4.2 Human resources
The total number of individuals employed in the Czech health sector at the end of 2012 was 249 658 in FTEs, 39 719 of whom were physicians and 7247 were dentists. There were a further 6265 pharmacists and 107 476 paramedical workers with professional qualifications (PWPQs). Of these PWPQs, 86 424 were general nurses and 4055 were midwives. At the end of 2012 approximately 71.1% of all physicians (including dentists) and about 51% of PWPQs were providing outpatient care (ÚZIS, 2013a). Table4.5 shows a further breakdown of different occupations as FTEs per 1000 population.
4.2.1 Health workforce trends
The number of physicians in the Czech Republic is slightly above the EU28 average, with 3.78 physicians per 1000 population in 2012. While the EU13 average (2.74) is slightly lower, the EU15 average (3.68) is very similar, as Fig4.2 shows. Only in recent years has the Czech Republic approached EU averages; prior to 2004 there was a wider gap. The increase in the Czech Republic’s physician-to-population ratio since 1990 is in line with the general development within the EU and is very similar to neighbouring Member States, with the exception of Poland (Fig4.2).
The number of patients registered with a physician varies across the Czech Republic and across specializations. The national average for the number of patients registered with a GP was 1632 at the end of 2012, with the highest numbers of patients per GP in Středočeský and Pardubický regions (1841) and the lowest number of patients per GP in Prague and Olomoucký regions (fewer than 1500) (ÚZIS, 2013c). An average paediatrician in the Czech Republic attended to 949 children, with a minimum in Prague (866) and a maximum in Středočeský and Ústecký regions (1023). On average, 3211 women were registered per gynaecologist in the Czech Republic in 2012, with the minimum in Prague (2488) and the maximum in Pardubický region (3852) (ÚZIS, 2013c; see also sections 5.3 and 7.3.2).
The ratio of dentists to population in the Czech Republic is above the EU28 average (Fig4.3). The distribution of dentists within the country is again uneven, with a higher-than-proportional share of dentists in urban areas. The minimum number of registered patients per dentist was 999 in Prague, the maximum 1444 in Vysočina (ÚZIS, 2013c). The high density of most health professionals in the Prague region is also explained by the fact that they also provide services to patients who only formally reside in other regions or who commute. This is especially relevant in cases of specialized treatments.
At the end of 2012 as many as 25% of all health staff were employed by state-run establishments, with a further 15% of personnel employed by non-state establishments which were, however, effectively owned by regions, cities or municipalities (joint stock companies in which regions, cities or municipalities owned a majority share). The remaining 60% of personnel worked for private establishments (owned by a physical person, the church or other legal entity) (ÚZIS, 2013c).
Almost 36% of physicians specialized in and practised one of the following fields (ranked by number of physicians): (1) general practical medicine, (2) internal medicine, (3) surgery, (4) gynaecology and obstetrics (see also Table4.6).
At the end of 2012, 56% of physicians were female. Surgical disciplines and urology have a markedly higher share of male physicians, whereas more women practise paediatrics and dermatology. The proportion of female dentists is higher compared to the share of female physicians, representing two thirds of all dentists. These distributions have been stable for several years. The share of women among pharmacists reached 84% in 2012 (ÚZIS, 2013c). At the end of 2012 an average physician was 48.1 years old (48.9 years for men, 47.5 years for women). The Czech physician population has been ageing, with 26.6% of physicians aged between 50 and 59 years and 21.1% of physicians aged 60 years or above in 2012. The average age of dentists was 50.0 years in 2012 and that of pharmacists 42.7 years in 2012 (ÚZIS, 2013c).
As shown in Fig4.4, the nurse-to-population ratio in the Czech Republic is higher than in the other Visegrád group countries. It is similar to the EU average and above the EU13 average (WHO Regional Office for Europe, 2014a). In 2012 one hospital nurse was responsible for 5.4 occupied beds (ÚZIS, 2013c).
