Health System Performance Assessment Framework for the Slovak Republic

3. Indicators to assess the performance of the Slovak health system

Abstract

An inclusive stepwise process was undertaken to select indicators for the Slovak HSPA, engaging health system stakeholders in several discussions, voting on indicator prioritisation, and approving the final set of HSPA indicators in November 2025. The Slovak HSPA framework is populated by 110 indicators, which are distributed across the framework’s 18 domains. Domains under the Resources area include 26 indicators, while Prevention and risk factors domains have 22, Healthcare services 29, Outcomes 23, and Efficiency 10 indicators.

The chapter describes the comprehensive HSPA indicator selection process, with active participation of Slovak experts from more than 23 stakeholder organisations and governmental bodies. In addition, the chapter provides description of indicators selected in each framework domain.

3.1. Indicator selection methodology and process

The process of selecting indicators for the Slovak HSPA was designed to be thorough, transparent, and grounded in international best practice. Drawing on the OECD’s extensive experience supporting national HSPA framework development, including in Estonia (OECD, 2023[1]) and Czechia (OECD, 2023[2]), the overall approach in the Slovak Republic combined technical rigor with a strong emphasis on stakeholder engagement. Figure 3.1 outlines key activities undertaken to reach the final set of indicators for the Slovak HSPA framework, described through seven distinct but partially overlapping activities undertaken by the Slovak PMT, the Slovak health system stakeholders, and the OECD team between May 2025 and January 2026.

Figure 3.1. Overview of the HSPA indicator selection process in the Slovak Republic

Source: Developing HSPA framework for the Slovak Republic project.

3.1.1. From a comprehensive indicator repository to a pre‑selected indicator set

Activities 1‑4 in Figure 3.1 outline the initial steps in the indicator selection process, undertaken mainly by the Slovak PMT and the OECD team with technical and contextual input from the Slovak health system stakeholders.

1. Firstly, a comprehensive indicator repository was compiled by the OECD team. This comprised a comprehensive set of existing and potential indicators from multiple sources, including 1 084 indicators from datasets and publications managed by national health system and data organisations in the Slovak Republic (OECD (2025[3]) and Annex B), and 3 805 from international databases from the OECD, Eurostat, European Centres for Disease Control (ECDC) and the WHO. For each indicator, the OECD documented initial metadata: indicator source and custodian, type, availability, available disaggregation, and other relevant characteristics. For inspiration and reference purposes, 2 411 indicators used in national HSPAs in other countries and in the work of the European Commission’s Expert Group on HSPA1 were listed without accompanying metadata. These, together with 131 other indicators from other resources, resulted in a large repository of 7 402 potential indicators to consider for the Slovak HSPA.

2. Secondly, the OECD and the PMT organised four Technical Focus Group meetings with national experts from different organisations between June‑July 2025 (Annex A). The purpose of the meetings was to discuss selected HSPA themes, identified based on high theme prioritisation by stakeholders in PWG meetings in January 2025 (see Chapter 2, Figure 2.4) or where it was not clear what indicators or measurement approaches would be best suited to capture the theme in the Slovak HSPA. The meetings focussed on: 1) integrated care, 2) workforce, 3) cost monitoring and efficiency, and 4) governance (Section A.3 in Annex A). These exchanges generated new ideas for indicators or highlighted relevant existing metrics or datasets, with 26 additional indicators added to the Slovak indicator repository, resulting in 7 428 indicators in total.

3. Thirdly, the PMT and the OECD mapped indicators in the repository onto the domains specified in the first draft of the Slovak HSPA framework (see section 2.3) and consolidated the lists of possible indicators per each domain in July-August 2025. The purpose of the step was to (a) align indicators from the repository to the emerging structure of domains via mapping each indicator to a suitable domain based on what the domain captures; and (b) to identify and remove metrics duplicates, redundancies, and inconsistencies from the repository. As part of this review, duplicate repository indicators were consolidated (e.g. indicators which featured more than once in the repository due to their existence in multiple source databases – such as for international data collection questionnaires and same indicators from national data, or international joint data questionnaires), and the teams examined the extent to which each domain was supported by available data. During this stage, indicators that did not correspond to any of the framework domain descriptions (see Section 2.2), or that did not match the overall purpose and scope of the HSPA framework (see Section 2.1), were excluded to ensure the set of framework-mapped indicators would be coherent, meaningful, and aligned with the framework’s structure. This step resulted in a consolidated list of 871 indicators.

4. Fourth, a rigorous pre‑selection process was carried out by the PMT with the support of the OECD team. The objective of the pre‑selection was to identify, from the consolidated list of indicators mapped to the framework structure, those indicators that were most relevant and useful for each HSPA domain based on each domain description. The criteria of indicator data availability and indicator benchmarking possibilities were also considered during the pre‑selection process. This process resulted in a shortlist of 249 pre‑selected indicators, organised into draft HSPA framework domains. The 618 non-pre‑selected indicators (e.g. indicators left out of the step 3 list of domain-mapped indicators) were kept in the documentation of each domain, to support stakeholder choice during the voting process (see section 3.1.2) and to allow stakeholders to indicate if they considered any alternative indicator to be more appropriate. At this step, an approximate target number of indicators for each domain was defined, which would sum up to a total of 100 indicators across the Slovak HSPA framework.

Through this multi-stage process, starting from an extensive indicator repository and gradually narrowing the list of possible indicators down, the initial pool of 7 428 indicators was reduced to 249 candidate indicators for voting by the Slovak health system stakeholders in the next step.

3.1.2. Stakeholder voting to identify a draft list of HSPA indicators

Activity 5 in Figure 3.1 comprises the voting on indicators undertaken by the Slovak health system stakeholders.

5. The list of 249 pre‑selected indicators, distributed across 18 domains of the draft HSPA framework, was shared with members of the PWG for their voting, which took place in September-October 2025. The PWG stakeholders received an Excel file and were asked to vote for a defined number of indicators in each domain. In their voting, stakeholders had to prioritise some indicators over others and were asked to consider the following three elements: 1) Relevance of an indicator in questions for measuring the health system performance; 2) the level of comprehensiveness that their selected set of indicators would have in terms of describing the particular HSPA framework domain as a whole; and 3) whether an indicator aligns with, or supports, the Slovak HSPA purpose (see Box 3.1 for details). To select a technically feasible number of relevant indicators, which would make the Slovak HSPA a useful tool for its purpose, a total of 100 votes were assigned across the Slovak framework domains, to guide the stakeholders’ voting in the Excel file. Additionally, stakeholders were offered flexible options to fill in the voting file: Individual experts might choose to work together as a stakeholder group and submit a joint response on behalf of their organisations, or experts could complete the voting file individually and submit several separate Excel file responses on behalf of one stakeholder organisation. The total of 26 voting files were received from around 50 individuals who participated in the indicator voting exercise, representing 23 organisations, associations and governmental bodies of the Slovak health system.

Box 3.1. Principles to consider by stakeholders when voting on indicators

1. Relevance for measuring health system performance: Indicators should have high informational value for the given domain and be meaningful for assessing key aspects of system performance, including the status, processes or outcomes within that domain.

2. Comprehensiveness of the indicator set: The voted-on indicators in each domain should collectively provide a balanced and sufficiently comprehensive representation of that domain, based on its domain description.

3. Alignment with the purpose of the HSPA: Indicators should support the objectives of the Slovak HSPA and be suitable for monitoring progress and developments in the Slovak population health and health system over time.

Source: Developing HSPA framework for the Slovak Republic project.

Votes received by each indicator were summed up to produce a single metric that allowed for quantitative benchmarking within a domain. Weighting was applied to reflect cases where a voting file represented the vote of multiple experts, in case of organisations with a substantial role in data ownership and custody, and when multiple experts of the same stakeholder submitted their indicator preferences separately.

Using the pre‑defined target numbers of HSPA indicators for each domain, top-scoring candidate indicators were reviewed and proposed for inclusion in the HSPA by the PMT and the OECD teams. In preparation of the proposal to the PWG, each domain’s indicator set was reviewed, and, where considered necessary, some lower-scoring indicators were retained for discussion and proposed for inclusion among the higher-scored ones if justified by high policy relevance, importance for the Slovak context, international benchmarking value, to complement higher-scoring indicators, or to enhance data interpretation. In some cases, additional indicators were proposed as contextualising indicators, which identify data outside of the HSPA framework that is relevant to consider in an analysis of a given HSPA indicator (NB, Annex D provides details on the final set of these contextualising indicators).

The results of the stakeholder voting, including the number of votes received, indication of the candidate indicators to be selected, and highlighting indicators retained for PWG group discussion, were shared with the PWG members ahead of dedicated PWG meetings, in which the candidate indicators were then reviewed and discussed by domain (see Activity 6 below).

3.1.3. Finalisation of the list of indicators for the HSPA

Activities 6 and 7 in Figure 3.1 focussed on finalisation of the list of Slovak HSPA indicators, including reaching a common agreement across stakeholder representatives.

6. Two PWG meetings were held in November 2025 to discuss voting results, validate indicator selection, and reach agreements on the final set of indicators for the Slovak HSPA that would reflect diverse perspectives across PWG members. During the meetings, the PMT and OECD provided an overview of the proposed candidate indicators within each domain based on the results of stakeholders’ voting. Each domain presentation was followed by a brief discussion allowing stakeholders to provide feedback, clarify or suggest further considerations on the proposed indicators. Ten framework domains were discussed during the first dedicated PWG meeting, and eight framework domains were discussed during the second PWG meeting. These meetings resulted in a commonly agreed-on set of indicators populating the 18 domains of the Slovak HSPA framework (see section 2.2 for domain description). The set of HSPA indicators consented by the PWG was presented to the HLAB and approved at its meeting in November 2025.

7. In the first quarter of 2026, the PMT, supported by the OECD team, further consulted the final set the Slovak HSPA indicators in bilateral meetings with stakeholders and data custodians to complement indicator specifications and refine technical details such as precising data availability, data source, and data update frequency; this information would feed into the development of indicator technical sheets during the HSPA implementation process. The consultations also confirmed HSPA indicator custodianships for the final list of indicators (see section 5.1.4).

Throughout the indicator selection process, Slovak stakeholders were actively engaged and contributed to various steps to reach the final list of HSPA indicators, ensuring indicator set populating the Slovak HSPA framework reflects their diverse perspectives. Box 3.2 provides a summary of activities that involved active contributions and inputs from a broad stakeholder representation throughout the Slovak HSPA indicator selection process.

Box 3.2. The Slovak health system stakeholders were actively involved in the selection of Slovak HSPA indicators

To ensure that Slovak HSPA indicators reflect diverse stakeholder perspectives, stakeholders across the Slovak health system were engaged in various steps of the Slovak HSPA indicator selection process, in particular in Activities 2, 5, 6 and 7 (see Figure 3.1).

• Activity 2 included four Technical Focus Groups (TFC), held in June and July 2025. Depending on the specific topic of the TFC, each TFC was attended by representatives from six to eight organisations who contributed their insights to identify relevant indicators and priorities.

• Activity 5 encompassed stakeholder voting in September-October 2025, which involved active participation (voting) of around 50 individuals representing 26 organisations in the Slovak health system. The methodology for Activity 5 was introduced to the PWG in its meeting in September 2025, attended by 26 participants, representing 19 health sector organisations and governmental bodies.

• Activity 6 to reach agreements on the final indicator set involved two meetings of the PWG and one meeting of the HLAB. Two PWG meetings on consecutive days in November 2025 were attended by around 29 participants, representing some 20 organisations and governmental bodies across the Slovak health system.

