sick Funds caused much dissatisfaction; among doctors for financial reasons, because of excessive workloads ( patients a day) and excessive administrative interference in the treatment process; as well as among Sick Fund administrators, who believed physicians applied irrational treatments, such as ordering diagnostic investigation without due cause or recommending climatic treatment. In December 1921, the Polish Sejm (lower chamber of the Polish Parliament) adopted a law on the system and scope of Physicians Chambers, which enabled the establishment of physicians self-government. In September 1932, the President adopted a regulation concerning the profession of physicians, and in March 1934 another Law on Physicians Chambers was passed. Figure 1. Primary healthcare models in the Republic of Poland in the 1920s PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1 31

4 Social insurance The economic crisis of the 1930s necessitated various changes, including unification of the system, particularly in the field of PHC. 2 5,10 12 On 23 March 1933, the Sejm adopted a Social Insurance Law ( consolidating law ), establishing the Social Insurance Enterprise, which took over the responsibilities of Sick Funds, miners insurance fraternities and the like. Social insurance organisations became part of the Enterprise. In 1935 home physicians, who before that date had functioned only in the area formerly annexed by Prussia, were introduced across the country, and provided treatment in outpatient clinics and at patients homes. A home physician was responsible for an area inhabited by approx. 1,000 patients (there were also palliative care and specialist care areas), and was to take care of insured persons, provide them with comprehensive treatment, take an interest in their hospital treatment, and collect their full medical history in order to ensure continuity of care. The process of introducing home physicians was, however, delayed by several factors; private practitioners unwillingness to take on what was, in their opinion, low-paid work; insurance companies, due to a lack of personnel, contracting unqualified physicians; and conflict with physicians from other fields of specialty arising from the priority given to primary care. 3 5,10 12 In 1937, of Poland s population of 36 million, only 1.5 million people made use of the services provided by local government health centres, and a little over 2 million persons (and their families) made use of outpatient clinics managed by the Social Insurance. By late 1938, 14.7% of the population was covered by sickness insurance in Poland. Insurance did not extend, however, to the rural population, which constituted approx. 70% of the nation. 8 On 15 th June 1939, the Sejm adopted a Law on Public Health Service. 12 The sanitary regulations remaining from the period of partition were lifted, and gmina (gmina the principal unit of territorial division in Poland) physicians were introduced. The law was suspended after the outbreak of the Second World War. It was, however, used, in July 1945, as the basis on which to establish the Ministry of Health, and to reconstruct the pre-war multisectoral healthcare structure. It was at this time that civil servants and their families were granted the right to free treatment in case of sickness. The development of social healthcare After the Second World War, outpatient treatment was provided by insurance treatment units (based on home physicians) and local government treatment units (in particular local government insurance treatment, re-established in 1945), and also by certain cooperative treatment units (included as part of so-called social health service ) and private surgeries. By 1948, as many as 37% of the country s population was covered by general health insurance. Primary care was provided to the insured by home physicians, who could, at the same time, practice privately. Only 12% of physicians earned their living exclusively as private practitioners. However, by 1947, several articles were published in the press accusing social insurance physicians and private practitioners of material errors, heartlessness and mercantilism. This sparked a discussion on the need to ensure universal access to free medical care. 2,13,14 The multisectoral system was abolished by the State-owned Health Service Enterprises and Planned Economy in Health Service Law of 28 th October 1948, which introduced a uniform social health service system governed and financed by the state. 