No Country for Sick Men: The Political Determinants of Health Policy in Poland

Abstract

Context: The objective of this article is to explain the political factors determining the relatively weak performance of the Polish health care (HC) sector. This can be treated as a critical case for several reasons. First, the Poles are among the most unsatisfied patients in the European Union, with one of the lowest life expectancy levels. Second, Poland spends one of the lowest shares of gross domestic product on HC-related expenditures among OECD countries. Third, the country is facing medical personnel shortages.

Methods: The analysis is based on the mixed-methods approach. The authors rely on quantitative data outsourced from a survey, which is supplemented by the semistructured, in-depth interviews with selected key HC stakeholders representing patients' advocacy groups, medical personnel organizations, and high-level decision-makers.

Findings: The Polish HC system remains weak due to the postcommunist legacy in terms of organization, a short-term approach by politicians, and weak decision-making processes.

Conclusions: The HC policy inertia in Poland is determined by a group of interrelated political factors that effectively block the development of any positive reform.

Although there is no ideal health care system, among the European nations it is the Polish patients who are among the most dissatisfied with the quality and efficiency of the health care (HC) system. Many sources confirm that this is not a country where sick people receive high-quality health services. According to the Euro Health Consumer Index, which assesses the performance of national HC systems in 35 countries, Poland comes in fourth-to-last place (HCP 2019). A survey conducted by CBOS Research (2018) shows that 66% of Poles assess the functioning of health care in Poland negatively. The worst-reported aspects of health care functioning include the availability of visits to specialists (83% negative reviews) and the insufficient number of medical personnel in hospitals (70% negative). Also, the Supreme Audit Office (2019) analyzing the functioning of the Polish HC system concluded that it is not patient-friendly, does not ensure the effective use of public funds, and creates problems for the heads of medical facilities and the staff employed in them.

The objective of this article is to explore and explain the political factors that have led to the weakness of the Polish HC system. This can be treated as a critical case for several reasons. First, as indicated, the Poles are among the most unsatisfied patients in the European Union. Second, among countries in the Organization for Economic Cooperation and Development (OECD), Poland spends one of the lowest shares of gross domestic product (GDP) on its HC-related public expenditures (OECD Health at a Glance 2022). Third, the number of doctors per 1,000 inhabitants remains at the lowest European level (OECD 2022). Last but not least, the health of Poles is worse than the average for the general population, and life expectancy in Poland is one of the lowest in the European Union (EU) and is decreasing. This trend had already started before the COVID-19 pandemic; during 2019–2021 Poland recorded a 2.4-year decrease in estimated life expectancy (OECD 2022).

New institutionalism, especially in its historical variant, adds substantial value to exploring the dynamics and logic of change and continuity that take place in HC policy. The transformations of HC system reforms represent a mix of change and continuity, which is a challenge for the entire theoretical family of institutionalism. The case of HC policy offers a particularly fruitful ground enabling analysts to see the policy process in the context of interconnectedness between the state and the political arena, and the complex structures of organizations and interests within the HC sector. This article is rooted in the path-dependency approach, as it describes the political determinants of HC policy inertia in Poland as mainly rooted in the nation's postcommunist legacy. According to the path-dependency principle, the development of certain processes depends on their historical formation, and institutional transformations are analogously conditioned by events that took place in the past (North 1990). By explaining these relationships, the article contributes to the understanding of the state of Polish HC policy today and political determinants of health in central and eastern Europe.

This article proceeds as follows: after this short introduction, we position our study in the growing body of literature dedicated to exploring the political determinants of HC. Then we provide a synthetic methodological background. Consequently, we move to the political determinants of HC policy in the Polish context. First and foremost, we focus on poor system funding and overambitious constitutional constraints—promising universal, equal, publicly provided, and state-financed HC—that limit policy options. Moreover, we highlight that part of the problem is related to short-term policy making that is unable to accomplish the strategic planning and long-term reforms that are required in the HC domain. Electoral politics is another crucial determinant that explains the lack of action in Polish HC policy. Any reform attempt would require an increase of social contribution or reforming the HC insurance scheme in Poland, which is unacceptable for the electoral bases of the largest ruling parties. Yet another outcome of the postcommunist legacy is a weak civil society that cannot mobilize any constructive action toward a systemic policy reform in the HC sector. To capture the big picture, our research is based on a mixed-methods design. We conclude with a short summary emphasizing how our study contributes to a better understanding of HC policy inertia in the largest state of the European Union's eastern periphery.

