Jan Cienski in Warsaw -

Healthcare has tripped up politicians from Hillary Clinton to Tony Blair, and dealt a terminal blow to Hungary's current government, so pity Polish Prime Minister Donald Tusk who is trying to finesse the issue as he steers between demands for better care from voters and a need to ensure he does not blow a huge hole in the budget.

His government's signature policy has become a plan that would hand over the ownership of hospitals, many of them haemorrhaging red ink, to local governments. As part of this, the government announced on June 6 that it is prepared to swallow almost €800m in debts owed to state coffers by hospitals. The scheme also aims to encourage the hospitals to change their legal status in return for other public aid. "The best administrator for the hospitals will be local governments. They have proved that they are able to care for the interests of their inhabitants," says Zbigniew Chlebowski, parliamentary leader of the ruling Civic Platform party.

The problem for Tusk is that his party promised solemnly that it would not privatise hospitals during last year's election campaign. Although the plan would not sell off hospitals directly, localities would be able to put a hospital on the market within a couple of years of gaining control of the institution. Aleksander Grad, the treasury minister, forthrightly explained the shift in position, saying: "Election campaigns have their own rules."

That may have been honest, but prompted howls of outrage from opposition parties. "We have been cheated," says Boleslaw Piecha, an MP for the opposition Law and Justice party and a deputy health minister in the previous government.

The government defends itself by pointing out that governments that are closer to voters are better placed to manage hospitals. It also says that it would make little sense for local authorities to sell off hospitals to be converted into apartments and other projects because officials would be called to account by angry voters during the next election.

The government argues it has to do something because the health service is struggling with about PLN10bn (€3bn) of debts, and making hospitals more efficient and market oriented may stop the losses. Patients would still be covered by the government health service and wouldn't really be aware of who owned their local hospital.

Time in hospital

Tusk has already devoted an enormous amount of time to healthcare during his first six months in office. Immediately after becoming prime minister he was faced with strike threats from doctors and then nurses unhappy over their low pay. He held two day-long "white summits" - conferences where representatives of the health sector were supposed to spell out what was wrong with the system and come up with ideas for fixing it. In the end, Tusk sat politely and listened to endless harangues with few practical ideas for how to make things better.

But so far Tusk's attempts to fix health care have floundered. The two most important medical reforms bills presented to parliament by Ewa Kopacz, the health minister, have run into trouble. "Two key bills have turned out to be inappropriate," says Marek Balicki, an MP for the opposition Social Democrats. "The actions of the government and PO (Civic Platform) are chaotic."

Tusk faces huge political risks if he does not do something to make the healthcare system more efficient. His predecessor, Jaroslaw Kaczynski, spent weeks as prime minister listening to angry nurses who had set up a tent city outside his office to protest his health policies. Kaczynski's ham-handed response to the nurses was one of the key reasons why his party lost last year's parliamentary elections.

The roots of Poland's healthcare woes are the same as in every other country: money, or rather the lack of it. Poland spends only about 6.2% of its GDP on health care, one of the lowest levels in the OECD. The average for the EU is 8.7%, and even Poland's ex-communist neighbours spend a percentage point more. Public spending on health care comes to a paltry 4.3% on GDP. "The main problem is that Poland simply spends too little on health care," says Konstanty Radziwill, head of the Polish Chamber of Physicians and Dentists.

The lack of funds collides with societal expectations shaped by almost 50 years of communism, where a well staffed - in fact usually massively overstaffed - and free heath service was one of the few tangible benefits of a system that otherwise produced economic chaos.

Following Poland's entry into the EU in May 2004, Poles began to compare themselves to their neighbours to the west, and began to demand a similar level of healthcare to Germany and the UK. Doctors also began to demand higher wages. People have the continued belief that hospitals and doctors will treat everyone for free, and the result has become health care rationed by immensely long waiting times, often alleviated by giving doctors bribes to speed the process along. Thousands of doctors, especially specialists like anaesthesiologists, as well as many nurses have left the country, attracted by the higher wages and easier working conditions in western Europe.

Tusk is never going to make all Poles happy about their health system - that achievement has eluded some of the world's most accomplished politicians - but if he cannot at least make the system solvent and improve the level of service, his party's current enormous popularity could begin to erode.

Send comments to The Editor