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Czech Healthcare System - below is a recent paper I wrote on the heathcare system of the Czech Republic. It is limited in scope, so I would appreciate any constructive input or comments:
Introduction
Nestled in the very heart of the Europe, the Czech Republic sits on the very ideological fault line that defined both the continent and the world for nearly 50 years during the Cold War. For the last ten years, this former socialist nation has wrestled with dramatic market reforms that have both stimulated and challenged its evolving healthcare industry. Despite these reforms, the Czech Republic has continued to embrace the tradition of social justice (Shi & Singh, 2001) for its citizens.
Background
The Czech Republic is bordered by European Union members Austria and Germany to its south and west, respectively; former fellow Warsaw Pact member Poland to the north; and former country-mate Slovak Republic to the southeast. As a result, Czech Republic enjoys a position at the geographic, political, and financial junction of Europe, ensuring a future of unprecedented challenges and opportunities not seen since its heyday several hundred years ago (Heritage, Castello-Cortes, & Jenkins, 2002).
Founded in 1924, the nation of Czechoslovakia emerged from the First World War, shaking off the mantle of the Austro-Hungarian rule to realize a long-held desire for nationhood. Czechoslovakia enjoyed a brief period of peace before ethnic Germans in the western region of the country fell for the dream of a Nazi empire. In 1939, under the Munich Treaty, Czechoslovakia was annexed by Germany and soon thrust into a Second World War. Although not suffering serious damage to its cities during the war, the country lost many of its intelligencia and tens of thousands of Jews to concentration camps. After liberation by the Soviet forces, Czechoslovakia was reestablished under the Warsaw Pact as a socialist satellite in 1948. After enduring communist oppression for two decades, Czechoslovakias doomed experiment with democratization in 1968 was brutally extinguished by Soviet tanks in what was called the Prague Spring. After two more decades under a single-party system, the Velvet Revolution of 1989 had enough widespread support to bring about dramatic peaceful political change. In 1990 Czechoslovakia held free and open elections, followed in 1993 by a peaceful split with Slovakia. The newly named Czech Republic emerged as a leader in post-Soviet economic and governmental reform, blazing a path toward a deep-seeded and long-held desire for political independence (Heritage, Castello-Cortes, & Jenkins, 2002).
Since the disintegration of the Soviet Union, Czech Republic has undergone profound economic, social and political reform in an effort to more closely mirror the affluent western European countries. This economic turnaround placed Czech at the forefront of the developing countries in central and Eastern Europe. Their recent integration into the North Atlantic Treaty Organization (NATO) has rewarded their efforts and is considered a key step toward attaining membership in the exclusive European Unions trade bloc. Helping their great strides toward meeting the EUs strict membership criteria, Czech has recently seen an decrease in inflation from a 1991 high of 56% (European Observatory on Health Care Systems, 1999) to a currently enviable low of 4.7% in 2001 (CIA, 2003). This number had continued to shrink in recent months to well below the 5% level. With unemployment on the rise to 8.5% in 1999, though, many have questioned the short-term benefits of the reforms and of accession into the European Union (EU) trading block (Heritage, Castello-Cortes, & Jenkins, 2002).
Czech Republic is a multiparty parliamentary democracy that elects a president every 5 years. The 200-member House of Representatives and the 81-member Senate decide issues of constitutional debate and introduces new laws (Heritage, Castello-Cortes, & Jenkins, 2002). Czech has a population of 10.2 million (CIA, 2003), with mostly ethnic Czech (81.2%) and a significant Moravian (13.2%) minority. The remainder of the population is made up of Slovakians, Polish, German, Silesian, Romani and Hungarian. The Romani, or Gypsy, minority experiences significant discrimination in the Czech Republic and are generally considered being in poorer health than the average Czech health indicator would suggest. Fully 75% of Czechs live in urban settings and enjoy a greater access to care than their rural counterparts. The remainder, living in the agricultural rural areas, experience a slight geographic maldistribution of specialty care (Shi & Singh, 2001). This is more acute with regard to specialty care and the use of medical technology, as the socialized system of regional rural hospitals provides adequate primary care for those living outside of cities.
