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Title page 1

Contents 8

Foreword 4

Acknowledgements 5

Acronyms 6

Executive summary 11

1. Introduction 13

1.1. Health System Performance Assessment (HSPA) as a policy tool 14

1.1.1. HSPA is a comprehensive evaluation of how a health system meets population needs, allocates resources and achieves policy goals 14

1.1.2. National HSPA frameworks are strategic tools that build on international learning and benchmarking 14

1.1.3. A systematised approach is needed to make an HSPA operational and sustainable 15

1.2. Towards a commonly shared HSPA framework in the Slovak Republic 17

1.2.1. Aiming for a tool to support evidence-based health policymaking 17

1.2.2. Objectives and scope of this report 17

1.2.3. Setting up the HSPA in the Slovak Republic: a stakeholder-inclusive process 18

References 21

2. The Slovak HSPA framework 22

2.1. The purpose and scope of the Slovak HSPA 23

2.2. The Slovak HSPA framework domains 24

2.3. Designing the Slovak HSPA framework with stakeholder ownership 28

2.3.1. Building consensus to develop the first framework draft 28

2.3.2. Improving the framework draft for structural coherence based on expert inputs 30

References 30

3. Indicators to assess the performance of the Slovak health system 31

3.1. Indicator selection methodology and process 32

3.1.1. From a comprehensive indicator repository to a pre-selected indicator set 33

3.1.2. Stakeholder voting to identify a draft list of HSPA indicators 34

3.1.3. Finalisation of the list of indicators for the HSPA 35

3.2. Indicators populating the Slovak HSPA framework 36

3.2.1. Resources 38

3.2.2. Prevention and risk factors 45

3.2.3. Healthcare services 51

3.2.4. Outcomes 57

3.2.5. Efficiency 61

References 64

Notes 65

4. Using the Slovak HSPA framework: Case study on equity 66

4.1. Equity in geographic distribution of health variables: preventive and outpatient healthcare 68

4.1.1. Variation in regional distribution of healthcare workforce implies differences in access to first-contact and specialist care 68

4.1.2. Provider network adequacy and unmet needs indicators can pinpoint geographic access gaps 68

4.1.3. Indicators on preventive care utilisation can reveal where access constraints may be suppressing uptake 70

4.1.4. Consultation rates can signal differences in early access and service efficiency 71

4.1.5. Outcome indicators can support a geographically sensitive lens on whether gaps persist in health status and mortality 72

4.2. Equity by demographic characteristics: Cardiovascular disease (CVD) 74

4.2.1. Differences in behavioural determinants are key to understand cardiovascular disease inequalities 74

4.2.2. For people at risk of or with cardiovascular disease, healthcare availability is valuable to support self-management 75

4.2.3. Healthcare services can be delivered or received differently by population groups 76

4.2.4. Cardiovascular disease outcomes often differ by gender 77

4.3. Equity by socio-economic status: Health status differences 79

4.3.1. Health status is impacted by health literacy, in turn affecting risk factors and engagement in prevention programmes 79

4.3.2. Disadvantaged socio-economic groups often experience barriers to healthcare access or may receive care that is of lower quality or less people centred 81

4.3.3. Outcomes area includes indicators that reflect socio-economic differences in health status 82

4.4. Understanding equity in health system performance through the Slovak HSPA framework 84

References 84

5. HSPA governance and implementation in the Slovak Republic 86

5.1. HSPA governance structure and roles of key stakeholders 87

5.1.1. Process undertaken to design the Slovak HSPA governance proposal 87

5.1.2. Setting accountability in the Slovak HSPA governance 88

5.1.3. Indicator custodianship and data governance in the Slovak HSPA 91

5.1.4. Steps to implementing the Slovak HSPA framework 94

5.2. Embedding the HSPA intelligence in the Slovak health policymaking 94

5.2.1. Clear roles, stakeholder accountability and engagement strengthen use of HSPA in policymaking 94

5.2.2. Aligning HSPA reporting with important policy timelines to maximise impact and sustainability 95

5.2.3. Aligning with strategic priorities to leverage use in policy development 96

5.2.4. Effective dissemination to foster HSPA intelligence use and impact on shaping policies 99

5.3. The HSPA methodological report as a blueprint to support the HSPA implementation 100

References 100

Annex A. The Slovak HSPA project - main project activities during the framework development and indicator selection process 101

Annex B. Health data landscape in the Slovak Republic as a basis for the HSPA 109

B.1. Health data custodians and governance 109

B.2. Data flows and linkage 111

B.3. Data gaps and limitations 112

B.4. Key data sources for indicators in the Slovak HSPA framework 113

References 117

Annex C. Technical sheet example 118

C.1. Technical information for the Slovak HSPA indicator sheets 118

C.2. Technical information - International practice 119

References 121

Annex D. The Slovak HSPA: Contextualising indicators and alternative indicator sources 122

Annex E. The HSPA framework for the Slovak Republic - domains in the Slovak language 125

Tables 10

Table 1.1. Principal Working Group meetings and workshops in 2024-2025 20

Table 2.1. Description of the Slovak HSPA framework domains 26

Table 3.1. Workforce domain indicators 39

Table 3.2. Financing domain indicators 41

Table 3.3. Infrastructure domain indicators 42

Table 3.4. Digitalisation and data domain indicators 43

Table 3.5. Governance domain indicators 44

Table 3.6. Research and innovation domain indicators 45

Table 3.7. Health literacy domain indicators 46

Table 3.8. Prevention domain indicators 47

Table 3.9. Behavioural determinants domain indicators 48

Table 3.10. Environment and AMR domain indicators 50

Table 3.11. Access domain indicators 51

Table 3.12. Quality and safety domain indicators 53

Table 3.13. Care coordination domain indicators 55

Table 3.14. People centredness domain indicators 57

Table 3.15. General health outcomes domain indicators 58

Table 3.16. Disease-specific health outcomes domain indicators 60

Table 3.17. Cost efficiency domain indicators 62

Table 3.18. Care provision efficiency domain indicators 63

Table 4.1. Selection of resource indicators that capture geographic disparities in supply of primary and outpatient care workforce 68

