The truth about health financing. What is the National Health Service doing with our money? Episode 65

Monika Rachtan
In Poland, we are very fond of counting money - both our own and that spent in the healthcare system. Today we will talk about what happens to our health premiums. My guest is Dr Małgorzata Gałązka-Sobotka. Welcome, Doctor.

Małgorzata Gałązka-Sobotka
Welcome, Madam Editor.

Monika Rachtan
Where does the money that leaves our employer go and what happens to it? I'm thinking of the ones that are destined for our health.

Małgorzata Gałązka-Sobotka
In the simplest terms, they go to the Social Insurance Institution. This is the institution defined in the legislation as the one that collects social insurance contributions, including health contributions. However, it is not the Social Insurance Institution that spends this money to finance health services, but passes it on, for example to the National Health Fund. And here it is worth noting that the annual fee for this cash flow transaction is more than PLN 250 million, which is a significant amount that we rarely talk about.

Małgorzata Gałązka-Sobotka
The transaction fee, which we can call it, is roughly half of the salary budget of the employees of the National Health Fund, which serves tens of thousands of treatment entities. This ZUS transaction fee is about 50% of the salary budget of the entire institution, both in the 16 provincial branches and in the headquarters of the National Health Fund.

Małgorzata Gałązka-Sobotka
The administrators of the National Health Fund manage a budget of around PLN 140 billion per year, of which the institution's administrative costs account for just under 0.75% of the total revenue collected. By comparison, public institutions in Western Europe spend, on average, around 7% on administrative costs, and private health insurers spend around 20% of their revenues. This makes the Polish public payer one of the cheapest in the world. If someone can find a cheaper insurance institution, I am prepared to put up an attractive prize. This shows how our health care system is structured - a bet has been made on very low operating costs, but does cheap always mean good?
Monika Rachtan
And is that money in the system that we pay into health? It is often the case that it passes through our fingers and there is. A lot of holes that if we sorted it out in the end, that patient would get better quality medical care.

Małgorzata Gałązka-Sobotka
Yes, it has been said for many decades that the Polish health care system is such a leaky bucket and that any money we pour into this bucket will leak anyway and will not actually bring added value to the patient, to the one who finances this system at the end or beginning of the day. Because we said to ourselves at the beginning that it is from our contribution that the health system is mostly funded. And indeed it is. There is not the slightest doubt that the Polish health care system is not one of the most efficient of those places of waste, loss of resources that could, through better organisation, simply give us more health. Faster, quicker diagnosis, quicker start of treatment, better care during the treatment process or care when the medical intervention ends. But the patient still needs expert, medical support. One example is the competence of medical staff. In Poland, medical staff still carry out a huge amount of bureaucratic duties that in the world are only carried out by secretaries and new technologies. In Poland, doctors still perform activities that in the world are performed by nurses and midwives, physiotherapists and even pharmacists.

Małgorzata Gałązka-Sobotka
One example is medication reviews. Today, it is on the shoulders of the doctor, e.g. primary care, the family doctor, to look at what medicines he or she prescribes and what other specialists prescribe. The prescription system already provides this opportunity. In the world, this is done by a pharmacist who is a member of the primary care team. Another example is the delivery model. Poland is one of those countries with the highest rate of hospitalisation, i.e. the highest number of people and procedures performed and resources placed in the system. The model used is one in which care is provided in a hospital stay.

Monika Rachtan
Doctors are used to having to hospitalise patients. Is it the system that forces them to hospitalise this patient, because, for example, some of the services cannot be provided to this patient if this hospital stay is not there. Do we Poles like lying in hospitals and willingly lie down in these wards?

Małgorzata Gałązka-Sobotka
I think Poles shouldn't be suspected of being fans of staying in hospital. When I meet anyone and we talk about it, most say. Hospital is the last resort, absolutely the last resort. If anything, it's for a while, a day at most. But certainly a long stay always scares everyone and puts them under enormous stress. So this is certainly not what patients expect, even though they are often aware that only a stay in hospital will allow them to have a comprehensive diagnosis by the attending physician and thus clearly decide what the health problem is and start it.

