retrospective medical law: medical insurance in Prykarpattia During the second Polish republic’s rule (1919–1939)

The study based on archival, published historical documents and other available information sources highlights the activity of sickness funds that functioned in Ukraine on the territory of modern Prykarpattia during the period of Polish rule in 1919–1939 (the Second Polish Republic, in Polish: II Rzeczpospolita Polska ) as a prototype of health insurance. The analysis of these documents allows to deter - mine the peculiarities of the activity of these institutions in relations with society and the state, methods of financing, rights and obligations of the members of these organizations, specific features of the decision-making management, insurance cases and ways of compensation. The retrospective approach used in this study makes it possible to recreate the picture of the past in the field of health care in general and health insurance in particular, even with the lack of historical and legal sources of a certain historical period. Seeing the present through a peculiar prism of the past helps to dive into the inner life of the society with all its manifestations and ideas contributing to better understanding of modern social processes. In other words, the longer you look back, the further you see ahead.


introduction
Medical insurance is an institution of medical law as a complex field of law, which includes a set of legal norms regulating social relations in the field of medical activity.Medical insurance, the legal essence of which is the expansion of opportunities for the patient, is tangential to such phenomena as the provision of medical care, its quality and availability, methods of financing, as well as legal support and organization of health care.
In Ukraine, despite the existence of a significant number of laws, which are related to health insurance in one way or another ('On Insurance', dated 7 March 1996,  No. 85  ', dated 19 November 1992, No. 2801-XII), the Verkhovna Rada of Ukraine has not yet adopted a special law, the provisions of which would directly regulate public relations in the field of mandatory or voluntary health insurance.
For more than two decades, voluntary health insurance has been developing in Ukraine, which functions in the form of 'hospital funds', as public, non-profit organizations that unite individuals on a voluntary basis and common interests in accordance with the Law of Ukraine 'On Association of Citizens'.Hospital funds became one of the areas of reforming the health care system, which arose as a reaction of the population to the limited possibilities of state funding to ensure quality and affordable medical care.The purpose of their creation was and still is to attract funds from the population on a voluntary basis to provide members of hospital funds with medicines on the condition of providing outpatient care, treatment in hospital conditions, conducting diagnostic examinations etc.
The creation and operation of hospital funds is based on voluntary participation, equality of its members, self-management, legality, publicity and has a public character, which does not contradict their interaction with state authorities and does not deprive them of the right to receive state support.The activity of hospital funds is not aimed at making a profit, and all funds collected in the form of membership fees are spent on insurance payments and covering necessary expenses.
The continuous work of these voluntary associations demonstrates that at the current stage, hospital funds have become an alternative source of attracting extra-budgetary funds for providing medical assistance to the population, and the experience of their activity has practical value for the development of a modern health care system.
The purpose of the research is to find out the specifics of the activity of hospital funds that operated in Ukraine on the territory of modern Prykarpattia during the period of Polish rule in 1919-1939 (the Second Polish Republic, in Polish: II Rzeczpospolita Polska) based on archival, published historical documents and other available information sources as a prototype of health insurance.
The research used the following methods: historical, retrospective and generalizing.
The few scientific studies devoted to the historical aspects of the functioning of insurance medicine in Ukrainian lands in the past mainly relate to the problem of insurance of workers in the Soviet period or the times when certain Ukrainian ethnic lands were part of the Russian Empire.Scientific articles by Ukrainian researchers A. Garagashyan, 3 Ya.Radish, 4 I. Furtak, 5 L. Davybida,6 and R. Chornenko are devoted to some aspects of the formation of insurance medicine and the activity of hospital funds in the western Ukrainian lands. 7 A. Kotychenko's research is valuable, in which the daily life and peculiarities of work in the cash registers of sick Polish doctors in the interwar period are revealed through the diaries they wrote and submitted in 1936 to the competition of the Social Insurance Administration. 8 (1918-1939): Historical Aspect, [in:] L. Davybida (ed.), "Scientific Bulletin of Chernivtsi University.History.Political Sciences.International Relations" 2013, 676-677, pp.114-118, http  Voivodeship (1921-1939), [in:] R. Chornenkyi, Scientific and Cultural and Educational Local History Journal "Halychyna", 2012, pp.243

health insurance funds
Historically, the Western Ukrainian lands, in particular the Carpathians, were part of various states in the 20th century -Austria-Hungary, Poland (II Commonwealth), the Western Ukrainian People's Republic, the Ukrainian People's Republic, the Soviet Union, and under German occupation.Frequent changes in various socio--economic formations, complex socio-political conditions, the transition of Prykarpattia under the jurisdiction of one state or another significantly affected the nature of social relations in the region, including the provision of medical care.
