European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Slovakia

3.4 Out of pocket payments

Private expenditure comprised approximately 25% of total health expenditure (€1460 million, according to national accounts) in 2014. It is primarily composed of private households’ cost-sharing (90% of total expenses are OOP payments). OOP payments in Slovakia mainly consist of (1) co-payments for prescribed pharmaceuticals and medical durables; (2) user fees for various health services, stomatology care and spa treatment; (3) direct payments for OTC pharmaceuticals, vision products and dietetic food; (4) above-standard care, preferential treatment and care not covered by SHI; and (5) a few standard fees – for 24/7 first aid medical services (€1.99), ambulance transport (€0.07/km), for prescriptions (€0.17), for accompanying people during a hospital stay (€3.32), as well as for food and accommodation in spas (€1.66 or more per day). See Table3.8 for a comprehensive overview.

The Slovak system supports underprivileged residents in the form of maximum limits for co-payments for prescribed pharmaceuticals, waiving of ambulance transport fees for chronically ill, and a wide range of medical devices with individually reduced cost-sharing. Moreover, around one-third of all reimbursed medicines have no co-payment.

In 2014 Slovakia had a share of 22.6% of total health expenditure paid out of pocket. As illustrated by Fig3.9, the level of OOP payments grew from 2004 to 2007. This was the result of a tax policy change (an increase of VAT on pharmaceuticals from 10% to 19% over 2003–2005) and the introduction of a variety of co-payments. Other reasons for increasing OOP expenditure were higher spending on OTC drugs and new products offered in pharmacies, increased use of private providers, and an increase of different fees for non-standard health care services.

It is important to note that the provided OOP expenditure is based on estimations, as indicated in Box3.1. The methodology of the Statistical Office of the Slovak Republic for calculating OOP expenditure also includes, besides co-payments for prescribed drugs, items that are sold in pharmacies but are only marginally health-related, e.g. decorative cosmetics. However, due to the technical limitations of reporting receipts to the Ministry of Finance, these items cannot be split from medicine expenditure. This may overestimate OOP expenditure in Slovakia (see Box3.1 for more information). On the other hand, OOP expenditure may be underreported given the weak reporting legislation for non-standard services by ambulatory and hospital visits, which include for example different administrative fees, booking of the exact time of appointment, and specialists’ examinations without referral from GPs. However, the providers are not obliged to report the entire sums of these payments.

Additionally, the Statistical Office overhauled the methodology of reporting private expenditure in 2010. This caused a significant reduction in private expenditure and a consequent decrease in the proportion of private expenditure. However, the office did recalculations only from 2011 onwards.

3.4.1 Cost-sharing (user charges)

A variety of policies were adopted to contain the increase in cost-sharing, such as the de facto abolishment5 of co-payments for outpatient care and hospital stay or lowering co-payments for prescribed medicines. Nonetheless, the proportion remains high, since most OTC drugs are not regulated and a small number of services (e.g. dental care or ophthalmology care) remain cost-shared, along with some anchored fees for emergency services, receipt processing, ambulance transportation and spa treatment. Table3.8 gives an overview on current cost-sharing in Slovakia.

5 Co-payments have never been abolished in practice, but their value was set in legislation to zero.

3.4.2 Direct Payments

Direct payments in the Slovak health sector comprise mainly payments for OTC pharmaceuticals and dietetic food and care not covered by SHI.

In 2015 the Ministry of Health introduced new legislation restraining possibilities for providers to charge for health care and health-related services. This was a response to the fact that although cost-sharing for medical services was regulated gradually, the providers were free to charge fees related to care (e.g. a payment for air conditioning in the waiting room, a payment for administrative tasks, payment for printed documents, etc.). These payments were identified as one of the key drivers of increasing OOP expenditure but were virtually outside legislative control. The new legislation since 2015 defined which nonmedical services can be charged for and enforced greater control by the SGRs. A brief overview of some of these direct payments is given in Table3.9. However, the legislation has been heavily criticized by health professionals and the public, as well as the media, and an amendment is planned during 2016.

3.4.3 Informal payments

According to a survey by Mužík & Szalayová (2013b), 71.4% of respondents (843 out of 1181 respondents) reported making an informal payment in the form of cash or presents. More up-to-date research by Transparency International did not confirm this high percentage, but concluded that almost 27% of respondents made informal payments. The total value of such payments is virtually impossible to estimate (Transparency International Slovakia, 2015).

Private expenditure comprised approximately 16.9% of the total health expenditure (estimated 952 million EUR, according to national accounts) in 2017. Slovakia had an estimated share of 15.27% of total health income paid from OOP.

There has been controversy about the underlying methodology to capture OOPs in Slovakia for years and criticism towards the Statistical Office to overstate OOPs. This has been tackled by two consequent corrections: 1) In 2010, the Statistical Office overhauled its methodology and re-calculated OOPs accordingly for 2011 and onwards; 2) In 2017, the Statistical Office corrected for receipts sent to the Ministry of Finance (therefore switching to the “household account” methodology) for  2015 and onwards. 

This resulted in a sharp decline of reported OOP payments to international databases like WHO and Eurostat. For instance, according to the old methodology OOP amounted to 1345,5 mil EUR in 2015, whereas the corrected value was by more than 500 mil EUR lower. In 2016, the old methodology resulted in a total of 1607 mil EUR for OOP, whereas the new methodology is capturing only 849 mil EUR as OOP.