For too many Slovak women, modern contraceptives remain tragically out of reach, according to a new report released by the Center and its partners Freedom of Choice Slovakia and Citizen, Democracy, and Accountability.
Contraception is critical to a woman’s ability to prevent unintended pregnancy and make some of the most basic decisions about her health and life. It’s not surprising then that international health and human rights standards require governments to make modern contraceptives affordable and accessible.
But unlike most other European Union countries, Slovakia does not help women pay for contraceptives. As a result, high costs deter many women from using contraception.
“If there is no money, then I only have one option: that I will not take contraceptives,” said Maria, a 19-year-old student. As we discovered while researching the report, low-income women are often forced to make a choice between feeding their families and buying contraceptives.
But instead of addressing the problem, the Slovak Ministry of Health is currently planning to exclude contraceptives from being covered by public health insurance.
Calculated Injustice: The Slovak Republic’s Failure to Ensure Access to Contraceptives documents the problems women and adolescent girls in Slovakia face because they lack access to affordable contraception. The Center gathered testimonies from women, healthcare providers, pharmacists, and other stakeholders.
We are using the report’s findings to urge the Slovak government to guarantee access to a wide range of affordable contraceptives and make sure they are covered by public health insurance just like any other essential drug.
International human rights law requires states to provide women with access to a full range of sexual and reproductive health services, which includes making acceptable and affordable contraceptive methods available. It also includes providing sufficient and appropriate information on those methods. These obligations are grounded in numerous internationally recognized human rights, including the rights to equality and nondiscrimination, the right to privacy, the right to decide the number and spacing of children, and the right to health. The UN Committee on Economic Social and Cultural Rights (ESCR) has made clear that the right to health encompasses the right to sexual and reproductive health, which obligates states to ensure affordable access to contraceptives and family planning information. The Committee has explicitly stated that all drugs on the World Health Organization (WHO) Model List of Essential Medicines, which includes contraceptives and emergency contraception, should be made accessible to all. It has also expressed the view that lack of access to contraception and to sexuality education are violations of the right to health. States thus have an obligation to provide all women with access to affordable, acceptable, and good-quality contraceptives. At the regional level, the Parliamentary Assembly of the Council of Europe (PACE)—the representative body of Europe’s human rights system, the Council of Europe—adopted a resolution in 2008 urging states to make contraceptives accessible and affordable, as well as ensure sexuality education in schools in order to prevent unwanted pregnancies and avoidable abortions. Moreover, denying access to services that only women need violates their fundamental rights to equality and non-discrimination—hallmark principles of international human rights law enshrined in major regional and international treaties. Regional and international human rights standards pay special attention to marginalized women—for example, poor women, women in rural areas, and young women—regarding information on and access to contraceptives. In addition, to ensure that states are fulfilling their human rights obligations, regional and international legal instruments underscore the importance of data collection on women’s status, health indicators, and education, disaggregated by relevant grounds, including gender, age, and ethnicity. Governments have clear international human rights obligations—as well as compelling economic, social, and public health reasons—to ensure women’s access to affordable and acceptable contraceptives and information and to collect data on the realization of those obligations. However, the Slovak government has largely ignored these obligations and policy justifications. The Committee on the Elimination of Discrimination against Women (CEDAW Committee) recognized this failure in 2008 when it emphasized that family planning services in Slovakia, of which contraceptives form an integral part, fell short of what is required under international law. The Committee urged the government “to take measures to increase the access of women and adolescent girls to affordable . . . reproductive healthcare, and to increase access to information and affordable means of family planning. . . .” The findings of this report bolster the CEDAW Committee’s observations and reveal that women in Slovakia face significant barriers to accessing contraceptives.
With the exception of emergency contraception, which is available over the counter, female hormonal contraception can be obtained only by prescription from a gynecologist, whom women may visit without a referral from a primary care physician. Such contraception includes pills, patches, injectables, vaginal rings, and implants. Slovakia’s public health insurance scheme, which is mandatory for the entire population, does not cover hormonal contraceptives, thus requiring women to pay for these items out of pocket. This policy exists despite the fact that Slovakia’s abortion law seeks to prevent unintended pregnancy by requiring that prescription contraceptives “be provided to a woman free of charge.” Furthermore, Slovakia’s requirements for including a drug on the list of medicinal products covered by public health insurance include the drug’s life-saving, curative, or preventative qualities. The only insured contraceptive method is surgical sterilization, which is permanent and irreversible and covered only when there are health indications. Therefore, women to whom pregnancy poses a health risk are given no other option under health insurance besides sterilization. The state also does not subsidize emergency contraception in any way.
Contraceptive use in Slovakia has improved since the early 1990s, when only 2.2% of women of reproductive age were using hormonal contraception. In 2008, the percentage increased tenfold to 22.3%. Yet, this figure remains low in comparison with other EU countries. In neighboring Czech Republic, 47.4% of women of reproductive age were using hormonal contraception in 2008. In France, 43.8% of women were using the pill in 2009, and use of contraceptive pills in Germany is among the highest in the world, at over 50%. When comparing overall data from the new European Union (EU) Member States of Central and Eastern Europe (CEE) to that of older EU Member States, serious gaps emerge. Prevalence of modern methods (including not just hormonal contraceptives, but also IUDs, female sterilization, and male condoms) stands at 36% in some countries of the CEE region—namely, Bulgaria, Czech Republic, Hungary, Poland, Romania, and Slovakia, which are all new EU Member States. This is nearly twice as low as in Western European countries, where the prevalence is on average 71%. For example, 28% of women in Poland and 40% of women in Bulgaria are using modern contraceptives, compared to 77% and 82% of women in France and the United Kingdom, respectively. This disparity indicates that contraceptive use is an issue worthy of attention across Europe. Return to top
Like many other governments in the CEE region, the Slovak government does not gather comprehensive data on reproductive health indicators, such as unintended pregnancies, contraceptive use, and the unmet need for contraception. The limited data that the state gathers on the prevalence of just a few contraceptive methods—namely, hormonal contraception and IUDs—is insufficient for understanding the reasons behind low usage rates in Slovakia. As a result, it is difficult to effectively identify measures that should be taken to meet the contraceptive needs of women and adolescent girls. Furthermore, public officials are able to remain unaccountable for neglecting to adequately address the health needs of the public due to their own failure to collect adequate and reliable data.
Slovakia is not the only EU country in which the high price of contraceptives is a barrier to access, in other new Member States, it is a problem as well. To effectively deal with this issue, state subsidization of reproductive healthcare services in the form of basic public health insurance is widely considered an appropriate measure. Of the twenty seven EU Member States, eighteen include contraceptives in their public health insurance package as a means to prevent pregnancy without there having to be an underlying health condition. Those states either fully or partially subsidize some hormonal contraceptive methods for all women, for low-income women, or for women under a certain age. However, the remaining nine EU Member States do not provide subsidies for hormonal contraceptives, despite their inclusion on the WHO’s essential medicines list. All but one of these nine countries are new Member States, among them Slovakia. Some of those same countries, including Slovakia, also either do not have national strategies for ensuring access to reproductive healthcare services or do not have effective strategies for making contraceptives affordable. EU Member States that subsidize contraceptives do so on public health grounds or to uphold fundamental rights. The Slovenian government, for example, considers family planning a fundamental human right guaranteed by the Constitution, which grants all citizens the right to determine whether to bear children. In Poland, while the Ombudsman for Human Rights found the withdrawal of subsidies for contraceptives to constitute discrimination on the ground of sex,the government has failed to reinstitute their subsidization. The Belgian Constitutional Court, in addressing the constitutionality of the law on pricing for pharmaceuticals, stated generally that the pricing scheme aims to improve access to drugs that promote public health and social benefits. The Court noted that contraceptives are a type of drug that must be accessible to the public at an affordable price. It explained that providing access to them is justifiable on the grounds of public health and social protection in order to reduce the number of unwanted pregnancies. Similarly, the Danish government considers family planning services, including subsidization of contraception, “an integral part of the national health service.” In France, research conducted by public authorities on the use of various oral contraceptives indicated that contraceptive subsidies “present an interest in terms of public health.”Also espousing the public health argument, the United Kingdom’s National Health Service Act mandates that contraceptives be available free of charge to “cut down the number of unwanted pregnancies and . . .decrease the number of abortions.” Return to top
When asked whether she offers patients different contraceptive options, Dr. Elena Molnárová, a gynecologist, responded:
I tell [a woman] about the possibilities and she tells me her financial limit. I tell her what I think is the best and most suitable for her, but the crucial thing is what she can afford. It has happened to me that a patient wanted to take more expensive contraception and she didn’t buy it because she couldn’t afford it, and she got pregnant.
Beáta, a 40-year-old mother of two, noted that of her approximately 30 female acquaintances, only one is using modern contraception. She explained why this figure is so low:
I think the main reason is first and foremost financial, that they cannot afford it. Simply in the case of some of my acquaintances or friends it’s either that she doesn’t work or her husband doesn’t work, they have two to three children, it is a problem to [get by], you understand. So I think it is a financial problem.
Ms. Vargová, a pharmacist, has noted that emergency contraception is prohibitively expensive (€22) for young women, particularly students, who lack income. She noted that when some of her customers see the price of emergency contraception, they realize that they cannot afford it and purchase a pregnancy test instead.
Ms. Apolónia Sejková, director of the NGO, MYMAMY, which provides support to women subjected to male violence, explained the following:
Abused women have complained about [their husbands not giving them money for] contraception. It is on the list of things that they do not have buying power after the abuse starts. . . . It is true that abusing men often use conception of more and more children for stronger control and for restricting the partner. In the socioeconomic situation most of our clients are in, and in general most of the average population of Eastern Slovakia, it is difficult to [come up with] any solution. If you have four or five children, no income, live in the house that belongs to the husband or his family, . . . [it is] difficult to leave the husband. Many women therefore stay in violent relationships because they take it as at least they have basic living needs covered and they rather stand to be hit or humiliated . . . they feel that it is the only way for their survival. Return to top
Klaudia, a 36-year-old mother of one, said that daughters of her Catholic friends go to meetings with Salesians, a Roman Catholic religious order, where they also receive information on contraception. However, the information provided is one sided, focusing on natural family planning and the negative side effects of hormonal contraception. Speaking about the Catholic Church hierarchy’s influence on women’s contraceptive use, Iveta, mentioned above, observed with apparent sarcasm: “The church gives [women] a great option: don’t use withdrawal, don’t use contraception, bring up your child on your own, and don’t go for abortion. And that is really great, really great.”
According to Ms. Olga Pietruchová, executive director of the Slovak Family Planning Association, access to contraception is impeded by conservative Catholic groups and individuals who spread half-truths and demonize contraception: Ideologically-based groups . . . have a big influence on power, either through the Catholic Church hierarchy or through some political parties. . . These groups, which include some NGOs and doctors, run negative campaigns, primarily against hormonal contraception by pointing to its negative side effects. But the information [they provide] is partial, they say one thing but don’t say the rest. They always talk about negatives [and] this dominates the public discussion.” According to Dr. Molnárová, the lack of access to contraceptives has to do with the way schools provide sexuality education: “[N]owadays, at many secondary schools there is sexual education, which is taught by catechists, or people who are from different parishes, and [their] explanation of this area is pronouncedly onesided. . . . We still have a problem [establishing] sexual education within the framework of classes at school. It’s still more or less up to biology teachers. In fact, it depends on the professor’s view in what direction it all goes.” Ms. Pietruchová of the Slovak Family Planning Association also cited lack of adequate sexuality education as a problem: “Sex education—that is, “Education for Marriage and Parenthood”—is not a mandatory subject, but if the school chooses to teach it, it should do it according to [official school] guidelines [set by the Ministry of Education]. However, these guidelines are very general, anything can be included under the topics addressed. Moreover, the name of the subject itself—“Education for Marriage and Parenthood”—is sick.”