Prykarpattia is a historical region in the west of Ukraine, the centre of which is the city of Ivano-Frankivsk.Until 1918, it was Stanisław -the Austrian version of Stanislau, until 1939 Stanislavi'v -the Polish version of Stanisławów.During the Soviet rule, the city again received the Austrian name of Stanislav, and in 1962, on the occasion of the 300th anniversary of its founding, it was renamed Ivano--Frankivsk. 9These lands have their own unique experience in the organization of power institutions, including the formation and development of health care, which was determined by the course of historical processes at that time.Frequent changes in various socio-economic formations, complex socio-political conditions, the transition of Prykarpattia under the jurisdiction of one state and another significantly affected the nature of social relations in the region, including the provision of medical assistance to the population of the region.
The first medical insurance institutions in the western Ukrainian lands -health insurance funds -appeared as early as in 1889, when Austria-Hungary began the transition to a system of compulsory medical insurance following Germany.In history, this system was called the 'Bismarck health care system' or insurance medicine.The main reason that prompted the government of the Austro-Hungarian Empire to resort to borrowing German insurance legislation was the need to attract additional financial infusions into the field of health care.The consequence of this step was an increase in the funds allocated for medical care at the expense of public funds, which were managed by the sick funds.The network of medical institutions began to expand at the expense of cash registers, in particular through the creation of new institutions that provided inpatient medical care. 10ubsequently, from 1919 to 1939, the Polish government also created its own health care system in subordinated Western Ukrainian lands, including Stanislaviv Voivodeship (present-day Carpathians), based on the legislation of the Austro--Hungarian Empire.The problem faced by the ministry was not only the lack of funds to provide all residents of the region with qualified medical care, but also the fact that these funds were allocated to the regions only for the fight against epidemics and in emergency situations.In order to attract additional financial infusions to the development of the health care system, it was decided to return to the practice of the existence of sick funds, whose activity was based on the use of insurance contributions to protect workers in case of accidents, illnesses or loss of working capacity.
At that time, more than a thousand health insurance funds (kasy chorych) operated in Poland, the legal regulation of which was determined by statutes and norms of private law, that is, there was no single and general system of social insurance.Such a state of affairs could not satisfy either the citizens or the state. 12he first Polish regulatory act that determined the creation and functioning of the hospital fund system was the decree 'On Universally Mandatory Health Insurance in Case of Illness' adopted on 11 January 1919 by the head of state Józef Piłsudski, based on the model of Austrian legislation. 13ubsequently, in order to attract additional financial infusions to the development of the health care system, on 19 May 1920, the parliament adopted the law 'On Social Insurance in Case of Illness', which approved the procedure for the creation and operation of health insurance funds in the form of sick funds, as a prototype of the insurance of medicine. 14ickness funds (city or county), which functioned even in Austrian times, had the right to continue their activities, provided that by the end of 1920 their own statutes were brought into compliance with the newly adopted law.In accordance with the statute, health insurance funds could acquire rights and obligations on their own behalf, had the right to sue in court and be a defendant in court, and were also legally responsible for all their property.The sickness fund had the right on the opening of its own units that were subordinate to it.the statute of the sick fund It is possible to find out the legal status of sick funds, that is, their position in legal reality, which is reflected in relations with society and the state, a set of rights and obligations, by analysing their founding documents, and in particular the main one of them is the statute.
In the State Archives of the Ivano-Frankivsk Region, among the documents stored there about the activities of the Stanislaviv Voivodeship 15 in general and individual counties in particular, there are statutes of the county sick funds of Dolyna, 16 Tlumach, 17 and Nadvirna, 18 the texts of which have become the subject of study.
