Czech healthcare system - equal access to services for all the insured?

The preamble of an official publication of the Czech Health Ministry reads: "Czech healthcare is founded on the following principles: solidarity; a high level of autonomy; multi-source financing, predominantly public health insurance; free choice of physician and healthcare facility; free choice of health insurer in the framework of public health insurance and equal access to services for all the insured..."

In today's Talking Point we'll be focusing on the last item on that list - that is "equal access to services for all the insured" - because that's exactly what is being put into question by some critics of the Czech healthcare system.

"The system makes a false impression that everything is free and available and the patient is entitled to everything, which, of course, is not the case. And that motivates the patient to find a way around it. If a patient wants some special services, such as a second opinion on his/her diagnosis, there is no official way to get it and pay for it. So the patients who know how to take advantage of the chaos will find a way of getting that extra service, either by simply relying on the health insurer to cover everything or by bribing someone."

Pavel Horak is the director of one of Prague's major hospitals run by the Health Ministry.

Dr Pavel Hrobon

A recent report on TV Nova exposed a surgeon from a North Bohemian hospital who openly asked a patient for roughly 850 dollars to move her up a waiting list for hip replacement surgery. She recorded the whole conversation and the money changing hands on a hidden camera.

The Czech branch of the corruption watchdog Transparency International is aware of the situation. The organisation's director Adriana Krnacova:

"This is a very nice case where it shows that if some systemic changes had been implemented some five or six years ago, then these cases couldn't occur. Because it happens always when there is a demand for something and we have to actually fill the demand by either bribing someone to come first on the list and not to wait for two or three years for the special surgery because it might happen that the patient is dead by that time. So the patient - because it is his personal interest - pays the doctor who somehow is operating in the framework of a system and he cannot make an exemption. This is a very asymmetric situation and the patient is paying a bribe just to balance the system."

One of the most vocal critics of the Czech healthcare system is Dr. Pavel Hrobon from the not-for-profit organisation Health Reform.cz. He says bribery is just one segment of corruption in the Czech healthcare sector.

Pavel Hrobon

"There are two types. One type I would call institutional corruption which is corruption in the relationships between institutions: between health care providers and health insurers, between providers and suppliers of technology, drugs etc. The second area of corruption is corruption on the patient-health system level which was very widespread in the time of communism. Since then it almost disappeared because this corruption is very susceptible to the accessibility of services. If services are accessible there is basically no reason for this corruption. As soon as the services become less accessible, which has happened in the last few months, the level of corruption will go up again."

The director of the Metal-Aliance health insurance company Vladimir Kothera went so far as to make his own private estimate of the overall volume of corruption within the Czech healthcare sector.

"My opinion is that it is possible that the volume of corruption in the Czech Republic's health care system is about 20 billion crowns."

Adriana Krnacova

Adriana Krnacova of Transparency International CR comes up with a whole list of specific cases of corruption.

"We start with public procurement. In fact, hospitals are among the biggest investors. And we know that public procurement in the Czech Republic is not treated in the most transparent way. The second is abuse of the utilities of the hospitals. In some cases the doctors use the hospitals for their special patients for their own practice. Then for example, if a doctor is employed in a hospital, it happens that he asks the patient to come to his private clinic instead of treating him in the hospital where he is employed. Then: abuse of medicines, absenteeism, fraud, embezzlement... It is a variety of symptoms which show that not everything is OK in this healthcare system."

Doctor Vladimir Dryml is Deputy Health Minister for health insurance and auditing. He firmly disagrees that the situation is as bleak as described by the critics.

"I believe the situation in the Czech Republic is better than in the other new EU countries. The Czech Republic has a certain tradition and corruption in the healthcare sector is not such a threat as in other Eastern European countries."

Dr Hrobon of Health Reform.cz on the other hand says there is a lack of transparency in the system and suggests two measures to improve the situation.

"One measure could be basically taken tomorrow and it is to make some official numbers public. For example: waiting times for selected diagnoses in individual hospitals. The second thing which is very necessary is to make clear what the right of citizens to health care covered by the statutory or social health insurance really means because in theory we are entitled to anything that can benefit our state of health. But the reality of the claim is tested only if you get to a particular problem to a particular hospital. Then and only then do you find out for how long you have to wait and whether you will get the care at all."

The last sentence is strongly disputed by Deputy Health Minister Vladimir Dryml.

"It is not true what the media sometimes says: that healthcare is not available here. The problem is that doctors take advantage of things that are not all stipulated by laws and regulations. The biggest problem of healthcare in the whole world is financing. All countries are aiming to find the best model or system but so far no one has succeeded. Our priority is to minimise the impact on the poorest people. It is important that we managed to stabilise the public health insurance debt and that's one of our major successes."

But Dr. Pavel Hrobon of Health Reform.cz has a different view on what the single biggest problem of the Czech healthcare sector, currently headed by the 12th minister in just 16 years, is.

"I think there is no clear agreed vision for the system, how it should go. So the biggest problem I would call uncertainty. The patients don't know what they are entitled to. The providers and the insurers have absolutely no idea what new law or what new order of the Health Ministry will come virtually overnight and change the rules. So it is uncertainty."