New paramedic scope of practice in Poland based on the 2022 reform.

Emergency medical systems in the world are mainly based on two main models: the Franco-German System (FGS) and the Anglo-American System (AAS). The characteristic feature of the FGS is the "Stay and Play" principle, while the AAS system is based on the "Scoop and Run" principle. The Polish model is a mix of those two systems mainly based on the work of paramedics. Their scope of operations and powers have changed over time. As a result of the advocacy undertaken by paramedics in Poland, legislation was drafted and became law in June 2023. The central changes include: the introduction of a paramedic register, the establishment of a professional self-government of paramedics, the expansion of professional competencies such as the ability to declare death, and new opportunities for professional development including speciality training or paid training leave. This article discusses the new law in the context of previous legislative solutions in the field of emergency medicine in Poland and in other European countries.

Interdisciplinary managerial interventions for healthcare workers' mental health - a review with COVID-19 emphasis.

Healthcare workers are representatives of occupations that are most exposed to high levels of stress in the work environment. These characteristics of work increase the probability of suffering from mental disorders. One aspect of mental disorder prevention in the workplace is the role of healthcare managers as those people who are responsible for minimizing the negative impact of work-related stress factors. Their role can be performed by creating effective initiatives supporting workers' mental health. The need to support the implementation of such initiatives has been highlighted by the COVID-19 pandemic. The aim of the review is to summarize available types of managerial interventions in the field of mental health protection of medical staff, considering the assessment of their prevalence, determinants of effectiveness, and limitations from the perspective of healthcare managers. The article was prepared based on the literature review method and covered publications from original research in English and Polish, published until June 2023 in the following databases: PubMed, Google Scholar, and PsycINFO. In addition to the original research, the review also includes documents developed by international health organizations. The determinants of effective managerial interventions that can be used for the needs of managers and decision-makers in the field of mental health management in the workplace have been presented. The greatest widespread of mental health initiatives concerned the pandemic period, but now the key systemic task should be to maintain the frequency of impacts outside the pandemic period, due to the constant nature of stressors. The determinants of their effectiveness include, among others: incorporating elements of psychological knowledge into the process of educating managers, involving healthcare specialists in the development of programs, and examining the needs of the staff each time at the stage preceding interventions. Med Pr Work Health Saf. 2024;75(1):57-67.

Factors affecting young doctors' choice of medical specialty-A qualitative study.

BACKGROUND: Young doctors' choice of medical specialty is essential to maintaining a sufficient health workforce and developing a sustainable healthcare system. The choice of specialization is the result of numerous factors, including doctors' preferences, population needs, and the number of available residency slots. The aim of this article is to explore the factors taken into consideration by young Polish physicians in choosing their future specialty. METHODS: We have conducted 30 structured interviews with randomly selected recent medical school graduates (17 female and 13 male). The study was conducted from December 2022 until February 2023 using online platforms. Data from in-depth interviews were coded using NVivo Release 1.6.1. Then thematic analysis was performed. RESULTS: Respondents indicated remuneration and career-associated factors as the main determinants, emphasizing that work-life balance, personal motivations, and the flexibility to choose the type of workplace (hospital vs. outpatient clinic) were even more important. Young doctors expect flexibility in working hours and better working conditions in future work, and these factors are important when choosing a medical specialty. Significant difficulties during the selection of medical specialty include limited residency slots in preferred specializations and lack of knowledge concerning the everyday aspects of work in a particular specialty. CONCLUSIONS: Factors and limitations influencing the choice of medical specialty should be taken into account by policymakers to address the shortages of doctors in deficit specialties. Knowledge about doctors' preferences regarding their medical specialty could support the development of targeted policies to increase the attractiveness of deficit specialties and reduce the uneven distribution of medical staff.

Medical deserts in Spain-Insights from an international project.

