1.

Public Health, Public Heath Achievements;

Epidemiological research in Public Health
Definitions
 Science and art of preventing disease, promoting health through organised community efforts to
ensure a standard of living adequate for maintenance of health (Acheson 1987, WHO)
 The process of mobilising local, state, national, and international sources and conditions to ensure
the health of the population (Oxford Textbook of Public Health, 2000)

History of Public Health

There were 4 periods in the development of public health:
 17-18th Century:
o Prevention of infectious epidemics
o Governmental efforts to control infectious diseases in most of Europe (plague, smallpox,
cholera) through water protection & sanitations
 19th Century:
o Social medicine – strong observations that disease are connected with poverty and poor
living conditions; to care about socially deprived groups to prevent avoidable diseases
 20 Century
th

o Health care systems – entitlement to healthcare, accessibility to health services;

healthcare management
 21 Century
st

o Focus of health promotion to reduce population’s behavioural health

o Risks: smoking, unhealthy nutrition, combat to addiction/development and
management of relevant health services, early detection of diseases through screening
etc

Main characteristics
 Multidisciplinary nature – draws on knowledge/skills of a wide range of disciplines: medicine,
sociology, anthropology, educational sciences, psychology, economics, demography, informatics &
statistics, ethics
 Prevention is a prime intervention strategy – focus (now) on economic, social and behavioural
determinants of health and diseases
 Primarily focused on population
 Linked to governmental and public policy
 Grounded in social justice philosophy
o Principle that everyone has the right to health protection and maintenance of health
o ‘Health inequalities that are preventable by reasonable measures are unfair’ (WHO,
Marmot 2007)
o In the majority of developed countries, the right to health protection and healthcare is
included among basic human rights

Theory & Practice of Public Health

Public health is a broad, multidisciplinary area having a specific theoretical background, methodology,
and practical implementation:
 Theory: study of health determinants of population. The study of human health related
behaviour, identification of vulnerable social groups with regard to health and health risks
  Practice: the creation and implementation of national/regional/local health policy designed to
contribute positively to the health of people thought the development of effective interventions;
to reduce health inequalities
 Public health is about ‘what we, as a society, do collectively to assure the condition for people to
be healthy’. Theses ‘conditions’ are related to the health determinants and play a critical role in
health inequalities

Main Functions of Public Health

 Monitor and assess health status of population, especially at risk groups
 Diagnose and investigate health problems and hazards in the community/country
 Inform, empower, and educate people about health issues, particularly those at risk
 Creation of public policies designed to solve identified national and local health problems and
priorities
 Creation of laws and regulations that protect health and ensure safety
 To assure that the whole population has access to appropriate health care, including health
promotion and disease prevention

Achievements
 Routine use of vaccination for infectious disease
 Control of infectious diseases through improved sanitation and clean water
 Safer foods from decreased microbial contamination
 Improvements in motor vehicles (child seats, seat belts) and workplace safety (WHO/ILO
guidelines)
 Acknowledgement of tobacco as a health hazard and development of anti-smoking campaigns
and anti-smoking legislation
 Cardiovascular risk prevention – during the last 2 decades, the age adjusted Coronary Heart
Disease and Stroke death rates declined significantly in most developed countries
 Prenatal care – improved maternal and infant death rates
 Access to healthcare

Public Health Domains

 Social medicine
o Social inequalities in health – some individuals/groups experience systematically better,
or worse, health that others
o Care about ‘vulnerable’ social groups – elderly, handicapped, chronically ill, those with
mental disorders, poor people, homeless, migrants
o Relevant health programmes to address special needs of the social groups at high risk
e.g. children
 Organisation of health services and health care management
 Health promotion and disease prevention
 Epidemiology (& biostatistics)
 Hygiene and environment
 Occupational medicine

Epidemiology in Public Health

See Q.3
2. WHO & its role in Public Health; Health 2020
WHO
 The body of the UN established in 1948. It has its headquarters in Geneva, Switzerland
 Leading world public heath organisation dealing with international health matters and global
public health
 Coordinator and leader of global health initiatives and strategies in international political context
 193 member countries, 6 Regions and Regional Offices. European regional office is in
Copenhagen, Denmark
Main Task of WHO
 Coordination and solution of the main acute health problems with the impact on global health
o HIV/AIDs, SARS, avian flu
 Humanitarian help and crises management – disasters, political conflicts
 Health policy – support to member states/assistance, consultancy
 Monitoring, assessment, HFA database
 Reports, campaigns, printing documents

Main Areas of WHO Activities

 Health systems: WHO’s priority is moving towards universal health coverage, through working
together with policy-makers, civil society to support countries to develop, implement and
monitor solid national health plans; support of countries to assure the availability of integrated
people-centred health services at an affordable price; to strengthen health information systems
 Noncommunicable diseases develops efforts aimed at reducing the prevalence
noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes and
chronic lung disease, mental health conditions, violence and injuries.
 Promoting health through the life-course: Promoting good health through the life-course takes
into account the need to address environmental risks and social determinants of health, as well
as gender, equity and human rights.
 Communicable diseases: WHO is working with countries to increase and sustain access to
prevention, treatment and care for HIV, tuberculosis, malaria and neglected tropical diseases
and to reduce vaccine-preventable diseases
Non-communicable Diseases – NCDs
 60% of deaths globally; 70% if injuries are included; 80% in developing countries
 >40% are premature
 75% of NCD are attributed to 4 main risk factors:
o Tobacco
o Unhealthy diet
o Lack of physical activity
o Harmful alcohol consumption

Health 2020
Leading public health strategy and policy framework recommended to be implemented in all EU and
other European member states. It aims to support action across government and society to:
“significantly improve the health and well-being of populations, reduce health inequalities, strengthen
public health and ensure people-centred health systems that are universal, equitable, sustainable and
of high quality”
 The individual countries have their modification of the Health 2020 to address health situation in
a country
  The 53 countries of the European Region approved a new value - and evidence-based health
policy framework for the Region, Health 2020 in 2012.
 Implementing Health 2020 in countries is now the fundamental top-priority challenge for the
Region.
 Health 2020 focuses on improving health for all and reducing health inequalities, through
improved leadership and governance for health
It focuses on today’s major health problems in four priority areas:
 Invest in health through a life-course approach and empower citizens – healthy and active
ageing is a policy priority as well as a major research priority.
 Tackle Europe’s major burdens of diseases.
o Health 2020 focuses on a set of effective integrated strategies and interventions to
address major health challenges across the European Region from both
noncommunicable and communicable diseases.
o The effectiveness of these interventions must be underpinned by actions on equity,
social determinants of health, empowerment and supportive environments.
 Strengthen people-centred health systems and public health capacity, including preparedness
and response capacity for dealing with emergencies
 Create supportive environments and resilient communities
o People’s opportunities for a healthy life are closely linked to the conditions in which they
are born, grow, work and age. Resilient and empowered communities respond
proactively to new or adverse situations, prepare for economic, social and
environmental change and cope better with crisis and hardship.

International Public Health

 Public heath in the international context emphasising a population and public health approach to
disease control and health improvement across populations and countries
 International public health is concerned with health problems in developing countries and the
flow of knowledge from developed to the developing countries
 To support of health care development and improving medical practice in poorer countries
within ‘international aid’

3. Concept of Health, Health Determinants,

Epidemiological Studies, Social Gradients in Health
Health
‘Health is a state or complete physical, mental, and social wellbeing and not merely absence of disease’
(WHO, 1948). An alternative definition from Huber et al (2011), ‘the ability to adapt and self-manage in
the face of social, physical and emotional challenges’. And why does the definition matter? It is
important for how we approach health – ‘…If health is the goal of healthcare and research, we need to
know what it looks like and how to measure it’ (Godlee, 2011). It affects the design and delivery of
healthcare interventions
Health Belief Model – a psychological model that attempts to explain and predict health behaviours by
focusing on the attitudes and beliefs of individuals. Health beliefs are a person’s idea, convictions and
attitudes about health and illness based on education, experience, culture, family history etc
Health & Related Terms
 Health
 Wellness
  Disease – objective state
 Illness – subjective perception
 Sickness – focused on social role of patient e.g. not being able to meet job requirements
 Impairment – any loss or abnormality of psychosocial, physiological or anatomic structure or
function
 Disability – any restriction or lack (resulting from an impairment) or ability to perform an activity
in a manner within the range considered normal for a human being
 Handicap – a disadvantage for a given individual resulting from an impairment or disability that
limits the fulfilment of a role that is normal (depending on age, sex, social and cultural factors) for
that individual

Health Determinants
Whether people are healthy or not, is determined by their life circumstances and environment. To a
large extent, factors such as where we live, the state of environment, income and education level, and
relationships with friends and family – all have considerable impacts on health, whereas the more
commonly considered factors such as access and use of health care services often have less impact.
Determinants of health are multiple and interactive. Many of them are connected with and influenced by
human behaviour, and include:
 Physical environment, ecology – safe water and clean air, healthy workplaces, safe houses,
communities and roads – all contribute to good health
 Education, income and social status –
o Higher education levels, higher income and social status are linked to better health.
o Low education levels are linked with poor health, more stress and lower self-confidence.
o The greater the gap between the richest and poorest people, the greater the differences
in health
 Employment and working conditions – people are healthier when have more control over their
working conditions
 Personal behaviour – healthy balanced eating, keeping active, not smoking, not drinking alcohol
much, management of life’s stresses
 Social support networks – greater support from families, friends and communities is linked to
better health
 Culture – customs and traditions, and the beliefs of the family and community all affect health
 Genetics
 Health services – access and use
 Gender
Population Determinants
 Biological factors, genetics – age, sex and hereditary factors (15-20%)
 General socioeconomic factors, community influences – living and working conditions and related
individual lifestyles: nutrition, exercise, smoking, alcohol/drug abuse (50-60%)
 Health services – accessibility, equity, quality (15-20%)
 Environmental factors – air/water pollution etc (15-20%)

Epidemiological Studies
Epidemiology
 Study of the distribution and determinants of health related states or events in human
populations and the application of this study to control of disease prevalence
 The core of epidemiology is the use of quantitative statistical methods to study causes and
dissemination of diseases
  Historically, the focus was on infectious diseases, while there is a shift to non-communicable
disease nowadays
Classic Studies
 Framingham Heart Studies
 Alameda longitudinal studies – to explore the influence of health practices and social
relationships on the physical and mental health
o Results – 7 habits shown to be associated with physical health status and mortality
 Eat regularly and not between meals
 Eat breakfast
 7 to 8 hours sleep every night
 Keep ‘normal’ weight
 No smoking
 Drink only in moderation
 Regular exercise
o Follow up studies in 1975, 1985 of the original cohort
o Persons in socially and economically disadvantaged groups tended to practice
unhealthy lifestyle
 Whitehall studies: UK based, started in the 60s, follow-up in 70s & 90s. Mortality studies among
employees of British Public Services focusing on cardiovascular and respiratory diseases in
connection to job position and working conditions
o Results:
 Age standardised mortality over a 10 year period was 3.5x higher for those in
manual positions as for those in senior positions
 Men and women with low job control had a higher risk of newly reported
chronic disease during the follow up study
 Lalonde report – key messages:
o The role of the medical care in premature death is secondary to that of other
influences
o Social and economic conditions of living and (related) people’s health habits are more
important that medical services
o Societies investment in healthcare is based on the wrong presumption that healthcare is
the major determinant
 British Doctors Study

Social Gradient in Health

All mentioned evidence based sources (studies, publications, statistics) are reflected in the concept of
Social Gradient in Health
 Global phenomenon which means that health gets progressively better as the socioeconomic
position of people and/or standard of living in the country improve
 Applies to all countries, irrespective of income; it works within countries and between countries
 The evidence shows that (in general) – low socio-economic position  worst health; social
inequalities are closely linked to health inequalities
 Social gradient in health is seen in low, middle, and high income countries
 East-West social gradient in the EU
 South-North social gradient in the world
 Figure 1: Life expectancy gaps between high and low education attainment at age 60
by sex. Demonstrates that higher education level is connected with a higher life
expectancy. This difference is more pronounced among men

4.

Figure 1: Bar graph demonstrates link between obesity and education in European
countries. It shows that obesity rates fall with higher levels of education

Medical Demography. Use of Demographic Indicators in

Healthcare
Demography
The statistical study of human populations especially with reference to size, structure, density, and vital
statistics:
 Size & structure
 Development
 Changes of population in response to birth, death, ageing and migration
Focus on:
 Reproduction of populations
  Relationship between the social conditions, population changes (growth/decline) and its
consequences for a society
Relevant Demographic Terms
 Population – all persons in a specifically defined area considered as a whole
 Target population – selected group who share the same set of qualities for epidemiological
purposes or for other public health interventions
 Cohort – groups whose members share a significant experience at a certain period of time or
have one or more similar characteristic e.g. people born the same year are the age cohort for
that year

Use of Demographic Indicators in Healthcare

 Provide information on health status of a population and its development over time
 Help to understand/explain patterns of disease in population
 Help identify risk groups
 Enable to plan public health intervention
 Help to know changes in population structure
 Enable planning/development of adequate structure for health services

Sources of Demographic Data

 Census – procedure of systematically recording information about all members of a given
population e.g. national population and housing censuses, once every 10 years (CR since 18 th
century)
 Routine birth/death statistics – based on birth/death certificates
 Evidence of migration
 Population register – a mechanism for continuous recording of selected information related to
all resident population of a country
 Special surveys – e.g. EUROSTAT (statistical office of the EU) performed special Eurobarometer
surveys based on in-depth thematical studies carried out for the European Commission or other
EU Institutions and the Member states

The Main Demographic Process

Populations are being changed through three processes: fertility, mortality, & migration
 Fertility involves the number of children that women have
o Birth rate in a population is the total number of live births per 1000 of a population in a
year
 Mortality involves the processes affecting deaths to members of the population, the causes,
consequences, and measurement of deaths
o Death rate – the number of people per 1000 of a population in a year who die in a
particular population during a particular period of time; the relative frequency of deaths
in a specific population
 Migration – physical movement by humans form one area to another

Global Demographic Trend

 Acceleration in the rise of the world population, but imbalance between continents and regions
 Current world population (2019) is estimated at 7.7 billion; projected to reach 9.8 billion in 2050
 Population growth – increase of people due to dramatic reduction of death rates, especially in
childhood
o Global child mortality fell from 18% in 1960 to 4% in 2016
o In developed countries, 95% of children survive to adulthood
  Ageing population, which is caused by
o ↓ fertility rates
o ↑ life expectancy
 Urbanisation – majority of the world’s population will live in cities
 Environmental issues, war conflicts, new infections can change population projections in ways
that are difficult to estimate

Demographic Indicators
Two categories:
 Demographic statics – statistics describing status of population in numbers according to age,
gender, education, geographical area, etc
o Population structure (entire population/population by geographic regions) is studied
according to a variety of characteristics:
 Biological signs – age, gender
 Social-legal characteristics – family status
 Socio-economic characteristics – economic activity, occupation, income,
education
 Cultural characteristics – religion, ethnicity
 Demographic dynamics – statistics of the changes in population. Common indicators are:
o Crude birth rate (CBR) – live births per year per 1000
o Crude death rate (CDR) – deaths per year per 1000
o Annual Growth Rate = CBR - CDR
 Natural changes (births/deaths)
 Mechanical changes (emigration/immigration)
 Social/legal changes (number of marriages, divorces)

Two Kinds of Demographic Development

 Natural increase – CBR exceeds CDR (more born than died)
 Natural decline – CDR exceeds CBR (more die than born)
 Natural increase/decline depends upon fertility, mortality, migration, and also on some
social/political events such as wars, natural disasters
 Long term natural decline is considered a threat to functioning society

Fertility Indicators
 Birth rates – number of live births in a given year per 1000 population
 Fertility rate – number of live births per 1000 women of fertility age (15-49)
 Trend in fertility rate – less children per woman and increasing age of (first) pregnancy
especially in Europe, even to a certain extent in developing countries in Africa and Asia
 Fertility rate in Czech Republic: 1.6 (2015)
 Natality rate in CR: 10 (2014)
 Mean age of Czech women at first birth: 30 (2015)

