WHY NONE OF HEALTH REFORM ATTEMPTS SUCCEEDED ? THE CASE OF THE CZECH REPUBLIC Marek Pavlík

Objective: Although there have been many attempts to start the health reform during past ten years in the Czech Republic; none of these attempts were successfully implemented. The exception is the partial success of the last health reform proposal (2007). The aim of the paper is to analyze two key conditions of initiation of the health reform in the Czech Republic. In other word, the paper will try to answer the question of why the last reform attempt seems to be more successful than previous ones. Considering the complexity of the health reform process the research is narrow down to examination only two of necessary conditions of successful health reform implementation. Author sets two conditions which are examined during the period 1998-2008. The first one is that the cabinet has to have majority in all important representative bodies (i.e. Chamber of deputies, Senate, Regions). This condition is based on assumption that each reform is inevitably tight with accepting new legislation. The second condition is that the Cabinet (fomated by more than one politicla party) has to reach at least 50% agreement on basic health reform principles. There is an assumption that the reform would be postponed in the case of disagreement.

Design and settings: The Czech political system and health policy situation are mentioned at the beginning of the paper. Consequences of the cabinet inner heterogenity are also mentioned. The second part of the paper introduces the methods of analysis, which are suggested by the author. The third part of the paper discovers the results of both examined conditions. The results are counted from the cabinet point of view aside from the fact if the cabinet was a coalition type or not.

Data and methods: The analysis is based on already published data: results of elections to the Chamber of Deputies, the Senate, regionals’ legislatures; data about members of the Cabinets and theirs members’ political affiliation; pre-election programs of the Cabinet political parties. Author suggested the method which allows displaying the cabinet position in the all lawmaking bodies. The analysis of the second condition – the agreement inside the cabinet coalition is done through analysis of the pre- election programs each of cabinet’s party. Using simple mathematic model was formed “the curve of the coalition cabinet’s concordance rate”. Both results are displayed in chart.

Results and conclusion: The main result of analysis is that all Cabinets had minority in all lawmaking bodies except close majority in the Chamber of Deputies since 2002b; and except the second Cabinet formed after the election in 2006 which gained more that 50% in all lawmaking bodies. The curve of the coalition cabinet’s concordance rate shows that all cabinets before the last one (since 2007) reached inner agreement about 25%. The second condition was also fulfilled only by the last Cabinet. There is no doubt of existence more than these conditions and therefore this paper is only part of complex analysis of the Czech health policy. However the extension of nonfulfilment these conditions is surprising and could be explanatory of previous hopeless health reform attempts.

Key words: health reform, government, health policy JEL classification : I 1, H 7

1 INTRODUCTION According to the theory of the policy cycle; the cabinet is seen as the key actor for the policy formulation and implementation (e.g. HOWLETT , RAMESH 2003). According to top-down approaches (HOWLETT , RAMESH 2003) or synthesizers accented top-down approach (BERGEN AND WHILE 2005), the cabinet is assumed as the key actor in the process of policy formulation and implementation.

Considering Czech inability to realize a coherent vision of health policy (HOL ČÍK 2004), we should search for the roots of such failure 1. Regardless of explanation of past failures we have to seek answers which would improve a chance for future success. Although there have been many attempts to reform the health care system during past ten years in the Czech Republic; none of these reform proposals were successfully implemented (DRBAL 2005, MALÝ , DARMOPILOVÁ 2005). The exception is partial success of the last health reform proposal (success in 2007, interruption of the reform process in 2008). The reasons of these failures would be rooted in the phase of the policy formulation and implementation (see NEMEC 2006).

