HEALTHCARE IN SLOVENIA: CHANGES AND ANALYSIS 1990–2009

Prof Dr Stanka Setnikar Cankar1 and Veronika Petkovšek2

1 Summary

The paper describes changes in the field of healthcare in Slovenia from 1990 to 2009. The aim of the research was to analyse significant data, changes and open issues within Slovenian healthcare. The final conclusions and results were arrived at by analysing and synthesising the data collected from statistical and health databases.

The paper first describes demographic and national economic data for Slovenia. This is followed by a chapter on healthcare spending, giving public and private spending as a proportion of GDP. Compulsory health insurance funds constitute the largest share of healthcare spending. The largest proportion of total healthcare spending is allocated to financing curative care services and medicines and medical goods. The chapter on factors of production presents trends in the numbers of doctors and other medical workers, hospital beds, and the value of equipment in Slovenian healthcare. Over the period studied, the number of nurses increased significantly, while the number of doctors increased more slowly. The number of hospital beds and their occupancy fell year by year.

The character of public healthcare and its predominant values are described next. The healthcare system in Slovenia is based on the principle of solidarity. Public healthcare services are mainly supplied via a network of providers that includes public institutions and private providers with a concession. Primary healthcare services in Slovenia are provided by health centres, secondary healthcare by hospitals, and tertiary by clinics and clinical institutions and departments. Compulsory health insurance provides Slovenian citizens with the right to healthcare services on the basis of a valid health insurance card.

This is followed by a chapter on health sector management, both public and private. The financing system for healthcare is based on a public-private financing model. The public funds come from the compulsory health insurance funds, and national and municipal budget funds. The private funds are from voluntary health insurance, direct payments for health services by patients, and funds from societies and charitable organisations.

Finally, there is a presentation of the history of the 1992 and 2003 healthcare reforms and the next planned reform in 2010. This is intended to address existing deficiencies that previous reforms failed to address or resolve. The paper then offers the final findings and the conclusions reached as a result of the research. Slovenia needs a more modern approach to healthcare that will ensure consistent provisions of services and financial sustainability, within the country’s material capacities.

2 Introduction

Health services have a very special position in every state. In most economies there is an aim to achieve suitable healthcare and maintain a satisfactory level of health for its inhabitants. The Healthcare and Health Insurance Act defines healthcare as a system of social, group and individual activities, measures and services to protect health, prevent disease, early detection, quick treatment, care and rehabilitation. It states that access to healthcare must be fair, and the quality of healthcare services must be the same for people with the same healthcare needs (Keber, 2003a, p. 20).

There is a need for change in the healthcare system and other health-related areas. These should be based on greater solidarity in providing the funds for the medical rights introduced by the reform, as well as greater fairness in their distribution, equal access to medical rights for all users, increased access, greater transparency and consequently, shorter waiting lists for medical treatment, better quality and efficiency of the healthcare system, a more active role on the part of users and better supervision. The changes must be planned in a manner that is fiscally sustainable in the long term.

3 Demographics

1 Full Professor of Public Sector Economics, Dean of Faculty of Administration, Faculty of Administration, University of Ljubljana, Slovenia2 Assistant, Public Sector Economics, Faculty of Administration, University of Ljubljana, Slovenia

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3.1 Geography and population number and density

The geographical size of the Republic of Slovenia is 20,273 km2. Slovenia’s population at the end of 2008 was 2,032,362. The population of Slovenia has grown by 100,000 since 1990, the year it gained independence. The population fluctuated until 1999 and since then has grown consistently.

