State of Health in the EU Poland Country Health Profile 2017

European

on Health Systems and Policies a partnership hosted by WHO b . Health in Poland

The Country Health Profile series Contents The State of Health in the EU profiles provide a concise and 1 • HIGHLIGHTS 1 policy-relevant overview of health and health systems in the EU 2 • HEALTH IN POLAND 2 Member States, emphasising the particular characteristics and 3 • RISK FACTORS 5 challenges in each country. They are designed to support the efforts of Member States in their evidence-based policy making. 4 • THE HEALTH SYSTEM 6 5 • PERFORMANCE OF THE HEALTH SYSTEM 9 The Country Health Profiles are the joint work of the OECD and 5.1 Effectiveness 9 the European Observatory on Health Systems and Policies, in 5.2 Accessibility 11 cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by Member 5.3 Resilience 14 States and the Health Systems and Policy Monitor network. 6 • KEY FINDINGS 16

Data and information sources The data and information in these Country Health Profiles are The calculated EU averages are weighted averages of the based mainly on national official statistics provided to Eurostat 28 Member States unless otherwise noted. and the OECD, which were validated in June 2017 to ensure the highest standards of data comparability. The sources and To download the Excel spreadsheet matching all the methods underlying these data are available in the Eurostat tables and graphs in this profile, just type the following Database and the OECD health database. Some additional data StatLinks into your Internet browser: also come from the Institute for Health Metrics and Evaluation http://dx.doi.org/10.1787/888933593741 (IHME), the European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Poland, 2015

Poland EU

Demographic factors Population size (thousands) 37 986 509 394 Share of population over age 65 (%) 15.4 18.9 Fertility rate¹ 1.3 1.6

Socioeconomic factors GDP per capita (EUR PPP2) 19 800 28 900 Relative poverty rate3 (%) 10.7 10.8 Unemployment rate (%) 7.5 9.4

1. Number of children born per woman aged 15–49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 50% of median equivalised disposable income.

Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors any territory, to the delimitation of international frontiers and boundaries and to the name of any and do not necessarily reflect the official views of the OECD or of its member countries, or of the territory, city or area. European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union. This document, as Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/ well as any data and map included herein, are without prejudice to the status of or sovereignty over

© OECD and World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Highlights . 1

1 Highlights Poland

While the health status of the Polish population has improved, life expectancy still lags behind the EU average. Risk factors such as smoking, excessive alcohol consumption and low physical activity, together with an ageing population, are adding pressure to an underfunded health system. The Polish government is proposing a set of structural health system reforms to address some of these challenges. Health status

Life expectancy at birth, years PL EU Life expectancy at birth in Poland was 77.5 years in 2015. Although it increased by 3.7 81 years since 2000, it remains three years below the EU average. Large inequalities exist, 80 80.6 79 with women expecting to outlive men by eight years while the gap between the highest- 78 77.3 77 77.5 and lowest-educated Poles is ten years. Less than half of the years lived after age 65 76 are spent free of disability. Cardiovascular diseases and lung cancer are the biggest 75 74 73.8 causes of mortality. 77.5 73 YEARS 2000 2015 Risk factors

% of adults in 2014 PL EU Over a third of Poland’s disease burden can be attributed to behavioural risk factors. Although the number of smokers fell over the past decade, more than a fifth of adults Smoking 23% continue to smoke every day. Alcohol consumption has increased substantially since 2000 and one in six adults report heavy drinking on a regular basis. Obesity rates also increased Binge drinking 17% and are now above the EU average.

Obesity 17% Health system

Per capita spending (EUR PPP) PL EU Health spending in Poland is among the lowest in the EU. In 2015, health expenditure was €3 000 EUR 1 259 per capita or 6.3% of GDP compared to the EU average of EUR 2 781 or 9.9%.

€2 000 Public funds account for 72% of spending, lower than the EU average (79%). Out-of-

€1 000 pocket spending is comparatively high (22%), raising accessibility concerns.

€0 2005 2007 2009 2011 2013 2015 Health system performance

Effectiveness Access Resilience Despite reductions, Poland’s amenable A relatively high proportion of the Polish Poland is facing mortality rate is still higher than in most EU population reports unmet needs for challenges to train and countries, suggesting that the health care medical care. Access to health care is retain a sufficient number system could be more effective in treating hampered by high out-of-pocket spending, of health workers, promote people with life-threatening conditions. a shortage of health professionals and a access to good-quality care relatively high number of uninsured. and respond to growing needs for long-term Amenable mortality per 100 000 population PL EU care. The government is embarking on a 250 % reporting unmet medical needs, 2015 237 reform programme that aims to address 225 High income All Low income 200 access and efficiency issues. PL 175 175 170

150 EU 125 126 2005 2014 0% 4% 8% 16%

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND 2 . Health in Poland

Poland 2 Health in Poland

Life expectancy is increasing, but remains Most of the life expectancy gains in Poland since 2000 were driven below the EU average by reduced mortality rates after the age of 65. Polish women at this age can expect to live another 20.1 years (up from 17.5 years Life expectancy at birth in Poland stood at 77.5 years in 2015, an in 2000). For Polish men this figure is 15.7 years (up from 13.5 increase of almost four years since 2000. This is still three years years in 2000). However, not all of these additional years of life are below the EU average, but represents a slight narrowing of the gap lived in good health. At age 65, Polish men can expect to live about compared to 2000 (Figure 1). half (7.6 years) of these years free of disability, while women can expect to live only two-fifths (8.4 years) of their remaining years An eight-year gap in life expectancy at birth persists between Polish free of disability.2 men and women (73.5 and 81.6 years, respectively) compared to 5.5 years, on average, in other EU countries. A considerable 1. Lower education levels refer to people with less than primary, primary or lower secondary education (ISCED levels 0–2) while higher education levels refer to people with gap also exists by socioeconomic status: Poles with a university tertiary education (ISCED levels 5–8). education live, on average, nearly 10 years longer than those who 2. These are based on the indicator of ‘healthy life years’, which measures the number of have not completed their secondary education.1 years that people can expect to live free of disability at different ages.

