Beata Plociennik, an elegant young doctor, believes that Medro - the private health centre she set up last autumn in central Warsaw - is going well. Rooms and corridor gleam with new paint, there are no queues in sight and patients appear content with the care they receive.

But not everyone is as happy as Ms Plociennik's patients. Since Poland introduced healthcare reform - through which most centres around the country have switched to private healthcare - many feel they are not getting access to the treatment they need, causing the government to lose support in opinion polls.

s Plociennik previously worked at a state-run health centre, which was shabby and ill equipped. "It still is like that, nothing has changed," she says.

Reforms, which came in at the beginning of January 1999, have opened the way to private healthcare, but she says that her former colleagues "don't seem to care either about setting up on their own or getting the local council which owns their centre to improve the situation".

eanwhile, Medro has registered 3,000 people for whom the state run "Health Fund", financed from individual health insurance contributions, pays 7 zlotys ($1.75) each a month.

This fee ensures that they receive free medical assistance at the level a general practitioner would provide in the UK. Some voluntarily pay Medro another 10 zlotys a month, which secures them immediate access, without extra payment, to specialists retained by Ms Plociennik's centre.

Those who do not want to pay the extra fee, have to pay to see the specialists or join a long waiting list if they want to have the visit paid for by the state health fund.

These contributions barely cover costs, says Ms Plociennik, adding that she is seeking contracts to provide corporate healthcare. Already, for example, she has signed up the Warsaw city traffic police force.

So far the switch to private primary healthcare has gone slowly in Warsaw. But other regions such as Poznan, Silesia and Krakow have seen an almost complete switch to private clinics, says Andrzej Rys, a deputy health minister.

He admits, however, that there are few plans to set up private hospitals, despite "intense interest" from foreign private healthcare providers and insurance companies.

r Rys, originally a doctor from Krakow, defends the reforms initiated by the governing Solidarity trade union movement AWS. The reforms aim to "cost" healthcare while defining - and so limiting - the extent of treatment paid for by the state-run insurance system.

Under the new system a health insurance fee, subtracted from earnings, is passed to 17 regional, state-run "Health Funds" which then contract to pay for healthcare in private and publicly owned clinics and hospitals.

Overall last year, 25bn zlotys ($6.25bn) was spent on healthcare - about 3.8 per cent of GDP. "Before, there was simply a black hole into which money was poured, without thought or plan," says Mr Rys. "Already after a year, we've managed to limit the growth in the health service's debt and spending on medicines has been limited."

The problem, however, is that the reform has not been popular. Indeed, if the AWS loses next year's parliamentary election, health reform will have been one of the main contributory factors.

The opinion poll results are damning. According to CBOS, an independent polling organisation, only 9 per cent of the population believe the healthcare system is functioning better now than before the changes were brought in. Another 68 per cent believe the situation has deteriorated.

"The problem is that the longer the reform is in force, the worse and not better the figures get," says Professor Lena Kolarska, whose Public Affairs Institute think tank is studying the subject.

What is more, institutions such as Dr Plociennik's gleaming new health centre, are not attracting patients purely because they think the level of treatment will be better.

The survey figures show that while 42 per cent of the people paid for some measure of healthcare last year, only a third of them did so for this reason. The same proportion said they "went private" because they couldn't get access to treatment funded by the Health Funds because of long waiting times for appointments.

As many as a fifth chose to pay for their doctor for both reasons. The authorities appear determined to forge ahead with the reform even though Mr Rys admits that "it has been as great a shock for people as the introduction of the market system was in 1990".

"The reform means that people both in the health service and the patients have begun to think in terms of the cost of the services the system provides," he adds. Nevertheless, for the first time in Poland, the reforms have raised the question of who should pay for a healthcare system.

ost money is spent on treating the elderly and the chronically infirm, yet contributions are equal across the population. It is a question which even supporters of the reform would prefer not to have had brought out into the open.

Andrzej Koronkiewicz, the head of the Warsaw Region Health Fund and one of the architects of the change, avoids a direct answer to questions about which age groups and which diseases cost his fund the most last year.

"The structure is the same as in most developed countries," he says defensively. Originally, the reform envisaged the establishment, from 2002 onwards, of privately-owned health funds alongside the state funds from.

These would have collected the insurance contributions from the state and paid for the healthcare of those registered with the fund. However, now even the pro-business Freedom Union party has suggested that the date be put back until 2005, for fear that the young and better off will register privately, leaving the old and poor with the state funds which would then go bankrupt.

"It's certainly a dilemma," Mr Rys admits.


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