Fig4.5 compares the number of nurses and physicians combined per 100 000 population for the latest available year in the WHO European Region. It thus complements Fig4.4 and Fig4.6. With 1209 doctors and nurses combined, the numbers in the Czech Republic are lower than the EU15 average, but relatively similar to the overall EU average of 1154.
Fig4.6 compares the number of pharmacists in selected countries showing an increasing trend in all of them in the past decades. Numbers in the Czech Republic are lower than the EU averages and also lower than in the other Visegrád group countries except Hungary (WHO Regional Office for Europe, 2014a).
4.2.2 Professional mobility of health workers
Of the approximately 1000 annual graduates of Czech medical faculties, some leave for better working conditions and salaries abroad. Verified numbers of professional migration from the health sectors are not available. The only possible source of data – the issuance of certificates allowing doctors to work abroad according to EC Directive 2005/36 – proved unreliable since not all applicants actually leave the country. Emigration flows for nurses are not known either.
Working conditions and salaries, as well as the system of postgraduate education, were strongly criticized in a campaign by the Physician Union Club called “Thank you, we’re leaving” (Děkujeme, odcházíme) in January–March 2011 (see section 3.7.2 for more details).
4.2.3 Training of health workers
Training of physicians
The Ministry of Education, Youth and Sports is responsible for setting standards for educating and training physicians towards their first degrees. University medical studies consist of six years’ study; dentistry and pharmacy studies require five years.
There are eight medical faculties in the Czech Republic at the time of writing, five of which are located at the Charles University in Prague (three in Prague, one in Plzeň and one in Hradec Králové). There are also two pharmacy schools, one of which is located in Hradec Králové and the other in Brno. Limits on the number of applicants who may be accepted to medical, nursing or pharmacy programmes are set by the schools themselves, not by the government (see Table4.7 for further details on the number of students of health-related degrees). The eight medical faculties had a total of 14 406 students (including 1372 dentistry students) as of 31 December 2011. Women represented about two thirds of all students.
To comply with European Directive 36/2005/EC, two laws enacted in 2004 established new conditions for obtaining and recognizing medical degrees and specialized postgraduate training for physicians and non-physician health professionals, including nurses. According to this legislation, graduates from medical schools must complete a training programme in a selected medical specialty and pass the state licensing exam (státní atestační zkouška) in order to be allowed to work independently (that is, without supervision) as a physician. The programmes are offered by a wide range of providers throughout the country, each of which must be accredited by the Ministry of Health. This programme generally takes five years to complete.
In 2009 new legislation defined 40 basic postgraduate medical specialties in the following 10 fields: 1) anaesthesiology; 2) gynaecology and obstetrics; 3) hygiene; 4) surgery; 5) internal medicine; 6) pathology; 7) paediatrics; 8) psychiatry; 9) radiology; and 10) general practice, and also three postgraduate specialties for dentists and seven for pharmacists. These specializations take three to five years to complete, depending on the specialty. The legislation specified 44 additional medical and pharmaceutical subspecialties, which will be optional and require an additional one to three years of training. In 2011 an amendment increased the number of basic medical fields from 10 to 16 (adding dermatology and venereology; neurology; ophthalmology; orthopaedics; otolaryngology; and urology), moved forensic medicine from additional subspecialties to basic specialties and defined some new subspecialties.
The Czech Medical Chamber requires that its members participate in continuous, lifelong education. As such, each physician must acquire a certain number of points every five years through publishing activities or further education (such as seminars, workshops, symposia and congresses). Active participation, such as giving a lecture, is awarded a higher number of points. The Czech Dental Chamber and the Czech Chamber of Pharmacists have analogous requirements.
