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7.5 Contribution of the health system to health improvement
|Introduction – Organization – Financing – Resources – Provision – Reforms – Assessment – Conclusions – Appendices
The Slovak health system is a system in progress. Major health reform in the period 2002–2006 replaced all relevant health care related legislation and meant a new approach based on individual responsibility and managed competition. The health insurance funds became profit-making companies, hard budgetary constraints were introduced, and a new regulatory and institutional framework was created. The model sought to create an environment in which societal goals are met through incentives for market players. The future of this system largely depends on political will. Opposing political views may lead to different decisions regarding market mechanisms and state control. The government that entered into power in 2010 pledged to move forward with the market reform agenda.
Although large improvements have been made, most notably in life expectancy and lower infant mortality, Slovakia’s health outcomes are generally still substantially worse than the averages for the EU15 and OECD, but close to the other Visegrád Four countries – the Czech Republic, Hungary and Poland.
Per capita health spending (in PPP) in Slovakia was fairly low in 2008 and around half the EU15 average. A large share of these resources was absorbed by pharmaceutical spending (28% in 2008, compared to 16% in OECD countries), effectively making spending on other components of care even lower.
Compared to OECD averages, relatively high hospital bed availability, relatively low occupancy rate in hospitals, high hospital discharge rates and a high number of consultations signal plenty of resources in the system but may also indicate excess bed capacity and overutilization.
The numbers of physicians and nurses per capita were similar to the EU15 until 2001. After 2001, Slovakia witnessed a continuous fall in the number of physicians and nurses in relation to the population, although their numbers remain above the EU12 average. These changes are closely linked with the migration of doctors and nurses abroad and the restructuring of health care facilities. National data show that since 2006, the health workforce has started to increase again. Yet the ageing workforce combined with the migration of health care workers may reinforce the shortage of health care workers.
The technical infrastructure of hospitals is outmoded with Slovak hospitals on average being 34.5 years old. Capital investments from the Ministry of Health budget were abolished in 2003. Instead these resources were allocated to health insurance companies to include amortization in their payments to providers.
Compared to the international benchmark, Slovakia has a progressive system of financing health care. Indirect taxes and out-of-pocket payments increased regressivity in the period 2002–2005, but this trend was offset by rising progressivity of direct taxes and SHI contributions in the same period. However, the health reform of 2002–2006 led to an increase in the number of households that contributed more from their income and the distributive impacts were not equitable, with the second and third quintiles reporting the highest increase. This was mainly caused by the introduction of a reference pricing scheme for pharmaceuticals, which substantially increased co-payments.
Going forward, some key challenges remain for the Slovak health system. Most importantly, attention needs to be focused on improving the health status of the population and the quality of care. This could be achieved by implementing clinical guidelines and protocols for the provision of health services, and by developing comprehensive sets of quality indicators and actively measuring them. This could help make the quality of health provision more accountable in the future and enable payment mechanisms that reward quality. Furthermore, all relevant quality information could be made publicly available so that patients can make informed decisions when selecting health providers and insurance companies.
The Slovak system, which has long been plagued by debt, must secure the future financial sustainability of the system. How this should be achieved remains the subject of considerable political controversy. With the chosen managed competition model, Slovakia has opted for a model that assumes that increased competition will lead to higher quality care at lower costs. For such a model to work, it will be necessary to explicitly define the scope of services (possibly with the help of a health technology assessment [HTA] agency); to foster competition by improving the risk-adjustment system and payment methods; to stimulate informed choices; and to reinforce the independent position of the HCSA.