Women living in the countryside had difficult access to outpatient gynecological and obstetric services financed from public funds – warns the Supreme Audit Office. Although the standards of perinatal care are clearly set, some gynecological clinics have problems with complying with them. Not all pregnant women have undergone the full range of tests recommended by the standards of perinatal care. There are still clinics that do not guarantee patients the right to intimacy.
- The data of the National Health Fund at the end of 2016 show that in many rural communes there were no gynecology and obstetrics clinics at all
- In the controlled voivodeships, rural residents were not provided with equal access to outpatient gynecological and obstetric services financed from public funds
- The findings of the inspection also indicate that the standards of perinatal care were not fully complied with by the medical staff of the inspected medical entities.
- Every fourth gynecological clinic did not provide patients with conditions for intimacy while providing medical services
The audit covered:
- eight Provincial Branches of the National Health Fund,
- 27 village counseling centers.
from the following voivodeships: Lubelskie, Łódzkie, Opolskie, Podkarpackie, Podlasie, Warmińsko-Mazurskie, Wielkopolskie and Zachodniopomorskie.
In the controlled voivodships, rural residents were not provided with equal access to outpatient gynecological and obstetric services financed from public funds. Outpatient clinics located in rural communes accounted for a negligible percentage of all such clinics, although approx. 40% live there. women and newborns. As a result, in the Podlaskie and Lubelskie voivodships, there were even 27 gynecological clinics in the countryside. women who, in extreme cases, were 50 km to the clinic.
The small number of clinics in rural communes in the Podlaskie and Lubelskie voivodships was justified by the National Health Fund by the lack of people willing to provide services. In 2016-2017, services were generally provided by entities selected by the NFZ OW during competitions conducted five – seven years earlier (2010-2011), including, for example, 67 out of 79 gynecological and obstetric practices registered in 2017 in voiv. Podlasie. According to the Supreme Audit Office, announcing competition procedures in subsequent years could be an impulse for service providers to apply for a contract with the National Health Fund or to create new clinics to provide services under a contract with the National Health Fund.
The Supreme Audit Office notes that the availability of gynecological and obstetric services may be supplemented by midwives’ offices operating within primary healthcare (POZ). However, in the Podlaskie Voivodeship, which is the voivodeship with the smallest number of obstetrics and gynecology clinics in rural communes, no medical entity signed a contract with the National Health Fund (until the end of 2017) for the care of a midwife over a pregnant woman. The reason is the amount of the rate proposed by the National Health Fund, which does not cover the costs of performing the necessary services. Improving the availability of gynecological and obstetric experiences in rural areas would be facilitated by setting the rate for services in the amount adequate to the costs of consultations and tests recommended by the standards of perinatal care. This will be a significant incentive not to limit the scope of services, to create more gynecological offices in these areas and to conduct pregnancy by midwives themselves.
In voivodships with a small number of rural clinics, in 2016 the highest rate of perinatal deaths was recorded – 33,64 / 100 thousand. births in the province Opolskie and 23,28 / 100 thousand. births in the province Podlasie. The situation in voivodships with a greater number of clinics was much better in this respect. In the province Podkarpackie, this ratio was 5,41 per 100 thousand. births, and in the province. Greater Poland 3,36 per 100 thousand births.
As revealed by the NIK auditors, in 17 inspected medical entities (63%), in accordance with the contracts with the National Health Fund, gynecological and obstetric services were provided only for 10 to 13 hours a week. In three entities (out of 27 audited) some services (ultrasound and CTG) were ordered from subcontractors located at a considerable distance from the clinic. For pregnant women, traveling long distances to perform basic research is particularly troublesome.
The different elements of medical care aimed at achieving the good health of the mother and child are set out in the standards of perinatal care. They list the recommended preventive services and activities in the field of health promotion as well as diagnostic tests and medical consultations during pregnancy, along with the period of their performance – from the 10th week of pregnancy to its termination.
The findings of the inspection also indicate that the standards of perinatal care were not fully complied with by the medical staff of the inspected medical entities. Only 22 patients (out of 1.132) whose medical records were analyzed by the Supreme Audit Office (NIK), had all 42 health services recommended by the standards of perinatal care performed and documented.
In 19 clinics (70,4% of the audited ones), none of the patients underwent a complete set of these services, and in three others there was no evidence confirming their performance. According to the doctors’ explanations, this was due to the overlooked or excess of the recommended services in relation to the needs resulting from the course of pregnancy. The package of services recommended by standards of perinatal care is the necessary minimum that should be performed during pregnancy and does not differ from those recommended in other European countries.
