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.
[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.