Lubomír Kukla, Brno

Basic health care for children and adolescents in the Czech Republic is provided by pediatricians in out - patient health facilities. They are also involved in psychological and social problems of children and young people, and closely cooperate with the family and schools.

Comprehensive care is based on primary care consisting of two component parts : preventive care and treatment. The extent and quality of primary care is governed by legal regulations and specified in the Medical Code. Targeted preventive care focuses on individuals jeopardized by the occurence or worsening of an illness, to prevent its chronic stage or resulting defects in a cases where medicine cannot prevent the progress of the disease. Over 3,000 pediatricians work in Czech health facilities, including hospital wards, specialized child clinics and sanatoriums. As of 1998, the Czech Republic had 19 sanatoriums with nearly 1,400 beds that provide therapeutic or convalescent care, including rehabilitation, physio - therapy and balneotherapy.

Dispensary care is related to preventive check-ups, and assures complete care of children who are chronically ill, have recurrent illnesses, are threatened by the environment, or are in selected risk groups. Medical care is most frequently given because of illnesses of the nervous system, sensory organs and respiratory system, or orthopedic and ophtalmologic disorders.

Monitoring of infectious and respiratory diseases is well-organized, and obligatory registration is forwarded by doctors to hygiene centers. The data are worked into final form at the National Reference Center for Analysis of Epidemiological Data at the State Institute of Public Health (SIPH) in Prague. An example is the monitoring of acute respiratory diseases (ARD), as well as influenza. At present, many private pediatricians do not offer data because of time constraints, or as a reaction to the excessive paperwork caused by the increasing bureaucratic demands of insurance companies.

In the field of health care, there are several Health Insurance Companies, the main is the General Health Insurance Company. However, financing health care and efficient privatization of some health facilities is still problematic. The problem of the status of doctors is apparent, especially with their low income in comparison with the incomes of lawyers and employees in banking and financing sectors. Repeated changes in the Ministry of Health is the sign of the difficulty of health care transformation.

Preventive care in the Czech Republic begins in the prenatal and perinatal periods with the cooperation of obstetricians, geneticists and pediatricians. Nearly all children are born in hospitals, and are examined by a pediatrician immediately after birth. If any medical condition is diagnosed, specific treatment begins. During the stay in the hospital following delivery, all children are vaccinated against tuberculosis and screened for the congenital metabolic defects as phenylketonuria, hypothyroidism alfa1- antitrypsin deficiency etc.

After release from the delivery ward of the hospital, the newborn is usually visited by a pediatric nurse within 24 hours, and is examined by a pediatrician by the end of the first week. Complex preventive examinations or check - ups are repeated during the nursing age. These examinations consist of monitoring height, weight, sight, hearing, vocalization, dental, locomotive and psychomotoric development, as well as checking family conditions. According to the results of these medical examinations and monitoring, children at ill risk are placed into dispensary groups. Children at risk are closely monitored by a child specialist and/or other corresponding specialists. The General Health Insurance Company covers the cost of preventive medical examinations or monitorings (to a maximum of ten) for the first year of life.

Preventive medical examinations are performed on the child at the ages of 18 months and three years, and before enterning school. During the third examination, mental development is also checked. Preventive health care continues for children during school years. Medical examinations are performed after school registration, and at the ages of 9, 11, and 13. The final examination is performed when the child finishes school, with the evaluation focused on the child°s health condition as related to the choice of future schooling or choice of profession.

In the system of practical pediatrics for primary health care, a child is treated by the same doctor performing the preventive examinations and check-ups. Because the physician is familiar with a particular child°s health history, the child is guaranteed individualized preventive care. The case load of children per physician is limited to no more than 1,100.

An expanded immunization program has been a primary objective of WHO since 1974. In 1984, representatives of European countries agreed to accept the goal of vaccination programs to eradicate certain infectious diseases by the year 2000. All of the considered infectious diseases have been virtually eliminated in what is now the Czech Republic : polio in 1960, diphtheria in the mid-1960s, and newborn tetanus in 1965 (with the exception of a few cases in the mid-1970s).

Children receive compulsory vaccinations against infectious diseases as they reach a specified age. Children are vaccinated against TB, diphtheria, tetanus, pertussis (whooping cough), polio, morbilli (measles), rubella (German measles), and mumps -

See Table 1.

Vaccinations are based on principals : they are compulsory and free - of - charge.

Children in the Czech Republic consume high amounts of fats and carbohydrates, and small amounts of fish products. As far as wheat products are concerned, breads are preferred. Above-average amounts of pork and meat products are being consumed, and not enough vegetables or trace elements. The health consequences are obesity, tooth decay, anemia, frequent infections, and occasional symptoms of malnutrition (mental anorexia and bulimia).

What is the main pediatric problem in our country ? Injuries, accidents and poisonings account for nearly half of all child deaths. They can be tackled by preventive measures, raising health care standards and stronger disciplining of children by their caregivers. Transportation fatalities play an important role in the deaths of school-age children. Injuries, accidents and poisonings account for 80 per cent of the mortality rate of 15-24 year-olds.

A significant amount of attention is being paid to prevention, which is in contrast with its insufficient representation in medical and social medicine practice, primarily in the area of psychosomatic "lifestyle" illnesses. An example of practical preventive effort is series of health promotion programs that are aimed at the general public, as well as particular families and individuals. These programs make an effort to remove the indifference of people to their own health, and to understanding its irreplaceable value.

Table 1: Vaccination calendar: regular vaccinations in the Czech Republic

4 days to 6 weeks TBC

9 to 12 weeks Diphteria, Tetanus, Pertussis (1st dose) Haemophilus infl.b, Hepatitis B

10 weeks to 14,5 months Poliomyelitis

13 to 16 weeks Diphteria, Tetanus, Pertussis (2nd dose) Haemophilus infl.b,

Hepatitis B

18 weeks to 16,5 months Poliomyelitis (2nd dose)

17 to 20 weeks Diphteria, Tetanus, Pertussis (3rd dose) Haemophilus infl.b

33 to 36 weeks Hepatitis B

14,5 to 26,5 months Poliomyelitis - 1st re-vaccination

15 months Measles, Mumps and Rubella

16,5 to 28,5 months Poliomyelitis - 2nd re-vaccination

18 to 20 months Diphteria, Tetanus, Pertussis (4th dose) Haemophilus infl.b

21th month and later Measles, Mumps and Rubella-re-vaccination

5th year Diphteria, Tetanus, Pertussis -re-vaccination

11th year TBC in tuberculin negative re-vaccination

12th year Hepatitis B - only children without vaccination in the first months of live

13th year Poliomyelitis - 3rd re-vaccination

14th year Tetanus (re-vaccination) and next vaccination in ten to fifteen years