The statute of the sick fund, which regulated the activity of the institution, as a typical document consisted of 10 sections, which in turn contained separate paragraphs -there were 113 of them.In particular: Section 1. Name and Location.Paragraphs 1-4.
Section 2. Terms of Membership.Paragraphs 5-17.This section included subdivisions that determined the procedures for voluntary and mandatory insurance, as well as entry and exit from the health insurance fund.Workers and members of their families and employers were necessarily involved in the health fund.During three days, the latter submitted information about hired and dismissed workers, their wages and family composition to the sick offices.
Membership in the health insurance fund was voluntary, subject to timely payment of membership fees.Necessary conditions for membership in the health insurance fund were also permanent residence in the area where the insurance fund is located, an age limit of up to 45 years at the time of insurance, an annual 15 State archive of Ivano-Frankivsk region: Guide, Vol.1: Funds of the Period until 1939, K., 2008, p. 257.16   State archive of Ivano-Frankivsk region, f. 2 'Stanislav Voivodeship Administration: Department of Labour, Guardianship and Health Care, 1921-1939', op. 4  Guardianship and Health Care, 1921-1939', op. 4, reference 24.Charter of the Nadvirnyan, Snyatyn, and Kalusa District Sick Funds, sheet 125.
206 oksana ya.soRoka, uliana v. khoMut income that did not exceed the maximum established amount, and a medical card attesting to good health.The grounds for termination of insurance were a person's statement or lack of insurance contributions within two months.
In this section, it was assumed that funds were deducted from the wages of employees of enterprises to the sick fund (the higher the salary, the higher the percentage of deductions), which were returned to him in the form of compensation during the loss of work capacity due to illness or when providing medical services.The duty to make deductions rested on employers and was collected monthly, which was 5% of the salary, of which 2% was contributed to the account of the sick fund by the worker and 3% by the employer.
Persons who were not engaged in wage labour could also voluntarily join this scheme, provided they paid their membership fees on time.
The insured person had his own personal insurance card 'certificate of a member of the sick fund' (a photograph is presented in Appendices 1.2 and 1.3).In these documents, the provided medical services and confirmation of payments to the members of the fund were recorded, which indicates the targeted direction of funds, as well as ensuring control over their use.
It was noted that health insurance funds could provide medical assistance to their members in case of their illness or the illness of someone from their family, including during childbirth, pay cash assistance to pregnant and nursing mothers, and pay for the burial of the deceased.
It was assumed that the main sources of funding for sick funds were deductions from enterprises and insured persons.Sickness funds had the right to attract funds from local authorities, patrons and various philanthropic societies.They had the right to make a profit and also to own their hospitals.Among such places in modern Prykarpattia is the health insurance fund for patients in the city of Stanislaviv (now Polyclinic No. 3, on I. Frank Street in the city of Ivano-Frankivsk), which mainly treated railway workers and their family members.Another institution the city bought from a private person is the so-called Doctor Gut's Sanatorium (phthisiopulmonary centre, located in 17 I.Frank Street in Ivano-Frankivsk), which was famous for its maternity ward and was the most fashionable maternity hospital in the city.Bookkeeping and reserve fund formation were regulated.The rules of financial discipline were also foreseen -it was not allowed to hide income, surpluses or shortages.The use of property and funds was allowed exclusively for the implementation of statutory activities.
The governing bodies ('power of the sick fund') were: the council, the board, the audit commission, the reconciliation commission, and the administration.The statute entered into force on the day of its approval by the local social insurance office in case of illness.

