Articles

Szymon Brzósko, Robert Mołdach

Diagnosis of the Supreme Audit Office

The 2025 report of the Supreme Audit Office (NIK) on the organization of care for people with chronic kidney disease (CKD) highlights the scale of the structural gaps that prevent the Polish healthcare system in this area from embarking on a trajectory of modern, planned, and proactive care [1]. NIK emphasized, in particular:

• Too low a rate of early diagnosis (a large difference between the number of people actually diagnosed and the epidemiologically estimated population),
• lack of uniform treatment pathways during the predialysis period,
• late referral to a nephrologist,
• high rates of renal replacement therapy (RRT) initiated urgently,
• excessive reliance on temporary central venous catheters (CVCs) at the start of hemodialysis,
• limited use of peritoneal dialysis (PD) as a home treatment method, and
• persistent regional differences in the availability of transplant preparation.

The report highlighted coordination deficits between primary care and nephrology, insufficient systemic patient education, fragmented digitalization (lack of interoperable, consistent clinical and administrative data streams), staffing shortages, and the lack of a coherent set of publicly reported clinical quality indicators. In the background, there remains a high burden of premature deaths and costs that could be avoided with optimal and earlier implementation of nephroprotective therapies. This is not a collection of isolated shortcomings – rather, it reflects a system focused, albeit ineffectively, on the end-stage stage of the disease, rather than on effective management of the chronic kidney disease (CKD) continuum from the early stages of the disease [1,2].

The Public Value Triangle of CKD Diagnosis and Treatment

In the context of the Supreme Audit Office (NIK) diagnosis, the Public Value approach, as conceptualized by Mark H. Moore [3], provides a methodological framework that provides direction for the transformation of the system for the diagnosis and treatment of patients with CKD. This framework spans the three corners of Moore’s strategic triangle. The first corner is created by identified, agreed-upon public value, shared by all stakeholders, beneficiaries, and also bondholders bearing the cost of the necessary transformation. The second corner is the political legitimization of public value – recognizing it as a significant socio-economic problem that deserves the financial and organizational support from state institutions necessary to achieve the assumed goals. The third corner represents the implementation capabilities of the state and stakeholders necessary to transform intentions into real actions on a scale that changes the status quo.

From this perspective, the first question that should be asked is whether the diagnosis and treatment of patients with CKD constitute a collectively valued public value. Although the clinical answer seems obvious, the Supreme Audit Office (NIK) report states:

In Poland, there were no programs or organizational standards for the care of patients with chronic kidney disease specifically aimed at early detection of this disease.

While the mere existence of appropriate CKD care programs could be considered an element of legitimization, support, and the state’s enforcement capacity, the development of organizational standards is an element of the process of identifying and agreeing on public value. If solving the problems of patients with CKD were indeed a collectively valued public value, such standards would be developed and agreed upon by stakeholder groups, including those with differing perspectives on how to address the problem. The reasons for the lack of consensus on these standards lie in the predominance of vested interests and the lack of political will to address this challenge, which constitutes what Moore calls Public Spirit—the indispensable willingness and enthusiasm of citizens or stakeholders to actively contribute to the achievement of a defined public goal.

As was to be expected, these phenomena impacted the legitimization and support of public value. The problems and limitations of early diagnosis and care for patients with CKD were not addressed in the state’s strategic documents. The Supreme Audit Office (NIK) describes this as follows.

Despite the Health Needs Maps diagnosing a problem with early CKD diagnosis and care for patients with this disease, this issue was not addressed in the national strategic documents prepared based on this Map, and organizational standards related to the care of patients with CKD were not introduced. The National Transformation Plan for 2022–2026 addresses kidney disease only in the context of palliative and hospice care, indicating that the scope of conditions eligible for treatment in this area should be expanded to include heart failure and chronic renal failure as a priority. However, it did not sufficiently address preventive measures aimed at detecting this disease in its early stages. Furthermore, kidney disease was included in the document “Healthy Future. Strategic Framework for the Development of the Healthcare System for 2021–2027, with an Outlook to 2030” under the category of other diseases important to public health.

Finał tych zdarzeń na poziomie zdolności wykonawczych państwa był na gruncie teorii Moore’a łatwy do przewidzenia. Chociaż, jak informuje raport NIK, między 2021 a 2024 rokiem liczba poradni nefrologicznych wzrosła o 10%, to średni czas oczekiwania na wizytę w poradniach: nefrologicznej oraz nefrologicznej dla dzieci w tym czasie istotnie wydłużył się, zarówno dla przypadków stabilnych, jak i pilnych. W przypadku tych ostatnich u dzieci ten czas wzrósł z 40 do 70 dni, a dorosłych 27 do 55 – to dwukrotny wzrost czasu oczekiwania. Jeżeli nałożyć na ten obraz nierównomierne rozłożenie poradni nefrologicznych, gdzie w województwie małopolskim na jedną poradnię przypadało 245 tys. mieszkańców, a w województwie łódzkim 124 tys., z jeszcze większymi dysproporcjami w zakresie leczenia nefrologicznego w oddziałach nefrologicznych, gdzie cztery województwa nie posiadały żadnego oddziału szpitalnego, możemy dostrzec, jak bardzo są ograniczone zdolności państwa realizacji polityki publicznej w zakresie diagnostyki i leczenia PChN.

Given the lack of an agreed-upon public value for CKD, competing health priorities, and limited state implementation capacity, it is hardly surprising that changes in the organization of care for patients with CKD receive only partial support from the Ministry of Health. Changing this situation requires, first, agreement on collectively valued outcomes and methods for achieving them, including support from groups not directly interested in reforming this area due to limited public funds, the costs of transformation, and the political attention that would be required to legitimize the proposed changes.

Public value is not just about improving individual clinical indicators, but also the simultaneous achievement of: (1) measurable health benefits for the CKD population (slowing down the rate of decline in renal filtration function (eGFR); reducing hospitalization rates; increasing the proportion of planned, safe RRT starts), (2) reducing regional and social inequalities, and (3) building legitimacy—that is, the acceptance and trust of stakeholders—along with establishing the operational capacity to sustainably deliver these outcomes. Expert statements emphasize that without parallel investment in legitimization (transparent data, co-creation of quality indicators that incorporate the patient’s perspective and experience) and operational efficiency and effectiveness (coordination of care for patients with CKD, data infrastructure), even the best declarations “disappear into organizational silos” devoid of real collaboration [2,4,5].

Value-Based Healthcare and Public Value

The concept of value-based healthcare (VBHC) expands this approach with precise measurement logic and a multidimensional definition of value, based on four interrelated perspectives (the so-called Quadruple Value Model). According to the EXPH report [6,7], value in VBHC is not only the relationship between clinical outcomes and costs, but a comprehensive construct encompassing: (1) personal value – providing appropriate care tailored to the patient’s individual goals and preferences, measured, among other things, by: through Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs), which emphasizes the importance of shared decision-making and avoiding unnecessary interventions; (2) technical value – achieving the best possible results with available resources for the entire group of patients with a given disease, using indicators such as Quality-Adjusted Life Years (QALYs) or Incremental Cost-Effectiveness Ratios (ICERs), in order to minimize waste and unjustified variability in clinical practices; (3) allocative value – fair distribution of resources between different patient groups and diseases, eliminating “inequity by disease” and socio-demographic disparities, assessed qualitatively at the level of social dialogue and quantitatively through budget measures and indicators of disparities in clinical outcomes; and (4) societal value – the contribution of healthcare to social cohesion, participation, and solidarity, measured, for example, through Health Impact Assessments (HIAs) and social productivity indicators, which emphasizes the role of health as a source of collective well-being.

In the context of chronic kidney disease, the value-formation cycle does not begin with the first dialysis or the entry into stage 5 of the disease, but much earlier, with established albuminuria, a persistent reduction in eGFR <60 ml/min, or an accelerated rate of decline. This requires integrated care encompassing all the discussed VBHC perspectives, from early prevention to post-diagnosis social support.

Experts aptly note that “without integrated care for this demanding disease, there is no value, only firefighting.” This reflects not only the enormous cost and clinical variability of unplanned RRT starts [6,8] but also illustrates broader disparities, such as regional differences in access to nephrology care (including key elements such as ensuring testing for kidney transplantation and adequate vascular access for dialysis), highlighted in the Supreme Audit Office report [1]. Assessing challenges and resolving issues within the four perspectives of VBHC, however, is impossible without looking through the lens of public value as conceptualized by Mark H. Moore, whose strategic triangle—comprising agreed-upon public value, political legitimacy, and implementation capacity—gives direction and crystallizes actions in the context of social solidarity.

Starting from the personal perspective of VBHC, focused on tailoring care to individual patient goals, challenges such as late referrals to nephrologists and lack of patient education require not only measurement tools such as PROMs but also the mobilization of stakeholders and the enthusiasm of co-creating standards, which are an integral element of Moore’s Public Value Chain (PVC), a method for identifying and agreeing on public value [9]. In the analyzed case, this process unfolds spontaneously at the level of dialysis centers, outpatient clinics, and nephrology departments, but not in a structured manner at the strategic level of the Ministry of Health.

From a technical perspective, focused on the efficient use of funds and resources, waste results from errors in their distribution and fragmented processes. The lack of consistent indicators and data limits the state’s corrective and enforcement capacity. The lack of objective evidence also hinders the legitimization of complex decisions within Moore’s strategic triangle [3]. For example, the directors of the National Health Fund’s provincial branches did not have data on the distance patients travel to dialysis treatments because contracts did not require providers to report such data [1]. However, if data exchange at the national level and system interoperability, along with tailored quality indicators, were ensured, it would be possible to manage the territorial distribution of dialysis facilities. Similarly, a dialogue on public value, in the spirit of Moore [3,9], could enable more precise expenditure planning and avoid situations such as the 1273% overestimation of costs in 2021 and the incorrect financing of correction factors amounting to PLN 46.5 million for 2022–2024 in the “Prevention 40 PLUS” pilot program. These issues would simply become more important and could prompt legislators to adopt solutions that reduce the risk of wasting public funds.

The allocation perspective reveals regional disparities in nephrology clinics, as described in the introduction, and opens the door to a discussion about the distribution of funds within the National Health Fund budget. However, any change in this area requires strong political legitimacy, as defined by Moore’s strategic triangle [3]. This legitimacy will not be achieved unless, at the level of social dialogue between supporters and opponents of a given solution, there is consensus on the jointly valued outcomes that constitute public value. Increasing one element of financing limits the growth of financing in other areas. In conditions of conflicting interests, the only way to reconcile opinions is to conduct a Public Value Account, without which, in such a sensitive area as health care, change will be impossible [9]. This is the only way to avoid “inequity by disease” and effectively redirect resources from palliative care to prevention, or from other areas to nephrology care.

Ultimately, the social perspective of VBHC, crucial to the European model of solidarity, cannot be assessed without tools for evaluating and improving public policies. How can we measure the contribution of renal care to social cohesion, for example, by reducing the isolation of patients with CKD through home-based peritoneal dialysis (PD) or transplant preparation [10,8], without an agreed-upon public value that engages citizens and bondholders in building legitimacy? This should be done in an iterative process, divided into stages, where the first is the identification of good problems (Good Problems), understanding their complex nature and sources, and analyzing gaps at the level of the AAA triangle – acceptance of goals (Acceptance), authorization of solutions (Authorization), and the ability to implement such a public policy (Ability) [11]. The next step should be analyzing the solution map and selecting those with the appropriate degree of feasibility and effectiveness [12]. Without such an approach, incomplete public policies most often produce fragmented and unsustainable results [13], failing to translate, as in this case, into measurable population benefits, such as slowing the decline in eGFR or reducing complications and hospitalizations [14,15], and reducing them to mere “firefighting” in organizational silos [5].

Thanks to the aforementioned set of tools [3,9,11-13], VBHC in its four dimensions becomes a comprehensive method for realizing public value. The transformation of nephrology care – from reactivity to proactivity – gains not only clinical but, above all, collective consent and legitimacy, serving to strengthen the health system’s implementation capacity. Moore’s public value lens allows for the operationalization of the VBHC approach in the social and political dimensions, highlighting the interconnectedness of these conceptual frameworks in building a sustainable health system.

