The projection examines impact of demographic changes and changes in health status on future (up to 2050) health expenditures. Next to it, future changes in the labour market participation and their impact on the health care system revenues are examined. Impact of demography on the health care system financial balanced is examined in four different scenarios: baseline scenario, death-related costs scenario, different longevity scenario and diversified employment rates scenario. Results indicate dynamic and systematic increase of the health expenditures in the next 30 years. Afterwards the dynamics of this process is foreseen to slow down. Despite the increase of the revenues of the health care system, the system will face deficit in the close future. This holds for each scenario, however the size of the deficit differs depending on longevity and labour market participation assumptions. Results lead to a discussion on possible reforms of the health care system.
Authored by: Stanislawa Golinowska, Ewa Kocot, Agnieszka Sowa
Published in 2008
The projection examines impact of demographic changes and changes in health status on future (up to 2050) health expenditures. Next to it, future changes in the labour market participation and their imact on the health care system revenues are examined. Results indicate that due to demographic pressures health expenditures will increase in the next 40 years and health care systems in the NMS will face deficit. Moreover, health revenues, expenditures and deficit/surplus are slightly sensitive to possible labour market changes. Health care system reforms are required in order to balance the disequilibrium of revenues and expenditures caused by external factors (demographic and economic), and decrease the premium needed to cover expenditures. Such reforms should lead, on the one hand, to the rationing of medical services covered by public resources, and on the other, to more effective governance and management of the sector and within the sector.
Authored by: Stanislawa Golinowska, Ewa Kocot, Agnieszka Sowa
Published in 2008
New financial institutions, pension funds, are being established in Central and Eastern Europe, that are also an important element of the social security system. They provide an additional source of income in old age. This source is all the more important insofar as public, pay-as-you-go pension systems in many countries are having problems with meeting previous pension commitments, which were often excessively generous and did not take into account potential changes in demographic conditions and the labour market.
The subject of our consideration will be the experiences relating to pension fund regulations from the point of view of their safety of operations in five countries of Central and Eastern Europe.
Authored by: Stanislawa Golinowska and Piotr Kurowski
Published in 2000
The purpose of this study is to explore and assess the costs and benefits of labour migration in Armenia and the potential of migration for contributing to the country’s development. We also examine how policy can be effectively formulated and implemented so that Armenia can get the most out of its migration experience. Lastly, we analyse how a phenomenon that emerged because of limited opportunities for employment – migration – evolved into a strategy towards development and prosperity.
Based on this analysis, this paper makes a strong argument in favour of implementing programs in Armenia that involve the active collaboration of government institutions and the Armenian Diaspora, duly considering the unusual influence the latter has on Armenia’s economic and human development.
Authored by: Gagik Makaryan and Mihran Galstyan
Published in 2013
Poland’s new Employee Capital Plans (PPK) scheme, which is mandatory for employers, started to be implemented in July 2019. The article looks at the systemic solutions applied in the programme from the perspective of the concept of the simultaneous reconstruction of the retirement pension system. The aim is to present arguments for and against the project from the point of view of various actors, and to assess the chances of success for the new system. The article offers a detailed study of legal solutions, an analysis of the literature on the subject, and reports of institutions that supervise pension funds. The results of this analysis point to the lack of cohesion between certain solutions of the 1999 pension reform and expose a lack of consistency in how the reform was carried out, which led to the eventual removal of the capital part of the pension system. The study shows that additional saving for old age is advisable in the country’s current demographic situation and necessary for both economic and social reasons. However, the systemic solutions offered by the government appear to be chiefly designated to serve short-term state interests and do not create sufficient incentives for pension plan participants to join the programme.
The transition process from a centralised to a market economy in Poland has been accompanied by an unprecedented increase in poverty and a deepening of inequality across households – not only in terms of income but also in terms of socio-economic status.
Although a small number of studies describing the economic situation of the poor in Poland have been undertaken, our understanding of the mechanisms that make poverty persist in the household context is considerably limited. The interaction of a number of factors may for example, result in individuals being trapped in a vicious circle of poverty. Low household income may lead to social exclusion and family distress, which is likely to have far-reaching consequences for all household members. Social exclusion may contribute to foster alcoholism, impede the human capital investment in children, and thus jeopardise the socioeconomic situation of the next generation. Socially excluded people experience severe difficulties in finding re-employment. Social transfers might even worsen the situation by providing a disincentive to seek work.
Authored by: Miriam Beblo, Stanislawa Golinowska, Charlotte Lauer, Katarzyna Pietka-Kosinska, Agnieszka Sowa
Published in 2002
The report discusses employment in the health care system in Poland based on analysis and projections of the demand and supply of medical workforce. The impact of the financial situation and policy on relativelly low employment level of medical personel was accounted for in the analysis while projections were driven by demographic changes in the following two decades. Results of different demographic variants of projections used in Neujobs project and additional scenarios show that while ageing is an important factor that may stimulate demand for provision of medical personnel, changes might be mitigated by further increase in efficiency of care. At the same time the supply of care will be affected by ageing too. The results indicate that more detailed monitoring of employment in the future will be needed in order to assure adequacy of provision of medical professionals, especially of nurses (critical gap), some medical specialists, physiotherapists and medical technical personnel.
This report was prepared within a research project entitled NEUJOBS, which has received funding from the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement no. 266833.
Written by Stanislawa Golinowska, Agnieszka Sowa and Ewa Kocot. Published in August 2014.
PDF available on our website at: http://www.case-research.eu/en/node/58694
The projection examines impact of demographic changes and changes in health status on future (up to 2050) health expenditures. Next to it, future changes in the labour market participation and their imact on the health care system revenues are examined. Results indicate that due to demographic pressures health expenditures will increase in the next 40 years and health care systems in the NMS will face deficit. Moreover, health revenues, expenditures and deficit/surplus are slightly sensitive to possible labour market changes. Health care system reforms are required in order to balance the disequilibrium of revenues and expenditures caused by external factors (demographic and economic), and decrease the premium needed to cover expenditures. Such reforms should lead, on the one hand, to the rationing of medical services covered by public resources, and on the other, to more effective governance and management of the sector and within the sector.
Authored by: Stanislawa Golinowska, Ewa Kocot, Agnieszka Sowa
Published in 2008
New financial institutions, pension funds, are being established in Central and Eastern Europe, that are also an important element of the social security system. They provide an additional source of income in old age. This source is all the more important insofar as public, pay-as-you-go pension systems in many countries are having problems with meeting previous pension commitments, which were often excessively generous and did not take into account potential changes in demographic conditions and the labour market.
The subject of our consideration will be the experiences relating to pension fund regulations from the point of view of their safety of operations in five countries of Central and Eastern Europe.
Authored by: Stanislawa Golinowska and Piotr Kurowski
Published in 2000
The purpose of this study is to explore and assess the costs and benefits of labour migration in Armenia and the potential of migration for contributing to the country’s development. We also examine how policy can be effectively formulated and implemented so that Armenia can get the most out of its migration experience. Lastly, we analyse how a phenomenon that emerged because of limited opportunities for employment – migration – evolved into a strategy towards development and prosperity.
Based on this analysis, this paper makes a strong argument in favour of implementing programs in Armenia that involve the active collaboration of government institutions and the Armenian Diaspora, duly considering the unusual influence the latter has on Armenia’s economic and human development.
Authored by: Gagik Makaryan and Mihran Galstyan
Published in 2013
Poland’s new Employee Capital Plans (PPK) scheme, which is mandatory for employers, started to be implemented in July 2019. The article looks at the systemic solutions applied in the programme from the perspective of the concept of the simultaneous reconstruction of the retirement pension system. The aim is to present arguments for and against the project from the point of view of various actors, and to assess the chances of success for the new system. The article offers a detailed study of legal solutions, an analysis of the literature on the subject, and reports of institutions that supervise pension funds. The results of this analysis point to the lack of cohesion between certain solutions of the 1999 pension reform and expose a lack of consistency in how the reform was carried out, which led to the eventual removal of the capital part of the pension system. The study shows that additional saving for old age is advisable in the country’s current demographic situation and necessary for both economic and social reasons. However, the systemic solutions offered by the government appear to be chiefly designated to serve short-term state interests and do not create sufficient incentives for pension plan participants to join the programme.
The transition process from a centralised to a market economy in Poland has been accompanied by an unprecedented increase in poverty and a deepening of inequality across households – not only in terms of income but also in terms of socio-economic status.
Although a small number of studies describing the economic situation of the poor in Poland have been undertaken, our understanding of the mechanisms that make poverty persist in the household context is considerably limited. The interaction of a number of factors may for example, result in individuals being trapped in a vicious circle of poverty. Low household income may lead to social exclusion and family distress, which is likely to have far-reaching consequences for all household members. Social exclusion may contribute to foster alcoholism, impede the human capital investment in children, and thus jeopardise the socioeconomic situation of the next generation. Socially excluded people experience severe difficulties in finding re-employment. Social transfers might even worsen the situation by providing a disincentive to seek work.
Authored by: Miriam Beblo, Stanislawa Golinowska, Charlotte Lauer, Katarzyna Pietka-Kosinska, Agnieszka Sowa
Published in 2002
The report discusses employment in the health care system in Poland based on analysis and projections of the demand and supply of medical workforce. The impact of the financial situation and policy on relativelly low employment level of medical personel was accounted for in the analysis while projections were driven by demographic changes in the following two decades. Results of different demographic variants of projections used in Neujobs project and additional scenarios show that while ageing is an important factor that may stimulate demand for provision of medical personnel, changes might be mitigated by further increase in efficiency of care. At the same time the supply of care will be affected by ageing too. The results indicate that more detailed monitoring of employment in the future will be needed in order to assure adequacy of provision of medical professionals, especially of nurses (critical gap), some medical specialists, physiotherapists and medical technical personnel.
This report was prepared within a research project entitled NEUJOBS, which has received funding from the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement no. 266833.
Written by Stanislawa Golinowska, Agnieszka Sowa and Ewa Kocot. Published in August 2014.
PDF available on our website at: http://www.case-research.eu/en/node/58694
The purpose of this study is to analyze the sources of economic growth in Ukraine, which has been observed from the second half of 1999. In addition, we intend to answer the question what is the sustainability of this growth, i.e. putting in other words, what are the chances and conditions for maintaining growth in the future.
Authored by: Marek Dabrowski and Malgorzata Jakubiak
Published in 2003
The analytical research on the economic developments in BH by international financial institutions, especially the IMF and World Bank, as well as domestic bodies, especially the Economic Policy Research Unit, was extensively exploited in the research. However, the primary focus of the research was on structural and institutional aspects facilitating or impeding functioning of a market economy in the BH and country's capacity to cope with competitive pressure and market forces within the EU. Therefore, the report focuses on background analysis of economic factors influencing the functioning of market economy and the capacity to withstand the competition in the EU market.
Authored by: Malgorzata Antczak, Rafal Antczak, Karina Kostrzewa, Ranko Markus, Wojciech Paczynski
Published in 2007
This report looks at the prospects for economic integration between Ukraine and the European Union. The so-called Orange Revolution of late 2004 saw the question of Ukraine’s future geopolitical orientation re-emerge, and the idea of closer integration with the EU received wide social support. Yet, already by mid-2006 the political support to the idea of Euro-Atlantic integration seem to diminish. It is not clear if, how and when the idea of deeper integration with the EU will be put into action.
Although the main steps have been charted at the official level (Ukraine becoming WTO member and both sides start to gradually lower barriers to trade in manufacturing goods), neither their timing, nor the steps going beyond them can be specified with any degree of certainty. This report aims at showing the possible and optimal policy options.
Authored by:
Authored by: Dmytro Boyarchuk, Inna Golodniuk, Malgorzata Jakubiak, Anna Kolesnichenko, Mykyta Mykhaylychenko, Wojciech Paczynski, Anna Tsarenko, Vitaly Vavryschuk
Published in 2006
William behan analysis 2018 dper and tcd 2017 reports on general practiceDrWilliamBehan
A Critical Analysis of 2018 DPER report and 2017 TCD report on Irish General Practice Reviewing:
1. The public spend on general practice
2. The private spend on general practice
3. Points 1. and 2. deliver a total spend on Irish general practice
4. Comparison of the Irish annual payment per GMS patient and UK NHS payment
5. The mis-calculation of the UK nurse activity rates relative to Irish GP nurse workload
6. The extrapolated savings benefits from utilising nurse triage is unreliable.
7. Suggesting a lack of proof of the efficiency of Irish general practice is a result of the ignorance of the authors
This report presents the methodology for the construction of the Financial Stress Index (FSI) and the Economic Sensitivity Index (ESI) and investigates the economic situation in twelve Central and East European Countries (CEECs) between 2001 and 2012. The objective of this paper was to capture key features of financial and economic vulnerability and examine the co-movement of economic turmoil and financial disturbances that strongly affected the CEECs in the last decade. The main finding is that the FSI can be used as a leading indicator and can be used to recognize changing trends in the index. A shift in the value of the index proves that EU accession has a positive, but minor influence on financial stability in the CEECs. On the other hand, the impact of the introduction of the euro in Estonia, Slovakia and Slovenia is ambiguous.
For most of the countries in our sample, the FSI started to grow rapidly in 2007, reaching its peak around the third quarter of 2008. Consequently, financial stress remained high for a few quarters and started to fall gradually. For a number of countries, we observe higher financial stress in the latest period of our analysis, i.e. 2010-2012. However, the value of the FSI was significantly lower than three years earlier.
The results show that indices might be helpful in predicting future recessions. Consequently, the model will be expanded by adding a forecasting module, the launch of which is planned for April 2014.
Written by Maciej Krzak and Grzegorz Poniatowski. Published in January 2014
PDF available on our website at: http://www.case-research.eu/en/node/58411
These Guidelines have been produced as part of the OECD Better Life Initiative, a pioneering project launched in 2011, with the objective to measure society’s progress across eleven domains of well-being, ranging from jobs, health and housing, through to civic engagement and the environment.
These Guidelines represent the first attempt to provide international recommendations on collecting, publishing, and analysing subjective well-being data. They provide guidance on collecting information on people's evaluations and experiences of life, as well as on collecting “eudaimonic” measures of psychological well-being. The Guidelines also outline why measures of subjective well-being are relevant for monitoring and policy making, and why national statistical agencies have a critical role to play in enhancing the usefulness of existing measures. They identify the best approaches for measuring, in a reliable and consistent way, the various dimensions of subjective well-being, and provide guidance for reporting on such measures. The Guidelines also include a number of prototype survey modules on subjective well-being that national and international agencies can use in their surveys.
Piotr Kozarzewski and Maciej Bałtowski analyse the causes and manifestations of this trend in economic policy in Poland. They use privatization policy as an example. The authors examine the effects of the privatization policy and point to a large unfinished agenda in ownership transformation that has had an adverse impact on the institutional setup of the Polish state, creating grounds for rent seeking and cronyism, which, in turn, impede the pace of privatization. They find out that it is the increasing capture of the state by rent-seeking groups, and not, contrary to popular opinion, the global financial crisis, that most contributes to the growing statist trends of Poland’s economic policy.
Credibility of an exchange rate policy is one of the most important factors contributing to success or failure of any stabilization program. Authorities usually hope that the public will trust official exchange rate commitments and take decisions regarding domestic currency holdings accordingly. However, as the experience of several countries analyzed in this study shows, this is not always the case. Economic agents behave in line with their own expectations which need not directly reflect central bank's commitments but are most often a combination of official policy and public's own notions regarding its actual future course.
Authored by: Georgy Ganev, Marek Jarocinski, Rossitza Lubenova, Przemyslaw Wozniak
Published in 2001
The last twenty years have seen a perhaps unprecedented level of economic and political reform on a global scale. It is our hope that with this report we have made some contribution to the understanding of the factors underlying the success of reforms as well as the dangers that face reformers and reforms. We should note that in discussing the success of reforms, and the factors underlying that success, we have defined success not only in terms of the degree to which the reformers’ goals were accomplished by the reforms, but also in terms of the ability of reformers to gain the acceptance among legislators and the general populace necessary for the implementation of reforms. We have been interested not only in what makes a reform “good” in a technical sense, but also in what makes it implementable and sustainable. Thus, we hope that we have not only deepened the understanding of the Polish experience in the years since 1989, but also provided some insights which may be of use for other reform efforts in other countries, perhaps in very different parts of the globe.