Migration
Migration is one way how to compensate demographic decline in developed countries. From 2000-2010,
global migration grew twice as fast as during the previous decade
 More than 200 million people live outside the country of their birth with an imbalance across the
globe
 East-West and South-North migration movement
 Most migrants live in developed countries
  Benefits and risk related to increasing migration

5. Measurement of Population Health, International

Health Databases
Measures of Population Health
Most are expanded on elsewhere
 Life Expectancy
 Mortality
 Morbidity
 QALYs
 Disability-Adjusted Life Years
 Health Related Quality of Life
 Disease Specific

Population structure
Population structure has a variety of consequences for healthcare, and other public services. The main
characteristics:
 Distribution by sex: index of masculinity – number of men to 1000 women
 Distribution by age and sex: population pyramids
o Progressive type – young group exceeds
o Stable type – balanced age structure
o Regressive type – post-reproductive groups exceed other groups

European Standard Population

 ‘Standard’ populations are artificial populations with fictitious age structures, that are used in
age standardisation as uniform basis for the calculation of comparable indicators for the
reference population(s)
 The used of a standard population is a useful tool for comparison of mortality rates as well as
other population-based rates such as disease incidence and some others
 The European Standard Population (ESP) includes the EU28 plus EFTA countries, on the basis of
2010-based population projections

Health/Public Health International Databases

 WHO database
 Eurostat Health statistics
 OECD Health Indicators: Health at Glance
 Medline: clinical medicine orientated – covers 52% of core public health serials
 Global Health – definitive international public health database

6. Mortality, Data Sources, Basic Indicators, Leading

Causes, International Comparison
Indicators
 Crude mortality rate – the total number of deaths per year per 1000 people
 Age-specific mortality rate – the total number or deaths per 1000 of a given age cohort per year
  Cause specific mortality rate – the number of deaths attributed to specific causes per 100,000
people
 Age Standardised Mortality Rate – the number of deaths, usually expressed per 100,000 that
would occur if population concerned had the same age structure as the ‘standard’ population
and the local age-specific mortality rates of the population are applied
o Standardised mortality rate shows what the crude mortality rate would have been if the
population had the same age distribution as the ‘standard’ population

Common Mortality Indicators

 Child mortality
o The death of infants and children under the age of 5 per 1000 live births
 Infant mortality
o The total number of infant (children <12 months) deaths per 1000 live births
 Neonatal mortality - <28 days
 Post-neonatal mortality – 28d – 1y
o Infant mortality is used to assess the quality of a healthcare system
 Maternal mortality
o The maternal mortality rate (MMR) is the annual number of female deaths per 100,000
live births from any cause related to pregnancy excluding accidental or incidental causes
o The MMR includes deaths during pregnancy, childbirth, or within 42 days of termination
of pregnancy for a specified year
o Maternal mortality in CR: 4.00 (2015)
o Maternal mortality is used to assess the quality of healthcare systems
 Life expectancy
o Average number of years an individual is expected to live if current mortality rates
continue
o Life expectancy at birth refers to the average number of years a new-born is expected
to live if mortality patterns at the time of its birth remain constant in the future
o Life expectancy is commonly used as an indicator of population’s health status in an
international comparison
o Its values depend on economic development, standard of living and quality of life in a
country and less to quality of the healthcare system
o Czech Republic (2017): Men – 76y; Women – 82y
Global Child Mortality Trends
Infant and child mortality in the world declined significantly since 1960 for both less developed countries
and developed countries. However, there are still about 6 million children under 5 years of age who die
annually worldwide
 Lowest child mortality – Finland, Luxemburg: 2.0
 CR has lower under-5 mortality rates than the EU average: 3 (comparable to Sweden, Slovenia,
Estonia)
 Infant mortality rate in CR (2018): 2.7
 CR are among the countries with the lowest infant deaths in Europe. This has been attributed to
the quality of healthcare

Global Child Mortality by Cause:

 7.4 million children under 5 died in 2011; 70% of these were in developing countries
 Most child deaths are from:
o Acute respiratory infection
o Diarrhoea
 o Measles
o Malaria
o Malnutrition
 The main causes:
o In developing countries – vaccine preventable diseases (3 million), diarrhoea (2.7
million), respiratory infections (1.7 million)
o In developed counties – most common are neonatal causes and congenital defects

Worldwide Determinants of Premature Deaths

 Decrease in mortality is generally caused by behaviour changes, increase in food supplies, better
living conditions, eradication of infections, better healthcare
 The ‘big 5’ causes of premature deaths/avoidable deaths responsible for around a quarter of all
premature deaths around the world each year:
o Poor childhood nutrition
o Unsafe sex
o Alcohol
o Bad sanitation
o High blood pressure

Leading Causes of Death - UK

 Ischaemic heart disease
 Alzheimer’s disease
 Stroke
 COPD
 Cancer: Lung > colorectal > breast > prostate

Worldwide
7. Morbidity, Data Sources, Basic Indicators, the Causes
of Global Morbidity
Healthy Life Expectancy (HALE)
The average number of years that a person can expect to live in ‘full health’ by taking into account years
lived in less than full health due to disease and/or injury. HALE combines estimates of self-assessed
health within estimates of life expectancy. It appears that CEE countries, SE Europe and the Baltic states
have shorted life expectancy, along with shorted expected lifespan in good health than countries in
Western Europe

Morbidity Indicators
Morbidity – the proportion of sickness or of a specific disease in a geographical locality. The incidence
or prevalence of a disease or of all diseases. There are a variety of indicators:
 Prevalence – the total number of cases of a disease in a given population at a specific time per
100000
 Incidence – number of new cases of disease in certain period (1 year) per 100000
o Age standardised incidence rate - represents what crude rates would have been if the
population had the same age distribution as the standard (European) population
 Number of hospitalised – total/by gender/age/cause
 Sickness leave (SL) – percentage of all economically active persons on SL in a given period; total
number of SL days, causes of SL, average length of sickness leave
 Number of out-patient visits
 Number of chronically ill patients – total/by age/gender/disease
 Self-reported health
o Reflects people’s overall perception of their own health, including both physical and
psychological dimensions
o Typically, survey respondents are asked about a question such as ‘how is your health in
general? Very good, good, fair, poor, very poor’
o OECD Health Statistics provide figures related to the proportion of people rating their
health to be good/very good online
 Disability rate

Sources of Morbidity Data

 National registers of disease: registers are collections of detailed data related to patients with a
specific diagnosis, conditions, or procedure; they play an important role in health status
monitoring within national health information system – all patients for whom a particular disease
was diagnosed are recorded in registry.
 Czech national disease registers:
o Cancer register (operating since 1976)
o Infection diseases register
o Congenital defects register
o Occupational diseases register
o Register of hospitalized patients
o Others
 Sickness Leave Register
 Special survey based on investigation by special questionnaire (subjective perception of health)
Disability Indicators
Figure 3: Most people
Disability-adjusted in OECD (Organisation
life expectancy for Economic
(DALE) – estimates Co-operation
are based & Development)
on the life tables for each country,
countries report being in good health. Source: OECD Health Data 2011
population representative sample surveys assessing physical and cognitive disability and general health
status, as well as detailed information about epidemiology of major disabling conditions in each county
Disability free life expectancy (DFLE) – the average number of years an individual is expected to live free
of disability if current patterns of mortality and disability continue to apply

Common Causes of Morbidity in Europe

 CVD, esp. strokes & heart  Premature births, other  Injuries
attacks perinatal deaths Cancer
 Infections including HIV/AIDS  Cancer  Depression
 Diabetes

Leading Causes of Morbidity Worldwide

Chronic disease – heart attack, stroke, cancer, chronic respiratory diseases and diabetes; these are by far
the leading cause of morbidity and mortality in the world, representing 60% of all deaths. This invisible
epidemic is an underappreciated cause of poverty and creates a barrier to economic development in
many countries

Key Facts – Global Morbidity/Mortality

 NCDs account for 63% of all deaths
 80% of NCDs deaths occur in low/middle income countries
 ¼ of NCD deaths occur in people >60y
 4 major risk factors for NCDs: tobacco use, harmful alcohol, poor diet, and physical inactivity
 Over one billion adults are overweight
 Tobacco use kills more than 5 million people per year; could rise to >8million by 2030
 Eliminating major risk factors could prevent most NCD

8. Quality of Life – Measuring Quality of Life; Health

Related Quality of Life
Quality of Life
‘What every physician wants for every one of his patients old or young, is not just the absence of death
but life with a vibrant quality that we associate with a vigorous youth. This is nothing less than a
humanistic biology that is concerned, not with material mechanisms alone, but with the wholeness of
human life, with the spiritual quality of life that is unique to man. Just what constitutes this quality of life
for a particular patient and the therapeutic pathway to it often is extremely difficult to judge and must lie
with the consciousness of the physician’. (Elkington, 1966)
Quality or life has 2 components:
 Objective components – i.e. components external to
an individual and measurable by ‘others’ (material
wealth, social status, physical well-being)
 Subjective components – i.e. personal assessments
of one´s own life or of particular aspects of life using
measures of satisfaction, happiness, or other self-
assessment scales
Examples of Definitions
 Quality of life is the satisfaction of an individual´s values, goals and needs through the
actualisation of their abilities or lifestyle (Emerson, 1985)
 Quality of life is the product of the interplay among social, health, economic and environmental
conditions which affect human and social development (Ontario Social Development Council,
1997)
 Quality of life is the overall enjoyment of life (National Institutes of Health, 2015)
WHO Definition
Quality of life is an individual´s perception of their position in life in the context of the culture and values
systems in which they live and in relation to their goals, expectations, standards and concerns. It is a
broad ranging concept affected in a complex way by the person´s physical health, psychological state,
personal beliefs, social relationships and their relationship to salient features of their environment
(WHO, 1997).

Models
A number of models trying to explain and cover the multidimensional term ‘quality of life’ have been
made
 Figure 2: Being, Belonging, Becoming - 3 broad categories of assessing QoL
Three Levels of QoL

Overal
l QoL
Assess
ment
Widely defined domains
(i.e. somatic, psychological,
economical, social,
spiritual)

Single partial items specifying every domain

Health Related Quality of Life

 Evolved since the 1980s
 The subset of QOL
 Encompass those aspects of overall quality of life that can be clearly shown to affect health—
either physical or mental
Health-related quality of life (HRQoL) is defined as an assessment of how the individual's well-being may
be affected over time by a disease, disability or disorder. It represents patient‘s subjective perception of
the impact of the disease on his/her everyday life, somatic, mental and social functioning and well-being.
It is a significant indicator of the result of provided healthcare.
QoL Measures
 Quantitative approach
 Qualitative approach
 Combined method
Generic Instruments
Which can be used with different population groups, healthy and clinical populations and various
diagnostic patient groups and therefore facilitate comparisons across groups
 Some instruments are intended for general use
 Many of the earlier questionnaires – emphasise the measurement of general health (the Sickness
Impact Profile; the Nottingham Impact Profile)
 Newer instruments – emphasise strongly subjective aspects, such as emotional, social and
existential issues
 One or more questions that explicitly enquire about overall QoL
 Examples:
o World Health Organization Quality of Life Assessment (WHOQOL100)
o World Health Organization of Life Assessment – Abbreviated Version (WHOQOL-BREF)
o ‘Better Life Index’ (OECD measure)
o Medical Outcomes Study, Short Form 36 (SF-36 Health Survey)
o The European Quality of Life (EUROQOL) or Euro-QoL 5- Dimensions (EQ-5D)
o Schedule for the Evaluation of Individual Quality of Life (SEIQoL)
o Assessment of Quality of Life – 8D (AQoL-8D)
o World Happiness Report
Indicator of Wellbeing (OECD measure)
Better Life Index – assessment of 11 specific aspects of life: income, job, health, education, environment,
social network, public administration, private safety, work/life balance, subjective satisfaction with life
 OECD publication – ‘How’s Life?’ (2011)
 Standard macroeconomic statistics like GDP fail to give a true account of people’s current and
future wellbeing.
 Income is a prime contributor, but other factors matter more; wellbeing is linked to good health,
a clean environment, a strong sense of community and civic engagement, a home in good shape
and a safe neighbourhood
Disease Specific Instruments
Which are assumed to have greater sensitivity to the implications of a single condition by including
questions specific to the condition in question
Examples:
 The EORTC Quality of Life questionnaires (The EORTC QLQ-C30)
 The Kidney Disease Quality of Life -36 (KDQOL-36)
 The Diabetes Quality of Life Clinical Trials Questionnaire Revised (DQLCTQ-R)
 The Minnesota Living with Heart Failure Questionnaire (MLHFQ)
 The Arthritis Impact Measurement Scales (AIMS)
 The Hospital Anxiety and Depression Scale (HADS)
 The McGill Pain Questionnaire (MPQ)
 The Stroke Specific Quality of Life scale (SS-QOL)
Importance of Quality of Life Measurement
 Is used to supplement objective clinical or biological measure of disease to assess the quality of
service, the need for health care, the effectiveness of intervention, and in cost utility analyses
 Can help determine the burden of preventable disease, injuries, and disabilities, and can provide
valuable new insights into the relationships between HRQOL and risk factors
 Can help monitor progress in achieving the nation’s health objectives
 Can help identify which needs people perceive as most significant
 Can help in developing health promotion and disease prevention programs
 Reflects a growing appreciation of the importance of how patients feel and how satisfied they
are with treatment in addition to the traditional focus on disease outcomes

9. Social Structure & Health: Inequalities in Health,

Access to Health Services, Vulnerable Social Groups
Wealth & Health
The key factors significantly influencing health of nations are wealth and income (social) inequalities.
 Wealth of the country – expressed by GDP per capita; Higher GDP = better health of population
 Income inequalities – expressed by the distribution of wealth in a society; higher GI = higher
income inequalities  worse health of population
 Indicator of income inequalities is the Gini Index

Gini Index
 Common indicator of the income inequalities
 Percentage of national wealth in the hands of the richest part of the population – higher GI
means that larger proportions of wealth is in the hands of a smaller proportion of the population
 Higher GI  lower chance for health and long life of population of as a whole
 Denmark 26, Sweden 26, Norway 26, Czech Republic 26, France 30, Germany 30, UK 37
 South Africa 63, Namibia 61, Botswana 61, Brazil 53
Relation of Life Expectancy to GDP and income inequalities (GI) in 2004
 The larger the GDP per inhabitant, the longer people live
 Average LE of top 50 GDP countries – 76y
 Average LE of bottom 50 countries – 45y

Inequalities in Health
Differences in the health status of various populations caused by various determinants of health; some of
these differences are perceived as being unfair. They are caused by barriers which prevent people from
accessing conditions better for their health. The most important determinants of health are:
 The way of life
 The place where people live
The Black Report
Report on the influence of social factors on health of the population of Great Britain (Douglas Black) at
the beginning of the 1980s. Epidemiological and sociologic research produced data showing the impact
of low income, low education, poor housing conditions, and poor work environment on health
Principle Questions Regarding Equity in Health
 Are there any social determinants of health?
 Is there any relationship between poverty and health, or accessibility to healthcare?
  Are there any differences in health related to
o Social status, social class?
o The place where people live or work?
o How people spend their free time?
 Are there any vulnerable social groups?

WHO Social Determinants of Health

Social gradient: low/middle/upper class Stress
Early life conditions Social Exclusion
Work (where/what kind) Unemployment
Social Support Addiction – drugs, alcohol
Food – quality & quantity Transport – access to healthcare

Equity vs Equality
Equality – a state of being equal; correspondence or similarity
 Natural inequalities – differences between people given by natural physiological constitutions
and conditions (sex, races, age, climate, genes). Usually perceived as normal, given, and fair
 Socioeconomically determined inequalities
o Facts which are perceived as avoidable & undesirable
o Can be influenced by lifestyle, habits, behaviour, economic activity and socioeconomic
position
Equity – a notion indicating justice or fairness
 In cases where inequalities in health are growing and perceived as unfair, unacceptable,
inhuman, influenceable, the question of equity appears (on global, international, and national
level)
 Equitable does not mean egalitarian (adjective: believing in or based on the principle that all
people are equal and deserve equal rights and opportunities)
 Equitable inequalities reflect the specific needs and strengths of various population groups

Figure 3: Picture from lecture. 'Why treat people, then send them back to the conditions that made them
sick?'

