Country and population

Slovakia is situated in central Europe, landlocked, with a territory of 49 034 km² and a population 5.41 million in 2008 of whom 51.5% are women. The mean density of the population was 110/km², with a natural increase in 2006 of 0.1%. Slovakia has an under-15 population of 15.8% and 12% are over 65 years of age (Národné centrum zdravotníckych informácií, 2008; Statistical Office of the Slovak Republic, 2008).

Development and economy

Slovakia is a parliamentary republic with a one chamber Parliament (Národná Rada Slovenskej Republiky) elected in general elections for a four-year term of office. The President is also elected in general elections for a five-year term of office. Slovakia has been an EU Member State since 2004 (Národné centrum zdravotníckych informácií, 2008; Statistical Office of the Slovak Republic, 2008).

In 2008 the GDP per capita (PPP) was US$ 22 141 – at the level of 72% of the EU average. The unemployment rate in 2010 was 13% and the Human Development Index in 2010 was 0.818 giving Slovakia 31st position in the world. The emigration rate in 2007 was 8.2%, with the main destination being western European countries (OECD, 2010; Statistical Office of the Slovak Republic, 2010; UNDP, 2010).

Population’s health

In 2008, life expectancy at birth for men was 70.9 years and for women 78.7 years. Life expectancy at the age of 60 was 16.5 and 21.1 years respectively in 2006. Main causes of death in 2007 were cardiovascular diseases (47% in males; 61% in females), neoplasms (25% in males 20% in females), external causes, diseases of the respiratory tract and digestive system diseases. Drug consumption in 2006 was 149.5 million packs (Národné centrum zdravotníckych informácií, 2008; Statistical Office of the Slovak Republic, 2008; Szalay et al., 2011).

Characteristics of the health care system

All citizens are covered by general health insurance. There are several competing insurance companies, but the Public Health Insurance Company is predominant (Národné centrum zdravotníckych informácií, 2008; Statistical Office of the Slovak Republic, 2008).

Table A25.1 shows there is a constant tendency of increasing spending on health care, yet this is still below the EU average. The number of hospital admissions has been almost steady over the past decade, while length of stay in hospital is decreasing. The number of outpatient consultations has also decreased but still is above the EU average. The ratio of GPs for adults is nearly constant and GPs account for about 18% of all physicians (Národné centrum zdravotníckych informácií, 2001, 2006, 2008; OECD, 2010; WHO Regional Office for Europe, 2010a).

Table A25.1

Development of health care resources and utilization.

2.1. Primary care governance

Although the idea has been widely discussed, there is no formal policy document describing the current state or vision on the future development of primary care in Slovakia. In 2010 the new government declared in a manifesto (among other things) significant changes in the health care system, including cancellation of general practice referrals to specialists. However the manifesto is considered to be more a political declaration than a real plan of action (Government of the Slovak Republic, 2010).

There is no special department at the level of the Ministry of Health or state inspection dealing with primary care issues. As a result, there is no clear governmental primary care policy, for example to regulate equal access to primary care providers or to stimulate multidisciplinary collaboration among health professionals. Primary care does not have a specific budget that can be separated from secondary care. Organizations of stakeholders or communities do not contribute to primary care policy development.

Only vocationally trained physicians, who complete a five-year postgraduate training programme, are allowed to work in primary care. A special licence is required to provide health care in general practice (Ministry of Health, 2004d).

Many clinical guidelines have been implemented in Slovakia, most of them developed by the Slovak Society of General Practice/Family Medicine, and others by different specialist scientific associations. Patients’ rights are guaranteed by law, including informed consent, protected access and confidential use of medical records, as well as procedures to process patient complaints (Ministry of Health, 2004e).

2.2. Economic conditions of primary care

In the year 2006 over 23% of total health expenditures in Slovakia were devoted to the provision of outpatient services. This amount includes not only primary care but also outpatient specialist services. According to expert estimations expenditure on primary care was 8% of total expenditures on health. In the same year 4.5% of the health care budget was spent on public health and preventive activities (Eurostat, 2010).

All Slovaks are medically insured, including for services provided by primary care and medicines prescribed by GPs (Ministry of Health, 2004c).

Nearly all primary care physicians are self-employed and have contracts with the health insurance funds. Only about 1% of them are salaried employees, hired by other GPs or local authorities. This last group is usually paid a flat salary, while the others are remunerated on the basis of a mixed system, including a capitation fee and additional payments for home visits, vaccinations or other preventive activities. Although some published data suggest that the average annual income of a GP can exceed US$ 28 000 (in PPP) (OECD, 2009), most of the national primary care experts agreed that, after expenses and taxation, it is closer to €12 000. Fig. A25.1 shows that medical specialists, dentists and occupational therapists generally have a (much) higher income than a mid-career GP. However GPs are better paid than nurses and other allied health personnel such as speech therapists. For example, the average income of a GP in Slovakia is more than twice that of a hospital nurse.

Fig. A25.1

How does the average income of mid-career health professionals relate to that of a mid-career GP?

