This analysis of the Slovak health system reviews developments in governance, organization, financing and delivery of care, health reforms and health system performance. Slovakia, a central European country with a population of 5.4 million, continues to face significant health and health care system challenges. Slovakia's health system is founded on universal coverage with compulsory health insurance, a broad benefits package and a competitive insurance model. Although life expectancy improved between 2000 and 2019, the COVID-19 pandemic reversed gains, and in 2023 Slovak life expectancy remained three years below the European Union (EU) average. Circulatory diseases and cancer are the leading causes of death, and noncommunicable diseases such as diabetes and mental illness are rising. Nearly one third of all mortality is linked to behavioural risk factors, including poor diet, high smoking rates, low physical activity and obesity. Slovakia's health care system features competition among three insurers - one state-owned (Všeobecná zdravotná poisťovňa, VšZP) and two private. Since major reforms in 2004, the system has decentralized responsibilities and adopted selective contracting to enhance efficiency. However, structural weaknesses remain, particularly in financial sustainability, accessibility and equity. Health spending from public sources was 8.3% of gross domestic product (GDP) in 2024, yet out-of-pocket (OOP) payments account for nearly 19% of expenditures, disproportionately burdening low-income households. Workforce shortages, especially in nursing and primary care, are worsened by emigration and an ageing staff. Urban-rural disparities persist, with modern infrastructure and specialized services concentrated in cities. Digital health advancements, such as the National Health Information System (NHIS), aim to modernize care and facilitate telemedicine, though implementation is uneven. Ongoing reforms target cost containment, infrastructure optimization and integration of long-term care (LTC). Key priorities include addressing regional disparities, improving workforce retention, reducing waiting times and enhancing eHealth adoption. Despite universal coverage, Slovakia must address persistent gaps in health outcomes, resource distribution and system resilience to meet the needs of its population.
This analysis of the Tajik health system reviews developments in its organization, governance, financing, provision of services, health reforms and health system performance. Tajikistan has made progress in reforming its health system away from the model inherited from the Soviet period, but challenges remain. In 2022 the country had the second lowest health spending per capita in the WHO European Region, and health spending is dominated by private out-of-pocket payments (both formal and informal) which undermines a range of health system goals, including financial protection. A basic benefits package was piloted for over 15 years but ended in 2023, and while a new package is in development it had not been introduced as of August 2024. Public financing depends primarily on regional and local authorities, which contributes to regional inequalities in funding. Health system efficiency is undermined by outdated provider payment mechanisms, although there have been efforts to introduce changes such as partial capitation-based payments. Quality of care is an ongoing concern, with challenges including insufficient health data, underinvestment in infrastructure and equipment, staff turnover, deficiencies in the training of health workers, and limited access to pharmaceuticals. The number of doctors and nurses per population in Tajikistan is lower than in other countries in Central Asia, although the number of nurses has increased in recent years. There is a particularly pronounced shortage of doctors in rural areas and a high rate of medical staff migration. Medical education has been a key area of reform, but family medicine continues to suffer from low prestige. Health reforms have aimed to strengthen primary health care, with other priorities including health financing, regulation and financial protection. Under its current national health strategy, the government is committed to promoting universal health coverage for the population by 2030, and has established strategic priorities for health system development in key areas such as governance, financing, workforce and health service quality. A substantial number of reforms and an increase in government spending will be required to deliver this vision.
