4.1. Physical resources

4.1.1. Infrastructure, capital stock and investments

Infrastructure

Of the 194 hospitals in Czechia in 2019, 154 were acute care hospitals (with 57 422 beds) and 40 were LTC hospitals (3078 beds). From the 1990s through 2013, Czechia set about decreasing acute care hospital beds and increasing LTC beds, though this trend slowed between 2014 and 2019. Czechia recorded an acute bed density of four beds per 1000 population in 2019, which was lower than neighbouring countries but similar to the EU average (see Fig4.1). Additionally, 119 specialized therapeutic institutes had a total of 16 937 beds in 2019. Specialized therapeutic institutes do not have the legal status of hospitals; they provide specialized follow-up care, especially for long-term or chronically ill patients. These include beds for psychiatric care (8610 for adults and another 210 for children in 2019), hospices (491 beds) and rehabilitation care (2407 beds) (ÚZIS, 2020a).

Fig4.1

The average length of stay in acute care hospitals stood at 5.7 days in 2019 (down from 6 days in 2013), the lowest among neighbouring countries. The occupancy rate of acute care hospital beds, at 68.6% in 2019, is the lowest recorded value since 1975 and lower than in Germany (79.1% in 2018) and Austria (72.9%), but higher than in Slovakia (65.9%), and is a result of a lack of nurses in acute care hospitals (Eurostat, 2022). Nurses often leave this area of care as it is very exhausting. As a result, not only does the occupancy rate decrease, but wards are often either partially or fully closed (MZČR, 2020a).

In principle, regulation of hospitals occurs through HIFs’ registration and contractual processes (Health Service Act, 2011). Quality and safety requirements must be fulfilled, too, though the number of beds in hospitals is not explicitly regulated. Providers reduce or expand their capacities according to agreements with those HIFs with whom they have contracts, and these agreements are guided by anticipated patient demand. In anticipation of lower demand or insufficient personnel, excessive beds mean higher operational costs, and as such are reduced.

Similar to other countries, specialized centres are concentrated in urban areas, while nursing care is rather prevalent in rural areas, though not missing in big cities (see Box4.1). Note that bigger acute care hospitals also include LTC wards. Fig4.2 shows the distribution of hospitals in Czechia in 2019.

Box4.1	Fig4.2

Current capital stock

Included in Czechia’s 154 acute care hospitals in 2019 are:

• 24 hospitals run by MZČR and other state bodies (ministries), including 10 university and military hospitals (36.0% of total bed capacity);
• 69 regional and district hospitals run by regional governments, including both budgetary and corporatized hospitals (38.2%);
• 27 municipal hospitals, including both budgetary and corporatized hospitals (7.6%); and
• a few single-specialty hospitals, such as maternity care hospitals (18.2%) (ÚZIS, 2020a).

In contrast to most inpatient facilities, almost all outpatient providers are privately run (mainly run by self-employed individual physicians).

With no comprehensive surveys of property conditions, it is difficult to objectively assess the state of physical resources, though anecdotal evidence and substantial investments from EU structural funds suggest that there have been some improvements in recent years. The state of physical resources in smaller hospitals is thought to be generally worse, as investments were predominantly allocated to larger facilities. Some form of ad hoc appraisal of conditions is usually used when planning future investments, though there are no formalized procedures that would facilitate formal assessments.

Regulation of capital investment

Renovations of hospital infrastructure are, in theory, financed by HIFs through their reimbursements for services. On the provider side, however, reimbursement revenues are usually insufficient for capital investments. In state-owned hospitals, investments are often supplemented by transfers from state or regional budgets. Decisions on using revenues and transfers for capital investments lie with individual hospital management teams, though they must enable hospitals to at least fulfil the minimal technical requirements set by an amendment to the Health Service Act (2011). As upkeep has long been underfinanced and facilities need repairs, university and state-owned hospitals have recently begun to receive state subsidies for improvements. Recent programmes through the European Regional Development Fund have also targeted smaller regional hospitals to improve care quality in these facilities. New national investment plans include seven major strategic investments to selected teaching and state-owned hospitals to improve infrastructure and maintain the current scope and quality of care, while also creating modern and pleasant environments for patients; these investments amount to CZK 12 billion (information provided by MZČR on 29 March 2022). Capital investments in the private sector are not regulated if financed from private resources.

Investment funding

In 2019, MZČR expenditure on capital investments, that is, transferred funds on top of HIF reimbursements, amounted to nearly CZK 2 billion, decreasing 15% from 2018 (CZK 2.4 billion) and 37% from 2015 (CZK 3.2 billion). These largely cover the purchase of equipment and renovations for state-owned hospitals, including for acute care, LTC and palliative care, both for children and adults (MFČR, 2016, 2019b, 2020a).