4 The Law enabled the nationalisation of healthcare units. Healthcare units previously financed and managed by insurance institutions, social organisations, foundations, congregations or religious societies or associations were taken over by state and local government administration. The health service system was subjected to the so-called section plan, being a part of the national economic plan. Planned actions were to be implemented by public health service enterprises governed by the state, local government and insurance institutions. According to Article 27 of the Law physicians were obliged to work in public health service clinics in the places where they lived, and their salaries were set by law. The Existing Social Insurance Enterprise gradually introduced mandatory insurance for respective employee groups. As part of health tasks introduced to the national socioeconomic development plan, free treatment was provided to retired people; patients suffering from infectious and social diseases subject to mandatory hospitalisation (tuberculosis, trachoma, venereal diseases); women during pregnancy, delivery and the postnatal period; infants and children to three years of age. Children up to 14 years of age were exempt from charges for diagnostic examinations, home visits in the case of bedridden patients, and nurse visits. Free of charge periodic medical examinations, dental treatment and prophylactic vaccinations were introduced for pre-school and school children. With time, free access to health services was extended. In 1957, free medical treatment was introduced for the blind; in 1958 to participants in voluntary labour corps; in 1962 to selected groups on the grounds of specific social or medical circumstances; in 1963 to members of the Soci- 32 PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1

5 ety of Fighters for Freedom and Democracy (ZBoWiD) and journalists; in 1964 to lawyers; in 1965 to craftsmen, students and contracted workers in the nationalised economy; in 1966 to social welfare beneficiaries; in 1968 to medical students; in 1969 to local social workers; in 1970 to members of agricultural production cooperatives and, in 1972 to individual farmers and their families. Full medical care was provided to citizens during military service, professional staff of the Polish Army, old age pensioners, military pensioners and their families, and personnel of the Ministry of Home Affairs. 14 The Semashko model In 1950, physicians were excluded from the group of freelance professions. A medical practitioner became a civil servant in a state, centralised health service system modelled after the uniform outpatient treatment system in the USSR (the so-called Semashko model ). The basis of the system constituted regional health centres with three outpatient clinics: general, for mothers with little children, and for preschool and school children. The centres were to provide free preventative care and treatment to all inhabitants of a given area. Home physicians contracted by social insurance institutions had to move their surgeries from private homes to health centres administered by local government, and to become employees of the state centres. Rural healthcare cooperatives were liquidated and replaced with state-owned institutions. 15 In the 1950s, the number of physicians doubled; however, outpatient practitioners (with the exception of paediatricians) were not required to have any specialty, and it happened quite often that graduates fresh from medical schools were ordered to start work. 13 In the period , the basic unit of the healthcare system was a local outpatient centre with three clinics: general for adults; for pregnant women and healthy children; and for ill pre-school and school children (to 14 years of age). Healthcare cooperatives were once more allowed in rural areas. 15 Facilities had to limit contact between healthy and ill patients, and had separate entrances to clinics for healthy and sick children respectively. 4 Despite the dynamic development of specialist vocational medical training in the 1960s, there remained an imbalance in the level of training between physicians working in hospitals and those working in outpatient clinics, especially in rural areas, where specialist physicians were rare. In 1963, the Minister of Health and Social Welfare introduced specialty in general medicine, to be obtained under the supervision of the Institute for Occupational Medicine and Rural Hygiene. However, this failed to ensure a sufficient number of practitioners with specialist training working in outpatient clinics. 16 The structure and organisation of the outpatient healthcare system was determined by a regulation of the Minister of Health and Social Welfare of 31 st July 1967, defining specific tasks for respective institutions in the fields of preventative care and individual medical services. The regulation was intended to ensure accessibility and continuity of healthcare. A uniform three-level system of preventative and outpatient services was introduced. The system consisted of local-area outpatient centres (lower level), regional specialist outpatient centres (middle level) and voivodeship (województwo the third and topmost level of territorial division in Poland) specialist outpatient centres (upper level). 9 The operation of the healthcare system was regionalised, and the inhabitants of a given area belonged to their respective health service institutions. For preventative and treatment purposes, voivodeships and cities were divided into districts, and districts into areas. Primary healthcare (in the field of preventative medicine, general medicine, paediatrics, obstetrics and gynaecology, and dentistry) was to be provided at the level of each individual area. A two-pronged development of outpatient healthcare, with local area outpatient clinics in towns and cities, and health centres (stateowned or cooperative) in rural areas, was legitimised. A rural area was supposed to comprise 3,000 6,000 inhabitants (or fewer, where an area exceeded 5 7 km in radius), and to have its own general medicine (or internist) specialist and dentist. Town areas were to consist of 3,000 5,000 inhabitants, and the healthcare provided was to be dependent upon the nature of the given town. Local area physicians were also differentiated. Voivodeship and poviat towns had internal medicine or general medicine specialists, paediatricians, obstetricians and gynaecologists, and dentists. Other towns and housing estates had specialists trained in general medicine. 