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15 September 2023 | Policy Analysis
Resignation of the Minister of Health -
01 May 2023 | Policy Analysis
New Health System Reform Strategy for Slovenia -
03 February 2023 | Policy Analysis
Whole-system Health Reform preparation formally launched in Slovenia
2.2. Organization
The Health Care and Health Insurance Act (1992), updated in 2018, and the Health Services Act (1992), which has not been changed considerably since its introduction, underpin the current SHI system in Slovenia. These ensure universal health insurance, permit privatization of services and transfer some regulatory and administrative functions to professional associations. The system is organized across the national and local (municipal) levels of government (Fig2.1).
Fig2.1
The National Parliament has primary administrative and regulatory authority and determines policy. Health and health care-related legislation is adopted by Parliament, which also approves relevant budgets annually.
The Parliamentary Committee on Health prepares legislative materials and seeks to obtain consensus on matters undergoing health-related parliamentary consideration.
The Ministry of Health (MoH) is responsible for governance and leadership of the health care system. Together with adjunct state agencies and offices, it implements legislation, standards and other mechanisms for ensuring health and health care. It determines health and health care policy through the national health care plan and oversees procurement for bigger investment projects, supervision of medicines and medical devices (see section 2.4) and implementation of international agreements. It also defines the master plan of public health care providers and regulates the numbers of students who can matriculate into medicine and health sciences programmes. The Ministry of Education, Science and Sport is responsible for the overall regulation and organization and financing of the medical and health sciences education (see section 4.2).[1] Finally, the MoH cooperates on health financing and health insurance matters and is the owner of public health care facilities at the secondary and tertiary care levels.
There are two component-offices within the MoH: the Health Inspectorate controls the implementation of health and health care legislation and the National Chemicals Office assesses and manages chemical-related hazards and risks, including maintaining a national register of chemicals and monitoring the trade and production and use of chemicals.
The Health Council is the highest professional body supporting the development of health policy and other governance issues, including ethics and medical doctrine.
Affiliated with the MoH, the Agency for Medicinal Products and Medical Devices of the Republic of Slovenia (Javna agencija Republike Slovenije za zdravila in medicinske pripomočke – JAZMP) is the official quality control laboratory for medicinal products and devices. It is the national regulatory body for pharmaceutical products and medical devices and is responsible for pharmacovigilance and materiovigilance. It maintains the national database of pharmaceuticals.
Several other ministries have mandates that impact on health policy, services or health determinants. The Ministry of Finance reviews and approves the budget of the MoH and health care-related investments. Distribution of the state budget, local authorities’ budgets, and compulsory health insurance[2] and pension and disability insurance are also approved by the Ministry of Finance and Parliament yearly. The ministries of Internal Affairs, Defence and Justice finance health services for police, military personnel on active duty and prisoners, respectively. The Ministry of Public Administration oversees public sector operational regulations, regulates the salary system in the public sector; coordinates the negotiations with trade unions concerning salaries and working conditions; and defines the procurement rules for all public sector agencies, including all publicly owned health care providers.
Municipalities define the local network of primary care providers and pharmacies and own CPHCs and local pharmacies. They have authority to grant concessions to private health care providers looking to work within the publicly operated primary health care system. Municipalities also decide on and ensure funding for local health care infrastructure investments (section 4.1) and pay health insurance contributions for individuals without income, though in reality they do not have sufficient capacities and are only 30% self-sufficient in terms of capital.
The Health Insurance Institute of Slovenia (Zavod za zdravstveno zavarovanje Slovenije – ZZZS) administers the centralized compulsory health insurance (SHI) and aligns its work to the National Health Plan and the MoH priorities. It collects employment-based payroll health care contributions and contracts health care providers, pharmacies and medical equipment suppliers. It monitors health expenditures and negotiates prices of health services. ZZZS has 10 regional branches responsible for contracting and supervising providers and 45 local offices. The ZZZS Assembly, comprising representatives of employers, the insured population, retirees, people living with disabilities and farmers, approves ZZZS’s annual financial plan, prepared by the MoH and the Ministry of Finance, which defines the level of funding for public health care services.
Three complementary health insurance companies, Vzajemna, Triglav zdravstvena zavarovalnica and Adriatic Slovenica zdravje, provide insurance for co-insurance (called co-payments in Slovenia) (section 3.5). According to law, their main purpose is not to make profit, but to complement SHI and strengthen financial protection.
The National Institute of Public Health (Nacionalni inštitut za javno zdravje – NIJZ) is responsible for essential public health functions, including health intelligence, health information and digitalization (e.g. data treatment and processing), health promotion, protection and disease prevention programmes, and provides support for health system and health care governance. It conducts public health research and education and is the key reporting institution for national health and health care statistics (section 2.6). NIJZ works closely with the National Laboratory for Health, Environment and Food (Nacionalni laboratorij za zdravje, okolje in hrano – NLZOH), Slovenia’s central and only public health laboratory and, since 2017, the official national laboratory that performs laboratory analyses for quality control of medicinal products. Each has a national and regional presence; NIJZ is headquartered in Ljubljana and NLZOH is in Maribor.