• Activity 7 comprised several bilateral meetings of the PMT and the Slovak health system stakeholders, mainly data custodians, to refine indicator details and agree on HSPA indicator custodianship.

Annex A provides an overview of the main stakeholder meetings throughout the project.

3.2. Indicators populating the Slovak HSPA framework

A total of 110 indicators populate the Slovak HSPA framework. The number and distribution of indicators across domains, selected through a rigorous multi-stage process (see section 3.1), seeks to balance practical feasibility with measurement depth to meet the objectives of the Slovak HSPA. Figure 3.2 summarises the distribution of indicators across the framework’s five thematic areas and 18 domains.

Sections 3.2.1 – 3.2.5 below provide an overview of indicators in the Slovak HSPA framework domains, with subsections starting with a description of each domain and complemented by tables summarising selected technical details on the indicators. For reference, Box 3.3 explains indicator technical details by providing definitions of terminology used in the indicator summary tables throughout this subchapter (more information on indicator technical sheets is provided in Annex C). Where relevant, the below subsections highlight information and topics considered particularly important by the Slovak health system stakeholders during the HSPA indicator selection process, in related discussions and in subsequent bilateral consultations. While organisations with responsibility for HSPA indicators are mentioned in this chapter, Chapter 5 on the Slovak HSPA governance and implementation summarises the specific roles of HSPA indicator custodians in the context of HSPA implementation.

Figure 3.2. Distribution of the Slovak HSPA indicators across the 18 framework domains

Source: Developing HSPA framework for the Slovak Republic project.

The majority of the 110 indicators populating the Slovak HSPA framework (Figure 3.2) come from data and indicator sources that are existent, i.e. readily available, reflecting the emphasis put on data availability during the indicator selection process. In addition, 23 HSPA indicators are placeholder indicators where further development is needed; among them, underlying data sources exist for 14 indicators while for 9 indicators Slovak data do not exist. Further, Slovak HSPA indicators are complemented by 25 contextualising indicators which offer additional information relevant to interpretation and analyses of selected HSPA indicators (see Annex D).

Among the Slovak HSPA indicators, 85 are derived from international data collections and databases, by default allowing for benchmarking with other countries (see Annex B for more information on the Slovak health data landscape).

The present list of Slovak HSPA indicators serves as a key input into the Slovak HSPA implementation. It is expected that further technical discussions among HSPA stakeholders, in particular with data and HSPA indicator custodians, would support development of indicator technical sheets detailing indicator definitions, calculation methods and reporting arrangements.

Box 3.3. Explanations of technical information included in indicator tables within Section 3.2, and related indicator statistics

Comparability: Indicates the geographic level at which benchmarking of the indicator is possible. Indicators comparisons are included as international (86 indicators) and regional (40 indicators). For three indicators, no possibilities to benchmark within or across countries are known. For several indicators, both international and regional comparisons are possible. In some cases, international data or regional breakdown is possible through using contextualising indicators. Comparability for 2 indicators has not been defined.

Indicator breakdown: Specifies available disaggregations, such as age, sex/gender, region, or socio-economic characteristics (e.g. education, income, employment status). Indicators can be available by NUTS2 territorial classification (4 territories exist in the Slovak Republic), region (8 regions exist in the Slovak Republic), and by district (79 districts in the Slovak Republic).

Responsibility in HSPA: Indicates the organisation responsible for the indicator within the HSPA framework. This would typically include indicator drafting and maintaining the indicator sheet, documenting calculation methodology, and providing analytical data interpretation. In several cases, joint HSPA indicator custodianship arrangements were assigned in the tables below (indicated through the use of square brackets [ ] where one of the organisations is leading, and the sign “+” where custodianship is planned to be equally shared between two organisations. Organisations marked in this column in italic are included as proposed indicator custodians whose role will be further clarified during the HSPA implementation process.

Indicator production and publication: Identifies where indicator can be sourced from for the HSPA, including the organisation that produces or disseminates the indicator and the associated survey, registry, or reporting mechanism through which the indicator is published (e.g. Eurostat database, OECD data collections and databases, national reports).

Custodian of the dataset: The organisation(s) responsible for managing the primary dataset(s) from which the indicator is calculated, such as administrative databases, registries, or surveys.

Availability: Describes the current readiness of the data for reporting purposes, distinguishing between indicators that are readily available (“Available”, 87 indicators), placeholders requiring calculation from existing data (“Placeholder (data available)”, 14 indicators), and placeholders for which data do not yet exist (“Placeholder”, 9 indicators).

Frequency: Indicates how often the data of an indicator is collected or an indicator source is updated. Most indicators (70) are updated annually, while fewer are updated more often (monthly or quarterly; 4 indicators), once every two years (11 indicators), or every three years or longer (21 indicators). Four indicators do not have a defined data update frequency.

Note: Detailed technical definitions (including calculation methods, data coverage, limitations, supplementary indicators, and rationale) as well as full descriptions of comparability categories, frequency tiers, and availability classifications are provided in Annex C.

3.2.1. Resources

In the Slovak HSPA framework, the thematic area of Resources reviews inputs into the healthcare provision process, both in terms of direct structures, such as human capacity and finances, and in terms of the overall system in which structures exist, such as governance and the relationship to research and development activities. The thematic area of Resources includes six domains, populated with a total of 26 HSPA indicators.

Workforce

The Workforce domain provides an overview of the availability, distribution and sustainability of the Slovak healthcare workforce. This domain includes eight indicators on physician and nursing workforce availability, primary care capacity and ageing, training outputs and wage costs (Table 3.1). This set of indicators enables assessment of staffing levels, regional capacity imbalances and long-term workforce sustainability.

Table 3.1. Workforce domain indicators

Name of the indicator	Comparability and indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Physicians per population	International, regional1 By age, groups of medical specialty, sex	NCZI	OECD (JQNMHS2: Health employment and education)	NCZI	Available3, updated annually
General practitioners per population	International, regional1	NCZI	OECD (JQNMHS2: Health employment and education)	NCZI	Available3, updated annually
Average age of general practitioners	Regional By district, region	ÚDZS	ÚDZS (Údaje o vyhodnotení sietí podľa zákona č. 578/2004 Z. z.4)	ÚDZS	Available, updated annually
Professionally active nurses per population	International By age, gender	NCZI	OECD (JQNMHS2: Health employment and education)	NCZI	Available, updated annually
Outpatient care: Physicians’ job posts (full-time equivalents, FTE) per population	Regional By district, medical specialty, region	ÚDZS	ÚDZS (Údaje o vyhodnotení sietí podľa zákona č. 578/2004 Z. z.4)	ÚDZS	Available, updated annually
Inpatient care: Evolution of the number of doctors and nurses	Regional By provider, region, specialty	NCZI	NCZI (Tematické výstupy: Posteľový fond [Thematic outputs: Hospital bed capacity])	NCZI	Available, updated annually
Medical graduates	International By nationality1, university	IZA [CVTI]	OECD (JQNMHS2: Health employment and education)	CVTI	Available, updated annually
Remuneration of salaried health professionals	International By profession (specialists, nurses), sex	NCZI	OECD (Health Data questionnaire: Remuneration of health professionals)	NCZI	Available, updated annually

Notes: 1. Breakdown is available through national sources for the same indicator (see Annex D for further information).

1. Joint Data Collection on Non-monetary Healthcare Statistics.

2. Indicator is available nationally in the Slovak Republic, but has not been reported to international sources.

3. Data on evaluation of healthcare networks as per the Act No. 578/2004 Coll.

Source: Developing HSPA framework for the Slovak Republic project.

Regarding workforce capacity and distribution, the indicator on Physicians per population allows for international comparison and assessment of the distribution of broad professional categories (e.g. general practitioners and specialist medical practitioners). The underlying national data are maintained by the NCZI through the National Healthcare Workers Registry and reported internationally to the OECD through the Joint Questionnaire on Non-Monetary Healthcare Statistics (JQNMHS), which provides a standard framework for cross-country comparison of health workforce indicators. The indicator has previously been reported for professionally active physicians only (regardless of whether they provide care for patients or work in other jobs requiring medical education) and without breakdowns by medical specialty. According to the Slovak national experts, it can, however, be calculated for practicing physicians only (i.e. those providing direct care for patients), and by medical specialty, and therefore used for international comparisons. Analyses of this indicator are accompanied by two contextualising indicators on the Number and density of doctors by regions, and the Share of doctors aged 55 and older, for insights into workforce sub-national granularity, geographical distribution and potential attrition due to retirement. Together, they allow for an understanding of the physician workforce and its sustainability.

A perspective on primary care is provided through the indicator on General practitioners (GPs) per population, which highlights current capacity. Similarly to the indicator on Physicians, it can be nationally calculated for practicing GPs and compared internationally. The indicator Average age of general practitioners serves as a proxy for anticipating upcoming GP replacement needs due to retirements. It is sourced from ÚDZS, which collects this information directly through its outpatient network evaluations, providing district-level precision. The analysis of this indicator is accompanied by a contextual indicator on the Share of GPs beyond retirement age (63 and older), also from ÚDZS.

The indicator on Professionally active nurses per population reflects the availability of nursing workforce per 1 000 inhabitants, capturing nurses who are currently employed in any field requiring prior nursing education. While it is sourced from the same data collection as for physicians, data limitations prevent identification of those currently providing direct patient care (“practicing” nurses). As such, the indicator reflects professionally active nurses rather than those actively delivering care.

Looking more closely at different care settings, the indicators Outpatient care: Physicians’ job posts (full-time equivalents, FTE) per population and Inpatient care: evolution of the number of doctors and nurses in inpatient healthcare provide a baseline view of staffing levels and trends in out- and inpatient settings, including potential regional imbalances. The indicators can be assessed by specific specialities (e.g. oncology, cardiology, etc.), allowing for a detailed analysis of availability gaps across specialisations. Both indicators additionally provide a breakdown by regions and districts, although international comparisons are not possible. The indicator on outpatient care is sourced from ÚDZS, as it holds the statutory mandate to evaluate outpatient provider networks, making it the most authoritative source for outpatient staffing data. The inpatient indicator is maintained by NCZI through its hospital bed capacity database, which is the central national repository for inpatient facility data.

Regarding educational capacity and the training pipeline, the indicator on Medical graduates looks at training outputs, sourced from the OECD JQNMHS collection with underlying data maintained by Centre for Scientific and Technical Information (CVTI) through its university yearbook. CVTI is the designated national authority for higher education statistics, making it the most reliable source for graduate counts. However, this indicator should be interpreted alongside migration patterns and the large presence of foreign students, as not all graduates remain in the Slovak Republic to practise (OECD/European Observatory on Health Systems and Policies, 2025[4]).

Remuneration of salaried health professionals adds an economic lens to workforce sustainability, supporting interpretation of recruitment and retention dynamics alongside staffing headcounts. Data are available for employees only, covering specialist doctors and nurses working in hospitals. The indicator can be expressed both as annual wage and as ratio to the national average wage, allowing for analysis of trends over time and comparison of remuneration in health professions relative to other occupations. This indicator is contextualised by the national indicator on Healthcare wage costs (inpatient care), sourced by NCZI facilities directly subordinated to the MoH, while private providers are not required to report these data. While this indicator provides a breakdown by specialty, its use for international comparison remains limited.