14 Specialist health services (preventative and individual specialist treatment) were to be provided in each district, covering a poviat or a city district (most typically inhabited by 40,000 60,000 persons). 9 The functioning of such a system met with increasing criticism. Primary healthcare was underfinanced, clinics were poorly equipped, PHC practitioners were little respected, and local area doctors did not identify themselves with their work and often changed location. 14,17,18 Attempts at improving the system In 1973, the Minister of Health and Social Welfare ordered organisational integration of hospital and outpatient clinic care (local area hospital and primary healthcare and special- PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1 33

6 ist clinic) into integrated healthcare centres (ZOZ). In 1975, voivodeship integrated hospitals and voivodeship integrated specialist centres (e.g. mother and child centres, psychiatric centres, industrial health service centres) were established. Voivodeship structures included a voivodeship hospital, specialist clinics, laboratories and emergency services (with the exception of the three largest cities). 19, 20 An integrated healthcare centre (ZOZ) was to cover the area of a poviat, town or town district, inhabited by 30, ,000 persons. The tasks of these integrated centres, namely patient care and improvement of health levels, were to be implemented by first contact physicians working in healthcare centres and local area clinics. In order to improve the level of training and prestige of such physicians, Medical Academies in Lodz, Gdansk and Poznan, in the late 1970s, introduced PHC courses at their respective medical faculties. Additionally, the Medical Centre of Postgraduate Education in Warsaw, in cooperation with the Institute of Occupational Medicine and Rural Hygiene in Lublin, developed a list of the competences of local area physicians. 21 In the 1980s, the need to ensure the leading role of PHC in the healthcare system was declared, and attempts were made at improving the local area physicians model, for example with pilot programmes allowing people to choose their physicians. 22 The possibility of returning to the idea of a general practitioner was also considered, and efforts were made to restore the prestige of general medicine as a separate clinical and scientific discipline, one of these being the establishment of the Polish Society of General Medicine in Also discussed were the introduction of housing estate physicians, and the reintroduction of home (family) physicians. Nonetheless, the PHC model based on generalist failed to win sufficient political support at the time. 23 A detailed analysis of the efficiency of the primary healthcare system in Poland, carried out in 1988, showed an unambiguously negative picture of the functioning of the system. It found access to healthcare to be poor, inefficiency in physicians work, significant understaffing in PHC, a high turnover rate, poor quality of care, flawed cooperation between PHC units and specialist clinics and hospitals, a poorlyfunctioning system of management, and faults in the postgraduate training system. 24 This negative evaluation of the system encouraged the Ministry of Health and Social Welfare to appoint an expert team to draw up the changes necessary to rationalize the system. 14,24 In the report document Reform Directions for the Health Care and Social Welfare System of 1989, in the part of concerning PHC, family physicians were given a key role. However, even before the paper was evaluated by the Socio-Political Committee of the Council of Ministers, the idea of the family physician as a fundamental element of the new system was replaced with the previous concept of local area physician. The amended document was analyzed by the Health Sub-team in the course of the Round Table Talks. The subteam recommended to the Minister of Health and Social Welfare the establishment of a Team for Reforming the Healthcare and Social Welfare System comprising representatives of both parties to the Round Table Talks, whose task would be to prepare a final version of a reform programme and basic principles of the regulations which would constitute a legal basis for action for the Minister of Health and Social Welfare. Discussion The changes which took place in the primary healthcare in Poland from the establishment of the 2 nd Republic until 1989 to some extent reflect the historical processes affecting the whole country. During the first few years of regained independence, attempts were made at legal and institutional unification of the various systems of the three formerly annexed territories. The complexity of the situation was exemplified in Upper Silesia, governed by German