Other hospitals may apply for EU funds, which MZČR then allocates; EU funding contributes substantially to capital investments, has supported the creation and modernization of psychiatric wards within hospitals and is expected to reach CZK 50 billion over the next five years. Investment priorities, set by MZČR, are aligned with Health 2030 to include modernizing emergency wards and support for nursing care, public health and eHealth initiatives (MZČR, 2020a).

Hospitals may also apply for REACT-EU funds, which was in response to the COVID-19 pandemic. These funds (CZK 22 billion) will go towards improving the health system through the Integrated Regional Operational Programme. Hospitals may further apply for subsidies from the Operational Programme Environment, the National Recovery Plan (Národní plán obnovy) and the Modernization Fund.

Other investments include European Economic Area and Norway Grants, which have financed over 140 health-related projects amounting to CZK 1.2 billion since 2004. These have recently gone towards strengthening patients’ roles within the Czech health system, child mental health and disease prevention.

There is no reliable information available on investments in private facilities, especially for outpatient care. Public–private partnerships are not common in the Czech health system.

4.1.2. Medical equipment

Proposals to purchase equipment for facilities are submitted to the Equipment Committee at MZČR, which considers the equipment’s need based on existing infrastructure. All equipment purchased using state or SHI funds above CZK 5 million is subject to committee approval. Czechia had 1.64 computed tomography (CT) scanners per 100 000 inhabitants in 2019, with an overwhelming majority in inpatient facilities (1.48); though increasing by nearly 70% between 2000 and 2019, this remains under the EU average (2.45). A similar trend exists for magnetic resonance imaging (MRI) units, which increased from 0.17 per 100 000 inhabitants in 2000 to 1.04 in 2019, also lower than the EU average (see Table4.1).

Table4.1

Although a lack of devices is not a problem, devices ageing is. There are also large differences between Prague and rest of the country, though medical facilities in Prague also serve inhabitants of other regions (see Box4.1). Czechia is also incorporating artificial intelligence (AI) and robotics into the health system. As of 2022, 12 da Vinci and 2 Cyberknife systems were in use in Czechia, among other AI products (icobrain, Brainomix), and Czech scientists have recently developed and applied AI to detect chronic diseases. The use of AI for health in Czechia is expected to accelerate when ethical and liability issues are fully resolved.

Box4.1

4.1.3. Information technology and eHealth

The share of Czech households connected to the Internet increased from 67% in 2013 to 81.7% in 2019 and Internet use is comparable to neighbouring countries (ČSÚ, 2021c; Eurostat, 2022). The share of Czechs accessing the Internet for health purposes stood at 52% for men and 72% for women in 2019, exceeding the EU averages (49% for men and 60% for woman) (ČSÚ, 2021c). NZIP websites in particular have useful health information (see section 2.8).

All HIFs have websites for communicating with their members; and members can view their record of administered and reimbursed care electronically (for example, mojeVZP and e-komunikace). Moreover, HIFs (minus VZP) have a common site (https://szpcr.cz/) for communicating with contracted providers, reducing the administrative burden for all parties. Some form of sharing records has existed at the regional level for about five years, particularly between emergency services and hospitals.

After being long fragmented into individual HIF initiatives, the first plan for nationwide data collection was unveiled in 2011, though implementation was paused because of a lack of funding. Nevertheless, MZČR adopted a national strategy for health system digitalization in 2016 for 2016–2020, which set the foundations, including electronic prescriptions and digital sick notes.

After a voluntary pilot period, electronic prescriptions were fully launched in 2018, requiring providers to issue them. This enabled patients to request prescriptions via phone or email without a physical visit, something greatly used throughout the COVID-19 pandemic. Phone consultations have also become more widespread and accepted. Digital sick notes were fully launched in January 2020, whereby providers electronically notify the social security system about a sick worker. Sick workers must still notify employers, but can now provide employers with an electronic copy. Other excusal notes (such as caring for a sick household member) still require the submission of physical documentation.

Nearly all health facilities in Czechia employ IT for reimbursement and accounting, and most large facilities have websites to provide patients with an overview of their services; 18.5% of facilities allow patients to book appointments online in Czechia, while 16.2% offer online consultations and a further 32.5% allow patients to request prescriptions online without needing to speak to a physician (ČSÚ, 2021c). Some private providers have built virtual clinics (see Table2.2).

Table2.2

Both the COVID-19 pandemic and the Act on eHealth (2021) have significantly accelerated digital health priorities in Czechia. The Act on eHealth (2021) introduced a basic legislative framework, defined obligations and standardized rules for communication, information sharing and data protection. It did not introduce electronic health records, though did introduce conditions for the safe sharing of documents among providers or between providers and HIFs. Patients have the right to receive transcripts of information shared about them at public administration contact points, although not all providers participate yet.