Causes of Inequality in Health & Health Provision

 Lack of resources (water, food, information, health facilities)
 Lack of political interest and absence of social responsibility of the states (limitation in public
resources for the health care and health promotion – extreme market orientation (individual
responsibility)
  Social, economic and cultural level of the country, the wealth and education of population and
social cohesion
o Social position of people in society (defined by education, occupation or economic
resources) – an important, central determinant of social inequities in health influencing
the type, magnitude and distribution of health risks experienced within different
socioeconomic groups

Indicators of Inequality
 Life expectancy
 Mortality – poorer the country, the higher the mortality (Wilkinson, 1996)
o In Europe, cardiovascular mortality and external causes contribute to a nearly 20 years
difference in life expectancy
o West-east gradient
 Expenditure – out of pocket health expenditures
o In many low and middle income countries, out-of-pocket healthcare expenditures are
high, and can be a significant financial risk to the poor.
o Universal health coverage (UHC) is about people having access to needed health care
without suffering undue financial hardship

Socioeconomic Deprivation
 Deprivation – a shortage of something which is needed and regarded as normal or appreciated in
society; a lack of resources to live the same way of life as the majority of other people
 Material deprivation – people live below a socially acceptable standard
 Social deprivation – barriers in participation in social life, social isolation, social exclusion,
discrimination, absence of social support
o Phycological consequences:
 Feeling of failure (of an individual/group/community)
 Changed self-perception (not accepted, excluded)
 Low motivation and aspirations
 Secondary disability
 Social exclusion

Socially Disadvantaged Communities

There is a tendency in economically well developed countries to form socially homogenous
communities. Socially disadvantaged communities experience social stress caused by:
Low income Unemployment Low educations
Low cohesion (social exclusions, High density of population in a Family dysfunction (divorced,
social ghettos) small area single mothers)
Institutionalised life Conflict and violence Alcoholism & drugs

Stigmatised communities are localities with bad reputations, with neglected and deprived population.
They become socially excluded are at risk of:
 Apathy and indifference – no interest to change something
 Lack of self-confidence and self-respect
 Lack of confidence to others
 Lack of interest in services (including health services) – sometimes refusing the mainstream of
the society, even aggression (blaming, criminality), or refusal of help
Subsequent Negative Impact of Social Stress on Health
 Higher infant mortality
  Higher morbidity at children
 Higher morbidity and incapability to work at adults (depression, injuries and violence, infectious
diseases, dermatological diseases, sexually transmitted diseases, bad dental health, diabetes,
TBC)
 Higher mortality both at children and at adults (socioeconomic gradient)

Tackling Inequalities in Health

 Critical reflections, monitoring and assessment
 Control of the market orientation impact (its values) on the increase of inequalities
 In resources allocation – think about health promotion and accessibility of care for vulnerable
social groups
 Community planning, community empowerment, education, health promotion

Vulnerable Social Groups

They have a higher risk of health problems because of their living conditions and way of life:
 Socially isolated people (seniors, homeless)
 Discriminated people (threatened because of their race, colour of their skin, religion, age, sex)
 Poor people
 Older people with long-term illness and people with disability
 Children, young people from deprived communities, too young, and incomplete families
(unemployment, criminality, drug, premature pregnancy, smoking, alcohol abuse)
 Rural inhabitants
 Roma population in CR
 Migrants

10. Social Paediatrics: The Risk Factors in Child Health

Development, Foster and Institutional Care, Related
Risks
Childcare
 Own (biological) family
 Extended family
 Substitute family
o Foster care
o Adoption
Reason for alternative care
Parents:
Cannot
 Also, deceased, serving time in prison, long term stay away from home, previous longer military
service
 Unemployment, poverty, high number of children
 Natural catastrophes/environmental disasters, military conflicts
 Handicapped, illness or parent/child
 Family disintegration – divorce, assigning one parent to care for the child
 Exoneration of discretion – placing of child into institutional care
 Father is unaware he is a parent
Don’t want to
  Parent is a disharmonic personality with psychopathic, maladaptation traits, alcoholic, drug
dependent, gambler etc
 Child is unwanted
 These are de facto socially orphaned children, put at risk by their own family environment
Don’t know how to take care of a child
 Parent‘s immaturity (adolescent parent) or on the contrary – old parents
 Inability to cope with non-standard situations (child born outside marriage, child with handicap,
child in substitute care etc.,)
 Inability to accept specific social norms
 Parent with mental or other handicap
Abuse of child – CAN syndrome

Trends in Today’s Families

 The number of children is decreasing (there is 1.44 children per one fertile woman) - negative
balance = "demographic conservation"
 The number of young couples which remain deliberately childless is increasing
 The number of couples which remain childless for the reasons of infertility (of one or both
parents) is – about 18 % - equally distributed in both sexes
 Having a baby is postponed to later time (before the revolution the average age of primipara was
19.5 years of age, today it is more than 30 years) – reasons are economic, social, educational
(university students), ‘travel and experience’, housing reasons etc.
 Good quality of contraceptives, which are much more used by women (about 3-4 times more
often than before 1989) – children are more planned, lower number of children, lower number
of children is unwanted
 Young people cohabitate without marriage much more often
 Higher ratio of children born outside marriage
 Time spent together (children and parents together in the family) is decreasing & there is lack of
time to spend on taking care of the child in general
 Numbers of marriages and divorces doesn‘t change much
 Since the year 2001 the number of live born children has steadily increased, as well as the
number of children born outside marriage
 The number of interruptions decreased until the year 2006, when it was stabilized
 ~10000 children in Institutional care

Institutional Care in CR
 Our country is criticized for having high number of children in institutional care
 It is partly caused by very high level of prenatal and neonatal care in our country with
corresponding low neonate and infant mortality; many children with various congenital defects
are saved yet sentenced to a stay in institutional care – the parents want a healthy child. (That’s
a pretty sweeping generalisation… 😐)
 Into school-type institutions the children come in most often between 10-14 years of age, the
family is failing in its function, the state does not leave the child on the street, immediately the
child is transferred into institutional care (unlike in other countries – USA, UK etc.)
Number of children in substitute family care
Up to Jan 1st 2006 6873
Up to Jan 1st 2007 7228
Up to Jan 1st 2008 7581
Up to Jan 1st 2009 8159
The trend in substitute family care and institutional care:
 The numbers of children in substitute family care increase every year (as well as in adoption as
in foster care)
 There is a maximum effort on the side of infant institutes (suckling homes, children homes and
children centres) to place the child in its own family, or at least substitute family
 There is a minimum shift of children under 3 years of age into school-type institutions (majority
into families)

Risk of Harm to Young Children in Intuitional Care (Save the Children)

Not from lecture but probably more useful
Young children are frequently placed in institutional care throughout the world. This occurs despite wide
recognition that institutional care is associated with negative consequences for children’s development.
An institution or residential care home for children is defined as a group living arrangement for more
than ten children, without parents or surrogate parents, in which care is provided by a much smaller
number of paid adult carers. Typically, in Europe this would be one carer to six children of a similar age
during the day and fewer staff at night. Staff are often inadequately trained and poorly supervised,
making basic mistakes such as feeding a child (who should be able feed himself) on his back in a sleeping
position. Residential care implies an organised, routine and impersonal structure to the living
arrangements for children (e.g. all children sleep, eat and toilet at the same time) and a professional
relationship, rather than parental relationship, between the adults and children.
Figure 4: Reasons for institutionalisation of children under three years in EU accession countries undergoing
economic transition, 2003 (data from Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania,
Malta, Romania, Slovakia and Turkey)
Typically, institutions for young children under four years are overcrowded, clinical environments with
highly regimented routines, unfavourable care-giver to child ratios, and unresponsive staff who see their
roles more related to nursing and physical care than to psychological care. An over control of the
children’s environment has a number of detrimental effects:
 Physical underdevelopment
 Hearing/vision problems that may result from poor diet/under stimulation
 Motor skill delays and missed developmental milestones
 Poor health and sickness from overcrowding
 Physical and learning disabilities
Children living in institutions without parents are reported to perform poorly on intelligence tests and to
be slow learners with specific difficulties in language and social development, in comparison to children
with foster parents. In addition, they had problems concentrating and forming emotional relationships,
and were often described as attention-seeking. The lack of an emotional attachment to a mother figure
during early childhood was attributed as the cause of these problems, which were considered to be long-
lasting.
Poor care-giver to child ratios not only inhibit social interaction, but also influence the way staff respond
to the needs of the children in residential care, which can significantly influence the children’s attention-
seeking behaviour
Full report: https://www.unicef.org/kyrgyzstan/media/2971/file/The%20Risk%20of%20Harm%20Young
%20Children%20Institutional%20Care%20EN.pdf%20.pdf

11. Social Paediatrics: Syndrome CAN

This is all from the lecture but its absolute drivel. Skip to end for notes from the Oxford handbook

Lecture
A qualified estimate of maltreatment or neglect if CR is at 1-2%, with sexual abuse being more frequent.
Some studies state that up to 10% of women and 5% of men have experienced some form of sexual
abuse.
 1950s – physicians began to take an interest in the occurrence of severe injuries (multiple
fractures, frequent rib and scapula fractures, fracturs of the humerus and femur under 2 years of
 age, etc) which cannot be explained by accidental injury. They called them non-accidental
injuries
 In 1963, Kempe described battered child syndrome and furthered the campaign aimed against
child maltreatment
Risk Factors for Abuse

From the child’s point of view:

Prematurity Unstable, anxious, tearful child
Restless, hyperactive, impulsive child – LCD, Skipping school, wandering, running away from
ADHD home
Handicapped child Child with chronic or repeated disease
Conduct disorders Child lying
Prematurity Not fulfilling the parent’s expectations

From the parent’s viewpoint:

Divorce
Psychiatric illness
Anomalies in personality development, often with
aggressive personality traits
Generally, being an arsehole
Followers of aggressive rituals
Atypical lifestyle
Neurotic difficulties (chronically frustrated)

From the viewpoint of family situation and relationship – situations that will strain the parent-child
dynamic:
Unwanted child Underage parents
Single parent Drug dependency
Alcoholism Homelessness
Larger families with many children in a confined space

From the point of view of wider social associations

 Ethnic groups or other minorities
 Child living in poverty
 Unemployed parents
 Rural, uncivilised areas
Risk Factors for Sexual Abuse
 Risk adults:
o Sexually hyperactive males
o Sexual deviants
o Alcoholism, drug addiction
o Older men with some form of senile dementia (limited control of instinctive behaviour)
 Children at risk
o Buxom girls of pleasant feminine shape – ‘mature’ ( ??? this lecture is absolute
horseshit)
o Affectionate, cuddly, flirty
 Risk situations
o In the past – confined life space of the family (parent sleeping with children)
o ‘Opportunity makes a thief’ – child might be ill, father takes care, care requires intense
body contact
o Family friend
o Loose sexuality in the family
 o Educators in various institutions
o Summer camps
o Interest groups, clubs

CAN Syndrome
Neglect Symptoms:
 Depressive, tearful child when cared for by different person
 Child visually uncared for – poor hygiene, ragged/unkept clothing
 Child remaining for long period of time without proper care, nutrition, supervision
 Two categories:
o Severe neglect (failure to thrive) – health & life endangered
o General neglect
 Physical, psychic neglect, neglect of upbringing and education
 Child living in irregular daily regimes and inadequate environment (e.g. passive smoking)
 Child (from indolence) ‘cast off’ into care of neighbour, friend, often not well taken care of
 Child ‘cast off’ into collective care
 Child without regular preventive checks, vaccination
Symptoms of Physical Maltreatment
Closed injuries:
 Concussion
 Shaken baby syndrome – extreme violence which can cause permanent neurological handicap
and even death
 Contusions – haematomas of varied age, ‘imprints’
 Injuries by instruments used for beating – belts, stick, hose, spatulas etc
 Bald spots from hair yanking
 Bite marks
 Muscle, tendon, joint, nerve, blood vessel lesions
 Bone lesions – fractures
o ‘Chip’ fractures – at the ends of long bones, originating from extensive pulling, twisting,
twitching
o Typical fractures caused by maltreatment – spiral fractures of humerus, femur fractures
in a child under 2 years of age, lateral part of clavicle fractured from frontal blow
 Strangulation lines and imprints
 Thermal injuries
 Flan scars from impact and burn/scald injures
 Frostbite
 Psychic maltreatment
 Sexual abuse
Open injuries:
 Cutting wounds
 Stabbing wounds
 Lacerations
 Slash wounds
 Deeper biting wounds
 Gunshot wounds
 Mucous lining lesions
 Burns
Symptoms which occur in acute emergencies
 Loss of consciousness
 Headaches
 Stomach-ache
 Vertigo
 Muscular pain, cramping
 Breathing, circulation irregularities
Poisoning of child also has to be taken into account:
 Chemicals
 Overdose with medication
 Poisons, pesticides
 Alcohol, drugs
Symptoms of Psychological Maltreatment
 Active element – some negative activity is happening to the child
o Belittling, ridicule, distrust, hostility
 Passive element – something which should take place isn’t happening
o Lack of love, lack of interest, inattention, lack of care from people the child loves
 Parents with strenuous work-load – don’t have time for the child, they still do everything for the
child’s wellbeing
o Worse results in school may occur
 Emotional blackmail, extortion
o Shaming for bad grades
o Blaming child
o ‘You are the same as your father’
o ‘You are so ungrateful, is that what I deserve for all the care I give you?’
 Comparing to siblings
Forms of Sexual Abuse
 Non-contact
o Exhibitionism
o Showing off adult sexual activities in front of children
o Offering erotic or pornographic material to the child
o Obscene talk and phone calls
 Contact
o ‘passive abuser’ – lets him/herself be touched or arouse in various ways
o Active abuser
 Harassment
 Molestation
 Sexual activities
 Commercial Sexual Abuse
o Child prostitution
o Child pornography
o Child trafficking

Special Forms of CAN

Examples:
 Child denied right to information
 Right to audition is denied to the child (?)
 Child is unjustly separated from the parents
  Child is traumatised by insensitive and repeated medical examinations
 Anxiety of the child caused by contact with the judicial system
 Insufficient services to help maltreated or abused child
Newer Forms
 Munchhausen syndrome by proxy
 Cyber-hazing
 Happy slapping (what year is it, 2007?)
 Bum fights
 Grooming

Principles of Examining a Child with CAN syndrome suspicion

 Fully examine a fully exposed child
 Observe the child’s conduct
 Take not of parent’s behaviours
 Be alert of eventual exaggerated shyness
 Properly record and document everything
 Use specialised examination rooms
 Be alert of secondary victimisation possibilities

Intervention Principles
 Help has absolute priority over punishment
 Necessity to prevent repetition
 Break medical discretion
 When child is in imminent and acute jeopardy, placement away from family is necessary
 Immediately being steps in legal process regarding child’s future
 The person who reported the wrongdoing must be guaranteed anonymity
 Child’s well-being is the top priority
 3 types of therapeutic intervention
o Acute, crisis intervention – solution ‘on the spot’; establishing a diagnosis, determining
the child’s treatment and its urgency, placing child in a neutral location
o Mid-term intervention – finishing the definitive diagnoses. Physician is obliged to
provide all the documentation necessary to investigate and solve the case
o Long term intervention – include complex, interdisciplinary activities beneficiary to the
child

Prevention of Violence Committed on Children

 National conception of family policy
 Conception of care for children in danger and social-legal protection of children
 Equality for women and men
 Help for families in material need
 Law regarding pedagogical personnel and consequent edicts
 Law regarding the execution of institutional or protective upbringing in school-type institutions
and preventive-educational care in school type institutions
 Methodical instruction towards ensuring safety and health protection of children, pupils and
students in schools and school-type institutions established by Ministry of Education
 Methodical instruction of the Minister of Education towards prevention and solution of hazing
among school and school-type institutions students
 Framework educational programs
 Civic rules of court novelization
  New penal code
 Law regarding probation and mediation service
 State policy conception for the area of children and adolescents
 National anti-drug policy strategy
 Criminality prevention, fighting extremism, racism and xenophobia
 Conception on fighting criminal activities in the IT area
 Supporting Romany community integration
 National plan on fighting commercial sexual abuse of children
 National plan on fighting human trafficking
 Long-term program for improvement of Czech Rep. populace health-status (Health for everyone
in the 21st century)
 National strategy for prevention of violence committed on children
 Methodical instrument of the Ministry of Health CR ‘Primary care physicians’ proceeding in case
of CAN syndrome suspicion

Notification Duty
 According to Penal code Nr. 40/2009 Sb.
 According to Law regarding social-legal protection of children nr. 359/1999 Sb. (§ 10, art. 4) &
amendment of this law
 The New Personal Law Nr. 89/2012 Sb.

