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HPI
Slovakia reintroduced a Bismarck model of health insurance in 1993. The Slovak National Health Insurance Fund was established in order to finance health insurance, sickness benefits and pensions. In 1994, the Act on Health Insurance was adopted, which enabled the establishment of other health insurance funds and legally defined SHI.
Compared to other countries, the number of physicians and nurses per capita was similar to those of 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 migration of health care workers may reinforce the shortage of health care workers. Although exact data on migration are lacking, this is considered common knowledge.
In 2008, there were 138 hospitals in Slovakia, 73 of which were general hospitals and 65 specialized hospitals or inpatient facilities. A study carried out in 2004 found that the technical infrastructure of hospitals is unsatisfactory and old fashioned, which leads to their ineffective management. In 2007, there were 26 546 acute beds, 4450 psychiatric beds and 4403 long-term beds in Slovakia. All three types of beds have seen a gradual decline in relative and absolute terms since 2000.
Providers are paid according to an individual contract, which determines the amount, the nature and quality of services as well as the payment system. A given health insurance company may have negotiated different prices for different providers, which is particularly the case in inpatient care.
Since Slovakia’s SHI system provides a broad range of benefits and universal coverage, the role of other sources of funding is rather limited. However, all employers must offer an occupational health service for employees working in high-risk environments since 2008.
Private VHI is part of the commercial insurance system. So far, private VHI plays only a marginal role due to the broad benefit package and low official cost-sharing requirements. According to the National Bank of Slovakia, total VHI premiums are approximately €1 million (in 2009). Thus they account for only 0.02% of total health expenditure and 0.2% of overall non-life insurance premiums.
Out-of-pocket payments in Slovakia mainly consist of (1) user fees for prescriptions and various health services; (2) co-payments for prescription pharmaceuticals and spa visits; and (3) direct payments for OTC pharmaceuticals, above-standard care, preferential treatment and care not covered by SHI. An average Slovak spends more than €200 annually on health out of pocket. In 2009, out-of-pocket expenditure amounted to 1.8% of GDP. As share of total health expenditure, Slovaks spent 23.6% on health out of pocket in 2009, a significant rise from 2002 when it was only 11.7%.
The range of benefits available to individuals covered by SHI in Slovakia is broad. The SHI system is financed through a combination of contributions from the economically active population and state contributions on behalf of the non-economically active population (“state-insured”). Contributions are collected and administered by health insurance companies. To alleviate the financial burden on health insurance companies with a higher-risk portfolio and to reduce the potential for risk selection, SHI contributions are redistributed among the health insurance companies using a risk adjustment scheme. Health care purchasing is based on selective contracting.
The main sources of revenue in the health system are contributions paid to the health insurance companies under the SHI system. These include contributions by (1) employees and employers, (2) self-employed people, (3) voluntarily unemployed, and (4) “state-insured”. The latter term is used for the significant group of mostly economically inactive people for whom the state pays contributions (approximately two-thirds of the population and one-third of total resources from contributions). Payments to providers are subject to a contract that determines the amount of payments, the type and quality of services, and the payment system. Furthermore, the health insurance companies fund the HCSA in proportion to their revenue.
In 2009, total health expenditure as share of GDP was 7.6% according to national sources. This high GDP share was rather exceptional. Before 2009, the share was around 6.5% of GDP for three consecutive years. Slovak health insurance companies spend a relatively high share of their revenue on pharmaceuticals. Pharmaceutical expenditure amounts to 30% of expenditures by health insurance companies – compared to 7% on primary care, 11% on ambulatory secondary care and 27% on inpatient care.