Authored by: Jacek Kochanowicz, Piotr Kozarzewski, Richard Woodward
Published i 2005
Haiti" World Bank Public Expenditure Management and Financial Accountability ...Stanleylucas
World Bank Country Studies are among the many reports originally prepared for internal use as part of the continuing analysis by the Bank of the economic and related conditions of its developing member countries and to facilitate its dialogs with the governments. Some of the reports are published in this series with the least possible delay for the use of governments, and the academic, business, financial, and development communities. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally- edited texts. Some sources cited in this paper may be informal documents that are not readily available.
The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the International Bank for Reconstruction and Development/The World Bank and its affiliated organizations, or those of the Executive Directors of The World Bank or the governments they represent.
The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank of the legal status of any territory or the endorsement or acceptance of such boundaries.
Presentation on marketing of medical devices in Europe (24.01.2012)Christian Dekoninck
Presentation on the legal implications & compliance in the sales & marketing of medical devices in Europe given at the 3rd annual Medical Device Reimbursement Conference in Brussels (Q1 Productions, January 24th, 2012)
The purpose of this study is to analyze the sources of economic growth in Ukraine, which has been observed from the second half of 1999. In addition, we intend to answer the question what is the sustainability of this growth, i.e. putting in other words, what are the chances and conditions for maintaining growth in the future.
Authored by: Marek Dabrowski and Malgorzata Jakubiak
Published in 2003
The analytical research on the economic developments in BH by international financial institutions, especially the IMF and World Bank, as well as domestic bodies, especially the Economic Policy Research Unit, was extensively exploited in the research. However, the primary focus of the research was on structural and institutional aspects facilitating or impeding functioning of a market economy in the BH and country's capacity to cope with competitive pressure and market forces within the EU. Therefore, the report focuses on background analysis of economic factors influencing the functioning of market economy and the capacity to withstand the competition in the EU market.
Authored by: Malgorzata Antczak, Rafal Antczak, Karina Kostrzewa, Ranko Markus, Wojciech Paczynski
Published in 2007
This report looks at the prospects for economic integration between Ukraine and the European Union. The so-called Orange Revolution of late 2004 saw the question of Ukraine’s future geopolitical orientation re-emerge, and the idea of closer integration with the EU received wide social support. Yet, already by mid-2006 the political support to the idea of Euro-Atlantic integration seem to diminish. It is not clear if, how and when the idea of deeper integration with the EU will be put into action.
Although the main steps have been charted at the official level (Ukraine becoming WTO member and both sides start to gradually lower barriers to trade in manufacturing goods), neither their timing, nor the steps going beyond them can be specified with any degree of certainty. This report aims at showing the possible and optimal policy options.
Authored by:
Authored by: Dmytro Boyarchuk, Inna Golodniuk, Malgorzata Jakubiak, Anna Kolesnichenko, Mykyta Mykhaylychenko, Wojciech Paczynski, Anna Tsarenko, Vitaly Vavryschuk
Published in 2006
William behan analysis 2018 dper and tcd 2017 reports on general practiceDrWilliamBehan
A Critical Analysis of 2018 DPER report and 2017 TCD report on Irish General Practice Reviewing:
1. The public spend on general practice
2. The private spend on general practice
3. Points 1. and 2. deliver a total spend on Irish general practice
4. Comparison of the Irish annual payment per GMS patient and UK NHS payment
5. The mis-calculation of the UK nurse activity rates relative to Irish GP nurse workload
6. The extrapolated savings benefits from utilising nurse triage is unreliable.
7. Suggesting a lack of proof of the efficiency of Irish general practice is a result of the ignorance of the authors
This report presents the methodology for the construction of the Financial Stress Index (FSI) and the Economic Sensitivity Index (ESI) and investigates the economic situation in twelve Central and East European Countries (CEECs) between 2001 and 2012. The objective of this paper was to capture key features of financial and economic vulnerability and examine the co-movement of economic turmoil and financial disturbances that strongly affected the CEECs in the last decade. The main finding is that the FSI can be used as a leading indicator and can be used to recognize changing trends in the index. A shift in the value of the index proves that EU accession has a positive, but minor influence on financial stability in the CEECs. On the other hand, the impact of the introduction of the euro in Estonia, Slovakia and Slovenia is ambiguous.
For most of the countries in our sample, the FSI started to grow rapidly in 2007, reaching its peak around the third quarter of 2008. Consequently, financial stress remained high for a few quarters and started to fall gradually. For a number of countries, we observe higher financial stress in the latest period of our analysis, i.e. 2010-2012. However, the value of the FSI was significantly lower than three years earlier.
The results show that indices might be helpful in predicting future recessions. Consequently, the model will be expanded by adding a forecasting module, the launch of which is planned for April 2014.
Written by Maciej Krzak and Grzegorz Poniatowski. Published in January 2014
PDF available on our website at: http://www.case-research.eu/en/node/58411
These Guidelines have been produced as part of the OECD Better Life Initiative, a pioneering project launched in 2011, with the objective to measure society’s progress across eleven domains of well-being, ranging from jobs, health and housing, through to civic engagement and the environment.
These Guidelines represent the first attempt to provide international recommendations on collecting, publishing, and analysing subjective well-being data. They provide guidance on collecting information on people's evaluations and experiences of life, as well as on collecting “eudaimonic” measures of psychological well-being. The Guidelines also outline why measures of subjective well-being are relevant for monitoring and policy making, and why national statistical agencies have a critical role to play in enhancing the usefulness of existing measures. They identify the best approaches for measuring, in a reliable and consistent way, the various dimensions of subjective well-being, and provide guidance for reporting on such measures. The Guidelines also include a number of prototype survey modules on subjective well-being that national and international agencies can use in their surveys.
Piotr Kozarzewski and Maciej Bałtowski analyse the causes and manifestations of this trend in economic policy in Poland. They use privatization policy as an example. The authors examine the effects of the privatization policy and point to a large unfinished agenda in ownership transformation that has had an adverse impact on the institutional setup of the Polish state, creating grounds for rent seeking and cronyism, which, in turn, impede the pace of privatization. They find out that it is the increasing capture of the state by rent-seeking groups, and not, contrary to popular opinion, the global financial crisis, that most contributes to the growing statist trends of Poland’s economic policy.
Credibility of an exchange rate policy is one of the most important factors contributing to success or failure of any stabilization program. Authorities usually hope that the public will trust official exchange rate commitments and take decisions regarding domestic currency holdings accordingly. However, as the experience of several countries analyzed in this study shows, this is not always the case. Economic agents behave in line with their own expectations which need not directly reflect central bank's commitments but are most often a combination of official policy and public's own notions regarding its actual future course.
Authored by: Georgy Ganev, Marek Jarocinski, Rossitza Lubenova, Przemyslaw Wozniak
Published in 2001
The last twenty years have seen a perhaps unprecedented level of economic and political reform on a global scale. It is our hope that with this report we have made some contribution to the understanding of the factors underlying the success of reforms as well as the dangers that face reformers and reforms. We should note that in discussing the success of reforms, and the factors underlying that success, we have defined success not only in terms of the degree to which the reformers’ goals were accomplished by the reforms, but also in terms of the ability of reformers to gain the acceptance among legislators and the general populace necessary for the implementation of reforms. We have been interested not only in what makes a reform “good” in a technical sense, but also in what makes it implementable and sustainable. Thus, we hope that we have not only deepened the understanding of the Polish experience in the years since 1989, but also provided some insights which may be of use for other reform efforts in other countries, perhaps in very different parts of the globe.
Authored by: Jacek Kochanowicz, Piotr Kozarzewski, Richard Woodward
Published i 2005
Haiti" World Bank Public Expenditure Management and Financial Accountability ...Stanleylucas
World Bank Country Studies are among the many reports originally prepared for internal use as part of the continuing analysis by the Bank of the economic and related conditions of its developing member countries and to facilitate its dialogs with the governments. Some of the reports are published in this series with the least possible delay for the use of governments, and the academic, business, financial, and development communities. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally- edited texts. Some sources cited in this paper may be informal documents that are not readily available.
The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the International Bank for Reconstruction and Development/The World Bank and its affiliated organizations, or those of the Executive Directors of The World Bank or the governments they represent.
The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank of the legal status of any territory or the endorsement or acceptance of such boundaries.
Presentation on marketing of medical devices in Europe (24.01.2012)Christian Dekoninck
Presentation on the legal implications & compliance in the sales & marketing of medical devices in Europe given at the 3rd annual Medical Device Reimbursement Conference in Brussels (Q1 Productions, January 24th, 2012)
Medtech start-ups from inception to exit: what are the key milestones and what are the ACTUAL timelines and costs?
A data-driven approach to figuring out the new reality of medical device venture capital investing.
MedTele Inc. offers small to mid-size medical device manufacturers the opportunity to introduce new and existing product lines to targeted specialists, hospitals, nursing homes, surgical centers and alternative healthcare facilities through our dedicated, highly experienced Sales and Marketing Services Organization.
Marketing Strategy for Medical Device CompanyAditya Thakur
The marketing strategy won the Annual Babson Marketing Case Competition ($5000 prize money) and involved participation from over 20 Business schools around the globe
2015 trends in global medical device strategy and issues for the supply chain...Tony Freeman
This presentation reviews critical business trends shared by major medical device companies and the implications for their manufacturing supply chain. Consolidation of device OEMs, product line and marketshare changes brought on by accountable care, and OEM desire for larger outsource partners are the dominant themes.
Marketing Strategy for a medical device companysaurabhmalani
This is a marketing strategy for a leading medical device company for a new product launch. This presentation won the Babson Marketing Case Competition - 2012 with prize money of $5000. 16 schools across the globe were competing in this competition.
The paper aims to assess the impact of selected elements of social harmonization on labor market performance in the European Union among two groups of workers—the total working population and the elderly. The aim is to examine whether upward changes in labor taxes affect employment, unemployment, and inactivity rates in the European Union.
The aim of this report is a deepened recognition of employment in long-term care (LTC). It presents past and future trends in the development of LTC employment. Authors collected scattered statistical information, estimated lacking data and projected future growth in the number of employed in care services. Performed analysis includes employment in the health and social sector and across various types of care. Projections of the demand for care and supply of the LTC workforce are based on the demographic prognosis of the population size and changes in the age structure taking into account different scenarios for demographic development. Results show the growing gap between demand and supply in the LTC employment. The policy towards aging in Poland must take up the challenge of growing care needs, family changes and lower opportunities for provision of informal care.
Authored by: Stanislawa Golinowska, Ewa Kocot, Agnieszka Sowa
Published in 2014
This paper explores the effects that the global financial crisis of 2008 - 2010 had on the funding and performance of the healthcare and education sectors in the Russian Federation (RF). Both education and healthcare expenditures increased in terms of total general government (GG) spending relative to GDP, partly as a result of reduced GDP. The crisis induced further centralization by increasing both the role of the federal budget in funding social services and the dependence of regions on federal transfers, but it did not result in enhanced resource allocation or more effective public spending. By revealing the inefficiencies that accumulated in education and healthcare financing and management throughout the 2000s, the crisis exposed acute funding shortages in contrast to the government's stated goals and an urgent need for reform in these sectors. The impact of the financial crisis on the delivery of education and health services appeared to be delayed and was mitigated by the resources accumulated during the pre-crisis boom. The paper concludes with several recommendations for the RF public service sector concerning improvements in the inter-governmental transfer system through increasing transparency and introducing performance-oriented budgeting.
Authored by: Irina Sinitsina
Published in 2011
Research & Analysis Report for Elderly and Health-related InformationCHEN DI
Design problem statement: What is the best way for delivering health-related information accurately to the elderly? In order To have a better understand target demographic, Hong Kong elderly people. Three research methodologies are used in this research process; those are survey, interview and task analysis. After collecting qualitative and quantitative data, we analyze, categorize and find patterns of information obtained .insights are generated according to the analysis and remarks to provide support and help for design.
WHO - Community management-of-opioid-overdoseEmergency Live
These guidelines were produced by the Management of Substance Abuse unit of the WHO Department of Mental Health and Substance Abuse in collaboration with the WHO HIV Department. Vladimir Poznyak and Nicolas Clark coordinated the development of these guidelines under the direction of Shekhar Saxena and in collaboration with Rachel Baggaley and Annette Verster. Members of the project’s WHO Steering Group included: Annabel Badderley, Rachel Baggaley, Nicolas Clark, Selma Khamassi, Elizabeth Mathai, Maggie Peden, Vladimir Poznyak, and Annette Verster (see Annex 7 for affiliations). The members of the project’s Guideline Development Group (GDG) were: Robert Balster (Chair), Barbara Broers, Jane Buxton, Paul Dietze, Kirsten Horsburgh, Raka Jain, Nadeem Ullah Khan, Walter Kloeck, Emran M Razaghi, Hendry Robert Sawe, John Strang, and Oanh Thi Hai Khuat (see Annex 7 for affiliations).
Comprehensive Multi-year Plan - Universal Immunization Program -
In India Universal Immunization Program - (UIP) is bring forward by the Government, UIP ( Universal Immunization Program) in India is among the most successful vaccination program and cost-effective public health interventions.
Routine Immunization Program in India, Immunization Technical Support, routine immunization services in India, Ministry of Health and Family Welfare, Adverse Event Following Immunization Secretariat, Vaccine logistics and supply chain,Universal Immunization Program in India
'Since 2008, the world economy has been facing the consequences of the global financial crisis. As a result, many economic policy paradigms have been revised, and this process is far from complete. The policy area, which needs a fundamental rethinking (especially in advanced economies), relates to the role of public finance and fiscal policy in ensuring economic growth and financial stability. The primary task will be to develop a new analytical approach and detailed indicators, which are necessary to provide a correct diagnosis and effective recommendations.'
What are the “safe” levels of budget deficit and public debt during “normal” or “good” times? Is there a single norm of fiscal safety?
These questions are discussed in the new paper by Marek Dabrowski: "Fiscal Sustainability: Conceptual, Institutional, and Policy Issues".
The publication is a part of CASE Working Papers series.
Until the early 1990s, the discussions on fiscal policy primarily centered on the functions of economic stabilization, income redistribution and resource allocation. Long-term growth was not usually viewed as an end itself, and fiscal policy was often not sufficiently tailored to the different circumstances and priorities of countries at different stages of development. It is only relatively recently that the discussion has gradually focused on the links between different dimensions of quality of public finances and economic growth.
Based on the conceptual framework for linking the quality of public finances and economic growth that has been developed by the European Commission and applied to the EU Member States, this study examines the conditions under which the budgetary policy, and more specifically expenditure, revenue and financing design would be supportive of growth in the Mediterranean partner countries of the European Union. The study also highlights some of the interlinkages between fiscal policy and growth and summarises empirical findings found in the literature with particular focus on Mediterranean partner countries of the European Union.
The study concludes by highlighting possible areas in the planning and execution of fiscal policy and governance where growth enhancing interventions can be applied.
Authored by: Leonor Coutinho, Luc De Wulf, Santiago Florez, Cyrus Sassanpour
Published in 2010
Purpose: This paper tries to identify the wage gap between informal and formal workers and tests for the two-tier structure of the informal labour market in Poland.
Design/methodology/approach: I employ the propensity score matching (PSM) technique and use data from the Polish Labour Force Survey (LFS) for the period 2009–2017 to estimate the wage gap between informal and formal workers, both at the means and along the wage distribution. I use two definitions of informal employment: a) employment without a written agreement and b) employment while officially registered as unemployed at a labour office. In order to reduce the bias resulting from the non-random selection of
individuals into informal employment, I use a rich set of control variables representing several individual characteristics.
Findings: After controlling for observed heterogeneity, I find that on average informal workers earn less than formal workers, both in terms of monthly earnings and hourly wage. This result is not sensitive to the definition of informal employment used and is
stable over the analysed time period (2009–2017). However, the wage penalty to informal employment is substantially higher for individuals at the bottom of the wage distribution, which supports the hypothesis of the two-tier structure of the informal labour market in Poland.
Originality/value: The main contribution of this study is that it identifies the two-tier structure of the informal labour market in Poland: informal workers in the first quartile of the wage distribution and those above the first quartile appear to be in two partially different segments of the labour market.