Figure 1. Life expectancy in Poland has increased substantially over the last 15 years

Poland Years 2015 2000 90 77.5years of age

85 EU Average 80.6 years of age 83.0 82.7 82.4 82.4 82.2 81.9 81.8 81.6 81.6 81.5 81.3 81.3 81.1 81.1 81.0 80.9 80.8 80.7 80.6

80 78.7 78.0 77.5 77.5 76.7 75.7 75.0 74.8 74.7 75 74.6

70

65

60 EU Italy Spain Malta Latvia France Cyprus Ireland Greece Austria Croatia Finland Estonia Poland Sweden Belgium Bulgaria Portugal Hungary Slovenia Romania Denmark Germany Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom Source: Eurostat Database.

Cardiovascular diseases and cancer are the More specifically, heart diseases and stroke remain the most largest contributors to mortality common causes of death, followed by lung cancer and pneumonia (Figure 3). The high mortality from respiratory diseases is likely a Cardiovascular diseases are the leading cause of death in Poland, legacy of the high smoking rates in Poland. Mortality from several followed by cancer (Figure 2). In 2014, around 50% of all deaths forms of cancer (e.g. colorectal cancer and breast cancer) and among women and 40% of all deaths among men were from diabetes increased between 2005 and 2014, reflecting the impact cardiovascular diseases. Polish people are about 60% more likely of population ageing and lifestyle factors. to die from circulatory diseases than the average EU resident and the reduction in cardiovascular mortality has been slower in Poland The proportion of deaths arising from transport accidents has than in most other EU countries. dropped since 2000, but nonetheless remains substantially higher than in most other EU countries (see Section 5.1).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Health in Poland . 3

Figure 2. Cardiovascular diseases and cancer together cause more than two-thirds of all deaths in Poland Poland

Women Men (Number of deaths: 180 915) (Number of deaths: 196 267)

15% 14% 3% Cardiovascular diseases 8% 4% Cancer 40% Respiratory diseases 5% 50% 4% Digestive system External causes 6% 24% Other causes 27%

Note: The data are presented by broad ICD chapter. Dementia was added to the nervous system diseases’ chapter to include it with Alzheimer’s disease (the main form of dementia).

Source: Eurostat Database (data refer to 2014).

Figure 3. Lung cancer is the fourth leading cause of death in Poland after heart diseases and stroke

2000 ranking 2014 ranking % of all deaths in 2014 1 1 Other heart diseases 15% 2 2 Ischaemic heart diseases 10% 3 3 Stroke 8% 4 4 Lung cancer 6% 5 5 Pneumonia 3% 6 6 Colorectal cancer 3% 7 7 Diabetes 2% 8 8 Lower respiratory diseases 2% 9 9 Breast cancer 2% 10 10 Suicide 2%

12 12 Stomach cancer 1% 13 17 Transport accidents 1%

Source: Eurostat Database.

Musculoskeletal problems and mental Self-reported data from the European Health Interview Survey health problems are among the leading (EHIS) indicate that nearly one in four people in Poland live with hypertension, one in twenty-four live with asthma and one in fifteen determinants of morbidity live with diabetes. Wide inequalities exist in the prevalence of these In addition to cardiovascular diseases and cancer, musculoskeletal chronic diseases by education level. People with the lowest level problems including low back and neck pain are an increasing of education are more than twice as likely to live with asthma, determinant of morbidity, measured in disability-adjusted life hypertension and diabetes than those with higher education. 4 years3 (DALYs), in Poland. Mental health problems including major depressive disorders and self-harm (suicide and attempted suicide) are also among the leading causes of disease burden (IHME, 2016). 4. Inequalities by education may partially be attributed to the higher proportion of older 3. DALY is an indicator used to estimate the total number of years lost due to specific people with lower educational levels; however, this alone does not account for socio- diseases and risk factors. One DALY equals one year of healthy life lost (IHME). economic disparities.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Poland STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –P 4 measles, hepatitisB,pertussisandHIVareallbelow theEUaverage. for bothsexeswasintroduced in2003.Poland’s notificationrates for against rubellawasintroducedin1988butonlyfor girls.Vaccination Control (ECDC). in EU/EEAcountriesaccordingtotheEuropeanCentrefor Disease In 2016,Polandaccountedfor 87%ofallreportedrubellacases prevalent thaninotherEUcountries but otherinfectious diseasesareless Poland hasaveryhighincidenceofrubella, people inthelowest incomequintile. reported tobeingoodhealth2015comparedwithjust53%of socioeconomic status:71%ofpeopleinthehighestincomequintile EU average(67%).Asubstantialgapexistsinself-ratedhealthby health (58%in2015),althoughthisproportionislower thanthe As canbeseeninFigure 4, mostPolishpeoplereportbeingingood income groups health, butlargedisparitiesexistbetween Most ofthepopulationreportsbeingingood . Health inPoland In 2015, the figure was 93%. Compulsory vaccination In 2015,thefigurewas93%.Compulsoryvaccination OLAND Source: EurostatDatabase,based onEU-SILC (datarefer to2015). 2. Thesharesfor the total populationandthehigh-incomeareroughlysame. 1. Thesharesfor the total populationandthelow-income populationareroughlythesame. good health compared to most EU countries’ populations countries’ EU most to compared health good in being report of Poles Alower proportion 4. Figure United Kingdom Slovak Republic Czech Republic Luxembourg Netherlands Lithuania Germany Denmark Romania² Slovenia Hungary Portugal Bulgaria Belgium Sweden Estonia Poland Finland Croatia Austria Greece¹ Ireland Cyprus France Latvia Malta Spain¹ Italy¹ EU 20 Low income 30 % ofadultsreportingtobeingoodhealth 40 50 Total population 60 70 High income 80 90 100 Risk factors . 5

3 Risk factors Poland

Behavioural risk factors are a major Alcohol consumption among adults in Poland has increased challenge in Poland substantially since 2000, rising from 8.4 litres per adult in 2000 to 10.5 litres in 2015, and is higher than the EU average. More than The health status of the population and health inequalities in one in six adults (17%) reported regular heavy alcohol consumption Poland are linked to a number of health determinants, including (so-called binge drinking5) in 2014, although this proportion is lower the living and working conditions of the population, the physical than the EU average (20%). environment in which people live, and behavioural risk factors. Heavy alcohol consumption is much more common among Polish It is estimated that more than one-third (36%) of the overall burden men (29%) than women (8%). Among adolescents, 26% of of disease in Poland in 2015 (measured in DALYs) can be attributed 15-year-olds report having been drunk at least twice in their life, to behavioural risk factors such as smoking, excessive alcohol which is above the EU average for girls (23.5%) and slightly below consumption, poor diet and low physical activity (IHME, 2016). This the average for boys (27%). proportion is higher than the EU average (29%) but is similar to that seen in neighbouring countries. Obesity especially among adults is a growing challenge in Poland Smoking rates declined but remain relatively high, while alcohol consumption is increasing Poor diet and lack of physical activity contribute to rising overweight and obesity problems. Based on self-reported data (which tend The proportion of daily smokers among adults in Poland fell from to underestimate true prevalence), more than one in six adults 28% in 2001 to 23% in 2014, but still remains higher than in (17%) in Poland were obese in 2014, up from one in eight in 2004. most EU countries (Figure 5). The smoking rate among 15-year-old adolescents also dropped, from 21% in 2001–02 to 15% in 5. Binge drinking behaviour is defined as consuming six or more alcoholic drinks on a 2013–14, but is still higher than in most other EU countries. single occasion, at least once a month over the past year.

Figure 5. Poland shows worse results than other EU countries for the majority of behavioural risk factors

Smoking, 15-year-olds

Physical activity, adults Smoking, adults

Physical activity, 15-year-olds Drunkenness, 15-year-olds

Obesity, adults Binge-drinking, adults

Overweight/obesity, 15-year-olds

Note: The closer the dot is to the centre the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas.

Source: OECD calculations based on Eurostat Database (EHIS in or around 2014), OECD Health Statistics and HBSC survey in 2013–14. (Chart design: Laboratorio MeS).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Poland STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –P factors contributetohealthinequalities. education. Thesedifferences intheprevalenceofbehaviouralrisk are almosttwiceashighamongpeoplewiththelowest levelof lowest-educated thanamongthehighest-educated. or income.InPoland,smokingratesare60%higheramongthe common amongpopulationgroupsdisadvantagedby education As inotherEUcountries,manybehaviouralriskfactorsaremore in disadvantagedpopulationgroups Behavioural riskfactorsaremoreprevalent promote healthybehaviours(seeSection 5.1). Health Programmetotacklethesepublichealthchallengesand Between 2016and2020,PolandisimplementingtheNational reported doingmoderatetovigorousphysicalactivityeachday). but isstillrelativelylow, particularlyamonggirls(only11% 15-year-olds inPolandishigherthanmostotherEUcountries, activity thanmen.Onamorepositivenote,physicalamong Polish womenarelesslikely toreportdoingregularphysical moderate physicalactivityeachweek.AsinotherEUcountries, Poland, withonly60%ofadultsin2014reportingdoingatleast The levelofphysicalactivityamongadultsisrelativelylow in although thisstillremainslower thaninmostotherEUcountries. than doubledbetween2001–02and2013–14(from7%to15%), Overweight andobesityamong15-year-oldadolescentsmore 6 . The healthsystem

Obesity rates OLAND observed, especiallyinprimaryhealthcare. in 1999,anemergenceofprivatehealthcareproviders hasbeen Since theimplementationofhealthandlocalgovernment reforms coordination ofservicesmoredifficult. across theselevelsofgovernment andlevelsofcaremakes the services atthenationallevel.Thisdivisionofresponsibilities National HealthInstitutesandclinicsofmedicaluniversitiesprovide availability ofservicesintheterritory. prevention. Additionally,Voivodeships areresponsiblefor ensuringthe governments alsohavesomeresponsibilitiesinhealthpromotionand typically own arangeofmostlyhigher-levelfacilitiesintheregion.Local hospitals providing basicservicesintheirterritoryandvoivodeshipswho delivery institutions.Thismostlyholdsfor somepowiats, owner of degree. Theyown andareaccountablefor thedeficitsofpublicservice (powiat) andmunicipal(gmina)levelsareinvolvedinhealthtoavarying function. Localgovernments attheregional(voivodeship),county created NationalHealthFundchargedwiththeoverall purchasing A degreeofrecentralisationoccurredin2003–04,withthenewly were establishedwiththeresponsibilityfor contractingproviders. health service.Sixteenmostlyautonomousregionalinsurancefunds (SHI) systemin1999,replacingitspreviouslytax-fundednational Poland introducedastronglydecentralisedsocialhealthinsurance poses challengesfor effective coordination A markedly decentralisedhealthsystem term careandeHealthsolutions(European Commission,2016). emergency medicalinfrastructure, preventionprogrammes,long- of theinvestmentstargetinghealth andhealthcareinclude Investment Fundsschemebetween2014and2020.Thescope for health-relatedactivitiesthroughtheEuropeanStructuraland Poland willreceivealmostEUR 3billionoffundingearmarked in 2015,thefifth lowest intheEU (Figure 6). EUR 1272 onhealth(adjustedfor differences inpurchasingpower) the EUaverage(9.9%in2015).Onapercapitabasis,Polandspent in 2000to6.3%2015.However, thislevelremainswellbelow The shareofGDPdevotedtohealthinPolandincreasedfrom5.3% remains relativelylow Health expenditureinPolandincreased,but 4 Thehealthsystem The health system . 7