INTRODUCTION: Medical deserts are a growing phenomenon across many European countries. They are usually defined as (i) rural areas, (ii) underserved areas or (iii) by applying a measure of distance/time to a facility or a combination of the three characteristics. The objective was to define medical deserts in Spain as well as map their driving factors and approaches to mitigate them. METHODS: A mixed methods approach was applied following the project "A Roadmap out of medical deserts into supportive health workforce initiatives and policies" work plan. It included the following elements: (i) a scoping literature review; (ii) a questionnaire survey; (iii) national stakeholders' workshop; (iv) a descriptive case study on medical deserts in Spain. RESULTS: Medical deserts in Spain exist in the form of mostly rural areas with limited access to health care. The main challenge in their identification and monitoring is local data availability. Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be identified in Spain. They can be related to demand for or supply of health care services. More national data, analyses and/or initiatives seem to be focused on the health care supply dimension. CONCLUSIONS: Addressing medical deserts in Spain requires a comprehensive and multidimensional approach. Effective policies are needed to address both the medical staff education and planning system, working conditions, as well as more intersectoral approach to the population health management.

Competencies of hospital managers - A systematic scoping review.

Hospital managers around the world work under constant pressure to adapt their organizations to new challenges and health policy goals. This requires a comprehensive set of competencies. The objective of this scoping review was to identify, map, and systematize the literature on hospital manager competencies. The review involved six steps: (1) defining research questions; (2) identifying relevant literature; (3) selecting publications; (4) data extraction; (5) data analysis and result reporting; and (6) consultations. A total of 57 full-text publications were included (46 empirical studies, six literature reviews, four expert opinions/guidelines, and one dissertation). Interest in this topic has grown in recent years, with most of the identified studies published since 2015. The empirical studies fall into three major groups: 34.8% (16/46) examined hospital managers' competencies in terms of their types or classifications; 30.4% (14/46) focused on their measurement; and 30.4% (14/46) examined both aspects. In majority of studies, both 'hard competencies,' such as specific technical knowledge or skills acquired through practical training, and 'soft competencies,' e.g., adaptability, leadership, communication, teamwork, are echoed for effective hospital management. These point out the importance of both 'external' formal education trainings as well as 'internal' peer-support and/or coaching as complementary competency improvement approaches. This scoping review helps build a knowledge base around the topic and provides implications for future research. The latter can involve: a targeted systematic review addressing the methods for measuring the level of competence of hospital managers or studies focused on identifying the need for new types of competencies.

Characteristics of medical deserts and approaches to mitigate them: a scoping review.

INTRODUCTION: Medical deserts are increasingly considered problematic and many countries employ a multitude of actions and initiatives to achieve a better distribution of the health workforce (HWF). This study systematically maps research and provides an overview of the definitions/characteristics of medical deserts. It also identifies contributing factors and approaches to mitigate medical deserts. METHODS: Embase, MEDLINE, CINAHL, Web of Science Core Collection, Google Scholar and The Cochrane Library were searched from inception to May 2021. Studies reporting primary research on definitions, characteristics, contributing factors and approaches to mitigate medical deserts were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies. RESULTS: Two-hundred and forty studies were included (49% Australia/New Zealand, 43% North America, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=160), characteristics (n=71), contributing/associated factors (n=113), and approaches to mitigate medical deserts (n=94). Most medical deserts were defined by the density of the population in an area. Contributing/associated factors consisted in sociodemographic/characteristics of HWF (n=70), work-related factors (n=43) and lifestyle conditions (n=34). Approaches focused on training adapted to the scope of rural practice (n=79), HWF distribution (n=3), support and infrastructure (n=6) and innovative models of care (n=7). DISCUSSION: Our study provides the first scoping review on definitions, characteristics, contributing/associated factors and approaches to mitigate medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate medical deserts.

Methods and Tools Used to Estimate the Shortages of Medical Staff in European Countries-Scoping Review.

