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Healthcare for children and adolescents in Poland

Despite the constant tendency to decrease the number of births, children and adolescents account for one-fifth of the Polish population. Healthcare for children is free and it is organized similarly to the care for adult patients. In primary healthcare, children can be under the medical care of general practitioners, family physicians or pediatricians. In secondary and tertiary care, pediatricians or physicians with pediatric subspecialties provide medical services. The number of pediatricians and nurses is not sufficient and still differs from the European average. Nonetheless, population health indicators (e.g. infant mortality rate) are constantly improving, and despite the strong influence of the anti-vaccine movements, 90% of children are vaccinated according to the schedule.


INTRODUCTION
Under Polish law, the right to health protection is guaranteed in Article 68 of the Constitution of the Republic of Poland of 1997. This article additionally contains a provision obliging public authorities to provide special health care to children [1].
The child's right to health protection is also safeguarded by international treaties, in particular by the United Nations Convention on the Rights of the Child (CRC, General Assembly of the United Nations, November 20, 1989) ratified by Poland in 1991, which among the rights of the child lists also the right to the best health care and facilities for the treatment of diseases and rehabilitation [2]. The health care system in Poland is based on the national social health insurance model, in which the main source of financing is an obligatory monthly fee calculated as a percentage of people's salary. The National Health Fund (NFZ) is a disposer of these funds acting in the system as the main payer. The costs of outpatient and stationary health care are covered by the NFZ in the form of a lump sum, a fee for a patient, or for specific services [3].
According to Polish law, every child (in legal terms, any person under 18 years old) has the right to free health care, regardless of his/her or their parents' insurance status. A child as a patient is entitled to at least the same rights as an adult, subject to the limitations resulting from their age and the rights of their parents or legal guardians.

DEMOGRAPHIC CHARACTERISTICS
Since 2010, the population of Poland has been slowly but gradually decreasing from 38,539,862 in 2010 to 38,433,558 in 2017 (Table 1). At the same time, the percentage of children and adolescents in the total population is also systematically declining (Fig. 1). In 1990, this group accounted for 32%, in 2000 -27.8%, and in 2017 only 20% of the total population. The number of live births also decreased from 14.4 per 1000 in 1990 to 10.4 in 2017 [4].
However, in the last two decades, the rate of stillbirths has decreased two-fold, from 7.3 per 1000 live births in 1995 to 2.9 in 2015 [5]. The perinatal mortality rate also decreased from 19.5 per 1000 births in 1990 to 4.8 in 2017.
In 1990-2017 the infant mortality in Poland declined continuously (Fig. 2). In 1990, 10,600 deaths of children under one year of age were registered, while in 2000 -3067, and in 2017 -1604. The infant mortality rate was 3.99 per 1000 live births in 2017, which was 4.12 lower than in 2000, and more than 15 lower in comparison with  Poland in the years 1990-2017   Characteristics  1990  1995  2000  2005  2010  2015  2017  Total population  38,073,000 38,284,000 38,253,955 38,157,055 38,529,866 38,437,239 38,433,558  Number of children and adolescents  aged 0-19   12,183,000 11,914,891 10,636,821 9,058,  . The average annual rate of decline in infant mortality in Poland in the analysed period was thus approximately 5.7%. Despite this positive trend, the infant mortality rate is still slightly higher than the European Union (EU) average (in 2016 in Poland -4.0, in the EU -3.6) [6].

HUMAN RESOURCES
One of the main problems of health care in Poland is the inadequate number of medical personnel. In comparison with other European Union member states, Poland has one of the lowest rates regarding the number of both doctors (2.4) and nurses (5.0) per 1000 citizens ( Table 2) [7].
In 2010-2017, the number of paediatricians ranged between 3216 and 3584 (Figs. 3 and 4). As a result of the reform of the health care system from 1999, the role of the paediatrician in primary care has been significantly reduced -it was family doctors and general practitioners who became the main decision-makers in the field of medical care for children. Therefore, a reduction of interest in specialising in the field of paediatrics was observed. In 2014, the law was amended and the paediatrician's leading role in caring for the patient up to the age of 18 years was restored [9].
In addition to primary care, paediatricians provide services in secondary care in general hospitals of various levels. In tertiary care, paediatricians with subspecialties provide services in specialist outpatient clinics or hospitals.
As in the case of doctors, the main problem of nursing care is staff shortage, which will probably increase due to the high average age and successive retirement of nurses, with too few people willing to work in this profession (Fig. 5) [10].

OUTPATIENT HEALTH CARE
In 2017, outpatient health care was provided in total by 21,685 health centres, 963 individual medical practices, and 4143 individual dental practices. Medical services are provided as part of primary or specialised health care [4].

PRIMARY HEALTH CARE
Until the end of the 20th century, children were assigned to the outpatient clinic nearest to the place of residence, and only there could they receive primary health care. In the cities, clinics had two separate parts: one for healthy children (assessing the child's development, providing e.g. vaccinations and dietary advice) and one for infectious children. In both sections medical services were provided only by physicians with a specialisation in paediatrics. In rural areas, children were under the care of general practitioners.
Since 1999, when the major reform of the health care system was introduced, primary health care for children was entrusted to physicians with a new specialisation: family medicine. Currently, after several changes in the regulations, children from birth to the age of 18 years can remain under the medical care of family doctors, general practitioners, or paediatricians. Parents and legal guardians of young patients have a guaranteed free choice of doctor.
In 2017, over 169 million medical services were provided in primary health care, of which 21.5% (36.3 million) were administered to children and young people up to 18 years of age [4].