4 The health system Poland

Coverage is lower than in many other EU Poland’s hospital system has a lot of countries and private spending is high capacity but is unevenly distributed Compulsory health insurance covers 91% of the population but with The number of hospital beds per 100 000 population has remained automatic entitlement extended to a number of other population groups fairly stable in Poland since 2005, at a level well above the EU (e.g. children aged under 18, people with HIV and tuberculosis, people average. Poland had 663 hospital beds per 100 000 population with mental health disorders). The 9% of the population not covered is in 2015, compared with an EU average of 515. The structure of mainly the result of casual or atypical work contracts. While entitlement hospital beds has not changed much since the early 2000s and a covers a broad range of services, public underfunding means that the surplus of acute care beds remains. supply of services is limited, resulting in long waiting times. Despite the general overcapacity in the system, access to care is In 2015, 70% of total health expenditure was from public sources. limited by the uneven geographical distribution of hospitals, with Private spending was mainly as a result of direct formal and informal some areas remaining underserved, and capacity based mainly on payments from households, with voluntary health insurance playing historical factors rather than current population health needs (see only a small role. In 2015, private out-of-pocket payments made Section 5.2). At the same time, a growing number of small private up more than one-fifth of health expenditure (23%), versus the EU hospitals are providing publicly funded services under contract with average of 15%, and were spent mainly on pharmaceuticals, for the National Health Fund NHF, especially in the more financially which coverage is low under the compulsory health insurance (see attractive specialties such as cardiac surgery. Section 5.2).

Figure 6. Poland spends comparatively less than other EU countries on health

EUR PPP % of GDP Per capita (le axis) Share of GDP (right axis) 6 000 12

5 000 10

4 000 8

3 000 6

2 000 4

1 000 2

0 0 EU Italy Spain Malta Latvia France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Bulgaria Portugal Hungary Slovenia Romania Denmark Germany Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom

Source: OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Poland STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –P EU the in population 1000 per nurses and doctors of practicing numbers lowest the 7. among Figure has Poland care. Primarycarephysiciansarealsotheproviders ofanumber health system,steeringpatients,asnecessary,tomorespecialised The primarycarephysicianistypicallytheentrypointinto conditions challenges remainfor patientswithchronic Primary carehasgrown inimportancebut to address(seeSection 5.3). particular challengeinPolandthatcurrentreforms areattempting medicine (aswellasotherdomains,suchanaesthesiology)isa is anissue.Recruitingandretainingdoctorstoworkinfamily advancement abroad,sooutwardmigrationofdoctorsandnurses remuneration, workingconditionsandprospectsfor professional not workinginmedicalentities.Polishphysicianscanreceivebetter the EU(Figure 7), althoughthismayundercountlicensedphysicians 2.3 per1000population, respectively,areamongthelowest in of practisingnursesandphysicians,whichat5.2 Shortages ofhealthworkers arereflectedinthelow numbers Poland A shortageofhealthprofessionals existsin 8 Source: hospital. in working those includes only it as underestimated is nurses of number the Greece, and Note: .

Practising nurses per 1 000 population, 2015 (or nearest year) The healthsystem In Portugal and Greece, data refer to all doctors licensed to practice, resulting in a large overestimation of the number of practising doctors (e.g. of around 30% in Portugal). In Austria Austria In Portugal). in 30% around of (e.g. doctors practising of number the of overestimation alarge in resulting practice, to licensed doctors all to refer data Greece, and Portugal In 10 15 20 Eurostat Database. Eurostat 0 5 1 Nurses Low Doctors Low Nurses High Doctors Low 2 Poland Practising doctorsper1000population,2015(ornearestyear) RO UK IE SI HR BE 3 LU OLAND LV HU EU average:3.6 FI FR SK EE NL EU CY CZ DK ES IT MT shortages ofnursingstafftoworkinthelong-termcaresector. has notkept pacewithdemandandthesituationisexacerbatedby growing toprovide formal long-termcareservices.Serviceprovision Given therapidpopulationageinginPoland,pressureisalso waiting liststhatareoftenverylong(seeSection 5.2). patients haveachoiceofhospitalsfor electivesurgery,butface the NHF. Onreferral fromprimarycareorspecialistoutpatientcare, care ispredominantlydeliveredby privateproviders contractedby Most hospitalsarepubliclyowned, whileoutpatient(orambulatory) services, theroleexpectedofafamilydoctor,israrelyperformed. hospitalisations (seeSection 5.1).Insummary,thecoordinationof with chronicconditionsinprimarycareandthelevelofavoidable specialist providers. Thishasimplicationsfor thecareofpeople means thatdoctorsoftenpushthecostofinvestigationonto at theprimarycarelevel,systemoffinancialincentives However, whilepreliminarydiagnosesaremeanttobeconducted by theincreasedutilisationofprimarycareservices. primary careinthePolishhealthsystemhasgrown, asevidenced preventive servicessuchasscreeningandvaccinations.Theroleof 4 BG DE SE LT PT 5 AT 6 EU average:8.4 Doctors High Doctors High EL Nurses High Nurses Low 7 Performance of the health system . 9

5 Performance of the health system Poland

5.1 EFFECTIVENESS than in most other EU countries. The overall amenable mortality rate reduced by 25% between 2007 and 2014. Amenable mortality rates in Poland are higher than the EU average Low mortality rates for people requiring An indicator of a health care system’s effectiveness is the mortality acute care suggest good hospital care for rate for conditions that are amenable to medical treatment, such as some conditions certain types of cardiovascular diseases and cancers. Hospitals in Poland generally provide effective treatment for In Poland, overall rates of amenable mortality6 are higher than the people requiring acute care, most notably in the area of cardiology. EU average (Figure 8), for both women (121 per 100 000 versus Substantial progress was made over the decade in reducing 98 per 100 000) and men (229 versus 158). This is mainly because mortality rates for people admitted to hospital for heart attack mortality rates from cardiovascular disease are higher in Poland through improvements in treatments and care processes (Figure 9).

