Articles

Robert Mołdach

“The burden on public finances could be reduced and access to healthcare improved by strengthening primary care” – this was the position expressed by the Council of the European Union back in 2014 as part of the European Semester, the annual process coordinating EU economic and social policy. However, a decade passed before these recommendations were transformed into support measures dedicated to primary healthcare (PHC) under the FEnIKS program, financed by the European Union’s cohesion policy.

2014 was a turning point for me personally, as I won a competition for expert support for the European Commission’s Directorate-General for Regional and Urban Policy (DG REGIO). My role concerned investments from the European Structural and Investment Funds in the healthcare sector in Poland. We worked on a strategy aimed at reducing the burden on public finances through the efficient use of EU funds. Strengthening primary healthcare was one of the top priorities at the time, especially in the face of an aging population and rising healthcare expenditure.

Therefore, it should come as no surprise that, like many of my colleagues, both in the Commission and in Poland, I am committed to working to reverse the benefits pyramid and strengthen primary healthcare. Ten years of working together is a long time – full of effort and hope for real change.

The disappointment at the beginning of this process was all the greater. Despite years of preparation, when the moment finally arrived, chaos ensued. Such an important undertaking should not have started with a false start, especially when everyone knew the project would attract enormous interest. Instead of proper planning, we faced systemic inefficiencies and errors that could have been predicted and avoided.

That’s why I’m surprised by the growing number of opinions from both sides of the aisle that everyone tried, that there’s no other way in public administration, and that the effort should be recognized. I have a different vision for public administration. But it requires not so much a change in people, but, above all, an organizational culture. After all, life isn’t just about trying. You also have to deliver. Especially when thousands of doctors spent those days not treating patients but dealing with the situation. Someone rightly asked what the health consequences were.

I also disagree with the view that the ministry assumed little interest in supporting primary healthcare investments under the FEnIKS program. On the contrary, everyone knew it was a project for several thousand entities and hundreds of thousands of złoty of assistance for each qualified applicant, without any contribution from the beneficiary. It was obvious it would generate enormous interest! This was evident even during its preparation years ago, and discussions on industry mailing lists months in advance only confirmed it. Better preparation was simply needed, support from those experienced in implementing such projects, listening to the community, analyzing the risks, and taking appropriate precautions.

Server performance, the architecture of the process itself, the quality of the forms – all of this could be discussed at length. The desperate recovery process and loss mitigation after the failed launch only underscore the scale of the problem. The crux of the whole situation is the fact that the National Health Fund (NFZ) didn’t even have the appropriate tools to handle webcasts of thousands.

To be clear, success will be announced in a month. The ministry has already launched a positive media campaign, emphasizing the value of the support. The allocation was exhausted at the outset. The ministry is meeting with the Zielona Góra Agreement to discuss “important systemic issues.” The protests seem to have subsided. The first funds will likely flow to primary healthcare systems in the fall. We managed it again.

We are masters of creating and managing chaos. But is this what an effective state aspiring to global leadership looks like?

Robert Mołdach

Introduction

The effectiveness of health data-driven actions and decision-making depends on many factors, including data quality, analytical tools, the organization of the data analysis process itself, and the manner in which the observations and conclusions derived from it are used. However, a key issue influencing all of these elements is public acceptance and trust in these actions, and this is where we will focus our attention. The use of health data poses numerous challenges, such as the protection of individual rights, data security, and the requirement for transparency and public participation. To analyze these issues, we will use Moore’s strategic triangle, which allows for a comprehensive view of the problem from the perspective of public value, its political justification, and the state’s enforcement capacity.

Recall that Moore’s strategic triangle is a concept of public management that serves to evaluate and improve the actions of public organizations. The triangle consists of three vertices: public value, political justification, and operational capacity. Public value refers to the benefits that actions bring to society. Political justification encompasses financial, organizational, and legal support, as well as the political legitimacy necessary to implement actions. Operational capabilities refer to the ability of government institutions and stakeholders to effectively carry out assigned tasks. In the context of health data, Moore’s strategic triangle will help us understand how these three dimensions influence the outcomes and effectiveness of decisions and actions.

Collective acceptance of public value

Public acceptance and trust in the purposes for which health data are collected are crucial to recognizing their public value. The conflict between the public interest and the individual’s right to privacy poses one of the greatest challenges in this area. The public interest encompasses the effective management of public health, the development of research, and new medical technologies, while the individual’s interest focuses on protecting the privacy and autonomy of personal data. The fact that public health data also serves the individual’s well-being by providing the best possible care is overlooked from the patient’s perspective. For this reason, the General Data Protection Regulation (GDPR) prioritizes the public interest over the individual’s interests, raising the question of whether this approach is fair and just.