Integrated and Coordinated Nephrology Care

The core of the transformation should be integrated, coordinated nephrology care – a structure with a clearly defined clinical trigger for entering the “advanced/high-risk CKD” program (e.g., eGFR <45 ml/min/1.73 m² with moderate or severe albuminuria – A2/A3; eGFR <30 ml/min/1.73 m² regardless of albuminuria; documented rapid decline in filtration; persistent A3 albuminuria despite therapy). Once this criterion is met, the patient does not “drift” between visits and specialists, but the system initiates a structured package of interventions with a predetermined sequence and standard, addressing multiple but known clinical challenges. Without such a threshold and protocolized mechanism, the system always “delays intervention” – such a diagnosis well explains why so many actions are currently undertaken only in conditions of decompensation [8,10].

The task of coordination is not to administratively “send documents,” but to manage the value stream: ensuring that all modules are launched and closed at the appropriate time. These modules include, among others: optimizing nephroprotective therapy (renin-angiotensin-aldosterone system inhibitors (RAASi); sodium-glucose cotransporter type 2 inhibitors (SGLT2i); mineralocorticoid receptor antagonists (MRA); controlling metabolic acidosis; preventing and treating hyperkalemia, and others); in the later stages of the disease, treating renal anemia according to applicable guidelines; managing mineral metabolism disorders; preparing vascular access for dialysis or qualifying for PD; early transplantation qualification; nutritional interventions; frailty assessment and psychosocial support; and systematic education with elements of shared decision-making. It is essential and invaluable to shift competencies from passive CKD surveillance to active management of its complex continuum [8,10,14,16-18].

The mechanism for creating public value is multi-layered and mutually reinforcing. First, slowing progression (maintaining full doses of nephroprotective therapies, reducing albuminuria, controlling blood pressure and acid-base balance) postpones the initiation of renal replacement therapy and reduces cardiovascular risk. Second, planned preparation for the initiation of RRT (informed choice of therapy type, planned establishment of dialysis access, transplant qualification before initiation of dialysis, and the option of family transplantation) lowers the rate of emergency initiations and reduces CVC-related infections, hospitalizations, and their complications. Third, systematic collection of PROMs (e.g., quality of life, symptom severity, fatigue, pruritus, therapy burden) increases adherence because the patient sees that their experience is being measured and adjusted. Fourth, transparent reporting with risk adjustment enables the identification of areas with the greatest gaps and the targeting of corrective actions/expenditures (targeted equity interventions) there [2,4,5,6,14].

For such a framework to be credible, a data layer is essential. The term “nervous system” used by experts reflects the role of interoperable streams: laboratory data (eGFR, albuminuria), primary care data (list of medications used, comorbidities), payer data (hospitalizations, costs, frequency of use of individual services), clinical data from nephrology centers (type of renal replacement therapy, type and status of vascular access, transplant status), and PROMs (patient-reported outcomes). These data are used to create near-real-time monitoring mechanisms – for example, an alert for accelerated eGFR decline (defined as a rate of loss >5 ml/min/1.73 m²/year) or an alert for an “incomplete predialysis module” (no documentation of transplant qualification within a specified time window). Only such an architecture allows for reliable risk segmentation – that is, systematic grouping of patients according to the predicted probability of specific events (e.g., transition to RRT within 12 months, cardiovascular hospitalization, unplanned start of dialysis). Risk segmentation is not an end in itself; its function is to allocate resource intensity (e.g., emphasis on appropriate educational elements, prior surgical consultations, prioritization of dietary interventions, etc.) to those patients for whom the marginal benefit of additional intervention is greatest [2,4,5,8,14].

Order in the Logic of Intervention

At this point, it is worth explaining several key concepts that structure clinical management and measurement reliability:

1/ Undercoding clinical complexity refers to a situation in which the full spectrum of comorbidities, risk factors, or clinical parameters is not incorporated into coding systems (e.g., failure to record cardiovascular disease, diabetes with complications, frailty syndrome). This results in distorted risk models, inappropriate adjustments to results for patient clinical complexity, and potentially unfair evaluation of centers when comparing their treatment outcomes. Underreporting—if not monitored—can also create incentives for risky management behaviors (similar to “cream skimming,” i.e., selectively favoring less clinically challenging patients with fewer comorbidities) [2].

2/ Transparent indicator specifications are publicly available documents describing for each indicator: data sources, calculation algorithm (including inclusion and exclusion criteria), definitions of numerators and denominators, follow-up period, risk adjustment principles, and interpretation constraints. Their function is threefold: (a) enabling replication (each stakeholder can independently reproduce the result), (b) limiting the scope for data manipulation, and (c) strengthening trust and legitimacy in the reporting process. Without transparent specifications, even a valid indicator can be questioned at the communication level [2,5].

3/ Risk classification – as indicated above – is the process of assigning patients to homogeneous groups (in terms of their expected clinical course) using variables such as the rate of eGFR decline (slope), albuminuria, age, cardiovascular disease, diabetes, nutritional status indicators, frailty, laboratory parameters (e.g., hemoglobin, potassium, bicarbonate), and adherence indicators. In more advanced stages of the disease, machine learning models can be used, but in the pilot phase, point scales and simple thresholds (tiering) can be the basis [8,15].

Legitimization—that is, social and institutional agreement on how resources are allocated—increases when results are presented clearly and honestly. This is facilitated by a public, understandable dashboard with key indicators and by genuinely involving patients in choosing what we measure in PROMs and what we consider important treatment outcomes for the patient. Experts point out that such a dashboard “embodies” the promise of coordination: it makes progress—or lack thereof—truly visible, instead of merely talking about it. [2,4,5]

The management model should simultaneously address four risks that often arise when implementing value systems: (a) selection of lower-risk patients (cream skimming), (b) underreporting of complexity (discussed above), (c) inflation or overload of the indicator set (leading to a dilution of priorities), and (d) erosion of trust due to a lack of transparency in methods. Countermeasures include: explicit clarification of indicator definitions; auditing of key indicators – e.g., the rate of emergency RRT starts, CVC participation by day 90 of therapy, the percentage of patients with a complete “predialysis” module; a stakeholder council (patients, clinicians, analysts, payer, social organizations), and periodic reviews of risk adjustment methods. Transparency is not a PR perk, but the “fuel of legitimization” [2,5].

Public Value Roadmap

As a result, the proposed change is not simply adding new procedures to the existing, reactive care stream, but redesigning the entire CKD continuum management cycle toward early capture of disease dynamics, planned preparation, and consistent and effective use of data. Public Value provides meaning, a social mandate, and a method for working on selected public policy; VBHC organizes the logic of measurement and comparative performance assessment; integrated coordinated care ensures day-to-day feasibility through roles (coordinator), modules (slowing down GFR decline, predialysis, planned RRT initiation, adequate access to dialysis, preemptive transplantation), and data (interoperable streams + PROMs). When these three layers converge operationally, slowing progression, reducing the need for sudden RRT initiations, increasing the use of home dialysis methods, improving patient satisfaction and safety, and reducing regional disparities will cease to be parallel ambitions – they will become mutually reinforcing elements of a single value-delivery system [2,4-6,8,10,14].

References

1. Supreme Audit Office. Organization of care for people with chronic kidney disease (CKD) in Poland: post-audit report 2025. Warsaw: NIK; 2025. Access: https://www.nik.gov.pl/kontrole/wyniki-kontroli-nik/kontrole,25587.html, access date: September 28, 2025.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academy Press; 2001. doi:10.17226/10027
3. Moore MH. Creating Public Value. Harvard University Press, 1995. doi:10.2307/2952401.
4. Teisberg E, Wallace S, O’Hara S. Defining and implementing value-based health care: A strategic framework. Acad Med. 2020; 95(5):682-685. doi:10.1097/ACM.0000000000003122
5. Berwick DM. The science of improvement. CAVITY. 2008;299(10):1182-1184. doi:10.1001/jama.299.10.1182
6. Porter M.E. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024
7. Opinion on Defining value in “value-based healthcare”. Expert Panel on effective ways of investing in health.Publications Office of the European Union, 2019. doi:10.2875/35471. Access: https://health.ec.europa.eu/document/download/634e0a0c-4bff-4050-ad5f-b80381f36f33_en, access date: 5/10/2025.
8. Kidney Disease: Improving Global Outcomes (KDIGO) 2024 CKD Guideline Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024;105 (4 Suppl):S117-S314. doi:10.1016/j.kint.2023.10.018
9. Moore M.H. Recognizing Public Value. Harvard University Press, 2013. doi:10.1002/pam.21776
10. Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164. doi:10.1053/j.ajkd.2019.12.001
11. Andrews M, Pritchett L & Woolcock M. Doing Problem Driven Work. CID Faculty Working Paper 2015.307. Andrews, Matthew; Pritchett, Lant; Woolcock, Michael; and the President and Fellows of Harvard College, 2015.
12. Andres M, Pritchett L & Woolcock M. Doing Iterative and Adaptive Work. CID Faculty Working Paper 2016.313. Andrews, Matthew; Pritchett, Lant; Woolcock, Michael; and the President and Fellows of Harvard College, 2016.
13. Andrews M.  Successful Failure in Public Policy Work. CID Faculty Working Paper Series 2021.402, Harvard University, Cambridge, MA, December 2021.
14. Mapes DL, Lopes AA, Satayathum S, McCullough KP, Goodkin DA, Locatelli F, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int. 2003; 64(1):339-349 doi:10.1046/j.1523-1755.2003.00072.x.
15. Tonelli M, Wiebe N, Guthrie B, James MT, Quan H, Fortin M, et al. Comorbidity as a driver of adverse outcomes in CKD: A systematic review and meta-analysis. Kidney Int 2015;88(4):859-876. doi:10.1038/ki.2015.228
16. Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, et al.; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446. doi:10.1056/NEJMoa2024816
17. Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, et al.; FIDELIO-DKD Investigators. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-2229. doi:10.1056/NEJMoa2025845
18. Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M, et al.; EMPA-REG OUTCOME Investigators. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med. 2016;375(4):323-334. doi:10.1056/NEJMoa1515920

Gabriela Moczeniat

The National Health Fund (NFZ) plays a fundamental role in the Polish healthcare system, fulfilling a key role in the organization and financing of medical services. Its main responsibilities include contracting services and distributing funds to healthcare providers. This system is intended to guarantee equal access to medical services and ensure financial stability for hospitals, clinics, and other healthcare facilities. This is crucial for their effective operation. In theory, this mechanism should create a coherent and sustainable ecosystem in which patient needs are met and healthcare providers can carry out their tasks without worrying about financial liquidity.

However, the reality proves much more complex and far from the intended goals. Medical facilities in Poland face numerous barriers that hinder their mission to promote public health.

The NFZ’s healthcare financing system, despite its intended purpose, does not fully meet expectations in terms of stability and efficiency. Delays in payments, especially for services performed above the limit, the lack of full reimbursement of these services, and the lack of adequate procedure pricing lead to chronic underfunding of medical facilities, which threatens the quality and accessibility of healthcare in Poland. Furthermore, late payment of obligations to contractors resulting from delays in the Fund’s transfer of funds results in interest accruing, which burdens facility budgets. Another significant challenge is the misalignment of pricing for medical procedures financed by the National Health Fund (NFZ) with statutory salary increases for medical staff, which generates additional financial pressures and limits the investment capacity of healthcare institutions. These problems stem from the growing funding gap in the National Health Fund (NFZ). According to the report “10 New Sources of NFZ Financing,” prepared by the SGH Think Tank for Healthcare, the projected funding gap in the NFZ, i.e., the difference between statutory expenditures and available funds, will amount to approximately PLN 111.4 billion between 2025 and 2027. The reasons for this deficit are varied, ranging from rising costs related to wages, an aging population, and the need to finance modern medical technologies, to an expanding benefit package and declining revenues from contributions from self-employed individuals. This article discusses the effects of the current financial gap in the healthcare system, felt by both patients and providers. It also discusses possible directions for change that could gradually reduce the financial gap in the healthcare system.

Problems with timely payment of National Health Fund (NFZ) funds

One of the most serious challenges healthcare providers face is delays in payments from the National Health Fund (NFZ), especially for so-called overpayments, i.e., medical services provided beyond the limits specified in contracts. In practice, overpayments are unavoidable, as hospitals and clinics cannot refuse care to a patient requiring medical intervention or suspend operations, for example, mid-year, simply because they have reached a contractual limit. Limiting themselves solely to the provisions of the NFZ contract would mean depriving many patients of access to essential healthcare services. Therefore, healthcare providers, guided by concern for the common good, provide additional services, prioritizing universal access to treatment over economic considerations. They act in the name of the public value of ensuring equal and universal access to treatment. This is an expression of concern for the health of society, as its absence would result in enormous harm, not only to the medical health of individual patients, but also to the social and economic well-being of the entire country. The problem, however, is that the National Health Fund (NFZ) often settles these payments with significant delays, often only after many months. This applies to unlimited services, such as oncology procedures or some outpatient specialist care services, the financing of which stems directly from the National Health Fund’s statutory obligations (Article 136 of the Act of August 27, 2004, on Healthcare Services Financed from Public Funds (Journal of Laws of 2004, No. 210, item 2135, as amended).

