The paradox of progress: persistent spatial health traps in Czechia after two decades of transition

Health inequalities represent a persistent challenge for public health policy, yet longitudinal evidence covering the full spectrum of their determinants remains scarce. Despite two decades of significant macro-economic growth and European integration, it remains unclear whether systemic progress in Czechia has mitigated or reinforced existing geographical health divides. This study examines the stability of spatial health inequalities in Czechia — a country that has undergone profound post-socialist socio-economic transformation — over a twenty-year period (2001–2021). Spatial differentiation of health determinants and outcomes was assessed at the LAU 1 level (77 units). Using a holistic framework, 57 indicators were integrated across seven categories of contextual determinants (Index A) and a composite index of population health outcomes (Index B). All indicators underwent min-max normalisation before aggregation via the Weighted Sum Approach. To identify spatial clustering and its temporal dynamics, Global Moran’s I and Local Indicators of Spatial Association (LISA) were applied at three time points coinciding with national censuses (2001, 2011, 2021). Regional inequality was quantified using the Theil Index, and temporal significance was assessed via the Wilcoxon Signed-Rank Test. Findings reveal a decoupling of trends that differs according to whether average index levels, regional inequality or spatial clustering is considered. Mean educational attainment (A.2) rose across both decades, whereas mean economic conditions (A.1) declined between 2001 and 2011 (0.539 to 0.470) before recovering above their initial level by 2021 (0.582). Regional inequality, measured by the Theil index, moved in the opposite direction to the mean for economic conditions, rising in the first decade (2.12 to 3.01) and falling only in the second (1.08), while educational inequality remained the highest of all categories throughout and declined only gradually (9.98, 9.09, 8.47). Inequality in healthcare accessibility (A.7) and environmental status (A.4) intensified during the second decade. LISA analysis identified Low-Low clusters in the northwestern and northeastern border peripheries that retained an unchanged classification at all three time points. Spatial autocorrelation in health outcomes remained consistently high (Moran’s I: 0.55, 0.44, 0.54) while that of determinants shifted (0.26, 0.51, 0.39); this contrast is compatible with a spatial-temporal lag between socioeconomic change and population health, but no lagged analysis was undertaken and the lag is offered as an interpretation rather than as a demonstrated finding. Macro-economic prosperity does not automatically translate into health equity. Without targeted, place-based interventions, peripheral areas face a compounding spatial penalty of cumulative disadvantage. This study offers a replicable methodological model for monitoring health equity in transitional economies and underscores the need for territorial cohesion policies that address the structural determinants — not merely the symptoms — of health injustice.