The aim of the paper is to find out if the cabinet was strong enough to enforce the policy implementation. This aim will be examined through analysis of cabinet support in representative bodies; and through analysis of cabinet’s inner agreement on health care reform principles. Therefore the paper analyzes two key conditions of initiation of the health reform in the Czech Republic 2. Consequently the paper will try to answer the question of why the last reform attempt seems to be more successful than previous ones. Considering the complexity of the health reform process the research is narrow down to examination only two of necessary conditions of successful health reform implementation. Author set two conditions which are examined during the period 1997-2008. The first one is that the cabinet has to have majority in all important lawmaking bodies (i.e. Chamber of deputies, Senate, regional legislatures). This condition is based on assumption that each reform is inevitably tight with accepting new legislature. The second condition is that the Cabinet (in the case of coalition) has to reach at least 50% agreement on basic health reform principles. There is an assumption 3 that the reform would be postponed in the case of disagreement between politicial parties in the coalition.

2 BACKGROUND Searching roots of implementation failures in Czech health care system there is necessary to consider many factors. Following analysis should be taken as a part of complex analysis of health policy implementation in the Czech Republic. Considering the cabinet as the key actor for the policy formulation and implementation conduce to necessity of investigation of cabinet’s relations with other “state” actors and also its inner relations; especially in the case of coalition cabinets. The first step is discussion the terms “state” and “cabinet” and its consequences for the policy formulation and implementation. Second step formulation of examined conditions and criteria of evaluation. Although terms as „state“, “government” or „cabinet“ are often used; understanding of theirs meaning could be different from the economist and politics point of view. Generally we suppose that the cabinet has to have a support of parliament under Parliamentary democracy conditions. It’s just that the cabinet formulates the policy and the parliament implements (through changes in legislature) the policy. Therefore we could simply assume that the cabinet is homogenous actor i.e. “state” which stands against other actors. Such stance is more close to scientist focused of public economy (see e.g. JACKSON , BROWN (2003), STIGLITZ (1997)). The problem of optimal allocation and effectiveness is studied on background of behavior of “state” and “other actors”.

1 The result of implementation can be either fulfilling the aims or implementation failure. LINDER AND PETERS (1987) consider implementation failure to be one of three policy failures: Implementation failure; Policy design (crippled at birth); Policy results (aims can be achieved; however it creates too many “side effects”, the situation could be worse than before). 2 Czech health care system is based on co-financing principle. Main sources are: National and local budget; Public health insurance (i.e. solidarity principle, payment to the system depends on income. Health insurance is provided by nine health insurance companies); Co-payment from patients; Foundation and sponsoring. The basic principle is shown in appendix 1. Total expenditures for health is around 7,1% of GDP and about 90% of total expenditures come from public sources. 3 The assumption is based on MARTIN (2004) which proves that agendas more attractive for the cabinet are preferred more than other, simultaneously is valid that political parties in coalition achieve more easily the agreement to these “favorite” agendas. On the other hand most of polimetricians and public policy scientist see difference between the state and the cabinet (see e.g. HEYWOOD (2004)). Polimetricians systematically examined relations between the cabinet and parliament as one of possible important factor for policy formulation and implementation 4. The problem of homogeneity could be seen not only as the problem of relation between the cabinet and parliament but also as a problem of relations inside the cabinet. Results of election to the Chamber of Deputies in the Czech Republic (see appendix 3) often faces the necessity of coalition cabinet formation. It is advisable to put stress on this factor. E.g. CARMIGNAMI (2001) examined 13 countries and conclude that delay in the policy formulation depend on the level of heterogeneity of opinions inside the cabinet. The cabinet cannot be considered as a homogeneous actor from the implementation theory point of view. The cabinet is heterogeneous actor which interacts with other state or non-state actors. The level of cabinet’s heterogeneity depends for example on: • Relation between Prime Minister and other ministers (the level of authority control). • The type of cabinet (the one party type or coalition type). • Diversification of opinions inside the coalition cabinet. • Personal relations between ministers. We consider the cabinet as heterogeneous actor which acts as one against other actors for the purpose of analysis. Therefore we examined both the cabinet’s inner homogeneity and cabinet’s relations to key representative bodies. The cabinet’s homogeneity is investigated through one of possible methods – analysis of political parties’ pre-election programs. We assume that it is necessary to enforce the cabinet’s will in the Parliament (or other actors) for implementation of the reform policy. Therefore inability to enforce the legislation changes is very restrictive for the potential Cabinet’s policy implementation. Analysis is based on assumption that the cabinet (respectively all coalition political parties) can count with support from own party-liners in representative bodies. History of voting in Chamber of Deputies shows that such party’s loyalty is not always guaranteed. Many laws were accepted due to help of “deserters“ or ”traitors” of cabinet’s parties. Previous presumptions are formulated to the following conditions: The cabinet has to have majority in all key representative bodies and if is the coalition type it has to achieve an agreement in key principles of health system organization. • We suppose that implementation of reform policy inevitably needs a legislation changes, hence without support of representative bodies the cabinet has no power to enforcement its policy. • The criterion of satisfaction this condition is achievement more 50% (majority) in each of representative bodies as well as achievement more than 50% agreement in basic principles of health care system organization.

