CEE healthcare systems affected by the crisis, but Czech Republic comparatively unperturbed

2009-11-12

Among the six CEE countries analysed, the Czech Republic took the lead in terms of its healthcare system, which was evaluated as stable and maintaining good standards despite the crisis. At the other end of the scale, Bulgaria brought up the rear and its healthcare system was evaluated as being in need of extensive reform. Slovakia, however, performed best in terms of access to medicines.

Czech Republic and Hungary take the lead in CEE
In the most recent evaluation of the healthcare systems of 33 European countries, prepared by the Health Consumer Powerhouse (HCP) since 2005, the Czech Republic was in 17^th position, midway between Western and Eastern Europe. The country had 667 points out of a possible 1,000 in six categories: patient rights and information, e-Health, waiting time for treatment, outcomes, range and reach of services provided and pharmaceuticals. The Czech Republic was also among only three of the countries analysed, along with the Netherlands – which led this edition of the ranking – and Ireland, to be singled out as examples of successful reforms bearing fruit in their healthcare systems and leading to high positions in the ranking. The Czech Republic was followed closely by Hungary, which was classified in 20^th place but which had fallen from 14^th in the previous edition, its progress in reforming its healthcare system being assessed as slow. Poland and Slovakia each scored around 560 points, bringing their health systems to 26^th place and 28^th respectively in the ranking. Romania and Bulgaria brought up the rear because of poor results in almost all areas of their health systems, and it is predicted that these might deteriorate further as a result of the crisis.



The Czech Republic and Hungary, two countries which have significantly reformed their public healthcare systems in recent years, were included in a group of 13 countries in which healthcare systems are developing more rapidly than the average in the direction of improved consumer friendliness. As both countries improved in terms of patient rights and information in this year’s ranking, it seems that the reforms have paid off. However, patient rights and information were evaluated as being still insufficiently developed in the Czech Republic, and there were signs that waiting lists have become longer than in previous years. There is still, therefore, room for improvement.

Range and reach of Czech medical services valued by patients from other countries
The country performed particularly well in the “Range and reach of services provided” category, in which it scored 121 points and not only outperformed other CEE countries but followed just behind the Netherlands, which leads the field, and Luxembourg, with 129 and 136 points respectively. Its health service can be compared with those of the West European countries such as Denmark, Finland, Norway and the UK, each also scoring 121 points. It therefore comes as no surprise that many foreign patients seek medical treatment in the Czech Republic. Czech hospitals treated almost 79,100 foreign patients in 2008, in contrast to 69,770 in 2007, according to data from the Czech Institute of Health Information and Statistics presented in September. Of this number, 40,200 patients came from European Union countries. Most patients from Slovakia, who accounted for 20% of all foreign patients treated in the Czech Republic in 2008, came to undergo expensive operations which are not available in Slovakia, such as transplants of various kinds. A study carried out by the European Human Reproduction and Embryology Authority also shows that the Czech Republic is one of the countries most frequently visited by women with fertility problems who are seeking medical treatment. There are 26 centres which deal with assisted reproduction in the Czech Republic, and most of them are visited by both domestic and foreign patients. The total cost of treating foreign visitors in the Czech Republic came to CZK 555m (€22.3m) last year.



Hungary – sacrifice required during the crisis?
On the other hand, although Hungary has been trying to reform its healthcare system for a few years, the results are relatively unconvincing, with the HCP finding that some progress has been made in patients’ rights and information. In this category the country appeared to be the unquestioned leader among the CEE nations, outperforming them with a high 136 score. It also had the highest score (147) among other CEE countries in terms of the waiting time for treatment, with the Czech Republic and Slovakia following, both with 133 points.
In general, the Hungarian system was assessed as suffering from extended generosity and its treatment results being surprisingly modest despite 60 years of experience of a public health system in the country. Hungary’s main challenge is to improve the transparency of its old-fashioned, hierarchical health system. The HCP predicts that the situation might deteriorate because of the crisis.