Political Determinants of Health as an Evolving Subfield

In the past years, the political-institutional perspective has gained increasing attention among scholars interested in understanding the development of HC systems (Immergut et al. 2021; Popic 2021b). This trend has been even more accelerated in the face of pandemic-related developments. The academic and public discourse around COVID-19 has brought the challenges at the interface (or overlap) between health and public policy into unprecedented sharp focus. Scholars try to explain the connections between political science and public health via various dimensions. Fafarad, Cassola, and Weldon (2022) propose a typology of the possible interactions between political science and public health, the ideal model of which is cooperation of both disciplines.

The scope and depth of this debate are still growing. It embraces many dimensions from party politics, organized interests, and legal-institutional setup (Dobbins, Piotrowska, and Riedel 2021), through policy ideas and public opinion and up to budgetary constraints, resource allocation, and governmental reactions to the pandemic (Popic and Moise 2022).

The wave of neoliberal policies—not exclusively on postcommunist territory—brought about changes in many spheres of life, including HC systems. Translation of these policies into the HC sector created a new policy environment that emphasized the need to reduce public authorities’ responsibility for the health of populations, privatization, and marketization of medical care as well as reforms to the insurance-based system. However, counterintuitively, and contrary to neoliberal claims, there has been no reduction in the public sector in most OECD countries. In most states, public spending (relative to GDP) has grown (Navarro 2009).

In the case of the postcommunist states, one of the fundamental determinants affecting the shape of the HC systems was, and to some extent still is, the historical legacy. The democratic revolutions did not change many of the path dependencies, not only in the sense of institutional continuity but also with regard to societal expectations about welfare. This is visible in the case of some countries’ HC systems and the citizens’ expectations toward them. Despite the post-1989 reforms undertaken very much in the neoliberal spirit, the postcommunist path dependencies still hold strong in various dimensions. Poland is an illustrative example of this.

Other scholars are interested in less structural determinants of HC policy, focusing on the so-called soft factors affecting the condition, shape, and evolution of HC systems. For example, in the 1990s Hugh F. Lena and Bruce London measured the specific parameters of regime ideology, state strength, multinational corporate penetration, and position in international relations and how they impact population health (Lena and London 1993). They concluded that high levels of democracy and strong left-wing regimes are associated with positive health outcomes, whereas strong right-wing regimes have populations with lower life expectancies and higher levels of various measures of mortality. Such findings support the thesis that political systems and their specific elements make a difference in health and well-being.

In more recent studies, party politics comes back to the core of the research agenda. This is because party system consolidation is one of the crucial factors determining welfare reforms (Popic 2021b), including the HC system. Again, apart from hard, institutional factors, the soft factors—such as the quality of political culture and debate—play a decisive role in the political decision-making process.

Tamara Popic's findings (2021b, 2023) created a useful analytical framework for examining political determinants of HC policies, which addressed two fundamental dimensions. The first dimension concerns the impact of political competition, institutions, and ideas. The second dimension concerns attitudes toward HC, particularly how these attitudes are shaped by policy feedback effects such as political ideology. According to Popic, the diversity of postcommunist health policy trajectories reflects differences in policy learning processes, which are dependent on prevailing ideas and are shaped by historical, institutional, and political factors.

Building on Popic's (2021a, 2023) explanations of political factors determining variations in HC policy-making trajectories across central and eastern European states, we add to this picture some elements that have played an important role in the processes shaping HC policy in Poland.

Note on Methods

This analysis is based on the mixed-methods approach. First, the authors rely on quantitative data outsourced from a survey as well as desk research results. The data is supplemented by the qualitative data gathered in semistructured, in-depth interviews with selected key HC stakeholders representing patients’ advocacy groups, medical personnel organizations, and high-level decision-makers.

The authors are using data from a large-scale online survey conducted in 2019/2020 among a representative sample of organized interests operating in HC politics. The research was conducted as a part of the research project “The ‘Missing Link’: Examining Organized Interests in Postcommunist Policy-Making” at the University of Konstanz, Germany, and the University of Opole, Poland, funded by the Beethoven 2—Polish-German Funding Initiative of the Deutsche Forschungsgemeinschaft and the Narodowe Centrum Nauki. The questionnaire was designed and administered so as to obtain reliable and credible results.

