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SLOVAKIA

The health care system in Slovakia is based on universal coverage, compulsory health insurance, a basic benefit package and a competitive insurance model with selective contracting and flexible pricing. Health care, with exceptions, is provided to those insured free at the point of service as benefits-in-kind (paid for by a third party). After fulfilling certain explicit criteria, there are no barriers to entry to the health care provision and health insurance markets. ( Bismarck Group of Health Systems )
Based on the quality of their services, health insurance companies compete for insured individuals. Health care purchasing creates room for competition. Health insurance companies are obliged to ensure accessible health care to those they insure according to provisions laid down by law. Health insurance companies fulfil this obligation by contracting health care providers.

The Health Care Surveillance Authority (HCSA) is responsible for monitoring health insurance, health care provision and the health care purchasing markets.

Since 2005, all health insurance companies are joint stock companies, that is, they were transformed from (public) health insurance funds to health insurance companies operating under private law. As of 2010, three health insurance companies operate in the market, one of which is state-owned (66% of insured) and two privately owned.
Different ownership structures characterize health care providers and health insurance companies. The state, represented by the Ministry of Health, is the owner of the largest health insurance company. Furthermore, the state owns the largest health care providers, including university hospitals, large regional hospitals, highly specialized institutions, and almost all psychiatric hospitals and sanatoria. The majority of them are contributory organizations, a Slovak form of legal entity that is established by a government (including regional and municipal governments), to which part of the entity’s budget is linked; that is, they may have other revenue sources. In 2006, five state-owned health care facilities were transformed into 100% state-owned joint stock companies. Since 2007, the health care facilities in state ownership must be contracted by health insurance companies. The government in power in the period 2006–2010 saw these care facilities as crucial in guaranteeing geographical accessibility, but critics argued that this may also have given an unfair competitive advantage to these hospitals. Health departments of the Ministry of Defence, Ministry of Transport, Ministry of the Interior and Ministry of Justice also manage several health care facilities.
Pharmacies and Pharmacies and diagnostic laboratories, as well as almost 90% of outpatient acilities are in private hands. Some outpatient specialists are employed by hospitals and provide ambulatory care in polyclinics attached to hospitals. Providers of emergency health care services are either in private or state ownership; four-year operating permits are issued by the Ministry of Health based on a successful tender.

State bodies (the Ministry of Health, HCSA) and self-governing regions, which have regional competences mainly in outpatient care, administer the system and issue permits to health care providers. Organized interest groups also participate in health policy-making. Although they are invited to comment on legislative proposals, their recommendations carry relatively little political weight. Representatives of employees and employers meet with government representatives at the Tripartite Economic and Social Council, but their mutual agreement is not needed to continue the legislative process. Professional associations (known as “chambers”) keep registers of health professionals and they issue or revoke licences. They cooperate in monitoring the management of
health care facilities and issue opinions on ethical issues concerning the medical profession. The membership in chambers is not compulsory.

Financing: After the establishment of the Slovak Republic in 1993, the Bismarck system of social health insurance (SHI) was reintroduced through the establishment of the National Insurance Fund. In 1994, the Act on Health Insurance was passed, which allowed the establishment of multiple health insurance funds. Since its inception in the early 1990s the system has suffered from financial instability. The 2002–2006 reforms sought to remedy this by tightening budgetary restrictions, increasing effectiveness in utilizing resources as well as identifying internal reserves of the system. The reform included a transformation of health Insurance funds into joint stock companies.
( HSiT )

The doctor claims that their rights are respected in terms of territorial equality

The doctor claims that their rights are respected in terms of territorial equality

The second panel of the day 'physicians’ rights, guarantee for patients', organized by the National Representatives of Private Medicine for Self Employed and Salaried Employees of the Medical College (OMC) in collaboration with the Professional Association of Physicians in Free Practice (ASPROMEL), analyzed the optional rights in the labor and salary level, being reflected that differences occur depending on the territory where it is provided, in addition to the variations between the public and private sectors.

Madrid 11/05/2016 medicosypacientes.com / RM
Drs. Luepke, Garcia, Abascal, Bolliger, Nieto, Briz, Hidalgo, Matas and Carmona. 

