WHO/Europe report outlines steps to protect households in Czechia from increasing out-of-pocket payments for health care

Financial hardship caused by out-of-pocket payments is lower in Czechia than in many European Union (EU) countries but has increased over time, a new WHO/Europe study reveals. In 2023, close to 6% of households in the country, or around 600 000 people, experienced catastrophic health spending. People who face catastrophic health spending may struggle to afford other basic needs like food, housing and heating.

"Can people afford to pay for health care? New evidence on financial protection in Czechia 2025" is the first comprehensive analysis of affordable access to health care in the country. It shows that catastrophic health spending is mostly concentrated in households with low incomes.

"We are happy to see that, according to this new analysis, people in Czechia face less financial hardship when they use health care than in many other EU countries," said Professor Vlastimil Válek, Minister of Health and Deputy Prime Minister of Czechia. "We are committed to taking forward the recommendations outlined in this report."

Drivers of financial hardship and unmet need

In 2023, 21% of households in the poorest fifth of the population experienced catastrophic health spending, up from 14% in 2018. Older people are also at high risk of catastrophic health spending.

In the poorest households, catastrophic health spending is mainly driven by out-of-pocket payments for outpatient medicines. Dental care is the main driver in the other income groups, followed by outpatient medicines.

Levels of unmet need for health care, dental care and prescribed medicines in Czechia are below the EU average, but have also increased in recent years. Unmet need is mainly driven by waiting times for health care and cost for dental care. There is a notable degree of income inequality in unmet need for dental care. More detailed comparative data are featured on UHC Watch - an online platform tracking progress on affordable access to health care in Europe and central Asia.

Strengths in coverage policy

WHO/Europe's report highlights 2 aspects of coverage policy in Czechia that contribute to stronger financial protection and are an example of good practice for other countries in Europe.

• Entitlement to social health insurance (SHI) benefits is based on permanent residence rather than payment of mandatory SHI contributions. As a result, all residents can access the full range of publicly financed health care, including those in precarious employment.
• Co-payments are not widely used in the health system.

"Czechia's decision to base entitlement to SHI benefits on residence is an example of good practice for other countries with SHI schemes," said Dr Natasha Azzopardi Muscat, Director of the Division of Country Health Policies and Systems at WHO/Europe. "Linking entitlement to payment of SHI contributions makes it difficult to cover the whole population, especially in a world where work is increasingly precarious for many."

Gaps in coverage persist

Despite these important positive features, the report notes that persistent gaps in coverage are likely to undermine financial protection, particularly for people with low incomes. One of them is the prevalence of avoidable co-payments for outpatient prescribed medicines - out-of-pocket payments that could have been avoided if prescribers, pharmacists and patients had selected the fully covered medicine within each reference group of interchangeable medicines.

There are also gaps in SHI coverage of medical products and dental care. For example, the SHI scheme does not cover corrective lenses for adults. Dental care is covered, but in practice many dentists do not offer covered services or materials.

Outpatient visits are affected by long waiting times and informal payments.

Mitigating the impact of population ageing

The report also notes that Czechia's relatively heavy reliance on employment-based contributions (payroll taxes) to finance the health system may be a challenge in the context of an ageing population.

As the working-aged share of the population declines, revenue from payroll taxes is likely to fall, increasing fiscal pressure - a concern echoed in another recent WHO study titled "How does population ageing affect health system financial sustainability and access to health care in Europe?".

In 2022, payroll taxes accounted for 55% of Czechia's public revenue for health - higher than in many other EU countries with SHI schemes. Unless Czechia takes steps to broaden its public revenue base for health, there is a strong risk that growing budgetary pressures could push up waiting times, erode coverage and increase catastrophic health spending.

Making health care more affordable

To reduce financial hardship and unmet need, particularly for households with lower incomes, the Government can consider the following options.

• Outpatient medicines: ensure that the fully covered medicine in each reference group is available in pharmacies and waive co-payment when it is not; exempt people with low incomes from co-payments currently eligible for the cap on co-payments or extend the lowest cap (500 Czech korunas) to people with low incomes; closely monitor avoidable co-payments and their causes; reduce the value-added tax rate for covered medicines; and improve access to pharmacies in underserved areas.
• Dental care: require dental care providers to offer covered services and materials; expand coverage of dental care, including the use of higher-quality materials; and improve access to dental care in underserved areas.
• Medical products: expand coverage, especially for people with low incomes.
• Outpatient care: remove administrative barriers to exemption from co-payments for emergency care or abolish this co-payment since it is unlikely to be addressing the root cause of inappropriate emergency care use; enforce laws prohibiting extra billing; and monitor and address long waiting times and informal payments.

To meet equity and efficiency goals now and in the future, the Government can also take steps to broaden the SHI scheme's revenue base, so that it will generate sufficient public funding for health as the population ages.

"Czechia has so far kept financial hardship from out-of-pocket payments lower than many other EU countries, but it has been growing over time - particularly in the poorest households," said Daniela Kandilaki, author of the WHO report and researcher at the Prague University of Economics and Business. "The report outlines policy options that can reverse this trend and make health care more affordable for everyone. Building a fairer and more resilient health system now will prevent more people from experiencing catastrophic health spending in the years ahead."

About the report and WHO/Europe's work on financial protection

This review is part of a series of country-based studies generating new evidence on affordable access to health care (financial protection) in health systems in Europe. It assesses the extent to which people in Czechia face financial barriers to access or experience financial hardship when they use health care. The report covers the period from 2017 to 2025 using data from household budget surveys from 2017 to 2023 (the latest available year), data on unmet need for health services up to 2024 (the latest available year) and information on coverage policy (population coverage, service coverage and user charges) up to May 2025.

WHO/Europe monitors affordable access to health care (financial protection) through the WHO Barcelona Office for Health Systems Financing, using regional indicators that are sensitive to equity. Financial protection is central to universal health coverage and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals and part of the European Pillar of Social Rights, and it is at the heart of the European Programme of Work, WHO/Europe's strategic framework.

Visit the UHC Watch platform to explore country-level and comparative data and analysis.

The report and UHC Watch benefited from financial assistance from the EU through the EU4Health programme.