- About Us
- Health System in Slovakia
- Healthcare in 2020
- Slovenská verzia
2.2 Historical background
|Introduction – Organization – Financing – Resources – Provision – Reforms – Assessment – Conclusions – Appendices
2.4 Decentralization and centralization
Health policy results from the interplay between the Ministry of Health (legislator), the health insurance companies (purchaser) and the HCSA (supervisor). Health policy is influenced by providers, as well as professional organizations. Patient organizations have little influence on the formulation of health policy. Different ownership forms exist among providers and health insurance companies. One of the main owners is the state, which owns the largest hospitals and the largest health insurance company. All the key players in the Slovak health care system are described below.
The Parliament has legislative power as well as powers of scrutiny and may carry out parliamentary inspections. The members of the Supervisory Board of the HCSA are elected by the Parliament.
The competences of the government are: adopting legislative measures (defining user fees for services related to health care, setting co-payments, determining accessibility parameters for minimum provider networks), and appointing/removing the Chair of the HCSA.
The Ministry of Health is a central administrative body and its responsibilities include drafting health policy and legislation, regulating health care provision, managing national health programmes, participating in the management of health education, managing national health registers, determining the scope of the basic benefit package, defining health indicators and setting minimum quality criteria. Competences in price regulation were transferred to the Ministry of Health in 2003. Furthermore, the state is an owner of some major health care facilities and the biggest health insurance company (General Health Insurance Company [that is, VŠZP], with a 68% market share in 2010 according to the HCSA). This leads to a conflict of interest because the state regulates providers and health insurance companies it owns.
The organization and funding of social care is the responsibility of the Ministry of Labour, Social Affairs and Family. The social care system and the health care system evolved separately, leading to a different kind of organization and different sources of funding, even though many of the services provided are practically identical. This may pose a barrier to effective solutions in the provision of long-term social care and health care. The management and supervision of health education and the curriculum is shared between the Ministry of Health and the Ministry of Education, the latter being responsible for the financing. The Ministry of Health coordinates health research in universities and the Academy of Sciences. This shared competence often leads to confusion. In addition, the Ministry of Finance has strong influence on the health budget development process.
The Ministry of the Interior, Ministry of Defence and Ministry of Transport have established health care facilities in their sectors which, with the exception of the Military Hospital in Ružomberok, play a marginal role in health care provision.
In 2004, to prevent further conflicts of interest, the monitoring and supervisory role of the Ministry of Health in the health system was transferred to the HCSA. The HCSA is responsible for the supervision of the health insurance, health care purchasing and health care provision markets (see Fig. 2.2). In the period 2007–2011, the government has the competence to withdraw the Chairman from his office, which reduced the independence of the HCSA. The HCSA’s Supervisory Board is elected by Parliament. The HCSA has strong competences and can impose sanctions. This includes banning a health care provider or a health insurance company from the market. Furthermore, the HCSA grants market access to health insurance companies after they have fulfilled certain conditions and supervises the fulfilment of these conditions (solvency, purchasing of health care services). The HCSA administers the risk-adjustment mechanism of financial resources between health insurance companies and manages several registers. Other competences of the HCSA include administering patients’ complaints regarding inadequate health care provision and decisions regarding autopsies to be performed in forensic and pathological anatomy laboratories. The HCSA acts as a liaison body for cross-border health care provision. The annual report describes the HCSA’s activities as well as SHI performance and is submitted to the government. An amount of 0.45% of contributions collected by health insurance companies is allocated to funding the HCSA.
The PHA is responsible for public health tasks. It is a state budgetary organization, which means that it is fully financed from the state budget. It is managed by the Chief Hygienist, who is appointed by the Minister of Health. The PHA develops the vaccination policy, directly controls radiation protection and issues permits for the sale of cosmetic products. Through its regional offices, the PHA carries out epidemiological monitoring, assesses the impact of environmental factors on health, issues approvals before putting any premises into operation, and monitors the quality of drinking and bathing water. The PHA can impose sanctions if a violation of the regulatory framework is found.