Healthcare workforce (HWF) shortages are the biggest challenges today in healthcare systems. Therefore, it is crucial to forecast the future needs of HWFs in order to plan accordingly. The purpose of this study was to identify, map, and synthesize the tools, methods, and procedures for measuring medical staff deficits in Europe. We used the Arksey and O'Malley scoping review methodology. Based on predefined criteria, 38 publications that were retrieved from multiple scientific databases, hand-searched on the internet, from relevant organizations, and scanned from references were considered. They were published between 2002 and 2022. There were 25 empirical studies, 6 theoretical papers, 5 reports, 1 literature review, and 1 guidebook. The majority estimated or measured shortages of physicians (14/38) and nurses (7/38) or looked at HWF generally (10/38). Various methods were used, including projections, estimations, predictions, simulation models, and surveys, which used tools such as special computer software or customized indicators, i.e., the Workload Indicators of Staffing Need method. Researchers estimated HWF shortages at both national and regional levels. Such projections and estimations were often based on demand, supply, and/or need. These methods and tools are not always suited to the needs of a country or medical facility, which is why they need to be further developed and tested.

The 2021 plan for hospital care centralization in Poland - When politics overwhelms the policy process.

The health system in Poland is characterized by oversized hospital infrastructure, with simultaneous deficits in the ambulatory and long-term care sectors. The main challenges of the hospital sector involve i.a. weak stewardship and fragmented governance with a concurrent problem of persistent hospital debts as well as huge workforce deficits. The objective of this paper is to present the government's 2021 plan for hospital care centralization. The reform project aimed i.a. at improving hospital service coordination by implementing a professional and centralized system for hospital sector supervision and effective restructuration processes. The proposed regulation project focused on three major issues: (1) adjusting the existing hospital network towards better concentration of specialized services; (2) launching an independent central agency responsible for monitoring public hospital financial standing as well as initiating and/or managing hospitals restructuration processes; and (3) introducing a formal certification of hospital managers competencies. The reform plans were developed in a relatively short time frame, with a top-down approach and strongly pushed towards the adoption in 2022. Many of the health system stakeholders were strongly opposed to the project which, in connection with new challenges faced by the health system in 2022 (the economic crisis) led the reform suspension. At the same time, a new restructuration and debt relief programme for public hospitals was announced.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries.

BACKGROUND: Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies). METHODS: We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes. RESULTS: Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%). CONCLUSION: Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

Factors Affecting Migration Intentions of Polish Physiotherapists and Students of Physiotherapy-A Cross-Sectional Study.

The phenomenon of professional migrations in the healthcare sector may exacerbate the problem of health workforce shortages. The scale of migration of medical personnel in Poland is estimated mainly on the certificates issued by the regional chambers confirming qualifications that grant the legal right to practice in other EU countries. Migrations concern also physiotherapists, who are the third largest group of health professionals. However, the problem of this phenomenon has not been assessed, and there is a lack of research in this area. The aim of the study was to compare the intention of migration among practicing physiotherapists and students in the last two years of master's studies in physiotherapy, as well as to identify the factors affecting their intentions to migrate. The study covered practicing physiotherapists and students in the last two years of master's studies in the field of physiotherapy in Poland. A total of 236 respondents took part in the study, including 119 physiotherapists and 117 students of physiotherapy. The tool used for the study was an online questionnaire. The scale of the intention to migrate was estimated at 45.3% among students and 47.1% in the group of practicing physiotherapists. The most frequently indicated destination countries for the migration of physiotherapy students and practicing physiotherapists were Germany, Norway, Switzerland, France and the United Kingdom. In both studied groups, the pull factors with the greatest impact on the intention to migrate were the possibility of obtaining higher earnings and working in better infrastructural conditions. In turn, the most important push factors turned out to be the low prestige of the profession in Poland, limited prospects for professional advancement and the stressful work environment. The respondents most often indicated separation from loved ones and poor command of foreign languages as significant barriers to professional migration. Both students of physiotherapy and practicing physiotherapists show great interest in the intention of professional migration, and the decisive determinant is economic factors.