In the case of limited overpayments, such as hospital services outside the field of oncology, the Fund sometimes covers only a portion of the receivables, ranging from 50% to 70%. Furthermore, according to recent statements by NFZ President Filip Nowak, full settlement of overpayments of limited services is not planned in the near future, and the period of full financing of such services was an exception related to additional financial reserves following the COVID-19 pandemic.

Settlement of limited overpayments occurs only after the close of the fiscal year, meaning facilities receive payment proposals only in the second quarter of the following year. Often, they receive reduced payments, such as 50% of the funds for services earned over the limit, only in the second half of the following year. In the meantime, they must finance patient treatment from their own funds or take out loans, leading to mounting debt and a risk of financial insolvency. Paradoxically, while fulfilling their ethical obligation to save the health and lives of patients, healthcare providers are falling victim to an inefficient financing system.

It is important to emphasize that delays and incomplete settlement of overpayments by the National Health Fund (NFZ) force medical facilities to act against their own financial stability, demonstrating the urgent need for reform of the healthcare financing system to support, rather than burden, entities fulfilling their public mission.

Interest charged by contractors

Delays in the settlement of overpayments by the NFZ generate serious financial consequences for medical facilities. Entities waiting months for funds owed lose their ability to timely settle their obligations to suppliers of medicines, medical devices, equipment maintenance, and related services. As a result, contractors, concerned about their own financial liquidity, charge statutory default interest. Responsibility for these additional costs, a direct consequence of the National Health Fund’s delays, falls solely on medical facilities, which, in fulfilling their public mission, must cover them from their own budgets.

As a result, funds that could be allocated to treating patients, modernizing infrastructure, or purchasing modern equipment are instead diverted to servicing these obligations. Instead of supporting public health, this financing mechanism paradoxically undermines it, burdening facilities with costs resulting from a flawed system.

This begs the question: Why is the National Health Fund (NFZ) not responsible for the resulting damage? After all, it not only financially destabilizes medical facilities but also limits their ability to fulfill their healthcare mission, thus undermining the common good.

Annual Pay Raises for Medical Staff and National Health Fund (NFZ) Pricing

For a decade, Poland has had a statutory mechanism for annual salary increases for medical staff. From a public value perspective, this solution is fully justified, as doctors, nurses, paramedics, and diagnosticians fulfill a mission of fundamental social importance and deserve decent working conditions. The idea of ​​pay raises also remains valid because for many years, salaries in the healthcare sector remained significantly lower than the European average, which led to staff frustration and contributed to the exodus of medical staff to the West.

The problem, however, is the lack of linkage between rising labor costs and the pricing of medical procedures set by the National Health Fund (NFZ). The state obliges hospitals to pay raises without providing sufficient funds to finance them. As a result, medical facilities are struggling with a growing gap between revenues and costs, forcing them to seek savings or incur debt instead of investing in development and improving the quality of services. The lack of systemic cohesion undermines the noble goal of raising employment standards in healthcare, and the costs of achieving this common good are shifted onto already struggling institutions.

It should be noted that some voices point to the harmfulness of this law. Therefore, meetings were held between representatives of the Presidium of the Tripartite Group for Healthcare regarding the future of the Minimum Wage Act in Healthcare. Available information indicates that key meetings took place in June and July 2025. These meetings did not yield any final decisions. The discussions focused on the need for changes to the Act due to its impact on the finances of the National Health Fund (NFZ) and hospitals, but the parties (trade unions, employers, and the Ministry of Health) often have divergent positions.

Consequences for Patients and the System

Underfunding, delays in payments for overpayments, and the failure to adjust medical procedure pricing to rising costs, including statutory staff salary increases, are leading to a profound destabilization of the healthcare system. These effects are felt most acutely by patients, who struggle with lengthening wait times for healthcare services due to the limited number of procedures financed by the National Health Fund (NFZ). A lack of funds for investment in modern equipment and hospital infrastructure limits the quality and access to care, while the need to repay interest on late payments to contractors consumes funds that could be allocated to facility development. Furthermore, the financial instability of the system discourages medical specialists from working in the public sector, leading to an outflow of personnel to the private sector and a decline in the quality of treatment. As a result, the foundation of the public healthcare system—equal and universal access to services—is gradually weakening, threatening the health security of citizens and the common good.

Possible New Financing Sources

The problems mentioned are undoubtedly a result of the insurance funding gap in the National Health Fund (NFZ). The authors of the report “10 New Sources of Financing for the National Health Fund” by the SHG Think Tank for Healthcare calculated that the insurance funding gap will total approximately PLN 111.4 billion between 2025 and 2027, which will exacerbate the aforementioned problems. Therefore, the goal of healthcare policy should be to implement corrective measures that will reduce the funding gap in the coming years.

The SGH Think Tank for Healthcare report presents several possible corrective measures. One of these is increasing the health insurance contribution. It is assumed that increasing this contribution by 0.25 percentage points annually for four years and limiting eligibility for preferential insurance with the Agricultural Social Insurance Fund (KRUS) could generate approximately PLN 36.6 billion in additional revenue between 2025 and 2027. However, this burden would fall primarily on employees and the self-employed.

The second proposal is to introduce a health insurance contribution partially financed by employers. A new contribution of 2.5 percent of gross salary paid by companies could contribute approximately PLN 41.9 billion to the National Health Fund (NFZ) budget between 2025 and 2027. This solution would bring Poland closer to the models in place in many European Union countries, but it would also mean higher labor costs.

Another measure that could increase revenues is extending and equalizing the retirement age for women and men to 65, and ultimately to 67. This change would increase the share of working people in the number of retirees and could generate an additional PLN 5.7 billion between 2025 and 2027.

The report also highlights the need to finance contributions for children from the state budget. Currently, approximately seven million children benefit from healthcare without paying contributions. Implementing a solution where their insurance would be financed from the state budget could generate an additional PLN 16 billion annually, or approximately PLN 48 billion over the three-year period under review.

Slightly smaller, but still significant, revenues could come from increasing the so-called “children’s pension contribution.” Taxes on “health sins” such as sugar, alcohol, and tobacco taxes, as well as the introduction of new levies, such as the fat tax, could also generate additional funds through co-payment mechanisms for selected services and the development of private health insurance. Collectively, these measures could generate approximately 2–3 billion złoty between 2025 and 2027.

To reduce the financing gap, action will be necessary on many fronts. Raising employee contributions alone will not solve the problem; greater state budget involvement, greater employee and employer participation in system financing, and demographic changes related to longer working lives are necessary. Better cost management and greater spending efficiency will also be important. A combination of these measures can significantly reduce the gap, although each requires political decisions, legal changes, and public acceptance.

Expected effects of the proposed financing changes

Reducing the funding gap in the National Health Fund could pave the way for implementing solutions that would allow healthcare providers to operate sustainably while ensuring broad and safe access to healthcare for the public. Below are key practices that could support such a model:

1. Timely settlement of overpayments, especially in the case of unlimited services, which are unavoidable and require payment under the Act of August 27, 2004, on Healthcare Services Financed from Public Funds. Ensuring predictability in this regard would allow medical facilities to operate stably.
2. The interest cost compensation mechanism, which prevents delays in financing, should generally be avoided, but if they do occur, they should not burden medical facilities alone. Implementing an effective compensation system is essential to ensuring financial stability for healthcare providers.
3. Realistic pricing of medical procedures should reflect actual labor and material costs and take into account annual salary increases for medical staff.

In addition to implementing measures to increase healthcare spending, it is also worth considering reforming the service contracting system. The current model, based on rigid limits, generates overperformance, so more flexible contracts based on the actual health needs of the population could alleviate the problem of facility debt.

The predominance of inpatient treatment and low spending on preventive care and outpatient care make the system less efficient than in Western European countries.6 Countries such as Germany, Denmark, and the Czech Republic are investing more in health, which translates into better access to services and a reduced burden of private costs on patients. Poland plans to increase spending to 7% of GDP by 2027, but proper resource allocation will be crucial. To match Western European standards, we would need to take a long-term view of public health, investing in effective preventive programs and striving for better public health. The goal of such actions would be to raise awareness among Poles about the importance of preventive care, thus reducing the need for late and costly treatment. Only such an approach offers a chance to create a healthcare system that is both efficient and equitable.

Summary

Medical entities providing services to patients under contracts with the National Health Fund (NFZ) are facing increasing financial challenges. The main cause of these growing difficulties is the insurance funding gap, i.e., the difference between the actual costs of healthcare and the funds allocated to its financing, which is widening each year. Delays in payment of due funds are an additional burden, forcing facilities to incur interest charges and rely on revolving credit facilities. Statutory increases in salaries and operating costs, which are not reflected in current pricing for medical procedures, also pose a problem, causing revenues to fail to keep pace with rising expenses. As a result, many hospitals and clinics are teetering on the brink of financial insolvency, and mounting debt is destabilizing the entire system. Unless additional funding sources are activated soon and legislative and organizational changes are implemented, the situation will worsen. Ultimately, patients will suffer, experiencing limited access to services, longer waits and a decline in the quality of healthcare may become commonplace if we do not take corrective action today.

Bibliography

1. Act of August 27, 2004, on Healthcare Services Financed from Public Funds (Journal of Laws of 2004, No. 210, item 2135, as amended).
2. Act of June 8, 2017, on the Method of Determining the Minimum Basic Salary of Certain Employees in Healthcare Facilities (Journal of Laws of 2017, item 1473).
3. Supreme Audit Office, “Hospital Financing by the National Health Fund,” NIK Report, Warsaw 2021.
4. Ministry of Health, “Strategy for the Healthcare System for 2021–2027,” Warsaw 2021.
5. Healthcare System Profile 2023 https://www.oecd.org/content/dam/oecd/pl/publications/reports/2023/12/poland-country-health-profile-2023_80434439/b12d3d03-pl.pdf
6. Raulinajtys-Grzybek, M. Więckowska, B. Świerc, Z. Białoszewski, A. 10 New Sources of National Health Fund Financing. SGH ThinkTank for Healthcare, 2025. https://gazeta.sgh.waw.pl/sites/gazeta.sgh.waw.pl/files/zalaczniki-2025/10-nowychzrodel-finansowania-nfz.pdf

Agnieszka Dubiel

Virtue as a Source of Organizational Development

Let’s start with a question. What does the word “deviation” commonly mean?

For 95% of people, the association will be exclusively negative. Deviation is a deviation from the norm. Derived from the Latin “deviatio,” it means “deviation,” so it doesn’t in itself mean anything negative. We assign specific meanings to words. So why not positive ones?

There is the concept of positive deviance as behavior that deviates from the norm but is perceived by society as beneficial or desirable.

Let’s now consider deviance in the context of an organization like the healthcare system. Like any organization, this one strives to organize and eliminate processes and behaviors that deviate from the norm. Theoretically, it aspires to be exactly in the middle of a continuum—not deviating too far to the left (negative) or right (positive). The moment actions that cause a shift to any extreme state occur, broadly defined resistance begins.

We can consider this using the examples of health and illness. The healthcare system focuses on the state of illness—how to diagnose, how to treat—something inherently negative. The moment we emerge from the state of illness, we disappear from the system. The goal of the process is to bring the patient precisely to the middle of the continuum—to a state somewhat subjectively assessed as well-being. But what next?

Kim Cameron’s rhetoric on organizational improvement features the Latin word “virtus,” meaning virtue/excellence. It is a natural human need to live in accordance with the highest moral standards. Initially, Cameron (2003) included these as compassion, integrity/honesty, forgiveness, trust, and optimism. The list has subsequently evolved somewhat, but the foundation of virtue as a source of excellence and competitive advantage has remained unchanged to this day and likely will remain so.

