From marketization to recentralization: the health-care system reforms in Poland and the post-New Public Management concept 1

Abstract

The aim of the article is to evaluate the outcomes of the post-1990 health-care system reforms in Poland in the context of New Public Management and post-New Public Management ideas. The most important arguments put forward in the public debate, both in favour and against the agencification, marketization and privatization of health services, are presented and discussed. They are confronted with quantitative data on the health situation in Poland. In the final sections, the programme of the recentralization and de-marketization of the hospital sector, proposed by the new government formed by the Law and Justice Party (in office since 2015), is analysed against the theoretical background of the post-New Public Management concept.

Points for practitioners

The transformation of the health-care system in Poland took place in 1999, almost 10 years after the democratic breakthrough of 1989, as a part of the second wave of territorial-administrative reforms. Commercialization and partial privatization of public hospitals following the New Public Management model of public sector reform has been much discussed in Poland for the last decade. Yet, this process, which is politically and socially very controversial, has proceeded at a moderate pace. The recent government’s proposals for the de-agencification and de-marketization of health care may be interpreted as a post-New Public Management reform aimed at achieving higher standards of coordination within the system but also as another step towards the consolidation of political power for the ruling party.

Keywords

Central and Eastern Europe de-marketization National Health Fund New Public Management post-socialist transformation privatization public hospitals

Introduction

During 25 years of political and socio-economical transition after 1990, Poland was the largest European country representing the post-socialist adaptation path to New Public Management (NPM) as a model for the organization and steering of public administration. The neoliberal agenda was perceived as a departure from long-lasting socialism and served as the ideological basis for transformations of public services in Poland, including partial commercialization and privatization. The general elections of 2015 brought about a significant political change as the new government formed by the right-wing Law and Justice Party announced its programme of de-agencification and de-marketization in health care, thus reversing some of the most important elements of NPM-inspired health-care reform of the late 1990s.

The aim of this article is to study the transformation of the Polish health-care system since the 1990s through the analytical lens of the NPM/post-NPM debate. As the article is part of a special issue that studies post-NPM in social service provision in different national contexts (Sweden, France, Germany, the UK, Italy and Poland), it is important to underline that these countries belong to different welfare state regimes and hence differ with respect to the institutional settings and actor constellations that characterize social service provision. The use of the NPM and post-NPM concepts in the context of health-care system reforms in Poland is a particularly interesting case as the evolution of public service provision in Poland has followed a development course different from that taken in most West European countries but typical of the Central and Eastern Europe (CEE) region.

Context: NPM impact on post-socialist health-care systems

The NPM-driven reforms in health-care organizations have sought to stimulate entrepreneurial hospital management by relying on quasi-market forces and competition rather than planning, by introducing strong performance measurement and monitoring mechanisms, and by improving information sharing and cooperation among health-care networks (Saltman et al., 2011; Simonet, 2015; Sześciło, 2016). The most significant outcome of NPM reforms in health-care systems is the transformation of patients into customers in a market of regulated competition. Another crucial element of the NPM agenda for health care is the increasing role of private providers of health services (Blank and Burau, 2014). However, as the NPM theory is a rhetorical construction with diverse intellectual roots, it is open to reinterpretation in diverse capitalist and institutional systems and shifts in implementation across countries (Simonet, 2011, 2015), which is especially important in the context of the CEE region.

The NPM debate in the late 1990s brought some scepticism about its generalized applicability, in particular, to developing countries (Allen, 1999; Manning, 2001; Sutch, 1999). Drechsler (2005) argues that in CEE, NPM has been imposed from outside, and that this concept is particularly unsuitable for transitional and developing countries alike because their need for public administration reforms is very different from those of the ‘Western’ countries for which NPM was developed. In his view, it is wrong to install NPM in CEE because the requirements there, due to transition and development features and the legacy of the past, can be better fulfilled by classical, ‘Weberian’ public administration. Nemec (2010) claims that NPM tools and mechanisms have delivered very mixed results in the CEE region, more negative than positive, not mainly because of their character, but because of wrong implementation, or non-implementation. On the other hand, Dan and Pollitt (2015) argue that NPM policy in the CEE region has not always been successful to the extent expected and promoted, but there is enough evidence to show that some of the central ideas in NPM have led to improvements in public service organization or provision across different organizational settings.