Monika Rachtan
He assesses this situation to be the case, that you have to go to hospital to find out what you are ill with.

Małgorzata Gałązka-Sobotka
Absolutely. This is one of the biggest weaknesses of the Polish health care system resulting from the financing model for guaranteed services that are made available to patients. In this system of public financing. Still in the process of tarification of benefits, that is, their valuation, the entity is ratified, which however pays, more money is paid for these benefits that are provided in the inpatient mode than in the outpatient mode. And many specialists say. It is not my me. My wish is that I put the patient, for example, for a three-day hospital stay. Only the basis for covering the costs associated with this diagnosis is that he or she nevertheless stays in this hospital for these three days. This is where a huge role is played by the regulator, the Minister of Health, who commissions the Agency for Health Technology Assessment and Tarification, the valuation of benefits and the National Health Fund, who all together, creating this regulatory, regulatory ecosystem, should strive to prefer, if only there are no medical counter-indications, to give preference to outpatient maximum one-day hospitalisation. Because modern medicine, the technologies that are at our disposal, absolutely provide such comfort.

Monika Rachtan
Patients often judge our doctors, their actions, their decisions, by looking at them very individually, that is. The doctor didn't give me because he didn't want to. The doctor told me to lie in hospital because he would then be paid more for me than he would have done on an outpatient basis. We as patients very often don't understand that there is a system behind the doctor, which simply imposes certain actions on him. And he. Well, as if a hospital is also a bit of a business, it too has to make a living somehow. And it doesn't happen completely by accident that doctors make certain decisions related to the organisation of the work of the ward and the life of the patient, so that they can be diagnosed, because they have to make sure that their employer stays in business. Well, and they kind of have no choice. This is absolutely no malice and patients should finally look at this healthcare system in the way that it is not the doctors themselves who make it, that there is this regulator there.

Małgorzata Gałązka-Sobotka
Absolutely yes. This system is very many layers or very many interconnected vessels that are closely interlinked, that is, what the patient gets at the end of the day is the consequence of the decisions of very, very many people who make the decisions. But it has to be said to ourselves straightforwardly that knowing how to navigate this system, what its rules of the game are, is still a secret knowledge. We have not given society, for many years, even in these such elementary rules of how to navigate the system and how the system works. The majority of Poles still do not know who actually makes the key decisions about which funds are used and for what purposes. But neither do medical professionals have this knowledge of what economic rules apply to the system. For the great importance of knowledge in the field of organisation and management of medical institutions, of the health care system, has not been included in the training of doctors. Each of us, when entering the professional environment for which he or she is being prepared in the process of education, nevertheless acquires an elementary knowledge of how the organisation functions at the university, in business schools, how the I don't know, courts or law firms function in the medical faculties.

Małgorzata Gałązka-Sobotka
Only for some time now has the importance of knowledge in the area of organisation and management also been emphasised. And practice and analysis of many medical entities show that there are places where the staff of a particular hospital and the management, but also the medical staff, have reached a much higher level of initiation. And despite the fact that the legal regulations, the regulations of the Ministry of Health or the National Health Fund are perhaps not conducive to this very optimal, rational operation, they are able to move better in this system and not by accident. There are hospitals where this outpatient mode has almost become commonplace today, but there are hospitals where there is still, it seems to me, because of low skills in navigating these intricate rules of accounting for services with the National Health Fund, a belief that you have to put the patient on this bed. And so it is explained to him that this is required by the National Health Fund, that it is the National Health Fund that has created such conditions, which is absolutely partly true, but the examples of other healthcare entities also show that it is also possible to provide much more outpatient services in a different way, by approaching the organisational concept.

Monika Rachtan
Even in Forest Mountain it was the case that the hospital director had organisational problems and said he had to manage and had already stopped treating. So it is also not always the case that a good doctor will be a good hospital director.

Małgorzata Gałązka-Sobotka
This is true.

Monika Rachtan
But I would still like to come back to this health premium.

Małgorzata Gałązka-Sobotka
Here you go.