Financing

The Financing domain addresses health system and care expenditures. It examines how much is spent on healthcare, where that money goes, who pays for it and whether current spending levels are sustainable in the long term. This domain includes seven indicators tracking overall health expenditure and its allocation across care settings, investment in physical infrastructure, pharmaceutical costs split between public insurers and patients, fiscal prioritisation and long-term spending projections (Table 3.2). The selection combines routinely available expenditure metrics with forward-looking projections, supporting both descriptive reporting and discussion on sustainability.

Table 3.2. Financing domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Health expenditure	International Total and by type of service1	ŠÚ SR [IZA]	Eurostat (Eurostat: National accounts)	ŠÚ SR	Available, updated annually
Expenditure on hospital care (by DRG, non-DRG categories)	National By group of providers (associations), HIC2, ownership of providers, provider	ÚDZS	ÚDZS (Správa o stave vykonávania verejného zdravotného poistenia)	ÚDZS	Available, updated quarterly
Annual capital expenditure3 (value of physical resources) in health sector	International By type of asset4	ŠÚ SR	OECD (Annual capital formation)	ŠÚ SR	Available, updated annually
Pharmaceutical costs of health insurers5	International By HIC, name of medicine, type of ATC, DG, type of reimbursement	NCZI	NCZI (Štatistika spotreby v zdravotníctve6)	NCZI	Available, updated quarterly
Pharmaceutical costs of patients (prescribed and over-the‑counter)	International By HIC, name of medicine, type of ATC, DG, type of reimbursement	NCZI	NCZI (Štatistika spotreby v zdravotníctve6)	NCZI	Available, updated quarterly
Public spending on health, percentage of total government spending	International By type of care	IZA [RRZ]	Eurostat (Economy and finance: Annual Government finance statistics)	ŠÚ SR and IZA	Available, updated annually
Public spending on healthcare and long-term care – baseline scenario, forecast to 2070	International By type of scenarios (e.g. healthy vs. no – healthy ageing)	IZA [RRZ]	European Commission (Economy and finance: Annual Government finance statistics)	European Commission and EPC-AWG7	Available, updated every 3 years

Notes: 1. Inpatient care, outpatient care, long-term care, medical goods, prevention, collective services.

1. Health Insurance Companies (HIC).

2. Annual capital expenditure (value of physical resources) in health sector refers to gross fixed capital formation.

3. A breakdown is available by type of asset: infrastructure (e.g. hospitals and clinics), machinery and equipment (e.g. diagnostic and surgical machinery, ambulances and ICT equipment), and software and databases.

4. Pharmaceutical costs of health insurers include hospital-administered drugs

5. Tematické štatistické výstupy – Spotreba humánnych liekov, zdravotníckych pomôôcok a dietetických potravín.

6. Economic Policy Committee – Ageing Working Group.

Source: Developing HSPA framework for the Slovak Republic project.

Capturing expenditure levels and allocation, Health expenditure indicator (total and by type of service) characterises how resources are distributed across care settings such as inpatient care, outpatient care, long-term care, medical goods, prevention and collective services. It is sourced from the Eurostat database on National Accounts, compiled nationally by ŠÚ SR using the methodology of the OECD’s System of Health Accounts (SHA), which ensures harmonised methodology for cross-country comparisons. Analyses of this indicator can be accompanied by a contextualising indicator on Health expenditure by financing type, which allows for an additional breakdown of expenditure by source. Expenditure on hospital care (DRG and non-DRG categories) looks at expenditure across payment categories, reflecting distribution of resources among hospitals. This allows detailed monitoring of inpatient care expenditures by payment mechanisms across hospital associations. This indicator is sourced from ÚDZS through its Report on the status of public health insurance implementation. It should be noted that payment mechanisms are gradually transitioning to the DRG system in the Slovak Republic, which affects time trends.

The indicator Annual capital expenditure (physical resources) in health and social work provides a proxy for investment in physical resources, such as infrastructure (e.g. hospitals and clinics), machinery and equipment (e.g. diagnostic and surgical machinery, ambulances and ICT equipment), as well as software and databases. It is sourced from the OECD using the classification methodology of the International Standard Industrial Classification of All Economic Activities.

Pharmaceutical financing is captured through two measures reflecting pooled financing and direct household spending: Pharmaceutical costs of health insurers (including by reimbursement type) and Pharmaceutical costs of patients (prescribed and over-the‑counter). Both are sourced from NCZI through its thematic outputs on consumption of human medicines, medical devices and dietetic foods, which is the most comprehensive national database on pharmaceutical consumption capturing both costs and volumes. The pharmaceutical costs of health insurers indicator includes pharmaceuticals used in hospitals, and analyses are complemented by a contextualising indicator National data by type of pharmaceutical reimbursement (% of A&AS-reimbursed pharmaceuticals in public expenditure on pharmaceuticals), which provides further insight into the structure of public pharmaceutical spending and the relative weight of different reimbursement mechanisms.

Regarding fiscal outlook, the indicator on Public spending on health as a share of total government spending signals positioning of healthcare within overall public finances, sourced from Eurostat’s Annual Government finance statistics database, with national data compiled by ŠÚ SR and IZA. Finally, the EC’s baseline forecast of Public spending on healthcare and long-term care to 2070 supports assessment of long-term fiscal sustainability pressures, drawing on the EC’s Ageing Report produced jointly with the Economic Policy Committee’s Ageing Working Group. This projection is updated every three years based on Eurostat’s population projections (EUROPOP) and allows comparison of sustainability pressures across EU member states.

International comparisons are available for all indicators in this domain except Expenditure on hospital care, which captures spending by national DRG categories.

Infrastructure

The Infrastructure domain provides an overview of current state of healthcare facilities, by capturing the physical capacity of the healthcare system to deliver care. Three indicators are in this domain, covering hospital bed density, beds in residential long-term care facilities and medical technology availability (Table 3.3). All three are aligned with international data collections, supporting cross-country benchmarking and contextual interpretation of capacity gaps.

Table 3.3. Infrastructure domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Hospital beds (number and density)	International, regional1 By care type, healthcare functions, ownership, region3	NCZI	OECD (JQNMHS2: Physical and technical resources)	NCZI	Available, updated annually
Beds in residential long-term care facilities	International	MPSVR3	OECD (JQNMHS2: Physical and technical resources)	MPSVR3	Available, updated annually
Medical technology availability (CT scanners, MRI units, and PET scanners)	International By medical technology type	NCZI	OECD (JQNMHS2: Physical and technical resources)	NCZI	Available, updated annually

Notes: 1. Regional comparison is available through national sources for the same indicator (see Annex D for further information).

1. Joint Data Collection on Non-monetary Healthcare Statistics.

2. Ministry of labour and social affairs of the Slovak Republic.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator on Hospital beds captures institutional care infrastructure in inpatient care, including beds that are regularly maintained and staffed and that are immediately available for use. Beds in residential long-term care facilities are not included in this indicator. Hospital beds are available by eight regions in the Slovak Republic. Additional breakdowns by hospital ownership (private vs. public), healthcare function (curative, rehabilitative, long-term care, other) and care type (somatic care, psychiatric care) are available and can be compared internationally. Beds in residential long-term care facilities captures care infrastructure formal residential long-term care, measured per 1 000 population aged 65 and over. It should be noted that this indicator does not include hospital beds intended for long-term care, nor beds in residential facilities such as adapted apartments that can be considered people’s homes.

Medical technology availability, measured through the number of CT scanners, MRI units and PET scanners per population, offers a practical proxy for diagnostic capacity and modern service readiness. As all three measures in this domain are sourced from the same international collection framework (OECD’s JQNMHS), they support benchmarking and contextual interpretation of capacity gaps relative to other countries.

Digitalisation and data

The Digitalisation and data domain reviews progress in adopting digital tools within healthcare delivery and information sharing. This domain includes three indicators covering teleconsultations, use of electronic referral tools and the share of providers using electronic health records to exchange patient information (Table 3.4). Together, these indicators support discussions on how digitalisation may influence access, care continuity and care provision efficiency.

Table 3.4. Digitalisation and data domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Teleconsultations per capita, and as a share of all consultations	National By age, gender, activity, HIC	IZA	IZA	NCZI	Placeholder (data available), updated annually
Patients referred by using electronic referral tools	Regional By age, gender, HIC, specialty of provider	NCZI	NCZI (eZdravie1)	NCZI	Placeholder (data available), updated annually
Providers using eRecords to share information	Regional By age, gender, HIC, specialty of provider	NCZI	NCZI (eZdravie1)	NCZI	Available, updated annually

Note: 1. eHealth.

Source: Developing HSPA framework for the Slovak Republic project.

Regarding use of digital services, the indicator on Teleconsultations, measured per capita and as a share of all consultations, quantifies remote care delivery. Although currently a placeholder, this indicator could be calculated by IZA using national country-specific methodology. As such, the indicator will allow for an analysis of national time trends as well as breakdowns by age and gender of the patients, but methodological differences may not support international comparisons. An additional breakdown by activity allows an analysis on whether the consultation took place by email/phone, as a video call or concerned reissuance of prescriptions and referrals, or psychotherapeutic interventions. In parallel, Patients referred using electronic referral tools as a percentage of all referrals captures digitalisation of patient pathways and referral management, an important mechanism for co‑ordination and demand management between levels of care. This indicator is sourced from NCZI’s eHealth (eZdravie) system, which also provides breakdowns by specialty of provider, age, gender and health insurance company. Both measures are currently marked as placeholders, as the indicators have not been calculated in the past.

Regarding interoperability and information sharing, the indicator on Providers using eRecords to share information about patients with other providers, measured as a percentage of all providers, provides am information on the progress toward routine exchange of patient information across the healthcare system. This measure is readily available for analysis, with data covering the past five years. It should be noted that the eHealth (eZdravie) dataset only includes statistics of doctors making entries into electronic health records, as non-medical health workers do not currently report to the system. Together, these indicators can support discussions on how digitalisation may influence concepts captured under domains of Access, Care continuity, and Care provision efficiency.

Governance

The Governance domain looks at population’s overall perceptions of the health and care system. This domain includes two indicators measuring satisfaction with the healthcare system and perceived availability of quality healthcare in the local area (Table 3.5). These complement technical performance measures in the HSPA framework by providing a population perspective on system performance.

Table 3.5. Governance domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Satisfaction with the healthcare system	International By extent of satisfaction (4 scales)	IZA	OECD (Survey on Drivers of Trust in Public Institutions)	OECD	Available, updated every 2 years
Population satisfied with the availability of quality healthcare in the area where they live	International	IZA [RRZ]	Gallup World Poll	Gallup World Poll	Available, updated annually

Source: Developing HSPA framework for the Slovak Republic project.

The indicator Satisfaction with the healthcare system is derived from the international OECD Survey on Drivers of Trust in Public Institutions, which collects data on public perceptions across OECD countries in a two‑year cycle since 2021. It provides an indication of the population’s overall assessment of the national health system, disaggregated by extent of satisfaction on a four‑point scale, and can be used to track trends over time. The indicator Population satisfied with the availability of quality healthcare in the area where they live, sourced from the Gallup World Poll, focusses more specifically on perceived local access to quality services. Gallup World Poll data are collected annually and cover more than ten years, offering a longer time series for trend analysis. These indicators are reflecting subjective assessments sensitive to governance of the health and healthcare system in the Slovak Republic.

Research and innovation

The Research and innovation domain monitors Slovak capacity for health-related research and innovation. This domain includes three indicators covering new clinical trials, pharmaceutical industry R&D investment and research activity (Table 3.6). The domain thus provides insight into the innovation ecosystem, research capacity and the country’s integration into international research networks.

