|Implemented in this survey?|
The government elected in November 2008 set as one of its most important goals a health care reform. As the main coalition political parties had been very critical of the previous developments in health care, it was something to be expected. This time around the Ministry of Health decided to approach the reform by proposing a completely revised set of basic health system laws, which would then represent the backbone of the new, reformed health care system in Slovenia.
Legislation of 1992 had been surpassed by many 'practical' solutions, while some legal definitions and solutions, especially those insufficiently defining the setting for private providers, relationships between key stakeholders and control functions of the system, had not been yet legally resolved. The main objectives behind the first newly revised system law are:
1. a redefinition of the role of primary health care centres, which are to remain but should have their functions adjusted to the present level of health system development. Primary care centers were developed gradually through history. The present setting and functions largely still reflect the organisation and the health system in the late 1980s. Organisationally, there is a need to organise health promotion differently, which has already developed as an activity and there are even financial provisions for it, home care and nursing, integration of health and social services and management of chronic patients.
2. a stronger role for the MoH and the Health insurance Institute of Slovenia in all regulatory matters,
3. a redefinition of the hospital network by abolishing the former principles of general hospitals as the minimum setting for any hospital (apart from the specialist hospitals)
4. a clearer definition of limits between the public and the private sector
5. stronger control and monitoring functions of the MoH and the Health Insurance Institute of Slovenia (HIIS)
6. introduction of new organisational approaches in the primary care, hospital care and private provider settings
The main instrument of the health care reform are new legal acts defining the health care system. They are to be discussed and revised in the course of public debates over the basic principles. The first characteristics of the new basic laws have already been made public.
Mostly the interventions could be summarised as follows:
1. A stronger role for the MoH in its stewardship and regulatory functions
2. A stronger position and new functions for the primary health care centres (PHCCs)
3. Redefinition of the hospital sector with the introduction of bispecialty hospitals ('local hospitals'), including only surgical and internal medicine departments
4. A very precise definition of the tendering procedure and procurement rules for the commissioning of services from private providers who would like to be reimbursed from public funds
5. Introduction of the status and function of a 'free medical specialist' (ie.a fully registered medical specialist, who is legally an entrepreneur, but does not contract his/her services directly with the health insurance. Instead, other providers, public and private, negotiate services and budgets, which they contract out to free medical specialists, who provide only the medical part of the care needed in a particular case. They cannot be formally employed anywhere, but depend on contracting the respective services in the manner described above)
6. Involvement of physicians in independent practices into regular clinical work in the regional specialty departments of general hospitals (locums, rosters, on-call, night shifts, etc.)
As only the initial legal setting of the new system's structure has been described so far (which is also not yet seen as a final proposal), it is very difficult to assess what kind of incentives would be enacted in practical terms.
Ministry of Health, Health Insurance Institute of Slovenia, health care providers - public and private
|Medienpräsenz||sehr gering||sehr hoch|
The principal reason for the proposed changes is the change in Government which happened after the general elections in September 2008. The previous centre-right coalition was replaced by a centre-left coalition, where only one political party, the Pensionists' party remained the same. Accordingly, the priorities set in the coalition contract and in health care priorities overall were changed. A bigger role for the State and for the state-controlled stakeholders, such as HIIS, was to be expected. In the new government, the voice of the 'Movement for the preservation of public health care' (Gibanje za ohranitev javnega zdravstva) was very strong. This meant that some of the first interventions would be directed to reformulating the area of granting concessions, the overall role of the private sector in health care, the role of professional associations (Chambers) in the negotiation and control processes, etc. A sign of certain interests, such as the society for the promotion of HPV vaccination , Kala, was clearly evident for example with the placing of the introduction of HPV vaccination in the coalition contract. Private initiative was to be reduced to those areas where public interest was lacking.
A considerable change in the political forces in the government
Complying with the comittments of the new coalition political parties to certain interest groups
|Implemented in this survey?|
The ideas of the concepts for the new health reform were defined in the political programs of the respective coalition political parties.
The approach of the idea is described as:
Other stakeholders will position themselves towards the proposals of the new legislation in the process of a broader public discussion.
|Health insurance institute of Slovenia||sehr unterstützend||stark dagegen|
|Professional associations||sehr unterstützend||stark dagegen|
|Association of public providers of health care||sehr unterstützend||stark dagegen|
|Movement for preservation of public health care||sehr unterstützend||stark dagegen|
The present legal proposal is setting the path for a new legal structure of a reformed health care system in Slovenia. But, at this stage, it is yet far too soon to estimate what will be the final shape of the proposed legal framework for the health care system in Slovenia.
The principal developments will be in the relationship between health policy represented by the MoH, the professional associations ('Chambers') and the municipal authorities. The latter are important in influencing decisions regarding both the role of the primary health care centres for which they are directly responsible for as well as for the hospitals for which they bear the informal, mostly social and poltical responsibility. The latter is usually expressed in a defensive way, stressing the potential 'losses' to the local environments, should hospitals become smaller or even close down.
|Health insurance institute of Slovenia||sehr groß||kein|
|Professional associations||sehr groß||kein|
|Association of public providers of health care||sehr groß||kein|
|Movement for preservation of public health care||sehr groß||kein|
The main stakeholder in this process is the MoH. It will, supported by the Government, have to run the campaign and co-ordination in trying to motivate stakeholders and the general public in favour of the proposed legislative changes. As there had been no major structural change for 17 years, a system's change is expected but positions of stakeholders range from the criticism of the basics of the system from 1992 to the demands for an even wider privatization and liberalization of the health care provider and services markets. The current financial and economic crisis is unlikely to favour the latter. On the contrary, it is likely that a wider social consensus be achieved around rather controlled, more state and more egalitarian based principles.
All actors will be actively participating in the process as the public discussion on the proposed legislation is yet to start in the next few days. Incentives for primary health care centers to restructure their services would help the process, as the introduction of a long term care insurance would help hospitals in shifting some resources into supportive and nursing care.
At this stage it is not yet possible to assess what means would be dedicated to monitoring and evaluation of this reform process.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
From the existing proposal, it is very difficult to estimate whether some of the proposed concepts, such as the enhanced and broader role of the primary health care centres, would eventually really lead to better quality of health care services and better cost efficiency. This is even more relevant to the potential reform of the hospital capacity envisaged through the changed role of some hospitals and through the shifting of resources to supportive and nursing care.
1. Draft Health Services Act, Ministry of Health of Slovenia, March 2009.
2. Gibanje za ohranitev javnega zdravstva - Movement for the preservation of public health care. website: www.ohranimo.si
3. Normative program of the government of Slovenia for the year 2009, p.143. (in Slovene). Accessed at: www.vlada.si/fileadmin/dokumenti/si/program_vlade/pdv2009_0409.pdf
4. Coalition agreement for the participation in the Government of Slovenia for the legislative term 2008-2012 - 'Implementation of responsibility for change', 6 November 2008.