This analysis of North Macedonia's health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Life expectancy improved prior to the COVID-19 pandemic, but remains far below the EU average, and the country still struggles with comparatively high levels of morbidity and mor¬tality. The social health insurance system covers almost the entire population and progress has been achieved in providing access to publicly covered essential health services. However, challenges remain for patients in access¬ing health services and in financial protection. Geographical accessibility of services varies, with better access in the capital and major cities compared to smaller towns and rural areas. In terms of health financing, the health system offers universal population coverage for a wide range of benefits and services, which are free at the point of delivery or require only minimal co-payments to prevent overuse. Yet the share of private spending on health as a percentage of current health expenditure is high, which undermines the achievement of key health system goals, such as financial protection, equity and efficiency. The health workforce has been a focus of health reforms and efforts are underway to strengthen education and training to improve the skill mix and competences of the health workforce to respond to new challenges and an ageing population. The ratio of physicians per population has increased markedly in recent years, but remains below the EU average. The priorities for the country in the National Health Strategy 2021-2030 are restructuring the hospital system, continuing the country's primary care reform, and improving quality of care while increasing the efficiency of resource use. Access to medicines has improved, but further efforts are needed to ensure access to innovative medicines and treatments. Overall, the Macedonian health system has made important progress, especially in terms of digitalization of health care and access to e-services and telemedicine, but unmet needs remain an issue. The main outstanding challenges include increasing the responsiveness of the health system to population needs; redistributing resources and activities from hospitals to primary care; ensuring access to medicines; and safeguarding the financial sustainability of the health system.
The analysis of the Cyprus health care system reviews all developments related to the newly introduced General Healthcare System (GeSY), in particular in relation to its organization and governance, financing, physical and human resources, provision of service and its performance after 4 years of operation. The implementation of the GeSY created a completely new health care environment, bringing together the public and private sectors into a single and competitive quasi market. Major and fundamental changes are being recorded in all health system areas (including administration, financing and remuneration of providers, coverage, access, freedom of choice, benefits, and financial protection) compared to the old system. The main characteristics of the GeSY are the universality of coverage, funding from contributions levied on people's income and the state budget, the provision of an integrated benefits package, including personal and family care through the introduction of general practitioners (GPs)/personal doctors with a gatekeeping role and a referral system to access specialties and hospitals. The GeSY has improved coverage, the available benefits package, access, freedom of choice and financial protection of beneficiaries compared to the previous system. The population of Cyprus has a relatively good health status with high life expectancy, while few older people relative to the European Union (EU) average report having chronic conditions. There are also low levels of unmet need, and the indexes for both preventable and treatable mortality are well below the EU averages. Diabetes, obesity and smoking remain the main health risk factors. Main challenges and areas for development are: a) the reorganization and reform of public hospitals in order to compete with private ones; b) the introduction and use of e-health, including electronic health records, the regulation of data storage and use of bio information; c) the implementation of university clinics in public hospitals; d) the integration of quality and performance indicators into the compensation mechanisms of GeSY providers; and e) the introduction of medical and therapeutic protocols and guidelines. Finally, a major challenge is the financial sustainability of the system in the long term.
This review of Luxembourg's health system analyses the country's health organization and governance, financing, health care provision, recent developments and reforms, as well as the system's performance. Luxembourg's statutory health insurance system ensures a comprehensive benefits basket for a large share of the population. Although health care accessibility is high in Luxembourg, administrative considerations, such as the requirement to possess an official address or the lack of automatic third-party payment mechanisms for several services, still constitute significant barriers for vulnerable populations to access care. Overall, Luxembourg performs well on health outcomes, although indicators on behavioural risk factors and socioeconomic disparities remain sources of concern given their adverse impact on population health. Historically, Luxembourg's health system legislation has been fragmented but the recent merger in 2023 of two ministries to compose the Ministry of Health and Social Security (known by the abbreviation M3S) sets a path towards more cohesive health care planning, legislation and financing. Nevertheless, elements of accountability and transparency in health policy-making still pose important challenges. Considering its small size, Luxembourg's health care system is highly centralized and the health infrastructure is well distributed. However, the country relies heavily on a foreign-trained health workforce, which raises concerns about the accessibility of care and may undermine the maintenance of high standards of quality of care for complex medical procedures if the retention of skilled medical professionals is not safeguarded. Hence, Luxembourg has been focusing on developing further initial education programmes for its health professionals, as well as developing a digital health care workforce registry and legal framework to encourage multiprofessional collaboration and task-shifting opportunities. Finally, despite efforts to enhance the sustainability of the health system via reforms for better cost containment, increased investments in preventive services and refinement of hospital services, overall efficiency could be improved. Luxembourg has one of the highest per capita expenditures on health compared with other countries with similar health system and population health outcomes and lacks a mechanism for priority setting in budget allocation, incentives for efficiency improvements, and an enhanced focus on prevention.