SPECIALISED HEALTH CARE
In 2017, over 116 million medical services were provided in specialized health care, of which 12.9% (nearly 15 million) were administered to children and young people up to 18 years of age.
As part of dental care for children and adolescents nearly 9 million items of medical advice were provided, which was approximately 29% of the total number of annual dental consultations (34.5 million) [4].

STATIONARY HEALTH CARE
In 2017, there were 951 general hospitals in Poland with 185.3 thousand beds and 191 day hospitals with   [4].
In 2017 the network of essential hospitals was established. It is intended to improve the organisation of providing health care services and increase patients' access to specialist treatment. The network includes 594 hospi-tals -general ones, divided into three levels of reference, along with specialised facilities: paediatrics (13), oncology (20), pulmonology (30) and nationwide multidisciplinary centres (90). Network hospitals have a guaranteed funding from NFZ in a flat-rate form, without the need to compete for financing with other institutions [11]. However, after a year of network functioning, it is difficult to unequivocally evaluate this new solution, because any assessment of its far-reaching impact requires much more time.

HEALTH RESORT TREATMENT
Health resort treatment in sanatoriums, spa towns, and rehabilitation centres are among the stationary care forms, which are an integral part of the health care system. In 2017, there were 271 health resort centres in Poland, of which 88.6% provided stationary care. The remaining 11.4% were outpatient clinics and physiotherapy centres. Younger children, between three and six years old, stay in sanatoriums with their legal guardian, while older children can stay there alone. Sanatoriums provide children with the opportunity to learn at elementary and middle school level, just like boarding schools; therefore, children aged 7-15 years can benefit from treatment throughout the year. Stationary care for adolescents is available during the school-free period.
Despite the undoubted benefits of health resort treatment, the possibility of continuing education and total coverage of treatments, accommodation and meals costs by NFZ, this type of services is not very popular. The main reason is the reluctance to being separated from family and friends, changing the school, and interrupting additional classes. Consequently, despite the great interest in sanatorium treatment in Poland (734,447 patients in 2017), only 3% of them are children and adolescents. In recent years, there has been a growing tendency to shut down facilities dedicated to children.

PREVENTIVE HEALTH CARE FOR CHILDREN AND ADOLESCENTS
In Poland, there is a legal obligation to perform periodic, preventive medical examinations with a comprehensive review of the children's and adolescents' health status, along with an assessment of the regularity of development. In the case of infants, nurses, midwives, and doctors come to the patient's home on so-called patronage visits. This type of health care is provided by primary health care facilities. In addition, there is a nurse or hygienist in every school, who takes preventive care of pupils, performs screening tests, and conducts health education in a broad meaning of this term.
However, according to the data provided by the Centre of Information Systems for Health Care in 2015, almost 14% of newborns did not have appropriate medical  care, and this percentage increased with the age of the child, reaching 26% at the age of one year (Fig. 6) [12]. Preventive examinations carried out in further years concern specific age groups: 2-, 4-, 6-, 10-, 13-, 16-, and 18-year-olds. Regrettably, in all these groups, the percentage of examined children and adolescents is insufficient (Fig. 7). This applies mainly to 4-year-olds (63.9%), 16-year-olds (64.6%), and 18-year-olds (48%), but also in the remaining age groups it does not exceed 75% (Fig. 8).
In 2010-2015, the percentage of preventive examined children dropped by about 5% [13]. This may be related to the increasing number of children who are solely under the care of private paediatricians because they are not obliged to report preventive health care actions.
An important element of preventive care is the prevention of infectious diseases, especially by vaccinations. An annually updated vaccination schedule, which contains a list of mandatory and recommended vaccinations, is published by the Chief Sanitary Inspectorate. Since mandatory vaccinations for children are paid for by the state, they are free of charge for the patients, while recommended vaccinations must be purchased by parents or guardians.
In 2016, the following were vaccinated according to the schedule: 98.5% of children at the age of two years, 97.8% in the third year of life, 96.9% at the age of seven years, 93.9% at the age of 11 years, 94.2% at the age of 15 years, and 93.4% of girls at the age of 14 years against rubella (Fig. 9) [14]. This high level of vaccinated population (over 90%) is sufficient to achieve a community resistance and to prevent the epidemic spread of disease. However, although the percentage of people vaccinated in Poland is still high, in recent years more and more parents have been refusing to vaccinate their children, out of fear of adverse effects and under the influence of anti-vaccine movement propaganda [15].

CONCLUSIONS
Regardless of their insurance status, Polish children and adolescents (0-18-years age group) have an unlimited right to use health care financed from public funds.
An unquestionable success of the Polish health care system is a significant reduction in the infant mortality rate, almost to the average level of the European Union countries, achieved thanks to its average annual decline of about 5.7% over the last 27 years.
Despite the fact that anti-vaccine movements are gaining more and more supporters around the world, including Poland, the percentage of vaccinated children remains high, and the epidemiological situation of infectious diseases in Poland is relatively favourable and stable. Providing children with proper health care is a task that should mainly belong to paediatricians. This applies to both primary and secondary care. Such tasks as careful assessment of the health status of each new-born child, tracking his or her development, and providing full access to preventive care, early diagnosis, and treatment of children's diseases will be best performed by people prepared to provide them. According to the authors, paediatricians are best prepared for this particular type of health care. Therefore, the shortage of these specialists should arouse justified anxiety.

DISCLOSURE
The authors declare no conflict of interest.