Palliative Care in the Czech Republic by Martin Loučka

1. Introduction
2. About the Centre for Palliative Care in Prague
3. Healthcare in the Czech Republic
4. The Origin of the Hospice Movement in the Czech Republic
5. Cesta domů: Broader than Hospice Care
6. The Czech Society for Palliative Medicine
7. Medical Specialisation
8. Money and Funding
9. Fundraising in Public Healthcare Systems
10. Collaboration
11. The Value of the Data
12. Introducing Palliative Care in Hospitals
13. Introducing Palliative Care in Nursing Homes
14. The Advisory Board
15. Building Communities
16. Introducing Palliative Care in Emergency Medical Services
17. Conclusion
18. Q&A

I became interested in palliative care through reading, while studying psychology at the university, specifically, reading books about existential psychotherapy and how death is one of the key themes in our lives.

At that time, however, there was not much going on in the Czech Republic, so I had to turn to other countries to learn from their experiences. I was fortunate to have the opportunity to undertake my PhD in the UK, and I also spent some time in other places, such as the Netherlands and the United States.

One advantage of palliative care over many other fields is that the needs of individuals at the end of life are remarkably similar across the globe.

When you examine the data, research, or service models from various countries, you see that we are all striving to tackle the same issue—in the Czech Republic, Kazakhstan, Japan, China, or South America. The human experience at the end of life is indeed a shared one.

People feel the same pain, the same anxiety, and we’re all trying to find ways to help.

My presentation today will be in four sections:

1. I will briefly describe our centre.
2. I will discuss how our healthcare system operates. It’s crucial to base all the information on the realities of our system.
3. I want to share five key points regarding the development of palliative care in our country, from my perspective. While there are undoubtedly many other significant moments and initiatives, these five are the ones I wish to highlight, and we can explore the various aspects later.
4. At the end of the presentation, I would like to share three examples of system change projects that my organisation has undertaken. Hopefully, this will inspire those working to improve palliative care in your countries.

I established an NGO, the Centre for Palliative Care, in 2014. It is the leading provider of palliative care education, with approximately 3,000 attendees at our seminars, webinars, and various courses each year. We train nurses and physicians in communication skills and conduct numerous ELNEC courses (End-of-Life Nursing Education Curriculum)—a notable example of a programme I highly recommend to anyone looking to adapt it in their respective countries. The programme is held in considerable respect and value across various nations. They provide extensive support and mentoring for those wishing to implement it.

We also conduct extensive research because it is essential for advancing palliative care. Many people become emotional when discussing palliative care, and such a response only carries us so far. When considering system development and improving access to palliative care nationally, you will encounter individuals not swayed by patient stories. They will seek data and models to implement within the system. Data is crucial for persuading policymakers and stakeholders involved.

We engage in education, research, and what we refer to as ‘service development projects’ or ‘system improvement projects’, focusing on various facets of our country’s health and social care system. We aim to enhance and address issues that we perceive as obstacles to progress.

We are an NGO, but we also strive for financial independence. We sell our services, which I had to learn to do. One should achieve a degree of financial independence. Many funders and donors want NGOs to pursue autonomy and not rely solely on external financing.

By providing essential services within the system, such as education and expert consultation for various stakeholders, including policymakers, councils, the Ministry of Health, and local governments in different regions, we have significantly enhanced our organisation’s reputation, strengthening our networks and relationships with service providers.

The Czech Republic has a population of around 10 million. We have been a member of the European Union since 2004, which is quite significant. This membership has enabled us to benefit from specific European legislation and regulations, which we have also utilised to support the development of palliative care.

A very important declaration, signed by all the Ministries of Health of the EU member states, advocated for the widespread implementation of palliative care. We’ve been referring to it since it was published twenty years ago.

We currently have around 200 hospitals, which is quite a substantial number for a country of our size. The Czech Republic covers approximately 79,000 square kilometres. Thus, with 200 hospitals in that area, there is a high density of medical institutions. Some people now criticise this as a somewhat outdated model—a remnant of the post-war system, where you effectively had a hospital around every corner. Currently, our system is undergoing reform.