Figure 8. Amenable mortality in Poland is higher than the EU average Women Men Spain 64.4 France 92.1 France 64.9 Netherlands 96.4 Luxembourg 67.7 Luxembourg 107.9 Cyprus 69.3 Italy 108.2 Italy 74.1 Belgium 110.5 Finland 77.4 Denmark 113.7 Sweden 79.4 Spain 115.1 Netherlands 79.7 Cyprus 117.0 Belgium 80.7 Sweden 117.2 Austria 83.0 Ireland 133.0 Portugal 83.9 Austria 138.0 Denmark 85.4 United Kingdom 139.1 Greece 85.5 Germany 139.6 Germany 88.2 Malta 149.0 Slovenia 88.7 Portugal 152.1 Ireland 92.3 Finland 154.4 United Kingdom 94.4 EU 158.2 EU 97.5 Slovenia 160.3 Malta 98.7 Greece 168.2 Czech Republic 119.9 Poland 229.0 Poland 121.5 Czech Republic 242.5 Croatia 147.8 Croatia 278.2 Estonia 152.5 Slovak Republic 335.9 Slovak Republic 168.2 Estonia 350.7 Hungary 192.3 Hungary 361.3 Lithuania 196.3 Bulgaria 388.8 Bulgaria 207.1 Romania 415.0 Latvia 214.9 Lithuania 473.2 Romania 239.5 Latvia 501.2 0 100 200 300 400 500 0 200 400 600 Age-standardised rates per 100 000 population Age-standardised rates per 100 000 population

Source: Eurostat Database (data refer to 2014).

6. Amenable mortality is defined as premature deaths that could have been avoided through timely and effective health care.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND 10 . Performance of the health system

Figure 9. Thirty-day mortality rate after hospital admission for heart attack in Poland fell considerably Poland

Age-sex standardised rates per 100 admissions of adults aged 45 years and over 2004 2009 2015 25

20

15

10

5

0 Italy Spain EU13 Latvia Finland Poland Sweden Hungary Slovenia Denmark Netherlands Luxembourg Czech Republic United Kingdom

Note: This indicator is based on patient-level data. The EU average is unweighted.

Source: OECD Health Statistics (data refer to 2015 or nearest year). Cancer care improved but still lags behind Avoidable hospital admissions are among other EU countries the highest in EU countries Survival of cancer patients in Poland is generally lower than in most Poland has comparatively high hospitalisation rates for chronic other EU countries. Data from the CONCORD programme show that conditions such as asthma and chronic obstructive pulmonary the five-year net survival rate for cervical cancer in Polish women disease (COPD), diabetes and congestive heart failure. These was 55% over 2010–14, one of the lowest among the EU countries. conditions are generally considered to be manageable in the This is in spite of comparatively high cervical cancer screening rates primary care sector, outside of the hospital. Potentially avoidable in women aged 20–69 (OECD/EU, 2016). The five-year survival rate hospitalisations therefore suggest a lack of effectiveness and for men and women diagnosed with colorectal cancer is also among coordination in the non-acute sectors. Admissions of patients with the lowest in the EU, as is Poland’s colorectal cancer screening rate. congestive heart failure are in particular high compared to other EU countries (Figure 10). In addition to nationwide cancer screening programmes and increased screening coverage for both breast and cervical cancers, High preventable mortality points towards a Poland introduced a comprehensive 10-year Cancer Strategy in need for more effective prevention policies 2015 in a more systematic and targeted approach to improve outcomes. This has a clearer focus on the governance of cancer Key indicators of preventable mortality, notably deaths related to care, promoting prevention, diagnosis and treatment of cancer, and traffic injuries, smoking and harmful alcohol consumption, place improving patients’ quality of life. Objectives are set in each policy Poland above the EU average. Poland has one of the highest area and progress is monitored regularly. traffic accident mortality rates in the EU (over 10.3 per 100 000 population in 2014 compared to the EU average of 5.8), although the rate has halved since 2000.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Performance of the health system . 11

5.2 ACCESSIBILITY Poland Poland’s levels of unmet medical needs are comparatively high, with a considerable gap Smoking rates declined over the last decade but the proportion of between income groups regular smokers was traditionally high and Poland’s lung cancer Unmet needs for medical care in Poland ranks fifth highest in the mortality is among the highest in the EU. EU. About 7% of the population reports some unmet needs of this type, with a considerable gap between high- and low-income To tackle rising obesity rates, Poland implemented a mass media groups (Figure 11) and between regions. About 4% of high-income campaign to promote healthy eating and increase fruit and households report unmet medical needs compared to 10% in the vegetable consumption (Jarosz and Tarczyk, 2011). The promotion lowest income bracket. Costs and waiting times are the greatest and advertising of certain foods sold at primary and secondary contributors to unmet needs in Poland. schools is also regulated by law. Economic levers such as taxes and broader regulations of sales (similar to the strategies for limiting alcohol consumption) have not been adopted (OECD, 2015). The health care benefits package is narrow, but Health Technology Assessment is in place Poland implemented a National Health Programme to address to assess cost-effectiveness these public health challenges and promote healthy behaviours. Polish authorities explicitly define the pharmaceuticals and medical The National Health Programme is aiming for a 2% reduction in procedures covered in the benefit package under the public health the share of the population smoking by 2020, a halving of the insurance scheme. While most conventional medical procedures are growth in obesity and diabetes rates by 2025, and a 10% cut in the included, the list of reimbursable drugs is narrow. Consequently, the number of alcohol abusers by 2025. share of out-of-pocket expenditure on pharmaceuticals in Poland (60%) is the fourth highest in the EU (after Romania, Bulgaria and Croatia) and considerably higher than the EU average (44%).

Figure 10. Avoidable hospital admissions for chronic conditions are high in Poland

Age-sex standardised rate per 100 000 population Congestive heart failure Diabetes Asthma & COPD 1 200

1 000

800

600

400

200

0 Italy Spain Malta EU21 France Ireland Austria Finland Estonia Poland Sweden Belgium Portugal Hungary Slovenia Denmark Germany Lithuania Czech Rep. Slovak Rep. Netherlands United Kingdom

Note: Rates are not adjusted by health care needs or health risk factors.

