REFORMA 3.3

Thank you very much, Richard — including for taking a little time away from the introduction I had planned. I am very pleased to be here. I should say that the Slovak Society for Telemedicine and Digital Health has the strongest representation in our team, which makes me very glad.

This is the first opportunity for us to tell you what we have prepared for healthcare. What I am going to present is not tied to any political programme or electoral cycle. Over the next fifteen minutes or so, I will show you the main areas we have prepared and plan to communicate over the coming months, particularly during the next year. For each area, you will see figures showing the situation in Slovakia today, how it compares internationally, and what the international evidence says. These are not promises of savings.

I want to stress one important point at the outset. Today, anyone can use artificial intelligence to write a five- or six-page healthcare strategy — all it takes is a good prompt. The problem is that, however strong the ideas in a strategy may be, you still need people who can implement them. The advantage of REFORMA 3.3 is that it was developed by people who genuinely understand its individual areas — whether medicines policy, telemedicine, digitalisation, hospitals or the other fields. They are also willing, when the opportunity arises, to step forward and do what they know how to do for that part of the healthcare system.

According to Eurostat projections, in 2025 there are 28.2 people aged 65 or over for every 100 people of working age. By 2050, this figure will reach 49.7 — roughly three quarters higher than today. The share of people aged over 80 will rise from 3.6% to 13.8% by 2070. Let me repeat what we all know: older people tend to have several conditions at once and need more coordinated care — and they will need it at a time when the workforce itself is also ageing.

The problem is therefore not only about money. It also lies in short-term budgeting, weak data, staff shortages and poor links between different parts of the system. Ageing magnifies every one of these weaknesses.

REFORMA 3.3 covers six areas but has one objective: the right care in the right place, at the right time, with predictable and sustainable funding. Many of you may wonder whether this is achievable at all. It certainly is. But if anyone who wants to become health minister tells you before an election that they will reform healthcare in four years, please do not believe them — it cannot be done. It can, however, be achieved step by step. REFORMA 3.3 was also created because, although Slovakia has had a Strategic Framework for Health 2014–2030 since 2013, it does not have a strategy that is implemented, regularly evaluated and used to connect the individual areas — from medicines policy to telemedicine. It is time to offer political parties something they can build on and that could finally become a strategic plan for the whole healthcare system.

When first contact does not work, patients end up in emergency departments. When follow-up care is missing, acute beds do not become available. When data are not connected, no one can see the patient pathway or where it has stalled. Reform must therefore be an interconnected structure, not six separate pillars. Each area could support at least a full-day conference of its own; anyone who wants to learn more will find the material on the Healthy Future of Slovakia website.

Primary care is the patient’s first point of contact with the system. According to the Health Care Surveillance Authority, Slovakia was short of 358 adult general-practice clinics as of September 2025, and 41% of these doctors were aged 63 or over in 2024.

Avoidable hospital admissions are one indicator of primary-care quality. Slovakia has roughly twice as many admissions for heart failure as the OECD average: 414 versus 210 per 100,000 people. According to the OECD, avoidable admissions for chronic conditions that can be managed in primary care account for around 6% of all bed-days in OECD countries.

The reform therefore turns an isolated practice into a team: a doctor, nurse, assistant, administrator and junior doctor. This increases capacity without waiting for an immediate rise in the number of physicians. The referral slip becomes a directed electronic referral: we know who accepted the patient and what happened next. The key principle is to treat when it is safe and refer when it is necessary. Outcome-based payment will be introduced only once outcomes can be measured reliably. In practice, this means less unnecessary shuttling of patients and more capacity for specialists to handle complex cases.

Hospitals currently absorb failures elsewhere in the system. A patient who needs outpatient or home care often ends up in a hospital bed. Slovakia has 5.7 hospital beds per 1,000 people, more than the EU average, yet only 61% of curative-care beds were occupied in 2023 — one of the lowest rates in the Union. The Supreme Audit Office reports that the liabilities of the thirteen largest hospitals exceeded €1 billion at the end of 2023, including almost €700 million overdue.

