New WHO report shows how Slovakia can make health care more affordable for households with low incomes

Slovakia provides people with relatively good protection from out-of-pocket payments for health care, a new WHO/Europe report finds. Levels of catastrophic health spending are lower in Slovakia than in many other European Union (EU) countries, but challenges remain: catastrophic health spending is concentrated among low-income households, older people and pensioners, and the country's heavy reliance on the labour market to finance health care could become a concern as the population ages. People who experience catastrophic health spending may struggle to afford other basic needs such as food, housing and heating.

The report "Can people afford to pay for health care? New evidence on financial protection in Slovakia" is the first comprehensive analysis of affordable access to health care in the country. It highlights policy options that can help Slovakia to make further progress towards universal health coverage (UHC).

In 2023, nearly 1 in 23 households (4.4%) - around 230 000 people - experienced catastrophic health spending, according to the latest available data. Among low-income households, catastrophic health spending is mainly driven by outpatient medicines followed by dental care. In other income groups, dental care is the leading cause followed by outpatient medicines and inpatient care.

Unmet need for both health care and dental care in Slovakia is lower than the EU average. For health care, unmet need is mainly due to waiting times, while cost is the primary barrier to accessing dental care. During the study period, there was significant income-related inequality in unmet need for both types of care. More detailed comparative data are featured on UHC Watch - an online platform tracking progress on affordable access to health care in Europe and Central Asia.

Strengths in coverage policy

WHO's report highlights aspects of coverage policy in Slovakia that contribute to stronger financial protection. For example, the benefits package is relatively comprehensive and user charges (co-payments) are limited to a few types of care (emergency visits, outpatient prescribed medicines, medical products and dental care treatment).

Gaps in coverage remain a challenge

Despite these positive features, the report notes that gaps in coverage continue to undermine financial protection, particularly for people with low incomes.

• Entitlement to social health insurance (SHI) benefits is based on payment of mandatory SHI contributions and people who fail to pay contributions for three months - as well as unemployed asylum seekers and homeless people - have very limited access to publicly financed health care. Undocumented migrants are not entitled to any publicly financed health care.
• Coverage of dental care and vision aids (glasses) is limited by legislation and in practice for dental care, as many providers do not offer covered services or materials.
• Waiting times and informal payments are pressing issues in outpatient care.
• The design of co-payments for outpatient prescribed medicines is unusual and complex. Also, while there are some mechanisms in place to protect people from co-payments, they do not seem to be protective enough for people with low incomes.
• Legal loopholes allow providers to charge people for non-clinical services (extra billing).

Making health care more affordable

Since 2015, the government has taken several steps to reduce out-of-pocket payments for outpatient medicines, dental care and outpatient care. Building on this, the study recommends that the government should now focus more on reducing unmet need and financial hardship in households with low incomes.

• Ensure people have access to outpatient prescribed medicines without co-payments by: including at least one medicine with a €0 co-payment medicine in every therapeutic reference group; guaranteeing the availability of this medicine in pharmacies throughout the country; strengthening adherence to clinical guidelines and International Nonproprietary Name (INN) prescribing by doctors and generic substitution in pharmacies; and simplifying the system of co-payments.
• Improve protection from co-payments by extending exemptions and caps to all co-payments, ensuring their applicability to all people with low incomes and, ideally, to those with chronic conditions.
• Reassess the role of co-payments for emergency care by tackling the root causes of overuse of emergency care.
• Expand publicly financed coverage of dental care and find ways to ensure that more providers offer covered services.
• Tackle inefficiencies in the health system that push people to pay out of pocket, such as long waiting times, informal payments and extra billing.
• Soften the link between entitlement to SHI benefits and the payment of mandatory SHI contributions and put an end to penalizing people who are not able to pay contributions by denying them access to health care.
• Expand the scope of publicly financed health care available to people who are not eligible for, or are not covered by, the SHI scheme.

Mitigate the impact of population ageing

The report also highlights Slovakia's heavy reliance on the labour market to finance health care as a potential challenge for affordable access to health care in the context of population ageing. As the population ages and the working-aged share of the population declines, public revenue generated through employment will fall, putting pressure on health budgets that rely heavily on SHI contributions levied on wages.

A recent study, "How does population ageing affect health system financial sustainability and access to health care in Europe?", finds that with nearly 70% of public revenue for the health system coming from SHI contributions levied on wages (as opposed to levied on all sources of income), Slovakia is likely to experience a significant decline in public revenue for health as the population ages.

Unless Slovakia takes steps to broaden its public revenue base for health, there is a strong risk that increasing budgetary pressure could push up waiting times and erode coverage.

"Although Slovakia has relatively low levels of catastrophic health spending now, this first in-depth analysis identifies gaps in financial protection and offers concrete policy options to reduce financial hardship and unmet need," said Mária Pourová, lead author of the report and Senior Analyst at the Health Policy Institute in Slovakia. "These measures are not only needed to improve fairness and efficiency in the health system today but are also key to ensuring its resilience to future shocks - including preventing more people from experiencing catastrophic health spending as the population ages and revenue from wage-based SHI contributions declines."

About the report and WHO/Europe's work on financial protection

This review is part of a series of country-based studies generating new evidence on affordable access to health care (financial protection) in health systems in Europe. It assesses the extent to which people in Slovakia face financial barriers to access or experience financial hardship when they use health care and covers the period from 2007 to 2025 using data from household budget surveys carried out between 2007 and 2023 (the latest available year), data on unmet need for health care up to 2024 (the latest available year) and information on coverage policy (population coverage, service coverage and user charges) up to May 2025.

WHO/Europe monitors affordable access to health care through the WHO Barcelona Office for Health Systems Financing (Spain) using regional indicators that are sensitive to equity. Financial protection is central to UHC and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals and part of the European Pillar of Social Rights and is at the heart of the European Programme of Work, WHO/Europe's strategic framework.

The report and UHC Watch benefited from financial assistance from the EU through the EU4Health programme.