Training of nurses and other non-physician health professionals
The Ministry of Education, Youth and Sports is responsible for the graduate education of nurses and other non-physician health professionals and assists in developing curricula in collaboration with the Ministry of Health, which sets minimum standards for various study programmes. Since 2004, when new conditions for obtaining and recognizing first degrees and specialized postgraduate training were established, nurses have been required to complete an accredited bachelor’s degree programme (ISCED 5) that consists of 2300 hours of theoretical education and 2300 hours of practical training. Nurses may also pursue a specialization by taking part in courses accredited by the Ministry of Health and passing the state licensing exam; the courses are offered at universities and other educational facilities, and the state licensing exams are administered by the Ministry of Health. In 2009 the requirements for and form of the licensing exam were adjusted by a directive of the Ministry of Health.
The providers of specialization courses that increase the qualifications of non-physician professionals are chosen on a competitive basis. For example, the Institute of Postgraduate Education in the Health System was the main provider of the Ministry of Health’s individual education programme “Improving non-physicians’ professional knowledge” from May 2010 to April 2013. More than 32 000 people received further education free of charge through this programme, which was supported financially by the EU Cohesion Fund.
After becoming general nurses (with or without specialization), individuals must prove every 10 years that they have received a certain number of credits in further education courses accredited by the Ministry of Health. The quality of the courses offered is also monitored by the Ministry.
4.2.4 Doctors’ career paths
After graduation from medical studies, doctors in the Czech Republic usually start training for their chosen specialization in hospitals. Certain requirements exist for each specialization (for example, length of training, rotations, number of procedures performed, and so on) but there is no structured progression as such (see previous section 4.2.3).
Professional development mainly depends on individual motivation and ambition. Part of the training for specialization can (or in certain fields must) be done in an ambulatory setting. After being awarded a specialty degree, doctors can either pursue a hospital career or work in an ambulatory surrounding. In ambulatory care doctors can found a private practice alone or with partners, or choose to be employed in a practice conglomerate. Individual private practice is by far the most common form of work for doctors in ambulatory care in the Czech Republic.
In hospitals doctors can progress from senior physician to assistant medical director and medical director. The larger health care facilities (hospitals) usually have some hierarchical structure and wards are directed by senior doctors (primář). In state-run facilities there is a link between the years served and salary, because part of the salary is determined in a way similar to that for civil servants, but generally there is no rule stating that doctors with more years of service should attain senior positions or earn more. In university hospitals doctors may combine clinical duties with research activities. Apart from personal merit and ambition, promotions and career progressions are dependent either on the superiors or the institutional board.
4.2.5 Other health workers’ career paths
Possibilities within the different health care professions are manifold and vary considerably. In general, career progression in all fields very much depends on personal capabilities, choices and desires. For example, pharmacists may decide to pursue a career in a competitive industry environment or choose to run a private pharmacy. Nurses can work in a hospital and progress to different levels of responsibility for patients as well as staff, or they may choose to work in ambulatory settings.
As with doctors, there is no set nationwide career path for other health care personnel apart from certain training requirements for health workers (see section 4.2.3). Hospital wards usually have a head nurse (staniční sestra), who is the counterpart for nursing to the senior doctor and is in charge of all other nurses. The link between salary and seniority for other health care workers is similar to that for doctors (see section 4.2.4). Other health care professionals, such as speech therapists, psychologists and hospital auxiliary staff, do not follow a defined career path either (for details on remuneration, see section 3.7.2).
For many health care professionals, a career in public health or in public administration can also be an option, again depending on personal goals and ambitions.
According to 2017 ÚZIS (1), the number of working physicians is expected to gradually decrease in the next decade. Therefore, according to the MoH, one possible remedy to the ageing of physicians is to increase the number of medical school students.
In 2018, the government agreed with all medical schools on a special financial subsidy, in total CZK 6.8 billion over the next 11 years, for medical schools to accommodate more applicants. As a result, medical schools enrolled 340 more medical students in the winter semester 2019/2020 than in previous years, i.e. almost 20% more first year students (2).
The extra money is to be used by medical schools to increase teachers’ wages. According to universities, ageing of medical schools’ teachers may pose another challenge and a bottleneck to increasing medical schools’ students. Previously, the average teacher wage was below the average physician earnings in public hospitals (3). The special subsidy is intended to eliminate this discrepancy.