Functioning of hospital funds
A Carpathian researcher of the activities of hospital funds in Galicia (1919Galicia ( -1933), 20 ), 20 describes in his research that the funds were not subject to state authorities and had an autonomous status close to local self-government.Sick funds were managed by the interested party, that is, the employees themselves and their employers through the board of the funds, electing their representatives to it every three years.A third of the seats in the council belonged to representatives of employers, the rest to workers.Council members made important decisions related to the operation of the cash register, in particular, appointed its direct management: management, audit and peace commissions, and resolved financial and legal issues.Boards of sick funds consisted of 9-18 people elected for 3 years by secret ballot according to the same ratio between workers and their employers as the board.Elected members of the board did not receive any fees for their participation in the management, except for covering their own expenses for participation in the public life of the fund.The administration of the cash register, consisting of the 208 oksana ya.soRoka, uliana v. khoMut director of the cash register, the chief physician and a representative of the audit commission, also belonged to the board.The board carried out the general management of the treasury's affairs, hired and dismissed employees on the recommendation of the director, implemented decisions made by the treasury 's board.The audit commission was elected annually and consisted of five members and deputies.Her powers included monitoring the activities of the cash register and its employees, checking financial and official books, and preparing a report for the next meeting of the board.The conciliation commission consisted of five elected persons and was supposed to deal with disputes between the members of the fund and its board, as well as cases related to fines for patients' violations of regulations or simulation.The researcher notes that the charter of the sick fund did not regulate the issue of the rights of doctors, their participation in the decision-making process in terms of the medical activities of these institutions.The statute did not provide for any significant influence of doctors on management processes in health insurance funds, which significantly limited the possibility of them conducting private medical practice.This circumstance provoked hostile relations between doctors and officials.
In general, the introduction of the insurance system in the event of illness is not very positive consequences: workers got the opportunity to use qualified medical care, but it had a number of disadvantages.First of all, the bulk of the peasant population of the region remained outside its borders, which was unable to pay contributions to the treasury.Secondly, a bureaucratic apparatus was created in the field of health care with all its negative manifestations: delays in the payment of funds, red tape.
The biggest inconvenience was caused by the fact that a member of a specific health fund could not leave the boundaries of its territorial powers without the consent of a special commission and a doctor's certificate; otherwise, he risked losing his insurance.Often, this procedure became an insurmountable obstacle to travel to another area.A vivid illustration of the above is the testimony of Ivan Gerasimovych, a contemporary of those events: 'I will probably have to leave Lviv, having neither the appointment of a doctor nor the commission of the Health Insurance Fund, because the summer will pass before the Lviv Health Insurance Fund will be able to fix the whole situation for a Ukrainian.a labyrinth of foreseen and unforeseen bureaucratic hooks…'.RetRospective Medical law: Medical insuRance in pRykaRpattia… 209 Sickness funds were also often accused (mainly by the medical community) of underestimating the real costs of medical services and blackmailing medical institutions that provided medical care.
Another evidence of the above is a note saying 'Equality is the same everywhere' in the newspaper Svoboda from 24 March 1933, which was published by the organization Ukrainian People's Union in the United States of America, about the doctor of the district health fund in Nadvirnaya, Dmytro Selepei, who treated poor townspeople and Hutsuls from the surrounding villages free of charge and bought medicines for them with his own funds.'The other day, in the discussion -on the new law on social security -in the Polish Diet, it was said that the country's doctors have white crows in their cash registers.That this statement is not empty is evidenced by the following fact: one of the best installed cash registers belongs to the cash register in Nadvirnaya (now assigned as a department to Stanislavov).He worked there for 6 doctors until now -a single countryman, Dr Dmytro Selepei, who won the favour of all patients with his conscience, and for this he collected the lowest salary of all doctors (400 zlotys), when several doctors collected it at 700 and more.Even now, to our great surprise, we learn that since 1 April, Dr Selepei has been spending his hours in cash registers, like a lone doctor in Krainets, although there are a large number of dependents in the Nadvirnya cash register in Krainets.' 22he life trajectories of doctors and the problems they faced while working at the sick register were unique challenges in the everyday life of these people.As noted by A.A. Kotychenko, the working conditions of Polish doctors in the interwar period were not easy, which was caused by the economic crisis of the 1930s.First of all, the lack of material support, low level of awareness of the population, mistrust and contemptuous attitude of patients towards doctors, activities of healers and quack doctors were indicated.At the same time, insufficient wages and limited financial opportunities often forced doctors to buy the necessary things at their own expense.The psychological atmosphere of the doctor's work was also difficult, which manifested itself in the offensive or dishonest attitude of patients, daily risks, provocations from the local population or their stereotypical ideas about treatment, as well as fatigue or even exhaustion. 23hese and other problems of the functioning of hospital funds laid the foundations for the social insurance reform in March 1933, which consisted in the replacement of sick funds with insurance companies and the creation of the Social Insurance Institute as a regulator of the national insurance system.The leadership of 22 Note Equality is the same everywhere, "Svoboda newspaper", Part 68, March 31, 1933, https://www.svoboda-news.com/arxiv/pdf/1933/Svoboda-1933-068.pdf.(access: 3.01.2023).