Monika Rachtan
Because we have a certain amount of money and now we would like to divide this cake. Where is our money going? What is funded by the health premium? Because as we're talking here, it turns out that this system is convoluted, I bet it's not like just my premium goes to my tablets. So if we could clarify absolutely yes.

Małgorzata Gałązka-Sobotka
The health contribution mostly goes one hundred per cent to the National Health Fund, Also, there is not the slightest doubt that what goes to the National Health Fund is spent on health services, on the provision of health care. The health care system is financed not only from the health contribution, but also from subsidies from the state budget, from funds coming from local government units. Therefore, I said overall, the system is financed from various sources and this money is used for investment, for personnel training, for infrastructure development, for public health. Which is already outside this perimeter of the National Health Fund. But if we pay something out of that salary we have agreed with our employer. This money goes to the Social Insurance Fund, then to the National Health Fund. They are the ones in 52% that go to fund hospital services today, primarily hospital services. So, when we look at this cake of the National Health Fund, which is about PLN 140 billion, there, already referring to the last years of the previous and current one, more than 50% of this amount is allocated to hospital services, and those using hospital services are about 8 million people.

Małgorzata Gałązka-Sobotka
Approximately 13% is used to fund primary health care, with.

Monika Rachtan
Parts we use.

Małgorzata Gałązka-Sobotka
We are using it more often. We are using it because 28 million Poles every year cross that threshold to the clinic, the family doctor, and ask for some kind of support, some kind of medical consultation. The third item is outpatient specialist care, for example.

Monika Rachtan
Such an orthopaedic clinic.

Małgorzata Gałązka-Sobotka
Exactly whether endocrinological or cardiological. Here, roughly about 16 17 million people benefit from these measures quite a lot. And we allocate around eight. Here, this financial share is fortunately steadily increasing, in line with the principle of outpatient care in the health system. It is no less important, however, that still this share of hospital treatment, which we have just been discussing, consumes more than half of this budget. More than half of it by far in healthcare systems that we consider to be better, that we consider to be better, because they guarantee better health for citizens, achieve better health, and secure more quickly the needs of the patient in terms of diagnosis and treatment. To treat more effectively, to treat friendlier, to treat more pleasantly with dignity, with patient rights. These are systems that allocate far less to inpatient care than we do, and far more to treatment. Precisely in the system of the family doctor, working very actively with specialists. Expenditure on medicines, on the reimbursement of drug technology, also plays an important part in this cake, in this purse. Here, too, this item has a very high position, such a percentage in this cake.

Małgorzata Gałązka-Sobotka
Nonetheless, Poland is one of the countries that spend the least on drug technologies in terms of public expenditure. In other words, in this matter we could perhaps also avoid many realisations, reduce the risk of disease development, if we made a wider range of these state-of-the-art technologies available to citizens. We have done tremendously in recent years.

Monika Rachtan
Progress, huge.

Małgorzata Gałązka-Sobotka
Progress.

Monika Rachtan
As many drugs as appeared in drug programmes, indeed. Here, Minister Miłkowski made sure that these programmes were full of modern therapies. However, I would like to ask what countries we should be following, on which we should model ourselves when it comes to financing, when it comes to spending this money. Who here is such a model for us?

Małgorzata Gałązka-Sobotka
For several years there was a phase in which they modelled themselves on the budgetary model of organising and financing health care, which was the British system, in which the key role is played by that important system regulator, the NHS. However, I think that the experience and quality of the British system, also transmitted by Poles who have moved to the UK in large numbers and have been able to use this system, has opened our eyes to the fact that the British system is probably not the most exemplary one and it is difficult for Poles to find their way in it. Poles who are used to having easy access to a specialist. Referring directly to your question, the most reference system for Poland today is the Dutch system, because it is a system which is oriented and built on the model of a value-based helper, that is to say a system oriented towards health value. And the foundation of this system is, above all, the constant monitoring and evolution of the results of treatment of hard results, those which are called in medicine the so-called endpoints of the treatment process. Also the outcomes that are expected by the patient who enters the healthcare system. Therefore, a very big role in this system. Dutch attention is paid to communication with the patient, to agreeing a treatment plan together with the patient.