Analysis
Czechs tradition of social justice emerged from its Austro-Hungarian tradition and reinforced a Bismarkian system of social and health insurance (European Observatory on Health Care Systems, 1999) that resonates even in todays health care legislation. Following the First World War, Czechoslovakia established the first social insurance system under the Health Insurance Act. This Act provided insurance coverage for employees, covering as much 33% of the population at the time. In 1948, private property was nationalized, including all healthcare facilities and resources. At this time, insurance was provided to all Czechs under a program called the Central National Insurance Fund. This amounted to a 6.8% outlay from workers wages with the remainder coming from the central budget. In 1952, the Semashko-model Soviet style Central System for Unified State Healthcare mandated that the government take control over the administration of all health care in the country. Financed through substantial general taxation, this system provided health care to all citizens free of charge. Physicians became state employees and earned wage-grade compensation for their efforts. This system also established regional representation of the Institute of National Health, with each district running a small-to-medium sized hospital that provided ambulatory care to the people of that district (European Observatory on Health Care Systems, 2000).
By the 1960s, this system began producing results. The high infant mortality and tuberculosis rates of the 1950s were brought under control and Czechoslovakias health statistics were internationally competitive (Institute of Health Information and Statistics of the Czech Republic, 2002). However, rigid central control began to restrict the systems flexibility and it suffered stagnation in its health status until the 1980s. In 1989 the newly democratic Czechoslovakia underwent a widespread liberalization of their healthcare system, dismantling the district health offices and allowing free choice of hospital while maintaining socialized health coverage for the population. 1991s General Health Insurance Law developed a compulsory health insurance model that is still in affect today (European Observatory on Health Care Systems, 1999).
The current health system in the Czech Republic, introduced in 1993, involves nine health insurance funds that reimburse health care providers for covered services. Based on solidarity and equity, this system is funded through mandated contributions from employees, employers and the state health ministry. Employers are required to contribute 9%, while employees contribute 4.5% of employee wages to the insurance funds. The government supplementing non-worker health care, including children, students, retirees, prisoners, women on maternity leave, soldiers, and those on welfare, for a grand total of 53% of the population being underwritten by the national government. This costs Czech Republic as much as 7.4% of their Gross Domestic Product to cover health care (Heritage, Castello-Cortes, & Jenkins, 2002). Due to its broad criteria for eligibility and the fact that entitlements are automatically covered, the Czech Ministry of Health has great difficulty budgeting such large numbers and continues to wrestle with the ever-rising costs (Weissert & Weissert, 2002). The prospect of integration into the European Union will cause further turmoil in the coming years, as Czechs accept the Euro as their primary currency, allowing for widespread revaluation of goods and services.
Like many other industrialized countries, Czechs healthcare costs are rising annually. A share of GDP, health care costs have risen 30% since 1990 (Heritage, Castello-Cortes, & Jenkins, 2002), posing a challenge to search for ways to increase efficiencies and reduce costs. This decentralized system is unique in that it allows the countrys private health care system to flourish despite government mandates, ensuring appropriate health care to all citizens (European Observatory on Health Care Systems, 1999). This also encourages private investment into emerging technologies and administrative techniques to better meet the future demands of their population. This balance of social and market justice will reap great benefits for the country, while also posing challenging debates for lawmakers and those within the health industry (Shi & Singh, 2001). Although efforts at total privatization within the health care industry have continued to increased at a rapid pace, fueled in part by the influx of western European and American health technology, Czech Republic still acknowledges their governments obligation to provide universal coverage, allocating medical resources to provide the greatest good (Shi & Singh, 2001).
Discussion
Despite the seemingly overwhelming task of the transition to a democratic political system and converting a deeply ingrained planned economy to a free-market model, the Czech Republic has achieved tremendous success. Satisfaction with their government is a serious concern, however. A full 60% are dissatisfied with their state, while only 36% say that they are satisfied. Comparably, though, the Slovak Republic rated 87% dissatisfaction, with only 11% satisfied; Poland rated 88% dissatisfied and only 9% satisfied. Germany, in keeping with most other western nations, rated 66% dissatisfaction and 31% satisfied. Overall, this dissatisfaction in the region is reflected in their opinion about their state economy. Despite its laudable successes, fully 60% of Czechs are unhappy with the economy. Compared with its neighbors, however, Czechs are comparably happier. Even economic powerhouse Germany rated 71% dissatisfaction among its citizens with regard to the overall economy and both Poland (91%) and Slovak Republic (92%) reflected nearly complete dissatisfaction with their respective economies.