The reform therefore changes the role of the hospital network. Acute care belongs where teams, sufficient volumes and patient safety are in place. International surgical evidence supports this: a 2021 review of 403 studies found that 86.6% identified a statistically significant relationship between hospital procedure volume and treatment outcomes. Local access will be protected through outpatient, day-case, follow-up, rehabilitation and palliative services. A smaller hospital is therefore not simply a scaled-down hospital; it gains new functions for its region.

The sequence matters: no change in a hospital’s profile without a functioning outpatient clinical filter, follow-up care, digital discharge and sufficient staff. We make no promise of guaranteed savings.

Long-term care determines whether hospital beds become available and whether families cease to be invisible care providers. Slovakia has 2.2 paid long-term-care workers per 100 people aged over 65; the OECD average is 5.0. Demand will rise: according to a European Commission projection, the number of care-dependent people aged over 65 is expected to increase from 289,000 in 2022 to 544,000 in 2070 — an 88% increase.

Our model, called “Home is the remedy”, makes the home and community the first choice. Residential care is complementary, but essential where care at home is not safe. The patient has one pathway and one plan. Why a plan? Because a Cochrane review indicates that an individual discharge plan probably reduces readmissions slightly — by 11% among older patients admitted with medical conditions. The system has three layers: healthcare, social care and a cash allowance. They are coordinated but remain separate, so that it is clear — above all to the patient — who pays for what. The system has four entry routes, including discharge from hospital and a gradual decline in independence.

Medicines policy is an area especially close to me. We have always sought balance, and we continue to do so: patients need timely access to medicines, while the system needs predictable expenditure. Medicines spending can be planned accurately — in 2025, net expenditure on medicines and dietetic foods differed from the budget decree by approximately €1 million out of more than €1.65 billion.

The problem is access. In Slovakia, a new cancer medicine is reimbursed on average 890 days after its EU registration; the EU average is 655 days. Of the 56 cancer medicines registered between 2021 and 2024, nine were available in Slovakia in January 2026. Across all new medicines, 35 of 168 were available — 21% — with a median delay of 628 days. These figures come from an EFPIA survey and therefore from industry, but they reflect a problem familiar from practice. An amendment to the medicines reimbursement law was promulgated at the end of October and will take effect in stages from November 2026 and January 2027. We hope the remaining work is completed successfully.

Medicines policy is not only about adding medicines to reimbursement lists. It is about creating a predictable environment and managing entry. We also need data. When you ask how much is being spent on medicines, you receive three different figures, which is absurd. For example, the Value for Money Unit, the ministry and the Health Care Surveillance Authority each report different manufacturer rebate figures for 2024. The National Health Information Centre has all the information, yet we make very little use of it. We need one figure — and in medicines policy we need it monthly, so that we know how much has been spent. We also need rational pharmacotherapy: according to the OECD, as many as one in ten hospital admissions may be caused by a medication-related event, while avoidable medication harm costs OECD countries more than USD 54 billion. This is why we need medication reviews, interaction alerts and the deprescribing of high-risk medicines. The first objective is patient safety, not savings. We state clearly that a new medicine is not automatically a saving. Without stability and predictability across political cycles, this simply will not work.

One weakness of our financing system is that the state contribution for state-insured persons is determined residually rather than systematically. Providers therefore cannot plan — and planning is exceptionally difficult today, whether for private networks or state hospitals. In 2023, Slovakia spent €2,088 per person on health in purchasing-power-parity terms, compared with an EU average of €3,832. In the same year, 4.4% of households — approximately 230,000 people — faced catastrophic health expenditure, mainly on medicines.

The reform therefore proposes a three-year budget framework. Multiannual planning is not unusual: three quarters of the OECD countries that responded to a survey include health expenditure in a medium-term budget framework. We also propose automatic indexation of the state contribution, with a correction mechanism. If spending deviates from the framework, a review and possible corrective action are triggered. Patient co-payments, currently a grey area, should be governed by clear and enforceable rules and supported by electronic receipts. One rule applies across all areas: every measure with a financial impact is subject to a joint assessment, and savings that have not yet been verified are not counted.