The limitations in commissioning tests to patients may be influenced by the amount of the pregnancy rate set in the contracts with the National Health Fund, which did not cover the costs of services resulting from the standards of perinatal care and the willingness to save on performing or ordering medical services. For example, the price of one of the drugs recommended for pregnant women was about PLN 400, while the National Health Fund paid medical entities three times as much, but for at least eight visits, during which 42 health services were to be performed.
In as many as 18 inspected medical entities, almost half of the patients were not educated in the field of practical and theoretical preparation for childbirth, puerperium, breastfeeding and parenthood, although it should be done during each visit, starting from the 21st week of pregnancy until its termination. The results of numerous scientific studies and publications – WHO, UNICEF, the American Academy of Pediatrics, scientific societies – indicate the superiority of mother’s milk over artificial mixtures based on cow’s milk. Future mothers should therefore have this information and be properly prepared to breastfeed their newborns.
NIK also points out that, due to the small number of clinics in small towns, the access of female residents of rural areas to the cervical cancer preventive health program was also limited. In all clinics contracted by the NFZ controlled by the IW, 2016 women in the province had cytology performed in 28.464. Podkarpackie to 120.956 in the province. Greater Poland, which constituted from 5,4 percent. up to 13,8 percent all female residents of these voivodships aged 25 to 59. The lowest percentage of cytologies performed on the inhabitants of rural communes was found in the voivodship Opole (0,4 percent), and the highest – 10,6 percent. in the province Podlasie. The situation in this respect could be improved by primary health care midwives, who can perform this test on their own from 1 January 2014. However, so far, they have practically not provided these services – the number of POZ clinics where midwives perform this examination under the contract with the National Health Fund is from two in the voivodeship. Zachodniopomorskie to 15 in the province. Lublin.
At the same time, NIK notes that the cytology rate was much better among women who came to the inspected gynecology and obstetrics clinics. In 2016, for reasons other than pregnancy, 23.135 women were admitted to them, which constituted 22,2% of the inhabitants of the communes over 18 years of age in which these clinics were located. Pap tests were performed on all patients randomly selected during the control in 16 patients, who in 2016-2017 visited the controlled clinics for reasons other than pregnancy. In the remaining 11 clinics, these tests were not performed or documented in 131 patients (9,7% out of 1.350 randomly selected in the inspected units).
Performing cytological tests (at least once every three years – according to the regulation of the Minister of Health on health programs) to patients who come to the clinic also for reasons other than pregnancy, indicates the legitimacy of spreading information among women about the need to undergo this examination, which is the most effective method early detection of cervical tumors. In 18, only every fifth woman over 2016 years of age residing in rural communes where the controlled clinics were located, consulted a gynecologist in XNUMX.
As revealed by the auditors of the Supreme Audit Office, every fourth gynecological clinic did not provide patients with conditions for intimacy while providing medical services. The places where services were provided were not properly shielded from outsiders when the door to the office was opened.
NIK conclusions
Due to the nature and scale of the disclosed irregularities, in particular concerning the restriction of the right of women living in rural areas to equal access to outpatient gynecological and obstetric services financed from public funds, the Supreme Audit Office requests that Minister of Health o:
- introducing in the regulation of 26 June 2012 on the detailed requirements to be met by the premises and equipment of the entity performing medical activities, regulations guaranteeing patients’ right to intimacy and dignity in examination rooms,
- using various information channels, appropriate for age groups, including social media, to conduct campaigns promoting preventive gynecological examinations as the most effective method of early detection of cervical and breast cancer,
- conducting a campaign informing women about the benefits due to them during pregnancy, resulting from the standards of perinatal care,
- with the participation of the Agency for Health Technology Assessment and Tariff System, to establish the tariff of obstetric and gynecological certificates adequate to their scope provided for in the standards of perinatal care.
- contracting outpatient gynecological and obstetric services in rural areas for the area smaller than the poviat,
- carrying out inspections of medical entities in terms of the correctness and implementation of health services recommended by the standards of perinatal care (the application is also addressed to provincial consultants in the field of obstetrics and gynecology).
- enforcing from medical personnel the performance of services recommended by the standards of perinatal care and proper keeping of medical records,
- ensuring conditions for a dignified and intimate provision of health services.