Similar to CASE Network Report 78 - Scenarios For Health Expenditure in Poland (20)
The report examines the social and economic drivers and impact of circular migration between Belarus and Poland, Slovakia, and the Czech Republic. The core question the authors sought to address was how managing circular migration could, in the long term, help to optimise labour resources in both the country of origin and the destination countries. In the pages that follow, the authors of the report present the current and forecasted labour market and demographic situation in their respective countries as well as the dynamics and characteristics of short-term labour migration flows between Belarus and Poland, Slovakia, and the Czech Republic, concentrating on the period since 2010. They also outline and discuss related policy responses and evaluate prospects for cooperation on circular migration.
Podręcznik został opracowany w celu przekazania trenerom i nauczycielom podstawowej wiedzy, która może być przydatna w prowadzeniu szkoleń promujących pracę rejestrowaną. Prezentuje on z jednej strony korzyści z pracy rejestrowanej, z drugiej – potencjalne koszty związane z pracą nierejestrowaną. W pierwszej kolejności informacje te przedstawiono w odniesieniu do pracowników najemnych (rozdział 2), podkreślając w sposób szczególny to, że negatywne konsekwencje pracy nierejestrowanej są ponoszone przez całe życie. Ze względu na specyficzną sytuację cudzoziemców pracujących w Polsce konsekwencje ponoszone przez tę grupę opisano oddzielnie (rozdział 3). Ponadto zaprezentowano skutki dotyczące pracodawców z szarej strefy z wyodrębnieniem tych, którzy zatrudniają cudzoziemców (rozdział 4). Uzupełnieniem przedstawionych informacji jest opis działań podejmowanych przez państwo w celu ograniczenia zjawiska pracy nierejestrowanej w Polsce (rozdział 5) oraz prowadzonych w Wielkiej Brytanii, czyli w kraju będącym liderem w walce z szarą strefą (rozdział 6).
European countries face a challenge related to the economic and social consequences of their societies’ aging. Specifically, pension systems must adjust to the coming changes, maintaining both financial stability, connected with equalizing inflows from premiums and spending on pensions, and simultaneously the sufficiency of benefits, protecting retirees against poverty and smoothing consumption over their lives, i.e. ensuring the ability to pay for consumption needs at each stage of life, regardless of income from labor.
One of the key instruments applied toward these goals is the retirement age. Formally it is a legally established boundary: once people have crossed it – on average – they significantly lose their ability to perform work (the so-called old-age risk). But since the 1970s, in many developed countries the retirement age has become an instrument of social and labor-market policy. Specifically, in the 1970s and ‘80s, an early retirement age was perceived as a solution allowing a reduction in the supply of labor, particularly among people with relatively low competencies who were approaching retirement age, which is called the lump of labor fallacy. It was often believed that people taking early retirement freed up jobs for the young. But a range of economic evidence shows that the number of jobs is not fixed, and those who retire don’t in fact free up jobs. On the contrary, because of higher spending by pension systems, labor costs rise, which limits the supply of jobs. In general, a good situation on the labor market supports employment of both the youngest and the oldest labor force participants. Additionally, a lower retirement age for women was maintained, which resulted to a high degree from cultural conditions and norms that are typical for traditional societies.
Until now, the banking sector has been one of the strong points of Poland’s economy. In contrast to banks in the U.S. and leading Western European economies, lenders in Poland came through the 2008 global financial crisis without a scratch, without needing state financial support. But in recent years the industry’s problems have been growing, creating a threat to economic growth and gains in living standards.
For an economy’s productivity to increase, funds can’t go to all companies evenly, and definitely shouldn’t go to those that are most lacking in funds, but to those that will use them most efficiently. This is true of total external financing, and thus funding both from the banking sector and from parabanks, the capital market and funds from public institutions. In Poland, in light of the relatively modest scale of the capital market, banks play a clearly dominant role in external financing of companies. This is why the author of this text focuses on the bank credit allocation efficiency.
The author points out that in the very near future, conditions will emerge in Poland which – as the experience of other countries shows – create a risk of reduced efficiency of credit allocation to business. Additionally, in Poland today, bank lending to companies is to a high degree being replaced by funds from state aid, which reduces the efficiency of allocation of external funds to companies (both loans and subsidies), as allocation of government subsidies is not usually based on efficiency. This decline in external financing allocation efficiency may slow, halt or even reverse the process, that has been uninterrupted for 28 years, of Poland’s convergence, i.e. the narrowing of the gap in living standards between Poland and the West.
The economic characteristics of the COVID-19 crisis differ from those of previous crises. It is a combination of demand- and supply-side constraints which led to the formation of a monetary overhang that will be unfrozen once the pandemic ends. Monetary policy must take this effect into consideration, along with other pro-inflationary factors, in the post-pandemic era. It must also think in advance about how to avoid a policy trap coming from fiscal dominance.
This paper is organized as follows: Chapter 2 deals with the economic characteristics of the COVID-19 pandemic and its impact on the effectiveness of the monetary policy response measures undertaken. In Chapter 3, we analyse the monetary policy decisions of the ECB (and other major CBs for comparison) and their effectiveness in achieving the declared policy goals in the short term. Chapter 4 is devoted to an analysis of the policy challenges which may be faced by the ECB and other major CBs once the pandemic emergency comes to its end. Chapter 5 contains a summary and the conclusions of our analysis.
The rule of law, by securing civil and economic rights, directly contributes to social prosperity and is one of our societies’ greatest achievements. In the European Union (EU), the rule of law is enshrined in the Treaties of its founding and is recognised not just as a necessary condition of a liberal democratic society, but also as an important requirement for a stable, effective, and sustainable market economy. In fact, it was the stability and equality of opportunity provided by the rule of law that enabled the post-war Wirtschaftswunder in Germany and the post-Communist resuscitation of the economy in Poland.
But the rule of law is a living concept that is constantly evolving – both in its formal, de jure dimension, embodied in legislation, and its de facto dimension, or its reception by society. In Poland, in particular, according to the EU, the rule of law has been heavily challenged by government since 2015 and has evolved amid continued pressure exerted on the institutions which execute laws. More recently, the outbreak of the COVID-19 pandemic transformed the perception of the rule of law and its boundaries throughout the EU and beyond (Marzocchi, 2020).
This Study contains Value Added Tax (VAT) Gap estimates for 2018, fast estimates using a simplified methodology for 2019, the year immediately preceding the analysis, and includes revised estimates for 2014-2017. It also includes the updated and extended results of the econometric analysis of VAT Gap determinants initiated and initially reported in the 2018 Report (Poniatowski et al., 2018). As a novelty, the econometric analysis to forecast potential impacts of the coronavirus crisis and resulting recession on the evolution of the VAT Gap in 2020 is reported.
In 2018, most European Union (EU) Member States (MS) saw a slight decrease in the pace of gross domestic product (GDP) growth, but the economic conditions for increasing tax compliance remained favourable. We estimate that the VAT total tax liability (VTTL) in 2018 increased by 3.6 percent whereas VAT revenue increased by 4.2 percent, leading to a decline in the VAT Gap in both relative and nominal terms. In relative terms, the EU-wide Gap dropped to 11 percent and EUR 140 billion. Fast estimates show that the VAT Gap will likely continue to decline in 2019.
Of the EU-28, the smallest Gaps were observed in Sweden (0.7 percent), Croatia (3.5 percent), and Finland (3.6 percent), the largest – in Romania (33.8 percent), Greece (30.1 percent), and Lithuania (25.9 percent). Overall, half of the EU-28 MS recorded a Gap above 9.2 percent. In nominal terms, the largest Gaps were recorded in Italy (EUR 35.4 billion), the United Kingdom (EUR 23.5 billion), and Germany (EUR 22 billion).
The euro is the second most important global currency after the US dollar. However, its international role has not increased since its inception in 1999. The private sector prefers using the US dollar rather than the euro because the financial market for US dollar-denominated assets is larger and deeper; network externalities and inertia also play a role. Increasing the attractiveness of the euro outside the euro area requires, among others, a proactive role for the European Central Bank and completing the Banking Union and Capital Market Union.
Forecasting during a strong shock is burdened with exceptionally high uncertainty. This gives rise to the temptation to formulate alarmist forecasts. Experiences from earlier pandemics, particularly those from the 20th century, for which we have the most data, don’t provide a basis for this. The mildest of them weakened growth by less than 1 percentage point, and the worst, the Spanish Flu, by 6 percentage points. Still, even the Spanish Flu never caused losses on the order of 20% of GDP – not even where it turned out to be a humanitarian disaster, costing the lives of 3-5% of the population. History suggests that if pandemics lead to such deep losses at all, it’s only in particular quarters and not over a whole year, as economic activity rebounds. The strength of that rebound is largely determined by economic policy. The purpose of this work is to describe possible scenarios for a rebound in Polish economic growth after the epidemic.
A separate issue, no less important, is what world will emerge from the current crisis. In the face of the 2008 financial crisis, White House Chief of Staff Rahm Emanuel said: “You never want a serious crisis to go to waste. And what I mean by that is an opportunity to do things that you think you could not do before.” Such changes can make the economy and society function better than before the crisis. Unfortunately, the opportunities created by the global financial crisis were squandered. Today’s task is more difficult; the scale of various problems has expanded even more. Without deep structural and institutional changes, the world will be facing enduring social and economic problems, accompanied by long-term stagnation.
"Many brilliant prophecies have appeared for the future of the EU and our entire planet. I believe that Europe, in its own style, will draw pragmatic conclusions from the crisis, not revolutionary ones; conclusions that will allow us to continue enjoying a Europe without borders. Brussels will demonstrate its usefulness; it will react ably and flexibly. First of all, contrary to the deceitful statements of members of the Polish government, the EU warned of the threats already in 2021. Secondly, already in mid-March EU assistance programs were ready, i.e. earlier than the PiS government’s “shield” program. The conclusion from the crisis will be a strengthening of all the preventive mechanisms that allow us to recognize threats and react in time of need. Research programs will be more strongly directed toward diagnosing and treating infectious diseases. Europe will gain greater self-sufficiency in the area of medical equipment and drugs, and the EU – greater competencies in the area of the health service, thus far entrusted to the member states. The 2021-27 budget must be reconstructed, to supplement the priority of the Green Deal with economic stimulus programs. In this way structural funds, which have the greatest multiplier effect for investment and the labor market, may return to favor. So once again: an addition, as a conclusion from the crisis, and not a reinvention of the EU," writes Dr. Janusz Lewandowski the author of the 162nd mBank-CASE seminar Proceeding.
Dla wielu rodaków europejskość Polski jest oczywista, trudno jest im nawet wyobrazić sobie, jak kształtowałyby się losy naszego kraju bez uczestnictwa w integracji europejskiej. Szczególnie młode pokolenie traktuje osiągnięty przez nas dzięki uczestnictwie w Unii ogromny postęp cywilizacyjny jako coś danego i naturalnego. Jednak świadomość tego, jaki był nasz punkt wyjścia, jaką przeszliśmy drogę i jak przyczyniły się do tego unijne działania oraz jakie wynikały z tego korzyści powinna nam stale towarzyszyć. Bez tej świadomości, starannego weryfikowania faktów i docenienia naszych osiągnięć grozi nam uleganie niesprawdzonym argumentom przeciwników integracji europejskiej i popełnienie nieodwracalnych błędów. Dla tych, którzy chcą poznać te fakty, przygotowany został raport "Nasza Europa. 15 lat Polski w Unii Europejskiej". Podjęto w nim ocenę 15 lat członkostwa Polski z perspektywy doświadczeń procesu integracji, z jego barierami i sukcesami, a także wyzwaniami przyszłości.
Raport jest wynikiem pracy zbiorowej licznych ekspertów z różnych dziedzin, od wielu lat analizujących wielowymiarowe efekty działania instytucji UE oraz współpracy z krajami członkowskimi na podstawie europejskich wartości i mechanizmów. Autorzy podsumowują korzyści członkostwa Polski w Unii Europejskiej na podstawie faktów, nie stroniąc jednakże od własnych ocen i refleksji.
This report is the result of the joint work of a number of experts from various fields who have been - for many years – analysing the multidimensional effects of EU institutions and cooperation with Member States pursuant to European values and mechanisms. The authors summarise the benefits of Poland’s membership in the EU based on facts; however, they do not hide their own views and reflections. They also demonstrate the barriers and challenges to further European integration.
This report was prepared by CASE, one of the oldest independent think tanks in Central and Eastern Europe, utilising its nearly 30 years of experience in providing objective analyses and recommendations with respect to socioeconomic topics. It is both an expression of concern about Poland’s future in the EU, as well as the authors’ contribution to the debate on further European integration.
Belarus was among the few post-communist countries to resign from comprehensive market reforms and attempt to improve the efficiency of the economy through administrative means, leaving market mechanisms only an auxiliary role. Since its inception, the ‘Belarusian economic model’ has undergone several revisions of a de-statisation and de-regulation kind, but still the Belarusian economy remains dominated by the state. This paper analyses the characteristic features of the Belarusian economic system – especially those related to the public sector – as well as its evolution over time during the period following its independence. The paper concludes that during the post-Soviet period, the Belarusian economy evolved from a quasi-Soviet system based on state property, state planning, support to inefficient enterprises and the massive redistribution of funds to a more flexible hybrid model where the public sector still remains the core of the economy. The case of Belarus shows that presently there is no appropriate theoretical perspective which, in an unmodified form, could be applied to study this type of economic system. Therefore, a new perspective based on an already existing but updated approach or a multidisciplinary approach that incorporates the duality of the Belarusian economy is required.
Belarusian economy has been stagnating in 2011-2015 after 15 years of a high annual average growth rate. In 2015, after four years of stagnation, the Belarusian economy slid into a recession, its first since 1996, and experienced both cyclical and structural recessions. Since 2015, the Belarusian government and the National Bank of Belarus have been giving economic reforms a good chance thanks to gradual but consistent actions aimed at maintaining macroeconomic stability and economic liberalization. It seems that the economic authorities have sustained more transformation efforts during 2015-2018 than in the previous 24 years since 1991.
As the relative welfare level in Belarus is currently 64% compared to the Central and Eastern Europe (CEE) countries average, Belarus needs to build stronger fundaments of sustainable growth by continuing and accelerating the implementation of institutional transformation, primarily by fostering elimination of existing administrative mechanisms of inefficient resource allocation. Based on the experience of the CEE countries’ economic transformation, we highlight five lessons for the purpose of the economic reforms that Belarus still faces today: keeping macroeconomic stability, restructuring and improving the governance of state-owned enterprises, developing the financial market, increasing taxation efficiency, and deepening fiscal decentralization.
Inflation in advanced economies is low by historical standards but there is no threat of deflation. Slower economic growth is caused by supply-side constraints rather than low inflation. Below-the-target inflation does not damage the reputation of central banks. Thus, central banks should not try to bring inflation back to the targeted level of 2%. Rather, they should revise the inflation target downwards and publicly explain the rationale for such a move. Risks to the independence of central banks come from their additional mandates (beyond price stability) and populist politics.
Estonia has Europe’s most transparent tax system (while Poland is second-to-last, in 35th place), and is also known for its pioneering approach to taxation of legal persons’ income. Since 2000, payers of Estonian corporate tax don’t pay tax on their profits as long as they don’t realize them. In principle, this approach should make access to capital easier, spark investment by companies and contribute to faster economic growth. Are these and other positive effects really noticeable in Estonia? Have other countries followed in this country’s footsteps? Would deferment of income tax be possible and beneficial for Poland? How would this affect revenue from tax on corporate profits? Would investors come to see Poland as a tax haven? Does the Estonian system limit tax avoidance and evasion, or actually the opposite? Is such a system fair? Are intermediate solutions possible, which would combine the strengths or limit the weaknesses of the classical and Estonian models of profit tax? These questions are discussed in the mBank-CASE seminar Proceeding no. 163, written by Dmitri Jegorov, deputy general secretary of the Estonian Finance Ministry, who directs the country’s tax and customs policy, Dr. Anna Leszczyłowska of the Poznań University of Economics and Business and Aleksander Łożykowski of the Warsaw School of Economics.
The trade war between the U.S. and China began in March 2018. The American side raised import duties on aluminum and steel from China, which were later extended to other countries, including Canada, Mexico and the EU member states. This drew a negative reaction from those countries and bilateral negotiations with the U.S. In June 2018 America, referring to Section 301 of its 1974 Trade Act, raised tariffs to 25% on 818 groups of products imported from China, arguing that the tariff increase was a response to years of theft of American intellectual property and dishonest trade practices, which has caused the U.S. trade deficit.
Will this trade war mean the collapse of the multilateral trading system and a transition to bilateral relationships? What are the possibilities for increasing tariffs in light of World Trade Organization rules? Can the conflict be resolved using the WTO dispute-resolution mechanism? What are the consequences of the trade war for American consumers and producers, and for suppliers from other countries? How high will tariffs climb as a result of a global trade war? How far can trade volumes and GDP fall if the worst-case scenario comes to pass? Professor Jan J. Michałek and Dr. Przemysław Woźniak give answers to these questions in the mBank-CASE Seminar Proceeding No. 161.
This Report has been prepared for the European Commission, DG TAXUD under contract TAXUD/2017/DE/329, “Study and Reports on the VAT Gap in the EU-28 Member States” and serves as a follow-up to the six reports published between 2013 and 2018.
This Study contains new estimates of the Value Added Tax (VAT) Gap for 2017, as well as updated estimates for 2013-2016. As a novelty in this series of reports, so called “fast VAT Gap estimates” are also presented the year immediately preceding the analysis, namely for 2018. In addition, the study reports the results of the econometric analysis of VAT Gap determinants initiated and initially reported in the 2018 Report (Poniatowski et al., 2018). It also scrutinises the Policy Gap in 2017 as well as the contribution that reduced rates and exemptions made to the theoretical VAT revenue losses.
The paper discusses the role of the state in shaping an economic system which is, in line with the welfare economics approach, capable of performing socially important functions and achieving socially desirable results. We describe this system through a set of indexes: the IHDI, the World Happiness Index, and the Satisfaction of Life index. The characteris-tics of the state are analyzed using a set of variables which describe both the quantitative (government size, various types of governmental expenditures, and regulatory burden) and qualitative (institutional setup and property rights protection) aspects of its functioning. The study examines the “old” and “new” member states of the European Union, the post-communist countries of Eastern Europe and Asia, and the economies of Latin America. The main conclusion of the research is that the institutional quality of the state seems to be the most important for creation of a socially effective economic system, while the level of state interventionism plays, at most, a secondary and often negligible role. Geographical differentiation is also discovered, as well as the lack of a direct correlation between the characteristics of an economic system and the subjective feeling of well-being. These re-sults may corroborate the neo-institutionalist hypothesis that noneconomic factors, such as historical, institutional, cultural, and even genetic factors, may play an important role in making the economic system capable to perform its tasks; this remains an area for future research.
EuroPACE is an innovative financial mechanism inspired by an American building improvement initiative called Property Assessed Clean Energy (PACE). The innovative character of the EuroPACE mechanism is that financing through EuroPACE is linked to the taxes paid on a property. In other words, the financing lent by a private investor is repaid through property taxes and other charges related to the buildings. EuroPACE is therefore in line with the EC’s objectives of (1) putting EE first, (2) contributing to the EU’s global leadership, and (3) empowering consumers to enable MS to reach their energy and climate targets for 2030. Last but not least, EuroPACE could contribute to the democratisation of the energy supply by offering cash-flow positive, decentralised EE solutions.
The EuroPACE mechanism engages several stakeholders in the process: local government, investors, equipment installers, and homeowners. To establish the EuroPACE programme, several conditions must be satisfied, each of which are relevant for different stakeholder at different stages of the implementation. For the purpose of this report, we divided these criteria into two categories: key criteria, which make the implementation possible, and complementary criteria, which make the implementation easier. For the time being, it is a pure hypothesis to be tested with potential EuroPACE implementation.
More from CASE Center for Social and Economic Research (20)
Seminar: Gender Board Diversity through Ownership NetworksGRAPE
Seminar on gender diversity spillovers through ownership networks at FAME|GRAPE. Presenting novel research. Studies in economics and management using econometrics methods.
US Economic Outlook - Being Decided - M Capital Group August 2021.pdfpchutichetpong
The U.S. economy is continuing its impressive recovery from the COVID-19 pandemic and not slowing down despite re-occurring bumps. The U.S. savings rate reached its highest ever recorded level at 34% in April 2020 and Americans seem ready to spend. The sectors that had been hurt the most by the pandemic specifically reduced consumer spending, like retail, leisure, hospitality, and travel, are now experiencing massive growth in revenue and job openings.
Could this growth lead to a “Roaring Twenties”? As quickly as the U.S. economy contracted, experiencing a 9.1% drop in economic output relative to the business cycle in Q2 2020, the largest in recorded history, it has rebounded beyond expectations. This surprising growth seems to be fueled by the U.S. government’s aggressive fiscal and monetary policies, and an increase in consumer spending as mobility restrictions are lifted. Unemployment rates between June 2020 and June 2021 decreased by 5.2%, while the demand for labor is increasing, coupled with increasing wages to incentivize Americans to rejoin the labor force. Schools and businesses are expected to fully reopen soon. In parallel, vaccination rates across the country and the world continue to rise, with full vaccination rates of 50% and 14.8% respectively.
However, it is not completely smooth sailing from here. According to M Capital Group, the main risks that threaten the continued growth of the U.S. economy are inflation, unsettled trade relations, and another wave of Covid-19 mutations that could shut down the world again. Have we learned from the past year of COVID-19 and adapted our economy accordingly?
“In order for the U.S. economy to continue growing, whether there is another wave or not, the U.S. needs to focus on diversifying supply chains, supporting business investment, and maintaining consumer spending,” says Grace Feeley, a research analyst at M Capital Group.
While the economic indicators are positive, the risks are coming closer to manifesting and threatening such growth. The new variants spreading throughout the world, Delta, Lambda, and Gamma, are vaccine-resistant and muddy the predictions made about the economy and health of the country. These variants bring back the feeling of uncertainty that has wreaked havoc not only on the stock market but the mindset of people around the world. MCG provides unique insight on how to mitigate these risks to possibly ensure a bright economic future.
What price will pi network be listed on exchangesDOT TECH
The rate at which pi will be listed is practically unknown. But due to speculations surrounding it the predicted rate is tends to be from 30$ — 50$.
So if you are interested in selling your pi network coins at a high rate tho. Or you can't wait till the mainnet launch in 2026. You can easily trade your pi coins with a merchant.
A merchant is someone who buys pi coins from miners and resell them to Investors looking forward to hold massive quantities till mainnet launch.
I will leave the telegram contact of my personal pi vendor to trade with.
@Pi_vendor_247
how to sell pi coins at high rate quickly.DOT TECH
Where can I sell my pi coins at a high rate.
Pi is not launched yet on any exchange. But one can easily sell his or her pi coins to investors who want to hold pi till mainnet launch.
This means crypto whales want to hold pi. And you can get a good rate for selling pi to them. I will leave the telegram contact of my personal pi vendor below.
A vendor is someone who buys from a miner and resell it to a holder or crypto whale.
Here is the telegram contact of my vendor:
@Pi_vendor_247
where can I find a legit pi merchant onlineDOT TECH
Yes. This is very easy what you need is a recommendation from someone who has successfully traded pi coins before with a merchant.
Who is a pi merchant?
A pi merchant is someone who buys pi network coins and resell them to Investors looking forward to hold thousands of pi coins before the open mainnet.
I will leave the telegram contact of my personal pi merchant to trade with
@Pi_vendor_247
Even tho Pi network is not listed on any exchange yet.
Buying/Selling or investing in pi network coins is highly possible through the help of vendors. You can buy from vendors[ buy directly from the pi network miners and resell it]. I will leave the telegram contact of my personal vendor.
@Pi_vendor_247
The secret way to sell pi coins effortlessly.DOT TECH
Well as we all know pi isn't launched yet. But you can still sell your pi coins effortlessly because some whales in China are interested in holding massive pi coins. And they are willing to pay good money for it. If you are interested in selling I will leave a contact for you. Just telegram this number below. I sold about 3000 pi coins to him and he paid me immediately.
Telegram: @Pi_vendor_247
how can I sell pi coins after successfully completing KYCDOT TECH
Pi coins is not launched yet in any exchange 💱 this means it's not swappable, the current pi displaying on coin market cap is the iou version of pi. And you can learn all about that on my previous post.
RIGHT NOW THE ONLY WAY you can sell pi coins is through verified pi merchants. A pi merchant is someone who buys pi coins and resell them to exchanges and crypto whales. Looking forward to hold massive quantities of pi coins before the mainnet launch.
This is because pi network is not doing any pre-sale or ico offerings, the only way to get my coins is from buying from miners. So a merchant facilitates the transactions between the miners and these exchanges holding pi.
I and my friends has sold more than 6000 pi coins successfully with this method. I will be happy to share the contact of my personal pi merchant. The one i trade with, if you have your own merchant you can trade with them. For those who are new.
Message: @Pi_vendor_247 on telegram.
I wouldn't advise you selling all percentage of the pi coins. Leave at least a before so its a win win during open mainnet. Have a nice day pioneers ♥️
#kyc #mainnet #picoins #pi #sellpi #piwallet
#pinetwork
What website can I sell pi coins securely.DOT TECH
Currently there are no website or exchange that allow buying or selling of pi coins..
But you can still easily sell pi coins, by reselling it to exchanges/crypto whales interested in holding thousands of pi coins before the mainnet launch.
Who is a pi merchant?
A pi merchant is someone who buys pi coins from miners and resell to these crypto whales and holders of pi..
This is because pi network is not doing any pre-sale. The only way exchanges can get pi is by buying from miners and pi merchants stands in between the miners and the exchanges.
How can I sell my pi coins?
Selling pi coins is really easy, but first you need to migrate to mainnet wallet before you can do that. I will leave the telegram contact of my personal pi merchant to trade with.
Tele-gram.
@Pi_vendor_247
Lecture slide titled Fraud Risk Mitigation, Webinar Lecture Delivered at the Society for West African Internal Audit Practitioners (SWAIAP) on Wednesday, November 8, 2023.
how to sell pi coins effectively (from 50 - 100k pi)DOT TECH
Anywhere in the world, including Africa, America, and Europe, you can sell Pi Network Coins online and receive cash through online payment options.
Pi has not yet been launched on any exchange because we are currently using the confined Mainnet. The planned launch date for Pi is June 28, 2026.
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5. The Authors
Stanisława Golinowska, Professor of Economics, is a co-founder of CASE – Center for
Social and Economic Research and Vice Chairwoman of the CASE Supervisory
Council, where she conducts her research. She is also a Director at the Institute of
Public Health, Jagiellonian University Medical College (Krakow, Poland). Stanisława
Golinowska graduated from the Faculty of Economics (Warsaw University) and studied
at the Mannheim University as a scholarship- holder of the Humboldt Foundation. She
is the author of numerous articles and books on social aspects of economics and social
policy reforms
Agnieszka Sowa is a researcher at CASE - Center for Social and Economic Research,
and holds an M.A. in the field of public policy from Warsaw University, Department
of Sociology as well as an MsC in Social Protection Financing from Maastricht
University, Faculty of Economics and Business Administration. She also completed a
public policy course at the University of Pittsburgh, Department of Russian and
Eastern European Studies. Her interests include healthcare system and modelling of
health expenditures, poverty, unemployment and social assistance programmes.
Since 2004 she has been teaching social policy and social security at the Institute of
Public Health, Collegium Medicum, Jagiellonian University.
Ewa Kocot is an assistant in the Institute of Public Health at Jagiellonian University
Medical College (Krakow, Poland). She graduated with a Masters in mathematics from
Jagiellonian University. She also completed the postgraduate study of management
and administration of public health at the School of Public Health in Krakow. She is
especially interested in health indicators and their potential application in healthcare
sector financing, modelling and forecasting. These issues were the subject of her
recently completed doctoral thesis.
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SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
6. Abstract
The report is a result of the Ageing, Health Status and Determinants of Health
Expenditure (AHEAD) project within the EC 6th Framework programme. The objective of
the research was to present the model of future health care system revenues and
expenditures in Poland and to discuss projection assumptions and results. The projections
are based on methodology adopted in the International Labour Organization (ILO) Social
Budget model. The projection examines impact of demographic changes and changes in
health status on future (up to 2050) health expenditures. Next to it, future changes in the
labour market participation and their impact on the health care system revenues are
examined. Impact of demography on the health care system financial balanced is
examined in four different scenarios: baseline scenario, death-related costs scenario,
different longevity scenario and diversified employment rates scenario. Results indicate
dynamic and systematic increase of the health expenditures in the next 30 years.
Afterwards the dynamics of this process is foreseen to slow down. Despite the increase of
the revenues of the health care system, the system will face deficit in the close future. This
holds for each scenario, however the size of the deficit differs depending on longevity and
labour market participation assumptions. Results lead to a discussion on possible reforms
of the health care system.
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7. DEVELOPMENT OF SCENARIOS FOR HEALTH EXPENDITURE...
Introduction
The question of ageing-related changes in health care system expenditure in
Poland was raised in the context of EU policy debate rather than in response to the
internal (locally raised ) discussions on the volume and structure of public health care
expenditures. Due to low level of public health care funding and dynamic institutional
changes in the sector, national policy making process is focused on the sources of
health care system funding, the size of funding and the efficiency of funding
allocation. Issues related to the level and individual determinants of expenditures are
not within the scope of main policy debate. Consequently, projecting scenarios of
future health expenditure development and its determinants is an innovative project
in Poland. Most likely, the same is true for other New Member States which have
recently gone through transition.
The objective of this Report is to present the model of future health care system
revenues and expenditures in Poland, and to discuss assumptions for the projection
and projection results.
Expenditure analysis is based on International Labour Organization (ILO) social
budget model, part of which is health budget model. The model takes into account the
revenue side of health care system as well, which is consistent with the above-mentioned
discussion on health care system funding and its sustainability. Moreover, until recently,
data and information sources applicable for long-term comparative projections in the
New Member States were limited. It is only from 2005 that such an analysis –
comparable with the EU-15 – will be feasible, based on EU-SILC survey panel data.
The first part of the Report is dedicated to social, and especially health-related,
expenditure models and projections applied in Poland. Following, detailed
description of data and information used in the current projection is presented.
Baseline projections of main demographic and macro-economic variables and
indicators used in the model are shown, and the assumptions for the development of
these indicators and their inter-relations are discussed. Three scenarios are presented:
the baseline scenario, death-related costs scenario, and the scenario with different
longevity improvements. Projection results cover both the revenue and the
expenditure side of health care system. Finally, conclusions are made and policy
recommendations are formulated, based on projection results.
CASE Network Reports No. 78/2008 7
8. Over the last 16 years, several social expenditure projections have been applied in
Poland in the process of economic and social reforms. These projections varied with
respect to their purpose (policy or research-related), time frame (short- or long-term),
or the scope of modeling (social or health budget and expenditures). Application of
these models was either coordinated by country institutions, including ministries and
research institutes, or by international institutions involved in reform. However, until
recently, there has been no projection exercise focused on health expenditures and
public health care system budget. Hereby, several models and projections that were
developed and used for policy purposes are briefly presented.
The first one – the ILO social budget model - was developed in the mid-1990’s. It
covered the entire social budget. It was applied not only in Poland, but also in other
Eastern European countries, i.e. Hungary and Slovakia. The purpose behind ILO
social budget model introduction was to monitor long-term social revenues and
expenditures, with focus on social budget balance. The model covered pension
scheme and short-term benefits revenue and expenditure projections (including social
assistance, family benefits and unemployment benefits). Originally, it was planned
that the model should also include health care budget, but despite the fact that some
of the data had been collected, the task was never completed, and health care budget
was never presented. Social budget model design was coordinated by the Ministry of
Labor, together with Gdansk Institute for Market Economics. To our knowledge, the
model is still used by the Ministry, with the input from economic and labor market
projections from the Ministry of Labor and Social Policy. Some sections of pension
model and estimations were also used for the European Commission (DG Economic
and Financial Affairs - DG ECFIN) Ageing Working Group (AWG) Project to estimate
the impact of ageing on the pension system. Generally speaking, the most
sophisticated social expenditure models concentrate on pensions. Long-term (50
years) pension expenditure projections were made by the government (Office of the
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Chapter 1.
Applied model of health revenues
and expenditures
9. Government Plenipotentiary for Social Security Reform), with the World Bank
assistance, during the work on three pillar pension reform in Poland (Chłoń et al.,
1999). Currently, long-term pension expenditure projection is also a task bestowed
upon social insurance institution, ZUS.