(1) ÚZIS (2017): Personální kapacity v českém zdravotnictví v r. 2016. Národní zdravotnický informační systém ČR (NZIS). NZIS Report č.1 (07/2017).
The Czech Ministry of Health announced a subsidy program to tackle uneven distribution of stomatology care throughout the country. Currently, problems to access stomatology care are reported in regions perceived as less attractive for health professionals. The aim of the program is to support a sufficiently dense stomatology care network. In pre-defined locations, dentists will be financially motivated to open a new practice, or to succeed a colleague in his/her practice, who plans to retire. The subsidy program will be opened in May 2018 and shall run till 2022 with an earmarked total of 100 mil CZK (4 mil EUR).
The MoH entered into cooperation with the Czech Stomatology Chamber to identify areas, where accessibility is insufficient (so called “white spots”). These areas, defined on the level of smaller-scale towns, will be eligible for the State subsidy program and will be chosen by the Committee on Stomatology Care Accessibility, newly founded by the MoH, with representatives of health insurance funds, MoH, and the Chamber. The selection process will be based on statistics provided by the Stomatology Chamber.
Although the average age of dentists in the Czech Republic is 50.2 years, there are some regions in which practicing dentists are on average aged above 65 years and with no young dentists to take over their practices. Just over the last five years, the Moravskoslezský region records 27 practices closed due to retirement without succession. Thus, it seems there is not an overall lack of dentists, but a problem of uneven distribution in favor of big cities. Whereas on average there are 1 629 inhabitants per 1 dentist FTE, 12.6 % of population lives in areas with more than 4 000 inhabitants per 1 dentist FTE (7.4 % of population in areas with more than 5 000 inhabitants per 1 dentist FTE) (more statistics available at www.dent.cz).
The current distribution of dentists reflects on the fact that in past years new practices were opened randomly based on who received a contract with health insurance funds, or even without receiving a contract. However, any clear practical strategy of the State or regional authorities to influence the network was missing. Though some regions are already running financial support programs to attract new dentists to their regions, these initiatives appear to be insufficient.
The new State subsidy program reflects regional experience and designs support as investment subsidy to purchase necessary dentist’s practice equipment, with up to 70 % of costs eligible to be covered from the program. Individual applications can be made for up to 1.2 mil CZK (48 000 EUR). The subsidy conditions include a 5-year commitment to provide stomatology care in the given location, the necessity to sign contract with at least four health insurance funds, at least 35 office hours provided over all working days, and a minimum of 1 500 registered patients within two years. Preference will be given to applicants that take over an existing practice from a senior dentist who plans to retire, and the subsidized dentist commits to accept and register all patients referred by the contracted health insurance fund and to accept children for care as well.
The MoH expects only few applicants in the first year and a gradual rise in number of submitted applications over next years.
Sources: Ministry of Health of the Czech Republic: Press release “MoH intends to support areas with limited accessibility to stomatology care” (in Czech). February 19, 2018.
Czech Stomatology Chamber: statistics provided at www.dent.cz, accessed on April 11, 2018.
Zdravotnický deník: “Dentists’ offices in remote areas will be supported by investment subsidies” (in Czech). http://www.zdravotnickydenik.cz/2018/02/praxe-zubaru-odlehlych-oblastech-podpori-dotace-investice-problemove-lokality-vytipuje-komise/, accessed on April 11, 2018.
In April 2017, the Czech Chamber of Deputies approved a change to the educational requirements for “qualified nurses”. According to this change that comes into force in September 2017 and should apply both to current students of medical high schools and their applicants, nurses who have graduated from medical high school will have to pass only 1 additional year of extension studies at higher vocational schools (called also extension schools, that are attended after high school and are a separate branch of higher education next to universities). Currently, qualified nurses are required to pass 4 years of high school education and 3 additional years of university education (BA) or 3 years of extension studies (Dis).
Prior to 2004, 4 years of medical high school was regarded as sufficient to become a qualified nurse. The new law also abolishes the need to converge with the education requirements (and enroll with required education programs) for those who have worked as a qualified nurse for a long time with only medical high school.