Table 1: Slovenia’s population size and density: 1990-2008

Year

Total population

as at 31 December

Total population as at 31 December

(chain-type index)

Population density

Population density index (1991=100)

   1990 1,999,945 - -

1991 1,998,912 99.9 94.4 -

1992 1,994,084 99.7 - -

1993 1,989,408 99.8 - -

1994 1,989,477 100.0 - -

1995 1,990,266 100.0 - -

1996 1,986,989 99.8 96.9 102.6

1997 1,984,923 99.9 - -

1998 1,978,334 99.7 - -

1999 1,987,755 100.1 - -

2000 1,990,094 100.1 - -

2001 1,994,026 100.2 - -

2002 1,995,033 100.1 - -

2003 1,996,433 100.1 - -

2004 1,997,590 100.1 - -

2005 2,003,358 100.3 - -

2006 2,010,377 100.4 - -

2007 2,025,866 100.8 - -

2008 2,032,362 100.3 100.2 106.2

Source: Statistični letopis 2009, 2009.

The growth in Slovenia’s population is mainly from immigration by foreigners. There has been a noticeable increase in the proportion of foreign citizens in the Slovenian population: at the end of 2007 the proportion was 2.6%, at the end of 2008 it was 3.5%. The number of immigrants is therefore increasing, while the number of Slovenian citizens returning from abroad is falling (Jakomin, 2006).

3.2 Urban areas

The population has been leaving areas poorly served by traffic communications and remote areas along the national borders for decades. Larger and economically more powerful towns are the demographic beneficiaries, due to the transition to a market economy, private and local initiatives, denationalisation, privatisation, investment policies, globalisation, etc. (Pak, 2002). Less populated areas find it more difficult to acquire development funds from the state. Population density is increasing most in the Central Slovenia region. The primary level of healthcare services has followed the urbanisation pattern. Towns that are the centre of a statistical region have received most as a result of these changes (Cigale, 2002).

3.3 Life expectancy at birth

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Table 2: Life expectancy at birth by sex: 1990 - 2007

Year Male Female 1990-1991 69 771991-1992 69 771992-1993 69 771993-1994 69 771994-1995 70 781995-1996 71 781996-1997 71 791997-1998 71 791998-1999 71 791999-2000 72 792000-2001 72 802001-2002 72 802002-2003 73 812003-2004 73 812004-2005 74 812005-2006 75 822006-2007 75 82

Source: Statistical Office of the Republic of Slovenia, Ministry of the Interior – Central Population Register, Slovenian Institute of Public Health.

Life expectancy at birth is increasing for both males and females. A boy born is Slovenia in 2006 or 2007, can expect to live to almost 75, while a girl can expect to live to almost 82 years. In the past twenty years, life expectancy at birth in Slovenia has increased by almost 6 years for females, and 7 years for males (Prvi oktober, mednarodni dan starejših, 2008).

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3.4 Infant mortality rate

Table 3: Infant mortality rate: 1990-2007

Year

Male infants (per 1000 live births)

Female infants (per 1000 live births)

Total (per 1000 live births)

1990 10.0 6.7 8.41991 10.5 5.8 8.21992 9.5 8.2 8.91993 8.0 5.4 6.81994 6.2 6.8 6.51995 6.0 5.1 5.51996 6.0 3.4 4.71997 5.7 4.6 5.21998 6.3 4.1 5.21999 4.8 4.2 4.52000 5.6 4.2 4.92001 4.9 3.6 4.22002 4.9 2.7 3.82003 4.1 3.8 4.02004 3.5 3.8 3.72005 4.4 3.9 4.12006 3.3 3.5 3.42007 2.7 2.9 2.8

Source: Statistical Office of the Republic of Slovenia, Ministry of the Interior – Central Population Register, Slovenian Institute of Public Health.

Between 1990 and 2007 the total number of infant deaths was 1,821, 1,051 of which male and 770 female. The data indicates that the number of infant death has fallen year by year. The number of infant deaths per 1000 live births was at 2.8 in 2007, while ten years ago it was still 5.2 per 1000 live births.