Exploration of Estimated Emigration Trends of Polish Health Professionals.

BACKGROUND: Due to the significant staff shortages, emigration of health professionals is one of the key challenges for many healthcare systems. OBJECTIVE: The aim of this article is to explore the estimated trends and directions of emigration among Polish health professionals. METHODS: The emigration phenomenon of Polish health professionals is still under-researched and the number of studies in this field is limited. Thus, the authors have triangulated data using two methods: a data analysis of five national registers maintained by chambers of professionals (doctors, nurses, midwives, physiotherapists, pharmacists, and laboratory diagnosticians), and data analysis from the Regulated Profession Database in The EU Single Market. RESULTS: According to the data from national registers, between 7-9% of practicing doctors and nurses have applied for certificates, which confirm their right to practice their profession in other European countries (most often the United Kingdom, Germany, Sweden, Spain, and Ireland). The relatively high number of such certificates applied for by physiotherapists is also worrying. Emigration among pharmacists and laboratory diagnosticians is rather marginal. CONCLUSIONS: Urgent implementation of an effective mechanism for monitoring emigration trends is necessary. Furthermore, it is not possible to retain qualified professionals without systemic improvement of working conditions within the Polish healthcare system.

Emigration from the perspective of Polish health professionals - insights from a qualitative study.

The Polish health workforce is facing many problems, including shortages, heavy workload, burnout, and dissatisfaction, which may lead to job emigration, mainly among younger generations. The objective of the article is to explore the reasons, consequences, and circumstances of the emigration of Polish health professionals with a qualitative approach. We have conducted semi-structured interviews with 15 practicing health professionals, exploring the perspectives of different professions and different generations. The interviews were conducted using the on-line MS Teams platform from February until March 2022. We transcribed all interviews verbatim and performed directed qualitative content analysis. Currently, the scale of emigration is rather stable and mainly affects the younger generations. The main reasons for emigration, as indicated by representatives of different health professions, are similar, including excessive workload and long working hours. However, doctors and dentists also emphasized problems with professional development and specialization training, while nurses, midwives, and physiotherapists underlined problems with low prestige and work autonomy. Taking into account the substantial shortage of health workforce and the high average age of practicing health professionals, emigration requires special attention from health decision makers. Implementation of an effective mechanism for monitoring the emigration of medical staff is recommended.

Financing Healthcare in Central and Eastern European Countries: How Far Are We from Universal Health Coverage?

After the fall of communism, the healthcare systems of Central and Eastern European countries underwent enormous transformation, resulting in departure from publicly financed healthcare. This had significant adverse effects on equity in healthcare, which are still evident. In this paper, we analyzed the role of government and households in financing healthcare in eight countries (EU-8): Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, and Slovenia. A desk research method was applied to collect quantitative data on healthcare expenditures and qualitative data on gaps in universal health coverage. A linear regression analysis was used to analyze a trend in health expenditure over the years 2000-2018. Our results indicate that a high reliance on out-of-pocket payments persists in many EU-8 countries, and only a few countries have shown a significant downward trend over time. The gaps in universal coverage in the EU-8 countries are due to explicit rationing (a limited benefit package, patient cost sharing) and implicit mechanisms (wait times). There is need to increase the role of public financing in CEE countries through budget prioritization, reducing patient co-payments for medical products and medicines, and extending the benefit package for these goods, as well as improving the quality of care.

Good practices in health promotion for older people - Significance for evidence in health policy.