healthcare law throughout the entire interwar period. Although the Polish administration had more independence elsewhere, differences, such as for example private versus public medical practice, remained visible between the respective territories formerly annexed by Prussia, Russia and Austria. The coexistence of private, congregational and public healthcare shows the diversified social and political situation of Poland in the 1920s. The 1930s, under the influence of the world economic crisis and the etatism of the Sanation government in Poland, was a period of strong consolidation of the healthcare system, the establishment of the Social Insurance Enterprise and the introduction of mandatory employee sickness insurance. As it proved some time later, however, those changes were to the dissatisfaction of physicians, patients and contributors alike. Conflicts arose between home physicians and those working in outpatient clinics. The outbreak of the Second World War cut short any attempts at improving the healthcare system. After 1945, it was restored to its previous shape, however, as early as 1948, the communist authorities started to nationalise the system and, in 1950, deprived physicians of their freelance status and forced them to work in a predetermined location and for statutory salaries. Under central administration, the regulated healthcare system deteriorated. Even though practically all social groups were included in the 34 PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1

7 Table I Temporary Council of State establishes a sanitary unit in the Ministry of Home Affairs The Chief of State decrees the establishment of the Ministry of Public Health Mandatory Health Insurance Law, establishment of employee Sick Funds General Directorate for Healthcare in the Ministry of Home Affairs takes over the duties of the Ministry of Public Health Social Insurance Law (the so-called consolidating law ) establishes the Social Insurance Enterprise 1935 introduction of home physicians across the country 1939 Public Healthcare Law introduces gmina physicians Milestones in the development of the healthcare system in Poland in establishment of the Ministry of Health and restoration of the pre-war multisectoral healthcare system Law on State-Owned Healthcare Institutions and Planned Economy in Healthcare introduces a uniform social healthcare system and enables nationalisation of healthcare units exclusion of physicians from the group of freelance professions and establishment of a system of regional healthcare centres Minister of Health and Social Welfare introduces specialty in general medicine introduction of a three-level model to ensure preventative care and outpatient treatment, and establishment of regions in the healthcare system the integrated healthcare centre (ZOZ) as an organisational combination of hospital and outpatient clinics key role of family doctors in the report Reform Directions of the Healthcare and Social Welfare System, the crucial document analysed by the Health Subteam during the Round Table sessions general health insurance system, and access to health services was growing, and despite numerous efforts to reform the system, patients were increasingly dissatisfied and the quality of services was falling. Primary healthcare, provided in local area centres until the end of the People s Republic of Poland, did not come up to the expectations of the Alma Ata Conference in Even the introduction of specialty in general medicine and primary healthcare courses at several medical academies did not significantly change the situation. The corrosion and collapse of the public, centrally managed healthcare system could be but another example of the inefficiency of social economy, dehumanised as it was and contrary to common sense and the rules of economy. It was only in 1989, the beginning of Poland s transformation into an independent state and market economy, that any real changes could eventually take place in the healthcare system. The strengths of this paper was the involvement of authors in a reform process starting in 1980s and 1990s and extended contact with primary care physicians undergoing vocational retraining at that time sharing their experiences of the former system. This paper was naturally limited by a shortage of relevant literature. Most studies relating to the problems discussed here were published in periodicals that were not indexed, and sometimes issued in a very limited number of copies. It is certain that the authors were not able to access certain sources or historical records which could have influenced their evaluation of the historical facts. Another constraint was undoubtedly bias due to the authors being family physicians with not much experience in analysing historical sources. Nonetheless, the authors chose this interesting yet little discussed topic and analysed all the available sources as reliably as possible. Conclusion After regaining statehood, Poland has tended to finance healthcare from public funds, and the role of primary care has fluctuated. Comparing the consecutive stages of development of primary healthcare in Poland after the Great War, the following conclusions may be drawn: 1. the state took responsibility for ensuring access to public healthcare; 