5. Provision of services
key feature of the Slovak health system is the clear institutional separation between public health and the provision of health care services. Historically, the Slovak Public Health Authority was responsible for hygiene and sanitation, surveillance of communicable diseases, and environmental and occupational health. Since 2007 the Slovak Public Health Authority also assumed responsibility for health prevention and promotion with the rising prevalence of NCDs.
Primary care services are provided by physicians predominantly working in private practices. Patients register with a GP or a specialist of their choice. HICs are required by law to contract each GP and paediatrician licensed by the SGRs. Since 2013 patients need a referral by a GP to see a specialist. The many sub-specializations in secondary care have led to a fragmented system with prolonged length of care for patients with multiple morbidities. Slovakia has a high number of outpatient contacts despite decreases over the years (11.0 contacts per capita in 2013 compared to 13.6 in 2008). For specialist care, legislation defines a minimal number of doctors in each specialty, but ultimately the HICs determine the quantity of specialized health services by individually contracting them.
Inpatient care is provided in general and specialized hospitals, which are owned and managed by a range of actors, including ministries, regions, municipalities, private entities and NGOs. The Ministry of Health grants permits for specialized hospitals, while all other permits are given by the SGRs. In both cases, predefined requirements have to be met. Providers included in the minimum network of providers, defined by the Ministry of Health, are automatically contracted by SHI companies. All other inpatient providers need to fulfil criteria set individually by all SHI companies and agree on a contract.
Providers of emergency services are licensed by the Ministry of Health. Pharmaceutical care is largely regulated, but drug expenditure containment remains unrealized. Recently, the re-export of drugs has become challenging. The demand for long-term and palliative care has substantially grown, but the system still relies on informal care. The fragmentation of LTC over the social and health care systems remains an unresolved issue and has created confusion among patients and led to extra bureaucracy. The Slovak endowment of psychiatric beds is rising but is insufficient to cope with the increase in incidence of mental health disorders. Only some dental care procedures are fully covered by SHI, whereas the majority of procedures are partially or fully covered by the patient. Special programmes exist for the 10% Roma minority who experience poorer health and living conditions.
5.1 Public health
Public health operations are traditionally organized separately from health curative services and focus on the surveillance of communicable diseases. The Ministry of Health oversees the public health network in Slovakia, which is solely financed from the state budget. The PHA is the coordinating and supervising body of the network of 36 regional PHI throughout the country that act as executive bodies of the PHA. The PHA is headed by the chief hygienist, a post which is nominated and appointed by the Minister of Health.
The PHA conducts research, provides advice on methodology, and closely cooperates with the 36 PHIs in accordance with Act no. 355/2007. The PHA is also responsible for international cooperation in public health, initiating legislation (also harmonization with EU norms) and adopts measures for health promotion, health protection and disease prevention. The PHA has two main tasks that are kept separate.
- Firstly, it is responsible for monitoring environmental factors and population health status, as well as the promotion of healthy lifestyles through administration of prevention programmes for both communicable and noncommunicable diseases.
- Secondly, PHA focuses on epidemiological surveillance of communicable diseases and the health status of the population and conducting epidemiological and laboratory investigations. It also initiates containment or preventive measures as necessary. The PHA collaborates closely with the state veterinary authorities in incidences of food contamination and food poisoning.
Traditionally the PHA was mostly focused in the past on the second task, e.g. the prevention of communicable diseases, hygiene and sanitation. With the Act on Protection, Support and Development of Public Health in 2007 (Act 355/2007), the tasks of the PHA were broadened to reflect also the rising prevalence of NCDs.
This marked a substantial change in the PHA’s position and role. Given the high prevalence of NCDs (e.g. cardiovascular, oncological, metabolic and mental disorders, etc.), the new responsibility is of great importance to population health (see section 1.4).
With allocations less than 4% of the total health budget for public health, Slovakia has a comparable budget to other European countries (see Fig5.1). But a broader set of responsibilities coupled with a fixed budget (and a cut during the 2008 financial crisis) hindered progress in developing public health. The financial situation has been improving recently thanks to EU structural funding and linking new competences to financial means.
In the current strategic national health programme, an intersectoral approach of care for individual patients’ and population health involving all relevant public and private actors is a key priority. This requires active involvement of the population in public health programmes aimed at nonmedical prevention of diseases by mitigating risk factors. PHA-led activities include smoking cessation programmes, community care or people-centred projects. Additionally, dedicated programmes target worsening public health indicators of socially disadvantaged communities in Slovakia (see section 5.14).
The basis for this key strategic document was the health policy framework “Health 2020” provided by the WHO Regional Office for Europe in 2012, which guides policy-makers in priority setting for public health. The Strategic Framework for Health 2014–2030 lists three strategic objectives that need reform to meet common objectives. These include (1) improved health status and well-being of the population, (2) reduction in health inequalities, and (3) universal people-centred health systems that are sustainable, equitable and of high quality (see section 2.5).