For example, health data is exempt from the right to erasure (the right to be forgotten) under the GDPR. This means that even if a patient requests the erasure of their data, their request will be denied, and their health data will continue to be stored and processed in the public interest. Data processing for public purposes is widely permitted, as it allows healthcare and research institutions to use this data under certain conditions without requiring additional consent from patients. This approach can be justified by arguments for the greater good that arises from analyzing large sets of health data. This allows for a faster response to epidemics, better planning of medical resources, and conducting research that can lead to breakthrough medical discoveries. For example, during the COVID-19 pandemic, access to large sets of health data has enabled scientists and policymakers to quickly make decisions and implement protective measures. It could even be argued that these opportunities have not been fully utilized, and as a result, the number of avoidable deaths caused by the pandemic has not been sufficiently reduced.

However, this approach also raises controversy and privacy concerns. In some countries, such as the United Kingdom, the approach to health data protection differs, offering patients greater rights to control their data. An example is the right to be forgotten for cancer patients, which allows them to have their data deleted from most registers if they deem it necessary. This approach places greater emphasis on individual autonomy and the right to privacy. The decision to delete data should rest with the patient, and information campaigns highlighting the value of data sharing can help increase public acceptance. Critics may fear that if too many people opt out of their data, the effectiveness of public action will be severely limited. However, British experience shows that the percentage of people who opt out is negligible. The motivations for such decisions are most often related to a desire to forget the trauma of illness, not a lack of trust in the healthcare system. Data erasure also carries personal consequences, as doctors, lacking a complete picture of the patient’s health, may struggle to make optimal clinical decisions. However, this can be prevented by making the patient the custodian of their own medical data. However, under the General Data Protection Regulation (GDPR), this concept sounds revolutionary.

The fundamental question of whether prioritizing the public interest over the individual’s interests is justified depends on the context and ethical perspective. On the one hand, the benefits of broad access to health data are undeniable and can contribute to significant improvements in public health. On the other hand, violations of individual privacy can lead to a loss of trust in the health system and fears of misuse, or even surveillance and medical espionage.

To balance these two interests, it is essential to ensure transparency in data collection and processing processes. Citizens must be aware of why their data is being collected, how it will be used, and what benefits it will bring to society. It is also crucial that data protection systems are flexible enough to accommodate the diverse needs and concerns of individuals while enabling the achievement of public goals.

To this end, public involvement in the decision-making process regarding the collection and use of health data is crucial and should not be a government-sponsored initiative. Public participation, implemented through consultations, citizen panels, and collaboration with non-governmental organizations, allows for the consideration of diverse perspectives and the development of a shared understanding. This operating model not only increases acceptance but also legitimizes decision-making processes among the public, which is essential for the long-term success of healthcare policies.

However, just as important as social dialogue is the subjective treatment of patients and their effective involvement in the process of controlling their data. Patients should be involved in the data processing process, and their participation should not merely consist of signing blanket consent forms before their first visit. Mechanisms such as blocking personal data from the PESEL register, used to prevent fraud and unauthorized use of data, could be successfully adapted to health data as well. Furthermore, introducing a system that allows patients to track and control access to their health data could significantly increase trust and social acceptance. Solutions from the credit information sector could serve as a model here.

In addition to patient empowerment, data security is the foundation of trust in system operations. Health data should remain personalized only to the extent strictly necessary for the purpose of processing, and all data processing procedures should comply with personal data protection regulations. Patients must be assured that their data is adequately protected against unauthorized access and breaches. Examples of misuse of medical data, particularly by politicians, or large-scale data leaks, undermine patient trust.

A second means of building trust is transparency in communicating the results of health data analyses. Regularly sharing results in a way that is understandable to the public provides evidence of how data is being used to improve public health. Examples of concrete successes where health data has contributed to improved health or saved lives can significantly increase public acceptance.

Social acceptance and trust in the purposes of health data collection are essential for recognizing the public value of these activities. Clear definition of goals, public participation, protection of individual rights, fairness in data processing, security, and transparency of activities are the foundations of this trust. Taking into account the rights and concerns of individuals while pursuing public goals allows for a harmonious balance between individual interests and the public interest. Only when individuals have confidence that their data is used responsibly and with respect for their rights will it be possible to achieve the full public value of health data.

