2.3. Organization

Health policy results from the interplay between the Ministry of Health (legislator), HICs (purchaser), health care providers, professional organizations and the HCSA (supervisor). Patient organizations have little influence on the formulation of health policy. The state owns the largest hospitals and the largest HIC.

2.3.1. The role of the state and its agencies

Parliament

The parliament has legislative as well as control powers and may carry out parliamentary inspections. The members of the supervisory board of the HCSA are elected by the parliament.

Government

The competences of the government are approving the budgets of HICs, adopting legislative measures (defining user fees for services related to health care, setting co-payments, determining accessibility parameters for minimum provider networks), and appointing/removing the chair of the HCSA.

Ministry of Health and other ministries

The Ministry of Health is a central administrative body and its responsibilities include drafting health policy and legislation, regulating health care provision, managing national health programmes, participating in management of health education, managing national health registers, determining the scope of the basic benefits package, defining health indicators and setting minimum quality criteria. Competences in price regulation were transferred to the Ministry of Health in 2003. Furthermore, the state is an owner of university hospitals, faculty hospitals, specialized national centres, sanatoria and the largest HIC. This leads to a conflict of interest because the state sets and regulates the framework in which several institutions that it owns operate (e.g. one HIC and several providers).

The management and supervision of health education and the curriculum are shared between the Ministry of Health and the Ministry of Education, the latter being responsible for financing. The Ministry of Health coordinates health research in schools and the Academy of Sciences. This shared competence often leads to confusion. In addition, the Ministry of Finance has a strong influence on the health budget development process.

The organization and funding of social care is the responsibility of the Ministry of Labour, Social Affairs and Family. The social care system and the health care system evolved separately, leading to different organizations and sources of funding, even though many of the services they provide are practically identical. This may pose a barrier to effective solutions in the provision of long-term social care and health care (see section 5.8).

The Ministries of the Interior, Justice, Defence and Transport have established health care facilities, notably the Military Hospital in Ružomberok and St Michael’s Hospital operated by the Ministry of the Interior, and play a marginal role in health care provision.

Health Care Surveillance Authority HCSA

In 2004, to prevent further conflicts of interests, the monitoring and supervisory role of the Ministry of Health in the health system was transferred to the newly established HCSA. The HCSA is responsible for the supervision of health insurance, health care purchasing and health care provision markets (also see Fig2.2). Since 2007 the government has had the competence to withdraw the chair from office, and has used it twice; this competence compromises the independence of the HCSA. The HCSA’s supervisory board is elected by parliament. The HCSA has strong competences and can impose sanctions. This includes banning a health care provider or a HIC from the market. Furthermore, the HCSA grants market access to HICs after fulfilling certain conditions and supervises the fulfilment of these conditions (solvency, purchasing of health care services according to legal regulation of, for example, the compulsory network). The HCSA administers the risk-adjustment mechanism of financial resources between HICs and manages several registers. Other competences of the HCSA include administering patients’ complaints regarding inadequate health care provision and deciding on autopsies to be performed in forensic and pathological anatomy laboratories.

Fig2.2

The HCSA also acts as a liaison body for cross-border health care provision. The annual report describes the HCSA’s activities as well as social health insurance performance and is submitted to the government. An amount of 0.45% of contributions collected by HICs is allocated to funding the HCSA.

Since 2010 the HCSA has been further responsible for the implementation of a DRG system in Slovakia. Currently, the DRG system is in the last testing phase and is intended to become fully operational between 2016 and 2020.

Public Health Authority of Slovakia (PHA)

The PHA is responsible for public health tasks. It is a state budgetary organization, which means that it is fully financed from the state budget. It is managed by the chief hygienist, who is appointed by the Minister of Health. The PHA develops the vaccination schedule, directly controls radiation protection and issues permits for the sale of cosmetic products. Through its regional offices, the PHA carries out epidemiological surveillance, assesses the impact of environmental factors on health, issues approvals before putting any premises into operation and monitors the quality of drinking and bathing water. The PHA can impose sanctions if a violation of the regulatory framework is found (e.g. for avoiding mandatory vaccination).

State Institute for Drug Control (SIDC)

The SIDC, a state budgetary organization, is responsible for surveillance of medicinal products and medical devices. The SIDC issues approvals on clinical trials, grants marketing authorizations, assesses pharmacies and maintains a pharmacopoeia. The SIDC can also impose sanctions. In the area of patient safety, it performs assessment of reports on adverse drug effects (pharmacovigilance) and medical device failures. It withdraws or suspends medicinal products or medical devices from (entering) the market. The SIDC is, however, not involved in reimbursement decisions concerning pharmaceuticals or medical devices.

