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.