-
22 July 2024 | Country Update
Political interference in the Slovak health system -
05 January 2020 | Policy Analysis
Tender for ambulant service providers went sideways
7.6. Transparency and accountability
Transparency in the health care sector is one of the most important issues in Slovakia and was one of the key topics of the election campaigns in March 2016. However, the concept of transparency is limited to the procurement process of the public sector and less attention is paid to the process of policy-making.
There is low accountability in the health system because few outcomes are measured. The key document that sets system goals is the Strategic Framework for Health 2014–2030. However, since there is no comprehensive monitoring that would ensure up-to-date information about the impact of various policies on these goals, it has very limited impact on the accountability in the system.
The Slovak population regards corruption as the third most important issue (FOCUS, 2015). Corruption was preceded only by unemployment levels and standards of living. The health care sector was identified to be the area with the highest prevalence of corruption (see Fig7.12). In 2015, 64% of respondents believed that corruption in health care was very prevalent, compared to only 2% who believed that corruption in health care was non-existent. These values have remained fairly constant since 1999, which indicates that corruption in health care is a long-term unresolved problem (FOCUS, 2015).
Fig7.12
Presumably, there are two key reasons for this public perception: first, levels of informal payments, and second, inadequate competition in public procurement which often leads to higher spending and public scandals.
Nearly 22% of respondents confirmed that they made informal payments. The key reason was to ensure better care (FOCUS, 2015) (see Fig7.13). Of these payments, 43% amounted to €25, 17% to €26–€50, 11% to €51–€100 and 12% more than €100. In 32% of these cases, the payment was provided to a GP, followed by to a general surgeon in 25% of cases.
Fig7.13
A 2013 survey among 1181 respondents concluded that roughly 71% of interviewees provided an informal payment in any form (not only financial), whereas 18.5% encountered demanded corruption (i.e. a provider demanded informal payment). About 23.5% of respondents provided an informal payment to a doctor as a “gratitude gift” (see Table7.8).
Table 7.8
According to INEKO and Transparency International Slovakia (2015), the second reason for poor perception of transparency of the Slovak health care system stems from the fact that 63% of procured volume (i.e. €331 million during April 2012–February 2014) was based on single bidder procurements (see Fig7.14). In fact, an average weighted number of bidders in the health care sector was 1.9 for 2013 (5.7 below Slovak industry average) (Zachar & Dančíková, 2014). INEKO further calculated that if these one-bidder procurements had two bidders with at least some level of competition, hospitals could have saved 11.6% of resources devoted to one-bidder procurements (i.e. more than €34 million).
Fig7.14
These inadequate procurement procedures have led to cases where high prices were paid for procured items. This has led to regular media outcries that eventually forced the Minister of Health (2012–2014) to resign, along with several senior officers at the Ministry and in hospitals. Corruption in the health care sector has become one of the key election topics and is regarded as one of the reasons why SMER lost its majority in parliament after the March 2016 elections.
However, the accountability of the system remains insufficient. None of the individuals and companies associated with these cases was tried or found guilty. The new government, elected in March 2016, has pledged to focus on improving system accountability.
As explained in a previous policy analysis (https://eurohealthobservatory.who.int/monitors/health-systems-monitor/analyses/hspm/slovakia-2016/slovakia-s-health-care-surveillance-authority-s-lacking-institutional-stability-and-independence), the Health Care Surveillance Authority (Úrad pre dohľad nad zdravotnou starostlivosťou in Slovak) plays an important regulatory role in the Slovak health system and is responsible for supervising health insurance, purchasing and healthcare markets. As with previous governments (no chair of the Health Care Surveillance Authority has served a full term since its establishment in 2004), the current government led by Prime Minister Robert Fico with Minister of Heath Zuzana Dolinková have politicized the role of the Authority’s chair. In February 2024, they used legislative amendments to §22 of Act 581/2004 to remove the then-incumbent Renáta Blahová.1, 2
More recently, the Fico government has adopted legislation to take effect on 1 August 2024 to change the criteria of who can serve as director of the National Institute for Value and Technologies in Healthcare (NIHO or Národný inštitút pre hodnotu a technológie v zdravotníctve), which was established in 2022 and is responsible for Health Technology Assessment in Slovakia. The new criteria specify that only a doctor or pharmacist could serve as head of the HTA agency (leading to the dismissal of the current head, Michal Staňák); the legislation also enables the Minister of Heath to dismiss the agency’s director at any time and without cause.
