Introduction
The IOWISZ health system investment assessment system, introduced in 2016, aims to rationalize investments in the Polish health sector by directing public and private funds where they best meet social needs. Fulfilling Mark Moore’s concept of public value, the system is based on transparent evaluation criteria that support the public mission, equitable distribution of resources, and benefits for patients. However, challenges such as the lack of linkage between a positive IOWISZ assessment and the National Health Fund contract and inequalities in access to investments between large and small facilities limit its effectiveness. This article analyzes how IOWISZ implements public value, identifies key issues, and proposes solutions to increase the system’s effectiveness.
The Problem
IOWISZ, the Health Sector Investment Application Assessment Tool, was introduced in 2016 in response to critical assessments of the effectiveness of public investments made, particularly under the 2007-2013 Community Cohesion Policy, which often served particular interests rather than the public interest. However, how can we distinguish public interest from private interests and ensure that particular ambitions do not overshadow public goals?
In his groundbreaking book, Creating Public Value: Strategic Management in Government (1995), Mark Moore introduced the concept of public value. It means equitably creating good for individuals and communities, responding to their needs, while respecting and recognizing the contribution of each individual. In the monograph, Recognizing Public Value (2013), Moore expanded on this idea, proposing, following the example of the Balanced Scorecard development method, a proven business model, the Public Value Scorecard, a tool for sustainable public management in the spirit of public value, taking into account the organization’s mission, fairness of action, and stakeholder satisfaction. In this approach, public value is the benefits and results delivered by public institutions in response to societal needs, consistent with their mission. The IOWISZ system is intended to fulfill this mission, but its effectiveness depends on factors not yet regulated and is therefore susceptible to political pressure and advocacy from various interest groups.
Theoretical Assumptions
Analyzing healthcare investment from the perspective of Moore’s Public Scorecard, the primary goal of the IOWISZ system is to organize healthcare investments and ensure rational and efficient spending of public funds in the context of the public mission, equitable distribution of resources, and benefits for patients and medical staff. The IOWISZ application takes all these perspectives into account. After submission, the Minister of Health and voivodes issue opinions on the investment’s advisability after consultation with the National Health Fund. A positive assessment indicates the project’s alignment with local healthcare needs in the spirit of Moore’s public value approach, while a negative assessment indicates a misalignment with healthcare policy priorities, health needs maps, and transformation plans.
This system is designed to counteract haphazard, unjustified investments by supporting the better allocation of public funds. In this approach, IOWISZ supports the creation of public value because investments are generally directed to those with genuine social need.
Operational Practice
The IOWISZ system operates under the provisions of the Act on Healthcare Services Financed from Public Funds and is supported by the Ministry of Health, provincial governors, and the National Health Fund (NFZ). The participation of stakeholders, such as the directors of the NFZ’s provincial branches, is intended to ensure social and political legitimacy. The evaluation criteria are based on publicly available documents, which increases transparency and public trust. However, it is worth emphasizing that a positive IOWISZ assessment does not guarantee a contract with the NFZ, as funding depends on additional factors such as budget, regional priorities, and the availability of resources. As Moore predicted, the agreed public value in the public health system must still be formally legitimized and supported by a contract with the NFZ. If a facility implements a costly investment based on a positive IOWISZ assessment but fails to secure funding, this can seriously threaten its financial stability, hinder its development, and reduce public trust. This indicates the need for better coordination between the IOWISZ assessment and the NFZ contracting process. The proposal to formally link a positive IOWISZ assessment to a contract promise with the National Health Fund (NFZ) has been repeatedly raised in the public domain, but has yet to receive legislative approval. As Robert Mołdach pointed out in a report commissioned by the European Commission, “External expertise on European Structural and Investment Funds Implementation in the healthcare sector in Poland” (2019), this would require increased decision-making power for the national payer, which, however, goes beyond current political consensus.
In practical terms, the IOWISZ system functions as an IT tool enabling the evaluation of applications according to precise point criteria (e.g., 6,200 points for investments expanding the scope of services). This process takes place within a clearly defined timeframe – the voivode has 45 days to issue an opinion.
However, the system also generates inequalities. Larger entities, with better financial and expert resources, can outsource the preparation of professional applications to consulting firms, increasing their chances of success. However, smaller facilities, especially those struggling financially, often lack the resources to prepare applications that meet stringent requirements. This leads to their rejection and, consequently, deepens inequalities in access to investment and healthcare.
Summary:
The IOWISZ system contributes to building public value by aligning investments with health-related goals.tne i kierując je zgodnie z potrzebami społeczeństwa. Jego mocne strony to transparentność, określone kryteria i automatyzacja. Wymaga jednak usprawnień:
- lepszej integracji z procesem kontraktowania w NFZ, aby uniknąć ryzyka niewykorzystania pozytywnie ocenionych inwestycji,
- wsparcia mniejszych świadczeniodawców, aby zmniejszyć nierówności w dostępie do środków i zwiększyć szanse na realizację potrzeb zdrowotnych w mniej uprzywilejowanych regionach.