There were three types of respondents: employee organizations, employer organizations, and patient organizations. The largest sample was represented by the latter. Only nationwide organizations were selected for the survey. The online questionnaire consisted of three large building blocks of questions addressing various dimensions of their functioning, environment, and relations with political stakeholders. The survey was scheduled to take approximately 15–20 minutes to complete. For this study, the authors have chosen only one issue related to the access of various groups of stakeholders to the four types of HC decision-makers and other political bodies in Poland: regulatory authorities, governing parties, opposition parties, and parliaments. Respondents (N = 46) were asked to subjectively rate their ability to access these bodies. The analyzed variable was “access” measured on a Likert scale of 1 to 5, with 1 being no access or extreme difficulty in access, and 5 being full access or very easy access. Then the authors administered the survey in 2022 to the same group of respondents, examining if and to what extent this access had changed during the COVID-19 pandemic. Because of the relatively small number of responses of the repeated survey (N = 21) and to make a comparison, the responses have been aggregated, without taking into account the results of individual interest groups. Again, this material was supplemented by additional interviews (N = 15) conducted with HC sector stakeholders, including decision-makers, opinion leaders, labor unionists, representatives of the medical professions, patients’ advocacy organizations, and others (see the list of informants at the end of the reference list).

No Country for Sick Men

HC systems around the world are in a constant state of flux (Cichon 1991) and permanent reform. However, in Poland it is hard to observe the changes of those schemes without a déjà vu feeling. The evolutionary trajectory of the Polish HC system follows the general trends defined by political tendencies, repeated at least twice in the last three decades: from a highly bureaucratic Semashko-like system inherited after the communist period, to more Bismarckian organizational changes with some attempts at decentralization and commercialization, up to recent recentralization tendencies together with a hidden privatization of HC under Law and Justice Party governance of the past few years (Szescilo 2017).

The neverending reforms of the HC provision system have not resulted in any substantial qualitative change. Under communism, Polish HC, like HC in other Eastern Bloc countries, relied on a centrally planned “Semashko” system that at least formally guaranteed universal and free medical services for all citizens, with no private-sector involvement. After the transition in 1989, the system remained unchanged for almost a decade, a unique lag compared to other countries in the region (Popic 2021a). Politicians’ inability to make reformist decisions in the early 1990s contributed to the cultivation of some preexisting patterns of fraud in the system, including bribery, out-of-pocket extra gratifications, the use of networking, and other types of corruption. These corrupt practices could be also seen as a reaction to an overly bureaucratized organizational machinery (Sitek 2010). Reforms in 1997 and 1999 aimed to reduce some major problems, such as high usage rates resulting in long queues, inefficient delivery of care, low salaries of health professionals, and poor access to innovative medical technologies. HC reforms in Poland generally followed the trends common to all postcommunist countries by switching to compulsory health insurance schemes, relying on private (both formal and informal) payment and based on primary care as the foundation of the whole system (Rechel and McKee 2009). In 1997 the government passed legislation to replace state financing with employers’ obligatory contributions to a national network of independent health funds. This meant not only the replacement of direct government financing but also management of a system of independent funds, targeted at stimulating privatization of the health system. Soon afterward in 2003 these funds were merged into one central fund acting as the only public insurer, which resulted in a lack of competition among the insurers and consequently a lack of competition among the medical service providers as well as one dominant source of funding—the monopoly of the National Health Fund (Jaworzynska 2016).

The current HC system in Poland is formally based on a general insurance scheme. The state is not divorced from financing and provision of health care: the National Health Fund does both. Voluntary health insurance is rather marginal (Popic 2021a). Thus, in its current form, the public insurance fund is a gatekeeper, limiting the patient's access to services. At the same time, private providers not only supplement but also overlap the basic, publicly funded system, creating a pathological hybrid in which the patients pay twice (the so-called hidden copayment). Furthermore, there is no space for a wide public discussion on the introduction of any substantial reform of the system aiming at the improvement of accessibility to HC services, such as additional insurance.

