Introduction

2.      Reconstruction of the health premium

Each of these arguments points to the need to extend the basis for calculating health insurance premiums and to eliminate the privileges relating to the obligation to insure in the National Health Fund and paid contributions.

Contrary to the suggestive title of the act introducing the Bismarck model in Poland, i.e. the Act of February 6, 1997 on universal health insurance and, contrary to popular opinion, insurance in sickness funds, and currently in the National Health Fund, does not cover all residents of Poland, and some social groups are excluded from the benefits and/or obligations defined by the principle of social solidarity. Such exceptions to the insurance obligation are not substantively justified[1]. While the number of these exceptions has decreased over the past decades, it is still significant. Even if persons not insured in the National Health Fund are in some cases entitled to certain basic health services (for which the state budget should pay), this does not change the fact that they are excluded from the operation of the principle of social solidarity under the insurance in the National Health Fund. Particular attention should be paid in this context to renters, i.e. persons who obtain income only from capital and/or property. As a rule, these are wealthy people who, with their contributions, could seriously support the financing of health services for poorer co-residents, but they do not have to do so [3]. Renters' contributions are used, for example, in Germany, but on the basis of voluntary insurance in sickness funds.

The argument of income solidarity is also a key argument in favor of extending the basis for calculating health insurance premiums to include income from capital and property. This is also supported by an elementary sense of justice, which essentially points to individual (or household-related) financial capacity as the basis for calculating individual health insurance premiums. Financial capacity certainly does not depend on the source of income of the insured person, but depends on the amount of disposable income. A fair contribution should be charged in the same way to all income of insured persons, and not only income from hired work (and derivatives - pensions, etc.) or from self-employment, as is the case in Poland. Extending the basis for calculating health insurance premiums with income from capital, and thus strengthening the financial foundation of the functioning of the health care system, is also supported by the changes in production technologies observed for decades, not only of goods, but also more and more often of services, as well as demographic changes leading to a growing deficit of qualified production staff and changes leading to a significant increase in the share of capital in the functional division of national income.

The rules for paying contributions by individual farmers require urgent reform. The current solution practically exempts this large professional group (and members of their families) from the obligation to pay contributions while maintaining the full right to benefits financed by the National Health Fund. The contribution of one zloty per hectare of owned land (and in addition collected from farmers only from the 6th so-called conversion hectare) can hardly be considered symbolic. Also other professional groups, such as clergymen, were granted unjustified privileges in Poland with regard to the obligation to pay health insurance, privileges that required liquidation. The only reason for exemption from paying health insurance contributions while maintaining the right to benefits should be the lack of ability to pay, i.e. the lack of sufficient disposable income[1].

Finally, the allocation argument speaks in favor of extending the insurance obligation and the basis for calculating health insurance premiums. Each fiscal burden - tax or compulsory social security contribution - apart from the theoretical case of Lindahl's "ideal tax", affects the taxpayer's decisions regarding the use of resources, in particular labor resources. The higher the marginal tax rate[2], the stronger the negative reactions from the taxpayer should be expected and the lower the motivation to engage in the creation of national income [37]. Although an isolated health insurance premium of a few to over a dozen percentage points should not yet generate negative allocation effects, but in the context of the analysis of these effects it must be perceived as an element of a larger whole, which also includes income tax and other social security contributions. This is also very high in Poland and forces many people who run their own business to end it. A further increase in the marginal rate of fiscal burdens by increasing the health insurance premium should therefore be treated as a serious threat to the economic development of the country. This risk can be reduced by substituting a further increase in the contribution rate with an extension of the basis for its calculation.

3. Introduction of a separate long-term care system

Long-term care is related to nursing and care benefits intended for dependent people who are unable to perform the so-called daily activities[3] [38]. There are two models of organization of this care in the world [39]: separate systems, i.e. a separate system of financing these benefits in the social security system (e.g. Japan, Germany), and non-separate systems - then the benefits are financed from different systems, most often under the health care and social assistance system (e.g. Finland, Slovakia, Poland). The advantage of a separate long-term care system is a separate pool of funds to cover the care and care needs of dependent people, and thus a clear demarcation between the scope of financing the health care system (in particular, lack of financing for nursing care) and the social assistance system.

