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6.1 Main reforms since the 1990s
|Introduction – Organization – Financing – Resources – Provision – Reforms – Assessment – Conclusions – Appendices
6.3 Key elements of the health reform, 2002–2006
Health reform in 2002–2006 introduced hard budget constraints and aimed at effectively utilizing scarce resources and uncovering internal system reserves. In practice the latter meant increasing the responsibility of patients, health insurance companies and health care providers. The state significantly reduced its active involvement in favour of regulated market mechanisms. During the restructuring period, the system changed from a hierarchical and centralized system to a decentralized and contractual system (Fig. 6.2).
The health reform from 2002 to 2006 was part of a larger reform plan, which can be labelled as “Slovakia’s neo-liberal turn” (Fisher, Gould & Haughton, 2007). Neoliberalism refers to liberal economic policies that increase personal responsibility for one’s own well-being and that seek to dismantle institutions that socialize the risk of failure in the economy (Harvey, 2006: 145). According to Fisher, Gould and Haughton (2007), Slovakia’s government distinguished itself in central Europe for its consistent adoption of liberal and neoliberal reforms between 2002 and 2006. Furthermore, the authors argue that the neoliberal turn emerged from a deep, ideologically informed collaboration between highly placed political officials and innovative policy advisers. While Slovakia’s reformers did not accomplish everything they wanted, they were able to put a neoliberal stamp on fiscal policy and taxation, the Labour Code, the pension system, investment regime, welfare payments, the judicial system, and the health and education sectors.
Unlike in Hungary (2006–2007) and in the Czech Republic (2007–2008), health system reform in Slovakia was part of broader reforms in public finances and the business environment. During this period, a 19% flat tax and the second pillar of the mandatory pension scheme, an enforcement of significant fiscal decentralization and a judicial reform, were implemented. Health reform comprised stabilizing measures, system measures and network measures. The stabilizing measures were aimed at halting rising debt and restricting overconsumption of health care services and drugs. The system measures were to create a new system of effective, fair and financially sustainable health care provision (Table 6.3; for details see section 6.3).
A more market-oriented system could not have been implemented had there not have been strong institutional and legal pillars upon which it could be built. The Standard Commercial Code, the Act on Competition and Compensation, and the Act on Accounting have played important roles and have provided a robust framework for the health care acts. The fact that Minister of Health Rudolf Zajac was able to hold on to his position during the whole of the government’s term (unlike several of his colleagues in neighbouring countries) played a crucial role in the implementation of health reform.
Experts viewed the 2002–2006 health reform as positive and welcomed the effort to establish an effective and financially sustainable system (Zachar, 2005). The plan to encourage personal involvement in decisions concerning one’s health received a largely positive response. However, critics pointed out that application of a new system based on market principles as used in other sectors may pose risks. They also raised the fact that the reformers did not listen enough to opponents and that the reform did not achieve a consensus of support across the political spectrum.
Although expert opinion was mainly positive, citizens largely disapproved. While professionals supported the introduction of user fees, up to 74% of the population disagreed. On the other hand, in the process of evaluating the reforms, health care did not rank as a priority issue when compared to other societal problems. This may indicate that, despite disagreeing with the reforms, people were adapting to the new health care system (IVO, 2007).