Unfortunately, our education system, from primary school to university, teaches that the foundation for success is focusing solely on deficits and the hard work required to minimize them. Cameron, however, proves that the key to achieving success, both as an organization and as an individual, is focusing on the positive – on strengthening and developing the ability to cultivate what is good, which Cameron calls “beautiful blossoming.” The effect that appears here as a consequence of multiplying positive behaviors/processes is the so-called heliotropic effect. A natural turning toward the sun, toward light. A process known from the biology of plants, which, as they grow, turn toward light. Every individual, the smallest cell, including the human body, gravitates toward what is bright and good and away from darkness. Naturally, people gravitate toward morality, goodness, and positive energy. And they flee from negativity. We therefore turn to what strengthens us, not weakens us. We are born with a natural tendency to learn based on positive reinforcement and then adapt to the environment we find ourselves in.

Let us consider whether such an effect could ever appear in the Polish healthcare system? Is consensus across divisions possible? Can we create conditions in which healthcare system reform will not be just a technical correction of institutions, but a moral transformation based on the language of virtues and not interests?

How can we turn the Polish healthcare system “toward the sun”?

The current tendency to focus solely on failures must change. We all focus solely on negative deviations, pointing out the mistakes of successive managers. We don’t seek solutions. We look for those responsible.

If we were to use one of the assumptions of the PDIA tool created by public management researchers and practitioners from Harvard Kennedy School, Andrews, Pritchett & Woolcock (2016), we could look at this differently. Part of the PDIA process involves searching for solutions among existing ones, which fall within the scope of so-called hidden practices or positive deviations (practices that are very effective, but not particularly effective). Are there really no actions in our healthcare system worth replicating? No attitudes that would enable the translation of diverse moral intuitions into a single, commonly identified public value in healthcare – a value that will endure regardless of changes in government or current political tensions? The state’s dominant focus on deficits would suggest this. However, if we look at this issue from the perspective of, for example, the development of electronic prescriptions or online patient accounts, the conclusion would be the opposite. The problem is that there are too few such actions that change the status quo by shifting in the positive direction – towards the sun, as we would like to put it –.

Undoubtedly, employing people with exclusively positive traits will not lead an organization to achieve extraordinary results. Why? People who, for example, are guided by kindness, are friendly, and supportive, but do so solely for their own interests, remuneration, or position, will not build a heliotropic effect in the organization. This would be pure manipulation. I will only be good if it benefits me. I will be loyal and act morally if in return I receive a position, a higher salary, or greater power.

For two decades, Kim Cameron has been studying organizations that achieve significant results across all dimensions – revenue, employee turnover, job satisfaction, etc. The results of this research are astonishing, showing that organizations whose organizational culture was based on cultivating fundamental moral principles achieved statistically better financial results, and their customers were more satisfied, cared for, and loyal. Doesn’t sound like healthcare, does it?

It’s not without reason that healthcare system reform is so demanding. It requires a radical shift in approach to what we call public value. Cameron’s aforementioned virtues lie at its foundation. Robert Mołdach (2025), as part of his work on the Agreement for Public Value, proposes using the following set of virtues in the Polish context and in relation to healthcare: forgiveness, compassion, gratitude, trust, optimism, and humility.

Forgiveness allows us not to dwell on accusations and past mistakes. Compassion will allow us to see the human side of disputes instead of dry arguments. Gratitude will rebuild appreciation and respect for the efforts of others, even if they are on the other side of the argument. Trust will provide a sense of stability and certainty that agreements won’t be overturned at the first change of political power. Optimism will open the imagination to the possibility that the system can be better than it is today, not just “less bad.” And finally, humility – the awareness that no one has a monopoly on the truth, and that shared solutions emerge only through dialogue. To turn the health system toward the sun, as Mołdach points out, we need to change our approach, organizational culture, and culture of dialogue, guided by the aforementioned virtues. But what specific actions should be taken in practice, and why is it so difficult?

The Heliotropic Effect in Positive Health System Practice

What prevents the light from reaching the system’s participants, and who is blocking it? In the author’s opinion, this is due to the following phenomena:

• Selfishness and polarization: individual freedom vs. collective responsibility
• hierarchical subordination and administrative pressure
• the decline of authority
• lack of dialogue, openness, and accountability
• the inability to agree on shared values—what we consider to be the common good, cross-party, and timeless

For the heliotropic effect to truly manifest in the Polish healthcare system, it’s necessary to remove the obstacles that keep the sun out of the eyes of system participants and keep them in deep shadow. Among these actions, the author sees:

• Rebuilding trust. Trust that the data we receive is accurate. That promises won’t end with the next term. That doctors tell patients what’s best for their health, not what’s most convenient for the system. This is what the National Health Fund (NFZ) will “hold accountable.” Trust takes years to build and is lost in an instant – that’s why we need a framework of transparency and accountability that doesn’t depend on who’s currently in power. Trust is the foundation of non-partisan stability.
• A return to humility – a virtue rarely associated with power, but absolutely crucial in healthcare. Humility is the recognition that no one has a monopoly on the truth. Not politicians, not doctors, not economists, not patients. Only through dialogue, in which each side contributes their perspective, can lasting solutions be developed. Humility opens the path to community – and without community, reforms will always be partial and short-lived.
• Changing the rhetoric and creating a culture that supports and reinforces good practices, including those derived from the experiences of other countries. This includes introducing mandatory quality monitoring systems, not to punish, but to educate, draw conclusions, and foster a sense of shared responsibility.

Kim Cameron points out that building an organization based on moral foundations and virtues has at least two measurable effects – the multiplier effect (reinforcement) and the buffering effect. The amplification effect is self-sustaining; people are naturally drawn to it. They turn “toward the sun,” are, in a sense, carried by the desire to do good, and want to be an inspiration to others. Organizational productivity increases when moral principles and values ​​are nurtured. Buffering refers to an organization’s resilience to, colloquially speaking, “damage.” Resource depletion, the maze of changing regulations and systems, confusing rules, demanding patients, broken trust, broken relationships, escalating conflicts. Research shows that organizations built on the foundations of morality and virtue are able to resist destabilization attempts much more quickly and effectively and return to balance much more efficiently. Isn’t this the healthcare system we want?

Sources

Universality of the heliotropic effect; Kim Cameron, TEDxUCCS, 2018

Ethics, Virtuousness, and Constant Change by Kim Cameron for Noel M. Tichy and Andrew R. McGill (Eds.) The Ethical Challenge, San Francisco: Jossey Bass. (pp. 85-94)

Cameron, K. (2003). Organizational Virtuousness and Performance. Positive Organizational Scholarship. Chapter 4 (pp. 48-65). San Francisco: Berrett-Koehler

Andrews, M. Pritchett L. & Woolcock, M. (2016) Doing Iterative and Adaptive Work. CID Working Paper No. 313.

Mołdach, R. (2025). Beyond Term Limits, Beyond Divisions – Public Value as a Strategy for Health System Reform. Healthcare Forum, Economic Forum. Institute of Eastern Studies.

Agnieszka Sikorska-Brzozowska

The Disappointment of the MDR

Some time ago, Szymon Brzósko and Robert Mołdach published the article “When Co-Creation Harms: On the Dysfunction of Creating Public Value.” I read it with great interest – not only because the topic is important, but also because it brilliantly illustrates the mechanisms I see every day as a practitioner. My perspective, however, is different – ​​I see all this through the eyes of a medical device manufacturer, and to make matters worse, a manufacturer operating from a so-called third country, namely the United Kingdom.

The European Union’s change of approach – the transition from the MDD and AIMDD directives to the MDR 2017/745 regulation – was intended to address the growing technological, social, and systemic challenges in healthcare. The main impetus was the need to improve patient safety, as patients increasingly use more complex, personalized medical devices, often classified as higher-risk.

For years, directives formed the foundation of the market, but they gave member states too much latitude in interpretation. The result? Inconsistency in oversight, conformity assessment, and product availability. In practice, this could pose a threat to patients – especially in the context of cross-border trade in devices.

The MDR was supposed to change this. It introduced direct applicability of regulations in all EU countries, without the need for transposition into national law. It sounded good – a uniform, more rigorous system, stricter clinical and technical requirements, expanded obligations for manufacturers, importers, and distributors, and a central EUDAMED database for greater transparency and oversight.

The introduction of the MDR was also a response to specific incidents – such as the PIP implant scandal – that demonstrated that the oversight system needed strengthening and public trust in medical devices needed to be restored.

The European Commission organized workshops, surveys, and working groups. Everything looked promising. The new regulation was supposed to address real market needs. But the reality after implementation proved brutal.

The MDR was supposed to be a shield – for patients, support for manufacturers, and a clear guide for everyone. It turned out differently.

As Brzósko and Mołdach brilliantly put it, the concept of “dis/value,” or the dysfunction or devaluation of co-creating public value, described by Eriksson, Williams, and Hellström in 2023, is gaining increasing importance. To understand its significance, it’s worth drawing on the public value framework of Mark H. Moore, a pioneer in public management. His model is based on the so-called strategic triangle: public value, legitimacy and support, and operational capabilities.

Public value is the core—it’s about real outcomes that matter to society: better health, equality, and access to services. Legitimization and support represent support from key stakeholders—politicians, citizens, and organizations. Operational capabilities represent the resources, competencies, and processes that enable these goals to be effectively achieved.

The Prose of Life

Okay – but how does this “co-creation dysfunction” translate into the everyday lives of medical device manufacturers? It does – and has for almost a decade. Unfortunately, not in a positive way.

The MDR was supposed to be a protective shield for patients and a convenience for manufacturers – it was supposed to organize regulations and provide clarity. Instead, it has become a barrier: for manufacturers, for notified bodies, for patients. Instead of protecting them, it has begun to limit the availability of medical devices. An urgent reform is needed to restore the balance between safety and accessibility – taking into account the voices of patients, SMEs, and experts.

Erik Vollebregt, a lawyer specializing in medical regulations, compared the MDR to “regulatory lasagna in a blender.” Aptly. The MDR overlaps with other EU regulations – from the GDPR to the AI ​​Act – creating chaos, a procedural maze, and fragmentation that, instead of protecting patients, distances them from the products they need.

A report by the European Patients’ Forum (EPF) shows that 44% of patients have experienced shortages or recalls of medical devices – insulin pumps, cochlear implants, and respiratory therapy equipment. Patients complain about a lack of information, a lack of channels for reporting problems, and concerns about the quality of substitutes. The regulation, intended to improve safety, has led to a reduction in safety – through the loss of access to proven products.

According to the latest European Commission survey (NB Survey 14), there are 51 notified bodies in the EU, the average certification time is 13–18 months, and by mid-2025, only 25,034 MDR and IVDR certificates had been issued. The system is overloaded, lacking resources, and lacking consistent interpretations – all of which lead to uncertainty and delays.

Notified bodies, associated with Team-NB and NBCG-Med, not only diagnose problems but also propose specific solutions: the creation of a Medical Device Coordination Office (MDCO), special pathways for innovative and orphan devices, simplified requirements for low-risk devices, fixed deadlines, and predictable certification costs. This is the voice of practitioners – people who face the consequences of MDR every day.

Besides Eric Vollebregt’s opinion on MDR, a growing number of experts and industry institutions are saying bluntly: MDR 2017/745 is not working as intended.

In their 2025 review of the scientific literature, Olivia McDermott and Breda Kearney point out that the greatest challenge facing MDR lies in the clinical evaluation requirements – particularly for medium-risk devices. Their research shows that:

• 54% of manufacturers plan to withdraw their products from the EU market after their certificates expire.
• The launch of new, innovative products is being postponed outside the EU.
• The lack of clear guidelines on “sufficient clinical data” leads to interpretation chaos.

In a study published in Therapeutic Innovation & Regulatory Science, Elisabeth Oltmanns, Michael D’Agosto, and Folker Spitzenberger show that:

• 80% of manufacturers consider the MDR requirements too stringent and unclear.
• Notified bodies interpret the regulations differently – some accept non-clinical data, others require full studies.
• For medium-risk devices, the cost of generating new data may exceed the product’s market value, leading to its recall.

Medical companies also point to:

• Excessive burdens on SMEs.
• Overloaded notified bodies.
• Lack of proportionality – low-risk products are subject to almost the same requirements as high-risk ones.
• Threat to innovation – manufacturers refrain from implementing new technologies in the EU.

All these voices – from scientists, manufacturers, and notified bodies – show one thing: MDR has structural problems. It lacks clarity, predictability, and proportionality. And all of this translates into a risk of losing access to products for patients.

This isn’t just a technical issue. It’s a classic “disfunction of co-creating public value.” Regulation, intended to protect, has begun to restrict.

