Some regions view the transformation of state-run hospitals into traditionally run businesses as the bulldozer needed to clear the road of mounting health care provider debt. Going head-to-head with the central government dominated by the Social Democrats, regions controlled by the senior opposition Civic Democrats believe that change would be the first step to long-awaited health reform. Oldrich Subrt, director of the Prague-based Na Homolce hospital, talks candidly with The Prague Post about why some change is necessary. In discussing the reasons behind it, Subrt says, "What we really need are just small changes to the system, and mainly to ensure that all existing rules are being kept."

1. If you were to address the most important question facing health care today, what would it be and how would you respond to it?

The question would be how we can ensure that society gets the maximum benefits from the development of medical sciences, even though it is now apparent that full access to all treatments for everyone is not realistic. To answer the question, we need expert analyses of available resources, and what the trade-off is between patients' solidarity [in financing the health system] and free-market principles. The issue of solidarity and the individual's responsibility is the main social problem facing health care today.

2. Transforming hospitals into business entities became a major issue of discussion in the health care sector this summer. Do you think changing the system to a profit-oriented industry is the first step to long-awaited health care reform, or will it only serve to bring chaos to a working system?

Well, local governments are traditional providers of health care in Central Europe and across the Continent. They appear to be the best caretakers of public institutions in general. The actual transformation is rather an insignificant issue.

However, the government did make a mistake after [the overthrow of communism] in 1989 when it did not introduce legislation for public hospitals. There is legislation for health insurers, radio, television, universities, but there's nothing for hospitals. It is true that the legal status of organizations that are financed by contributions — which is appropriate for schools or a museum — and that of private enterprises is not the best choice for hospitals.

There's no danger of chaos; closing the gap between the health care granter [the local government] and the provider [the hospital] will be a good step forward.

3. Aren't you afraid that when hospitals are transformed, only profitable treatments will be provided and that that could bring about a virtual collapse of the universal health care system?

The answer is the same as the last. Local governments will continue to hold great responsibility since the public would have better control. It has nothing to do with the legal status of a hospital, but rather with its owner. Local governments are more sensitive to the actual needs of the people than the central government, which tends to follow centrally set policies.

4. Is the current health care system actually sustainable in the long term? What are its major weaknesses from the point of view of a hospital director?

Our system is as sustainable or unsustainable as anywhere else in the world. Its major weaknesses can be seen worldwide — basic controversies consist of conflicts between the [limited] size of [financial] resources and the portfolio of new and expensive treatments. There is also a conflict between solidarity and personal responsibility [in making financial contributions to the system].

In our country, solidarity [in financing the system] tends to prevail and we try to get the maximum benefits from what can be achieved through medicine, regardless of how much it costs and where the money comes from. We are wasting money when we are not enforcing patient participation [in paying for basic pills and medicine].

5. How do you think the viewpoint of a Prague hospital director differs from that of a hospital director outside Prague?

It's similar. Maybe there's a bigger fight for patients in Prague, thanks to the larger number of hospitals in the city. Also, patients in Prague are more demanding of the quality of health care. But I think it's all positive. It's a pity that Prague does not exercise similar ownership rights of its hospitals as some regions do.

6. Czech Medical Chamber President David Rath earlier this year accused insurers of 'clientelism.' He said that payments to some hospitals, including Na Homolce, depend on the managerial skills of hospital directors. What is your response? How important are your personal meetings with insurance company directors?

I don't think we can talk about clientelism. Our hospital aspires to maintain good relations with insurer directors. We always discuss openly the needs and capabilities of the two parties. We accept delays in some insurance payments; they on the other hand understand our need to have money available when paying out larger bonuses to employees. From my own experience as a Prague hospital director and a member of the Association of Hospitals, I'm not aware of any hospitals receiving preferential treatment [from insurers].

7. Prime Minister Jirí Paroubek recently said that the number of health insurers in this country should be reduced. Do you think such a reduction would help increase the efficiency of the system?

To have a large number of insurance companies operating on a market where they are not allowed to freely compete [as it is now] is absurd. We should either introduce free market competition or reduce the number of insurers. The current situation is stupid.

8. The government declared that payment tariffs in state-run hospitals will rise by 8 percent as of September. Most hospitals run by local governments will find it difficult to offer similar pay raises. Isn't this move just an effort to raise opposition against hospital reform, which the government opposes?

Well, I've always advocated the adoption of basic laws on wages rather than tariffs in the health sector. Tariffs, in fact, harm many doctors since [doctors'] remuneration could be higher if basic laws on wages were applied instead. The planned tariff increase without a change in payment levels from insurers is not logical and is harmful. The level of wages should depend on negotiations between employers and employees and not be dictated by the government.

9. Another frequently discussed issue is the launch of e-books, an online database that would help doctors monitor the use of health care by individual patients. Do you think that the current system, which allows patients an unlimited number of doctor visits, should be reduced?

The reduction of visits to ambulance doctors and a cut in the amount of prescribed medicine are essential. The [quality] of health care is reduced as a result of this benevolence [toward patients' unlimited choice of treatments].

10. Health reform and pension reform are becoming the most crucial issues on the agenda of many local governments. What do you think needs to be done so that some reform is adopted?

Society must put pressure on politicians and demand expert analyses to determine better ways of allocating the current 250 million Kc [$10.5 million] given to the health sector. Personally, I think that the word reform is just [a word to captivate the public]. What we really need are just a few small changes to the system and guarantees to ensure that all existing rules are followed and kept.