Implementation of patients' rights in the Slovak Republic

- Alexandra Brazinová*, M.D., Ph.D., Emília Janská, M.D., Ph.D., Richard Jurkovi_*, M.D.
*Ministry if Health of the Slovak Republic, Bratislava, Slovak Republic
Email: janska@yw.catv.ne.jp
Email: janska@yw.catv.ne.jp

Eubios Journal of Asian and International Bioethics 14 (2004), 90-91.


Abstract
The purpose of this article is to share the experience of promoting patients' rights in the Slovak Republic. According to the Constitution of the Slovak Republic, the state provides its citizens with the right to quality health care, health protection, safety, privacy, health information, etc., but these rights were not implemented sufficiently in daily life. A successful Dutch model of the promotions of patients' rights was used for 18 months from January 2002 - June 2003. Educational and training activities with special emphasis on public awareness were among the priorities of the project. The initial survey to estimate public awareness and an identical survey conducted at the end of the project were compared. The ultimate goal of the project was to enhance the capacity of professionals and citizens to enforce the patients' rights.

Introduction
The Slovak Republic was established in 1993 and, as each democratic state, observes the rights of its citizens by declaring them in the constitutional laws. This creates mechanisms for protection and promotion of these rights and supports citizens in their active participation. Healthcare, although being fundamentally a moral enterprise, must be built on sound business principles where clients and providers know their rights and responsibilities (Hirsh 2002).
Within the last decade there were several activities concerning patients' rights in Slovakia. For example, a working group of Slovak Association of Hospitals carried out an awareness survey on public perception of patients' rights in mid 90s and based on the result a "Charter of Hospitalized Patient" was developed. However, it was published only in a limited number of magazines and never publicly acknowledged.
Another public awareness survey was conducted in 1999 and again showed unsatisfactory general knowledge. In April 2001 the "Charter of Patients' Rights" was adopted by the Government of the Slovak Republic. To have a charter as a well defined summary of all patients' rights was the first step in improving the situation. The next step was applying these rights in everyday practice. For the international cooperation and an expertise the Dutch government was approached, and as a result the project "Promotion of Patients' Rights in Slovakia" was implemented and financed by the government of the Netherlands.