The SIDC, a state budgetary organization, is responsible for monitoring medicinal products and medical devices. The SIDC issues approvals of clinical trials, grants marketing authorizations, assesses pharmacies and maintains a pharmacopoeia. The SIDC can also impose sanctions. In the area of patient safety it carries out assessments of reports on adverse drug effects (pharmacovigilance) and medical device failures. It withdraws or suspends medicinal products from the market, or prevents medical devices from entering the market. The SIDC is not involved in reimbursement decisions concerning pharmaceuticals or medical devices.
The National Emergency Centre of the Slovak Republic is a state budgetary organization, which controls all components of emergency medical services. It is responsible for processing all telephone emergency calls as well as cooperation with all other components of the integrated emergency system.
The Ministry of Health has established the NCHI as a state contributary organization to deal with e-health issues, standardization of health information systems, collection, processing and provision of health statistics as well as provision of library and information services in the area of medical research and health. The NCHI operates the national health registers.
The National Haematology Centre is a state contributory organization established in 2004 by the Ministry of Health to carry out haemotherapy and tasks related to complex production of blood products.
Health insurance companies play a key role in the system as purchasers of health care. It is their legal duty to ensure health care to their insured individuals. Purchasing is based on selective contracting; the main criteria are quality indicators and flexible prices. The contractual relations between health insurance companies and health care providers are supervised by the HCSA. All health insurance companies are joint stock companies and obliged to meet certain solvency criteria. Being under hard budget constraints, they are fully responsible for financial shortfalls. Ownership regulation allows both the state and private sectors to be shareholders in the health insurance companies. Although there were seven health insurance companies in 2006, among which there were two new entrants, a wave of mergers led to increased consolidation in the market (see also section 2.8.1 Regulation and governance of third-party payers). As of 2010, the state owned one of the three remaining health insurance companies (the General Health Insurance Company) and the private sector owned two. Representatives of health insurance companies are seated on ministerial committees. These committees define the basic benefit package, that is, the health services covered by SHI, and participate in draft legislation.
Certain local operative competences were transferred from the state to the eight self-governing regions to decentralize power. The self-governing regions’ responsibilities include issuing permits for the operation of health care facilities, appointing ethical committees, issuing approvals for outpatient biomedical research, maintaining health documentation of providers that cease to operate, and securing health care provision resulting from a provider’s permit or licence being temporarily put on hold. The Ministry of Health deals with appeals against decisions of the self-governing regions. The self-governing regions also assist in improving the network of providers where the accessibility of health services in the region is deteriorating – for example, by appointing a physician when patients have difficulties finding a GP or accessing medical treatment. Self-governing regions took over the responsibilities for monitoring health care provision and can impose sanctions on health care providers for neglecting their duties. Sanctions include financial penalties and temporary or permanent revocation of a licence. The power to ban a provider from the market is a strong legal instrument. As a rule, self-governing regions will only impose sanctions at the recommendation of the HCSA, based on the results of monitoring and detected shortcomings.
The Chief Physician of the self-governing region is appointed by the Chair of the self-governing region with the approval of the Minister of Health. The Chief Nurse, appointed with the approval of the Minister of Health, is responsible for nursing care provision and midwifery services.
Self-governing regions own some health care facilities and can make decisions on management of these facilities independently. Since transferring responsibility for health care facilities to the self-governing regions in 2003 (see also section 2.4), most hospitals have been transformed into joint stock companies or non-profit-making organizations, or they have been fully privatized into commercial companies. Some of these health care facilities have been rented out to private health care providers. Self-governing regions have been negotiating the entry of other strategic investors into the health market.
Political parties have great influence on the health sector. Politicians manage and make decisions on the majority of resources in health care not only at national level, but also at the regional and municipal levels. The political interests of the parties vary regionally, and they may also be influenced by lobbyist groups. The technical expertise of political parties in the area of health policy is generally low.
The largest trade union, with 40 000 members, is the Association of Health and Social Trade Unions. It negotiates collective contracts with the employers’ representatives. The Trade Union of Physicians is a smaller organization, which mainly advocates for the financial interests of its members.
