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26 January 2024 | Policy Analysis
National Health Fund tasked with financing non-insurance-based healthcare services
3.2. Sources of revenue and financial flows
Table3.2 shows current spending on health by sources of financing between 1999 and 2016. Table3.3 shows spending on health in 2016 broken down by the type of provider. In that year, statutory health insurance contributions channelled via the NFZ accounted for the majority (nearly 60%) of total current spending on health and 85.7% of public spending on health. These funds go mostly towards financing of inpatient curative care (50.7% of NFZ’s expenditure in 2017; Table3.4). NFZ’s spending on inpatient care increased from 44.2% of the total NFZ expenditure in 2005, which can be seen as an indication that reforms since 1999 have failed to reduce the share of expenses on inpatient care by transferring less serious cases to more cost-efficient outpatient services (see sections 5.3 and 5.4). However, some of this increase may be due to the fact that the lump sums received by hospitals since 2017 are meant to cover both inpatient and outpatient care (see section 3.7.1). According to NHA, 91% of hospital care was financed by the NFZ in 2016 (Table3.3). The share of NFZ’s resources spent on primary care increased slightly from 11.0% in 2005 to 13.4% in 2017 and for outpatient specialist care from 7.1% to 7.4%.
| Table3.2 | Table3.3 |
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Table3.4
NFZ’s spending on the reimbursement of medicines decreased from 19.2% of its total expenditure in 2005 to 10.8% in 2017 (Table3.4). This could be attributed to reimbursement policies becoming more restrictive (e.g. some reimbursed medicines have been shifted from outpatient use to hospital use only), a cap on NFZ’s spending on pharmaceuticals (in 2012, NFZ’s annual budget on pharmaceuticals[6] has been capped at 17% of its total spending), and savings achieved thanks to the use of risk sharing instruments (according to estimates, the clawback system brings about PLN 200 million of savings per year; see section 2.4.6). However, it is more likely that this declining trend in NFZ’s spending on the reimbursement of medicines is the result of increasing NFZ’s budget and increased spending on other items in the NFZ’s budget (other than medicines).
Households’ OOP payments were the second largest financing source, accounting for nearly 23% of the current spending on health in 2016. The bulk of this spending is attributable to pharmaceuticals – households pay close to 66% of the cost of medicines out if their own pockets (59.5% of households’ OOP spending goes on medicines and medical non-durables; see section 3.4). Consumption of OTC medicines is very high in Poland. The OECD health expenditure statistics show that Polish households spend more on OTC medicines than on prescribed medicines (PLN 316 versus PLN 89 per capita in 2015), and that expenditure on OTC medicines has been growing more rapidly (OECD, 2018b). Expenditure of VHI schemes is concentrated in the ambulatory health care sector (see section 3.5).
After the introduction of the universal health insurance system (1999), the importance of the state budget as a source of health care financing decreased. In 2016 general government accounted for 10% of current spending on health (Table3.2 and Table3.3).
Since 2007, when the state took over the financing of medical outpatient emergency services (see section 5.5), they have become the largest item in its health budget (Table3.5). Another large item in the state’s health budget is the financing of health insurance contributions (see section 3.3.2) and other benefits for uninsured children and pregnant women. The state also covers the cost of certain highly specialized services (e.g. organ transplants) and publicly financed health policy programmes as well as the sanitary inspection.
Table3.5
Health budgets of territorial self-governments go mainly towards funding investments in the hospitals they own (36% of their total budget in 2017; Table3.6; see also section 4.1), financing of services and insurance premiums for non-contributing persons (23%) and financing of programmes to prevent and counteract alcohol addiction (21%).
Table3.6
An outline of the resource flow for funds allocated to health care in the Polish health care system is presented in Fig3.7.
Fig3.7
- 6. This cap applies to medicines, foodstuffs for special nutritional use and medical devices that are reimbursed and can be purchased in community pharmacies, medicines included in pharmaceutical programmes and medicines used in chemotherapy. ↰
The amendment to the Act on the Medical and Dental Professions and certain other acts introduces significant changes to the financing system of the Polish public healthcare system. According to the new regulations, the National Health Fund (NHF, Polish: Narodowy Fundusz Zdrowia, NFZ) was tasked with financing a wide range of non-insurance-based services, which were previously financed from the state budget and guaranteed to all people in Poland, regardless of their statutory insurance status.
The NHF took over the financing of
- emergency medical services;
- medicines for people over 75 and pregnant women;
- highly specialized services;
- compulsory vaccinations;
- insurance contributions for students, soldiers and the unemployed; and
- medicines under the health policy programmes of the Ministry of Health:
- treatment of haemophilia,
- antiretroviral treatment for people living with HIV, and
- antiviral treatment for hepatitis C for prisoners.
Previously, all these tasks were financed from the state budget. Currently, these tasks are financed from compulsory health insurance contributions (paid as a payroll tax via the social insurance system), without any further increase in this source of NHF income [2].
The reform was met with numerous protests from the medical community, mainly due to the lack of guaranteed additional financial resources for the NHF. As a result, patients’ access to health services may be restricted. The reform was introduced at a time when the NHF has been experiencing a budget surplus since 2021 due to unused health services, initially due to COVID-19 and later due to a shortage of professionals [3]. The surplus is also the result of a new tax reform that increased the health care contributions of self-employed people with higher incomes [4].
References
[1] Law of 16 November 2022 on amending the Act – Law on the medical and dental professions and certain other laws, Ustawa z dnia 16 listopada 2022 r. o zmianie ustawy o zawodach lekarza i lekarza dentysty oraz niektórych innych ustaw (Dz.U. 2022 poz. 2770): https://isap.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=WDU20220002770
[2] Rzeczpospolita, NFZ straci miliardy złotych na leczenie, 18 November 2022 [access: 26 January 2024] https://www.rp.pl/sluzba-zdrowia/art37440561-nfz-straci-miliardy-zlotych-na-leczenie-w-sejmie-przeglosowano-ustawe-pis
[3] Piotr Wójcik, NFZ zamknął 2022 rok z kilkumiliardowym zyskiem, MedExpress: 1 September 2023 [access: 26 January 2024] https://www.medexpress.pl/ochrona-zdrowia/nfz-zamknal-2022-rok-z-kilkumiliardowym-zyskiem
[4] Money.pl, Polski Ład docisnął przedsiębiorców. Kwota odprowadzonej składki zdrowotnej robi wrażenie, 20 June 2023, [access: 26 January 2024] https://www.money.pl/podatki/polski-lad-docisnal-przedsiebiorcow-kwota-odprowadzonej-skladki-zdrowotnej-robi-wrazenie-6910964818020928a.html