3 METHODS OF ANALYSIS The cabinet‘s support is counted based on election results to following representative bodies: • Parliament of the Czech Republic • Chamber of Deputies • Senate • Regional representative bodies (13 Regions) Examined period is determined by the year 1998 and the cabinet with Prime Minister J. Tošovský and finished in the year 2008 with the cabinet of Prime Minister M. Topolánek II. During this period took places three elections to the Chamber of Deputies (1998, 2002, and 2006) and showed that no political party had the power to organize the cabinet itself. The first period 1998-2002 was the cabinet of Social democratic party ( ČSSD) 5 because of the opposition treat between ČSSD and ODS (Civic Democratic Party). The second period 2002-2006 was the coalition cabinet formed from ČSSD, KDU-ČSL (Christian Democrats) and US-DEU (Freedom Union). Coalition parties were more right oriented than “leader” party ČSSD.

4 DIERMEIER, ERASLAN, MERLO (2003) examined on 9 countries conditions of formation and stability of coalition cabinets and they try to determine conditions of such coalition cabinets functioning. They conclude that formal relations between the cabinet and the Parliament are crucial (e.g. what conditions have to come on for the mistrust declaration). 5 See appendix 2 for the list of political parties in czech and english language and theirs abbreviations. The third period from the year 2006 has begun the coalition cabinet of ODS, KDU-ČSL and SZ (Green Party). The Ministries of Health were always appointed by the leader party.

3.1 Inner homogeneity of the Cabinet 6 As it was mentioned above, the cabinet cannot be considered as a homogenous actor. Therefore it is analyzed of how many members of the cabinet is from coalition parties and which members are without political affiliation. The Minister without political affiliation is nominated by some political party however we have to respect following point: • The Minister without political affiliation is not bounded by decisions of party’s leaders • The Minister without political affiliation is not a member of Chamber of Deputies, hence he cannot support the cabinet Without proper analysis such non-affiliated ministers cannot be considered as a risk for successful implementation. Thus the curve constructed based on following formula has only supplemental information value.

Following cabinets represented by Prime Ministers were analyzed 7: • The cabinet of Mirek Topolánek II. (09.01.2007-26.3.2009 8) • The cabinet of Mirek Topolánek I. (04.09.2006-09.01.2007) • The cabinet of Ji ří Paroubek (25.04.2005-04.09.2006) • The cabinet of Stanislav Gross (04.08.2004-25.04.2005) • The cabinet of Vladimír Špidla (15.07.2002-04.08.2004) • The cabinet of Miloš Zeman (22.07.1998-12.07.2002) • The cabinet of Josef Tošovský (02.01.1998-17.07.1998) Hence inner homogeneity of cabinet is given by: • HV – means inner homogeneity of the cabinet • M – means a member of the cabinet • P – marks a political affiliation to the leader party • K – marks a political affiliation to one of coalition parties • B – marks that the member of cabinet has no political affiliation • r – means year • m, j, s – are indexes represents a number of cabinet members with given political affiliation Then:  m j s   P + K − B × ∑ M r ∑ M r ∑ M r  100 =  n=1 i=1 t=1  HV r m j s . P + K + B ∑ M r ∑ M r ∑ M r n=1 i=1 t=1