Political Determinants of HC Policy in Poland

The first basic political determinant of the HC policy inertia in Poland is the overambitious constitutional provision adopted in 1997 promising universal, publicly organized, equal, publicly financed HC. Copayments are formally forbidden from the legal point of view, so the citizen cannot legally pay for any additional service within public care, which is not covered by the public insurer. As a result, many patients are being pushed out of the system and are forced to choose whether to wait in line for the public operator or to pay for the full private service. Physicians allocate their time to both sector services. A recent study shows that allowing physicians to have such a dual practice, from which they benefit economically, crowds out public provision and results in lower overall HC provision (Brekke and Sørgard 2007).

A recurring theme in the interviews was the perception of doctors as beneficiaries of a flawed Polish HC system. As one informant said:

As another informant said, despite antibribery education, the legacy of the old system is still alive: “A doctor in a high position should earn enough not to act privately and take bribes, and I know this is still happening” (W/18/06/2019). The constitutional promise only creates additional confusion and introduces a sense of social injustice by blocking those in power from making it clear that certain things must be paid for separately. As one of the respondents said, “The state should start to fulfil its obligation secured by the Constitution and provide free access to all HC services available according to the newest medical knowledge” (W/13/06/2019). Such an approach is quite popular in Poland, and it leads to an elementary lack of understanding of constitutional provisions. In fact, the constitutional principle of equality does not result in the obligation of public authorities to provide free services. Services only should be equal for all citizens and guaranteed to be financed from public funds, which does not exclude the usage of private suppliers (Urbaniak 2013). As a result, social disappointment only intensifies, making any discussion on different ways of financing Poland's HC system impossible. Thus, it seems that the postcommunist legacy as manifested in the system's organization and constitutional promises make it impossible to break the deadlock in Polish HC policy. Institutional factors also play an important role, but they are somewhat derivative of legacy-related factors.

Electoral politics and party competition are other crucial determinants explaining the lack of action on Polish HC policy. Any reform attempt would require an increase of the social contribution or (at least partially) privatizing the HC insurance scheme in Poland, which is unacceptable for the electoral bases of the largest ruling parties. No matter whether neoliberal schemes or recentralized patterns dominate in decision-making in Poland, there is still a lack of any open discussion on HC system reform. Under the liberal-conservative Civic Platform and the Christian-democratic government, a large-scale system change involving supplementary private health insurance schemes has frequently appeared on the health policy agenda (Popic 2021a). For example, in January 2008, a draft law on additional insurance was submitted to the parliament. It did not allow people to opt out from the compulsory public insurance system, but it allowed the insured to move certain services from public coverage to complementary insurance. Additional insurance could also cover services requiring copayments and services excluded from the public offer. In 2011 another draft law on additional health insurance was presented by the Ministry of Health. It met with criticism from almost all sides, and the government ultimately abandoned it. “The political cost of such a solution would be too big, so we decided to step back immediately,” said the Civic Platform vice minister during an interview (W/17/10/2019).

Moreover, Polish politics is characterized by shortsightedness and strategic planning for the short term, but in the field of HC policy, a long-term vision and long-term reforms are required. Politicians are more likely to listen to the voters’ voice before every election, which was empirically observed by the patients organization representatives we interviewed (W/15/05/2019; W/07/06/2019; W/20/06/2019). In the case of health policy, which is an arena of constant social disappointment and political conflict in Poland, politicians prefer to implement the most urgent, ad hoc changes, or as one of the respondents put it, to “patch the biggest holes” (W/17/10/19). This is why policy makers generally listen more to cardiologists and oncologists while discriminating against specialists focused on rare or mental diseases. Any major remodeling of the HC system would undoubtedly involve at least temporary social discontent. It seems that politicians still remember the high political price paid for the bold four reforms, including HC system reform, carried out in 1999 by the center-right government coalition Electoral Action Solidarity–Freedom Union. As a result, the state has avoided describing and defining the place and role of the private operators in the system for years, acting like everything is covered by the public operators.

Another political determinant of HC policy inertia in Poland is underfunding. The scale of public health expenditure reflects the political priority given to health issues. In Poland, despite the country's economic development of the country as measured by GDP dynamics, total expenditure on HC is low and inadequate to economic growth. The problem of underfunding the HC sector in Poland seems obvious and has been raised by experts for decades. Domestic government health expenditure as a share of general government expenditure in Poland is almost the lowest among the region's countries (Tambor, Klich, and Domagala 2021). This situation is undoubtedly affected by a shortage of state financial resources and political decisions on the allocation of funds. Since the amount of money is insufficient, and for political reasons it is frozen at such low levels, private financing kicks in (Statistics Poland 2020). The public-private mix in HC is nothing special in Europe (Immergut et al. 2021); however, the relations between public and private can be organized in various ways. A high reliance on out-of-pocket payments persists in many central and eastern European countries (Tambor, Klich, and Domagala 2021). The use of additional private funding sources in Poland does not take the form of voluntary private health care insurance, but rather direct payments in the system that theoretically offers everything for free (Borda 2008).