Besides the political sphere pushing itself into the decision-making levels of these two seemingly independent organizations within the health system, the current government has also used their existing authority to make the following changes in healthcare institutions and providers around the country since coming into office in October 2023 (the dates refer to when the officials were dismissed or replaced):
- Tomáš Janík, director of Faculty Hospital Trenčín, 14 November 2023.3
- Vladislav Šrojta, director of Faculty Hospital Trnava, 30 November 2023.4
- Pavol Bartošík, general director of Central Slovak Institute of Heart and Vascular Diseases (Stredoslovenský ústav srdcových a cievnych chorôb), 5 December 2023.5
- Ľubomír Šarník, director of Faculty Hospital Prešov, 6 December 2023.6
- Jozef Tekáč, director of Faculty Hospital Poprad, December 2023.7
- Eduard Dorčík, director of the hospital in Žilina, December 2023.8
- Peter Potůček, director of State Institute for Drug Control (Štátny ústav pre kontrolu liečiv), 31 December 2023.9
- Ľubica Hlinková, general director of VšZP (Všeobecná zdravotná poisťovňa), the state-owned Health Insurance Company, 10 January 2024.10
- Peter Lukáč, director of National Centre for Health Information (Národné centrum zdravotníckych informácií), 10 January 2024.11
- Ivan Kocan, director of University Hospital Martin, 10 January 2024.12
- Július Pavčo, director of Emergency Medical Service Operations Centre (Operačné stredisko záchrannej zdravotnej služby), 31 January 2024.13
- Renáta Blahová, Chair of Health Care Surveillance Authority, 6 February 2024.14
- Michal Fajin, director of Faculty Hospital Nitra, 14 February 2024.15
- Matej Mišík, chief of the Institute for Healthcare Analyses (Inštitút zdravotných analýz) at the Ministry of Health was revoked on 20.6.2024 without any reason. The Institute focuses on: epidemiological studies and data analysis, sector analysis and health policies, implementation of optimization of the hospital network and the development of the DRG reimbursement mechanism.16
- Michal Staňák, director of NIHO, according to legislation set to take effect on 1 August 2024, enabling the Minister of Health to dismiss the NIHO at any time and without giving a reason. The Ministry of Health has already published the announcement for the selection procedure for the position of the new director.17
Authors
References
1. https://spectator.sme.sk/c/23346445/slovak-health-minister-direct-power-independent-body.html
5. https://www.health.gov.sk/Clanok?mz-suscch-vedenie-nove
6. https://domov.sme.sk/c/23281567/fajin-nemocnica-nitra-dolinkova-pellegrini-hlas-rozhovor.html
7. https://domov.sme.sk/c/23272033/zuzana-dolinkova-zdravotnictvo-nemocnice-cistky.html
8. https://dennikn.sk/minuta/3744432
11. https://zive.aktuality.sk/clanok/SdYXsqi/odvolali-riaditela-nczi-kto-bude-na-cele
13. https://www.health.gov.sk/Clanok?operacne-zachranka-riaditel
14. https://www.tyzden.sk/zdravotnictvo/106251/vlada-odvolala-sefku-udzs-na-jej-miesto-zasadne-palkovic
15. https://domov.sme.sk/c/23281567/fajin-nemocnica-nitra-dolinkova-pellegrini-hlas-rozhovor.html
Licences for providing ambulance and emergency care services (EMS) are issued every 6 years and reimbursed by a fixed monthly payment after winning a public tender. In total, 328 EMS stations are subject to a public tender, done by the HCSA in summer 2019. The MoH could not undertake the procurement, given the fact that some of the current EMS are state-owned (Kosice and Bratislava). The total worth of the 6-year contract exceeds 800 mil. EUR.
However, the procurement committee comprised several members who were in direct conflict of interest with the most successful tenderee, the private company LSE ambulances which won 107 licences. As a result, the head of the HCSA resigned in autumn of 2019, but licenses could not have been revoked. Consequently, the bureau of public procurement started an audit and asked the EU commission for an official statement (likely a fine for breaching law of public procurement). The newly licenced providers of EMS are to deliver services from 2020 onwards. The current largest private provider, Danish Falck company did not participate in the tender and left the Slovak healthcare system.
Authors
References
Filo and Krempaský (2019) Kalavská po zisteniach SME navrhla odvolať šéfa úradu pre dohľad Haška (Kalavaska proposed to fire a chief of healthcare surveillance authority). Available online: https://domov.sme.sk/c/22228703/kalavska-po-zisteniach-sme-odvolala-sefa-uradu-pre-dohlad-haska.html
Trend (2019) Falck končí so záchrankami a odchádza zo Slovenska (Falck will not operate emergency services and leaves Slovak market). Available online: https://www.etrend.sk/firmy/falck-konci-so-zachrankami-a-odchadza-zo-slovenska.html