Oxford Handbook of Clinical Specialities – Paediatric Non-accidental

injury
In England, the Children’s Act states that the child’s safety is always paramount.
Child abuse is defined as the deliberate infliction of harm to a child or failure to prevent harm, and may
be physical, sexual, emotional, bullying and online abuse, or neglect
Neglect is a persistent failure to meet a child’s basic physical or psychological needs that is likely to result
in serious impairment of the child’s health or development
Munchausen’s by proxy – a parent fabricates alarming symptoms in their child to gain attention via
unnecessary intervention.
When to suspect abuse:
 Disclosure by child
 Odd story, incongruent with injury; odd modes of injury
 Delayed presentation to doctor, or brought by someone who isn’t the parent
 History inconsistent with child’s development. Can the baby really walk?
 Efforts to avoid full examination e.g. after an immersion burn
 Psychological sequelae from sexual or emotional abuse
 Unexplained fractures e.g. forearm or rib
 It is rare for a non-ambulant baby to sustain accidental fractures
 Buttock, perineum or facial injuries
 Also: cigarette burns, whip marks (belt buckle marks), bruised non-mobile baby, finger marks
Next steps
 The first aim is to prevent organ damage, murder, or other significant harm. If there is a real
concern, admit the child and contact the duty social worker e.g. for an emergency protection
order.
 Offer help to the parents
  Learn to listen, leaving blame and punishment to the judges; as a doctor our duty is to care for
the patient by recognising possible abuse and get help, not diagnose abuse
After informing social services, liaise with health visitor (may be a useful source of information) or NSPCC:
 Admission to a place of safety e.g. hospital or foster home
 Continuing support for parents and protection of siblings
 Preventions: encourage impulses to be shared, not acted upon
 Attend a case conference (social worker, health visitor, paediatrician; police)
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/protecting-children-and-young-
people

12. Demographic Ageing & Longevity, and Consequences

for Health Policy & Health Care
Population Ageing
 Decreasing fertility and
increasing life expectancy
are causing population
ageing
o 1999 – 593 million
persons aged 60+
(10% of world
population)
o 2050 - ~2 billion
persons aged 60+
(22% of world
population)
 The old-old (individuals aged 85+) are the fastest growing group of older aged people
 Europe has (and is expected to continue to have) the highest proportion of older aged people
 Developing (low and middle income) countries are going to see the most dramatic change
o Less time to deal with the consequences of ageing
 The EU27 population will rise from 495 million in 2008, to 521 million in 2035, and thereafter
decline to 506 million in 2060

Life Expectancy in CR
 LE at birth: Male 71.8 Female 78.6
 LE at 65: Male 13.8 Female 17.4
 LE rapid growth since 1990, still 2-3 years shorter compared to EU
 All causes of mortality: Male 1162 Female 691
 1.5x higher than EU countries
UK Population Pyramids

Figure 5: Population
in UK 1950 & 2010
and projected for
2050 & 2100. Source
United Nations,
AGE
 AGE
Department of Economic and Social Affairs, Population Division (2011): World Population Prospects: The 2010
Revision. New York

POPULATION NUMBER (Millions)

Impact of Population Ageing

 Health status: Quality of Life, medication use, functional ability, disease
 Social status: loneliness, wellbeing, happiness
 Policy implications: driving service utilisation, care cost, promoting health
 Biological influences: cellular changes associated with disease; genetic factors associated with
longevity
 Cognitive function: age related decline, mild cognitive impairment (MCI) and dementia

Medication Use
Current Trends in Treatment Utilisation (Source: The Medical Research Council (MRC) Cognitive Function
& Ageing Study (CFAS))
 High medication use: of people aged 65-74y 25% reported not taking any medication, compared
to 16% of people aged 75+
 Polypharmacy (5 or more medications) was found to be substantial:
o Reported in more than 10% of people aged 65-74y
o Nearly 15% of people aged 75y+
 Differences in frequency of use of drug classes – cardiovascular medication most frequently used

Priority Areas for Action

 Align health systems
o Place older people at the centre of health care
o Shift the care focus from managing disease to
optimising what people can do
o Develop a health workforce
 Develop long-term care system
o Establish the foundation for a functioning
system
o Develop the long-term care workforce
o Ensure the quality of long-term care
 Create age-friendly environments
o Combat ageism
o Enable autonomy
 o Support Health Ageing in all policies
 Improve measurement, monitoring, and understanding
o Agree on metrics, measures and analytical approaches
o Improve understanding of the health status and needs of older populations
o Increase understanding of ageing trajectories and what can be done to improve them
Investing in Healthy Ageing means creating a future that gives older people the freedom to live lives that
previous generations could never have imagined
Useful link: https://www.who.int/ageing/en/

13. Chronic Morbidity, Disability, & its Social

Consequences in Older People
Age Associated Disease
Increased incidence and prevalence of age associated diseases:
 Cardiovascular disease
 Cancer
 Arthritis
 Dementias
 Sensory loss – hearing/visual
impairment
 Obesity
 Cerebrovascular Disease
 Diabetes

Dementia
An acquired, persistent impairment of Figure 8: Gender differences in age related disease. Shows
mental abilities often accompanied by need for different targets depending on gender. Source
changes in personality and behaviour. Medical Research Council (MRC) Cognitive Function and
Impaired daily living, occupational Ageing Study (CFAS)
functioning and social interaction
Consequences of Different Dementia Stages
 Mild (often overlooked)
o Forgetfulness
o Losing track of time
o Becoming lost in familiar places
 Moderate (signs & symptoms clearer, and more restricting)
o Forgetful of recent events & names
o Lost at home
o ↑ communication difficulties
o Help with personal care
o Behavioural changes, including wandering and repeated questioning
 Severe (near total dependence and physical inactivity)
o Unaware of time and place
o Difficulty recognising relatives & friends
o ↑ need for assisted self-care
o Difficulty walking
 o Behavioural changes that may escalate and include aggression
Relevance of Dementia
 Prevalence of dementia doubles with every 5 year increase across the age range 65-95+
 Higher rates in institutions
o 55.6% in persons 65-69y
o 64.8% in persons aged 95+

40

35

30
Prevalence (%)

25

20

15 F (%)
M (%)
10

0
65–69 70–74 75–79 80–84 85–89 90–94 95+
Age Group
Figure 6: Dementia prevalence by age group & gender. Source: Dementia UK Full Report, 2007)

Impact
 Mainly through years lived with disability, not mortality
 Contributes much more than other chronic illness to
o Disability
o Need for care
o Carer strain
 Alzheimer’s disease is in the top 5 leading causes of death in the Western World in adults aged
65+

Disability
A person is disabled when: he or she is not able without help or without difficulty to carry out ‘main’
age-appropriate activity (go to school, work and participate in societal activities). In old age – when not
able to live independent life in the community and take care about him/herself and his/her household.
Independence and functional capacity are paramount
Disability & Autonomy
Autonomous (self-sufficient) is a person who is not physically nor mentally limited and is able to carry out
all activities of daily living in his/her own household without help or assistance of others.

Main Characteristics of Disability in Old Age

 Hierarchy of functional loss (early loss- in complex activities e.g. driving, transportation, late loss-
in basic selfcare)
 Prevalence and severity increases with age
 Gender difference (female live longer but are more often disabled)
 Causes different from young and middle aged
 Importance of environmental (housing) and social (low income, availability of caregiver) e.g.
‘nonmedical’ factors

How to Measure Disability

What to measure? Assessment of functional status by use of standardised, validated, sensitive and
reliable scales:
  Self-care with Activities of Daily Living (ADL) scales e.g. Barthel ADL Scale, Katz ADL Scale
 Independent living with Instrumental Activities of Daily Living (IADL) scales e.g. Lawton IADL
 Mental status (cognition and mood problems) e.g. Mini Mental State Exam (MMSE), Geriatric
Depression Scale (GDS)

Domains to be assessed
 Health status, health risks and comorbidities
 Physical functioning and fitness, level of dependence
 Mental health and psychological wellbeing, presence of psychiatric symptoms
 Social status and economic situation
 Quality of housing and environment

‘Successful’ Ageing

Prospective epidemiological studies have shown that positive health behaviours are associated with:
 Reducing all causes of mortality
 Lower levels of CVD
  Higher life expectancy
 Greater health and wellbeing in older age
Sedentary behaviour is a risk factor for poor health outcomes. Among older adults, compared to those
who were sedentary (4 hours or more/day), those who were:
 Moderately sedentary (2-4 hours/day) were 38% (OR: 1.38; CI: 1.12- 1.69) more likely to age
successfully
 Least sedentary (<2 hours/day) were 43% (OR: 1.43; CI: 1.25-1.67) more likely to age successfully
Among middle-aged adults, those who were least sedentary were 43% (OR: 1.43; CI: 1.25-1.63) more
likely to age successfully

Exercise
 Better levels of aerobic fitness act beneficially on the autonomic control of post-exercise heart
rate, preserving the vagal re-entry velocity in healthy middle-aged volunteers.
 However, it does not attenuate the decrease in heart rate variability due to the natural aging
process.
 Recommendations for adults aged 65 years or older to take a minimum of 30 minutes moderate
activity at least five times a week
 For those regularly active, a minimum of 75 minutes of moderate to vigorous intensity activity
spread across the week

Social Activity & Isolation

476 cognitively healthy Hong Kong community dwellers (aged 60-92 years) assessed with a battery of
cognitive tests and questionnaires on their sense of loneliness and leisure activities.
 High level of cognitive activity participation (r = 0.13, p = 0.03)
 Low level of loneliness (r = -0.15, p = 0.01)
 Were associated with better cognitive test performance.
 More years of education (odds ratio = 1.27, P < 0.001)
 Higher frequency of drinking (odds ratio = 1.17, p = 0.05)
 were associated with high cognitive function
Stay married – after controlling for education, some diseases, chronological age and leisure activity as
covariates married people showed significantly better memory performances than singles in recall and
recognition. The rate of decline in episodic memory was significantly larger for singles and widowed than
other groups over the 5-year time period of the study. The positive relation found between marriage and
health can be extended to the relation between marriage and cognitive performance
Active Healthy Ageing

Social & Economic Consequences of Ageing

Opportunities
 Reflect success in medicine and technology (childhood disease) as well as advancement in social
and environmental conditions (sanitation)
 Resource for families/communities, formal/informal workforce, knowledge
Challenges (without adapting)
 Strain pension & social security systems
 Increased demand for acute and primary health care
 Require a larger and better trained health workforce
 Increase the need for long term care (mobility & dementia)
 Awareness – lack of awareness and late diagnosis leads to poorer outcomes

14. Social Health Care for Elderly & Integrated

Community Care
Healthcare Social Care
Primary and community-based GP, visiting nurse geriatric nurse Home-making
care outpatient dept geriatric office Home-help/personal home
home health-care agencies services
Personal assistance
Intermediate care Day hospitals Day centres
Day rehabilitation Clubs
Apartments with care
Intramural care Acute hospital beds Home pensions
Geriatric department Residential homes
Post-acute and chronic care Social nursing
Respite care
15. Health Promotion & Disease Prevention, WHO
Programmes. Health Literacy
Health Promotion
‘Health promotion is the process of enabling people to increase control over, and to improve their health’
- Health Promotion Glossary, 1998.

3 Pillars of Health Promotion

Good Governance
Strengthening policy-makers across all governmental departments to make decisions and to create
sustainable systems which promote the health and well-being of all.
Health promotion requires policy makers across all government departments to make health a central
line of government policy. This means they must factor health implications into all the decisions they
take and prioritize policies that prevent people from becoming ill and protect them from injuries and
make healthy life choices accessible and affordable for all.
These policies must be supported by regulations that match private sector incentives with public health
goals. For example, by aligning tax policies on unhealthy or harmful products such as alcohol, tobacco,
and food products which are high in salt, sugars and fat with measures to boost trade in other areas.
Legislation can also support healthy urbanization by creating walkable cities, reducing air and water
pollution, and enforcing the wearing of seat belts and helmets

Healthy Cities
Promoting well-being and multi-disciplinary approaches to health within the setting of everyday
urban life. Aim to:
  Create a healthy-supportive environment
 Achieve a good QoL
 Provide basic sanitation and hygiene needs
 Supply access to healthcare
The Healthy Cities programme is the best-known example of a successful Healthy Settings approach.
Cities have a key role to play in promoting good health. Strong leadership and commitment at the
municipal level is essential to healthy urban planning and to build up preventive measures in
communities and primary health care facilities. From healthy cities evolve healthy countries and,
ultimately, a healthier world. Health city progress:
 Shanghai Consensus on Healthy Cities - in 2016, the 9th Global Conference on Health
Promotion was held in Shanghai. The international Mayors Forum is one of the unique features
of the conference, which recognizes that mayors have a crucial role to play in creating healthy
urban environments due to the increasing urbanization of the world’s population. Over 100
mayors committed to advancing health and sustainable urban development by adopting the
Shanghai Consensus on Health Cities 2016
 2030 Agenda for Sustainable Development

Health Literacy
Health literacy is the degree to which individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate health decisions. It is dependent on
individual and systemic factors:
 Communication skills of lay persons and professionals
 Lay and professional knowledge of health topics
 Culture
 Demands of the healthcare and public health systems
 Demands to the situation/context
It affects people’s ability to:
 Navigate the healthcare system, including filling out complex forms and locating providers and
services
 Share personal information, such as health history, with providers
 Engage in self-care and chronic-disease management
 Understand mathematical concepts e.g. probability and risk
Health literacy includes numeracy skills. For example, calculating cholesterol and blood sugar levels,
measuring medications, and understanding nutrition labels all require math skills. Choosing between
health plans or comparing prescription drug coverage requires calculating premiums, co-pays, and
deductibles.
In addition to basic literacy skills, health literacy requires knowledge of health topics. People with
limited health literacy often lack knowledge or have misinformation about the body as well as the nature
and causes of disease. Without this knowledge, they may not understand the relationship between
lifestyle factors such as diet and exercise and various health outcomes.
Health information can overwhelm even persons with advanced literacy skills. Medical science
progresses rapidly. What people may have learned about health or biology during their school years
often becomes outdated or forgotten, or it is incomplete. Moreover, health information provided in a
stressful or unfamiliar situation is unlikely to be retained.
More info: https://health.gov/communication/literacy/quickguide/factsbasic.htm
Health Promoting Schools
Strengthening the capacity of schools to be healthy settings for living, learning and working. The WHO
promotes school health programmes as a strategic means to prevent important health risks among
youth and to engage the education sector in efforts to change the educational, social, economic and
political conditions that affect risk.

Social Mobilisation
Engaging and galvanizing people, whether at a national or local level, to take action towards the
achievement of good health and well-being in a way that gives ownership to the community as a
whole.
Social mobilization is the process of bringing together all societal and personal influences to raise
awareness of and demand for health care, assist in the delivery of resources and services, and cultivate
sustainable individual and community involvement. In order to employ social mobilization, members of
institutions, community partners and organizations, and others collaborate to reach specific groups of
people for intentional dialogue. Social mobilization aims to facilitate change through an interdisciplinary
approach.

