Brief Report: Long-term Care for the Aged in Poland

Rachel Filinson & Darek Niklas & Piotr Chmielewski

Published online: 17 September 2010# Springer Science+Business Media, LLC 2010

Abstract This report examines the impact of a 2004 law in Poland intended tosubstitute medically-oriented, central government-funded institutional long-term carewith social care-oriented welfare homes, market alternatives and increased informaland community-based alternatives. Data were extracted from recently publishedreports, government statistics and a survey of 69 social care homes in Poland. Theresults indicate the continued dominance of hospital-based long-term care, the lackof shift to social care provision, the anemic growth of privatization and the dearth ofinformal and community-based care. The 2004 law was insufficient in shifting theburden of long-term care from the national health insurance fund to localmunicipalities, the social assistance sector and consumers.

Keywords Assisted living . Long-term care . Law . Poland

Introduction

In Poland, nearly 16% of the population consists of males aged 65 and older andfemales aged 60 and older (Ministry of Labour and Social Policy, 2008), theproportion of older adults is expected to increase by more than 8% by 2050 (TheWorld Bank 2007) and a large change in the old age dependency ratio is predicted(The World Bank 2007). Despite this rapid aging of the population, only 2% of the

Ageing Int (2010) 35:286–292DOI 10.1007/s12126-010-9070-3

P. ChmielewskiInstitute of Sociology, University of Warsaw, Warsaw, Polande-mail: chmielep@is.uw.edu.pl

R. Filinson (*) :D. NiklasSociology Department/Gerontology Center, Rhode Island College, 600 Mt. Pleasant Ave, Providence,RI 02908, USAe-mail: rfilinson@ric.edu

D. Niklase-mail: dniklas@ric.edu

population in Poland currently uses long-term care (compared to 12% in northernEurope) (The World Bank 2007) and no change is expected in the percentage ofGDP that will be spent on long term care (Ministry of Labour and Social Policy2008). Nevertheless, the delivery of long-term care has posed a challenge (EuropeanCommission 2008), chiefly the challenge of coordinating its medical and socialcomponents which derive from separate budgets, are under the aegis of differentgovernment entities, and have disparate expectations for supplementation by privateand informal support. Its (underfunded) national health insurance fund financesskilled medical care for those needing long-term care provision but does not coverboard and accommodation (Ministry of Labour and Social Policy, 2008) nor socialand residential types of care. The latter are funded at the local government level orprivately. A 2004 law in Poland proposed to reduce the reliance on medicallyoriented, institutional long-term care, provided in wards for the chronically ill andnursing wards (referred to in Polish as socio-medical care wards or ZOL) bypromoting social welfare homes (Dom Pomocy Spolecznej or DPS), that would befunded at the municipal level or privately. The law not only was intended to divertthe expense of care away from the national health insurance by mandating sixmonths limit on stays in ZOL, but also to enlarge the private contributions to the costof care. It requires that the stay at a “social welfare home” (DPS), (corresponding toassisted living facility in the USA) be paid for by a combination of 70% of aresident’s pension and family alimentation calculated according to an algorithm, withgmina (the lowest administrative unit of self-government, roughly corresponding tomunicipality in the USA) responsible for covering the balance.

The purpose of this research is to examine the impact of this law intended totransform the organization of long-term care in Poland. The first question to beconsidered is whether the law appears to have prompted a reduction in the medicalprovision of long-term care with a corresponding increase in social care. The secondquestion concerns whether a shift from government financed and delivered formalcare to private, a market version has occurred. The third question centers on whetheran increase in informal and community-based care has ensued.

Method

This research utilizes data derived from already published reports, governmentstatistics, and a survey of DPS (social care homes) identified on an internet site.The criteria for inclusion on the site are broad and include the homes that use itto advertise services as well as the ones which are merely listed as an address.DPS can be of three types based on their target population of older adults,chronically ill, or mentally disabled, but in reality, the populations are rarelyhomogenous according to the above classification. After excluding from thesampling frame orphanages and homes for the socially distressed (e.g. unwedexpectant mothers) listed on the site, questionnaires were mailed to 298 homes ofwhich 69 (or 23%) responded. The preamble to the questionnaire outlined ourinterest in homes serving the aged population and the responding homes formentally and physically disabled persons of any age indicated that the majoritywere elderly: 54% (N=37) of respondents described their DPS as primarily for

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older adults, 14% (N=10) for chronically ill, and 20% (N=14) for the mentallydisabled. An additional 12% (N=8) designated their facility simply as providingnon-medical care of an assisted living type.