Before the collapse of the communist system, countries in the CEE region had applied very similar patterns of organizing their health systems, named after its creator – Semashko’s model. The main assumption of this solution was to provide the same and possibly the most complete medical services to all citizens (Skrzypczak and Rogoś, 2011), though, in practice, it had numerous flaws and deficiencies (e.g. shortages of medications, poor-quality health care, obsolete medical equipment). After 1989, all CEE countries implemented large-scale health-care reforms, though the pace of change was different: faster in Central Europe and slower in the former Soviet Union. It is also possible to identify countries where the communist paradigm remained alive, with merely a minimum scope of changes implemented (Romaniuk and Szromek, 2016). The changes differ among CEE countries depending very much on the specific conditions present at the start of and during the processes. However, there are some common issues. Most notably, key aspects of these changes are: an almost universal switch to health insurance financing systems to replace general taxation-based models; privatization and the introduction of private payments and co-payments; and efforts to strengthen primary health care, often with a model of family medicine delivered by general practitioners (Nemec and Kolisnichenko, 2006; Rechel and McKee, 2009; Sześciło, 2014).

Much was expected from the outcome of the changes but the evidence indicates that many expectations from the ‘marketization’ of health care were not fulfilled (Nemec and Kolisnichenko, 2006). According to Rechel and McKee (2009), many decisions about health policy, such as the introduction of health insurance systems or general practice, took into account political issues more than objective data and arguments, and the evidence for whether health reforms have achieved their intended results is sparse.

Analytical framework: post-NPM concept and research methods

As Poland has been recently called a ‘large but under-researched country’ in terms of health policy analysis (Busse, 2016), we try in this article to partially fill the gap by evaluating the outcomes of the post-1990 reforms in the context of NPM and post-NPM ideas. For many years, the international critical discussion on NPM and its consequences was absent from political discourse in Poland. Modernization, ‘Europeanization’ and ‘catching up with the West’ were intellectually and rhetorically identified with support for the free market, private ownership and encouraging foreign investment in all sectors of industry and services (Mikuła and Walaszek, 2016). In fact, we could not find any scientific paper that explicitly referred to the ‘post-NPM’ concept in the specific Polish context.

However, when studying the most recent developments of the Polish health-care system, we find a number of reforms and proposals that could be interpreted as a reaction to the many serious or imagined shortcomings of the NPM project. The proposed reform measures contain elements of what is called ‘post-NPM’ in other national contexts.

The concept of post-NPM in the social sector is still at an early stage of institutionalization; however, despite being an umbrella term for quite different reform trends, some of its general features may be indicated. In this article, we use the research framework proposed by Klenk and Reiter (2018) based on a comprehensive literature review, with their four ways of interpreting post-NPM:

the organizational models promoted by the concept;

the predominant mode of governance of public administration;

the ideas of the user role in public service provision and consumption; and

the criteria for assessing administrative performance.

The organizational models promoted by the post-NPM concept are based on the ideas of administrative recentralization and vertical reintegration, as well as on functional coordination in the horizontal dimension (Andersson and Liff, 2012; Egeberg and Trondal, 2016; Zafra-Gomez et al., 2012). Proponents of post-NPM criticize the implementation of market-like governance arrangements in the course of NPM reforms as bringing about a strong fragmentation of the public sector, a lack of coordination and thus communicative and informational deficiencies (Anttiroiko and Valkama, 2016; Aulich et al., 2010; Bezes et al., 2013). In many cases, politicians have lost political control over administration due to agencification and the privatization of public services (Egeberg and Trondal, 2009). Therefore, as indicated by Klenk and Reiter (2018), coordination is seen as the primary mode of governance in the post-NPM concept, although there is still a rather high variance concerning the means and instruments to improve it. In this regard, post-NPM organizational ideas such as functional (re)integration and the formation of networks have been portrayed as alternative drafts of NPM to overcome coordination problems (Althaus and Vakil, 2013; Bumgarner and Newswander, 2012; Ramia and Carney, 2010).

Another important post-NPM feature is the idea of users of public services as not merely customers, but citizens in the first place, participating in the democratic control of public management (Byrkjeflot et al., 2014). As political accountability is a broadly shared element of the post-NPM concept, some authors go further by indicating that the user can also be considered as a co-producer of public services (Bartels, 2013; Bartenberger and Sześciło, 2016).