And at the end of this whole puzzle is the patient. A patient who won’t always be operated on by a surgical robot – but will always need a scalpel, scissors, gauze, and a bandage. And it’s precisely these basic resources that may be lacking.

My Perspective

My perspective – that of an MDR practitioner who “delivered” MDR certificates for one company and delivers more for another – is unequivocally negative. I agree with every voice I cited above. But I want to add another dimension: cost.

For every £1,000 we spend on MDR, my organization must sell £7,000 worth of products. And my budget doesn’t end with those 1,000 – costs are rising, and the market is changing. I’m increasingly considering presenting the board with a list of products that, in my opinion, don’t generate enough profit to justify updating the MDR documentation. And that means one thing: these products could potentially disappear from the market. Disappear from hospitals. Disappear from patients… somewhere in Europe.

Eight years after the MDR entered into force, even the European Commission has begun to recognize that the original vision of the regulation needs adjustment – ​​hence the publications and editions of new MDCG documents and guidelines, which aim to streamline the system and adapt it to market realities.

And now the European Commission is tackling another piece of legislation – this time, biotechnology – the Biotech Act.

Sound familiar? Centralization, harmonization, new obligations, new forms, new definitions. And although I’m an optimist by nature, it’s hard for me to believe this time will be any different than last time. Everything points to biotechnology becoming the next area where the EU will attempt to implement a centralized regulatory approach – similar to the MDR. Unfortunately, it seems we are once again heading towards another dysfunctional act that, instead of fostering innovation, could disrupt the market – especially among SMEs and manufacturers of products with high potential but limited resources.

Sources

Vollebregt, E. (2023). MDR and IVDR: Regulatory lasagna in a blender. Axon Lawyers Blog.

Vollebregt, E. (2024). The EU MDR: What went wrong and how to fix it. Presentation at the RAPS Euro Convergence conference.

EPF (2024). Patient Perspectives on Implementation Challenges of the EU Medical Devices Regulations. European Patients’ Forum.

European Commission (2025). NB Survey 14 – Summary of Results. Directorate-General for Health and Food Safety.

Team-NB & NBCG-Med (2025). Notified Body Perspective on Future Governance in the EU Medical Device Sector. Team-NB.

Team-NB (2022). Best Practice Guidance for Technical Documentation under MDR 2017/745. Team-NB.

McDermott, O. & Kearney, B. (2025). A review of the literature on the new European Medical Device Regulations requirements for increased clinical evaluation. International Journal of Pharmaceutical and Healthcare Marketing.

Oltmanns, E., D’Agosto, M., & Spitzenberger, F. (2025). Appropriateness of Clinical Data Under Regulation (EU) 2017/745 – A Case Study and Survey. Therapeutic Innovation & Regulatory Science.

GB Pharma (2024). Compliance Insights: Understanding the Regulatory Landscape – the Impact of MDR 2017/745 on Medical Devices. GB Pharma Blog.

Brzosko, S. & Mołdach, R. (2025). When co-creation harms: on the “dysfunction” of public value creation. Agreement for Public Value.

New European biotech act. Which way forward? European Commission Briefing (2025).

Katarzyna Jajuga, Emilia Kowalczyk

The National Recovery Plan (KPO) was intended to be a catalyst for Poland’s dynamic development after the pandemic, when the healthcare system was on the brink of collapse. Investments were promised at the time that would not only compensate for losses but also modernize medicine. Project D1.1.1 in oncology, which envisaged advanced diagnostics, accelerated treatment, and greater patient comfort – in short, a tangible improvement in the quality of life and health – raised particular hopes.

But why, instead of enthusiasm, do fears prevail today? Why do managers and doctors complain about bureaucratic chaos instead of celebrating breakthroughs? Mark Moore’s public value theory provides the key to understanding this. It assumes that every government action must meet three criteria: build public trust, be based on the actual capacity of the institution, and generate lasting benefits for citizens. In the case of the KPO, the problem lies precisely in the shortcomings of these elements. What exactly failed, and how can it be fixed?

The Chaos Begins

Problems with the KPO’s implementation became apparent even before its launch. Lengthy negotiations with the European Commission caused significant delays, and the Polish side seemed to simply expect flexibility in using the new “financial envelope,” while the European Commission expected a precise intervention logic. When funding finally became available, calls for proposals were announced hastily, and project implementation deadlines were drastically shortened. These issues were not merely technical shortcomings, but a clear signal that the state lacked control over the entire process, indicating insufficient operational capacity.

The Ministry of Health failed to provide adequate staffing to manage the program. Project supervisors frequently changed, managing dozens of cases simultaneously and being transferred between different initiatives. As beneficiaries noted, not only was contact with supervisors very difficult; in fact, there was often a complete lack of contact for several weeks, and as it later turned out, the supervisor was replaced, often twice. This reflects the situation repeatedly described by Moore, where the state’s operational capacity is seriously overestimated, preventing effective management.

How, then, can a program worth billions of złotys be implemented if public institutions lack the necessary resources to support it? This neglect underscores the failure to ensure the state’s operational capacity at the required level, jeopardizing the success of the entire endeavor.

A Crisis of Legitimacy and Trust

According to Moore’s theory, the legitimacy of state actions rests on their transparency, fairness, and predictability. However, the implementation of the National Health Fund (KPO) in the healthcare sector revealed serious shortcomings in this regard. An unclear legal basis and a lack of precise regulations—and in some cases, their complete absence—created unstable ground for the program’s implementation. The Ministry of Health itself struggles to interpret its own rules, and competition rules are often established ad hoc. One example is the change in regulations less than three weeks before the end of the application period: initially, it was assumed that a healthcare entity could submit only one application, regardless of the number of facilities within its structure. Just before the end of the application period, this interpretation was changed, allowing for the submission of separate applications for each facility meeting the competition criteria.

According to beneficiaries, this translates into chaos: constant change, uncertainty, and a sense that the rules of the game can be arbitrarily modified during implementation. This type of unpredictability undermines public trust in public institutions and the entire process. How can we build confidence in the effectiveness and integrity of state actions in such circumstances? The lack of a stable legal framework and transparency in the KPO not only hinders program implementation but also deepens the crisis of legitimacy and public support.

Public Value on the Margins

Mark Moore emphasizes that effective public governance requires a balance between three elements: public value, legitimacy and support, and operational capacity. However, in the case of the National Recovery Plan, a key element – ​​public value – has been relegated to the background. Instead of focusing on questions such as: What benefits will the program bring to patients? How will it lastingly improve the healthcare system? – attention is focused on financial settlements and meeting deadlines.

This shortsighted perspective creates the risk of creating sham investments. Modern equipment is purchased without a plan for its use, renovated buildings may lie empty due to lack of staff, and projects, although formally completed, will not translate into real improvements in patient health. As a result, the National Recovery Plan risks becoming a program serving bureaucratic statistics rather than people. Ignoring public value as a primary goal undermines the program’s purpose and distances it from meeting real social needs.

If nothing changes

Without changes in the approach to implementing the National Health Fund, we face a disturbing scenario: funds will be spent and formally accounted for, but they will not deliver significant social benefits. Patients will not see improvement, oncology will not reach modern standards, and growing public disillusionment will undermine trust in future public programs. Furthermore, Poland risks losing credibility in the eyes of the European Union, perceived as a country capable of “ticking off” billions but unable to translate them into real improvements in public services.

Furthermore, numerous studies on the implementation of EU funds, such as the 2020 ECA Report, emphasize that the hasty implementation of crisis funds in the EU’s healthcare sector often leads to inefficient use of funds if there is a lack of adequate administrative capacity and a clear legal framework.

The Supreme Audit Office (NIK) report, “The Functioning of the Healthcare System in Poland in 2019–2021,” confirms these problems. It reveals chronic staffing shortages in the Ministry of Health and the units responsible for implementing healthcare programs. The lack of sufficient qualified staff and frequent changes in project supervisors lead to organizational chaos. NIK reports also point to cases of “false investments,” where NIK criticizes the purchase of medical equipment that remains unused due to staff shortages or contracts with the National Health Fund. One example is the temporary hospitals that cost over PLN 600 million but failed to deliver benefits to patients due to a lack of staffing and coordination. This directly addresses the concern that new diagnostic laboratories within the KPO could become unused infrastructure without integration with the National Health Fund’s financing system.

These examples illustrate the risk that the KPO could become an Excel-like program, where funds are spent but do not translate into improved patient quality of life, which contradicts Moore’s concept of public value.

It is worth noting that the problems faced by KPO are by no means unique to the challenges faced by governments around the world implementing structural changes involving billions of dollars or euros of public funds.  Matt Andrews provides a prime example of this in his study of the effectiveness of 999 World Bank-funded projects. Only less than 30% of the projects produced satisfactory or highly satisfactory results. This disappointing result, of course, cannot even remotely explain the shortcomings of the observed NPOs, but it does illustrate the scale of the challenges.

How to reverse course?

Moore’s theory isn’t an abstract concept – it’s a practical guide that can steer a program on the right path. However, it requires the courage to abandon the mechanical “checking off projects” approach and focus on the quality of the results achieved. What does this mean in practice?

• Stability and transparency of rules – Competition rules should be clear from the outset and consistent throughout implementation. Any change on the fly undermines participant confidence and complicates task completion.
• Strengthening institutions – It is necessary to increase the number and competence of program staff. Currently, instead of benefiting from state support, beneficiaries often struggle with excessive bureaucracy.
• Integration with the National Health Fund (NFZ) system – This is one of the key challenges. Projects under the KPO plan to open new diagnostic laboratories but do not provide contracts with the National Health Fund. As a result, hospitals invest in infrastructure they cannot fully utilize – without a contract, it is difficult to achieve the required indicators. The risk is significant: instead of improving service accessibility, the subsidy threatens to be returned, and facilities will be left with expensive equipment that cannot be financed from current operations.
• Prioritizing public value – Project evaluation should focus on a fundamental question: what difference does this investment make for patients and physicians? The pace and method of implementation are equally important. The system cannot effectively manage dozens of competitions and large-scale projects simultaneously. It is better to plan a phased schedule, which will facilitate coordination, provide real support to beneficiaries, and achieve the intended results. Assumptions must be specific and tailored to the realities of a given facility and its patients’ needs – otherwise, the resulting infrastructure will be impressive on paper but inadequate to address local challenges.
• Honesty with reality – An honest debate is needed about the fact that implementing the program in such a short timeframe does not allow for lasting reforms. Instead of pretending that everything is going according to plan despite the obstacles encountered, it is better to negotiate an extension of deadlines.

In other words, it’s not just about spending money and “ticking off” indicators. The point is to ensure that these billions translate into real improvements in the quality of care and a lasting strengthening of the healthcare system.

What’s really at stake?

The National Recovery Plan in the healthcare sector isn’t just a matter of finances—it’s a test of the state’s ability to act strategically and consistently in the interests of citizens. Reducing it to tables and reports is a sure path to a double failure: wasted money and a loss of public trust.

As Mark Moore reminds us, public administration exists to create public value. It should be the compass for decision-makers. Not political interests, not deadline pressure, but the key question: will patients and healthcare workers experience real improvements?

Only by investing in quality, not simply rushing through milestones, can we transform the billions from the National Recovery Plan into the lasting foundations of the healthcare system. Otherwise, we risk not only wasting an opportunity—a particularly painful one, as it concerns health and life—but also deepening the frustration of patients and medical professionals who most expect change.

Let the KPO become a symbol of wise, thoughtful transformation, not another chapter in bureaucratic struggles. Let us act strategically, with the future and the people who count on us in mind.

Emilia Kowalczyk

The Polish healthcare system has been grappling with challenges for years, including unequal access to medical services, inefficient spending of public funds, and a lack of a coherent investment strategy. In response to these problems, a number of interventions have been undertaken, including instruments such as the National Transformation Plan (KPT) and Voivodeship Transformation Plans (WPT), which are intended to increase the system’s efficiency and better address social needs, particularly in the context of EU funds for 2021–2027. The key question is: do these adopted plans meet citizens’ expectations, ensuring equitable allocation of resources, or do they remain merely formally required documents whose implementation encounters systemic and political barriers?

Responding to social needs and fairness in resource allocation

A 2019 European Commission report indicated that many healthcare investments from EU funds in the 2007–2013 and subsequent years failed to deliver the expected benefits due to a lack of coherent planning. Projects were often implemented with local interests in mind, rather than social priorities, leading to fragmentation of the system and suboptimal use of resources.