In early 2018, as a result of young doctors’ protest, an amendment to the act on health care services financed from public funds was adopted, with a gradual increase in public expenditure on HC to 6% of GDP in 2024. Despite that, this change has turned out to be just a political public relations trick, as the Law and Justice government has adopted a special method of calculating this amount on an outdated GDP basis (Karpinska 2023). As a result, nothing has changed from the patient's perspective. To access HC services, patients are still forced to wait or purchase them from the private sector. This concerns both diagnosis and treatment, which we confirmed via the in-depth interviews we conducted with the patient organization representatives. Patients often go on a “diagnosis odyssey,” queuing from one doctor to another for many years, seeking any concrete result (W/12/06/2019). Regarding public spending on HC, one informant said they believed that increasing citizens’ compulsory contributions for HC would help to increase public funding of the system, resulting in better performance (W/15/05/2019). Another interviewee argued the opposite: “Over 100 billion PLN spent on health care seems to be enough. The problem is that decision-makers face organizational problems and spend money inefficiently” (W/28/05/2019). Another informant pointed out that “the real problem is lack of trust and understanding between patients and doctors. You cannot buy that for any money” (W/28/06/2019). Inadequate spending policy, failure to count total costs (including indirect costs, which often exceed the direct costs of treating diseases) of particular diseases, unclear prioritization (and hence financing), and finally an ad hoc approach to budget management means that relatively scarce funds for HC services are sometimes wasted.

Decision-makers in Poland did not work out a coherent policy prescription regarding the systemic features of the HC system. One reason for that is the lack of a proper dialogue with key stakeholders. Meanwhile, an analysis of the best-performing HC systems proves that this is one of the factors related to success, such as in the Netherlands (HCP 2019). Other research on 39 low- and low-middle-income countries proved that it is not cost-effective for governments to ignore nonstate actors (Saksena et al. 2012).

It takes two to tango in terms of dialogue involving the decision-makers and stakeholders of HC policy. First, politicians need to listen, which requires the proper institutional dialogue infrastructure. Patients’ organizations in Poland are not treated as partners: most organizations (86%) complain about bureaucracy in contact with public administration, and 74% perceive it as having limited openness to the health sector's demands (Klon/Jawor 2018). Once the patients manage to develop professional expertise, decision-makers use it without involving them: “They just take our findings and recommendations and act as if it was they who invented it. As a result we have no impact on final implementation, and we just watch as good ideas go in the wrong direction” (W/12/06/2019).

To illustrate decision-makers’ low level of openness to a dialogue with key HC stakeholders, we provide the answers to the survey question on their access to selected political bodies. It is clear that difficulties with access became even worse during the COVID-19 pandemic. However, the low level of organized interests’ access to the decision-making process should not be excused entirely by the pandemic circumstances and related restrictions. It was already problematically low before 2020, especially in the case of access to the regulatory authorities (which are crucial in the case of HC lobbying). Nonetheless, the lowest levels were noticed in the case of the governing parties. In contrast, the opposition parties showed much more openness, which proves that it is not the sanitary restrictions that played a critical role here. Finally, the interest groups’ access worsened in the case of the parliament. Bearing in mind that Poland is a parliamentary democracy, this development undermines the democratic legitimacy of the decision-making process (deparliamentarization), and as such it contributes to the picture of Poland's deeper democratic backsliding during the pandemic.

Moreover, stakeholders need to know how to be heard. Organized interests and tripartite dialogue inherited a difficult legacy in central and eastern Europe (Howard 2003). Under communism, civil society demands were more or less exclusively channeled through the Communist Party; therefore the development of civil society and participation processes were delayed, as interest organizations lacked courage and experience with collective mobilization (Szyszkowska and Riedel 2022). Even if the official government narrative and general impression is that nongovernment stakeholders are more powerful than they were a decade ago, only a few organizations are really strengthening their voice and place in the whole ecosystem. Patients remain, as Olson would say, “those who suffer in silence”: a large, latent, unorganized group with no representation or lobbying capacity (Olson 1965: 165). A few informants during the interviews before the pandemic said that they conducted meetings with decision-makers or even initiated parliamentary roundtables, but in most cases their efforts did not result in success, understood as the demanded change in policy being made (W/07/06/2019; W/09/06/2019). Another informant said, “I feel like I hit a wall that I cannot break” (W/28/06/2019).

