Poland: Health care system, including accessibility to Roma; availability of insurance and social service medical coverage for healthcare to Roma, including minors; state efforts to address accessibility of Roma to health care services (2011-July 2014)

1. Overview of Poland's Health Care System

In a report to the UN International Human Rights Instruments, Polish state authorities note that the right to health protection is guaranteed by the Constitution and that the state is obliged to provide special health care for children, pregnant women, people with disabilities and the elderly (Poland 4 Mar. 2013, para. 139).

Sources indicate that Poland has a national health insurance program called the National Health Fund (NHF) (Poland 2013, 92; ibid. 4 Mar. 2013, para. 30; HFHR 10 July 2014). In a report to the UN, Polish authorities explain:

The Polish health care system is mostly based upon the health insurance scheme. The National Health Fund is the only external payer in the Polish health insurance scheme. The Fund and its regional branches provide health care services based on contracts with providers of health services. The people under compulsory coverage (i.e. the employed, self-employed, those receiving unemployment benefits, pensioners, soldiers, civil servants etc.) pay insurance contributions as a percentage of their income. (Poland 4 Mar. 2013, 7)

According to a 2013 report by the Social Insurance Institution, a public institution providing support for Poland's social security system (Poland 2013, 7), revenues from health insurance contributions are the main source of financing for health care services, and contributors pay a fixed rate of 9 percent of income into the Fund (Poland 2013, 92). This source states that the compulsory health insurance system "covers almost the whole population of the country" (ibid.).

In the UN report, government authorities indicate that, in addition to the people who pay into the National Health Fund, Polish citizens who live in Poland and meet the requirements for social assistance (as defined by the 12 March 2004 Act on Social Assistance) are entitled to receive health care services funded by the central budget of the state (Poland 4 Mar. 2013, para. 29). According to the website of the Ministry of Labour and Social Policy, the provisions of the 12 March 2004 Act on Social Assistance indicate that "persons holding Polish citizenship, residing and staying within the territory of the Republic of Poland, and foreigners residing and staying on the territory of the Republic of Poland, holding a residence permit or refugee status, as well as citizens of the European Union and European Economic Area, who stay on the territory of Poland and who hold a stay permit are entitled to social assistance benefits" (Poland n.d.a). The Ministry of Labour and Social Policy reports that the main recipients of social assistance are the homeless, the unemployed, the disabled, the poor, the elderly, families and children, and victims of natural disasters (ibid.).

The Social Insurance Institution indicates that the central budget finances health care insurance for farmers with farms less than 6 conversion hectares and their family members, as well as "unemployed persons without the right to benefits" and "recipients of social assistance allowances" (Poland 2013, 93). The same source indicates that the state budget further finances some uninsured people, such as low-income persons who are approved for benefits by the decision of a town or village mayor, people with drug or alcohol addictions, and people suffering from communicable or mental illnesses (ibid.).

In the report to the UN, the Polish government indicates that people entitled to health care coverage receive the following services: "diagnostic examinations, basic health care, out-patient specialist care, some dental services, hospital treatment, highly specialised services, medical life-saving services," as well as partial reimbursement for "spa treatment, medicines, medical products and devices" (Poland 4 Mar. 2013, para. 32).

1.1 Effectiveness of Publicly Funded System and Use of Private Services

In the 2014 country report for Poland of Bertelsmann Stiftung's Transformation Index (BTI), an index produced by a private German foundation that measures the success of countries in "targeting the dual goals of a democracy under rule of law and a market economy equipped with sociopolitical safeguards" (Bertelsmann Stiftung n.d.), the Polish health care system is described as "inadequately funded" and poorly functioning "due to a centralized, inefficient organizational structure" (ibid. 2014, Sec. 10). In a 2013 comparative study of 35 European countries, the Health Consumer Powerhouse, a Swedish-based company that monitors and compares healthcare systems among European and other countries (HCP n.d.), ranked Poland's health care system as 32 out of 35 countries, scoring it above Serbia, Romania and Latvia, and below western European countries and several eastern and central European countries, including Bulgaria, Albania, Hungary, Macedonia, Estonia, Slovakia, Croatia and others (HCP 2013, Fig. 4.1).