Małgorzata Gałązka-Sobotka
It is happening, it absolutely is happening. It is not yet widespread. We need to develop this practice and we certainly need to pay more attention to the patient's satisfaction and experience of using the service. Because we today, for many years in this deficit system, have sought only to simply give care to the patient. We have forgotten what the quality of that care is, whether it is certainly effective and whether it is certainly comfortable for the patient. I think that as the 20th economy of the world, we are coming to terms with the fact that the development of civilisation also includes the social dimension of the provision of public services, and that even in offices we have ceased to pay attention only to the service provided to the patient, but also to whether the citizen is satisfied with the service, and whether the service is provided to him or her in a professional manner. We also discuss this in the health sector. The Quality, Patient Safety Act, which was passed. It draws attention to the fact that quality in healthcare, in health care, should be assessed in the clinical dimension, i.e. whether it produces the expected medical results, in the consumer dimension, i.e. how the patient is served in the process, but also in the management dimension.

Małgorzata Gałązka-Sobotka
For health is money, and money is health. So we in medicine and in health care also have to look at the quality of the organisation, the facilities, the quality of the management of the public funds that are at the disposal of the managers. Because we should aim to get as much health as possible out of every unit of money. And the Dutch are teaching us this.

Monika Rachtan
And isn't it the case that the attitude of doctors has also changed a little bit, because still 10, 15 and certainly 20 years ago the doctor was put in the role of God Either he saves my life or he doesn't. Absolutely not. We thought about the fact that the doctor is actually treating us, he is doing his job for which he gets paid and he has the right not to like the work of the hairdresser and we are able to pay attention to her, because we say we pay for hair then we want a nice blonde. In the same way, I can assess the work of a doctor and it doesn't always have to be a positive assessment. If I am right and if this service was given to me according to standards, it was not qualitative, then I as a patient, as a payer, because I pay a contribution to the system, have the right here to express my opinion and it does not always have to be flattering.

Małgorzata Gałązka-Sobotka
Absolutely all of us in the relationship between service provider and service recipient, whether in the nomenclature of the National Health Fund we call service providers and service recipients, should strive to keep the relationship as professional as possible, and this professionalism of medical services consists not only in the precision of carrying out the diagnostic and treatment procedure itself properly in accordance with current medical knowledge, but also in the very culture of communication and the very culture of serving the patient. In this regard, it should not come as a surprise to medical professionals, although it is sometimes surprising because it has simply never been discussed in their training process that it is something natural, that the patient comes and expects not only the service itself, but also pays attention to under what circumstances, in what form these services are provided. Not only in terms of whether we have chairs in the corridor and we have somewhere to sit, whether there is a well-organised queue, whether there are no crowds, because it is good to organise this traffic and make appointments for the next patient visit, but also what the language looks like.

Monika Rachtan
We have from you.

Małgorzata Gałązka-Sobotka
From the receptionist or the lady at the window to the very nurse or doctor or professor who is talking to us. Not only do we have the right to expect a culture of respect for the other person, because the Code of Medical Ethics, for example, says so, but the standards of personal culture and simply professionalism and professional attitudes in any profession we practice say so. So medicine is certainly not outside the margin of those principles which we consider universally applicable. Applicable or principles that should universally apply.

Monika Rachtan
Does it pay to be treated at the National Health Fund in Poland?

Małgorzata Gałązka-Sobotka
In Poland, it is impossible not to stay healthy and fight illness if you do not have public health insurance. We have to say to ourselves straightforwardly that as long as we are young and lucky enough not to be ill, or to be ill only with minor problems, minor infections, uncomplicated illnesses, we can afford it. If we have a job, we have a reasonably. I would say an average income, then the average citizen can afford to pay for a morphology, pay for an abdominal ultrasound or pay for some basic specialist consultations out of their own pocket. If he wasn't, if that person wasn't insured. But when a serious illness happens in our lives, a very serious illness happens to us, a very serious oncological illness, a neurological illness or even a serious illness. From a respiratory point of view or a serious accident where we have multiple injuries, then no.

Monika Rachtan
We are able to do this.