Source: OECD Health Statistics (data refer to 2015 or nearest year).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Poland STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –P Source: used. instrument survey the in variations some are there as countries across data the comparing in required is Caution times. waiting or travel to distance costs, Note: EU the in care for medical needs unmet level of highest fifth the has 11. Poland Figure 12 Ombudsman for Patients’ Rights(Auraaenetal.,2016). representatives areincludedinHTA decisionsthroughthePolish threshold issetatthreetimesthePolish GDPpercapita).Patient cost-effectiveness ratio used to inform coverage decisions (the current technologies inthebenefitpackage, andtopublishtheincremental cost-effectiveness ofalternativetechnologies,toperiodically reassess centrally. Polandisalsooneofthefew countriestocomparethe Assessment (HTA). Coverage andreimbursement decisionsaremade Poland hasacomprehensiveapproachtoHealthTechnology people aged75andover by upto60%by 2025. It isexpectedthatthiswillreduceout-of-pocket paymentsamong for peopleaged75andover. Thelistis updated everytwomonths. funds provides for agreaternumberofdrugs tobefullyreimbursed A recentamendmenttotheActonhealthservicescovered by public United Kingdom Slovak Republic Czech Republic . 23% Luxembourg Netherlands The data refer to unmet needs for a medical examination or treatment due to to due treatment or examination amedical for needs unmet to refer data The Performance ofthehealthsystem Eurostat Database, based on EU-SILC (data refer to 2015). to refer (data EU-SILC on based Database, Eurostat Lithuania Germany Denmark Romania Slovenia Hungary Portugal Bulgaria Belgium Sweden Poland Estonia Finland Croatia Austria Greece Ireland Cyprus France Latvia Malta Spain Italy EU 5% 0 Poland 2% High income 70% % reportingunmetmedicalneed,2015 Total population 10 Out-of-pocket health insurance Public/Compulsory Other insurance Voluntary health Low income OLAND 20 comparable tocountrieslike EstoniaandHungary. in 2014–highcomparedtomostotherEUcountries,although ‘catastrophic’ out-of-pocket payments EU averageof2.3%.However, theshareofpopulationfacing expenditure by Polishresidentswas2.5%in2015,closetothe As ashareofhouseholdconsumption,averageout-of-pocket greater thaninmostotherEUcountries(Figure 12). payments). Directout-of-pocket paymentsby householdsare financed outofprivatesources(mainlythroughout-of-pocket care spendingwerestableover thelastdecade,withabout28% The sharesofpublicandprivatehealthexpendituresintotal in Poland Affordability ofhealthcareisa key concern Source: 40% oftotalhousehold spendingnetofsubsistenceneeds(i.e.food, housingandutilities). 7. Catastrophicexpenditureisdefinedashousehold out-of-pocket spendingexceeding Poland is paid out of pocket out is paid Poland in spending care of health share Alarge 12. Figure 23% OECD Health Statistics, Eurostat Database (data refer to 2015). to refer (data Database Eurostat Statistics, Health OECD 23% 15% 5% Poland 2% 5% 5% Poland 2% 1% 70% EU 79% 70% 7 inPolandwasover 8% Other Out-of-pocket health insurance Public/Compulsory insurance Voluntary health

Other Out-of-pocket health insurance Public/Compulsory insurance Voluntary health 15% 15% 5% 1% EU 5% 79% 1% EU 79% Performance of the health system . 13

Figure 13. Catastrophic out-of-pocket health care attributed to the unregulated, unofficial private practice by many spending is especially high among Poland’s poorest providers – funded by informal out-of-pocket payments – relatively Poland households low coverage of the population (see Section 4) and the absence of Poorest 2nd 3rd 4th Richest a formal private health insurance market in Poland. 40 Poland has some of the longest waiting times in the EU 30 In addition to costs, the availability of services in Poland is constrained by the low number of health care practitioners. The result is that Poland has the longest waiting times in the EU for 20 health care interventions such as cataract and joint replacement surgery, such as cataract and joint replacement surgery (Figure 14). Specialists may have an incentive to maintain waiting lists to % of households in quintile 10 boost demand for their own private services paid out-of-pocket by patients, and the practice of double employment is fairly widespread and poorly regulated in Poland (European Commission, 2016).

0 Contributing to this problem is the uneven geographical distribution 2014 2005 of services and allocation of resources. For example, waiting times Source: Wożniak, 2017. for some specialities can be up to 12 months in some regions The lowest income quintile is disproportionately affected by (Kowalska et al., 2014). In addition, the share of patients waiting for catastrophic out-of-pocket payments (Figure 13). This pattern a neurology, ophthalmology, cardiac, endocrinology or orthopaedic has been quite steady in recent times. In addition to the limited appointment in 2014 varied almost three-fold across Poland’s 16 coverage of pharmaceuticals described above, this can be regions (World Bank Group, 2015).

Figure 14. Poland has the longest waiting times for cataract surgery and hip replacement