Moore’s concept of public value assumes that public institutions should generate the common good by responding to real needs and ensuring equitable distribution of resources. In healthcare, this means investing in areas with the greatest impact on society’s health, including marginalized groups, such as residents of regions remote from major medical centers or selected social groups. The National and Regional Public Health Plans (KPT) and the Regional Public Health Plans (WPT), introduced under the 2004 amendment to the Healthcare Services Act, are intended, according to the recommendations of the aforementioned report, to address these challenges. However, their effectiveness depends on translating general assumptions into concrete actions, precise monitoring, and resistance to political pressure and lobbying. A lack of coordination between the national and regional levels and between individual regions can limit their ability to ensure equitable allocation of resources.

A Strategic Approach to Health System Transformation

The KPT and WPT are based on the principles of strategic public management and are based on a health needs map, which provides data on the availability of services and identifies areas requiring intervention. This document serves as the foundation for strategies such as “Healthy Future. Strategic Framework for the Development of the Healthcare System for 2021–2027, with a 2030 Outlook” and operational programs such as the National Recovery Plan (KPO) and the Cohesion Policy 2021–2027.

The KPT encompasses the modernization of medical infrastructure, human resources development, long-term care, and service coordination. It emphasizes the need to strengthen the role of outpatient specialists in the diagnostic and treatment process, in order to reduce the burden on hospital care.

The WPT, developed by regional health needs councils, is intended to take into account local conditions in its assumptions, allowing for tailored actions to the specific needs of the regions. The process of creating these plans involved consultations with stakeholders, including the Ministry of Health, the National Health Fund (NFZ), local governments, patient organizations, and employers, which should foster transparency and consensus building. These plans are intended to direct public funds where they will yield the greatest health benefits, supporting the concept of public value. However, their success depends on the proper interpretation of the National Transformation Plan when creating the Provincial Transformation Plans, as well as the correct identification of local needs, taking into account actual social needs. This also requires effective implementation and monitoring, as well as the ability to counteract political influence.

The WTP should therefore be aligned with the KTP and respond to local needs. The scope of these activities is broad, and the choice is not obvious. Among the competing priorities, the investments listed in the WTP should include infrastructure and equipment in outpatient clinics, allowing, in particular, for the shift of imaging tests from hospitals to outpatient clinics where clinically justified. The concept of an inverted pyramid of services, promoting a broader base of outpatient clinics, also suggests the need for greater access to outpatient tests, especially for marginalized groups.

Updates to Provincial Transformation Plans in the Context of Imaging Diagnostics

An analysis of the Provincial Transformation Plans (PTPs) formulated in 2021 and amended in 2024, focusing on magnetic resonance imaging and the inverted pyramid concept, reveals a trend toward greater detail and adaptation to health challenges such as an aging population, increased demand for diagnostics (e.g., in oncology, neurology, cardiology), and experiences from the COVID-19 pandemic. The updates are based on data from the System Analysis and Implementation Database (BASiW), introducing metrics such as wait times (up to 200 days), diagnostic equipment utilization (over 3,750 tests per year), and demand forecasts. However, progress is uneven across the country – in some regions, updates are limited or no changes have been implemented.

In the author’s opinion, the advantages of the PTP updates over the original plans include:

• More precise data: The introduction of metrics such as wait times and equipment utilization allows for better resource allocation. Examples include the Kuyavian-Pomeranian and Masovian Voivodeships, which addressed queues and justified new investments.
• Integration with other areas: WPTs in the Lubusz and Lesser Poland Voivodeships combine diagnostic imaging with oncology, cardiology, and neurology, shortening treatment processes.
• Expansion of activities: The Kuyavian-Pomeranian Voivodeship increased the number of new MRI scanners to 10 in selected counties, reducing the distance to examinations (to 40 km).
• The Silesian and West Pomeranian Voivodeships have implemented recommendations for monitoring and optimization.
• The author also notes the following shortcomings of the WPT update:
• Uneven progress: In the Opole, Podkarpackie, and Greater Poland Voivodeships, the lack of data updates suggests stagnation.
• Marginalization of the inverted pyramid: This concept, crucial for reducing hospital workload, is omitted from the WPT or treated vaguely.
• Lack of a Systemic Approach: Focusing on equipment investments at the expense of organizational and staffing reforms limits the comprehensiveness of the plans.
• Implementation of the National Medical Research Programme (KPT) in the Updated Medical Research Programmes (WPT)

An analysis of the WPT and KPT shows that most voivodeships are implementing the KPT goals through investments in diagnostic equipment, the creation of MRI laboratories, and infrastructure modernization, which improves access to tests. However, the consistency between regional and national plans varies. The initial WPT from 2021 was too general and opaque, allowing for biased interpretations that allowed for the pursuit of vested interests. However, the 2024 updates introduce more data and focus on improving diagnostic imaging. Key advantages include detailed metrics and integration with other areas of the healthcare system, although the lack of uniform data remains a challenge, hindering plan comparison and system evaluation at the national level.

In light of the above observations, the author proposes the following proposals for standardizing the WPT:

• Standard indicators: Number of MRI scanners, equipment age, waiting times, workload at the laboratory, distances or travel times to facilities.
• Uniform structure: Standardization of diagnostic sections in each WTP.
• Integration with the MPZ: Incorporation of data from the BASiW into all plans.
• Monitoring the inverted pyramid: Introducing metrics for the number of tests in primary care and outpatient clinics compared to hospitals.

Conclusions

The KPT and WPT have the potential to respond to social expectations, ensuring equitable allocation of resources. The 2024 updates indicate progress in their creation in the form of precise data and investments. At the same time, they do not fully meet the hopes of the legislator legitimizing the transformation plans and their original assumptions formulated in R. Mołdach’s report for the European Commission. Data standardization, integration with the MPZ, and a greater emphasis on systemic reforms are crucial to creating a coherent and effective healthcare system that fully realizes the concept of public value.

Tomasz Rowiński, Emilia Kowalczyk, Robert Mołdach

Fot.: Jose A.Thompson (Unsplash)

The Uncertain Future of the Pilot

Does the Mental Health Center (MHC) pilot program have a chance of becoming a lasting reform, or will its effects prove limited and difficult to sustain in the long term? This is a question worth asking today, when experiences in child psychiatry show that even well-planned changes can encounter organizational barriers and lengthening wait times.

The MHC pilot program, introduced in 2018 and already costing nearly PLN 8 billion, is based on community-based treatment close to the patient’s home. Each center serves residents of a specific district/county or group of districts/counties, offering comprehensive care – from clinics, through crisis services, to day and 24-hour wards. Its goal is to increase access to psychiatric and psychological care, ensure proportionality, shorten waiting times, provide treatment closer to home, and reduce hospitalizations in favor of treatment that takes into account local community resources, thus simplifying community-based therapy.

However, according to Moore’s strategic triangle concept, the success of reform requires a balance between three elements: clearly defined public value, stable political and social legitimacy, and adequate implementation capacity. A lack of coherence in these areas could limit the long-term impact of the pilot project and hinder the transformation of adult psychiatry in Poland.

Lessons from Child Psychiatry and the Application of Moore’s Strategic Triangle

The article on the dysfunction of public value creation by Szymon Brzósko and Robert Mołdach (Brzósko & Mołdach, 2025) highlighted the similarity of the phenomena described there to the experiences of the Team for Child and Adolescent Mental Health at the Ministry of Health (Minister of Health, 2018a), as reported by Tomasz Rowiński. The same mechanisms are currently being replicated in the Team for Systemic Solutions in Mental Health Centers (Minister of Health, 2024). In child psychiatry, a lack of coherence has led to a missed opportunity to increase public value, which has resulted in, among other things, long waiting lines and unmet beneficiary expectations.

To avoid a similar scenario in adult psychiatry, the authors propose using Mark Moore’s strategic triangle as an analytical framework. It allows for understanding the dynamics of decision-making processes in public management, where services engage multiple stakeholders and impact millions of citizens. Moore’s triangle encompasses three fundamental questions from the perspective of public service management:

Has public value been broadly agreed upon within public policy?

Does the state or entities/institutions responsible for its development have the executive capacity to implement it?

Does the solution have sufficient political and social legitimacy, accepted by current decision-makers and the broadly understood stakeholders and beneficiaries of the change?

In the authors’ opinion, this concept aptly explains the “fatigue” of healthcare providers, decision-makers, and specialists during the longest pilot program in the history of the Polish healthcare system. The CZP pilot, which has been underway since 2018, stands at a crossroads between a tremendous opportunity for systemic transformation and the risk of wasting public resources and the social capital that has been built during its duration. This analysis allows us not only to identify current challenges but also to identify paths to overcoming them, taking into account experiences from child psychiatry.

(Un)Agreed Public Value

The history of the Mental Health Center pilot program has shown that public value was relatively clearly defined at the declarative level, including: rapid access to support close to home, coordination of services across the entire care continuum, and a shift away from a model dominated by hospitalization. These goals, also defined in subsequent editions of the National Mental Health Program, were intended to address the problems of people experiencing mental health crises, who often lose their jobs and close relationships (family, friends). They were formulated in the regulation of the Minister of Health launching the pilot program (Minister of Health, 2018b), its subsequent amendments, and in regulations of the President of the National Health Fund (NFZ) (President of the NFZ, 2018; President of the NFZ, 2020). Government communications and health strategies reiterated the theme of equal opportunities in access to care, emphasizing the program’s social value. However, a key problem emerged in the lack of an answer to the original question: do patients recover mentally faster and more effectively in such organized healthcare facilities?

The conflict between the professional community involved (including psychiatrists) and National Health Fund officials led to the first serious crisis in the pilot project, despite initial legitimization by decision-makers and the state’s organizational capabilities. In practice, public value proved to be a “dynamic” goal – repeatedly modified and interpreted differently. Subsequent decisions to extend the pilot, without setting a firm end date or a logical transition to systemic solutions, caused the “value” to lose its sharp outlines. It functioned more as an idea than a specific state obligation, supported by earmarked financial resources. At the height of the crisis, triggered by an attempt to forcefully impose a “different model,” the concept of “mental health centers” took on multiple meanings, depending on the speaker’s position. The culmination came on December 5, 2024, when decision-makers used the term “Personal Health Care” perversely – retaining the name but changing its meaning. This led to an erosion of trust in the Ministry of Health and the National Health Fund, revealing a creeping lack of definitive agreement on public value in practice, despite statutory provisions.

Without a clearly defined, stable vision and genuine state involvement, the idea of ​​”Personal Health Care” becomes an empty slogan. The opportunity for real improvement in psychiatric care turns into chaos, deepening distrust and the suffering of those in need.

From the outset, a valid evaluation (research) model was not developed that would provide scientifically valid knowledge about patient recovery, the degree of goal achievement, and control of variables during and at the end of the pilot. This “original error” was the root of the frustration for all parties in the PLN 8 billion project, which was intended to provide reliable knowledge to decision-makers. The National Health Fund (NFZ) President’s Order introduced Annexes 3 and 5 to monitor the centers’ performance, but they failed to address key issues or provide methodologically sound information. The collected data did not allow for reliable identification of trends or assessment of effectiveness, rendering the order largely a blank slate that did not translate into conclusions or improvements. The lack of reliable evaluation data, combined with changes in decision-makers within the Ministry of Health, deepened the chaos and lack of consensus regarding public value for patients and the healthcare system. Each personnel change brought a new vision, leading to divergent interpretations of goals. Examples include the liquidation of the Pilot Office, the varying interpretations of the “reserve” by NFZ provincial branches, and the announcement of competitions for identical scopes for the CZPs in the pilot area. This complicated the financing and operation of the centers, leading to a gradual loss of financial liquidity for the pilot project implementers. As a result, instead of a unified, evidence-based policy, the pilot became a patchwork of individual agendas, weakening coherence and effectiveness.

Divergent approaches and a lack of strategic continuity meant that the CZPs operated in an atmosphere of uncertainty, with priorities dependent on current leadership. Differences in policies, combined with a lack of evaluation, transformed the ambitious project into a mosaic of conflicting priorities, with leaders imposing visions based on methodologically flawed data. As a result, the program became a field of experimentation, mired in chaos, instead of bringing tangible improvements to a growing number of patients.

Stability of Political Decisions

Political decision-makers legitimized the project with the language of its mission: “a modern, community-based model of care for the entire country.” This narrative created a broad but soft legitimacy—based on general benefits, but without a formal framework that would establish value as a legal and organizational standard. The lack of a clear deadline for transitioning from “test” to “policy” meant that social and political consent was largely symbolic. Social legitimacy seemed strong, but political legitimacy remained fragile.