The average expenditure on long-term care in OECD countries is 1.7% of GDP [40]. Over the next 50 years, according to Eurostat demographic projections, the structure of the population will change radically. The proportion of people aged 65+ is expected to increase from 19.2% in 2016 to 31% in 2070, while the proportion of the oldest Europeans (aged 80+) is expected to increase from 5% to 13% over the same period. This translates into the need to increase public spending on long-term care from 1.6% to 2.7% of GDP [40]. Moreover, we can expect an increase in the percentage of people who will require long-term care and a simultaneous decrease in the number of people providing informal care [41]. In general, the stimulus to isolate the long-term care system is usually the increase in demand (and thus the spending pressure) for formal[4] (implemented by institutions) care benefits resulting from the aging of the population and changes in the structure of families (nuclear families, late parenthood or lack of it, divorces), limiting the ability to provide care by the closest relatives [39]. A good example here may be Japan, where in the 1980s and 1990s of the twentieth century, due to the lack of family care opportunities and the lack of appropriate institutions, many hospital beds were occupied by disabled elderly people for a long time. This phenomenon has been called “social hospitalization” [42]. The situation changed only in 2000, after the introduction of care insurance.

Separate systems can be financed both from taxes (procurement systems) and from premiums (insurance systems). Regardless of the system, benefits may take the form of a cash benefit (e.g. Austria, Germany, Sweden, Italy), the amount of which usually depends on the degree of dependence (e.g. in Austria from EUR 154.2 to 1655.8) and/or a benefit in kind [ 43]. It is believed that cash benefits provide greater flexibility in securing needs, i.e. the beneficiary himself/herself decides on what scope of care he/she wants to allocate the received funds. However, it should be noted that the amount of the cash benefit is not always adequate in the context of the prices of care benefits, and sometimes it can even stimulate price increases, as was the case in the Czech Republic, where the average fee for using community care services almost doubled within a year from the introduction of changes (2006 vs. 2007) [44].

The subject of a separate care insurance system is not a new topic in Poland. Already in 2006, Minister Zbigniew Religa appointed a team for the development of the assumptions of the draft act on social care insurance [45]. It was a reaction to the projected rapid increase in the number of dependent people in Poland, caused primarily by the increase in the number of elderly people (aging of post-war baby boomers). Subsequent works (2010-2015) were carried out by the Senate Committee headed by Mieczysław Augustyn (a draft act on assistance to dependent people was drafted), which was finally submitted as a legislative initiative in 2018. Unfortunately, none of the actions taken so far have resulted in a systemic change. Currently, instead of anticipating the risk of failure of the social security system in the area of long-term care services, we are still at the stage of reactive actions, taken as a result of strikes by carers of dependent people or media reports on the quality of institutional care. As stated by prof. Piotr Błędowski in the introduction to the report Opieka długoterminowa w Polsce dzisiaj i jutro (Long-term care in Poland today and tomorrow) [46]: “The year that has passed since the presentation of the original version has not brought a breakthrough in the discussion on the concept of long-term care in Poland. For generally known reasons, however, it brought about a deterioration of the situation of the patients/wards themselves. This makes the debate on the organization and financing of long-term care all the more necessary and urgent.”

The introduction of a separate long-term care system in Poland would certainly have a significant impact on the finances of the health care system in the form of "release" of funds already in the system. It is not only about expenses related to those care and nursing benefits that will be outside the health benefits package (which will be financed under the "new" system). Separating the long-term care system may lead to a reduction in expenditure on the so-called hospitalizations for social reasons. In addition, increasing the level of care for dependent people could reduce expenses on the so-called avoidable hospitalizations. These "released" funds can be used to cover unsatisfied health needs, manifested primarily by long waiting periods for services in the health care system.

4.      Determining the space for patient co-payment and preparing the possibility of its compensation through insurance, e.g. mutual insurance

In order to determine the elements of improving the financing streams of the Polish health care system, a change in the state's share in covering the costs of health services may be considered. This share should be high enough to cover the maximum significant level of service costs, while leaving the "own contribution" to patients at an acceptable level (the so-called co-payment). Currently, in Poland we are dealing with the process of co-payment in the field of, for example, co-payments for medicines, fees for dental treatment or supplementary financing of medical supplies (dentures, spectacle lenses or wheelchairs). In practice, this stream is an additional expense for patients. The amount of funds additionally spent by the insured in Poland is estimated at approx. 23% [48]. It is also worth noting that there is no comprehensive compensation for these expenses in Poland (apart from minor exceptions, e.g. through PIT tax relief for the disabled). In practice, therefore, we are dealing with a financial stream that can be managed and in which other important activities can be intertwined (extend co-payment), as is the case in other European countries. It is worth emphasizing that regulations on the sources of financing healthcare, including various forms of co-payment, are the most important regulator of the allocation of financial resources for healthcare.

One of the most common forms of co-payment in practice in various countries is a fixed percentage share of patient insurance in the costs of services received, the so-called co-insurance. This share may refer to selected types of benefits, e.g. a 15% share in the costs of hospitalization in an ophthalmology department in Slovenia [49]. It may also apply to all medical benefits obtained in a specific period of time (e.g. 5% of the cost of all benefits obtained during the year). Another form of co-payment is the patient's share in the cost of medical services. It consists in fixed patient fees paid for each obtained unit of service. Such fees may, for example, be charged to each visit to the doctor or each prescription issued. Countries where this mechanism has been used include: Belgium, Austria, Croatia, Finland, Norway, Slovakia or Italy, whereby the payment applies to different scopes with different deductibles. The fees paid by patients are not related to salary contributions, but relate to the actual use of specific health services under the statutory health insurance [50]. In this form of co-payment, payment is most often made for visits to specialist doctors, costs of food in the hospital, dental services, diagnostic tests or rehabilitation equipment. In addition to an additional source of financing the system, the regulatory function of the state is then emphasized [51].

Another form of payment is franchise. In this solution, the insured person bears all the costs of benefits himself using direct payments until a certain amount (franchise amount) is reached. Costs of benefits exceeding the franchise sum are paid by the insurer [52]. An example of the use of this solution is the financing of healthcare in the Netherlands, Switzerland, Sweden and the United States.

However, a particularly interesting solution was introduced in France. The French health care system is financed primarily from social insurance, which is an element of the state structure, and by health insurers on a complementary basis. The general system operates throughout the country and covers 80% of the population. Compulsory health insurance in France is levied on every working resident of the Republic, be it a citizen or merely a resident. The French system is based on a fixed patient's own contribution to the financing of services. The patient pays the full cost and can then claim part of it from the local health insurance fund. The insurer's payments only partially cover medical expenses, and there are also upper limits on the prices of services reimbursed by the payer. In order to receive the maximum reimbursement of co-payments for all health services, you must/can additionally be insured with a private insurer. From January 2016, it is mandatory for all employees based on an employment contract. You can choose the insurer yourself or take advantage of the offer proposed by the employer.

If the employer or company, for various reasons, does not provide collective supplementary insurance, it is possible to purchase supplementary insurance in a mutual fund, social security institution or insurance company in order to obtain full or partial coverage of health care costs. In France, about 90% of the population is covered by private health insurance, which complements public insurance. More than half of the insured obtain insurance through their employer through group contracts [53].

The main advantage of the French system over the Polish one is that in the former basic services (such as tooth extraction or setting a broken leg) are reimbursed by the state fund in 70%. Benefits related to the treatment of chronic diseases (such as cardiovascular diseases or cancer) are covered in 100%. In this way, less money is spent on services that most citizens can afford anyway. There is also a system of incentives to reduce unjustified visits to the doctor, so as to reduce the cost of maintaining primary care. These incentives include, above all, higher amounts of reimbursement of visits or medicines.

However, this system is not without flaws. When constructing solutions for Poland, the problems observed in France should be taken into account and the way of solving them should be considered. The basic problem is the inability to purchase additional insurance by the poorest inhabitants of France. In 2000, the French government introduced a free supplementary health insurance plan that covers most of the out-of-pocket payments that the poorest 10% of the population have problems with [54]. However, the use of this possibility is surprisingly small in practice [55].