The model 4+1 as opposed to 4+3 is expected to result in more graduated nurses for inpatient care in the long run. Nurses are currently desperately lacking in many inpatient wards of Czech hospitals sometimes threatening their existence. Overall, the Czech Republic had 8 practicing nurses per 1 000 population, which is below the EU average of 8.4.
For the profession not to degrade, a change to medical high school curricula is necessary as the opponents to the law argue. After 2004, the share of specialized subjects at medical high schools decreased from 65 % to 40% as they were largely taken up by universities and extension schools.
Data on nurses per 1000 population available at: http://ec.europa.eu/eurostat/data/database
Starting from July 2017, a new legislation (Act No. 67/2017 Coll.) amending the 2004 law on training of physicians, dentists and pharmacists will come into effect. There are three main goals or purposes of the new legislation:
First, to clearly define the responsibilities and competencies of physicians in training and their supervisors and allowing for physicians in training to legally work in hospitals wards according to their abilities, training, and obtained level of experience. The current legislation builds on the former (before 2004) system of 2-level state examination, newly requiring an exam after the completion of training in a basic medical field of 30 months. Responsibilities and supervision requirements during the training of physicians are newly (and more clearly) defined, distinguishing two levels of work supervision. For medical school graduates the professional supervision is more strict than professional surveillance over the work of physicians in training after passing the basic medical field exam. As before, only upon the completion of the training in a medical specialty and passing the state licensing exam, a physician can work independently, i.e. without any supervision.
Second, reduce the number of basic medical specialties and shorten the length of training. This shall enable horizontal permeability among medical specialties, which is assumed to ease the potential retraining of physicians in case of their shortage in a medical specialty. Since 2009, frequent changes in specialized training of physicians led to a total of 96 different specialties, which is roughly double the EU average (PSP 2017, ČTK 2017). The current legislation aims at stabilizing the system of postgraduate education by defining 43 basic medical specialties in 19 fields directly in the law, hence making it more attractive for young doctors.
Third, to allow for the physicians in training to pass most of their training in their “home” healthcare facilities while only the necessary parts of their training is to undergo in specialized healthcare centers. The revised system of training requirements is to change the current practice in which physicians in training are required to spend many months in specialized centers or hospitals of higher level. This resulted in a tendency of physicians to prefer specialized or bigger hospitals after the completion of their training and a shortage of licensed physicians in smaller hospitals for some specialties. The new system of training requirements should allow for the physicians in training to receive most of their training in their home healthcare facility and therefore motivate young physicians to stay there.
The reform to physician’s postgraduate medical specialty training was discussed since 2014, also by high level commissions to the Minister of Health. However, an early draft was met with opposition by the Czech Medical Chamber resulting in political tensions until January 2017. Some criticism to the legislation persists as e.g. perceiving the number of basic medical specialties as too high, and concerns about the pending clarification on important details, these are yet to be published by MoH’s executive directives.
Information available at:
Act No. 67/2017 Coll. which amends Act No. 95/2004 Coll. on conditions for obtaining and recognizing professional qualification and specialized qualification of medical doctors, dentists and pharmacists. Available on-line at https://www.sbirka.cz/POSL4TYD/NOVE/17-067.htm[in Czech]
PSP, 2017: Důvodová zpráva k návrhu zákona, kterým se mění zákon 95/2004 Sb.; v Sněmovní tisk 723/0, část č. 1/6 [Chamber of Representatives, 2017: Reason report to the law proposal amending Act No. 95/2004 Coll.; in Parliamentary Press 723/0, part 1/6]. Available online at http://www.psp.cz/doc/00/12/51/00125125.pdf [in Czech]
Czech Press Agency (ČTK), 2017: http://www.ceskenoviny.cz/zpravy/zmeny-ve-vzdelavani-lekaru-budou-platit-novelu-podepsal-zeman/1449903. [in Czech]. Accessed on April 3, 2017.