Mean waiting times (days) Hip replacement Cataract surgery 500 464

405 400

300 290

253

200

146 150 135 108 97 103 104 105 100 87 88 79 72 55 50 42 37

0 United Netherlands Denmark Italy Kingdom Finland Portugal Hungary Spain Estonia Poland

Source: OECD Health Statistics, Eurostat Database (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Poland STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –P environments, sudden shocks orcrises. 8. Resiliencerefers tohealthsystems’capacityadapteffectively tochanging 3.7 million people(11%) problems, andthisnumberisprojectedtoincreasemorethan (6.8% ofthe population)livewithseveredisabilitiesduetohealth of long-termcare.Currently,about2.6millionPolishpeople the Polishhealthsystemiscurrentorganisationandfinancing Another factorunderminingthesustainabilityandefficiencyof hospital sector and overly reliantoninformal careandthe The long-termcaresectorisunderfunded, short term,generateconsiderablepatientdissatisfaction. procedures (hipandkneereplacements),whilelowering costsinthe medium term.Longwaitinglistsandlow ratesfor someelective and long-termcarecapacityundermineallocativeefficiencyinthe The relativeoversupply ofhospitalandundersupplynon-acute underway inPoland(seeBox 1). long-term caresector. Structuralhealthsystemreform iscurrently nature ofphysicianemployment; andincreasecapacityofthe balance betweenspecialistsandgeneralists;addressthedual the shortageofhealthworkers (Section 4)andrestoreabetter That said,somemedium-termstrategiesarerequiredto:address coming demographicchallenges(EuropeanCommission,2016). due toanunfavourablebudgetpositionandtheneedmeet European Commission’s EconomicPolicyCommittee,principally system financialsustainabilityisconsideredtobemedium by the capita termsandasashareofGDP(Section 4).Therisktohealth Health expenditureinPolandiscomparativelylow, bothinper investment initshealthworkforce isneeded medium financialsustainabilityrisk, While thePolishhealthsystemfaces 5.3 14 Figure 15. The adoption of eHealth among general practitioners and hospitals was among the lowest in 2013 in lowest the among was hospitals and practitioners general among of eHealth adoption 15. The Figure Source: EuropeanCommission(2013,2014). See OECD/EU(2016),HealthataGlance:Europe2016 –StateofHealthintheEUCyclefor furtherinformation. Note: ThecompositeindicatoronGPrangesfrom0 to4whereasthecompositeindicatoronhospitalsrangesfrom01. practitioners . Hospitals General Performance ofthehealthsystem RESILIENCE 1.3 0 Lithuania 8 Lithuania 9 by 2060. 0.1 1.5 Poland Poland 0.2 1.7 OLAND 0.3 EU EU 1.9 resources betweenhospitalsandlong-termcarefacilities. to futuredemandfor long-termcare,coupledwith arebalancingof It islikely thatmorefundingwillberequiredtorespondadequately workforce. Itisalsooftenprovided inhospitals,whichisinefficient. with broadersocietalchangessuchasmorewomenjoiningthe not besustainableinacontextofpopulationageingcombined by familymembers(EuropeanCommission,2016).Thismay underfunded. Itisgoverned by severallawsandprincipallyprovided Long-term careinPolandiscurrentlyveryfragmentedand hospitals wassecondlowest, behindLithuania.. Commission, 2013).Similarly,theavailabilityanduseofICTin among GeneralPractitionerswasfifth lowest intheEU(European are currentlyunderway(Figure 15).In2013,eHealthadoption and helpPolandcatchupinthespreadadoptionofICT Investment Funds(Section 4),todigitalisethehealthcaresystem Several projects,partlyfundedby EuropeanStructuraland health sector Investing topromotedigitisationofthe Index.aspx?DataSetCode=POP_PROJ# 9. BasedonOECDprojectionsofthefuturepopulation ofPolandhttps://stats.oecd.org/ (OECD/EU, 2016). Theaforementioned NationalHealthProgramme among men,arereducingemployment andeconomicgrowth Premature deathsfrompreventablecauses,particularly reducing pressuresonthehealthandlong-termcaresystems. health statusandreduceinequalities,whileatthesametime between diseasepreventionandcaremayhelptoimprove population smoking, harmfulalcoholconsumptionandobesity,abetterbalance health. Giventhehighlevelsofbehaviouralriskfactorssuchas average of3.0%,withabouthalfthisallocatedtooccupational initiatives andhealthpromotionactivitiescomparedtotheEU Poland dedicates2.6%ofitshealthexpendituretopublic better targetedspending Public healthcanbestrengthenedthrough 0.4 2.1 0.5 2.3 0.6 Denmark 2.5 Estonia 0.7 Performance of the health system . 15

BOX 1. FUNDAMENTAL HEALTH REFORM IN POLAND Poland

In 2016, the Polish Ministry of Health embarked on a far- reaching health reform programme aimed at improving access to care and care coordination, improving efficiency and reducing duplication. This includes a commitment to increase public expenditure on health by about 35% over the next seven years.

The most fundamental reform proposal is the abolition of the NHF to be replaced by a new funding system controlled by the Ministry, and financed out of tax revenues. Health authorities will finance health services at the regional level, supervise hospitals, and be responsible for forward planning.

The reforms will change the contracting process for acute care. Activity-based funding will be replaced with annual budgets. The number and structure of hospital beds will be adjusted based on health need. Current maximum contractual limits will be replaced by minimum volumes that hospitals will have to meet to receive funding.

A linkage of inpatient with outpatient and ambulatory services is proposed, with bundling of budgets across care types a key lever to achieve this. is a step forward in strengthening public health policies. The The creation of health care teams comprising doctors, nurses, programme explicitly aims to improve health status and reduce school nurses, midwives and dieticians aims to strengthen health inequalities by setting up six strategic goals covering: primary care. The objectives of these teams will be health nutrition and physical activity; addiction prevention; mental health promotion, as well as gatekeeping and coordination of care and well-being; environmental risks including work, habitation and for patients across settings. education; healthy ageing and reproductive health. To address health workforce shortages, the government Reform will need to be matched by strong is proposing to increase salaries for medical staff. governance and accountability Implementation of this ambitious reform programme is expected to begin in 2017–18. Health care financing and care delivery underwent substantial changes in Poland over the past 30 years. The current financial management model built around the central role of the NHF has All activity – from budgeting to clinical practice – will be at risk proved inefficient, resulting in some of the problems outlined in during the transition period, and will need to be monitored closely. this profile (e.g. long waiting times). The Polish government has The reforms centralise more control to the Ministry. It will be embarked on a programme of ambitious reforms of the health interesting to observe what shape the necessary accountability system, and some of these reforms will influence health care and oversight framework will take and how it will be implemented governance, accountability and planning (Box 1). to accompany the restructuring. Communication and engagement of key stakeholders – health professionals, system administrators The creation of regional health authorities to perform a range of and of course the public – will be a crucial determining factor in the financing, supervisory and planning functions will have profound success of these reforms. implications on accountability, allocation of resources and strategic planning. Similarly, the replacement of activity-based funding with prospective annual budgets, and the switch from maximum to minimum limits, represent a substantial transition in hospital management and administration, and pose a challenge to ensure financial and clinical accountability, as well as monitoring and evaluation of performance.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND Poland STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –P l l l l 16