On the other hand, there is still no agreement in the field of post-NPM on the model of performance assessment. Typical NPM criteria like efficiency are still highly significant for public managers, even in post-NPM settings (Bumgarner and Newswander, 2012; Christensen and Lægreid, 2011), but they are supplemented by new performance goals that widen the scope for evaluation. One may point to the idea of democratic control and political accountability as a performance indicator in a post-NPM environment (Zafra-Gómez et al., 2012) or social conditions such as solidarity (Park and Joaquin, 2012), but a full set of new post-NPM criteria has not been proposed.

The relation between NPM and post-NPM is not fully antagonistic. Klenk and Reiter (2018) argue that ‘post-NPM is seen as a reaction to NPM only in some respects, in particular when it comes to administrative organisation (decentralization and fragmentation vs. re-centralization and reintegration) or the “right” way to govern (market-driven vs. coordinative/collaborative)’. However, they indicate that the post-NPM concept is still far from being uniform as it is understood ‘not only as the successive model of the NPM period, but as a “scheme of improvement” of NPM, sometimes even as an “anti-NPM-model”’ (Klenk and Reiter, 2018). Moreover, recent literature shows the growing importance of ‘hybrid NPM and post-NPM tools’ (Marchand and Brunet, 2017), ‘a complicated combination of elements from NPM and post-NPM reforms’ (Christensen and Fan, 2016) or ‘convergence toward a hybrid system rather than toward a post NPM paradigm’ (Simonet, 2015).

Our main field of interest is the adaptation of the post-socialist, post-transitional countries like Poland to internationally spreading administrative reform trends that have to be interpreted against their historical background. We question whether the NPM-inspired model of health-care system transformation has come to an end and is now being replaced by new regulations that can be considered as an ‘offshoot’ of international post-NPM tendencies.

To study the transformation of the health-care system in Poland, we have proceeded as follows, combining different data sources:

based on legal acts, policy documents and wider literature, we have drawn the outline of the specific historical development path of the health-care system in Poland, much influenced both by long-lasting Communist Party rule and by the dynamic – democratic and market-oriented – transformation of the 1990s, with privatization processes in the hospital sector in Poland as the important and probably most controversial aspect of NPM-driven reforms after 1999;

further, we discuss new regulations introduced by the Act of 23 March 2017 Amending the Act on Health Care Services Financed from Public Funds – the so-called ‘hospital network act’ – that radically changes the health-care system following the political agenda of the Law and Justice Party;

through analyses of parliamentarian debates and the opinions of prominent political figures on health policy in Poland² presented in traditional and electronic mass-media, we reconstruct the most important arguments in favour and against the recent reform; and

despite a relatively short period of time having passed since the introduction of the new hospital system (in force since 1 October 2017), we decided to check initial reaction to the new solutions, conducting seven face-to-face interviews in the City of Poznań area with hospital supervisors from City Hall, general managers and financial directors of municipal hospitals.

We interpret the transformation of the health-care system in Poland across four dimensions of the post-NPM concept (the organizational models promoted by the concept; the predominant mode of governance of public administration; the ideas of the user role in public service provision and consumption; and the criteria for assessing administrative performance) within the conceptual framework of Klenk and Reiter (2018), using the same analytical lens for the 1990–2015 period and more recent developments. Finally, we question whether the recent hospital sector reform in Poland can be regarded as ‘post-NPM in action’ or is just a consequence of some political ‘anti-NPM’ resentments.

Evolution of the health-care system in Poland

The complex transformation of the health-care system in Poland took place in 1999, almost 10 years after the democratic breakthrough of 1989, as a part of the second wave of territorial and administrative reforms. In general, the organizational models promoted in this period were mainly based on the principles of the decentralization, agencification and commercialization of health care. The reform of 1999 relied on abandoning the budget-related system of financing health care, adopting a mixed budget–insurance model and establishing a system of 16 regional (and one specialized) health insurance funds (named in Polish ‘kasy chorych’ – a direct translation of the German ‘Krankenkasse’), divided in line with the country’s territorial structure (Piotrowska-Marczak and Kietlińska, 2001). Decentralization of the health-care system indicated that most hospitals (the ownership of infrastructure and responsibility for managing the services) were transferred to the jurisdiction of counties and regional governments (Surówka, 2010).