Dr. Vicente Matas, national representative of Urban Primary Care, explained that, although Article 14 of the Constitution contains, the Spaniards are equal before the law without any discrimination due to birth, race, sex, religion, opinion or any other condition or personal or social circumstance, reality shows that the autonomous communities act with differing views on what the compensation rights of doctors concerns. 

The laws provide a National Health System (NHS) to protect the health of the entire Spanish population, under conditions of effective equality, coordinated by the Inter-Territorial Council, inter alia in procurement policy and personnel. On the theoretical side, the doctor has the right to employment stability in his exercise or actual performance of the profession or duties corresponding to his appointment, to the timely collection of the remuneration and allowances by reason of service in each set, the continued training, appropriate to the role and recognition of their professional qualifications in relation to those functions.

The legislation also includes the right of the physician to receive effective protection in safety and health at work, as well as in general risks at the health center or derivatives of regular work, as well as in information and specific training in this area in accordance with the Law on Prevention of occupational Risks in addition to voluntary mobility, internal promotion and professional development, how to provide for the provisions in each case applicable, as well as the necessary rest by limiting the duration of working time, regularly paid holidays and permissions on the established terms .

Dr. Matas explained that the pay scheme for regulated staff is comprised of basic remuneration and additional remuneration and responds to the principles of technical and professional qualifications and ensuring the maintenance of a common model in relation to the basic remuneration. The fringe benefits are primarily aimed at staff motivation, the motivation of the activity and quality of service, dedication and achievement of the planned objectives.

According to Dr. Matas, "the tremendous effort required to become a medical specialist (note of admission, six years of school a year and preMIR four or five MIR) and major responsibilities assumed in the performance of the profession,  are not sufficiently recognized by the authorities, especially from the point of retributive view ", so he argued that" we need a sufficiently funded public health by means of finalists equitable budgets, enabling Spanish doctors to pay quality health care to all citizens ".

doctor-patient relationship

Dr. José Briz, vice president of the Professional Association of Doctors in Free Practice (ASPROMEL), analyzed the relationship between doctor and patient, which plays an important role in the practice of medicine and is essential for the provision of high quality health care. So, he emphasized that "most medical schools teach their students from the beginning to maintain a professional relationship with their patients, observing their dignity and respecting their privacy." Among the general rights of doctors, Dr. Briz said that they are freely chosen by their patients as depository of their health and confidence, receive dignity and respect and to participate freely in patient care. 

He also explained that the patient must have confidence as to the competence of their doctor and should feel they can give him confidence. He also noted that "the better the relationship (mutual respect, understanding, trust, shared values ...), the better the quantity and quality of information about the patient's condition to be exchanged in both directions, improving the accuracy of diagnosis." If the ratio is poor, it is more likely that the patient distrusts the diagnosis and proposed treatment, reducing treatment adherence.

In this Round-Table, which was moderated by Dr. José María Nieto, national representative OMC of Private Medicine, Dr. Juan Antonio Abascal, secretary of ASPROMEL, showed how professional authority arises in the course of a long process of personal and professional maturation, as demonstrated by the lives of Socrates, Plato, Aristotle, Hippocrates, Dioscórido, Avicenna, Averroes, Al Farabi and others to this day. While power is achieved, the authority is recognized. The doctor achieved by this authority, to be recognized from power and society, the ability to exercise their profession freely and without pressure of any kind. Clinical judgment and freedom of prescription (diagnosis and treatment) is respected. “ Medical knowledge"  is a "knowledge” from civilization  and society. From the twelfth century the teaching of medical knowledge is performed under regulation, and compulsory membership of a professional corporation to exercise the profession, is established. Codes of Ethics are established. It is from the union authority from which will settle the social contract, not as a manifestation of power but as a social achievement. The citizen partakes of this achievement and is already the subject of law.

Failure to respect the fundamental rights inherent to their professional medical authority would amount to a breach of the social contract. The doctor has the right to generate social value, from social inclusion and civil development. He has the right to advance human rights through solidarity and international participatory movement. He has the right to fight against gender discrimination and for human rights of 3rd and 4th generation.

Dr. Olga Garcia, Treasurer of ASPROMEL presented the results of a survey on  two fundamental rights of doctors which are 1) To participate on a basis of partnership in commissions on development and establishment of budgets, rates and scales of their health care. 2 ). To participate on a basis of partnership in the planning, development and management of health systems. The conclusion which can be drawn from the survey is that in Bismarck –models of health systems the right concerning partnership in questions of budgets, rates and scales is respected from a certain to a great extent, whereas in Beveridge-models is barely respected. Concerning the right of partnership in issues of planning, development and management, in both models of health systems the right is not respected at all.