Disease Prevention
In the European Region, preventable diseases continue to impose a high burden of premature mortality,
and unfortunately, simple and cost-effective preventive and curative interventions are underused.
WHO/Europe aims to strengthen public health programmes to prevent communicable and
noncommunicable diseases, and address risk factors. A high prevalence of risk factors can put
populations or communities at a greater risk and result in more disease. These risk factors accumulate
throughout the life-course and have economic, social, gender, political, behavioural and environmental
determinants. Comprehensive action on the leading causes, conditions and the high coverage of proven
health interventions can significantly reduce the burden of disease, premature death and disability in
Europe. Areas covered include:
 Alcohol use  Antimicrobial resistance  Food safety
 Health Literacy  Nutrition  Oral Health
 Physical activity  Tobacco  Vaccines/Immunisations
 Violence & injuries
Vaccines & Immunisation
WHO/Europe's work in the area of vaccines and immunization is guided by the European Vaccine Action
Plan (EVAP), an ambitious roadmap to ensure equitable and optimal protection of Europe’s population
from vaccine-preventable diseases. The Plan was adopted on 17 September 2014 by the 64th session of
the WHO Regional Committee for Europe.
Through adoption of EVAP, Member States pledged to step up their efforts and political commitment to:
 Sustain polio-free status
 Eliminate measles and rubella
 Control hepatitis B infection;
 Meet regional vaccination coverage targets at all administrative levels throughout the Region;
 Make evidence-based decisions about the introduction of new vaccines; and
 Achieve financial sustainability of national immunization programmes.
1. Health Policy in EU, principles, objectives, strategic
documents
Health Policy, WHO 1986
Health Policy: National strategy of the government implemented in the field of health care services
(organization and delivery) as well as in the field of health protection, health promotion and disease
prevention. It defines health goals at international, national or local level and specifies the decisions,
plans and actions to be undertaken to achieve these goals. In other words: health policy is vision for the
future.
 Health policy should reflect major health determinants in a country
 Health policy is expressed in the strategic political documents and implemented by the
legislative tools (laws, rules, regulations) and by the financial measures/regulations.
 Health policy is implemented on the international (WHO, EU), national (CR), and regional level
(Prague)

Goals
 The main objective of the policy is to achieve good health of the general population
o By positive influence on major health determinants
o By reducing of the risk factors
o Through systematic ‘societal effort’ and by multisector approach
 ‘Healthy public policy’ (Ottawa Charter, WHO 1986): strategic decisions in all sectors (transport,
construction, industry etc.) should be based on the assessment of the impact on the population
´s health: all ministries and society as such should take a care about health

Common Objectives
 Universal access
 Universal coverage
 Macroeconomic efficiency:
o To achieve the best health for available resources health expenditures should consume
appropriate fraction of GDP (about 10%)
 Quality of health services: to achieve the best quality for available resources
 Patient satisfaction: to provide patient centred health care

Health Policy Dilemma

Antagonism between moral imperative of maintaining solidarity, equity and accessibility of health care vs
need to control health expenditures in the situation of growing demand for healthcare services due to
technological progress of medicine, aging population and high prevalence of chronic/degenerative
diseases

The Role of WHO in Health Policy

 Providing global leadership on matters critical to health and engaging in partnerships where
joint action is needed
 Shaping the health research agenda and stimulating generation, translation and dissemination
of valuable knowledge
 Articulating ethical and evidence-based health policy options
 Providing technical support, facilitate change, and building sustainable institutional capacity in
public health
  Monitoring the health situation and assessing health in all member states
 Comparison of the countries across regions and in the world
 Health 21: leading public health strategy and policy framework recommended to all member
states
 Each region run its programme addressed health situation in Region – based on Health 21
 Health 2020

Health Agenda of the European Commission

 European Commission (EC) set up strategic health policy recommendations to be followed by
the Member States
 DG SANCO: Directorate General for Health and Consumer Protection – EC body responsible
for health issues
 DG SANCO agendas:
o Food and feed safety
o Consumer affairs, including health systems, responsiveness of health services, patient
satisfaction etc.
o Public health

Health Policy in EU
 Treaty of Maastricht 1993: No common health policy - health care is included in national policy
agenda but shared common principles – solidarity, accessibility, equity as expressed in
Amsterdam Treaty (1997), Article 152
 Public health protection is important part of EU policy agenda: rules and regulations, warning
system, (e.g. Rapid Alert System for Food and Feed Safety)
 Health policy agenda in the EU are recently linked to WHO strategy, especially to strategic plan
for WHO European Region ‘Health 2020’ – dealing with major burden of diseases in EU

Health 2020 – Strategic EU Health Program

 The major burden of diseases in Europe: A relatively small group of health conditions is
responsible for a large part of the disease burden in Europe. European Region is the most
affected by non-communicable diseases (NCDs), and their growth is startling.
 The impact of the major NCDs: diabetes, cardiovascular diseases, cancer, chronic respiratory
diseases and mental disorders is equally alarming: taken together, these five conditions
account for an estimated 86% of the deaths and 77% of the disease burden in the Region.
 Mental ill health accounts for almost 20% of the burden of disease in the WHO European
Region and mental health problems affect one in four people at some point during life. Nine of
the ten countries with the highest rates of suicide in the world are in the European Region
o 4 for mental health including:
 High-quality information
 Empowering service users and careers
 Developing services
 Improving the state of social care homes in Europe

2. Current trends in the world health systems

 Need to control cost of health care: efforts to reduce health care costs through various
regulations, incl. co-payment, regulated price per procedure, maximum number of procedures
per provider etc
  Accent on primary care: well developed and well organized primary care is considered the most
cost-benefit segment of medical care
 Restructure and intensification of hospital care: shorter hospital stay, one day surgery, a
decrease of acute beds, decline in the number of hospitals, restructuring of hospitals into acute
hospitals, aftercare hospitals, palliative care hospitals etc
 Population aging increase demand for a various long term health services closely connected
with provision of social services: social health care
 Emphasis on disease prevention: Preventive procedures (screenings, smoking cessation,
preventive medical checks up) are included in basic package of health services
 Personalised Medicine: adjust medical procedures to the unique needs, genetic makeup, and
lifestyle of each patient will continue to be an important trend in healthcare
 International comparison of the health systems: monitoring and comparing the quality of care
according to agreed indicators - at the national and international levels (WHO, OECD Health
Data, European Health Consumer Index)

3. Migration, ethnicity, and health

Race
 The concept of race – classification of populations into subgroups based on biological factors
(physical appearance) such as skin colour, facial shape and hair type
 The idea of race is changing to incorporate social factors and a shared history  converging with
ethnicity
 Genetic technologies  a reappraisal of the biological race concept
 Historical harms but remains important in public health
 Criticism:
o ‘race should be used with caution for its history is one of misuse and injustice’
o ‘the continued used of ‘race’ suggests there are biological differences between different
groups of human beings’

Ethnicity
 Depends on cultural and social factors such as cultural heritage, family origin (ancestry),
language, diet, and religion to classify humans
 In Europe, the concept of ethnicity has largely replaced the concept of race, but internationally,
race and ethnicity are often used synonymously
Main Methods of Assigning Migration Status, Race, or Ethnicity
 Skin colour/physical features
 Country of birth of self or parents/grandparents
 Name analysis
 Family origin, and ancestry or pedigree analysis
 Self-assessed ethnic or racial group
 Self-reported migration status details: length of residence, country or birth or origin, whether
asylum seeker, refugee or undocumented migrant
Epidemiological Research Challenges

Ethnic Health Inequalities

CVD
 UK: men born in South Asia are 50% more likely to have a heart attack or angina than men in the
general population (Bangladeshis – highest rates, then Pakistani, Indians, and other South Asians)
 By contrast, men born in the Caribbean are 50% more likely to die of stroke than the general
population, but have a much lower mortality to coronary heart disease
 Potential mechanisms
o Not related to classical risk factors – smoking, BP, obesity, cholesterol
o Socioeconomic factors?
o Biological differences?

Migration
Migration is inevitable (demography, catastrophes), necessary (development) and desirable (regular &
safe)
UN convention on the Rights or Migrants:
 The term migrant can be understood as ‘any person who lives temporarily or permanently in a
country where he or she was not born, and has acquired some significant social ties to this
country’
 The term migrant should be understood as covering all cases where the decision to migrate is
taken freely by the individual concerned, for reasons of personal convenience and without
intervention of an external compelling factor
The definition indicates that migrant, in principle does not refer to refugees, or others forced to leave
their homes
Causes of Migration
 Fundamental human behaviour and driving forces creating multi-ethnic societies
 Work and study
 War conflicts, ethical conflicts
 Natural disasters
Reasons and motivations:
 Business (trade and commerce)
 Demand for work
 Demand for workers
 Education
  Personal aspirations, family reunification
 Political refugees, ‘environmental’ refugees
 Curiosity
Migrants
 Migrants – regular, legally residing
o Economic migrant – someone who leaves his/her country of origin purely for financial
and/or economic reasons; choose to move in order to find a better life
 Undocumented migrants – irregular
o Do not refer to them as ‘illegal’ – denies them of their humanity. A person can never be
illegal – migration is not a crime. It is discriminatory. Denies them of rights
o ‘Irregular entry’ is the correct term
Forced Migrants
Refugees – A person who has fled their country of origin and is unable or unwilling to return because of
a well-founded fear of being persecuted because of their race, religion, nationality, membership of a
particular social group, or political opinion
Asylum seekers – An asylum seeker in an individual who is seeking international protection but has not
yet claimed refugee status. Not every asylum seeker will ultimately be recognised as a refugee, but every
refugee is initially an asylum seeker
Internally Displaced Persons (IDP) has been forced or obliged to flee or to leave their homes or places
of habitual residence in particular as a result of or in order to avoid the effects of armed conflict,
situations of generalized violence, violations of human rights or natural or human-made disasters, and
who have not crossed an internationally recognized State border.
Development-induced displaced
Environmental and disaster-induced displaced (sometimes called ‘environmental refugees’ or ‘disaster
refugees’)
Trends in Migration
 1/7 persons is a migrant
 >1 billion migrants; 244 million internationally, 740 million internally
 Labour migration: 150 million labour migrants in 2013; >50 million irregular migrants in 2010
 The traditional separation between migrants, refugees and asylum seekers is getting more and
more blurred
 Voluntary migration and forced migration tend to overlap
 Many forced migrants are becoming irregular (undocumented)
 Many refugees are no longer living in camps
 The majority of migrants are from middle income countries moving to high income countries
 The countries with the highest number of international migrants in 2015: USA, Germany, Russia,
Saudi Arabia, UK)
 Luxembourg has the highest proportion of migrants in Europe
 Involuntary/forced migration
o 65.3 million by the end of 2015
 21.3 million refugees
 40.8 million IDP due to conflicts & violence
 3.2 million asylum seekers
o >19.3 million as a result of catastrophes in 2014
Health Aspects of Migration
 Migrants differ from major population in disease patterns and health related behaviour
 Migrants ae considered a vulnerable group from a health point of view:
o They tend to be more vulnerable to certain communicable diseases, occupational
health hazards, injuries, poor mental health, diabetes mellitus, and maternal/child
health problems
 Some groups mighty be at particular risk of non-communicable diseases arising from obesity and
insufficient physical activity
Determinants of Migrant Health Inequalities
 Culture & lifestyle
 Social, educational, and economic status
 Living conditions before & after migration
 Working conditions
 Early life development
 Genetics
 Access to health care including preventive services

The ‘Healthy Migrant’ Effect

An empirically observed mortality advantage (and relatively lower morbidity as well) of migrants from
certain countries of origin relative to the majority population in the host countries, usually in the
industrialised world. The well-known health advantage of migrant populations – typical for labour
migration in the first period after arrival to a host country
 Healthy migrant effect – phenomenon caused by the preselecting of the young, strong and
healthy people to migrate
 The first generation of migrants experience usually better subjective health, less chronic
diseases, less prevalence of disease as such
  Since arrival in a new country, this advantage (good health) migrants have is gradually lost due
to extreme workload and psychological stress connected with migration, social isolation, loss of
family/friends
 The more time spent in the new host country, the worse their health
 The ‘healthy migrant effect’ does not continue in subsequent generations

Cultural Competence
A set of congruent behaviours, attitudes, and polices that come together in a system, agency or amongst
professionals and enables that system, agency, or those professionals to work effectively in cross-cultural
situations
Intercultural competence – focuses more specifically on the interaction and dialogue between different
cultures and the need to address healthcare needs within intercultural contexts – ‘cultural humanity
5 Component Model for Developing Cultural Competence
 Cultural awareness – involves self-examination of in-depth exploration of one’s cultural and
professional background. This begins with insight into one’s cultural healthcare beliefs and
values
 Cultural knowledge – involves seeking and obtaining an information base on different cultural
and ethnical groups
 Cultural skills – involves the ability to collect relevant cultural data regarding a patient’s
presenting problem and accurately perform a culturally specific analysis
 Cultural encounter – defined by the process that encourages health professionals to directly
engage in cross cultural interactions with patients from culturally diverse backgrounds
 Cultural desire – refers to motivation to become culturally aware and seek cultural encounters.
Involves willingness to be open to others, to accept and respect cultural differences and to be
willing to learn from others

4. Models of Health Systems in the World, International

Comparison
Health Systems
Aim to maintain and improve health; health of the population is affected relatively little by health care –
only by about 15-20%
Besides health services, health systems have other functions in a society:
 A (well-functioning) health system is a source of social security and a factor influencing the
stability of a society
 Health system are a good and stable employer and consumer of many goods and services
 Healthcare is an important economic entity – it consumes resources and also contributes to their
creation
Basic Characteristics
 Large variability of the health systems in the world
 Health systems are very ‘national’ specific – each individual health system is unique
 Actual framework health system depends on:
o History, culture, and values
o Political situation and policy development
o Social economic situation
 o Health needs – reflection of morbidity and mortality patterns in health resource
allocation
 Typology of health systems is possible when it is uses appropriate criterion

Health Care Systems in Developed Countries – Europe vs USA

 Different tradition in Europe vs USA manifesting in healthcare financing as well as in a legal
entitlement to healthcare
 Europe: universal access to healthcare and universal coverage for all citizens
o Principle of solidarity and equity are declared as a basis of health policy in the EU
(Maastricht Treaty 1992)
 USA: emphasis on individual responsibility
o Government guarantees healthcare only for socially disadvantaged groups such as
elderly, poor people, handicapped, and some others

The National Health Service (NHS) – UK

National Health Service (NHS) was established in 1948 and provides health care to all British residents
including migrants. There are four national systems operates independently, and politically accountable
to the relevant government: the Scottish, Welsh Governments , the Northern Ireland Executive, and the
UK Government which is responsible for England's NHS.
 NHS is financed largely (about 80%) through general taxes; health budget flowing from the
national level down to the regional, and then to the district /local level.
 Services are free to patients at the point of use
 Co-payment (not much totally): dental care & eyeglasses; drugs outside the hospital (prescription
are free in Scotland), wigs, hearing aids, etc
5 Strategic Domains of NHS
 Preventing people from dying prematurely
 Enhancing quality of life for people with long-term conditions
 Helping people to recover from episodes of ill health and following injuries
 Ensuring that people have a positive experience of care
 Treating and caring for people in a safe environment; and protecting them from avoidable harm
NHS in England
NHS is divided into two relatively independent and self-governed integrated segments
Primary care (Outpatient sector)
 Fundamental basis of the UK health system – component of integrated community care
 General practitioners – generally organized in group practices, paid by capitation according to
number of the patients on their list (1900 patients on average)
o Gatekeepers to healthcare system
o Not government employees – they are self-employed and receive about half of their
income from capitation contracts
 Referral system – patients have to be registered by the GP according to place of residence; no
free choice. Patients have to be referred to the consultants as well as to hospital care by the GPs
 Outpatient specialists (consultants) work in the outpatient clinics attached to hospitals or in
private sector outside NHS
 No ‘field’ specialists working in independent practices
 In 2013 Primary care trusts were abolished as part of the Health and Social Care Act 2012, with
their work taken over by
 o Clinical Commissioning Groups (CCG): NHS organisations to organise the delivery of NHS
services in England: their area overlap one local authority area (200 CCGs in England); all
GP practices must belong to some CCG (no solo practice GP );
o CCGs include all of the GPs groups in their geographical area
o CCG governing body (3 persons): GPs, at least one registered nurse and a doctor who is a
secondary care specialist;
o CCGs are given 65% of NHS budget to purchase needed services for their registered
patients
o Roles:
 Providing primary care: standard primary care includes also basic ORL, skin,
gynaecological /prenatal care, small surgeries;
 Commissioning: choosing and buying health services for the population in the
area, allocation of resources
Secondary care (hospital sector)
 Trend: centralisation and concentration: Significant part of the hospitals are integrated and
managed by the hospital trusts
 Hospital trusts (about 60 NHS trust) are regional or national networks of specialized hospitals
providing secondary health services; they were commissioned to provide these services by
clinical commissioning groups
 There are several kinds of trusts: Acute trusts (surgery, standard hospital care), Mental Health
Trusts, Children´s Trusts and some others
 Hospitals have the outpatient clinics providing outpatient specialised services
 Hospitals are public and self-governed having a lot of autonomy