Table 3.6. Research and innovation domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
New clinical trials	International Total and by sponsorship type (public, industry)	ŠÚKL	European Medicines Agency (Clinical Trials Information System)	The European Medicines Agency	Available, updated annually
Pharmaceutical industry R&D investment	International None	ŠÚ SR	OECD (BERD1 expenditure statistics)	ŠÚ SR	Available, updated annually
Number of publications from research projects, organisations funded from public sources	Regional By provider, region, type of a publication	IZA [CVTI]	MoH and CVTI2 (Research and development database SK CRIS)	CVTI	Placeholder (data available)

Notes: 1. Business Enterprise Expenditure on R&D (BERD).

1. Centrum vedecko technických informácií.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator on the New clinical trials per million population per year provides an internationally recognisable proxy for clinical research intensity and the attractiveness of the country as a location for trials. It is sourced from the European Medicines Agency via its Clinical Trials Information System platform, which lists trials that have been registered in European countries. It should be noted clinical trials are often active in many countries at once. The indicator on Pharmaceutical industry R&D investment (available as percentage of GDP and per capita PPP) provides a financing lens on innovation capacity and private sector activities. Both indicators come from international sources, with comparison to other countries possible.

The third indicator in this domain, Number of publications from research projects in healthcare organisations funded from public sources, measures the research output and scientific productivity of publicly funded providers. Currently a placeholder, it will be produced by IZA using MoH internal data collection and the national R&D database (SK CRIS), with CVTI as the data custodian. This analysis is complemented by a contextualising indicator, Number of organisations involved in biomedical research and clinical trials, which is also sourced from IZA and provides additional insight into the scale of organisational participation in research activities.

3.2.2. Prevention and risk factors

The area of Prevention and risk factors focusses on healthcare services and circumstances which relate to disease avoidance or disease progression. The Prevention and risk factors thematic area includes four domains, with a total of 22 indicators selected.

Health literacy

The Health literacy domain looks at population’s ability to access, understand and use health information. This domain includes three indicators covering general health literacy levels, perceived complexity of health issues and confidence in using online health information for decision making. The three selected indicators support identification of vulnerable groups and can help inform targeted education and communication strategies (Table 3.7).

Table 3.7. Health literacy domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Percentage of respondents by categorical level of general health literacy as measured by the HLS19‑Q12	International	IZA	WHO (HLS1)	ÚVZ	Available, updated every 5 years
Health literacy – Patients reporting that most health issues are too complex for them to understand	International By age, education, gender, income	IZA	OECD (PaRIS2)	IZA	Placeholder, updated every 4 years
Digital health literacy – patients reporting they are confident in using information from the internet to make health decisions	International By age, education, gender, income	IZA	OECD (PaRIS2)	IZA	Placeholder, updated every 4 years

Notes: 1. Health Literacy Survey (a project of M-POHL).

1. Patient-Reported Indicator Surveys.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator on the Percentage of respondents by categorical level of general health literacy from the European Health Literacy survey provides a structured measurement of health literacy, classifying scores into categories of inadequate, problematic, sufficient and excellent (The HLS19 Consortium of the WHO Action Network M-POHL, 2021[10]). While other compound indicators on health literacy are not currently available for the Slovak population, this indicator can still be used to discuss whether barriers to effective prevention and service use are partly driven by information access, comprehension, and confidence. Consideration will be given to the representativeness of the Slovak sample responding to the survey.

In addition, two self-reported health literacy indicators from the OECD Patient-Reported Indicators Surveys (PaRIS) look at primary care users aged 45 and above, most of whom have chronic health conditions. The indicator Health literacy is defined through the proportion of patients who report that most health issues are too complex to understand, and the indicator Digital health literacy is defined through the proportion of patients who are confident using internet information to make health decisions. These indicators are placeholder indicators in the Slovak HSPA framework as of 2026, as the Slovak Republic was not participating in the first cycle of the OECD PaRIS survey; participation in the 2028 cycle of the survey is however planned. Inclusion of these placeholder indicators anticipates future strengthening of the framework with internationally comparable patient-reported data and a clear link between literacy and performance in primary care.

Prevention

The Prevention domain focuses on healthcare services that can prevent disease onset or development, and on services leading to early disease detection. This domain includes eight indicators capturing expenditure on prevention, childhood and adult vaccination coverage, cancer screening programme and preventive check-ups attendance (Table 3.8). The indicator set supports a comprehensive assessment ranging from prevention inputs (expenditure) to prevention outputs (programme participation and coverage), encompassing simultaneously policy effort and population responses.

Table 3.8. Prevention domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Expenditure on prevention, percentage of total health expenditure	International By financing scheme, type of provider	ŠÚ SR	Eurostat (National accounts)	ŠÚ SR	Available, updated annually
Childhood vaccination rates among eligible children	International1, regional By district, region, vaccine	ÚVZ	ÚVZ (Vyhodnotenie administratívnej kontroly očkovania2)	ÚVZ	Available, updated annually
HPV vaccination among girls aged up to 15	International By number of doses	NSC	WHO (WHO/UNICEF Joint Reporting Form on Immunisation)	NCZI	Available, updated annually
Influenza vaccination rate among older adults	International By gender	ÚVZ	OECD (JQNMHS3)	ÚVZ	Available, updated annually
Mammography screening within the past two years (women 50‑69)	International, regional4 By age, district4, education1, income1, region4	NSC [NCZI]	OECD (JQNMHS3: Healthcare activities)	NCZI	Available, updated annually
Colorectal cancer screening	International, regional4 By age, district4, education1, gender, income1, region4	NSC [NCZI]	OECD (JQNMHS3: Healthcare activities)	NCZI	Available, updated annually
Cervical cancer screening	International, regional4 By age, district4, education1, income1, region4	NSC [NCZI]	OECD (JQNMHS3: Healthcare activities)	NCZI	Available, updated annually
Preventive check-ups attendance, based on patients’ entitlement under Act No. 577/2004	Regional By HICs, region, type of preventive check-up	ÚDZS	ÚDZS (Správa o stave vykonávania verejného zdravotného poistenia5)	ÚDZS	Available, updated annually

Notes: 1. Available when using contextualising indicators.

1. Evaluation of administrative vaccination control

2. Joint Questionnaire on Non-monetary Health Statistics.

3. Regional comparison is available through national sources for the same indicator (see Annex D for further information).

4. Report on the status of public health insurance implementation.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator Expenditure on prevention as a share of total health expenditure provides a financing anchor to interpret prioritisation of prevention in the health system and policy. It measures prevention expenditure as a percentage of total health expenditure, with breakdowns available, and internationally comparable, by financing scheme and type of provider. The indicator captures spending on activities such as vaccination, screening and health promotion. Although it is connected to expenditure indicators included in the Financing domain, this indicator was included for dedicated analysis in the Prevention domain. It should be noted that the Slovak Republic did not previously report all types of vaccines in the immunisation programmes sub-category, which made prevention expenditure somewhat under-reported in international comparisons; plans are to improve this reporting category as of now.

Childhood immunisation coverage is captured via the indicator Childhood vaccination rates among eligible children, capturing children who have received mandatory vaccines (Diphtheria-Tetanus-Pertussis (DTP), Measles-Mumps-Rubeola (MMR), Polio and Hepatitis B). The indicator is available for each vaccine included in the national vaccination schedule at specific ages and can be analysed on a regional and district level. It should be noted the data is collected by ÚVZ directly from providers of primary care services, rather than health insurance company data, and data validity is not independently verified. This country-level indicator is contextualised by two indicators from international data collections on Vaccination of children against DTP and measles, which contextualise developments in communicable disease incidence. Among teenagers, the indicator on Human papillomavirus (HPV) vaccination among girls aged 15 relates to voluntary vaccination uptake and service delivery. This indicator is complemented by the contextualising indicator on HPV vaccination in boys aged 15. Influenza vaccination rate among older adults tracks coverage for a key vaccine‑preventable risk. It should be noted that Slovak data refer to the eligible population aged 59 and over, rather than the international definition of age 65 and over.

Regarding screening, three indicators on Breast, Cervical, and Colorectal cancer screening provide a measure of uptake of core secondary prevention programmes and allow for international comparisons in a given year. All three are sourced from the OECD JQNMHS data collection on healthcare activities, with national data maintained by NCZI using a mixture of health insurance data and oncology screening programme records. Analyses of these are complemented by three contextualising indicators from the European Health Interview Survey (EHIS), which provide self-reported measures on screening coverage within recommended timeframes, alongside breakdowns by age, education and income: Self-reported breast examination by x-ray among women, Self-reported cervical smear test among women and Self-reported colorectal cancer screening test. Additionally, country-level analyses by region and district are supported by national sources for the HSPA indicators.

Finally, the indicator on Preventive check-ups attendance captures attendance in primary care checkups defined in legislature at specific ages and defined intervals, based on patients’ entitlement under Act No. 577/2004. It is sourced from ÚDZS through its Report on the Status of Public Health Insurance Implementation, using claims and reimbursement data. As the data are based on health insurance company reports, direct out-of-pocket preventive services may not be captured.

Behavioural determinants

The Behavioural determinants domain focuses on modifiable lifestyle and behavioural risk factors linked to non-communicable disease burden. This domain includes eight indicators covering the mortality burden attributable to behavioural risks, as well as smoking, alcohol consumption, fruit and vegetable intake, sugar-sweetened drink consumption, physical activity and body mass index (Table 3.9). The selection provides a broad behavioural profile that can be linked to health outcomes and supports equity analysis through detailed socio‑economic and demographic breakdowns.

Table 3.9. Behavioural determinants domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Burden of mortality attributable to risk factors (behavioural risks)	International By age, diseases, groups, gender, risk factors	ÚVZ	IHME1 (Global Burden of Disease study)	ŠÚ SR	Available, updated every 2‑3 years
Daily smokers of cigarettes	International By age, education, economic activity, income, number of cigarettes smoked, sex	ÚVZ [ŠÚ SR]	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years
15‑year‑olds who have smoked cigarettes at least once over the last 30 days	International By gender, perceived family affluence	ÚVZ	WHO (HBSC3)	Pavol Josef Šafárik Universiy in Košice	Available, updated every 4 years
Frequency of alcohol consumption	International By age, education, economic activity, income, sex	ÚVZ [ŠÚ SR]	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years
Daily consumption of fruit, vegetables	International By age, education, economic activity, income, sex	ÚVZ [ŠÚ SR]	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years
Frequency of drinking sugar-sweetened soft drinks	International By age, education, economic activity, income, sex	ÚVZ [ŠÚ SR]	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years
Performing health-enhancing physical activity	International By age, education, income, sex	ÚVZ [ŠÚ SR]	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years
Body mass index (underweight, normal weight, moderate obesity and obesity)	International By age, education, income, sex	ÚVZ [ŠÚ SR]	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years

Notes: 1. Institute for Health Metrics and Evaluation.

1. The European health interview survey.

2. Health Behaviour in School-aged Children (HBSC) study.

Source: Developing HSPA framework for the Slovak Republic project.

Burden of mortality attributable to behavioural risks provides a summary measure connecting behaviours to downstream mortality impacts, supporting a narrative that links determinants to outcomes in other framework domains (such as the Disease‑specific health outcomes domain). The indicator is derived from estimates in the Global Burden of Disease study of the Institute of Health Metrics and Evaluation, and can be analysed using breakdowns by disease, risk factor and gender. The study is updated approximately every two to three years and covers data going back to 1990, enabling long-term trend analysis.

