Health care systems in transition: Slovakia
|Autor||Hlavacka S, Wágner R, Riesberg A
Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies|
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Slovakia has managed largely to transform its health care sector into a pluralistic and decentralized social ealth insurance system. However, many reforms have not materialized in the way the population or policy-makers had expected. Most notably, the aspired increase of financial resources, accountability and quality of care has not been realized. Increasing internal and external debts have created a perception of financial and organizational crisis that paved the way for comprehensive reforms since 2002. The 2004 reform has set out to restructure health care, limit the scope of publicly funded benefits and increase the role of private funding. Organizational structure of the health care system The Ministry of Health is the key policy-maker and regulator in the system, collaborating closely with the Ministry of Finance. Since 2002, municipalities and “higher territorial units” at regional level own, operate and supervise a significant proportion of hospitals and outpatient facilities for secondary care. There is free choice of currently five health insurance companies. They act as collectors, purchasers and thirdparty payers in the health system. Primary care physicians practise mainly in private single practices, while almost all specialists and other health care professionals are salaried employees. Physicians, dentists, pharmacists and nurses are mandatory members of professional chambers. Besides professional development and supervision they are involved in carrying out inspection and control of both state and private health care facilities, in developing mandatory legal regulations and a performance related pay scheme. The 2004 reform virtually redefines the roles and competencies of all health care actors and their interrelations to clarify responsibilities. Planning, regulation and management: Until 2001 the planning, regulation and management of health care financing and delivery largely was centralized at the Ministry of Health, which also owned most of the hospitals and many outpatient specialist facilities. Since then the ownership of most hospitals and clinics for secondary outpatient care, including 3 HiT summary: Slovakia, 2004 competencies to plan, regulate and operate, have been devolved to self-governing municipalities and higher territorial units at regional level. The five not-for-profit health insurance companies are governed by bi-partite selfgoverning structures with little discretion over their operations since, for example, parliament defines uniform contribution rates. Parliament also approves the amount and structure of the annual budgets of the two major statutory health insurance companies.
Decentralization has been pursued in three waves, while a fourth has recently been enacted. In the early 1990s, health care financing was delegated to social health insurance companies. Almost all primary care physicians, pharmacies, spas and pharmaceutical industries were privatized. From 1995, multiple insurance companies were introduced to compete for insured persons while pooling financial risks. In practice, competition was limited.
Until January 2002, the Ministry of Health owned and operated almost all inpatient health care facilities. Since then, most secondary care hospitals and adjacent polyclinics have been transformed into non-profit public benefit entities or devolved to self-governmental municipalities or higher territorial units at regional level; and some outpatient clinics have been sold to private providers. Tertiary care hospitals continued to be owned by central government. The 2004 reform provides for a gradual privatization of state-owned hospitals and other health care facilities into for-profit joint stock companies supervised by the Office of Health Care Supervision.