XXI. MEZINÁRODNÍ KOLOKVIUM O REGIONÁLNÍCH VĚDÁCH. SBORNÍK
PŘÍSPĚVKŮ.
21ST
INTERNATIONAL COLLOQUIUM ON REGIONAL SCIENCES.
CONFERENCE PROCEEDINGS.
Place: Kurdějov (Czech Republic)
June 13-15, 2018
Publisher: Masarykova univerzita, Brno
Edited by:
Viktorie KLÍMOVÁ
Vladimír ŽÍTEK
(Masarykova univerzita / Masaryk University, Czech Republic)
Vzor citace / Citation example:
AUTOR, A. Název článku. In Klímová, V., Žítek, V. (eds.) XXI. mezinárodní kolokvium
o regionálních vědách. Sborník příspěvků. Brno: Masarykova univerzita, 2018. s. 1–5.
ISBN 978-80-210-8969-3.
AUTHOR, A. Title of paper. In Klímová, V., Žítek, V. (eds.) 21st
International Colloquium
on Regional Sciences. Conference Proceedings. Brno: Masarykova univerzita, 2018. pp. 1–
5. ISBN 978-80-210-8969-3.
Publikace neprošla jazykovou úpravou. / Publication is not a subject of language check.
Za správnost obsahu a originalitu výzkumu zodpovídají autoři. / Authors are fully responsible for the
content and originality of the articles.
© 2018 Masarykova univerzita
ISBN 978-80-210-8969-3
ISBN 978-80-210-8970-9 (online : pdf)
Sborník příspěvků XXI. mezinárodní kolokvium o regionálních vědách Kurdějov 13.–15. 6. 2018
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DOI: 10.5817/CZ.MUNI.P210-8970-2018-92
THE SUPPLY OF OUTPATIENT SERVICES AND ITS
GEOGRAPHICAL DISTRIBUTION WITHIN THE REGIONS
OF THE CZECH REPUBLIC
Nabídka ambulantních služeb a její rozdělení v rámci krajů České
republiky
JANA ROZMARINOVÁ
Katedra veřejné ekonomie
Ekonomicko-správní fakulta
Masarykova univerzita
Department of Public Economics
Faculty of Economics and Administration
Masaryk University
 Lipová 41a, 602 00 Brno, Czech Republic
E-mail: 450924@econ.muni.cz
Annotation
Equal quality of care for everyone should be an important public policy goal. The goal of this paper is to analyze
the geographical distribution of the health care in the Czech Republic; the method used in the research is the
calculation of the four inequalities measurements: the absolute range, relative range, Robin Hood index and the
Gini coefficient. The trend over time is analyzed quantitatively in the case of 1) the outpatient care and 2) the
dentist care. The results of our analysis show that the supply of outpatient services and the supply of the dental
care are inequitably distributed in the Czech Republic. For example, 13 % of the dentist was concentrated in the
capital in 2003 and even 15.5 % of the dentists in 2013. The analysis showed that the distribution of the outpatient
physicians has become less equitable during the observed period both for the physicians and for the special case
of the outpatient care – the dentists. In the second part, we focus on the central government's activities
encouraging the supply in the undersupplied regions. In this context, the role of the region´s government is
discussed.
Klíčová slova
health economics, resource allocation
Anotace
Rovný přístup ke zdravotní péči by měl být jedním z hlavních cílů veřejné politiky. Cílem našeho výzkumu bylo
analyzovat regionální rozdělení zdravotní péče v České Republice. Metodou použitou k výzkumu byl výpočet
nerovnosti na základě čtyřech ukazatelů: absolutní variační rozpětí, relativní variační rozpětí, Robin Hood indexu
and Gini koeficientu. Trend byl analyzován kvantitativně a to na příkladu 1) rozdělení ambulantní péče a 2)
rozložení ambulantních ordinací zubařů. Výsledky naší analýzy ukazují, že nabídla ambulantní péče lékařů je v
České Republice rozložena nerovnoměrně. Například v roce 2003 bylo 13 % zubařů koncentrováno v hlavním
městě, v roce 2013 se jednalo o 15.5 % zubařů. Analýza ukázala zejména rostoucí trend směrem k
nerovnoměrnému rozložení (2003, 2013) a to jak pro ambulantní lékaře, tak i pro speciální případ ambulantní
péče (zubaře). V další části jsme se zaměřili na aktivity centrální vlády, které by měly vést ke zvýšení nabídky
zdravotních služeb v relativně méně zásobených regionech, v daném kontextu je také navíc diskutována role
regionálních vlád.