This article is devoted to convincing policy makers to use good practices in encouraging older people to pursue adequate and effective health policies. Long-term scientific research focused on the effects of health promotion programmes is rarely undertaken, although its scope is still expanding. At the same time, it is strongly desirable to form health policy based on scientific evidence. In this situation, an indication of good practices characterised by precisely defined features and their systematic evaluation could be an alternative to an insufficient number of empirical studies. The first step of the methodology was a literature review on health promotion for older people, aimed at defining good practices and criteria used for their selection. The authors searched the following databases: PubMED, Embase and Cochrane Library, as well as international databases dedicated to health promotion programmes for older people (e.g. Age-friendly World (https://extranet.who.int/agefriendlyworld/age-friendly-practice-database-launched); HealthProElderly (www.healthproelderly.com/database/index.php?id=16); JA-CHRODIS (www.chrodis.eu); EuroHealthNet (www.eurohealthnet.eu) and ProFouND; (www.profound.eu.com). As relevant health policy information is usually available in national languages, the authors then approached national experts in 10 European countries, who filled in a dedicated survey on health promotion programmes for older people and indicated examples of good practices from their countries. Practical evidence, based on real implemented programmes, is valuable as inspiration for health promotion programmes, their planning and management. Selecting good practices from among implemented and evaluated actions makes it possible to establish their value. The significance of good practices in health promotion is to deliver real benefits and health effects for a target group, which, in the case of evident benefits, renders the practices credible and worthy of further dissemination. The EU already successfully shares good practices in migrant health and environmental protection. Creating databases on good practices helps policy makers promote the sustainability of already implemented activities and enhances their applicability by other organisations and in different settings.

Testing the 2017 PHC reform through pilots: Strengthening prevention and chronic care coordination.

Numerous official reports have highlighted insufficient provision of preventive services within primary health care (PHC) in Poland. Other identified weaknesses include inappropriate referrals to ambulatory care that contribute to long waiting times for specialist consultations. Since mid-2018, a new model of PHC organization has been piloted and can be seen as an attempt to address some of these weaknesses. It draws on the Primary Health Care Act of 2017 and puts much more emphasis on disease prevention and health promotion within PHC as well as shifts management of common chronic conditions to multidisciplinary PHC teams. The implementation of this model has been supported by a range of financial and non-financial measures, including a special grant that helps PHC practices to adapt their IT systems to the requirements of the pilot. Yet, the overall requirements were prohibitive to most PHC practices and only 42 were eventually included in the pilot. In this paper, we describe the content of this model, the difficulties in its implementation and how they were addressed and discuss its possible effects on PHC and the health system more broadly.

A Multidimensional Questionnaire to Measure Career Satisfaction of Physicians: Validation of the Polish Version of the 4CornerSAT.

To study physicians' satisfaction with a multidimensional approach, the 4CornerSAT questionnaire to measure the career satisfaction of physicians was conceptualized in English and later adapted into Polish. In this study, we aimed to test the reliability and validity of the adapted 4CornerSAT questionnaire in Poland and confirm its the tetra-dimensional structure. In 2018, physicians working in 15 Polish hospitals were invited to participate in a survey that included the Polish 4CornerSAT. We evaluated the questionnaire's reliability by computing Cronbach's alpha coefficients. We also computed a Pearson correlation coefficient between the reported global item of satisfaction and the standardized level of career satisfaction. A confirmatory factorial analysis (CFA) tested the tetra-dimensional structure of the questionnaire in Polish. In total, 1003 physicians participated in this study. The questionnaire's internal consistency and concurrent validity were optimal. In the CFA, good model fit indicators were observed. In conclusion, the Polish version of the 4CornerSAT demonstrated good psychometric properties. The adapted questionnaire has evidence of its validity and reliability in Poland to be used in further studies and to monitor physicians' wellness as a health care system indicator. Our approach to adapt and validate this questionnaire could be replicated in other settings.

Exploring Satisfaction and Migration Intentions of Physicians in Three University Hospitals in Poland.