Capturing tobacco consumption, indicators include Daily smokers of cigarettes, measuring the percentage of persons aged 15 and over who smoke daily, and a youth-focussed measure of 15‑year‑olds who smoked at least once in the last 30 days. Together, these support discussion of cohort risk and prevention policy relevance. The adults’ indicator is sourced from the EHIS, conducted every five years (2014, 2019 and 2025), with national data compiled by ŠÚ SR. It can be analysed with breakdowns by age, sex, education, income and economic activity. The youth indicator is sourced from the Health Behaviour in School-aged Children (HBSC) survey, conducted every four years (2014, 2018 and 2022), with national data maintained by Pavol Josef Šafárik Universiy in Košice (UPJŠ). It can be analysed by gender and perceived family affluence, reflecting socio-economic differences in young people. Analyses of smoking among 15‑year‑olds are complemented via a contextual indicator on the Percentage of 15‑year‑olds who have used e‑cigarettes at least once over the last 30 days, capturing an emerging health risk among younger populations.

Alcohol-related risk is captured through Frequency of alcohol consumption, which reviews the proportion of the population who report drinking daily. The analyses are complemented by the internationally comparable contextualising indicator of Alcohol consumption in adults, measured in litres per capita per year. The indicators on Daily consumption of fruit and vegetables, Frequency of sugar-sweetened soft drink consumption, Performing health-enhancing physical activity, and Body mass index categories (underweight, normal weight, overweight and obesity) provide a broad behavioural and metabolic profile linked to health outcomes. All four indicators are sourced from the EHIS, collected every five years by ŠÚ SR. All indicators are internationally comparable, and can be analysed with breakdowns by socio‑economic and demographic variables such as age, sex, education, income.

Environment and antimicrobial resistance (AMR)

The Environment and AMR domain focuses on environmental health determinants and antimicrobial resistance as systemic risks. This domain includes three indicators covering the use antibiotics, antimicrobial resistance and population exposure to fine particulate matter (PM2.5) (Table 3.10).

Table 3.10. Environment and AMR domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Percentage (%) of WHO “Access” group antibiotics consumed out of total AWaRe consumption (community and hospital sectors combined)	International	Comenius University Bratislava	ECDC Antimicrobial consumption in the EU/EEA (ESAC-Net) – Annual Epidemiological Report	Comenius University Bratislava and NIHO	Available, updated annually
Antimicrobial resistance rates by pathogen and antibiotic expressed as percentage of resistant isolates	International By type of pathogen resistance to specific antibiotics types	ÚVZ	ECDC Antimicrobial resistance in the EU/EEA (EARS-Net) – Annual Epidemiological Report	ÚVZ	Available, updated annually
Population exposure to PM2.5	International, regional By region	IZA [SHMU]	IHME (Global Burden of Disease study)	IHME1 and ŠÚ SR	Available, updated every 2‑3 years

Note: 1. Institute for Health Metrics and Evaluation.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator on the Share of WHO “Access” group antibiotics out of total AWaRe consumption reflects prescription patterns, measuring the use proportion of antibiotics that belong to the low-risk group where use is not restricted, relative to higher-risk groups of “Watch” and “Reserve” classes where use should be limited. A higher share of “Access” antibiotics is associated with more appropriate prescribing and lower risk of antimicrobial resistance. Analyses are complemented with a contextualising OECD indicator on the Volume of cephalosporines and quinolones (second line antibiotics) as a proportion of all systemic antibiotics prescribed. The indicator Antimicrobial resistance rates by pathogen and antibiotic expressed as percentage of resistant isolates measures the percentage of tested isolates that are resistant for specific pathogen-antibiotic combinations (such as MRSA, cephalosporin-resistant E. coli and carbapenem-resistant Klebsiella pneumoniae). It is an outcome‑focussed metrics that can be linked to prescribing practices and surveillance. Both indicators are sourced from the ECDC through its Antimicrobial Consumption Surveillance Network (ESAC-Net) Annual Epidemiological Report, though are nationally maintained by different organisations (respectively, NCZI and ÚVZ). Data for the Slovak Republic are available starting 2019.

Regarding environmental exposures, Population exposure to PM2.5 captures a key environmental determinant with strong links to premature mortality and morbidity, measured as average population exposure to fine particulate matter in micrograms per cubic metre. The data are derived from estimates in the Global Burden of Disease study of the Institute of Health Metrics and Evaluation, with national data provided by Slovak Hydrometeorogical Institute (SHMU), updated every two to three years. Its regional granularity supports discussion of geographic inequality in exposure and a bridge between determinants and outcomes indicators. All three indicators in this domain have internationally comparable data available for benchmarking.

3.2.3. Healthcare services

The area of Healthcare Services focusses on factors and processes that influence healthcare delivery and its quality. The Healthcare services thematic area includes four domains, with a total of 29 indicators selected.

Access

The Access domain focusses on barriers to accessing healthcare, whether financial, geographic or time-related. This domain includes 11 indicators covering self-reported unmet needs for medical and mental healthcare, out-of-pocket and catastrophic health spending, waiting times for inpatient and outpatient care, emergency medical service responsiveness, supply-side network coverage of primary and specialist providers, and timeliness of access to innovative medicines (Table 3.11). The indicator set combines demand-side (patient-reported), supply-side (provider network coverage) and system-level (financial protection, emergency response) perspectives on access.

Table 3.11. Access domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Self-reported unmet needs for medical examination by main reason declared	International, regional By age, education, income, main reason declared, NUTS 2, sex	ŠÚ SR	Eurostat (EU-SILC1)	ŠÚ SR	Available, updated annually
Self-reported unmet needs for mental healthcare in the population	International By age, education, income, reason, sex	ŠÚ SR	Eurostat (EHIS2)	ŠÚ SR	Available, updated every 5 years
Out-of-pocket spending by type of service and as percentage of current health expenditure	International By type of service3 and as a percentage of health expenditure	ŠÚ SR [IZA]	Eurostat (National accounts)	ŠÚ SR	Available, updated annually
Share of households with catastrophic health spending by consumption quintile	International By consumption quintile	IZA	WHO (Financial protection in the European Region)	ŠÚ SR	Placeholder, updated every 4 years
Share of patients on waiting lists waiting above the legislative waiting time limits (inpatient care)	Regional By age group, disease DG, gender, HIC, provider, region, treatment type	NCZI/ IZA	NCZI (Národný portál zdravia: eČakačky4)	NCZI	Placeholder (data available), updated annually
Waiting times for an outpatient specialist appointment		IZA	NCZI (Elektronicky vymenny listok5)		Placeholder (data available), updated annually
Evolution of the number of all incoming calls to emergency line (LTV 155) by region	Regional By region	OS ZZS SR	OS ZZS SR (Výročná správa OS ZZS6)	OS ZZS SR	Available, updated annually
Percentage of patients with the most serious priority (K; critical) were reached by emergency medical service within acceptable time after call	Regional By region	OS ZZS SR	OS ZZS SR (Výročná správa OS ZZS6)	OS ZZS SR	Available, updated annually
GP providers as percentage of optimal network	Regional By districts, HICs, regions	ÚDZS	ÚDZS (Údaje o vyhodnotení sietí podľa zákona č. 578/2004 Z. z.7)	ÚDZS	Available, updated annually
Outpatient specialist providers as percentage of optimal network	Regional By districts, HICs, medical specialty and regions	ÚDZS	ÚDZS (Údaje o vyhodnotení sietí podľa zákona č. 578/2004 Z. z.7)	ÚDZS	Available, updated annually
Average time from national application-to-reimbursement inclusion (categorisation) for innovative medicines (within a given period)	International8 By ATC group, medicine	MoH (SFLP9)	MoH (Categorisation portal of the MoH for reimbursement)	MoH	Placeholder (data available), updated monthly

Notes: 1. EU statistics on income and living conditions.

1. European health interview survey.

2. medical goods, outpatient, dental, inpatient, long-term care, etc.

3. National health portal: eWaiting lists.

4. Electronic referral letter.

5. Annual report of the Emergency Medical Services Section.

6. International comparison possible using contextualising indicators.

7. Data on evaluation of networks under Act No. 578/2004 Coll.

8. Section of Medicines and Pharmaceutical Policy.

Source: Developing HSPA framework for the Slovak Republic project.

Perceptions of access are monitored through using the indicator Self-reported unmet needs for medical examination (due to financial reasons, waiting lists, or distance). It is collected annually by ŠÚ SR via the EU-SILC survey, with over ten years of historical data available. While the indicator is collected in both EHIS and EU-SILC, EU-SILC was selected for the Slovak HSPA due to data on the main reasons for unmet needs. Self-reported unmet needs for mental healthcare was collected as part of the 2025 EHIS survey. Prior to this, data on this indicator was reported through the Eurofound’s Living and Working in the EU e‑survey (starting 2021). Both indicators can be used to assess equity through breakdowns by education, income, sex, age and NUTS2‑level geographical categories, and compared internationally.

Financial access is further represented through Out-of-pocket spending by type of service, which shows the service areas where households pay most, capturing spending on medical goods, outpatient, dental care, inpatient and long-term care. This indicator can be compared internationally to assess levels of financial protection. Share of households with catastrophic health spending by consumption quintile reflects risk of financial hardship due to healthcare costs, with the possibility to measure variation across income groups. The indicator is sourced from the WHO’s Financial Protection in the European Region report, with national data based on ŠÚ SR household budget surveys, and covers the period 2000 to 2021.

Regarding timeliness and geographic access, the indicator on Waiting lists above legislative waiting-time limits (inpatient care, procedures) is included as a placeholder in the Slovak HSPA. Although data is available through NCZI’s National Health Portal eWaiting Lists system, the methodology for calculating the proportion of patients whose wait exceeded legally defined maximum waiting times remains under discussion. The indicator could be broken down by provider, region, health insurance company, age group, gender, diagnosis and treatment type. Waiting times for an outpatient specialist appointment is also a placeholder indicator, reflecting a known measurement gap where the data source (electronic referral system) exists but the methodology for deriving a comparable indicator has not yet been agreed. Both indicators are national in scope (cannot be compared internationally), with the inpatient waiting list indicator offering equity breakdowns by gender, age and provider.

Operational access in emergency care access is captured via two indicators. The Evolution of incoming calls to the emergency line (155) by region tracks trends in demand for urgent medical assistance across regions, helping to identify pressures on emergency and primary care services. Percentage of critical-priority patients reached within target times (8 minutes in urban areas, 15 minutes in rural areas) measures the ability of the emergency medical service to deliver rapid life‑saving interventions to the most serious cases. Both indicators are sourced from the Annual Report of the Emergency Medical Services section (OS ZZS SR), with over ten years of data available and regional breakdowns supporting sub-national comparisons of emergency care performance.

Geographical differences in supply of providers are represented by GP providers as percentage of optimal network and Outpatient specialist providers as percentage of optimal network, which support interpretation of unmet needs in relation to local capacity and demand. Both indicators measure the level of coverage of provider networks against optimal networks defined by the MoH and regional self-governing authorities under Act No. 578/2004 Coll. The indicators are sourced from ÚDZS through its evaluation of outpatient provider networks, with breakdowns available by region and district. The specialists’ indicator additionally allows analyses by selected medical specialties. Outpatient clinics operating within hospitals are included only if they serve the general public.

Average time from national application-to-reimbursement inclusion (categorisation) for innovative medicines (within a given period) supports assessment of efficiency and responsiveness of pricing and reimbursement processes. The indicator supports transparency and informs policies aimed at improving timely access to new treatments. It is sourced from internal data of the MoH’s Categorisation portal, with breakdowns available by individual medicine and ATC group. This is a national indicator, selected because the national categorisation process is directly within the scope of domestic policy action. Although more than ten years of underlying data are available, the indicator requires calculation from portal inputs and is therefore currently marked as a placeholder. The contextualising indicator Time from central approval to availability provides internationally comparable data on the duration from marketing authorisation by the European Medicines Agency (same for all EU countries) until the drug becomes available nationally (added to the country’s reimbursement list).

