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.