Another important problem is that in France private health insurance (PHI) has an exceptionally high level of coverage and accounts for as much as 13.7% of health expenditure. As a complementary and voluntary system, it has historically been dominated by non-profit mutuals. However, over the past 20 years, the market share of for-profit insurance companies has increased by 47%. The financialization of the field has developed and competition based on new risk management strategies has increased [56]. Such actions certainly increase the costs of the additional insurance system. At the same time, PHI is moving towards collectivization: with increased competition, supplementary health insurance is gradually becoming standardized and based on the needs of the company, not the patient [56].

Despite the limitations indicated above, it is worth considering the implementation of solutions using voluntary insurance to cover additional expenses incurred for health care. Research shows that in countries with universal health insurance, despite the cost-cutting policy, there is no crisis of confidence in the system or loss of support among the public [57].

Research conducted in Poland, concerning the willingness to co-pay for health services, gives a positive picture of the situation [48]. According to 41% of the respondents, the imbalance between the funds allocated to health and the expected good quality of health care can be solved by introducing subsidies to health services borne by patients. It should also be emphasized that almost 60% of respondents declare their consent to incur small flat-rate fees for health services. And although these studies, according to the authors, cannot be an indicator of a decision, they nevertheless present a specific picture of the situation. Other studies, although conducted on a relatively small group (over 500 people), also give positive answers [58], mainly in the group of young people with a higher income and with a higher level of education. It should be added, however, that the authors of this study also warn against formulating conclusions regarding a large group on this basis.

It should be emphasized that the basic function of co-payment is to improve the health of individuals and the whole society. The purpose of subsidies is not to reduce costs or to obtain additional revenues, but to better allocate resources and stop wasting them. In view of the above, it is recommended to determine the scope of benefits under which the introduction of co-payment would bring benefits (e.g. limiting the unnecessary number of visits), and to determine the level of these payments. At the same time, it is worth preparing solutions to "reduce the discomfort" related to the necessity of co-payment by establishing, for example in France, a mutual insurance system covering the costs of this co-payment.

Disposal of medical waste, due to the specific composition and heterogeneity of the material, may pose a serious threat to the environment. In Poland, a common method of hazardous waste disposal is incineration [59]. The waste management strategy in most European countries is focused on recycling as much as possible, rather than incineration [60,61].

As a result of properly conducted waste management through the creation of facilities enabling the change of the form of waste, its decontamination and fractionation, it is possible to obtain secondary raw materials as a result of a planned process. Secondary raw materials obtained as a result of the recycling process can be a source of energy or a building material used in other branches of the economy [62].

In Poland, the obligation of proper waste management in a medical entity results from two legal acts, i.e. Act of 14 December 2012 on waste [63] and Regulation of the Minister of Health of 5 October 2017 on the detailed method of handling medical waste [64]. They show that currently only disposal by incineration is possible, which exposes medical entities to unnecessary high costs in at least several areas of activity. Significant funds spent uneconomically for this purpose could be used as a source of financing current operations or necessary investments of medical entities. Prior to disposal, the waste is initially stored at the hospital, divided into different categories. This activity requires a lot of staff time, physical infrastructure and records (sorting plants, internal and external warehouses, elevators). Solid waste is transported through corridors, employees take away solid medical waste packed in plastic bags, on carts intended for this, through the hospital's communication routes. In most cases, the same communication routes and elevators are used by patients and employees, and the transported waste can be potentially dangerous.

The change in the rules of handling solid and liquid waste (including medical waste) in a healthcare facility assumes a clear impact on the environmental protection sector (e.g. through safe disposal, without the need to transport waste; obtaining secondary raw materials from waste and sewage; obtaining energy by burning biogas; reduction of the hospital's carbon footprint; treatment and disinfection of hazardous medical waste on site in accordance with relevant regulations).