Poland and Slovakia on a constructive path, but improvement still needed
The HCP has found that, despite a low overall score (26), Poland had remained strong at a time at which the situation in most other CEE countries deteriorated, and was slowly but steadily improving. Those aspects of the Polish healthcare system singled out for praise included the involvement of patient organisations and certain characteristics of the public system, such as regular vaccinations of children and dental care financed from mandatory health insurance.
However, the HCP stressed that Poland should address the problems of poor healthcare management and low pay for doctors in the public system, which it said were leading to a proliferation of private practices, with negative consequences for productivity and the quality of human resources in the public system.
The performance of the Slovak healthcare system has deteriorated in comparison with last year, as the country was classified as 28^th in the ranking, six places lower than it was in 2008. Slovakia was evaluated as a country which embarked quickly on the road of healthcare reform but has not been able to maintain the quality of care provided.
Slovakia scored relatively badly in most categories, with the exception of patients’ rights, access to general practitioners and the range of services covered by the obligatory health insurance scheme. However, the country was included among the 13 which provide clear and user-friendly information. Indeed, Slovakia appears to have made an effort to improve in this area. The Slovak Health Ministry recently initiated a public campaign aimed at encouraging the country’s citizens to buy cheaper, generic medicines in the form of a facility on the health ministry’s website. Patients can use this to see how much they have to pay or contribute to a reimbursed medicine and whether a cheaper equivalent is available on the market. By means of a link placed on the website the patient is transferred to another portal, where he or she can enter the full or partial name of the medicine in which they are interested, check the patient co-payment level required for this drug and compare the co-payment levels of other medicines available in the same therapeutic category. Patients can also browse the medicines database by selecting a relevant ATC group. The patient co-payment amount is displayed in both euro and Slovak crowns.

Romania and Bulgaria in need of healthcare reform
Romania cannot boast even rudimentary patient rights or e-health, and it has improved only slightly in other categories. It appears that informal payments expected from patients are still a serious problem and an obstacle for a health system based on fair and equal access for everyone. One of the very few areas in which the country was singled out was its “Layman-adapted pharmacopeia”, as it was classified among 13 countries which have a user-friendly guide for average users. Unfortunately, the situation may deteriorate in the country, as it is struggling with a serious public funds deficit, which will lead to reductions in spending on healthcare and medicines. The budget of its National Health Insurance Fund is at a 9-year low this year, and various industry associations fear that the system could collapse in mid-2010.
The HCP is concerned that a similar situation could arise in Bulgaria. The country, which was in the lowest, 33^rd, position, performed badly in all categories analysed, and, in particular, in the range and scope of medical services provided and access to medicines, and had not made any progress since the previous ranking. It is not surprising that in the face of poor access to the public healthcare system, an additional health insurance market is growing in Bulgaria. Private health insurance firms collected gross premiums worth BGN 23m (€11.8m) in H1 2009 in Bulgaria, a 53% year-on-year increase. The reason for the increase is the rise in the number of people purchasing additional health insurance. According to the Financial Supervisory Commission (FSC), the number of such people increased by 27% to 37,000.
At present, Bulgaria is preparing an extensive reform of its healthcare system, which will, it is hoped, improve its deplorable condition. The Health Ministry is also trying to undertake a number of drastic measures to address the huge National Health Insurance Fund shortfall. At the moment, it is estimated that 800,000 Bulgarians are not paying their premiums, thus costing the country approximately €500m per year in lost revenues. One such measure is a ban on foreign travel for people with outstanding healthcare contributions of more than six months, under proposals unveiled by the country’s Health Ministry in September. The Ministry would also like to be able to impose fines for non-payment, in addition to charging punitive interest.


Slovakia leads the field in terms of access to medicines
In the category of most interest to pharmaceutical companies, i.e. “Pharmaceuticals”, Slovakia took the lead with 113 points, followed by the Czech Republic and Hungary, with 100 each. Slovakia was the only CEE country in which an Rx subsidy (understood as the proportion of total sales of prescription drugs paid for by public subsidy) exceeded 90%. In the Czech Republic, Hungary and Poland the subsidy was between 60 and 90%, and in the remainder – below 60%.
With regard to access to new drugs, understood as the time between registration and inclusion in the subsidy system, Poland and the Czech Republic were the only CEE countries in which the period was less than 300 days, the best score being less than 150 days. In the rest of the CEE countries it was more than 300 days.
It is worthy of note that in four of the six CEE countries analysed in this article (the Czech Republic, Hungary, Romania and Slovakia), there was a layman-adapted pharmacopeia readily available to the public, e.g. by a publicly accessible website. The pharmacopeia in Poland was assessed as not genuinely accessible or frequently updated, and none exists in Bulgaria.



Joanna Swatowska-Rybak
Managing Editor, Newsletters
Joanna.swatowska-rybak@pmrpublications.com