Sources indicate that some Polish citizens pay for private health care services in Poland, particularly to avoid long wait times to see specialists (Public Opinion Research Centre Mar. 2012; Polish News Bulletin 3 Apr. 2014; CP 18 Dec. 2013). According to a 2012 public opinion poll in Poland by the Public Opinion Research Centre [1] about the use of publicly and privately funded health services, including dental services, 40 percent of respondents used a combination of publicly- and privately-funded health services, 36 percent used only publicly funded health services, 6 percent used only privately funded health services, and 18 percent did not use any health services in the 6 months prior to the survey (Public Opinion Research Centre Mar. 2012). The most common reason for choosing paid services over national health insurance was to shorten the wait time (66 percent) (ibid.). Twenty percent of those who paid for services said that they did so because they could not get it with the national health insurance (ibid.).

1.2 Health Coverage for Minors and Pregnant Women

Sources indicate that minors under the age of 18 and pregnant women in Poland are entitled to receive health care coverage regardless of whether they qualify for social assistance (Poland 4 Mar. 2013, para. 29; ibid. 2013, 93; HFHR 10 July 2014). In a telephone interview with the Research Directorate, a representative from the Helsinki Foundation for Human Rights (HFHR) said that this right to health care coverage for minors includes children whose parents are uninsured (ibid.). She also noted that pregnant women who are uninsured through the NHF are entitled to health care until 6 months after giving birth (ibid.). Polish government sources indicate that services for minors and pregnant women who are not insured through the NHF are financed through the state budget (Poland 4 Mar. 2013, para. 29; ibid. 2013, 93).

2. Roma Access to Health Insurance

In a 2011 survey by the European Agency for Fundamental Rights (FRA) and the UN Development Programme (UNDP), 670 Roma households and 505 non-Roma households were interviewed on a number of issues, including health insurance (EU and UN 2012, 20-21, 30). Of respondents 18 years of age and older, 91 percent of Roma responded that they were insured, while 9 percent said that they did not have insurance (ibid., 20-21). In comparison, 98 percent of respondents of non-Roma ethnicity indicated that they were insured, while 2 percent were uninsured (ibid.). The survey notes that at least 66 percent of the Roma surveyed lived in urban areas (ibid., 30).

The HFHR representative said that Roma have the same rights to the national health care services as other Polish citizens, but that Roma are often uninsured (HFHR 10 July 2014). She explained that in order for people over 18 years old to qualify for health insurance, they need to have the "official status of an unemployed person" (ibid.). She said that many unemployed Roma do not qualify for this status due to prolonged unemployment, however, she was not aware of how many people this affected (ibid.). This information could not be corroborated among the sources consulted by the Research Directorate within the time constraints of this Response.

2.1 Barriers Roma Face to Accessing Health Care

In correspondence with the Research Directorate, a representative of the Organization for Security and Co-operation in Europe (OSCE)'s Office for Democratic Institutions and Human Rights (ODIHR), who specializes in Roma and Sinti issues, noted that Roma in Poland face a number of barriers in accessing healthcare (OSCE 11 July 2014). The OSCE representative quoted information originating from a 2011 report about promoting social inclusion of Roma in Poland by the Centre for Social and Economic Research (CASE), a Warsaw-based non-profit economic and public policy research institution (CASE n.d.). In the report, an activist and plenipotentiary of the regional authorities for minority issues in Malopolska voivodship indicated that Roma face the following barriers in accessing health care:

discrimination against Roma in the form of refusal to grant basic medical assistance,

lack of knowledge of the Roma customs by medical personnel,

taboos related to sexual behaviour and shortage of hygiene products useful before visiting a doctor reported by Roma women, all leading to insufficient prenatal and pregnancy care,

customs and norms making it difficult for Roma women to look for medical consultation during periods, pregnancies or after delivery, and

extreme poverty of Roma resulting in lack of funds for travelling to health centres or for buying medicines. (CASE Aug. 2011, 10)

According to a report by the Council of Europe's Advisory Committee on the Framework Convention for the Protection of National Minorities, Roma representatives report that Roma experience "ongoing discrimination" in a number of areas, including access to health care (COE 7 Feb. 2014, para. 52). Without providing details, the Council of Europe's European Commission Against Racism and Intolerance (ECRI) report for Poland states that people with low incomes and/or living in remote areas, including Roma, experience problems in the area of health and are subject to racial discrimination in the field of health (COE 15 June 2010, para. 75-76).