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4 National economic data

4.1 Total GDP, GDP per capita, GDP growth rate and inflation rate

Table 4: Total GDP, GDP per cap., GDP growth rate, and inflation rate: 1995–2009

Year GDP (EUR million, current prices)

GDP per cap. (EUR)

GDP growth

Inflation rate

1995 10,294.30 8,101 4.1 12.61996 11,866.20 8,431 3.6 9.71997 13,508.40 9,034 4.9 9.11998 14,969.10 9,715 3.6 7.91999 16,806.80 10,486 5.4 6.12000 18,480.70 10,858 4.4 8.92001 20,654.30 11,441 2.8 8.62002 23,128.50 12,281 4.0 7.52003 25,114.00 12,900 2.8 5.72004 27,073.40 13,599 4.3 3.72005 2,749.60 14,369 4.5 2.52006 31,050.40 15,467 5.8 2.52007 34,568.20 17,123 6.8 3.82008 37,135.40 18,367 3.5 5.52009 34,893.90 17,092 -7.8 0.9

Source: SORS, Eurostat, 2010

The rate of economic growth in Slovenia changed over the period from 1995 to 2009. The highest growth in GDP was in 2007, when it grew 6.8%, while the lowest was in 2009 when it was minus 7.8%. Such a large fall in economic growth was due to the global economic crisis, which also affected Slovenia and slowed down its economy. GDP per capita increased throughout these years, only falling last year – by 1,275 euros per capita – which can again be attributed to the global economic crisis. The inflation rate fell until 2000, and then increased slightly, before falling again from 2000 to 2006. In 2007 and 2008 the inflation rate increased to 5.5%, before dropping to 0.9% in 2009.

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5 Health spending

5.1 Public spending at all levels and public spending as % GDP

Table 5: General government spending as % GDP, Slovenia, 2005-2008 2005 2006 2007 2008

Total 45.2 44.5 42.4 44.2

General public services 5.8 5.5 5.2 5.1

Defence 1.3 1.5 1.5 1.4

Public order and security 1.7 1.7 1.6 1.6

Economic affairs 3.9 4.1 4.1 4.7

Environmental protection 0.8 0.8 0.8 0.8

Housing and community amenities 0.5 0.6 0.6 0.9

Healthcare 6.3 6.3 5.9 6.1

Recreation, culture and religion 1.3 1.3 1.2 1.7

Education 6.6 6.4 5.9 6.2

Social protection 16.8 16.4 15.5 15.9

Source: Prva statistična objava, 2009.

General government spending in 2008 represented 44.2% of GDP, with healthcare spending at 6.1% of GDP. This includes spending on general, specialist and hospital healthcare services, the supply of medicines and other medical products, aids and equipment and applied research and development and other healthcare activities (Prva statistična objava, 2009).

5.2 Total healthcare spending and total healthcare spending as % of GDP

Total healthcare spending is the total sum of all public and private expenditure on the provision of healthcare services, and for prescribed medicines and medical goods for residents of Slovenia. It includes spending on curative care services, rehabilitation, long-term medical care, auxiliary healthcare services, medicines and other medical goods, preventive and public health services, and healthcare and health insurance management. Public and private healthcare differ in the material conditions, method of financing, and ownership of material resources (equipment, premises).

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Table 6: Estimate of total healthcare spending in Slovenia from 2007 to 2013 in current prices and as % of GDP.3

Table 6: Estimate of total healthcare spending in Slovenia from 2007 to 2013 in current prices and as % of GDP (continued)

Table 6: Estimate of total healthcare spending in Slovenia from 2007 to 2013 in current prices and as % of GDP (continued)

Source: SORS – General government expenditure for 2001 to 2006. Ministry of Finance – Draft financial plan 2008, financial projections for 2009 and 2010 and stability programmes and projections for 2011-2013.

3 Spending from 2001 to 2005 was converted from SIT to EUR. The projection of private spending was prepared using the private to total healthcare spending ratio for health in 2006, according to the SHA methodology.