The SIDC also supervises the regulation of re-exports. Since 2013 permission to export drugs is tied to the obligation to report the planned drug export 30 days in advance to the SIDC. If the SIDC does not refuse the export, the distributor or producer has three months in which to realize the export. The actual exported volume of drugs must be reported to the SIDC within one week after the export. The SIDC may ban the export of a reported drug if the drug is scarce and its export would harm the availability of the drug in Slovakia (Szalayová et al., 2014).

Operational Centres of Emergency Medical Services (OC-EMS)

The National Emergency Centre of Slovakia is a state contributory organization, which controls all components of emergency medical services. Administratively, it is divided into headquarters and eight regional operation centres of emergency medical services, which are located in every region and form the control and coordination centre of the integrated rescue systems, together with focal points of the integrated rescue systems.

It is responsible for admission and processing all telephone emergency calls, as well as cooperating with all other components of the integrated emergency system. Operational centres issue instructions for the emergency medical services ambulance crew; manage, coordinate and evaluate the emergency medical service in order to ensure its smooth operation and continuity; provide training for employees; and organize first aid courses and first aid instructor courses.

An amount of 0.35% of contributions collected by HICs is allocated to funding OC-EMS.

National Centre for Health Information (NCHI)

The Ministry of Health established the NCHI as a state contributory organization to deal with e-health issues, standardization of health information systems, and the collection, processing and provision of health statistics, as well as provision of library and information services in the area of medical research and health. The NCHI operates the national health registers.

Furthermore, the NCHI is responsible for the national health portal. It is expected to feature e-prescription, e-medication, electronic health records for citizens, and an electronic system to coordinate appointments with health providers, and the integration of these applications into one functional unit with a high level of security is the main priority. The implementation of the national health portal, however, has been delayed (see sections 2.7.1 and 4.1).

An amount of 0.41% of contributions collected by HICs is allocated to fund the National Health Information System.

National Transfusion Service (NTS)

The NTS is a state contributory organization established in 2004 by the Ministry of Health to carry out tasks related to the complex production of blood products, securing haemotherapy of the highest possible quality and safety of the required volume.

The purpose of establishing the NTS was that blood and its components, irrespective of their intended use, which are part of the blood transfusion chain have comparable quality and safety across all regions. The NTS has 14 offices all around Slovakia.

National Transplant Organization (NTO)

The NTO was established as a state contributory organization by the Ministry of Health in 2013. Its tasks include the national coordination of donations and transplantation of organs, tissues and cells, and maintaining the National Reference Laboratory for human leukocyte antigen (HLA). The NTO is responsible for running the national transplant register, which includes the maintenance of waiting lists for transplants of all organs, registering donors, keeping records of the activities of providers and procurement, and recording the activities of transplantation centres, including aggregated numbers of donors, and the types and quantities of organs procured, and transplanted organs, tissues and cells. In 2014 its total budget accounted for roughly €300 000.

2.3.2. The role of health insurance companies (HICs)

HICs play a key role in the system as purchasers of health care services. It is their legal duty to ensure health care for their insured. Purchasing is based on selective contracting. Each HIC is allowed to develop its own payment mechanisms and set up its own pricing policy towards contracted providers. The contractual relations between health insurance companies and health care providers are supervised by the HCSA (see section 3.3.4 for more information on the contracting criteria of HICs).

All HICs are joint-stock companies and are obliged to meet solvency criteria. This should guarantee scheduled payments within 30 days after the issuing of a provider’s invoice. Ownership regulation allows both the state and the private sector to be shareholders of the HICs. Although there were seven HICs in 2006, a wave of mergers led to increased consolidation in the market (see also section 2.8.1). In 2016 there are three HICs left: the state-owned Všeobecná ZP (later called General HIC), and two privately owned companies: Dôvera and Union (see Table2.1). Representatives of HICs are seated in ministerial committees. These committees define the basic benefits package (i.e. the health services covered by SHI), and participate in draft legislation.

2.3.3. The role of self-governing regions (SGRs)

Certain local operative competences were transferred from the state to the eight SGRs to decentralize power. The SGRs’ responsibilities include issuing permits for the operation of health care facilities, appointing ethical committees, issuing approvals for outpatient biomedical research, maintaining health documentation following the cessation of providers and securing health care provision resulting from a provider’s temporary hold of permit or licence. The Ministry of Health deals with appeals against decisions made by the SGRs. The SGRs also assist in improving the network of providers in case the accessibility of health services in the region is deteriorating; for example, by appointing a physician when patients have difficulties receiving and finding treatment.

