Laure Akai analyses the neoliberal reforms to Poland's health service as the doctors' strike enters its fourth month.
Some hospitals have given up the strike, some hospitals are concluding private deals with doctors. Nurses have organised separately from the doctors with a slightly different agenda. And it well may turn out that the results of the strike are strikingly different salaries for health care workers throughout Poland and increased privatization of the health care industry.
The Strike and the Disturbing Approach of the Doctors
The health care workers’ strikes in Poland may prove to be the most problematic industrial actions I’ve ever witnessed. Doctors initially called the strike, which affected hundreds of hospitals. Thousands of doctors in over 70 hospitals in Poland actually gave in their notice. And while some hospitals have reached agreements with doctors, well over a hundred are still functioning only in case of emergency. Some time after the doctors’ strike commenced, nurses and other health care workers also went on strike and held a protest camp outside the Prime Minister’s office. But the different parties were just barely united in their demands and tended to hold both separate protests and negotiations.
It is hard to speak of “the doctors’ position” since one never knows whether the doctors’ main union, OZZL, actually reflects the position of all of its members. We can assume that in fact it reflects the opinion of at least a majority of them. OZZL is headed by Krzystof Bukiel, a former member of Union of the Right, currently involved with right-wing libertarian capitalists from the Union of Real Politics (UPR) headed by Janusz Korwin-Mikke.
A word about them: although they claim to be somehow inspired by libertarians, their politics are actually much more conservative and contain heavy doses of anti-semitism and national patriotism. They campaign heavily for the death penalty, want to criminalise communists and their leader is a raving sexist. Mr. Bukiel has, in the past, campaigned for the privatisation of health care in Poland; OZZL had a program and many texts drawn up by think-tanks such as the Adam Smith Institute.
Somehow, these issues were not discussed during the strike, and during it Mr. Bukiel never called for privatisation, and some texts were removed from the web site. It is not clear whether this reflected the wishes of the doctors, some reconsideration of the issues or whether Mr. Bukiel just decided to keep his agenda hidden. During the strike OZZL did come up with some typical right-wing proposals such as providing vouchers to patients instead of continuing the current system. These vouchers would be issued in equal amounts to all patients – regardless of their real medical need.
The OZZL however presented other more reasonable demands during most of the strike, including pay rises for doctors and raising the percentage of the budget spent on medical care to 6%. Currently Poland has the second lowest level of health-care expenditure among OECD countries. In this respect, they had similar demands as the nurses. Why then didn’t the doctors and nurses join together in a better-coordinated strike action?
The situation was more complicated than that. Many other unions are present in the health-care sector, most notably OPZZ and Solidarnosc. Since the majority of leaders of Solidarnosc support the government, it is politically difficult for them to support any strike which is labeled “a provocation against the government” by the leaders of the ruling Law and Justice party. The different approaches of some unions were one thing. The other was that quite simply, OZZL was looking out only for what it perceived as it’s interests and that these did not necessarily find a conjuncture with those of the nurses. For one thing, with the government’s constant claims of “having no money”, probably OZZL figured that demanding raises for just doctors might have more chances of success than if the whole industry were to ask for raises. But also, as it is now perfectly clear, many doctors are convinced that working on privately-negotiated contracts will be beneficial to them, whereas nurses are against it. Simply put, doctors can take more money for performing more operations or seeing more patients since many patients pay for services anyway. They have more room for negotiating with hospitals since their labour is valued differently than the nurses.
The fact is in Poland that many patients are forced to pay for medical services despite theoretical “free” health care. Doctors have long supplemented their incomes by taking extra money for “quicker” or “special” service. (This fact was used against the doctors during the strike as the police stepped up arrests of corrupt doctors.) Right now that government has decided to legalize this, allowing hospitals to offer “basic” and “special services” and setting up a list of state-covered medical treatment and treatment which should be paid out of pocket. So doctors who want to earn more are simply thinking of ways to see more “special patients” who will pay them extra. Or to make time for seeing more private patients, sometimes seeing them at state hospitals and using state-funded equipment.