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Converted from SIT to EUR

1. PUBLIC SPENDING

Compulsory health insurance

National budget funds

Municipal budget funds

2. PRIVATE SPENDING

3. TOTAL SPENDING

4. GDP

1. PUBLIC SPENDING

Compulsory health insurance

National budget funds

Municipal budget funds

2. PRIVATE SPENDING

3. TOTAL SPENDING

4. GDP

4. GDP

3. TOTAL SPENDING

2. PRIVATE SPENDING

1. PUBLIC SPENDING

Compulsory health insurance

National budget funds

Municipal budget funds

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

%GDP

The vast majority of public resources comes from compulsory health insurance, while national budget funds represent approximately 4.5% and municipal budget funds under 1.5% of total public resources. Further gradual reductions in central government expenditure on compulsory health insurance as a proportion of GDP until 2013, and gradual growth in the proportion of private spending, so that in 2013 private funding will represent 2.5%.

The proportion of private spending given in statistical data is lower than the actual figure. Private cash payments for healthcare should be included in the private spending figure, but they are difficult to measure. The value of the grey economy is assessed on the basis of tax inspections, mainly in the area of failure to issue invoices. From June to August 2009 the tax administration carried out tax inspections in the dentistry sector and found irregularities in 35% of procedures. A total of 161 inspections were carried out, with 23 verbal warnings, and fines worth 56,400 euros issued. The irregularities related primarily to failing to issue invoices and cash held not being reconciled with issued invoices (Pikon, 2009).

Figure 1: Trends in public and private healthcare spending: 2001-2009

Source: Resolucija o nacionalnem planu zdravstvenega varstva 2008-2013, 2009.

The average annual growth in the nominal value of total health spending from 2003 to 2007 was 5.6%, while average GDP growth was 8.3%. The difference in annual growth between nominal GDP and healthcare spending was largest in 2007 (GDP growth was 11.3% that year, while healthcare spending grew 5.4%). The lag in the nominal growth in healthcare spending behind GDP growth was expressed in the reduction of total health spending as a proportion of GDP, and from 2003 to 2007 fell from 8.7 % to 7.8%. Current spending and total healthcare spending (excluding investment) as a proportion of GDP fell from 8.1% to 7.4% (Prva statistična objava, 2008).

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Public spendingPrivate spending

Spen

ding

in E

ur m

illio

n

Table 7: Healthcare spending by treatment type and sources of financing, Slovenia, 2003 and 2007

2003 2007Total Public

sectorPrivate sector

Private sector as %

Total Public sector

Private sector

Private sector as %

EUR thousand EUR thousand Curative care services 1,104,951 873,597 231,354 20.9 1,402,408 1,083,530 318,878 22.7

Rehabilitation services 45,673 26,190 19,483 42.7 59,485 32,401 27,084 45.5

Long-term medical care 156,668 147,804 8,864 5.7 217,862 201,247 16,615 7.6

Auxiliary healthcare services 54,056 38,834 15,221 28.2 77,287 55,563 21,725 28.1

Medicines and medical goods 506,321 282,901 223,420 44.1 602,270 319,861 282,409 46.9

Preventive and public health services

74,146 57,122 17,024 22.9 102,242 75,969 26,274 25.7

Healthcare and health insurance management

98,491 58,294 40,198 40.8 112,444 58,773 53,670 47.7

Investment 134,572 80,129 54,443 40.5 127,676 107,735 19,942 15.6

Totalhealth treatment and products

2,174,878 1,564,870 610,008 28.0 2,701,675 1,935,079 766,596 28.4

Source: SORS, Prva statistična objava, 2008.

Over three-quarters of current healthcare spending over the period studied (77.9% in 2007) was used to finance curative healthcare services and medicines and medical goods. They are followed, as a proportion of total current spending, by spending on long-term care (8.5% in 2007) (Prva statistična objava, 2008).

In the current healthcare spending structure for 2007, spending on healthcare services provided in hospitals and health institutions stood at 44.1%, while spending on services provided at out-patient clinics was 25.9%. Both these proportions were higher in 2007 than in 2003 (spending on hospitals and health institutions totalled 42% in 2003, while spending in out-patient clinics was 25.4%) (Prva statistična objava, 2008).