Digitalisation connects everything else — it is the common backbone of all the areas I have mentioned. Today, patients often carry paper documents between clinics; the same data are entered repeatedly and the same examinations are repeated. Only 16% of people in Slovakia accessed their health record online in 2024, compared with 28% in the EU. I admit that I opened mine for the first time in my life this year. Apart from prescriptions, I did not find much there, but it is improving and I believe there will be far more information in a year’s time. At the same time, some people find it much harder than we do to access their electronic health record.

We underestimate digital health. In 2023, Slovakia invested €0.41 million per 100,000 people — the lowest amount in the European Union. The objective should be connected data, a shared patient pathway and automated reporting: data entered once and reused. The national system must work first, followed by European exchange. The European framework sets clear dates: from March 2029, patient summaries and e-prescriptions are to be exchanged throughout the EU; from March 2031, medical images, laboratory results and discharge reports will follow. The European Commission estimates the gross benefit of the European Health Data Space at more than €11 billion over ten years across the Union. This is an estimate before costs are deducted, not a promise for Slovakia. Success cannot be measured by the number of projects. Several ministers have said they had thirty projects ready, only to deliver two. The real question is whether we are giving time back to healthcare professionals and shortening the patient’s journey through the system.

Telemedicine — one of our favourite subjects — has a clear place in the reform. It should become a routine part of care, but only where it is clinically appropriate. At the beginning, my colleague Dvorový described where we would like to see it used in the future, so I will not repeat that. Evidence is available: a Cochrane review found that home telemonitoring for heart failure reduced heart-failure hospitalisations by 29% and all-cause mortality by 20%. For high blood pressure, home measurement alone had no demonstrated effect; with intensive support during treatment, systolic blood pressure fell by 6.1 mmHg. Technology helps when it is part of care.

Telemedicine therefore follows a precise sequence: suitable indications, updated pathways and triage, a reimbursement model, pilot validation — and only then scale-up. We want to start with follow-up consultations, people with chronic conditions, triage, e-consultations and home monitoring of treatment.

We also have three safeguards, all of which are crucial. First, there must always be a non-digital pathway. Only 22% of people aged 65–74 in Slovakia have at least basic digital skills, compared with 33% in the EU, so every digital process must have an alternative. Second, authorised access must be available to relatives and carers. Third, a human must always make the decision when artificial intelligence is used, even though AI can help us dramatically. Telemedicine indicators are measured only against clinically appropriate indications, not against all procedures.

Although I am convinced that our team includes people who know what they are talking about, we also asked an international Advisory Board to review the reform. Six members submitted written comments in August and September, and we are now working through their recommendations; they are not yet adopted decisions. One particularly interesting proposal is a clinical test for each rule: what will a new measure change for the patient, who will carry it out, what capacity is available, and what happens if the system fails? The Board welcomed the prudent financing approach — specifically, that the framework does not count unverified savings — while calling for a clear bridge between needs and resources. We are bringing together further ideas from experienced people so that the document remains a living and regularly updated framework.

If any of this is implemented, the first 18 months after adoption of the reform programme will be critical: establishing the legal framework, introducing electronic records and receipts, and conducting pilot validation. Up to 2030, resources should gradually shift towards prevention and primary care; after 2030, the system should adapt to population ageing. If adoption of the programme is delayed, the milestones will move accordingly. One principle applies everywhere: people are the prerequisite — nothing can be scaled without healthcare professionals.

Why have we prepared this now? One reason is that, unless we begin to change the healthcare system gradually today, we will end up with healthcare only for the wealthy. Speaking for myself, that is something I genuinely do not want. We have a fundamentally sound system; it needs capable people who know how to move it in the right direction. The figures you have seen today are not promises of savings. They show where the system is losing people, time and money, and where evidence suggests that change makes sense. We would welcome your contribution as well. When you read the documents, contact us if you have a good idea, comment or practical experience to share. Your experience from practice is the best test of every proposal we make. Thank you very much for your attention.