We have approximately 1,000 long-term care facilities in addition to hospitals. These include what you might consider standard nursing homes—similar to those found in many countries—but also encompass what we refer to as ‘long-term care hospitals’. These are not social care institutions but medical facilities that employ physicians and nurses while providing long-term care. Patients may reside there for months, and many of them are, in fact, patients at the end of life.

When I began working in the field, I realised that if we genuinely wanted to create national-level change, we couldn’t achieve that by focusing on just one type of care.

Of course, we require specialised palliative care services. We also need home-based care and hospital-based palliative care teams. However, all these services must work together in a balanced manner. The system becomes unbalanced if you have excellent hospice services but lack resources in your hospitals.

We must support general palliative care providers—those who aren’t specialists but still deliver essential care—and highly specialised palliative care professionals.

In our country, we’re fortunate to have excellent access to opioids. I understand this is not the case in many Eastern countries, so we recognise how lucky we are. Opioids are readily available, and nearly any physician involved in the care of patients at the end of life can prescribe them. General practitioners, internal medicine doctors, pediatricians, and oncologists—nearly all relevant specialties are authorised to prescribe opioids. Furthermore, these medications can be obtained from local pharmacies—you don’t need to travel to the capital city to access them. This is extremely important. I should also note that several European initiatives have supported enhanced opioid access.

Another critical aspect to emphasise is the role of general practitioners (GPs). We have approximately 5,000 GPs in the country, who are essential to the system. GPs should serve as primary care coordinators for patients nearing the end of life. So again, I encourage everyone to consider what they are doing to support general practitioners in their role in providing palliative care.

In the Czech Republic, our healthcare system is public and based on universal mandatory health insurance. Everyone contributes a portion of their salary and gains access to healthcare that is essentially free at the point of use. The cost covers both an initial visit to a GP and complex procedures like neurosurgery. This universal model closely resembles the systems in the UK and several other countries. It is a publicly funded healthcare system.

We also have a social care system, which includes nursing homes and various community-based services that fall under the umbrella of social care. This support is very beneficial.

From our experience with policymakers, we have observed that these two sectors sometimes shift responsibility onto one another. Palliative care is an excellent example of a truly multidisciplinary field—it does not conform neatly to either system; it straddles both.

In countries where separate ministries or institutions oversee healthcare and social care, I strongly recommend involving both sides as early as possible. Palliative care is one of those rare areas where both ministries agree that it is an important issue warranting coordinated attention. Once one ministry is engaged, the other tends to follow—constructive competition can develop. This creates a dynamic.

We have approximately 17 inpatient hospices across the country. Each of our 14 regions has at least one inpatient hospice facility, and these hospices provide around 500 beds. We’re very close to meeting that target when comparing this to the recommendations from the WHO and the EAPC, which suggest about 100 hospice beds per 1,000,000 people. Therefore, we’re in a relatively good position regarding the number of inpatient hospice beds.

In the Czech Republic’s modern history, palliative care began with the emergence of hospices in the 1990s. One extraordinary woman, Dr. Marie Svatošová, was the founder and is widely regarded as the mother of the hospice movement in our country. She emulated the model of St. Christopher’s Hospice in London, the first modern hospice in the UK. Dr. Svatošová traveled to England, visited St. Christopher’s, and then raised the funds to build the first inpatient hospice unit in the Czech Republic in 1995.

Hospice was—and still is—operated as a non-governmental organisation, functioning outside the mainstream healthcare system. This is one of the key lessons we learned during that early phase. After the first hospice opened in 1995, similar services began to emerge in other regions of the Czech Republic—all established as standalone organisations outside the national healthcare system and relying heavily on donations, fundraising, and philanthropic support. Many hospice services worldwide have begun this way. Hospices in the Czech Republic are now fully comparable to those in other Western countries.

Such an approach made sense up to a certain point. Over time, our hospices became somewhat isolated. They existed in their bubble, and the connection between the hospice movement and the broader healthcare system simply didn’t exist. For almost twenty years, there was no real integration. As a result, we found ourselves in a bizarre situation. We had excellent facilities providing high-quality palliative care, yet only about 3% of people in the country died in a hospice.