Dr. Erik Luepke Estefan, chairman of a Working Committee of ASPROMEL  presented on one hand potential conflicts of interest in the field of the rights of doctors, on the other hand a comparative study between two health systems of Beveridge model, the UK with the NHS  and Spain with its SNS. 

Concerning potential conflicts of interest, Dr. Luepke proposed the following definition: "A conflict of interest is a situation in which the judgment of the individual concerning his primary interest, and integrity of action tend to be unduly influenced by a secondary interest, usually financial or of personal type “.

Comparing British NHS to Spanish SNS Dr. Luepke showed that the British system is more centralized which means that also information is more centralized and easier to understand for both patients and physicians. The Spanish system is non-centralized. It is more difficult to gain information and to understand what it really means.

In the conclusions, Dr. Manuel Carmona, national representative of Private Medicine OMC said the physician's right to be freely chosen by patients as custodians of health and confidence, and to receive decent treatment for their part . 

Regarding the workplace, he stressed that the Constitution speaks of the same rights and duties for all, although there are notable differences depending on the territory in which one moves and in the health sector where one exercises. He insisted in claiming the right to participate in the planning, development and management of health systems.

Madrid Meeting ASPROMEL-CGCOM-OMC on Fundamental Rights of Physicians

Madrid Meeting ASPROMEL-CGCOM-OMC on Fundamental Rights of Physicians
 

The imbalance between rights and duties of the physician affects the quality of care

Inherent to the practice of medicine are a series of physicians’ rights and duties whose imbalance may come to affect the quality of care, as was highlighted at a conference on the fundamental rights in the exercise of medical profession, organized by the representatives of Private Medicine , of the General Council of medical Colleges CGCOM-OMC in collaboration with the Professional Association of Physicians in Free Practice (ASPROMEL). In the same a review was made to a number of rights related to the exercise of the profession that must always be present and on which a "collective thinking" is required, as many of the participants agreed.

Madrid 05/11/2016 medicosypacientes.com/SP
From left. to right .: Drs. Nieto, Bolliger, Rodriguez Sendín, Carmona and Romero.
 
During the meeting the participants talked about the rights linked to clinical practice and related to the exercise of the profession, the doctor-patient relationship, the field of health systems and health of physicians itself, to training, research and teaching, and also related to labor policy and salary. All of them represent a quality -guarantee for the patient as well as a support for confidence and security of citizens.
 
The conference was inaugurated by Dr. Juan José Rodriguez Sendin, president of the Medical College OMC, and Dr. André Bolliger Horisberger, president of the Professional Association of Physicians in Free Practice (ASPROMEL) 
 
Dr. Carmona, national representative of private medicine, said the aim of the meeting  to be "very timely in these times" where "the rights of doctors must be approached in a transversal way, as they cover all categories and specialties." However, as he regretted "these rights of doctors, despite everyone's assumes them as facts are not written anywhere."
 
The origin of this meeting, as recalled by the national representative of private medicine arises from the "Madrid Declaration", June 2015, (http://www.medicosypacientes.com/articulo/medicos-de-ejercicio-libre-de-europa-estudian-el-modelo-de-colaboracion-publica-privada-en) expressed in a resounding rejection of the violation of certain fundamental rights to every physician, driven by the European Association of Physicians in Free Practice  (EANA).
 
 
The chairman of the OMC, Dr. Rodriguez Sendín recalled during the inauguration, the obligations and commitments of doctors are necessarily linked to a number of rights; "It is impossible to serve those duties without guaranteed rights," he said.
 
At another point in his speech he said that the medical profession is justified on a bases of science, and grounded on four premises: "Using always the applied knowledge to the needs of patients. This knowledge grows through scientific development and innovation; a constant research for possible improvements will be pursued, and the scope of excellence is only possible if accompanied by ethical components established by the code of ethics ".
 
The link between rights and duties were illustrated with some examples such as freedom of prescription, the use of  techniques, as well as the right to a correct living wage. "Salaries and conditions of employment are a clear example of our rights, but they should be considered as a response to the duties with our patients," according to his words.
 