Małgorzata Gałązka-Sobotka
It is even households with an average wallet that struggle to bear the cost of such treatment. Therefore, really more than 90% of the Polish population has health insurance and the number of people who take out insurance. Even when they do not have permanent employment with the National Health Fund and the employer is not obliged to pay for this health insurance, they take out voluntary insurance, and this number is steadily increasing in Poland. This is precisely because this health protection is then incomparably greater. The basket of guaranteed benefits offered by the National Health Fund as part of public insurance is huge. Of course, we are aware that it is often declarative, because the waiting time for this procedure is so long that we know that somewhere ahead of us there is the prospect of being able to benefit from this operation or this treatment. But at the end of the day, that time is very long, and that is why it is no coincidence that many people, in addition to the National Health Insurance Fund, opt for private insurance, or try to have savings for the circumstance. Well, just the anticipation of the fact that with this our health is sometimes different and it may be necessary to make use of this private health sector.

Monika Rachtan
I would just like to summarise what you said, and in fact I might put this knowledge together, that we can insure ourselves, if we are entrepreneurs, we can insure ourselves, and thus benefit from these public services. I am talking here of course about the National Health Fund. Our employer can do it, should do it, must do it.

Małgorzata Gałązka-Sobotka
It is we, as sole traders, who also have to do this. Health insurance for every person who runs a business, is in some form of employment, whether in their own business, in a company, or working under a contract of employment has a health insurance obligation. We are talking about voluntary insurance for those who do not have legal, official employment. There are people who cannot be insured by, i.e. covered by, a spouse, for example, and who are single and no longer have current employment status, such as unemployed. And they then lose the right to insurance, and they assume that sometimes they simply have to turn to this National Health Fund. And it is out of these savings that this insurance is taken out for the circumstances, precisely for the occurrence of this illness and the awareness of what the costs of treatment will be later on. This is what you do privately.

Monika Rachtan
You have already explained to us what the National Health Fund spends our health contribution on. But I would still like to talk about an example of a service, because we often do not realise how much something costs. I have just taken this endoprosthesis, which everyone has recently heard that such operations are being performed, i.e. hip endoprosthesis implantation. And now. Is it the same operation, do we only pay for the operation, or how do other services and benefits add up to make this whole event so expensive?

Małgorzata Gałązka-Sobotka
Everything that involves crossing the threshold of this hospital, to which, in which we will have this experience carried out. Covering is that price which is paid by the National Health Fund, then the providers, that is, since you have to this cost of this endoprosthesis, hip plasticity include covering the cost of the work of the lady registrar in the window the work of the nurse who will start to prepare the medical documentation the anaesthesiologist who will carry out the consultation before the anaesthesia before the orthopaedic surgery and the whole team who will perform this surgery. Covering the cost of electricity, covering the cost of food, covering the cost of the prosthesis, because this is a very important component of this procedure, which is the medical device itself, which is also included in this valuation that is paid for by the National Health Fund. So, as in any activity, we are talking about the so-called costs directly related to the procedure And most often the patient thinks to himself like, this is my orthopaedic doctor, this is the anaesthetist who is doing me there, so that, so that I am not fully aware of how this operation is going to go. And it wasn't, it didn't involve pain. And maybe the nurses or the physiotherapist who helps me afterwards.

Małgorzata Gałązka-Sobotka
To unblock this my musculoskeletal system after a procedure and we usually think that this is the direct cost, but often the patient does not see these indirect costs, these hospital overheads, because this procedure also has to be included, at least a part of the work of the director, at least a part of the work of the administrative director, at least a part of the work of a huge number of people whom we patients often do not see, who deal with billing, who deal with keeping records of various types for the needs of various institutions. Also, as in any activity we try to understand, especially when we work in different places, including the hospital, this cost of a given procedure. This cost of a given procedure is made up of very, very many components. Importantly, for many, many years we didn't quite have the knowledge of that. So going to the director of a hospital and asking him the question, Mr Director, how much does it cost you in your hospital to implant just such a primary hip endoprosthesis? It doesn't matter what technique, because there are differences. And very often the director of the hospital or the head of the department would answer us with a question, not how much it costs, but how much the National Health Fund pays for it, that is, what revenue the medical unit will receive, when the report, the realisation of a given service.