Quality and safety

The Quality and safety domain describes outputs of healthcare delivery process, focusing on clinical care outcomes and patient safety. This domain includes eight indicators covering stage of cancer at diagnosis, 30‑day stroke mortality, post-operative complications, healthcare worker perceptions of patient safety, healthcare‑associated infection rates (ICU-acquired, surgical site and nosocomial infections), and hospital admissions due to falls in long-term care (Table 3.12). The domain indicators span effectiveness, safety and workforce strain dimensions of quality of care.

Table 3.12. Quality and safety domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Stage of cancer at diagnosis	International By age, gender and type of cancer	NOI [NCZI]	OECD (Cancer Pilot 2025)	NCZI	Placeholder (data available), updated annually
30‑day mortality rate following hospital admission for ischemic stroke (patient/linked data)	International By gender	NCZI	OECD (HCQO1 collection)	NCZI	Available, updated every 2 years
Post-operative hospital admissions following a one‑day surgery	Regional By age group, procedure	NCZI	NCZI (Ročenka NCZI [NCZI Yearbook])	NCZI	Available, updated annually
Health workers’ perceptions of adequate staff levels and work pace	International By staff categories2	IZA	OECD (HCQO1 collection)		Placeholder, updated every 2 years
ICU-acquired bloodstream infection rates	International	ÚVZ	ECDC (Annual Epidemiological Report)	ÚVZ	Available
Surgical Sites Infections (SSIs)	International By type of surgical procedure	ÚVZ	ECDC (Annual epidemiological report3)	ÚVZ	Available, updated annually
Incidence of nosocomial infections in inpatient facilities	International4, regional By infection type, region	ÚVZ	ÚVZ (Analýza epidemiologickej situácie a činnosti odborov epidemiológie5)	ÚVZ	Available, updated annually
Hospital admissions due to falls among people in long-term care	International	NCZI	OECD (Long Term Care Quality Pilot)	NCZI (in the future)	Placeholder (data available)

Notes: 1. Healthcare quality and outcomes.

1. Doctors, nurses, other clinical staff, support staff, management.

2. Surgical site infections.

3. Available when using contextualising indicators.

4. Analysis of the epidemiological situation and activities of epidemiology departments.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator Stage of cancer at diagnosis looks at timeliness and effectiveness dimension of cancer pathways where early diagnosis is crucial for outcomes. It measures the distribution of newly diagnosed cancer cases by stage at diagnosis as a percentage of all new cases. International data collection methodology has been piloted for breast, cervical, colorectal and prostate cancer, and can be disaggregated by gender and age. Interpretation of these indicators is related to screening programme coverages, as well as health literacy and accessibility of primary care. The indicator is sourced from NCZI’s National Oncology Register, with international data available from the OECD Cancer Pilot 2025 collection. It remains a placeholder as it has not been calculated in the Slovak Republic in the past, although national data to produce the indicator are available. It should be noted that historical data in the National Oncology Register currently extend only up to 2016, with new data expected to be published.

The indicator 30‑day mortality following admission for ischaemic stroke provides an established methodology to assess acute care quality and care pathway effectiveness through clinical outcomes, measured as deaths within 30 days per 100 admitted patients. It is sourced from the OECD Healthcare Quality and Outcomes (HCQO) data collection every two years, with national data maintained by NCZI available for the last ten years. Data linkage between hospital admission reports and the database of the deceased allows following patients across settings, with disaggregation by gender available.

Surgical safety and efficiency are captured through Post-operative hospital admissions following one‑day surgery, which can serve as a proxy for clinical complications and highlight where ambulatory pathways may require improvement. The indicator is disaggregated by procedure and patient age group, sourced from the NCZI Yearbook, and is available at the national and regional level, although international comparisons are not possible.

The inclusion of a placeholder indicator on Health workers’ perceptions of adequate staffing levels and work pace reflects interest in linking workforce strain to quality and safety risks. Perceived understaffing and excessive work pace are associated with burnout, reduced quality of care and increased staff turnover, all of which can compromise patient safety and service delivery. The indicator is collected through the OECD HCQO collection among various staff categories (doctors, nurses, other clinical staff, support staff and management), but the Slovak Republic has not yet conducted a national survey to report data. Internationally, the indicator is collected every two years.

Three indicators capture patient safety through healthcare associated (nosocomial) infections. The indicator ICU-acquired bloodstream infection rates measures the percentage of patients staying in an intensive care unit for more than two days who develop at least one healthcare‑associated infection (pneumonia, bloodstream infection or urinary tract infection). Surgical site infections (SSIs) indicator is measured as the percentage of SSIs per 100 surgeries and disaggregated by type of surgical procedure. Both indicators are sourced from ECDC’s Annual Epidemiological Report, with national data maintained by ÚVZ, and cover acute care hospitals. A national indicator on the Incidence of nosocomial infections in inpatient facilities (including regional distribution) is maintained by ÚVZ through its annual epidemiological analyses of the epidemiological situation, disaggregated by infection type and region. This indicator is accompanied by a contextualising indicator on Hospital incidence density of healthcare‑associated Clostridioides.

To reflect ageing and its consequences on service provision, indicator Hospital admissions due to falls among people in long-term care was also selected, based on OECD pilot study of long-term care. The methodology was piloted for the first time in 2025 as part of the OECD Long-Term Care Quality Pilot data collection. Although Slovak data was not calculated for the pilot, underlying data sources could be available. Research and development on the indicator are planned in the coming years to establish it for reliable international comparisons, but the methodology can already be used to monitor national trends.

Care coordination

The Care coordination domain looks at how effectively care is managed across providers, settings and time. This domain includes six indicators covering avoidable hospital admissions, post-discharge mortality or readmission for congestive heart failure and ischaemic stroke, post-discharge suicide among mental health patients, polypharmacy among older adults, and patient-reported experienced co‑ordination of care (Table 3.13). The indicator set focuses on outcomes sensitive to continuity and integration of care rather than acute events alone.

Table 3.13. Care coordination domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Primary care quality: Avoidable hospital admissions	International By disease1, gender	NCZI	OECD (HCQO2 collection)	NCZI	Available, updated annually
Congestive heart failure: mortality or readmission within 365 after discharge	International By gender	NCZI	OECD (HCQO2 collection)	NCZI	Placeholder (data available), updated every 2 years
Ischemic stroke mortality or readmission within 365 after discharge	International By gender	NCZI	OECD (HCQO2 collection)	NCZI	Placeholder (data available), updated every 2 years
Death from suicide within 1 year after discharge among patients diagnosed with a mental disorder	International By gender	NCZI	OECD (HCQO2 collection)	NCZI	Available, updated every 2 years
Proportion of 75 years and over who are taking more than 5 medications concurrently	International By gender	NCZI	OECD (HCQO2 collection)	NCZI	Placeholder (data available), updated every 2 years
Patient’s experienced co‑ordination of care (composite score)	International By age, co‑ordination component, education, gender and income	IZA	OECD (PaRIS3)	MoH	Placeholder, updated every 2 years

Notes: 1. Asthma, chronic obstructive pulmonary disease (COPD), diabetes, congestive heart failure.

1. Healthcare quality and outcomes.

2. Patient-Reported Indicator Surveys.

Source: Developing HSPA framework for the Slovak Republic project.

Capturing coordination-sensitive outcomes, Avoidable hospital admissions (for asthma, COPD, diabetes, and congestive heart failure) provide a structured view of whether primary care is preventing exacerbations of conditions that could be managed outside of hospitals. Data are collected every two years and cover more than ten years of time trends, with disaggregation by disease and gender available. Post-discharge co‑ordination is further captured through indicators on Mortality or readmission within 365 days after discharge for congestive heart failure and for ischaemic stroke, which focus on adverse outcomes occurring across the hospital-community interface. Following acute events, these conditions require long-term management and continuity of care; outcomes within one year after discharge capture the effectiveness of discharge planning, follow-up and chronic disease management across providers. Both indicators are sourced from the OECD HCQO data collection, with national data maintained by NCZI through linkage of hospital admission reports and the database of the deceased. They remain placeholders, as the Slovak data are available but require calculation. Disaggregation by gender is available.

On mental healthcare, the indicator on Death from suicide within one year after discharge among patients diagnosed with a mental disorder captures a high-severity outcome following institutional care. The period following discharge from psychiatric care is associated with a significantly elevated risks, making this indicator particularly important for assessing the quality of post-discharge follow-up, crisis support and continuity of mental healthcare. It is sourced from the OECD HCQO data collection, with national data maintained by NCZI through two linked datasets: the reporting on causes and circumstances of intentional self-harm and the reporting on patients in institutional psychiatric care. The indicator is disaggregated by gender and covers more than ten years of data.

The domain also includes the Proportion of people aged 75 and over taking more than five medications concurrently, reflecting polypharmacy as a co‑ordination and medication management challenge. Polypharmacy is associated with increased risks of adverse reactions, drug interactions, hospitalisations and functional decline in older adults. The indicator is aligned with the OECD HCQO data collection methodology but remains a placeholder as the indicator has not been previously calculated.

Finally, the planned inclusion of Patient-reported experienced co‑ordination of care through the OECD PaRIS survey is currently a placeholder as the Slovak Republic has not previously participated in the PaRIS survey. The indicator is a composite score (range 0 to 15) among primary care patients aged 45 and over with chronic conditions, composed of five components: care joined up, single named contact, overall care planning, support to self-manage, and information to self-manage.

People centredness

The People centredness domain reviews patients’ experience with the health system and healthcare delivery, focussing on quality of patient-doctor relationship and system responsiveness. This domain includes four indicators covering shared decision making with doctors, respectful treatment of mental health patients, patient-reported satisfaction with primary care quality, and planned hospital-based patient experience measures (PREMs) (Table 3.14). The indicator set signals commitment to developing patient-centred monitoring, though most indicators remain placeholders pending future data collection.

Table 3.14. People centredness domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Doctor involving patients in decisions about care	International By age, education, gender, income	IZA	OECD (PaRIS1)	IZA	Placeholder, updated every 4 years
Care providers treating mental health patients with courtesy and respect	International By gender		OECD (HCQO2 collection)		Placeholder, updated every 2 years
Experienced quality – patients who report they are satisfied with medical care provided by their primary care centre in the past 12 months	International By age, education, gender, income	IZA	OECD (PaRIS1)	IZA	Placeholder, updated every 4 years
Indicator from hospital surveys for PREMs for maternity care and day surgery		IZA			Placeholder

Notes: 1. Patient-Reported Indicator Surveys.

1. Healthcare quality and outcomes.

Source: Developing HSPA framework for the Slovak Republic project.

Two indicators include measures about interpersonal dimensions of health system interaction, namely shared decision making and respectful care, that shape trust, adherence and perceived quality. Doctor involving patients in decisions about care or treatment reflects the patient’s interactions with their primary care provider. Sourced from the OECD PaRIS survey, this indicator is currently a placeholder as the Slovak Republic has not yet conducted the survey. Care providers treating mental health patients with courtesy and respect reflects patients’ experience during their last interaction with a mental health professional. This indicator is included to provide a perspective on experiences within mental healthcare; it is a placeholder indicator which is not yet planned to be incorporated in a specific survey in the Slovak Republic, though international comparators are available through the OECD HCQO data collection.