Partial results are shown in appendix no. 4

6 Problems of cabinet’s power and relations inside the coalition cabinets are measurable through indexes of election power, which examines actors and theirs power and contribution to decision porcess. E.g. Shapley-Shubik index, Banzhaf index, Coleman index, etc. Suggested method of investigation of cabinet’s homogeneity is intended as altenative way of how to display the risk of implementation failure 7 quoted according http://www.vlada.cz/cs/vlada/historie/prehled_vlad.html [online] Available 26.1.2008 8 The Prime minister resigned after Chamber of Deputies declared its mistrust 3.2 Cabinet’s position in the Chamber of Deputies Cabinets’ position in the Camber of Deputies is given by number of seats for the leader party and their coalition parties expressed in percentages 9. There are counted only seats for the cabinet party inn the case of period 1998b (after election) to 2002a (before election) due to following reasons: • Although there was the opposition treat between ČSSD and ODS, this treat guaranteed only necessary support for the cabinet but not a support for reform changes in health or any other public sector. Respectively any reform which could be in antagonism with ODS’s pre-election program was not allowed. • ODS had no members in the cabinets. Exact measurement such criterion has to take into account these elected members who changed their political affiliation (i.e. switched the party or became a M.P. without affiliation). Due to close majority or the cabinet, these deserters are often crucial for achieving majority. But these deserters are not counted to the total results because of the fact that theirs support is not always predictable. Calculation of Cabinets’ position in the Camber of Deputies Hence • PV PS – means the Chamber of Deputies’ support to the Cabinet • V – means number of seat in the Chamber of Deputies gained by given political party (in %); and indexes mean: • P – leader party • K – coalition parties • r – year Then:

n PS = P + K PV r Vr ∑Vr . i=1 Partial results are shown in appendix 5

3.3 Cabinet’s position in the Senate Cabinet’s position in the Senate is changing every two years when third of the Senate is re-elected. The cabinet’s position is also counted as percentage of gained seats for given party. Senators’ relation to the political party is counted based on their political affiliation or the fact, that they became the party’s candidate. Calculation of Cabinets’s position in the Senate Hence: • PV S – means the Senate’s support to the Cabinet • V – means number of seat in the Senate gained by given political party (in %); and indexes mean: • P – leader party • K – coalition parties • r – year Then:

n S = P + K PV r Vr ∑Vr . i=1 Partial results are shown in appendix no. 6

9 See appendix 3 for review of election resuls during 1998-2008 3.4 Cabinet’s position in Regions Cabinet’s position in Regions is counted without deserters including. The reason is the same as for the Chamber of Deputies and data gathering would be difficult. The principle of calculation is the same as previous ones Calculation of Cabinet posistion in the region (i) Hence • PV K,i – means cabinet’s position in the region (i) • V – means number of seat in the Regional representative body gained by given political party (in %); and indexes mean: • P – leader party • K – coalition parties • r – year Then:

n K ,i = P + K PV r Vr ∑Vr . i=1 Following graph shows results from the cabinet’s political party (parties) point of view. It means that in the given year for the given cabinet is expressed by the given value. For the purpose of transparency are results divided into two groups (alphabetically). KDU-ČSL was in coalition with three other parties during regions’ election in the year 2000b. The result is counted for “the coalition of four” but we could expect that inside the coalition would also be various opinions. Graph 1: Cabinet’s position in region regions (group 1) in %

65,00 60,00 55,00 50,00 45,00 40,00 35,00 30,00 25,00 20,00 15,00 10,00 5,00 0,00 2000 2001 2002a 2002b 2003 2004a 2004b 2005a 2005b 2006a 2006b 2007 2008a 2008b

Central Bohemian Region South Bohemian Region Plze ň Region Karlovy Vary Region Ústí nad Labem Region Liberec Region Hradec Králové Region

Source: author Results show that except the election in 2006 all regions were always in opposition to the cabinet. Support from regions was over 50% except one region in the year 2006b. Regions are considered as important especially in the health care sector just because of theirs wide authority in the field of providing of the health care. It is used an average result (see bellow) for teh purpose of display of total result of analysis.