Małgorzata Gałązka-Sobotka
But you have to distinguish between revenues and costs.

Monika Rachtan
And it turned out that the National Health Service pays well.

Małgorzata Gałązka-Sobotka
And it turns out that we don't really know whether the National Health Service pays well, because we don't know how much it costs us in the hospital. And this is one of the reasons why a few years ago an obligation was introduced for every healthcare entity to keep a cost account according to a uniform standard, so that it would be possible, in fact, for a better tarification, that is, a more up-to-date valuation and a more reliable valuation of these services by the National Health Fund, so that knowledge could be gathered from healthcare providers as to what are the components of the costs on their side, so that such, such a procedure could take place at all, how much does it cost them and to what extent the price paid by the National Health Fund allows them to cover their costs and, nevertheless, make some profit. Because it is also unpopular to talk about profit in health care. There were even some politicians in our modern history who said that in medicine one should not think about profit at all, that profit should not appear in every activity. Profit should appear and the National Health Fund should and the Minister of Health should price health services in such a way that their providers can provide patients with such an organisation that will guarantee the best outcome of treatment. The best experience of the service will allow them to cover the costs of this service and obtain at least a few percent of the so-called margin, because this margin is needed to carry out renovations, to invest in the development of employees, in new technologies, absolutely in health care.

Małgorzata Gałązka-Sobotka
Just as in any other activity to appear profit, because without this profit there is no development, no qualitative development and no this development. The kind of development that is important in terms of the ability to increase the efficiency of the health care system. And we need to increase this efficiency of the system, because there are more and more health needs, if only because of the ageing population.

Monika Rachtan
And when you analyse all these medical services that are served up to us by the National Health Fund, which one is the most expensive? One that simply makes your hair stand on end.

Małgorzata Gałązka-Sobotka
Well, here is such a group. I'm not going to talk about specific ones, specific procedures, but the items that have the highest unit value in the budget of the National Health Fund, which is the amount of care that is guaranteed to one patient per year. These are mostly rare diseases. We reckon that these are conditions that occur in single cases in the patient population. In Poland, these therapies are very expensive, and they are expensive all over the world precisely because the process of creating this technology is very expensive, often very time-consuming, and unfortunately the number of patients in the world who can benefit from it is small. So the developer of this technology, the pharmaceutical company that provides it to the patient clinician, naturally covers these costs for itself by sharing it with this small patient population. The larger the patient population, the cheaper the therapy is. This is natural. A very simple calculation. And here, in fact, there are therapies that cost more than several million PLN per patient per year, even reaching up to ten million PLN. Examples include stock market therapies, for example in the treatment of SMA costing several million per patient.

Małgorzata Gałązka-Sobotka
But I think we have all learnt our lesson, that investment, that spending on health should be seen as an investment and not as a cost. Because, today, guaranteeing a young child who has been diagnosed with spinal muscular atrophy through screening and guaranteeing him effective treatment in those first few weeks will mean that his life will be completely normal, that he will be able to work, that he will be able to create, that he will be able to pay taxes, that he will be able to pay a health contribution. More importantly from the point of view of our topic. And surely this turnaround may turn out, if he turns out to be a talented, hard-working, ambitious man, it may turn out that the values he will bring to the economy, to the public finances, will be thoroughly higher than what the state has invested in his therapy and in his treatment.

Monika Rachtan
When the state raises the health insurance premium, does it automatically guarantee us higher quality care? We have been in such a situation in recent years, when more money has disappeared from our wallets. Indeed, more money for health. And indeed, after these, as I recall, two years we are almost already seeing the benefits of this increase.