Recycling of medical waste would consist in the use of a new organizational and premises infrastructure intended for this purpose. The components of this structure would be systems of waste shredders located directly at the organizational units (clinics), which would shred solid and liquid waste to the same fraction that could be moved through the existing sewage system. The liquid form would be decontaminated, and the main element would be a tank with anaerobic biodigestion features. As a result of fermentation processes, biogas would be obtained, which would then be used to heat water (in particular for space heating systems). Implementation of the system is possible in stages, which allows for precise monitoring of progress and costs of work. Similar systems are implemented in various healthcare facilities in Europe [65-67].

The use of waste processing technology in a large healthcare facility should bring a number of measurable benefits:

•        Enabling the implementation of a safer, simpler and more hygienic working practice, with simpler procedures related to the treatment and transport of waste in the hospital.

•        Decrease           risk of occurrence       cross infections.

•        Optimization of staff work efficiency.

•        Savings on sewage.

•        Purification and reuse of water in a hospital.

•        Savings on waste.

•        Processing and disinfection of all hazardous medical waste on site in accordance with applicable regulations.

•        Preventing the discharge of SARS-CoV-2 (COVID-19), antimicrobials, pharmaceuticals and all other healthcare-specific contaminants, micropollutants and pathogens in hospital wastewater into public infrastructure.

•        Reducing the hospital's carbon footprint.

•        Insuring the hospital against additional costs and requirements that may arise in the future.

The financial resources released in this way could be used for other purposes as part of managing the finances of the medical entity.

The recommendations presented above are of an evolutionary nature, in line with the health insurance system functioning in Poland. Although many critical comments on the construction and operation of insurance in the National Health Fund are justified, it is not recommended to return to the budgetary financing of health care, not only for organizational reasons (another cost-intensive institutional change without a substantively justified goal), but also because of concern for the stability of financing of health care in Poland[5]. The presented postulates are incremental. Their leitmotif is striving to increase the sustainability and resilience of the health care system by obtaining additional sources of revenue to finance the constantly growing health needs of the Polish society.

1.      Brundtland Commission (World Commission on Environment and Development). Our Common Future. Oxford: Oxford University Press, 1987. [Online] 14.04.2023. https://sustainabledevelopment.un.org/content/documents/5987our-common-future.pdf

2.      GUS. Rocznik Demograficzny 2022. Warszawa: GUS, 2022. [Online] 14.04.2023. https://stat.gov.pl/obszary-tematyczne/roczniki-statystyczne/roczniki-statystyczne/rocznik-demograficzny-2022,3,16.html

3.      Sowada Christoph. Łączenie solidaryzmu z wolnością w ubezpieczenia zdrowotnych. Warszawa: Wydawnictwo Naukowe Scholar, 2013.

4.      Sowada Christoph i Kowalska-Bobko Iwona. Sustainability of the Polish health care system. [in:] Baltagi Badi H. and Moscone Francesco [ed.]. Sustainability of health care systems in Europe. Bingley: Emerald Publishing Limited, 2021, pp. 117-137.

5.      GUS. Wydatki na ochronę zdrowia w latach 2019-2021, Warszawa: GUS, 2022. [Online] 14.04.2023. https://stat.gov.pl/obszary-tematyczne/zdrowie/zdrowie/wydatki-na-ochrone-zdrowia-w-latach-2019-2021,27,2.html

6.      Sowada Christoph. Starzenie się człowieka i starzenie się populacji. Podział odpowiedzialności za skutki finansowe w systemie opieki zdrowotnej. Zdr Publ Zarządz. 2011, t. 9, no. 1, pp. 86-100.

7.      Oberender Peter et al. Bayreuther Versichertenmodell. Bayreuth: P.C.O. Verlag, 2006.

8.      Björnberg Arne and Yung Phang Ann. Euro Health Consumer Index 2018. [Online] 14.04.2023. https://healthpowerhouse.com/media/EHCI-2018/EHCI-2018-report.pdf

9.      Sowada Christoph et al. Poland: Health system review. Health Systems in Transition. 2019, vol. 21, no. 1, pp. 1-235. [Online] 14.04.2023. https://eurohealthobservatory.who.int/publications/i/poland-health- system-review-2019

10.    Golinowska Stanisława et al. Co dalej z ochroną zdrowia w Polsce - stan i perspektywy. Zeszyty mBank - CASE, 2018, no. 156, pp. 7-50. [Online] 14.04.2023. https://www.case-research.eu/files/7id_plik=5724

11.    Javadinasab Hamideh et al. Comparing selected countries using sin tax policy in sustainable health financing: implications for developing countries. Int J Health Plann Manage. 2020, vol. 35, no. 1, pp. 68-78.