The self-administered questionnaire asked for information concerning type of careprovided, manner of financing, sources of additional revenue, received suggestions forexpanding activities, institutions exercising control over the DPS, services no longerfinanced by the government, and size of the facility. We also asked respondents to ratethe services, their financial affordability and their cost-effectiveness.

Results

Has a Medical Long-term Care Orientation been Replaced by a Social Care One?

Data from a wide range of sources do not suggest that the law has catalyzed thischange. The number of long-term care facilities (funded by Poland’s NationalHealth Fund) actually increased from 115 to 419 from 1999 to 2006 and thecorresponding number of beds rose from 9,382 to 20, 942 (Ministry of Labourand Social Policy, 2008). While there was also an increase in places and peopleusing social welfare homes, the non-medical alternative for long-term care, theincrease was not nearly as dramatic. Between 2003 and 2007, the number of placesin social welfare homes rose from 92,762 to 101, 101 (sic) and the number ofoccupants rose from 91, 824 in 2003 to 96, 696 in 2007 (GUS 2007). Golinowska(2010) points out that the higher salaries for personnel in the health care comparedto the social assistance sector could be a factor in the slow growth of the latter.Furthermore, expenditures on long-term care from both the National InsuranceFund (the source of medical care) and from state and local governments (for socialassistance inpatient care) rose between 2005 and 2008, though remaining wellbelow 1% of GDP (Wieckowska 2010). In other words, rising social care costshave not been offset by diminished medical care costs. The average length of stayin a (medical) long-term care facility hovers around 3 months (Ministry of Labourand Social Policy 2008), supporting the conjecture of a revolving doorarrangement in which the elderly person enters the hospital intermittently after ashort stay with the family. This allows older adults to receive medical long-termcare repeatedly (Rakowska-Boron and Sikora 2007).

In our survey of social care homes, respondents were asked to identifyservices that they provide, which are no longer covered by the Health Ministryof the Central Government, as a result of changes in national health care and the2004 law on provision of social services. Nearly three-quarters of respondents(N=50; 72%) did not identify any gaps in service after the overhaul of the systemthat eliminated an array of payments for medical and nursing services by theNational Health Fund. The most commonly indicated decline in coverage referredto nursing care (N=14; 22%), in a few cases combined with rehabilitation (N=6;9%), which used to be covered by the Fund. A recent decision to start reimbursingnurses in social care homes from the funds of the central government (PAP 2008)underlines that its role in long-term care has not diminished as the 2004 law hadintended.

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Has Long-term Care Become Privatized?

The data show that limited privatization has occurred in the wake of the 2004 law.For 2005–2007, the number of social welfare facilities identified in government dataas under the governance of one of the three self-government levels: gmina(municipality), poviat (county) or voivodship (state/province), actually increasedfrom 576 to 706 facilities while the total number of welfare homes actually droppedfrom 823 in 2005 to 821 in 2007 (GUS 2007). Similar findings from the Ministry ofLabour and Social Policy (2008) corroborate that two thirds of social assistanceplaces are run by local governments. It should be pointed out that the prevalence ofprivate facilities may be understated in official statistics because some operatorsavoid registration with voivodship authorities (Jakubczak 2007), risking fines ratherthan the high cost of compliance with licensure requirements. Adherence toregulations might raise costs above a level affordable for most potential customersand eliminate profit for prospective investors. Golinowska (2010) estimates thatthere are currently over 200 profit-making care homes but only about half havelegalized status.

The survey findings confirm the continued dominance of social care provision bylocal government authorities. The vast majority of respondents (N=54; 78%) classifiedtheir facility as a municipal one, with a small proportion declaring to be “non-profit”(N=7; 10%) or church-based (N=6; 9%). One facility identified itself as affiliated withthe central government and one as private. Municipal facilities turned out to have alarger number of employees (Pearson’s r=29; sig=.013) and larger number ofresidents (Pearson’s r=.25; sig=.035), while the private or non-governmental onesserve smaller groups of clients. The responses to our questionnaire contained very fewcases of municipal authorities contracting with a private provider for care. In acomment included in one of the questionnaires a respondent noted that municipalauthorities may even keep indigent elderly in homeless shelters where the cost is halfof that in DPS. Optional services for which residents would need to pay out-of-pursewere rarely mentioned.