Organizations of health care providers and professional chambers promote and advocate for the interests of their members in their relations with the state, self-governing regions and health insurance companies. They participate in drafting legislation, in educational programmes and represent their members in contract negotiations with health insurance companies. They maintain the register of health professionals and provide continuous education. Chambers also have competences such as granting licences and imposing sanctions. Since 2005, membership in chambers is voluntary and the chambers cannot impose obligations on non-members beyond the extent prescribed by law. Despite this fact, the oldest chambers (Slovak Medical Chamber, Slovak Chamber of Dental Physicians, Slovak Pharmaceutical Chamber, Slovak Chamber of Nurses and Midwives) have managed to keep a large member base, and thus constitute influential interest groups. The most significant organizations of providers are the Association of Hospitals of Slovakia, the Association of University Hospitals, the Association of Private Physicians of the Slovak Republic and the Slovak Medical Union of Specialists.
The Slovak Medical Society is an association of professional medical and pharmaceutical societies, regional associations of physicians and pharmacists, with almost 20 000 members. The Society focuses on technical and ethical issues as well as the dissemination of scientific knowledge. Professional societies within the Slovak Medical Society delegate their professionals to different committees (for example, the Reimbursement Committee for Medicinal Products and the Catalogue Committee for medical procedures at the Ministry of Health).
Private businesses advocate their interests individually. Their common interests are represented by umbrella organizations, particularly from the pharmaceutical market: the Association of Suppliers of Drugs and Medical Devices (ADL), the Slovak Association of Medical Device Suppliers (SK-MED), the researchoriented Slovak Association of Pharmaceutical Societies (SAFS) and the Association of Generic Producers (GENAS).
Patient organizations vary in their activities. How active they are often depends on the efforts of dedicated individuals and the level of financial resources. The groups, as well as their interests, are fragmented and they are represented by various umbrella organizations. Successful promotion of their interest is often hindered by the division of competences between health and social care. The issues of people with disabilities belong to the agenda of the Ministry of Labour, Social Work and Family. Most patient organizations, as well as organizations of people with special health care needs, directly approach the responsible Ministry with their problems.
Organizations representing people with chronic conditions are the most active. These include the Union of Diabetics of Slovakia, the Slovak Association of Sclerosis Multiplex, the Slovak Osteotomy Association, League against Rheumatism in Slovakia, the Club of Parents and Friends of Children with Cystic Fibrosis, and the Down Syndrome Association in Slovakia. Numerous educational projects aimed at oncology patients and their relatives as well as the public take place under the auspices of the charitable non-profit-making organization the League against Cancer. Psychiatrists, psychotherapists and patient organizations cooperate within the League for Mental Health to actively advocate for mental health promotion. The Association for Patients’ Rights Protection is active in the area of patient rights.
Most research projects are carried out by universities and the Slovak Academy of Science, which administratively belong to the educational sector. The Ministry of Health is responsible for coordinating health research. This shared responsibility has made the coordination and management of health research a complex task and the Ministry of Health is at times criticized as ineffective. In addition, biomedical research facilities need permission from the Ministry of Health in order to operate. The Research Institute of Medicinal Products in Modra, a part of the German hameln group, provides research and a developmental platform for global pharmaceutical companies. The Institute of Preventive and Clinical Medicine, a research centre of the Ministry of Health until 2003, is now part of the Slovak Health University, a public institution managed and monitored by the Ministry of Health.
The professional medical press is disadvantaged by a small market. This results in low demand for published articles of high quality and a higher dependence on medical advertisements. The influence of the media on public opinion is an effective tool, utilized by various actors, to inform, educate or influence health policy. However, only few media have the expertise to cover health policy adequately.
The WHO is the most active organization in the health sector in Slovakia and enjoys a high reputation. The WHO has initiated cooperation programmes, including exchanges of information, technical support and experts, as well as providing financial and material support. The WHO has had a substantial impact on Slovak health policy. Slovakia recognizes the 1998 document Health for All in the 21st Century, as well as several WHO strategies (for example the European Strategy for Prevention and Control of Noncommunicable Diseases, the Charter against Obesity and the European Action Plan for Environment and Child Health). In addition, Slovakia is actively involved in the European Commission’s Health Security Committee and in the Joint Medical Committee of NATO.