Initial reforms were haphazard and there was little continuity in the reform process, which could be explained by the varying political agendas of the parties in power and by a lack of expertise and capacity for in-depth analysis preceding the reforms (Busse, 2016). In 2003, new legal and organizational changes were introduced, involving the partial recentralization of financing and the establishment of a single National Health Fund (NHF). The legal status public health-care funding also changed: health insurance funds were regional self-government institutions while the NHF is a central government agency with a legal personality. Kolwitz (2010) argued that the retreat from the 1999 reform had negative consequences for the system, pointing out that the new system was not allowed to stabilize, and that the planned second stage of the reform programme – the introduction of private health insurance schemes – had not been implemented.

As a result of a reform introduced in 1999, an internal market for medical services was, in fact, established. The facilities gained independence and were supposed to be self-reliant from then on by charging for each patient and the rendered services. The quasi-market approach became the predominant mode of governance in the health-care sector. Yet, in many cases, the revenues from the NHF were not sufficient to cover all the costs of health-care institutions (Sagan et al., 2011). As a result, they have increasingly sunk into debt. Indebted hospitals, but also the potentially profitable ones, have been most frequently designated for privatization following the NPM model of the public sector reform. Local governments could sell or lease indebted hospitals for fear of excessive costs, as well as profitable hospitals in order to acquire funds needed in other sectors of local public policy.

This process of ‘spontaneous liberalization through privatization’ (Kozek, 2011), which is politically and socially very controversial, has proceeded at a moderate pace. Between 1 January 1999 and 30 June 2011, 113 hospitals underwent transformation. The process of proprietary transformations in the health-care sector in Poland gathered momentum despite a lack of specific regulations that would allow directly transforming public hospitals into limited liability companies. Adoption of the Act on Medical Treatment on 1 July 2011 was of significance to the health-care system (Sagan and Sobczak, 2014). The Act’s major goals included the standardization of the names of medical facilities, increasing the shared responsibility of the founding institutions for financing the respective facilities and the simplification of the commercialization procedure (Wielicka, 2014). The Act offered a brand new possibility of transforming an independent public medical facility into a limited liability company or a public company. This new type of legal transformation does not necessitate liquidation and the takeover of all the facilities’ liabilities by the local government. Between 1 July 2011 and 2014, 48 more facilities were transformed. All in all, the process of commercialization has encompassed 18% of all the hospitals in Poland (PMR, 2014).

It should be noted that the rapid development of private health care in Poland has relied not only on the privatization of large public hospitals, but also, in much larger scale, on an expansion in the number of private medical practices, pharmacies and compact hospitals and clinics (Dziubińska-Michalewicz, 2004). To a great extent, therefore, there is a rather uncoordinated process of marketization taking place beyond the public sector reform.

The reform in 1999 was accompanied by the slogan ‘money follows the patient’ (Sześciło, 2016). As a result, the idea of the user role in the system and the patient’s position has changed. He/she has become someone desirable, someone to care for. Of course, the change was most rapid in the commercial facilities, yet the public ones have also started to act like private companies. They started to attract ‘profitable’ patients but also to extend the basis for profitable operations in order to finance loss-making facilities (Balicki, 2017). The hospital could negotiate the intensity of the services provided, but it had no influence regarding the reimbursement rate. That was because of the prospective system payment (Silva and Cyganska, 2016). Access to medical treatment has greatly improved since 1999, but a limiting mechanism was introduced together with the reform: we will pay for every patient but not more than the predefined total amount. There was a reason for this policy; originally, there were well-grounded concerns that the switch to paying for a service would increase the number of services (Balicki, 2017). A new phenomenon has emerged, called ‘over-performance’: hospitals admitting more patients than the contract would allow in the hope that, sooner or later, they would be remunerated for it.

As an outcome of the transformation of the health-care system, economic efficiency emerged as the most important element among the criteria for assessing administrative performance. Therefore, the commercialization of hospitals has become one of the most important elements of the reform schemes between 1999 and 2014. The prospect of commercializing hospitals has given rise to social concern that the newly established companies would have the liberty to limit the scope of health-care services. On the other hand, it is claimed that private hospitals have offered patients many benefits. For several decades, the government failed to solve the problem of access to medical treatment:

There was no money for resonance imaging, computer tomography, new laboratories to save patients with myocardial infarction etc. These problems have been solved by private investors within a few years since the establishment of the Health Care Funds. They helped the state out. The emergence of private hospitals and clinics stimulated public providers to redecorate their facilities and improve the conditions in which patients are treated. (Sośnierz, 2017)

Over the past 15 years, the private expenditures of households on health services have doubled but, in general, Polish citizens do not accept health-related reforms like cost sharing or additional voluntary health insurance. However, according to a comparative study of six CEE countries, they are more willing to pay than their counterparts in, for example, Hungary, Lithuania or Romania (Danyliv et al., 2014).