Many doctors have been conducting deals with hospitals which circumvent government any official agreement and which may be even disadvantageous for other doctors. For example, in at least a couple of hospitals, the fact that the doctors gave their notice meant there was a decision to liquidate hospitals and to merge them with others to be more cost effective. Then some doctors were rehired – but the merged hospitals will have fewer doctors, so some people were not able to negotiate positions. In addition, many of those rehired were hired either through outsourcing companies or were hired back as independent contractors. They agreed to higher salaries but now have to pay social insurance costs themselves and are not entitled to paid vacation or other benefits.
The merging of hospitals can have a terrible effect on patients. For example, one local hospital here in Praga (in the center of Warsaw) is being merged with a hospital in Miedzylesie (on the outskirts) – which is probably about 15 kilometers away.
Even worse, there is now a question about overtime for doctors and moves to circumvent limits. Last year, in a landmark case, a doctor won a case and got back payment for overtime. In many hospitals, doctors can work 60 or 80 hours a week whereas EU law perscribes a maximum of 48 hours and sets out requirements for breaks and vacation given when doctors work long shifts. Since EU authorities found the practice in Poland to be in contradiction to EU laws, the authorities have been shitting in their pants about the amount of lawsuits they might face. They have been discouraging these lawsuits by any means possible, including illegal ones – for example recently they sent doctors who started lawsuits on long vacations in lieu of overtime payments with clear signals that they’ll have no jobs to come back to. There is currently legislation being adopted by parliament which would allow doctors to “waive their rights” to the 48 hour limits. The response of the OZZL to this is disturbing: while encouraging doctors not to sign such waivers, Bukiel says that these waivers should be used to negotiate higher salaries – in other words, it’s OK if you work 80 hours a week, provided you’re getting paid for it.
Talking to people from the nurse’s union, we heard a different story. They were against the privatization of hospitals and also criticized contract work. The agreed that some people working on contracts received more money – but they said that they tended to work harder and longer to get it. In the worst case scenarios, some nurses who worked on contracts ended up worse off than those regularly employed by hospitals.
Privatization by the Back Door
Although the populist government ostensibly is against privatization of health care, it is clearly continuing the policies of the former government to promote private health care solutions through a combined strategy of negligence and gradual legislative measures. Currently, about half of the population has private insurance and even more count on private medical services if something goes wrong. That is because the state has been so negligent of the health care system that one cannot rely on it in case of need. In many cases, the queues for treatment are so-long that care cannot be given on time leading to long-term or irrevocable health probelms. In some cases, treatment is simply not available in public hospitals or medicines and equipment, one is told, can only be procured by extra payment. In many more simple cases, working people simply cannot afford to take entire days off to wait in the queue at poorly organized clinics without even any guarantee of being seen. The tax system encourages people and businesses to buy private insurance by allowing deductions.
The other way of forcing people into private health care is by liquidating their hospitals or certain units in them.
Amazingly, the government still pretends it supports a functional health care system. During the strike, they even went to far as to blame greedy health care workers for threatening the system.
It looks like in the future that the people will have to deal with a poorer version of the American model – with many times less funding, worse technology and a smaller labour pool. Those who are lucky enough to have private insurance will use it but will be due for many rude awakenings when faced with more serious problems. (Somebody I know, who has a rather expensive policy had to have an operation and found out that a. there are no facilities in this city to do it – he’d have to go to Lodz – and b. that he’d have to make a large payment. Still he’s happy that at least he’ll get the operation. And he can afford it. He’s in the top 5% income bracket.)
Large portions of society will remain uninsured since they won’t be able to afford it. They’ll use health care only when faced with an emergency and will let some problems go undetected. (We’re already seeing rising incidence of this. For example, there is an alarming trend in post-natal problems which doctors ascribe to the liquidation of free pre-natal care in many hospitals.) Public health care will increasingly be the poorer-quality option for those with no choice.
The brain drain will continue with even larger portions of health care workers, trained with public funds, going abroad to work. Some health care workers will remain dangerously overworked as they work overtime to earn extra money and keep up with prices in a society which has increasing consumer expectations. The future for all of us doesn’t look very bright at all.