Czech health two decades on from the Velvet Revolution

20 years ago, half a million citizens took to the streets of Prague to protest against the increasingly oppressive Communist Government. After a week of peaceful demonstrations and strikes, the 40-year regime ended and democracy returned to the Czech people. Today, the citizens are protesting once again—not against oppression, but against health-care copayments. The controversy is the latest chapter in the Czech health-care system’s unique 20-year transformation from an ineffective command-controlled system to one of the most successful and respected in the world. Since the introduction of fees for health-care services in January, 2008, the Czech Social Democratic Party has represented the large portion of the population that opposes this controversial change. For many, it is not the payment of 30 Czech crowns (US$1·60) for a visit to the doctor or for a prescription, the 60 crowns ($3·20) for each day of hospitalisation, nor the 90 crowns ($4·79) for an emergency room visit. It is the principle that health care has always been free. However, the latest attempt by the Social Democrats to abolish the fees was rejected by the Czech Senate.1 The June 18 ruling was well received by the Ministry of Health, which has defended the fees to ensure the financial stability of the health system. Because nearly 80% of health-care expenditure is financed by income-based payments, the Czech system is particularly vulnerable during an economic downturn: this year, the insurance system is projected to lose as much as 13 billion crowns ($692 million) in revenue. This loss could be as high as 20 billion crowns ($1·07 billion) without the health-care fees.2 Furthermore, preserving the fees might discourage the overuse of health-care resources, for which the country has an unusually high demand. In 2007, Czech citizens had an average of 14·6 outpatient contacts with medical personnel per person—the highest in Europe. Similarly, the numbers of acute-care admissions, inpatient admissions, and average lengths of hospital stays have all been higher than the European Union (EU) average since 2000.3 Yet financially, the Czech health-care system is remarkably efficient. Expenditure per capita is among the lowest in the world, at $1490 per person in 2006 (about 20% of 2006 US expenditure). Similarly, only 6·8% of the country’s total gross domestic product was spent on health care in 2006, a remarkably low proportion when compared internationally (figure).4 Figure Health expenditure and life expectancy for selected developed countries and Czech Republic, 1990 versus 2006 Despite the apparent contradiction between the health-care system’s high use and low expenditure, the health of the population has improved dramatically in the past 20 years. Life expectancies increased 5·4 years in men and 4·6 years in women, compared with average increases of 4·4 and 3·2 years, respectively, in richer countries.4 Over this period, the infant mortality rate has dropped to a quarter of what it was, to 3·14 deaths per 1000 livebirths—well below the EU average and among the lowest in the world.3 Mortality rates are typical of developed countries, with diseases of the circulatory system, cerebrovascular diseases, and cancers accounting for three-quarters of all deaths in 2007.7 Investments in prevention and containment have led to rates of communicable disease that are among the lowest in the EU. The prevalence of tuberculosis is low for the region, and similar patterns are seen for viral hepatitis, scarlet fever, and viral encephalitis.4,7 HIV has also been well contained throughout the country—there were only 147 new cases in 2008.8 Despite effective disease control, there is still great concern over the country’s high rates of obesity and tobacco use, especially in young people. Clearly, the Czech health-care system is not without its share of challenges. Besides the overuse of health-care resources and the ongoing controversy over copayments, the country has also faced human capital loss since the opening of EU borders, as many physicians have explored higher-paying opportunities in neighbouring countries. However, the accomplishments have certainly out weighed the difficulties. In 20 years, an effective health-care system has replaced that left by the country’s Communist rule. As one of the most successful overhauls of a health-care system in history continues, modern challenges must be properly dealt with in the next 20 years and beyond.