The reform of the hospital sector in 2017 and initial reactions

The general elections of 2015 brought about a significant political change as the new government formed by the right-wing Law and Justice Party announced its plans for new organizational solutions in the health-care system. The diagnosis of the problem in Polish health care in the eyes of the Health Minister Konstanty Radziwiłł (in office since 2015) has been described as follows: Polish patients are divided into profitable and unprofitable ones, that is, the latter are perceived as undesirable in hospitals. What is more, specialized private hospitals ‘pick up the best bits’, rendering medical services profitable and leaving whatever is left to public medical institutions (Balicki, 2017). The minister has even publicly used much stronger phrases: ‘The enormous pressure of toxic competition … the result of this deadly market-based situation in health care, which is generally under-funded for a very long time, is that hospitals have legitimate concerns about their existence and some simply disappear’ (Radziwiłł, 2017). This problem of the rising public–private sector gap is also experienced in other countries, for example, France (Simonet, 2014).

The Ministry of Health has heralded changes related to establishing a system of basic hospital provision of medical care, that is, the so-called network of hospitals. The announced goal of the change is to provide patients with access to hospital treatment and outpatient specialist care in hospital clinics, as well as to ensure the continuity and comprehensive nature of medical benefits. A hospital that fulfils the conditions and qualifies for the network will have a 100% guarantee of financing over a four-year period in the form of a global grant and would not have to take part in a contest. Approximately 91% of the funds with which hospital treatment is financed will now be allocated in this way. On the other hand, hospitals that fail to be incorporated into the network (entirely or with respect to a specific scope of benefits), will have an opportunity to attempt to contract medical treatment following a competitive procedure.

Finally, the liquidation of the NHF is planned, with the redistribution of its responsibilities between the Ministry of Health and newly created regional health offices. It will be coupled with the switch from an insurance to a budgetary model, fulfilling the state’s constitutional responsibility of ensuring that health care is available to all citizens (Radziwiłł, 2017).

The heated political debate about new solutions was focused on the key arguments presented in Table 1. The legal regulations on the so-called ‘hospital network’ have been passed relatively quickly (Sejm RP, 2017); however, more general changes, including the liquidation of the insurance-based system and the NHF, have been postponed for the next parliamentary term. The prospects for their implementation are therefore not clear.

Table 1.

Key elements of the political debate on the 2017 health-care reform in Poland.

Arguments in favour of reform	Arguments against reform
Ensuring state responsibility for public health instead of market-like solutions More stability – the best hospitals or clinics will have four years of guaranteed financing (like ‘heaven on earth’; Balicki, 2017) More user-oriented approach – continuity of medical procedures, complex treatment Before the reform funds were provided not for the entire healing process, but only for a treatment, a surgery, a visit, a stay in hospital etc. – the arbitrary prices set for medical services are either inflated or too low with respect to the costs involved Better standard of health service in night-time and holiday periods	Overthrowing a system familiar to everyone after 17 years of operations The global grant will demotivate hospitals (‘a terrible idea’; Sośnierz, 2017) – every patient will be a cost and, after exceeding a limit of admissions, it will be an unwanted cost No guarantee that all the rendered services will be paid for Adoption of the criteria excludes all the new facilities and the ones without contracts for emergency units – most of them private – some hospitals or specific medical units will be closed down No new hospitals are planned in the network Marginalization of certain areas of medicine, e.g. rehabilitation or cardiology An institution similar to the NHF will operate in every region anyway, only its subordination will change

Arguments in favour of reform

Arguments against reform

Ensuring state responsibility for public health instead of market-like solutions

More stability – the best hospitals or clinics will have four years of guaranteed financing (like ‘heaven on earth’; Balicki, 2017)

More user-oriented approach – continuity of medical procedures, complex treatment

Before the reform funds were provided not for the entire healing process, but only for a treatment, a surgery, a visit, a stay in hospital etc. – the arbitrary prices set for medical services are either inflated or too low with respect to the costs involved

Better standard of health service in night-time and holiday periods

Overthrowing a system familiar to everyone after 17 years of operations

The global grant will demotivate hospitals (‘a terrible idea’; Sośnierz, 2017) – every patient will be a cost and, after exceeding a limit of admissions, it will be an unwanted cost

No guarantee that all the rendered services will be paid for

Adoption of the criteria excludes all the new facilities and the ones without contracts for emergency units – most of them private – some hospitals or specific medical units will be closed down

No new hospitals are planned in the network

Marginalization of certain areas of medicine, e.g. rehabilitation or cardiology

An institution similar to the NHF will operate in every region anyway, only its subordination will change

Source: Own compilation based on Balicki (2017), Panek (2017), Radziwiłł (2017), Sejm (2017) and Sośnierz (2017).