Table 4.2. Selection of Slovak HSPA indicators that capture geographic disparities in supply and access to primary and outpatient care services 69

Table 4.3. Selection of Slovak HSPA indicators that capture geographic disparities in utilisation of preventive care 70

Table 4.4. Selection of Slovak HSPA indicators that capture geographic disparities in utilisation outpatient care 71

Table 4.5. Slovak HSPA indicators that capture geographic disparities in outcomes sensitive to primary and outpatient healthcare 72

Table 4.6. Selection of Slovak HSPA indicators that capture demographic differences in behavioural determinants 74

Table 4.7. Selection of Slovak HSPA indicators that capture demographic differences in service availability and use 75

Table 4.8. Selection of Slovak HSPA indicators that capture demographic differences 76

Table 4.9. Disease prevalence and mortality can be captured by demographic factors 77

Table 4.10. Selected indicators with socio-economic disaggregations in the Prevention and risk factors domain 80

Table 4.11. Selected socio-economic disaggregation in the healthcare services domain 81

Table 4.12. Socio-economic indicators of health status 83

Table 5.1. Stakeholders' HSPA indicator custodianship in the Slovak HSPA 92

Table 5.2. Data custodianship among different stakeholders in the Slovak HSPA 93

Table 5.3. Degree of alignment between Slovak national health strategies and HSPA indicators 97

Figures 9

Figure 1.1. Organisation of project teams and groups to set up the HSPA in the Slovak Republic 18

Figure 2.1. The purpose of the Slovak HSPA 24

Figure 2.2. The scope of the Slovak HSPA 24

Figure 2.3. The Slovak HSPA framework has 18 domains organised in five areas 25

Figure 2.4. A total of 195 ideas were identified, clustered into 31 possible framework domain themes, out of which 18 received stakeholder priority votes 28

Figure 3.1. Overview of the HSPA indicator selection process in the Slovak Republic 32

Figure 3.2. Distribution of the Slovak HSPA indicators across the 18 framework domains 37

Figure 4.1. Indicators that allow for equity assessment in the Slovak HSPA framework 67

Figure 4.2. Distribution of districts by percentage of optimal capacity fulfilment of the network of general outpatient care 69

Figure 4.3. Mandatory vaccination across regions and colorectal cancer screening time trend in a specific region 71

Figure 4.4. Selected indicators with geographic distribution under the Outcomes thematic area 73

Figure 4.5. Gender differences in rates of obesity and overweight 75

Figure 4.6. Avoidable hospital admissions for congestive heart failure (2023 or nearest year) 77

Figure 4.7. Cardiovascular disease mortality rate, people under the age of 65 (2022) 78

Figure 4.8. Socio-economic distribution within the Outcomes and the Prevention and Risk Factors thematic areas 81

Figure 4.9. Share of households with catastrophic health spending by consumption quintile 82

Figure 4.10. Distribution in the percentage of people reporting good or very good self-perceived health by income quintile (2024) 83

Figure 5.1. Phases for establishing Slovak HSPA governance and delivering HSPA reports 87

Figure 5.2. Common main tasks and functions in a regular national HSPA cycle 88

Figure 5.3. The proposed governance structure for the Slovak HSPA 90

Figure 5.4. HSPA implementation timeline for the first report of the Slovak HSPA 94

Figure 5.5. Possible HSPA timeline and reporting cycles 96

Boxes 14

Box 1.1. What is a Health System Performance Assessment (HSPA)? 14

Box 1.2. Concepts behind national HSPA frameworks development and international practice 15

Box 1.3. Slovak stakeholders participating in the project and actively involved in the development of Slovak HSPA - members of the Principal Working Group for the Slovak Republic 19

Box 2.1. What is an HSPA framework domain? 25

Box 2.2. The process and methodology of the development of the first HSPA framework draft proposal for the Slovak Republic 29

Box 3.1. Principles to consider by stakeholders when voting on indicators 34

Box 3.2. The Slovak health system stakeholders were actively involved in the selection of Slovak HSPA indicators 36

Box 3.3. Explanations of technical information included in indicator tables within Section 3.2, and related indicator statistics 38

Box 4.1. Marginalised Roma Communities in the Slovak Health System Performance Assessment framework 79

Box 5.1. From monitoring to action: linking HSPA with strategic priorities and decisions 96

Annex Tables 10

Table A C.1. Proposal for definitions of technical details for the Slovak HSPA indicator sheets 118

Table A D.1. Contextualising indicators in the Slovak HSPA 122

Table A D.2. Indicators where an additional source adds relevant breakdowns or comparisons 123

Annex Figures 9

Figure A A.1. August 2025 version of the draft Slovak HSPA framework 103

Figure A B.1. Overview of data custodians in Slovak healthcare sector 111

Figure A B.2. Categories of data available at the NCZI and relevant considerations for HSPA indicators 112

Figure A B.3. Selected elements of the health data infrastructure strengths, challenges, and opportunities for the purposes of developing national HSPA in the Slovak Republic 113

Figure A C.1. Overview of international practice in HSPA indicator technical detail provision across national HSPAs 120

Figure A E.1. The HSPA framework for the Slovak Republic in the Slovak language 125

Annex Boxes 114

Box A B.1. Sources of indicators in the Slovak HSPA derived from OECD and other international collections 114

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