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6 Factors of production in healthcare

6.1 Doctors and other medical staff

The number of doctors in Slovenia fluctuated until 1999, and since that year has gradually increased. The number of nurses has increased since 1992.

Table 8: Number of doctors and nurses: 1992-2006

Year No of doctors Doctors per 100,000 inhabitants

No of nurses Nurses per 100,000 inhabitants

1992 4,169 209 11,223 5621993 4,039 203 11,739 5901994 4,356 219 11,889 5981995 4,206 212 12,705 6391996 4,251 213 13,051 6551997 4,251 214 13,313 6701998 4,299 217 13,447 6781999 4,254 214 13,698 6902000 4,317 217 13,765 6922001 4,361 219 14,245 7152002 4,475 224 14,327 7182003 4,518 226 14,748 7382004 4,617 213 14,863 7442005 4,723 236 15,057 7522006 4,766 237 15,361 765

Source: Institute of Public Health, 2009

In addition to doctors and nurses, in 1990 there were 32 pharmacists per 100,000 inhabitants in Slovenia, while in 2006 there were 47 pharmacists per 100,000. There were 56 dentists per 100,000 inhabitants in 1990, and 59 in 2006 (European Health for All Database (HFA-DB), 2010).

Figure 2: Number of medical workers: 1990-2006

Source: European Health for All Database (HFA-DB), 2010

From 1990 to 2006 only the number of nurses grew. The number of doctors and pharmacists grew minimally, while the number of dentists remained unchanged.

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Doctors

Nurses

Pharmacists

Dentists

6.2 Hospital beds

The number of hospital beds fell year by year. Occupancy also fell from year to year. This is an indicator that more diseases and injuries are treated via other forms of care. Hospital bed occupancy fluctuated between 69 and 80% over the period. In 2007 there were 466 hospital beds per 100,000 inhabitants. The EU average in 2005 was 590. In Slovenia the number of beds per 100,000 inhabitants fell by 15.6% from 2000 to 2006 (UMAR/IMAD, 2008).

Table 9: Number of hospital beds, occupancy and number of hospital beds per 100,000 inhabitants: 1992-2007

Year No of hospital beds Occupancy of hospital beds (%)

Hospital beds / 100,000 inhabitants

1992 11,839 79 5931993 11,540 81 5801994 11,493 79 5781995 11,411 77 5741996 11,276 77 5661997 11,233 78 5651998 11,097 75 5601999 10,959 73 5522000 10,745 71 5402001 10,286 70 5162002 10,147 69 5082003 9,895 68 4952004 9,584 73 4802005 9,666 70 4832006 9,567 71 4762007 9,414 69 466

Source: Institute of Public Health, 2009

The Health Insurance Institute of Slovenia (HIIS) annually leases or agrees contracts for approximately 85% of all hospital beds. This figure does not include beds in social institutions (e.g. homes for the elderly). In addition to this, the HIIS agrees contract with health spas for rehabilitation programmes, ensuring another 800 beds per year in that way (Oder, 2008).

6.3 Equipment

Over the period 2001-2008 the value of equipment fell compared to the total value of all funds. Investment is needed to upgrade health sector equipment.

Table 10: Value of equipment and other tangible assets in EUR thousand

Source: HIIS annual reports, 2001–2008.

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YEAR EQUIPMENT VALUE PROPORTION OF HIIS FUNDS IN TOTAL ASSETS (%)

2001 8,554 9.42002 5,378 5.42003 3,927 4.12004 4,919 4.92005 4,257 2.92006 4,735 3.32007 5,301 2.12008 7,643 2.6

7 Systemic issues in Slovenian healthcare

7.1 Public healthcare in Slovenia

Compulsory health insurance is provided on the basis of the principles of social fairness and solidarity. Public healthcare services are mainly provided via a network of providers that includes public institutions and private providers with a concession. The basic primary healthcare providers are health centres, while hospitals provide secondary healthcare. Tertiary healthcare is provided by clinics, and clinical institutions and departments (draft Healthcare Act, 2009).