As the new organizational model of the hospital sector was introduced on 1 October 2017, there has only been a relatively short time for the assessment of its practical outcomes. However, there are some interesting remarks from interviewed hospital supervisors and general and financial managers of municipal hospitals that should be taken into account:

Hospital managers and supervisors generally praise the greater stability given by the global grant.

However, as the global grant allows for more flexibility in transferring funds from the NHF between hospital units, it also requires a larger managerial responsibility (‘It is more business-like management now, not only administering money for precisely targeted medical procedures’).

As some hospital units did not enter into the ‘network’ scheme, they must take part in open contest for funding – there is strong atmosphere of uncertainty about their future existence.

With the year of 2015 set as the basis for calculating the global grant for individual hospitals, it seems that there is, in general, less money than before – the problem of ‘over-performance’ from previous years is still not resolved. However, detailed accounts will be available within only a few more months.

Discussion: How much ‘post-NPM’ is there in the new reforms?

Considering the transformation of the health-care system in Poland after 1990, we can conclude that a comprehensive reform carried out in 1999 was widely rooted in the traditions of NPM (Sześciło, 2014). The reform brought the implementation of a quasi-market of medical services, competition between public and private hospitals, and the possibility of the transformation of public hospitals into commercial companies. In this context, there is a need for broader reflection on the interpretation of the reform proposed in 2016 and partly introduced in 2017, which is the result of general political change, in relation to the understanding of the term ‘post-NPM’. For the analysis of the recent government’s proposals, we use the analytical framework proposed by Klenk and Reiter (2018), with their four ways of post-NPM interpretation mentioned earlier.

When it comes to organizational models, recently proposed reforms of the hospital sector in Poland are mainly based on criticism of the characteristic features of NPM: the marketization, agencification and fragmentation of the public sector. The recentralization on the vertical dimension is the essential point of the reform; however, another post-NPM element – functional integration on the horizontal dimension – can hardly be seen. It should also be noted that the NPM model has not, in fact, been fully implemented in the hospital sector since the 1999 reform:

Marketization: medical services were contracted by the NHF in a quasi-market competition scheme but the cost of different medical procedures is arbitrarily set by the NHF.

Agencification: as a government agency, the NHF has extended decision-making autonomy, which resulted in many conflicts between the NHF and Ministry of Health. However, it remains under the strong political control of changing parliamentary majority parties. It is certainly not ‘depoliticized’.

Fragmentation: 16 regional offices of the NHF have some margin of independence in their policies, which leads to differentiation of medical standards across the country, but, in general, they follow the recommendations of NHF central bodies.

Another problem with interpreting the government’s proposals for the hospital sector in post-NPM terms is the complete absence of such organizational ideas as functional reintegration, the formation of networks or new opportunities for inter-agency coordination. The new law on health reform is popularly called the ‘Act on the Hospital Network’, even in official announcements of the government, but it is a very specific understanding of ‘network’: a hierarchical organizational scheme of hospitals designed by the state administration.

If post-NPM, as indicated by Klenk and Reiter (2018), is ‘thought to represent a new idea of organizing public administration and public policy by adding a new layer of administrative structures and processes on NPM settings’ and is not associated with a ‘return’ of the Weberian bureaucracy, then proposed reforms of the hospital sector in Poland cannot be considered as ‘post-NPM’ – although they definitely can be described as ‘anti-NPM’.

If we move towards the discussion on coordination as the primary mode of public governance within a post-NPM administrative setting, and the criticism of communicative and informational deficiencies as the consequences of the implementation of market-like governance arrangements, then recent proposals for hospital sector reform in Poland seem to fit into this scheme, at least in more general terms. The ‘quasi-market’ competitive system of contracting medical services by the NHF, usually for a one-year period – flexible, but unstable – was one of the most criticized elements of the health-care system. On the other hand, the idea of strengthening the politicization of public management is one of the most dominating features of the Law and Justice Party’s governmental agenda. If we consider coordination as a key issue of public governance in the post-NPM concept, then the means and instruments to improve it proposed for the hospital sector in Poland seem to be very radical. The vision of a ‘coordinated hospital network’ means the far-reaching rejection of the existing health-care system and is strongly related to the reimposition of direct political control over the health-care sector. The improvement of the public sector’s ‘capacity to act’ is one of the key arguments for the transformation of the hospital system but there are serious fears that this element of the reform will dominate over other important values, especially the quality of medical services.