Information about the ability of Roma minors to access free health care services could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

3. State Efforts to Address Accessibility of Roma to Health Care Services

According to the Council of Europe's Advisory Committee on the Framework Convention for the Protection of National Minorities, the National Programme for the Roma Community in Poland, which was established in 2004, is the "main operating tool for the implementation of the government policies" on Roma issues (COE 7 Feb. 2014, para. 186). The same source notes that there are plans to extend the programme until 2020, and that there has been "some progress" in improving access to health care for Roma under this programme (ibid., para. 21). According to the US Department of State's Country Reports on Human Rights Practices for 2013, Poland allocated approximately US$3.2 million to its Roma program in 2013, and projects included initiatives to improve Roma health (US 19 Apr. 2014, 26). According to the CASE report, only 2-3 percent of the budget of the Programme for the Roma Community is spent on funding projects to improve Roma health (CASE Aug. 2011, 17). Poland's Human Rights Defender in the Area of Equal Treatment questioned the ability of local authorities to improve living conditions under this programme, due to a lack of funding and because local authorities make the decision on whether to apply for funds and also decide to which activities the funds would be allocated (Poland June 2014, 14).

Several sources indicate that the Polish government has provided support for programs addressing Roma health issues (EU 4 Apr. 2014; Poland n.d.b.; European Network 1 Jan. 2013, 94). One area of support is the establishment of community [or special] nurses for Roma (EU 4 Apr. 2014; Poland n.d.b; European Network 1 Jan. 2013, 94). According to a document about Poland's Programme for the Roma Community in Poland, which was produced by the Roma Minority Division of the Department of Denominations and National and Ethnic Minorities of the Ministry of Administration and Digitization of Poland, community nurses provide medical help and guidance and distribute subsidized medications and personal hygiene products (Poland n.d.b). This source indicates that there were 32 community nurses for Roma in 2011 (ibid.). The European Network of Legal Experts in the Non-discrimination Field indicates that there were 34 community nurses for Roma in 2012 (European Network 1 Jan. 2013, 94).

Organizing immunization and health screening is another area of support (EU 4 Apr. 2014; Poland n.d.b.; European Network 1 Jan. 2013, 94). According to the document by the Roma Minority Division, 2,182 Roma received preventative health exams and vaccinations in 2011 (Poland n.d.b). The European Network of Legal Experts in the Non-discrimination Field indicates that in 2012, 1,719 Roma received preventative health exams and vaccinations (European Network 1 Jan. 2013, 94).

The Polish government also financed so-called "'white days'" in which doctors with different specialities gave free medical advice to Roma (ibid.; Poland n.d.b). There were reportedly 23 of these events held in 2011 (ibid.). There were 8 held in 2012 (European Network 1 Jan. 2013, 94). According to Poland's Roma Minority Division, the Programme for the Roma Community in Poland also includes funding medical equipment, dental treatment and rehabilitation services for Roma (Poland n.d.b). Further information about these services could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

In addition to support for vaccinations and community nurses, the European Commission's 2014 review of Poland identified "preventive health measures focusing on Roma women and children" and "co-financing medicine," as "key steps" that Poland has taken between 2011 and 2014 to address the issue of health for Roma (EU 4 Apr. 2014). The same source identified a need for "measures to improve access of Roma to healthcare" as one of the "identified gaps" in the national program for Roma integration (ibid.).

This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim for refugee protection. Please find below the list of sources consulted in researching this Information Request.

Notes

[1] The Public Opinion Research Centre is a publicly funded independent research centre in Poland (Public Opinion Research Centre n.d.).