Political legitimization and systemic support

Political legitimacy and systemic support are the second pillar of effective public policy implementation, including those using health data. In a rapidly changing geopolitical and economic environment, political priorities often focus on immediate and urgent challenges, such as armed conflicts, migration, or economic crises. For decisions based on health data to gain political attention, it is necessary to demonstrate their value in the context of current priorities and understand how these investments can support broader strategic goals. In other words, arguing that health is paramount and, therefore, that tools using health data should be developed to guide optimal public interventions will most often be ineffective.

Healthcare communities, which prioritize patient well-being, will find this situation difficult to understand. However, politicians will be more likely to support public policies based on health data if they see clear and broad benefits that can generate voter support. The problem is that lofty public goals too easily fade in the shadow of all sorts of particularisms. Political parties’ priorities are determined not only by what is just and fair, but also by what will allow them to seize or maintain power. It is true that data-driven actions can yield quick and tangible results. The implementation of e-prescriptions is a prime example of this in recent years. However, recognizing future benefits in the face of current challenges remains a formidable challenge. For this purpose, one need only examine the decade since the adoption of the Public Health Act.

So how can we convince political circles to fully utilize health data for public health purposes, on the one hand, and optimally treat individual patients, on the other? Public value accounting, a method for analyzing public policy goals developed by Mark Moore, provides the answer.

Moore’s public value accounting is a proven tool for assessing public policy priorities. Public value analysis allows for a comprehensive understanding of the costs and benefits associated with investing in health data, taking into account financial, social, and individual aspects. The development of applications serving millions of citizens, investments in technological infrastructure, database maintenance, and information protection require significant resources that could be allocated to more direct interventions. To justify such expenditure and commitment, it is necessary to provide evidence that the benefits of such investments outweigh the costs.

When analyzing the costs, financial costs include both capital expenditures on technological infrastructure and application development, as well as ongoing costs related to database maintenance, information security, management, and general administrative activities. From a social perspective, these investments can generate costs related to potential social resistance to new technologies and the need to educate the public on the benefits of processing health data. This is precisely what we observed in the case of e-prescriptions.

However, understanding the full costs and benefits requires an analysis of both expected and unexpected consequences. Among the latter, negative consequences can be identified, such as increased bureaucracy and digital exclusion, which can hinder access to health services for certain social groups. From an individual perspective, it is crucial to minimize concerns about the misuse of health data by implementing effective privacy protection mechanisms and the impossibility of withdrawing consent to data processing.

On the benefits side, the financial benefits of investing in health data are now clear. Effective health data management leads to savings through better resource planning, reduced hospitalizations, and support for research that can lead to the discovery of new therapies and drugs, which in the long term reduces medical costs. Societal benefits include improved population health through more effective prevention programs, faster responses to health threats, and greater social cohesion through transparency and participation.

From an individual perspective, the benefits of collecting health data include access to more personalized care and improved health outcomes through faster diagnosis and more effective treatments. Patients can benefit from a more integrated healthcare system where their medical history is easily accessible to various providers, improving continuity and quality of care. However, this must first be made clear to them.

Moore’s public value calculus is an indispensable tool in assessing public policy priorities, particularly in the context of data-driven public health investments. By taking into account financial, social, and individual costs and benefits, it allows for a comprehensive analysis and presentation of the value of such investments. In the face of competing political priorities, this calculus demonstrates that public health and medical data can be treated as political goals on a par with combating economic or geopolitical crises. Its most important feature is providing policymakers with arguments that help justify long-term investments by demonstrating that they deliver tangible benefits that outweigh the initial costs.

These premises inspired the author to submit to the Patient Rights Ombudsman a proposal during the first months of the COVID-19 pandemic for applying public value calculus to the discussion and selection of optimal public interventions in the face of the pandemic. This proposal received a positive opinion from the Patient Rights Ombudsman’s Expert Team. However, it was not accepted by the Prime Minister, who regulated the decision-making process for state interventions in the face of the epidemic threat in a different way. Even from today’s perspective, the lack of a transparent system for making critical decisions that impact the lives of millions of citizens, based on public value, remains, in the author’s opinion, a mistake.

Executive abilities

Executive capabilities constitute the third key cornerstone of Moore’s strategic triangle, essential for effective operations and decision-making based on health data. While a well-developed technological infrastructure, staff competencies, and effective data management processes are the foundations of these capabilities, their actual translation into operational action depends on the understanding of the purpose by those involved in their implementation. Effective implementation of these capabilities requires the commitment and awareness of employees, who must see the meaning and value of their work to avoid routine checkboxes and potential errors resulting from misunderstanding the purpose of activities.

