5. Provision of services
he Czech Republic has an extensive public health network responsible for a range of services, including epidemiological surveillance, immunization logistics, quality analyses for consumer and industrial products, and monitoring the impact of environmental factors on health status. Its main actors are the SZÚ, the RPHA, and two regional institutes of public health.
Regulatory authority for primary care, which includes GPs, paediatricians, gynaecologists, dentists and pharmacists, is divided among the state, the regions and the health insurance funds. Approximately 95% of primary care services are provided by physicians working in private practice, usually as sole practitioners. Patients register with a primary care physician of their choice, but can switch to a new one every three months without restriction. Primary care physicians do not play a true gatekeeping role; patients are free to obtain care directly from a specialist and frequently do so. Secondary care services in the Czech Republic are offered mainly by private practice specialists, health centres, polyclinics, hospitals and specialized inpatient facilities. After a variety of reforms in the 1990s, hospitals that formerly belonged to the state are now owned and managed by a range of actors, including government ministries, regions, private entities and churches. Almost all pharmacies in the Czech Republic are run as private enterprises, and at the time of writing there is a trend towards the establishment of pharmacy chains, especially in urban areas.
The systems of long-term health care and long-term social care in the Czech Republic have traditionally been separate in terms of organization and funding, which has led to frequent complications, especially in the reimbursement of services. The 2006 Act on Social Services was aimed at improving coordination between the two systems by providing individuals with a flexible care allowance, allowing cross-funding between the two systems and requiring that providers of long-term care fulfil certain quality criteria before they may receive funding. However, in 2014 the transfer of patients between health care facilities and social care was still inadequate and there are strong financial incentives for patients to try to remain in health care facilities, even if it is not justified by their medical condition.
5.1 Public health
The public health sector has seen several reforms since 2000. In 2014 the main actors in the Czech system of public health were the SZÚ, the two regional institutes of public health and the 14 RPHA (Fig5.1). All of these institutions are directly subordinate to, and managed by, the Ministry of Health and its chief public health officer, who is also a deputy minister of health. For more detailed information on public health reforms, see section 6.1.
The SZÚ conducts research, provides advice on methodology and drafts expert opinions on the safety of various products, such as cosmetics, food supplements and other items of daily use. It also systematically monitors the impact of environmental factors on the health status of the population and helps prepare legislation in the field of health protection, including the harmonization of Czech legislation with EU norms. In the areas of disease prevention and health promotion, the SZÚ focuses on the epidemiological surveillance of important communicable diseases and on promoting healthy lifestyles. The SZÚ coordinates the different actors in the public health system and supports their activities in a variety of ways, such as through the publication of educational materials.
The two regional institutes of public health are located in Ústí nad Labem and in Ostrava, with branches in several other cities (see Chapter 6). In the area of epidemiological surveillance, the two regional institutes of public health (zdravotní ústavy) share duties with the SZÚ and the Ministry of Health. In 2014 the Czech Republic had a system of surveillance for some 50 diseases and public health hazards. The two institutes of public health are health facilities, the chief domains of which are science and research. Additionally, living and working conditions and the quality of consumer and industrial products are assessed and evaluated by these institutes. Furthermore, the two institutes of public health (and their branches) are permitted to compete with private laboratories. Some criticism of the merger of the previously 14 institutes has been voiced. Opponents felt strongly that the merger would lower the competition for private providers in this field and might favour certain private providers.
The 14 RPHA are responsible for a range of public health services, including epidemiological surveillance, immunization logistics, and certifications and authorizations. Any physician who diagnoses a communicable disease must inform the relevant RPHA. This office subsequently reports total incidence levels to the Ministry of Health using the Epidemiological Data (EPIDAT) information system, which is part of the NHIS, operated by the SZÚ. Patients with certain communicable diseases, such as tuberculosis or viral hepatitis, must obtain treatment from hospital departments specially designated for this purpose. Regarding immunization logistics, the two public health institutes collaborate with primary care facilities, which are responsible for providing vaccinations and antenatal services.
The Ministry of Health and the Ministry of Labour and Social Affairs are jointly responsible for occupational health and injury prevention. Occupational diseases are the responsibility of occupational medicine departments within the public health authorities. Any measurements that need to be carried out as part of an investigation are conducted by accredited laboratories, usually run by the two institutes of public health and their branches. The National Register of Occupational Diseases is administered by the SZÚ.
Preventive care services covered by SHI include:
- compulsory vaccination and preventive examinations for children of specific age groups;
- compulsory vaccination and voluntary periodic examinations by GPs (every two years), dentists (every year) and gynaecologists (every year) for adults;
- cancer screening programmes – for cervical cancer (once per year), breast cancer (once every two years from 45 years of age) and colorectal cancer (occult blood test once between 50 and 54 years of age and then every two years or colonoscopy once every 10 years from 55 years of age); and
- voluntary vaccination against HPV for teenage girls since 2012.