In addition, Experienced quality (satisfaction with medical care in the primary care centre in the last 12 months) is included but remains a placeholder, from the OECD PaRIS survey. The indicator measures patient-reported satisfaction among patients with chronic conditions, with breakdowns available by age, gender, education and additional variables. The PaRIS survey is expected to collect data every four years.

Finally, a planned national indicator was selected for the Slovak HSPA indicator set, which will be sourced from Hospital surveys on PREMs for maternity care and day surgery, with the MoH co‑ordinating future collection (expected by 2028). A specific indicator will be identified at a later stage, but inclusion of the survey among the Slovak HSPA data sources allows the domain capture nationally tailored monitoring of patient experiences.

3.2.4. Outcomes

The area of Outcomes describes key outcomes of population health. These are influenced by the healthcare provision as well as prevention activities and risk factors. The Outcomes thematic area includes two domains - general (population) health outcomes and disease-specific outcomes - with a total of 23 indicators selected.

General health outcomes

The General health outcomes domain focuses on population health through mortality, morbidity and self-reported measures, providing an overview of the health status of Slovak population. This domain includes 12 indicators covering life expectancy at birth and at age 65, causes of mortality, infant and under-five mortality, avoidable mortality (preventable and treatable) and its causes, potential years of life lost, self-perceived health, long-standing illness prevalence, incapacity to work, and patient-reported quality of life (Table 3.15). The indicator set combines administrative mortality data with subjective health status assessments.

Table 3.15. General health outcomes domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Life expectancy at birth	International, regional By gender, NUTS2	OVZ	Eurostat (Population and social conditions: Mortality)	ŠÚ SR	Available, updated annually
Life expectancy among men and women at 65	International, regional By gender, NUTS2	OVZ	Eurostat (Population and social conditions: Mortality)	ŠÚ SR	Available, updated annually
Causes of mortality	International, regional1 By cause, district1, NUTS2, region1, sex	ŠÚ SR [MoH (SZ)]	Eurostat (Population and social conditions: Mortality)	ŠÚ SR	Available, updated annually
Infant mortality	International, regional By NUTS2, sex	MoH (SZ)	Eurostat (Population and social conditions: Mortality)	ŠÚ SR	Available, updated annually
Mortality rates for children under 5 years of age	International, regional1 By age, region1, sex	MoH (SZ)	Eurostat (Population and social conditions: Mortality)	ŠÚ SR	Available, updated annually
Avoidable mortality	International By category, sex	OVZ	Eurostat (Causes of death: public health themes)	ŠÚ SR	Available, updated annually
Causes of treatable and preventable mortality of residents	International By cause, sex	OVZ	Eurostat (Causes of death: public health themes)	ŠÚ SR	Available, updated annually
Potential years of life lost	International By age, disease groups, sex	OVZ	Eurostat (Causes of death: public health themes)	ŠÚ SR	Available, updated annually
Self-perceived health	International By age, education, income, sex	ŠÚ SR	Eurostat (EU-SILC2)	ŠÚ SR	Available, updated annually
People having a long-standing illness or health problem (self-perceived)	International By age, education, income, sex	MoH (SZ)	Eurostat (EU-SILC2)	ŠÚ SR	Available, updated annually
Sickness and accident incapacity for work	Regional By cause, duration of incapacity, economic activity, industry and region	ŠÚ SR	ŠÚ SR (ŠÚ SR: Demografia a sociálne štatistiky)	ŠÚ SR	Available, updated annually
Perception of quality of life among primary care users with chronic conditions	International By age, education, gender and income	IZA	OECD (PaRIS3)	IZA	Placeholder, updated every 4 years

Notes: 1. Detailed regional comparison is available through national sources for the same indicator (see Annex D for further information).

1. EU statistics on income and living conditions.

2. Patient-Reported Indicator Surveys.

Source: Developing HSPA framework for the Slovak Republic project.

Regarding longevity, indicators include Life expectancy at birth, which has gender and regional breakdowns. It is sourced from Eurostat’s population and social conditions statistics on mortality, with national data maintained by ŠÚ SR through its demography and social statistics on deaths and causes of death. The indicator Life expectancy at age 65, sourced from the same Eurostat data collection, takes a lens looking at older adults and provides a gender breakdown. This indicator is complemented by a contextual indicator - Healthy life years at 65, which is a measure commonly used to reflect on quality of life in older people.

Causes of mortality indicator can be disaggregated by sex and disease groups, providing a comprehensive picture of most common causes of death in the Slovak Republic. The indicator is sourced from the Eurostat database, with national data maintained by ŠÚ SR. Regional breakdowns are also available at NUTS2 level internationally, while national data can be used to obtain comparisons by region and district. Looking at specific ages, Infant mortality and Mortality rates for children under 5 have breakdowns by sex and NUTS2 region. Within-country differences in mortality are sensitive to healthcare accessibility and broader socio-economic determinants.

The inclusion of Avoidable mortality (preventable and treatable), measured per 100 000 inhabitants under age 75, provides a direct bridge between mortality outcomes and health system performance, as these categories are used internationally to distinguish whether improvements are needed in prevention policies or in healthcare quality and access to timely treatment. Causes of treatable and preventable mortality of residents helps to understand the specific conditions driving avoidable deaths, disaggregated by gender and disease groups. Both indicators are sourced from Eurostat’s causes of death public health themes, with national data maintained by ŠÚ SR. Potential years of life lost highlights the burden of premature mortality by placing greater weight on deaths occurring at younger ages, sourced from the Eurostat database with underlying data maintained by ŠÚ SR. On self-reported health status and morbidity, the indicator on Self-perceived health measures the percentage of the population reporting very good to very bad health status on a five‑level scale, focussing on the extremities of the distribution. It is sourced from the Eurostat’s EU-SILC survey, collected annually by ŠÚ SR, and allows for equity-relevant disaggregation by education, income, sex and age. It is accompanied by a national contextualising indicator on Self-reported health status and life expectations (limitations due to health problems, opinion on life expectancy, life evaluation, belief in a better future) from ÚVZ. People with a long-standing illness or health problem looks at prevalence of chronic conditions through self-reporting, also sourced from the EU-SILC survey with breakdowns by age, sex, education and income. Both indicators support assessment of health status beyond mortality and identification of social and demographic inequalities. Sickness and accident incapacity for work adds an economic-functioning dimension that complements other health status indicators, measuring the number of cases of inability to work per 100 employed persons. It is sourced from ŠÚ SR’s demography and social statistics, with breakdowns available by region, type of sickness, industry and duration of incapacity, enabling analysis of work incapacity patterns across sectors and geographic areas.

The indicator Perception of quality of life among primary care users with chronic conditions is included as a placeholder, anticipating future inclusion of further patient-reported outcomes to complement mortality-focussed metrics. Derived from the PaRIS survey, it is used as a proxy for mental health, based on a person’s response to four questions on quality of life, emotional distress and social health, using the PROMIS Global Scale. It reflects perceptions among primary care users with chronic conditions aged 45 and above, with breakdowns available by age, gender, education and income.

Disease-specific health outcomes

The Disease‑specific health outcomes domain provides insights on selected diseases and chronic conditions, including burden and trends. This domain includes 11 indicators covering cancer incidence, mortality and survival, cardiovascular mortality and prevalence, vaccine‑preventable disease trends, respiratory disease mortality, musculoskeletal disorders prevalence, dementia prevalence, suicide attempts and alcohol-related hospital admissions (Table 3.16). The indicator set links prevention and care performance to disease‑specific outcomes across oncology, cardiovascular, communicable, musculoskeletal and mental health areas.

Table 3.16. Disease-specific health outcomes domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Cancer incidence	International By age groups, gender and types of cancer	NSC [NCZI]	ECIS4	NCZI	Available, updated annually
Cancer mortality	International, regional10 By age group, district10, region10 and sex	NSC [NCZI]	Eurostat (Causes of death: General mortality)	NCZI	Available, updated annually
Five‑year survival: Colon cancer five‑year	International	NSC [NCZI]	CONCORD and Ministry of Health, IZA (CONCORD6)	IZA	Placeholder (data available), updated every 4‑6 years
Cardiovascular disease mortality	International, regional10 By gender, region	ŠÚ SR	Eurostat (Causes of death: General mortality)	ŠÚ SR	Available, updated annually
Prevalence of cardiovascular diseases1	International By disease type, economic activity status, sex	ŠÚ SR	Eurostat (EHIS7)	ŠÚ SR	Available, updated every 5 years
Trends in the incidence of selected vaccine‑preventable diseases	Regional By region, type of a disease	ÚVZ	ÚVZ (Ročenka NCZI [NCZI Yearbook])	NCZI	Available, updated annually
Respiratory system diseases mortality	International, regional10 By disease2, gender, region10	ŠÚ SR + MoH (SZ)	Eurostat (Causes of death: General mortality)	ŠÚ SR	Available, updated annually
Prevalence of musculoskeletal disorders3	International By disease type, economic activity status, sex	ŠÚ SR	Eurostat (EHIS7)	ŠÚ SR	Available, updated every 5 years
Prevalence of dementia	International By age groups, location type, receivership of care	IZA/ NCZI8	OECD (Dementia Pilot 2025)	IZA8	Placeholder (data available)
Evolution of the number of suicide attempts by area of residence and sex and age	Regional By area of residence, age, sex	NCZI	NCZI (Tematické výstupy: Samovraždy a samovražedné pokusy9)	NCZI	Available, updated annually
Number of hospital admissions for diseases where alcohol is the main cause	Regional By age, gender, region	NCZI	NCZI (Ročenka NCZI [NCZI Yearbook])	NCZI	Available, updated annually

Notes: 1. Myocardial infarction, vascular heart disease or angina pectoris, high blood pressure, stroke, high blood cholesterol or lipid levels.

1. Asthma, COPD, pneumonia, influenza.

2. Arthrosis, lower back disorder, neck disorder.

3. The European Cancer Information System (ECIS)

4. Thematic outputs: Oncology.

5. Programme for world-wide surveillance of trends in cancer survival, led by the London School of Hygiene and Tropical Medicine.

6. European health interview survey.

7. The dataset is not yet available but will be custodied by IZA in the future, while the indicator responsibility will be for IZA or NCZI.

8. Thematic outputs: Suicides and suicide attempts.

9. Regional comparison is available through national sources for the same indicator (see Annex D for further information).

Source: Developing HSPA framework for the Slovak Republic project.

Regarding cancer outcomes, the indicators include estimated Cancer incidence, measured as age‑standardised new cases per 100 000 population, sourced from the European Cancer Information System (ECIS) with national data maintained by NCZI through the National Oncology Register. It can be disaggregated by age groups, gender and type of cancer. Cancer mortality, measured per 100 000 population, is sourced also from Eurostat, with national breakdowns available by region, district, sex and age group. National data cover more than ten years, although the National Oncology Register data currently extend up to 2016 with new data expected. A planned indicator on Five‑year survival for colon cancer is noted as under development, with data sourced from the CONCORD global cancer survival programme. The most recent data from CONCORD are from 2008 and 2014, with an update currently in process (CONCORD‑4). The indicator can also be calculated at national level from NCZI data, one‑, three‑ and five‑year survival rates. Five‑year survival for other cancer sites (breast, cervical, lung, pancreas, etc.) from the same source can be used to provide additional contextual information and hence was selected as a contextualising indicator for this domain.