Moreover, he referred to the dilemma of how far "the duties of doctors and their rights may be conditioned to the means that the administration or the payer want to impose," or, on the contrary, "should remain a series of constant rights or duties “ In his view," the patient's life depends not only on the physician but also on the environment and the system in which the latter exercises “.
 
During the inauguration, the president of ASPROMEL and Treasurer of EANA,  Dr. André Bolliger, brings the best wishes from Brussels to Madrid for the organization and the success of today’s meeting. He thanked the President and the National Representatives of Private Medicine of the OMC, for the excellent cooperation they already have shown a year ago for the organization of EANA meeting in this very building. As a Psychiatrist and Psychotherapist, he explained that the respect of the fundamental rights of physicians have to be center-stage, because the severe and chronic imbalance between duties and rights are a major cause for burnout syndrome in health professionals. And we need healthy health professionals in healthy health systems in healthy societies. 
 
In the first Round-Table of the day, Dr. André Bolliger, noting the need for this type of Forum or Think Tank where  to talk about fundamental rights of doctors , focused his speech on" Human rights and the Doctor “. From his point of view," rights should not remain 'abstract letter', but "must be lived and implemented".
 
He approached at another point in his speech, the link between human rights and the doctor who, in his opinion, "is bidirectional". "The doctor, as a human being, is a beneficiary of human rights that protect him and, contemporary, as a professional is the guarantor of these same human rights for his patient, being the point from which emanate codes of practice and ethics".
 
The Vice-President of the OMC, Dr. Serafin Romero, also participating in this first table, elaborated on the "Rights in the field of doctors' own health and to be recognized socially." He recalled that doctors as citizens must have the right to health and as workers must have guaranteed services in labour health , tailored to their jobs and protected by regulations.
 
Dr. Romero cited the Code of Ethics where the protection of the health of physicians is also contemplated and therefore as a citizen who gets assistance, which results in the Comprehensive Care Program for Sick Doctors (PAIME) that provides for the health of health professionals. The OMC asks that health of health professionals  is certified through a Periodic Validation.
 
Moreover, in the international arena, Dr. Romero claimed that " international declarations that protect the volunteer and cooperating doctors have to be maintained in order to allow the development of their work."
 
At another point in his speech, he referred to the right to defend the professional prestige, "only from the professionalism and the abandonment of the culture of complaint we’ll be able to renew our social contract,  which is what  guarantees  us the recognition by the citizens “.
 
Rights in the exercise of the profession
 
For his part, the President of the Medical Association of Badajoz, Dr. Pedro Hidalgo, focused on the "Rights in the exercise of the medical profession” by means of a Decalogue based on the Code of Ethics, which includes, among others , the right to exercise their medical activities freely and without pressure of any kind. 
 
In addition, the doctor has the right to be respected in his clinical judgment (diagnosis and treatment) and in his freedom of prescription, as well as in its decision to reject the care of a patient, provided that such aspects are sustained on ethical, scientific and normative bases .
 
Another of the rights to which referred Dr. Hidalgo is to develop his career in facilities which ensure the safety and hygiene, according to the provisions of the regulations.
 
To receive from the institution which makes the provision of services, personal support services, supported by fully trained personnel and equipment, instruments and supplies equipment, tools needed, according to the service provided is another of the rights to which he referred.
 
Dr. Hidalgo also included the rights to refrain from guarantee results in relation to a particular healthcare process and the right to abstain to make final judgments about the expected outcomes of care .
 
Other rights mentioned by the speaker were those relating to respectful treatment, access to continuing medical education, to participate in research and teaching, to associate in organizations, professional associations, to facilitate defense of their professional prestige and be paid for professional services rendered according to their employment, contract or the agreement with the patient's condition.
 
To conclude his paper Dr. Hidalgo showed that the Spanish Penal Code still does not recognize the physician as an authority.
 
The first Round-Table was concluded by the national representative of employed doctors in Private Medicine , Dr. José María Nieto, who presented his approach on "Rights and Professional Training in the field of Research and Teaching" highlighting the right to specialized training, after obtaining the grade. Regarding continuing education he stressed the duty and the right on it by the professionals. In addition, he referred to the physician's right to participate in research projects and teaching as part of their professional development. 
 
In short, and in his view, "it is society itself that should give the professional the right to training, since it is  receiving the benefit of improving the skills manifested in the professionalism of the doctor."