210 oksana ya.soRoka, uliana v. khoMut the Polish state adopted the law 'On Social Insurance', which introduced insurance for cases of illness, maternity, loss of working capacity due to disability or death of the insured.According to this law, the newly created insurance companies were supposed to function on principles similar to those used by the health insurance funds, and the principles of their self-governance, independence, and organizational autonomy were formally observed. 24he culmination of the process of reforming insurance medicine in all of Poland, and in Galicia in particular, was the presidential order of 24 October 1934 on amendments to the law 'On Social Insurance', according to which a single department of social insurance (Zakład Ubezpieczeń Społecznych) was created.The adoption of this legal act completed the process of centralization and unification of social insurance in Poland. 25he newly created department immediately became an important part of the social policy of the state, the main task of which was to ensure social protection of the Polish population, organize educational and preventive measures for labour protection and public health, finance summer camps for children.hospitals, sanatoriums and health care facilities.
All these measures laid the foundation for the formation of the sphere of medical care for the population, but they did not bring tangible changes in the state of health care in the Stanislaviv Voivodeship.Both under the rule of Austria and later under the rule of Poland, Prykarpattia remained one of the most backward and medically understaffed provinces of these states.The existing medical insurance system, represented by the sickness funds, did not cover all segments of the population, but was available mainly to employees of enterprises and their family members.The high fee for medical services also did not contribute to the availability of medical care for the population of the region.

Conclusions
The research revealed that the Polish state (the Second Polish Republic) in 1919-1939 was gradually formed as a subject of legal relations in the field of social security of citizens, placing social responsibility on the workers themselves and their employers.Compared to other territories of Poland, Prykarpattia was a more agricultural region with a small number of workers in the industrial sector of the RetRospective Medical law: Medical insuRance in pRykaRpattia… 211 economy, and therefore sick funds, which were introduced as health insurance, were not widely used in this territory.
It has been established that the legal status of health insurance funds, i.e. their position in legal reality, is reflected in the founding documents, and in particular, the organization's charter.The analysis of these documents makes it possible to determine the peculiarities of the regulation of their activities in relations with society and the state , the set of rights and obligations of both the organization in general and its members in particular.
The historical experience of the activities of health insurance funds is not only of scientific interest, but will also have practical value for the construction of a modern health care system.Therefore, the existence of health insurance funds and the subsequent rejection of them in favour of insurance companies, as a prototype of medical insurance, require further comprehensive study.
The vision of the present through a peculiar prism of the past will contribute to a better understanding of modern social processes, will help to better evaluate the implementation of state programs for medical care of the population in general and medical insurance in particular.
The obtained results can be used in the future during the development of draft laws that directly regulate social relations in the field of voluntary health insurance, as well as for the preparation of monographic studies, general works, textbooks and study guides on the history of medical law of Ukraine and Poland, the socio--cultural history of the countries of Eastern Europe.

3
Y.A. Garagash, The Heyday of Health Care in the Soviet Carpathian Region, [in:] A.A. Garagashyan, Paraschak P.V.-K.(eds.),Health, 1972, p. 139. 4 I. Radish, Medical Insurance: educational manual, Publishing House of NADU, 2005, p. 88. 5 I. Furtak, Historical Aspects of State Management of the Implementation of Insurance Medicine in Ukraine, [in:] I. Furtak, Effectiveness of State Management.Coll. of science Ave. of the Lviv Regional Institute of Public Administration of the National Academy of Public Administration under the President of Ukraine, 2010, Iss. 25, p. 71.6 L. Davybida, Implementation of Elements of Insurance Medicine in Galicia in the Interwar Period
17 18 State archive of Ivano-Frankivsk region, f. 2 'Stanislav Voivodeship Administration: Department of Labour, Features of the activities of the management bodies of sick funds are presented in Appendix 1.4.Section 8. Final Provisions.Paragraphs 110-111.Section 9. State Supervision.Paragraph 112.Control over statutory activities was carried out in accordance with the procedure defined by the law "On Social Insurance in Case of Illness' dated 19 May 1920.