The network of public healthcare providers includes health centres, pharmacies, individual doctors’ surgeries and out-patient centres, hospitals, clinics and other medical institutions. Municipalities and central government (Ministry of Health) either founded these, or authorised them by granting concessions to perform healthcare services provided to the population and other persons by law. The position of individual providers in the network must be defined in a way that provides the best possible access to people. Municipalities decide on health centres, doctors offering primary healthcare and pharmacies. The ministry decides on hospitals, specialist out-patient clinics, and other clinics and medical institutions (Kako do zdravnika, 2009).

7.2 The welfare principle and predominant values in healthcare

Compulsory health insurance provides Slovenian citizens with the right to healthcare services with a selected personal physician and via specialists. The waiting time for the same health services differs significantly between individual providers, so data on waiting times are also important.

Insured parties have the right to freely select a doctor and health institution. Women also select a personal gynaecologist. All insured parties also select a personal dentist. The lack of dentists in public healthcare has led to between 20,000 and 30,000 citizens being without public dental care (Kako do zdravnika 2009).

The partners in the governing coalition have committed themselves to ensuring equitable provision of healthcare. They announced a reform that would increase access to a more effective system of public healthcare (Koalicijski sporazum za delovanje v vladi Republike Slovenije za mandat 2008–2009, 2009).

8 Health sector management

8.1 Main sources of financing

The financing system for healthcare in Slovenia is based on a public-private financing model. The public funds come from the compulsory health insurance funds, and national and municipal budget funds. Private sources of financing include voluntary health insurance, some accident insurance funds, direct payments for healthcare from the population, and funds from various charities and donors (Resolucija o nacionalnem planu zdravstvenega varstva 2008-2013, p. 74).

The sources of public financing are linked to an ongoing payment system, which does not offer the Slovenian healthcare system long-term stability. Slovenia does not have an insurance fund to draw down on when financing healthcare. Demographic change, and specifically, population aging has a negative impact on an ongoing payment system (Mrkaić, 2007, p. 92).

8.2 Contractual and payment models

The distribution of funds to healthcare service providers is carried out by means of a contractual or integrated model. The contract model is the most widespread. It is used within healthcare systems in which management powers, tasks and responsibilities are divided within the system between separate, clearly-defined legal subjects (partners). The distribution of funds in Slovenia uses the contract model.

The relevant model for hospital treatment is the diagnostic-related group (DRG) model. The benefit of this model is that it encourages providers to search for internal reserves, to reduce hospital stays and to transfer to out-patient treatment. Financial risk is distributed equally between service providers and paying agents. Primary

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healthcare uses a capitation model, which is suitable mainly for units with similar numbers of patients (e.g. health centres). For private practitioners a payment by service system is the most appropriate.8.3 Ownership

Inefficiency in healthcare is often also dependent on ownership. The possible combinations of public and private provision and financing of healthcare services are given in Table 11.

Table 11: Combinations of public and private provision and financing of healthcare services

Public healthcare network “Pure” private medical workers Public health institutions Concession holders

Programme Public Private Public Private PrivateCompulsory health insurance

Healthcare market

Compulsory health insurance

Healthcare market

Healthcare market

Provision Public Public Private Private PrivateFinancing Public Private Public Private Private

Source: Brezovšek, 2005, pp. 456.

Local communities (municipalities) define and provide for the public healthcare network at the primary level, and participate in planning the secondary level network. Via representatives on the board of the HIIS they also have a direct influence over the management of all public health institutions.

Until 1992, healthcare services were provided in Slovenia by public health institutions alone. Since 1992 private healthcare service providers have been able to operate within the public healthcare network on the basis of concessions. The scope of private healthcare provision via concessions has increased over the studied period (Gregorič Rogelj, 2009, p. 9).

Figure 3: No of HIIS contracts with health centres: 1993-2008

Source: Gregorič Rogelj, 2009, p. 9.