Klíčová slova
ekonomie zdravotnictví, rozdělení zdrojů
JEL classification: I14, I18
1. Úvod
The monitoring of health inequality is a practice that fosters continuous improvement within health care systems
(WHO, 2015). The importance of such some practices is emphasized with both World Health Organization (WHO)
Sborník příspěvků XXI. mezinárodní kolokvium o regionálních vědách Kurdějov 13.–15. 6. 2018
700
and the Organization for Economic Co-operation and Development (OECD) (Devaux, 2015). Both organizations
emphasize the necessity of measuring equity in the distribution of system resources. The report of WHO claims,
that data disaggregation to a regional level presents a major challenge for many countries with the purpose of the
regional monitoring to help to identify the disadvantaged populations. Equality in the health services, even from
the geographical point of view in relation to the political aim of the universal access to health services is
considering being one of the basic principles of the health systems. If the issue of equity is related to the public
policy, we can define the ensuring of equal access to the health care as an important policy goal (e.g. Scott, 2001).
Even if the social background of the equity is more often emphasized topic, we can argue that the understanding
of the geographic distribution of health care resource and trends inequality of access to health care can offer a
different.
In the study, which we present here we use the Gini coefficient and Robin Hood index to measure variations in
the distribution of physicians. The Gini Coefficient measures departure from a uniform distribution, indicating if
resources within a 14 Czech´s regions. We try to find if the resources are distributed equally or not across all the
Czech´s regions relative to their population size. The approach we applied was inspired by international studies
of measuring inequalities. Even if the Gini coefficient was originally used to make comparisons of inequalities in
the distribution of income and welfare, it is an often a tool how to measure these inequalities in health care
resources allocation from the geographic point of view (e.g. Chang, 1998; Horev, 2004; Jian 2015; Omrani-Khoo,
2013; Mobaraki, 2013; Chen, 2014; Gravelle 2001). On the other hand it is not the only approach how to study
and understand the inequalities on the health care allocation, e.g. Wilkinson (2000) use a Robin Hood Index to
describe the distribution of general practitioners in States and Territories of the Australia.
During our study of the topic we have found only one study which try to describe the geographical supply of
outpatient services in the Czech Republic with respect to individual regions. The research was made by Dlouhý
(2000) on the data for the period of 1990 to 2002; it was found that the supply of outpatient services is unevenly
distributed with the trend to more inequality from 1990 to 2002. The inequality of geographical distribution was
measured by the Gini coefficient, and with the help of simple indicators of the absolute range and the relative
range. This study becomes also our inspiration to try to measure the inequalities in distribution of outpatient care
on a newer data.
In our paper the geographical disparities is discussed in the context of the supply of the health care in the Czech´s
regions. Our hypothesis is that the Czech Republic faces the increasing the inequalities over time.
The main goal of our research in this paper was specified by its partial research targets:
 Analysis of the differences in supply of the outpatient care and dentist care among Czechs Regions was made.
Trends over time during the chosen period will be described and discussed.
 Analysis of the activities made by the central government, government of the regions and health insurance
companies
2. Data a method used
Open data were used for our research. The data of the location of outpatient practitioners and dentists were
extracted from the Institute of Health Information and Statistics of the Czech Republic, the subsection prepared
by the Institute for the individual regions was used (e.g. “A year book of Health care in the Vysočina region”).
Period 2003 and 2013 was used to examine trends in inequalities over time. The number of outpatient physicians
includes both those with independent practices and those from hospital department (outpatient hospital care); the
same principle is valid for the data concerning the amounts of the dentist physician. Further, it was used the
population size as a need for the care (obtained from the Institute of Health Information and Statistics of the Czech
Republic furthermore). The calculation of the number of physician per 10 000 patients followed. For the
measurement of inequality, we used four measures: the absolute and Relative Range, which both are a simple
indicators based on extreme values and Gini coefficient and Robin Hood index.