They didn’t know anyone who worked in a hospice, and referrals were rare and difficult to obtain. In practice, if someone ended up in a hospice, it usually occurred through word of mouth. That was the extent of visibility and access—entirely informal.

When we established our organisation, one of our first goals was to change that. We realised this is what we need to work on: we need to open the doors and windows and build bridges between these incredible hospice services and the rest of the healthcare system. It simply didn’t make sense to have world-class services that hardly anyone could access.

People didn’t know much about hospices, and there were many stereotypes. They often thought it was only for Christians because the first facility had been affiliated with a Catholic charity. Many assumed that its primary goal was to baptise everyone before they died. Of course, this was not true at all. Yet these misconceptions persisted, trapping people in them.

Early hospice pioneers made significant first steps. Everyone in our country’s palliative care is deeply grateful to Dr. Svatošová for her work. She even negotiated the first reimbursement model for hospice care, which was introduced in 1998. That was such an achievement. To put that into perspective: she managed to secure a financial reimbursement scheme only.

The second significant milestone was the establishment of home-based or community hospice care. As is the case in many countries, if you ask people where they would prefer to die, the vast majority will choose home. So we had to start thinking seriously about how to bring that same level of expert hospice and palliative care to people who could and wanted to remain at home until the end.

It all began with an organisation called Cesta domů, which translates to ‘the way home’ or ‘homecoming’. Established in 2001, it became the first home hospice organisation in Prague. I want to highlight their example because it is a truly special organisation. Interestingly, Cesta domů was founded by an artist, Martina Špinková. With enthusiasm, she gathered like-minded individuals, including nurses and physicians, who shared her passion for helping people at the end of life. Together, they began building this organisation from the ground up.

From the beginning, they didn’t focus solely on providing care; they also prioritised education, outreach, and advocacy.

Cesta domů serves as an excellent example of this approach. Early on, they opened a specialised library, imported books from abroad, and created a small yet outstanding resource centre for palliative care. As a student in another city, I travelled to Prague to borrow books for my bachelor’s and master’s theses. That little library made a significant difference—it provided people like me access to resources and ideas that weren’t otherwise available. It played a crucial role in shaping the next generation of palliative care professionals.

They also support public campaigns and lobbying efforts. Over time, they even established their own publishing house. Today, they are the largest publisher of palliative care literature in the Czech Republic. They translate books from abroad and encourage local authors to document and publish their experiences. If you seriously consider developing palliative care as a field, you need textbooks. You need educational materials that can be utilised in nursing schools, medical faculties, and other training institutions.

The third significant step was the formation of the Czech Society for Palliative Medicine. Our country has an overarching body called the Czech Medical Chamber, which encompasses every medical discipline through its specialist organisations. These entities are responsible for professional training and specialisation and serve as advisory groups to the Ministry of Health. Therefore, when new legislation is being discussed—whether it pertains to cardiology, general practice, or palliative care—the ministry consults these expert societies.

That’s why it was crucial that the Czech Society for Palliative Medicine was formally established in 2009. Creating a proper professional society for palliative medicine is essential—a formal space where professionals can meet, share ideas, and develop strategic plans to advance the field. Such a society also aids in establishing palliative care as a legitimate and respected medical discipline, equal to other specialties. Without it, a crucial piece of the puzzle is missing.

The Czech Society for Palliative Medicine played a crucial role in establishing palliative care as an independent subspecialty for physicians in the Czech Republic. This specialisation has existed since 2005, even before our professional organisation was founded. However, at that time, it was a combined specialisation in palliative and pain medicine. Many physicians on that path were more focused on pain management and treating patients with chronic pain, leaving very few genuinely interested in practicing palliative care full-time.

In 2016, the Czech Society for Palliative Medicine distinguished these two areas, establishing palliative medicine as a standalone medical specialisation—or subspecialisation—for physicians. Today, approximately 15 to 20 physicians complete this specialty training each year, which is significant.
To provide some context, this number exceeds the number of new clinical oncologists we train each year in the Czech Republic. Palliative medicine is becoming increasingly popular, and formally recognising it as a subspecialty is crucial in legitimising and advancing the field.