Professional associations such as the Medical Chamber of Slovenia and the Slovene Pharmaceutical Chamber have supervisory, (postgraduate) educational and administrative functions related to their constituencies. The Nursing Chamber has authority over the licensing and registration of nurses, midwives and health technicians. There is also a Chamber of Physiotherapists and of Laboratory Biomedicine. The Slovene Medical Association convenes physicians to discuss professional and operational issues. The Association of Health Institutions of Slovenia is also open to ZZZS-contracted private providers (concessionaires) and represents the interests of its members in negotiations with payers of services, and informs and advises them on topics related to management and legislation.
Several trade unions represent the interests of health professionals: the Slovene Union of Physicians and Dentists, the Slovene Health Service and Social Service Union, the Federation of Slovene Free Unions (Health Care and Social Care Union Department) and the Union of Health Care Workers of Slovenia. Slovenia has a fairly strong health-related nongovernmental organization (NGO) sector. NGOs provide health promotion services and ensure public participation in decision-making processes (section 2.5).
Employers are responsible for ensuring safe and healthy workplaces, covering part of the SHI contribution and paying a special contribution for work injuries and occupational illness. Their representatives in the ZZZS Assembly participate in ZZZS governance, which includes decisions on the allocation of health care funds. The organization of service providers in Slovenia is described in chapter 5.
- 1. This includes medical doctors, doctors of dental medicine, physiotherapists, occupational therapists, nurses, clinical psychologists, radiotherapists, laboratory engineers, and others providing primary health services. ↰
- 2. Throughout this HiT, the terms statutory health insurance and compulsory health insurance, or iterations thereof, will be used to describe the same system. ↰
On 7 July 2023, the then Minister of Health, Danijel Bešić Loredan, presented his signed resignation to the Prime Minister, Dr. Robert Golob, ending a period of mounting pressure related to differences in the approach to health reform between the Minister and the Prime Minister.
The process probably started with the appointment of a broader Strategic Council (SC) for Health Reform directly by the Prime Minister’s cabinet and including members of the previous Health Minister’s advisory body and several additional members (see “Whole-system Health Reform preparation formally launched in Slovenia” https://eurohealthobservatory.who.int/monitors/health-systems-monitor/analyses/hspm/slovenia-2022/whole-system-health-reform-preparation-formally-launched-in-slovenia). This move indicated that the Prime Minister wanted to play an active role in the process.
Meanwhile, the Minister was scarcely attending SC sessions and acted “solo” at least twice thereafter. First, despite a SC subcommittee preparing a comprehensive reform of health care financing, the Minister moved quickly to present the abolishment of the complementary health insurance, with members of the SC learning about this move only from the media. Abolishment of complementary health insurance was a cornerstone commitment of the coalition agreement regarding health and health care, and triggered by the threat of increasing premiums announced by the complementary health insurance companies, the Minister’s proposal was swiftly presented and adopted within two months.
Second, the MoH presented the proposal of the Digitalisation Act. This important Act introduces several significant changes to the current system of health reporting and data management and appoints a private company for its overall management (see “Whole-system Health Reform preparation formally launched in Slovenia” https://eurohealthobservatory.who.int/monitors/health-systems-monitor/analyses/hspm/slovenia-2022/whole-system-health-reform-preparation-formally-launched-in-slovenia). However, it received a negative opinion of the Information Commissioner, who basically declared its core in breach of data privacy, exposure of sensitive data to a private environment without clear supervision of the MoH and the creation of extensive national databases with numerous linkages and numerous responsible entities, undermining transparency. The Act has consequently been withdrawn and a new version is to be prepared.
The Minister’s resignation was presented at a moment that was important for some legislation proposals to be passed, and it was the result of significant pressure from coalition parties, the public and the Prime Minister. It was received as a positive move by a large part of the political spectrum and was not unexpected. Interestingly, the Medical Chamber was one of the few stakeholders expressing their concerns because the resignation would have a negative impact on the negotiations on salary reform for doctors as well as a significant slowdown on the course of the key health reforms.
The Prime Minister is now acting Minister and has appointed two new State Secretaries, Marjan Pintar, director of the Association of Public Health Care Providers, and Valentina Prevolnik Rupel, a health economist at the Institute of Economic Research, who served also as a member of the SC. In August 2023, the new team presented a “Directions of health policy for the years 2024–2025”, which is currently being discussed among health policy stakeholders. The appointment of the new Minister is expected to take place in October 2023.
Authors
The Prime Minister(PM)’s 22-member Advisory Board for the health system reform process has been meeting weekly to advance reform efforts. (See the policy analysis of 3 February 2023: “Whole-system Health Reform preparation formally launched in Slovenia”.) It has several subgroups, including medical faculties, primary care, financing of healthcare, health system governance, emergency medical services, and absenteeism. By the end of April 2023, it had prepared the following recommendations:
- Medical education – increase future admissions by at least 20%; enhance training capacity in regional hospitals and establish a possible third medical faculty.
