There are 36,686 doctors working in the Czech Republic, and 14,120 of these are in the state sector (1998 figures). My view is the view of a doctor working in the state sector; I cannot judge the situation in the private sector where the problems are different.
After the 1989 Velvet Revolution, there were fundamental changes in the health service: the market was opened to manufacturers of medical equipment, aids and medicines, and Parliament announced the right for everyone to choose their own doctor. In my opinion, the health service was not sufficiently prepared for these fundamental changes. In the public's mind the idea of "free health care" survived and continues to survive from the Communist period, as does the idea that all of us are equal as long as we are healthy ("teorie stejných žaludků" - "theory of equal stomachs"). The sick man in many cases loses this equality and cannot himself pay by legal means for what the state, or rather the insurance companies, have no resources to provide.
Public expenditure on health in 1998 reached CZK 119.7 billion; its growth has slowed down in recent years. The share of this expenditure in the gross national product (GNP) was 6.57% in the year mentioned. We must realise that this percentage is approximately the same as in other European countries (14% in the USA), but the GNP is between a third and a quarter of that in these countries. Working in a university hospital, however, I would suggest that the health care of Czech citizens is comparable with care in the countries of Western Europe and in many respects surpasses it (for example, the long waiting times for various operations in England).
The health system's lack of preparation for revolutionary changes caused and continues to cause, among other things, a problem in medicinal policy, where the prices of imported medicines are high and paying for them causes problems for the insurance companies. The "free choice of doctor" results in patients visiting doctors more frequently on average than in other European countries. They can also visit several doctors in the course of one day. On the other hand, throughout these ten years no one has built a "safety net" for the sick who require hospitalisation. As a result, many sick people, especially more complex cases, wander from hospital to hospital.
The earlier categorisation of hospitals into types I, II and III was abandoned and the requirement for follow-up care between the "lower" and "higher" types of hospital is not stated anywhere. The pre-revolutionary system of zoning hardly applies any more today. Over the last ten years, a number of medical facilities have been closed and new ones opened elsewhere, such as those near new housing estates. But there has been no innovation in the system. The original method of financing state hospitals according to the number of procedures and treatments carried out, has now been replaced by lump-sum payments.
In this author's opinion there is still a problem with non-ethical means of financing, whereby one lump-sum payment received by the hospital from the insurance companies for a certain period is used to finance all the costs of both employees and medical care. (In this way we have returned to the centrally planned financing of the Communist period). So, for management the situation arises where it is possible to increase bonuses for employees only by saving costs on medical care.
In general, we could say that the majority of patients are satisfied with the current situation in health care. We cannot say the same, however, about employees in the state health sector, who have already gone on strike twice. In my opinion the fundamental problem of the Czech health service is the fact that it provides the public with a "European standard," perhaps up to the point of "hotel services" in hospitals, for which European levels of financing are required but which, bearing in mind the size of the GNP, are difficult to find.
The attempt to standardise therapy in our country cannot move forward on a system of "world standards", but rather "Czech" standards. It would be necessary to determine beforehand the financial means which our society is capable of spending on a particular diagnostic-therapeutic approach, and then create from it our own standard.
Prof MUDr Pavel Pafko, DrSc, 9 March 2000
Professor Pafko is Head of the Third Surgery Department, Charles University Faculty Hospital, Prague
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