12.    US Department of Health, Education, and Welfare. Smoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service, Department of Health, Education and Welfare. Washington DC: US Government Printing Office, 1964. [Online] 14.04.2023. https://www.govinfo.gov/content/pkg/GPO-SMOKINGANDHEALTH/pdf/GPO- SMOKINGANDHEALTH.pdf

13.    Liu Franklin. Sin taxes: have governments gone too far in their efforts to monetize morality. Boston Coll Law Rev. 2018, vol. 59, no. 2, pp. 763-789.

14.    Perkins Rachelle H. Salience and sin: designing taxes in the new in era. Brigham Young Univ Law Rev. 2014, no. 1, pp. 143-184.

15.    Cashin Cheryl, Sparkes Susan, and Bloom Danielle. Earmarking for health: from theory to practice. Geneva: WHO, 2017. [Online] 14.04.2023. https://apps.who.int/iris/handle/10665/255004

16.    Mazurek-Chwiejczak Małgorzata. Polish ‘sugar fee' in the light of global experience with sugar sweetened beverages taxation. Ekonom Prawo. Econom Law. 2021, vol. 20, no. 2, pp. 287-303.

17.    WHO. Taxes on sugary drinks: why do           it.         WHO, 2017. [Online] 13.12.2022. https://apps.who.int/iris/bitstream/handle/10665/260253/WHO-NMH-PND-16.5Rev.1-eng.pdf;sequence=1.

18.    Ustawa z dnia 14 lutego 2020 r. o zmianie niektórych ustaw w związku z promocją prozdrowotnych wyborów konsumentów (Act of 14 February 2020 amending certain acts in connection with the promotion of health-promoting consumer choices). Journal of Laws 2020, item 1492.

19.    Bloom David E. et al. The global economic burden cf noncommunicable diseases. Geneva: World Economic Forum, 2011. [Online] 14.04.2023. https://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf

20.    Wykowski Jacek. Opłata cukrowa: wiemy, ile pieniędzy i na co przekazał NFZ. Puls Med. [Online] 13.12.2022. https://pulsmedycyny.pl/oplata-cukrowa-wiemy-ile-pieniedzy-i-na-co-przekazal-nfz-1148134

21.    Baltagi Badi H. i Goel Rajeev K. State tax changes and quasi-experimental price elasticities of U.S. cigarette demand: an update. J Econ Finance. 2004, vol. 28, no. 3, pp. 422-429.

22.    Dye Christopher, Reeder John C. and Terry Robert F. Research for universal health coverage. Sci Transl Med. 2013, vol. 5, no. 199, 199ed13.

23.    Haile Andrew J. Sin taxes. When the state becomes the sinner. Elon University Law Legal Studies Research Paper No. 2009-05 [Online] 14.04.2023. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1425621.

24.    Omran Abdel R. The epidemiological transition revisited thirty years later. World Health Statist Quart. 1998, vol. 53, no. 2-3-4, pp. 99-119.

25.    WHO. Noncommunicable diseases. [Online] 13.12.2022. https://www.who.int/health-topics/noncommunicable-diseases#tab=tab_1

26.    Wojtyniak Bogdan i Goryński Paweł [ed.]. Sytuacja zdrowotna ludności Polski i jej uwarunkowania. Warszawa: Narodowy Instytut Zdrowia Publicznego Państwowy Zakład Higieny, 2020.

27.    Schang Laura K., Czabanowska Katarzyna M. and Lin Vivian. Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland. Health Promot Int. 2012, vol. 27, no. 2, pp. 295-305.

28.    Mann Roberta F. Controlling the environmental costs of obesity. Environment Law. 2017, vol. 47, no. 3, pp. 695-739.

29.    Brzeziński Bogumił. Opodatkowanie niepożądanej społecznie konsumpcji. Wprowadzenie do tematyki. Kwart Prawa Podatk. 2021, no. 1, pp. 9-24.