The legislative changes aimed to make the residents pay for the stay in the DPS withdeductions from their pension, combined with financial contributions of familymembers (determined through means testing). The local governments are obliged tosubsidize the difference from the “real” cost stipulated by the voivodship (ca. 2000 PLN,in 2006). In spite of these legislative changes, the predominant source of financingremained the Urban Center for Social Assistance (n=59; 86%), which administerswelfare that is the municipality’s responsibility. Additional public revenue came fromthe central government (N=10; 14%), the middle level territorial self government,corresponding to county in the USA, i.e. poviat (N-8; 12%) and the National HealthFund (N=5; 7%). The voivodship (province) is obligated to cover the cost forresidents admitted before the 2004 law came into effect (N=11;16%).

The questionnaire raised the issue of public control over the DPS, which turnedout to be exercised predominantly on the county and secondarily on the provinciallevel. The county government and in a few cases county legislature were mentionedmost frequently (N=24; 35%), and the voivodship (provincial) agencies were next(N=19; 28%). The voivodship authorities register and issue the license to operate thehomes, while the counties coordinate the supply of personnel and inspect the

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conditions of the physical facility. The operating funds of a home are dependent onthe cooperation between the management and the county authorities, since thehomes would not be able to secure the funds on their own. In some cases thiscoordinating function is fulfilled by the Urban Center for Social Assistance (N=12;17%) mainly in the case of institutions located in larger towns. Fourteen homesindicated the central government as the control agency, reflecting its obligation topay for residents accepted before the 2004 law.

Did the Law Expand Community-based or Informal Care?

One unintended consequence of the new rules of financing could have been anincentive to keep the elderly household member at home (Tawczynska-Turek 2004)allowing families to avoid a loss of 70% of the elderly kin’s pension, as well as therequired amount of prorated familial contribution. It is hard to determine if this is thecase because informal care has overwhelmingly and consistently been the mostlikely source of care for disabled older adults in Poland anyway (Golinowska 2010;Bien et al. 2007). In contrast, statistics recently reported by the Commission of theEuropean Communities (2008) indicate that Poland has one of the lowestproportions of informal helpers (among those aged 50 or above) of any country inthe European Union. The preponderance of informal care is the outcome of both thelack of long-term care and a tradition of filial commitment. The latter wasdocumented by a cross-national comparative survey which showed substantialsupport by Polish respondents for the statement that informal care would be the bestoption for an elderly person living alone and in need of long-term care (Hoffman andRodrigues 2010). A recent survey of informal carers in the European Union(Hoffman and Rodrigues 2010) showed that Poland had the lowest proportion ofsupportive formal care (home) services among these countries. Given the low levelof services which could reduce the burden of informal caregiving, it is not surprisingthat Poland had the highest proportion of respondents on a 2007 Eurobarometersurvey indicating that “dependent people have to rely too much on relatives”(Hoffman and Rodrigues 2010)

It may be that the pension and familial contributions that are supposed to be made toassisted living facilities have in fact been poorly enforced. In our survey, nearly one thirdof homes (N=20; 29%) indicate that they do not receive required deductions fromresidents’ pensions as a contribution to their revenue, and contributions by the familyto the cost of care were listed by only slightly over half of the homes (N=35; 51%).Moreover, the reference to family contribution in all cases was accompanied by aqualification of “negligible” or “very rare” implying that respondents were accountingfor legal provisions rather than the effective sources of revenue. A study of familycaregivers in Poland (Bien 2006) found not a single family being helped by a NGO orvoluntary organization, which may have prompted a recent initiative to providefunding for informal caregivers (The World Bank 2007).

Voluntary organizations and domiciliary nursing agencies have recently beenencouraged to develop community-based services (TheWorld Bank 2007) but evidenceof the growth of non-custodial alternatives to long-term care is meager. In our surveyof DPS, only three facilities mentioned offering day care and just one offered meals.Although 42% (N=29) note that they offer rehabilitative services, only two mention

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that these services are a source of additional revenue. Six (9%) obtained additionalrevenue from catering, and two each for renting out their facility or market services.

Respondents were asked whether government agencies prompted expansion ofactivities or made specific suggestions based on a broader vision of the needs in thearea. The vast majority (N=61; 89%) did not mention a single suggestion. Of thosewho provided a response, rehabilitative service was the most common (N=7; 10%),with other options including day care, occupational therapy, nursing care and a ThirdAge University.