Until 2004, health care expenditures on aggregate level had not been subject to
analysis and projections in Poland. It was then that CASE-Center for Social and
Economic Research launched AHEAD Project1 and the first modeling attempts were
initiated. Interestingly, the 1999 (introduction of health insurance) and 2003
(centralization of regional Sickness Funds and establishment of one insurance
institution – National Health Fund) health care sector reforms were not supported or
justified by revenue and expenditure projections. Only short-term revenue and
expenditure projections were made by the National Health Fund and the Ministry of
Finance during the work on the state budget. In November 2004, the Ministry of
Health appointed a group of experts to collect the data and information on health
care system expenditures in Poland, and to prepare a Green Book of Health Care
Financing (MZ 2004). At that time, the work on health care budget model carried out
within AHEAD Project was intensified, and preliminary results of health care budget
were presented in the Green Book. This task was performed by the experts from CASE
and the Institute of Public Health, Collegium Medicum of Jagiellonian University,
under AHEAD Project. Side by side with long-term projections, short term projections
based on econometric model, made by the University of Warsaw, Economics
Department, were presented in the Green Book, as well. Short-term projections
covered a 3-year period and demonstrated estimated levels of aggregate public and
private health expenditures and public revenues of the health care system (MZ 2004).
In 2005 Poland, as an EU member, was included in the European Commission
project, coordinated by the DG ECFIN and targeted towards the estimation of ageing-related
costs in EU-25 member states. Based on country data on medical service single
expenditure and long-term care costs, experts from DG ECFIN prepared a 50-year
projection of health and long-term care expenditures. In comparison to health budget
model used in AHEAD projections, DG ECFIN estimations cover only the expenditure
side, whereas health budget focuses on balance between revenues and expenditures
(European Commission 2006). Both models take into account the impact of
demographic changes, as well as changes in mortality and costs related to premature
deaths. Furthermore, both models refer to a number of economic and labor market
variables needed to estimate revenues and expenditures side of projections.
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SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
1 The Ageing, Health Status and Determinants of Health Expenditure (AHEAD) project has been started in 2004
by an ENEPRI consortium led by Centre for European Policy Studies (CESPS). Information about the
project is available at http://www.enepri.org/Ahead.
CASE Network Reports No. 78/2008
10. Projections of health care system financing and financial balance were made based
on the actuarial model prepared by the Social Security Department (SECSOC) of the
International Labour Organization (ILO). The baseline model of social budget was
restricted to health care budget and further adjusted for country situation, health care
system performance and country legal regulations.
The model has one significant advantage, compared to other models that have
been applied in health care financing projections in Poland: namely, it covers not only
health care system expenditures, but also revenues. In effect, it is useful not only for
international comparisons of health care system expenditures – as was the case with
the Ageing Working Group projection – but also for country-based policy makers who
are interested in health care system long-term financial sustainability. Moreover, the
model focuses on insurance revenues and expenditures, which aptly reflects the
structure of the Polish health care system, which since 1999 has been a health
insurance system, with only a minor role for government revenues and expenditures.
Demographic development data and information include population size, fertility
and life expectancy. Labour market factors include the size of labour market active
and employed population which contributes to health care system revenues and is
entitled to utilize medical services. Economic factors are applied for the projection of
future increase in health care system expenditures, while governance factors can be
applied to check system sensibility and to project future reforms. Health care system
financial projections should also include information on population health. In the
model adjusted for Poland, information on the size of population close to death and
costs borne by this population is used. In order to assure projections’ best fit, variables
used on both the revenue and the expenditure side should be as accurate as possible.
When accurate data is not available, appropriate estimations can be used.
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Chapter 2.
Application of the ILO
health budget model
11. Chapter 3.
Sources of data for the ILO
health budget model
The model is built on a number of data, covering four main areas:
• demographic development,
• labour market changes,
• economic changes,
• aggregate health care system expenditures and expenditures by single cohorts.
ILO model data includes cross-sectional and time series data, as well as results of
projections prepared by international and government institutions. Data for the model
was collected from various national institutions, mainly public, governmental
organizations, and represents official statistics. The same rule was applied to
demographic, labour market and economic projections – whenever possible, official
projections prepared by governmental organizations were used. However, in some
cases we needed to rely on expert knowledge regarding future development of specific
indicators such as, for example, the ‘wage growth’. Assumptions regarding the
development of specific indicators were based on past trends, taking into account the
experience of EU-15 countries and in line with convergence plan Poland has adopted.
3.1. Sources of demographic data
There are several available data sources covering demography at the base year and
demographic projections. These include: demographic data from the Central
Statistical Office of Poland (GUS) and GUS population projections, population
projections by EUROSTAT (Cruijsen et al. 2004), also used within the AWG project,
and population projections by the United Nations (2002 version). Data for the base
year (2003) is taken from national statistics provided by the Central Statistical Office,
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SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
12. while demographic projection is based on assumptions prepared by the United
Nations (UN). Consequently, GUS projections are not applied in the model, since they
only cover the 2003-2030 period, while the model is designed to cover the period up
to 2050. Since the UN population projections are the best fit for the ILO social budget
model, as their structure is the same as the one the demographic part of the model is
built upon, UN projections were applied in the model. UN population projections
cover the period of 2003-2050.
3.2. Sources of labour market and economic data
Analogically, GUS statistical information represents the main source of data on labour
market and economic development. With respect to the base year, publicly available and
regularly published GUS data is used, covering labour market participation rates and
employment rates by 5-year cohorts and sex, unemployment rate and shares of employed
by employment status. Listed labour market indicators are calculated based on Labour
Force Survey (LFS) results, and published on a quarterly basis.
The data on key macro-economic variables (GDP, CPI) is taken from GUS and
government statistics published together with the national budget information
(execution and plans).
Projections concerning future development of those variables are made by
government experts and were published in government documents such as, in
particular:
• National Development Plan (Ministry of Economy 2005);
• Convergence Program (Ministry of Finance 2006).
Macro-economic projection assumptions and results were discussed among CASE
experts and government experts involved in AWG activities. Long-term macro-economic
and employment projections correspond to Lisbon Strategy objectives.
3.3. Sources of data on health care system
The original ILO health care model was based on the information regarding the
levels of medical services utilization. In Poland, however, detailed administrative
data on utilization by sex and age cohorts is not available, while there is detailed
information on the cost of services by single ages, provided by the National Health
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13. Fund, so that data is used for modeling purposes. The data also includes
information on insurance inpatient and outpatient care expenditures for survivors
and non-survivors. The original model is adjusted for this change. Besides the data
on expenditure levels by age, sex and type of medical service, aggregate information
from National Health Accounts on overall public health care system expenditures
level is used (Annex 3).
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SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
14. Projection base year is 2003. This is the last year for which all the necessary data
was available at the time when the work on the model was initiated. This is also the
last year for which the National Health Accounts data is published by the GUS.
Following the structure of the model, variables used in the analysis and projections
cover four areas, namely: demography, labour market, economic performance, and
governance.
4.1. Demographic projection
Demographic part of the model is based on the United Nations demographic
projection for Poland and future developments of main variables (including Total Fertility
Rate – TFR, and Life Expectancy – LE) typical of Eastern European region. Base year
(2003) data reflects Polish demographic situation as presented by GUS. For the base year,
the actual population size by single ages is introduced. Further, size of the population
changes depending on the assumptions concerning fertility level and longevity.
4.1.1. Total Fertility Rate
For the base year (2003), TFR is taken from the actual GUS data and is equivalent
to 1.22. In 2003, GUS prepared a projection on future development of population size,
which assumes further decline of the population, accompanied by TFR decrease until
2010 (to the 1.1 level), and then slow increase in TFR, but still much below population
reproduction level (GUS 2004). Changes in fertility level are mostly driven by changes
on the labour market and higher labour market participation of women. Yet, one
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Chapter 4.
Projecting the development
of variables
15. important factor which affects the overall fertility level is increasing age of women
having children. According to GUS, the average age of women having children will
increase in the next 30 years from 28 to more than 30 (GUS 2004). However, this
projection covers only the period of 2003-2030, while our projections are targeted
towards the year 2050. Therefore, a medium variant of UN population projection is
used in the model. The UN population projection was prepared by the Population
Division of the Department of Economic and Social Affairs of the United Nations
Secretariat2 and revised in 2004. In UN projections Poland is classified as a low fertility
country, which means that in recent years fertility level was below replacement level
(2.1 children per one woman). UN projection is built on the assumption that fertility
level in every country will eventually converge to the level of 1.85 per one woman3.
However, some countries (Poland being one of them) will not reach that level even in
the target year 2050. In Poland, fertility is assumed to stay below the level of 1.85
children per woman during the whole projection period. Over the first 5-10 years of
projection period, fertility level and fertility pattern follow recently observed trends,
but later on fertility level is expected to increase in a linear fashion at the level of 0.07
children per woman per quinquennium. This assumption holds for the medium fertility
scenario, used in our model. The medium scenario implies further decline of
population size, though to a lower extent that it is at the moment. Next to the medium
scenario, additional scenarios are prepared for each country, including Poland: high
fertility scenario, low fertility scenario and constant fertility scenario (Table 1).
Table 1. Total Fertility Rate in Poland, 2000-2050
Period Medium variant High variant Low variant Constant fertility variant
2000-2005 1.26 1.26 1.26 1.26
2045-2050 1.764 2.26 1.26 1.26
Source: UN (2006) World Population Prospects: the 2004 Revision Population Database
In the high fertility scenario, TFR is projected to be 0.5 percentage points higher
than in the medium scenario. This implies reaching the reproduction level at the end
of projection period. In contrast, in the low fertility scenario fertility is projected 0.5
percentage points lower than in the medium scenario. In the case of Poland this
means that, in the long run, fertility level will be the same as in 2000-2005 period, and
in the medium term fertility level will be very low: it is projected to be less than 1 child
per woman in fertile age.
15
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
2 Population estimations and the development of main variables are presented at http://esa.un.org/unpp/p2k0data.asp
3 UN demographic projection methodology and assumptions are described at http://esa.un.org/unpp/index.asp?panel=4
4 According to UN population projections published in 2007 (World Population Prospects: The 2006 Revision and
World Urbanization Prospects, http://esa.un.org/unpp/p2k0data.asp), TFR for the years 2045-2050 equals 1.6.
Presented model is based on previous projection, which was effective when the model was being prepared.
CASE Network Reports No. 78/2008
16. 4.1.2. Life Expectancy at Birth
Following on GUS data on longevity, LE for male was accepted at the level of 70.4
in the model, and for female at 78.9 for the base year (GUS 2004). Again, it was
impossible to rely on GUS life expectancy projection data due to the different
projection periods (2003-2030 for GUS projections).
Original ILO model provides three scenarios of life expectancy development: fast,
medium and a slow one, and this source of projection was used. For the baseline
scenario, medium development of LE was chosen. In the second and the third
scenario, the impact of fast and slow development of LE was analyzed.
4.1.3. Migration
Another factor often included in demographic projections is migration level. The
assumption on migration size is especially important for the short-term projections,
given its strong impact on the labour market. GUS projection also assumes
migrations from urban to rural areas (GUS 2004) and between regions
(voivodships). Hereby, as projection of health care system revenues and
expenditures is at the macro (national) level, internal migrations do not influence
projection output. On the other hand, external (cross-country) migrations are very
difficult to predict due to lack of adequate and detailed data. For the moment,
Poland is facing a widespread emigration to the EU-15 countries. However, impact
of the emigration process on the long-term projection may not be that strong. In the
long run emigration will be balanced by immigrants from Asia and Africa that
would come to Poland. Since the scale of these processes is difficult to predict in the
long run, migration factor is not included in projections.
Table 2 (below) presents the values of demographic variables for the base year and
their projected development. Despite life expectancy increase, population is shrinking
due to low TFR levels. Even though TFR is slowly increasing during the whole
projection period, even when reaching the top value it stays much below population
reproduction level.
Overall, female life expectancy increases by 5 years, while male longevity increases
by 6.9 years. In consequence, the gap between sexes is shrinking (from 8.4 to 6.5
years.) Faster improvement in male health status is a result (compensation) of its
previous deterioration and high mortality in the communist period (Okólski 2004). In
the next 50 years that trend among male population is expected to reverse.
Demographic projection indicates that Poland, analogically to other European
countries, will enter the phase of population ageing in the next decade, with increase
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17. Table 2. Development of main demographic variables for Poland, 2003-2050
2003
(base year) 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
TFR 1.22 1.26 1.35 1.43 1.51 1.58 1.64 1.69 1.73 1.75 1.76
LE – males 70.5 70.9 71.9 72.8 73.6 74.4 75.2 75.9 76.4 76.9 77.4
LE – females 78.9 79.2 80.0 80.7 81.2 81.7 82.2 82.7 83.1 83.5 83.9
(in number) of elderly cohorts and decrease of younger cohorts (Graph 1 and Graph
2.) This process will be accelerated after the year 2010 (Graph 3).
Graph 1. Poland: Population histogram – 2003
10
96
92
88
84
80
76
72
68
64
60
56
52
48
44
40
36
32
28
24
20
16
12
8
4
0
400 300 200 100 0 100 200 300 400
Age
Source: Own calculations
Baby-boom generation, which in the base year is at the age of 17-21, will enter the
elderly (pensioners) cohort in the target year of 2050. We can also observe that the
number of newborn babies is decreasing with each year, which is reflected in the
number of children and youngsters in the next decades.
The total population number will stop to grow in 2015, approximately, and from
2015 onwards it is foreseen to decrease. By 2050, total population decrease is
17
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
Females Males
Source: Own calculations and the ILO model
18. Graph 2. Poland: Population histogram – 2050
10
96
92
88
84
80
76
72
68
64
60
56
52
48
44
40
36
32
28
24
20
16
12
8
4
0
400 300 200 100 0 100 200 300 400
Age
equivalent to 13.2% of base year population. The share of the elderly (65+) will by
2050 increase from about 13% to nearly 30%, and the share of active age population
(15-64) is expected to decrease from 70% to 56% (Graph 3).
According to population estimation based on UN fertility and longevity
assumptions (UN 2006), the Polish population in the first years does not shrink as fast
as EUROSTAT and GUS projections forecast (European Commission 2006, GUS
2004). However, the ageing effect keeps for more than one cohort, and a drop in
population size is even stronger after 2025. At the end of projection period, there is
greater convergence between EUROSTAT and model projections (Graph 4).
4.2. Labour market and economic projection
Three economic and labour market indicators are crucial for future development
of revenues and expenditures of the public health care system: GDP changes,
employment/unemployment level, and productivity of workers in the future.
Assumptions on the development of those indicators were discussed with experts from
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Source: Own calculations
Females Males
19. 19
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Graph 3. Projected population size, 2003-2050
40000
38000
36000
34000
32000
30000
28000
26000
24000
22000
20000
2003 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
Source: own calculations
Graph 4. Projected age structure of the Polish population, 2003-2050
100,0%
80,0%
60,0%
40,0%
20,0%
0,0%
2003
2005
2007
2009
2011
CASE Network Reports No. 78/2008
Years
In thousands
ILO model (UN assumptions)
Eurostat
GUS
Source: Own calculations
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
0-14 15-64 65+
20. the Ministry of Labour and Social Policy, and with CASE experts. Assumptions are
also based on government policy documents in which short-term developments of
main economic indicators are analyzed, and long-term objectives for labour and
economic policy are set forth. These include: the National Development Plan (MGiP
2004), the national budgets (Ministry of Finance 2006), the convergence strategy
(Ministry of Finance 2006), and the labour market strategy (MGiP 2005).
4.2.1. GDP
GDP development assumptions are based on the relation between employment rate
and productivity. It is foreseen that during projection period GDP will develop in two
stages. In the next decade, annual GDP growth in real terms will reach app. 5%. The
following factors will contribute to GDP growth during that time: high investments rate,
increasing employment and high labour productivity. These economic changes result
from European enlargements and expansion to the European market. It is expected,
however, that this growing trend is going to reverse after 2015, and GDP growth rate is
projected to decrease. Decreasing GDP growth trend is caused predominantly by labour
market changes and decreasing number of the employed which does not go hand in
hand with corresponding increase in productivity – at least the increase is not strong
enough to maintain dynamic economic growth (Table 5). In consequence, in the year
2050 annual real GDP growth is forecasted to reach the level of 1%.
Similar short-term assumptions are presented in a short-term projection included in
the 2007-2009 national budget prepared by the Ministry of Finance (Ministry of Finance
2006), in the National Development Plan (MGiP 2004), and in the National Employment
Strategy adopted by the government in 2005 (MGiP 2005.) According to these
projections, annual average real GDP growth in 2007-2009 will reach the level of 4.9%.