Graph 2: Cabinet’s position in regions (group 2) in %

75,00 70,00 65,00 60,00 55,00 50,00 45,00 40,00 35,00 30,00 25,00 20,00 15,00 10,00 5,00 0,00 2000 2001 2002a 2002b 2003 2004a 2004b 2005a 2005b 2006a 2006b 2007 2008a 2008b

Pardubice Region Vyso čina Region South Moravian Region Olomouc Region Zlín Region Moravian-Silesian Region

Source: author

Calculation of Cabinet’s position in regions – average result Hence: • PV PK – means Cabinet’s position in regions • PV K,i – means cabinet’s position in the region (i) • I – is number of regions • r – means year Then:

i K ,i ∑ PV r PK n=1 PV = ; r I Partial results are shown in appendix no. 7 Alternative result could be shown though the number of regions with majority; nevertheless such number doesn’t bring different conclusion.

3.5 The coalition cabinet’s concordance ratio Calculation of coalition’s concordance ratio is divided into two steps. The first one is evaluation of pre-election programs according to following rules. The second step is the calculation of average value for parties’ opinions. The coalition was always created by three parties (There are “leader party” which is party entrusted with the cabinet formation and two others are “coalition parties”). Due to limited number of coalition parties is following formula written in simplified form. Although is obvious that coalition parties in the cabinet are not equal; we consider support of coalition parties as crucial and necessary for enforcement of legislature changes. Therefore the opinions of coalition parties have same weight as the leader party. The concordance ratio doesn’t express parties’ opinion but only the fact if parties have the same opinion. Hence: • C – means party’s attitude to normative statement; C ∈{ 1;5,0;0 } • A – is the coalition cabinets’ concordance ratio for one of normative statement (o) • F – means the total (average) coalition cabinet’s concordance ratio • r – means election year • o – is the normative statement • m – is number of normative statement (o) • p – means political party which gained the Ministry of Health (always the same as “leader party”) • k1 – is coalition political party no.1 • k2 – is coalition political party no. 2 The evaluation 10 is based on the part of pre-election program related to health care tasks and considering basic party’s ideas. Six normative statements (o) of health care system were chosen: • Solidarity principle support in health care provision; • Competition among health care providers and insurance companies; • Increasing patients' co-payments; • Increasing public budgets support; • Support of the idea of a powerful role of state in the health care system; • No restrictions in provided health care services. The concordance ratio is based on analysis of pre-election programs. From this programs are deduced each party’s attitude to every normative statement (o). This attitude is marked as positive (agreement with given statement), neutral or negative. Each party’s attitude to the given normative statement (o) is given by C 11 ; where: • C = 1 is strong support of the given idea (Aims of Party’s election program correlated with that idea); • C = 5,0 shows neutrality (Party’s election program declared neutrality or possible areas for negotiation); • C = 0 means opposition to the idea (Party’s election program expressed disagreement with the idea). o = p = k 1 = k 2 Ar 100 , if C r C r C r ;

o = p = k1 p ≠ k 2 P − k 2 = Ar 50 , if: Cr Cr /\ Cr Cr /\ Cr Cr 5,0 ; or p = k 2 p ≠ k1 P − k1 = Cr Cr /\ Cr Cr /\ Cr Cr 5,0 ; o = Ar 0 , other cases; Then total coalition cabinet’s concordance ratio is given by:

m

∑ Ar o=1 F = ; r m Together with previous calculation is examined the standard deviation:

(x − x) 2 σ = ∑ ; n Results are in following table and show that coalition cabinet’s concordance rate (2007) is significantly higher that the previous cabinets during period 2002b-2006a. Compared to the majority requirement in representative bodies there is no strict border for “fulfillment” of this condition. Generally we can say that higher concordance rate is desirable, but due to negotiations between parties and possible “agenda’s trade” across public sector we cannot set a strict border. The only way for such border determination is to ex-post analysis and derivation such border. We have also consider another issue; MARTIN (2004) shows that agendas more attractive for the cabinet will be preferred before other ones. Hence we have to respect that health sector belong more to less attractive (due to difficulties with achieving of agreement) than others.