One third of concession holders within the public healthcare system are found at the primary level. In 2007, 13.2% of contracts for provision of agreed programmes were made with private concession holders (O javni zdravstveni službi, 2009). In 2008 the HIIS concluded contracts with a total of 1,767 providers, 221 being public institutions and 1,546 private concession holders. In addition to private practitioners within the public healthcare network with an HIIS contract, there are also ‘purely private’ practitioners providing services that are not included in the public healthcare network. Patients must pay for all their services themselves, expect for urgent medical assistance (Gregorič Rogelj, 2009, p. 9).

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Private concession holders

Public institutions

Figure 4: No of doctors in health institutions and no of doctors with concessions in 2008

Source: HIIS annual report, 2008.

The data indicates that there is great interest in acquiring a concession than in purely private practice. The growth in the number of concession holders is approximately 2.6 times that of private practitioners without a concession.

8.4 Public-private partnership

Public-private partnership allows the private sector to enter the public system and transfer some risk to the private sector indirectly reducing the pressure on public financing. Public-private partnership has to be organised as a partial privatisation. Despite the fact there is Public-Private Partnership Act in force, since 2007 there have not been any major investments in equipment or facilities in Slovenia. The public sector’s main motive for engaging in public-private partnership projects is to acquire funds for investment and the provision of better quality services to users within the scope of limited public funds (Gregorič Rogelj, 2009, p.11).

The first cases of joint PPP investment projects were implemented 10 years ago. One such case is Sežana Hospital, which carried out the construction of a dialysis centre in 2004 and 2005 as a PPP investment worth EUR 2.5 million. Sežana Hospital acquired an investor that was prepared to implement construction work and purchase equipment for the dialysis centre. The hospital completed the investment in 2005. The next case was the Brežice General Hospital, which agreed a partnership contract in 2006 on energy provision, fuel supply and reconstruction of boiler plants. This would reduce heating costs by 26.6%. The project represents a financing model that also includes the planning and installation of new devices, plant supervision, management, servicing and maintenance. The third case of public-private partnership in Slovenian healthcare is the case of three primary healthcare facilities in the Gorenjska region, featuring cooperation between three partners: municipalities, the state (ministries), public health institutions, and private investors. The total value of all three facilities was EUR 6,550,000 (Gregorič Rogelj, 2009, pp. 15-20).

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Doctors with concessions

Doctors in health institutions

General practitioners Dentists Dispensary specialists

Gynecologists

9 History of healthcare reform in Slovenia

9.1 Major changes in decision-making powers on the allocation of funds and distribution of financial risk in healthcare financing

Slovenia’s first healthcare reform took place in 1992. This introduced compulsory health insurance which was based on solidarity among insured parties, who contribute funds according to their income capacities. The Public Institutions Act was adopted, which made hospitals, health centres and pharmacies into public institutions. The state became the owner of hospitals, clinics and institutes operating at the secondary and tertiary level while municipalities became the owners of primary level capacities. This act also changed the method of managing health institutions. The highest body of management is the institute board, to which the owner or founder of the institute, insured parties and employees appoint a number of representatives. The next healthcare reforms were carried out in 2003. With this reform we developed and introduced a payment method in which the money follows the patient. There were also intended to improve operations, leadership and management of the healthcare system (Keber, 2003b).

The existing healthcare system in Slovenia faces a number of problems: first, inappropriate distribution of capacity; second, lack of adequate information required for decision-making; third, problems at different management levels in the healthcare system; fourth, challenges related to the mission of healthcare. In Slovenia a new reform is therefore planned in 2010 due to these problems.

9.2 Short-term and medium-term results of healthcare reform

The draft for an amended Healthcare Act (2010) sets out:

- The enhancement of primary healthcare. The function of health centres has been reduced in past years, but was now to be restored. These means that even health centres with a large number of concession holders will have the opportunity to better implement their functions (Eržen, 2009, p. 4).