- Absenteeism – address the current impasse, in which many patients experience a status between long-term sickness absence and disability.
- Primary care – clarify the status of patients not able to register with a GP of choice; incentivize junior doctors to choose primary care; revise completely the existing capitation formula, which has been applied since 2017 for workforce calculation, despite not being designed for this.
- Pharmacies – strengthen the role of pharmacies in local communities, potentially adding preventative services.
Additionally, three legal acts are under public discussion:
- Separate law for the Health Insurance Institute of Slovenia (HIIS): A separate law on the HIIS would reform the status, set-up and management of HIIS. HIIS would be registered as an insurance company, not a public institution. Rather than three management bodies – the CEO, the Management Board and the 45-member Assembly (25 insured representatives, 20 employers representatives) – the CEO and Board of three members – General CEO, vice-chair for compulsory health insurance and vice-chair for long-term insurance – would merge. The Assembly would also decrease to 11 members, representing the insured (6), employers (2), government (2), and employees of the HIIS (1).
- Law on digitalisation of the health information system: A special independent agency would be set up to oversee and implement the entire e-health and national reporting infrastructure. This would be managed by a special company and financed from a fixed percentage of the total health insurance budget. This is initially set at 3% and increased to 4.5% after three years; altogether, almost 10 times more money would be dedicated to e-health and digitalisation than currently, though there are some doubts to the feasibility of the funding source. Further, all national registries and data collection would transfer to five basic registries. It is unclear how these would be managed content-wise or by what methodology since the new agency would primarily oversee IT infrastructure. Nor is it clear how the complex international reporting obligations to Eurostat (legally binding), WHO and OECD would be fulfilled under this new system.
- Abolishment of complementary health insurance (CoHI) and corresponding amendments to the Health Care and Health Insurance Act (HCHIA): Triggered by a large increase in premiums by one CoHI company of almost 30% from 1 May 2023, the PM announced the future abolishment of CoHI. The proposal includes a freeze on premiums until September 2023 by which time the necessary amendments to the HCHIA should be adopted. This means that the present system of expansive CoHI would cease to exist by January 2024 at the latest. While this change may be an opportunity to (re)define the basic benefits basket and establish co-insurance for services not covered, it is unclear when and how this will occur.
References
- Law on the Health Insurance Institute of Slovenia, Draft law: https://e-uprava.gov.si/si/drzava-in-druzba/e-demokracija/predlogi-predpisov/predlog-predpisa.html?id=15438
- Law on the Health Information System: https://e-uprava.gov.si/si/drzava-in-druzba/e-demokracija/predlogi-predpisov/predlog-predpisa.html?id=15432
In January 2023, the Government of Slovenia appointed a Strategic Advisory Group (SAG) to assist in the preparation of a whole-system health reform. Its establishment had been previously announced by the Minister of Health, Danijel Bešić Loredan, and a specially prepared background document serves as the base. The inaugural session of the SAG on 27 January 2023 was opened by the Prime Minister, Robert Golob, along with the Minister of Health. The SAG is under the leadership of Dr Erik Brecelj, an oncological surgeon and harsh critic of the current state of play of the Slovenian health care system. The SAG is tasked with preparing changes in several working areas:
- financing of health care (including a transformation of the Health Insurance Institute of Slovenia from a payer into an active purchaser of health services);
- digitalisation of health care (seen as an imminent priority by all stakeholders);
- quality and patient safety;
- governance and management;
- absenteeism (mainly due to soaring costs of sickness leaves, which reached €700 million in 2022);
- emergency services;
- nursing;
- education for health professionals; and
- patients (including improvement of their participatory and stakeholder role and communication).
In addition, another area of special interest is shortages and salaries of family doctors in primary care, and of registered nurses in hospital settings. And health workforce planning is also strongly in the focus due to the inadequately managed planning of medical specialty training needs. This is currently in the domain of the Ministry of Health, which has not taken enough action to relate the future needs for medical specialists to projected developments of the Slovenian health system.
As input for its work, the Minister of Health has put forward practices from other countries. These include achievements in e-health and data management for health insurance in Estonia as well as integration of health and social care in the course of the health reform in Finland.
The timeline for the SAG’s work is relatively short, given the pressures of the above-listed focal points. Most of the work should be completed during 2023 and will pave the way for structural reforms, along with the necessary legal changes. This includes amendments to two Acts – The Health Services Act and the Health Care and Health Insurance Act – which have so far been relatively unmodified since they went into force.Authors
References
Pregled stanja na področju zdravstva v Sloveniji – januar 2023. Ministrstvo za zdravje, Ljubljana: 2023, accessible at: https://www.gov.si/assets/ministrstva/MZ/DOKUMENTI/NOVICE/Zdravstveni-sistem-v-Sloveniji-januar-2023.pdf