Effective use of public funds must be based on targeted allocation and measurable indicators, always with the patient in focus. The SAO therefore recommends that the government assign the Ministry of Health the task of implementing transparent and results-based resource distribution, including regular public reporting. Only then can the system begin to benefit patients and reduce indebtedness. These audit findings were submitted to the government and also shared with members of the National Council of the Slovak Republic.

The SAO has long focused on the healthcare sector, which receives the second-largest share of public funding after the social sector. Since making healthcare a priority in 2018, the office has conducted 17 audits, with more planned. These audits reveal major systemic issues in how public healthcare funds are allocated and used. For example, although hospitals bill insurance companies using the DRG (Diagnosis-Related Group) system, the insurers themselves do not use this method when making payments. Instead, they rely on complex, non-transparent monthly limits specified in individual contracts.

Each insurance company uses its reimbursement model, leading to inconsistencies and inequality in hospital financing. “The reimbursement model is part of a freely negotiated contract between the insurer and the hospital. Ongoing contract amendments, sometimes running dozens of pages, make these agreements hard to compare and create data chaos,” said Andrassy. For example, University Hospital Bratislava had 45 amendments to one contract, and 29 or 31 to another, some referencing nonexistent rules. Roosevelt Faculty Hospital in Banská Bystrica had 59 contracts with insurers, many with dozens of amendments.

Comparing data from 2019 and 2023, the SAO found a major shift in funding priorities. In 2019, state-owned hospitals received the highest payments; by 2023, private hospitals dominated the list of the top 30 healthcare facilities with the highest payment rates. This fragmented reimbursement model is unsustainable and inefficient, resulting in lower output for higher costs, with patients ultimately paying the price. “Healthcare resources are being distributed unfairly and inconsistently, without clear performance or quality indicators. For example, state university hospitals receive less funding from insurance companies than lower-tier regional hospitals,” Andrassy said. The SAO stresses the need for systemic reforms in hospital financing and performance measurement.

Its audit also revealed that from 2019 to 2023, the state-owned General Health Insurance Company (VšZP) paid €333 million more for DRG cases than private insurers. This difference may help explain its long-standing financial losses. Overall, DRG payments rose sharply, from €1.5 billion in 2019 to €2.3 billion in 2023, with Union Health Insurance Company recording a 124% increase.

The Supreme Audit Office (SAO) notes that since its introduction in 2010, the DRG system still does not function as a universal reimbursement mechanism. In its current form, there is no direct correlation between reimbursement and actual output. Hospitals are not funded based on their current production levels but instead receive a contractually guaranteed fixed income, which is adjusted differently by each health insurance company for the following period. A paradox in reimbursement arises when a hospital deliberately reduces its output, yet the health insurer does not respond with a proportionate reduction in funding. Additional room for manoeuvre is created for hospitals that shift part of their services to one-day surgeries, where long hospital stays are not required and payments are not capped. In this way, hospitals that reduce their output may gain an economic advantage by receiving higher payments per unit of care. As a result, different providers may receive significantly different payments for the same medical service. The system, therefore, fails to reward higher production—hospitals receive the same funding regardless of their actual performance.

In 2023, hospital output declined by 11% (to under 889,000 cases) compared to over 1 million in 2019, even though funding rose significantly. Inpatient care spending rose from €1.7 billion in 2020 to €2.5 billion in 2023. The decline mainly affected smaller, general hospitals—level 1 hospitals saw a 24% drop and level 2 hospitals an 18% drop. By contrast, cardiac and cancer institutes maintained or increased their outputs. Ironically, some small hospitals now receive higher base reimbursement rates than top-tier speciality facilities. In 2019, level 1 and 2 hospitals rarely appeared among the top 30 institutions by payment rate; by 2023, they made up half the list. For example, the private facility Novapharm was supposed to receive €2,160 per case under DRG but was paid over €11,000 by Dôvera and over €10,000 by VšZP. The Kysuce Hospital in Čadca was to receive €2,160 but was paid €4,527 by Union and €3,870 by Dôvera.

The SAO also highlights a steep rise in patient charges for pre-examination services, which may limit access to care. Many of these charges are not legally regulated and are often collected by private providers without legal basis, with state institutions overlooking this issue. These "grey" charges channel hundreds of millions of euros into the system unofficially.

Long-term indebtedness—especially among university and faculty hospitals—is another persistent issue. These hospitals often cannot meet their obligations to suppliers or pay social insurance, violating both commercial and social insurance laws. Delayed payments also breach the EU directive on late payments, which has triggered legal action. At the end of 2023, healthcare facilities under the Ministry of Health had €735.57 million in overdue liabilities. Personnel costs absorb up to 82% of public insurance revenues, leaving too little for essential operations. On average, overdue liabilities make up 71% of all hospital debt. One unpaid invoice dates back to 1997.

This recurring debt cycle is largely due to hospitals receiving less funding than needed to cover the services provided. The 13 largest state hospitals perform the most complex and costly procedures, and also play a crucial role in training new doctors. Instead of fixing the root causes, the state has repeatedly resorted to ad hoc debt forgiveness—five times since 2003, totalling approximately €2.2 billion. Yet the problem persists, with total debt once again nearing €2 billion. A growing concern is the purchase of hospital debt by private firms. The largest creditor from supplier relationships is BFF Central Europe s.r.o., which specialises in acquiring and monetising public receivables. During the most recent debt relief period (2018–2023), it held claims worth around €140 million, plus an estimated €80 million in interest, posing a serious risk to hospitals and the public health insurance system.

For more than 20 years, the Ministry of Health has failed to implement effective, systemic reforms to halt hospital indebtedness. The ministry acts more as an observer than as a regulator, despite being responsible for public health policy. “Improving healthcare efficiency and outcomes cannot be achieved through partial fixes. A fundamental revision of healthcare spending is needed—especially regarding the allocation of public funds, which are paid into the system by citizens and must be transparently managed under the ministry’s oversight,” Andrassy concluded. The SAO emphasises that the current state of healthcare is the result of poorly managed public health policy. The Ministry of Health must use its authority to implement systemic change.