- Organisation of secondary healthcare. The act defines the compulsory stationary hospital activity of general hospitals based on national need. Specialist centres will be developed in the following years. This envisages greater mobility for medical workers, particularly the best trained. The introduction of modern information and communication technology will also contribute to more effective work. The development of new activities demanded by the healthcare needs of the population will continue in parallel. Several measures are envisaged, such as: changing or increasing the powers of health institution management boards and separating the powers of management boards from the powers and function of public institute supervisory boards (Eržen, 2009, pp. 4-5).

-Establishing a quality system that supports safe and effective healthcare provision to patients. The act lays down the establishment of a Public Institute for Healthcare Quality and Safety that will coordinate the preparation of clinical guidelines and application to normal work, monitor their realisation and measure them on the basis of relevant indicators (Eržen, 2009, pp. 5-6).

- Changes in economic conditions in the field of healthcare. The experience of mixed public-private healthcare in Slovenia indicates significant failures due to inappropriate procedures and the conditions for awarding of concessions. Invitations for concessions to provide public healthcare services will be published when a public health institute can no longer provide specific healthcare services alone (Gregorič Rogelj, 2009, pp. 10-11). Private capital investment in medical activities requires the definition and acceptance of standards, norms, networks, and that the state’s directing and supervisory role in set in place (Gregorič Rogelj, 2009, pp. 21-22).

- Introduction of e-health project. The project combines the implementation of information and communications technology in the healthcare sector, which will ensure more effective healthcare services. The project is currently one of the largest public service computerisation programmes. The introduction of the project will create a modern national information infrastructure for the health system. It will ensure secure electronic operations and the efficient management of captured health information. The results of the project will make it easier for various groups of individuals to communicate with healthcare employees. At

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the same time, the project will provide a basis for optimising healthcare processes, increasing efficiency, and designing amended service provision. The results will enable more comprehensive and better quality patient treatment and better cooperation with clinical specialists and other medical workers (Eržen, et. al., 2009).

10 Conclusion

Public spending on healthcare in Slovenia totals around 6% of GDP. Compulsory health insurance funds represents over 90% of that total, while national budget funds represent below 5% and municipal budget funds around 1.5%. Private spending on healthcare represents around 2.5% of GDP. Total healthcare spending as a proportion of GDP fell from 8.1% to 7.4% over the period from 2003 to 2007.

The number of doctors, pharmacists and dentists gradually increased over the period from 1990 to 2006, while the number of nurses increased significantly. The number of hospital beds and their occupancy fell year by year. This trend is explained by the lower average length of hospital stays. The value of equipment from 2001 to 2008 gradually fell, and in 2008 totalled 2.6% of the total assets, while in 2001 it had been 9.4% of total assets.

Healthcare services can be provided by public or private institutes or clinics. Until 1992 healthcare services were provided exclusively by public health institutions. Since 1992 the awarding of concessions has enabled the private provision of healthcare services within the public healthcare system. The number of concession holders grew significantly from 1994 to 2000, and growth was again strong after 2004 and continues today. The number of concession holders is growing faster than the number of private practitioners without a concession.

There are not many major projects public-private partnership projects in Slovenia outside the concession system. The reason for this can be primarily ascribed to the lack of a stimulating environment, and a lack of motivation to seek better opportunities to implement planned projects.

Slovenia carried out two health reforms, in 1992 and 2003, which were intended to improve its health system. Nevertheless, certain deficiencies remained within the health system, which led to preparations of a new health reform in 2010. The healthcare sector requires new and more modern approach. Against a backdrop of increased requirements from the population, it must provide content and financial sustainability within the country’s material capacities. The reform therefore envisages the strengthening of primary and secondary healthcare, improved healthcare management, the introduction of a quality system, the organisation and standardisation of concession awards, and the creation of an environment that supports PPP.

The 2010 reform will therefore attempt to clearly define the separation of public and private healthcare (separation of financing, ownership, services, etc.), and the awarding of concessions. A clear system is required that prevents migrations from public to private and vice versa in the fields of managing public institutions, the work of doctors and medical workers, medical associations, hospitals and institutional powers.

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