Private Sector in UK
 15-20% of healthcare in UK
 Coverage by private insurance or payment
 During last decade it has been developing rapidly, especially elective surgery, dentistry, and
specialised ambulatory services due to long waiting times in the NHS
 Individuals with private insurance are still entitled to use the NHS

Germany – Model Country for Bismarck Model

Health insurance is mandatory to all citizens (since last reform in 2007). Insurance fee is not defined
equally in all health insurance funds. Insurance company is responsible for setting up percentage of an
insurance fee; equal for all within particular insurance company
 National average of insurance fee: about 15.5% of wage
 Mandatory participation in public health insurance for all persons with annual income less than
€57,600 a year (€4,800 a month in 2017) - 75% of population
 If gross salary is above, then membership in the public health insurance is not mandatory:
persons exceeding income limit (25% of population) can make voluntarily choice between
public or private health insurance
 Private health insurance is primarily dedicated to self-employed persons
 Altogether about 10% of population in private insurance: self-employed; young, healthy and
wealthy people
Scope of Healthcare Covered by Compulsory Health Insurance
 Medical treatment, with free choice among out-patient doctors and dentists
 Drugs, and aids such as hearing aids and wheelchairs
 Hospital treatment
  Home long term care
 Some or all the cost of necessary for rehabilitation treatment
 Procedures for the prevention and early detection of certain diseases
o Children in the first six years of their life and at the beginning of puberty; adults every
two years from the age of 35
o Women from the age of 20 and men from the age of 45 are entitled to annual cancer
screening
Co-payment
 Hospitalization fee: 10 EUR per one day of hospitalization (28 days maximum)
 Drug fee: per one item: 10% of the price - minimum 5 EUR/maximum 10 EUR
 Children up to 18: no fees
 Pensioners and chronic patients: total amount of fees is maximum 1% of annual income

US Health System
Basic Principles
US Government does not guarantee health care for all citizens. Some part of population are eligible for
public health programs
 Medicare: a system for the elderly and disabled and handicapped people
o Permanent legal residents for 5 continuous years, and they are 65 years or older
o Or they are disabled and have been receiving either social security or disability benefits
for at least 24 months
o Or they get continuing dialysis or need a kidney transplant
o Medicare has several parts: part ‘A’ covering hospital stay and part ‘B’ covering generally
out–patient care: medication is covered under Part B only if it is administered by the
physician during an office
 Medicaid: a system for the poor (under poverty line - ~15% of population)
o Financed through federal taxes and individual state taxes 50/50
o Difference in coverage and in scope of services among US states
 The Veterans Administration and Military Health Care System
o War veterans, their dependants, and state officials
 The Indian Health Service – for native Americans
 Public Health Services (hygiene, sanitation services)
 Emergency care
o Must be provided to all individuals in need (by the Emergency Care Act) - regardless of
citizenship legal status, or ability pay;
Private Health Insurance
Individuals not eligible for public health programs may voluntarily purchase private health insurance.
About 65% of Americans are insured in private health insurance plans. The majority obtain health
insurance through their employer
 Employers may elect to purchase health insurance for their employees or share the cost of
health insurance with employees
 Only 5% of Americans purchased health insurance individually
 Insurance premium is often provided as family insurance (better price)
Private health insurance companies:
 Private health insurance companies (about 1000 in the USA) may operate as for profit or not-for
profit organizations
  All private health insurance companies are profitable, having high overheads costs - 30% of
premium (before 2014)
 Private health insurance companies are very important stakeholders in health care reform: not
support health care reform
Causes of High Health Expenditure in USA
 Advanced technology
 Fee for service payment of physicians
 High prescription of drugs
 High prices of drugs
 Increasing price of malpractice insurance, defensive medicine
 Unnecessary care
 Rising wages in the health care sector
 Limited cost regulations outside public health programs
US Health Reform: Patient Protection and Affordable Care Act
 The objective: comprehensive health insurance reforms to assure access to quality health care
for all Americans
 The Law passed by the US Congress and signed by President Obama in March 2010 that
reformed health care system in the USA
 The act is known as ‘Obamacare’
 The reform was implemented into practice since 2014, strongly supported by Democratic Party
and their voters
 Health insurance became (more or less) obligatory (2014-2018)
 The uninsured are penalized: pay higher taxes
 Employers who employed more than 50 employees have to pay health insurance for all
employees
 Medicaid covers larger part of population (responsibility of the individual US states)
 Overheads costs of private insurance companies have to be reduced to 15-20 % of premiums!
 For Americans not included in above mentioned programs but not enough rich to purchase
private health insurance was created ‘exchange health insurance market’: private health
insurance companies operate voluntarily to offer health insurance under the regulated
conditions - not possible to reject risk clients
 Government provides subsidize for health insurance to the citizens without sufficient financial
sources
Obamacare nowadays
US population is divided into those supporting (Democrats) and those rejecting health reform (and
supporting of Impeached President Trump). Impeached President Trump intends to cancel the reform
and replace it with his version of health reform: up to now it has not happened.
 In 2018: Trump achieved abolition of tax penalty for uninsured
 4 million Americans cancelled their health insurance for 2019 and number of Americans without
health insurance again increased
 Practical implementation of the healthcare reform and functioning varies from one US state to
another, depending on the political situation
 Future: unclear and hardly to predict – strong opposition against reform from the leading
Republican Party
 US Health Reform is considered the most pressing issue of US domestic politics in the years to
come
5. Strengths & Weaknesses of the World Health System
State Health Systems
Strengths
 Accessibility, equity: Equitable provision of care, the universal nature of the service is beneficial
for a whole population
 Clarity, simple organization
 Well-developed primary care
 Lower total health expenditures in long term perspective
 Macro-economic regulation is relatively easy
Weaknesses
 Long waiting lists for the expensive procedures
 Long waiting time for specialised out-patient services
 Bureaucracy, no free choice of providers
 Short time spent in doctor´s office on average – conveyer belt style

Bismarck Health Systems

Strengths
 Free choice and plurality of outpatient providers
 Good quality of care
 Patient satisfaction
Weaknesses
 High price of care
 High administrative costs (operating costs of insurance companies, IT technology is widely used
 Complicated relationships among patients-providers-third-party payers, complicated
negotiations among providers - payers – politicians
 The dependence on the economic cycle, extreme vulnerability to economic crisis – system
operates under a pay-as-you-go financing

US Healthcare System
Strengths
 Quality care for the well-insured US citizens, free choice of providers
 Advanced medical research and fast implementation of the results into practice (in the centres
of excellent medicine)
 Good supply of high technology
 Developed quality assurance, quality management
 Good compensation of physicians: the best paid are specialists in orthopaedic surgery,
cardiology, gastroenterology, and urology (2018)
Weaknesses
 High health expenditure: 16 - 18 % GDP (18% in 2017)
 The most fragmented health care system in the world
 Social inequalities in access: 12 mil. Americans not insured (2018), mainly the following groups:
‘low- income Americans’, young people under 25 years, employees in small businesses, self-
employed
 Large numbers of the underinsured Americans (25% of all US adults in 2018)
 Many judicial trials regarding malpractice: the consequences - expensive malpractice insurance
and ‘defensive medicine’
  Unnecessary care: estimated at 20 – 25 %
 High administrative costs: Private insurance industry has the world’s highest administrative costs
of any health care payer in the world
 Illness is perceived as an economic threat; stress, anxiety in society because of not universal
health care system
 Risk of financial ruin due to medical bills: medical bankruptcy is a unique American problem:
60% of bankruptcies were a result of the high medical bills (about 700,000 Americans/year) -
before Obama reform)

6. Assessment & Comparison of the Health Systems in the

EU; European Health Consumer Index
Bismarck-Beveridge Comparison
 Bismarck healthcare systems: Systems based on social insurance, where there is a multitude of
insurance organizations (Krankenkassen, Sickness funds etc.), who are organizationally
independent of the health providers
 Beveridge systems: Systems where financing and provision are handled within one
organizational system, i.e. financing bodies and providers are wholly or partially within one
organisation, such as in the NHS of the UK or in the Nordic states, South European countries or in
Cuba
 For more than half a century, there has been intense debating over the quality and benefits of
these two types of health systems

European Health Consumer Index

Comparative study based on assessment of health systems performance in Europe (35 states) conducted
by the Swedish company ‘Health Consumer Powerhouse’ annually since 2008.
 Benchmarking: ranking from the best No1 country - to the worst country
 Based on the key healthcare values which are expressed in the 48 indicators
 Provides insight into European healthcare systems and helps to identify strengths and
weaknesses in individual countries
 Patient perspective ‘ideology’: how patient preferences, needs and perceptions are reflected in
health system performance
 Data used for assessment and scoring: public national/international statistics (WHO, OECD),
research surveys, reports and also independent research based on questionnaire survey
managed in all countries to get information not available through ‘hard data’. Respondents are
patient organisations, experts, selected physicians/nurses
Scoring: the index is constructed by scoring of performance according to indicators as good (3),
intermediate (2) or not good (1). Total score for particular country is based on the sum of achieved
value of all indicators. The maximum theoretical score attainable for a national healthcare system is
the 1000, and the lowest possible score is 333. Indicators (48) are grouped into 6 sub-disciplines:
Outcomes (8) Waiting time (6)
 30 days fatality for AMI and stroke (decrease  GP same day access
in CVD and stroke death rate)  Direct access to specialists
 Cancer survival; infant mortality  CT scan < 7days
 Potential lost years of life  Cancer treatment < 21 days
 COPD mortality  Major non-acute operations
 Share of resistant hospital infections
 Range & Reach of Services (8) Patient rights and information (12)
 Equity of healthcare systems  Relevant healthcare law
 Cataract surgery/100 000 inhabitants 65+  Patient organizations involved in health policy
 Kidney transplants/1 million, informal  Right to second opinion; access to medical
payment for doctors, dental care included records
 Long term care for elderly  Access to on-line booking of appointments
 Register of legit doctors
Pharmaceuticals Prevention
 Percentage of total drug sales paid by public  Infant 8-disease vaccination
sources  Alcohol consumption
 Availability of new drugs  Tobacco control
 Statin use, antibiotics use  Hours of physical education in school
 Traffic deaths
 Blood pressure control
Sub-discipline is weighted for their importance: waiting time and outcomes are weighted the most.
Indexes Available
There are several indexes available every year:
 EHCI total score: of maximum 1000
 Score by sub-disciplines
 Score by specific kind of medical care (not done every year): cardiac care, diabetic care and
others.

EHCI 2016 – Best Score in Sub-disciplines

Nordic countries, Germany, Netherland & Switzerland
 Outcomes – Finland, Iceland, Norway, Germany, Netherland, Switzerland
 Waiting times – Belgium, Switzerland
 Range and reach of services – Netherlands, Sweden
 Patient Rights & Information – Norway
 Pharmaceutical – Germany, Ireland, Switzerland, Netherlands
 Prevention – Norway

EHCI comparison

Figure 10: EHCI total scores from 2008 and 2018. Czech Republic has been highlighted in cyan
 The majority of the top countries have dedicated Bismarck healthcare systems
 It seems that for total customer benefit, the Bismarck model is more satisfying of consumer
needs
 On the other side: National health service systems spend a lower portion of GDP for healthcare
and produce comparable outcomes
  The health system in Netherland (Bismarck) is assessed as the best
 Denmark (state system), Norway are also perfect!

Comparisons
Number of Physicians per capita

Reported Unmet Health Needs

Probability to see doctor adjusted to need

Waiting Time 4+ months for Elective Surgery

Conclusion EHCI
EHCI is a good tool for assessing a health system by using clearly defined indicators. Participating
countries can learn about strengths and weaknesses of national health system comparing to others doing
the same things. DG SANCO: Directorate General for Health and Consumer Protection - European
Commission body responsible for health issues uses EHCI as an important source of information

7. Health Expenditure, Public/Private Ratio, Current

Trends, Influencing Factors
Economic Aspects of Health Systems
 Healthcare is expensive
 Measured as a percentage of GDP spent for health care in a particular year. Average expenditure:
o OECD: 9-10% - about 3000 US PPP $ per capita
o Czech Republic: 7.2% (2017)
 Scotland
o Total budget for Health, wellbeing & sport (2016/7) was £13.04bn. Accounted for 35.1%
of the Scottish Government budget
o Public spending per person 2018/19 - £11,247 (17% above UK average)
 (England £9,296)
Expenditure
 Long-term trends: tendency to increase health expenditure mainly due to technology
development including new drugs, increasing salaries, ageing population
 In recent years: health expenditure has more or less stabilised
 Some European countries reduced their health expenditure due to economic crisis in 2008-2013
 Wealthy developed countries invest into healthcare a higher proportion of GDP (on average)
than less wealthy countries
 Health expenditures do not share a linear relationship with health outcomes – a lot of money
does not always mean the best outcomes
Countries with low health expenditures but with significant improvement of health services in the last
decade:
 Previously had high death rates
 Low/lower middle income in 1991  achieved high levels of health status by 2011
 Largely because of well managed health sector interventions based on prevention and better
access to health services
 4 C countries: Costa Rica, Cuba, Chile, China
o Low/moderate health expenditure: 400-1200 USD per capita/year
o But continuously increasing % of GDP to health sector
Most of this Q is covered elsewhere.

8. Models of Health Care Financing. Reimbursement of

Health Care Services
Typology of World Health Systems
There are 3 (predominant) ways of health system financing:
 General taxation: state health systems
 Public (mandatory) health insurance Bismarck (public) health insurance systems
 Private (voluntary) health services: Market Orientated (Liberal) Health Systems

Financing Based on General Taxation

Main Principles
 Health care is a Human Right and guaranteed by the Constitution
 Government is responsible for health and health care
 Accessible to all
 (Basically) Free at the point of consumption
 Focus on primary care
 Community Involvement – close cooperation with social sector
 Emphasis on Disease Prevention
Two forms: Beveridge & Semashko
 Beveridge model: UK, Canada, Australia, New Zealand, Sweden, Norway, Finland, Denmark,
Island, Ireland Spain, Portugal, Greece, Italy: Named after William Beveridge, the daring social
reformer who designed Britain's National Health Service.
 Semashko model : established in the former USSR and in all former CEE countries incl.
Czechoslovakia in 1950-1992; nowadays in Cuba and in some Africa´s countries (Angola, Uganda)
 Difference Beveridge -Semashko:
 o Beveridge: existence of the private sector as the alternative choice (15-20% of all health
services)
o Semashko: no private sector, ban of provision private services
 Both forms based on the same principles: accessibility and equity; ‘justice’ in the health care;
 Health care is provided and funded by the government – through tax payments
 Financing: health services are reimbursed through central/regional budget; government
(central, regional, local ) is a key ‘stakeholder’ in health sector
 Public ownership of the significant part of the health facilities, especially hospitals; many, but not
all, hospitals and clinics are owned by the government
 Out-patient facilities can be run as private practices but have contracts with public health
authorities and funded by public sources;
 Primary care is considered a basis of health system – General Practitioners play an important
role and have a lot of competences
 The NHS in the UK is a typical model of this

