1. Healthcare Reform in Slovakia
Rudolf Zajac

2. I. Introduction - Slovakia
Population: 5.4 million people
Living Standard: 51% of EU average
Middle income country

3. Expenditure on Health Care
Expenditure on health care as % of GDP
USA
GER CZ
SVK
DEN
ESP
IRE
ROM
GDP per capita at PPP in USD
source: OECD

4. Deficit of Public Finances (% of GDP)

5. Breakdown of Current System
solidarity
excess of solidarity over resources
resources:
5 (income from privatisation)
17 (informal payments) 8
23 (taxes)
(direct payments)
47 (payroll taxes)
solidarity
resources:

6. Excess of demand over supply
Consequences
Excess of demand over supply 3
Expenditure 1 2
Prices / spending 3
Infinite demand 1
Volume

7. Efficiency gap LUX CZ SVK HUN
Through corrections in pay levels, employment and age structure it RISES to a ratio of:
Input : Output
0,526 : 0,612

8. Efficiency in Health Care
The Netherlands
Slovakia
Efficiency = 1.000
Efficiency = 0.612

9. Slovakia, the leader in Reforms?
Tax Reform (2003) – Corporate and Wage Tax – 19 %
Pension Reform (2003) – Two pillars (public and private)
Public Administration Reform (2004) – Fiscal Decentralization
Labour Market Reform (2003) – Modern Labour Code
Health Care Reform - Stabilization (2003) Reform Acts (2004)

10. Pre-reform "preparation" of citizens, or stabilisation (June 2003) Application of marginal co-payments
Patient
Health Insurance Fund
Provider (pharmacy)
Primary care
20 Sk
0 Sk
Secondary care
Accomodation and food in inpatient care
50 Sk
Transport
2 Sk/km
Prescription fee
15 Sk
5 Sk

11. The Reform Jigsaw Healthcare Act
Healthcare legislation and supervision of health care
Healthcare Providers and Professional Bodies Act
Health Insurance Act
Act on the Scope of Health Care Covered by Public Health Insurance
Healthcare Emergency Services Act

12. Principles of Reform Equal care for equal need Ability to pay
Universal coverage
Protection of patients' rights
Enforcement of fair play
Health care is a technical service and an ethical vocation
Guaranteed free access for licensed providers to the healthcare market

13. Main Philosophial Changes
Increased responsibility of health insurers for the purchase of health care and the financial protection of the patient
Increased responsibility of providers for health care provision
Increased responsibility of patients for their health

14. Health care is a technical service and an ethical vocation
Basic principle:
Health care is a technical service and an ethical vocation

15. Clear definitions and rules
Definition of procedure "lege artis"
Definition of urgent treatment
Definition of informed consent
Access to and provision of medical records and protection of patients' personal information
Catalogues of actions leading to diagnosis and treatments leading to the cure of illnesses (see the law on scope)
Integrated European Charter of Patients' Rights (e.g. the right to choose a provider, to respectful treatment of patient by doctor, to information on their health condition,...)
Principles of bioethics (transplantation, sterilisation, biomedical research)

16. Health insurance Respects: Must ensure: solidarity ability to pay
universal coverage without regard to the social status of the recipient

17. Health insurance Scope set by special legislation, compulsory
Public health insurance (solidarity)
Emp 10+4%
Scope set by special legislation, compulsory
Individual health insurance
Covers individual needs, optional

18. Redistribution according to rating of costs (risk)
Objective: for all insured to have access to an equal volume of resources corresponding their risk rating

19. Healthcare legislation and supervision of health care
Health insurers
Duty to provide health insurance
Option of individual insurance
Option of sickness insurance
Transformation of the current public institutions into joint stock companies
Supervisory office
Issues permission (licenses) to health insurers
Monitors the solvency of health insurers
Supervises and monitors
whether insurers have purchased health care in the scope required by law
whether providers have provided it "lege artis"