4.2.2. Employment Rate
Future employment developments are contingent upon the changes in two types of
factors that determine the level of employment:
• demographic changes, especially in the size of labour market active age
population (population aged 15-64),
• assumptions on the level of investments and changes in the level of
entrepreneurial activity, development of knowledge-based economy and
future level of exports.
Future employment level assumptions draw on the National Employment Strategy
(MGiP 2005). drafted by the Ministry of Economy and Labour5. Despite unfavorable
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21. demographic trend expected after 2010, the forecasts prepared by the Ministry of
Labour and Social Policy (MGiP) shows employment rate increase to the level of 58-
62% (depending on the scenario) by 2013. In the model, the most pessimistic scenario
is followed. Given very low level of employment rate observed in recent years (about
52%), a slower increase of employment rate is presented in the projection – up to the
level of 58% in 2013. Employment rate increase in both short- and long-term could be
fostered by an extension in the length of professional activity of women, up to age of
65 (which is currently discussed in the Ministry of Labour and Social Policy).
In the following decades, the ageing process will not contribute to employment
level increase. Poland, however, is going to implement Lisbon Strategy with the
objective of employment level at 70%. Pursuant to the National Employment Strategy,
Poland will reach such level of employment in 2030. Later on, in the last two decades
included in the projection, slower increase of employment rate is foreseen, up to the
level of 74%. Increase in employment will be possible thanks to the factors other than
demography (inter alia, the impact of restrictions to early retirement introduced in
the funded pension scheme.) Such employment level is necessary to keep the economy
growing, even if productivity growth is high.
Another important feature of Polish labour market which was taken into account
in the model and which exerts big impact on the revenue side of health care system is
the structure of employment, with high share of the self-employed in agriculture (over
20%). For the base year, structure of employment introduced in the model follows
GUS statistics (GUS 2004), with domination of private sector employees (37.3%),
followed by public sector employees (26.5%.) Convergence rule and internal
migration trends guide us to assume that in the next years the share of the self-employed
in agriculture is going to decrease. According to GUS data (GUS 2004), the
number of individuals employed in agriculture was, on average, decreasing by 3%
annually in the period of 1995-2002 (Table 3). This trend is expected to continue, but
with a milder slope. Therefore, it is assumed in the model that the share of employed
in agriculture will further decrease by 2% annually. In effect, the share of self-employed
in agriculture in the year 2050 will decrease by more than a half.
21
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Table 3. Employment in agriculture in Poland, 1994-2002
Employment in agriculture
(thousands)
Percentage of change
versus previous year -4.78 -0.99 -5.88 -6.11 -8.84 2.21 -0.16 -2.18
Source: GUS (2004)
1994 1995 1996 1997 1998 1999 2000 2001 2002
3498 3331 3298 3104 2914 2657 2715 2711 2652
5 Currently Ministry of Labour and Social Policy.
CASE Network Reports No. 78/2008
22. It is projected that the decreasing share of employed in agriculture will be
accompanied by increasing share of employment in private formal sector and the self-employed
outside agriculture. Employment increase in those groups will progress
gradually and equally between the two said groups of employed. The share of
employment in public sector is kept constant during the whole projection period.
4.2.3. Unemployment Rate
The level of unemployment rate depends on economic and institutional factors,
with special emphasis on the development of business-friendly regulations and the
incentive to stay employed, built in the funded pension scheme. It is assumed that
unemployment rate decrease will be rather slow.
According to the National Employment Strategy, in the optimistic and middle
scenario unemployment rate should go down to the level of 8-10% in 2013. In view of
that fact, however, that unemployment in Poland is structural in nature and strongly
related to age, presented projection follows pessimistic scenario in the short term,
assuming that unemployment rate will reach the level of 12% by 2013. In the
following decades, unemployment rate will further decrease to the average European
level of 7% (European Commission 2006).
4.2.4. Labour Productivity
Assumptions on labour productivity play the key role in future development of
GDP and employment levels. Negative impact of demographic changes on the
economy and GDP growth can only be offset with labour productivity increase. In
spite of rapid growth of labour productivity in Poland in the last 10-15 years (Table 4),
productivity level in Poland is still over 30% lower than in the EU-15.
Table 4. Labour productivity in Poland as compared to the EU-15 level
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 average 1996-2006
EU-15 100 100 100 100 100 100 100 100 100 100 100 100.00
Poland 54.3 55.6 56.1 59.9 62.4 53.9 55.0 63.4 65.9 66.8 67.0 60.02
Thus, it is assumed that productivity level in Poland will increase further to reach
the average level of productivity in the EU-15, with small fluctuations related to
economic situation. Although high labour productivity growth in the next decades will
by lower than GDP growth. Only in the last years of projection period will labour
productivity dynamics be slightly higher than GDP growth dynamics.
22
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
Source: Eurostat, http://epp.eurostat.ec.europa.eu/
23. Overall, the impact of ageing on productivity level in the long run is unclear. On
the one hand, older employees are perceived as less flexible in their approach to new
technologies and tasks, which may hamper productivity level. On the other hand,
changes in work organization designed to better exploit the potential and expertise of
older workers may have positive impact on labour productivity (Carone et al. 2005).
All in all, we arrive at the following scenarios for the development of main
economic and labour market indicators:
Table 5. Development of main economic and labour market indicators
GDP growth (%) 5.3 5.1 4.8 4.2 3.7 3.2 2.6 2.1 1.5 1.0
Employment rate (%) 51.2 55.3 59.4 62.9 66.5 70.0 71.0 72.0 73.0 74.0
Labour productivity
growth (%)
Source: Own estimations
2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
3.0 3.3 4.4 4.2 3.4 2.7 3.1 3.2 3.0 2.7
4.3. Policy assumptions
To observe the impact of ageing on health care system performance, the status quo
of currently binding legal regulations is assumed (non-policy changes) (Kohman,
Weale 2006.) This implies that current financial regulations are in place for the whole
projection period, especially on the revenue side. Health insurance contribution rate
is expected to grow to the level of 9% in 2007, and remains at that level afterwards.
Similarly, the level of contributions paid by local self-government authorities for the
unemployed was kept stable. It is calculated either in relation to unemployment
benefit (for those eligible for the benefit), or as 40% of nursing benefit (for those not
eligible for unemployment benefit).
Apart from an increase in contribution rate for the employed, another important
political issue currently discussed by decision-makers which may be modified in the
future is the concept that farmers should contribute at the same level as the
employees. At present, farmers are covered under the Agricultural Social Insurance
Fund, and they do not contribute pursuant to the same legal regulations as employees.
In our model, insurance contribution per one self-employed in agriculture was
estimated based on Agricultural Social Insurance Fund total expenditure on health
care and the number of self-employed in agriculture. The amount of contribution per
one farmer is kept stable for the whole projection period.
The final governance-related issue that should be discussed is the level of spending
from the general budget. According to legal regulations, general budget financing
23
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
24. covers emergency services, medical university hospitals, public health activities,
highly specialized procedures, education and training. The level of spending is
difficult to project in the long run since it depends on political decision taken for each
budgetary year. Consequently, it is assumed that the level of government spending as
a share of insurance expenditure calculated in the National Health Accounts (16.3%)
will not change in the coming years.
4.4. Other assumptions
4.4.1. Income elasticity
Public health expenditures, including government and insurance expenditures, are
estimated on the basis of the National Health Accounts for 2003 (GUS 2006). Increase in
the level of expenditure is driven by GDP per capita growth, which constitutes the most
important non-demographic driver in health expenditures. It is assumed in the model that
health expenditure income elasticity is equivalent to unity. As a result, average health
expenditure growth equals annual increase of GDP per capita. A similar pattern of
increase in GDP and health expenditures is regarded as the closest approximation
possible, given that the model does not include other factors that affect health expenditure
increase, such as technological advancements or Baumol effect6. Unfortunately, the
research on income elasticity of health expenditure growth has not been conducted in
Poland to date, and the identification of such research in other countries from the region
was unsuccessful, except for one estimation by OECD experts suggesting that health
expenditure income elasticity in Poland in the period of 1992-2002 equals 0.96 (European
Commission 2006). However, as authors admit, the period for which the data is available
is very short, which can adversely affect the soundness of the analysis.
4.4.2. Health insurance contributors
Another employment-related factor of big importance for the revenue side of
projections is the number of contributors to health insurance system. According to
National Health Fund estimations, contribution collection rate for the employed for the
base year is at the level of 83%. In the model, it is assumed that contribution collection
24
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
6 Baumol Effect is a phenomenon described by W.J.Baumol and W.G.Bowen in the 1960s, originally in
performing art sector. In sectors which labour-intensive production (also health care sector) relatively low
labour productivity growth over time is observed. So wages increase cause prices increase and production is
relatively more expensive over time.
CASE Network Reports No. 78/2008
25. rate is going to improve to the level of 90% in 2050. The number of old age and disability
pensioners who contribute to health insurance is estimated thanks to the comparison
between the number of pensioners in 2003 and the number of contributors.
Contribution collection rate among pensioners was estimated at 92%. Further
improvement in collection rate in this group is foreseen, up to the level of 95% in 2050.
The average number of dependants covered by health insurance per one insured
person was estimated as being equal to the average reported by the insurer (0.6). This
indicator is projected to decrease during projection period (average 0.5 in 2025, and
0.4 in 2050).
4.4.3. Expenditures on pharmaceuticals and technology
According to OECD studies, public expenditure on pharmaceuticals increases
faster than the expenditure on medical services utilization related to ageing (Martins
2006). Detailed analysis shows that in the period of 1990 – 2002 annual public
expenditure on pharmaceuticals in developed countries was 30% higher than the
increase in other expenditures (Orosz 2003). Therefore, the annual increase in public
expenditure on pharmaceuticals is assumed to be 1.3 times bigger than other
insurance health expenditures.
The model does not include specific indicators regarding technology development
in health care and the impact of such development on overall expenditure level and
health system budget.
25
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
26. Projection was performed for three scenarios. All the scenarios are presented and
discussed below:
I. Baseline scenario;
II. Death-related costs scenario, with different average expenditure for
survivors and deceased;
III. Variations in health improvement and mortality trends (baseline scenario
assumes middle longevity improvement, the other two scenarios – fast and
slow longevity improvement.)
5.1. Baseline scenario
Insurance expenditure profile differs significantly for males and females.
Discrepancies in medical services utilization pattern have been presented in earlier
studies based on survey data (Golinowska, Sowa 2005), and can be accounted for by
different needs for health care services. Graph 5 presents average expenditures per
capita, by gender and 5-year age groups.
High level of expenditures at the earliest stage of life, gender notwithstanding, is
related to intensive care for infants and big health needs of children in the first years
of life (vaccinations, common hospitalization in case of any health problems). Later,
as children grow, the level of expenditure decreases. For males, the level of
expenditure is almost stable until 40 years of age, with even lower levels at the age of
20-35. This stage of life, on average, represents the best health status in the course of
a lifetime. For females, rapid increase in health expenditures related to pregnancy
and birth can be observed (20-40 years of age). Between 40 and 55 years of age,
expenditures for both sexes increase with similar dynamics. Between the age of 55
and 75, health expenditures for males grow faster than for females, and then drop
after the age of 75. Expenditures on females grow much slower and reach their peak
26
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
Chapter 5.
Projection results
27. at later stages of life. These discrepancies can be attributed to differences in longevity
and to the fact that the highest expenditures are incurred during the one or two years
CASE Network Reports No. 78/2008
27
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Source: Own calculations
Graph 5. Average per capita insurance expenditures as percent of GDP per capita, base year (2003)
0,00%
2,00%
4,00%
6,00%
8,00%
10,00%
12,00%
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
males females
Source: Own calculations
Graph 6. Projected total expenditures by single ages, 2003, 2025, 2050 (PLN per capita)
0,0
5 000,0
10 000,0
15 000,0
20 000,0
25 000,0
30 000,0
35 000,0
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
2005 2025 2050
28. directly preceding death. Females live longer, so they tend to generate higher level of
expenditures at a later stage in life than men.
Presented pattern of total health expenditures changes in the course of projection
period. The changes are presented in Graph 6.
One can distinguish between two types of factors affecting the level of
expenditures. First, expenditure increase is related to income changes, which brings
the total expenditure level upwards. This goes back to the assumption of equal growth
of expenditure by single ages in line with GDP per capita. Simultaneously, the pattern
of total insurance expenditure changes to a great extent with age, which shifts the
expenditure upwards for the cohort of 55/60 to 85 years of age. The increase in
projected total expenditure level for older cohort is caused by growing numbers of the
elderly. We can observe that in the year 2025 expenditures for middle age cohort grow
(35–50 years of age), while in 2050 - due to a decrease in the size of population at this
age - expenditures for this cohort even slightly decrease (Graph 6). In the model, there
is no assumption of health status improvement of elderly cohorts (except for LE
improvement assumption) that would shift the expenditure curve to the right, with
higher expenditures incurred later on in life cycle.
When we look at the macro level, total public health expenditures increase sharply
due to the ageing process and increase of expenditures commensurate with the
national income (Graph 7). The steepest increase can be observed over the first 30
28
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
Graph 7. Projected public expenditure on health care in Poland as a share of GDP
CASE Network Reports No. 78/2008
7,50%
7,00%
6,50%
6,00%
5,50%
5,00%
4,50%
4,00%
3,50%
3,00%
2005
2007
2009
2011
Source: Own calculations
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
29. years of projection period; later on the increase in expenditures slows down. Overall,
public health expenditures are expected to increase by 57% (in GDP share category).
Insurance expenditures constitute the main part of public health expenditures.
They are, in fact, the expenditures on medical services driven by health needs of the
population and strongly related to changes in the population structure. They account
for 86% of total public health expenditures. The remaining 14% stand for central and
local government expenditures. These expenditures are not directly related to changes
in population size or health status.
Insurance expenditures increase constantly during the whole projection period
(Graph 8), from 4% to over 6% of GDP. Already in the base year (2003) health
insurance system in Poland is under-funded – expenditures slightly exceed insurance
revenues (0.3% of GDP). The deficit is shrinking with the increase in contribution rate
and decrease in unemployment in the first years of projection period, but starting
from 2007/2008, health insurance deficit begins to increase again (see also Graph 9).
Graph 8. Projected insurance revenues and expenditures in Poland as a share of GDP
6,50%
6,00%
5,50%
5,00%
4,50%
4,00%
3,50%
3,00%
2005
2007
2009
2011
Source: Own calculations
2013
2015
2017
The amount of total insurance revenues - measured in relation to GDP during
projection period - changes depending on population and employment changes, as
well as growth in wages (which reflects productivity changes), with an assumption of
policy stability and unchanged (after 2007) contribution rate.
29
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
insurance expenditures insurance revenues
30. Overall, despite some small fluctuations, projected deficit in health insurance system
goes up during the whole projection period by 1% of GDP (Graph 9, Table 6). The
highest deficit can be observed in years 2040-2045, and afterwards it slowly decreases
(Graph 9). The decrease can be attributed to population shrinking accompanied by high
increase in productivity and continued GDP growth (1% annually).
30
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
Graph 9. Projected deficit in insurance health care system in Poland as a share of GDP
Graph 10. Health insurance contribution rate real and needed to cover expenditures
CASE Network Reports No. 78/2008
5,00%
4,50%
4,00%
3,50%
3,00%
2,50%
2,00%
1,50%
1,00%
0,50%
0,00%
2005
2007
2009
2011
Source: Own calculations
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
13,00%
12,00%
11,00%
10,00%
9,00%
8,00%
7,00%
6,00%
5,00%
4,00%
3,00%
Source: Own calculations
real contribution rate
needed contribution rate (without death-rate costs)
2005
2007
2009
2011
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
31. Table 6. Summary of results – baseline scenario
Total public
expenditure
as % of GDP
Insurance
expenditure
as % of GDP
Insurance
revenues
as % of GDP
Insurance
deficit (%) 0.29 0.18 0.26 0.44 0.56 0.72 1.04 1.28 1.39 1.39 1.28
Contribution
rate needed (%) 8.64 8.90 9.60 10.03 10.32 10.67 11.36 11.86 12.08 12.01 11.73
Source: Own estimations
2003 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
4.51 4.63 4.93 5.22 5.53 5.88 6.24 6.56 6.80 6.96 7.08
3.88 3.98 4.24 4.49 4.75 5.06 5.37 5.64 5.85 5.98 6.09
3.58 3.80 3.97 4.04 4.19 4.34 4.33 4.37 4.45 4.60 4.81
5.2. Death-related costs scenario
In this scenario, expenditures incurred in the last year of patient’s life are
separated from the other years. In fact, such a separation could constrain rapid
increase in total expenditures on health care, i.e. expected increase would be smaller
than in the baseline scenario. This is a results of a fact that expenditures in the last
year of life of younger population are significantly higher than for the elderly (due to
more common utilization of intensive and costly treatment for younger population,
types of diseases related to age and moving the costs of care of elderly outside the
health care system – to a long term care and home care) (Brockmann 2002).