30.    Duckett Stephen and Swerissen Hal. A sugary drinks tax: recovering the community costs of obesity. Carlton: Grattan Institute, 2016. [Online] 14.04.2023. https://grattan.edu.au/report/a-sugary- drinks-tax-recovering-the-community-costs/

31.    Duffey Kiyah J. et al. Food price and diet and health outcomes: 20 years of the CARDIA study. Arch Intern Med. 2010, vol. 170, no. 5, pp. 420-426.

32.    Włodarczyk Włodzimierz C. [ed.]. Systemy zdrowotne: zrozumieć system. Warszawa: PZWL, 2021.

33.    Maresso Anna et al. [ed.]. Economic crises, health systems and health in Europe. Country experience. Copenhagen: European Observatory on Health Systems and Politics, 2015. [Online] 14.04.2023. https://apps.who.int/iris/handle/10665/174010

34.    Zweifel Peter. The theory of social health insurance. Foundat Trends Microeconom. 2007, vol. 3, no. 3, pp. 183-273.

35.    Jeurissen Patrick and Maarse Hans. The market reform in Dutch health care. Copenhagen: European Observatory on Health Systems and Politics, 2021. [Online] 14.04.2023. https://eurohealthobservatory.who.int/publications/i/the-market-reform-in-dutch-health-care- results-lessons-and-prospects

36.    Kocher Gerhard and Oggier Willi. Gesundheitswesen Schweiz 2004-2006: eine aktuelle Übersicht. Bern: Huber, 2004.

37.    Sowada Christoph [ed.]. Ekonomika świadczeniodawców w sektorze ochrony zdrowia. Warszawa: PZWL, 2021.

38.    Błędowski Piotr. Lokalna polityka społeczna wobec ludzi starych. Warszawa: SGH, 2002.

39.    Więckowska Barbara. Ubezpieczenie pielęgnacyjne. Warszawa: SGH, 2008.

40.    Spasova Slavina et al. Challenges in long-term care in Europe - a study of national policies. Brussels: European Commission, 2018. [Online] 14.04.2023. https://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=8128&furtherPubs=yes

41.    Nagode Mateja and Lebar Lea. Trends and challenges in long-term care in Europe. Rev Soc Pol. 2019, vol. 26, no. 2, pp. 255-262.

42.    Sudo Kyoko et al. Japan's healthcare policy for the elderly through the concepts of self-help (Ji-jo), mutual aid (Go-jo), social solidarity care (Kyo-jo), and governmental care (Ko-jo). BioSci Trends. 2018, vol. 12, no. 1, pp. 7-11.

43.    Ilinca Stefania et al. European protection systems in the areas of childcare and long-term care: Good practices and lessons learned. Vienna: European Centre for Social Welfare Policy and Research, 2015. [Online] 14.04.2023. https://www.euro.centre.org/downloads/detail/1535

44.    Łuczak Paweł. Opieka długoterminowa w Polsce i w Republice Czeskiej. Poznań: Wydawnictwo Uniwersytetu Ekonomicznego, 2015.

45.    Ordinance of the Minister of Health of 9 February 2007 on the appointment of a Team for the development of a draft act on social care insurance. Official Journal of the Ministry of Health 2007, no. 3, item 7.

46.    Błędowski Piotr [ed.]. Opieka długoterminowa w Polsce dzisiaj i jutro: wydanie zaktualizowane i rozszerzone. Warszawa: Koalicja „Na pomoc niesamodzielnym”, 2020. [Online] 14.04.2023. https://niesamodzielnym.pl/uploads/RAPORT_OPIEKA_DLUGOTERMINOWA_2020.pdf

47.    Anttonen Anneli and Karsio Olli. Eldercare service redesign in Finland: deinstitutionalization of longterm care. J Social Serv Res. 2016, vol. 42, no. 2, pp. 151-166.