Effectively transforming executive capabilities into concrete operational actions begins with ensuring that everyone involved in the process has a clear understanding of the goals and benefits of collecting and analyzing health data. Employees must be aware that their work directly impacts public health and the quality of healthcare. Therefore, investing in education and training that not only teaches technical skills but also demonstrates how these skills translate into tangible benefits for patients and society is crucial.

One of the key challenges is ensuring that employees understand and respect both the collective and individual interests. For example, in data analysis, there is a risk that focusing solely on population-based results may lead to the disregard of the specific needs and rights of individuals. To avoid this, effective implementation of ethical and legal principles that protect patient privacy and ensure that data is used in accordance with the highest ethical standards is essential.

Enforcement capabilities must also ensure that new obligations do not impose an excessive administrative burden on all parties involved, including stakeholders. It is not successful to impose a new public obligation without providing implementation tools that allow it to be fulfilled almost imperceptibly or without providing the necessary organizational, technological, or financial support.

An organizational culture that promotes openness, transparency, and collaboration is also crucial. In healthcare organizations, where data is a key resource, this culture must support information exchange and collaboration between various departments and specialists. Interoperability of IT systems and data exchange standards are essential for the effective integration of data from various sources, which in turn enables a better understanding of population health and more informed decision-making.

Implementation capabilities also encompass data quality management. Data must be accurate, complete, and up-to-date to be effectively used for decision-making. Data quality management is a continuous process that requires the involvement of all employees, from data collection standards and collection to analysis and reporting. Employees must be aware of the importance of data quality, have the appropriate tools, and be accountable for maintaining it.

Implementation capabilities are crucial for transforming theory into practice in health data-driven operations. Success depends on ensuring an appropriate data collection and processing environment, and on the involvement and awareness of employees, who must understand the goals of their activities and the value their work brings to the healthcare system.

Summary
Moore’s strategic triangle is a key tool for shaping public interventions, which ideally encompass the development of data-driven public health and health systems. It encompasses three main perspectives: public value, political legitimacy, and implementation capacity.

From a public value perspective, understanding policy objectives by all stakeholders and effectively communicating the benefits are crucial. Political legitimacy requires addressing the concerns of all stakeholders, sustained government support, and effective communication. Politicians will be more likely to support data-driven health policies if they see clear benefits that can generate voter support. Implementation capacity requires adequate resources, an effective organizational structure, and an organizational culture.

In summary, Moore’s strategic triangle allows public health, health systems, and health data to be treated as equal priorities in strategic policy priorities, alongside other key challenges such as economic or geopolitical crises.

Robert Mołdach

An empowered society

Raulinajtys-Grzybek and Włodarczyk[1] present actions that the state should undertake or develop to address the needs of patients and the challenges of the healthcare system in Poland, in order to improve the efficiency, quality, and effectiveness of healthcare, and reduce health inequalities. In the area of ​​services, the proposed actions include the availability and comprehensiveness of preventive screenings, digital technologies, the ecosystem of healthcare facilities, contracting services, the legal framework for operations, financing models, quality of care, the potential of medical professions, and, finally, organizational culture and staff education. These goals are entirely justified. In this situation, it is worth questioning the state’s ability to achieve them. It is worth identifying the barriers the state must face and the gaps in its potential.

Answering the question about the shape of effective public interventions in healthcare in Poland requires, first and foremost, a discussion of the state’s capacity to shape and implement public policies. This capacity determines the choice of intervention objectives and means to achieve the expected results, as well as their effectiveness. Let us begin by recalling an archival legislative framework, which could be encountered during the presentation of regulatory concepts at the beginning of this century. Its axis and first element was the so-called legislative “idea,” i.e., a regulatory concept proposed by the ministry undertaking the legislative initiative, intended to solve an identified public problem. The problem is that neither the choice of the issue nor its solution resulted from broad social dialogue. The prevailing belief, some of which can still be discerned, was that the role of public authorities is to choose directions and methods of development, while stakeholders have the sole right to assess them. It was, and to a large extent still is, rare for public authorities to present to stakeholders a problem and alternative solutions developed in a prior, broad expert dialogue. Situations where society participates in defining problems have been and remain even rarer, unless it concerns situations popularly known as “firefighting,” where social protest produces direct political consequences.

