Countries covered by the HSPM platform

15 August 2025 | Country Update
Slovakia’s €2 billion ambulance tender sparks political and legal turmoil
15 August 2025 | Policy Analysis
Out-of-pocket payments in Slovakia reach EUR 1.7 billion with very low transparency and high legal uncertainty
16 February 2024 | Policy Analysis
Slovakia’s Health Care Surveillance Authority’s lacking institutional stability and independence

7.1. Stated objectives of the health system

Set out in the Slovak Constitution and a variety of legal acts, the health system should ensure universality, equity and free access to health services at the point of delivery. Interpretation of these objectives depends heavily on the ideological orientation of the government in charge. Additional guidance for Slovak health policy comes from the Strategic Framework for Health 2014–2030 which influences the long-term direction of Slovak health policy by defining goals and priority areas. Prior to the Framework, decisions were made without a comprehensive assessment of health needs (see section 2.5).

The government that took office in March 2016 further emphasized the importance of access to care without cost-sharing. Its manifesto on health care consists of the following:

the patient should come first: ensure solidarity, shorten waiting times and improve equality of access;
improve transparency: ensure trustworthy and transparent hiring and procurement process;
improve effectiveness of spending: improve cost-effectiveness of care, rationalize the network of providers, implement e-health and DRG;
improve credibility of health care professionals: create payment structures that better align to goals and improve clinician training and education; and
modernize the health care infrastructure and ensure that sufficient resources are allocated for continuous improvement in the future.

The new government also pledged to prepare a new strategy for the health care system up to 2030, even though the Strategic Framework is still in place.

Slovakia is facing a major public procurement controversy involving the tendering of its emergency medical services. The EUR 2 billion contract, covering both ground and air ambulance operations from 2025 to 2031, has become the largest healthcare tender of the current government – and is now mired in allegations of cronyism, lack of transparency and possible breaches of procurement law. Political tensions, media scrutiny and prosecutorial involvement have converged to make this one Slovakia’s most significant governance crises of 2025.

Tender overview

The Operational Centre of the Emergency Medical Service, on behalf of the Ministry of Health, launched the tender to allocate licences for 344 ground ambulance stations and 7 air ambulance bases nationwide in May 2025. The aim was to ensure the provision of high-quality, continuous emergency services across Slovakia. The winning bidders would secure operational rights for a six-year period, with the contract value estimated at EUR 2 billion (The Slovak Spectator, 2025a).

Transparency concerns

Criticism quickly emerged from opposition parties, the Slovak Medical Chamber and transparency watchdogs. They highlighted opaque selection procedures, including a refusal to disclose the names and qualifications of tender committee members.

In July 2025, preliminary results of the tender and the names of the commission members were leaked to the media, which confirmed concerns about poor transparency and fairness of the tender (The Slovak Spectator, 2025a).

One particularly contentious claim is that the tender process might be structured to favour certain bidders, notably Agel SK, Slovakia’s second-largest private healthcare provider, and a relatively unknown entrant, Emergency Medical Solutions (EMS). Both have reportedly been in positions to gain a disproportionately large share of contracts (The Slovak Spectator, 2025b). EMS was later proven to be linked to the second largest coalition party, HLAS-sociálna demokracia, which also nominated (as of this writing) incumbent Minister of Health, Kamil Šaško.

As a consequence, on 8 August 2025, Penta Hospitals, Slovakia’s largest private healthcare network, withdrew its bid, citing serious concerns over transparency and suggesting possible breaches of EU procurement law (The Slovak Spectator, 2025b).

The Slovak National Party (SNS), another governing coalition partner, demanded not only the cancellation of the tender but also the resignation of Health Minister Šaško. Prime Minister Robert Fico publicly acknowledged that the process could be scrapped or restarted if doubts persisted (TASR, 2025).

The General Prosecutor’s Office, led by Maroš Žilinka, initiated a preliminary review into the tender process. This action signals potential criminal investigations for alleged mismanagement of public funds and violations of procurement rules (The Slovak Spectator, 2025b).

Nevertheless, the management of the Operational Centre of the Emergency Medical Service delivered the results of the tender to the Ministry of Health on 11 August, thereby de facto announcing the successful selection procedure. On the same day, Minister of Health Šaško, announced that he would not sign it and would cancel the tender procedure, and would come up with an alternative for procuring emergency services in Slovakia, pending agreement within the governing coalition. Conclusions of such discussions are expected by the end of August 2025.

The opposition and experts claim that Health Minister Šaško could not terminate the tender and did so in violation of the law, which may cause the bidders to suffer lost profits, and are therefore demanding his resignation (TASR, 2025b).

Authors

Martin Smatana

References

The Slovak Spectator (2025a) News digest: Unqualified officials, secret committees. Ambulance tender raises red flags. SME.sk. Available at: https://spectator.sme.sk/politics-and-society/c/news-digest-unqualified-officials-secret-committees-ambulance-tender-raises-red-flags (Accessed: 15 August 2025).

The Slovak Spectator (2025b) News digest: Ambulance tender turmoil – Penta walks, prosecutor limbers up. SME.sk. Available at: https://spectator.sme.sk/politics-and-society/c/news-digest-ambulance-tender-turmoil-penta-walks-prosecutor-limbers-up (Accessed: 15 August 2025).