Bismarck Health Systems

 Employment based health insurance named by the Prussian Chancellor Otto von Bismarck, who
established compulsory social insurance (the welfare) within the unification of Germany - late
the 19th century
 Based on solidarity principle: payment of health insurance according to ability to pay and
consumption of health services according to health needs
 Applied in Germany, France, Austria, Netherlands, Switzerland, Belgium, Luxembourg, Japan,
Israel and to a degree - in Latin America
 In the 90´s Bismarckian model was implemented in the ČR, Slovakia, Poland, Hungary; in a
specific form also in Russia.
Basic Principles
 Health insurance is mandatory, either public (majority) or private
 Mandatory health insurance is a part of comprehensive social insurance: health insurance +
pension insurance + sickness insurance + accident insurance + unemployment insurance
 All salaried persons have to participate and pay insurance fee
 Insurance fee (premium) is set up as a percentage of a gross salary (before taxation): paid jointly
by employers and employees
 Children, students, pensioners, unemployed, people under poverty line and others are usually
exempted from payment of health insurance
 Self-employed persons :
o They have to participate (in some countries, e.g. ČR) – but have more or less ‘softer’
conditions
o They can purchase alternatively private health insurance – in some countries (Germany)
Insurance fee
 Health insurance has to be usually paid up to defined annual income limit (multiple of average
wage)
 Some countries have no limit (e.g. ČR) i.e. health insurance is paid from all income
 Insurance fee is defined as the percentage of income and has to be paid monthly
 It differs between countries 3 - 18% (14-15 % on average)
Public Health Insurance Companies
 Different number of public health insurance companies: Germany 113, Austria 21, Hungary only
1 with its regional offices, CR 7
  Public health insurance companies are usually based on occupation or place of residence of the
clients or might be open to all public
 Obliged to insure everyone; not profit oriented
 Crucial role in creation of network of health services; obliged to have so many contracts with
health providers to cover all health needs of their clients
 Health care providers: they have the formal bound contracts with public health insurance
companies to provide all needed services to their patients
 Patients: free choice of health providers, if possible

US Model
Mentioned earlier

Out of Pocket Model

 Rural regions of Africa, India, Indonesia
 ‘No-system’ countries where WHO, UNICEF, and other international agencies provide basic
health care for the most vulnerable people such as children, pregnant women, handicapped.
 Random ‘network’ of some private providers of a various quality providing health services to
people being able to pay for it
 Characteristics:
o No comprehensive insurance or government plan
o Only the rich get medical care; the poor stay sick or die
o Most medical care is paid for by the patient out-of-pocket

Methods of Health Service Reimbursement to Providers (CR)

Outpatient
 Primary Care: capitation – fee per one registered patient (per capita)
 Fee for service: specialised health services
 Combination of both
Inpatient
 Budgeting – agreed budget for an entire year based on a historical cost
 Diagnosis Related Groups (DRG) – certain amount of money for the group of diseases
comparable in cost of treatment
 Fee for services/specific procedure/specific diagnosis – applied to expensive health services:
transplantation, neurological surgeries, dialysis, etc

9. Czech Health System; the Main Principles, Public

Health Insurance
Socioeconomic Overview of Czech Republic
 Number of Inhabitants: 10.5 million
 GDP per capita in PPP (2016) 31 072 USD (ranking 35)
 Proportion of the health expenditures /GDP 7,3 % (2016)
 Average salary 2018 31 000 CZK (1200 €)
 Minimal average 2018 12 200 CZK (470 €)
 Unemployment rate 2018 3.5 %
 Human Development Index 2016 – 27
Czech Health System (History)
 1918 – 1951: ‘Old ‘Bismarck’ model; not universal access; farmers were not covered
 1951- 1992: Semashko national health system - totally nationalised (similar to British NHS); no
private services
 Since 1992 : Public health insurance health system was re-established (neo-Bismarck)

The Main Principles

 Health care is considered a basic human right and guaranteed by the Constitution: Universal
access, universal coverage
 Health care is provided to the Czech citizens and to other entitled persons on the basis of
mandatory public health insurance (payroll tax)
 Public health insurance is managed and administrated by the independent public health
insurance funds (companies)
 Czech citizens have an obligation to be registered with public health insurance company by free
choice: health insurance company can be changed once per year
 Citizens have a free choice of the physicians and health facilities: GP can be changed after
three months
 Health services are provided by network of independent medical facilities: there is about 32 000
independent health establishments. Their sizes vary from individual private practice of out-
patient specialist to large University hospitals
 Health providers have contracts with public health insurance company/companies to provide
medically indicated health services for their clients
 Obtaining contract is not guaranteed for both sides of contract: insurance companies can make
a choice among providers and providers among insurance companies as well

The Role of Public Insurance Companies

 Network of the seven Public Health Insurance Companies:
o General Health Insurance Company (Všeobecná zdravotní pojišťovna VZP) – 60% of
population + other six companies
o Basically sectorial (e.g. Military Heath Insurance Company, Metal-Alliance Health
Insurance Company, Skoda Health Insurance Company, and others)
 Key role in accessibility of health services - creation of appropriate network of health providers
to cover entire Czech territory
 Public health insurance funds make the contracts with health providers: they have to make
sufficient contracts to be able to address all health needs of their clients
 Health providers working out of public health insurance system are rare - except of dental care
providers

Participants of Public Health Insurance

By the Public Health Insurance Act No. 48/1997 the following persons participate:
 All permanent residents at the Czech territory
 All employees of the employers registered in the CR, incl. migrants
 EU residents living in the CR on the long-term basis, their children and partners
 Asylum seekers

Payers of Public Health Insurance

 All economically active Czech residents: employees, employers, self-employed
 Government: for pensioners, children up to 18, students up to 26 years, person on the parental
leaves, unemployed, prisoners, people living under the poverty line. Note: all groups together =
~55% of population
  Individuals without any taxable income, e.g. students older 26 years, housewives
 Insurance premium (insurance fee) is paid monthly at 13.5 % of gross wage before taxation
o Paid jointly by employees 4.5% + Employers 9%
 Self-employed: 13.5% - minimally 2000 CZK (2018)
 Government pays insurance fee for: children, students, pensioners, unemployed, prisoners,
those under the poverty line (55% of population)
 Re-distribution of health insurance premiums on 100% level among health insurance companies
according to age structure of the clients to balance insurance budget and prevent adverse
selection of clients (‘young and healthy’)

Scope of Healthcare Covered by Public Health Insurance

 All indicated medical procedures, incl. basic dental care, diagnostic procedures, long-term care,
preventive care and pharmaceuticals
 Health aids, medical equipment, transport to/from health facility, experts activities for social
insurance reason, medical check-up of dead person, autopsy

Dental Care Coverage

 Dental care is divided into two parts: covered by public health insurance (standard) and not
covered (above standard)
 Covered dental care is specified in the Anex to Public Health Insurance Act: complete list of all
covered dental services: basic routine procedures, tooth extraction, preventive check-up (2
times per year)
 Covered dental services are determined by the material and procedure used: if there is any
difference, dental procedure have to be paid fully by patient
 Dentists (contracted by public health insurance company) is obliged to offer to patients fully
covered procedure, if possible
 Dentist is also obliged to inform in advance about price of procedure, if uncovered by public
health insurance.

Healthcare Excluded from Public Health Insurance

 Cosmetic surgery, homeopathy, acupuncture, ‘above standard’ dental care and some others (It
is specified in Annex to Public Health Insurance Act)
 Medical examinations requested personally by the patient and not medically indicated, e.g.
health certificate for any personal/private use
 Some health aids

Pharmaceutical Policy
 Pharmaceuticals make 1/3 of all health expenditures
 The leading regulative authority in pharmaceutical policy: Ministry of Health and its
subordinated State Institute for Drug Control /SUKL)
 Prices are regulated by defined maximum price for producer: business surcharge is from 37% to
4% of producer´s price: the cheapest category of drugs = 37%; the most expensive drugs - 4%)
 Pharmaceuticals are divided into three groups: full covered ; partially covered ; not covered
 Full covered: at least one pharmaceutical is included into every indication pharmaceutical
groups
 The prices are set up according to ‘reference’ prices in the EU (reference countries are France,
Portugal, Lithuania, Estonia, Greece, Hungary…) In theory there is a chance to consume all
needed drugs without any co-payment
 Pharmaceutical not covered:
 o Vitamins, hypnotics, homeopathies, nutrition adds, contraceptives, all nasal drops,
common drugs used for intestine disorders, ordinary analgesics
o Some pharmaceuticals are sold at free market and some of them are tied to medical
prescription (contraceptives, selected analgesics)

10. National & Regional Health Authorities in the Czech

Republic; Structure of Health Services
State Administration of Czech Healthcare
Two levels
 National levels – Ministry of Health
 Regional Level - CR is divided into 14 regions, including City of Prague: Health Departments of
the Regional Offices are responsible for health and health care agendas in the regions

Ministry of Health
Nationwide Responsibility for:
 Public health and health services: accessibility, quality, effectiveness, efficiency health
research, health information system
 Sustainability of public health insurance fund (shared with Ministry of Finance)
 Direct Supervision: University hospitals (11), specialized medical institutes:
o IKEM Prague, Masaryk´s Oncological Institute, Institute of Rheumatology, Endocrinology …
and others
o Institute for Postgraduate Medical Education in Prague
o National Centre for Postgraduate Education in Nursing and Other Health Professions - in
Brno
o Institute of Health Information and Statistics (ÚZIS ČR)
o Institute of Public Health in Prague (SZÚ Praha)
o State Institute for Drug Control (SÚKL)

Regional Health Authorities: Health Departments at Regional Offices

Responsible for:
 Accessibility and quality of primary and secondary health service in a region
 Authorization of all (new) health establishments in region, i.e. confirmation that all
preconditions for provision of health services are in accordance with the law and defined
standards (staff, equipment's, etc.)
 Supervision of health establishment in the region except of those supervised by the Ministry of
Health
 Emergency care: supervision and management of the regional units of emergency care
ambulances
 Monitoring of population health status in a region incl. health promotion intervention

Structure of Health Services in Czech Health System

Outpatient (Ambulatory) care (60% of all physicians):
 Primary care
o GP for adults
 1600 persons/1 GP
 5200 registered GP
o GP for Children & Youth
  1100 children (0-19y)/1 GP
 2200 registered GPs
o Outpatient gynaecologist: 3300 women/1 physician
o Outpatient dentist: 1700/1 dentist
 Home care agencies (nursing)
 Specialized health services
o Internal medicine, surgery, neurology, diabetology… etc. ( 40 specialties), also clinical
psychologists, speech therapists, physiotherapists
o About 5000 registered practices:
 3/4 of all specialists are field private practices having contracts with public health
insurance funds
 ¼ of all specialists work in out-patient clinics associated to hospitals
Inpatient care: Hospitals; Specialized Clinical Institutes and other health establishments
o 1/3 of all physicians
o 189 Acute hospitals: 60300 beds
o 147 Hospitals for semi-acute/successive care: 42500 be
 Hygienic service network (regional centres for public health protection)
 Pharmaceutical service (the majority of pharmacies are private and owned by the international
global companies)
 Emergency medical services (rescue care)
 Number of physicians : 46 000
 Non physicians health professionals: 104 400
 Number of health establishments: 32 000
 Beds: 100 400

Centralisation of High Specialised Health Care into Regional Networks

Trends in the last decade:
 To increase quality and effectiveness of health services
 To decrease health inequalities in access to highly specialised health services
 To reach an effective use of modern technology and highly specialised health personnel
 Network of highly specialised regional centres
o Cardiovascular centres 18
o Cerebrovascular centres 10 + Stroke units 23
o Oncological centres 13
o Trauma centres 11
o Perinatological centres 12

EHCI 2016 – Position of the Czech Republic in the Sub-disciplines

 Outcomes – 238 (Finland 288)
 Accessibility/waiting times – 213 (Belgium, Switzerland 225)
 Range & Reach of Services – 104 (Netherlands, Sweden 125)
 Patient Rights & Information – 87 (Norway 125)
 Pharmaceuticals – 62 (Germany 86)
 Prevention – 77 (Norway 119)

EHCI CR 2008-2016 Strengths

 The Czech Republic has always been the star performer among CEE countries, 13th place,
leading the group of CEE countries
  The system is generous with a wide range and reach of services. Overall, health care in the CR is
steadily improving.
 CR is already among the 13 European countries with a health system which is favourable to the
consumers.
 High ‘cost-effectiveness’: Czechs are very well as regards the value of the healthcare provided
for the money spent (doing the right things in the right way ?)
 ‘The Czech Republic seems to have a degree of fundamental stability and freedom from
corruption in its healthcare system, which is relatively rare in CEE states’
 In the outcomes and scope of care sub-disciplines: focus on younger generations; good results
in prenatal/neonatal care and vaccination
Good Performances
 Accessibility, equity: second opinion, access to patients records, free choice of GP, access to GP
without delay, access to CT scans, low waiting times in emergency rooms
 Decrease of stroke mortality, low infant mortality
 Access to kidney transplant and to cataract surgery, dental care included in covered services;
 High vaccination rate
 Adequate antibiotics per capita; appropriate diabetic medication, patient friendly
pharmacopoeia

EHCI CR 2008-2016 Weaknesses

 Patients are still relatively weak, especially given healthcare information: ‘Czech patients
should have more co-decision on treatment’ (2008)
 ‘Country does not have very good results in preventive medicine’ (2013)
 The Czech Republic stands out as a bad example in the region in the sense that it does not work
adequately in the area of health risks from smoking and alcohol and in an ineffective blood
pressure measurement, which is manifested by a number of serious health problems“ (2014)
 While maintaining a rather restrictive pharmaceutical policy, it is clear that what we now need
to do is informing patients together with increasing the level of prevention (2016)
 There is also a need to improve e-health
Weak Performances
 Weak health promotion and disease prevention: in frame of strategic development of the
Czech Republic, adequate attention is not paid to health promotion
 Non-declining CV mortality; increasing blood pressure in population/missing systematic and
population based screening
 Delay in start of cancer treatment: more than 3 weeks after diagnosis
 Poor access to kidney dialysis at homes
 Delay in access to the latest drugs
 Not advanced ‘malpractice insurance’

11. Health Status of the Czech Population; Leading

Causes of Death and Morbidity
Health Trends
 Continuous mortality decrease and increase in life expectancy: M. 76; F: 82 (2016) but increase
of social inequalities, especially for men
 Infant mortality: 2.8 in 2016; neonatal mortality: 1,8; under five mortality: 3
  Cardiovascular mortality still is leading cause of death (42 %): ischemic heart disease is the
most frequent cause of the cardiovascular deaths
 Increase incidence and prevalence of oncological diseases; 2nd cause of all deaths (M: 28% ; F:
23% of all deaths); the most frequent is lung cancer for both genders
 Accidents are the most common cause of work incapacity; 3rd cause of male mortality
 Increase of metabolic diseases (diabetes, obesity)
 Increase of allergies
 Low prevalence HIV/AIDS (1675 cases notified totally since 1985 )
 Infectious disease are not actual threat: low prevalence and continuing TB decline
 Respiratory diseases are the most common cause of morbidity (children, seniors)

Population Pyramid (2015)

Leading Causes of Death

 Cardiovascular disease ~42%
 Cancers ~27%
o Males – lung, colorectal, prostate
o Female – lung, breast, colorectal
o Cancer incidence is increasing
o Colorectal ca and pancreatic ca are highest in the world
 External causes ~6-8% - injuries, accidents, poisoning (mainly men)

Major Health Risks

 Neglected prevention and health promotion
 Unhealthy lifestyle:
o High alcohol consumption
o Smoking (24% of population)
o Obesity and overweight related to unhealthy eating habits (55% are overweight/obese)
12. Convention on Human Rights & Biomedicine, & its
application in Health Care
Council of Europe Legal Acts
 The European Convention on Human Rights
 Convention for the Protection of Human Rights and Dignity of the Human Being with regard to
the Application of Biology and Medicine: Convention on Human Rights and Biomedicine -
Oviedo, 4.IV.1997
 Additional Protocol to the Convention for the Protection of Human Rights and Dignity of the
Human Being with regard to the Application of Biology and Medicine, on the Prohibition of
Cloning Human Beings - Paris, 1998
 Additional Protocol to the Convention on Human Rights and Biomedicine, on Transplantation
of Organs and Tissues of Human Origin - Strasbourg, 24.I.2002
 Additional Protocol to the Convention on Human Rights and Biomedicine, concerning
Biomedical Research - Strasbourg, 25.I.2005