Poland’s accession to the OECD in 1996, followed by Poland’s adoption in 2001 of the principles of good legislation formulated in the 1995 OECD Council Recommendations[2], raised hopes that the relationship between government and society would be more inclusive, respecting the subjectivity of society and the social partners representing it. The aforementioned OECD Council Recommendations outlined good lawmaking practices in the form of a ten-point checklist. The first question on the list concerned a fundamental issue: the definition of the problem—whether it had been properly defined. As we read in the Recommendations, the problem to be solved should be precisely defined, clearly indicating its nature and size (scale), and its description should explain why it arose (that is, identifying the motivations of the entities affected and the resulting behaviors). This second part, identifying relationships and analyzing root causes, continues to pose difficulties. These questions cannot be answered without listening to and considering the voices of the social partners.

Government leaders around the world are eager to take shortcuts that bypass a thorough identification of the problem and its underlying causes. What is the reason? The answer is complex and requires individual assessment in each case. However, in the background, we usually find the temptation of easy steps instead of pursuing demanding and politically risky goals, a belief in the universality of certain solutions, a desire to introduce rapid change, a misguided programmatic axis, a blind doctrine, and finally, a lack of competence. As a result, the beloved legislative “idea” keeps resurfacing as a way to solve only seemingly understandable problems. To counteract this, the voice of the scientific community is essential. The proposals put forward by Raulinajtys-Grzybek and Włodarczyk align with this demand. However, to give them real value, openness on the part of the authorities is necessary, allowing for public reflection that the optimal solutions are not yet known.

Top-down or jointly with stakeholders?

The call for problem identification, as outlined in the OECD Council recommendations, is a well-recognized issue in building a state’s capacity to shape public value. In many cases, not only in Poland, decision-makers make the mistake of focusing on a chosen solution without properly framing and discussing the problem. This leads to designing typical “business-as-usual” interventions without addressing the underlying issues. However, most problems in the public sector, and particularly in healthcare, are highly complex and require precise decomposition before a solution can be identified.

Compton and Hart[3], who presented fifteen in-depth case studies illustrating successful strategies from various countries and economic sectors, demonstrated, among other things, the complex reasons behind the British NHS’s success in reducing waiting times for healthcare services. This is also an important goal for the National Health Fund. In the case of the NHS, solving this problem was no shortcut. As Andrews[4] notes, successes such as this are driven by two competing methodologies. The first, abbreviated as SLDC, is characterized by Solution and Leader Driven Change (SLDC). This represents perhaps the most common approach in policymaking and emerges particularly from Spence’s Growth Commission research[5]. This methodology posits that successful transformations occur when, in times of crisis, appropriate public policies are enacted by undisputed leaders, who then hold stable power for a sufficiently long period to implement top-down solutions. We find this narrative in contemporary Poland, where it takes on a special dimension in the period before the 2023 parliamentary elections.

The second methodology, abbreviated as PDIA, is characterized by an iterative approach based on problem analysis (Problem Driven Iterative Approach/Adaptation). This approach to development policy was developed at Harvard University and validated over the past two decades in a number of countries. Unlike SLDC, which relies on the influence of leading leaders and universal patterns (models), PDIA is focused on the problem and its full understanding[6]. It assumes that successful transformations occur when change ambassadors do not adopt hegemonic attitudes but, inspired by stakeholders, collaborate in processes that provide answers to specific problems understood at the level of their root causes by interdisciplinary problem-solving teams.

SLDC and PDIA represent two contrasting approaches to development policy. The former is based on adopting a model solution drawn from political doctrine, the leaders’ own experience, and the experience of other countries or economic sectors where this solution has proven effective. These are precisely the “ideas” for legislative solutions implementing public policies that we have witnessed, and to some extent continue to witness. In this case, the leader, aspiring to the role of reformer, thoroughly understands the challenge and is convinced that the solution he proposes will deliver the desired result. The problem is that successful implementation of public policies in complex social and economic conditions based on the SLDC approach is not an everyday occurrence. The failures of such reforms stem not only from flawed strategic concepts but also from the lack of a stable political environment guaranteeing consistent adherence to the plan. In healthcare, even if we assume that certain reforms of recent decades were intentional, we often were unable to see their final results due to changes in political configurations.

When analyzing Raulinajtys-Grzybek and Włodarczyk’s proposals for feasibility, it’s worth taking the observations on the effectiveness of public policies implemented with World Bank financial support as a cautionary tale. As Andrews[7] demonstrated, the results of 999 such projects implemented in over 100 countries between 2016 and 2020 are mixed. Of these, only 295 measures produced satisfactory or very satisfactory results, 105 were highly unsatisfactory or simply unsatisfactory, while the remaining 599 were considered moderately satisfactory or moderately unsatisfactory. As if that weren’t enough, Andrews showed that in 477 projects, i.e., in almost half of the cases, there was a high or significant risk that their results would not be sustained.