. suggesting room for improvement in non-acute sectors. sectors. non-acute in for room improvement suggesting failure, heart congestive and COPD asthma, as such conditions for rates chronic hospitalisation high has also Poland implemented. being currently are prevention and screening improve to Programmes average. EU the is than rate higher mortality cancer the and countries EU other to low are compared cancers colorectal and cervical for rates breast, favourable. Survival less are Poland in care for cancer outcomes hand, other the On data. these report that countries EU in patients attack for rates heart case-fatality lowest of the one has Poland of quality, for high patients. especially cardiac and is relatively effective Polish in hospitals care Acute countries. EU other most in slowerbeen than has mortality cardiovascular in reduction the and resident average EU the than disease likely die acirculatory from to more 60% about are Polish people inactivity. physical and adults), obesity among is (which increasing consumption alcohol especially factors, risk behavioural to attributed be can of disease burden total of the athird About incomes. lower on those than health good report earners high more Many countries. EU other to is low health compared good in being report who of Polish residents proportion The disability. from will free be years half these than less but respectively, 20years, and 16 live to another expect can 65 aged women and men is levels Polish 10 years. education highest and lowest the with those between gap while the women, and men Polish separate years Eight groups. population different between observed are life in Disparities expectancy average. EU the lower but than countries, neighbouring most in is than higher Poland in at birth Life expectancy the EU. Compulsory health insurance covers only 91% only covers insurance health of Compulsory EU. the in procedures for elective lists waiting longest the and care for medical need of levels unmet high has Poland imbalances, allocative and workforce to part in Due Poland. in key are concerns needs medical unmet and Affordability Key findings 6 Keyfindings OLAND l l

face catastrophic health care costs. care health face catastrophic of lower-income number Polish households alarge a result, As of levels out-of-pocket high in have payments. resulted coverage of pharmaceuticals public limited and market insurance health private undeveloped An is limited. services of supply the that means underfunding public of services, range abroad covers entitlement While population. the situation. this improve could management and planning better and investment, infrastructure funding, Increased workforce. the in women’s participation growing and demographics changing given is unsustainable This family members. by of provision is source care informal principal the but hospitals, in provided is often care long-term Some laws. by numerous governed and is fragmented sector The of reform. is need in Poland in care Long-term for the Polish people. for the outcomes better in result indeed do reforms these ensure to needed are oversight and accountability governance, Sound coordination. care and promotion health planning, and financing care health to changes fundamental include reforms The efficiency. technical and allocative improving and coordination and access improving at aimed system, health of reforms the structural of implementing process is the in government The Health in Poland . c

Key sources Poland

OECD/EU (2016), Health at a Glance: Europe 2016 – State of Sagan, A. et al. (2011), “Poland: Health System Review”, Health Health in the EU Cycle, OECD Publishing, Paris, http://dx.doi. Systems in Transition, Vol. 13(8), pp. 1–193. org/10.1787/9789264265592-en.

References

Auraaen, A. et al. (2016), “How OECD Health Systems Define the Jarosz, M. and I. Traczyk (2011), “Developments in Prevention Range of Good and Services To Be Financed Collectively”, of Obesity and Other Noncommunicable Diseases in Poland OECD Health Working Papers, No. 90, OECD Publishing, Paris, through Nutrition and Physical Activity [presentation]”. http://dx.doi.org/10.1787/5jlnb59ll80x-en. Kowalska, I. et al. (2014), “The First Attempt to Create a National European Commission (2016a), “Joint Report on Health Care and Strategy for Reducing Waiting Times in Poland: Will It Long-term Care Systems & Fiscal Sustainability”, Institutional Succeed?”, Health Policy, Vol. 119, pp. 258-263. Paper 37, Vol. 2. OECD (2015), Tackling Harmful Alcohol Use: Economics and European Commission (2016b), Mapping of the Use of European Public Health Policy, OECD Publishing, Paris, http://dx.doi. Structural and Investment Funds in Health in the 2007-2013 org/10.1787/9789264181069-en. and 2014-2020 Programming Periods. World Bank Group (2015), “Poland Policy Notes 2015. How European Commission (2014), European Hospital Survey: Poland Can Accelerate Growth with Inclusion”, World Bank, Benchmarking Deployment of eHealth Services. Washington. European Commission (2013), Benchmarking Deployment of eHealth Among General Practitioners. Wożniak, M. (2017), “Moving Towards Universal Health Coverage: New Evidence on Financial Protection in Poland”, WHO IHME (2016), “Global Health Data Exchange”, Institute for Health Regional Office for Europe, Copenhagen. Metrics and Evaluation, available at http://ghdx.healthdata. org/gbd-results-tool.

Country abbreviations Austria AT Denmark DK Hungary HU Malta MT Slovenia SI Belgium BE Estonia EE Ireland IE Netherlands NL Spain ES Bulgaria BG Finland FI Italy IT Poland PL Sweden SE Croatia HR France FR Latvia LV Portugal PT United Kingdom UK Cyprus CY Germany DE Lithuania LT Romania RO Czech Republic CZ Greece EL Luxembourg LU Slovak Republic SK

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – POLAND State of Health in the EU Country Health Profile 2017

The Country Health Profiles are an important step in the Each Country Health Profile provides a short synthesis of: European Commission’s two-year State of Health in the EU l  health status cycle and are the result of joint work between the Organisation l  the determinants of health, focussing on behavioural risk for Economic Co-operation and Development (OECD) and the factors European Observatory on Health Systems and Policies. This l  the organisation of the health system series was co-ordinated by the Commission and produced with l  the effectiveness, accessibility and resilience of the health the financial assistance of the European Union. system

The concise, policy relevant profiles are based on a transparent, This is the first series of biennial country profiles, published in consistent methodology, using both quantitative and qualitative November 2017. The Commission is complementing the key data, yet flexibly adapted to the context of each EU Member findings of these country profiles with a Companion Report. State. The aim is to create a means for mutual learning and voluntary exchange that supports the efforts of Member States For more information see: ec.europa.eu/health/state in their evidence-based policy making.

Please cite this publication as:

OECD/European Observatory on Health Systems and Policies (2017), Poland: Country Health Profile 2017, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. http://dx.doi.org/10.1787/9789264283510-en

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