The longest pilot in the history of the Polish mental health system is underway, but its completion is being delayed by the political calendar, not a substantive timeline. The National Health Fund (NFZ) legitimized the change conditionally: accepting the direction but emphasizing accountability and cost control. In fact, this occurred outside the pilot’s results, as an agreed-upon research model and methodology were lacking (Appendices 3 and 5 to the NFZ President’s orders). The debate surrounding the population-based flat-rate program revealed a crack in Moore’s triangle. From the payer’s perspective, the fee-for-service model provided greater transparency and control, while for centers and patients, the flat-rate program was crucial for flexible response to needs and proactively reaching out to people in crisis. The lack of agreement on financial instruments undermined the feasibility of implementing public value – value without a stable mechanism becomes a declaration without tools.

The professional community defended the model’s integrity, emphasizing the need to maintain standards and stable funding for long-term planning. The state, through its control apparatus (e.g., selected Supreme Audit Office (NIK) reports), pointed to organizational shortcomings, poor oversight of the National Health Fund (NFZ), and prolonged “temporariness.” Psychiatrists and directors of the entities implementing the pilot program legitimized the solution through practice – the CZPs covered a significant portion of the adult population – but demanded predictability and system sustainability, which have been lacking to date. Furthermore, the pilot program itself became a component of the transformation of mental health care, including key entities such as psychiatric hospitals. A prime example is the Małopolska Voivodeship, where public value has been agreed upon locally. This voivodeship is almost entirely covered by a network of CZPs, where the service pyramid has been reversed (the number of hospitalizations is below the target of 25 beds per 100,000 inhabitants), and outpatient, day, and community services have been expanded (nearly 60% of the voivodeship’s psychiatric care budget falls under the “non-hospital services” section).

Organizational Capacity of Medical Facilities: “The Miracle on the Vistula”

Despite the lack of an agreed public value and unstable political legitimacy, the pilot program has covered over 50% of Poland’s adult population. Furthermore, over 100 applications from various healthcare providers are awaiting consideration and inclusion in the CZP program. This represents enormous social capital in healthcare, generated by the wave of change – despite the resistance of some National Health Fund officials and Ministry of Health decision-makers. The program has provided an opportunity to realize the public value of recovery after a mental health crisis. In the authors’ opinion, this aspect of Moore’s Triangle constitutes a kind of “miracle on the Vistula” – the operational capabilities of healthcare providers have demonstrated surprising resilience and adaptability, despite systemic shortcomings. Healthcare providers, including psychiatric hospitals and outpatient centers, have managed to organize comprehensive care in conditions of financial and regulatory uncertainty. For example, many centers have implemented innovative solutions, such as mobile crisis teams, which have allowed for interventions in patients’ homes, reducing the need for hospitalization.

Tomasz Rowiński’s experience demonstrates that these operational capabilities are based on the commitment of professionals – psychiatrists, psychologists, nurses, recovery assistants, and many other specialists – who, despite the uncertainty and temporary nature of the situation, maintain a high level of service. In turn, the social capital built around the program encompasses not only medical personnel but also local communities and non-governmental organizations that supported the implementation of the community-based model.

According to Tomasz Rowiński, since 2018, the average percentage of the population covered by CZP support within the entrusted budget has increased by almost 50 percent. The same healthcare entities that received funding for services provided covered a much smaller percentage of the population. After transforming into a mental health center, we have observed a steady increase in the percentage of the population receiving assistance. This was achieved for the same per capita cost. And without the traditionally understood overcompensation,” the author adds.

This example demonstrates how flexible financing and service coordination can truly support recovery by building trust among beneficiaries. However, these achievements are fragile – without stable systemic support, operational capacity can be exhausted. It is important to emphasize that this “miracle” stems from a grassroots initiative but requires strengthening by the state to avoid the burnout of human and organizational resources. In the context of public management, these capacities demonstrate the potential of reform, but also emphasize the need for better integration with the other elements of Moore’s Triangle to transform temporary successes into lasting systemic change.

Contra spem spero

According to Moore’s model, the CZP pilot achieved consensus at the conceptual level, partial agreement on the tools, and fragile formal legitimacy. The strategic triangle provides a structural framework for thinking about change in public policy, allowing not only for defining public value but also for testing the state’s capacity for implementation and the political and social support for sustainability. In the case of the CZP, this model reveals that even a widely accepted idea can remain fragile without coherence between these three dimensions: concept, tools, and legitimization.

The lack of this coherence leads to “fatigue” among all parties. Healthcare providers struggle with unclear guidelines and increasing financial adjustments, losing motivation. Healthcare providers that fully implement community-based care based on local resources lose the most due to its “temporariness,” while those that invest so heavily in developing this form of treatment do not necessarily gain. Decision-makers, changing with governments, introduce conflicting visions, destabilizing the program. Specialists, including psychiatrists, feel frustrated by the lack of evaluation data and constant changes that hinder patient support. This fatigue stems from a long-standing lack of consensus on goals and insufficient systemic support that would allow for the stable implementation of reforms.

However, there are people – specialists, physicians, and healthcare provider employees – ready to change Polish psychiatry for the better. The question is, will the Ministry of Health finally provide a coherent vision, stable funding, and a clear framework to transform their energy into lasting success, or will it allow their enthusiasm to fade in bureaucratic uncertainty?

References

Brzósko, S., & Mołdach, R. (2025). When co-creation is harmful: on the “dysfunction” of creating public value. Public Value Agreement.

Minister of Health. (2018a). Regulation of the Minister of Health of February 20, 2018, on the establishment of the Team for Mental Health of Children and Adolescents.

Minister of Health. (2018b). Regulation of the Minister of Health of April 27, 2018, on the pilot program in mental health centers. Journal of Laws 2018, item 852.

Minister of Health. (2024). Order of the Minister of Health of December 4, 2024, on the establishment of the Team for Systemic Changes in Mental Health Centers. Official Journal of the Minister of Health.

President of the National Health Fund (NFZ). (2018). Order No. 55/2018/DSOZ of the President of the National Health Fund of June 22, 2018, on specifying the conditions for concluding and implementing agreements for pilot programs in mental health centers.

President of the National Health Fund (NFZ). (2020). Order No. 55/2020/DSOZ of the President of the National Health Fund on agreements for the implementation of a pilot program in mental health centers.

Szymon Brzósko, Robert Mołdach

Co-creation Failure

Imagine a situation in which a hospital introduces a new model of care for patients with type 2 diabetes. The well-intentioned project team decides to engage patients themselves in the co-creation process. They organize workshops, surveys, and working groups where patients share their experiences, needs, and ideas. Everything seems promising – the new service is designed to be perfectly tailored to their realities.

However, after implementation, the reality turns brutal. Many patients feel overwhelmed by the sheer number of new recommendations and tools. Some forgo follow-up visits because, although their voices were “heard,” in practice they were ignored. The solutions implemented were more responsive to the needs of medical staff than the individuals themselves. Instead of improved quality of life, there is frustration; instead of improved health indicators, there is stagnation. Instead of success, there is failure, costing everyone: patients, the hospital, and the entire system.

This is a phenomenon that researchers call “co-creation dysfunction” – situations in which processes intended to increase public value lead to unintended negative consequences.

Why is this topic so important? Mark Moore’s Public Value Framework

The concept of “dis/value,” or the dysfunction or devaluation of the co-creation of public value, described by Eriksson, Williams, and Hellström in 2023, is gaining traction in the context of public policy management. To understand its deeper implications, it is worth considering the public value framework developed by Mark H. Moore, a pioneer in the field of public management. Moore’s model emphasizes that effective public management is based on a strategic triangle, consisting of three interconnected elements: public value, legitimacy and support, and operational capabilities.

Public value is at the core—it concerns outcomes desired by society, such as improved health, equity, or service efficiency. Legitimacy and support encompass support from key stakeholders, including politicians, citizens, and organizations, which provides the authorizing environment necessary for action. Operational capabilities, on the other hand, are the resources, skills, and processes that enable the actual achievement of goals.

Traditionally, when discussing co-creation, co-design, or co-innovation in public services, we focus solely on the positives. We assume that actively engaging citizens automatically increases public value, leading to more effective services because it takes into account the voices of those affected. Within Moore’s Triangle, co-creation could strengthen all elements: increasing value through better service alignment, building legitimacy through participation, and developing operational capabilities through new ideas. However, research shows that this is not always the case – sometimes the effect is quite the opposite, disrupting the triangle’s balance. Dysfunction can erode legitimacy when citizens feel cheated, weaken public value by reinforcing inequalities, and overwhelm operational capabilities if processes are poorly managed. Understanding this in the context of Moore’s model helps avoid pitfalls and build more sustainable public strategies.

What exactly is “dysfunction”?

Dysfunction/devaluation refers to the unintended negative effects and consequences of co-creating public services. Instead of positive outcomes, these interactions can destroy value or generate outcomes that are more harmful than beneficial. As the authors emphasize, dysfunction is an inevitable consequence of interactions between service providers and their users. This is not a flaw in the system, but rather a natural feature that must be anticipated and managed – especially in light of Moore’s triangle, where an imbalance between value, support, and capacity can lead to systemic failures.

In this context, the distinction between public value and private value, which often conflict during co-creation processes, becomes crucial. Public value, according to Moore’s model, refers to collective benefits desired by society as a whole – such as social justice, equal access to services, or the long-term efficiency of public systems. Private value, on the other hand, focuses on individual or group benefits that benefit specific individuals or entities, such as personal satisfaction, time savings, or financial gain. In co-creation processes, where public actors (e.g., state institutions) collaborate with private actors (citizens, NGOs, and businesses), these two value spheres can be both co-created and co-degraded.

For example, co-creation spaces and civil society can generate private value for selected individuals or groups, while the public sector is tasked with creating public and social value. In complex public service environments, the goals of public and private value often intersect, leading to the destruction of value at the interface between these spheres.

This conflict is part of a broader journey from “I” to “We”—that is, a shift from individual interests (a selfish “I” focused on private values) to collective harmony (a “We” based on public value). Co-creation of public services is theoretically intended to facilitate this transformation, building a bridge between personal needs and the common good through networked relationships in which value is created only through interactions between the parties.

However, the competition between private and public values ​​can hinder this path: the individual “I” strives to maximize their own benefits (e.g., faster medical care for themselves), which can undermine the collective “We” (e.g., equal access for all). As a result, instead of integration, dysfunction emerges – private interests dominate, reinforcing inequalities, or public goals are ignored, leading to frustration and a devaluation of the entire process.

To illustrate this, think of a group of friends planning a vacation together. Everyone has a say, everyone participates in decisions – sounds ideal? Not necessarily. Such a “democratic” process often ends in arguments, compromises that satisfy no one, and vacations that are remembered rather negatively. In this scenario, private value (individual preferences, such as one friend’s choice of a beach for relaxation) competes with the group’s public value (the collective “We,” meaning a harmonious trip for all). If one participant’s “I” – for example, the stubborn pursuit of a luxury hotel – prevails, it can destroy collective joy, leading to the devaluation of the entire adventure. Similarly, in public services, the lack of management of this competition turns co-creation into a source of conflict, where the private benefits of some destroy public value for all.

Three Levels of Value Creation/Destruction

The process of value creation or destruction occurs at three levels, which can be analyzed through the lens of Moore’s strategic triangle, where dysfunction disrupts the balance at the individual, group, and societal levels.

At the individual level, concerning the patient or user, co-creation can bring a sense of self-efficacy, increased knowledge, a sense of belonging, and tangible improvements in health or life situation—thus strengthening public value. But it can also lead to frustration, disappointment, a lack of agency, and even a loss of self-esteem, which undermines the legitimacy of the process. The reasons? Poor communication, unprofessional staff behavior, poorly designed information, or time constraints. Take the example of consultations regarding a new bus line: residents spend evenings at meetings, fill out surveys, and feel they are co-shaping the future of the neighborhood. And then it turns out the route was pre-determined for technical reasons, and their opinions are thrown in the trash.

At the group level, encompassing communities or patient groups, the benefits include improved services tailored to specific needs, a better understanding of the problems of different groups, and more effective interactions between them – which builds operational capacity. However, devaluation occurs when services fail to address these needs, reinforcing existing inequalities and weakening social support. The main risk is the recruitment of people from economically, professionally, or socially advantaged backgrounds, even from minority groups, into co-creation processes – which creates a false impression of representativeness. Imagine a neighborhood council discussing a new preschool: the participants are primarily educated, affluent parents who can afford evening meetings. The voices of parents working shifts, single mothers, and those in financial hardship remain unheard.