Dialogue and cooperation

So what should be done to implement interventions like those advocated by Raulinajtys-Grzybek and Włodarczyk? How can we decide which problems are paramount and which patient health initiatives should be undertaken to address them?

Choosing the optimal actions in public healthcare policy is a challenge in itself. Objectification in Poland was sought through tools such as the Health Needs Map (HNM), the BASiW (BASiW), the IOWISZ investment assessment system, the Policy Paper, and transformation plans. However, these tools are more a result of the SLDC approach than the PDIA. In a report on structural investments in healthcare and their coordination, Moldova[8] demonstrated how difficult it was in practice to apply these tools to determine which of two competing centers with overlapping service scopes should develop a specific area and which should choose a different development direction.

Mark Moore of Harvard University, the creator of the concept of public value, emphasizes the social value of government interventions, not just their financial or economic value[9]. He recommends the use of non-financial metrics and the use of non-economic motivations and non-market processes to shape social outcomes. This requires dialogue and collaboration that goes beyond public consultations on proposed legislation or even task forces appointed by the Minister of Health. This represents a completely different scale of cooperation between the state and citizens, one that has yet to emerge in Poland.

Public value, which escapes attention in the Polish healthcare system and which should be the main axis of intervention logic, according to Moore requires cooperation in three areas: acceptance by all stakeholders, decision-makers, and political centers of the form of public value being created, the technical capacity to implement it, and the legal framework and necessary support from all involved institutions. These form a strategic triangle of action[10] that determines the achievement of intended public policy goals. The utmost care must be taken when creating and adopting specific public policies. Particular attention should be paid to opponents who come from a different perspective or are guided by specific values. In complex socio-economic processes, a seemingly minor error in assumptions can cause cascading consequences, leading to the collapse of the entire strategy. As an example, consider the complex fate of the bill on the modernization and improvement of the efficiency of hospitals, which omitted the non-financial aspects highlighted by Moore.

Many authors point to the challenges facing public policymakers, and failed public policies have even earned their own branch of science. In conclusion, let us quote Patricio V. Marquez of Johns Hopkins University, an expert at the World Bank, who emphasizes the risk of confusing “means” with “ends”[11] in the development of healthcare systems. In his opinion, governments and social stakeholders must, above all, clearly formulate and define the overall social goals for the country in the medium and long term. By focusing on actions, the Polish program document “Healthy Future” does not fully follow this path. It does not define endpoints and sustainable impact in the intervention logic, and formulates goals in a loose manner – as increases, decreases, increases, or decreases in specific parameters describing the health reality. Each of its planned tools may be valuable in its own way, but taken together, they do not guarantee a change in the status quo.

Public authorities can only find solutions to the challenges described through sincere, engaging, inspiring, inclusive, and data-driven methodical collaboration with stakeholders. This challenge faces not only the regulator but also social partners. As Ganz[12] demonstrates, examining the conditions for social and political mobilization around shared goals, this type of collaboration requires not only addressing challenges facing one’s own environment but also considering the problems of the broader community and the challenges of the moment. Only then will the valuable proposals formulated by Raulinajtys-Grzybek and Włodarczyk have a chance to shape effective public policy.

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^[1] Raulinajtys-Grzybek, M. Włodarczyk, A. Leki, świadczenia, technologie: proponowane kierunki zmian w perspektywie 5-letniej, Raport otwarcia. Think Tank #SGH dla ochrony zdrowia, 2023.

^[2] Recommendation of the Council of the OECD on Improving the Quality of Government Regulation (Adopted On 9 March 1995), Including the OECD Reference Checklist For Regulatory Decision-Making and Background Note, OCDE/GD(95)95

^[3] Compton, ME. ‘t Hart, P. ‘Great Policy Successes’. Oxford University Press, 2019. https://fdslive.oup.com/www.oup.com/academic/pdf/openaccess/9780198843719.pdf

^[4] Andrews, M. ‘How do governments become great?’ WIDER Working Paper No. 2013/091. United Nations University, World Institute for Development Economic Research, 2013. https://www.wider.unu.edu/sites/default/files/WP2013-091.pdf

^[5] Brady, D. Spence, M. ‘Leadership and Politics: A Perspective from the Commission on Growth and Development’. In D. Brady and M. Spence (eds) Leadership and Growth. Washington, DC: World Bank, 2010. https://documents1.worldbank.org/curated/en/375571468152966660/pdf/527080PUB0lead101Official0Use0Only1.pdf

^[6] Andrews, M. ‘The Limits of Institutional Reform in Development: Changing Rules for Realistic Solutions’. Cambridge: Cambridge University Press, 2013.