Prevalence of cardiovascular diseases is represented through major cardiovascular conditions and risk factors (including myocardial infarction, angina, high blood pressure, stroke and high cholesterol), which enables discussion of both outcomes and underlying risk burden. It is sourced from the EHIS and collected every five years by ŠÚ SR (data available for 2014, 2019 and 2025), with breakdowns by condition, sex and economic activity status. Cardiovascular diseases mortality rate is measured per 100 000 population and sourced from Eurostat’s causes of death statistics, with national data maintained by ŠÚ SR. The indicator has gender and regional breakdowns and is linked to the Slovak national strategy Strategic Framework for Healthcare for the years 2014-2030, where a specific target has been defined. International comparisons are available for both indicators.

Effective communicable disease control is represented through Trends in selected vaccine‑preventable diseases, disaggregated by region and type of disease. It is sourced from ÚVZ through its annual report, with national data maintained by NCZI, enabling regional analysis. Additionally, Respiratory diseases mortality (asthma, COPD, pneumonia, influenza) links prevention and care performance to disease‑specific outcomes. It is sourced from Eurostat’s causes of death statistics with underlying data from ŠÚ SR, with gender and regional breakdowns. Both indicators are collected annually and available for international comparisons.

Further disease prevalence measures include Musculoskeletal disorders prevalence (arthrosis, lower back disorders and neck disorders), sourced from the EHIS survey collected every five years, with breakdowns by disease type, sex and economic activity status. A planned indicator on Prevalence of dementia remains a placeholder, with methodology aligned with the OECD Dementia Pilot 2025; primary data is not yet available in the Slovak Republic.

Regarding mental health, the indicator Evolution of suicide attempts tracks changes over time in suicide attempts per 100 000 inhabitants, sourced from NCZI’s thematic outputs on suicides and suicide attempts. It is disaggregated by area of residence, sex and age, with more than ten years of national and regional data available. The outcome‑relevant measure of Alcohol-related hospital admissions (where alcohol is the main cause for hospitalisation) captures the direct health burden of harmful alcohol use, sourced from the NCZI Yearbook with breakdowns by gender, age and region, and more than ten years of national and regional data availability. Both indicators support national and regional analysis, although international comparisons are not directly available through these specific data sources.

3.2.5. Efficiency

The thematic area of Efficiency reviews the overall efficiency of the health system, reviewing whether healthcare is provided in an efficient way. It includes two domains, with a total of ten indicators selected.

Cost efficiency

The Cost efficiency domain reviews healthcare cost efficiency with a specific focus on hospitals and pharmaceuticals, including reviews of cost structures and cost-efficient prescription. This domain includes four indicators covering costs and revenue by type of healthcare, the share of labour costs in hospital revenues, generic pharmaceutical market share, and overdue invoices as a share of public health expenditure (Table 3.17). The indicator set supports interpretation of cost drivers, payment discipline challenges and pharmaceutical prescription efficiency alongside workforce and expenditure indicators in other HSPA domains.

Table 3.17. Cost efficiency domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Costs and revenue in healthcare	By type of healthcare (inpatient, outpatient)	NCZI	NCZI (Tematické výstupy: Vybrané ekonomické ukazovatele v zdravotníctve1)	NCZI	Available, updated annually
Share of labour costs in total hospital revenues	Regional By group of providers	NCZI	NCZI (Tematické výstupy: Vybrané ekonomické ukazovatele v zdravotníctve1)	NCZI	Available, updated annually
Share of generics in respective pharmaceutical market	International By market type	NCZI	OECD (Health Statistics: Pharmaceutical market)	NCZI	Available, updated annually
Invoices after due‑date as percentage of public health expenditure	Regional By days after due date, group of providers, provider, region and type of invoice	MoH (Sekcia centralneho riadenia nemocnic)/ IZA	MoH/IZA (Správa o vývoji dlhov v rezorte zdravotníctva and ŠÚ SR: Systém národných účtov2)	MoH for numerator; ŠÚ SR for denominator	Placeholder (data available), updated annually

Notes: 1. Thematic outputs: Selected economic indicators in healthcare.

1. Report on debt development in the healthcare sector and ŠÚ SR: System of National Accounts.

Source: Developing HSPA framework for the Slovak Republic project.

The indicator Costs and revenue in healthcare provides insight into expenditure and financial status of healthcare providers and facilities. The data is derived from provider reporting of financial data to NCZI and is considered complete for state‑owned hospitals. Additional data for outpatient facilities, including private, is available, and development of dedicated methodology can help to assess financial status of outpatient care based on available information. The Share of labour costs in total hospital revenues further captures cost pressures by measuring the proportion of labour costs in total hospital revenues, with breakdowns by group of providers (associations or hospital ownership) and region. Both indicators are sourced from NCZI’s thematic outputs on selected economic indicators in healthcare, collected annually with more than ten years of data available. These measures are useful for describing cost drivers and interpreting efficiency results alongside workforce trends and cost indicators in the HSPA Resources domain, topics relevant to public debate on the efficiency of the Slovak healthcare system.

Regarding pharmaceutical and payment-system efficiency, the indicator on the Share of generics in the respective pharmaceutical market captures a standard international lever for cost containment, and can be assessed by market type (in hospitals, community pharmacies or third-party payer markets). The share in a given market can be expressed in value and in volume of generics dispensed, offering two complementary perspectives on generic uptake. It is sourced from the OECD Health Statistics on the pharmaceutical market, with national data maintained by NCZI through its thematic outputs on consumption of human medicines, medical devices and dietetic foods. International comparisons are available.

In addition, Invoices after due date as a percentage of public health expenditure is included as a placeholder (data are available but require calculation), intended to describe liquidity and payment discipline challenges that can affect provider stability and system efficiency beyond unit-cost measures. The indicator is disaggregated by provider, group of providers, type of overdue invoice and days after due date. Its calculation requires combining two data sources: the numerator is sourced from the MoH’s Report on Debt Development in the Healthcare Sector (published as part of the State Public Accounts), while the denominator is drawn from ŠÚ SR’s System of National Accounts. National and regional data are available for more than ten years, although the indicator has not been calculated in the past.

Care provision efficiency

The Care provision efficiency domain reviews operational performance and service utilisation patterns, focusing on efficient provision of care. This domain includes six indicators covering one‑day surgery volumes, hospital average length of stay, bed occupancy rates, outpatient care visits, physician visits, and total systemic antibacterial consumption (Table 3.18). The indicator set provides an overview of inpatient and outpatient throughput, including bed utilisation and antimicrobial stewardship.

Table 3.18. Care provision efficiency domain indicators

Name of the indicator	Comparability and Indicator breakdown	Responsibility in HSPA	Indicator production and publication	Custodian of the dataset	Availability and frequency
Number of one‑day surgery, by region of healthcare provider	International3, regional By age group, medical specialisation and region of healthcare provider	NCZI	NCZI (Ročenka NCZI [NCZI Yearbook])	NCZI	Available, updated annually
Hospital average length of stay (curative care beds)	International, regional3 By region3, district, specialisation and type of bed	NCZI	OECD (JQNMHS2: Physical and technical resources)	NCZI	Available, updated annually
All-bed occupancy rate in inpatient healthcare facilities by specialisation	International, regional3 By region3, specialisation and type of bed	NCZI	OECD (JQNMHS2: Physical and technical resources)	NCZI	Available, updated annually
Number of consultations with a physician per person	International, regional3 By type of consultation, age3, region3, district3, medical specialty3	NCZI	OECD (JQNMHS2: Healthcare activities)	NCZI	Available, updated annually
Visits to general practitioners, specialists and dentists; by time interval since last visit.	International By age, economic activity, sex	ŠÚ SR [IZA]	Eurostat (EHIS1 survey data)	ŠÚ SR	Available, updated every 5 years
Total consumption of antibacterials for systemic use	International By ATC sub-group	NCZI	ECDC (ESAC-Net Annual Epidemiological Report)	NCZI	Available, updated annually

Notes: 1. European health interview survey

1. Joint data collection on non-monetary healthcare statistics.

2. Comparison is available through international (one‑day surgery only) or national sources for the same indicator (see Annex D for further information).

Source: Developing HSPA framework for the Slovak Republic project.

Hospital efficiency and substitution for less intensive care are captured via indicators One‑day surgeries (surgeries where the patient is not kept in the hospital overnight; as a number and share of selected surgical procedures), Hospital average length of stay (curative care beds), and the All-bed occupancy rate in inpatient facilities by specialisation. Together, these provide an operational picture of healthcare throughput, bed utilisation, and the extent to which cases are shifted to ambulatory pathways. The one‑day surgery indicator is sourced from the NCZI Yearbook, with breakdowns by region, age group and medical specialisation; international comparability is available for selected procedures through the OECD Health Statistics. Hospital average length of stay and Bed occupancy rate are both sourced from the OECD JQNMHS data collection on physical and technical resources, with national data maintained by NCZI through its hospital bed capacity database. Both indicators can be disaggregated by specialisation, region and type of bed, and are available for international and regional comparison with more than ten years of data. The analysis of the indicator is accompanied by a contextualising indicator on Average length of stay in days by area of permanent residence of the patient, sourced from NCZI. This indicator can provide insights on inequalities between populations at the district-level, within the Slovak Republic.

Regarding utilisation patterns and service mix, the indicators include the Number of consultations with a physician per person, available by type of consultation and medical doctors/dentists, sourced from the OECD JQNMHS data collection on healthcare activities with national data maintained by NCZI. It is accompanied by a contextualising indicator on Number of outpatient clinic visits by patients per 100 000 inhabitants, by age, region, district and specialty, sourced from NCZI. The indicator Visits to general practitioners, specialists and dentists (by time since last visit) adds a patient-reported dimension, sourced from the Eurostat’s EHIS survey collected every five years by ŠÚ SR, with breakdowns by economic activity, sex and age.

Finally, Total consumption of systemic antibacterials (defined daily doses (DDDs) per 1 000 inhabitants per day) adds a stewardship-relevant efficiency dimension, as antimicrobial use patterns relate both to clinical appropriateness and long-term system costs through resistance. The indicator is sourced from ECDC’s Antimicrobial Consumption Surveillance Network (ESAC-Net) Annual Epidemiological Report, with national data maintained by NCZI through its thematic outputs on consumption of human medicines. It can be disaggregated by ATC sub-group, covers more than ten years of data, and is available for international comparisons.

References

[3] OECD (2025), Situational analysis of Slovakia’s health data infrastructure for HSPA purposes, OECD Publishing, Paris, https://www.oecd.org/content/dam/oecd/en/about/projects/the-oecd-technical-support-to-national-hspa-development/Slovakia-Health-data-HSPA.pdf.

[1] OECD (2023), Health System Performance Assessment Framework for Estonia, OECD Publishing, Paris, https://doi.org/10.1787/e67df802-en.

[2] OECD (2023), Health System Performance Assessment Framework for the Czech Republic, OECD Publishing, Paris, https://doi.org/10.1787/5d59b667-en.

[4] OECD/European Observatory on Health Systems and Policies (2025), Country Health Profile 2025: Slovakia. State of Health in the EU, OECD Publishing, Paris, https://www.oecd.org/content/dam/oecd/en/publications/reports/2025/12/country-health-profile-2025-country-notes_7e72146d/slovak-republic_a9b397e5/02c29a7f-en.pdf.

[5] The HLS19 Consortium of the WHO Action Network M-POHL (2021), International Report on the Methodology, Results, and Recommendations of the European Health Literacy Population Survey 2019-2021 (HLS19) of M-POHL.

Note

← 1.  The European Commission’s HSPA Expert Group provides the EU countries with a forum to exchange experiences on HSPAs at national level.