SGRs took over the responsibilities for health care provision surveillance and can impose sanctions on health care providers for neglecting their duties. Sanctions include financial penalties and temporary or permanent revocation of a licence. The power to ban a provider from the market is a strong legal instrument. SGRs will as a rule only impose sanctions after a recommendation from the HCSA, based on surveillance results and detected shortcomings.

The chief physician of the SGR is appointed by the chair of the SGR with the approval of the Minister of Health. The chief nurse, appointed with the approval of the Minister of Health, is responsible for nursing care provision and midwifery services.

SGRs own some health care facilities and can independently make decisions on the management of these facilities. Since responsibility for health care facilities was transferred to the SGRs in 2003 (also see section 2.4), some hospitals have been transformed either into joint-stock companies, not-for-profit organizations, or they have been fully privatized into commercial companies. Some of these health care facilities were rented out to private health care providers. SGRs have been negotiating the entry of other strategic investors into the health market.

The role of political parties and trade unions

Politicians manage and make decisions on the majority of resources in health care, not only at national level but also at regional and municipal level. The political interests of the parties vary regionally, and may also be influenced by lobbyist groups. The technical expertise of political parties in the area of health policy is generally low.

The largest trade union, with 40 000 members, is the Association of Health and Social Trade Unions. It negotiates collective contracts with the employers’ representatives. The Trade Union of Physicians is a smaller organization, which mainly becomes active to advocate financial interests.

2.3.4. Organizations of health care providers and professional associations

Organizations of health care providers and professional chambers promote and advocate the interests of their members in relation to the state, SGRs or HICs. They participate in draft legislation and educational programmes, and represent their members in contract negotiations with HICs. They maintain the register of health professionals and provide continuous education. Chambers also have competences such as granting licences and imposing sanctions. Since 2005 membership of chambers has been voluntary and the chambers cannot oblige non-members beyond the extent prescribed by law. Despite this fact, the oldest chambers (the Slovak Medical Chamber, the Slovak Chamber of Dental Physicians, the Slovak Pharmaceutical Chamber, and the Slovak Chamber of Nurses and Midwives) managed to keep a large member base, and thus constitute influential interest groups. The most significant organizations of providers are the Association of Hospitals of Slovakia, the Association of University Hospitals, the Association of Private Physicians of Slovakia and the Slovak Medical Union of Specialists.

The Slovak Medical Society is an association of professional medical and pharmaceutical societies, and regional associations of physicians and pharmacists, with almost 20 000 members. They focus on technical and ethical issues, as well as the dissemination of scientific knowledge. Professional societies within the Slovak Medical Society delegate their professionals to serve on different committees (such as the Reimbursement Committee for Medicinal Products and the Catalogue Committee for medical procedures at the Ministry of Health).

Private sector

Private businesses advocate their interests individually. Their common interests are represented by umbrella organizations, particularly from the pharmaceutical market: the Association of Suppliers of Drugs and Medical Devices (ADL), the Slovak Association of Medical Device Suppliers (SK-MED), the Slovak Association of Producers and Distributors of Diagnostic Medical Devices “in vitro” (SEDMA), the research-oriented Association of Innovative Pharmaceutical Industry (AIFP), and the Association of Generic Producers (GENAS).

Patient/consumer groups

Patient organizations vary in their activities. How active they are often depends on the efforts of dedicated individuals and the level of financial resources available. The groups, as well as their interests, are fragmented and they are represented by various umbrella organizations. Successful promotion of their interest is often hindered by the division of competences between health and social care. The issues of people with disabilities belong to the agenda of the Ministry of Labour, Social Work and Family. Most patient organizations, as well as organizations of people with special health care needs, directly approach the responsible ministry with their problems.

Patient organizations representing people with chronic conditions are the most active. These include the Union of Diabetics of Slovakia, the Slovak Association of Multiple Sclerosis, the Slovak Osteotomy Association, League against Rheumatism in Slovakia, the Club of Parents and Friends of Children with Cystic Fibrosis, and the Down Syndrome Association in Slovakia. Numerous educational projects aimed at oncological patients and their relatives, as well as the public, take place under the auspices of the League against Cancer, a charitable non-profit organization. Psychiatrists, psychotherapists and patient organizations cooperate within the League for Mental Health to actively advocate mental health promotion. The Association for Patients’ Rights Protection is active in the area of patient rights.

Patient organizations in Slovakia are relatively passive. In the period 2010–2012 only 14 out of 300 Slovak patient organizations commented on seven of the 110 legislative acts that were being discussed in this period, despite the fact that their comments were in 63% of cases regarded as substantial and 77% of them were accepted (Balík & Starečková, 2012).