^[7] Andrews, M. ‘Successful Failure in Public Policy Work’. Andrews, M; and the President and Fellows of Harvard College. CID Faculty Working Paper No. 402, December 2021. https://bpb-us-e1.wpmucdn.com/websites.harvard.edu/dist/c/104/files/2023/01/2021-12-cid-wp-402-successful-failure.pdf

^[8] Mołdach, R. ‘External expertise on European Structural and Investment Funds implementation in the healthcare sector in Poland’. European Commission, 2019. https://ec.europa.eu/regional_policy/sources/docgener/studies/pdf/implem_healthcare_pl_pl.pdf

^[9] Moore, MH. ‘Creating public value: strategic management in government’. Harvard University Press, 1995.

^[10] Ibid.

^[11] Marquez, PV. ‘Ethics, values, and health systems: Key considerations for building back better’. Patricio V. Marquez blog, 2022. http://www.pvmarquez.com/ethicsvalueshealthsystems

^[12] Ganz, M. Leading Change Leadership, Organization, and Social Movements in Handbook of Leadership Theory and Practice: A Harvard Business School Centennial Colloquium. Edited by Nitin Nohria and Rakesh Khurana. Harvard Business Press, 2010.

Robert Mołdach

The pandemic is creating a crisis on three levels: health, economic, and social. None of these levels will remain the same after the pandemic ends. We must understand that there is no way back, only forward. The role of those in power is to answer the question of what kind of society this is leading to.

Three dimensions of state intervention. In the initial phase of the COVID-19 pandemic, the majority of government actions naturally focused on treating infected patients and preventing the spread of the epidemic. When the scale of measures restricting interpersonal contact, travel, and the provision of services to the public threatened the safety of businesses and entrepreneurs and created the risk of job and income loss for large numbers of people, governments began to propose appropriate protective measures. The resulting discussion about the economic impact of the pandemic gained importance as the risk of depleting the financial reserves of businesses and individuals increased. The third perspective emerged most slowly, yet very consistently. This is the social perspective. Its source lies in the daily changes in social relations, customs, and habits, as well as the fear of a potentially lethal disease. Interest in the novelty of “tele-relationships” on this scale, intended to replace physical contact and protect against infection, is slowly giving way to anxiety, loneliness, and a longing for normal life. Not everyone copes equally well. Even those segments of society that appreciate the benefits of teleworking—flexibility in time management and the ability to balance work with household responsibilities—are recognizing the drawbacks of social isolation. Concerns are arising over cases of domestic violence and the mistreatment of loved ones, especially children. Personal problems are mounting, threatening lasting trauma and the explosion of hidden dramas in the near future.

Looking at the processes described in summary, it’s worth noting that they are interdependent. This means that a change in the status of each of them individually impacts the other two. The scale of this impact depends on the nature of the given phenomenon. Thus, state intervention focused on one aspect of the pandemic—health, economic, and, in the future, social—impacts the others. This interdependence appears to have been underappreciated to date. Saving the health and lives of COVID-19 patients clashes with the future economic and social consequences of these actions. It also impacts the state’s ability to save the health and lives of other patients. Similarly, economic measures shielding businesses and workplaces exhaust the compensatory potential of economies and limit the ability to provide public services, including healthcare, to other groups in need. However, mobilizing social capital to its physical limits in the fight against the pandemic also unfortunately produces negative consequences in the health and economic spheres, which is particularly evident in the case of medical and social personnel.

Therefore, the analysis of the appropriateness, effectiveness, and proportionality of each state intervention should be conducted independently from three perspectives: health, economic, and social. In each case, it should take into account that the state’s potential is limited. The use of its resources for specific actions in one perspective limits the scale of possible actions in the remaining ones. Each intervention can be considered optimal in the interests of the patient, society, and the economy only after considering the limitations of state resources and a multidimensional analysis of its effects.

The concept of primary importance in this approach is the resilience of the healthcare system, the economic system, and social cohesion at the national, community, and individual levels. Exceeding the limits of these resilience levels, or even approaching them, raises concerns. It raises questions about the appropriateness of specific interventions and may lead to uncontrolled social reactions.

As a result, something that, within the framework of a discussion from one of the perspectives discussed, seems purposeful, sensible, not to say optimal, may in the aggregate result turn out to be an action far from broadly understood social expectations.