INTRODUCTION: University hospitals constitute a unique group of health care organizations which traditionally link three functions: (1) providing highly specialized services, (2) teaching activities, and (3) conducting research. OBJECTIVES: To assess the level of carrier satisfaction among physicians working in three university hospitals in Poland (1); to assess whether the physicians have the intention to migrate and what the main reasons for migration are (2); and to identify the actions that might be taken at the hospital level to mitigate physicians' intentions to migrate (3). METHODS: Cross-sectional study with both quantitative and qualitative components. In the quantitative part, an online questionnaire was distributed among physicians working in three university hospitals. A total number of 396 questionnaires were analyzed. In the qualitative part, in-depth interviews with six hospital managers were conducted and analyzed using thematic analysis. RESULTS: On a scale from one "very dissatisfied" to six "very satisfied", the mean career satisfaction of physicians was 4.0 (SD = 0.74). The item with the lowest mean concerned salary level (2.8, SD = 1.41). In the sample, 34% of physicians declared intentions to migrate from Poland. The main reasons for the intention to migrate were: Better working conditions abroad, higher earnings, the ability to maintain better work-life balance, better training opportunities abroad, and problems due to a stressful current workplace. Hospital managers considered the actions that can be taken at the hospital level to mitigate physicians' migration to be specific to those focused on the working environment. CONCLUSIONS: Career development opportunities and features related to the working environment are the main factors influencing physicians' satisfaction and migration intentions that can be modified at the university hospital level.

Migration intentions among physicians working in Polish hospitals - Insights from survey research.

BACKGROUND: Health workforce shortages could lead to burnout, excessive workload, dissatisfaction and consequently to migration. In Poland the exact scale of physician migration is unknown due to insufficient data. METHODS: A quantitative, cross-sectional survey of physicians working in Polish hospitals was conducted between March and June 2018. 15 Polish hospitals were included in the study (7 general, 5 specialist, 3 university). The data was gathered via an on-line, self-administered questionnaire, sent to physicians working in the included hospitals. Associations between the intention to migrate and demographic characteristics as well as work-related variables and overall satisfaction were measured. Simple and multivariable logistic regression analysis was conducted to determine significant predictors of migration. RESULTS: 1003 questionnaires were analyzed (response rate: 38%). 273 doctors declared the intention to migrate: 4.5% answering 'definitely yes' and 22.7% 'probably yes'. The main reasons were: higher earnings, better working conditions and better work-life balance abroad. Age and higher career satisfaction were negatively related to the intention to migrate: OR = 0.94 (95% CI 0,92-0,95) and OR = 0.44 (95% CI 0.34-0.56) respectively. Women were 54% less likely to intend to migrate than men (OR = 0.46, 95% CI 0.33-0.65). Almost 62% of physicians intending to migrate considered a temporary stay abroad. CONCLUSIONS: Special attention should be paid to improving working conditions, including salary, but also reducing bureaucracy, improvement of work-climate and training opportunities.

Poland: Health System Review.

This analysis of the Polish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In late 2017, the Polish government committed to increase the share of public expenditures on health to 6% of GDP by 2024. If the GDP continues to grow in the years to come, this will present an opportunity to tackle mounting health challenges such as socioeconomic inequalities in health, high rates of obesity, rising burden of mental disorders and population ageing that put strain on health care resources. It is also an opportunity to tackle certain longstanding imbalances in the health sector, including overreliance on acute hospital care compared with other types of care, including ambulatory care and long-term care; shortages of human resources; the negligible role of health promotion and disease prevention vis-a-vis curative care; and poor financial situation in the hospital sector. Finally, the additional resources are much needed to implement important ongoing reforms, including the reform of primary care. The resources have to be spent wisely and waste should be minimized. The introduction, in 2016, of a special system (IOWISZ) of assessing investments in the health sector that require public financing (including from the EU funds) as well as the work undertaken by the Polish health technology assessment (HTA) agency (AOTMiT), which evaluates health technologies and publicly-financed health policy programmes as well as sets prices of goods and services, should help ensure that these goals are achieved. Recent reforms, such as the ongoing reform of primary care that seeks to improve coordination of care and the introduction of the hospital network, go in the right direction; however, a number of longstanding unresolved problems, such as hospital indebtedness, need to be tackled.