Just yesterday, I met with colleagues from the UK, who shared that in their country, palliative medicine is now the 11th largest specialty in the entire healthcare system. That’s an incredible achievement. This model works quite well, especially in systems like ours, where palliative medicine is offered as a subspecialty for doctors with backgrounds in internal medicine, oncology, or other relevant fields. It’s practical and encourages interdisciplinary expertise.

Money and funding are, of course, critical factors. All these beautiful projects and initiatives come with a cost. So, where does the money come from?
I was nervous when I finished my PhD in the UK and considered returning to the Czech Republic. I was more than nervous—I was pessimistic about how we would secure funding for our work. Especially after spending a few years in the UK, with its long and rich tradition of philanthropy and charity work, where people willingly volunteer and support nonprofit organisations, returning to the Czech Republic felt somewhat daunting.

Because of our history, such as during the communist era, people weren’t willing or able to contribute that way. Even if they had wanted to, the culture of giving simply didn’t exist. We had a minimal tradition of donating to charities, volunteering our time, or using financial resources to support causes. Therefore, I was skeptical about whether we could make it work.

But it did change, gradually yet significantly. Even when I returned in 2014, I noticed successful entrepreneurs and companies interested in supporting meaningful causes. Today, many excellent foundations, companies, and individual philanthropists genuinely want to support good causes. After more than 30 years since the Velvet Revolution, we can no longer attribute our limitations to the old regime. We can achieve great things; it’s simply a matter of discovering how to build the right relationships.

I believe fundraising isn’t just about getting money from someone—it’s about building relationships with people who share your vision and passion.

In our experience, we were lucky enough to find brilliant, successful people genuinely interested in supporting systemic change.

Donors may contribute money if you present them with a touching story—an elderly woman lying in bed, her granddaughter holding her hand, perhaps a dog curled up next to them. That’s beautiful. That’s powerful. And yes, they may send you some money to assist that lady. However, if you aim to create change on a national level, it’s a different story.

And we found them. Many didn’t just donate money—they provided other forms of support, such as connections, expertise, and long-term partnerships. That made all the difference.

One standout example is the Abakus—or Avast—Foundation. Since 2014, it has invested over six million euros in palliative care projects nationwide. Initially established by a private company that developed antivirus software, it has remained a key driving force behind the advancement of palliative care in the Czech Republic.

Over time, we were fortunate to find more donors. Some came from large financial institutions, such as major banks. Others were independent philanthropists or private family foundations. But the bottom line is that you need to secure funding to create change. Often, this means learning how to communicate with those who can support your work emotionally and strategically.

One of the important lessons I’d like to share with you is how to use money effectively in countries with public healthcare systems. This is a significant distinction. For example, in the United States, it’s quite common to see hospital plaques recognising individuals who funded a building or donated to a department. However, that kind of recognition doesn’t tend to resonate in our country, where we have free, universal healthcare. People here don’t believe they should pay service providers for what is already covered by the national system.

Based on our experience, donors usually do not want to provide permanent funding for services the state is responsible for. However, they are open to supporting pilot projects—often quite generously—and collaborating on new, innovative, and meaningful initiatives that can enhance the effectiveness of the healthcare system. Nevertheless, there is a shared understanding: they do not wish to finance these efforts indefinitely. That expectation is reasonable. In a country with universal healthcare, once something proves effective, the government should ultimately take on its funding.

Governments often take time to adopt new ideas, pilot innovations, and implement changes. That’s why we have found it so effective to collaborate with philanthropic donors—those willing to provide significant funding to test promising pilot models, measure their impact with data, and then use that data as a foundation for advocacy. This is how we engage policymakers and advocate for systemic change.

One of the most recent examples of remarkable philanthropic support is the Karel Komárek Family Foundation, which was established several years ago in the Czech Republic and promotes paediatric palliative care. They have committed a significant amount of resources to this cause. One of their goals is to make the Czech Republic a global leader in paediatric palliative care within the next ten years. They are working with tremendous energy and focus, and their contribution is transformational.

Please contact me if you are involved in pediatric palliative care and would like to connect with them. I would be glad to assist you in getting in touch—they are very open to international cooperation and dialogue.