Małgorzata Gałązka-Sobotka
I think individual patients in different areas are seeing, because we are seeing the fact that the waiting period for this induced endoprosthesis for plastic surgery has shortened for us today and usually within one year if the patient is qualified, or even a few, of course a few months can benefit. We no longer wait in such queues for cataract surgery. We definitely have easier access to imaging tests, specialised imaging tests. But has this situation improved significantly? There are still many patients who feel bitter and unsatisfied. And from the data we observe in the National Health Fund, we can see that outlays on health services have increased very significantly, also in connection with changes in the system of collecting contributions, because the health contribution has not increased. The rules of its collection have changed, because a significant part of this contribution is deducted from income, and this has actually resulted in depleted state budget revenues. The money in us from our wallets did not flow to the end for this contribution. However, after the introduction of the Polish order, in fact, this 9% contribution for those employed under a contract of employment is redirected to the Social Insurance Institution. And for many citizens, this was a perceptible loss in their income, given that it was intertwined with growth, with inflation, with other expenses for everyday functioning, household maintenance.

Małgorzata Gałązka-Sobotka
So it was only natural that citizens began to speak out about the fact that they expected this clear, this marked improvement in the quality of care. And here we still have a great deal to do in many areas. There is no doubt about it, because the organisational model we have today, which unfortunately has not changed significantly, has not changed yet. It means that we are almost getting the same thing, only for a lot more money. As citizens, we pay a larger contribution, in value terms our salaries have increased from our income too, so it's 9%. Proportionally it's quantitatively more and more money. But unfortunately, when it comes to taking advantage of this health insurance, it turns out that this queue is very large. This access to the doctor is very long and this patient satisfaction is average, as shown by social studies. Therefore, it is necessary to continue to develop such measures in the health care system which will allow a real increase in access to the health care system. An example of such a change is the implementation and development of coordinated and care in primary care. The idea behind this reform is that the family doctor, with the budget allocated for diagnostics, should not send us to the ED to carry out tests, and should not send us to a specialist so that it is the specialist who covers the costs of this diagnostics, but should, already at the level of this first visit to the family doctor, refer us to the necessary package of tests, perhaps even consult a doctor, a specialist, a specialist, without sending the patient away, but the doctor does this.

Małgorzata Gałązka-Sobotka
In such a model, the doctor consults with the physician precisely in order to take care of the patient more quickly and incorporate treatment, rather than using up those more expensive resources that should be made available to those patients whose conditions actually require specialised or highly specialised medicine.

Monika Rachtan
And is the 9% for health that we pay in Poland compared to other countries in Europe, the world, a lot?

Małgorzata Gałązka-Sobotka
This is a drop in the ocean. We are the infamous leader here. We are almost at the podium in Europe, because our public spending on health, calculated according to Eurostat methodology, the OECD methodology, is today 5% of GDP, with a European average of over eight. Therefore, we really are constantly, despite the fact that we often hear from politicians that, once again, healthcare spending has been increased, it has been increased. It is me who always tries to convey at every opportunity that when politicians tell us that they have increased healthcare spending, let us remember that it is most often we who have done so. They have increased premiums precisely because they are constantly in the general pot. The resources allocated to health in our state. The health premium is the largest contributor. That is, we are the biggest contributor. And when even for the last years we see this increase in the amount of these funds, it is our health premiums that have the largest share in this increase. And here, unfortunately, we have to say to ourselves that our expectation that we will secure modern, comprehensive, well-coordinated, friendly and effective health care with such low outlays as we have today for this sector, for these services, is a promise that is unlikely to be fulfilled.

Małgorzata Gałązka-Sobotka
We have to be clear that without an increase in public tributes, including our taxes or contributions, because if we are not open to an increase in the health contribution, at least in some near future, we will have to be prepared for more funds to be diverted from the state budget to health care, and therefore perhaps taxes will have to be increased. Be that as it may, some tribute will have to increase in order to better safeguard our expectations in terms of social services, in terms of public services. We are talking here about not only better organisation of health care, but better organisation of social care, long-term care. We are getting older, which means that there will be more people needing perhaps less treatment and more social support, social support. Better provision for educational needs. In this matter, our expectations are growing, but as an informed society, we must have the knowledge that it is impossible to increase and improve quality, to increase access and to improve the quality of high-quality public services. If we do not contribute more to this common goal, Poles will continue to pay low health premiums. The average public insurance premium in Europe is 11%, in our country it is 9%.