References

Bertelsmann Stiftung. 2014. "BTI 2014--Poland Country Report." [Accessed 3 July 2014]

_____. N.d. "Transformation Index BTI 2014." [Accessed 15 July 2014]

Canadian Press (CP). 18 December 2013. "Poland's Health Minister Seeks Dismissal of the Head of Controversial State Health Fund." (Factiva)

Centre for Social and Economic Research (CASE). August 2011. Irena Topinska. Poland. Second Semester Report. Promoting Social Inclusion of Roma. Sent to the Research Directorate by the OSCE ODIHR, 11 July 2014.

_____. N.d. "About Us." [Accessed 14 July 2014]

Council of Europe (COE). 7 February 2014. Advisory Committee on the Framework Convention for the Protection of National Minorities. Third Opinion on Poland. [Accessed 7 July 2014]

_____. 15 June 2010. European Commission Against Racism and Intolerance (ECRI). ECRI Report on Poland (Fourth Monitoring Cycle). [Accessed 7 July 2014]

European Network of Legal Experts in the Non-discrimination Field. 1 January 2013. Lukasz Bojarski. Report on Measures to Combat Discrimination. Country Report 2012: Poland. [Accessed 7 July 2014]

European Union (EU). 4 April 2014. European Commission. "The European Union and Roma--Factsheet: Poland." [Accessed 3 July 2014]

European Union and United Nations Development Programme (UNDP). 2012. The Situation of Roma in 11 EU Member States. [Accessed 3 July 2014]

Health Consumer Powerhouse (HCP). 2013. Euro Health Consumer Index 2013. [Accessed 3 July 2014]

_____. N.d. "About Us." [Accessed 14 July 2014]

Helsinki Foundation for Human Rights (HFHR). 10 July 2014. Telephone interview of a representative by the Research Directorate.

Organization for Security and Co-operation in Europe (OSCE). 11 July 2014. Office for Democratic Institutions and Human Rights (ODIHR). Correspondence from a representative to the Research Directorate.

Poland. June 2014. Office of the Human Rights Defender. Report on the Activity of the Human Rights Defender (Ombudsman in Poland) in the Area of Equal Treatment in 2013. [Accessed 7 July 2014]

_____. 4 March 2013. Common Core Documents Forming Part of the Reports to State Parties. (HRI/CORE/POL/2012) [Accessed 3 July 2014]

_____. 2013. Social Insurance Institution. Social Insurance in Poland. [Accessed 10 July 2014]

_____. N.d.a. Ministry of Labour and Social Policy. "Social Assistance." [Accessed 11 July 2014]

_____. N.d.b. Agnieszka Gajewska. Ministry of Administration and Digitization of Poland. "Programme for the Roma Community in Poland." [Accessed 7 July 2014]

Polish News Bulletin. 3 April 2014. "Reform to Improve Situation of Patients and Condition of Health Services." (Factiva)

Public Opinion Research Centre. March 2012. "Consumption of Medical Services." [Accessed 7 July 2014]

_____. N.d. "About Us." [Accessed 15 July 2014

United States (US). 19 April 2014. "Poland." Country Reports on Human Rights Practices for 2013. [Accessed 7 July 2014]

Additional Sources Consulted

Oral sources: Attempts to contact representatives of the following organizations were unsuccessful within the time constraints of this Response: Institute for Law and Society; Poland - Human Rights Defender, Ministry of Administration and Digitization of Poland, Ministry of Health, National Health Fund; Roma People Association of Poland. Representatives of the following organizations were unable to provide information: Association for Legal Intervention; Polish Society of Antidiscrimination Law; Stefan Batory Foundation.

Internet sites, including: Amnesty International; Association for Legal Intervention; Decade of Roma Inclusion; European Association of Health Law; ecoi.net; European Network Against Racism; European Roma Rights Centre; EU - European Network on Social Inclusion and Roma under the Structural Funds; Factiva; Freedom House; Human Rights Watch; International Federation for Human Rights; Legislationline; Minority Rights Group International; Poland - Ministry of Health, National Health Fund, National Institute of Public Health; Roma People Association in Poland; socialwatch.eu; Stefan Batory Foundation; Transitions Online; UN - Refworld, World Health Organization.