This last point brings us closer to the user perspective and the interpretation of proposed reforms for the hospital sector in Poland in terms of an idea of users. If the post-NPM concept underlines the role of users as citizens and voters in a democratic political system, instead of being ‘clients’ or ‘customers’, then this layer of thinking is relatively weak in the pro-reform narrative. The official speeches of senior government members and parliamentarians of the Law and Justice Party are often full of rhetorical figures like ‘will of the Nation’ or ‘Sovereign’s will’ to justify proposed measures in almost all sectors of public policy. However, in fact, this only refers to the result of the last general election in 2015, which gave an absolute majority in Parliament to the party (with 37% of the vote). Then, the concept of political legitimacy and accountability in hospital system reform is very fuzzy: citizens gave the ruling power to one party, so it has full freedom to change the health-care system in accordance with its ideas and beliefs. In fact, the quasi-market competitive procedures of the NHF will be replaced by criteria imposed by the central administration and the ‘credits system’. The democratic control function is limited to the general parliamentary election, held every four years. In this field, the reform of 1999 that transferred control over the majority of general hospitals from the state administration to the directly elected county and city councils was much more progressive.

The last dimension of the post-NPM concept concerns the criteria of how to assess administrative performance. As Klenk and Reiter (2018) indicate, the institutionalization of post-NPM in this field is still low and, so far, no common set of criteria has been established. In this context, the idea of ‘responsibility’ as an additional performance assessment dimension is especially important for the interpretation of proposed reforms in Poland. It is one of the essential arguments in the discussion: to replace the existing system of short-term contracting, the detailed pricing of individual medical procedures and ‘keeping up with standard costs’ with the idea of a medium-term global financial grant and the responsibility for the whole process of medical treatment in case of individual patients. This kind of approach can also refer to constitutional or ethical values in the field of health care.

Conclusions

The post-NPM concept is still at an early stage of institutionalization, but Klenk and Reiter (2018) conclude that at the theoretical level, we can see the start of consolidation of the understanding of this idea. What we have learnt from the case of proposed reform of the hospital sector in Poland, described in this article, brings more questions about the interpretation of the post-NPM concept in a practical context. This radical reform is a reaction to many serious or imagined shortcomings of the NPM project. The programme of the de-marketization and de-agencification of health care shows many traces of the post-NPM concept but it can also be perceived as a politically driven action to strengthen the tight control of the ruling party over an important part of the public sector, in parallel with its efforts in other fields like education, media or the justice system. However, both perspectives may not be mutually exclusive if post-NPM can be viewed as an option for the political centre to ‘strike back’ and to regain control over administrative action (Dommett and Flinders, 2015). Even though we find elements of post-NPM in the most recent reform, the communicative legitimization of the reform, the rhetoric behind it and the politics of the reform differ from what we can observe in Western Europe. The final outcomes of the reform are still unknown, but an important question emerges in conclusion: should we consider every ‘anti-NPM’ action as a part of the more or less institutionalized ‘post-NPM’ concept?

Footnotes

Notes

Łukasz Mikuła is Associate Professor in the Institute of Socio-Economic Geography and Spatial Management at the Adam Mickiewicz University (AMU), Poznań, Poland. He holds a Masters in Spatial Management (2005), Masters in Law (2007) and PhD in Human Geography (2009). His research interests include local government, public administration, spatial and strategic planning, and metropolitan governance. An expert of the Metropolitan Research Center (CBM) at AMU, he is also Chairman of the Spatial Policy Committee of Poznań City Council and Metropolitan Planning Commission for the Poznań Metropolis.

Urszula Kaczmarek is Associate Professor in the Institute of Socio-Economic Geography and Spatial Management at the Adam Mickiewicz University (AMU), Poznań, Poland. She holds a Masters and PhD in Human Geography. Her research interests include social policy, social factors of local development and the geography of rural areas. She is an expert of the Metropolitan Research Center (CBM) at AMU.

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