Finally, at the societal level, concerning the public interest, positive effects include increased trust, improved system efficiency and innovation, and strengthened participatory democracy – harmonizing the entire Moorean Triangle. But devaluation occurs when broader values, such as justice, equal access, and public accountability, are violated, threatening legitimacy. The main threat is the blurring of public organizations’ responsibilities, which shift responsibilities onto NGOs, families, or associations. An example would be the system of “adopting” parks by residents: it sounds ecological and democratic, but in practice, wealthy districts have beautiful green spaces, while poor ones are neglected because residents lack the time and resources.

Lessons from Reality: Three Case Studies

Lessons from real-world experience emerge from three case studies from the healthcare sector, which researchers analyzed to demonstrate the mechanisms of dysfunction—and how they disrupt Moore’s strategic triangle.

In the first, concerning pulmonary rehabilitation in the UK, patients with lung disease co-created the program, but despite their involvement, many felt worse than before. This was due to poor communication among medical staff, unprofessionally prepared information, and a lack of understanding of how patient feedback was being used—resulting in low attendance, frustration, and poor well-being, weakening public value and operational capacity.

The second case study, concerning cancer prevention among immigrants in Sweden, encouraged research by engaging local leaders in co-design. A positive effect was a 42 percent increase in participation, but recruitment of the most integrated immigrants with better economic and social circumstances was problematic. As a result, the most vulnerable groups remained outside the system, undermining the legitimacy and equity of Moore’s triangle.

The third example is a cancer support center in Sweden, where cancer patients co-created and ran a meeting space. The physical center was established, which was a success, but the challenges were similar: better representation for “better-off” patients, and in Swedish culture, funding public services through private charity raises suspicion. The risk is the blurring of public organizations’ responsibilities, shifting services to friends, family, and associations—which can exclude certain groups and create value for some while destroying it for others in the system, thus disrupting the entire strategic triangle.

An Analogy with Quality Improvement Methodology: “Balancing Measures”

The concept of co-creation “dysfunctions” is reflected in quality improvement methodologies in medicine, particularly in the concept of “balancing measures,” which originate from approaches to quality management in healthcare, such as the IHI (Institute for Healthcare Improvement) model. Balancing measures are tools used in service improvement processes to identify and monitor unintended negative consequences of changes introduced that are intended to improve a specific aspect of the system—for example, reducing wait times for appointments. Their origins lie in Lean and Six Sigma methodologies, which were adopted in healthcare in the 1990s to ensure that improvements in one area (e.g., efficiency) do not result in harm in another (e.g., access to services). Balancing measures are crucial to a holistic approach to change management because they force us to look beyond the primary goals and consider potential collateral costs.

Similarly, the co-creation dysfunction described by Eriksson and colleagues suggests that initiatives such as co-creation, while intended to generate public value, can also have detrimental effects if not managed appropriately. This parallel resonates with Moore’s strategic triangle, where an imbalance between public value, legitimacy, and operational capacity leads to the erosion of system value. For example, introducing a new queuing system may reduce waiting times for appointments (public value), but if it excludes patients who do not use the internet, it undermines legitimacy (lack of social support) and exposes operational capacity limitations (e.g., lack of alternative access channels). Balancing measures in this case could include monitoring the percentage of patients excluded from the system to identify and minimize negative impacts.

Both concepts—dysfunction and balancing measures—encourage a holistic approach to avoid the “tragedy of co-design” and ensure a positive balance of efforts. The common denominator is an awareness of the pitfalls and unintended consequences that can undermine the initiative’s success. Through meaningful monitoring and risk management, Moore’s Triangle can be better balanced, ensuring that co-creation not only generates value but also minimizes its destruction.

What to do? A guide in the context of Moore’s Triangle and the public value chain.

To manage dysfunction in co-creation processes, it’s worth leveraging best practice, integrating it not only with Moore’s strategic triangle—focusing on balancing public value, legitimacy and support, and operational capacity—but also with his concept of the public value chain (PVC). In Moore’s model, this chain describes the process of creating public value as a sequence of steps in which resources (including human and financial) are transformed into actions, and these are transformed into outcomes desired by society. A key role here is played by beneficiaries—direct recipients of services, such as patients or residents, who benefit from improved quality of life; obligates—those who bear costs or obligations, such as taxpayers who finance the system but do not always directly benefit; public spirit—collective engagement and civic enthusiasm that drives participation and builds trust; and supporting enablers or facilitators – partners such as NGOs, experts, or community leaders who facilitate progress by providing resources, knowledge, and motivation.

When considering the public value chain, it is crucial to identify who may be excluded at various stages: beneficiaries from marginalized groups (e.g., immigrants or the poor) may not receive benefits if co-creation processes favor the better-off; bondholders, such as taxpayers from lower social classes, may feel burdened by costs without influence, eroding legitimacy; a lack of public spirit among excluded groups weakens collective commitment, leading to stagnation; and an insufficient role of facilitators can stifle innovation by overloading operational capacity. Integrating these elements helps avoid dysfunction, ensuring that the value chain creates inclusive, not destructive, value.

Using best practice, start with key questions that relate directly to the value chain: who actually benefits from co-creation processes (beneficiaries?), whose voices remain unheard and why (bondholders or groups without public spirit?), where are the boundaries—when the harms outweigh the benefits (e.g., when the costs for bondholders exceed the benefits for beneficiaries), how to better represent the most vulnerable groups (including supporters), and how to eliminate institutional biases (by building public spirit). These questions help maintain legitimacy and balance in the value chain.

Before starting a project, identify risk groups—those who may be excluded from the value chain—e.g., beneficiaries without access to technology or bondholders ignored in consultations. Plan diverse recruitment channels instead of relying on standard channels (including supporters from local communities), and develop “balancing metrics” to measure negative impacts, such as the erosion of public spirit or an imbalance between benefits and costs. This strengthens operational capabilities and ensures the chain is seamlessly built.

During implementation, monitor the process continuously, without waiting until completion, regularly check that all voices are heard (including those of beneficiaries and bondholders), and build early warning systems for dysfunction, for example, through surveys measuring public spirit. Engaging supporters at this stage helps push the envelope, building public value, and preventing disruptions in the chain.

After completion, evaluate the actual outcomes, not just the positive ones – analyzing how the chain impacted beneficiaries (benefits), bondholders (costs), public spirit (engagement), and supporters (efficiency). Learn from the future and share experiences with other organizations. This ensures ongoing support and legitimacy, closing the loop in the public value chain in a sustainable manner.

Don’t Idealize Co-Creation: Realism in Moore’s Framework

Remember: citizen engagement is neither good nor bad in itself; it is a tool that can serve different purposes and deliver different outcomes. In the context of Moore’s strategic triangle, co-creation can be a powerful mechanism for enhancing public value, but only if balanced with legitimacy and operational capacity. Equally important is the perspective of the Public Value Chain, which emphasizes that value is created through a sequence of activities where beneficiaries (recipients of services), bondholders (cost bearers), public spirit (the public spirit driving engagement), and facilitators (partners supporting the process) must work together to avoid dysfunction. Imbalances in this chain—for example, excluding beneficiaries from marginalized groups, disproportionately considering the interests of certain groups in need, ignoring bondholders, or weakening public spirit—can lead to value destruction rather than creation.

This isn’t about abandoning participation, as that would be a disaster for democracy. It’s about doing it wisely, with full awareness of the risks and a willingness to manage them. Instead of blind faith in the power of participation, we need a mature, balanced approach that considers both the benefits and the risks—so that both Moore’s Triangle and the public value chain remain in balance. This means designing co-creation processes that strengthen public spirit, engage diverse beneficiaries and bondholders, and effectively utilize facilitators, ensuring that public value isn’t built at the cost of exclusion or frustration.

This isn’t pessimism, but realism, which can protect us from costly mistakes and truly improve the quality of public services, creating a coherent value chain that serves the entire society.

Emilia Kowalczyk

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.

Robert Mołdach

Reflections after the Public Value Agreement webinar

The webinar, organized on July 14th as part of the Public Value Alliance, focused on the role that the public value-based public management concept and method can play in reforming the healthcare system and public governance more broadly. This topic is of paramount importance given the challenges we face as a country and society.

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Public value as a axis of change in the health system

Robert Mołdach, PhD, presented a starting point. He pointed out that the discussion on health reform is taking place in conditions of weakened community and social capital. He drew on the reflections of Robert Putnam, who demonstrated how the breakdown of social bonds leads to the fragmentation of communities and, consequently, the ineffectiveness of public institutions, and on Mark H. Moore’s concept of public value. The latter, developed in response to the challenges of contemporary administration, is based on the assumption that the role of public leadership is not merely to implement policies but to create sustainable public value.

Moore’s strategic triangle model, encompassing the creation of public value, building legitimacy, and implementing capacity, was presented. It was emphasized that although this approach originated in the American context, its essence—linking the meaning of actions with their real feasibility and social mandate—remains universal. This remains particularly relevant in times of challenges and conflicts.

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From concept to practice – tools and approaches

Later in the meeting, Emilia Kowalczyk demonstrated how the strategic triangle can be used as a tool for planning and implementing changes in the healthcare system. Gabriela Moczeniat, PhD, EMBA, discussed the concept of public value accounting as a method for assessing actions in the context of social utility, and Agnieszka Dubiel introduced the concept of the public value chain – from political intention to actual outcomes experienced by citizens.

It was pointed out that viewing public value through the lens of public value allows us to transcend institutional and particularistic logic. It enables a more coherent approach to planning and evaluating reforms – regardless of who currently holds the decision-making role.

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How is the public value approach different?

One of the questions concerned what the public value approach brings to the table compared to existing public management methods used in Poland. Emilia Kowalczyk emphasized that the difference lies not only in the tools, but also in the starting point: it’s not about improving the effectiveness of institutions for their own sake, but about giving meaning to public actions by referencing socially recognized values. It is by aligning these values ​​that work on public policies should begin. Agnieszka Dubiel added that this requires a change in current practice and an understanding by public leaders of the public value chain based on real needs, social justice, and fairness.

It was emphasized that public value is neither a tool for optimization nor an economic category. It is a framework that allows us to understand who the system serves, what creates its legitimacy, and what resources are needed to maintain and develop this value.

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Voices from Practice: Accountability, Coherence, and Constraints

In an open discussion, superbly moderated by Tomasz Rowiński, PhD, EMBA, Agnieszka Dubiel spoke directly about staff burnout and internal tensions – and how change begins not with another regulation, but with a culture of collaboration. Magdalena Łasińska-Kowara highlighted the lack of distributed responsibility in the healthcare system and the need to think in terms of teams and collective outcomes. Gabriela Moczeniat, PhD, EMBA, emphasized the role of technical and information limitations that hinder the realization of the concept of public value, such as distributed IT systems and lack of interoperability. Łukasz Bruski cited the example of the decision of the deaf parents of a deaf child who opposed the implantation of a hearing-restoring implant for their child, fearing it would exclude the child from their community. He demonstrated that understanding public value requires sensitivity, dialogue, and consideration of individual identities and relationships, not just data and procedures. Dariusz Dziełak brought this discussion to a close by pointing out that a conversation about values ​​must begin before political deadlines and campaigns emerge. This is a task not only for politicians but also for professional, academic, and civic communities.

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Leadership Research and the Need to Talk About the Meaning of Reform

In the final section, one participant mentioned her research on the attitudes of leaders in primary care. Robert Mołdach, PhD, suggested that such research should also be extended to political decision-makers – for example, members of the Council of Ministers or the Chancellery of the Prime Minister – to understand their beliefs regarding public value and their willingness to think long-term about reform. The question, however, is whether they would be willing to undergo such research and share its results with the public?

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Conclusions and perspectives

The meeting confirmed that the concept of public value can be a starting point for a more sustainable, meaningful, and socially acceptable approach to changes in the healthcare system. Not as an alternative to efficiency, but as its complement – ​​organizing goals, defining meaning, and helping to build a common language in a fragmented system. It also creates conditions for the objective selection of state priorities and ensures effective implementation.

The next meeting of the Agreement for Public Value is planned for the Economic Forum in Karpacz, as part of the Fishbowl session, to which you are cordially invited.

p.s. Special thanks to Iga Lipska MD PhD MPH for inspiring this unique discussion format.