In 2023, total out-of-pocket spending (OOP) in Slovakia reached EUR 1.7 billion EUR, and just over 18% of current heealth expenditure. At the same time, OOP payments are legally inconsistent, economically inequitable and lack transparency (see Table 1). Analysis of OOP spending reveals several key issues:
Low transparency and information asymmetries
Patients often do not know what exactly they are entitled to, do not understand the differences between a fee and a co-payment, or betweenstandard and above-standard service. Patients are often not informed by providers of these differences. Patients are often not issued receipts in practice, further reducing transparency.
There is also a variation in patients‘ readiness to pay, with some unwilling or unable to do so. Some are unwilling based on the principle of free healthcare at the point of service, while others, especially in poor regions, simply cannot afford to pay. There are also those willing to pay OOP, giving them priority and more adequate consultation times, scheduled appointments, and an individual, higher-quality approach.
Gaps in regulation, inconsistent approaches and legal uncertainties
There legal uncertainty surrounding the interpretation regarding providers’ ability to charge fees. After approximately 600 amendments since their adoption, laws 576, 577, and 578 of 2004 (core laws underpinning the major 2004 health system reform) create contradictory motivations for providers.
As stated by providers, a main reason for rising fees is due to insufficient reimbursements from insurers, leading them to seek alternative sources of funding to try to maintain levels of care quality. Other given reasons include rising staff wages (especially in public hospitals), the introduction of a transaction tax, general inflation across the economy and increasing energy costs.
Beginning in 2006, legal restrictions against direct payments were introduced. However, in practice, a chaotic “fee jungle” has emerged, with exploitation of numerous legal loopholes. This is also reflected in the varying levels of patient information (differing communication and price list publication methods), reducing predictability of patient costs.
Furthermore, the absence of regulation has led to variability in the fees charged among providers even within the same specialty. Price lists reveal regional differences: the highest charges are in Bratislava (sometimes multiple times higher), while in smaller towns or rural areas, fees tend to be lower or nonexistent.
Finally, an outdated performance catalogue does not reflect technological progress nor current market prices for materials. Notably, the catalogue was originally intended as a tool for introducing innovation (for example, telemedicine, AI, interventional radiology), not solely as a pricing mechanism.
Table 1: Legislative anchoring of direct payments and their relationship to public health insurance
| Occurrence of direct payment | Purpose of direct payment | Legislative basis |
| Before provision | Patient management | Act 576/2004 allows for charging for services beyond standard public coverage. However, annual care program services may be covert payments for services that should be free (Act 577/2004 prohibits fees for appointment scheduling, priority treatment, and administrative tasks). There are often collected by intermediaries (not the providers themselves); the healthcare service itself is reimbursed by an insurer. |
| Reservation portal | Legal loophole: current laws prohibit providers from charging for scheduled appointments.
Exploited by third-party private companies offering booking systems independent from the state and healthcare providers. | |
| During provision | Fees for services related to care provision. | Regulated in §38 of Act 577/2004 in which Slovakia’s Constitutional Court confirmed that such charges are constitutional. |
| Co-payments for medicines, medical aids, durables and materials and dietetic food | Yes, most clearly regulated type.
Defined entitlements and transparent costs for both insurer and patient. | |
| Direct payments to non- contracted providers | Governed by commercial code | |
| Price list fees | Partially regulated: not clearly defined in Act 577/2004 and indirectly referenced in Act 578/2004 requiring a public price list submitted to regional authorities Legally questionable in some cases (e.g., booking fees, prescription printing, spa referral), and often charged due to outdated reimbursement catalogue or lack of coverage in practice. | |
| After provision | Second opinion | While not explicitly defined in law or reimbursement systems, this is usually billed to insurers as a regular consultation or repeat exam. Sometimes charged separately, especially for advisory consultations. |
Source: Pažitný et al. 2025
An examination of the health financing in Slovakia’s specialized outpatient care sector reveals a fragmented landscape of patient cost sharing and direct payments. Legal ambiguity, regulatory inconsistency and increasing financial burdens for patients create significant challenges for fairness, transparency and sustainability. Key areas for reform, not only to simplify rules and protect patients but also to restore trust and ensure long-term sustainability of the health system could include the following:
- Legalizing all types of co-payments – being clearly defined in Act 577/2004 and making any fees and co-payments transparent and understandable.
- Extend informed consent – informing patients of the amount in advance and for what service they are paying.
- Issue receipts for every healthcare service provided – an invoice showing exactly what services were provided, and what is paid by the insurer and what by the patient.
- Health insurers must be involved – informing insurers about any patient charges collected by providers.
- Introduce effective financial protection via co-payment limits – with eligible populations clearly defined.
- Shift the control of patient charges to regional authorities – via legislation to allow them to define scope and amount of allowed fees locally.
- Creation of a reimbursement mechanism to help cover some administrative costs – with the involvement of the Slovak Social Insurance Agency, health insurers and providers