Slovakia’s major hospital reforms plagued by delays and controversies

Slovakia’s much-needed hospital reforms aim to create an optimised network of categorised hospitals in Slovakia, ensuring higher quality of provided health care for patients. However, the system is plagued by delays and controversies. 

The reform, officially called ‘Optimisation of the Hospital Network’, centres around establishing five categories of hospitals, each with clearly defined boundaries dictating the basket of medical services it should offer.

The five defined levels of hospitals do not determine their quality but rather the scope of healthcare services provided. Level 1 offers only basic services, such as same-day surgeries and community care, while a Level 5 hospital is meant to offer the most complex services in the country.

“The promise of creating the optimised hospital network was to increase the quality and safety for patients and to create pressure on hospitals to continually improve,” Dr Elena Marušáková, the vice-president of the Association for the Protection of Patients’ Rights in Slovakia (AOPP), told Euractiv.

Adapting to changing needs

The scope of each category was based on multiple criteria: the catchment area, the minimum number of procedures to ensure quality and safety, and expected demand.

In addition to the network itself, quality indicators (evaluated annually) and personal and technological requirements were also specified for every category to guarantee best practices and the highest standards of hospital care.

The legislation also establishes waiting lists, mandating maximum waiting times for almost 700 procedures in outpatient care.

This designated network of hospitals is not definitive, and mechanisms are set up to respond to changing population needs.

“We perceived the whole process from the beginning as very demanding and complex, which should be systematically perfected,” Marušáková added.

This comprehensive overhaul had been long overdue, spanning across multiple administrations and health ministers’ tenures.

“It was only thanks to the joint pressure of the European Commission through the Recovery and Resilience Programme and the gradually collapsing hospital sector that forced policymakers and politicians to lay legislative foundations for a full-fledged reform of hospitals in 2021,” health analyst Martin Smatana told Euractiv.

Implementing the network of categorised hospitals is one of the milestones of the Recovery and Resilience Programme. Despite the financial incentive, the reform encounters setbacks.

Delays

The legislation was adopted in 2021, with the intended proper launch of the reform planned for 2024.

“The details of the reform were defined in several decrees and methodological guidelines, which have been regularly updated since 2022 with an original aim to achieve a ‘hot’ start of the reform from 2024. The full-fledged start of the reform had to be postponed for both technical and political reasons,” Smatana explained.

As Euractiv already reported, the section of the reform on implementation of maximum waiting times has already been postponed from January 2024 to 2025.

Smatana added: “The actual categorisation of hospitals into tiers had a similar fate. The Ministry of Health did not have time to implement the process of categorisation of the lowest categories of hospitals (level one and two) in 2023, so the Ministry was forced to postpone the categorisation by a year to 2025.”

The reform must be finalised and completed by the end of 2025 to satisfy the Recovery and Resilience Plan milestones and not jeopardise payments from the Fund.

Five categories based on medical services provided

A Level 5 hospital (only in Bratislava) ensures highly specialised care with rare occurrences, such as a heart transplant. Level 4 provides specialised care with low volumes – cardiac surgery, complex neurosurgery, highly complex oncology, and specialised care for children. These hospitals have a catchment of 1.4 – 2 million people and are reachable within 90 minutes for 90% of citizens from the region.

Level 3 hospitals deliver complex acute and planned care, for heart attacks, strokes, polytrauma, complex oncology and planned procedures, for example – with a catchment of 450,000–900,000. They are reachable within 60 minutes for 90% of citizens from the region.

Level 2 secures standard acute care on a regional level, providing basic surgeries (appendectomy, hip replacement), standard internist and pediatric care, the catchment of 100,000-220,000, and reachable within 30 minutes for 90% of citizens from the region.

Level 1 provides long-term care, urgent and complex ambulatory care, same-day surgeries, and psychiatric and community care.

The rarest and medically most demanding cases will be concentrated in the higher-level hospitals. On the other hand, medically less demanding but more commonly utilised care will be more accessible and closer to the patient’s residence.

Controversy around ‘re-categorisation’

Decisions regarding which procedures each hospital can offer have encountered resistance in several cases. The most recent controversies surrounding hospitals in Bratislava, Košice, and Brezno.

The two newly built hospitals in Bratislava (Level 3) and Košice (Level 4) were only conditionally categorised because they did not have a history of types and number of procedures.

The levels assigned to these new hospitals were met with backlash from the opposition due to the alleged improper level of categorisation.

Furthermore, a hospital in the Brezno district (Central Slovakia region) was promoted by one level beyond its originally assigned classification without proper justification, according to some stakeholders.

“The reasons for the inclusion of the new Bratislava and Košice hospitals have their rationale. It would have been foolish not to include the newest hospitals in the network,” Smatana continued.

The circumstances around the re-categorisation of the Brezno hospital were less clear.

“The reasons for the reassignment of the hospital in Brezno were different and, to a great extent, only political, as it is a region with a large voter base for the government coalition,” said Smatana.

“This is therefore a dangerous precedent that may significantly slow down the implementation of the whole reform in the future as many other hospitals are expected to use political pressure to receive a higher status in the categorisation of hospitals,” said Smatana.

The patients’ rights association AOPP disagrees with the opposition politicians who contested the levels assigned to the three hospitals.

“We fully support the categorisation of the three hospitals at their respective levels. We follow legislative processes and defend patients’ rights at every level, and we perceive that the re-categorisation of these hospitals puts pressure on other hospitals to strive for better quality and safety, which was precisely the goal of the reform,” Marušáková remarked.

[By Filip Áč, Edited by Vasiliki Angouridi, Brian Maguire | Euractiv’s Advocacy Lab]

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