Conclusion

Findings from published reports, government statistics and a survey of social care homespresent a picture of preponderant medically based long-term care, limited social careentrepreneurship, and negligible expansion of community-based care in Poland.

Acknowledgements This research project owes a great debt to Elzbieta Chmielewska who providedinvaluable assistance at every stage. The Rhode Island College Faculty Research Fund granted support forRachel Filinson and Darek Niklas.

References

Bien, B. (Ed.). (2006). Family caregiving for the elderly in Poland. Bialystok: Wydawnictwo Trans-Human.

Bien, B., Wojszel, B., & Sikorska-Simmons, E. (2007). Rural and urban caregivers of older adults inPoland: perceptions of positive and negative impact of caregiving. International Journal of Aging andHuman Development, 65(3), 185–202.

Commission of the European Communities (2008). European Demography Report 2008. Available athttp://ec.europa.eu/social/main.jsp?langId=en&catId=89&newsId=419, retrieved 2/24/2010.

European Commission (Employment, Social Affairs & Equal Opportunities). (2008). European UnionReport: Long-term care in the European Union. Available at http://ec.europa.eu/social/main.jsp?catId=792&langId=en, retrieved 2/24/2010.

Golinowska, S. (2010) The system of long-term care in Poland. European Network of Economic PolicyResearch Report No 83, June, available at http://www.ceps.eu/book/system-long-term-care-poland,retrieved 7/24/2010.

GUS (Main Statistical Office) Regional Data Bank. (2007) www.stat.gov.plJakubczak, P. (2007). Kilkaset domów opieki poza kontrolą państwa. Gazeta Prawna, November 12th.Hoffman, F., & Rodrigues, R. (2010). Informal carers.Who takes care of them? Policy Brief April 2010 European

Centre. Available at http://www.euro.centre.org/data/1274190382_99603.pdf retrieved 7/24/2010.Ministry of Labour and Social Policy. (2008). National strategy report on social protection and social inclusion,

2008–2010. Available at http://ec.europa.eu/social/main.jsp?catId=757&langId=en, retrieved 2/24/2010.PAP. (2008). Pielęgniarki w DPS-ach będą opłacane przez NFZ., July, 10th.Rakowska-Boron, I., & Sikora, D. (2007). W domach pomocy spolecznej jest coraz wiecej pustych

miejsc. Gazeta Prawna, February 12th.Tawczynska-Turek, J. (2004). Pustoszeja domy pomocy spolecznej. Rzeczpospolita, September 2nd.The World Bank. (2007). From red to gray—The “third transition” of aging populations in Eastern Europe

and the former Soviety Union. Available at http://siteresources.worldbank.org/INTUKRAINE/Resources/Red_to_Grey_eng.pdf, retrieved 2/24/2010.

Wieckowska, B. (2010). Long-term financing—the case of Poland. Presented at “Long-term care inEurope—discussing trends and relevant views,” Budapest, February. Available at http://www.euro.centre.org/data/1267718533_34607.pdf, retrieved 7/25/2010.

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Rachel Filinson, PhD in Sociology from University of Aberdeen, UK, has been a professor of Sociologyand Gerontology Coordinator at Rhode Island College (Providence, RI, USA) since 1987. She hasconducted numerous research projects in gerontology on program evaluation and comparative socialpolicy. Recent publications based on her research can be found in the Journal of Cross-CulturalGerontology, Journal of Elder Abuse & Neglect, and Social Policy and Administration.

Darek Niklas, PhD in Sociology from University of Warsaw, was Research Director for the Report on theConditions of the Disabled in Poland, prepared under the aegis of the Polish Academy of Sciences. Since1989 he has been teaching sociology at Rhode Island College, Providence, RI. Research on the changes inPolish health care conducted in the early 2000s has been published in “Communist and Post-CommunistStudies” and “Journal of Aging and Social Policy”.

Piotr Chmielewski, PhD in Sociology, University of Warsaw, is Professor of Sociology at the Unversityof Warsaw, and Associate Dean in Kozminski Academy, Warsaw. His research interests cover severalareas, including the sociology of health care, employing the neoinstitutional perspective. The mostrecent of his numerous publications can be found in “Polish Modernization” edited by W. Morawski(Warsaw, 2010).

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