The Absolute Range is a simple descriptive statistic based on the maximum values only, it gives us an indication
of that how spread the values for the individual regions is by subtracting the minimum from maximum values.
The relative range is a similar statistic to an absolute range with the only difference that it is calculated relatively.
The percent relative range refers to the percentage ratio of the range to the average value in the set.
The Robin Hood index (originally used for measuring the income inequalities in the society) is the proportion of
the whole supply (amount of outpatient physicians or amount of dentist) which is needed to be redistributed so to
reach a perfect equality among the regions.
Sborník příspěvků XXI. mezinárodní kolokvium o regionálních vědách Kurdějov 13.–15. 6. 2018
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The Gini Coefficient was as the Robin Hood index primarily used for the measurement of income inequalities. It
relates to the well-known economic theory. The Gini coefficient is approached from the summary of the Lorenz
Curve of the income distribution. We can derive the Gini Coefficient as the difference between the area under the
Lorenz Curve for a population in which everyone receives the same income (for the regions in which each of them
has the same amount of the physicians or dentists per 10 000 patients). The Gini coefficient ranges from 0, in the
case of perfect equality, to 1, in the case of perfect inequality.
For the analysis of the activities aimed at reducing inequalities and improving access to health care in less-supplied
regions, we used the documents of the Ministry of Health Care, the statements of the insurance companies and the
strategic plans for Healthcare of individual regions.
3. Regional Distribution - analysis
The results of our analysis can be shown in Table 1 and in Table 2. The numbers of the physicians extracted from
the yearbooks of the particular regions where extracted and recalculated to the number of the physicians (resp.
dentists) per 10 000 patients. The inequalities among the supply of the health care in individual regions we can
see even from the first dataset (tab.1). Especially the regions Středočeský, Vysočina, Liberecký, Ústecký are
deeply under the average of the Czech Republic, the average for the Czech Republic is 27.27 outpatient physician
per 10 000 patients. The trend in the development of the inequalities can be described on the example of the region
Středočeský and Ústecký. These relatively undersupplied regions belong to those, where the increase of the
outpatient’s physicians is deeply under the average of the Czech Republic (the average change is 12. 2 %).
Tab. 1: The number of physicians and dentists in individual regions – absolute numbers
Region
Population 2003 2003 2013 2013
2003 2013 Physicians Dentists Physicians Dentists
Prague 1,161,851 1,244,762 5,736 1,123 7,385 1,452
Středočeský 1,131,402 1,297,209 2,440 528 2,823 619
Jihočeský 624,958 636,443 1,597 381 1,877 409
Plzeňský 549,307 572,882 1,709 402 1,877 423
Karlovarský 304,078 300,999 717 160 834 171
Ústecký 819,851 825,842 1,930 416 2,039 425
Liberecký 427,096 438,473 993 234 1,156 253
Královéhradecký 547,720 552,053 1,573 354 1,841 398
Pardubický 506,389 515,781 1,262 283 1,374 303
Vysočina 517,572 510,522 1,154 283 1,267 315
Jihomoravský 1,121,669 1,168,577 3,400 760 4,075 924
Olomoucký 636,227 636,659 1,807 415 2,070 451
Zlínský 592,300 586,594 1,425 381 1,640 419
Moravskoslezský 1,261,229 1,223,923 3,165 712 3,499 802
Czech Republic 10,201,649 10,512,732 28,908 6,432 33,757 7,364
Source: Author, based on data
When considering the amount of special case outpatient physicians, the dentist in our case, relatively the most
under-supplied are Středočeský, Ústecký and Karlovarský region. If we examine the trend over time, the Plzeňský,
Ústecký and Středočeský are regions which suffer from the lowest increase in the amount of dentist. We do again
pose the situation when the regions with the lowest supply belong to the regions with the lowest increase of the
dentists (case of Ústecký and Středočeský region). On the other hand, the capital, Prague, which holds a unique
position with the far highest supply of services per capita both for outpatient physicians and for the dentists, we
witness the further increase by 20.2 % concerning all outpatient physicians and 20.7 concerning the dentists see
Table 2.