TASR (2025) Ambulance tender scandal: Political pressure mounts, PM and SNS weigh in. TASR. Available at: https://www.tasr.sk/tasr-clanok/TASR%3A2025080700000344 (Accessed: 15 August 2025).

TASR (2025b) According to Šaško, the tender for ambulances was cancelled in accordance with the law. “Anyone who questions this is lying”, he said. PRAVDA. Available at: https://spravy.pravda.sk/domace/clanok/763156-sasko-tender-na-zachranky-bol-zruseny-zakonnym-sposobom Accessed: 15 August 2025).

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.
Before provision	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

Authors

References

Pažitný, Kandilaki, Macko-Forgáčová, Löffler, Zajac: Direct Payments in Specialist Outpatient Care in Slovakia, June 2025

Smatana, M. et al. (2025) in press. Slovakia: health system review 2024. Health Systems in Transition

The Health Care Surveillance Authority (HCSA) plays an important regulatory role in the Slovak health system. Responsible for supervising health insurance, purchasing and healthcare markets, HCSA chairs are elected for five-year terms and are theoretically independent, given an irrevocable mandate as chair. This independence was written in the original legislation from 2004 that specified that a chair’s mandate could only end due to their own resignation, by power of the government (only after the chair committed an intentional crime) or the chair died.

Successive governments over the past two decades, however, have worked to install chairs corresponding to their particular (political) needs, given the prominent role the HCSA plays in regulation. Thus, through the years, changes of chair have become common after legislative amendments to §22 of Act 581/2004, the law that defines the conditions of a chair’s appointment and the revocation process (for example, clauses permitting the removal of the chair were added regarding subjective evaluations of the chair’s performance, or general (subjective) views of the Government that the chair cannot complete the mandate due to personal, moral or professional reasons). Since the establishment of the HCSA 20 years ago, not one of the seven chairs have served a full term (see Table 1): their mandates were either revoked (3x) or they resigned on their own (4x).

As no chair has served a full term, the record of longest term was Monika Pažinková, who served 75% of her term (2012–2016), while the shortest was under the first chair, Alexandra Novotná (2004–2005). Additionally, and crucially, the HCSA had no chair from the end of 2019 through the first year of the COVID-19 pandemic, a total of 553 days. Chairs are typically changed following parliamentary elections, so there is little overlap of incumbent chairs continuing to serve in a new government, even if their term is ongoing. There have also been four instances of new HCSA chairs coming into office within the first five months after parliamentary elections.

The four cases of chairs withdrawing from leading the HCSA include:

Alexandra Novotná served for 150 days in 2005 (8% of the planned mandate duration). After establishing and stabilizing the institution, she relinquished her position to the State Secretary of the Ministry of Health, Ján Gajdoš, who decided to assume the role he had originally planned to take. As a result of her resignation, a position exchange occurred with the then-State Secretary, Ján Gajdoš [1].
Ján Gajdoš after 703 days in 2012 (39% of planned term). His resignation came in reaction to an amendment of law 581/2004 that once again enabled the Minister of Health to remove the chair of the HCSA. Gajdoš cited disagreements with the politicization of the office of HCSA Chair and a de facto subordination to the Ministry of Health [2].
Monika Pažinková after 1368 days in 2016. Pažinková became a symbol of patronage in office, being closely connected to businessmen from the city of Košice and the Smer political party [3].
Tomáš Haško after 1269 days in 2019 because of irregularities in tender process for emergency vehicles that he oversaw [4].

The three cases of governments revoking mandates for HCSA chairs include:

Ján Gajdoš after 663 days in 2007. While the Health Minister at the time (Valentovič) stated Gajdoš’ dismissal was the result of the office's performance given the state of healthcare in Slovakia at the time, Gajdoš himself considered it to be political, not professional [5].
Richard Demovič after 1310 in 2010. He was dismissed by Health Minister Uhliarik using the same reasoning (poor performance) [6].
Renáta Bláhová after 1013 days in 2024. The Health Minister’s (Dolinková) dismissal justified this by saying that Bláhová does not meet the qualifications to be chair as required by law and that she is a political nominee, appointed to the position of chair without a selection process [7].

Increasing the institutional stability and independence of the regulatory frameworks (see for example, Balík (2012 [8])) and environment in Slovakia requires

reestablishing the HCSA Chair’s independence by abolishing the legislative clause on their removal by the government without formal reason,
strengthening the competences of the HCSA’s Board by transferring the decision-making powers from the chair, making the HCSA a collective decision-making body and not a single “one-person show”, and
transferring the HCSA’s supervisory role over health insurance companies (HICs) to the National Bank of Slovakia and thus fulfilling an initial plan from 2004 when the HCSA was established.

The National Bank of Slovakia is an independent financial institution that could effectively supervise the financial situation of HICs. This would achieve the diversification of authority and preserve independence and resistance to political power, which is characteristic of regulators in other countries with competition-based systems (that is, multiple health insurers), like Germany (Federal Office for Social Security [9] and Federal Financial Supervisory Authority [10]), Switzerland (the Federal Office of Public Health [11] and the Financial Market Supervisory Authority (FINMA) [12]) and the Netherlands (The Dutch Healthcare Authority [13] and the Netherlands National Bank [14]).

Table 1