One of the best things I ever heard from a mentor was this: You can never achieve great things alone. And it’s true. If you want to create meaningful change, especially at a national level, you must do it with others.

In our context, we faced a situation where numerous pioneers had their perspectives, approaches, and legacies to navigate. People from the inpatient hospice movement were the true pioneers. Then we came and started advancing palliative care in hospitals, integrating it into the mainstream healthcare system, reaching more patients dying in hospitals.

Sometimes, different groups, all deeply committed to palliative care but not always aligned, create tensions. Even in this beautiful field, we struggle to work together rather than compete. But this mindset—collaboration over competition—is crucial. To have a tangible impact, you must learn to work with others and discover ways to cooperate across disciplines, institutions, and ideologies.

Only data-driven, evidence-based change will last.

Because eventually, the project will end. Or you’ll face a moment when you must advocate for more resources, staff, or broader implementation. And at that point, stories alone won’t be enough. As moving as they are, patient stories won’t convince everyone. You will need solid data.

Consider these questions from the start:

The Centre for Palliative Care, was founded to provide an evidence base. While many of our colleagues offer clinical care in hospitals or hospices, our organisation aims to be an objective, evidence-based resource for policymakers and system-level change.

You don’t need to establish a standalone NGO like ours to do this work. You can reach out to local universities. I’m confident that within your academic institutions—medical schools or public health departments—there are individuals capable of conducting the type of research and academic efforts that systemic change demands. From my experience, academics are often eager to collaborate with professionals in the clinical field.

I’d like to share several examples of our projects. When we started in 2014, there was virtually no palliative care in Czech hospitals. Yet, as in many countries, most people here die in hospitals. Therefore, one of our first missions was to introduce palliative care into that setting.

This became a great example of a pilot project, funded by a private philanthropic foundation. We collaborated with the Czech Society for Palliative Medicine, which gave our small NGO initiative credibility. We collaborated with 26 hospitals for nearly five years to establish palliative care services.

One aspect we take particular pride in is that we didn’t dictate their actions from the outset. We persuaded the Abakus Foundation—our philanthropic partner—to fund the hospitals directly; they were very receptive to this approach because it aligned with their philosophy. The concept was to ask the hospitals what they needed and what their current development stage was, and to identify the next significant step to enhance palliative care.

We didn’t say that every hospital must establish a palliative care team with a specific number of nurses, physicians, and patients. Instead, we inquired about their needs and how we could assist them in making progress.

The flexibility was essential because not every hospital requires a full specialist palliative care team. Many hospitals can provide excellent general palliative care, and it’s crucial to support that as well. Sometimes it’s even more challenging to persuade departments to invest in training their general staff, as there’s less visibility than if a new unit were being opened.

We collected data to analyse the different trajectories hospitals had taken after two years and again after four. We examined the impact of these interventions at the institutional level and across various regions with differing population needs, and then published the results. We created comprehensive guidelines, compiling all the evidence and practical lessons learned, and made them publicly available to anyone interested, from policymakers to local hospitals and NGOs.

This is an important principle I want to emphasise: If you’re starting an initiative like this, consider the end from the beginning. Think about what you’ll want to have on hand when the project concludes to build on its success.

As I mentioned earlier, nursing homes are significant providers of end-of-life care in the Czech Republic. Five times as many people die in nursing homes compared to hospices, which is a striking statistic. So, figuring out how to better support nursing homes in providing palliative care was crucial.

We conducted two rounds of this programme, collaborating with 15 nursing homes in each round, 30 in total. I’d like to emphasise that this initiative wasn’t solely about education. Yes, we provided training, but more importantly, we offered mentoring focused on systemic change.

The challenge in nursing homes often lies in organisational culture. It’s not just about teaching nurses how to manage symptoms; it’s about shifting the entire mindset of the organisation. This requires engaging everyone, from the director to the receptionist. Everyone in the facility must understand that part of their mission is to provide good end-of-life care.

The outcome was incredible: when the programme ended, 28 out of the 30 nursing homes had successfully convinced their funders to continue financing the coordinator position because it had made such a clear and measurable difference. In fact, during the programme, we achieved a 30% reduction in terminal hospitalisations across those nursing homes. This represents a huge impact, both in terms of quality of care and resource allocation.