Sborník příspěvků XXI. mezinárodní kolokvium o regionálních vědách Kurdějov 13.–15. 6. 2018
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Tab. 2: The number of physicians and dentists recalculated per 10 000 patients
Region
Population 2003 2003 2013 2013 Physicians Dentists
2003 2013 Physicians Dentists Physicians Dentists
Change in
%
Change
in %
Prague 1,161,851 1,244,762 49.37 9.67 59.33 11.66 20.2 20.7
Středočeský 1,131,402 1,297,209 21.57 4.67 21.76 4.77 0.9 2.3
Jihočeský 624,958 636,443 25.55 6.10 29.49 6.43 15.4 5.4
Plzeňský 549,307 572,882 31.11 7.32 32.76 7.38 5.3 0.9
Karlovarský 304,078 300,999 23.58 5.26 27.71 5.68 17.5 8.0
Ústecký 819,851 825,842 23.54 5.07 24.69 5.15 4.9 1.4
Liberecký 427,096 438,473 23.25 5.48 26.36 5.77 13.4 5.3
Královéhradecký 547,720 552,053 28.72 6.46 33.35 7.21 16.1 11.5
Pardubický 506,389 515,781 24.92 5.59 26.64 5.87 6.9 5.1
Vysočina 517,572 510,522 22.30 5.47 24.82 6.17 11.3 12.8
Jihomoravský 1,121,669 1,168,577 30.31 6.78 34.87 7.91 15.0 16.7
Olomoucký 636,227 636,659 28.40 6.52 32.51 7.08 14.5 8.6
Zlínský 592,300 586,594 24.06 6.43 27.96 7.14 16.2 11.0
Moravskoslezský 1,261,229 1,223,923 25.09 5.65 28.59 6.55 13.9 16.1
Czech Republic 10,201,649 10,512,732 27.27 6.18 30.3 6.77 11.1 9.5
Source: Author, based on data
Relative range is based on the difference of the extreme values, when the percent relative range was calculated
(the percentage ratio of the range to the average value in the set).
Tab. 3: The inequality of the regional distribution of the physicians
Inequality Measure
Physicians
2003 2013
Absolute range 27.8 37.57
Relative Range 1.02 1.22
Robin Hood index (in%) 5.8 6.6
Gini coefficint 0.1102 0.1259
Source:Author, own processing
Firstly we have investigated the developments in the total supply of the outpatient’s services, regardless of the
type of specialty. To examine, if the total numbers may hide the great variability among the specialties we explore
furthermore the development of dentists as a one selected specialty. The results from the measures of inequality
on the 2003 data were: the relative range was increased from 1.02 to 1.22. The Robin Hood index increased from
5.8 to 6.6 and the Gini coefficient increased from 0.11 to 0.12. All measurement of inequalities showed trend to
its increase over time 10 years. As for the concentration of the care in the city of Prag (18.5 % in 2003 and 20 %
in 2013 of the all outpatient physician were concentrated in the capital.
Further we have focused (from the reasons mentioned above) for a special outpatient care, the dentist outpatient
care. There were 8,435 of the dentists in 2003 and 9,377 in 2013 in the Czech Republic. The growth rate of the
number of the dentists was 11 % between 2003 and 2013. This is a lower rate than the average rate for all outpatient
services 15.7 % between 2003 and 2013. The results from the measures of inequality on the 2003 data were: the
relative range was 1.02 the Robin Hood index was 7.1 and the Gini coefficient was 0.0983. These numbers imply
a greater inequality in the distribution of outpatient dentist services than that of all outpatient services. The dental
care is less concentrated in the city of Prag, where 13 % of the dentist are concentrated in the capital in 2003 and
15 % in 2013, than the outpatient physician care as a whole (18.5 % in 2003 and 20 % in 2013).
Sborník příspěvků XXI. mezinárodní kolokvium o regionálních vědách Kurdějov 13.–15. 6. 2018
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Tab. 4: The inequality of regional distribution of the dentist
Inequality Measure
Dentists
2003 2013
Absolute range 5 6.89
Relative Range 1.00 1.02
Robin Hood index (in %) 7.1 8.2
Gini coefficient 0.0983 0.1832
Source:Author, own processing
4. The institutions and their efforts to a better geographical distribution of health care
services
The Healthcare in the Czech Republic is based on statutory health insurance, which is provided by nine health
insurance companies. Financing healthcare is controlled by a wide range of legislation, but the main law is the Act
No. 48/1997 Coll., on Public Health Insurance, which regulates public health insurance and extent conditions
under which healthcare is provided.