2.3. Primary care workforce development

Only GPs, paediatricians, gynaecologists, ophthalmologists and dentists are available without referrals (Ministry of Health, 2004a, 2004b). To see any other specialist, formal referral from a primary care physician is required. According to the database of the Slovak Medical Chamber, the ‘average GP’ in the country is 56 years old. Only 11% of them are younger than 35 years, 16% are between 35 and 45 years of age, 38% are between 45 and 55 and 35% are older than 55 years.

GPs are obliged to provide services 40 hours per week and their responsibilities are described in the concept document issued by the Ministry of Health (Ministry of Health, 2006).

General practice is not a very popular medical specialty in Slovakia. Their financial remuneration seems to be modest as shown by Fig. A25.1. In 2007 only 6% of medical graduates chose it as their future professional career. As a consequence, between the years 2002 and 2006 the percentage of all medical specialists who are vocationally trained in general practice has decreased by one-sixth. This development in supply of primary care professionals is illustrated by Fig. A25.2 (Eurostat, 2010; WHO Regional Office for Europe, 2010a). A similar trend was observed, for other medical specialties, while for most of the allied health professions an increase was observed. In 2007 GPs constituted 12% of all medical specialists in Slovakia (Ministry of Health, 2006; Národné centrum zdravotníckych informácií, 2008).

Fig. A25.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period. Sources: Národné centrum zdravotníckych informácií 1997, 2003, 2004, 2005, 2006, 2007 (more...)

In Slovakia general practice was established as a medical specialty in 1978. The Postgraduate Medical Academy – a central institution responsible for postgraduate education in all medical specialties – runs vocational training in family medicine. None of the medical universities in the country has a department of family medicine, although the subject is taught at all schools, mainly by other specialists. Vocational training lasts five years, including one year spent in general practice (Ministry of Health, 1988). There is no special training for community or practice nurses.

GPs have their own association, dealing with both scientific and professional development of the discipline. Also an educational journal (Slovensky Lekar) is published bimonthly and a scientific journal (Via Practica) is published quarterly. Nurses have neither their own professional association nor a specialist journal dealing with family or community nursing issues.

3.1. Access to primary care services

In 2007 there were 50.5 GPs for adults per 100 000 adult population and 68.2 GPs for children and adolescents per 100 000 children and adolescents. The respective indicator for gynaecologists was 28.7 and for dentists, 48.6. In 2007 the geographical availability of GPs per 100 000 inhabitants slightly varied between the regions and was highest in Bratislavski kraj (54.6) and lowest in Presovsky kraj (47.3) (Národné centrum zdravotníckych informácií, 2008). Data on rural–urban differences are not available. No major problems are reported by experts in urban or rural areas on access to general practice care or community pharmacies.

Fig. A25.3 shows the extent to which certain organizational arrangements commonly exist in primary care practices or centres. Modern communication techniques like e-mail consultations or practices with web sites are seldom or only occasionally present. Limited data show that about a quarter of GPs might have their own practice web site and only slightly more than 2% could communicate with their patients via e-mail (Dobrev et al., 2008). The use of appointment systems is not part of everyday practice, occurring only occasionally. GPs only rarely offer special sessions or clinics for certain patient groups (e.g. diabetics, pregnant women).

Fig. A25.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres. Source: Dobrev et al., 2008 and expert interviews.

The number of daily hours of availability is not strictly regulated by law. After-hours care is provided mainly by walk-in centres, where face-to-face contact with a GP or nurse is available. In some limited cases special deputizing services or hospital emergency departments serve patients with health problems after office hours. Most of the services, like general practice or specialist consultation and home visits, are free of charge for patients. Co-payment is required for certain medicines prescribed by physicians. In the year 2007 only 14% of Slovaks considered their health care system not very or even not at all affordable. In the same year, 83% of patients found access to their GPs easy in general (European Commission, 2007; Projekt rozvoja kvality zdravotnej starostlivosti, 2005).

3.2. Continuity of primary care services

All Slovaks are on the lists of their primary care physicians. The average list size (calculation based on internal data of General Health Insurance Company) is 2163 persons. Ninety-eight per cent of patients reported consulting their usual primary care physician for their common health problems.

All GPs routinely keep clinical records from medical consultations. Computers are widely used and 90% of GPs use them for administrative purposes. Nearly the same proportion (89%) store patients’ records electronically and 79% of GPs keep electronic records of prescriptions issued to their patients (Dobrev et al., 2008).

Referral letters are commonly used in general practice. Normally specialists report back to GPs about an episode of treatment provided to their patients. Information about out-of-hours contacts is also usually communicated to GPs. Patients have a free choice of GP or centre (Ministry of Health, 2004c). Fig. A25.4 shows that 84% of patients reported being satisfied with the quality of the doctor–patient relationship. Ninety per cent of patients trust their GPs and 87% are satisfied with the explanations about medical management given by them (Projekt rozvoja kvality zdravotnej starostlivosti, 2005). Even though consultations generally take 4–5 minutes, the majority of patients are satisfied with this.

Fig. A25.4

Patient satisfaction with aspects of care provision. Source: Projekt rozvoja kvality zdravotnej starostlivosti, 2005 and expert interview.