Małgorzata Gałązka-Sobotka
Also, we need to realise that in addition to these often 11% basic insurance, in very many Western European countries there is an extensive system of additional, voluntary insurance. And citizens not only pay this significantly higher basic premium, but also invest in this insurance. And we also have to realise that if we want to have better health protection and greater health security, we have to decide to spend a little more on it. Today, when asked in surveys whether they are open to an increase in health premiums, Poles say no. Why? Because they do not see the result so far.

Monika Rachtan
But we also certainly spend a lot of money in this private sector. But let's not kid ourselves, But I don't think I know a person who hasn't used private medical care. I don't know a person who would go to a dentist on the National Health Fund. I don't think such things happen. To the gynaecologist. When girls have problems they tend to avoid women.

Małgorzata Gałązka-Sobotka
He is receiving treatment, receiving care in the private system of course.

Monika Rachtan
And do you politicians say they care about our health? And does the state that serves us alcohol on the shelves of shops? Does the state that serves us cigarettes? Does the state want to make money on our health by giving us such tributes?

Małgorzata Gałązka-Sobotka
This is indeed such a most sensitive side of the health policy discussion and the discussion of state policy in relation to health. A very sensitive, politically unpopular one, because the Prime Minister of the government or the ministers of the various ministries have to make choices that will try to balance very often conflicting interests. Because, on the one hand, we are a citizen who wants to be healthy, who wants to have good healthcare, and on the other hand, we are a farmer who grows crops that are primarily used to produce alcohol or to produce tobacco. And Poland is standing still. These are industries that are among those thriving in Poland, in the Polish economy. And now there is this dilemma as to whether the state, in conducting its activities, should consider its objectives as paramount, right? Are these economic goals, or these goals? Those related to the development of various sectors of the economy or agriculture. Or is it the objective. The overriding objective should be the health of citizens. And this is not a question that we, as Poles, ask ourselves. It is a question that accompanies discussions in all countries at the level of all governments, which have to make this choice and move these decisions in such a relatively safe and flexible way that the decision in relation to health does not have a very strong, radical impact on a certain sector, so that it does not in turn cause some kind of collapse in individual areas.

Małgorzata Gałązka-Sobotka
Nevertheless, the question is which is more important? And those states to which we refer, those states that we consider to be exemplary. These are the countries that nevertheless said to themselves many years ago that health should be the parameter to which you treat as superior. That is to say, among other things, when taking important new interventions, statutory decisions in relation to the industrial sector, the environment or agriculture. One evaluates each regulation through the prism of what its impact on health will be. That is to say, if today we have a law on excise duty on alcohol or excise duty on cigarettes, we turn to and carry out analyses that check whether these excises are too low. As a result, a great many Poles are turning to stimulants, the negative impact of which on health has long been proven. And unfortunately, epidemiological statistics show that tobacco is the key risk factor taking Poles' lives. An analysis of the amount of excise duty levied on tobacco products, as well as the rules of law governing the distribution of tobacco products, such as electronic cigarettes, shows that Poland still applies fairly liberal principles and rules, which shows that health is not yet the priority.

Małgorzata Gałązka-Sobotka
I dream of a time when, in government policy, the Prime Minister or the Prime Minister will actually stand up and say yes, we are opening a new decade in Polish state policy, and we are going to pay much more attention to what policy we pursue in order to make its impact on the health of our society the best it can be, that is to say, how do we reach out to stimulate health, see policy from the education department or the sports department. But on the other hand, in the area of other sectors that naturally generate externalities, such as industry, for example, or agriculture, how do we reduce this negative impact on health? Here, it really requires such a very strong embedding of health as a priority and capital, health as the one considered most valuable in the design, economic development of a country. I believe that we are reaching such a point. I am beginning to see signs of this. We are being helped here, for example, by the European Green Deal and the discussion on sustainable development, in which great importance is attached to balancing the concept of one health, in which countries should strive for the health of their populations as well as the health of the environment and the health of animals, since we function within this ecosystem.

Małgorzata Gałązka-Sobotka
Human health is largely determined by the quality of the environment and also by the quality of the food we eat every day. So here there is a great deal of connection between the economy and health, between the various sectors of the economy and what condition we are in today and what health condition we will be in in the future.