Project methods and results
Methods of social marketing, consensus development, professional and continuing education and media based enhancement of public awareness of patients' rights were the main approaches used in the project. The project lasted for 18 months.
First, the Strategic Committee (SC), consisting of representatives of 30 stakeholders institution, was established. Members were responsible for outlining and designing the National Program of Patients' Rights (NPPR). They developed their own Action Plans to be included into the Program as a primary tool to initiate and sustain activities of the individual organizations - from the patients self-help groups through the health insurance companies to the municipal and state health authorities. The project was evaluated every trimester. Once the Action plans were developed and publicly discussed the Program became a lively document providing useful navigation through various activities and indicating targets for next actions.
To evaluate a level of success of public understanding of patients' rights issues a questionnaire survey was deployed in both initial and final phases of the project with a time difference of one year. The questionnaire was distributed by students of Public Health among 200 respondents in 4 cities and statistically analyzed. Initial survey showed that less than 60% of population was aware that the rights of patients are encoded in legislation, and more than 80% thought that these rights were not observed. In response to the practical implementation of particular rights, such as the right to information, informed consent, the choice of physician or health care facility, the refusal of treatment or participation in medical research, a very low number of respondents were familiar with their rights (50-60%). The identical survey after one year revealed that public awareness on the issue increased in several areas. More respondents reported that they were properly informed and instructed while receiving health care.
The priority of the project was to develop and facilitate the educational and training activities. First, a set of 14 educational modules was designed and later used in the project activities:
1. Patients' Rights in the SR and selected European Countries.
2. Human rights and patients' rights
3. Choice of a provider of health care
4. Information for patients
5. Communication
6. Acceptation and consent
7. Health care strategies
8. Quality of health care
9. Professional Ethics
10. Patients' rights and specific patients groups
11. Advocacy
12. Stakeholders' involvement, complaint procedure
13. National Program On Patients' Rights
14. Project Management
Each module comprised the outline of the session, the Power Point presentation frame and the list of suggested examples. Those were used during the entire project period for the training seminars and workshops. Final version of the modules was distributed on CD's as well as in the form of a booklet to all project stakeholders. The training events were organized for representatives of patients, for employees of the Advisory Centers of the State Health Institutes and for the inspector physicians from the General Health Insurance Company. All selected trainees (130) were to act as intermediaries between the public and the health care system and were prepared to promote patients' rights in their future work.
Pilot projects were deployed to demonstrate methodology and to sensitize the public. Four locations (the capital, western, eastern and central Slovakia) were selected to test the impact of activities developed by the project team. The primary focus was on developing and supporting community activities to raise public awareness on patients' rights.
In Bratislava (the capital) the lectures for the public were organized with the City Hall. Several seminars were organized for employees of the State Health Institute of the SR, the national headquarters of 36 regional and district institutions.
In Trnava (western Slovakia), a close cooperation with the local civic organizations was initiated with 3 roundtables on priorities and development of patients' right promotion. The project experts participated twice in the annual Trnava Health Days, a town festival dedicated to health promotion. A public lecture was organized in cooperation with the educational center of the community catholic church. The state health institute of Trnava hosted a seminar on patients' right advocacy, a role for health promotion officers.
In Banska Bystrica (central Slovakia) a close cooperation with the regional State Health Institute and the City University was established. One day seminars on patients' rights for students and comprehensive training for employees of the Advisory Centers of all state health institutes in Slovakia were organized.
In Levoca (eastern Slovakia) an active group of hospital managers was formed to make patients more familiar with services provided by the hospital. They focused on restructuring their information strategy, developed a general information brochure for admitted patients and then revised the patients satisfaction questionnaire.
Continuous information campaigns and effective cooperation with the local and national media were organized, and all project activities were presented in public. With regard to media coverage within the project period, ten articles were published in the national newspapers and twenty were published in the local newspapers. Two national and six local television news reports covered the project events, four national and six local radio broadcasts gave information about the activities. The Charter of Patients' Rights in the Slovak Republic was published in a form of a brochure and widely distributed.
Two national conferences contributed to development of the national policy on patients' rights in Slovakia. They enabled an exchange of ideas, experience and good examples of patients' rights promotion between both Dutch and Slovak participants. As a result of those two conferences the "National Program of Patients' Rights" was adopted. This strategic document defines the current situation of patients' rights in Slovakia and areas of concern and indicates the concrete activities that are necessary to be implemented for efficient patients' rights promotion. As an administrative support "the Patients' Rights Unit" was established at the Ministry of Health of the SR. Its role is to carry on the activities initiated within the project and to oversee the successful implementation of the National Program of Patients' Rights. The active counseling for citizens is accessible through their website www.pravapacientov.sk.

Discussion
The comparison of the legislation on patients' rights in the European countries were made by Leenen (1993) and Mackenney (2001). The Slovak Republic was established in 1993, which allows a shorter time for promotion of patients' rights. In addition, these are very narrowly defined in our legislation, compared with several European countries. For example, a Slovak citizen has a right to look into his health record and take notes. However, he is not entitled to make a copy of it. Only the patient himself may check his documentation, nobody else, not even a close relative or a legal representative.
Some rights are stated by legislation but to achieve them is often difficult. The right to choose a satisfactory general practitioner or health care facility could serve as an example but the right to accomplish this is obstructed by a lack of good information and also by a lack of official criteria from which to choose. In addition, when talking about a problematic access to health information we need to remember also the minorities speaking foreign languages. In some European countries interpreters for health care services are contracted in areas dominated by the minorities (Rollins, 2002).
The implemented project positively motivated public discussion on patients' rights and stimulated the cooperation of large scale stakeholders in their promotion. Interestingly, some of the cooperating health care professionals expressed their fear that the public might misuse gained advocacy skills. This originated in the current economic situation in Slovakia where inadequate financing, education and management are a barrier for physicians to serve the patients' best interest.
Continuous upgrading of education of health care employees in medical bioethics, and strengthening the active role of patients in pursuing their rights would be of a significant benefit.

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