The Ministry of Health is a central administrative body created by a state and its framework of responsibilities
includes the health care and its ensurement. As the activities of the Ministry concerning the inequalities in the
supply of health care, the Ministry recently announced that subsidies will be provided to 100 new dentists. In total,
it has over 4 million euro should be provided. The aim of the program should ensure sufficient availability of
dental care in all regions of the Czech Republic so that the care would be available and not concentrated only in
larger cities. The ministry wants to motivate physicians to set up practices in remote areas.
A similar program concerning outpatient care in the less supplied regions was announced in 2017. Up to half a
million crowns to equip the nursing practice can be applied by a practitioner. The grant can be applied for the
places where the tender for a practitioner´s position was repeatedly unsuccessful. The declaration of the health
insurance company to ensure the contract for the contract for a potential doctor is an enclosure of the application
for this kind of support. The role of the Health insurance companies is very important because the system is based
on the capitation payments.
The governments of individual regions especially those, where the care is lacking rarely mention
this problem in their strategic plans. We have found evidence that only the region Ústecký, which
disposal of a quite comprehensive health care concept emphasizes that the average number of the
outpatient is deeply below the average values for the Czech Republic. Further, the text describes the
development of outpatient health care in the Region as insufficient. Namely the document describes that the
situation is more complicated in the domain of the intern, diabetology, orthopedics, ocular, radiation, clinical
oncology and medical genetics. From the concept it can be seen that the region´s government realizes its
disadvantage in healthcare supply and as a result the strategic document accents that activities to strength the
outpatient physician extent is needed. Further we do not find evidence, that the activities are further more concrete
described. From the press releases ensues that negotiation between the region´s governor and representatives of
the General Health Insurance Company in 2014 aimed at the finding a concept leading to increasing no of the
outpatient physician was carried out.
Conclusion
We have not found evidence that the outpatient services are well geographically distributed. Both based on our
observations and based on the inequality measurement it can be stated, that the supply of outpatient services is
inequitably distributed. This is not surprising that the Capital city has most favourable situation. The uniqueness
of the Prague is obvious in most of comparativeness studies (Wokoun, Viturka, 2014). Our results are similar with
the results of research from which academic literature describes. In the whole outpatient’s patient, for example,
20 % of the supply was concentrated in the capital in 2013. We identified the region with the lowest number of
the physician per 10 000 (Středočeský, Vysočina, Liberecký, Ústecký). What is more important is that further the
measurement of inequalities shows, that the trend to a higher inequality over time (2003 – 2013) is increasing.
When comparing our results with study of Dlouhý, where the tendency to more inequitable distribution is
emphasized on the data for 1996 and 2002, we show here that the trend to more inequitable distribution is ongoing.
From the point of view of central government, we described that subsidies are provided by the State under the
given conditions. Concerning the government’s regions, we have found that only one region, the Ústecký region
shows on the region´s disadvantage in its health strategic plan, but proposal of measures lacks. In the future
Sborník příspěvků XXI. mezinárodní kolokvium o regionálních vědách Kurdějov 13.–15. 6. 2018
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research the Czech experience with encouraging supply in the relatively undersupplied regions should be more
detailed described and discussed, but therefore we argue that our analysis has managed to outline this problem.
Further (but more complicated) would be a research to determine implications for health outcomes.
The distribution of outpatient care tends to unequal distribution from 2003 to 2013. For the future research we
suggest to try to find the reasons why the care is inequitably distributed, e. g. to examine if the outpatient physician
concentrates in the regions with high per capita income or which role plays the university hospitals. In our opinion,
the geographic distribution of the outpatient physician in the Czech Republic can require a more complex policy
aimed at improvement of distribution in undersupplied regions, hardly current effort of the government, the ad
hoc subsidies can significantly help and lead to a better geographical distribution of the outpatient care.
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The author is thankful to the Grant Agency of Masaryk University for the grant No MUNI/A/1029/2017.