THERAPIES that the government has prescribed for the health care sector, and the way some of its treatments have been performed, seem to be deepening the trauma rather than helping to heal.
In the middle of an unpopular project to reduce the number of institutions that are guaranteed contracts with the country's health insurers, the boss of the major state-run insurer has resigned from his post, and speculation has begun about whether the health minister might soon follow him.
The Health Ministry rejected rumours that the health minister may be sacked, and denied any connection between the resignation of the insurer boss and the ongoing project of hospital contracts revision.
Health policy analysts say the eventual departure of the minister would not shake the department, while the new head of the health insurer will be greatly limited in pursuing any plan that does not fit the strategy of ruling politicians.
In response to criticism of the plan to revise contracts with the country's hospitals, Prime Minister Robert Fico said earlier this year that no health institution would be closed down because it lacked contracts with the major state-run health insurer. However, some hospitals continue to express alarm over the measure, and observers are still calling for rules clearly specifying the standards that hospitals have to meet in order to make it on to the list.
The ministry said that Anton Kováčik made the decision to resign from the top post at Všeobecná Zdravotná Poisťovňa (VšZP) for personal reasons. Kováčik had been general director since September 9, 2006.
"The ministry respects his decision but still intends to cooperate with him at an expert level," Health Ministry spokeswoman Silvia Horváthová told The Slovak Spectator.
While local media speculated about alternatives to the board of directors of VšZP, the ministry said that changes have been made to only two posts on the board, one of them being the outgoing general director's.
The ministry also said that the insurer will stick to plans to revise its contracts with the hospitals.
"The changes will not influence the operation of the health insurer, which will continue the process of revising its contracts with health care providers," Horváthová said.
In March, VšZP will publish a list of hospitals that will be guaranteed contracts with the insurer, according to the public service broadcaster, Slovak Radio.
Slimming cure for hospitals
Last autumn the government decided that only health care facilities controlled by Slovakia's Health Ministry could make it onto the list of institutions that are guaranteed contracts with the state health insurers. The future of other health care providers would depend on the goodwill of insurers.
An analysis by the health ministry suggests that there were 36,805 hospital beds in Slovakia in November 2006, while the ministry wants to have 29,170 hospital beds in a minimum network covered by health insurers.
On October 24, 2007 the cabinet approved a minimum public network of 34 state health care facilities, with health insurers only having to provide contracts to hospitals included on the list.
The ministry said that private health care facilities were dropped from the list because the state can only guarantee care provided by state-run health facilities, which are directly under the ministry's control.
The opposition has been critical of the plan, arguing that the rule preferring state-run hospitals is discriminatory.
The opposition Slovak Democratic and Christian Union (SDKÚ) party said on February 22 that it was concerned about the state of the health care sector and the way the government has handled the state-run health insurer VšZP.
The party criticised the ministry for what they called unclear criteria for signing contracts with health care facilities.
SDKÚ's Viliam Novotný said that all non-state facilities with balanced budgets could end up with disadvantageous contracts, ultimately leading to their liquidation, while indebted state hospitals get "incredibly good contracts".
SDKÚ leader Mikuláš Dzurinda, quoted by the SITA newswire, described the process as a "witch hunt" against private ownership, and also bait for property "vultures".
Will Valentovič's head roll?
Another opposition politician, the Christian Democratic Movement (KDH) boss Pavol Hrušovský, has said that the ministerial career of Ivan Valentovič might end soon.
"We have information that Prime Minister Fico is losing patience with the work of the current minister," said Hrušovský after a meeting of opposition parties in late February.
Hrušovský, without specifying his sources, also suggested that the Smer party boss might give Valentovič's job to one of two new hospital heads in the Nitra Region. Smer deputy Jozef Valocký was recently given the job of managing Nitra Hospital, while Imrich Matuška was appointed to head the hospital in Nové Zámky. Matuška also has close ties with Smer, according to the Sme daily.
Health Ministry spokeswoman Silvia Horváthová told The Slovak Spectator that, based on a statement that the Cabinet Office delivered to her ministry on February 25, 2008, KDH boss Hrušovský's statements about the possible dismissal of the health minister are untrue.
Smer party spokeswoman Katarína Kližanová Rýsová said Hrušovský's statements were nonsense.
"If Mr. Hrušovský has a dream he should open the book of dreams, but we will not comment on his statements," Kližanová Rýsová said.
Valentovič has been one of the most heavily criticised ministers of the Fico government; while the health minister's position has traditionally been among the least popular ministerial seats.
Out with the old, in with the new
Meanwhile, Zuzana Zvolenská was appointed the director of the state-run health insurer and will also sit at the head of the board of directors. Zvolenská previously served as director general of the state-run Spoločná Zdravotná Poisťovňa (SZP) health insurer.
In fact before being appointed to the top post of VšZP, former director Kováčik had also served as the director of SZP.
VšZP is the country's largest insurer in terms of policyholders and is entirely under the management of the state. Health policy watchers doubt that there will be any considerable change to the way the insurer is managed.
"There will be no change in the orientation of the VsZP, since the key decisions are made by politicians and not the managers of the insurer," Tomáš Szalay, head of the Health Policy Institute, told The Slovak Spectator. "If the management of the insurer wanted to pursue their own plans, sooner or later they would find themselves in conflict with the politicians."
Szalay said that this is the reason for the frequent changes in the leadership of the company, adding that this perhaps gives some clues for the reason behind the departure of Kováčik.
"Kováčik's effort to reduce the number of hospital beds was his most notable move," said Szalay. "In this area he did more work than all his predecessors."
The VšZP has refused to sign contracts with six hospitals and has been working on a list of additional hospitals, which would have lost their contracts in the summer of 2008, according to Szalay. Kováčik had been proceeding according to the ministry's wishes, he added.
"I understand, that during these necessary but unpopular measures, Kováčik did not feel he was receiving enough support from the politicians," Szalay said.
According to Szalay, hospital closures, no matter how well argued or justified, are unpopular everywhere in the world.
"Governments which follow opinion polls will never have the courage to carry out the necessary reduction in redundant health institutions," Szalay told The Slovak Spectator. "This is why I assume that the will to reduce the number of hospitals will fade somewhat, due to the new management's instinct for self-preservation."
The Health Policy Institute said that as far as providing the state's health care obligations to citizens is concerned, the way to go is to close down hospitals which fail to meet minimum standards.
"Closing such hospitals could be communicated positively," Szalay said. "In fact, it protects citizens from low quality health care."
However, for this to happen, it is crucial that the ministry publishes these minimum standards by making them legally binding. This has not happened so far, Szalay added.
Reducing the number of hospitals by means of withholding contracts from them has already cost the position of one director, Szalay said, adding that the new management will be most probably be very cautious.
As far as Valentovič is concerned, Szalay said he has not really helped the Slovak health care sector.
"He halted the transformation of health institutions but has never introduced any acceptable alternative," Szalay said.
According to Szalay, the minister has given up solving the problems of the department. "The eventual departure of the minister will not result in any loss to the department," said Szalay. "However, it is not clear whether his successor would be a better or even a worse minister."
According to Szalay, health care is the department that might decide the next elections and "indecisiveness is in no way a good strategy".