3.3. Coordination of primary care services

GPs, paediatricians, gynaecologists, ophthalmologists and dentists are directly accessible for patients in Slovakia. For other specialists a referral letter from a primary care physician is required. Alternatively, patients are expected to cover costs of a specialist visit without referral out of pocket (Ministry of Health, 2004c). In Slovakia all GPs run solo practices, which means that they have an individual list of patients. As a rule, patients consult their own GP, who only in case of absence may occasionally be replaced by another GP. It is very uncommon for nurses to run specialist (e.g. diabetic) clinics or conduct health education activities. Also specialists normally do not visit their primary care colleagues to consult them or to provide joint care. Similarly, GPs rarely or never make a telephone call to seek direct advice from medical specialists. Data from patient records collected by GPs are very seldom or never used to identify health needs or priorities. Only incidentally are surveys, conducted on local level, used to improve the quality of care provided by GPs.

3.4. Comprehensiveness of primary care services

General practices are always equipped with sets of dressing or bandages and urine strips or glucose tests. Usually they also have otoscopes but ECG machines are only occasionally available, while peak flow meters and gynaecological or surgical instruments are almost never available.

Table A25.2 provides an overview of the primary care providers’ involvement in the delivery of various primary care services.

Table A25.2

GPs’ involvement in delivery of various primary care services.

General practice care in Slovakia in certain areas is limited by age, sex and type of complaints, presented by the patients (see Table A25.2) (Ministry of Health, 2008). Children are always seen by paediatricians (GP for children and adolescents), women with gynaecological or pregnancy related problems are usually served by gynaecologists. Most GPs would however see a person with psychosocial problems or even psychiatric disorders (e.g. suicidal inclinations or alcohol addiction), at least initially.

Many specialists are involved in overall medical care, however most of the GPs usually care for patients suffering from chronic diseases like congestive heart failure, peptic ulcer and mild depression, or even cancer. Patients who are in nursing homes are also usually under the care of their GPs. Conditions like chronic bronchitis would only occasionally be followed by general practice, while uncomplicated diabetes type II or rheumatoid arthritis seldom or never.

In total 72.2% of patients’ consultations in primary care are handled solely by GPs without referral to other specialists.

Minor surgery (e.g. resection of ingrown toenail, wound suturing, excision of warts), gynaecological procedures (e.g. insertion of IUD) or other manual procedures (e.g. fundoscopy, removal rusty spot from the cornea or joint injection) would seldom or never be performed in primary care settings. Setting up an intravenous infusion would be done only occasionally. Most of the above procedures would be performed by surgeons, gynaecologists, ophthalmologists or orthopaedic surgeons respectively.

GPs are responsible for tetanus or high-risk groups’ influenza vaccination. They also usually conduct HIV/AIDS and cholesterol screening or tests for sexually transmitted diseases. Breast cancer screening is done by GPs only occasionally, whereas allergy vaccinations and cervical cancer screening seldom or never. Family planning and routine antenatal care, or paediatric surveillance is performed by gynaecologists and paediatricians respectively. Vaccinations against childhood communicable diseases (e.g. diphtheria, pertussis, mumps or rubella) are performed exclusively by GPs for children and adolescents (district paediatricians). GPs, however, are usually involved in lifestyle counselling in the case of obesity, poor physical activity, smoking or problematic alcohol consumption. Most of these services are provided on an individual basis and group health education is rarely or never performed by GPs (Ministry of Health, 2004b, 2006).

4.1. Quality of primary care

In 2008 an average Slovak GP issued 418 prescriptions per 1000 patient contacts. Data from 2007 show that all ambulatory physicians prescribed 25.3 DDD of antibiotics per 1000 inhabitants per day (ESAC, 2009) .

The number of hospital admissions for primary care sensitive conditions provides insight into the quality of care provided at primary care level. Fig. A25.5 shows that relatively high hospital admission rates occur in Slovakia (in 2007) for patients with a diagnosis of pelvic inflammatory disease, ENT infection and dehydration (Národné centrum zdravotníckych informácií, 2008).

Fig. A25.5

Number of hospital admissions per 100 000 population with a primary care sensitive diagnosis in most recent year. Source: Národné centrum zdravotníckych informácií, 2008.

Precise data about quality of care provided to diabetic or COPD patients are not available. Fig. A25.5 shows a relatively low hospitalization rate for asthma patients.

Vaccination rates among children, , performed by GPs for children and adolescents, are among the highest in the EU and are above 99% (OECD, 2009).

In 2007 21.3% of Slovak women aged 60–68 years had received a mammography (Masak & Plesko, 2007; OECD, 2009) and 20% of women 18–64 years old had received a pap smear (Masak & Plesko, 2007; OECD, 2009). Both these procedures are performed mainly outside of primary care settings.

4.2. Efficiency of primary care

In 2007 GPs for adults in Slovakia provided on average 4.75 consultations per capita. The average length of general practice consultation was 4–5 minutes (Projekt rozvoja kvality zdravotnej starostlivosti, 2005).

Home visits constituted 3.4% of all patient contacts; on average a GP makes nine home visits per week.

In 2008 GPs issued 278 referrals per 1000 listed patients per year.