10 Note: The pre-election programs were examined for the years 2002 and 2006 because the coalition cabinet was appointed. 11 See appendix 8 for results of evaluation of pre-election programs „C“ Table x: Coalition cabinet’s concordance rate in %12 Year 2002 2007 Solidarity principle in health care provision should be emphasized 0,0 50,0 Competition among health care providers and insurance companies is desirable 100,0 50,0 It is necessary to increase patients' co-payments 50,0 100,0 Public budgets support should be increased 0,0 50,0 Powerful role of the government in health care system is desirable 0,0 50,0 Restrictions in provided health care services are unwished 0,0 50,0 Concordance rate 25,0 58,3 Standard deviation (%) 38,0 18,0 Source: author

4 RESULTS OF ANALYSIS Total results are given by homogeneity of the cabinet; cabinet’s support in key representative bodies; and concordance ratio of the coalition cabinets. Following graph shows results from the cabinet’s political party (parties) point of view. It means that in the given year for the given cabinet is expressed given value. It’s obvious that only in 2007 were all conditions fulfilled. Therefore the defined conditions were not fulfilled with except of the year 2007. Graph 3: Cabinets’ position in representative bodies; Inner homogeneity of Cabinets and Coalition cabinets’ concordance ratio (in %)

105 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 1998 2000 2002a 2003 2004b 2005b 2006b 2008a

Chamber of Deputies Senate Cabinet's homogeneity Regions Coalition cabinet's concordance rate

Source: author Note 1: Year divided into “a” and “b” parts were the election years and values represents situation before and after election Note 2: The curve of the Coalition cabinet’s concordance ratio is not counted for the period 1998-2002a (the cabinet assembled by ČSSD) and the Cabinet of M. Topolánek I. in the year 2006b.

12 The concordance ratio doesn’t expreess parties opinion but only the fact if parties have the same opinion. 5 CONCLUSION There were ten Ministers of Health during 1998-2008 and most of them declared the intention to reform health care system. Most ministers also submitted more or less detailed plan of reform. However only in beginning of the year 2007 were implemented a few systematic changes (especially increasing patients’ co-payment thou additional fees for doctor visit, receipt etc.). After this first period of health care reform was prepared the key legislation changes however support to the minister of health became unstable. The election to the regions’ representative bodies also brings a fall of cabinet’s strong position during the year 2008. After replacement of minister of health (January 2009) the cabinet still has been declared the intention to reform health care system but the cabinet’s position became unstable also in the Chamber of Deputies (the cabinet’s position depends on few members of the Chamber and there were attempt to declare of mistrust to the cabinet). At the beginning of 2009 the cabinet was forced to resign. Although we can simply see in the previous graph no 3, that only one reform successful episode were tight with period of strong cabinet’s position in representative bodies; it is obvious that we could find more reasons of why the health care reform wasn’t implemented. The key representative body is the Chamber of Deputies and unfortunately during whole period were support of this body very close and uncertain. We cannot simplify the results but we could put the stress on the cabinet’s position as one of crucial reform factor at least. Interesting challenge could be the research of this factor in the comparison with other countries and across public sector. It seems that many problems of policy formulation and implementation simply depends on position (power) of the cabinet. According to the result of this analysis there is an evident recommendation: The change of electoral system as the only chance for longtime improving of the cabinet’s position.