Their world ranking for life expectancy (76 years) has increased to 40th place worldwide. Although this is less then their EU neighbors Germany and Austria (both 78 years life expectancy, tied for 13th place), it is a significant improvement and is an improvement over those of its eastern neighbor Slovakia and Poland (both 73 years, tied for 52nd place) (Heritage, Castello-Cortes, & Jenkins, 2002). This trend is also seen in infant mortality. In 2001, Czech had an infant mortality of five per 1,000 births, placing them 9th in the world, tying Germany, but falling short of Austria (4 deaths, ranking 3rd worldwide). This was a far cry better than Poland (nine deaths per 1,000, placing 43rd) and Slovakia (eight deaths, ranking 36th) (Heritage, Castello-Cortes, & Jenkins, 2002). These rates can be further improved if the Czech Republic concentrates their efforts on quality of care throughout the nation and, more importantly, on lifestyle-related improvements like more preventative initiatives (Shi & Singh, 2001).
According to the Pew Report, Czech people enjoy the greatest level of overall satisfaction with their life (41%), an 18-point increase since 1991. When compared with their former Soviet Block neighbors, Poland (28%) and Slovak Republic (29%), who both saw a 16-point increase since 1991, they compare very favorably. As expected, however, Czech satisfaction falls slightly below the satisfaction of their more affluent neighbor, Germany (49%), who saw only a 5-point increase. Of note is that the population of the former East Germany rated life satisfaction at a mere 36, a 21-point increase since reunification with their western countrymen (The Pew Research Center for the People and the Press, 2002). Czechs were listed as having the least concern about economic problems (46%) as their top personal concern, significantly less then their Slovak and Polish neighbors, scoring 63% and 73% respectively. Only 33% of Germans rated economic problems as their chief personal concern (The Pew Research Center for the People and the Press, 2002). Only 29% of Czechs listed health problems as a primary concern, with 35% of Germans and 26% of Slovaks echoing that opinion (The Pew Research Center for the People and the Press, 2002).
Overall, slightly over 33% of Czechs feel optimistic about the next five years, compared with a 25% pessimistic rating among its people. Poland rated 36 optimistic and 19 pessimistic; Slovak scored 45% optimistic and 23% pessimistic; Germany scored 35% optimistic and 19% pessimistic. Czechs also felt satisfaction with their household (58%), family life (88%) and job (77%), compared to Slovak Republic (44%, 87% and 78%); Poland (33%, 78% and 73%) and Germany (69%, 91% and 84%).
All in all, Czechs commitment to reform in healthcare and within the rest of the economy will continue to improve the future health of their people. Through the challenging times ahead, Czechs social justice tradition will continue to ensure access to health for all its citizens, neatly fixing the cost (to individuals) and access. In order to temper the euphoria of overcoming several decades of sacrifice to individual rights, the Czechs must embark on a nation-wide campaign (such as a Healthy Czechs 2010) to promote healthier lifestyles through moderate drinking, balanced diets, exercise and reduced consumption of tobacco products (Shi & Singh, 2001). This will aid their journey toward better health and facilitate their complete integration with the European Union community.
References
CIA. (2003). CIA World Fact Book. Retrieved February 1, 03, from http://cia.gov
European Observatory on Health Care Systems (2000). Health Care Systems in Transition, Czech Republic.
Heritage, A., Castello-Cortes, I., & Jenkins, W. (Eds.). (2002). Financial Times World Desk Reference (4th ed.). New York, NY: Dorling Kindersley Publishing.
Shi, L., & Singh, D. A. (2001). Delivering Health Care in America (2nd ed.). Gaithersburg, MD: Aspen Publishers. The Pew Research Center for the People and the Press. (2002). What the World Thinks in 2002 [Brochure]. Washington DC: Author.
Institute of Health Information and Statistics of the Czech Republic (July 2002). Health Care and Health Servicves in the Czech Republic 2001.
Weissert, C. S., & Weissert, W. G. (Eds.). (2002). Governing Health; Thje Politics of Health Policy (2nd ed.). Baltimore: The Johns Hopkins University Press.
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