The situation is not drastically different for medical staff representatives, which indicates that the Law and Justice government during the pandemic was closed to their input. “This access is only a subject of the preference of the authority that allows or blocks selected stakeholders,” said one of the informants (W/13/02/2022). Another said, “State bodies are very reluctant to invite to their meetings entities or organizations that have different views on the subject under discussion” (W/15/02/2022). What is more, the patient groups who are most discriminated against in terms of access to services are those who have no formal representation or strong voice to reach out to public opinion and decision-makers, such as geriatrics and psychiatric patients, according to three respondents (W/15/05/2019; W/21/05/2019; W/18/06/2019). Another representative of the medical community said that, despite participating in the advisory bodies of the Ministry of Health, he felt that no one listened to him (W/18/02/2022). The inefficient design of the HC system has never triggered a wave of mass protests or public resistance. The only group of participants in the system that occasionally protests are mainly junior doctors and nurses. This weakness of civil society is also part of the legacy of the old system.

Conclusions

The objective of this article is to explain the political factors determining the performance of the Polish HC sector. As a starting point, we built our argument on some earlier analyses (Popic 2021a) explaining the political factors determining the variation in HC policy trajectories across the postcommunist states: namely, individual countries’ legacies, institutions, and dynamics of party competition. We then added to this picture some other elements that have played an important role in HC policy reform in Poland.

The analysis showed that it is mainly because of the postcommunist legacy that HC policy in Poland cannot break the deadlock. Paradoxically, the crucial problem in reforming the Polish HC system turns out to be overambitious (relative to the Polish economy's potential) constitutional rules rooted in a communist regime, promising universal, equal, publicly provided, and state-financed HC. These rules are treated as virtual veto points (Popic 2021b), blocking any strategic or long-term attempt to reform the system. As a result, the design of the HC system remains flawed, aggregating the costs in the public domain and the benefits in the private one. The diffused interests of patients—reflecting the general weakness of civil society in Poland—do not lend themselves to political mobilization to disrupt the unfavorable status quo, which is an additional argument that in Poland the main causes of HC policy inertia are conditioned by the country's postcommunist, path-dependent legacy.

In addition, institutional factors play a role, such as the institutional framework allowing dialogue between the system's stakeholders or the design of HC institutions. Also important are factors related to partisan politics and therefore to the allocation of financial resources, political competition, and the calculation of political costs, resulting in a lack of bold decisions. Nevertheless, these are, in our view, derived from Poland's postcommunist legacy.

The path dependency factor causes the Polish HC sector to gravitate more and more toward its historical roots, that is, a state-funded, state-controlled, centralized system. The lesson from Poland is that the superficial institutional change that happened in the transitional period resulted in the system's stubborn path dependence. The core nature of the institutions that evolved—public ownership, political dependence, and notorious underfinancing—resulted in similar outcomes, no matter which institutional form the intermediating institutions took (Stark and Bruszt 1998). In other words, the Polish case proves the stability of institutions, including interests and preferences.

With this analysis we contribute to the growing body of literature at the intersection of public policy and comparative political science. Our conclusions deliver a critical case study allowing a better understanding of HC policy inertia in Poland, the largest state on the EU's eastern periphery. Additional studies are needed, not only in the postcommunist area but also across various locations and contexts. The broad new public health agenda, with its multitude of competing issues and perspectives, requires a much more sophisticated understanding of government and the policy process. Drawing on the insights of both public health and political science is not just highly desirable but simply essential (Fafard, Cassola, and Weldon 2022).

Acknowledgments

This research was funded by the National Science Centre (Narodowe Centrum Nauki) within the OPUS program (grant number 2020/37/B/HS5/00230) under the title “Determinants and Dynamics of Differentiated Integration in a Post-Brexit Europe.” The research was also supported by the Jean Monnet Module “European Union: European Values and Ethics in Politics and Economy” under grant #101127158 ERASMUS-JMO-2023-HEI-TCH-RSCH.

References