Vaccination rates for major immunizable diseases vary from 98% to 99% (WHO Regional Office for Europe, 2014a). The compulsory child vaccination programme covers tuberculosis, diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps and rubella. Vaccination against hepatitis B and Haemophilus influenzae type B was added in 2001. Vaccination against hepatitis A, tick-borne encephalitis and meningococcal disease is available upon request but generally not covered via SHI; some health insurance funds offer full or partial reimbursement for these vaccinations as part of their own prevention programmes. Vaccination for some vulnerable groups of patients is covered by SHI (for example, vaccination against influenza for patients aged 65 years and over or for patients recovering from organ transplantation). In terms of financing, the vaccinations as well as the vaccines have been paid through SHI since 2010. This was a change from previous arrangements when the state paid for the vaccine through general taxation. It has added to the financial strain on health insurance funds as the additional responsibilities for vaccination were not matched by rising rates of health insurance premiums. Estimates suggest that this shift led to savings from the state budget of approximately CZK 850 million (€31.2 million) per year.
A long-term public health strategy, the National Health Programme, was submitted for government approval and accepted as early as 1995. The chief goal of the programme is to encourage individuals to take an active approach to their health; it includes projects for healthy schools, homes, workplaces and cities. The National Health Board, led by the Minister of Health, is responsible for implementing the programme and reviewing applications for funding submitted by public and private organizations. A new strategic document was adopted in 2012 to better reflect the institutional changes which have happened since 1995 and also to reflect the WHO Health 2020 Strategy. The new document emphasized the promotion of healthy lifestyles and raising awareness about the available preventive services such as screenings.
Laws prohibiting smoking in public places and regulating the advertising of tobacco products on radio and television were enacted in 1989 and 1995, respectively. Greater restrictions on tobacco advertising came into force in 2004, and a new law on tobacco and tobacco product control was enacted in 2005, further restricting smoking in public places. A proposal to ban smoking in all restaurants and other public areas was made in 2013. Before the dissolution of the Chamber of Deputies in 2013, the law was not put to a vote. Whether similar proposals will be made by future administrations is as yet unclear.
Following the tobacco products excise tax increase in January 2020 (approximately by 10%, see log from 01/06/2019), the government proposed a plan on its further increase for 2021, 2022, and 2023. Each year, the excise tax should increase by approximately 5 %, raising some additional CZK 2 bill in 2021 and CZK 1.9 in 2022 and 2023, accounting for the change in consumers’ behavior, decreased tobacco consumption and number of its consumers. The final change in cigarette prices is, however, unclear as producers may transform the tax increase only partly to consumers’ price.
Government of the Czech Republic, the electronic library, accessed May 29, 2020. https://apps.odok.cz/veklep-detail?pid=KORNBMCM4YA7
Preschool facilities are not allowed to accept a child without the documentation on all compulsory vaccination, according to the age of the child and the vaccination schedule, if not exempted for medical reasons or due to life-long immunity. Formerly, the requirement applied only to kindergartens that qualified for a state subsidy from the Ministry of Education. The just-approved amendment to the law broadens the vaccination requirement to any childcare facility, including the so-called children groups (organized mainly by employers) and other types of childcare facilities for preschool-age children. Care providers can be fined if violating the law. According to the MoH, the measure is aimed at reverting the negative trend in vaccination coverage and to level the regulation for all childcare providers.
Newly, the non-compulsory vaccination against meningococcal diseases will be free of charge for children up to the age of one year.
Parliamentary press No.530 on Amendment to the Act on public health protection (No. 258/2000 Coll)
The compulsory child vaccination program covering diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B and Haemophilus influenzae type B has changed from a 3+1 to a 2+1 vaccination schedule as of 2018. Currently, children up to 1 year of age should receive the first two doses with a break of 2 months. The third dose should be provided between the age of 11 and 13 months.
In parallel, the compulsory vaccination schedule for measles, mumps, and rubella have changed. The first dose is to be provided to children aged 13 to 18 months, and the second dose is postponed to the age of 5 to 6 years. Parents can be fined up to 10 000 CZK (400 EUR) for not following the vaccination schedule, if there are no medical reasons to exempt a child.
CR Ministry of Health’s Decree No. 537/2006 Coll., on vaccination against infectious diseases, as amended by MoH’s Decree No. 355/2017 Coll.
Act on public health protection, No. 258/2000 Coll
National Institute of Public Health, current Vaccination Schedule in the CR (in Czech), http://www.szu.cz/tema/vakciny/ockovaci-kalendar-v-cr, last accessed May 28, 2018
In early 2017, after years of discussions and several legislative attempts, a new law prohibiting smoking in all public places was finally approved by the Parliament, the Senate and signed by the President of the Czech Republic. It will come into effect on May 31, 2017, i.e. on the World No Tobacco Day 2017. The Czech Republic now aligns with several other EU member states in banning smoking from public places. Current legislation extends the scope of smoke-free areas as stated in older legislation and overrules several made exemptions. Now all restaurants (including bars and pubs without exemptions), all public transport stops (including the unroofed ones), health care facilities including surrounding areas, all indoor facilities used for public entertainment and for other public events, and zoological gardens are supposed to be smoking-free. Furthermore, the law regulates the use of electronic cigarettes in public places. Besides, the law puts more restrictions on alcohol sale (ban on alcohol vending machines or sale of alcohol on children’s events), and increases fines in cases of noncompliance.
Source in Czech: http://www.mzcr.cz/dokumenty/30kvetna-den-posledniho-tipnutiprezident-podepsal-protikuracky-zakon-_13383_1.html