Discussion Papers 1988.
Spatial Organization and Regional Development 207-219. p.
2 07
Ludwik MAZURKIEWICZ
SPATIAL ORGANIZATION OF THE HEALTH CARE SYSTEM
IN POLAND
In contemporary human geography, great at-
tention has focussed recently upon a multicontext
problem of human wellbeing, Among factors deter-
mining the well-being or welfare status of the
population living in a given territory, the factors
related to the health of the population play an im-
portant role. The discipline concerning them is
medical geography, which in general deals with spa-
tial aspects of health and health care delivery.
Medical geography, well developed in other countries,
is still almost unknown and practically not applied
in Poland.
In 1986, a research program was established
under the title "Spatial determinants of socio-
economic development of Poland" and the Institute
of Geography and Spatial Organization of the Polish
Academy of Sciences is responsible for coordinating
and conducting the program. As its part, studies
concerning typical problems of medical geography
have been initiated in the form of a research sub-
program entitled "Spatial determinants of popula-
tion health and modelling an optimal spatial struc-
ture of the health care system".
In this paper, some preliminary results of
the first stage of the above mentioned studies are
presented. The results deal with the spatial organi-
zation of the system of health care services at the
scale of the territory of Poland. To recognize all

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
aspects of this organization, proper data are needed,
which are spread, however, among many offices and
institutions and, as usually in such a situation,
substantial difficulties have been encountered to
collect the information required. The process of
data collecting is now in progress, but not all the
necessary empirical material is gathered as yet.
This is the main reason that only a fragmentary
picture of the spatial structure of the health care
system can be presented in this paper,
The health care delivery system in Poland is
composed of all health institutions within the Na-
tional Health Service, which serves approximately
37  million people. These institutions were called
into being by legal acts of  1973,  when health in-
stitutions were put together; and of  1975,  when
welfare facilities were added. Establishing new or-
ganizational form of health care was part of a wider
program of reorganizing the whole administrative
structure of the state. A spatial aspect of this ad-
ministrative reform was to divide the territory of
the country into 49 voivodship regions replacing the
old partition including 22 units.
All the health institutions within the National
Health Service, except the supraregional viovidship
health care and special health services, are laid
down and administered by the voivodship authorities.
This falls into autonomous liabilities of voivodships
and their administrative authorities, The other
health institutions within the National Health Ser-
vice are founded by the Minister of Health.
The health care system in Poland, as a com-
plex socio-economic system covering the whole ter-
ritory of the country, is hierarchical in its

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
structure. Three hierarchical levels /tiers/ con-
stitute the structure of this system. The lowest
tier is that of primary care.
The most common and typical institutions in
the first level of the health care system are Local
Health Care Complexes /in Polish abbreviation -
ZOZ's/. Local Health Care Complexes /LHCC's/ were
founded in 1973 to ensure integral health care for
the district population. A district was at that
time an intermediary unit between the province and
the comune. When LHCCs arose, there were 392 dis-
tricts with an average of 85000 inhabitants each.
The 1975 administrative reform abolished districts.
LHCC lost support at that administrative authority
level maintaining, however, their tasks and activity
areas.
The LHCC is designed to provide a full range
of medical services. Included are such services as:
- primary health care with social welfare
provided at the domicile;
- hospital services;
- specialist out-patient services;
- first aid;
- diagnostic laboratory and other services;
- institutional care of infants and the
elderly.
Those services are subject to common management and
are financed from the same budget. As single-handed
institutions, LHCCs carry on such tasks as: person-
nel policy planning, laying-out the development of
institutions and facilities, cost planning, and
maintenance and repair of facilities and equipment.

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
210
In 1983 there were 404 Local Health Care Complexes
in Poland serving approximately  37  million popula-
tion, which gave the average of 91,500 inhabitants
per one LHCC.
The spatial distribution of LHCCs and their
sizes measured in number of population served is
presented in  Figure 1.
There are distinguished six
classes of sizes, which range from almost 17,000
to nearly 400,000 population. Four LHCCs serve a
population larger than 300,000, and 22 LHCCs a po-
pulation larger than 200,000 in each case. The
first ten largest LHCCs are: Szczecin /399,670/,
Katowice /381,336/, Lublin /320,200/, Kielce
/314,000/, Praga Pld., one of seven districts of
Warsaw, /287,900/, Nowa Huta /270,000/, Rzesz6w
/260,000/, Krowodrza, part of KrakOw city, /260,000/,
Sosnowiec /258,000/ and Radom /250,000/, In Warsaw
there are 11 LHCCs. Their sizes have been summarized
and presented in Figure 1 in the form of  7  larger
units corresponding to the main administrative dis-
tricts into which the city is divided.
On the other hand, the smallest LHCCs are
Miedzych6d in Gorz6w voivodship, /16,878/, Pionki
and Nowe Miasto, both in Radom voivodship, /18,000/,
and Chelmza, Torun voivodship, /20,000/. In Figure
1, the average size of LHCC typical of this region
also is attached to each voivodship. As may be seen
from the Figure, the smallest average size LHCCs
are in Gorz6w voivodship /43,1/, Suvalki  /48,6/,
Pila /56,0/, and Olsztyn /58,9/: while the largest
ones are in KrakOw voivodship /191,7/, Wroclaw
/154,9/, L6dz /145,7/ and Bielsko Biala /142,51;
all numbers in brackets are in thousands.