Since 1991 a register for communicable diseases run by the PHA has been a part of the epidemiological information system of communicable diseases (EPIS) that supplies data to WHO and ECDC. This register is the focus of infection control for Slovakia.
Enforced since 1986, the National Immunization Plan aimed to eliminate and eradicate vaccine-preventable communicable diseases by targeting children. It is updated annually based on WHO recommendations and reported incidences in the previous year. Vaccination against diseases listed in the plan remains compulsory as stipulated by Act no. 355/2007. The current list includes vaccinations against diphtheria, pertussis, poliomyelitis, pneumococcal pneumonia, Haemophilus influenzae, type B viral hepatitis, rubella, morbilli and parotitis. Vaccines and vaccination under the valid immunization plan are fully covered by HIC.
Historically, vaccination rates against major communicable diseases varied between 98–99% and low or zero incidences of vaccination-preventable diseases have been reported. The last registered case of poliomyelitis was recorded in 1960 and of diphtheria in 1980.
Since 2012 vaccination rates have been falling (see Table5.1), driven by the Bratislava region, which recorded a low 90.1% MMR vaccination rate for 2015 (PHA, 2016). In 2014 a group of vaccination opponents filed a case against this compulsory vaccination at the Constitutional Court of the Slovak Republic. The court ruled in favour of maintaining the policy as it does not breach human rights to privacy and integrity, but protects public health. Thus, parents who refuse to have their children vaccinated can be penalized (SITA, 2014). Between 2013 and 2014 the PHA registered 6209 refusals of compulsory vaccinations, of which 369 cases were charged a fine (PHA, 2014). This represents a 263% increase in fines compared to 2012 (Krempaský, 2015).
In 2012 compulsory vaccination against tuberculosis was taken off the list after tuberculosis incidence reached an all-time low at 5.94 per 100 000 inhabitants. The current increase to 7.35 in 2013 is worrying and is driven by an outbreak among the Roma minority. The incidence of type A viral hepatitis (VH-A) continues to decline thanks to childhood vaccination of children living in communities with low hygiene standards. In recent years viral hepatitis C has been on the rise, especially among drug users. The cumulative number of HIV-infected persons since 1985 has plateaued at approximately 550, but a substantial increase of new cases in 2014 poses a challenge for the future.
Health promotion and prevention of major chronic diseases
The paradigm shift towards more health prevention and promoting healthy lifestyles to mitigate NCDs in Slovakia is laid out in Act no. 355/2007. In 2014 the National Health Promotion Programme (NHPP) was adopted by the government in an intersectoral approach to minimize risk factors and consequences of risk behaviour.
The NHPP, through cooperation with health service providers, HICs and other relevant institutions (e.g. patient organizations and relevant NGOs), aims at the continuous improvement of population health status (see Box5.1). Based on health monitoring of the Slovak population through various national surveys, two priority areas were formulated to align with current WHO and EU strategies (Health for All, Health2020, EU public health policy, etc.)
Implementation of these priority areas of intervention is realized through several national programmes and action plans, either on a regional level (children and adolescent health) or as an integral part of the Slovak-wide public health system. In priority area A, the chief activities are the National Action Plan for mitigating alcohol use and the Plan for tobacco control. In priority area B the National Plan for containing diabetes and cardiovascular diseases prevalence are the main tools. A full list is shown in Box5.2.
Additionally, screening programmes exist for cervical, breast and colon cancer. Screening rates in 2013 were around 48% for cervical cancer, and 38.9% for breast cancer (compared to over 80% in Slovenia, Denmark, Austria and the Netherlands) (OECD, 2015). A National Plan for Cancer is necessary to achieve comparable targets, but it is not yet developed. Costs of screening programmes are fully included in the Slovak benefits basket.
Health promotion counselling centres were established as an integral part of PHA and PHIs to advise on health risk factors, healthy nutrition and physical activity, smoking cessation, mental health and stress management, and occupational health. They also provide non-pharmacological treatment for early stages of NCDs, advise on environmental factors, quality of housing, drinking and recreational waters, and can provide flu vaccinations. In 2015 the centres saw 10 384 clients, of whom 5964 were first-time users of these services. Altogether, the centres have seen more than 230 000 patients since 1993 (PHA, 2016). These centres organize various events to raise awareness about specific public health problems. Because of insufficient state funding of the government-adopted health promotion and primary prevention programmes, the activities and campaigns are often conducted and co-financed in partnership with NGOs and the private sector.
Evaluation of the public health system after the 2007 reform
With the reorientation from communicable to noncommunicable diseases in 2007, a whole range of new competences, tasks and instruments were introduced. In 2013 an evaluation of the public health system in Slovakia was carried out in collaboration with the WHO Regional Office for Europe using the EPHO (European Public Health Operations) Tool, which mapped its strengths and weaknesses and proposed future measures (see Box5.3).
The evaluation proposed several measures to improve the public health system in Slovakia by strengthening the systematic monitoring of health, creating an independent institution for the coordination of health promotion and preventive programmes, and improving the educational standards of the public health workforce.