Convention of Human Right & Biomedicine

The Convention is the first legally-binding international text designed to preserve human dignity, rights
and freedoms, through a series of principles and prohibitions against the misuse of biological and
medical advances. The Convention's starting point is that the interests of human beings must come
before the interests of science or society. It lays down a series of principles and prohibitions concerning
bioethics, medical research, consent, rights to private life and information, organ transplantation, public
debate etc.
It bans all forms of discrimination based on the grounds of a person's genetic make-up and allows the
carrying out of predictive genetic tests only for medical purposes. The treaty allows genetic engineering
only for preventive, diagnostic or therapeutic reasons and only where it does not aim to change the
genetic make-up of a person's descendants. It prohibits the use of techniques of medically assisted
procreation to help choose the sex of a child, except where it would avoid a serious hereditary condition.
The Convention sets out rules related to medical research by including detailed and precise conditions,
especially for people who cannot give their consent. It prohibits the creation of human embryos for
research purposes and requires an adequate protection of embryos where countries allow in-
vitro  research.
The Convention states the principle according to which a person has to give the necessary consent for
treatment expressly, in advance, except in emergencies, and that such consent may be freely withdrawn
at any time. The treatment of persons unable to give their consent, such as children and people with
mental illnesses, may be carried out only if it could produce real and direct benefit to his or her health.
The Convention stipulates that all patients have a right to be informed about their health, including the
results of predictive genetic tests. The Convention recognises also the patient's right not to know. The
Convention prohibits the removal of organs and other tissues which cannot be regenerated from people
not able to give consent. The only exception is, under certain conditions, for regenerative tissue
(especially bone marrow) between siblings.
The Convention recognises the importance of promoting a public debate and consultation on these
questions. The only restrictions are those prescribed by law and which are necessary in a democratic
society in the interest of public safety, for the prevention of crime, for the protection of public health or
for the protection of the rights and freedoms of others. Additional Protocols are foreseen to clarify,
strengthen and supplement the overall Convention.
Article 1 – Purpose and object
Parties to this Convention shall protect the dignity and identity of all human beings and guarantee
everyone, without discrimination, respect for their integrity and other rights and fundamental freedoms
with regard to the application of biology and medicine. Each Party shall take in its internal law the
necessary measures to give effect to the provisions of this Convention
Article 2 – Primacy of the human being
The interests and welfare of the human being shall prevail over the sole interest of society or science
Article 3 – Equitable access to health care
Parties, taking into account health needs and available resources, shall take appropriate measures with a
view to providing, within their jurisdiction, equitable access to health care of appropriate quality
Article 4 – Professional standards
Any intervention in the health field, including research, must be carried out in accordance with relevant
professional obligations and standards
Covered further in Q.14

13. The EU Legal Health Regulation, Cross-border

Healthcare
Law of the EU
History
 Unique legal system which operates alongside the laws of Member States of the European
Union
 The EU is based on a series of treaties/treaty of Paris – European Coal and Steel Community,
EEC – European Economic Community, Euratom- European Atomic Energy Community
 The main legislative acts of the EU come in two forms: Regulations and Directives.
Nature of the System
 Supranational law
 EU law has direct effect within the legal systems of its Member States, and overrides national
law in many areas, especially in terms of economic and social policy
 Three pillar structure
o I. – law concerning economic and social rights and how European institutions are set up
/EC law/
o II. – law concerning the European Union Common Foreign and Security Policy (CFSP)
o III. – law concerning Police and Judicial Cooperation in Criminal Matters (formerly 'Justice
and Home Affairs').
 Who can apply EU Law?
o The Court of Justice of the European Communities, usually called the European Court of
Justice
o National court
Fundamental Rights
 At present the EU does not have a codified catalogue of fundamental rights against which its
legal acts might be judged
 ‘Constitutional traditions common to the Member States’
 In 2000 the EU drew up the Charter of Fundamental Rights. The Charter is not legally binding at
present but would become so if the Lisbon Treaty comes into force.
Council of Europe
 The oldest international organisation working towards European integration
 It has a particular emphasis on legal standards, human rights and democratic development
 Legislative acts: recommendations, standards, charters and conventions
European Court of Human Rights
 Was established under the European Convention on Human Rights (ECHR) of 1950 to monitor
compliance by Contracting Parties
 Very important in cases of unlawful detention in cases of mental disorders

Healthcare & Institutions

 Council of Europe
 EU

Council of Europe – the European Directorate for the Quality of Medicines

Came into being in its current form in 1996. It consists of the Technical Secretariat of the European
Pharmacopoeia Commission long referred to as the European Pharmacopoeia set up in 1964 by the
European Pharmacopoeia Convention, and other, more recent services which provide support activities
related to use of the European Pharmacopoeia such as the certification of suitability of monographs and
the European Network of Official Control Laboratories (OMCL) for medicines for human and veterinary
use (set up in 1995).
Responsible for:
 For the preparing and publishing adopted texts and distributing the European Pharmacopoeia
and other publications
 For organising activities related to the procedure for the certification of suitability of European
Pharmacopoeia monographs
 For a number of activities, in collaboration with the EU, related to Surveillance of
Pharmaceutical Products marketed and distributed in Europe
Summary: The EDQM (Council of Europe) is a key European Organisation involved in Harmonisation & Co-
ordination of Standardisation, Regulation & Quality Control of Medicines, Blood Transfusion and Organ
Transplantation.

EU Law & Health Care – Legal Acts

4 main focuses of EU legislative activity:
 Public Health
 Pharmaceutical medicinal products
o Much of the impetus behind the first Community legislation in this sector, Directive
65/65/EEC, stemmed from the determination to prevent the recurrence of the
thalidomide disaster of the early 1960s
 Cross-border healthcare
 Blood, tissues, organs
EU is responsible
 Evaluation of medicinal products and marketing authorisations
 Good manufacturing practice (GMP) and inspection
 Pharmacovigilance
  Veterinary medicinal products

Cross Border Healthcare in EU

 The citizens of the EU member states have a free movement across EU territory
 They have a legal entitlement to health services in the territory of all EU Member States.
 There are applied two principles:
o Principle of equal access: the equal rights, equal conditions as the residents do
o Principle of the only one health insurance: the EU citizens should be insured in the EU
member state when they work and live
 The extent of health care varies depending on whether it is a short-term/tourist stay (<3
months) or long-term stay, i.e. if a citizen of one EU country lives and works in another EU
country for a longer time
o Tourist stay – entitlement to emergency and acute care
o Long-term stay: citizens of other EU countries participate in the health care system in
their country of residence, incl. children and non-working family members; entitlement to
the same amount of care as for domestic residents

European Health Insurance Card (EHIC)

When stay in other EU country and need health services – EU citizens are asked to certify their identity by
a European Health Insurance Card. European Health Insurance Card (EHIC): unified document issued in
domestic country and valid at the territory of EU; EHIC also confirms that person participates in health
insurance system in domestic country.
 EHIC enables to health providers to get reimbursement of provided health services in case of
treatment of people from another EU member state during short –term stay
 All EU residents have to be provided all needed health services in the EU territory at the same
conditions as for residents (also the same co-payment)
 EU residents living in any other EU Member State on long term basis are required to be
registered by relevant health insurance fund in a new country as domestic population does
  In the CR: Centrum mezistátních úhrad (Centre for International Reimbursement) is the
institution assisting to EU citizens and to health providers in a process of health services
reimbursement (www.cmu.cz)

14. Informed Consent, Medical Confidentiality

Informed Consent
What is informed consent?
Informed consent is the process by which a fully informed patient can participate in choices about
his/her health care. It originates from the legal and ethical right the patient has to direct what happens
to their body and from the ethical duty of the physician to involve the patient in their health care
Legal Framework
Convention on Human Rights & Biomedicine Article 5 – General rule;
 An intervention in the health field may only be carried out after the person concerned has given
free and informed consent to it
 This person shall beforehand be given appropriate information as to the purpose and nature of
the intervention as well as on its consequences and risks
 The person concerned may freely withdraw consent at any time
Protection of persons not able to consent – Article 6
 Intervention can only be carried out on a person who does not have capacity for his or her direct
benefit (Article 17 & 20)
o The individual shall as far as possible take part in the authorisation procedure
 A minor does not have capacity to consent to an intervention, the intervention can only be
carried out with the authorisation of his/her representative, or an authority/person/body
provided for by law
o The opinion of minor shall be taken into consideration as an increasingly determining
factor in proportion to his/her age and degree of maturity
Intervention without consent
 Article 7 – Protection of persons who have a mental disorder
o without his/her consent, to an intervention aimed at treating his/her mental disorder
only where, without such treatment, serious harm is likely to result to his/her health
 Article 8 – Emergency situation
o Any medically necessary intervention may be carried out immediately for the benefit of
the health of the individual concerned
Elements of full informed consent
 The most important goal of informed consent is that the patient has an opportunity to be an
informed participant in his healthcare decisions. It is generally accepted that complete informed
consent incudes a discussion of the following elements:
o The nature of the decision/procedure
o Reasonable alternatives to the proposed intervention
o The relative risk, benefits, and uncertainties related to each alternative
o Assessment of patient understanding
o The acceptance of the intervention by the patient
 The way of informing – the attending physician must inform the patient:
o Appropriately and comprehensibly of his state of health and the essential medical
procedures
 o Information must be given in a clear manner that the patient understands and so can
consider the need and purpose of the intended therapy freely and without pressure
o Inform the patient of the right to make a free decision on further proposed healthcare
procedures unless this law or special legal regulation completely rule this out
 The patient must also have an opportunity to ask supplementary questions and the attending
physician must respond
 Only in special cases is written informed consent is required – medical research, interventions
that are not in the direct interest of the person concerned, donation and transplantation
 Next to expressed consent (that can be either oral or verbal), there is also implied (also called
non-verbal)
Minors
 Czech law does not provide for a fixed age of ‘medical majority’
 The Civil Code majority is acquired by achieving the age of 18. If a minor cannot be considered
as competent, the consent has to be given by his parent(s). In such a case, the right to
information is delegated to the parent(s)
 If a parent of guardian refuses to give consent for an intervention that is considered necessary to
save a child’s life or health, the attending physician may nevertheless proceed with the
intervention
Incapables
If individuals are not capable to legal act, they shall be represented by their legal representatives

Medical Confidentiality
Respect for confidentiality is firmly established in the codes of medical ethics
International Code of Ethic:

‘Except when obligated by the law of the country concerned, a doctor shall not
disclose, without the consent of the patient, information which he has obtained in the
course of his professional relationship with the patient’

 Foundation of trust in doctor/patient relationship

 Fiduciary relationship – a person puts trust and confidence in another to act in good faith for his
best interests
 Confidential communication – privileged communication intended only for the knowledge of a
particular persons
 Keep private information secret or undisclosed
 Children, elderly, mentally disabled and the dead all have the same right to confidentiality
Importance
 Encourages free exchange of information which is important for effective medical intervention
 Respects patient autonomy
 Right to determine with whom, when and how much of the personal medical information is
shared
 Natural human desire for privacy
 Fear of social embarrassment or disapproval
 Fear of discrimination, stigmatisation
 Information misused against patients
 Builds confidence and open communication
 Demonstrates doctor’s fidelity to the patient
 Respects patient’s privacy, dignity, and individuality
Legal Framework
Convention of Human Rights & Biomedicine Article 10 – Private life and right to information
 Everyone has the right to respect for private life in relation to information about his or her
health.
 Everyone is entitled to know any information collected about his or her health. However, the
wishes of individuals not to be so informed shall be observed
 In exceptional cases, restrictions may be placed by law on the exercise of the rights contained in
paragraph 2 in the interest of the patients
Restrictions
 Article 26 – restrictions on the exercise of the rights
 No restrictions shall be placed on the exercise of the rights and protective provisions contained
in this Convention other than such as are prescribed by law and necessary in a democratic
society in the interest of public safety, for the prevention of crime, for the protection of public
health or for the protection of the rights and freedoms of others
Under Czech Law:
 Article 55, section 1, lit. d) of the Health Care Act 1966
 Each health care professional has to maintain confidentiality about all the facts he was informed
about in relation to the exercise of his/her occupation expect in case the person concerned
agrees to allow a third party to be informed or if he is exempt from this duty by the law
Disclosure
 Medical confidentiality is not absolute
 Disclosure
o To proper authorities – need to know, defined by law
o Now beyond what is required or relevant
o Reason for disclosure documented in the medical record
 When:
o With patient’s consent
o When required by law
 Court order – medical, criminal cases, compensation cases, insurance, etc.
 Public health risk
o Medical research, audit, registries
 Other
o For benefit of patient?
o Prevent harm to others?
 When harm to others outweighs his duty to the patient
 E.g. HIV+ patient – should the doctor disclose this fact to his family? Wife?
 Seriousness of harm vs likelihood of occurrence of harm
 Disciplinary action against doctor
Useful link: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality

15. Legal Aspects of Patient/Doctor relationships; Patient

Rights; Medical Malpractice
Medical Records
 Article 67b of the Health Care Act 1966; Provision N 385/2006 Sb on medical records
  All health care establishments are obliged to keep medical files of their patients. The health
documentation must be evidentiary, correct and readable continually supplemented
Contents of the medical file:
 A patient’s personal data to the extent necessary for his identification and anamnesis
o Information on the patient’s disease
o Course and results of examinations
o Treatment
o Important factors of his health condition
o Health care procedures
o UK – NHS/CHI number
 Date, identification and signature of the record maker

Patient’s Rights
A patient has a right to the information included in health documentation and related to him or
information in other reports concerning his health condition. The patient has a right to have a copy of
the record
Refusing Care
If a patient refused necessary care, in spite of the appropriate information about his health condition, the
attending physician will ask him for a written confirmation of this refusal. The form is prescribed in
provision 385/2006 Sb on the medal record

Medical Malpractice
Definition
Medical malpractice is professional negligence by act or omission by a health care provider in which
care provided deviates from accepted standards of practice in the medical community and causes injury
to the patient. Standards and regulations for medical malpractice vary by country or jurisdiction within
countries. 78% of EU citizens classify medical errors as an important problem in their country, with 38%
ranking the issue as very important
Professional Standards
Convention on Human Rights & Biomedicine Article 4 – Professional Standards
 Any intervention in the health field, including research, must be carried out in accordance with
relevant professional obligations and standards
Article 11 of the Health Care Act 1966
 The content of professional standards, obligations, and rules of conduct is not identical in all
countries, but the fundamental principles of the practice of medicine apply in all countries.
Doctors and, in general, all professionals who participate in a medical act are subject to legal and
ethical imperatives. They must act with care and competence, and pay careful attention to the
needs of the patient
Liability
 A duty was breached – liability of the doctor
 Civil liability/compensation
 Criminal liability
 Administrative liability – removal of licence
The Medical Malpractice Claim
A damage resulting from health services is compensated according to the rules of the Civil Code which
does not contain special provisions on the liability when providing health services. When liability cannot
be established, the state can exceptionally provide an injured person with a benefit
  The parties
 The plaintiff is or was the patient, or a legally designated party acting on behalf of the patient
 The defendant is a health care provider
The elements of the case:
 A plaintiff must establish all four elements of the tort of negligence for a successful medical
malpractice claim
 A duty was owed – a legal duty exists whenever a hospital or healthcare provider undertakes
care or treatment of a patient
 A duty was breached – the provider failed to conform to relevant standards of care. The
standard of care is proven by expert testimony or by obvious errors (the doctrine of res ipsa
loquitur or ‘the thing speaks for itself’)
 The breach caused an injury – the breach of duty was a proximate cause of injury
 Damages – without damages (losses which may be pecuniary or emotional), there is no basis for
a claim, regardless of whether the medical provider was negligent.
The Trial
 The plaintiff has the burden of proof to prove in 100%
 In these cases, the court will usually present and expert to testify as to the standard of care
required, and other technical issues
Damages
 The plaintiff’s damages may include compensatory damages
 Compensatory damages are not both economic and non-economic
 Economic damages include financial losses such as lost wages (sometimes called lost earning
capacity), medical expenses and life care expenses. These damages may be assessed for past
and future losses
 Non-economic damages are assessed for the injury itself: physical and psychological harm, such
as loss of vision, loss of limb or organ, the reduced enjoyment of life due to a disability or loss of
a loved one, severe pain and emotional distress
Criticism of Medical Malpractice Lawsuits/USA
 Doctors’ groups, patients, and insurance companies have criticised medical malpractice litigation
as expensive, adversarial, unpredictable, and inefficient
 For every dollar spend on compensation, 54 cents went to administrative expenses (including
lawyers, experts and courts)