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
211
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FIGURE 1
The distribution and sizes of 404 Local Health
Care Complexes in Poland

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
212
Apart from LHCCs, primary health care also
includes health institutions dealing exclusively
with the health care of workers employed in areas
that actually overlap areas of the LHCCs activi-
ties. These institutions, termed Industrial Health
Complexes/IHC/, are established in highly industri-
alized areas with a great number of workers. They
provide primary health care activities and a vast
range of ambulatory services; in certain areas
hospital treatment is also provided, but not social
services
The second level in the health care system
hierarchy consists of institutions covering by
their services the population of particular voivod-
ships. The idea of integration applied at the re-
gional level gave rise to the concept of Integrated
Voivodship Hospitals /IVH/. An Integrated Voivod-
ship Hospital performs not only specialist medical
functions, but also developmental and manpower
tasks, In compliance with regulations, the IV Hos-
pitals should involve:
- health related tasks: inpatient services,
ambulatory specialist services, and emergency ser-
vices;
- developmental and staff functions: organi-
zation of medical personnel training for regional
centres, development of social welfare, planning
and programming of activities;
- auxiliary tasks: administrative, economic
and technical tasks, personal policy and social
services.
Integrated Voivodships Hospitals have been
established mainly in newly created voivodships.

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
213
This is shown in Figure 2 where locations of hos-
pitals are underlined when they are situated in
new regions. Few of these regions do not set up
a IVH and instead organize Voivodship Hospitals.
In the case of new voivodships, these hos-
pitals do not carry on specialized functions. But
at the same time specialized services are provided
by Voivodship Hospitals localized in "old" voivod-
ships, that is, in regions remaining as fragments
of those existing before the administrative reform.
On Figure 2, these hospitals are mostly in cities
whose names are not underlined. As compared with
hospitals created in new regions, the Voivodship
Hosipitals in the old voivodships, by reason of
longer treatment traditions, are better equiped,
their personnel is much better trained, and they
provide a larger range of specialized functions.
Thus two kinds of institutions constitute the second
level in the health care system hierarchy - Voivod-
ship Hospitals and Integrated Voivodship Hospitals -
excluding some specialized wards in the case of the
latter hospitals as well as in the case of Voivod-
ship Hospitals, when they are situated in old voi-
vodships.
The third level of the health care system
in Poland is the supraregional tier, constituted
of numerous "narrow" specialities provided by cer-
tain wards of Voivodship Hospitals, Medical Acad-
emies hospitals, and medical research institutes.
As examples of specialized wards in Voivodship Hos-
pitals, the dialysis centres and oncological clin-
ics are presented on Figure 3
and Figure 4
respecti-
vely.

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
214
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+ Voivodship Hospitals
Dots represent locations of LHCCs.
FIGURE 2
The distribution of the Voivodship Hospitals
in Poland

•
▪
Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
216
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Source: Dziennik Urzedowy MZiOS, 1975, 18.
FIGURE  4
Location of oncological hospitals in Poland
in relation to areas they serve.

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
21_7.
In Figure 3, locations of 25 dialysis centres
and their catchment areas are shown. A national
average is almost extly one centre per two voivod-
ships. This proportion varies and so, on the one
hand, there are centres serving three voivodships
each, like Katowice, Szczecin, Bydgoszcz, Bialystok,
and Warszawa; while on the other hand, some voivod-
ships have their own dialysis centres, for example:
Plock, Pila, Konin, Slupsk, Kielce, and Radom.
On Figure 4, the spatial distribution of 16
oncological clinics and wards is presented. In this
case, the country average is one clinic per three
voivodships. As may be seen from Figure 4, dispari-
ties in the sizes of areas being served are quite
large. The largest catchment areas have Warszawa and
Lodz, six and five voivodships to be served respecti-
vely, and the smallest areas of influence are in the
case of Katowice and Czestochowa as well as Olsztyn
and Bialystok, Spatial organization of oncological
treatment services is such that patients living
anywhere in a given set of voivodships are served
by two oncological centres excluding the areas of
influence of Warszawa, LOdz, Lublin, and Szczecin
clinics.
Medical Academies, due to a 1982 regulation,
act singlehandedly, independent of both the Minister
of Health and administrative authorities. The range
of services provided is subject to an agreement be-
tween the Medical Academy and administrative author-
ities of several ndghbouring voivodships. In Poland
there are several Medical Academies, eleven each
covering the population of 4-6 voivodships. Figure 5
shows the distribution of Academies andthestzeor( lrea
under their influence, The largest catchment areas

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
218
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The catchment area composed of two separate parts is
hatched. Dots represent locations of LHCCs.
Sources Dziennik Urzedowy MZiOS, 1975, 18.
FIGURE 5 Location and catchment areas of Medical
Academies in Poland.

Ludwik Mazurkiewicz : Spatial Organzation of the Health Care System in Poland. In : Spatial Organization and Region Development.
Pécs,Centre for Regional Studies, 1988. 207-219. p. Discussion Papers, Spatial Organization and Regional Development
219
are related to Medical Academies in Krak6w, which
serves 8 voivodships and Warsaw and Poznan - 6 voi-
vodships each; while the smallest areas are con-
nected with Medical Academies of Bydgoszcz, Katowice,
Szczecin, and Gdansk.
Medical research institutes are designed to
carry out studies, render specialist services,
whether ambulatory or hospitals, organize post-
graduate training, and supervise medical quality.
The areas of their activity cover in practice the
territory of the whole country.