20. Multiple insurers – yes or no?
SELECTION
SELECTION
SELECTION
REDISTRIBUTION
PURCHASE OF HC
PURCHASE OF HC
PURCHASE OF HC

21. Instruments of Purchase
Health insurance provider
Selection of provider by quality and price
Quality standards
The law does not stipulate the payment mechanism to be used

22. Objective: to increase the responsibility of the insurer
Patient Management
Hospital
Patient
Health insurance provider
MD (GP, Specialist)

23. Healthcare Emergency Services
Part of the integrated emergency system (IES)
Organisation of a network of healthcare emergency services so that in cooperation with IES, 98% of citizens can be reached in under 10 minutes

24. Healthcare Providers Act
Basic principles:
Ensure free access to authorised (licensed) providers
Transfer the performance of first level state administration to professional bodies
The act contains an ethical codex for providers, obligation to provide lifelong learning and monitoring
Transforms the largest hospitals into joint stock companies whose shareholders will be universities, towns and regions

25. Equal care for equal need
Act on Scope
Basic principle:
Equal care for equal need

26. List of citizens' priorities
Illness %
Hear-circulatory illnesses
74,2
Cancer
68,8
Diabetes and defects in metabolism
26,2
Illnesses of the locomotive organs
16,6
Psychological, Psychiatric, Neurological and Stress-related Illnesses
16,1
Flu
12,1
Allergies
10,9
Bronchial illnesses
8,6
Infectious diseases, hepatitis, TB and AIDS
6,3
Bad lifestyle, obesity
6,2
Alcoholism, smoking, drug abuse
4,6
Stomatological problems
1,4
Skin diseases
0,9
Gynecological illnesses
0,8
source: FOCUS, January 2004

27. Categorisation criteria (§ 9)
The categorisation of diagnoses takes into consideration:
the seriousness of the illness,
the ability of diverse groups of patients to cofinance their treatment*
* - the amount contributed by the insured can depend on symptoms, age and the priorities of health policy.

28. Catalogues of actions
Establishment of a standard diagnostic and therapeutic procedure (Act on Health Care)
Actions leading to the diagnosis of illness (diagnostic actions)
ILLNESS
Actions leading to the cure of illness (treatment actions)

29. - actions partly covered
Categorisation model
ACTIONS 1 2 3
...
cca 9 000
ILLNESSES
- actions fully covered
- actions partly covered
- actions not covered

30. Social Balance The amount that citizens contribute does not change,
but the structure of expenditure changes
according to priorities.

31. Categorisation Model in Use1 2 3
...
cca 9 000
ê ê PARLIAMENT ê ê
Critical risks:
financial protection of patients against the risk of high costs
urgent treatment
chronic illnesses
ILLNESSES

High level of cofinancing  
insurers 5

Low level of cofinancing

Optimal level 
Cofinancing 
 3 3
the ministry
experts
- payment by pulic insurer
- cofinancing by patient

32. Patient's responsibility
Specification of the patient's responsibility for prevention and adherence to the treatment programme
The health insurer has the right
To enforce claims against the insured for repayment of costs of health care where it was demonstrably provided as a result of a breach in a treatment programme or the use of an addictive substance,
To pay the insured partial costs corresponding to the cofinancing by the patient if the insured regularly receives a preventative check-up, innoculations and follows a healthy lifestyle.

33. Role of political decisions
What resources?
Increase effectiveness and
decrease the expectations of citizens
Efficiency
Netherlands
Slovakia
What benefits ?
1,000
0,612

34. NEW PLAYERS Supervisory office Health insurer Scope
Finances
HI Supervision
HI Supervision
Health insurer
Finances
Providers
of Health Care
Scope
Permission
Licence
Regional govt., SR MH
Prof. Bodies
Finances
Permission
Licence
Emergency services

35. ... ??? ...
We're lucky that the hole is not on our side

36. THANK YOU FOR LISTENING
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