Healthcare is one of the highly regulated sectors. Quality control has a major impact on the results it achieves. The reforms are aimed at altering regulatory instruments and their settings. The tenth anniversary of the Slovak health care reform is therefore primarily an anniversary of successful application of a comprehensive legislative change. There on this occasion, in Bratislava on 25 September 2014 we organized a major HPI conference with interesting guests. Former ministers Rudolf Zajac and Ivan Mikloš, former Czech Health Minister Tomáš Julínek, collaborators from the time of drafting the reform, directors of Slovak hospitals, managers of health insurance companies, pharmaceutical companies, supplier and graduates of the Health Management Academy, and many others joined us to celebrate.
Tomáš Szalay, co-founder of HPI: “After ten years we can still say that all of the then reform laws are still valid today. The vast majority of measures, institutions and instruments are kept until today. Despite the criticism, an alternative, perhaps better health system has still not been formulated. No one has been able to describe the system and transpose the change into a legislative proposal. ”
For the 10 years we have witnessed several attempts to change the legislative setting. Not even an idea of a major change, 2012 plan to monopolize health insurance, contain any concept of a new system. It did not make it into a public consultation stage. 2007 brought a suggestion to create a single public health insurance company, which would co-exist alongside the existing public limited companies. A draft of mandatory switch of the state insurees into a state insurance company reached the consultation procedure. However, all of these partial “solutions” out of context lacked a clear vision supported by the data.
The 2002 – 2006 health care reform was first described in detail in the so – called Blue Paper Strategy for Health Care Reform – Real Reform for a Citizen by Peter Pažitný and Rudolf Zajac (2001). Description of problems and solutions allowed for a professional discussion and later served as a substantive base for legislative changes.
The reform truly started in spring 2003 by the approval of the Triple Bill. After breaking the then President’s veto members of parliament supported the Triple Bill, as of June 2003 Slovak patients started to pay fees for services related to the health care. A fixed surcharge for medicines was introduced and speculative late fees, until then guaranteed by law in the creditable amount of 0.1% per day, were decreased.
Work on the reform bill continued until the end of 2003. The original intention to change only insurance laws soon proved unsatisfactory. Changes required a fundamental reconstruction of other health legislation. We created a so called reform laws puzzle, each of which governed a different part of the sector, but together created a harmonizing whole.
Laws alone (without attachments, further amended laws and implementing regulations) had 64,549 words. Consultation procedure then brought 3,288 comments, out of which 1,435 were substantive. 2,341 (71%), of which 1,017 were substantive were finally fully or partially accepted.
On 21 April 2004 the government approved the reform laws which saw the first reading in the Parliament. However its approval was deferred until the fall. On 21 and 22 September 2004 the Parliament approved the laws by a simple majority of all deputies. Law on emergency medical service got the highest number of votes (88 of the 150 members of parliament). Despite President Ivan Gasparovic’s veto of all six bills, after being sent again to the parliament for second voting, on 21 October 2004 they were approved by a qualified majority.
The first to become effective as of 1 November 2004 the , the Act on Health Insurance Companies established the Healthcare Surveillance Authority, other laws followed as of 1 January 2005. Follow-up of individual steps was crucial for successful management of the transitive period. Effectiveness of individual provisions was therefore timed in detail.
The 10 years have seen several changes. The six laws were amended together 144 times. Act no. 578/2004 Coll. on Health Insurance was amongst those most amended; 38 times. Although most of these amendments that were of a technical nature, 47 amendments primarily focused on substantive modifications. The first amendments took place before the effect of the new legislation, to correct some technical errors.
These changes increased the scope of the laws from 64,549 to 118,406 words. The increase was caused mainly by amending and supplementing then valid provisions and measures. Some of the innovations are as follows:
The Constitutional Court ruled in a number of issues in the healthcare legislation over the last 10 years. Four of them were directly related to the reform changes. In all four cases, the Constitutional Court ruled in favour of the reform: