By: Hendrik Drößler and Richard Patassy
The Current Challenges in Slovakia’s Health System
The Slovak healthcare system stands at a crossroads, grappling with profound challenges that have long plagued its foundations. Underfunded and burdened by workforce shortages and stagnant reform efforts, it has become emblematic of a sector in gradual decline, struggling to meet the needs of its people (EU Commission Country Health Report 2023 , WHO Health System Review). Personnel often seek better opportunities abroad, which leads to a lack of staff and even more frustration from the patients. The COVID-19 pandemic has exposed challenges in healthcare access and poor working conditions for healthcare workers, with the OECD noting Slovakia's life expectancy as among the lowest in Europe.
These conditions have led to a plethora of healthcare professionals putting forward their letters of resignation, aiming to pressure the Slovak Government to change their current policies. With the threat of the healthcare sector in Slovakia falling, the Slovak Government on the 8th of December 2024 adopted contentious legislation, aiming to counter this. However, the coercive nature of this legislation, compelling doctors to work, has sparked widespread debate across Slovakia. This measure may conflict with Slovakia’s human rights obligations under various international instruments, particularly in light of the European Convention on Human Rights (ECHR) and the ILO Forced Labour Conventions.
The New Law
The Slovak Government has introduced a legislative proposal designed to amend existing laws in a bid to address the ongoing healthcare crisis. Much like patching a leaky roof in the middle of a storm, the proposal primarily focuses on ensuring the delivery of healthcare services during declared emergencies, aiming to reinforce the system’s most vulnerable points. By amending law regarding the protection of civilian population and the criminal law, the proposal aims to avoid a situation of “critical unavailability” of healthcare services during a declared emergency. Upon enactment and after declaring the state of emergency, the legislation mandates medical staff in the 12 most affected districts to remain in service despite the formal effect of their resignations as of January 1 (§290c). The declared state of emergency may be extended once, permitting a maximum duration of 120 days.
Noncompliance with the measures may result in imprisonment of up to one year, with an increased penalty of up to five years if noncompliance results in patient injury or death (§290d (1)). The severity of these sanctions raises proportionality concerns under Article 4 ECHR, as the European Court of Human Rights (ECtHR) has repeatedly emphasized that labour must not impose an undue burden on individuals (Van der Mussele v. Belgium, § 34). In contrast to cases where emergency obligations were imposed on professionals, such as Steindel v. Germany, the Slovak measure not only prevents resignation but also criminalizes refusals, arguably exceeding the standard of ‘normal civic obligations’ under Article 4(3)(d) ECHR. These measures underscore the Government’s recognition of the healthcare system’s critical condition but have failed to address the ongoing disputes and demands of doctors' unions or the underlying systemic issues plaguing Slovakia's healthcare sector.
As of the time of the writing of this blog, the Slovak Parliament has adopted the legislation, aimed at forcing doctors to work during the extraordinary event, and was signed by the President, Peter Pellegrini.
Assessing the compliance of the new measures vis-à-vis International Human Rights Law
The Government’s Reasoning
The Slovak government has defended the legislation as necessary, to ensure that the lives and health of the people are not endangered. In its supplementary report following the proposal, the Government argues that this change reflects the State’s positive obligations towards its citizens, both under international and domestic law. The drafters justify the creation of the "extraordinary event" of critical unavailability of constitutional healthcare as necessary and compliant with the Constitution and international obligations, specifically the ILO Forced Labour Convention (1930) and the Abolition of Forced Labour Convention (1957).
Legislation’s Critics
Despite the justifications, the legislation has faced severe backlash from the parliamentary opposition, doctors and civil society. Critics argue that negotiations concerning working conditions in this sector should have been initiated much earlier and that the legislation solely masks the lack of genuine commitment to enact reforms. Currently, the doctor’s unions are asking Pellegrini to stop this legislation. Some are also considering challenging the new legislation in front of the Constitutional Court. A Slovak oncologist has reacted stating that:
“A quick collapse of the system and the threat of the endangerment of health and loss of life especially with the inadequacy of acute care could lead to anarchy. This measure however is not a solution to the situation and increases disappointment and unwillingness to stay working in Slovakia.”
Legislative Measures Under the Lens of International Human Rights
Definition of forced labour
While some might argue that Article 4 ECHR is a ‘difficult’ provision to apply in this case, the prohibition of forced labour remains one of the strongest human rights protections under the Convention. Unlike other provisions, Article 4(2) is an absolute right, meaning that it cannot be restricted. The ECtHR has defined forced labour as work exacted under the menace of any penalty without the voluntary consent of the individual (Zoletic and Others v. Azerbaijan, 2021, § 148). Similarly, the International Labour Organization’s Convention No. 29 defines forced labour as "all work or service which is exacted from any person under the menace of any penalty and for which the said person has not offered himself voluntarily" (Article 2). In Slovakia’s case, the invalidation of doctors’ resignations potentially undermines the voluntariness criterion, raising the question of whether the measures amount to forced labour.
Article 4(2) of the ECHR prohibits forced or compulsory labour, excluding certain scenarios outlined in Article 4(3). These include work or service exacted in case of emergencies threatening the life or well-being of the community (Article 4(3)(c)) and work considered part of normal civic obligations (Article 4(3)(d)).
Assessment of the measure
A pivotal question arises as to whether the newly enacted Slovak measures amount to forced labour under Article 4(2) of the ECHR, a concern echoed by more general reports of specialized human rights bodies. The Council of Europe’s Group of Experts on Action against Trafficking in Human Beings (GRETA) has previously stressed that coercive employment measures—particularly those involving state-imposed restrictions on resignation—must be examined against Article 4 ECHR and relevant ILO conventions. Similarly, the International Labour Organization (ILO) Forced Labour Convention (No. 29, Article 2) defines forced labour as ‘all work exacted under the menace of any penalty and for which the person has not offered themselves voluntarily.’ In addition, the ECtHR has repeatedly emphasized the need for voluntariness in labour. In Adigüzel v. Turkey (2018, § 31), the Court ruled that a doctor required to work overtime was not subjected to forced labour, reasoning that he had voluntarily chosen to work as a civil servant and should have been aware from the outset that he might be required to work beyond standard hours without additional compensation. In contrast, Slovak doctors are explicitly denied the right to resign, removing any element of voluntariness. In addition to these two elements, the disproportionate burden test must also be taken into account as a factor in order to determine whether a measure meets the threshold of forced labour. In Van der Mussele v. Belgium a lawyer required to provide free legal aid services was deemed to have faced a disproportionate burden, qualifying as forced labour (1983, § 34). Similarly, Slovak doctors are compelled to work under threat of imprisonment, and the burden is compounded by systemic healthcare failures, including chronic understaffing and poor working conditions. Thus, due to the absence of voluntariness and the threat of criminal sanctions, the legislative measure may be classified as forced labour under Article 4 of the ECHR.
The legislation as a legal emergency measure under Article 4(3) ECHR?
While Article 4(2) ECHR imposes a strict ban on forced labour, Article 4(3) recognizes limited situations where compulsory work can be lawful, prompting the question of whether Slovakia’s measure qualifies for such. However, if the Slovak government invokes Article 4(3)(c) ECHR, it must still satisfy the ECtHR’s necessity and proportionality requirements. The Zoletic and Others v. Azerbaijan (2021, § 148) case confirmed that States must demonstrate that no less intrusive alternative was available as part of the proportionality assessment. While the protection of public health is a legitimate aim, the government's failure to adopt meaningful healthcare reforms or improve working conditions, as extensively examined and proposed by Slovak coalitions, practitioners, as well international organisations like the WHO, undermines the necessity argument, especially when considering the threat of criminal sanctions for non-adherence.
The legislation's blanket approach to compel staff to work without adequately addressing systemic issues in Slovakia's healthcare system could render it disproportionate and inconsistent with Slovakia's international obligations vis-a-vis Article 4 ECHR. Slovakia's healthcare system faces challenges such as regional disparities in access to medical care, fragmented supervision of social care, and the need for hospital network optimization (compare suggestions by the EU Commission 2023). Moreover, while civic obligations under Article 4(3)(d) may justify certain mandatory duties, these obligations must not impose an undue burden or deny fundamental freedoms, such as the right to resign. The Slovak legislation criminalizing refusals to work risks crossing this threshold, as it disproportionately impacts healthcare workers’ autonomy and professional freedom.
To illustrate, in Steindel v. Germany (2010, § 52), the Court found that mandatory emergency medical services did not constitute forced labour because (i) the services were remunerated, (ii) they fell within the scope of professional and civil solidarity, and (iii) the burden was not disproportionate. While the Slovak case may meet conditions (i) and (ii), it fails on condition (iii): the denial of the right to resign imposes a disproportionate burden on healthcare workers who already face high workloads and systemic challenges.
Conclusion
The Slovak government’s legislation compelling doctors to continue working under threat of criminal penalties raises acute concerns under Article 4(2) ECHR. While public health emergencies can justify certain extraordinary measures, the denial of resignation rights and imposition of severe sanctions appear to contravene the voluntariness criterion the ECtHR has consistently upheld. In the absence of robust structural reforms, this coercive approach risks intensifying the healthcare crisis rather than resolving it, and may falter under European human rights scrutiny.
Update (12 February 2025)
As of the time of updating this article (12 February 2025), the doctor’s union and the Ministry of Health have agreed to redact the newly adopted emergency situation due to the critical unavailability of healthcare. The parties have also agreed to increase the transparency regarding the financing of the hospitals but also, amongst other things, an increase in the renumeration of doctors.
Bios:
Hendrik Mathis Drößler holds a LL.M. in Public International Law (cum laude) from the University of Groningen and a double bachelor's degree in Law and Political Science from Georg-August University Göttingen. He currently serves in the Deutsche Bundestag, supporting a member of parliament in Asylum and Citizenship Law, whilst working as a research intern at the T.M.C. Asser Institute. His research focuses on the broader theme of the rule of law, compliance with the International Court of Justice, and the law of armed conflict.
Richard Patassy is a LL.M. candidate in both Global Criminal and Public International Law, building on his LL.B. in International and European Law at the University of Groningen. His research interests span the complexities of international crimes, the dynamics of cooperation within international criminal justice in the European Union, and the intriguing question of attributing legal personality to animals under international law.