2. the system was gradually institutionalised, and medical staff were increasingly professionalised; 3. accessibility of healthcare was improved; 4. the role of primary healthcare in the system fluctuated over time. Competing interests The authors declare no conflict of interest. Authors contributions Maciek Godycki-Ćwirko conceived of the study, participated in the design of the study and performed literature search, coordinated data analysis, participated in drafting the manuscript. Marek Oleszczyk participated in literature analysis, coordinated and helped to draft the manuscript. Adam Windak participated in study design, helped to draft the manuscript and participated in critical revision. All authors read and approved the final manuscript. PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1 35

8 References: 1. Włodarczyk C. Podstawowa Opieka Zdrowotna w programach Światowej Organizacji Zdrowia na marginesie dokumentu MZiOS (Primary Healthcare in WHO programmes in a Ministry of Health and Social Welfare paper). Antidotum 1994;10: Brzeziński T. Historia medycyny (History of medicine). Wydawnictwo Lekarskie PZWL: Warszawa, 1995: Bunsch-Konopka H. Historia ochrony zdrowia w Polsce (History of healthcare in Poland). CMKP: Warszawa, 1980: Fijałek J. Główne etapy i cechy rozwoju podstawowej opieki zdrowotnej w Polsce (Main stages and characteristics of the development of primary healthcare in Poland). Zdrowie Publiczne 1986;97(8): Więckowska E. Formy opieki zdrowotnej na ziemiach polskich w końcu XIX wieku do lat 30. wieku XX (Healthcare models in Poland from the late 19th c. until the 1930s). Wiad Lek 1984;13: Godycki-Ćwirko M, Nowak P, Kosiek K. Zarys historii lecznictwa otwartego na terenie ziem polskich do roku 1918 (An outline history of outpatient healthcare in Poland until 1918). Probl Med Rodz 2003;3(10): Fijałek J. Tradycje zdrowia publicznego w historii medycyny powszechnej i polskiej (Public health traditions in the history of world and Polish medicine). Medical Academy of Lodz: Łódź, 1998: Janiszewski T. Projekt uzupełnienia Traktatu Wersalskiego (Draft supplement to the Treaty of Versailles). Zdrowie 1922;12: Indulski J, Leowski J. Podstawy medycyny społecznej (Basics of social medicine). Państwowy Zakład Wydawnictw Lekarskich: Warszawa, 1971: Sadowska J. Lecznictwo ubezpieczeniowe w II Rzeczpospolitej (Insurance medical treatment during the 2nd Republic). AM w Łodzi: Łódź, 1990: (habilitation dissertation). 11. Bunsch-Konopka H. U źródeł ubezpieczeń zdrowotnych i społecznych w Polsce (Sources of health and social insurance in Poland). Zdrowie Publiczne 1993;104(9-10): Sadowska J. Europejskie koncepcje ubezpieczenia na wypadek choroby w XIX i na początku XX w. (European concepts of health insurance in the 19th and early 20th century). Zdrowie Publiczne 1989;100(6): Jastrzębowski Z. Kształtowanie się koncepcji społecznej służby zdrowia w Polsce do 1953 r. (Development of the idea of social healthcare in Poland until 1953). Medical Academy of Lodz: Łódź, 1986: Indulski J. Organizacja Ochrony Zdrowia (Organisation of the healthcare system). Państwowy Zakład Wydawnictw Lekarskich: Warszawa, 1984: Kosinski S, Tokarski S. Ochrona zdrowia ludności wiejskiej (Healthcare among rural population). Państwowe Wydawnictwo Naukowe: Warszawa-Łódź, 1987: Sułkowski H. Założenia ideowe i programowe podstawowej opieki zdrowotnej (Ideological and programme assumptions of primary healthcare) [in:] Wybrane zagadnienia z medycyny społecznej dla lekarzy POZ (Selected social medicine issues for PHC doctors) by Latalski M, CMKP: Warszawa, 1987: Miśkiewicz M. Ocena stanu i rozwoju opieki zdrowotnej specjalistycznej w latach (Evaluation of the condition and progress of specialist healthcare in Poland in ). Zdrowie Publiczne 1968;4: Saldach B. Rozwój otwartej opieki zdrowotnej w miastach (Development of outpatient healthcare in towns). Zdrowie Publiczne 1964;7: Poździoch S, Ryś A. Zdrowie publiczne (Public Health). School of Public Health, Collegium Medicum of Jagiellonian University, Kraków, 1996: Regulation of the Minister of Health and Social Welfare of 4 July 1975 on the organisation and model statutes of healthcare units. Official Journal of the Ministry of Health and Social Welfare, No. 12 of 22 December Hebanowski M, Koseda M. Węzłowe problemy kształcenia przeddyplomowego i podyplomowego lekarzy w Polsce dla potrzeb podstawowej opieki zdrowotnej (Crucial problems of under- and postgraduate medical education in Poland for the purposes of primary healthcare). Polski Tygodnik Lekarski 1987;21: Godycki-Ćwirko M. Organizacja praktyki polskiego i brytyjskiego lekarza rodzinnego odniesienie wzorów do modelu (Organisation of the practice of the Polish and the British family doctor the relation between patterns and model). Medical Academy of Lodz: Łódź, 1999:16 21 (PhD thesis). 23. Balicki M, Łuczak RJ. Medycyna rodzinna początki w Polsce (Beginnings of family medicine in Poland) [in:] Medycyna rodzinna (ed. Kochen MM), Wydawnictwo Lekarskie PZWL: Warszawa, 1996: Matuszkiewicz W. Sprawność podstawowej opieki zdrowotnej w Polsce (Efficiency of primary healthcare in Poland). Zdrowie Publiczne 1988;10: PROBLEMY MEDYCYNY RODZINNEJ, MAY 2010, VOL. XII, No. 1

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