Assuming increasing life expectancy and decreasing mortality rates, the moment
of death and higher health expenditures is moved towards older age. The average
expenditures by age change over the years so, that in every age cohort the share of
persons generating higher costs (costs related to death) decreases (Ahn et al. 2005,
Batljan 2004, Seshamani and Gray 2004).
In that approach the concept of “healthy ageing” is applicable (Felder et al. 2000).
In 2003, the average public per capita expenditure on health care in Poland equals
PLN 963 (4.5% of GDP per capita). However, there are substantial discrepancies in
health care expenditures between the survivors and the deceased. Graph 11 presents
average insurance expenditures on an individual in the last year of life, while Graph
12 presents expenditures per survivor (by gender and 5- year cohorts.) Expenditures
are presented as a share of GDP per capita.
Expenditure level and structure vary to a great extent, depending on individual’s
status (survivor of deceased) and age. Below the age of 65, expenditures for deceased
31
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
32. men are much lower than expenditures for deceased women. This can be attributed
to high rates of fatal accidents among men aged 20-50, and relatively low cost of
related hospital treatment. In subsequent years of life the level of expenditure is nearly
equal for both sexes, while after the age of 70 expenditures for deceased men are
slightly higher than those for deceased women. The gap in older age, however, does
not exceed 5 percentage points.
32
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
Graph 11. Average insurance expenditures per deceased as a share of GDP, base year (2003)
Graph 12. Average insurance expenditures per survivor as a share of GDP, base year (2003)
CASE Network Reports No. 78/2008
80,0%
75,0%
70,0%
65,0%
60,0%
55,0%
50,0%
45,0%
40,0%
35,0%
30,0%
25,0%
20,0%
15,0%
10,0%
5,0%
0,0%
0 - 4
5 - 9
10 - 14
15 - 19
Source: Own calculations
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
males females
9,00%
8,00%
7,00%
6,00%
5,00%
4,00%
3,00%
2,00%
1,00%
0,00%
0 - 4
5 - 9
10 - 14
15 - 19
Source: Own calculations
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
males females
33. Steep increase in average expenditure per deceased is observed at the age of 45–60
(Graph 11). This trend is conspicuous for both sexes and can be explained by the fact
that middle age is characterized by deterioration in health status. Oftentimes, the
diseases that occur at this stage of life are civilization diseases (circular system
diseases and cancer), which are difficult to cure and require expensive medical
treatment based on advanced modern technology.
At the outset of older age (after 60), average expenditure in the last year of life
decreases radically. Between the age of 60 and 90, expenditure decrease is equivalent
to 37 percentage points for women and 33 percentage points for men (in the GDP per
capita category). Such reduction in expenditures is related chiefly to a less intensive
utilization of expensive treatment at that age. Another important factor is the fact that
treatment is shifted out of hospitals and there is growing need for palliative care or
home care at later stages of life.
Structure of expenditures for survivors is reversed in comparison to the age
structure of expenditures for deceased (Graph 12). After the period of high
expenditures related to neonatal care and extensive care in the first years of life, the
level of expenditures is relatively low. Up to 19 years of age, and at the age of 40-54,
the levels of expenditures for females and males are similar. At the age of 20-39, while
expenditures for men are rather stable (fluctuations of 0.2 percentage point),
expenditures for women grow due to more intensive care related to pregnancy and
childbirth. Men at this age exhibit the lowest health needs in their life cycle, and the
lowest level of expenditures. The situation changes after 40 years of age, when health
needs begin to increase. Average expenditures grow faster for men than for women.
This tendency continues up to age of 75-79, when expenditures for both sexes reach
their peak (6.74% of GDP per capita for female and 8.51% for male). After the age of
80, one can observe a slow decrease in the level of expenditures.
When we compare an average level of expenditures per survivor to an average
level of expenditures per person with indifferent status, we see that up to the age
of 45 health expenditures are almost identical (Graph 13 and Graph 14). This
observation holds for men and women alike. Differences appear at older ages and
are related to increasing mortality for every cohort. In consequence, due to high
mortality levels, even though expenditures per single deceased decrease in a
single year, the overall share of total expenditures for deceased men and women
is increasing.
In the first five years of life, death-related costs per person are higher than in
subsequent years. This is explained by higher probability of mortality than in the next
years of life. Later in the life cycle, up to 30 years of age, the share of expenditures
related to death is low. In the age 30 – 35 it slowly starts to increase. After the age of
55 for men and 65 for women, expenditures on health care in the last year of life
33
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
34. exceed 10% of total expenditures, and this share keeps increasing. Above-mentioned
changes in the level of expenditure are shown in Graph 15 and Graph 16.
34
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
Source: Own calculations
Graph 13. Insurance expenditures per survivor and per person in general as a share of GDP
per capita - males, base year (2003)
0,00%
1,00%
2,00%
3,00%
4,00%
5,00%
6,00%
7,00%
8,00%
9,00%
10,00%
11,00%
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
survivors total
Source: Own calculations
Graph 14. Insurance expenditures per survivor and per person in general as percent of GDP
per capita - females, base year (2003)
0,00%
1,00%
2,00%
3,00%
4,00%
5,00%
6,00%
7,00%
8,00%
9,00%
10,00%
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
survivors total
35. CASE Network Reports No. 78/2008
35
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Source: Own calculations
Graph 15. Share of total expenditures in the last year of person's life in total health care
expenditures - males, base year (2003)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
death related costs survivor costs
Source: Own calculations
Graph 16. Share of total expenditures in the last year of person's life in total health care
expenditures - females, base year (2003)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
death related costs survivor costs
36. In the oldest cohorts, the rate of increase of the share of death–related costs is
slower, but it is still increasing. In case of individuals over 95, the share of expenditures
in the last year of life is close to 50% for male, and slightly above 40% for female.
The value of indicator representing the relation between average expenditures per
person in the last year of life and per survivor, according to age and sex (k indicator7),
is presented in Graph 17.
For male, the highest value of k-indicator is observed between the ages of 20 and
30. This can be explained by the relatively good health status of men at this age,
resulting in low expenditures on medical services for survivors on the one hand, and
high average expenditure per deceased on the other hand. High expenditure per
deceased is related to a substantial number of fatal accidents among young men and
the cost of ineffective treatment observed in such cases.
For female at this age (20-30), the value of k-indicator decreases predominantly
due to high expenditures on survivors related to increasing health needs in the child-bearing
period.
The differences pertaining to k-indicator development between men and women
tend to disappear after age 40. After 80, indicator value is lower than 4, and at the last
stage of life it is relatively close to 1 (1.7 for male over 95, and 1.8 for female). The
tendency shows that the gap between expenditures on survivors and the deceased is
36
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
Graph 17. Value of k-indicator (average expenditures per deceased/average expenditures
per survivor) for 5-year cohorts
CASE Network Reports No. 78/2008
60,00
50,00
40,00
30,00
20,00
10,00
0,00
0 - 4
5 - 9
10 - 14
15 - 19
Source: Own calculations
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
7 Detailed description of k-indicator estimation is presented in Annex 2.
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
males females
37. getting smaller with age. It may be related to lower level of hospital care utilization
at this age, lower utilization of expensive medical treatment, as well as the
predominance of nursery, palliative and home care.
37
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Graph 18. Projected public expenditures on health care in Poland as a share of GDP:
baseline and death-related costs scenarios
7,50%
7,00%
6,50%
6,00%
5,50%
5,00%
4,50%
4,00%
3,50%
3,00%
Source: Own calculations
Graph 19. Projected insurance system revenues and expenditures in Poland as a share
of GDP: death-related costs scenario
6,00%
5,50%
5,00%
4,50%
4,00%
3,50%
3,00%
CASE Network Reports No. 78/2008
without death-related costs with death-related costs
2005
2007
2009
2011
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
Source: Own calculations
insurance expenditures insurance revenues
2005
2007
2009
2011
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
38. When death-related costs are taken into account, projected public health
expenditures grow more slowly than in the case when costs are calculated for the
population irrespective of individual status (survivor or deceased.) The discrepancy
accounts for up to 1% of GDP (Graph 18). Insurance expenditures in the second
scenario are lower as well, with similar difference in the level of expenditure in
relation to GDP.
Graph 20. Projected insurance deficit as a share of GDP: baseline and death-related costs scenarios
5,00%
4,50%
4,00%
3,50%
3,00%
2,50%
2,00%
1,50%
1,00%
0,50%
0,00%
without death-related costs with death-related costs
2005
2007
2009
2011
Table 7. Comparison of contribution rate needed (in %) in a baseline scenario and death-related
costs scenario
As a result, the gap between health insurance revenues and expenditures is smaller
than in the baseline scenario (Graph 19). The deficit amounts to 1.1% of GDP in the
years 2040-2045, and after 2045 it slightly decreases to the level just below 1% of GDP
(Graph 20). Lower expenditures are reflected in the calculation of the contribution
rate required for expenditures and revenues to meet. Contribution rate in death-related
costs scenario increases stepwise, but more slowly than in the baseline
scenario, reaching 11.5% of insurable earnings in 2040, and slowly decreasing to the
level of 11%, approximately (Graph 21, Table 7).
38
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
Source: Own calculations
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
Source: Own estimations
2003 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
Baseline scenario 8.64 8.90 9.60 10.03 10.32 10.67 11.36 11.86 12.08 12.01 11.73
Death related costs
scenario 8.64 8.87 9.51 9.87 10.01 10.37 10.97 11.39 11.55 11.42 11.09
39. Graph 21. Health insurance contribution rate needed to cover expenditures: baseline and death-related
costs scenarios
13,00%
12,00%
11,00%
10,00%
9,00%
8,00%
7,00%
6,00%
5,00%
4,00%
3,00%
Source: Own calculations
5.3. Fast and slow longevity increase scenarios
The third scenario included in the projection allows for a differentiation in the
scale of life expectancy improvement in subsequent decades on the basis of different
longevity trends. It is assumed in the baseline scenario that life expectancy will
develop with medium dynamics, as was the case in the last decade. It is possible,
however, that longevity increase will not be medium. Therefore, two alternative
situations of fast and slow life expectancy improvement are tested. The differences in
life expectancy improvement do not imply that ageing will be healthier. In fact, with
changes in longevity we assume that the health status for each single age-group
remains unchanged (OECD 2006). Consequently, the share of life years of each cohort
assumed to be spent in good and in bad health is the same as today, and as longevity
improves, the time spent in poor health status for each cohort expands analogically,
as these years do not translate into years of better health status. This approach is close
to the expansion of morbidity hypothesis8. Hereby, scenarios of healthy ageing
39
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
8 “The hypothesis that increases in longevity translate into a higher share of life lived in relatively bad health”
(OECD 2006, page 9).
CASE Network Reports No. 78/2008
real contribution rate
needed contribution rate (with death-related costs)
needed contribution rate (without death-rate costs)
2005
2007
2009
2011
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
40. (dynamic equilibrium)9 or compression10 of morbidity are not tested, the scale of
longevity improvement being the only issue in question.
In fast longevity improvement scenario, it is assumed that in the year 2050 life
expectancy of males will be equivalent to 78.7 (compared to 77.4 in the middle
longevity improvement scenario), and for females it will reach 85.2 years of age
(compared to 83.9 in the middle longevity scenario). What that means is that,
compared to the base year, male longevity improves by 8.2 years, and female longevity
improves by 6.3 years.
In the slower longevity improvement scenario it is assumed that in the year 2050 life
expectancy of males will be equivalent to 75.8 years (compared to 77.4 in the middle
longevity improvement scenario), and for females it will reach 82.3 (compared to 83.9
in the middle longevity scenario.) This means, compared to the base year, that male
longevity will improve only by 5.3 years, and female longevity will improve by 3.4 years.
Slower longevity improvement has a cost-constraining effect, whereas faster
increase in longevity translates into growth in public health expenditures, although it
does not entail cost explosion. All in all, the differences in public health expenditures
and health insurance expenditures between middle longevity growth and slow/fast
longevity improvement account for GDP changes at the level of 0.2 percentage points,
approximately, in the year 2050 (Table 8), and even less in the mid-term (year 2025).
Table 8. Different longevity scenarios – Summary of results
Source: Own estimations
The differences in health insurance revenues in 2050 are even smaller than the
differences in the level of expenditures, when three longevity scenarios are analyzed.
Differences in insurance revenues amount to 0.07-0.08% GDP. This implies that,
while longevity changes have impact on the level of expenditures, the level of revenues
is more affected by changes in employment and productivity.
40
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
9 “The hypothesis that the number of life years lived in bad health remains constant in the wake of increased
longevity (or increased life expectancy translates into additional years of life in good health” (OECD 2006, p. 9).
10 “The hypothesis that increases in longevity translate into a lower share of life lived in relatively bad health”
CASE Network Reports No. 78/2008
(OECD 2006, p. 9).
LE –slow growth
LE – middle growth
(baseline scenario) LE – fast growth
2005 2025 2050 2005 2025 2050 2005 2025 2050
Public expenditure (%GDP) 4.63 5.84 6.92 4.63 5.88 7.08 4.63 5.92 7.25
Insurance expenditure
(%GDP)
3.98 5.02 5.95 3.98 5.06 6.09 3.98 5.09 6.24
Insurance revenues (%GDP) 3.80 4.32 4.74 3.80 4.34 4.81 3.80 4.36 4.89
Insurance deficit (%GDP) 0.18 0.71 1.21 0.18 0.72 1.28 0.18 0.73 1.35
Contribution rate needed (%) 8.90 10.65 11.62 8.90 10.67 11.73 8.90 10.70 11.84
41. 5.4. Higher and lower employment rate scenarios
Scenario 4 assumes negative and positive changes in employment rate projection,
as compared to the baseline scenario. The optimistic scenario assumes that by the
year 2013 employment rate will change in line with the National Employment
Strategy (MGiP 2005), and after that period it will be by 2 percentage points higher
than in the baseline scenario. The pessimistic scenario assumes that in the period of
2005-2013 employment rate will be lower than in the baseline scenario - by the year
2013 it will be by 2 percentage points lower, and after that period the difference
between the baseline scenario and the pessimistic scenario will be held constant at the
2 percentage points level.
Table 9. Different employment rate scenarios – Summary of results
Source: Own estimations
Optimistc version
of employment rate
As might be expected, health insurance revenues are higher in the optimistic
scenario, and lower when pessimistic development of employment rate is projected. The
differences in both cases - in comparison to baseline scenario – are equivalent to less
than 0.1 percentage point (+0.8 in optimistic scenario and -0.7 in pessimistic one). The
level of expenditures does not change when Scenario 4 is applied, thus, the same
differences are observed in the size of the deficit. Differences expressed as share of GDP
may not be very impressive, but in nominal terms they amount to almost PLN 3 billion.
41
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
development
Baseline scenario
Pessimistic version
of employment
rate development
2005 2025 2050 2005 2025 2050 2005 2025 2050
Public revenues (%PKB) 4.45 5.24 5.88 4.45 5.16 5.80 4.45 5.08 5.73
Public expenditures (%GDP) 4.63 5.88 7.08 4.63 5.88 7.08 4.63 5.88 7.08
Insurance revenues (%GDP) 3.80 4.42 4.89 3.80 4.34 4.81 3.80 4.26 4.74
Insurance expenditures
(%GDP) 3.98 5.06 6.09 3.98 5.06 6.09 3.98 5.06 6.09
Deficit (%GDP) 0.18 0.64 1.20 0.18 0.72 1.28 0.18 0.80 1.35
Contribution rate needed 8.90 10.46 11.54 8.90 10.67 11.73 8.90 10.89 11.94
42. Presented results refer to three main elements: the level of public health care
expenditures during projection period, the level of public revenues, and the size of
financial deficit in public health care system.