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Appendix 1: Structure of financial flow in the health care system in the Czech Republic

Government Health care Employer Health insurance providers companies

Local municipalities Patients

Source: the author

Appendix 2: List of political parties and theirs abbreviations Name (in Czech) Abbreviation Name (in English) Česká strana sociáln ě demokratická ČSSD Czech Social Democratic Party Křes ťansko demokratická unie – KDU-ČSL Christian Democrats Československá strana lidová Komunistická strana Čech a Moravy KS ČM Communist Party of Bohemia and Moravia Ob čanská demokratická strana ODS Civic democratic party Strana zelených SZ Green party Unie svobody – Demokratická unie US-DEU Union of Freedom – Democratic Union Source: assembled by author

Appendix 3: Election results of Chamber of Deputies expressed as percent of gained seats Political Party/Year 1998 2002 2006 ČSSD 37,00 35,00 37,00 KDU-ČSL 10,00 7,75 6,50 KS ČM 12,00 20,50 13,00 ODS 31,50 29,00 40,50 SZ 0,00 0,00 3,00 US-DEU 9,50 7,75 0,00 Total 100,00 100,00 100,00 poll 74,03 58,00 64,47 Source: Assembled by the author based on information available at www.volby.cz Note: KDU-ČSL was in coalition in US-DEU in the 2002. Therefore for each party is counted half of votes.

Appendix 4: Cabinet homogeneity Year Cabinet homogeneity Year Cabinet homogeneity 1998 vlády 33,33 2004b 94,12 1999 93,33 2005a 94,12 2000 94,12 2005b 94,74 2001 100,00 2006a 94,74 2002a 100,00 2006b 60,00 2002b 100,00 2007 94,44 2003 100,00 2008a 94,44 2004a 94,74 2008b 94,44 Source: author Note: Year divided into “a” and “b” parts were the election years and values represents situation before and after election. Appendix 5: Ratio of Cabinet’s support in the Chamber of Deputies of the Czech Parliament Year Ratio of Cabinet’s support Year Ratio of Cabinet’s support 1998 10,0 2004b 50,5 1999 37,0 2005a 50,5 2000 37,0 2005b 50,5 2001 37,0 2006a 50,5 2002a 37,0 2006b 50,0 2002b 50,5 2007 50,0 2003 50,5 2008a 50,0 2004a 50,5 2008b Source: author Note: Year divided into “a” and “b” parts were the election years and values represents situation before and after election. Appendix 6: Ratio of Cabinet’s support in the Senate of the Czech Parliament Year Ratio of Cabinet’s support Year Ratio of Cabinet’s support 1998 17,28 2004b 29,63 1999 28,40 2005a 29,63 2000 18,52 2005b 29,63 2001 18,52 2006a 29,63 2002a 13,58 2006b 64,20 2002b 37,04 2007 64,20 2003 37,04 2008a 64,20 2004a 37,04 2008b Source: author Note: Year divided into “a” and “b” parts were the election years and values represents situation before and after election Appendix 7: Ratio of Cabinet’s support in regions (average results of 13 regions) Year Ratio of Cabinet’s support Year Ratio of Cabinet’s support 2000 41,79 2005a 28,66 2001 41,79 2005b 28,66 2002a 41,79 2006a 28,66 2002b 41,79 2006b 56,17 2003 41,79 2007 56,17 2004a 41,79 2008a 56,14 2004b 28,66 2008b Source: author Note: Year divided into “a” and “b” parts were the election years and values represents situation before and after election Appendix 8: Each party’s attitude to the given normative statement (o), based on analysis of election programs (C) Normative statement ODS KDU-ČSL KS ČM ČSSD US-DEU SZ 2002/2006 2002/2006 2002/2006 2002/2006 2002/2006 2002/2006 Solidarity principle support in health care provision 0,5/ 0,5 0,5/0,5 1/1 1/1 0,5/x x/1 Competition among health care providers and insurance companies 1/1 0,5/0,5 0/0 0,5/0 0,5/x x/1 Increasing patients' co-payments 0,5/1 0/1 0/0 0/0 0,5/x x/1

Increasing a public budgets support 0/0 0/0,5 1/1 0,5/0,5 0/x x/0 Support to the idea of powerful role of state in the health care system 0/0 0,5/0,5 1/1 1/1 0,5/x x/0 No restrictions in provided health care services 0,5/0,5 0,5/0,5 1/1 1/1 0,5/x x/1 Source: the author Note: If the party didn’t succeed in the election year, its result is „x“