The value of health interventions. The concept of value in health care is a subject of widespread debate among health care scientists and practitioners worldwide. Over the past decade, a number of definitions of value have been proposed, taking into account its various aspects. Following a broad expert debate conducted under the auspices of the European Commission, the expert panel on effective ways of investing in health, initiated by the Directorate-General for Health and Food Safety, proposed that the value of health investments should be considered from four perspectives[1]:

• technical value,
• social value,
• personal value, and
• allocative value.

In the context of combating the SARS-CoV-2 coronavirus epidemic, technical value, in its simplest terms, is a measure of how many people will die, how many lives will be saved, or how many patients will be prevented from developing a severe form of viral pneumonia requiring intensive care, relative to the measures implemented. It seems that the technical value of an intervention currently has a decisive advantage, relegating other dimensions of the value of health investments to the background.

Meanwhile, the importance of other dimensions of value should not be underestimated. Recall that the social value of health investments is a measure of how specific actions impact social relations and community cohesion, both those formed in the residential and workplace environments, as well as at the local and national levels. Cohesion can be expressed through the level of social inequality among various groups, not just COVID-19 patients. This applies equally to patients treated for cancer, cardiovascular diseases, diabetes, and those suffering from rare diseases. Their situation has changed as a result of the outbreak of the pandemic and the actions taken. In this context, it is also worth asking about the economic consequences of fighting the epidemic for healthy individuals. States’ resources are limited. This is felt, for example, internationally by refugees from Africa and the Middle East located in transit camps, whose situation illustrates the importance of social inclusion for vulnerable and marginalized groups.

A change in our quality of life, assessed from an individual perspective, creates the personal value of an investment in health. A classic example of personal value is the patient’s right not to undergo persistent resuscitation, or the right to choose a medical treatment method, so important for cancer patients in advanced stages of cancer. A dramatic example of personal value is the need, as indicated by doctors in countries stricken with the epidemic, to decide which patient to allocate limited life-saving resources to. This is all the more shocking considering that it is not the patient who decides the personal value of their life, but rather medical personnel who are forced to do so for them. This aspect is particularly evident when combined with technical value, and today, it seems, determines the type and scale of remedial actions undertaken by individual countries.

Taking the three dimensions together, we can hypothesize that the allocation dimension is crucial in assessing the value of health investments. Given the limited resources of the state, the equitable distribution of these resources, ensuring the balanced satisfaction of the interests of all groups, all citizens, across all key dimensions, has a crucial impact on assessing the value chain of public interventions. Such interventions should be considered not only in the short term, when their direct effects occur, but also in the medium and long term, when their secondary effects are observed and felt.

State resources are and will remain limited. The allocative dimension of state intervention, taking into account the well-being of all social groups, cannot be overlooked in the fight against the pandemic.

A new world. Today, public debate lacks a comprehensive analysis of the value of health investments. As one might suspect from governments’ communication, it is also lacking in the closed expert debates shaping national decisions. Meanwhile, the health consequences of these decisions for other patients, the economic consequences, and their impact on social life are already visible. At the same time, economic relations are changing permanently, as are our habits and customs. A new economy and social culture are being created. The problem is that the scale and nature of these changes have not been publicly discussed. Governments made this decision on behalf of their citizens, guided largely by the technical value of health investments, neglecting, or perhaps rather underestimating, its other dimensions. Even if they did, they failed to communicate the results of their analysis to society. Only when these changes began to take shape did messages about their irreversible, or at least multi-year, nature, or their scale, sometimes compared to a global earthquake, sometimes to World War II, appear in the public sphere.

As Poland is still in the early stages of the crisis, and its global impact has not yet fully manifested, it is time to assess the public value chain of planned actions. Such an assessment should be conducted holistically across the three perspectives described above – health, economic, and social. According to Moore’s public value chain concept[2], when shaping the optimal state intervention in each perspective, not only the benefits for direct beneficiaries but also obligations to other social groups should be considered. 

When choosing a specific intervention, it’s also worth considering the four dimensions of health investment value: technical, social, personal, and allocative. It’s important to remember that emerging from the crisis, we will encounter a different economy, a different society, and different social relations. It’s crucial that this change is implemented consciously, with public participation. The costs of making a mistake in this regard will be difficult to imagine.

When responding to the challenges posed by the pandemic, it’s important to remember that there’s no way back. There’s only a way forward. It’s important to know where it will lead and the cumulative consequences of the actions we take.

Robert Mołdach

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[1] Defining value in “Value-based Healthcare”. Report of the Expert Panel on effective ways of investing in Health (EXPH). Brussels, 26.06.2019. https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/docsdir/024_defining-value-vbhc_en.pdf

[2] Moore, MH. Creating Public Value. Harvard University Press. Cambridge, London 1995.