The impact of the main factors (age and income) on final results is different in each
scenario under analysis: (1) baseline scenario, (2) death-related costs scenario, (3)
different longevity scenario, and (4) different employment rate scenario.
42
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
Table 10. Average yearly increases of expenditures and revenues (%)
CASE Network Reports No. 78/2008
Chapter 6.
Conclusions
Source: Own estimations
2003-2010 2011-2020 2021-2030 2031-2040 2041-2050
EXPENDITURES
Baseline scenario 6.36 5.92 4.92 3.44 1.90
Scenario 2 (death-related costs) 6.22 5.79 4.79 3.35 1.78
Slow increase of LE 6.35 5.88 4.86 3.37 1.84
Scenario 3
Fast increase of LE 6.37 5.96 4.99 3.52 1.97
Optimistic
employment rate 6.36 5.92 4.92 3.44 1.90
Scenario 4
Pessimistic
employment rate 6.36 5.92 4.92 3.44 1.90
REVENUES
Baseline scenario 6.56 5.36 4.14 2.96 2.22
Scenario 2 (death-related costs) 6.56 5.36 4.14 2.96 2.22
Slow increase of LE 6.55 5.33 4.09 2.91 2.17
Scenario 3
Fast increase of LE 6.57 5.39 4.18 3.01 2.27
Optimistic employm
ent rate 6.77 5.38 4.13 2.95 2.20
Scenario 4
Pessimistic employ
ment rate 6.45 5.27 4.14 2.97 2.23
DEFICIT
Baseline scenario 9.81 13.11 10.24 5.62 0.62
Scenario 2 (death-related costs) 10.05 12.56 10.37 5.56 0.60
Slow increase of LE 9.76 13.02 10.13 5.45 0.45
Scenario 3
Fast increase of LE 9.85 13.21 10.40 5.75 0.75
Optimistic
employment rate 14.71 14.71 11.04 5.85 0.57
Scenario 4
Pessimistic
employment rate 11.19 13.10 9.60 5.42 0.65
43. All value increases in Table 10 were calculated in nominal terms (and were not
related to GDP).
In the baseline scenario, there is a systematic increase in health care system
expenditures in the next 30 years. Afterwards expenditure growth pace will slow
down, in proportion to slower GDP dynamics. The average increase in health care
sector revenues is lower until 2040, but in the final ten years of the projection period
it will exceed average expenditure growth. That will lead to a very slow increase of
deficit in this period (average 0.62% in 2041-2050). In general, the average dynamics
of deficit increase is lower after 2011.
Projection results are different when additional elements are taken into account,
such as the assumption of death-related costs, different scenarios of longevity
improvement and employment rate development.
With regard to different longevity dynamics, typical (trivial) tendency in shaping
the aggregate function of health care expenditures is indicated (Christiansen et al.
2006). We observe that the bigger the longevity improvement, the higher the
expenditures, in comparison to the baseline scenario. Greater longevity improvement
leads to an increase on the revenue side of projections as well. Such increase,
however, cannot compensate for the growth in expenditures to the same extent as in
the baseline scenario. In consequence, health care system deficit growth is the highest
in the case of fast longevity increase scenario.
At the same time, when we take death-related costs into account, the level of
expenditures decreases in comparison to the baseline scenario (with no changes on
the revenue side) and, finally, to the level of deficit.
43
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Table 11. Summary of projection results, different scenarios
Scenario
of different
longevity
increases
(% of GDP) % of change* 0 31 61 0 23 40 0 152 366
*in comparison to the base year
Source: Own calculations
CASE Network Reports No. 78/2008
Expenditures Revenues Deficit
Scenario
2003 2025 2050 2003 2025 2050 2003 2025 2050
Baseline (% of GDP) 4.51 5.88 7.08 4.22 5.16 5.80 0.29 0.72 1.28
% of change* 0 30 57 0 22 37 0 148 341
Death-ralated costs scenario
(% of GDP) 4.51 5.71 6.70 4.22 5.16 5.80 0.29 0.55 0.90
% of change* 0 27 49 0 22 37 0 90 210
slow 4.51 5.84 6.92 4.22 5.13 5.71 0.29 0.71 1.21
% of change* 0 29 53 0 22 35 0 145 317
fast 4.51 5.92 7.25 4.22 5.19 5.91 0.29 0.73 1.35
optimistic 4.51 5.88 7.08 4.22 5.24 5.88 0.29 0.64 1.20
% of change* 0 30 57 0 24 39 0 121 313
pessimistic 4.51 5.88 7.08 4.22 5.08 5.73 0.29 0.80 1.35
Scenario
of different
employment
rate
assumptions
(% of GDP)
% of change* 0 30 57 0 20 36 0 175 365
44. In Scenario 4 (employment rate changes), expenditures do not change, while the
revenues change due to differences in the number of employed and insured.
44
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
Graph 22. Projected public revenues on health care in Poland as a share of GDP, different scenarios
Graph 23. Projected public expenditures on health care in Poland as a share of GDP,
different scenarios
CASE Network Reports No. 78/2008
6,50%
6,00%
5,50%
5,00%
4,50%
4,00%
2005
2007
2009
2011
2013
Source: Own calculations
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
Baseline scenario LE-slow
LE-fast Optimistic employment rate
Pessimistic employment rate
7,50%
7,00%
6,50%
6,00%
5,50%
5,00%
4,50%
4,00%
3,50%
3,00%
Source: Own calculations
Baseline scenario Death-related costs scenario LE-slow LE-fast
2005
2007
2009
2011
2013
2015
2017
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
45. 45
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
Graph 24. Projected public deficit in health care in Poland as a share of GDP,
different scenarios
3,00%
2,50%
2,00%
1,50%
1,00%
0,50%
0,00%
Baseline scenario LE-slow
LE-fast Optimistic employment rate
Pessimistic employment rate Death-related costs scenario
2005
2007
2009
2011
Source: Own calculations
2013
2015
2017
CASE Network Reports No. 78/2008
2019
2021
2023
2025
2027
2029
2031
2033
2035
2037
2039
2041
2043
2045
2047
2049
46. The model applied in the study belongs to a group of models which concentrate on
external factors that affect the growth in health expenditures Thanks to such model
structure, one can identify the impact of demographic, economic and labour market
factors. Moreover, the model allows for the analysis of expenditure side as well as the
revenue side of finances in the health care sector.
Research objective was to identify the impact exerted on health expenditures by
demography and the ageing process in Polish society. Consequently, the analysis
focused on estimations of per capita health expenditures according to cohort and
gender. The level of health expenditures strongly depends on projected population
size and its age structure.
Some difficulties in the application of the model arise when economic and labour
market factors are taken into account. It is necessary to project future development of
economic and labour market variables, since historical data or simple extrapolation
of past trends are not sufficient. In the case of a transition country (such as Poland),
which faces economic restructuring and significant changes in the economic system,
projection of future economic developments and changes on the labour market over
the next half of a century is a risky task. However, long term projection (covering the
next 45 years) is a necessity, given that in the impact of demographic changes cannot
be observed over a shorter time period. Population projection is more credible than
economic and labour market projections. At the same time, however, the results of
possible mis-estimation multiply, as demographic development affects economic and
labour market performance.
Another issue for discussion is the assumption of inter-relations between variables.
One of the most important assumptions built in the model is the premise that income
elasticity of health expenditures is equal to a unity over the whole projection period.
According to income elasticity estimations, its level is slightly higher than one, but the
research is incomprehensive due to lack of necessary data and short-time series of
46
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
Chapter 7.
Discussion of the model
and the results
47. historical data on revenues and expenditures. Therefore, the assumption of income
elasticity equal unity is rather intuitive, based on the observation of historic changes
of this relation in Western Europe and the USA at the times when economic
development of these regions was similar to Poland’s present situation. The
assumption of neutral income elasticity is rather conservative. With dynamic
economic development, income elasticity will be higher than one (health will become
a luxury item!), which will lead to projected increase in health expenditure deficit.
Basic version of the model does not include changes in population health status.
Average life expectancy is the only variable that reflects health status of the
population. Nevertheless, its changes only have impact on demographic projection
and do not directly influence per capita health expenditures. The only scenario which
takes into consideration some changes in population health status is the death-related
costs scenario. In each age cohort, assumed mortality rates directly impact health
expenditures per capita. It is related to changes in the number of deaths in each age
cohort and does not describe changes in the health status that affect mortality.
It is assumed that health care system organization and other factors that impact
expenditures (i.e. medical technologies) are unchanged during the whole projection
period. Quantification of those variables and their introduction to the model still
remains a challenge to health care system and policy analysts.
When discussing the model and projection results one must be aware of model
limitations, as well as the uncertainly of future development of projected variables.
The greatest advantage of the model is the simulation which provides answers to the
questions on what could happen if the variables should develop in a projected way,
while other variables – those not included in the model – remain unchanged (ceteris
paribus assumption.) Projection outcome for Poland is somewhat disturbing and
should be perceived as a warning signal. It shows that external factors will continue
to generate disequilibrium between health care system revenues and expenditures.
Health care system reforms will be faced with a challenge to increase efficiency in
order to compensate for the deficit generated by external factors.
47
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
CASE Network Reports No. 78/2008
48. Presented scenarios of future health care system revenues and expenditures
provide a useful frame for potential choices made by policy makers. On the one hand,
we forecast possible development of factors responsible for future revenues in the
health care system: GDP and employment accompanied by projected growth of labour
productivity level, leading to the convergence of Polish economy to the average EU-
15 level. On the other hand, we arrive with a picture of possible shapes of future
health care system expenditures determined by demographic changes and health
status. Factors that are taken into account include: structure of the population by age
(especially the increasing share of elderly population), longevity improvement, and
increasing costs during the latest stage of life and those related to death.
The juxtaposition of revenue and expenditure side of the health care sector
provides information on the active/adverse balance of the national health care budget.
In each of the scenarios assumed and calculated, the projection implies deficit in the
health care sector. This means that the needs of the sector, which to a large extent are
determined by the demographic structure of the population and increasing longevity,
combined with the assumption regarding medical service utilization pattern and
utilization level tendencies (including utilization of new technologies and medicines),
generate higher health care sector expenditures than the revenues which can be
assured with current insurance contribution rate and assumed trends in future GDP
and employment development.
In recent years, one could observe lack of financial balance in health care sector
in Poland. In consequence of that fact, medical service providers have been falling
into debt in their attempts to provide services and fulfill the constitutional obligation
to take care of each patient in need, irrespective of financial resources available. The
projection implies that in the future, in the face of increasing longevity, this financial
imbalance may grow. This should represent a strong incentive for public sector (and
especially the health care system) financial reform.
Several policy paths could be discussed in order to reduce the deficit. One of them
would be to constrain the basket of medical services available under public health
48
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
Chapter 8.
Policy recommendations
49. insurance and increase the cost- effectiveness of health insurance system; yet another
would be to increase the amount of insurance contribution in order to meet the
demand for medical services. The latter was tested in projections. The estimations
indicate that in order to cover health insurance deficit, further increase of
contribution rate, after the year 2008, would be required. To balance increasing
expenditures, contribution rate should increase by another 3-4%, in line with
expenditures, and in 2050 it should reach not less than 11.7% of individual insurable
earnings. The mere increase in insurance contribution rate, (or any other form of
health care tax), however, and the adjustments to the revenue and expenditure side,
although tested in the projection, do not represent a solution in the face of relatively
high non-wage labour costs in Poland and low employment rate11.
Yet, among other social contribution rates, health insurance contribution is
relatively low, and the pension contribution is dominant. Thus, there is room for
reform in the social welfare contribution rate system. On the other hand, though, it
would be extremely difficult to reduce pension expenditures due to political
implications (pensioners constitute a substantial part of the electorate voting for the
political parties that win the elections), and the ongoing pension system reform that
introduces a funded pension system for future generations. In a transition period –
from the PAYG to the funded pension scheme – the so-called “transition costs” are
relatively high and put a strain on public finances.
A question is raised, whether it would be possible to adjust the expenditure side to
revenue side of the health care system. Various proposals and programs targeted
towards cost reduction and management improvements in the sector are limited by
low funding of the health care system. Expenditures geared towards improvements in
system efficiency and management (information, analytical, institutional, human
resources, technological, and other improvements) compete with current
expenditures on payments for medical services, routine renovations, better equipment
and increasing salaries of medical staff, especially nurses and young doctors who
often emigrate in search of higher income.
Projection of health care revenues and expenditures provides arguments for the
preparation of comprehensive health care system reform in Poland. Such
restructuring effort should include changes to the revenue and expenditure side of the
health care system. On one hand, it is necessary to increase health insurance
contribution rate (without increasing total social insurance contribution rate, if
possible.) On the other hand, it is necessary to implement reforms targeted towards
49
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
11 The so-called ‘tax wedge’, resulting from high taxation put on labour, is referred to as one of the reasons for
high unemployment in Poland (Golinowska, Neneman 2006.)
CASE Network Reports No. 78/2008
50. improvements in system efficiency and rationing of medical services. A proposal for a
complex health care system reform in Poland was prepared by CASE Doradcy (CASE-Doradcy
2005.) Policy makers, however, are neither ready or able to undertake long-term
reforms, as they focus on urgent problem issues that emerge (strikes of medical
personnel, requests from patients with regard to resources for the hospitals they use,
countermeasures against increasing emigration of medical personnel, unrest caused
by management failures in some health care units.) Finally, one more important
policy issue is the lack of awareness that solving the problems the health care system
may face in the future is an important tool for current improvements in health care
system management.
50
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008
51. Annex 1.
Projection methodology
– baseline scenario
Health insurance expenditures
Health insurance expenditure estimation is based on the data on individual per
capita insurance expenditures by gender and age cohort. All estimations are made for
5-year age groups and based on National Health Fund data. The data does not include
pharmaceutical expenditures. Therefore, additional assumption is made that the
structure of pharmaceutical expenditures is identical with the structure of other
health expenditures. Primary health care services in Poland are financed via
capitation system, thus for this type of care identical individual expenditures are
assumed, with no differentiation by gender or age.
The National Health Fund data covers the year 200412, while the base year for
projections is the year 2003. Thus, it is assumed that the structure of expenditures by
gender and age did not change during one year. As the next step, individual
expenditures in 2003 are estimated based on the structure of expenditures in 2004.
Individual expenditures in each category sum up to the amount of expenditures listed
in the National Health Accounts from 2003.
Individual expenditures for each age cohort are estimated based on the
assumption of annual growth equal to GDP growth per citizen (pharmaceutical
expenditures are assumed to grow 30% faster than other expenditures):
where:
a∈{1,..,20}
(1 ) a, p,n a, p,n 1 n AE = AE ⋅ + r −
, 5-age cohort
, sex: m – male, f – female
p∈{m, f }
n – the following year of projection,
51
SCENARIOS FOR HEALTH EXPENDITURE IN POLAND
12 This was the first year when individual expenditure data by gender and single ages was collected.
CASE Network Reports No. 78/2008
52. rn – GDP growth per capita in the year n (for pharmaceuticals 1,3 * other
expenditures growth rate)
Total hospital and outpatient care expenditures (including pharmaceuticals) are
calculated through the multiplication of annual individual expenditures by projected
population structure:
, , =Σ ⋅ +Σ ⋅
TE AE N AE N n a m n a , m , n a , f ,
n
, ,
= =
where Na,m,n, Na,f,n is the population number in age cohort a, year n and sex (m – male,
f – female).
Resulting expenditures are aggregated with the remaining insurance expenditures,
which represent mainly administrative cost. Since most of administrative costs are
wages, they are multiplied on annual basis by assumed wage growth.
Government expenditures on health care
It is extremely difficult to prepare a projection of government expenditures on
health, since the expenditures are decided upon each year during parliamentary
debate, and then incorporated into the annual budget. It is assumed that government
expenditures on health constitute a share of health insurance expenditures that is
stable in time. This share is set at the base year and equals 16.3%.
Health insurance revenues
The revenue side of projections is based mainly on the assumptions pertaining to
labour market future development. Projected employed population is divided in each
year according to employment structure. These include: public sector employees,
private sector employees, self-employed outside agriculture, and self-employed in
agriculture. Separately, the unemployed, the disabled, pensioners and voluntarily
insured are taken into account in projections.
Revenues from insurance are estimated separately for each group, assuming the
status quo of insurance legal regulations.
a f n
a
a
20
1
20
1
52
Stanisława Golinowska, Ewa Kocot, Agnieszka Sowa
CASE Network Reports No. 78/2008