Another major success was the development of advanced care planning tools. As you may know, palliative care is not just about morphine; it involves planning, asking the right questions early, and ensuring that the care provided aligns with the patient’s goals and values. Therefore, we created practical tools for staff to engage in meaningful conversations with residents and families. These tools assisted them in establishing care goals and documenting preferences for end-of-life care. This represents a significant shift—from reactive care to proactive, values-driven planning.

From the beginning, we invited representatives from all relevant institutions and stakeholder groups to join our Advisory Board, not necessarily as active implementers but as observers. This played a significant role not only in the hospital programme but also in the nursing home programme—and even in the most recent initiative involving emergency medical services.

We consistently reached out to individuals from the Ministry of Health, the Ministry of Social Affairs, insurance companies, and other key institutions, requesting that they nominate someone from their organisation to join our extended advisory board. We clearly communicated that we did not require anything specific from the participants and did not impose any commitments. We simply sought their perspectives and opinions. This approach was effective.

The extended advisory board proved invaluable when it came time to scale up or expand the programme’s results. So, if you’re planning a national-level initiative, I highly recommend establishing this inclusive advisory structure. It fosters relationships, builds trust, and encourages future buy-in.

Establishing communities of practice is significant. You might have noticed a pattern: We typically collaborated with a group of 15 or 20 pilot organisations, and we didn’t merely provide them with tools but actively invested resources in facilitating the development of strong, collaborative networks. We supported them in cultivating trust and sharing their practices.

Even after official funding concludes, those relationships persist. They foster a platform where individuals can keep sharing ideas, supporting each other, and even mentoring the next generation of providers or institutions.

In this field, individuals and organisations often feel isolated, as if they are alone in their fight against the system. However, when gathered together in the same room, they realise that they are not alone and are facing similar challenges. This realisation can be incredibly empowering and can accelerate development far more effectively than individual organisations working alone ever could.

The last example I want to share is a project we ran with emergency medical services (the EMS programme). We conducted some research and found that every paramedic transported at least one patient to the hospital daily, even when they knew it wasn’t the right solution for that particular person. EMS is a key provider of general palliative care, and we must collaborate with them to enhance the system as a whole. We implemented the same strategy used in previous programmes. Our country has 14 regional EMS providers, so we contacted each and requested them to nominate a colleague from their team to serve as a palliative care ambassador.

Typically, the CEOs or directors of EMS organisations aren’t very interested in palliative care. They’re more focused on acquiring new helicopters or advanced life support technology, which isn’t exactly our topic. However, once they officially nominated someone, that individual suddenly gained recognition within their organisation. This meant they had the authority to email colleagues, organise training, introduce research, and advocate for new initiatives. Many of these ambassadors exceeded our expectations. They generated brilliant ideas—even better than some of what we had initially planned! By granting them this official role, we enabled them to advance matters far more quickly than we could have.

To wrap up, I`ll summarise what I consider to be key aspects of a successful journey from fragmented local initiatives to system-wide integration of palliative care at the national level.

1. You need passionate pioneers and advocates. It always starts with people. You must look around and find others who are enthusiastic about doing this work. It’s hard work—it takes a toll—but I firmly believe that in every country, people are willing to join you. Don’t do it alone. Find at least one or two others who can walk the path with you.
2. You need to build beacon organisations—real-life examples demonstrating how it works. You need excellent care providers who can showcase what palliative care looks like when it’s done right. These beacon organisations must also possess educational capacity, as one challenge we now face in the Czech Republic is that the demand for palliative care education is outpacing our ability to train new people. Therefore, consider this from the beginning. If you’re creating a model hospice or hospital service, reflect on how you will share what you’ve learned and train others.
3. Seek donors to support pilot projects. Frame these as pilots—demonstrate to the funders that they will see tangible results, and that those results will be utilized to negotiate with ministries and insurers.
4. Finally, data, data, data. I’ve said it a thousand times, and I believe in it. You need data. If you already have a good clinical organisation, I suggest building partnerships with universities rather than trying to do all the academic work yourself. Having a strong evidence base is essential if your ultimate goal is systemic change.