48.    Kolasa Katarzyna, Leśniowska Joanna and Borek Ewa. Współpłacenie pacjentów za świadczenia medyczne. Warszawa: Fundacja MY Pacjenci, 2018. [Online] 14.04.2023. https://mypacjenci.org/wp-content/uploads/2018/08/Wspolplacenie_pacjentow_za_swiadczenia_medyczne_ostateczna.pdf

49.    Juszczyk Grzegorz. Współpłacenie i prywatne ubezpieczenia zdrowotne w Słowenii. Służba Zdr. 2003, no. 77-80, pp. 25.

50.    Lenio Paweł. Źródła finansowania ochrony zdrowia w Polsce i w Niemczech. Praw Budżet Państw Samorząd. 2018, vol. 6, no. 1, pp. 53-73.

51.    Kolwitz Marcin. Polski system ochrony zdrowia - perspektywy i możliwości zastosowania systemów ochrony zdrowia innych państw Unii Europejskiej. Ann Acad Med Stetin. 2010, vol. 56, no. 3, pp. 131-143.

52.    Mucha Joanna. Jeszcze jeden pomysł na zreformowanie sektora opieki zdrowotnej - dopłaty do usług medycznych. Rocz Nauk Społ. 2007, vol. 35, no. 3, pp. 93-117.

53.    Franc Carine, Perronnin Marc and Pierre Aurelie. Private supplementary health insurance: retirees' demand. Geneva Pap Risk Insur Issues Pract. 2008, vol. 33, pp. 610-626.

54.    Grignon Michel, Perronnin Marc and Lavis John N. Does free complementary health insurance help the poor to access health care? Evidence from France. Health Econ. 2008, vol. 17, no. 2, pp. 203-219.

55.    Guthmuller Sophie, Jusot Florence and Wittwer Jerome. Improving takeup of health insurance program: a social experiment in France. J Human Resour. 2014, vol. 49, no. 1, pp. 167-194.

56.    Benoit Cyril and Coron Gael. Private health insurance in France: between Europeanization and collectivization. Milbank Q. 2019, vol. 97, no. 4, pp. 1108-1150.

57.    Wendt Claus. Social health insurance in Europe: basic concepts and new principles. J Health Polit Policy Law. 2019, vol. 44, no. 4, pp. 665-677.

58.    Wyszkowska Zofia. Ocena stopnia gotowości pacjentów do współpłacenia za świadczenia opieki zdrowotnej. Nierówności Społeczne a Wzrost Gospodarczy. 2020, no. 64 pp. 181-193.

59.    Pikoń Krzysztof and Dowlaszewicz A. Ekologiczne aspekty termicznego przekształcania odpadów medycznych. Arch Gosp Odpad Ochr Środ. 2008, vol. 7, pp. 29-42.

60.    Merkisz-Guranowska Agnieszka. Logistyka recyklingu odpadów, jako jeden z elementów Systemu Logistycznego Polski. Prace Nauk Politech Warsz Transport. 2010, n. 75, pp. 89-96.

61.    Rolewicz-Kalińska Anna. Odpady medyczne w liczbach. Recykling. 2009, no. 4, pp. 16-17.

62.    Łączny Jacek M. and Smuda Krystian. Możliwości pozyskania surowców wtórnych zawartych w odpadach komunalnych z obiektów służby zdrowia. Ochr Powietrza Probl Odpad. 2006, vol. 40, no. 3, pp. 97-105.

63.    Act of 14 December 2012 on waste. Journal of Laws 2013, item 21.

64.    Regulation of the Minister of Health of October 5, 2017 on the detailed method of handling medical waste. Journal of Laws 2017, item 1975.

65.    Batelaan MV. Evaluation report Pharmafilter: full scale demonstration in the Reinier de Graaf Gasthuis (Hospital) Delft. Amersfoort: STOWA, 2013. [Online] 14.04.2023. https://edepot.wur.nl/258343

66.    Paulus Gabriela K. et al. The impact of on-site hospital wastewater treatment on the downstream communal wastewater system in terms of antibiotics and antibiotic resistance genes. Int J Hyg Environ Health. 2019, vol. 222, no. 4, pp. 635-644.

67.    van der Hoek Peter Jan, de Fooij Heleen and Struker Andre. Wastewater as a resource: strategies to recover resources from Amsterdam's wastewater. Resources Conservation Recycling. 2016, vol. 113, pp. 53-64.

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